Abst ract
Submitted: April 5, 2016 0RGL¿FDWLRQ-XO\ Accepted: August 1, 2016
I m pact of inhalat ion t herapy on t he
incidence of carious lesions in pat ient s
wit h ast hm a and COPD
Obj ect ive: The aim of t his st udy was t o invest igat e t he incidence of FDULRXVOHVLRQVWKHDPRXQWRIVDOLYDU\ÀRZUDWHDQGS+YDOXHLQSDWLHQWVZLWK asthm a and chronic obstructive pulm onary diseases (COPD), using inhalation therapy. The obtained results were com pared with the results of adult healthy subj ect s, form ing a cont rol group. Mat erial and Met hods: The st udy included 80 part icipant s aging bet ween 18 and 65 years. The experim ent al group ( EG) was com prised of 40 part icipant s, previously diagnosed wit h ast hm a RU&23'XQGHUJRLQJLQKDODWLRQWKHUDS\IRUPRUHWKDQ¿YH\HDUV7KHFRQWURO group ( CG) , com prised of 40 participants, m irrored the sam e age and gender st at us of t he EG. Dent al st at us was det erm ined by decayed, m issing, and ¿OOHGWHHWK'0)7LQGH[4XDQWLW\DQGS+YDOXHRIVDOLYDZHUHGHWHUPLQHG LQWKHODERUDWRU\5HVXOWV,QWKH(*WKHPHDQYDOXHRIWKHVDOLYDU\ÀRZUDWH DQGS+YDOXHZHUHVWDWLVWLFDOO\VLJQL¿FDQWO\ORZHUWKDQLQWKH&*S Patients in the EG had a higher value of DMFT index when com pared with the &*DOWKRXJKWKHGLIIHUHQFHZDVQRWVWDWLVWLFDOO\VLJQL¿FDQWS 0HDQ num ber of decayed teeth, as well as m issing teeth, in the EG was statistically VLJQL¿FDQWO\KLJKHUWKDQLQWKH&*S0HDQQXPEHURI¿OOHGWHHWK LQ WKH (* ZDV VWDWLVWLFDOO\ VLJQL¿FDQWO\ ORZHU WKDQ LQ WKH &* S Conclusion: I t was found t hat pat ient s undergoing inhalat ion t herapy face LQFUHDVLQJULVNRIGHQWDOFDULHVGXHWRWKHORZHUVDOLYDU\ÀRZUDWHDQGS+YDOXH along wit h t he inhalat ion t herapy. They should receive int ensive prevent ive care, including oral hygiene inst ruct ion and diet ary advice.
Ke y w o r d s: Dent al car ies. Ast hm a. Chr onic obst r uct ive pulm onar y diseases. Saliva. Salivat ion. I nhalat ion t herapy.
Branislava Velicki BOZEJAC1,2
Ivana STOJŠIN2,3
0LUQDĈ85,û2,4
Biljana ZVEZDIN2,4
7DWMDQD%5.$1,û2,3
Evica BUDIŠIN2,4
Karolina VUKOJE2
1HYHQD6(ý(12,4
http://dx.doi.org/10.1590/1678-7757-2016-0147
1Stomatološka poliklinika Dentaland Novi Sad, Srbija.
2Medicinski fakultet Novi Sad, Univerzitet u Novom Sadu, Srbija.
3Odeljenje za bolesti zuba i endodonciju, Klinika za stomatologiju Vojvodine, Novi Sad, Srbija 4,QVWLWXW]DSOXüQHEROHVWL9RMYRGLQH6UHPVND.DPHQLFD6UELMD
I nt roduct ion
Dent al caries represent s a m ult ifact orial disease and it is one of t he m ost prevalent chronic diseases worldwide. Caries lesion form s t hrough a com plex
LQWHUDFWLRQEHWZHHQFDULRJHQLFRUDOÀRUDDELR¿OP
and ferm ent able carbohydrat es on t he t oot h surface. The occurrence of carious lesions is an out com e of t he dist urbed balance bet ween diet et ic- bact erial fact ors and host fact ors, and t he usage of different drugs
PD\VLJQL¿FDQWO\LQÀXHQFHWKLVPLVEDODQFH11. Based on studies3,6,13,15,24, patients undergoing inhalation therapy are subj ected to higher risk of dental caries, due to the reduced saliva secretion, decreased pH value, enlarged num ber of cariogenic bacteria caused by inappropriate
VXJDUFRQVXPSWLRQLQVXI¿FLHQWÀXRULGHH[SRVXUHSRRU
oral hygiene, and t he usage of inhaling m edicam ent s wit h dry powder. These changes could be relat ed t o basic diseases or t o t he prescribed t herapy.
