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Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 119-125

Scanning Electron Microscopic Evaluation of Erosive Potential of Pediatric Liquid Medicaments on Primary Teeth

1 Department of Pedodontics and Preventive Dentistry, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India
2 Department of Oral and Maxillofacial Pathology, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India
3 Department of Public Health, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India

Date of Submission30-Sep-2020
Date of Decision30-Nov-2020
Date of Acceptance11-Dec-2020
Date of Web Publication16-Feb-2021

Correspondence Address:
Dr. Mantri Pushpanjali
Department of Pedodontics and Preventive Dentistry, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jofs.jofs_229_20

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Introduction: Pediatric liquid medicaments (PLMs) are the most accepted form of medication prescribed for children to treat different infirmities, however, their harmful effects on a child’s dental health are unaware for most of us. The present in vitro study was aimed to evaluate the erosive potential of two commonly used PLM’S on primary teeth and the remineralizing potential of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) paste on these erosive lesions. Materials and Methods: Forty deciduous teeth were randomly assigned to five groups (n = 8) in which group I samples were treated with Meftagesic-P, group II with Kofarest-PD, group III with Meftagesic P + CPP-ACP paste, group IV with Kofarest-PD + CPP-ACP paste, and group V samples were immersed in artificial saliva (control). Photomicrographs were taken at 2000× and 5000× magnification using a scanning electron microscope (SEM). Results: SEM photomicrographs elicited erosive changes in the enamel surface of all the samples in both groups I and II, however, the erosive changes in group II samples were more pronounced. The enamel surface of group III and IV samples that were treated with CPP-ACP after exposure to medicaments showed remineralization of erosed areas. Conclusion: Both the PLMs used in the study showed an erosive effect on the primary enamel surface. The severity of erosion increased with the exposure time. However, the application of CPP-ACP paste following the exposure to PLMs showed noticeable remineralization.

Keywords: Casein phosphopeptide amorphous calcium phosphate, dental erosion, pediatric liquid medicaments, remineralization, scanning electron microscope

How to cite this article:
Pushpanjali M, Sai Sankar AJ, Sridevi E, Sankar KS, Kumar KK, Balaji K. Scanning Electron Microscopic Evaluation of Erosive Potential of Pediatric Liquid Medicaments on Primary Teeth. J Orofac Sci 2020;12:119-25

How to cite this URL:
Pushpanjali M, Sai Sankar AJ, Sridevi E, Sankar KS, Kumar KK, Balaji K. Scanning Electron Microscopic Evaluation of Erosive Potential of Pediatric Liquid Medicaments on Primary Teeth. J Orofac Sci [serial online] 2020 [cited 2021 Aug 5];12:119-25. Available from:

  Introduction- Top

Diseases can be devastating for anyone, but it seems particularly unfair because of their belligerent nature when they affect children. Poor dietary, hygiene practices and feebly developed immunological defenses increase the predisposition of children to diseases. To tackle such conditions, medicines in liquid form are widely used to facilitate easy administration. Apart from having main active ingredients medications are usually colored, flavored, and sweetened with various excipients such as acids and sugars to improve their palatability and shelf life. Long-term or frequent usage of these medications with low pH values will have a high erosive and cariogenic effect on primary teeth.[1] Over the past decade, there is a decline in the caries prevalence worldwide, however, it has been accompanied by a remarkable increase in the incidence of noncarious lesions, such as dental erosion, that lead to an irreversible loss of tooth structure.

It is currently recognized as a challenging clinical condition affecting the younger age group, as deciduous teeth are more susceptible to erosion compared to their permanent successors because of the softer, thinner, and less mineralized enamel.[2] In the event of illness consumption of medicines at bedtime, reduced salivary flow, content, and prolonged salivary clearance time have also been linked to its increased prevalence. Erosion in children may lead to various clinical problems such as dental hypersensitivity, altered occlusion, eating difficulties, poor aesthetics, pulpal exposure, and abscesses. Therefore, it is important to prevent and control the progression of these erosive lesions that can be achieved by removing the cause and the factors that enhance it or making the tooth more resistant to acid attack.[3]

