Editor's note: This is part two of a two-part series. Read part one.
Globally, as of 2018, an estimated 339 million people were affected by asthma, with approximately 1,000 deaths reported daily.1 Adequate knowledge and understanding of this disease and its treatment are crucial for dental hygienists to provide safe and proper care for these patients. In the first installment of this two-part column, we explored the etiology and pathophysiology of asthma. In this second installment, we will explore the medications used in the pharmacologic management of asthma and the clinical care considerations associated with this disease.
The goal of pharmacological therapy for asthma is twofold: (1) treat and prevent the occurrence of acute episodes and (2) reduce airway obstruction and inflammation to prevent the occurrence of future episodes. Short-acting beta-2 agonists, such as albuterol (ProAir HFA), are indicated for the short-term relief of acute episodes, while long-acting beta-2 agonists, such as salmeterol (Serevent), are indicated for long-term maintenance therapy to prevent future episodes. Another mainstay of long-term maintenance therapy is the use of inhaled corticosteroids, such as fluticasone (Flovent), to reduce airway inflammation.
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Combination products that include both long-acting beta-2 agonists and inhaled corticosteroids, such as the combination of fluticasone and salmeterol (Advair), are widely available for patient convenience and to ease compliance. Other long-term maintenance medications that may be useful for patients with severe, persistent asthma symptoms include leukotriene receptor antagonists, such as montelukast (Singulair), and long-acting muscarinic antagonists, such as tiotropium (Spiriva).
The most recent additions to the arsenal of medications used in long-term maintenance therapy are injectable biologics, such as benralizumab (Fasenra) and omalizumab (Xolair), which are dosed on a weekly, rather than a daily, schedule. It is important to note that medications used in the long-term maintenance therapy of asthma are not indicated for the management of acute episodes.
Effects of asthma medications
Patients with asthma who use short-term and long-term maintenance medications are at a higher risk of developing oral complications.2-8 These patients experience xerostomia due to decreased salivary flow rate from inhaler use, which leads to the development of dental caries and erosion. Reduced salivary flow
rate and changes in the oral pH from asthma medications may increase biofilm accumulation and calculus formation, resulting in both inflammation and periodontal breakdown. The immunosuppressive properties of inhaler corticosteroids and injectable biologics may increase the risk of opportunistic infection, especially Candida albicans, which can result in oropharyngeal candidiasis of the soft tissues.3-7 In addition, corticosteroid use has been linked to a generalized reduction in bone mineral density, which can lead to periodontal bone loss.3,4,7,9-11
Dental hygienists are an invaluable resource in educating patients who have asthma about the oral consequences of inhaled medications and in implementing preventive measures to maintain and improve the oral health of these patients.3,4,7,12 Regular recall appointments and frequent fluoride application and scaling are advised to prevent the progression of dental caries and periodontal disease.3,4,7 Dental hygienists should advise patients with asthma to rinse their mouth with water or fluoridated mouthwashes and to brush and floss after each inhaler use whenever possible. This will help mechanically remove residual medication in the mouth and, thus, counteract the acidic pH of inhaled medications, minimize oral mucosal changes, and reduce xerostomia.3,4,6,7 Home application of neutral 1.1% fluoride gel may be encouraged as well as the daily use of xylitol-containing products to stimulate salivary flow.12
Accommodating acute asthma issues in the dental practice
Asthma contributes to 5% of all medical emergencies in a dental practice.13 Risk assessment and strategies to prevent acute episodes during dental hygiene procedures should be one of the primary goals of treatment. Unfortunately, the dental office may be an ideal environment for patients to experience asthmatic symptoms. Acute dental anxiety and stress can trigger acute episodes of asthma, so stress-reduction and relaxation techniques should be employed in patients undergoing dental hygiene procedures.14 Pain management with local anesthetic agents can greatly reduce dental anxiety, but sulfite preservatives in local anesthetics containing epinephrine may (albeit rarely) trigger an allergic response in susceptible patients. In addition, materials and high-speed equipment used in dental procedures may provoke an allergic response and exacerbate asthmatic symptoms, and thus should be avoided or used with caution.5-7,12
