The document discusses various respiratory disorders and their dental management considerations. It provides information on common respiratory conditions like sinusitis, nasal polyps, obstructive sleep apnea, allergic rhinitis, tonsillitis, pharyngitis, laryngitis, influenza, post nasal drip syndrome, chronic obstructive pulmonary disease, bronchitis, asthma, emphysema and pneumonia. It outlines the symptoms, causes, diagnosis and treatment for these conditions. It emphasizes the importance of thorough medical history taking and providing treatment with precautions based on a patient's respiratory condition.

1. Dr. Ishaan Adhaulia
Bharti Vidyapeeth Dental College & Hospital, Pune

2. Medical decision-making requires a thorough
understanding of the manifestations of the disease,
acquisition and organization of the relevant data.
It is an orderly and logical interpretative process. Data
acquisition develops from a complex interaction
between patient and physician known as the clinical
interview.

3. The first important piece of information obtained
is the chief complaint. This statement reveals the
patient’s reason for seeking medical attention.
physician focuses on this point while acquiring facts
extracted from the history of present illness. The
history of present illness affords the physician the
opportunity to methodically examine the chief
complaint.
Examination of such issues as the onset,
duration and course of the symptoms, successful or
unsuccessful intervention, exacerbating or ameliorating
factors and prior hospitalizations must be
explored exhaustively.

4. Only with the help of collective effort of ascertaining
symptoms and signs, of course, through thorough clinical
examination with respect to each and every system in the
body can help in correlation and arrive at a point to
deduce very relevant kind of differential diagnosis for the
concerned respiratory disorders

5. Age respirations per minute
Newborn = 30-60
 1 year old = 18-30
16 year old = 16-20
Adult = 12-20

6. Symptoms
Cough and expectoration
Haemoptysis
Pain in chest
Dysphagia
Hoarseness of voice.
Present History
Detailed history of present illness.
Past History
Measles, whooping cough during childhood, diabetes, TB, HT,
pneumonia, chest injury, epilepsy, pregnancy and exposure to
STD and HIV.
Family History
Allergy (e.g. hay fever, asthma), TB, etc.
Personal History
Habits, e.g. smoking, alcoholism.

8.  Barrel shaped chest (increased antero-posterior diameter
due to hyperinflation)
 Pigeon-shaped chest due to hyperinflation in early childhood
 Flattening of the upper anterior chest is a consequence of
fibrosis of the underlying lung
 Distended veins over the chest such as jugular may indicate
superior vena cava obstruction, portal hypertension and air
hunger .

10. The most generalized classification
includes two types of respiratory disorders
:-
Upper respiratory tract disorders
Lower respiratory tract disorders

11.  Obstructive respiratory disorders (e.g., emphysema,
bronchitis, asthma attacks)
 Granulomatous respiratory disorders (e.g., fibrosis,
sarcoidosis, alveolar damage, tuberculosis)
 Vascular respiratory disorders (e.g., pulmonary edema,
pulmonary embolism, pulmonary hypertension)
 Infectious, environmental and other respiratory
disorders (e.g., pneumonia, asbestosis, particulate
pollutants, COVID)

12. Occupational and Environmental Lung
Disorders
Interstitial and Inflammatory Lung
Disorders
Sleep Disorder concerning the respiratory
system

13. Common cold – Acute / Chronic Cough
Nasal Polyps
Sinusitis
Obstructive Sleep Apnea (OSA)
Hay Fever (Seasonal Allergic Rhinitis)
Tonsillitis, Pharyngitis, Laryngitis
Influenza
Post Nasal Drip Syndrome (PNDS)

14.  Persistence of cold symptoms for 7 to 10 days is the
most consistent clinical feature of acute sinusitis. Viral
infections of upper respiratory tract are the most
important precursors of sinusitis. Such infections
produce increased amounts of mucus and cause
mucosal edema and block sinus ostium
 Symptoms of acute sinusitis include purulent nasal secretion
or postnasal drip. Sinus pain which is frequently worse when
patient bends over or is supine. Fever may be present in acute
bacterial sinusitis.
 Since the sinus cavities are near the upper molars, this
pressure can make your teeth sore.
 Dental management : Nasal decongestants with
Xylometazoline, placing warm damp towel around your nose
cheeks and eyes

15.  Acute cough usually begins suddenly and is most
commonly short-lived. It is most often due to upper
respiratory tract viral infections, particularly the
common cold, acute tracheobronchitis or pneumonitis
or bacterial infections like acute bacterial sinusitis, and
Bronchopneumonia.
 Cough is secondary to stimulation of receptors in
the nasal, pharyngeal, and laryngeal mucosa, due to
secretions from the nose and sinuses draining into the
throat.

