1. Debi Downer

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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?

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. Treatment – Complications
The drugs used in the treatment of depression have many potential complications including side effects and adverse drug interactions

15. 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

16. 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

17. 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

18. Treatment - Complications
SNRIs – second generation antidepressants
Side effects similar to SSRIs including:
May cause adverse sexual side effects
Increase in blood pressure

19. 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

20. 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

21. 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?

22. 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

23. 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

24. 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

25. 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

26. 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

27. Dental Management Side Note:
When treatment planning, FLEXIBILITY is key
Reduce stress
Involve family and/or caretakers

28. 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?

29. 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?

30. 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?

31. 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

32. 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?

33. 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

34. 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

35. 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

36. Dental Algorithm

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. Other Psychiatric Disorders Encountered by the Dental Practitioner

46. 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.

47. 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

48. 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.

49. 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

50. 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

51. 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

52. B This presentation was brought to you by the letter
Baylon, Berg, Berge, Booth, Bowers, Brady