Year : 2007 | Volume
: 25 | Issue : 2 | Page : 65--68
Effect of antiasthmatic medication on dental disease: Dental caries and periodontal disease
ND Shashikiran, V.V.S Reddy, P Krishnam Raju
Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere, India
N D Shashikiran
Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere - 577 004, Karnataka
The prevalence of asthma has been increasing since the 1980s. Asthma and tooth decay are the two major causes of school absenteeism. There are few studies present in the literature. The objectives of the present study were to know the severity of dental caries and periodontal problems in children before and after taking antiasthmatic medication. The present study was conducted on 105, six- to fourteen-year-old asthmatic children to determine the condition of their dental caries and their periodontal status before and after taking antiasthmatic medication, for a period of 1 year and these were matched with their controls. The results showed that salbutamol inhaler shows increased caries rate with high significance over other groups, which was followed by salbutamol tablets and beclamethasone inhaler respectively. It has been concluded that antiasthmatic medication has its effects on dental caries and periodontal disease and asthmatic patients are recommended to adopt more precautionary oral hygiene practices and keep their caries activity and periodontal health under constant check.
|How to cite this article:|
Shashikiran N D, Reddy V, Raju P K. Effect of antiasthmatic medication on dental disease: Dental caries and periodontal disease.J Indian Soc Pedod Prev Dent 2007;25:65-68
|How to cite this URL:|
Shashikiran N D, Reddy V, Raju P K. Effect of antiasthmatic medication on dental disease: Dental caries and periodontal disease. J Indian Soc Pedod Prev Dent [serial online] 2007 [cited 2019 Nov 20 ];25:65-68
Available from: http://www.jisppd.com/text.asp?2007/25/2/65/33450
Asthma is a chronic inflammatory condition of the airways characterized by hyper-responsiveness and episodic, reversible symptoms of airflow obstruction.  The prevalence of asthma has been increasing since the 1980s across all ages, gender and racial groups and is higher among children than adults.  Asthma and tooth decay are the two major causes of school absenteeism.  Asthma is viewed by many as a fairly benign disorder; the mortality rate for this disease has almost tripled during the last 20 years, reaching a peak of more than 3,000 annual deaths. This number is projected to be doubled within the next two decades. 
Children with chronic medical disorders requiring long-term medication are at a risk of dental caries as a side effect.  A possible mechanism for an effect on dental caries could be the involvement of β adrenoceptors in asthma, with an effect also on salivary gland function. Asthma is frequently treated with β adrenoceptor agonists, which promote bronchial relaxation. β adrenoceptors are also present in the secretory system and have a strong impact on salivary composition.  A dose-response effect of the treatment with β2 adrenoceptor agonists is the impairment of salivary secretion and it also has an effect on its composition in asthmatic patients.
This study was performed with an objective to determine the effect of antiasthmatic medication, i.e., salbutamol inhaler, salbutamol tablets and beclamethasone inhaler on dental caries and periodontal disease over a period of 1 year.
Materials and Methods
A case control study with 1-year follow-up was chosen, which included 143 asthmatic children as cases, but 38 children did not report after the study period. One hundred five asthmatic children in the age group of 6-14 years were followed up after 1 year. One hundred six controls were taken from different schools and followed up for 1 year. The data was collected in the outpatient block of the hospitals, with the patient seated in a normal chair, with the help of a hand torch and using sterile instruments. The dental caries and periodontal status of the patients were examined and noted before starting the medication and at the end of 1 year.
The cases were divided equally into three groups, with 35 patients in each group - viz, beclamethasone inhaler group, salbutamol inhaler group and salbutamol tablets group. All examinations were conducted by the same examiner, while a trained clerk assisted in the survey. The patients were recalled after 1 year and examined again. Dental caries were assessed using DMFT, DMFS, dft and dfs indices and periodontal status was determined by using CPITN index. The data was analyzed by statistical analysis. A 'p' value of , The large standard deviation indicated that the caries experience data was not evenly distributed, showing that some children had a lot of decay and some had very little. This may be partly explained by examining the practice group, i.e., those children taken from private hospitals, having a higher socioeconomic profile than the hospital group, i.e., those children taken from government hospitals. It is well documented that higher socioeconomic groups have better dental health than groups with lower socioeconomic status.  In addition, asthmatic children lead a restricted lifestyle, missing so much school and not being able to play sports and participate in normal activities; these children may frequently consume sweets, leading to increase in caries levels. Also, due to increased attention given to their general asthmatic condition, they may give little importance to oral hygiene procedures.  Drummond suggested that the association between asthma and dental caries is seen primarily in younger children and there is no evidence of an association between asthma and dental caries in older children. 
