**DENT 4217** **Neurological drugs and psychotropics** Dr Thuy Linh Truong thuy.truong@uwa.edu.au # **DENT 4217: Neurological drugs and psychotropics** Dr Thuy Linh Truong thuy.truong@uwa.edu.au > [!info] Overview > This lecture provides an overview of key neurological and psychotropic medications, focusing on their mechanisms, adverse effects, and specific implications for dental practice. The content serves as a consolidation of knowledge from DENT3005, with an emphasis on practical application through case scenarios. **Acknowledgement of country** The University of Western Australia acknowledges that its campus is situated on Noongar land, and that Noongar people remain the spiritual and cultural custodians of their land, and continue to practise their values, languages, beliefs and knowledge. Artist: Dr Richard Barry Walley OAM Abstract Indigenous artwork with black line patterns on a beige background # **Acknowledgement of country** The University of Western Australia acknowledges that its campus is situated on Noongar land, and that Noongar people remain the spiritual and cultural custodians of their land, and continue to practise their values, languages, beliefs and knowledge. Artist: Dr Richard Barry Walley OAM **Learning Outcomes** 1. Consolidate and build upon foundational pharmacological knowledge from DENT3005 2. Identify commonly prescribed psychiatric and neurological medications 3. Understand and evaluate potential drug interactions in the dental setting 4. Identify oral and dental side effects associated with psychiatric and neurological pharmacotherapies 5. Apply this knowledge to tailor dental treatment plans based on a patient’s medical history and pharmacological profile 6. Demonstrate clinical reasoning in case-based scenarios involving patients on neurological and psychiatric medications # **Learning Outcomes** 1. Consolidate and build upon foundational pharmacological knowledge from DENT3005 2. Identify commonly prescribed psychiatric and neurological medications 3. Understand and evaluate potential drug interactions in the dental setting 4. Identify oral and dental side effects associated with psychiatric and neurological pharmacotherapies 5. Apply this knowledge to tailor dental treatment plans based on a patient’s medical history and pharmacological profile 6. Demonstrate clinical reasoning in case-based scenarios involving patients on neurological and psychiatric medications **Neurological drugs** - Epilepsy - Parkinson’s disease - Migraine - Alzheimer’s disease - Multiple sclerosis # **Neurological drugs** > [!note] > The human nervous system is a complex network governing all bodily functions. Neurological disorders can significantly disrupt this system, often requiring lifelong management. This lecture focuses on the pharmacotherapy for several major neurological conditions frequently encountered in clinical practice. - Epilepsy - Parkinson’s disease - Migraine - Alzheimer’s disease - Multiple sclerosis > [!warning] Note > While the lecturer intended to cover Epilepsy, Parkinson’s Disease, Alzheimer’s Disease, Migraine, and Multiple Sclerosis, the latter two were omitted due to time constraints. **Epilepsy** - **Seizures**: transient uncontrolled electrical discharges - Causes: biochemical imbalance, structural - Partial Vs generalized - **Epilepsy**: recurrent, unprovoked seizure, different types - **Pharmacological targets** - Inhibitory GABA Vs excitatory glutamatergic pathways - Voltage gated membrane channels # **Epilepsy** - **Seizures**: transient uncontrolled electrical discharges - Causes: biochemical imbalance, structural - Partial Vs generalized - **Epilepsy**: recurrent, unprovoked seizure, different types > [!info] Clarification > It is important to distinguish this from a provoked seizure, which can occur due to temporary conditions like high fever or drug withdrawal and is not considered epilepsy. - **Pharmacological targets** - Inhibitory GABA Vs excitatory glutamatergic pathways - Voltage gated membrane channels <table> <thead> <tr> <th>Seizure</th> <th>Characteristics</th> </tr> </thead> <tbody> <tr> <td><strong>Absence (generalized)</strong></td> <td>Sudden transient loss of consciousness</td> </tr> <tr> <td><strong>Myoclonic (generalized)</strong></td> <td>Convulsive movements of body</td> </tr> <tr> <td><strong>Tonic (generalized)</strong></td> <td>Muscle contractions forcing body into rigid & fixed positions</td> </tr> <tr> <td><strong>Tonic-clonic (generalized)</strong></td> <td>Collapse, followed by rigidity then violent convulsions, and deep seep postictally, unresponsiveness, deep confusion</td> </tr> <tr> <td><strong>Aura (simple partial)</strong></td> <td>Usually experiencing sedation (e.g. olfactory, visual or aural) w/ no stimulus present</td> </tr> <tr> <td><strong>Jacksonian (simple partial)</strong></td> <td>Muscle spasms characterized by sequential involvement of body parts</td> </tr> <tr> <td><strong>Psychomotor (complex partial)</strong></td> <td>Transient aberrant behavior such as mood alteration, psychotic behavior or apparent drunkenness</td> </tr> </tbody> </table> ## **Seizure Characteristics** > [!note] > A seizure is a symptom resulting from a transient, abnormal, and uncontrolled electrical discharge in the brain's cerebral cortex. > - **Focal Seizure:** The discharge is localized to a specific brain region. > - **Generalised Seizure:** The discharge involves a larger area of the brain. > - **Note:** The term | Seizure | Characteristics | | :--- | :--- | | **Absence (generalized)** | Sudden transient loss of consciousness | | **Myoclonic (generalized)** | Convulsive movements of body | | **Tonic (generalized)** | Muscle contractions forcing body into rigid & fixed positions | | **Tonic-clonic (generalized)** | Collapse, followed by rigidity then violent convulsions, and deep seep postictally, unresponsiveness, deep confusion | | **Aura (simple partial)** | Usually experiencing sedation (e.g. olfactory, visual or aural) w/ no stimulus present | | **Jacksonian (simple partial)** | Muscle spasms characterized by sequential involvement of body parts | | **Psychomotor (complex partial)** | Transient aberrant behavior such as mood alteration, psychotic behavior or apparent drunkenness | **Antiepileptics** <table> <thead> <tr> <th>First line</th> <th>Second line</th> </tr> </thead> <tbody> <tr> <td><strong>Focal (partial) seizures</strong></td> <td>carbamazepine<sup>1</sup>, clobazam, lamotrigine<sup>1</sup>, levetiracetam<sup>1</sup>, oxcarbazepine, phenobarbital, phenytoin, pregabalin, tiagabine, topiramate, valproate, zonisamide</td> </tr> <tr> <td><strong>Generalised tonic-clonic seizures</strong></td> <td>valproate, carbamazepine<sup>2</sup>, clobazam, lamotrigine<sup>1</sup>, oxcarbazepine<sup>2</sup>, phenobarbital, phenytoin<sup>2</sup>, topiramate</td> </tr> <tr> <td><strong>Absence seizures</strong></td> <td>ethosuximide<sup>3</sup>, valproate, clonazepam, lamotrigine</td> </tr> <tr> <td><strong>Myoclonic seizures</strong></td> <td>valproate, clonazepam, levetiracetam, phenobarbital</td> </tr> <tr> <td><strong>Infantile spasms</strong></td> <td>prednisolone, tetracosactide, vigabatrin<sup>4</sup>, clonazepam, valproate</td> </tr> </tbody> </table> <sup>1</sup> may be first line in females of child-bearing potential <sup>2</sup> do not use if juvenile myoclonic epilepsy is suspected (often presents with a tonic-clonic seizure) as it may be ineffective or worsen seizures <sup>3</sup> does not prevent generalised tonic-clonic seizures which often coexist in juvenile absence epilepsy <sup>4</sup> use only if no safer alternative ## **Antiepileptics** > [!info] Treatment Goal and Initiation > The primary goal of antiepileptic drug (AED) therapy is the prevention of seizures and their associated complications, such as physical injury and reduced quality of life. AEDs are also used for the acute treatment of severe conditions like status epilepticus. > > **Treatment Initiation:** > - Treatment typically begins when the risk of further seizures outweighs the potential risks of drug therapy. > - After a first seizure, recurrence occurs in 30-50% of individuals, so medication is not always started immediately. > - Treatment is clearly indicated after two or more unprovoked seizures within a 6-12 month period. | | First line | Second line | | :--- | :--- | :--- | | **Focal (partial) seizures** | carbamazepine¹, clobazam, lamotrigine¹, levetiracetam¹, oxcarbazepine, phenobarbital, phenytoin, pregabalin, tiagabine, topiramate, valproate, zonisamide | | | **Generalised tonic-clonic seizures** | valproate, carbamazepine², clobazam, lamotrigine¹, oxcarbazepine², phenobarbital, phenytoin², topiramate | | | **Absence seizures** | ethosuximide³, valproate, clonazepam, lamotrigine | | | **Myoclonic seizures** | valproate, clonazepam, levetiracetam, phenobarbital | | | **Infantile spasms** | prednisolone, tetracosactide, vigabatrin⁴, clonazepam, valproate | | ¹ may be first line in females of child-bearing potential ² do not use if juvenile myoclonic epilepsy is suspected (often presents with a tonic-clonic seizure) as it may be ineffective or worsen seizures ³ does not prevent generalised tonic-clonic seizures which often coexist in juvenile absence epilepsy ⁴ use only if no safer alternative **Barbiturates** - **MOA**: Prolong inhibitory postsynaptic potential - **Drug