Posted by: Indonesian Children | April 15, 2010

Caries is Associated with Asthma and Epilepsy

PMCID: PMC2761161

Eur J Dent. 2009 October; 3(4): 297–303.

Copyright 2009 European Journal of Dentistry. All rights reserved.

Caries is Associated with Asthma and Epilepsy

Ida Anjomshoaa,a Margaret E. Cooper,b and Alexandre R. Vieiraa

a Department of Oral Biology, School of Dental Medicine, University of Pittsburgh, PA, USAb Department of Oral Biology, Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, PA, USA

Corresponding author: Alexandre R. Vieira, 614 Salk Hall, Department of Oral Biology, School of Dental Medicine, University of Pittsburgh, 3501 Terrace Street, Pittsburgh, 15261, PA, USA., Phone: (412) 383-8972, Fax: (412) 624-3080,



There is evidence of association between systemic diseases and oral conditions, although it is not clear if these are direct or mediated by underlying factors such as health behaviors. The aim of this work was to evaluate whether self-reported systemic diseases were associated with caries experience.
Medical history data and caries experience (DMFT and DMFS; Decayed, Missing due to caries, Filled Teeth/Surface) were obtained from the University of Pittsburgh School of Dental Medicine Dental Registry and DNA Repository. Information on 318 subjects (175 females and 143 males) was evaluated. Regression analysis was used to test for association between caries experience and disease status.
The stronger associations were found between caries experience and asthma and epilepsy. With respect to asthma, DMFT above 15 (R2 = 0.04) and DMFS above 50 (R2 = 0.02) were associated. After controlling for gender differences in asthma, the associations remained strong (R2 = 0.05 for both DMFT and DMFS). For epilepsy, DMFT above 15 (R2 = 0.18) and DMFS above 50 (R2 = 0.14) were associated.
Asthma and epilepsy are associated with higher caries experience.
Keywords: Caries, Asthma, Epilepsy, Cardiovascular Diseases, Diabetes
Over the last decade, the possible role of oral health as a risk factor for systemic disease has been highlighted in multiple instances. On one hand, it is suggested that every individual should visit her/his dentist at least once a year.1 However, poor and minority individuals, who experience greater levels of both dental and systemic disease, frequently face cost and other system-level barriers to obtain care in the private practice dental delivery system.24 For these individuals, non-traditional sources of dental care, such as physician offices, other medical settings, and the hospital emergency room, have been alternative options.5 On the other hand, according to a cross-sectional, random digit telephone survey which was sponsored by the CDC and all U.S. states and territories in 2003,6 although periodic medical examinations of healthy individuals aiming to foster patients’ good health is proposed,7 only 2.6% of 97,001 healthy adults reported have received primary prevention.
Whereas issues related to access to care need to be addressed, dentistry has an important role in promoting the overall health. While physicians are missing opportunities to provide primary prevention, the promotion of oral health has been suggested as a way to promote systemic health, since there is a possible role of oral infections as a risk factor for systemic disease. Caries remains the most prevalent non-transmissible infectious disease in the U.S. and in the rest of the world.8 Research on the relationship between caries and systemic diseases has provided evidence that caries may be associated with cardiovascular diseases,9 esophageal cancer,10 and asthma.11
A better understanding of the possible relationships between caries experience and systemic diseases may provide new insight on the influences of oral health on systemic health. Our goal was to study a high risk population to investigate if caries experience indicators are associated with concomitant systemic disease.
Here we report analysis of a high risk population for oral and systemic diseases from Pittsburgh and provide data that supports an association between caries experience and specific systemic diseases, namely asthma and epilepsy. Pittsburgh is the largest city in the Appalachian region of the United States, and one of the poorest in the country. Pittsburgh has had fluoridated water since 1953, however, nearly half of the children in Pittsburgh between six and eight have had cavities according to a 2002 State Department of Health report.12 More than 70% of 15-year-olds in the city have had cavities, the highest percentage in the state. Close to 30% of the city’s children have untreated cavities. That is more than double the state average of 14%.
Medication intake is also shown to influence caries experience and can be viewed as an indicator of access to health care and overall wellbeing. In our population, 48% of those 48 individuals with asthma and 34% of those 108 with CVD were not on prescription medications. Only 23% of the 13 epileptics and only 15% of the 20 diabetics were not receiving medication.
There were no significant ethnic differences in those without medication (P>.20 for those with diabetes, CVD, epilepsy and asthma).
Asthma is one of the most common chronic medical ailments in children and its frequency has steadily increased in the last two decades.13,14 A number of studies have investigated oral health in individuals with asthma, but the results are conflicting. Whereas several studies suggested asthmatic children have higher indexes of caries,11,1523 some studies did not find this same correlation.2427 Individuals with asthma appear to accumulate higher amounts of dental biofilm, as well as present with higher salivary levels of mutans streptococci.23 β2 agonists cause decreased saliva secretion rate and patients taking these medications have increased levels of lactobacilli and mutans streptococci.15,16 Although it is possible that medication intake increases susceptibility for caries, our data does not suggest that medications are associated with higher caries experience in asthmatics. Genes in the immune signaling pathway are differentially expressed in asthmatic individuals28 and could underlie the association between asthma and high caries experience. One of these genes is CD-14, which is described as a classical example of gene-environment interactive factor in asthma.29 Variation in CD-14 has been also associated with resistance to abscess or fistula formation in children with four or more caries lesions.30 Immune response regulators may be the common factors that underlie the association between asthma and caries.
