Transcript Debi Downer - University of Minnesota

Debi Downer
Ms. Debi Downer
► Somewhat
depressed 34 yr old female
► Presents for emergency extraction of #1-8
► Health history states she is taking Nardil
and Prozac
► She also had an “allergic reaction” to
“Novocain” from dental treatment several
years ago
► Her dentist moved to Australia
Mood Disorders
► Group
of mental disorders characterized by
extreme exaggeration and disturbance of
mood and affect
► Associated with physiologic, cognitive, and
psychomotor dysfunction
► Tend to be cyclic and include depression
and bipolar disorder
Incidence and Prevalence
► 5%
of adults in U.S. have a significant mood
disorder
► Mood disorders more common in women
► Major depression can occur at any age but
prevalence highest in the elderly
► Percentage of people who experience
depression at some point in their life:
 20% to 25% of women
 7% to 12% of men
Incidence and Prevalence
► Prevalence
for major depression:
 4.5% to 9.3% in women
 2.3% to 3.2 % in men
► One
third of whom require hospitalization
► Consistent across race and culture
► No clear association with social class but
poverty can be a significant stressor
Incidence and Prevalence
► Lifetime
prevalence of dysthymia, a chronic
mild form of depression:
 2.2% in women
 4.1% in men
► 0.4%
to 1.6% of adults in U.S. have bipolar
disorder with an equal occurrence in both
men and women
Etiology
Several theories exist to explain mood disorders
► Reduced brain concentrations of norepinephrine and
serotonin are believed to lead to depression
► Increased levels have been attributed to the onset of
mania
► The causes of depression/mania appear to be much
more complex
► Genetic component?
►
Clinical Presentation
• Major Depressive Episode - Five of the following
symptoms present for 2 weeks:
►Depressed
Mood
►Loss on interest or pleasure in daily activities
►Weight gain or weight loss
►Insomnia or hypersomnia
►Loss of energy
►Feelings of worthlessness or guilt
►Inability to concentrate or indecisiveness
►Thoughts of death or suicide
Clinical Presentation
► Major
Depressive Episode – Not including:
 Drugs or mood altering substances
 Death of a loved one
 Delusions before, during, or after mood
symptoms
 No superimposed schizophrenia or other
psychotic disorder
Clinical Presentation
► Dysthymia
– Depressed mood >2 years
including two or more of the following:


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

Poor appetite
Insomnia or hypersomnia
Loss of energy
Low self-esteem
Inability to concentrate or indecisiveness
Feelings of hopelessness
Clinical Presentation
► Dysthymia





– not including:
Without symptoms for longer than two months
Major depressive episode during that period
Manic episodes
Drugs or mood altering substances
Significant functional impairment
Clinical Presentation
► Bipolar
Disorder – cyclic recurrences of
manic episodes and depression or mixed
states
 Manic episode
►Euphoric
and cheerful mood
►Loud, rapid, and excessive speech
►Decreased need for sleep
►Colorful and strange wardrobe
►Poor judgment with financial and legal decisions
Treatment
► Antidepressents


