Research Article PREVALENCE OF DENTAL CARIES IN 6-12 YEARS OLD ASTHMATIC CHILDREN: A CASE CONTROL STUDY. University Journal of Dental Sciences

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1 PREVALENCE OF DENTAL CARIES IN 6-12 YEARS OLD ASTHMATIC CHILDREN: A CASE CONTROL STUDY University Journal of Dental Sciences Seema Jabeen, Saumya Navit, Suleman A.Khan, Anshul Sharma, Neha Jaiswal 1,4 Senior Lecturer, Professor and Head, Professor, Post Graduate Student, Department of Pediatric and Preventive Dentistry, Saraswati Dental College; Lucknow Research Article ABSTRACT : Aim: The aim of the study was to determine the dental caries status and salivary properties of asthmatic children. Methods: Salivary samples were collected to measure the salivary flow rate, salivary ph and its buffering capacity. Dental caries examination was carried out according to WHO criteria. Results: Asthmatic children undergoing treatment showed diminished salivary production and secretion resulting in lower flow rate and buffer capacity. Since saliva is the most important defensive factor against dental caries, these alterations in the salivary properties attribute to increased prevalence of dental caries in asthmatic children. Conclusion: The current study found supporting evidence for the higher caries prevalence among asthmatic children than healthy control. Salivary flow rate, ph and buffering capacity of saliva was significantly lower in asthmatic children as compared to the non-asthmatic healthy controls. Key words : Asthma, salivary ph, flow rate, buffering capacity, dental caries Source of support : NIL Conflict of interest : NIL INTRODUCTION : According to Global Alliance against Chronic Respiratory Disease in the year 2010, worldwide, 1 billion persons suffered from chronic lung diseases of which 300 million were affected with asthma [1]. Due to increasing prevalence of asthma in pediatric population it is essential to scrutinize how the disease status and its pharmacotherapy affect oral health in children especially dental caries. Asthmatic children have shown to have a high prevalence of caries and this increases with the severity and duration of asthma [2]. The drugs used to manage asthma are known to have an effect on salivary secretion. Saliva has a critical role to play in the prevention of dental caries by maintaining the equilibrium between demineralization and remineralization. Asthma medication thus reduces the protective ability of saliva against caries. Role of asthma as being a probable determinant for increased caries possibility was first studied in the late 1970's. Since then, several studies have evaluated the effect of asthma disease on caries prevalence. Few studies [3,4,5,6,7] have evaluated the possible cariogenic mechanisms related to use of asthma medications while some studies [8,9,10]show no association between asthma and caries. Since the previous studies have produced conflicting results, present study was designed to evaluate association of asthma and dental caries in 6 to 12 old years children in an Indian population. Therefore, the current study was undertaken to determine the influence of asthma medication on salivary properties like flow rate, ph and buffering capacity and in turn its effect on dental caries in asthmatic children. MATERIAL AND METHOD : The present case control study involved children aged 6-12 years from two experimental groups: asthma and asthma free group comprising of 62 children in each group. Both the groups were matched for age, gender and socioeconomic status [11]. For the asthma group, children from both genders were randomly selected from the patients who attended the Outpatient Department (OPD) of Department of Pediatrics at Vivekanand Polyclinic, Lucknow. Children for control group were selected from various in and around Lucknow school. University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 57

2 The study protocol was approved by the ethical committee of Saraswati Dental College. Informed consent was obtained from the parents/guardians of the children involved in the study. Inclusion Criteria: 1)Child with asthma diagnosed by physician. 2)Taking medication for past one year. 3) Those willing to participate Exclusion Criteria: 1) Children undergoing any other medical treatment that might affect salivary properties Study Design: This study design constituted of two parts: A) An interview preforms instead of; It was designed specifically for the study. It consisted of two sections. Section 1 contains three items pertaining to age, gender and socioeconomic status.[11] Section 2 contains grading of asthma according to severity into intermittent, mild persistent, moderate persistent and severe persistent given by National Heart, Blood and Lung Institute Expert Panel Report 3 [12]. B) Clinical examination: Clinical examination was divided into salivary properties examination and dental examination 1) Salivary examination Salivary examination was done to assess the quantitative and qualitative properties of saliva. Quantitative being salivary flow rate and qualitative being ph of resting saliva and buffering capacity of stimulated saliva. Salivary examination was done by using GC saliva check buffer kit (GC India Dental Pvt Ltd). Procedure to measure: a) ph of resting saliva; Patient was asked to expectorate any pooled/resting saliva into the collection cup. The ph strip was taken and placed into the sample of resting saliva for 10 seconds, and then checked for the color of the strip. This was compared with the testing chart available in the package. b) Salivary flow rate: In order to measure the rate of salivary flow patient was instructed to chew paraffin wax for 5 minutes and then saliva was collected into the collection cup at regular interval of 1 minute each. The quantity of saliva was measured by checking the millilitre markings on the side of the cup and rate was evaluated under 3 categories [<3.5 ml is very low, between ml is low and >5.0 ml is normal] c) Buffering capacity: Sufficient amount of saliva was drawn with the help of pipette from the collection cup and one drop was dispensed onto each of the three test pads. The test pad begins to change color immediately and after 2 minutes the final result was calculated by adding the points according to the final color of each pad.[0-5 very low,6-9 low and normal/high] 2) Dental Examination: In the present study the age group was 6-12 years hence diagnosis of dental caries for both primary and permanent dentition i.e. deft (decayed, extracted due to caries or filled tooth) and DMFT (decayed, missing or filled tooth) respectively was established according to World Health Organization guidelines for epidemiological studies [13]. RESULT : Comparison of salivary physical properties between two groups was done [Table 1]. To test the significance of two means the student 't' test was used. It was found that salivary ph, flow rate and buffering capacity was significantly lower in cases as compared to controls (p<0.001). [Table-1]: Comparison of salivary Physical Properties between two groups [Table 2 & 3] show association of DMFT/deft with salivary ph. To test the significance of two means between ph <7 and >7 the student 't' test was used for overall and cases. In case of control group there was only one subject with salivary ph<7 with 'zero' DMFT value. [Table-2]: Association of DMFT (permanent dentition) with salivary ph [Table-3]: Association of deft (primary dentition) with salivary ph University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 58

