|Year : 2015 | Volume
| Issue : 4 | Page : 167-171
Dental caries in 3-12-year-old Sudanese children with bronchial asthma
Sara Mohamed Hamid1, Fatima Elkhadir Elhassan2, Awatif Hassan1
1 Department of Pediatric Dentistry, University of Alneelain, Khartoum, Sudan
2 Department of Pediatric Dentistry, Faculty of Dentistry, University of Khartoum, Khartoum, Sudan
|Date of Web Publication||17-Feb-2016|
Sara Mohamed Hamid
Department of Pediatric Dentistry, University of Alneelain, Khartoum
Source of Support: None, Conflict of Interest: None
Background: There is a lack of consensus regarding the relationship between the risk of dental caries and asthma in the child population. Most studies concluded that asthmatic children are at risk of dental caries from the disease status or its pharmacotherapy. The objectives of this study werer to assess the dental caries status of asthmatic patients in the age group of 3-14 years and to examine the possible association of these conditions to various aspects of bronchial asthma and its management. Materials and Methods: The present study is a hospital-based case-control cross-sectional study. One hundred and five asthmatic patients were studied. The children were examined for their dental caries status, and the scores were compared with age-, gender- and socioeconomic status-matched group of 112 nonasthmatic patients selected randomly from public schools (control group). Caries lesions were assessed using decayed, missing, filled teeth/decayed, missing, and filled surfaces (DMFT/DMFS) and dmft/dmfs index according to the WHO criteria (1987). Parents or guardians provided information about oral hygiene and dietary habits by direct interview. Asthma-related data (type and form of medication, severity and duration of asthma) were collected from medical records and/or parental interview. Results: The mean age of asthmatics was (7.7 ± 3.5) years and (7.8 ± 3.5) for nonasthmatics. The results showed significantly higher prevalence and severity of dental caries among asthmatic group. As comparing asthmatic children using β2-agonists to those children using β2-agonists and corticosteroids, the results revealed that there were no statistically significant differences in caries index between the two groups. In their primary teeth, children with severe asthma had higher dmft/dmfs than children with moderate and mild asthma unlike in the permanent teeth. Form of medication used - an inhaler or a noninhaler combination (syrup and tablets) - had no effect on caries index. In this study, there was no correlation between duration of asthma and the caries indices. Conclusion: Children suffering from bronchial asthma appear to be at higher risk of having caries. This risk is increased with the severity of bronchial asthma. Form of the medications being used had no effect on caries experience.
Keywords: Bronchial asthma, children, dental caries
|How to cite this article:|
Hamid SM, Elhassan FE, Hassan A. Dental caries in 3-12-year-old Sudanese children with bronchial asthma. J Dent Res Rev 2015;2:167-71
|How to cite this URL:|
Hamid SM, Elhassan FE, Hassan A. Dental caries in 3-12-year-old Sudanese children with bronchial asthma. J Dent Res Rev [serial online] 2015 [cited 2019 Jul 16];2:167-71. Available from: http://www.jdrr.org/text.asp?2015/2/4/167/176681
| Introduction|| |
Asthma is one of the most common chronic medical conditions during childhood, and it increased during the last decades.  The incidence of asthma in Sudan has doubled between 1998 and 2002 and prevalence of asthma in children was estimated to be 12% in urban areas and 5% in rural areas. Dental caries is the single most common chronic childhood disease. It is 5 times more common than asthma and 7 times more common than hay fever.  Children with chronic medical disorders mostly require long-term medication. This put them at high risk of dental diseases in general and dental caries in particular. This high risk is either a consequence of their disease or as a side-effect to their medication.  Previous studies investigating the effect of asthma on dental health are conflicting. Some authors have reported a correlation between childhood asthma and dental caries in children, whereas others have found no such association.  It is suggested that the increase in caries prevalence was associated with prolonged use of ß2-agonists, which lead to decreased salivary flow, alter saliva composition, and decreased pH, therefore, reducing and modifying the protective effects of saliva.  There was also an increase in the number of lactobacilli and Streptococcus mutans in the oral cavity which contributed to increased caries susceptibility.  Higher rates of caries among asthmatics were considered possibly due to antiasthma medications containing fermentable carbohydrate and sugar. ,, Moreover, drugs inhaled to combat asthma may have a pH low enough to cause hydroxyapatite dissolution. 
