Pulmonary Diseases - Dental Management

Pulmonary Diseases Dental Management of Patients with Pulmonary Diseases

Outline  Lung

Infections: Tuberculosis  Chronic Obstructive Pulmonary Disease – Chronic Bronchitis – Emphysema  Asthma

Tuberculosis       

Epidemiology: TB is the No. 2 killer infectious disease (no. 1 AIDS) in the world 1/3 of the world’s population is already infected with TB. Every second, someone in the world becomes newly infected. Over the centuries, TB has taken over 1 billion lives. Every year, more than 8 million new people develop active TB Every year, 2 million people die from TB.

Tuberculosis    

Epidemiology: No. 6 cause of death in the Phils (2000) – 7.5% of all cases No. 6 cause of sickness in the Phils.(2002) – 8 out of 10 are infectious diseases US CDC: rates of TB are 10 times higher among Asians

10 Highest Burden TB Countries: 1. India 2. China 3. Indonesia 4. Nigeria 5. Bangladesh 6. Pakistan 7. Ethiopia 8. Philippines 9. South Africa 10. DR Congo as of October 2003; source: WHO 2004 Global Tuberculosis Report

Cause and Spread Cause: tubercle bacillus (Mycobacterium tuberculosis)  aerobic, nonmotile, rods with a high lipid content in their cell walls.  acid-fast bacilli, because once they are stained, they resist decoloration with acid-alcohol. Transmission:  through inhalation of aerosolized bacteria (1 droplet = 1-10 bacilli)  From coughing, sneezing or speaking by people with active TB  These small droplets can remain suspended in the air for several hours.  Infection will occur if inhalation results in the organism reaching the alveoli of the lungs.

Symptoms  Fever  Night

sweats  Anorexia  Nonproductive cough  Weight loss  Malaise  Fatigue

Diagnosis 1.

History  

2. 3. 4.

Immunocompromised patient Exposure to person with active TB

Chest x-ray Sputum test – (+)AFB (acid-fast bacilli) Tuberculin Skin Test

Immunocompromised Conditions diabetes mellitus  malignancies requiring chemotherapy  steroid-dependent diseases, such as asthma or collagen vascular disease  malnutrition related to alcohol/drug abuse, smoking, extremes of age, and HIV  infection as well as demographic and socioeconomic factors  end-stage renal disease 

Positive PPD test PPD (purified protein derivative) Or Mantoux test Or TST (tuberculin skin test) (+)Result:=/>10mm

Chest X-ray

Class Type

Description

0

No TB exposure Not infected

No history of exposure Negative reaction to tuberculin skin test

1

TB exposure No evidence of infection

History of exposure Negative reaction to tuberculin skin test

2

TB infection No disease

Positive reaction to tuberculin skin test Negative bacteriologic studies (if done) No clinical, bacteriological, or radiographicevidence of active TB

3

TB, clinically active

M. tuberculosis cultured (if done) Clinical, bacteriological, or radiographic evidence of current disease

4

TB Not clinically active

History of episode(s) of TB OR Abnormal but stable radiographic findings Positive reaction to the tuberculin skin test Negative bacteriologic studies (if done) AND No clinical or radiographic evidence of current disease

5

TB suspected

Diagnosis pending

Pathology of TB

TB bacilli Strong immune system CD4 helper T cells tell macrophages to kill intracellular TB bacilli; CD8 suppressor T cells lyse macrophages Granuloma forms Mycobacteria cannot grow in acidic extracellular environment; granuloma calcifies Controlled infection

Immune system overwhelmed Lymphocytes excrete cytotoxic substances Hydrolytic enzymes cause caseation (“cheese-like”) necrosis Liquefaction and cavitation More bacteria multiply in cavitation; Active infection

Treatment 

Multiple Drug Therapy – – – –



Isoniazid (INH) Pyrazinamide (PZN) Rifampicin Streptomycin

Regimen – 2 months INH, PZN, Rifampicin, Streptomycin – 7-10 months INH and Rifampicin



