debi downer

Debi DownerDebi Downer

Ms. Debi DownerMs. Debi Downer

►Somewhat depressed 34 yr old femaleSomewhat depressed 34 yr old female►Presents for emergency extraction of #1-Presents for emergency extraction of #1-

88►Health history states she is taking Nardil Health history states she is taking Nardil

and Prozac and Prozac ►She also had an “allergic reaction” to She also had an “allergic reaction” to

“Novocain” from dental treatment “Novocain” from dental treatment several years agoseveral years ago

►Her dentist moved to AustraliaHer dentist moved to Australia

Mood DisordersMood Disorders

►Group of mental disorders Group of mental disorders characterized by extreme characterized by extreme exaggeration and disturbance of mood exaggeration and disturbance of mood and affectand affect

►Associated with physiologic, cognitive, Associated with physiologic, cognitive, and psychomotor dysfunctionand psychomotor dysfunction

►Tend to be cyclic and include Tend to be cyclic and include depression and bipolar disorderdepression and bipolar disorder

Incidence and PrevalenceIncidence and Prevalence

►5% of adults in U.S. have a significant 5% of adults in U.S. have a significant mood disordermood disorder

►Mood disorders more common in womenMood disorders more common in women►Major depression can occur at any age Major depression can occur at any age

but prevalence highest in the elderlybut prevalence highest in the elderly►Percentage of people who experience Percentage of people who experience

depression at some point in their life:depression at some point in their life: 20% to 25% of women 20% to 25% of women 7% to 12% of men 7% to 12% of men


►Prevalence for major depression:Prevalence for major depression: 4.5% to 9.3% in women 4.5% to 9.3% in women 2.3% to 3.2 % in men2.3% to 3.2 % in men

►One third of whom require One third of whom require hospitalizationhospitalization

►Consistent across race and cultureConsistent across race and culture►No clear association with social class but No clear association with social class but

poverty can be a significant stressorpoverty can be a significant stressor


►Lifetime prevalence of dysthymia, a Lifetime prevalence of dysthymia, a chronic mild form of depression:chronic mild form of depression: 2.2% in women2.2% in women 4.1% in men4.1% in men

►0.4% to 1.6% of adults in U.S. have 0.4% to 1.6% of adults in U.S. have bipolar disorder with an equal bipolar disorder with an equal occurrence in both men and womenoccurrence in both men and women

EtiologyEtiology

► Several theories exist to explain mood Several theories exist to explain mood disordersdisorders

► Reduced brain concentrations of Reduced brain concentrations of norepinephrine and serotonin are believed to norepinephrine and serotonin are believed to lead to depressionlead to depression

► Increased levels have been attributed to the Increased levels have been attributed to the onset of maniaonset of mania

► The causes of depression/mania appear to be The causes of depression/mania appear to be much more complexmuch more complex

► Genetic component?Genetic component?

Clinical PresentationClinical Presentation

• Major Depressive Episode - Five of the Major Depressive Episode - Five of the following symptoms present for 2 weeks:following symptoms present for 2 weeks:

►Depressed MoodDepressed Mood►Loss on interest or pleasure in daily activitiesLoss on interest or pleasure in daily activities►Weight gain or weight lossWeight gain or weight loss►Insomnia or hypersomniaInsomnia or hypersomnia►Loss of energyLoss of energy►Feelings of worthlessness or guiltFeelings of worthlessness or guilt►Inability to concentrate or indecisivenessInability to concentrate or indecisiveness►Thoughts of death or suicideThoughts of death or suicide


►Major Depressive Episode – Not Major Depressive Episode – Not including:including: Drugs or mood altering substancesDrugs or mood altering substances Death of a loved one Death of a loved one Delusions before, during, or after mood Delusions before, during, or after mood

symptomssymptoms No superimposed schizophrenia or other No superimposed schizophrenia or other

psychotic disorderpsychotic disorder


►Dysthymia – Depressed mood >2 Dysthymia – Depressed mood >2 years including two or more of the years including two or more of the following:following: Poor appetitePoor appetite Insomnia or hypersomniaInsomnia or hypersomnia Loss of energyLoss of energy Low self-esteemLow self-esteem Inability to concentrate or indecisivenessInability to concentrate or indecisiveness Feelings of hopelessnessFeelings of hopelessness


