Influence of anti-asthmatic medications on dental caries in children in Slovenia
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Transcript of Influence of anti-asthmatic medications on dental caries in children in Slovenia
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DOI: 10.1111/j.1365-263X.2012.01243.x
children in Slovenia
Influence of anti-asthmatic medications on dental caries inTOMI SAMEC1, BENNETT TOCHUKWU AMAECHI2, TADEJ BATTELINO3, UROS KRIVEC4
& JANJA JAN1
1Department of Cariology and Endodontics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia, 2Department
of Comprehensive Dentistry, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA, 3Division of
Paediatrics, Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, Ljubljana,
Slovenia, and 4Unit of Pulmonary Diseases, Division of Paediatrics, University Medical Centre Ljubljana, Ljubljana, Slovenia
International Journal of Paediatric Dentistry 2012
Objective. The study investigated the influence of
exposure to anti-asthmatic medications and of
various factors on the caries prevalence in chil-
dren in Slovenia.
Methods. The study population consisted of chil-
dren aged 2- to 17 years (n = 220) under treat-
ment for asthma, who had used anti-asthmatic
medications for at least 1 year; 220 controls were
matched for age. Caries status was determined by
the number of decayed, missing, and filled sur-
faces through clinical examination by two cali-
brated dentists using the International Caries
Detection and Assessment System-II scoring crite-
ria. Questionnaires completed by parents and data
Correspondence to:
T. Samec, Department of Cariology and Endodontics,
Faculty of Medicine, University of Ljubljana, Hrvatski trg 6,
SI – 1000 Ljubljana, Slovenia.
E-mail: [email protected]
� 2012 John Wiley & Sons Ltd, BSPD and IAPD
from the patients’ medical records provided infor-
mation on various confounding factors.
Results. Asthmatic children had significantly higher
(P £ 0.01) prevalence of caries on primary and
permanent teeth in all age groups, and the pro-
portion of caries-free children was significantly
smaller (P £ 0.05). In multivariate regression anal-
ysis, asthma diagnosis, child’s age, daily use of
inhaled glucocorticoids, length and frequency of
medicine application, spacer use, mouth rinsing
with water after medicine application, parents’
education, frequent food and drink consumption,
and frequency of toothbrushing were associated
with caries experience of asthmatic children.
Conclusion. Children with asthma who had used
anti-asthmatic medications had higher caries
experience in primary and permanent teeth.
Introduction
Dental caries is one of the most prevalent
chronic diseases worldwide. Caries lesion
forms through a complex interaction over
time between acid-producing bacteria and fer-
mentable carbohydrates and is also affected
by many host factors including saliva and
the inherent nature of the teeth. Risk of
dental caries development includes physical,
biological, environmental, behavioural, and
lifestyle-related factors, such as presence of
dental plaque, high numbers of cariogenic
bacteria, inadequate salivary flow, insufficient
fluoride exposure, poor oral hygiene, inap-
propriate sugar consumption, and usage of
various medicines1. The caries process is a
continuum result from many cycles of demin-
eralization and remineralization, which is the
body’s natural attempt of repairing caries
lesions2.
Asthma, on the other hand, is a chronic
lung disease that demonstrates reversible air-
way obstruction, inflammation of the airway,
and increased responsiveness of the airways
to stimuli. Asthma is a major global health
problem, and the prevalence is increasing in
most countries, especially among children3. It
is a leading cause of childhood hospitaliza-
tions4. The treatment of asthma starts with
avoidance to stimuli, but controlling the
symptoms with anti-asthmatic medicines is
the main component of most asthma treat-
ments. Pharmacological management of
chronic childhood asthma involves two main
categories of drugs: bronchodilators and anti-
inflammatory agents. Children with mild
1
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2 T. Samec et al.
asthma often are managed only with inhaled
b2-agonist bronchodilators. Inhaled glucocor-
ticoids are effective anti-inflammatory agents,
recommended for use in children with mod-
erate to severe asthma3.
A link between oral diseases and the com-
monly used anti-asthma inhalant medications
has biological credibility. Decreased salivary
flow rate in asthmatic children and also
changes in saliva composition and its pH are
linked to the use of anti-asthmatic medica-
tions. This association was observed for
inhaled b2-agonists5,6 and in combination
with glucocorticoids7–12. They can thus
reduce the effect of saliva in the aid of protec-
tion against caries. Adolescents and young
adults with asthma showed lower plaque ini-
tial pH values and plaque pH drop after a
sucrose rinse compared to the control
group10,11. Associations between increasing
prevalence of caries13 and lower salivary flow
rate12,14 with increasing severity of asthma
were observed, most likely due to the
increased dosage and frequency of medication
required to treat more severe asthma.
