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An interdisciplinary approach to the dental care of the mentally disabled
CLINICAL
REPO RTS
An interdisciplinary approach to the dental care of the mentally disabled Gary L. Ellenor, P h a rm D Steve Zimmerman, R P h John Kriz, D D S , N a m p a , Id a h o
In institutions fo r mentally disabled persons, dental care of the patient is often difficult because of uncooperative behavior. Premedication is sometimes necessary. The mentally disabled patient frequently receives other medication fo r behavioral control, cerebral palsy, seizures, or the like, that may interact with the dental premedication. Because of the problems that may develop, a program between an institution’s dental department and a university’s clinical pharmacy department was developed that provided an approach to the selection of premedication fo r the dental patient who is mentally disabled.
P
A roblems in providing dental care to mentally disabled persons have led to a valuable interprofes sional approach in the care of these patients. To provide proper and adequate dental care, the dentist must be able to manage the un cooperative behavior and body movements typical of severely and profoundly retarded persons. With out such control, there are major in terruptions and the dentist cannot examine or treat the patient com pletely; thus, the therapy may be compromised. For example, dental
procedures such as examination of the mouth with the use of a tongue blade often stimulates and arouses the patient. With the additional use of aspiration instruments, ultrasonic scaler, and the like, a new level of arousal of the mentally disabled pa tient is created. As other methods of management of behavior have proven partially ineffective (for instance, physical restraint), one solution to these problems is the use of premedica tions. The goal is for the dental pro cedure to be less traumatic to the patient and allow uncompromised treatment. Through an interprofes sional approach to the dental care of mentally disabled patients, we de signed and implemented a program that facilitated optimal dental care of these patients. The program was developed through a joint effort of the Idaho State University College of Phar macy, Clinical Pharmacy Program and the Idaho State School and Hospital dental department. The Idaho State School and Hospital has approximately 475 mentally dis abled persons and provides 24-hour residential, medical, and treatment programs. Of these persons, approx imately 80% are severely or pro foundly retarded, approximately 25% have cerebral palsy, and ap proximately 60% are epileptic. The dentist provides services to the Idaho State School and Hospital on a consulting basis, including regular recall, restorative care, and emergency services. In addition, a
full-time dental assistant is employed in the dental clinic. The pharmacy staff consists of an assis tant professor of clinical pharmacy and ten to 20 senior (fifth year) pharmacy students from Idaho State University. This is one of several programs in which students are in volved during their clinical train ing. A pharmacy resident with the Idaho State School and Hospital also participates in the program. For routine dentistry, such as prophylaxis and examinations, it is not considered economical or safe to place patients under general anesthesia; thus, premedication is desirable. As dentists are generally unfamiliar with treating mentally disabled persons, the pharmacist was consulted about the use of premedications. As many of these patients are re ceiving other medications, such as antipsychotic and anticonvulsant agents, problems of interactions be tween drugs must be considered. It is, therefore, important to com pletely review each patient’s drug history. As many patients have other medical problems (such as epilepsy and cerebral palsy) consid eration must also be given to in teractions between the drug and the disease.
Method The dentist begins the procedure by recording pertinent information on the “Dental Clinic— Clinical Phar macy” form (Fig 1,2). Defined den tal problems usually consist of beJADA, Vol. 97, September 1978 ■ 491
CLINICAL
REPO R TS
Fig 1 ■ Page 1 of evaluation form. DE N T A L CLINIC - C L I N I C A L P H A R M A C Y
Patient : Present Medications: ff Drug
_Age
Location:
Sex:
Dose 6 Schedule
Student:^ Date :___ Ht:
Define Problems: I A*. Der Dental
A
W t:
B
II-" Other
F r
B V r
ii._
u
m ._
IV.
^.ergies 6 Sensitivities: "V^ # uggested Pre-dental Medications: Sug Dose, route of Drug administration, #of repeats 8 frequency
Reason for selection of this medication (use references when possible)
1)
D O
3)
Fig 2 ■ Page 2 of evaluation form.
