pulmonary diseases

Mosul university- College of dentistry-oral & maxillofacial surgery department

DENTALMANAGEMENTOF THE MEDICALLYCOMPROMISED PATIENT
Dr.Ziad H. Delemi B.D.S, F.I.B.M.S (M.F.)
Pulmonary diseases

Mosul university- College of dentistry-oral & maxillofacial surgery department

Chronic Obstructive Pulmonary Disease
COPD: is a slowly progressive disease that is characterized by a gradual loss of lung function, It includes chronic bronchitis, chronic obstructive bronchitis, or emphysema, or combinations of these conditions.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Chronic Bronchitis
Inflammation of the main airway passages (bronchi) to the lungs, which results in the production of excess mucous, a reduction in the amount of airflow in and out of the lungs, & shortness of breath

Mosul university- College of dentistry-oral & maxillofacial surgery department

Emphysema
A respiratory disease characterized by breathlessness brought on by the enlargement, or over-inflation of, the air sacs (alveoli) in the lungs



Mosul university- College of dentistry-oral & maxillofacial surgery department
Pathophysiology & Complications
In chronic bronchitis, thickening of bronchial walls with inflammatory cell infiltrate, & collapse of peripheral airways resulting from loss of surfactant , Obstruction is present on inspiration & expiration. in emphysema, by contrast, smoke injures alveolar epithelium & causes release of inflammatory mediators that attract activated neutrophils. These neutrophils release enzymes (elastase) that destroy the alveolar walls, resulting in enlarged air spaces distal to the terminal bronchioles & loss of elastic recoil of the lungs . Obstruction is present on expiration not inspiration.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Pathophysiology & Complications
-With presence of primary etiologic factors (cigarette smoking, environmental pollutants), COPD usually results in progressive dyspnea &hypercapnia to severe debilitation. -Recurrent pulmonary infections with Haemophilus influenzae, Moraxella Catarrhalis, & Streptococcus pneumoniae are especially common with bronchitis. - Pulmonary hypertension can develop, leading to cor pulmonale (right-sided heart failure) in chronic bronchitis, whereas patients with emphysema more frequently experience enlarged air space, thoracic bullae, & pneumothorax. Poor quality of sleep.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Mosul university- College of dentistry-oral & maxillofacial surgery department
Clinical Features of COPD Patients
Mild COPD: no abnormal signs, smokers cough, little or no breathlessness Moderate COPD: breathlessness with/without wheezing, cough with/without sputum Severe COPD: breathlessness on any exertion/at rest, wheeze & cough prominent, lung inflation usual, cyanosis, peripheral edema, & polycythemia in advanced disease.

Clinical Features of COPD Patients

Mosul university- College of dentistry-oral & maxillofacial surgery department
Diagnosis
-Spirometry Breathing test which measures the amount & rate at which air can pass through the airways -Chest X-ray -Arterial Blood Gas Shows oxygen level in blood

Mosul university- College of dentistry-oral & maxillofacial surgery department

Medical Management of COPD Patient
Smoking cessation & elimination of environmental pollutants Palliative measure such as regular exercise, good nutrition, flu & pneumonia vaccines Bronchodilators, corticosteroids.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Dental Management of COPD Patient
Review history for concurrent heart disease Avoid treatment if upper respiratory tract infection is present Treat in upright position Avoid rubber dam in severe cases Use pulse oximetry (if pulse ox <91%, use low flow 2-3L/min) Avoid Nitrous oxide/oxygen in severe cases Avoid barbiturates, narcotics. If patient is on steroid regimen, supplement as needed Drug interactions with COPD medication

Mosul university- College of dentistry-oral & maxillofacial surgery department

Patients with COPD who are chronic smokers have an increased likelihood of developing halitosis, extrinsic tooth stains, nicotine stomatitis, periodontal disease, and oral cancer. In rare instances, Theophylline has been associated with the development of Stevens-Johnson syndrome.
Oral Complications & Manifestations

Mosul university- College of dentistry-oral & maxillofacial surgery department

After: 20 min.: heart rate drops. 12 hrs.: (CO) level in the blood drops to normal. 2 wks - 3 months: the circulation improves & the lung function increases. 1 - 9 months: Coughing & shortness of breath decrease; cilia (tiny hair like structures that move mucus out of the lungs) regain normal function in the lungs, increasing the ability to handle mucus, clean the lungs, & reduce the risk of infection.
Benefits of Quitting Smoking

Mosul university- College of dentistry-oral & maxillofacial surgery department

1 year: The excess risk of coronary heart disease is half that of a smoker's. 5 years: the stroke risk is reduced to that of a nonsmoker 5 to 15 years after quitting. 10 years: The lung cancer death rate is about half that of a continuing smoker. Risks of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decrease. 15 years: The risk of coronary heart disease is that of a nonsmoker.
Benefits of Quitting Smoking