16. A cough persisting for > 3 weeks is chronic cough.
Common causes of chronic cough
 Postnasal drip syndrome (PNDS)
 Gastro-esophageal reflux disease (GERD)
 Asthma
 Chronic bronchitis
 Medication related (ACE-inhibitor, beta-blockers)
 Pulmonary eosinophilia
Less Common Causes of Chronic Cough
 CHF
 Bronchogenic Carcinoma
 Bronchiectasis
 TB and other Chronic infections (i.e. fungal infection)
 Dental management : Antihistamines, corticosteroids and
decongestants. They are seldom accompanied by Antibiotics and Proton
Pump Inhibitors

17.  The air filled cavities (sinuses) provide a reduced weight to
the skull and contributes to nasal tone of the voice
 Para-nasal sinuses drain into the nasal cavity. These
cavities are named by the skull bone in which they are
found: frontal, ethmoid, maxillary and sphenoid
 In sinusitis, there is inflammation of the mucous mem that
lines the cavity. It can be diagnosed by radiographic tech.
like Water’s view & OPG’s which show cloudy antrum, fluid
level & often polyps.
 Stomp positive sign is when teeth hurt while patient is
descending stair’s, jumps or runs

18.  Viruses, allergens, bacteria cause sinusitis
 Environmental Conditions
- barometric pressure, airplane flight, swimming or diving activities, and
perhaps stale or contaminated indoor air
- tooth extraction or prior dentoalveolar procedures (Odontogenic
Sinusistis), abscesses, and allergens. Sinusitis, and infection of the
sinuses, can be caused by nasal congestion blocking sinus drainage
 Chronic sinus infections causes a pt. to breathe from the mouth leading
to dry mouth and is susceptible to gigivitis.
 Important clinical sign is sensitivity to percussion of group of maxillary
teeth without any obvious periodontal or pulp pathology
 Dental Management : most cases of Acute sinusitis resolve on its own
without t/t
 Chronic Sinusitis requires medical intervention with provision of
Antibiotics, Corticosteroid Sprays
 Patient should be informed of the complication and advised to avoid
vigorous mouth rinsing and blowing of nose for 10 days, minimum.
 Severe cases of sinusitis require surgical intervention with procedures
like Functional Endoscopic Sinus Surgery or Septoplasty

19.  Nasal polyps are noncancerous growths within the
nose or sinus passageway. The exact cause of
these growths is unknown.
 There are mainly two kinds of Nasal polyps –
Ethmoidal NP and Antrochoanal NP, arising from
Ethmoidal & Maxillary Sinuses respectively.
 Certain chemicals found within these polyps
suggest that they may be instrumental in causing
the extra tissue formations
 Large polyps cause nasal drainage, interfere with
olfactory senses, and, on rare occasions may be
linked to obstructive sleep apnea (OSA)
 Dental Management : Dentists should look for
Nasal Polyps on routine Radiographic
examinations like on an OPG, if they find such
polyps, dentists should refer the patients to a
concerned Otolaryngologist who might prescribe
Oral or Intranasal Corticosteroid sprays for long
term use.

20.  The most common sleep disorder
 The apnea is noted by cessation of
breathing during the night due to a non
foreign obstruction like an inhaled object,
but caused by enlarged parts.
 Usually occurs in middle age, and in
overweight males
 Individuals awake tired, without energy, and
feel lethargic most of the day while
functioning at low capacity
 Four or five episodes per hour is severe;
some people experience 100-500 apneas in
a single night

21.  Obstructive apnea causes heavy, long, and loud
snoring and snorting
 During this interruption, decreased blood flow to
the brain has occurred
 With upper airways blocked, lungs do not fill
properly, which creates a pressure in the chest
that compresses the heart, and therefore reduces
blood flow
 Diagnosis is made by investigations such as
Polysomnography, Limited Channel Testing, Split
Night Testing and Oximetry.
 Dental management : First modality being
Behavior Management, followed by insertion of
Oral Devices suited to the patient, Continuous
Positive Airway Pressure (CPAP) and lastly
Surgical options for patients with moderate to
severe OSA.
Mandibular Advancement
Device (MAD)

22.  Also called seasonal allergic rhinitis, it is
characterized by sensitivity to airborne
allergens, especially from pollens of ragweed
and grasses
 Respiratory mucosa secrete excessive mucus
causing a runny nose and congestion
 Mucosal surfaces of the eyes also react to the
allergens causing redness, watery secretions,
and itching
 The release of histamine causes these
unpleasant effects
 Dental management : Nasal Corticosteroids,
Antihistamines, Decongestants, Cromolyn
Sodium, Leukotriene Modifiers, Nasal
Ipratropium and Oral Corticosteroids

