Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2010; 55: 128133

REVIEW

doi: 10.1111/j.1834-7819.2010.01226.x

Asthma and oral health: a review

MS Thomas,*A Parolia,* M Kundabala,* M Vikram*
*Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, India.

ABSTRACT
Asthma is a chronic inflammatory condition that causes the airways to constrict and produce excess mucus, making
breathing difficult. It is characterized by the obstruction of airflow which is variable over a short period of time. This
condition is reversible, either spontaneously or can be controlled with the help of drugs. Asthma medication comprises
bronchodilators, corticosteroids and anticholinergic drugs. Most of these drugs are inhaled using various forms of inhalers
or nebulizers. The effect of these drugs on oral health is the subject of debate among dental practitioners. Patients taking
asthma medication may be at risk of dental caries, dental erosion, periodontal diseases and oral candidiasis. Hence, patients
with bronchial asthma on medication should receive special prophylactic attention. This article reviews the correlation
between asthma and oral health, and suggests various measures to counter possible oral health problems related to asthma.
Keywords: Asthma, beta-2 agonist, dental caries, dental erosion, inhaled corticosteroids, oral candidiasis, periodontal disease, salivary flow.
Abbreviations and acronyms: GOR = gastro-oesophageal reflux; ICS = inhaled corticosteroids.
(Accepted for publication 27 September 2009.)

INTRODUCTION
Asthma is a growing public health problem affecting
over 300 million people worldwide. It is estimated that
an additional 100 million may be diagnosed with
asthma by 2025.1 Asthma is characterized by chronic
airway inflammation and increased airway hyperresponsiveness, leading to symptoms such as wheezing,
coughing, chest tightness and dyspnoea. It is characterized by the obstruction of airflow which varies over a
short period of time and is reversible, either spontaneously or with treatment.
Asthma treatment has two main objectives: to
control, as well as to reduce the airway inflammation,
and reopen the airways. Drugs that achieve the first
objective are called anti-inflammatory agents and those
that achieve the second are called bronchodilators.
Asthma medication falls into two categories: quick
relief medication and long-term control medication.
Quick relief medication comprises of short-acting
bronchodilators, systemic corticosteroids and anticholinergic drugs. Long-term control medication includes
anti-inflammatory agents, long-acting bronchodilators
and leukotriene modifiers.1 Most asthma drugs are
inhaled using various forms of inhalers or nebulizers.
Patients should be carefully trained in the use of
inhalers for these to be effective. Patients should also
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be instructed to use inhalers regularly as prescribed.

Inhalers which deliver these medicaments may be used
up to four times a day over a long period. As the
prevalence of asthma is on the rise, the problems caused
by asthma medication could result in a significant
worldwide dental health problem. Therefore, it is
necessary to scrutinize the effects of asthma and its
medication on oral health.
Studies show that prolonged use of beta-2 agonist
can reduce salivary flow.2,3 Ryberg et al.3 observed that
the secretion rates of whole and parotid saliva
decreased by 26% and 36%, respectively, in asthmatics
on medication when compared to the non-asthmatic
control group. Asthmatic subjects also showed a
decrease in output per minute of total protein, amylase,
hexosamine, salivary peroxidase, lysozyme and secretory IgA in stimulated parotid saliva.4 Any factor which
reduces the quality and quantity of saliva can negatively
affect oral health because saliva plays an important role
in its preservation (Table 1).5
The association of asthma with oral conditions such
as dental caries, dental erosion, periodontal diseases
and oral mucosal changes has been the subject of debate
among dental practitioners.6 This article reviews the
correlation between asthma and oral health, and
suggests various measures to counter possible oral
health problems related to asthma (Table 2).
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Asthma and oral health

Table 1. Role of saliva in preservation of oral health
Function

Component responsible

Mode of protection

Lubrication and maintenance

of mucosal integrity

Mucin, proline-rich
glycoproteins, water

Cleansing and dilution

Water

Buffering capacity
and remineralization

Bicarbonate, phosphate,
calcium, statherin, proline-rich
anionic proteins, fluoride