►Dysthymia – not including:Dysthymia – not including: Without symptoms for longer than two Without symptoms for longer than two

monthsmonths Major depressive episode during that Major depressive episode during that

periodperiod Manic episodesManic episodes Drugs or mood altering substancesDrugs or mood altering substances Significant functional impairmentSignificant functional impairment


►Bipolar Disorder – cyclic recurrences of Bipolar Disorder – cyclic recurrences of manic episodes and depression or manic episodes and depression or mixed statesmixed states Manic episodeManic episode

►Euphoric and cheerful moodEuphoric and cheerful mood►Loud, rapid, and excessive speechLoud, rapid, and excessive speech►Decreased need for sleepDecreased need for sleep►Colorful and strange wardrobeColorful and strange wardrobe►Poor judgment with financial and legal Poor judgment with financial and legal

decisionsdecisions

TreatmentTreatment

►Antidepressents – Antidepressents – Tricyclics - NE and 5-HT reuptake inhibitorTricyclics - NE and 5-HT reuptake inhibitor SSRIs – selective 5-HT reuptake inhibitorSSRIs – selective 5-HT reuptake inhibitor SNRIs – 5-HT and NE reuptake inhibitorSNRIs – 5-HT and NE reuptake inhibitor MAOIs – monoamine oxidase inhibitorMAOIs – monoamine oxidase inhibitor

►Bipolar drugs- Bipolar drugs- Lithium – mood stabilization Lithium – mood stabilization Carbamazepine and Valproate – Carbamazepine and Valproate –

anticonvulsantsanticonvulsants

Treatment – ComplicationsTreatment – Complications

►The drugs used in the treatment of The drugs used in the treatment of depression have many potential depression have many potential complications including side effects complications including side effects and adverse drug interactionsand adverse drug interactions

Treatment - ComplicationsTreatment - Complications

►Tricyclics – All are equally effective in Tricyclics – All are equally effective in the management of depression but the management of depression but have different adverse effects have different adverse effects including:including: Dry mouth, constipation, blurred vision, Dry mouth, constipation, blurred vision,

tachycardia, hypotension, allergic tachycardia, hypotension, allergic reactions, and drug interactionsreactions, and drug interactions


►Tricyclic drug interactions:Tricyclic drug interactions: Potentiates CNS depressants, Potentiates CNS depressants,

anticholinergics, sympathomimetic agents anticholinergics, sympathomimetic agents (Epi & Levonodefrin)(Epi & Levonodefrin)

Levels of tricyclics reduced by the use of oral Levels of tricyclics reduced by the use of oral contraceptive, alcohol, barbiturates, and contraceptive, alcohol, barbiturates, and dilantindilantin

Induction of hypertensive crisis if taken with Induction of hypertensive crisis if taken with or soon after MAOIor soon after MAOI

Overdosage can be lethal due to cardiac Overdosage can be lethal due to cardiac arrhythmia or respiratory failurearrhythmia or respiratory failure


►SSRIs – considered first line drugs for SSRIs – considered first line drugs for treatment of depression; just as treatment of depression; just as effective as tricyclics but better effective as tricyclics but better tolerated tolerated Not as lethal in overdose as tricyclicsNot as lethal in overdose as tricyclics Considerably more expensiveConsiderably more expensive Most frequent side effect is nausea (25%)Most frequent side effect is nausea (25%) Can induce serotonin syndrome when Can induce serotonin syndrome when

combined with MAOIscombined with MAOIs


►SNRIs – second generation SNRIs – second generation antidepressantsantidepressants Side effects similar to SSRIs including:Side effects similar to SSRIs including:

►May cause adverse sexual side effectsMay cause adverse sexual side effects►Increase in blood pressureIncrease in blood pressure

Treatment - ComplicationsTreatment - Complications► MAOIs – Both nonMAOIs – Both nonselective and irreversible; first and irreversible; first

effective drug used to treat depressioneffective drug used to treat depression Many adverse side effects most importantly Many adverse side effects most importantly

are the many drug interactionsare the many drug interactions Can cause hypertensive crisis when combined Can cause hypertensive crisis when combined

with sympathomimetic amines including with sympathomimetic amines including tyramine tyramine ►Foods containing tyramine include aged Foods containing tyramine include aged

cheeses, wine, pickled fish, bananas, cheeses, wine, pickled fish, bananas, chocolate, and almost any foods with chocolate, and almost any foods with yeast.yeast.