Factors related to chronic asthmatic condition and/or asthma medication might increase the risk of caries.  Patients with bronchial asthma are affected both by the disease and the drug. It is therefore difficult to dissociate the effects of the two, but there are indications that the drug treatment exerts the stronger effect.  Various forms of medication play an important role. Conolly et al. suggested that the decrease in pH of saliva and plaque in asthmatics was caused by the drug and not the disease.  Kargul et al.,  stated that the low pH in asthmatics is due to the use of inhaler. A large proportion of inhaled drug is retained in oropharynx, ranging from 80% with a metered dose inhaler and 60% with a dry powder inhaler with extension tube. In addition, some dry powder inhalers contain sugar so that the patient can tolerate the taste of the drug when it is delivered. Frequent oral inhalation of sugar combined with a decrease in salivary flow rate and decrease in pH of saliva may contribute to increase in caries. Ryberg et al., suggested that the changes in saliva secretion and synthesis of salivary proteins are caused by the drug used for treatment. 
This study reveals that asthmatic patients using salbutamol inhaler had a significant increase in caries as compared to other groups, which was followed by salbutamol tablets. Ryberg et al.,  showed that the increase in caries is associated with use of β2 agonists, which leads to reduced salivary flow. The secretion rates of whole and parotid saliva is decreased by 26% and 36% respectively in asthmatic patients when compared with healthy control group. As reduced salivary flow is accompanied by concomitant increase in lactobacilli and streptococcus mutans in the oral cavity, it may be one of the major contributing factors for increase in caries rate. Intake of medication at night before retiring to bed is commonly seen due to poor patient awareness and also no oral hygiene measures were usually taken after medication. Diminution of salivation and lack of masticatory movements during the night might have further increased the cariogenic potential of medicines.
The increase in caries prevalence with the severity of asthma may be mainly due to the increase in the dosage and frequency of medication.  Lower outputs of saliva in the asthmatic group are not only explained by secretion of a smaller volume of saliva alone but also by changes in the composition of saliva. A low output also reflects a lower rate of biosynthesis of biologically active substances, which over a long period of time may increase dental caries activity. Availability of biologically active components is a decisive factor. The output of the antibacterial components was lower in the asthma patients. This should favor both bacterial colonization and plaque growth. 
In this study, asthmatic patients using beclamethasone inhaler showed an increase in dental caries, which was not statistically significant as compared to other groups. Inhaled beclamethasone compromises the oral immunity and interferes with the inflammatory components as it acts as an anti-inflammatory agent.  Inhaled beclamethasone is known to cause oropharyngeal candidiasis and there might be alterations in the composition of plaque. 
Hyppa et al.,  suggested that the gingivitis in asthmatic children could be explained, in part, by an altered immune response and by their tendency to breathe through the mouth, especially during an episode of an acute asthmatic attack and the dehydration of alveolar mucosa during mouth-breathing. Karl et al.,  suggested that asthmatics had more periodontal disease and lower stimulated salivary flow rate than non-asthmatic subjects. Higher prevalence of calculus in asthmatic children is due to increased levels of calcium and phosphorous in submaxillary saliva and parotid saliva.  Wotman et al.,  suggested that children with asthma have more calculus than normal children. Lenanader et al.,  suggested that though there was decrease in the salivary flow rates, the myeloperoxidase concentration was increased in asthmatic patients. The concentration of IgE in gingival tissue was found to be elevated in patients with asthma, which causes periodontal destruction. ,
This study reveals that there is significant increase in caries in asthmatic children when compared to controls. When the drug-related effect was analyzed, beclamethasone inhaler showed an increase in caries but not very significant when compared to salbutamol inhaler and salbutamol tablets. The salbutamol tablets showed an increase in caries more than beclamethasone inhaler but less than salbutamol inhaler. This can be attributed to its systemic effect on the salivary secretions. Salbutamol inhaler showed higher degree of caries than beclamethasone inhaler and salbutamol tablets. It could be due to its local effects of decreased pH and altered salivary secretion levels and salivary composition. The presence of gingivitis and calculus was more when compared to controls but the comparison between the drugs did not reveal any significance.
The antiasthmatic medication has its effects on dental caries and periodontal status, but these can be taken care of by prophylactic treatment - which is beneficial to the patient considering the severity of the asthmatic disease and the necessity of medication during life-threatening episodes. Asthmatic patients are recommended to adopt more precautionary oral hygiene practices and keep their caries activity and periodontal health under constant check.
