Asthma patients may need drilling before dental visit
Researcher finds lung function can suffer
Young asthmatics may need to take some precautions before sitting down in the dental chair, says researcher Tanya Mathew, BDS, MS, clinical assistant professor and research associate in the College of Dentistry at The Ohio State University in Columbus.
In her research, Mathew found one in 10 asthmatic children suffer a decline in lung function following visits to the dentist. But the message isn’t to deter patients from seeking dental care for their asthmatic kids or to cause parents and practitioners undue alarm. It just may mean taking preventative steps, something that some dentists are doing already.
Mathew says she still doesn’t know why some children experienced statistically significant declines in lung function when she studied them as part of her master’s degree thesis while a resident at Columbus Children’s Hospital.
Working out the mechanisms will require further inquiry in an area that so far hasn’t received much attention, she says.
"The idea is to always be careful with patients and not take [asthma] lightly," Mathew says. "There’s no denying the fact that the area of our operation in the mouth is very close to the sensitive area for asthmatics."
A potential relationship between lung function and dental treatments has surfaced mostly as anecdotes but has not been studied thoroughly. When she reviewed the literature, she found conflicting recommendations about managing asthmatics in dental settings.
Some researchers have suggested dentists limit their manipulation of the hyperactive airways and patients use prophylactic medications before treatments. Oxygen therapy also may be helpful, placing patients in a semi-reclined or upright position and treating patients soon after they take their daily dose of prophylactic medications using bronchodilators.
Still other researchers have suggested that patients taking steroids receive a supplement before major dental treatments.
Mathew’s study involved a nonrandom sample of 57 children with asthma ages 6 to 18, identified through a patient database at Columbus Children’s Hospital.
Each child underwent a hygiene visit, an operative visit, or both. The visits were scheduled after 1 p.m. to account for daily variations in responses.
The hygiene visits included a dental examination and fluoride treatments. The operative visits included sealants, restorations, or extractions. Treatments were provided by students at the College of Dentistry.
The study showed a clinically significant decrease in lung function in 10% to 14% of the subjects immediately after the visit, depending on the testing mechanism; 11% to 12% experienced a decrease 30 minutes postoperatively.
The decrease in lung function was small — 2.1% to 4.3% — but still more than is expected by chance. But exactly why remains unclear, requiring further research.
"We looked at a whole bunch of factors, but didn’t find any of the factors to be significant," Mathew says. "We don’t know exactly whether it’s anxiety or something in the material that’s used or the setting in a dental clinic or the aerosol created."
Other studies have suggested a variety of possible triggers: improper positioning of the suction devices, aerosols from plaque or lesions, and aeroallergens created in a dental setting such as tooth enamel dust.
Mathew’s group found stress and dental anxiety didn’t contribute to the reduction in lung function. Few of the subjects were extremely anxious, and some patients who showed asthma symptoms had not been anxious during the dental visit.
The study also considered factors such as each child’s number of emergency department visits in the past year, history of hospitalizations, time since last asthma attack, last emergency department visit, and dose of asthma medication, as well as missed school days, severity of asthma, and frequency of medication use. But the researchers found that history variables did not help predict which patients would go on to have asthma symptoms.
Most symptoms reported were mild, including cough and congestion. Less than 7% of the children studied developed symptoms such as wheezing or difficulty breathing. They generally suffered more symptoms during the visits.
"Some [dentists] feel like it’s fine to do whatever with their patients," Mathew says. Others have seen negative reactions in their patients and now are extremely careful, giving prophylactics before dental treatments.
"Their comfort levels are very different," she says. "Some are comfortable with asthma, and others are paranoid."
One area Mathew recommends studying further is using a dose of B-2-agonist inhaler before dental appointments to prevent a possible decrease in lung function.
She recommends patients who use bronchodilators to bring them to their dental appointments in case of a problem. And if symptoms start, she urges providers to stop treatment immediately.
Dental treatment "is never so vital or urgent that their health should be compromised," Mathew says.
And if patients are experiencing symptoms before their visits, the appointments probably should be rescheduled.
Robert Beall, DMD, a pediatric dentist in private practice in Charleston, SC, treats many young patients with asthma. He routinely takes careful histories from parents, inquiring about how often children have experienced attacks and when the last ones occurred. If patients suffer from more severe asthma, Beall talks to their pediatricians and even specialists who have treated the children.
Beall will treat asthmatics "if they’re pretty well controlled, not having any difficulties, and are feeling OK with their current medications." If patients are not in control of their disease, they should see their physicians before they see their dentists.
"If they come in and they’re not having problems, they’re usually fine," he says.
Beall also supplements patients with oxygen, sometimes using scented, brightly colored balloons that attach to the nose to deliver oxygen or nitrous oxide.
On the other hand, some dentists treat asthma patients much like other patients. "There’s not really anything in the standard of care," says Matthew Healey, DMD, who’s in private practice in Greenville, SC, and whose patient base is about 20% children.
He can’t recall any patients who have suffered significant asthma-related problems. Therefore, he doesn’t do anything different when treating his patients with asthma, although he says he would recommend taking preventative medications ahead of time if a severe asthmatic came to him for care.
"There is a significant amount of aerosol during almost any dental procedure," Healey says, adding that’s especially true during drilling procedures.
The bottom line, Mathew adds, is that practitioners need to be aware of their patients with asthma and keep in mind that problems could arise. "By the same token, we would like more answers," she says.
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