Chapter 66 The Patient with a Respiratory Disease Discussion
IntroductionToday’s patient is a 45 year old male. During the air polishing procedure the patient puts up his hand and asks to sit up. He starts coughing and you can hear wheezing when he takes a breath. His face is flushed, he starts sweating and his pupils are dilated. What do you think is happening and how should you proceed?Remember: All posts and responses should contain proper grammar, be free of spelling errors, be substantial, and reflect critical thinking.
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DEH 2806 Ch66
Chapter 65. The Patient With a Respiratory Disease. The next three slides are a brief review of
the respiratory system. There was a previous National Board question that asked where gas
exchange occurs. And as you can see here, it’s the alveoli. There was also a previous question on
the National Board that asked about goblet cells.
There are several methods to assess a patient’s respiration. The first two listed here, vital signs.
That’s what we do in the clinic. Hopefully you’ll do it in your offices. So you would check for
respirations. The second one listed here is spirometry, and that’s a done by a device called a
speedometer. And what it does is it registers the amount of air a person inhales or exhales, and
the rate at which the air is moving in and out of the lungs.
The third method is a pulse oximetry, and it’s performed with a pulse oximeter. There’s a picture
of it on the next slide. What it does, it attaches to a person’s finger, and it measures blood oxygen
saturation levels. If you’ve ever been in an office where they do oral surgery, this is attached, and
you can read it on a meter.
These meters have digital readouts so you can watch them. And an oxygen saturation level of
between 97% and 100% is a good level. If the saturation level is 91% or below that signifies
poor oxygen exchange. Chest radiography or chest imaging. That would be the fourth method.
And that would either be an X-ray or it would be a CT scan.
The fifth way to evaluate a person’s respiration is called a blood-gas analysis, and that’s a blood
test. The sixth one is cytology and hematology. So it’s a blood test that’s looking for
microorganisms that are causing respiratory diseases. And it’s also taking samples from various
parts of the lung.
Respiratory diseases are reclassified according to the upper respiratory tract and the lower
respiratory tract. Please know what structures are part of the upper and the lower respiratory
tract. This table is from your book, and it’s a good review of which diseases are in the upper
respiratory tract, and which ones are in the lower respiratory tract. And which ones are acute, and
which ones are chronic.
The rest of this PowerPoint discusses various respiratory diseases. We’ll start with infections of
the upper respiratory tract, which would be something like sinusitis or allergic reactions. Those
are transmitted by inhalation of airborne droplets, or indirectly by hands, or articles that are
freshly-soiled with discharge from a person’s nose or throat.
To avoid getting a respiratory infection, or passing on a respiratory infection, you want to make
sure that you observe standard precautions. Also once a year you should get a flu shot, a flu
vaccine. In general, lower respiratory tract infections are more serious than upper respiratory
tract infections. Listed here are acute diseases and chronic diseases. Please know which ones are
classified as acute, and which ones are classified as chronic.
Acute bronchitis, as the name states, it’s an acute respiratory infection. It is differentiated from
pneumonia, because when a chest X-ray is taken there is no significant finding if a person has
bronchitis. The symptoms are listed here. There are two types of acute bronchitis. One is viral
and one is bacterial.
By far, the most common is viral. And that’s treated with bedrest and fluids. It is not treated with
an antibiotic, because we know that antibiotics don’t kill viruses. If you have a bacterial
infection, then it’s going to be treated with an antibiotic.
Pneumonia is also an acute infection and it can be caused by viruses, which is the most common
method. Bacteria or fungi. Pneumocystis, pneumonia, that’s found most commonly in people that
have suppressed immune systems, such as somebody who’s HIV positive or has AIDS.
Healthy individuals can fight off the pathogens that cause pneumonia, but when a person has a
suppressed immune system such as we just discussed– HIV or AIDS– or they have diminished
salivary flow, they can’t cough forcefully, they have problems swallowing, they don’t perform
good oral hygiene, or they have some other type of physical disability, that puts them at an
increased risk of aspiration of these pathogens. And then becoming infected with a disease.
Pneumonias are categorized either by location and/or by procedure. This is a relatively new
categorization. And it has to do with the fact that a lot of individuals pass away in nursing
homes, or institutionalized settings, or in hospitals, from pneumonia that they acquire in those
settings.
