THE UNIVERSITY OF
WESTERN
AUSTRALIA
DENT 3005:Introduction to
Pharmacology
**Respiratory Drugs**
Dr Thuy Linh Truong
thuy.truong@uwa.edu.au
Acknowledgement: Sheetal Maria Rajan
# **DENT 3005: Introduction to Pharmacology**
## **Respiratory Drugs**
Dr Thuy Linh Truong
thuy.truong@uwa.edu.au
Acknowledgement: Sheetal Maria Rajan
<img align="right" src="The_University_of_Western_Australia_logo.png" style="width: 200px; height: 100px;"/>
# Acknowledgement
# of country
The University of Western Australia acknowledges that its
campus is situated on Noongar land, and that Noongar
people remain the spiritual and cultural custodians of their
land, and continue to practise their values, languages, beliefs
and knowledge.
<img align="right" src="Abstract_Indigenous_Art.png" style="width: 300px; height: 500px;"/>
Artist: Dr **Richard Barry Walley OAM**
| | **Emphysema "Pink Puffers"** | **Chronic Bronchitis "Blue Bloaters"** |
| :--- | :--- | :--- |
| **Usual Presentation** | Shortness of breath and scant sputum production | Chronic productive cough |
| **General Appearance** | Thin, sometimes cachectic, with rosy skin tones | Often overweight, obese |
| **Adventitious Sounds** | Less common | Ronchi and Wheezes |
| **Sputum** | Scanty, Mucoid (Evaporated Milk) | Copious, Purulent (Condensed Milk) |
| **Cough** | Dyspnea before cough (less prominent) | Cough before dyspnea (more prominent) |
| **Cor Pulmonale** | Rare, except at the late stages | More prominent |
| **Radiographic Findings** | Hyper-inflated lungs | Normal sized lungs |
| | Small heart | (R) Ventricular hypertrophy |
| | Diaphragm: low & flat | Normal shaped diaphragm |
| | +/- bullae (pockets of air) | (+) Dirty lung appearance |
| **Other Findings** | (+) Barrel Chest | (+) Cyanotic |
| | (+) Use of accessory muscles of respiration | (+) Peripheral Edema |
**Learning Outcomes**
Learning objectives
1) Understand the classes and mechanisms of
common respiratory drugs
2) Recognise common respiratory conditions
treated with these drugs
3) Management of emergencies related to
respiratory conditions in the dental setting
4) Understand drugs interactions with dental
medications
5) Recognise oral and dental side effects of
respiratory drugs
6) Applied knowledge to clinical scenarios
# Introduction
**Rationale for drug therapy**
* Symptom control & relief
* Prevent exacerbation, acute asthma & death
* Improve & maintain lung function & QOL
**Airflow obstruction**
* Constriction of bronchioles
* Increased mucous production
* Increase oedema
* Problems: nasal cavity $\rightarrow$ alveoli
**Pharmacotherapy**
**Aetiology**
* Infection: viral, fungal, bacterial
* Immune: allergies, asthma
* Inflammatory: bronchitis, asthma, emphysema
**Drug therapy**
* Beta₂ agonists
* Anticholinergics
* Theophylline
* Corticosteroids
* Cromones
* Other
* Leukotriene receptor antagonist
* Monoclonal antibody against IgE
**Pathophysiology**
Obstructive airway diseases
* Restricted expiratory airflow
* Asthma
* Reversible
* Bronchospasm
* Mucous hypersecretion
* Oedema
* COPD
* A group of respiratory disease
* Chronic & recurrent obstruction
* Chronic bronchitis, emphysema
* Cystic fibrosis
* Inheritable
* Abnormal secretions
* Obstruct: AW & pancreatic ducts
**Asthma**
* A chronic condition that inflames and narrows the airways in the lungs
* Reversible airway obstruction
* Characteristics
* Narrowing/complete obstruction
* Extrinsic & intrinsic
* Two phases of an acute attack
* Can affect people of all ages
* **Symptoms**: coughing, wheezing, shortness of breath, and chest tightness
**NORMAL LUNG**
**ASTHMATIC LUNG**
Muscle relaxed
Muscle tighter
Normal lining
Swollen lining
AIRWAY
Normal amount of mucus
Excess mucus
<img width="50%" height="auto" src="https://o.aolcdn.com/images/dims?resize=2000%2C2000%2Cshrink&image_uri=https%3A%2F%2Fs.yimg.com%2Fos%2Fresizer%2Fapi%2Fresizer.jpg&client=ampersand-mags&signature=f4e56598c0d9a60e0a4f5f14e2d3e9c402e3b2c2" alt="Diagram illustrating the difference between a normal lung airway and an asthmatic lung airway."/>
# **Pathophysiology: Asthma**
| **Extrinsic (Allergic)** | **Intrinsic (Non-allergic)** |
| ------------------------ | ---------------------------- |
| - Aetiology: allergic nature | - Provoked by factors other than allergens |
| - Acute attack: early & late phase | - Triggers: |
| - Triggers: grass, pollen, dust... | &nbsp;&nbsp;&nbsp;&nbsp;- Sudden changes in weather |
| - Infections |
| - Emotional state |
| **Early Phase (10-20mins)** | **Late Phase (6-9hours)** |
| - Trigger $\rightarrow$ release chemical mediators $\rightarrow$ vasodilation $\rightarrow$ increase permeability $\rightarrow$ viscous mucous $\rightarrow$ constriction bronchioles | - Eosinophils, macrophages, T-lymphocytes, neutrophils |
| - Mast cell degranulation $\rightarrow$ Mediators released | - Inflammation |
| &nbsp;&nbsp;&nbsp;&nbsp;- Histamine | - AW hypersensitivity |
| &nbsp;&nbsp;&nbsp;&nbsp;- Prostaglandin |
| &nbsp;&nbsp;&nbsp;&nbsp;- Leukotrienes |
- Asthma attacks can be divided into two phases: **the early phase** and **the late phase**.
