The Dental Patient with Asthma PDF

The dental patient with asthma: An update and oral health considerations DEREK M. STEINBACHER and MICHAEL GLICK J Am Dent Assoc...

The dental patient with asthma: An update and oral health considerations DEREK M. STEINBACHER and MICHAEL GLICK J Am Dent Assoc 2001;132;1229-1239 The following resources related to this article are available online at jada.ada.org ( this information is current as of February 2, 2009 ): Downloaded from jada.ada.org on February 2, 2009 Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/cgi/content/full/132/9/1229 This article appears in the following subject collections: Pharmacology http://jada.ada.org/cgi/collection/pharmacology Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/prof/resources/pubs/jada/permissions.asp © 2009 American Dental Association. The sponsor and its products are not endorsed by the ADA.  D E N T I S T R Y & M E D I C I N E ABSTRACT Overview. Asthma is a serious global health problem that has steadily increased in prevalence during the past two decades. COVER STORY New classification and treatment guidelines have been published, and dental providers The dental patient with need to be aware of these changes. Literature Reviewed. The authors asthma searched textbooks and MEDLINE, looking for the most updated medical information on asthma, as well as for previous publica- An update and oral health tions on treatment of asthmatic patients in a dental setting. considerations Results. More than 9,000 articles on asthma were published in English between 1997 and 2000. From 1960 until 2000, DEREK M. STEINBACHER, D.M.D.; MICHAEL GLICK, Downloaded from jada.ada.org on February 2, 2009 D.M.D. approximately 40 articles specifically addressed asthma and dental care. The authors reviewed more than 300 articles sthma is a serious global health problem, from the medical literature and all articles A affecting more than 100 million people after 1980 that directly focused on oral worldwide. The prevalence of asthma in the health issues for importance and relevance. United States has increased steadily for the Conclusions. Recent information past two decades with no end in sight.1 It is regarding the etiology, pathogenesis and estimated that more than 17 million Americans are treatment of asthma had not been ade- affected, with a projected increase to as many as 22 mil- quately addressed in the dental literature. lion cases by 2010 and 29 million cases by 2020. Dental care of asthmatic patients may Although asthma is viewed by many as necessitate considerations beyond what has previously been published in the dental lit- In the treatment a fairly benign disorder, the mortality erature. rate for this disease has almost tripled of asthma, oral Clinical Implications. In the treat- in the past 20 years, reaching a peak of health care more than 5,000 annual deaths.2 This ment of asthma, as with treatment of most providers play a somber number is projected to double medical conditions, oral health care providers play a role that is important in role that is within the next two decades. Children, young adults and racial terms of both the patient’s overall health important in and ethnic minorities living in urban and the systemic condition’s effect on oral terms of both health. This article provides dentists with a areas compose the group of people at the patient’s timely update on asthma and the relation- highest risk. This is not surprising, as overall health health disparities play a significant role ship between asthma and oral health, and and the systemic in putting people at risk of developing it offers suggestions for safe and appro- priate dental care. condition’s this disease. However, other, less effect on understood factors also contribute to the 3-6 oral health. noted increased prevalence. Poverty- stricken inhabitants of the inner city social burden, accounting for numerous have a greater chance of developing the hospitalization stays and missed days of disease, and their disease often has a more severe pro- school and work. gression. Many different factors have been put forth as With increasing numbers of affected explanations of this phenomenon—crowded living condi- patients, oral health care workers need tions with poor ventilation, lack of access to quality to be adept at recognizing the signs and health care, reduced long-term adherence to and main- symptoms of asthma. Modifications to tenance of therapeutic regimens, family dysfunction, dental treatment may be indicated, and weak social supports and paucity of education.7-9 practitioners need to be capable of han- Asthma care represents a significant economic and dling acute exacerbations. To that end, JADA, Vol. 132, September 2001 1229 Copyright ©1998-2001 American Dental Association. All rights reserved.  D E N T I S T R Y & M E D I C I N E Airway inflammation in asthma has been char- FACTORS THAT PRODUCE AIRWAY acterized as acute, subacute or chronic. The acute OBSTRUCTION IN ASTHMA.