In the framework of asthma healthcare, a team involves a general physician, a pulmonologist, a respiratory therapist, and sometimes an emergency room doctor. However, one essential healthcare provider often overlooked is the dentist. As we mark World Asthma Day this May, it's crucial to shed light on a lesser-known aspect of asthma care: dental health. From the side effects of asthma medications to the oral implications of the condition, asthmatic individuals encounter distinct challenges when it comes to maintaining optimal oral hygiene.

Asthma, a chronic lung disease, affects individuals of all ages. Inflammation, tightening of muscles around the airway, and narrowing of air small airways lead to breathing difficulties. Symptoms range from mild to severe, including persistent coughing (especially at night), wheezing (on inhalation and exhalation), chest tightness, and shortness of breath, with varying frequency and intensity. In 2019, asthma affected an estimated 262 million people and caused 455,000 deaths. Asthma is triggered by cold weather, dust, smoke, fumes, grass and tree pollen, animal fur and feathers, strong soaps, perfume, etc. Inhaled medication can control asthma symptoms and allow people to lead a normal, active life. Inhaled corticosteroids (ICS), inhaled beta~2 receptor agonists, anti-cholinergic drugs, terbutaline sulfate, inhaled mast cell stabilizers, oral anti-leukotriene agents, systemic corticosteroids, and newer monoclonal antibodies are used to treat asthma.

Bronchial asthma itself can be considered a risk factor for poor oral health. Rhinitis present in almost 80% of asthmatic patients could be a confounding factor in the pathogenesis of oral disease in asthmatics. Moreover, asthmatic drugs like inhaled corticosteroids (ICS), inhaled beta 2 agonists and inhaled cholinergics can have systemic and local effects being involved in oral diseases through different pathways. Dry powder inhalers (DPIs) which have lactose monohydrate to mask the bitter medication taste and improve patient tolerance also contribute to compromised oral hygiene. Inhaled therapy taken at night before going to bed without any oral hygiene and the lack of masticatory movements might increase the damage in the oral environment.

Due to prolonged disease duration and lack of preventive dental care, partly due to insufficient information about drug side effects, extraction of teeth emerged as the most common therapy for dental conditions like caries in asthmatics

Despite physicians' efforts to optimize treatment and minimize adverse effects of asthma medication, patients still experience oral complications. As dentists, it's essential to address these issues and prioritize the oral health of asthma patients through early preventive and therapeutic dental care.

• Educate asthmatic patients about their susceptibility to oral health problems

• Encourage regular dental check-ups

• Advocate strict oral hygiene practices

• Adopt dental caries preventive measures (fluoride supplements and pit and fissure sealants)

• Advise the use of antimicrobial mouthwashes (dental caries, candidiasis) and mouthwashes with sodium bicarbonate or neutral sodium fluoride (dental erosion) after using inhalers

• Advise the patients to rinse the mouth immediately and brush teeth after using an inhaler

• Encourage patients to drink water more often to counteract dry mouth

• Prescribe sugar-free chewing gum and sialagogue medications to increase salivary output

• Ensure that the patients use their inhaler properly

• Encourage the use of spacer device to deliver the inhaled drugs directly to the airway

• Recommend to avoid sugary medications with the advise of their physician

• Refer to a gastroenterologist to rule out gastrointestinal disease

• Prescribe antimycotics oral fluconazole or nystatin oral suspension to prevent oral candidiasis

Before the commencement of dental treatment in asthmatic patients, informed consent should positively be obtained from their concerned physician. As a general dentist, obtaining a comprehensive medical history is paramount to assess the severity of the condition and the effectiveness of asthma management.

It's crucial to note the

• Frequency and timing of exacerbations

• Symptoms

• Exercise limitations

• Any recorded peak expiratory flow (PEF)

• Forced expiratory volume in 1 second (FEV1)

• Severity of disease (previous hospitalizations or emergency room visit)

• Medication usage

• Common triggers

The dentist should ensure that the patient has recently taken their medication. Patients currently using an inhaled bronchodilator should be asked to bring it with them to their dental appointment. A bronchodilator as a premedication before dental treatment can be beneficial. For patients on high doses of oral corticosteroids, consultation with their general physician regarding the need for steroid coverage during prolonged or stressful treatment is advisable. Those who are on systemic maintenance glucocorticoids (taken daily or every other day) may experience adrenal suppression. In such cases, it may be necessary to supplement them by doubling their usual daily dose on the day of dental surgery with the advise of their physician. Any updates or changes in the patient's medication at each appointment should be enquired. This may impact their care and appointment scheduling.

To reduce the risk of an asthma attack, it is recommended to schedule the patient's appointment for late morning or late afternoon. Prior to treating patients with moderate to severe asthma, it is essential to employ standard monitors such as pulse oximetry, end-tidal SAGO2, EKG, and blood pressure cuff, along with intubation equipment.

The use of a rubber dam will decrease chance of particulate inhalation, significantly reduce the likelihood of an attack and protect the airway. Suction tips, fluoride trays, or cotton rolls placed incorrectly might cause a hyperreactive airway response in sensitive people. During the procedure, eliciting a cough reflex should be avoided. Prevention of accidental foreign body (small dental materials and components) inhalation during procedures is also crucial.