3 With increasing duration of disease and its severity, an increase in DMFT/deft was observed [Table 4 & 5]. Analysis of Variance (ANOVA) test was used to compare the within group and between group variances amongst the study groups. ANOVA provided F" ratio, where a higher "F" value depicted a higher inter-group difference. [Table-4]: Association of DMFT with duration of asthma and its severity [Table-5]: Association of deft with duration of asthma and its severity Asthmatic children were found to have higher mean DMFT (2.37 ± 1.80) / deft (3.73 ± 1.61) scores than the control children's DMFT (0.87 ± 1.06) and deft (1.74 ± 1.38) which was statistically significant [Table 6]. [Table-6]: Comparison of Dental Caries in Permanent (DMFT) and Primary teeth (deft) of children in two groups DISCUSSION: Asthma a serious global health problem affecting people of all ages and its prevalence is increasinge specially in children. Dental caries is found to be 5 times more common than asthma and it is the most common disease of childhood [14]. For this purpose a total of 62 asthmatic children and an equal number of demographically matched healthy children were enrolled in the study. Age of children ranged from 6 to 12 years. Although it affects people of all ages, most cases of asthma occur in childhood, with a peak prevalence between 6 and 11 years old. Any factor which reduces the quality and quantity of saliva, can negatively affect oral health. The present study was is undertaken in order to find an association of medication prescribed in asthmatics with dental caries. In the present study it was observed that the ph of resting saliva was significantly lower in asthma group as compared to nonasthmatics [Table1].The results of the present study also show that with respect to salivary ph, ph less than 7 was found to be significantly associated with higher mean DMFT/deft as compared to ph more and equal to 7, and the association was significant statistically in overall assessment as well as in asthma group [Tables2 and 3].We assume that the change in acidity can be best explained with the effect of medication on the salivary gland secretion. Our findings are consistent with the previous study done by Conolly et al and who proposed that the reduction in ph of saliva and plaque in asthmatics was caused by the drug [15]. Asthmatic children enrolled in this study had significantly lower salivary flow rate when compared with control group [Table 1]. The present result is consistent with findings of Ersin et al [16]. Study done by Ryberg et al. (1987, 1991, 1990) showed that the flow rates of whole and parotid saliva in asthmatic children treated with â2-agonist inhalers were 26% and 36% lower, respectively, compared to the control group [3,4,17]. This could be attributed to the fact that the medications required in asthmatics are xerostomic in nature. On measuring buffering capacity it was found to be significantly higher in control group [Table 1], which was consistent with the finding of previous study done by Mazzoleni et al and in contrast to the finding presented by Paganini et al. [18,19]. This finding can be explained by the fact that reduced salivary flow rate influences negatively on buffering and clearing effect of saliva. The present study shows that with increasing duration of disease and its severity a significant increase in DMFT can be University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 59

