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Susceptibility of Human Deciduous Enamel to Erosive Wear after Exposure to Commonly Prescribed Oral Pediatric Liquid Medicaments: An AFM Based in vitro Analysis

Sandleen Feroz , Sidra Aamir, Shazia Nawabi
International Journal of Dental Sciences and Research. 2018, 6(5), 138-142. DOI: 10.12691/ijdsr-6-5-6
Received August 03, 2018; Revised September 13, 2018; Accepted September 28, 2018

Abstract

Aim: The aim of this in vitro analysis was to determine the effects of various commonly prescribed pediatric oral liquid medicaments on deciduous teeth. Material and methods: Thirty extracted human deciduous incisors were cleaned and then sectioned longitudinally resulting in 60 samples from a total of 30 tooth samples. After polishing all samples were randomly divided into three groups. Group 1: untreated group, Group 2: Immersion of samples in Paracetamol (sugar-free), Group 3: Immersion of samples in Chlorpheniramine. All the tooth samples in Group 2 and 3 were exposed to twenty cycles of 15 seconds immersion at 6 hours’ interval. The root mean square roughness (Rrms) was calculated for surface roughness assessment from the AFM images. Anova and Tuckey’s post hoc test were used to analyze the differences in mean roughness values between the three groups. Results: One way Anova showed a statistically significant differences (p-value of 0.00) between the mean roughness values of three groups. Furthermore, Tuckey post hoc test revealed a statistically significant difference between the surface roughness values of Group 2 and Group 3 (0.158±0.012) and between Group 1 and Group 2 (0.085±0.012), indicating that mean surface roughness values increased significantly after frequent exposures to pediatric oral liquids. Conclusion: The tested pediatric oral liquids could significantly increases the surface roughness values of all treated tooth surfaces giving encorughment to the erosive potential of these oral liquid medicaments towards more enamel loss.

1. Introduction

Dental erosion also referred as acid erosion is a process of irreversible loss of tooth substance (chemical dissolution) due to the acids whose source of production could be extrinsic or intrinsic. Most commonly included intrinsic sources are recurrent vomiting, regurgitation or gastro esophageal reflux, whereas, extrinsic agents are acidic food and drinks (like carbonated drinks, sports drinks, wines etc) 1. In oral cavity our teeth are continuously exposing to cycles of demineralization and remineralization, but this delicate cycle can easily be disturbed due to extensive consumption of acidic drinks which ultimately leads to dissolution of inorganic tooth substance 2. This process of chemical dissolution, if not timely treated, may also cause tooth sensitivity, reduce tooth vertical dimension, pulpal exposure and inflammation (in severe cases) 3, 4.

In developing countries like Pakistan, prevalence of dental erosion along with dental caries is very high not only in adults but in adolescent and children due to dietary habits and lack of standardized guidelines for diagnosis 5, 6. Studies showed that primary dentition is more prevalent to surface enamel loss mainly due to thin enamel layer and greater susceptibility to acidic dissolution as compare to permanent dentition 7, 8, 9. Therefore, children on long term medications to treat various chronic diseases like asthma, epilepsy, allergies are more likely to show enamel surface loss due to dental erosion 10. Mostly the drugs prescribed to children are in liquid form, colored, sweetened and flavored to mask their bitter tastes. Besides the main active ingredients various additives like flavoring agents, sweeteners, acids, preservatives and coloring agents are added in most pediatric liquid medications to minimize the unpleasant taste 11. In order to further improve the taste of these pediatric liquid medications mostly acids are added 12, 13. This acidic contents also serves as buffering agents and results in controlling the tonicity of the drug 12.

However, due to the presence of acidic content and fermentable carbohydrate, the frequent use of these flavored pediatric medications showed cariogenic potential 14, 15, 16, 17, 18, 19, 20. A study conducted in 2007 concluded that about half of 97 most commonly prescribed liquid pediatric medications have an endogenous pH level below 5.5 and thus are capable of causing loss of enamel surface layer 12. Additionally, these acidic formulations when consumed by children at night could further aggravate the process of erosion and dental caries 21.

