Sunday, November 28, 2011 - Greater New York Dental Meeting

87 th
Annual Session
Sunday, November 28, 2011

Welcome to the Greater New York Dental Meeting
2011
Celebrity Luncheon Speaker
Fourth Annual INVISALIGN®- GNYDM EXPO
4 Days of Programming: Sunday - Wednesday
Invisalign Clear Essentials I; Invisalign Clear Essentials II;
Invisalign Advanced Programs & Team Building Courses
Botox/Dysport and
Dermal Filler
Hands-on Workshops
Hands-On Training
Using Botulinum Toxin
(Botox®) To Treat
Dento-Facial Conditions
COURSE DISCLAIMER
4 Days of Seminars &
The Greater New York Dental Meeting makes every effort to present high caliber speakers in their respective areas of expertise.
The presentations of these speakers in no way Hands-on imply endorsement Workshops
of any product, technique or service presented in the course of these presentations.
The Greater New York Dental Meeting specifically disclaims responsibility for any material presented.
Programs may be subject to change due to circumstance beyond our control.
George Stephanopoulos
Monday, November 28
12:00 - 2:00 - Ticket #4010
$75.00
6 Days of Education
Seminars, Hands-on Workshops & Essays
Friday - Wednesday
SPEAR Education
Seminars and Workshops
Friday - Monday
SomnoMed Sleep & Appliance Expo
Sunday Scientific Poster Sessions
4 Days of Exhibits
Sunday - Wednesday
Hands-On Training
Using Injectible
Hyaluronic Acid
Soft Tissue (Dermal) Fillers
to Augment Dento-Facial
Smile Esthetics
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Continuing Education Registry and your ExpoCard sponsored by Invisalign®/Align Technologies, Inc. is located on the Exhibit Floor Aisle 5400
and on the south side of the Registration Area. You are provided an ExpoCard with a personalized magnetic strip containing your registration data.
• The use of your ExpoCard allows you to record your attendance at a
course and receive written documentation at any time during the Meeting on
appropriate computers.
• The ExpoCard can be used at participating exhibitor booths to quickly
record your contact information for exhibitors to follow-up after the Meeting.
FREE “Live” Dentistry Hi-Tech 300 Seat Arena
SUNDAY
AM AM AM AM
Voco America, Inc.
Dr. Frank J. Milnar
Anterior Composites
PM
Discus Dental, LLC
Dr. Michael A. Miyasaki
Cosmetics and Restoration
MONDAY
Voco America, Inc.
Dr. Frank J. Milnar
Class IV Restorations
PM
OcoBioMedical, Inc.
Dr. Aza Nazarian
Implant Placement
TUESDAY
Discus Dental, LLC
Dr. Marilyn Ward
Whitening Technique
PM
Henry Schein Dental
Dr. Ruben Cohen &
Dr. Gary Kaye
Implants, Restorations &
Technology
WEDNESDAY
Nobel Biocare
Dr. Hooman M. Zarrinkelk &
Dr. Joseph J. Massad
Overdentures
PM
Dr. Joseph J. Massad
Dentures and Implants

Timely Topics in Medicine for Dentistry
Steven Ganzberg, DMD, MS
Clinical Professor of Anesthesiology
Director, Section of Dental Anesthesiology
UCLA School of Dentistry
Los Angeles, California
Timely Topics in Medicine for Dentistry
What We Will Cover Today:
An#coagulants and An#-­‐platelet Drugs:
Will Coumadin Become Obsolete
Hypertension
Anything New & Dental Considera#ons
Psychotropic Medica#ons
Why is everybody on them and what do I
need to know
Timely Topics in Medicine for Dentistry
What We Will Cover Today:
An#coagulants and An#-­‐platelet Drugs:
Will Coumadin Become Obsolete
Hypertension
Anything New & Dental Considera#ons
Psychotropic Medica#ons
Why is everybody on them and what do I
need to know
Review of Normal Hemostasis
Normal Vessel Wall Integrity
Adequate Platelet Plug Formation
Intact Coagulation System
Normal Fibrinolytic System
Platelet Plug Formation
1

Platelet Activation
Coagulation Cascade
D irected
C
e ll
S
u rface-
H e
m ostasis
PL
2

Test of Coagulation
Platelet Testing
aPTT - Partial Thromboplastin Time
Normal 25 – 35 sec
Measures Factors I, II, V, VIII, IX, X, XI, XII (Intrinsic)
PT - Prothrombin Time
Normal 12 – 14 sec
Measures Activity of Factors I, II, V, VII, X (Extrinsic)
INR - International Normalized Ratio Used
Used to Compare PT From One Laboratory to Another
INR = Patient’s PT ÷ Mean Lab PT Adjusted by International
Sensitivity Index
Platelet Count
Normal 150,000 – 300,000 cells/µL
Thrombocytopenia < 100,000 cells/µL
> 50,000 cells/µL Needed For Surgical Hemostasis
< 20,000 cells/µL Can Cause Spontaneous Bleeding
Platelet Life Span 9 – 11 Days
Bleeding Time
Evaluates Qualitative Platelet Function & Vascular
Integrity
Blood Pressure Cuff Inflated to 40 mmHg and
Standard Incision Blotted Every 30 sec (Ivy Method)
Normal 5 ± 2 min (Range: 30 sec – 10 min)
9½ min (Range: 4 – 21 min) on Aspirin*
No Longer Regularly Ordered
Tests of Coagulation
-Qualitative Platelet Studies-
PFA-100**
Tests Ability of Platelets to Aggregate to Collagen-
Epinephrine and Collagen-ADP
Main Screening Test
Platelet Aggregometry
Tests Ability of Platelets to Aggregate With:
ADP, Collagen, Arachidonic Acid, or Epinephrine
Ultegra
Tests Ability of Platelets to Bind Fibrinogen
*Blood MIELKE et al. 34 (2): 204. (1969)
3

