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Psychiatric Illness: Impact on the Individual and Dental Management Considerations

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Psychiatric Illness: Impact on the Individual and Dental Management Considerations PACIFIC DENTAL CONFERENCE March 8, 2007 Vancouver, British Columbia – PowerPoint PPT presentation

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Title: Psychiatric Illness: Impact on the Individual and Dental Management Considerations


1
Psychiatric Illness Impact on the Individual and
Dental Management Considerations
  • PACIFIC DENTAL CONFERENCE
  • March 8, 2007
  • Vancouver, British Columbia
  • David Clark BSc.,DDS,MSc.,FAAOP,FRCD(C)

2
CHRONIC MENTAL ILLNESS
  • an equal opportunity illness affecting all ages,
    all races, all economic groups and both genders
  • Chronic mental illness and its medical
    management carry inherent risks for significant
    oral disease.

3
How common is Mental Illness?
  • 1 in 5 adult Canadians will meet the psychiatric
    criteria for a mental disorder.
  • 1998 U.S. Census 44.3 M
  • disorder ---- impairment is key
  • concept of risk factors can considered as
    potential important clues or as the weak links
    in the mental health chain.

4
STATISTICS
  • Mental illness/addictions cost the Can. economy
    33B/yr in lost productivity.
  • Mental health claimsgtheart disease for disability
    costs (gt 5B/yr. lost work days.
  • 85 with serious mental disorder are unemployed.

5
STATISTICS - Suicide
  • rate in Canada 12-15/100,000
  • male female 31
  • 300 teens(10-19 yrs) commit suicide/yr.(Feb/05)
    Canada the leader. (rates inc. in males 15-19
    by 350 in past 20 years)
  • 530,000 kids have treatable MI but only 150,000
    get treatment.
  • highest rates 43/100,000 gt 80 yrs.
  • 30/100,000 gt 75 yrs.

6
STATISTICS
  • 20 prison pop. suffer mental illness(gt50 if
    addiction problems included).
  • gt1/3 homeless people have mental illness(75F).
  • 25 of 34M hospital days/yr in Canada used to
    treat patients with mental illness.( 8.5 M
    hosp. days)

7
No one chooses to have a mental disorder
  • .admitting to mental illness is not the same
    thing as admitting to any other serious health
    issue since it can often result in more suspicion
    than support
  • misconceptions flourish

8
Mental Health Fact..
  • people with a psychiatric illness experience a
    doubleburden which includes both the s/s of
    the disease the social stigma, isolation,
    discrimination that result from having that
    disease
  • stigmasocial isolation, homelessness,
    unemployment, substance abuse, prolonged
    institutionalization

9
Dental Perspectives..
  • Medications used to treat mental illness can
    interact with drugs used in dentistry.
  • Some oral health problems arise as manifestations
    of mental illness.
  • Oral health problems as side effects of
    psychotropic medications.
  • Decreased compliance to oral health care/ability
    to obtain or tolerate oral care treatment.

10
Dental Perspectives..
  • When was your mental illness diagnosed?
  • Who is the GP/Psychiatrist treating this
    condition?
  • Have you experienced any dental side effects,
    such as dry mouth, burning tongue, excessive
    saliva or swollen gums?
  • Sample Mental Health History
  • What psychiatric medications are you taking?
  • How long have you been taking the medication and
    does it help?
  • What are/were your symptoms?

11
DSM IV Diagnostic Statistical Manual of
Mental Disorders
  • a descriptive approach to diagnosis based on
    symptoms rather than causes. The disorders listed
    include a clinical significance criterion re
    significant distress or impairment.
  • there is no blood test, brain scan or specific
    x-ray to make a diagnosis as with other medical
    problems.

12
Axis I Clinical Disorders
  • Dementia, delirium, amnesia, other cognitive
    disorders
  • Schizophrenia/other psychoses
  • Mood disorders
  • Substance-related disorders
  • Eating disorders
  • Somatoform disorders
  • Anxiety disorders

13
WHAT IS A PSYCHOSIS?
  • Psychosis is a disordered pattern of thought,
    perception, emotion and behaviour. The psychotic
    person has a bizarre sense of reality, with
    emotional and cognitive impairment leading to
    loss of function in the environment.

