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Acknowledgement To begin with I bow my head to the Almighty God for bestowing the gift of life on me and providing me footrests to become a human being without which no endeavour of mine would ever be a success. With these words I humbly acknowledge the kind and affectionate attitude of my respected teachers throughout my work. Language with all elaborations seems to have limitations when with supreme sincerity, deep sense of gratitude I express my most sincere thanks to my esteemed guide Dr. Sabyasachi Saha, Professor & Head, Department of Public Health Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow. He is an excellence personified with the highest of ideals and depth of knowledge which has been truly inspirational to me. His constructive inputs and the zeal to strive towards excellence have always been instrumental in moulding me as a professional and as a mentor supporting me to complete this dissertation I sincerely extend my heartfelt thanks to Dr. G. V. Jagannath, Reader, Department of Public Health Dentistry, Sardar Patel Post Graduate Institute of Dental And Medical Sciences, Lucknow, for his constructive counselling, support, encouragement and ever helping hand to bring this dissertation to completion. Words are inadequate when I owe my deep sense of gratitude and heartfelt thanks to my esteemed teacher and Co-Guide Dr. Sanjay Singh, Senior lecturer, Department of Public Health Dentistry, Sardar Patel Post Graduate Institute of Dental And Medical Sciences, Lucknow, for his invaluable guidance, undeterred patience & tireless pursuit for knowledge during my work. His singular devotion to the subject of Public Health Dentistry is miraculous, which has helped me in every juncture of my work. Needless to say, this work has been accomplished by the mark of his gracious direction, academic excellence and meticulous attention. I sincerely thank him for teaching me to think and reason while learning which has been the chief source of inspiration during my work. I am highly grateful to my respected teacher Dr. Bharat. G, Professor, Dr. L.Vamsi Reddy, Reader, Department of Public Health Dentistry, Sardar Patel Post Graduate Institute of Dental And Medical Sciences, Lucknow, for his constant encouragement, support and total emphasis has helped me to sail through this challenging task. I sincerely extend my gratitude and heartfelt thanks to my respected teachers Reader, Dr. Shafaat Mohd., Senior lecturer, Dr. Minti Kumari, Senior Lecturer, and Dr. Rama Sharma, Senior lecturer Dept. of Public Health Dentistry, Sardar
Acknowledgement
Patel Post Graduate Institute Of Dental And Medical Sciences, Lucknow, who spared their valuable time and efforts in imparting quality, substance and fineness to the study and mitigating me through many troughs encountered during the study. It gives me immense pleasure to express my heartfelt thanks to my dear Postgraduate seniors Dr. Kunal Jha, Dr. Ridhi Narang & Dr. Paramjeet Singh for all the help rendered during various stages of this dissertation. I thank my Post Graduate Colleague Dr. Sourav Sen, Dr. Gautam Biswas, and Juniors Dr. Ekta Singh, Dr. Mitali Raja, Dr. Vamshi Krishna. B, Dr Harshita Pawar, Dr. Sanjukta Bagchi and Dr. Saifulla Akhtar for their constant moral support and caring counsel during the preparation of this project. With deep sense of gratitude, a very special thanks to Dr. Sonali Saha, Senior lecturer, Department of Pedodontics and Preventive Dentistry for her unflinching encouragement and caring counsel during the preparation of this project. Tough times became easier and arduous tasks became manageable because of her. My special thanks Dr. Kusum who with her sublime presence makes arduous task easy by being around and motivates me to give my best in every task I perform. I am grateful to Late Dr. O. P. Chaudhary, Founder Chairman, Shri Anurag Singh, Chairman and Dr. Snehlata Chaudhary, Secretary, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow for giving me the opportunity for pursuing Post-graduation course in his esteemed institution. I wish to express my sincere thanks to Dr. Praveen Mehrotra, Principal, Sardar Patel Post Graduate Institute of Dental And Medical Sciences, Lucknow for facilitating my study. I would also like to thank all the asthmatic children who participated in my study. My due thanks to Mr. Asif Akhtar, M.Sc. (Statistician) and Arun Photostat for their invaluable help rendered to present this dissertation in a neat form. Whatever I am today, is the replica of hard labour and devotion of my parents. They constantly supported me and were by my side throughout this endeavour. They have held my hands and taken me ahead step by step, paving a path for me that provided great encouragement to help me accomplish this task. I touch their feet for their innumerable sacrifices and choicest of blessings. Last, but not the least, I express my thanks to all who directly or indirectly helped me complete this dissertation. -Pramod
CONTENTS
S. No.
Title
Page No.