Pharmacists's Comments : Fhysician's Comments: Dentist's Comments:
ft
Effectiveness of Pre-Meds (Rate 0 to U): "Observations 5 Description of Effect of Mecication(s):
D Possible Reason(s) for Success or Failure:
CLIN ICAL
havioral problems (uncooperative, combative, and the like) or other problems, such as excessive tongue movements or excessive drooling. The form is then sent to the pharmacist (students or resident), who compiles a medical history that includes age, sex, weight, height, living area, and diagnosis or perti nent medical problems (Fig IB). The current medical status of the patient is reviewed, including med ical problems, laboratory data, and functioning of the vital organs. The pharmacist evaluates the patient’s drug history, including current drug therapy, dosage and schedule, sensitivities, allergies, and other adverse reactions to drugs (Fig 1C). This information is then evaluated, the literature is researched regard ing potential drug-related problems, and premedication is recommended to manage the patient’s problems. The proprietary name of the drug, dosage, route of administration, number of times dosage may be re peated, and frequency or interval between repeated doses are re corded. In addition, the reason for the selection of the medication is given, and references to the litera ture are cited (Fig ID). The forms completed by pharmacy students are evaluated by their instructor who enters his comments on the form (Fig 2A). The form is returned to the den tist who adds his notes (Fig 2B) and who may submit the form to a physician for the physician’s analysis and comments (Fig 2C). The dentist then writes the medica tion orders on the patient’s ward chart. Pharmacy students, when avail able, assist the dentist in treating the patient and record their observa tions on the effects of the drug. The students also enter the possible rea sons for the success or failure of the drug therapy (Fig 2D). At the com pletion of the dental visit, the den tist rates the effectiveness of the medication on a clinical scale of 0 to + 4 (Fig 2E), and adverse reac tions to the drug are noted. The pa tient is observed periodically for the appearance of possible reactions to
the drug for the next 24 hours by the pharmacist or student. If ad verse reactions occur, the pharma cist assists the physician and den tist by providing information and literature about the correct treat ment of adverse reactions.
Report of case A request was made by the dentist for a pharmacy student to recommend pre medications for a patient who was to re ceive a dental examination and prophylaxis. The medical history showed that the patient was a 17-year-old boy whose condition was diagnosed as moderate mental retardation and epilepsy; but no seizures were reported during the past year. At nine months of age a high fever and subsequent seizures developed. Al though he was hospitalized, no diag nosis was made, and the seizures con tinued despite therapy. The patient was recently brought to the hospital by his parents who decided that they could no longer take care of him. He was thought to be a threat to others because he often had violent temper tantrums. His medi cal and behavioral problems were de fined as aggression, temper tantrums, and seizures. Laboratory data and func tion of vital organs were w ithin normal lim its. His drug history before admis sion was not available; however, when he was admitted he was receiving phenytoin (Dilantin), 100 mg, twice a day; phenobarbital, 30 mg, three times a day; and chlorpromazine HC1 (Thorazine), 50 mg, three times a day. Chlorpromazine therapy was changed to thioridazine HC1 (Mellaril), 50 mg, three times a day, in an attempt to decrease the seizures, which may have been ag gravated by the chlorpromazine. His be havior was stable and thioridazine was later given only at bedtime; however, the frequency of the seizures showed lit tle change. The dosage of phenytoin was increased to 100 mg, three times a day, without a significant decrease in sei zures and, several months later, carbamazepine (Tegretol), 100 mg, twice a day, was given with a subsequent de crease in the frequency of seizures. The patient is currently receiving Mellaril, 150 mg, at bedtime; Dilantin, 100 mg, three times a day; phenobarbital, 30 mg, three times a day; and Tegretol, 100 mg, twice a day. No allergies, sensitivities, or other adverse reactions to the drugs were noticed.
In evaluating the case, several factors
REPO RTS
