International Journal of Medical Dentistry 21

AbstractBronchial asthma is one of the most common

pathologies of the chronic diseases of childhood, record-ing an ever-increasing frequency. The paper develops acontrol-type case study on the carious experience of 25children suffering from bronchial asthma, comparativelywith 25 healthy children. In both groups, the dmf-t/DMF-T indices were calculated and the presence of Streptococ-cus mutans (SM) and Lactobacillus acidophillus (LA) in sti-mulated saliva, in concentrations with high cariogeneityrisk, was determined.

Carious experience and the SM level in concentrationswith cariogenic risk were statistically significant in chil-dren with bronchic asthma (p=0.02). The presence of LAin concentrations with cariogenic risk was also higher inthese children, yet statistically insignificant, compara-tively with the reference (p>0.05).

Keywords: bronchial asthma, caries, cariogenic bacteria

INTRODUCTION

Chronic lung diseases represent a major pro-blem of public health all over the world. Accord-ing to Global Alliance against Chronic RespiratoryDiseases [1], in the year 2010, worldwide, 1 bil-lion persons suffered from chronic lung diseases,of which 300 millions were affected with asthmaand 210 millions – with chronic obstructive lungdiseases (BPOC)[2,3]. Bronchial asthma is morefrequently diagnosed in children, comparativelywith adults, 9.6% of the children all over thewhole world having this pathology [4]. InRomânia, according to WHO data for 2004, 7%of the children suffered from bronchial asthma[5]. The number of newly-diagnosed cases is in-creasing, the registered percent values being of7.2% in the urban medium, a value almost dou-ble than the one recorded in the rural areas. [6,7]

Systemic diseases show their signs at the levelof the oral cavity – for example, lung pathologies

CARIOUS EXPERIENCE IN CHILDREN SUFFERING FROMBRONCHIAL ASTHMA

Mona Olar1, Rodica Luca2, C. Marica3

1. PhD. Student, Dept of Pedodontics, Faculty of Medical Dentistry, „Carol Davila” U.M.Ph. Bucure[ti2. Prof. PhD., Dept of Pedodontics, Faculty of Medical Dentistry, „Carol Davila” U.M.Ph. Bucure[ti3. Prof. PhD., Clinics of Lung Diseases, Institute of Pneumophysiology, „Carol Davila” U.M.Ph. Bucure[tiCorresponding author: Mona Olar – monaolar@yahoo.com, Rodica Luca – luca1945@yahoo.com

frequently cause reduction of salivary secretion,modifications of saliva composition and pH, themain cause being the mouth breathing of the illones [8]. The medication administered for lungdiseases may cause reduction of bone density(corticosteroides) and of saliva (2 agonistes). [9]

As the frequency of the chronic lung diseasesis constantly increasing, the authors of the pre-sent study attempt at completing and enrichingthe existent data on the consequences of caries inchildren suffering from bronchial asthma, com-paratively with a group of healthy children.

MATERIALS AND METHOD

The observation sheets of the patients suffer-ing from lung diseases, among which 62 chil-dren with bronchial asthma, registered in theDepartment of Pneumology – “Marius Nasta”Hospital of Lung Diseases, Bucure[ti, were iden-tified. Invitations were sent to the families ofthese children, to participate to a stomatologicalcontrol. Out of the total number of 62 children,only 25 – which actually formed the experimen-tal group – came to the stomatological consult.These children, with ages ranging between 5 and14 years, suffered from bronchial asthma withvarious degrees of severity, according to the Glo-bal Initiative for Asthma, 2010 [10], followingtrratments with various antiasthmatic drugs.The reference group was formed of other 25 chil-dren, similar as to age and sex with those of theexperimental batch.

In the case of children suffering from asthma,the demographic data and the medical history –registered in their files – provided the followingvariabiles: age, sex, medium of life: rural or urban,

Pediatric Dentistry

22 volume 2 • issue 1 January / March 2012 •

socio-economic level of the family, mothers’ edu-cation level, administered medication and dura-tion of administration. Mention was made, foreach child, of the utilization of the inhalatingmedication with or without a spacer. The chil-dren were examined in the Clinics of Lung Dis-eases, with sterile instruments, the light sourcebeing assured – according to WHO indications –by a halogen lamp [5].

The children from the reference group wereexamined in a dental office.