1.
Introduction
2.
Aim and Objectives
3.
Review of Literature
5-35
4.
Materials & Methods
36-41
5.
Basic Considerations
4-5
6.
Results
59
7.
Discussion
9-10
8.
Summary & Conclusion
10-10
9.
Suggestions
10-107
10.
References
1-11
11.
Annexures
11-127
1-3 4
LIST OF TABLES Table No.
Title
Page No.
1
Shows Gender wise distribution of asthmatic children in different age groups.
67
2
Shows Gender and age wise distribution of asthmatic children according to their oral hygiene practices.
68
3
Shows Age and Gender wise tooth brushing in asthmatic children.
69
4
Shows Age and Gender wise distribution of adverse oral habits in asthmatic children.
70
5
Shows Age and Gender wise distribution of frequency of sugar consumption in asthmatic children.
71
6
Shows Age and Gender wise distribution of consistency & form of sugar consumption of asthmatic children.
72
7
Shows duration of asthma
73
8
Shows Age and Gender wise distribution related to type of medication taken by asthmatic children.
74
9
Shows Age and Gender wise distribution of type of systemic medication taken by the asthmatic children.
75
10
Shows Age and Gender wise distribution of routs of drug administration in asthmatic children.
76
11
Shows Age and Gender wise distribution of history of dryness of mouth in asthmatic children.
78
12
Shows Age and Gender wise distribution of history of dental visits by the asthmatic children.
79
List of Tables
13
Shows Age and Gender wise distribution of (Mean±SD) DMFTscore of asthmatic children.
80
14
Shows Age and Gender wise distribution of (Mean±SD) OHI-S in asthmatic subjects.
81
15
Shows Age and Gender wise distribution of Mean±SD GI Score
82
16
Shows Gender wise correlation of duration of asthma with (Mean±SD) DMFT, OHI-S, GI Score.
83
17
Shows Gender wise correlation between history of dryness of mouth and (Mean±SD) DMFT, OHI-S, GI Score.
84
18
Shows Gender wise correlation between history of dental visit and (Mean±SD) DMFT, OH-SI, GI Score.
85
19
Shows Gender wise correlation between type of medication and (Mean±SD) DMFT,OHI-S, GI Score.
86
20
Shows correlation between form of systemic medication and (Mean±SD) DMFT, OHI-S, GI Score.
87
21
Shows Gender wise correlation between routs of drug administration and (Mean±SD) DMFT, OHI-S, GI Score
88
22
Shows Age and Gender wise treatment needs in asthmatic children
89
COLOUR PLATES 1
Map of Lucknow City
2
Armamentarium
3
Examiner visiting the Hospital OPD
4
Examiner performing the oral examination of school children
LIST OF GRAPHS Graph No.
Title
Page No.
1
Shows Gender wise distribution of asthmatic children in different age groups.
67
2
Shows Gender and age wise distribution of asthmatic children according to their oral hygiene practices.
68
3
Shows Age and Gender wise tooth brushing in asthmatic children.
69
4
Shows Age and Gender wise distribution of adverse oral habits in asthmatic children.
70
5
Shows Age and Gender wise distribution of frequency of sugar consumption in asthmatic children.
71
6
Shows Age and Gender wise distribution of consistency & form of sugar consumption of asthmatic children.
72
7
Shows duration of asthma
73
8
Shows Age and Gender wise distribution related to type of medication taken by asthmatic children.
74
9
Shows Age and Gender wise distribution of type of systemic medication taken by the asthmatic children.
