Relation between Childhood Asthma and Dental Erosion in Al-Kharj Region of Saudi Arabia: A Cross-Sectional Study.

BACKGROUND: Asthma is a long-lasting disease that affects large number of the society and could impact on the oral health leading to increase in the needs of prevention and treatment. Currently, the prevalence of childhood asthma in Saudi Arabia is ranging from 9% to 33%.
OBJECTIVE: the objective was to evaluate dental erosion in control children and those with asthma.
MATERIALS AND METHODS: This was a cross-sectional study, with a sample of 100 children aged 3-12 years. Equally distribution of subjects was between the asthmatic and non-asthmatic group, at Prince Sattam Bin Abdulaziz University Dental Clinics, Alkharj, Saudi Arabia. The assessment consisted of an oral examination assessing erosive wear according to the American Academy of Pediatrics 2018 guidelines and a questionnaire to the parents/guardians addressing the background details and information about the child asthma.
RESULTS: Among 12 (24%) asthmatic children and 9 (18%) non-asthmatic children had dental erosion. In the adjusted analysis, no association was found between asthma and erosion. It has been shown that oral hygiene may have an effect occurrence or severity of erosion; brushing teeth once or more per day appeared to have less incidence of dental erosion compared with those not brushing their teeth regularly.
CONCLUSIONS: This article provided no additional data than that given earlier, where no correlation was observed between asthma and dental erosion in children aged from 3 to 12 years. Copyright:

INTRODUCTION

Affecting more than 300 million people around the world, asthma is a growing health problem and may reach 100 million people more by 2025 according to the studies.[1] Asthma is a chronic inflammatory condition that affects the lower part of the airway, causing different airflow limitation. Analysis of the asthma intensity, frequency, and associated symptoms will indicate its severity. Other severity factors include medication required, history of hospitalization, yearly need for systemic corticosteroids, or mechanical ventilation.[2] The airway obstruction is reversible spontaneously or by medication.[2] Depends on the asthma severity, it may affect children and parents' life. Limitation in playing sports, missing school days, so the attention that goes toward the general asthmatic condition may lead to less attention of oral health care.[3] Dental erosion is the most common type of tooth surface loss resulted from a chemical process.[4] Erosion was defined as the damage of dental hard tissue (i.e., enamel and dentine) due to chemical action where it does not involve bacterial invasion.[5] Cross-sectional studies done showed that the prevalence of dental erosion varies extensively between populations, but still it is considered a common occurrence, especially among children and adolescences. Its prevalence in the Saudi Arabian population was about 34% in children[4] and 16% in adolescence.[6] This defect may be due to extrinsic or extrinsic factors; any acidic substance placed in the mouth could be a causative factor causing the loss of dental hard tissue. Dental erosion may occur on all dental surfaces but most commonly occurring on the palatal surface of maxillary molars and occlusal surface of mandibular first molars.[67] Clinical diagnosis of erosive lesions can be made using simple ordinal scales to more advanced methods as optical/laser scanning to a more recent technique with the digital scanning system.[78] A debate is still present in the association between asthma and tooth wear in young children and adolescence.[12] Some studies confirm the association[59] where others have not found any correlation between both diseases.[10] Medications taken by asthmatic patients cause a decrease in salivary flow and quality, thereby reducing the cleansing and protection mechanisms of the saliva, especially in beta-2 adrenoceptor agonist medications.[1112] This change in quality and flow of the saliva will lead to alteration in the composition of the salivary pellicle, thus losing the tooth's defense against erosion.[13]

Another factor is the instant drop in intraoral salivary PH.[14] Dry powder inhalers are more acidic in nature causing a higher drop in the PH,[15] where this drop in PH below the critical level is considered as a challenging risk factor in the progression of dietary tooth wear.[14]

Considering that inhaled corticosteroids are considered to be the main treatment for asthma along with other medications sometimes,[16] the prolonged use of beta-2 agonist as those present in asthma inhalers can affect the salivary flow by reducing it.[17]

Children can experience erosion in both primary and permanent dentition according to the Children Dental Health survey in the United Kingdom. In 2013, the survey reported that erosion affects more than half of children's lingual anterior teeth surface. It is been reported that children with asthma are more prone to dental erosion compared to nonasthmatic children.[17]

Objective

This study intended to investigate the association of dental erosion occurrence in nonasthmatic children and children with asthma aged from 3 to 12 years in Alkharj, Saudi Arabia. Furthermore, to examine whether these factors involved with the condition.

MATERIALS AND METHODS

This cross-sectional study was carried out in dental college clinics, Prince Sattam University, Alkharj, Kingdom of Saudi Arabia, between December 2019 and February 2020.

Ethical Approval for the research was obtained from the Research Ethics Committee at College of Dentistry, Prince Sattam University (IRB ID. PSAU2020004).

Study sample

The sample includes both asthmatic and nonasthmatic children aged 12 years and below that meet the inclusion criteria, which include obtaining parents' consents and the child is free from other systematic diseases.

