Pediatrics International (2006) 48, 549–554 doi: 10.1111/j.1442-200X.2006.02281.

Original Article

Oral and dental manifestations of young asthmatics related

to medication, severity and duration of condition

NAZAN KOCATAŞ ERSIN,1 FIGEN GÜLEN,2 NESRIN ERONAT,1 DILSAH COGULU,1

ESEN DEMIR,2 REMZIYE TANAÇ2 AND ŞÖHRET AYDEMIR3
1
Department of Pedodontics, 2Department of Pediatrics, Division of Allergy and Pulmonology and
3
Department of Microbiology, Ege University, Bornova-Izmir, Turkey

Abstract Background: The aim of this study was to investigate the caries risk of asthmatics in relation to dental plaque
indices, salivary flow rate, pH and buffer capacity, saliva composition and salivary levels of Streptococcus
mutans compared with healthy subjects and also to evaluate these parameters within different groups of asth-
matics according to their medication, duration and severity of the disease.
Methods: The study group composed of 106 asthmatics and 100 healthy controls with the same age and social
background aged between 6 and 19-years-old. For dental examinations, World Health Organization criteria and
for plaque indices the Silness and Löe plaque index was used. All data were analyzed using t-test, ␹2-test, Spear-
man rank correlation, Kruskal– Wallis, Mann–Whitney U-tests and Logistic Regression Anaylsis with Forward
Stepwise Likelihood ratio method.
Results: A statistically significant decrease in the salivary flow rate and pH were found in the asthmatic group.
The children in the asthmatic group aged between 6 and 10 years had significantly higher caries prevalence
compared with the control group at the same age. There was a negative correlation between the duration of
medication and the salivary pH and a positive correlation between duration of illness and the salivary levels of
S. mutans in the asthmatics.
Conclusion: It was found that asthma, through its disease status and its pharmacotherapy, carries some risk
factors including decreased salivary flow rate and pH for caries development. It was also demonstrated that the
duration of medication and illness had significant influences on the risk of caries in asthmatics.

Key words asthma, caries, saliva composition, salivary pH and flow rate, Streptococcus mutans.

