Risk Stratification and Dental Management of The Patient With ...

Risk Stratification and Dental Management of The Patient With ...

THE PATIENT WITH CENTRAL NERVOUS SYSTEM DISORDERS Risk Assessment and Dental Management Gza T. Terzhalmy, D.D.S., M.A. Professor and Dean Emeritus School of Dental Medicine Case Western Reserve University Cleveland, Ohio [email protected] The Patient With CNS Disorders Primary inhibitory neurotransmitter in the CNS Gamma-aminobutyric acid (GABA)

GABA receptor activation opens ligand-gated A Cl ion channels and allows the influx of Cl ions GABA receptors activate G proteins, which B open K+ channels and allow for the efflux of K+ ions 02/21/2020 2 The Patient With CNS Disorders The inward flow of Cl and efflux of K+

result in hyperpolarization and decrease the excitability of target cells GABAergic neurotransmission depresses the CNS 02/21/2020 3 The Patient With CNS Disorders ANXIETY

02/21/2020 4 The Patient With CNS Disorders (anxiety) Anxiolytic agents in the top 200 2010 02/21/2020 5

The Patient With CNS Disorders (anxiety) Benzodiazepines alprazolam lorazepam diazepam 02/21/2020 6 The Patient With CNS Disorders (anxiety) Mechanisms of action

Benzodiazepines potentiate GABA binding to GABAA receptors Open ligand-gated Cl- ion channels, which allow the influx of Cl- ions and decrease the excitability of target cells 02/21/2020 7 The Patient With CNS Disorders (anxiety) ADEs

Potential CNS depression with concomitant use of other CNS depressants Local anesthetic agents Opioid analgesics 02/21/2020 8 The Patient With CNS Disorders (anxiety)

Others zolpidem tartrate Ambien CR (zolpidem) Lunesta (eszopiclone) 02/21/2020 9 The Patient With CNS Disorders (anxiety) Mechanisms of action Zolpidem is structurally different from benzodiazepines Potentiates

GABA binding to GABAA receptors Open ligand-gated Cl- ion channels, which allow the influx of Cl- ions and decrease the excitability of target cells 02/21/2020 10 The Patient With CNS Disorders (anxiety) ADEs Potential

CNS depression with concomitant use of other CNS depressants Local anesthetic agents Opioid analgesics 02/21/2020 11 The Patient With CNS Disorders (anxiety) Risk assessment Disease-related

variables 02/21/2020 12 The Patient With CNS Disorders (anxiety) Anxiety Medical illnesses Cardiovascular Metabolic Respiratory

02/21/2020 13 The Patient With CNS Disorders (anxiety) Psychiatric Major illnesses depressive syndrome Bipolar disorder Psychoses

Psychological Phobias 02/21/2020 anxiety 14 The Patient With CNS Disorders (anxiety) Treatment strategies Vital signs Determine baseline values prior to the initiation of

dental intervention Consider the patients overall health as reflected by the medical history and vital signs May 02/21/2020 not tolerate long procedures 15 The Patient With CNS Disorders

(anxiety) Age-related changes in GABAA-receptor- benzodiazepine-complex interactions are responsible for the high sensitivity of elderly patients to benzodiazepines 02/21/2020 16 The Patient With CNS Disorders (anxiety) Inappropriate drugs in older adults (independent of medical diagnosis or condition)

flurazepam (Dalmane) diazepam (Valium) quazepam (Doral) halazepam (Paxipam) 02/21/2020 Long half-life in elderly patients (often several days): Prolonged sedation Increased the risk of falls 17

The Patient With CNS Disorders (anxiety) Potentially inappropriate drugs in older adults (independent of medical diagnosis or condition) lorazepam (Ativan), 3 mg oxazepam (Serax), 60 mg Smaller doses may be alprazolam (Xanax), 2 effective as well as safer: mg Daily doses should rarely exceed the suggested temazepam (Restoril), maximums

