Oral Diagnosis and Dental Radiology-II: Diseases of the Respiratory Tract PDF

ORAL DIAGNOSIS AND DENTAL RADIOLOGY-II Diseases of the Respiratory Tract Assoc. Prof. Büşra YILMAZ School of Dental Medicine Department of Oral and Maxillofacial Radiology [email protected] OUTLINE UPPER AIRWAY DISEASES • Viral Upper Respiratory Infections • Allergic Rhinitis • Otitis Medi...

ORAL DIAGNOSIS AND DENTAL RADIOLOGY-II Diseases of the Respiratory Tract Assoc. Prof. Büşra YILMAZ School of Dental Medicine Department of Oral and Maxillofacial Radiology [email protected] OUTLINE UPPER AIRWAY DISEASES • Viral Upper Respiratory Infections • Allergic Rhinitis • Otitis Media • Sinusitis • Pharyngitis and Tonsillitis LOWER AIRWAY DISEASES  Acute Bronchitis  Pneumonia  Bronchiolitis  Asthma  Chronic Obstructive Pulmonary Disease (COPD)  Cystic Fibrosis (CF)  Pulmonary Embolism  Pulmonary Neoplasms  Tuberculosis Diseases of the Respiratory Tract Respiration: number of inspirations recorded in 1 minute Normal: 14-20 TASYPNE; • Effort • Febrile diseases • Emotional states • Diseases that narrow the upper respiratory tract • Heart failure • Anemia • Hyperthyroidism BRADIPNE; • Sleep • Use of hypnotic narcotic drugs • Increased intracranial pressure Diseases of the Respiratory Tract Causes of Dyspnea; (difficulty breathing)  Bronchial asthma (due to bronchospasm)  Pneumonia, Angina Pectoris, Myocardial infarction  Obstructive causes in the upper respiratory tract (nasal polyps, nasal septum deviations, sinusitis)  Obesity Diseases of the Respiratory Tract Dyspnea Mouth breathing Xserostomia Hyperplastic Gingivitis Rampant caries UPPER AIRWAY DISEASES 1. Viral Upper Respiratory Infections  Rhinoviruses are transmitted from person to person by close contact, as a respiratory droplet infection.  The dentist should take preventive measures in this regard, and no intervention other than emergency interventions should be made during this period.  Anticholinergics used for a runny nose and decongestants used to reduce nasal congestion can cause dry mouth by slowing down the flow of saliva. UPPER AIRWAY DISEASES 2. Allergic Rhinitis Allergic Rhinitis (hay fever)(TR: Saman nezlesi) Chronic recurrent inflammatory disease of the nasal mucosa. It has seasonal characteristics, it is an allergic reaction to pollen, it reflects the allergic tendency of the individual. The most obvious symptoms are; • sneezing, • itching, • clear gray runny nose, • nasal congestion UPPER AIRWAY DISEASES 3. Otitis Media  It is an infection of the middle ear cavity and tissues.  It is most often seen in children under 8 years of age.  The most common symptoms are earache and fever.  Since the antibiotics used are mostly preferred preparations for dental infections, resistance may have developed in the oral cavity flora against these antibiotics. For this reason, when prescribing drugs for these patients, drug preference should be made according to the antibiotics that the patient has taken in the last 4-6 months. UPPER AIRWAY DISEASES 4. Sinusitis  Inflammation of the epithelium lining the paranasal sinuses.  Reasons; Acute upper respiratory tract infections, allergic rhinitis, odontogenic infections,  If sinus drainage is blocked by these factors, mucosal secretion accumulates, bacterial accumulation increases and acute sinusitis occurs, and if the process continues, it becomes chronic.  Sinusitis pain can be confused with toothache. These pains should be distinguished from each other, especially the upper jaw teeth should be carefully evaluated.  There is mouth breathing in chronic sinusitis, resulting in dry mouth, bad breath, an increase in gingivitis and caries is observed UPPER AIRWAY DISEASES 5. Pharyngitis and Tonsillitis  It is the inflammation of the pharynx and tonsil seen with viral or bacterial infections.  There is a viral infection relationship in 90% of cases with sore throat.  The most important viral etiological agents; EpsteinBar virus, coxsackie virus, adeno virus, rhino-virus and measles virus.  The most common agents of tonsillopharyngitis are group A beta hemolytic streptococci. LOWER AIRWAY DISEASES Acute Bronchitis The clinical picture that occurs as a result of inflammation in the large bronchi, which is more often caused by viruses than bacteria. Bacterial bronchitis is most commonly caused by streptococcal pneumonia. Bacterial bronchitis often occurs in those with chronic lung disease. LOWER AIRWAY DISEASES Acute Bronchitis In acute bronchitis, persistent fever, weakness, muscle pain, headache, runny nose are usually observed. Along with these symptoms, there is also a cough, a burning sensation behind the sternum. The possibility of bacterial resistance to antibiotics used in dentistry should be considered, especially in patients with bacterial bronchitis. LOWER AIRWAY DISEASES Pneumonia  It is an infection usually caused by bacteria, viruses and fungi, accompanied by inflammation affecting the parenchyma of one or both lungs.  