Over the years with clinically proven research, fluoride has been documented to promote remineralization, however, the distribution of fluoride is not the same throughout the world, there are some areas with endemic fluoride which may increase the risk of toxicity.[4] To overcome these drawbacks newer remineralizing agents were developed that are derived from a major protein found in milk called casein. The casein phosphopeptide (CPP) binds to amorphous calcium phosphate (ACP) in metastable solution preventing the dissolution of calcium and phosphate ions. The ACP-CPP also acts as a reservoir of bio-available calcium and phosphate, and maintains the solution supersaturated, thus facilitating remineralization.[5]

Many studies have emphasized the erosive potential of Pediatric liquid medicaments (PLMs) on primary teeth but the surface changes after application of remineralizing agents have not yet been evaluated to date. Thus, considering these facts, the present in vitro study was aimed to analyze the surface changes of the enamel caused by the consumption of PLM’s and subsequent remineralization of erosive lesions following the application of CPP-ACP paste under SEM.

  Materials and Methods Top

Ethical approval for this study (protocol no: 30/IEC/SIBAR/2015) was provided by the Ethical Committee of SIBAR Institute of dental sciences, Guntur. On 8 November 2015. The sample included sound human caries-free primary teeth (either extracted for orthodontic reasons, over-retained, or exfoliated teeth). Carious, hypoplastic, discolored teeth, and teeth with cracked areas and white spots were excluded from the study. The selected teeth were washed, cleaned of debris, and were stored in thymol solution until further use. The sample size was determined using G* power The power of the study was 80%, the effect size was 1.518, Type I error was 0.05, and the sample size derived was 40. The teeth were randomly divided into five groups with eight teeth in each using the computer randomization method. Group I samples were treated with Meftagesic-P (Medication I); Group II with Kofarest–PD (Medication II); Group III: Medication I + CPP-ACP paste (GC Tooth Mousse, GC India Dental Private Limited, Europe); Group IV: Medication II + CPP-ACP paste, and Group V samples are kept in artificial saliva [Table 1]. The viscosity of PLMs and the artificial saliva was measured in centipoises (cP) using a calibrated digital rotational viscometer (ViscoStar Plus, Funjilab, Spain).
Table 1 Table showing the composition, pH, viscosity, and uses of medicaments and CPP-ACP

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Viscosity of Medication I, II, and artificial saliva were 401.54 ± 0.60 cP, 508.41 ± 7.10 cP, and 15.5 ± 2.8 cP, respectively. The total sugar content of Medication I was 73% wt/wt and Medication II was 77% wt/wt, which was determined by the volumetric method.

The pH of the medicaments used in the study was determined using a pH meter that was calibrated with standard solutions between each measurement for accuracy. The values obtained for medication I, II, and artificial saliva were 6.31, 5.66, and 7.2, respectively.

Immersion cycling protocol proposed by Lussi and Amechi et al.[2] was adopted to simulate the usual number of intakes by the patients. Group I and II samples were immersed in 5 mL undiluted syrups in separate air-tight containers and agitated using a magnetic stirrer bath (300 rpm) for a period of 2 minutes thrice daily for a test period of 28 days. Later the samples were washed using distilled water and placed in 10 mL of artificial saliva at 37°C until the next immersion cycle. Fresh medicament was used for each immersion.

After treating the groups III and IV samples with their respective medicaments, they were washed with distilled water and stored in artificial saliva for 30 minutes. Later CPP-ACP paste was applied on the test site of the samples for 3 minutes using gloved finger as per the manufacturer’s instructions. Further these samples were washed with distilled water and stored in artificial saliva. This procedure is repeated thrice daily for the whole test period.

Group V (Control) samples were preserved in artificial saliva for the whole test period and the solution was changed daily. The specimens were analyzed for surface changes under SEM at the end of 7, 14, 21, and 28 days. The mesio-buccal surface of the test site of each tooth was scanned and photomicrographs were taken at 2000× and 5000× magnifications, respectively.

Photomicrographs in all the groups were examined for the surface erosion and remineralizing changes in the enamel. The entire procedure was performed by a single operator. However, to avoid bias, a second operator who was unaware of the prior results evaluated the samples randomly. An interexaminer reliability statistic of 0.93 was achieved indicating excellent agreement (intraclass correlation coefficient = 0.93), hence the prior observations were only considered.

  Results Top

Qualitative analysis of the SEM photomicrographs [Figure 1] showed erosive changes in the enamel surface of all the samples in both groups I and II. The intensity of surface changes increased with the exposure time. The erosive changes produced in group II samples were more pronounced than those of group I samples.
Figure 1 Evident irregularities on the enamel surface with prominent enamel rods with focal areas of distorted enamel rods after 28 days (group II).

