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CDHO Advisory: Chronic Obstructive Pulmonary Disease

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CDHO ADVISORY

SCOPE

RECOMMENDATIONS

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

CONTRAINDICATIONS

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with chronic obstructive pulmonary disease.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Chronic Obstructive Pulmonary Disease, 2020-05-28

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

Chronic obstructive pulmonary disease

INTENDED USERS

Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have chronic obstructive pulmonary disease, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Record keeping.
  9. Advising the patient/client.

TARGET POPULATION

Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged, 80 and over
Male
Female
Family caregivers of persons with chronic obstructive pulmonary disease.

MAJOR OUTCOMES CONSIDERED

For persons who have chronic obstructive pulmonary disease: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Terminology used in this Advisory

Resources consulted

Chronic obstructive pulmonary disease (COPD) is a respiratory disorder 

  1. largely caused by smoking.
  2. characterized by 
    1. progressive, partially reversible airway obstruction 
    2. chronic bronchitis (inflammation of the bronchi coupled with excessive bronchial mucus production and chronic sputum-producing cough)2
    3. emphysema (lung hyperinflation and irreversible destruction of alveolar walls)
    4. systemic manifestations
    5. increasing frequency of exacerbations.

Other terminology

  1. Candida, oral candidiasis, also termed thrush or oral moniliasis, is 
    1. a yeast infection of the mouth or throat 
    2. most commonly caused by Candida albicans.
  2. Dose-response relation, a complex statistical function that
    1. expresses the correlation between the amount of harmful chemical, beneficial medication, or another type of measurable cause delivered to the body or organ, and the effect as measured by the occurrence of a specific outcome 
    2. when established with rigorous research provides strong but nonetheless insufficient evidence that the cause does in fact create the effect
    3. may not exist between some causes, such as viral infection, and some effects that are definitively linked with particular causes, such as a particular viral disease.
  3. Emphysema, an irreversible chronic lung disease
    1. in which the lung tissues become damaged
    2. which is most commonly caused by smoking.
  4. Independent risk factor, an established risk factor that is unrelated to one or more other established risk factors.
  5. Occurrence, a term used in epidemiology to provide information about diseases and their trends, commonly measured by
    1. mortality, the number of deaths yearly per 1000 of population at risk
    2. incidence, the number of new cases yearly per 100,000 of population at risk
    3. prevalence, as defined for cancer, the number or percent of people alive on a certain date in a population who have been diagnosed with cancer.
  6. Palliative care, services of care for persons towards the end of life with terminal illnesses such as cancer, when the focus of the care 
    1. is relieving symptoms
    2. attending to physical and spiritual needs.
  7. Risk factor, a term
    1. used strictly to identify anything that affects the person’s chances of developing a disease such as oral cancer
    2. used loosely to refer to things that in themselves may not affect the person’s chances of developing a disease such as oral cancer but which may signal the presence of things that are risk factors as strictly defined; for example problematic dentition and poor oral hygiene may signal smoking and considerable alcohol consumption, which are independent risk factors for oral cancer
    3. that informs medical history-taking and examination, which takes account of evidence based on dose-response relations such that between the type and amount of smoking and the development of oral cancer
    4. that, in the absence of clear-cut epidemiological data, often cannot be quantified or even rank-ordered for importance.
  8. Sicca syndrome, a term reserved for the combination of dryness of the mouth and eyes, regardless of cause; when accompanied by lymphocyte infiltration of the salivary glands is named Sjögren syndrome (CDHO Advisory).
  9. Supportive care, services of care to help persons meet the physical, emotional and spiritual challenges arising from the condition or its treatment.
  10. Xerostomia, abnormal dryness of the mouth resulting from decreased secretion of saliva; has various causes including
    1. chemotherapy (CDHO Advisory)
    2. head and neck radiation therapy (CDHO Advisory)
    3. sicca syndrome
    4. Sjögren syndrome (CDHO Advisory)
    5. some medications.

