DEFINITIONDIABETES MELLITUS An endocrine disorder in which there isinsufficient amount or lack of insulinsecretion to metabolize carbohydrates. It is characterized by hyperglycemia,firstname.lastname@example.org
Diabetes MellitusPathophysiology The beta cells of the Islets of Langerhanof the Pancreas gland are responsible forsecreting the hormone insulin for thecarbohydrate metabolism. Remember the concept - sugar into email@example.com
Diabetes MellitusTypes Type 1 - IDDM– little to no insulinproduced– 20-30% hereditary– Ketoacidosis Gestational– overweight; risk forType 2 Type 2 - NIDDM– some insulinproduced– 90% hereditary Other types include SecondaryDiabetes :– Genetic defect beta cellor insulin– Disease of exocrinepancreas– Drug or chemicalinduced– Infections-pancreatitis– Others-steroids,firstname.lastname@example.org
Risk for Injury Related toHyperglycemia Interventions include:– Dietary interventions, blood glucosemonitoring, medications– Oral Drugs Therapy(Continued)email@example.com
Risk for Injury Related toHyperglycemia (Continued)– Oral therapy Sulfonylurea agents Meglitinide analogues Biguanides Alpha-glucosidase inhibitors Thiazolinedione antidiabetic firstname.lastname@example.org
Oral HypoglcemiasKey Points Monitor serum glucose levels Teach patient signs and symptoms ofhyper/hypoglycemia Altered liver, renal function will affect medicationaction Avoid OTC meds without MD approval Assess for GI distress and sensitivity Know appropriate time to administer email@example.com
Whole-PancreasTransplantationOperative procedureRejection managementLong-term effectsComplicationsIslet cell transplantation hindered by limitedsupply of beta cells and problems causedby antirejection firstname.lastname@example.org
Chronic Pain Interventions include:– Maintenance of normal blood glucose levels– Anticonvulsants– Antidepressants– Capsaicin email@example.com
Diabetes MellitusSummary Treatable, but not curable. Preventable in obesity, adult client. Diagnostic Tests Signs and symptoms of hypoglycemia andhyperglycemia. Treatment of hypoglycemia and hyperglycemia –diet and oral hypoglycemics. Nursing implications – monitoring, teaching andassessing for firstname.lastname@example.org
Diabetes Oral Health Connection Oral Health Complications of Diabetes– Tooth loss– Oral pain– Extensive Periodontal Disease– Coronal and root caries– Soft tissue pathologies– Decrease in salivary email@example.com
Tooth Loss and Diabetes Usually associated with:– Periodontal disease– Smoking habits– Poor Controlikassem@dr.com
Oral Soft Tissue Pathologies with Diabetesikassem@dr.com
Glossitis The range of symptoms used to describe atongue suffering the pain of glossitis are:– pain– sore– tender– swelling– smooth appearance– chew, swallow, talk difficulties– Color ~ dark red, bright red, firstname.lastname@example.org
Orthodontic considerationsOrthodontic treatment should not beperformed in a patient with uncontrolleddiabetes. If the patient is not in goodmetabolic control (HbA1c 9%), everyeffort should be made to improve bloodglucose email@example.com
There is no treatment preference withregard to fixed or removable appliances. Itimportant to stress good oral hygiene,firstname.lastname@example.org
specific diabetic changes in theperiodontium are more pronounced afterorthodontic tooth email@example.com
A leading cause of SICKNESS andDEATHCoronary Heart Diseaseikassem@dr.com
Risk Factors for CardiovascularDisease Hypertension High cholesterol Obesity Cigarette smoking Physical inactivity Diabetes mellitus Kidney disease Older age (>55 ♂; > 65 ♀) Family history of premature cardiovasculardisease Obstructive sleep apnea Periodontal disease ?firstname.lastname@example.org
Coronary Heart Disease:Myocardial Ischemia Decreased bloodsupply (and thusoxygen) to themyocardium that canresult in acutecoronary syndromes:– Angina pectoris (Stable )– Unstable Angina– Myocardial infarction– Sudden death (due tofatal arrhythmias)email@example.com
Ischaemic heart diseaseDefinition An imbalance between the supply of oxygen andthe myocardial demand resulting in myocardialischaemia. Angina pectorissymptom not a diseasechest discomfort associated with abnormalmyocardial function in the absence of myocardialnecrosis Supply– Atheroma, thrombosis, spasm, embolus Demand– Anaemia, hypertension, high cardiac output(thyrotoxicosis, myocardial hypertrophy)firstname.lastname@example.org
Ischaemic heart diseaseEpidemiology Commonest cause of death in the Western world.(up to 35% of total mortality) Over 20% males under 60 years have IHD Health Survey :3% of adults suffer from angina1% have had a myocardial infarction in the past email@example.com
Ischaemic heart diseaseAetiology Fixed– Age, Male, +ve family history Modifiable – strong association– Dyslipidaemia, smoking, diabetes mellitus, obesity,hypertension Modifiable - weak association– Lack of exercise, high alcohol consumption, type Apersonality, OCP, soft waterAtherosclerosisikassem@dr.com
Risk Factors for Ischemic HeartDisease Family History Smoking Hypertension Diabetes Mellitus Hypercholesterolaemia Lack of exercise Obesity Age & SexPRIMARY PREVENTIONikassem@dr.com
Spectrum of the AtheroscleroticProcess Coronary Arteries (angina, MI, suddendeath) Cerebral Arteries (stroke) Peripheral Arteries (claudication)firstname.lastname@example.org
