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 Table of Contents  
Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 60-64

Changes in the dental plaque pH due to pediatric liquid medicaments

1 Department of Dentistry, Belagavi Institute of Medical Sciences, Belagavi, Karnataka, India
2 Private Practitioner, Arush Multispecialty Dental Care, Koramangala, Bengaluru, Karnataka, India

Date of Web Publication13-Apr-2017

Correspondence Address:
L R Kumaraswamy Naik
Department of Dentistry Belagavi Institute of Medical Sciences, Belagavi, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jioh.jioh_12_16

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Background: The deleterious effect of liquid oral medicaments has been studied since 1953. Many coworkers have confirmed that these preparations are cariogenic and acidogenic in nature. In vitro studies have observed that the commonly used pediatric liquid medicaments (PLMs) are acidogenic and cariogenic in nature. Aim: To assess the change in the dental plaque pH after oral rinsing with the commonly prescribed PLMs.Materials and Methods: For the study purpose, eight commonly used PLMs were selected. On the test day, first the baseline resting plaque pH was measured, and then the volunteers were asked to rinse 5 ml of the sample PLM and asked to swish all around the oral cavity for 10 s and then to spit out. The supragingival plaque samples were collected using harvesting method at baseline and at different time intervals, following rinse with each medication. The pH of plaque was determined using a digital pH meter. The obtained data were statistically analyzed using one ANOVA and Tukey's multiple post hoc test. Results: A significant decrease in plaque pH was recorded in most of the subjects; maximum pH drop was seen within min of rinse of PLM. Among all the PLM, Crocin® showed maximum drop in plaque pH. There was a gradual recovery to the near-normal pH within 60 min. Conclusions: Reducing the cariogenic potential of PLM should be a matter of concern to all health professionals.

Keywords: Pediatric liquid medicaments, pH, plaque

How to cite this article:
Kumaraswamy Naik L R, Girish Babu K L, Doddamani GM. Changes in the dental plaque pH due to pediatric liquid medicaments. J Int Oral Health 2017;9:60-4

How to cite this URL:
Kumaraswamy Naik L R, Girish Babu K L, Doddamani GM. Changes in the dental plaque pH due to pediatric liquid medicaments. J Int Oral Health [serial online] 2017 [cited 2023 Sep 22];9:60-4. Available from:

  Introduction Top

Despite the various developments in preventive dentistry, children still suffer from dental caries. Many parents are aware that there is a direct relation between the various forms of sugar and dental caries.[1] They commonly relate this to consumption of sweets in the form of chocolates and biscuits. However, they are unaware of the hidden, added sugars in many pediatric liquid medicaments (PLMs).[2]

The addition of sugar to PLM has been reported since the time of 15th century. Added sugar masks the unpleasant taste of some active constituents, allowing for better acceptance by patients. The pharmaceutical industry uses sugar, especially sucrose, in large quantities as it acts as a preservative, an antioxidant, a solvent, a demulcent, and a bulking agent.[3] It is a nontoxic sweetening agent and free from after taste. It is widely used because it is cheap, nonhygroscopic, easy to process, and available in a number of pure, dry, chemically and physically stable forms, with different particle sizes.[4] Along with the addition of sugars, surplus acids are also added to these PLMs.[5] PLM with sugars and low endogenous pH may produce unwanted dental side effects such as dental caries and erosion in children.[5] Studies have emphasized that a significant portion of the population ignores the type and concentration of sugars added to pediatric formulations.[2],[6]

Children with chronic or recurrent health problems who frequently use the medicines are particularly at risk.[7],[8],[9],[10],[11] Other coworkers have confirmed that these preparations are cariogenic and acidogenic in nature.[7],[8],[12],[13],[14]

The oral bacteria metabolize sugar and increase local concentration of organic acid in the inner layer of dental plaque on the tooth surface, which lowers the oral pH resulting in a process of demineralization.[15] In our previous in vitro studies,[16],[17],18] we observed that the commonly used PLMs are acidogenic and cariogenic in nature. Hence, a step further was taken to assess the acidogenic potential of these PLMs in in vivo condition. This was studied by assessing the change in the plaque pH after oral rinsing with the commonly prescribed PLM.

  Materials and Methods Top

To conduct this prospective study, eight commonly used PLMs were selected. The study duration period was 2 years. Ethical Committee Clearance was obtained before start of the study. The PLM included each of the two most commonly prescribed analgesics, antibiotics, anti-asthmatic drugs, and nutritional supplements. A digital pH electrode meter was used to measure the endogenous pH of the PLM [Table 1].[1],[19] High-performance liquid chromatography (Agilent 1100 System, UK) was used to analyze the type and concentration of sugars (sucrose and glucose) present in the PLM.[19],[20] Five milliliters of each PLM was pipetted into a 10 ml volumetric flask, to which 2 ml of diluent was added and sonicated for 5 min. Microdilutions of 1 ml were passed through a 0.45 μm filter paper, and the supernatant was used for chromatography. All samples were prepared in triplicate.
Table 1: Mean pH and concentration of sugars of the pediatric liquid medicaments

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A total of 80 volunteers belonging to the age group of 18–20 years of both sexes were selected. Inclusion criteria included (1) normal and healthy subject, (2) subjects with complete permanent dentition, (3) decayed, missed and filled teeth score ≤3, and (4) simplified oral hygiene index score is ≤1.2. Exclusion criteria included (1) subjects with diseases and treatment affecting salivary physical and chemical characteristics, (2) subjects on antibiotic therapy, (3) subjects with periodontal diseases, (4) subjects with lack of teeth needed for harvesting the plaque, and (5) subjects with index teeth with dental caries or any restoration.