were considered. The patient had a his tory of seizures; therefore, drugs known to aggravate or precipitate seizures should not be used (for example, anti psychotic agents). The patient was receiving four central nervous system depressants, which indicated that care should be taken to prevent respiratory depression. The benzodiazepines (for instance, diazepam [Valium ] and oxazepam [Serax]) have anticonvulsant, sedative, and antianxiety properties and, there fore, would be an excellent choice for the patient who has seizures. Oxazepam has an advantage of having a shorter half-life, so it should have less of a hang-over effect.1 Approximately 60 mg of oxazepam is equivalent to 10 to 20 mg of diazepam2(p199). A ll of these drugs should be administered after the patient has fasted because they are absorbed fas ter that way than when administered with food.3'4 Barbiturates have a higher propensity to produce respiratory de pressions as compared with drugs of other classes, such as benzodiazepines.1 The dental clinic form was then eval uated by the instructor. The choice of diazepam or oxazepam appeared rea sonable. Pentobarbital was probably a poor choice as the patient was receiving two enzyme inducers, phenobarbital and phenytoin, which should increase the metabolism of pentobarbital. Pentobarbi tal is also structurally sim ilar to phenobarbital. Diazepam, in healthy persons not tak ing other central nervous system depres sants, produces no clinically important respiratory depression. However, possi ble interactions with other central ner vous system depressants have not been adequately evaluated. All sedativehypnotics should be used with caution when respiration may be impaired, as when using other central nervous sys tem depressants.2(p148) As the patient was receiving four central nervous sys tem depressants, close observation would be made, even when the patient was receiving diazepam, for the devel opment of respiratory depression (Fig 3). The form was returned to the dentist who evaluated the choices, made com ments, and, if needed, obtained an opin ion from a physician (Fig 4). The dentist wrote the m edication orders for the first choice, Valium. On the day of the dental procedure, the patient was brought to the dental of fice after fasting, and Valium, 40 mg, was given orally. Forty minutes later, the procedure began and observations were recorded by the pharmacy student
Ellenor-Zimmerman-Kriz : INTERDISCIPLINARY APPROACH TO DENTAL CARE OF MENTALLY DISABLED ■ 493
CLIN ICAL
REPO RTS Fig 3 ■ Page 1 of tilled out evaluation form. DENTAL CLINIC - CLINICAL PHARMACY
Patient: R .L . Present Medications : Drug PHENOBARBITAL
_Age :
17
Sex: MALE
Location:
Dose £ Schedule
100 MG TTH
TEGRETOL
100 MG BID
MELLARIL
150 MG HS
COT. 4
Define Problems: A. Dental
30 MG TID
DILANTIN
Student : Date :__ 6/23/76 Ht: S'8h Wt: 136#
I - PROPHYLAXIS AND EXAMINATION
I I
. ___________________________________________________
III.________________________ IV.________________________ V. Other I. AGGRESSION II. TEMPER TANTRUMS III. SEIZURES IV.
Allergies £ Sensitivities: NONE NOTED Suggested Pre-denta 1 Medications: Dose, route of administration, #of repeats £ frequency
Drug
Reason for selection of this medication (use references when possible) ■ P A T im iS SEIZURE HISTORY REQUIRES USE Qf_A DRUG WHICH WILL
40 MG P .O . ON EMPTY STOMACHE, 1-2 HRS. PRIOR TO PROCEDURE. MAY REPEAT 10 MG X 1 IN 1 HR. I F NEEDED
1)
VALIUM
2)
SERAX
100 MG P .O . ON EMPTY STOMACHE. MAY REPEAT 30 MG X 1 HR. I F NEEDED
PENTOBARBITAL
100 MG P .O . ON EMPTY STOMACHE. MAY REPEAT 100 MG X 1 IN 1 HR. I F NEEDED
NOT PRECIPITATE S EIZ U R ES.
SANT EFFECTS.
VALIUM HAS BOTH ANTICONVULSANT AND SEDATIVE
PROPERTIES. WITH NO RESPIRATORY DEPRESSION PRODIICFD WITH DOSAGES OF .7 7 MG/KG ( 1 ) .
3)
THEREFORE. RULE OUT ANTTPSYrHOT-
SAME REASONS FOR SFRAX.
PENTO
BARBITAL PRODUCED NO RESPIRATORY DEPRESSION TN HFAI THY SUBJECTS AT A DOSE OF 200 MG m . ________________________________ (1 ) GREENBLATT & SHADER. BENZODIAZEPINES IN Cl INICAI
PRAC
T IC E , RAVEN PRESS, NEW YORK, 1974, p. 147__________________________
Fig 4 ■ Page 2 of filled out evaluation form. Pharmacist's Comments: FIR S T AND SECOND DRUGS ARE FIN E . ALREADY RECEIVING PHENOBARBITAL.
PENTOBARBITAL MAY NOT BE EFFECTIVE AS PATIENT IS
PATIENT IS RECEIVING OTHER CNS-DEPRESSANTS AND THEREFORE COULD DEVELOP RESPIRA
TORY DEPRESSION EVEN WITH VALIUM OR SERAX.____________________________________________________________________________________________________ ___
Physician's Comments:
OK - DR. ABLE____________________________________________________________________________________________________________
Dentist's Comments: WILL PRESCRIBE CHOICE #1. Effectiveness of Pre-Meds (Rate 0 to 4):
4
Observations £ Description of Effect of Medication( s ) : 1 : 1 Q p.M . _ VALIUM GIVEN. ATAXIC. AND COOPERATIVE WITH NO E X C IT A B IL IT Y .
PROCEDURE BEGAN AT 1:50 P.M .
P.M . - PROCEDURE COMPLETED. S T IL L LETHARGIC AND ATAXIC.
OF HEADACHE
4 :0 0 P.M . - SOMEWHAT ATAXIC BUT TALKATIVE.
FQR..APPRQXIMAT ELY ONE HOUR.___ NO OTHER ADR'S OBSERVED DURING 24 HOURS.
FOLLOWING MORNING.
1 :4 5 P.M . - LETHARGIC
NO PROBLEMS DURING PROCEDURE.