The aims of the present study were to investigate if there is an association between asthma and dental caries among 3-14 years old Sudanese children, caries index in asthmatics in relation to severity of asthma, the effect of different types of asthma medication on caries development, and to correlate caries index with duration of asthma medication.
| Materials and Methods|| |
The case group comprised 105 asthmatic patients aged 3-14-year-old who were suffering from bronchial asthma and receiving treatment at the Khartoum and Omdurman Children's specialized hospitals. Only those patients who were on asthmatic medications (both β2-agonists and corticosteroids) for at least 6 months were included in the study. There were categorized into mild, moderate, and severe categories according to the National Heart, Lung, and Blood Institute of classification system created in the USA in 1997. Asthmatic children having other debilitating medical conditions were excluded from the study. Medical information regarding the duration and severity of asthma, type of medication prescribed, and the frequency of administration was obtained from the medical records of the patients. The control nonasthmatic group comprised 112 children, they were randomly selected from children attending kindergartens/schools in Khartoum State. They were matched for age, gender, and socioeconomic status with the asthmatic group.
A single examiner performed all examinations throughout the study in accordance with the WHO Guidelines for Oral Health Surveys (1987).
Clinical examination of subjects was done under artificial light on suitable ordinary chairs using standard examination sets. Data were collected by means of a preformed design to collect information regarding patient's age, gender, and their oral hygiene practices. The decayed, missing, filled teeth/decayed, missing, and filled surfaces (dmft/dmfs) and DMFT/DMFS indices were recorded using the WHO Guidelines for Basic Research Methods (1987).
The results were analyzed using Statistical Package for Social Sciences Version 11.0 0 (SPSS Inc. IBM Statistics, Chicago, USA) computer software as follows:
- Test was used in the case that the scores were normally distributed. Otherwise, Mann-Whitney test was used
- One-way ANOVA or Kruskall-Wallis in case of nonnormal data, was used to compare dental status across the levels of severity
- The correlation between dmft and DMFT and duration of asthma was calculated using Pearson correlation coefficient.
Furthermore, standard descriptive statistics were used to summarize and present the result of each group, and inferential statistics were used to detect the existence of significance difference in dmft/and DMFT and DMFT/DMFS level between case and control groups.
| Results|| |
General characteristics of asthmatic versus nonasthmatic children
A total of 217 children were enrolled in this study. The study group comprised 105 asthmatic children (48.4%) with a mean age of (7.70 ± 3.48) years. The control group consisted of 112 nonasthmatic children (51.6%) with a mean age of (7.77 ± 3.49) years.
Male asthmatic children represented 52.6% (59) whereas female asthmatics represent 47.4% (45). In the control group, males represented 65.2% (60) whereas females represented 43.8% (52).
Characteristics of the asthmatic group
The percentage of subjects using medication in the form of inhaler was 79.1% whereas the percentage of users of noninhaler medication (syrup and tablets or combination) was 20.9%. Within the inhaler group, the percentage of patients using β2-agonists and patients using β2-agonists with corticosteroids was 79.4% and 20.6% (65 and 18), respectively. Regarding the severity of asthma, there were 46 mild, 41 moderate, and 18 with severe asthma cases.
Asthmatic versus nonasthmatic as far as dental caries is concerned
The percentage of children with caries-free primary dentition in the asthmatic and nonasthmatic groups was 17.4% and 33.5%, respectively, while the percentage of children with caries-free permanent dentition in the asthmatic and nonasthmatic groups was 13.6% and 34.2%, respectively. Comparison of dental caries in the two groups using Mann-Whitney test, the result showed a significantly higher prevalence and severity of dental caries among asthmatic patients as compared to the matched nonasthmatic group in both primary and permanent dentitions [Table 1].
|Table 1: Comparison of caries experience in asthmatic and non-asthmatic groups|
Click here to view
Dental caries and asthma-related factors
When comparing the caries experience in asthmatic children using β2-agonists with children using β2-agonists and corticosteroids, the results revealed that there were no statistically significant differences in the dmft/dmfs and DMFT/DMFS between the two groups (P > 0.05) [Table 2]. Furthermore, the difference in caries experience between users of the various drug regimens (inhaler and noninhaler) was regarded nonsignificant (P > 0.05).
|Table 2: Comparison of the dmft/dmfs and DMFT/DMFS in patients using β2-agonists with those using β2-agonists + inhaled corticosteroids|
Click here to view
In their primary teeth, children with severe asthma had higher dmft/dmfs than children with moderate and mild asthma; however, Kruskal-Wallis test showed that there was no statistically significant difference when comparing DMFT/DMFS (permanent teeth) in patients with different levels of asthma severity [Table 3] and [Table 4].
|Table 3: Comparison of decayed, missing, filled teeth/decayed, missing, and filled surfaces in different groups according to asthma severity, using Kruskal-Wallis test|
Click here to view
|Table 4: Comparison of decayed, missing, filled teeth/decayed, missing, and filled surfaces in different groups according to asthma severity, using Kruskal-Wallis test|
Click here to view
Pearson correlation revealed that there was no relationship between the duration of asthma and caries index.