- These phases reflect the timing and types of inflammatory responses in the airways after exposure to an allergen or irritant.
| | Early Phase (10-20 minutes) | Late Phase (6-9 hours) |
|---|---|---|
| | IgE binds to receptors on mast cells | Activated T$_{H}$2 lymphocytes release cytokines that recruit more proinflammatory cells |
| | $\downarrow$ | $\downarrow$ |
| | Mast cells degranulate and release histamine, proteolytic enzymes, cytokines, leukotrienes, and prostaglandins | Eosinophils, Mast cells, IgE-producing B cells |
| | $\downarrow$ | $\downarrow$ |
| Symptoms: | Bronchoconstriction, vasodilation, and airway inflammation | Airway hyperresponsiveness, edema, mucus production, fibrosis, and airway remodeling |
| **Clinical presentation** | **Wheezing, Shortness of breath, Chest tightness, Coughing** | **Persistent Wheezing, Prolonged Shortness of breath, Continued Chest tightness, Ongoing Coughing** |
| **Treatment:** | **SABAs – albuterol (relax the bronchial muscles)** | **IC, LABAs, Leukotriene modifiers, in severe cases systemic corticosteroids** |
# **Chronic Obstructive Pulmonary Disease (COPD)**
**COPD**
* Airflow limitation in COPD is persistent, **progressive & not fully reversible**
* Symptoms: breathing difficulty, cough, mucus production, wheezing
* Typically caused by **long-term exposure to irritating gases- cigarette smoke**
* People with COPD- increased risk of developing heart disease, lung cancer and other conditions
* Clinical manifestations
* Emphysema
* Chronic bronchitis
<img alt="The figure shows a simplified illustration of the human respiratory system affected by COPD, specifically showing a narrowed bronchiole blocked with mucus (Chronic Bronchitis) and damaged alveoli membranes (Emphysema)." />
**BRONCHIOLES NARROWED AND BLOCKED WITH MUCUS** (Referring to Chronic Bronchitis)
**EMPHYSEMA - ALVEOLI MEMBRANES BREAK** (Referring to Emphysema)
**LUNGS**
| | **Chronic Bronchitis** | **Emphysema** |
| :--- | :--- | :--- |
| **Symptoms** | Chronic cough + phlegm | SOB, cough |
| **Cause** | Damaged bronchi | Damaged Alveoli |
**EMPHYSEMA** vs. **CHRONIC BRONCHITIS**
<img Emphysema and Chronic Bronchitis comparison visual. </img>
| | **Emphysema "Pink Puffers"** | **Chronic Bronchitis "Blue Bloaters"** |
|---|---|---|
| Usual Presentation | Shortness of breath and scant sputum production | Chronic productive cough |
| General Appearance | Thin, sometimes cachectic, with rosy skin tones | Often overweight, obese |
| Adventitious Sounds | Less common | Ronchi and Wheezes |
| Sputum | Scanty, Mucoid (Evaporated Milk) | Copious, Purulent (Condensed Milk) |
| Cough | Dyspnea before cough (less prominent) | Cough before dyspnea (more prominent) |
| Cor Pulmonale | Rare, except at the late stages | More prominent |
| Radiographic Findings | Hyper-inflated lungs | Normal sized lungs |
| | Small heart | (R) Ventricular hypertrophy |
| | Diaphragm: low & flat | Normal shaped diaphragm |
| | +/- bullae (pockets of air) | (+) Dirty lung appearance |
| Other Findings | (+) Barrel Chest | (+) Cyanotic |
| | (+) Use of accessory muscles of respiration | (+) Peripheral Edema |
**Drug Therapy**
| **ASTHMA** | **COPD** |
