University of Babylon/ College of dentistry

DENTAL MANAGEMENT FOR

PATIENT WITH ASTHMATIC ATTACK

Supervision by : Dr Ahmed Maky(M.SC Oral surgeon)

‫إعداد الطلبة‬

‫ذوالفقار علي محسن‬

‫مصطفى ابراهيم خليل‬
‫محمد ياسين جاسم‬

_group B ‫ الرابعة‬:‫المرحلة‬
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Overview
1 Asthma is inflammatory disease of the airway that lead to
bronchospasm and overproduction of thick mucus in the airway.

2- This lead to symptoms of coughing, dyspnea and wheezing.

3 - Every 250 death in the world, 1 death is due to asthma, however, it is

a benign reversible disease that can be managed with proper care and
most deaths are due to lack of treatment.

4-Types of asthma includes: allergic (extrinsic), non-allergic (intrinsic),

drug-induced and exercise-induced
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Signs and symptoms

1 -Attacks usually occur at night, but may also follow exposure to
allergen, exercise, respiratory infection, or emotional upset or
excitement.

2-Asthma attack characterized by airway hyper-responsiveness (hyper-

sensitivity).

3-Symptoms include: wheezing, dyspnea, coughing, chest tightness, and

flushing.

Dental management
1-i Identify asthmatic patients by history. Ask the patient about type of
asthma, precipitating factors, severity and frequency of attacks, the time
of day that attack most often occur, and whether he has been hospitalized
for acute asthmatic attack.

2- Patient with unstable disease should be referred for medical care and
dental appointment is postponed.
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3-Patient who has night asthmatic attack should be given late-morning

appointment.

4-Avoid aspirin, NSAIDS, barbiturates, and narcotics because they may

precipitate an asthmatic attack.

5- Avoid macrolides antibiotics (clindamycin, azithromycin, etc..) and

ciprofloxacin in patients taking theophylline to avoid theophylline
toxicity.

6-Ask patient to bring his medication/inhalator with him.

7- Prophylactic inhalation before dental procedure is recommended.

8-Stress during dental appointment should be reduced to avoid an

asthmatic attack.

9- Nitrous oxide is a recommended sedative in stressed asthmatic patient

because it has no respiratory-depressing properties.

10-If oral sedative required, low-dose short acting benzodiazepines (e.g,

diazepam) may be used.

11-Local anesthesia containing epinephrine or levonordefrin also

contain sulfite component which may precipitate asthmatic attack.
Therefore plain local anesthesia is recommended, especially in
moderate to severe asthmatic patients.

12-Asthmatic patient taking long-term systemic steroids may

require supplemental dose of his medication in major surgeries
(not required in routine dental treatment). However, long-term
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inhalation of steroids require no supplemental doses, unless daily

inhalation dose is very high.

Asthmatic attack
1 -An acute asthmatic attack require immediate therapy.

2-Fast acting bronchodialtor (Ventolin, Proventil) should be provided

immediately and it is most effective.

3-In severe asthmatic attack that not responsive to previous treatment,

subcutaneous epinephrine(0.3-0.5 mL, 1:1000) injection is helpful.
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4-Other supportive measures include providing oxygen and repeating

inhalation every 20 minutes.

5-Call ambulance if the situation required.

Oral manifestation
1- Nasal symptoms, allergic rhinitis, and mouth breathing are common
with allergic-type asthmatic patient.

2-Asthmatic patient who are mouth-breather has increased height of

palatal vault, greater overjet and higher prevalence of crossbite.

3-Gastroesophageal reflux is common in asthmatic patient which may

cause teeth erosion.

4-Some asthmatic medication may affect oral environment such as

decreasing salivary flow, and increased prevalence of gingivitis and
caries.

5- Rarely, asthmatic patient develop oral candidiasis due to steroid

inhalation without a spacer. It is very responsive to antifungal
treatment.
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Dental management of children with

asthma

Safe dental management of children

with asthma depends on the pulmonary status of the patient at the time of
the dental intervention. For patients with asthma, the practitioner should
consider the following to determine how well the disease is controlled:
1) the frequency of asthmatic attacks, 2) the type of medica- tions used
chronically and during acute attacks, and 3) the length of time since the
child was last seen emergently with acute asthma. Physical examination
may include auscultation of the lungs, observation of the rate and depth
of respiration, use of accessory muscles for respiration, shortness of
breath, and cough- ing. For a severe asthmatic, consultation with the
patient's primary care physician is recommended. Dental procedures may
be accomplished in the clinic setting for the asymptomatic or well-
controlled asth- matic. A wheezing or poorly controlled patient should
be reappointed. If a patient has been or is currently using a metered dose
inhaler bronchodilator, it should be brought to each dental appointment.
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Anxiety is a trigger in children with asthma, and the dental envi-

