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EARN This course was written for dentists, 3 CE dental hygienists, CREDITS and dental assistants. Dreamstime.com | Kaspars Grinvalds ©

Asthma, allergic rhinitis, and decay

A peer-reviewed continuing education course written by Erinne Kennedy, DMD, MMSc, MPH

PUBLICATION DATE: DECEMBER 2020

EXPIRATION DATE: NOVEMBER 2023

SUPPLEMENT TO ENDEAVOR PUBLICATIONS EARN 3 CE CREDITS This continuing education (CE) activity was developed by Endeavor Business Media with no commercial support. This course was written for dentists, dental hygienists, and dental assistants, from novice to skilled. Educational methods: This course is a self-instructional journal and web activity. Provider disclosure: Endeavor Business Media neither has a leadership position nor a commercial interest in any products or services discussed or shared in this educational activity. No manufacturer or third party had any input in the development of the course content. Requirements for successful completion: To obtain three (3) CE credits for this educational activity, you must pay the required fee, review the material, complete the course evaluation, and obtain an exam score of 70% or higher. CE planner disclosure: Laura Winfield, Endeavor Business Media dental group CE coordinator, neither has a leadership nor commercial interest with the products or services discussed in this educational activity. Ms. Winfield can be reached at , allergic rhinitis, [email protected]. Educational disclaimer: Completing a single continuing and tooth decay education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop ABSTRACT skills and expertise. Asthma and seasonal allergies are chronic, yet treatable conditions that Image authenticity statement: The images in this have been shown to alter the oral microbiome. As oral health providers, we educational activity have not been altered. Scientific integrity statement: Information shared in this are called to help our patients cultivate the microbiome of their oral cavity CE course is developed from clinical research and represents the most current information available from evidence-based to achieve and maintain health. Specifically, this course will define asthma . and seasonal allergies, explain the current treatment recommendations, and Known benefits and limitations of the data: The information presented in this educational activity is derived discuss how these processes and treatments affect oral health. This from the data and information contained in the reference course also identifies ways that oral health professionals can help patients section. Registration: The cost of this CE course is $59 for three (3) with seasonal allergies and/or asthma achieve oral and overall wellness. CE credits. Cancellation and refund policy: Any participant who is not 100% satisfied with this course can request a full refund by EDUCATIONAL OBJECTIVES contacting Endeavor Business Media in writing. 1. Understand the impact of asthma and seasonal allergies locally (for the Provider information: patient) and nationally Dental Board of California: Provider RP5933. Course registration number CA code: 03-5933-20003. Expires 2. Review the current treatment recommendations for asthma and seasonal 7/31/2022. “This course meets the Dental Board of California’s allergies requirements for three (3) units of continuing education.”

3. Compare and contrast how both disease processes and their subsequent Endeavor Business Media treatments can impact oral health is a nationally approved PACE program provider for FAGD/MAGD credit. 4. Discuss how changing patient behaviors and using innovative products Approval does not imply acceptance by any regulatory authority or AGD endorsement. can improve oral health in patients with asthma and allergic rhinitis (AR) 11/1/2019 to 10/31/2022. Provider ID# 320452 AGD code: 010

Endeavor Business Media is designated as an approved provider by the American Academy of Dental Hygiene Inc. #AADHPNW (January 1, 2019–December 31, 2020). Approval does not imply acceptance by a state or provincial board of dentistry. Licensee should maintain this document in the event of an audit.

Endeavor Business Media is an ADA CERP–recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of dental continuing education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at ada.org/goto/cerp.

Go online to take this course. DentalAcademyofCE.com QUICK ACCESS CODE 20003 DENTAL ACADEMY OF CONTINUING EDUCATION

