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Islam Kassem, BDS , MSc, MOMS RCPS Glasg,FFD RCSIConsultant Oral & Maxillofacial SurgeonMedical Topics inOrthodonticsikass...
Diabetesikassem@dr.com
DEFINITIONDIABETES MELLITUS An endocrine disorder in which there isinsufficient amount or lack of insulinsecretion to met...
ikassem@dr.com
ikassem@dr.com
Diabetes MellitusPathophysiology The beta cells of the Islets of Langerhanof the Pancreas gland are responsible forsecret...
Diabetes MellitusTypes Type 1 - IDDM– little to no insulinproduced– 20-30% hereditary– Ketoacidosis Gestational– overwei...
Assessment History Blood tests– Fasting blood glucose test: two tests > 126mg/dL– Oral glucose tolerance test: blood glu...
Urine Tests Urine testing for ketones Urine testing for renal function Urine testing for glucoseikassem@dr.com
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ikassem@dr.com
ikassem@dr.com
Risk for Injury Related toHyperglycemia Interventions include:– Dietary interventions, blood glucosemonitoring, medicatio...
Risk for Injury Related toHyperglycemia (Continued)– Oral therapy Sulfonylurea agents Meglitinide analogues Biguanides...
Oral HypoglcemiasKey Points Monitor serum glucose levels Teach patient signs and symptoms ofhyper/hypoglycemia Altered ...
ikassem@dr.com
ikassem@dr.com
Insulin Regimens Single daily injection protocol Two-dose protocol Three-dose protocol Four-dose protocol Combination...
ikassem@dr.com
ikassem@dr.com
Diabetic Education -Preventive Medicine Proper skin and footcare Proper Eye Exam Proper diet andfluids Diabetic Neurop...
Diabetes MellitusComplications Hyperglycemia Hypoglycemia Diabetic Ketoacidosis Hyperosmolar Hyperglycemic NonketoticS...
ikassem@dr.com
Chronic Complications ofDiabetes Cardiovascular disease Cerebrovascular disease Retinopathy (vision) problems Diabetic...
Whole-PancreasTransplantationOperative procedureRejection managementLong-term effectsComplicationsIslet cell transplantati...
Chronic Pain Interventions include:– Maintenance of normal blood glucose levels– Anticonvulsants– Antidepressants– Capsai...
Diabetes MellitusSummary Treatable, but not curable. Preventable in obesity, adult client. Diagnostic Tests Signs and ...
Diabetes Oral Health Connection Oral Health Complications of Diabetes– Tooth loss– Oral pain– Extensive Periodontal Disea...
Diabetes impact on oral healthikassem@dr.com
Periodontal Diseaseikassem@dr.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– swelli...
Oral health impact on diabetesikassem@dr.com
Oral Examination Caries identification– Surface caries easily identifiable– Incipient decay harder to identify but moreim...
Caries/Cavitiesikassem@dr.com
Caries/Cavitiesikassem@dr.com
Periodontal Diseaseikassem@dr.com
Periodontal Pocketsikassem@dr.com
Orthodontic considerationsOrthodontic treatment should not beperformed in a patient with uncontrolleddiabetes. If the pati...
There is no treatment preference withregard to fixed or removable appliances. Itimportant to stress good oral hygiene,ikas...
specific diabetic changes in theperiodontium are more pronounced afterorthodontic tooth movement.ikassem@dr.com
Cardiovascular diseaseikassem@dr.com
A leading cause of SICKNESS andDEATHCoronary Heart Diseaseikassem@dr.com
Risk Factors for CardiovascularDisease Hypertension High cholesterol Obesity Cigarette smoking Physical inactivity D...
Coronary Heart Disease:Myocardial Ischemia Decreased bloodsupply (and thusoxygen) to themyocardium that canresult in acut...
Ischaemic heart diseaseDefinition An imbalance between the supply of oxygen andthe myocardial demand resulting in myocard...
Ischaemic heart diseaseManifestations Sudden death Acute coronary syndrome ( Myocardial Infarction &Unstable Angina ) S...
Ischaemic heart diseaseEpidemiology Commonest cause of death in the Western world.(up to 35% of total mortality) Over 20...
Ischaemic heart diseaseAetiology Fixed– Age, Male, +ve family history Modifiable – strong association– Dyslipidaemia, sm...
Risk Factors for Ischemic HeartDisease Family History Smoking Hypertension Diabetes Mellitus Hypercholesterolaemia L...
Non-Modifiable Risk Factor:SEXikassem@dr.com
Non-Modifiable Risk Factor:AGEikassem@dr.com
Non-Modifiable RiskFactor: FAMILYHISTORYikassem@dr.com
Modifiable Risk Factor:DIABETESikassem@dr.com
Modifiable Risk Factor:SMOKINGikassem@dr.com
Modifiable Risk Factor:OBESITYikassem@dr.com
Modifiable Risk Factor:DYSLIPIDEMIAikassem@dr.com
Spectrum of the AtheroscleroticProcess Coronary Arteries (angina, MI, suddendeath) Cerebral Arteries (stroke) Periphera...
Ischaemic heart diseaseAcute coronary syndromesAtherosclerosisFatal /Non-Fatal AMI UnstableAnginaCoronaryArtery spasmikass...
Warning Signs and Symptoms of Heartattack1) Pressure, fullness or a squeezing pain in the center ofyour chest that lasts f...
Angina Pectoris At least 70% occlusion of coronaryartery resulting in pain. What kindof pain?– Chest pain– Radiating pain...
Clinical Patterns of AnginaPectorisStable - pain pattern andcharacteristics relativelyunchanged over past severalmonths (...
TREATMENTMEDICATIONS1) Nitrates- vasodilator eg: ISDN. ISMN2) Pain reliever- eg: Morphine3) Beta-blockers4) Statins- chole...
Ischaemic heart diseaseRelevance to Dentistry IHD is common Subjects with IHD have more severedental caries and periodon...
Myocardial Infarction Partial or total occlusion of one or more ofthe coronary arteries due to an atheroma,thrombus or em...
Chest PainMyocardial ischaemia SiteJaw to navel, retrosternal, left submammary RadiationLeft chest, left arm, jaw….mandi...
Chest PainDifferential diagnosis Cardiac pathology– Pericarditis, aortic dissection Pulmonary pathology– Pulmonary embol...
