Asthma And Its Effect On The Respiratory System
The aim of this essay is to assess the medical condition of asthma as well as the oral cavity. Furthermore, the essay seeks to discuss the oral manifestations related to this condition and the treatments available, along with commended precautions that should be taken with such patients in a dental environment.
Asthma is described as a chronic inflammatory condition due to reversible bronchial constriction (Weinberg et al, 2015). Sufferers of asthma have inflamed air passages that narrow the airways, resulting in less oxygen reaching the lungs (Lozano et al, 2011). Asthma can be identified into two distinct categories, extrinsic and intrinsic. Extrinsic asthma is caused by an allergic reaction where patients tend to have higher levels of Immunoglobulin E (IgE) in their blood. Contrarily, intrinsic asthma is non-allergic and triggered by stimuli such as stress, cold or dry air (Pulmonary Associates, 2017).
Accordingly, asthmatic sufferers are known to have inflamed and dilated blood vessels as well as excess mucus that contribute to airflow obstruction and narrow airways, causing problems during the process of respiration (Baker, Currie, 2012). Remodelling of airways is another important structural change that occurs during this condition. This means that the small and large airways are affected, causing the airway walls to thicken and further disrupt breathing. However, early diagnosis and prevention mean that this process can be stopped to improve control over symptoms (Bergeron, Ramli, Hamid, 2009). The measures taken to identify and treat this condition can have a direct impact on the oral cavity, which will be discussed in the latter stages of the essay.
Asthma is known to adversely impact the respiratory system which consists of the nose, throat, larynx, trachea and lungs (Hollins, 2018). The function of the respiratory system is to absorb oxygen from the air into the blood and release carbon dioxide in a process called ventilation (Greenwood, Meechan, Bourke, 2009).
Consequently, the process of ventilation depends on the size of each breath, the ventilation rate and the resistance of the airways. The process of ventilation happens approximately 16 times per minute, but the rate of each breath can increase greatly when exercising but also during an anxious situation, such as the aspect of dental treatment (Hollins, 2018). Ultimately, the likelihood of an asthma attack is increased in affected patients, when attending dental appointments.
As highlighted previously, respiratory diseases such as asthma can affect the respiratory system by adversely impacting the airways and the lung tissue. The symptoms of such a condition and the treatments required are known to affect the oral cavity. Hence, in order to aid the dental procedure, thorough investigations such as previous asthma history and the use of inhalers must be conducted (Greenwood, Meechan, Bourke, 2009).
Diagnosis of asthma relies on the symptoms presented by the patient, however; the diagnosis of asthma is not always straightforward. This is because asthmatic symptoms mirror symptoms that of COPD, cystic fibrosis and hyperventilation among others. Therefore, many elements such as assessment of spirometry, radiological and laboratory findings are essential for an asthmatic diagnosis (Currie, Baker, 2012). Clinical features of asthma include dyspnoea, cough, wheeziness and chest tightness (Scully, Cawson, 2005).
Of all the conditions mentioned above symptoms presented by asthma patients are most similar to those of COPD. However, over years research has provided some features that help to differentiate between the two conditions such as breathlessness is episodic in asthma sufferers but persistent in COPD patients – refer to table 2.1 (Currie, Baker, 2012). Therefore, a correct diagnosis is vital to ensure that the treatment is provided accordingly.
During asthma diagnostic techniques such as spirometry has proven to be fundamental. This involves the patient performing a forced breathing procedure to assess the forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and the ratio between the two volumes (Currie, Baker, 2012). This test can identify asthma as the structural changes in the airways would cause the FVC to be impaired, indicating asthma. Baker and Currie (2012, p.17) suggest that based on the results of the spirometry, the nature of asthma can be identified into high, intermediate or low probability. If airflow obstruction is present then the probability will be intermediate or low, helping to diagnose asthma. In addition, other diagnostic examinations such as chest radiographs and skin tests can also be used to identify increased IgE concentrations in terms of extrinsic asthma (Scully, Cawson, 2005).