So the first one is community-acquired pneumonia. That is outside of a hospital or extended care
facility. That’s strictly a person-to-person transmission. The next category is healthcareassociated pneumonia. That occurs when the infection starts within 48 to 72 hours after
admission to a healthcare facility, whether that’s a hospital or a nursing home. It’s a major cause
of death.
Unfortunately, it’s commonly multi-drug resistant, which means it’s very hard to kill those
pathogens. It’s more common in the very elderly, somebody that’s over the age of 80. And it’s for
the various reasons that we just discussed– is they don’t have a forceful cough. They can’t get
those pathogens out of their lungs. They have a reduced salivary flow. And they have a
diminished immune response.
The next two categories are nursing-home-acquired pneumonia and hospital-acquired
pneumonia. These would occur past that 72-hour period. These persons have been in a nursing
home, or have been in a hospital past 72 hours, and then they get pneumonia.
In the hospital, they break it into ventilator-associated pneumonia– that would mean the person
is ventilated– or non-ventilator-associated pneumonia. There is a pneumonia periodontal disease
connection, and I’m just going to read through this slide.
So when a person has untreated periodontitis, those oral pathogens continuously stimulate cells
of the oral tissues. And what happens is they release a variety of cytokines. Those cytokines are
immune system proteins that act as chemical messengers. And what they do is they stimulate
inflammation in the respiratory epithelium.
So the release of these cytokines increases a person’s susceptibility to colonization of respiratory
pathogens. So you have a weakened host, they do not have the mechanisms that allow this
bacteria that is associated with periodontitis to be expelled from their lungs. So it stays there, it
proliferates, and it results in infection and tissue destruction.
In periodontal disease, the bacteria, they colonize supragingivaly and subgingivaly. And that
bacteria is shed into the person’s saliva. That saliva is then aspirated, meaning it’s translocated,
into the lower respiratory tract. That’s where the infection starts.
So therefore that dental plaque, dental biofilm, is a reservoir of infection, especially if somebody
is hospitalized or institutionalized. Hopefully this is just a review of what a biofilm is, but please
do know that a biofilm is a well-organized cooperating community of microorganisms. The rest
of the diseases in this PowerPoint are all chronic diseases.
So tuberculosis is a chronic, infectious, communicable, highly-communicable disease. And it has
worldwide significance. In the United States we don’t hear about it very often, we have treatment
for it. But worldwide, it is a huge problem.
The tubercle bacillus, they’re airborne. They’re transmitted in airborne droplets. You can see
from this woman’s sneezing in the bottom, if you’re infected with TB, how easily that is spread to
individuals around you that come into contact with those droplets.
So an individual would inhale those droplets, they travel to the lung alveoli, and that’s where the
local infection begins. After these droplets are inhaled, within about 2 to 10 weeks an immune
response will start. And what happens is it limits the further growth of these tuberculous bacilli.
Not all bacilli will be eliminated in this process, so some people develop what’s known as latent
TB. These little bacilli, there’s like a cocoon that’s formed around them, and they kind of stay in
the lungs. About 5% to 10% of the people that have latent TB, if they become
immunocompromised later in life, maybe they get some type of chronic disease, this latent TB
can come forward and can then become active TB.
There are several diagnostic tests for TB. You have all had one. The one that you’re familiar
with, the one that’s on the National Board, usually, is called the tuberculin skin test. You’ll see it
on the National Board as PPD, which means Purified Protein Derivative, and it’s also called the
Mantoux test.
And you know that this protein is injected under the skin of the forearm. And within 72 hours
you go back and they check their circumference, see if there’s any swelling there. This test, as I
have italicized, does not determine active TB. All this test says is that you were exposed to it, or
you were not exposed to it. You can only give a definitive diagnosis of active TB through a
laboratory sputum smear.
Another test for exposure only is Interferon-Gamma Release Assays. Again, to determine
whether that’s active TB, you need a laboratory sputum smear that is cultured. If you have tested
positive on the PPD test, you’re then sent to have a chest X-ray.
Each year, if you have tested positive, there’s no sense in going back and taking that PPD test
again because you’re going to test positive. You need a chest X-ray, which is the middle test.
Because if the chest X-ray comes up negative nothing else is done. If it comes up positive, then
the next step would be to have the sputum sample taken and cultured.
