Etiology

Various substances or environmental factors can precipitate an asthmatic attack, including specific antigens such as pollen, ragweed, molds, foods, cockroaches, and house dust mites. Chemical irritants such as tobacco smoke, scents, and house sprays may trigger an asthmatic attack. Exposure by dental personnel to methacrylates found in dental restorative and sealant materials also has been cited as a possible link with occupational asthma.³ Other nonallergic stimulators—respiratory infections, environmental pollutants and irritants, exercise, cold air, and emotional stress—also can cause an attack. Generalized narrowing of bronchi and bronchioles caused by mucosal inflammation, increased secretions, and smooth muscle contraction produce asthmatic symptoms.^4,5

Signs and Symptoms

Clinical manifestations of asthma include periodic wheezing, dyspnea (difficulty in breathing), coughing, and chest tightness. These and other signs and symptoms are listed in Box 49-1. The onset of an asthmatic attack usually begins with mild wheezing and coughing, progressing to increased difficulty in breathing. As the attack develops, the individual may experience a sense of pressure or tightness in the chest and a feeling of suffocation. A severe asthmatic attack that does not respond to treatment with an adequate dose of commonly used bronchodilators is referred to as status asthmaticus. This condition may produce bronchospasms for hours or days without remission and often requires hospitalization.

Implications for Dental Hygiene Care

To prevent an acute asthmatic attack and to address the unique needs of the asthmatic client, the dental hygienist should do the following:

Assess the frequency, conditions and time of onset, and type—intermittent or persistent (mild, moderate, or severe)—of asthmatic attacks experienced; their management, including the type of medication used and precipitating factors; and whether an attack has warranted emergency treatment.⁴

Seek a medical consultation in cases of persistent moderate to severe asthma or when reported symptoms suggest poorly controlled asthma. Document if the client is taking systemic corticosteroids, such as prednisone, for chronic asthma. The physician may want to increase the regular dose of prednisone to prevent an adrenal crisis during a particularly stressful dental appointment.⁴

Note the precipitating factors reported by the client, and avoid these factors during professional care.

Instruct clients to bring the medical inhalers prescribed by the physician to every appointment, for use in case of an acute attack or prophylactically when chronic moderate to severe disease is present.

Note that some medications used by asthmatics cause xerostomia (dry mouth) and unpleasant taste sensation after inhalation use. Consequently the asthmatic client may be more prone to dental caries and gingivitis. Children in particular may increase their sucrose intake to combat the unpleasant taste from the inhalant. Table 49-1 describes drugs commonly used in the treatment of asthma.

Instruct the client to avoid drugs listed in Table 49-2, such as aspirin-containing medications, nonsteroidal anti-inflammatory drugs, barbiturates, and narcotics, because they can precipitate an attack.

Avoid use of the air polisher, a power-driven polisher, or an ultrasonic scaler (Table 49-3).

Use a local anesthetic agent without epinephrine or levonordefrin because some asthmatics are sensitive to the sulfite preservatives present in these anesthetic solutions.⁴

Make the oral care environment as stress-free as possible because anxiety can induce an asthmatic attack in many people, particularly children (see Chapter 37).

Use nitrous oxide–oxygen analgesia and/or small doses of diazepam, as prescribed by the dentist, to reduce stress if indicated⁴ (see Chapter 40).

Convey a calm, caring, and compassionate attitude to relax the client and to reduce stress-induced asthmatic attacks.

Evaluate children carefully for malocclusion; many asthmatic children are mouth breathers, and a correlation has been observed between higher palatal vaults, greater overjets, posterior crossbite incidence, and mouth breathing in children.⁶

Observe any asthmatic symptoms during and after dental procedures, because decreased lung function can be triggered by anxiety, supine positioning, tooth enamel dust, and aerosols commonly created by dental procedures.

Take prompt action to manage symptoms of an acute asthmatic episode (Procedure 49-1).⁴

Set goals with the client to achieve meticulous homecare to combat negative effects of medication and mouth breathing on oral health.

TABLE 49-1 Drugs Commonly Used in the Treatment of Asthma

TABLE 49-2 Contraindicated Drugs for the Individual with Asthma

TABLE 49-3 Techniques to Be Avoided in Individuals with Certain Respiratory Diseases

COPD, Chronic obstructive pulmonary disease.

