mental health Flashcards
an inpatient with schizphrenia attends with this social history - dicuss
Smokes 30 tobacco cigarettes per day
past cannabis use
Mother will always attend with patient to appointments
She wishes no teeth to be removed from her son’s mouth.
She feels implants should be provided for her son.
Smoking, alcohol and previous use of substances of misuse and abuse
Cannabis can have a significant impact on dentistry and has an association with Schizophrenia.
Consent? establish whether he has capacity
cannabis impact on dentistry
attend dentist regularly
increased caries rate - xerostomia and increase hunger following cannabis’s action on hormone leptin
increased levels of periodontal disease and gingival enlargement
oral leukoplakias and oral cancer
cannabis impact on cardiovascular system
induces tachycardia with widespread vasodilation
can become an acute medical issue if an adrenaline containing LA is given to the pt during a tachycardic period
Schizophrenia
This is a psychiatric diagnosis. The person will experience both disorder of perception (hallucinations: which can be auditory, visual etc.) and thought (delusions).
causes of schizophrenia
The cause of schizophrenia is not fully understood.
However, there are a number of arguments presented in relation to the aetiopathogenesis:
- Imbalance of neurotransmitters in the brain such as dopamine, serotonin and glutamate
- Genetic predisposition – there is no one particular gene identified but a combination of genes
- There is a role for triggers in the clinical presentation of schizophrenia in a person who is already at risk of the illness such as stress encountered during significant life events e.g. bereavement or loss of a job
- Drug misuse appears to be a trigger in people who are susceptible including the use of cannabis, LSD and cocaine.
- Some experts argue that schizophrenia may be partly a disorder of the brain as it affected during development. However, this argument is not fully accepted as the changes reported are not seen in every person who has schizophrenia.
possible managments for schizophrenia
- drug therapy
- talking therapies
- learning of life skills and coping mechanisms such as cooking, art, music
- exercise
clozapine
not a first line medication for the management of schizophrenia and therefore this gives us some insight into this gentleman’s previous experience with controlling his schizophrenia. It is an a-typical antipsychotic.
side effects including:
- Neutropenia and potentially fatal agranulocytosis – this requires regular blood monitoring
- Myocarditis and cardiomyopathy
Interestingly, this drug is known for causing hypersalivation
psychiatric inpatient consideration for dental tx planning
This will determine what dental treatment should be planned.
He may well have a proposed discharge date which may affect what treatment can be delivered.
Once he is discharged from the IPCU there is a risk we will never see him again.
smoking history - record
a) Smoker, non-smoker or never-smoker
b) Type of substance being smoked – cigarettes, tobacco, cannabis
c) No. of cigarettes per day
d) Period of time the person has been a smoker for
e) Cessation status
smoking and mental health pts
However, some sensitivity around smoking in patient with mental health conditions is required.
- For many, the effects of smoking are beneficial as they find it both relaxing and it becomes habitual.
Patients who are in an IPCU are there because their mental health situation is very severe.
Battling with a patient over smoking cessation in this situation is not justified and it may become a barrier to your ability to be able to provide oral healthcare for them.
- This group of patients, perhaps more than any other group, need to build up trust in you as a person and a healthcare practitioner.
- They are susceptible to perceiving an altered reality through no fault of their own
clozapine and smoking
levels of clozapine present in the plasma can change significantly upon the withdrawal of tobacco smoke.
- can be dangerous and lead to severe toxicity patients in withdrawal.
Thus, any attempts at smoking cessation in patients who are taking clozapine should be done in liason with the consultant psychiatrist.
anaesthesia and mental health patients
Local anaesthetic only
- provides greater scope to attempt to retain some teeth with a view to transitioning this person into an edentulous mouth
Sedation
- Dentist led sedation is contraindicated for patients with active, uncontrolled psychiatric disease.
- may have unpredictable reactions and increased tolerance.
- some clinicians may use this modality in certain circumstances.
General anaesthetic
- taking everything into consideration it is likely that a full clearance would be provided under general anaesthetic.
- patient may well be better seen on an inpatient basis to manage complications of the general anaesthetic and ensure he has appropriate immediate post-operative support and care
if adult pt attends with mother, with poor OH status but she wants implants for her son if he is to have extractions
how to deal with situation
sensitively
- provided the patient has capacity only he can determine his wishes for his mouth.
- maybe heavily influenced by his Mother.
justification by the clinician as to why these would not be appropriate:
- Poor levels of oral hygiene
- Smoking significantly increases the risk of failure of implants
- Implant placement is a longish procedure, if he cannot tolerate more than one tooth being removed at a time he will not tolerate a surgical procedure
- There is value in removing the infected teeth at this stage as the infection is affecting the quality of the bone which the implants will be placed into.
They requested a second opinion. He was referred to a restorative department who again advised that he was not a suitable candidate for dental implants. The patient and his mother have also sought a private source for a further opinion. The private source also declined to place implants for this patient.
describe the soft tissue lesion
The lesion is present on left posterior aspect of the hard palate anterior to the ah line. It does not cross the midline. The lesion represents a full thickness ulcer of 1.5 – 2cm diameter. The appearance is homogenous and there is a clearly defined margin. The lesion appears to be traumatic in nature
describe the dental hard tissues
There are a number of remarkable changes to the hard tissues of the mouth.
- NCTSL This appears to be overwhelming due to erosion. The palatal aspects of the maxillary teeth have been affected There is a translucent appearance to the teeth.
- There is evidence of caries
potential reasons for this pattern of oral disease
The erosive pattern presented here is most likely to be due to gastric secretions.
- However, other causes including acidic dietary factors or chemicals associated with working environments that can cause erosison.
The cause of the gastric secretions could be due to:
- GORD
- Sickness as a side effect of a disease process of medications
- Bulimia Nervosa
- Anorexia Nervosa
how to manage the situation if you feel pt is hiding a medical issue from you
(says asthma only)
not reported any other medical conditions other than Asthma.
Yet, from his presentation to you it is clear there is another significant issue which needs to be addressed.
- most likely to be due to bulimia nervosa.
hugely sensitive and hard conversation to have with a patient.
- responsibility to ensure we are looking after them.
- We can’t just pretend we didn’t see it.
- Unless the root cause is managed any dentistry, you provide will also fail.
It is possible to list a number of causes for the gentleman’s presentation and see if he is willing to open up to you.
- However, there is often resistance to this and your sensitive enquiry may well be met with a wall of anger as a defence mechanism.
If the person does open up to you, you have an opportunity to sign post them in the direction of medical help.
- You cannot manage their mental health but you can facilitate their care.
If the person refuses to disclose their situation to you it can be very difficult to know what to do.
- may choose to speak to other colleagues for an opinion or to the patient’s GMP to discuss their concerns.
- There is a slight risk with speaking to the GMP as the patient has not given their consent to this. However, it is undoubtedly in their best interests.
how to manage this existing disease in bulima nervosa pt
Prevention:
- Desensitising toothpaste, toothpaste with an increased fluoride concentration to manage caries risk and hypersensitivity
- Consider: OHI, DA and Diary, PGI, maybe valuable to take study model to monitor the loss of tooth sturcture
Stabilisation Phase -
- essential that the active caries is stabilised along with NCTSL
- There are significant benefits to using composite in these situations.
- due to the quality of the tooth structure the bonding ability can be impaired.
Re-evaluation
Restorative phase
- If there has been a loss of vertical dimension as a result of the NCTSL - decision has to be made whether you will conform to the existing occlusal scheme or adopt a reorganised approach