Ischaemic heart diseaseAcute coronary syndromesAtherosclerosisFatal /Non-Fatal AMI UnstableAnginaCoronaryArtery email@example.com
Warning Signs and Symptoms of Heartattack1) Pressure, fullness or a squeezing pain in the center ofyour chest that lasts for more than a few minutes.2) Pain extending beyond your chest to your shoulder,arm, back or even your teeth and jaw.3) Increasing episodes of chest pain4) Prolonged pain in the upper abdomen5) Shortness of breath- may occur with or without chestdiscomfort6) Sweating7) Impending sense of doom8) Lightheadedness9) Fainting10) Nausea and firstname.lastname@example.org
Angina Pectoris At least 70% occlusion of coronaryartery resulting in pain. What kindof pain?– Chest pain– Radiating pain to: Left shoulder Jaw Left or Right arm Usually brought on by physicalexertion as the heart is trying topump blood to the muscles, itrequires more blood that is notavailable due to the blockage of thecoronary artery(ies) Is self limiting usually stops whenexertion is email@example.com
Clinical Patterns of AnginaPectorisStable - pain pattern andcharacteristics relativelyunchanged over past severalmonths (better prognosis)Unstable - pain pattern changingin occurrence, frequency, intensity,or duration (poorer prognosis); MIikassem@dr.com
Ischaemic heart diseaseRelevance to Dentistry IHD is common Subjects with IHD have more severedental caries and periodontal disease –association or causation? Angina is a cause of pain in the mandible,teeth or other oral tissues Stress provokes ACSfirstname.lastname@example.org
Myocardial Infarction Partial or total occlusion of one or more ofthe coronary arteries due to an atheroma,thrombus or emboli resulting in cell death(infarction) of the heart muscle When an MI occurs, there is usuallyinvolvement of 3 or 4 occluded email@example.com
Chest PainMyocardial ischaemia SiteJaw to navel, retrosternal, left submammary RadiationLeft chest, left arm, jaw….mandible, teeth, palate Quality/severitytightness, heaviness, compression…clenched fists Precipitating/relieving factorsphysical exertion, cold windy weather, emotionrest, sublingual nitrates Autonomic symptomssweating, pallor, peripheral vasoconstriction,nausea and firstname.lastname@example.org
Acute Myocardial InfarctionAssessment 30% of deaths occur in the first 2 hours.(Cardiac muscle death occurs after 45 mins ofischaemia) Symptoms and signs of myocardialischaemia Also– Changes in heart rate /rhythm– Changes in blood email@example.com
Acute Myocardial InfarctionTreatment Stop dental treatment Call for help Rest, sit up and reassure patient Oxygen Analgesia (opiate, sublingual nitrate) Aspirin Thrombolysis Primary angioplasty Beta-Blockers ACE inhibitors Prepare for basic life firstname.lastname@example.org
Acute Myocardial InfarctionComplications Sudden Death (18% within 1 hour, 36% within24 hours) Non-fatal arrhythmia Acute left ventricular failure Cardiogenic shock Papillary muscle rupture and mitralregurgitation Myocardial rupture and tamponade Ventricular aneurysm and thrombus Distal Embolisationikassem@dr.com
Sudden Death Sudden Cardiac Death is also known as a“Massive Heart Attack” in which the heartconverts from sinus rhythm to ventricularfibrillation In V-Fib, the heart is unable to contract fullyresulting in lack of blood being pumped to thevital organs V-Fib requires shock from defibrillator“SHOCKABLE RHYTHM”email@example.com
Dental Considerations Assessment and Overall Management Pharmaceuticals Emergency Situations Oral Effects of Pharmaceuticals Antibiotic Prophylaxis Post MI: when to treat Consider three areas:– How severe or stable the ischemic heartdisease is– The emotional state of the patient– The type of dental firstname.lastname@example.org
RISK Major Risk for Perioperative Procedures:– Unstable Angina (getting worse)– Recent MI Intermediate Risk for Perioperative Procedures:– Stable Angina– History of MI Most dental procedures, even surgical proceduresfall within the risk of less than 1% Some procedures fall within an intermediate risk ofless than 5% Highest risk procedures those done undergeneral email@example.com
Management for Low-Intermediate Risk Short appointments AM appointments Comfort Vital Signs Taken Avoidance of Epinephrine within LocalAnesthetic or Retraction Cord O2 Availabilityikassem@dr.com
Dentistry & Cardiovascular Medicine AMI– GA within 3/12 of AMI: 30% re-infarction rate@ 1/52 post op– Avoid routine LA dental treatment for 3/12(emergency treatment only)– Avoid excess dosage, reduce anxiety– Avoid elective surgery under GA for1 year(specialist)– Be aware of medications (bleeding,hypotension)firstname.lastname@example.org
Post MI: When to Treat Why delay treatment?– Remember that with an MI there is damage to the heart, be itsevere or minimal that may effect the patient‟s daily life MI within 1 month Major Cardiac Risk MI within longer then 1 month:– Stable routine dental care ok– Unstable treat as Major Cardiac Risk Older studies suggest high re-infarction rates when surgeryperformed within 3 months, 3-6 months… however, this wasabdominal and thoracic surgery under general anesthesia New research suggests delaying elective tx for 1 month isadvisable. Emergent care should be done with local anestheticwithout epinephrine and monitoring of vital signs When in doubt:– CONSULT THE CARDIOLOGISTikassem@dr.com
