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

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”

“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

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

Dr. David Clark Ontario Shores CMHS

Dr. David Clark Ontario Shores CMHS

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

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

Dr. David Clark Ontario Shores CMHS

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

How is the diagnosis of
Schizophrenia made?

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.

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

What are the symptoms of
Schizophrenia?

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

SCHIZOPHRENIA
Symptoms
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 )

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

SCHIZOPHRENIA
Symptoms
Negative symptoms : the absences of behaviour that should 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).

Positive
SYMPTOM
- Hallucinations
Positive - Delusions
Negative - Disturbances of
Affect
MANIFESTATION
Auditory, command type, tactile (electrical, tingling, burning sensation) somatic
Persecutory type, reference type, thought broadcasting, thought insertion, thought withdrawal, being controlled by others
Absence of emotion, monotony of speech, cold and incongruous attitude, lack of expression
Negative - Impaired interpersonal relationships
Disorganized - Psychomotor
Disturbances
Disorganized - Thought
Disturbances
Social withdrawal, emotional detachment
Grimacing, repetitive and awkward movements, rigidity, mutism, pacing
Incoherent speech, rapid shift of ideas, poor relation of thoughts
Disorganized
Negative - Lack of self- care, motivation, initiative
Ritualistic, stereotypical behaviour
***Poor oral/general hygiene, dental caries, periodontal disease***

What about Schizophrenia and violence?

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

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

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)

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

Schizophrenia:
Historical Treatments

Dr. David Clark

Pharmacological Treatment
ANTIPSYCHOTICS

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: dystonia(~2%) tardive dyskinesia
(20%); acute
Dr. David Clark Ontario Shores CMHS

“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


“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

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

Dr. David Clark Ontario Shores CMHS

How does Schizophrenia relate to one’s general health?

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

FACT…
“…. the vast majority of people with mental illness die prematurely
because of the illnesses attacking their minds, but the ones destroying their
….
”
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, proinflammatory state, abdominal obesity.
Dr. David Clark Ontario Shores CMHS

Causes of Death
100
80
60
40
20
0
General
Population
Serious Mental
Illness
Dr. David Clark Ontario Shores CMHS
Other
CVD

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

Dr. David Clark Ontario Shores
CMHS

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 patients may 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

Factor
Patient Specific Factors in
Schizophrenia
Prevalence in schizophrenia
Prevalence in general pop.
Smoking 65% 21%
Obesity
Diabetes
HIV
Hepatitis C
Other: inactivity, poor nutrition, substance abuse
50%
14%
3%
20%
33%
7%
0.3%
1.8%

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

Medication side-effects
1. Motor side effects( extra-pyramidal sideeffects 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)

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

Medication side-effects
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!!!
Dr. David Clark Ontario Shores CMHS

How does Schizophrenia affect one’s oral health?

…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…

“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

…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.
Dr. David Clark Ontario Shores CMHS

Side-effects of antipsychotic medications – implications for
 dentistry??
Excessive sedation – lose interest in eating –weight loss common in elderly
 Drug-induced EPS – decrease ability to feed oneself; affect choice of foods …
 Oral dyskinesia – lessen ability to chew/swallow
 Esophageal dysmotility – choking behaviours
 Dry mouth – chewing/swallowing

Antipsychotic medications
 judicious use of epinephrine(L.A.) – orthostatic hypotension
 potentiation of other sedative, hypnotic, narcotic agents
 bone marrow suppression(clozapine)
 neuroleptic malignant syndrome
Dr. David Clark Ontario Shores CMHS

Schizophrenia: Oro-facial findings
Xerostomia
Saliva:
A Precious Body Fluid

DRY MOUTH/XEROSTOMIA
Can lead to:
• Choking, dysphagia
• Difficulty speaking
• Dental decay
• Bad breath
• Dysgeusia, burning sensation
• Swollen, red tongue; candidiasis
• Painful, bleeding gums
• Difficulty keeping dentures in

