HOSPI LAB
MODULE 5A: DENTAL MANAGEMENT OF
PATIENTS
WITH ASTHMA
Asthma is a common chronic disease of the
airways that is characterized by airflow obstruction,
bronchial hyperresponsiveness, and recurrent episodes of
acute symptoms such as wheezing, coughing, chest
tightness, and shortness of breath. This is due to the
contraction of the smooth muscles in the wall of the
airways, more specific in the bronchi and the swelling
inner wall of the airway and more mucus production.
An asthma attack occurs when the symptoms
become severe. It can begin suddenly and range from
mild to life-threatening. In some cases, swelling in the
airways can prevent oxygen from reaching the lungs.
This means that oxygen cannot enter the bloodstream or
reach vital organs. Therefore, people who experience
severe symptoms need urgent medical attention.
Health professionals do not know exactly what
causes asthma, but genetic and environmental factors
both seem to play significant roles. Risk factors for
asthma can be categorized as either host factors such as
genetics, pregnancy, obesity, activity status, age, or
environmental factors like stress, infections, exposure to
tobacco smoke, air pollution, molds, dust, animal hair,
and dander.
M5A - LESSON 1 : TYPES, DIAGNOSTICS, AND
MEDICATIONS
Types of Asthma
Asthma is a multifactorial disease whose exact
etiology is not well defined. There are two main types of
asthma:
- Extrinsic (allergic)- may be precipitated
particularly by allergens like climate, foods,
drugs, environmental pollutants, and airborne
substances and is typical asthma in children.
This tends to resolve by adult life and usually
associated with family history.
- Intrinsic (nonallergic)- appears to relate to mast
cell instability and hyper-responsive airway. It is
usually seen in middle-aged adults and no
family history of asthma. It is associated with
emotional stress, exercise, excitement, and
respiratory viral infections such as cold and flu.
Typical symptoms of the disease consist of
reversible episodes of breathlessness, chest tightness,
wheezing, a cough that is worse at night, and flushing.
Onset is usually sudden. Respiration becomes difficult
and is accompanied by expiratory wheezing. Tachypnea
and prolonged expiration are characteristics. The
termination of the attack is commonly accompanied by a
productive cough with stringy mucous.
DIAGNOSTICS
The diagnosis of asthma begins with a detailed
history and physical examination. A typical history is an
individual with a family history of allergic conditions or
a personal history of allergic rhinitis who experiences
coughing, wheezing, and difficulty breathing, especially
with exercise, and viral infections.
The doctor may also carry out a lung function
test to assess how well the lungs are working. A
spirometry test is one example of a lung function test.
The person will need to breathe in deeply and then
breathe out forcefully into a tube. The tube links up to a
machine called a spirometer, which shows how much air
a person inhales and exhales and the speed at which they
expel the air from the lungs.
The doctor will then compare these results with
those of a person who is similarly aged but who does not
have asthma.
To confirm the diagnosis, the doctor may then
give the person a bronchodilator drug — to open the air
passages — and repeat the test. If these second results
are better, the person may have asthma.
A FeNO test or exhaled nitric oxide test, in
patients with allergic or eosinophilic asthma, is a way to
determine how much lung inflammation is present and
how well inhaled steroids are suppressing this
inflammation. With allergic or eosinophilic asthma,
sometimes you may feel your breathing is fine, but when
you measure your exhaled nitric oxide, it may still be
significantly elevated, and you might do better in the
long-term using slightly more of your inhaled steroid to
suppress this inflammation. Another lung function test is
a Methacholine challenge test, also known as a
bronchoprovocation test, which is performed to evaluate
how “reactive” the lungs to things in the environment.
Other tests for diagnosis include a skin test that
can be used to identify a specific allergy. Treating the
underlying allergic triggers for your asthma will help
you avoid asthma symptoms. Sputum test and chest x-
ray can be used to rule out other conditions such as
bronchitis and sinusitis.
MEDICATIONS
There are two forms of medication for asthma.
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- Controller medications are the most important
because they prevent asthma attacks. When you
use these drugs, your airways are less inflamed
and less likely to react to triggers.
- Quick-relief medications -- also called rescue
medications which relax the muscles around
your airway.
