reckless overprescription of anxiolytic agents is ________. with rational use the psychotropic drugs are relatively _______
rare
safe
List 3 common contributors or factors that can cause anxiety.
medical illness: consider reason for distress
psychiatric illness: consider reason for illness
psychological anxiety
Which type of anxiety is persistent and irrational fear of specific object, activity, or situation, resulting in the desire to avoid it?
psychological anxiety
Antianxiety agents are prescribed for what 3 conditions?
dental phobia
panic disorders
withdrawal from substance abuse
What type of drugs are more selectively anxiolytic, with fewer adverse effects and less risk for acute withdrawal? They have an affinity for certain neuronal receptors? Examples are drugs in the controlled substance schedule IV?
benxodiazepines
What type of drug's mechanism of action is to reduce anxiety by enhancing the inhibitory properties found naturally in the CNS, also thought to exert an anxiolytic effect by selectively depressing the hyperactivity of neuronal circuits in the limbic system?
benzodiazepines
What type of drug is used to reduce anxiety, induce skeletal muscle relaxation, and exert an anticonvulsant effect? Also used for the the reduction of morbidity and mortality associated with alcohol withdrawal syndrome?
benzodiazepines
What are 2 things that benzodiazepines should not be used with?
alcohol
in pts who have status epilepticus
What are 5 adverse effects of benzodiazepines?
amnesia: can be a good effect if used appropriately
sedation and impairment of performance
xerostomia
increased salivation
taste disturbance
metallic taste
no memory during drug therapy while memory before administration of drug intact
anterograde amnesia: an ADE with the use of benzodiazepines
What are 3 sedation and impairment of performance ADEs associated with the use of benzodiazepines?
pt rapidly acquires tolerance to sedative effects
alertness and eye-hand coordination, ability to drive automobile, and personality are effected
CNS depression
Physiologic dependance of benzodiazepines is more likely to occur with what?
loger drug exposure: so minimize duration of tx
What type of benzodiazepam is more commonly abused but appropriate for dental anxiety?
diazepam (Valium)
The following are symptoms of what condition?
tremors
sweating
sensitivity to light and sound
difficulty sleeping
abdominal pain
systolic hypertension
depression
psychosis
seizures
benzodiazepine withdrawal
true or false. fatal overdose with benzodiazepine taken alone is rare; there is an increased dpression of CNS when they are combined with other dangerous substances.
true
Death from benzodiazepine overdose is the result of what?
respiratory depression and asphyxia
What are 3 effects of bezodiazepines on the elderly?
may cause confusion and severe impairment of mental function
reduce drug effect dose by 50%
use small initial dose and dosage increments made gradually
There appears to be a two to three-fold rise in the plasma levels of benzodiazepines in pts with what condition?
liver disease
What are the benzodiazepine agents of choice in pts with liver disease, and why?
short-acting benzodiazepines
they do not tend to accumulate significantly in pts with liver disease
Which antianxiety medication has shown to cause an increase in incidence of cleft lip and palate in children when used during the first trimester, so it is in pregnancy category D?
benzodiazepines
triazolam and temazepam are benzodiazepines in what pregnancy category?
category X
When is it ok to use benzodiazepines for children?
only to manage convulsions
What is the name of a benzodiazepine receptor antagonist that is able to revese sedative effects after surgical, diagnostic prodedures, anesthesia, or overdose of benzodiazepines? It does not antagonize opioids, nonbenzodiazepine sedatives, or anesthetic drugs.
Flumazenil (Mazicon)
What are 6 ADEs of flumazenil (Mazicon)? (benzodiazepine receptor antagonist)
nausea
dizziness
headache
blurred vision
increased sweating
anxiety
potential drug-drug interactions between benzodiazepines and what 4 agents have been documented? And what is their mechanism of action?
acetaminophen
antifungal agents
disulfiram
macrolide antibacterial agents
reduction in hepatic metabolism
How do corticosteroids decrease the effect of midazolam?
by increased metabolism
benzodiazepines may delay the onset of __________. and additive with opioid analgesics may cause what?
naproxen
increased depression
What are 6 dental considerations with pts taking benzodiazepines?
premedicate anxious or phobic pt: fast-acting with short half-life; this allows for resumption of normal activity soon after tx
give instructions to pt in writing
bring someone with them to appointment
do not sign important papers
do not operate equipment
What agent may be used to reverse the sedative effects of a benzodiazepine?
flumazenil
What are sedative and hypnotic agents that depress the CNS?
