8A. Clinical Considerations Flashcards
Introduction
• Mortality data indicate that those patients who suffer from a serious mental health disorder (schizophrenia, bipolar disorder, major depression) will die, on average, ____ years earlier than the general population.
• This shortened life span is not attributable to increased rates of suicide but rather to the increased rates of ischemic heart disease, type 2 diabetes, respiratory illness, and cancer.
25
Introduction
• Risk factors such as ____, hypertension, and alterations in glucose metabolism arise largely from medication side effects as well as the significant lifestyle differences in those who suffer from severe mental illness.
• An increase in modifiable risk factors (smoking, alcohol & substance use, poor nutrition, and obesity) coupled with inadequate access to health care heighten the risk of morbidity and mortality in this vulnerable population.
obesity
Introduction
• Between 50% and 80% of patients suffering from severe mental health issues ____ compared with approximately 25% of the general population.
• Increased vigilance on the part of the dental professional is required as part of a routine head and neck examination whenever opportunistic screening is available.
smoke
Psychiatric Considerations
Type, severity, and stage of mental illness
• Mental illness is regarded as a chronic disease with symptoms that tend to ____.
• The symptoms depend on the diagnosis, as well as the response to medications and psychotherapy.
• In some situations, ____ symptoms may be the first presenting feature identified by the dental practitioner of an underlying mental health problem.
fluctuate
oral
Psychiatric Considerations
Mood, motivation and self-esteem
• Preventive dental education remains a critical for patients suffering from psychiatric illnesses.
• Due to the ____ and recurrent nature of these conditions, the dental practitioner may need to apply modifications to oral care treatment regimens.
• Mental illness can result in poor ____, unreliable attendance, and late cancellation of appointments.
• Irregular attendance is often fueled by fear, anxiety, and lack of consistent financial resources or support
episodic
compliance
Psychiatric Considerations
Mood, motivation and self-esteem
• Dental patients may be reluctant to ____ a history of psychiatric care because of the stigma and embarrassment that they feel and because they often do not understand how it relates to their dental care.
• The dental practitioner must understand more than just the diagnosis: The severity, treatments, and effectiveness of those treatments are important to understand.
disclose
Psychiatric Considerations
Lack of perception of oral health problems
- If the patient is unable or unwilling to believe that oral health needs are important, the oral health will quickly suffer.
- This may necessitate more frequent appointment ____ or other treatment modifications, particularly for those patients suffering from xerostomia secondary to psychotropic medications
scheduling
Psychiatric Considerations
Patient’s habits, lifestyle and ability for self-care
• Individuals with mental illness often experience a ____-burden that includes not only the signs and symptoms associated with a specific condition, but also the ____ and discrimination that create barriers to receiving health care resources.
double
stigma
Psychiatric Considerations
Side effects of medications
• Along with the various modalities of psychotherapy, ____ remains a cornerstone for the stabilization and long-term management of most psychiatric illnesses.
• Like many medications, psychotropic medications can have significant ____ effects that manifest within the oral cavity.
pharmaco-therapy
side effects
Psychiatric Considerations
Side effects of medications
• ____ remains the most common and frequently
reported side effect of these medications resulting in:
-Increased incidence of caries (especially root caries)
-Gingivitis
-Stomatitis
-Oral ulceration
-Dysphagia
-Burning mouth
-Diminished taste acuity
-Difficulty chewing and speaking
-Increased susceptibility to candidal infections.
xerostomia
Psychiatric Considerations
Side effects of medications
• Drug-induced orofacial movement disorders or oral dyskinesias are represented by abnormal involuntary movements.
• One subtype, ____ dyskinesia, is a complication seen in approximately 25% of patients undergoing treatment with some antipsychotic drugs (____ and haloperidol).
• The incidence has decreased with the more widespread use of the atypical ____ such as olanzapine, risperidone, quetiapine, ziprasidone, and clozapine, but may still develop as a long-term side effect.
tardive
chlorpromazine
antipsychotics
Psychiatric Considerations
Side effects of medications
• Facial grimacing, lip smacking, jerky tongue movements, and generalized head and neck tremors are features of tardive dyskinesia and depending on severity, may significantly impact the provision of dental care.
