Access the full text.
Sign up today, get DeepDyve free for 14 days.
www.nature.com/bdjopen ARTICLE OPEN The association between erosive toothwear and asthma – is it signiﬁcant? A meta-analysis 1 2 3 Gowri Sivaramakrishnan , Kannan Sridharan and Muneera Alsobaiei © The Author(s) 2023 BACKGROUND: 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. Existing evidence indicates that an inhaler is the most common and effective way of delivering the asthma medications directly into the lungs. Few studies in the past attributed this association to the changes in salivary ﬂow caused due to these medications. Considering this unclear association, the aim of the present meta-analyses is to identify the association between erosive toothwear and asthma from individual studies conducted until date. METHODOLOGY: Electronic databases were systematically searched until 30th September 2022. Articles identiﬁed using the search strategy were imported to RAYYAN systematic review software. Data was extracted relating to study design, geographic location, year of publication, sample size, the assessment method for erosive toothwear and asthma. The Newcastle Ottawa scale was utilized to assess the quality of evidence reported from the included studies. RevMan Version 5.3 was used to perform a random- effects meta-analysis to produce pooled estimates from OR and 95% CI of included studies. The I² statistic was used to determine the extent of heterogeneity. A funnel plot was generated to visually assess the potential for publication bias. Sensitivity analyses were performed by excluding individual studies one at a time. GRADE approach was used for grading the evidence for key comparisons. RESULTS: Twelve articles were included in the ﬁnal meta-analysis. A total of 1027 asthmatics and 5617 non-asthmatics were included. All studies demonstrated moderate to low risk of bias. The overall pooled estimate (OR: 2.03; 95% CI: 0.96, 4.29) and subgroup analyses in children (OR: 1.67; 95% CI: 0.63, 4.42) did not show statistically signiﬁcant difference in the occurrence of dental erosion between the asthmatic and non-asthmatic group. However, asthmatic adults had signiﬁcantly greater dental erosion in comparison to the control adults (OR: 2.76; 95% CI: 1.24, 6.16). Sensitivity analyses also provided inconclusive evidence. Funnel plot asymmetry indicated signiﬁcant heterogeneity, changes in effect size and selective publication. CONCLUSION: The association between inhalational asthmatic medication and tooth wear is inconclusive. There are a number of confounding factors that play a greater role in causing dental erosion in these patients. Dentist must pay particular attention to these factors while treating asthmatic patients. The authors produce a comprehensive checklist in order to ensure complete assessment before providing advice on their medications alone. BDJ Open (2023) 9:9 ; https://doi.org/10.1038/s41405-023-00137-9 INTRODUCTION used in the form of inhalations, tablets, capsules and injections, Asthma is a chronic airway inﬂammatory disease that causes etc. The dose and frequency of the medications is dependent increased airway hyperresponsiveness, leading to symptoms such upon the severity of the disease and its related symptoms . as wheezing, coughing, chest tightness and dyspnoea Itis Inhalers are devices that deliver the medication directly into the characterized by the obstruction of airﬂow that varies over a airway through the mouth. Majority of the asthma patients use period, and is reversible spontaneously, or with medications . various forms of inhalers that are prescribed for use for upto three Asthma is a global public health problem and recent estimates times daily . Inhalation preparations include solutions for reveal that over 400 million people may be diagnosed with nebulization, metered-dose inhalers, and powdered inhalers . asthma by 2025 . The treatment of asthma usually involves Existing evidence indicates that an inhaler is the most common prescription of drug classes such as beta-2 agonists, corticoster- and effective way of delivering the asthma medications directly oids, antimuscarinics, leukotriene inhibitors and xanthines . into the lungs . However, each inhaler is unique in their They primarily act by controlling, as well as to reducing the airway mechanism of action. Some inhalers emit an aerosol jet when inﬂammation, and reopen the airways . These medications are activated. They work better in conjunction with a spacer, which is 1 2 Specialist Prosthodontist and Dental Tutor, Dental Postgraduate training department, Ministry of Health, Manama, Bahrain. Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain. Acting Head of Training Affairs, Dental Postgraduate training department, Ministry of Health, Manama, Bahrain. email: email@example.com Received: 15 December 2022 Revised: 15 February 2023 Accepted: 19 February 2023 1234567890();,: G. Sivaramakrishnan et al. a plastic or metal container, with a mouthpiece at one end and a were obtained during the initial search. The search was limited to hole for the inhaler at the other end. The spacer helps in humans, adults and publications in the English language. delivering the medication straight into the lungs. This means that there is less medication ending up in the mouth or throat, which Study selection and eligibility criteria has been reported to cause irritation or soreness. Spacer also helps Articles identiﬁed using the search strategy was imported to in coordinating breathing in and pressing the puffer . RAYYAN systematic review software . Using this software, The association of asthma with oral conditions such as dental duplicates were removed, and two independent reviewers (GS and caries, dental erosion, periodontal diseases and oral mucosal KS) screened all titles and abstracts. Potentially relevant full-text changes has been the subject of debate among dental articles were then read to determine if an article met the inclusion practitioners . Anti-asthmatic medications speciﬁcally the criteria. A discussion between the two reviewers was held to reach inhalers are always associated with causing dental erosion and an agreement. In order to test agreement between the ﬁrst and toothwear. Dentists that strongly believe in this association second reviewers, kappa values were calculated at each stage of between erosive toothwear and asthma suggested the use of data extraction. spacer or advice other alternative medications to their patients . Few studies in the past attributed this association to the Inclusion and exclusion criteria changes in salivary ﬂow caused due to these medications [10, 11]. All human studies performed in either children or adults which Reports in the past also showed decreased output of salivary included a dental assessment (oral examination) for erosive amylase, hexosamine, salivary peroxidase, lysozyme and secretory toothwear using any standardized indices that are available, and IgA in stimulated saliva of asthmatic patients . These changes asthma disease and medication assessment (medical assessment in the quality and quantity of saliva has been linked to toothwear or self-reported), were eligible for inclusion. Case reports, case and dental erosion. Inspite of all the available evidences that seem series, opinion papers and reviews were excluded. to associate erosion with asthma, majority of the individual studies conducted in the past did not show statistically signiﬁcant Data extraction and study quality assessment differences in prevalence of erosive toothwear between asthma Data was extracted relating to study design, geographic location, patients and asthma controls [12, 13]. In addition higher year of publication, sample size, the assessment method for prevalence of toothwear was reported in asthmatic patients with erosive toothwear and asthma. The Newcastle Ottawa scale (NOS) additional confounding factors such as acidic diet, parafunctional was utilized to assess the quality of evidence reported from the habits, gastrointestinal reﬂux diseases etc. . This is important included studies . from the dentist perspective because dentist that strongly believe in the association may not be interested to look at other Statistical analysis confounding factors for toothwear. It is extremely important for Review Manager (RevMan Version 5.3, The Cochrane Collabora- the dentist to manage the confounding factors as well, and not tion) was used to perform a random-effects meta-analysis to only focus on asthma and its medications in patients presenting produce pooled estimates from odds ratios (OR) and 95% with erosive toothwear. Considering this unclear association, the conﬁdence intervals (CI) of included studies. The OR and 95% CI aim of the