Ast h m a an d ch r o n i c o b st r u ct i v e p u l m o n ar y diseases (COPD) are predom inantly chronic respiratory diseases, t he prevalence of which grows in m any count ries as well as in Serbia ( Europe) . According t o Global I nit iat ive for Ast hm a8, it is est im at ed t hat around 400 m illion people suffer from ast hm a. The prevalence of ast hm a in Serbia is 4- 5% , and in 2011,
IRU WKH ¿UVW WLPH LW ZDV RI¿FLDOO\ SXEOLVKHG WKDW
ast hm a prevalence on t he t errit ory of Serbia was 6.8%17. According t o Global I nit iat ive for Obst ruct ive Lung Disease, it is est im at e t hat COPD is a leading cause of m orbidit y and m ort alit y wordlwide26. The COPD prevalence has increased from 7% t o 14% in t he past nine years28. The lat est dat a from t he
6HUELDQSULPDU\KHDOWKFDUHFHQWHUVFRQ¿UPHGWKDWWKH
percentage of patients with a clinical suspicion of COPD was 21.9%27. The causes and t he pat hophysiological charact erist ics of ast hm a and COPD are different , yet bot h chronic diseases share com m on funct ional charact erist ics, i.e., a lim it ed air passage t hrough respirat ory airways. I nhalat ion drugs such as bet a- 2 agonist s, ant icholinergic bronchodilat ors, and inhaled cort icost eroids have advant age in ast hm a and COPD t herapy8,26.
Th e m aj or pr opor t ion of t h e in h aled dr u g is ret ained in t he oral cavit y and oropharynx and it m ay interfere in the norm al physiology of oral tissues9. The usage of t he inhaled bet a- 2 agonist in com binat ion wit h glucocort icoids in ast hm at ic pat ient s cause t he
GHFUHDVHGVDOLYDU\ÀRZUDWH18 and they can reduce the
effect of saliva in the aid of protection against caries21.
:KHQVDOLYDU\ÀRZLVGLPLQLVKHGRUDEVHQWDQGWKH
pH value is lower, t here is increased food ret ent ion, an acidic environm ent is encouraged and persist s longer9. Prolonged use of beta-2 agonists is associated wit h t he increased frequency of caries, which could be explained t hrough t he basic effect of bet a- 2 agonist s t hat are connect ed t o t he present bet a- 2 recept ors in t he parot id and ot her salivary glands4.
The increased suscept ibilit y t o dent al caries can also be due t o t he frequent use of dry powder inhaler cont aining fer m ent able car bohy drat es. The m ost com m on is lact ose m onohydrat e, and alt hough it is one of t he least cariogenic sugars, it can st ill lead t o an increased dental caries risk25. Risk factor for higher caries experience in pat ient s can also be poor hygiene and lack of inform at ion about proper m aint enance of oral hygiene and prevent ive m easures t o preserve dent al healt h. Many DXWKRUVDVVHVVHGWKHLQÀXHQFHRI inhalat ion t herapy on t he oral healt h in children and adolescent s6,15,18,21,23 while few aut hors addressed t his
issue focusing on t he adult populat ion12,13.
Therefore, the m ain aim of this study was verifying GHQWDOFDULHVDQGVDOLYDFKDUDFWHULVWLFVVDOLYDU\ÀRZ rate, pH value) of patients who suffer from asthm a and COPD wit h inhalat ion t herapy. I n addit ion, we aim ed t o assess whet her part icipant s were inform ed about proper m aint enance of oral hygiene and prevent ive m easures and whet her t hey adhere t o t hem . No such evaluat ion has been perform ed in Serbian pat ient s.