75
10
Shows Age and Gender wise distribution of routs of drug administration in asthmatic children.
77
11
Shows Age and Gender wise distribution of history of dryness of mouth in asthmatic children.
78
Shows Age and Gender wise distribution of history of dental visits by the asthmatic children.
79
Shows Age and Gender wise distribution of (Mean±SD) DMFTscore of asthmatic children.
80
12
13
14
Shows Age and Gender wise distribution of (Mean±SD) OHI-S in asthmatic subjects.
81
15
Shows Age and Gender wise distribution of Mean±SD GI Score
82
16
Shows Gender wise correlation of duration of asthma with (Mean±SD) DMFT, OHI-S, GI Score.
83
17
Shows Gender wise correlation between history of dryness of mouth and (Mean±SD) DMFT, OHI-S, GI Score.
84
18
Shows Gender wise correlation between history of dental visit and (Mean±SD) DMFT, OHI-S, GI Score.
85
19
Shows Gender wise correlation between type of medication and (Mean±SD) DMFT,OHI-S, GI Score.
86
20
Shows correlation between form of systemic medication and (Mean±SD) DMFT, OHI-S, GI Score.
87
21
Shows Gender wise correlation between routs of drug administration and (Mean±SD) DMFT, OHI-S, GI Score
88
22
Shows Age and Gender wise treatment needs in asthmatic children
90
Introduction
A
sthma has become one of the most common chronic diseases in industrialized countries and its prevalence is increasing throughout the
world.1 Asthma affects all age groups and is often persistent, accounting for a large proportion of health care spending and loss of work.2-5 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.6 Asthma is a growing public health problem affecting over 300 million people world- wide. It is estimated that an additional 100 million may be diagnosed with asthma by 2025.7 In India, about 15 to 20 million people are suffering from bronchial asthma.8 Saliva plays a major role in the health of the oral cavity and any changes in the amount or quality of saliva may alter the oral health status.9,
10
Saliva
contains several defence systems aiming to protect dental enamel and oral mucous membranes. Their effects on the mechanisms of action of various antimicrobial systems and bacterial, fungal and viral species present in human saliva have been extensively studied in vitro.11, 12. However, little is known of
·1¶
Introduction
their possible significance in vivo, and in particular with respect to systemic medication or systemic disease.13-15 Asthmatic children have an altered immune response and a high tendency to mouth breathing especially during an episode of rhinitis or an attack thus predisposing them to serious oral health problems. Relatively few studies exist on the oral health of asthmatic patients. Findings, indicating an increased risk of oral diseases in asthmatic patients are mainly obtained from studies on children and adolescents. According to most published reports, young asthmatic patients suffer more from caries and/or periodontal diseases than non-asthmatic subjects.16-22 These findings were mainly obtained from small-scale studies and there are two recently published studies that found no association between dental caries and childhood asthma 23
, or association over time between asthma and caries increment.24 In their
reports Ryberg et al.(1987)25 linked the increased incidence of dental caries to the regular
use of inhaled ß2-agonists used in the treatment of
asthma..However, during the 1990’s the treatment modalities of asthma has changed dramatically. Haahtela et al.(1992,1994)26,27 have shown that the regular use of inhaled ß2-agonists is not efficient and the early introduction of inhaled steroids is an internationally approved approach to the treatment of asthma.28,29.Ryberg et al.(1987) have also reported differences in salivary flow rate and saliva composition between asthmatic and non-asthmatic children. 30, 31
·2¶
Introduction
The two most common oral diseases dental caries and periodontal disease are preventable to some extent and early recognition of populations at high risk may help to focus dental health care resources more effectively on the prevention of these diseases. Based on clinical experience, asthmatic patients are also sometimes worried about the possible side effects of inhaled antiasthma medications on their mouths. Hence the present study has been undertaken to “Assess the oral health status and treatment needs of Asthmatic children aged 6 – 12 years in Lucknow”.
·3¶
Aim & Objectives AIM: To assess the oral hygiene status, gingival condition, and prevalence of dental caries & treatment needs of Asthmatic children aged 6 – 12 years in Lucknow.
