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Kathmandu University Medical Journal (2008), Vol. 6, No. 3, Issue 23, 370-374 Asthma and dental erosion
Manuel ST1, Kundabaka M2, Shetty N3, Parolia A1
1Assisstant professor, 2Professor, 3Associate professor, Department of Conservative Dentistry and Endodontotics, Manipal College of Dental Science, Mangalore, India Abstract
Asthma is a chronic inÀ ammatory condition of the airway, characterised by the presence of airÀ ow obstruction which is variable over short periods of time, or is reversible with treatment. Medication comprises of bronchodilators, corticosteroids and anticholinergic drugs. Most asthma drugs are inhaled using various forms of inhalers or nebulizers. Inhaled drugs must be used regularly. The effects of these drugs on the dentition such as tooth decay and erosion have been a subject of debate among dental practitioners. Asthmatic medications can place the patient at risk of dental erosion by reducing salivary protection against extrinsic or intrinsic acids. Asthmatic individuals are one of the higher risk groups suffering from dental erosion. Therefore patients with bronchial asthma should receive special prophylactic attention. This article presents a case of an asthmatic with dental manifestations and reviews the possible causes and management of the same. Key words: Asthma, dry powder inhalers, beta-2 agonist, gastro-esophageal reÀ ux, dental erosion.
asthma. The effects of these drugs on the dentition such The prevalence of asthma has increased steadily over the latter part of the last century. Currently as tooth decay and erosion have been a subject of debate estimates suggest that 300 million people world-wide suffers from asthma and an additional 100 million may be diagnosed with asthma by 20251. Asthma is a Review of the literature
chronic inÀ ammatory condition that causes the airways Inhalers which deliver these medicaments may be used (bronchi) to produce excess mucus and close, making up to four times a day over long periods and since breathing dif¿ cult. It is characterised by the presence of more than 5% of the population is affected by asthma, airÀ ow obstruction which is variable over short periods erosion produced by associated medication could pose of time, or is reversible with treatment. The aetiology a signi¿ cant population-wide dental health problem. of asthma is complex, and multiple environmental and However the evidence for such an association is unclear. Although Shaw et al and McDerra et al reported that children with asthma were at an increased risk of Treatment has two main objectives: ¿ rst, to control developing erosion 3, 4, 5; few other studies yielded no and reduce inÀ ammation and, second, to reopen the clear association between asthma and dental erosion 6. airways. Drugs that achieve the ¿ rst goal are called anti-inÀ ammatory agents, and those that bring about Asthmatic medications can place the patient at risk of the second are called bronchodilators. Many asthma dental erosion by reducing salivary protection against sufferers inhale these medications. Medications for extrinsic or intrinsic acids7 (Table 1). asthma fall into two categories: Quick relief medication comprises of short acting bronchodilators, systemic corticosteroids and anticholinergic drugs. Long-term control medication includes anti-inÀ ammatory agents, long-acting bronchodilators, and leukotriene modi¿ ers2. Most asthma drugs are inhaled using various forms of inhalers or nebulizers. Inhaled drugs must be used Correspondence
Dr. Manuel S. Thomas
regularly as prescribed and the patient carefully trained Assist. Prof., Dept of Conservative Dentistry and Endodontotics in their use in order for them to be effective and safe. Several studies have examined a possible association between erosion and inhaled medication used to treat Saliva is considered to be one of the main neutralizing erosion. Harding reported that gastro-oesophageal factors in the pathogenesis of dental erosion. The oral ux symptoms are more prevalent in asthma clearance of dietary acid will be related to the rate of patients compared with control populations, with a secretion and buffering capacity of saliva8. There is prevalence of approximately 75%14. Part of the inhaled newer evidence that medicines taken by dry-power medication might be swallowed. This may cause minor inhaler may cause tooth erosion in children by changing stomach upset or “heartburn,” which can do long- the mouth’s chemical environment. They reduce the term damage. The beta 2 adrenoreceptors and drugs production of saliva, affecting the mouth’s natural such as Aminophylline and Theophylline can cause way of maintaining its chemical balance. Ryberg relaxation of other smooth muscles such as the lower et al found a lowered secretion rate of whole and oesophageal sphincter. This relaxation is associated with parotid saliva, decreased secretion of saliva proteins gastrooesophageal reÀ ex4. The relationship between and higher streptococcus mutans counts in asthmatic gastrointestinal disease and dental erosion has been subjects treated with beta 2-adrenoceptor agonists noted by several researchers 15, 16, 17. So, this may also than in matched healthy controls 9. The effects of the provide at least a partial explanation of the relationship beta adrenoceptors on salivary composition and À ow rate were further investigated by Kargul et al10. They considered the effects of Salbutamol and Fluticasone Management
