Dental care for the patient with schizophrenia.

ABSTRACT

Background: Dental hygienists will often be required to treat people who have psychiatric disorders such as depression, bipolar disorder and schizophrenia. Often the signs and symptoms of these illnesses are not obvious so it is incumbent upon the dental health practitioner to have a basic understanding of the more common psychiatric disorders including their presentation and medical management. Discussion: This knowledge will be important in the further understanding of the many oral health problems that may arise as manifestations of a particular mental illness including the side effects of the numerous psychotropic medications used in the pharmacotherapeutic management of these disorders. Because psychiatric problems often are invisible, one may not acknowledge the associated and very real impairments that are indeed an integral part of each disorder. The focus is on a description of one of the most serious of all psychiatric diagnoses, schizophrenia, and a review of the impact this illness may have from a dental health practitioner's perspective. Conclusion: The implications for this illness on a patient's oral health, the contribution to specific oral clinical findings, and the considerations for dental management are highlighted.

RESUME

Contexte: Les hygienistes dentaires doivent souvent soigner des personnes qui ont des troubles psychiatriques, telles la depression, la psychose maniacodepressive ou la schizophrenie. Les signes et symptomes de ces maladies ne sont pas toujours evidents. Il incombe donc aux praticiens des soins dentaires d'avoir des connaissances de base au sujet des troubles psychiatriques les plus communs et de leurs manifestations ainsi que de la prise en charge medicale. Discussion : Ces connaissances seront importantes pour mieux comprendre les problemes de sante buccodentaire dont les manifestations pourraient resulter d'une maladie mentale particuliere, y compris les effets secondaires de nom-breux medicaments psychotropes utilises dans le traitement pharmaceutique de ces troubles. Comme les problemes psychiatriques sont souvent invisibles, on peut ne pas reconnaitre les deficiences reelles qui y sont associees et font effectivement partie de chacun d'entre eux. L'on se concentre sur la description d'un des plus serieux diagnostics psychiatriques, la schizophrenie, et passe en revue les impacts que cette maladie peut avoir sur la prestation des soins buccodentaires. Conclusion: L'article met l'accent sur les implications de cette maladie sur la sante buccodentaire du patient, la contribution des caracteristiques cliniques buccales particulieres et la gestion de la pratique dentaire.

Key words: schizophrenia, antipsychotic medications, adverse effects, oral health complications

**********

In any given year approximately 1 in 5 adult Canadians will experience and suffer from some form of mental illness. (1,2) In Canada, approximately 85 per cent of hospitalizations for mental illness occur in general hospitals with approximately 1 in 12 hospital beds used for patients with schizophrenia. This represents more beds than those needed for any other single illness outside of cardiovascular diseases. (3) Epidemiological studies in Canada reveal that schizophrenia affects approximately 1 per cent of the Canadian population (1 in 100 adults) and the onset of the illness is often in late teens to early adulthood, at a time when people are pursuing further educational opportunities or embarking on a new career path. (1) While men and women are affected equally by the illness, symptoms often tend to develop earlier in males. Schizophrenia occurring in children is rare, with a reported incidence of approximately 1 in 40,000 children. Symptomatology is essentially the same as for that displayed in adults although difficulty may be encountered in differentiating this from other disorders such as autism. After the age of 45, in what is referred to as late-onset schizophrenia, women tend to have higher rates of the illness including rates of hospitalization compared to men. The implication of these statistics means that virtually every oral health care practice will include patients who are suffering from a particular psychiatric illness but whose symptomatology is often not obvious or easily recognized. The client's thoughts, behaviour, emotions, general health and social relationships are invariably involved and affected by psychiatric illness and further exacerbated by the specific treatments used in the management of these conditions.

WHAT IS SCHIZOPHRENIA?

Mental illnesses can take many forms including such common psychiatric diagnoses as mood disorders (major depression, bipolar disorder), anxiety disorders, eating disorders, panic disorders, and schizophrenia. Schizophrenia however is quite distinct from bipolar illness and panic disorders, and while first identified as a discrete mental illness in 1887, did not become so named until 1911. (4) The word has Greek origins, split (schizo) and mind (phrenia), a mind split from reality. This early definition contributed to the misperception of the illness being confused with someone having a split personality which is a distinct and less common psychiatric disorder. Schizophrenia represents the most common and serious form of psychosis affecting mood, thought and behaviour, and for which there is currently no cure. A psychosis is an extremely disordered pattern of thought, perception, emotion and behaviour. Consequently the psychotic person will have a very bizarre sense of reality accompanied by emotional and cognitive impairments leading to the loss of normal function in his/her environment. Because schizophrenia affects an individual's ability to function effectively in selfcare, family relationships, school, employment and social life in general, this illness is sadly overrepresented in both the prison and homeless populations. A common misconception about schizophrenia and psychiatric illness in general, is that most patients are violent and dangerous. This has been fuelled for decades largely by the media as well as the print and film industries. In reality, only about 5 per cent or less are considered dangerous and this encompasses those individuals who exhibit primarily acute psychotic symptoms (e.g. from non compliance with medications) often exacerbated with the use of street drugs or alcohol or their combination. Individuals suffering from psychiatric illness in general are often the victims of crime rather than the perpetrators of these events. (2) Substance abuse involves up to 80 per cent of those affected with schizophrenia and can result in reduced effectiveness of ongoing treatments, exacerbation of symptoms and a higher tendency towards non compliance for treatment regimens. 40-60% of patients with schizophrenia will attempt suicide with 10-15% (5,6) ultimately achieving this end.

