Respiratory disease

Respiratory disease 4,5,6,12,32,33

Viral Upper Respiratory Infections

Allergic Rhinitis

Sinusitis

Pharyngitis and Tonsillitis

Asthma

Chronic Obstructive Pulmonary Disease

Cystic Fibrosis

Viral Upper Respiratory Infections

The most common cause of acute respiratory illness is viral infection, which

occurs more commonly in children than in adults. Rhinoviruses account for the

majority of upper-respiratory infections. In addition to rhinoviruses, several other

viruses, including Coronavirus, influenza virus, parainfluenza virus, adenovirus,

Enterovirus, coxsackievirus, and respiratory syncytial virus, have also been

implicated as causative agents. Infection by these viruses occurs more commonly

during the winter months in temperate climates.

Clinical manifestations –

Common symptoms include rhinorrhea, nasal congestion, and oropharyngeal

irritation. Nasal secretions can be serous or purulent. Other symptoms that may be

present include cough, fever, malaise, fatigue, headache, and myalgia.

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Oral manifestations –

The most common oral manifestation of upper respiratory viral infections is the

presence of small round erythematous macular lesions on the soft palate. These

lesions may be caused directly by the viral infection, or they may represent a response

of lymphoid tissue. Treatment of upper respiratory infections with decongestants may

cause decreased salivary flow, and patients may experience oral dryness.

Allergic Rhinitis

Allergic rhinitis is a chronic recurrent inflammatory disorder of the nasal mucosa.

The basis of the inflammation is an allergic hypersensitivity (type I hypersensitivity)

to environmental triggers. Allergic rhinoconjunctivitis can be seasonal or perennial.

Typical seasonal triggers include grass, tree, and weed pollens. Common perennial

triggers include dust mites, animal dander, and mold spores.

Clinical manifestations –

The symptoms of allergic rhinoconjunctivitis can vary from patient to patient and

depend on the specific allergens to which the patient is sensitized. Nasal symptoms

may include sneezing, pruritus, clear rhinorrhea, and nasal congestion. Other

symptoms can occur, such as postnasal drainage with throat irritation, pruritus of the

palate and ear canals, and fatigue.

Oral manifestations –

The use of decongestants and first-generation antihistamines may be associated

with oral dryness. There may also be an increased incidence of oral candidiasis in

long-term users of topical corticosteroid-containing sprays.

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Sinusitis

Sinusitis is defined as an inflammation of the epithelial lining of the paranasal

sinuses. The most common trigger is an acute upper respiratory infection.

Clinical manifestations –

The symptoms of acute sinusitis include facial pain, tenderness, and headache

localized to the affected region. Other symptoms that are commonly described include

purulent nasal discharge, fever, malaise, and postnasal drainage with fetid breath.

Occasionally, there may be toothache or pain with mastication. Patients with chronic

sinusitis often present with other symptoms that are often vague and poorly localized.

Chronic rhinorrhea, postnasal drainage, nasal congestion, sore throat, facial fullness,

and anosmia are common complaints.

Oral manifestations –

Patients with sinus infections who present with a complaint of a toothache are

commonly encountered in a dental office. Chronic sinus infections are often

accompanied by mouth breathing. This condition is associated with oral dryness and

increased susceptibility to oral conditions such as gingivitis.

Pharyngitis and Tonsillitis

Inflammation of the tonsils and pharynx is almost always associated with

infection, either viral or bacterial. More than 90% of cases of sore throat are related to

viral infections. These infections can be associated with fever, rhinorrhea, and cough.

