1
Q
COPD stages according to this class
A
- Bronchitis (Stage I COPD)
- Emphysema (Stage II COPD)
2
Q
lung anatomy
#lobes?
A
3 in R, 2 in L
3
Q
airway path
A
trachea>primary bronchus>secondary bronchus>tertiary bronchi> respiratory bronchioles> alveoli
4
Q
asthma
A
Chronic inflammatory airway disorder
* Airway hyper-responsiveness to stimuli
* Bronchial edema
* Narrowing of the airways i.e., obstruction
5
Q
asthma airway events
A
smooth mm contraction and increased mucus
6
Q
normal vs asthmatic airway
A
7
Q
asthma signs and symptoms
A
Recurrent, reversible episodes of:
*Dyspnea (shortness of breath)
*Wheezing
*Coughing
*Tightness of chest
8
Q
Which of the following is a “true”
asthma symptom?
*Dyspnea (shortness of breath)
*Wheezing
*Coughing
*Tightness of chest
A
chest tightness
9
Q
asthma aggrivating and complicating factors
A
● Smoking
● Air pollutants (quality)
- urban
- industrial
10
Q
stages of asthma
A
- Controlled
- Partially Controlled
- Uncontrolled
11
Q
controlled asthma
A
12
Q
partially controlled asthma
A
13
Q
uncontrolled asthma
A
14
Q
types of asthma
A
- Extrinsic
- Exercise Induced
- Intrinsic
- Drug Induced
15
Q
extrinsic asthma
* common?
* demo?
* family history?
* Triggered by?
* Exaggerated host response?
A
- Most common
- Children and young adults
- Typical positive family history
- Triggered by allergens (pollen, dust, house
mites, animal dander, mold etc.) - Exaggerated inflammatory response
16
Q
extrinsic asthma pathway
A
Allergen→ T Helper Lymphocyte Type 2 (Th2)
→ antibody production of high levels of IgE → activation of mast cells, basophils and eosinophils → bradykinin, histamine, leukotrienes → bronchoconstriction
17
Q
exercise induced asthma
* Unknown?
* demo?
* Triggered by?
* Cold air role?
A
- Unknown pathogenesis
- Children and young adults
- Triggered by exercise and thermal changes
- Cold air irritates mucosa resulting in airway
hyperactivity
18
Q
exercise induced asthma pathway
A
Allergen→ T Helper Lymphocyte Type 2 (Th2)
→ antibody production of high levels of IgE
→ activation of mast cells, basophils and eosinophils
→ bradykinin, histamine, leukotrienes
→ bronchoconstriction
same as extrinsic
19
Q
intrinsic asthma
* common?
* demo?
* Triggered by?
* Infrequently associated with?
A
- Second most common
- Middle-aged individuals
- Triggered by respiratory irritants (tobacco, air
pollution, emotional stress, gastroesophageal reflux
disease (GERD) - Infrequently associated with family history
20
Q
how is intrinsic asthma pathway dif from the others?
A
normal IgE levels
21
Q
drug indcued asthma
subset of?
demo?
A
- Subset of intrinsic
- Affects children, young adults & middle-aged adults
22
Q
common drugs of drug induced asthma
A
➢NSAIDs, ASA
➢β-blockers
➢ACEi
➢Anticholinergic drugs (?)
