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Year : 2016  |  Volume : 5  |  Issue : 1  |  Page : 17-23

Association between oral manifestations and inhaler use in asthmatic and chronic obstructive pulmonary disease patients

1 Department of Oral Pathology and Microbiology, Panineeya Dental College and Research Centre, Hyderabad, Telangana, India
2 Department of Respiratory Medicine, Deccan College of Medical Sciences, Hyderabad, Telangana, India

Date of Web Publication18-Mar-2016

Correspondence Address:
Sana Khaled
Department of Oral Pathology and Microbiology, Panineeya Dental College and Research Centre, Hyderabad - 500 060, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2277-8632.178950

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Objectives: To examine the association between oral manifestations and type, frequency and duration of inhaler usage, also type and dosage of medication used in asthmatic and chronic obstructive pulmonary disease (COPD) patients.
Materials and Methods: A cross-sectional study was conducted on 250 patients of both sexes suffering from asthma and COPD who were using inhalers. Frequency of oral manifestation seen on the tongue, buccal mucosa, teeth, periodontium, palate, floor of the mouth, lips, and xerostomia in inhaler users depending on the type of inhaler, type and dosage of medication, frequency and duration of use of inhaler were examined. Chi-square test was used for statistical analysis and P < 0.05 was considered statistically significant.
Results: Ulceration (36.6%) and candidiasis (27.1%) on the tongue were most commonly found among those who were 25-50 years old and the elderly group, respectively. The differences were not statistically significant (P = 0.081). A significant association was observed (P < 0.05) for a higher percentage of females (59.7%) with gingivitis/gingival enlargement and periodontitis in males (25.6%). The teeth were affected in all types of users but it was not statistically significant (P > 0.05). Gingivitis/gingival enlargement (53.6% and 51.5%) was almost similar but periodontitis was higher in those using >500 μg. Significant association (P < 0.05) was observed with duration <1 year; oral manifestations seen were taste alterations (53.2%) in tongue, ulcerations (63.6%) in the buccal mucosa, teeth affected (87%), gingivitis/gingival enlargement (66.2%), and xerostomia (89.6%).
Conclusions: As asthmatics and COPD patients are at a higher risk of developing oral diseases during inhalation therapy, it is necessary to educate patients on proper oral health care and maintenance.

Keywords: Asthma, chronic obstructive pulmonary disease (COPD), inhalers, medication, oral manifestations

How to cite this article:
Ayinampudi BK, Gannepalli A, Pacha VB, Kumar JV, Khaled S, Naveed MA. Association between oral manifestations and inhaler use in asthmatic and chronic obstructive pulmonary disease patients . J NTR Univ Health Sci 2016;5:17-23

How to cite this URL:
Ayinampudi BK, Gannepalli A, Pacha VB, Kumar JV, Khaled S, Naveed MA. Association between oral manifestations and inhaler use in asthmatic and chronic obstructive pulmonary disease patients . J NTR Univ Health Sci [serial online] 2016 [cited 2022 Aug 12];5:17-23. Available from: https://www.jdrntruhs.org/text.asp?2016/5/1/17/178950

  Introduction Top

An inhaler or puffer is a medical device used for delivering medication into the body via the lungs. [1] Inhaled therapy is the commonly used treatment in respiratory diseases manifesting with airway obstruction such as asthma and chronic obstructive pulmonary disease (COPD). [2] Chronic respiratory diseases represent a major disease burden, with COPD and asthma estimated to affect 64 million and 235 million people worldwide, respectively. [3]

Asthma is a major noncommunicable disease characterized by recurrent attacks of breathlessness and wheezing, which vary in severity and frequency from person to person. [4] Asthma is a global health problem affecting around 300 million individuals of all ages, ethnic groups, and countries. It is estimated that around 250,000 people die prematurely each year as a result of asthma. The concepts of asthma severity and control are important in evaluating patients and their responses to treatment as well as for public health, registries, and research (clinical trials, epidemiologic, genetic, and mechanistic studies). [4]

COPD is a lung ailment that is characterized by a persistent blockage of airflow from the lungs. [2] In the latest estimates, COPD was the fourth leading cause of death in 2004, causing around three million deaths or 5.1% of all deaths in the world; in 2030, COPD is projected to become the third leading cause, with 5.8 million or 8.6% of total deaths. [3] Asthma morbidity and mortality account for around 1% of all disability-adjusted life years (DALYs), equivalent to 16 million DALYs lost per year worldwide. [3]

