Pulmonary diseases

Medically compromised patient

 Pulmonary diseases
Respiratory tract consists of:
• Upper respiratory tract: nose, paranasal sinuses, pharynx and larynx.
• Lower respiratory tract: trachea, bronchi, bronchioles and the lungs
(respiratory bronchioles, alveolar ducts alveolar sacs and alveoli).
 Chronic obstructive pulmonary diseases (COPD)
• It is a general term for pulmonary disorders characterized by chronic air flow
limitation from the lungs that is not fully reversible. The two most common
diseases classified as COPD are chronic bronchitis and emphysema.
Chronic bronchitis :
is defined as excessive trachea-bronchial mucous production causing chronic
cough and sputum production .for at least 3 months 1n at least 2 consecutive
years.
• Pathological changes:
• Thickened bronchial walls.
• Inflammatory cell infiltrate.
• Increased size of the mucous glands and goblet cell hyperplasia.
• Narrowing of the small airways, increased sputum production and ' collapse of
the peripheral airways.
• Obstruction of the airflow is on inspiration and expiration.
Emphysema :
It is the distention of the air spaces distal to the terminal bronchioles
because of the destruction 0f the alveolar walls and septa.
Pathological Changes:
Injury to the epithelium causing the release of the inflammatory mediators
that attract neutrophils which release the enzyme (elastase) causing
destruction of the alveolar walls. The obstruction is caused by the collapse
of these unsupported and enlarged air spaces on expiration.
Etiology
1. Genetic susceptibility.
2. Smoking.
3. Pollution.
4. Absence of alpha 1-antitrypsin.
Clinical presentation
Chronic bronchitis:
1. chronic cough .
2. copious sputum.
3. patients are usually overweight.
4. cyanotic.
5. edematous.
6. and breathless .
7. Patients have frequent respiratory infections; it may progress to Cor pumonale
(right sided heart failure).
Clinical presentation
Emphysema:
dyspnea on exertion.
non-productive cough.
patients are barrel chested.
weight loss.
expiration with pursing lips to forcibly exhale the air (pink puffers).
Diagnosis :
1. Measuring forced vital capacity (FVC) and forced expiratory volume in one
second (FEV1) by spirometry. FEV1/FVC ratio of less than 70% indicates
COPD.
2. Arterial blood gas measurement. In chronic bronchitis there is increased partial
pressure of CO2 (PCO2) and reduced partial pressure of 02 (PO2), while 1n
emphysema there is relatively normal PCO2 and reduced PO2, '
3. Chest radiographs.
Medical management
1. Smoking cessation and elimination of exposure to pollutants.
2. Exercise and good nutrition.
3. Prevention of infection.
4. Low flow supplemental oxygen when P02 is 88% or less.
5. Medical treatment which include among other drugs:
 Bronchodilators:
• inhaled agents are short and long-acting anticholinergics (e.g., ipratropium,
tiotropium)
• short-and long acting β2 adrenergic agonists bronchodilators that relax smooth
muscle
• inhaled corticosteroids.
 Phosphodiesterase inhibitors like theophylline.
 phosphodiesterase-4-selective inhibitors (e. g., roflumilast, cilomilast) .
 Antibiotics for pulmonary infections.
 Dental management
1. History and examination for the presence of COPD.
2. Encourage patients who Smoke to quit.
3. Assessment of the severity of the disease and the degree of control.
4. Patients with signs and symptoms of COPD; shortness of breath, respiratory
tract infection or reduced oxygen saturation (less than 91% by oximetry) should
be referred for medical evaluation and treatment and dental treatment should be
deferred.
5. Stable patients should be treated in upright or semi-supine position and to
avoid anything that could further depress respiration.
6. Local anesthesia is satisfactory but bilateral inferior dental nerve or palatal
nerve block should-be avoided
7. Avoid rubber dam application.
8. Low flow oxygen (2-3 L/ min.) should be considered when oxygen saturation
is reduced below 95%.
• 9. Avoid Nitrous oxide (N20) in severe COPD.
• 10. Avoid Barbiturates and narcotics (respiratory depression), anticholinergic
and antihistamine drugs (drying of the mucous membrane and increased
tenacity of mucous), because patients with chronic bronchitis may be already
taking these types of drugs and concurrent administration may cause additive
effects.
• 11. Patients who are treated with corticosteroids may need supplementation.
• 12. Patients may have hypertension and coronary heart disease and must be
managed accordingly.
• 13. Avoid macrolide antibiotics (e. g. erythromycin) and Ciprofloxacin 1n
patients taking theophylline to avoid toxicity (symptoms include. anorexia,
nausea, vomiting, nervousness, headache, agitation and cardiac arrhythmia.
• 14. Avoid outpatient GA, it should be in hospital setting.
Oral complications and manifestations
- Chronic smokers may exhibit increased likelihood for halitosis, extrinsic
tooth stains, nicotine stomatitis, periodontal diseases premalignant oral lesions
and oral cancer.
-Theophylline has been associated with Steven-Johnson syndrome.