Increased salivary levels of Streptococcus mutans
were observed in asthmatic children, and
they were proved to be an important risk fac-
tor for increased caries experience15.
Risk factor for higher caries experience in
asthmatic children can also be more frequent
consumption of sweet drinks and sweets
between meals16. The reason proposed is
lower saliva secretion and dry mouth, which
are present in asthmatic patients5–9, especially
those on glucocorticoids17. The increased sus-
ceptibility to dental caries can also be due to
the frequent use of anti-asthmatic medica-
tions containing fermentable carbohydrates.
The most common is lactose monohydrate,
and although it is one of the least cariogenic
sugars, this still can lead to increased dental
caries risk18.
The mode of anti-asthmatic medicine appli-
cation may be an important factor for caries
risk. It has been shown that most of the med-
icine is retained in the mouth or throat: 80%
when using controlled-dose inhaled and in
dry powder inhaled form and 60% when
using spacer19. To remove the retained
medication from the oropharyngeal region,
patients are advised to rinse their mouths
with water after medication use.
Epidemiological studies investigating the
effect of asthma on dental caries are conflict-
ing. The majority of the studies conclude that
asthmatic children have a higher dental caries
prevalence6,10,13,16,20–23, whereas some oppose
such conclusions5,24–27. The discrepancies
between the different studies can be
explained by different study populations,
sample sizes, methodological differences, dif-
ferences in disease severity, and anti-asth-
matic medications used. In the study of
Ryberg et al.5, children currently using only
b2-agonists were included, whereas Stensson
et al.10 included adolescents with only severe
and very severe asthma with daily glucocorti-
coid treatment for a minimum of 4 years. In
the study of Shulman et al.26 no significant
associations between asthma and higher prev-
alence of dental caries were found. In this
study, <45% of the children with severe
asthma were prescribed anti-asthmatic medi-
cation, and there is a possibility that despite
their doctor’s prescription, they did not take
medicines. Only a few children from the
moderate and severe asthma group would use
glucocorticoids, and only for a short duration.
The number of studies that investigate the
association between asthma and oral health
has increased in the last decade, but more
studies are needed, as asthma affects more
than 300 million people worldwide4. There-
fore, our main aim was to investigate the
influence of exposure to anti-asthmatic medi-
cations on the caries prevalence in children
in Slovenia. In addition, we aimed to assess
the influence of various factors, for example
glucocorticoid dose, length and frequency of
medicines application, sugar presence in med-
icines, spacer use, rinsing the mouth after
medicine application, child age, sex, dietary
habits, oral hygiene habits, time since last
dental visit, and parents’ education on dental
caries susceptibility.
Materials and methods
The study population consisted of 2- to 17-
year-old children (n = 220) under treatment
for chronic bronchial asthma at the University
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Anti-asthmatic medications and dental caries 3
Children’s Hospital, Ljubljana, Slovenia. The
study was approved by ethics committee at
the Ministry of Health in Slovenia. All the
parents gave written informed consent. To
have a more homogenous group by disease
severity, the asthmatic children must have
used anti-asthmatic medications daily for at
least 1 year. To be included in the study, they
had to have physician-diagnosed asthma.
Children suffering from additional diseases
such as heart diseases, gastro-oesophageal
reflux, chromosomal abnormalities, infectious
diseases, eating disorders, and frequent vomit-
ing were excluded from the study. Controls
were healthy children matched for age
(±6 months) who went to the University
Dental Clinic in Ljubljana, Slovenia. They
were treated by undergraduate students and
had their dental charts available. Children
had equal preventive treatment and educa-
tion. A total of 440 children were examined
(mean age, 8.5 ± 3.0 years, range, 2–17 years).
