Childhood Asthma: Part II Children with Asthma and Oral Health

Pages: 113-133

Kalyoncu Isil Ozgul (1), Durhan Müesser Ahu (2), Kargul Betul (3)

(1) PhD. DDS, Assistant Professor, Department of Paediatric Dentistry, Marmara University Dental Schoool, Istanbul, Turkey; (2) PhD. DDS, Assistant Professor, Department of Paediatric Dentistry, Marmara University Dental Schoool, Istanbul, Turkey; (3) PhD. DDS. Prof., Department of Paediatric Dentistry, Marmara University Dental Schoool, Istanbul, Turkey

Part I: Childhood Asthma: Part I. General aspects and Oral Features

Special health care needs include any physical, developmental, mental, sensory, behavioural, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs. The condition may be congenital, developmental, or acquired through disease, trauma, or environmental cause and may impose limitations in performing daily self-maintenance activities or substantial limitations in a major life activity. Health care for individuals with special needs requires specialized knowledge, as well as increased awareness and attention, adaptation, and accommodative measures beyond what are considered routine [1].
Medically-necessary care (MNC) is the reasonable and essential diagnostic, preventive, and treatment services (including supplies, appliances, and devices) and follow-up care as determined by qualified health care providers in treating any condition, disease, injury, or congenital or developmental malformation to promote optimal health, growth, and development. MNC includes all supportive health care services that, in the judgment of the attending dentist, are necessary for the provision of optimal quality therapeutic and preventive oral care. These services include, but are not limited to, sedation, general anaesthesia, and utilization of surgical facilities. MNC must take into account the patient’s age, developmental status, and psychosocial well-being, in addition to the setting appropriate to meet the needs of the patient and family. Dental care is medically-necessary to prevent and eliminate orofacial disease, infection, and pain, to restore the form and function of the dentition, and to correct facial disfiguration or dysfunction [1].

Definitions of Childhood Asthma

Asthma is the commonest chronic disease in childhood. Pediatric asthma is a common chronic condition with wide-ranging implications for children’s health, their families, and the health care system [2]. Due to the various different phenotypes of childhood asthma, it has been difficult to agree on a clear definition of the condition and instead an operational description is used: ‘Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role [3].

Childhooh Asthma and Medications

Inhaled β2-agonists are important reliever medication, for both acute and chronic asthma. Combination treatment consisting of an inhaled corticosteroid and an inhaled long-acting β2-agonist has proved to be very effective in adult asthma care, but in childhood asthma and especially in pre-school children, the treatment response has not been as good [4].

Children should be monitored carefully to assess the response to treatment, and treatment that proves to be ineffective should be stopped. Asthma care involves much more than just pharmacological treatment, although this is a very important part of the treatment plan. Participation in physical activity is of prime importance in childhood asthma and should be encouraged [3].

Oral Manifestations and Prevention

There is a consensus in the literature that this disease causes an impact that directly affects the quality of life of an individual, not only due to the respiratory alterations, but also the behavioural, functional, and physical losses, as exemplified by children’s school absenteeism [5].  In addition, there is a growing body of evidence from clinical or epidemiological studies suggesting a significant increase in oral diseases in asthmatic children, including increased prevalence of caries, enamel defects, malocclusion, erosion, oral candidiasis, and changes in salivary composition and flow, which worsens in children who do not have access to dental care [6, 7].

A systematic review and meta-analysis concluded, based on a study of 25 articles from 1950 to 2010, that asthma significantly increases the risk of caries in the deciduous and permanent dentition. One of the predisposing factors is possibly the medication taken, which acts on saliva secretion and the content of immunoglobulin A. [8]. On the other hand, another literature review based on the study of 27 articles found that, although recent studies show little evidence of a relationship between asthma and dental caries, most show that the severity of the disease and its pharmacotherapy (types of drugs) are factors for an increased risk of caries [6].  Moreover, we highlighted that most of the published studies was developed in hospital context, and this study provides evidence to primary health care setting. Therefore, the increase in caries in asthmatics seems to be more associated with the treatment, especially the use of salbutamol, than with the disease itself, which is according findings in this study, in a primary health care setting [9].

