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 it’s medical management carry inherent risks for significant oral disease.

3. How common isMental 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 “weaklinks” in the mental health chain.

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

5. STATISTICS - Suicide • rate in Canada: 12-15/100,000 • male: female – 3:1 • 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 > 80 yrs. 30/100,000 > 75 yrs.

6. STATISTICS • 20% prison pop. suffer mental illness(>50% if addiction problems included). • >1/3 homeless people have mental illness(75%F). • 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 “double–burden” which includes both the s/s of the disease + the social stigma, isolation, discrimination that result from having that disease… …stigma=social 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. 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? 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? Dental Perspectives…..

11. 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. DSM IV – Diagnostic & Statistical Manual of Mental Disorders

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) > F • 10%= chronic hospitalization; 30-40% long-term serious handicap. • 40% risk of suicide attempts • 60% alcohol abuse/15-25%street drugs • 20% shorter life expectancy(>vulnerability to medical problems (lifestyle)

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

18. SCHIZOPHRENIASymptomatology • 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. SCHIZOPHRENIASymptomatology 3. Negative symptoms: the absences of behaviour thatshould 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 one’s self care (general/oral).

20. SCHIZOPHRENIAMedical 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 disorders*[oral 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. SchizophreniaMedication 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. • >25% 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. ORAL DYSKINESIAS (drug-induced) conventional antipsychotics atypical antipsychotics antiemetics antiparkinsonion TCA’s SSRI’s lithium anticonvulsants antihistamines methamphetamines Schizophrenia-Medication Side Effects

24. ORAL DYSKINESIAS-Complications tooth wear oral pain/injury TMJ degeneration speech impairment chewing difficulties inadequate food intake…wt. loss displacement/poor retention of RPD’s…decreased tolerance social sequelae Schizophrenia-Medication Side Effects

25. SchizophreniaMedication 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. SchizophreniaMedical 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. SchizophreniaMedical Management CLOZAPINE • remains the drug of choice in treatment resistant cases; reduce cravings for alcohol/illicit drugs; reduced/delayed risk of suicide attempts. • But1% of patients develop agranulocytosis after 12-24 wks. Patients required to have weekly WBC counts i.e. > 3000/c.c. • can cause initial sialorrhea; hypotension, sedation, tachycardia.

28. SchizophreniaMedical 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. SchizophreniaMedical Management BUT, atypical antipsychotics can compound at patient’s 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. SchizophreniaOral 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. SchizophreniaOral 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. SchizophreniaOral 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. SCHIZOPHRENIADental Considerations

35. SCHIZOPHRENIADrug Interactions • Epinephrine used with caution to prevent severe hypotensive episode – limit to 2 carpules 1:100,000; 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 pH…caries, hypersensitivity • loss of lubrication…oral ulcerations, difficulties eating, speaking, wearing dentures • dec. amount of saliva…inc. infections (viral, bacterial, fungal) digestion problems, ease of trauma to oral mucosa, gingivitis & periodontitis

37. sipping water frequently restrict caffeine, colas sugar free gum, candies. saliva substitutes, oral moisturizers e.g. MouthKote, Biotene products (contain key enzymes[3] 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 DENTAL MANAGEMENTDry Mouth Protocol

38. “an equal opportunity illness” –all ages, races, all economic classes. an illness (as is diabetes, heart disease) leading cause of suicide (15%)*** F > M: 2:1 highest risk for those with family Hx. Of depression – genetic component, further advanced by emotional deprivation or childhood trauma. elderly > 65. those with physical illness/disabilities. Depression is…..

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. 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 Major Depressive Disorder • 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. 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 one’s behaviour e.g. of a sexual nature Bipolar I Affective Disorder(MANIC EPISODES)

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? - > 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(MAOI’s)Phenelzine (Nardil)Tranylcypromine (Parnate)Moclobemide (Manerix) • heralded era of antidepressants- 1950’s • prevent enzymatic breakdown of noradrenaline/serotonin in synaptic cleft with inc. levels of both neurotransmitters. • used in cases(10%) refractory to TCA’s, SSRI’s or “other” antidepressants.

46. MAOI’s • 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 Antidepressantsamitriptyline (Elavil)clomipramine (Anafranil)imipramine (Tofranil)desipramine (Norpramin) • initially most popular first line Rx.- 1960’s • 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 InhibitorsSSRIsfluvoxamine (Luvox)fluoxetine (Prozac)paroxetine (Paxil)sertraline (Zoloft)citalopram (Celexa) • inc. use as first line Rx.- 1990’s. (second generation) • prevent re-uptake of serotonin from synaptic cleft resulting in inc. levels of enhanced neuronal activity. • Adv. – less sedation & cardiotoxicity, < dry mouth(18%) • Disadv. – GI upset, insomnia, sexual dysfunction, poss. Inc. in bleeding time.

50. “other” antidepressantsbuproprion (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.