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
–
Tricyclics - NE and 5-HT reuptake inhibitor
SSRIs – selective 5-HT reuptake inhibitor
SNRIs – 5-HT and NE reuptake inhibitor
MAOIs – monoamine oxidase inhibitor
► Bipolar
drugs-
 Lithium – mood stabilization
 Carbamazepine and Valproate – anticonvulsants
Treatment – Complications
► The
drugs used in the treatment of
depression have many potential
complications including side effects and
adverse drug interactions
Treatment - Complications
► Tricyclics
– All are equally effective in the
management of depression but have
different adverse effects including:
 Dry mouth, constipation, blurred vision,
tachycardia, hypotension, allergic reactions, and
drug interactions
Treatment - Complications
► Tricyclic
drug interactions:
 Potentiates CNS depressants, anticholinergics,
sympathomimetic agents (Epi & Levonodefrin)
 Levels of tricyclics reduced by the use of oral
contraceptive, alcohol, barbiturates, and dilantin
 Induction of hypertensive crisis if taken with or
soon after MAOI
 Overdosage can be lethal due to cardiac
arrhythmia or respiratory failure
Treatment - Complications
► SSRIs
– considered first line drugs for
treatment of depression; just as effective as
tricyclics but better tolerated
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Not as lethal in overdose as tricyclics
Considerably more expensive
Most frequent side effect is nausea (25%)
Can induce serotonin syndrome when combined
with MAOIs
Treatment - Complications
► SNRIs
– second generation antidepressants
 Side effects similar to SSRIs including:
►May cause adverse sexual side effects
►Increase in blood pressure
Treatment - Complications
►
MAOIs – Both nonselective and irreversible; first
effective drug used to treat depression
 Many adverse side effects most importantly are
the many drug interactions
 Can cause hypertensive crisis when combined
with sympathomimetic amines including tyramine
►Foods containing tyramine include aged
cheeses, wine, pickled fish, bananas,
chocolate, and almost any foods with yeast.
 Potentiate the pressor effects of
phenylethylamine and phenylephrine with are
found in many cold medications
 Induce serotonin syndrome when combined with
SSRIs or SNRIs
Treatment Complications
► Bipolar
lithium
Disorder – most commonly treated with
 Lithium - mode of action unclear
►Used
to treat and prevent manic episodes
►Effective by itself in 60-80% of patients
►Complications associated with long term use are:
 Non-toxic goiter, hypothyroidism, arrhythmia, T-wave depression,
and vasopressin-resistant nephrogenic diabetes insipidus
►NSAIDs
increase serum lithium leading to toxicity
Dental Management
Depression and Bipolar Disorder
► Preoperative:
 Signs and Symptoms
 Refer
for medical evaluation and treatment
 Thrombocytopenia and Leukopenia
 Request
drug change by physician
► Medications
and Determine Status
 Drug interactions? Suicidal?
Dental Management
Depression and Bipolar Disorder
► No
medical contraindications to treat
patient;
BUT, best management:
 Immediate dental needs only
 Defer elective/complex treatment
►Difficult
to manage; poor compliance with
appointments and/or treatment
Dental Management
Depression and Bipolar Disorder
► Operative:
 Limit use of epinephrine (avoid if possible)
• 1:100,000 epi - ok
• Limit to 2 carpules
• Avoid retraction cords with epi
 Avoid or reduce dosage of Sedatives, Hypnotics,
Narcotic agents (respiratory depression)
 Postural Hypotension – change chair position slowly
Dental Management
Depression and Bipolar Disorder
► Postoperative:
 Avoid Sedatives, Narcotics, Hypnotics
 Patients taking Lithium:
►Avoid NSAIDs, Tetracycline, Metronidazole
► Lithium Toxicity
 Avoid Diazepam
►Hypothermia
Dental Management
Oral Complications
► Oral lesions, fever or
antipsychotic drug use)
sore throat (w/
 Agranulocytosis
► Muscular problems (dystonia, dyskinesia or
tardive dyskinesia) w/ antipsychotic agents
► Self-destructive behavior
 Eye gouging, sharp objects into ear canal, lip
biting, check biting, burning oral tissues,
mucosal injury with sharp object
Dental Management
Oral Complications
► Oral
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Hygiene Issues (apathy)
Increased dental caries rate
Periodontal disease
Decreased salivary flow (meds)
Facial pain syndromes (common)
OHI very important
Dental Management
Side Note:
When treatment planning, FLEXIBILITY is key
Reduce stress
Involve family and/or caretakers
Questions for Debi
► How
are you feeling today?
► What is your normal blood pressure?
► How often do you take you blood pressure?
► Have you had any headaches or changes in
vision?
► Are you being treated for hypertension?
Questions for Debi
► How
is your depression today?
► Have you had any suicidal thoughts
recently?
► Do you ever have periods of extreme
happiness and feel very productive?
► Do you drink alcohol or smoke cigarettes?
How often?
► Do you use any other drugs? How often?
Questions for Debi
► Meds
Are you taking both Nardil and Prozac?
How often do you take your medications?
How long have you been taking them?
Do you avoid eating any foods?
What other medications have you taken for your
depression?
 Has there been a change in your medications?
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Questions for Debi
► Allergy
to Local Anesthetic
 Do you have any other allergies? (preservatives,
medications, etc.)
 Did your dentist name a specific component you
were sensitive to?
 Were you taking both Nardil and Prozac when