* state of inflammation is caused by the release of Airway Smooth Muscle Spasm chemical mediators from activated resident cells, such as local airway mast cells undergoing his- Alterations in Respiratory Secretions With Mucous Plugging of Smaller Airways tamine degranulation. Subacute inflammation is marked by early cellular infiltrates, especially Inflammation eosinophils that release mediators with direct Eosinophil and lymphocyte infiltration and toxic effects on the respiratory epithelium. The activation airway inflammation is described as chronic when Mast cell activation lymphocytes and eosinophils mediate a persis- Subepithelial collagen deposition tent, ongoing inflammation, thus resulting in a continuous cycle of damage and repair. Long- Denudation of airway epithelium standing chronic inflammation can lead to irre- Edema of airway mucosa versible airway obstruction in a subset of patients * Based on information from Lemanske.11 with asthma. Downloaded from jada.ada.org on February 2, 2009 Bronchial smooth muscle contraction con- tributes markedly to the airway obstruction seen this article provides a review of asthma pathogen- in asthma, while vasodilation, diapedesis and esis, diagnosis and classification, treatment and vascular permeability account for the edematous pertinent oral health considerations. changes.11 These changes are attributed to cell- derived mediators. Mucus hypersecretion is also PATHOPHYSIOLOGY observed and can result in the development of The definition of a disease needs to be all- mucus plugs and associated dyspnea. encompassing and yet specific enough to single The strongest identified risk factor for the out afflicted people. This is important not only for development of asthma is atopy, an inherited epidemiologic purposes, but also for the develop- propensity to exhibit allergic reactions, and ment of efficient and appropriate treatment people with a family history of allergy have an strategies. When the pathogenesis is poorly understood, management many times will consist mainly of symptomatic therapy. At present, it is DIFFERENTIAL DIAGNOSIS OF not clear if asthma is one of numerous different ASTHMA.* diseases and conditions that have similar signs Chronic Obstructive Pulmonary Disease and symptoms, but different causes. Congestive Heart Failure Asthma is described as a chronic inflammatory disorder involving many cell types, manifesting Cough Secondary to Drugs (Angiotensin-Converting Enzyme Inhibitors) with episodes of chest tightness, coughing, labored breathing and wheezing, all of which are Laryngeal Dysfunction related to bronchiole inflammation. Symptoms Lower Respiratory Tract Infection can last for a few moments or for as long as days. Bronchitis (acute and chronic) The acceptance of inflammation and subsequent fibrosis as the underlying causes of disease pro- Bronchiectasis gression was the basis for a 1997 report on Bronchiolitis asthma diagnosis and management by a National Croup Heart, Lung and Blood Institute, or NHLBI, expert panel.10 The airway obstruction in asthma Viruses is initiated by inflammation and muscle spasm Mechanical Obstruction of the Airways but is mostly reversible (box, “Factors That Pro- Pulmonary Infarction or Embolism duce Airway Obstruction in Asthma”). It gener- ally is believed that both genetic and environ- Pulmonary Infiltration With Eosinophilia mental factors, as well as allergens, are Vocal Cord Dysfunction important in the initiation and continuation of * Source: National Heart, Lung and Blood Institute.10 the airway inflammation. 1230 JADA, Vol. 132, September 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.  D E N T I S T R Y & M E D I C I N E TABLE CLASSIFICATION OF ASTHMA BY SEVERITY.*† CLASSIFICATION MEDICATION(S) USED CLINICAL FEATURES BEFORE LUNG FUNCTION AT TIME (FREQUENCY) TREATMENT OF TREATMENT Step 4 Inhaled corticosteroids Continuous symptoms FEV1‡/PEF§ ≥ 60 percent Severe Persistent or of predicted values inhaled β2 agonist or Frequent exacerbations ipratropium bromide or Frequent nighttime symptoms PEF variability > 30 β2 agonist tablets or percent syrup Limited physical activity and/or oral corticosteroids (all used daily) Step 3: Inhaled corticosteroids Daily symptoms FEV1/PEF ≥ 60 percent Moderate or to < 80 percent of inhaled β2 agonist or Downloaded from jada.ada.org on February 2, 2009 Persistent Exacerbations that affect activity predicted values ipratropium bromide or Nighttime asthma symptoms PEF variability > 30 β2 agonist tablets or > one time per week percent syrup (all used daily) Daily use of inhaled short- acting β2 agonist Step 2: Inhaled corticosteroids Symptoms > two times per FEV1/PEF ≥ 80 percent Mild Persistent or week but < one time per day predicted value cromolyn or Exacerbations that may affect PEF variability 20-30 inhaled β2 agonist or activity percent ipratropium bromide or Nighttime asthma symptoms β2 agonist tablets or > two times per month syrup (all used daily) Step 1: Inhaled β2 agonist or Symptoms ≤ two times per FEV1/PEF ≥ 80 percent of Mild Intermittent ipratropium bromide, week predicted value but not more than three times per week Brief exacerbations (from a few PEF variability < 20 (both used as needed) hours to a few days) percent Nighttime asthma symptoms < two times per month Asymptomatic and normal lung function between exacerbations * Sources: National Heart, Lung and Blood Institute8; National Heart, Lung and Blood Institute.10 † The presence of one of the features of severity is sufficient to place a patient in that category. A person should be assigned to the most