Dental Caries

There are many factors related to dental caries etiology, such as diet, salivary flow, salivary components, host defenses, and socioeconomic conditions. Considering the importance of an early identification of populations at risk of dental caries, this study intended to evaluate whether the asthmatic population needs special dental attention in the form of prevention programs.  There is some controversy in the scientific community about the relationship between asthma and caries, and regarding the different methodologies used to study these diseases. In this study, widely known indexes and methodologies-were used, that allowed comparison between groups with or without asthma. The risk of dental caries in people that use asthma medications regularly has been well documented and its occurrence is mainly due to alterations in salivary parameters [10].

There has been considerable debate in the literature regarding the caries risk of asth­matic patients. Studies have demonstrated higher caries prevalence in both the primary and permanent dentitions of children with asthma [11, 12].

The long-term use of sugary medications, includ­ing antibiotics and analgesics, which may occur in the asthmatic population has been shown to be deleterious to dental health [13, 14].

Some authors found that asthmatic subjects could have higher caries risk, paying special attention to the medication used. Increased caries experience was associated with prolonged use of bronchodilators, which leads to reduced salivary flow [15].

In addi­tion, Kargul et al. described a decrease in salivary and plaque pH to below the criti­cal value of 5.5, 30 minutes after the use of agonist (salbutamol 400 mcg) and inhaler corticosteroid (fluticasonepropionate 250 mcg) [16].

Asthma itself was considered a risk factor for dental caries by some authors [17, 18]) or the medication used for asthma treatment was blamed [17, 19-21].  But there are other authors who did not find a correlation between asthma and/or the medication used and an increased caries risk [22]. Despite these divergent views, all studies conclude that asthmatic children are at risk and that special preventive programs are needed. The asthmatic through either its disease status or its pharmacotherapy carries several factors for an increased caries risk. pH values of most inhalant powders are less than 5.5. A decrease of the salivary and plaque pH has been detected in asthmatic children after use of these inhalers. This low pH value associated with a reduced salivary flow rate (caused by beta-adrenergic agonists and by anti-histaminic medication) makes asthmatics more susceptible to caries and erosion. There are only a few studies that take into account that asthma is a disease with a large diversity of severity and duration. This approach could help to clarify some variability in caries risk [23].

There are only few studies reporting its impact on the oral cavity. Children with chronic conditions such as asthma require an oral and dental preventive program as part of their interdisciplinary care [24].

It is evident that preventive strategies can be used to address the increase in caries risk in asthmatics. These include an increase in the frequency of dental maintenance visits, fluoride interventions and adherence to caries-prevention measures. All age groups should be made aware of the problem and be encouraged to have regular dental check-ups. Patients should be instructed to rinse their mouths after using an inhaler.

Casein phosphopeptide-amorphous calcium phosphate complexes

CPP-ACP is calcium phosphate is able to remineralize initial enamel lesions equivalent to fluorides [25].  In order to manage the development of carious lesion through minimising the solubility of enamel during an acid attack, the individual’s tooth surfaces should be exposed to supersaturated levels of calcium, phosphate and fluoride that are available in products containing these ions in a bio-available form [26].

Moreover, additive effects were obtained when CPP-ACP was used in conjunction with fluoride, CPP-ACP is better used as a self-applied topical coating after the teeth have been brushed with a fluoridated toothpaste by children who have a high risk of dental caries [27].

Combination of CPP-ACP and Fluoride (CPP-ACFP)

The clinical study indicated that twice daily topical applications of CPP-ACP containing paste as an adjunct to a standard oral hygiene programme which includes fluoridated toothpaste, significantly improve the remineralisation of white spot lesions. The usage of CPP-ACP paste with fluoride toothpaste could be effective for preventing demineralization and promoting remineralization of enamel subsurface lesions [28]. In addition, the Percentage Surface Microhardness Recovery (% SMHR) of enamel samples were 10% CPP-ACP+ 900 ppm Fluor (GC MI Paste Plus) >10% CPP-ACP(GC Tooth Mousse) > C3H7CaO6P+ MgCl2+10% Xylitol(R.O.C.S. Remineralizing Gel) > Control (Remineralization Solution). However, statistically significant differences were not observed between the groups (p=0.290). Three different agents can be considered as an effective agent for remineralizing artificial carious lesions [29].

Calcium Glycerophosphate (CGP)

Calcium Glycerophosphate, C3H7CaO6P, (CGP) is the salt of glycerophosphoric acid. It is typically used as a food ingredient and a nutrition supplement. The first studies from 1972 evaluating the cariostatic effect of this organic calcium phosphate by Bowen used CGP as a nutrient supplement.