Clinical manifestation -

Sore throat is the predominant symptom. Associated clinical findings are based on

the infectious etiology. Patients with Epstein-Barr virus infections develop infectious

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mononucleosis, a disease characterized by exudative tonsillopharyngitis,

lymphadenopathy, fever, and fatigue. Herpangina is a disease that is characterized by

ulcers that are 2 to 3 mm in size and located on the anterior tonsillar pillars and

possibly the uvula and soft palate. Hand-foot-and-mouth disease is characterized by

ulcers on the tongue and oral mucosa, in association with vesicles found on the palms

and/or soles. Measles is a disease with a prodromal phase that is characterized by

symptoms of upper respiratory infection, tonsillopharyngitis, and small white lesions

with erythematous bases on the buccal mucosa and inner aspect of the lower lip

known as Koplik’s spots. Streptococcal pharyngitis is characterized by exudative

tonsillitis and fever.

Oral manifestations –

The association between Group A β Hemolytic Streptococci infection and the

development of severe complications, such as rheumatic fever and its associated heart

condition, is well known.

Dental management –

- Clinical manifestations of allergic conditions is produced after the release of

mediators. Mediators have direct effect on tissues, producing increased

vascular permeability, bronchoconstriction, and hypersecretion of mucus.

Histamine being the most common mediator released. Narcotics should be

avoided, since they can cause histamine release, a potential precipitator of an

asthmatic attack.

- Use of rubber dam is advocated for the patient with nasal obstruction,

although a slight modification is made in its application. Utilize a 5 Х 5 inch

dam rather than the 6 inch used in most adult operative procedures. Centre the

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quadrant to be islolated on the dam rather than centering the dam over the

facial structures. With the young frame this modification will shift the dam to

one side of the mouth, allowing easier oral breathing and evacuation of

secretions within the oral cavity. The dam will also prevent further palatal or

pharyngeal irritation.

Asthma

Asthma is a chronic disease that affects the lower airways. It is characterized by

recurrent and reversible airflow limitation due to an underlying inflammatory process.

Clinical manifestations –

Clinical features of asthma are recurrent reversible airflow limitation and airway

hyper-responsiveness. The signs and symptoms of asthma, which include intermittent

wheezing, coughing, dyspnea, and chest tightness. Symptoms of asthma tend to

worsen at night and in the early morning hours. Triggers include allergens, exercise,

cold air, respiratory irritants, emotional extremes, and infections. Corticosteroids are

the most effective anti-inflammatory agents used in asthma therapy, reducing the

number of inflammatory cells and their activation in the airways. Corticosteroids

reduce eosinophils in the airways and sputum, and numbers of activated T

lymphocytes and surface mast cells in the airway mucosa. These effects may account

for the reduction in airway hyper responsiveness that is seen with chronic

corticosteroid therapy.

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Corticosteroids inhibit
Phospholipase A2 phospholipase and COX
pathway

Arachadonic acid
Aspirin inhibits the
COX - 1 COX - 2 cycloxygenase
pathway

Prostaglandin thromboxanes Prostaglandins

Oral manifestations –

- An increased prevalence in caries has been reported in patients with moderate

to severe asthma. This may be implicated to β agonists effects on the salivary

gland function. The β agonists causes release of thick mucous secretion from

the salivary acini by stimulation of the β receptors.

- The impaired nasorespiratory function has been suggested as an etiologic

factor in the development of certain dentofacial deformities. Patient with

chronic rhinitis and mouth breathing have been found to present with

increased upper anterior and total anterior facial height, higher palatal vaults,

greater overjets and higher prevalence of posterior cross bites. It causes

rotation of the mandible in a clockwise manner so that the mandible is in aa

more vertical and backward direction, cusing elongation of the lower anterior

face height, and retrognathia.

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- The use of nebulized corticosteroids can result in throat irritation, dysphonia

and dryness of mouth, oropharyngeal candidiasis and, rarely, tongue

enlargement.

- Gingivitis is also seen in asthmatic patients which is attributed to the use of

inhaled corticosteroids and mouth breathing habit frequently seen in these

children.

Dental management –

- Dental management of children depends on the pulpmonary status of the

patient at the time of the dental intervention.

- The practitioner should consider the following points to know how well the

disease is controlled :

 The frequency of asthmatic attacks.

 The type of medications used chronically and during acute attacks.

