Year : 2009 | Volume
: 27 | Issue : 1 | Page : 44--48
An analysis of concentration of sucrose, endogenous pH, and alteration in the plaque pH on consumption of commonly used liquid pediatric medicines
S Sunitha1, GM Prashanth1, Shanmukhappa2, GN Chandu1, VV Subba Reddy3,
1 Department of Preventive and Community Dentistry, College of Dental Sciences, Mysore, India
2 Department of Chemical Branch, Bapuji Institute of Eng. and Technology, India
3 Department of Pedodontia, College of Dental Sciences, Mysore, India
Department of Preventive and Community Dentistry, JSS Dental College and Hospital, Mysore
Background: Many parents are often unaware of the hidden, added sugars in many foods and drinks including pediatric liquid medicines; thus, hidden sugar in the form of pediatric medications has not been focused upon as cariogenic agents. Objective: (i) assess concentration of sucrose in six pediatric drugs, (ii) determine endogenous pH of these drugs, and (iii) estimate drop in the plaque pH in the oral cavity in first 30 minutes after consumption of the drugs. Materials and Methods: Ten adult volunteers with mean age of 22 years were double blinded for the study. Concentration of sucrose was assessed by volumetric method at Department of Chemical Branch of Engineering. Endogenous pH and drop in the plaque pH after consumption of the drugs were assessed using digital pH meter. Statistical analysis: SPSS software was used to assess the pH level at different time intervals and expressed as mean ± SD. Changes in pH were assessed by one-way ANOVA followed by Wilcoxons signed rank test. P-value was set at 0.05. Result: There were varying amounts of fermentable sucrose detected in the drugs; all the drugs were acidic. There is a significant drop of plaque pH after consumption of the drug. Conclusion: These sweeteners along with their low endogenic pH form a high cariogenic formulation. Thus, nonsucrose (noncariogenic) or sugar-free medications are needed to be prescribed along with proper oral hygiene care to the children under medication.
|How to cite this article:|
Sunitha S, Prashanth G M, Shanmukhappa, Chandu G N, Subba Reddy V V. An analysis of concentration of sucrose, endogenous pH, and alteration in the plaque pH on consumption of commonly used liquid pediatric medicines.J Indian Soc Pedod Prev Dent 2009;27:44-48
|How to cite this URL:|
Sunitha S, Prashanth G M, Shanmukhappa, Chandu G N, Subba Reddy V V. An analysis of concentration of sucrose, endogenous pH, and alteration in the plaque pH on consumption of commonly used liquid pediatric medicines. J Indian Soc Pedod Prev Dent [serial online] 2009 [cited 2019 Nov 14 ];27:44-48
Available from: http://www.jisppd.com/text.asp?2009/27/1/44/50817
Despite the advances we have made so far in the field of preventive dentistry, prevention and managing of dental caries among children has remained a formidable task. It has been a well-established fact that there is a direct relation between the type, concentration, and frequency of consumption of sugar in various forms and dental caries. Knowing the root causative factor of dental caries also has not helped us to completely erase the dental caries from the scene. As many parents are aware that the sugars cause tooth decay, they commonly relate this solely to consumption of sweets and biscuits. They are often unaware of the hidden, added sugars in many foods and drinks including pediatric liquid medicines. 
Most of these liquid or chewable preparations are usually made palatable by sweetening additives. Although active ingredients of the drugs are necessary for general recovery of the child, the sweetening additives pose danger to the dental health. 
Pharmaceutical firms sweeten liquid preparation of drugs with sugars such as sucrose, fructose, and glucose to increase the palatability, add bulk, and supposedly to increase compliance.  Sucrose remains widely used because it is cheap, nonhygroscopic, and easy to process. 
Children who were found to have receiving sucrose-based medicines had significantly more carious teeth and gingivitis. 
Aims and objectives
This study was conducted in order to: (i) assess the concentration of sucrose of six most commonly prescribed and commercially available drugs, (ii) determine the endogenous pH of these drugs, and (iii) estimate the drop in the plaque pH in the oral cavity in the first 30 minutes after consumption of these drugs.
Materials and Methods
As the present study consisted of three objectives, firstly, the six most commonly available over-the-counter drugs were randomly selected, of which two were antibiotics, two analgesics/antipyretics, and two cough syrups [Figure 1]. These randomly chosen drugs belonged to different pharmaceutical manufacturing units. These drugs were chosen after a brief enquiry from the local pharmacist and pharmaceutical distributors of Davangere city regarding most frequently prescribed pediatric medication and those purchased over the counter. The literatures and the labels on these bottles were also collected so as to gather any information necessary for the study. Ethical clearance was obtained from the ethical committee of College of Dental Sciences, Davangere. Verbal and written consent was obtained from the participants of the study.