Dental examinations were carried out in
2008 at the University Dental Clinic in a den-
tal chair under artificial light by two cali-
brated dentists using a standard dental mirror
and rounded dental probe. The dental exam-
iners were blinded to children with and with-
out asthma. We used a subtler, newly
developed International Caries Detection and
Assessment System-II (ICDAS II) scoring cri-
teria28, which measures the disease process at
its different stages. Caries status was deter-
mined by the number of decayed [non-cavi-
tated primary (d1) and permanent (D1), and
cavitated primary (d2) and permanent (D2)],
Table 1. International Caries Detection and Assessment System-II
Score Clinical criteria description
0 Sound tooth: no evidence ofwith developmental defects(attrition, abrasion and eros
1 First visual change in enameair-drying, which is not or h
2 Distinct visual change in enalesion must still be visible w
3 Localized enamel breakdown4 Underlying dark shadow from5 Distinct cavity with visible de6 Extensive distinct cavity with
possibly reaching the pulp.
� 2012 John Wiley & Sons Ltd, BSPD and IAPD
missing (M), and filled (f ⁄F) surfaces [primary
(dfs) and permanent (DMFS)] teeth. The basic
codes range from measurement of the first
visible carious change in enamel caused by
carious demineralization (code 1) to extensive
cavitation with visible dentin (code 6) as
shown in Table 1. Only permanent teeth
extracted as a consequence of dental caries
were marked as missing. Radiograph was not
included in the examination. Calibration
among the examiners was conducted prior to
the study by a cariologist, who is experienced
in caries diagnosis. Intra- and inter-examiner
reproducibility was tested on 10% of the chil-
dren.
Questionnaires completed by parents and
data from the patients’ medical records pro-
vided information on demographics, medical
history, medication usage, dietary history,
oral hygiene habits, fluoride exposure, and
for asthmatic children also on type, dose, fre-
quency, length and mode of medicine appli-
cation. For the glucocorticoid dose, we used
the dose the children had been using for the
previous 6 months.
For the purpose of the study, the popula-
tion was divided into three age groups. The
first age group was composed of 2- to 6-year-
old children (n = 120), the second age group
of 7- to 12-year-old children (n = 282), and
the third age group of 13- to 17-year-old chil-
dren (n = 38). Dental caries experience on
primary teeth was recorded in the first and
second age groups only, and on primary and
permanent teeth in the second and third age
groups.
(ICDAS II) scoring criteria.
caries after prolonged air-drying (5 s), surfaces(enamel hypoplasia, fluorosis), tooth wear
ion), and extrinsic or intrinsic stains will be recorded as sound.l: opacity or discoloration is visible after prolongedardly seen on a wet surface.mel: opacity or discoloration distinctly visible when wet,hen dry.owing to caries with no visible dentin or underlying shadow.dentin with or without localized enamel breakdown.
ntin: visual evidence of demineralization and dentin exposed.visible dentin with more than half of the tooth surface involved or
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4 T. Samec et al.
Data on caries experience were presented
in primary teeth as d1fs (non-cavitated
decayed and filled surfaces), d2fs (cavitated
decayed and filled surfaces), d12fs (non-cavi-
tated, cavitated, and filled surfaces), and in
permanent teeth as D1MFS (non-cavitated
decayed, missing, and filled surfaces), D2MFS
(cavitated decayed, missing, and filled sur-
faces), D12MFS (non-cavitated, cavitated,
missing, and filled surfaces).
Statistical methods
A chi-square test was used to test the distri-
bution of subjects between groups for cate-
gorical independent variables. Mann–Whitney
U-tests were used to test the association
between dental caries as dependent variable
and independent variables. Multiple linear
regression analyses were performed to explore
the effect of independent variables on d12fs
and D12MFS as dependent variables. Children
were categorized according to frequency of
medicine application (1, 2 times ⁄day), spacer
use (no spacer, spacer), mouth rinsing after
medicine application (no mouth rinsing,
mouth rinsing), sugar content in medications
(non-sugar-containing and sugar-containing
medicines), length of medicine applications
(1–3, ‡4 years), consumption of food and
drinks (£5, >5times ⁄day), frequency of tooth-
brushing (1, 2, 3 times ⁄day), glucocorticoid
dose (50, 125, 250 lg), and parents’ educa-
tion (elementary school, vocational school,
secondary school, high school, university,
postgraduate studies).
The data were analysed using the SPSS
12.0 statistical software package for Windows
(SPSS Inc., Chicago, IL, USA). The level of
statistical significance was set at P £ 0.05.