Recently many pharmaceutical companies have introduce sugar-free pediatric liquid medications but this reduction of sugary contents results in the addition of weak acids, to enhance their palatability concerns and other properties, which might cause tooth surface loss due to acid erosion 19. However, there is still dearth of information regarding the erosive potential of most commonly prescribed sugar containing and sugar-free pediatric medications.

The aim of this in vitro analysis is to evaluate the effects of most commonly prescribed pediatric medications on enamel surface by the aid of Atomic Force Microscope Nano indentation.

2. Methodology

2.1. Sample Preparation

Thirty human deciduous incisors used in this in – vitro analysis were extracted from children 2-6 years old. The parents signed the written consent form that the extracted teeth could be used for the purpose of this experimental study. After removing the soft tissue debris by ultrasonic scalar further disinfection was done by immersion in sodium hypo chloride solution (5%) for one hour. The radicular portion of the tooth samples were separated from the coronal portion using slow speed cutting machine (Laizhou weiyi Co.Ltd Model DTQ-5) under running water. The labial portion of each incisor was further sliced longitudinally parallel to its long axis so that 60 tooth samples were obtained from 30 extracted primary incisors. The labial surfaces of enamel sections were polished using silica carbide paper ( grades 600-1200) and then fixed in position within the preform Teflon molds ( 10mm x 8mm x 2mm) by flow able composite resin.

2.2. Oral Liquid Medicaments

Most commonly prescribed pediatric drugs to relieve some respiratory symptoms were chosen to serve as a demineralizing bath to induce dental erosion, i.e., Paracetamol and Chlorpheniramine. Paracetamol (Glaxo SmithKline Pakistan Limited) is classified as mild analgesic to treat fever, headache and is also available in “sugar-free” composition. To relieve the allergic symptoms and common cold an anti-histamine such as Chlorpheniramine (Ferozsons Laboratories LTD) is mostly prescribe. Pediatric oral liquids from two different brands were selected to make a comparison. The Chlorpheniramine group (Bronochol syrup) contains sugar while the Paracetamol (Panadol Syrup) belongs to sugar free type. All these drugs were purchased from local pharmacies of Islamabad, Pakistan.

2.3. Surface Roughness Assessment

For surface roughness evaluation images were taken with Atomic Force Microscopy Auto Probe CP 100 equipped with piezoelectric scanner of tapping mode. At least ten different film areas were used for root mean square (Rrms) calculation with a resolution of 256 x 256 pixels.

2.4. pH Measurement

The pH of the testing liquid medicaments was measured at room temperature (20 C) by using Digital pH meter. All the primary tooth specimens were then assigned to the following three groups (n=10) as shown in Table 1. The samples placed in Group 1 were not exposed to any treatment. However, to evaluate the erosive potential of medications enamel sections in Group 2 and 3 were subjected to twenty consecutive rounds of 15 seconds immersion in 10 ml of medicated liquids at 6 hour intervals at room temperature. Before and after exposure to different liquid medicaments all specimens were stored in a 100 ml deionizing water.

3. Statistical Analysis

Data was analyzed by using SPSS 11.O software. The mean roughness values of different groups were compared by using ANOVA. To determine the differences among three groups Tuckey’s post hoc test were then performed.

4. Results

4.1. pH Values

The pH value of all three groups have been shown in the Table 2. The values indicate that all the pediatric oral medicaments exhibited an acidic pH.

4.2. Mean Surface Roughness Values

The mean surface roughness values have been shown in Table 3. One way Anova showed a statistically significant differences (p-value of 0.00) between the mean roughness values of three groups. Furthermore, Tuckey post hoc test revealed a statistically significant difference between the surface roughness values of Group 2 and Group 3 (0.158±0.012) and between Group 1 and Group 2 (0.085±0.012), indicating that mean surface roughness values increased significantly after frequent exposures to pediatric oral liquids.

