Dental Management of the Medically Compromised Patient, Ch. 7

Chronic obstructive pulmonary disease (COPD)
A general term for pulmonary disorders characterized by chronic airflow limitation from the lens that is not fully reversible
1. Chronic bronchitis
2. Emphysema
2 main diseases that COPD encompasses
Chronic bronchitis
A condition associated with excessive tracheobronchial mucus production (at the bronchial level) sufficient to cause a chronic cough with sputum production for at least 3 months in at least 2 consecutive years in patient whom other causes of productive chronic cough have been excluded
Emphysema
The presence of permanent enlargement of the air spaces distal to the terminal bronchioles accompanied by destruction of alveolar walls or septa (at the acing level) without obvious fibrosis
COPD
The third leading cause of death in the US and is estimated to affect more than 24 million people
tobacco smoking
Worldwide, the most important cause of COPD is..
inflammatory mediators (i.e., cytokines)
The genetic susceptibility to the production of ______________ in response to smoke exposure plays an important role in the development of COPD
FALSE–It affects both large and small airways
T/F: Chronic bronchitis only affects large airways
expiration
inspiration
Obstruction from emphysema is caused by the collapse of unsupported and enlarged air spaces and is evident on _____________ and not _________________
cor pulmonale (R sided heart failure)
If COPD is untreated, pulmonary hypertension can develop and, in the absence of supplemental oxygen therapy, lead to…
FALSE–It is an irreversible process with no cure
T/F: With proper treatment, COPD can be reversed and, in some cases, cured
40
The onset phase of COPD takes many years in most patients and usually begins after age…
-Chronic cough with sputum
-Dyspnea that is persistent and progressive or worsens with exercise
Early sights of COPD
Measures of expiratory airflow (forced vital capacity and forced expiratory volume on a spirometer)
The key diagnostic procedures for COPD testing
70
A diagnosis of COPD is assigned when patients have pulmonary symptoms and forced expiratory volume in one second (FEV1) less than _____% of predicted volume in the absence of any other pulmonary disease
1. Overweight
2. Chronic productive cough
3. Copious mucopurulent sputum
4. Mild dyspnea
5. Frequent respiratory infections
6. Elevated PCO2, decreased PO2
7. Cor pulmonale
8. Chest radiograph showing prominent blood vessels and large heart
Features of chronic bronchitis
1. Thin physique
2. Barrel-chested
3. Seldom coughing
4. Scanty sputum
5. Severe dyspnea
6. Few respiratory infections
7. Normal PCO2, decreased PO2
2. Chest radiograph showing hyperinflation and small heart
Features of emphysema
1. Smoking cessation
2. Influenza and pneumococcal vaccinations
3. Use of short- and long-acting bronchodilators
Management of COPD
Stage I – mild COPD
Stage of COPD defined by an FEV1/FVC ratio of less than 70% and an FEV1 of 80% or more of that predicted
Stage II – moderate COPD
Stage of COPD that is characterized by worsening airflow limitation and FEV1/FVC less than 70% and FEV1 of 50% to less than 80% predicted
Stage III – severe COPD
Stage of COPD that is characterized by FEV1/FVC less than 70% and FEV1 of 30% to less than 50% predicted, with further worsening of airflow limitation
Stage IV – very severe COPD
Stage of COPD that is characterized by FEV1/FVC less than 70%; FEV1 less than 30% predicted, with chronic respiratory failure and exacerbations that may be life-threatening
Bronchodilators
Cornerstone of COPD management
Theophylline
A methylxanthine nonselective phosphodiesterase inhibitor that relaxes bronchial smooth muscle cells, but has a limited role in COPD management because of its narrow therapeutic range and likelihood of adverse affects
unstable and should be rescheduled.
A patient coming to an office for routine dental care who displays shortness of breath at rest, a productive cough, upper respiratory infection, or an O2 saturation level of less than 91% is..