Mann-Whitney test revealed that there was statistically significant difference in sweet consumption between the two groups (P > 0.05).
| Discussion|| |
The relationship between the asthmatic disease and caries prevalence in preschool children is multifactorial and difficult to investigate. The asthma condition, its severity and the medication, often fluctuate over time according to the seasons.  The results of the present study have shown higher caries experience in the asthmatic compared to the nonasthmatic Sudanese children. Factors related to the asthmatic condition and/or its medication, were most probably behind this increase in the risk of caries. These findings concerning caries in asthmatics are in harmony with previous studies, ,,,,,, who showed a high prevalence of caries in asthmatic children. The results of present study, however, contradict the studies conducted by Shulman et al. and Meldrum et al. , and Bjerkeborn et al. who failed to detect any significant difference in caries experience between asthmatic and nonasthmatic children. The disagreement with the findings of Meldrum et al.  could be related to the difference in the study designs. Their study was a cohort one while ours was a case-control. A possible explanation for the conflicting results reported by Shulman et al. could be due to the difference in the age group, they examined children up to 16 years, and among them the age group 14-16 years had the highest number of caries-free teeth. This age group, however, was not included in our study. The contradiction with the study conducted by Bjerkeborn et al., in 1987,  may be due to the use of newer generations of asthmatic drugs during recent decades that could cause the higher caries index seen in our study. Another finding of this study is that there is no statistically significant difference between children who received β2-agonists alone and those using corticosteroids and β2-agonists in their caries experience. This finding contradict the results of Khalilzadeh et al. The explanation may be due to fewer number of patients using corticosteroids and β2-agonists in our study (20.6% or 18 patients). Furthermore, based on our study, the form of asthma medication used an inhaler or a noninhaler combination (syrup and tablets) has no effect on dmft/dmfts and DMFT/DMFTS scores. This result is similar to the finding of Ghasempour et al.  but disagrees with Reddy et al.,  who reported higher caries index in children using the drug in a form of syrup. However, in our study, there were no children using syrup or tablets alone-always combination. Hence, the two findings are not strictly comparable. Although the higher rates of caries reported in the literature among asthmatic patients were related also to the antiasthma medications containing fermentable carbohydrate and sugar, ,, the percentage of users of noninhaler medications (syrup and tablets) in our study was only 20.9% as compared to the 79.1% using inhaler medication. This finding precludes the possibility of the local effect of sugars added to the drug as a causative factor for caries, and raises an important question whether the systemic effect of the disease and/or the drug or the local effect of the lowered pH of the inhaled drug that may be responsible of the higher caries rate. Drugs inhaled to combat asthma were reported to have a pH low enough to cause hydroxyapatite dissolution. The inhalations of acidic mists have been demonstrated to cause great destruction to exposed teeth. ,, Furthermore, this study revealed a positive correlation between the caries experience and severity of asthma in the primary dentition. The increase in caries prevalence with the severity of asthma may be due to the increase in the dosage and frequency of medication. These findings agree with Reddy et al.,  but conflict the findings of Ghasempou et al.  and Stensson et al.,  who could not find any similar correlation in both primary and permanent dentitions. The disagreement with the latter may be due to homogeneity of their children. Their study was conducted in preschool children aged 3 years and 6 years; all children were registered as having asthma within the selected geographical areas while our sample was heterogeneous with respect to age and residence. This study, however, failed to reveal any correlation between severity of asthma and caries index in the permanent dentition. This is contradicting with a study conducted by Milano et al.,  who found that the duration of asthma medication use was associated with a decreased likelihood of caries experience in children in the mixed dentition. Furthermore, our results failed to disclose a correlation between caries experience and duration of asthma. These findings are similar to the findings of Eloot et al.  and Ersin et al. However, they contradict those of Reddy et al., lack of association between the caries experience and the duration of asthma seen in this study has no clear explanation, and further studies are recommended to unveil the reasons. When sweet consumption was compared between the two groups, it was found that asthmatic children consumed more sweets than nonasthmatic. This difference was statistically significant and of clinical importance as this might worsen their oral health state. Shashikiran et al. in their study found that asthmatic children had 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. This is in accordance with this study which found that asthmatic children consume more sweets. In the present study, no difference was found in brushing habits between the two groups. This supports the idea that the increase in the prevalence of dental caries in asthmatic children may be due to systemic reasons related to the disease itself and/or the medication used rather than local factors. Although all of the children in both groups had used the toothbrush, around 55% of them brushed their teeth only once per day. This might also lead to more deterioration in their oral health and strengthen the inherent susceptibility to caries attack in the asthmatic group. Dental education directed toward maintaining good oral hygiene should be strongly emphasized for these children.
| Conclusion|| |
Based on the findings from our study, we concluded that asthmatic children had higher dental caries than nonasthmatics. Caries increased with the severity of bronchial asthma. Neither the duration of asthma nor the type and form of medication were found as risk factors for caries development in asthmatic children.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mannino DM, Homa DM, Pertowski CA, Ashizawa A, Nixon LL, Johnson CA, et al.