Figure 1 shows untreated tooth samples (Group 1). Figure 2 and Figure 3 reveals enamel surfaces after exposure to two different oral medicaments (Group 2 & 3)

5. Discussion

The erosive effects of medicated paediatric oral liquids using AFM has not been addressed in literature till now. The bleaching effects of various agents were first studied with the aid of AFM by Hegedus et al who compared the results obtained from SEM with those of AFM 22. AFM is an important modern tool to study the effects of various paediatric liquid medicaments on enamel surfaces as it provides high resolution images. The topographic features of polished tooth surfaces were observed by using tapping mode AFM (TM AFM) and net differences in the mean surface roughness values between exposed and un exposed enamel surfaces were calculated. Thus AFM based nano indentation helps to accurately identify the remineralized and demineralized tooth surfaces 1.

The erosive effects of two different, most commonly prescribed, paediatric liquid medicaments were studied and then compared with untreated tooth surfaces. The results suggested a statistically significant difference with a p – value of 0.00 indicating the demineralizing effect of these drugs on tooth surface. Enamel subsurface, more frequently seen on the deciduous teeth surfaces, is less mineralized than enamel surface. In order to minimize the natural enamel surface variations between different teeth, which respond in a different manner to acidic dissolution, polished tooth specimens were used 23. However, these polished enamel surfaces exhibit more dissolution of surface layer as compared to natural tooth surfaces in the oral cavity. In this in vitro analysis, two most commonly used liquid formulations were used. These pediatric medicaments contained many other constituents besides the active ingredient such as flavouring agent, sweeteners, bulk materials, preservatives and coloring agents etc. Acidic content of these liquid medicaments not only improved palatability but also helped to maintain chemical stability, tonicity and physiological compatibility. Most commonly added acid in these formulations was citric acid. According to studies frequent exposure to citric acid has been linked directly to tooth erosion due to its ability cause acidic dissolution of hydroxyapatite crystals. Similarly, lactic acid at low pH conditions proven to be more erosive than citric and maleic acid.

The deciduous tooth surfaces of Group B & C were exposed to 20 cycles of 15 seconds immersion in their respective drugs. The enamel sections in group B were exposed to sugar free composition of Paracetamol (pH 4.6) exhibit lower values of mean surface roughness values (0.144±0.018) as compared to mean surface roughness (Rrms) values of tooth samples in Group C (0.301±0.054).

Mean surface roughness assessment of enamel surfaces revealed that both sugar containing and sugar-free liquid medications have erosive potential. However, more extensive clinical studies are required in this regard to minimize the risk of erosion during frequent consumption of these liquid formulations by children.

6. Conclusion

Within the limitations of this in vitro analysis, it can be concluded that all the samples showed increase in the values of surface roughness after exposure to all the tested medicated pediatric oral liquids. Thus there is a possible association between the formulation of theses liquid medicaments and tooth surface erosion.

References

[1]  Poggio C LM, Dagna A, Chiesa M, Bianchi S. Protective effect on enamel demineralization of a CPP-ACP paste: An AFM invitro study. J Dent 2009; 37:949-954.
In article      View Article  PubMed
 
[2]  Padma Gandi MS, Sangeeta Meena and Pallavi Waghmare. Comparative Study on remineralizing ability of Casein hosphopeptide Amorphous calcium phosphate and b-tricalcium phosphate on dental erosion: An invitro AFM Study. Gandi et al, Dentistry, 2015; 5:8.
In article      
 
[3]  Lazarchik DA, Filler SJ. Effects of gastroesophageal reflux on the oral cavity. The American journal of medicine. 1997; 103(5): 107-13.
In article      View Article
 
[4]  Harley K. Tooth wear in the child and the youth. British dental journal. 1999; 186(10).
In article      View Article
 
