medical problems 2 4
TRANSCRIPT
Islam Kassem, BDS , MSc, MOMS RCPS Glasg,
FFD RCSI
Consultant Oral & Maxillofacial Surgeon
Medical Topics in Orthodontics
DEFINITION DIABETES MELLITUS
An endocrine disorder in which there is insufficient amount or lack of insulin secretion to metabolize carbohydrates.
It is characterized by hyperglycemia, glycosuria.
Diabetes Mellitus Pathophysiology
The beta cells of the Islets of Langerhan of the Pancreas gland are responsible for secreting the hormone insulin for the carbohydrate metabolism.
Remember the concept - sugar into the cells.
Diabetes Mellitus Types
Type 1 - IDDM
– little to no insulin produced
– 20-30% hereditary
– Ketoacidosis
Gestational
– overweight; risk for Type 2
Type 2 - NIDDM
– some insulin produced
– 90% hereditary Other types include Secondary
Diabetes : – Genetic defect beta cell
or insulin – Disease of exocrine
pancreas – Drug or chemical
induced – Infections-pancreatitis
– Others-steroids,
Assessment
History
Blood tests
– Fasting blood glucose test: two tests > 126 mg/dL
– Oral glucose tolerance test: blood glucose > 200 mg/dL at 120 minutes
– Glycosylated hemoglobin (Glycohemoglobin test) assays
– Glucosylated serum proteins and albumin
FSBS – (finger stick) monitoring blood sugar
Urine Tests
Urine testing for ketones
Urine testing for renal function
Urine testing for glucose
Risk for Injury Related to Hyperglycemia
Interventions include:
– Dietary interventions, blood glucose monitoring, medications
– Oral Drugs Therapy (Continued)
Risk for Injury Related to Hyperglycemia (Continued)
– Oral therapy
Sulfonylurea agents
Meglitinide analogues
Biguanides
Alpha-glucosidase inhibitors
Thiazolinedione antidiabetic agents
Oral Hypoglcemias Key Points
Monitor serum glucose levels
Teach patient signs and symptoms of hyper/hypoglycemia
Altered liver, renal function will affect medication action
Avoid OTC meds without MD approval
Assess for GI distress and sensitivity
Know appropriate time to administer med
Insulin Regimens
Single daily injection protocol
Two-dose protocol
Three-dose protocol
Four-dose protocol
Combination therapy
Intensified therapy regimens
Diabetic Education - Preventive Medicine
Proper skin and foot
care
Proper Eye Exam
Proper diet and fluids
Diabetic Neuropathy
Diabetic Retinopathy
Diabetic Nephropathy
Diabetic
gastroparesis
Diabetes Mellitus Complications
Hyperglycemia
Hypoglycemia
Diabetic Ketoacidosis
Hyperosmolar Hyperglycemic Nonketotic
Syndrome
Chronic Complications of Diabetes
Cardiovascular disease
Cerebrovascular disease
Retinopathy (vision) problems
Diabetic neuropathy
Diabetic nephropathy
Male erectile dysfunction
Whole-Pancreas Transplantation
Operative procedure
Rejection management
Long-term effects
Complications
Islet cell transplantation hindered by limited supply of beta cells and problems caused by antirejection drugs
Chronic Pain
Interventions include:
– Maintenance of normal blood glucose levels
– Anticonvulsants
– Antidepressants
– Capsaicin cream
Diabetes Mellitus Summary
Treatable, but not curable.
Preventable in obesity, adult client.
Diagnostic Tests
Signs and symptoms of hypoglycemia and hyperglycemia.
Treatment of hypoglycemia and hyperglycemia – diet and oral hypoglycemics.
Nursing implications – monitoring, teaching and assessing for complications.
Diabetes Oral Health Connection
Oral Health Complications of Diabetes
– Tooth loss
– Oral pain
– Extensive Periodontal Disease
– Coronal and root caries
– Soft tissue pathologies
– Decrease in salivary function
Tooth Loss and Diabetes
Usually associated with:
– Periodontal disease
– Smoking habits
– Poor Control
Glossitis The range of symptoms used to describe a
tongue suffering the pain of glossitis are:
– pain
– sore
– tender
– swelling
– smooth appearance
– chew, swallow, talk difficulties
– Color ~ dark red, bright red, pale
Oral Examination
Caries identification
– Surface caries easily identifiable
– Incipient decay harder to identify but more important with preventive strategies
Gum disease
– Gingivitis vs. periodontal disease
Orthodontic considerations
Orthodontic treatment should not be performed in a patient with uncontrolled diabetes. If the patient is not in good metabolic control (HbA1c 9%), every effort should be made to improve blood glucose control.
There is no treatment preference with regard to fixed or removable appliances. It important to stress good oral hygiene,
specific diabetic changes in the periodontium are more pronounced after orthodontic tooth movement.
Risk Factors for Cardiovascular Disease
Hypertension High cholesterol Obesity Cigarette smoking Physical inactivity Diabetes mellitus Kidney disease Older age (>55 ♂; > 65 ♀)
Family history of premature cardiovascular disease
Obstructive sleep apnea Periodontal disease ?
Coronary Heart Disease: Myocardial Ischemia
Decreased blood
supply (and thus oxygen) to the myocardium that can result in acute coronary syndromes: – Angina pectoris (
Stable ) – Unstable Angina – Myocardial infarction – Sudden death (due to
fatal arrhythmias)
Ischaemic heart disease Definition
An imbalance between the supply of oxygen and the myocardial demand resulting in myocardial ischaemia.
Angina pectoris symptom not a disease chest discomfort associated with abnormal
myocardial function in the absence of myocardial necrosis
Supply – Atheroma, thrombosis, spasm, embolus
Demand – Anaemia, hypertension, high cardiac output
(thyrotoxicosis, myocardial hypertrophy) [email protected]
Ischaemic heart disease Manifestations
Sudden death
Acute coronary syndrome ( Myocardial Infarction & Unstable Angina )
Stable angina pectoris
Heart failure
Arrhythmia
Asymptomatic
Ischaemic heart disease Epidemiology
Commonest cause of death in the Western world. (up to 35% of total mortality)
Over 20% males under 60 years have IHD
Health Survey :
3% of adults suffer from angina
1% have had a myocardial infarction in the past 12 months
Ischaemic heart disease Aetiology
Fixed – Age, Male, +ve family history
Modifiable – strong association
– Dyslipidaemia, smoking, diabetes mellitus, obesity, hypertension
Modifiable - weak association
– Lack of exercise, high alcohol consumption, type A personality, OCP, soft water
Atherosclerosis [email protected]
Risk Factors for Ischemic Heart Disease
Family History
Smoking
Hypertension
Diabetes Mellitus
Hypercholesterolaemia
Lack of exercise Obesity
Age & Sex
PRIMARY PREVENTION [email protected]
Spectrum of the Atherosclerotic Process
Coronary Arteries (angina, MI, sudden death)
Cerebral Arteries (stroke)
Peripheral Arteries (claudication)
Ischaemic heart disease Acute coronary syndromes
Atherosclerosis
Fatal /
Non-Fatal AMI Unstable
Angina
Coronary
Artery spasm
Warning Signs and Symptoms of Heart attack
1) Pressure, fullness or a squeezing pain in the center of your chest that lasts for more than a few minutes.