15 mg triazolam (Halcion), 0.25 mg 02/21/2020 18 The Patient With CNS Disorders (anxiety) Potentially inappropriate drugs in older adults (considering medical diagnoses or conditions) All benzodiazepines 02/21/2020

Stress incontinence Incontinence Depression Depression COPD Respiration Syncope/falls

Ataxia syncope/falls 19 The Patient With CNS Disorders (anxiety) Preventive strategies Oral hygiene Conventional vs. electromechanical toothbrushes Antibacterial mouthwashes

Topical fluorides Oral moisturizing agents, lubricants, and saliva substitutes Sialagogues Pilocarpine (Salagen) Cevimeline (Evoxac) 02/21/2020 20 The Patient With CNS Disorders (anxiety) Potential

medical emergencies Anticipate medical emergencies based on the patients medical history and vital signs 02/21/2020 21 The Patient With CNS Disorders (anxiety)

02/21/2020 22 The Patient With CNS Disorders Neuronal action potentials Propagated by alternating currents of Na+ influx (depolarizing) and K+ efflux (hyperpolarizing) The firing neurons activate neighboring neurons and interneurons Transmit

inhibitory (GABA) signals resulting in surround inhibition 02/21/2020 23 The Patient With CNS Disorders These events impose a limit on the frequency of firing i.e., prevent repetitive firing

Disruption of this intricate balance (abnormal synchronous discharge) is characteristic of all forms of seizures 02/21/2020 24 The Patient With CNS Disorders In addition T-type calcium channels associated with relay neurons connecting the thalamus to the cortex

Under physiological conditions are depolarized and inactive during the awake state May undergo paroxysmal hyperpolarization and initiate absence (petit mal) seizure 02/21/2020 25 The Patient With CNS Disorders SEIZURE DISORDERS 02/21/2020

26 The Patient With CNS Disorders Anticonvulsants in the top 200 2010 02/21/2020 27 The Patient With CNS Disorders (seizure disorders)

Inhibitors of voltage-gated sodium channels Lamictal Inhibits 02/21/2020 (lamotrigine) depolarizing Na+ ion influx into neurons 28

The Patient With CNS Disorders (seizure disorders) GABA-related neuronal inhibitors clonazepam gabapentin valproic acid Potentiate 02/21/2020 GABA binding to GABAA receptors 29 The Patient With CNS Disorders

(seizure disorders) Ca++ channel inhibitors Lyrica (pregabalin) Inhibits T-type Ca++ channel-related paroxysmal hyperpolarization 02/21/2020 30 The Patient With CNS Disorders (seizure disorders)

Other Topamax (topiramate) Mechanism 02/21/2020 of action unknown 31 The Patient With CNS Disorders (seizure disorders) Risk assessment Disease-related variables

02/21/2020 32 The Patient With CNS Disorders (seizure disorders) Primary generalized tonic-clonic (grand mal) seizure Loss of consciousness usually preceded by an aura (visual, auditory, epigastric, or psychic) Tonic component characterized by opisthotonos (convexity in the ventral body

region) caused by the violent spasm of back muscles 02/21/2020 33 The Patient With CNS Disorders (seizure disorders) Clonic component characterized by rhythmic movements (contraction and relaxation of muscles) of all limbs Post-seizure depression of motor and sensory

function Respiratory depression is a potential serious complication of a seizure attack 02/21/2020 34 The Patient With CNS Disorders (seizure disorders) Partial seizures Physical injury to head Consciousness

is typically preserved Involuntary repetitive movements (motor cortex) Paresthesia (sensory cortex) Flashing lights (visual cortex) 02/21/2020 35 The Patient With CNS Disorders (seizure disorders) Abnormal activity in the temporal or frontal

lobes Altered consciousness Involuntary automatism (smacking of lips or wringing of hands) 02/21/2020 36 The Patient With CNS Disorders (seizure disorders) Absence (petit mal) seizures Most often seen in pre-pubertal years