➢Food dye
➢Metabisulfites in food and in local anesthetics with
epinephrine
23
Q
asthma tx
A
inhaled B2 agonists
SABA
LABA
24
Q
inhlaed b2 agonists
A
bind to ẞ2 receptors in lungs
smooth muscle relaxation
i.e., bronchodilation
25
SABA
are single use (rescue) medications used alone
26
LABA
used in combination with steroids on a scheduled protocol used alone leads to CVD complications ( arrythmias, etc)
27
side effects asthma tx
Tremors
tachycardia
Increases blood sugar
Cough
K decrease
28
common SABA
albuterol
29
LABA often used with what asthma stage
uncontrolled
30
anticholergenics used for asthma
atrovent and spiriva
31
methyxanthine used for asthma
theophylline
32
mast cell stabilizer for asthma
cromolyn
33
corticosteroids for asthma
used with LABA
demethasone, fludrocotisone, methylprednisolone, predinosone
34
LT receptor antag for asthma name
singulair
35
combo inhalers names
advair diskus and symbicort
36
asthma oral signs
* Mouth breather (high palatal vault, overjet, crossbite, greater facial height)
* Dry mouth
* Candida
* Enamel defects and caries
* Gingivitis/periodontitis
* Enamel erosion possible with GERD
37
uncontrolled Asthma
Dental Treatment Considerations
* Dental treatment should be limited to urgent care
only
* Treatment of acute pain, bleeding, or infection
38
stable asthma dental tx considerations
* Any indicated dental treatment may be provided if
management protocols are considered
* Consult with physician for severe persistent
asthma
use of inhlaer before appt
39
asthma rx interactions
* Aspirin?
* NSAIDs?
* Opioids and barbiturates?
* Sulfites in epinephrine?
* Aspirin can trigger asthma➢Avoid in susceptible patients
* NSAIDs can trigger asthma➢ Avoid in susceptible patients
* Opioids and barbiturates➢ Worry about respiratory depression; avoid use
* Sulfites in epinephrine preparation of local anesthetics➢Avoid in susceptible patients
40
asthma pt on Theophylline with macrolides or ciprofloxacin
➢Potent inhibition of CYP3A4
➢Increases levels of theophylline
➢Toxicity (arrhythmia and seizures)
41
asthma and cholergenic agonists
➢Effect of cholinergic agents promotes bronchoconstriction
➢Sialogogues are contraindicated in patients with uncontrolled asthma
42
Status Asthmaticus
→ Severe prolonged asthma attack (more than 24 hours)
→ life threateningAsthma
43
drug of choice for acute asthma attacks
SABA inhaler
44
dental tx considerations of any asthma
avoid?
reducing risk?
* Avoid known precipitating factors
* Reduce risk of attack:
➢Have patient bring medication inhaler to each
appointment
➢Recommend prophylaxis with inhaler before
appointments for those with moderate to severe
asthma.
45
Rx to avoid with dental tx ans asthma
➢Aspirin, NSAIDs, Narcotics, Macrolide antibiotics
like erythromycin.
➢Sulfite (preservative) containing local anesthetics
may need to be avoided
46
sedation for asthma pts
➢Nitrous (better)
➢Short-acting benzodiazepine
47
before any tx for severe asthma what should be done?
consult
48
asthma emergency pt presentation
* Respiratory rate >25 breaths/min, labored breathing
* Tachycardia >110 beats/min
* Flushed appearance
49
what to do with an asthma emergency in clinic
* Stop treatment, inform supervising faculty, administer O2, and call 4444
➢ Remove all items from patient’s mouth
➢ Record the time attack began
➢ Raise the dental chair
➢ Give short-acting β2-adrenergic agonist inhaler
➢ Administer oxygen
o Administer 0.3-0.5 ml of 1:1000 epinephrine –small doses are SM dilators
o Call an ambulance
o Re-administer short-acting β2-adrenergic agonist inhaler every 20 minutes until EMS arrive
o The emergency team will continue treating the patient with bronchodilators and oral systemic corticosteroids
50
Chronic obstructive bronchiolitis defined
Chronic obstructive bronchiolitis (obstruction small airways)
* Excessive tracheobronchial mucus production to cause coughing and sputum production for >/=3 months for >/=2 consecutive years in the absence of infection or other causes of chronic cough
51
II. Emphysema
* Longterm Chronic obstructive bronchiolitis leads to destruction of lung parenchyma and alveolar walls
* Decreased elastic recoil
* Difficulty in maintaining airway opening during expiration
52
3rd leading cause of death in US
COPD
53
COPD and corticosteroids
Corticosteroid-resistant progressive chronic inflammatory disease
* Poorly reversible/irreversible airway obstruction
* Entrapment of air and dyspnea upon exertio
54
copd airway compared to healthy airway
55
Aggravating/Complicating Factors of copd
● Smoking
● Air pollutants (quality)- urban and industrial
● CVD- comorbidity
56
sign and symptoms COPD
dyspnea, cough, sputum
57
stages and severity of COPD
58
stage 1/mild COPD spirometry and s/s?
