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I gave this lecture as part of the course syllabus of Principles of Internal Medicine (Principles of Medicine) in undergraduate dental school.
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Pulmonary DiseasesPulmonary Diseases
Dental Management of Dental Management of Patients with Pulmonary Patients with Pulmonary
DiseasesDiseases
OutlineOutline
Lung Infections: TuberculosisLung Infections: Tuberculosis Chronic Obstructive Pulmonary Chronic Obstructive Pulmonary
DiseaseDisease– Chronic BronchitisChronic Bronchitis– EmphysemaEmphysema
AsthmaAsthma
TuberculosisTuberculosis Epidemiology: Epidemiology: TB is the TB is the No. 2No. 2 killer infectious disease (no. 1 killer infectious disease (no. 1
AIDS) in the worldAIDS) in the world 1/31/3 of the world’s population is already infected of the world’s population is already infected
with TB. with TB. Every secondEvery second, someone in the world becomes , someone in the world becomes
newly infected. newly infected. Over the centuries, TB has taken over Over the centuries, TB has taken over 1 billion 1 billion
lives.lives. Every year, more than Every year, more than 8 million new people8 million new people
develop active TBdevelop active TB Every year, Every year, 2 million people die2 million people die from TB. from TB.
TuberculosisTuberculosis Epidemiology: Epidemiology: No. 6 cause of death in the Phils (2000) – 7.5% of No. 6 cause of death in the Phils (2000) – 7.5% of
all casesall cases No. 6 cause of sickness in the Phils.(2002) – 8 out No. 6 cause of sickness in the Phils.(2002) – 8 out
of 10 are infectious diseasesof 10 are infectious diseases US CDC: rates of TB are 10 times higher among US CDC: rates of TB are 10 times higher among
Asians Asians
10 Highest Burden TB Countries:10 Highest Burden TB Countries:
1. India1. India2. China2. China3. Indonesia3. Indonesia4. Nigeria4. Nigeria5. Bangladesh5. Bangladesh6. Pakistan6. Pakistan7. Ethiopia7. Ethiopia8. 8. PhilippinesPhilippines9. South Africa9. South Africa10. DR Congo10. DR Congo
as of October 2003; source: WHO 2004 as of October 2003; source: WHO 2004 Global Tuberculosis Report Global Tuberculosis Report
Cause and SpreadCause and SpreadCause: tubercle bacillus (Mycobacterium tuberculosis)Cause: tubercle bacillus (Mycobacterium tuberculosis) aerobic, nonmotile, rods with a high lipid content in their cell walls.aerobic, nonmotile, rods with a high lipid content in their cell walls. acid-fastacid-fast bacilli, because once they are stained, they resist decoloration with bacilli, because once they are stained, they resist decoloration with
acid-alcohol. acid-alcohol.
Transmission:Transmission: through inhalation of aerosolized bacteria (1 droplet = 1-10 bacilli)through inhalation of aerosolized bacteria (1 droplet = 1-10 bacilli) From coughing, sneezing or speaking by people with active TBFrom coughing, sneezing or speaking by people with active TB These small droplets can remain suspended in the air for several hours.These small droplets can remain suspended in the air for several hours. Infection will occur if inhalation results in the organism reaching the alveoli Infection will occur if inhalation results in the organism reaching the alveoli
of the lungs.of the lungs.
SymptomsSymptoms
FeverFever Night sweatsNight sweats AnorexiaAnorexia Nonproductive coughNonproductive cough Weight lossWeight loss MalaiseMalaise Fatigue Fatigue
DiagnosisDiagnosis
1.1. HistoryHistory Immunocompromised patientImmunocompromised patient Exposure to person with active TBExposure to person with active TB
2.2. Chest x-rayChest x-ray3.3. Sputum test – (+)AFB (acid-fast bacilli)Sputum test – (+)AFB (acid-fast bacilli)4.4. Tuberculin Skin TestTuberculin Skin Test
Immunocompromised ConditionsImmunocompromised Conditions
diabetes mellitus diabetes mellitus malignancies requiring chemotherapy malignancies requiring chemotherapy steroid-dependent diseases, such as steroid-dependent diseases, such as
asthma or collagen vascular disease asthma or collagen vascular disease malnutrition related to alcohol/drug malnutrition related to alcohol/drug
abuse, smoking, extremes of age, and HIV abuse, smoking, extremes of age, and HIV infection as well as demographic and infection as well as demographic and
socioeconomic factors socioeconomic factors end-stage renal disease end-stage renal disease
Positive PPD test Positive PPD test
PPD (purified protein PPD (purified protein derivative)derivative)
Or Mantoux testOr Mantoux test
Or TST (tuberculin skin Or TST (tuberculin skin test)test)
(+)Result:=/>10mm(+)Result:=/>10mm
Chest X-rayChest X-ray
Class Type Description
0 No TB exposureNot infected