interactions** - Phenobarbital + metronidazole - Other CNS depressants: monitor sedation - CYP3A4 substrates: clarithromycin, codeine, erythromycin, azoles, oxycodone, tramadol… - **ADR** - Sedation, cognitive impairment, altered mood and behaviour - [Rare]: exfoliative dermatitis <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Phenobarbital</td> <td>Phenobarb</td> </tr> <tr> <td>Primidone</td> <td>Mysoline</td> </tr> </tbody> </table> ## **Antiepileptic Drug Classes** ### **Barbiturates** - **MOA**: Prolong inhibitory postsynaptic potential It depresses neuronal excitability by enhancing chloride ion influx at the GABA-A receptor, leading to membrane hyperpolarization. - **Drug interactions** - Phenobarbital + metronidazole Phenobarbital increases the metabolism of metronidazole, potentially reducing its effectiveness. The dose of metronidazole may need to be increased. - Other CNS depressants: monitor sedation - CYP3A4 substrates: clarithromycin, codeine, erythromycin, azoles, oxycodone, tramadol… - **ADR** - Sedation, cognitive impairment, altered mood and behaviour - [Rare]: exfoliative dermatitis - Induction of liver enzymes (e.g., **CYP3A4**), affecting the metabolism of many other drugs. - Risk of physical dependence with long-term use. | Generic name | Brand Name | | :--- | :--- | | Phenobarbital | Phenobarb | | Primidone | Mysoline | **Benzodiazepines** - **MOA**: potentiate inhibitory effect of GABA - **Drug interactions** - Other CNS depressants: monitor sedation - Alprazolam: itraconazole, ketoconazole → enhance sedation & respiratory depression - Diazepam + fluconazole → increase adverse effect - Midazolam + [CYP3A4 inh] → enhance sedation & respiratory depression - **ADR**: fatigue, drowsiness, muscle weakness, ataxia, dry mouth, hypersalivation 😊 and many more <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Clobazam</td> <td>Frisium</td> </tr> <tr> <td>Clonazepam</td> <td>Rivotril</td> </tr> <tr> <td>Diazepam</td> <td>Valium</td> </tr> <tr> <td>Lorazepam</td> <td>Lorazepam inj</td> </tr> <tr> <td>Midazolam</td> <td>Hypnovel inj</td> </tr> </tbody> </table> Ataxia refers to a loss of coordination and balance, resulting in clumsy or awkward movements, often affecting walking, speech, and fine motor skills. ### **Benzodiazepines** - **MOA**: potentiate inhibitory effect of GABA - **Drug interactions** - Other CNS depressants: monitor sedation - Alprazolam: itraconazole, ketoconazole → enhance sedation & respiratory depression - Diazepam + fluconazole → increase adverse effect - Midazolam + [CYP3A4 inh] → enhance sedation & respiratory depression - **ADR**: fatigue, drowsiness, muscle weakness, ataxia, dry mouth, hypersalivation 😊 and many more > [!info] Note on Hypersalivation > Hypersalivation can occur paradoxically if sedation and muscle relaxation impair the swallowing reflex, leading to saliva pooling and drooling. | Generic name | Brand Name | | :--- | :--- | | Clobazam | Frisium | | Clonazepam | Rivotril | | Diazepam | Valium | | Lorazepam | Lorazepam inj | | Midazolam | Hypnovel inj | Ataxia refers to a loss of coordination and balance, resulting in clumsy or awkward movements, often affecting walking, speech, and fine motor skills. **Gabapentinoids** - **MOA**: bind to alpha-2 delta protein subunit of high threshold voltage-dependent calcium channels → reduce calcium influx & neurotransmitter release - **Drug interactions**: other CNS depressants - **ADR** - Drowsiness, sedation, dizziness, vertigo - Dysarthria - Ataxia - Tremor - Dry mouth - [Rare]: Steven Johnson's syndrome <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Gabapentin</td> <td>Neurontin</td> </tr> <tr> <td>Pregabalin</td> <td>Lyrica</td> </tr> </tbody> </table> ### **Gabapentinoids** - **MOA**: bind to alpha-2 delta protein subunit of high threshold voltage-dependent calcium channels → reduce calcium influx & neurotransmitter release They are structurally similar to GABA but do not act on GABA receptors. - **Drug interactions**: other CNS depressants - **ADR** - Drowsiness, sedation, dizziness, vertigo - Dysarthria - Ataxia - Tremor - Dry mouth - [Rare]: Steven Johnson's syndrome | Generic name | Brand Name | | :--- | :--- | | Gabapentin | Neurontin | | Pregabalin | Lyrica | <table> <thead> <tr> <th>Selected drug (brand)</th> <th>Selected ADR</th> </tr> </thead> <tbody> <tr> <td>Carbamazepine (Tegretol)</td> <td><strong>[common]</strong>: drowsiness, ataxia, dizziness, dry mouth<br><strong>[rare]</strong>: severe skin reactions, orofacial dyskinesia</td> </tr> <tr> <td>Ethosuximide (Zarontin)</td> <td><strong>[common]</strong>: dizziness, drowsiness, ataxia<br><strong>[rare]</strong>: Steven Johnson’s</td> </tr> <tr> <td>Lamotrigine (Lamictal)</td> <td><strong>[common]</strong>: dizziness, ataxia, hyperkinesia<br><strong>[rare]</strong>: severe skin reactions</td> </tr> <tr> <td>Levetiracetam (Keppra)</td> <td><strong>[common]</strong>: drowsiness, dizziness, vertigo, ataxia<br><strong>[rare]</strong>: severe skin reactions</td> </tr> <tr> <td>Oxcarbazepine (Trileptal)</td> <td><strong>[common]</strong>: dizziness, tremor, ataxia, nystagmus<br><strong>[rare]</strong>: severe skin reactions</td> </tr> <tr> <td>Phenytoin (Dilantin)</td> <td><strong>[common]</strong>: sedation, ataxia, nystagmus, vertigo, gingival hyperplasia<br><strong>[rare]</strong>: severe skin reactions</td> </tr> <tr> <td>Topiramate (Topamax)</td> <td><strong>[common]</strong>: dizziness, nervousness, agitation, speech disorder<br><strong>[infrequent]</strong>: aphasia, nystagmus, taste disturbance</td> </tr> <tr> <td>Valproate (Epilim)</td> <td><strong>[common]</strong>: ataxia, dizziness, tremor</td> </tr> </tbody> </table> ### **Summary of Selected Antiepileptics and ADRs** > [!note] > Most antiepileptics can cause some degree of drowsiness or dizziness, especially at the start of treatment or during dose adjustments. Dentists should be aware of several key neurological side effects: > - **Ataxia:** Loss of coordination and balance. > - **Orofacial Dyskinesia:** Involuntary movements of the face and mouth. > - **Hypokinesia:** Excessive or abnormal muscle activity, making patients restless. > - **Aphasia:** Difficulty with speaking or understanding language. > - **Nystagmus:** Rapid, involuntary eye movements. > - **Serious Skin Reactions:** Be vigilant for early signs of **SJS** or **Toxic Epidermal Necrolysis (TEN)**, which can manifest on the face and oral mucosa. <table border="1" class="dataframe"> <thead> <tr> <th>Selected drug (brand)</th> <th>Selected ADR</th> </tr> </thead> <tbody> <tr> <td>Carbamazepine (Tegretol)</td> <td><strong>[common]</strong>: drowsiness, ataxia, dizziness, dry mouth<br><strong>[rare]</strong>: severe skin reactions, orofacial dyskinesia</td> </tr> <tr> <td>Ethosuximide (Zarontin)</td> <td><strong>[common]</strong>: dizziness, drowsiness, ataxia<br><strong>[rare]</strong>: Steven Johnson’s</td> </tr> <tr> <td>Lamotrigine (Lamictal)</td> <td><strong>[common]</strong>: dizziness, ataxia, hyperkinesia<br><strong>[rare]</strong>: severe skin reactions</td> </tr> <tr> <td>Levetiracetam (Keppra)</td> <td><strong>[common]</strong>: drowsiness, dizziness, vertigo, ataxia<br><strong>[rare]</strong>: severe skin reactions</td> </tr> <tr> <td>Oxcarbazepine (Trileptal)</td> <td><strong>[common]</strong>: dizziness, tremor, ataxia, nystagmus<br><strong>[rare]</strong>: severe skin reactions</td> </tr> <tr> <td>Phenytoin (Dilantin)</td> <td><strong>[common]</strong>: sedation, ataxia, nystagmus, vertigo, gingival hyperplasia<br><strong>[rare]</strong>: severe skin reactions</td> </tr> <tr> <td>Topiramate (Topamax)</td> <td><strong>[common]</strong>: dizziness, nervousness, agitation, speech disorder<br><strong>[infrequent]</strong>: aphasia, nystagmus, taste disturbance</td> </tr> <tr> <td>Valproate (Epilim)</td> <td><strong>[common]</strong>: ataxia, dizziness, tremor</td> </tr> </tbody> </table> **Anti-epileptics drugs** **Dental implications** - **Drug interactions** - CNS depressants - CYP3A4 - **ADR** - **[common]**: drowsiness, oversedation, cognitive impairment, altered mood and behaviour, lightheadedness, hypersalivation, ataxia, dizziness, vertigo, dysarthria, tremor, dry mouth, nystagmus, taste disturbances - **[rare]**: serious skin reactions - Phenytoin: gingival hyperplasia ## **Epilepsy: Dental Implications** ### **Pharmacological Considerations** - **Drug interactions** - CNS depressants - CYP3A4 - **ADR** - **[common]**: drowsiness, oversedation, cognitive impairment, altered mood and behaviour, lightheadedness, hypersalivation, ataxia, dizziness, vertigo, dysarthria, tremor, dry mouth, nystagmus, taste disturbances - **[rare]**: serious skin reactions - Phenytoin: gingival hyperplasia - **Drowsiness/Dizziness:** Assist patients when moving in the dental chair. - **Hypersalivation:** Can interfere with resin-based restorations; use of a rubber dam is recommended. - **Dry Mouth (Xerostomia):** Increases caries risk. - **Motor Disturbances (e.g., tremor):** Can make procedures like taking radiographs difficult. - **Gingival Hyperplasia:** A known side effect of **phenytoin**, complicating oral hygiene and increasing periodontal disease risk. Meticulous care is essential, and referral to the GP for medication review may be necessary. **Epilepsy Dental implications** - Patient management - Appointment when the concentration of the