Dental Management of Children with Asthma

Title: Dental management of children with asthma
Authors: Jian Fu Zhu DDS, Humberto Hidalgo MD MS, Corbett Holmgren DDS MD
Journal: Pediatric Dentistry 18:5 1996
Summary: Asthma is a chronic airway disease characterized by both inflammation and broncho-constriction due to genetic and environmental factors. It affects approximately 5-10% of children and is the leading cause of pediatric hospitalization in the US. Symptoms of asthma include coughing, wheezing, chest tightness and dyspnea. Tachypnea, tachycardia, diaphoresis and labored breathing can occur when the bronchial constriction is more severe. Asthma is broken down into mild (wheezing fewer than 2 days per week, no nocturnal symptoms and relatively good exercise tolerance), moderate (wheezing 2-5 days per week with nocturnal symptoms and poor exercise tolerance) and severe (daily wheezing, exercise intolerance and frequent nocturnal symptoms. Bronchocontstriction is mainly due to a hyper-responsive bronchus in the presence of triggering agents due to normal inflammation.
The most common cause of asthma attack is allergen exposures, viral or mycoplasma respiratory tract infections, nonspecific airway irritants, tapering of medication and exercise particularly in cold weather. More severe asthma is found in children of parents who smoke. Emotional and psychological stress may also bring on attacks. Aspirin and other beta adrenergic blockers may precipitate attacks, epinephrine may be used for these.
The two main types of drugs used to combat asthma are anti inflammatory drugs and bronchodilators. Mild asthma is usually controlled with only a beta receptor agonist such as albuterol or terbutaline (typically 2 puffs every 4-6 hours prn symptoms). Cromolyn sodium and nedocromil sodium are anti inflammatory agents that prevent mast cell release of mediators and are used in moderate cases, but have little effect against acute attacks. Inhaled corticosteroids are effective anti-inflammatories recommended for use in children with moderate to severe asthma. Systemic prednisone is also considered for those with acute severe asthma.
Asthma attacks should be considered as a medical emergency whose initial treatment is typically with albuterol, either from an inhaler or a nebulizer once the dental treatment has been discontinued. Keep the airway open and administer oxygen. If there is no improvement or the patient is worsening, administer epinephrine and summon medical assistance
There is evidence of a link between asthma and increased caries incidence, likely due to the 20% decrease in whole and 35% in parotid saliva due to beta agonist effects. Decreased nasorespiratory function can lead to mouth breathing which has been linked to narrower and higher palates, greater facial heights and increased risk of posterior crossbite. Inhaled steroid therapy has been associated with adrenal suppression, dysphonia, dryness of mouth, oropharyngeal candidiasis and rarely, tongue enlargement.
Asthmatics have a higher correlation with psychological problems. High dose prednisone therapy may result in anxiety or depression. Inhaled albuterol has also ben linked to hand tremors. Parents of asthmatic children tend to have a higher anxiety level than parents of healthy children.
When treating an asthmatic patient, the dentist can estimate how well the disease is controlled by asking: the frequency of attakcs, type of medication used chronically and for acute attacks and the length of time the child was last seen emergently due to asthma. A wheezing or poorly controlled patient should be reappointed, and inhalant bronchodilators should be brought to every appointment. Hydroxyzine is antihistaminic and benzodiazepines which are anxiolytic are recommended as agents of conscious sedation. Barbiturates and narcotics should be avoided in children with asthma because they may stimulate histamine release. Nitrous oxide use in children with mild to moderate asthma can help prevent acute attacks, but should be avoided in children with severe asthma since it can be an airway irritant. Ketamine is safe for asthmatic patients but may pose problems for children with cardiopulmonary problems. When possible, children with asthma should be treated with pulse oximetry, EKG and BP cuff present, with intubation materials available.
Patients taking theophylline should not receive erythromycin and it has been recommended to not use LA with vasocontrictors due to its beta agonist nature and the presence of meta bisulfites which may be highly allergic. Asthmatic children are three times more likely to have post operative complications than healthy children. Children who have been on daily or alternate day glucocrticoid therapy may become adrenally suppressed during treatment and should receive double their normal dose the day of treatment. These are patients who have had 4 or more 4-5+ day courses or a continuous 10-14 day course of systemic GC for acute asthma within the previous year and those who have taken systemic GC within the last 30 days. It has been recommended that these patients take 60mg hydrocortisone 6-8 hours before and 1 hour before, although this is not agreed upon.