Overview of chronic obstructive pulmonary disease

Resources consulted

Chronic obstructive pulmonary disease 

  1. Is a leading cause of death in Canada3, and is estimated to affect about one million Canadians over the age of 35 years comprising  
    1. 0.5 million who have been diagnosed with the disease
    2.  an estimated 0.5 million who are undiagnosed.
  2. Has historically caused a higher percentage of all deaths among men than women but by 2011 the gap between the sexes had virtually disappeared.
  3. When manifested as symptoms, does not usually appear in people below the age of 55 years; but the lung changes originate many years earlier.
  4. Is strongly linked with long-term smoking, which is responsible for 80 to 90 percent of the incidence of chronic obstructive pulmonary disease; is associated with second-hand smoke.
  5. Is also caused by
    1. air pollution by dust and chemicals 
    2. repeated lung infections during childhood
    3. alpha-1 antitrypsin deficiency, a rare genetic disorder.
  6. Cannot be cured, but can be treated well enough to support an active life in many persons; is preventable in most cases.
  7. Should be considered for persons aged over 35 years who have some combination of
    1. persistent or progressive dyspnea 
    2. chronic cough or sputum production
    3. decline in level of activity 
    4. a history of smoking 
    5. a family history indicative of genetic factors pertaining to respiratory disease
    6. a history of significant environmental or occupational exposures: as many as one out of six Americans with the disease has never smoked. 
  8. Impairs the ability of the lungs to absorb oxygen and remove carbon dioxide because of the combined effects of lung hyperinflation (emphysema) and chronic bronchitis.
  9. May sometimes be associated with spasms of the airways.
  10. Is subject to exacerbations provoked by environmental triggers, such as 
    1. air pollution, smog
    2. second-hand smoke 
    3. strong fumes, perfume, scented products 
    4. weather changes 
    5. cold air or hot and humid air. 
  11. In its acute phase is marked by symptoms such as
    1. dyspnea
    2. wheezing
    3. productive cough with sputum that thickens and changes colour to yellow, green or brown
    4. chest pain
    5. fever
    6. swollen ankles
    7. a need to sleep propped up
    8. difficulty sleeping, morning headaches, dizziness and confusion
    9. feeling of unwellness.
  12. Is generally accompanied by symptoms such as
    1. feelings of fatigue
    2. progressive deterioration in quality of life
    3. restrictions of activity
    4. depression (CDHO Advisory) and other psychological conditions arising from the disability and discomfort.
  13. As it advances, is increasingly predisposed to acute exacerbations usually provoked by viral or bacterial infection; the resulting inflammation increases mucus production and causes swelling of the walls of the bronchial tubes, which leads to narrowing of the airways.
  14. In its later stage, results in 
    1. a physical state in which persons
      1. may be malnourished and underweight
      2. often exhibit muscle wasting and weakness of the thoracic musculature
    2. the consumption of insufficient calories and nutrients from dietary sources by as many as 60 percent of persons with the disease (CDHO Advisory)
    3. a nutritional challenge: on the one hand, good nutrition may reduce the risk of respiratory infections; on the other hand, fatigue, depression, or side effects of medications may undermine the motivation to eat (CDHO Advisory)

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with chronic obstructive pulmonary disease but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 

Persons with chronic obstructive pulmonary disease are reportedly at increased risk of comorbid conditions or complications such as

  1. angina
  2. cataract
  3. osteoporosis (CDHO Advisory)
  4. pneumonia
  5. pulmonary hypertension
  6. right-sided heart failure
  7. respiratory infection.

Oral health considerations

Oral health considerations centre on possible links between pulmonary infection and oral disease.