Symptoms of the disease may be different depending on the causative microorganism.  But common symptoms are fever, chest pain, cough, and purulent sputum (tr: balgam). LOWER AIRWAY DISEASES Pneumonia • Bacterial pneumonia is common. • Pneumonia in the lower respiratory tract may also occur with aspiration of salivary secretion containing oral bacteria. • Periodontal-related anaerobes and facultative types have been isolated in many pneumonia cases. • This type of pneumonia is mostly seen in patients in intensive care units, elderly people with poor oral hygiene in elderly care homes. LOWER AIRWAY DISEASES Pneumonia Dentist Approach in Pneumonia:  Dental treatments should be postponed in patients with active pneumonia because of low body resistance.  Short-term work can be done by taking necessary precautions for emergency procedures.  When the effects of the infection wear off, the patient can be treated again. LOWER AIRWAY DISEASES Asthma  Bronchial asthma is a disease characterized by paroxysmal, bouts of dyspnea (difficult breathing), and wheezing, due to excessive secretion of bronchial glands and contraction of bronchial smooth muscles.  Oxygenation of the blood is decreased due to the narrowing of the airways. Although it can start at any age, it occurs before the age of 10 in approximately half of the cases.  There are two clinical types. LOWER AIRWAY DISEASES Asthma 1. Exogenous asthma: It starts in childhood due to seasonal changes, familial history of allergy and the effect of other allergens such as eczema and urticaria. It occurs as a result of antigen-antibody fusion in the bronchial mucosa that has been sensitized by antigen. It occurs mostly with inhaled allergens (dust, pollen, fungal spores, animal fur, industrial fumes) and less commonly with ingested allergens (egg, fish, chocolate and drugs). Serum IgE levels are high in the cases. LOWER AIRWAY DISEASES Asthma 2. Endogenous asthma: It is a more serious form that usually develops after the age of 30, due to respiratory infections such as viral respiratory tract infections, chronic sinusitis and nasal polyps, without a history of allergy. During a severe asthma attack, the patient uses auxiliary respiratory muscles. Status asthmaticus, where the seizures last more than 24 hours and does not respond to treatment, may be seen. The patient's consciousness is blurred, there is tachycardia and cyanosis, abdominal breathing, respiratory sounds are not heard. These patients should be hospitalized immediately and oxygen inhalation should be started. LOWER AIRWAY DISEASES Asthma Drugs used in asthmatic patients: Drugs used in these patients to minimize the severity and frequency of acute bronchospasm attacks; 1. Beta mimetic drugs. They provide a bronchodilator effect by stimulating beta receptors. There are two types of beta receptors. • beta 1-adrenergic receptors; located in the myocardium • beta 2-adrenergic receptors; found in bronchial smooth muscle. Betamimetic drugs that stimulate both beta 1 and 2 receptors (eg, adrenaline and isoprenaline) have side effects such as tachycardia and arrhythmia on the heart as well as bronchodilator effects. In fact, adrenaline and ephedrine increase blood pressure by acting on alpha receptors in addition to beta receptors. For this reason, betamimetic drugs (terbutaline, metaproterenol, salbutamol) that selectively act on beta 2 receptors are preferred today. LOWER AIRWAY DISEASES Asthma 2. Xanthine derivatives: (theophylline, aminophylline) They are bronchodilators. It has side effects such as nausea, vomiting, headache, dizziness, insomnia. In excessive doses, they cause arrhythmia and tachycardia. 3. Mast cell stabilizers: (cromolyn) They inhibit the release of substances with bronchoconstrictor effects, such as histamine, from mast cells. These drugs do not have bronchodilator effects, do not reduce bronchial edema or inhibit mucus production. They are not therapeutic during an asthma attack, they are used prophylactically in the prevention of the attack. LOWER AIRWAY DISEASES Asthma 4. Corticosteroids: Although the exact mechanism of action in asthma is not known, • They reduce bronchial edema and bronchial mucus production due to their anti-inflammatory effect. • By increasing the sensitivity of beta adrenergic receptors to betamimetic drugs, they help to increase the bronchodilator activity of these drugs. • They prevent allergic reactions by inhibiting the formation of antibodies such as IgE and IgG. Corticosteroids are drugs that should be used last in the prevention of asthma attacks due to their many side effects. When administered intravenously or orally, they take effect within 4-6 hours at the earliest. Therefore, they are not therapeutic during an acute crisis. LOWER AIRWAY DISEASES Asthma Side effects of corticosteroids: 1. People who use these drugs, because they cause immunosuppression, develop viral and fungal infections easily. 