WHAT IS ASTHMA? HELPING PATIENTS WITH ASTHMA From a pharmacological perspective, Asthma is a chronic lung condition that Examples of ways to reduce these trig- SABA and LABA inhalers are associ- results in in the bronchial gers include ensuring that you clean the ated with adverse outcomes, such as an tubes that carry air (with oxygen) in and room and keep it ventilated prior unpleasant taste, , sinusitis, and out of the lungs. Patients with asthma to the patient’s arrival. Severe asthmatic .4 In one study, no specific den- often have an inflammatory reaction to patients may request the first appointment tal interactions were reported with leu- their environment, emotions, or physical of the day to reduce the number of fumes, kotriene receptor antagonists, mast activities. Triggers can include, but are aerosols, or irritants in the room or office. stabilizers, or methylxanthines. Among not limited to, time of day, viral respira- For other patients, you may find it helpful immunomodulators used to treat asthma, tory , allergens or irritants (sea- to source alternatives to chemical agents benralizumab was associated with pharyn- sonal, e.g., grass; environmental, e.g., dust that evaporate or release fumes into the air gitis, and reslizumab was associated with in apartment; occupational, e.g., fumes), when possible, ensure that a rubber dam oropharyngeal pain.4 weather changes, laughing, crying, stress, is used to prevent chemical odors in their or exercise.1 The frequency, severity, and airway, or keep the appointment shorter ASTHMA AND TOOTH DECAY source of triggers for asthma attacks are to reduce total exposure to triggers. Disease processes and have unique to each individual. Understanding Additionally, having a discussion with an effect on overall health, including oral asthma is important because patients can the patient about sources of stress that health. For many years, individual stud- be exposed to many of the environmental cause fear or dental anxiety can be help- ies evaluating the relationship between triggers for an asthma attack during a den- ful. For many patients, knowing what is asthma and tooth decay were inconclusive. tal appointment. Environmental triggers going on, being aware and working through However, in 2010, a systematic review and can include fumes from a cleaning agent finances in advance, or knowing they are meta-analysis conducted on asthma and or (e.g., chemicals used to in control can reduce stress and anxiety. tooth decay in primary dentition clarified disinfect the office, dental bonding agent, It can be helpful to have a patient walk the relationship. A review of 14 articles or materials associated with acrylic ) through his or her most successful medi- from 1950–2010 demonstrated that chil- or aerosols. When aerosols are generated cal visit for you out loud. You will be able dren with primary dentition have more from a procedure, physical particles, chemi- to clearly articulate alongside the patient than double the odds (OR = 2.73) of hav- cals, pathogens, and water are dispersed in what a successful visit will look and feel ing tooth decay if they were diagnosed the air around the chair and can be inhaled like for this patient. Simple environmental with asthma.5 Additionally, for children and cause irritation. Providers wear masks, controls for anxiety relief include weighted and adults with permanent dentition who but often patients are exposed to this aero- blankets, using music or podcasts during have asthma, their risk for developing tooth sol, and this cloud of irritants can trigger the procedure, holding a suction or raising decay is more than doubled (OR = 2.04).5 an asthma attack during a dental appoint- a hand as a signal, or having a care animal There are a few plausible explanations ment. Lastly, stress or a response due to in the practice. for this relationship that have been eluci- stress (e.g., crying, anxiety) can trigger an dated by research, including the change asthma attack. Reducing environmental ASTHMA TREATMENTS in due to the disease process and triggers or stress can help prevent asthma Successfully treating asthma is not medication. Research has shown that attacks during dental appointments. achieved by taking alone. salivary composition changes in patients Surveillance from the 2016–2018 Health-care providers do prescribe oral with asthma, including electrolyte con- National Health Interview Survey (NHIS) or inhalation medications to treat symp- centration, flow rate, and inflammatory estimates that across the US, 7.7% of the toms, but they also develop a process to components, meaning that the inflam- population suffered from asthma in 2018.2 remove or reduce exposure to triggers. matory disease process of asthma may This accounts for roughly 5.5 million cases Patients will likely have a quick-relief alter saliva. A comparative study in 2016 in children and 19 million cases in adults. inhaled medication such as a short- evaluated children who were healthy and Patients who are female, low income, acting beta2-agonist (SABA) to relieve children with asthma. This study showed or Black are more likely to suffer from symptoms, such as shortness of breath, tooth decay increases with inhaler usage, asthma.2 It is estimated that more than wheezing, coughing, or chest tightness. suggesting that the side effect of medi- 11 million asthma attacks occur each year Long-term asthma control medications cations could have more of an impact to among people with asthma, which includes include one or a combination of the caries risk than the disease process alone. about 45% of all patients with the diag- following: inhaled corticosteroid, oral- Medications used to treat asthma have nosed condition.2 According to 2014–2017 systemic corticosteroid, inhaled long-act- various side effects, and many inhaled NHIS data from across the US, the range ing beta2-agonist (LABA), leukotriene medications have a low pH and/or have of asthma attacks varied geographically by receptor antagonist, immunomodulators a sweetener as a carrier for the inhaled state and was as low as 23.1% in Nebraska (anti-IgE), mast cell stabilizer (nebulizer medication. SABA and LABA are known to to as high as 66.6% in Alaska.3 treatment), or methylxanthines. induce oral health–related adverse effects,

