Pulmonary Diseases

Dental Management of
Patients with Pulmonary
Diseases
 Outline
 Lung Infections: Tuberculosis
 Chronic Obstructive Pulmonary
Disease
– Chronic Bronchitis
– Emphysema
 Asthma
 Tuberculosis
 Epidemiology:
 TB is the No. 2 killer infectious disease (no. 1
AIDS) in the world
 1/3 of the world’s population is already infected
with TB.
 Every second, someone in the world becomes
newly infected.
 Over the centuries, TB has taken over 1 billion
lives.
 Every year, more than 8 million new people
develop active TB
 Every year, 2 million people die from TB.
 Tuberculosis
 Epidemiology:
 No. 6 cause of death in the Phils (2000) – 7.5%
of all cases
 No. 6 cause of sickness in the Phils.(2002) – 8
out of 10 are infectious diseases
 US CDC: rates of TB are 10 times higher among
Asians
10 Highest Burden TB Countries:
1. India
2. China
3. Indonesia
4. Nigeria
5. Bangladesh
6. Pakistan
7. Ethiopia
8. Philippines
9. South Africa
10. DR Congo

as of October 2003; source: WHO 2004

Global Tuberculosis Report
 Cause and Spread
Cause: tubercle bacillus (Mycobacterium tuberculosis)
 aerobic, nonmotile, rods with a high lipid content in
their cell walls.
 acid-fast bacilli, because once they are stained, they resist
decoloration with acid-alcohol.

Transmission:
 through inhalation of aerosolized bacteria (1 droplet = 1-10
bacilli)
 From coughing, sneezing or speaking by people with active
TB
 These small droplets can remain suspended in the air for
several hours.
 Infection will occur if inhalation results in the organism
reaching the alveoli of the lungs.
 Symptoms
 Fever

 Night sweats
 Anorexia

 Nonproductive cough

 Weight loss

 Malaise

 Fatigue
 Diagnosis
1. History
 Immunocompromised patient
 Exposure to person with active TB
2. Chest x-ray
3. Sputum test – (+)AFB (acid-fast bacilli)
4. Tuberculin Skin Test
 Immunocompromised Conditions
diabetes mellitus
 malignancies requiring chemotherapy

 steroid-dependent diseases, such as

asthma or collagen vascular disease
 malnutrition related to alcohol/drug
abuse, smoking, extremes of age, and HIV
 infection as well as demographic and
socioeconomic factors
 end-stage renal disease
Positive PPD test

PPD (purified protein

derivative)
Or Mantoux test
Or TST (tuberculin skin
test)
(+)Result:=/>10mm
Chest X-ray
Class Type Description
0 No TB No history of exposure
exposure Negative reaction to tuberculin skin test
Not infected
1 TB exposure History of exposure
No evidence of Negative reaction to tuberculin skin test
infection
2 TB infection Positive reaction to tuberculin skin test
No disease Negative bacteriologic studies (if done)
No clinical, bacteriological, or radiographicevidence of active
TB
3 TB, clinically M. tuberculosis cultured (if done)
active Clinical, bacteriological, or radiographic evidence of current
disease
4 TB History of episode(s) of TB
Not clinically OR
active Abnormal but stable radiographic findings
Positive reaction to the tuberculin skin test
Negative bacteriologic studies (if done)
AND
No clinical or radiographic evidence of current disease
5 TB suspected Diagnosis pending
Pathology
of TB
 TB bacilli

Strong immune Immune

system system
overwhelmed
CD4 helper T cells
tell macrophages to Lymphocytes excrete
kill intracellular TB cytotoxic substances
bacilli; CD8
suppressor T cells
Hydrolytic enzymes
lyse macrophages
cause caseation
(“cheese-like”) necrosis
Granuloma
forms
Liquefaction
Mycobacteria cannot grow
and cavitation
in acidic extracellular
environment; granuloma
calcifies More bacteria
multiply in
Controlled cavitation; Active
infection infection
 Treatment
 Multiple Drug Therapy
– Isoniazid (INH)
– Pyrazinamide (PZN)
– Rifampicin
– Streptomycin
 Regimen
– 2 months INH, PZN, Rifampicin, Streptomycin
– 7-10 months INH and Rifampicin
 DOT- directly observed treatment
 Dental Management
 In Active TB:
1. patients should be in negative pressure
rooms
2. Health professionals should wear N-95
respirator masks or with HEPA filters
 Dental Management
 Before treating, make sure:
 Clinical improvement is seen (no
fever and cough)
 Sputum test is free of mycobacteria