The treatment and management of asthma can be done in two different ways, non-pharmacological and pharmacological management (Currie and Baker, 2012). The non-pharmacological approach actively involves the patient in the treatment and requires the patient to have some knowledge of the condition in order to help them control the symptoms. Patients with extrinsic asthma are advised to avoid their personal identified allergens in order to keep the symptoms under control. Baker and Currie (2012, p.27) advise that a correct dietary plan should be given for example, in the case of overweight asthmatics. Such guidance should be provided to lose weight to avoid further breathlessness related to obesity rather than asthma.
The pharmacological treatments however have a more direct effect on the oral cavity. These treatments include a step-wise method and treatment can be started at any five steps, depending on the severity of symptoms of an individual. The first step involves the SABA’s such as salbutamol and terbutaline which act directly upon the smooth muscle and cause the airways to dilate up to 6 hours. These inhalers, also known as beta2-agonist work instantly and are the first resort for an asthmatic (Currie, Baker, 2012). But such agonists can cause xerostomia or dry mouth and also lower the salivary PH (Scully, Cawson, 2005). These dental conditions will be discussed further in the following paragraphs.
Furthermore, step two involves the use of Inhaled corticosteroids (ICSs) which are important for intense sufferers of asthma. These are known to be the most effective in the long-term approach in controlling asthma (Currie, Baker, 2012). They decrease inflammation by “switching off” activated inflammatory genes which helps to reduce hyper responsiveness. ICSs are frequently used by sufferers of persistent asthma but can also be used alongside SABA’s mentioned above (Barnes, 2010). However, side effects such as oropharyngeal candidiasis a form of oral thrush is usually seen in patients administering ICSs twice daily (Barnes, 2010). Some forms of dental local anaesthesia can also cause asthma attacks to occur in patients using ICSs and therefore, it is recommended to avoid vasoconstrictor local anaesthetics in such dental patients (Scully, Cawson, 2005).
To continue, step 3 in the pharmacological treatments includes the use of Long-acting bronchodilators (LABA’s) these are a type of beta2 agonists and include salmeterol. These drugs last up to 12 hours are more effective than the SABA’s and ICSs combined (Currie, Baker, 2012). LABA’s help to keep the muscles around the airways relaxed but do not contribute to reducing inflammation (Asthma UK, 2019). Note that LABA’s are also prone to administering some side effects such as feeling of nervousness and headaches. Hence, requiring more care in a dental environment (Currie, Baker, 2012).
The fourth step consists of Leukotrienes Receptor Antagonists (LTRAs) that are available in tablet form and are not steroidal based. Asthma UK (2019) describes these as an “add-on” treatment only and are to be used alongside the inhalers prescribed ahead of this. These help to reduce the inflammation of the airways as well as reducing the response towards identified allergens by blocking leukotrienes produced by the body against or during an allergic reaction (Asthma UK, 2019). The LTRA’s are also known to have some side effects such as sore throats and infections; however, they do not have an adversarial impact on the oral cavity.
Lastly, methylxanthines are a type of inflammatory mediator inhibitor; these drugs therefore are used by asthmatics for the anti-inflammatory affects (Currie, Baker, 2012). Theophyllines are the most common types of methylxanthines and should be used in relatively low doses and along with ICS and LABA. Other drugs for asthma sufferers also include anti-IgE drugs that are effective in allergic asthma (Currie, Baker, 2012).
The information above describes the various treatments provided to asthma sufferers and outlined some of the dental problems that could be caused by the treatments methods provided such as inhalers. As mentioned previously, beta2- agonist can cause xerostomia due to airway constriction and therefore, patients are forced to breathe through their mouth more often to be able to get enough oxygen into the body. This condition also causes a lower saliva PH, leading to dental conditions such as caries and gingivitis.