• This is ____ – if it impacts delivery of care, the dental practitioner should contact the mental health provider and discuss changing ____.
involuntary
medications
Psychiatric Considerations
Side effects of medications
• An increased incidence of both clenching and bruxism has been reported with the use of the ____ class of antidepressants, thought to be a consequence of the effect these drugs have on ____ receptors.
• The practitioner should follow ____ symptoms and dental health closely.
selective serotonin reuptake inhibitor (SSRI)
serotonergic
TMJ
Psychiatric Considerations
Overcoming barriers to oral health care
• Studies have shown that individuals suffering from psychiatric disorders experience disparities in the quality of health care services and achievement of expected screening, diagnostic, and treatment benchmarks.
• Among individuals with severe mental illness, ____ health care is frequently overlooked by other healthcare providers and simply noted as “poor dentition.”
oral
Psychiatric Considerations
Overcoming barriers to oral health care
• Patients with mental health issues bring unique needs and differing priorities to a dental practice.
• The dental health practitioner must demonstrate ____, flexibility, empathy, and a nonstigmatizing attitude in caring for these patients.
patience
Neurodevelopmental Disorders
Autism spectrum disorder (ASD)
- ASD involves a decrease in ____ communication/ interaction and is associated with ____ patterns of behavior, interest, and activity.
- Sensory sensibility, hyperactivity, and self- ____ are common problems among ASD patients, causing difficulty in communication as well as making routine dental visits difficult.
social
repetitive
aggression
Neurodevelopmental Disorders
Autism spectrum disorder (ASD)
• The chief oral health problems observed in these individuals are difficulty with ____ control, dental ____, and ____ disease.
• Some children with ASD may have significant ____ about going to the dentist. This may result in uncooperative behavior and difficulty complying with any dental procedures.
biofilm
caries
periodontal
anxiety
Neurodevelopmental Disorders
Autism spectrum disorder (ASD)
• ____ techniques and a gradual approach of learning to tolerate dental procedures may be necessary.
• This will involve a series of ____ visits to the dental practitioner. Each visit should involve practicing a specific behavior and should end on a ____ note.
• For example, a first visit may simply involve walking into the dental practitioner’s office, other visits will slowly build on this.
desensitization
short
positive
Neurodevelopmental Disorders
Autism spectrum disorder (ASD)
• Despite attempts to engage patients with ASD, ____ or general anesthesia may be required to complete the necessary treatment safely.
• Generally speaking, patients with ASD are physiologically ____ and there are no specific contraindications to sedation.
• However, they may not comply with starting an IV or N2O sedation (____ sedation may be required).
sedation
healthy
IM
Schizophrenia Spectrum Disorders
Schizophrenia
• Schizophrenia represents a form of psychotic illness that affects mood, thought, and behavior.
• Individuals lose touch with ____, becoming increasingly unsure whether their thoughts and experiences are real.
• These thought disturbances and aberrant behaviors, reduce their ability to maintain self-____, or to maintain meaningful social and work relationships.
• Lack of ____ to perform activities of normal daily living, including oral care, is unfortunately often misconstrued by others.
reality
care
motivation
3 types of symptoms in schizophrenic patients:
• 1. Positive symptoms — these behaviors should ____ be present
◦Example: “Barack Obama is giving me an award tomorrow bc I saved a cat”
• 2. Negative symptoms — behaviors that should be ____, but are not
◦Example: these patients can seem kinda “flat” (lack emotion)
• 3. Disorganized symptoms — their minds/thoughts are going from one ____ to another
not
present
place
Schizophrenia Spectrum Disorders
Schizophrenia
• Delusional or paranoid ideation will affect the acceptance of dental treatment and often leads to extended periods of ____.
• Rampant decay may be diagnosed at such a time that ____ are often inevitable.
• Delusional thoughts may focus directly on the oral cavity. Suspicions may be aroused that restorations placed into one’s teeth may in fact contain tiny ____, etc.
neglect
full mouth extractions
transmitters
Schizophrenia Spectrum Disorders
Schizophrenia
• Acts of orofacial self-mutilation have been reported, particularly in those individuals at the height of an ____ psychotic episode.
• These acts have included multiple ____, glossectomy, self-enucleation of the eye, ____ of gingival tissues, and burning of the gingiva with caustic substances.
acute
autoextractions
excoriation
Schizophrenia Spectrum Disorders
Schizophrenia
• A caregiver or ____ should accompany the patient to the office.