2) Pain extending beyond your chest to your shoulder, arm, back or even your teeth and jaw.
3) Increasing episodes of chest pain 4) Prolonged pain in the upper abdomen 5) Shortness of breath- may occur with or without chest
discomfort 6) Sweating 7) Impending sense of doom 8) Lightheadedness 9) Fainting 10) Nausea and vomiting
Angina Pectoris At least 70% occlusion of coronary
artery resulting in pain. What kind of pain? – Chest pain – Radiating pain to:
Left shoulder Jaw Left or Right arm
Usually brought on by physical exertion as the heart is trying to pump blood to the muscles, it requires more blood that is not available due to the blockage of the coronary artery(ies)
Is self limiting usually stops when exertion is ceased
Clinical Patterns of Angina Pectoris
Stable - pain pattern and
characteristics relatively unchanged over past several months (better prognosis)
Unstable - pain pattern changing
in occurrence, frequency, intensity, or duration (poorer prognosis); MI pending
TREATMENT
MEDICATIONS 1) Nitrates- vasodilator eg: ISDN. ISMN 2) Pain reliever- eg: Morphine 3) Beta-blockers 4) Statins- cholesterol lowering drugs. Eg:
Atorvastatin, Simvastatin
Ischaemic heart disease Relevance to Dentistry
IHD is common
Subjects with IHD have more severe dental caries and periodontal disease – association or causation?
Angina is a cause of pain in the mandible, teeth or other oral tissues
Stress provokes ACS!
Myocardial Infarction
Partial or total occlusion of one or more of the coronary arteries due to an atheroma, thrombus or emboli resulting in cell death (infarction) of the heart muscle
When an MI occurs, there is usually involvement of 3 or 4 occluded coronary vessels
Chest Pain Myocardial ischaemia
Site Jaw to navel, retrosternal, left submammary Radiation Left chest, left arm, jaw….mandible, teeth, palate Quality/severity tightness, heaviness, compression…clenched fists Precipitating/relieving factors physical exertion, cold windy weather, emotion rest, sublingual nitrates Autonomic symptoms sweating, pallor, peripheral vasoconstriction,
nausea and vomiting
Chest Pain Differential diagnosis
Cardiac pathology – Pericarditis, aortic dissection
Pulmonary pathology – Pulmonary embolus, pneumothorax, pneumonia
Gastrointestinal pathology – Peptic ulcer disease, reflux, pancreatitis, „café
coronary‟
Musculoskeletal pathology – Trauma, Tietze‟s Syndrome
Acute Myocardial Infarction Assessment
30% of deaths occur in the first 2 hours.
(Cardiac muscle death occurs after 45 mins of ischaemia)
Symptoms and signs of myocardial ischaemia
Also
– Changes in heart rate /rhythm
– Changes in blood pressure [email protected]
Acute Myocardial Infarction Treatment
Stop dental treatment
Call for help
Rest, sit up and reassure patient
Oxygen
Analgesia (opiate, sublingual nitrate)
Aspirin
Thrombolysis
Primary angioplasty
Beta-Blockers
ACE inhibitors
Prepare for basic life support
Surgical Treatment
Percutaneous Transluminal Coronary Angioplasty (PTCA)
– balloon expansion that can provide 90% dilitation of vessel lumen
Stent Placement
With use of just the balloon, re-occlusion of the artery can occur within months
Placement of a stent delays or prevents re-occlussion
Surgical Treatment
Coronary Artery By-Pass Graft (CABG)
The graft bypasses the obstruction in the coronary artery
Graft sources: – saphenous vein
– internal mammary artery
– radial artery
Acute Myocardial Infarction Complications
Sudden Death (18% within 1 hour, 36% within 24 hours)
Non-fatal arrhythmia Acute left ventricular failure Cardiogenic shock Papillary muscle rupture and mitral
regurgitation Myocardial rupture and tamponade Ventricular aneurysm and thrombus Distal Embolisation
Sudden Death
Sudden Cardiac Death is also known as a “Massive Heart Attack” in which the heart converts from sinus rhythm to ventricular fibrillation
In V-Fib, the heart is unable to contract fully resulting in lack of blood being pumped to the vital organs
V-Fib requires shock from defibrillator “SHOCKABLE RHYTHM”
Dental Considerations
Assessment and Overall Management
Pharmaceuticals
Emergency Situations
Oral Effects of Pharmaceuticals
Antibiotic Prophylaxis
Post MI: when to treat
Consider three areas: – How severe or stable the ischemic heart
disease is
– The emotional state of the patient
– The type of dental procedure
RISK
Major Risk for Perioperative Procedures: – Unstable Angina (getting worse)
– Recent MI
Intermediate Risk for Perioperative Procedures: – Stable Angina
– History of MI
Most dental procedures, even surgical procedures fall within the risk of less than 1%
Some procedures fall within an intermediate risk of less than 5%
Highest risk procedures those done under general anesthesia
Management for Low-Intermediate Risk
Short appointments
AM appointments
Comfort
Vital Signs Taken
Avoidance of Epinephrine within Local Anesthetic or Retraction Cord
O2 Availability
Dentistry & Cardiovascular Medicine
AMI – GA within 3/12 of AMI: 30% re-infarction rate
@ 1/52 post op
– Avoid routine LA dental treatment for 3/12 (emergency treatment only)
– Avoid excess dosage, reduce anxiety
– Avoid elective surgery under GA for1 year (specialist)
– Be aware of medications (bleeding, hypotension)
Post MI: When to Treat Why delay treatment?
– Remember that with an MI there is damage to the heart, be it severe or minimal that may effect the patient‟s daily life
MI within 1 month Major Cardiac Risk
MI within longer then 1 month:
– Stable routine dental care ok
– Unstable treat as Major Cardiac Risk
Older studies suggest high re-infarction rates when surgery performed within 3 months, 3-6 months… however, this was abdominal and thoracic surgery under general anesthesia
New research suggests delaying elective tx for 1 month is advisable. Emergent care should be done with local anesthetic without epinephrine and monitoring of vital signs
When in doubt:
– CONSULT THE CARDIOLOGIST [email protected]
Dental Management Correlate
Elective dental care is ok if it has been longer than 4-6 weeks since the MI and the patient does not report any ischemic symptoms.
