blood volume pumped per minute (RV, LV).
How to calculate cardiac output?
stroke volume (blood pumped per ventricle per contraction) x heart rate
volume of blood returned to the heart before it contracts (veins)
peripheral vascular resistance to blood flow into body
sustained elevation in arterial blood pressure.
50+ million Americans.
Age 55+ have 90% lifetime risk of developing.
Primary: unknown cause. Secondary: physical cause. Malignant: Highly elevated BP-bc of tumors-rare.
Signs and Symptoms
Renal: retains Na+ and water. RAAS: vasoconstriction, retain Na+ and water. Sympathetic CNS: Vasoconstriction (alpha, beta 2).
Sedentary lifestyle, drugs, diseases.
mild to moderate often asymptomatic, complications occur with persisting HTN (stroke).
Hypertension Stage 1
Hypertension Stage 2
Initial Drug choices:
Initial drug therapy for healthy patients: Phase one: Thiazide-type diuretic. Phase 2: 2-drug combo.
Initial drug therapy for unhealthy patients: Other antihypertensive drugs.
Thiazides (Hydrochlorothiazide), Loop (Furosemide/Lasix), K+ sparing (Dyrenium, Aldactone, Dyazide).
1st line and DOC in uncomplicated stage 1 HTN.
MOA: inhibit resorption of Na, Cl, and water, decreases peripheral resistance.
Hypokalemia (limit LA epi dose), Hyperuricema (gout hx), Xerostomia,.
NSAIDs long term use decreases effect of diuretics.
Most commonly 1st line drug for mild hypertension?
Thiazides: Hydochlorothiazide (HCTZ)
Beta receptors: B1 increases heart rate, contractility, B2 increases skeletal muscle vasodialation and bronchodialation. Propranolol (nonselective), Metroprolol and atenolol (B1 selective).
Stage 1 and 2 HTN.
Decreases heart rate and CO=decreases bp, decreases renin=decrease plasma volume and venous return, decrease peripheral resistance.
bradychardia and lethargy, xerostomia.
increased vasopressor response to epi, decreased effect if used with NSAIDs.
Hypertension Calcium Channel Blockers
Diphenylalkylamines (verapamil), Benzothiazepines (Diltiazem), Dihydopyridines (Difedipine, amalodipine).
Stage 1 and 2 HTN.
Block channels inhibiting extracellular Ca++movement into cardiac and vascular smooth muscle cells.
Orthostatic hypotension, Headache, Gingival enlargement (Nifedipine>diltiazem and verapamil)
Hypertension ACEI\'s and ARB\'s
ACEI\'s: Lisinopril (ace inhibitor=stage 2)
ARB\'s: Valsartan (Diovan) & Losartan (Cozaar).
Stage 1 and 2 HTN.
Hypertension ACEI\'s and ARB\'s
Hypotension, ACEI dry cough (10%), Altered taste, ARB\'s have fewer AE\'s (dysgeusia).
NSAID\'s long term use decreases effect.
Hypertension Key Dental AE
Xerostomia (B-blockers), Dysgeusia \"altered taste\" (Alpha 2 receptor blockers), Gingival Enlargement (CCBs), Orthostatic hypotension (CCBs), Constipation (CCBs with opiods), Sedation (B-blockers with opoids and benzoiazepines)
Coagulation Screening Test
PT test: Prothrombin time. INR/PT: standardized test providing compairable results for patients on warfarin therapy. INR=1 for healthy adults. Goal to decrease prothrombin activity to 25% of bi. INR goal of 3 with range of 2.5 to 3.5 for high intensity warfarin therapy.
Warfarin (Coumadin and Jantoven)
Prophylaxis and tx of thrombeoembolic disorders:DVT and PE, prevent thromboembolic complications: AF and cardiac valve replacement. Reduce embolic risk: Post MI and stroke. Prevention of recurrent TAI\'s (off label).
Produces inactive clotting factors: blocks regeneration of active vitamin K.
high plasma protein binding, metabolism CYP450, onset of action 24-72 hrs.
major or fatal bleeding.