On parents' approval to participate, a questionnaire used in a previous study was handled to parents to collect information regarding parents' education and their child's demographic data and information about the child's asthmatic condition if present (type, medication, and severity).[3]

Following taking the child's assent, a dental examination was performed in regular dental sitting using a mouth mirror under artificial light. Two dentists performed the examination after receiving training from the specialist pediatric dentist about indexed to be used and assessment criteria to be done. Images were used between the two examiners and the examiners themselves. Intra-examiner and interexaminer calibration were checked for assessing erosion. Dental erosion was assessed as a whole (not by tooth) using the Smith and Knight tooth wear index.[18]

Statistical analysis

In order to analyze the demographic characteristics of the patients and the outcome variables, both the Fisher test and Chi-square test were used. The odds ratio was used to measure the magnitude of the relationship between dental erosion and the independent variables at the significant level of 5% and confidence interval of 95%. SPSS software was used (SPSS Inc., Chicago, IL, USA).

RESULTS

One hundred children aged between 3 and 12 years participated in this cross-sectional study [Figure 1].

Figure 1

Flow chart of the study population

Overall analysis showed no correlation between any of the variables (gender, age, hygiene, type of asthma, and parents' education level) and the occurrence of dental erosion [Tables 1 and 2].

Table 1

Effect of age, gender, hygiene, and level of parents’ education on the occurrence of erosive dental lesions

	No erosion (%)	Eroded (%)
Education level of parents
Others	38	8
University	38	16
Teeth brushing routine per day
Not regular	52	16
Once a day	12	4
Twice a day	10	4
Three a day	2	0
Gender
Female	40	18
Male	36	6
Age group (years)
3-6	36	4
7-10	32	14
11-14	8	6

Table 2

Effect of type of asthma on the occurrence of the erosive dental lesion

	No erosion (%)	Eroded (%)
Type of asthma disease
Intermittent light	0.46	20
Continuous light	0.1	2
Continuous moderate	0.02	0
Continuous severe	0.02	0
Severe continuous	0.16	2

Forty percent of females and about 30% of males' asthmatic children showed no erosion whereas only 18% of female and 6% of male asthmatic children had erosion.

The analysis clarified a statistical difference between children maintaining some kind of oral hygiene (once, twice, or three times a day) compared to not maintaining [Table 1], where it was not statistically significant in the number of times the child brushed their teeth in the day.

Parents' level of education had no relation with the occurrence or absence of the dental erosive lesions. Furthermore, the type of asthma that the patient has been diagnosed with has no significant effect on the resultant erosive lesion. Table 3 clarifies the regression analysis for the presence of dental erosive lesions.

Table 3

Regression analysis for the presence of dental erosive lesions

	SD	Confidence level (95.0%)
Gender	0.4985694	0.1416919
Age group	0.694291593	0.197315488
Type of asthma disease	1.55720839	0.44255373
Education level of parents	1.8736628	0.5324891
Teeth brushing routine per day	0.814411	0.2314531

SD: Standard deviation

DISCUSSION

This study was conducted to address one of the most encountered chronic diseases in Saudi Arabia and to study its relation to dental erosion. Asthma onset could occur at any age affecting 7%–10% of girls and about 15% of boys during their childhood. The possible occurrence at young age with its high prevalence drove dentists to seek if there is a relation or association between increased risk for oral diseases and bronchial asthma.[19]

In regards to erosion, the literature reported several intrinsic and extrinsic contribution factors. Asthmatic medications are considered among the extrinsic factors. However, our study found no relation between these medications and the presence of chemical surface loss. This finding agreed with a study done by Dugmore and Rock in 2003.[10] Their study recorded the presence or absence of dental erosion for school children at age of 12 and 14 years and they yielded that there is no significant difference between asthmatic and nonasthmatic children in regard to dental erosion. On the other hand, a case–control study by Al-Dlaigan et al. in 2002 found that asthmatic children have higher erosion prevalence when compared to the control group.[5] However, they addressed other contributing factors such as the consumption of soft drinks. Often, drinks with a low pH and high titratable acidity are consumed and linked to dental erosion. Another study was done in Norway included 380 5 years old children found a strong relation between asthma and dental erosion reaching about 80% of the participant. However, another factor was taken in to consideration for dental erosion in the participant like grinding teeth habit by the male participant (48%).[20]

This study found no association between dental erosion and oral hygiene behavior by brushing teeth, but some significance was observed in those members not maintain any sort of oral hygiene. This issue appears to be controversial in literature as some studies reported more erosive wear for those without plaque. Moreover, some studies have reported less erosive wear when among people with daily brushing habits of two or more times. On contrary, others found no such association.[20]

This study sample was limited to 100 participants. At the time of the study, the college was accepting few number of patients for cross-infection precautions due to the COVID-19 pandemic. It is recommended to assess the finding considering multicenter/multicity's to achieve health benefits of prevention and enhance the quality of oral care of asthmatic children.

CONCLUSIONS

Considering the limitation of the present study, there is no evidence for an association between asthma and erosion in children aged from 3 to 12 years in Alkharj, Saudi Arabia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.