[Music] hey everyone ryan here and welcome back to our oral medicine series this video will be about copd and asthma these are two of the main pulmonary diseases that appear on the board exam so copd stands for chronic obstructive pulmonary disease chronic referring to the fact that it's long term actually causes irreversible damage obstructive meaning blocking pulmonary referring to air flow so altogether it's the term for a preventable respiratory disorder that involves the restriction of air flow that is not fully reversible it's currently the third leading cause of death in the united states and the most common cause for it is cigarette smoking so there are two main clinical manifestations of this disorder on the left we have chronic bronchitis and on the right we have emphysema so chronic bronchitis is all about chronic inflammation in the airways so cigarette smoke or environmental pollutants irritate the bronchial walls and increase the size of mucous glands and goblet cells so this causes lots and lots of mucus production on top of the airways getting inflamed and narrowed so it's a lot harder for that patient to breathe both in and out so the classic chronic bronchitis patient is known as a blue bloater and they have this chronic productive cough with lots of sputum they have a noisy chest with ronchi which refers to this rattling sound and also they might have some wheezing sounds the chest x-ray actually appears normal but they have elevated hemoglobin peripheral edema and the patients tend to be cyanotic with blue skin and overweight hence the blue bloater moniker now on the right we have emphysema which involves only the alveoli or the air sacs which are the functional units of the lung distal to or after the terminal bronchioles so chronic smoke inhalation damages the lung epithelium releasing these inflammatory mediators and enzymes like elastase that end up destroying lung tissue resulting in these enlarged air spaces or enlarged alveoli so they also lose elastic recoil as a result of these enzymes like elastase so this makes breathing a lot more difficult specifically breathing out or expiration so how you can remember this whereas chronic bronchitis affects both inspiration and expiration emphysema affects more expiration so e for emphysema e for expiration the classic emphysema patient is known as a pink puffer so they usually don't have a cough or much sputum and they have a pretty quiet chest no rock eye or wheezing however their chest is often barrel shaped with these over inflated lungs due to the trapping of air because they really struggle to expirate that air so as a result the diaphragm is usually flattened and the heart is usually smaller because it's squished between those oversized lungs and then the puffer part comes from having smoked for a long period of time so pink puffers tend to be old thin and have severe dyspnea or trouble breathing now most patients with copd may exhibit features of both of these diseases so you could fall into one category or the other or you could exhibit symptoms and signs from both of these unique categories so how about diagnosis of copd well we have a couple of methods the spirometer is used to measure the amount of air that a person can breathe out so how this works is the patient would take a deep breath and blow into this tube as hard as possible with a clip on their nose so all the air is being released through the mouth and it's hooked up to a machine that records the results and so the forced expiratory volume in one second that's fev1 that is less than 70 the predicted volume called the forced vital capacity or fvc for short in the absence of any other pulmonary disease is given a copd diagnosis now depending on the severity copd is labeled anywhere from stage one for mild to stage four for very severe we can also do pulse oximetry so a pulse oximeter is a lot easier to do and it measures the oxygen saturation or the percentage of hemoglobin saturated with oxygen in the arterial blood so it isn't used to diagnose copd but it can be used to supplement a diagnosis or in our case help determine the patient's current health status and pulmonary function while in the dental chair so the spirometer is something that a medical professional would be involved in to diagnose the patient the pulse oximeter is just something that we could use in the dental chair to monitor their current status arterial blood gas measurement and chest radiographs can also aid in the diagnosis of copd now although copd is irreversible medications can be used in order to slow the progression or at least manage the disease so inhaled anticholinergics are considered bronchodilators and they function to reduce mucus secretion in the airways and relax smooth muscle in order to open up the airways by blocking acetylcholine at the muscarinic receptors so some examples would be iprotropium and teotropium the tropiums now next we have the inhaled beta-adrenergic agonists and these are also called bronchodilators and these are also considered bronchodilators and they function to relax smooth muscle of the airways by increasing cyclic amp levels some are fast acting like epinephrine while others are longer acting like indicatoral combining these two categories can have significant benefits because they work by different mechanisms but they work to achieve the same outcome they both function to open the airways essentially and make breathing easier for these copd patients corticosteroids work by reducing inflammation and suppressing the immune response some examples are fluticasone which is an inhaled drug and prednisone which is an oral medication and