If there is any doubt or question, consult with the cardiologist.
Common Situations:
– Orthostatic Hypotension due to use of anti-hypertensives (beta blockers, nitroglycerin…)
Raise chair slowly
Allow patient to take his/her time
Assist patient in standing
– Post-Op Bleeding:
When patients on Plavix or Aspirin, expect increased bleeding because of decreased platelet aggregation
Dental Considerations for IHD
Dental Considerations for IHD
Emergent Situations:
– Possible MI:
Remember that pain in the jaw may be referred pain from the myocardium assess the situation, have
good patient history, follow ABC‟s
– Angina:
In situations of angina pectoris, all operatories should have nitroglycerin to be placed sublingually
Dental Considerations for IHD
Emergent Situations:
– Chest Pain-MI:
STOP PROCEDURE
Remove everything from patient‟s mouth
Give sublingual nitroglycerin
Wait 5 minutes if pain persists, give more
nitroglycerin, assume MI
101
Give chewable aspirin ABC‟s
Dental Management: Stable Angina/Post-MI >4-6 weeks
Minimize time in waiting room
Short, morning appointments
Preop, intra-op, and post-op vital signs
Pre-medication as needed – anxiolytic (triazolam; oxazepam); night before and 1 hour before
– Have nitroglycerin available – may consider using prophylacticaly
Use pulse oximeter to assure good breathing and oxygenation
Oxygen intraoperatively (if needed)
Excellent local anesthesia - use epinephrine, if needed, in limited amount (max 0.04mg) or levonordefrin (max. 0.20mg)
Avoid epinephrine in retraction cord [email protected]
Dental Management: Unstable Angina or MI < 3 months
Avoid elective care
For urgent care: be as conservative as possible; do only what must be done (e.g. infection control, pain management)
Consultation with physician to help manage
Consider treating in outpatient hospital facility or refer to hospital dentistry
ECG, pulse oximetry, IV line
Use vasoconstrictors cautiously if needed [email protected]
Intraoperative Chest Pain Stop procedure
Give nitroglycerin
If after 5 minutes pain still present, give another nitroglycerin
If after 5 more minutes pain still present, give another nitroglycerin
If pain persists, assume MI in progress and activate the EMS
– Give aspirin tablet to chew and swallow
– Monitor vital signs, administer oxygen, and
be prepared to provide life support [email protected]
Conclusion: When treating patients with Ischemic Heart
Disease or recent MI…
– Use caution and common sense
– When in doubt:
CONSULT THE CARDIOLOGIST
Obesity
orthodontist will have between 1 in 6 and 1 in 5 patients who are clinically overweight or obese, depending on the state or region in which he or she practices.
Cephalometric and facial analyses should be altered when examining obese or overweight patients. These patients tend to have larger mandibles and shorter upper face heights that could change potential treatments.
Obese patients tend to have flatter or more concave profiles because of increased mandibular length and increased tissue thickness.
Psychosocial problems are likely the rule with
obese patients. The clinician should monitor for problems such as depression and anxiety, because these conditions tend to be more likely in obese patients.
Psychology in Dentistry
Dentistry and Health
Consistent brushing and flossing and routine dental hygiene critical to maintenance of oral health
– Psychology as the science of behavior
Psychology and Dentistry
Communications skills and rapport building
Dental fears
Psychology and Dentistry
Pain
– Acute
– Chronic
Temporomandibular disorders
Neuralgias
Oral parafunctional behaviors
– Clenching
– Grinding (“bruxism”)
Psychology and Dentistry
Special needs populations
– Mentally challenged
– Chronically ill
– Geriatrics
Public health
– Community interventions
Psychology and Dentistry
Quality of life
– Craniofacial abnormalities
– Edentualism
Esthetic dentistry
– Orthodontics
– Crowns, veneers
– Reconstruction
Psychology Skills Useful for Dental Students
Communication
Fear/anxiety management
Management of disruptive child
Patient interventions to enhance self-care
– Motivational interviewing
Pain management
CHRONIC MENTAL ILLNESS “an equal opportunity illness affecting all ages, all races, all economic groups and both genders”
Chronic mental illness and it‟s medical management carry inherent risks for significant oral disease.
How common is Mental Illness?
“disorder” ---- impairment is key
concept of risk factors can considered as potential important clues or as the “weak links” in the mental health chain.
STATISTICS - Suicide male: female – 3:1 300 teens(10-19 yrs) commit 530,000 kids have treatable MI but only
150,000 get treatment. highest rates: 43/100,000 > 80 yrs. 30/100,000 > 75 yrs.
“No one chooses to have a mental disorder…………”
….admitting to mental illness is not the same thing as admitting to any other serious health issue since it can often result in more suspicion than support…
…misconceptions flourish…
Mental Health Fact…..
… people with a psychiatric illness experience a “double–burden” which includes both the s/s of the disease + the social stigma, isolation, discrimination that result from having that disease…
…stigma=social isolation, homelessness, unemployment, substance abuse, prolonged institutionalization…
Dental Perspectives…..
Medications used to treat mental illness can interact with drugs used in dentistry.
Some oral health problems arise as manifestations of mental illness.
Oral health problems as side effects of psychotropic medications.
Decreased compliance to oral health care/ability to obtain or tolerate oral care treatment.
Dental Perspectives…..
Sample Mental Health History
What psychiatric medications are you taking?
How long have you been taking the medication and does it help?
What are/were your symptoms?
When was your mental
illness diagnosed? Who is the
GP/Psychiatrist treating this condition?
Have you experienced any dental side effects, such as dry mouth, burning tongue, excessive saliva or swollen gums?
DSM IV – Diagnostic & Statistical Manual of Mental Disorders
a “descriptive” approach to diagnosis based on symptoms rather than causes. The disorders listed include a “clinical significance” criterion re: significant distress or impairment.
there is no blood test, brain scan or specific x-ray to make a diagnosis as with other medical problems.
Axis I – Clinical Disorders
Dementia**, delirium, amnesia, other cognitive disorders**
Schizophrenia**/other psychoses
Mood disorders**
Substance-related disorders**
Eating disorders**
Somatoform disorders**
Anxiety disorders**
WHAT IS A PSYCHOSIS?
Psychosis is a disordered pattern of thought, perception, emotion and behaviour. The psychotic person has a bizarre sense of reality, with emotional and cognitive impairment leading to loss of function in the environment.
