ASTHMA

Dr. Jamil Salman

Oral & Maxillofacial Surgeon
Assistant prof. AAUP
 DEINITION
Asthma is a chronic inflammatory disease of the airways characterized
by reversible episodes of increased airway hyper responsiveness, which
results in recurrent episodes of dyspnea, coughing, and wheezing.
 Epidemiology

• affects 2–5% of the overall population and is increasing,

particularly in childhood.
• Usually begins in childhood or early adult life.
• about half the patients with asthma develop it before age
10.
 ETIOLOGY
• The exact cause is not completely understood.
• Multifactorial, interaction between the environment and
genetic susceptibility,
Allergic or extrinsic asthma
Intrinsic asthma
Ingestion of certain drugs. [e.g. aspirin and other
NSAIDs, beta-blockers and angiotensin converting
enzyme (ACE) inhibitors].
Exercise-induced asthma. (possibly due to cold air).
Infectious asthma (especially viral, mycoplasmal or
fungal).
 Allergic or extrinsic asthma

(allergic asthma), the main childhood type,

may be precipitated by allergens in
• animal dander, feathers or hair,

• inhaled seasonal allergens such as pollens, dust, house mites.

• food (e.g. eggs, fish, fruit, milk, nuts),
• drugs [e.g. non-steroidal anti-inflammatory drugs (NSAIDs)
and some antibiotics],
• This type of asthma is associated with IgE
overproduction on exposure to allergens, and release of
mast cell mediators (histamine, leukotrienes,
prostaglandins, bradykinin and platelet activating factor),
which cause bronchospasm and edema.
• About 75% of asthmatic children loose their asthma or
improve by adulthood.
 Intrinsic asthma

is usually of adult onset and is not allergic. Rather, it appears

to be related to mast cell instability and airway hyper-
responsivity,
• triggered by emotional stress,
• gastroesophageal reflux or
• vagally mediated responses.
 PATHOPHYSIOLOGY

In asthma, obstruction of airflow

occurs as the result of

• bronchial smooth muscle spasm,

• inflammation of bronchial
mucosa,

• mucus hyper secretion,

• and sputum plugging.

Histologic findings are those of inflammation and airway remodeling, including

(1) thickening of the basement membrane (from collagen deposition) of the bronchial
epithelium,

(2) edema,

(3) mucous gland hypertrophy and goblet cell hyperplasia,

(4) hypertrophy of the bronchial wall muscle,

(5) accumulation of mast cell and inflammatory cell infiltrate,

(6) epithelial cell damage and detachment, and

(7) blood vessel proliferation and dilation.

These changes contribute to decreased diameter of the airway, increased airway

resistance, and difficulty in expiration.
 CLINICAL PRESENTATION
Signs and Symptoms
Typical symptoms and signs of asthma consist of

• wheezing,

• reversible episodes of breathlessness (dyspnea),

• cough,

• chest tightness,

• flushing.

• Tachypnea and prolonged expiration.

• The onset usually is sudden, with peak symptoms occurring within 10 to 15 minutes.

• Termination of an attack commonly is accompanied by a productive cough with thick, stringy mucus.

• Episodes usually are self- limiting, although severe attacks may necessitate medical assistance.
 COMPLICATIONS

Good prognosis, especially those in whom the disease develops during childhood.

The condition can progress to

• COPD,

• respiratory failure,

• or status asthmaticus, the most serious manifestation of asthma, may occur.

 Status asthmaticus

• is a particularly severe and prolonged asthmatic attack (one lasting longer than
24 hours) that is refractory to usual therapy.

• Signs include increased and progressive dyspnea, jugular venous pulsation,

cyanosis, and pulsus paradoxus (a fall in systolic pressure with inspiration).

• often is associated with a respiratory infection and can lead to exhaustion, severe
dehydration, peripheral vascular collapse, and death.
 LABORATORY AND DIAGNOSTIC FINDINGS

Diagnosis of asthma is based on clinical history and presentation, laboratory tests for asthma are
relatively nonspecific, and no single test is diagnostic.