Mat erial and m et hods
This cross sect ional st udy was approved by t he Et hical Com m it t ee of t he Dent al Clinic of Voj vodina, Faculty of Medicine, University of Novi Sad, Serbia (no. 01- 47/ 18- 2013) . Writ t en inform ed consent form was obt ained from all pat ient s. The st udy was conduct ed from 2014 to 2015, and it has included 80 participants aged between 23 and 65. The experim ental group (EG) consist ed of 40 part icipant s t hat suffer from ast hm a or chronic obstructive pulm onary disease ( COPD) . The diagnosis of ast hm a and COPD was prepared based on m edical anam nesis, clinical ex am inat ion, and functional tests at the I nstitute for Pulm onary Diseases of Voj vodina, Novi Sad, Serbia. The m ain inclusion
m ild, m oderat e, and severe according t o t he st at us of t he disease report ed by pulm onologist s. The EG part icipant s were all using a dry powder or aerosol inhaler. The control group (CG) consisted of 40 healthy participants of the sam e age, gender status, and in the sam e geographic area as in the EG. The CG participants were pat ient s t reat ed at t he Depart m ent of Dent ist ry and Endodont ics, Dent al Clinic of Voj vodina, Novi Sad, Serbia. The part icipant s suffering from any ot her
NLQGRIDFXWHRUFKURQLFGLVHDVHVWKDWFRXOGLQÀXHQFH
saliva secret ion were excluded from t he st udy. The obtained results have been com pared with results from t he cont rol group ( healt hy people) . St andard dent al anam nesis and dental status of patients were obtained.
Quest ionnaire dat a
A quest ionnaire was com plet ed by all part icipant s, wit h t he assist ance of t he dent ist , and dat a were collect ed for inform at ion about pat ient s’ age, gender, diet ary habit s ( t he m ost consum ed beverage) , oral K\JLHQHKDELWVXVHRIÀXRULGHÀXRULGHULQVHWKHLU awareness and knowledge of t he proper m aint enance of oral hygiene, and t he frequency of t heir checkups at t he dent ist . Anam neses of EG was addit ionally support ed wit h quest ions about t he t ype and severit y of t h e d iag n osed ast h m a an d COPD, len g t h of t reat m ent , regularit y of t herapy applicat ion, t ype RI XVHG PHGLFDWLRQV DQG WKHLU KDELWV ± ZHWKHU WKH pat ient s rinsed t he m out h wit h wat er aft er using t he inhaler.
Clinical caries exam inat ion
Dent al ex am inat ion w as car r ied out by t hr ee dent ist s. Three exam iners perform ed dat a collect ion, one responsible for t he quest ioner, anot her for saliva
GHWHUPLQDWLRQ VDOLYDU\ ÀRZ UDWH DQG VDOLYDU\ S+
value) , and t he last one for t he dent al diagnosis. The exam iners were blinded t o t he subj ect ’s group assignm ent . Dent al caries diagnosis was perform ed accor ding t o WHO cr it er ia29, and DMFT index for perm anent t eet h ( num ber of decayed, m issing, and ¿OOHG WHHWK ZHUH FDOFXODWHG Check up was m ade under st andard dent al cont rol using a dent al m irror an d den t al pr obes w it h ar t if icial illu m in at ion . A clinical st udy cont ained a dent al checkup com prising part icipant s’ healt h st at us of hard dent al t issues and t he presence of m anifest carious lesions. Radiograph was not included in t he exam inat ion.
Salivary and pH analyses
Laborat or y invest igat ion com pr ised r egist er ing
WKHVDOLYDU\ÀRZUDWHVRIQRQVWLPXODWHGVDOLYDDQG
t he pH value. Before t he saliva sam ple com plet ion, t he part icipant s of bot h groups were inform ed about t he m easures t hat have t o be adhered t o, i.e., t hat before the com pletion they should refrain from alcohol use ( for 12 hours) , from subst ant ial m eals ( for 60 m inutes) as well as from richly sweet, caffeine, or sour drinks and foods. The part icipant s were also inform ed t hat t hey should not have any dent al checkups or int ervent ions in t he previous 48 hours, nor clean t heir t eet h in t he 45 m inut es prior t he exam inat ion. Saliva was collect ed bet ween 8.00 and 10.00 a.m .20. During t he procedure, part icipant s were passively seat ed in the dental chair with their heads leaning forward. Each
SDUWLFLSDQWZRXOGEHJLYHQDSRO\XUHWKDQHÀDVNDQGD
glass funnel. They should incessant ly allow collect ing
VDOLYDLQWKHLUPRXWKVDQGVSLWWLQJLWLQWRWKHLUÀDVNV
continuously in the period of 10 m inutes. The quantity of saliva w as det er m ined by r eading t he graded
ÀDVNV DIWHU WKH EXEEOHV GLVDSSHDU WR VHWWOH VDOLYD
The salivary pH value was m easured im m ediat ely aft er collect ion. Salivary pH values were det erm ined wit h a pH indicat or paper, and t he colour change of t he indicat or would be com pared wit h t he exist ing colour code. The precision of t he pH int ervals is 0.2 according to the Saliva- Check buffer ( GC Corporation, Tokyo, Japan) .