Mosul university- College of dentistry-oral & maxillofacial surgery department
Stop the damaging effects of tobacco on the appearance, including : Premature wrinkling of the skin Bad breath Stained teeth Gum disease Bad smelling clothes and hair Yellow fingernails Food tastes better Sense of smell returns to normal Ordinary activities no longer leave out of breath (climbing stairs, light housework, etc.)
Benefits of Quitting Smoking

Mosul university- College of dentistry-oral & maxillofacial surgery department

Asthma is a chronic inflammatory pulmonary disorder that is characterized by reversible obstruction of the airways
Asthma

Mosul university- College of dentistry-oral & maxillofacial surgery department

Etiology
Cause of asthma is unknown but many factors play a part: Genetic factors: Asthma tends to run in the family Environmental factors: pollen, dust, mold, tobacco smoke Occupational exposure: chemicals and gases

Mosul university- College of dentistry-oral & maxillofacial surgery department

Pathophysiology
in asthma, obstruction of airflow occurs as the result of bronchial smooth muscle spasm, inflammation of bronchial mucosa, mucous hypersecretion, & sputum plugging.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Pathophysiology



Mosul university- College of dentistry-oral & maxillofacial surgery department
Clinical Features of Asthmatic Patients
General: intermittent wheezing, coughing, and breathlessness During an attack: decreased peak flow, tachypnea, use of accessory muscles to breathe, hyperinflation or barrel chest, and prolonged inspiration

Mosul university- College of dentistry-oral & maxillofacial surgery department

History Clinical examination Chest radiographs (for hyperinflation), Skin testing (for specific allergens), histamine , Sputum smears and blood counts (for eosinophilia) Arterial blood gases, antibody-based enzyme-linked immunosorbent assay (ELISA) Spirometry (a peak expiratory flow meter that measures pulmonary function) before and after administration of a short-acting bronchodilator.
Diagnosis

Mosul university- College of dentistry-oral & maxillofacial surgery department

Medical treatment

Mosul university- College of dentistry-oral & maxillofacial surgery department

ORAL CHANGES IN PATIENTS WITH ASTHMA

Mosul university- College of dentistry-oral & maxillofacial surgery department

Dental Management of Asthmatic Patient
Identify and assess status Avoid precipitating factors Bring inhaler for each appointment Drug considerations Avoid aspirin-containing medications Avoid (NSAIDs) Avoid barbiturates & narcotics Avoid erythromycin & macrolide antibiotics Discontinue Cemitidine 24 hr before intravenous sedation in patients taking Theophylline

Mosul university- College of dentistry-oral & maxillofacial surgery department

-Local anesthetic considerations (may elect to avoid solutions containing epinephrine or levonordefrin because of sulfite preservative). -Chronic corticosteroid users may require steroid supplementation -For sedation, nitrous oxide/oxygen and/or small doses of oral diazepam is recommended -Provide stress-free environment


Dental Management of Asthmatic Patient

Mosul university- College of dentistry-oral & maxillofacial surgery department

Recognize asthmatic attack :-Inability to finish sentences with one breath -Ineffectiveness of bronchodilators to relieve dyspnea -Tachypnea ≥25 breaths per minute -Tachycardia ≥110 beats per minute -Accessory muscle usage -Paradoxical pulse Administer fast-acting bronchodilator (Note: Corticosteroids have delayed onset of action), oxygen, &, if needed, subcutaneous 0.3 to 0.5 ml of epinephrine (1:1000) Repeat use of fast-acting bronchodilator every 5 minutes Dental Management of Asthmatic Patient

Mosul university- College of dentistry-oral & maxillofacial surgery department

Tuberculosis
Bacterial infection, caused by Mycobacterium tuberculosis; an aerobic, acid-fast rod with thick cell wall composed of high molecular weight lipids; very slow growing Most commonly affects the lungs (pulmonary TB); transmission most commonly by inhalation of infected droplets

Mosul university- College of dentistry-oral & maxillofacial surgery department

Pathophysiology & Complications
The infection of primary pulmonary TB begins with inhalation of infected droplets. that are carried into the lungs alveoli, where bacteria are engulfed by macrophages. Replication occurs & spread of infection occurs locally to regional (hilar) lymph nodes. Distant dissemination through the bloodstream may occur; the vast majority of disseminated bacteria are destroyed by natural host defenses. after 2 to 8 weeks delayed hypersensitivity to the bacteria develops mediated by T(CD4)

Mosul university- College of dentistry-oral & maxillofacial surgery department

Pathophysiology & Complications
Once the infection has been successfully interrupted, the lesion heals spontaneously, then undergoes hardening, encapsulation, and calcification. Although the lesion “heals,” some bacteria may remain dormant. Widespread infection with multiple organ involvement is called miliary tuberculosis.