Asthma is a chronic airway disease characterized by inflam-
mation and bronchoconstriction.1,2 It is a serious global health
problem affecting more than 100 million people worldwide
and in most of the countries it is reported in, the prevalence
has increased during the past two decades.3 Although it
affects people of all ages, most cases of asthma occur in
childhood with peak prevalence between the ages of 6 and
11 years.4
Multiple causative factors including familial, infectious,
allergenic, socioeconomic, psychosocial and environmental
have been reported.5 The major clinical manifestations include
wheezing, coughing and chest tightness.6 Studies in the litera-
ture investigating the effect of asthma on dental caries are con-
Correspondence: Dr Nazan Kocataş Ersin, Department of Pedodon-
tics, Ege University, Bornova-Izmir 35100, Turkey. Email: nazan.
ersin@ege.edu.tr
Received 5 April 2005; revised 31 August 2005; accepted 1
September 2005.
flicting. While similar caries prevalence with healthy
individuals is reported in some studies,7–9 most of the others
have suggested that asthmatic children are at higher risk for
oral diseases than non-asthmatic children due to either their
disease or their pharmacotherapy.10–13 It is suggested that the
increase in caries prevalence was associated with prolonged
use of ß2 agonists, which lead to decreased salivary flow and
pH, therefore, reducing and modifying the protective effects
of saliva. So, in another study a decrease in the secretion of
whole saliva by 26% and parotid saliva by 36% and also an
increase in the number of lactobacilli and Streptococcus
mutans in the oral cavity which contribute to increased caries
susceptibility are reported.14
Although, there are many studies in the literature consider-
ing the relationship between dental caries risk and asthma, a
few studies investigated the effect of severity, type of medica-
tion and duration of the disease on caries development. The
aim of the present study was to investigate the caries risk in
asthmatics in relation to disease status (mild, moderate, severe),
550 NK Ersin et al.
type of medication and duration of illness, and to compare the
caries experience and oral hygiene status, salivary flow rate,
pH and buffer capacity, saliva composition and salivary level
of S. mutans of the asthmatics with healthy subjects.
Materials and methods
The study group consisted of 106 young asthmatics aged be-
tween 6 and 19 years old, who attended to the Department of
Pediatrics in Medical Faculty of Ege University, Turkey, for
their regular controls and who were using medications for
asthma for at least 1 year. In total, 100 healthy subjects of the
same age and social background who attended the Well Child
Care Outpatient Clinic at the Ege University, Faculty of
Medicine for their regular controls were also included as con-
trols. All of the participants were lifelong inhabitants of Izmir
which has water fluoridation of 0.3 p.p.m. Morover, subjects
who had taken antibiotics within 3 months prior to the study
were not included.
Clinical parameters
The study was approved by the Ethical Committee of Ege
University and written informed consents were obtained from
the parents of all patients. The subjects were examined for
dental caries using a probe and a mirror under daylight condi-
tions. Two qualified dentists who were blinded about which
subject was asthmatic performed dental examinations.
Calibrations among the examiners were conducted prior to the
study and kappa values of 0.95 for intra-examiner reproduci-
bility and 0.87 for inter-examiner reproducibility were found.
The children were divided into two age groups; 6–10 years
and 11–19 years since the age range was large. The caries expe-
rience, dental plaque indices and salivary flow rate, pH and
buffer capacity were evaluated in all subjects. The diagnosis of
dental caries was performed using World Health Organization
criteria (WHO; decay, filling, surface index for deciduous teeth,
and decay, missing, filling, surface index for permanent teeth)15
and dental plaque indices were recorded using Silness and Löe
plaque index.16 No radiographs were taken and decay was
recorded at the level of cavitation. The personal data about den-
tal status also included the oral hygiene (tooth brushing fre-
quency, usage of fluoride supplements) and dietary habits. The
frequency of sugar-rich food and beverages and acidic con-
sumption between meals for every child was recorded for 3 days
including a weekend. The data obtained included: the current
and past medication schedules; types of medications: (i) ␤2
agonists, (ii) ␤2 agonists + inhaled corticosteroids, (iii) ␤2 ago-
nists + inhaled corticosteroids + anti-inflammatory agent or
leukotriene antagonists; duration of medication usage; the
length of time the child had been suffering from asthma; and
the severity of asthma. The asthmatics were categorized as
mild, moderate and severe according to the status of the disease
which meant 69 patients were categorized as mild, 34 patients
as moderate and three patients as severe. 17
Saliva samples
Whole stimulated saliva samples were collected between 09.00
and 11.00 hours to minimize the circadian rhythm effects. Each
participant was instructed not to eat and drink for 2 h preceding
the appointment. Prior to saliva collection, each subject was in-
formed about the tests and seated on a chair and given time to
accommodate to their surroundings. Whole saliva was stimu-
lated by chewing paraffin wax for 30 s. The collected saliva
during the first 10 s was discarded and then collected for 5 min
into ice-chilled test tubes. The pH of saliva was measured im-
mediately after collection and flow rate was calculated. Buffering
capacity was determined by the modified Ericsson method.18
To determine the salivary level of S. mutans, the saliva was
serially diluted after agitation for 30 s in a vortex mixer
(Baxter Scientific, McGraw Park, IL, USA). Dilutions were
cultured on Mitis–Salivarius agar (Difco, Detroit, MI, USA)
containing 15% sucrose and 0.2 Units/mL of bacitracin pre-
pared according to Gold et al.19 All plates were incubated at
37°C in a 5% CO2 atmosphere for 48 h. The number of colony
forming units (CFU) was counted by the same microbiologist
throughout the study and the CFU/mL of S. mutans of saliva was
then calculated. NCTC 10449 S. mutans strain was also incu-
bated as a control plate to confirm bacterial identification.
The remaining saliva was used to measure total protein,
amylase, phosphate, calcium, sodium and potassium. Total
protein was determined by the method of Lowry et al. using
bovine serum albumin as standard.20 Amylase activity was
determined spectrophotometrically by the method described
by Fischer and Stein,21 as modified by Bellavia et al.22 Total
phosphate was determined spectrophotometrically at 700 nm
after the molybdic reaction.23 Total calcium was determined
by atomic absorption spectrophotometer at 422.7 nm in an air-
acetylene flame. Saliva sodium and potassium concentrations
were determined by atomic absorption spectrophotometer as
described previously.24
Statistical analysis
All data were analyzed by using SPSS 13.0 software program
and presented as mean ± standard deviation (SD). The ␹2-test
was used for the categorical data (gender etc.) between groups.
Mann–Whitney U-test was used to analyse proportional data.
Numerical data was analysed by t-test and Mann–Whitney
U-test. Spearman rank correlation test was used for the determin-
ation of correlations. Kruskal–Wallis test was performed for
 Oral health status of asthmatics 551

Table 1 The distribution of the mean decay, missing, filling, surface scores and plaque indices in both groups according to age with standard
deviation†

Age (years) n Mean DMFS ± SD Mean dfs ± SD Plaque index ± SD

Asthmatic group 6–10 42 3.3 ± 2.8* 9.2 ± 7.6* 1.9 ± 0.4

11–19 64 4.1 ± 3.4 — 1.8 ± 0.6
Control group 6–10 50 1.5 ± 2.1 5.7 ± 4.7 1.7 ± 0.7
11–19 50 3.8 ± 4.0 — 1.8 ± 0.7

*Statistically significant P < 0.05.

