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Year : 2017  |  Volume : 15  |  Issue : 4  |  Page : 319-322

Association between asthma and chronic periodontitis -A Case–Control Study in Shimla-Himachal Pradesh

1 Department of Public Health Dentistry, H.P. Government Dental College and Hospital, Shimla, Himachal Pradesh, India
2 Department of Periodontology, H.P. Government Dental College and Hospital, Shimla, Himachal Pradesh, India
3 Department of Orthodontics and Dentofacial Orthopaedics, H.P. Government Dental College and Hospital, Shimla, Himachal Pradesh, India

Date of Web Publication13-Dec-2017

Correspondence Address:
Dr. Vinay Kumar Bhardwaj
Department of Public Health Dentistry, HP Government Dental College and Hospital, Shimla - 171 001, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_85_16

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Introduction: The colonization of respiratory pathogens appears to be a risk factor for lung infection in high-risk individuals. Evidences dictate a bidirectional relationship between periodontitis and asthma. Aim: The aim of this study is to explore this potential association between asthma and periodontal disease. Materials and Methods: In a case–control study the individuals were selected from patients attending asthma clinic in a hospital. Individuals consist of fifty asthmatics and fifty nonasthmatic healthy controls evaluated for plaque index (PI), gingival index (GI), papillary bleeding index (PBI), calculus index (CI), and clinical attachment level (CAL). The data were analyzed by SPSS version 16. Results: Mean PI scores was 0.649 ± 0.316 for control group in comparison to 1.168 ± 0.46 for asthmatic group. Statistically significant difference among two groups was obtained on a comparison of GI score (P = 0.0231) CI scores (0.0461) for control group. CAL was 3.817 ± 0.722 mm and 4.964 ± 0.871 mm in control group and case group, respectively. The difference of CAL for two groups was statistically highly significant (P = 0.004). Comparison of PBI of test group and control group showed significant difference Comparison of all the parameters for two subgroups (mild asthmatics and moderate-to-severe asthmatics), i.e. PI, CI, GI, and PBI was statistically significant with P value for respective scores as 0.0281, 0.04, 0.027, and 0.0162. CAL measurement for both groups was highly significant (P = 0.001). Conclusion: The present study reveals an association between the occurrence of chronic periodontitis and asthma. Both periodontal and respiratory diseases have an inflammatory nature. Parameters measured using different indices have revealed higher scores for the asthmatics than nonasthmatics.

Keywords: Asthma, chronic periodontitis, clinical attachment level, oral health

How to cite this article:
Bhardwaj VK, Fotedar S, Sharma D, Jhingta P, Negi N, Thakur AS, Vashisth S. Association between asthma and chronic periodontitis -A Case–Control Study in Shimla-Himachal Pradesh. J Indian Assoc Public Health Dent 2017;15:319-22

How to cite this URL:
Bhardwaj VK, Fotedar S, Sharma D, Jhingta P, Negi N, Thakur AS, Vashisth S. Association between asthma and chronic periodontitis -A Case–Control Study in Shimla-Himachal Pradesh. J Indian Assoc Public Health Dent [serial online] 2017 [cited 2023 Jun 8];15:319-22. Available from: https://journals.lww.com/aphd/pages/default.aspx/text.asp?2017/15/4/319/220725

  Introduction Top

A chronic respiratory infection is a constant potential source of infection and has been considered as a separate risk factor for respiratory diseases. Evidence indicates a bidirectional relationship between periodontitis and respiratory diseases.[1] The impact of periodontal infection on systemic conditions and diseases has been widely investigated in the last decades, to the point that the impact of periodontitis on a systemic level has been associated with unfavorable gestational outcomes, cardiovascular diseases, and insulin resistance, as well as respiratory tract diseases.[2],[3],[4],[5],[6]

The prevalence of bronchial asthma in a study conducted in Himachal Pradesh was found to be 2.3%.[7] The prevalence of asthma has been increasing across all age, gender, and racial groups and is found to be higher among children than adults.[2] Many cells and cellular elements play a role in asthma, in particular, eosinophils, T lymphocytes, neutrophils, and epithelial cells. In susceptible individuals, the inflammation causes recurrent episodes of coughing, wheezing, chest tightness and difficulty breathing, especially at night and in the early morning; however, asthma is a disease with many faces.[3]