antiepileptic medication is the most optimal - Avoid potential triggers - Know first aid protocols - DRSABCD - Clear AW - Supine position - Remove dangerous equipment - Protect patient: injury & falls - No attempt should be made to open the patient’s mouth - Call medical services ### **Patient Management** - Patient management - Appointment when the concentration of the antiepileptic medication is the most optimal - Avoid potential triggers - Ask patients if they experience a pre-seizure warning sign (aura). - Know first aid protocols - DRSABCD - Clear AW - Supine position - Remove dangerous equipment - Protect patient: injury & falls - No attempt should be made to open the patient’s mouth - Call medical services > [!danger] In-Chair Seizure Management > 1. Immediately remove all sharp instruments. > 2. Place the patient in a supine position. > 3. Follow the DR'S ABCD emergency protocol. > 4. Ensure the airway is clear, but **never force anything into the patient's mouth** to avoid fractures, lacerations, or injury to the dental professional. > 5. Call for emergency services. **Case 1: Mr Shake Scaler** **Scenario:** Mr SS, 29-year-old male with known epilepsy suddenly experiences a generalized tonic-clonic seizure mid-treatment. The dental chair is reclined, and several sharp instruments on the dental tray, operator side ## **Case Studies: Epilepsy** ### **Case 1: Mr Shake Scaler** **Scenario:** Mr SS, 29-year-old male with known epilepsy suddenly experiences a generalized tonic-clonic seizure mid-treatment. The dental chair is reclined, and several sharp instruments on the dental tray, operator side **Management:** - **Immediate Steps:** Remove dangerous instruments, keep the patient supine, follow emergency protocols, clear the airway without force, and call for emergency services. - **Potential Complications:** Fractured teeth, soft tissue lacerations, injury to the dental team. - **Prevention:** Avoid triggers, schedule appointments when medication is at optimal levels, and maintain regular communication with the patient's GP. Emphasize meticulous plaque control and schedule regular cleanings (e.g., 3-6 monthly). **Case 2: Ms Seizure Sinus** **Scenario:** Ms SS, a 43-year-old female with epilepsy presents with gingival enlargement and bleeding gums. She has been on phenytoin for several years and reports difficulty maintaining oral hygiene ### **Case 2: Ms Seizure Sinus** **Scenario:** Ms SS, a 43-year-old female with epilepsy presents with gingival enlargement and bleeding gums. She has been on phenytoin for several years and reports difficulty maintaining oral hygiene **Case 3: Mr Vertigo Veneer** **Scenario:** Mr VV, a 35-year-old male with newly diagnosed epilepsy presents for a check-up. He reports feeling dizzy and having a very dry mouth. He recently started gabapentin ### **Case 3: Mr Vertigo Veneer** **Scenario:** Mr VV, a 35-year-old male with newly diagnosed epilepsy presents for a check-up. He reports feeling dizzy and having a very dry mouth. He recently started gabapentin **Management:** - **Precautions:** Assist the patient when getting on and off the dental chair due to dizziness. Educate him on managing dry mouth to reduce caries risk. - **Side Effects Impacting Treatment:** Drowsiness, dizziness, ataxia, and tremors can interfere with patient cooperation and the precision of dental procedures. - **Drug Interactions:** Be cautious with other CNS depressants (e.g., benzodiazepines for pre-procedure anxiety), especially since the patient has just started the medication. Consider deferring treatment until the patient has stabilized on the new drug. **Parkinson’s Disease** - Usually **older** population - **Characteristics**: tremor, difficulty coordinating fine movements, hypokinesia, shuffling gait, skeletal muscle rigidity - **Normal muscle movement**: balance muscarinic cholinergic and dopaminergic activities - **Parkinson’s disease**: dopaminergic fibres and/or dopamine receptor degenerate - **Rationale tx**: provide sx relief - **Pharmacological**: dopamine agonists, anticholinergics, MAO-B, others # **Parkinson’s Disease** - Usually **older** population - **Characteristics**: tremor, difficulty coordinating fine movements, hypokinesia, shuffling gait, skeletal muscle rigidity - **Normal muscle movement**: balance muscarinic cholinergic and dopaminergic activities - **Parkinson’s disease**: dopaminergic fibres and/or dopamine receptor degenerate - **Rationale tx**: provide sx relief - **Pharmacological**: dopamine agonists, anticholinergics, MAO-B, others **Dopamine agonists** - **MOA**: stimulate dopamine receptor - **Drug interactions** - Apomorphine: clarithromycin, erythromycin, fluconazole → prolong QT - Bromocriptine + erythromycin: increase ADR - Cabergoline + clarithromycin, itraconazole: increase ADR - **ADR** - Dizziness, drowsiness - Orthostatic hypotension - Dyskinesia - Impulse control disorders <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Apomorphine</td> <td>Movapo inj</td> </tr> <tr> <td>Pramipexole</td> <td>Sifrol</td> </tr> <tr> <td>Rotigotine</td> <td>Neupro</td> </tr> <tr> <td><strong>Ergot derivative</strong></td> <td></td> </tr> <tr> <td>Bromocriptine</td> <td>Parlodel</td> </tr> <tr> <td>Cabergoline</td> <td>Dostinex</td> </tr> </tbody> </table> ## **Drug Classes for Parkinson's Disease** ### **Dopamine agonists** - **MOA**: stimulate dopamine receptor - **Drug interactions** - Apomorphine: clarithromycin, erythromycin, fluconazole → prolong QT - Bromocriptine + erythromycin: increase ADR - Cabergoline + clarithromycin, itraconazole: increase ADR - **ADR** - Dizziness, drowsiness - Orthostatic hypotension - Dyskinesia - Impulse control disorders - Headache - Nasal congestion (can make breathing difficult during treatment) > [!warning] Impulse Control Disorders > This is a significant psychiatric side effect that can manifest as problem gambling, compulsive shopping, or **binge eating** (increasing caries risk). Patients may also compulsively commit to expensive cosmetic dental treatments. | Generic name | Brand Name | | :--- | :--- | | Apomorphine | Movapo inj | | Pramipexole | Sifrol | | Rotigotine | Neupro | | **Ergot derivative** | | | Bromocriptine | Parlodel | | Cabergoline | Dostinex | **Anticholinergics** - **MOA**: block muscarinic actions of acetylcholine - **Drug interactions** - Benzatropine, trihexyphenidyl: nil dental interactions - **ADR** - Dizziness, drowsiness - Orthostatic hypotension - Dyskinesia - Dry mouth <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Benzatropine</td> <td>Benztrop</td> </tr> <tr> <td>Trihexyphenidyl</td> <td>Artane</td> </tr> </tbody> </table> **Tertiary amines** - Atropine, Atropine (antidote) - Benzatropine - Darifenacin - Hyoscine hydrobromide - Orphenadrine - Oxybutynin - Solifenacin - Tolterodine - Trihexyphenidyl **Quaternary amines** - Glycopyrronium (anaesthesia) - Hyoscine butylbromide - Propantheline ### **Anticholinergics** - **MOA**: block muscarinic actions of acetylcholine - **Drug interactions** - Benzatropine, trihexyphenidyl: nil dental interactions - **ADR** - Dizziness, drowsiness - Orthostatic hypotension - Dyskinesia - Dry mouth | Generic name | Brand Name | | :--- | :--- | | Benzatropine | Benztrop | | Trihexyphenidyl | Artane | #### **Tertiary amines** - Atropine, Atropine (antidote) - Benzatropine - Darifenacin - Hyoscine hydrobromide - Orphenadrine - Oxybutynin - Solifenacin - Tolterodine - Trihexyphenidyl #### **Quaternary amines** - Glycopyrronium (anaesthesia) - Hyoscine butylbromide - Propantheline **Monoamine oxidase inH type B** - **Aka MAOB inH** - **MOA**: inH MAOB, reduce breakdown of dopamine, may block dopamine re-uptake - **Drug interactions**: nil dental interactions - **ADR** - Orthostatic hypotension - Dyskinesia <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Rasagiline</td> <td>Azilect</td> </tr> <tr> <td>Safinamide</td> <td>Xadago</td> </tr> <tr> <td>Selegiline</td> <td>Eldepryl</td> </tr> </tbody> </table> ### **Monoamine oxidase inH type B (MAOB inH)** - **Aka MAOB inH** - **MOA**: inH MAOB, reduce breakdown of dopamine, may block dopamine re-uptake - **Drug interactions**: nil dental interactions - **ADR** - Orthostatic hypotension - Dyskinesia (involuntary, erratic muscle movements of the face or limbs that can make it challenging for patients to remain still) | Generic name | Brand Name | | :--- | :--- | | Rasagiline | Azilect | | Safinamide | Xadago | | Selegiline | Eldepryl | **Other drugs for Parkinson** - **Drug interactions**: Entacapone + adrenaline: dental relevance? - **Amantadine [ADR]**: Orthostatic hypotension, dizziness, dry mouth - **Entacapone [ADR]**: Orthostatic hypotension, dry mouth, dyskinesia - **Opicapone [ADR]**: Dry mouth, dizziness, dyskinesia - **Combination [ADR]**: orthostatic hypotension, dyskinesia, drowsiness, impulse control disorder <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Amantadine</td> <td>Symmetrel</td> </tr> <tr> <td>Entacapone</td> <td>Comtan</td> </tr> <tr> <td>Levodopa + benserazide</td> <td>Madopar</td> </tr> <tr> <td>Levodopa + carbidopa</td> <td>Kinson, Sinemet</td> </tr> <tr> <td>Levodopa + carbidopa & entacapone</td> <td>Carlevent, Lecteva</td> </tr> <tr> <td>Opicapone</td> <td>Ongentys</td> </tr> </tbody> </table> ### **Other drugs for Parkinson’s** > [!note] > The lecturer advised students to read up on other drug classes