Dental Management Correlate Elective dental care is ok if it has been longerthan 4-6 weeks since the MI and the patientdoes not report any ischemic symptoms. If there is any doubt or question, consultwith the email@example.com
Common Situations:– Orthostatic Hypotension due to use of anti-hypertensives (beta blockers, nitroglycerin…) Raise chair slowly Allow patient to take his/her time Assist patient in standing– Post-Op Bleeding: When patients on Plavix or Aspirin, expect increased bleedingbecause of decreased platelet aggregationDental Considerations for IHDikassem@dr.com
Dental Considerations for IHD Emergent Situations:– Possible MI: Remember that pain in the jaw may be referred painfrom the myocardium assess the situation, havegood patient history, follow ABC‟s– Angina: In situations of angina pectoris, all operatoriesshould have nitroglycerin to be placed firstname.lastname@example.org
Dental Considerations for IHD Emergent Situations:– Chest Pain-MI: STOP PROCEDURE Remove everything from patient‟s mouth Give sublingual nitroglycerin Wait 5 minutes if pain persists, give morenitroglycerin, assume MI 101 Give chewable aspirin ABC‟email@example.com
Dental Management:Stable Angina/Post-MI >4-6 weeks Minimize time in waiting room Short, morning appointments Preop, intra-op, and post-op vital signs Pre-medication as needed– anxiolytic (triazolam; oxazepam); night before and 1 hour before– Have nitroglycerin available – may consider using prophylacticaly Use pulse oximeter to assure good breathing andoxygenation Oxygen intraoperatively (if needed) Excellent local anesthesia - use epinephrine, if needed, inlimited amount (max 0.04mg) or levonordefrin (max.0.20mg) Avoid epinephrine in retraction firstname.lastname@example.org
Dental Management:Unstable Angina or MI < 3 months Avoid elective care For urgent care: be as conservative aspossible; do only what must be done (e.g.infection control, pain management) Consultation with physician to help manage Consider treating in outpatient hospitalfacility or refer to hospital dentistry ECG, pulse oximetry, IV line Use vasoconstrictors cautiously if email@example.com
Intraoperative Chest Pain Stop procedure Give nitroglycerin If after 5 minutes pain still present, give anothernitroglycerin If after 5 more minutes pain still present, giveanother nitroglycerin If pain persists, assume MI in progress and activatethe EMS– Give aspirin tablet to chew and swallow– Monitor vital signs, administer oxygen, andbe prepared to provide life firstname.lastname@example.org
Conclusion: When treating patients with Ischemic HeartDisease or recent MI…– Use caution and common sense– When in doubt:CONSULT THE CARDIOLOGISTikassem@dr.com
Obesity orthodontist will have between 1 in 6 and1 in 5 patients who are clinicallyoverweight or obese, depending on thestate or region in which he or email@example.com
Cephalometric and facial analyses shouldbe altered when examining obese oroverweight patients. These patients tendto have larger mandibles and shorterupper face heights that could changepotential firstname.lastname@example.org
Obese patients tend to have flatter ormore concave profiles because ofincreased mandibular length andincreased tissue email@example.com
Psychosocial problems are likely the rulewith obese patients. The clinician shouldmonitor for problems such as depressionand anxiety, because these conditionstend to be more likely in obese firstname.lastname@example.org
Psychology and Dentistry Special needs populations– Mentally challenged– Chronically ill– Geriatrics Public health– Community interventions
Psychology and Dentistry Quality of life– Craniofacial abnormalities– Edentualism Esthetic dentistry– Orthodontics– Crowns, veneers– Reconstruction
Psychology Skills Useful for DentalStudents Communication Fear/anxiety management Management of disruptive child Patient interventions to enhance self-care– Motivational interviewing Pain management
CHRONIC MENTAL ILLNESS“an equal opportunity illness affecting allages, all races, all economic groups andboth genders”Chronic mental illness and it‟s medicalmanagement carry inherent risks forsignificant oral disease.
How common isMental Illness? “disorder” ---- impairment is key concept of risk factors can considered aspotential important clues or as the “weaklinks” in the mental health chain.
STATISTICS - Suicide male: female – 3:1 300 teens(10-19 yrs) commit 530,000 kids have treatable MI but only150,000 get treatment. highest rates: 43/100,000 > 80 yrs.30/100,000 > 75 yrs.
“No one chooses to have a mentaldisorder…………”….admitting to mental illness is notthe same thing as admitting toany other serious health issuesince it can often result in moresuspicion than support……misconceptions flourish…
Mental Health Fact…..… people with a psychiatric illnessexperience a “double–burden” whichincludes both the s/s of the disease + thesocial stigma, isolation, discrimination thatresult from having that disease……stigma=social isolation, homelessness,unemployment, substance abuse,prolonged institutionalization…
Dental Perspectives….. Medications used to treat mental illnesscan interact with drugs used in dentistry. Some oral health problems arise asmanifestations of mental illness. Oral health problems as side effects ofpsychotropic medications. Decreased compliance to oral healthcare/ability to obtain or tolerate oral caretreatment.