St at ist ical analysis
Obt ained dat a w er e pr ocessed w it h st andar d procedures of descript ive and com parat ive st at ist ics. The m ethods of descriptive statistics used in this study were m easures of cent ral t endencies, of variabilit y for num eric param et ers, and absolut e and relat ive values for attributive m arkers. Statistical analysis was perform ed using the I BM SPSS Statistics 20.0. All data were present ed as m ean± st andard deviat ion ( SD) . The Shapiro-Wilk t est showed norm al dist ribut ion of the data ( p> 0.05) for: age, m ean pH value, and DMFT index. These num eric variables were analysed using param et ric t est s ( t- t est ) while num ber of decayed,
Result s
I n the present study, 80 patients were enrolled, 40 in EG and 40 in CG. The obt ained result s are shown in 7DEOH7KHUHZDVQRVWDWLVWLFDOO\VLJQL¿FDQWGLIIHUHQFH bet ween EG and CG regarding gender ( p= 1.000) and age ( p= 1.000) . Prior t he beginning of t he st udy, m ore t han 30% of pot ent ial part icipant s were excluded because of som e reasons.
Regarding t he t ype of disease, 70% of pat ient s were suffering from ast hm a and 30% were suffering from COPD in t he EG. Most of t he part icipant s in bot h groups were allocat ed int o t he m oderat e t ype DVWKPD±&23'±$VIRUWKHOHQJWK of t reat m ent , m ost of t he part icipant s in bot h groups had been using inhalat ion t herapy for 5-10 years DVWKPD ± &23' ± 7KH TXHVWLRQ about regularit y of undergoing t herapy was posit ively DQVZHUHGE\PRVWRISDUWLFLSDQWVDVWKPD± &23'±GDWDVKRZQLQ7DEOH
The EG participants in their treatm ent of asthm a or COPD used a com binat ion of t wo or m ore m edicines. Frequency of m edicine application of the participants in t he EG who used inhalat ion t herapy regularly was t wo tim es/ day. We found out that the EG participants used m edicines in t he aerosol form ( iprat ropium brom ide + fenot erol 65% ) and in t he powder form ( salm et erol + ÀXWLFDVRQHEXGHVRQLGHIRUPRWHURO t iot ropium 27.5% , beclom et hasone dipropionat e + form ot erol 12.5% , salbut am ol 5.0% and form ot erol 2.5% ) . Most of t he m edicines in t he powder form oft en cont ain lact ose in t he form of lact ose- hydrat e or lact ose- m onohydrat e. Out of 40 part icipant s, 90% used t hese t ypes of m edicam ent s.
&RQFHUQLQJPRXWKULQVLQJZHYHUL¿HGWKDWLWZDV
never perform ed by 21.44% of pat ient s wit h ast hm a and 50% of patients with COPD; som et im es perform ed by 28.57% of patients with asthm a and 0% of patients wit h COPD; oft en perform ed by 10.71% of pat ient s wit h ast hm a and 8.33% of pat ient s wit h COPD; and alw ays perform ed by 39.28% of pat ient s wit h ast hm a and 41.67% of pat ient s wit h COPD.
Table 3 show s t hat t her e w as no st at ist ically VLJQL¿FDQW GLIIHUHQFH EHWZHHQ (* DQG &* SDWLHQWV in t h eir r epor t s of t h e t y pe of bev er age m ost ly consum ed ( p= 0.054) or in t heir use of t oot hbrush DQG WRRWKSDVWH S GHQWDO ÀRVV S and int er dent al t oot hbr ush ( p= 0. 155) . How ev er, VWDWLVWLFDOO\VLJQL¿FDQWGLIIHUHQFHVZHUHIRXQGLQWKH following responses obt ained: int erdent al t oot hbrush was reported to have been used by 27.5% participants RI &* DQG QR (* SDUWLFLSDQWV S ÀXRULGH solut ion for m out hwash was never used by 80% of EG par t icipan t s com par ed w it h 4 2 . 5 % of CG part icipant s ( p< 0.001) ; t he lack of inform at ion about t he proper oral hygiene was report ed by m ore t han KDOIRIWKH(*SDUWLFLSDQWV±FRPSDUHGZLWK only 12.5% of CG part icipant s ( p< 0.001) ; adherence t o oral hygiene recom m endat ions was report ed by 37.5% of EG part icipant s and as m any as 67.5% of CG part icipant s who had been inform ed about t he proper m aint enance ( p< 0.001) ; scheduling a dent al checkup only when t here is a problem was report ed by 80% of EG part icipant s com pared wit h 17.5% of CG part icipant s ( p< 0.001) .