DentalAcademyOfCE.com 3 DENTAL ACADEMY OF CONTINUING EDUCATION

including hyposalivation. Researchers have episodic when it is due to an occasional decay has been growing, as the disease fre- shown that the interdental plaque pH environmental exposure. Frequency is quency and treatment change. Historically, decreases for 30 minutes after the use of based on how often the patient reports cross-sectional research did not show a an inhaler, and this low pH is maintained symptoms—intermittent or persistent.11 relationship between AR and tooth decay. even after rinsing with water.6 In addition Lastly, the patient will report symptoms However, a recent case-control study found to a decreased interdental plaque pH, a based on severity and the impact they have an association between AR and tooth decay study evaluated asthmatic and nonasth- on their quality of life. While IgE-mediated in primary and transitional dentition in matic patients’ unstimulated saliva and AR is often caused by an outdoor environ- children. Researchers also found that the found that the pH, buffering capacity, and mental exposure (e.g., pollen), it can also severity of AR is linked to an increased flow rate all decreased among asthmatics.7 arise from common household or environ- number of restorations and decreased car- This study found increased tooth decay, mental allergens, such as dry skin, urine, ies severity.15 An explanation for this might erosion score, and gingival bleeding. Gin- saliva, pet dander, mold, or excrement that be that a patient with severe AR who is at gival bleeding has been attributed to the are present throughout the year.12 Com- increased risk for caries visits the dentist pathogenic and to behavioral habits mon symptoms of AR or hay fever include more frequently and receives restorative of asthmatics, such as mouth-breathing.8 nasal congestion, nasal itching, sneezing, care. Additionally, this study showed a rela- In 2016, a study of asthmatic and non- rhinorrhea (runny nose), or conjunctivitis.13 tionship between patients with AR who asthmatic children showed an increased AR is estimated to affect one in six US use corticosteroids or and level of mutans and Lactoba- adults, making it one of the most common tooth decay. cillus among children with asthma, dem- chronic .11 According to the 2018 A study was conducted on adults using onstrating the change in the microbiome NHIS, 7.3% of adults report having hay fever, a national data source in Taiwan, which that follows the environmental change of and it is more common among females found an association between AR and the saliva.9 In 2019, the full oral microbi- and adults ages 45–74.14 Geographically, dental caries, periodontitis, , and omes among children with asthma with and hay fever is most common among adults gingival and oral ulcers.16 This study mim- without tooth decay were evaluated. While in the Northeastern (9.1%) and Western icked the results from the study in children the composition of the microbiome was not (8.0%) regions of the United States.14 Due in which the use of intranasal corticoste- statistically significant, the abundances of to the varying severity of symptoms, many roids was related to increased dental vis- several microorganisms varied. Bacterial cases are left undiagnosed and untreated.13 its for treatment of oral disease, suggesting species that were significantly associated Like asthma, after diagnosis and catego- oral disease severity with the use of these with caries included Veillonella, Haemoph- rization of the symptoms for AR, patients medications.16 ilus haemolyticus, Kingella oralis, Prevotella are encouraged to limit exposure to the It is important to understand the mech- histicola, and Prevotella loescheii.10 allergen. For many patients, complete anism or cause for which AR is related to This study suggests the plaque of children elimination of exposure to the allergen dental caries. Research has suggested an with asthma is “colonized by opportunistic is not possible, so medications to reduce overall decrease in salivary flow rate, an with a high pathogenic capacity,”10 or eliminate symptoms are needed. The altered microbiome, and various habits, meaning that while the community may Clinical Practice Guideline: Allergic Rhini- such as mouth-breathing, as contribut- look similar regarding different species or tis recommends oral second-generation ing factors.16 A comparative study of adult taxa, the abundance within the groups is and/or either intranasal patients compared the salivary flow rate in different and may explain the pathogenicity corticosteroids or antihistamines.11 Oral four groups consisting of healthy patients, of tooth decay in these children. antihistamines, even second-generation patients with allergies who took no med- medications, affect the oral cavity by induc- ications, and patients with allergies who WHAT IS ALLERGIC RHINITIS? ing xerostomia. The side effects of spe- took either fexofenadine or loratadine. Seasonal allergies, also known as aller- cific inhaled corticosteroids vary; however, They found that patients taking fexofena- gic rhinitis (AR) or hay fever, can be the many are associated with headaches, nasal dine (second-generation antihistamine) or result of a true allergy (IgE-mediated) or irritation (e.g., burning or nose bleeds, i.e., presented with allergies alone had higher of an , or can be autonomic or an epistaxis), pharyngitis, nausea or vomiting, rates of xerostomia.17 Among a small group idiopathic mechanism. The focus of this and asthma symptoms (e.g., cough, diffi- of children, some who had AR (40) and oth- course is to discuss seasonal AR due to culty breathing). It is interesting that some ers who were healthy (40), patients with AR IgE. Many patients will report seasonal AR of the medications used to treat allergies had statistically significant higher levels based on the temporal pattern, frequency, actually induce asthma-like symptoms. of S. mutans.18 and severity.11 The temporal pattern can be described as seasonal when symptoms ALLERGIC RHINITIS HOW CAN ORAL HEALTH occur during a certain time of the year AND TOOTH DECAY PROVIDERS HELP PATIENTS? when an outdoor allergen is high, peren- Over the last few decades, the evidence 1. Review the asthma action plan nial when symptoms occur year-round, or for the relationship between AR and tooth Patients will work with their primary care

