Medical problems 2 4

Islam Kassem, BDS , MSc, MOMS RCPS Glasg,
FFD RCSI
Consultant Oral & Maxillofacial Surgeon
Medical Topics in
Orthodontics
ikassem@dr.com

DEFINITION
DIABETES MELLITUS
 An endocrine disorder in which there is
insufficient amount or lack of insulin
secretion to metabolize carbohydrates.
 It is characterized by hyperglycemia,
glycosuria.
ikassem@dr.com

Diabetes Mellitus
Pathophysiology
 The beta cells of the Islets of Langerhan
of the Pancreas gland are responsible for
secreting the hormone insulin for the
carbohydrate metabolism.
 Remember the concept - sugar into the
cells.
ikassem@dr.com

Diabetes Mellitus
Types
 Type 1 - IDDM
– little to no insulin
produced
– 20-30% hereditary
– Ketoacidosis
 Gestational
– overweight; risk for
Type 2
 Type 2 - NIDDM
– some insulin
produced
– 90% hereditary
 Other types include Secondary
Diabetes :
– Genetic defect beta cell
or insulin
– Disease of exocrine
pancreas
– Drug or chemical
induced
– Infections-pancreatitis
– Others-steroids,
ikassem@dr.com

Assessment
 History
 Blood tests
– Fasting blood glucose test: two tests > 126
mg/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 sugar
ikassem@dr.com

Urine Tests
 Urine testing for ketones
 Urine testing for renal function
 Urine testing for glucose
ikassem@dr.com

Risk for Injury Related to
Hyperglycemia
 Interventions include:
– Dietary interventions, blood glucose
monitoring, medications
– Oral Drugs Therapy
(Continued)
ikassem@dr.com

Risk for Injury Related to
Hyperglycemia (Continued)
– Oral therapy
 Sulfonylurea agents
 Meglitinide analogues
 Biguanides
 Alpha-glucosidase inhibitors
 Thiazolinedione antidiabetic agents
ikassem@dr.com

Oral Hypoglcemias
Key Points
 Monitor serum glucose levels
 Teach patient signs and symptoms of
hyper/hypoglycemia
 Altered liver, renal function will affect medication
action
 Avoid OTC meds without MD approval
 Assess for GI distress and sensitivity
 Know appropriate time to administer med
ikassem@dr.com

Insulin Regimens
 Single daily injection protocol
 Two-dose protocol
 Three-dose protocol
 Four-dose protocol
 Combination therapy
 Intensified therapy regimens
ikassem@dr.com

Diabetic Education -
Preventive Medicine
 Proper skin and foot
care
 Proper Eye Exam
 Proper diet and
fluids
 Diabetic Neuropathy
 Diabetic
Retinopathy
 Diabetic
Nephropathy
 Diabetic
gastroparesis
ikassem@dr.com

Diabetes Mellitus
Complications
 Hyperglycemia
 Hypoglycemia
 Diabetic Ketoacidosis
 Hyperosmolar Hyperglycemic Nonketotic
Syndrome
ikassem@dr.com

Chronic Complications of
Diabetes
 Cardiovascular disease
 Cerebrovascular disease
 Retinopathy (vision) problems
 Diabetic neuropathy
 Diabetic nephropathy
 Male erectile dysfunction
ikassem@dr.com

Whole-Pancreas
Transplantation
Operative procedure
Rejection management
Long-term effects
Complications
Islet cell transplantation hindered by limited
supply of beta cells and problems caused
by antirejection drugs
ikassem@dr.com

Chronic Pain
 Interventions include:
– Maintenance of normal blood glucose levels
– Anticonvulsants
– Antidepressants
– Capsaicin cream
ikassem@dr.com

Diabetes Mellitus
Summary
 Treatable, but not curable.
 Preventable in obesity, adult client.
 Diagnostic Tests
 Signs and symptoms of hypoglycemia and
hyperglycemia.
 Treatment of hypoglycemia and hyperglycemia –
diet and oral hypoglycemics.
 Nursing implications – monitoring, teaching and
assessing for complications.
ikassem@dr.com

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 function
ikassem@dr.com

Diabetes impact on oral health
ikassem@dr.com

Periodontal Disease
ikassem@dr.com

Tooth Loss and Diabetes
 Usually associated with:
– Periodontal disease
– Smoking habits
– Poor Control
ikassem@dr.com

Oral Soft Tissue Pathologies with Diabetes
ikassem@dr.com

Glossitis
 The range of symptoms used to describe a
tongue suffering the pain of glossitis are:
– pain
– sore
– tender
– swelling
– smooth appearance
– chew, swallow, talk difficulties
– Color ~ dark red, bright red, pale
ikassem@dr.com

Oral health impact on diabetes
ikassem@dr.com

Oral Examination
 Caries identification
– Surface caries easily identifiable
– Incipient decay harder to identify but more
important with preventive strategies
 Gum disease
– Gingivitis vs. periodontal disease
ikassem@dr.com

Caries/Cavities
ikassem@dr.com

Periodontal Pockets
ikassem@dr.com

Orthodontic considerations
Orthodontic treatment should not be
performed in a patient with uncontrolled
diabetes. If the patient is not in good
metabolic control (HbA1c 9%), every
effort should be made to improve blood
glucose control.
ikassem@dr.com

There is no treatment preference with
regard to fixed or removable appliances. It
important to stress good oral hygiene,
ikassem@dr.com

specific diabetic changes in the
periodontium are more pronounced after
orthodontic tooth movement.
ikassem@dr.com

Cardiovascular disease
ikassem@dr.com

A leading cause of SICKNESS and
DEATH
Coronary Heart Disease
ikassem@dr.com

Risk Factors for Cardiovascular
Disease
 Hypertension
 High cholesterol
 Obesity
 Cigarette smoking
 Physical inactivity
 Diabetes mellitus
 Kidney disease
 Older age (>55 ♂; > 65 ♀)
 Family history of premature cardiovascular
disease
 Obstructive sleep apnea
 Periodontal disease ?ikassem@dr.com

Coronary Heart Disease:
Myocardial Ischemia
 Decreased blood
supply (and thus
oxygen) to the
myocardium that can
result in acute
coronary syndromes:
– Angina pectoris (
Stable )
– Unstable Angina
– Myocardial infarction
– Sudden death (due to
fatal arrhythmias)
ikassem@dr.com