DOT- directly observed treatment

Dental Management 

In Active TB: 1. patients should be in negative pressure rooms 2. Health professionals should wear N-95 respirator masks or with HEPA filters

Dental Management  Before

treating, make sure:  Clinical improvement is seen (no fever and cough)  Sputum test is free of mycobacteria  At least two weeks of multiple drug therapy completed

Chronic Obstructive Pulmonary Disease (COPD) 

     

a disease state characterized by the presence of airflow obstruction due to chronic bronchitis or emphysema May also have symptoms of asthma Symptoms: Productive cough Breathlessness Wheezing Signs: barrel chest, wheezing, prolonged expiration

Chronic Obstructive Pulmonary Disease (COPD)  Primary

cause: cigarette smoking

– 20 pack years= 20 years of smoking 1 pack a day  Others:

air polllution; airway hyperresponsiveness  No. 7 killer disease in the Phils. (2000) or 4.3% of cases  Common in patients >50 yrs old

Chronic Bronchitis Chronic bronchitis = the presence of a chronic productive cough for 3 months during each of 2 consecutive years (other causes of cough being excluded)  Mucous gland enlargement  Mucous plugs in airway  Lots of phlegm (“talaba”)  “Blue bloaters”  Cyanosis  Overweight patients 

Chronic Bronchitis

Emphysema 

 

Emphysema is defined as an abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis. Chronic Bronchitis (clinical findings) Emphysema (anatomic findings)

Emphysema

Emphysema  Difficulty

in expiration because of loss of elasticity in alveolar wall  “Pink puffers”  Barrel-chested  Scanty mucus  Severe dyspnea

Depressed diaphragm

Treatment  Smoking

cessation  Mucolytic agents  Oxygen therapy  Antibiotics  Oral steroids  Inhaled steroids  Bronchodilators  Anticholinergic agents

Dental Management  Treat

patient in supine position  Avoid use of rubber dam  May need oxygen supplementation while treating  Don’t use bilateral blocks  GA contraindicated

Asthma  hyperreactive

airway disease  a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role, in particular, mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells

Asthma 

 3) 4) 5)

Symptoms: wheezing, breathlessness, chest tightness and coughing, particularly at night or in the early morning Components: airway inflammation intermittent airflow obstruction bronchial hyperresponsiveness.

Causes/Triggers

allergens

exercise

medications

Causes/Triggers – – – – – – – – – – –

Environmental allergens Viral respiratory infections Exercise; hyperventilation Gastroesophageal reflux disease Chronic sinusitis or rhinitis Aspirin or nonsteroidal anti-inflammatory drug hypersensitivity, sulfite sensitivity Use of beta-adrenergic receptor blockers (including ophthalmic preparations) Environmental pollutants, tobacco smoke Occupational exposure Emotional factors Irritants such as household sprays and paint fumes

Diagnosis  PFT

(pulmonary function test)  Allergen skin test

Types of Asthma 







Step 1 - Intermittent – Intermittent symptoms occurring less than once a week – Brief exacerbations Step 2 - Mild persistent – Symptoms occurring more than once a week but less than once a day – Exacerbations affect activity and sleep – Nocturnal symptoms occurring more than twice a month Step 3 - Moderate persistent – Daily symptoms – Exacerbations affect activity and sleep – Nocturnal symptoms occurring more than once a week Step 4 - Severe persistent – Continuous symptoms – Frequent exacerbations – Frequent nocturnal asthma symptoms – Physical activities limited by asthma symptoms

Dental Management Never treat a patient with an asthma attack  Have anti-asthma medication (inhaler) on hand  Good suction and evacuation of water and saliva  Avoid allergens (incl. NSAIDs)  Decrease stress experience  Avoid respiratory depressants (opioid drugs) 

Dental Management  Patient

History: frequency, severity of attacks, triggers  Refer for medical consult if needed

WORDS TO LIVE BY: For the Lord gives wisdom, from His mouth come knowledge and understanding. Proverbs 2:6