What is the act of calming or reducing activity or excitement in an individual while allowing consciousness; but a larger dose wil lproduce hypnosis?
sedation
What is a condition of artificially induced sleep or a trance resembling sleep?
hypnosis
The principal effect of what type of antianxiety drug is that of CNS depression of transmission of impulses with sedateive and hypnotic doses?
barbiturates
true or false. barbiturates have NO analgesic effect
true
the selection of barbiturates is based on what 2 things?
duration of action
clinical situation
What are 4 indications of use of barbiturates?
sedation for anxiety
essential hypertension
hyperthyroidism
insomnia
What are 3 different types of barbiturates?
short-acting
intermediate-acting
long-acting
true or false. barbiturates, in sedative and hypnotic doses, are safe, but have a narrow safety margin.
true
the use of barbiturates can cause exaggerated CNS depression in pts with what 4 conditions?
elderly
debilitated
kidney disease
liver disease
What are 6 effects of abrupt withdrawal of barbiturates?
tremors
anxiety
restlessness
weakness
vomiting
cardiac arrest
What type of drug is a general CNS depressant with effects similar to alcohol? It is a common antianxiety premed for kids because it has a rapid onset and fairly short duration of action. It is safe for the use in children or the elderly?
Chloral hydrate: a nonbarbiturate sedative and hypnotic
the nonbarbiturate sedative and hypnotic CHLORAL HYDRATE may have an exaggerated effect in pts with what 2 conditions?
kidney disease
liver disease
What can the nonbarbiturate sedative and hypnotic CHLORAL HYDRATE be taken with to minimize GI irritation?
milk
What is a dental drug interaction with the use of the nonbarbiturate sedative and hypnotic Chloral hydrate?
increases CNS depression with other CNS depressants, and nitrous oxide
The following drugs are what class; and what type of sedative and hypnotic?
Diphenhydramine (Benadryl, Vistaril)
Midazolam (Versed)
antihistamines
nonbarbiturate sedatives and hypnotics
Which type of nonbarbiturate sedative and hypnotic are safe compounds, and effective antianxiety agents with a mild sedative effect and no abuse potential?
antihistamines
Diphenhydramine (benadryl, vistaril) is an antihistamine (nonbarbiturate sedative and hypnotic) that is widely used in what kind of dentistry?
pediatric
What are 2 dental drug interactions with the use of antihistamines for antianxiety?
decrease metabolism of many drugs
elderly may pose a problem
What are 3 main rules for the dental prescriber in prescribing antianxiety agents?
know the pt well before prescribing
be alert for drug dependence and concurrent meds being taken
provide instruction in writing and warnings for use
true or false. All anxiolytic agents add to the effects of other CNS depressants
true
true or false. Antianxiety agents are a substitute for pt rapport or for proper psychological approach to pt care.
FALSE; they are NOT a substitute
Name 2 types of depressive disorders.
depression
mania
What are 2 characteristics of depressive disorders?
sadness
loss of interest
What is a psychiatric illness with mood, thouhgts, and behavioral patterns impaired for long periods that is treated with counseling and pharmacologic therapy?
major depressive disorder (MDD)
What are 3 causes of tx failure for depression?
insufficient doses
inadequate time
non compliance
What class of drug is the irst drug of choice for tx of severe depression? All drugs in this class are similar in effectiveness?
tricyclic antidepressants (TCA)
Name the two tricyclic antidepressant drugs that are used most extensively of any in the class
Imipramine: Tofranil
Amitriptyline: Elavil
What is the name of a new drug that has been added to the tricyclinc antidepressant class of drugs?
Tricyclic amoxapine (Asending)
What are the most common adverse reactions with the use of tricyclic antidepressant drugs, so we should limit treatment with them? And which group of people are more susceptible to these effects?
anticholinergic effects
elderly
Which type of antidepressant drug can slow intraventricular conduction and cause complete heart block or ventricular dysrhythmia; overdosage can be lethal; and clomipramine (a drug in the class) can interact with vasoconstrictors in local anesthetics.
Tricyclic antidepressant drugs
Buproprion (wellbutrin) and velafaxine (Effexor) exert their effects through different mechanisms, and are drugs in what class of antidepressants?
atypical
What type of antidepressant drugs are as effective as serotonin reuptake inhibitors; are used along with SSRIs as first-line tx for individuals with mild to moderate depression?
atypical antidepressants: bupropion; venlafaxine
Which type of antidepressant can cause orthostatic hypotension; ECG changes, tachycardia, and agranulocytosis?