2 :5 0
COMPLAINED
NO ATAXIA OR 1 FTHARGY THF
NO RFSPTRATORY DEPRESSION NOTFD._________________________________________________________________________________________
Possible ReasonCs) for Success or Failure:
C L IN IC A L
(Fig 4). At the com pletion of the proce dure, the dentist rated the effectiveness of the m edication on a clinical scale of 0 to + 4 and recorded his observations as to the effectiveness and adverse effects of the therapy. In this case, the Valium was rated + 4. The pharmacy student con tinued to observe the patient periodi cally during the next 24 hours for the appearance of adverse reactions to the drug. Other than the expected lethargy and ataxia, the patient had a headache for approximately an hour. This was not thought to be significant. The next morning, the patient had no adverse ef fects. No respiratory depression was ob served. Premedication was both effective and safe in this case.
Discussion Through the program, several guidelines have been developed for the use of premedications in dental treatment for the mentally disabled. The effects of current and previous medications used on the patient should be evaluated. Dentists should be familiar with the patient’s physical and psychological history. The function of the vital organs should be evaluated, and possible effects of premedication on any ab normalities should be determined. Dentists should be aware that pa tients who have a history of use of psychotropic drugs usually tolerate higher doses of premedications, and that if a patient is on a medication of a similar chemical class, toler ance may have developed, particu larly if the drug is a known enzyme
inducer (for example, patients re ceiving phenobarbital for seizures probably will not respond to sec obarbital as premedication5). Den tists should remember that the use of phenothiazines (particularly chlorpromazine or promazine [Sparine] may precipitate a sei zure,6 and that sedative-hypnotics are absorbed more quickly after fast ing.3,4 The patient’s history should be reviewed for sensitivities and al lergies to drugs. Drugs with similar pharmacological properties should be avoided. The pain threshold is generally increased in the developmentally disabled patient. The dentist should be aware of possible adverse reac tions to the premedication and how to treat them. All personnel should be instructed about the possible ef fects of the premedication. In exchange for the involvement by the pharmacist and student in the program, the dentist lectures the pharmacy students about the therapeutic use of oral health agents and the provision of dentistry to developmentally disabled patients. The students thus gain an under standing of the dental needs of the patient and the professional needs of the dentist. In addition, the pro gram also provides the students with an excellent example of clini cal pharmacy through evaluation of patients’ drug regimens, recom mendations of appropriate pre medication, and observation of the effects of therapy.
REPORTS
Conclusion The realization by the dental and pharmacy professions of the need for an interdisciplinary approach to the care of mentally disabled per sons not only benefits the patient, but the professions as well. Through this program, a greater number of residents have been pro vided with uncompromised dental care and safe and effective premedi cation has been made available for patients requiring sedation or other medical procedures. Pharmacy stu dents have been given valuable clinical experience. Pharmacists and students have gained informa tion on proper dental hygiene, den tal problems, and dental supplies, and the dentist has gained in creased knowledge about drugs and their effects.
1. Greenblatt, D.J. and Shader, R.I. Drug therapy: benzodiazepines. N Engl J Med 291:1011 Nov 7, 1974. 2. Greenblatt, D.J., and Shader, R.I. Ben zodiazepines in clin ical practice. New York, Raven Press, 1974. 3. Sm ith, R.B., and others. Pharm acokine tics of pentobarbital after intravenous and oral administration. J Pharmacokinet Biopharm 1:5 Jan 1973. 4. Johnson, P.C.; Braun, G.A.; and Cressman, W.A. Nonfasting state and the ab sorption of a hypnotic. Arch Intern Med 131:199 Feb 1973. 5. Kales, A., and others. Chronic hypnoticdrug use. Ineffectiveness, drug-withdrawal in som nia, and dependence. JAMA 227:513 Feb 4 , 1974. 6. Appleton. Psychoactive drugs: a usage guide. Dis Ner Syst 32:607 Sept 1971.
THE AUTHORS Dr. Ellenor was assistant professor at the College of Pharmacy, Idaho State University, and is currently assistant professor, College of Pharmacy and College of Allied Health Professions, Center for Interdisciplinary Education, 915 S Limestone, Lexington, Ky 40506. Mr. Zimmerman was a pharmacy resident at the Idaho State School and Hospital, and is currently chief pharmacist, St. Elizabeth Community Hospital, Baker, Ore. Dr. Kriz is consulting dentist, Idaho State School and Hospital, Nampa, Idaho. Address requests for reprints to Dr. Ellenor.