for Parkinson's disease in their own time. - **Drug interactions**: Entacapone + adrenaline: dental relevance? - **Amantadine [ADR]**: Orthostatic hypotension, dizziness, dry mouth - **Entacapone [ADR]**: Orthostatic hypotension, dry mouth, dyskinesia - **Opicapone [ADR]**: Dry mouth, dizziness, dyskinesia - **Combination [ADR]**: orthostatic hypotension, dyskinesia, drowsiness, impulse control disorder | Generic name | Brand Name | | :--- | :--- | | Amantadine | Symmetrel | | Entacapone | Comtan | | Levodopa + benserazide | Madopar | | Levodopa + carbidopa | Kinson, Sinemet | | Levodopa + carbidopa & entacapone | Carlevent, Lecteva | | Opicapone | Ongentys | **Drugs for PD** **Dental implications** - Drug interactions - QT prolongation drugs - CYP3A4 - ADR - [common]: dizziness, drowsiness, orthostatic hypotension, dyskinesia, impulse control disorders, dry mouth ## **Parkinson's Disease: Dental Implications** ### **Pharmacological Considerations** - **Drug interactions** - QT prolongation drugs - CYP3A4 - **ADR** - [common]: dizziness, drowsiness, orthostatic hypotension, dyskinesia, impulse control disorders, dry mouth **PD Dental implications** - Orthostatic hypotension - Fatigue and exhaustion due to disturbed sleep patterns - Impaired executive functions which leads to distraction and inattention - Short appointments if possible - Patient should take levodopa and symptomatic medication 1 hour prior to planned procedure! - Minimise muscle tone resting jaw opening or possible uncontrolled tremor - Side-effects from medications ### **Patient Management** - Orthostatic hypotension - Fatigue and exhaustion due to disturbed sleep patterns - Impaired executive functions which leads to distraction and inattention - Short appointments if possible - Patient should take levodopa and symptomatic medication 1 hour prior to planned procedure! - Minimise muscle tone resting jaw opening or possible uncontrolled tremor Use a bite block and provide frequent breaks to minimize muscle strain. - Side-effects from medications **Case 1: Mr Dopamine Dentrifice** **Scenario:** Mr DD, 72 years old, presents for a dental extraction. He has Parkinson’s disease with prominent resting tremor and is currently taking **levodopa/carbidopa** and **entacapone**. His caregiver mentions he sometimes feels dizzy when standing up ## **Case Studies: Parkinson's Disease** ### **Case 1: Mr Dopamine Dentrifice** **Scenario:** Mr DD, 72 years old, presents for a dental extraction. He has Parkinson’s disease with prominent resting tremor and is currently taking **levodopa/carbidopa** and **entacapone**. His caregiver mentions he sometimes feels dizzy when standing up **Management:** - **Chair Positioning:** Reposition the patient slowly from supine to sitting to prevent orthostatic hypotension. - **Adrenaline in LA:** The patient's medication (e.g., entacapone) may increase the risk of tachycardia with adrenaline. Use proper aspiration technique, especially for blocks, to avoid intravascular injection. - **Medication Timing:** Taking PD medication before the appointment helps reduce tremor and rigidity, improving cooperation. **Case 2: Mrs Rigid Root-Canal** **Scenario:** Mrs RR is a long-standing Parkinson’s patient on **amantadine** and **benztropine**. She complains of dry mouth and difficulty chewing ### **Case 2: Mrs Rigid Root-Canal** **Scenario:** Mrs RR is a long-standing Parkinson’s patient on **amantadine** and **benztropine**. She complains of dry mouth and difficulty chewing **Management:** - **Cause of Xerostomia:** Both amantadine and benztropine can cause dry mouth. - **Oral Complications:** Chronic dry mouth increases the risk of caries, mucosal irritation, oral infections, and dysphagia. - **Management:** Recommend sugar-free saliva substitutes, increased hydration, and meticulous oral hygiene. Consider liaising with her GP about the severity of the side effect. **Alzheimer’s Disease** - A form of dementia - Characteristics: neuronal cell loss, brain shrinkage, enlarged ventricles, significant histological changes in brain tissue - Progressive deterioration - Pathophysiology: neuronal cell death, B-amyloid plaques, neurofibrillary tangles - Reduction in Ach and raised glutamate? - Pharmacological: inH acetylcholinesterase, glutamate receptor antagonists # **Alzheimer’s Disease** - A form of dementia - **Characteristics**: neuronal cell loss, brain shrinkage, enlarged ventricles, significant histological changes in brain tissue - Progressive deterioration - **Pathophysiology**: neuronal cell death, B-amyloid plaques, neurofibrillary tangles - Reduction in Ach and raised glutamate? - **Pharmacological**: inH acetylcholinesterase, glutamate receptor antagonists **Anticholinesterases** - **MOA**: decrease breakdown of acetylcholine - **Drug interactions [Galantamine]** - QT prolongation: clarithromycin, erythromycin, fluconazole - [CYP3A4 inh] - **ADR** - Drowsiness, dizziness, tremor, increased sweating, hypertension, fainting <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Donepezil</td> <td>Arazil, Aricept</td> </tr> <tr> <td>Galantamine</td> <td>Galantyl, Reminyl</td> </tr> <tr> <td>Rivastigmine</td> <td>Exelon</td> </tr> </tbody> </table> ## **Drug Classes for Alzheimer's Disease** ### **Anticholinesterases** - **MOA**: decrease breakdown of acetylcholine Used in early-stage AD, these drugs inhibit the anticholinesterase enzyme, which normally breaks down acetylcholine. This increases the availability and prolongs the action of acetylcholine in the brain. - **Drug interactions [Galantamine]** - QT prolongation: clarithromycin, erythromycin, fluconazole - [CYP3A4 inh] - **ADR** - Drowsiness, dizziness, tremor, increased sweating, hypertension, fainting | Generic name | Brand Name | | :--- | :--- | | Donepezil | Arazil, Aricept | | Galantamine | Galantyl, Reminyl | | Rivastigmine | Exelon | **Other drugs for Alzheimer's** - **MOA**: N-methyl-D-aspartate (NMDA) antagonist - **Drug interactions**: limited information - **ADR** - [common]: confusion, dizziness, drowsiness, headache, agitation, hallucinations, dyspnoea - [infrequent]: anxiety <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Memantine</td> <td>Ebixa, Memanxa</td> </tr> </tbody> </table> ### **Other drugs for Alzheimer's (NMDA Antagonists)** - **MOA**: N-methyl-D-aspartate (NMDA) antagonist In AD, excessive glutamate levels cause overstimulation of NMDA receptors, leading to excessive calcium influx and neuronal damage. Memantine blocks these receptors, preventing this harmful overstimulation. - **Drug interactions**: limited information - **ADR** - [common]: confusion, dizziness, drowsiness, headache, agitation, hallucinations, dyspnoea - [infrequent]: anxiety | Generic name | Brand Name | | :--- | :--- | | Memantine | Ebixa, Memanxa | **Drugs for AD** **Dental implications** - **Drug interactions** - QT prolongation drugs - CYP3A4 - **ADR** - [common]: Drowsiness, dizziness, tremor, increased sweating, hypertension, fainting, confusion, headache, agitation, hallucinations, dyspnoea - [infrequent]: anxiety ## **Alzheimer's Disease: Dental Implications** - **Drug interactions** - QT prolongation drugs - CYP3A4 - **ADR** - [common]: Drowsiness, dizziness, tremor, increased sweating, hypertension, fainting, confusion, headache, agitation, hallucinations, dyspnoea - [infrequent]: anxiety ### **Patient Factors** - Recognize the patient's level of cognitive decline. - A carer or legal representative may be required for informed consent. **Case 1** **Mr Forgetful Fillings** **Scenario:** Mr. FF, 78, presents for a routine dental check-up. He has early-stage Alzheimer’s and is currently taking **galantamine**. His medical history also includes hypertension. He reports dizziness and occasional fainting spells ## **Case Studies: Alzheimer's Disease** ### **Case 1: Mr Forgetful Fillings** **Scenario:** Mr. FF, 78, presents for a routine dental check-up. He has early-stage Alzheimer’s and is currently taking **galantamine**. His medical history also includes hypertension. He reports dizziness and occasional fainting spells **Management:** - **Implications of Galantamine:** Dizziness and fainting can complicate patient positioning and tolerance of treatment. - **Adrenaline in LA:** Use a correct and slow LA technique with negative aspiration. Use the minimum effective dose and monitor the patient closely. - **Drug Interactions:** Avoid prescribing CYP3A4 inhibitors like erythromycin or fluconazole if possible. **Case 2** **Ms Confused Composite** **Scenario:** Ms CC, 81, with moderate Alzheimer’s disease, is on **memantine** (an NMDA antagonist). She arrives for an extraction and is visibly confused and agitated. Her caregiver reports recent hallucinations ### **Case 2: Ms Confused Composite** **Scenario:** Ms CC, 81, with moderate Alzheimer’s disease, is on **memantine** (an NMDA antagonist). She arrives for an extraction and is visibly confused and agitated. Her caregiver reports recent hallucinations **Management:** - **Influence of ADRs:** Confusion, agitation, and hallucinations can severely complicate communication and patient cooperation. - **Behavioral Strategies:** Use calm communication, give clear and simple instructions, schedule shorter appointments, and involve a familiar caregiver to reduce anxiety. - **Consent:** Ensure valid consent is obtained, either from the patient if they