23.  A peritonsillar abscess (quinsy) may follow
untreated streptococcal pharyngitis.
Patients have severe sore throat and
speak with a ‘hot potato’ voice. Immediate
aspiration by an ENT surgeon is required
along with
antibiotic therapy.
 These upper respiratory airway structures
can become infected with bacteria,
viruses, or other pathogens
 Infections of these tissues lead to
dysphagia, redness and pain in the throat

24.  An inflammation of the pharynx
characterized by pain in the throat. Foreign
objects, hot liquids, or spicy foods may
contribute to short term pharyngitis
 Just breathing through the mouth, due to
stuffiness, or falling asleep with an open
mouth may cause a brief discomfort caused
by excessive drying and exposure
 Strep throat, a pharyngitis caused by
streptococci, is common, resulting in a red,
purulent throat
 Dental management : Rest, Ibuprofen for
throat pain, Hydration Therapy to prevent
dehydration and Warm salt water gargling 3-
4 times a day along with Povidone-Iodine
Mouthwash.

25.  An inflammation of the larynx or
“voice box”, is characterized by
hoarseness and aphonia
 A “lost voice” may be caused by
bacteria or viruses or perhaps
fungi, but it can also stem from
allergies, overuse of the voice
 Dental Management : Acute
laryngitis resolves on its own, in
Chronic Laryngitis t/t is aimed at
underlying condition such as
heartburn or smoking. Medications
like Throat Lozenges, Antacids,
NSAID’s and Proton pump
inhibitors

26.  A viral infection of the upper respiratory system, occurs usually
in epidemics, most commonly spread in households and
institutions
 The onset of the disease is sudden. The individual experiences
chills and a fever, cough, sore throat, and runny nose. Chest
pains, muscular aching, and gastrointestinal disorders may also
be the symptoms
 The virus can destroy the respiratory epithelium, a strong line of
defense against bacterial invasion
 With loss of the protective epithelium, bacterial infection can
invade any part of the respiratory tract. Pneumococci,
streptococci, and staphylococci are all capable of causing
pneumonia in patients with severe influenza.
 Most sporadic cases are identifiable only as
viral respiratory infections unless the virus is isolated
or demonstrated by fluorescent antibody technique

27.  Dental Health Care Professionals (DHCP) – dentists should
receive influenza vaccines every year. They should wear
personal protective equipment (PPE) while treating any
suspected or confirmed cases. Care should be taken during
donning and doffing of the PPE. Proper hygiene should be
maintained by the use of alcohol based hand sanitizers,
overnight UV sterilization of instruments & equipments and
routine fumigation with 0.5% Sodium Hypochlorite.
 Patient Management – patients should be priorly called over
phone and asked for their history in influenza vaccination, any
present symptoms like fever, sore throat, persistent
headaches and lethargy. Such patients which confirm the
symptoms should be appropriately handled with
precautionary measures in the dental scenario.

28.  Patients with PNDS present with cough, a sensation of something dripping into the
throat, a need to clear the throat, a tickle in the throat, nasal congestion and nasal
discharge
 Often there is a history of an upper respiratory illness (a cold). There may also be
the presence of a wheeze. On physical examination they are found to have
drainage in the posterior pharynx.
 Treatment with an older generation of antihistamine/decongestant combination has
been shown to be effective
 If PNDS is due to allergic rhinitis, then nasal steroids and or cromolyn sodium are
usually the initial drug of choice. Antihistamines can also be used.
 Dental Management : Over-the-counter decongestants like pseudoephedrine can
help reduce congestion and eliminate PNDS. Newer, non-drowsy antihistamines
like loratadine-pseudoephedrine can work to get rid of (PNDS)

29. Chronic Obstructive Pulmonary Disease
Bronchitis
Asthma
Emphysema
Pneumonia
Pulmonary
Tuberculosis

30.  Chronic Obstructive Pulmonary Disorder (COPD), includes a number of
conditions in which the exchange of respiratory gasses is ineffective
 It starts as chronic bronchitis, the symptoms of which are slowly progressive
over years.
 There may be a long smoking history, there is history of efforts in tolerance.
 The changes in the lung is in the form of emphysema which are largely
irreversible.
 Apart from cigarette smoke, viral, anti-protease deficiency, air pollution has
been found to be very important cause
 Dental Management : The drug regime used in the treatment of patients
with COPD can have profound implications for clinical dental practice,
manifested as dry mouth or oral candidiasis. Drugs include Bronchodilators
and Steroids. Affected patients are treated sitting upright in the dental chair
as they may find it difficult to breathe when lying in the horizontal position

31.  The most important concern for the dentist is to preserve
the patient’s respiratory capacity during treatment
 A more upright chair position
 Refrain from CNS depressing drugs i.e, narcotics and
barbiturates
 Refrain from xerostomic medications i.e anticholinergic &
antihistamines will dry the respiratory mucosa
 Use rubber dam with caution
 N2O and other anesthetic gasses should be
contraindicated
 Supplemental corticosteroids should be considered.