Commonly ordered tests include

1. 6-minute walk test,

2. spirometry before and after administration of a short-acting bronchodilator,

3. chest radiographs (to detect hyperinflation),

4. skin testing (for specific allergens),

5. bronchial provocation (by histamine or methacholine chloride challenge) testing,

6. sputum smear examination and cell counts (to detect neutrophilia or eosinophilia),

7. arterial blood gas determination,

8. antibody-based enzyme-linked immunosorbent assay (ELISA) for measurement of environmental

allergen exposure.
 Classification
• Intermittent or persistent disease

• (mild, moderate, or severe asthma).

• Severity is based on ; age , frequency of symptoms, impairment of lung function, and

risk of attacks.

Intermittent
• Symptoms ≤2 per week;

• brief exacerbations; asymptomatic between exacerbations;

• nocturnal symptoms <2 per month;

• FEV >80%
1
Mild persistent asthma
• Persons older than 12 years of age ,
• symptoms more than twice per week but not daily
• FEV greater than 80%.
1

• Symptoms generally last less than 1 hour.

Moderate persistent asthma

• FEV1 greater than 60% but less than 80% and ,
• daily symptoms that affect sleep and activity level and,
• require occasional emergency care.

Severe persistent asthma

• FEV1 less than 60%
• symptoms throughout the day that limit normal activity.
• Attacks are frequent or continuous, occur at night,
• and result in emergency hospitalization.
 MEDICAL MANAGEMENT

The goals of asthma therapy are:

• limit exposure to triggering agents,

• allow normal activities,

• restore and maintain normal pulmonary function,

• minimize the frequency and severity of attacks,

• control symptoms,

• and avoid adverse effects of medications.

These goals are best accomplished by

• educating patients for precipitating factors (e.g., smoking cessation)

and comorbid conditions (rhinosinusitis, obesity).

• a plan for regular self-monitoring, and regular follow-up care.

• Antiasthmatic drug based on the type and severity of asthma and

whether the drug is to be used for long-term control or quick relief.
Current guidelines recommend a “stepwise” approach

• Inhaled anti-inflammatory agents as first-line drugs (the preferred inhalational agent

is a corticosteroid preparation, with a leukotriene inhibitor as an alternative) for the

long-term management and prophylaxis of persistent asthma.

• β2-adrenergic agonists (salmeterol or salbutamol) are recommended for intermittent

asthma , and are secondary agents that should be added (i.e., not to be used alone) for

persistent asthma when anti-inflammatory drugs are inadequate alone .

• Alternative drugs include mast cell stabilizers (cromolyn and nedocromil),

immunomodulators, anticholinergics (tiotropium), and theophylline. Combination

therapy with these medications often is used to improve lung function.

 DENTAL MANAGEMENT
The primary goal in dental management of patients with asthma is to
prevent an acute asthma attack .
Identification and Risk Assessment.
• a good history, to determine the severity and stability of disease.

• adherence to medication use (especially in the previous 4 weeks),

• the type of asthma (e.g., allergic versus nonallergic),

• precipitating substances,

• frequency and severity of attacks,

• times of day when attacks occur,

• whether asthma is a current or past problem,

• how attacks usually are managed,

• and whether the patient has received emergency treatment for an acute attack.
• Obtain medical consultation if asthma is poorly controlled (as indicated
by wheezing or coughing or a recent hospitalization) or is undiagnosed or if
the diagnosis is uncertain.

• Encourage current smokers to stop smoking

• Routine dental treatment should be postponed until better control is

achieved.
 Recommendations
• Patients who have nocturnal asthma should be scheduled for late-morning appointments,
when attacks are less likely.

• Use of operatory odorants (e.g., methyl methacrylate) should be reduced before the
patient is treated.

• Patients should be instructed. to use their medications, to bring their inhalers

(bronchodilators) to each appointment, to inform the dentist at the earliest sign or
symptom of an asthma attack.

