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MANAGEMENT IN DENTAL CARE OF THE 
ASTHMA PATIENT
FOR THE DENTAL HEALTH PROFESSIONAL

Preventing a sudden episode of airway obstruction is essential when treating an asthmatic patient

MANAGEMENT IN DENTAL CARE

Updating patients health history at every visit about these following factors will help you identify the risk of an acute exacerbation:

bulletFrequency of asthmatic attacks
bulletPrecipitating agents
bulletTypes of pharmacotherapy used 
bulletLength of time since an emergency visit owing to acute asthma 

As a general rule, elective dentistry should be performed only on asthmatic patients who are asymptomatic or whose symptoms are well-controlled

The symptomatic person should not be treated, and the presence of asthmatic symptoms such as coughing and wheezing necessitate reappointment

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Be Aware

Be aware of the potential for dental materials and products that exacerbate asthma. These items include:

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dentifrices

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fissure sealants

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tooth enamel dust 

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methyl methacrylate 

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fluoride trays and cotton rolls also have been implicated in 
      promoting asthmatic events

bulletcorticosteroid-dependent asthmatic people may have a higher tendency for having an adverse reaction to sulfites.

The health care provider must know the symptoms of an asthma "attack" and be ready to treat it.

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Before Treatment

When an asthmatic dental patient seeks care, the dental professional must: 

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Assess the patient's risk level by taking an oral history of the illness. 

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Ascertaining the frequency and severity of acute episodes.

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Reviewing the patientís medications thoroughly (as they provide an indication of disease severity).

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Determining the patientís specific triggering agents.

It should be recognized that dental treatment can invoke a significant decrease in pulmonary function among asthmatic patients. It has been demonstrated that there is a reduction of lung function in 15 percent of asthmatic patients studied while receiving dental care.

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During Dental Treatment

The most likely times for an acute exacerbation are:

  1. During and immediately after local anesthetic administration. 

  2. With stimulating procedures such as extraction, surgery, 
    pulp extirpation.

At each visit make sure:

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Confirm that they have taken their most recent scheduled dose of medication. Inhaled corticosteroids are used for maintenance therapy and do not improve an acute attack.

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The patientís own metered-dose inhaler bronchodilator should be on hand at each visit to minimize the risk of an attack.

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Patientís appointment should be in the late morning or the late afternoon.

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If the asthmatic patient does not use a bronchodilator, make sure the emergency kit has both a bronchodilator and oxygen .

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Prophylactic dose of b2 agonist bronchodilator could prevent diminished lung function during dental treatment. The H1-blocking antihistamines, too, have been shown to be useful in blunting the bronchoconstrictor response with a pretreatment dose. Promethazine and diphenhydramine have the benefit of being antiemetic and sedative as well as antihistaminic.

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Anxiety is a known asthma trigger thus the dental environment is a common site for an acute asthmatic attack. Therefore, it should be ascertained that the patient has taken his or her most recent scheduled dose of antiasthma medication before treatment. 

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Additionally, substantive stress-management techniques should be used. 

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The use of N2O in patients with mild-to-moderate asthma can prevent acute stress related symptoms. However, because of its potential for causing airway irritation, N2O is contraindicated for use in patients with severe asthma. It is advisable to obtain a medical consultation before administering N2O to such patients

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Consequently, patients with severe persistent asthma and those who are prone to severe abrupt episodes of airway obstruction are best given dental treatment in the hospital.

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During treatment check for:

  1. Improper positioning of suction tips

  2. If fluoride trays or cotton rolls could trigger a hyperreactive airway response in your patient.

  3. Rubber dams should be used cautiously to avoid possible respiratory compromise or aggravation. 

  4. Avoid prolonged supine positioning.

  5. Bacteria-laden aerosols from plaque or carious lesions and 
    ultrasonically nebulized water also can be asthma triggers in the 
    dental setting.