Long-Term Control Medications
Some of these drugs should be taken daily to get
your asthma under control and keep it that way. Others
are taken on an as-needed basis to reduce the severity of
an asthma attack. The most effective ones stop airway
inflammation. The doctor may suggest combining an
inhaled corticosteroid, an anti-inflammatory drug with
other drugs such as:
- Long-acting beta-agonists. A beta-agonist is a
type of drug called a bronchodilator (Links to an
external site.), which opens your airways.
- Long-acting anticholinergics. Anticholinergics
relax and enlarge the airways in the lungs,
making breathing easier (bronchodilators).
- Tiotropium bromide (Spiriva Respimat) is an
anticholinergic available for anyone ages 6 and
older. This medicine should be used in addition
to your regular maintenance medication.
- Leukotriene modifiers block chemicals that
cause inflammation.
- Mast cell stabilizers curb the release of
chemicals that cause inflammation.
- Theophylline is a bronchodilator used as an add-
on medication for symptoms that are not
responding to other medications.
- An immunomodulator is an injection given if
you have moderate to severe asthma related to
allergies or other inflammation caused by the
immune system that doesn’t respond to certain
drugs.
M5A - LESSON 2: DENTAL MANAGEMENT
The goal of the management of asthmatic
patients should be identifying the patient and prevention
of asthmatic attacks.
1. Detailed history—age of onset, the severity of
asthma, precipitating factors, medications being
taken, and a necessity for emergency care.
2. Medical consultation for severe active asthmatic
patients.
3. Elective dental care should be deferred in severe
asthmatics until they are in a better phase.
4. Provide a stress-free environment through the
establishment of rapport, since stress is
implicated as a precipitating factor.
5. Oral premedication may be accomplished with
small dose short-acting of benzodiazepine and it
is used with caution. Benzodiazepines can
precipitate respiratory failure.
6. A local anesthetic is preferred and general
anesthesia (GA) is best avoided. GA may be
complicated by hypoxia, and hypercapnia,
leading to pulmonary edema. The risk of
postoperative collapse of lung or pneumothorax
is increased.
7. If conscious sedation is used nitrous oxide-
oxygen is preferred to I/V sedation.
8. Patients with nocturnal asthma should be
scheduled for late morning appointments.
9. Operatory odorants (e.g. methyl methacrylate)
should be reduced before the patient is treated.
10. Patients are instructed to bring their usual
medication/inhaler for every appointment and
keep it available. Prophylactic inhalation of the
patient’s bronchodilator at the beginning of
appointment is a valuable method of preventing
an asthmatic attack.
11. The use of pulse oximeter is valuable for
determining the oxygen saturation of the patient.
A drop below 90% indicates poor oxygen
exchange and the need for intervention.
12. Drug considerations:
- Avoid aspirin and NSAIDS (use
acetaminophen)
- Allergy to penicillin may be more
frequent.
- Interactions of theophylline with
adrenalin, erythromycin, azithromycin,
clarithromycin, ciprofloxacin or
clindamycin may result in dangerously
high levels of theophylline and resulting
in theophylline toxicity (Theophylline
toxicity is characterized by anorexia,
nausea, nervousness, insomnia,
agitation, thirst, vomiting, headache,
cardiac arrhythmias, and convulsions.
- Avoidance of barbiturates and narcotics
(histamine release) since the asthmatic
attack may be precipitated by these
drugs.
- Avoid local anesthetic solutions
containing adrenalin or levonordefrin
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because of sulfite preservatives. Sulfites
may precipitate an asthmatic attack.
Also, adrenalin is contraindicated in
patients using theophylline as it may
precipitate dysrhythmias. (Previously it
was considered that adrenalin containing
local anesthetic may be safely used
since beta-adrenergic receptors serve to
reverse the effects of an asthmatic
attack).
- Patients who are on long term systemic
steroids require supplementation.
- When GA is used halothane, isoflurane,
or enflurane are preferred anesthetics.
MANAGEMENT OF AN ACUTE ASTHMATIC
ATTACK
1. Stop the surgical procedure and clear the airway.
2. Seat the patient upright.
3. Take two puffs on their inhaler.
4. Administration of fast-acting bronchodilator
(corticosteroids have delayed onset of action).
5. Provide positive-flow oxygenation.
6. Monitor vital signs.
7. If needed subcutaneous 0.3 to 0.5 ml of
adrenalin (1:1000) is administered.