14
SCHIZOPHRENIA
  • 1- 2 worldwide.
  • late teens/early adulthood gradual/sudden.
  • M (earlier) gt F
  • 10 chronic hospitalization 30-40 long-term
    serious handicap.
  • 40 risk of suicide attempts
  • 60 alcohol abuse/15-25street drugs
  • 20 shorter life expectancy(gtvulnerability to
    medical problems (lifestyle)

15
SCHIZOPHRENIA Etiology
  • Causation of schizophrenia remains not well
    understood (syndrome?). Theories include
  • (genetics) altered expression of genes(10-15
    with one parent 30-40 - 2 parents
  • differences in brain chemistry-(imbalances in
    neurotransmitters, e.g. dopamine)
  • differences in brain structure

16
SCHIZOPHRENIA Etiology
  • Schizophrenia is NOT
  • a multiple or split personality
  • caused by bad parenting/character flaws
  • the result of childhood trauma
  • an isolated condition 1 in 100 incidence?
  • an automatic precursor to criminal violence

17
SCHIZOPHRENIA Symptomatology
  • Positive symptoms does not mean good but
    rather s/s that are present but shouldnt be
    there. Exaggeration, distortion of normal
    function, e.g. delusions (control of ones
    thoughts, actions) hallucinations (sensory
    auditory- patient hearing voices
  • visual, tactile)

18
SCHIZOPHRENIA Symptomatology
  • Disorganized symptoms a rapid shift of ideas,
    incoherent speech, poor thought relation.
    Disorganized, bizarre behaviour e.g.
    stereotypical, imitation of others speech,
    gestures etc.

19
SCHIZOPHRENIA Symptomatology
  • 3. Negative symptoms the absences of behaviour
    that should be there. i.e. flat
    emotions/emotional expression, lack of
    motivation, monotony of speech apathy, social
    withdrawal, absence of normal drives or interests
    such as those involving ones self care
    (general/oral).

20
SCHIZOPHRENIA Medical Management
  • Conventional Antipsychotics
    (Neuroleptics)
  • chlorpromazine(Thorazine),
    methotrimeprazine (Nozinan),
    haloperidol(Haldol),
  • early 1950s blocking of dopamine D2 receptors in
    the mesolimbic system of the brain affecting mood
    thought processes e.g. effective in managing
    positive symptoms only.
  • major side effect movement disordersoral
    dyskinesias - often with orofacial component.
    Arise from blockade of basal ganglia dopamine D2
    receptors in extrapyramidal system (EPS)

21
Schizophrenia-Medication Side Effects
  • ORAL DYSKINESIAS
  • Abnormal involuntary, uncontrollable movements
    affecting primarily the tongue, lips, jaws (can
    extend to trunk/limbs)
  • Causes 1. drug induced( conventional
    antipsychotics)
  • 2. neuropsychiatric conditions
  • 3. edentulousness
  • (tardive
    dyskinesia)

22
Schizophrenia Medication Side Effects
  • Tardive Dyskinesia (TD)
  • late stage effect of slow, rhythmic involuntary
    grimacing/twitching in facial area e.g. repeated
    smacking of lips, tongue movements, facial
    contortions.
  • gt25 of patients on conventional antipsychotics
    having TD after 5 years of treatment.
  • Ironically, the signs of TD reinforce the
    crazy stereotype, which in reality is only a
    side effect of treatment.

23
Schizophrenia-Medication Side Effects
  • ORAL DYSKINESIAS (drug-induced)
  • conventional antipsychotics
  • atypical antipsychotics
  • antiemetics
  • antiparkinsonion
  • TCAs
  • SSRIs
  • lithium
  • anticonvulsants
  • antihistamines
  • methamphetamines

24
Schizophrenia-Medication Side Effects
  • ORAL DYSKINESIAS-Complications
  • tooth wear
  • oral pain/injury
  • TMJ degeneration
  • speech impairment
  • chewing difficulties
  • inadequate food intakewt. loss
  • displacement/poor
  • retention of RPDsdecreased tolerance
  • social sequelae

25
Schizophrenia Medication Side Effects
  • Side effects of movement disorders are often
    managed by Rx. anticholinergic medications e.g.
    Cogentin. These drugs in turn exhibit their own
    spectra of side effects.
  • Other side effects include EKG changes,
    orthostatic hypotension, dry mouth, constipation,
    blurred vision, nasal stuffiness.