  6. Additionally, aeroallergens such as tooth-enamel dust and methyl methacrylate have been reported to trigger asthmatic attacks.

Emergency protocol needs to be in place to provide safe care for patients especially when they experience "air hunger"

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Emergency Protocol for Managing Asthmatic Exacerbation:

Assessment of Severity

Acute exacerbations are manifested by episodes of bronchospasm and resulting hypoxia and hypercarbia. 

Management strategy is directed at determining the level of hypoxia and correcting it

The following indicate that the exacerbation is severe:

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peak expiratory flow rate, or PEFR, is at or below 50 percent of reference value;

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oxygen saturation is below 91 percent;

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bronchodilator does not improve PEFR by at least 10 percent after two treatments;

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patient has difficulty speaking;

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patient is struggling for air.

Managing an Acute Asthmatic Attack

  1. Discontinue the dental procedure and allow the patient to assume a comfortable position.

  2. Establish and maintain a patent airway and administer b2 agonists via inhaler or nebulizer.

  3. Administer oxygen  6-10 liters via face mask, nasal hood or cannula. If no improvement is observed and symptoms are worsening, administer epinephrine subcutaneously (1:1,000 solution, 0.01 milligram/ kilogram of body weight to a maximum dose of 0.3 mg).

  4. Document in time form the beginning of the event.

  5. Alert emergency medical services-911.

  6. Maintain a good oxygen level until the patient stops wheezing and/or medical assistance arrives.

  7. Begin diligent basic life support A, B,C,Ds activity as needed.

  8. Escort patient to hospital as needed.

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General Oral Health Care Instructions

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Prescribe fluoride supplements for all asthmatic patients, but especially for those taking b2 agonists

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Instruct patients to rinse their mouths after using an inhaler

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Reinforce oral hygiene instructions to help minimize gingivitis

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Be aware of possible need to prescribe antifungal agents for patients who chronically use nebulized corticosteroids

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Summary of Recommendations:

Before Treatment

  1. Schedule appointments for late morning or afternoon.

  • Assess severity of asthmatic condition.

  • Consider antibiotic prophylaxis for immunosuppressed patients

  • Consider corticosteroid replacement for adrenally suppressed patients

  • Avoid using dental materials that may elicit an asthmatic attack

  • Have supplemental oxygen and bronchodilators available in case of acute asthmatic exacerbation

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    During Treatment

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    Use vasoconstrictors judiciously

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    Avoid using local anesthetics containing sodium metabisulfite

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    Use rubber dams cautiously

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    Avoid eliciting a coughing reflex

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    Use techniques to reduce the patientís stress:
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    Avoid using barbiturates

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    Avoid using nitrous oxide in people with severe asthma

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    After Treatment

    1. Be aware that some patients may have an adverse reaction to nonsteroidal anti-inflammatory drugs.

    2. Use tetracycline cautiously.

    3. Avoid use of erythromycin in patients taking theophylline.

    4. Avoid use of phenobarbitals in patients taking theophylline.

    5. Analgesic of choice for these patients is acetaminophen.

    Oral health care providers play a role that is important in terms of both the patient's overall health and the systemic condition's effect on oral health. 

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    News Updates

    Dentists and dental hygienist should be attuned to adult patients who have asthma and exhibit signs of anxiety and/or other physical symptoms, or indicators of stress that can exacerbate asthma during or prior to dental treatment

    Dental Anxiety, Dental Health Attitudes, and Bodily Symptoms as Correlates of Asthma Symptoms in Adult Dental Patients with Asthma Author(s): Linda Russell RDH, PhD, CHES  Source: Journal of Dental Hygiene    2004;78(3):3  Publisher: American Dental Hygienists' Association 

    February 27, 2007

    The Dental Patient With Asthma: An Update and Oral Health Considerations
    Steinbacher D.M.[1], Glick M.[2] JADA The Journal of the American Dental Association - September 2001
    Asthma, Dr. Smith, pg 6 Nebraska Dental Association, November 2002.

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