| :--- | :--- |
| • Short acting Beta₂ Agonist | • Short acting bronchodilators |
| • ICS | &nbsp;&nbsp;&nbsp;&nbsp;o SABA |
| • Long acting Beta₂ agonist | &nbsp;&nbsp;&nbsp;&nbsp;o SAMAs |
| &nbsp;&nbsp;&nbsp;&nbsp;o Always with ICS | • Long-acting bronchodilators |
| • Montelukast | &nbsp;&nbsp;&nbsp;&nbsp;o LABAs |
| • Omalizumab | &nbsp;&nbsp;&nbsp;&nbsp;o LAMAs |
| | • Corticosteroids |
| | &nbsp;&nbsp;&nbsp;&nbsp;o No role in monotherapy |
| | • Other |
| | &nbsp;&nbsp;&nbsp;&nbsp;o Theophylline |
# **Drug Therapy Comparison**
| **ASTHMA** | **COPD** |
| :--- | :--- |
| - Short acting Beta₂ Agonist | - Short acting bronchodilators |
| - ICS | - SABA |
| - Long acting Beta₂ agonist | - SAMAs |
| - Always with ICS | - Long-acting bronchodilators |
| - Montelukast | - LABAs |
| - Omalizumab | - LAMAs |
| | - Corticosteroids |
| | - No role in monotherapy |
| | - Other |
| | - Theophylline |
**Respiratory Medications**
| Category | Medications |
|---|---|
| **Relievers** | - SABA (Short-acting $\beta2$ agonist) - LABA (Long-acting $\beta2$ agonist with Rapid onset) |
| **Preventers** | - ICS (Inhaled Corticosteroids) - Leukotriene Modifiers - Mast Cell Stabilizers |
| **Adjuvant** | - LABA - Theophylline - Anti-immunoglobulin (IgE) – Omalizumab - Anti-interleukin-5 (IL5) - Mepolizumab - LAMA (Long-acting muscarinic antagonist) |
# **Respiratory Medications**
| Category | Medications |
| :--- | :--- |
| **Relievers** | - SABA (Short-acting $\beta2$ agonist) <br> - LABA (Long-acting $\beta2$ agonist with Rapid onset) |
| **Preventers** | - ICS (Inhaled Corticosteroids) <br> - Leukotriene Modifiers <br> - Mast Cell Stabilizers |
| **Adjuvant** | - LABA <br> - Theophylline <br> - Anti-immunoglobulin (IgE) – Omalizumab <br> - Anti-interleukin-5 (IL5) - Mepolizumab <br> - LAMA (Long-acting muscarinic antagonist) |
**Short acting Beta$_2$ Agonists – (SABAs) Relievers**
* MOA: relax bronchial smooth muscle
* Indication
* Sx relief of asthma & COPD
* Prevention of exercise induced bronchoconstriction
* ADR
* Tremor, palpitations, headache
* Serious hypokalemia in high doses
* Salbutamol (*Ventolin/asmol*)
* 100-200mcg prn
* Terbutaline (*Bricanyl*)
* 500-1500mcg prn
![]()
An image of two inhalers, a green metered-dose inhaler and a white/blue Turbuhaler
# **Drug Classes in Detail**
## **Short acting Beta₂ Agonists – (SABAs) Relievers**
- **MOA:** relax bronchial smooth muscle
- **Indication**
- Sx relief of asthma & COPD
- Prevention of exercise induced bronchoconstriction
- **ADR**
- Tremor, palpitations, headache
- Serious hypokalemia in high doses
- **Salbutamol (*Ventolin/asmol*)**
- 100-200mcg prn
- **Terbutaline (*Bricanyl*)**
- 500-1500mcg prn
**Long acting Beta$_2$ Agonists (LABAs) Relievers**
* MOA: relax bronchial smooth muscle
* Indication
* Maintenance tx of asthma in patients on inhaled/oral CS
* COPD
* ADR
* Tremor, palpitations, headache
* Serious hypokalemia in high doses
* Eformoterol (*Turbuhaler/Rapihaler*)
* Indacaterol (*capsules*)
* Salmeterol (*MDI/Accuhaler*)
***
Description of the product images: Inhalers and their packaging, including Symbicort Turbuhaler, Onbrez Breezhaler, and a Seretide diskus.