Ischaemic heart disease
Definition
 An imbalance between the supply of oxygen and
the myocardial demand resulting in myocardial
ischaemia.
 Angina pectoris
symptom not a disease
chest discomfort associated with abnormal
myocardial function in the absence of myocardial
necrosis
 Supply
– Atheroma, thrombosis, spasm, embolus
 Demand
– Anaemia, hypertension, high cardiac output
(thyrotoxicosis, myocardial hypertrophy)
ikassem@dr.com

Manifestations
 Sudden death
 Acute coronary syndrome ( Myocardial Infarction &
Unstable Angina )
 Stable angina pectoris
 Heart failure
 Arrhythmia
 Asymptomatic
ikassem@dr.com

Epidemiology
 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 angina
1% have had a myocardial infarction in the past 12
months
ikassem@dr.com

Aetiology
 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 A
personality, OCP, soft water
Atherosclerosis
ikassem@dr.com

Risk Factors for Ischemic Heart
Disease
 Family History
 Smoking
 Hypertension
 Diabetes Mellitus
 Hypercholesterolaemia
 Lack of exercise Obesity
 Age & Sex
PRIMARY PREVENTION
ikassem@dr.com

Non-Modifiable Risk Factor:
SEX
ikassem@dr.com

Non-Modifiable Risk Factor:
AGE
ikassem@dr.com

Non-Modifiable Risk
Factor: FAMILY
HISTORY
ikassem@dr.com

Modifiable Risk Factor:
DIABETES
ikassem@dr.com

SMOKING
ikassem@dr.com

OBESITY
ikassem@dr.com

DYSLIPIDEMIA
ikassem@dr.com

Spectrum of the Atherosclerotic
Process
 Coronary Arteries (angina, MI, sudden
death)
 Cerebral Arteries (stroke)
 Peripheral Arteries (claudication)
ikassem@dr.com

Acute coronary syndromes
Atherosclerosis
Fatal /
Non-Fatal AMI Unstable
Angina
Coronary
Artery spasm
ikassem@dr.com

Warning Signs and Symptoms of Heart
attack
1) Pressure, fullness or a squeezing pain in the center of
your 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 pain
4) Prolonged pain in the upper abdomen
5) Shortness of breath- may occur with or without chest
discomfort
6) Sweating
7) Impending sense of doom
8) Lightheadedness
9) Fainting
10) Nausea and vomiting
ikassem@dr.com

Angina Pectoris
 At least 70% occlusion of coronary
artery resulting in pain. What kind
of pain?
– Chest pain
– Radiating pain to:
 Left shoulder
 Jaw
 Left or Right arm
 Usually brought on by physical
exertion as the heart is trying to
pump blood to the muscles, it
requires more blood that is not
available due to the blockage of the
coronary artery(ies)
 Is self limiting usually stops when
exertion is ceased
ikassem@dr.com

Clinical Patterns of Angina
Pectoris
Stable - pain pattern and
characteristics relatively
unchanged over past several
months (better prognosis)
Unstable - pain pattern changing
in occurrence, frequency, intensity,
or duration (poorer prognosis); MIikassem@dr.com

TREATMENT
MEDICATIONS
1) Nitrates- vasodilator eg: ISDN. ISMN
2) Pain reliever- eg: Morphine
3) Beta-blockers
4) Statins- cholesterol lowering drugs. Eg:
Atorvastatin, Simvastatin
ikassem@dr.com

Relevance to Dentistry
 IHD is common
 Subjects with IHD have more severe
dental 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

Myocardial Infarction
 Partial or total occlusion of one or more of
the coronary arteries due to an atheroma,
thrombus or emboli resulting in cell death
(infarction) of the heart muscle
 When an MI occurs, there is usually
involvement of 3 or 4 occluded coronary
vessels
ikassem@dr.com

Chest Pain
Myocardial ischaemia
 Site
Jaw to navel, retrosternal, left submammary
 Radiation
Left chest, left arm, jaw….mandible, teeth, palate
 Quality/severity
tightness, heaviness, compression…clenched fists
 Precipitating/relieving factors
physical exertion, cold windy weather, emotion
rest, sublingual nitrates
 Autonomic symptoms
sweating, pallor, peripheral vasoconstriction,
nausea and vomiting
ikassem@dr.com

Chest Pain
Differential diagnosis
 Cardiac pathology
– Pericarditis, aortic dissection
 Pulmonary pathology
– Pulmonary embolus, pneumothorax, pneumonia
 Gastrointestinal pathology
– Peptic ulcer disease, reflux, pancreatitis, „café
coronary‟
 Musculoskeletal pathology
– Trauma, Tietze‟s Syndrome
ikassem@dr.com

Acute Myocardial Infarction
Assessment
 30% of deaths occur in the first 2 hours.
(Cardiac muscle death occurs after 45 mins of
ischaemia)
 Symptoms and signs of myocardial
ischaemia
 Also
– Changes in heart rate /rhythm
– Changes in blood pressure
ikassem@dr.com

Treatment
 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 support
ikassem@dr.com

Surgical Treatment
 Percutaneous
Transluminal
Coronary
Angioplasty (PTCA)
– balloon expansion
that can provide
90% dilitation of
vessel lumen
ikassem@dr.com

Stent Placement
 With use of just
the balloon, re-
occlusion of the
artery can occur
within months
 Placement of a
stent delays or
prevents re-
occlussion
ikassem@dr.com

Surgical Treatment
 Coronary Artery
By-Pass Graft
(CABG)
 The graft bypasses
the obstruction in
the coronary artery
 Graft sources:
– saphenous vein
– internal mammary
artery
– radial artery
ikassem@dr.com

Complications
 Sudden Death (18% within 1 hour, 36% within
24 hours)
 Non-fatal arrhythmia
 Acute left ventricular failure
 Cardiogenic shock
 Papillary muscle rupture and mitral
regurgitation
 Myocardial rupture and tamponade
 Ventricular aneurysm and thrombus
 Distal Embolisation
ikassem@dr.com

Sudden Death
 Sudden Cardiac Death is also known as a
“Massive Heart Attack” in which the heart
converts from sinus rhythm to ventricular
fibrillation
 In V-Fib, the heart is unable to contract fully
resulting in lack of blood being pumped to the
vital organs
 V-Fib requires shock from defibrillator
“SHOCKABLE RHYTHM”
ikassem@dr.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 heart
disease is
– The emotional state of the patient
– The type of dental procedureikassem@dr.com

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 procedures
fall within the risk of less than 1%
 Some procedures fall within an intermediate risk of
less than 5%
 Highest risk procedures  those done under
general anesthesia
ikassem@dr.com