GENETIC AND ENVIRONMENTAL FACTORS

While the etiology of schizophrenia continues to remain unclear, genetic factors have begun to be implicated in the etiology and pathogenesis of not only this disease but many other psychiatric disorders as well. Children with one parent suffering from schizophrenia have a 10-13% risk of developing the illness. This figure will jump to almost 46 per cent if both parents suffer from schizophrenia. For first-degree relatives, the risk for developing schizophrenia is 5-10% while for second-degree relatives, the risk is 2-4%. (6,7) A combination of genetic and biochemical factors are now considered to be increasingly responsible for the development of functional abnormality and hyperactivity at dopaminergic receptor sites in the brain causing the positive, disorganized and negative symptoms of the illness. Abnormal regional cerebral blood flow and cerebral metabolism has also been reported in some patients. (8) More recently, diagnostic imaging studies (MRI, CT, PET) are showing evidence of cerebral atrophy, ventricular enlargement and other anatomic abnormalities in the brain structure of patients with schizophrenia. (9) This evidence offers further support for an organic component to the etiology of this disease. It also appears that schizophrenia may be triggered by certain environmental events in an individual genetically predisposed to this illness. Substance abuse, stressful psychosocial events, medical illness and the chronic stress of poverty all have been reported to be so-called trigger factors unmasking this underlying disease. (6)

SYMPTOMS

There are two illnesses which, while sounding similar to schizophrenia, are distinct disease entities. Schizoaffective disorder shows features of both schizophrenia and a mood disorder (e.g. depression) simultaneously. On the other hand, schizophreniform disorder must include two or more symptoms of schizophrenia but unlike schizophrenia, the disorder lasts a much shorter time of 1-6 months.

As with other psychiatric illnesses, a diagnosis of schizophrenia is generally made on the basis of a cluster of particular symptoms, each with a clinical significance or impairment criterion. It is this methodology that comprises the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM IV) which is the standard reference for defining and classifying psychiatric disease in North America. (10) There is currently no blood test, X-ray or CT scan that will provide a diagnosis of schizophrenia. The longterm outcome of schizophrenia varies greatly between individuals. While approximately 25 per cent may experience a significant remission of the symptoms of the disease, (with ongoing medication and psychotherapy), another 25 per cent may exhibit mild yet persistent symptoms. However, the larger number of those affected (approximately 50 per cent) will describe having chronic moderate to severe signs and symptoms throughout their lifetime. (6)

The symptomatology profile of schizophrenia comprises what are referred to as positive, negative and disorganized symptoms. (6,7,11) During an acute phase of the illness, psychotic symptoms predominate and represent the so-called "positive" indications of the illness. These are not good symptoms but rather those aspects of the disease which should not be present in a healthy person. Such positive symptoms will include delusions, hallucinations, thought disturbances and sometimes a catatonic behaviours in the individual. A predominance of positive symptoms is considered to correlate with an ultimately better response to current pharmacological management of the illness. Auditory hallucinations are among the most prevalent of the positive symptoms and may present with the patient hearing the voices of others often making either complimentary, reassuring comments or more often negative, punitive or defamatory comments about them. The latter comments may prove critical in contributing towards any attempts at suicidal behaviour. The reduction in the frequency of hearing these voices is often an important standard by which the effectiveness of a particular anti-psychotic medication is gauged. The cause of these voices is poorly understood but several theories have been put forward to explain this phenomenon. One theory proposes a malfunction in the communication system within the brain whereby, because of an increase in dopamine receptors or the heightened sensitivity of such receptors, perceptions coming in overwhelm the ability of the brain to discern, direct and assimilate each message. As a result, there will be a misdirection of such signals resulting in a disturbance of normal thought, emotional and response processes for that individual. (3) Very recent studies using MRI have discovered specific structural and functional abnormalities in the brain regions associated with the capacity of human voice processing in patients with schizophrenia experiencing chronic auditory hallucinations. Identifying and marking such regions may in time elicit more effective treatment strategies. (12)