<img />
## **Long acting Beta₂ Agonists (LABAs) Relievers**
- **MOA:** relax bronchial smooth muscle
- **Indication**
- Maintenance tx of asthma in patients on inhaled/oral CS
- COPD
- **ADR**
- Tremor, palpitations, headache
- Serious hypokalemia in high doses
- **Eformoterol (*Turbuhaler/Rapihaler*)**
- **Indacaterol (*capsules*)**
- **Salmeterol (*MDI/Accuhaler*)**
***
Description of the product images: Inhalers and their packaging, including Symbicort Turbuhaler, Onbrez Breezhaler, and a Seretide diskus.
Short acting anticholinergic
(SAMAs)
- **MOA**
* Relaxes airway smooth
* Block M3 muscarinic receptor
* Rapid bronchodilation (15-30 mins)
- **Indication**
* Initial management of sx in mild COPD
* Severe acute asthma attack when SABA is inadequate
- **ADR**
* Dry mouth, throat irritation
- Ipratropium (Atrovent)
![]()
Image showing Atrovent Metered Aerosol and Atrovent 500 mcg/2ml Unit Dose Vials
## **Short acting anticholinergic (SAMAs)**
- **MOA**
- Relaxes airway smooth
- Block M3 muscarinic receptor
- Rapid bronchodilation (15-30 mins)
- **Indication**
- Initial management of sx in mild COPD
- Severe acute asthma attack when SABA is inadequate
- **ADR**
- Dry mouth, throat irritation
- **Ipratropium (Atrovent)**
**Long acting anticholinergic
(LAMAs)**
* MOA
* ∘ Relaxes airway smooth
* ∘ Block M3 muscarinic receptor
* Indication
* ∘ Treatment of COPD
* ADR
* ∘ Dry mouth, throat irritation
* Tiotropium (*Spiriva*)
* Glycopyrronium (*Seebri*)
![]()
Images of Spiriva HandiHaler and Seebri Breezhaler inhalers.
## **Long acting anticholinergic (LAMAs)**
- **MOA**
- Relaxes airway smooth
- Block M3 muscarinic receptor
- **Indication**
- Treatment of COPD
- **ADR**
- Dry mouth, throat irritation
- **Tiotropium (*Spiriva*)**
- **Glycopyrronium (*Seebri*)**
**Beta$_{2}$ agonists & anticholinergics Dental implications**
* Anticholinergics: lower saliva secretions
* Dry mouth $\rightarrow$ caries risks
* Combination w/ ICS
* Oral candidiasis
* Patient factors
* Sx control: increase inhaler use increases dental risks
* Oral hygiene: poor oral hygiene predispose to increase caries risks
# **Dental Implications of Specific Drug Classes**
## **Beta₂ agonists & anticholinergics**
- **Anticholinergics:** lower saliva secretions
- Dry mouth $\rightarrow$ caries risks
- **Combination w/ ICS**
- Oral candidiasis
- **Patient factors**
- Sx control: increase inhaler use increases dental risks
- Oral hygiene: poor oral hygiene predispose to increase caries risks
**Xanthine Bronchodilator**
* MOA
* Relax smooth muscles in AW
* Reduce AW responsiveness to histamine, adenosine, methacholine & allergens
* Indication
* Severe AW obstruction, including acute asthma
* Maintenance tx in severe asthma & COPD
* Side effects
* Nausea, vomiting, GORD, headache, anxiety, tremor, palpitations
* **Aminophylline & theophylline**
* **Not commonly used**
![]()
Two images of medications: one clear glass vial labeled "Aminophylline Injection, USP" and a box of tablets labelled "Theophylline Nuelin SR 250" next to a blister pack of the tablets.
## **Xanthine Bronchodilator**
- **MOA**
- Relax smooth muscles in AW
- Reduce AW responsiveness to histamine, adenosine, methacholine & allergens
- **Indication**
- Severe AW obstruction, including acute asthma
- Maintenance tx in severe asthma & COPD
- **Side effects**
- Nausea, vomiting, GORD, headache, anxiety, tremor, palpitations
- **Aminophylline & theophylline**
- **Not commonly used**
**PDE inhibitors
Dental
implications**
* Narrow therapeutic index
* Know signs of adverse effects
* Drug interaction(s)
* Acyclovir
* Benzodiazepine
* Beta$_{2}$ agonists
* Macrolide Abs (alternative in penicillin allergy)
* Patient factors
* Can they be placed in supine position?
