Asthma and Oral Health
© Juliette Reeves 2005

Introduction

The National Asthma Campaign nominated the 3th May 2005 as World Asthma Day. This year the National Asthma Campaign will be raising awareness of asthma and its impact on the lives of 5.1 million people in the UK. In a world wide study completed by The International Study of Asthma and Allergies in Childhood. (ISAAC) 1998, the UK was ranked as having the highest incidence of asthma in the world followed by Australia , New Zealand and Ireland (1). One in eight children have asthma in the UK, this represents a six fold increase over the last twenty five years. Asthma costs the NHS £850 million each year.(2)

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Asthma

Bronchial asthma is a state of bronchial hyperactivity characterised by paroxysmal expiratory wheezing and dyspnoea (shortness of breath). Generalised reversible bronchial narrowing is caused by increased bronchial smooth muscle tone, mucosal oedema and congestion , and excess mucus secretion.
Asthma in children is typically described as allergic or extrinsic asthma. These children often develop other allergic conditions such as eczema, hay fever and drug sensitivities. This type of asthma is associated with increased production of Immunoglobulin E (IgE) on exposure to allergens and the release of mast cell metabolites which induce bronchospasm and oedema. Intrinsic asthma, however, appears not to be allergic in nature and seems to be related to mast cell instability and “hyper-responsive” airways. There are many potential triggers for asthma attacks. Triggers can range from harmless factors such as cold air or taking exercise to more harmful substances such as pollution and certain drugs. Table 1.

During an asthma attack, inflamed airways become increasingly constricted, making it difficult, sometimes impossible to breathe.Table 2.

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Management of Asthma

Investigations usually include blood tests to determine raised or specific IgE concentrations. Skin tests to help identify potential allergens. Chest x-rays and objective measurement of airway obstruction with a peak flow meter are also performed.

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Management of asthma usually includes a combination of the avoidance of known allergens or irritants and drug therapy. Sodium cromoglycate ( Nalcrom ) is used as an inhalant for prophylaxis , particularly in children , however some do fail to respond. Selective beta2adrenoreceptor agonists or stimulants (Ventolin, Bricanyl in blue or green inhalers) are used routinely as bronchodilators. Ipratropium bromide (Atrovent) is used particularly in patients where asthma is associated with bronchitis. Theophylline (Nuelin) is used as an oral sustained-release alternative, which is useful for controlling nocturnal asthma. If both of these fail, corticosteroid aerosol inhalations (Becotide, Pulmicort, Flixotide in red brown or yellow inhalers) are prescribed.(3)

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Dental Treatment Considerations

The medical profession now recognises that asthma is a complex inflammatory disease rather than a solely respiratory condition. The treatment of asthma therefore, is becoming increasingly multifactorial. This is demonstrated by a shift towards the use of corticosteroids in addition to pulmonary medication. As a profession therefore, we need to be aware of the affect these pharmaceutical agents have on the needs and treatment of our patients.(4) Dental management involves attention to the status of the patient and awareness of stimulants of the reactive airway.(5) We should be aware that dental treatment can invoke a significant decrease in pulmonary functionamong asthmatic patients.

Be aware of the potential for dental materials and products to exacerbate asthma. These items include: dentifrices and prophypaste, fissure sealants, fluoride trays and cotton rolls have also been implicated in promoting asthmatic events. Additionally, aeroallergens such as tooth-enamel dust and methyl methacrylate have been reported to trigger asthmatic attacks.

Dental Drug Interactions

Antibiotics : Allergy to penicillin may be more frequent in asthmatic patients. It has also been suggested that erythromycin, clindamycin and ciprofloxacin are also best avoided, as they may slow the metabolism of theophylline and cause toxicity.(6) It is recommended that tetracyclines are used cautiously.(7)
Local Anaesthetic: Corticosteroid-dependent asthmatic people may have a higher tendency for having an adverse reaction to sulphites.(8) Some patients with asthma may react to sulphites such as sodium metabisulphate, present in local anaesthetic containing vasoconstrictors. Locals containing adrenaline should be used with caution if at all and administered with an aspirating syringe. Perusse et al.(9), believe anaesthetics with vasoconstrictors can be safely used in non-steroid-dependent asthmatics unless the patient reports a previous reaction to sulphites. In the steroid-dependent asthmatic patient, vasoconstrictors should be avoided. It is possible that adrenaline could enhance the risk of dysrhythmias with beta agonists.(6 )

Non Steroidal Anti-inflammatoryDrugs (NSAIDs): Aspirin and other NSAIDS, mefenamic acid, paracetamol and pentazocine may also precipitate asthma attack in some patients and are recommended as best avoided.6

Beta blockers

Beta-blocker agents such as propranolol can precipitate bronchospasm and are contraindicated.6

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Asthma and Oral Health

The most common oral health conditions affecting asthmatic children include oral thrush/ candidosis, xerostomia, gingival conditions, dental erosion and caries.

