It is defined as a chronic inflammatory disorder of the airways characterized by reversible airflow obstruction causing cough, wheeze, chest tightness and shortness of breath
EARLY ONSET / ATOPIC / EXTRINSIC
Begins in childhood, generally occurs in atopic individuals who readily form IgE antibodies to commonly encountered allergens
LATE ONSET / NON ATOPIC / INTRINSIC ASTHMA
Develops in adults who are non atopic and is related to mast cell instability and hyperesponsive airways
Episodic shortness of breath( dyspnea )
Bouts of coughing
Chest X rays
Arterial blood gases
MANAGEMENT OF CHRONIC PERSISTENT ASTHMA
It is now known as Severe acute asthma
It is the most severe clinical form of asthma
Patient experiences wheeze, dyspnea and hypoxia that are refractory to 2-3 doses of β adrenergic agents
If not treated the patient may die of respiratory collapse
Fluoride supplements should be instructed for all asthmatics ,particularly those taking B2 agonists
The patient should be instructed to rinse the mouth after the use of inhalers
Antifungal medications should be administered as needed especially to those on corticosteroids
Steroid prophylaxis is to be used for those on long term steroids
Use of stress reducing techniques
Avoid dental materials that may precipitate an attack for e.g. acrylics, fissure sealants
Schedule appointments for late mornings to minimize te risk of an attack
Have oxygen and bronchodilators ready in case of an attack
LA – preservatives such as methyl bisulfite may precipitate an attack
Upto 10% of adult asthmatics are allergic to aspirin and other NSAIDS
Drug interactions with theophylline are common
ciprofloxacin and macrolides increase the level and phenobarbitals reduce the level
CHRONIC OBSTRUCTIVE AIRWAYS DISEASE
is defined as the excessive production of mucus and persistent cough with sputum production for more than 3 months in a year over 3 consecutive years
leads to production of excessive, viscous mucus, which is ineffectively cleared from the airway, stagnates & becomes infected with S. pneumoniae and H. influenzae
Emphysema is dilatation of air spaces distal to the terminal bronchioles with destruction of alveoli and a reduction in the alveolar surface area available for respiratory exchange.
Early morning mucoid cough
Dyspnoea on effort
Chronic hypoxaemia (‘BLUE BLOATED’ appearance)
Clinically supported by chest radiography
Respiratory function tests
Occasionally arterial blood gas estimations
In presence of infection:
-Co-trimoxazole or amoxycillin. lpratropium bromide, or other bronchodilators may be beneficial.
Respiratory failure and cor pulmonale may also need to be treated
Dental treatment : LA
Patients are best treated in the upright position as they may become increasingly breathless if laid flat
Do not use rubber dam
GA only if absolutely necessary, and only in hospital after full preoperative assessment
Diazepam and midazolam are also mild respiratory depressants and should not be used for intravenous sedation
Intravenous barbiturates are totally contraindicated.
Patients taking ipratropium may have a dry mouth
Spirometry and carbon monoxide perfusion are essential to assess respiratory function
cessation of smoking for at least 1 week preoperatively
Respiratory infections must also be eradicated
Sputum : culture and sensitivity, but antimicrobials such as co-trimoxazole or amoxycillin should be started without awaiting results
Bronchodilator drugs are useful for bronchospasm
Thorough and frequent chest physiotherapy is important preoperatively and, if there is congestive cardiac failure, diuretics are indicated
It is safest to avoid premedication
Morphine is certainly contraindicated since it can impair the cough reflex or precipitate bronchospasm
Pethidine can be used if the patient is in pain
Atropine and related antimuscarinics are also best avoided since they dry up the airways and increase the risk of postoperative pulmonary complications.
Close continuous assessment
In hypoventilation or excess secretions : tracheostomy
Bedridden patients with chronic obstructive airways disease may have added complications if given a general anaesthetic
Impaired cardiovascular responses may lead to profound hypotension if agents such as barbiturates are used.
Cor pulmonale may be aggravated by the cardio-depressant activity of drugs used in anaesthesia or by the water retention that follows surgery or anaesthesia.
Secondary polycythaemia may predispose to thromboses postoperatively
Caused by Mycobacterium Tuberculosis
Primary infections involve spread by inhalation of mycobacteria laden respiratory micro droplets
Different states include:
asymptomatic primary tuberculosis
symptomatic primary tuberculosis
progressive primary tuberculosis
General debilitating disease including human immunodeficiency virus
Iatrogenic immunosuppression overcrowded living conditions
Certain respiratory diseases such as silicosis
As a result of improved public health measures and the availability of anti tuberculosis drugs, the incidence of tuberculosis had decreased, unfortunately increased incidence of immunosuppressive diseases like AIDS, tuberculosis remains a major concern and challenge to health services
Blood streaked sputum
Prolonged productive cough for more than 3 months
Loss of weight
PERSONS AT HIGH RISK FOR CONTRACTING TB
Oral lesions are an infrequent occurrence in tuberculosis and are observed more often in patients with advanced disease.
Oral tuberculous lesions may be either primary or secondary.
Primary oral tuberculous lesions are relatively rare and generally occur in younger patients. The mechanism of primary inoculation is not definite, but it is believed that organism enter the mucosa through a small surface break.
The secondary lesions on the contrary are more common and are seen mostly in older persons through sputum.
The bony structures of the oral cavity are affected less frequently than the soft tissue.
Tongue is the commonest site for oral tuberculous lesion but lesions they may also occur in the gingiva, floor of mouth, palate, lips and Buccal mucosa
It may also present around the upper aero digestive tract as parotitis, intra–osseous lesion, trachitis and laryngitis.
In the primary type, the causative organisms are directly inoculated in the oral mucosa of a person who has not had tuberculosis earlier and who has not acquired immunity to the disease. In the secondary type tuberculosis of the oral cavity it is usually consistent with pulmonary disease and is primarily a self – inoculation
Mucosal lesions may appear as ulcer, nodules, fissures, sometimes with mild to moderate induration. Human infections from bovine type occur with the ingestion of infected milk. The pathogenesis is similar to M. tuberculosis except that the primary inoculation is in the mouth tonsil or intestine.
Mycobacterium avium intracellulare
. Differential diagnosis of oral tuberculosis includes a traumatic ulcer, apthous ulcer actinomycosis, syphilitic ulcer, Wegener’s granuloma, carcinoma, Sarcoidosis, deep mycotic infections.
Rifampicin 450mg once a day
Isoniazid 300mg once a day
Ethambutol 600mg once a day
Pyridoxine supplement with isoniazid
This regime for 2 months
followed by Rifampicin and
isoniazid for 7 months
PREVENTION OF CROSS INFECTION
Reduction of splatter and aerosols by minimising coughing, avoiding ultrasonic instruments and by use of rubber dams
Improved ventilation, ultraviolet lights , new masks and personal respirators
Use of heat sterilization
GA contraindicated risk of contamination of instruments, impaired pulmonary function
ANTI TUBERCULAR THERAPY