 Asthma
• Is a chronic inflammatory respiratory disease that is associated with increased
airway hyper-reactivity, resulting 1n episodes of dyspnea, cough and
wheezing ,The exact cause is not completely understood but it is multifactorial.
Types:
• Extrinsic (allergic or atopic): the most common (35%) it is an exaggerated
inflammatory response that is triggered by inhaled seasonal allergens such as
pollens, dust, house mites, and animal dander's. it is IgE mediated sensitization
and is generally seen in children and young adults.
• Intrinsic (non-allergic): it occurs in about 30% of patients. This form of asthma
generally is seen in middle-aged adults, and its onset is associated with
endogenous factors such as emotional stress, gastroesophageal acid reflux, or
vagally mediated responses.
• Drug induced (salicylates, NSAlDs, cholinergic drugs, ACE inhibitors and B
adrenergic blocking drugs).
• Exercise induced.
• Infectious asthma, which may occur' due to Viral or fungal infections
• Some authors believe that asthma is 'of two types only; Extrinsic and Intrinsic,
and that both types can be precipitated by drugs, exercise and infections.
• The obstruction of the air flow occurs as a result of bronchospasm,
inflammation of the bronchial mucosa, mucous hypersecretion and sputum
plugging.
 Clinical presentation :
• Reversible episodes of breathlessness (dyspnea), Wheezing, cough, chest
tightness, tachypnea and expiratory wheezing The onset is sudden.
• Classification :
• Mild: brief attacks less than 2 days / week (FEV1) is more than 80%. It is
either intermittent or persistent.
• Moderate, several days/ week limited exercise tolerance, affect sleep and
FEV1 between 60%- 80%.
• Severe, frequent daily exacerbations, nocturnal asthma, exercise intolerance
and FEV1 less than 60%.
• Medical management
• Antiasthmatic drugs include:
• Anti-inflammatory
• Corticosteroids .
• β2 - adrenergic agonists.
• Anticholinergic drugs
• Systemic corticosteroids
Dental management
• The goal is to prevent acute asthmatic attack of the dental patient.
1. History: the dentist must determine type and severity of asthma, precipitating
factors, level of control (frequency, time of day, severity of attacks,
management, medications taken and the necessity of hospitalization).
2. Precipitating factors must be avoided.
3. For patients with severe unstable asthma, routine dental care should be
postponed and medical consultation is sought.
4. Always ask the patients to bring their bronchodilator inhalers With them, in
patients with history of moderate or severe asthma, a prophylactic inhalation
before dental treatment may be considered.
 5. Drugs:
A. Avoid Aspirin and other NSAIDs, use Paracetamol.
B. Avoid Barbiturates and narcotics
C. In patients taking Theophylline, macrolide antibiotics (e.g. Erythromycin) and
Ciprofloxacin should be avoided. Also Cimetidine is discontinued 24 hours before
I.V. sedation.
D. Patients taking corticosteroids may need supplementation.
E. Patients With Leukotriene modifying drugs may have prolonged INR and bleeding
tendency due to impaired liver metabolism.
6. Provide stress free environment, if pre or intraoperative sedation is required, N20 is
the best or small dose of Diazepam. In children Hydroxyzine or Ketamine can be
used.
7. Local anesthesia is used in dental treatment. Asthmatic patients may react
to sulfites (sulphites) used as a preservative in vasoconstrictor containing
local anesthesia.
• If local anesthesia With adrenalin is used it should be given with aspirating
syringe to avoid disarrhythmia in patients taking beta agonists.
Management of asthmatic attack :
1. Recognize signs and symptoms of acute attack:
A. Inability to finish sentences with one breath.
B. Tachypnea, more than 25 breaths / min.
C. Tachycardia, more than 100 beats / min.
D. Diaphoresis .
E. Accessory muscle usage
F. Ineffectiveness of bronchodilators to relieve dyspnea
G. Paradoxical pulse.
2. Stop the procedure.
3. Administer fast acting bronchodilator (Ventolin) at the first sign of the
attack.
4. Corticosteroids and long acting beta 2 agonists provide delayed response
5.Subcutaneous injection of adrenalin O. 3 - O. 5 ml 1:1000.
6.Positive flow oxygenation.
7. Repeat bronchodilators if needed
8. Monitor Vital signs.
9.Seek immediate medical assistance.
Oral complications and manifestations :
1. Nasal symptoms, allergic rhinitis and mouth breathing.
2. Altered naso-respiratory function leading to increased upper anterior facial height,
higher palatal vault, greater overjet and crossbite.
3. Beta agonists may cause decreased salivary flow leading to increased incidence of
gingivitis and dental caries.
4. Patients taking beta agonists and Theophylline may have increased risk of
gastroesophageal acid reflux leading to enamel erosion.
5. Patients with prolonged use of corticosteroid inhalers may have candidiasis
although rare.
6. Headache and facial pain are frequent in patients taking anti leukotrienes or
Theophylline.
 Tuberculosis (TB)
It is caused by infection with Mycobacterium Tuberculosis and it is primarily
a disease of the’ pulmonary System, although any organ of the body can be
involved. Other species of mycobacteria are encountered such as; M. avium
complex.