Asthma is unlikely to be a single disease but rather a series of complex, overlapping individual diseases or phenotypes, each defined by its unique interaction between genetic and environmental factors. These conditions include syndromes characterized by allergen-exacerbated, non-allergic, and aspirin-exacerbated factors along with syndromes best distinguished by their pathologic findings (eosinophilic, neutrophilic, pauci-granulocytic), response to therapy (corticosteroid resistant), and natural history (remodeling prone).31 The data available for this study is from self-reported medical history and none of the detailed descriptions listed above were available. Allergic sensitization can be detected by a positive skin test result to at least one common allergen in 93.5% of cases with severe asthma.32 Non-allergic asthma has a more likely onset during adulthood, female predominance, and a higher degree of severity.33 This is interesting since our results suggest that asthmatic females have a slightly higher caries experience (asthmatic females DMFT=18.79 versus asthmatic males DMFT=17.33) although in our study females in general did not (female DMFT=15.29 versus males DMFT=15.42). Females in general have higher caries experience,34 and caries contributing genetics factors in the X chromosome have been suggested by our group.3537 Our future investigations aim to identify the genetic factors contributing to caries and how they modulate disease.
Our work also suggests epileptic individuals have a higher caries experience. A Finnish study with 60 females ages 8–18 years and matched controls suggested that caries lesions would be present sooner after eruption of upper first and second molars, and central incisors of epileptic girls.38 The authors speculated that factors related to epilepsy, in particular its medication, might increase the risk of caries. However, a previous study compared two groups of epileptic children 8–14 years, one being treated with sodium valproate for one to four years and the other recently diagnosed and had never received the drug. No differences in caries prevalence, oral hygiene state, salivary secretion rate, salivary buffer capacity, and lactobacillus count was found.39 Further investigations are warranted aiming to understand the possible relationship between caries experience and epilepsy.
With respect to cardiovascular diseases, our results are in agreement with recent work that suggests that caries and cardiovascular diseases are mostly explained by confounding factors.40 In our data, age above 43 years is the best indicator of cardiovascular diseases, a result that is obviously expected. A link between active root caries and cardiac arrhythmias may exist in individuals older than 80 years9 but our study is not enriched by individuals that old and this possible association would be easily missed by us. Similarly, diabetes is associated with older age.41 Our data does not suggest that cardiovascular diseases and diabetes are associated with higher caries experience.
This study has several weaknesses that deserve consideration. Caries data was extracted from clinical patient records and, although we can assume a good level of standardization in the description of the presence of caries lesions, fillings, and extracted teeth due to the fact that the records belong to the same educational institution that follows a single philosophy, still the data can be influenced by variation in the way caries is described. The definitions of systemic diseases we used, although in general are comprehensive, are based on self-reported information, and may lack, in some instances, precision. Regarding the DMFT and DMFS scores, one can argue that they may be inflated in adults by the inherent deficiencies of restorative materials and techniques. In addition, failed fillings are relatively common and replaced with larger ones encroaching on more surfaces. Common periodontal and prosthetic reasons for tooth removal, and simple economic choices also can inflate caries scores. Although, we considered these factors when extracting the caries data, the data could still have been influenced by these variables. We did additional modeling just using the number of decayed teeth and the results did not considerable change (data not shown), which may partially suggest that the caries experience data we are using is not heavily influenced by the variables just described above. Caries incidence rates and years of systemic disease experience would have been more desirable measures but this kind of data was not possible to be extrapolated from the majority of individuals studied.
Although our study is based on self-reported medical history, and therefore cannot access in more detail the specific types of the conditions the subject reported, we had the advantage of studying a group at higher risk for systemic diseases and with very high caries experience. This factor likely decreased heterogeneity and improved our ability to find associations. In summary, we report here that asthma and epilepsy are associated with high caries experience in adults. These results are significant because they suggest that individuals suffering from asthma or epilepsy should receive more individualized attention regarding caries prevention.
  • Asthma is associated with higher caries experience, particularly in females.
  • Epilepsy is associated with higher caries experience.
  • Caries experience appears to not increase in individuals with cardiovascular diseases or diabetes.
The authors are indebted to the individuals that participated in this study. Data for this study was provided by the Dental Registry and DNA Repository of the School of Dental Medicine, University of Pittsburgh. Financial support was provided by the School of Dental Medicine, University of Pittsburgh. IA was supported by the CTSI START UP program, the short term pre-doctoral award through the Clinical and Translational Science Institute and the Institute for Clinical Research Education at the University of Pittsburgh (NIH Grant 5TL1RR024155-02).
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