present meta-analyses is to identify the association were calculated from prevalence data reported in the study. The I² between erosive toothwear and asthma from individual studies statistic was used to determine the extent of heterogeneity in conducted until date. included studies and values above 50% was considered as substantial heterogeneity . A funnel plot was generated to visually assess the potential for publication bias. Sensitivity MATERIAL AND METHODOLOGY analyses were performed by excluding individual studies one at Protocol and registration a time with the intention of assessing the robustness of the This systematic review and meta-analysis was conducted and pooled data. We used grades of recommendation, assessment, reported according to PRISMA (Preferred Reporting Guidelines for development and evaluation (GRADE) approach for grading the Systematic Reviews) guidelines . A protocol was developed evidence for key comparisons. (CRD42022324844) and submitted to PROSPERO. The protocol can be assessed @ https://www.crd.york.ac.uk/prospero/export_ details_pdf.php. The systematic review protocol clearly described RESULTS the intention to study the bidirectional relationship between The initial search strategy identiﬁed articles, which was reduced to erosive toothwear and asthma and its related medications. 42 articles after duplicates were removed. Thirty-four articles met Since majority of the studies reported the prevalence of erosive the inclusion criteria for full text assessment. After excluding 22 toothwear asthmatics, this study is particularly restricted to erosive papers following the full text screening, 12 [12–14, 18–26] articles tooth wear. Since this is a meta-analysis, formal ethics approval is were included in the ﬁnal meta-analysis. The detailed search not required for this type of study. strategy is presented in the PRISMA Flow diagram (Fig. 1). Data sources and search strategy Asthma and dental erosion Ovid MEDLINE, Scopus, Embase, and Web of Science electronic Eight studies were conducted in children and four studies in adult databases were systematically searched until 30th September population. A total of 1027 asthmatics and 5617 non-asthmatics 2022. The gray literature was hand searched for records that were were included in the meta-analysis. 775 (75%) asthmatic patients not electronically accessible or for those manuscripts without an were taking inhalational anti-asthmatic medications. Majority of electronic abstract. Further searches were undertaken to cross these medications were inhalational steroids, bronchodilators like check references not available in the electronic databases. The salbutamol or a combination of these. The corticosteroid inhalers search strategy included synonyms for erosive toothwear com- included drugs such as budesonide, ﬂuticasone or betametha- bined with synonymous terms for asthma, asthmatic medications sone. Four [18, 20, 21, 23] out of the included 12 studies did not and asthma related symptoms. The keywords were searched alone mention the details regarding the medication. The asthmatic and in combination to retrieve relevant literature. This systematic history was extracted subjectively using questionnaire given to review included two types of studies: cross-sectional and case- adult patients, or parents of asthmatic children. The erosive control, which analyzed the association between erosive tooth- toothwear was examined objectively using clinical examination wear and asthma. There were no randomized controlled trials that and classiﬁed according to indices such as Basic erosive wear BDJ Open (2023) 9:9 G. Sivaramakrishnan et al. Fig. 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA) ﬂow diagram. An evidence-based minimum set of items for reporting in systematic reviews and meta-analyses. examination, Smith and knight index etc in all the included children in the control group. The pooled estimates in children (OR: studies. The confounding factors that were considered were oral 1.67; 95% CI: 0.63, 4.42) did not show statistically signiﬁcant hygiene and brushing habits, acidic food consumption, acidic or differences in the presence of dental erosion in asthmatics and non- soft drinks, saliva quality, gastric disorders and activities like asthmatics. However, asthmatic adults had signiﬁcantly greater swimming. Not all studies included all the confounding