Management for Low-Intermediate Risk
 Short appointments
 AM appointments
 Comfort
 Vital Signs Taken
 Avoidance of Epinephrine within Local
Anesthetic or Retraction Cord
 O2 Availability
ikassem@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)
ikassem@dr.com

Post MI: When to Treat
 Why delay treatment?
– Remember that with an MI there is damage to the heart, be it
severe 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 surgery
performed within 3 months, 3-6 months… however, this was
abdominal and thoracic surgery under general anesthesia
 New research suggests delaying elective tx for 1 month is
advisable. Emergent care should be done with local anesthetic
without epinephrine and monitoring of vital signs
 When in doubt:
– CONSULT THE CARDIOLOGIST
ikassem@dr.com

Dental Management Correlate
 Elective dental care is ok if it has been longer
than 4-6 weeks since the MI and the patient
does not report any ischemic symptoms.
 If there is any doubt or question, consult
with the cardiologist.
ikassem@dr.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 bleeding
because of decreased platelet aggregation
Dental Considerations for IHD
ikassem@dr.com

 Emergent Situations:
– Possible MI:
 Remember that pain in the jaw may be referred pain
from the myocardium  assess the situation, have
good patient history, follow ABC‟s
– Angina:
 In situations of angina pectoris, all operatories
should have nitroglycerin to be placed sublingually
ikassem@dr.com

 Emergent Situations:
– Chest Pain-MI:
 STOP PROCEDURE
 Remove everything from patient‟s mouth
 Give sublingual nitroglycerin
 Wait 5 minutes  if pain persists, give more
nitroglycerin, assume MI
 101
 Give chewable aspirin  ABC‟s
ikassem@dr.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 and
oxygenation
 Oxygen intraoperatively (if needed)
 Excellent local anesthesia - use epinephrine, if needed, in
limited amount (max 0.04mg) or levonordefrin (max.
0.20mg)
 Avoid epinephrine in retraction cord
ikassem@dr.com

Dental Management:
Unstable Angina or MI < 3 months
 Avoid elective care
 For urgent care: be as conservative as
possible; do only what must be done (e.g.
infection control, pain management)
 Consultation with physician to help manage
 Consider treating in outpatient hospital
facility or refer to hospital dentistry
 ECG, pulse oximetry, IV line
 Use vasoconstrictors cautiously if needed
ikassem@dr.com

Intraoperative Chest Pain
 Stop procedure
 Give nitroglycerin
 If after 5 minutes pain still present, give another
nitroglycerin
 If after 5 more minutes pain still present, give
another nitroglycerin
 If pain persists, assume MI in progress and activate
the EMS
– Give aspirin tablet to chew and swallow
– Monitor vital signs, administer oxygen, and
be prepared to provide life support
ikassem@dr.com

Conclusion:
 When treating patients with Ischemic Heart
Disease or recent MI…
– Use caution and common sense
– When in doubt:
CONSULT THE CARDIOLOGIST
ikassem@dr.com

Obesity
 orthodontist will have between 1 in 6 and
1 in 5 patients who are clinically
overweight or obese, depending on the
state or region in which he or she
practices.
ikassem@dr.com

 Cephalometric and facial analyses should
be altered when examining obese or
overweight patients. These patients tend
to have larger mandibles and shorter
upper face heights that could change
potential treatments.
ikassem@dr.com

 Obese patients tend to have flatter or
more concave profiles because of
increased mandibular length and
increased tissue thickness.
ikassem@dr.com

 Psychosocial problems are likely the rule
with
 obese patients. The clinician should
monitor for problems such as depression
and anxiety, because these conditions
tend to be more likely in obese patients.
ikassem@dr.com

Dentistry and Health
 Consistent brushing and flossing and
routine dental hygiene critical to
maintenance of oral health
– Psychology as the
science of behavior

Psychology and Dentistry
 Communications skills and rapport building
 Dental fears

 Pain
– Acute
– Chronic
 Temporomandibular disorders
 Neuralgias
 Oral parafunctional behaviors
– Clenching
– Grinding (“bruxism”)

 Special needs populations
– Mentally challenged
– Chronically ill
– Geriatrics
 Public health
– Community interventions

 Quality of life
– Craniofacial abnormalities
– Edentualism
 Esthetic dentistry
– Orthodontics
– Crowns, veneers
– Reconstruction

Psychology Skills Useful for Dental
Students
 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 all
ages, all races, all economic groups and
both genders”
Chronic mental illness and it‟s medical
management carry inherent risks for
significant oral disease.

How common is
Mental Illness?
 “disorder” ---- impairment is key
 concept of risk factors can considered as
potential important clues or as the “weak
links” in the mental health chain.

STATISTICS - Suicide
 male: female – 3:1
 300 teens(10-19 yrs) commit
 530,000 kids have treatable MI but only
150,000 get treatment.
 highest rates: 43/100,000 > 80 yrs.
30/100,000 > 75 yrs.

“No one chooses to have a mental
disorder…………”
….admitting to mental illness is not
the same thing as admitting to
any other serious health issue
since it can often result in more
suspicion than support…
…misconceptions flourish…

Mental Health Fact…..
… people with a psychiatric illness
experience a “double–burden” which
includes both the s/s of the disease + the
social stigma, isolation, discrimination that
result from having that disease…
…stigma=social isolation, homelessness,
unemployment, substance abuse,
prolonged institutionalization…

Dental Perspectives…..
 Medications used to treat mental illness
can interact with drugs used in dentistry.
 Some oral health problems arise as
manifestations of mental illness.
 Oral health problems as side effects of
psychotropic medications.
 Decreased compliance to oral health
care/ability to obtain or tolerate oral care
treatment.

Dental Perspectives…..
Sample Mental Health
History
 What psychiatric
medications are you
taking?
 How long have you
been taking the
medication and does it
help?
 What are/were your
symptoms?
 When was your mental
illness diagnosed?
 Who is the
GP/Psychiatrist treating
this condition?
 Have you experienced
any dental side effects,
such as dry mouth,
burning tongue,
excessive saliva or
swollen gums?

DSM IV – Diagnostic & Statistical
Manual of Mental Disorders
 a “descriptive”
approach to
diagnosis based on
symptoms rather
than causes. The
disorders listed
include a “clinical
significance”
criterion re:
significant distress
or impairment.
there is no blood
test, brain scan
or specific x-ray
to make a
diagnosis as with
other medical
problems.