CV Dental Considerations
\"Absolute\" contraindications: recent actue MI, unstable or recent onset of angina, symptomatic HF or arrhythmias, significantly elevated or uncontrolled HTN. Majority of patients with controlled CV disease can receive dental treatment-monitor BP and pulse & INR.
LA with vasoconstrictors for CV patients...
may be administered, but with severe CV disease limit epi to 0.04 mg (two cartridges of 1:100,000 epi)
More Dental Considerations for CV patients..
Common AE\'s: orthostatic hypotension & xerostomia. Angina patients should have nitroglycerin available. Know INR of warfarin patients. Low dose Aspirin does not cause excessive bleeding during dental procedures. Also, don\'t take stent patients off of aspirin!
Chronic Respiratory diseases
Asthma, Chronic obstructive pulmonary disease (COPD): chronic bronchitis & emphysema; 10% of the population. Seasonal allergy and allergic rhinitis.
Asthma 2 kinds
Intermittent (few episodes) & Persistent (mild, moderate, and severe).
Asthma Reversible airway obstruction
Allergen or stress exposure: release of histamine, PG\'s, and leukotrienes. Inflammation and increases secretions. Bronchoconstriction. Decreased Expiratory flow.
wheezing, dyspnea, and breathing difficulty (SOB).
Asthma Drugs: B-antagonist
Abuterol (Proventil), Salmeterol (Serevent).
Stimulate Beta2 receptors: bronchodialation.
Nervousness; irregular heartbeat.
Xerostomia, increases HR.
Asthma Drugs: Steroids
decreases inflammation; best to increase lung function.
Candidiasis*, taste, xerostomia.
Asthma Drugs: Steroids & LABA
Bronchodialation and decreased inflammation.
Candidiasis*, taste, xerostomia.
Asthma Drugs: Leukotriene Antagonists (LTRA)
Block LTs-decreases inflammation, bronchodialation.
Asthma Drugs: Methylxanthine
Inhibit mast cell release of histamine and SRS-A Sm muscle relaxant and Bronchodialator.
Nervousness, insomnia, GI.
Erthromycin increases levels.
Asthma Drugs: Mast cell degranulation inhibitor-prophylaxis of asthma.
stabalize mast cells prevent histamine release by IgE mast cell interaction.
Nausea, headache, cough.
Burning mouth, poor taste.
Asthma Drugs: Recombinant monoclonal antibody-Ashtma due to allergens
Prevent IgE from binding to mast cells and basophils or SQ injection q 2-4 weeks.
Injection site irritation, risk of anaphylaxis.
Asthma Drug Management
goal to treat inflammation and airway constriction. step-wise management approach
Asthma Dental Considerations
discuss frequency of symptoms and control with patients. reduce stress during treatment. inhaler available (albuterol), Avoid ASA and NSAIDs, monitor for candidiasis, use nitrous oxide with caution, avoid erythromycin with theophylline.
Chronic bronchitis: chronic inflammation & septum production, emphysema: alveolar destruction.
chronic irreversible airway obstruction: bronchospasm, compromised ventilation
risk factors: smoking.
Step-wise management of COPD
smoking cessation, 1st step SABA, 2nd step LABA, Anticholinergics: inhalation (Atrovent, Combivent, Spirvia).
Allergic rxns, Anti-emetic, Motion sickness & vertigo, Pre-op sedation (hydroxyzine & promethazine), OTC sleep aids.
H1 Histamine Receptors
H2 Histamine Receptors
H1: (smooth muscle) vasodialation: increase capillary permeability, bronchoconstriction, itching, edema, erythema.
H2: (gastric acid secretion, cardiac stimulation and vasodialation) increases gastric acid secretion, small vessel relaxation and increase permeability, direct chrono- and ino-tropic effect.
Antihistamine Drugs: Ethanolamines
Sedation, Anti-cholinergic, and Anti-emetic* (only one).
Ethanolamines (Benedryl), Alkylamines (Chlor Trimeton), Piperazine (Vistaril)
Loratidine (Claritan), Fexofenadine (Allegra), Cetirizine (Zyrtec)
Peptic Ulcer Disease (PUD), Gastroesophageal reflux disease (GERD), Diarrhea, Emesis, Chronic inflammatory bowl disease (IBD)
PUD and GERD Drugs: Antacids
Neutralize acids, dyspepsia, acute relief.
