Respiratory Diseases in Children-Oral Findings and Dentist Approaches

Intraoral Findings of OSA

Dental caries, dental erosions and periodontal diseases are seen due to xerostomy in children with OSA (Figure 1) [3]. Periodontal diseases may develop especially in patients with OSA due to nasopharyngeal obstruction due to adenoid and tonsillar hypertrophy. Periodontal problems may occur as a result of snoring and mouth breathing in children with neuromuscular insufficiency without adenotonsillar hypertrophy. Bacteria that can be isolated from dental plaque (such as pseudomonas aeruginosa, staphylococcus aureus) have been reported to have a high risk of pneumonia in patients hospitalized in the intensive care unit of the hospital, and periodontitis has been reported to trigger lung infection [3, 5].

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Children with OSA usually have craniofacial anomalies [6]. Long-term exposure of children to non-invasive mechanical ventilation causes problems in facial development including maxilla [1].

Dentist Approach in Children with OSA

Correction of oral hygiene is of great importance in children with OSA and correction of oral hygiene is of paramount importance in order to prevent lung infections due to aspiration of microorganisms in the teeth [3, 5]. Orthodontic approach is important in these children in terms of craniofacial anomalies [1].

Intraoral Findings of Asthma

Mouth breathing occurs in children with asthma due to nasal obstruction. Xerostomy is observed in these patients due to both decongestant and antihistaminic use and oral respiration. In addition, these children have an increased incidence of caries, especially in permanent teeth, due to oral respiration and the use of inhalers to reduce the amount of saliva. Furthermore, increased susceptibility to increased calculus, hyperplastic gingivitis (Figure 2), dental erosion, bad breath, atypical ulceration, mucosal atrophy and opportunistic infections (candida) are also seen [3, 7, 9].

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In children with allergic rhinitis, findings such as deep palatinal arch, tongue protrusion and overbite are observed [7].

The majority (approximately 80%) of beta 2-antagonist inhalers of asthma medicines are kept in the oral cavity [10]. Inhalation powder usually contains a sugar such as lactose [11]. Inhalers reduce the amount of saliva and increase carotid bacteria and cause caries. This is exacerbated by the lack of mouth rinsing, especially after taking the medication before sleeping at night [5, 7]. In addition, acid secretion increases with the effect of asthma medications and gastroesophageal reflux in patients and the risk of developing dental erosion increases proportionally [3]. The use of long-term topical steroide-containing sprays increases the susceptibility to oral candida infections, but also leads to adrenal suppression [7].

Dentist Approach in Children with Asthma

When taking anamnesis of asthmatic children, especially the frequency of asthma attacks, drugs used during long- term or acute attacks and the time of the last acute asthma attack should be learned [12].

In children with asthma, successful dental treatment can be achieved by eliminating the increased tissue reaction to specific or non-specific stimuli. With the common approach of pediatrician and pediatric dentist, specific factors should be identified, stress should be reduced and prepared for emergency [10]. Because asthma patients are prone to allergies, dental polishing products, acrylics and similar substances should be used with caution. In the dentistry clinic, potential allergens should be evaluated and measures to reduce fear should be taken as asthma attacks due to excessive fear can be triggered [12]. During treatment, the patient is in a supine position, the position of the saliva ejector, and cotton rolls may cause an attack. Therefore, patients should be treated by sitting upright or semi-upright. Preoperative bronchodilators may be used to prevent acute symptoms during the procedure [10]. When acute asthma attack develops during the procedure; a) Dental treatment should be stopped, the patient should be seated or extended in a comfortable position. b) The airway should be kept open and inhaled beta-2 agonist spray should be given. c) Oxygen should be given by nose mask or cannula. d) If no improvement is observed and the patient is deteriorating, subcutaneous epinephrine should be administered and the patient should be referred to the hospital [12].

Patients should be advised that the mouth should be rinsed with water after each steroid inhalation.

It is very important to prevent the development of caries by correcting oral hygiene and treating allergic rhinitis [7]. Due to the high risk of caries, regular preventive treatments (fluoride treatments) should be performed [7].

Since there may be a risk of developing airway obstruction and spreading infection deeper in upper and lower respiratory diseases, treatment should be postponed until the control of asthma under general anesthesia. In these patients, general anesthesia can be performed only under special conditions and by taking detailed precautions. Narcotics cause histamine release and cause respiratory depression. When drugs that cause histamine release are used, antihistamine should be given first to prevent histamine release. When sedation is required, nitrous oxide/ oxygen sedation is recommended. Other sedatives may cause respiratory failure [12].

Intraoral Findings of Cystic Fibrosis

It has been reported that dental plaque formation and defects in tooth enamel develop due to long-term antibiotic use in children with cystic fibrosis [13]. The risk of caries development is increased in patients who do not pay attention to oral hygiene and nutrition as a high-energy but caretogenic diet is required for normal maintenance of growth and development in cystic fibrosis [3]. Frequent use of antibiotics, administration of pancreatic enzymes, and decreased salivary calcium and protein levels are other factors that predispose to caries development. Steroid use can change the oral flora and cause extrinsic tooth discoloration and candidiasis. Clogging of the nasal cavity and maxillary sinus may develop in children with cystic fibrosis after recurrent infections. This may lead to an increase in the amount of mouth opening and anterior open closure and a deep palate dome [10]. As with other mouth breathing patients, these patients have open closure and may require orthodontic treatment [7].

Dentist Approach in Children with Cystic Fibrosis

The dentist should avoid exacerbating the underlying disease in patients with cystic fibrosis. It should be noted that gases with high viscosity, such as nitrous oxide/oxygen, may dehydrate respiratory fluids and cause further blockage and infection. Rubber-dam can be used to reduce possible aspiration of air droplets from dental hand pieces [10].

Dentist Approach in Children with Tuberculosis

Since the presence of tuberculosis lesions in the mouth is important in tuberculosis patients, it should be investigated whether the patient is in active tuberculosis period or not. Patients with active symptoms (fever, weakness, night sweats, weight loss, sputum) should have a delayed dental procedure until the sputum culture is (-) because patients with tuberculosis lesions in the mouth have high infectiousness. Because the bacillus in the sputum can easily settle into traumatic lesions of the oral mucosa and tongue, traumatic conditions such as rotten teeth or incompatible dentures should be treated. As dentists are at risk for tuberculosis contagiousness, masks, gloves and strong aspirators should be used. Sterilization of instruments used in patient’s needs to be very careful and instruments that cannot be sterilized should be sterilized with formaldehyde or ethylene oxide gases. Since suppurative periodontal lesions may cause bacteremia even with chewing or tooth brushing, they should be treated as they may exacerbate the picture of tuberculosis [7].

Intraoral Findings of Bronchopulmonary Dysplasia

Hohoff, et al. 20 reported that the development of palate in preterm infants was affected by intubation, feeding type, diet, nasogastric feeding tube, tube characteristics, head structure and birth weight in premature and low birth weight babies. Long-term oral intubation is known to produce asymmetries with changes in the palate structure. In long- term follow-up of neonates in intensive care units, anomalies of the head bones are observed. Nasal oxygen administration or nasogastric tube feeding leads to nasal obstruction and mouth breathing, but it causes OSA due to deepening of palate dome and enlargement of adenoid structure. In infants with low body weight, it is reported that the base of the head is short and the maxilla is smaller, as well as the retrognatic face structure [3, 20, 21].