First, What About Platelet Inhibitors
Aspirin Therapy
Irreversibly Inhibits Cyclooxygenase Leading to
Decrease in Thromboxane A2 Synthesis
Platelet Dysfunction For Life of Platelet (10d)
Bleeding Time Prolonged
9½ min (Range: 4 – 21 min) on Aspirin
Effect on Minor Surgery
Major Surgery
Orthognathic Surgery, Facial Cosmetic, ICBG, etc
Wait 4 Half Lives = 94% Drug Elimination
NSAID Beta Half Life (Approximate)
Ibuprofen 2 hrs
Naproxen Sodium 15 hrs
Ketoprofen 2 hrs
Flurbiprofen 7 hrs
Diclofenac 2.5 hrs
NSAIDs
What About Other Drugs
Clopidogrel (Plavix ® ) & Prasugrel (Effient ® )
Plavix
Effient
Indicated for Secondary Prevention
Stroke, Post MI, *Post Coronary Stenting*
Plavix ®
Prodrug – Active Metabolite Via CYP 2C19
Irreversible Antagonist of Platelet ADP Receptor
Spontaneous Bleeding Less Than With Aspirin
Plasma Half Life 20 – 50hrs (Highest in Elderly)
Dental Management As For Aspirin
Do Not D/C For Routine Dentistry/Oral Surgery
Never D/C Post-Drug Eluting Stent (DES) < 1 Year
Cardiologist May Recommend D/C > 3 mo. Post BMS
*If* Cardiologist Recommend D/C, Generally Need At Least
6 Days
Indicated for Secondary Prevention
Stroke, Post MI, *Post Coronary Stenting*
Effient ®
Prodrug – Active Metabolite Via CYP 3A4 & 2B6
Irreversible Antagonist of Platelet ADP Receptor
Spontaneous Bleeding Less Than With Aspirin
Plasma Half Life 7 hrs (Higher in Elderly)
Dental Management As For Plavix
4

Therapeutic Anticoagulation
Coumadin
Brand Name for Warfarin
Coumadin and Heparins…….
Competitive Antagonist of Vitamin K (Epoxide
Reductase)
And Now, Dabigatran & Rivaroxaban
(And Soon, Apixaban)
*
*
*
*
Coumadin
Coumadin: Dental Management
Takes Several Days For Full Effect & Offset
Numerous Drug/Food Interactions
Effect Measured By PT/INR
Common Conditions Requiring Coumadin:
INR 2.0 – 2.5: Deep Vein Thrombosis (DVT), Post
Pulmonary Embolus, A-Fib, Post MI/CVA,
Composite Aortic Valve
INR 2.5 – 3.5: Prosthetic Mitral/Aortic Valve
Determine Medical Condition
More Risk w/o Coumadin vs. Bleeding Risk
Confirm PT/INR Level
As Close To Time Of Surgery As Possible
No More Than 24 Hours Prior to Minor Oral Surgery
Evaluate For Type of Surgery/Infection
Dental Surgery/Injection/Single Tooth Extraction OK with
INR < 3
What About 3.5 4
Multiple Tooth Extraction/Major Surgery with INR > 1.5 →
MD Consult For Bridge Therapy
Coumadin: Dental Management
-Aides to Coagulation Process-
Pressure Packs
Agents to Promote Platelet Aggregation
Gelfoam ® – Absorbable Gelatin Sponges
Avatine ® – Microfibular Collagen
Surgicel ® – Oxidized Methylcellulose
Also Precipitates Fibrin
Hemcon ® – Polysaccharide Chitosan
ActCel ® – Collagen-like (From Cellulose)
Agents to Promotes Coagulation
Thrombostat ® – Thrombin
Coumadin: Dental Management
Inform Patient Of Possible Transfusion
PT/INR Day of Surgery
Within 12 – 24 hrs For Dental/Minor Oral Surgery
Avoid ASA & NSAIDs
Acetaminophen** & Opioids OK
Reevaluate Patient in 24 Hours
If Coumadin Reduced, Return to Normal Dose
5