59
stage 2/ moderate copd spirometry and s/s?
60
stage 3/severe copd spirometry and s/s?
61
stage 4/severe copd spirometry and s/s?
62
copd exacerbating infections
Triggered by viral or bacterial infections
* Haemophilus influenza
* Moraxella catarrhalis
* Streptococcus pneumoniae
63
copd complications
* Pulmonary hypertension
* Cor pulmonale (R-sided heart enlargement)
* Thoracic bullae
* Nocturnal hypoxia
64
copd comorbidities
* Hypertension
* Ischemic heart disease
* Heart failure
* MI
* Muscle wasting
* Osteoporosis
65
copd tx rx
| only intervention that can reduce progression?
* Inhaled long-acting bronchodilators
* Corticosteroids if asthma also present and/or more reversible obstruction
* Smoking cessation is only intervention that actually reduces disease progression
66
copd oral manifestations
* Dry mouth
* Steven-Johnson syndrome with theophylline
Exacerbates Smoking Side Effects of:
* Halitosis
* Tooth staining
* Nicotine stomatitis
* Periodontal disease
* Oral potentially malignant disorders
* Leukoplakia
* Erythroplakia
* Oral squamous cell carcinoma
67
copd dental tx consideration of copd stage
Determine stage and severity of COPD
➢ Medical consultation for mild to moderate COPD to
determine the presence of respiratory failure right-sided heart failure
➢ If COPD Stage III or higher or who have respiratory and heart failure= Consider dental treatment in a hospital setting
68
dental tx if less than stage 3 copd
➢ Place the patient in?
➢ Avoid using a?
➢ Avoid treating if what is present?
➢ Local anesthetic with epi and low flow O2 (2L/min)?
o May need to limit epi if?
➢ Place the patient in a semi-supine position to avoid
respiratory distress
➢ Avoid using a rubber dam (??)
➢ Avoid treating if upper respiratory infection is present
➢ Local anesthetic with epi is acceptable and low flow O2 (2L/min) can be used
o May need to limit epi if concomitant CVD
69
meds to avoid with dental tx in copd
* Avoid medications that cause respiratory depression
➢Barbiturates
➢Narcotics
➢Nitrous oxide is contraindicated
➢Benzodiazepines (low dose may be acceptable in
certain situations)
o Consult physician
70
copd pts taking theophylline should not be prescribed?
* Erythromycin, macrolide antibiotics (clarithromycin, azithromycin, etc.) and ciprofloxacin
71
TB
Granulomatous infectious disease caused by
Mycobacterium tuberculosis
Lungs are most common site of infection
Due to the multiple species of Mycobacterium (m.
bovis, m. abscessus, m.microti, m.africanuum,
etc.), TB can also affect cutaneous, lymphatic and
other tissues
72
how much of population has TB
estimates 1/3 of human population is infected, greatest single pahtogen killer
73
why does the US have lower TB rates
* better sanitation
* improved hygiene
* more efficient delivery of anti TB medications
74
majority of new USA cases are?
54% of new USA cases are in foreign born
migrants or travelers; this rate has been on the
increase since 1993
75
at risk TB populations
* Racial and ethnic minorities
* Inner city residents in congregate facilities
* immunocompromised patients (HIV, medication
suppressed, DM, etc
76
Disproportionate affected populations of TB are?