• For patients who are not able to perform oral hygiene procedures, a family member/caregiver should be instructed.
• Consider artificial saliva products, ____, and fluoride mouth products to promote good oral hygiene.
• Patients should be recalled at ____-month intervals for examination, oral prophylaxis, and application of a fluoride gel or varnish.
family member
chlorhexidine gluconate
3
Schizophrenia Spectrum Disorders
Schizophrenia
• If the standard approach does not allow for proper dental management, the dentist should consider ____, which should be provided in consultation with the patient’s physician.
• ____ are frequently used.
sedation
benzodiazepines
Schizophrenia Spectrum Disorders
Schizophrenia
• Antipsychotic medications may add or potentiate the actions of other CNS depressants such as ____.
• When these agents are used, caution must be exercised to avoid excessive ____ depression, hypotension, ____, and respiratory depression.
opiate analgesics
CNS
orthostatic hypotension
Schizophrenia Spectrum Disorders
Schizophrenia
• Clozapine is an atypical antipsychotic medication that carries a 1% risk of ____ (white blood cell count <3000/mm3).
• The dental practitioner should evaluate for signs and symptoms of ____, including fever, pain, and oral ulceration.
• Also, 1/3 of patients taking this will complain of ____ (sialorrhea). This effect is not well understood.
agranulocytosis
infection
drooling
Bipolar and Related Disorders
Bipolar disorder
• Patients experiencing a ____ or hypomanic phase of bipolar disorder may be aggressive with their daily oral hygiene (excessive ____ lesions to the teeth, gingival lacerations).
manic
abrasion
Bipolar and Related Disorders
Bipolar disorder
• Lithium, which is used to manage bipolar disorder has
a ____ therapeutic index.
• Lithium can cause ____ and stomatitis.
• Concurrent use of lithium and ____ or erythromycin, can cause lithium toxicity.
• Lithium toxicity can cause ____, seizures, kidney failure, hyperthermia, and even death.
narrow
xerostomia
NSAIDs
tremors
Bipolar and Related Disorders
Bipolar disorder
• Patients who do not respond to lithium are usually treated with a ____ drug.
• Phenothiazines can cause ____ suppression and fluctuations in blood pressure.
• The clinician should examine the patient for signs of ____ and leukopenia which can lead to infection or excessive bleeding.
• Phenothiazine drugs ____ the sedative action of sedative medications.
phenothiazine
bone marrow
thrombocytopenia
potentiate
Depressive Disorders
Major depressive disorder
• Patients experiencing a major depressive episodes will often show a total ____ for maintaining any daily oral hygiene care.
• Salivary gland output may ____ and along with an increased consumption of carbohydrates, patients are at increased ____ and periodontal disease.
• Complaints of ____ (burning mouth) and various facial pain syndromes are common.
disregard
decrease
caries
glossodynia
Depressive Disorders
Major depressive disorder
• No medical ____ to dental treatment during a depressive episode has been recognized.
• Most depressed patients, however, may be best served by addressing only their ____ dental needs during the depressive episode.
• When the patient has responded to ____ treatment, more complex dental procedures can be performed.
contraindication
immediate
medical
Depressive Disorders
Major depressive disorder
• The classes of medications used to treat depression include:
-____: fluoxetine (Prozac), sertraline (Zoloft).
-____: duloxetine (Cymbalta), venlafaxine (Effexor).
-____: bupropion (Wellbutrin).
-____: Amitriptyline
-____: tranylcypromine (Parnate)
SSRI SNRI atypica antidepressants TCAs MAOIs
Depressive Disorders
Major depressive disorder
• There is highly contradictory evidence and controversy in the literature about the possible drug interactions with antidepressants.
• There is an ____ of detailed, broadly based studies which could be used to clarify the situation.
• Furthermore, few case reports of drug interactions in dental practice have been published.
absence
Depressive Disorders
Major depressive disorder
• SSRIs do not interact with ____.
• SNRIs block norepinephrine uptake and have the potential to interact with ____,
resulting in pressor responses.(Increased ____)
• TCAs have the potential to interact with ____ and should be limited or avoided.
