|Year : 2011 | Volume
| Issue : 2 | Page : 144-148
Effect of sucrose in different commonly used pediatric medicines upon plaque pH in human subjects
Arun Sharma1, Shobha Deshpande2
1 Department of Pedodontics and Preventive Dentistry, I.T.S Centre for Dental Studies and Research, Delhi-Meerut Road, Murad Nagar, Ghaziabad, UP, India
2 Department of Pedodontics and Preventive Dentistry, K.L.E.S Institute of Dental Sciences, Belgaum, Karnataka, India
|Date of Web Publication||9-Sep-2011|
A-18, Ground Floor, Lajpat Nagar-III, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: This study was conducted with the aim to investigate the acidogenic potential of three commonly used pediatric medicines (benadryl syrup, crocin syrup, and novamox dry syrup) upon plaque pH. Materials and Methods: The protocol used in the study followed the guidelines laid down at Scientific Consensus Conferences on methods for assessment of cariogenic potential of food, San Antonio, Texas. Ten young healthy adult volunteers were selected for the study. Subjects were refrained from brushing their teeth for 48 h and did not eat or drink for at least 2 h prior to each appointment. pH measurements were taken at baseline to determine resting plaque pH and at time interval of 5, 10, 15, 20, 25, and 30 min following a 1 min rinse with each medication. A pooled sample of plaque was removed from buccal / lingual surfaces, thoroughly mixed with 0.6 ml of double distilled deionized water and plaque pH was determined using a glass combination electrode. Data were compared with plaque pH changes after rinsing with control solution of 10 % sucrose and 10 % sorbitol. Analysis of minimum pH, maximum pH drop, and area under the baseline pH was computed for each medicine and for each case and the test of significance was conducted through the unpaired Student 't' test. Results: There was no significant difference between the benadryl syrup, crocin syrup, and sucrose solution as the medicines behaving essentially same as ten percent sucrose solution with respect to their potential to generate acids.
Keywords: Acidogenic potential, critical pH, plaque acidity, plaque pH
|How to cite this article:|
Sharma A, Deshpande S. Effect of sucrose in different commonly used pediatric medicines upon plaque pH in human subjects. J Indian Soc Pedod Prev Dent 2011;29:144-8
|How to cite this URL:|
Sharma A, Deshpande S. Effect of sucrose in different commonly used pediatric medicines upon plaque pH in human subjects. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2019 Nov 14];29:144-8. Available from: http://www.jisppd.com/text.asp?2011/29/2/144/84688
| Introduction|| |
Human dental caries results from the production of acid from dietary carbohydrate by plaque bacteria on the tooth surfaces. Dietary carbohydrate is the most important factor affecting chemical composition of plaque. The type of bacteria found in plaque and the metabolic activity of cariogenic streptococci are the factors being considered as potential candidates for production of dental caries.
A reasonable approach to elucidate the mechanism of the disease development should involve comprehensive evaluation of each factor given above. As a critical initial step in implementing such an approach would be an evaluation of acid metabolism within the plaque, accurate monitoring of anabolism, and catabolism and/or neutralization of plaque acid. A fall in plaque pH caused by intraplaque bacterial fermentation of dietary carbohydrate leads to a shift in the equilibrium concentration and consequently to enamel dissolution.
Acid production by the bacteria within the dental plaque is perhaps the most important activity in the pathogenesis of dental caries.
In an attempt to reduce dental caries, dietary sugar restriction has been attempted and number of sweeteners has been substituted experimentally for sucrose as a more practical measure. In the recent years, it has become apparent that high incidence of dental caries is due to dietary changes in civilized society and their effect on plaque microflora and metabolism rather than to specific causative organisms.
The plaque pH estimation may be used to develop a scale of relative cariogenicity of prescriptional and non-prescriptional medicines and identity low caries risk medicinal components and their pattern.
The pharmaceutical company uses sugars, especially sucrose in large quantities as a vehicle for medicines and is included in nearly all formulations prepared especially for children in order to make them more palatable. Few physicians, pharmacists, dentists, and only a minute fraction of patients are really aware of quantities of hidden sugar in these products. The abundant use of non-prescriptional pharmaceutical products should be of special concern to dental profession because such products are often used according to the leaflet instructions in small quantities but throughout the day.