ronment is a common site for an acute asthmatic at- tack." A calm and
confident approach by the dental staff may help alleviate anxiety. If
conscious sedation is required, hydroxyzine (Vistaril™, Pfizer Labs,
NY, NY), which has antihistaminic and sedative effects, and
benzodiazepines, which are anxiolytic and do not in- duce
bronchoconstriction, are usually recommended.". 4* Barbiturates and
narcotics (especially morphine and meperidine) should be avoided in
children with asthma because of their potential for stimulating histamine
release, which can lead to bronchospasm. The anal- gesic and anxiolytic
properties of nitrous oxide (N,O), as well as the supplemental oxygen
received during N,O administration, are thought to help manage chil-
dren with asthma.® According to Malamed,º the use of N,O in children
with mild to moderate asthma can effectively prevent acute symptoms.
However, because N,O is somewhat irritating to the airway, its use in
chil- dren with severe asthma is contraindicated, and medi- cal
consultation is recommended prior to N,O use in these children.9. 50 IV
sedation should be used with extreme caution as asthmatics have limited
control of their airways. Ketamine, a dissociative anesthetic with
sedative, an- algesic, and bronchodilating properties,%. 53 has been used
safely in asthmatic patients.. 54 However, ketamine's sympathetic
activation is of concern for patients with a history of cardiovascular or
hyperten- sive heart disease. Patients who have anything more than mild
asthma should have procedures performed where standard monitors
(pulse oximetry, end-tidal SaCO, EKG, and blood pressure cuff) and
intubation equipment are available. Patients with asthma who are prone
to abrupt and severe episodes of airway obstruc- tion are best treated in a
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hospital. Children with asthma may be at risk for significant adverse

reactions to medications commonlyused in dental practice. Nearly 4%of
patients with asthmaare allergic to aspirin and other nonsteroidal anti-
inflam-

matory agents, s5 Thus, acetaminophen usually is rec-

ommended for these children. Patients taking theo-

phylline preparations should not receive erythromycin,

because it interferes with the metabolism of theophyl-49

line and raises its blood level into the toxic range.

Historically, dentists have been warned not to use lo- cal anesthetics with
vasoconstrictors in asthmatic pa- tients because vasoconstrictors contain
sodium metabisulfite, a highly allergenic substance.S6, 57 Despite

this warning, local anesthetics with vasoconstrictors

have been used safely2 s However, from another point

of view, local anesthetics with vasoconstrictors should

be used with caution since they may add to the effects

of ~2-agonists, resulting in palpitations, increased blood

pressure, and arrhythmias.

Asthmatic children exposed to systemic glucocorti-

coids (GC) may be at risk for developing adrenal insuf-

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ficiency during major dental procedures or general

anesthesia. They also have a greater risk (up to three

times) than children without asthma for developing

anesthesia-related complications postoperatively,

Children with asthma on maintenance systemic GC (daily or every other

day) are adrenally suppressed and

need to be supplemented on the day of the dental pro-

cedure by doubling the patient’s usual daily dose.

Children at risk for developing adrenal insufficiency with major dental

procedures or general anesthesia

include those who have had four or more brief courses (4-5 days/course)
6° or a continuous 10-14 day course of systemic GCfor acute asthma
within the previous

year, and those who have taken systemic GC within 30-59 days

replacement doses of steroids (60 mg hydrocortisone m2/dose) 6-8 hr

before, and again I hr before the pro- cedure, 61 although this is not
generally agreed to by all authors.Sg, 62 Children with asthma whodo
not fit these

categories,categories, and those who do but are undergoing only minor

dental procedures, such as routine examination, cleaning, and simple
operative procedures, do not re- quire supplemental steroids. Children
with severe asthma require an anesthesi- ology evaluation to avoid the
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risk of developing peri- and postoperative complications. A review of

the patient's history, a physical examination, and in se- lected patients, a
determination of pulmonary function (chest radiograph and peak
expiratory flow or spirom- etry) may be necessary to identify those who
require adjustment of their asthma therapy prior to dental treatment.
Pulmonary function tests can identify some patients who are
asymptomatic but are significantly obstructed and have a below-normal
FEV, (the forced expiratory volume in 1 sec, a common measure of air-
obstruction). Poorly controlled patients and those 59 way with nocturnal
wheezing, frequent severe attacks, un- controlled exercise-induced
bronchospasm, or poor pulmonary function, should have dental
treatment postponed until the asthma is controlled.
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Reference
1-Little and Falace's Management of Medically Compromised
Patients, 8th Edition

2. McCarthyTP, Lenney W: Managementof asthma in pre-

school children. Br J GenPract 42:429-34,1992.

3. CloughJ: Asthmain the very young. Practitioner 239:198- 202,

1995.

4. Brook U, WeitzmanA, Wigal JK: Parental anxiety associated

with a child’s bronchial asthma. Pediatr Asthma Allerg Immunol
5:15-20, 1991.

Thank you