Both groups of children were consulted bythe same stomatologist (MO), and their dento-periodontal status was registered. To evidencethe carious experience, the dmf-t/DMF-T indi-ces, as well as their mean values, were calcu-lated for each child in part. [11]

Determination of Streptococcus mutans (S.M)and Lactobacillus acidophilus (L.A) concentrationsin the saliva of children from both groups wasbased on test kits. S.M concentration was deter-mined with the Saliva Check Mutans (GC) test kitswith stripes with monoclonal antibodies, whichidentify concentrations above 105 bacteria. Atsuch concentrations, the test band from the con-trol strip gets coloured, the test being interpretedas positive for a high carioactivity risk.

For the determination of L.A concentration,slides loaded with a selective culture mediumfor L.A, Dentocult LB System (Orion Diagnostica)were employed. These slides have two sides, thestimulated saliva collected from the patients be-ing deposited on each of them. The slides wereincubated at 370C for 4 days, after which thenumber of adhering L.A colonies was comparedwith the control images of the test. In the case inwhich, for each patient, different results wereobtained on the two sides of the slide, their aver-age value was considered. The presence of a bac-terial concentration lower or equal to 104 wasconsidered as inducing a lower risk of cario-geneity, while a value equal or higher than 105

expresses a high cariogeneity risk.All data obtained were recorded in IBM® SPSS

Statistics Desktop V20.0., for Windows and ExcelOffice. For subsequent statistical processing, thet, chi square, exact Fisher, Kendall, Mann-Whitney tests were employed. A p value < 0.05was considered as statistically significant.

RESULTS 

A. Distribution of children in theexperimental groupBronchial asthma was more frequently ob-

served in females (56%), in the patients comingfrom the urban areas (64%), in those with a lowsocio-economic level (68%), as well as in thosewith a lower education level (62%). As to its dis-tribution on groups of age, bronchial asthma wasmore frequent in boys (20%) than in girls (16%),in the 5-10 year group of age while, in the 10-14year group of age, the frequency was higher ingirls (36%), comparatively with boys (28%). (fig. 1)

Only two of the patients suffering from bron-chial asthma, coming from the urban area, andhaving a high socio-economic status, made useof a spacer for the administration of the inha-lating medication.

Figure 1. Distribution of children affected withbronchial asthma (%) on groups of age

B. Carious experienceThe mean values of the cariuos experience are

higher in the experimental group, comparativelywith the reference, for all variables under analy-sis (age, sex, socio-economic level, mothers’ edu-cation level) p<0.05. (table 1)

The mean values of the dmf-t/DMF-T indiceswere listed in table 2, for orientative purposes, ifconsidering the reduced number of children suf-fering from asthma, treated with various anti-asthmatic drugs. Mention should be made of thefact that, in the case of children having used aspacer for the administration of the inhalatingdrugs, the mean value of the dmf-t /DMF-T in-dex is lower than in those which did not use thisdevice. At the same time, even if the indices ofcarious experience are higher than those of thereference, the differences are not statistically

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International Journal of Medical Dentistry 23

significant (p>0.05). If considering the oldnessof the asthma, the dmf-t/DMF-T index was of4.48, respectively, 4.87, in children with bron-chial asthma diagnosed more than 2 years ago.In the children with asthma diagnosed eariler

than 2 years, the dmf-t/ DMF-T index was of4.05/4.51. (table 2)

In the reference group, formed of childrenwithout asthma, the mean value of the dmf-t/DMF-T index was of 3.65/4.05. (table 2)

dmf-t DMF-T Variable

Experimental group

Reference group

Experimental group

Reference group

Whole group (5-14 years)

4.27±2.80 3.65±2.06 4.65±1.86 4.05±1.82

5-7 6.85±2.03 5.73±1.07 3.23±0.7 1.95±2.04 8-9 7.49±1.5 6.65±1.02 4.25±1.01 3.73±1.56 10-12 2.75±1.05 2.23±2.85 5.01±1.96 4.57±2.02

Age (years)

13-14 - - 6.11±2.04 5.85±1.79 Girls 4.65±1.31 3.92±1.04 4.94±1.78

4.35±0.9 Sex

Boys 3.9±1.03 3.38±1.3 4.36±1.55 3.76±1.87 Low 4.35±2.04 4.05±2.01 4.96±1.4 4.48±1.2 Medium 4.19±1.25 3.59±1.43 4.58±0.82 4.12±0.5