Surveillance for asthma - United States, 1960-1995. MMWR CDC Surveill Summ 1998;47:1-27.
McDonald RE, Avery DR, Dean JA. Dentistry for the Child and Adolescent. 8 th
ed. Missouri: Mosby, USA: Elsevier; 2004.
Shashikiran ND, Reddy VV, Raju PK. Effect of antiasthmatic medication on dental disease: Dental caries and periodontal disease. J Indian Soc Pedod Prev Dent 2007;25:65-8.
Stensson M, Wendt LK, Koch G, Oldaeus G, Birkhed D. Oral health in preschool children with asthma. Int J Paediatr Dent 2008;18:243-50.
Ersin NK, Gülen F, Eronat N, Cogulu D, Demir E, Tanaç R, et al.
Oral and dental manifestations of young asthmatics related to medication, severity and duration of condition. Pediatr Int 2006;48:549-54.
Ryberg M, Möller C, Ericson T. Effect of beta 2-adrenoceptor agonists on saliva proteins and dental caries in asthmatic children. J Dent Res 1987;66:1404-6.
Maguire A, Rugg-Gunn AJ, Butler TJ. Dental health of children taking antimicrobial and non-antimicrobial liquid oral medication long-term. Caries Res 1996;30:16-21.
Holbrook WP, Kristinsson MJ, Gunnarsdóttir S, Briem B. Caries prevalence, Streptococcus mutans
and sugar intake among 4-year-old urban children in Iceland. Community Dent Oral Epidemiol 1989;17:292-5.
Storhaug K. Caries experience in disabled pre-school children. Acta Odontol Scand 1985;43:241-8.
O'Sullivan EA, Curzon ME. Drug treatments for asthma may cause erosive tooth damage. BMJ 1998;317:820.
Mehta A, Sequeira PS, Sahoo RC. Bronchial asthma and dental caries risk: Results from a case control study. J Contemp Dent Pract 2009;10:59-66.
Wierchola B, Emerich K, Adamowicz-Klepalska B. The association between bronchial asthma and dental caries in children of the developmental age. Eur J Paediatr Dent 2006;7:142-5.
Ghasempour M, Mohammadzade I, Hosaininia K. Dental health status in asthmatic children. J Isfahan Dent Sch 2005;1:41-6.
Mazzoleni S, Stellini E, Cavaleri E, Angelova Volponi A, Ferro R, Fochesato Colombani S. Dental caries in children with asthma undergoing treatment with short-acting beta2-agonists. Eur J Paediatr Dent 2008;9:132-8.
McDerra EJ, Pollard MA, Curzon ME. The dental status of asthmatic British school children. Pediatr Dent 1998;20:281-7.
Shulman JD, Taylor SE, Nunn ME. The association between asthma and dental caries in children and adolescents: A population-based case-control study. Caries Res 2001;35:240-6.
Meldrum AM, Thomson WM, Drummond BK, Sears MR. Is asthma a risk factor for dental caries? Finding from a cohort study. Caries Res 2001;35:235-9.
Bjerkeborn K, Dahllöf G, Hedlin G, Lindell M, Modéer T. Effect of disease severity and pharmacotherapy of asthma on oral health in asthmatic children. Scand J Dent Res 1987;95:159-64.
Khalilzadeh S, Salamzadeh J, Salem F, Salem K, Vala MH. Dental caries-associated microorganisms in asthmatic children. Tanaffos 2007;6:42-6.
Reddy DK, Hegde AM, Munshi AK. Dental caries status of children with bronchial asthma. J Clin Pediatr Dent 2003;27:293-5.
Ten Bruggen Cate HJ. Dental erosion in industry. Br J Ind Med 1968;25:249-66.
Arnrup K, Lundin SA, Dahllöf 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.
Milano M, Lee JY, Donovan K, Chen JW. A cross-sectional study of medication-related factors and caries experience in asthmatic children. Pediatr Dent 2006;28:415-9.
Eloot AK, Vanobbergen JN, De Baets F, Martens LC. Oral health and habits in children with asthma related to severity and duration of condition. Eur J Paediatr Dent 2004;5:210-5.
[Table 1], [Table 2], [Table 3], [Table 4]