Acute Myocardial InfarctionAssessment 30% of deaths occur in the first 2 hours.(Cardiac muscle death occurs after 45 mins...
Acute Myocardial InfarctionTreatment Stop dental treatment Call for help Rest, sit up and reassure patient Oxygen Ana...
Surgical Treatment PercutaneousTransluminalCoronaryAngioplasty (PTCA)– balloon expansionthat can provide90% dilitation of...
Stent Placement With use of justthe balloon, re-occlusion of theartery can occurwithin months Placement of astent delays...
Surgical Treatment Coronary ArteryBy-Pass Graft(CABG) The graft bypassesthe obstruction inthe coronary artery Graft sou...
Acute Myocardial InfarctionComplications Sudden Death (18% within 1 hour, 36% within24 hours) Non-fatal arrhythmia Acut...
Sudden Death Sudden Cardiac Death is also known as a“Massive Heart Attack” in which the heartconverts from sinus rhythm t...
Dental Considerations Assessment and Overall Management Pharmaceuticals Emergency Situations Oral Effects of Pharmaceu...
RISK Major Risk for Perioperative Procedures:– Unstable Angina (getting worse)– Recent MI Intermediate Risk for Perioper...
Management for Low-Intermediate Risk Short appointments AM appointments Comfort Vital Signs Taken Avoidance of Epinep...
Dentistry & Cardiovascular Medicine AMI– GA within 3/12 of AMI: 30% re-infarction rate@ 1/52 post op– Avoid routine LA de...
Post MI: When to Treat Why delay treatment?– Remember that with an MI there is damage to the heart, be itsevere or minima...
Dental Management Correlate Elective dental care is ok if it has been longerthan 4-6 weeks since the MI and the patientdo...
 Common Situations:– Orthostatic Hypotension due to use of anti-hypertensives (beta blockers, nitroglycerin…) Raise chai...
Dental Considerations for IHD Emergent Situations:– Possible MI: Remember that pain in the jaw may be referred painfrom ...
Dental Considerations for IHD Emergent Situations:– Chest Pain-MI: STOP PROCEDURE Remove everything from patient‟s mout...
Dental Management:Stable Angina/Post-MI >4-6 weeks Minimize time in waiting room Short, morning appointments Preop, int...
Dental Management:Unstable Angina or MI < 3 months Avoid elective care For urgent care: be as conservative aspossible; d...
Intraoperative Chest Pain Stop procedure Give nitroglycerin If after 5 minutes pain still present, give anothernitrogly...
Conclusion: When treating patients with Ischemic HeartDisease or recent MI…– Use caution and common sense– When in doubt:...
Obesity orthodontist will have between 1 in 6 and1 in 5 patients who are clinicallyoverweight or obese, depending on thes...
 Cephalometric and facial analyses shouldbe altered when examining obese oroverweight patients. These patients tendto hav...
 Obese patients tend to have flatter ormore concave profiles because ofincreased mandibular length andincreased tissue th...
 Psychosocial problems are likely the rulewith obese patients. The clinician shouldmonitor for problems such as depressi...
ikassem@dr.com
Psychology in Dentistry
Dentistry and Health Consistent brushing and flossing androutine dental hygiene critical tomaintenance of oral health– Ps...
Psychology and Dentistry Communications skills and rapport building Dental fears
Psychology and Dentistry Pain– Acute– Chronic Temporomandibular disorders Neuralgias Oral parafunctional behaviors– Cl...
Psychology and Dentistry Special needs populations– Mentally challenged– Chronically ill– Geriatrics Public health– Comm...
Psychology and Dentistry Quality of life– Craniofacial abnormalities– Edentualism Esthetic dentistry– Orthodontics– Crow...
Psychology Skills Useful for DentalStudents Communication Fear/anxiety management Management of disruptive child Patie...
CHRONIC MENTAL ILLNESS“an equal opportunity illness affecting allages, all races, all economic groups andboth genders”Chro...
How common isMental Illness? “disorder” ---- impairment is key concept of risk factors can considered aspotential import...
STATISTICS - Suicide male: female – 3:1 300 teens(10-19 yrs) commit 530,000 kids have treatable MI but only150,000 get ...
“No one chooses to have a mentaldisorder…………”….admitting to mental illness is notthe same thing as admitting toany other s...
Mental Health Fact…..… people with a psychiatric illnessexperience a “double–burden” whichincludes both the s/s of the dis...
Dental Perspectives….. Medications used to treat mental illnesscan interact with drugs used in dentistry. Some oral heal...
Dental Perspectives…..Sample Mental HealthHistory What psychiatricmedications are youtaking? How long have youbeen takin...
DSM IV – Diagnostic & StatisticalManual of Mental Disorders a “descriptive”approach todiagnosis based onsymptoms ratherth...
Axis I – Clinical Disorders Dementia**, delirium, amnesia, othercognitive disorders** Schizophrenia**/other psychoses M...
WHAT IS A PSYCHOSIS?Psychosis is a disordered pattern ofthought, perception, emotion andbehaviour. The psychotic person ha...
SCHIZOPHRENIA ~1- 2% worldwide. late teens/early adulthood;gradual/sudden. M (earlier) > F 10%= chronic hospitalizatio...
SCHIZOPHRENIAEtiologyCausation of schizophrenia remains notwell understood (syndrome?). Theoriesinclude: (genetics) alter...
SCHIZOPHRENIAEtiologySchizophrenia is NOT:• a multiple or “split” personality• caused by bad parenting/character flaws• th...
SCHIZOPHRENIASymptomatology1. Positive symptoms: does not mean“good” but rather s/s that are presentbut shouldn‟t be there...
SCHIZOPHRENIASymptomatology2.Disorganized symptoms: a rapidshift of ideas, incoherent speech, poorthought relation. Disorg...
SCHIZOPHRENIASymptomatology3. Negative symptoms: the absencesof behaviour that should be there. i.e.flat emotions/emotiona...
SCHIZOPHRENIAMedical Management“Conventional” Antipsychotics(Neuroleptics)chlorpromazine(Thorazine), methotrimeprazine(Noz...
Schizophrenia-Medication Side EffectsORAL DYSKINESIASAbnormal involuntary, uncontrollablemovements affecting primarily the...
SchizophreniaMedication Side EffectsTardive Dyskinesia (TD) late stage effect of slow, rhythmic involuntarygrimacing/twit...