†
Mann–Whitney U-test.
dfs, decay, filling, surface; DMFS, decay, missing, filling, surface; SD, standard deviation.

the comparisons in the asthmatic group. According to the
Bonferroni correction, Mann–Whitney U-test was used to
control the experimentwise error rate. A multivariable logistic
regression model (Forward Stepwise Likelihood Ratio) was also
used. The potential covariates were medication use, asthma
severity and numeric (continuous) variables which were age,
duration of asthma, duration of medication, plaque scores, pH,
buffer capacity, flow rate of saliva and S. mutans counts. The
critical level for statistical significance was set as P < 0.05.
Results
The mean ages and the gender distribution of the asthmatic
and healthy subjects were similar between the groups
(␹2, t-tests). The mean ages of the asthmatics and controls
were 11.6 ± 3.5 and 10.8 ± 3.0 years, respectively. There
were 56 males in the asthmatics group and 50 males in the
controls.
The duration of asthma were 1–2 years in 27 patients, 1 year
in 21 patients and 5 or more years in 58 patients with a mean
time of 5.14 ± 2.97 years.
In the group assigned as mild, 13 patients used inhaled ␤2
agonists, 20 patients used both inhaled corticostreoids and ␤2
agonists, and 36 patients who needed additive therapy used the
inhaled corticostreoids and ␤2 agonists with an anti-inflammatory
agent or leukotriene antagonists. In the group assigned as
moderate, 16 used both inhaled corticostreoids and ␤2 agonists
regularly, while 18 used the same drugs with the addition of
anti-inflammatory agent or leukotriene antagonists. In the
severe asthmatic group, two patients were given inhaled corti-
costreoids and ␤2 agonists regularly and one combination with
the other drugs. The mean duration of drug administration
was 1.92 ± 2.30 years and the mean duration of past medica-
tion was 1.35 ± 2.20 years.
The children in the asthmatic group aged between 6 and
10 years had significantly higher caries prevalence (higher
dfs and DMFS scores) than the control group of the same
age. The caries experience was found similar in both groups
of children aged 11–19 years (Table 1, Mann–Whitney
U-test). The scores for dental plaque did not differ statistically
between the study and control groups for both age groups
(Mann–Whitney U-test). The correlations between the
severity of asthma, the type, and duration of medication and
caries prevalence were not statistically significant. There
was a negative correlation between the duration of medica-
tion and the saliva pH (P = 0.017, r = −0.28) as well as
between the salivary flow rate and caries prevalence
(P = 0.023, r = −0.22), although they were weak inverse cor-
relations (Kruskal–Wallis, Mann–Whitney U-test, Bonfer-
roni correction tests). The number of colony forming units
of S. mutans were 7.9 × 105 and 1.28 × 105 CFU/mL in the
asthmatic and control groups, respectively. There was no
statistical difference between the salivary S. mutans levels
in both groups (t-test).
A statistically significant decrease for the salivary flow
rate and pH were found in the asthmatic group compared
with the control group while buffering capacities were simi-
lar in both groups (Mann–Whitney U-test, Table 2). Flow
rate of saliva was found as the only statistically significant

Table 2 The mean salivary flow rates, pH and buffer capacity of whole stimulated saliva for both groups with standard deviations†

Age (years) n pH ± SD Flow rate ± SD (mL/min) Buffer capacity ± SD (mL/min)

Asthmatic group 6–10 42 6.91 ± 0.19* 0.56 ± 0.47* 4.21 ± 0.51

11–19 64 6.90 ± 0.22* 0.76 ± 0.43* 4.44 ± 0.67
Control group 6–10 50 7.03 ± 0.16 0.87 ± 0.27 4.22 ± 0.20
11–19 50 7.03 ± 0.22 1.01 ± 0.42 4.26 ± 0.29

*Statistically significant P < 0.05.