Potentiate the pressor effects of Potentiate the pressor effects of phenylethylamine and phenylephrine with are phenylethylamine and phenylephrine with are found in many cold medicationsfound in many cold medications

Induce serotonin syndrome when combined Induce serotonin syndrome when combined with SSRIs or SNRIswith SSRIs or SNRIs

Treatment ComplicationsTreatment Complications►Bipolar Disorder – most commonly Bipolar Disorder – most commonly

treated with lithiumtreated with lithium Lithium - mode of action unclearLithium - mode of action unclear

►Used to treat and prevent manic episodesUsed to treat and prevent manic episodes►Effective by itself in 60-80% of patientsEffective by itself in 60-80% of patients►Complications associated with long term use are:Complications associated with long term use are:

Non-toxic goiter, hypothyroidism, arrhythmia, T-wave Non-toxic goiter, hypothyroidism, arrhythmia, T-wave depression, and vasopressin-resistant nephrogenic depression, and vasopressin-resistant nephrogenic diabetes insipidusdiabetes insipidus

►NSAIDs increase serum lithium leading to toxicity NSAIDs increase serum lithium leading to toxicity

Dental ManagementDental ManagementDepression and Bipolar DisorderDepression and Bipolar Disorder

►Preoperative:Preoperative: Signs and SymptomsSigns and Symptoms

Refer for medical evaluation and treatmentRefer for medical evaluation and treatment

Thrombocytopenia and LeukopeniaThrombocytopenia and Leukopenia Request drug change by physicianRequest drug change by physician

►Medications and Determine StatusMedications and Determine Status Drug interactions? Suicidal?Drug interactions? Suicidal?


►No medical contraindications to treat No medical contraindications to treat patient;patient;

BUT, best management:BUT, best management: Immediate dental needs onlyImmediate dental needs only Defer elective/complex treatmentDefer elective/complex treatment

►Difficult to manage; poor compliance with Difficult to manage; poor compliance with appointments and/or treatmentappointments and/or treatment


►Operative:Operative: Limit use of epinephrine (avoid if possible)Limit use of epinephrine (avoid if possible)

• 1:100,000 epi - ok1:100,000 epi - ok• Limit to 2 carpulesLimit to 2 carpules• Avoid retraction cords with epiAvoid retraction cords with epi

Avoid or reduce dosage of Sedatives, Avoid or reduce dosage of Sedatives, Hypnotics, Narcotic agents Hypnotics, Narcotic agents (respiratory (respiratory depression)depression)

Postural Hypotension – Postural Hypotension – change chair position change chair position slowlyslowly


►Postoperative:Postoperative: Avoid Sedatives, Narcotics, HypnoticsAvoid Sedatives, Narcotics, Hypnotics Patients taking Lithium:Patients taking Lithium:

►Avoid NSAIDs, Tetracycline, Avoid NSAIDs, Tetracycline, MetronidazoleMetronidazole

► Lithium ToxicityLithium Toxicity Avoid Diazepam Avoid Diazepam

►HypothermiaHypothermia

Dental ManagementDental ManagementOral ComplicationsOral Complications

►Oral lesions, fever or sore throat Oral lesions, fever or sore throat (w/ (w/ antipsychotic drug use)antipsychotic drug use) AgranulocytosisAgranulocytosis

►Muscular problems (dystonia, Muscular problems (dystonia, dyskinesia or tardive dyskinesia) dyskinesia or tardive dyskinesia) w/ w/ antipsychotic agentsantipsychotic agents

►Self-destructive behaviorSelf-destructive behavior Eye gouging, sharp objects into ear canal, Eye gouging, sharp objects into ear canal,

lip biting, check biting, burning oral lip biting, check biting, burning oral tissues, mucosal injury with sharp objecttissues, mucosal injury with sharp object