factors dental erosion in comparison to the control adults. The pooled mentioned above. Two studies [12, 22] however did not clearly estimate was statistically signiﬁcant (OR: 2.76; 95% CI: 1.24, 6.16). mention the confounders they considered in their patients. Two studies demonstrated that 100% of the participants in the Sensitivity analyses asthmatic and non-asthmatic groups had dental erosion[14, 19]. Sensitivity analyses after removing the outlier study  identiﬁed 61 out of the 64 asthmatic patients in these two studies were on using visual examination of the forest plot did not show signiﬁcant medications. All studies demonstrated moderate to low risk of Bias difference in the pooled estimate. However, this study was majorly on eight domains as observed using the New Castle Ottawa Scale contributing to the heterogeneity as observed by the I value. (Table 1). The characteristics of included studies is presented in Sensitivity analyses removing Grugel et al. study yielded Table 2. statistically signiﬁcant pooled estimated (OR: 2.32; 95% CI: 1.07, 5.05) with greater dental erosion in asthmatic group (Fig. 3). The Subgroup analyses pooled estimates forest plot after removing the study by Grugel et al. is presented in Forest plot was generated using the software and the overall Fig. 3. Studies that did not mention the details regarding the pooled estimate (OR: 2.03; 95% CI: 0.96, 4.29) did not show asthmatic medication in children were removed and the pooled statistically signiﬁcant difference in the occurrence of dental estimate showed statistically signiﬁcant lesser odds of dental erosion between the asthmatic and non-asthmatic group (Fig. 2). erosion in children reported to be on inhalational asthmatic Subgroup analyses was done for studies in children and in adults. medication (OR: 0.71; 95% CI: 0.59, 0.86). The other signiﬁcant Studies in children included 897 asthmatic children and 5095 ﬁndings from the sensitivity analyses are presented in Table 3. BDJ Open (2023) 9:9 G. Sivaramakrishnan et al. Funnel plot and publication bias The funnel plot depicted in Fig. 4 does not suggest any publication bias in adult population. However, asymmetry was observed in children, probably caused due to signiﬁcant heterogeneity between the studies. This heterogeneity can be deﬁned as the differences in the size of the effect according to the study size. Majority of the included studies had greater number of patients in the control group. There are also major differences in the underlying confounding factors between the studies. The intervention group had greater differences in the drug, dose, and frequency of the inhaled anti-asthmatic medication. All these factors can lead to the asymmetry as shown in the funnel plot. Asymmetrical funnel plot in studies in children also indicates selective publication of studies according to the results obtained. Grading the strength of outcome measure Grading the strength of outcomes in various study populations is summarized in Table 4. Either a low or very low strength of evidence was observed due to serious limitations in risk of bias/ precision of the estimates and publication bias. DISCUSSION The present meta-analysis is an attempt to identify the association between dental erosion and asthma. This association has been strongly believed by many dentists. The results from the present study does not offer conclusive evidence to point a clear association between anti-asthmatic medications and dental erosion. Although some of the results obtained may show statistical signiﬁcance, considering the increased heterogeneity in these studies, a conclusive association cannot be elucidated. This is similar to the ﬁndings of Moreira et al.  however only two studies were included for the analysis. It is extremely important that dentists understand that there are variety of factors that can contribute to dental erosion such as consumption of acidic pickled fruits and vegetables, frequent intake of citrus juices, ﬁzzy drinks, systemic gastric disorders like gastro esophageal reﬂux diseases (GERD), bulimia, and frequent vomiting due to various causes. The association between GERD and dental erosion is clearly demonstrated in a recent meta- analysis by Jordao et al. . The study demonstrated that the objectively assessed patients with GERD showed greater odds of erosive toothwear. It is to be