Schizophrenia-Medication Side EffectsORAL DYSKINESIAS(drug-induced) conventionalantipsychotics atypical antipsychotics ...
Schizophrenia-Medication Side EffectsORAL DYSKINESIAS-Complications tooth wear oral pain/injury TMJ degeneration speec...
SchizophreniaMedication Side EffectsSide effects of movement disorders are oftenmanaged by Rx. anticholinergic medications...
SchizophreniaMedical Management“atypical antipsychotics”First appeared in late 1980s; e.g.clozapine(Clozaril), risperidone...
SchizophreniaMedical ManagementCLOZAPINE remains the drug of choice in treatmentresistant cases; reduce cravings for alco...
SchizophreniaMedical ManagementRisperidone, Olanzapine,Quetiapine-provide better management of both“positive”,“negative” &...
SchizophreniaMedical ManagementBUT, atypical antipsychotics cancompound at patient‟s risk for diabetes,heart disease, obes...
Antipsychotic Medications: Impact onDental Care Conventional Antipsychotics:chlorpromazine, haloperidol, perphenazineOral...
SchizophreniaOral Findings…people who suffer from schizophrenia areat a far greater risk of dental caries,gingivitis/advan...
SchizophreniaOral Findings higher prevalence of bruxism and signs of TMD= severe tooth damage due to extensiveattrition....
SchizophreniaOral Findings can be…. precipitated by the psychosocialdeficiencies inherent in the disease itself. a resul...
SCHIZOPHRENIADental Considerationsfluoride supplements(e.g.Prevident)oral hygienesalivary substitutes(re: dry mouth)Clozap...
SCHIZOPHRENIADrug Interactions Epinephrine used with caution toprevent severe hypotensive episode –limit to 2 carpules 1:...
COMPLICATIONS OF XEROSTOMIA acidic plaque pH…caries, hypersensitivity loss of lubrication…oral ulcerations,difficulties ...
DENTAL MANAGEMENTDry Mouth Protocol sipping waterfrequently restrict caffeine, colas sugar free gum,candies. saliva su...
Depression is….. “an equal opportunityillness” –all ages,races, all economicclasses. an illness (as isdiabetes, heartdis...
Depression is….. second leading cause of death anddisability in the world in age category of15-44 yrs. (M & F) – W.H.O. ...
Major Depressive DisorderMental illness of at least 2 weeks durationencompassing at least 5 of the followingDSM-IV diagnos...
Bipolar I Affective Disorder“ a roller coaster of mood” lowest of lows = s/s ofmajor depression highest of highs = manic...
Bipolar I Affective Disorder(MANIC EPISODES) feelingindescribably good require little or nosleep easily explode intoang...
Depression(Postpartum Depression)Condition diagnosedwithin 1 yr. ofchildbirth. (not “babyblues”) often underdiagnosed/wid...
Late-life DepressionWho? - > 65 yrs.What? – impairmentof mood, thoughtcontext, behaviour =distress, compromisedsocial func...
Monamine Oxidase Inhibitors(MAOI‟s)Phenelzine (Nardil)Tranylcypromine (Parnate)Moclobemide (Manerix) heralded era of anti...
MAOI‟s Disadv. – dietary + drug-druginteractions causing severehypertension.(tyramines in cheese,meats, red wine are not ...
Tricyclic Antidepressantsamitriptyline (Elavil)clomipramine (Anafranil)imipramine (Tofranil)desipramine (Norpramin) initi...
Other Side Effects of AntidepressantDrugs (Tricyclics)Common: dry mouth, nausea/vomiting,constipation, urinary retention,i...
Selective Serotonin Reuptake InhibitorsSSRIsfluvoxamine (Luvox)fluoxetine (Prozac)paroxetine (Paxil)sertraline (Zoloft)cit...
Electroconvulsive Therapy (ECT) for severe depression refractory tomedication. ? – a CNS seizure induced via electriccur...
Drug-Drug Interactions…Tricyclics & MAOI’sTCA‟s block re-uptake of levonordefrincausing dramatic inc. of BP, cardiacdysrh...
Drug-Drug Interactions…SSRI’s e.g. Prozac, Paxil, Wellbutrin reduce efficacy ofcodeine containing cmpds./erythromycin via...
Side Effects of Long Term Use ofLithium• Neurologic lethargy, fatigue, weakness, finetremors, memory impairment• Renal ren...
Antidepressant/Mood StabilizersImpact on Dental Care Mood stabilizers:LithiumOral side effects: xerostomia, lichenoid sto...
Antidepressant/Mood StabilizersImpact on Dental Care Selective serotonin reuptakeinhibitors(SSRIs):citalopram, fluoxetine...
Summary of Oral Findings
Summary of Oral Findings increased presence of TMD signs (14% of patients withsigns of TMD also have comorbid psych. symp...
EATING DISORDERSAnorexia NervosaBulimiaNervosa living in fear of food; of being fat diagnosis has reached epidemicpropor...
ANOREXIA NERVOSA“ceaseless pursuit ofthinness” 1% of females aged12 – 25 yrs. mostly white/middleclass background. extr...
ETIOLOGY OF EATING DISORDERSgeneticpredispositionsocietalpressuresachieve control,approvaldepression,feelingsof guiltdisto...
ANOREXIA NERVOSASigns & Symptomsuse of laxatives, diureticsenergetic, hyperactivestrenuous exercise regimenfearful to ...
ANOREXIA NERVOSASigns & SymptomsProgressing to….. amenorrhea,constipation, kidney dysfunction, UTI,impaired conc. & ration...
BULIMIA (“ox-hunger”)NERVOSA“binge eating andpurging” 1-5% of females aged12 – 25 yrs.( morecommon than A.N.) 35% of pat...
BULIMIA NERVOSADiagnostic CriteriaBinge eating twice weekly over a 3month period of time followed byself-induced vomiting,...
BULIMIA NERVOSASigns & Symptoms compulsiveingestion ofexcessively largeamounts of food. depressed uponthe cessation ofea...
BULIMIA NERVOSAComplications aspiration pneumonias. esophageal/gastric rupture. hypokalemia – cardiac arrythmias. panc...
MEDICAL COMPLICATIONS Anorexia Nervosa: arise as a result ofstarvation (restricting) and weightloss. Bulimia Nervosa: re...