What About Heparin
Unfractionated Heparin
Glycosaminoglycan
Heparin Infusion in Hospital
Half Life 1 – 2 Hours (Reminder: Dialysis)
Mechanism of Action
Heparin/Antithrombin III Complex Increases AT-III
Activity by 1000X
Inactivates Thrombin, Activated Factors X****, XII, XI, IX
& Thrombin Activated V, VII
Evaluate Infusion On PTT 1.5 – 2 X Normal
Point of Care By ACT
Unfractionated Heparin
Low Molecular Weight Heparins
Dose: 25 – 100 U/kg Based on Procedure
Onset Within 3 Minutes IV
Clinical Duration: ~ 60 – 120 Minutes
Ineffective Against Existing Thrombus
Protamine: Reversal @ 1 mg/100 U Heparin
Heparin Induced Thrombocytopenia: 3%
Heparin/Platelet Factor 4 Complex to IgG
Morbidity 30%; Mortality 7%
LMWH Patients May Be Outpatients
Half Life ~ 5 hours
Therapeutic Anticoagulation ~ 12 hours
Active Against Xa (Not Thrombin; Less IIa))
Enoxaparin (Lovenox ® ) Most Commonly Used
Indicated Following Total Knee/Hip Surgery, DVT,
Asymptomatic Pulmonary Embolus
Less Heparin Induced Thrombocytopenia
Enoxaparin - Lovenox ®
Dosage
30mg BID For Hip/Knee Replacement or 40mg QD
For Hip Replacement
1mg/kg BID For DVT w-w/o PE
80mg QD Also Used
Dental Treatment
Delay Treatment If Possible
Consult with MD To Discontinue in Emergency
Stop Lovenox in AM for Morning Surgery
Enoxaparin - Lovenox ®
Useful As Bridge For Coumadin Patients
D/C Coumadin and Start Lovenox ®
Monitor PT for Coumadin/PTT of Lovenox
Stop Lovenox AM of Surgery
Restart Lovenox Post-Op with Coumadin
D/C Lovenox ® When Coumadin Therapeutic
Not Indicated For Prosthetic Heart Valve
Prophylaxis
6

Synthetic Pentasaccharide
Fondaparinux - Arixtra ®
t ½β = 17 – 21 Hours
77% of Single Dose Eliminated in 72 Hours
Renally Excreted Unchanged
Enhances Activity of Antithrombin III by 1000X
Xa Antagonist (No Thrombin Activity)
Even Less Heparin Induced Thrombocytopenia
FDA Approved For:
DVT/Pulmonary Embolus Prevention
Treatment of Above In Conjunction With Coumadin 2.5mg QD
5 mg (body weight 100 kg)
Hip/Knee Replacement/Hip Fracture Surgery 2.5mg QD
The Next Wave:
Direct Thrombin Inhibitors
& Factor Xa Inhibitors
Direct Thrombin Inhibitors
Direct Thrombin Inhibitors
Lepirudin (Refludan) First
Developed From Saliva of Medicinal
Leech
FDA Approval for HIT
Also Used for Patients with HAAb
IV Only
Anticoagulation Measured Via ACT
Point of Care Via Ecarin Clotting
Time (ECT)
More Specific Than Heparin/LMWH
Active Against Soluble & Thrombus-Bound Thrombin
Minimizes Thrombin Vascular Effects
Effects on Vascular Protease-Activated Receptors
Proliferation of Vascular Smooth Muscle
Upregulates Endothelial Growth Factor Expression
Pro-Inflammatory Role
Decreased Platelet Expression of P-Selectin
Decreases Platelet-Leukocyte Interactions
Direct Thrombin Inhibitors
Dabigatran Etexilate (Pradaxa)
Orally Administered Twice a Day
FDA Approval 9/2010 for Stroke Prevention in A-Fib
RE-LY Study – 18,000 A-Fib Patients
110 mg dose “Non-inferior” to Coumadin
150 mg dose Superior; Same Bleeding Risk
RE-COVER Study – 2539 Patients
Non-Inferior To Coumadin For Tx of Acute VTE
Less Minor/Same Major Bleeding Episodes
7

Pharmacokinetics
Oral Prodrug of Dabigatron
Dabigatron Etexilate Converted Via Serum Esterase
Onset of Action: Within 1 Hour
Half Life: 12 – 17 hours (CrCl > 30 ml/min)
80% Renally Excreted Unchanged
Remainder Congugated With Biliary Excretion
No CYP 450 Or Food Interactions
Dose: 150 mg bid; 75 mg bid In Renal Insuff.
Clinical Issues
No Laboratory Tes#ng Done For Dabigatran
Ecarin CloKng Time Most Accurate
Rarely Performed AnywhereAc#vated
CloKng Time Quickest Test
No Reversal Agents
Factor VII Does NOT Reverse Effect
Dialysis Will Remove Drug (60% Over 2 -­‐3 hrs)
FFP & RBC’s If Necessary
Maintain Adequate Diuresis
Higher Rates of MI However
Office Oral Surgery & Dabigatran
No Data On How Long To Withhold
Or Even *If* To Withhold
Consider Withholding 2 Doses If Needed
Ex: Surgery on Wednesday
Skip Tuesday AM & PM Doses
Surgery Wednesday AM
Restart Dabigatran in PM
Assuming 12 hr Clearance
3 β-half lives Passed = 87% Clearance
And, Now......…..
Oral Factor Xa Inhibitors
Apixiban & Rivaroxaban
Oral Factor Xa Inhibitors
Rivaroxaban (Xarelto)
Rivaroxaban (Xarelto)
FDA Approved For;
VTE Prevention Post Hip/Knee Replacement
Panel Approval Stroke Prevention in A-Fib
Apixiban (Eliquis)
FDA Panel Approved Superior to ASA for A-Fib
AVERROES Trail Stopped Early Due to Clear Benefit
of Stroke Reduction
Superior to Lovenox for Hip/Knee Replace.
10 mg Once Daily Dosing
One Molecule Inhibits One Molecule Xa
Beta Half-­‐life = 7 – 11 hrs
2/3 Hepa#c Metabolism (CYP 3A4, 2J2)
1/3 Renal Excre#on Unchanged
Factor Xa Ac#vity Begins Returns to Normal Afer
24 hrs.
No An#dote in Overdose
8