Dental Perspectives…..Sample Mental HealthHistory What psychiatricmedications are youtaking? How long have youbeen taking themedication and does ithelp? What are/were yoursymptoms? When was your mentalillness diagnosed? Who is theGP/Psychiatrist treatingthis condition? Have you experiencedany dental side effects,such as dry mouth,burning tongue,excessive saliva orswollen gums?
DSM IV – Diagnostic & StatisticalManual of Mental Disorders a “descriptive”approach todiagnosis based onsymptoms ratherthan causes. Thedisorders listedinclude a “clinicalsignificance”criterion re:significant distressor impairment.there is no bloodtest, brain scanor specific x-rayto make adiagnosis as withother medicalproblems.
WHAT IS A PSYCHOSIS?Psychosis is a disordered pattern ofthought, perception, emotion andbehaviour. The psychotic person hasa bizarre sense of reality, withemotional and cognitive impairmentleading to loss of function in theenvironment.
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(>vulnerabilityto medical problems (lifestyle)
SCHIZOPHRENIAEtiologyCausation of schizophrenia remains notwell understood (syndrome?). Theoriesinclude: (genetics) altered expression of genes(10-15% with one parent; 30-40% - 2 parents differences in brain chemistry-(imbalancesin neurotransmitters, e.g. dopamine) differences in brain structure
SCHIZOPHRENIAEtiologySchizophrenia is NOT:• a multiple or “split” personality• caused by bad parenting/character flaws• the result of childhood trauma• an isolated condition: 1 in 100incidence?• an automatic precursor to criminalviolence
SCHIZOPHRENIASymptomatology1. Positive symptoms: does not mean“good” but rather s/s that are presentbut 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)
SCHIZOPHRENIASymptomatology2.Disorganized symptoms: a rapidshift of ideas, incoherent speech, poorthought relation. Disorganized, bizarrebehaviour e.g. stereotypical, imitationof others speech, gestures etc.
SCHIZOPHRENIASymptomatology3. Negative symptoms: the absencesof behaviour that should be there. i.e.flat emotions/emotional expression,lack of motivation, monotony of speechapathy, social withdrawal, absence ofnormal drives or interests such asthose involving one‟s self care(general/oral).
SCHIZOPHRENIAMedical Management“Conventional” Antipsychotics(Neuroleptics)chlorpromazine(Thorazine), methotrimeprazine(Nozinan), haloperidol(Haldol), early 1950s; blocking of dopamine D2 receptors in themesolimbic 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 basalganglia dopamine D2 receptors in extrapyramidal system (EPS)
Schizophrenia-Medication Side EffectsORAL DYSKINESIASAbnormal involuntary, uncontrollablemovements affecting primarily the tongue,lips, jaws (can extend to trunk/limbs)Causes: 1. drug induced( conventionalantipsychotics)**2. neuropsychiatric conditions3. edentulousness(**tardive dyskinesia)
SchizophreniaMedication Side EffectsTardive Dyskinesia (TD) late stage effect of slow, rhythmic involuntarygrimacing/twitching in facial area e.g. repeatedsmacking of lips, tongue movements, facialcontortions. >25% of patients on conventional antipsychoticshaving TD after 5 years of treatment.Ironically, the signs of TD reinforce the“crazy” stereotype, which in reality is onlya side effect of treatment.
SchizophreniaMedication Side EffectsSide effects of movement disorders are oftenmanaged by Rx. anticholinergic medicationse.g. Cogentin. These drugs in turn exhibittheir own spectra of side effects.Other side effects include EKG changes,orthostatic hypotension, dry mouth,constipation, blurred vision, nasal stuffiness.
SchizophreniaMedical Management“atypical antipsychotics”First appeared in late 1980s; e.g.clozapine(Clozaril), risperidone(Risperdal),olanzapine(Zyprexa), quetiapine(Seroquel). *rarely cause movement disorders* why? – thesedrugs possess a high ratio of serotonin to D2activity and are therefore referred to as serotonin-dopamine antagonists vs. conventionalantipsychotics or “dopamine antagonists.”
SchizophreniaMedical ManagementCLOZAPINE remains the drug of choice in treatmentresistant cases; reduce cravings for alcohol/illicitdrugs; reduced/delayed risk of suicide attempts. But 1% of patients develop agranulocytosisafter 12-24 wks. Patients required to haveweekly WBC counts i.e. > 3000/c.c. can cause initial sialorrhea; hypotension,sedation, tachycardia.
SchizophreniaMedical ManagementRisperidone, 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 thereforecompliance with these “atypical” medicationsensure less chances for relapse that was seen withconventional antipsychotic therapy.
SchizophreniaMedical ManagementBUT, atypical antipsychotics cancompound at patient‟s risk for diabetes,heart disease, obesity, hyperlipidemia(“metabolic syndrome”)Dental implications are relevant withrespect to clinical management of thediabetic, cardiac patient etc.
