Acute u pper r espiratory i nfections
These are commonly associated with the common cold and make the delivery of dental care more trying for the patient as well as increasing the exposure of the operator to infection. When a patent nasal airway is mandatory in, for example, inhalation sedation or GA, elective treatment needs to be deferred.
Asthma
This is defi ned as repeated, reversible attacks of wheeze on breathing out, shortness of breath and a cough as a result of narrowing of the airway. Infl ammation (oedema) and infection (mucus plugs) may follow. It is a syndrome caused by allergy (dust mites, foods, drugs), pollution, infections, stress, exercise and non - compliance with drugs, and is seen in atopic individuals (eczema, hay fever).
Management of asthma consists of:
■ avoidance of allergens and known precipitating factors ■ the use of inhaled bronchodilators and steroids.
To avoid the potential for an acute attack:
■ sit the patient up
■ check the airway for any obstructions
■ advise the patient to use their bronchodilator inhaler.
The patient should be admitted urgently to hospital if the attack continues despite these measures. On admission, the patient may be given oxygen, nebulised bronchodila- tors, systemic steroids, antimicrobial drugs (if infection is the cause) and ventilation if the attack progresses to status asthmaticus (sudden and sustained aggravation of asthma).
The use of epinephrine, aspirin and NSAIDs in asthmatic patients should be avoided.
Local anaesthetic agents such as articaine should be used with caution. There is the potential for candida infection in the palate from the use of inhalers. Asthmatic patients may be more susceptible to dental erosion as a consequence of gastro - oesophageal refl ux because of coughing. Patients on steroids may have a steroid crisis. Respiratory depres- sants, especially sedatives and tranquillisers, should be avoided.
Chronic o bstructive a irway d isease
This is also called chronic bronchitis or emphysema. It presents as bronchospasm and destruction/distension of the alveoli and is commonly seen in smokers.
Patients may be taking steroids and so may need supplemental steroids for invasive, stressful dental care because the endogenous supply of steroid will be suppressed. They may also be predisposed to oral candida infection as well. Patients taking theophylline should not be given erythromycin and some other antimicrobials because they result in toxic levels of theophylline.
Sedatives, tranquillisers, hypnotics and narcotics should be avoided. High - fl ow oxygen may take away the respiratory drive and as such may be a relative contraindication to use of nitrous oxide sedation during which levels of oxygen are higher than in inspired room air. Consultation with the patient ’ s physician will clarify whether this is a real problem.
Scoliosis
Patients who have a lateral curvature of the spine (kyphosis, anterior curvature; lordosis, posterior curvature) may have associated cardiac and respiratory disorders.
Oral and d ental c onsiderations
■ General anaesthetics may be contraindicated in a person who has severe scoliosis because of the poor ventilation of portions of the respiratory tree.
■ Patient comfort is paramount – seating with good support (Tumle cushions) is very important.
■ Patients may wear a brace – the Milwaukee brace encases the thorax and abdomen and has a chin cap extension; such orthopaedic splinting may produce a malocclusion.
■ Chairside aspiration must be high vacuum to protect the airway in a patient in whom respiratory infection would be complex to manage.
Cystic fi brosis
This is not strictly a respiratory disorder but it predominantly affects the respiratory tree.
It is the most common inherited condition in humans with 1 in 25 of the population as carriers. The disorder is of mucus - secreting exocrine glands, therefore effects are seen principally in the respiratory and gastrointestinal tracts. Patients will be taking a number of drugs, some of which may have affected the teeth during development. Problems with the pancreas mean that diabetes is seen in these patients. Orally/dentally patients may present with:
■ discoloured teeth (from underlying disease and/or antibiotic therapy) ■ enamel hypoplasia
■ caries resistance (because of high pH of saliva) ■ increased prevalence of calculus
■ salivary gland enlargement.
Water lines in dental clinics should be carefully sterilised to avoid contamination with Pseudomonas aeruginosa , which is very resistant to treatment once it colonises the lungs.
Patients may be uncomfortable if treated supine and will need daily physiotherapy.
Some patients will require parenteral nutritional supplements as well as prophylactic antibiotics.
Tuberculosis
This used to be the most common infective disease, but better living conditions and widespread availability of treatment with antibiotics reduced its prevalence. However, drug resistance and human immunodefi ciency virus (HIV) infection has brought about
a recurrence of this infection. Patients with active tuberculosis (TB) lose weight, complain of feeling tired, have night sweats and are breathless. They have a chronic cough with blood in the sputum (haemoptysis).
Transmission of TB is usually by droplets but occasionally from infected, non - pasteur- ised milk. Healing may take place and the only sign in later life is calcifi ed nodes on a lung x - ray. Progression of TB may occur through blood spread to involve other organs or re - activation of a previous infection, seen in the lungs as cavitation.
Patients with active disease (positive sputum) or who are still coughing should not receive dental care, except for dental emergencies. Most patients will have negative sputum cultures after three to four weeks of treatment and are then not infective. Non - compliance with drug therapy, which takes months, is the usual cause of a prolonged infective period.