2. They cause Cushing's syndrome iatrogenically. (Cushing's syndrome: A clinical picture characterized by signs of lunar face, lubrication on the neck and back, and muscle weakness, which occurs with excessive increase in cortisol amount.) 3. Wound healing is delayed. 4. Since they cause hyperglycemia, it makes diabetes more evident in those with latent diabetes. In diabetic patients, they increase the need for insulin. 5. They cause the development of peptic ulcer or perforation of the existing ulcer. When the decision is made to use corticosteroids in the asthmatic patient, inhalation forms should be preferred first, but inhalation preparations used during attacks may worsen the crisis. LOWER AIRWAY DISEASES Asthma The dentist's approach:  The dentist should question the age of onset and type of asthma, frequency and severity of seizures, factors that initiate seizures, and medications used in patients with asthma, with a careful anamnesis.  Seizures are rare in patients with exogenous asthma and may not require continuous treatment. Patients in this group can be treated like other patients and do not carry any risk, provided that stress is reduced and sedation is applied.  If the patient applying for dental treatment has dyspnea, wheezing, coughing in the form of seizures, the treatment should be postponed. Patients who have frequent asthma attacks despite being on continuous medication are in the risk group for dentistry and these patients should be treated after the doctor's control.  Advanced surgical procedures should be performed in a hospital setting. LOWER AIRWAY DISEASES Asthma  In patients on long-term corticosteroid therapy, signs of infection may be masked as a result of facilitating the occurrence of viral and fungal sepsis due to immunosuppression and decreased reaction to infection. For this reason, antibiotic prophylaxis should be applied before dental procedures where tissue trauma may occur in these patients.  Dry mouth and candidiasis may occur in patients using inhaled corticosteroids (beclomethasone). This possibility should be reduced by cleaning the oral cavity by gargling after inhalation. LOWER AIRWAY DISEASES Chronic Obstructive Pulmonary Disease (COPD) COPD is a clinical picture characterized by persistent airway obstruction, often in the peripheral and rarely in the central airways. COPD includes several diffuse lung diseases such as chronic bronchitis, asthma, cystic fibrosis, bronchiectasis, and emphysema.  The most common clinical forms of the disease are chronic bronchitis and emphysema. LOWER AIRWAY DISEASES Chronic Obstructive Pulmonary Disease (COPD) The most important cause of COPD is smoking. Although it is mostly seen in men over 40 years of age and smoking, the incidence has also increased in women. LOWER AIRWAY DISEASES Chronic Obstructive Pulmonary Disease (COPD) Chronic bronchitis and emphysema often coexist in COPD. Clinically; • Cough increasing with exercise, • Expectoration, • Wheezing (difficulty in breathing with whistling sound during breathing), • Short-term breathing, • Recurrent respiratory infections, • Weakness, weight loss are seen. LOWER AIRWAY DISEASES Chronic Obstructive Pulmonary Disease (COPD) Chronic Bronchitis: It is a syndrome characterized by chronic or recurrent cough and sputum production. It occurs as a result of exposure of the airway to bronchial irritants such as cigarette smoke and polluted air. Chronic bronchitis should be considered if the patient has cough and sputum production on most days for at least 3 months in each of two consecutive years and if other causes such as bronchiectasis, tuberculosis, and lung abscess are not present. LOWER AIRWAY DISEASES Chronic Obstructive Pulmonary Disease (COPD) Emphysema: It is characterized by enlarged air spaces distal to the terminal bronchioles. It causes destruction of the lung parenchyma and loss of elasticity of the alveolar walls. The most common symptom in patients with emphysema is dyspnea during exercise. As the disease progresses, dyspnea occurs even with minimal exercise. The anterior-posterior diameter of the chest has increased and its expansion capacity has decreased. The patient uses accessory respiratory muscles to breathe. LOWER AIRWAY DISEASES Chronic Obstructive Pulmonary Disease (COPD)  The clinical course of COPD is usually progressive, with progressive declines in lung function over the years, which can be severe. In severe cases, right heart failure, called cor pulmonale, develops due to the increase in pulmonary artery pressure and pulmonary vascular resistance.  