3. 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
6. 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
7. 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
18. Risk for Injury Related to
Hyperglycemia
Interventions include:
– Dietary interventions, blood glucose
monitoring, medications
– Oral Drugs Therapy
(Continued)
ikassem@dr.com
19. Risk for Injury Related to
Hyperglycemia (Continued)
– Oral therapy
Sulfonylurea agents
Meglitinide analogues
Biguanides
Alpha-glucosidase inhibitors
Thiazolinedione antidiabetic agents
ikassem@dr.com
20. 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
32. 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
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 function
ikassem@dr.com
38. 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
45. 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
46. There is no treatment preference with
regard to fixed or removable appliances. It
important to stress good oral hygiene,
ikassem@dr.com
47. specific diabetic changes in the
periodontium are more pronounced after
orthodontic tooth movement.
ikassem@dr.com
49. A leading cause of SICKNESS and
DEATH
Coronary Heart Disease
ikassem@dr.com
50. 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
51. 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
52. 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
54. Ischaemic heart disease
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
55. Ischaemic heart disease
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
56. Risk Factors for Ischemic Heart
Disease
Family History
Smoking
Hypertension
Diabetes Mellitus
Hypercholesterolaemia
Lack of exercise Obesity
Age & Sex
PRIMARY PREVENTION
ikassem@dr.com
66. 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
67. 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
68. 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
70. Ischaemic heart disease
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
71. 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
72. 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
74. 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
75. Acute Myocardial Infarction
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
77. 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
78. 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
79. Acute Myocardial Infarction
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
80. 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
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 heart
disease is
– The emotional state of the patient
– The type of dental procedureikassem@dr.com
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 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
83. 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
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. 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
86. 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
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 bleeding
because of decreased platelet aggregation
Dental Considerations for IHD
ikassem@dr.com
88. Dental Considerations for IHD
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
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 more
nitroglycerin, assume MI
101
Give chewable aspirin ABC‟s
ikassem@dr.com
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 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
91. 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
92. 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
93. 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
94. 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
95. 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
96. Obese patients tend to have flatter or
more concave profiles because of
increased mandibular length and
increased tissue thickness.
ikassem@dr.com
97. 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
100. Dentistry and Health
Consistent brushing and flossing and
routine dental hygiene critical to
maintenance of oral health
– Psychology as the
science of behavior
103. Psychology and Dentistry
Special needs populations
– Mentally challenged
– Chronically ill
– Geriatrics
Public health
– Community interventions
104. Psychology and Dentistry
Quality of life
– Craniofacial abnormalities
– Edentualism
Esthetic dentistry
– Orthodontics
– Crowns, veneers
– Reconstruction
105. Psychology Skills Useful for Dental
Students
Communication
Fear/anxiety management
Management of disruptive child
Patient interventions to enhance self-care
– Motivational interviewing
Pain management
106. 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.
107. 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.
108. 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.
109. “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…
110. 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…
111. 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.
112. 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?
113. 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.
115. 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.
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(>vulnerability
to medical problems (lifestyle)
117. 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
118. 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
119. 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)
121. 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).
122. 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)
123. 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)
124. 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.
126. Schizophrenia-Medication Side Effects
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
127. 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.
128. 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.”
129. 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.
130. 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.
131. 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.
132. 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
133. 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…
134. 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.
135. 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.
137. 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.
138. 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
140. 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.
141. 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)
142. 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
143. 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.
144. 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
146. 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
147. 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.
148. 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.
149. 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%).
150. 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.
151. 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.
152. 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.
153. 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.
154. 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.
155. 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
156. 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.
157. 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
159. 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
161. ANOREXIA NERVOSA
“ceaseless pursuit of
thinness”
1% of females aged
12 – 25 yrs.
mostly white/middle
class background.
extreme
distortion/perception
of body image.
162. 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
163. 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)
165. 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 .
35% of patients with
Bulimia abuse
alcohol/drugs.
50% of patients with
Bulimia suffer
personality disorders.
166. 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)
167. BULIMIA NERVOSA
Signs & Symptoms
compulsive
ingestion of
excessively large
amounts of food.
depressed upon
the cessation of
eating.
secrecy
component.
Russell‟s sign.
169. MEDICAL COMPLICATIONS
Anorexia Nervosa: arise as a result of
starvation (restricting) and weight
loss.
Bulimia Nervosa: related to the mode
and frequency of purging.
170. 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.)
171. 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
172. 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
173. EATING DISORDERS
Objectives for Preventive Dental Treatment
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
175. 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*****
176. 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.
177. 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.
178. 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.
179. 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
180. 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.
181. 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%
182. 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
183. 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.
184. 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.
185. 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.
186. 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.
187. 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)
188. 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
190. 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.
191. Somatoform Disorders
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.
192. Somatoform Disorders
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.
193. Somatoform Disorders
Examples of Oral Symptoms
burning, painful tongue
numbness/tingling
sensation of soft tissues
facial pain
194. Somatoform Disorders
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.
195. Somatoform Disorders
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.
196. 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.
199. 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.
200. 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
201. Oral Disease and Systemic Disorders
Periodontitis has an association
with:
• Infective Endocarditis
• Diabetes
• Cardiovascular Disease
• Pre-Term, Low Birth Weight Infants
• Pulmonary Disease
202. Oral Disease and Systemic Disorders
Periodontitis and pregnancy
203. Oral Disease and Systemic Disorders
Periodontitis and pregnancy
204. 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
205. 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.
Dental Considerations
207. Recommendations
Regular dental examinations for all
pregnant patients
Aggressive periodontal therapy for
infections
Frequent reinforcement of oral hygiene
and dental care by medical providers
208. Also know as pyogenic granuloma.
Rare, usually painless lesion, develops on gums in
response to plaque
Non-cancerous
209. •Subside shortly after childbirth
•No treatment is required unless causes problems
with eating, speaking, or swallowing
•If treatment is needed, it is surgically removed
210. 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.
211. 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.
214. 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
215. 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
216. 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
225. 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
232. 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
233. 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
234. 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