Maprotiline
Which type of antidepressant drug infrequently causes agranulocytosis and neutropenia?
Mirtazapine
Phenelzine (nardil) is an older antidepressant agent in which class of antidepressants?
monoamine oxidase inhibitors (MAOI)
Which type of antidepressants are helpful in pts not responding to TCAs and those with 'atypical depression? And their mechanism of action is that of non selective inhibition of monoamine oxidase at the synapse so norepinephrine and seratonin levels are high.
Monoamine oxidase inhibitors (MAOIs)
Which type of antidepressant has the following adverse reactions?
dizziness, orthostatic hypotension, hypertension, anorexia; has food interactions with aged meats, red wine, beer, and some cheeses
Avoid the use of decongestants and drugs containing ephedrine with this drug
Monoamine Oxidase Inhibitors (MAOI)
Which type of antidepressant is the most common agent used for depressive disorders?
Selective Serotonin Reuptake inhibitors (SSRI)
What are 4 common ADEs with the use of selective serontonin reuptake inhibitors?
reactions differ among the wide variety of them
xerostomia and dysgeusia
individuals with depression are prone to periodontitis
clenching, bruxism, or both
The following 2 drugs are new antidepressant agents, what class does each fall under?
Maprotiline
Trazodone
Maprotiline: tetracyclinc compound
Trazodone: atypical agent
What are 3 ADEs of Maprotiline (a tetracyclic compound)
few anticholinergic effects
can cause orthostatic hypotension and sedation
increase in premature contractions
What are 6 ADEs of the new agent trazodone (an atypical agent)?
dry mouth
dizziness
orthostatic hypotension
tachycardia
nausea
blurred vision
There are some adverse drug-drug interactions between selective serotonin reuptake inhibitors and some meds used in dentistry, what is a med to avoid with SSRIs?
aspirin
Barbiturates and bezodiazepines can increase __________ in most antidepressant agents
depression
true or false. Clomipramine and maprotiline interat with severl drugs used in dentistry.
true
With the use of what 2 antidepressant drugs must we use small concentrations of epi; levonordefrin is contraindicated; and acetominophen should be used in small doses?
tricyclic
tetracyclics
Can pts taking MAOIs recieve local anesthetics with vasoconstrictors?
yes
In pts taking antidepressants, what should be done if drug abuse is suspected?
medical consultation
If pts taking antidepressants have a history of alcohol abuse, what are 5 tests that need to be performed if bleeding is anticipated?
liver function data test
CBC
INR
PT
PTT
What are 6 dental hygiene care plan considerations to be aware of with pts on antidepressants?
consider possible lack of attention to selfcare resulting in periodontal inflammation: 3 month recall
excessive toothbrushing may result in injury
chronic xerostomia
chronic facial pain or TMJ disorder: profound anesthetic
allow elderly to place feet on floor and exercise leg muscles while seated to avoid hypotensive event: BP may need to be taken
Mania is a _________ disorder
bipolar
What is the drug of choice in the treatment of mania?
Lithium
How long does it take for the therapeutic effect of lithium (drug of choice for mania) to take place?
2-3 weeks
monitor serum concentration levels
What are 2 drugs that are taken to treat mania if they do not respond to lithium, or when side effects can not be tolerated?
Valproate
carbamazepine
What are 5 ADEs with the use of lithium (drug of choice for mania)?
nausea and fatigue in first weeks of tx
fine tremors of hand, edema, and weight gain may persist for duration of tx
confusion: toxic effect of lithium
hypthyroidism
oral: increased thirst and dry mouth
What is a dental drug interaction with the use of lithium (drug of choice for mania)?
erythromycin and COX inhibitors can lead to reduced metabolism of lithium and lead to increased blood levels and toxicity
The following are characteristics of what disease?
major disturbance in thought content, bizarre behavior, or regression in intellectual functioning, inaapropriate expressions, hallucinations, and delusions
schizophrenia
What is the biochemical theory for the cause of schizophrenia?
excess amount of dopamine
Chronic schizphrenia requires _______ weeks of tx before any benefits are seen, and full improvement may take __________
2-3 weeks
months
List 3 different types of agents that are used in the pharmacologic therapy for schizophrenia
first-generation phenothiazines
butyrophenones (haloperidol)
second-generation atypical antipsychotic agents
Second-generation atypical antipsycnotic drugs are being used more often in the tx of schizophrenia now, even though they have no important advantages except what?
