Review Article

Dental management
of children with asthma
Jian-Fu Zhu, DDS, MS HumbertoA. Hidalgo, MD, MS W. Corbett Holmgreen, DDS, MD
Spencer W. Redding, DDS, MEdJan Hu, BDS, PhDRobert J. Henry, DDS, MS

Abstract
Asthmaaffects aboutI in 10 children. The condition is
characterizedby acute respiratory distress broughton by
environmentalfactors. The condition is treated with medications aimedto reducereaction to stimulants by the airway. Dental management
involves attention to the status
of the patient and awarenessof stimulants of the reactive
airway. Clinical recommendations
are provided. (Pediatr
Dent 18:363-70, 1996)
sthmais a chronic airway disease characterized
by inflammation and bronchoconstriction.
Both genetic and environmentalfactors are responsible for this disease, which affects approximately
5-10%of children. I, 2 Althoughthe pathophysiology is
well understood, morbidity and mortality rates are increasing? Asthmais the leading cause of pediatric hospitalization and accounts for nearly 1%of all U.S. medical expense. 4 The prevalence of childhood asthma
necessitates that dental practitioners be familiar with
this disease. This paper will review the pathophysiology and medical management of asthma in children
and discuss some of the oral problems and behavioral
changes associated with this disease.

Clinical manifestations and

pathophysiology of asthma
The typical symptoms of asthma are coughing,
wheezing, chest tightness, and dyspnea. More severe
bronchial obstruction results in labored breathing, tachypnea, tachycardia, pulsus paradoxus (a decline of
10 mmHg or more in blood pressure during inspiration comparedto expiration), and diaphoresis (profuse
perspiration). 5 Asthma seems to be a heterogeneous
disease, particularly in early childhood.6 About75%of
asthma in early childhood is mild, with minimal or no
daily symptoms, and short-lived exacerbations often
secondaryto viral respiratory tract infections. 7 Wheezing in the first 3 years of life is generally self-limiting
with 60%of these children being symptom-free by age
86 years.
Pediatric
Dentistry- 18:5,1996

The National Heart, Lung, and Blood Institute

(NHLBI)of the National Institutes of Health has recently released an advisory on asthma that categorizes
asthma as mild, moderate, or severe, based in part on
the frequency and severity of daytime symptoms, exercise tolerance, and night-time symptoms.9 Children
with mild asthma experience wheezing fewer than 2
days per week, lack nocturnal symptoms, and have
relatively good exercise tolerance. Those with moderate asthma have wheezing 2-5 days per week with
nocturnal symptomsand limited exercise tolerance.
Patients with severe asthma have daily wheezing, exercise intolerance, and frequent nocturnal symptoms.
Bronchial inflammation is a major factor in the
pathophysiology of childhood asthma. Inflammation
potentiates the bronchial hyper-responsiveness to various triggering agents that is characteristic of asthma.
The cellular inflammatory response has been shownto
include infiltration of eosinophils, mast cells, and lymphocytes (mainly CD4+T lymphocytes), together with
respiratory epithelial cell damageand subepithelial
thickening. I Patients with acute severe asthma have
significant increases of three surface proteins associated
with T lymphocyte activation: interleukin 2 receptor
(IL-2R, CD25); class II histocompatibility antigen (HLADR); and "very late activation" antigen. 1~ Lymphocytes
and other inflammatory cells are a major source of
cytokines, such as interleukins-3 (IL-3), IL-4 and IL-5,
and granulocyte-macrophage
colony stimulating
factor (GM-CSF).~2 Several mediators including
histamine, cysteinyl leukotrienes, kinins, and eosinophil breakdownproducts, such as eosinophil cationic
protein (ECP), also can be found in the asthmatic airway.I3 These mediators have potent inflammatory and
smooth muscle-constricting properties, which exacer14
bate the disease.
Precipitating factors
The most commoncauses of asthma exacerbations
are allergen exposures (e.g., pollens, mold spores,
house dust, and insect and animal emanations), viral
American
Academy
of PediatricDentistry363