Recently, a product called “ROCS mineral gel” claiming to manage the early carious lesions. Moiseeva et al. (2018) [30] reported that the application of gel containing the new mineral complex of magnesium and calcium resulted in a positive remineralizing effect which was obtained in patients with early stages of dental caries as well as those with non-caries lesions. White spots (early stage of caries) completely disappeared in 80% cases after 15 applications of this product.

A study by Kargul et al. showed that chewing sugar-free gum for at least one minute after using an inhaler can neutralize the interdental plaque pH. Therefore, the use of sugar-free chewing gum to stimulate salivary flow and buffer oral acids is encouraged [31]. Use of probiotics chewable tablets or supplements also showed some evidence in controlling the caries in children. However, its effectiveness to prevent caries is still under investigation [32].

In conclusion, asthmatic children and adolescents presented greater caries prevalence in permanent teeth after 10 years of age, as well as poor oral hygiene and greater Streptococcus Mutans salivary levels, an important bacterial group involved in the etiology of caries. Besides other important factors that should be evaluated, our results suggest that asthmatic children and adolescents should receive special dental attention for the prevention of caries [12, 22].

Dental Erosion

The increased risk of dental erosion may be attributed to the reduction in salivary flow as mentioned previously [19].

Despite the fact that asthma inhalers, particularly lactose-based inhalers, produce a low oral pH, their titratable acid­ity has not been shown to have an erosive potential for dental tissues [33].

An increased risk of dental erosion may be explained by the increased incidence of gastro-oesophageal reflux disease (GORD) amongst asthma sufferers [34].

However, it is unclear whether there is a causal relationship between asthma and GORD, or alternatively, whether this represents a chance association between two common childhood conditions. There are a number of possible explanations for this increased prevalence [35]. A significant association between asthma and GORD has been reported in the literature, although the direction of causality remains unclear [36]. As there is a strong association between asthma and GORD, all dentists must be proactive at making appropriate referrals if tooth erosion is noted [14].

To minimize the effects of medication and help prevent dental erosion, patients can be encouraged to rinse with water or fluoride mouthwashes following adminis­tration of medication in order to neutralize oral pH. The use of a spacer device to direct the acidic medication directly into the lungs may help. Patients are also advised to brush twice daily with a fluoride toothpaste.

In the case of asthmatics, there is a hypothesis that medications used in the form of oral inhalants, which come into direct contact with the palatal or lingual surfaces, resulting in higher degrees of erosion due to the low pH of medications, especially if they remain for prolonged periods in contact with the tooth surface. Despite clinical studies showing this relationship, it was, however, not seen in this study, which can be explained by the fact that the SSC asthma protocol recommends the use of spacers, which reduce the permanence of drugs deposited in the mouth, and rinsing the mouth with water after the use of medications, followed by tooth brushing. It is shown that dry powder inhalers used for asthma have an acidic pH. Therefore, patients can be encouraged to rinse their mouth immediately after using the inhaler with neutral pH or basic mouthrinses, such as liquid antacids, sodium bicarbonate in water, milk or neutral sodium fluoride mouthrinses [37].

Studies have reported a greater prevalence of erosion in children with a higher socioeconomic level, as these have different eating patterns, with greater access to the consumption of industrialized beverages, and oral hygiene habits with a higher brushing frequency [14].

Enamel Defects

The prevalence of developmental defects of enamel is reported to be increased in the asthmatic patient with its consequent risk of caries. The dental enamel defects (enamel opacity) correlated with greater asthma severity [5].

A recent systematic review including 25 studies on the aetiology of MIH found, in several studies, an association of early childhood illnesses, such as asthma, as an aetiological factor for MIH, but the results were conflicting regarding the use of medications [38].

In brief, the authors concluded that the use of asthma medications before age three did not present an increased risk for the development of marked opacities in the first molar, if compared with children that did not take medications, but had a greater chance of developing hypoplasia [39].

There is no consensus in the literature over the relationship between asthma and the occurrence of caries, enamel defects, and erosion; therefore, longitudinal studies need to be carried out to establish a possible cause-effect relationship between asthma and oral alterations in children [9].

Nevertheless, there was a relationship between caries prevalence and use of salbutamol, regardless of asthma type and severity, and erosion with high frequency of oral hygiene [9].