Resources consulted

  1. Various studies suggest associations between pulmonary infection and oral diseases, but an association is demonstrated only for patients/clients with severely compromised health, as in
    1. persons in intensive care 
    2. frail and debilitated elderly persons living in nursing homes
    3. persons with chronic pulmonary diseases, including advanced chronic obstructive pulmonary disease.
  2. While the most likely mechanisms of infection involve accumulation of plaque on teeth or dentures, and periodontal pathogens, more research is needed to confirm and clarify the mechanisms.
  3. In the populations of patients/clients studied, various risk factors would often be present; few studies demonstrated that oral hygiene and periodontal pathogens were independent as risk factors.
  4. For chronic respiratory infection, the association with oral disease appears to be demonstrable. But the causal relation may be explainable by host susceptibility factors common to both pulmonary infection and oral disease.
  5. It seems reasonable to encourage at-risk patients/clients to maintain or improve oral hygiene, given
    1. the suggestive observations that 
      1. plaque accumulation is a potential risk factor for pulmonary disease
      2. poor oral hygiene and some oral diseases can lead to or exacerbate morbidity of various causes
    2. the various authoritative recommendations for the management of chronic obstructive pulmonary disease emphasize the importance of healthy eating, and that the disease may undermine motivation to eat. 

MEDICATIONS SUMMARY

Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 

Types of medications

Resources consulted

Warnings

Individual medications may be subject to important warnings, which

  1. change from time to time
  2. may affect the appropriateness, efficacy or safety of the Procedures
  3. are accessible via the links to the particular medications listed below or through the specialized organizations listed above
  4. through the links, should be viewed by dental hygienists in the course of their familiarizing themselves about a medication or combination of medications identified in the patient/client’s medical and medications history.

Medications (often taken in combination forms)

  1. Bronchodilators, which open up airways to relieve or reduce shortness of breath and wheezing; vary in the time taken to act and in the duration of action; chiefly comprise 
    1. Short-acting beta2-agonists (SABA) and long-acting beta2-agonists (LABA), administered by inhalation to reduce constriction of the musculature of the bronchi and bronchioles, such as
      1. formoterol (Oxeze®, a LABA) 
      2. indacaterol ((Arcapta®, Onbrez®, which are LABAs)
      3. olodaterol (Stiverdi®, Respimat®, which are LABAs)
      4. salbutamol/albuterol (Ventolin®, a SABA)
      5. salmeterol (Serevent®, a LABA) 
    2. Short-acting anticholinergics (SAAC) [also known as short-acting muscarinic antagonists (SAMA)] and long-acting anticholinergics (LAAC) [also known as long-acting muscarinic antagonists (LAMA)], administered by inhalation to reduce constriction of the musculature around the bronchi, are often used in combination with beta2-agonists; include 
      1. aclidinium (Tudoraza®, Pressair®, which are LAAC-LAMAs) 
      2. ipratropium (Atrovent®, a SAAC-SAMA)
      3. glycopyrronium (Seebri®, a LAAC-LAMA)
      4. umeclidinium (Incruse Ellipta®, a LAAC-LAMA) 
      5. tiotropium (Spiriva®, a LAAC-LAMA) 
    3. theophyllines (a non-selective phosphodiesterase inhibitor), administered orally, may also improve the function of respiratory musculature and possibly reduce inflammation but is not commonly used because of side effects and drug interactions; includes
      1. theophylline (Uniphyl®, Theodur®).
  2. Corticosteroids, anti-inflammatories administered 
    1. by inhalation (inhaled corticosteroid – ICS – puffers) which yield fewer side effects compared to oral administration because, during inhalation, the corticosteroids pass directly to the airways; with oral administration, they are distributed widely to other parts of the body.
    2. often in combination with a bronchodilator
      1. used
        1. long term, to reduce cough and airway inflammation
        2. at the first sign of a flare-up to reduce complications
      2. include
        1. fluticasone and salmeterol oral inhalation (Advair® combination product, which is Flovent® [fluticasone corticosteroid] combined with Serevent®) 
        2. Symbicort® (as a combination product containing budesonide [a corticosteroid] and formoterol); see budesonide oral inhalation and formoterol oral inhalation
    3. ccasionally orally as pills, such as
      1. prednisone 
    4. occasionally intravenously, such as 
      1. methylprednisolone
  3. Phosphodiesterase-4 inhibitors, which have both bronchodilator and anti-inflammatory effects, include (as tablets)
    1. roflumilast (Daliresp®)
  4. Antibiotics, used to treat the more severe increases in expectoration of yellow, green or brown sputum, and breathlessness, include
    1. amoxicillin (Amoxil®, Trimox®, many generic brands/names)
    2. doxycycline (Doxycin® Vibramycin®)
    3. tetracycline (many generic brands/names)
    4. sulfamethoxazole/trimethoprim injection (historically – Bacterim®, Septra®; many generic brands/names)
    5. extended spectrum macrolides (e.g., clarithromycin – Biaxin®; azithromycin – Zithromax®)
    6. second- or third-generation cephalosporins (e.g., cefuroxime-AX – Ceftin®; cefprozil – Cefzil®)
    7. amoxicillin/clavulanic acid (Augmentin®, Clavulin®)
    8. fluoroquinolones (e.g., levofloxacin — Levaquin®; moxifloxacin — Avelox®; ciprofloxacin – Cipro®)
  5. Supplemental oxygen, used selectively and for variable periods for persons 
    1. subject to significantly low blood-oxygen levels
    2. experiencing temporary respiratory impairment caused by infections.
  6. Influenza and pneumonia immunizations, to prevent lung infection, to which persons with chronic obstructive pulmonary disease are especially vulnerable.