Etiology

Cigarette smoking has been identified as the major risk factor in COPD. Air pollutants and industrial dust and fumes may contribute to COPD.^7,8 In some parts of the world air pollutants may be a primary risk factor for COPD.⁸ Underlying respiratory disease, severe respiratory infection in early childhood, underdeveloped lungs (during gestation and childhood), and genetic tendencies can all be risk factors for COPD.⁸

Signs and Symptoms of Chronic Obstructive Pulmonary Disease

Chronic bronchitis symptoms appear gradually but intensify in individuals who smoke or when atmospheric concentrations of sulfur dioxide and other air pollutants increase. A cough producing large amounts of sputum may linger for several weeks after a winter cold seems to be cured. With time, upper respiratory infections become more serious, and coughing and expectoration of phlegm continue for longer periods after each episode.⁹ Dyspnea (difficulty breathing) initially is mild and is brought on only by exercise or exertion. Eventually, breathing difficulty becomes more frequent and is brought on with less effort. At this point other symptoms of respiratory failure will be evident.⁴ As the disease progresses and becomes more obstructive, there may be evidence of prolonged expiration and wheezing. Acute attacks of breathing distress with rapid, labored breathing, intensive coughing, and bluish skin can occur; hence the term blue bloater has been used to describe an individual with these signs.⁶ As seen in Figure 49-1, COPD damages the airways and sacs in the lungs by reducing the elasticity, thereby making breathing more difficult.

Figure 49-1 Comparing healthy lungs and lungs with chronic obstructive pulmonary disease (COPD). The elasticity of airways and sacs in healthy lungs allows air to move quickly in and out of lungs. The airways and sacs in lungs with COPD lack the elasticity to allow lungs to retain their original shape. These airways lack support and become enlarged and lined with mucus, thereby making breathing more difficult.

(From NHLBI Health Information Center, www.LearnAboutCOPD.org.)

Emphysema can be localized or generalized. Individuals with localized emphysema may have no symptoms. At the early stage, symptoms of chronic bronchitis with cough and expectoration will predominate. As with chronic bronchitis, dyspnea occurs only with exertion but gradually over time intensifies in severity and frequency. Some individuals may experience rapid progression of dyspnea and disability, and others will experience a slower progression. Chronic coughing with expectoration, wheezing, recurrent respiratory infection, and fatigue may also be present. In later stages, severe dyspnea, cyanosis, and other signs of respiratory failure may be evident.⁴ As with chronic bronchitis, individuals may experience periods of exacerbation of symptoms usually related to infections or other complications.

Physical findings may be normal in cases of mild or localized emphysema. However, in more advanced cases there is usually weight loss and a “barrel-chest” appearance.^6,7 The client may appear short of breath and use accessory respiratory muscles. Many may find it easier to breathe in a sitting position, bent over and resting their elbows on their thighs. Usually, the expiration phase of respiration is prolonged and the client may be breathing against pursed lips. With some individuals, wheezing may be heard on expiration. In advanced stages of emphysema, cyanosis may be evident along with other signs of respiratory failure such as a change in mental state, headache, weakness, and muscle tremor or twitching.⁴

Management of Chronic Obstructive Pulmonary Disease

The management of COPD includes the following components⁸

As shown in Figure 49-2, treatment options begin with self-management, education, and avoidance of risk factors, especially smoking. Relieving symptoms and improving overall health through exercise, nutritional counseling, and treatment of complications as part of pulmonary rehabilitation can greatly improve the quality of life for these individuals.^8,10

Figure 49-2 Chronic obstructive pulmonary disease (COPD) is a progressive disease but with early diagnosis may progress slowly. Providers must monitor COPD clients carefully, ensuring the treatment is appropriate for the level of disease.

(From NHLBI Health Information Center, www.LearnAboutCOPD.org.)

