Respiratory Disorders Sem 1 PDF

RESPIRATORY DISORDERS  Respiratory structures such as the airways, alveoli and pleural membranes may all be affected by various disease processes. These respiratory diseases include: 1. Infections such as pneumonia. 2. Obstructive disorders that obstruct airflow into and out...

RESPIRATORY DISORDERS  Respiratory structures such as the airways, alveoli and pleural membranes may all be affected by various disease processes. These respiratory diseases include: 1. Infections such as pneumonia. 2. Obstructive disorders that obstruct airflow into and out of the lungs such as asthma, bronchitis and emphysema. 3. Restrictive disorders are conditions that limit normal expansion of the lungs such as respiratory distress syndrome and cystic fibrosis. 4. Cancers or exposure to Inhaled particles alter the pulmonary function. General symptoms of respiratory disease ✵ Hypoxia : Decreased levels of oxygen in the tissues ✵ Hypoxemia : Decreased levels of oxygen in arterial blood ✵ Hypercapnia : Increased levels of CO2 in the blood ✵ Hypocapnia : Decreased levels of CO2 in the blood ✵ Dyspnea : Difficulty breathing ✵ Tachypnea : Rapid rate of breathing ✵ Cyanosis : Bluish discoloration of skin and mucous membranes due to poor oxygenation of the blood ✵ Hemoptysis : Blood in the sputum  Tissues of our body utilize oxygen for metabolic purposes and produce carbon dioxide as a result of metabolism. The major purpose of respiratory system is to extract the oxygen from the atmosphere ,to deliver it to tissue and to take carbon dioxide from the tissue and discharge it into the atmosphere The entire system is conventionally divided into some major divisions: A. Ventilation B. Gaseous exchange at alveolar level C. Carriage of oxygen and carbon dioxide by the blood. D. Exchange of gases at tissue level E. Utilization of oxygen and production of carbon dioxide by tissues (internal respiration) RESPIRATORY SYSTEM The respiratory system consists of: Nasal cavity Nasopharynx Trachea Bronchi Bronchioles Alveoli The lung is designed primarily for gaseous exchange. SYMPTOMS OF RESPIRATORY DISEASE Patients with respiratory disease typically have one of six symptoms: 1. Cough (usually indicates bacterial, fungal, or viral infection, long term smoking, early chronic bronchitis) 2. Breathlessness (dyspnea) (usually indicates CO2 retention) Orthopnea, tachypnea, hyperventilaiton 3. Sputum (thick & glue like blood tinged) 4. Expectorated blood (hemoptysis) (indicate tuberculosis or neoplastic invasion to lung tissue) 5. Wheezing (is classically associated with inspiratory effort in asthma) 6. Chest pain (most often indicates pleural involvement)  Patients with respiratory diseases may be identified by medical history and physical examination Visual examination will reveal Barrel shaped chest (increased anteroposterior diameter due to hyperinflation Pigeon – shaped chest due to hyperinflation in early childhood Flattening of the upper anterior chest is a consequence of fibrosis of the underlying lung Distended veins over the chest such as the jugular may indicate superior vena cava obstruction, portal hypertension and air hunger RESPIRATORY DISORDERS - Upper respiratory tract disorders Infections Sinusitis Lower respiratory tract disorders Acute bronchitis Pneumonia Bronchiolitis Asthma COPD ( Chronic bronchitis and emphysema) Cystic fibrosis Pulmonary embolism BRONCHITIS CLINICAL FINDINGS Acute viral bronchitis usually presents with a viral prodrome consisting of fever, malaise, myalgias, headache, and weakness. Upper-respiratory-tract symptoms that may include sore throat and rhinorrhea usually follow. As the illness progresses, lower tract symptoms develop, with a prominent nonproductive cough. Chest discomfort may occur; this usually worsens with persistent coughing bouts. Other symptoms, such as dyspnea and respiratory distress, are variably present. Physical examination may reveal wheezing. Symptoms gradually resolve over a period of 1 to 2 weeks. Symptoms of acute bacterial bronchitis may include fever, dyspnea, productive cough with purulent sputum, and chest pain. ORAL HEALTH CONSIDERATIONS Resistance to antibiotics may develop rapidly and last for 10 to 14 days. Thus, patients who are taking amoxicillin for acute bronchitis should be prescribed another type of antibiotic, (such as clindamycin or a cephalosporin) when an antibiotic is needed for an odontogenic infection ASTHMA Asthma Is divided into 5 categories Extrinsic (allergic or atopic) Intrinsic (nonallergic or not atopic) Exercise -induced Drug induced Infectious SIGNS & SYMPTOMS Coughing, wheezing Difficulty breathing Rapid, shallow breathing Increased respiratory rate Excess mucus production Significant anxiety Oral manifestations - asthma Chronic use of corticosteroid inhalants can occasionally locally immunosuppress oral mucosa and promote pseudomembranous candidiasis overgrowth Dysphonia may follow persistent