 At least two weeks of multiple drug

therapy completed
 Chronic Obstructive Pulmonary
Disease (COPD)
 a disease state characterized by the presence of
airflow obstruction due to chronic bronchitis or
emphysema
 May also have symptoms of asthma
 Symptoms:
 Productive cough
 Breathlessness
 Wheezing
 Signs: barrel chest, wheezing, prolonged
expiration
 Chronic Obstructive Pulmonary
Disease (COPD)
 Primary cause: cigarette smoking
– 20 pack years= 20 years of smoking 1
pack a day
 Others: air polllution; airway
hyperresponsiveness
 No. 7 killer disease in the Phils.
(2000) or 4.3% of cases
 Common in patients >50 yrs old
 Chronic Bronchitis
 Chronic bronchitis = the presence of a
chronic productive cough for 3 months
during each of 2 consecutive years (other
causes of cough being excluded)
 Mucous gland enlargement
 Mucous plugs in airway
 Lots of phlegm (“talaba”)
 “Blue bloaters”
 Cyanosis
 Overweight patients
Chronic Bronchitis
 Emphysema
 Emphysema is defined as an abnormal,
permanent enlargement of the air spaces distal to
the terminal bronchioles, accompanied by
destruction of their walls and without obvious
fibrosis.
 Chronic Bronchitis (clinical findings)
 Emphysema (anatomic findings)
Emphysema
 Emphysema
 Difficulty in expiration because of
loss of elasticity in alveolar wall
 “Pink puffers”

 Barrel-chested

 Scanty mucus

 Severe dyspnea
Depressed diaphragm
 Treatment
 Smoking cessation
 Mucolytic agents
 Oxygen therapy
 Antibiotics
 Oral steroids
 Inhaled steroids
 Bronchodilators
 Anticholinergic agents
 Dental Management
 Treat patient in supine position
 Avoid use of rubber dam

 May need oxygen supplementation

while treating
 Don’t use bilateral blocks

 GA contraindicated
 Asthma
 hyperreactive airway disease
 a chronic inflammatory disorder of
the airways in which many cells and
cellular elements play a role, in
particular, mast cells, eosinophils, T
lymphocytes, macrophages,
neutrophils, and epithelial cells
 Asthma
 Symptoms: wheezing, breathlessness, chest
tightness and coughing, particularly at night or
in the early morning
 Components:
3) airway inflammation
4) intermittent airflow obstruction
5) bronchial hyperresponsiveness.
 Causes/Triggers

allergens exercise

medications
 Causes/Triggers
– Environmental allergens
– Viral respiratory infections
– Exercise; hyperventilation
– Gastroesophageal reflux disease
– Chronic sinusitis or rhinitis
– Aspirin or nonsteroidal anti-inflammatory drug
hypersensitivity, sulfite sensitivity
– Use of beta-adrenergic receptor blockers (including
ophthalmic preparations)
– Environmental pollutants, tobacco smoke
– Occupational exposure
– Emotional factors
– Irritants such as household sprays and paint fumes
 Diagnosis
 PFT (pulmonary function test)
 Allergen skin test
 Types of Asthma
 Step 1 - Intermittent
– Intermittent symptoms occurring less than once a week
– Brief exacerbations
 Step 2 - Mild persistent
– Symptoms occurring more than once a week but less
than once a day
– Exacerbations affect activity and sleep
– Nocturnal symptoms occurring more than twice a month
 Step 3 - Moderate persistent
– Daily symptoms
– Exacerbations affect activity and sleep
– Nocturnal symptoms occurring more than once a week
 Step 4 - Severe persistent
– Continuous symptoms
– Frequent exacerbations
– Frequent nocturnal asthma symptoms
– Physical activities limited by asthma symptoms
 Dental Management
 Never treat a patient with an asthma
attack
 Have anti-asthma medication (inhaler) on
hand
 Good suction and evacuation of water and
saliva
 Avoid allergens (incl. NSAIDs)
 Decrease stress experience
 Avoid respiratory depressants (opioid
drugs)
 Dental Management
 Patient History: frequency, severity
of attacks, triggers
 Refer for medical consult if needed
 WORDS TO LIVE BY:

For the Lord gives

wisdom, from His mouth
come knowledge and
understanding.
Proverbs 2:6