ELLENOR
ZIMMERMAN
KRIZ
Ellenor-Zim m erm an-K riz : INTERDISCIPLINARY APPROACH TO DENTAL CARE OF MENTALLY DISABLED ■ 495
REPO RTS
An interdisciplinary approach to the dental care of the mentally disabled Gary L. Ellenor, P h a rm D Steve Zimmerman, R P h John Kriz, D D S , N a m p a , Id a h o
In institutions fo r mentally disabled persons, dental care of the patient is often difficult because of uncooperative behavior. Premedication is sometimes necessary. The mentally disabled patient frequently receives other medication fo r behavioral control, cerebral palsy, seizures, or the like, that may interact with the dental premedication. Because of the problems that may develop, a program between an institution’s dental department and a university’s clinical pharmacy department was developed that provided an approach to the selection of premedication fo r the dental patient who is mentally disabled.
P
A roblems in providing dental care to mentally disabled persons have led to a valuable interprofes sional approach in the care of these patients. To provide proper and adequate dental care, the dentist must be able to manage the un cooperative behavior and body movements typical of severely and profoundly retarded persons. With out such control, there are major in terruptions and the dentist cannot examine or treat the patient com pletely; thus, the therapy may be compromised. For example, dental
procedures such as examination of the mouth with the use of a tongue blade often stimulates and arouses the patient. With the additional use of aspiration instruments, ultrasonic scaler, and the like, a new level of arousal of the mentally disabled pa tient is created. As other methods of management of behavior have proven partially ineffective (for instance, physical restraint), one solution to these problems is the use of premedica tions. The goal is for the dental pro cedure to be less traumatic to the patient and allow uncompromised treatment. Through an interprofes sional approach to the dental care of mentally disabled patients, we de signed and implemented a program that facilitated optimal dental care of these patients. The program was developed through a joint effort of the Idaho State University College of Phar macy, Clinical Pharmacy Program and the Idaho State School and Hospital dental department. The Idaho State School and Hospital has approximately 475 mentally dis abled persons and provides 24-hour residential, medical, and treatment programs. Of these persons, approx imately 80% are severely or pro foundly retarded, approximately 25% have cerebral palsy, and ap proximately 60% are epileptic. The dentist provides services to the Idaho State School and Hospital on a consulting basis, including regular recall, restorative care, and emergency services. In addition, a
full-time dental assistant is employed in the dental clinic. The pharmacy staff consists of an assis tant professor of clinical pharmacy and ten to 20 senior (fifth year) pharmacy students from Idaho State University. This is one of several programs in which students are in volved during their clinical train ing. A pharmacy resident with the Idaho State School and Hospital also participates in the program. For routine dentistry, such as prophylaxis and examinations, it is not considered economical or safe to place patients under general anesthesia; thus, premedication is desirable. As dentists are generally unfamiliar with treating mentally disabled persons, the pharmacist was consulted about the use of premedications. As many of these patients are re ceiving other medications, such as antipsychotic and anticonvulsant agents, problems of interactions be tween drugs must be considered. It is, therefore, important to com pletely review each patient’s drug history. As many patients have other medical problems (such as epilepsy and cerebral palsy) consid eration must also be given to in teractions between the drug and the disease.
Method The dentist begins the procedure by recording pertinent information on the “Dental Clinic— Clinical Phar macy” form (Fig 1,2). Defined den tal problems usually consist of beJADA, Vol. 97, September 1978 ■ 491
CLINICAL
REPO R TS
Fig 1 ■ Page 1 of evaluation form. DE N T A L CLINIC - C L I N I C A L P H A R M A C Y
Patient : Present Medications: ff Drug
_Age
Location:
Sex:
Dose 6 Schedule
Student:^ Date :___ Ht:
Define Problems: I A*. Der Dental
A
W t:
B
II-" Other
F r
B V r
ii._
u
m ._
IV.
^.ergies 6 Sensitivities: "V^ # uggested Pre-dental Medications: Sug Dose, route of Drug administration, #of repeats 8 frequency
Reason for selection of this medication (use references when possible)
1)
D O
3)
Fig 2 ■ Page 2 of evaluation form.