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The incidence of oral candidosis has been found to be significantly greater in asthmatic patients taking inhaled steroids compared with those who are not.(10,11) It is helpful to advise patients to rinse their mouths with water after using steroid inhalers.

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Evidence of the effect of asthma on the periodontal condition and caries rate in children is mixed. A recent study from New Zealand has suggested there is little evidence to support a causal relationship between asthma and caries.(12) A recent UK study, however, has revealed that asthmatic children had significantly more plaque, gingivitis, and calculus compared with the control group. It was concluded that asthmatic children have more decay affecting their permanent teeth, poorer periodontal status, and more tooth surface loss than the healthy controls.(13)

There are a number of factors which may predispose an asthmatic child to caries and periodontal conditions. One primary factor is that the use of short-acting beta2-agonists is associated with impaired saliva secretion, thus increasing the risk of caries. (14) The use of short-acting beta2-agonists is also associated with oral mucosa injuries that are probably provoked by decreased concentrations of immunoglobulin A (IgA) in saliva.(15) It has also been suggested that a decrease in pH of saliva and plaque in medicated asthmatics could be caused by inhaler drugs such as beta2-agonists and inhaled corticosteroids. (16)

Asthma medication also places patients at risk of dental erosion by reducing salivary protection against extrinsic or intrinsic acids. Clinical differences are a higher incidence of tooth hypersensitivity, xerostomia and salivary gland abnormalities,(17)

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Nutritional Influences in Asthma

The dietary intake of antioxidant micronutrients,essential fatty acids and the exclusion of food allergens appears to be the most significant nutritional intervention in asthma. Compared with the non-asthmatic child, the asthmatic child has a 14-fold higher risk of developing a severe allergic reaction to the ingestion of food. The most commonly cited foods are fruits with a rind, cow's milk and nuts.(18) Fifty- five percent of children reporting a severe wheeze also report eczema or hay fever, highlighting the link between respiratory and allergic conditions.(19)

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Oxidative stress is implicated in the pathogenesis of asthma, and clinical studies show an imbalance in the level of oxidants to thelevel of antioxidants in subjects with asthma (20) It has been suggested that reactive oxygen species play an important role in the modulation of airway inflammation.(21) Levels of vitamin C are also lower in asthmatic patients suggesting that reactive oxygen species may be a contributing factor in asthma.(22) Magnesium is involved in a wide range of biological activities, including some that may protect against the development of asthma and chronic airflow obstruction. High dietary magnesium intake is associated with better lung function, and a reduced risk of airway hyper-reactivity and wheezing in adults.(23) Low magnesium intake may therefore be involved in the aetiology of asthma and chronic obstructive airways disease.

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Fish consumption in the first year of life may reduce the risk of developing asthma and allergic rhinitis in childhood.(24) There are indications that inclusion of omega three fatty acids in the diet may be useful in the treatment of asthma(25). Fish oil in the diet has been shown to ameliorate the symptoms in some animal models of chronic inflammatory disease and to protect against the effects of endotoxin and similar inflammatory challenges. Clinical studies have reported that oral fish oil supplementation has beneficial effects in rheumatoid arthritis and among some patients with asthma, supporting the idea that the omega three fatty acids in fish oil have anti-inflammatory properties. (26) 

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Conclusion

In the treatment of asthma, as with treatment of most medical conditions, the dental profession plays a role that is important in terms of both the patient's overall health and the effect the condition has on oral health. By understanding the relationship between asthma and oral health, and keeping ourselves up to date with current nutrition and treatment modalities we are able to offer safe and apropriate dental care.

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References

(1)ISACC: Worldwide variations in the prevalence of asthma symptoms: The International Study of Asthma and Allergies in Childhood. ISACC) : Eur J Resp 1998 12:315-35.

(2)www. asthma.org.uk

(3)C. Skully, R.A. Cawson Medical Problems in Dentistry 4th Ed Reed Publishing Ltd

(4)Coke JM, Karaki DT.:The asthma patient and dental management. Gen Dent. 2002 Nov-Dec;50(6):504-7.

(5)Zhu JF, Hidalgo HA, Holmgreen WC, Redding SW, Hu J, Henry RJ.: Dental management of children with asthma: .Pediatr Dent. 1996 Sep-Oct;18(5):363-70.