26
Schizophrenia Medical Management
  • atypical antipsychotics
  • First appeared in late 1980s e.g.
    clozapine(Clozaril), risperidone(Risperdal),
    olanzapine(Zyprexa), quetiapine(Seroquel).
  • rarely cause movement disorders why? these
    drugs possess a high ratio of serotonin to D2
    activity and are therefore referred to as
    serotonin-dopamine antagonists vs. conventional
    antipsychotics or dopamine antagonists.

27
Schizophrenia Medical Management
  • CLOZAPINE
  • remains the drug of choice in treatment
    resistant cases reduce cravings for
    alcohol/illicit drugs reduced/delayed risk of
    suicide attempts.
  • But 1 of patients develop agranulocytosis after
    12-24 wks. Patients required to have weekly WBC
    counts i.e. gt 3000/c.c.
  • can cause initial sialorrhea hypotension,
    sedation, tachycardia.

28
Schizophrenia Medical Management
  • Risperidone, Olanzapine, Quetiapine
  • -provide better management of both
    positive,negative disorganized symptoms.
  • Minor sedation, weight gain, sexual dysfunction,
    dry mouth, no agranulocytosis.
  • the improved clinical course and therefore
    compliance with these atypical medications
    ensure less chances for relapse that was seen
    with conventional antipsychotic therapy.

29
Schizophrenia Medical Management
  • BUT, atypical antipsychotics can compound at
    patients risk for diabetes, heart disease,
    obesity, hyperlipidemia (metabolic syndrome)
  • Dental implications are relevant with respect
    to clinical management of the diabetic, cardiac
    patient etc.

30
Antipsychotic Medications Impact on Dental Care
  • Conventional Antipsychotics
  • chlorpromazine, haloperidol, perphenazine
  • Oral side effects xerostomia, tardive dyskinesia
  • Atypical Antipsychotics
  • clozapine,olanzapine,quetiapine,risperidone
  • Oral side effects xerostomia, dysphagia,
    stomatitis, dysgeusia

31
Schizophrenia Oral Findings
  • people who suffer from schizophrenia are at a
    far greater risk of dental caries,
    gingivitis/advanced periodontal disease, tooth
    loss, lack of dentures, poor oral hygiene,
    mucosal diseases
  • poor dietary habits, smoking, alcohol
    abuse, substance abuse

32
Schizophrenia Oral Findings
  • higher prevalence of bruxism and signs of TMD
    severe tooth damage due to extensive attrition.
  • ? CNS abnormalities and/or neuroleptic induced
    mechanisms.
  • actual pain sensitivity thresholds higher in
    pats. with schizophrenia vs. healthy controls.
    While more prone to suffer TMD problems, pain
    sensitivity thresholds cause delays in dx. and
    tx. resulting in serious clinical consequences.

  • OOOOE-in press,2006

33
Schizophrenia Oral Findings can be.
  • precipitated by the psychosocial deficiencies
    inherent in the disease itself.
  • a result of a disinterest in regular oral care
    is due to financial hardships, prolonged periods
    of hospitalization and non-existent support
    networks.
  • also a result of an unwillingness on the part of
    the DDS to understand and/or be comfortable in
    the dental management of these patients.

34
SCHIZOPHRENIA Dental Considerations
35
SCHIZOPHRENIA Drug Interactions
  • Epinephrine used with caution to prevent severe
    hypotensive episode limit to 2 carpules
    1100,000 avoid epinephrine in retraction cords
    inject slowly.
  • Neuroleptics may intensify effects of sedatives,
    hypnotics, opioids, antihistamines leading to
    severe respiratory depression consult with MD.
  • Neuroleptics can dec. blood levels of warfarin.

