Oral health related habits, knowledge and attittude in children with asthma

Summary Introduction The aim of this research was to determine oral hygiene related habits, knowledge and behavior in children with asthma compared to healthy children. Methodology This study included 136 children, between 6 to 16 years of age, divided into the two groups. The first group included children with asthma (study group - SG), while the second included healthy children (control group - CG). A questionnaire containing three groups of questions related to oral-hygiene and dietery habits as well as oral health related behaviour in children was prepared. Results The percentage of children from SG that brush teeth several times a day was 60.2% compared to 77.2% of CG children (p<0.05). 19.1% of SG group children versus 38.2% of CG children brush their teeth longer than 2 minutes (p<0.05). There was no significant difference in the level of knowledge about plaque impact on oral health between the two groups (p>0.05). More than half (52.9%) of CG respondents regularly visit dentist, while 50.0% of SG goes regularly (p<0.01). 51.5% of CG children visit the pediatric dentist due to preventive reasons, while SG children goes mainly due to rehabilitation of teeth (42.6%). The fear of dental procedures is more pronounced in SG compared to CG children (p<0.001). Conclusion Oral hygiene related habits and oral health behavior were worse in children with asthma, while no difference was found in relation to the knowledge among the observed groups.


INTRODUCTION
Asthma is chronic inflammatory disease of airways, which usually begins in childhood. Once exposed to certain stimuli, airways narrow due to muscle spasm, mucus plugs and swelling of mucous membranes causing limited airflow [1]. It is one of the leading causes of hospitalization in children age.
Asthma treatment aims either to alleviate symptoms or to exhibit antiinflamatory effect. Literature data indicate [2] that some of anti-asthmatic medications affect the composition and the amount of saliva and therefore expose affected persons to increased risk of caries, tooth erosions, increased prevalence of oral mucosa changes, gingivitis, periodontitis, orophageal candidiasis and orofacial irregularities [2]. Therefore, children with asthma require greater attention because they can be considered risky group for developing oral diseases.
Due to oral hygiene importance in childhood many studies have addressed risk factors that can lead to oral diseases. Based on numerous epidemiological studies it has been recognised that parents' oral health related hab-its as well as their lifestyle, are transmitted to children and thus directly and indirectly affect the occurrence of tooth decay [3].
The fear of dental procedures affects large number of people, regardless of age, gender, physical and mental maturity, level of education, economic status, occupation and in children specifically, parents approach towards dental treatment [4,5]. "Fear of dentist" is the most common reason for avoiding treatment, causing the absence of adequate dental care, which may lead to deterioration of oral health [5,6].
Patients that have asthma are risk patients in dental office as dental stress and strong smell can cause asthmatic attack. Also, due to close proximity of the upper respiratory tract, patients with chronic respiratory problems such as asthma represent risk patients in dentistry. Acute asthma attacks may be one of the factors that increase fear of dental visits as well as affect oral health related behavioral model of asthmatic children.
The aim of this study is to investigate oral hygiene related habits, knowledge and behavior of children with asthma compared to healthy children.

MATERIALS AND METHODS
The research was conducted at the Department of Dentistry, Faculty of Medicine, University of East Sarajevo, according to the recommendations of the Helsinki Declaration and principles of Good Clinical Practice. Parents and children were informed about the purpose of research, and approval for participation was obtained.
This cross sectional study included children between 6 to 16 years of age (10.49 ± 3.28). A total of 136 children were divided into the two groups. Study group (SG) (n = 68) consisted of children with asthma symptoms. The control group (CG) (n = 68) included healthy children. Asthma diagnosis was established by a competent pediatrician or family medicine physician based on the following criteria: existence of typical asthma symptoms, spirometry findings, reaction to asthma medication (reversibility of obstruction), allergy existence, positive family history and absence of other conditions that may give similar symptoms or signs [1].The study was designed in a way that children from the control group corresponded by gender and age to children from the study group.
For the purpose of this study a questionnaire was created and included three groups of questions: about oral hygiene and dietary related habits, oral health knowledge and established behavioral habits related to dental visits.
Obtained data were processed through standard statistical procedures using statistical program SPSS 19.0 for Windows. To test differences between genders and education level of parents, χ2 test was used. Values of p <0.05 were considered statistically significant.

RESULTS
Asthma was more frequently diagnosed in boys (77.9%) compared to girls (22.1%) (p<0.05) (Figure1). High (18.4%) and secondary education (31.6%) were more prevalent among mothers of children in the CG, compared to primary (4.2%) or secondary education (39.7%) of mothers of SG children (p<0.05) ( Figure 2). The difference was not observed in relation to the level of education of fathers in these two groups (p>0.05).
Almost 83% of SG children used only toothbrush and toothpaste for oral hygiene in comparison to the CG children that used mouthwashes (26.5%) as an adjunct to basic hygienic agents (Table 1). 60.2% of SG children brushed their teeth several times a day, while that percentage was 77.2% in the control group. Parents more frequently supervised the CG children while maintaining oral hygiene (28.0%), compared to the parents of the study group 20.6%. Almost 15% of SG group children were not supervised. Both groups consumed cariogenic food and drink, while larger percentage was observed in the study group (p>0.05). Good self-observed oral health was noted at 45.6% of children in the study and 75.0% in the control group (p<0.001) ( Table 2).
52.9% of children in the control group had frequent checkups with dentist while 50.0% of study group children occasionally went to dentist (p<0.01) ( Table 3). In-terestingly 7.4% of SG children have never been to the dentist, compared to 2.9% of children in the control group. CG children (51.5%) would visit dentist for preventive reasons while SG children most frequently (42.6%) visited dentist for dental treatment. Fear of dental interventions was more pronounced in the study group of children compared to control group (p<0.001). High percentage of SG children acquired knowledge about oral health importance from parents (55.9), while that prcentage was 61.8% in CG children (Table 3).