7KHPHDQYDOXHRIWKHVDOLYDU\ÀRZUDWHLQWKH(* ZDVP/PLQZKLOHLQWKH&*LWZDVKLJKHU± 0.496 m L/ m in. The difference bet ween t hese values
Parameter Value EG CG
Gender, n(%)
S FemaleMale 14 (35%) 26 (65%) 14 (35%) 26 (65%)
Age group
S 0HDQ6'min - max 23-65 23-65
Table 1- Demographic characteristics of the studied population
Variable Category Asthma COPD Total
Type of disease Mild
Moderate Severe
25.0% 53.6% 21.4%
25.0% 41.7% 33.3%
25.0% 50.0% 25.0%
Length of treatment 5-10 yrs.
11+ yrs. 53.6% 46.4% 91.7% 8.3% 65.0% 35.0%
Therapy Regular
when necessary 85.7% 14.3% 75.0% 25.0% 82.5% 17.5%
ZDV IRXQG WR EH VWDWLVWLFDOO\ VLJQL¿FDQW S as well as t he one in t he m ean salivary pH value ( p< 0.001) , which was 6.63 in t he EG and 7.23 in t he CG ( Table 4) .
The m ean value of DMFT index in t he EG was 21.2, while in t he CG t his value was lower, i.e., 19.4, but no VWDWLVWLFDOO\VLJQL¿FDQWGLIIHUHQFHZDVIRXQGEHWZHHQ the groups ( p= 0.199) . However, we found statistically VLJQL¿FDQWGLIIHUHQFHVEHWZHHQJURXSVLQWKHIROORZLQJ com ponent s: m ean num ber of decayed t eet h in t he EG was 3.68, while in t he CG t his value was lower, 1.40 ( p< 0.001) ; m ean num ber of m issing t eet h in
t he EG was 12.3, while in t he CG t his num ber was VLJQL¿FDQWO\ORZHUSPHDQQXPEHURI ¿OOHGWRRWKVXUIDFHVLQWKH(*ZDVZKLOHLQWKH CG t his result was higher, 11.6 ( p< 0.001) ( Table 5) .
Based on t he result s of DMFT index ( p= 0.177) and caries lesion ( p= 0.153) regarding t he severity degree RI WKH GLVHDVH QR VWDWLVWLFDOO\ VLJQL¿FDQW GLIIHUHQFH was observed. Also bsed on t he result s of DMFT index ( p= 0.541) and caries lesion ( p= 0.689) concerning WKHOHQJWKRIWKHGLVHDVHQRVWDWLVWLFDOO\VLJQL¿FDQW difference was found eit her.
EG CG p value
The most consumed beverag -water
-sparkling water, fruit juice, sport beverage -milk, yoghurt
87.5% 5.0% 7.5%
82.5% 17.5% 0%
S
Means for oral hygene -toothbrush and toothpaste
GHQWDOÀRVV
-interdental toothbrush
100% 15%
0%
100% 27.5% 27.5%
S S S
Oral hygene - toothbrushing -more than 2 times a day -2 times a day
-once a day -once a week -once a month
20% 55% 10% 10% 5%
27.5% 62.5% 10%
0% 0%
S
)OXRULGHH[SRVXUHKLVWRU\XVHRIÀXRULGHULQVH
-every day -once a week -once a month -never
10% 7.5% 2.5% 80%
17.5% 25% 15% 42.5%
S
Being informed about the proper maintanance of oral hygene
-yes, and adhere to these recommendations -yes, and do not adhere to these recommendations -no, not informed about proper oral hygene
37.5% 10% 52.5%
67.5% 20% 12.5%
S
'HQWDOFKHFNXSVIUHTXHQF\
-every six months -once a year -once every 3 years
7.5% 12.5%
0% 80%
45.5% 32.5% 5% 17.5%
S Table 3-6WXG\VDPSOHRIH[SHULPHQWDOJURXS(*DQGFRQWUROJURXS&*UHJDUGLQJWKHGLHWDU\KLVWRU\RUDOK\JLHQHÀXRULGHH[SRVXUH LQIRUPDWLRQDERXWSURSHURUDOK\JLHQHDQGIUHTXHQF\RIFKHFNXSVDWWKHGHQWLVW
&ODVVL¿FDWLRQ Group N Mean SD min Max median p
6DOLYDU\ÀRZ
EG 40 0.279 0.169 0.07 0.71 0.245
CG 40 0.496 0.318 0.06 1.49 0.402
pH value
EG 40 6.63 0.44 5.6 7.6
CG 40 7.23 0.28 6.8 7.8
Table 4-0HDQVDOLYDU\ÀRZUDWHVQRQVWLPXODWHGVDOLYDP/PLQDQGPHDQVDOLYDU\S+YDOXHIRUERWKJURXSV
Discussion
The present st udy shows t hat adult s who suffer from ast hm a and COPD and have been undergoing inhalat ion t herapy for som e years have higher caries prevalence, lower salivary secret ion rat e, and lower pH value com pared wit h healt hy individuals.
