Medical Problem
Respiratory System Disorders
- Respiratory disorders are very common since they include the upper respiratory tract infections; and the upper RTI are of the most common infections (along with gingivitis). The common cold, sinusitis, sore throat, pharyngitis, laryngitis and tracheatis are of the most common infections.
- Respiratory disorders are important since they're common and since there’s a high probability of cross infection between patients and between the patients and dentist.
- They are also important since emergency situations could take place such as a patient having an asthma attack in the dental clinic. Also these patients take medications that could have certain side effects or modifications or interactions with other drugs.
- These patients also offer a challenge when choo sing the method of anesthesia (general vs local). Mostly it is preferable to treat patients under local anesthesia since g eneral anesthesia requires that the patient has a clear respiratory tract, for a patient with COPD or emphysema general anesthesia is avoided. Generally with all problems or diseases of the respiratory system GA is best avoided; unlike a lot of systemic diseases.
- The most common symptom for respiratory disorder is the cough; which could be a dry cough cou gh or it may be a productive cough. The dry cough could be idiopathic, allergic, or as a side effect of certain drugs. The productive cough produc es discharge that could be solid or semisolid; 1 purulent sputum (has an odor) if it contains pus meaning there is an active infection, 2- it could contain mucus (does not have an odor), 3- it could also be blood hemoptysis which is indicative of either cancer or chest infection like TB. Mucoid sometimes indicates chronic bronchitis; which is a structural and functional disease that produces mucus.
- Another symptom is the difficulty in breathing or dyspnea or wheezing on expiration which is an indication of the constriction of the trachea and bronchi and airways. Chest pain pa in is also a symptom in cases of pneumonia and sometimes cyanosis occurs when the lungs are inca pable of oxygen exchange with the blood. Chronic lung diseases and congenital diseases could could finger clubbing, and also difficulty in normal breathing where the person has to hold on to walls in order to breath; this activates the accessory muscles like the pectoralis muscles in order to breathe since the diaphragm alone isn't sufficient.
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- Investigations for respiratory disorders is a che st x-ray. x-ray. Any individual older that 40 4 0 years old and undergoing GA is asked for a complete workout plus a chest x-ray. A respiratory respiratory function test is also requested using a spirometry to test the air capa city of the lung, and sputum cytology and culture where the sputum is taken and a culture is made to figure out which type of antibiotic should be used especially in the case of pneumonia where some types of bacteria are resistant. Some types of nosocomial infections causes pneumonia and it contains Klebsiella pneumoniae which is resistant to normal antibiotics so a culture is mad e to know what kind of antibiotic can be used to control the infection.
- Upper respiratory tract infections include the nasal, sinus, larynx and pharynx and trachea, the bronchi and lungs are lower respiratory tract infection (the line between upper and lower is the furcation between the trachea and bronchi). Upper respiratory tract infections are commonly viral. Most common is the common cold which wh ich is caused by the rhinoviruses, EBV, EBV, cox virus, or influenza virus. Pharyngitis and tonsillitis are mostly virus even in children, there is also laryngitis or laryngotracheitis which has a cough and potato sound due to the edema present over the vocal chords in the larynx. The redness of the pharynx without the pus discharge indicates that it’s viral.
- Certain conditions or diseases create a greater risk for respiratory diseases such as HIV and bronchiectasis which is the damage to the structure of the bronchus and bronchioles. Cystic fibrosis which is damage to the exocrine glands causing mucus secretion and stagnation. These conditions increase the risk for for respiratory diseases.
- If the common cold isn't treated it could be converted into sinusitis or it could turn into a lower respiratory tract infection moving from the nasal to the lower respiratory cause pneumonia. Pharyngitis and tonsillitis could cause lower respiratory tract infections but they could also cause quinsy which is a peritonsillar abscess; which is a facial space near the lateral pharyngeal space; this abscess should be incised. These could also cause the eustachian tube to get blocked and discharge is released and otitis media occurs.
- Differential diagnosis of pharyngitis is very important. Especially in pharyngitis in children since it could be caused by b y influenza virus, rhinovirus, or cox A virus (which causes herpangina which is redness with ulceration and it lingers for 10 days). There could also be glandular fever which is infectious mononucleosis or diphtheria.