Delusions are firm convictions perceived by the patient that have no basis in reality. These may reflect one's belief that they have no control over their thoughts or that their thoughts and actions are controlled by someone else. Thought broadcasting, thought insertion, and thought withdrawal comprise this category of symptoms. For example, an individual may believe that as a result of a dental procedure such as the placement of a filling or a tooth extraction, a transmitter device has been inserted into the tooth or extraction socket. This may require one of many collaborative relationships between the dental health practitioner and a mental health professional to attempt to reassure the patient that such a delusion is completely false. Acts of orofacial and self mutilation have also been described in the literature as occurring during an acute psychotic episode and have taken the form of autoextractions (13), glossectomy (14), self enucleation of the eye (15) and excoriation of gingival tissues with sharp fingernails (16). In the early studies of schizophrenia, the so-called "negative" symptoms comprised part of the initial subtyping of the illness based on the symptomatology of the disease. (17) It was considered at that time that these negative symptoms correlated more with the chronicity of the disease. Lack of motivation or apathy is unfortunately often confused with simple laziness. This will lead to neglect, not only of one's general self care, but also of oral health care in particular. Blunted affect refers to a flattening of emotional expression but generally does not reflect the individual's inner ability to continue to feel strong emotions and a desire to be receptive to the kindness and consideration of others. Depression and ultimately social withdrawal complete the negative symptom complex and play a role in the high rate of attempted suicides in this patient population.

Disorganized symptoms complete the triad of symptomatology that may be expressed in a patient suffering from schizophrenia. These include a rapid shift of ideas and poor thought relation reflecting an inability to concentrate on one subject for any length of time. Bizarre stereotypical behaviours may be highlighted by facial grimacing, repetitive awkward movements, pacing or even mutism. A summary of the symptomatology associated with schizophrenia is presented in Table 1.

In general, the signs and symptoms of the illness must be present for a least a six-month period including an active phase of the illness where some of the more characteristic psychotic symptoms (e.g. delusions, hallucinations, and bizarre behaviours) are present. Schizophrenia is described as having four phases of existence and as such the signs and symptoms tend to recur in a cyclical pattern with varying severity and frequency. (3,6) The earliest phase of the illness is referred to as the prodromal phase wherein the commonly described signs of social withdrawal, deterioration in work or school performance, reduced concentration, irritability and suspiciousness all become manifest. The relapse or active phase of the disease is characterized by the appearance of the so-called positive symptoms including delusions, hallucinations, agitation and bizarre behaviours. An individual may often require hospitalization at this stage of the illness usually for one's own safety as well as for being able to initiate medical treatment and provide rest and nutrition for the patient. During the residual phase of schizophrenia, the negative symptoms become more obvious and include a lack of motivation and emotion (flat affect), poor general and oral hygiene, withdrawal, and poor thought and speech patterns. The final phase that is described for this illness is that of the recovery or maintenance phase where some stability may have been achieved via medical intervention and psychotherapy allowing an individual to slowly integrate back into their social, educational and vocational spheres of life. There is often however a continuous flux between each of the latter three phases of this illness and this unfortunately contributes to the high rate of chronic hospitalization seen in those suffering from schizophrenia.

MEDICAL MANAGEMENT

1. Associated risk factors

Compared to the general population, individuals with schizophrenia suffer from a higher risk of developing significant health problems such as coronary artery disease (CAD), diabetes, obesity, respiratory and genitourinary illnesses. (18-22) A multiplicity of factors can be seen as playing a role in this increased incidence of physical illness. These include not only the effects of the illness itself but also the side effects of the antipsychotic medications as well as significant lifestyle differences in this patient population. Mortality data indicate that patients with schizophrenia have a life expectancy which is 20 per cent shorter than that of the general population and this statistic is not fully attributable to the increased rates of suicide and accidents among these individuals. (18) CAD is considered to be the chief cause of the premature mortality rates in this specific patient population. (21-23) The major risk factors for CAD include smoking, hypercholesterolemia, obesity, hypertension and diabetes and it is these factors that are far more prevalent in the patient with schizophrenia. Almost 70 per cent of patients with schizophrenia smoke versus approximately 25 per cent of the general population. (23) It is therefore not surprising that the incidence of death from lung cancer is approximately twice that of the general population. (19) The impact of smoking on the oral health of an individual is also significant not only from a periodontal standpoint but also for the increased risk of oral cancer. This necessitates an increased vigilance on the part of the dental hygienist for the early detection of suspicious oral lesions as part of a comprehensive head and neck examination. In particular, such high risk sites as the floor of mouth, ventral surface of the tongue and lower lip must be thoroughly evaluated for each patient. (24) In addition, cigarette smoking can interfere with the metabolism and effectiveness of antipsychotic medication requiring the administration and watchful titration of higher doses of these drugs. (19) While lifestyle modifications are critical to reducing these risk factors, patients with schizophrenia face additional barriers in this regard.

2. Medications and side effects

Lack of compliance in taking prescribed antipsychotic medications occurs in over 50 per cent of patients with schizophrenia due largely to both their personal ineffectiveness and intolerable side effects of medications. As well, through a lack of education into the illness itself, many patients feeling better while on specific antipsychotics will decide they are no longer needed and discontinue these drugs. Financial concerns, lack of access to proper medical care including routine screening, as well as receiving less than optimal care during acute cardiovascular episodes are additional hurdles that these individuals may face. (21)

Along with various psychotherapy modalities, social, living and vocational skills training, the use of various psychotropic or neuroleptic medications remains the cornerstone of treatment for schizophrenia, shown in Table 2. No less important will be the degree of social and family supports that individuals receive once discharged from the hospital environment to promote self esteem and a sense of well being.