So let’s say the individual has tested positive on their chest X-ray, then the sputum sample is
taken, and then this acid-fast dye type of thing is put on the bacilli. And if they turn pink, then
TB is suspected. But it can’t be really a definitive diagnosis until those bacilli are then grown in a
culture.
The drugs that are used to treat TB are on slide 37. Those drugs need to be taken for six months.
It sounds silly. As listed here, usually somebody will watch that person take those drugs. The
reason for that is that what has developed worldwide is a multi-drug resistant TB bacteria. And
we’ve discussed how easily it’s transmitted. So when you have an easily-transmitted bacteria that
is deadly, that’s quite serious worldwide.
If a person is resistant to the drugs that are treating TB, it can be a primary resistance, meaning
they’ve never taken it before, but for some reason it’s not working on them. And then there’s,
most often, an acquired resistance, meaning that individual has taken the drugs but has not taken
them correctly, or has not taken them long enough.
There’s two types of resistance, one being more serious than the other. The first one is multi-drug
resistant. So that person is resistant to at least two of the first-line drugs. Extensively drug
resistant, they’re resistant to three of the first-line drugs, and at least one of the second-line drugs.
Oral manifestations of TB are not common. If there is a manifestation, it will appear as
something like this ulcer on the tongue. That can also appear on the palate, lips, buccal mucosa,
and gingiva And it would need to be biopsied to have a definitive diagnosis of TB.
Sometimes the person may have swelling in their lymph nodes also, in the cervical or
submandibular lymph nodes. Common sense would tell you, you don’t treat a person that has TB
in a dental office or anywhere else. If there’s some type of emergency type of situation, they
would need to be hospitalized, and they would need to be isolated.
In years gone past, there were tuberculosis sanitariums. There wasn’t treatment for them, so
people were put in hospitalized sanitarium-type atmospheres. And way back when in the old
Western days TB was called consumption.
If somebody is marked on their medical history that they have a history of TB, and that we have
at least one patient in the clinic, you want to find out how long ago that was. Our patient in the
clinic, I think it was 40 or 50 years ago, so you would be fine to work on that patient. But you
want to know how far back that went before you treat the patient, either in a dental office, or in
the clinic here.
If it’s a fairly recent history of TB, you would really want to consult the physician to make sure
that they have taken their medication for at least six months to a year, before you would treat
them in a dental office or in the clinic here. The next chronic respiratory disease is asthma. There
are five types of asthma. We’re going to review them in the next few slides. I would like you to
know what they are.
The first one is extrinsic, also known as allergic or atopic. It’s the most common type of asthma.
And what it is, it’s an exaggerated response to certain allergens in the environment that a person
might inhale, such as tobacco smoke, animal dander. Mold is a very common one. So are dust
mites. How the hypersensitivity reaction occurs is shown here in this picture, and it’s also
described on the next slide.
The next type of asthma is called intrinsic, or non-allergic. Or it’s also known as idiosyncratic.
What happens there is there’s triggers from within the body, such as GERD, or emotional
distress. So a person becomes tense, stressed, and it causes them to have an asthma attack. This
is usually seen in adults.
The third kind is drug or food-induced. What happens with this person, they are allergic to
aspirin and they take it. Or they’re allergic to incense, or they’re allergic to some type of
medication, such as beta blockers. These are common foods that persons are allergic to when
they have food-induced asthma. Nuts, shellfish, milk, strawberries, yellow food dye.
Metabisulphite is a preservative that’s used in a lot of food. Wine, beer, shrimp, dried fruit.
Metabisulphite is also a preservative in local anesthetics when it contains epinephrine. So we
have a few patients that will say, I’m allergic to local anesthetic. They’re not allergic to the
epinephrine. They’re allergic to the preservative.
The next type is called exercise-induced. That’s rather self-explanatory. Infection-induced would
be that a person develops an asthma attack when they have some type of infection from a virus,
or a bacteria, or a fungi. What happens when a person has an asthma attack, is they are believed
to hyper-react to the IGE antibiodies that are normally produced in the body. Then they begin to
have symptoms of wheezing, coughing, shortness of breath.
When a person cannot respond to treatment it’s referred to as status asthmaticus, and it’s a lifethreatening condition. A person can die from an asthma attack. Listed here are the signs and
symptoms when a asthma attack is worsening.