steroid inhalant use (impairment of voice production) Oral considerations - ASTHMA Stress reduction protocol is of paramount importance in stress induced asthma patients. Patients who use inhalers should have the device readily accessible during all appointments. Prior to invasive traumatic procedures a few puffs of inhaler are recommended. Aspirin, NSAID, narcotics and barbiturates shouldn’t be prescribed to asthmatic patients because of their precipitating effect. Patients who are taking corticosteroids may require steroidal supplementation. Oral considerations - ASTHMA Antihistamines can precipitate dryness of the oropharyngeal area. Epinephrine containing local anesthetics can induce cardiac stimulating effect. Sulfites containing local anesthetics can be allergenic on intrinsic asthma. Erythromycin, Ciprofloxacin and clindamycin should be prescribed with caution. ASTHMA-DENTAL HYGIENE CARE BEFORE TREATMENT Remind the patient to bring inhaler (rescue drug) and/or other medications. Assess risk level: Review medical history, frequency, and severity of acute episodes, medications, and triggering agents. Questions to ask: In the past 2 weeks, how many times have you: a. had problems with coughing, wheezing, shortness of breath, or chest tightness during the day? b. awakened at night from sleep because of coughing or other asthma symptoms? c. awakened in the morning with asthma symptoms? d. had asthma symptoms that did not improve within 15 minutes of using inhaled medication. e. had symptoms while exercising or playing? Evaluate current symptoms: Reappoint if symptoms are not well controlled. Ask if all prescription medication has been taken. Schedule late morning or late afternoon appointments. Have bronchodilator and oxygen available. Obtain a medical consultation for patients with severe acute asthma or if on corticosteroid to determine necessity of steroid replacement and/or antibiotics to prevent infection. Use bronchodilator as a preventive measure before the appointment. Provide a stress-free environment. ASTHMA-DENTAL HYGIENE CARE DURING TREATMENT Prevent triggering a hypersensitive airway by properly placing cotton rolls, fluoride trays, and suction tip. Use local anesthetic without sulfites. Give fluoride treatment for patients with asthma. If asthma attack occurs, stop treatment, rule out foreign body obstruction, initiate emergency procedures. ASTHMA-DENTAL HYGIENE CARE AFTER TREATMENT Home care instructions: advise patient to rinse mouth with water after using inhaler to decrease oral candidiasis. Analgesic drug of choice is acetominophen (aspirin or NSAIDs may trigger attack). Chronic obstructive pulmonary disease COPD Consists of two major diseases Chronic bronchitis Emphysema They are both characterized by chronic airflow obstruction during normal ventilatory efforts COPD Chronic bronchitis Chronic inflammatory condition of the bronchoalveolar epithelium, of at least 3 month duration for more than 2 consecutive years characterized by: Productive cough Reduced forced rate of expiration Wheezing Shortness of breath Exertional dyspnea 7:1 male predominance Cigarette smoking is major etiologic factor Environmental pollution and dust are second Chronic bronchitis Clinical & pathologic features 1. Increased mucous secretion, mucous plugging 2. Edema, fibrosis 3. Hypertrophy of bronchial mucosa 4. Hyperplasia of mucous cells and goblet cells 5. Irreversible narrowing of bronchial airway 6. Decrease in ciliary and macrophage activity 7. Diminished gaseous air exchange 8. Increased risk for secondary bacterial infections mostly hemophilus influenza streptococcus pneumoniae 9. Increased risk for pulmonary hypertension respiratory failure Oral manifestations Smoke related oral lesions such as melanosis, nicotine stomatitis, dysplastic changes* of oral mucosa, leukoplakic or erythroplakic lesions. *changes in the cells that make up the lining (epithelium) of the mouth. MELANOSIS NICOTINE STOMATITIS Dental management The most important concern of the OHCP is to preserve patient’s respiratory capacity during treatment A more upright chair position Refrain from CNS depressing drugs i.e. narcotics and barbiturates Refrain from xerostomic medications i.e antihistamines which also dry respiratory mucosa Use Rubber dam with caution N2O and other anesthetic gases are contraindicated Emphysema (air in tissue) Irreversible lower airway obstructive lung disease. Alveolar wall destruction. Enlargement and dilatation of alveolar acini and collapse of terminal bronchioles. Diminished surface for gas exchange. Loss of elastic recoil. Long term air entrapment.  