The first generation or so-called conventional antipsychotics were introduced in the early 1950s and revolutionized the treatment of schizophrenia and the practice of psychiatry in general. (7,25) These antipsychotics functioned as antagonists of D2 dopamine receptors proving most efficacious against the positive symptoms of the disease. However, these drugs were not without a high rate of side effects including such early extrapyramidal signs as Parkinsonian-like movements (e.g. oral dyskinesias) and akathisia (extreme restlessness). (6,7)

Oral dyskinesias are abnormal, involuntary and uncontrollable movements affecting mainly the tongue, lips and jaws that will vary in severity and distribution. Such involuntary movement disorders are often drug related and have generated more interest since the advent of the conventional antipsychotic drugs within the past fifty years. (26) One subtype of the oral dyskinesias, tardive dyskinesia, is a late stage extrapyramidal effect. Tardive dyskinesia, from the literature studies, has a prevalence rate of 20-25% of those individuals undergoing longterm treatment with antipsychotic (primarily the conventional antipsychotics) medication, all of which are potent D2 (dopamine) receptor blockers. (6,7,20) Tardive dyskinesia is characterized by rhythmic and the involuntary movements of the tongue (fly-catcher's tongue), face (bonbon sign) and jaws as well as, in some cases, the extremities resulting in fine tremor-like motions of the fingers, hands and feet. (6) Flycatcher's tongue refers to a darting motion of the tongsocio-economicue in and out of the mouth. Bonbon sign refers to a pushing of the tongue against the inside of the cheek as if a piece of candy were being pressed against the cheek wall. These movements may lead to abnormal chewing habits and facial tics. Premature tooth wear, impaired retention of removable prostheses, speech impairment and social embarrassment are some other consequences of this late stage side effect. The incidence of tardive dyskinesia in young adults is between 4 and 5% per year with a risk reportedly 3 to 6 times greater in more elderly individuals with schizophrenia. Risk factors other than age also may include a female predilection as well as a prior history of extrapyramidal reactions to neuroleptic agents. (6,26)

In most cases, the prevalence of movement disorders as a side effect of conventional antipsychotic medication has been removed by the second generation or "atypical" antipsychotics such as Clozapine, Ripseridone, Olanzapine and Seroquel. (27) These newer medications have a lower affinity for binding to the D2 receptors with a concomitant lower risk for extrapyramidal adverse effects. At the same time, they demonstrated significant effectiveness against both the positive, disorganized and negative symptoms of schizophrenia.

3. Monitoring for other health risks

Clozapine was one of the first of this category of drugs introduced in the 1980s and is effective in many treatment resistant cases. However, between 1 and 2% of patients receiving Clozapine will suffer from its most serious side effect--agranulocytosis (white cell count less than 3000/[mm.sup.3]). (9,25,27) The development of this condition does not appear to be dose related nor does it correlate with any known predisposing factors. Patients taking this antipsychotic require weekly blood monitoring to assess for the onset of agranulocytosis which, if diagnosed would result in the immediate cessation of Clozapine. Another side effect reported by over one-third of patients taking Clozapine is hypersalivation. Causation is speculated to occur as a result of the drugs combined antagonistic and agonistic effects on the muscarinic receptors (M3, M4) present in salivary gland tissue with the net result being hypersalivation. Other theories however question the possible effect of Clozapine on deglutition resulting in a pooling of saliva in the mouth and the subsequent development of clozapine induced hypersalivation. (25) Overall, this side effect may be highly stigmatizing and functionally disabling for some patients resulting in an increased non compliance to one's overall psychiatric treatment. While the newer second generation agents have been more efficacious than their firstline counterparts in reducing such adverse effects as the extrapyramidal symptoms and managing the entire symptomatology of schizophrenia, these advantages have been increasingly overshadowed by their propensity to contribute to hypertension, excessive visceral fat distribution, and alterations in both lipid and glucose metabolism. This has resulted in an increased risk for coronary artery disease and Type 2 diabetes. (25,27,28) It is these same risk factors that define the cluster of findings known as the Metabolic Syndrome; a symptom complex seen in greater frequency in patients suffering from schizophrenia. (19,29) Other risk factors inherent in this illness also undoubtedly play a role in the development of this syndrome and include lifestyle changes, poor diet and lack of exercise. An outline of the more commonly used antipsychotic medications and their adverse effects are shown in Table 3. A rare yet serious side effect of antipsychotic drug therapy is malignant neuroleptic syndrome. Seen in predominantly young male patients, the syndrome is characterized by tachycardia, dyspnea, tremors, muscle rigidity, dystonia, labile blood pressure and a spike in body temperature (up to 41 [degrees]C). Symptoms will persist for up to ten days after withdrawal of the particular neuroleptic medication and mortality rates of 10-20% have been reported. (6)