Side effects of medications

See also the links for the individual medications listed above.

Resources consulted

Beta agonist side effects, which are often dose-related, include 

  1. Tachycardia 
  2. Palpitations 
  3. Premature ventricular contractions 
  4. Tremors 
  5. Sleep disturbances 
  6. Decreased potassium levels (hypokalemia)

Anticholinergic side effects include 

  1. Xerostomia
  2. Metallic taste after inhalation 

Theophylline (oral) side effects include

  1. Serious
    1. Cardiac dysrhythmia 
    2. Convulsions 
  2. Mild
    1. Headache
    2. Nausea
    3. Vomiting
    4. Diarrhea
    5. Heartburn

Corticosteroids 

  1. With chronic obstructive pulmonary disease, pneumonia risk is on some evidence increased by inhaled corticosteroids at the highest doses, possibly because of immune system suppression.
  2. Oral thrush (Candida albicans) is a common side effect of inhaled corticosteroids. It is minimized by use of a spacer attached to the inhaler to prevent the medication from depositing in the mouth or on the back of the throat.
  3. For older adults side effects from inhaled corticosteroids, especially at high doses may include osteoporosis and osteonecrosis (CDHO Advisory) with possible oral health implications, and cataracts.

THE MEDICAL AND MEDICATIONS HISTORY

The medical  and medications history-taking should 

  1. Focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities.
  2. Explore the need for advice from the appropriate primary or specialized care provider(s).
  3. If the patient/client has a history of chronic obstructive pulmonary disease with or without complications, inquire about
    1. the patient/client’s understanding and acceptance of the need for oral healthcare
    2. symptoms indicative of exacerbation of the chronic obstructive pulmonary disease, such as coloured sputum and increased breathing difficulties
    3. medications considerations, including over-the-counter medications, herbals and supplements
    4. problems with previous dental/dental hygiene care
    5. problems with infections generally and associated with dental/dental hygiene care
    6. the patient/client’s current state of health
    7. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition. 

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

  1. Record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number.
  2. Obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider.
  3. Use a consent/medical consultation form, and be prepared to securely send the form to the provider.
  4. Include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.

UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Infection control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2022)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

  1. There is no specifically proscribed contraindication to the Procedures. 
  2. With an otherwise healthy patient/client whose symptoms are under control and whose treatment is proceeding normally, the dental hygienist should implement the Procedures, though these may be postponed pending medical advice, which is likely to be required if the patient/client has
    1. symptoms or signs of exacerbation of chronic obstructive pulmonary disease
    2. comorbidity, complication or an associated condition of chronic obstructive pulmonary disease4
    3. not recently or ever sought and received medical advice relative to oral healthcare procedures
    4. recently changed significant medications, under medical advice or otherwise
    5. recently experienced changes in his/her medical condition such as medication or other side effects of treatment
    6. is deeply concerned about any aspect of his or her medical condition.