Saliva plays a vital role in the oral cavity, it is 99% water and 1% other combined electrolytes and proteins, its two main functions are to facilitate speech and mastication and to protect the oral tissues. Dodds et al (2015) explains the importance of saliva in avoidance of dental diseases in Dental Journal (BDJ) as it helps to neutralise the acids and control plaque pH to stop demineralisation of the tooth surface as well as remineralise of the enamel to stop the advancement of tooth caries and other conditions. However, the saliva flow rate is affected in patients who suffer from xerostomia due to decreased function of the salivary glands, commonly seen in patients’ using pharmacological treatments for asthma.
As mentioned above, xerostomia and the decrease in saliva rate leads to a lower saliva pH which means that the tooth minerals such as calcium are removed from the tooth surface by the plaque present, leading to demineralisation of the tooth and in turn caries (Dodds et al, 2015). Dental caries is described as “a chemical dissolution of a tooth surface brought about by metabolic activity in the microbial deposit, covering a tooth surface at any given time” (Kidd, Fejerskov, 2016, p.6). As the pH is lowered in the oral fluids due to the use of SABA’s, white spot lesions develop on the enamel surface which, if not stopped can progress on into the dentine, due to a lower saliva rate as remineralisation of the enamel cannot occur (Kidd, Fejerskov, 2016).
The effects of xerostomia described above are not pleasant for asthma sufferers however; these effects are reversible if diagnosed at an early stage. Asthmatic and therefore xerostomia patients are advised to rinse their mouth after the use of inhalers as it is found that some medications used in pharmacological treatments use sugar additives for a more pleasant taste for the patient. This therefore, increases the chances of caries, hence, rinsing of the mouth and brushing after the use of inhalers is advised (Delta Dental, 2018). Patients are also required to drink more water to stay hydrated and to stop the effects of the dry mouth.
In some cases, saliva substitutes can also be prescribed by the dentist (Villa, Connell, Abati, 2014). Saliva substitutes are a form of artificial saliva for xerostomia sufferers; these are available in the form of rinse or spray (Colgate 2019). In contrast, saliva stimulants are also another possibility, as the name suggests these are used to stimulate more saliva flow e.g. through sugar free chewing-gum.
ICSs are another form of pharmacological treatment prescribed for asthmatics; these are associated with oropharyngeal candidiasis which is also known as oral thrush. This appears like a removable white covering and red lesions on the soft tissues in the mouth (Hollins, 2018). Candida is an organism that is found in the oral cavity and is harmless until affected e.g. through medication in inhalers, this then begins to multiply and produce symptoms (Mayo Clinic, 2018). Such fungal infections can be found in two different forms, denture stomatitis which is visible under removable dental appliances and the second is known as angular cheilitis, these are sores at the edge of the mouth (Hollins, 2018). Symptoms can include soreness when eating and swallowing, bleeding, and soft white lesions to name a few.
Therefore, the excruciating affect of inhalers on the oral cavity are evident hence, the management too is dispensable. Accordingly, oropharyngeal candidiasis is a type of fungal infection and therefore, treatments include antifungal agents usually in the form of oral gels, solutions or tablets such as Fluconazole. (Hollins, 2018).
To continue, asthmatic patients using LABA’s are found to experience higher levels of anxiety and this can aggravate during dental treatment or at an aspect of future dental appointments. There are two ways described by Hollins (2018, p. 399) that are considered to help lower anxiety. These include the use of general anaesthesia (GA) that can only be performed in hospital setting or a conscious sedation that can be performed in a dental setting and can be done in multiple ways.
GA is a loss of complete consciousness, that means that such nervous patients are referred to an appropriate hospital by the dental professional where nasal masks are used to deliver the anaesthesia, this technique is mostly used for children suffering from asthma (Hollins, 2018). Conscious sedation can be performed by a trained dental professional, during this procedure longer dental treatments can be performed under local aesthetic (LA) (Hollins, 2018). However, this is not ideal for all asthma patients as LA contains sulphites which can react with vasoconstrictor- containing LA and cause an asthma attack (Scully, Cawson, 2005). For other asthmatics with no such problem oral sedation, inhalation sedation and intravenous sedation are the options available.
