Current research demonstrates a variety of conflicting information regarding the impact of Asthma on oral health. An analysis of the existing literature demonstrated one conclusive result; Asthma doubles risk of caries. Asthma is currently classified based on the severity of the condition and how well it is controlled. The current classifications are: Controlled, partially controlled, uncontrolled. A patient with controlled asthma will demonstrate “minimal symptoms with no restrictions on activity, near normal lung function” with worsening and less controlled cases falling into the other categories. Recommendations to the dental professional are that the classification of a patient’s asthma should be assessed and noted at each appointment.
Medications used to manage asthma include inhaled cortical steroids, beta-2 agonists, anti-cholinergic drugs. Inhaled mast cell stabilizers, oral anti-leukotriene agents, systemic corticosteroids, monoclonal antibodies. There are few medications used by dental professionals that are contraindicated in patients with Asthma. Aspirin, due its ubiquity of use and potential for harm is a primary concern. Approximately 7%-14% of asthma patients have Aspirin Exacerbated Respiratory Disease, which can trigger fatal anaphylaxis. Other NSAIDS have demonstrated cross-sensitivity with aspirin in asthma patients and should thus be avoided.
Opioids are also contraindicated because they lead to respiratory depression and histamine release, potentially causing a severe attack. Paracetamol is drug of choice for pain relief in patients with asthma because of the previously noted contraindications. Dental antibiotic prescribing has generally not been found to have contraindications, and most antibiotics do not interfere with asthma treatment. Of note, Macrolides like erythromycin should be avoided because they can lead to toxic levels of methylxanthine in the blood. Many fluoride varnishes contain the ingredient colophony which is contraindicated in children with severe asthma.
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This ingredient can result in a reaction requiring hospitalization. The use of local anesthetics have inclusive recommendations, sodium metabisulphate, a common ingredient in anesthetics causing vasoconstriction has been shown to produce reactions in asthma sufferers. The severity of reaction varies and is uncommon, likely because the amount of sulfite is small. Further it has been shown that around 96% of asthmatics are not sensitive to sulfites. Local anesthetics can be used, however caution is advised and only anesthetics without vasoconstrictors should be used.
According to the literature identification and management of an acute attack is as follows: “A severe acute asthma attack may present as breathlessness and expiratory wheeze. The child may not manage to complete a sentence or may be too breathless to feed. Respiratory rate may be >40/min (2–5yrs) or >30 (>5 yrs). Heart rate may also be increased at >140/min (2–5 yrs) and >125/ min (>5 yrs). In the case of a life threatening attack the patient may present with cyanosis, reduced respiratory effort, reduced heart rate, neurological signs such as confusion, or reduced consciousness or loss of consciousness. Assess airway, breathing, circulation, disability, and exposure. If the patient is conscious, sit them upright and administer two puffs of a short-acting beta agonist (salbutamol 100 mcg/puff inhaler) and repeat if necessary. If the patient is unable to use the inhaler appropriately, administer the drug using a spacer device. Administer oxygen at 15/L minute. If there is no improvement, or the asthma attack is severe, phone for an ambulance. If the patient loses consciousness, begin cardio-pulmonary resuscitation”.
It is commonplace for children to translate for adults who may be less fluent in English, also called language brokering. Often the children must translate topics that are beyond their maturity and comprehension. Among these topics are healthcare considerations, and their ability to translate is critical for the health, well-being, and normal functioning of the family. Studies are mixed regarding the effect language brokering has on the child, with some studies demonstrating negative effects on mental health and scholastic performance, and others demonstrating positive academic and self-esteem effects. This can vary due to family dynamics and individual characteristics. One study found a particularly strong correlation between being a language broker between the ages of 9 and 13 and negative mental health effects. The researchers suggested additional support for language brokers and particularly within this age category in order to alleviate stress and prevent negative impact to the mental and emotional well-being of the broker.
Informed consent must be obtained for any patient. If however, the patient is under 18 they cannot give consent. Parent or legal guardian must give consent to treat. This is complicated if parents are divorced or if minor is brought to appointment by a nanny or other caregiver that is not legally empowered to give consent. It is recommended that a parent of legal guardian accompany a minor patient to a first appointment and that an agreement is reached, and confirmed in writing about when parental/guardian presence is required at an appointment. In certain conditions a minor may provide consent for themselves. For dental treatment a legally emancipated minor or a situationally emancipated minor may provide consent themselves. In the case of an emergency where a delay in treatment could be life threatening to the patient and no parent or legal guardian is present, consent can be assumed. Any subsequent treatment however, must receive consent.
When Sophia and her Grandmother arrive at the clinic the very first thing that must be done, while she and her grandmother are filling out her medical history, is to contact her parents and determine if her Grandmother is able to provide consent as Sophia is a minor and unable to provide consent for herself. After consent has been granted, her Asthma should be assessed and classified both by asking Sophia questions regarding when her last attack was and how she is responding to medication, and by contacting the physician that diagnosed her. It would be best if the provider and the staff were fluent in Spanish, but if none of the employees are fluent, having a translator on-call who is competent to translate dental and medical terminology to Sophia’s grandmother would be the next best option.
Alleviating Sophia of the need and stress of translating, especially as it will become more difficult for her to do so while she is being examined and treated. Her long term prognosis is that her diagnosis of Asthma increases her likelihood of caries and other oral issues. She should be counseled on why this occurs, and what she needs to do in her daily life to reduce the possibility. The current state of decay speaks to the impact her Asthma is already having and it needs to be impressed upon her, her grandmother and her parents that it is absolutely critical she is vigilant about her oral health and regular about cleanings and check-ups. The clinic should keep in stock products that are asthma patient friendly, including fluoride varnish without colophony and local anesthetics. Sophia and her family needs to be advised that she cannot be given Aspirin or any NSAIDs, and only prescribed paracetamol for pain.
As well as noting these drug concerns in her chart, it must also include the prohibition again prescribing macrolides for infections. Finally a procedure should be in place and practiced in how to identify a severe Asthma attack and how to respond, including having her bring her rescue inhaler, having her PCP’s contact information readily available, and oxygen readily accessible. The response should be practiced so the staff is prepared for any patient that suffers an asthma attack, especially one who may not be diagnosed as asthmatic.
