2: Patient with Asthma

Case 2
Patient with Asthma

Medical History

Her medical history is pertinent for mild persistent extrinsic asthma (precipitated by dust, strong odors, tree pollen, and aspirin) that was diagnosed when she was a teenager. She is currently taking Flovent® (flucticasone) steroid inhaler, Singulair® (montelukast) leukotriene inhibitor, and Serevent® (salmeterol) long‐acting ®‐2 agonist inhaler twice a day. She uses Proventil HFA® (albuterol) inhaler (short acting ®‐2 agonist) as needed (two or three times a week most of the year but daily in the springtime when her allergies are most severe). Her last emergency room visit for asthma was 18 months ago, precipitated by an upper‐respiratory infection. She also takes birth control pills and a multivitamin.

  • Allergies:
    • No known drug allergies (NKDA)
  • Vital signs:
    • Blood pressure: 135/85 mmHg
    • Pulse: 72 beats/min
    • Respiration: 12 breaths/min
    • Height: 5′5”
    • Weight: 135 lbs
    • BMI: 22.5

Social History

Never used tobacco, uses alcohol socially two to three times a month.

Dental History

She uses an electric toothbrush twice a day and flosses occasionally. She had orthodontics as a teenager with four third‐molar extractions to correct “buck teeth.” She has routine periodic exams and cleanings. She has intact occlusal restorations on all molars, as well as buccal restorations on her mandibular molars. Periodontal probing depths <3 mm.

Dental Examination

Extraoral examination is unremarkable. Oral hygiene appears good with no visible plaque. Intraoral soft tissue exam reveals marginal inflammation present on maxillary anterior gingiva. Patchy erythema is noted on posterior palate and oropharynx as well as patchy depapillation of the posterior dorsum of the tongue. Her saliva appears frothy. Upon questioning, the patient states that she often feels that her mouth is dry, especially when she wakes up, and that she frequently “mouth breathes” at night.

Medical Considerations

Asthma is a chronic inflammatory disorder of the airways that affects 17.7 million (7.4%) adults and 6.3 million (8.6%) children living in the United States (Centers for Disease Control and Prevention 2013.) It is characterized by a hyperactive response to stimuli that results in periodic episodes of contractions of bronchial smooth muscle that causes reversible narrowing of airways leading to wheezing, coughing, chest tightness, and difficulty in breathing. Exposure to a variety of triggers (allergens such as dust, pet dander, mold and pollen; respiratory irritants such as tobacco smoke or pollution; upper‐respiratory infections, exercise, cold air) result in the release of histamine and cytokines that cause bronchospasm, hypersecretion of mucus, and impaired mucociliary clearance in the bronchi and bronchioles. Most patients have mild to moderate disease and have normal function with minimal symptoms between acute exacerbations. Classification of severity of disease is based on presence of symptoms (particularly nocturnal symptoms), interference with normal activity, decrease in lung function, and need for short‐acting (or rescue) medications. There are four levels of asthma severity: intermittent, mild persistent, moderate persistent, and severe persistent based on the frequency of symptoms, presence of nocturnal symptoms, and the effect on pulmonary function before treatment (National Asthma Education Program 2007).

Medical management of asthma includes reduction in risk factors by minimization of exposure to triggers and management of inflammation and acute symptoms. The goals of treatment are to:

  • prevent chronic symptoms and progressive loss of lung function,
  • maintain normal activity levels,
  • decrease the need for rescue medications, and
  • prevent exacerbation of acute attacks and minimize hospital visits (National Asthma Education Program 2007).

Pharmacologic management of asthma is divided into controller or maintenance drugs that are taken chronically to control and prevent asthma symptoms and reliever or rescue drugs that are used to relieve acute symptoms. Medications with different pharmacologic actions are added in a controlled manner depending on the severity of the symptoms. Common medications include:

Reliever/Rescue Drugs

  • Rapid‐onset/short‐acting drugs that are used to treat acute symptoms and have immediate effect
  • Short‐acting β2 agonists
    • Albuterol (Proventil®, Ventolin®, ProAir®) levalbuterol (Xopenex®), metaproterenol, pirbuterol, terbutaline

Controller/Maintenance Drugs

  • Slow‐onset/long‐acting drugs that are used to treat the underlying inflammatory component but have no immediate effect
    • Long acting β2 agonists
      • Arformoterol, (Brovana®), formoterol (Fordil®), salmeterol (Serevent®)
    • Anti‐cholinergics
      • Ipratropium bromide (Atrovent®), tiotropium (Spiriva®), methylxanthines, theophylline
    • Mast cell stabilizers
      • Cromolyn, nedocromil
    • Corticosteroids (inhaled)
      • Beclomethasone (Qvar®), budesonide (Pulimcort®), fluticasone (Flovent), mometasone
    • Corticosteroids (systemic)
      • Dexamethasone, fludrocortisone, methylprednisolone, prednisone
    • Leukotriene receptor antagonists
      • Montelukast (Singulair®), zafirlukast, zileuton (Zyflo®)
    • Combination inhalers
      • Fluticasone/salmeterol (Advair Diskus®), ipratropium/albuterol (Combivent®), budesonide/formoterol (Symbicort®)

Oral side effects of asthma drugs include xerostomia and potential increased caries risk (short‐ and long‐acting β2 agonists and anticholinergics) and oropharyngeal candida (inhaled steroids).