• MAOIs may interact with ____ so care should be used.
vasoconstrictors vasoconstrictors BP vasoconstrictors vasoconstrictors
Anxiety Disorders
Generalized anxiety disorder
• Potentially painful dental procedures can be a source of anxiety for patients. Dental related anxiety can be categorized as a specific, situational phobia.
• Generalized Anxiety Disorder (GAD), is characterized by excessive, uncontrollable, and often, irrational ____ about everyday life, that is disproportionate to the actual source of worry.
• Patients with GAD have a ____x the risk of dental anxiety.
worry
2
Anxiety Disorders
Generalized anxiety disorder
• Opening a dialogue about the patient’s anxiety may help the practitioner better understand their patient, and help them take the necessary steps to alleviate the patient’s anxiety.
• The most common concerns are ____, disfigurement, pain, a sense of vulnerability, and a fear of the unknown.
• Fear of ____ is the most prevalent fear amongst dental patients.
• Patients will focus on ‘____ injections and procedures.’
death
pain
painless
Anxiety Disorders
Generalized anxiety disorder
• Remember, pain and anxiety are interrelated states: anxiety ____ the pain threshold and an innocuous stimulation, may be experienced as ____.
• Fear of vulnerability: Dental care is often carried out in a manner that makes patients feel ____ and helpless (reclined and unable to observe their own treatment).
• Fear of the unknown: The procedure may not fully be ____ by the patient.
lowers
painful
vulnerable
understood
Anxiety Disorders
Generalized anxiety disorder
• Recognizing dental ____ in patients with GAD is important.
• Obverse for signs and symptoms of dental anxiety: ____; cold and diaphoretic hands; diaphoresis; ____ behavior or apparent unease; stiff or awkward posture; and “____ syndrome” or clenching of the dental chair.
• A review of the dental record may reveal another red flag: a history of ____ appointments for routine and preventative care, coupled with only seeking ____ care.
anxiety trembling hypervigilant white-knuckle broken emergency
Anxiety Disorders
Generalized anxiety disorder
• Management of the anxious patient can be done with ____ management or sedation.
• A ____ visit is an opportunity to explain the nuances of the procedure in a neutral, non-clinical setting such as a consultation room rather than the operatory.
• ____ or positive terms should be used to explain the procedure (rather than using the word ‘pain’ use ‘pressure’).
behavior
pre-operative
neutral
Anxiety Disorders
Generalized anxiety disorder
• Effective ____ prior to the procedure is important in demystifying the “unknown.”
• A discussion of patient ____ of the procedure and postoperative course creates an opportunity to educate patients regarding any misconceptions they may have.
• Furthermore, an informed discussion of the ____, benefits, and alternatives to the procedure and any sedation modalities can be reviewed.
communication
perceptions
risks
Anxiety Disorders
Generalized anxiety disorder
• Pharmacologic options for sedation include the use of ____, inhalation agents (N2O), and general anesthesia.
• Sedation is often most effective when used in combination with ____ guidance techniques.
• ____ medication is needed when behavior management is used in conjunction with sedation as compared to when using sedation alone.
oral sedatives
behavioral
less
Obsessive Compulsive and Related Disorders
Obsessive compulsive disorder (OCD)
• An anxiety disorder whereby individuals will describe the presence of ____, preoccupying thoughts that make them anxious and upset.
• The individual will carry out ____ or repetitive behaviors (most commonly cleaning and checking) to alleviate their anxiety.
• Such compulsive behavior begins to dominate a person’s life interfering with day-to-day activities, relationships and work.
• This can lead to ____ and depression.
intrusive
compulsive
embarrassment
Obsessive Compulsive and Related Disorders
Obsessive compulsive disorder (OCD)
• Oral manifestations may include ____ oral hygiene practices (tooth brushing, prolonged use of mouthwashes) that may lead to excessive tooth or soft tissue ____.
overzealous
trauma
Obsessive Compulsive and Related Disorders
Body dysmorphic disorder
• With body dysmorphic disorder, the individual develops a preoccupation with an exaggerated defect in some aspect of their physical ____.
• This condition may be one of the underlying causes of patient dissatisfaction with certain physical or dental features, such as facial asymmetry, or the shape and size of lips and jaws or the appearance of the teeth.