DENTAL MANAGEMENT

Just as any patient presenting with a systemic illness must be thoroughly evaluated, so too should we be able to comfortably assess our patients who present with a history of chronic mental illness. It is important to ascertain among other things an accurate list of current medications, the degree of stability of the illness, issues around the granting of consent and side effects of both the illness and its current medical management. Sample questions that may be used by the dental hygienist in their history taking to elicit this specific information are presented in Table 4. The difficulties inherent in a diagnosis of schizophrenia relate to some of the more typical clinical oral findings. These difficulties include financial hardships from loss of work, high rates of readmission to hospital, lack of family and/or community support networks and the stigma of the disease itself, ultimately contributing to the high rate of dental caries and periodontal disease seen in this group of individuals. (6,11,30-33) Xerostomia remains a profound oral side effect of many antipsychotic medications further contributing to the decay process particularly the increased incidence of root caries. (6,7,30,32,34,35) In addition, xerostomia may often result in painful oral ulcerations (e.g. denture related trauma), burning mouth, dysphagia, difficulty in speaking, and candidiasis. Due to the lack of a normal amount of saliva, great difficulty may be experienced in wearing dentures comfortably, impacting not only on the patient's overall nutritional status but their psychological status as well. Polypharmacy is often a factor in the pharmacotherapeutic management of psychiatric illnesses including schizophrenia and together these combinations of drugs enhance the signs and symptoms of dry mouth. Often no drug substitution is available upon consultation with the patients' physician or psychiatrist and adjunctive measures are required to help relieve the severity of the dry mouth.

1. Education and clinical care

To that end, preventive dental education remains a critical aspect of dental management in a patient suffering from chronic schizophrenia as with any other chronic mental illness. (6,7,36) This however is not without some modification on the part of a dental hygienist in light of the possible episodic and recurrent nature of the different phases of schizophrenia. Co-operation may vary considerably as exemplified by a patient's understanding at one time and apparent lack of understanding at another of the importance of oral hygiene and the techniques involved. Non compliance to appropriate dental care may mirror a non compliant attitude to medical intervention in general and it will be these perceptions of need that can prove to be the most challenging for the dental hygienist. This may necessitate more frequent appointment scheduling particularly in those patients suffering from severe xerostomia due to their psychotropic medication. Enlisting the support of family members in the instruction of oral hygiene techniques may be required for those patients who routinely fail to carry out daily oral hygiene practices through lack of motivation or interest. As part of a dry mouth management protocol, commercially available saliva substitutes, e.g. Biotene products (Laclede Inc, California) are recommended as well as salivary stimulants including sugarless gum and candies. Avoiding alcoholic, caffeinated and carbonated beverages helps serve to reduce the intensity of the xerostomia as well as lessen the secondary erosive effects of such beverages in an already compromised dentition. Dietary counselling is also a paramount objective on the part of the dental hygienist in an attempt to reduce the high caries index. There is often a tendency to avoid the coarser and more textured foods in favour of easily ingested carbohydrate snack foods in someone experiencing a moderate to severe dry mouth. Antibacterial mouthrinses containing chlorhexidine have proven effective in reducing the severity of gingivitis keeping in mind the secondary side effects of transient tooth discolouration and taste alterations with this treatment modality. Application of fluoride varnishes such as Durafluor (Pharmascience, Montreal, PQ) and Cavity Shield (OMNII Oral Pharmaceuticals, Florida) are useful adjuncts in caries prevention. Other fluoride containing products such as Prevident toothpaste (Colgate Oral Pharmaceuticals) and 0.4 per cent stannous-fluoride mouthrinses also comprise a critical part of the preventive armamentarium. Regular scaling, root planning, prophylaxis, and oral hygiene instruction remain the mainstay of any dental hygiene program followed by any necessary restorative, surgical and prosthetic care. Three-month recall intervals may often be required for re-examination, prophylaxis, and topical fluoride rinse/varnish treatments.

Appointment scheduling may also require consultation and coordination with either a patient's social worker or family or both in order to be able to successfully implement an effective recall program.

Local anesthetics with judicious use of a vasoconstrictor can be utilized for most procedures but in order to circumvent a severe hypertensive episode, generally no more than two cartridges of a 1:100,000 solution are recommended. (6) This would also presume that the dentist or dental hygienist aspirates during injection as well as injecting slowly. Epinephrine in retraction cords or applied topically to control hemorrhage is contraindicated.

Patients taking Clozapine are at increased risk of developing signs and symptoms related to agranulocytosis and as such the dental health practitioner must be alert as to the symptoms of pain (e.g. from oral ulcerations), fever, and sore throat in those patients taking this medication. A prior history of alcohol or street drug abuse or both may also be factors that complicate the dental management of a patient with a history of schizophrenia. Liver function may be irreversibly altered predisposing one to increased risk of hemorrhage, delayed wound healing, increased risk of infection and an alteration in drug metabolism to many of the commonly used drugs in dentistry including acetaminophen, amide-containing local anesthetics and codeine. In addition, dental health care practitioners need to be cognizant of the significant drug interactions that may occur in those patients being managed with antipsychotic medications. These interactions are listed in Table 5.