this happened?
Questions for psychiatrist/physician
► How
long has she been taking both an MAO
inhibitor and an SSRI?
► Has she had a hypertensive crisis in the past?
► Would you consider her mood to be stable?
► What is her history of suicide attempts?
► Is there anything else that would be important for
me to know?
Debi Downer
Somewhat depressed 34-y.o female
Emergency extraction of abscessed tooth #1
Taking Nardil (MAOI) and Prozac (SSRI)
“Allergic” reaction to “novocaine” where she felt
very weak, her heart fluttered and she nearly
passed out
Debi Downer ASA-PS III or IV
► Physically
she is fine, but look at meds, and
blood pressure
► MAOIs and SSRIs dangerous drug
interaction – potential for severe
hypertensive crisis and serotonin syndrome
► Past history of possible interaction with
vasoconstrictor – orthostatic hypotension
What would you do for Debi Downer
today?
► Take
Blood Pressure
► Delay elective treatment, but need to
address abscess
► Avoid/Limit Epinephrine – potentiate
possibility of hypertensive crisis,
hypotensive episode, and a myocardial
infarction
Dental Algorithm
A
► Anesthetics:
limit amount of epinephrine
 < 2 carpules
 EPI effects are potentiate
► Antibiotics:
tricyclics interferes with
erythromycin
► Anxiolytics: avoid barbiturates,
benzodiazepines
 increased CNS depressant effects
► Analgesics:
avoid opioids
 increased sedative effects
 NSAIDS okay, but not with lithium
► Blood
pressure:
 MAOIs & tyramine- HTN crisis (also MAOIs &
tricyclics)
 HTN serious adverse side effect
 Hypotension adverse side effect of tricyclics,
MAOIs, & SSRIs
 Tricyclics block the antihypertensive effects of
guanethidine
► Bleeding:
tricyclics & SSRIs
 inhibit warfarin metabolism
 Increased INR values
B
C
► Cardiac
complications:
 MAOIs & SSRIs- bradycardia
 Tricyclics - tachycardia
►OD
can cause death because of arrhythmia
 MAOIs & tyramine- arrhythmia
► Oral
Complications
 Xerostomia
►Caries
and candidiasis
 Poor hygiene
D
► Drug
interactions (Table 29-6 Pg. 521)
 Antihistamines with tricyclics & MAOIs
►CNS
depression
 Anticonvulsants with tricyclics & MAOIsinterfere with actions
►Tricyclics
can lower seizure thresholds
 Cimetidine (H2-receptor antagonist) with
tricyclics & SSRIs
►
Inhibits clearance leading to toxicity
D
►
Drug interactions: MAOIs &
SSRIs
 Serotonin syndrome
 Dangerously high levels
of serotonin
 Requires immediate
medical treatment
 Usually resolves in 24
hours
►
Signs & Symptoms
 Confusion
 Restlessness
 Hallucinations
 Extreme agitation
 Fluctuations in blood
pressure
 Increased heart rate
 Nausea & vomiting
 Fever
 Seizures
 Coma
D
► Dental
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Management
Medical consult
Small amounts of Epi
Reduce sedative medications
Only treat immediate needs
Minimize stress
Evaluate patient whether legally able to make
rationale decisions
E
► Emergency
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Treatment
Medical consult if possible
Identify drugs patient is taking
Minimize drug interaction with sedatives & EPI
Minimize amount of EPI used
Treat immediate need only
F
► Food
Interactions
 Tyramine with tricyclics & MAOIs must be
avoided
►Hypertension
& arrhythmia
 Caffeine with tricyclics should be avoided
►Increased
drug levels in blood
 Alcohol
►Increased
CNS depressant effects
Other Psychiatric Disorders
Encountered by the Dental
Practitioner
Schizophrenia
► Psychiatric
diagnosis describing a disorder
characterized by impairments in the
perception of reality
► Common manifestations include auditory
hallucination, paranoia, disorganization of
speech and thought
► Often causes significant social and/or
occupational dysfunction.
► The
onset of symptoms usually occurs in early
adulthood
► approximately 1-1.5% of the population is
affected
► Since there is no laboratory test for
schizophrenia, diagnosis is based on the
patient's experiences and observed behavior
► A clear cause cannot be found, though some
studies suggest that genetic, psychological and
social processes could all play a role
► A common misconception is the schizophrenia is
synonymous with multiple personality disorder,
they are actually quite distinct
Treatment / Commonly Encountered
Pharmacologic Agents
► Drug
therapy has had the most profound
and positive effect on the management of
schizophrenic symptoms
► The disorder is treated with anti-psychotic
medications, including newer atypical antipsychotics such as clozapine, olanzapine,
risperidone, etc.
► The
atypical anti-psychotics have a
decreased incidence of the sometimes
serious anti-cholinergic side effects seen in
traditional antipsychotic drugs
► Although, 1-2% of patients taking atypical
can develop agranulocytosis, therefore
regular blood tests must be performed
► Smoking and use of antacids cause drug
interactions that hinder the absorption and
effectiveness of these anti-psychotic
agents
Somatoform Disorders
► Individuals
that have physical complaints for
which no medical cause can be found
► These disorders include somatization,
conversion disorder, pain disorder,
hypochondriasis
► Prevalence is around 5%, mostly in women
Treatment Approach
► Treatment
usually consists of pharmacotherapy
in conjuntion with psychiatric counselling
► It is common to treat an underlying depression
► The dental practitioner must attempt to avoid
unneeded medical procedures, as well as
manage the patients expectations about and
perceptions of their oral health
►
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