Antimicrobial action

IgA, immunoglobulins, proline-rich

glycoproteins Lysozyme, lactoferrin,
lactoperoxidase, mucins, cysteine, histatins

Forms a seromucosal covering that lubricates and protects

the oral tissues against irritating agents
Modulates the adhesion of micro-organisms to the oral
tissue surfaces which contributes to the control of
bacterial and fungal colonization
Cleanses the residues present in the mouth such
as non-adherent bacteria, cellular and food debris
Salivary flow eliminates excess carbohydrate, thus
limiting the availability of sugars to the micro-organisms
Maintains the physical-chemical integrity of tooth
enamel by modulating remineralization and demineralization
Buffers (neutralizes) the acids produced by
acidogenic micro-organisms, thus preventing
enamel demineralization
Inhibits microbial adhesion to oral tissues
Prevents proliferation of micro-organisms

Table 2. Possible causes for the increase in prevalence of oral health problems in asthmatics and various measures
to prevent these problems
Oral health condition
Dental caries

Dental erosion

Periodontal disease

Oral candidiasis

Possible causes

Precautionary measures

Decrease salivary flow rate caused by

beta-2 agonist
Increase in Lactobacilli and Streptococcus
mutans count
Decrease in the salivary and plaque pH
due to the use of inhalers
Fermentable carbohydrate present in
anti-asthma medications
Increase in the frequency of consumption
of cariogenic drinks
Reduction in the buffering capacity and
salivary flow rate due to beta-2 agonist
Increase in the exposure of teeth to acids
Extrinsic source Acidic soft drinks
Acidity of medication
Intrinsic source Gastro-oesophageal reflux
Decrease in salivary protection due to
the reduction in salivary flow and
concentration of secretory IgA
Dehydration of alveolar mucosa
due to mouth breathing
Alteration of immune response and
increase concentration of IgE in gingival tissue
Higher incidence of calculus due to
increased levels of calcium and
phosphorous in saliva.
Decrease in bone mineral density
associated with inhaled corticosteroids
Generalized immunosuppressive and
anti-inflammatory effects of steroids
Higher salivary glucose concentration
that could promote growth and
proliferation of Candida
Low salivary flow rate

Educate asthmatic patients about their

susceptibility to oral health problems
Encourage regular dental check-ups
Advocate precautionary oral hygiene practices
Adopt caries preventive measures
(fluoride supplements and pit and fissure sealants)
Advise the use of antimicrobial mouth washes
Advise the patients to rinse the mouth
immediately after using an inhaler
Encourage patients to drink water more
often to counteract dry mouth
Prescribe sugar-free chewing gum
to increase salivary output
Train patients to use their inhaler properly
Provide spacer device to deliver the inhaled
drugs directly to the airway
Refer to a gastroenterologist to rule
out gastrointestinal disease
Administer lowest possible dose of inhaled corticosteroids
Prescribe topical antimycotics to prevent oral candidiasis

Asthma and dental caries

McDerra et al.7 pointed out that asthmatic children
have more tooth decay affecting permanent teeth.
A study by Reddy et al.8 suggested that asthmatic children
have a high prevalence of caries and this increases with
the severity of bronchial asthma. Ersin et al.9 showed
2010 Australian Dental Association