Periodontal  Diseases

Studies investigating the association between asthma and periodontal disease have shown equivocal results [7]. It has been suggested that the relationship between the two may be attributed to either the side effects of the asthma medication, pathological activation of the inflammatory and immune process or a combination of the two. The protective mechanisms within saliva balance the interactions between bacterial and immunological factors and help maintain periodontal health. A decrease in salivary flow and secretory IgA, caused by long term use of asthma medication, reduce its protective qualities and therefore place the patient at greater risk of developing periodontal disease. In addition to this, studies have reported that gingival tissues of asthmatic patients have markedly elevated IgE levels, which are responsible for periodontal destruction [40].

Oral hygiene has been shown to be poor in the asthmatic population. McDerra et al. (1998) [41] reported higher plaque deposits in 4–10-year-old asthmatic children, compared with controls. This was not replicated in the 11–16 year group. It was suggested that parents of the younger age group did not consider dental health to be a high priority, compared with the asthma diagnosis. Increased levels of gingivitis and calculus levels have also been demonstrated in asthmatic children. This may be exacerbated by chronic mouth breathing secondary to sinupulmonary disease.

Asthmatic patients are recommended to adopt more precautionary oral hygiene practices and keep their periodontal health under constant check.

Candida

The long-term use of ICS is strongly associated with increased incidence of oral candidal infection, in particular, pseudomembranous candidosis [42].

Asthmatic patients have increased incidence of oral candidal infection, which can be attributed to the generalised immunosuppressive and anti-inflammatory effects of the corticosteroids. In addition, many dry powdered inhalers contain lactose monohydrate. The elevated oral glucose levels provide an encouraging environment for candidal adhesion and proliferation in the oral cavity, thus elevating the risk of mucosal infection in the asthmatic patient. As mentioned previously, the use of beta-2 agonists reduces salivary flow, which may further predispose the asthmatic patient to candidal infection [7].

The risk of oral infection can be minimised by a number of simple methods. It would be prudent to advise the patient to rinse with water or to brush teeth following administration of the inhalers to reduce its topical effects on the mucosa. Increasing salivary flow though chewing sugar-free gum, along with the use of antimicrobial mouthwashes may also reduce the risk of candidal colonisation. Treatment involves the prescription of oral fluconazole or alternatively Nystatin Oral Suspension [43].

Dental Treatment in Children with Asthma

Management Consideration for the Asthmatic Patient

There are numerous management considera­tions for the dental treatment of the asth­matic patient (Table. 1). The main concern in managing asthmatic patients undergoing dental treatment is to avoid an acute attack. This will involve not only care during the procedure, but also care before and after the procedure. As a general dentist, one of the most important things to complete is a full disease history in order to ascertain the severity of the condition and adequacy of asthma control. Note frequency of exacer­bations and the date of the last exacerba­tion. Enquire about frequency of symptoms and any exercise limitation. If the patient is aware of their peak expiratory flow (PEF) or forced expiratory volume in 1 second (FEV1), then record this in the notes. Document hos­pitalisation and medication history. Record any common triggers (Table. 2). If the patient is taking a high dose of oral corticosteroids then there may be a risk of adrenal insuffi­ciency and it would be prudent to check with the general medical practitioner whether steroid cover is required for prolonged or stressful treatment. During treatment, care should be exercised to take measures to prevent exacerbation. Aerosols from ultra­sonic hand-pieces as well as tooth enamel dust and dental material residues have been shown to be triggers for asthma, together with prolonged supine positioning [44]. The use of a rubber dam in such patients may greatly help to reduce the likelihood of an attack occurring and also ensure protection of the airway [14].

Table. 1 Dental management of the asthmatic patient

Educate patients about their increased susceptibility to oral disease
Encourage regular dental check-ups with enhanced prevention including the prescription of high-strength Fluoride toothpaste and Fluoride mouth rinse, if age appropriate
Advise mouth rinsing or tooth brushing after inhaler utilisation.
Advise the use of a spacer device to deliver asthmatic drugs directly to the airway.
Advise the use of sugar-free chewing gum, particularly after meals to increase salivary _ow and buffer the acidic effects of medication.  
Be aware that asthmatic patients tend to mouth breath, have a reduced salivary flow and tend to ‘wash away the taste of the medication’ all of which results in an increase flourid intake. Therefore, it is important to ensure that patients understand the implications of frequent intake of sugary drinks and advise the consumption of water only.  
Be aware of the increased risk of dental erosion and make appropriate referrals as necessary.  
Dental antibiotic prescribing in asth­matics has not been found to have many contra-indications and most antibiotics do not interfere with asthma treatment. (Little J W., 1993).  
Extractions should be completed as atraumatically as possible and if it is a particularly difficult extraction, a referral to a specialist oral surgeon or maxillofacial team may be appropriate. There is currently no evidence to support antibiotic or topical antiseptic prophylaxis in the prevention of BRONJ ( Harrington, N., 2016).  