Patterns of Dental ErosionLingual surface erosive pattern: Bulimia (perimyolysis), chronicgastritis secondary to chronica...
EATING DISORDERSOral ComplicationsFinding Anorexia Nervosa Bulimia NervosaLingual erosion no yesTooth sensitivity no yesXe...
EATING DISORDERSObjectives for Preventive Dental Treatment1. Reduce frequency of acid exposure onteeth. achieving a reduc...
EATING DISORDERSObjectives for Preventive Dental Treatment3. Neutralize acids in the mouth. use of alkaline mouth rinse i...
EATING DISORDERSObjectives for Preventive Dental Treatment5. Minimize abrasive brushing techniques soft brush, circular m...
EATING DISORDERSDental Tx. Planning(complex restorative care)Anorexia Nervosa:– regain lost weight– stabilize physical hea...
ANXIETY DISORDERSAnxiety – what is it?“emotional pain or a feeling that all isnot well-a feeling of impendingdisaster”The ...
ANXIETY DISORDERS may involve an internal psychologicalconflict, environmental stressors,physical disease, side effects o...
ANXIETY DISORDERSEtiology no single theory available usually a combination ofpsychosocial/biological processes(neurobiol...
ANXIETY DISORDERSMild form of anxiety towardsdental care –Treatment Strategies1. General attitude/anxietyreducing treatmen...
ANXIETY DISORDERSPOST-TRAUMATIC STRESS DISORDERResult of exposure to a traumatic event outside ofusual realm of human expe...
Post-Traumatic Stress Disorder 4th most common psych. illness in U.S. F > M *** Personal pre-disposition necessary fors...
Post-Traumatic Stress DisorderDental Findings• poor OH• rampant caries/periodisease• > abfraction lesions• chronic atypica...
ANXIETY DISORDERSPANIC DISORDER experiencing of recurrent & unexpected panicattacks not associated with any external even...
Panic Disorder5% in females; 2% in males.~ 1 M Canadians 15 yrs or older.lifelong illness with variableresponse to trea...
Panic DisorderDiagnosisr/o medical conditions e.g. MI, hyperthyroidism,xs. caffeine use, stimulant use, alcohol /drugwithd...
ANXIETY DISORDERSOBSESSIVE-COMPULSIVEDISORDER(OCD)Obsessive thoughts and compulsive actionscausing distress and functional...
Obsessive-Compulsive DisorderDental Management• preventive oralcare• MD consult re:current status &meds.Dental Findings• s...
ANXIETY DISORDERSDental Management summary Pre-op: - explain, honesty, answer questions,consistent communication.**oral s...
Somatoform Disorders“Psychological disorderscharacterized by the presence ofphysical symptoms that are not fullyexplained ...
Psychosomatic vs. Somatoform– Psychosomatic:disorders in whichthere is REAL physicalillness that is largelycaused bypsycho...
Somatoform DisordersPatients may experience multiple, unexplained somaticsymptoms that may last for years.Examples:hypocho...
Somatoform Disordersbody dysmorphic disorder“pre-occupation with an imagined or exaggerateddefect in physical appearance”O...
Somatoform DisordersExamples of Oral Symptoms burning, painful tongue numbness/tinglingsensation of soft tissues facial...
Somatoform DisordersPATH TO DIAGNOSISsymptoms do not follow knownanatomic nerve distribution.lab tests/MD consult have r...
Somatoform DisordersMedical Perspectivepsychiatric Tx. re: somatoform disordersfocuses on coping vs. cure.anxiety/depres...
CONCLUSIONDental Perspectives for patientsdiagnosed with mental illnessSome patients who undergo psychiatric care fore.g. ...
EatingSpeakingEsthetics(smiling and self esteem)
The taking of dentalradiographs duringpregnancy continues to bea controversial issue.It should be noted,however, that a pr...
You lose a tooth forevery pregnancyBabies drain thecalcium from your teethEvery time you arepregnant your gumsbleed and yo...
Oral Disease and Systemic DisordersPeriodontitis has an associationwith:• Infective Endocarditis• Diabetes• Cardiovascular...
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 bac...
American Academy of Periodontology Report 2004•Preventive oral care services should beprovided as early in pregnancy as po...
Review
Recommendations Regular dental examinations for allpregnant patients Aggressive periodontal therapy forinfections Frequ...
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 t...
Preterm Low Birth Weight BirthsSmoking, alcohol use, and drug use contribute to mothers having babies thatare born prematu...
If nausea and vomiting is a problem, it isimportant to frequently brush or rinse withwater. The acid could cause erosion o...
GIT diseases
Esophagus
Dysphagia difficulty in swallowing sensation that the food „stops“ in the oesophagusCause disorder of oesophagus motili...
Achalasia disorder of esophageal motility defect of ezophagus peristalsisCause defect of ezophagus wall innervationSign...
Definitions Gastroesophageal reflux (GER) – involuntary movement of gastric(sometimes also duodenal) content to the esoph...
EsophagusdiaphragmHIS-angleA - normal anatomyB – hiatal hernia pre-stageC - sliding hiatal herniaD - paraesophageal type
SymptomsMain symptoms Pyrosis – heartburn – chest pain Regurgitation Dysphagia, odynophagia Salivation Nausea, vomiti...
GERD complications Reflux esophagitis– erosions, ulcers Barrett´s esophagus– metaplasia – replacement ofthe epithelial c...
Stomach
Definition ulceration in the upper GIT– stomach– proximal part of duodenum– esophagusCauses Helicobacter pylori (70 – 90...
Intestines
Definitions Malabsorption – abnormal absorption of nutrients by gut mucosa Maldigestion – abnormal digestion of nutrient...
SymptomsIrritable Bowel Syndrome (IBS)
Definition a multifactorial inflammatory disease of theintestines (ileum, large intestine) that may affectany part of the...
Gastrointestinal symptoms abdominal pain diarrhea, fecal incontinence flatulence, bloating, intestinal discomfort naus...
perianal fistulas perianal fissuraerythema nodosumpyoderma gangrenosumuveitisSymptoms of Crohn´s disease
 bowel obstruction, fistulae, abcesses, perforation, bleeding intestinal strictures and adhesions infection malnutriti...
Definition an chronic inflammatory bowel disease (colon)Cause unknown autoimmune process genetical predisposition env...