SchizophreniaOral Findings…people who suffer from schizophrenia areat a far greater risk of dental caries,gingivitis/advanced periodontal disease,tooth loss, lack of dentures, poor oralhygiene, mucosal diseases…+poor dietary habits, smoking, alcoholabuse, substance abuse…
SchizophreniaOral Findings higher prevalence of bruxism and signs of TMD= severe tooth damage due to extensiveattrition. ? CNS abnormalities and/or neuroleptic inducedmechanisms. actual pain sensitivity thresholds higher in pats.with schizophrenia vs. healthy controls. Whilemore prone to suffer TMD problems, painsensitivity thresholds cause delays in dx. and tx.resulting in serious clinical consequences.
SchizophreniaOral Findings can be…. precipitated by the psychosocialdeficiencies inherent in the disease itself. a result of a disinterest in regular oralcare; is due to financial hardships,prolonged periods of hospitalization andnon-existent support networks. also a result of an unwillingness on thepart of the DDS to understand and/or becomfortable in the dental management ofthese patients.
SCHIZOPHRENIADrug Interactions Epinephrine used with caution toprevent severe hypotensive episode –limit to 2 carpules 1:100,000; avoidepinephrine in retraction cords; injectslowly. Neuroleptics may intensify effects ofsedatives, hypnotics, opioids,antihistamines – leading to severerespiratory depression – consult with MD. Neuroleptics can dec. blood levels ofwarfarin.
COMPLICATIONS OF XEROSTOMIA acidic plaque pH…caries, hypersensitivity loss of lubrication…oral ulcerations,difficulties eating, speaking, wearingdentures dec. amount of saliva…inc. infections(viral, bacterial, fungal) digestionproblems, ease of trauma to oral mucosa,gingivitis & periodontitis
Depression is….. “an equal opportunityillness” –all ages,races, all economicclasses. an illness (as isdiabetes, heartdisease) leading cause ofsuicide (15%)*** F > M: 2:1 highest risk for thosewith family Hx. Ofdepression – geneticcomponent, furtheradvanced by emotionaldeprivation orchildhood trauma. elderly > 65. those with physicalillness/disabilities.
Depression is….. second leading cause of death anddisability in the world in age category of15-44 yrs. (M & F) – W.H.O. an illness affecting the entire body leading cause of alcohol/drug abuse (1/3of patients)Depression will be….. The second leading cause of healthimpairment worldwide by 2020.(WHO)
Major Depressive DisorderMental illness of at least 2 weeks durationencompassing at least 5 of the followingDSM-IV diagnostic symptom criteria: depressed mood diminishedinterest/pleasure dec./inc. in wt. orappetite insomnia/hypersomnia inability to thinkor concentrate fatigue/loss ofenergy thoughts ofdeath/suicide
Bipolar I Affective Disorder“ a roller coaster of mood” lowest of lows = s/s ofmajor depression highest of highs = manicepisode, preceded oftenby “hypomania” - one“feels good”, excitable,talkative, energized, ableto think/concentrate veryclearly- but notdangerous to self/others.
Bipolar I Affective Disorder(MANIC EPISODES) feelingindescribably good require little or nosleep easily explode intoanger flight of ideas,impairedjudgment lose touch withreality excessivelytalkative uninhibited; lack ofinsight into one‟sbehaviour e.g. of asexual nature
Depression(Postpartum Depression)Condition diagnosedwithin 1 yr. ofchildbirth. (not “babyblues”) often underdiagnosed/widelymisunderstood due tostigmatization
Monamine Oxidase Inhibitors(MAOI‟s)Phenelzine (Nardil)Tranylcypromine (Parnate)Moclobemide (Manerix) heralded era of antidepressants- 1950‟s prevent enzymatic breakdown ofnoradrenaline/serotonin in synaptic cleftwith inc. levels of both neurotransmitters. used in cases(10%) refractory to TCA‟s,SSRI‟s or “other” antidepressants.
MAOI‟s Disadv. – dietary + drug-druginteractions causing severehypertension.(tyramines in cheese,meats, red wine are not inactivated;MAOI + ephedrine); potentiation ofdepressant activity of the opioids. also dizziness, dry mouth, insomnia,wt. gain, orthostatic hypotension.
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 toS/E of dry mouth (50%).
Other Side Effects of AntidepressantDrugs (Tricyclics)Common: dry mouth, nausea/vomiting,constipation, urinary retention,insomnia, sexual dysfunction,postural hypotension.Serious: mania, seizures, leukopenia,cardiac arrhythmias, MI, stroke.
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 cleftresulting 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.
Electroconvulsive Therapy (ECT) for severe depression refractory tomedication. ? – a CNS seizure induced via electriccurrent (under GA) = inc. responsivenessof neuronal membranes toneurotransmitters. Dental: r/o loose/broken teeth re:possible aspiration; identify CD/RPD. Useof bite blocks to protect teeth & tongue.
Drug-Drug Interactions…Tricyclics & MAOI’sTCA‟s block re-uptake of levonordefrincausing dramatic inc. of BP, cardiacdysrhythmias and delayed cardiacconduction. **avoid levonordefrin**potentiate effects of CNS depressants incl.ethanol, opioids, benzodiazepines.inhibit metabolism of warfarin – inc. INR.