Dental ManagementDental ManagementOral ComplicationsOral Complications

►Oral Hygiene Issues (apathy)Oral Hygiene Issues (apathy) Increased dental caries rateIncreased dental caries rate Periodontal diseasePeriodontal disease Decreased salivary flow (meds)Decreased salivary flow (meds) Facial pain syndromes (common)Facial pain syndromes (common)

OHI very importantOHI very important

Dental ManagementDental Management

Side Note: Side Note:

When treatment planning, FLEXIBILITY is When treatment planning, FLEXIBILITY is keykey

Reduce stressReduce stress

Involve family and/or caretakers Involve family and/or caretakers

Questions for DebiQuestions for Debi

►How are you feeling today?How are you feeling today?►What is your normal blood pressure?What is your normal blood pressure?►How often do you take you blood How often do you take you blood

pressure?pressure?►Have you had any headaches or Have you had any headaches or

changes in vision?changes in vision?►Are you being treated for Are you being treated for

hypertension?hypertension?


►How is your depression today?How is your depression today?►Have you had any suicidal thoughts Have you had any suicidal thoughts

recently?recently?►Do you ever have periods of extreme Do you ever have periods of extreme

happiness and feel very productive?happiness and feel very productive?►Do you drink alcohol or smoke Do you drink alcohol or smoke

cigarettes? How often?cigarettes? How often?►Do you use any other drugs? How often?Do you use any other drugs? How often?

►MedsMeds Are you taking both Nardil and Prozac?Are you taking both Nardil and Prozac? How often do you take your medications?How often do you take your medications? How long have you been taking them?How long have you been taking them? Do you avoid eating any foods?Do you avoid eating any foods? What other medications have you taken What other medications have you taken

for your depression?for your depression? Has there been a change in your Has there been a change in your

medications?medications?


►Allergy to Local AnestheticAllergy to Local Anesthetic Do you have any other allergies? Do you have any other allergies?

(preservatives, medications, etc.)(preservatives, medications, etc.) Did your dentist name a specific Did your dentist name a specific

component you were sensitive to?component you were sensitive to? Were you taking both Nardil and Prozac Were you taking both Nardil and Prozac

when this happened?when this happened?


Questions for Questions for psychiatrist/physicianpsychiatrist/physician

►How long has she been taking both an MAO How long has she been taking both an MAO inhibitor and an SSRI?inhibitor and an SSRI?

►Has she had a hypertensive crisis in the Has she had a hypertensive crisis in the past?past?

►Would you consider her mood to be stable?Would you consider her mood to be stable?►What is her history of suicide attempts?What is her history of suicide attempts?► Is there anything else that would be Is there anything else that would be

important for me to know?important for me to know?

Debi DownerDebi Downer

Somewhat depressed 34-y.o femaleSomewhat depressed 34-y.o female

Emergency extraction of abscessed tooth #1Emergency extraction of abscessed tooth #1

Taking Nardil (MAOI) and Prozac (SSRI)Taking Nardil (MAOI) and Prozac (SSRI)

““Allergic” reaction to “novocaine” where she Allergic” reaction to “novocaine” where she felt very weak, her heart fluttered and she felt very weak, her heart fluttered and she nearly passed outnearly passed out

Debi Downer ASA-PS III or IVDebi Downer ASA-PS III or IV

►Physically she is fine, but look at meds, Physically she is fine, but look at meds, and blood pressureand blood pressure

►MAOIs and SSRIs dangerous drug MAOIs and SSRIs dangerous drug interaction – potential for severe interaction – potential for severe hypertensive crisis and serotonin hypertensive crisis and serotonin syndromesyndrome

►Past history of possible interaction with Past history of possible interaction with vasoconstrictor – orthostatic hypotensionvasoconstrictor – orthostatic hypotension

What would you do for Debi What would you do for Debi Downer today?Downer today?