PUD and GERD Drugs
Acid reducer H2 blocker (Cimetidine), Acid reducer proton pump inhibitor (PPI), Prostaglandin (Misoprostal, Cytotec), Protective barrier (Sulfcralfate, Carfate), Prokinetic (Metoclopramide, Regalen). All pretty much reduce acids, increase gastric mucosa, and binds to ulcer.
Peptic Ulcer Disease
circumscribed GI mucosal loss/break extending into smooth muscle- esophagus, stomach, and duodenum.
E: H. pylori enzyme release, excessive acid production, risk factors, NSAIDs, steroids, alcohol, smoking, genetics.
eradicate H. pylori & lower acid production.
PUD Drug Therapy
Combination therapy for PUD
Clarithmycin+metronidazole or amoxicillin+ PPI.
Bismuth+metronidazole_tetracycline+PPI or H2 antagonist.
H2 receptor antagonist.
higher potential incidence of AE's and D-DI's. compliance issues.
reflux of gastric contents into esophagus.
Heartburn, Dysphagia, Tooth erosion.
Smoking, NSAIDs, and sphincter tone (H. pylori does not increase rise).
GERD Therapy Goals
decrease acid production, increase stomach-esophageal sphincter tone.
Lifestyle changes, Antacids (for acute relief), H2 receptor antagonists, Proton pump inhibitors (DOCs for frequent or more severe symptoms), GI stimulants (metclopromide-Reglan) increases sphincter tone, H pylori does not increase GERD risk or reflux esophagitis.
Kaolin & pectin (Kaopectate) - absorbant, Diphenoxylate with atropine (Lomotil) and Ioperamide (Imodium)- decrease GI smooth muscle peristalsis.
Phenothiazines: Promethazine (Phenergan), Prochlorperazine (Compazine), Anticholinergics: Dimenhydrinate (Dramamine), Meclizine (Bonine).
Chronic Inflammatory Bowel Disease
Etiology is multifactorial.
Ulcerative colitis: Autoimmune response, involves primarily mucosa, Distal colon and rectum.
Crohn's Disease: involves all of the intestine walls, colon most commonly affected.
Laxatives, Nonaspirins (Sulfasalazine:Azulfidine), Diphenoxylate w/ atropine (Lomotil) and Ioperamide (Imodium), Prednisone, Immune modifiers: Cyclosporin, Antibiotics: Metronidazole (Flagyl).
Dental Considerations for GI Diseases
Avoid NSAIDs and ASA. Supine position may exacerbate GERD symptoms. Monitor for xerostomia (avoid alcohol containing mouth rinses).
Psychosis: Schizophrenia. Affective Disorders: unipolar (depression), bipolar ( depression with mania). Neurosis anxiety disorders: Gerneralized anxiety disorder, Panic disorder, Phobias, Posttraumatic stress disorder, OCD. Sleep induction.
Prevalence of mental disorders.
Schizophrenia affects 0.5-1% of the population. Major depressive episodes during lifetime= 10-25% of women, 5-12% of men. Episodic and often progressive. DSM-IV criteria: diagnostic and statistical manual of mental disorders.
P: Hallucinations, paranoia, delusions and agitation (increase in dopamine production).
N: Flat affect, uninvolved and withdrawn (decrease in dopamine production).
T: older conventional drugs. treat positive symptoms. Anti-emetic effect (nausea).
A: newer, 1st line drugs, treat positive and negative symptoms of schizophrenia, fewer AE.
Antipsychotic Drug Actions
Histamine blockage (H1)=sedation, anxiolysis, xerostomia, weight gain, drowsiness, hypotension.
Muscarinic= increase anticholinergic effects, xerostomia, constipation, blurred vision, urinary retention, increased HR.
A2 adrenergic= increases 5-HT and norepi. postural hypotension, dizziness, relax tachy.
Dopamine= decrease positive symptoms. xerostomia, extrapyramidal, sexual dysfunction.