32.  Inflammation of the bronchi,
which may be acute or
chronic
 The mucous membrane
lining the bronchi becomes
swollen and red, the typical
inflammatory response.
Irritants such as industrial
fumes, automobile exhaust,
viruses, or bacteria can
cause acute bronchitis

33.  Most serious in small children, the chronically ill, and
the elderly
 Tiny bronchioles of children can easily become
obstructed. The elderly or chronically ill are likely to
develop a secondary infection, such as pneumonia
 Acute bronchitis is characterized by chest pains,
dyspnea, cough, fever, and sometimes chills
 The sputum coughed up may contain pus
 Dental Treatment : most acute bronchitis gets treated
on its own symptomatically in 7-10 days

34.  Indicated by repeated attacks of acute bronchitis and chronic
coughing with sputum production, lasting for at least 3 months
for 2 consecutive years
 On physical examination the patient is a “blue bloater” (i.e.;
exhibits peripheral edema, obesity and central cyanosis)
 The cough is caused by chronic airway inflammation due to
contact with irritants (commonly smoke)
 This inflammation results in an overproduction of mucus and
prevents cilia from doing their job of clearing mucus from the
airway
 Dental Management : Best treatment is smoking cessation
(works in 94-100% of patients), t/t of bacterial bronchitis
includes antibiotics like amoxicillin and second gen.
cephalosporins. bronchodilators are also prescribed mostly in
the form of inhalors or pills.

35.  Characterized by hypersensitivity to
various allergens like dust, mold,
pollen, animal dander and various
foods.
 80% children affected, 50% adults
effected
 The allergens trigger constriction of
smooth muscles in the walls of the
bronchi, narrowing the lumen of the
tubes.
 Mucous mem. becomes swollen
with fluid, also narrowing the lumen.
Excessive secretion of mucus adds
to the obstruction.
A tense situation or
an emotional
experience can
trigger an attack

36.  Unfortunately there is no permanent cure for asthma
yet.
 In a dental scenario during attack – Suspend the
dental procedure and raise the patient to a comfortable
position. Establish and keep the airways free, and
administer an inhalatory β2 agonist.
 Drugs used in can cause Xerostomia, oropharyngeal
candidasis and an increased prevalence of caries.
 Life style changes are recommended. Medications
include long-acting ß2 agonist (LABA’s). These
inhalers deliver low doses of steroids to the lungs with
minimal side effects if used properly.

37. Methylxanthines
• Theophylline
• Oxytriphylline (choledyl)
• Aminophylline
Mast Cell Stabilizers
• Cromolyn Sodium (Intal)
Corticosteroids
• Prednisone
• Beclomethasone
• Dipropionate (beclovent)
• Flunisolide (aerobid)
Anticholinergics
• Ipratropium bromide (Atrovent)

38.  A crippling & debilitating disease with chronic lung obstruction and
destruction
 The word emphysema means inflation. The lungs become filled
with air that is high in CO2 . This air cannot be adequately exhaled to
allow oxygen to enter.
 Person experiences a suffocating feeling & great distress from
inability to breathe. Severe pain accompanies the difficult
breathing.
 Etiology is unknown but is frequently associated with heavy
cigarette smoking
 Dental Management : Patients offered a professional and
reassuring environment with short, focused dental treatments early
in the day, placing a patient in a reclined position or the use of
rubber dam can contribute to a severe respiratory compromise.
Low-flow supplemental oxygen administration via nasal canula
at rates of 2 to 4 L/minute is appropriate even in patients with
severe disease. Theophylline is useful. Any kind of sedation, GA,
anticholinergics are avoided

39.  Acute inflammation of the lungs in which air spaces in
the lungs become filled with inflammatory exudates
 Oxygen exchange is impaired, causing difficulty in
breathing
 Fever, chest pain, and a productive cough accompany
this disease.
 Pneumonia can be caused by a variety of micro-
organisms, and it may affect different areas of the lungs
 Three types of pneumonia – Bacterial/Viral/Fungal
 Dental Management : associated pyrexia is controlled
by NSAID’s like ibuprofen, penicillin is effective for
empirical t/t initially, erythromycin is the antibiotic of
choice for pneumonia caused by legionella or
mycoplasma. Hydration therapy is given to loosen up
phlegm. OTC lozenges helps with cough.