Pharmacists's Comments : Fhysician's Comments: Dentist's Comments:
ft
Effectiveness of Pre-Meds (Rate 0 to U): "Observations 5 Description of Effect of Mecication(s):
D Possible Reason(s) for Success or Failure:
CLIN ICAL
havioral problems (uncooperative, combative, and the like) or other problems, such as excessive tongue movements or excessive drooling. The form is then sent to the pharmacist (students or resident), who compiles a medical history that includes age, sex, weight, height, living area, and diagnosis or perti nent medical problems (Fig IB). The current medical status of the patient is reviewed, including med ical problems, laboratory data, and functioning of the vital organs. The pharmacist evaluates the patient’s drug history, including current drug therapy, dosage and schedule, sensitivities, allergies, and other adverse reactions to drugs (Fig 1C). This information is then evaluated, the literature is researched regard ing potential drug-related problems, and premedication is recommended to manage the patient’s problems. The proprietary name of the drug, dosage, route of administration, number of times dosage may be re peated, and frequency or interval between repeated doses are re corded. In addition, the reason for the selection of the medication is given, and references to the litera ture are cited (Fig ID). The forms completed by pharmacy students are evaluated by their instructor who enters his comments on the form (Fig 2A). The form is returned to the den tist who adds his notes (Fig 2B) and who may submit the form to a physician for the physician’s analysis and comments (Fig 2C). The dentist then writes the medica tion orders on the patient’s ward chart. Pharmacy students, when avail able, assist the dentist in treating the patient and record their observa tions on the effects of the drug. The students also enter the possible rea sons for the success or failure of the drug therapy (Fig 2D). At the com pletion of the dental visit, the den tist rates the effectiveness of the medication on a clinical scale of 0 to + 4 (Fig 2E), and adverse reac tions to the drug are noted. The pa tient is observed periodically for the appearance of possible reactions to
the drug for the next 24 hours by the pharmacist or student. If ad verse reactions occur, the pharma cist assists the physician and den tist by providing information and literature about the correct treat ment of adverse reactions.
Report of case A request was made by the dentist for a pharmacy student to recommend pre medications for a patient who was to re ceive a dental examination and prophylaxis. The medical history showed that the patient was a 17-year-old boy whose condition was diagnosed as moderate mental retardation and epilepsy; but no seizures were reported during the past year. At nine months of age a high fever and subsequent seizures developed. Al though he was hospitalized, no diag nosis was made, and the seizures con tinued despite therapy. The patient was recently brought to the hospital by his parents who decided that they could no longer take care of him. He was thought to be a threat to others because he often had violent temper tantrums. His medi cal and behavioral problems were de fined as aggression, temper tantrums, and seizures. Laboratory data and func tion of vital organs were w ithin normal lim its. His drug history before admis sion was not available; however, when he was admitted he was receiving phenytoin (Dilantin), 100 mg, twice a day; phenobarbital, 30 mg, three times a day; and chlorpromazine HC1 (Thorazine), 50 mg, three times a day. Chlorpromazine therapy was changed to thioridazine HC1 (Mellaril), 50 mg, three times a day, in an attempt to decrease the seizures, which may have been ag gravated by the chlorpromazine. His be havior was stable and thioridazine was later given only at bedtime; however, the frequency of the seizures showed lit tle change. The dosage of phenytoin was increased to 100 mg, three times a day, without a significant decrease in sei zures and, several months later, carbamazepine (Tegretol), 100 mg, twice a day, was given with a subsequent de crease in the frequency of seizures. The patient is currently receiving Mellaril, 150 mg, at bedtime; Dilantin, 100 mg, three times a day; phenobarbital, 30 mg, three times a day; and Tegretol, 100 mg, twice a day. No allergies, sensitivities, or other adverse reactions to the drugs were noticed.
In evaluating the case, several factors
REPO RTS