noted that the prevalence of GERD is reported to be approximately 75% in patients with asthma . This indicates that all patients that present with dental erosion should be assessed for GERD. Direct aspiration of the gastric contents into the lung tissue stimulates and damages the epithelial cells, leading to the release of inﬂammatory cytokines. This causes chronic airway inﬂammation, airway hyperresponsive- ness and airway obstruction. Hence, all asthmatic patients, especially those who are obese should be objectively tested for GERD and other gastric disorders. Obesity asthma phenotype is considered as distinct in view of greater severity and poor asthma control . None of the included studies considered this strong association and evaluated their patients for obesity or gastric disorders. It is necessary to understand from the evidence that anti-asthmatic medications are unlikely to be solely responsible for toothwear, and every possible reason that is mentioned above must be excluded. The most widely used inhaled drugs are corticosteroids, β- adrenergic agonists, and muscarinic antagonists. In patients with persistent asthma, long-term regular use of inhaled corticoster- oids is prescribed to achieve asthma control. In severe asthma, additional medications are prescribed to achieve symptom control and prevent exacerbations . The most important feature of these devices is to deliver signiﬁcant portion of the medication upto the terminal airways to ensure high bronchial deposition. Four main types of inhalers available today are BDJ Open (2023) 9:9 Table 1. Risk of bias using New Castle Ottawa scale. Study Id Selection Comparability Outcome Representativeness of Selection of the Ascertainment of Outcome of Comparability Assessment Follow-up Adequacy Quality score exposed cohort non-exposed exposure interest was of cohorts of outcome long of follow- cohort from same not present enough for up source as at start outcome exposed cohort of study to occur Alazmah * * * * * * * * 8 Al-Dlaigan et al. N * * * N * * * 6 Alves et al. N * * * N * * * 6 Arafa et al. N * * * N * * * 6 Dugmore and RockN* * * N * * * 6  Farag and Awood** * * * * * * 8  Jain et al. * * * * * * * * 8 Jacob et al. N * * * N * * * 6 Gurgel et al. N * * * N * * * 6 Rezende et al. * * * * * * * * 8 Stensson et al. * * * * * * * * 8 Sivasithamparam N* * * N * * * 6 et al.  G. Sivaramakrishnan et al. BDJ Open (2023) 9:9 Table 2. Key characteristics of included studies. Study id Location Age range of Asthma Erosive toothwear Confounders Risk of Bias study looked at assessment Diagnosis Number Taking Diagnosis Outcome in participants using New cases/ asthma Cases/ (in years) castle control medication control Ottawa scale Alazmah  Saudi Arabia 3–12 Questionnaire 50/50 Not Smith and 12/9 Brushing Low mentioned knight index frequency Al-Dlaigan et al. UK 11–18 Questionnaire 20/40 20 Smith and 20/40 Heartburn, Moderate  knight index stomach problems, vomiting Alves et al.  Brazil 12 Interview 118/1410 Not Basic erosive wear 20/210 Daily consumption Moderate mentioned examination of soft drinks, regurgitation, heart burn Arafa et al.  Saudi Arabia 4–12 Questionnaire 60/120 Not Smith and 48/8 Saliva ﬂow Moderate mentioned knight index rate, DMFT Dugmore and Rock UK 12–14 Questionnaire 479/2582 479 Basic erosive index 294/1787 None Moderate  Farag and Awooda Saudi Arabia 18–60 Questionnaire 40/40 40 Basic erosive wear 36/35 None Low  examination Jain et al.  India Above 18 Questionnaire 51/51 51 Community 39/35 Oral hygiene habit, Low periodontal index intake of of treatment needs soft drinks Jacob et al.  India Above 12 Questionnaire 19/411 19 Basic erosive wear 16/173 GERD, citrus and Moderate examination soft drinks, oral hygiene habits Gurgel et al.  Brazil 12–16 Questionnaire 14/398 Not Obrien Index 1/82 Gastric disorders, Moderate mentioned acidic drinks, activities like swimming Rezende et al.  Brazil 6–12 Questionnaire 112/116 105 Modiﬁed Dental 36/44 Oral Low examination hygiene habits Stensson et al.  