severe grade in which any feature occurs. A person‘s classification may change over time. ‡ FEV1: Forced expiratory volume in one second. § PEF: Peak expiratory flow. increased predilection for developing asthma. of asthmatic attacks. Additional triggers leading Common precipitating allergens underlying to asthma exacerbations include wood smoke, asthma pathogenesis include tobacco smoke, dust physical activity, emotional upset, cold air, food mites, animal fur, cockroaches, pollens, molds additives and aspirin.8 People with asthma vary and other airborne irritants (including acrylic and widely in their response to triggering factors. other aerosolized dental materials).8,12 Viral respi- DIAGNOSIS AND CLASSIFICATION ratory infections, small birth size and diet also may contribute to the development of asthma.8 Airway inflammation and hyperreactivity charac- The above-listed factors contributing to asthma terize asthma but do not have to be elicited for a development also are involved in the provocation diagnosis to be made. Demonstration of reversible JADA, Vol. 132, September 2001 1231 Copyright ©1998-2001 American Dental Association. All rights reserved. D E N T I S T R Y & M E D I C I N E such as bronchiolitis, croup, viral infections, acute CLASSIFICATION OF ASTHMA BY and chronic bronchitis and bronchiectasis. Sev- ETIOLOGY.* eral less common conditions are included in the Aspirin-Induced Asthma asthma differential diagnosis (box, “Differential Diagnosis of Asthma”[page 1230]). It should be Coexistent Asthma and Chronic Obstructive Pulmonary Disease assumed, until proven otherwise, that a patient with wheezing and related symptoms has asthma. Cough-Equivalent Asthma The course of the disease can change over time Exercise-Induced Asthma in affected people. For instance, symptoms can be Extrinsic Asthma moderate in childhood and mild in adulthood, becoming severe only during certain seasons.8 Factitious Asthma Asthma exacerbations can be mild, moderate or Intrinsic Asthma severe (Table). Asthma classifications based on Mixed Asthma etiology also exist, but these do not give an indi- cation of disease severity (box, “Classification of Occupational Asthma Asthma by Etiology”). It is important to realize Downloaded from jada.ada.org on February 2, 2009 Potentially Fatal Asthma that patients at any level of disease severity may * Sources: National Heart, Lung and Blood Institute 10; Reed.16 experience acute exacerbations. MANAGEMENT AND PHARMACOTHERAPY airway obstruction is the clinical criterion for asthma. In addition to the clinical manifestations Treatment of asthma begins with patient educa- of cough, shortness of breath, chest tightness and tion, particularly about avoidance of precipitating wheezing, it is not uncommon to see tachypnea, factors (such as animal dander). The goal of tachycardia, use of accessory respiratory muscles asthma therapy is to control the symptoms with and pulsus paradoxus.13 the least amount of medication necessary (box, Classically, reversible airway obstruction is “Treatment Goal: Control of Asthma”). This com- demonstrated by alleviation of the symptoms of monly is referred to as a stepwise approach, obstructed pulmonary functions with a bron- because with intensifying asthma severity, the chodilator. Pulmonary function tests are not number, potency and frequency of pharmacologic always necessary to diagnose asthma.13 A review agents are increased.8 For patients with mild, of symptoms, such as cough or dyspnea occurring intermittent asthma, the occasional use of an after exercise and relieved by bronchodilator, often inhaled short-acting ß2 agonist is indicated. By suffices.13 Also, if during a clinical examination the contrast, a regular regimen of asthma medication clinician observes wheezing and tachypnea, which is required for people with persistent moderate are accompanied by a respiratory infection that asthma. Additionally, pre-emptive measures can can be reversed with administration of a ß2 ago- be used to prevent exacerbations and severe nist, he or she also can suspect a positive asthma airway obstruction. diagnosis. During acute exacerbations, patients The rationale behind antiasthma treatment may show signs of respiratory distress, with involves an understanding of the underlying tachypnea, intercostal muscle retractions, nasal pathophysiologic condition. Appropriate pharma- flaring and cyanosis. However, clinical features cotherapy is designed with the salient features of can be misleading, and spirometry and peak expi- asthma pathogenesis in mind and is tailored to ratory flow rate meters are useful diagnostic and the disease’s level of severity. The characteristic monitoring adjuncts. airway inflammation and hyperresponsiveness Chest radiography may be useful, especially as are combated with the use of anti-inflammatory a means of excluding other diseases. drugs. Controlling inflammation leads to Although recurrent episodes of coughing, decreased bronchial hyperreactivity and an breathlessness and wheezing almost always are overall reduction of asthma symptomology. Con- due to asthma, a clinician should be cognizant versely, inflammation left unchecked can lead to that several other causes of airway obstruction fibrosis and irreversible airway obstruction. To manifest themselves in a similar manner. For address bronchospasm, asthmatic patients can instance, a localized obstruction of the airways use an aerosolized bronchodilator (that is, a ß2 can be due to lower respiratory tract infection agonist or theophylline). 