†
Mann–Whitney U-test.
SD, standard deviation.
552 NK Ersin et al.

Table 3 Concentrations of the components in stimulated whole In the present study, the caries prevalence in asthmatic chil-
saliva (mean ± standard deviation)† dren aged between 6 and 10 years old was found statistically
higher compared with the control group, while no difference
Asthmatic group Control group
was in asthmatic children aged between 11 and 19 years old
Protein (mg/L) 478 ± 171 541 ± 250 compared with the control group. The explanation for not
Amylase (U/L) 387 ± 205 477 ± 250 detecting any difference in the older group could be that the
Calcium (mg/dL) 4.8 ± 1.8 4.6 ± 1.3 majority of the children were aged 11–13 years old and this age
Phosphate (g/dL) 9.6 ± 2.5 9.8 ± 2.2
Sodium (mm/L) 9.6 ± 3.7 10.2 ± 4.1 group have the highest number of caries-free teeth. In most of
Potassium (mm/L) 19.6 ± 2.8 19.4 ± 3.4 the related studies, an increase in the prevalence of dental caries
in asthmatic children was found compared with the non-asth-
†
Mann-Whitney U-test. matic children.12,13,27–29 Kankaala et al. reported that asthmatic
children had more restorations and extractions of primary
bivariate (logistic) variable in caries development (odds ratio molars due to caries than their non-asthmatic pairs.25 However,
[OR] = 6.233; 95% confidence interval [CI], 1.293; 30.045) Meldrum et al.8 and Shulman et al.9 found that asthmatic chil-
There was no significant difference within the groups for dren did not have a higher caries experience than controls. Lau-
both age groups. rikainen and Kuusisto also found that asthmatic adults did not
Concentration of calcium, sodium, phosphate and potassium have more caries than the non-asthmatic controls.7
in the saliva were similar in both the asthmatic and healthy Among the limitations of the study the results were not
children while the concentration of total protein and amylase fully comparable with all of the earlier studies due to the use
were lower in the asthmatic group, but the results were not of inhaled corticosteroids as a part of asthma management
statistically significant (Table 3). during recent decades. The fact that inhaled ␤2 agonists have
There was no significant correlation between the severity been shown to induce higher caries risk should not have the
of asthma, type of medication and the salivary pH, flow rate, major effect in this study because a few of the patients were
buffer capacity and the number of S. mutans of the asthmatic using only this medication, most of them were using the com-
children (Tables 4 and 5). However, there was a significant dif- bination of the medication which limited the results of the
ference in the salivary levels of S. mutans of the children who study and the individual effect of the drugs could not be evalu-
had been suffering from asthma for more than 2 years (Table 6; ated.14,30 The patients were also not equally distributed accord-
P = 0.015). ing to the severity of asthma. However, a positive relationship
There were no significant differences in sugar consumption between duration of illness and the salivary levels of S. mutans
and nutritional values of the diet or of fluoride intake. Also no and a negative correlation between the duration of medication
significant difference was found in oral hygiene habits between and the salivary pH were demonstrated. The decrease in the
the asthmatic and control groups (P > 0.05). salivary pH was likely to encourage the growth of the acido-
philic S. mutans in the asthmatics. Therefore, duration of med-
ication and length of time the child had been suffering from
Discussion asthma could be considered as risk factors for caries develop-
ment. However, the findings of Eloot et al. who found that
The literature has described several oral health conditions as- neither the period of the disease nor the medication had a sig-
sociated with asthma: an increased rate of caries development nificant influence on the risk of caries in asthmatic children is
and reduced salivary flow rate and pH.7,25–28 However, there is not in accordance with ours.31 Using the WHO criteria of car-
a lack of consensus among studies that may be attributed to ies without other diagnostic aids maybe another limitation
differences in asthma severity and medication types about because no radiographs were taken. However, it is considered
whether asthmatic children are at greater risk of caries than that use of the WHO criteria could reduce the possible bias
non-asthmatic children.25 because the lesions are diagnosed at the level of cavitation.

Table 4 Effects of the types of medication on mean salivary pH, buffer capacity, flow rate and Streptococcus mutans in the asthmatics†

Medication n pH ± SD Buffer capacity ± SD (mL/min) Flow rate ± SD (mL/min) S. mutans (CFU/mL)

ß2 agonist 13 6.9 ± 0.2 4.3 ± 0.6 0.6 ± 0.3 8.9 × 106

ß2 agonist + inhaler 38 6.9 ± 0.2 4.4 ± 0.6 0.7 ± 0.4 1.4 × 106
corticosteroids
Combination 55 6.9 ± 0.2 4.2 ± 0.6 0.8 ± 0.6 1.7 × 106
†
Mann–Whitney U-test and Kruskal–Wallis test.
CFU, colony forming units; SD, standard deviation.