Gastrointestinal symptoms diarrhea with blood or mucus abdominal pain, cramps mouth aphtous ulcersSystemic symptoms lo...
Liver
Icterus• yellowish pigmentation of the skin, sclera and the mucousmembranes caused by hyperbilirubinemia over 22 mmol/l -...
haemoglobinREShaemglobin bilirubinbloodbilirubinliverconjugation of bilirubinbileintestineurobilinogen urobilin bilirubin...
Retention of unconjugated bilirubinGilbert’s syndrome(Familiar unconjugated nonhaemolytic hyperbilirubinaemia) mild diso...
Chronic liver insufficiencyCauses Viral - hepatitis Toxins and drugs – alcohol Wilson disease hemochromatosis autoimm...
My Contact ikassem@dr.com You can ge thelectures form http://www.slideshare.net/islamkassem/newsfeedikassem@dr.com
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  1. 1. Islam Kassem, BDS , MSc, MOMS RCPS Glasg,FFD RCSIConsultant Oral & Maxillofacial SurgeonMedical Topics inOrthodonticsikassem@dr.com
  2. 2. Diabetesikassem@dr.com
  3. 3. DEFINITIONDIABETES MELLITUS An endocrine disorder in which there isinsufficient amount or lack of insulinsecretion to metabolize carbohydrates. It is characterized by hyperglycemia,glycosuria.ikassem@dr.com
  4. 4. ikassem@dr.com
  5. 5. ikassem@dr.com
  6. 6. 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 thecells.ikassem@dr.com
  7. 7. 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,ikassem@dr.com
  8. 8. Assessment History Blood tests– Fasting blood glucose test: two tests > 126mg/dL– Oral glucose tolerance test: blood glucose >200 mg/dL at 120 minutes– Glycosylated hemoglobin (Glycohemoglobin test)assays– Glucosylated serum proteins and albumin FSBS – (finger stick) monitoring blood sugarikassem@dr.com
  9. 9. Urine Tests Urine testing for ketones Urine testing for renal function Urine testing for glucoseikassem@dr.com
  10. 10. ikassem@dr.com
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  12. 12. ikassem@dr.com
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  14. 14. ikassem@dr.com
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  18. 18. Risk for Injury Related toHyperglycemia Interventions include:– Dietary interventions, blood glucosemonitoring, medications– Oral Drugs Therapy(Continued)ikassem@dr.com
  19. 19. Risk for Injury Related toHyperglycemia (Continued)– Oral therapy Sulfonylurea agents Meglitinide analogues Biguanides Alpha-glucosidase inhibitors Thiazolinedione antidiabetic agentsikassem@dr.com
  20. 20. 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 medikassem@dr.com
  21. 21. ikassem@dr.com
  22. 22. ikassem@dr.com
  23. 23. Insulin Regimens Single daily injection protocol Two-dose protocol Three-dose protocol Four-dose protocol Combination therapy Intensified therapy regimensikassem@dr.com
  24. 24. ikassem@dr.com
  25. 25. ikassem@dr.com
  26. 26. Diabetic Education -Preventive Medicine Proper skin and footcare Proper Eye Exam Proper diet andfluids Diabetic Neuropathy DiabeticRetinopathy DiabeticNephropathy Diabeticgastroparesisikassem@dr.com
  27. 27. Diabetes MellitusComplications Hyperglycemia Hypoglycemia Diabetic Ketoacidosis Hyperosmolar Hyperglycemic NonketoticSyndromeikassem@dr.com
  28. 28. ikassem@dr.com
  29. 29. Chronic Complications ofDiabetes Cardiovascular disease Cerebrovascular disease Retinopathy (vision) problems Diabetic neuropathy Diabetic nephropathy Male erectile dysfunctionikassem@dr.com
  30. 30. Whole-PancreasTransplantationOperative procedureRejection managementLong-term effectsComplicationsIslet cell transplantation hindered by limitedsupply of beta cells and problems causedby antirejection drugsikassem@dr.com
  31. 31. Chronic Pain Interventions include:– Maintenance of normal blood glucose levels– Anticonvulsants– Antidepressants– Capsaicin creamikassem@dr.com
  32. 32. 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 complications.ikassem@dr.com
  33. 33. 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 functionikassem@dr.com
  34. 34. Diabetes impact on oral healthikassem@dr.com
  35. 35. Periodontal Diseaseikassem@dr.com
  36. 36. Tooth Loss and Diabetes Usually associated with:– Periodontal disease– Smoking habits– Poor Controlikassem@dr.com
  37. 37. Oral Soft Tissue Pathologies with Diabetesikassem@dr.com
  38. 38. 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, paleikassem@dr.com
  39. 39. Oral health impact on diabetesikassem@dr.com
  40. 40. Oral Examination Caries identification– Surface caries easily identifiable– Incipient decay harder to identify but moreimportant with preventive strategies Gum disease– Gingivitis vs. periodontal diseaseikassem@dr.com
  41. 41. Caries/Cavitiesikassem@dr.com
  42. 42. Caries/Cavitiesikassem@dr.com
  43. 43. Periodontal Diseaseikassem@dr.com
  44. 44. Periodontal Pocketsikassem@dr.com
  45. 45. 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 control.ikassem@dr.com
  46. 46. There is no treatment preference withregard to fixed or removable appliances. Itimportant to stress good oral hygiene,ikassem@dr.com
  47. 47. specific diabetic changes in theperiodontium are more pronounced afterorthodontic tooth movement.ikassem@dr.com
  48. 48. Cardiovascular diseaseikassem@dr.com
  49. 49. A leading cause of SICKNESS andDEATHCoronary Heart Diseaseikassem@dr.com
  50. 50. 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 ?ikassem@dr.com
  51. 51. 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)ikassem@dr.com
  52. 52. 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)ikassem@dr.com
  53. 53. Ischaemic heart diseaseManifestations Sudden death Acute coronary syndrome ( Myocardial Infarction &Unstable Angina ) Stable angina pectoris Heart failure Arrhythmia Asymptomaticikassem@dr.com
  54. 54. 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 12monthsikassem@dr.com
  55. 55. 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
  56. 56. Risk Factors for Ischemic HeartDisease Family History Smoking Hypertension Diabetes Mellitus Hypercholesterolaemia Lack of exercise Obesity Age & SexPRIMARY PREVENTIONikassem@dr.com
  57. 57. Non-Modifiable Risk Factor:SEXikassem@dr.com
  58. 58. Non-Modifiable Risk Factor:AGEikassem@dr.com
  59. 59. Non-Modifiable RiskFactor: FAMILYHISTORYikassem@dr.com
  60. 60. Modifiable Risk Factor:DIABETESikassem@dr.com
  61. 61. Modifiable Risk Factor:SMOKINGikassem@dr.com
  62. 62. Modifiable Risk Factor:OBESITYikassem@dr.com
  63. 63. Modifiable Risk Factor:DYSLIPIDEMIAikassem@dr.com
  64. 64. Spectrum of the AtheroscleroticProcess Coronary Arteries (angina, MI, suddendeath) Cerebral Arteries (stroke) Peripheral Arteries (claudication)ikassem@dr.com