Schizophrenia: Oro-facial findings
(can in turn be a separate stigma producing influence against overall patient rehabilitation & recovery!!)
Dr. David Clark Ontario Shores CMHS

Dr. David Clark Ontario Shores CMHS

Schizophrenia:
Management with Clozapine
Clozapine-induced hypersalivation
 1/3 of cases, early in treatment, nighttime
 stigmatizing with inc. rates of noncompliance
Why?
 antagonist M3/agonist M4(muscarinic receptors) = hypersalivation
 impaired swallowing mechanism=pooling of saliva=hypersalivation

Schizophrenia: Oro-facial findings
Dr. David Clark Ontario Shores CMHS

Schizophrenia
Medication Side Effects
Tardive Dyskinesia : a side effect of longstanding use of antipsychotic medication - ~ 20% of patients; higher risk in elderly earlier on in tx.
Abnormal involuntary movement of the tongue, facial/neck muscles, extremities and trunk.

Schizophrenia
Medication Side Effects
Involuntary tongue movements = tongue thrusting/protrusions; lip smacking; puckering of lips; chewing movements; cheek puffing; repetitive movements of the extremities and trunk

Schizophrenia: Oro-facial findings
Dr. David Clark Ontario Shores CMHS

Delusional thinking…
 placement of transmitters into teeth
 oro-facial/self-mutilation –cheek biting, lip biting
 excoriation of gingiva
 burning of oral tissues e.g. cigarette
Dr. David Clark Ontario Shores CMHS

Schizophrenia
…other 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. pain sensitivity thresholds cause delays in diagnosis and Tx. resulting in serious clinical consequences.
Triple O Journal- Jan.2007

limiting factor for use:
AGRANULOCYTOSIS
<3000 wbc/c.c.
-1-2% risk
-patients require routine biweekly bloodwork
-we need to know!

METH MOUTH

What about
NITROUS OXIDE (N20)?

• Should be used in caution in people on psychotropic medications due to potential for initiating a hypotensive reaction and increased risk of hallucination in psychotic patients.
• Use of N20 in recovered alcoholics and drug abusers could increase the risk of relapse.
Dr. David Clark

So…. what can we do??
CLIENT EDUCATION and
REINFORCEMENT of DENTAL
SELF-CARE – build awareness wherever/whenever possible….
Dr. David Clark Ontario Shores CMHS

Treatment Planning
 Consult with GP/psychiatrist –ensure stability, control, capacity to consent.
 Be flexible and dynamic
 Positive attitude
 Aggressive on prevention- frequent use of auxiliary preventive agents
 Morning appointments(?)
Dr. David Clark Ontario Shores CMHS

Possible guidelines for communication with patients with CMI
Persons with MI:
So you need to… have trouble with
“reality”………… be simple, truthful are fearful………...
are insecure……...
have trouble concentrating.....
stay calm be accepting be brief, repeat

Possible guidelines for communication with patients with CMI
Persons with MI:
So you need to… easily agitated………… recognize agitation, allow escape poor judgment…… not expect rational discussion are over stimulated……… limit input, not force discussion

Possible guidelines for communication with patients with CMI
Persons with MI: are preoccupied………
So you need to… get attention first have changing plans… believe delusions…….
stick to one plan ignore, don’t argue have low self-esteem, lack motivation…….
stay positive!!!

Conclusion
Oral health can reflect a record of the peaks and valleys of a person’s life i.e. the times when people are healthy and the times when they stop caring for themselves e.g. psychosis, depression etc.
Dr. David Clark

Contact Information
Clinical Associate in Dentistry
(part-time)
Dept. of Oral Medicine
Faculty of Dentistry
University of Toronto
Dr. David Clark
BSc. DDS, MSc.(Oral Path)
FAAOP, FRCDC
Director, Dental Services
Ontario Shores Centre for Mental Health Sciences
700 Gordon Street
Whitby, Ontario, CANADA
L1N 5S9
(905)430-4033 ext 6168 clarkd@ontarioshores.ca
davidclark1461@gmail.com