 The length of time since the child was last seen with acute asthma.

- Dental procedures may be accomplished in the clinic setting for the

asymptomatic or well controlled asthmatic.

- Preventive approach is the mainstay for asthmatic children. Simple daily

routine procedures such as drinking of water or swishing the mouth with

water after taking liquid medicaments would help in clearing the oral cavity.

- If a patient has been or is currently using a metered dose inhaler

bronchodilator, it should be brought to each dental appointment.

- Anxiety is a trigger in children with asthma, and dental environment is a

common site for an acute asthmatic attack. A calm and confident approach by

the dental staff may alleviate anxiety.

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Conscious sedation-

- If conscious sedation is required, hydroxyzine, which has antihistaminic and

sedative effects, and benzodiazepines, which are anxiolytic and do not induce

bronchoconstriction, are usually recommended.

- Barbiturates and narcotics should be avoided in children with asthma

because of their potential for stimulating histamine release, which can

lead to bronchospasm.

- According to Malamed, the use of N2O in children with mild to moderate

asthma can effectively prevent acute symptoms. However, because N 2O is

somewhat irritating to the airway, its use in children with severe asthma

is contraindicated, and medical consultation is recommended prior to

N2O use in these children.

General anesthesia management-

- IV sedation should be used with extreme caution as asthmatics have

limited control of their airways. Ketamine, a dissociative anesthetic with

sedative, analgesic and bronchodilating properties has been used safely in

asthmatic patients.

- Patients who have anything more than mild asthma should have

procedures performed where standard monitors and intubation

equipment are available.

- Nearly 4% of patients with asthma are allergic to aspirin and other NSAIDS.

Thus, acetaminophen usually is recommended for these children.

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- Patients using theophylline preparations should not receive

erythromycin, because it interferes with the metabolism of theophylline

and raises its blood level to toxic levels.

- Local anesthetics with vasoconstrictors should be used with caution since they

may add to the effects of β agonists, resulting in palpitations, increased blood

pressure, and arrhythmias.

- Asthmatic children exposed to systemic glucocorticoids may be at risk for

developing adrenal insufficiency during major dental procedures or general

anesthesia. They have a greater risk of developing anesthesia related

complications post- operatively.

- Children with asthma on maintenance systemic Glucocorticoids are

adrenally suppressed and need to be supplemented on the day of the

dental procedure by doubling the patients usual dose.

- Antifungal medications has to be administered for oral candidiasis,

particularly in patients who are taking inhaled corticosteroids.

- Poorly controlled patients with nocturnal wheezing, frequent severe attacks,

uncontrolled exercise induced bronchospasm, or poor pulmonary function,

should have dental treatment postponed until the asthma is controlled.

Emergency management -

- The following steps should be taken to manage an acute asthmatic attack in

the dental office :

 Discontinue the dental procedure and allow the patient to sit or lie

down in a position.

 Keep the airway open and administer β2 agonists with inhaler or

nebulizer.

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 Administer O2 via face mask, nasal hood, or cannula.

 If no improvement takes place and the patient is worsening,

administer epinephrine subcutaneously( 1:1000 solution, 0.01mg/kg

of body wt to maximum of 0.3mg) and call for medical assistance.

Chronic Obstructive Pulmonary Disease

“Chronic obstructive pulmonary disease” is a term used to describe chronic and

largely irreversible airway obstruction due to inflammation of the lower airways.

Chronic bronchitis is diagnosed on clinical criteria and is defined as coughing and

sputum production for 3 or more months per year for at least 2 consecutive years.

Emphysema is diagnosed by histopathology and is defined by enlarged air spaces and

the loss of alveolar tissue. The hallmark features of COPD are dyspnea and

hypoxemia.