8. Activating emergency medical system.
MODULE 5B: DENTAL MANAGEMENT OF
PATIENTS
WITH DIABETES MELLITUS
As dental professionals, the first thing we do
when the patient enters our clinic is history taking. We
ask questions like: Is the patient in pain? Does he or
she have an underlying medical condition? Prior to the
treatment plan, we have to be sure of the need of the
patient as a standard of dental care.
One of the debilitating conditions of patients
that are medically compromised is Diabetes. It is a
chronic disease that causes an increase of sugar in the
blood. It is the leading cause of cardiovascular disease,
kidney failure and even blindness. A dentist can help
identify patients with diabetes and will prevent future
problems.
DIABETES
- is a chronic disease when the pancreas is no
longer available to make insulin or when the
body cannot make good use of the insulin it
produces.
- It is a disease complex with metabolic and
vascular components.
- According to WHO, diabetes is a “Global
Pandemic”. It is a chronic, metabolic disease
characterized by elevated levels of blood
glucose (or blood sugar) which leads overtime to
serious damage to the heart, blood vessels, eyes,
kidneys and nerves.
Insulin - is a hormone made by pancreas that acts like a
key to let glucose from the food we eat passes from the
blood stream into the cells in the body to produce
energy.
- All carbohydrate foods are broken into glucose
in the blood. Insulin helps glucose into the cells.
SYMPTOMS:
- Increased hunger
- Increased thirst
- Weight loss
- Frequent urination
- Blurry vision
- Extreme fatigue
- Sores that do not heal or slow to heal
- Tiredness
- Erectile dysfunction (men)
- Poor muscle strength (men)
- Urinary Tract infections (women)
- Yeast infections (women)
- Dry, Itchy skin (women)
RISK FACTORS
Type 1 – genetics
Type 2 - increases when:
- Overweight
- Age 45 or older
- Have a parent or sibling with the condition
- Not physically active
- Have had gestational diabetes
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- Have prediabetes - Long-acting insulin starts to work a few hours

- Have high blood pressure, high cholesterol, or after injection and lasts 24 hours or longer.
high triglycerides
- Have African American, Hispanic or Latino Type 2 diabetes
American, Alaska Native, Pacific Islander, - Diet
American Indian, or Asian American ancestry - Exercise
- Medication
Gestational Diabetes - increases when: Types of How they work Example(s)
- Overweight drug
- Over age 25 Alpha- Slow your body’s Acarbose (Precose)
- Had gestational diabetes during a past pregnancy glucosidase breakdown of and miglitol
- Have given birth to a baby weighing more than 9 inhibitors sugars and (Glyset)
pounds starchy foods
- Have a family history of type 2 diabetes Biguanides Reduce the Metformin
amount of (Glucophage)
- Have polycystic ovary syndrome (PCOS)
glucoseyour liver
makes
Complications:
DPP-4 Improve your Linagliptin
- Heart disease, Heart attack, and stroke inhibitors blood sugar (Tradjenta),
- Neuropathy without making it saxagliptin
- Retinopathy and vision loss drop too low (Onglyza), and
- Hearing Loss sitagliptin (Januvia)
- Infections and sores that don’t heal Glucagon- Change the way Dulaglutide
- Skin conditions such as bacterial and fungal like your body (Trulicity),
infections peptides produces insulin exenatide (Byetta),
- Depression and liraglutide
- Dementia (Victoza)
*Uncontrolled Gestational diabetes can lead to problems Meglitinide Stimulate your Nateglinide
that affect both the mother and baby. s pancreas to (Starlix) and
Complications affecting the Baby: release more repaglinide
insulin (Prandin)
- Premature Birth
SGLT2 Release more Canagliflozin
- Higher than normal birth weight
inhibitors glucose into the (Invokana) and
- Increased risk for type 2 diabetes later in life urine dapagliflozin
- Low blood sugar (Farxiga)
- Jaundice Sulfonylur Stimulate your Glyburide
- Stillbirth eas pancreas to (DiaBeta, Glynase),
Complications Affecting the Mother: release more glipizide(Glucotrol)
- High blood pressure (preeclampsia) insulin , and glimepiride
- Type 2 diabetes (Amaryl)
- May require a caesarian delivery Thiazolidin Help insulin Pioglitazone
- Increased risk of gestational diabetes in future ediones work better (Actos) and
pregnancies rosiglitazone
(Avandia)
TREATMENT ** You may need to take more than one of these drugs.
Type 1 diabetes - INSULIN Some people with type 2 diabetes also take insulin.
Four types of insulin most commonly used.
