Lecture 1: Dental Management of Patients with Respiratory Conditions Flashcards
COPD: 3 ways to prevent potential problems
- Suggest smoking cessation
- Awareness of potential comorbid conditions (hypertension and coronary heart disease)
- Awareness of drug interactions
6 potential oral complications if COPD patient is a chronic smoker
Halitosis Stains Nicotinic stomatitis Periodontal disease Premalignant mucosal lesions Oral cancer
Define nicotinic stomatitis
White patches and red dots on palate
Potential oral complication if COPD patient is taking anticholinergic drug
Dry mouth
Potential oral complication if COPD patient is taking theophylline
Rare instances of induced Stevens-Johnson syndrome (SJS)
Define SJS
A life-threatening skin condition, in which cell death causes the epidermis to separate from the dermis
Method of determining the potential issues or factors of concern for the dental management of respiratory patients
ABCDEF
List the 5 categories under A for potential issues
Analgesics Antibiotics Anesthesia Anxiety Allergy
List the 2 categories under B for potential issues
Bleeding
Blood pressure
List the category under C for potential issues
Chair position
List the 2 categories under D for potential issues
Devices
Drugs
List the 2 categories under E for potential issues
Equipment
Emergencies
List the category under F for potential issues
Follow-up
Antibiotics: What to avoid in a patient taking theophylline (for COPD)
Erythromycin
Macrolide antibiotics
Ciprofloxacin
What to be aware of in terms of COPD patients who have received antibiotics for upper respiratory infections
Oral and lung flora may include antibiotic resistant bacteria
COPD: things to consider in terms of anesthesia
Local anesthesia can be used without change in technique. Avoid outpatient general anesthesia
COPD: things to consider in terms of anxiety management
Avoid nitroud oxide-oxygen inhalation sedation for COPD stage 3 or worse
Alternative = low does oral diazepam or another benzodiazepine (may cause oral dryness)
COPD: optimal chair position
Semisupine or upright chair position
COPD: considerations for device use
Avoid rubber dams in patients with severe disease
Use pulse oxymetry to monitor O2 sat.
Spirometry readings helpful to determine control level
COPD: drugs to avoid
Barbiturates and narcotics can depress respiration
Antihistamines and anticholinergic drugs can further dry mucosal secretions
COPD: corticosteroid use prior to dental visit
Normal morning dose should be taken on the day of surgical procedures
COPD: Equipment considerations
Monitor O2 sat during sedation and invasive procedures
Use low flow (2 - 3 L/min) supplemental O2 when drop <95%
COPD: follow up considerations
Encourage patient to quit smoking
Examine oral cavity for lesions that make be related to smoking
Avoid treatment if upper respiratory infection is present
Potential oral complication of inhaled corticosteroids (COPD and asthma patients)
May contribute to development of oral candiasis if used improperly or excessively (should wash mouth after every use)
Define oral candiasis
A type of yeast in mouth
Potential complication of systemic corticosteroids
Possible adrenal suppression; cushingoid features with long term use
Adverse drug interactions with phosphodiesterase (PD) inhibitors such as theophylline
Erythromycin
Azithromycin
(Serum levels should be monitored)
Most serious manifestation of asthma
Status asthmaticus
Define status asthmaticus
Sever prolonged asthmatic attack (1 hr to longer than 24 hours)
Associated conditions to status asthmaticus
Respiratory infection leading to exhaustion, severe dehydration, peripheral vascular collapse and death (uncommon)
Number of deaths per year due to asthma complications
4000 deaths per year in USA in >45 year olds
5 things to consider in order to prevent asthma complications during dental treatment
History (determine severity and stability of disease)
Type (allergic/nonallergic; precipitating factor)
Frequency and severity of attack; current/past
Spirometer
Oximeter
If asthma is sever and uncontrolled, what do you do?
Postpone treatment until stabilization
If the patient experiences nocturnal asthma attacks, what do you do?