Dental Considerations

Elective care should only be done on asymptomatic, well‐controlled patients. Patients exhibiting symptoms (wheezing, coughing or history of an acute attack within the last 24 hours) should be rescheduled. Patients should be asked about:

  • Triggers of acute attacks
  • Frequency and severity of symptoms and acute attacks
    • Emergency room visit and hospitalizations
    • Attack management
  • Treatment
    • Controller drugs
    • Rescue drugs and frequency of use
  • Presence of symptoms currently
  • If patient uses a short‐acting bronchodilator, is the inhaler present?

Reduction or elimination of agents known to be triggers for the patient should be attempted. These include

  • Minimizing exposure to materials with strong or irritating odors (disinfectants, methylacrylate).
  • Be careful when using particulate irritants like prophy paste.
  • Avoid having the patient sit with mouth open for prolonged periods of time to avoid drying out the oropharynx and precipitating coughing.
  • Carefully position cotton rolls and suction tips to avoid stimulating the cough reflex.
  • Temperature in the operatory should be kept moderate.
  • Positioning patients who have difficulty breathing when fully reclined in a semisupine position.

Patients with drug‐related xerostomia should be educated about the potential of increased caries risk and an aggressive prevention plan should be initiated including regular dental appointments and daily fluoride supplements. Strategies such as sipping water frequently, using sugarless gum and mints, avoiding alcohol containing oral products and using over the counter salivary substitutes can be initiated (Table 10.2.1) to increase patient comfort but do not decrease the risk of caries. Patients who use inhaled steroids should be monitored for candidiasis and treated with antifungal medications as needed. Use of a spacer and instructing patients to rinse their mouths out with water immediately after use can help decrease the incidence of fungal infections.

Table 10.2.1: Specific Considerations for this Case.

Issue Potential problem Management
Asthma
  • Acute Attack
  • Make sure patient is asymptomatic and has taken all her daily medications
  • Have patient take puff of rescue medication before procedure
  • Have patient’s rescue inhaler on bracket table
Bleaching procedure Potential triggers

  • Pumice/prophy paste
  • Bleaching chemicals
  • Prolonged time in chair with mouth open
  • Make sure that smell is not potential trigger
  • Keep patient in semi‐supine position
  • Careful positioning of suction tip
  • Use rubber dam
  • Apply oral lubricant to prevent oral and airway drying
Acute attack
  • Airway compromise
  • Desaturation
  • Hypoxia
  • Wipe off bleach, remove lip retractors, dental dam and saliva evacuator.
  • Make note of time attack started
  • Sit patient up and allow them to assume position that makes them comfortable (usually will be sitting slightly forward)
  • Administer the short‐acting β2 agonist (repeat as needed) and administer low‐flow oxygen (3–4 L/min) via a nasal cannula or hood
  • Activate emergency response if no response after several minutes or condition deteriorates
Medication induced xerostomia
  • Increase caries risk and gingival disease
  • Patient comfort
  • Regular dental maintenance appointments
  • Excellent oral hygiene
  • Daily fluoride supplements
    • Toothpaste
    • Gel
    • Rinse
  • Daily application of CPP‐ACP
  • Avoid alcohol containing mouthrinses
  • Salivary replacements
Inhaled steroid use
  • Oropharyngeal candidiasis
  • Treat with topical antifungals
  • Use a spacer
  • Instruct patient to rinse mouth out immediately after use
Mouth breathing Anterior gingival inflammation Nightly application of dry mouth treatment gel to affected area

Take‐Home Hints

  1. Update medical history at every visit in terms of asthma activity, increased frequency of use of rescue medications and any changes in or presence of symptoms.
  2. Elective dentistry should only be performed on asymptomatic patients. The presence of coughing, wheezing or an upper‐respiratory infection necessitates reappointment.
  3. Make sure patient has taken most recent scheduled dose of antiasthma medications.
  4. Be aware of potential triggers present in the office and reduce or eliminate exposure.
  5. The patient’s own short‐acting β2 agonist should be readily available.
  6. Have the patient take a prophylactic dose of short‐acting β2 agonist immediately prior to procedure.

Jul 18, 2020 | Posted by in Dental Hygiene | Comments Off on 2: Patient with Asthma
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