Sweden 18–24 Interview 20/20 20 Johansson et al. 15/8 Oral hygiene, Low grading system caries status, salivary factors Sivasithamparam Australia 15–55 Interview 44/379 41 Scanning electron 44/379 Acid consumption, Moderate et al.  microscope soft drink consumption, gastric complaints G. Sivaramakrishnan et al. Fig. 2 Forest plot. Diagram depicting the association between asthma and dental erosion. Fig. 3 Forest plot. Diagram after removing the study by Grugel et al. BDJ Open (2023) 9:9 G. Sivaramakrishnan et al. Table 3. Sensitivity analyses. Sensitivity analyses Asthmatic group (N) Non-asthmatic control Pooled estimate at 95% Heterogeneity I2 (N) CI Overall – Removing Grugel et al. 1013 5219 2.32 [1.07, 5.05] 92% Overall – Removing Arafa et al. – 967 5497 1.28 [0.82, 2.02] 70% outlier study Overall – Removing Arafa et al. and 953 5099 1.37 [0.86, 2.18] 73% Grugel et al. Overall – studies with no confounders 508 2995 2.51 [0.92, 6.82] 90% removed Overall – studies with moderate ROB 233 237 1.43 [0.74, 2.76] 55% removed Studies in Adults: Removing Stensson et al. 110 502 2.43 [0.88, 6.77] 57% Studies in Children Removing Arafa et al. 837 4975 0.83 [0.63, 1.11] 30% Studies with no asthmatic medication details 655 3117 0.71 [0.59, 0.86] 0% removed Statistically signiﬁcant. Fig. 4 Funnel plot. Diagram depicting publication bias. Table 4. Grading the strength of evidence. Comparisons Illustrative comparative risks (per 1000) Effect estimates and quality of evidence for mixed (95% conﬁdence intervals) treatment comparisons Assumed risk Corresponding risk Proportion of patients (adults/children) with 500 per 1000 670 (600 to 811) 2.03 [0.96, 4.29] b,c dental erosions ⊕⊕⊝⊝; Low Proportion of adults with dental erosions 479 per 1000 716 (533 to 849) 2.76 [1.24, 6.16] b,c,d ⊕⊝⊝⊝; Very low Proportion of children with dental erosions 293 per 1000 409 (207 to 647) 1.67 [0.63, 4.42] b,c,d ⊕⊝⊝⊝; Very low Low: Further research is very likely to have an important impact on our conﬁdence in the estimate of effect and is likely to change the estimate; Very low quality: We are very uncertain about the estimate. Assumed risk was the median control group (non-asthmatics) risk across the studies. Downgraded one level for including studies with high risk of bias. Downgraded one level as publication bias could not be assessed/ruled out. Downgraded one level for serious limitations in the precision of the estimates. BDJ Open (2023) 9:9 G. Sivaramakrishnan et al. meta-analysis. There are a number of confounding factors that Table 5. Checklist for dentist when treating patients with asthma. play a greater role in causing dental erosion in these patients. Dentist must pay particular attention to these factors while 1 History of asthma – age of onset, frequency, severity treating asthmatic patients. The authors produce a comprehensive 2 Anti-asthmatic medication – drug class, type of inhaler, checklist in order to ensure complete assessment before providing duration of use, use of spacers, method of use (eg. Swishing advice on their medications alone. There is a greater need for the mouth with water after use), compliance with the use of future studies considering all the factors that are discussed in inhalers this paper. 3 Body mass index, obesity, Sleep disordered breathing, sleep apnoea REFERENCES 4 Diet- acidic/ pickled food, citrus, ﬁzzy drinks 1. Boulet LP, Boulay MÈ. Asthma-related comorbidities. Expert Rev Respir Med. 5 Objective assessment of gastric disorders 2011;5:377–93. 6 Local factors – condition of the enamel, hypomineralisation etc 2. Mims JW. Asthma: deﬁnitions and pathophysiology. Int Forum Allergy Rhinol. 2015:S2–S6. https://doi.org/10.1002/alr.21609. 3. Gerald JK, Wechsler ME, Martinez FD. Asthma medications should be available for nebulizers, dry powder inhalers (DPIs), pressurized metered-dose over-the-counter use: pro. Ann Am Thorac Soc. 2014;11:969–74. inhalers (pMDIs), and soft mist inhalers (SMIs) . Currently, the 4. Zahran HS, Bailey CM, Qin X, Johnson C. Long-term control medication use and most popular inhalation device is the DPI, which is considered asthma control status among children and adults with asthma. J Asthma. 2017; environment friendly and easy to use . However, it is to be 54:1065–72. noted that DPI cannot be used with a spacer, which may 5. Cloutier MM,Dixon AE,KrishnanJA, Lemanske RF Jr,PaceW,SchatzM. contribute to dental erosion. In the included studies, clear Managing asthma in adolescents and adults: 2020 asthma guideline update description of the type of inhaler used by the participants was not from the National Asthma Education and Prevention Program. JAMA. 2020; 324:2301–17. provided. This may have an inﬂuence on the results obtained. 