The following are different types of inhalers, which are used for medication purposes: [5],[6]

Metered-dose inhalers (MDIs)

The most common type of inhaler in this category is the pressurized MDIs. In MDIs, medication is most commonly stored in solution in a pressurized canister that contains a propellant. The MDI canister is attached to a plastic, hand-operated actuator. On activation, the MDI releases a fixed dose of medication in aerosol form. The correct procedure for using an MDI is to first fully exhale, place the mouthpiece of the device into the mouth, just start to inhale at a moderate rate, and depress the canister to release the medicine. The aerosolized medication is drawn into the lungs by continuing to inhale deeply before holding the breath for 10 seconds to allow the aerosol to settle on the walls of the bronchial and other airways of the lung.

Dry powder inhalers (DPI)

These inhalers do not contain the pressurised inactive gas to propel the medicine. Patient have to push the canister to release a dose and dose is triggered by breathing in at the mouthpiece.


This type of inhalers supply the medication as an aerosol created from an aqueous formulation. It is used along with a face mask or mouthpiece.

Inhaler with spacer devices

Spacer devices are used with pressurized MDIs. The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed. A valve at the mouth end ensures that the drug is kept within the spacer until one breathes in. When one breathes out, the valve closes. A face mask can be fitted on to some types of spacers instead of a mouthpiece. Drugs (medicines) used inside inhalers go straight into the airways when the person breathes in. The airways and lungs are treated but little of the drug gets into the rest of the body.

In the treatment of asthma and COPD, the drugs inside inhalers can be classified into three groups.

Reliever inhalers

These contain bronchodilator drugs. The drug in a reliever inhaler relaxes the muscle in the airways. This opens the airways wider and the symptoms usually quickly ease. These drugs are called bronchodilators as they dilate (widen) the bronchi (airways). The two main reliever drugs are salbutamol and terbutaline. There are different inhaler devices that deliver the same reliever drug. If the symptoms appear every now and then, then the occasional use of a reliever inhaler is indicated.

Preventer inhalers

These usually contain steroid drugs. These are taken every day to prevent the symptoms from developing. The type of drug commonly used in preventer inhalers is steroid. Steroids work by reducing the inflammation in the airways. When the inflammation has gone, the airways are much less likely to become narrow and cause symptoms such as wheezing. Steroid inhalers are usually taken twice per day. In cases of exacerbation (flare-up) of one's asthma or COPD symptoms, preventer inhaler is more often indicated. The main inhaled steroid preventer medications are: Beclometasone, budesonide, ciclesonide, fluticasone, and mometasone.

Long-acting bronchodilator inhalers

The drugs in these inhalers work in way similar to relievers but work for up to 12 h after taking each dose. A long-acting bronchodilator may be advised in addition to a steroid inhaler if the symptoms are not fully controlled by the steroid inhaler alone. Examples of combination inhalers are: Fostair (formoterol and beclometasone), Seretide (salmeterol and fluticasone), and Symbicort (formoterol and budesonide).

Recent researches have proven that the type of inhaler, high dosage of medication, frequency, and long duration of inhalation therapy have been closely linked with several adverse effects on the oral tissues. [7] Therefore, the present study was conducted to assess the oral manifestations in inhaler users.

  Materials and methods Top

In the present cross-sectional study, 250 adult asthmatic and COPD patients reporting to the Princess Esra Hospital, Hyderabad, Telangana, India using an inhaler without any other comorbidities and also not using any other medications were considered. The study protocol was reviewed by the Ethical Committee of Panineeya Dental College and Research Centre, Hyderabad, Telangana, India and was granted ethical clearance. Official permissions were obtained from the Princess Esra Hospital.

General information such as age, gender, type, frequency and duration of inhaler usage, also type and dosage of medication were noted. The patients were divided into the following three age groups: Group I-less than 25 years, Group II-25-50 years, and Group III-above 50 years. The types of inhalers used were MDI, DPI, inhaler with spacer and nebulizer. The types of medication mostly used in inhalers were fluticasone, budesonide, and salbutamol. Dosage of medication used was either less than 500 μg or above it. Frequency of per day usage of inhaler was considered as once a day (OD), twice a day (BD), or thrice a day (TD). Duration of use of inhaler was also taken into account and was classified in four following categories: Less than 1 year, 1-10 years, 11-20 years, and above 20 years.