4 DentalAcademyOfCE.com DENTAL ACADEMY OF CONTINUING EDUCATION

providers or specialists to develop an asthma mouth. Spacers help improve the delivery do not have the rebound side effects that action plan (AAP). AAPs help patients of the inhaled medication into the airway corticosteroids and antihistamines have is develop new health habits (taking medica- and help prevent the medication from being important. For patients with seasonal AR, tions regularly and removing triggers), learn inhaled directly onto the tongue. Spacers the use of intranasal corticosteroids and to adjust medications when symptoms are are particularly helpful with children and antihistamines relieves symptoms tem- more frequent or severe, and know when new users. A study by Kargul et al. showed porarily. However, many drugs, including to seek medical attention. Prior to starting that the pH remained low 30 minutes after corticosteroids (such as fluticasone pro- dental treatment, it’s helpful to get to know using an inhaler even when the patient had pionate) have been shown to induce irre- how asthma affects your patient. A few ques- rinsed. This research study demonstrated versible ciliostasis, or lack of movement of tions that are helpful include: that -free improved the cilia that line the nasal passages and sinus • Do you have an asthma action plan? If buffer capacity and returned the pH to nor- cavities.21 Additionally, has been so, would you like to share it? mal after inhaler use.6 For children or adoles- shown to alter the ability for pathogenic • When was your last asthma attack? cents who have sports-induced asthma, it’s bacteria to adhere to the epithelial lining.22 • When, if ever, were you hospitalized important to remind the patient to take out Postnasal drip is one of the common com- for asthma? his or her mouthguard, rinse, and then put plaints from patients who have seasonal • Have you ever had an asthma attack the mouthguard back in. Rinsing with either allergies. Postnasal drip often combines in a dental office or during a dental xylitol/water or baking soda/water may also with saliva. When a patient uses xylitol appointment? help improve and neutralize the pH quickly. nasal spray or rinse, the postnasal drip will • If so, do you know the cause of this Research shows that chewing xylitol gum be combined with a xylitol solution that asthma attack? after inhaler use is beneficial for patients has been shown to have anticaries effects • How often do you see the health-care who use inhalers regularly. In a study of 90 by decreasing pathogenic (and cariogenic) provider who treats your asthma? children ages 6–12, xylitol gum was shown bacteria and increasing the growth of com- • Are you regularly taking your medica- to improve salivary flow, increase pH, and mensal bacteria. tions? Do you notice any side effects increase buffer capacity when compared to The use of inhalers (e.g., SABA) has been from these medications? chewing paraffin wax pellets or nothing.20 associated with chronic sinusitis as a side • What do you do immediately after you effect. Many patients who use corticoste- use your inhaler? 3. Address medication-induced roid inhalers expose their oral and nasal Once you have reviewed the AAP, you or disease-induced xerostomia cavities to corticosteroids regularly, and can discuss with your patient ways that For patients who use oral antihistamines— these have the potential to change the nor- you can help prevent asthma attacks in the or inhaled corticosteroids, antihistamines, mal or commensal flora and allow more dental office by changing the environment or steroids—medication-induced xerosto- pathogenic flora to flourish. Additionally, to help address some of the side effects of mia is a challenge and concern. In order exposure to corticosteroids—whether his or her medications. Always remember to combat this, it can be helpful to mea- orally or intranasal—results in cilia that that it is important for the patient to have sure salivary markers on a regular basis to are paralyzed.21 For patients with chronic an inhaler with them at all times. help titrate products or chemotherapeutics sinusitis who regularly use an inhaler, rins- to help the patient achieve oral wellness. ing nasal passages after inhaler use with 2. Review best practices for inhaler use There are systems on the market that can a xylitol and sea sinus rinse can help Patients with asthma often use inhalers measure flow rate, pH, buffer capacity, and relieve these symptoms and reduce any that contain a SABA, LABA, or corticoste- various oral bacteria levels, so you can help residual medication in those passages. As roid medication along with fillers. These the patient find an oral health routine that always, consult with either the primary inhaled medications have been shown to objectively reduces risk for disease. Oral care physician or allergist when working decrease the salivary flow or cause short- sprays that contain xylitol can help alleviate with patients to achieve overall wellness. term dry mouth and decrease the pH of the symptoms of dry mouth. The benefit to the oral cavity.19 In addition, the medica- using xylitol sprays is that the patient can CONCLUSION tion inside inhalers has been shown to carry the small bottle in a purse, pocket, In conclusion, patients with asthma and have a low pH. This salivary environment, gym bag, or car, or set it on a nightstand. seasonal allergies can be triggered by vari- one that is dry and acidic, puts the patient Xylitol sprays can also be helpful to use right ous exposures in the dental office. Under- more at risk for tooth decay. In order to after using a nasal spray or inhaler when standing their diagnosed condition and combat tooth decay, patients are encour- the mouth might be the driest. how triggers can be eliminated or reduced aged to immediately rinse their mouths can be the key to successful dental care. out with water and spit after using their 4. Recommend a xylitol Additionally, reviewing patients’ medica- inhalers and/or spacers. A spacer is a small nasal spray or rinse tions and their side effects will help you, piece of plastic that creates a space or tube For many patients with AR, finding alter- the oral health-care provider, to address in between the inhaler and the patient’s natives to help with symptom relief that any side effects that have the potential to