36
COMPLICATIONS OF XEROSTOMIA
  • acidic plaque pHcaries, hypersensitivity
  • loss of lubricationoral ulcerations,
    difficulties eating, speaking, wearing dentures
  • dec. amount of salivainc. infections (viral,
    bacterial, fungal) digestion problems, ease of
    trauma to oral mucosa, gingivitis periodontitis

37
DENTAL MANAGEMENT Dry Mouth Protocol
  • sipping water frequently
  • restrict caffeine, colas
  • sugar free gum, candies.
  • saliva substitutes, oral moisturizers e.g.
    MouthKote, Biotene products (contain key
    enzymes3 found naturally in saliva)
  • avoid alcohol/alcohol containing mouthrinses
  • fluoride rinses(0.05)
  • fluoride gels(0.04)
  • CHX mouth rinse (alcohol-free TBA)
  • restrict/avoid tobacco products

38
Depression is..
  • an equal opportunity illness all ages, races,
    all economic classes.
  • an illness (as is diabetes, heart disease)
  • leading cause of suicide (15)
  • F gt M 21
  • highest risk for those with family Hx. Of
    depression genetic component, further advanced
    by emotional deprivation or childhood trauma.
  • elderly gt 65.
  • those with physical illness/disabilities.

39
Depression is..
  • second leading cause of death and disability in
    the world in age category of 15-44 yrs. (M F)
    W.H.O.
  • an illness affecting the entire body
  • leading cause of alcohol/drug abuse (1/3 of
    patients)
  • Depression will be..
  • The second leading cause of health impairment
    worldwide by 2020. (WHO)

40
Major Depressive Disorder
  • Mental illness of at least 2 weeks duration
    encompassing at least 5 of the following DSM-IV
    diagnostic symptom criteria
  • depressed mood
  • diminished interest/pleasure
  • dec./inc. in wt. or appetite
  • insomnia/hypersomnia
  • inability to think or concentrate
  • fatigue/loss of energy
  • thoughts of death/suicide

41
Bipolar I Affective Disorder
  • a roller coaster of mood
  • lowest of lows s/s of major depression
  • highest of highs manic episode, preceded often
    by hypomania - one feels good, excitable,
    talkative, energized, able to think/concentrate
    very clearly- but not dangerous to self/others.

42
Bipolar I Affective Disorder (MANIC EPISODES)
  • feeling indescribably good
  • require little or no sleep
  • easily explode into anger
  • flight of ideas, impaired judgment
  • lose touch with reality
  • excessively talkative
  • uninhibited lack of insight into ones behaviour
    e.g. of a sexual nature

43
Depression (Postpartum Depression)
  • Condition diagnosed within 1 yr. of
    childbirth. (not baby blues)
  • Canadian statistics
  • 10-15 of mothers affected (335,000 births in
    2003)
  • .2 suffer acute psychosis (high risk) e.g.
    Toronto MD, 2000.
  • often under diagnosed/widely misunderstood due to
    stigmatization

44
Late-life Depression
  • Who? - gt 65 yrs.
  • What? impairment of mood, thought context,
    behaviour distress, compromised social
    function, poor self care sadness, loss of
    interest, wt. changes, fatigue inc. suicide risk

45
Monamine Oxidase Inhibitors (MAOIs) Phenelzine
(Nardil) Tranylcypromine (Parnate) Moclobemide
(Manerix)
  • heralded era of antidepressants- 1950s
  • prevent enzymatic breakdown of noradrenaline/serot
    onin in synaptic cleft with inc. levels of both
    neurotransmitters.
  • used in cases(10) refractory to TCAs, SSRIs or
    other antidepressants.

46
MAOIs
  • Disadv. dietary drug-drug interactions
    causing severe hypertension.(tyramines in cheese,
    meats, red wine are not inactivated MAOI
    ephedrine) potentiation of depressant activity
    of the opioids.
  • also dizziness, dry mouth, insomnia, wt. gain,
    orthostatic hypotension.

47
Tricyclic Antidepressants amitriptyline
(Elavil) clomipramine (Anafranil) imipramine
(Tofranil) desipramine (Norpramin)
  • initially most popular first line Rx.- 1960s
  • prevent re-uptake of noradrenaline serotonin
    inc. levels.
  • problems with non-compliance due to S/E of dry
    mouth (50).