Apixiban (Eliquis)
So……Will Coumadin Become
Obsolete
ARISTOTLE Study
18,201 Pts. With A-­‐Fib vs. Coumadin
1.2% vs. 1.6% Risk of Stroke/Embolism Favoring
Apixiban
Hazard Ra#o Lower at 0.79
Lower Risk of Hemorrhagic Stroke
Probably, But Physicians Are Slow To
Change When the Stakes Are High
Some Take Home Lessons
Check INR Within 24 Hours For Coumadin Pa#ents
Have Hemosta#c Adjuncts When Trea#ng
An#coagulated Pa#ents
And Pa#ents Taking An#platelet Drugs
Consider Stopping Two Doses of Pradaxa For
Selected Procedures With Physician Consult
Consider Stopping One Dose of Xa Inhibitors For
Selected Procedures With Physician Consult
Timely Topics in Medicine for Dentistry
What We Will Cover Today:
An#coagulants and An#-­‐platelet Drugs:
Will Coumadin Become Obsolete
Hypertension
Anything New & Dental Considera#ons
Psychotropic Medica#ons
Why is everybody on them and what do I
need to know
Hypertension
Morbidity and Mortality Increase
Linearly with Increasing BP
Systolic BP > 140 mmHg
Diastolic BP > 90 mmHg
2/3 Over Age 65 Exhibit Hypertension
↑ Risk of MI
Male & Systolic BP > 140 mmHg
9

Physiologic Blood
Pressure Control
Autonomic Nervous System
Autonomic Nervous System
Sympathetic
Parasympathetic
Renal Mechanisms
The Kidney Is Critical
Blood Pressure Regulation
The RAA System
Lung
Adrenal Cortex → Aldsoterone
Blood Pressure Regulation
Blood Pressure Regulation
10

Types of Hypertension
Essential (Primary) Hypertension
90 - 95% of Cases
Unknown Etiology
Includes Young Adults!!
Secondary Hypertension
Renal Causes
Endocrine
Hyperthyroidism
Adrenal Medulla Tumor (Pheochromocytoma)
Coarctation of Aorta
Drugs
White Coat Hypertension
> 140/90 In Office & < 135/85 In Ambulatory Settings
15% of Stage I Hypertension
Risks of Hypertension
Cerebrovascular Accident
Myocardial Infarction
Renal Disease
Congestive Heart Failure
Excessive Bleeding
Hypertension
Normal < 120/80
Pre-Hypertension 120 - 139/80 – 89
60 Million Americans
Stage 1 Hypertension 140-159/90-99
Stage 2 Hypertension >160/>100
70 Million Americans in Stage I & II
When Systolic & Diastolic In Different Categories, Use Higher Category
Newest Guidelines Place HTN As One Factor in
Overall CV Risk Regarding Treatment
Hypertensive Crisis
Systolic BP > 220mmHg
Diastolic BP > 120 mmHg
High Risk of:
Stroke
Heart Failure
Retinal Hemorrhages
Renal Damage
Treatment
Sodium Nitroprusside
Nicardipine
Nitroglycerin
Clonidine
Hypertension - Signs & Symptoms
Usually None!!!
When Severe and Prolonged, May See:
Retinal/Visual Changes
Constriction of Retinal Arterioles
Scotoma, Visual Loss
Papilledema
Headache
Dizziness
Tinnitus (Ringing in Ears)
Left Ventricular Hypertrophy (LVH)
Physical Exam & ECG
Treatment
Diuretics
Angiotensin Converting Enzyme Inhibitors
ACE Inhibitors
Angiotensin Receptor Blockers
ARBs
β-Blockers
α-Blockers
Ca ++ Channel Blockers
Direct Acting Vasodilators
Centrally Acting α2 Agonists
Renin-inhibiting Agents
11