Periodontal disease has been known as an inflammatory disease with a reaction to bacterial plaque causing chronic inflammation, gingival bleeding, increasing pocket depth, and ultimately, alveolar bone loss. In fact, bacterial antigens irritate the immune response of the host leading to the effects of the disease.[2] The main factor in diminishing the periodontal disease is the interaction between bacterial and immunological factors.[8] The biologic plausibility linking periodontal infection and severe asthma seem to be related to immunologic components common to both diseases that affect epithelial integrity, in both periodontal and respiratory tissue.[9] The tissue breakdown present in periodontitis results, for the most part, from the actions of the immune system and of the related mechanisms. Similarly, bronchial inflammation is the result of complex interactions among inflammatory cells, chemical mediators, and the structural cells of the airways.[10] Of these immunologic components, matrix metalloproteinases stand out. They are responsible for the breakdown of collagen and are found at elevated levels during the periodontal breakdown process. In the same way, these enzymes are also associated with bronchial remodeling in individuals with severe asthma.

The literature relating to the role of periodontitis in asthma is very limited with very few studies [6],[8],[11],[12],[13] which are conducted on small sample size, and no clear definition of the exposure factor, periodontal disease, and bronchial inflammation. No literature exists which depicts an association between asthma and periodontal diseases. Hence, this pioneer study has been taken up to find out an association between periodontitis on asthma.

  Materials and Methods Top

Himachal Pradesh is a state in North India with a wide variation of climate which varies from hot and subhumid tropical in the southern tracts to, with more elevation, cold, alpine, and glacial in the northern and eastern mountain ranges. The present case–control study was carried out on a convenient sample of 100 participants (54 males and 46 females with mean age of 41.62 years and 38.7 years, respectively), from June 2013 to December 2013. The study was approved by Institutional Ethical Committee for research. Written informed consent was obtained from all the participants who participated in the study. Fifty participants represented the cases of asthma reported to the asthma clinic of Department of Chest and tuberculosis, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh.

Individuals suffering from mild to severe asthma, not suffering from any other systemic diseases which could affect the periodontal health status, not taking any medication, nonsmokers, and similarity with the control group in gender and socioeconomic aspects were included. The control group (n = 50) included individuals who were nonasthmatic, not suffering from any systemic disease and who visited Dental College and Hospital Shimla for dental treatment.

To compare the clinical attachment level (CAL) of participants suffering from asthma, the cases were further categorized into three subgroups on the basis of severity of asthma, as described by Halterman et al.[14] as follows:

  • Severe asthmatic: Two hospitalizations or four asthma-related acute visits
  • Moderate: One hospitalization or two acute visit or three episodes of wheezing
  • Mild: No hospitalization, one acute visit, two episodes of wheezing.

All the study patients in the test group suffered from moderate to severe asthma. (1) Group A1: Patients suffering from mild asthma (n = 30) and (2) Group A2: Patients suffering from moderate to severe asthma (n = 20).

Clinical parameters evaluation according to different indices, i.e. plaque index (PI), calculus index (CI), gingival index (GI), papillary bleeding index (PBI), CAL, of each individual was performed by a single calibrated examiner. CAL was measured as the distance from the cementoenamel junction to the base of periodontal pocket using William's periodontal probe.

Data collected in the study were subjected to statistical analysis, carried out using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, USA, version 16.0 for Windows). The quantitative variables were estimated using mean and standard deviation. Unpaired t-test was applied to compare Group 1 and Group 2. One side t-test was performed for comparing quantitative variables among control group, Group A1 and Group A2. P < 0.05 and <0.01 was considered as statistically significant and highly significant, respectively.