  65. 65. Ischaemic heart diseaseAcute coronary syndromesAtherosclerosisFatal /Non-Fatal AMI UnstableAnginaCoronaryArtery spasmikassem@dr.com
  66. 66. 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 vomitingikassem@dr.com
  67. 67. 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 ceasedikassem@dr.com
  68. 68. Clinical Patterns of AnginaPectorisStable - pain pattern andcharacteristics relativelyunchanged over past severalmonths (better prognosis)Unstable - pain pattern changingin occurrence, frequency, intensity,or duration (poorer prognosis); MIikassem@dr.com
  69. 69. TREATMENTMEDICATIONS1) Nitrates- vasodilator eg: ISDN. ISMN2) Pain reliever- eg: Morphine3) Beta-blockers4) Statins- cholesterol lowering drugs. Eg:Atorvastatin, Simvastatinikassem@dr.com
  70. 70. 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 ACS!ikassem@dr.com
  71. 71. 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 coronaryvesselsikassem@dr.com
  72. 72. 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 vomitingikassem@dr.com
  73. 73. Chest PainDifferential diagnosis Cardiac pathology– Pericarditis, aortic dissection Pulmonary pathology– Pulmonary embolus, pneumothorax, pneumonia Gastrointestinal pathology– Peptic ulcer disease, reflux, pancreatitis, „cafécoronary‟ Musculoskeletal pathology– Trauma, Tietze‟s Syndromeikassem@dr.com
  74. 74. 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 pressureikassem@dr.com
  75. 75. 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 supportikassem@dr.com
  76. 76. Surgical Treatment PercutaneousTransluminalCoronaryAngioplasty (PTCA)– balloon expansionthat can provide90% dilitation ofvessel lumenikassem@dr.com
  77. 77. Stent Placement With use of justthe balloon, re-occlusion of theartery can occurwithin months Placement of astent delays orprevents re-occlussionikassem@dr.com
  78. 78. Surgical Treatment Coronary ArteryBy-Pass Graft(CABG) The graft bypassesthe obstruction inthe coronary artery Graft sources:– saphenous vein– internal mammaryartery– radial arteryikassem@dr.com
  79. 79. 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
  80. 80. 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”ikassem@dr.com
  81. 81. 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 procedureikassem@dr.com
  82. 82. 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 anesthesiaikassem@dr.com
  83. 83. 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
  84. 84. 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)ikassem@dr.com
  85. 85. 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
  86. 86. 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 cardiologist.ikassem@dr.com
  87. 87.  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
  88. 88. 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 sublinguallyikassem@dr.com
  89. 89. 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‟sikassem@dr.com
  90. 90. 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 cordikassem@dr.com
  91. 91. 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 neededikassem@dr.com
  92. 92. 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 supportikassem@dr.com
  93. 93. Conclusion: When treating patients with Ischemic HeartDisease or recent MI…– Use caution and common sense– When in doubt:CONSULT THE CARDIOLOGISTikassem@dr.com
  94. 94. 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 shepractices.ikassem@dr.com
  95. 95.  Cephalometric and facial analyses shouldbe altered when examining obese oroverweight patients. These patients tendto have larger mandibles and shorterupper face heights that could changepotential treatments.ikassem@dr.com
  96. 96.  Obese patients tend to have flatter ormore concave profiles because ofincreased mandibular length andincreased tissue thickness.ikassem@dr.com
  97. 97.  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 patients.ikassem@dr.com
  98. 98. ikassem@dr.com
  99. 99. Psychology in Dentistry
  100. 100. Dentistry and Health Consistent brushing and flossing androutine dental hygiene critical tomaintenance of oral health– Psychology as thescience of behavior
  101. 101. Psychology and Dentistry Communications skills and rapport building Dental fears
  102. 102. Psychology and Dentistry Pain– Acute– Chronic Temporomandibular disorders Neuralgias Oral parafunctional behaviors– Clenching– Grinding (“bruxism”)
  103. 103. Psychology and Dentistry Special needs populations– Mentally challenged– Chronically ill– Geriatrics Public health– Community interventions
  104. 104. Psychology and Dentistry Quality of life– Craniofacial abnormalities– Edentualism Esthetic dentistry– Orthodontics– Crowns, veneers– Reconstruction
  105. 105. Psychology Skills Useful for DentalStudents Communication Fear/anxiety management Management of disruptive child Patient interventions to enhance self-care– Motivational interviewing Pain management
  106. 106. 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.
  107. 107. 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.
  108. 108. 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.
  109. 109. “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…
  110. 110. 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…
  111. 111. 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.
  112. 112. 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?
  113. 113. 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.
  114. 114. Axis I – Clinical Disorders Dementia**, delirium, amnesia, othercognitive disorders** Schizophrenia**/other psychoses Mood disorders** Substance-related disorders** Eating disorders** Somatoform disorders** Anxiety disorders**
  115. 115. 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.
  116. 116. 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)
  117. 117. 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
  118. 118. 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
  119. 119. 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)
  120. 120. SCHIZOPHRENIASymptomatology2.Disorganized symptoms: a rapidshift of ideas, incoherent speech, poorthought relation. Disorganized, bizarrebehaviour e.g. stereotypical, imitationof others speech, gestures etc.
  121. 121. 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).
  122. 122. 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)
  123. 123. 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)
  124. 124. 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.