- Rapid-acting insulin starts to work within 15 Gestational Diabetes
minutes and its effects last for 3 to 4 hours. Monitor blood sugar levels several times a day
- Short-acting insulin starts to work within 30 during pregnancy. If it’s high, dietary changes and
minutes and lasts 6 to 8 hours. exercise may or may not be enough to bring it down.
- Intermediate-acting insulin starts to work within
1 to 2 hours and lasts 12 to 18 hours. According to the Mayo Clinic, about 10 to 20
percent of women with gestational diabetes will need
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insulin to lower their blood sugar. Insulin is safe for the
growing baby.
Diet - Eating the right types of foods can both
control your blood sugar and help you lose any excess
weight.
Emphasize healthy foods such as:
- Fruits
- Vegetables
- Whole grains
- Lean protein such as poultry and fish
- Healthy fats like olive oil and nut
- Attention must be paid to the patients fluid and
electrolyte balance and dietary needs.
- Adrenalin antagonizes the effects of insulin. So,
theoretically it might be best to avoid using
adrenalin containing local anesthetic solutions.
However, in clinical practice this precaution
may be unnecessary considering the minute dose
used.

DENTAL MANAGEMENT:
- In Non insulin-dependent patient: All
procedures can be performed without special
precautions, UNLESS, complications are
present.
- Avoid extractions or surgical procedures in
uncontrolled or poorly controlled diabetes since
wound healing is significantly delayed and the
risk of post operative infections is high.
- Ensure that the dental procedure does not
interfere with the patient’s dietary intake and
thethe patient takes their regular dose of insulin
or hypoglycemic medication to avoid shock.
- Morning appointments are usually best.
- When the planned surgery is likely to be
associated with swelling and trismus, the patient
should be advised to take a semisolid and liquid
diet.
- If the surgery is expected to significantly hinder
food intake, then the patient is best managed in a
hospital environment.
- Be prepared for hypoglycemic attack at all
times. Have glucose readily available.
- Antibiotic prophylaxis can be considered for
patients with brittle diabetes (i.e. difficult to
control, requires high dose of insulin) and who
also have chronic states of oral infection.
- When acute oral infection is present, patients
receiving insulin usually require additional
insulin which should be prescribed by their
physician.
- Noninsulin- controlled patients may need more
aggressive medical management of their
diabetes, which may include insulin during this
period.
- Oral infection must be treated with incision and
drainage, antibiotic and extraction.
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MODULE 5C: DENTAL MANAGEMENT OF
PATIENTS
WITH HEPATITIS
Hepatitis, or inflammation of the liver, can be caused
by several very different viruses. Symptoms of hepatitis are
universal, regardless if caused by an infectious agent or
chronic condition, and can include fatigue, anorexia,
abdominal pain, fever, diarrhea, vomiting, jaundice, dark
urine, and pale clay-colored stools. The mode of transmission,
communicability, and incubation period differ greatly with the
type of virus.
GRAPHIC ORGANIZER
Lesson 1: Importance of Liver
LIVER – Largest lobed glandular organ in the body and
is located in the upper right quadrant of the abdomen. It
is made up of 4 lobes; a large right lobe, a smaller left
lobe and small quadrate and caudate lobes. It’s the
body’s filter and warehouse. Almost all cells and tissues
in the body depend on the liver. When something goes
wrong with the liver, it can have a serious effect on
almost every other organ in the body. In addition, the
liver controls blood-clotting factors, which prevent
excessive bleeding.
FUNCTIONS:
1. Bile formation and secretion
- Emulsifies fat and facilitates its
absorption
- Bile is composed of water, bile salts and
a yellow pigment called bilirubin
(breakdown product of hemoglobin)
- In patients with liver disease, bilirubin
accumulates in plasma due to decrease
liver metabolism and transport
2. Carbohydrate metabolism
- Maintains normal glucose concentration
in the blood stream through:
- Release of glucose from glycogen
- Conversion of galactose and fructose
into glucose
- Conversion of some amino acids to
glucose (through gluconeogenesis)
3. Fat metabolism
- Fatty acids are broken down for energy
if glucose is not available
- Cholesterol is formed for steroid
hormone production
- Some carbohydrates and proteins are
converted into fats
4. Protein metabolism
- Urea is formed
- Plasma proteins, including clotting
factors are manufactured. Vitamin K,
catalyses prothrombin into thrombin in
the liver
5. Removal, excretion, detoxification and
inactivation of drugs, hormones and toxins take
place in the liver
LESSON 2: WHAT IS HEPATITIS?