  Results Top

Asthmatics were having a higher prevalence of periodontal disease than nonasthmatics. The difference of CAL for two groups was statistically highly significant. Mean PI scores of 0.649 ± 0.316 were recorded for control group in comparison to 1.168 ± 0.461 of test group (P = 0.003). Statistically significant difference among two groups was obtained on a comparison of GI score (P = 0.036) CI scores (0.42). CAL in millimeters 3.817 ± 0.722 and 4.964 ± 0.871 was recorded in control group and test group, respectively (P = 0.004). Comparison of PBI of test group and control group showed significant difference (P = 0.0346) [Table 1].
Table 1: Indices measurements of asthmatic and nonasthmatic group

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Group 2 was further categorized into two categories on the basis of severity of asthma, and all the parameters were compared. Comparison of all the parameters, i.e. PI, CI, GI, and PBI was statistically significant with P value 0.0281, 0.04, 0.027, and 0.0162, respectively. However, when the two groups were compared for the scores of CAL (mm) the difference was highly significant (P = 0.006) [Table 2]. CAL measurements of the subgroups T1 and T2, when compared with control group yielded statistically significant results [Table 3].
Table 2: Indices measurements of mild asthmatic and moderate-to-severe asthmatic patients

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Table 3: Comparison of “clinical attachment level” measurements of control group, mild asthmatic patients and moderate-to-severe asthmatic patients

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  Discussion Top

The relationship between asthma and periodontal health has previously been reported by many studies globally.[2],[3],[4] Considering the inflammatory nature of both asthma and periodontal disease, also the presence of variants and covariant affecting the results of such studies, proving such an association seems existing.[7] Periodontal infection can adversely affect systemic health. Systemic diseases and disorders have also been implicated as risk indicators or factors in periodontal disease.[15] In the current study, periodontal status of case and control groups (identical in age, gender, and socioeconomic status) was evaluated and an attempt was made to find an association between asthma and periodontal disease.[11]

CAL is a hallmark of chronic periodontal disease. Periodontal destruction was greater in asthmatic group as compared to nonasthmatic group as indicated by CAL values. When the comparison was done among two subgroups of cases again, the severe asthmatics were having more periodontal destruction than mild or moderate asthmatics. Studies have also reported that asthmatics have poor periodontal health than nonasthmatics.[6],[13],[16],[17] However, a study [18] reported contrasting results and no significant association was found between the two groups. More destruction of periodontal apparatus in asthmatic group may be due to increased levels of IgE in gingival tissue [19] which may result in hypersensitivity reaction and decrease in IgA levels.[20] Another fact could be that there is continuity between oral cavity and respiratory tract. Intraoral lesions may play a role in causing asthma and other respiratory diseases.[3]

PBI and GI scores indicate the prevalence of gingivitis. In the current study, it was higher among cases than controls. Severe asthmatics were having more statistically significant scores as compared to the mild and moderate asthmatic. Various previous studies have also reported similar findings.[6],[16],[17] Increased gingivitis in asthmatic group may be because of an altered immune response. Dehydration of gingiva due to mouth breathing during asthmatic attack and subsequent dehydration of gingiva may be a contributing factor for prevalence of gingivitis.[20] A study [7] has reported contrasting results to this study where reported differences in GI, PBI of asthmatic, and nonasthmatic participants were statistically not significant.

The plaque scores were significantly higher among asthmatics than the healthy control group. A similar direct relationship between bacterial pneumonia and dental plaque has also been reported.[12] This can be explained that periodontal pockets can be a favorable place for the growth and multiplication of anaerobic bacteria which could play a remarkable roll in asthma.[6]

CI was significantly higher in test group as compared to control group and this is similar to results of previous studies. This may be because of the increased levels of calcium and phosphorus in submaxillary and parotid saliva of asthmatic patients.[21]

Immune response is the mechanism involved in pathogenesis and progression of asthma. Regression in immune functioning in asthma may lead to periodontal destruction. A decrease in IgA levels has been reported in asthmatic patients.[22] As IgA acts as a first-line defense for mucosa and plays an important role in restricting periodontal disease, its reduced levels in asthmatic patients may be associated with periodontal destruction.[20]

The sample size examined and analyzed in this study was smaller and the association between periodontal diseases and asthma and various confounding factors have not been taken into consideration. In future studies with similar objectives, having larger sample size, confounder analysis, and longitudinal follow-ups in different geographic areas to be carried out to strengthen the result outcome of the present study.

