Lecture 1: Dental Management of Patients with Respiratory Conditions

Question 1

COPD: 3 ways to prevent potential problems

Answer 1

• Suggest smoking cessation
• Awareness of potential comorbid conditions (hypertension and coronary heart disease)
• Awareness of drug interactions

Question 2

6 potential oral complications if COPD patient is a chronic smoker

Answer 2

Halitosis
Stains
Nicotinic stomatitis
Periodontal disease
Premalignant mucosal lesions
Oral cancer

Question 3

Define nicotinic stomatitis

Answer 3

White patches and red dots on palate

Question 4

Potential oral complication if COPD patient is taking anticholinergic drug

Answer 4

Dry mouth

Question 5

Potential oral complication if COPD patient is taking theophylline

Answer 5

Rare instances of induced Stevens-Johnson syndrome (SJS)

Question 6

Define SJS

Answer 6

A life-threatening skin condition, in which cell death causes the epidermis to separate from the dermis

Question 7

Method of determining the potential issues or factors of concern for the dental management of respiratory patients

Answer 7

ABCDEF

Question 8

List the 5 categories under A for potential issues

Answer 8

Analgesics
Antibiotics
Anesthesia
Anxiety
Allergy

Question 9

List the 2 categories under B for potential issues

Answer 9

Bleeding

Blood pressure

Question 10

List the category under C for potential issues

Answer 10

Chair position

Question 11

List the 2 categories under D for potential issues

Answer 11

Devices

Drugs

Question 12

List the 2 categories under E for potential issues

Answer 12

Equipment

Emergencies

Question 13

List the category under F for potential issues

Answer 13

Follow-up

Question 14

Antibiotics: What to avoid in a patient taking theophylline (for COPD)

Answer 14

Erythromycin
Macrolide antibiotics
Ciprofloxacin

Question 15

What to be aware of in terms of COPD patients who have received antibiotics for upper respiratory infections

Answer 15

Oral and lung flora may include antibiotic resistant bacteria

Question 16

COPD: things to consider in terms of anesthesia

Answer 16

Local anesthesia can be used without change in technique. Avoid outpatient general anesthesia

Question 17

COPD: things to consider in terms of anxiety management

Answer 17

Avoid nitroud oxide-oxygen inhalation sedation for COPD stage 3 or worse
Alternative = low does oral diazepam or another benzodiazepine (may cause oral dryness)

Question 18

COPD: optimal chair position

Answer 18

Semisupine or upright chair position

Question 19

COPD: considerations for device use

Answer 19

Avoid rubber dams in patients with severe disease
Use pulse oxymetry to monitor O2 sat.
Spirometry readings helpful to determine control level

Question 20

COPD: drugs to avoid

Answer 20

Barbiturates and narcotics can depress respiration

Antihistamines and anticholinergic drugs can further dry mucosal secretions

Question 21

COPD: corticosteroid use prior to dental visit

Answer 21

Normal morning dose should be taken on the day of surgical procedures

Question 22

COPD: Equipment considerations

Answer 22

Monitor O2 sat during sedation and invasive procedures

Use low flow (2 - 3 L/min) supplemental O2 when drop <95%

Question 23

COPD: follow up considerations

Answer 23

Encourage patient to quit smoking
Examine oral cavity for lesions that make be related to smoking
Avoid treatment if upper respiratory infection is present

Question 24

Potential oral complication of inhaled corticosteroids (COPD and asthma patients)

Answer 24

May contribute to development of oral candiasis if used improperly or excessively (should wash mouth after every use)

Question 25

Define oral candiasis

Answer 25

A type of yeast in mouth

Question 26

Potential complication of systemic corticosteroids

Answer 26

Possible adrenal suppression; cushingoid features with long term use

Question 27

Adverse drug interactions with phosphodiesterase (PD) inhibitors such as theophylline

Answer 27

Erythromycin Azithromycin (Serum levels should be monitored)

Question 28

Most serious manifestation of asthma

Answer 28

Status asthmaticus

Question 29

Define status asthmaticus

Answer 29

Sever prolonged asthmatic attack (1 hr to longer than 24 hours)