Clinical manifestations –

Patients with chronic bronchitis present with dyspnea, cough, and sputum

production. An increase in the production of often purulent sputum is a sign of

exacerbation due to respiratory infection. Physical findings include diffuse wheezing,

possibly associated with signs of respiratory distress including the use of accessory

muscles of respiration (retractions) and tachypnea. Liver enlargement due to

congestion, ascites, and peripheral edema can develop as the disease progresses to

pulmonary hypertension and cor pulmonale. This leads to the characteristic clinical

patient presentation termed the “blue bloater.” Patients with emphysema present

primarily with dyspnea. Patients can be adequately oxygenated in the early stages of

the disease and thus can have fewer signs of hypoxia; the term “pink puffer” has been

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used to describe these patients. Physical findings include an increase in chest wall

size. Wheezing is present to varying degrees.

Cystic Fibrosis

Cystic fibrosis (CF) is a genetic disorder characterized by hyperviscous secretions

in the respiratory and gastrointestinal tracts. Thickened secretions affect the pancreas

and intestinal tract, causing malabsorption and intestinal obstruction. In the lungs,

viscid mucus causes airway obstruction, infection, and bronchiectasis. Cystic fibrosis

is an autosomal recessive inherited disease. The responsible gene, which codes for the

cystic fibrosis transmembrane conductance regulator (CFTR), is located on

chromosome 7.

Clinical manifestations –

Patients with CF may present in infancy with extrapulmonary manifestations such

as meconium ileus or failure to thrive. Pulmonary manifestations include coughing,

recurrent infections of the lower respiratory tract, and bronchospasm. As the disease

progresses, digital clubbing and bronchiectasis may become apparent.

Dental considerations –

- The dental management of cystic fibrosis patient the dental history should

include the severity of pulmonary insufficiency, the presence or absence of

emphysema, past and current antibiotic exposure and the number of

superimposed infections.

- Orofacial examination should include the nature and production of mucus

secretions, nasal obstruction with or without polyps, the presence of chronic

sinusitis, salivary gland enlargement with the production of thick ropy saliva,

and periodontal and/or caries problems.

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- Periodontal conditions from mouth breathing and calculus accumulations

appear to be significantly related and hence care must be taken to maintain the

oral hygiene.

- Sedation must be used with caution, narcotics and major tranquilezers should

not be used, for they can further depress the respiration.

- Since the N2O – O2 administration tends to dry the respiratory membranes, the

parent should be adviced to increase the number of postural drainage periods

for a few days to aid in eliminating the mucus.

- The patient will often prefer an upright chair position to facilitate breathing

and the management of secretions. The rubber dam should be adjusted as

described for the allergic patients.

General anesthesia consideration in respiratory disease

- The most important cause of bronchospasm during general anesthesia is

tracheal intubation. For this reason tracheal intubation is avoided when

possible and, when necessary, is performed only after airway reflexes are

thoroughly depressed with both general and local anesthetic agents.

- Lidocaine prevents reflex induced bronchospasm and can be given IV 1 –

2mg/kg. Lidocaine 1 – 3mg/kg/h by infusion can also be a useful adjunct in

patients whose airways require more anesthesia than their cardiovascular

systems can tolerate.

- For patients who demonstrate active bronchospasm at the time anesthesia is

induced, ketamine 1 -2mg/kg IV is probably the drug of choice, since it

increases circulatory concentrations of epinephrine and directly dilates

tracheal smooth muscle.

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- If wheezing develops during the course of anesthesia, bronchospasm is the

most likely cause. Once bronchospasm is assumed to be present, 100% O 2 and

an increased concentration of inhalational agents are delivered.

- If increasing anesthetic depth does not resolve the bronchospasm, β agonists

are the drugs of choice.

- In cystic fibrosis, the patient is well hydrated to prevent further inspissation of

secretions.

- Patients are administered parenteral Vit. K.

- Atropine is usually avoided because it may inhibit the clearance of secretions.

- If a general anesthetic is required, halothane is useful because it allows rapid

induction and emergence from anesthesia, is potent enough to allow

administration of high concentration oxygen, and is bronchodilating.

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