Axis I – Clinical Disorders
 Dementia**, delirium, amnesia, other
cognitive disorders**
 Schizophrenia**/other psychoses
 Mood disorders**
 Substance-related disorders**
 Eating disorders**
 Somatoform disorders**
 Anxiety disorders**

WHAT IS A PSYCHOSIS?
Psychosis is a disordered pattern of
thought, perception, emotion and
behaviour. The psychotic person has
a bizarre sense of reality, with
emotional and cognitive impairment
leading to loss of function in the
environment.

SCHIZOPHRENIA
 ~1- 2% worldwide.
 late teens/early adulthood;
gradual/sudden.
 M (earlier) > F
 10%= chronic hospitalization; 30-40%
long-term serious handicap.
 40% risk of suicide attempts
 60% alcohol abuse/15-25%street drugs
 20% shorter life expectancy(>vulnerability
to medical problems (lifestyle)

SCHIZOPHRENIA
Etiology
Causation of schizophrenia remains not
well understood (syndrome?). Theories
include:
 (genetics) altered expression of genes(10-
15% with one parent; 30-40% - 2 parents
 differences in brain chemistry-(imbalances
in neurotransmitters, e.g. dopamine)
 differences in brain structure

SCHIZOPHRENIA
Etiology
Schizophrenia is NOT:
• a multiple or “split” personality
• caused by bad parenting/character flaws
• the result of childhood trauma
• an isolated condition: 1 in 100
incidence?
• an automatic precursor to criminal
violence

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

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

SCHIZOPHRENIA
Symptomatology
3. Negative symptoms: the absences
of behaviour that should be there. i.e.
flat emotions/emotional expression,
lack of motivation, monotony of speech
apathy, social withdrawal, absence of
normal drives or interests such as
those involving one‟s self care
(general/oral).

SCHIZOPHRENIA
Medical Management
“Conventional” Antipsychotics
(Neuroleptics)
chlorpromazine(Thorazine), methotrimeprazine
(Nozinan), haloperidol(Haldol),
 early 1950s; blocking of dopamine D2 receptors in the
mesolimbic system of the brain affecting mood &
thought processes; e.g. effective in managing “positive”
symptoms only….
 major side effect: *movement disorders*[oral dyskinesias] -
often with orofacial component. Arise from blockade of basal
ganglia dopamine D2 receptors in extrapyramidal system (EPS)

Schizophrenia-Medication Side Effects
ORAL DYSKINESIAS
Abnormal involuntary, uncontrollable
movements affecting primarily the tongue,
lips, jaws (can extend to trunk/limbs)
Causes: 1. drug induced( conventional
antipsychotics)**
2. neuropsychiatric conditions
3. edentulousness
(**tardive dyskinesia)

Schizophrenia
Medication Side Effects
Tardive Dyskinesia (TD)
 late stage effect of slow, rhythmic involuntary
grimacing/twitching in facial area e.g. repeated
smacking of lips, tongue movements, facial
contortions.
 >25% of patients on conventional antipsychotics
having TD after 5 years of treatment.
Ironically, the signs of TD reinforce the
“crazy” stereotype, which in reality is only
a side effect of treatment.

ORAL DYSKINESIAS
(drug-induced)
 conventional
antipsychotics
 atypical antipsychotics
 antiemetics
 antiparkinsonion
 TCA‟s
 SSRI‟s
 lithium
 anticonvulsants
 antihistamines
 methamphetamines

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

Schizophrenia
Medication Side Effects
Side effects of movement disorders are often
managed by Rx. anticholinergic medications
e.g. Cogentin. These drugs in turn exhibit
their own spectra of side effects.
Other side effects include EKG changes,
orthostatic hypotension, dry mouth,
constipation, blurred vision, nasal stuffiness.

Schizophrenia
Medical Management
“atypical antipsychotics”
First appeared in late 1980s; e.g.
clozapine(Clozaril), risperidone(Risperdal),
olanzapine(Zyprexa), quetiapine(Seroquel).
 *rarely cause movement disorders* why? – these
drugs possess a high ratio of serotonin to D2
activity and are therefore referred to as serotonin-
dopamine antagonists vs. conventional
antipsychotics or “dopamine antagonists.”

Schizophrenia
Medical Management
CLOZAPINE
 remains the drug of choice in treatment
resistant cases; reduce cravings for alcohol/illicit
drugs; reduced/delayed risk of suicide attempts.
 But 1% of patients develop agranulocytosis
after 12-24 wks. Patients required to have
weekly WBC counts i.e. > 3000/c.c.
 can cause initial sialorrhea; hypotension,
sedation, tachycardia.

Schizophrenia
Medical Management
Risperidone, Olanzapine,
Quetiapine
-provide better management of both
“positive”,“negative” & “disorganized” symptoms.
 Minor sedation, weight gain, sexual dysfunction,
dry mouth, no agranulocytosis.
 **the improved clinical course and therefore
compliance with these “atypical” medications
ensure less chances for relapse that was seen with
conventional antipsychotic therapy.

Schizophrenia
Medical Management
BUT, atypical antipsychotics can
compound at patient‟s risk for diabetes,
heart disease, obesity, hyperlipidemia
(“metabolic syndrome”)
Dental implications are relevant with
respect to clinical management of the
diabetic, cardiac patient etc.

Antipsychotic Medications: Impact on
Dental Care
 Conventional Antipsychotics:
chlorpromazine, haloperidol, perphenazine
Oral side effects: xerostomia, tardive
dyskinesia
 Atypical Antipsychotics:
clozapine,olanzapine,quetiapine,risperidone
Oral side effects: xerostomia, dysphagia,
stomatitis, dysgeusia

Schizophrenia
Oral Findings
…people who suffer from schizophrenia are
at a far greater risk of dental caries,
gingivitis/advanced periodontal disease,
tooth loss, lack of dentures, poor oral
hygiene, mucosal diseases…
+
poor dietary habits, smoking, alcohol
abuse, substance abuse…

Schizophrenia
Oral Findings
 higher prevalence of bruxism and signs of TMD
= severe tooth damage due to extensive
attrition.
 ? CNS abnormalities and/or neuroleptic induced
mechanisms.
 actual pain sensitivity thresholds higher in pats.
with schizophrenia vs. healthy controls. While
more prone to suffer TMD problems, pain
sensitivity thresholds cause delays in dx. and tx.
resulting in serious clinical consequences.

Schizophrenia
Oral Findings can be….
 precipitated by the psychosocial
deficiencies inherent in the disease itself.
 a result of a disinterest in regular oral
care; is due to financial hardships,
prolonged periods of hospitalization and
non-existent support networks.
 also a result of an unwillingness on the
part of the DDS to understand and/or be
comfortable in the dental management of
these patients.