Preparing for an emergency, you’re obviously going to stop dental treatment. If the person has an
inhaler, such as a bronchodilator inhaler, you’re going to get that for the person and you’re going
to give it to them. That’s why it’s out on the counter. You’ve going to give oxygen. If needed,
they will get an injection of epinephrine. If they do not respond EMS is called.
There are two main types of medications used to treat asthma. One of them is long-term
controlled medications, and the other is quick-relief medications such as rescue inhalers. They’re
listed on the next slide. Hopefully, they’re just a review from pharmacology.
Listed here are the potential harmful drugs if somebody has asthma. Aspirin. About 10% of the
people that have asthma are allergic to aspirin. Also incense can be a problem. And any sulphitecontaining local anesthetic, as we discussed several slides ago.
Narcotics and barbiturates, they suppress the respiratory function, so they should be avoided in a
person with asthma. Also macrolide antibiotics such as erythromycin. A person may have a
reaction to that. If oral manifestations are seen, it’s usually from the use of inhalers. Oral
candidiasis would be one of the most common conditions that would be seen, along with gingival
inflammation and dental caries from the dry mouth.
The patient may have GERD, and that would result in enamel erosion. Chronic Obstructive
Pulmonary Disease, known as COPD, there are two basic diseases. Chronic bronchitis and
emphysema. Cigarette smoking is identified as the major risk factor in COPD. So 80% to 90% of
the people that die from COPD have used tobacco.
The other 10%, 20%– air pollutants. They’ve been exposed to air pollutants, so it’s an
environmental factor. Or they’ve worked in an industry. Their occupation exposed them. Let’s
say it was asbestos, and that contributed to their COPD. When diagnosing somebody with
chronic bronchitis, it has a lot to do with this mucus and phlegm that the person has in their
lungs.
And so if they have been coughing up this mucus for at least three months of the year for two or
more years, they’re given the diagnosis of chronic bronchitis. What separates bronchitis from
emphysema, is that this person has problems breathing both in and out. So inspiration and
expiration are restricted.
Signs and symptoms of chronic bronchitis are listed here. You see the term “blue bloaters” on the
bottom of this slide? It’s a term that’s been used in previous National Boards to identify
somebody with chronic bronchitis. On the slides to come, emphysema, the name is pink puffers.
A person with emphysema, they have difficulty breathing only upon expiration. So they can
breathe in fine. The air becomes trapped and they cannot breathe out. Signs and symptoms of
emphysema are listed here. And as I stated before, pink puffers is the term that’s associated with
a person that has emphysema.
There is no cure for COPD. It can only be managed. And listed here are a few recommendations
for a patient who has COPD. There are five stages of COPD. And depending on which stage the
patient is in when they present you in the dental office, that will determine how you would
modify treatment for that patient.
Managing COPD. It might involve bronchodilators. It might involve inhaled corticosteroids.
There might be other medications that the patient is using. Also the patient may present with
some type of oxygen therapy, such as shown in these pictures.
If a patient presents with oral manifestations, it’s going to be similar to a patient that has asthma.
And the reason for that, is both types of patients– COPD and asthma– often use inhalers. If a
patient has used tobacco, which most people that have COPD have used tobacco, they may
present with any one of these other conditions.
Dental hygiene care. The chair is going to be in a semi-supine, or even an upright position. This
is truly a patient who, especially if they have severe COPD, cannot lean back. They can’t breathe
if you lay them flat. You may need to shorten the appointment time. You’re not going to use air
polishers or power-driven scalers. And you want to also avoid nitrous oxide.
Cystic fibrosis is an inherited disorder. It’s not an acquired disorder, meaning the person is born
with this. A person with cystic fibrosis has a very thick, sticky mucus in their lungs, and it has to
do with the normal movement of salt into and out of certain cells. And those cells line the lungs,
and they also line the pancreas.
A person with cystic fibrosis, that mucus is plugging their lungs, it’s clogging their lungs, and
they have great difficulty breathing. They also are very prone to respiratory infections, because
their lungs cannot clear this mucus properly. Symptoms of cystic fibrosis, they vary widely from
person to person. One person may present with very mild symptoms, when the next person may
present with very severe symptoms.
Treatments have improved greatly over the years. People can now live from 30 to 40 years of
age, but it is a progressive and fatal disease. Medical management would include the use of
antibiotics, nebulizers, …
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