Renin-Inhibiting Agents
Questions To Ask - Hypertension
What Is Your Typical Blood Pressure
How Long Have You Taken Your Current
Hypertension Medications
Did You Take Your Medication TODAY
Remember Rebound Hypertension with Beta Blockers
and Alpha-2 Agonists
What Is Your Typical Your Heart Rate
Do You Ever Get Lightheaded Feel Palpitations
Get Chest Pain
Exercise Tolerance (METS) May Not Help
Evaluation; Asymptomatic!!
Hypertension - Dental Management
Identify Hypertensive Patient
Stress Reduction Protocol For Dental Treatment
For All Hypertensive Patients
For Non-Treated Patient
140-159/90-99 → Generally OK for Restorative Treatment
MD Referral Within Two Months
160-179/100-109 → Caution for Dental Treatment
MD Referral Within Two Weeks
Consider Postponing Treatment Based on Procedure
≥180/110 (Uncontrolled) → Emergency Dental Treatment
MD Referral Within Days If No Symptoms
Treated Pt: Confirm Best Control & Use Judgment
Limit Vasoconstrictor Use in Local Anesthetics
Confirm Physician Evaluation and Consider Delaying
Further Treatment Until Blood Pressure Controlled
Approach to Vasoconstrictors
Durations of Action: Maxillary Infiltration
CAUTION in CV Disease/Possible Drug Interaction
Consider Non-Vasconstrictor Local Anesthetics
For Vasoconstrictor-Containing Local Anesthetics
Take Vital Signs Prior to Injection
Aspiration; Slow!!! Injection; Small Dose For Local
Vasconstriction, Then More Local Anesthetic
Take Vital Signs 2-3 minutes Post Injection
Administer Additional LA/Epi If Vital Signs Acceptable
± 20% of Baseline
Do Not Administer More Than 0.04mg Epi At One Time
Two Cartridges of Local Anesthetic with 1:100,000 Epi
Four Cartridges Articaine/Bupivicaine with 1:200,000 Epi
Preparation
lidocaine + epi
articaine + epi
mepivacaine plain
mepivacaine + levo
bupivacaine + epi
prilocaine + epi
prilocaine plain
Pulp Soft tissue
60 150
60 120 - 360
20 60 - 90
50 180 - 300
60 240 – 540
40 120
15 60 - 90
12

Durations of Action: IAN Block
Preparation
lidocaine + epi
articaine + epi
mepivacaine plain
mepivacaine + levo
bupivacaine + epi
prilocaine + epi
prilocaine plain
Pulp Soft tissue
75 180 - 300
75 120 - 360
40 120 - 180
75 180 - 300
180 240 – 540
75 180
60 150
Antihypertensives
Dental Drug Interactions
Non-Selective β Blockers
Sympathetic Nervous System - CV
With Vasoconstrcitors
Epinephrine
α1, β1, β2 effects
Levonordefrin ®
α-methyl-norepinephrine
80% α & 20% β
α1 - Increase Blood Pressure
β1 - Increase Heart Rate
β2 - Decrease Blood Pressure
Beta-Blockers
Non-Selective β-Blocker Interactions
Non-Selective - Blocks Both β1 & β2
e.g., Propranolol, Nadolol (Corgard), Timolol
(Blocadren), Pindolol (Visken), Sotolol (Betapace),
Carteolo (Cartrol), Penbutolol (Levatol), Oxprenolol
(Trasicor)
Cardioselective - Blocks β1 Only
e.g., Atenolol, Metoprolol, Acebutolol (Sectral),
Betaxolol (Kerlone), Bisoprolol (Zebeta)
Combined α and β Blockers
Labetalol (Normodyne, Trandate), Carvedilol
(Coreg)
α1 - Increased Blood Pressure
β1 - Increase Heart Rate
β2 - Decrease Blood Pressure
→ Hypertension & Reflex Bradycardia
With Both Epinephrine and Levonordefrin
No Interaction Likely With Cardio-selective
β1 Agents Or Combined α & β Blockers
13

Drug Interactions - NSAID’s
↓ Renal Blood Flow & Drug Excretion
Digoxin
↑ DIGOXIN LEVELS
Can Occur With Short Term Use,
Especially Elderly
NSAIDs Used Cautiously in CHF Patients
Due to Fluid Retention Anyway
NSAID’s – Possible CV Effects
Peripheral Edema
Decreased Glomerular Filtration
Increased Na + Intake – Some NSAIDs
Decreased Effect of Antihypertensives
Decreased Glomerular Blood Flow
Interpreted As Hypotension
Increased Renin Release
RAA System → Increased BP
Decreased Effect of Diuretics
Drug Interactions - NSAID’s
Antihypertensives/Diuretics
Decreased Effects
Renal Toxicity
ACE Inhibitors
Beta Blockers
Probably Angiotensin Receptor Blockers
Generally Requires At Least Few Days
Treatment For Above Effects
Shorter Duration Possible In Elderly For
Adverse Effect
Short Term Post-Op Pain Likely Safe
Also Occurs with Cox 2 Inhibitors
Renal Blood Flow Regulation
Prostaglandins
Promotes Vasodilation of Afferent Arteriole
↑ Glomerular Blood Flow
Blocked By NSAIDs
Angiotensin II
Promotes Vasoconstriction of
Efferent Arteriole
↑ Gomerular Filtration Pressure
Blocked By ACEI, ARBs, β-Blockers
Special Issues
Increased Incidence of Angioedema
ACE Inhibitors
Renin-Inhibiting Agents
Gingival Enlargement
Calcium Channel Blockers
Some Take Home Lessons
Check BP/Heart Rate Every Visit
Counsel Patients With Untreated HTN
Limit Vasoconstrictor Use When Possible
3% Mepivicaine In Maxilla/Mandible
4% Articaine - 1:200,000 Epi In Maxilla
0.5% Bupiviciane - 1:200,000 Epi In Mandible
Non-Selective Beta Blockers & Epinephrine
Avoid Long Term NSAID Use In Patients
With Hypertension
Or Monitor and Refer
14