- Sinusitis could be caused by viral, bacterial, bac terial, or as an extension to odontogenic odontoge nic infections (infection from the upper 5,6,7). Most bacteria is aerobic like s. pneumonia and h. influenza. For patients with immunocompromised and uncontrolled diabetes secondary fungal infection
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is expected; these infections are serious. Mucormycosis in patients with uncontrolled diabetes resorbs the bone at the base of o f the skull, it is very aggressive; anti fungal should be taken and debridement of the sinuses should be done. done . Aspergillosis Aspergillosis is common in the USA and it occurs in patients with HIV and immunocompromised patients. Long-term intubation also causes sinusitis; the tubes should be changed every three days so that there would be no accumulation of bacteria, however when it’s not changed routinely sinusitis results. Nosocomial infections are usually aggressive and the bacteria are usually very resistant. resistant. Usually sinusitis is treated with antibiotics before resorting to surgery; however if it becomes chronic surgical debridement becomes necessary to rid the sinus of the bacteria and inflammatory processes. A swab is taken from the nose to figure out the type of bacteria causing the sinusitis since the discharge of the sinus is in the nose. The antibiotics given are against aerobic bacteria such as augmentin or azithromycin, anaerobic antibiotic like metronidazole and analgesic like NSAIDS, and decongestants to decrease the inflammation of the sinus membrane so that when the ostium of the sinus is incised the fluid and infection are drained. If there is a root or implant inserted into the sinus, or if there is an oroantral fistula(which causes inflammation and pus discharge into the mouth, so before b efore removing the fistula surgically the sinusitis should be treated first, since the infection and drainage into the oral cavity is what helps the communication persist, so irrigate through the oroantral fistula in order to debride for a couple of days, and prescribe antibiotics, until the infection is cured then treat the fistula surgically by sutures). In the old days tertiary syphilis used to infect the sinus an d reach the base of the skull but this is not common nowadays since the primary and secondary syphilis respond very well to treatment.
- Lower respiratory tract infections include everything below the trachea involving the bronchi and bronchioles and lungs. So there is bronchitis, bronchiolitis (common in children in late summer/ early winter, the children are wheezing and have a fever and are given ventolin: these kids have bronchiolitis which is a viral infection that is transmitted rapidly between children at school. In the late summer/fall there are two common diseases which are bronchiolitis and gastroenteritis they give rofinal.) Bronchitis occurs in adults and bronchiolitis in children, and lobular pneumonia which is an infection of o f the air spaces distal to the bronchioles; the lung is filled with fluids and the chest x-ray is white due to the infection and fluid.
- The predisposing factors are the immunodeficiency or structural diseases in the lung such as cystic fibrosis or bronchiectasis or lung cancer that causes abnormality in the structure. Poor oral hygiene increase the chances of transmission of bacteria from the oral cavity to the RT. RT. Nosocomial infections are particularly serious in ICU’s ICU’s and hospitals; thats why it is important to minimize hospitalization/ admission time. 3
- GA is usually contraindicated in cases of upper or lower RTI’s RTI’s since there is a chance of spreading the infection to the blood stream that way. Any dental treatment should be delayed delay ed until the infection is controlled.
- The infections that occur other than pneumonia is TB; even though it has decreased but now the incidence is increasing especially in societies in which the vaccine is neglected and there is poor cross infection control. TB is caused by mycobacterium tuberculosis which originated originated in cows and was transmitted to humans through cow-milk. The vaccine is controversial however still in some areas of the worlds the BCG vaccine which is against the bacilli is given. This infection is transmitted through inhalation of air-droplets and aerosols. This is important since the closest contact the patient has is to the patients. TB affects a lot of people but it may be a dormant infection or the patients heal from it; however the active form of TB is uncommon. TB could be dormant in the lungs or hilar lymph nodes for years waiting for ac tivation through meliary. The incidence is arising especially that there are emergents and whatnot and since the IV drug user percentage is much higher than it was and this is all due to neglect. The most important symptom of TB is the chronic cough, hemop tysis, unexplained weight loss, and night sweats and fever for a prolonged period. These symptoms are common in pneumonia and TB but the hemoptysis is affirmative of TB. There are atypical forms of TB like those occurring in HIV patients; a resistant type of mycobacterium avium intracellulare. Many types of TB could affect areas other than the lungs and hilar LN such as Pott's disease where the TB affects the vertebral bodies, and Scrofula which is when the TB affects the lymph nodes. When TB affects the skin it’s known as cutics-orofacialis at the angle of the mouth and lupus vulgaris; there are oral ulcerations associated with TB. The TB ulcerations are odd ulcerations like cancer and fungal ulcers; they are odd in shape and an d usually there’s only one ulcer, this usually occurs at the base of the tongue in less than 1% of people and it is usually formed when the patient is coughing and the bacteria gets entrapped in the oral cavity and it’s implanted in the tissue and causes ulceration. The histopathology of the inflammatory reaction is a granulomatous disease that causes caseation. Caseation could also be caused by syphilis and certain fungi and multisystemic sarcoidosis. The stain used is the Ziehl–Neelsen stain.
