Introduction: Sulfate inhalers. Common adult dosing is two inhalations,

Introduction:  Asthma is classified as a chroniccondition that results in the inflammation of the airway space – because ofthis, constriction of the bronchial tubes occurs.

 With narrower airways, breathing becomes difficult.  Symptoms of asthma include coughing,shortness of breath, chest tightness, wheezing.  Asthma is a fairly common disease among bothadults and children.  It has beenestimated that 1/12 adults or 18.

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4 million people, and 1/11 children or 6.2million people have the disease. (Center for Disease Control & Prevention,2017)  This disease disrupts activitiesof daily living and is responsible for the most missed work or school daysamong the population.Asthma is said to be caused bytriggers and there are two types, allergenic and non-allergenic.  Allergenic asthma can be caused by seasonal,pet, or dust allergies, while non-allergenic can be stress-induced.  The best treatment for asthma is prevention,thus keeping yourself away from the triggers that may cause an attack.  Although asthma is a chronic disorder, thereare many medications available for controlling the disease, both in tablets andinhalers. Medications can be short or long term acting.

  Short term medications, like a rescueinhaler, are used during an episode. Long term medications are taken daily and used to help the patient have”fewer and milder attacks.” (Centers for Disease Control & Prevention,2017) “Beta-2agonists, anticholinergic bronchodilators, inhaled corticosteroids, and sodiumcromoglycate are often used alone or in combination in an inhaled form.”(Godara et. al, 2011)In many cases a bronchodilator and anti-inflammatorycombination is used to maintain sufficient airway space.

  Selective B2 Agonists, or bronchodilators,are used for the medical management of asthma. Control of bronchospasms is accomplished through the use of Albuterol Sulfateinhalers.  Common adult dosing is twoinhalations, every four to six hours as needed. Xerostomia is a side effect of albuterol inhalers that effects the oralcavity.  When a patient has dry mouth,his susceptibility to caries increases due to the lack of salivary flow.  The purpose of this case report is to lookdeeper into the correlation of asthmatic patients who use inhalation therapywith their prevalence of caries. The patient I will be following throughoutthis report is Mr.

F, a 40-year-old male who has both allergenic andnon-allergenic induced asthma; he states his attacks are caused by dust, cathair, and anxiety.  He uses an AlbuterolSulfate inhaler monthly.  He presented tothe clinic for restorative treatment.

 While most of his mandibular teeth could be restored with composite,many maxillary teeth were deemed non-restorable – these teeth have since beenextracted and a maxillary partial denture is currently being fabricated.   Literature Review:Clinical Question:Do patients using inhalation therapyto manage their asthma have an increased susceptibility to developing caries? P: Patients with asthmaI: Patients using inhalation therapyC: Patients not using inhalation therapyO: Increased risk of caries               I conductedtwo PubMed searches in order to obtain relevant articles on this topic.  My searches included the keywords “asthma andcaries” and “asthma and inhalation therapy and caries.”            Thefirst study I am reviewing is titled, “Asthmaand Caries: A Systematic Review and Meta-Analysis.”  This study searched for related articlesinvolving asthma and caries in both primary and permanent dentitions on the USNational Library of Medicine/Ovid Medline and PubMed.  Heterogeneitybetween the studies was an important factor in this meta-analysis in order toachieve appropriate comparable data.  Five inclusion criteria were used “1)provided relevant and applicable quantitative information on the relationbetween asthma and caries; 2) was an original study that had an independentstudy population; 3) was a case-control, cohort, or cross-sectional study; 4)had an adequate definition of asthma; and 5) had an adequate definition andmeasurement of caries using DMFS/dmfs.” (Alavaikko et.

al, 2011)  The studies were evaluated using odds ratioand confidence intervals.  For bothprimary and permanent dentitions, the forest plots displayed that those withasthma had a higher caries prevalence than those without.  P values were less than 0.001 and CI 95% weregreater than 1.

  “Altogether, 11 studieson primary dentition and 14 studies on permanent dentition were identified asrelevant and included in the analyses. Random-effects models showed asignificant association between asthma and caries for both primary andpermanent dentition, the odds ratios being 2.73 (95% CI: 1.61, 4.64) and 2.

04(95% CI: 1.44, 2.89), respectively.” (Alavaikko et.

al, 2011)  Primary TeethPermanent Teeth Overall the results showed that there was a correlationbetween asthmatic patients and an increase in caries, but the underlying reasonfor this is not completely understood and additional research has to beconducted. The study goes on to discuss the possibilities for causation.  First, asthma medications are listed as acontributing factor due to the fact they are known to decrease salivary flow.  There is also an increase in the amount ofStreptococcus mutans and Lactobacilli present in asthmatic patients’mouths.  Additionally, inhalation therapymedications have also been reported to decrease salivary pH.  There is also the possibility of a geneticpredisposition focusing on the lack of secretory IgA.  All of these factors contribute to anincrease in caries risk.