Oral microorganisms are thus provided with fermentable sugar all day long which may lead to practically continuous acidification of dental plaque and continuous challenge to the teeth.
While plaque acidogenicity of any pharmacological item, i.e. its potential to cause low pH values in plaque, cannot be directly equated with cariogenicity.
In the present study, three most commonly prescribed pediatric medicines benadryl syrup, crocin syrup, and novamox dry syrup were selected to investigate the effect of these medicines upon dental plaque pH.
| Materials and Methods|| |
The present study was conducted in the Department of Pedodontic and Preventive Dentistry at K.L.E's Institute of Dental Studies, Belgaum, Karnataka. Ten young healthy adult volunteers (five males and five females) were selected for the study. The consent of the participant was taken on the consent form. The subjects participated in the study were randomly selected according to the following criteria.: age group: 18 to 24 years, each had a minimum of 8-12 DMFS, no filling on the labial /lingual surfaces of the teeth present and no gross malocclusion was present in subjects with special reference to crowding. The plaque score of each participating volunteer was brought to zero/normal. Subjects were instructed to abstain from oral hygiene practice for 48 h so that sufficient plaque would have accumulated. Participants were asked not to eat or drink for at least 2 h prior to each appointment. All experiments on each subject were carried out in the morning to minimize the variation in salivary flow and its composition. On the test day, each subject was seated on the dental chair. A sample of plaque was collected by pooling samples (buccal /lingual surfaces) using a double-ended excavator. The sample of approximately 1 mg of plaque was collected for every measurement which was thoroughly mixed with 0.6 ml of double distilled deionized water in the vials and the pH was measured with a glass combination electrode (Toshniwal pH meter CL 46 and glass combination electrode) which was previously calibrated by standard buffer solution at pH 4 and pH 7. For every measurement, the glass combination electrode was washed with distilled water and dried with tissue paper. To control the bias, pH measurement was done within 30 to 40 s. Plaque was harvested as far as possible from the same site. The pH was measured at the baseline to determine the resting pH for each subject and subject was asked to rinse his/her mouth for 1 min within 5 ml of test medicines/control solution, following which the plaque samples were collected and the pH was recorded at 5, 10, 15, 20, 25, and 30 min . The orders of medicines tested by each subject were randomly determined and at least 8 days were allowed to elapse between each test.
For the data collected the analysis was done through three independent parameters: minimum pH, maximum pH drop and area under the base line pH (the area enclosed by the plaque pH curve and a line drawn from the baseline pH parallel to the X axis). For each medicine and each case the values of minimum pH, maximum pH drop, and area under the baseline were computed.
The minimum pH is defined as the lowest pH recorded during the test sessions. The maximum pH drop is defined as the difference between the initial prerinse plaque pH (resting pH) and the minimum plaque pH obtained. The area under the base line pH was calculated by dividing the total area into different trapezia by dropping perpendiculars at different time points. For each trapezium, area was separately calculated and then each was added to get the total area under the curve.
Corresponding to different medicines/control solutions, the values of mean and standard deviation were calculated. Using these mean and standard deviations, the test of significance was conducted through the unpaired Student 't' test.
| Results|| |
The results are summarized in [Table 1],[Table 2],[Table 3]. The test showed that benadryl syrup and crocin syrup mean minimum pH value comparable with the sucrose solution. Novamox dry syrup showed a slightly elevated mean minimum pH value than the sucrose solution. The sorbitol solution showed higher minimum pH value than the sucrose solution. The mean maximum pH drop was highest for crocin syrup and was lowest for the sorbitol solution.
|Table 1: Mean plaque pH and standard deviation for test medicines/ control solutions at resting pH and following 1 minute rinse at different time intervals |
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|Table 2: Mean and standard deviation of the resting plaque pH, minimum pH value, maximum pH drop, and the area under the baseline pH for each pediatric and control solution |
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|Table 3: 't' value for comparison of minimum pH, maximum pH drop and area under the baseline pH between different test medicines/control solutions |
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Distribution of the area under the baseline pH was significantly higher for benadryl syrup and crocin syrup which was comparable with the sucrose solution. A comparison of the area below the resting pH depicts that the area covered by the crocin syrup was the largest, whereas the area below the resting pH covered by the sorbitol solution was smallest.