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After 28 days, the SEM images of group II samples clearly displayed structural loss with hardly identifiable enamel prisms [Figure 1]. Group I specimens exhibited a noticeable structural loss. The surface was irregular with small enamel depressions, with areas of enamel prisms and interprismatic substance [Figure 2]. No microstructure alterations were observed in group V specimens [Figure 3]. The photomicrographs of groups III and IV where the teeth samples were treated with CPP-ACP paste after exposing to medicaments revealed deposition of hyperdense amorphous substance in the prismatic areas of enamel surface indicating the significant amount of remineralization [Figure 4] and [Figure 5] when compared to samples in groups I and II, and also the amount of remineralization increased with timeperiod.
Figure 2 Irregular surface with areas of enamel prisms and inter prismatic substance were noticed after 28 days (group I).

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Figure 3 Smooth enamel surface with small elevations were observed after 28 days (group V).

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Figure 4 After 28 days enamel surface showed hyperdense areas with round- to ovoid-shaped enamel rods (group III).

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Figure 5 Surface illustrates smooth hyperdense areas covering the enamel rods after 28 days (group IV).

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When endogenous pH, viscosity, and total sugar contents of both the medicaments were compared. Medication II showed low pH (5.66), viscosity (508.41±7.10), and increased total sugar content (77%) than medication I (6.31; 401.54 ± 0.60; 73%).

  Discussion Top

Medications are becoming a part of the daily routine for children because of their increased susceptibility to diseases compared to adults.[6] But children differ from adults in many aspects of drug pharmacokinetics, pharmacodynamics, potential routes of administration, medicine-related toxicity, and taste preferences. Among the routes of drug administration, the oral route is the most preferred one in children. As solid forms of the drugs are associated with the risk of choking, PLMs were preferred in younger children because of their ease and simple mode of administration.

In order to improve the patient’s acceptance and palatability, various ingredients are added to the PLMs along with their main active ingredients. The frequent usage of PLMs that are acidified with acids such as citric and malic acids and sweetened with sucrose, fructose, or a combination of both has been linked to causing dental erosion, caries, and a drop in the plaque pH.[7],[8]

The deleterious effect of PLM’s was first studied by Imfeld way back in 1953. But Maguire et al.[9] in their study reported that over half of the PLMs surveyed had pH values significantly below the critical pH and have high erosive potential. Studies done by Greenwood et al.[10]- and Mackie and Hobson[11] have confirmed that these preparations were cariogenic and acidogenic in nature.

Development of erosion is a complex process and occurs either by hydrogen ion attack or by the action of chelating anions that combine with carbonate, phosphate, or both, and detach the mineral ions from the surface. The result of exposure to erosive agents decreases enamel microhardness, which upon exposure to mechanical forces, makes the surface more susceptible to disruption.[12]

The biological factors that play a crucial role during an erosive challenge involve mainly the salivary protective mechanisms such as dilution and clearance of an erosive agent from the mouth, neutralization and buffering of acids, and slowing down the rate of enamel dissolution.[13] Numerous studies that evaluated the relationship between various salivary parameters and the risk of dental erosion have supported the protective value of saliva, with the strongest association of decreased salivary flow rate and low buffering capacity.[14]

Dental erosion is more prevalent in children due to reduced salivary flow and content that prolong the salivary clearance rate, thus making the nocturnal exposure to erosive agents more destructive. Moreover, studies have reported that 75.7% of parents would use a fever reducer or cough suppressants to relieve their discomfort while the child is partially asleep, which further increases its deleterious effect.[15]

An interesting correlation between erosion and caries arises from the postulation that the acidic oral environment is likely to encourage the growth of acidophilic Streptococcus mutans, thus increasing the individual’s susceptibility to caries. Supporting studies by Kazoullis et al.[16] showed elevated counts of S. mutans and early childhood caries in primary dentition in children with severe erosion. Apart from encouraging the growth of cariogenic bacteria these PLMs contribute to caries indirectly by reducing the salivary secretion and also cause deleterious effects on the restorations.[17]

As it may not be practical to eliminate the cause of tooth wear, it is desirable to develop effective preventive strategies like the usage of topical fluoride, which is considered as a gold standard agent for remineralization. However, to overcome certain drawbacks[18] of fluorides, Longbottom et al.[19] have proposed an ideal remineralizing agent that releases calcium and phosphate ions (CPP-ACP) into the oral environment. This CPP-ACP (GC Tooth Mousse) paste, unlike remineralizing the carious lesions, repairs the eroded tooth structure by depositing the mineral ions into the porous zone rather than crystal regrowth.[20]

Hence, the present in vitro study was conducted to analyze the surface changes of the enamel caused by frequent consumption of PLMs and subsequent remineralization of surface erosive lesions following the application of CPP-ACP paste under SEM.