4 observed except for mild persistent asthma which shows a lesser DMFT value [Table 4]. This could be explained to the fact that since dental caries is a multifactorial disease, other confounding factors like oral hygiene maintenance, mouth breathing, sugar intake etc.could also influence dental caries process. Mean deft was also found to be more but it was not statistically significant [Table5]. This is line with the study done by Reddy et al. (2003) who suggested that asthmatic children have a high prevalence of caries and this increases with the severity of asthma [2]. Ersin et al. (2006) also stated in their study that the duration of medication and illness has a considerable influence on the risk of developing caries in asthmatics [16]. Increasing risk of caries prevalence with the severity of asthma may be mainly due to the increase in the dosage and frequency of medication [20]. Within the framework of the present study, the Mean DMFT as well as mean deft of cases was found to be significantly higher as compared to that of controls [Table-6]. This is in accordance with studies carried out by other investigators who reported significantly higher deft /DMFT scores in asthmatic children (Reddy et al. 2003, Milano et al. 2006) [3,21]. However, it is in contradiction to other investigators who reported no significant difference in caries increment between asthmatic and non-asthmatic participants (Bjerkeborn et al. 1987, Shulman et al. 2001, Meldrum et al. 2001) [7,8,9]. Limitation of the study is thata more longitudinal study design on a larger population is defendable with children newly diagnosed with asthma and following them for a longer duration of time see the development of dental caries. CONCLUSION: Positive attributes of our study was that asthmatic children undergoing treatment with anti-asthmatic medication showed diminished salivary production and secretion resulting in lower flow rate, ph and buffering capacity. Since saliva is the most important defensive factor against dental caries, these alterations in the salivary properties attributes to increased prevalence of dental caries in asthmatic than healthy control. The caries risk increases with increase in severity of the disease. A special oral health care program should be designed for asthmatic children to improve their quality of life by educating the parents about the nature of the disease and informing them about the adverse effects of medication in increasing the susceptibility for dental caries. Moreover, it can be recommended that dentists should be included in the multi-professional team involved in asthmatic assistance. References 1) Report of the Global Alliance against Respiratory Diseases, 5th General Meeting, Toronto, Canada, 1-2 June, ) Reddy DK, Hegde AM, Munshi AK. Dental caries status of children with bronchial asthma. J ClinPediatr Dent 2003;27: ) Ryberg M, Moller C, Ericson T. Effect of Beta 2- adrenoceptor agonists on saliva proteins and dental caries in asthmatic children. J Dent Res 1987;66: ) Ryberg M, Moller C, Ericson T. Saliva composition and caries development in asthmatic patients treated with Beta 2-adrenoceptor agonists: A 4-year follow up study. Scand J Dent Res 1991;99: ) Wogelius P, Poulsen S, Sorensen HT. Use of asthma drugs and risk of dental caries among 5 to 7 year-old Danish children: A cohort study. Community Dent Health 2004;21: ) Milano M. Increased risk for dental caries in asthmatic children. Texas Dent J 1999;116: ) Bjerkeborn K, Dahllof G, Hedlin G, Lindell M, Modeer T. Effects of disease severity and pharmacotherapy of asthma on oral health in asthmatic children. Scand J Dent Res 1987;95: ) 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: ) Meldrum AM, Thomson WM, Drummond BK, Sears MR. Is asthma a risk factor for dental caries? Findings from a cohort study. Caries Res 2001;35: ) Taylor WR, Newacheck PW. Impact of childhood asthma on health. Pediatrics 1992;90: ) Gururaj, Maheshrawan. Kuppuswamy's Socio- Economic Status Scale A Revision of Income Parameter For International Journal of Recent Trends in Science and Technology 2014;11(1): ) Guidelinesfor the diagnosis and management of asthma. National Asthma Education and Prevention Program Expert Panel Report University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 60

5 October. Available from: m.pdf. 13) World Health Organization. Oral Health Surveys Basic methods. 4th edition. Geneva: World Health Organization, ) Benzamin RM. Oral health: The Silent Epidemic. Public Health Rep 2010;125(2): ) Conolly ME, Greenacre JK. The lymphocyte ß adrenoceptor in normal subjects and patients with bronchial asthma. J Clin Invest 1976;8: ) Ersin NK, Gu len F, Eronat N et al. Oral and dental manifestations of young asthmatics related to medication, severity and duration of condition. PediatrInt 2006;48: ) Ryberg M, Moller C, Ericson T. Saliva composition in asthmatic patients after treatment with two dose levels of beta 2-adrenoceptor agonists. Arch Oral Biol 1990;35: ) Mazzoleni S, Stellini E, Cavaleri E, AngelovaVolponi A, Ferro R, FochesatoColombani S. Dental caries in children with asthma undergoing treatment with short-acting beta2-agonists. Eur J PaediatrDent 2008;9(3): ) Paganini M, Dezan CC, Bichaco TR, Andrade FB, Neto AC, Fernandes KB. Dental caries status and salivary properties of asthmatic children and adolescents. Int J Paediatr Dent 2011;21: ) 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 Þ brosis and in asthma. ClinPediatr (Phila) 1969;8: ) 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: CORRESPONDING AUTHOR: Dr. Seema Jabeen 5/893 Vikas Nagar Lucknow drsimlko@gmail.com University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 61