The clinical examination was carried out by the well-trained and calibrated examiner (AMM) according to Type III examination of the World Health Organization (WHO) Oral Health Survey Basic Methods (WHO 1997). [8] Sterile and disposable ice-cream wooden sticks, mouth mirrors, explorers, and a normal (incandescent) head-mounted light were used for examination. All the standard precautions and infection control techniques were followed during the study. The oral manifestations observed on the tongue, buccal mucosa, teeth, periodontium, palate, floor of the mouth, lips, and xerostomia in inhaler users were considered.

On the tongue, the oral manifestations considered were candidiasis, ulcerations, depapillation, taste alterations, and other tongue lesions (petechiae, median rhomboid glossitis, and pigmentation). In the buccal mucosa, pigmentation and ulcerations were seen. Periodontal diseases considered were gingivitis or gingival enlargement, gingival pigmentation, and periodontitis. Presence of xerostomia and teeth affected with dental caries, abrasion, erosion, and recession were also observed. Other oral lesions included were the lesions seen on the palate, lips, and the floor of the mouth.

The recorded data were compiled and entered in a spreadsheet computer program (Microsoft Excel 2007) and then exported to SPSS version 14 (SPSS Inc., Chicago, IL, USA) for analysis. Chi-square test, stepwise multiple linear, and logistic regression were used for statistical analysis. Statistical significance was set at <0.05 level.

  Results Top

In our study, oral manifestations when analyzed for different age groups and both genders of patients [Table 1] showed that ulceration (36.6%) on the tongue was most commonly found in those among 25-50 years old followed by 35% in Group I. Candidiasis (27.1%) was most frequently examined in the elderly group. The differences were not statistically significant (P = 0.081). On the buccal mucosa, ulceration was the major oral manifestation in Group I (80%) and Group III (70.1%) patients. In the elderly group, around 86.9% of the persons' teeth were affected; their periodontium involvement included gingivitis/gingival enlargement (47.7%) and periodontitis (31.8%). A majority (65.4%) were also found positive for xerostomia. The above differences are statistically significant (P < 0.05).
Table 1: Association of oral manifestations with the age and gender of the patients

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In relation to sex, lesions on the tongue mainly involved candidiasis and ulcerations (28.1%) among males and ulceration (34.1%) among females. On the buccal mucosa, the ulcerations were more in males (65.3%) than in females (57.4%). A significant association was observed (P < 0.05) for a higher percentage of females (59.7%) with gingivitis/gingival enlargement and periodontitis in males (25.6%).

Oral manifestations with regard to the types of inhalers and types of medication used are reported in [Table 2]. Ulceration on the tongue and buccal mucosa were commonly observed in all types of inhalers though (66.7%) and (100%) were found in those using inhaler with spacer. Candidiasis was the next common observation among MDI (25.9%) and nebulizer (25%) users.
Table 2: Association of oral manifestations with type of inhaler and type of medication used

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The teeth were affected in all the users but it was not statistically significant (P > 0.05). Periodontitis was common among those using inhalers with spacer (33.3%) and nebulizers (37.5%) and the difference was statistically significant (P < 0.05). The percentages of xerostomia (64.5%) and other oral lesions (45.2%) were higher among those with DPI type of inhalers.

According to the type of medication used, budesonide was found to be commonly associated with candidiasis (41.9%) and ulcerations (35.5%) on the tongue. This observation was statistically significant (P < 0.05). Salbutamol users were found to have ulcerations (73%) on the buccal mucosa and also gingivitis (59.5%). Fluticasone users were affected with periodontitis (19.8%) and xerostomia (62.6%).

Oral manifestations were associated with the dosage of medication and frequency of inhaler use. No statistical significance was observed with the dosage and lesions as the occurrence was similar in both the groups. The most common oral manifestations seen were ulceration (41.1%) and candidiasis (27.3%) on the tongue. Gingivitis/gingival enlargement (53.6% and 51.5% in Group I and Group III, respectively) was almost similar but periodontitis was higher in those using >500 μg [Table 3].
Table 3: Association of oral manifestations with dosage of medication and frequency of inhaler usage

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Those reporting frequent usage (thrice daily) were found with ulceration (33.3%), candidiasis (26.7%), and other lesions like pigmentation, median rhomboid glossitis, and petechaie (40%) on the tongue. Ulceration was also seen on the buccal mucosa irrespective of the frequency and the above differences were statistically significant (P < 0.05). Affected teeth (56.3%), gingivitis/gingival enlargement (62.5%), and xerostomia (68.8%) were seen in those who were once users.