We would like to express our gratitude to Dr. Vidyasagar and Dr. Suresh Babu for their timely help, advice and provision of the entire necessary infrastructure for this study.
|1||US department of health and human services. NIH practical guide for the diagnosis and management of asthma. 1997. Publication no: 97-4053.|
|2||Schulman JD, Nunn ME, Taylor SE, Hidalgo FR. The prevalence of periodontal related changes in adolescents with asthma: Results of third annual national health and nutrition examination survey. Pediatr Dentist 2003;25:279-84.|
|3||Rees J, Price J. ABC of asthma. 3 rd ed. BMJ Publishing Group: London; 1995.|
|4||Derek MS, Michael G. The dental patient with asthma: An update and oral health considerations. J Am Dent Assoc 2001;132:1229-39.|
|5||Hobson P. Sugar based medicines and dental disease. Community Dent Health 1985;2:57-62.|
|6||Baum BJ. Neurotransmitter control of secretion. J Dent Res 1987;66:628-32.|
|7||McDerra JC, Pollard MA, Curzon ME. The dental status of asthmatic british school children. Pediatr Dent 1998;20:281-7.|
|8||Arnrup K, Lundin SA, Dahlof G. Analysis of paediatric dental services provided at a regional hospital in Sweden. Dental treatment need in medically compromised children referred for dental consultation. Swed Dent J 1993;17:255-9.|
|9||Locker D. Measuring social inequality in dental health services research: Individual, household and community based measures. Community Dent Health 1993;10:139-50.|
|10||Deepthi KR, Amitha MH, Munshi AK. Dental caries status of children with bronchial asthma. J Clin Pediatr Dent 2003;27:293-5.|
|11||Drummond B. Association between childhood asthma and caries using oral examination and health interview data from the third national health and nutrition examination survey. Int J Pediatr Dent 2002;12:148.|
|12||Kankaala TM, Virtonen JI, Larmas MA. Timing of first fillings in the primary dentition and permanent molars of asthmatic children. Acta Odontol Scand 1998;56:20-4.|
|13||Conolly ME, Greenacre JK. The lymphocyte β adrenoceptor in normal subjects and patients with bronchial asthma. J Clin Invest 1976;8:1307-16.|
|14||Kargul B, Tanboga I, Ergeneli S, Karakoc F, Dagli E. Inhaler medicament effects on saliva and plaque ph in asthmatic children. J Clin Pediatr Dent 1998;22:137-40.|
|15||Ryberg M, Moller C, Ericson T. Effect of β2 adrenoceptor agonists on saliva proteins and dental caries in asthmatic children. J Dent Res 1987;66:1404-6.|
|16||Ryberg M, Moller C, Ericson T. Saliva composition and caries development in asthmatic patients treated with β2 adrenoceptor agonists: A 4 year follow up study. Scand J Dent Res 1991;99:212-8.|
|17||Mandel ID, Eriv A, Kutscher A, Denning C, Thompson RH Jr, Kessler W, et al . Calcium and phosphorus levels in submaxillary saliva. Changes in cystic fibrosis and in asthma. Clin Pediatr (Phila) 1969;8:161-4.|
|18||Magnusson I, Ericson T, Pruitt K. Effect of salivary agglutinins on bacterial colonization of tooth surfaces. Caries Res 1976;10:113-22.|
|19||Goodman, Gilman. The pharmacological basics of therapeutics. 10 th ed. Medical Publishing Division: McGraw-Hill; 2001.|
|20||Hyppa TM, Koivikko A, Paunio KU. Studies on periodontal conditions in asthmatic children. Acta Odontol Scand 1979;37:15-20.|
|21||Hyppa T. Gingival IgE and histamine concentrations in patients with asthma and in patients with periodontitis. J Clin Periodontol 1984;11:132-7.|
|22||Karl L, Hakamima. Asthma and oral health. A clinical and epidemiological study. Acta Electronica Universitatis Tamperensis 2002. p. 193. Available from: http://acta.uta.fi.|
|23||Wotman S, Mercandante J, Mandel ID, Goldman RS, Dening C. The occurrence of calculus in normal children, children with cystic fibrosis and children with asthma. J Periodontal 1973;44:278-80.|
|24||Lenander-Lumikarim M, Laurikainen K, Kuvsisto P, Vilija P. Stimulated salivary flow rate and composition in asthmatic and non asthmatic adults. Arch Oral Biol 1998;43:151-6.|
|25||Hyppa T. Salivary immunoglobulins in children with asthma. J Periodontol Res 1980;15:227-31.|