or mycoplasmalrespiratory tract infections, exposures

to nonspecific airway irritants (such as cigarette
smoke), and tapering of anti-inflammatory medications
either by design or noncompliance.Exercise, especially
in cold weather, triggers symptomsin approximately
80%of children with asthma.15 Cigarette smoke is a
nonspecific airway irritant that can increase the frequency and severity of respiratory symptomsin children with asthma. More severe asthma, diminished
lung function, and increased episodes of respiratory
infections are seen often in children whose parents
smoke.16 Emotional and psychological stress also may
trigger asthmatic attacks. Aspirin and beta adrenergic
blockers have been shown to trigger bronchospasmby
a non-IgE-mediated mechanism. Reactions to food or
food additives as well as IgE-mediatedinsect reactions
and adverse responses to allergen desensitization treatments also have been reported27 IgE-mediated bronchospasmfollowing ingested or injected agents mayoccur independently, but typically is part of a more
generalized allergic reaction depicted clinically by angioedema, urticaria, and/or anaphylaxis. Epinephrine
is indicated in subjects whoseacute asthma is a component of such a systemic reaction.

Medical management
Acute and chronic asthma are classified into mild,
moderate, and severe according to the severity and frequency of occurrence of the signs and symptomsand
according to the degree of airway obstruction as measured with pulmonary function tests (Table 1). The
medical management of childhood asthma is determinedaccording to these criteria. However,the severity of either acute or chronic asthma mayvary within
the same patient over time, and therefore adjustments
in treatment frequently are necessary. The goals of
asthma therapy according to NHLBI guidelines
include:
1. Maintainingnormal activity levels (including exercise)
2. Maintaining near normal pulmonary function
3. Preventing chronic symptoms
4. Preventing recurrent exacerbations of asthma
5. 9Avoidingadverse effects from asthma medication.
Pharmacological managementof chronic childhood
asthma involves two main categories of drugs: antiinflammatory agents and bronchodilators (Table 2).
Children with mild asthma often are managed only
with inhaled ~2 receptor agonist bronchodilators, such
as albuterol and terbutaline sulfate. The typical outpatient maintenance dose of albuterol is one to two
puffs (90 ~g each) every 4 to 6 hr as needed for symptoms. However,excessive use of ~2 agonists (more than
200 inhalations per month)is a sign of poorly controlled
asthma. Cromolyn sodium and nedocromil sodium are
anti-inflammatory agents that work in part by preventing mast cell release of mediators and are used in patients with moderate asthma. Given prophylactically,
364American
Academy
of PediatricDentistry

cromolyn and nedocromil can prevent allergen-induced early asthmatic responses and late asthmatic
responses, and may help reduce airway reactivity28
These medications, however, have no significant role
in the management
of acute asthma attacks29 Oral theophylline, which has bronchodilator and some anti-inflammatory effects, is another option for moderate
asthma. Lastly, inhaled corticosteroids are very effective anti-inflammatory agents and are recommended
for use in children with moderate to severe asthma,
although there are more concerns about their long-term
safety. Inhaled steroids provide good control for
chronic asthma symptomsand are convenient because
they can be administered twice dailyo 2 In general,
asthmathat is morethan mild in severity requires treatment with an anti-inflammatory agent and with ~R agonists "as needed", preferably via inhalation.
Acute asthma is a medical emergencyand initiation
of therapy should not be delayed. The goal in treating
acute asthma is to eliminate symptoms and improve
lung function as quickly as possible. 2~ Initial treatment
for acute severe asthma typically involves an inhaled
~2 agonist such as albuterol. = Albuterol is a rapid-acting drug whose maximal effects are seen within minuteso23 Administrationin the hospital is via a jet nebulizer driven by 100%oxygen through a face mask~4 or
via a metered dose inhaler with a "spacer". Spacers are
aerosol holding chambersthat help coordinate metered
dose inhaler actuation with inhalation; their use also
helps minimizeoral and enhance lung deposition of the
aerosolized
drugs. Ipratropium
bromide (an
anticholinergic) is a less potent bronchodilator used by
some patients with moderate or severe acute asthma
because whenit is administered with albuterol, it provides an additive effect. Moderate doses of systemic
corticosteroids (about 2 mg/kg/day of prednisone or
equivalent) also are recommendedfor patients with
acute severe asthma. 21 Finally, supportive treatment of
acute severe asthma includes supplemental oxygen,
fluid and electrolyte maintenance, anxiety relief, and
endotracheal intubation and, in extreme situations,
2
mechanical ventilation.