►Take Blood PressureTake Blood Pressure►Delay elective treatment, but need to Delay elective treatment, but need to

address abscessaddress abscess►Avoid/Limit Epinephrine – potentiate Avoid/Limit Epinephrine – potentiate

possibility of hypertensive crisis, possibility of hypertensive crisis, hypotensive episode, and a myocardial hypotensive episode, and a myocardial infarctioninfarction

Dental AlgorithmDental Algorithm

AA►Anesthetics: limit amount of epinephrine Anesthetics: limit amount of epinephrine

< 2 carpules < 2 carpules EPI effects are potentiateEPI effects are potentiate

►Antibiotics: tricyclics interferes with Antibiotics: tricyclics interferes with erythromycinerythromycin

►Anxiolytics: avoid barbiturates, Anxiolytics: avoid barbiturates, benzodiazepinesbenzodiazepines increased CNS depressant effectsincreased CNS depressant effects

►Analgesics: avoid opioidsAnalgesics: avoid opioids increased sedative effects increased sedative effects NSAIDS okay, but not with lithiumNSAIDS okay, but not with lithium

BB►Blood pressure: Blood pressure:

MAOIs & tyramine- HTN crisis (also MAOIs MAOIs & tyramine- HTN crisis (also MAOIs & tricyclics)& tricyclics)

HTN serious adverse side effectHTN serious adverse side effect Hypotension adverse side effect of Hypotension adverse side effect of

tricyclics, MAOIs, & SSRIstricyclics, MAOIs, & SSRIs Tricyclics block the antihypertensive Tricyclics block the antihypertensive

effects of guanethidineeffects of guanethidine►Bleeding: tricyclics & SSRIs Bleeding: tricyclics & SSRIs

inhibit warfarin metabolisminhibit warfarin metabolism Increased INR valuesIncreased INR values

CC►Cardiac complications:Cardiac complications:

MAOIs & SSRIs- bradycardiaMAOIs & SSRIs- bradycardia Tricyclics - tachycardiaTricyclics - tachycardia

►OD can cause death because of arrhythmiaOD can cause death because of arrhythmia

MAOIs & tyramine- arrhythmiaMAOIs & tyramine- arrhythmia

►Oral ComplicationsOral Complications XerostomiaXerostomia

►Caries and candidiasisCaries and candidiasis

Poor hygiene Poor hygiene

DD

►Drug interactions (Table 29-6 Pg. 521)Drug interactions (Table 29-6 Pg. 521) Antihistamines with tricyclics & MAOIsAntihistamines with tricyclics & MAOIs

►CNS depressionCNS depression

Anticonvulsants with tricyclics & MAOIs- Anticonvulsants with tricyclics & MAOIs- interfere with actionsinterfere with actions►Tricyclics can lower seizure thresholdsTricyclics can lower seizure thresholds

Cimetidine (HCimetidine (H22-receptor antagonist) with -receptor antagonist) with tricyclics & SSRIstricyclics & SSRIs► Inhibits clearance leading to toxicityInhibits clearance leading to toxicity

DD► Drug interactions: MAOIs Drug interactions: MAOIs

& SSRIs& SSRIs Serotonin syndromeSerotonin syndrome Dangerously high Dangerously high

levels of serotoninlevels of serotonin Requires immediate Requires immediate

medical treatmentmedical treatment Usually resolves in 24 Usually resolves in 24

hourshours

► Signs & SymptomsSigns & Symptoms ConfusionConfusion RestlessnessRestlessness HallucinationsHallucinations Extreme agitationExtreme agitation Fluctuations in blood Fluctuations in blood

pressurepressure Increased heart rateIncreased heart rate Nausea & vomitingNausea & vomiting FeverFever SeizuresSeizures ComaComa

DD

►Dental ManagementDental Management Medical consultMedical consult Small amounts of EpiSmall amounts of Epi Reduce sedative medicationsReduce sedative medications Only treat immediate needsOnly treat immediate needs Minimize stressMinimize stress Evaluate patient whether legally able to Evaluate patient whether legally able to

make rationale decisionsmake rationale decisions

EE

►Emergency TreatmentEmergency Treatment Medical consult if possibleMedical consult if possible Identify drugs patient is takingIdentify drugs patient is taking Minimize drug interaction with sedatives Minimize drug interaction with sedatives

& EPI& EPI Minimize amount of EPI usedMinimize amount of EPI used Treat immediate need onlyTreat immediate need only

