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: 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 – Bipolar drugs- 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 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 Disorder – most commonly treated with lithium 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 1st drugs can increase resp. depression 2nd metabolism can increase lithium toxicity

Dental Management Oral Complications Oral lesions, fever or sore throat (w/ antipsychotic drug use) 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 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?

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? Levonordeferin, phenylepherine

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

B Blood pressure: Bleeding: tricyclics & SSRIs 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

C Cardiac complications: Oral 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 & MAOIs- interfere 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 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 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 anti-psychotics 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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