Socio- economic level High 3.87±1.6 3.32±1.55 4.41±1.02 3.56±1.3

Secondary school

5.61±1.2 4.65±1.27 5.74±2.01 4.87±1.52

High school

4.18±2.02 3.74±1.68 4.43±1.34 4.03±1.73

Mother’s education

University 3.04±1.03 2.58±1.33 3.78±1.65 3.25±0.5

Table 1. Indices of carious experience

Table 2: dmf-t/DMF-T indices versus oldness of bronchial asthma andadministered drugs

No.

copies Mean dmf-t

Mean DMF-T

P

Reference group 25 3.65±2.06 4.05±1.82 Experimental group 25 4.27±2.80 4.65±1.86 P=0.02 Inhalating (CSI) Beclometasone corticosteroides

6 4.13±2.98 4.32±2.04 P=0.03

β2 inhalating agonistes with long-term action Salmeterol

5 4.47±2.96 5.19±2.38 P=0.01

CSI + β2 inhalating agonistes (budesonide +formoterol) Symbicort®

4 4.39±2.86 4.71±1.04 P=0.04

Leukotriene inhibitors, tablets + CSI 4 4.35±2.83 4.62±2.12 P=0.05 β2 agonistes Salbutamol tablets 2 4.43±2.95 4.95±1.83 P=0.02

Tablets

Leukotriene inhibitors Montelukast/Zafirlukast

2 4.25±2.74 4.49±1.07 P=0.04

β2 inhalating agonistes adminisetred only when necessary Salbutamol (Ventolin®)

2 3.87±2.33 4.27±2.56 P>0.05

Children using a spacer for the administration of inhalating drugs

2 3.89±1.04 4.28±1.73 P>0.05

Children with asthma diagnosed for more than 2 years

17 4.48±2.13 4.87±1.92 P=0.02

Children with asthma diagnosed for less than 2 years

8 4.05±1.76 4.51±1.04 P=0.04

CARIOUS EXPERIENCE IN CHILDREN SUFFERING FROM BRONCHIAL ASTHMA

24 volume 2 • issue 1 January / March 2012 •

C. Analysis of Streptococcus mutans (S.M)and Lactobacillus acidophillus (L.A)concentrationsThe children with bronchic asthma registered

positive values – of 64% – for the presence ofS.M in risk concentrations, in the stimulatedsaliva, comparatively with only 48% of the chil-dren from the reference (statistically significantfor p=0.01). The difference was statistically non-significant among the children from the refer-ence and those suffering from bronchial asthma,to whom Ventolin was administered only whennecessary. (p=0.6) Also, the differences were sta-tistically non-significant among the childrenwith asthma, treated with various types ofdrugs. Higher values were registered in childrentreated with 2 agonistes (p=0.01). As to the riskL.A concentration, the children with asthmawere found positive (in ratios of 45%, comparati-vely with 43% in the children from the referencegroup). Such a value is statistically insignificant(p>0.05). (fig 2)

a

b

Figure 2. Positive tests for S.M (a) and L.A (b)

DISCUSSION

The results of the present study show thatmost of the patients affected with asthma werefemales, differences being nevertheless regis-tered on groups of age. Thus, in the 5-10 yeargroup of age, it was the boys that suffered fromasthma and not the girls, while, after the age of

10 years, the frequency of the disease was higherin girls, the hormonal modifications manifestedat this age having, probably, some influenceupon the higher frequency of asthma in females.Also, asthma was more frequently diagnosed inchildren with a low socio-economic level, fromthe urban areas, with mothers having a low edu-cation level. Similar results on the frequency ofbronchial asthma were obtained by other au-thors, as well. [12-14]

Carious experience was larger, with statisti-cally significant values of the dmf-t/DMF-T in-dices, in children with asthma, comparativelywith those from the reference (p=0.02). Highervalues of the indices of carious experience wereregistered in children with asthma from the ru-ral medium (p=0.04) and in those coming fromfamilies with a low socio-economic level(p=0.04). The girls from the group suffering fromasthma recorded statistically significant highervalues of the dmf-t/DMF-T indices than in theboys with asthma (p=0.04). Similar results werealso obtained in studies devoted to the cariousexperience of asthmatic children. [14]

