management of asthmatic patient in dental clinic

1. ASTHMATIC PAEDIATRIC
PATIENT IN DENTAL CLINIC
PRESENTED BY –
Dr KRITIKA SINGH
JR III
DEPARTMENT OF
PAEDIATRIC DENTISTRY
KGMU LKO

2. Asthma is the most common disease of childhood as measured in emergency
department visits and hospitalizations.
Its prevalence has increased considerably over the past 20 years, especially in
children .
Asthma, irrespective of the severity, is a chronic inflammatory disorder of the airways.
An allergic reaction, the airways swell, and the muscles around the airway tighten,
making it difficult for air to move out of the lungs .
BURDEN OF ASTHMA IN CHILDREN :
What is asthma
Last reviewed Thu 1 November 2018By Adam Felman Reviewed by Debra Sullivan, PhD, MSN, RN,
CNE, COI

3. Definition of Asthma
Asthma is a chronic inflammatory disorder of the airways,
causes recurrent episodes of wheezing, breathlessness, chest
tightness, and coughing, particularly at night or in the early
morning.
Last reviewed Thu 1 November 2018By Adam Felman Reviewed by Debra Sullivan, PhD, MSN, RN, CNE, COI

4. Epidemiology

5. Many terms are used to describe the
different types of asthma:
o Allergic bronchopulmonary mycosis
o Aspirin-induced asthma
o Adult-onset asthma
o Asthma with fixed airflow obstruction
o Exercise-induced asthma
o Cough-variant asthma
o Work-related asthma
o Night time (Nocturnal) asthma
o Asthma with obesity
What types of asthma are there?

7. Signs & symptoms

8. Wheezing is one of the most problems
for which preschool children are seen
in the pediatrician's office .
Many parents who report “wheezing”
or “noisy breathing” in their child
expect a diagnosis of asthma.
However, not all wheezing is asthma .

9. Some factors thought to be involved in asthma include:

10. Diagnosis of asthma
• Asthma diagnosis in age group of 5 year & younger is
difficult
• Respiratory symptoms (wheezing and cough) also common in
children without asthma.
• Spiro metric lung function are difficult to perform in young
children, because active cooperation is needed for successful
measurements.

11. Tests to diagnose and monitor asthma
1.Peak flow meter
• A peak flow meter measures how much air
a child can quickly exhale.
• Low readings indicate worsening asthma.
• This will help recognize when to adjust
treatment to prevent an asthma flare-up.

12. Tests to diagnose and monitor asthma
2.Spirometry:
 Is a lung function test .
 This test checks how much
and how quickly air can
exhale .
 This test differentiates
asthma from other lung
diseases.

13. 3. Allergy testing :
 Can identify people with severe allergic
asthma.
Sometimes there is a clear link between
an allergen and asthma symptoms.
Tests to diagnose and monitor asthma

14. Tests to diagnose and monitor asthma
4. High eosinophils :
 When people have an allergic disease or infection. .
 Indicate more severe asthma.
 Corticosteroids are effective for people with high eosinophil
levels
 People with few or no eosinophils do not usually respond well to
corticosteroids.

15. 5.Nitric oxide testing :
 The amount of exhaled nitric oxide is related to the amount of
inflammation in the lungs.
 Inhaled corticosteroids are usually effective for people with high
levels of nitric oxide.
 People with low levels of nitric oxide should be stop taking their
corticosteroids
Tests to diagnose and monitor asthma

16. ACCESSORY DIAGNOSTIC TESTS OF ASTHMA :
• Chest X- Ray (CXR)
• Pulmonary Function Test (PFT)
• Arterial Blood Gases (ABGs)

17. Can asthma be cured?
 Fortunately…asthma can be effectively
treated and most patients can achieve
good control of their disease(virtual cure)
but it is not a curable disease.