The selected volunteers were verbally explained about the procedure to be performed and their informed written consent was obtained. The eighty volunteers were divided into four groups, with twenty in each group. Each group was further subdivided into two subgroups of ten volunteers each. To ensure uniform baseline, thorough oral prophylaxis was done for the selected volunteers. The volunteers were instructed to abstain from brushing their teeth or using any oral hygiene measures for the next 2 days before the test. All the tests were conducted early in the morning.

On the day of test, the volunteers were asked to report in the morning with total avoidance of food except plain water.[21] First, the baseline resting plaque pH was measured, and then, the volunteers were asked to rinse 5 ml of the sample PLM and asked to swish all around the oral cavity for 10 s and instructed not to swallow the drug. The supragingival plaque samples was collected using harvesting method [22],[23] from the maxillary buccal surface of molars at baseline and at time intervals of 5, 10, 15, 30, 45, and 60 min, following rinse with each medication. Sterile stainless steel spoon excavator was used to collect the plaque samples. The harvested plaque samples were mixed with 20 ml of distilled water in a sterile plastic bottle.

The volunteers were made to rinse their mouth with plain tap water immediately after the procedure, and supervised toothbrushing was advocated after 1 h of the procedure and instructed to resume their routine oral hygiene measures. The same procedure was repeated for all the individuals.

The collected plaque sample bottles were sealed immediately. The pH of plaque was determined using digital pH meter within an hour of collection of the sample. Before and after each plaque pH reading, the electrode was cleaned with double distilled water and wiped with blotting paper and then placed in a standard pH solution of 7.0. This ensured stable readings and a constant check of the drift of the readings. The readings were repeated for three times and the average was taken.

Statistical analysis

The obtained data were statistically analyzed using one ANOVA and Tukey's multiple post hoc test and SPSS software 19.0 (IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp.). The pH level at different time intervals was recorded and was expressed as mean ± standard deviation.

  Results Top

Salbid ® showed an acidic pH of 6.05 and Theopid ® had basic pH of 7.71. Seven PLMs had sucrose in them and glucose was seen in five PLMs [Table 1]. The resting plaque pH was between 6 and 7. A significant decrease in plaque pH was recorded in most of the volunteers; maximum pH drop was seen within 5 min of rinse of PLM. Among all the PLMs, Crocin ® showed maximum drop in plaque pH. There was a gradual recovery to the near-normal pH within 60 min [Table 2].
Table 2: Changes in the plaque pH after rinsing with various pediatric liquid medicaments at different time intervals

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  Discussion Top

PLM are very commonly prescribed, widely available and are easily accepted by both parents and children. Studies have shown that children with chronic diseases and on long-term medication are at greatest risk of developing dental caries. [4,24-26] This is due to the presence of sugars such as sucrose, glucose, or fructose in the liquid preparations.[25],[26] These sugars are added to the liquid preparations to make them palatable and to gain patient compliance.[27] Furthermore, many of the liquid syrups are maintained in acidic pH, to maintain the shelf life of the medicaments. The added sugar and the endogenous low pH of the liquid medications may itself contribute to demineralization or at least inhibit the demineralization–remineralization process in newly erupted teeth.[15],[28] The endogenous pH of a medication can be rapidly changed intraorally by salivary buffers. The bacteria metabolize the sugar to acid end-products, thus decreasing the plaque pH that is relatively unavailable to salivary buffering. Low pH near the tooth surface causes ionic dissolution from the hydroxyapatite crystals and eventually carious lesions.[29] Hence, the aim of the study was to assess the changes in dental plaque pH after rinsing with commonly used PLM.

On an average, 60% of the population of developed countries take some forms of medicine, of which about half are bought over the counter [30] and 17% of children are given nonprescription cough medicine.[31] Analgesics, cough medicines, and multivitamins are the commonly dispensed over-the-counter liquid preparations given to children.[32] These observations formed the basis for the selection of PLM in our study.