are deemed capable or from their legal power of attorney. **Psychotropic drugs** - Major depression - Anxiety & related disorders - Eating disorders - Bipolar disorder - Insomnia - ADHD - Alcohol withdrawal - Long term treatment for alcohol dependence - Nicotine dependence - Opioid dependence # **Psychotropic drugs** - Major depression - Anxiety & related disorders - Eating disorders - Bipolar disorder - Insomnia - ADHD - Alcohol withdrawal - Long term treatment for alcohol dependence - Nicotine dependence - Opioid dependence **Antidepressants** - **Major depression** - Relieve psychological and physical symptoms - Improve functional capacity - Reduce the likelihood of self-harm or suicide - **Anxiety and related disorders** - Control symptoms and improve social functioning - **Eating disorders** - A multidisciplinary approach - Psychological treatments [cognitive behaviour therapy, interpersonal psychotherapy, family psychotherapy] - SSRIs: bulimia nervosa, binge eating disorder # **Antidepressants** ## **Indications** - **Major depression** - Relieve psychological and physical symptoms - Improve functional capacity - Reduce the likelihood of self-harm or suicide - **Anxiety and related disorders** - Control symptoms and improve social functioning - **Eating disorders** - A multidisciplinary approach - Psychological treatments [cognitive behaviour therapy, interpersonal psychotherapy, family psychotherapy] - SSRIs: bulimia nervosa, binge eating disorder **Antidepressants: adverse effects** - **Serotonin toxicity** - Tramadol - **Withdrawal effects** - Nausea, vomiting, anxiety, agitation, tremor and many more ## **General Adverse Effects** - **Serotonin toxicity** - Tramadol - **Withdrawal effects** - Nausea, vomiting, anxiety, agitation, tremor and many more **MOA inhibitors** - **MOA**: Nonselective MAOIs irreversibly inhibit monoamine oxidases A and B - **Drug interactions** - Serotonin toxicity: tramadol (CI) - Adrenaline: may increase effect of adrenaline (caution) - Tapentadol: increase risks for HTN (CI) - **ADR [common]** - Orthostatic hypotension, headache, drowsiness, fatigue, weakness, agitation, tremors, twitching, myoclonus, hyperreflexia, dizziness, dry mouth *(CI) = Contraindicated* Myoclonus: sudden, brief, involuntary muscle jerks or twitches, often described as shock-like movements, that can affect a single muscle or a group of muscles. Figure: Table listing Generic and Brand Names for MOA inhibitors ## **Antidepressant Drug Classes** ### **MOA inhibitors** - **MOA**: Nonselective MAOIs irreversibly inhibit monoamine oxidases A and B - **Drug interactions** - Serotonin toxicity: tramadol (CI) - Adrenaline: may increase effect of adrenaline (caution) - Tapentadol: increase risks for HTN (CI) - **ADR [common]** - Orthostatic hypotension, headache, drowsiness, fatigue, weakness, agitation, tremors, twitching, myoclonus, hyperreflexia, dizziness, dry mouth *(CI) = Contraindicated* Myoclonus: sudden, brief, involuntary muscle jerks or twitches, often described as shock-like movements, that can affect a single muscle or a group of muscles. **SSRIs** - **MOA**: SSRIs selectively inhibit the presynaptic reuptake of serotonin - **Drug interactions** - Serotonin toxicity: tramadol - Citalopram, escitalopram, fluoxetine + QT prolongation - Fluoxetine, fluvoxamine + CYP3A4 inH - **ADR [common]** - Agitation, drowsiness, tremor, dry mouth, dizziness, headache, sweating, weakness, anxiety <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Citalopram</td> <td>Celapram</td> </tr> <tr> <td>Escitalopram</td> <td>Lexapro</td> </tr> <tr> <td>Fluoxetine</td> <td>Zactin</td> </tr> <tr> <td>Fluvoxamine</td> <td>Luvox</td> </tr> <tr> <td>Paroxetine</td> <td>Paxtine</td> </tr> <tr> <td>Sertraline</td> <td>Setrona</td> </tr> </tbody> </table> ### **SSRIs** - **MOA**: SSRIs selectively inhibit the presynaptic reuptake of serotonin , increasing its concentration in the synaptic cleft. - **Drug interactions** - Serotonin toxicity: tramadol - Citalopram, escitalopram, fluoxetine + QT prolongation - Fluoxetine, fluvoxamine + CYP3A4 inH - **ADR [common]** - Agitation, drowsiness, tremor, dry mouth, dizziness, headache, sweating, weakness, anxiety | Generic name | Brand Name | | :--- | :--- | | Citalopram | Celapram | | Escitalopram | Lexapro | | Fluoxetine | Zactin | | Fluvoxamine | Luvox | | Paroxetine | Paxtine | | Sertraline | Setrona | **Tricyclic antidepressants** - **MOA**: inhibit reuptake of noradrenaline and serotonin into presynaptic terminals - **Drug interactions** - QT prolongation drugs - CNS depressant drugs - Adrenaline: added sympathomimetic effects (caution) - Clomipramine, imipramine: serotonin toxicity - **ADR [common]** - Sedation, dry mouth, orthostatic hypotension, tremor, dizziness, sweating, agitation, anxiety, confusion <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Amitriptyline</td> <td>Endep</td> </tr> <tr> <td>Clomipramine</td> <td>Anafranil</td> </tr> <tr> <td>Dothiepin</td> <td>Dothep</td> </tr> <tr> <td>Doxepin</td> <td>Deptran</td> </tr> <tr> <td>Imipramine</td> <td>Tofranil</td> </tr> <tr> <td>Nortriptyline</td> <td>Allegron</td> </tr> </tbody> </table> ### **Tricyclic antidepressants** - **MOA**: inhibit reuptake of noradrenaline and serotonin into presynaptic terminals - **Drug interactions** - QT prolongation drugs - CNS depressant drugs - Adrenaline: added sympathomimetic effects (caution) - Clomipramine, imipramine: serotonin toxicity - **ADR [common]** - Sedation, dry mouth, orthostatic hypotension, tremor, dizziness, sweating, agitation, anxiety, confusion | Generic name | Brand Name | | :--- | :--- | | Amitriptyline | Endep | | Clomipramine | Anafranil | | Dothiepin | Dothep | | Doxepin | Deptran | | Imipramine | Tofranil | | Nortriptyline | Allegron | **SNRIs** - **MOA**: inH serotonin and noradrenalin reuptake - **Drug interactions** - Serotonin toxicity - Desvenlafaxine + CYP3A4 inH - **ADR** - **[common]**: dry mouth, yawning, sweating, dizziness, headache, tremor - **[infrequent]**: orthostatic hypotension and fainting <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Desvenlafaxine</td> <td>Pristiq</td> </tr> <tr> <td>Duloxetine</td> <td>Tixol</td> </tr> <tr> <td>Venlafaxine</td> <td>Efexor</td> </tr> </tbody> </table> ### **SNRIs** - **MOA**: inH serotonin and noradrenalin reuptake - **Drug interactions** - Serotonin toxicity - Desvenlafaxine + CYP3A4 inH - **ADR** - **[common]**: dry mouth, yawning, sweating, dizziness, headache, tremor - **[infrequent]**: orthostatic hypotension and fainting | Generic name | Brand Name | | :--- | :--- | | Desvenlafaxine | Pristiq | | Duloxetine | Tixol | | Venlafaxine | Efexor | <table border="1" class="dataframe"> <thead> <tr style="text-align: right;"> <th>Generic name (Brand)</th> <th>Selected drug interaction</th> <th>Selected ADR</th> </tr> </thead> <tbody> <tr> <td>Agomelatine (Valdoxan)</td> <td>Nil dental</td> <td><b>Infrequent (0.1–1%)</b>: Anxiety, fatigue, excessive sweating, itch</td> </tr> <tr> <td>Mianserin (Lumin)</td> <td>Nil dental</td> <td><b>Common (>1%)</b>: Sedation, dry mouth, dizziness, vertigo</td> </tr> <tr> <td>Mirtazepine (Axit)</td> <td>Maybe contribute to serotonin toxicity???</td> <td><b>Common (>1%)</b>: Sedation, weakness<br><b>Rare (<0.1%)</b>: Orthostatic hypotension, seizures</td> </tr> <tr> <td>Moclobemide (Amira)</td> <td>Serotonin toxicity (tramadol)</td> <td><b>Common (>1%)</b>: Dry mouth, anxiety, dizziness, headache</td> </tr> <tr> <td>Reboxetine (Edronax)</td> <td>CYP3A4 inH</td> <td><b>Common (>1%)</b>: Dry mouth, sweating, orthostatic hypotension, headache, paraesthesia, dizziness</td> </tr> <tr> <td>Vortioxetine (Brintellix)</td> <td>Maybe contribute to serotonin toxicity???</td> <td><b>Common (>1%)</b>: Dry mouth, itch</td> </tr> </tbody> </table> ### **Other Antidepressants** <table border="1" class="dataframe"> <thead> <tr style="text-align: right;"> <th>Generic name (Brand)</th> <th>Selected drug interaction</th> <th>Selected ADR</th> </tr> </thead> <tbody> <tr> <td>Agomelatine (Valdoxan)</td> <td>Nil dental</td> <td><b>Infrequent (0.1–1%)</b>: Anxiety, fatigue, excessive sweating, itch</td> </tr> <tr> <td>Mianserin (Lumin)</td> <td>Nil dental</td> <td><b>Common (>1%)</b>: Sedation, dry mouth, dizziness, vertigo</td> </tr> <tr> <td>Mirtazepine (Axit)</td> <td>Maybe contribute to serotonin toxicity???</td> <td><b>Common (>1%)</b>: Sedation, weakness<br><b>Rare (<0.1%)</b>: Orthostatic hypotension, seizures</td> </tr> <tr> <td>Moclobemide (Amira)</td> <td>Serotonin toxicity (tramadol)</td> <td><b>Common (>1%)</b>: Dry mouth, anxiety, dizziness, headache</td> </tr> <tr> <td>Reboxetine (Edronax)</td> <td>CYP3A4 inH</td> <td><b>Common (>1%)</b>: Dry mouth, sweating, orthostatic hypotension, headache, paraesthesia, dizziness</td> </tr> <tr> <td>Vortioxetine (Brintellix)</td> <td>Maybe contribute to serotonin toxicity???