## **PDE inhibitors Dental implications**
- **Narrow therapeutic index**
- Know signs of adverse effects
- **Drug interaction(s)**
- Acyclovir
- Benzodiazepine
- Beta₂ agonists
- Macrolide Abs (alternative in penicillin allergy)
- **Patient factors**
- Can they be placed in supine position?
**Inhaled Corticosteroids**
* MOA
* Reduce AW inflammation and bronchial hyper-reactivity
* Indication
* Maintenance tx of asthma and COPD
* Side effects
* Dysphonia, oropharyngeal candidiasis, facial irritation w/ nebs
* Inhalations: single agent or combination w/ Beta$_{2}$ agonist
* Oral: acute severe asthma, not for prevention
![]()
Image showing various inhaled corticosteroid products, including Pulmicort Turbuhaler, Alvesco, Flixotide Evohaler/Accuhaler, and Qvar Autohaler.
## **Inhaled Corticosteroids (ICS)**
- **MOA**
- Reduce AW inflammation and bronchial hyper-reactivity
- **Indication**
- Maintenance tx of asthma and COPD
- **Side effects**
- Dysphonia, oropharyngeal candidiasis, facial irritation w/ nebs
- **Inhalations:** single agent or combination w/ Beta₂ agonist
- **Oral:** acute severe asthma, not for prevention
# Corticosteroids
| Inhaled | Oral |
|---|---|
| • Beclomethasone | • Hydrocortisone |
| o Qvar | o Solu-cortef inj |
| • Budesonide | • Methylprednisolone |
| o Pulmicort | o Methyl-pred, solu-Medrol inj |
| • Ciclesonide | • Prednisolone |
| o Alvesco | o Solone, predmix, redipred |
| • Fluticasone | |
| o Flixotide | |
![]()
Images of various corticosteroid inhalers and oral formulations.
## **Corticosteroids**
| Inhaled | Oral |
| :--- | :--- |
| - **Beclomethasone** | - **Hydrocortisone** |
| - Qvar | - Solu-cortef inj |
| - **Budesonide** | - **Methylprednisolone** |
| - Pulmicort | - Methyl-pred, solu-Medrol inj |
| - **Ciclesonide** | - **Prednisolone** |
| - Alvesco | - Solone, predmix, redipred |
| - **Fluticasone** | |
| - Flixotide | |
**ICS in the dental setting**
* Side effects
* Oropharyngeal candidiasis
* Increased susceptibility to infection\*
* Impaired wound healing\*
* \*Prolonged oral dose
* Increase carries risks
* Pregnancy before 12 weeks linked w/ orofacial cleft
* Drug interaction
* Budesonide, fluticasone, methylprednisolone + azole: increase steroid adverse effects
* Aspirin: decrease salicylate concentration
* NSAIDs + oral steroids: increase risks GI ulceration
## **ICS in the dental setting**
- **Side effects**
- Oropharyngeal candidiasis
- Increased susceptibility to infection\*
- Impaired wound healing\*
- \*Prolonged oral dose
- Increase carries risks
- Pregnancy before 12 weeks linked w/ orofacial cleft
- **Drug interaction**
- Budesonide, fluticasone, methylprednisolone + azole: increase steroid adverse effects
- Aspirin: decrease salicylate concentration
- NSAIDs + oral steroids: increase risks GI ulceration
**Corticosteroids**
**ADRs**
* Infection
* Delayed wound healing
* Steroid rosacea
* Perioral dermatitis
* Skin atrophy
* Bruising
* Acne
* Facial flushing
* Pupura
* Depigmentation
* Telangiectasia
* Steroid induced crushing's
![]()
Images showing various skin conditions (rosacea, perioral dermatitis, purpura) linked to corticosteroid adverse drug reactions, including an illustration of facial fat deposit buildup (Cushingoid features).