SCHIZOPHRENIA
fluoride supplements
(e.g.Prevident)
oral hygiene
salivary substitutes
(re: dry mouth)
Clozapine use &
agranulocytosis
freq. recall
appts.
empathy, support,
MD consultation
meds/consent/psych.
status

SCHIZOPHRENIA
Drug Interactions
 Epinephrine used with caution to
prevent severe hypotensive episode –
limit to 2 carpules 1:100,000; avoid
epinephrine in retraction cords; inject
slowly.
 Neuroleptics may intensify effects of
sedatives, hypnotics, opioids,
antihistamines – leading to severe
respiratory depression – consult with MD.
 Neuroleptics can dec. blood levels of
warfarin.

COMPLICATIONS OF XEROSTOMIA
 acidic plaque pH…caries, hypersensitivity
 loss of lubrication…oral ulcerations,
difficulties eating, speaking, wearing
dentures
 dec. amount of saliva…inc. infections
(viral, bacterial, fungal) digestion
problems, ease of trauma to oral mucosa,
gingivitis & periodontitis

DENTAL MANAGEMENT
Dry Mouth Protocol
 sipping water
frequently
 restrict caffeine, colas
 sugar free gum,
candies.
 saliva substitutes, oral
moisturizers e.g.
MouthKote, Biotene
products (contain key
enzymes[3] found
naturally in saliva)
 avoid alcohol/alcohol
containing
mouthrinses
 fluoride
rinses(0.05%)
 fluoride gels(0.04%)
 CHX mouth rinse
(alcohol-free TBA)
 restrict/avoid tobacco
products

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

Depression is…..
 second leading cause of death and
disability in the world in age category of
15-44 yrs. (M & F) – W.H.O.
 an illness affecting the entire body
 leading cause of alcohol/drug abuse (1/3
of patients)
Depression will be…..
 The second leading cause of health
impairment worldwide by 2020.
(WHO)

Major Depressive Disorder
Mental illness of at least 2 weeks duration
encompassing at least 5 of the following
DSM-IV diagnostic symptom criteria:
 depressed mood
 diminished
interest/pleasure
 dec./inc. in wt. or
appetite
 insomnia/hypersom
nia
 inability to think
or concentrate
 fatigue/loss of
energy
 thoughts of
death/suicide

Bipolar I Affective Disorder
“ a roller coaster of mood”
 lowest of lows = s/s of
major depression
 highest of highs = manic
episode, preceded often
by “hypomania” - one
“feels good”, excitable,
talkative, energized, able
to think/concentrate very
clearly- but not
dangerous to self/others.

Bipolar I Affective Disorder
(MANIC EPISODES)
 feeling
indescribably good
 require little or no
sleep
 easily explode into
anger
 flight of ideas,
impaired
judgment
 lose touch with
reality
 excessively
talkative
 uninhibited; lack of
insight into one‟s
behaviour e.g. of a
sexual nature

Depression
(Postpartum Depression)
Condition diagnosed
within 1 yr. of
childbirth. (not “baby
blues”)
 often under
diagnosed/widely
misunderstood due to
stigmatization

Late-life Depression
Who? - > 65 yrs.
What? – impairment
of mood, thought
context, behaviour =
distress, compromised
social function, poor
self care = sadness,
loss of interest, wt.
changes, fatigue =
inc. suicide risk

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

MAOI‟s
 Disadv. – dietary + drug-drug
interactions causing severe
hypertension.(tyramines in cheese,
meats, red wine are not inactivated;
MAOI + ephedrine); potentiation of
depressant activity of the opioids.
 also dizziness, dry mouth, insomnia,
wt. gain, orthostatic hypotension.

Tricyclic Antidepressants
amitriptyline (Elavil)
clomipramine (Anafranil)
imipramine (Tofranil)
desipramine (Norpramin)
 initially most popular first line Rx.- 1960‟s
 prevent re-uptake of noradrenaline &
serotonin = inc. levels.
 **problems with non-compliance due to
S/E of dry mouth (50%).

Other Side Effects of Antidepressant
Drugs (Tricyclics)
Common: dry mouth, nausea/vomiting,
constipation, urinary retention,
insomnia, sexual dysfunction,
postural hypotension.
Serious: mania, seizures, leukopenia,
cardiac arrhythmias, MI, stroke.

Selective Serotonin Reuptake Inhibitors
SSRIs
fluvoxamine (Luvox)
fluoxetine (Prozac)
paroxetine (Paxil)
sertraline (Zoloft)
citalopram (Celexa)
 inc. use as first line Rx.- 1990‟s. (second generation)
 prevent re-uptake of serotonin from synaptic cleft
resulting in inc. levels of enhanced neuronal activity.
 Adv. – less sedation & cardiotoxicity, < dry mouth(18%)
 Disadv. – GI upset, insomnia, sexual dysfunction, poss.
Inc. in bleeding time.

Electroconvulsive Therapy (ECT)
 for severe depression refractory to
medication.
 ? – a CNS seizure induced via electric
current (under GA) = inc. responsiveness
of neuronal membranes to
neurotransmitters.
 Dental: r/o loose/broken teeth re:
possible aspiration; identify CD/RPD. Use
of bite blocks to protect teeth & tongue.

Drug-Drug Interactions…
Tricyclics & MAOI’s
TCA‟s block re-uptake of levonordefrin
causing dramatic inc. of BP, cardiac
dysrhythmias and delayed cardiac
conduction. **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 of
codeine containing cmpds./erythromycin via
action 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 renal
excretion of lithium, thereby inducing lithium
toxicity.

Side Effects of Long Term Use of
Lithium
• Neurologic lethargy, fatigue, weakness, fine
tremors, memory impairment
• Renal renal failure
• Thyroid lithium-induced hypothyroidism
• CVS T-wave depression on ECG
• GI nausea, vomiting, diarrhea, abdominal
pain
• Hematologic benign leukocytosis
 ORAL xerostomia, lichenoid
stomatitis, metallic
taste sensation

Antidepressant/Mood Stabilizers
Impact on Dental Care
 Mood stabilizers:
Lithium
Oral side effects: xerostomia, lichenoid stomatitis,
metallic taste
 Tricyclic antidepressants:
Amitryptilline, clomipramine, imipramine
Oral side effects: xerostomia, possible potentiation
of pressor effects in epinephrine in local
anesthetics; use of levonordefrin
contraindicated; use of retraction cord with
epinephrine contraindicated.