5-HT and norepi reuptake= decrease negative or depression. xerostomia, extrapyramidal, sexual dysfunction.
(all interfers with receptors and neurotransmitters)
Typical Antipsychotic Drugs
Thorazine. low potency. high sedation.
Novane. medium potency. high extra-pyramidal. orthostatic hypotension.
Haldol. high potency. high extra-pyramidal.
*all are dopamine receptor antagonists. block dopamine activity by binding to D1-5.
Atypical Antipsychotic Drugs
Xyprexa. High D2 affinity. High anti-cholinergic.
Seroquel. Positive and Negative. High sedation.
*antagonists at multiple receptors (dopamine, serotonin, and norepinephrine). more metabolic effects (weight gain, hypoglycemia..)
Antipsychotic Drugs Drug Interactions
complex liver metabolism (CYP450 system). potential CNS depressant.
Antipsychotic drugs Dental/Misc.
Epi may be used (consider limit to 2 carpules). Orthostatic hyptension, xerostomia, additive sedation with anxiolytics and opiods, caution with verbal patient interactions. TMJ pain.
Major depression: symptoms include depressed mood, sleep changes, weight gain, poor concentration, and fatigue. Symptoms present for more than 2 or 5 weeks. DMS-IV criteria.
Antidepressant Drugs: Drug classes
Monoamine oxidase inhibitors (MAOI), Tricyclic antidepressants (TCA), Selective serotonin reuptake inhibitors (SSRI), Dopamine/serotonin-norepinephrine reuptake inhibitors, serotonin modulators.
*Black box warning: suicide in young people.
Antidepressant Drugs: MAOIs
Parnate. AE: increased sedation & orthostatic hypotension.
Nonselective irreversible inhibition of MAO (increased norepi activity).
use has decreased due to AE's and new drugs. avoid sympathomimetics and tyrosine in diet. no contraindications with eip.
Antidepressant Drugs: Tricyclics
Elavil. AE: increased sedation, anti-cholinergic, orthostatic hypotension.
inhibit reuptake of norepi and or serotonin at neural synapses (keeps neurotransmitters firing). use alone or with atypical antipsychotics.
Liver metabolism, CNS depressants, anticholinergics, potentiate sympathomimetics, extensive plasma protein binding.
La use with vasoconstrictor (2 carpules & avoid levonordefrin). Xerostomia. Orthostatic hypotension. Cardiac toxicity due to anticholinergics. Declined use: OD risk and AE effects.
Antidepressant Drugs: SSRIs
Zoloft. no AE's.
Lexapro. no Ae's.
Generic Porzac. only AE: anti-cholinergic.
inhibit presynaptic reuptake of 5-HT (serotonin).
nausea, diarrhea, headache, and nervousness=early onset. sexual dysfunction & weight gain=late onset.
numerous potential interactions, serotonin syndrome=severe hypertension, confusion, CV collapse.
Indications also include OCD, panic disorders, anxiety, and PSTD. Induce bruxism. No effect on LA with epi. Taste changes and glossitis. Xerostomia less likeley. increased bleeding risk with NSAIDs and warfarin.
Antidepressant Drugs: Dopamine-Norepi Reuptake Inhibitors
Wellbutrin, Zyban. Depression and smoking cessation.
Nausea and agitation. Seizures.
Limit LA with epi. Taste disturbances.
Antidepressant Drugs: Serotonin Modulators
Desyrel. Increased sedation and orthostatic hyptension.
Irregular course of mania and depression.
Euphoria, grandiosity, restlessness, demanding, hallucinations, delusions and "flight of ideas".
Insomnia, impaired thinking, and dysphoria.
1.5% lifetime prevalence. recurrence rates of >50%. 60% abuse illicit drugs 10-15% commit suicide.
genetic contribution. neurotransmitter abnormalities (decreased inhibitory GABA, increased norepi and dopamine). Combination drug therapies common.
Acute: mood stabilizers for mania, antipsychotic, bensodiazepine. Maintenance: mood stabilizer, antidepressant.
Bipolar Disorder Drug Therapy
Mild to Moderate:
monotherapy (mood stabilizers): Lithium!