  125. 125. Schizophrenia-Medication Side EffectsORAL DYSKINESIAS(drug-induced) conventionalantipsychotics atypical antipsychotics antiemetics antiparkinsonion TCA‟s SSRI‟s lithium anticonvulsants antihistamines methamphetamines
  126. 126. Schizophrenia-Medication Side EffectsORAL DYSKINESIAS-Complications tooth wear oral pain/injury TMJ degeneration speech impairment chewing difficulties inadequate foodintake…wt. loss displacement/poorretention ofRPD‟s…decreasedtolerance social sequelae
  127. 127. 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.
  128. 128. 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.”
  129. 129. 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.
  130. 130. 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.
  131. 131. 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.
  132. 132. Antipsychotic Medications: Impact onDental Care Conventional Antipsychotics:chlorpromazine, haloperidol, perphenazineOral side effects: xerostomia, tardivedyskinesia Atypical Antipsychotics:clozapine,olanzapine,quetiapine,risperidoneOral side effects: xerostomia, dysphagia,stomatitis, dysgeusia
  133. 133. 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…
  134. 134. 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.
  135. 135. 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.
  136. 136. SCHIZOPHRENIADental Considerationsfluoride supplements(e.g.Prevident)oral hygienesalivary substitutes(re: dry mouth)Clozapine use &agranulocytosisfreq. recallappts.empathy, support,MD consultationmeds/consent/psych.status
  137. 137. 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.
  138. 138. 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
  139. 139. DENTAL MANAGEMENTDry Mouth Protocol sipping waterfrequently restrict caffeine, colas sugar free gum,candies. saliva substitutes, oralmoisturizers e.g.MouthKote, Bioteneproducts (contain keyenzymes[3] foundnaturally in saliva) avoid alcohol/alcoholcontainingmouthrinses fluoriderinses(0.05%) fluoride gels(0.04%) CHX mouth rinse(alcohol-free TBA) restrict/avoid tobaccoproducts
  140. 140. 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.
  141. 141. 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)
  142. 142. 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
  143. 143. 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.
  144. 144. 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
  145. 145. Depression(Postpartum Depression)Condition diagnosedwithin 1 yr. ofchildbirth. (not “babyblues”) often underdiagnosed/widelymisunderstood due tostigmatization
  146. 146. Late-life DepressionWho? - > 65 yrs.What? – impairmentof mood, thoughtcontext, behaviour =distress, compromisedsocial function, poorself care = sadness,loss of interest, wt.changes, fatigue =inc. suicide risk
  147. 147. 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.
  148. 148. 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.
  149. 149. 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%).
  150. 150. 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.
  151. 151. 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.
  152. 152. 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.
  153. 153. Drug-Drug Interactions…Tricyclics & MAOI’sTCA‟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.
  154. 154. 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.
  155. 155. 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
  156. 156. 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.
  157. 157. Antidepressant/Mood StabilizersImpact on Dental Care Selective serotonin reuptakeinhibitors(SSRIs):citalopram, fluoxetine, paroxetine,sertraline, venlafaxine, buproprionOral side effects: xerostomia, dysgeusia,stomatitis, glossitis, bruxism
  158. 158. Summary of Oral Findings
  159. 159. 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
  160. 160. EATING DISORDERSAnorexia NervosaBulimiaNervosa living in fear of food; of being fat diagnosis has reached epidemicproportions
  161. 161. ANOREXIA NERVOSA“ceaseless pursuit ofthinness” 1% of females aged12 – 25 yrs. mostly white/middleclass background. extremedistortion/perceptionof body image.
  162. 162. ETIOLOGY OF EATING DISORDERSgeneticpredispositionsocietalpressuresachieve control,approvaldepression,feelingsof guiltdistorted bodyimageextreme exerciseregimenissues re:self-esteem
  163. 163. ANOREXIA NERVOSASigns & Symptomsuse of laxatives, diureticsenergetic, hyperactivestrenuous exercise regimenfearful to gain weight (usuallyabout 15% below normal wt.)increased incidence in females withType 1 diabetes (deliberate avoidanceof taking insulin to induce weight loss)
  164. 164. ANOREXIA NERVOSASigns & SymptomsProgressing to….. amenorrhea,constipation, kidney dysfunction, UTI,impaired conc. & rational thinking,muscle spasms, seizures, intoleranceto cold, hypotension, bradycardia,alopecia, nail fragility, electrolyteimbalance, sudden death (ventriculartachyarrhythmias)
  165. 165. 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.
  166. 166. 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)
  167. 167. BULIMIA NERVOSASigns & Symptoms compulsiveingestion ofexcessively largeamounts of food. depressed uponthe cessation ofeating. secrecycomponent. Russell‟s sign.
  168. 168. BULIMIA NERVOSAComplications aspiration pneumonias. esophageal/gastric rupture. hypokalemia – cardiac arrythmias. pancreatitis. Ipecac – inducedmyopathy/cardiomyopathy. EKG aberrations
  169. 169. MEDICAL COMPLICATIONS Anorexia Nervosa: arise as a result ofstarvation (restricting) and weightloss. Bulimia Nervosa: related to the modeand frequency of purging.
  170. 170. Patterns of Dental ErosionLingual surface erosive pattern: Bulimia (perimyolysis), chronicgastritis secondary to chronicalcoholism, GERD.(+/- affecting the occlusalsurfaces of premolars/molars,further exacerbated by attrition.)
  171. 171. 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
  172. 172. 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
  173. 173. 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
  174. 174. EATING DISORDERSObjectives for Preventive Dental Treatment5. Minimize abrasive brushing techniques soft brush, circular motion, floss avoid brushing immediately after episodes ofvomiting6. Caries prevention NaF varnishes sealants? snack substitutes desensitizing agents
  175. 175. 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*****
  176. 176. 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.
  177. 177. 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.
  178. 178. 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.
  179. 179. 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
  180. 180. 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.
  181. 181. 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%
  182. 182. Post-Traumatic Stress DisorderDental Findings• poor OH• rampant caries/periodisease• > abfraction lesions• chronic atypical facialpain• s/e of SSRI‟sDental Management• preventive care• mgmt. of xerostomia• oral Ca.screening• caution re: oral surg.inlong-term alcoholism• caution re: use ofcertainanalgesics,antibiotics,sedatives
  183. 183. 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.
  184. 184. Panic Disorder5% 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.
  185. 185. 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.
  186. 186. 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.