Disproportionate affected populations are India,
eastern Europe, China
77
trnasmission TB
Airborne Transmission via infectious respiratory droplets from
* Coughing
* Sneezing
* Talking
* Singing
78
s/s of TB
* Persistent, unexplained cough
* Fever
* Malaise
* Night sweats
* Unintentional weight loss
* Hemoptysis
* Dyspnea
79
TB risk factors:
* Individuals from countries with?
* Individuals who visited areas with?
* Close contact with?
* Individuals who reside or work in?
* Individuals from countries with high incidence or prevalence of TB
* Individuals who visited areas with high prevalence of active TB
* Close contact with individuals who have TB
* Individuals who reside or work in facilities with high risk exposure
➢Health care facilities
➢Nursing homes
➢Correctional facilities
➢Homeless shelters
➢Accommodations for the mentally disabled
80
TB risk factors
* Individuals who have had?
* Individuals at increased risk of?
* Infants, children and adolescents exposed to?
* Individuals who have had skin test conversion within the past 2 years
* Individuals at increased risk of latent TB
➢Medically disadvantaged/underserved
➢Low income
➢Alcohol or drug use disorder
* Infants, children and adolescents exposed to
➢Individuals at increased risk of latent TB or active TB
➢Individuals with a positive TB skin test
81
TST and IGRA TB test results
82
TB oral signs
uncommon
* More frequent presentation:
➢ Deep irregular, painful ulcer on the tongue dorsum
➢ May occur in other areas as well (gingiva, lips, palate, buccal mucosa)
* SCROFULA
83
scrofula
* TB involvement of cervical and submandibular lymph nodes
* Lymph nodes are enlarged and painful
* Abscess with purulence may be present
84
Risk of Progression to Active TB pt populations
demogrpahics
85
TB tx phases for antibiotic regimen
86
multidrug resistant TB tx
87
multidrug resistant TB tx
88
dental tx considerations for TB, determining infectivity?
Determining if a Patient is Noninfectious
* Patient has taken?
* Patient has been compliant with?
* acid-fast bacillus (AFB) testing?
* Patient is?
* Unlikely?
* All close contacts?
Determining if a Patient is Noninfectious
* Patient has taken standard multidrug therapy for TB for 2-3 weeks
* Patient has been compliant with standard multidrug therapy for TB
* Three (3) consecutive negative sputum smears on acid-fast bacillus (AFB) testing
* Patient is clinically improved
* Unlikely (negligible) multidrug-resistant TB
* All close contacts were identified, evaluated, and began treatment for latent TB, if necessary
89
Dental Treatment Considerations
Active Sputum-Positive TB
* Emergency care only in hospital environment
➢ Isolation
➢ Negative pressure ventilation
➢ Respiratory protection
* If hospital unavailable treat urgent dental problems with palliative care (medications: analgesics, antibiotics)
* Consult physician before treatment
➢ Place patient in an isolated area
➢ Provide patient with a mask
➢ Arrange transportation
90
Recent Conversion to Positive Tuberculin Skin Test dental tx
* Consult physician
➢ Rule out active TB
➢ Verify adequate completion of therapy (9 months)
* If ”no clinically active tuberculosis” → treat as normal
patient (noninfectious)
91
if s/s of TB approach as?
sputum positive
92
dental tx with hx of TB
* If consistently negative sputum?
* History to know?
consult/request?
when to postpone?
* If consistently negative sputum
➢ Treat as normal (non-infectious)
* History
➢ When
➢ How treated
➢ Exposures
➢ Treatment duration
➢ Review of systems
* Consult physician before treatment
* Request
➢ Results from periodic chest radiographs
➢ Results from recent physical examinations
* Postpone treatment if
➢ Treatment time reported seems questionable
➢ Follow-up protocols since TB treatment are
inadequate
➢ Signs and symptoms of reactivation/relaps
93
hx of latent TB dental tx
* Similar to?
* Verify?
* Treat as?
* Similar to history of TB
➢ Medical history
➢ Review of systems
➢ Consult physician to rule out active disease
* Verify prophylactic isoniazid therapy (at least 6
months of therapy)
* Treat as non-infectious
MED COMP PTS
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