Timely Topics in Medicine for Dentistry
What We Will Cover Today:
An#coagulants and An#-­‐platelet Drugs:
Will Coumadin Become Obsolete
Hypertension
Anything New & Dental Considera#ons
Psychotropic Medica#ons
Why is everybody on them and what do I
need to know
Why is everybody on them and what do I
need to know
Axis I: Clinical Disorders
Axis II: Personality Disorders
Axis III: General Medical Conditions
Axis IV: Psychosocial/Environmental Problems
Axis V: Global Assessment of Functioning
Anxiety Disorders
Mood Disorders
◦ Depression
◦ Bipolar Disorders
Attention Deficit/Hyperactivity Disorders
Schizophrenia
Eating Disorders
Substance Abuse Disorders
Many Others: See DSM-IV
Personality Disorders (Axis II)
Paranoid Personality Disorder - 0.5-2.5%
Schizotypal Personality Disorder - 3%
Antisocial Personality Disorder
◦ 3% Of Men, 1% Of Women
Borderline Personality Disorder - 2%
Histrionic Personality Disorder - 2-3%
Narcissistic Personality Disorder - Less Than 1%
Avoidant Personality Disorder - 0.5-1%
Obsessive-Compulsive Personality Disorder - 1%
Anxiety Disorders
Mood Disorders
◦ Depression
◦ Bipolar Disorders
Attention Deficit/Hyperactivity Disorders
Schizophrenia
Eating Disorders
Substance Abuse Disorders
Many Others: See DSM-IV
15

Emotional Pain or Feeling All Is Not Well
◦ Feeling of Impending Doom
May Not Have Conscious Focus
◦ Fear: Aware of What The Problem Is
With or Without Somatic Features
◦ Tachycardia, Palpitations, Headaches, Sweating,
Chest Pain
Phobia: Irrational Fear That Interferes With
Normal Behavior
Panic Disorder: Sudden, Overwhelming Sense
of Terror
Generalized Anxiety Disorder
Phobias
◦ Agoraphobia
◦ Social Phobias: Public Speaking, Embarrassment
◦ Simple Phobias: Snakes, Heights, Needles, Dentistry
Panic Attacks
◦ 15% Cardiology Patients Diagnosed With Panic
◦ Acute Phase Usually Lasts 20 – 30 Minutes
Posttraumatic Stress Disorder (PTSD)
Cognitive-Behavioral Therapy
Psychotherapy
Medications
◦ Antidepressants – SSRIs, TCAs, Benzodiazepines,
Antihistamines, Beta Blockers
Most Common Fears
◦ Public Speaking
◦ Going to the Dentist (Injections)
◦ Snakes
◦ Spiders
◦ Heights
15% of Population Voluntarily Avoid Seeking
Dental Care Due to Fear of Dentistry
> 40,000,000 People
Generally Short-Lived
Disappears When
External Danger or
Threat Passes
Both Psychological and
Physical Reaction
◦ Tachycardia, Sweating,
Hyperventilation, Shaking
Fear
Internalized
Generally Learned
Response
Arises From
Anticipation of an
Event, Especially When
the Outcome is
Unknown
Anxiety
16

Fear of Pain
Fear of the Unknown
Fear of Helplessness & Dependency
Fear of Bodily Change and Mutilation
Fear of Death
#1 Most Important: TLC – Be Nice To People
◦ Recognize Fear & Anxiety
◦ Provide Cognitive-Behavioral Therapy!
If Needed, Provide Sedation
◦ Nitrous Oxide/Oxygen
◦ Oral Sedation
◦ Intravenous Sedation
General Anesthesia
Anxiety Disorders
Mood Disorders
◦ Depression
◦ Bipolar Disorders
Attention Deficit/Hyperactivity Disorders
Schizophrenia
Eating Disorders
Substance Abuse Disorders
Many Others: See DSM-IV
~ 5% of US Population Are Depressed
>20% of Woman & 10% of Men Will At Some
Time Be Diagnosed With Major Depression
Elderly Most Common, 30 – 40 YO, Then
Teenagers
Consistent Across Race & Cultures
Suicide Real Risk of Depressive Illness
Major Depression vs. Dysthymia
Depressed Mood Most of the Day
Marked Loss of Interest In Most Activities
Significant Weight Loss/Gain; No Appetite Δ
Insomnia or Hypersomnia
Psychomotor Agitation/Retardation
Fatigue/Loss of Energy
Inability to Think/Concentrate
Suicidal Ideation With/Without Plan/Attempted
Neurotransmitter Imbalance
◦ Decreased CNS Serotonin/Norepinephrine
Psychosocial/Interpersonal Theory
◦ Loss In Vulnerable Individuals
Psychoanalytic
◦ Unconscious Mental Conflict
◦ Incomplete Psychological Development
Cognitive
◦ Distorted Thinking Leads To Negative Views
17