SCHIZOPHRENIA
~1- 2% worldwide. late teens/early adulthood;
gradual/sudden. M (earlier) > F 10%= chronic hospitalization; 30-40%
long-term serious handicap. 40% risk of suicide attempts 60% alcohol abuse/15-25%street drugs 20% shorter life expectancy(>vulnerability
to medical problems (lifestyle)
SCHIZOPHRENIA Etiology
Causation of schizophrenia remains not well understood (syndrome?). Theories include:
(genetics) altered expression of genes(10-15% with one parent; 30-40% - 2 parents
differences in brain chemistry-(imbalances in neurotransmitters, e.g. dopamine)
differences in brain structure
SCHIZOPHRENIA Etiology
Schizophrenia is NOT:
• a multiple or “split” personality
• caused by bad parenting/character flaws
• the result of childhood trauma
• an isolated condition: 1 in 100 incidence?
• an automatic precursor to criminal violence
SCHIZOPHRENIA Symptomatology
1. Positive symptoms: does not mean “good” but rather s/s that are present but shouldn‟t be there. Exaggeration, distortion of normal function, e.g. delusions (control of one‟s thoughts, actions) hallucinations (sensory: auditory- [patient hearing “voices”]
visual, tactile)
SCHIZOPHRENIA Symptomatology
2.Disorganized symptoms: a rapid
shift of ideas, incoherent speech, poor
thought relation. Disorganized, bizarre
behaviour e.g. stereotypical, imitation
of others speech, gestures etc.
SCHIZOPHRENIA Symptomatology
3. Negative symptoms: the absences of behaviour that should be there. i.e. flat emotions/emotional expression, lack of motivation, monotony of speech apathy, social withdrawal, absence of normal drives or interests such as those involving one‟s self care (general/oral).
SCHIZOPHRENIA Medical Management
“Conventional” Antipsychotics (Neuroleptics)
chlorpromazine(Thorazine), methotrimeprazine (Nozinan), haloperidol(Haldol),
early 1950s; blocking of dopamine D2 receptors in the mesolimbic system of the brain affecting mood & thought processes; e.g. effective in managing “positive” symptoms only….
major side effect: *movement disorders*[oral dyskinesias] - often with orofacial component. Arise from blockade of basal ganglia dopamine D2 receptors in extrapyramidal system (EPS)
Schizophrenia-Medication Side Effects
ORAL DYSKINESIAS Abnormal involuntary, uncontrollable
movements affecting primarily the tongue, lips, jaws (can extend to trunk/limbs)
Causes: 1. drug induced( conventional antipsychotics)**
2. neuropsychiatric conditions 3. edentulousness (**tardive dyskinesia)
Schizophrenia Medication Side Effects
Tardive Dyskinesia (TD)
late stage effect of slow, rhythmic involuntary
grimacing/twitching in facial area e.g. repeated
smacking of lips, tongue movements, facial
contortions.
>25% of patients on conventional antipsychotics
having TD after 5 years of treatment.
Ironically, the signs of TD reinforce the
“crazy” stereotype, which in reality is only
a side effect of treatment.
Schizophrenia-Medication Side Effects
ORAL DYSKINESIAS (drug-induced)
conventional antipsychotics
atypical antipsychotics
antiemetics
antiparkinsonion
TCA‟s
SSRI‟s
lithium
anticonvulsants
antihistamines
methamphetamines
Schizophrenia-Medication Side Effects
ORAL DYSKINESIAS-Complications
tooth wear
oral pain/injury
TMJ degeneration
speech impairment
chewing difficulties
inadequate food intake…wt. loss
displacement/poor
retention of RPD‟s…decreased tolerance
social sequelae
Schizophrenia Medication Side Effects
Side effects of movement disorders are often
managed by Rx. anticholinergic medications
e.g. Cogentin. These drugs in turn exhibit
their own spectra of side effects.
Other side effects include EKG changes,
orthostatic hypotension, dry mouth,
constipation, blurred vision, nasal stuffiness.
Schizophrenia Medical Management
“atypical antipsychotics”
First appeared in late 1980s; e.g.
clozapine(Clozaril), risperidone(Risperdal),
olanzapine(Zyprexa), quetiapine(Seroquel).
*rarely cause movement disorders* why? – these
drugs possess a high ratio of serotonin to D2
activity and are therefore referred to as serotonin-
dopamine antagonists vs. conventional
antipsychotics or “dopamine antagonists.”
Schizophrenia Medical Management
CLOZAPINE
remains the drug of choice in treatment resistant cases; reduce cravings for alcohol/illicit drugs; reduced/delayed risk of suicide attempts.
But 1% of patients develop agranulocytosis after 12-24 wks. Patients required to have weekly WBC counts i.e. > 3000/c.c.
can cause initial sialorrhea; hypotension, sedation, tachycardia.
Schizophrenia Medical Management
Risperidone, Olanzapine, Quetiapine
-provide better management of both
“positive”,“negative” & “disorganized” symptoms.
Minor sedation, weight gain, sexual dysfunction, dry mouth, no agranulocytosis.
**the improved clinical course and therefore compliance with these “atypical” medications ensure less chances for relapse that was seen with conventional antipsychotic therapy.
Schizophrenia Medical Management
BUT, atypical antipsychotics can compound at patient‟s risk for diabetes, heart disease, obesity, hyperlipidemia (“metabolic syndrome”)
Dental implications are relevant with respect to clinical management of the diabetic, cardiac patient etc.
Antipsychotic Medications: Impact on Dental Care
Conventional Antipsychotics:
chlorpromazine, haloperidol, perphenazine
Oral side effects: xerostomia, tardive dyskinesia
Atypical Antipsychotics:
clozapine,olanzapine,quetiapine,risperidone
Oral side effects: xerostomia, dysphagia, stomatitis, dysgeusia
Schizophrenia Oral Findings
…people who suffer from schizophrenia are at a far greater risk of dental caries, gingivitis/advanced periodontal disease, tooth loss, lack of dentures, poor oral hygiene, mucosal diseases…
+ poor dietary habits, smoking, alcohol
abuse, substance abuse…
Schizophrenia Oral Findings
higher prevalence of bruxism and signs of TMD = severe tooth damage due to extensive attrition.
? CNS abnormalities and/or neuroleptic induced mechanisms.
actual pain sensitivity thresholds higher in pats. with schizophrenia vs. healthy controls. While more prone to suffer TMD problems, pain sensitivity thresholds cause delays in dx. and tx. resulting in serious clinical consequences.
Schizophrenia Oral Findings can be….
precipitated by the psychosocial deficiencies inherent in the disease itself.
a result of a disinterest in regular oral care; is due to financial hardships, prolonged periods of hospitalization and non-existent support networks.
also a result of an unwillingness on the part of the DDS to understand and/or be comfortable in the dental management of these patients.