There was no significant difference between the benadryl syrup, crocin syrup, and sucrose solution as the medicines behaving essentially same as 10% sucrose solution with respect to their potential to generate acids.
| Discussion|| |
During the last few decades, dental researchers have put an increasing amount of efforts into the investigation of dental plaque and its adverse efforts on the teeth and supporting structures, in an attempt to gain further insight into the mechanism leading to dental diseases. Dental caries is one of the most important oral diseases which have been attributed to dental plaque. It has now been established that dental plaque is a prerequisite of caries. The relationship between plaque and caries is complex because dietary carbohydrates are used as substrates for the plaque microflora which is essential for cariogenicity, and individuals, teeth may exhibit varying degrees of caries resistance. Sucrose has long been considered as the "arch criminal" for dental caries because of its unusual biochemical properties and the form of sugar most eaten by humans. Many different bacteria of the plaque are equipped with a variety of sugar degrading enzymes leading to different end product of carbohydrate metabolism. Streptococci which generally produces lactic acid and the situation is further complicated by variation in microbial composition, pH, and the redox potential of the plaque in the presence or the absence of various substrates causing induction and repression of enzyme.
Stephan demonstrated that mouth rinsing with glucose caused a pH drop of 1.5 to 3.0 pH units to a minimum value of 4.7 to 5.2  since these mono and disaccharides diffuse into the plaque easily and are utilized rapidly by plaque bacteria.
In contrast, the sugar alcohols mannitol, sorbitol, xylitol do not produce pH drop in human plaque. 
The pH below which the demineralization will occur has been called as critical pH and on the basis of in vitro experiments and theoretical considerations has been reported to be in the range of 5.0 to 6.0, most probably 5.5. The pH fall itself will depend upon the acidogenicity of the plaque microflora, the nature of the acids formed, the formation of neutralizing metabolic products, the buffering power of the plaque, the concentration of substrate surrounding the bacteria, and the duration of this supply of the substrate, the diffusion of substrate and metabolic products in plaque, the influence of the saliva environment of these parameters.
The medicines tested in this study were chosen following the discussions with pharmacist and the pediatricians. These were found to be most frequently prescribed medicines and frequently and commonly purchased over the counter. The protocol used in the study followed by guidelines laid down at the Scientific Consensus Conference on methods for assessment of cariogenic potential of foods, San Antonio, Texas.  The following factors were established at this conference, any food/drink was considered acidogenic if it produced similar plaque pH response to 10% sucrose solution and hypoacidogenic if its response was similar to 10% sorbitol solution.
Children are an established group of high caries risk and would therefore be an important group to use in plaque pH studies; however, human investigations review considerations and potential problems on subject compliance make use of minors in cariogenicity assessment studies problematic. , Imfeld and Lutz indicated that acidogenic profile of children and adults are similar and support to the extrapolation of results obtained in adult subjects for those in children. 
In addition to having acidogenic plaque, subjects must be in good general and oral health, i.e. no evidence of systemic disease, advanced periodontitis, rampant caries, or any other disorder that may be exacerbated by the experimental procedures. More so in human studies, subjects should also be selected on the basis of expected compliance, since some of the aspects of plaque acidity study require adherence to schedule and putting up with inconvenience of suspended oral hygiene.  In the present study, the acidogenic profile of dental plaque of healthy adults was investigated.
The several method of plaque sampling have been discussed; ,,, however, in this study the method used for plaque sampling was according to Frostell. 
Considerations of the relative harmfulness of each medicines under study depends upon which of the two parameters, minimum pH or the area under the base line pH, is considered the most valid estimate of cariogenicity. It is not possible to decide the relative validity of the two parameters.
From the purely chemical point of view, there is much evidence to support the concept of critical pH. The pH 5.5 is thought to be the approximate value of the critical pH, which may be influenced by number of factors such as plaque calcium and phosphate. It is difficult to determine to critical pH at each plaque-enamel interface. Since the critical pH for each subject, for each medicine testing could not be measured easily, two measurements (minimum pH and area under the base line pH) were evaluated in the study.
The mean areas and standard deviation for each medicine are shown in [Table 2]. It can be seen from the values that the area under baseline pH was significantly less for the sorbitol solution (control solution). No significant difference was found between the benadryl/crocin syrups and sucrose solution. Same was observed with the minimum plaque pH. These results for benadryl and crocin were in accordance with Marathaki., Pollard, and Curzon. 