Results
Weighted Cohen’s kappa values for intra-
examiner reproducibility were 0.87 (JJ) and
0.91 (TS), and for inter-examiner reproduc-
ibility, 0.81. The mean length of anti-asth-
matic medication use in 220 asthmatic
children was 4.7 ± 3.1 years. Thirty-five
(15.9%) asthmatic children used medicines
for 1 year, 159 (72.3%) used them from 2 up
to 8 years, and 26 (11.8%) from 9 up to
16 years. All asthmatic children used
glucocorticoid daily and bronchodilator as cir-
cumstances required. Of the asthmatic chil-
dren, 28 (12.7%) used additional leucotriene
antagonists and 5 (2.3%) used antihistamines.
Glucocorticoid in controlled-dose inhaled
form was used by 173 children (78.6%) and
in dry powder inhaled form by 35 (15.9%).
After medicine application, 180 (81.8%) asth-
matic children rinsed their mouths with
water. Inhalers with spacer were used by 168
(76.4%) children. Non-sugar-containing med-
ications were used by 157 (71.4%) children.
There was no statistically significant differ-
ence between the children with and without
asthma with respect to gender, fluoride
intake, dietary habits, oral hygiene, last den-
tal visit, and parents’ education (Table 2).
Asthmatic children aged 2–6 years had sig-
nificantly (P < 0.01) higher scores of d1, d2,
d2fs, and d12fs on their primary teeth
(Table 3), and significantly (P < 0.01) less car-
ies-free children than their non-asthmatic
counterparts. Asthmatic children aged
7–12 years had significantly (P < 0.01) higher
scores of d1, d2, d2fs, and d12fs on their pri-
mary teeth (Table 3), significantly (P < 0.01)
higher scores of D1, D2, F, D1MFS, D2MFS,
and D12MFS on their permanent teeth
(Table 4), and significantly (P < 0.01) less car-
ies-free children compared to the non-asth-
matic children in that age group. Asthmatic
children aged 13–17 years had significantly
(P < 0.05) higher scores of D1, D2, F, D1MFS,
D2MFS, and D12MFS when compared with
the non-asthmatic children (Table 4), the dif-
ference in the number of caries-free children
was not statistically significant (P = 0.071).
Multiple linear regression was used to
assess the influence of length, mode (i.e.,
spacer use, mouth rinsing with water after
medicine), and frequency of medicine appli-
cation, and its glucocorticoid dose and sugar
content on dental caries experience in perma-
nent teeth. The analysis was conducted in the
group of 125 asthmatic children, 7- to 17 years
old. They used glucocorticoid daily only via
controlled-dose inhaler; therefore, it was pos-
sible to assess the use of spacer in this group.
They used bronchodilator only in the acute
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Table 2. The study sample of asthmatic children and their controls with regard to gender, fluoride exposure history, dietaryhistory, oral hygiene, time since last dental visit, and parents’ education.
Asthmatic children Controls *P-value
Gender, n (%)Male 139 (63.2) 125 (56.8) 0.173Female 81 (36.8) 95 (43.2)
Fluoride exposure history, n (%)Use of fluoride pills 91 (41.4) 101 (45.9) 0.338Use of fluoride rinse or gel 40 (18.2) 47 (21.4) 0.402
Dietary history, n (%)Consuming food and drinks ‡5 times ⁄ day 133 (60.5) 128 (58.4) 0.668Drinking sweet drinks between meals 143 (65.0) 130 (59.4) 0.223Use of acid sport drinks 13 (5.9) 18 (8.2) 0.352Use of sweets 125 (56.8) 111 (50.5) 0.181Daily use of milk and cheese 162 (73.6) 166 (75.5) 0.662
Oral hygiene, n (%)Toothbrushing 1 time ⁄ day 41 (18.0) 36 (16.4) 0.530Toothbrushing 2 times ⁄ day or more 179 (81.4) 184 (83.6)
Last dental visit, n (%)In the last 6 months 178 (80.9) 178 (80.9) 1.000More than 6 months 42 (19.1) 42 (19.1)
Parents’ education, n (%)Elementary school 13 (5.9) 9 (4.1) 0.118Profession school 34 (15.5) 20 (9.1)Secondary school 89 (40.5) 80 (36.4)High school 22 (10.0) 29 (13.2)University 52 (23.6) 71 (32.3)Postgraduate studies 10 (4.5) 11 (5.0)
*P-value is from chi-square test.
Table 3. Mean ± SD number of decayed (d1-non-cavitated, d2-cavitated, d12-non-cavitated and cavitated) and filled (f)surfaces among asthmatic children and controls in primary teeth.