[5]  A. L. Erosive tooth wear_ a multifactorial condition of growing concern and increasing knowledge. Monogr Oral Sci 20: 1-8. 2006.
In article      View Article  PubMed
 
[6]  Jaeggi TLA. Prevalence, Incidence and distribution of erosion. Monogr Oral Sci 20:44-65. 2006.
In article      View Article  PubMed
 
[7]  Bartlett D, Coward P, Nikkah C, Wilson R. The prevalence of tooth wear in a cluster sample of adolescent schoolchildren and its relationship with potential explanatory factors. British dental journal. 1998; 184(3): 125-9.
In article      View Article  PubMed
 
[8]  Shaw L, Smith A. Paediatric Dentistry: Dental erosion-the problem and some practical solutions. British dental journal. 1999; 186(3): 115-8.
In article      View Article
 
[9]  Milosevic A, Young P, Lennon M. The prevalence of tooth wear in 14-year-old school children in Liverpool. Community Dental Health. 1994; 11(2): 83-6.
In article      PubMed
 
[10]  Neves, B.G.; Farah, A.; Lucas E.; de Sausa, V.P.; Maia, L.C. Are paediatric medicines risk factors for dental caries and dental erosion? Commun. Dent. Health 2010, 27, 46-51.
In article      PubMed
 
[11]  Mennella, J.A.; Spector, A.C.; Reed, D.R.; Coldwell, S.E. The bad taste of medicines: Overview of basic research on bitter taste. Clin. Ther .2013, 35, 1225-1246.
In article      View Article  PubMed
 
[12]  Maguire, A.; Baqir, W.; Nunn, J.H. Are sugars-free medicines more erosive than sugars-containing medicines? An in vitro study of paediatric medicines with prolonged oral clearance used regularly and long-term by children. Int. J.Paediatr. Dent. 2007, 17, 231-238.
In article      View Article  PubMed
 
[13]  Liem, D.G.; Mennella, J.A. Heightened sour preferences during childhood. Chem. Senses 2003, 28, 173-180.
In article      View Article  PubMed
 
[14]  Marquezan, M.; Pozzobon, R.,; Oliveira, M. Medicines used by pediatric dentistry patients and its cariogenic potential. RPG Rev.Pos. Grad. 2007, 13, 334-339.
In article      
 
[15]  Durward, C.; Thou, T. Dental caries and sugar-containing liquid medicines for children in New Zealand. N.Z.Dent. J.1997, 93, 124-129.
In article      PubMed
 
[16]  Feigal, R.J.;Jensen , M.E.;Mensing , C.A. Dental caries potential of liquid medications. Pediatrics 1981, 68,416-419.
In article      PubMed
 
[17]  Babu, K.L.; Doddamani, G.M., Naik, L.R.; Jagadeesh, K.N. Pediatric liquid medicaments- Are they cariogenic? An in vitro study. J. Int. Soc. Prev. Commun. Dent.2014, 4, 108-112.
In article      View Article  PubMed
 
[18]  Arora , R.; Mukherjee, U.; Arora , V. Erosive potential of sugar free and sugar containing pediatric medicines given regularly and long term to children. Indian J. Pediatr. 2012, 79, 759-763.
In article      View Article  PubMed
 
[19]  Babu, K.L.G.; Rai, K.; Hedge, A.M. Pediatric liquid medicaments – Do they erode the teeth surface? An in vitro study: Part I. J. Clin. Pediatr. Dent .2008, 32, 189-194.
In article      View Article  PubMed
 
[20]  Sahgal, J.; Sood, P.B.; Raju, O.S. A comparison of oral hygiene status and dental caries in children on long term liquid oral medications to those not administered with such medications. J. Indian Soc. Pedod. Prev. Dent. 2002, 20,144-151.
In article      PubMed
 