- Investigations for TB is a chest radiograph, sputum culture, heaf test or tuberculin test or Mantoux test; these tests are PCR. BCG vaccine at one week old, the vaccine is controversial; and there is chemoprophylaxis such as rifampicin and isoniazid for two weeks which is given to a person as prophylaxis therapy when whe n visiting the Far East or any area a rea related to TB. If the person gets TB there are two types of therapy. therapy. The patient must be treated for a year, year, 3 months of initial therapy with three drugs which are rifampicin, isoniazid and either streptomycin or Ethambutol. Each of these drugs has different d ifferent side effects, rifampicin rifampicin causes red saliva and red 4
urine. Isoniazid causes peripheral neuropathy (metronidazole also cau ses peripheral neuropathy), streptomycin causes circumoral paresthesia, Ethambutol causes ocular damage and is often avoided by people; these much be taken for 3 months in the case of acute active infection. And then for 9 months the rifampicin and isoniazid are taken d aily. aily.
- Dental aspect of TB: it is uncommon that a patient with an active infection presents to the clinic; however if the patient has fever or coughing it could be TB. That’s why it’s important to take proper history and wear personal protective equipment to prevent the transmission especially if the patient has an active state of the infection or if the staff is immunocompromised and the patient has an inactive form or is healing from the infection. If these patients show up for elective treatment it is better to refer them until later when the patient is in the healing phase and is controlled. If the situation is an emergency emergency situation wear double masks and double gloves and goggles and high-power suction to reduce the amount of aerosol, use rubber-dam, air the clinic out and cha nge the masks. Whenever the mask gets wet it must be changed. GA should be avoided in these patients since it could lead to the dissemination of the infection to the blood stream and other parts of the body. There is ulcerations and cervical lymphadenopathy known as Scrofula.
- Legionnaires' disease is a type of pneumonia initially discovered in a meeting where aerosol air-conditioning (dessert AC; the water is stagnated causing bacteria to accumulate) was used and all members of the meeting got pneumonia. It is caused by bacillus bacteria that’s aerobic and gram negative and it’s it’s called legionella nemophila since it causes ca uses lobular pneumonia. This is a serious infection in immunocompromised patients, in smokers and in males; it is present in Turkey and Spain that have a lot of tourist. The mortality rate in iemunocompramsied patients is 80%, and in smokers it is up to 10%. This is important since there stagnant water in the dental clinic in the 3 in 1, 1 , so the dental unit should be flushed after holidays to reduce the stagnation.
- Bronchiectasis is dilation and distortion of bronchi, with excessive sputum/mucus production which leads to coughing, since there is accumulation of the mucus due to poor drainage. The release of mucus is a relief since mucus is stuck inside the airway and prevents the normal no rmal function of the bronchi making breathing difficult. The patient hence gets a lower respiratory tract infection; pneumonia and pleurisy. The etiology is due to structural changes in the bronchi; loss of ciliated epithelium in the bronchi which expels the mucus; this causes stagnation of the mucus. Signs and symptoms include cough, dyspenia, hemoptysis (like TB or lung cancer) , finger clubbing, cyanosis, some patients might even develop a cerebral abscess which explains why before GA prophylactic antibiotics are given to avoid spread of the
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infection to the brain. Generally all respiratory diseases that are obstructive or in which there are structural abnormalities GA is avoided to the greatest extents like pregnant women, it is only given in emergency since GA either pushes infections down into the lung or out of the lung and into the blood stream. Mucus stagnation causes infections especially for immunocompromised such as diabetic patients, or if there is seasonal v iral and bacterial infections such as in the fall or if there is an epidemic; however not all people experience e xperience the same symptoms. The treatment is to take mucolytic agents such as carbocisteine and bronchodilators such as beta-2 agonists, and positional drainage (the congestion might increase with laying down for example) and with physiotherapy (they teach the geriatric g eriatric patients to expectorate) which includes the induction of coughing. The importance is that there is sputum and chronic cough due to damage in the bronchial system; these patients are very prone to any infection and this diseases is a major risk factor for any lower respiratory respiratory tract infections such as pneumonia, pleurisy, and TB. Bronchiectasis and cystic fibrosis occur at a younger age than COPD and are given vaccination that’s that’s called DPT. There are seasonal influenza vaccines for many types including the rhinoviruses.