(6)C. Skully, R.A. Cawson Medical Problems in Dentistry 4th Ed Reed Publishing Ltd

(7)Anderson JA: Allergic reactions to drugs and biological agents. JAMA 1992. 268(20): 2845-57.

(8)Bush RK., Taylor SL., Holden K,: et al: Prevalence of sensitivity to sulphating agents in asthmatic patients. Am.J.Med. 1986. (5):816-20.

(9)Perusse R., Goulet J.R., Turcotte J.Y.: Contraindications to vasoconstrictors in dentistry: Part II Oral Surg. Oral Med. Oral Pathol. 1992: 74(5):687-91.

(10)Fukushima C, Matsuse H, Tomari S, Obase Y, Miyazaki Y, Shimoda T, Kohno S.: Oral candidiasis associated with inhaled corticosteroid use: comparison of fluticasone and beclomethasone. Ann Allergy Asthma Immunol. 2003 Jun;90(6):646-51

(11)Guillot B.Adverse skin reactions to inhaled corticosteroids.: Expert Opin Drug Saf. 2002 Nov;1(4):325-9.
(12)Meldrum AM, Thomson WM, Drummond BK, Sears MR.: Is asthma a risk factor for dental caries? Finding from a cohort study. aries Res. 2001 Jul-Aug;35(4):235-9.

(13) McDerra EJ, Pollard MA, Curzon ME.: The dental status of asthmatic British school children.Pediatr Dent. 1998 Jul-Aug;20(4):281-7.

(14)Ryburg M., Moller C., Ericson T : Saliva composition and caries development in asthmatic patients treated with B2- adrenoceptor agonists: a 4 year follow up study. Scan J Dent Res 1991 99(3): 212-8.

(15)del-Rio-Navarro BE, Corona-Hernandez L, Fragoso-Rios R, Berber A, Torres-Alcantara S, Cuairan-Ruidiaz V, Sienra-Monge JJ.: Effect of salmeterol and salmeterol plus beclomethasone on saliva flow and IgA in patients with moderate-persistent chronic asthma.:Ann Allergy Asthma Immunol. 2001 Nov;87(5):420-3.

(16)Kargul B, Tanboga I, Ergeneli S, Karakoc F, Dagli E.: Inhaler medicament effects on saliva and plaque pH in asthmatic children . J Clin Pediatr Dent. 1998 Winter;22(2):137-40.

(17)Sivasithamparam K, Young WG, Jirattanasopa V, Priest J, Khan F, Harbrow D, Daley TJ.: Dental erosion in asthma: a case-control study from south east Queensland.: Aust Dent J. 2002 Dec;47(4):298-303.

(18)Rance F, Micheau P, Marchac V, Scheinmann P.: Food allergy and asthma in children: Rev Pneumol Clin. 2003 Apr;59(2 Pt 1):109-13.

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(19)ISACC

(20)Corradi M, Folesani G, Andreoli R, Manini P, Bodini A, Piacentini G, Carraro S, Zanconato S, Baraldi E.: Aldehydes and glutathione in exhaled breath condensate of children with asthma exacerbation.: Am J Respir Crit Care Med. 2003 Feb 1;167(3):395-9.

(21)Nadeem A, Chhabra SK, Masood A, Raj HG.: Increased oxidative stress and altered levels of antioxidants in asthma: .J Allergy Clin Immunol. 2003 Jan;111(1):72-8.

(22)Vural H, Uzun K.: Serum and red blood cell antioxidant status in patients with bronchial asthma.: Can Respir J. 2000 Nov-Dec;7(6):476-80.

(23)Britton J, Pavord I, Richards K, Wisniewski A, Knox A, Lewis S, Tattersfield A, Weiss S.: Dietary magnesium, lung function, wheezing, and airway hyperreactivity in a random adult population sample: Lancet. 1994 Aug 6;344(8919):357-62

(24)Nafstad P, Nystad W, Magnus P, Jaakkola JJ.: Asthma and allergic rhinitis at 4 years of age in relation to fish consumption in infancy: .J Asthma. 2003 Jun;40(4):343-8.

(25)Okamoto M, Mitsunobu F, Ashida K, Mifune T, Hosaki Y, Tsugeno H, Harada S, Tanizaki Y.: Effects of dietary supplementation with n-3 fatty acids compared with n-6 fatty acids on bronchial asthma.: Intern Med. 2000 Feb;39(2):107-11.

(26)Calder PC: Dietary modification of inflammation with lipids: .Proc Nutr Soc. 2002 Aug;61(3):345-58.