DISCUSSION
Literature has shown that childhood asthma is more common in boys, possibly due to physiologically narrower airways and increased muscle tone, which is lost after 10 years of age while girls are more frequently affected by teenage asthma [7]. The results of our research indicated that asthma was more common in boys.
Inadequate knowledge of parents about oral deseases in children with asthma and prevention resulted in an increased incidence of oral diseases. Based on the recent   SG -Study group; CG -Control group; AR -All respondents; N -number of respondents; P -statistical significance (Pearson Chi-Square χ2); % -percentage of the respondents SG -studijska grupa; KG -kontrolna grupa; SI -svi ispitanici; N -broj ispitanika; P -statistička značajnost (Pearson Chi-Square χ2); % -procenat ispitanika  study conducted in Croatia, parents can influence their children in terms of oral hygiene maintainance [3]. The study in Iran demonstrated that mothers who took good oral hygiene, transfer their knowledge and attitudes to their children [8]. The level of education and parents incomes influence the incidence of oral diseases [9,10]. In this study, it was observed that mothers in the study group had lower education than mothers in the control group. Proper and regular oral hygiene includes daily, often and long enough teeth brushing, as well as application of some additional hygiene methods. Children often do not understand the importance of brushing their teeth [11].
Efficient removal of dental plaque is crucial for the health of teeth and periodontal tissues. Proper habits, attitudes and behavior toward oral health are best to be established in childhood. The results of this research showed that children in the study group irregularly maintain hygiene, do not brush long enough, and mostly use toothbrush and toothpaste only. Unlike our study, research conducted in Sweden showed that there was no difference in oral hygiene maintainince habits between children with and without asthma [12]. Studies of Mazzoleni  Adequate oral hygiene of parents and supervision of children when brushing their teeth are important predictors of good oral health [15]. Supervision of children should be conducted up to 10 years of children's age, until their manual skills are sufficiently developed to properly brush teeth. The results of our study showed that children in the study group were less supervised than children from control group. One of the possible explanations for this phenomenon could be greater devotion of parents to their children's basic illness.
If everyday diet often includs sweet foods, especially between meals, combined with improper oral hygiene maintenance, there is great chance of tooth decay appearance. Analyzing the results of the current study, it was noted that children in the study group consumed more sweets or drunk sweet drinks several times a day. However, frequent consumption of candy and beverage in this group of children did not indicate statistically significant difference in relation to the control group. The results of our research are in accordance with Stensson at al. [12]. Similar eating habits were also reported in children from the experimental and control groups in the study conducted by Mazzoleni at al. in Italy [13]. On the other hand, children with asthma from Belgium consumed less sweets [14]. Higher consumption of non-alcoholic drinks rich in sugars was observed in subjects with asthma from South Australia [16], and Norway [17] compared to their healthy peers. Parents of children with asthma should be adequately educated about possible oral health problems related to food and drinks consumption, especially after inhalation, the importance of fluoride use and maintaining oral hygiene. In some countries, parents of children suffering from asthma in hospital conditions take greater care and attention to improving their children's oral hygiene habits, and thus better control of the disease [14].
Poor oral hygiene and periodontal disease may increase the incidence of lung infections in risky patients. Oral cavity has been considered a potential reservoir for respiratory infections microorganisms as dental plaque may trap respiratory pathogenic microorganisms [18]. Good oral health is important not only to prevent oral diseases but also to maintain good respiratory function. Mechanical removal of soft deposits reduces the number of gram-negative bacteria that also helps keep airways open in children with asthma [19]. Knowledge about dental plaque of all subjects from both groups in our study was poor.
Our study indicated that children with asthma understood the importance of oral health and stated their oral health was not at satisfactory level. However, they visited dentist mainly when they had a specific problem. Studies have confirmed that children who practice dental visits more frequently are better informed about mouth and teeth health [20].
Regular dental checkups should be performed at least twice a year. However, if a person has potentially higher risk of developing oral disease, as seen in asthma [2], examinations should be more frequent. The result of our questionnaire suggested that children with asthma only occasionally went to dentist. Toothache was one of the main reasons for visiting dentist [20,21,22], rarely check-up or tooth restoration. These findings are consistant with results of other studies [22,23].
Wogelius at al. in their research found more frequent presence of dental anxiety in children with asthma [24]. It was more pronounced in younger children [24]. In our study, children with asthma had greater degree of fear even just in planning their visit to the dentist, as well as possible use of dental needles that would cause dental visits delay. Delaying dental visits on the other hand would increase dental fear creating vicious circle [25].
The role of the dentist in advising parents about adequate way to apply preventative measures and preserve oral health has undeniable significance as children acquire first knowledge, attitudes or habits about oral health importance from parents [20].

CONCLUSION
Children with asthma have partially developed oral hygiene habits compared to healthy children. Also, their level of knowledge and behavior toward their own oral health is not adequate. Fear of dental interventions is one limiting factor. For successful dental treatment of children with asthma, good communication skills are important given their previous experience (being in hospital due to asthma, injection therapy, ongoing checkups). It is necessary to emphasize the importance of the first contact with dentist in the earliest age, primarily due to acquisition of positive habits, as well as introduction of preventive measures.