2. Schizophrenia--developmental or psychotic disorder?

Preliminary research has also proposed the theory that schizophrenia is more of a developmental disorder in which psychosis is present rather than it being a true psychotic disorder. This has arisen through the demonstration of concurrent developmental abnormalities throughout the body and in particular the oral cavity. (37,38) Patients with schizophrenia were shown to have a significantly wider palate as well as a greater incidence of other dental developmental abnormalities such as diastemas, rotated teeth, crowding, peg laterals, and interarch toothsize discrepancies. This group of researchers looking at both their evidence as well as that of others involving both physical and neuropsychiatric comorbidity in schizophrenia suggest more of a whole body model to schizophrenia rather than one defined largely on the basis of psychotic symptomatology. Other research has demonstrated a higher prevalence of both bruxism and temporomandibular disorders (TMD) in psychiatric patients, reflecting yet another significant comorbidity to the primary illness. (39) Patients with schizophrenia in particular have shown higher pain thresholds and pain tolerance levels than agematched healthy control subjects. Whether the TMD and signs of bruxism reflect abnormal central nervous system activities or are neuroleptic induced problems remains to be determined. The alteration in pain threshold may lead to delays in diagnosis and treatment resulting in more longterm serious clinical consequences. A summary of oral findings is presented in Table 6.

3. Treatment planning

Treatment planning considerations for the patient suffering from schizophrenia must be both flexible and realistic and in many cases remain aggressive in terms of preventive care. The goal of any treatment plan will be to maintain oral health, comfort and function and in this specific patient population, will often require interprofessional consultation with a physician or psychiatrist in establishing the current pharmacotherapeutic regimens, psychological status and if needed, issues surrounding consent and competency towards treatment. (40) In addition, considerations for the provision of some sedative modalities prior to undertaking dental treatment would require prior physician consultation in order to prevent any potentiation of side effects of current psychotropic medications. Advanced procedures such as implant therapy may require a more detailed case study and analysis with respect to the degree of xerostomia, level of oral hygiene and in many cases, the availability of financial resources or support.

CONCLUSION

Admitting to having a mental illness is not the same thing as admitting to any other serious health issue since it often results in more suspicion than support. People with schizophrenia as well as those with any other psychiatric illness experience a "double-burden" with their illness including not only the signs and symptoms of their illness but also the social stigma and discrimination that results from having the disorder. This unfortunate stigma and discrimination remains the most tragic reality that faces these individuals. Stigmatization of people with mental disorders has persisted throughout history and is exemplified by distrust, bias, fear, stereotyping, embarrassment, and often avoidance. In turn, this complicates and even reduces the patient's ability to access resources and opportunities for treatment. The end result often leads to low self esteem, substance abuse, isolation and a sense of hopelessness. Schizophrenia impacts on an individual's quality of life in numerous ways highlighted by a lack of one's personal perception of both general and oral health concerns. Lifestyle habits including an inability to sustain self care as well as socio-economic factors and medication side effects all serve to affect their quality of life in a detrimental fashion.

Current neuroleptic medication regimens and psychotherapeutic treatments have revolutionized the treatment of schizophrenia within the past fifty years. These changes have enabled many individuals with this illness to resume a relatively normal lifestyle from both an occupational as well as an interpersonal perspective. As healthcare professionals, dental hygienists can play a vital role to help continue to deprogram the stereotypical approach that many other patients continue to experience with a diagnosis of schizophrenia and alternatively, exhibit more sensitivity to patient vulnerability factors and psychological problems in particular, as it may relate directly to oral sign and symptom presentation, and ultimately dental treatment planning.

REFERENCES

1. Schizophrenia. Report on Mental Illnesses in Canada.Ottawa: Public Health Agency of Canada; 2002 [Cited 2002 October]. Available from: http://www.phac-aspc.gc.ca.

2. Simmie S, Nunes J. The Last Taboo. Toronto: McClelland & Stewart; 2001.

3. Schizophrenia: A Handbook for Families. Ottawa: Health Canada;1991 [Cited 2007 Aug 26]. Available from: www.mentalhealth.com.

4. The History of Schizophrenia. Available from: http://www.schizophrenia.com/history.htm

5. Pompili M, Girardi P, Tatarelli R. Suicide in Schizophrenic patients: a neglected issue. (Letter to the Editor). Am Fam Physician. 2004;70(4):648.

6. Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the Medically Compromised Patient. 7th ed. St. Louis: Mosby Elsevier; 2008.

7. Friedlander A, Marder SR. The psychopathology, medical management and dental implications of schizophrenia. JADA. 2002;133(5):603-610.

8. Berman KF, Illowsky BP, Weinberger DR. Physiological dysfunction of dorsolateral prefrontal cortex in schizophrenia, IV: Further evidence for regional and behavioural specificity. Arch Gen Psych 1988;45:616-622.

9. Chuong R. Schizophrenia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;88(5):526-528.

10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision. 4th ed. (DSM-IV-TR). Washington, D.C.: American Psychiatric Association; 2000.