## **Corticosteroids ADRs**
- Infection
- Delayed wound healing
- Steroid rosacea
- Perioral dermatitis
- Skin atrophy
- Bruising
- Acne
- Facial flushing
- Pupura
- Depigmentation
- Telangiectasia
- Steroid induced crushing's
## **Leukotriene receptor antagonist**
* MOA
* Inhibit cysteinyl leukotriene receptor
* Antagonist AW smooth muscle contraction
* Indication
* Maintenance tx of asthma
* Prevention of exercise induced bronchoconstriction
* Side effects
* Headache, nausea, vomiting, abdominal pain
* Montelukast (**singulair**)
<img src="A box of Singulair 10mg film-coated tablets (Montelukast) made by MSD." />
## **Leukotriene receptor antagonist**
- **MOA**
- Inhibit cysteinyl leukotriene receptor
- Antagonist AW smooth muscle contraction
- **Indication**
- Maintenance tx of asthma
- Prevention of exercise induced bronchoconstriction
- **Side effects**
- Headache, nausea, vomiting, abdominal pain
- **Montelukast (singulair)**
**Monoclonal antibody against**
**IgE**
* MOA
* Reduces immune's system response to allergen
* Indication
* Maintenance tx of mod-severe allergic asthma in patients tx w/ ICS and w/ raised serum IgE levels
* Side effects
* Inj site rxn, rash, bleeding
* Omalizumab
* Xolair
Description of the drug presentation: Xolair (omalizumab) Injection 150 mg/mL pre-filled syringe
## **Monoclonal antibody against IgE**
- **MOA**
- Reduces immune's system response to allergen
- **Indication**
- Maintenance tx of mod-severe allergic asthma in patients tx w/ ICS and w/ raised serum IgE levels
- **Side effects**
- Inj site rxn, rash, bleeding
- **Omalizumab**
- Xolair
Description of the drug presentation: Xolair (omalizumab) Injection 150 mg/mL pre-filled syringe
# Other
* **Benralizumab (Fasenra 30ng inj)**
* Binds to and blocks the interleukin-5 receptor
* ADR: pharyngitis
* **Dupilumab (Dupixent 200mg, 300mg inj)**
* Inhibits activity of the cytokines interleukin-4 and -13
* ADR: labial herpes simplex
* **Mepolizumab (Nucala 100mg inj)**
* Binds to interleukin-5 (IL-5), reducing the production and survival of eosinophils
* ADR: infections, nasal congestion
## **Other Monoclonal Antibodies**
- **Benralizumab (Fasenra 30ng inj)**
- Binds to and blocks the interleukin-5 receptor
- **ADR:** pharyngitis
- **Dupilumab (Dupixent 200mg, 300mg inj)**
- Inhibits activity of the cytokines interleukin-4 and -13
- **ADR:** labial herpes simplex
- **Mepolizumab (Nucala 100mg inj)**
- Binds to interleukin-5 (IL-5), reducing the production and survival of eosinophils
- **ADR:** infections, nasal congestion
**Cromones, leuk.**
**Receptor antag.**
**& monocloncal**
**anti IgE**
**in the dental**
**setting**
* **Medication factors**
* No serious drug interactions
* Adverse rxn relating to cough & throat irritation
* Omalizumab: monitor bleeding
* **Patient factor: sx control of asthma**
## **Cromones, Leukotriene Receptor Antagonists & Monoclonal Anti-IgE in the Dental Setting**
- **Medication factors**
- No serious drug interactions
- Adverse rxn relating to cough & throat irritation
- Omalizumab: monitor bleeding
- **Patient factor: sx control of asthma**
**Asthma & COPD**
**in the dental**
**setting**
* **Medications side effects**
* Dry mouth → caries risks
* GORD
* Oropharyngeal candidiasis
* Enamel defects
* Periodontal disease
* **Patient factors**
* Precipitating factors: avoidance
* Sx control
* Analgesic considerations
* **Recognize signs & symptoms of acute attack**
# **Asthma & COPD in the Dental Setting**
- **Medications side effects**
- Dry mouth → caries risks
- GORD
- Oropharyngeal candidiasis
- Enamel defects
- Periodontal disease
- **Patient factors**
- Precipitating factors: avoidance
- Sx control
- Analgesic considerations
- **Recognize signs & symptoms of acute attack**
**Dental implications**
* **Oral Health**
* Preventative care
* Mouth breathing
* Reduced salivary flow
* Increase risk dental decay
* **Patient education**
* Regular check ups
* Dietary advice
* Monitor dry mouth & tx accordingly
* Spacer device
* Rinse after ICS
# **Implications for Dentistry**
## **Oral Health**
- Preventative care
- Mouth breathing
- Reduced salivary flow
- Increase risk dental decay
## **Patient education**
- Regular check ups
- Dietary advice
- Monitor dry mouth & tx accordingly
- Spacer device
- Rinse after ICS
**Implications for Dentistry**
(Continued.)
* **Hypoxia in COPD:** impairs oral health and delays wound healing
* **Breathing difficulties:** medications and physical limitations affect oral breathing
* **Xerostomia:** reduced saliva due to anticholinergics and $\beta 2$ agonists
* **Inhaled corticosteroids:** risk of oral candidiasis
* ***Preventive care:*** rinse mouth after use, maintain regular brushing
![]()
An image showing two separate images of the human tongue and mouth. The top image shows a tongue affected by oral candidiasis, and the bottom image shows a cracked tongue consistent with severe xerostomia.