that asthma, through its disease status and its pharmacotherapy, includes some risk factors such as a decrease
in the salivary flow rate and salivary pH for caries
development. They also demonstrated that the duration
of medication and illness has a significant influence on
the risk of developing caries in asthmatics. Shashikiran
and co-workers10 revealed that asthmatic patients,
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MS Thomas et al.
especially those using salbutamol inhalers, have more
caries than the control group. The results of a study by
Stensson et al.11 also indicated that preschool children
with asthma have a higher prevalence of caries than
children without asthma. Factors leading to this may be
due to a higher intake of sugary drinks and mouth
breathing.
In contrast to the above mentioned studies, there are
other studies that do not demonstrate a positive
correlation between asthma and dental caries. Bjerkeborn et al.12 showed that neither asthma per se nor
disease severity affects the prevalence of caries in
asthmatic children. A study by Eloot et al.13 also did
not recognize any connection between the severity of
the asthma, the period of exposure to medication and
the prevalence of caries.
Ryberg et al.2 stated that the increase in risk of dental
caries in asthmatic children medicated with beta-2
agonist was most often associated with a decrease in the
salivary flow rate and the increase in Lactobacilli and
Streptococcus mutans. This diminished flow rate can
jeopardize the protective ability of the saliva to clear the
oral cavity of fermentable substances and also decrease
its buffering capacity. Kargul et al.14 showed a significant decrease in the pH of saliva and plaque, below the
critical value for enamel demineralization of 5.5 in
asthmatic children, 30 minutes after treatment with
beta-2 agonist inhalers.
The reason for a higher rate of caries observed in
people with asthma can also be attributed to the
presence of fermentable carbohydrate in asthma medications. Some dry powder inhalers contain sugar
(lactose monohydrate) so that the patient can tolerate
the taste of the drug when it is delivered. Frequent oral
inhalation of these sugar-containing drugs, combined
with a decrease in the salivary flow rate may contribute
to an increased risk of caries. Kenny and Somaya15
stated that the long-term use of liquid oral medications
containing sugar can lead to an increase in the caries
rate. Reddy et al.8 pointed out that the highest caries
prevalence in asthmatics is seen in those taking
medications in syrup form.
Frequent consumption of cariogenic drinks due to
excessive thirst can also be a reason for an increase in
the caries rate in asthmatics. The increase in the intake
of these drinks may be related to a number of factors:
an attempt to wash away the taste of the inhaled
medication; to counter the desiccating effect of mouth
breathing and the reduction in the salivary flow caused
by beta-2 agonist.11 In addition, asthmatic children
may have a restricted lifestyle where they miss school
and are not able to play sports and participate in other
normal childhood activities. McDerra et al.7 reported
that families may overindulge children with frequent
consumption of sweets, leading to an increase in caries
levels. Moreover, the increased attention to their
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general asthmatic condition may result in oral hygiene

care being neglected.8
It is evident that oral prophylactic strategies can be
used to address the increase in caries risk in asthmatics. These include an increase in the frequency of
dental maintenance visits, fluoride interventions and
adherence to caries-prevention measures. All age
groups should be made aware of the problem and be
encouraged to have regular dental check-ups. Fluoride
supplements should be prescribed for all asthmatic
patients, especially for those taking beta-2 agonists.
Patients should be instructed to rinse their mouths
after using an inhaler.6 They may also be advised
to use saliva substitutes, sip plain water and use
a fluoridated mouthrinse daily to compensate for
xerostomia. A study by Kargul et al.14 showed that
chewing sugar-free gum for at least one minute after
using an inhaler can neutralize the interdental plaque
pH. Therefore, the use of sugar-free chewing gum to
stimulate salivary flow and buffer oral acids is
encouraged.
Asthma and dental erosion
McDerra et al.,7 Al-Dlaigan et al.16 and Sivasuthamparam et al.17 reported that children with asthma are
at an increased risk of developing dental erosion.
However, a study by Dugmore and Rock18 yielded
no clear association between asthma and dental
erosion.
Asthma medication can place the patient at a risk of
dental erosion by reducing salivary protection against
extrinsic or intrinsic acids. Saliva is considered to be
one of the main neutralizing factors in the pathogenesis of dental erosion. The oral clearance of dietary
acid is related to the rate of secretion and buffering
capacity of saliva. As mentioned earlier, studies have
shown a lowered salivary flow rate in asthmatic
subjects treated with beta-2 adrenoceptor agonists
when compared to non-asthmatic groups.2 This reduction in the production of saliva can affect the natural
way in which the mouth maintains its chemical
balance. There can be an increased dryness of the
mouth in asthmatics due to the effects of bronchodilators and or mouth breathing. So it is possible that
there will be an increase in the consumption of drinks
to compensate oral dehydration. Often drinks with a
low pH and high titratable acidity are consumed. This
may result in dental erosion.16
There is evidence that medicines taken by a dry
powder inhaler may cause tooth erosion by changing
the chemical environment of the mouth. OSullivan
et al.19 showed that the main asthmatic drugs in current
use, especially the powdered drugs, have a pH less than
the critical level of 5.5 required for hydroxyapatite
dissolution. Even though, in a study by Tootla et al.,20
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Asthma and oral health