The study concludes with how dentists and doctorsshould manage patients with asthma to decrease their probability of gettingcaries – Fluoride being the number one preventative measure.  Since medications are also noted as acontributing factor, doctors should recommend that their patients payparticular attention to maintaining their oral hygiene after using an inhaler.  Patients should rinse their mouths and cleanthe mouth piece on the inhaler after each use as fermentable carbohydrates aresometimes an ingredient.  Promoting adiet low in cariogenic foods and beverages will also help decrease the chanceof caries development.

            The next study focuses in more on theeffects that inhalation therapy has on caries risk; it is titled “Effect of Inhaled Medication and InhalationTechnique on Dental Caries in Asthmatic Patients.”  The study was separated into two groups offorty patients containing both males and females between the ages of twenty andthirty; one group contained those with asthma and the other group was thecontrol.  The two groups were evaluatedbased on DMFT by a single dentist and pulmonary function test (PFT) throughspirometry.  The subjects were followedfor one year.  Those patients in theasthmatic group were additionally assessed based on the type of inhaler used,the dosage, inhalation technique, and the length of time the patient has hadthe disease.              As expected, PFT was lower in theasthmatic group compared to the control, where P value was less than 0.001 inall cases.

Incidences of dental caries were higher in the asthmatic groupcompared to the control, where P was less than 0.005 for DMFT.  Inhalation technique was assessed within theasthmatic group; the patients were organized based upon if they shook theinhaler before use, if they closed their lips around the mouthpiece, how fastthey inspired, and if they washed the mouthpiece or rinsed their mouths afteruse.  When the asthmatic group wasevaluated further, “there was no significant correlation between dental cariesscore and disease duration, disease severity, asthma symptoms, chest wheeze,PFT values, dose of medication or inhalation use technique score.” (Boskabadyet. al, 2012)               This study concluded by comparingits’ results to other studies that have been published when children were evaluatedas subjects.  While this study displayeda statistically significant difference in caries incidence between asthmaticand non-asthmatic groups, previous studies following child subjects didnot.

  “These results can indicate that thetime period of inhalation therapy could be a determinant factor causing dentalcaries.” (Boskabady et. al, 2012)              While I expected to see more of adifference in caries incidence based on inhalation technique, I believe therewas a lack of an adequate amount of evidence based on small sample size and limitedage range, similar dosing was also present among the participants.  Had the study chosen patients with varyinginhalation therapies, more detailed results would have been obtained.  Ultimately, the study did verify thehypothesis that asthmatics do have a higher incidence of caries thannon-asthmatics.              My laststudy is “Impact of Inhalation Therapy onOral Health.”  This paper focuses onthe effects of various inhalation therapies, like Beta-2 Agonists and InhaledCorticosteroids, on the oral cavity.

 Asthma is commonly diagnosed in children; because of this, asthmaticpatients are usually on an inhalation therapy for the duration of their lives.  The impact that inhalation therapy has onoral health increases with the dose, frequency, and duration of use.              Long term use of Beta-2 Agonists decreases salivaryflow, leading to xerostomia.  “Reducedsalivary rate is accompanied by a concomitant increase in Lactobacilli andStreptococcus Mutans in the oral cavity,” which ultimately results in anincreased risk for caries.  (Godara et.

al, 2011)  “Normal salivary action getsfurther altered by decreased availability of biologically active componentslike amylase, calcium ions, secretory IgA, peroxidase, and lysozyme. Thedecreased output of antibacterial components favors both bacterial colonizationand plaque growth.” (Godara et. al, 2011) Inhalers may also be responsible for decreasing salivary pH, thusincreasing the risk for tooth demineralization.             The paper continues with definingall of the possible oral manifestations that may occur from prolonged inhaleruse – these include: xerostomia, dental caries, candidiasis, ulceration, tastedisturbances, halitosis, and gingivitis or periodontitis.  These diagnoses are formulated through bothclinical and radiographic representations.

 Prevention is the best treatment method, this can be done throughincreasing water intake, using saliva substitutes, and Fluoride.  Candida infections can be treated withanti-fungal topical agents.  Patientsshould maintain adequate oral hygiene and continue to receive dental check-upsand prophylaxis every six months.

            The “Impact of Inhalation Therapy on Oral Health” described the possiblenegative effects that long term inhaler usage can have on the oral cavity.  There were weaknesses present in this article– it was not a true study that followed groups of patients and gave results.  Rather, he authors clearly relayed theresearched information they discovered.

Current research on this topic was much more limitedthan I expected.  Many of the articlespresent in my PubMed search focused solely on the negative effects that chronicrespiratory diseases’ had on oral health, instead of the effects of theirmedicaments.  When we are gathering ahealth history on our patients, we must be alert of the oral health sideeffects their medications can have, dry mouth being a common one.  Xerostomia increases a person’ssusceptibility to caries due to the lack of saliva existing in the mouth; thisis why I wanted to focus my search on the effects of inhalation therapiesrather than the disease alone.After reading the above three studies, it has beendeemed that prolonged use of inhalation therapy does have negative impacts on apatient’s oral health.  While eacharticle had weaknesses, such as a small sample size, or a short follow up, theyall agreed that asthmatic patients were more susceptible to oral findings.  The studies shared the common ideas that inhaleruse results in decreased saliva production leading to dry mouth; salivary pHwas also noted to be decreased.