20. Medication delivery devices
Most asthma medications are given with a
device that allows a child to breathe medication
directly into the lungs.
1. Metered dose inhaler(MDI)
2. Dry powder inhalers
3. Nebulizer

21. • Inhaled corticosteroids
• Inhaled long-acting b2- agonists
• leukotriene receptor antagonists
• Oral sustained release theophylline's Relievers
• Inhaled fast-acting b2-agonists
Inhaled therapy constitutes the cornerstone of asthma
treatment in young age group.
Medications for Asthma Management

23. QUICK-RELIEF MEDICATIONS
Drugs, including short-acting inhaled or oral beta2 agonists,
short-course oral corticosteroids or ipratropium are taken
as needed for immediate relief of acute symptoms .
Overuse reduces their efficacy and has been associated
with increased bronchial hyper-reactivity, central nervous
system overstimulation, worsening asthma and death.
Oral corticosteroids have broad anti-inflammatory effects
and may be used in a limited, short course (three to 10
days) to gain initial control of the asthma.
Management of Asthma in ChildrenJAMES P. KEMP, M.D., University of California School of Medicine, San Diego, California
JUDITH A. KEMP, D.O., San Diego, California
Am Fam Physician. 2001 Apr 1;63(7):1341-13 This article exemplifies the AAFP 2001 Annual Clinical Focus on allergies and asthma

24. The anticholinergic drug Ipratropium is not approved by the U.S.
Food and Drug Administration for the treatment of asthma in
children 12 years or younger.
However, it has been prescribed for off-label use in children
with asthma and may be helpful in those rare children who do
not tolerate inhaled beta2 agonists, or it may be added to a
beta2 agonist such as albuterol (Ventolin) to treat acute asthma
exacerbations

25. LONG-TERM CONTROL MEDICATIONS
Inhaled corticosteroids are the most potent and effective long-term anti-
inflammatory medications.
The FDA recently approved budesonide inhalation suspension (Pulmicort
Respules ), the only nebulizable corticosteroid for children 1 to 8 years.
It is available in unit doses of 0.25 mg and 0.50 mg for once- or twice-daily
dosing.
Improper & Long-term use at high doses of inhaled corticosteroids may inhibit
growth velocity; therefore, children's growth should be monitored regularly.
Management of Asthma in ChildrenJAMES P. KEMP, M.D., University of California School of Medicine, San Diego, California
JUDITH A. KEMP, D.O., San Diego, California
Am Fam Physician. 2001 Apr 1;63(7):1341-13 This article exemplifies the AAFP 2001 Annual Clinical Focus on allergies and asthma

29. (For a severe asthmatic patient’s, consultation with the
primary care physician is recommended. )
(Dental procedures may be accomplished in the
clinic setting )

30. Risk of asthma :
• Dental treatment may lead to ANXIETY of
patient this lead to bronchoconstriction.
• If not treated immediately it may lead to a
condition called status asthmaticus .
• It consider as severe form of paroxysmal
asthma and considered as life threat .

31. Don’t use the following:
• Sulphites
• Cotton rolls
• Tooth Enamel dust
• Methyl methacrylate
Things to avoid :
• Barbiturates& narcotics
• Aspirin & NSAIDs
• Macrolide antibiotic &
ciprofloxacin( in patient
on theophylline )

32. For patients with asthma, the practitioner should
consider the following to determine how well the
disease is controlled:
1) The frequency of asthmatic attacks,
2) The type of medications used chronically and
during acute attacks,
3) The length of time since the child was last seen
emergently with acute asthma.
4) Precipitating agents
Dental management of children with asthma Jian-Fu Zhu, DDS, MS Humberto A. Hidalgo, MD, MS W. Corbett Holmgreen, DDS, MD Spencer W. Redding, DDS, MEd Jan
Hu, BDS, PhD Robert J. Henry, DDS, MS
Updating patient history at every visit about these factors :

33. Conscious sedation ?
If conscious sedation is required, hydroxyzine and
benzodiazepines, which are anxiolytic and do not induce
bronchoconstriction, are usually recommended.
According to Malamed , the use of N20 in children with mild to
moderate asthma can effectively prevent acute symptoms.
N20 is somewhat irritating to the airway, its use in children with
severe asthma is contraindicated, and medical consultation is
recommended prior to N20 use in these children.
Dental management of children with asthma Jian-Fu Zhu, DDS, MS Humberto A. Hidalgo, MD, MS W. Corbett Holmgreen, DDS,
MD Spencer W. Redding, DDS, MEd Jan Hu, BDS, PhD Robert J. Henry, DDS, MS

34. Conscious sedation ?
• IV sedation should be used with extreme caution as asthmatics have
limited control of their airways.
• Ketamine, has been used safely in asthmatic patients.
• Although no adverse effects were reported, it must be remembered that
midazolam is a sedative drug, which may cause respiratory depression, and
caution is required when sedating the asthmatic patient.*
• Patients who have anything more than mild asthma should have
procedures performed where standard monitors (pulse oximetry, end-
tidal SAGO2, EKG, and blood pressure cuff) and intubation equipment are
available.