Combo therapy: 1st line lithium or Depakote, Atypical antipsychotics (xyprexa or Buprpion), Carbamazepine (Equestro), or Benzodiazepine.
Lithium or lamotrigine, lithium +antidepressant, no response add SSRI.
Lithium, Valproate or Depakote, Zyprexa, Lamictal, Equestro.
Bipolar Drugs: Lithium
Changes neuron function by unknown mechanisms. Low TI* monitor plasma levels!
Renal excretion, no liver metabolism.
Tremor and nausea.
Bipolar Drugs: Lithium
NSAIDs increase plasma levels. Metronidazole increases plasma levels.
Xerostomia, Stomatitis, Lichenoid rxns, Orthostatic hypotension.
15% of US adults use annually.
anxiety disorders, skeletal muscle relaxation, epileptic seizures, alcohol withdrawal, dentistry (conscious sedation)
facilitate GABA inhibitory neurotransmitter.
typically lipid soluable, highly protein bound and unioned, metabolism phase 1:active metabolites phase 2:lack of drug interactions or affect from liver disease, wide TI.
CNS depression, CV effects-minimal, Respiratory depression, Anterograde amnesia, paradoxiacal reactions.
Valium, Xanax, Ativan, Serax, Halcion, Versed.
Overdose treated with reversal drug * = Flumazenil (Romazican). Avoid in pregnancy and nursing.
Barbiturates, Choral hydrate (Noctec), Zolpidem (Ambien)
Sedative Hypnotics: Barbiturates
Brevital. IV*. Immediate onset.
Seconal. PO, IM, IV. 10-15 min onset.
Amytal. PO, IM, IV. 40-60 min onset.*
PO, IM, IV. 30-60 min onset. lasts 10-16 hrs. *
Sedative Hypnotics: Barbiturates
Multiple drug interactions:
Physical and psychological dependence. Tolerance.
Sedation; AM hangover. Nausea, vomiting, diarrhea.
Induce liver enzymes (doxycycline). Highly albumin protein bound. Additive with CNS depressants.
Contraindicated with hx of porphyria
Sedative Hypnotics: Chloral Hydrate (Noctec)
short-term sedation: preop sedation of children onset .5 hrs and duration 4 hours.
AE: mucosal and gi irritation.
Sedative Hypnotics: Zolpidem (Ambien)
Acts at GABA receptor at benzodiazepine BZ receptor.
Xerostomia & Pharyngitis*
Neurodevelopmental disorder; pattern of inattention, restlessness, and impulsivity.
4-9% of US children-persistent into adulthood in 45-60% of the cases. increased diagnosis in adults (4-5%). 50% of adults have concurrent psychiatric disorder.
Adderall: for narcolepsy. increases HR, BP, xerostomia, and taste loss. limit LA w epi.
Stattera: suicide ideation*
Wellbutrin: for antidepressant, smoking cessation.
Norpramin, Tofranil: antidepressant. orthostatic hypotension, xerostomia.
Ritalin, Concerta: for narcolepsy.
** all increase heart rate, so limit LA epi! Xerostomia.
release and blocking reuptake of dopamine and norepinephrine at presynaptic neurons.
Dental: AM appointments, smoking, caries risk, taste loss with amphetamines, monitor CV vital signs and limit epi.
CNS disorder affecting 0.5-1% of the population.
abnormal, excessive synchronous CNS neuron discharges. involuntary convulsions and muscle contractions.
Hypoxia, birth injury, infection, fever, and genetics.
Epilepsy Classification of Seizures
P: consciousness may be impaired.
G: loss of consciousness, absence (petit mal), tonic-clonic (grand mal):most common.
U:Status epilepticus, medical emergency.
Seizure disorders, Neurologic pain and migraine headaches.
AE: narrow TI, CNS depressants, GI distress.
Anticonvulsants: Phenytoin (Dilantin)
1st line grand mal and partial.
Narrow TI, gingival enlargment.
Monitor for AE's: xerostomia, orthostatic hypotension. LA w/ epi may be used.
Prescribe NSAIDs or opoids with caution. Monitor phenytoin patients for gingival enlargment & reinforce oral hygiene.