DentalAcademyOfCE.com 5 DENTAL ACADEMY OF CONTINUING EDUCATION

contribute to oral disease and to develop nonasthmatic adult patients visiting a tertiary in patients with allergic rhinitis. Int Arch an oral wellness plan with your patient care hospital. Cureus. 2019;11(10):e5957. Allergy Immunol. 2006;141(3):276-280. for safe use of these medications. The use doi:10.7759/cureus.5957 doi:10.1159/000095297 of xylitol spray and nasal rinse can help 9. Meldrum AM, Thomson WM, Drummond 19. Wongkamhaeng K, Poachanukoon O, reduce some of the known side effects BK, Sears MR. Is asthma a for Koontongkaew S. Dental caries, cariogenic of medications commonly used to treat dental caries? Findings from a cohort microorganisms and salivary properties asthma and seasonal allergies. study. Caries Res. 2001;35(4):235-239. of allergic rhinitis children. Int J Pediatr doi:10.1159/000047463 Otorhinolaryngol. 2014;78(5):860-865. REFERENCES 10. Chellaih P, Sivadas G, Chintu S, et al. doi:10.1016/j.ijporl.2014.03.001 1. National Heart, Lung, and Blood Institute. Effect of anti-asthmatic drugs on dental 20. Bozejac BV, Stojšin I, Ðuric M, et al. Impact Guidelines for the diagnosis and management health: a comparative study. J Pharm of inhalation therapy on the incidence of of asthma (EPR-3). US Department of Health Bioallied Sci. 2016;8(Suppl 1):S77-S80. carious lesions in patients with asthma and and Human Services, National Institutes of doi:10.4103/0975-7406.191973 COPD. J Appl Oral Sci. 2017;25(5):506-514. Health. September 2012. Accessed April 8, 11. Cherkasov SV, Popova LY, Vivtanenko TV, et doi:10.1590/1678-7757-2016-0147 2020. http://www.nhlbi.nih.gov/health-pro/ al. Oral microbiomes in children with asthma 21. Llop R, Jimeno G, Acién M, Dalmau B. Effects guidelines/current/asthma-guidelines and dental caries. Oral Dis. 2019;25(3):898-910. of xylitol chewing gum on salivary flow rate, 2. Centers for Disease Control and Prevention. doi:10.1111/odi.13020 pH, buffering capacity and presence of Most recent national asthma data. Last 12. Seidman MD, Gurgel RK, Lin SY, et al. Clinical in saliva. Eur J Pediatr reviewed March 24, 2020. Accessed April 8, practice guideline: allergic rhinitis. Otolaryngol Dent. 2010;11(1):9-14. 2020. https://www.cdc.gov/asthma/most_ Head Neck Surg. 2015;152(1 suppl):S1-S43. 22. Jiao J, Zhang L. Influence of intranasal drugs on recent_national_asthma_data.htm doi:10.1177/0194599814561600 human nasal mucociliary clearance and ciliary 3. Centers for Disease Control and Prevention. 13. Rhinitis (hay fever) overview. American beat frequency. Allergy Asthma Immunol Res. AsthmaStats. Last reviewed April 20, 2020. Academy of Allergy Asthma and Immunology. 2019;11(3):306. doi:10.4168/aair.2019.11.3.306 Accessed April 8, 2020. https://www.cdc.gov/ Accessed April 9, 2020. https://www.aaaai.org/ 23. Ferreira A, Leme AFSP, Raposo NRB, da Silva SS. asthma/asthma_stats/default.htm. conditions-and-treatments/allergies/rhinitis By passing microbial resistance: xylitol controls 4. Mayo Clinic. Asthma medications: Know your 14. Small P, Kim H. Allergic rhinitis. Allergy Asthma microorganisms growth by means of its anti- options. Accessed June 4, 2020. Clin Immunol. 2011;7(S1):S3. adherence property. Curr Pharm Biotechnol. 5. https://www.mayoclinic.org/diseases-conditions/ 15. Tables of Summary Health Statistics for U.S. 2015;16(1):35-42. doi:10.2174/1389201015666 asthma/in-depth/asthma-medications/ Adults: 2018 National Health Interview Survey. 141202104347 art-20045557 National Center for Health Statistics. 2019. 6. Alavaikko S, Jaakkola MS, Tjäderhane L, http://www.cdc.gov/nchs/nhis/SHS/tables.htm ERINNE KENNEDY, DMD, MMSC, MPH, graduated Jaakkola JJK. Asthma and caries: a systematic 16. Chuang CY, Sun HL, Ku MS. Allergic rhinitis, from Nova Southeastern review and meta-analysis. Am J Epidemiol. rather than asthma, is a risk factor for dental College of Dental Medicine in 2011;174(6):631-641. doi:10.1093/aje/kwr129 caries. Clin Otolaryngol. 2018;43(1):131-136. 2015. She received her 7. Kargul B, Tanboga I, Ergeneli S, et al. Inhaler doi:10.1111/coa.12912 master’s of science in dental medicament effects on saliva and plaque 17. Ho S-W, Lue K-H, Ku M-S. Allergic rhinitis, rather education from the Harvard School of Dental Medicine and pH in asthmatic children. J Clin Pediatr Dent. than asthma, might be associated with dental is a board-certified specialist 1998;22(2):137-140. caries, periodontitis, and other oral diseases who practices clinical dentistry at the Alliance 8. Fathima R, Shenoy R, Jodalli PS, et al. in adults. PeerJ. 2019;7:e7643. doi:10.7717/ Dental Center LLC, in Quincy, Massachusetts. Evaluation of salivary parameters and peerj.7643 oral health status among asthmatic and 18. Elad S, Heisler S, Shalit M. Saliva secretion