proprionate inhalers on plaque and saliva pH in Proper oral hygiene instructions: Since it has been asthmatic children aged 6–14 years. The authors found shown that the dry powder inhalers used for asthma that pH values decreased in plaque and saliva in the have an acidic pH, to offset these side effects, the 30 min following inhalation of the drugs. In asthma, patients should be persuaded to get into the habit drug-induced xerostomia is dose-dependent. At higher of rinsing their mouth immediately after using the bronchodilator concentrations a reduction is seen in inhaler with neutral pH or basic mouth rinses, such the natural anti-bacterial compounds and buffering as liquid antacids, sodium bicarbonate in water, agents normally found in saliva such as IgA, calcium, milk or neutral sodium À uoride mouth rinses. lactoferrin and total protein. Reduced salivary buffering Patients should also be instructed not to brush their power makes patients more vulnerable to the erosive teeth immediately after exposure to acids as it may action of acids, either extrinsic or intrinsic. Modi¿ cation of drug delivery system: Another Anti-asthmatic drugs can cause tooth erosion in children simple measure to reduce tooth erosion is by using and the culprit is thought to be the newer dry-powder a spacer device to deliver the powder. Spacers inhalers. Dry powder inhalers are convenient and easy to such as ‘Volumetric’ are clear plastic balloon- use. They dispense medicine directly to the place where like devices with a one-way valve. By providing it is needed, greatly reducing side effects as compared a spacer between the inhaler and the mouth, the with medicines taken as pills or tablets. They also velocity of the powder is reduced, thus reducing deliver medicine to the troubled site quickly, without the ferocity of the impact of the powder on the need for absorption, digestion and circulation. And they oropharnyx. The time lag in delivery permits more can deliver long-lasting anti-inÀ ammatory bene¿ ts or of the propellant to evaporate; hence more particles short-acting, quick-relief bronchodilation when needed. No other way of taking asthma drugs is so versatile. The Increasing the salivary À ow and buffering capacity: powder versions of preventer therapies e.g. Becotide Use of sugarless chewing gum to stimulate salivary and Flixotide and relief bronchodilators e.g. Ventolin À ow and buffer the oral acids should also be and Bricanyl, the mainstays of asthma treatment, are encouraged 18. Experimentally, chewing gum for at acidic with a pH below 5.5 11, 12. Reports from clinical least one minute after using an inhaler neutralized experiments demonstrated a fall in the pH of interdental the interdental plaque pH10. Adult asthmatics can be plaque and saliva during the thirty minutes following advised to use saliva substitutes, sip plain water and the use of inhaler medication for asthma. Enamel starts use daily À uoride mouth rinse to compensate for the to dissolve below pH 5.5. The powder in the puffers can xerostomia. All age groups of asthmatics should be erode the tooth enamel when used regularly 13. It is also made aware of the problem and encouraged to have possible that there will be an increased consumption of drinks to compensate for oral dehydration, often drinks with a low pH, which could also cause erosion 4. Treatment of gastric reÀ ex: The evidence is strong that gastro-oesophageal reÀ ux plays an important Conditions such as vomiting, heartburn and stomach role in some patients with asthma. Presumptive problems were more commonly reported in the asthma diagnosis by the dentist should lead to appropriate and erosion groups and were associated with dental referral for further investigation. Most often it will be to a gastroenterologist for gastroscopy and 24- complain of sensitivity to cold food. He also complained hour measurement of oesophageal pH. Anti-acid of discoloured restorations in his upper and lower front drugs have to be prescribed to the patients having teeth. Patient’s medical history revealed that he is an asthmatic on medication. He has been suffering from De¿ nitive treatment: Once the preventive measures this chronic inÀ ammatory condition since 18 years and have been instituted, de¿ nitive restoration of the his asthmatic attacks are triggered by dust. Since then dentition can begin. Indication for restoration he has regularly been on medication (table 2).
may include protection of the remaining tooth structure, aesthetic consideration, prevention of When asked about his oral hygiene habits, it was dentin sensitivity, severe vertical discrepancies and understood that the patient brushes his teeth 2 to 3 times temporomandibular joint dysfunction. Treatment a day, immediately after the use of the inhaler.
may range from simple to exceedingly complex, depending on the extent of tooth destruction and Clinical examination revealed saucer shaped loss of the ability of the masticatory system as a whole to tooth structure on the labial surface of the teeth 23, 34, 35, 44 and 45. There were also discoloured composite restorations on the labial surface of the teeth 22, 31, 32 Case report
and 33 (Fig 1). Minimal attrition of posterior teeth was A male patient 43 years of age came to the Department of Conservative dentistry and Endodontics, with a chief Table 1: Possible cause for increased incidence of erosion in asthmatics
I) Reduced buffering capacity and salivary À ow rate caused by ȕ 2 agonist II) Increased exposure of the teeth to acids Intrinsic source - Gastro-esophageal reÀ ux Table 2: Medication taken by the patient.
Long term relief medica-tion ( to prevent asth- matic attacks and control chronic symptoms) Fig 1: Pre-operative photograph shows saucer shaped
Fig 2: Post-operative photograph shows the restoration
loss of tooth structure on the labial surface of of the erosive lesions and the replacement of the teeth 23, 34, 35, 44 and 45 and discoloured discoloured restoration with composite resin. composite resin restorations on the labial surface of the teeth 22, 31, 32 and 33 Discussion
The most probable cause for tooth structure loss in
4. Al-Dlaigan YH, Shaw L, Smith AJ. Is there a this patient could be due to the brushing of the teeth relationship between asthma and dental erosion? immediately after the use of dry powder inhaler. The A case control study. Int J Paediatr Dent. 2002; reason for tooth wear also could be supplemented by drug induced gastritis for which he is taking medication.
The dental status of asthmatic British school Treatment plan: The patient was instructed to rinse his children. Paediatric Dentistr.y 1998; 20: 281–7.
mouth with a À uoride mouth wash immediately after the 6. Dugmore CR, Rock WP. Asthma and tooth use of the inhaler. He was also instructed not to brush erosion. Is there an association? Int J Paediatr his teeth as soon as the inhaler is used. The defects on the labial surfaces of teeth 23, 34, 35, 44 and 45 where restored with composite resin. The discoloured V, Priest J, Khan F, Harbrow D, Daley TJ. composite restorations on the labial aspect of the teeth Dental erosion in asthma: a case-control study 22, 31, 32 and 33 were also replaced (¿ g 2).
from south east Queensland. Aust Dent J. 2002; 47:298-303. Conclusion
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