were considered. The patient had a his tory of seizures; therefore, drugs known to aggravate or precipitate seizures should not be used (for example, anti psychotic agents). The patient was receiving four central nervous system depressants, which indicated that care should be taken to prevent respiratory depression. The benzodiazepines (for instance, diazepam [Valium ] and oxazepam [Serax]) have anticonvulsant, sedative, and antianxiety properties and, there fore, would be an excellent choice for the patient who has seizures. Oxazepam has an advantage of having a shorter half-life, so it should have less of a hang-over effect.1 Approximately 60 mg of oxazepam is equivalent to 10 to 20 mg of diazepam2(p199). A ll of these drugs should be administered after the patient has fasted because they are absorbed fas ter that way than when administered with food.3'4 Barbiturates have a higher propensity to produce respiratory de pressions as compared with drugs of other classes, such as benzodiazepines.1 The dental clinic form was then eval uated by the instructor. The choice of diazepam or oxazepam appeared rea sonable. Pentobarbital was probably a poor choice as the patient was receiving two enzyme inducers, phenobarbital and phenytoin, which should increase the metabolism of pentobarbital. Pentobarbi tal is also structurally sim ilar to phenobarbital. Diazepam, in healthy persons not tak ing other central nervous system depres sants, produces no clinically important respiratory depression. However, possi ble interactions with other central ner vous system depressants have not been adequately evaluated. All sedativehypnotics should be used with caution when respiration may be impaired, as when using other central nervous sys tem depressants.2(p148) As the patient was receiving four central nervous sys tem depressants, close observation would be made, even when the patient was receiving diazepam, for the devel opment of respiratory depression (Fig 3). The form was returned to the dentist who evaluated the choices, made com ments, and, if needed, obtained an opin ion from a physician (Fig 4). The dentist wrote the m edication orders for the first choice, Valium. On the day of the dental procedure, the patient was brought to the dental of fice after fasting, and Valium, 40 mg, was given orally. Forty minutes later, the procedure began and observations were recorded by the pharmacy student
Ellenor-Zimmerman-Kriz : INTERDISCIPLINARY APPROACH TO DENTAL CARE OF MENTALLY DISABLED ■ 493
CLIN ICAL
REPO RTS Fig 3 ■ Page 1 of tilled out evaluation form. DENTAL CLINIC - CLINICAL PHARMACY
Patient: R .L . Present Medications : Drug PHENOBARBITAL
_Age :
17
Sex: MALE
Location:
Dose £ Schedule
100 MG TTH
TEGRETOL
100 MG BID
MELLARIL
150 MG HS
COT. 4
Define Problems: A. Dental
30 MG TID
DILANTIN
Student : Date :__ 6/23/76 Ht: S'8h Wt: 136#
I - PROPHYLAXIS AND EXAMINATION
I I
. ___________________________________________________
III.________________________ IV.________________________ V. Other I. AGGRESSION II. TEMPER TANTRUMS III. SEIZURES IV.
Allergies £ Sensitivities: NONE NOTED Suggested Pre-denta 1 Medications: Dose, route of administration, #of repeats £ frequency
Drug
Reason for selection of this medication (use references when possible) ■ P A T im iS SEIZURE HISTORY REQUIRES USE Qf_A DRUG WHICH WILL
40 MG P .O . ON EMPTY STOMACHE, 1-2 HRS. PRIOR TO PROCEDURE. MAY REPEAT 10 MG X 1 IN 1 HR. I F NEEDED
1)
VALIUM
2)
SERAX
100 MG P .O . ON EMPTY STOMACHE. MAY REPEAT 30 MG X 1 HR. I F NEEDED
PENTOBARBITAL
100 MG P .O . ON EMPTY STOMACHE. MAY REPEAT 100 MG X 1 IN 1 HR. I F NEEDED
NOT PRECIPITATE S EIZ U R ES.
SANT EFFECTS.
VALIUM HAS BOTH ANTICONVULSANT AND SEDATIVE
PROPERTIES. WITH NO RESPIRATORY DEPRESSION PRODIICFD WITH DOSAGES OF .7 7 MG/KG ( 1 ) .
3)
THEREFORE. RULE OUT ANTTPSYrHOT-
SAME REASONS FOR SFRAX.
PENTO
BARBITAL PRODUCED NO RESPIRATORY DEPRESSION TN HFAI THY SUBJECTS AT A DOSE OF 200 MG m . ________________________________ (1 ) GREENBLATT & SHADER. BENZODIAZEPINES IN Cl INICAI
PRAC
T IC E , RAVEN PRESS, NEW YORK, 1974, p. 147__________________________
Fig 4 ■ Page 2 of filled out evaluation form. Pharmacist's Comments: FIR S T AND SECOND DRUGS ARE FIN E . ALREADY RECEIVING PHENOBARBITAL.
PENTOBARBITAL MAY NOT BE EFFECTIVE AS PATIENT IS
PATIENT IS RECEIVING OTHER CNS-DEPRESSANTS AND THEREFORE COULD DEVELOP RESPIRA
TORY DEPRESSION EVEN WITH VALIUM OR SERAX.____________________________________________________________________________________________________ ___
Physician's Comments:
OK - DR. ABLE____________________________________________________________________________________________________________
Dentist's Comments: WILL PRESCRIBE CHOICE #1. Effectiveness of Pre-Meds (Rate 0 to 4):
4
Observations £ Description of Effect of Medication( s ) : 1 : 1 Q p.M . _ VALIUM GIVEN. ATAXIC. AND COOPERATIVE WITH NO E X C IT A B IL IT Y .
PROCEDURE BEGAN AT 1:50 P.M .
P.M . - PROCEDURE COMPLETED. S T IL L LETHARGIC AND ATAXIC.
OF HEADACHE
4 :0 0 P.M . - SOMEWHAT ATAXIC BUT TALKATIVE.
FQR..APPRQXIMAT ELY ONE HOUR.___ NO OTHER ADR'S OBSERVED DURING 24 HOURS.
FOLLOWING MORNING.
1 :4 5 P.M . - LETHARGIC
NO PROBLEMS DURING PROCEDURE.