lastly we have the phosphodiesterase inhibitors like theophylline as sort of a last resort this medication can have some side effects that are not so fun now i like these drug categories because they're as easy to remember as a b c d and so that's how i tend to remember these drug categories and one possible management strategy is to start with an anticholinergic for stage 1 copd and then adding a long-acting bronchodilator if that patient's stage 2 adding a corticosteroid to the mix if they're stage 3 and then using theophiline as a last resort for stage four very severe copd so not only do we have this order abcd but it also tends to be the order in which those drugs are prescribed for copd patient so a nice little memory tip to help you remember those drug categories next let's talk about some considerations for copd patients that are in the dental chair so smoking cessation is the most effective and cost-effective intervention that can help manage copd so we want to encourage that for patients who are actively smoking some innovational therapies include things like nicotine replacement and bupropion therapy we want to avoid pulmonary irritants so excellent isolation and suction is really useful for these types of patients patients with moderate to severe copd should be placed in a semi-supine or upright chair position instead of a supine position to help prevent difficulty breathing and discomfort for the patient bilateral mandibular blocks or bilateral greater palatine blocks can cause an unpleasant airway constriction feeling in some of these patients so that should be avoided whenever possible rubber dams can also constrict breathing ability for patients with severe disease so avoid those also when possible we certainly want to avoid narcotics and barbiturates because they are respiratory depressants and we do not want to be depressing pulmonary function we want to avoid macrolide antibiotics like erythromycin and also ciprofloxacin if the patient is taking theophylline because these antibiotics can reduce the metabolism of theophylline resulting in theophylline toxicity which may involve things like nausea vomiting insomnia headache arrhythmia and even convulsions a pulse oximeter should be used to monitor oxygen saturation throughout the dental procedure nitrous oxide inhalation generally should not be used for severe copd patients because nitrous oxide might accumulate in the air spaces of the compromised lung low flow oxygen at a rate of 2 liters per minute is recommended if a person's oxygen saturation is below 95 and general anesthesia is not recommended for copd patients for airway concerns lastly if the patient's taking systemic corticosteroids for copd they might require supplementation for major surgical procedures due to the concern for adrenal suppression and this is a consideration for anyone who takes corticosteroids chronically and we'll talk more about that in the next video in this series now for a poorly controlled or unstable copd patient this is somebody who's symptomatic with shortness of breath at rest productive cough upper respiratory infection or an oxygen saturation that's below 91 those are things that we're considering unstable and that type of patient should be rescheduled and the appropriate medical referral should be made it's what i call defer and refer so as in the past if the patient needs emergency care you can consider some conservative treatment or a hospital referral depending on the presence or absence of symptoms your own emergency preparedness and a multitude of other factors but for the board exam if a situation is unstable it's uncontrolled it's symptomatic then we want to refer for medical consultation now also for a copd patient we want to look out for cardiovascular comorbidities which are very common in copd patients and then follow those patient considerations when necessary far as oral manifestations of copd we see things like halitosis staining of the teeth nicotine stomatitis periodontal disease and oral cancer that are related to smoking because the vast majority of these patients are going to be chronic smokers poor oral hygiene might lead to aspiration pneumonia in these patients the pneumonia is an infection of the lungs and or airways and aspiration pneumonia occurs when something containing bacteria like food or even saliva is breathed into the lungs or airways leading to this pneumonia dry mouth is something we see in a lot of these conditions that we've talked about so far in the series but in this case specifically it's due to the side effects of the anticholinergic medications those tropiums and then stevens johnson syndrome has been linked to theophylline use all right so the second half of this video is going to be about asthma asthma is also a chronic respiratory disease associated with airway obstruction but this one is characterized by reversible episodes of increased airway responsiveness that leads to episodes of breathing difficulty coughing or wheezing and the bronchiolar tissue is sensitive to several stimuli and there are many things that can trigger an asthma attack or flare-up it could be an allergen like pollen an upper respiratory infection exercise cold air nsaids chemicals smoke and even anxiety and stress and one of the first things you should ask an asthmatic patient is what triggers their attacks and then make sure to avoid those things in the dental setting as much as possible as far as pathophysiology for this one airway obstruction can be the result of many different things that could be smooth muscle spasm inflammation of the bronchial mucosa and or goblet cell hyperplasia that means too