1232 JADA, Vol. 132, September 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.  D E N T I S T R Y & M E D I C I N E Bronchodilators. Initial asthma therapy involves the use of a ß2 agonist metered-dose TREATMENT GOAL: inhaler, or MDI, for symptomatic relief. Self- CONTROL OF ASTHMA.* dosage is performed at the onset of an asthmatic Outcome: Control of Asthma episode or before exposure to aggravating stimuli, Minimal (or no) chronic symptoms, such as exercise or allergens. The achieved sym- including nocturnal symptoms pathomimetic effects include marked bronchodila- Infrequent episodes tion and a reduction in bronchial irritability. The MDI means of formulation and administration is No emergency department visits preferable to systemic delivery, because it demon- Minimal need for additional β2 agonist strates similar efficacy with fewer adverse effects. No limitations on activities, including However, it has been shown that up to one-half of exercise patients using inhalers use them improperly, Peak expiratory flow, or PEF, variability which results in less than optimal effectiveness.14 of less than 20 percent between PEF Also, use of the parenteral route occasionally may measurement on arising in the morning and PEF measurement in the afternoon be necessary in people who have severe airway Downloaded from jada.ada.org on February 2, 2009 obstruction, owing to the resultant reduction in Normal or near-normal PEF tidal volume.15 Another option for the person with Minimal (or no) adverse effects from mild asthma is the inhalation of cromolyn, either medicine alone or in combination with a ß2 agonist inhaler. Inhaled corticosteroids. When symptoms * Source: National Heart, Lung and Blood Institute.8 are more persistent and a short-acting ß2 agonist alone does not provide relief, the next tier of potency of nebulized corticosteroids. treatment should include inhaled corticosteroids. Leukotriene antagonists. Recently, Generally, the person with moderate asthma leukotriene antagonists have gained considerable requires medication daily. Inhaled corticosteroids attention as a more progressive treatment are used at a low dose—400 to 800 micrograms modality. Antileukotriene drugs, like zafirlukast, per day, or µg/day, of beclamethasone (up to a directly inhibit bronchoconstriction and have maximum of 2,600 µg/day).10,16 With inhaled corti- been shown to exhibit anti-inflammatory effects costeroids, rare systemic adverse effects are as well.20 The 1997 NHLBI Expert Panel Report observed. Local untoward manifestations include listed antileukotriene drugs as possible alterna- oral candidiasis, dysphonia and cough.17 If symp- tives to preferred therapy with inhaled cortico- tomatic relief still is not achieved with a modest steroids for the treatment of adult patients with dose of aerosolized corticosteroids, the inhalation mild persistent asthma.10 Although their efficacy concentration usually is increased to 2,000 µg of has not been wholly established, antileukotriene beclamethasone per day (or equivalent), or a long- drugs offer an attractive option for additive acting ß2 agonist (such as salmeterol) is added. therapy in patients who are treated with low to When these two alternatives are directly com- moderate doses of inhaled corticosteroids yet still pared, the results with salmeterol are favored, are symptomatic. but they vary greatly among individual Theophylline. The bronchodilator theo- patients.18,19 phylline also can be used in addition to, or in lieu Cromolyn and nedocromil. If the patient of, a ß2 agonist.17 However, theophylline has fallen cannot tolerate inhaled corticosteroids, the con- out of favor as of late owing to its narrow thera- ventional substitute for prophylactic therapy is peutic window and potentially severe adverse either cromolyn sodium or nedocromil sodium. effects. Erythromycin should be avoided in cromolyn is a mast cell stabilizer with virtually patients who are taking theophylline, as concomi- no adverse effects and can be used instead of or in tant use may result in elevated theophylline blood addition to aerosolized corticosteroids. levels. Nedocromil sodium is an anti-inflammatory agent Anticholinergics. The role of anticholiner- that inhibits mediator release and reduces airway gics, such as ipratropium bromide, in the treat- hyperreactivity.17 Both cromolyn and nedocromil ment of asthma is not clear. Some patients are used for maintenance therapy, rather than for respond well while others do not. It is known that treatment of acute attack, and both lack the anticholinergics have a slow peak onset of bron- JADA, Vol. 132, September 2001 1233 Copyright ©1998-2001 American Dental Association. All rights reserved. D E N T I S T R Y & M E D I C I N E chodilation (up to 90 minutes). No long-standing flow, an increased prevalence of oral mucosal xerostomic effects are noted when it is adminis- changes, increased levels of gingivitis and orofa- tered at therapeutic doses, but a bad taste in the cial abnormalities.29-33 mouth has been reported.21 