[21]  Cavalcanti, A.; de Oliveira, K.; Xavier , A.; Pinto, D.; Vieira, F. Evaluation of total soluble solids content (TSSC) and endogenous ph in antimicrobials of pediatric use. Indian J.Dent. Res. 2013, 24, 498-501.
In article      View Article  PubMed
 
[22]  Hegedus C BT, Flora-Nagy F, Keszthelyi G, Jenei A. “An atomic force microscopy study on the effect of bleaching agents on enamel surface”. J Dent ; 27: 509-15. 1999.
In article      View Article
 
[23]  Adebayo OA BM, Tyas MJ. “An SEM evaluation of conditioned and bonded enamel following carbamide peroxide bleaching and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) treatment”. J Dent; 37: 297-306. 2009.
In article      View Article  PubMed
 

Published with license by Science and Education Publishing, Copyright © 2018 Sandleen Feroz, Sidra Aamir and Shazia Nawabi

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Cite this article:

Normal Style
Sandleen Feroz, Sidra Aamir, Shazia Nawabi. Susceptibility of Human Deciduous Enamel to Erosive Wear after Exposure to Commonly Prescribed Oral Pediatric Liquid Medicaments: An AFM Based in vitro Analysis. International Journal of Dental Sciences and Research. Vol. 6, No. 5, 2018, pp 138-142. http://pubs.sciepub.com/ijdsr/6/5/6
MLA Style
Feroz, Sandleen, Sidra Aamir, and Shazia Nawabi. "Susceptibility of Human Deciduous Enamel to Erosive Wear after Exposure to Commonly Prescribed Oral Pediatric Liquid Medicaments: An AFM Based in vitro Analysis." International Journal of Dental Sciences and Research 6.5 (2018): 138-142.
APA Style
Feroz, S. , Aamir, S. , & Nawabi, S. (2018). Susceptibility of Human Deciduous Enamel to Erosive Wear after Exposure to Commonly Prescribed Oral Pediatric Liquid Medicaments: An AFM Based in vitro Analysis. International Journal of Dental Sciences and Research, 6(5), 138-142.
Chicago Style
Feroz, Sandleen, Sidra Aamir, and Shazia Nawabi. "Susceptibility of Human Deciduous Enamel to Erosive Wear after Exposure to Commonly Prescribed Oral Pediatric Liquid Medicaments: An AFM Based in vitro Analysis." International Journal of Dental Sciences and Research 6, no. 5 (2018): 138-142.
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[1]  Poggio C LM, Dagna A, Chiesa M, Bianchi S. Protective effect on enamel demineralization of a CPP-ACP paste: An AFM invitro study. J Dent 2009; 37:949-954.
In article      View Article  PubMed
 
[2]  Padma Gandi MS, Sangeeta Meena and Pallavi Waghmare. Comparative Study on remineralizing ability of Casein hosphopeptide Amorphous calcium phosphate and b-tricalcium phosphate on dental erosion: An invitro AFM Study. Gandi et al, Dentistry, 2015; 5:8.
In article      
 
[3]  Lazarchik DA, Filler SJ. Effects of gastroesophageal reflux on the oral cavity. The American journal of medicine. 1997; 103(5): 107-13.
In article      View Article
 
[4]  Harley K. Tooth wear in the child and the youth. British dental journal. 1999; 186(10).
In article      View Article
 
[5]  A. L. Erosive tooth wear_ a multifactorial condition of growing concern and increasing knowledge. Monogr Oral Sci 20: 1-8. 2006.
In article      View Article  PubMed
 
[6]  Jaeggi TLA. Prevalence, Incidence and distribution of erosion. Monogr Oral Sci 20:44-65. 2006.
In article      View Article  PubMed
 
[7]  Bartlett D, Coward P, Nikkah C, Wilson R. The prevalence of tooth wear in a cluster sample of adolescent schoolchildren and its relationship with potential explanatory factors. British dental journal. 1998; 184(3): 125-9.
In article      View Article  PubMed
 