Hepatitis - Is a general term that means inflammation of
the liver. The Ancient Greek word hepa refers to the
liver, and itis means inflammation.
Inflammation of the liver has several possible causes,
including:
- Toxins and chemicals such as excessive amounts
of alcohol
- Autoimmune diseases that cause the immune
system to attack healthy tissues in the body
- Fat which may cause fatty liver disease
- Microorganisms, including viruses
Types of Hepatitis:
- Infectious – Viral infection of the liver due to
acute or chronic viral hepatitis (HAV, HBV,
HCV, HDV, HEV).
- Non-infectious – Due to excessive or prolonged
use of toxic substances that are metabolized in
the liver (e.g. acetaminophen, alcohol,
halothane, ketoconazole, methyldopa and
methotrexate) and sometimes due to auto
immune system response in the body.
Lesson 3: Types of Viral Hepatitis
1. Hepatitis A (RNA-Piconavirus)
- Transmission: enteric (fecal-oral route)
- Often occurs as an epidemic because the
reservoir for infection is frequently a
common food or water source
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- Incubation period: ̴25 days
- Persons of any age may be infected but
occurs primarily in children and young
adults
- Mild severity
- No carrier state
- Recovery conveys immunity against
infection
- Vaccine developed in 1995
2. Hepatitis B (DNA-Hepadnavirus)
- Transmission:
o Direct percutaneous inoculation
or transfusion of infected blood
or products
o Indirect percutaneous
introduction of infected blood
and blood products through
minute skin cuts or abrasion
o Absorption of infected blood or
blood specimen into the
mucosal surface of the mouth or
eye
o Absorption of infected
secretions like saliva and semen
into mucosal surfaces
o Transfer of infected serum or
plasma through inanimate
environmental surfaces
- Fecal transmission does not occur.
Airborne droplets not important
- Incubation period: 75 days
- Permucosal and percutaneous
inoculation of infectious saliva is
necessary for transmission of the disease
- Compared with Hepatitis A, Hepatitis B
tends to have greater associated
morbidity or mortality, especially in the
very young and older patients
3. Hepatitis C (RNA-Flaviviridae)
- Transmission: Parenteral (primarily by
blood to blood products)
- Accounts for 90-95% of all cases of
post-transfusion hepatitis infections
- Similar to HBV in behavior and
characteristics
- Unprotected sex and perinatal
transmission have not been recognized
as significant factors
- Incubation period: ̴80 days
4. Hepatitis D (defective RNA virus)
- Uses the Hepatitis B surface antigen
(HBsAg) for its viral envelope
- Occurs as a co-infection in patients with
acute Hepatitis B and as a super-
infection in Hepatitis B virus carriers
- Transmitted parenterally by infected
blood or blood products
- Frequently associated with more severe
fulminant infections than infection with
Hepatitis B alone (Hepatitis B/D >
Hepatitis B)
- Incubation period: ̴35 days
5. Hepatitis E (non-developed RNA virus)
- Enterically transmitted Hepatitis Non-A-
Non-B (NANB) virus
- Perinatal transmission possible. 20%
fatality rate in pregnant women in their
third trimester
- Incubation period: ̴40 days
CLINICAL SIGNS AND SYMPTOMS:
- Appearances of types A, B, C, D and E hepatitis
are similar
- Characterized by degeneration & necrosis of
liver cells: entire liver lobule is inflamed
Presents in three phases:
1. 1st phase – Prodromal phase [pre-icteric]
- Resembles flu-like symptoms (anorexia,
nausea, vomiting, fatigue, myalgia,
malaise, fever). May also demonstrate
arthralgia, rash and angioedema.
- Symptoms present 1-2 weeks before the
onset of jaundice
2. 2nd phase – Icteric phase
- Clinical jaundice (yellowish brown hue
of the eyes, skin, oral mucosa and urine)
- Some prodromal symptoms may subside
but gastrointestinal symptoms increases
- 2-8 weeks
- (+) hepato- and splenomegaly
3. 3rd phase – Convalescent/Recovery phase [post-
icteric]
- Symptoms disappear but abnormal liver
function and hepatomegaly may persist
- Recovery period usually completed ̴4
months after onset of jaundice. Hepa B
and C have longer recovery periods