No history of exposure Negative reaction to tuberculin skin test
1 TB exposureNo evidence of infection
History of exposure Negative reaction to tuberculin skin test
2 TB infectionNo disease
Positive reaction to tuberculin skin test Negative bacteriologic studies (if done) No clinical, bacteriological, or radiographicevidence of active TB
3 TB, clinically active
M. tuberculosis cultured (if done) Clinical, bacteriological, or radiographic evidence of current disease
4 TBNot clinically active
History of episode(s) of TBOR 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
PathologyPathologyof TBof TB
TB bacilliTB bacilli
Liquefaction Liquefaction and cavitationand cavitation
CD4 helper T cells CD4 helper T cells tell macrophages to tell macrophages to kill intracellular TB kill intracellular TB
bacilli; CD8 bacilli; CD8 suppressor T cells suppressor T cells lyse macrophageslyse macrophages
Hydrolytic enzymes Hydrolytic enzymes cause caseationcause caseation
(“cheese-like”) necrosis(“cheese-like”) necrosis
Lymphocytes excrete Lymphocytes excrete cytotoxic substancescytotoxic substances
Immune Immune system system
overwhelmedoverwhelmed
Strong immune Strong immune systemsystem
More bacteria More bacteria multiply in multiply in
cavitation; Active cavitation; Active infectioninfection
Granuloma Granuloma formsforms
Mycobacteria cannot Mycobacteria cannot grow in acidic grow in acidic extracellular extracellular
environment; granuloma environment; granuloma calcifiescalcifies
Controlled Controlled infectioninfection
TreatmentTreatment
Multiple Drug TherapyMultiple Drug Therapy– Isoniazid (INH)Isoniazid (INH)– Pyrazinamide (PZN)Pyrazinamide (PZN)– Rifampicin Rifampicin – StreptomycinStreptomycin
RegimenRegimen– 2 months INH, PZN, Rifampicin, Streptomycin2 months INH, PZN, Rifampicin, Streptomycin– 7-10 months INH and Rifampicin7-10 months INH and Rifampicin
DOT- directly observed treatmentDOT- directly observed treatment
Dental ManagementDental Management
In Active TB: In Active TB: 1.1. patients should be in negative patients should be in negative
pressure roomspressure rooms
2.2. Health professionals should wear N-95 Health professionals should wear N-95 respirator masks or with HEPA filtersrespirator masks or with HEPA filters
Before treating, make sure:Before treating, make sure: Clinical improvement is seen (no Clinical improvement is seen (no
fever and cough)fever and cough) Sputum test is free of mycobacteriaSputum test is free of mycobacteria At least two weeks of multiple drug At least two weeks of multiple drug
therapy completedtherapy completed
Dental ManagementDental Management
Chronic Obstructive Pulmonary Chronic Obstructive Pulmonary Disease (COPD)Disease (COPD)
a disease state characterized by the presence of a disease state characterized by the presence of airflow obstruction due to chronic bronchitis or airflow obstruction due to chronic bronchitis or emphysemaemphysema
May also have symptoms of asthmaMay also have symptoms of asthma Symptoms:Symptoms: Productive coughProductive cough BreathlessnessBreathlessness WheezingWheezing Signs: barrel chest, wheezing, prolonged Signs: barrel chest, wheezing, prolonged
expirationexpiration
Chronic Obstructive Pulmonary Chronic Obstructive Pulmonary Disease (COPD)Disease (COPD)
Primary cause: cigarette smokingPrimary cause: cigarette smoking– 20 pack years= 20 years of smoking 1 20 pack years= 20 years of smoking 1
pack a daypack a day Others: air polllution; airway Others: air polllution; airway
hyperresponsivenesshyperresponsiveness No. 7 killer disease in the Phils. No. 7 killer disease in the Phils.
(2000) or 4.3% of cases(2000) or 4.3% of cases Common in patients >50 yrs oldCommon in patients >50 yrs old
Chronic BronchitisChronic Bronchitis
Chronic bronchitis = the presence of a Chronic bronchitis = the presence of a chronic productive cough for 3 months chronic productive cough for 3 months during each of 2 consecutive years (other during each of 2 consecutive years (other causes of cough being excluded) causes of cough being excluded)
Mucous gland enlargementMucous gland enlargement Mucous plugs in airwayMucous plugs in airway Lots of phlegm (“talaba”)Lots of phlegm (“talaba”) ““Blue bloaters”Blue bloaters” CyanosisCyanosis Overweight patientsOverweight patients
Chronic BronchitisChronic Bronchitis
EmphysemaEmphysema
Emphysema is defined as an abnormal, Emphysema is defined as an abnormal, permanent enlargement of the air spaces distal to permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by the terminal bronchioles, accompanied by destruction of their walls and without obvious destruction of their walls and without obvious fibrosis. fibrosis.