[8]  Shaw L, Smith A. Paediatric Dentistry: Dental erosion-the problem and some practical solutions. British dental journal. 1999; 186(3): 115-8.
In article      View Article
 
[9]  Milosevic A, Young P, Lennon M. The prevalence of tooth wear in 14-year-old school children in Liverpool. Community Dental Health. 1994; 11(2): 83-6.
In article      PubMed
 
[10]  Neves, B.G.; Farah, A.; Lucas E.; de Sausa, V.P.; Maia, L.C. Are paediatric medicines risk factors for dental caries and dental erosion? Commun. Dent. Health 2010, 27, 46-51.
In article      PubMed
 
[11]  Mennella, J.A.; Spector, A.C.; Reed, D.R.; Coldwell, S.E. The bad taste of medicines: Overview of basic research on bitter taste. Clin. Ther .2013, 35, 1225-1246.
In article      View Article  PubMed
 
[12]  Maguire, A.; Baqir, W.; Nunn, J.H. Are sugars-free medicines more erosive than sugars-containing medicines? An in vitro study of paediatric medicines with prolonged oral clearance used regularly and long-term by children. Int. J.Paediatr. Dent. 2007, 17, 231-238.
In article      View Article  PubMed
 
[13]  Liem, D.G.; Mennella, J.A. Heightened sour preferences during childhood. Chem. Senses 2003, 28, 173-180.
In article      View Article  PubMed
 
[14]  Marquezan, M.; Pozzobon, R.,; Oliveira, M. Medicines used by pediatric dentistry patients and its cariogenic potential. RPG Rev.Pos. Grad. 2007, 13, 334-339.
In article      
 
[15]  Durward, C.; Thou, T. Dental caries and sugar-containing liquid medicines for children in New Zealand. N.Z.Dent. J.1997, 93, 124-129.
In article      PubMed
 
[16]  Feigal, R.J.;Jensen , M.E.;Mensing , C.A. Dental caries potential of liquid medications. Pediatrics 1981, 68,416-419.
In article      PubMed
 
[17]  Babu, K.L.; Doddamani, G.M., Naik, L.R.; Jagadeesh, K.N. Pediatric liquid medicaments- Are they cariogenic? An in vitro study. J. Int. Soc. Prev. Commun. Dent.2014, 4, 108-112.
In article      View Article  PubMed
 
[18]  Arora , R.; Mukherjee, U.; Arora , V. Erosive potential of sugar free and sugar containing pediatric medicines given regularly and long term to children. Indian J. Pediatr. 2012, 79, 759-763.
In article      View Article  PubMed
 
[19]  Babu, K.L.G.; Rai, K.; Hedge, A.M. Pediatric liquid medicaments – Do they erode the teeth surface? An in vitro study: Part I. J. Clin. Pediatr. Dent .2008, 32, 189-194.
In article      View Article  PubMed
 
[20]  Sahgal, J.; Sood, P.B.; Raju, O.S. A comparison of oral hygiene status and dental caries in children on long term liquid oral medications to those not administered with such medications. J. Indian Soc. Pedod. Prev. Dent. 2002, 20,144-151.
In article      PubMed
 
[21]  Cavalcanti, A.; de Oliveira, K.; Xavier , A.; Pinto, D.; Vieira, F. Evaluation of total soluble solids content (TSSC) and endogenous ph in antimicrobials of pediatric use. Indian J.Dent. Res. 2013, 24, 498-501.
In article      View Article  PubMed
 
[22]  Hegedus C BT, Flora-Nagy F, Keszthelyi G, Jenei A. “An atomic force microscopy study on the effect of bleaching agents on enamel surface”. J Dent ; 27: 509-15. 1999.
In article      View Article
 
[23]  Adebayo OA BM, Tyas MJ. “An SEM evaluation of conditioned and bonded enamel following carbamide peroxide bleaching and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) treatment”. J Dent; 37: 297-306. 2009.
In article      View Article  PubMed