Before the first appointment, hygienists should obtain a complete medical history of the patient and update this information at every subsequent appointment. This should include the frequency and severity of asthmatic attacks, the date of the most recent attack, any precipitating factors, and the times of the day when attacks are most likely to occur. The dental hygienist should record the name, dosage, and frequency of all medications the patient uses to control their asthma, as well as any strategies used to prevent acute asthma episodes.5-7,15,16
Dental hygiene appointments should be booked when acute episodes are least likely to occur, based on the patient’s own experience. Patients should be instructed to bring their own short-acting beta-2 agonist medications to every dental hygiene appointment and keep those inhalers easily accessible throughout the appointment.5,6,8,17,18 Many patients suffering from asthma may not tolerate prolonged periods in a supine position, thus it is important to consider scheduling shorter appointments and to place the patient in a semi-supine position whenever possible.5-7,17
Based on the frequency in which asthma is encountered in both children and adults, dental hygienists are likely to encounter patients with varying levels of severity and stability. It is essential to be aware of various patient-specific treatment-induced triggers for acute asthma episodes, medications used to treat asthma and their effects on dental hygiene treatment and overall oral health, and, finally, strategies to properly manage and provide safe care for patients.
Editor's note: This article appeared in the July 2022 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
References
1. The Global Asthma Report 2018. Global Asthma Network. Accessed May 1, 2022. http://www.globalasthmareport.org/
2. Bozejac BV, Stojšin I, Duric M, et al. Impact of inhalation therapy on the incidence of carious lesions in patients with asthma and COPD. J Appl Oral Sci. 2017;25(5):506-514. doi:10.1590/1678-7757-2016-0147
3. Thomas MS, Parolia A, Kundabala M, Vikram M. Asthma and oral health: a review. Aust Dent J. 2010;55(2):128-133. doi:10.1111/j.1834-7819.2010.01226.x
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5. Little JW, Miller CS, Rhodus NL. Little and Falace’s Dental Management of the Medically Compromised Patient. Elsevier, Inc.; 2018.
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10. Shen TC, Chang PY, Lin CL, et al. Risk of periodontal disease in patients with asthma: a nationwide population-based retrospective cohort study. J Periodontol. 2017;88(8):723-730. doi:10.1902/jop.2017.160414
11. Lee SW, Lim HJ, Lee E. Association between asthma and periodontitis: results from the Korean National Health and Nutrition Examination Survey. J Periodontol. 2017;88(6):575-581. doi:10.1902/jop.2017.160706
12. Adults with respiratory disorders: asthma and allergies. Oral health fact sheet for dental professionals. University of Washington School of Dentistry DECOD (Dental Education in the Care of Persons with Disabilities) Program. March 2012. Accessed May 1, 2022. https://dental.washington.edu/wp-content/media/sp_need_pdfs/Asthma-Adult.pdf
13. Jevon P. Updated posters to help manage medical emergencies in the dental practice. Br Dent J. 2015;219(5):227-229. doi:10.1038/sj.bdj.2015.688
14. Appukuttan DP. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin Cosmet Investig Dent. 2016;8:35-50. doi:10.2147/CCIDE.S63626
15. Hupp WS. Dental management of patients with obstructive pulmonary diseases. Dent Clin North Am. 2006;50(4):513-527. doi:10.1016/j.cden.2006.06.005
16. Gesek DJ. Respiratory anesthetic emergencies in oral and maxillofacial surgery. Oral Maxillofac Surg Clin North Am. 2013;25(3):479-486. doi:10.1016/j.coms.2013.04.004
17. Greenwood M, Meechan JG. The respiratory system and dental practice. In: BDJ Clinician’s Guides General Medicine and Surgery for Dental Practitioners, 3rd ed. Springer International. 2019; 27-37. https://doi.org/10.1007/978-3-319-97737-9
18. Renton T, Woolcombe S, Taylor T, Hill CM. Oral surgery: part 1. Introduction and the management of the medically compromised patient. Br Dent J. 2013;215(5):213-223. doi:10.1038/sj.bdj.2013.83