- Cystic fibrosis: usually occurs in children; it is a hereditary disorder of the exocrine glands which secretes products outside the blood circulation; such as saliva, sweat, tears, sebaceous products. The pancreas is both and endocrine and exocrine. It is common occurring in 1:2000 and there is increased secretion of mucus and an d the pancreas is affected and it suffers from insufficiency and it affects the growth of children. The children get recurrent upper respiratory tract infections and it forms chronic nasal polyps. It affects the pancreas and the liver and it has many serious complications in children; including diabetes mellitus (type I) in children and liver cirrhosis which are the most serious complications. Cystic fibrosis mainly involves the sweat and salivary glands. In order to diagnose cystic fibrosis there is a test called sweat test where the sweat sodium concentration is higher than 70 mmol/l. This is treated by pancreatic replacement therapy, therapy, especially the digestive enzymes by giving tablets containing digestive enzymes; if this tablet dissolves in the child’s mouth the enzymes will cause lysis and degradation of the tissues, protein; so this causes u lcers. The children must have a low fat and high vitamin and carbohydrate diet since the pancreas produces the enzymes of the fat digested while the carbohydrate digestion begins in the oral cavity.
- Measles, whooping cough, diphtheria and pertussis. Prophylactic antibiotic therapy with tetracycline used to be given in the old days and these patients used to suffer from staining. Even though in the 70 ’s tetracyclines were used greatly in both topica l and systemic forms, it used to be a godfather for drug groups. It only has two side effects like GI disturbances and staining. Dental aspect: GA could be a contraindication, there is sialosis which is the non6
inflammatory, inflammatory, non-neoplastic, non- bilateral swelling of salivary glands. Sialosis occurs with older age, acromegaly, thyroid, diabetes, drugs, and cystic fibrosis. Sialosis is also associated with enamel hypoplasia and delayed eruption of teeth. Tetracycline staining (rarely seen), oral ulcerations, goblet cells are affected which secrete mucus but the high caries risk since there is a low fat high carbs diet.
- Asthma, chronic bronchitis, and emphysema: chronic bronchitis and emphysema are known as COPD. Asthma is restrictive restrictive and not obstructive and it is reversible: it is a state of bronchial hypersensitivity where is constricts and then dilates by itself and with children it improves with maturity; however with older people with age it becomes a chronic symptoms. Asthma affects 2% of the population (asthma is more common that Cystic fibrosis). There are two types of asthma; extrinsic due to allergies or intrinsic due to mast cell instability (idiopathic). Triad asthma: asthma, nasal polyp, and aspirin hypersensitivity; with asthma aspirin and all NSAIDs are contraindicated. Severity of attacks; if the asthma is controlled controlled it is safe to treat the patient, if the asthma is not controlled wait u ntil it’s it’s controlled to treat the patient. In order o rder to find out if it’s controlled ask the patients about previous visits to the ER, did the patent need any hospital admissions recently, what type of medication does the patient need since some patients don't take medicine and only use an inhaler, and some patient take many medication together such as ipratropium bromide, theophylline, steroids, steroids, bronchodilators, salbutamol because of how severe the asthma is. The type of medication given to the patient should be known since if it’s a cortisone the management is giving double dose. Ipratropium bromide causes dry mouth and it’s anti-asthmatic drug that causes bronchodilation. If the patient is controlled check that the inhaler is with him; Ventolin Ventolin is salbutamol which is a beta-2 agonist (beta-blockers block the bronchi). Refer treatment until asthma is controlled, there should be an anxiety reduction protocol, and the inhaler should be present at all times, and avoid all NSAIDs. The patient will usually have two complications which are dry mouth due to ipratropium bromide and oral thrush due to steroid use (which can be wiped, and a nd the erythammoatous inflamed area will bleed: pseudomembranous candidacies).