48
Other Side Effects of Antidepressant Drugs
(Tricyclics)
  • Common dry mouth, nausea/vomiting, constipation,
    urinary retention, insomnia, sexual dysfunction,
    postural hypotension.
  • Serious mania, seizures, leukopenia, cardiac
    arrhythmias, MI, stroke.

49
Selective Serotonin Reuptake Inhibitors SSRIs fluv
oxamine (Luvox) fluoxetine (Prozac) paroxetine
(Paxil) sertraline (Zoloft) citalopram (Celexa)
  • inc. use as first line Rx.- 1990s. (second
    generation)
  • prevent re-uptake of serotonin from synaptic
    cleft resulting in inc. levels of enhanced
    neuronal activity.
  • Adv. less sedation cardiotoxicity, lt dry
    mouth(18)
  • Disadv. GI upset, insomnia, sexual dysfunction,
    poss. Inc. in bleeding time.

50
other antidepressants buproprion (Wellbutrin,
Zyban) venlafaxine (Effexor) nefazodone (Serzone)
  • Wellbutrin selective norepinephrine dopamine
    re-uptake inhibitor. Acts mainly on dopamine
    system and little on serotonin reuptake.
    (atypical antidepressants)
  • Effexor serotonin, noradrenaline re-uptake
    inhibitor. (3rd generation antidepressants)
  • Mirtazapine(Remeron)
  • ____________________________________
  • Antipsychotics are also used in the more
    psychotic tx. resistant cases of depression but
    note the side effects as for schizophrenia.

51
Electroconvulsive Therapy (ECT)
  • for severe depression refractory to medication.
  • ? a CNS seizure induced via electric current
    (under GA) inc. responsiveness of neuronal
    membranes to neurotransmitters.
  • Dental r/o loose/broken teeth re possible
    aspiration identify CD/RPD. Use of bite blocks
    to protect teeth tongue.

52
Drug-Drug Interactions
  • Tricyclics MAOIs
  • TCAs block re-uptake of levonordefrin causing
    dramatic inc. of BP, cardiac dysrhythmias and
    delayed cardiac conduction. avoid
    levonordefrin
  • potentiate effects of CNS depressants incl.
    ethanol, opioids, benzodiazepines.
  • inhibit metabolism of warfarin inc. INR.

53
Drug-Drug Interactions
  • SSRIs
  • e.g. Prozac, Paxil, Wellbutrin reduce efficacy of
    codeine containing cmpds./erythromycin via action
    on P450 hepatic microsomal enzymes.
  • inhibit metabolism of warfarin inc. INR
  • potentiate depressant effects of sedatives,
    barbiturates.
  • Lithium
  • NSAIDs and COX-2 inhibitors impair renal
    excretion of lithium, thereby inducing lithium
    toxicity.

54
Side Effects of Long Term Use of Lithium
  • Neurologic lethargy, fatigue, weakness, fine
  • tremors, memory impairment
  • Renal renal failure
  • Thyroid lithium-induced hypothyroidism
  • CVS T-wave depression on ECG
  • GI nausea, vomiting, diarrhea, abdominal pain
  • Hematologic benign leukocytosis
  • ORAL xerostomia, lichenoid
  • stomatitis,
    metallic
  • taste sensation

55
Antidepressant/Mood Stabilizers Impact on Dental
Care
  • Mood stabilizers
  • Lithium
  • Oral side effects xerostomia, lichenoid
    stomatitis, metallic taste
  • Tricyclic antidepressants
  • Amitryptilline, clomipramine, imipramine
  • Oral side effects xerostomia, possible
    potentiation of pressor effects in epinephrine in
    local anesthetics use of levonordefrin
    contraindicated use of retraction cord with
    epinephrine contraindicated.