Alt hough in t his st udy t here was a clinically higher value of t he m ean DMFT index in t he EG t han in t he &*WKHGLIIHUHQFHZDVQRWFRQ¿UPHGWREHVWDWLVWLFDOO\ VLJQL¿FDQW S! ZKLFK LV LQ DFFRUGDQFH ZLWK t h e f in din gs of an ot h er st u dy1 3. How ev er, som e
researchers12 showed t hat DMFT index in ast hm at ic
group was higher when com pared wit h t he cont rol group, resulting from the prolonged use of drugs. I n the current study, the m ean num ber of decayed teeth was higher in t he EG t han in t he CG ( p< 0.001) , which was sim ilar to other studies3,15,19,22. These results m ay be the
a consequence of eit her t he inhalat ion m edicam ent s them selves or their application techniques3, and could
be a det erm inant fact or causing dent al caries. I n contrast to the aforem entioned studies, som e authors5
did not recognize any connection between the severity of ast hm a, t he period of exposure t o m edicat ion, and t he prevalence of caries. I n t he present ed st udy, t he m ean num ber of m issing t eet h was higher in
WKH(*WKDQLQWKH&*SZKLFKLVD¿QGLQJ DOVRFRQ¿UPHGE\RWKHUUHVHDUFKHUV3. These result s
support t he fact t hat ext ract ion t herapy is t he m ost com m only used t herapy for caries in t hese pat ient s. 2QWKHRWKHUKDQGWKHPHDQQXPEHURI¿OOHGWHHWK in t he EG was lower t han in t he CG ( p< 0.001) . Such dist ribut ion of DMFT index st ruct ural com ponent s m ay be at t ribut ed t o t he fact t hat EG part icipant s did not visit t heir dent ist s for checkups regularly and did not have adequat e dent al care, which m ight be due t o t he lack of inform at ion about proper m aint enance of solid dent al t issues, t he lack of necessary funds,
or sim ply because t hey were m ore concerned wit h prim ary healt h issues t hat m ay hinder t heir qualit y of life and daily act ivit ies t o a larger ext ent . Under t he circum st ances, t eet h are perm anent ly covered wit h non- st im ulat ed saliva. Wit hin t he result s of t his VWXG\WKHPHDQYDOXHRIVDOLYDU\ÀRZUDWHLQWKH(* was lower t han in t he CG ( p< 0.001) . Sim ilar result s were received by ot her aut hors who considered t hat t he decreased salivary secret ion rat e in ast hm at ics is probably caused by t he drugs bet a- 2 agonist and cort icost eroids6,23. Fact ors t hat reducet he quant it y of
saliva can negat ively affect oral healt h, since saliva plays an im port ant role in it s preservat ion24. The pH
value of non- st im ulat ed saliva in t his st udy was lower in the EG than in the CG (p< 0.001), which corroborates t he result s of ot her aut hors6,18,23. Alt hough salivary pH
was lower in t he experim ent al group, it was not below t he “ crit ical pH” ( 5.5) , which result ed in t he enam el dem ineralisat ion25.