many goblet cells which is also seen in chronic bronchitis and the excess mucus from these goblet cells would plug up the airways making this volume a lot smaller and as far as diagnosing as with copd spirometry is the gold standard the allergy testing and sputum smears could also be done in addition to that so now for asthma medications there is a lot of overlap with the copd ones and i have another abcd but this one comes with some caveats so anti-asthmatics for asthma management are used either for long-term control or short-term immediate relief and a combination of those two is usually used to improve lung function and i actually want to start this one with the c the corticosteroid because inhaled corticosteroids are currently the most effective anti-inflammatory medication for treating persistent asthma and similar with copd they reduce inflammation so some examples are aprenozone budesonide and fluticasone now we also have our bronchodilators back once again these beta adrenergic agonists and they activate the beta2 receptors to relax smooth muscle of the airways just like they did with copd for an acute asthma attack the first line of defense is going to be a short-acting bronchodilator like albuterol via an inhaler or a nebulizer you can also pair this with supplemental oxygen via a face mask or nasal hood and if the symptoms worsen or do not improve after that then you would administer epinephrine subcutaneously and likely activate ems a.k.a call 9-1-1 what's cool is that there are combination drugs that combine a corticosteroid with a long-acting beta-adrenergic agonist for example a four-motorole and budesonide combined become symbicort or salmeterol and fluticasone combined become adver and you may have heard of those names before and that's what's going on with those drugs let's go to our a for antihistamines and those block the histamine receptor histamine is an organic compound released by mast cells during degranulation which happens when an allergen binds to the ige the immunoglobulin e attached to those mast cells and histamine is responsible for three things in the classic allergic response redness swelling and itchiness so blocking that with diphenhydramine or benadryl or fexophenidine which is allegra and you may have heard of those two before helps to calm the allergic response now there's an asterisk after antihistamines because antihistamines are not prescribed for asthma they're given for allergies but if allergies trigger your asthma then that's when an antihistamine can be used to help control asthma and prevent those asthma attacks so hopefully that makes sense decongestants rd do exactly what you'd expect they reduce nasal congestion and pseudo ephedrine brand name sudafed is an a1 or alpha-1 selective agonist which means it's a vasoconstrictor so it constricts nasal blood vessels reducing nasal swelling and inflammation it's mostly used to treat cold flu allergies and sinusitis but once again if allergies are the precipitating factor for asthma it can be used to indirectly manage your asthma and lastly we have leukotriene receptor antagonists which of course block leukotriene which is a pro-inflammatory mediator that the body releases after coming in contact with an allergen and these lucas are examples of the leukotriene receptor antagonists so patient considerations for asthma if we see asthma on the patient's patient box what are things we want to be thinking about well the primary goal is to prevent an acute asthma attack that's the last thing that we want in the dental chair so we want to avoid any precipitating factors so what are those precipitating factors stress and anxiety is one of them so we want to reduce stress be kind and gentle again explain the procedures answer their questions and we also could consider a short-acting benzodiazepine before the appointment and we can consider nitrous oxide during the appointment as long as the patient isn't symptomatic for asthma at that moment they're not actively wheezing or something like that we also want to confirm the patient is taking their asthma medication as directed and we want to have their rescue inhaler and an epipen ready and accessible if they have an attack once again we want to have excellent isolation to minimize any tooth enamel dust or any other pulmonary irritants that could trigger an episode we want to avoid nsaids because they have been shown to precipitate asthma attacks in a small percent of the population so that's very very important to note once again avoid narcotics and barbiturates because they have respiratory depressive properties and can also trigger an attack we want to track the patient's oxygen saturation once again valuable information to have it should be between somewhere between 97 and 100 percent and if it drops below that 95 percent level then consider oxygen supplementation that low flow oxygen and again i would reschedule defer and refer if the patient is actively coughing wheezing they forgot to take their medication that they usually do etc oral manifestations of asthma xerostomia or dry mouth this time is due to the usage of inhalers that dry out the mouth as opposed to the anticholinergics from copd which also dry out the mouth these patients have increased caries risk due to the decreased salivary flow gastroesophageal reflux disease is common in patients with asthma and is exacerbated by the use of bronchodilators and theophiline oral candidiasis occurs in about five percent of patients who use inhaled corticosteroid for long periods of time enamel defects have been associated with severe asthma in children while periodontitis has been associated