OBJECTIVES: x To estimate dental caries, gingivitis and oral hygiene status among 6 to 12 year old asthmatic children using suitable indices. x To assess the association of oral health in asthmatic children with special reference to the form & route of medications being taken and duration of the disease. x To suggest suitable measures if any, required to achieve optimal oral health among these asthmatic children.
·4¶
Review of Literature
S
erra Batlles J, Plaza V, Morejon E, Comella A, Brugues J. (1998)4 conducted study on “Costs of asthma according to the degree of
severity”. Authors stated that an increase in asthma-related morbidity and mortality has been reported, resulting in a substantial increase in the economic impact of this condition. Little information is available relating to the costs of asthma depending on the degree of severity of the disease. Total, direct and indirect costs generated by asthma patients who sought medical care for asthma control over a one-year period in a northern area of Spain were determined. Data were obtained from the patients themselves and severity of illness was classified into mild, moderate and severe according to the International Consensus Report on Diagnosis and Treatment of Asthma, 1992.Authors concluded that the average total annual asthma-derived cost was estimated at US$2,879 per patient, with averages of US$1,336 in mildly asthmatic patients, US$2,407 in moderate asthma and US$6,393 in severe asthma. At all levels of severity, indirect costs were twice as high as direct costs, and at the same degree of severity, direct costs due to medication and hospitalization were higher among females than males. A minority of severe asthmatics incurred some 41% of the total costs. The cost of asthma was surprisingly high and varied substantially depending on the degree of severity of the disease.
·5¶
Review of Literature
Von Mutius E (2000)2 Conducted study on “the burden of childhood asthma” Author Stated that Paediatric asthma is a major clinical concern worldwide and represents a huge burden on family and society. It accounts for a large number of lost school days and may deprive the child of both academic achievement and social interaction. Childhood asthma also places strain on healthcare resources as a result of doctor and hospital visits and the cost of treatment. Author concluded that prevalence of asthma varies worldwide, possibly because of different exposure to respiratory infection, indoor and outdoor pollution, and diet. Certain risk factors appear to predispose children to developing asthma and atopic disease, including incidence and severity of wheezing, atopy, maternal smoking, and number of fever episodes. Haby MM, Peat JK, Marks GB, Woolcock AJ, Leeder SR (2001)35 conducted study on “Asthma in preschool children: prevalence and risk factors”. Authors stated that the prevalence of asthma in children has increased in many countries over recent years. To plan effective interventions to reverse this trend we need a better understanding of the risk factors for asthma in early life. This study was undertaken by the authors to measure the prevalence of, and risk factors for, asthma in preschool children. Parents of children aged 3–5 years living in two cities (Lismore, n=383;Wagga Wagga, n=591) in New SouthWales, Australia were surveyed by questionnaire to ascertain the presence of asthma and various proposed risk factors for asthma in their ·6¶
Review of Literature
children. Recent asthma was defined as ever having been diagnosed with asthma and having cough or wheeze in the last 12 months and having used an asthma medication in the last 12 months. Atopy was measured by skin prick tests to six common allergens. They concluded that the prevalence of recent asthma was 22% in Lismore and 18% in Wagga Wagga. Factors which increased the risk of recent asthma were: atopy (odds ratio (OR) 2.35, 95% CI 1.49 to 3.72), having a parent with a history of asthma (OR 2.05, 95% CI 1.34 to 3.16), having had a serious respiratory infection in the first 2 years of life (OR 1.93, 95% CI 1.25 to 2.99), and a high dietary intake of polyunsaturated fats (OR 2.03, 95% CI 1.15 to 3.60). Breast feeding (OR 0.41, 95% CI 0.22 to 0.74) and having three or more older siblings (OR 0.16, 95% CI 0.04 to 0.71) decreased the risk of recent asthma. Authors concluded that of the factors tested, those that have the greatest potential to be modified to reduce the risk of asthma are breast feeding and consumption of polyunsaturated fats. Shulman J.D, S.E. Taylor S.E, Nunn M.E (2001)23 conducted study on “the Association between Asthma and Dental Caries in Children and Adolescents: A Population-Based Case-Control Study”. Authors explored the potential association between childhood asthma and caries using oral examination and health interview data from the Third National Health and Nutrition Examination Survey 1988–1994 (NHANES III). They fitted GEE Poisson regression models with adjustment for parents’ income, gender, race, exposure to potentially xerostomic drugs, and the presence of pit and fissure ·7¶