Antidepressant/Mood Stabilizers
Impact on Dental Care
 Selective serotonin reuptake
inhibitors(SSRIs):
citalopram, fluoxetine, paroxetine,
sertraline, venlafaxine, buproprion
Oral side effects: xerostomia, dysgeusia,
stomatitis, glossitis, bruxism

Summary of Oral Findings
 increased presence of TMD signs (14% of patients with
signs of TMD also have comorbid psych. symptoms c/w
depression i.e. wt. loss, sleep disturbances, energy loss,
changes in concentration)
 increased dental attrition/incidence of bruxism
WHY?
 CNS abnormalities of
a psychiatric patient?
 neuroleptic-induced?
-more research needed

EATING DISORDERS
Anorexia Nervosa
Bulimia
Nervosa
 living in fear of food; of being fat
 diagnosis has reached epidemic
proportions

ANOREXIA NERVOSA
“ceaseless pursuit of
thinness”
 1% of females aged
12 – 25 yrs.
 mostly white/middle
class background.
 extreme
distortion/perception
of body image.

ETIOLOGY OF EATING DISORDERS
genetic
predisposition
societal
pressures
achieve control,
approval
depression,
feelings
of guilt
distorted body
image
extreme exercise
regimen
issues re:
self-esteem

ANOREXIA NERVOSA
Signs & Symptoms
use of laxatives, diuretics
energetic, hyperactive
strenuous exercise regimen
fearful to gain weight (usually
about 15% below normal wt.)
increased incidence in females with
Type 1 diabetes (deliberate avoidance
of taking insulin to induce weight loss)

ANOREXIA NERVOSA
Signs & Symptoms
Progressing to….. amenorrhea,
constipation, kidney dysfunction, UTI,
impaired conc. & rational thinking,
muscle spasms, seizures, intolerance
to cold, hypotension, bradycardia,
alopecia, nail fragility, electrolyte
imbalance, sudden death (ventricular
tachyarrhythmias)

BULIMIA (“ox-hunger”)
NERVOSA
“binge eating and
purging”
 1-5% of females aged
12 – 25 yrs.( more
common than A.N.)
 35% of patients with
Anorexia Nervosa also
suffer from Bulimia .
Bulimia abuse
alcohol/drugs.
Bulimia suffer
personality disorders.

BULIMIA NERVOSA
Diagnostic Criteria
Binge eating twice weekly over a 3
month period of time followed by
self-induced vomiting, laxatives,
diuretics, enemas, excessive exercise
regimens.
(may in fact be of a more normal weight)

BULIMIA NERVOSA
Signs & Symptoms
 compulsive
ingestion of
excessively large
amounts of food.
 depressed upon
the cessation of
eating.
 secrecy
component.
 Russell‟s sign.

BULIMIA NERVOSA
Complications
 aspiration pneumonias.
 esophageal/gastric rupture.
 hypokalemia – cardiac arrythmias.
 pancreatitis.
 Ipecac – induced
myopathy/cardiomyopathy.
 EKG aberrations

MEDICAL COMPLICATIONS
 Anorexia Nervosa: arise as a result of
starvation (restricting) and weight
loss.
 Bulimia Nervosa: related to the mode
and frequency of purging.

Patterns of Dental Erosion
Lingual surface erosive pattern:
 Bulimia (perimyolysis), chronic
gastritis secondary to chronic
alcoholism, GERD.
(+/- affecting the occlusal
surfaces of premolars/molars,
further exacerbated by attrition.)

EATING DISORDERS
Oral Complications
Finding Anorexia Nervosa Bulimia Nervosa
Lingual erosion no yes
Tooth sensitivity no yes
Xerostomia yes yes
Dental caries no yes
Perio. disease no yes
Enlarged parotid** yes yes
Mucosal atrophy yes no
Poor oral hygiene no yes

EATING DISORDERS
Objectives for Preventive Dental Treatment
1. Reduce frequency of acid exposure on
teeth.
 achieving a reduction in the no. of
episodes of vomiting to complete
cessation.
2. Enhance salivary flow.
 sugar free mints, chewing gum to
stimulate salivary flow
 water for oral lubrication

EATING DISORDERS
3. Neutralize acids in the mouth.
 use of alkaline mouth rinse immediately
after vomiting(NaHCO3), water, milk
4. Increase resistance of enamel to
demineralization.
 daily fluoride rinse 0.5%
 fluoride gels (1.1%) in custom trays

EATING DISORDERS
5. Minimize abrasive brushing techniques
 soft brush, circular motion, floss
 avoid brushing immediately after episodes of
vomiting
6. Caries prevention
 NaF varnishes
 sealants?
 snack substitutes
 desensitizing agents

EATING DISORDERS
Dental Tx. Planning
(complex restorative care)
Anorexia Nervosa:
– regain lost weight
– stabilize physical health
Bulimia Nervosa:
– end cycle of binge eating/ vomiting
– temporary coronal coverage followed by eventual
RCT/ cast restorations as required (Relapse is
common if vomiting recurs)
– parental involvement*****

ANXIETY DISORDERS
Anxiety – what is it?
“emotional pain or a feeling that all is
not well-a feeling of impending
disaster”
The physiological reaction/response
occurs via ANS- can include inc. heart
rate, sweating, dilated pupils, inc. urge
of urination, diarrhea.

ANXIETY DISORDERS
 may involve an internal psychological
conflict, environmental stressors,
physical disease, side effects of
medications or combination of these
findings.
 the consequences of anxiety are
profound emotional, occupational and
social impairments.

ANXIETY DISORDERS
Etiology
 no single theory available
 usually a combination of
psychosocial/biological processes
(neurobiological theories)
 low level anxiety can be “normal” but…
anxiety often is a component of other
psychological disorders such as mood
disorders, dementias, panic disorder,
psychoses etc.