NOTES

6 DentalAcademyOfCE.com QUICK ACCESS CODE 20003 ONLINE COMPLETION Take this test online for immediate credit. Visit dentalacademyofce.com and sign in. If you have not previously purchased the course, select it from the “Online Courses” listings and complete your purchase. The exam will then be added to your “Archives” page, where a “Take Exam” link will be provided. Click on this link, complete all questions, and submit your answers. An immediate grade report will be generated. If you receive a score of 70% or higher, your verification form will be provided immediately for viewing and printing. View and print forms at any time by visiting the site and returning to your “Archives.”

QUESTIONS

1. Which of the following can trigger 7. Which of the following character- 13. Which of the following is a side asthma? istics is likely associated with an effect of an immunomodulator such A. Environmental allergens increased risk for asthma? as benralizumab? B. Viral respiratory infections A. Female A. Xerostomia C. Emotions B. Male B. Pharyngitis D. All of the above C. High income C. Glossitis D. Caucasian D. Sinusitis 2. Which of the following is an example of an occupational irritant? 8. Approximately how many asthma 14. In 2010, a systematic review showed A. Chemical fumes attacks occur each year in the US? that patients with asthma and pri- B. Pollen A. 8 million mary dentition were at increased C. Cold air B. 11 million risk for having tooth decay. For D. Grass C. 15 million patients with asthma, what was the D. 19 million overall odds ratio for having tooth 3. Which of the following aspects of decay in primary dentition? triggers is unique to each individual 9. Which of the following states had the A. 0.73 patient? highest rate of asthma attacks? B. 1.73 A. Frequency A. Alabama C. 2.73 B. Severity B. Alaska D. 3.73 C. Source C. Arkansas D. All of the above D. None of the above 15. In 2019, researchers reviewed the oral microbiome of patients with 4. Which of the following is a trigger 10. Which of the following is the rec- asthma who did or did not have that a patient is not likely to experi- ommended course of treatment for tooth decay present. Which of the ence during a dental appointment? asthma? following findings is true? A. Anxiety A. Removing triggers alone A. The composition of the microbiomes B. Pollen exposure B. Inhaled and oral medications only was different, but the abundance was the C. Fumes from disinfectant C. Removing or reducing exposure to trig- same. D. Aerosol gers alongside short- and long-term B. The composition of the microbiomes and medications the abundance of various bacteria were 5. Which of the following is a control D. No treatment required different. that helps the patient reduce anxi- C. The composition of the microbiomes was ety during the visit? 11. Which of the following is not a long- the same; however, the abundance of cer- A. Use of rubber dam term-control asthma medication? tain bacteria was different. B. Early appointments A. Inhaled short-acting-beta2-agonist D. None of the above C. Weighted blankets (SABA) D. None of the above B. Immunomodulators (anti-IgE) 16. Which of the following include all C. Mast cell stabilizer (nebulizer treatment) true side effects of inhaler use? 6. According to the NHIS, what percent- D. Methylxanthines A. Hyposalivation, glossitis, decreased pH of age of adults suffer from asthma in saliva the US? 12. What are the common side effects of B. Hyposalivation, glossitis, increased pH of A. 6.7% SABA and LABA inhaler use? saliva B. 7.7% A. Glossitis C. Hypersalivation, glossitis, decreased pH C. 8.7% B. Sinusitis of saliva D. 9.7% C. Xerostomia D. Hypersalivation, glossitis, increased pH of D. All of the above saliva