FALSE–They should be in a semi-supine or upright position to prevent orthopnea and a feeling of respiratory discomfort
T/F: COPD patients should be placed in a supine position when undergoing dental treatment
FALSE–No contraindication of the use of local anesthetic has been identified
**However, bilateral mandibular blocks or bilateral palatal blocks can cause an unpleasant airway constriction sensation in some patients
T/F: Local anesthetics are contraindicated in patients with COPD
TRUE–Can be used with caution in patients with mild to moderate chronic bronchitis, but should not be used at all on patients with severe COPD
T/F: Use of nitrous oxide sedation should be avoided in patients with COPD
TRUE–because of their respiratory depressant properties
T/F: Narcotics and barbiturates should not be given to patients with COPD
Macrolide antibiotics (e.g., erythromycin, azithromycin) and cirpofloxacin hydrochloride
Antibiotics to avoid for patients with COPD
Asthma
A chronic inflammatory disease of the airways characterized by reversible episodes of increased airway hyper responsiveness resulting in recurrent episodes of dyspnea, coughing, and wheezing.
TRUE–from about 2% to 7% or greater
T/F: In the United States, the prevalence of asthma has more than doubled since the 1960s.
1. Extrinsic (allergy or atopic)
2. Intrinsic (idiosyncratic, nonallergic)
3. Drug-induced
4. Exercise-induced
4 categories of asthma triggers
Allergic or extrinsic asthma
The most common form of asthma that accounts for approximately 35% of all adult cases
Status asthmaticus
A particularly severe and prolonged asthmatic attack (one lasting more than 24 hours) that is refractory to usual therapy
Mild persistant asthma
Asthma that is characterized by symptoms that occur once per week but less than once daily with an FEV1 greater than 80%
Moderate asthma
Asthma that is characterized by an FEV1 greater than 60% but less than 80% and daily symptoms that affect sleep and activity level and, on occasion, require occasional emergency care.
Severe asthma
Asthma that is characterized by less than 60% FEV1, which results in ongoing symptoms that limit normal activity. Attacks are frequent or continuous, occur at night, and result in emergency hospitalization.
Inhaled corticosteroids
The most effective anti inflammatory medications currently available for the treatment of persistent asthma
FALSE–It is okay to use nitrous oxide on a patient with asthma
T/F: It is contraindicated to use nitrous oxide on a patient with asthma
TRUE–Because aspirin ingestion is associated with the precipitation of asthma attacks in a small percentage of patients
T/F: Aspirin containing medications or other NSAIDs should not be given to patients with asthma
Tuberculosis
An important human disease caused by an infectious and communicable organism, Mycobacterium tuberculosis
1/3
WHO estimates that ____ of the world population is infected with TB
TRUE
T/F: TB kills more adults worldwide each year than does any other single pathogen
Ghon complex
The combination of a primary granulomatous lung lesion and infected hilar lymph node from TB
Miliary tuberculosis
Widespread TB infection with multiple organ involvement
1. Tuberculin (Mantoux) skin test (TST)
2. Interferon-gamma release assay
Two tests that are used for the diagnosis of LTBI
low risk
The CDC places most dental facilities in the __________ category for potential occupational exposure to TB
1. Active TB
2. A history of TB
3. A positive tuberculin test
4. Signs or symptoms suggestive to TB
4 infectivity categories of TB
TRUE–Treatment is best rendered in a hospital setting with appropriate isolation, sterilization, and special engineering control systems and filtration masks
T/F: Patients with clinically active TB and positive sputum cultures should not be treated on an outpatient basis
After receiving chemotherapy for at least 2-3 weeks and after receiving confirmation from the physician that the patient is noninfectious and lacks complicating factors
When can a patient with clinically active TB be treated on an outpatient basis?
FALSE–They can be treated as an outpatient because bacilli are found only rarely in the sputum of young children
T/F: Children with active TB who is receiving chemotherapy cannot be treated as an outpatient.
acetaminophen
A patient who is taking Isoniazid for treatment of TB should avoid taking….
Painful, deep, irregular ulcer on the dorsum of the tongue. The palate, lips, buccal mucosa, and gingiva may also be affected
**Note–this is not very common and is usually seen in men about 30 years of age and in children
Oral manifestation of TB
Scrofula
Condition that occurs when TB infects the cervical and submandibular lymph nodes. The nodes may become enlarged and painful, and abscesses may form.