Ms. Debi DownerSomewhat depressed 34 yr old femalePresents for emergency extraction of #1-8Health history states she is taking Nardil and Prozac She also had an allergic reaction to Novocain from dental treatment several years agoHer dentist moved to Australia
Mood DisordersGroup of mental disorders characterized by extreme exaggeration and disturbance of mood and affectAssociated with physiologic, cognitive, and psychomotor dysfunctionTend to be cyclic and include depression and bipolar disorder
Incidence and Prevalence5% of adults in U.S. have a significant mood disorderMood disorders more common in womenMajor depression can occur at any age but prevalence highest in the elderlyPercentage of people who experience depression at some point in their life:20% to 25% of women 7% to 12% of men
Incidence and PrevalencePrevalence for major depression:4.5% to 9.3% in women 2.3% to 3.2 % in menOne third of whom require hospitalizationConsistent across race and cultureNo clear association with social class but poverty can be a significant stressor
Incidence and PrevalenceLifetime prevalence of dysthymia, a chronic mild form of depression:2.2% in women4.1% in men0.4% to 1.6% of adults in U.S. have bipolar disorder with an equal occurrence in both men and women
EtiologySeveral theories exist to explain mood disordersReduced brain concentrations of norepinephrine and serotonin are believed to lead to depressionIncreased levels have been attributed to the onset of maniaThe causes of depression/mania appear to be much more complexGenetic component?
Clinical PresentationMajor Depressive Episode - Five of the following symptoms present for 2 weeks:Depressed MoodLoss on interest or pleasure in daily activitiesWeight gain or weight lossInsomnia or hypersomniaLoss of energyFeelings of worthlessness or guiltInability to concentrate or indecisivenessThoughts of death or suicide
Clinical PresentationMajor Depressive Episode Not including:Drugs or mood altering substancesDeath of a loved one Delusions before, during, or after mood symptomsNo superimposed schizophrenia or other psychotic disorder
Clinical PresentationDysthymia Depressed mood >2 years including two or more of the following:Poor appetiteInsomnia or hypersomniaLoss of energyLow self-esteemInability to concentrate or indecisivenessFeelings of hopelessness
Clinical PresentationDysthymia not including:Without symptoms for longer than two monthsMajor depressive episode during that periodManic episodesDrugs or mood altering substancesSignificant functional impairment
Clinical PresentationBipolar Disorder cyclic recurrences of manic episodes and depression or mixed statesManic episodeEuphoric and cheerful moodLoud, rapid, and excessive speechDecreased need for sleepColorful and strange wardrobePoor judgment with financial and legal decisions
TreatmentAntidepressents Tricyclics - NE and 5-HT reuptake inhibitorSSRIs selective 5-HT reuptake inhibitorSNRIs 5-HT and NE reuptake inhibitorMAOIs monoamine oxidase inhibitorBipolar drugs- Lithium mood stabilization Carbamazepine and Valproate anticonvulsants
The drugs used in the treatment of depression have many potential complications including side effects and adverse drug interactions
Treatment - ComplicationsTricyclics 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 - ComplicationsTricyclic drug interactions:Potentiates CNS depressants, anticholinergics, sympathomimetic agents (Epi & Levonodefrin)Levels of tricyclics reduced by the use of oral contraceptive, alcohol, barbiturates, and dilantinInduction of hypertensive crisis if taken with or soon after MAOIOverdosage can be lethal due to cardiac arrhythmia or respiratory failure
Treatment - ComplicationsSSRIs considered first line drugs for treatment of depression; just as effective as tricyclics but better tolerated Not as lethal in overdose as tricyclicsConsiderably more expensiveMost frequent side effect is nausea (25%)Can induce serotonin syndrome when combined with MAOIs
Treatment - ComplicationsSNRIs second generation antidepressantsSide effects similar to SSRIs including:May cause adverse sexual side effectsIncrease in blood pressure
Treatment - ComplicationsMAOIs Both nonselective and irreversible; first effective drug used to treat depressionMany adverse side effects most importantly are the many drug interactionsCan 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 medicationsInduce serotonin syndrome when combined with SSRIs or SNRIs
Treatment ComplicationsBipolar Disorder most commonly treated with lithiumLithium - mode of action unclearUsed to treat and prevent manic episodesEffective by itself in 60-80% of patientsComplications associated with long term use are:Non-toxic goiter, hypothyroidism, arrhythmia, T-wave depression, and vasopressin-resistant nephrogenic diabetes insipidusNSAIDs increase serum lithium leading to toxicity
Dental ManagementDepression and Bipolar DisorderPreoperative:Signs and SymptomsRefer for medical evaluation and treatmentThrombocytopenia and LeukopeniaRequest drug change by physicianMedications and Determine StatusDrug interactions? Suicidal?
Dental ManagementDepression and Bipolar DisorderNo medical contraindications to treat patient; BUT, best management:Immediate dental needs onlyDefer elective/complex treatmentDifficult to manage; poor compliance with appointments and/or treatment
Dental ManagementDepression and Bipolar DisorderOperative:Limit use of epinephrine (avoid if possible)1:100,000 epi - okLimit to 2 carpulesAvoid retraction cords with epiAvoid or reduce dosage of Sedatives, Hypnotics, Narcotic agents (respiratory depression)Postural Hypotension change chair position slowly
Dental ManagementDepression and Bipolar DisorderPostoperative:Avoid Sedatives, Narcotics, HypnoticsPatients taking Lithium:Avoid NSAIDs, Tetracycline, Metronidazole Lithium ToxicityAvoid Diazepam Hypothermia
Dental ManagementOral ComplicationsOral lesions, fever or sore throat (w/ antipsychotic drug use)AgranulocytosisMuscular problems (dystonia, dyskinesia or tardive dyskinesia) w/ antipsychotic agentsSelf-destructive behaviorEye gouging, sharp objects into ear canal, lip biting, check biting, burning oral tissues, mucosal injury with sharp object
Dental ManagementOral ComplicationsOral Hygiene Issues (apathy)Increased dental caries ratePeriodontal diseaseDecreased salivary flow (meds)Facial pain syndromes (common)
OHI very important
When treatment planning, FLEXIBILITY is keyReduce stressInvolve family and/or caretakers
Questions for DebiHow 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 DebiHow 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 DebiMedsAre 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 DebiAllergy to Local AnestheticDo 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/physicianHow 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 DownerSomewhat 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 pressureMAOIs and SSRIs dangerous drug interaction potential for severe hypertensive crisis and serotonin syndromePast history of possible interaction with vasoconstrictor orthostatic hypotension
What would you do for Debi Downer today?Take Blood PressureDelay elective treatment, but need to address abscessAvoid/Limit Epinephrine potentiate possibility of hypertensive crisis, hypotensive episode, and a myocardial infarction
AAnesthetics: limit amount of epinephrine < 2 carpules EPI effects are potentiateAntibiotics: tricyclics interferes with erythromycinAnxiolytics: avoid barbiturates, benzodiazepines increased CNS depressant effectsAnalgesics: avoid opioidsincreased sedative effects NSAIDS okay, but not with lithium
BBlood pressure: MAOIs & tyramine- HTN cri