Obstructive Respiratory Disorders Emphysema Emphysema is a respiratory disease that is characterized by destruction and permanent enlargement of terminal bronchioles and alveolar air sacs Alveolar Respiratory duct Terminal bronchioles bronchiole septum alveoli Emphysema Characteristics Occur at 50 - 70years Hx Heavy smoking Thin patient ( asthenic) Exertional dyspnea Tachypnea Emphysema Pink face ( pink puffer) Barrel-chested Carries his shoulders high, slightly forward; unable to catch his breath Cough nonproductive. Wheezing on expiration Distended neck veins Oral manifestations Smoke related oral lesions such as melanosis, nicotine stomatitis, dysplastic changes of oral mucosa, leukoplakic or erythroplakic lesions. Pursed lips expirations therefore xerostomia Dental management Patients with mild to moderate disease can safely receive dental treatment as long as their respiratory capacity is adequate Patients with severe disease are NOT recommended for stressful dental treatment Sedation, GA, bilateral mandibular block, antihistaminic medications should be avoided Chair position should be adjusted to a more upright position Cystic Fibrosis Cystic fibrosis (CF) is a genetic disorder characterized by hyperviscous secretions in the respiratory and gastrointestinal tracts. In the lungs, viscid mucus causes airway obstruction, infection, and bronchiectasis. Pulmonary complications are the major factors affecting life expectancy in patients with CF. Cystic fibrosis is an inherited disease. Symptoms Symptoms may include Salty-tasting skin When newborn is kissed Steatorrhea Greasy, bulky and foul smelling stools Poor growth/weight gain in spite of good appetite Chronic coughing, at times with phlegm Frequent lung infections CLINICAL FINDINGS Pulmonary manifestations include coughing, recurrent infections of the lower respiratory tract, and bronchospasm. Tachypnea and *crackles can be found on physical examination. As the disease progresses, digital clubbing and **bronchiectasis may become apparent. Airway obstruction tends to worsen with disease progression although some patients with CF have mild pulmonary disease. *short interrupted breath sounds eg. clicking, rattling, or crackling noises **chronic lung condition where the walls of your airways (bronchi) widen and are thickened from inflammation and infection. DIGITAL CLUBBING ORAL HEALTH CONSIDERATIONS Treat patients with respiratory conditions in a semisupine or upright chair position to help improve breathing and respiratory comfort. Take measures to prevent or treat gingivitis and periodontal diseases. Recommend that patients rinse with sodium bicarbonate or use xylitol after consuming drinks or snacks with sugar, after using their inhaler/nebulizer Recommend home fluoride treatment based on caries risk TUBERCULOSIS It is a systemic infectious disease of worldwide prevalence and of varying clinical manifestations. It is an infectious granulomatous disease caused by mycobacterium tuberculosis. TUBERCULOSIS Clinical findings Episodic fever chills Dyspnea Fatigue Anorexia Weight loss Sputum production can be green, yellow or purulent Persistent cough with hemoptysis* typically in the morning Chest pain due to pleural involvement *Expectoration of blood or blood-tinged sputum from the lungs Oral manifestations of tuberculosis Dissemination of mycobacterium from lungs to oral cavity can produce a secondary infection of the mouth – which is frequently appearing as ulcers Typically they are found in the posterior part of the oral cavity, dorsum or lateral margin of tongue, labial mucosa (comissure) however can appear in other places Oral manifestations TB TB ulcers can be painful/less painful they slowly increase in size Center of ulcer is grayish while margins are lumpy ( cobble stoned) and undermine Base of ulcer can be purullent and contains active organisms Cervical lymphadenopathy is common Oral manifestations TB Non-typical oral lesions consist of fissures, granulomas, osteomyelitis of jaws and sialadenitis of major salivary glands mostly parotid Calcified lymphnodes in arrested disease can be ocassionaly discovered on x-rays Anti TB drugs may manifest adverse effects such as excessive salivation & metallic taste, gingival bleeding ORAL CONSIDERATIONS Consultation with physician can determine the infective status of patient Patients on anti TB therapy can be safely treated after 2-3 weekS of the antibiotic treatment Emergency situations in the infective period should be managed by palliative treatment ( antibiotic analgesic) Dental personnel should be aware that cold sterilization or chemical sterilization solutions are ineffective for TB Clinical signs suggestive of TB, do NOT treat. ORAL CONSIDERATIONS Patients pulmonary capacity should be evaluated before any sedation or narcotic administration Acetaminophen can interact with hepatotoxic effect of rifampin TONSILLITIS Tonsillitis is the inflammation of the pharyngeal tonsils It is predominantly the result of a viral or bacterial infection and, when uncomplicated, presents as a sore throat. Acute tonsillitis is a clinical diagnosis. Differentiation between bacterial and viral causes can be difficult; however, this is crucial to prevent the overuse of antibiotics. Oral Considerations Patients