## **Implications for Dentistry (Continued)**
- **Hypoxia in COPD:** impairs oral health and delays wound healing
- **Breathing difficulties:** medications and physical limitations affect oral breathing
- **Xerostomia:** reduced saliva due to anticholinergics and $\beta 2$ agonists
- **Inhaled corticosteroids:** risk of oral candidiasis
- **Preventive care:** rinse mouth after use, maintain regular brushing
Use of Oral NSAIDs in
Uncontrolled Asthma
* Oral NSAIDs may worsen uncontrolled asthma
* Inhibit cyclooxygenase (COX) enzymes
* Leads to overproduction of cysteinyl leukotrienes (CysLT)
* Increases type 2 eosinophilic inflammation
* Results in increased bronchoconstriction and asthma exacerbation
* Management: Use inhaled corticosteroids $\pm$ long-acting $\beta_2$ agonists
![]()
An image containing boxes of Voltaren Rapid 25 and Nurofen products as well as a sign for the Australian Competition Consumer Commission
# **Use of Oral NSAIDs in Uncontrolled Asthma**
- Oral NSAIDs may worsen uncontrolled asthma
- Inhibit cyclooxygenase (COX) enzymes
- Leads to overproduction of cysteinyl leukotrienes (CysLT)
- Increases type 2 eosinophilic inflammation
- Results in increased bronchoconstriction and asthma exacerbation
- **Management:** Use inhaled corticosteroids $\pm$ long-acting $\beta_2$ agonists
**NSAID-Exacerbated**
**Respiratory Disease (NERD)**
* Moderate-to-severe asthma
* Increased risk of chronic rhinosinusitis/nasal polyps
* NSAIDs (e.g., aspirin, ibuprofen) can worsen respiratory symptoms
* **Management:**
* Inhaled corticosteroids ± long-acting β2 agonists
* Acetaminophen preferred for pain relief over NSAIDs
*Image depicting a Seretide $\text{Accuhaler}$ device and packaging*
**Seretide** Accuhaler
**50/250 mcg**
Salmeterol
Fluticasone Propionate
Powder for inhalation
$1 \text{ Accuhaler}$
$60 \text{ inhalations}$
# **NSAID-Exacerbated Respiratory Disease (NERD)**
- Moderate-to-severe asthma
- Increased risk of chronic rhinosinusitis/nasal polyps
- NSAIDs (e.g., aspirin, ibuprofen) can worsen respiratory symptoms
- **Management:**
- Inhaled corticosteroids ± long-acting β2 agonists
- Acetaminophen preferred for pain relief over NSAIDs
*Image depicting a Seretide $\text{Accuhaler}$ device and packaging*
**Seretide** Accuhaler
**50/250 mcg**
Salmeterol
Fluticasone Propionate
Powder for inhalation
$1 \text{ Accuhaler}$
$60 \text{ inhalations}$
**Signs of poor asthma control**
* Use of relivers >3x/week (not during times of illness/exercise)
* Sx of asthma on most days of the week
* Wheezing, coughing etc
* Early-morning or night-time sx at least once a week
* Frequent exacerbation of asthma at least every 6wks
* Poor level of peak expiratory flow
* Less than 80% of their best score
* Attacks may occur infrequently but are life threatening or severe
* Referral to MGP for assessment and medication review
# **Signs of poor asthma control**
- Use of relivers >3x/week (not during times of illness/exercise)
- Sx of asthma on most days of the week
- Wheezing, coughing etc
- Early-morning or night-time sx at least once a week
- Frequent exacerbation of asthma at least every 6wks
- Poor level of peak expiratory flow
- Less than 80% of their best score
- Attacks may occur infrequently but are life threatening or severe
- Referral to MGP for assessment and medication review
Community
first aid
protocol
**Rule of 4's**
* Sit the patient comfortably in an upright position
* Give 4 puffs of salbutamol
* Give each puff one at a time, with 4 breaths after
each puff
* Use a spacer if possible
* Wait 4 minutes
* If no improvement give 4 more puffs
* If still no improvement call 000 immediately
* Continue to give 4 puffs every 4 minutes until the
ambulance arrives
**Terbutaline / ICS+LABA**
* Give 2 doses initially, wait 4 minutes then give 1
more dose
* If no improvement call 000 and continue to give 1
dose every 4 minutes
# **Community first aid protocol**
## **Rule of 4's**
- Sit the patient comfortably in an upright position
- Give 4 puffs of salbutamol
- Give each puff one at a time, with 4 breaths after each puff
- Use a spacer if possible
- Wait 4 minutes
- If no improvement give 4 more puffs
- If still no improvement call 000 immediately
- Continue to give 4 puffs every 4 minutes until the ambulance arrives
## **Terbutaline / ICS+LABA**
- Give 2 doses initially, wait 4 minutes then give 1 more dose
- If no improvement call 000 and continue to give 1 dose every 4 minutes
**References**
* Ritter JM, Flower RJ, Henderson G, Loke YK, MacEwan D, Robinson E,
editors. *Rang & Dale’s pharmacology*. 10th ed. Edinburgh: Elsevier;
2023
* Australian Medicines Handbook Online [Internet]. Adelaide (AU):
Australian Medicines Handbook Pty Ltd;2000. Respiratory,
Genitourinary; [updated 2025; cited 2025]. Available from: UWA
Onesearch
* Pharmaceutical Society of Australia. Australian Pharmaceutical
Formulary and Handbook: A Guide to Best Practice. 25th ed.