Associatedoral problems
A 1993 restrospective study from Sweden reported
an increased prevalence in caries in children with moderate to severe asthma.25 The mechanismfor this development may relate to ~2-agonist effects on salivary
gland function. Another report found that these agents
decrease the secretion of whole saliva by 20%and parotid saliva by 35%,and are associated with an increase
in the numberof lactobacillio 26 These adverse changes
contribute to an increased caries susceptibility. Dueto
this risk asthmatic children should receive special caries prevention attention.
The role of impaired nasorespiratory function as an
etiologic
factor in the development of certain
dentofacial deformities has been suggested.~7,~8 Bresolin
Pediatric
Dentistry- 18:5,1996

TABLE
1.

CATEGORIZATION OF ACUTE AND CHRONIC ASTHMA IN CHILDREN

Asthma Tyt;e
Acute
Symptoms

Mild

Moderate

Severe

Respiratory rate
above mean

Normal to 30%
above mean

30-50% above
mean

> 50% above mean

Dyspnea

Mild if present
severe

Present but not

speech

Fragmented

Color/level of
consciousness

Good / normal

Pale / normal

Maybecyanotic /
maybe decreased

Retractions
intercostal

Noneto slig.ht
SCMretraction

Intercostal and
and nasal flaring

Increasing effort

Auscultation
wheezes

End-ext~iratory
atory wheezes

Inspiratory/expisounds

Decreased breath

PEFR" (% of
baseline)

70-90%

50-70%

< 50%

SaO2*in room air

> 95%

90-95%

< 90%

Treatment
[~2-agonist

Inhaled

Inhaled
subcutaneous

Inhaled or

Oxygen

No

Yes

Yes

+ Oral 4-5 days

Oral 4-5 days

Discharged

+ Hospitalized

Hospitalized,

None

Occasional ER
hospital

ER/ occasional

Symptoms
Frequency
Du~rhtion

< 2 days/week
< 1/2 hour

~ 2 days/week
May last few days

Daily
Almost continuous

PEFR(% baseline)

> 80%

60-80%

< 60%

~.r.n.
romolyn or low

Daily
High dose

Systemic steroids
Usual outcome
Chronic
History of ER/
hospital use

Treatment
[~2-agonists
Anti-inflammatory

Other

Dental

management

None;
dose inhaled
steroids

+ ICU

dose inh~aled
steroids plus
theophy~line

None;
rarely oral
steroids 4-5 days

Theophylline,
oral steroids

Frequent or daily

Routine
examination,
clea~i__ng, simple
operative procedures

Routine
examination and
cle~ng

Defer dental visit

until controlled

PEFR
(peakexpiratoryflow rate): the highestexpiratoryflow rate that canbeachieved
duringa maximally
forceful exhalation
that starts at total lungcapacity.Thisflowrate correlateswell with the degree
of bronchial
obstructionandcanbemeasured
easily in the home
or office with relatively inexpensive
hand-held
devices.
Sa02:transcutaneous
oxygensaturation of hemoglobin.