Tricyclics
◦ Elavil, Sinequan, Pamelor, Tofranil, Others
◦ Most Often Used for Pain Management
SSRIs- Selective Serotonin Reuptake Inhibitors
◦ Prozac, Zoloft, Paxil, Luvox, Celexa, Lexapro
SNRIs – Serotonin-Norepinephrine Reuptake Inhibitors
◦ Effexor, Cymbalta, Pristiq, Savella
◦ Also Used for Pain Management
MAOIs – Monoamine Oxidase Inhibitors
◦ Nardil, Parnate – Rarely Used
Miscellaneous
◦ Trazadone, Remeron, Others
◦ Frequently Used As Sleep Aides
Atypical Antipscyhotics Now Frequently Added
MAO
Antidepressants
Block
* Brand Names Uses In This Slide
Approach Patient Compassionately
Exaggerated Response to Epinephrine at
Synaptic Cleft With NE Reuptake Inhibitors ()
◦ Tricyclic Antidepressants & SNRIs
◦ Risk Variable
More Likely At Higher Tricyclic Doses At Least > 50mg
Possibly More Likely With SNRIs
◦ Assess BP/HR Frequently During Injections
Most Antidepressants Also Anticholinergic
Depressed Patients May Have Poor Hygiene
MAO Inhibitors (Nardil ® , Parnate ® )
◦ Interaction Improbable
◦ Historically, Usually Cited As Interaction
No/Minimal Interaction With:
◦ SSRIs
◦ Trazadone (Desyrel ® ), Nefazadone (Serzone ® )
◦ Buproprion (Wellbutrin ® , Zyban ® )
◦ Mirtazapine (Remeron ® )
Periods of Depression Alternating With Mania
◦ Mania May Be:
Inflated Self Esteem, “Can Do Anything”, “Flight of
Ideas”
OR Irritability and Anger
Can Break Through On Antidepressant Therapy
Lithium Historical Treatment
◦ Narrow Therapeutic Margin
AEDs Commonly Prescribed
◦ Valproate (Depakote), Carbamazepine (Tegretol),
Lamotrigine (Lamictal), Others Off Label
Approach Patient Compassionately
NSAIDs With Lithium Toxicity
◦ NSAIDs Decrease Renal Blood Flow
◦ Lithium Excreted Unchanged By Kidney
◦ Less Renal Blood Flow, Less Excretion, Higher
Plasma Levels
18

