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



Asthma is classified as a chronic
condition that results in the inflammation of the airway space – because of
this, 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 both
adults and children.  It has been
estimated that 1/12 adults or 18.4 million people, and 1/11 children or 6.2
million people have the disease. (Center for Disease Control & Prevention,
2017)  This disease disrupts activities
of daily living and is responsible for the most missed work or school days
among the population.

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Asthma is said to be caused by
triggers 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, there
are many medications available for controlling the disease, both in tablets and
inhalers. Medications can be short or long term acting.  Short term medications, like a rescue
inhaler, 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,

agonists, anticholinergic bronchodilators, inhaled corticosteroids, and sodium
cromoglycate are often used alone or in combination in an inhaled form.”
(Godara et. al, 2011)

In many cases a bronchodilator and anti-inflammatory
combination 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 Sulfate
inhalers.  Common adult dosing is two
inhalations, every four to six hours as needed. 
Xerostomia is a side effect of albuterol inhalers that effects the oral
cavity.  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 look
deeper into the correlation of asthmatic patients who use inhalation therapy
with their prevalence of caries.

The patient I will be following throughout
this report is Mr. F, a 40-year-old male who has both allergenic and
non-allergenic induced asthma; he states his attacks are caused by dust, cat
hair, and anxiety.  He uses an Albuterol
Sulfate inhaler monthly.  He presented to
the 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 been
extracted and a maxillary partial denture is currently being fabricated. 


Literature Review:

Clinical Question:

Do patients using inhalation therapy
to manage their asthma have an increased susceptibility to developing caries?


P: Patients with asthma

I: Patients using inhalation therapy

C: Patients not using inhalation therapy

O: Increased risk of caries



            I conducted
two PubMed searches in order to obtain relevant articles on this topic.  My searches included the keywords “asthma and
caries” and “asthma and inhalation therapy and caries.”

first study I am reviewing is titled, “Asthma
and Caries: A Systematic Review and Meta-Analysis.”  This study searched for related articles
involving asthma and caries in both primary and permanent dentitions on the US
National Library of Medicine/Ovid Medline and PubMed.  Heterogeneity
between the studies was an important factor in this meta-analysis in order to
achieve appropriate comparable data.  Five inclusion criteria were used “1)
provided relevant and applicable quantitative information on the relation
between asthma and caries; 2) was an original study that had an independent
study population; 3) was a case-control, cohort, or cross-sectional study; 4)
had an adequate definition of asthma; and 5) had an adequate definition and
measurement of caries using DMFS/dmfs.” (Alavaikko et. al, 2011)  The studies were evaluated using odds ratio
and confidence intervals.  For both
primary and permanent dentitions, the forest plots displayed that those with
asthma had a higher caries prevalence than those without.  P values were less than 0.001 and CI 95% were
greater than 1.  “Altogether, 11 studies
on primary dentition and 14 studies on permanent dentition were identified as
relevant and included in the analyses. Random-effects models showed a
significant association between asthma and caries for both primary and
permanent 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 Teeth

Permanent Teeth


Overall the results showed that there was a correlation
between asthmatic patients and an increase in caries, but the underlying reason
for this is not completely understood and additional research has to be
conducted. The study goes on to discuss the possibilities for causation.  First, asthma medications are listed as a
contributing factor due to the fact they are known to decrease salivary flow.  There is also an increase in the amount of
Streptococcus mutans and Lactobacilli present in asthmatic patients’
mouths.  Additionally, inhalation therapy
medications have also been reported to decrease salivary pH.  There is also the possibility of a genetic
predisposition focusing on the lack of secretory IgA.  All of these factors contribute to an
increase in caries risk.

The study concludes with how dentists and doctors
should manage patients with asthma to decrease their probability of getting
caries – Fluoride being the number one preventative measure.  Since medications are also noted as a
contributing factor, doctors should recommend that their patients pay
particular attention to maintaining their oral hygiene after using an inhaler.  Patients should rinse their mouths and clean
the mouth piece on the inhaler after each use as fermentable carbohydrates are
sometimes an ingredient.  Promoting a
diet low in cariogenic foods and beverages will also help decrease the chance
of caries development.