Increased rate of caries development and Systemic corticosteroids. If the pathog- reduced salivary flow. Several studies have nomonic pulmonary symptoms of asthma are suggested that people with asthma have a greater refractory to aerosolized bronchodilators, anti- rate of caries development than do their nonasth- inflammatory agents and combinations thereof, the matic counterparts.34 This phenomenon has been last level of pharmacotherapy involves oral sys- attributed to prolonged use of ß2 agonists, which temic corticosteroids. These usually are reserved is associated with diminished salivary production for patients who continue to show poor control. and secretion.35 The effect of reduced salivary flow The adverse effects of short-term high doses of has been elucidated in both human and animal steroids include increased appetite, fluid reten- studies.34-37 One study demonstrated a reduction tion, insomnia and mood alteration, while long- of whole and parotid saliva by 26 percent and 36 term systemic steroid therapy can result in osteo- percent, respectively.38 As reduced salivary flow is porosis, hypertension, cataracts, diabetes, accompanied by concomitant increases in lacto- Downloaded from jada.ada.org on February 2, 2009 proximal myopathy and pituitary-adrenal axis bacilli and Streptococcus mutans in the oral suppression.22 With respect to maintenance cavity, it is not unlikely that this particular steroid therapy, it is imperative to use the lowest change among asthmatic people may be one of the possible dose in attempts to minimize these nega- major contributing factors in the noted increased tive effects. Patients receiving long-term oral cor- caries rate.35,39 In addition to reduced salivary ticosteroid therapy, or who recently have com- concentrations and increases in cariogenic micro- pleted such a regimen, may require a larger dose biota, higher rates of caries have been observed in before undergoing dental treatment or in the people with asthma, possibly due to antiasthma presence of an odontogenic infection.22 medications containing fermentable carbohydrate Epinephrine. For treatment of acute exacer- and sugar.40-42 It is evident that oral prophylactic bations refractory to nebulized bronchodilator, an strategies should be used to address the height- epinephrine solution of 1:1,000 weight per ened caries risk in asthmatic people. This volume, or wt/vol, remains the standard of includes increased frequency of dental mainte- therapy.23,24 For most adults, a dose of three- nance visits, fluoride interventions and adherence tenths of a milliliter of a 1:1,000 wt/vol solution is to caries-prevention measures. adequate and can be repeated every 15 minutes Oral mucosal changes. The use of nebulized for up to three doses.23 If signs of severe asthma corticosteroids can result in throat irritation, dys- still are exhibited after the second dose, the phonia and dryness of mouth, oropharyngeal can- patient should be sent to the emergency depart- didiasis and, rarely, tongue enlargement.24,43 ment. These side effects may be attributed to the topical New therapies. New immunomodulatory effects of these medications on the oral mucosa, treatments are being investigated for asthma as only 10 percent to 20 percent of the dose from management.25-27 These therapies focus on selec- an inhaler actually reaches the lungs; the rest tive antagonism of specific T-lymphocyte function remains in the oropharynx.44 Using a spacer and and response, blocking the effect of cytokines such rinsing the mouth with water after steroid as interleukin-5, as well as blocking the effect of inhalation can minimize the potential for candida asthma-triggering immunoglobulin E.28 Although growth.45 specific immunotherapy in the treatment of Gingivitis. Use of inhaled steroids has been asthma has shown promise as an additional ther- linked to increased levels of gingivitis.46,47 How- apeutic intervention, more research is necessary ever, the common practice of mouth-breathing in to substantiate it as a standard of care. asthmatic people, as well as various immunolog- ical factors, also may contribute to the observed ORAL HEALTH CHANGES IN PATIENTS WITH ASTHMA increase in gingival inflammation. It also has been suggested that asthmatic children exhibit The literature has described several oral health more calculus than do healthy children.47 This conditions associated with asthma: an increased possibly is caused by increased levels of calcium rate of caries development and reduced salivary and phosphorus found in submaxillary and 1234 JADA, Vol. 132, September 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.  