56
Antidepressant/Mood Stabilizers Impact on Dental
Care
  • Selective serotonin reuptake inhibitors(SSRIs)
  • citalopram, fluoxetine, paroxetine, sertraline,
    venlafaxine, buproprion
  • Oral side effects xerostomia, dysgeusia,
    stomatitis, glossitis, bruxism

57
Summary of Oral Findings
58
Summary of Oral Findings
  • increased presence of TMD signs (14 of patients
    with signs of TMD also have comorbid psych.
    symptoms c/w depression i.e. wt. loss, sleep
    disturbances, energy loss, changes in
    concentration)
  • increased dental attrition/incidence of bruxism
  • WHY?
  • CNS abnormalities of
  • a psychiatric patient?
  • neuroleptic-induced?
  • -more research needed
  • OOOOE-in press

59
EATING DISORDERS
  • Anorexia Nervosa
  • Bulimia Nervosa
  • living in fear of food of being fat
  • diagnosis has reached epidemic proportions

60
ANOREXIA NERVOSA
  • ceaseless pursuit of thinness
  • 1 of females aged 12 25 yrs.
  • mostly white/middle class background.
  • extreme distortion/perception of body image.

61
ETIOLOGY OF EATING DISORDERS
62
ANOREXIA NERVOSA Signs Symptoms
  • use of laxatives, diuretics
  • energetic, hyperactive
  • strenuous exercise regimen
  • fearful to gain weight (usually about 15 below
    normal wt.)
  • increased incidence in females with Type 1
    diabetes (deliberate avoidance of taking insulin
    to induce weight loss)

63
ANOREXIA NERVOSA Signs Symptoms
  • Progressing to.. amenorrhea, constipation,
    kidney dysfunction, UTI, impaired conc.
    rational thinking, muscle spasms, seizures,
    intolerance to cold, hypotension, bradycardia,
    alopecia, nail fragility, electrolyte imbalance,
    sudden death (ventricular tachyarrhythmias)

64
BULIMIA (ox-hunger) NERVOSA
  • binge eating and purging
  • 1-5 of females aged 12 25 yrs.( more common
    than A.N.)
  • 35 of patients with Anorexia Nervosa also suffer
    from Bulimia .
  • 35 of patients with Bulimia abuse
    alcohol/drugs.
  • 50 of patients with Bulimia suffer personality
    disorders.

65
BULIMIA NERVOSA Diagnostic Criteria
  • Binge eating twice weekly over a 3 month period
    of time followed by self-induced vomiting,
    laxatives, diuretics, enemas, excessive exercise
    regimens.
  • (may in fact be of a more normal weight)

66
BULIMIA NERVOSA Signs Symptoms
  • compulsive ingestion of excessively large amounts
    of food.
  • depressed upon the cessation of eating.
  • secrecy component.
  • Russells sign.

67
BULIMIA NERVOSA Complications
  • aspiration pneumonias.
  • esophageal/gastric rupture.
  • hypokalemia cardiac arrythmias.
  • pancreatitis.
  • Ipecac induced myopathy/cardiomyopathy.
  • EKG aberrations

68
MEDICAL COMPLICATIONS
  • Anorexia Nervosa arise as a result of starvation
    (restricting) and weight loss.
  • Bulimia Nervosa related to the mode and
    frequency of purging.

69
Patterns of Dental Erosion
  • Lingual surface erosive pattern
  • Bulimia (perimyolysis), chronic gastritis
    secondary to chronic alcoholism, GERD.
  • (/- affecting the occlusal surfaces of
    premolars/molars, further exacerbated by
    attrition.)

70
EATING DISORDERS Oral Complications
71
EATING DISORDERS Objectives for Preventive Dental
Treatment
  • Reduce frequency of acid exposure on teeth.
  • achieving a reduction in the no. of episodes of
    vomiting to complete cessation.
  • Enhance salivary flow.
  • sugar free mints, chewing gum to stimulate
    salivary flow
  • water for oral lubrication

72
EATING DISORDERS Objectives for Preventive Dental
Treatment
  • Neutralize acids in the mouth.
  • use of alkaline mouth rinse immediately after
    vomiting(NaHCO3), water, milk
  • Increase resistance of enamel to
    demineralization.
  • daily fluoride rinse 0.5
  • fluoride gels (1.1) in custom trays