Drugs Commonly Used in the Treatment of Chronic Obstructive Pulmonary Disease

Although there is no cure for COPD and medications cannot alter disease progression, they can improve airflow, relieve symptoms, and enhance the quality of life.⁸ Antibiotics are often prescribed during the acute attack of symptoms (exacerbation), particularly if there is a bacterial infection present. Bronchodilators, such as those used by asthmatics, have been commonly used as treatment. These drugs, particularly the beta₂ agonists, are fast acting and, in addition to relaxing the bronchial tubes, improve mucous clearance.⁸

Advanced cases of COPD are often treated with the addition of more medications as the disease state progresses. Treatment is individualized and monitored based on the response to therapy and side effects reported during treatment. A long-acting beta₂ agonist along with an anticholinergic may be followed by a methylxanthine as an add-on therapy for clients who have insufficient relief of symptoms. An inhaled glucocorticosteroid or combinations of medications in one inhaler may also be effective. At this stage many individuals are also on long-term oxygen therapy at home. Surgical removal of one lung may be indicated for some individuals.

Implications for Dental Hygiene Care

To meet the specialized needs of the individual with COPD, the dental hygienist should do the following:

Seat the client in a semisupine or upright chair position.

Plan short appointments to decrease stress if client does not tolerate sitting in dental chair for long periods of time.

Assess severity, frequency of symptoms, and conditions that exacerbate symptoms.

Review the health history for evidence of concurrent heart disease; take appropriate precautions if heart disease is present (see Chapter 42).

Assess for ineffective salivary flow related to medication-induced xerostomia.

If applicable, advise client to stop smoking and set goals with the client to initiate a smoking cessation program.

Monitor periodontal status; client is at increased risk for disease if a smoker.

Be especially observant of the potential for oral lesions if client is a smoker.

Avoid use of a rubber dam if possible, as this may further obstruct respiration.

When needed, cautiously use dental materials with a powder component (alginate or powdered gloves), as they may worsen the client’s airway obstruction if inhaled.

Also avoid use of a power-driven polisher or an ultrasonic scaler (see Table 49-3).

Offer low-flow (2 to 4 L/min) supplemental oxygen if needed.

Avoid nitrous oxide–oxygen inhalation sedation with emphysema (see Table 49-3).

Suggest low-dose oral diazepam or other benzodiazepine, as prescribed by the dentist, if needed to reduce stress.

Be aware that clients taking systemic corticosteroids may need supplementation to avoid adrenal crisis, particularly for major dental procedures.

Instruct the client to consult physician regarding herbal and drug interactions and use of alcohol if client is taking theophylline.⁸

Etiology

TB is caused by the bacterium Mycobacterium tuberculosis. Close contact with persons having TB increases the incidence of disease transmission to others. The following groups are at greatest risk for contracting TB:

Those infected with HIV

Alcoholics and intravenous drug abusers

Residents and employees of shared habitation settings: prisons, nursing homes, mental institutions, shelters

Healthcare workers who care for high-risk individuals

Immigrants from countries that have a high occurrence of TB

Medically underserved persons

High-risk racial or ethnic minority populations

Signs and Symptoms

The diagnosis of TB is made via an evaluation of several assessments, including a Mantoux tuberculin skin screening, commonly called a PPD test (purified protein derivative), chest radiograph, sputum culture, and review of clinical symptoms. TB is usually a chronic infection with various clinical manifestations, depending on the stage and duration of the disease.¹¹ Persons with primary pulmonary infection often have no clinical evidence of the disease. They test positive on a tuberculin skin test but do not have active TB and are not infectious. When symptoms are present, they are usually mild and include a low-grade fever, listlessness, loss of appetite, and occasional cough. The most common obvious symptom of active TB is a chronic cough. Other signs of disease progression include fever, night sweats, weight loss, central pulmonary necrosis (death of lung tissue), and cavitation (hollow spaces in the lungs).⁷

Treatment

Treatment of TB is dependent on whether an individual has active TB or only latent TB infection. Those persons who test positively for TB but do not have the disease may be treated with a preventive therapy. This treatment usually involves a daily dose of isoniazid (also called INH) or rifampin for 4 to 9 months.¹¹ Treatment for individuals with active TB may include a short hospital stay along with the concurrent administration of several drugs prescribed for 6 to 9 months.¹¹ Multi–drug-resistant TB is a dangerous form of TB often resulting from low patient compliance. A treatment referred to as “directly observed therapy,” which involves observing patients as they take each dose of medication, has been successful in some cases to remedy this problem. It is imperative for patients on a TB drug therapy regimen to be vigilant about taking medication as it has been prescribed even if symptoms have subsided.¹¹

