Re: Clozapine: Agonistic and Antagonistic Salivary Secretory Act

[Anonymous]

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.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 caries
or tooth decay

Localized disease that causes decay and cavities in teeth. It begins at the tooth’s surface and may penetrate the dentin and the pulp cavity. and periodontal disease seen in this group of individuals.

Xerostomiaxerostomia remains a profound oral side effect of many antipsychotic medications further contributing to the decay process particularly the increased incidence of root caries.

In addition, xerostomia may often result in painful oral , 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.

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.
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 chlorexidine have proven effective in reducing the severity of gingivitis.
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.
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.

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. 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.