SCHIZOPHRENIA Dental Considerations
fluoride supplements (e.g.Prevident)
oral hygiene
salivary substitutes (re: dry mouth)
Clozapine use & agranulocytosis
freq. recall appts.
empathy, support, MD consultation
meds/consent/psych. status
SCHIZOPHRENIA Drug Interactions
Epinephrine used with caution to prevent severe hypotensive episode – limit to 2 carpules 1:100,000; avoid epinephrine in retraction cords; inject slowly.
Neuroleptics may intensify effects of sedatives, hypnotics, opioids, antihistamines – leading to severe respiratory depression – consult with MD.
Neuroleptics can dec. blood levels of warfarin.
COMPLICATIONS OF XEROSTOMIA
acidic plaque pH…caries, hypersensitivity
loss of lubrication…oral ulcerations, difficulties eating, speaking, wearing dentures
dec. amount of saliva…inc. infections (viral, bacterial, fungal) digestion problems, ease of trauma to oral mucosa, gingivitis & periodontitis
DENTAL MANAGEMENT Dry Mouth Protocol
sipping water frequently
restrict caffeine, colas
sugar free gum, candies.
saliva substitutes, oral moisturizers e.g. MouthKote, Biotene products (contain key enzymes[3] found naturally in saliva)
avoid alcohol/alcohol containing mouthrinses
fluoride rinses(0.05%)
fluoride gels(0.04%)
CHX mouth rinse (alcohol-free TBA)
restrict/avoid tobacco products
Depression is…..
“an equal opportunity
illness” –all ages, races, all economic classes.
an illness (as is diabetes, heart disease)
leading cause of suicide (15%)***
F > M: 2:1
highest risk for those with family Hx. Of depression – genetic component, further advanced by emotional deprivation or childhood trauma.
elderly > 65.
those with physical illness/disabilities.
Depression is…..
second leading cause of death and disability in the world in age category of 15-44 yrs. (M & F) – W.H.O.
an illness affecting the entire body
leading cause of alcohol/drug abuse (1/3 of patients)
Depression will be…..
The second leading cause of health impairment worldwide by 2020.
(WHO)
Major Depressive Disorder
Mental illness of at least 2 weeks duration encompassing at least 5 of the following DSM-IV diagnostic symptom criteria:
depressed mood
diminished interest/pleasure
dec./inc. in wt. or appetite
insomnia/hypersomnia
inability to think or concentrate
fatigue/loss of energy
thoughts of death/suicide
Bipolar I Affective Disorder
“ a roller coaster of mood”
lowest of lows = s/s of major depression
highest of highs = manic episode, preceded often by “hypomania” - one “feels good”, excitable, talkative, energized, able to think/concentrate very clearly- but not dangerous to self/others.
Bipolar I Affective Disorder (MANIC EPISODES)
feeling
indescribably good require little or no
sleep easily explode into
anger flight of ideas,
impaired judgment
lose touch with reality
excessively talkative
uninhibited; lack of insight into one‟s behaviour e.g. of a sexual nature
Depression (Postpartum Depression)
Condition diagnosed within 1 yr. of childbirth. (not “baby blues”)
often under diagnosed/widely misunderstood due to stigmatization
Late-life Depression
Who? - > 65 yrs.
What? – impairment of mood, thought context, behaviour = distress, compromised social function, poor self care = sadness, loss of interest, wt. changes, fatigue = inc. suicide risk
Monamine Oxidase Inhibitors (MAOI‟s)
Phenelzine (Nardil) Tranylcypromine (Parnate)
Moclobemide (Manerix)
heralded era of antidepressants- 1950‟s prevent enzymatic breakdown of
noradrenaline/serotonin in synaptic cleft with inc. levels of both neurotransmitters.
used in cases(10%) refractory to TCA‟s, SSRI‟s or “other” antidepressants.
MAOI‟s
Disadv. – dietary + drug-drug interactions causing severe hypertension.(tyramines in cheese, meats, red wine are not inactivated; MAOI + ephedrine); potentiation of depressant activity of the opioids.
also dizziness, dry mouth, insomnia, wt. gain, orthostatic hypotension.
Tricyclic Antidepressants amitriptyline (Elavil)
clomipramine (Anafranil) imipramine (Tofranil)
desipramine (Norpramin)
initially most popular first line Rx.- 1960‟s
prevent re-uptake of noradrenaline & serotonin = inc. levels.
**problems with non-compliance due to
S/E of dry mouth (50%).
Other Side Effects of Antidepressant Drugs (Tricyclics)
Common: dry mouth, nausea/vomiting, constipation, urinary retention, insomnia, sexual dysfunction, postural hypotension.
Serious: mania, seizures, leukopenia, cardiac arrhythmias, MI, stroke.
Selective Serotonin Reuptake Inhibitors SSRIs
fluvoxamine (Luvox) fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft)
citalopram (Celexa)
inc. use as first line Rx.- 1990‟s. (second generation)
prevent re-uptake of serotonin from synaptic cleft resulting in inc. levels of enhanced neuronal activity.
Adv. – less sedation & cardiotoxicity, < dry mouth(18%)
Disadv. – GI upset, insomnia, sexual dysfunction, poss. Inc. in bleeding time.
Electroconvulsive Therapy (ECT)
for severe depression refractory to medication.
? – a CNS seizure induced via electric current (under GA) = inc. responsiveness of neuronal membranes to neurotransmitters.
Dental: r/o loose/broken teeth re: possible aspiration; identify CD/RPD. Use of bite blocks to protect teeth & tongue.
Drug-Drug Interactions…
Tricyclics & MAOI’s
TCA‟s block re-uptake of levonordefrin causing dramatic inc. of BP, cardiac dysrhythmias and delayed cardiac conduction. **avoid levonordefrin**
potentiate effects of CNS depressants incl. ethanol, opioids, benzodiazepines.
inhibit metabolism of warfarin – inc. INR.
Drug-Drug Interactions… SSRI’s
e.g. Prozac, Paxil, Wellbutrin reduce efficacy of codeine containing cmpds./erythromycin via action on P450 hepatic microsomal enzymes.
inhibit metabolism of warfarin – inc. INR
potentiate depressant effects of sedatives, barbiturates.
Lithium
NSAID‟s and COX-2 inhibitors impair renal excretion of lithium, thereby inducing lithium toxicity.
Side Effects of Long Term Use of Lithium
• Neurologic lethargy, fatigue, weakness, fine
tremors, memory impairment • Renal renal failure • Thyroid lithium-induced hypothyroidism • CVS T-wave depression on ECG • GI nausea, vomiting, diarrhea, abdominal
pain
• Hematologic benign leukocytosis
ORAL xerostomia, lichenoid stomatitis, metallic taste sensation
Antidepressant/Mood Stabilizers Impact on Dental Care
Mood stabilizers: Lithium Oral side effects: xerostomia, lichenoid stomatitis,
metallic taste Tricyclic antidepressants: Amitryptilline, clomipramine, imipramine Oral side effects: xerostomia, possible potentiation
of pressor effects in epinephrine in local anesthetics; use of levonordefrin contraindicated; use of retraction cord with epinephrine contraindicated.