none of the inhalers demonstrated a clinically significant acidiogenic response, a drop in salivary pH and
plaque pH was observed with a lactose-based dry
powder inhaler. When used several times a day, these
drugs may contribute to the dissolution of teeth.
Another possible explanation for acidic erosion of
teeth in people with asthma is that they have an
increased incidence of gastro-oesophageal reflux
(GOR).21 The prevalence of reflux symptoms, oesophagitis and abnormal oesophageal acid is higher in
patients with asthma than in the control population.
Harding21 reported that GOR symptoms are more
prevalent in asthmatic patients (approximately 75%)
when compared to the control group. The oesophagus
and the lungs interact through a variety of mechanisms. Oesophageal acid-induced bronchoconstriction
can be provoked by a vagally mediated reflex, neural
enhancement of bronchial reactivity or by microaspiration. Potential mechanisms whereby asthma may
predispose to the development of GOR include
autonomic dysregulation, an increase in the pressure
gradient differential between thorax and abdomen, a
high prevalence of hiatal hernia, and alterations in
crural diaphragm function.21 Asthma medications
may also be one of the factors that promote GOR
development in asthmatics. Certain inhaled beta-2
adrenoreceptor drugs partly swallowed when used
may decrease the lower oesophageal sphincter pressure
and the oesophageal contraction amplitude. This
relaxation is associated with GOR.16 The relationship
between gastrointestinal disease and dental erosion is
well documented.22 Hence an increased prevalence
of GOR in asthmatics can provide a partial explanation of the relationship between asthma and dental
erosion.
It is shown that dry powder inhalers used for asthma
have an acidic pH. Therefore, patients can be encouraged to rinse their mouth immediately after using the
inhaler with neutral pH or basic mouthrinses, such as
liquid antacids, sodium bicarbonate in water, milk or
neutral sodium fluoride mouthrinses.23 The use of a
spacer device may also be of help in delivering the dose
effectively into the lungs.19 Since evidence is strong that
GOR plays an important role in some patients with
asthma, presumptive diagnosis by the dentist should
lead to appropriate referral for further investigation.
Most often it will be to a gastroenterologist for
gastroscopy and 24-hour measurement of oesophageal
pH. Antacids should be prescribed to patients having
gastrointestinal disorders.
Asthma and periodontal disease
Studies examining the association between periodontal
diseases and asthma have reported varying results.
Hyyppa et al.,24 McDeera et al.,7 Shashikiran et al.10
2010 Australian Dental Association