</td> <td><b>Common (>1%)</b>: Dry mouth, itch</td> </tr> </tbody> </table> **Antidepressant drugs** **Dental implications** - **Drug interactions** - **Adrenaline** + TCAs/MAOIs → Risk of **hypertensive crisis** - **Tramadol** + SSRIs/SNRIs/MAOIs → Risk of **serotonin toxicity** - **CYP3A4 inhibitors** (e.g. fluoxetine, fluvoxamine, desvenlafaxine) → Affects drug metabolism - **Adverse drug reactions (ADRs)** - **Dry mouth** → Increased caries, periodontal risk - **Drowsiness, dizziness, orthostatic hypotension** → Caution with chair positioning, longer procedures - **Tremors, anxiety, sweating** → May affect cooperation - **Patient factors** - Mental health status: **anxiety, depression, withdrawal** - Long-term therapy → **Compliance, oral hygiene challenges** - Monitor for **withdrawal symptoms** (esp. with short half-life drugs) ## **Antidepressants: Dental implications** - **Drug interactions** - **Adrenaline** + TCAs/MAOIs → Risk of **hypertensive crisis** - **Tramadol** + SSRIs/SNRIs/MAOIs → Risk of **serotonin toxicity** - **CYP3A4 inhibitors** (e.g. fluoxetine, fluvoxamine, desvenlafaxine) → Affects drug metabolism - **Adverse drug reactions (ADRs)** - **Dry mouth** → Increased caries, periodontal risk - **Drowsiness, dizziness, orthostatic hypotension** → Caution with chair positioning, longer procedures - **Tremors, anxiety, sweating** → May affect cooperation - **Patient factors** - Mental health status: **anxiety, depression, withdrawal** - Long-term therapy → **Compliance, oral hygiene challenges** - Monitor for **withdrawal symptoms** (esp. with short half-life drugs) **Antipsychotics** - **Indication**: acute & chronic psychosis, bipolar disorder - **MOA**: blockade of dopaminergic transmission? - **Drug interactions** - **CNS depressants**: check individual monograph - **QT prolongation**: Amisulpride, droperidol, haloperidol, ziprasidone - **CYP3A4 inH**: Aripiprazole, brexpiprazole, cariprazine, haloperidol, lurasidone, quetiapine, ziprasidone - **ADR [common]**: sedation, anxiety, agitation, EPSE, orthostatic hypotension, dry mouth - **EPSE**: dystonia, akathisia, parkinsonism, tardive dyskinesia **Antipsychotics** - Amisulpride - Aripiprazole - Asenapine - Brexpiprazole - Cariprazine - Chlorpromazine - Clozapine - Droperidol - Flupentixol - Haloperidol - Lurasidone - Olanzapine - Paliperidone - Periciazine - Quetiapine - Risperidone - Ziprasidone - Zuclopenthixol # **Antipsychotics** - **Indication**: acute & chronic psychosis, bipolar disorder > [!note] > These drugs are used to relieve distressing symptoms like hallucinations, delusions, and severely abnormal thoughts or behaviors. They also have sedative effects that are useful in agitated or aggressive patients. - **MOA**: blockade of dopaminergic transmission? - **Drug interactions** - **CNS depressants**: check individual monograph - **QT prolongation**: Amisulpride, droperidol, haloperidol, ziprasidone - **CYP3A4 inH**: Aripiprazole, brexpiprazole, cariprazine, haloperidol, lurasidone, quetiapine, ziprasidone - **ADR [common]**: sedation, anxiety, agitation, EPSE, orthostatic hypotension, dry mouth - **EPSE**: dystonia, akathisia, parkinsonism, tardive dyskinesia (abnormal muscle tone affecting facial muscles) ### **List of Antipsychotics** - Amisulpride - Aripiprazole - Asenapine - Brexpiprazole - Cariprazine - Chlorpromazine - Clozapine - Droperidol - Flupentixol - Haloperidol - Lurasidone - Olanzapine - Paliperidone - Periciazine - Quetiapine - Risperidone - Ziprasidone - Zuclopenthixol **Antipsychotic drugs** **Dental implications** - **Drug interactions** - QT prolongation risk, CYP3A4 inhibitors, CNS depression - **Adverse effects relevant to dentistry** - Dry mouth, orthostatic hypotension, sedation, dizziness, agitation, EPSEs - **Patient considerations** - Assess mental state, ability to consent, and cooperation level - Consider increased sensitivity to stress or invasive procedures - Evaluate the need for additional support, shorter appointments, or sedation alternatives ## **Antipsychotics: Dental implications** - **Drug interactions** - QT prolongation risk, CYP3A4 inhibitors, CNS depression - **Adverse effects relevant to dentistry** - Dry mouth - Peripheral edema (especially perioral) , orthostatic hypotension, sedation, dizziness, agitation, EPSEs - **Patient considerations** - Assess mental state, ability to consent, and cooperation level - Consider increased sensitivity to stress or invasive procedures - Evaluate the need for additional support, shorter appointments, or sedation alternatives # Drugs for bipolar disorder - **Pharmacological** - Antipsychotics, antiepileptics (carbamazepine, lamotrigine, valproate) – mentioned in antiepileptic lectures - Lithium (Lithicarb, Quilonum SR) - **Lithium**: [MOA] unknown? Inh dopamine release? Enhance serotonin release? - **Drug interactions** - Serotonin toxicity: tramadol - NSAIDs: reduce renal lithium excretion - **ADR [common]**: metallic taste, fatigue, headache, vertigo, tremor, acne, psoriasis # **Drugs for bipolar disorder** - **Pharmacological** - Antipsychotics, antiepileptics (carbamazepine, lamotrigine, valproate) – mentioned in antiepileptic lectures - Lithium (Lithicarb, Quilonum SR) - **Lithium**: [MOA] unknown? Inh dopamine release? Enhance serotonin release? - **Drug interactions** - Serotonin toxicity: tramadol - NSAIDs: reduce renal lithium excretion (low-dose aspirin is generally considered safe) - **ADR [common]**: metallic taste, fatigue, headache, vertigo, tremor, acne, psoriasis **Drugs for bipolar disorder** **Dental implications** - **Lithium interactions** - Avoid NSAIDs (except low-dose aspirin) → risk of lithium toxicity - Monitor for signs of toxicity if analgesics are prescribed - **Serotonin toxicity risk**: caution with tramadol - **Common side effects relevant to dentistry** - Metallic taste → altered taste perception - Tremor, fatigue → difficulty with fine motor control, cooperation during procedures - Dry skin or acne → consider skin sensitivity around oral cavity - **Communication and care** - Assess for sedation, mental alertness, and ability to consent - Schedule shorter or more frequent appointments if needed ## **Bipolar Disorder Drugs: Dental implications** - **Lithium interactions** - Avoid NSAIDs (except low-dose aspirin) → risk of lithium toxicity - Monitor for signs of toxicity if analgesics are prescribed - **Serotonin toxicity risk**: caution with tramadol - **Common side effects relevant to dentistry** - Metallic taste → altered taste perception - Tremor, fatigue → difficulty with fine motor control, cooperation during procedures - Dry skin or acne → consider skin sensitivity around oral cavity - **Communication and care** - Assess for sedation, mental alertness, and ability to consent - Schedule shorter or more frequent appointments if needed **Drugs for anxiety & sleep disorders** - **Non-pharmacological** - CBT first line: insomnia & anxiety - Remove source of sleep disturbance - Sleep hygiene principles - **Pharmacological** - Benzodiazepines - Non-amphetamine psychostimulants - Orexin receptor antagonists - Other: diphenhydramine, doxylamine, melatonin, zolpidem, zopiclone # **Drugs for anxiety & sleep disorders** - **Non-pharmacological** - CBT first line: insomnia & anxiety - Remove source of sleep disturbance - Sleep hygiene principles - **Pharmacological** - Benzodiazepines - Non-amphetamine psychostimulants - Orexin receptor antagonists - Other: diphenhydramine, doxylamine, melatonin, zolpidem, zopiclone **Benzodiazepines** - **MOA**: potentiate inhibitory effect of GABA - **Drug interactions** - Other CNS depressants: monitor sedation - Alprazolam: itraconazole, ketoconazole → enhance sedation & respiratory depression - Diazepam + fluconazole → increase adverse effect - Midazolam + [CYP3A4 inh] → enhance sedation & respiratory depression - **ADR**: drowsiness, oversedation, lightheadedness, hypersalivation, ataxia Ataxia refers to a loss of coordination and balance, resulting in clumsy or awkward movements, often affecting walking, speech, and fine motor skills. **Alprazolam** **Bromazepam** **Clobazam** **Clonazepam** **Diazepam** **Flunitrazepam** **Lorazepam, Lorazepam (neurology)** **Midazolam (anaesthesia), Midazolam (neurology)** **Nitrazepam** **Oxazepam** **Temazepam** ## **Drug Classes for Anxiety & Sleep Disorders** ### **Benzodiazepines** > [!warning] > Used for short-term relief due to the high risk of dependence. - **MOA**: potentiate inhibitory effect of GABA They target the GABA-A receptor complex, but require the presence of GABA to enhance its inhibitory action, increasing chloride ion influx and causing hyperpolarization. > [!warning] > Not suitable for long-term antiepileptic therapy due to the development of tolerance. - **Drug interactions** - Other CNS depressants: monitor sedation - Alprazolam: itraconazole, ketoconazole → enhance sedation & respiratory depression - Diazepam + fluconazole → increase adverse effect - Midazolam + [CYP3A4 inh] → enhance sedation & respiratory depression - **ADR**: drowsiness, oversedation, lightheadedness, hypersalivation, ataxia Ataxia refers to a loss of coordination and balance, resulting in clumsy or awkward movements, often affecting walking, speech, and fine motor skills. - Alprazolam - Bromazepam - Clobazam - Clonazepam - Diazepam - Flunitrazepam - Lorazepam, Lorazepam (neurology) - Midazolam (anaesthesia), Midazolam (neurology) - Nitrazepam - Oxazepam - Temazepam **Non-amphetamine psychostimulants** - **MOA**: unknown - **Drug interactions** - CYP3A4 inH - **ADR**: dry mouth, headache, anxiety, palpitations, nervousness, dizziness, hypertension <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Armodafinil</td> <td>Nuvigil</td> </tr> <tr> <td>Modafinil</td> <td>Modafin</td> </tr> </tbody> </table> ### **Non-amphetamine psychostimulants** - **MOA**: unknown - **Drug interactions** - CYP3A4 inH - **ADR**: dry mouth, headache, anxiety, palpitations, nervousness, dizziness, hypertension | Generic name | Brand Name | | :--- | :--- | | Armodafinil | Nuvigil | | Modafinil | Modafin | **Orexin receptor antagonists** - **Indication**: chronic insomnia - **MOA**: block the binding of wake-promoting orexin A and B neuropeptides - **Drug interactions** - CYP3A4 inH - **ADR**: headache <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Lemborexant</td> <td>Dayvigo</td> </tr> <tr> <td>Suvorexant</td> <td>Belsomra</td> </tr> </tbody> </table> ### **Orexin receptor antagonists** - **Indication**: chronic insomnia - **MOA**: block the binding of wake-promoting orexin A and B neuropeptides - **Drug interactions** - CYP3A4 inH - **ADR**: headache | Generic name | Brand Name | | :--- | :--- | | Lemborexant | Dayvigo | | Suvorexant | Belsomra | **Other** - **Drug interactions**: other CNS depressants - **Sedating antihistamines**: diphenhydramine, doxylamine - **ADR**: sedation, psychomotor impairment, dizziness, confusion, headache, dry mouth - **Melatonin**: control of circadian rhythms - **ADR**: nil dental - **GABA agonists**: zolpidem, zopiclone - **[Zopiclone] ADR**: taste disturbance (bitter), dry mouth, drowsiness, impaired alertness the next morning <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Melatonin</td> <td>Circadin</td> </tr> <tr> <td>Zolpidem</td> <td>Stilnox</td> </tr> <tr> <td>Zopiclone</td> <td>Imrest</td> </tr> </tbody> </table> ### **Other** - **Drug interactions**: other CNS depressants - **Sedating antihistamines**: diphenhydramine, doxylamine - **ADR**: sedation, psychomotor impairment, dizziness, confusion, headache, dry mouth - **Melatonin**: control of circadian rhythms - **ADR**: nil dental - **GABA agonists**: zolpidem, zopiclone - **[Zopiclone] ADR**: taste disturbance (bitter), dry mouth, drowsiness, impaired alertness the next morning Many of these drugs can cause a bad taste. | Generic name | Brand Name | | :--- | :--- | | Melatonin | Circadin | | Zolpidem | Stilnox | | Zopiclone | Imrest | **Drugs for anxiety & sleep disorder** **Dental implications** - **Sedation & CNS depression**: increased risk with benzodiazepines, antihistamines, GABA agonists - **Cognitive/psychomotor impairment**: affects alertness and safety, especially with sedating antihistamines - **Dry mouth**: common; raises risk of caries and mucosal issues - **Taste disturbance**: noted with zopiclone - **Headache & anxiety**: possible with orexin antagonists and psychostimulants - **Management**: schedule when alert, avoid CNS depressants, emphasize oral hygiene, clear aftercare instructions ## **Anxiety & Sleep Disorder Drugs: Dental implications** - **Sedation & CNS depression**: increased risk with benzodiazepines, antihistamines, GABA agonists - **Cognitive/psychomotor impairment**: affects alertness and safety, especially with sedating antihistamines - **Dry mouth**: common; raises risk of caries and mucosal issues - **Taste disturbance**: noted with zopiclone - **Headache & anxiety**: possible with orexin antagonists and psychostimulants - **Management**: schedule when alert, avoid CNS depressants, emphasize oral hygiene, clear aftercare instructions **Drugs attention deficit hyperactivity disorder** - **Chronic condition**: inattentive, hyperactive-impulsive, combination - **Pharmacological** - Drug choice: psychostimulants - Other: Atomoxetine, guanfacine or clonidine - **Lack of evidence** - Dietary replacement - Supplementation of selected vitamins - Biofeedback - Perceptual stimulation # **Drugs for attention deficit hyperactivity disorder (ADHD)** - **Chronic condition**: inattentive, hyperactive-impulsive, combination - **Pharmacological** - Drug choice: psychostimulants - Other: Atomoxetine, guanfacine or clonidine - **Lack of evidence** - Dietary replacement - Supplementation of selected vitamins - Biofeedback - Perceptual stimulation **Psychostimulants** - **MOA**: enhance dopaminergic and noradrenergic neurotransmission - **Drug interactions**: Nil dental - **ADR** - **[common]**: dry mouth, anxiety, irritability, headache, dizziness, aggression, palpitations - **[Infrequent]**: movement disorders, tics <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Dexamfetamine</td> <td>Dexamfetamine</td> </tr> <tr> <td>Lisdexamfetamine</td> <td>Vyvanse</td> </tr> <tr> <td>Methylphenidate</td> <td>Concerta</td> </tr> </tbody> </table> ## **Drug Classes for ADHD** ### **Psychostimulants** - **MOA**: enhance dopaminergic and noradrenergic neurotransmission - **Drug interactions**: Nil dental - **ADR** - **[common]**: dry mouth, anxiety, irritability, headache, dizziness, aggression, palpitations - **[Infrequent]**: movement disorders, tics | Generic name | Brand Name | | :--- | :--- | | Dexamfetamine | Dexamfetamine | | Lisdexamfetamine | Vyvanse | | Methylphenidate | Concerta | ### Other - **Atomoxetine**: selectively inhibits presynaptic noradrenaline reuptake - **Drug interactions**: nil dental - **ADR [common]**: dry mouth, dizziness, irritability, aggression, temper tantrums - **ADR [infrequent]**: palpitations, orthostatic hypotension - **Guanfacine**: selective alpha₂ₐ adrenoreceptor agonist - **Drug interactions**: CNS depressant, CYP3A4 inH - **ADR [common]**: drowsiness, dizziness, dry mouth, headache, hypotension, fatigue, sedation - **ADR [infrequent]**: fainting <table> <thead> <tr> <th>Generic name</th> <th>Brand Name</th> </tr> </thead> <tbody> <tr> <td>Atomoxetine</td> <td>Atomoxetine</td> </tr> <tr> <td>Guanfacine</td> <td>Intuniv</td> </tr> </tbody> </table> ### **Other** - **Atomoxetine**: selectively inhibits presynaptic noradrenaline reuptake - **Drug interactions**: nil dental - **ADR [common]**: dry mouth, dizziness, irritability, aggression, temper tantrums - **ADR [infrequent]**: palpitations, orthostatic hypotension - **Guanfacine**: selective alpha₂ₐ adrenoreceptor agonist - **Drug interactions**: CNS depressant, CYP3A4 inH - **ADR [common]**: drowsiness, dizziness, dry mouth, headache, hypotension, fatigue, sedation - **ADR [infrequent]**: fainting | Generic name | Brand Name | | :--- | :--- | | Atomoxetine | Atomoxetine | | Guanfacine | Intuniv | **Drugs for ADHD** **Dental implications** - **Psychostimulants (dexamfetamine, methylphenidate, lisdexamfetamine)** - ADR: dry mouth, anxiety, irritability, headache, palpitations, movement disorders (rare) - Drug interactions: none significant in dentistry - **Atomoxetine** - ADR: dry mouth, dizziness, irritability, aggression, temper tantrums, palpitations (rare) - Drug interactions: none significant in dentistry - **Guanfacine** - ADR: drowsiness, dry mouth, dizziness, hypotension, sedation, fainting (rare) - Drug interactions: CNS depressants, CYP3A4 inhibitors ## **ADHD Drugs: Dental implications** - **Psychostimulants (dexamfetamine, methylphenidate, lisdexamfetamine)** - ADR: dry mouth, anxiety, irritability, headache, palpitations, movement disorders (rare) - Drug interactions: none significant in dentistry - **Atomoxetine** - ADR: dry mouth, dizziness, irritability, aggression, temper tantrums, palpitations (rare) - Drug interactions: none significant in dentistry - **Guanfacine** - ADR: drowsiness, dry mouth, dizziness, hypotension, sedation, fainting (rare) - Drug interactions: CNS depressants, CYP3A4 inhibitors **Drugs for alcohol dependence** - **Alcohol withdrawal sx**: CNS depressants (benzodiazepines) - Symptomatic tx: analgesics, antiemetics, antipsychotics (severe agitation & hallucination) - **Long term tx for alcohol dependence** - Support ongoing abstinence from alcohol. - Decrease alcohol intake where abstinence is not achieved. - Minimise social, physical and psychological consequences. - **Drug choice** - **Acamprosate**: MOA unclear, nil ADR in dental - **Naltrexone**: [ADR] transient, subsides after 1-2wks, interact w/ opioids - **Disulfiram**: [ADR] drowsiness, headache, avoid metronidazole # **Drugs for Substance Dependence** ## **Alcohol Dependence** - **Alcohol withdrawal sx**: CNS depressants (benzodiazepines) - Symptomatic tx: analgesics, antiemetics, antipsychotics (severe agitation & hallucination) - **Long term tx for alcohol dependence** - Support ongoing abstinence from alcohol. - Decrease alcohol intake where abstinence is not achieved. - Minimise social, physical and psychological consequences. - **Drug choice** - **Acamprosate**: MOA unclear, nil ADR in dental - **Naltrexone**: [ADR] transient, subsides after 1-2wks, interact w/ opioids - **Disulfiram**: [ADR] drowsiness, headache, avoid metronidazole **Drugs for nicotine dependence** - **Nicotine**: CNS stimulant → feelings of pleasure, relief of anxiety etc - Smoking cessation: unpleasant withdrawals - **Non-drug treatment**: counselling, behavioural techniques, encouragement and support - **Drug choice** - **Bupropion**: MOA unclear, [ADR] dry mouth, dizziness, agitation, anxiety, tremor, headache - **NRT**: [ADR] dizziness, headache, burning-lip sensation (mouth spray), hiccups, cough (inhalation), vivid dreams (especially 24-hour patch) - **Varenicline**: [ADR] headache, taste disturbance, abnormal dreams, sleep disorder ## **Nicotine Dependence** - **Nicotine**: CNS stimulant → feelings of pleasure, relief of anxiety etc - Smoking cessation: unpleasant withdrawals - **Non-drug treatment**: counselling, behavioural