73
EATING DISORDERS Objectives for Preventive Dental
Treatment
  • Minimize abrasive brushing techniques
  • soft brush, circular motion, floss
  • avoid brushing immediately after episodes of
    vomiting
  • Caries prevention
  • NaF varnishes
  • sealants?
  • snack substitutes
  • desensitizing agents

74
EATING DISORDERS Dental Tx. Planning (complex
restorative care)
  • Anorexia Nervosa
  • regain lost weight
  • stabilize physical health
  • Bulimia Nervosa
  • end cycle of binge eating/ vomiting
  • temporary coronal coverage followed by eventual
    RCT/ cast restorations as required (Relapse is
    common if vomiting recurs)
  • parental involvement

75
ANXIETY DISORDERS
  • Anxiety what is it?
  • emotional pain or a feeling that all is not
    well-a feeling of impending disaster
  • The physiological reaction/response occurs via
    ANS- can include inc. heart rate, sweating,
    dilated pupils, inc. urge of urination, diarrhea.

76
ANXIETY DISORDERS
  • may involve an internal psychological conflict,
    environmental stressors, physical disease, side
    effects of medications or combination of these
    findings.
  • the consequences of anxiety are profound
    emotional, occupational and social impairments.

77
ANXIETY DISORDERS Etiology
  • no single theory available
  • usually a combination of psychosocial/biological
    processes (neurobiological theories)
  • low level anxiety can be normal but anxiety
    often is a component of other psychological
    disorders such as mood disorders, dementias,
    panic disorder, psychoses etc.

78
ANXIETY DISORDERS
  • Mild form of anxiety towards dental care
  • Treatment Strategies
  • General attitude/anxiety reducing treatment style
  • providing trust
  • providing control
  • providing realistic information
  • apply high level of predictability
  • Pharmacological support
  • pre-medication
  • nitrous oxide sedation
  • Teaching of coping strategies
  • distraction
  • relaxation
  • hypnosis

79
ANXIETY DISORDERS
  • POST-TRAUMATIC STRESS DISORDER
  • Result of exposure to a traumatic event outside
    of usual realm of human experiences e.g. during
    combat, sexual/physical abuse, MVA, natural
    disasters etc.
  • Cardinal features
  • hyper arousal
  • intrusive symptoms
  • numbing of ones psyche
  • Diagnosis made if onset of s/s is at least 6
    mths. post
  • trauma or when s/s have been present gt 3 mths.

80
Post-Traumatic Stress Disorder
  • 4th most common psych. illness in U.S.
  • F gt M
  • Personal pre-disposition necessary for s/s to
    develop after traumatic event / genetic factors
    contributing to individual vulnerability
  • 80 have co-morbid psych. disorder.
  • rate of attempted suicide 20

81
Post-Traumatic Stress Disorder
  • Dental Findings
  • poor OH
  • rampant caries/perio disease
  • gt abfraction lesions
  • chronic atypical facial pain
  • s/e of SSRIs
  • Dental Management
  • preventive care
  • mgmt. of xerostomia
  • oral Ca.screening
  • caution re oral surg.in long-term alcoholism
  • caution re use of certain analgesics,antibiotics,
    sedatives

82
ANXIETY DISORDERS
  • PANIC DISORDER
  • experiencing of recurrent unexpected panic
    attacks not associated with any external event or
    situation.
  • c/o palpitations, chest pain, difficulty
    breathing, dizziness, sweating- adrenergic
    surge
  • becomes a problem when there is impairment of
    ones outlook on life day to day living.

83
Panic Disorder
  • 5 in females 2 in males.
  • 1 M Canadians 15 yrs or older.
  • lifelong illness with variable response to
    treatment.
  • resulting social/occupational impairments are a
    massive cost to society.

84
Panic Disorder
  • Diagnosis
  • r/o medical conditions e.g. MI,
    hyperthyroidism, xs. caffeine use, stimulant use,
    alcohol /drug withdrawal.
  • Subgroup of patients with panic disorder are
    found with a unique set of medical problems
    including UTD, hypothyroidism and MVP (mitral
    valve prolapse) 8-33 of patients with panic
    disorder have MVP vs.25 of gen. pop.