Previous st udies have a com m on st at em ent t hat pat ient s who suffer from ast hm a or COPD and who are undergoing inhalat ion t herapy have considerably reduced saliva secret ion as well as a lower salivary pH value6,18, and t his could be a det erm inant fact or
causing dent al caries. However, t he quest ion whet her t hese pat ient s have a higher prevalence of caries if FRPSDUHG ZLWK KHDOWK\ FRQWUROV FUHDWHV FRQÀLFWLQJ opinions and cont radict ed r esult s as w ell as t he quest ion w het her t he sever it y and lengt h of t he disease correlat es wit h a higher incidence of caries lesions. A group of aut hors t hink t hat t here is a higher prevalence of caries in pat ient s undergoing inhalat ion t herapy1,3,21,22, which is in accordance wit h t he result s
of t his st udy. However, anot her group of aut hors16,18
found t hat pat ient s wit h ast hm a have sim ilar dent al caries prevalence when com pared wit h t he cont rol group, suggest ing t hat t his m ight be due t o t he fact that this particular group of patients had proper access
Parameter Group N Average SD min max p
DMFT EG
CG 40 40 21.2 19.4 6.89 5.84 7 5 31 32 0.199**
Decayed (D) EG
CG 40 40 3.68 1.40 2.91 2.36 0 0 11 9
Missing (M) EG
CG
40 40
12.3 6.30
6.82 4.43
2 0
25
24
Filled (F) EG
CG
40 40
5.25 11.6
4.75 5.36
0 2
21
23
Table 5-'HFD\HGPLVVLQJDQG¿OOHGWHHWK'0)7LQGH[YDOXHVDQGFRPSRQHQWVLQH[SHULPHQWDO(*DQGFRQWUROJURXSV&*
t o dent al car e18. I n t his r esear ch, no st at ist ically
VLJQL¿FDQWFRUUHODWLRQZDVREVHUYHGEHWZHHQFDULHV lesions and t he severit y of t he respirat ory disease, since m ost part icipant s of t he EG, i.e., 50% , suffer IURPPRGHUDWHIRUPVRIGLVHDVHV±DVWKPD DQG ± &23' DQG D VPDOOHU QXPEHU VXIIHU from m ild or severe form s. These relat ively sm all-scale r esear ch r esu lt s sh ou ld t h u s b e car ef u lly FRQVLGHUHGHYHQWKRXJKWKH\FRQ¿UPWKH¿QGLQJVRI ot her st udies3,5,6. Som e aut hors believe t hat a higher
prevalence of caries m ight be linked t o t he severit y of t he disease and t he consequent high frequency and dosage of the required m edicine19. I n this research we
IRXQGQRVLJQL¿FDQWFRUUHODWLRQEHWZHHQFDULHVOHVLRQV and t he lengt h of t he t herapy eit her, which m ight be linked t o t he fact t hat m ost of t he part icipant s in t he EG ( 65% ) have been suffering from t he disease for 5 t o 10 years and m ay st ill not have felt t he side effect s of t he t herapy. These result s are in accordance wit h t he result s of ot her st udies5. Discrepancies bet ween
t he m ent ioned st udies regarding t he obt ained result s PD\EHLQÀXHQFHGE\WKHQXPEHURIDQDO\VHGVXEMHFWV diversity of m ethods, different intensity of the disease DVZHOODVWKHGLIIHUHQWGR]HVW\SHVDQGHI¿FDF\RI t he m edicam ent s used 24.
Previous st udies showed increased precipit at ion of inhaled drugs in m out h cavit y2, and suggest ed
t hat it can m anifest secondary negat ive side effect s on t he oral t issue because of t he int eract ion bet ween t he drug m et abolism and t he saliva9. The pat ient s
involved in t his st udy used t he com binat ion of t wo or m ore inhalat ion m edicam ent s, and at least one of t hem was in a form of dry powder ( DPI ) . I nhalat ion m edicam ent s t hat are in t he form of dry powder oft en cont ain addit ional lact ose, which can cause a VLJQL¿FDQWGHFUHDVHLQVDOLYDU\S+YDOXHVFRPSDUHG wit h ot her inhalers t hat do not cont ain such sugars. I t is suggest ed t hat t his m ay be an im port ant cause of en am el dem in er alizat ion an d pr olif er at ion of cariogenic bact eria25. I n t he present ed st udy, 90%
of EG part icipant s used a t ype of drug t hat cont ained additional lactose. However, som e authors21 found that
t he associat ion bet ween lact ose in inhalat ion drugs DQGFDULHVSUHYDOHQFHZDVQRWVLJQL¿FDQW
Rinsing t he m out h w it h w at er aft er m edicine applicat ion is suggest ed t o be a prot ect ive fact or in caries developm ent , since it can facilit at e cleansing away of residual sugar from tooth surfaces21. Although
m out h rinsing reduces residual deposit ion of inhaled
ant i-ast hm a drugs, according t o som e aut hors, t here is no clear evidence that it also reduces dental caries14.