35. GENERAL ANESTHESIA IN ASTHMATIC PATIENT
GOAL: To depress airway reflexes with anesthetic drugs to avoid
bronchoconstriction of the child’s hyperactive airways in response to
mechanical stimulation.
• Sevoflurane is excellent for an inhalational induction.
• The anesthesiologist must be aware of associated problems in
children with asthma undergoing anesthesia .
• Choice of route or agent may be influenced by a history of asthma
Management of Asthma in ChildrenJAMES P. KEMP, M.D., University of California School of Medicine, San Diego,
CaliforniaJUDITH A. KEMP, D.O., San Diego, CaliforniaAm Fam Physician. 2001 Apr 1;63(7):1341-13 This article exemplifies
the AAFP 2001 Annual Clinical Focus on allergies and asthma

36. BEFORE DENTAL TREATMENT
1. Patients appointment should be Early morning .
2. Assess severity of ASTHAMATIC condition.
3. Consider antibiotic prophylaxis for immunosuppressed
patients
4. Consider corticosteroid replacement for adrenally suppressed
patients.

37. At each visit make sure that :
They have taken their most recent scheduled dose of medication.
The patient’s own MDI bronchodilator should be on hand to minimize the risk of
an attack.
Emergency kit with a bronchodilator and oxygen.
Avoid using dental materials that may elicit an ASTHMATIC ATTACK
If asthmatic patients does not use a bronchodilator ,make sure the emergency kits has
both a bronchodilator & oxygen.

38. During treatment :
1. Rubber dams should be used cautiously.
2. Use technique to reduce patient stress :
Avoid prolonged supine positioning
Avoid nitrous oxide in people with sever ASTHMA.
Avoid using BARBITURATES.
3. Avoid using LA containing SODIUM METABISULFIDE.
4. Use vasoconstrictor judiciously

39. After treatment :
1. TETRACYCLINE should be used cautiously.
2. Avoid use of ERTHROMYCIN in patients
taking THEOPHYLLINE.
3. Avoid use of PHENOBARBITALS in patients
taking THEOPHYLLINE.
4. Analgesic of choice for these patients is
ACETAMINOPHEN.

40. The most likely time for an acute
exacerbation :
• During and immediately after local
anesthetic administration.
• Stimulating procedures such as
extraction, surgery , pulp extirpation.

41. When ARE YOU in trouble ?!
You gave local anesthesia to your patient & all of a
sudden patient:
1. Has difficulty in breathing
2. Talking in phrases
3. You could hear loud wheezes
4. Using accessory muscles
5. Slightly agitated

43. Managing an acute asthmatic attack : during dental treatment :
Discontinue the dental
procedure and allow the
patient to assume a
comfortable position.
Establish and maintain a
patent airway and
administer b2 agonists via
inhaler or nebulizer.
Administer oxygen 6-10 liters via face
mask, nasal hood or cannula. If no
improvement is observed and symptoms
are worsening, administer epinephrine
subcutaneously ( 0.01 milligram/ kilogram
of body weight to a maximum dose of 0.3
mg).
Alert emergency medical
services.
Maintain a good oxygen level
until the patient stops
wheezing and/or medical
assistance arrives.
Dental management of children with asthma
Jian-Fu Zhu, DDS, MS Humberto A. Hidalgo, MD, MS W. Corbett Holmgreen, DDS, MD Spencer W. Redding, DDS, MEd Jan Hu, BDS, PhD Robert J. Henry, DDS, M

44. Follow-up care :
Once the child has improved sufficiently to be
discharged home, inhaled salbutamol through a
metered dose inhaler should be prescribed with a
suitable (not necessarily commercial) spacer and
the mother is instructed on how to use it.