Schedule for late morning appointments
Operatory odorants (methyl methacrylate) and asthma: what to do
Reduce
Follow up with asthmatic patients
Instruct to use regularly their medication; bring their inhalers
Oral premedication for asthma
Benzodiazepine
Hydrozyizine (reasonable alternatives with children)
Ketamine (bronchodilation)
Drugs to avoid with asthmatic patients
Barbiturates and narcotics (particularly meperidine) since histamine releasing = can provoke attack
Outpatient anesthesia
Asthma and sulfite preservative found in local anesthetic containing epinephrine
Less than normally found in certain foods but acute asthma attack has been reported
Advisable to not use epinephrine with moderate to sever condition and discuss any past allergic responses (talk to MD)
Sedation for anxious asthmatics
Nitrous oxide-oxygen inhalation sedation and/or small doses of oral diazepam
Allergy concerns in asthmatics
Asthmatics with nasal polyps at increased risk for allergy to aspirin, so avoid use
Blood pressure and asthmatics
Monitor BP in event of asthma attack to observe for development of status asthmaticus
Optimal chair position for asthmatics
Semisupine or upright
Signs and symptoms of a severe asthma attack (8)
Inability to finish sentences in one breath
In effectiveness of bronchodilators to relieve dyspnea
Recent drop in FEV
Tachypnea with a respiratory rate of 25/min
Tachycardia with HR of 110 bpm
Diaphoresis
Accessory muscle usage
Paradoxical pulse
Protocol if patient is experiencing a severe asthma attack
1) Administer fast acting bronchodilator, oxygen, and (if needed) subcutaneous epinephrine (0.3 - 0.5 mL)
2) Activate emergency medical system (EMS)
3) Repeat administration of fast acting bronchodilator every 20 min until EMS arrive
Initial careful workup of tuberculosis patient (information to acquire) (5)
Medical history (i.e. diagnosis and date)
Type of treatment provided
ROS
History of periodic physical examinations
CXR for evidence of reactivation
When do you postpone treatment of a TB patient?
Questionable adequacy of treatment time
Lack of appropriate medical follow up evaluation since recovery
Signs and symptoms of relapse
How to manage TB patient if positive PPD
Verify evaluation by MD to rule out active disease
Verify completion of drug therapy with isoniazid for 9 months
Normal manner
How to manage patient if exhibiting signs and symptoms suggestive of TB
Refer to MD for evaluation and postpone treatment
If treatment necessary, treat as for patient with sputum positive
5 adverse effects of isoniazid
1) Hepatotoxicity and elevation in serum animotransferase
2) Cofactor increase risk of hep (i.e. age, daily alcohol intake, previous history of liver disease)
3) GI and neurologic adverse events
4) Adverse interactions with acetaminophen
5) Increases concentration of other drugs (i.e. diazepam)
3 adverse effects of rifampin
1) Induces Cytochrone P-450
2) Lower plasma level of oral contraceptive, diazepam, midazolam, clarithromycin, ketoconazole, itraconazole, fluconazole
3) Leukopenia, hemolytic anemia, thrombocytopenia = increase risk of infection, delayed healing, gingival bleeding
4 oral manifestations of asthma
- Allergic rhinitis
- Headache
- Dry mouth and related sequela
- Opportunistic infection
Define allergic rhinitis
Mouth breathing leading to increased upper anterior and total anterior facial height, higher palatal vault, greater overjet and higher prevalence of crossbite
5 oral manifestations of TB
1) Oral lesions –> painful, depp, irregular ulcer on dorsum of tongue (palate, lips, BM, gingiva may also be affected
2) Granular; nodular; leukoplakic and painless
3) Osteomyelitis if extension to jaw
4) Lymphadenopathy –> scrufola
5) Salivary gland or TMJ (rare)
What is the potential significance of finding an enlarged neck lymph node?
If history of TB, can possibly be reactivation
Describe the findings of oral candiasis
Wide spread, yellowish membrane that can be removed (peeled off)
Erythema (inflammatory red patch near back of mouth)
Describe the findings of nicotinic stomatitis and explain what these are exactly
Wide spread red dots (salivary gland inflammation) White patch (keratosis)
Define leukoplakia
White patch without evidence of friction or injury (i.e. idiopathic)