with viral or bacterial infection should be reschedule Lung Cancer Lung cancer is the leading cause of cancer death for men and women. It is also the most preventable form of cancer. Tobacco use accounts for 87% of lung cancers. There are two major types of lung cancer: 1. Non-small cell lung cancer (87%) 2. Small cell lung cancer (13%) Each grows and spreads in different ways and is treated differently. Lung Cancer Who Is At Risk? Cigarette smoking is by far the greatest risk factor for lung cancer. The longer a person uses tobacco and the more they use, the greater their risk. If a person quits before cancer develops, the damaged lung tissue gradually improves. Others at risk include: Nonsmokers who breathe in secondhand smoke. Occupational or environmental exposure to radon, asbestos, certain metals, radiation or air pollution. If people are exposed to the above carcinogens & also smoke, their risk is greatly increased. Lung Cancer SYMPTOMS OF LUNG CANCER Coughing that gets worse or doesn’t go away. Chest pain. Shortness of breath. Wheezing. Coughing up blood. Feeling very tired all the time. Weight loss with no known cause.  Lung cancer is treated in several ways, depending on the type of lung cancer and how far it has spread. non-small cell lung cancers can be treated with surgery, chemotherapy, radiation therapy, targeted therapy, or a combination of these treatments. small cell lung cancers are usually treated with radiation therapy and chemotherapy. Oral Manifestations of Chemotherapy These complications include the development of one or more of the following 1. Mucositis 2. Ulceration 3. Xerostomia Oral Manifestations of Chemotherapy Hemorrhage Intraoral hemorrhage Intestinal and/or hepatic damage may lower vitamin K-dependent clotting factors contributing to the hemorrhage. Oral Manifestations of Chemotherapy Hemorrhage Oral petechiae and ecchymosis secondary to even minor trauma are the most common presentations. The labial mucosa, tongue and gingiva are the sites most commonly involved with oral bleeding. Xerostomia Dry mouth is a frequent complication of radiation therapy as salivary glands are very sensitive to radiation. The effect may begin within a week of initiation of the radiation therapy. Sequelae of Radiation-Induced Xerostomia These sequelae include 1. A decrease in saliva with an increase in viscosity. 2. A decrease in the pH of the oral cavity. 3. Development of dysphagia. 4. Development of mucositis. Sequelae of Radiation-Induced Xerostomia 5. A decrease in retention of removable prostheses due to an increase in sore spots. 6. Adherence of food and cellular debris to the oral structures. 7. A shift in the diet to softer foods, which are usually carbohydrates. 8. A shift of the microflora to include a greater abundance of Lactobacilli, cariogenic Streptococci and Candida. The patient should be instructed to 1. Rinse frequently with sterile water/saline. 2. Use commercially available artificial saliva substitutes. 3. Use salivary stimulants such as sugarless gum/candy or institute drug therapy. 4. Apply lubricating agents to the lips to prevent cracking.  Radiation Caries This rampant form of dental caries is, of course, xerostomia induced. Radiation caries is predominantly cervical in location. The dental team should strive for prevention. Prevention of Radiation Caries The patient must be educated as to the role of dental plaque in the etiology of dental caries and periodontal disease. Ten to fourteen days prior to radiation therapy, the patient should receive a complete prophylaxis including scaling if necessary. Brushing and flossing techniques must be taught and reinforced. Prevention of Radiation Caries A fluoride program should be instituted and maintained. Neutral fluoride is best tolerated by patients with an oral mucositis. Fluoride gel delivery is best accomplished through the use of custom trays. Daily five-minute application is recommended during therapy with weekly office visits. Prevention of Radiation Caries Some of these rinses, which may be used 4 to 6 times per day are: 1. Baking soda, ½ teaspoon in 8 ounces of warm water. 2. Milk of magnesia mixed in equal parts with warm water. 3. Three percent hydrogen peroxide mixed with equal parts with warm water. 4. If oral infections occur, antibiotic/antifungal mouth rinses may be prescribed as needed. Prevention of Radiation Caries Gentle water lavage may be used to remove thick, ropy saliva and debris. If tooth brushing cannot be tolerated, single-use toothettes, gauze squares and cotton-tipped applicators may be used. Some saliva substitutes not only lubricate the mucosa but contain chemicals which promote remineralization and inhibit decay. Prevention of Radiation Caries A successful recall program is critical to maintaining optimal oral health. Following completion of radiation therapy, dental appointments should be scheduled at 1 to 3 month intervals depending upon the patients needs.