Drug-Drug Interactions…SSRI’s e.g. Prozac, Paxil, Wellbutrin reduce efficacy ofcodeine containing cmpds./erythromycin viaaction on P450 hepatic microsomal enzymes. inhibit metabolism of warfarin – inc. INR potentiate depressant effects of sedatives,barbiturates.Lithium NSAID‟s and COX-2 inhibitors impair renalexcretion of lithium, thereby inducing lithiumtoxicity.
Side Effects of Long Term Use ofLithium• Neurologic lethargy, fatigue, weakness, finetremors, memory impairment• Renal renal failure• Thyroid lithium-induced hypothyroidism• CVS T-wave depression on ECG• GI nausea, vomiting, diarrhea, abdominalpain• Hematologic benign leukocytosis ORAL xerostomia, lichenoidstomatitis, metallictaste sensation
Antidepressant/Mood StabilizersImpact on Dental Care Mood stabilizers:LithiumOral side effects: xerostomia, lichenoid stomatitis,metallic taste Tricyclic antidepressants:Amitryptilline, clomipramine, imipramineOral side effects: xerostomia, possible potentiationof pressor effects in epinephrine in localanesthetics; use of levonordefrincontraindicated; use of retraction cord withepinephrine contraindicated.
Antidepressant/Mood StabilizersImpact on Dental Care Selective serotonin reuptakeinhibitors(SSRIs):citalopram, fluoxetine, paroxetine,sertraline, venlafaxine, buproprionOral side effects: xerostomia, dysgeusia,stomatitis, glossitis, bruxism
Summary of Oral Findings increased presence of TMD signs (14% of patients withsigns of TMD also have comorbid psych. symptoms c/wdepression i.e. wt. loss, sleep disturbances, energy loss,changes in concentration) increased dental attrition/incidence of bruxismWHY? CNS abnormalities ofa psychiatric patient? neuroleptic-induced?-more research needed
EATING DISORDERSAnorexia NervosaBulimiaNervosa living in fear of food; of being fat diagnosis has reached epidemicproportions
ANOREXIA NERVOSA“ceaseless pursuit ofthinness” 1% of females aged12 – 25 yrs. mostly white/middleclass background. extremedistortion/perceptionof body image.
ETIOLOGY OF EATING DISORDERSgeneticpredispositionsocietalpressuresachieve control,approvaldepression,feelingsof guiltdistorted bodyimageextreme exerciseregimenissues re:self-esteem
ANOREXIA NERVOSASigns & Symptomsuse of laxatives, diureticsenergetic, hyperactivestrenuous exercise regimenfearful to gain weight (usuallyabout 15% below normal wt.)increased incidence in females withType 1 diabetes (deliberate avoidanceof taking insulin to induce weight loss)
BULIMIA (“ox-hunger”)NERVOSA“binge eating andpurging” 1-5% of females aged12 – 25 yrs.( morecommon than A.N.) 35% of patients withAnorexia Nervosa alsosuffer from Bulimia . 35% of patients withBulimia abusealcohol/drugs. 50% of patients withBulimia sufferpersonality disorders.
BULIMIA NERVOSADiagnostic CriteriaBinge eating twice weekly over a 3month period of time followed byself-induced vomiting, laxatives,diuretics, enemas, excessive exerciseregimens.(may in fact be of a more normal weight)
MEDICAL COMPLICATIONS Anorexia Nervosa: arise as a result ofstarvation (restricting) and weightloss. Bulimia Nervosa: related to the modeand frequency of purging.
Patterns of Dental ErosionLingual surface erosive pattern: Bulimia (perimyolysis), chronicgastritis secondary to chronicalcoholism, GERD.(+/- affecting the occlusalsurfaces of premolars/molars,further exacerbated by attrition.)
EATING DISORDERSOral ComplicationsFinding Anorexia Nervosa Bulimia NervosaLingual erosion no yesTooth sensitivity no yesXerostomia yes yesDental caries no yesPerio. disease no yesEnlarged parotid** yes yesMucosal atrophy yes noPoor oral hygiene no yes
EATING DISORDERSObjectives for Preventive Dental Treatment1. Reduce frequency of acid exposure onteeth. achieving a reduction in the no. ofepisodes of vomiting to completecessation.2. Enhance salivary flow. sugar free mints, chewing gum tostimulate salivary flow water for oral lubrication
EATING DISORDERSObjectives for Preventive Dental Treatment3. Neutralize acids in the mouth. use of alkaline mouth rinse immediatelyafter vomiting(NaHCO3), water, milk4. Increase resistance of enamel todemineralization. daily fluoride rinse 0.5% fluoride gels (1.1%) in custom trays
EATING DISORDERSDental Tx. Planning(complex restorative care)Anorexia Nervosa:– regain lost weight– stabilize physical healthBulimia Nervosa:– end cycle of binge eating/ vomiting– temporary coronal coverage followed by eventualRCT/ cast restorations as required (Relapse iscommon if vomiting recurs)– parental involvement*****
ANXIETY DISORDERSAnxiety – what is it?“emotional pain or a feeling that all isnot well-a feeling of impendingdisaster”The physiological reaction/responseoccurs via ANS- can include inc. heartrate, sweating, dilated pupils, inc. urgeof urination, diarrhea.