Sudden, brief loss of consciousness Patients stare off into space No associated aura Occasional motor symptoms Smacking 02/21/2020 of lips or rapid blinking 37 The Patient With CNS Disorders (seizure disorders) Myoclonic seizures

Most often seen in patients with uremia hepatic failure hereditary degenerative conditions Creutzfeldt-Jacob disease 02/21/2020 38 The Patient With CNS Disorders (seizure disorders) Treatment strategies Vital signs Determine

baseline values prior to the initiation of dental intervention Consider the patients overall health as reflected by the medical history and vital signs May 02/21/2020 not tolerate long procedures 39

The Patient With CNS Disorders (seizure disorders) Consider the patients degree of seizure control Confirm compliance with anticonvulsant regimen Potential CNS depression with concomitant use of other CNS depressants 02/21/2020

40 The Patient With CNS Disorders (seizure disorders) Preventive strategies Oral hygiene Conventional vs. electromechanical toothbrushes Antibacterial mouthwashes Topical fluorides Oral moisturizing agents, lubricants, and saliva substitutes

Sialagogues Pilocarpine (Salagen) Cevimeline (Evoxac) 02/21/2020 41 The Patient With CNS Disorders (seizure disorders) Potential medical emergencies Anticipate a

seizure attack Other medical emergencies based on the patients medical history and vital signs 02/21/2020 42 The Patient With CNS Disorders

(seizure disorders) 02/21/2020 43 The Patient With CNS Disorders Most central adrenergic neurons employ norepinephrine as their neurotransmitter Some central adrenergic neurons synthesize and use dopamine There

are two main classes of dopamine receptors D 02/21/2020 1 and D2 44 The Patient With CNS Disorders The cerebral cortex and limbic structures are innervated by dopaminergic cell bodies

Appear to play a role in Motivation Goal-directed thinking Regulation of affect Positive reinforcement (reward) 02/21/2020 45 The Patient With CNS Disorders

In addition Serotonin (5HT )-receptor activation appears 2 to lower the threshold for neuronal firing in the CNS Particularly 02/21/2020 the cortex 46 The Patient With CNS Disorders

Dysregulation of dopaminergic and/or serotonergic neurotransmission in mesolimbic and mesocortical systems Appears, at least partially, to be involved in the pathogenesis of psychoses 02/21/2020 47 The Patient With CNS Disorders PSYCHOTIC DISORDERS

AND DEMENTIA 02/21/2020 48 The Patient With CNS Disorders (psychotic disorders and dementia) Antipsychotic agents in the top 200 2010 02/21/2020

49 The Patient With CNS Disorders (psychotic disorders and dementia) Mixed serotonin (5HT - and dopamine 2) (D2)-receptor antagonists 02/21/2020 Zyprexa (olanzapine), Seroquel (quetapine) and Risperidal (risperidone) Antagonize serotonin (5HT )- and dopamine (D ) 2

2 receptors Antagonize adrenergic alpha - and alpha -receptors 1 2 and histamine H1-receptors 50 The Patient With CNS Disorders (psychotic disorders and dementia) Risk assessment Disease-related variables

02/21/2020 51 The Patient With CNS Disorders (psychotic disorders and dementia) Psychosis (schizophrenia) Major disturbances in thought content Bizarre behavior Regression in intellectual functioning Inappropriate affective expression Hallucinations and delusions Social/occupational dysfunction 02/21/2020

52 The Patient With CNS Disorders (psychotic disorders and dementia) Treatment strategies Vital signs Determine baseline values prior to the initiation of dental intervention Mixed serotonin (5HT - and dopamine (D 2) 2) receptor antagonism Adrenergic alpha - and alpha -receptors and 1 2

histamine H1-receptor antagonism 02/21/2020 53 The Patient With CNS Disorders (psychotic disorders and dementia) Consider the patients overall health as reflected by the medical history and vital signs May