 Thus,asthmatics are a higher risk for caries than those patients without asthma.  Dosage, frequency, and duration of use werealso defining factors that enhanced the effects of inhalation therapy.             PatientDescription:            Patient Mr. F is a 40-year-old malewith a fairly involved medical history that is complicated by his tobaccouse.

  He has been a smoker for manyyears, averaging about 0-5 cigarettes per day. He said he was interested in quitting, but has not started to takeaction on doing so. Mr. F is HIV+; he was diagnosed in 1996 and hasreported that he has not been symptomatic. He gets his blood work checked every 5 months, and his last reportedCD4+ level was 900.  He is currentlytaking Truvada 200-300 mg and Viramune XR 400 mg for this condition.  Mr. F is a carrier for Hepatitis B.

  He also responded yes to frequent upset stomach/abdominalpain and reports what he called an intestinal disorder that was diagnosed in2006; he did not have any more information on this condition.  He is taking Crestor 10 mg and Niacin 500 mgfor high cholesterol.  Mr. F alsocomplains of moderate anxiety; he does not take Xanax regularly, only if he ishaving an attack.

  He responded yes tomuscle and joint weakness, limited range of motion, and arthritis, includingcarpel tunnel and plantar fasciitis. These ailments are not being controlled by any medications.  Mr. F is also an asthmatic.  His attacks are precipitated by dust, pethair, and anxiety.  He complains ofshortness of breath on walking.

  He useshis rescue inhaler monthly.  For hisasthma he uses an Albuterol Sulfate 0.083% inhaler.  He also receives the flu vaccine, Alfuria, inhopes of decreasing his symptoms.  Discussionof Positive Findings:            As a controlled asthmatic, Mr. F hasan MCS classification of 1A, meaning he has a controlled and/or stablecondition with no anticipated complications. His dental modifications include DM1; he must keep his inhaler on thebracket table throughout the whole appointment in case something during theprocedure exacerbates an asthma attack. His asthma causes him to have xerostomia and the use of his AlbuterolSulfate 0.

83% inhaler enhances this risk. Dry mouth increases his probability to developing caries.  Due to extensive decay, many maxillary teethhad to be extracted over the last few years.

 I am currently in the process of fabricating him a maxillary removablepartial denture.  His mandibular arch hasa full complement of teeth, with the exception of missing secondpremolars.  Both anterior and posteriormandibular teeth have many composite restorations.  The patient has the possibility of becoming infectedwith opportunistic infections because he is HIV+, candidiasis being the mostcommon one in the mouth.  Smoking also suppressesthe immune system and increases the risk for developing complications involvingthe upper respiratory system.  The othermedications he takes daily do not have any dental related side effects.  During a carpel tunnel flare up he can havedifficulty correctly holding a toothbrush – an electric toothbrush has sincebeen recommended.

  His family history ispositive for his mother having diabetes and high blood pressure.  His vitals are fairly stable averaging 137/88mmHg, with a pulse of 76 bpm.  These vitalsplace him in the pre-hypertensive category. He is also genetically predisposed to high blood pressure since hismother has the disease.  After extraction of Mr.

F’s non-restorable teeth, heexclaimed he wanted to replace the missing teeth with implants.  Based on his health condition and his highcaries risk, placing implants would be contraindicated.  The ethical dilemma present in this case waswhether or not we should place the implants because that is what the patientwanted, rather than give him the treatment that would work best for his currentstatus.  After educating him on thepotential that the implants could fail in a few years, he agreed that theremovable appliance was the better choice. Conclusions& Health Promotion: Arepatients using inhalation therapy to manage their asthma at an increasedsusceptibility to developing caries?  Theanswer is a resounding yes – but there are many ways dentists can monitor andtreat these patients.  Prevention is key.  We can begin by explaining to a patient thathis inhaler use can increase his likelihood of caries due to dry mouth.  The patient can choose to use gum or candieswith xylitol to stimulate saliva production, or he can use a mouth-rinse likeBiotene made specifically to help with xerostomia.

  Maintaining adequate oral hygiene is a must.  Regular check-ups every six months will berecommended, with close observation both clinically and radiographically. Fluoridevarnish or gel should be used after each prophylaxis in-office, and the patientshould implement the use of a high percentage Fluoride toothpaste likePrevident at home.  Sealants can also beplaced on the pits and fissures of all posterior teeth.  All of the strategies can easily be incorporatedinto a treatment plan for a patient using an inhaler for asthma or anotherchronic respiratory disease.