            The next study focuses in more on the
effects that inhalation therapy has on caries risk; it is titled “Effect of Inhaled Medication and Inhalation
Technique on Dental Caries in Asthmatic Patients.”  The study was separated into two groups of
forty patients containing both males and females between the ages of twenty and
thirty; one group contained those with asthma and the other group was the
control.  The two groups were evaluated
based on DMFT by a single dentist and pulmonary function test (PFT) through
spirometry.  The subjects were followed
for one year.  Those patients in the
asthmatic group were additionally assessed based on the type of inhaler used,
the dosage, inhalation technique, and the length of time the patient has had
the disease. 

            As expected, PFT was lower in the
asthmatic group compared to the control, where P value was less than 0.001 in
all cases. Incidences of dental caries were higher in the asthmatic group
compared to the control, where P was less than 0.005 for DMFT.  Inhalation technique was assessed within the
asthmatic group; the patients were organized based upon if they shook the
inhaler before use, if they closed their lips around the mouthpiece, how fast
they inspired, and if they washed the mouthpiece or rinsed their mouths after
use.  When the asthmatic group was
evaluated further, “there was no significant correlation between dental caries
score and disease duration, disease severity, asthma symptoms, chest wheeze,
PFT values, dose of medication or inhalation use technique score.” (Boskabady
et. al, 2012)   

            This study concluded by comparing
its’ results to other studies that have been published when children were evaluated
as subjects.  While this study displayed
a statistically significant difference in caries incidence between asthmatic
and non-asthmatic groups, previous studies following child subjects did
not.  “These results can indicate that the
time period of inhalation therapy could be a determinant factor causing dental
caries.” (Boskabady et. al, 2012) 

            While I expected to see more of a
difference in caries incidence based on inhalation technique, I believe there
was a lack of an adequate amount of evidence based on small sample size and limited
age range, similar dosing was also present among the participants.  Had the study chosen patients with varying
inhalation therapies, more detailed results would have been obtained.  Ultimately, the study did verify the
hypothesis that asthmatics do have a higher incidence of caries than

            My last
study is “Impact of Inhalation Therapy on
Oral Health.”  This paper focuses on
the effects of various inhalation therapies, like Beta-2 Agonists and Inhaled
Corticosteroids, on the oral cavity. 
Asthma is commonly diagnosed in children; because of this, asthmatic
patients are usually on an inhalation therapy for the duration of their lives.  The impact that inhalation therapy has on
oral health increases with the dose, frequency, and duration of use. 

            Long term use of Beta-2 Agonists decreases salivary
flow, leading to xerostomia.  “Reduced
salivary rate is accompanied by a concomitant increase in Lactobacilli and
Streptococcus Mutans in the oral cavity,” which ultimately results in an
increased risk for caries.  (Godara et.

al, 2011)  “Normal salivary action gets
further altered by decreased availability of biologically active components
like amylase, calcium ions, secretory IgA, peroxidase, and lysozyme. The
decreased output of antibacterial components favors both bacterial colonization
and plaque growth.” (Godara et. al, 2011) 
Inhalers may also be responsible for decreasing salivary pH, thus
increasing the risk for tooth demineralization. 

            The paper continues with defining
all of the possible oral manifestations that may occur from prolonged inhaler
use – these include: xerostomia, dental caries, candidiasis, ulceration, taste
disturbances, halitosis, and gingivitis or periodontitis.  These diagnoses are formulated through both
clinical and radiographic representations. 
Prevention is the best treatment method, this can be done through
increasing water intake, using saliva substitutes, and Fluoride.  Candida infections can be treated with
anti-fungal topical agents.  Patients
should maintain adequate oral hygiene and continue to receive dental check-ups
and prophylaxis every six months.

            The “Impact of Inhalation Therapy on Oral Health” described the possible
negative 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 the
researched information they discovered.

Current research on this topic was much more limited
than I expected.  Many of the articles
present in my PubMed search focused solely on the negative effects that chronic
respiratory diseases’ had on oral health, instead of the effects of their
medicaments.  When we are gathering a
health history on our patients, we must be alert of the oral health side
effects their medications can have, dry mouth being a common one.  Xerostomia increases a person’s
susceptibility to caries due to the lack of saliva existing in the mouth; this
is why I wanted to focus my search on the effects of inhalation therapies
rather than the disease alone.