In case of novamox syrup [Table 2], the mean minimum pH was above 5.5 and it can be argued that during testing of that particular medicine the subject's enamel was not at risk.
The main finding of this study was the drop in pH which was well established during the 10 min and the mean minimum pH observed was 5.518 and 5.511 respectively for benadryl syrup and crocin syrup which were comparable to the sucrose solution (5.506).
An in vitro assessment of acidogenic potential of these medicines (benadryl syrup and crocin syrup), found that syrup caused depression. Many frequently used liquid medicines have been found to contain more than 40% sucrose from the range of 0% to 84%. These medicines with the higher concentration of sucrose produce larger fall in pH and therefore had a greater potential to damage the teeth.  The control solution which were tested in the present study are in agreement to Rugg-Gunn  who showed that the mean minimum pH for sucrose was 5.33 and the area under the base line pH was 27.42, and for sorbitol the minimum pH 6.20 and the area under the base line pH was 1.70
All the medicines tested apart from sucrose and sorbitol (control solution) were complex substances, i.e. they were made up of different ingredients. The properties that may modify their acidogenic potential include retention in mouth, physical form, acidogenic properties, protective effect of ingredients, their effect on bacterial colonization, and quantities and the type of carbohydrate composition. Individual salivary flow will also affect the acidogenicity of the product.
This study mainly concerns with plaque pH changes and not the cariogenicity therefore confirmation by carrying out the clinical trials is required before extrapolating the findings to the practical advice, nevertheless these data do indicate possible ways in which careful choice of different prescriptional and non prescriptional medicines can influence large pH.
Attempts have been made to replace sucrose by other sugar substitutes or sugar analogs. A major problem in using these types of sugar analogs is the cost of its production and the need to compensate for the bulk and texture components of wide variety of medicines contributed to sucrose. From the dental point of view, preparations less harmful to teeth than their sugar-based counterpart should be under development. It is hoped that concerned physicians, dentist and pharmacist shall focus their attention in achieving awareness and attention on sugar-containing pharmaceuticals products.
| References|| |
|1.||Stephen RM. Changes in hydrogen-ion concentration on tooth surfaces and in carious lesions. J Am Dent Assoc 1940;27:718-23. |
|2.||Frostell G. Dental plaque pH in relation to intake of carbohydrate products. Acta Odontol Scand 1969;27;3-29. |
|3.||Edgar WM, Geddes DAM. Plaque acidity models for cariogenicity testing- some theoretical and practical observations. J Dent Res 1986;65:1498-502. |
|4.||Harper DS, Abelson DC, Jensen ME. Human plaque acidity models. J Dent Res 1986;65:1503-10. |
|5.||Imfeld T, Lutz F. Intraplaque acid formation assessed in vivo in children and young adults. Pediatr Dent 1980;2:87-93. |
|6.||Stephen RM. Intra-oral hydrogen-ion concentration associated with dental caries activity. J Dent Res 1944;23:257-66. |
|7.||Kleinlberg I. Study on dental plaque, I: The effect of different concentration of glucose on the pH of dental plaque in vivo. J Dent Res 1961;40:1087-111. |
|8.||Jensen ME, Polansky PJ, Schachtele CF. Plaque sampling and telemetry for monitoring acid production on human buccal tooth surfaces. Arch Oral Biol 1982;27:21-31. |
|9.||Edgar WM, Bibby BG, Mundorff S, Rowley J. Acid production in plaques after eating snacks: Modifying factors in food. J Am Dent Assoc 1975;90:418-25. |
|10.||Frostell G. Effects of milk, fruit juices and sweetened beverages on the pH of dental plaque. Acta Odontol Scand 1970;28:609-22. |
|11.||Marathaki E, Pollard MA, Curzon ME. The effect of sucrose in medicines on plaque pH. Int J Paediatr Dent 1995;5:231-8. |
|12.||Feigal RJ, Jensen ME. The cariogenic potential of liquid medications: A concern for the handicapped patient. Special Care Dent 1982;2:20-4. |
|13.||Rugg-Gunn AJ. Effect of lycasin upon plaque pH when taken as a syrup or as a boiled sweet. Caries Res 1988;22:375-6. |
[Table 1], [Table 2], [Table 3]