40.  A chronic disease characterized by necrosis of vital
lung tissue.
 Caused by the bacterium Mycobacterium tuberculosis
 The inhaled bacteria infect the lungs and induce a
chronic inflammatory response that leads to necrosis
 The tissue in the this site becomes soft and cheese-
like
 The tissue heals with fibrosis and calcification, walling
off the bacteria for month or many years. These
lesions are called tubercles.
 Mantoux test is preferable skin test for detection of
tuberculosis

41.  TB ulcers can be painful/less painful &
they slowly increase in size
 Center of ulcer is grayish while
margins are lumpy (cobble stoned)
and undermined
 Base of ulcer can be purullent and
contains active organisms
 Cervical lymphadenopathy is common
 Biopsy or smears should be taken and
special stains for pathology should be
used for confirming the disease.

42.  For DHCP - When TB is suspected, it is advisable to
postpone all non-emergency dental treatment until the
patient has been cured or is no longer infectious
 Cold sterilization or chemical sterilization solutions are
ineffective for TB
 If emergency dental treatment proves necessary in
patients with suspected TB or active disease, the
adoption of respiratory protection measures helps
reduce the risk of exposure
The dental professional must avoid inhaling the
infectious droplets by wearing PPE or Masks
 For Patients – first line t/t options include Isoniazid,
rifampicin, ethambutol and pyrizinamide. Patients
pulmonary capacity should be evaluated before any
sedative administration. Patients on anti-TB therapy
can be safely treated after the second week of
antibiotic therapy.

43. Various Adrenal gland disorders known
• Addision’s disease
• Addisonian Crises
• Cushing’s syndrome
mineralocorticoids
glucocorticoids
androgens
adrenaline,
noradrenaline,
dopamine and
progesterone

44.  In Addison’s disease or primary
adrenal insufficiency, there is a
deficiency in the secretion of
glucocorticoid and mineralocorticoid
hormones by the adrenal cortex.
 It is associated with idiopathic,
surgical, infectious destruction, tumor
of parenchyma of the adrenal gland,
infiltration of the cortex by sarcoidosis,
tuberculosis or amyloidosis
 The oral mucosa can in turn develop
black-bluish plaques, mainly affecting
buccal mucosa but it can also be seen
on the gums, palate, tongue and lips.

45. Most of these patients are treated with corticosteroids, different
stages are observed in the patient :
 Stage 1: doses of corticosteroids do not produce adrenal
suppression
 Stage 2: The body stops producing cortisol physiologically.
This stage is therefore characterized by adrenocortical
suppression, though the administered corticoid dose is still
insufficient to cover the organic needs in the event of stress-
inducing situations.
 Stage III: the administered corticoid dose is sufficiently high to
continue suppressing the adrenal cortex but also to cover the
body needs in the event of stress.

46.  Addisonian crises or acute adrenococortical
insufficiency is a rare but serious complication in
patients with primary Addison’s disease.
 The reason for this is the sudden withdrawal of
exogenous corticoids
 It presents as a sudden failure of the adrenal
cortex function. It results in shock with nausea,
vomiting, abdominal pain and hypotension. At
worst, fever and hypothermia may be observed
and can lead to coma and death

47.  Prevention is the best management
approach for Addisonian crises
 We should interrupt dental
procedure, place the patient in
dorsal decubitus and contact with
the corresponding emergency
medical service (EMS)
 Until medical help arrives, the
patient should be administered
oxygen (5-10 liters/min)
 basic vital support should be
provided in accordance to the
patient’s condition

48.  Cushing’s syndrome (CS) also known
as Hyperadrenocorticism. It refers to
manifestations induced by chronic
exposure to excess glucocorticoids
produced by the adrenal cortex
 It most commonly arises from iatrogenic
causes (due to administration of
exogenous glucocorticoids) & a high
production of adrenocorticotropic
hormone (ACTH).
 CS is suspected in the presence of
central obesity with supraclavicular fat
accumulation, moon face, thinned skin,
acne, HT, glucose intolerance,
menstrual irregularity, osteoporosis,
pathological fractures and delayed
healing is also observed.

49.  Dental management in these patients consists in
prevention of infections, pathological fractures
during surgical treatments and complications
such as hypertension, hyperglycemia,
depression and delayed healing
 In patients on steroids we must evaluate the
need to administer additional corticosteroids.