Children suffering from asthma treated withlong-term 2 agonistes, administered as inhala-tion (Salmeterol), recorded an average value ofthe dmf-t/DMF-T index higher than the othergroups, being followed by the subjects treatedwith Salbutamol (tablets), Symbicort® (inhala-tion), Montelukast + Beclometasone, Montelu-kast (tablets), Beclometasone (inhalation) andSalbutamol – administered only when necessary.The values of the dmf-t/DMF-T indices were sta-tistically more significant in the group sufferingfrom asthma, comparatively with the reference,even if the statistical differences recorded amongthe groups of persons affected with asthma,treated with different types of antiasthmaticmedication, were not significant. (table 2) Theresults of the present study agree with those re-ported by Eloot et al., Ersin et al. and Ryberg et al.on the carious experience in children withasthma treated with various antiasthmatic drugs[15-17]. Such investigations should be developedon larger groups of children treated with thesame type of drugs, however, for the time being,the results of the present study attest that ago-nist medication has most obvious adverse effects

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International Journal of Medical Dentistry 25

upon the carious experience in asthmatic chil-dren. Similar results were also obtained by otherauthors, in studies devoted to the effects ofantiasthmatic medication., the corticosteroideinhalating medication being correlated withlower indices of carious experience in asthmaticchildren, comparatively with the 2 agonisticmedication [4,16-19]. Only two of the childrenincluded in the study, who came from the urbanarea, and having a high socio-economic level,used a spacer for the administration ofantiasthmatic inhalating medication (Beclotide,respectively Symbicort) – which explains thelower values of the dmf-t/DMF-T indices regis-tered for them, comparatively with the rest ofthe subjects of the experimental group, who didnot use such a device. As to the carious experi-ence versus the oldness of asthma, the childrendiagnosed with asthma since more than 2 yearsregistered higher values of the dmf-t/DMF-Tindex, which agrees with the conclusions ofShashikiran et al., Mazzoleni et al., Santos et al. [18-20] The largest carious experience was identifiedin the 8-9 year groups of age, including bothasthmatic and healthy children, followed by theage interval of 10-12 years, again in both groupsof investigated children.

The concentration of cariogenic bacteria iden-tified in the stimulated saliva of the children hereunder analysis evidenced that, in children withbronchial asthma, the positive tests for establish-ing the SM presence in saliva, in concentrationswith high risk of carious lesions’ development(>105), were statistically more significant, com-paratively with those obtained for the childrenof the reference group (p=0.03). Similar resultswere obtained by Hegde et al. [21] Thus, thehigher values of the indices of carious experi-ence may be also correlated with the higher fre-quency of the positive tests for S.M in childrenwith asthma, comparatively with the reference.As to the L.A level, even if the children withasthma had positive tests more frequently thanthe ones included in the reference, the differ-ences were statistically non-significant (p>0.05).Such results support the existing literature data,according to which S.M participates to the initia-tion of the carious process, while L.A contributesto the progress of the caries [11]. The results of

the present study agree with those of other au-thors, who put into evidence statistically signi-ficant correlations between the S.M level, andstatistically non-significant ones, respectively,for the L.A level and the level of the carious ex-perience in children with asthma, comparativelywith the reference groups [21].

CONCLUSIONS

Carious experience in children suffering frombronchial asthma is statistically more significantthan in healthy ones, being correlated, on onehand, with the SM level, which is statisticallymore significant in children suffering fromasthma and, on the other, with the influence ofantiasthmatic medication upon the saliva. 2agonistes reduce the production of saliva, withall afferent biochemical modifications (increaseof salivary viscosity, qualitative modifications ofsaliva), while CS produces disequilibria in theecology of the oral bacterial flora, favourizingthe development of cariogenic species (SM, LA).Children should be educated to use spacerswhen taking their inhalating medication and torinse the mouth immediately after, for reducing,as much as possible, the adverse effects of theantiasthmatic drugs upon the health status of theoral cavity.

If considering the numerous factors that mayinfluence the oral health condition of childrensuffering from bronchial asthma and the rela-tion established among asthma, antiasthmaticmedication and the pathology of the oral cavity,special attention should be paid to their oral hy-giene and to their prophylaxy, as well. The typesof drugs and the modalities of their administra-tion might be modified by the pneumologist/pediatrist, in favour of the drugs with reducedadverse effects. Utilization of a spacer for theadministration of inhalating medication shouldbe extended to each child, as well as a subse-quent abundant mouth rinsing.

However, additional studies should be deve-loped on such topic, including more numeroussubjects and several variables, for a completeelucidation of the relation between bronchialasthma and the carious pathology of children.

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26 volume 2 • issue 1 January / March 2012 •

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