techniques, encouragement and support - **Drug choice** - **Bupropion**: MOA unclear, [ADR] dry mouth, dizziness, agitation, anxiety, tremor, headache - **NRT**: [ADR] dizziness, headache, burning-lip sensation (mouth spray), hiccups, cough (inhalation), vivid dreams (especially 24-hour patch) - **Varenicline**: [ADR] headache, taste disturbance, abnormal dreams, sleep disorder **Drugs for opioid dependence** - Chronic, frequently relapsing illness - Opioids produce euphoric effects but tolerance develops rapidly - **Withdrawals symptoms**: extreme anxiety, restlessness, insomnia, nausea, unpleasant but not life threatening - **Drug choice** - **Buprenorphine**: [ADR] not dental related, interaction (opioids, ketoconazole) - **Methadone**: [interaction] QT prolongation - **Naltrexone**: already mentioned ## **Opioid Dependence** - Chronic, frequently relapsing illness - Opioids produce euphoric effects but tolerance develops rapidly - **Withdrawals symptoms**: extreme anxiety, restlessness, insomnia, nausea, unpleasant but not life threatening - **Drug choice** - **Buprenorphine**: [ADR] not dental related, interaction (opioids, ketoconazole) - **Methadone**: [interaction] QT prolongation - **Naltrexone**: already mentioned <table border="1" class="dataframe"> <thead> <tr style="text-align: right;"> <th>Substance of abuse</th> </tr> </thead> <tbody> <tr> <td><strong>Drug</strong></td> <td><strong>Dental implications</strong></td> </tr> <tr> <td>Cannabis</td> <td>• Poor oral and periodontal health<br>• Acute dose + LA w/ adrenaline may prolong tachycardia<br>• Chronic smokers: oral leucoplakia, oral cancer, oral candidiasis</td> </tr> <tr> <td>Methamphetamine</td> <td>• Poor OH, rampant caries<br>• Bruxism, clenching, non-carious tooth wear<br>• Xerostomia<br>• LA w/ vasoconstrictor avoid when patient is intoxicated</td> </tr> <tr> <td>Cocaine</td> <td>• Bruxism, clenching, non-carious tooth wear<br>• Gingival erosions, retraction, ulceration</td> </tr> <tr> <td>Opioids</td> <td>• Rampant caries, periodontitis<br>• Anxiety<br>• Injectables → risks blood borne viruses & infective endocarditis</td> </tr> </tbody> </table> ## **Dental Implications of Substance Abuse** <table border="1" class="dataframe"> <thead> <tr style="text-align: right;"> <th>Substance of abuse</th> <th>Dental implications</th> </tr> </thead> <tbody> <tr> <td>Cannabis</td> <td>• Poor oral and periodontal health<br>• Acute dose + LA w/ adrenaline may prolong tachycardia<br>• Chronic smokers: oral leucoplakia, oral cancer, oral candidiasis</td> </tr> <tr> <td>Methamphetamine</td> <td>• Poor OH, rampant caries<br>• Bruxism, clenching, non-carious tooth wear<br>• Xerostomia<br>• LA w/ vasoconstrictor avoid when patient is intoxicated</td> </tr> <tr> <td>Cocaine</td> <td>• Bruxism, clenching, non-carious tooth wear<br>• Gingival erosions, retraction, ulceration</td> </tr> <tr> <td>Opioids</td> <td>• Rampant caries, periodontitis<br>• Anxiety<br>• Injectables → risks blood borne viruses & infective endocarditis</td> </tr> </tbody> </table> > [!info] Note on Moclobemide > Moclobemide (a reversible MAOI) can interact with sympathomimetic agents like adrenaline. **Drugs for dependence Dental implications** - Poor diet & oral hygiene worsen oral health - Smoking increases risk of oral cancer - Watch for “doctor shoppers” requesting analgesics/anxiolytics - Know drug preferences & risks; refuse supply if unsure - Multiple drug use common: cannabis, methamphetamine, cocaine, opioids - Coordinate care with other healthcare providers for safe management ## **General Dental Implications for Dependence** - Poor diet & oral hygiene worsen oral health - Smoking increases risk of oral cancer - Watch for “doctor shoppers” requesting analgesics/anxiolytics Be suspicious of patients who seem overly knowledgeable about specific drugs or brands. It is acceptable to refuse to prescribe when in doubt. - Know drug preferences & risks; refuse supply if unsure - Multiple drug use common: cannabis, methamphetamine, cocaine, opioids - Coordinate care with other healthcare providers for safe management **CASE 1: major depression** **Scenario:** 45-year-old female on **sertraline (SSRI)** for major depression presents for routine dental extraction. She complains of dry mouth and occasional dizziness # **Case Studies: Psychotropics** ## **Case 1: Major Depression** **Scenario:** 45-year-old female on **sertraline (SSRI)** for major depression presents for routine dental extraction. She complains of dry mouth and occasional dizziness **Management:** - SSRIs commonly cause dry mouth and initial dizziness. Watch for **serotonin toxicity** if considering **tramadol**. If the patient is non-compliant with her medication, advise her to see her GP. **Case 2: Schizophrenia** Scenario: 32-year-old male on **haloperidol** for schizophrenia complains of dry mouth and tremors; requires scaling and root planning ## **Case 2: Schizophrenia** **Scenario:** 32-year-old male on **haloperidol** for schizophrenia complains of dry mouth and tremors; requires scaling and root planning **Management:** - Haloperidol can cause dry mouth, sedation, orthostatic hypotension, and **extrapyramidal side effects (EPS)** like tremor, which can impair oral hygiene. Monitor for **QT prolongation** and be cautious with **CYP3A4 inhibitors**. **Case 3: bipolar disorder** Scenario: 40-year-old male on lithium therapy presents for dental implant surgery. He reports metallic taste and mild tremor ## **Case 3: Bipolar Disorder** **Scenario:** 40-year-old male on lithium therapy presents for dental implant surgery. He reports metallic taste and mild tremor **Management:** - Metallic taste and tremor are common with lithium. **NSAIDs must be used with extreme caution** as they can increase lithium levels and cause toxicity. **Case 4: anxiety & sleep disorders** Scenario: 28-year-old female on diazepam for short term relief of anxiety requests extraction due to painful tooth ## **Case 4: Anxiety & Sleep Disorders** **Scenario:** 28-year-old female on diazepam for short term relief of anxiety requests extraction due to painful tooth **Management:** - Diazepam causes sedation and dizziness. It can also cause dry mouth or hypersalivation (drooling), which can interfere with restorative work. Avoid co-administration with other CNS depressants. **Case 5: ADHD** **Scenario:** 15-year-old male treated with methylphenidate for ADHD has dental caries and complains of dry mouth ## **Case 5: ADHD** **Scenario:** 15-year-old male treated with methylphenidate for ADHD has dental caries and complains of dry mouth **Management:** - Psychostimulants commonly cause dry mouth, increasing caries risk. There are no major drug interactions of concern for dentists. Management involves meticulous oral hygiene education, regular recalls, and fluoride treatments. **Case 6: substance dependence treatment** Scenario: 38-year-old male in methadone maintenance therapy for opioid dependence complains of rampant caries and poor oral health ## **Case 6: Substance Dependence Treatment** **Scenario:** 38-year-old male in methadone maintenance therapy for opioid dependence complains of rampant caries and poor oral health **Management:** - Patients on methadone often have high rates of caries and periodontal disease. For pain management, **avoid prescribing opioids** to prevent relapse; use non-opioid analgesics instead. Be cautious with other CNS depressants and drugs that **prolong the QT interval**. References - Ritter JM, Flower RJ, Henderson G, Loke YK, MacEwan D, Robinson E, editors. *Rang & Dale’s pharmacology*. 10th ed. Edinburgh: Elsevier; 2023 - Australian Medicines Handbook Online [Internet]. Adelaide (AU): Australian Medicines Handbook Pty Ltd; 2000. Psychotropics; [updated 2025; cited 2025]. Available from: UWA Onesearch - Pharmaceutical Society of Australia. *Australian Pharmaceutical Formulary and Handbook: A Guide to Best Practice*. 25th ed. Canberra: Pharmaceutical Society of Australia; 2021 - Ali K. *Clinical dental pharmacology*. 1st ed. Oxford: Wiley-Blackwell; 2023 - Bullock S, Manias E. *Fundamentals of pharmacology*. 8th ed. Frenchs Forest, NSW: Pearson Australia; 2017 - MIMS Australia. *eMIMSelite: Consumer medicine information, specific clinical monograph* [Internet]. Sydney: MIMS Australia; [updated 2025; cited 2025 Apr 17]. Available from: UWA Onesearch Illustrations of a person with medication bottles and pills, depicting themes of medicine and health. # **References** - Ritter JM, Flower RJ, Henderson G, Loke YK, MacEwan D, Robinson E, editors. *Rang & Dale’s pharmacology*. 10th ed. Edinburgh: Elsevier; 2023 - Australian Medicines Handbook Online [Internet]. Adelaide (AU): Australian Medicines Handbook Pty Ltd; 2000. Psychotropics; [updated 2025; cited 2025]. Available from: UWA Onesearch - Pharmaceutical Society of Australia. *Australian Pharmaceutical Formulary and Handbook: A Guide to Best Practice*. 25th ed. Canberra: Pharmaceutical Society of Australia; 2021 - Ali K. *Clinical dental pharmacology*. 1st ed. Oxford: Wiley-Blackwell; 2023 - Bullock S, Manias E. *Fundamentals of pharmacology*. 8th ed. Frenchs Forest, NSW: Pearson Australia; 2017 - MIMS Australia. *eMIMSelite: Consumer medicine information, specific clinical monograph* [Internet]. Sydney: MIMS Australia; [updated 2025; cited 2025 Apr 17]. 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