Question 30

Associated conditions to status asthmaticus

Answer 30

Respiratory infection leading to exhaustion, severe dehydration, peripheral vascular collapse and death (uncommon)

Question 31

Number of deaths per year due to asthma complications

Answer 31

4000 deaths per year in USA in >45 year olds

Question 32

5 things to consider in order to prevent asthma complications during dental treatment

Answer 32

History (determine severity and stability of disease) Type (allergic/nonallergic; precipitating factor) Frequency and severity of attack; current/past Spirometer Oximeter

Question 33

If asthma is sever and uncontrolled, what do you do?

Answer 33

Postpone treatment until stabilization

Question 34

If the patient experiences nocturnal asthma attacks, what do you do?

Answer 34

Schedule for late morning appointments

Question 35

Operatory odorants (methyl methacrylate) and asthma: what to do

Answer 35

Reduce

Question 36

Follow up with asthmatic patients

Answer 36

Instruct to use regularly their medication; bring their inhalers

Question 37

Oral premedication for asthma

Answer 37

Benzodiazepine Hydrozyizine (reasonable alternatives with children) Ketamine (bronchodilation)

Question 38

Drugs to avoid with asthmatic patients

Answer 38

Barbiturates and narcotics (particularly meperidine) since histamine releasing = can provoke attack Outpatient anesthesia

Question 39

Asthma and sulfite preservative found in local anesthetic containing epinephrine

Answer 39

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)

Question 40

Sedation for anxious asthmatics

Answer 40

Nitrous oxide-oxygen inhalation sedation and/or small doses of oral diazepam

Question 41

Allergy concerns in asthmatics

Answer 41

Asthmatics with nasal polyps at increased risk for allergy to aspirin, so avoid use

Question 42

Blood pressure and asthmatics

Answer 42

Monitor BP in event of asthma attack to observe for development of status asthmaticus

Question 43

Optimal chair position for asthmatics

Answer 43

Semisupine or upright

Question 44

Signs and symptoms of a severe asthma attack (8)

Answer 44

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

Question 45

Protocol if patient is experiencing a severe asthma attack

Answer 45

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

Question 46

Initial careful workup of tuberculosis patient (information to acquire) (5)

Answer 46

Medical history (i.e. diagnosis and date) Type of treatment provided ROS History of periodic physical examinations CXR for evidence of reactivation

Question 47

When do you postpone treatment of a TB patient?

Answer 47

Questionable adequacy of treatment time Lack of appropriate medical follow up evaluation since recovery Signs and symptoms of relapse

Question 48

How to manage TB patient if positive PPD

Answer 48

Verify evaluation by MD to rule out active disease Verify completion of drug therapy with isoniazid for 9 months Normal manner

Question 49

How to manage patient if exhibiting signs and symptoms suggestive of TB

Answer 49

Refer to MD for evaluation and postpone treatment | If treatment necessary, treat as for patient with sputum positive

Question 50

5 adverse effects of isoniazid

Answer 50

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)

Question 51

3 adverse effects of rifampin

Answer 51

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

Question 52

4 oral manifestations of asthma

Answer 52

- Allergic rhinitis - Headache - Dry mouth and related sequela - Opportunistic infection

Question 53

Define allergic rhinitis

Answer 53

Mouth breathing leading to increased upper anterior and total anterior facial height, higher palatal vault, greater overjet and higher prevalence of crossbite

Question 54

5 oral manifestations of TB

Answer 54

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)

Question 55

What is the potential significance of finding an enlarged neck lymph node?

Answer 55

If history of TB, can possibly be reactivation

Question 56

Describe the findings of oral candiasis

Answer 56

Wide spread, yellowish membrane that can be removed (peeled off) Erythema (inflammatory red patch near back of mouth)

Question 57

Describe the findings of nicotinic stomatitis and explain what these are exactly

Answer 57

``` Wide spread red dots (salivary gland inflammation) White patch (keratosis) ```

Question 58

Define leukoplakia

Answer 58

White patch without evidence of friction or injury (i.e. idiopathic)