11. Stanfield M. Schizophrenia and Oral Healthcare. Dent Update. 2004;31:510-515.

12. Marti-Bonmati L, Lull J, Garcia-Marti G, Aguilar EJ, Moratal-Perez, D, Poyatos C et al. Chronic Auditory Hallucinations in Schizophrenic Patients: MR Analysis of the Coincidence between Functional and Morphologic Abnormalities. Radiology 2007;244(2):549-556.

13. Altom RL, DiAngelos AJ. Multiple autoextractions: Oral self-mutilation reviewed. Oral Surg 1989;67:271-274.

14. Tenzer JA, Orozco H. Traumatic glossectomy. Oral Surg 1970;30:182-184.

15. MacLean G, Robertson BM. Self-enucleation and psychosis. Arch Gen Psych 1976;33:242-249.

16. Mester R. The psychodynamics of the dental pathology of chronic schizophrenic patients. Isr J Psychiat Relat Sci 1982;19:255-261.

17. Andreasen NC, Olsen S. Negative vs. Positive schizophrenia: definition and validation. Arch Gen Psych 1982;39:789-794.

18. Ryan MCM, Thakore JH. Physical consequences of schizophrenia and its treatment. The metabolic syndrome. Life Sciences. 2002;71:239-257.

19. Lumby B. Guide Schizophrenia Patients to Better Physical Health. The Nurse Practitioner. 2007;32(7):30-37.

20. Marder SR, Essock SM, Miller AL, Buchanan RW, Casey DE, Davis JM et al. Physical Health Monitoring of Patients with Schizophrenia. Am J Psych 2004;161:1334-1349.

21. Seeman MV. An Outcome Measure in Schizophrenia: Mortality. Can J Psych 2007;55(1):55-60.

22. Newcomer JW, Haupt DW. The Metabolic Effects of Antipsychotic Medications. Can J Psych 2006;51(8):480-491.

23. Hennekens CH, Hennekens AR, Hollar D, Casey DE. Schizophrenia and increased risks of cardiovascular disease. Am Heart J. 2005;150:1115-1121.

24. Ibsen OAC, Phelan JA. Neoplasia. In: Oral Pathology for the Dental Hygienist. 4th ed. St Louis: Saunders; 2004;260-264.

25. Abidi S, Bhaskara SM. From Chlorpromazine to Clozapine--Antipsychotic Adverse Effects and the Clinician's Dilemma. Can J Psych. 2003;48:749-755.

26. Blanchett PJ, Rompre PH, Lavigne GJ, Lamarche C. Oral Dyskinesia: A Clinical Overview. Int J Prosthodont. 2005;18(1):10-19.

27. Lieberman JA, Stroup TS, McEvoy JP, Swatrz MS, Rosenheck RA, Perkins DO et al. Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia. N Engl J Med 2005;353(12):1209-1223.

28. Schizophrenia and Diabetes 2003. Expert Consensus Meeting, Dublin. Br J Psych. 2004;184:112-114.

29. Friedlander AH, Weinreb J, Friedlander I, Yagiela JA. Metabolic syndrome. Pathogenesis, medical care and dental implications. JADA. 2007;138(2):179-187.

30. Yaltirik M, Kocaelli H, Yargic I. Schizophrenia and dental management: Review of the literature. Quintessence Int 2004;35:317-320.

31. Kilbourne AM, Horvitz-Lennon M, Post EP, McCarthy JF, Cruz M, Welsh D et al. Oral Health in Veterans Affairs Patients Diagnosed with Serious Mental Illness. J Pub Health Dent. 2007;67(1):42-48.

32. McCreadie RG, Stevens H, Henderson J, Hall D, McCaul R. Filik R, et al. The dental health of people with schizophrenia. Acta Psychiatr Scand. 2004;110(4):306-310.

33. Thomas A, Lavrentzou E, Karouzos C, Kontis C. Factors which influence the oral condition of chronic schizophrenia patients. Spec Care Dent. 1996;16(2):84-86.

34. Gater L. Understanding xerostomia. AGD Impact. 2006;34(6). Available from: http://www.agd.org/publications/articles/?ArtID=91

35. Goldie MP. Xerostomia and quality of life. Int J Dent Hygiene. 2007;5:60-61.

36. Clark DB. Dental Care for the Psychiatric Patient: Chronic Schizophrenia. J Can Dent Assoc 1992;58(11):912-920.

37. Kirkpatrick B, Hack GD, Higginbottom E, Hoffacker D, Fernandez-Egea E. Palate and dentition in schizophrenia. Schizophr Res 2007;91:187-191.

38. Abnormalities of the mouth associated with schizophrenia. Science Daily.[Cited 2007 March]. Available from: http://www.sciencedaily.com/releases/2007/03/070314082032.htm

39. Winocur E, Hermesh H, Littner D, Shiloh R, Peleg L, Eli I. Signs of bruxism and temporomandibular disorders among psychiatric patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103:60-63.

40. Clark DB. Dental Management Considerations for Patients with Psychiatric Disorders. Ontario Dentist 2006;83(1):22-25.