less weight gain
true or false. Some agents used to pharmacologically treat schizophrenia are also FDA approved to manage symptoms of bipolar disorder and Alzheimer's disease
true
All agents used to treat schizophrenia cause extrapyramidal symptoms including what 3 effects?
rigidity, akinesia, tremor, and adathesia
tardive dyskinesia: most serious side effect; that occurs after prolonged therapy and may continue for life; involuntary movements: lips and tongue initially, but also finger, toes, or trunk
Less frequent symptoms with newer atypical antipsychotics
All antipsychotic agents cause what?
chronic dry mouth
true or false. There are no documented drug-drug interactions between agents used to manage schizophrenia and dental therapeutics; however, the absence of eficenc is not evidence of safety.
both are true
Which antipsychotic drug may produce anxiety and respiratory distress with lorazepam; so avoid concurrent use?
Loxapine
Which antipsychotic drug may cause increased orthostatic hypotension with the use of diazepam; so avoid concurrent use?
olanzapine
What are 3 management considerations of DH treatment with pts who suffer from tardive dyskinesia due to the use of antipsychotic drugs?
observe pattern of tongue movement and avoid contact with instruments
pano may be the only wat
dry mouth
If a pt is taking the drug lithium, which agent should not be prescribed or administered by the dentist?
COX inhibitor: it will reduce metabolism, leading to increased blood levels and toxicity of lithium
The ascending reticular activation system (ARAS) a diffuse collection of neuron cell bodies and neuron fibers in the cnetral barin stem, is the physiologic mechanism for the mainenance of what?
"awake" and "asleep" cerebral cortex
What are the 2 different states of sleep?
NREM: nonrapid eye movement
REM: rapid eye movment
Difficulty in falling asleep; inability to remain asleep; or a combination of both are characteristics of what condition?
insomnia
sleep disturbances occur with many psychiatric and medical diseorders, and the primary treatment for them is directed at what?
the underlying illness
true or false. hypnotic agents may be prescribed for temporary tx of insomnia.
true
What is prescribed when pain causes anxiety and insomnia?
analgesics
What 4 drug agent classes are the most common agents used to treat insomnia?
benzodiazepines
barbiturates
nonbarbiturate sedatives
antihistamines
What are 3 reasons that short-acting benzodiazepines are preferred for the tx of insomnia?
less likely to accumulate with chrnic use
less daytime sedation
residual effects on driving ability: may oddur with flurazepam however
Which type of drugs used to treat insomnia can lose effectiveness after continued use, and can cause severe toxicity with overdose, and some are widely abused?
barbiturates
Which type of barbiturate agent was previously used for daytime sedation, but is not used anymore because of addicting properties and abuse potential?
meprobamate
List 4 different types of nonbarbiturate sedatives (miscellaneous nonbarbiturates) that are used in the tx of insomnia.
zolpidem tartrate
zaleplon
ramelteon
eszopiclone
Which nonbarbiturate sedative used to treat insomnia, is recommended for short term treatment (7-10 days); is to be taken immediately before bedtime, elderly pts may be sensitive to the effects, and they should avoid alcohol and other CNS depressants while taking this drug?
zolpidem tartrate (Ambien, Ambien CR)
What are 7 ADEs with the use of Zolpidem tartrate (Ambien) a nonbarbiturate sedative used to treat insomnia?
drowsiness
headache
lightheadedness
nausea
diarrhea
dry mouth
flu-like symptoms
Which type of nonbarbiturate sedative used to treat insomnia is recommended for short-term treatment; elderly pts are sensitive to this so give them an initial dose reduction; this agent is not shown to increase total sleep or decrease number of awakenings.
Zalephon (Sonata)
What are ADEs associated with the use of Zalephon (Sonata) a nonbarbiturate sedative?
short term memory loss
hallucinations
impaired coordination
dizziness
lightheadedness
Which type of nonbarbiturate sedative used to treat insomnia; is the newest agent, was approved for use with difficulty in sleep onset, and is to be taken within 30 minutes of going to bed?