• Prophylactic inhalation of a patient’s bronchodilator at the beginning of the appointment

is a valuable method of preventing an asthma attack.

• The use of pulse oximeter is valuable for determining the patient’s oxygen saturation level.
Capacity to Tolerate Care. (stress reduction )
• all dental staff members should make every effort to identify
patients who are anxious and provide a stress- free environment.

• Preoperative and intraoperative sedation may be desirable.

‣ nitrous oxide–oxygen inhalation is best.

‣ Oral premedication with small dose of a short-acting

benzodiazepine.

‣ Reasonable alternatives with children are hydroxyzine (Vistaril),

for its antihistamine and sedative properties, and ketamine, which
causes bronchodilation.
 Drug Consideration

• Barbiturates and narcotics: should be avoided. particularly meperidine, they are histamine-releasing
drugs that can provoke an attack.

• Outpatient general anesthesia: generally is contraindicated for patients with asthma.

• Patients with high-dose systemic corticosteroids: may require supplementation for major surgical
procedures if their health is poor . ( >1.5 mg of beclomethasone dipropionate)

• Aspirin & NSAIDs: is not advisable because they can provoke asthma attack .

• Antihistamines : have beneficial properties but should be used cautiously because of their drying effects.
• Antibiotics

Macrolide antibiotics (i.e., erythromycin and azithromycin) or ciprofloxacin hydrochloride

shouldn’t be given to a Patients who are taking theophylline preparations because they
reduce its metabolism causing toxicity.

Allergy to penicillin may be more frequent in asthmatics.

• Local anesthesia

‣ the use of local anesthetic without epinephrine or levonordefrn may be advisable for
patients with moderate to severe disease.

‣ Sulfite preservatives are found in local anesthetic solutions that contain epinephrine or
levonordefrin,

‣ discuss with the patient any past responses to local anesthetics and allergy to sulfites
 Emergency (Asthma Attack).

Recognize the signs and symptoms of a severe or worsening asthma attack,

• inability to finish sentences with one breath,

• ineffectiveness of bronchodilators to relieve dyspnea,

• recent drop in FEV1 as determined by spirometry,

• tachypnea with respiratory rate of 25 ≥breaths/min,

• tachycardia with heart rate of ≥110 beats/min,

• Perspiration,

• accessory muscle usage,

 Management

• Administer fast-acting bronchodilator, short-acting β2-

adrenergic agonist inhaler (Ventolin, Proventil) is the most
effective and fastest acting bronchodilator. (note: corticosteroids
have delayed onset of action).
• Subcutaneous epinephrine (1 : 1000) in a dose of 0.3 to 0.5 mL
or inhalation of epinephrine (Primatene Mist).
• Monitoring vital signs (including oxygen saturation, 90% or
higher),
• Activate EMS;
• Positive-flow oxygenation,
• repeat administration of fast-acting bronchodilator every 20
minutes until EMS personnel arrive.
 Oral Complications and Manifestations

Nasal symptoms, allergic rhinitis, and mouth breathing are common with
asthma. mouth breathers may have altered nasorespiratory function, which may be
associated with

• increased upper anterior and total anterior facial height,

• higher palatal vault,

• greater overjet,

• higher prevalence of crossbite.

Severe asthma in children is associated with dental enamel defects;

Severe asthma in adults, is associated with periodontitis.

β2-agonist inhalers reduce salivary flow by 20% to 35%, decrease plaque pH, and
are associated with increased prevalence of gingivitis and caries in patients with
moderate to severe asthma.

Gastroesophageal acid reflux is common in patients with asthma and is

exacerbated by the use of β-agonists and theophylline. This reflux can contribute to
erosion of enamel.

Oral candidiasis (acute pseudo- membranous type) occurs in approximately 5% of

patients who use inhalation steroids for long periods at high dose or frequency.
Summery
“THANK YOU …”

Dr. Jamil Salman