The Need to Support Underprivileged Asthmatic Pediatric Dental Patients
Abigail Peterson, DMD
Across the United States, the incidence of children diagnosed with asthma has been rising steadily in recent decades.1 Children from low socioeconomic status (SES) households are diagnosed with asthma at an increased rate compared to the general population2 and have a higher caries rate than children not living in poverty.3 A literature review exploring the relationship between asthma and dental caries found “no strong evidence suggesting that a causal link exists.”4 However, the correlation between children diagnosed with asthma and higher caries rate specifically in urban, low SES households has not been studied.
Kids Smiles is a not-for-profit pediatric dental organization with two offices located in inner city areas of Philadelphia. Its mission is to “provide children in underserved communities with preventive and restorative oral health care as well as innovative health education programs, focusing on the prevention of dental disease and the development of positive, personal health behaviors.”5 At Kids Smiles, the dentists and staff frequently treat children diagnosed with asthma, many of whom present with caries and require operative treatment.
Risk factors for asthma diagnosis and attack include outdoor air pollution, cockroach allergen, pets, dust mites, and environmental tobacco smoke.6 Children in urban settings from low SES families frequently encounter these conditions, which can lead to increased risk for asthma attack.
Treatment of asthma can include both inhaled corticosteroids for long-term control and inhaled short-acting beta-2 agonists.7 Inhaled corticosteroids are effective at managing symptoms but also result in the side effect of xerostomia.8 Commonly known as “dry mouth,” xerostomia is correlated with increased risk of caries due to a reduced salivary flow, which diminishes the benefits of saliva (eg, neutralizing acids produced by bacteria, limiting bacterial growth, and flushing away food particles).9 This side effect becomes more significant when a child is in an “asthma flare,” a period often associated with an upper respiratory infection when the child requires multiple inhaled corticosteroid sessions for several days.
Most children who present at Kids Smiles with caries are safely and effectively treated in the office. The adjunct use of nitrous oxide, which is not contraindicated for asthma patients,10 is often employed to help young and apprehensive patients cooperate for operative treatment. However, it is sometimes necessary for children to be treated in the operating room under general anesthesia. Reasons for this may include very young age, significant treatment needs (eg, all four quadrants), special needs, or dental phobia. Asthma complicates this process. Children with severe or uncontrolled asthma often are not candidates for elective treatment under general anesthesia.11
Children from low SES families suffer from higher rates of both dental caries and asthma. Dental caries is the most common disease of childhood,12 and asthma is the most common noncommunicable disease among children.13 Does living in an urban, low SES setting result in higher caries rate for asthmatic children? If it does, what can be done to help lower the risk?
A chief component of the mission of Kids Smiles involves education of children and their families, helping to empower them with respect to their own health. However, it has been noted through a statistical analysis (SPSS, IBM, ibm.com) of 322 patients at Kids Smiles that 50% of children who receive three oral health lessons and graduate from the Kids Smiles Dental Detective Academy do not show improvement in dental outcomes. The analysis also revealed that asthma was the most prevalent chronic disease of the group, affecting 31% of the patients. This raises several questions: Is the negative effect of asthma enough to mitigate the positive effect of dental education? Do children with diagnoses that negatively affect oral health outcomes require more or different interventions in education or treatment? What can be done to support these children and families?
Perhaps an education program tailored specifically for families of asthmatic children should be established. Parents and caregivers could be instructed on rinsing after inhaler treatments and consuming extra water to help alleviate the effects of medication-induced xerostomia. Further, perhaps patients with both asthma and increased caries rate should be on 3-month recall with fluoride application instead of 6-month recall.
As dentists serving an urban, predominantly low SES population, we at Kids Smiles see many children with high caries rates. Many of these children suffer from asthma concurrently. More investigation into any relationship between the two conditions is needed.
References
1. Zahran HS, Bailey C, Garbe P. Vital signs: asthma prevalence, disease characteristics, and self-management education—United States, 2001–2009. MMWR Morb Mortal Wkly Rep. 2011;60(17):547-552.
2. Asthma disproportionately affects low-income populations. ScienceDaily website. December 17, 2010. https://www.sciencedaily.com/releases/2010/12/101217091203.htm. Accessed January 8, 2018.
3. Tinanoff N, Kanellis MJ, Vargas CM. Current understanding of the epidemiology, mechanisms, and prevention of dental caries in preschool children. Pediatr Dent. 2002;24(6):543-551.
4. Maupomè G, Shulman JD, Medina-Solis CE, Ladeinde O. Is there a relationship between asthma and dental caries? A critical review of the literature. J Am Dent Assoc. 2010;141(9):1061-1074.
5. Our Mission. Kids Smiles website. kidssmiles.org/about-us. Accessed January 8, 2018.
6. Common asthma triggers. Centers for Disease Control and Prevention website. Updated August 20, 2012. www.cdc.gov/asthma/triggers.html. Accessed January 8, 2018.
7. Asthma, Treatment. National Heart, Lung, and Blood Institute website. https://www.nhlbi.nih.gov/health-topics/asthma?_fb_05_22_13_asthma=#Treatment. Accessed January 8, 2018.
8. Asthma medications: know your options. Mayo Clinic website. https://www.mayoclinic.org/diseases-conditions/asthma/in-depth/asthma-medications/art-20045557. Accessed January 8, 2018.
9. Dry mouth. Mayo Clinic website. https://www.mayoclinic.org/diseases-conditions/dry-mouth/symptoms-causes/syc-20356048. Accessed January 8, 2018.
10. XI. Indications and Contraindications for the Use of Nitrous Oxide. Interactive Web Courses. UT Health Science Center San Antonio Dental School website. https://icourses.uthscsa.edu/courses/nitrous/indications.html. Accessed January 8, 2018.
11. von Ungern-Sternberg BS, Boda K, Chambers NA, et al. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet. 2010;376(9743):773-783.
12. Clark MB, Slayton R; Section on Oral Health. Fluoride use in caries prevention in the primary care setting. Pediatrics.2014;134(3):626-633.
13. 10 facts on asthma. World Health Organization website. Updated August 2017. https://www.who.int/features/factfiles/asthma/en/. Accessed January 8, 2018.