Mycobacterium tuberculosis is an acid fast, non motile, intracellular rod which
is obligate aerobic.
The organism is contracted by infected air borne droplets of mucus and saliva
during coughing, sneezing and talking. Another mode of transmission is by
ingestion of contaminated milk. Oral tissues may be infected by their own
sputum.
 Clinical presentation :
• In primary TB, there are few manifestations in 90% of the infected people.
Primary pulmonary TB is seen most often in infants and children; however,
cavitation is rare in these age groups, and children generally do not actively
produce or expectorate sputum while the usual form Of disease found in adults
18 called secondary or reinfection TB, which occurs with delayed reactivation
of persistent dormant viable bacilli and probably represents relapse of a
previous infection. Progression of the disease is associated with underlying
conditions that cause depression of the immune system.
• Symptoms include:
1. cough,
2. lassitude,
3. malaise,
4. anorexia,
5. weight loss,
6. fever,
7. night sweats,
8. sputum is mucoid but may become purulent,
9. hemoptysis
10. and dyspnea
11. 10- 20% of the cases have extra-pulmonary signs and symptoms which may include LAP,
back pain, GIT disturbance, dysuria and hematuria ‘ 1
• Some of the common sequelae of TB include:
• Pleurisy and pleural effusion.
• Meningitis.
• Miliary or disseminated TB.
• Isolated organ involvement other than that of the lung may occur, with the
pericardium, peritoneum, kidneys, adrenal glands, and bone (known as
Pott’s disease
Laboratory tests and investigations
1. Tuberculin skin test (TST)(Mantoux);
2. Interferon gamma release assays (IGRA)
3. Chest radiographs are helpful but not pathognomonic, they show cavitation and
hilar LAP.
4. Microscopic examination of the sputum for the presence of acid fast bacilli.
5. Culture or direct molecular tests that identify the M. tuberculosis or other
species from body fluids and tissues.
Medical management:
1. Patient education and compliance.
2. Appropriate selection of the drugs.
3. Multiple antibiotics like isoniazid, Rifampin and Pyrazinamide for sufficient
time (usually 6 months), but this can be extended for 12-24 months in cases of
drug resistance.
4. During treatment sputum culture should be tested for drug resistant bacteria
(most threatening feature of the disease).
• Multidrug Resistant TB (MDR-TB): is defined by the WHO as resistant to the
two strongest antituberculosis drugs, isoniazid and rifampin, it is the most
threatening feature of TB, it occurs in HIV infected persons and 1n many
countries Where TB is endemic.
 Dental management
• Many patients with infectious diseases cannot be identified, therefore all
patients should be treated as though they are potentially infected and standard
precautions for infection control should be strictly followed
I. Patients with clinically active sputum-positive TB
• 1. Consult with the physician before treatment.
• 2. Perform urgent care only.
• 3. Treatment, especially when hand piece is required, should be done in
hospital setting (proper sterilization, isolation, gloves, mask, gown and special
ventilation) and not as out patient.
• 4. Children under 6 years receiving TB therapy can be treated as normal non-
infectious patients and in outpatient setting, because cavitary disease is rare
and due to the inability of children to cough up sputum effectively.
• 5. Patients older than 6 years are treated in hospital setting and only urgent care
performed.
• 2. Patients with past history of TB
• Fortunately relapse is rare but this is not the case in patients with inadequate
treatment and those immunocompromised.
• 1. Obtain careful good history about treatment duration.
• 2. A good review of systems is essential.
• 3. Obtain history of periodic physical examination and chest radiograph to rule
out reactivation or relapse.
4 .Consult the physician if:
a. History of inadequate duration of treatment (less than 6 months)
b. Lack of appropriate follow up after recovery.
c. Signs and symptoms of the disease.
5. Treat as normal patient with standard precautions of infection control, if the
patient is free of clinically active disease.
 3. Patients with positive tuberculin test :
• Those patients in the absence of signs and symptoms of active disease are
considered to have latent TB and are not infectious.
• 1. Evaluation by a physician to rule out active disease.
• 2. Verify receiving Isoniazid for 9 months for prophylaxis.
• 3. Treat as normal patients with standard precautions of infection control.
4. Patients with signs and symptoms suggestive of TB
1. Any dental treatment should be postponed, the patient should be
referred for medical treatment.
2. If urgent care is necessary, treatment is the same as in the first group.
Oral complications and manifestations :
• Painful, deep irregular ulcer on the dorsum of the tongue, the palate, lips,
buccal mucosa and gingiva may be affected.
• Granular, nodular or leukoplakia mucosal lesions.
• Cervical and submandibular lymph node infections (enlarged and abscessed).
• Osteomyelitis When the infection extends to the bone.
• Rifampin can cause leukopenia, hemolytic anemia and thrombocytopenia
resulting in increased incidence of infection delayed healing and gingival
bleeding. - - Isoniazid, Rifampin and Pyrazinamide can cause hepatotoxicity so
Acetaminophen containing drugs should be avoided.
 Thank
You
For
Listening
Q/ Male patient 40 years old presented with predisposing disease of
infective endocarditis, he is allergic to penicillin, write the
prophylactic regime during dental treatment for this patient.