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  • Asthma is a chronic inflammatory disease of the airways, characterized by reversible episodes of increased airway hyperresponsiveness which results in recurrent episodes of dyspnea, coughing and wheezing.

  • Attacks may be provoked by:

    • Extrinsic or Allergic (35% of cases)

      • ​Allergens

        • pollens, dust, house mites, animal dander

        • chemicals

        • smoke

    • Intrinsic (30% of cases)

      • Endogenous factors

        • Emotional stress, anxiety, nervousness

        • Gastroesophageal acid reflux

        • Vagally mediated responses

    • Drug induced

      • Aspirin, NSAIDs, beta blockers, ACE inhibitors

    • Foods

      • Nuts, shellfish, strawberries, milk, food dyes

    • Metabisulfate preservatives in foods, sometimes in local anesthetics (as preservatives in epinephrine)

    • Exercise induced - cold air?

    • Infectious asthma

 

 

 

 

Asthma

Introduction

Risks to the dental patient

Management During Treatment

  • Provocation of severe asthmatic attack during dental treatment

  • Status asthmaticus (attack lasting longer than 24 hours)

    • Signs

      • Increased and progressive dyspnea

      • Jugular venous pulsation

      • Cyanosis

      • Pulsus paradoxus (fall in systolic pressure on inspiration)

    • Often associated with with a respiratory infection 

    • Can lead to

      • exhaustion

      • severe dehydration

      • peripheral vascular collapse

      • death

Questions to Ask 

  • For severe or unstable asthma, routine dental treatment should be postponed until better control is achieved.

    • Inadequate treatment and poor stability

      • Shortness of breath, wheezing, increased respiratory rate (more than 50% above normal), poor drug use compliance, emergency department visits within the previous 3 months

    • High risk for severe attack

      • Use of more than 1.5 canisters of a beta agonist (emergency) inhaler per month OR

      • Recent doubling of monthly use of emergency inhaler.

Prevention 

  • Patients with nocturnal asthma - schedule for late-morning appointments

  • Patients should regularly bring their rescue inhaler to their appoinments

  • Prophylactic inhalation of bronchodilator at the beginning of the appointment for moderate to severe disease

  • Stress reduction protocol

  • Have patient inform the dentist at the earliest sign of an attack

  • Nitrous oxide-oxygen inhalation is the best sedation to use.  Nitrous is not a respiratory depressant nor an irritant to the tracheobronchial tree

  • Avoid barbiturates and narcotics which can provoke an attack

Post-Operative Care

  • Avoid narcotic analgesics

  • Avoid analgesics which include aspirin

References

Dental Management of the Medically Compromised Patient.  Little, Falace, Miller and Rhodus. 8th Edition

Medical Consultation Recommended 

  • What type of asthma do you have?

  • Are you having symptoms today?

  • What causes attacks?

  • How often do you have attacks?

  • How do you manage the attacks?

  • ​Have you ever been hospitalized or had to go to urgent care or the emergency room because of an asthma attack?

  • How often do you see your physician?

  • What medications are you taking?

  • Did you take your medications today?  Do you take your medications every day as directed?

  • How do you feel about dental treatment? Do you feel anxious or fearful?

Emergency

  • Signs/Symptoms

    • Dyspnea (inability to finish sentences with one breath)

    • Expiratory wheezing

    • Chest tightness

    • Flushing

    • Tachypnea (> 24 breaths/minute)

    • Tachycardia (> 110/minute)

    • Diaphoresis (sweating)

    • Accessory muscle use for inhalation

  • Treatment

    • Administer fast-acting bronchodilator every 20 minutes

    • Oxygen

    • Subcutaneous epinephrine (1:1000) in a dose of 0.3 to 0.5 mL

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