02/21/2020 not tolerate long procedures 54 The Patient With CNS Disorders (psychotic disorders and dementia) Consider the patients degree of control Confirm compliance with antipsychotic regimen

CNS depression with concomitant use of other CNS depressants May not understand complex treatment plans 02/21/2020 55 The Patient With CNS Disorders (psychotic disorders and dementia) Preventive strategies Oral hygiene Conventional vs. electromechanical toothbrushes

Antibacterial mouthwashes Topical fluorides Oral moisturizing agents, lubricants, and saliva substitutes Sialagogues Pilocarpine (Salagen) Cevimeline (Evoxac) 02/21/2020 56 The Patient With CNS Disorders

(psychotic disorders and dementia) Potential medical emergencies Anticipate medical emergencies based on the patients medical history and vital signs 02/21/2020

57 The Patient With CNS Disorders (psychotic disorders and dementia) 02/21/2020 58 The Patient With CNS Disorders Serotonin (5HT) and norepinephrine (NE) neurotransmitter systems Modulate the firing of neurons in a

diffuse or global manner 02/21/2020 59 The Patient With CNS Disorders 5HT-containing cells within the raphe nuclei AND NE-containing cells within the locus coerulius project Project broadly throughout the cerebral cortex

with other projections to the limbic system 02/21/2020 60 The Patient With CNS Disorders Both 5HT and NE play critical roles in regulating mood and are involved in many other complex neuropsychiatric processes 02/21/2020

61 The Patient With CNS Disorders DEPRESSION 02/21/2020 62 The Patient With CNS Disorders (depression) Antidepressants in the top 200

2010 02/21/2020 63 The Patient With CNS Disorders (depression) Selective serotonin reuptake inhibitors (SSRIs) citalopram Lexapro (escitalopram) fluoxetine

paroxetine sertraline Effexor XR (venlafaxine) 02/21/2020 64 The Patient With CNS Disorders (depression) Mechanisms Inhibit 02/21/2020 of action

presynaptic reuptake of 5HT 65 The Patient With CNS Disorders (depression) Tricyclic antidepressants amitriptyline hydrochloride 02/21/2020 66 The Patient With CNS Disorders

(depression) Mechanisms Inhibit 02/21/2020 of action presynaptic reuptake of both 5HT and NE 67 The Patient With CNS Disorders (depression)

Atypical antidepressants trazodone hydrochloride Budeprion XL (budeprion) Cymbalta (duloxetine) 02/21/2020 68 The Patient With CNS Disorders (depression) Mechanisms Inhibit 02/21/2020

of action presynaptic reuptake of both 5HT and NE 69 The Patient With CNS Disorders (depression) Risk assessment Disease-related variables 02/21/2020

70 The Patient With CNS Disorders (depression) Major depressive disorder (MDD) Recurrent major depressive events Social/occupational dysfunction Loss of interest in nearly all activities Weight change of significant change in appetite 02/21/2020 71

The Patient With CNS Disorders (depression) Insomnia Psychomotor slowing Fatigue or loss of energy Impaired concentration Sense of worthlessness or guilt Thought of suicide or death 02/21/2020 72

The Patient With CNS Disorders (depression) Bipolar disorder (BPD) Extremes in mood Presence of mania Abnormally elevated mood Inflated self-esteem or grandiosity Rapid, laud, emphatic speech Psychomotor agitation Social/occupational 02/21/2020

dysfunction 73 The Patient With CNS Disorders (depression) Treatment strategies Vital signs Determine baseline values prior to the initiation of dental intervention 02/21/2020

74 The Patient With CNS Disorders (depression) Consider serotonin syndrome Tachycardia Cardiac arrhythmia Hypertensive syndrome Stroke Hyperthermia Muscle rigidity Fluctuations in mental state