  187. 187. Obsessive-Compulsive DisorderDental Management• preventive oralcare• MD consult re:current status &meds.Dental Findings• s/e of medication-induced xerostomia• somatic obsessions• > abrasion lesions(overzealous oralhygiene practices=compulsions)
  188. 188. 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
  189. 189. 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.”
  190. 190. 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.
  191. 191. 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.
  192. 192. 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.
  193. 193. Somatoform DisordersExamples of Oral Symptoms burning, painful tongue numbness/tinglingsensation of soft tissues facial pain
  194. 194. Somatoform DisordersPATH TO DIAGNOSISsymptoms do not follow knownanatomic nerve distribution.lab tests/MD consult have r/ounderlying systemic cause e.g.anemia, CA, diabetes.
  195. 195. Somatoform DisordersMedical Perspectivepsychiatric 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.
  196. 196. 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.
  197. 197. EatingSpeakingEsthetics(smiling and self esteem)
  198. 198. 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.
  199. 199. 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
  200. 200. Oral Disease and Systemic DisordersPeriodontitis has an associationwith:• Infective Endocarditis• Diabetes• Cardiovascular Disease• Pre-Term, Low Birth Weight Infants• Pulmonary Disease
  201. 201. Oral Disease and Systemic DisordersPeriodontitis and pregnancy
  202. 202. Oral Disease and Systemic DisordersPeriodontitis and pregnancy
  203. 203. 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
  204. 204. 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
  205. 205. Review
  206. 206. Recommendations Regular dental examinations for allpregnant patients Aggressive periodontal therapy forinfections Frequent reinforcement of oral hygieneand dental care by medical providers
  207. 207. Also know as pyogenic granuloma.Rare, usually painless lesion, develops on gums inresponse to plaqueNon-cancerous
  208. 208. •Subside shortly after childbirth•No treatment is required unless causes problemswith eating, speaking, or swallowing•If treatment is needed, it is surgically removed
  209. 209. 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.
  210. 210. 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.
  211. 211. GIT diseases
  212. 212. Esophagus
  213. 213. 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
  214. 214. 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
  215. 215. 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
  216. 216. EsophagusdiaphragmHIS-angleA - normal anatomyB – hiatal hernia pre-stageC - sliding hiatal herniaD - paraesophageal type
  217. 217. SymptomsMain symptoms Pyrosis – heartburn – chest pain Regurgitation Dysphagia, odynophagia Salivation Nausea, vomitingOther symptoms Chronic cough Laryngitis, pharyngitis AsthmaOral symptoms Teeth hypersensitivity Erosion of dental enamel
  218. 218. GERD complications Reflux esophagitis– erosions, ulcers Barrett´s esophagus– metaplasia – replacement ofthe epithelial cells fromsquamous to columnar– premalignant condition Esophageal adenocarcinoma
  219. 219. Stomach
  220. 220. Definition ulceration in the upper GIT– stomach– proximal part of duodenum– esophagusCauses Helicobacter pylori (70 – 90%) Nonsteroidal anti-inflammatory drugs – aspirin, ibuprofen... Gastrinoma - Zollinger-Ellison syndrome– hyperproduction of gastrin from pancreatic orextrapancreatic (e.g. duodenal) tumourur stressRisk factors smoking spicesPeptic Ulcer Disase - PUD
  221. 221. Intestines
  222. 222. Definitions Malabsorption – abnormal absorption of nutrients by gut mucosa Maldigestion – abnormal digestion of nutrientsCauses pancreatic insuficiency– pancreatitis– carcinoma– cystic fibrosis cholestasis– obstruction specific deficits– lactase deficiency systemic diseases– celiac disease infection– Whipple´s disease inflammation– Crohn diseaseMalabsorption
  223. 223. SymptomsIrritable Bowel Syndrome (IBS)
  224. 224. 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
  225. 225. Gastrointestinal symptoms abdominal pain diarrhea, fecal incontinence flatulence, bloating, intestinal discomfort nausea, vomiting perianal discomfort (itchiness, pain), fistula, abscess around the anus mouth – aphtous ulcers, ezophagus – dysphagia stomach - painSystemic symptoms growth failure loss of apetite, wight loss fever malabsorptionExtraintestinal symptoms eye (uveitis) skin inflammation - erythema nodosum, pyoderma gangrenosum spondyloarthopathy autoimmune hemolytic anemia finfers deformity osteoporosis neurological symptoms – seizures, peripheral neuropathy, headacheSymptoms of Crohn´s disease
  226. 226. perianal fistulas perianal fissuraerythema nodosumpyoderma gangrenosumuveitisSymptoms of Crohn´s disease
  227. 227.  bowel obstruction, fistulae, abcesses, perforation, bleeding intestinal strictures and adhesions infection malnutrition, malabsorption smal intestinal cancerComplications of Crohn´s disease
  228. 228. Definition an chronic inflammatory bowel disease (colon)Cause unknown autoimmune process genetical predisposition environmental factors– diet -  fiber content protective factor: breastfeedingUlcerative colitis
  229. 229. Gastrointestinal symptoms diarrhea with blood or mucus abdominal pain, cramps mouth aphtous ulcersSystemic symptoms loss of apetite, wight lossExtraintestinal symptoms joints – arthritis eye - uveitis skin - erythema nodosum, pyoderma gangrenosum liver – pericholangitis, fatty liver blood – hemolytic anemia, tromboembolic disease (rare)Symptoms of ulcerative colitis
  230. 230. Liver
  231. 231. 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
  232. 232. 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
  233. 233. Retention of unconjugated bilirubinGilbert’s syndrome(Familiar unconjugated nonhaemolytic hyperbilirubinaemia) mild disorder of uptake of bilirubin to hepatic cells and conjugation mild hyperbilirubinaemia good prognosisHemolytic icterus haemolysis - congenital - red cell enzymes or membranedefects, haemoglobin defects- acquired - toxins, incompatible blood transfusion
  234. 234. Chronic liver insufficiencyCauses Viral - hepatitis Toxins and drugs – alcohol Wilson disease hemochromatosis autoimmune hepatitis heart failureComplications liver encephalopathy – coma portal hypertension – ascites, esophageal, rectal - varices coagulopathy – bleeding cancerLiver insufficiency
  235. 235. My Contact ikassem@dr.com You can ge thelectures form http://www.slideshare.net/islamkassem/newsfeedikassem@dr.com
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