Analysis of sugars was performed by volumetric method at the Department of Chemical Branch of Engineering, Bapuji Institute of Engineering and Technology, Davangere. The pH of all the drugs was determined using digital pH meter (Analion - PM 600) with glass combination electrode, which was previously calibrated with pH 7 and pH 4 buffer solutions. Data are presented as medians of mean values of free sugars concentration (g/100 ml %) and pH.
To estimate the drop in the plaque pH, 10 adult volunteers (five females and five males) with mean age 22 were selected with approximately similar oral hygiene status and who showed to produce a drop in plaque pH to less than 5.5 after a rinse with 10% sucrose solution. The volunteers were requested to refrain from brushing for 48 hours prior to test. The test was conducted early in the morning. On each test day, a sample of 5 ml of the drug was dispensed to them and they were instructed to swish it around the mouth for over a minute and spit it out. Plaque was collected using harvesting method at baseline to determine resting plaque pH and at time intervals of 5, 10, 15, 20, 25, and 30 minutes following rinse with each medication. (A sample of 1 mg plaque was collected for every measurement from the buccal surfaces of posterior teeth.) This was mixed with 20 ml of distilled water and the pH was determined using digital pH meter.
The sample plaque was collected in the early mornings so as to minimize variation in saliva flow and composition.
The obtained data was subjected to statistical analysis where SPSS software was used to assess the pH level at different time intervals and expressed as mean ± SD. Changes in pH were assessed by one-way ANOVA followed by Wilcoxons signed rank test for any significant difference from baseline pH. A P -value 0.05 was considered for statistical significance.
[Table 1] presents the endogenous pH of the drugs and the amount of sucrose weight by volume.
Graph 1 -[SUPPORTING:1], Graph 2-[SUPPORTING:2], Graph 3-[SUPPORTING:3] show the drop in the plaque pH after 1 minute of rinsing with the particular drug. This southward trend was similar to that of drop in pH followed by 10% sucrose solution as shown in Graph 4-[SUPPORTING:4].
Graph 5-[SUPPORTING:5] presents the drug response toward plaque pH.
[Table 2] shows results of ANOVA and Wilcoxon's rank sum tests.
The ANOVA test showed that the sucrose-containing medicines produced a significantly lower minimum pH, which was not significantly different from the plaque response to sucrose.
The Wilcoxon rank sum test considered to check the level of significance in the fall of pH after medication with the baseline was observed to be significant.
We found that endogenous pH of all the drugs considered were acidic in nature with the cough syrup being below the cariogenic critical pH. In the study conducted by Lima et al ,  74.2% of the drugs examined had pH lower than 5.5, similar to the study by Grenby  where the pH of throat lozenges showed pH in the range of 2.6-3.7, which was attributed by the flavoring agents.
These drugs also contained sucrose in varying concentrations, that adds up to the cariogenic potential of the drugs.
Any food is been considered to be acidogenic if it produces a similar pH response as that of 10% sucrose solution.  Thus, the plaque pH fall following the drug intake was compared with the fall in pH following the consumption of 10% sucrose solution.
Our results of the fall in pH after the drug was ingested showed a high similarity as in the studies conducted earlier by Martaki et al ,  Rekola M,  Lokken et al ,  and Srinivas and Reddy  Although adults have participated in this study, a previous report using indwelling electrode to measure plaque pH found similar results in adults and children. 
As expected, all these sucrose-containing preparations have produced a significant decrease in pH. The liquid medications have a great potential for causing dental caries when inappropriately used. 
Majority of children did not brush their teeth after taking drugs.  A long-term use of sugar-containing drugs has been considered a cause of dental caries in children.  The increase of prescribed medicine intake and of self-medication in developed countries exposes a growing number of children to medication caries, which can be considered a public health problem. 
More extensive measurement on numerous medications is necessary to closely define which characteristics lead to which plaque pH alterations.
Further the health workers should be informed regarding the cariogenic potential of the liquid medicaments so as to guide the parents and guardians to introduce oral hygiene measures after the consumption of the same.
A medication in the syrup form is most commonly prescribed to the patients of younger age group. To make it palatable for children sweetening additives are added. These sweeteners along with the low endogenous pH form highly cariogenic formulation. We recommend incorporation of nonsweetened or sugar-free sweeteners in the drugs, especially the syrup formulations, as they are yet to be available in India. Also, dental personnel should take care to advice the mothers and caretakers to introduce oral hygiene practices after the consumption of the medications.
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