and Stensson et al.11 revealed that asthmatics have

poorer periodontal health than the control population,
whereas Bjerkeborn et al.12 and Eloot et al.13 did not
find any difference in the prevalence of periodontal
disease in asthmatics.
An association between asthma and periodontal
disease may involve either pathological activation of
the immune and inflammatory process, the side effect
of the asthma medications, or the interaction between
the two. Hyyppa et al.24 suggested that gingivitis in
asthmatic children could be explained by an altered
immune response and the dehydration of alveolar
mucosa due to mouth breathing. The concentration of
IgE in gingival tissue is found to be elevated in patients
with asthma, which can also cause periodontal destruction.25 Interaction between bacterial and immunological factors are found to be the main cause of
destruction of periodontal tissue. Saliva undoubtedly
impacts this interaction through its protective
mechanism. Since many asthma drugs modify salivary
secretion in a significant percentage of patients, the
periodontal health of these patients may be affected
negatively.
McDeera et al.7 suggested that children with asthma
have more calculus than normal children. Higher
prevalence of calculus in asthmatic children is thought
to be due to an increase in the levels of calcium and
phosphorous in submaxillary and parotid saliva. This
can also contribute to an increase in periodontal
problems in asthmatics.
Inhaled corticosteroids (ICS) may be absorbed into
the systemic circulation, either through the lungs or by
the swallowing of drugs that are not inhaled but are
deposited at the back of the throat.26 Studies show that
ICS can cause a decrease in bone mineral density.2628
Hanania et al.27 in their study showed that regular use
of conventional doses of ICS by patients with asthma
can suppress the adrenal function and decrease bone
density in a dose-related fashion. Systemic bone loss
caused by these drugs, especially when high doses are
used for a long time, may have an impact on the onset
and progression of periodontal disease.29 Recently, in a
study by Han et al.,30 tooth loss in asthma patients
undergoing long-term treatment with topically potent
ICS was shown to be related to a decrease in bone
mineral density, especially in the mandible. Therefore,
it is suggested that patients using these types of ICS
should have their mandibular bone mineral density
checked regularly, especially if they have any risk
factors for osteoporosis. In addition, it may be wise for
such patients to reduce their ICS dose. The lowest
possible dose of ICS to maintain control should be
prescribed.26
Asthmatic patients are recommended to adopt more
precautionary oral hygiene practices and keep their
periodontal health under constant check.
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MS Thomas et al.
Asthma and oral candidiasis
Oropharyngeal candidiasis is a condition commonly
associated with the use of nebulized corticosteroids.31
This side effect may be attributed to the topical effects
of these medications on the oral mucosa, as only 10 to
20% of the dose from an inhaler actually reaches the
lungs, while the rest remains in the oropharynx. The
incidence of oral candidiasis can vary from 1 to 77%
with ICS treatment, probably because of the difference
in methods used to detect it. This local side effect is
mainly seen among patients who use high doses of ICS
regularly.32
Generalized immunosuppressive and anti-inflammatory effects of steroids are thought to play a major
role in the pathogenesis of candidiasis.33 A study by
Fukushima et al.34 suggested that ICS can decrease
salivary IgA. This host factor can contribute to the
development of oral candidiasis. Knight and Fletcher35
reported that patients who are treated with corticosteroids show a higher level of salivary glucose than
the control group. Also, many of the dry powder
inhalers contained lactose monohydrate as the carrier
vehicle in proportion of 1025 mg per dose.20 This
higher glucose concentration can also promote
growth, proliferation and adhesion of Candida to
the oral mucosal cells.36 As mentioned earlier, asthmatics who are medicated with beta-2 agonist show a
decreased salivary flow rate. This decreased salivary
flow rate can be associated with higher oral Candida
counts.37
A number of preventive measures can be adopted to
minimize oral candidiasis during steroid inhalation.33
Selroos et al.38 reported that the frequency of Candida
colonization in patients using dry powder inhalers was
diminished by rinsing the mouth after use. Use of a
spacer device which can be attached to the inhaler can
reduce the local effect of steroids in causing oral
candidiasis by minimizing the oropharyngeal deposition of the drug and maximizing the lung deposition.39
Increasing salivary output in subjects with low salivary
flow rate can also reduce oral Candida counts. Methods
used to increase the salivary flow rate include the use of
sialogogue medications, as well as chewing sugar-free
gums. Other measures used to reduce colonization by
Candida include the use of antimicrobial mouthrinses.40 Controlled administration of topical antimycotics, such as nystatin, is also shown to prevent oral
candidasis.41

CONCLUSIONS
Asthmatic patients may be at a higher risk of developing dental diseases. Dental practitioners should be
aware of the correlation between asthma and oral
health. They should educate their patients to follow
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precautionary measures to prevent adverse effects on

oral tissues.
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Address for correspondence:

Dr Manuel S Thomas
Department of Conservative Dentistry
and Endodontics
Manipal College of Dental Sciences
Mangalore
India
Email: manuel2dr@gmail.com

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