PediatricDentistry- 18:5,1996

AmericanAcademyof Pediatric Dentistry 365

TABLE
2. A LIST
Categon?
Bronchodilator
Inhaled t2
Short acting

OF COMMONLY
USED DRUGSIN THE TREATMENTOF ASTHMATIC CHILDREN

Generic
Name

Common
Trade Names

Albuterol

TM,
Ventolin
TM
Proventil

Comments

Side Effects

First line
drugs;
recommended
use "as
needed" for
mptoms.
fects last 4-6

Transient
tachycardia,
tremor,
nausea; less
frequently
nervousnes,
palpitations

~
Terbutaline
Bitolterol
Pirbuterol
Metaproternol"
Long acting

TM
Brethaire
TM
Tornalate
Maxair
TM
Autohaler
TM,
Alupent
TM
Metaprel

Salmeterol

Serevent T~

Used as
maintenance
therapy with
anti-inflammatory drugs

Sameas short
acting

Ipratropium

TM
Atrovent

Not used as
first line drug
in children

Cough,
nervousness
nausea

Theophylline

TM,
Theodur
TM
Slobid

Used as
maintenance
therapy, may
need to
monitor blood
levels. Fever,
erythromycin
and cimetidine
increase blood
levels

Nausea,
vomiting,
epigastric
pain. Less
trequently
caffeine-like
CNSeffects

Most effective
inhaled antiinflammatory
agents. Impact
on growth in
children remains
controversial

Oropharyngeal
candidiasis,
hoarseness,
throat
irritation.
Very high
doses may
cause adrenal
suppression

Inhaled
Anticholinergic

Oral

Anti-inflammatory
TM,
Inhaled Steroids Beclomethasone
Beclovent
TM
Vanceril

Triarncinolone
Flunisolide
Other Inhaled
Anti-inflammatory Agents
Cromolyn

Nedocromil

TM
Azmacort
TM
Aerobid

TM
Intal

Safest inhaled
Cough,
anti-inflammawhe~ing throat
tory agent, first
irritation
choice in children

TM
Tilade

Similar to
cromolyn

Bad taste,
cough,
wheezing

"Alsoavailablein nebulizersolution.

366 AmericanAcademyof Pediatric Dentfstry

PediatricDentistry- 18:5, 1996

and coworkers evaluated 45 children with chronic

rhinitis
and mouth breathing
and found that
they presented with an increased upper anterior and
total anterior facial height, higher palatal vaults,
greater overjets, and higher prevalence of posterior
crossbites. 29 In another controlled study, Venetikidou
reported a greater incidence of posterior crossbite in
s
asthmatic children,
Inhaled steroids are being used increasingly as
31
first-line therapy in children with moderate asthma.
However, inhaled steroid therapy has potential side
effects including adrenal suppression,
growth
impairment,B2 throat irritation, dysphonia, dryness of
the mouth, oropharyngeal candidiasis, 33 and rarely,
34
tongue enlargement.
Associated behavior problems
Psychological disturbances have been shown to be
more commonin patients with severe asthma than in
healthy children. 35, 36 For example, Mrazekfound that
25%of severe asthmatics suffered from emotional disturbances. By Someauthors suggest a "vicious cycle":
asthma contributes to the development of behavioral
problems, which, in turn, trigger or exacerbate asth38, 39
matic symptoms.
Asthmamedications also have been associated with
behavioral, affective, and neuropsychological changes
in children. Patients were found to be easily tired, argumentative, irritable, and sad when receiving steroids. 4 High-dose prednisone therapy, commonlyused
to treat acute severe asthma, mayresult in anxiety or
depression, particularly for children with a history of
emotional difficulty. 4 Oral ~2 agonists have been reported to cause psychotic reactions in adult patients.
In children, inhaled albuterol frequently induces a
short-term hand tremor. 41 The National Asthma Education ProgramExpert Panel Report: Guidelines for the
Diagnosis and Managementof Asthma has designated
theophylline as a "second line drug", or a therapeutic
alternative to cromolynor inhaled corticosteroid in the
42
treatment of moderately severe childhood asthma.
Like caffeine, theophylline is a CNSstimulant and its
side effects, which tend to increase with increasing
plasma levels, include gastrointestinal discomfort,
headache, nausea, vomiting, nervousness, insomnia,
17
and rarely, seizures.
Studies have found that parents of asthmatic children also have a higher anxiety level than parents of
healthy children. 43, 4~ Parental and child anxiety may
result in overprotection and interfere with the childs
39 The fear of precipitatability to develop autonomy.
ing an asthma attack mayresult in parental failure to
set appropriate limitations on behavior. Another commonfamily dysfunction problem is child neglect. In a
study of neglected children with chronic illness from
4~
low-incomefamilies, 16%were found to be asthmatic.
Dental management
Safe dental management of children with asthma
PediatricDentistry
- 18:5,1996