DentalAcademyOfCE.com 7 QUICK ACCESS CODE 20003 ONLINE COMPLETION Take this test online for immediate credit. Visit dentalacademyofce.com and sign in. If you have not previously purchased the course, select it from the “Online Courses” listings and complete your purchase. The exam will then be added to your “Archives” page, where a “Take Exam” link will be provided. Click on this link, complete all questions, and submit your answers. An immediate grade report will be generated. If you receive a score of 70% or higher, your verification form will be provided immediately for viewing and printing. View and print forms at any time by visiting the site and returning to your “Archives.”

QUESTIONS

17. What are other medical terms used 22. Which of the following is a common 26. Patients with asthma and allergic to describe seasonal allergies? side effect of second-generation oral rhinitis often present with similar A. Allergic rhinitis antihistamines used to treat allergic changes to the oral cavity. Which B. Hay fever rhinitis? of these symptoms is not simi- C. Both A and B A. Epistaxis lar between asthma and allergic D. None of the above B. Pharyngitis rhinitis? C. Xerostomia A. Increased salivary flow rate 18. How are seasonal allergies best diag- D. None of the above B. Mouth breathing nosed and classified? C. Altered microbiome A. Temporal pattern, frequency, triggers 23. Which of the following medications D. None of the above B. Temporal pattern, frequency, severity used to treat allergic rhinitis can C. Onset, frequency, severity induce asthma as a side effect? 27. Many patients with allergic rhini- D. Onset, frequency, triggers A. Oral antihistamines tis take antihistamines for symptom B. Inhaled corticosteroids relief. Which of the antihistamines 19. What are common household trig- C. Both A and B is a second-generation antihista- gers for allergic rhinitis? D. None of the above mine associated with xerostomia? A. Urine A. Loratadine B. Dry skin 24. Which of the following recommen- B. Diphenhydramine C. Pet dander dations are similar among patients C. Fexofenadine D. All of the above with both asthma and allergic D. Brompheniramine rhinitis? 20. Geographically, where is hay fever A. If possible, limit exposure to allergen or 28. Which of the following should you most common in the US? trigger. review with patients who present to A. Northeast B. Use inhaled corticosteroids when your office with asthma? B. Midwest necessary. A. Antihistamine action plan C. South C. Developed an asthma action plan with B. Allergy action plan D. Southwest your provider. C. Anti-allergy action plan D. None of the above D. Asthma action plan 21. Please select an answer that includes the most common medica- 25. Among patients with allergic rhi- 29. Which of the following habits best tions used to treat seasonal allergic nitis, which of the following best helps patients return their oral rhinitis. describes their risk for oral disease? pH back to normal after using an A. Oral first-generation antihistamine, A. Increased risk for tooth decay in primary inhaler? inhaled corticosteroid, intranasal and transitional dentition A. Drinking bottled water antihistamine B. Increased disease severity B. Rinsing with water B. Oral first-generation antihistamine, C. Increased dental visits for treatment of C. Chewing xylitol gum intranasal corticosteroid, topical disease D. Waiting 30 minutes antihistamine D. All of the above C. Oral second-generation antihista- 30. When using an intranasal cortico- mine, inhaled corticosteroid, intranasal steroid such as fluticasone propi- antihistamine onate, which of the following is a D. Oral second-generation antihistamine, common result? intranasal corticosteroid, intranasal A. Reversible ciliostasis antihistamine B. Irreversible ciliostasis C. Reversible ciliopathy D. Irreversible ciliopathy

8 DentalAcademyOfCE.com PUBLICATION DATE: DECEMBER 2020 ANSWER SHEET

EXPIRATION DATE: NOVEMBER 2023 Asthma, allergic rhinitis, and tooth decay

Name: Title: Specialty:

Address: Email: AGD member ID (if applies):

QUESTIONS City: State: ZIP: Country:

Telephone: Primary ( ) Office ( )

Requirements for obtaining CE credits by mail/fax: 1) Read entire course. 2) Complete info above. 3) Complete test by marking one answer per question. 4) Complete course evaluation. 5) Complete credit card info or write check payable to Endeavor Business Media. 6) Mail/fax this page to DACE. A score of 70% is required for CE credit. For questions, call (800) 633-1681. Course may also be completed at dentalacademyofce.com. Mail/fax completed answer sheet to: EDUCATIONAL OBJECTIVES Endeavor Business Media Attn: Dental division 1. Understand the impact of asthma and seasonal allergies locally (for the patient) and nationally 7666 E. 61st St. Suite 230, Tulsa, OK 74133 2. Review the current treatment recommendations for asthma and seasonal allergies Fax: (918) 831-9804 3. Compare and contrast how both disease processes and their subsequent treatments can impact oral health  Payment of $59 is enclosed.

4. Discuss how changing patient behaviors and using innovative products can improve oral health in Make check payable to Endeavor Business Media patients with asthma and allergic rhinitis (AR) If paying by credit card, please complete the COURSE EVALUATION following: MC Visa AmEx Discover 1. Were the individual course objectives met? Acct. number: ______

Objective #1: Yes No Objective #2: Yes No Exp. date: ______CVC #: ______

Objective #3: Yes No Objective #4: Yes No Billing address: ______

Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. ______

2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Charges on your statement will show up as PennWell / Endeavor. 3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 1. 16. 5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 2. 17. 6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 3. 18. 7. Was the overall administration of the course effective? 5 4 3 2 1 0 4. 19.

8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 5. 20.

9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0 6. 21. 7. 22. 10. Do you feel that the references were adequate? Yes No 8. 23. 11. Would you participate in a similar program on a different topic? Yes No 9. 24. 12. If any of the continuing education questions were unclear or ambiguous, please list them. 10. 25. ______11. 26. 13. Was there any subject matter you found confusing? Please describe. ______12. 27. 13. 28. 14. How long did it take you to complete this course? ______14. 29.

15. What additional continuing dental education topics would you like to see? 15. 30. ______

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. INSTRUCTIONS PROVIDER INFORMATION All questions have only one answer. If mailed or faxed, grading of this examination is done Endeavor Business Media is an ADA CERP–recognized provider. ADA CERP is a service of the Endeavor Business Media is designated as an approved provider by the American Academy manually. Participants will receive confirmation of passing by receipt of a Verification of American Dental Association to assist dental professionals in identifying quality providers of of Dental Hygiene Inc. #AADHPNW (January 1, 2019–December 31, 2020). Approval does not Participation form. The form will be mailed within two weeks after receipt of an examination. continuing dental education. ADA CERP neither approves nor endorses individual courses imply acceptance by a state or provincial board of dentistry. Licensee should maintain this or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns document in the event of an audit. COURSE EVALUATION AND FEEDBACK about a CE provider may be directed to the provider or to ADA CERP at ada.org/gotocerp. We encourage participant feedback. Complete the evaluation above and e-mail additional RECORD KEEPING feedback to Aileen Gunter ([email protected]) and Laura Winfield (lwinfield@ Endeavor Business Media is designated as an approved PACE program provider by the Endeavor Business Media maintains records of your successful completion of any exam for a endeavorb2b.com). Academy of General Dentistry. The formal continuing dental education programs of this minimum of six years. Please contact our offices for a copy of your CE credits report. This report, program provider are accepted by the AGD for fellowship, mastership, and membership which will list all credits earned to date, will be generated and mailed to you within five business COURSE CREDITS AND COST maintenance credit. Approval does not imply acceptance by a state or provincial board of days of receipt. All participants scoring 70% or higher on the examination will receive a verification form for dentistry or AGD endorsement. The current term of approval extends from 11/1/2019 to three (3) continuing education (CE) credits. Participants are urged to contact their state dental 10/31/2022. Provider ID# 320452. AGD code: 010. CANCELLATION AND REFUND POLICY boards for CE requirements. The cost for courses ranges from $20 to $110. Participants who are not 100% satisfied can request a refund by contacting Endeavor Business Dental Board of California: Provider RP5933. Course registration number CA code: 03-5933- Media in writing. 20003. Expires 7/31/2022. “This course meets the Dental Board of California’s requirements for three (3) units of continuing education.” IMAGE AUTHENTICITY The images in this educational activity have not been altered..

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