Low endogenous pH and added sugars in liquid medicaments may markedly contribute to the erosive and cariogenic potential of these solutions. The PLM datasheet used in the current study did not specify any valuable information about the endogenous pH or the specific kind of sucrose present. It reads only, along with the specific composition, sweetened with a particular flavor. Therefore, the pH of each PLM used in the present study was measured using a pH electrode meter. The use of a portable standard digital pH meter has the advantage that many samples/subjects could be investigated within a short period.[1],[19] The pH of the liquid medicaments ranged between 6.05 (Salbid ®) and 7.71 (Theopid ®). Lima et al.[19] and Grenby [33] observed that the pH of many drugs are below critical pH. Cavalcanti et al.[34] reported very low pH values in four out of seven pediatric antitussive medicines tested. One of the medicines (Mucolin ®) presented an extremely low pH of 2.65. Greenwood reported an acidic pH of 2.86 in a liquid syrup.[12] Previous Brazilian studies have demonstrated that several pediatric syrups present endogenous pH below the critical pH of 5.5, ranging from 2.64 to 5.4.[20],[35]

Sugar is used as a vehicle for medicines and it is included in nearly all the formulations prepared, especially for children. The amount of sucrose present in PLM varies from 0% to 67%.[11],[19] Concentrations of sucrose ranging from 11% to 86% were observed in 10 of 23 samples.[19] An Indian study reported the presence of sugars in a range of 20.62%–68.26% in PLM.[3] Pomarico et al.[36] observed the presence of sucrose in seven of the ten samples studied, ranging between 5 and 54 g%. Some studies have shown that the sugar content in pediatric syrups ranged from 12.0% to 54.87%.[20],[29] Investigators stated that, when sugar containing liquid medicaments given to chronically sick children for prolonged period, they pose potential threat to their dental health.[15],[29]

As dental caries is irreversible in nature, a true caries test on human subjects would be unethical. Studies have shown that changes in the pH of human dental plaque following ingestion of food can be correlated with acidogenic and cariogenic potential of the consumed food.[37],[38] Fosdick et al.[22] proposed evaluating the magnitude of plaque pH response, following ingestion of food. In the present study, a modification to this technique as suggested by Frostell [23] was used. The age of plaque is an important factor for plaque pH measurement. In a study, in terms of pH changes, the 2-day-old plaque responded more rapidly than older, mature plaque when exposed to fermentable carbohydrates.[39] Hence, in the present study, oral prophylaxis was performed and volunteers were instructed not to brush their teeth for 48 h before taking the pH measurements. Thus, there was an optimal responsiveness to carbohydrate challenge.

The resting plaque pH usually ranges between 6 and 7.[40],[41] We also observed the resting plaque pH between 6 and 7. Similar observations were also made by other authors,[42],[43],[44] and they concluded that this value of resting pH is not related to the caries prevalence. However, there will be drop in the plaque pH when liquid preparations with sugar and acids or low pH is consumed. Oral bacteria are able to metabolize the sugars present in the liquid medicaments, decreasing the oral pH.[15] Lökken et al.[45] suggested that the cariogenic potential present in medicines is due to the presence of sucrose and its availability to the oral plaque bacteria. Bibby [41] showed that sucrose, glucose, and fructose had the same effect on the plaque acidity.

In the present study, a significant decrease in plaque pH was recorded after oral rinsing with PLM. Maximum fall was recorded in most of the volunteers; pH drop was seen within 5 min of rinse of PLM. The greatest pH fall may be due to the prolonged period of exposure to PLM which could expose the teeth to low pH. Our findings were similar to earlier studies.[1],[2],[14],[19],[21],[45],[46] Among all the PLMs, Crocin ® showed maximum drop in plaque pH. This may be due to the presence of high amount of sucrose. In all the volunteersexposed to PLM, there was a gradual recovery of the oral pH to the near-normal value within 60 min. This can be due to the salivary buffering system (mainly bicarbonates), which gets activated with the increased salivary secretion and occurs due to an acidogenic challenge. If the low pH remains for prolonged period and reaches the so-called “critical pH,” it initiates dissolution of enamel. It was reported that the solubility of dental tissues increases by a factor of 7–8 with each decrease of pH by 1 unit, thereby significantly increasing the potential risk of demineralization.[47] Among the PLMs included in our study, none of them caused the drop in the plaque pH to critical pH (5.5). This may not mean that enamel decalcification may not occur in such situations as it was observed in previous studies that dissolution of enamel may also occur due to chelation. Chelation means the removal of ions by “clawing” them from their surroundings even at a neutral pH.[48]

It is incumbent for us as dentists to provide appropriate counseling tailored for particular individual. First, all physicians can arrange an early parental counseling with a pediatric dentist or general dentist. This will get the oral hygiene measures underway as soon as the first incisors erupt. Parents and professionals should enhance their knowledge about acidogenic and cariogenic potential of PLM. Dentists who work in hospitals and health centers along with doctors should influence the doctors in prescribing sugar-free PLM. Dentists who treat chronically sick children who are taking long-term sugar containing medicines should suggest using sugar-free alternative. Recommendations have to be made to pharmaceutical industries to produce sugar-free medicines. A public health policy must be implemented to limit sugar in medicines.

This study analyzed only a small number of PLMs which are routinely used in the pediatric practice on adult volunteers. Future studies should assess the deleterious effects of PLMs which are used by medically compromised children. Furthermore, ill effect of these PLMs on primary teeth should be known as these PLMs are used by young children.

All the tested PLMs showed highest fall in plaque pH within 5 min of rinsing, and there was gradual recovery of the oral pH to the near-normal value within 60 min.

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Conflicts of interest

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  [Table 1], [Table 2]

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