David B. Clark, BSC, DDS, MSC(ORAL PATHOLOGY), FRCDC 

Submitted 6 Sept. 2007; Revised 13 Nov. 2007; Accepted 14 Nov. 2007

Correspondence to: Dr. DB Clark, Director Dental Services, Whitby Mental Health Centre, 700 Gordon Street, Whitby, ON L1 N 5S9; [e-mail]

Positive symptoms-                             Negative symptoms-absence
behaviours that should                         of behaviour that should
not be present          Disorganized symptoms  be present

Exaggeration of ideas   Thought disturbances   Disturbances of affect-
and thoughts            -rapid shifting of     flat emotions, lack of
(grandiose)             ideas, poor thought    expression, monotony of
                        relation, incoherent   speech
Delusions-persecutory   speech
type, thought                                  Impaired interpersonal
broadcasting,           Bizarre behaviour-     relationships
thought insertion,      ritualistic/
thought withdrawal,     stereotypical,         Lack of motivation,
being controlled by     gesturing, imitating   apathy, and social
others.                 the speech of others,  withdrawal.
                        mutism, pacing.
Hallucinations                                 Absence of normal drives,
(auditory-e.g.                                 interests including self-
"voices", visual,                              care=poor general/oral
tactile-electrical,                            hygiene (dental caries,
burning, tingling)                             periodontal disease, loss
                                               of teeth)

Table 1: Symptomatology of schizophrenia

Class                         Generic name            Trade name

Phenothiazines                Chlopromazine           Thorazine
                              Fluphenazine decanoate  Modecate
                              Trifluoperazine         Stelazine
                              Methotrimeprazine       Nozinan
                              Perphenazine            Trilafon
                              Thioridazine            Mellaril
Diphenylbutylpiperidine       Pimozide                Orap
                              Quetiapine*             Seroquel
                              Ziprasidone*            Ceodon
Butyrophenone                 Haloperidol             Haldol
Dibenzoxazepine               Loxapine                Loxitane
Benzisoxazole                 Risperidone*            Risperdal
                              Olanzapine*             Zyprexa
                              Clozapine*              Clozaril
atypical (second generation)
antipsychotics

Table 2: Commonly used antipsychotic medications

                     Adverse effects
Drug                 General                                Oral

Conventional (first  EKG changes, orthostatic hypotension,  xerostomia,
  generation)        blurred vision, constipation,          tardive
Antipsychotics       nasal congestion, dizziness, skin      dyskinesia
* Chlorpromazine     pigmentation, extrapyramidal
* Haloperidol        symptoms -e.g. Parkinsonian-like
* Perphenazine       movements
* Methotrimeprazine  Malignant neuroleptic syndrome

Atypical (second     minor sedation, hypotension, sexual    xerostomia,
  generation)        dysfunction, Metabolic syndrome:       dysphagia,
Antipsychotics       increased incidence Type 2 diabetes,   stomatitis,
* Clozapine          obesity, hyperlipidemia, heart         dysgeusia
* Olanzapine         disease.                               drooling
* Quetiapine         Malignant neuroleptic syndrome         (Clozapine)
* Risperidone        agranulocytosis (Clozapine only)

Table 3: Adverse effects of antipsychotic medications

Sample questions

1. When was your mental illness diagnosed?
2. Which psychiatric medications are you taking?
3. How long have you been taking these medications?
4. Who is the primary care physician currently managing your condition?
5. Do you experience any medication side effects such as dry mouth,
   burning tongue or drooling?

Derived from Oral Diagnosis Manual, 2007 used by the Department of Oral
Diagnosis, Faculty of Dentistry, University of Toronto

Table 4: Sample questions used to enquire about a patient's mental
health history

Neuroleptic (antipsychotic) Drugs

Interacting drug   Effect

warfarin sodium    decrease blood levels of warfarin
                   sodium-lower INR level
tricyclic          increase serum level of both drugs;
  antidepressants  marked anticholinergic effect
opioid analgesics  increase sedative effect of opioids;
                   increase risk of respiratory
                   depression
antihypertensives  increase risk of hypotension
alcohol            increase risk of hypotension;
                   increase risk of respiratory
                   depression
anxiolytics        increase risk of sedation; increase
                   risk of respiratory depression
nicotine           decrease blood levels of all
                   antipsychotics
anticonvulsants    decrease effects of antipsychotic
                   medications

Table 5: Drug interactions involving antipsychotic medications

Oral findings

Poor oral hygiene
Dental caries--rampant caries, root caries
Periodontal disease
Xerostomia
Tardive dyskinesia
Dysphagia
Impaired gag reflex
Trauma secondary to acts of self-mutilation (e.g. in acute psychotic
  states)
Candidiasis (e.g. immunocompromsed patients)
Mucosal lesions (e.g. ulcerations secondary to agranulocytosis due to
  Clozapine)
Ill-fitting dentures; poor denture hygiene; inflammatory papillary
  hyperplasia
Delusional behaviours (e.g. "transmitters" placed within fillings)
Psychomotor disturbances (e.g. facial grimacing)
Hallucinations-somatic type (e.g. worms crawling in the mouth--in acute
  psychotic states)

Table 6: Oral findings in schizophrenia