ANXIETY DISORDERS may involve an internal psychologicalconflict, environmental stressors,physical disease, side effects ofmedications or combination of thesefindings. the consequences of anxiety areprofound emotional, occupational andsocial impairments.
ANXIETY DISORDERSEtiology no single theory available usually a combination ofpsychosocial/biological processes(neurobiological theories) low level anxiety can be “normal” but…anxiety often is a component of otherpsychological disorders such as mooddisorders, dementias, panic disorder,psychoses etc.
ANXIETY DISORDERSMild form of anxiety towardsdental care –Treatment Strategies1. General attitude/anxietyreducing treatmentstyle providing trust providing control providing realisticinformation apply high level ofpredictability2. Pharmacological support pre-medication nitrous oxide sedation3. Teaching of copingstrategies distraction relaxation hypnosis
ANXIETY DISORDERSPOST-TRAUMATIC STRESS DISORDERResult of exposure to a traumatic event outside ofusual realm of human experiences e.g. duringcombat, sexual/physical abuse, MVA, naturaldisasters etc.Cardinal features: hyper arousal intrusive symptoms numbing of one‟s psycheDiagnosis made if onset of s/s is at least 6 mths. posttrauma or when s/s have been present > 3 mths.
Post-Traumatic Stress Disorder 4th most common psych. illness in U.S. F > M *** Personal pre-disposition necessary fors/s to develop after traumatic event /genetic factors contributing to individualvulnerability*** 80% have co-morbid psych. disorder. rate of attempted suicide = 20%
ANXIETY DISORDERSPANIC DISORDER experiencing of recurrent & unexpected panicattacks not associated with any external eventor situation. c/o – palpitations, chest pain, difficultybreathing, dizziness, sweating- “adrenergicsurge” becomes a problem when there is impairmentof one‟s outlook on life & day to day living.
Panic Disorder5% in females; 2% in males.~ 1 M Canadians 15 yrs or older.lifelong illness with variableresponse to treatment.resulting social/occupationalimpairments are a massive cost tosociety.
Panic DisorderDiagnosisr/o medical conditions e.g. MI, hyperthyroidism,xs. caffeine use, stimulant use, alcohol /drugwithdrawal.* Subgroup of patients with panic disorder arefound with a unique set of medical problemsincluding UTD, hypothyroidism and MVP(mitral valve prolapse) – 8-33% of patientswith panic disorder have MVP vs.~25% of gen.pop.
ANXIETY DISORDERSOBSESSIVE-COMPULSIVEDISORDER(OCD)Obsessive thoughts and compulsive actionscausing distress and functional impairment.Obsessions = unwanted, persistent andrecurrent ideas permeating one‟s consciousnesscausing significant anguish. May be trivial ormore highly charged thoughts and actions.
ANXIETY DISORDERSDental 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 todo/not do, possible complications( i.e. pain,bleeding, infections), who to contact.**analgesics, +/- antibiotics
Somatoform Disorders“Psychological disorderscharacterized by the presence ofphysical symptoms that are not fullyexplained by a medical condition, theeffects of a substance, or by anothermental disorder.”
Psychosomatic vs. Somatoform– Psychosomatic:disorders in whichthere is REAL physicalillness that is largelycaused bypsychological factorssuch as stress andanxiety.– Somatoform: disordersin which there is anAPPARENT physicalillness for which thereis no organic basis.
Somatoform DisordersPatients may experience multiple, unexplained somaticsymptoms that may last for years.Examples:hypochondriasisPre-occupation with fear of having a serious disease on the basisof one‟s misinterpretation of bodily symptoms/bodily functions.conversion disorderPatient resolves an underlying conflict (“primary gain”) by theunconscious use of the symptom(s). (e.g. conversionparalysis/blindness) Increased attention as a result = secondarygain.
Somatoform Disordersbody dysmorphic disorder“pre-occupation with an imagined or exaggerateddefect in physical appearance”One of the underlying causes of patientdissatisfaction with certain physical or dentalfeatures such as the appearance of teeth, facialasymmetry or disproportion of shape and size oflips, mouth or jaw.
Somatoform DisordersExamples of Oral Symptoms burning, painful tongue numbness/tinglingsensation of soft tissues facial pain
Somatoform DisordersPATH TO DIAGNOSISsymptoms do not follow knownanatomic nerve distribution.lab tests/MD consult have r/ounderlying systemic cause e.g.anemia, CA, diabetes.
Somatoform DisordersMedical Perspectivepsychiatric Tx. re: somatoform disordersfocuses on coping vs. cure.anxiety/depression contribute to s/s in33% of patients with SD. Treatment ofthese conditions will facilitatemanagement of somatoform disorders.psychotherapy, SSRI‟s.
CONCLUSIONDental Perspectives for patientsdiagnosed with mental illnessSome patients who undergo psychiatric care fore.g. depression may be reluctant to admit thisfact due to the stigma attached to thepsychiatric diagnosis.Dentistry must overcome such barriers: obtain all relevant information supportive, non-judgmental attitude ensuring confidentiality emphasizing the need to be provided safe dentalcare.
EatingSpeakingEsthetics(smiling and self esteem)
The taking of dentalradiographs duringpregnancy continues to bea controversial issue.It should be noted,however, that a pregnantpatient who is properlyshielded can safelyreceive dental x-rays atany time.
