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2011-04-10 13:59:53
chapter eighteen

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