An increase in cough and dyspnea is an indicator of progressive worsening of the disease.  Symptoms usually occur after an upper respiratory tract infection and are accompanied by bronchospasm.  Such exacerbations can lead to life-threatening conditions such as cor pulmonale and acute respiratory failure, especially in patients with severe COPD. LOWER AIRWAY DISEASES Chronic Obstructive Pulmonary Disease (COPD) MEDICAL TREATMENT Medical treatment does not provide complete recovery in patients with COPD, but control of acute exacerbations and symptomatic relief are achieved. • Antibiotic therapy; Antibiotic therapy should be initiated when infections causing acute exacerbations and the first signs of acute infective bronchitis occur, but prophylactic long-term antibiotic use is not indicated as it will generate resistant organisms. • Bronchodilators; A bronchodilator is used in patients with reversible chronic airway obstruction due to bronchospasm and excessive mucus secretion, and corticosteroids can be used in more severe cases. • O2 therapy; Hypoxia that develops in acute exacerbations due to infection is treated by administering low-intensity oxygen. CO2 retention and respiratory failure may develop when high concentrations of oxygen are given. • Diuretics; In cases with developed heart failure, treatment with the use of diuretics and controlled sodium intake is required. LOWER AIRWAY DISEASES Chronic Obstructive Pulmonary Disease (COPD) Patients with COPD may have periods of severe depression and anxiety. The compassionate approach of the physician and the education of the patient are very important. Sedatives, narcotics and tranquilizers should not be used as they suppress respiratory movements and coughing. LOWER AIRWAY DISEASES Chronic Obstructive Pulmonary Disease (COPD) The dentist's approach: The dentist should deepen the history to evaluate patients over 40 years of age with a history of smoking or exposure to pulmonary irritants (eg working in coal mines) and respiratory conditions such as wheezing for COPD. In the anamnesis, the patients; 1. Dyspnea during exercise, 2. Cough with phlegm, 3. Symptoms related to acute respiratory infections 4. Whether he used medication for these complaints, 5. It should be asked whether he has been treated in the hospital before due to severe breathing difficulties. LOWER AIRWAY DISEASES Chronic Obstructive Pulmonary Disease (COPD) LOWER AIRWAY DISEASES Chronic Obstructive Pulmonary Disease (COPD) Low risk group patients; They are patients who complain of dyspnea only during vigorous exercise and are usually not treated with bronchodilators or steroids. All kinds of dental treatment can be done according to the normal protocol. Sedation is useful in restless and fearful patients. LOWER AIRWAY DISEASES Chronic Obstructive Pulmonary Disease (COPD) Moderate risk group patients; These are patients with dyspnea and hypoxia during moderate exercise, using continuous bronchodilators, and recently administered corticosteroids. Before dental treatment, a serious treatment plan and doctor consultation are required. LOWER AIRWAY DISEASES Chronic Obstructive Pulmonary Disease (COPD) 1. Some of the Betamimetics (isoprenaline, adrenaline, etc.) used as bronchodilators have serious side effects on the heart such as tachycardia and arrhythmia. Therefore, additional use of vasoconstrictor-containing local anesthetics such as adrenaline may cause arrhythmias. 2. Antibiotics such as erythromycin and clindamycin should not be given to patients using these drugs (theophylline) due to their toxicity-increasing effects against xanthine derivatives, and alternative antibiotics should be given instead. 3. In patients with IV sedatives and general anesthesia indication, hospital environment should be preferred due to the risk of hypoxemia. 4. Side effects (osteoporosis, delayed wound healing, propensity to infection) due to adrenal suppression and steroid treatment should be evaluated in those receiving chronic steroid treatment, and the steroid dose should be doubled on the day of dental treatment after the doctor's consultation, considering that dental operations can also provoke adrenal suppression, In the next 2-3 days, it should be gradually reduced and returned to the old dose. There is no need for such an adjustment in patients whose steroid treatment has been discontinued for the last 1 year. 5. Treatment sessions should be kept short and measures should be taken to reduce stress. LOWER AIRWAY DISEASES Chronic Obstructive Pulmonary Disease (COPD) High risk group patients; • They are patients who have dyspnea even at rest and develop cor pulmonale. • These may be patients with COPD symptoms present but undiagnosed or in an acute exacerbation of acute respiratory infection at the time of presentation to the dentist. • Undiagnosed patients with COPD symptoms should have a medical evaluation before starting dental treatment. • Dental treatment of COPD patients with respiratory tract infections should be delayed until the acute crisis period is over. LOWER AIRWAY DISEASES Chronic Obstructive Pulmonary Disease (COPD) 1. Stress should be reduced, 2. Treatment sessions should be short 3. Drugs that depress respiratory functions (sedatives, tranquilizers, narcotics) should not be given without the consent of the patient's doctor. 4. When analgesics are required, non-narcotic analgesics should be preferred. 5. Necessary arrangements should be made for those undergoing steroid treatment, 6. Local anesthetics without adrenaline should be used to eliminate the risk of arrhythmia in patients with cor pulmonale. 7. Considering that infections in the mouth can cause acute exacerbations, all foci of infection in the mouth should be eliminated and oral hygiene education should be given to the patient. 8. Complicated surgical procedures should be performed in a hospital setting. LOWER AIRWAY DISEASES Tuberculosis  Caused by Mycobacterium tuberculosis.  Individuals acquire TB by inhaling airborne particles from other infected people.  Once inhaled, TB proliferates inside of alveolar macrophages. LOWER AIRWAY DISEASES Tuberculosis  Patients who initially develop TB (also called the primary disease stage) generally have fevers and other nonspecific symptoms.  TB generally presents with a chronic respiratory infection with cough, fevers, night sweats, and weight loss.  Once primary TB symptoms resolve, patients are considered to have latent TB.  This means that they likely still have residual TB bacteria, which can reactivate at some point later in life. LOWER AIRWAY DISEASES Tuberculosis  Medical risk factors for TB include HIV, diabetes, malnutrition, smoking, and alcohol use  Societal risk factors for TB include overcrowding, poorly ventilated housing, malnutrition, smoking, stress, social deprivation, and poor social capital LOWER AIRWAY DISEASES Tuberculosis Dental Considerations • Oral manifestations may occur in up to 3% of patients with long-term active TB. • The oral lesions of tuberculosis are rare and usually manifest as a solitary ulcer. • Stellate ulcers affecting the dorsal surface of the tongue are a classic presentation. • Lesions may occur in the oral tissues and the neck lymph nodes. The latter is termed scrofula. • Oral lesions can be found in various soft tissues and very occasionally in supporting bone. • Oral lesions may be primary or secondary to pulmonary tuberculosis. LOWER AIRWAY DISEASES Tuberculosis Dental Considerations Oral tuberculosis appears as a painless or painful ulcer, usually single and rarely multiple. Clinically, the ulcer is irregular at the periphery with thin margins, vegetated base covered by a yellowish-gray exudate and has a soft base. The size ranges from 1 to 5 cm. The dorsal surface of the tongue is most commonly affected LOWER AIRWAY DISEASES Tuberculosis Dental Considerations LOWER AIRWAY DISEASES Tuberculosis Dental Considerations  A TB oral ulcer usually has undermined edges and a granulating floor, but the clinical picture can be variable.  Lesions may also affect the gingiva, floor of the mouth, palate, lips, and buccal mucosa. LOWER AIRWAY DISEASES Tuberculosis Dental Considerations  Standard fluid-resistant masks likely provide some protection against TB for dental healthcare personnel.  However, routine dental care should be postponed in patients who remain contagious with TB.  If oral care must be provided for a patient who is contagious with TB, patients should be placed in a negative pressure room and healthcare workers should wear an N95-, FFP2-, or FFP3-level respirator. LOWER AIRWAY DISEASES Tuberculosis Dental Considerations  If an oral medicine provider plans on treating a patient with active TB, it is strongly recommended to consult with an infection prevention specialist or hospital epidemiologist, who may be able to share clinic- or hospital-specific protocols.  TB protocols may recommend scheduling the patient as the last case of the day to minimize exposure to other patients and staff.  TB patients should be instructed to wear a surgical mask while in patient care areas. References • Michael Glick (ed.); Martin S. Greenberg (ed.); Peter B. Lockhart (ed.); Stephen J. Challacombe (ed.). Burket's Oral Medicine. 13th edition. Wiley-Blackwell. June 2021. ISBN: 9781119597780