depends on the pulmonarystatus of the patient at the

time of the dental intervention. For patients with
asthma, the practitioner should consider the following
to determine howwell the disease is controlled: 1) the
frequency of asthmatic attacks, 2) the type of medications used chronically and during acute attacks, and 3)
the length of time since the child was last seen
emergently with acute asthma. Physical examination
mayinclude auscultation of the lungs, observation of
the rate and depth of respiration, use of accessory
musclesfor respiration, shortness of breath, and coughing. For a severe asthmatic, consultation with the
patients primary care physician is recommended.
Dental procedures maybe accomplishedin the clinic
setting for the asymptomaticor well-controlled asthmatic. A wheezing or poorly controlled patient should
be reappointed. If a patient has been or is currently
using a metered dose inhaler bronchodilator, it should
be brought to each dental appointment. Anxiety is a
trigger in children with asthma, and the dental environment is a commonsite for an acute asthmatic attack. 46 A calm and confident approach by the dental
staff mayhelp alleviate anxiety. If conscious sedation
is required, hydroxyzine (VistariVM, Pfizer Labs, NY,
NY),which has antihistaminic and sedative effects, and
benzodiazepines, which are anxiolytic and do not in4y,
duce bronchoconstriction, are usually recommended.
48 Barbiturates and narcotics (especially morphineand
meperidine) should be avoided in children with asthma
because of their potential for stimulating histamine
release, which can lead to bronchospasm.~9 The analgesic and anxiolytic properties of nitrous oxide (N20),
as well as the supplemental oxygen received during
N20administration, are thought to help managechil~ the use
dren with asthma.49 According to Malamed,
of N20 in children with mild to moderate asthma can
effectively prevent acute symptoms. However,because
N20is somewhatirritating to the airway, its use in children with severe asthma is contraindicated, and medical consultation is recommendedprior to N20 use in
these children.49, 30
IV sedation should be used with extreme caution as
asthmatics have limited control of their airways.
Ketamine, a dissociative anesthetic with sedative, analgesic, and bronchodilating properties, s~, 22 has been
used safely in asthmatic patients. ~3, 54 However,
ketamines sympathetic activation is of concern for
patients with a history of cardiovascular or hypertensive heart disease. Patients who have anything more
than mild asthma should have procedures performed
where standard monitors (pulse oximetry, end-tidal
SAGO2, EKG,and blood pressure cuff) and intubation
equipment are available. Patients with asthma whoare
prone to abrupt and severe episodes of airway obstruction are best treated in a hospital.
Children with asthma maybe at risk for significant
adverse reactions to medications commonlyused in
dental practice. Nearly 4%of patients with asthma are
American
Academy
of PediatricDentistry367