02/21/2020 75 The Patient With CNS Disorders (depression) Consider the patients overall health as reflected by the medical history and vital signs May 02/21/2020

not tolerate long procedures 76 The Patient With CNS Disorders (depression) Consider Confirm the patients degree of control compliance with antipsychotic regimen Potential CNS excitation with concomitant use of other CNS stimulants Use local anesthetic agent containing a

vasoconstrictor with caution Potential CNS depression with concomitant use of CNS depressants May not understand complex treatment plans 02/21/2020 77 The Patient With CNS Disorders (depression) Preventive strategies Oral hygiene Conventional

vs. electromechanical toothbrushes Antibacterial mouthwashes Topical fluorides Oral moisturizing agents,lubricants, and saliva substitutes Sialagogues Pilocarpine (Salagen) Cevimeline (Evoxac) 02/21/2020

78 The Patient With CNS Disorders (depression) Potential medical emergencies Anticipate medical emergencies based on the patients medical history and vital

signs 02/21/2020 79 The Patient With CNS Disorders (depression) 02/21/2020 80

Recently Viewed Presentations

  • Last Stuff Quiz Review

    Last Stuff Quiz Review

    This is the SR to LR Adjustment for the previous slide. Notice it began with a recessionary gap. As input costs decline, the AS shifts rightward, restoring the Full-Employment Equilibrium level of GDPr. Please note: When there is an ....
  • DECOLONIZATION Postwar Themes  Cold War  Decolonization  Self-Determination?  Nationalism?

    DECOLONIZATION Postwar Themes Cold War Decolonization Self-Determination? Nationalism?

    Decolonization. The creation of independent states from a territory in (Asia and Africa) that was part of a European nations empire. National independence in the developing world has been a profound social movement this century
  • Achievement Standard 2.2 Demonstrate understanding of how and ...

    Achievement Standard 2.2 Demonstrate understanding of how and ...

    Self-paced skill are usually closed skills and an example is a javelin throw. Externally-paced skills: The environment, which may include your opponent controls the rate of performing the skill. This type of skill involves reaction and is usually and open...
  • First Year Organic Chemistry 2006-07 The Complete Lecture

    First Year Organic Chemistry 2006-07 The Complete Lecture

    C6H6 Resonance Structure - Rearrange the bonding electrons Delocalised or Conjugated System - p-bonding electrons can move within the molecule Delocalisation, Resonance -Stabilise molecules, so make them less reactive High Carbon content - burn with a smoky flame In aromatic...
  • Your Skill And Experience Is A Valuable Resource To Your ...

    Your Skill And Experience Is A Valuable Resource To Your ...

    Your Skills and Experience Are a Valuable Resource to Your Department and to the City of Houston. We Wish You an Expedited Recovery and Safe Return to Work We understand that Texas Workers' Compensation policies and procedures mixed with the...
  • Godly Brutality: The Cromwellian Conquest of Ireland

    Godly Brutality: The Cromwellian Conquest of Ireland

    Thesis. The Irish campaign was not one of genocide, despite its brutality, zealotry, and rhetoric. Rather, Cromwell's campaign was characterized by his pragmatic and religious commitment to complete victory in Ireland - a drive to pacify the island through whatever...
  • MIT course on Oscillations and Waves (by Prof. Walter Lewis)

    MIT course on Oscillations and Waves (by Prof. Walter Lewis)

    Solutions: Comparing Solutions: Waves are the key to sound, color, and much more: Rainbow Sunglint Tsnunamis Earthquakes Cel Phone signals Microwave ovens Musical Instruments … Rainbow Physics Cloud Rainbow observed from space: F-M. Breon, P. Goloub, 1998. The Sunglint What...
  • + Monitoring Access Tools and Accommodations in a

    + Monitoring Access Tools and Accommodations in a

    Accoms must be available - however, this does not mean a student MUST use them. our current system has no way of tracking if a student uses or not - and this will be addressed later in presentation. Show next...