ANXIETY DISORDERS
Mild form of anxiety towards
dental care –
Treatment Strategies
1. General attitude/anxiety
reducing treatment
style
 providing trust
 providing control
 providing realistic
information
 apply high level of
predictability
2. Pharmacological support
 pre-medication
 nitrous oxide sedation
3. Teaching of coping
strategies
 distraction
 relaxation
 hypnosis

ANXIETY DISORDERS
POST-TRAUMATIC STRESS DISORDER
Result of exposure to a traumatic event outside of
usual realm of human experiences e.g. during
combat, sexual/physical abuse, MVA, natural
disasters etc.
Cardinal features:
 hyper arousal
 intrusive symptoms
 numbing of one‟s psyche
Diagnosis made if onset of s/s is at least 6 mths. post
trauma 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 for
s/s to develop after traumatic event /
genetic factors contributing to individual
vulnerability***
 80% have co-morbid psych. disorder.
 rate of attempted suicide = 20%

Post-Traumatic Stress Disorder
Dental Findings
• poor OH
• rampant caries/perio
disease
• > abfraction lesions
• chronic atypical facial
pain
• s/e of SSRI‟s
Dental Management
• preventive care
• mgmt. of xerostomia
• oral Ca.screening
• caution re: oral surg.in
long-term alcoholism
• caution re: use of
certain
analgesics,antibiotics,
sedatives

ANXIETY DISORDERS
PANIC DISORDER
 experiencing of recurrent & unexpected panic
attacks not associated with any external event
or situation.
 c/o – palpitations, chest pain, difficulty
breathing, dizziness, sweating- “adrenergic
surge”
 becomes a problem when there is impairment
of one‟s outlook on life & day to day living.

Panic Disorder
5% in females; 2% in males.
~ 1 M Canadians 15 yrs or older.
lifelong illness with variable
response to treatment.
resulting social/occupational
impairments are a massive cost to
society.

Panic Disorder
Diagnosis
r/o medical conditions e.g. MI, hyperthyroidism,
xs. caffeine use, stimulant use, alcohol /drug
withdrawal.
* Subgroup of patients with panic disorder are
found with a unique set of medical problems
including UTD, hypothyroidism and MVP
(mitral valve prolapse) – 8-33% of patients
with panic disorder have MVP vs.~25% of gen.
pop.

ANXIETY DISORDERS
OBSESSIVE-COMPULSIVE
DISORDER(OCD)
Obsessive thoughts and compulsive actions
causing distress and functional impairment.
Obsessions = unwanted, persistent and
recurrent ideas permeating one‟s consciousness
causing significant anguish. May be trivial or
more highly charged thoughts and actions.

Obsessive-Compulsive Disorder
Dental Management
• preventive oral
care
• MD consult re:
current status &
meds.
Dental Findings
• s/e of medication-
induced xerostomia
• somatic obsessions
• > abrasion lesions
(overzealous oral
hygiene practices=
compulsions)

ANXIETY DISORDERS
Dental 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 to
do/not do, possible complications( i.e. pain,
bleeding, infections), who to contact.
**analgesics, +/- antibiotics

Somatoform Disorders
“Psychological disorders
characterized by the presence of
physical symptoms that are not fully
explained by a medical condition, the
effects of a substance, or by another
mental disorder.”

Psychosomatic vs. Somatoform
– Psychosomatic:
disorders in which
there is REAL physical
illness that is largely
caused by
psychological factors
such as stress and
anxiety.
– Somatoform: disorders
in which there is an
APPARENT physical
illness for which there
is no organic basis.

Patients may experience multiple, unexplained somatic
symptoms that may last for years.
Examples:
hypochondriasis
Pre-occupation with fear of having a serious disease on the basis
of one‟s misinterpretation of bodily symptoms/bodily functions.
conversion disorder
Patient resolves an underlying conflict (“primary gain”) by the
unconscious use of the symptom(s). (e.g. conversion
paralysis/blindness) Increased attention as a result = secondary
gain.

body dysmorphic disorder
“pre-occupation with an imagined or exaggerated
defect in physical appearance”
One of the underlying causes of patient
dissatisfaction with certain physical or dental
features such as the appearance of teeth, facial
asymmetry or disproportion of shape and size of
lips, mouth or jaw.

Examples of Oral Symptoms
 burning, painful tongue
 numbness/tingling
sensation of soft tissues
 facial pain

PATH TO DIAGNOSIS
symptoms do not follow known
anatomic nerve distribution.
lab tests/MD consult have r/o
underlying systemic cause e.g.
anemia, CA, diabetes.

Medical Perspective
psychiatric Tx. re: somatoform disorders
focuses on coping vs. cure.
anxiety/depression contribute to s/s in
33% of patients with SD. Treatment of
these conditions will facilitate
management of somatoform disorders.
psychotherapy, SSRI‟s.

CONCLUSION
Dental Perspectives for patients
diagnosed with mental illness
Some patients who undergo psychiatric care for
e.g. depression may be reluctant to admit this
fact due to the stigma attached to the
psychiatric diagnosis.
Dentistry must overcome such barriers:
 obtain all relevant information
 supportive, non-judgmental attitude
 ensuring confidentiality
 emphasizing the need to be provided safe dental
care.

Eating
Speaking
Esthetics
(smiling and self esteem)

The taking of dental
radiographs during
pregnancy continues to be
a controversial issue.
It should be noted,
however, that a pregnant
patient who is properly
shielded can safely
receive dental x-rays at
any time.

You lose a tooth for
every pregnancy
Babies drain the
calcium from your teeth
Every time you are
pregnant your gums
bleed and you have
problems with them
False to all:
Meticulous oral hygiene
with fluoride regimen
will help to prevent all
tooth and gum problems
experienced during
pregnancy

Oral Disease and Systemic Disorders
Periodontitis has an association
with:
• Infective Endocarditis
• Diabetes
• Cardiovascular Disease
• Pre-Term, Low Birth Weight Infants
• Pulmonary Disease

Oral Disease and Systemic Disorders
Periodontitis and pregnancy

Biologic Mechanisms for PTLBW Infants
Entry of inflammatory products (PgE2, Il-6, TNF- α), endotoxin, and/or
periodontal bacteria into the bloodstream and their translocation
to the fetus and decidual tissues

American Academy of Periodontology Report 2004
•Preventive oral care services should be
provided as early in pregnancy as possible.
•If exam indicates a need for periodontal
therapy, these procedures should be scheduled
early in the 2nd trimester.
•The presence of acute infection, abscess, or
other potentially disseminating sources of
sepsis may warrant prompt intervention,
irrespective of the stage of pregnancy.

Recommendations
 Regular dental examinations for all
pregnant patients
 Aggressive periodontal therapy for
infections
 Frequent reinforcement of oral hygiene
and dental care by medical providers

Also know as pyogenic granuloma.
Rare, usually painless lesion, develops on gums in
response to plaque
Non-cancerous

•Subside shortly after childbirth
•No treatment is required unless causes problems
with eating, speaking, or swallowing
•If treatment is needed, it is surgically removed

Preterm Low Birth Weight Births
Smoking, alcohol use, and drug use contribute to mothers having babies that
are 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 more
likely to have a baby that is born too early and too small.