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2)

For a patient/client with a history of chronic obstructive pulmonary disease, the dental hygienist should specifically record

  1. A summary of the medical and medications history.
  2. Any advice received from the physician/primary care provider relative to the patient/client’s condition.
  3. The decision made by the dental hygienist, with reasons.
  4. Compliance with the precautions required.
  5. All Procedure(s) used.
  6. Any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

The patient/client is urged to alert any healthcare professional who proposes any intervention or test that he or she has a history of chronic obstructive pulmonary disease.

As appropriate, discuss 

  1. The importance of the patient/client’s
    1. self-checking the mouth regularly for suspicious signs or symptoms
    2. reporting to the appropriate healthcare provider any changes in the mouth indicative of suspicious lesions.
  2. The need for regular oral health examinations and preventive oral healthcare. 
  3. Oral self-care including information about 
    1. choice of toothpaste
    2. tooth-brushing techniques and related devices
    3. dental flossing
    4. mouth rinses
    5. management of a dry mouth. 
  4. The importance of an appropriate diet in the maintenance of oral health.
  5. For persons at an advanced stage of a disease or debilitation
    1. regimens for oral hygiene as a component of supportive care and palliative care
    2. the role of the family caregiver, with emphasis on maintaining an infection-free environment through hand-washing and, if appropriate, wearing gloves
    3. scheduling and duration of appointments to minimize stress and fatigue. 
  6. Comfort level while reclining, and stress and anxiety related to the Procedures.
  7. Medication side effects such as dry mouth, and recommend treatment.
  8. Mouth ulcers and other conditions of the mouth relating to chronic obstructive pulmonary disease, comorbidities, complications or associated conditions, medications or diet.
  9. Pain management.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

  1. Promotion of health through oral hygiene for persons who have chronic obstructive pulmonary disease.
  2. Reduction of the adverse effects, such as oral-infection-related provocation of an exacerbation of chronic obstructive pulmonary disease by
    1. particular attention to sources of oral infection
    2. generally increasing the comfort level of persons in the course of dental hygiene interventions 
    3. using appropriate techniques of communication
    4. providing advice on scheduling and duration of appointments.
  3. Reduction of risk of oral health needs being unmet.

POTENTIAL HARMS

  1. Causing infection which affects the respiratory system.
  2. Performing the Procedures at an inappropriate time, such as 
    1. a phase of excessive fatigue, depression, or side effects of medications
    2. in the presence of complications for which prior medical advice is required
    3. in the presence of acute oral infection without prior medical advice.
  3. Disturbing the normal dietary and medications routine of a person with obstructive pulmonary disease.
  4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

ORIGINALLY DEVELOPED

2009-11-24

DATE OF LAST REVIEW

2010-07-15; 2015-08-12; 2020-05-28

ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow
MD, MHSc, MBA, DTM&H, CHE, CCFP, DABPM, LFACHE, FCFP, FACPM, FRCPC

Lisa Taylor
RDH, BA, MEd

Elaine Powell
RDH

Robert Farinaccia
RDH, BSc

Kyle Fraser
RDH, BComm, BEd, MEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2009, 2010, 2015, 2020 College of Dental Hygienists of Ontario

FOOTNOTES

1 Persons includes young persons and children.
2 Some authorities (e.g., American Thoracic Society [ATS]) no longer consider chronic bronchitis to be a type of COPD. Instead, the term obstructive bronchiolitis is used to describe the condition in which chronic inflammation and swelling cause airways to be smaller than normal (particularly prolonging the expiration phase of breathing). In the ATS schema, COPD is comprised of obstructive bronchiolitis, emphysema, or a combination of both conditions.
3 COPD caused 4.4% of all deaths in Canada in 2011.
4 If systemic steroids are being taken on an ongoing basis for COPD, the patient/client’s physician may wish to increase the regular dose to prevent an adrenal crisis during a particularly stressful appointment. As well, prolonged use and/or high doses of systemic (oral or intravenous) steroids may predispose to infection, and medical clearance should be sought in these circumstances. Also, while antibiotic prophylaxis for Procedures is not typically required, it may be considered for patients/clients at risk of immunosuppression (e.g., prolonged use and/or high doses of systemic steroids).