allergic to aspirin and other nonsteroidal anti-inflammatory agents, s5 Thus, acetaminophen usually is recommended for these children.
Patients taking theophylline preparations should not receive erythromycin,
because it interferes with the metabolism of theophyl49
line and raises its blood level into the toxic range.
Historically,
dentists have been warned not to use local anesthetics with vasoconstrictors
in asthmatic patients
because vasoconstrictors
contain sodium
metabisulfite, a highly allergenic substance.S6, 57 Despite
this warning, local anesthetics with vasoconstrictors
have been used safely2 s However, from another point
of view, local anesthetics with vasoconstrictors should
be used with caution since they may add to the effects
of ~2-agonists, resulting in palpitations, increased blood
4s
pressure, and arrhythmias.
Asthmatic children exposed to systemic glucocorticoids (GC) may be at risk for developing adrenal insufficiency during major dental procedures or general
anesthesia. They also have a greater risk (up to three
times) than children without asthma for developing
s9
anesthesia-related
complications postoperatively,
Children with asthma on maintenance systemic GC
(daily or every other day) are adrenally suppressed and
need to be supplemented on the day of the dental pros9
cedure by doubling the patients usual daily dose.
Children at risk for developing adrenal insufficiency
with major dental procedures or general anesthesia
include those who have had four or more brief courses
(4-5 days/course) 6 or a continuous 10-14 day course
of systemic GC for acute asthma within the previous
year, and those who have taken systemic GC within 30
days. 59 These children probably need to receive stress
replacement doses of steroids (60 mg hydrocortisone
m2/dose) 6-8 hr before, and again I hr before the procedure, 61 although this is not generally agreed to by all
authors.Sg, 62 Children with asthma who do not fit these
categories,
and those who do but are undergoing only
minor dental procedures, such as routine examination,
cleaning, and simple operative procedures, do not res9
quire supplemental steroids,
Children with severe asthma require an anesthesiology evaluation to avoid the risk of developing periand postoperative
complications.
A review of the
patients history, a physical examination, and in selected patients, a determination of pulmonary function
(chest radiograph and peak expiratory flow or spirometry) may be necessary to identify those who require
adjustment of their asthma therapy prior to dental
treatment. Pulmonary function tests can identify some
patients who are asymptomatic but are significantly
obstructed and have a below-normal FEV1 (the forced
expiratory volume in I sec, a commonmeasure of airway obstruction). Poorly controlled patients and those
with nocturnal wheezing, frequent severe attacks, uncontrolled
exercise-induced
bronchospasm, or poor
pulmonary function,
should have dental treatment
postponed until the asthma is controlled.
368 AmericanAcademyof Pediatric Dentistry

The following steps should be taken to manage an

acute asthmatic attack in the dental office:
1. Discontinue the dental procedure and allow the
patient to sit or lie down in a comfortable position
2. Keep the airway open and administer ~2-agonists with inhaler or nebulizer
3. Administer oxygen via face mask nasal hood,
or cannula
4. If no improvement takes place and the patient
is worsening, administer epinephrine subcutaneously (1:1000 solution,
0.01 mg/kg of body
weight to a maximumdose of 0.3 mg), and sums
mon medical assistance,
It is very important to continue the therapy and keep
a satisfactory oxygen saturation level until the patient
is free of wheezing or until medical transportation
is
available to take the patient to an emergency room. The
episode should be documented in detail and reported
to the childs primary care physician.
Wethank Drs. EdwardSweeneyand David King, department of
pediatric dentistry; Dr. Daniel Chan, departmentof restorative
dentistry; Dr. Alan Cox, department of pediatrics; Mrs. Dianne
Scales, departmentof pediatric dentistry, University of Texas
Health ScienceCenterat San Antonio,Texas, for their assistance
and advice.
Dr. Zhuis a fellow, pediatric dental service, ChildrensHospital
of Pittsburgh, Pennsylvania. Dr. Huis assistant professor, Dr.
Henryis associate professor and director of the postdoctoral programat departmentof pediatric dentistry; Dr. Hidalgois associate professor and chief, division of pulmonology,departmentof
pediatrics; Dr. Holmgreenis associate professor and director in
the division of dental anesthesiology,departmentof anesthesiology; Dr. Reddingis associate dean for advancededucation and
hospital affairs, DentalSchool,Universityof TexasHealthScience
Center at San Antonio,Texas.
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