I n t he present st udy, never r insing t he m out h w it h w at er was report ed by 21.44% of ast hm a pat ient s, and 50% of COPD patients. The m aj ority of individuals in t he present st udy used t he inhaler t wo t im es/ day, at bedt im e and m orning t im e. The cariogenic act ivit y LQFUHDVHVGXULQJWKHQLJKWGXHWRORZHUVDOLYDU\ÀRZ and lack of m ast icat ory m ovem ent s10.
The interdental toothbrush was used only by 27.5% part icipant s of t he CG and none of t he EG part icipant s ( p< 0.001) . Moreover, 80% of EG part icipant s never used fluor ide solut ion for m out hw ash ( p< 0. 001) com pared with a sm aller percentage of CG participants ( 42.5% ) . I t is assum ed t hat lact ose in inhaler m ay lodge between the teeth to cause caries in patients who use inhalat ion m edicines21, and t he use of int erdent al t oot hbr ush is t her efor e v it ally im por t ant so t hat t he rem ains of food and sugar could be elim inat ed. Ad d it ion ally, r in sin g m ou t h w it h f lu or id e- b ased
VROXWLRQV LV DOVR UHFRPPHQGHG VLQFH ÀXRULGH KDV EHHQVKRZQWRVLJQL¿FDQWO\UHGXFHWKHUDWHRIFDULHV7.
The dat a on part icipant s being inform ed about t h e pr oper m ain t en an ce an d or al hy gien e is by no m eans encouraging, since only 37.5% of t he EG part icipant s have been well- inform ed by t heir d en t ist s an d r ep or t ed ly r esp ect t h e p r ev en t iv e m easures suggest ed. However, m ore t han half of t he EG part icipant s ( 52.5% ) have not been adequat ely inform ed about t he proper oral hygiene m aint enance. The result s show t hat t he part icipant s are likely t o have learnt about oral hygiene from t heir parent s or from m ass m edia, and t hat dent al services have not m ade an effort t o provide prevent ive dent al care for t his group of pat ient s.
Because of ignorance, anxiousness, or discom fort associat ed wit h dent al procedures, it is only when t here is a problem ( pain, m ost com m only) , t hat 80% of EG part icipant s decide t o visit a dent ist , whereas t his percent age in t he CG is considerably sm aller
± S 'HQWDO SURFHGXUHV FDUULHG RXW
and changes in t he t em porom andibular j oint ) .
7KH ¿QGLQJV RI WKLV VWXG\ LQGLFDWH WKDW SDWLHQWV suffering from asthm a and COPD who need to undergo inhaled t herapy should be m ore aware of t he im pact of these drugs on oral health. I t is therefore necessary t o design and im plem ent prevent ive dent al care for t his group of pat ient s as well as t o encourage and m ot ivat e t hem in such a way t hat t heir qualit y of life can im prove. The results should encourage dentists to educat e t hem selves t o discover early changes in t he oral tissues in patients on long-term inhalation therapy. Prevent ive m easures should be designed t o decrease caries lesions and thus involve. Such m easures include DGYLFHRQGLHWDU\KDELWVVDOLYDVWLPXODWLRQÀXRULGH supplem ent at ion, and appropriat e inform at ion about oral hygiene m aint enance.
Local st rat egies of prevent ive dent al care, as well as cooperat ion bet ween dent ist s and pulm onologist s, m ay considerably im prove t he oral healt h of pat ient s undergoing inhaler t herapies. Prevent ion and early diagnosis of t hese diseases are also very im port ant becau se of h igh cost s of t r eat m en t s t h at m igh t be unnecessar y if adequat e pr event ive m easur es were t aken. The im provem ent can be achieved if program m es of dent al healt h care and prevent ion DUHLPSOHPHQWHGRQDODUJHUVFDOH±ZLWKLQWKHZKROH count ry or region.
Conclusion
We found t hat pat ient s under going inhalat ion t herapy face increasing risk of dent al caries due t o a ORZHUVDOLYDU\ÀRZUDWHDQGS+YDOXHDVVRFLDWHGZLWK t he inhalat ion t herapy. I n order t o st op t he disease progression in t he hard dent al t issue of t he m out h cavit y, it is necessary t o apply adequat e prevent ive m easures and posit ively m ot ivat e t heir cont inuous applicat ion in t his caries- risk populat ion.
A bet t er m ut ual collaborat ion am ong dent ist s, general practitioners, and pulm onary specialists would cont ribut e t o im prove general oral and dent al healt h in t hese pat ient s.
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