The patient with respiratory abnormalitis risk assessment and dental management
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THE PATIENT WITH RESPIRATORY ABNORMALITIS Risk 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 [email protected]

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THE PATIENT WITH RESPIRATORY ABNORMALITIS Risk Assessment and Dental Management

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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

[email protected]


The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy

  • H1 receptor antagonists

    • 1st generation

      • promethazine hydrochloride

    • 2nd generation

      • fexofenadine hydrochloride


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


The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy

  • Vascular endothelial cells – H1 blockade

    • Relaxation of endothelial cells

      • Reduce edema, wheal response


The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy

  • Lungs – H1 blockade

    • Bronchodilation

      • Reduce asthma-like symptoms


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


The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy

  • Stomach – H2 blockade

    • Decreased gastric acid secretion

      • Reduce pepsin synthesis, heartburn


The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy

  • Heart – H2 blockade

    • Reduce Ca2+ influx into myocytes

      • Decrease in heart rate and contractility


The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy

  • CNS – H3 blockade

    • Block histamine-dependent neurotransmission

      • Modulate circadian rhythms and wakefulness


The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy

  • ADEs

    • Xerostomia


The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy

  • Risk assessment

    • Disease-related variables


The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy

  • Clinical indications

    • Allergic rhinitis

      • Seasonal allergies

      • Perennial allergies

    • Urticaria

    • Angioedema

    • Atopy


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


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)


The Patient With Respiratory AbnormalitiesAllergic Rhinitis, Urticaria, Atopy

  • Medical emergencies

    • To be anticipated based on the patient’s medical history and vital signs


The Patient With Respiratory Abnormalities

ASTHMA AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)


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)


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


The Patient With Respiratory Abnormalities(Asthma and COPD)

  • Risk assessment

    • Disease-related variables


The Patient With Respiratory Abnormalities(Asthma and COPD)

  • Asthma

    • Often begins in childhood

      • Coughing

      • Wheezing

      • Shortness of breath


The Patient With Respiratory Abnormalities(Asthma and COPD)

  • 10% of asthmatics have a triad of

    • ASA intolerance

    • Nasal polyps

    • Chronic sinusitis


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


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


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


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)


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