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Poisoning by direct inhibitors of acetylcholinesterase presents as an acute cholinergic crisis, they do not develop late type muscular weakness.
Indirect inhibitors do not develop signs of cholinergic crisis, but show persistent fasciculations along with sudden increase in atropine requirement.
Cholinergic crisis develops due to too much acetylcholine on the cholinergic receptors.
Table I Dental Hygiene Discussion Topics for Patients with Myasthenia Gravis * * Importance of avoiding exacerbation of MG by obtaining regular and frequent recare appointments to prevent oral infection * Scheduling dental hygiene appointments in the mid morning * Avoiding drugs that can cause muscle weakness and exacerbate MG * Taking anticholinesterase drugs on time, as ordered by the MD, and 1 1/2 hour's before the dental hygiene appointment * Alertness to signs of myasthenic crisis and cholinergic crisis * Necessity of prompt treatment of oral disease and infection * Stress reduction strategies Adapted from Armstrong S.
Patients can experience either a cholinergic crisis or a myasthenic crisis.
The symptoms of cholinergic crisis usually develop 30 to 60 minutes after the medication is taken and is a result of "locking up" the available receptors with ACh (the medication has interfered with the enzyme needed to clear them).
Since the desired effect of immunosuppressant therapy is to decrease the disease symptoms, the dose and timing of the anticholinesterase medications may need to be adjusted as the myasthenic symptoms diminish to avoid cholinergic crisis.
Sign-symptoms of cholinergic crisis, noted in this study, are matched with that of literature.
Close observation of the patients for ventilatory & supportive care after the cholinergic crisis is over, remains the cornerstone treatment of this syndrome.