Table 2: Asthma triggers  (Harrington N.,et al. 2016)

Know your triggers in the dental surgery
Anxiety
Aerosols
Tooth enamel  dust
Residue from dental materials
Prolonged supine positioning
NSAIDs • Opioid drugs
Products containing sulphites

It is widely appreciated that fluoride var­nish application may be contra-indicated in children with severe asthma (usually those requiring hospitalization). The rea­son for this is the possible reaction to the ingredient colophony. Colophony is used in certain fluoride varnish preparations as a natural resin to help the varnish adhere to the tooth surface and is known to cause sensitivity reactions [14].

Asthma in the Dental Setting

Anxiety in the dental environment is a common trigger for acute asthma attacks (Fast, 1986). and, as such, clinicians should adhere to stress reduction protocols to avoid such an attack from occurring. Sedation may be indicated, but judicious case selection is nec­essary in the asthmatic patient. The use of nitrous oxide inhalation sedation in patients with mild-to-moderate asthma is thought to prevent acute symptoms [14].

However, it is advisable to obtain a medical consultation in patients with severe asthma as nitrous oxide has the potential to cause airway irritation, which may exacerbate an attack. A 2003 study by Kil et al. found that sedation with midazolam had no adverse effects on paedi­atric asthmatic patients [45], a result which con­firmed the findings of Fraone et al. in 1999 [46].

Although no adverse effects were reported, it must be remembered that midazolam is a sedative drug, which may cause respiratory depression, and caution is required when sedating the asthmatic patient. There is limiteddata on the incidence of this problem and, indeed, it is thought that the reaction is not a common one, even in sulphite-sensitive patients. This is due to the fact that dental anesthetics only contain a small amount of metabisulfate. Studies indicate that around 96% of asthmatics are not actually sensi­tive to sulfites; and those who are, are usu­ally severe, steroid-dependent asthmatics [47].

Although many articles have advised the avoidance of these sulphite-containing solu­tions, equally the use of local anaesthetics with vasoconstrictors has been used safely in asthmatic patients [47]. Therefore, it is unclear what the true recommendation should be. If a patient has a history of previous sensitiv­ity, excise caution and use a local anesthetic without a vasoconstrictor [14].

Vigilance should be exercised when deliv­ering local anaesthetic to dental patients with asthma. This is due to the presence of sodium metabisulphate, which is found in local anaesthetic solution containing vasoconstrictors and is used to prevent the breakdown of the vasoconstrictor. This agent may induce hypersensitivity reactions, thereby precipi­tating an asthma attack [48].

Management of the Acute Attack

A severe acute asthma attack may present as breathlessness and expiratory wheeze. The child may not manage to complete a sentence or may be too breathless to feed. Respiratory rate may be >40/min (2–5yrs) or >30 (>5 years). Heart rate may also be increased at >140/min (2–5 years) and >125/min (>5 years). In the case of a life threat­ening attack the patient may present with cyanosis, reduced respiratory effort, reduced heart rate, neurological signs such as con­fusion, or reduced consciousness or loss of consciousness [44, 49].

Assess airway, breathing, circulation, dis­ability, and exposure. If the patient is con­scious, sit them upright and administer two puffs of a short-acting beta agonist (salbu­tamol 100 mcg/puff inhaler) and repeat if necessary. If the patient is unable to use the inhaler appropriately, administer the drug using a spacer device. Administer oxygen at 15/L minute. If there is no improvement, or the asthma attack is severe, phone for an ambulance. If the patient loses consciousness, begin cardio-pulmonary resuscitation [50]. 

Conclusion

Asthmatic patients are at a greater risk of developing dental diseases and the dental setting contains a multitude of common triggers for asthma attacks. This highlights the importance for dental practitioners to be vigilant and to recognize the correla­tion between asthma and its associated oral health problems. Early diagnosis, cor­rect intervention and prevention can help minimize the risks of developing dental diseases and reduce the occurrence of acute exacerbations.

Note: This research is part of 2019-1-RO01-KA202-063820 Erasmus+ Project „Oral Special Care Academic Resources” (OSCAR)

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