D E N T I S T R Y & M E D I C I N E parotid saliva in children with asthma.48,49 taking. Only the most severely affected asthmatic Orofacial abnormalities. The association patients who are taking large doses of systemic between asthma and dentofacial morphology has corticosteroids fall into this category. The same been assessed, evaluated and discussed for many category of patients also may be at risk of adrenal years. The basis for this discourse is the descrip- suppression. The clinician should consider the tion of impaired nasorespiratory function in asth- need for prophylactic administration of antibiotics matic people, which has been coupled with the to prevent postoperative complications and for presence of specific dentofacial abnormalities.50,51 corticosteroid replacement therapy to prevent Studies have described increased upper anterior acute adrenal crisis. and total anterior facial height, higher palatal Before treatment. When an asthmatic dental vaults, greater overjets and higher prevalence of patient seeks care, the clinician must assess his posterior crossbites in children with chronic or her risk level by taking an oral history of the rhinitis and a tendency toward mouth- illness: ascertaining the frequency and severity of breathing.52,53 Although a long and tapered facial acute episodes, reviewing the patient’s medica- form, increased lower facial height and narrow tions thoroughly (as they provide an indication of maxillary arch have been observed in patients disease severity) and determining the patient’s Downloaded from jada.ada.org on February 2, 2009 with nasal respiratory obstruction and accompa- specific triggering agents. nying mouth breathing, a developmental It should be recognized that dental treatment causative relationship has never been substanti- can invoke a significant decrease in pulmonary ated with unequivocal answers.54,55 function among asthmatic patients. Mathew and colleagues56 demonstrated a reduction of lung MANAGEMENT IN DENTAL CARE function in 15 percent of asthmatic patients The administration of safe dental treatment for studied while receiving dental care. However, an asthmatic patient depends on his or her pul- they did not wholly elucidate the specific monary function, propensity for developing an causative aspects of dental treatment responsible acute asthmatic episode at the time of treatment, for this reduction. During dental treatment, the immune function and adrenal status. Preventing most likely times for an acute exacerbation are a sudden episode of airway obstruction is essen- during and immediately after local anesthetic tial when treating an asthmatic patient. The fre- administration and with stimulating procedures quency of asthmatic attacks, precipitating agents, such as extraction, surgery, pulp extirpation, and the types of pharmacotherapy used and the induction of or recovery from sedation or general length of time since an emergency visit owing to anesthesia. The major concern in the manage- acute asthma all should be taken into account ment of asthmatic patients undergoing routine when identifying the risk of an acute exacerba- dental care is preventing an acute exacerbation. tion.24 As a general rule, elective dentistry should For most patients, this may consist simply of con- be performed only on asthmatic patients who are firming that they have taken their most recent asymptomatic or whose symptoms are well- scheduled dose of medication. The patient’s own controlled. The symptomatic person should not be metered-dose inhaler bronchodilator should be on treated, and the presence of asthmatic symptoms hand at each visit. Ideally, to minimize the risk of such as coughing and wheezing necessitate reap- an attack, the patient’s appointment should be in pointment. However, the clinician also should the late morning or the late afternoon.63 If the realize that a patient could have significant asthmatic patient does not use a bronchodilator, airway obstruction and yet be asymptomatic he or she should be given one from the emergency during dental treatment.56 kit. Both a bronchodilator and oxygen should be Oral health care providers need to be aware available during treatment.39,64 of the potential for dental materials and products Inhaled corticosteroids are used for mainte- to exacerbate asthma. These items include denti- nance therapy and do not ameliorate an acute frices, fissure sealants, tooth enamel dust and attack. It has been suggested that a prophylactic methyl methacrylate.57-61 Fluoride trays and dose of ß2 agonist bronchodilator could prevent cotton rolls also have been implicated in pro- diminished lung function during dental treat- moting asthmatic events.62 ment.56 The H1-blocking antihistamines, too, have Patients’ immune status depends on the level been shown to be useful in blunting the bron- of immunosuppressive medications they are choconstrictor response with a pretreatment dose. JADA, Vol. 132, September 2001 1235 Copyright ©1998-2001 American Dental Association. All rights reserved.  D E N T I S T R Y & M E D I C I N E Ketamine has been used EMERGENCY PROTOCOL FOR MANAGING ASTHMATIC safely in asthmatic patients, EXACERBATION IN A DENTAL SETTING. but its exuberant adrenergic activity is a concern for Assessment of Severity* Acute exacerbations are manifested by episodes of bronchospasm patients with a history of and resulting hypoxia and hypercarbia. Management strategy is cardiovascular or hyperten- directed at determining the level of hypoxia and correcting it. The following indicate that the exacerbation is severe: sive heart disease.68,69 It is dpeak expiratory flow rate, or PEFR, is at or below 50 percent of suggested that dental reference value; doxygen saturation is below 91 percent; patients who have more than dbronchodilator does not improve PEFR by at least 10 percent after mild asthma should undergo two treatments; dpatient has difficulty speaking; procedures only where stan- dpatient is struggling for air. dard monitors and intuba- Managing an Acute Asthmatic Attack† tion equipment are avail- 1. Discontinue the dental procedure and allow the patient to assume able. A pulse oximeter is an a comfortable position. 