Antidepressant/Mood Stabilizers Impact on Dental Care
Selective serotonin reuptake inhibitors(SSRIs):
citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, buproprion
Oral side effects: xerostomia, dysgeusia, stomatitis, glossitis, bruxism
Summary of Oral Findings
Summary of Oral Findings
increased presence of TMD signs (14% of patients with signs of TMD also have comorbid psych. symptoms c/w depression i.e. wt. loss, sleep disturbances, energy loss, changes in concentration)
increased dental attrition/incidence of bruxism
WHY? CNS abnormalities of a psychiatric patient? neuroleptic-induced? -more research needed
EATING DISORDERS
Anorexia Nervosa
Bulimia Nervosa
living in fear of food; of being fat
diagnosis has reached epidemic proportions
ANOREXIA NERVOSA
“ceaseless pursuit of thinness”
1% of females aged 12 – 25 yrs.
mostly white/middle class background.
extreme distortion/perception of body image.
ETIOLOGY OF EATING DISORDERS
genetic predisposition
societal pressures
achieve control, approval
depression, feelings of guilt
distorted body image
extreme exercise regimen
issues re: self-esteem
ANOREXIA NERVOSA Signs & Symptoms
use of laxatives, diuretics
energetic, hyperactive
strenuous exercise regimen
fearful to gain weight (usually about 15% below normal wt.)
increased incidence in females with Type 1 diabetes (deliberate avoidance of taking insulin to induce weight loss)
ANOREXIA NERVOSA Signs & Symptoms
Progressing to….. amenorrhea, constipation, kidney dysfunction, UTI, impaired conc. & rational thinking, muscle spasms, seizures, intolerance to cold, hypotension, bradycardia, alopecia, nail fragility, electrolyte imbalance, sudden death (ventricular tachyarrhythmias)
BULIMIA (“ox-hunger”) NERVOSA
“binge eating and purging”
1-5% of females aged 12 – 25 yrs.( more common than A.N.)
35% of patients with Anorexia Nervosa also suffer from Bulimia .
35% of patients with Bulimia abuse alcohol/drugs.
50% of patients with Bulimia suffer
personality disorders.
BULIMIA NERVOSA Diagnostic Criteria
Binge eating twice weekly over a 3 month period of time followed by self-induced vomiting, laxatives, diuretics, enemas, excessive exercise regimens.
(may in fact be of a more normal weight)
BULIMIA NERVOSA Signs & Symptoms
compulsive ingestion of excessively large amounts of food.
depressed upon the cessation of eating.
secrecy component.
Russell‟s sign.
BULIMIA NERVOSA Complications
aspiration pneumonias.
esophageal/gastric rupture.
hypokalemia – cardiac arrythmias.
pancreatitis.
Ipecac – induced myopathy/cardiomyopathy.
EKG aberrations
MEDICAL COMPLICATIONS
Anorexia Nervosa: arise as a result of starvation (restricting) and weight loss.
Bulimia Nervosa: related to the mode and frequency of purging.
Patterns of Dental Erosion
Lingual surface erosive pattern:
Bulimia (perimyolysis), chronic gastritis secondary to chronic alcoholism, GERD.
(+/- affecting the occlusal surfaces of premolars/molars, further exacerbated by attrition.)
EATING DISORDERS Oral Complications
Finding Anorexia Nervosa Bulimia Nervosa
Lingual erosion no yes
Tooth sensitivity no yes
Xerostomia yes yes
Dental caries no yes
Perio. disease no yes
Enlarged parotid** yes yes
Mucosal atrophy yes no
Poor oral hygiene no yes
EATING DISORDERS Objectives for Preventive Dental Treatment
1. Reduce frequency of acid exposure on teeth.
achieving a reduction in the no. of episodes of vomiting to complete cessation.
2. Enhance salivary flow.
sugar free mints, chewing gum to stimulate salivary flow
water for oral lubrication
EATING DISORDERS Objectives for Preventive Dental Treatment
3. Neutralize acids in the mouth.
use of alkaline mouth rinse immediately after vomiting(NaHCO3), water, milk
4. Increase resistance of enamel to demineralization.
daily fluoride rinse 0.5%
fluoride gels (1.1%) in custom trays
EATING DISORDERS Objectives for Preventive Dental Treatment
5. Minimize abrasive brushing techniques
soft brush, circular motion, floss
avoid brushing immediately after episodes of vomiting
6. Caries prevention
NaF varnishes
sealants?
snack substitutes
desensitizing agents
EATING DISORDERS Dental Tx. Planning (complex restorative care)
Anorexia Nervosa:
– regain lost weight
– stabilize physical health
Bulimia Nervosa:
– end cycle of binge eating/ vomiting
– temporary coronal coverage followed by eventual
RCT/ cast restorations as required (Relapse is
common if vomiting recurs)
– parental involvement*****
ANXIETY DISORDERS
Anxiety – what is it?
“emotional pain or a feeling that all is not well-a feeling of impending disaster”
The physiological reaction/response occurs via ANS- can include inc. heart rate, sweating, dilated pupils, inc. urge of urination, diarrhea.
ANXIETY DISORDERS
may involve an internal psychological conflict, environmental stressors, physical disease, side effects of medications or combination of these findings.
the consequences of anxiety are profound emotional, occupational and social impairments.
ANXIETY DISORDERS Etiology
no single theory available
usually a combination of psychosocial/biological processes (neurobiological theories)
low level anxiety can be “normal” but… anxiety often is a component of other psychological disorders such as mood disorders, dementias, panic disorder, psychoses etc.
ANXIETY DISORDERS
Mild form of anxiety towards dental care –
Treatment Strategies
1. General attitude/anxiety reducing treatment style
providing trust
providing control
providing realistic information
apply high level of predictability
2. Pharmacological support
pre-medication
nitrous oxide sedation
3. Teaching of coping strategies
distraction
relaxation
hypnosis
ANXIETY DISORDERS
POST-TRAUMATIC STRESS DISORDER Result of exposure to a traumatic event outside of
usual realm of human experiences e.g. during combat, sexual/physical abuse, MVA, natural
disasters etc.
Cardinal features:
hyper arousal
intrusive symptoms
numbing of one‟s psyche
Diagnosis made if onset of s/s is at least 6 mths. post
trauma or when s/s have been present > 3 mths.
Post-Traumatic Stress Disorder
4th most common psych. illness in U.S.