2 :5 0
COMPLAINED
NO ATAXIA OR 1 FTHARGY THF
NO RFSPTRATORY DEPRESSION NOTFD._________________________________________________________________________________________
Possible ReasonCs) for Success or Failure:
C L IN IC A L
(Fig 4). At the com pletion of the proce dure, the dentist rated the effectiveness of the m edication on a clinical scale of 0 to + 4 and recorded his observations as to the effectiveness and adverse effects of the therapy. In this case, the Valium was rated + 4. The pharmacy student con tinued to observe the patient periodi cally during the next 24 hours for the appearance of adverse reactions to the drug. Other than the expected lethargy and ataxia, the patient had a headache for approximately an hour. This was not thought to be significant. The next morning, the patient had no adverse ef fects. No respiratory depression was ob served. Premedication was both effective and safe in this case.
Discussion Through the program, several guidelines have been developed for the use of premedications in dental treatment for the mentally disabled. The effects of current and previous medications used on the patient should be evaluated. Dentists should be familiar with the patient’s physical and psychological history. The function of the vital organs should be evaluated, and possible effects of premedication on any ab normalities should be determined. Dentists should be aware that pa tients who have a history of use of psychotropic drugs usually tolerate higher doses of premedications, and that if a patient is on a medication of a similar chemical class, toler ance may have developed, particu larly if the drug is a known enzyme
inducer (for example, patients re ceiving phenobarbital for seizures probably will not respond to sec obarbital as premedication5). Den tists should remember that the use of phenothiazines (particularly chlorpromazine or promazine [Sparine] may precipitate a sei zure,6 and that sedative-hypnotics are absorbed more quickly after fast ing.3,4 The patient’s history should be reviewed for sensitivities and al lergies to drugs. Drugs with similar pharmacological properties should be avoided. The pain threshold is generally increased in the developmentally disabled patient. The dentist should be aware of possible adverse reac tions to the premedication and how to treat them. All personnel should be instructed about the possible ef fects of the premedication. In exchange for the involvement by the pharmacist and student in the program, the dentist lectures the pharmacy students about the therapeutic use of oral health agents and the provision of dentistry to developmentally disabled patients. The students thus gain an under standing of the dental needs of the patient and the professional needs of the dentist. In addition, the pro gram also provides the students with an excellent example of clini cal pharmacy through evaluation of patients’ drug regimens, recom mendations of appropriate pre medication, and observation of the effects of therapy.
REPORTS
Conclusion The realization by the dental and pharmacy professions of the need for an interdisciplinary approach to the care of mentally disabled per sons not only benefits the patient, but the professions as well. Through this program, a greater number of residents have been pro vided with uncompromised dental care and safe and effective premedi cation has been made available for patients requiring sedation or other medical procedures. Pharmacy stu dents have been given valuable clinical experience. Pharmacists and students have gained informa tion on proper dental hygiene, den tal problems, and dental supplies, and the dentist has gained in creased knowledge about drugs and their effects.
1. Greenblatt, D.J. and Shader, R.I. Drug therapy: benzodiazepines. N Engl J Med 291:1011 Nov 7, 1974. 2. Greenblatt, D.J., and Shader, R.I. Ben zodiazepines in clin ical practice. New York, Raven Press, 1974. 3. Sm ith, R.B., and others. Pharm acokine tics of pentobarbital after intravenous and oral administration. J Pharmacokinet Biopharm 1:5 Jan 1973. 4. Johnson, P.C.; Braun, G.A.; and Cressman, W.A. Nonfasting state and the ab sorption of a hypnotic. Arch Intern Med 131:199 Feb 1973. 5. Kales, A., and others. Chronic hypnoticdrug use. Ineffectiveness, drug-withdrawal in som nia, and dependence. JAMA 227:513 Feb 4 , 1974. 6. Appleton. Psychoactive drugs: a usage guide. Dis Ner Syst 32:607 Sept 1971.
THE AUTHORS Dr. Ellenor was assistant professor at the College of Pharmacy, Idaho State University, and is currently assistant professor, College of Pharmacy and College of Allied Health Professions, Center for Interdisciplinary Education, 915 S Limestone, Lexington, Ky 40506. Mr. Zimmerman was a pharmacy resident at the Idaho State School and Hospital, and is currently chief pharmacist, St. Elizabeth Community Hospital, Baker, Ore. Dr. Kriz is consulting dentist, Idaho State School and Hospital, Nampa, Idaho. Address requests for reprints to Dr. Ellenor.
ELLENOR
ZIMMERMAN
KRIZ
Ellenor-Zim m erm an-K riz : INTERDISCIPLINARY APPROACH TO DENTAL CARE OF MENTALLY DISABLED ■ 495