Review of Literature
sealants. There was no association between the use of drugs commonly used by asthmatics (antihistamines, corticosteroids, and antiasthmatic inhalers) and df/DMF scores. Asthmatic children 4–10 years of age at all severity levels had similar dfs scores to the controls, however, severely asthmatic children 4–10 years of age had significantly lower DMFS (p = 0.010) and DMFT (0.049) scores than controls. Similarly, severely asthmatic children 11–16 years of age had significantly lower DMFT scores than controls (p = 0.024) and DMFS scores approaching statistical significance (p = 0.053). Author’s analysis adjusted for covariates, potential confounders such as fluoride intake from water, diet, use of topical fluorides, and dose of anti-asthmatic medication could not be primarily in younger children with no evidence of an association between asthma and addressed. They concluded that that any association between asthma and dental caries may occur dental caries as children mature. AL DLAIGA I Y H, SHAW L, SMITH A J (2002)36 conducted study to assess and compare the prevalence of dental erosion and dietary intake between three groups of children; children with asthma, those with significant tooth erosion but with no history of asthma and or other medical problems. Secondly, to discover whether there was a relationship between medical history and dietary practises of these children and the levels of dental erosion. Thirdly, to measure and compare their salivary flow rates, pH and buffering capacity. The study consisted of 3 groups of children aged 11-18 years attending Birmingham Dental Hospital: 20 children with asthma requiring long-term ·8¶
Review of Literature
medication, 20 children referred with dental erosion, and 20 children in the age and sex matched control group. Tooth wear was recorded using a modification of the tooth wear index (TWI) of Smith and Knight. Data on the medical and dietary history were obtained from a self-reported questionnaire supplemented by a structured interview. The salivary samples were collected under standard methods for measurements. Author found that fifty percent of the children in the control group had low erosion and 50% moderate erosion. However, high levels were recorded in 35% of children in the asthma group and 65% in the erosion group. There appeared to be no overall differences in diet between the groups. There was an association between dental erosion and the consumption of soft drinks, carbonated beverages and fresh fruit in all, the three groups. More variables related to erosion were found in the erosion and asthma groups. A comparison between the three groups showed no significant differences in unstimulated and stimulated salivary flow rates, or pH and buffering capacity. Author concluded that there were significant differences in the prevalence of erosion between the three groups. Children with asthma having a higher prevalence than the control group. Paramesh H (2002)37 conducted study on “Epidemiology of asthma in India”. Author stated that allergic respiratory disorders, in particular asthma are increasing in prevalence, which is a global phenomenon. Even though genetic predisposition is one of the factors in children for the increased prevalence urbanisation, air pollution and environmental tobacco smoke contribute more ·9¶
Review of Literature
significantly. He stated that hospital based study on 20,000 children under the age of 18 years from 1979, 1984, 1989, 1994 and 1999 in the city of Bangalore showed a prevalence of 9%, 10.5%, 18.5%, 24.5% and 29.5% respectively. The increased prevalence correlated well with demographic changes of the city. Further to the hospital study, a school survey in 12 schools on 6550 children in the age group of 6 to 15 years was undertaken for Prevalence of asthma and children were categorized into three groups depending upon the geographical situation of the school in relation to vehicular traffic and the socioeconomic group of children. Author concluded that Group I-Children from schools of heavy traffic area showed prevalence of 19.34%, Group I I-Children from heavy traffic region and low socioeconomic population had 31.14% and Group Ill-Children from low traffic area school had 11.15% respectively. (P: I & II; II & III s vuqefr iznku djsaA
fnukad
ANNEXURE-2 ORAL HEALTH STATUS AND TREATMENT NEEDS OF ASTHMATIC CHILDREN OF AGE 6-12 YEARS OF LUCKNOW CITY SURVEY FORM GENERAL INFORMATION 1. FORM NO…………………………..