2. Establish and maintain a patent airway and administer β 2 especially useful monitoring agonists via inhaler or nebulizer. device. An oxygen saturation Downloaded from jada.ada.org on February 2, 2009 3. Administer oxygen via face mask, nasal hood or cannula. If no improvement is observed and symptoms are worsening, administer of 97 percent to 100 percent epinephrine subcutaneously (1:1,000 solution, 0.01 milligram/ should be achieved on room kilogram of body weight to a maximum dose of 0.3 mg). 4. Alert emergency medical services. air. An oxygen saturation 5. Maintain a good oxygen level until the patient stops wheezing below 91 percent is an indi- and/or medical assistance arrives. cation for hospitalization. * Based on information from Copp.82 Consequently, patients with 29 30 † Based on information from Laurikainen and Kuusisto, Lenander-Lumikari and colleagues and Perusse 74 and colleagues. severe persistent asthma and those who are prone to severe abrupt episodes of Promethazine and diphenhydramine have the airway obstruction are best given dental treat- benefit of being antiemetic and sedative as well ment in the hospital. as antihistaminic. The oral health care provider should be aware Anxiety is a known asthma trigger, and the of the possibly skewed clinical presentation of a dental environment is a common site for an acute patient receiving anti-inflammatory treatment. asthmatic attack.65 Therefore, it should be ascer- Long-term use of these medications can compli- tained that the patient has taken his or her most cate diagnoses by masking infection and inflam- recent scheduled dose of antiasthma medication mation. Furthermore, patients who are receiving before treatment. Additionally, substantive or who recently finished receiving chronic cortico- stress-management techniques should be used. steroid therapy may need steroid replacement The anxiolytic protocol can include nitrous oxide, therapy before undergoing dental treatment.70 66 or N2O. According to Malamed, the use of N2O These same patients also may exhibit an in patients with mild-to-moderate asthma can increased susceptibility to bacterial infections, prevent acute symptoms. However, because of its which would indicate the need for antibiotic pro- potential for causing airway irritation, N2O is phylaxis before receiving treatment. contraindicated for use in patients with severe During treatment. The practitioner should asthma.66,67 It is advisable to obtain a medical con- be cognizant of several factors that can accen- sultation before administering N2O to such tuate asthma during dental care. Mungo and col- patients. leagues62 found that improper positioning of suc- Hydroxyzine and benzodiazepines usually are tion tips, fluoride trays or cotton rolls could used when a clinician performs conscious sedation trigger a hyperreactive airway response in sensi- in asthmatic patients. Narcotics and barbiturates tive subjects. Rubber dams should be used judi- should be avoided owing to their histamine- ciously to avoid possible respiratory compromise releasing properties, which can lead to bron- or aggravation. Prolonged supine positioning, chospasm and a potentiated allergic response. bacteria-laden aerosols from plaque or carious Clinicians should use extreme caution when using lesions and ultrasonically nebulized water also intravenous sedation in patients with asthma can be asthma triggers in the dental setting.56 because of the limited control of their airways. Additionally, aeroallergens such as tooth-enamel 1236 JADA, Vol. 132, September 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.  D E N T I S T R Y & M E D I C I N E dust and methyl methacrylate have been DENTAL CARE FOR ASTHMATIC PATIENTS. reported to trigger acute General Oral Health Care Instructions* episodes in a dental set- Prescribe fluoride supplements for all asthmatic patients, but especially for those taking β agonists 2 ting.60,61,71 Obviously, Instruct patients to rinse their mouths after using an inhaler potential asthma precipi- Reinforce oral hygiene instructions to help minimize gingivitis Be aware of possible need to prescribe antifungal agents for tants should be elimi- patients who chronically use nebulized corticosteroids nated or minimized Before Treatment where possible. Schedule appointments for late morning or afternoon In the event of an Assess severity of asthmatic condition Consider antibiotic prophylaxis for immunosuppressed patients acute asthmatic attack Consider corticosteroid replacement for adrenally suppressed during dental treatment, patients Avoid using dental materials that may elicit an asthmatic attack the clinician should stop Use techniques to reduce the patient’s stress: the procedure, remove dAvoid using barbiturates dAvoid using nitrous oxide in people with severe asthma all intraoral implements Have supplemental oxygen and bronchodilators available in case and rule out foreign body of acute asthmatic exacerbation Downloaded from jada.ada.org on February 2, 2009 aspiration, and initiate