THE PATIENT WITH RESPIRATORY ABNORMALITIS Risk Assessment and Dental Management

1. THE PATIENT WITH RESPIRATORY ABNORMALITISRisk Assessment and Dental Management Géza T. Terézhalmy, D.D.S., M.A. Professor and Dean Emeritus School of Dental Medicine Case Western Reserve University Cleveland, Ohio gtt2@case.edu

2. The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy • H1 receptor antagonists • 1st generation • promethazine hydrochloride • 2nd generation • fexofenadine hydrochloride

3. The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy • Mechanisms of action • Vascular smooth muscle – H1 blockade • Contraction of post-capillary venule and terminal arteriole • Reduce rubor

4. The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy • Vascular endothelial cells – H1 blockade • Relaxation of endothelial cells • Reduce edema, wheal response

5. The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy • Lungs – H1 blockade • Bronchodilation • Reduce asthma-like symptoms

6. The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy • Nerves – H1 blockade • Reduce sensitivity of afferent nerve terminals to chemical mediators of inflammation • Reduce Itching, pain

7. The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy • Stomach – H2 blockade • Decreased gastric acid secretion • Reduce pepsin synthesis, heartburn

8. The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy • Heart – H2 blockade • Reduce Ca2+ influx into myocytes • Decrease in heart rate and contractility

9. The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy • CNS – H3 blockade • Block histamine-dependent neurotransmission • Modulate circadian rhythms and wakefulness

10. The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy • ADEs • Xerostomia

11. The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy • Risk assessment • Disease-related variables

12. The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy • Clinical indications • Allergic rhinitis • Seasonal allergies • Perennial allergies • Urticaria • Angioedema • Atopy

13. The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy • Treatment strategies • First generation H1 receptor antagonists may produce sedation • Additive with other CNS depressants • Anxiolytic agents • Local anesthetics • Opioid analgesics

14. The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy • Preventive strategies • Oral hygiene • Conventional vs. electromechanical toothbrushes • Antibacterial mouthwashes • Topical fluorides • Sialagogues • Pilocarpine (Salagen) • Cevimeline (Evoxac)

15. The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy • Medical emergencies • To be anticipated based on the patient’s medical history and vital signs

16. The Patient With Respiratory Abnormalities ASTHMA AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

17. The Patient With Respiratory Abnormalities(Asthma and COPD) • 2-receptor agonists and anticholinergic agents • Advair Diskus (fluticasone propionate w/ salmeterol) • Proventil HFA (albuterol) • Albuterol • ProAir HFA (albuterol) • Combivent (ipratropium w/albuterol) • Spiriva HandHaler (tiotropium bromide)

18. The Patient With Respiratory Abnormalities(Asthma and COPD) • Mechanisms of action • Albuterol is a short-acting 2-receptor agonist • Salmeterol is a long-acting 2-receptor agonist • Ipratropium and tiotropium block the action of acetylcholine

19. The Patient With Respiratory Abnormalities(Asthma and COPD) • Risk assessment • Disease-related variables

20. The Patient With Respiratory Abnormalities(Asthma and COPD) • Asthma • Often begins in childhood • Coughing • Wheezing • Shortness of breath

21. The Patient With Respiratory Abnormalities(Asthma and COPD) • 10% of asthmatics have a triad of • ASA intolerance • Nasal polyps • Chronic sinusitis

22. The Patient With Respiratory Abnormalities(Asthma and COPD) • Chronic bronchitis • Usually smokers 35 years or older • Recurrent respiratory infections • Productive cough • Hypoxic hypoxemia • Polycythemia • Right sided heart failure • Cyanosis

23. The Patient With Respiratory Abnormalities(Asthma and COPD) • Emphysema • Usually preceded by chronic bronchitis • Smoking • Stimulates proteases •  protease inhibitor activity • May be hereditary • Lack of protease inhibitor • Right sided heart failure • Peripheral edema • Hepatomegaly

24. The Patient With Respiratory Abnormalities(Asthma and COPD) • Treatment strategies • Physiological stress (physical, emotional) may lead to respiratory distress • Reduce anxiety • Ensure profound anesthesia • Post operative pain management • Avoid opioids

25. The Patient With Respiratory Abnormalities(Asthma and COPD) • Preventive strategies • Oral hygiene • Conventional vs. electromechanical toothbrushes • Antibacterial mouthwashes • Topical fluorides • Sialagogues • Pilocarpine (Salagen) • Cevimeline (Evoxac)