Age group n d1 ± SD d2 ± SD f ± SD d12fs ± SD
Asthmatic 2–6 60 2.50 ± 3.05** 9.98 ± 15.00** 2.43 ± 3.95 14.52 ± 14.90**7–12 141 0.57 ± 1.44** 5.09 ± 8.78** 2.99 ± 4.29 8.65 ± 10.49**
Controls 2–6 60 1.15 ± 1.97 2.82 ± 4.54 3.00 ± 4.89 6.97 ± 7.267–12 141 0.13 ± 0.53 0.84 ± 2.48 2.93 ± 3.79 3.90 ± 4.62
**P < 0.01, Mann–Whitney U-test.
Table 4. Mean ± SD number of decayed (D1-non-cavitated, D2-cavitated, D12-non-cavitated and cavitated), missing (M), andfilled (F) surfaces among asthmatic children and controls in permanent teeth.
Age group n D1 ± SD D2 ± SD M ± SD F ± SD D12MFS ± SD
Asthmatic 7–12 141 2.00 ± 2.85** 1.95 ± 2.58** 0 3.06 ± 4.11** 7.01 ± 5.59**13–17 19 5.16 ± 5.00* 8.53 ± 6.42** 0.63 ± 2.75 14.26 ± 9.55** 28.58 ± 12.71**
Controls 7–12 141 0.57 ± 1.32 0.13 ± 0.49 0 0.99 ± 2.15 1.69 ± 2.6313–17 19 2.05 ± 3.67 0.84 ± 1.07 0.32 ± 1.38 6.79 ± 6.49 10.00 ± 7.04
*P < 0.05, **P < 0.01, Mann–Whitney U-test.
Anti-asthmatic medications and dental caries 5
phase. We limited the age of the children to
those with permanent teeth only. In this
group, the influence of length, mode, and fre-
quency of medicine application, its glucocorti-
coid dose and sugar content on dental caries
� 2012 John Wiley & Sons Ltd, BSPD and IAPD
experience in permanent teeth was assessed.
The mean length of anti-asthmatic medication
use was 4.9 ± 2.8 years, with a maximum
length of 12 years. Inhalers with spacer were
used by 110 (88.0%) children. After medicine
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6 T. Samec et al.
application, 103 (82.4%) children rinsed their
mouths with water, and 110 (88.0%) were
using non-sugar-containing medications. In
multivariate linear regression analysis, the
number of non-cavitated and cavitated caries,
missing, and filled surfaces (D12MFS) was the
dependent variable. The variance explained
by the model was 43%. Only the child’s age
was significantly (P = 0.00) associated with
caries experience of asthmatic children. High
glucocorticoid dose, increased frequency of
application, spacer use, and increased length
of medicine use were associated with high
D12MFS, but not statistically significant.
Mouth rinsing with water after medicine
application and sugar presence in medicines
was associated with low D12MFS, but not sta-
tistically significant.
To assess the influence of various con-
founding factors on caries experience in pri-
mary and permanent teeth in children of
different age groups, we utilized standard
multiple regression analysis (Table 5). Vari-
ables with P-values <0.20 in bivariate analysis
were selected for inclusion in a multivariate
model, as well as variables that previous stud-
ies had suggested were plausible predictors of
caries occurrence. The best models, based on
statistical significance for d12fs or D12MFS as
the dependent variable, were the models with
the following predictors: child age, asthma
diagnosis, parents’ education, consumption of
food and drinks ‡5 times ⁄day, daily glucocor-
ticoid dose, and frequency of toothbrushing.
In children aged 2–6 years, significantly
(P < 0.01) higher d12fs were found in children
with asthma diagnosis and of less educated
parents. In children aged 7–12 years, signifi-
cantly (P < 0.01) higher d12fs were found in
children of less educated parents and with
higher daily dose of glucocorticoid, and signifi-
cantly (P < 0.05) higher d12fs were found also
in children with asthma diagnosis and in
those who had consumed food and drinks
‡5 times ⁄ day. Higher D12MFS in children aged
7–12 years were significantly (P < 0.01) associ-
ated with asthma diagnosis and less-frequent
toothbrushing. In children aged 13–17 years,
only asthma diagnosis proved to be statistically
significantly (P < 0.01) associated with high
D12MFS in the model.