The commonly prescribed PLMs for the management of conditions such as pyrexia, headache, cold, ear pain, cough, asthma, and acute sore throat by the pediatricians were selected (Meftagesic-P; Kofarest-PD). Both the selected medicaments displayed the ingredients, but none contained any information regarding the pH. Therefore, the pH values were measured using pH electrode meter (Meftagesic-P 6.31; Kofarest-PD 5.66), which are acidic. The findings of the present study were in accordance with the study conducted by Neves et al.[21] in which all the 23 tested pediatric medications showed an acidic pH.

PLMs are usually viscous syrups that penetrate in fissures and proximal areas of teeth that are inaccessible to the toothbrush. Regular and long-term use of these medications with prolonged oral clearance may increase the risk of dental erosion and caries as they contain sugars and acids.[22] Viscosity values of PLMs used in this study were 401.54 ± 0.60 cP (Meftagesic-P) and 508.41 ± 7.10 cP (Kofarest-PD), respectively.

Sugars added to these PLMs are metabolized by bacteria to acidic end-products and lower the plaque pH that causes ionic dissolution of the hydroxyapatite crystals, leading to enamel and dentin demineralization. The total sugar content of medicaments I and II used in this study is 73% and 77%, wt/wt, respectively.

Enamel erosion can be measured by various methods such as loss of enamel weight, SEM, light microscope, microradiograph, image analysis, electron probe analysis, and profilometry. However, in the present study, SEM was used as it is a simple, rapid, and cost-effective method to observe the topographical changes of the enamel.[23]

The results of the present study revealed that both groups I and II showed erosive changes on the enamel surface, whereas the control group (group V) showed no significant surface variations and areas of remineralization on the erosed enamel surface were noticed in group III and IV samples. The surface changes of the enamel in group II samples were more pronounced than group I, which could be due to high viscocity, low pH, and the chelating properties of ambroxol hydrochloride and salbutamol present in Kofarest-PD. Similar results were noticed in a study by Kulkarni et al.[24] in which antitussive drug (Ambrolite-D) showed the highest erosive potential compared to other drugs.

The surface changes were noted from 7th to 28th day in both the groups. In group I samples, the enamel surface illustrated minimum irregularities on the seventh day, whereas irregular enamel surface with areas of enamel prism and areas of inter prismatic substance was observed at 28 days interval. In the case of group II samples on the seventh day, prominent irregular structures with few enamel rods were noticed but at the end of 28 days, irregular surfaces with prominent enamel rods and distorted enamel sheaths were evident. The experimental period of 28 days was chosen to simulate the changes that would happen with long-term usage of these PLMs. Similar results were noticed in studies conducted by Tupalli[25] and Mittal et al.[26]

The photomicrographs of the samples in groups III and IV revealed the deposition of granular structures on the enamel surface that is a sign of remineralization and it was more pronounced in group IV. Similar findings were observed in studies by Ranjitkar[27] and Gaber et al.[27]

The results of this in vitro study may not be completely applicable for clinical situations because of over/underestimation of the values, however, they give a brief overview of the possible consequences. As the presence of pellicle in in vivo conditions will protect the teeth from acidic challenges, even it has been suggested that the amount and quality of saliva, in particular its buffering capacity, were important in the occurrence of dental erosion.[28] From the standpoint of both hard tissue quality and salivary conditions, deciduous teeth seem to be at greater risk from erosive challenges than permanent teeth.

  Conclusion Top

Thus, based on the results obtained from the present study, it can be concluded that both the PLMs were erosive on the primary enamel surface. The antitussive drug used in group II showed more surface changes. The severity of the erosive changes increased with exposure time. Application of remineralizing agents such as CPP-ACP paste following the exposure to PLMs had considerably reduced their erosive effect.

Thus, it is important to educate the professionals and parents about the possible ill effects of long-term usage of PLMs and the importance of using remineralizing agents.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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