You lose a tooth forevery pregnancyBabies drain thecalcium from your teethEvery time you arepregnant your gumsbleed and you haveproblems with themFalse to all:Meticulous oral hygienewith fluoride regimenwill help to prevent alltooth and gum problemsexperienced duringpregnancy
Oral Disease and Systemic DisordersPeriodontitis has an associationwith:• Infective Endocarditis• Diabetes• Cardiovascular Disease• Pre-Term, Low Birth Weight Infants• Pulmonary Disease
Oral Disease and Systemic DisordersPeriodontitis and pregnancy
Oral Disease and Systemic DisordersPeriodontitis and pregnancy
Biologic Mechanisms for PTLBW InfantsEntry of inflammatory products (PgE2, Il-6, TNF- α), endotoxin, and/orperiodontal bacteria into the bloodstream and their translocationto the fetus and decidual tissues
American Academy of Periodontology Report 2004•Preventive oral care services should beprovided as early in pregnancy as possible.•If exam indicates a need for periodontaltherapy, these procedures should be scheduledearly in the 2nd trimester.•The presence of acute infection, abscess, orother potentially disseminating sources ofsepsis may warrant prompt intervention,irrespective of the stage of pregnancy.Dental Considerations
Recommendations Regular dental examinations for allpregnant patients Aggressive periodontal therapy forinfections Frequent reinforcement of oral hygieneand dental care by medical providers
Also know as pyogenic granuloma.Rare, usually painless lesion, develops on gums inresponse to plaqueNon-cancerous
•Subside shortly after childbirth•No treatment is required unless causes problemswith eating, speaking, or swallowing•If treatment is needed, it is surgically removed
Preterm Low Birth Weight BirthsSmoking, alcohol use, and drug use contribute to mothers having babies thatare born prematurely at a low birth weight.Evidence suggests a new risk factor – periodontal disease.Pregnant women who have periodontal disease may be seven times morelikely to have a baby that is born too early and too small.
If nausea and vomiting is a problem, it isimportant to frequently brush or rinse withwater. The acid could cause erosion of theteeth.If you are craving sweets, this could causean increase in cavities. So, just remember tosnack on raw veggies and fruits.
Dysphagia difficulty in swallowing sensation that the food „stops“ in the oesophagusCause disorder of oesophagus motility – neuro-muscular problems –multiple sclerosis, myasthenia gravis, Parkinson disease... obstruction tumor psychogenic – phagophobia painful swallowingCause disorder of motility obstruction infection reflux oesophatitisOdynophagia
Achalasia disorder of esophageal motility defect of ezophagus peristalsisCause defect of ezophagus wall innervationSigns and symptoms dificulty swallowing regurgitation chest pain burning sensation in esophagusCause GERDPyrosis
Definitions Gastroesophageal reflux (GER) – involuntary movement of gastric(sometimes also duodenal) content to the esophagus– normal physiological process – 1- 4x/h during 3 h after eating Gastroesophageal reflux disease (GERD) – chronic damage of theesophagus caused by a GERCauses abnormal relaxation of the lower esophageal sphincter (LES)– triggers – fat, chocolate, onion, alcohol, peppermint... hiatal hernia– protrusion of the upper part of the stomach into the thoraxthrough a tear or weakness in the diaphragm - change in the LESposition – change in the LES tonusProtective mechanisms tonic contraction of lower esophageal sphincter peristalsis neutralization of acidic content by salivaGastroesophageal Reflux Disease - GERD
EsophagusdiaphragmHIS-angleA - normal anatomyB – hiatal hernia pre-stageC - sliding hiatal herniaD - paraesophageal type
Definition a multifactorial inflammatory disease of theintestines (ileum, large intestine) that may affectany part of the GIT (from mouth to rectum),with a variety of GIT and extraGIT symptomsCause autoimmune process genetical predisposition (mutation of NOD2gene) + external factor (bacterias, milk protein) risk factors: smoking, contraceptivesCrohn´s disease
Icterus• yellowish pigmentation of the skin, sclera and the mucousmembranes caused by hyperbilirubinemia over 22 mmol/l - hyperbilirubinaemiaunconjugated bilirubinconjugated bilirubin over 35 mmol/l - icterus
haemoglobinREShaemglobin bilirubinbloodbilirubinliverconjugation of bilirubinbileintestineurobilinogen urobilin bilirubin productionhaemolytic icterus conjugation of bilirubinGilbert’s diseaseCrigler-Najjar syndromeLucey-Driscoll syndromeneonatal icterus excretion of bilirubin to bileDubin-Johnson syndromeRotor syndromehepatocellular icterusintra- a extrahepatic biliar obstructiongallstones, carcinomasDisorders of bilirubin metabolismunconjugatedbilirubinconjugatedbilirubin
Retention of unconjugated bilirubinGilbert’s syndrome(Familiar unconjugated nonhaemolytic hyperbilirubinaemia) mild disorder of uptake of bilirubin to hepatic cells and conjugation mild hyperbilirubinaemia good prognosisHemolytic icterus haemolysis - congenital - red cell enzymes or membranedefects, haemoglobin defects- acquired - toxins, incompatible blood transfusion