Schizophrenia: A Break with Reality – Implications for Dental Care

1. Schizophrenia: A Break with Reality – Implications for Dental Care 26th Annual Meeting on Special Care Dentistry Chicago, Illinois

2. What is Schizophrenia? “YOUTH’S GREATEST DISABLER” commonest form of psychosis affecting mood, thought and behaviour = delusions, hallucinations. one of the most serious of all mental illnesses. no “cure”

3. CHRONIC MENTAL ILLNESS “Mental illness doesn’t choose the most talented or the smartest or the richest or poorest. It shows no mercy and often arrives like an unexpected storm, dropping an endless downpour on young dreams” “The Soloist” Dr. David Clark Ontario Shores CMHS

4. Who gets Schizophrenia? ~1- 2% world pop. onset often late teens/early adulthood - gradual or sudden. M > F (young age); M=F(adulthood) Schizophrenia(2006) – $4.35B(Can) $62B(US) Dr. David Clark Ontario Shores CMHS

5. Dr. David Clark Ontario Shores CMHS

6. Dr. David Clark Ontario Shores CMHS

7. Prevalence: U.S. - ~ 7.2 per 1,000 pop. Incidence: U.S. - ~ 1 in 4,000 per year. Dr. David Clark Ontario Shores CMHS

8. What is the cause of Schizophrenia? • (genetics) altered expression of genes(10-15% with one parent; 30-40% - 2 parents • differences in brain chemistry-(imbalances in neurotransmitters, e.g. dopamine) • changes in brain structure (MRI,CT,PET) Dr. David Clark Ontario Shores CMHS

9. Dr. David Clark Ontario Shores CMHS

10. Schizophrenia is NOT: caused by bad parenting/character flaws a multiple or “split” personality the result of childhood trauma an isolated condition: 10 in 1000 AND 6 will attempt suicide. an automatic precursor to criminal violence Dr. David Clark Ontario Shores CMHS

11. How is the diagnosis of Schizophrenia made?

12. DSM V – Diagnostic & Statistical Manual of Mental Disorders • there is no blood test, brain scan or specific x-ray with which to make a diagnosis.

13. DSM V – Diagnostic & Statistical Manual of Mental Disorders • a “descriptive” approach to diagnosis based on symptoms rather than causes. • “clinical significance criterion

14. What are the symptoms of Schizophrenia?

15. SCHIZOPHRENIA A diagnosis is further subcategorized according to the dominant presenting symptom: positive (e.g. paranoia, “voices”) disorganized (e.g. catatonic) negative ( e.g. withdrawal). Dr. David Clark Ontario Shores CMHS

16. SCHIZOPHRENIASymptoms Positive symptoms: does not mean “good” but s/s that are present but shouldn’t be there. • exaggeration of thought • distortion of normal function, e.g. delusions (control of one’s thoughts, actions) hallucinations (sensory: auditory- [patient hearing “voices”] visual, tactile)

17. SCHIZOPHRENIASymptoms Disorganized symptoms: • rapid shift of ideas • incoherent speech • poor thought relation • disorganized, bizarre behaviour e.g. stereotypical, imitation of others speech, gestures etc.

18. SCHIZOPHRENIASymptoms Negative symptoms: the absences of behaviour thatshould be there. • flat affect • lack of motivation • monotony of speech • apathy • social withdrawal • ***absence of normal drives or interests such as those involving one’s self care (general/oral).

20. What about Schizophrenia and violence?

21. Dr. David Clark Ontario Shores CMHS People who DO NOT have a mental disorder commit more than 95% of violent crime in the community….. But the “axe-wielding psycho” is just one of numerous commonly held myths about mental health.

22. FACT….. Dr. David Clark Ontario Shores CMHS …if we cured schizophrenia, depression and bipolar disorder overnight, >95% of violent crime towards others would still occur in our society…

23. FACT….. ….the reality is that patients will harm themselves more than others…. ….and they are the victims of crime more than the perpetrators of crime….(2.5% > general population)

24. Violence in metal illness… Dr. David Clark Ontario Shores CMHS …associating mental illness with violence helps perpetuate prejudice and discrimination – dangerousness and unpredictability are stereotypes underlying social intolerance….