• The dental practitioner must show increased vigilance to the potential presence of ____ concerns, particularly in planning comprehensive esthetic treatment plans.
appearance
disproportionate
Trauma and Stressor Related Disorders
Posttraumatic Stress Disorder (PTSD)
- PTSD is a syndrome of psychophysiologic signs and symptoms that develop after exposure to a traumatic event outside the usual range of human experience, such as combat exposure, rape, or a civilian disaster such as a hurricane.
- The three cardinal features of PTSD are ____; ____ to the initial trauma; and ____
hyperarousal
flashbacks
psychic numbing
Trauma and Stressor Related Disorders
Posttraumatic Stress Disorder (PTSD)
• Diagnostic criteria for PTSD consist of a history of a ____ experience and reexperiencing of the event through ____ memories, disturbing dreams, “flashbacks,” and psychological or physical distress in response to reminders of the event; another criterion is ____ of things associated with the trauma.
traumatic
intrusive
avoidance
Trauma and Stressor Related Disorders
Posttraumatic Stress Disorder (PTSD)
• First-line treatment for PTSD consists of ____ (exposure therapy, group therapy, patient and family education) and ____ therapy.
• Second-line treatment consists of a combination of ____ and ____ therapy. ____ and ____ are frequently used.
psychotherapy cognitive-behavioral psychotherapy pharmacologic SSRIs benzo's
Trauma and Stressor Related Disorders
Posttraumatic Stress Disorder (PTSD)
• During the ____ stage of PTSD, patients often show a total disregard for oral hygiene procedures and are at increased risk for development of dental caries, periodontal disease, and pericoronitis.
• They may report atypical facial pain, glossodynia, temporomandibular joint (TMJ) disorder, and bruxism.
• They may associate dental treatment with loss of ____; so good ____ is essential to developing trust.
depressive
control
communication
Somatic Symptom and Related Disorders
Somatic symptom disorder
• Patients who have been diagnosed as suffering from a somatoform disorder may present with complaints of ____ symptoms suggestive of a physical disorder but for which there is no demonstrable underlying ____ basis.
• The characteristics of a somatoform disorder include the following:
-No ____ lesion or pathologic condition can be found.
-The disorder or reaction has an ____ cause.
-The disorder is not ____ to the patient.
-The disorder is a ____ for the patient in terms of reducing the level of anxiety.
physical physical identifiable emotional dangerous defense
Somatic Symptom and Related Disorders
Somatic symptom disorder
• Reducing anxiety by converting it into a symptom is called ____.
• Patients also may have ____ as a result of their condition - for example, because of their symptoms, they may not be able to ____, or they may receive increased ____ from their family.
primary gains
secondary gains
work
attention
Somatic Symptom and Related Disorders
Somatic symptom disorder
• Examples of oral symptoms that can be produced by somatoform disorders are ____ tongue, numbness of soft tissue, and pain in the facial region.
• The diagnosis of a somatoform disorder should be made only after the following criteria have been met:
- A thorough search from a clinical standpoint has ____ to provide any evidence of a disease process that could explain the symptoms.
-The symptoms have been present ____ enough that if they were related to a disease process, a lesion would have developed.
-Symptom localization does not reflect known anatomic distribution of ____.
-Underlying systemic conditions that could produce the symptoms have been ruled out by ____ or by referral to a physician.
burning failed long nerves laboratory tests
Somatic Symptom and Related Disorders
Somatic symptom disorder
• The process of establishing the diagnosis of somatoform disorders is ____ and time consuming.
• Dental treatment should ____ be provided on the basis of a patient’s symptoms unless a dental cause can be found.
• Many patients have undergone needless ____, root canal treatments, and other procedures in an attempt to address somatoform symptoms.
• The diagnosis of a somatoform disorder should not be reached until a thorough search has been made over time that ____ to uncover pathologic findings that could explain the symptoms.
slow
not
extractions
fail
Somatic Symptom and Related Disorders
Somatic symptom disorder
• Management of these patients can be difficult.
• They should be ____ that they do not have a life- threatening diseases such as cancer.
• A series of regular ____ appointments should be scheduled to reexamine the patient for possible signs of disease, to discuss symptoms, and to provide ____ that tissue changes are not clinically evident.
assured
short
reassurance