FF

►Food InteractionsFood Interactions Tyramine with tricyclics & MAOIs must be Tyramine with tricyclics & MAOIs must be

avoided avoided ►Hypertension & arrhythmiaHypertension & arrhythmia

Caffeine with tricyclics should be avoidedCaffeine with tricyclics should be avoided►Increased drug levels in bloodIncreased drug levels in blood

AlcoholAlcohol►Increased CNS depressant effectsIncreased CNS depressant effects

Other Psychiatric Other Psychiatric Disorders Encountered Disorders Encountered

by the Dental by the Dental PractitionerPractitioner

SchizophreniaSchizophrenia

►Psychiatric diagnosis describing a Psychiatric diagnosis describing a disorder characterized by impairments disorder characterized by impairments in the perception of reality in the perception of reality

►Common manifestations include Common manifestations include auditory hallucination, paranoia, auditory hallucination, paranoia, disorganization of speech and thoughtdisorganization of speech and thought

►Often causes significant social and/or Often causes significant social and/or occupational dysfunction. occupational dysfunction.

► The onset of symptoms usually occurs in early The onset of symptoms usually occurs in early adulthoodadulthood

► approximately 1-1.5% of the population is approximately 1-1.5% of the population is affectedaffected

► Since there is no laboratory test for Since there is no laboratory test for schizophrenia, diagnosis is based on the schizophrenia, diagnosis is based on the patient's experiences and observed behaviorpatient's experiences and observed behavior

► A clear cause cannot be found, though some A clear cause cannot be found, though some studies suggest that genetic, psychological studies suggest that genetic, psychological and social processes could all play a roleand social processes could all play a role

► A common misconception is the schizophrenia A common misconception is the schizophrenia is synonymous with multiple personality is synonymous with multiple personality disorder, they are actually quite distinctdisorder, they are actually quite distinct

Treatment / Commonly Treatment / Commonly Encountered Pharmacologic Encountered Pharmacologic

AgentsAgents

►Drug therapy has had the most Drug therapy has had the most profound and positive effect on the profound and positive effect on the management of schizophrenic management of schizophrenic symptomssymptoms

►The disorder is treated with anti-The disorder is treated with anti-psychotic medications, including psychotic medications, including newer atypical anti-psychotics such as newer atypical anti-psychotics such as clozapine, olanzapine, risperidone, etc.clozapine, olanzapine, risperidone, etc.

►The atypical anti-psychotics have a The atypical anti-psychotics have a decreased incidence of the sometimes decreased incidence of the sometimes serious anti-cholinergic side effects serious anti-cholinergic side effects seen in traditional antipsychotic drugsseen in traditional antipsychotic drugs

►Although, 1-2% of patients taking Although, 1-2% of patients taking atypical can develop agranulocytosis, atypical can develop agranulocytosis, therefore regular blood tests must be therefore regular blood tests must be performedperformed

►Smoking and use of antacids cause Smoking and use of antacids cause drug interactions that hinder the drug interactions that hinder the absorption and effectiveness of these absorption and effectiveness of these anti-psychotic agentsanti-psychotic agents

Somatoform DisordersSomatoform Disorders

► Individuals that have physical Individuals that have physical complaints for which no medical cause complaints for which no medical cause can be foundcan be found

►These disorders include somatization, These disorders include somatization, conversion disorder, pain disorder, conversion disorder, pain disorder, hypochondriasishypochondriasis

►Prevalence is around 5%, mostly in Prevalence is around 5%, mostly in womenwomen

Treatment ApproachTreatment Approach

► Treatment usually consists of Treatment usually consists of pharmacotherapy in conjuntion with pharmacotherapy in conjuntion with psychiatric counsellingpsychiatric counselling

► It is common to treat an underlying It is common to treat an underlying depression depression

► The dental practitioner must attempt to The dental practitioner must attempt to avoid unneeded medical procedures, as avoid unneeded medical procedures, as well as manage the patients expectations well as manage the patients expectations about and perceptions of their oral healthabout and perceptions of their oral health

► This presentation was This presentation was brought to you by the brought to you by the letter letter

BBBaylon, Berg, Berge, Baylon, Berg, Berge, Booth, Bowers, Brady Booth, Bowers, Brady

debi downer

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