Implications for Dental Hygiene Care

When considering treatment options for the individual with TB, the major concern is the risk of disease transmission.¹ TB may be transmitted from clients to dental professionals; conversely, if the clinician is infected, clients and other staff members may contract the disease. To prevent disease transmission and meet the needs of the client with TB, the dental hygienist does the following:

Uses universal infection control precautions, keeping in mind that many clients with infectious diseases such as TB may not be identified during assessments¹²

Recognizes signs and symptoms of TB when assessing the client’s health history, informs the dentist, and refers for medical care

Questions a client who reports a history of TB, or a positive result from a skin test for TB, concerning dates and results of chest radiographs, sputum cultures, and physical examinations by his or her physician

Determines the type of tuberculosis reported and the current health status of the individual

Consults with a physician to determine if it is safe to treat the client outside of a hospital setting; a client with active tuberculosis should be treated in a hospital setting under strict infection control conditions¹²

Minimizes aerosol contamination during treatment

Instructs client with suspected or confirmed TB to observe strict respiratory hygiene and cough etiquette protocols; clients should be kept in the dental setting no longer than is absolutely necessary¹²

Avoids use of an air polisher or an ultrasonic scaler (see Table 49-3)

CLIENT EDUCATION TIPS

Explain that rinsing the mouth with water after using an inhaler will decrease the risk of oral candidiasis and dental caries.

Explain that the use of a spacer attached to a metered dose inhaler may prevent candidiasis in asthmatics.

Explain that if the client experiences xerostomia and/or an unpleasant taste after inhalant therapy, the use of xylitol-containing chewing gum will increase salivary flow, minimizing the risks of dental caries and gingivitis.

Explain to clients undergoing drug therapy for tuberculosis (primary or active) the importance of compliance. Inconsistent or incomplete therapy may result in multi–drug-resistant tuberculosis and/or a longer recovery period.

Explain that smoking cessation is one necessary strategy for managing clients with respiratory diseases.

LEGAL, ETHICAL, AND SAFETY ISSUES

Acute asthma attacks may occur before, during, and after dental procedures. Dental hygienists must be knowledgeable in the management of such an attack. Avoidance of precipitating factors is the best risk-management strategy.

Clients reporting a history of asthma must have their bronchodilators at each dental appointment for immediate administration if necessary.

Clients with active tuberculosis should be treated in a hospital setting to minimize risk of disease transmission to personnel or other clients.

KEY CONCEPTS

Asthma is a respiratory disease characterized by an increased responsiveness of the airways to various stimuli, which causes periodic wheezing, dyspnea, coughing, and chest tightness.

An asthma attack may be triggered by allergens, anxiety, cold air, or exercise, or no apparent irritant may be involved.

Many asthma medications have side effects, including oral candidiasis and xerostomia.

Two major diseases categorized as chronic obstructive pulmonary disease (COPD) are emphysema and chronic bronchitis.

COPD is most often caused by cigarette smoking, but chronic exposure to occupational and environmental pollutants is also a risk factor contributing to COPD.

The major risk associated with treating clients with active tuberculosis is disease transmission; clients with active tuberculosis should be treated in a hospital setting only for emergency dental care.

Patient compliance problems during lengthy drug therapy for tuberculosis have contributed to the problem of multi–drug-resistant strains of tuberculosis.

There is a link between periodontal disease and systemic illnesses such as lower respiratory tract infections.

Pathogenic bacteria found in oral biofilm may be aspirated into the lungs of a seriously ill patient. These bacteria, along with epithelial changes in lung tissue associated with the inflammatory process, may increase the client’s susceptibility to a lower respiratory tract infection.

Effective daily oral hygiene care reduces the amount of oral bacteria available for aspiration into the lungs and may prevent lower respiratory tract infection such as pneumonia. Twice daily use of an antimicrobial mouth rinse is recommended.

Refer to the Procedures Manual where rationales are provided for the steps outlined in the procedure presented in this chapter.