A significant association (P < 0.05) was observed between the oral manifestations and duration of the use of inhaler [Table 4]. With the duration <1year, the oral manifestations seen were taste alterations (53.2%) in the tongue, ulcerations (63.6%) in the buccal mucosa, teeth affected (87%), gingivitis/gingival enlargement (66.2%), and xerostomia (89.6%). When used for a span of 1-10 years, inhalers show ulcerations (39.3%) in the tongue, ulcerations (62.7%) in the buccal mucosa, affected teeth (66%), and gingivitis/gingival enlargement (45.3%). With the use of inhaler for 11-20 years, oral manifestations were other lesions (47.1%) in the tongue, ulcerations (41.2%) in the buccal mucosa, affected teeth (70.6%), gingivitis/gingival enlargement (47.1%), and xerostomia (58.8%). When the use of inhaler was for more than 20 years, the oral manifestations seen were candidiasis and depapillation (50%) in the tongue, ulcerations and pigmentation (50%) in the buccal mucosa, affected teeth (100%), gingivitis/gingival enlargement and periodontitis (50%), xerostomia (83.3%), and other oral lesions (66.7%).
Table 4: Association of oral manifestations with the duration of inhaler usage

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  Discussion Top

Oral manifestations are very common with the use of inhalers and they are directly associated with doses, frequency, duration of medication, and inhaler use. [7],[9] Oral findings found to be associated with inhaler users were the same irrespective of age and gender. However, the dosage of medication and type, frequency, and duration of inhalers showed similar findings with time and severe manifestations were observed. [10],[11],[12],[13],[14]

Ulcerations are seen associated with the tongue and buccal mucosa occasionally on the gingiva due to xerostomia and immune suppression caused by inhaled drugs. [15],[16] Candidiasis was also very common among inhaler users and the reason attributed was generalized immunosuppressive and anti-inflammatory effects of steroids, which cause low salivary flow rate and higher salivary glucose concentration that could promote growth and proliferation of Candida. [17],[18] Xerostomia was also seen due to use of inhaled immunosuppressants and it also causes burning sensation, taste alterations, or sore mouth. [19] Periodontium was affected in severe cases like gingivitis/gingival enlargement/ periodontitis, which was due to decrease in salivary protection owing to the reduction in salivary flow and concentration of secretory immunoglobin A (IgA) or dehydration of alveolar mucosa due to mouth breathing that causes alteration of immune response and increase concentration of immunoglobin E (IgE) in the gingival tissue, which leads to higher incidence of calculus due to increased levels of calcium and phosphorous in the saliva and also causes decrease in bone mineral density associated with inhaled corticosteroids. [20],[21] Dental caries is due to decreased salivary flow rate due to inhaled drugs, which cause an increase in food retention on teeth and increased lactobacilli and Streptococcus mutans count and decrease in salivary and plaque pH. [14],[22],[23],[24],[25],[26] Dental erosion is due to reduction in the buffering capacity and salivary flow rate due to inhaled drugs. [22],[23],[27],[28]

  Conclusion Top

Inhalers are used as the main course of treatment for asthma and COPD. As only 10-20% of the dose reaches the lung while the rest is retained in oral cavity and oropharynx, it interferes with the normal oral tissues and causes adverse effects of the inhalation therapy that can lead to deleterious consequences in the absence of intervention on oral tissues. The intensity and frequency of oral diseases occuring in inhalers users are dependent on the effects of the drugs used in inhalers, type, frequency of use, duration of use of inhalers and dosage of medication. Several oral conditions such as dental caries, dental erosion, candidiasis, ulceration, gingivitis, gingival enlargement, pigmentation, median rhomboid glossitis, periodontitis, xerostomia, and taste alterations have been majorly associated with inhalation therapy. With the high prevalence of chronic respiratory diseases, proper optimal oral care to the individuals receiving inhalation therapy is needed.

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  [Table 1], [Table 2], [Table 3], [Table 4]

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