Chronic Bronchitis (clinical findings)Chronic Bronchitis (clinical findings) Emphysema (anatomic findings)Emphysema (anatomic findings)
EmphysemaEmphysema
EmphysemaEmphysema
Difficulty in expiration because of Difficulty in expiration because of loss of elasticity in alveolar wallloss of elasticity in alveolar wall
““Pink puffers”Pink puffers” Barrel-chestedBarrel-chested Scanty mucusScanty mucus Severe dyspneaSevere dyspnea
Depressed diaphragmDepressed diaphragm
TreatmentTreatment
Smoking cessationSmoking cessation Mucolytic agentsMucolytic agents Oxygen therapyOxygen therapy AntibioticsAntibiotics Oral steroidsOral steroids Inhaled steroidsInhaled steroids BronchodilatorsBronchodilators Anticholinergic agentsAnticholinergic agents
Dental ManagementDental Management
Treat patient in supine positionTreat patient in supine position Avoid use of rubber damAvoid use of rubber dam May need oxygen supplementation May need oxygen supplementation
while treatingwhile treating Don’t use bilateral blocksDon’t use bilateral blocks GA contraindicatedGA contraindicated
AsthmaAsthma
hyperreactive airway disease hyperreactive airway disease a chronic inflammatory disorder of a chronic inflammatory disorder of
the airways in which many cells and the airways in which many cells and cellular elements play a role, in cellular elements play a role, in particular, mast cells, eosinophils, T particular, mast cells, eosinophils, T lymphocytes, macrophages, lymphocytes, macrophages, neutrophils, and epithelial cells neutrophils, and epithelial cells
AsthmaAsthma
Symptoms: wheezing, breathlessness, chest Symptoms: wheezing, breathlessness, chest tightness and coughing, particularly at night or tightness and coughing, particularly at night or in the early morning in the early morning
Components:Components:
1)1) airway inflammationairway inflammation
2)2) intermittent airflow obstructionintermittent airflow obstruction
3)3) bronchial hyperresponsiveness. bronchial hyperresponsiveness.
Causes/TriggersCauses/Triggers
allergensallergens exerciseexercise
medicationsmedications
Causes/TriggersCauses/Triggers
– Environmental allergensEnvironmental allergens– Viral respiratory infectionsViral respiratory infections– Exercise; hyperventilationExercise; hyperventilation– Gastroesophageal reflux diseaseGastroesophageal reflux disease– Chronic sinusitis or rhinitisChronic sinusitis or rhinitis– Aspirin or nonsteroidal anti-inflammatory drug Aspirin or nonsteroidal anti-inflammatory drug
hypersensitivity, sulfite sensitivityhypersensitivity, sulfite sensitivity– Use of beta-adrenergic receptor blockers (including Use of beta-adrenergic receptor blockers (including
ophthalmic preparations)ophthalmic preparations)– Environmental pollutants, tobacco smokeEnvironmental pollutants, tobacco smoke– Occupational exposureOccupational exposure– Emotional factorsEmotional factors– Irritants such as household sprays and paint fumesIrritants such as household sprays and paint fumes
DiagnosisDiagnosis
PFT (pulmonary function test)PFT (pulmonary function test) Allergen skin testAllergen skin test
Types of AsthmaTypes of Asthma Step 1 - IntermittentStep 1 - Intermittent
– Intermittent symptoms occurring less than once a week Intermittent symptoms occurring less than once a week – Brief exacerbations Brief exacerbations
Step 2 - Mild persistentStep 2 - Mild persistent– Symptoms occurring more than once a week but less Symptoms occurring more than once a week but less
than once a day than once a day – Exacerbations affect activity and sleep Exacerbations affect activity and sleep – Nocturnal symptoms occurring more than twice a month Nocturnal symptoms occurring more than twice a month
Step 3 - Moderate persistent Step 3 - Moderate persistent – Daily symptoms Daily symptoms – Exacerbations affect activity and sleep Exacerbations affect activity and sleep – Nocturnal symptoms occurring more than once a week Nocturnal symptoms occurring more than once a week
Step 4 - Severe persistent Step 4 - Severe persistent – Continuous symptoms Continuous symptoms – Frequent exacerbations Frequent exacerbations – Frequent nocturnal asthma symptoms Frequent nocturnal asthma symptoms – Physical activities limited by asthma symptoms Physical activities limited by asthma symptoms
Dental ManagementDental Management
Never treat a patient with an asthma Never treat a patient with an asthma attackattack
Have anti-asthma medication (inhaler) on Have anti-asthma medication (inhaler) on handhand
Good suction and evacuation of water and Good suction and evacuation of water and salivasaliva
Avoid allergens (incl. NSAIDs)Avoid allergens (incl. NSAIDs) Decrease stress experienceDecrease stress experience Avoid respiratory depressants (opioid Avoid respiratory depressants (opioid
drugs)drugs)
Dental ManagementDental Management
Patient History: frequency, severity Patient History: frequency, severity of attacks, triggersof attacks, triggers
Refer for medical consult if neededRefer for medical consult if needed
WORDS TO LIVE BY:WORDS TO LIVE BY:
For the Lord gives For the Lord gives wisdom, from His mouth wisdom, from His mouth
come knowledge and come knowledge and understanding.understanding.Proverbs 2:6Proverbs 2:6