Canberra: Pharmaceutical Society of Australia; 2021
* Ali K. Clinical dental pharmacology. 1st ed. Oxford: Wiley-Blackwell;
2023
* Bullock S, Manias E. *Fundamentals of pharmacology*. 8th ed. Frenchs
Forest, NSW: Pearson Australia; 2017
* MIMS Australia. *eMIMSelite: Consumer medicine information, specific*
*clinical monograph* [Internet]. Sydney: MIMS Australia; [updated 2025;
cited 2025 Apr 17]. Available from: UWA Onesearch
![]()
A selection of cartoon images related to medication and illness.
# **References**
- Ritter JM, Flower RJ, Henderson G, Loke YK, MacEwan D, Robinson E, editors. *Rang & Dale’s pharmacology*. 10th ed. Edinburgh: Elsevier; 2023
- Australian Medicines Handbook Online [Internet]. Adelaide (AU): Australian Medicines Handbook Pty Ltd;2000. Respiratory, Genitourinary; [updated 2025; cited 2025]. Available from: UWA Onesearch
- Pharmaceutical Society of Australia. Australian Pharmaceutical Formulary and Handbook: A Guide to Best Practice. 25th ed. Canberra: Pharmaceutical Society of Australia; 2021
- Ali K. Clinical dental pharmacology. 1st ed. Oxford: Wiley-Blackwell; 2023
- Bullock S, Manias E. *Fundamentals of pharmacology*. 8th ed. Frenchs Forest, NSW: Pearson Australia; 2017
- MIMS Australia. *eMIMSelite: Consumer medicine information, specific* *clinical monograph* [Internet]. Sydney: MIMS Australia; [updated 2025; cited 2025 Apr 17]. Available from: UWA Onesearch
# **Opioid cough suppressants**
* MOA
* Depress medullary cough centers
* Indication
* Symptom relief in non-productive cough
* Side effects
* Drowsiness, constipation, nausea, vomiting
* Precaution
* Asthma
* Contra-indication
* COPD
* *Codeine, dextromethorphan, dihydrocodeine, pholcodine*
# **Mucolytics**
* MOA
* Reduce mucous viscosity & aid expectoration
* Indication
* Adjunct in disease w/ excessive mucous production
* Side effects
* Nausea, bronchospasm, cough
* Not for chronic bronchitis & COPD
* *Acetylcysteine, bromhexine*
# **Opioid cough suppressants**
- **MOA**
- Depress medullary cough centers
- **Indication**
- Symptom relief in non-productive cough
- **Side effects**
- Drowsiness, constipation, nausea, vomiting
- **Precaution**
- Asthma
- **Contra-indication**
- COPD
- *Codeine, dextromethorphan, dihydrocodeine, pholcodine*
# **Mucolytics**
- **MOA**
- Reduce mucous viscosity & aid expectoration
- **Indication**
- Adjunct in disease w/ excessive mucous production
- **Side effects**
- Nausea, bronchospasm, cough
- Not for chronic bronchitis & COPD
- *Acetylcysteine, bromhexine*
**Discontinued: Cromones**
* MOA
* Inhibit release of inflammatory mediators from mast cells
* Indication
* Maintenance tx of asthma
* Prevention of exercise induced bronchoconstriction
* Side effects
* Cough, throat irritation, bitter taste, transient bronchospasms
* Cromoglycate
* Nedocromil
![]()
Intal CFC-free Inhaler and Tilade CFC-Free Inhaler
# **Discontinued: Cromones**
- **MOA**
- Inhibit release of inflammatory mediators from mast cells
- **Indication**
- Maintenance tx of asthma
- Prevention of exercise induced bronchoconstriction
- **Side effects**
- Cough, throat irritation, bitter taste, transient bronchospasms
- **Cromoglycate**
- **Nedocromil**
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