15.3
Schizophrenia
Section I: Clinical Scenario and Dental Considerations
Clinical Scenario
A 53‐year‐old male presents for an emergency dental appointment complaining that a crown in the upper right quadrant (#14) became the day before when he was eating. There is no associated pain or swelling. The patient has brought the crown with him and wants it recemented. He attends with his wife.
Medical History
- Schizophrenia
- Diagnosed when 19 years old; first episode associated with an incident of severe stress
- Followed by hospital admission for 1 month during which he received 3 electroshock therapy sessions
- Under treatment with psychiatrist; several inpatient admissions over the years
- In the past managed with pipotiazine injections twice a month for 11 years, but discontinued due to the development of severe tardive dyskinesia
- Tardive dyskinesia predominantly of the hands and face (persistent movement of the mandible)
- Depression
- Hypertension
- Hypercholesterolaemia
- Gastro‐oesophageal reflux disease
- Nasal obstruction due to polyps
- Possible mild cognitive deterioration (reported by wife)
Medications
- Quetiapine
- Trihexyphenidyl
- Fluoxetine
- Hydrochlorothiazide
- Losartan
- Atorvastatin
- Metoclopramide
Dental History
- Irregular attender; only attends if there are dental problems; last visit was a month ago to a mobile clinic close to his home after his anterior bridge came off – he had this recemented
- Prior to this, no dental treatment for the last 5 years
- He states that he does not trust dentists because every time he visits, they are always trying to take his teeth out
- Brushes once a day (only in the morning)
- Uses a mouthwash intermittently as he has a bad taste in his mouth
- Highly cariogenic diet, including high‐sugar carbonated drinks 4–6 times/day
Social History
- Lives in the countryside with his wife, 2 daughters and 3 grandchildren
- ‘Disappears’ occasionally and has been found in shelters (reported by wife)
- Currently unemployed; has difficulty keeping jobs due to paranoid thoughts; previously worked as a security guard
- Receiving disability pension
- Relies on his wife to accompany him to his appointments as he reports that he has extreme exhaustion
- Tobacco consumption: 20–30 cigarettes daily for 30 years
- Alcohol consumption: sporadic; binge‐drinking episodes weekly with 15–20 units consumed
- Cocaine use: 2 recent episodes associated with suicide attempts
Oral Examination
- Incompetent lips with gingival show
- Mouth breather
- Xerostomia (Figure 15.3.1)
- Bilateral tongue and cheek biting (clenches teeth together when stressed)
- Fissured tongue
- Generalised periodontal disease
- Gingival recession
Figure 15.3.1 Anterior dentition – gingival recession, xerostomia.
- #14: retained and carious root (Figure 15.3.2)
- #12: grade II mobility
- Bridge upper left quadrant: grade I mobility, gingival recession
- #46: pus exudate from buccal sinus
Radiological Examination
- Orthopantomogram undertaken (Figure 15.3.3)
- #14: short retained root, no endodontic treatment, radiolucent periapical area
- #15: endodontic treatment (short in length)
- #12 and #21: endodontic treatment
- #46: perio‐endo lesion with advanced bone loss
- Generalised bone loss (~60–70%) and subgingival calculus present
Structured Learning
- How may this patient’s schizophrenia have affected his dental attendance?
- Low dental care utilisation is more common
- This may be related to factors such as heightened anxiety, lack of interest in self‐care, amotivational state/extreme exhaustion, unemployment (limited financial means)
Figure 15.3.2 Maxillary dentition – retained root #14, extensive subgingival caries.
- What information would you need in order to carry out an appropriate risk assessment for the management of this patient?
- Further detail on the management of his mental illness and compliance with treatment
- Presence of any comorbidities/confirmation of the details with his medical practitioner
- Social history/availability of escort (wife normally looks after the grandchildren)
- What characteristics of this specific patient are likely to have had a negative impact on his oral health?
- Compliance issues in daily life (reported by wife)
- Lack of perceived need
- Attitudinal and possibly cognitive difficulties
- Underlying depression (see Chapter 15.2)
- Motor problems due to tardive dyskinesia
- Long‐term tobacco consumption
- Mouth breather
- Dry mouth (related to mouth breathing and polypharmacy)
- Poor oral health habits and diet
- Gastro‐oesophageal reflux disease
- The tooth #14 retained root has subgingival caries. The core has fractured and is inside the detached crown. The bad taste in his mouth originates from the #46 draining buccal sinus. The #14 and #46 require extraction. What are the challenges when discussing this with the patient?
- Mistrust due to problems with inference of people’s intentions (particularly with dentists)
- Anxiety and phobia
- Cognition and potential attention defects
- Delusions/disorganised thought processes
- Irregular attender – may not return if he feels you are not providing the treatment he wants (tooth replacement)
- After a lengthy discussion, the patient agrees to have the #14 and #46 extracted as long as the gaps are filled immediately. What are some of the gap replacement options and associated risks?
- Removable prosthesis (immediate/post‐immediate denture): cost, compliance, reduced retention due to xerostomia and dyskinetic movements, loss of denture, poor aesthetics (high smile line, gaps)
- Fixed prosthesis: cost, periodontal disease, poor support from potential abutment teeth, multiple gaps, maintenance
- Dental implants: cost, periodontal disease, smoking, clenching, compliance, maintenance
- What factors do you need to consider in your risk assessment for the management of this patient?
Figure 15.3.3 Orthopantomogram showing generalised bone loss, #46 perio‐endo lesion, retained root #14.
- Social
- Availability/suitability of wife as an escort
- Impact of binge drinking prior to dental visits on attendance and ability to proceed with dental treatment, especially sedation, and capacity to provide informed consent
- Limited financial means
- Medical
- Side‐effects of medication, most notably tardive dyskinesia
- Depression (see Chapter 15.2)
- Hypertension (see Chapter 8.1)
- Potential airway obstruction due to nasal polyps
- Possible mild cognitive deterioration (reported by wife)
- Dental
- Lack of perceived need for dental care, poor attendance
- High caries risk: highly cariogenic diet, xerostomia, suboptimal oral hygiene habits, irregular dental attender
- Access to the mouth impaired by persistent movements of the mandible
- Gastro‐oesophageal reflux disease is associated with an increased risk of dental erosion
- Capacity and compliance for dental treatment are likely to be impaired
- Social
General Dental Considerations
Oral Findings
- Severity of schizophrenia is negatively related to oral health, with more severe symptoms associated with more caries, periodontal disease and prosthetic unmet needs
- Presence of negative symptoms has been linked to self‐neglect
- Patients treated with atypical antipsychotics may have better oral health when compared to individuals treated with typical neuroleptics
- Oral findings associated with schizophrenia include:
- Poor oral hygiene (limited compliance, tardive dyskinesia)
- Caries
- Periodontal disease
- Heavily stained teeth/prostheses (associated with tobacco consumption) (Figure 15.3.4
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