Pathophysiology and Complications

The sequelae of TB include progressive primary TB, cavitary disease, pleurisy and pleural effusion, meningitis. Isolated organ involvement other than that of the lung may occur and commonly affects the pericardium, peritoneum, kidneys, adrenal glands, and bone (known as Pott's disease when it affects the spine). The tongue and other tissues of the oral cavity also are involved infrequently
Mosul university- College of dentistry-oral & maxillofacial surgery department

Mosul university- College of dentistry-oral & maxillofacial surgery department

Symptoms of Pulmonary TB
Symptoms are often mild and non-specific A cough that will not go away Feeling tired all the time Weight loss Loss of appetite Fever Coughing up blood Night sweats

Mosul university- College of dentistry-oral & maxillofacial surgery department

Tuberculin Skin Test (Mantoux)
A measured amount of purified protein derivative (PPD) is injected intracutaneously into the forearm 48-72 hours later the diameter of induration (not redness) is measured A positive test means that the person has been infected with M. tuberculosis Further evaluation is necessary to determine if there is active TB disease
TST

Mosul university- College of dentistry-oral & maxillofacial surgery department

Interpretation of TST
> 5 mm: considered positive if close contact with infected person, abnormal chest x-ray, or HIV positive >10 mm: considered positive if other medical risk factors present, foreigner, medically underserved, alcoholic, long-term care resident > 15 mm: positive

Mosul university- College of dentistry-oral & maxillofacial surgery department

Diagnosis of TB
Medical history Skin test Physical examination Chest radiograph Bacteriologic or histologic examination Sputum smear for AFB Culture & sensitivity

Mosul university- College of dentistry-oral & maxillofacial surgery department

Three sputum samples are collected for smear and culturing Finding of acid-fast rods in smear of sputum is presumptive of tuberculosis Culturing and sensitivity testing are done to confirm diagnosis and drug sensitivity C&S can take 1 to 2 weeks
Diagnosis of TB


Mosul university- College of dentistry-oral & maxillofacial surgery department
Oral/Head &Neck Manifestations of TB
Oral lesions are uncommonPosterior dorsum of tongue most common; deep, non-painful ulcerLesions also reported of gingiva, buccal mucosa, floor of mouth, lips, and palateInfection of cervical lymph nodes called “scrofula”.

Mosul university- College of dentistry-oral & maxillofacial surgery department

3 drugs (isoniazid+rifampin+pyrazinamide) for 2 months Followed by 2 drugs (isoniazid and rifampin without pyrazinamide) for 4 months 6 months total treatment time
Medical treatment

Mosul university- College of dentistry-oral & maxillofacial surgery department

1-Active sputum-positive tuberculosis -Consult with physician before treatment -Perform urgent care only;palliate urgent problems with medication if contained facility in a hospital environment is not available Perform urgent care that requires the use of a handpiece (older than 6 years)only in a hospital setting with isolation, sterilization (gloves, mask, gown), and special ventilation -Treat those under the age of 6 years as normal patients (noninfectious after consultation with physician to verify status) -Treat the patient who produces consistently negative sputum as a normal patient
Dental Management of the Patient With a History of T.B

Mosul university- College of dentistry-oral & maxillofacial surgery department

2-noninfectious—confirm with physician -History of tuberculosis -Approach with caution, obtain good history of disease & its treatment duration, make appropriate review of systems mandatory -Obtain from patient a history of periodic chest radiographs & physical examination to rule out reactivation or relapse -Consult with physician & postpone treatment if there is: Questionable history of adequate treatment times Lack of appropriate medical follow-up since recovers Sign or symptom of relapse Dental Management of the Patient With a History of T.B

Mosul university- College of dentistry-oral & maxillofacial surgery department

3-Recent conversion to positive tuberculin skin test Verify if evaluated by physician to rule out active disease Verify if receiving isoniazid for 6 months to 1 year for prophylaxis then Treat as a normal patient. 4-Treat as normal patient if present status is free of clinically active disease
Dental Management of the Patient With a History of T.B

Mosul university- College of dentistry-oral & maxillofacial surgery department

-The classic mucosal lesion is a painful, deep, irregular ulcer on the dorsum of the tongue. The palate, lips, buccal mucosa, & gingiva also may be affected. Mucosal lesions have been reported to be granular, nodular, or leukoplakic & sometimes painless. -Extension into the jaws can result in osteomyelitis. -The cervical & Submandibular lymph nodes may become infected with TB; this condition is called scrofula. The nodes become enlarged & painful , & abscesses may form & drain. -Involvement of the salivary glands is rare.
Oral Complications & Manifestations