If nausea and vomiting is a problem, it is
important to frequently brush or rinse with
water. The acid could cause erosion of the
teeth.
If you are craving sweets, this could cause
an increase in cavities. So, just remember to
snack on raw veggies and fruits.

Dysphagia
 difficulty in swallowing
 sensation that the food „stops“ in the oesophagus
Cause
 disorder of oesophagus motility – neuro-muscular problems –
multiple sclerosis, myasthenia gravis, Parkinson disease...
 obstruction
 tumor
 psychogenic – phagophobia
 painful swallowing
Cause
 disorder of motility
 obstruction
 infection
 reflux oesophatitis
Odynophagia

Achalasia
 disorder of esophageal motility
 defect of ezophagus peristalsis
Cause
 defect of ezophagus wall innervation
Signs and symptoms
 dificulty swallowing
 regurgitation
 chest pain
 burning sensation in esophagus
Cause
 GERD
Pyrosis

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 the
esophagus caused by a GER
Causes
 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 thorax
through a tear or weakness in the diaphragm - change in the LES
position – change in the LES tonus
Protective mechanisms
 tonic contraction of lower esophageal sphincter
 peristalsis
 neutralization of acidic content by saliva
Gastroesophageal Reflux Disease - GERD

Esophagus
diaphragm
HIS-angle
A - normal anatomy
B – hiatal hernia pre-stage
C - sliding hiatal hernia
D - paraesophageal type

Symptoms
Main symptoms
 Pyrosis – heartburn – chest pain
 Regurgitation
 Dysphagia, odynophagia
 Salivation
 Nausea, vomiting
Other symptoms
 Chronic cough
 Laryngitis, pharyngitis
 Asthma
Oral symptoms
 Teeth hypersensitivity
 Erosion of dental enamel

GERD complications
 Reflux esophagitis
– erosions, ulcers
 Barrett´s esophagus
– metaplasia – replacement of
the epithelial cells from
squamous to columnar
– premalignant condition
 Esophageal adenocarcinoma

Definition
 ulceration in the upper GIT
– stomach
– proximal part of duodenum
– esophagus
Causes
 Helicobacter pylori (70 – 90%)
 Nonsteroidal anti-inflammatory drugs – aspirin, ibuprofen...
 Gastrinoma - Zollinger-Ellison syndrome
– hyperproduction of gastrin from pancreatic or
extrapancreatic (e.g. duodenal) tumourur
 stress
Risk factors
 smoking
 spices
Peptic Ulcer Disase - PUD

Definitions
 Malabsorption – abnormal absorption of nutrients by gut mucosa
 Maldigestion – abnormal digestion of nutrients
Causes
 pancreatic insuficiency
– pancreatitis
– carcinoma
– cystic fibrosis
 cholestasis
– obstruction
 specific deficits
– lactase deficiency
 systemic diseases
– celiac disease
 infection
– Whipple´s disease
 inflammation
– Crohn disease
Malabsorption

Symptoms
Irritable Bowel Syndrome (IBS)

Definition
 a multifactorial inflammatory disease of the
intestines (ileum, large intestine) that may affect
any part of the GIT (from mouth to rectum),
with a variety of GIT and extraGIT symptoms
Cause
 autoimmune process
 genetical predisposition (mutation of NOD2
gene) + external factor (bacterias, milk protein)
 risk factors: smoking, contraceptives
Crohn´s disease

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 - pain
Systemic symptoms
 growth failure
 loss of apetite, wight loss
 fever
 malabsorption
Extraintestinal symptoms
 eye (uveitis)
 skin inflammation - erythema nodosum, pyoderma gangrenosum
 spondyloarthopathy
 autoimmune hemolytic anemia
 finfers deformity
 osteoporosis
 neurological symptoms – seizures, peripheral neuropathy, headache
Symptoms of Crohn´s disease

perianal fistulas perianal fissura
erythema nodosum
pyoderma gangrenosum
uveitis
Symptoms of Crohn´s disease

 bowel obstruction, fistulae, abcesses, perforation, bleeding
 intestinal strictures and adhesions
 infection
 malnutrition, malabsorption
 smal intestinal cancer
Complications of Crohn´s disease

Definition
 an chronic inflammatory bowel disease (colon)
Cause
 unknown
 autoimmune process
 genetical predisposition
 environmental factors
– diet -  fiber content
 protective factor: breastfeeding
Ulcerative colitis

Gastrointestinal symptoms
 diarrhea with blood or mucus
 abdominal pain, cramps
 mouth aphtous ulcers
Systemic symptoms
 loss of apetite, wight loss
Extraintestinal symptoms
 joints – arthritis
 eye - uveitis
 skin - erythema nodosum, pyoderma gangrenosum
 liver – pericholangitis, fatty liver
 blood – hemolytic anemia, tromboembolic disease (rare)
Symptoms of ulcerative colitis

Icterus
• yellowish pigmentation of the skin, sclera and the mucous
membranes caused by hyperbilirubinemia
 over 22 mmol/l - hyperbilirubinaemia
unconjugated bilirubin
conjugated bilirubin
 over 35 mmol/l - icterus

haemoglobin
RES
haem
globin bilirubin
blood
bilirubin
liver
conjugation of bilirubin
bile
intestine
urobilinogen urobilin
 bilirubin production
haemolytic icterus
 conjugation of bilirubin
Gilbert’s disease
Crigler-Najjar syndrome
Lucey-Driscoll syndrome
neonatal icterus
 excretion of bilirubin to bile
Dubin-Johnson syndrome
Rotor syndrome
hepatocellular icterus
intra- a extrahepatic biliar obstruction
gallstones, carcinomas
Disorders of bilirubin metabolism
unconjugated
bilirubin
conjugated
bilirubin

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 membrane
defects, haemoglobin defects
- acquired - toxins, incompatible blood transfusion

Chronic liver insufficiency
Causes
 Viral - hepatitis
 Toxins and drugs – alcohol
 Wilson disease
 hemochromatosis
 autoimmune hepatitis
 heart failure
Complications
 liver encephalopathy – coma
 portal hypertension – ascites, esophageal, rectal - varices
 coagulopathy – bleeding
 cancer
Liver insufficiency

My Contact
 ikassem@dr.com
 You can ge the
lectures form
 http://www.slides
hare.net/islamkass
em/newsfeed
ikassem@dr.com

Medical problems 2 4

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Medical problems 2 4