25. Schizophrenia:Historical Treatments

26. Dr. David Clark

27. Pharmacological Treatment ANTIPSYCHOTICS

28. SCHIZOPHRENIA “Conventional” Antipsychotics chlorpromazine(Thorazine), methotrimeprazine (Nozinan), haloperidol(Haldol), Mid-1950s; blocking of dopamine D2 receptors in the basal ganglia/mesolimbic system of the brain affecting mood & thought processes; e.g. wrere effective in managing “positive” symptoms only…. BUT…. Major side effect:tardive dyskinesia (20%); acute dystonia(~2%) Dr. David Clark Ontario Shores CMHS

29. Schizophrenia “atypical antipsychotics” First appeared in late 1980’s Clozapine (Clozaril)***** Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone** (Zeldox,Geodon) Dr. David Clark Ontario Shores CMHS

30. Schizophrenia “atypical antipsychotics” *rarely cause movement disorders* why? – these drugs possess a high ratio serotonin:D2 activity …therefore referred to as “serotonin-dopamine antagonists” vs. conventional antipsychotics or “dopamine antagonists.” provide better management of both “positive”, “negative” & “disorganized” symptoms. Dr. David Clark Ontario Shores CMHS

31. Atypical antipsychotics Often used in the elderly for control of agitation especially in the nursing home setting. Oral dyskinesia not as prevalent with these drugs.

32. Dr. David Clark Ontario Shores CMHS

33. How does Schizophrenia relate to one’s general health?

34. FACT… “adults with serious mental illness treated in the public health systems die about 25 years earlier than Americans overall, a gap that’s widened since the early ’90s when major mental disorders cut life spans by 10 to 15 years” USA Today - May 3, 2007 Globe & Mail – October 18, 2007 Dr. David Clark Ontario Shores CMHS

35. FACT… “…. the vast majority of people with mental illness die prematurely notbecause of the illnesses attacking their minds, but the ones destroying their hearts….” Dr. David Clark Ontario Shores CMHS

36. What is Metabolic Syndrome? Dr. David Clark Ontario Shores CMHS • Dysregulation of glucose & lipids predisposing to hyperlipidemia, cardiovascular disease and diabetes. • Cardiometabolic risk factors: insulin resistance, HTN, prothrombotic state, pro-inflammatory state, abdominal obesity.

37. Dr. David Clark Ontario Shores CMHS

38. Co-morbidities resulting from… Dr. David Clark Ontario Shores CMHS Preventable/modifiable behaviours Disease-specific symptoms/behaviours (e.g. depression) Social deprivation Homelessness Poor access Biased attitudes of HCP’s and………….

39. Issues around non-compliance Dr. David Clark Ontario Shores CMHS

40. Schizophrenia “an illness of impairments in the brain” = psychotic & cognitive symptoms (e.g. memory difficulties). Cognitive impairments ( parietal lobe) may underlie the reason why 60-80% of patientsmay not believe or recognize that they have the illness. Therefore… will not seek treatment….will not take prescribed meds… Dr. David Clark Ontario Shores CMHS

41. Patient Specific Factors in Schizophrenia

42. Obesity associated with caries, hyposalivation, periodontal disease = tooth loss….. Dental implicationsare also very relevant with respect to overall clinical management of the diabetic, cardiac patient etc.

43. Medication side-effects 1. Motor side effects( extra-pyramidal side- effects EPS) • Parkinsonism – slow, stiffness of limbs, neck; rigid = falls risk!! (acute) • Dystonia – spasm of axial muscles e.g. neck(acute) • Akathisia – restlessness espec in legs(acute) • Tardive dyskinesia – abnormal involuntary movement (chronic)

44. Medication side-effects Dr. David Clark Ontario Shores CMHS 2. Psychiatric side-effects: • Sedation –falls risk!!! • Apathy • Confusion

45. Medication side-effects Dr. David Clark Ontario Shores CMHS 3. Medical complications: • Glucose/lipid intolerance – 2-4x higher risk for diabetes. • Cardiac conduction problems(arrhythmias) • Bone marrow alterations • Increase INR (quetiapine) • Orthostatic hypotension- falls risk!!!

46. DENTAL PERSPECTIVES

47. How does Schizophrenia affect one’s oral health?

48. …strong connection exists between the health of one’s teeth and a person’s mental health. Dental health has everything to do with caring for yourself…

49. “Ryan” Case History: 20 y.o. male with schizophrenia Hx. of self-neglect; social isolation x 4 yrs Hx. of substance abuse starting age 15 drank ~12 cokes/day+ 1 ppd. smoker Tx: full mouth ext’n complete U/L dentures inserted 08-03-03 Dr. David Clark Ontario Shores CMHS

50. Dental Perspectives….. Dr. David Clark Ontario Shores CMHS …demonstrate a positive, empathetic, caring and understanding attitude to what may be the more unique needs and differing priorities of our patients dealing with issues of mental illness.