Anxiety Disorders
Mood Disorders
◦ Depression
◦ Bipolar Disorders
Attention Deficit/Hyperactivity Disorders
Schizophrenia
Eating Disorders
Substance Abuse Disorders
Many Others: See DSM-IV
Diagnosis: Based on 1994 American
Psychiatric Association's DSM-IV
◦ Signs & Symptoms At Least Moderate In Degree, In
At Least 2 Settings
◦ Signs & Symptoms Present Before 7 Years Old, For
At Least 6 Months
◦ Signs & Symptoms Should Be Considered
Inappropriate & Unmanageable
Difficulty processing
work
Doesn’t have goals
Looks hurried & too
busy
Doesn’t finish tasks
Doesn’t seem to listen
Easily distracted by
irrelevant stimuli
Inattention
Unable to concentrate
Doesn’t stay with one
activity
Has careless errors or
omits details
Doesn't follow
instructions
Hyperactivity
High levels of activity
Fidgets or squirms
Leaves seat or
classroom
Excessively runs or
climbs
“Driven by a motor”
Talks excessively
Impulsivity
Speaks out in class
Can’t wait his/her
turn
Interrupts others
Use DSM-IV Criteria
Symptoms Must Be Present In More Than 1
Environment
Extensive Exam
Treat As A Chronic Condition
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Learning Disabilities
◦ 15-20% Of ADHD Patients
◦ 50% Of LD Patients Have ADHD
Anxiety Or Mood Disorders = 10-20%
Oppositional Disorder/Antisocial
Behavior In ~50%
Tic Disorders/Tourette’s Disorder In 60%
Miscellaneous
Psychotherapy
Stimulants
◦ Blocks Dopamine Reuptake
Methylphenidate
◦ Blocks Dopamine/Norepinephrine Reuptake
Dextroamphetamine/Amphetamine
Releases Catecholamines
Mild MAO Inhibition
Blocks Norepinephrine
Reuptake
◦ Blocks Norepinephrine Reuptake
Atomoxetine
Methylphenidate
◦ Concerta
◦ Metadate
◦ Methylin
◦ Focalin
◦ Ritalin
Amphetamines
◦ Adderall
◦ (Dextroamphetamine)
NE Reuptake Inhibitor
◦ Strattera
Clonidine or Guanfacine
◦ Commonly With Stimulants
Slower Onset Than Stimulants
Ineffective For Inattention
Effective For:
◦ Drug-induced Insomnia
◦ Impulsivity & Overactivity
◦ Some Patients With Tic Disorders, Excessive
Hyperactivity And Conduct Disorder
Generally Have Patient Take Regular
Medications At Usual Times
Possible Interaction with Vasoconstrictors
◦ Likely Most Pronounced with Amphetamines
Black Box Warning
May Appoint Adult Pts. In AM and Withhold Medication
◦ Also Atomoxetine
Consider Clonidine In AM Rather Than
Stimulant as Oral “Sedative” Prior to Dentistry
Anxiety Disorders
Mood Disorders
◦ Depression
◦ Bipolar Disorders
Attention Deficit/Hyperactivity Disorders
Schizophrenia
Eating Disorders
Substance Abuse Disorders
Many Others: See DSM-IV
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Incidence ~ 1%; All Cultures; Both Genders
Condition of Disordered Thinking
◦ Can Not Tell Real From Unreal
◦ Negative Symptoms
Social Withdrawal
Reduced Affect
◦ Positive Symptoms
Inappropriate Emotional Responses
Can Have Hallucinations and Delusions
Poor Hygiene Common
Greek Roots: Schizein = Split; Pren = Mind
Psychiatric Diagnosis Consisting of:
◦ Impairment in Perception of Reality
◦ Auditory Hallucinations
◦ Bizarre Delusions
◦ Disorganized Speech and Thinking
◦ In Severe Cases: Catatonia
◦ Blunted Affect and Emotion
◦ Anhedonia
Onset: Age 20 – 30 Years
~ 1% Population; All Cultures; Both Genders
Comorbid Depression & Anxiety Common
Increased Dopaminergic Neurotransmission in
Parts of Striatum Linked to the Limbic System
and Nucleus Accumbens
Anti-Dopamine Agents Primary Treatment
D2 Receptor Thought To Be Primary
Traditional Antipsychotics (Neuroleptics)
◦ High and Low Potency
◦ Difffuse Dopamine Antagonist at D2
“Atypical” Antipsychotics
◦ Serotonin (5-HT 2 ) Antagonist & D2 + D4
Antagonist; Some Affect Other Receptors
Phenothiazines:
◦ Chlorpromazine (Thorazine ® )
◦ Fluphenazine (Prolixin ® )
◦ Perphenazine (Trilafon ® )
◦ Prochlorperazine (Compazine ® )
◦ Thioridazine (Mellaril ® )
◦ Trifluoperazine (Stelazine ® )
◦ Promazine
Thioxanthenes:
◦ Chlorprothixene
◦ Thiothixene (Navane ® )
Butyrophenones:
◦ Haloperidol (Haldol ® )
◦ Pimozide (Orap ® )
Used to treat Tourette
syndrome
Reduce Hallucinations and Delusions
Anhedonia, Depressed Affect Less Influenced
“Calming” Effect
Sedation
Must Continue Medication for Efficacy
Antiemetic Effect (Decreased Nausea)
Tardive Dyskinesia Common!!
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Clozapine (Clozaril)
◦ Risk of Agranulocytosis
Olanzapine (Zyprexa)
◦ Risk of Weight Gain and Diabetes Mellitus
Risperidone (Risperdal)
◦ Off Label: Tourette’s Syndrome
Quetiapine (Seroquel)
◦ Off Label: Insomnia and Restless Leg Syndrome
Ziprasidone (Geodon)
◦ Possible Cardiac Dysrythmias ( QT Interval)
Paliperidone (Invega)
◦ Derivative of Risperidone
Aripiprazole (Abilify)
◦ Partial Dopamine Agonist
Clozapine Has Least Effect On D2 Receptor and
Least Extrapyramidal Effects
Risperidone Low EP Effects As Well
Better at Treating Negative Symptoms
◦ Catatonia, Blunted Affect, Anhedonia
Psychiatric
◦ May Require General Anesthesia Even With
Medical Treatment
Tardive Dyskinesia
◦ TMJ Problems
◦ Difficulty With Dentistry (Pt. Moving)
Anticholinergic Effects of Drugs
◦ Xerostomia
Hypersalivation With Clozapine at Night
Leukopenia
Orthostatic Hypotension
Severe Hypotension Due To Alpha
Adrenergic Blockade
When Epinephrine Used, Can Cause
“Epinephrine Reversal”
◦ α Blockade; β1 and β2 Predominate
◦ Effect: Tachycardia and Hypotension
Not Generally Associated with Low Dose
Epineprhine in Local Anesthetics
Anxiety Disorders
Mood Disorders
◦ Depression
◦ Bipolar Disorders
Attention Deficit/Hyperactivity Disorders
Schizophrenia
Eating Disorders
Substance Abuse Disorders
Many Others: See DSM-IV
Anorexia Nervosa
◦ Severe Food Restriction Leading to Starvation
Bulimia Nervosa
◦ Restriction Alternating With Binge Eating/Purging
◦ Worse Prognosis Than Anorexia Nervosa
> 90% Woman; Higher Socioeconomic Groups
◦ ~ 1% Incidence; Onset Teenage Years
Treatment: Psychotherapy, Antidepressants
Severe Dental Decay In Bulemics
Treat As Debilitated Patient
22

Anxiety Disorders
Mood Disorders
◦ Depression
◦ Bipolar Disorders
Attention Deficit/Hyperactivity Disorders
Schizophrenia
Eating Disorders
Substance Abuse Disorders
Many Others: See DSM-IV
Definitions
◦ Abuse
Excessive Use of Drug, Usually Early On
◦ Dependence
Specific Withdrawal Syndrome On Abrupt Discontinuation
◦ Tolerance
Adaptation Where Continued Drug Use Leads to Effect
◦ Addiction
Continued Use of Drug Despite Harm; Impaired Control
Nicotine
Alcohol
Opioids
Methamphetamine
Cocaine
Inhalants
Sedatives
Hallucinogens
Marijuana
Be Alert to Signs of Substance Abuse
Rampant Decay – Methamphetamine (Cocaine)
◦ Any Addicted Person with Poor Hygiene
Delay Dental Treatment For 8 Hours
◦ Last Use of Cocaine, Methamphetamine
Caution Opioid Prescription For Former Opioid
Abuser
That’s It..... Thank You!!!!
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