2. DATE: …………………….
3. NAME …………………………..
4. AGE: ……………………....
5. GENDER
`
M
F
6. EDUCATION 7.ADDRESS…………………………………………………………………………… ……………………….………………………………………………………………… PERSONAL INFORMATION 8. ORAL HYGIENE PRACTICES. x Type of cleaning:
●
Material used:
1) Brush
1) Tooth Paste
2) Finger
2) Tooth Powder
3)
3)
Stick
4) Any other
Charcoal
4) Sand/ Brick
x Frequency of cleaning / brushing: 1) Once 2) Twice 3) Thrice 9. HABITS RELATED TO ORAL CAVITY. x x x x x
Mouth breathing Thumb sucking Tongue thrusting Bruxism Lip biting / nail biting / pencil biting
10. ADVERSE HABITS (if any) --------------------------------------------------------------
11. DIETARY PATTERN ¾ Sugar consumption (per day) – x Frequency 1) 2) 3) 4)
● Form & Consistency
Once Twice Thrice More than thrice
1) Solid 2) Liquid 3) Sticky 4) Non-sticky
12. HISTORY OF ASTHMATIC MEDICATION a. Duration of Asthma x
1 year
x
More than 1 year
b. Type of medicate x
Beta 2 adrenoceptor agonists
x
Steroids
x
Both
c. Type of systemic medication x
Tablets
x
Syringes / suspensions
x
Both
d. Route of administration x
Systemic medication
x
Metered dose inhalers
x
Nebulizers
x
Systemic medications and metered dose inhalers
x
Systemic medication and nebulizers
e. History of dryness of mouth f. History of Dental visits x
Occasionally
x
Frequently
x
Never
Yes / No
CLINICAL ASSESSMENT 13. W.H.O. ORAL HEALTH ASSESSMENT FORM (1997) DENTITION STATUS AND TREATMENT NEED
18
17
16
48
47
46
55
54
53
52
51
61
62
63
64
65
15
14
13
12
11
21
22
23
24
25
85
84
83
82
81
71
72
73
74
75
45
44
43
42
41
31
32
33
34
35
26
27
28
36
37
38
Crown Root
Crown Root
Primary Teeth Crown A B
Permanent teeth Crown/Root 0 0 1 1
C D E
2 3 4
2 3 -
-
5
-
F G
6 7
7
8
8
T 9
9
T -
STATUS Sound Decayed Filled, with decay Filled, no decay Missing, as a result Of caries Missing, any other reason Fissure sealant Bridge abutment, Special crown or Veneer/implant Unerupted tooth, (crown)/unexposed root Trauma (fracture) Not recorded
TREATMENT 0 = None P = Preventive, caries arresting care F = Fissure sealant 1 = One surface filling 2 = Two or more surface fillings 3 = Crown for any reason 4 = Veneer or laminate 5 = Pulp care and restoration 6 = Extraction 7 = Need for other care (specify)……….. 8 = Need for other care (specify)………….. 9 = Not recorded
14. SIMPLIFIED ORAL HYGIENE INDEX (OH1 -S) (John C Green & Jack R. Vermillion.; 1964) A. Debris Index – Simplified (DI – S) 16
11
26 Score Good: Fair: Poor:
46
31
36
B. Calculus Index – Simplified (CI – S) 16
11
26 Score Good:
Fair: 46
31
36
Poor:
Good: Fair:
OHI – S = DI - S + CI – S
Score
Poor: 15. GINGIVAL INDEX (Loe H. & Silness J.; 1963) DM B P 17
16 15
14
13
12
11
21
22
23
24
25 26
27
47
46 45
44
43
42
41
31
32
33
34
35 36
37
B L
Score
17. NEED FOR IMMEDIATE CARE AND REFERRAL:
INVESTIGATOR SIGNATURE
ANNEXURE-3