F > M
*** Personal pre-disposition necessary for s/s to develop after traumatic event / genetic factors contributing to individual vulnerability***
80% have co-morbid psych. disorder.
rate of attempted suicide = 20%
Post-Traumatic Stress Disorder
Dental Findings
• poor OH
• rampant caries/perio disease
• > abfraction lesions
• chronic atypical facial pain
• s/e of SSRI‟s
Dental Management
• preventive care
• mgmt. of xerostomia
• oral Ca.screening
• caution re: oral surg.in long-term alcoholism
• caution re: use of certain analgesics,antibiotics, sedatives
ANXIETY DISORDERS
PANIC DISORDER experiencing of recurrent & unexpected panic
attacks not associated with any external event or situation.
c/o – palpitations, chest pain, difficulty breathing, dizziness, sweating- “adrenergic surge”
becomes a problem when there is impairment of one‟s outlook on life & day to day living.
Panic Disorder
5% in females; 2% in males.
~ 1 M Canadians 15 yrs or older.
lifelong illness with variable response to treatment.
resulting social/occupational impairments are a massive cost to society.
Panic Disorder
Diagnosis
r/o medical conditions e.g. MI, hyperthyroidism, xs. caffeine use, stimulant use, alcohol /drug withdrawal.
* Subgroup of patients with panic disorder are found with a unique set of medical problems including UTD, hypothyroidism and MVP (mitral valve prolapse) – 8-33% of patients with panic disorder have MVP vs.~25% of gen. pop.
ANXIETY DISORDERS
OBSESSIVE-COMPULSIVE DISORDER(OCD)
Obsessive thoughts and compulsive actions causing distress and functional impairment.
Obsessions = unwanted, persistent and recurrent ideas permeating one‟s consciousness causing significant anguish. May be trivial or more highly charged thoughts and actions.
Obsessive-Compulsive Disorder
Dental Management
• preventive oral care
• MD consult re: current status & meds.
Dental Findings
• s/e of medication-induced xerostomia
• somatic obsessions
• > abrasion lesions (overzealous oral hygiene practices=
compulsions)
ANXIETY DISORDERS Dental Management summary
Pre-op: - explain, honesty, answer questions, consistent communication.
**oral sedation (benzodiazepines)
Operative: - answer questions, reassurance.
**L.A. oral/IM/IV sedation, N2O2
Post-op: - explain what to expect, what to do/not do, possible complications( i.e. pain, bleeding, infections), who to contact.
**analgesics, +/- antibiotics
Somatoform Disorders
“Psychological disorders characterized by the presence of physical symptoms that are not fully explained by a medical condition, the effects of a substance, or by another mental disorder.”
Psychosomatic vs. Somatoform
– Psychosomatic: disorders in which there is REAL physical illness that is largely caused by psychological factors such as stress and anxiety.
– Somatoform: disorders in which there is an APPARENT physical illness for which there is no organic basis.
Somatoform Disorders
Patients may experience multiple, unexplained somatic symptoms that may last for years.
Examples:
hypochondriasis
Pre-occupation with fear of having a serious disease on the basis of one‟s misinterpretation of bodily symptoms/bodily functions.
conversion disorder
Patient resolves an underlying conflict (“primary gain”) by the unconscious use of the symptom(s). (e.g. conversion paralysis/blindness) Increased attention as a result = secondary gain.
Somatoform Disorders
body dysmorphic disorder “pre-occupation with an imagined or exaggerated
defect in physical appearance”
One of the underlying causes of patient dissatisfaction with certain physical or dental features such as the appearance of teeth, facial asymmetry or disproportion of shape and size of lips, mouth or jaw.
Somatoform Disorders
Examples of Oral Symptoms
burning, painful tongue
numbness/tingling sensation of soft tissues
facial pain
Somatoform Disorders
PATH TO DIAGNOSIS
symptoms do not follow known anatomic nerve distribution.
lab tests/MD consult have r/o underlying systemic cause e.g. anemia, CA, diabetes.
Somatoform Disorders Medical Perspective
psychiatric Tx. re: somatoform disorders focuses on coping vs. cure.
anxiety/depression contribute to s/s in 33% of patients with SD. Treatment of these conditions will facilitate management of somatoform disorders.
psychotherapy, SSRI‟s.
CONCLUSION Dental Perspectives for patients diagnosed with mental illness
Some patients who undergo psychiatric care for e.g. depression may be reluctant to admit this fact due to the stigma attached to the psychiatric diagnosis.
Dentistry must overcome such barriers: obtain all relevant information
supportive, non-judgmental attitude
ensuring confidentiality
emphasizing the need to be provided safe dental care.
Eating
Speaking
Esthetics (smiling and self esteem)
The taking of dental
radiographs during
pregnancy continues to be
a controversial issue.
It should be noted,
however, that a pregnant
patient who is properly
shielded can safely
receive dental x-rays at
any time.
You lose a tooth for every pregnancy
Babies drain the calcium from your teeth
Every time you are pregnant your gums bleed and you have problems with them
False to all: Meticulous oral hygiene with fluoride regimen will help to prevent all tooth and gum problems experienced during pregnancy
Oral Disease and Systemic Disorders
Periodontitis has an association with:
• Infective Endocarditis
• Diabetes
• Cardiovascular Disease
• Pre-Term, Low Birth Weight Infants
• Pulmonary Disease
• Others
Oral Disease and Systemic Disorders Periodontitis and pregnancy
Oral Disease and Systemic Disorders Periodontitis and pregnancy
Biologic Mechanisms for PTLBW Infants
Entry of inflammatory products (PgE2, Il-6, TNF- α), endotoxin, and/or periodontal bacteria into the bloodstream and their translocation to the fetus and decidual tissues
American Academy of Periodontology Report 2004
•Preventive oral care services should be provided as early in pregnancy as possible.
•If exam indicates a need for periodontal therapy, these procedures should be scheduled early in the 2nd trimester.
•The presence of acute infection, abscess, or other potentially disseminating sources of sepsis may warrant prompt intervention, irrespective of the stage of pregnancy.
Dental Considerations
Review
Recommendations
Regular dental examinations for all pregnant patients
Aggressive periodontal therapy for infections
Frequent reinforcement of oral hygiene and dental care by medical providers
Also know as pyogenic granuloma.
Rare, usually painless lesion, develops on gums in response to plaque
Non-cancerous
•Subside shortly after childbirth
•No treatment is required unless causes problems with eating, speaking, or swallowing
•If treatment is needed, it is surgically removed
Preterm Low Birth Weight Births
Smoking, alcohol use, and drug use contribute to mothers having babies that are born prematurely at a low birth weight.
Evidence suggests a new risk factor – periodontal disease.
Pregnant women who have periodontal disease may be seven times more likely to have a baby that is born too early and too small.