Discussion
In this study, the influence of exposure to
anti-asthmatic medications on the caries prev-
alence in children in Slovenia was investi-
gated. For the first time, it was shown that
asthmatic children have more non-cavitated
(i.e., ICDAS codes 1 and 2) as well as cavi-
tated lesions in their primary and permanent
teeth, and the proportion of caries-free chil-
dren was also smaller among the children
with asthma. The existence of non-cavitated
lesions, which were more prevalent than cav-
itated lesions, is an evidence of newly devel-
oping caries with chances of progressing to
cavitated caries, if an effective preventive
treatment is not implemented. These sug-
gested that there are factors that tilt the bio-
chemistry of the oral environment of
asthmatic children towards high caries risk,
indicating that asthmatic children are at a
high-caries-risk status.
The recognized importance of non-cavitated
primary lesions for caries risk assessment28
was ignored by previous studies, with few
exceptions, where also initial caries lesions
were recorded5,6,10,11,13,16,24. Inclusion of
early stages of the caries process improves the
precision of studies28. This trend was also
shown in the studies on adolescents and
young adults with asthma, where different
results were observed with initial and mani-
fested (frank) caries lesions; initial lesions
were significantly higher in patients with
asthma compared to the healthy controls,
whereas in manifested lesions, patients with
and without asthma had similar numbers10,11.
Asthmatic children had an increased preva-
lence of filled teeth surfaces on their perma-
nent teeth compared with controls, which is
an indication of a higher treatment need to
restore cavitated lesions. This observation is
consistent with the report of Kankaala et al.20
that asthmatic children receiving inhaled
glucocorticoids showed higher filling incre-
ments in the primary molars. Previous caries
prevalence studies showed that children in
younger age groups are more susceptible to
caries than older children29. Also, permanent
teeth were reported to be more at risk of car-
ies development30. In contrary, this study
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Table 5. Multiple regression analysis, on 440 children on primary teeth in 1 (2–6 years) and 2 (7–12 years) age group and onpermanent teeth in 2 and 3 (13–17 years) age group.
Independent variables B* SE† b‡ P-value
95% Confidenceinterval for B
Lower bound Upper bound
Model 1 (n = 120, age group: 2–6); dependent variable: d12fsConstant 11.04 4.98 0.029 1.17 20.91Child age (years) 1.47 0.89 0.14 0.101 )0.29 3.23Asthma 6.23 2.10 0.25 0.004 2.08 10.39Parents’s education )2.82 0.87 )0.29 0.002 )4.55 )1.10R2 = 0.18
Model 2 (n = 282, age group: 7–12); dependent variable: d12fsConstant 30.30 3.30 0.000 23.79 36.80Child age (years) )2.39 0.29 )0.42 0.000 )2.96 )1.82Asthma 2.38 1.08 0.14 0.028 )0.26 4.50Consuming food and drinks ‡5times ⁄ day 2.04 0.85 0.12 0.017 0.37 3.72Parents’s education )1.36 0.33 )0.21 0.000 )2.01 )0.71Daily glucocorticoid dose (lg) 0.01 0.01 0.18 0.004 0.01 0.02R2 = 0.32
Model 3 (n = 282, age group: 7–12); dependent variable: D12MFSConstant )2.83 1.94 0.145 )6.64 )0.98Child age (years) 0.76 0.15 0.22 0.000 0.43 1.09Asthma 5.22 0.50 0.51 0.000 4.24 6.20Frequency of toothbrushing )1.25 0.46 )0.13 0.007 )2.15 0.34R2 = 0.34
Model 4 (n = 38, age group: 13–17); dependent variable: D12MFSConstant )50.14 19.19 0.013 )89.09 )11.19Child age (years) 4.28 1.36 0.34 0.003 1.52 7.03Asthma 18.58 2.98 0.68 0.000 12.52 24.68R2 = 0.58
*B, unstandardized regression coefficient; †SE, standard error; ‡ b, standardized regression coefficient.