- Asthma and cystic fibrosis both occur in children. - COPD has two divisions which are chronic bronchitis and emphysema. Both have cough, but the chronic bronchitis is a persistent, productive cough for more than 3 months for 3 consequent years to be able to diagnose chronic bronchitis; 99% of chronic bronchitis patient are smokers. Chronic bronchitis is a chronic disease and it has certain complications; it is not an infection that is always treated; it is similar to Bronchiectasis and pneumon ia and and lower RTI; hence that’s why it’s specified that it should be for 3 months and 3 years. Emphysema is
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a disease in which the alveoli distal to the bronchioles are damaged; where oxygen exchange takes place. When the bronchiole has alveoli which are reduced to 1 or 2 out of 5 or 6 and the remaining two sacs increase in size; the surface area for oxygen exchange decreased. Another type of emphysema is alpha-1- antitrypsin deficiency. When a pregnant woman gives birth before 37 weeks; the baby is put in an incubator because there is no surfactant; hence the pregnant woman at 34 weeks that is expected to give birth early is given four doses dexamethasone IM and this causes maturity of the lungs in the premature baby, however if the baby is born prematurely the baby is given surfactant.
- Signs and symptoms are cough, dyspnea, dy spnea, wheezing (expiration; if there was obstruction there would be a sound on inspiration: Stridor). Chronic complications are chronic hypoxia, followed by heart failure as it tries to compensate and meet the oxygen demand.
- Dental management of patients with COPD: defer treatment until the condition is controlled, and avoid GA and barbiturates (phenobarbital). GA is either inhalation or IV and both are serious since they cause respiratory depression; since they affect the centers of the brain. Are barbiturates preferable over LA? Wrong. Wrong. Never give COPD patients oxygen since they depend on the CO2 concentrations centers and when the Oxygen levels are increased the concentration centers are messed with and there will be something wrong with the balance of gases. COPD patients have not only an oximeter but also a carbogram (CO2 curve) is used too. Since giving oxygen causes a counter result since the centers detect CO2.
- Signs of COPD: 1- Blue bloated: cyanosis + edema because of the chronic hypoxia and the heart failure; 2- Pink panther: due to CO or CO2 retention since all oxygen is consumed (this is similar to people that turn on the heater in winter with no oxygen).
- Never give oxygen to a patient with COPD or hyperventilation; never deal with stress or neurosis with oxygen; unlike with MI and chest pain and syncope. Oxygen may be deadly.
- Never use a rubber dam with these patient since the patients already have difficulty in breathing. The patient should be treated in upright position. The upright position is contraindicated only in syncope; but indicated in COPD, heart failure and MI.
- Sarcoidosis: found in children and early adolescents, multisystem; multisystem; granulomatous (caseating (caseating and non-caseating); caseation is only with TB and syphilis. Non-caseating are orofacial granuloma, leprosy, Parkinson disease, Crohn’s disease (sarcoidosis, b eryllium disease, hypersensitivity pneumonitis, drug reactions, tuberculoid leprosy. leprosy. Crohn's disease)
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- Sarcoidosis typically causes bilateral, hilar lymphadenopathy 4 groups of lymph nodes, it causes gingival enlargement, acute uveitis (eye involvement), hypercalcemia which with time causes renal failure, more susceptibility to lymphomas; which are serious complications. It also causes non-caseating granuloma; impaired cell mediated immunity affecting T-cells T-cells (what’s (what’s the meaning of humoral) causing lymphopenia, positive test in more than 80%, ESR is increased, increased serum angiotensin converting enzyme levels, increased adenosine deaminase, however there are decreased levels of serum albumin since it’s a chronic infection and usually albumin is decreased with chronic infections. It also causes uveoparotid fever called Heerfordt–Mylius syndrome, Heerfordt–Waldenström Heerfordt–Waldenström syndrome, and Waldenström's Waldenström's uveoparotitis
- Dental aspect: there are respiratory problems, there are granulomas and lung problems. It also causes jaundice and renal failure, and it’s treatment is steroids. Any chronic inflammation like rheumatoid arthritis, systemic lupus are all treated with steroids. Also sialosis occurs. It also causes uveoparotid fever called called Heerfordt–Mylius syndrome, Heerfordt–Waldenström Heerfordt–Waldenström syndrome, and Waldenström's Waldenström's uveoparotitis. It also causes ca uses gingival enlargement; and the biopsy for sarcoidosis is taken from the enlarged enlarged gingiva which could be one of the early signs of sarcoidosis (it is also caused by phenytoin, cycosporin A and Calcium Channel blockers). Leukemia patients get gingival enlargement and bleeding.
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