6. Kim LHY, Saleh C, Whalen-Browne A, O’Byrne PM, Chu DK. Triple vs dual inhaler A recent study regarding the ph levels of saliva following therapy and asthma outcomes in moderate to severe asthma: a systematic inhalation medication reported that all inhalers in the study failed review and meta-analysis. JAMA. 2021;325:2466–79. to depress the salivary ph below 6. A substantial pH drop was 7. Sorino C, Negri S, Spanevello A, Visca D, Scichilone N. Inhalation therapy devices observed only with the use of lactose-based DPIs, although for the treatment of obstructive lung diseases: the history of inhalers towards the not below pH 6 . This study suggests that the theory ideal inhaler. Eur J Intern Med. 2020;75:15–8. correlating inhalation medication related ph drop and enamel 8. Rogliani P, Calzetta L, Coppola A, Cavalli F, Ora J, Puxeddu E, et al. demineralization cannot be justiﬁed. Other factors that are Optimizing drug delivery in COPD: the role of inhaler devices. Respir Med. mentioned previously play a major role in causing dental erosion 2017;124:6–14. 9. Newman SP. Spacer devices for metered dose inhalers. Clin Pharmacokinet. in asthmatic patients. 2004;43:349–60. The subgroup analyses conducted in the present study showed 10. Thomas MS, Parolia A, Kundabala M, Vikram M. Asthma and oral health: a review. contradicting results in children and adults, with adult asthmatics Aust Dent J. 2010;55:128–33. presenting with signiﬁcant dental erosion. The sensitivity analyses 11. Manuel ST, Kundabala M, Shetty N, Parolia A. Asthma and dental erosion. Kath- also showed varied results that cannot offer meaningful conclu- mandu Univ Med J. 2008;6:370–4. sions. In the overall analyses, the number of participants in the 12. Dugmore CR, Rock WP. Asthma and tooth erosion. Ia there an association. Int J non-asthmatic group outnumbered the comparator group. This Paediatr Dent. 2003;13:417–24. has led to signiﬁcant heterogeneity that is evident from the 13. Rezende G, Dos Santos NML, Stein C, Hilgert JB, Faustino-Silva DD. Asthma and oral changes in children: associated factors in a community of southern Brazil. Int analyses. The investigators in the included studies did not J Paediatr Dent. 2019;29:456–63. consider many confounding factors that are discussed previously 14. Sivasithamparam K, Young WG, Jirattanasopa V, Priest J, Khan F, Harbrow D, et al. that has an inﬂuence on the outcome. This means that the Dental erosion in asthma: a case-control study from southeast Queensland. Aust intervention and comparator groups, in majority of the studies, Dent J. 2002;47:298–303. were ideally non-comparable at baseline. Hence, the results 15. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The obtained are not conclusive. Although this is the limitation, this PRISMA 2020 statement: an updated guideline for reporting systematic reviews. meta-analysis identiﬁes that there is a deﬁnite need for future BMJ. 2021;29:372:n71. studies that should have participants in the treatment and 16. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile comparator groups that are comparable at baseline. This might app for systematic reviews. Syst. Rev. 2016;5:210. possibly help in reducing the heterogeneity and provide 17. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2001; conclusive evidence. There were also limited number of studies 25:603–5. on adults and children that were available for inclusion that might 18. Alazmah A. Relation between childhood asthma and dental erosion in have inﬂuenced the results obtained. Al-Kharj Region of Saudi Arabia: a cross-sectional study. J Pharm Bioallied Sci. Erosive toothwear occurs because of prolonged exposure of the 2021;13:S293. surfaces of the tooth to acid attacks. Dental treatment strategies 19. Al‐Dlaigan YH, Shaw L, Smith AJ. Is there a relationship between asthma and are aimed to suggest the use of spacers, alternate medications, dental erosion? A case control study. Int J Paediatr Dent. 2002;12:189–200. speciﬁc oral hygiene instructions such as mouth rinsing following 20. Alves LS, Brusius CD, Damé-Teixeira N, Maltz M, Susin C. Dental erosion among inhalation for patients on anti-asthmatic medications. Although it 12-year-old schoolchildren: a population-based cross-sectional study in South is not inappropriate to provide the above-mentioned instructions Brazil. Int Dent J. 2015;65:322–30. 