After reading the above three studies, it has been
deemed that prolonged use of inhalation therapy does have negative impacts on a
patient’s oral health.  While each
article had weaknesses, such as a small sample size, or a short follow up, they
all agreed that asthmatic patients were more susceptible to oral findings.  The studies shared the common ideas that inhaler
use results in decreased saliva production leading to dry mouth; salivary pH
was also noted to be decreased.  Thus,
asthmatics are a higher risk for caries than those patients without asthma.  Dosage, frequency, and duration of use were
also defining factors that enhanced the effects of inhalation therapy.



            Patient Mr. F is a 40-year-old male
with a fairly involved medical history that is complicated by his tobacco
use.  He has been a smoker for many
years, averaging about 0-5 cigarettes per day. 
He said he was interested in quitting, but has not started to take
action on doing so.

Mr. F is HIV+; he was diagnosed in 1996 and has
reported that he has not been symptomatic. 
He gets his blood work checked every 5 months, and his last reported
CD4+ level was 900.  He is currently
taking 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/abdominal
pain and reports what he called an intestinal disorder that was diagnosed in
2006; he did not have any more information on this condition.  He is taking Crestor 10 mg and Niacin 500 mg
for high cholesterol.  Mr. F also
complains of moderate anxiety; he does not take Xanax regularly, only if he is
having an attack.  He responded yes to
muscle and joint weakness, limited range of motion, and arthritis, including
carpel 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, pet
hair, and anxiety.  He complains of
shortness of breath on walking.  He uses
his rescue inhaler monthly.  For his
asthma he uses an Albuterol Sulfate 0.083% inhaler.  He also receives the flu vaccine, Alfuria, in
hopes of decreasing his symptoms.


of Positive Findings:

            As a controlled asthmatic, Mr. F has
an MCS classification of 1A, meaning he has a controlled and/or stable
condition with no anticipated complications. 
His dental modifications include DM1; he must keep his inhaler on the
bracket table throughout the whole appointment in case something during the
procedure exacerbates an asthma attack. 
His asthma causes him to have xerostomia and the use of his Albuterol
Sulfate 0.83% inhaler enhances this risk. 
Dry mouth increases his probability to developing caries.  Due to extensive decay, many maxillary teeth
had to be extracted over the last few years. 
I am currently in the process of fabricating him a maxillary removable
partial denture.  His mandibular arch has
a full complement of teeth, with the exception of missing second
premolars.  Both anterior and posterior
mandibular teeth have many composite restorations. 

The patient has the possibility of becoming infected
with opportunistic infections because he is HIV+, candidiasis being the most
common one in the mouth.  Smoking also suppresses
the immune system and increases the risk for developing complications involving
the upper respiratory system.  The other
medications he takes daily do not have any dental related side effects.  During a carpel tunnel flare up he can have
difficulty correctly holding a toothbrush – an electric toothbrush has since
been recommended.  His family history is
positive for his mother having diabetes and high blood pressure.  His vitals are fairly stable averaging 137/88
mmHg, with a pulse of 76 bpm.  These vitals
place him in the pre-hypertensive category. 
He is also genetically predisposed to high blood pressure since his
mother has the disease.  

After extraction of Mr. F’s non-restorable teeth, he
exclaimed he wanted to replace the missing teeth with implants.  Based on his health condition and his high
caries risk, placing implants would be contraindicated.  The ethical dilemma present in this case was
whether or not we should place the implants because that is what the patient
wanted, rather than give him the treatment that would work best for his current
status.  After educating him on the
potential that the implants could fail in a few years, he agreed that the
removable appliance was the better choice.


& Health Promotion:

patients using inhalation therapy to manage their asthma at an increased
susceptibility to developing caries?  The
answer is a resounding yes – but there are many ways dentists can monitor and
treat these patients. 

Prevention is key.  We can begin by explaining to a patient that
his inhaler use can increase his likelihood of caries due to dry mouth.  The patient can choose to use gum or candies
with xylitol to stimulate saliva production, or he can use a mouth-rinse like
Biotene made specifically to help with xerostomia.  Maintaining adequate oral hygiene is a must.  Regular check-ups every six months will be
recommended, with close observation both clinically and radiographically. Fluoride
varnish or gel should be used after each prophylaxis in-office, and the patient
should implement the use of a high percentage Fluoride toothpaste like
Prevident at home.  Sealants can also be
placed on the pits and fissures of all posterior teeth.  All of the strategies can easily be incorporated
into a treatment plan for a patient using an inhaler for asthma or another
chronic respiratory disease.