If nausea and vomiting is a problem, it is important to frequently brush or rinse with water. The acid could cause erosion of the teeth.
If you are craving sweets, this could cause an increase in cavities. So, just remember to snack on raw veggies and fruits.
GIT diseases
Esophagus
Dysphagia
difficulty in swallowing sensation that the food „stops“ in the oesophagus
Cause disorder of oesophagus motility – neuro-muscular problems –
multiple sclerosis, myasthenia gravis, Parkinson disease... obstruction tumor psychogenic – phagophobia
painful swallowing
Cause disorder of motility obstruction infection reflux oesophatitis
Odynophagia
Achalasia disorder of esophageal motility defect of ezophagus peristalsis
Cause defect of ezophagus wall innervation
Signs and symptoms dificulty swallowing regurgitation chest pain
burning sensation in esophagus
Cause GERD
Pyrosis
Definitions Gastroesophageal reflux (GER) – involuntary movement of gastric
(sometimes also duodenal) content to the esophagus – normal physiological process – 1- 4x/h during 3 h after eating
Gastroesophageal reflux disease (GERD) – chronic damage of the esophagus caused by a GER
Causes abnormal relaxation of the lower esophageal sphincter (LES)
– triggers – fat, chocolate, onion, alcohol, peppermint... hiatal hernia
– protrusion of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm - change in the LES position – change in the LES tonus
Protective mechanisms tonic contraction of lower esophageal sphincter peristalsis neutralization of acidic content by saliva
Gastroesophageal Reflux Disease - GERD
Esophagus
diaphragm
HIS-angle
A - normal anatomy
B – hiatal hernia pre-stage
C - sliding hiatal hernia
D - paraesophageal type
Symptoms
Main symptoms
Pyrosis – heartburn – chest pain
Regurgitation
Dysphagia, odynophagia
Salivation
Nausea, vomiting
Other symptoms
Chronic cough
Laryngitis, pharyngitis
Asthma
Oral symptoms
Teeth hypersensitivity
Erosion of dental enamel
GERD complications
Reflux esophagitis – erosions, ulcers
Barrett´s esophagus
– metaplasia – replacement of the epithelial cells from squamous to columnar
– premalignant condition
Esophageal adenocarcinoma
Stomach
Definition ulceration in the upper GIT
– stomach – proximal part of duodenum – esophagus
Causes Helicobacter pylori (70 – 90%) Nonsteroidal anti-inflammatory drugs – aspirin, ibuprofen... Gastrinoma - Zollinger-Ellison syndrome
– hyperproduction of gastrin from pancreatic or extrapancreatic (e.g. duodenal) tumourur
stress
Risk factors smoking spices
Peptic Ulcer Disase - PUD
Intestines
Definitions Malabsorption – abnormal absorption of nutrients by gut mucosa Maldigestion – abnormal digestion of nutrients
Causes pancreatic insuficiency
– pancreatitis – carcinoma – cystic fibrosis
cholestasis – obstruction
specific deficits – lactase deficiency
systemic diseases – celiac disease
infection – Whipple´s disease
inflammation – Crohn disease
Malabsorption
Symptoms
Irritable Bowel Syndrome (IBS)
Definition a multifactorial inflammatory disease of the
intestines (ileum, large intestine) that may affect any part of the GIT (from mouth to rectum), with a variety of GIT and extraGIT symptoms
Cause autoimmune process genetical predisposition (mutation of NOD2
gene) + external factor (bacterias, milk protein) risk factors: smoking, contraceptives
Crohn´s disease
Gastrointestinal symptoms abdominal pain diarrhea, fecal incontinence flatulence, bloating, intestinal discomfort nausea, vomiting perianal discomfort (itchiness, pain), fistula, abscess around the anus mouth – aphtous ulcers, ezophagus – dysphagia stomach - pain Systemic symptoms growth failure loss of apetite, wight loss fever malabsorption Extraintestinal symptoms eye (uveitis) skin inflammation - erythema nodosum, pyoderma gangrenosum spondyloarthopathy autoimmune hemolytic anemia finfers deformity osteoporosis neurological symptoms – seizures, peripheral neuropathy, headache
Symptoms of Crohn´s disease
perianal fistulas perianal fissura erythema nodosum pyoderma gangrenosum uveitis
Symptoms of Crohn´s disease
bowel obstruction, fistulae, abcesses, perforation, bleeding intestinal strictures and adhesions infection malnutrition, malabsorption smal intestinal cancer
Complications of Crohn´s disease
Definition an chronic inflammatory bowel disease (colon)
Cause unknown autoimmune process genetical predisposition environmental factors
– diet - fiber content
protective factor: breastfeeding
Ulcerative colitis
Gastrointestinal symptoms diarrhea with blood or mucus abdominal pain, cramps mouth aphtous ulcers
Systemic symptoms loss of apetite, wight loss
Extraintestinal symptoms joints – arthritis eye - uveitis skin - erythema nodosum, pyoderma gangrenosum liver – pericholangitis, fatty liver blood – hemolytic anemia, tromboembolic disease (rare)
Symptoms of ulcerative colitis
Liver
Icterus
• yellowish pigmentation of the skin, sclera and the mucous
membranes caused by hyperbilirubinemia
over 22 mmol/l - hyperbilirubinaemia
unconjugated bilirubin
conjugated bilirubin
over 35 mmol/l - icterus
haemoglobin
RES
haem
globin bilirubin
blood
bilirubin
liver
conjugation of bilirubin
bile
intestine
urobilinogen urobilin
bilirubin production
haemolytic icterus
conjugation of bilirubin
Gilbert’s disease
Crigler-Najjar syndrome
Lucey-Driscoll syndrome
neonatal icterus
excretion of bilirubin to bile
Dubin-Johnson syndrome
Rotor syndrome
hepatocellular icterus
intra- a extrahepatic biliar obstruction
gallstones, carcinomas
Disorders of bilirubin metabolism
unconjugated bilirubin
conjugated bilirubin
Retention of unconjugated bilirubin
Gilbert’s syndrome
(Familiar unconjugated nonhaemolytic hyperbilirubinaemia)
mild disorder of uptake of bilirubin to hepatic cells and conjugation
mild hyperbilirubinaemia
good prognosis
Hemolytic icterus
haemolysis - congenital - red cell enzymes or membrane
defects, haemoglobin defects
- acquired - toxins, incompatible blood transfusion
Chronic liver insufficiency
Causes Viral - hepatitis Toxins and drugs – alcohol Wilson disease hemochromatosis autoimmune hepatitis heart failure
Complications liver encephalopathy – coma portal hypertension – ascites, esophageal, rectal - varices coagulopathy – bleeding cancer
Liver insufficiency
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