85
ANXIETY DISORDERS
  • OBSESSIVE-COMPULSIVE DISORDER(OCD)
  • Obsessive thoughts and compulsive actions causing
    distress and functional impairment.
  • Obsessions unwanted, persistent and recurrent
    ideas permeating ones consciousness causing
    significant anguish. May be trivial or more
    highly charged thoughts and actions.

86
Obsessive-Compulsive Disorder
  • Dental Findings
  • s/e of medication-induced xerostomia
  • somatic obsessions
  • gt abrasion lesions (overzealous oral hygiene
    practices
  • compulsions)
  • Dental Management
  • preventive oral care
  • MD consult re current status meds.

87
ANXIETY DISORDERS Dental Management summary
  • Pre-op - explain, honesty, answer questions,
    consistent communication.
  • oral sedation (benzodiazepines)
  • Operative - answer questions, reassurance.
  • L.A. oral/IM/IV sedation, N2O2
  • Post-op - explain what to expect, what to
    do/not do, possible complications( i.e. pain,
    bleeding, infections), who to contact.
  • analgesics, /- antibiotics

88
Somatoform Disorders
  • Psychological disorders characterized by the
    presence of physical symptoms that are not fully
    explained by a medical condition, the effects of
    a substance, or by another mental disorder.

  • DSM-1V TR, 2004

89
Psychosomatic vs. Somatoform
  • Psychosomatic disorders in which there is REAL
    physical illness that is largely caused by
    psychological factors such as stress and anxiety.
  • Somatoform disorders in which there is an
    APPARENT physical illness for which there is no
    organic basis.

90
Somatoform Disorders
  • Patients may experience multiple,
    unexplained somatic symptoms that may last for
    years.
  • Examples
  • hypochondriasis
  • Pre-occupation with fear of having a
    serious disease on the basis of ones
    misinterpretation of bodily symptoms/bodily
    functions.
  • conversion disorder
  • Patient resolves an underlying conflict
    (primary gain) by the unconscious use of the
    symptom(s). (e.g. conversion paralysis/blindness)
    Increased attention as a result secondary gain.

91
Somatoform Disorders
  • body dysmorphic disorder
  • pre-occupation with an imagined or
    exaggerated defect in physical appearance
  • One of the underlying causes of patient
    dissatisfaction with certain physical or dental
    features such as the appearance of teeth, facial
    asymmetry or disproportion of shape and size of
    lips, mouth or jaw.

92
Somatoform Disorders
  • Examples of Oral Symptoms
  • burning, painful tongue
  • numbness/tingling sensation of soft
    tissues
  • facial pain

93
Somatoform Disorders
  • PATH TO DIAGNOSIS
  • symptoms do not follow known anatomic nerve
    distribution.
  • lab tests/MD consult have r/o underlying systemic
    cause e.g. anemia, CA, diabetes.

94
Somatoform Disorders
  • Medical Perspective
  • psychiatric Tx. re somatoform disorders focuses
    on coping vs. cure.
  • anxiety/depression contribute to s/s in 33 of
    patients with SD. Treatment of these conditions
    will facilitate management of somatoform
    disorders.
  • psychotherapy, SSRIs.

95
CONCLUSION Dental Perspectives for patients
diagnosed with mental illness
  • Some patients who undergo psychiatric care for
    e.g. depression may be reluctant to admit this
    fact due to the stigma attached to the
    psychiatric diagnosis.
  • Dentistry must overcome such barriers
  • obtain all relevant information
  • supportive, non-judgmental attitude
  • ensuring confidentiality
  • emphasizing the need to be provided safe dental
    care.

96
  • David Clark
  • BSc. DDS, MSc. FAAOP, FRCDC (Oral Path)
  • Director, Dental Services
  • Whitby Mental Health Centre
  • 700 Gordon Street
  • Whitby, Ontario L1N 5S9
  • CANADA
  • (905)668-5881 ext 6168
  • clarkd_at_wmhc.ca
  • Clinical Associate in Dentistry (part-time)
  • Dept. of Oral Medicine
  • Faculty of Dentistry
  • University of Toronto
  • Toronto, Ontario, CANADA
  • da.clark_at_utoronto.ca
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