During Treatment the emergency protocol Use vasoconstrictors judiciously Avoid using local anesthetics containing sodium metabisulfite for managing acute asth- Use rubber dams judiciously matic exacerbation (box, Avoid eliciting a coughing reflex “Emergency Protocol for After Treatment Managing Asthmatic Be aware that some patients may have an adverse reaction to nonsteroidal anti-inflammatory drugs Exacerbation in a Dental Use tetracycline judiciously Setting”). Avoid use of erythromycin in patients taking theophylline Avoid use of phenobarbitals in patients taking theophylline Many articles and books put forth the rec- 82 * Based on information from Copp. ommendation of avoiding dental local anesthetics with vasoconstrictors in asthmatic patients, as as 20 percent of patients with asthma may experi- many vasoconstrictors contain sodium metabisul- ence severe exacerbations of bronchoconstriction fite, a preservative that is highly allergenic.72,73 after ingesting aspirin and other nonsteroidal However, vasoconstrictor-containing local anes- anti-inflammatory drugs, or NSAIDs.78-80 Aspirin- thetics have been used safely with these induced asthma is most common in the third or patients.74 An additional concern with vasocon- fourth decades of life and, as with other NSAIDs, strictors is their interaction with specific medica- is thought to be related to the inhibition of the tions commonly used by asthmatic patients. enzyme cyclo-oxygenase as well as to allergy. Vasoconstrictors may add to the effects of ß2 Examples of offending NSAIDs include ketorolac, agonists, causing excessive adrenergic activity ibuprofen and naproxen sodium. As a result, that results in palpations, increased blood pres- the analgesic of choice for these patients is sure and dysrhythmias.75 On the other hand, it acetaminophen. However, recent studies (as cited also has been suggested that stress-induced in Shaheen and colleagues81) have suggested that release of a patient’s own epinephrine may act long-term daily or weekly acetaminophen use is as a bronchodilator.76 Perusse and colleagues77 associated with a more severe asthma.81 Although recommended a contraindication to vasocon- there is reason for caution, acetaminophen still is strictor-containing anesthetics in corticosteroid- the preferred analgesic for asthmatic patients. dependent asthmatic patients. The premise for The increased potential for developing toxic this recommendation is the authors’ assumption levels of theophylline with concomitant use of ery- that corticosteroid-dependent asthmatic people thromycin has been addressed in the dental liter- are more severely affected by their asthma and ature.67 There is a theoretical risk of this type of therefore have a higher predilection for having an interaction, though there are very few actual doc- adverse reaction to sulfites. It is not clear if this umented cases. Yet it is preferable to avoid using is the case. macrolide antibiotics when appropriate antibiotic After treatment. Owing to allergy, as much substitutes are available. One viable alternative JADA, Vol. 132, September 2001 1237 Copyright ©1998-2001 American Dental Association. All rights reserved. D E N T I S T R Y & M E D I C I N E is azithromycin. Phenobarbitals N Engl J Med 1991;325:425-6. 17. Toogood JH. Complications of topical steroid therapy for asthma. have the ability to potentiate the Am Rev Respir Dis 1990;141(2 part 2):89-96. breakdown of theophylline via 18. Higgins BG. Current asthma management. Practitioner 1999;243:376-84. liver enzyme induction, and con- 19. Woolcock A, Lundback B, Ringdal N, Jacques LA. Comparison of comitant use may reduce the addition of salmeterol to inhaled steroids with doubling of the dose of inhaled steroids. Am J Respir Crit Care Med 1996;153:1481-8. efficacy of theophylline owing to 20. Wenzel SE. Antileukotriene drugs in the management of asthma. an increase in the rate of bio- Dr. Glick is a professor JAMA 1998;280:2068-9. of oral medicine and 21. Householder GT. Drugs acting on the respiratory system. In: transformation. the director, Programs Yagiela JA, Neidle EA, Dowd FJ, eds. Pharmacology and therapeutics for Medically Complex for dentistry. St. Louis: Mosby; 1998:444-5. CONCLUSION Patients, University of 22. Glick M, Somerman M. Glucocorticosteroids. In: Ciancio SG, ed. Pennsylvania School of ADA guide to dental therapeutics. 2nd ed. Chicago: ADA Publishing; Oral health care providers play Dental Medicine, 4001 2000:119-25. Spruce Street, Philadel- 23. Zeiss CR. Intense pharmacotherapy. Chest 1992;101(6 supple- an important role in monitoring phia, Pa. 19104, e-mail ment):407S-409S. patients with asthma82 (box, “[email protected]. 24. Zhu J, Hidalgo HA, Holmgreen WC, Redding SW, Hu J, Henry upenn.edu”. Address RJ. Dental management of children with asthma. Pediatr Dent “Dental Care for Asthmatic reprint requests to Dr. 1996;18:363-70. Patients”). As such, they need to Glick. 25. Pelaia G, Vatrella A, Calabrese C, Mazzarella G, Marsico SA. New perspectives in asthma treatment. Allergy 2000;55(supplement understand the pathogenesis of 61):60-6. Downloaded from jada.ada.org on February 2, 2009 the condition and what causes exacerbations and 26. Winther L, Malling HJ, Mosbech H. 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