Nitrous oxide analgesia is suitable for patients with mild to moderate asthma but should be avoided during wheezing episodes. For conscious sedation, hydroxyzine and benzodiazepines may be used. IV sedation can be administered but extra precautions are necessary due to their limited respiratory airway control. Ketamine is considered safe but it should be avoided in patients with cardiovascular or hypertensive heart disease. It's essential to have supplemental oxygen readily available during dental treatment to address any acute asthmatic exacerbations. The patient's breathing should be continuously monitored and it should be ensure that the airway remains unobstructed throughout the dental procedure.

Cross-sensitivity has been noted between aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs). Therefore, therapy with NSAIDs should be avoided or used cautiously in asthmatic patients. Opiates are contraindicated because they can cause respiratory depression and histamine release. Paracetamol is the drug of choice for pain relief. Most antibiotics are safe, but those on theophylline should avoid macrolides like erythromycin to prevent toxicity. High-dose ICS can cause systemic effects and are treated with vitamin D, calcium, bisphosphonates, or monoclonal antibodies. Patients on bisphosphonates need careful planning for dental procedures to prevent osteonecrosis of the jaw (BRONJ), and difficult extractions should be referred to specialists.

There are several asthma triggers in a dental setting

• Anxiety of dental procedures

• Prolonged supine positioning in the dental chair

• Stimulating procedures (e.g. teeth extractions)

• Dental materials (dentifrices, fissure sealants, methyl

  methacrylate, fluoride varnish containing colophony)

• Aerosols from dental handpieces

• Tooth enamel dust

• NSAIDs

• Opioid drugs

• Local dental anesthetics containing metabisulphite

• Cotton rolls

• Latex containing gloves, rubber dams, prophylactic cups, orthodontic elastics

A severe acute asthma attack may manifest as breathlessness and expiratory wheezing. The patient may struggle to complete a sentence or be too breathless to eat. Respiratory rates may exceed normal levels and elevated heart rates may also be observed. In life-threatening situations, symptoms may include cyanosis, diminished respiratory effort, reduced heart rate, and neurological signs such as confusion or loss of consciousness.

The airway, breathing, circulation, disability, and exposure should be assessed. If the patient is conscious, they should be positioned upright and given a bronchodilating agent to inhale. It can be repeated if necessary. If the patient cannot use the inhaler effectively, the medication should be administered using a spacer device. Oxygen via a face mask should be administered. If there is no improvement, the patient's condition deteriorates, epinephrine is injected subcutaneously. If there is no improvement or the asthma attack is severe, call for emergency medical assistance. Optimal oxygen levels should be maintained until the patient's wheezing subsides or medical assistance arrives. If the patient loses consciousness, cardiopulmonary resuscitation (CPR) should be initiated.

In case of foreign body inhalation, symptoms of respiratory distress, such as choking, wheezing, and difficulty breathing, accompanied by the rapid onset of accessory muscle use, are clear indicators that immediate action is needed. At first, the patient should be asked to sit up straight and cough vigorously. If a severe cough does not alleviate the obstruction, the Heimlich maneuver (a technique used for people who are choking) should be performed. If this proves ineffective, the patient must be taken to the nearest emergency room immediately. While waiting for transfer, the dentist should take critical measures, including performing a cricothyrotomy to open the airway if necessary.

In conclusion, providing dental care for asthmatic patients requires a thorough understanding of their unique needs and potential complications. Effective communication and careful planning are essential to minimize stress and prevent asthma attacks during dental procedures. Pre-treatment assessments should include a detailed medical history and consideration of any asthma medications the patient is using. Preventive measures and prompt response to any signs of respiratory distress are crucial to ensure patient safety. By implementing these strategies, dental professionals can provide safe and effective care for asthmatic patients.

References

1. Asthma [Internet]. [cited 2024 May 14]. Available from: https://www.who.int/news-room/fact-sheets/detail/asthma.

2. Gani F, Caminati M, Bellavia F, Baroso A, Faccioni P, Pancera P, et al. Oral health in asthmatic patients: a review. Clin Mol Allergy [Internet]. 2020 [cited 2024 May 15]; 18:22. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7648282/.

3. Harrington N, Prado N, Barry S. Dental treatment in children with asthma – a review. Br Dent J [Internet]. 2016 [cited 2024 May 15]; 220(6):299–302. Available from: https://www.nature.com/articles/sj.bdj.2016.220.

4. Dubey C, Prakash A. Dental and Orthodontic Management of Asthmatic Patients. Indian Medical Journal. 2019; 113(12). https://www.researchgate.net/publication/344153494_Dental_and_Orthodontic_Management_of_Asthmatic_Patients

5. Chhabra K, Sood S, Sharma N, Singh A, Nigam S. Dental Management of Pediatric Patients with Bronchial Asthma. Int J Clin Pediatr Dent [Internet]. 2021 [cited 2024 May 17]; 14(5):715–8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8645623/.

By Dr. Nirainila Joseph

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