Ramelton (Rozerem)
Why is it important to avoid high fat meals before taking Ramelton (a nonbarbiturate sedative)?
because the fat will decrease absorption of the drug
What are 6 ADEs with the use of Ramelton (the newest nonbarbiturate sedative)?
somnolence
dizziness
nausea
fatigue
headache
insomnia
What is a dental drug interaction with the use of Ramelton (the newest nonbarbiturate sedative)?
azole antifungals
Which type of nonbarbiturate sedative used to treat insomnia improves the sleep onset and maintenance, is to be taken immediately before bedtime, and not after high-fat meal, and doses should be reduced in the elderly; also, it's precise mechanism of action is unknown.
eszopiclone (Lunesta)
What are 8 ADEs with the use of eszopiclone (a nonbarbiturate sedative)?
anxiety
confusion
depression
dizziness
headache
respiratory infection
unpleasant taste
dry mouth
Which class of drug used to treat insomnia uses diphenhydramine for sedative effect; is present in most OTC sleep remedies, is non uniformly effective, and can cause dry mouth as a side effect?
antihistamines
What is the 4th most common heurodegenerative disorder in the elderly?
Parkinson's disease
Loss of dopaminergic neurons -> depletion of striateal dopamine stores -> degeneration of the dopaminertic nigrostriatal pathway -> chemical imbalance: excitatory (acetylcholine) and inhibitoray (dopamine) neurotransmitters in the corpus striatum -> impairment of extrapyrimidal tracts that control complex body movements: tremors, rigidity, bradykinesia, postural instability.
Is the pathopysiology of what disease?
parkinson's disease
List 4 cardinal motor symptoms of PD.
muscular rigidity
resting tremor
bradykinesia
loss of postural reflexes
List 6 additional motor symptoms of PD.
masklike face
decreased blinking
blurred vision
dysphagia
dysarthria
micrographia
List 13 nonmotor signs and symptoms (autonomic) of PD.
bladder dysfunction
GI problems
constipation
orthostatic hypotension
increased sweating
increased salivation
sexual dysfunction
difficulty swallowing
dermatitis
olfactory hypofunction
sensory disturbances
paresthesia
pain
List 7 cognitive/mood disorders of PD.
dementia
impaired attention
impaired cognition
depression
anxiety
sleep disturbances
hallucinations
effects of tremors and rigidity of oralfacial musculature on oral health include what 4 effects?
TMJ discomfort
cracked teeth
soft tissue trauma
attrition
true or false. There is no available therapy shown to stop progression of parkison's disease, so medical management is directed at controllling symptoms and maintaining pt's functional independence.
both are true
Xerostomia is seen in as many as _____% of PD pts.
55%
xerostomia along with what 5 other things are oral problems with PD, and may contribute to nutritional deficiencies and weight loss?
difficulty with: mastication, swallowing, and speech
increase dental caries
exacerbates periodontal disease
dysgeusia
esophageal injury
agents used in the pharmacologic treatment of PD include those which increase ____________ as well as ____________
dopamine
anticholinergics
List 4 dopaminergic agents used in the treatement of PD.
lefodopa-carbidopa
selegiline (L-deprenyl)
bromocriptine
amantadine
Which dopaminergic agent used in the tx of PD; increases synthesis of dopamine; the amt used depends on the severity of PD, and development of involuntary movements may limit the usefulness of the agent?
Lefodopa-carbidopa
What are 4 oral manifestations of use of levodopa-carbidopa?
constant chewing
biting
opening and closing of the mouth
What is done to avoid movements associated with the use of levodopa-carbidopa?
increase frequency of drug administration and decrease dose
Which type of dopaminergic agent used in the treatment of PD is used in combination with levodopa and carbidopa; and should NOT be administered with meperidine (Demerol) because it causes fatal drug interactions?
selegiline (L-Deprenyl)
What are 4 oral healthcare ADEs associated with the dopaminergic agent selegiline?
tremors
tardive dyskinesia
involuntary movements
back and leg cramps
Which dopaminergic agent used to treat PD, has a direct dopamine receptor agonist effect, and is effective in some pts, but not all?
bromocriptine
Which dopaminergic agent used to treat PD is used to reverse drug-induced extrapyramidal reactions; and is an effective prophylactic agent for preventions of respiratory infections cause by the asian flu strains?
amantadine (symmetrel)
Why are anticholinergic agents effective to lessen some of the symptoms of PD?
because a deficiency of dopamine results in hyperactivity of cholinergic receptors
Orthostatic hypotension is a dental management consideration for all of the following drugs except one, which one is the exception?
bupropion
monoamine oxidase inhibitors
serotonin reuptake inhibitors
tetracyclics
phenothiazines