21. Arafa A, Aldahlawi S, Fathi A. Assessment of the oral health status of asthmatic to these patients, it is important that the confounding factors also children. Eur J Dent. 2017;11:357–63. be addressed accordingly. A summarized checklist to be used by 22. Farag ZH, Awooda EM. Dental erosion and dentin hypersensitivity among adult dentists when treating asthmatic patients in presented in Table 5. asthmatics and non-asthmatics hospital-based: a preliminary study. Open Dent J. All these factors needs to be considered in order to treat dental 2016;10:587. erosion in these patients. 23. Gurgel CV, Rios D, Buzalaf MA, da Silva SM, Araújo JJ, Pauletto AR, et al. Dental erosion in a group of 12-and 16-year-old Brazilian schoolchildren. Pediatr Dent. 2011;33:23–8. CONCLUSION 24. Jacob S, Babu A, Latha SS, Glorine SJ, Surendran L, Gopinathan AS. Independent variables of dental erosion among tertiary care hospital patients of a developing The association between inhalational asthmatic medication and country. J Int Soc Prev Community Dent. 2019;9:612. tooth wear is inconclusive from the results obtained in the present BDJ Open (2023) 9:9 G. Sivaramakrishnan et al. 25. Jain M, Mathur A, Sawla L, Nihlani T, Gupta S, Prabu D, et al. Prevalence of dental COMPETING INTERESTS erosion among asthmatic patients in India. Rev Clín Pesq Odontol. 2009;9:247–54. The authors declare no competing interests. 26. Stensson M, Wendt LK, Koch G, Oldaeus G, Ramberg P, Birkhed D. Oral health in young adults with long-term, controlled asthma. Acta Odontol Scand. 2011;69:158–64. ADDITIONAL INFORMATION 27. Moreira LV, Galvão EL, Mourão PS, Ramos-Jorge ML, Fernandes IB. Association Supplementary information The online version contains supplementary material between asthma and oral conditions in children and adolescents: a systematic available at https://doi.org/10.1038/s41405-023-00137-9. review with meta-analysis. Clin Oral Investig. 2022. https://doi.org/10.1007/ s00784-022-04803-4. Correspondence and requests for materials should be addressed to Gowri 28. Jordão HWT, Coleman HG, Kunzmann AT, McKenna G. The association between Sivaramakrishnan. erosive toothwear and gastro-oesophageal reﬂux-related symptoms and disease: a systematic review and meta-analysis. J Dent. 2020;95:103284. Reprints and permission information is available at http://www.nature.com/ 29. Paoletti G, Melone G, Ferri S, Puggioni F, Baiardini I, Racca F, et al. Gastro- reprints esophageal reﬂux and asthma: when, how, and why. Curr Opin Allergy Clin Immunol. 2021;21:52–8. Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims 30. Gupta S, Lodha R, Kabra SK. Asthma, GERD and obesity: triangle of inﬂammation. in published maps and institutional afﬁliations. Indian J Pediatr. 2018;85:887–92. 31. Crompton GK. Dry powder inhalers: advantages and limitations. J Aerosol Med. 1991;4:151–6. 32. Janson C, Henderson R, Löfdahl M, Hedberg M, Sharma R, Wilkinson AJK. Carbon footprint impact of the choice of inhalers for asthma and COPD. Thorax. Open Access This article is licensed under a Creative Commons 2020:82–4. https://doi.org/10.1136/thoraxjnl-2019-213744. Attribution 4.0 International License, which permits use, sharing, 33. Tootla R, Toumba KJ, Duggal MS. An evaluation of the acidogenic potential of adaptation, distribution and reproduction in any medium or format, as long as you give asthma inhalers. Arch Oral Biol. 2004;49:275–83. https://doi.org/10.1016/ appropriate credit to the original author(s) and the source, provide a link to the Creative j.archoralbio.2003.11.006. Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by AUTHOR CONTRIBUTIONS statutory regulation or exceeds the permitted use, you will need to obtain permission GS: Contributed to conception, design, data acquisition and interpretation, drafted directly from the copyright holder. To view a copy of this license, visit http:// and critically revised the manuscript. KS: Contributed to conception, data acquisition creativecommons.org/licenses/by/4.0/. and interpretation, performed all statistical analyses, drafted and critically revised the manuscript. MA: Contributed to conception, performed all statistical analyses, drafted and critically revised the manuscript. © The Author(s) 2023 BDJ Open (2023) 9:9
BDJ Open – Springer Journals
Published: Mar 1, 2023
Access the full text.
Sign up today, get DeepDyve free for 14 days.