Anti-asthmatic medications and dental caries 7
showed that asthmatic children had signifi-
cantly higher caries prevalence in all age
groups in primary as well as in permanent
teeth. This is an indication that children with
asthma have some common factors predispos-
ing them to the risk of dental caries. This
study demonstrated these factors to include
the frequent and long-term exposure to
inhaled glucocorticoids, which was found to
be significantly associated with high caries
prevalence in both primary and permanent
teeth. This result is consistent with those of
Stensson et al.13, who found higher caries
experience in children with severe and very
severe asthma and doing regular use of
higher doses of glucocorticoids, compared to
those with mild and moderate asthma, who
would use glucocorticoids only periodically in
lower doses or not at all. Also, frequent use
of anti-asthmatic medications23 or the
increased severity of asthma22 was found to
be associated with increased caries experi-
ence. Previous studies also reported a dose–
� 2012 John Wiley & Sons Ltd, BSPD and IAPD
response effect of b2-agonists on impairment
of saliva secretion and composition14, adverse
effect of asthma severity on salivary flow
rate12, the correlation of the duration of med-
ication with decreased salivary pH and higher
salivary levels of Streptococcus mutans29, and
other important determinants that can influ-
ence caries process1.
The presence of lactose in some anti-asth-
matic medicines could, along with a
decreased salivary flow rate, promote the pro-
liferation of cariogenic bacteria18,22. In this
study, however, the association between lac-
tose-containing anti-asthmatic medications
and caries prevalence (D12MFS) was not sig-
nificant. This may be due to the sample size
where only 12% of the investigated children
were users of lactose-containing medications,
with some of them rinsing after medication
intake. In addition, although the proximal
surfaces were examined visually from the
buccal and lingual sides of the dentition, the
proximal caries, especially the incipient
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8 T. Samec et al.
lesions, may have been underscored in this
study because of exclusion of bitewing radio-
graph from the examination. This is particu-
larly important because it has been predicted
that lactose in inhaler may lodge between the
teeth to cause caries in asthmatic children.
Bitewing radiograph as one of examination
methods was rejected by the ethics commit-
tee, who considers it an unnecessary expo-
sure of the children to ionizing radiation,
because there is no treatment component to
the study.
In this study, the use of spacer and rinsing
the mouth with water after medicine applica-
tion demonstrated to be protective factors in
caries development, although not statistically
significant. Spacer is believed to reduce the
amount of the lactose reaching the tooth sur-
face, whereas rinsing after medication intake
can facilitate cleansing away of residual sugar
from the tooth surfaces.
Asthmatic children did not differ signifi-
cantly from their non-asthmatic counterparts
with respect to gender, fluoride intake, die-
tary habits, oral hygiene, time since last den-
tal visit and parents’ education, although the
number of children consuming sweet drinks
between meals and consuming sweets was
higher in the group of asthmatic children,
which is in line with the results of Stensson
et al.16, where preschool children with asthma
showed higher intake of sugary drinks than
healthy controls. It was suggested that this
may be due to the dry mouth associated with
lower saliva secretion in asthmatic patients.
In this study, consumption of food and drinks
‡5 times ⁄ day proved to be a significant pre-
dictor in the model for the caries prevalence
in primary teeth as the dependent variable,
which confirms previous research16. Dental
caries lesions result from a shift in the ecol-
ogy and metabolic activity of the biofilm1,
which can be dramatically enhanced by add-
ing fermentable carbohydrates.
Parents’ education was associated with den-
tal caries prevalence in primary teeth,
whereas in permanent teeth caries prevalence
was influenced by frequency of toothbrush-
ing. This is in line with the observations of
previous studies31, showing that as the child
grows up, the influence of parents’ behavio-
ural factors gets smaller, and self-behaviour is
more important. In the study, we have not
considered variables such as mouth breathing,
saliva, or lifestyle in asthmatic children,
although these might also be potential con-
founding factors for dental caries.
The results of this study showed that chil-
dren with asthma who had used anti-asth-
matic medications had higher prevalence of
caries in primary and permanent teeth. This
calls for the development of an integrated
multidisciplinary oral health preventive pro-
gramme for these high-caries-risk population.
Further investigation is needed to elucidate
factors responsible for the association of anti-
asthmatic drugs with high caries prevalence.
Why this paper is important for paediatric
dentistsd This study shows that children with asthma that had
used anti-asthmatic medications had higher prevalence
of caries in primary and permanent teeth. The associa-
tion was observed with non-cavitated as well as with
cavitated caries lesions.d For these high-caries-risk children, an integrated mul-
tidisciplinary oral health preventive programme is
needed.
Acknowledgements
Supported by Slovenian Ministry of Science
and Education (No. P3-0374).
Conflict of interest
The authors declare no conflict of interest.
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