45. NOTE:
Aminophylline :
• Is not recommended in children with mild-to-
moderate acute asthma.
• It is reserved for children who do not improve
after several doses of a rapid-acting
bronchodilator given at short intervals plus oral
prednisolone.

46. Magnesium sulfate :
• Iv magnesium sulfate may provide additional benefit in children
with severe asthma treated with bronchodilators and
corticosteroids.
• It can be used in children who are not responsive to the
medications .
• Give 50% magnesium sulfate as a bolus of 0.1 ml/kg (50 mg/kg)
IV over 20 min.
NOTE:

47. NOTE:
Antibiotics :
• Should not be given routinely for asthma or to a
child with asthma who has fast breathing without
fever.
• Only indicated, when there is persistent fever and
other signs of pneumonia

48. Asthma and anxiety:
Asthma attacks can be induced by stressful situations.
Strategies to curb anxiety:
1.Slow down and breathe:
2.Avoid caffeine:
Before a dental appointment. Caffeine can intensify anxiety.
3.Eat a proper meal:
Opt for protein over sugar to stabilize mood.
4. Plan carefully:
For some people, this might mean a Saturday or an early-morning appointment (less
stressful time).

49. Dental health risks:
Most common dental problems associated with
asthma are :
• Xerostomia / Dry mouth :
• Oral sore
• Dental caries
• Oral candidiasis
• Dental erosion
• Periodontal disease
• Halitosis
• Altered taste
Impact of inhalation therapy on oral healthNavneet Godara, Ramya Godara1, Megha Khullar
Departments of Conservative Dentistry and Endodontics and 1Periodontics, Jaipur Dental College,
Dhand, Jaipur, Rajasthan, India

50. Preventive strategies for oral risk
• Educate the patients about the possible adverse effects of the
inhalation therapy.
• Insist on the use of inhalers with a spacer device to reduce the
medication deposits in the oral cavity and oropharynx.
• Encourage regular dental check-ups at least every 6 months.
• Promote oral hygiene practices
• Instruct the patients to adequately rinse the mouth with neutral
pH or basic mouth rinses (milk, water, sodium fluoride 0.05%
mouth rinses) immediately after using an inhaler especially
before bedtime .
Impact of inhalation therapy on oral healthNavneet Godara, Ramya Godara1, Megha Khullar Departments of Conservative Dentistry and Endodontics and 1Periodontics,
Jaipur Dental College, Dhand, Jaipur, Rajasthan, India

51. • Immediate brushing of the teeth after using
inhaler should be avoided as it may damage the
already weakened enamel due to acidic pH .
• Institute dietary modification that includes
restriction of sugary foods or drinks between
meals.
• Sugar substitutes such as aspartame, saccharin,
xylitol, and sorbitol can be used as sweeteners.
Prescribe nutritional supplements and advice
more fluid intake.
• Recommend pit and fissure sealants, and fluoride
varnishes and gels (1% sodium fluoride or 0.4%
stannous fluoride).
Preventive strategies for oral risk

53. Conclusion
• As a pedodontist we should be well aware of the management of
patients suffering from asthma and should also know how to deal
with an acute attack of asthma.
• If an asthamatic patient comes to our clinic we should take a proper
history of the patient and tell them about the dental risks of taking
asthmatic medications.
• Also ,provide them with all preventive strategies available for such
oral health issues.

55. MCQS
Q1. Immediate action after acute asthmatic attack during dental
treatment is :
A. Discontinue the dental procedure and given b2 agonist .
B. Discontinue the dental procedure and put the patient in supine
position .
C. Discontinue the dental procedure and allow the patient to assume a
comfortable position.
D. Discontinue the dental procedure and hospitalize him/her .

56. Q2. Which of the following drug may cause respiratory depression :
a. Ketamine
b. N2O
c. Midazolam
d. Salbutamol

57. Q3. Signs & symptoms of asthmatic child are all except :
A. Shortness of breath
B. Wheezing & coughing
C. Sleeping problem
D. Chest tightness& burning

58. Q4. Analgesic of choice for asthamatic patients is :
A. IBUGESIC
B. DICLOFENAC SODIUM
C. ASPIRIN
D. ACETAMINOPHEN

59. Q5. Most common dental problems associated with asthma
are all except :
A. Staining of teeth
B. Oral candidiasis
C. Dental erosion
D. Dental caries