with severe asthma in adults and asthmatics who are mouth breathers may be associated with higher rates of malocclusion specifically excess overjet posterior crossbite high palatal vault and an increased face height all associated with habitual mouth breathing since we're talking about pulmonary diseases i wanted to briefly cover indications and contraindications to both nitrous oxide in this slide and oxygen on the next slide the two most used gases in dentistry nitrous oxide can be helpful for someone with dental anxiety a strong gag reflex and what we just talked about asthma and since nitrous oxide is not irritating to the trachea and the bronchi asthma is not a contraindication to the use of nitrous oxide provided the patient is not having an attack or wheezing at that moment so poorly controlled asthma we defer and refer but otherwise nitrous is totally fine and in fact there's a benefit in administering nitrous oxide since in many asthmatics the primary precipitant is usually emotional stress especially in children so you could see how nitrous oxide could actually help prevent us from having an attack in the chair now there are a lot of contraindications most of which are relative not absolute contraindications but i still want to mention them so you're aware of them when it's time for you to sit for your board exam so patients with copd have a reduced ability to move gases into and out of the lungs we talked about that very beginning of this video therefore it's more difficult to administer nitrous oxide and more importantly is more difficult to get it out of the patient's lungs while it can be used in mild to moderate cases severe copd patients have a respiratory drive triggered by decreased oxygen levels as opposed to a healthy patient whose drive to breathe is triggered by increased carbon dioxide levels so what that means is administering nitrous oxide which is always given alongside lots of oxygen can actually decrease the patient's drive to breathe which is potentially very very dangerous for a severe copd patient so we could put a little asterisk here it's not and for mild to moderate copd patients it's okay but once we get to that severe and above level we really want to try to avoid nitrous oxide for those patients nasal obstruction so since nitrous oxide must be administered through a nasal mask this is a relative contraindication depending on how severe the obstruction is even habitual mouth breathers may have difficulty using the nasal mask multiple sclerosis involves nerve debilination especially in the central nervous system and leads to weakness poor muscle coordination speech disturbances among other neurological disturbances and chronic use of nitrous oxide can produce similar symptoms so it's not recommended to use nitrous oxide chronically in these patients one or two times is perfectly fine though pregnancy this is an important one nitrous oxide readily enters fetal circulation and it can be toxic to cells undergoing mitosis so pregnant patients should avoid nitrous oxide especially when they are early on in their pregnancy psychiatric disorders are often managed with prescribed medications but they can be difficult to manage it's probably a good idea to consult the patient's psychiatrist before administering nitrous oxide because the reaction to inhalation sedation could be unpredictable along with that communication barriers are important because much of the monitoring of a patient's conscious sedation with nitrous oxide is done verbally to make sure it's working properly you're checking in with the patient checking to see how they're feeling and confirming with the patient that they're at the right stage of sedation so having a language barrier could be a potential problem otitis media so nitrous oxide should be avoided in children with a middle ear infection that's what otitis media is because of concerns about pressure buildup and gas diffusion and lastly sickle cell disease so regular use of nitrous oxide can actually interfere with vitamin b12 metabolism which is a problem because these patients the sickle cell patients have a b12 deficiency already all right and lastly let's talk about a couple indications and contraindications for oxygen use so in the yes column we have copd and asthma the two main diseases we talked about and humidified low flow oxygen can be provided to copd patients safely to help alleviate an unpleasant airway and oxygen is also safe and sometimes indicated for asthma patients we talked about this in those patient consideration slides for both copd and asthma so that makes perfect sense i want to be clear that once again there are no absolute contraindications to oxygen but it should be administered with caution in two specific scenarios and that's for patients who have taken or are currently taking bleomycin which is a chemotherapeutic agent that can damage the lungs and patients who are suffering from paraquat poisoning which is a toxic herbicide and since oxygen is administered alongside nitrous oxide when doing inhalation sedation these two things would also be contra indications to nitrous oxide sedation as well all right so that's it for this video guys thank you so much for watching please like this video if you enjoyed it and subscribe to this channel for much more on dentistry if you'd like to support me please check out my patreon page and thank you to all of my patrons here for their support you can unlock access to my video slides to take notes on and practice questions for the board exams so go check that out the link will be in the description thanks again for watching everyone i'll see you in the next video