Table 5 Effects of the severity of asthma on the mean salivary pH, buffer capacity, flow rate and Streptococcus mutans†
Severity of asthma n pH ± SD Buffer capacity ± SD (mL/min)
Mild 69 6.8 ± 0.2 4.4 ± 0.7
Moderate 34 6.9 ± 0.2 4.3 ± 0.5
Severe 3 6.9 ± 0.2 3.9 ± 0.5
†
Mann–Whitney U-test and Kruskal–Wallis test.
CFU, colony forming units; SD, standard deviation.
Table 6 Effects of the duration of asthma on the mean salivary pH, buffer capacity, flow rate and Streptococcus mutans†
Duration of asthma n pH ± SD Buffer capacity ± SD (mL/min)
=1 year 27 6.9 ± 0.2 4.4 ± 0.7
1< × ⱕ2 years 21 6.9 ± 0.2 4.3 ± 0.6
>2 years 58 6.9 ± 0.2 4.4 ± 0.7
*P = 0.015. †Mann–Whitney U-test.
CFU, colony forming units; SD, standard deviation.
Ryberg et al. studied the saliva composition of asthmatic
children and found significantly lower concentrations of total
protein and amylase in stimulated parotid saliva and higher
S. mutans counts in saliva compared with control group.14 They
reported the decreased salivary flow of stimulated whole saliva
in asthmatic children by 26%. Kargul et al. investigated the
effects of the ␤2 agonists such as Salbutamol Ventolin Inhaler
(Glaxo Wellcome, Auckland, New Zealand) on salivary com-
position and flow rate.30 They reported that pH values decreased
in plaque and saliva 30 min following inhalation of the drugs.
Lenander-Lumikari et al. stated that the mean stimulated
salivary flow rate was lower in the asthmatic group than the
control group, but no differences in microbial counts were
found in their study.26 In the present study, the salivary flow
rate and pH value were found to be statistically lower in the
asthmatic group and there was a significant weak negative cor-
relation between the salivary flow rate and caries development
(P = 0.023). No differences were found in the levels of S.
mutans compared with controls. In addition, the concentra-
tions of total protein and amylase in stimulated whole saliva
were found lower in the asthmatic children, but it was not sta-
tistically significant. Although the salivary pH was statistically
lower in asthmatics than non-asthmatics, it was not below the
‘critical pH’ (5.5) which resulted with the enamel deminerali-
zation. Tootla et al. also found that none of the inhalers were
able to demonstrate an acidogenic response below the ‘critical
pH’.32 However, they found that lactose-based dry powder
inhalers produced significantly lower salivary pH and plaque
pH with other inhalers (␤2 agonists, combination) and sug-
gested that this may be an important consideration for enamel
demineralization.
Reddy et al. found that asthmatic children had high caries
prevalence and it increased with the severity of disease due to
the increase in the dosage and frequency of medication.29 In
Oral health status of asthmatics 553
Flow rate ± SD (mL/min) S. mutans (CFU/mL)
0.7 ± 0.4 1.3 × 106
0.6 ± 0.4 1.5 × 106
0.6 ± 0.3 4.7 × 106
Flow rate ± SD (mL/min) S. mutans (CFU/mL)
0.8 ± 0.5 7.2 × 105
0.6 ± 0.3 1.4 × 106
0.5 ± 0.4 1.7 × 107*
the present study, no correlation was found between the sever-
ity of asthma and caries prevalence. This could be explained by
the low number of patients with moderate and severe asthma
(n = 37) in which 70% of the patients were classified as mild.
The results of Eloot et al. were in accordance with our results
which found that the severity of asthma had no significant
influence on the risk of caries in asthmatic children.31
The results of this study supported the hypothesis that fac-
tors related to asthmatic condition and/or medication might
increase the risk of caries due to the lower salivary flow rate
and pH in the asthmatics. In addition, the duration of medica-
tion and the duration of illness were found as risk factors for
caries development in asthmatic children although the type of
medication does not affect the salivary pH, buffer capacity or
flow rate of saliva. In conclusion, asthmatic patients especially
in the younger age should receive intensive preventive care,
including oral hygiene instruction, dietary advice and regular
topical fluoride treatments.
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