Medical emergencies can occur with asthmatics, this is common in both intrinsic and extrinsic types of asthma as some patients may react to allergens in the dental surgery whereas others react with nervousness causing an asthma attack to arise. During a medical emergency concerning asthma, signs such as wheeziness, cough and blueness of the lips can be seen, patient may also feel symptoms such as a sense of breathlessness and drowning upon stressful situations (Hollins, 2018). Dental professionals are trained to deal with such situations and all dental surgeries are required to have an emergency drug box, containing pharmacological solutions for multiple different types of medical emergencies. Assistance by other team members in such cases is also important in case the situation takes a life-threatening turn.
During an asthma attack in the dental chair, the trained professional is required to administer salbutamol inhaler, the first step into a pharmacological solution for asthma, mentioned previously (Hollins, 2018). The second step would be to give oxygen to increase the process of ventilation whilst another member of staff should also spend time reassuring the patient. If the condition seems to deteriorate further than an emergency call to 999 should be placed, during the duration of the ambulance arrival, the patient should be monitored closely and comforted (Weinberg, Segelnick, Insler, and Kramer, 2015).
In addition, precautions should be taken with asthmatic sufferers present in the dental surgery to avoid the instance of a medical emergency, mentioned above from occurring. Firstly, the medical history with such patients should be clearly assessed and monitored at every visit. It is important to know the asthmatic history and the previous and most recent asthma attack as well as the number of visits to the emergency doctors (Weinberg, Segelnick, Insler, and Kramer S, 2015). This information is vital in accessing the likelihood of an asthma attack occurring during a dental treatment.
To continue, the extent and the type of asthma should be determined before starting any dental treatment and this should be recorded for future reference. Asthma, as mentioned previously can take different forms such as intermittent, mild or severe. Weinberg et al (2015) explain that in intermittent and mild asthmatics dental treatment can be approached as planned however, severe asthmatics may require more medical attention and therefore, the dental treatment should be postponed and carried out at a different time in case of present symptoms.
Other precautions are also required such as the requirement for the patient to have their prescribed inhaler with them at all times and within reach. This question should be asked before beginning any treatment and in a forgetful instance, an inhaler from the emergency drug box should be placed for the patient to use (Weinberg, Segelnick, Insler, and Kramer, 2015).
All the instances mentioned above require dental professionals to ask necessary questions before the start of treatment however, vital precautions should also be taken during the treatment e.g. patients should not be put in a supine position in the dental chair as this increases the chances of difficulty in breathing (Weinberg, Segelnick, Insler, and Kramer, 2015). Patients should also be provided with correct oral hygiene instructions to reduce the chances of problems such as caries and oral thrush from occurring. Asthmatic dental patients should be given advice such as the use of mouthwash after use of inhalers, correct interdentally cleaning and brushing techniques to avoid gum disease such as gingivitis (Scully, Cawson, 2005).
To conclude, this essay provided a detailed insight into the condition of asthma and its effect on the respiratory body system. Research showed that asthma is constriction of airways and ultimately leading to breathing difficulty. Treatments are then provided accordingly such as SABA’s and LABA’s etc. These are very effective is reducing airway inflammation and improving breathing however, these may also adversely impact the oral cavity by way of xerostomia, cavities, gum disease, oral thrush and anxiety.
The solutions for the listed dental problems are also explained in the essay such as medications and advice from dental professionals. Management and cautions should also be taken when dealing with asthma patients these include medical history checks, an inhaler close-by as well as correct positioning of the dental chair. Ultimately, although the inhalers are an effective way asthmatic management they are proven to impact the oral cavity. However, note that such problems can also be prevented and controlled.