  Conclusion Top

An association exists between the occurrence of chronic periodontitis and asthma. As both periodontal and respiratory diseases have an inflammatory nature and there are many factors that can affect their incidence and severity. Revealing acceptable and explainable results firmly depends on a precise study design.


We would like to acknowledge all the participants who agreed to take part in the study, administrative head of HP Government Dental College and Hospital Shimla and Indira Gandhi Medical College and Hospital Shimla.


Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Takeuchi N, Ekuni D, Irie K, Furuta M, Tomofuji T, Morita M, et al. Relationship between periodontal inflammation and fetal growth in pregnant women: A cross-sectional study. Arch Gynecol Obstet 2013;287:951-7.  Back to cited text no. 2
Offenbacher S, Beck JD, Moss K, Mendoza L, Paquette DW, Barrow DA, et al. Results from the periodontitis and vascular events (PAVE) study: A pilot multicentered, randomized, controlled trial to study effects of periodontal therapy in a secondary prevention model of cardiovascular disease. J Periodontol 2009;80:190-201.  Back to cited text no. 3
Moodley A, Wood NH, Shangase SL. The relationship between periodontitis and diabetes: A brief review. SADJ 2013;68:260, 262-4.  Back to cited text no. 4
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Stensson M, Wendt LK, Koch G, Oldaeus G, Ramberg P, Birkhed D, et al. Oral health in young adults with long-term, controlled asthma. Acta Odontol Scand 2011;69:158-64.  Back to cited text no. 8
Thomas MS, Parolia A, Kundabala M, Vikram M. Asthma and oral health: A review. Aust Dent J 2010;55:128-33.  Back to cited text no. 9
Barnes PJ. Severe asthma: Advances in current management and future therapy. J Allergy Clin Immunol 2012;129:48-59.  Back to cited text no. 10
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Matsui EC. Respiratory symptoms in asthma: The view through a wide-angle lens. J Allergy Clin Immunol 2012;130:408-9.  Back to cited text no. 12
Uppal RS, Brar R, Goel A. Association between asthma and chronic periodontitis: A clinical study. Pak Oral Dent J 2015;35:448-51.  Back to cited text no. 13
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Scannapieco FA, Ho AW. Potential associations between chronic respiratory disease and periodontal disease: Analysis of National Health and Nutrition Examination Survey III. J Periodontol 2001;72:50-6.  Back to cited text no. 15
McDerra EJ, Pollard MA, Curzon ME. The dental status of asthmatic British school children. Pediatr Dent 1998;20:281-7.  Back to cited text no. 16
Hyyppä TM, Koivikko A, Paunio KU. Studies on periodontal conditions in asthmatic children. Acta Odontol Scand 1979;37:15-20.  Back to cited text no. 17
Shulman JD, Nunn ME, Taylor SE, Rivera-Hidalgo F. The prevalence of periodontal-related changes in adolescents with asthma: Results of the third annual National Health and Nutrition Examination Survey. Pediatr Dent 2003;25:279-84.  Back to cited text no. 18
Hyyppä T. Gingival IgE and histamine concentrations in patients with asthma and in patients with periodontitis. J Clin Periodontol 1984;11:132-7.  Back to cited text no. 19
Ostergaard PA. IgA levels, bacterial carrier rate, and the development of bronchial asthma in children. Acta Pathol Microbiol Scand C 1977;85:187-95.  Back to cited text no. 20
Wotman S, Mercadante J, Mandel ID, Goldman RS, Denning C. The occurrence of calculus in normal children, children with cystic fibrosis, and children with asthma. J Periodontol 1973;44:278-80.  Back to cited text no. 21
Scannapieco FA. Systemic effects of periodontal diseases. Dent Clin North Am 2005;49:533-50.  Back to cited text no. 22


  [Table 1], [Table 2], [Table 3]

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