Children, possible victims of sucrose medications

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Regardless of the duration of their administration, liquid pediatric medicines containing sugar increase the risk of cavities among children with chronic diseases.

Pediatricians, unlike pediatricians dentists, have the opportunity and the privilege to be the first to influence the importance of oral health as part of general health, given that they establish the first care and monitoring contact with young patients. Before the dentist, before the onset of dentition, or during the eruption of temporary/permanent dentition, pediatricians occupy an ideal position for prevention or therapeutic prescription of pediatric drugs. On the other hand, our fellow pediatricians have an ungrateful mission to ensure the compliance of young patients with the prescribed medication.

Liquid pediatric drugs have a long history in medicine and are commonly prescribed, accessible in pharmacies, and easily accepted by both parents and children. Young patients with chronic heart, kidney, respiratory diseases (asthma), leukemia, etc. represent a significant group of liquid medicines consumers (1).

Taste, compliance, and cost

Pediatric liquid medicines (PLMs) contain agents to optimize their appearance, stability, bioavailability, palatability, and implicitly, compliance. They also contain acidic agents, which act as buffering agents in order to maintain chemical stability, control tonicity, and ensure physiological compatibility. Compliance with these substances has been successfully optimized by adding sugar.

The syrup, which best improves the palatability of PLMs, has become children’s most preferred form and, consequently, the most frequently prescribed by pediatricians. Because of these so-called “inactive ingredients”, many PLMs have a high sugar concentration, a low pH, and an acid titratability (2).

However, for many pediatricians, the most relevant criteria for prescribing pediatric medication are bodyweight, cost of medication, favoring access, and their respective manufacturing company. The added sugar content often goes unnoticed or remains either unknown or unimportant information.

Table: Examples of sweetened or not pediatric medicines

They affect immature tooth enamel

Indeed, pharmaceutical companies are widely incorporating sugar, in the form of sucrose, fructose, glucose, into the composition of PLMs. Sucrose is most commonly used due to its preservative, antioxidant, solvent, and thickening properties. In addition, it is cheap, non-hygroscopic, and easy to process. But all sugar-optimized PLMs possess a high viscosity and adhesion to tooth enamel and, in addition, are very easily fermented by acidogenic oral bacteria (3).

With all their advantages, sugar-sweetened PLMs also have undesired side effects, which compromise dental health, especially that of children with an already compromised general health, and those with chronic diseases.

As a result, there has been a growing concern among pediatric dentists recently about the hidden sugar in PLMs, especially for children with chronic diseases (4). It is a well-known fact that temporary teeth are less mineralized (78%) than permanent teeth (98%). In addition, the surface of their enamel is still immature immediately after their eruption, which guarantees them a special vulnerability to tooth decay (5).

In the last decade, scientific literature abounds in evidence-based documents regarding the relationship between PLMs and dental caries, but long-standing clinical observations of PLM-induced rampant cavities date back to 1953, when James P.M. and Parfitt G.J. (7) described extensive cavities on the palatal and lingual face of children’s teeth that swallowed iron supplements in the form of syrup. The most conclusive study is considered to be conducted by Roberts and Feigal, who showed that continuous administration of PLMs containing sugar, causes tooth decay and gingivitis. Rekola showed that sucrose or fructose combined with sorbitol causes a marked and long-lasting decrease in the pH of the cariogenic bacterial plaque.

Prolonged and repeated consumption (including at bedtime or at night) of oral PLMs, and good acidogenic substrate for cariogenic bacteria, may be incriminated as an etiological and/or aggravating factor for erosions and severe tooth decay. Here are the reasons why (6):

1. Although saliva plays a potentially key role against primary demineralization, salivary volume decreases significantly during the night. In addition, certain drugs, such as anticonvulsants, sedatives, or antihistamines, further decrease salivary volume through their mechanism of action. The dryness of the oral cavity overnight creates a very favorable environment for the metabolism of cariogenic bacteria.

2. In young children, salivary clearance is significantly lower than in adults, due to lower salivary flow, but also due to the lack of coordination and regional muscular stimulation ability.

3. Lack of child’s interest or ability to remove particles retained in the mouth after swallowing food/liquids.

4. The presence of fermentable carbohydrates in high concentrations in PLM can facilitate the development of S. mutans and the rapid transformation of sugar into acids, thus initiating enamel demineralization.

“Sugar-free” or “noncariogenic”

As a consequence of concerns about the cariogenic potential of MLP, pharmaceutical companies have introduced PLMs with sugar substitutes, the so-called “sugar-free” drugs, sweetened with xylitol, mannitol, and sorbitol. Although sugar substitutes are viewed with reservations by many pediatricians, sugar-free PLMs are only 10% more expensive and do not lose any of their previous characteristics. On the contrary, they are equally effective, and, in addition, due to the lack of sugar, they starve cariogenic bacteria (8). As ‘sugar-free’ can be interpreted as ‘sweet-free’, the designation ‘sucrose-free’ or ‘noncariogenic’ could improve the attitude of professionals towards promoting them. And the higher costs involved in procuring them could protect the child from many medical and dental complications that potentially involve an even higher cost for their treatment.

It is true that the administration of PLM is usually short-lived. But children with chronic diseases or common respiratory infections use them on a daily basis. It is true that these active ingredients are necessary, and for some, they are even vital in maintaining good health, but inactive ingredients, if left unnoticed, can cause serious damage to dental health, in the absence of oral care recommendations after administration (8-10).

Many parents, although aware of the cariogenic effects of added sugar, only worry about the cookies and candies ingested by their child, ignoring the hidden sweet component of PLM. However, the general opinion is that pediatricians are primarily responsible for prescribing sugary PLMs, but also for giving additional information to parents. It is therefore essential that pediatricians should be aware of the involvement of sugar in the etiology of dental cavities and make an informed decision about prescribing it.
Monitoring of children with chronic diseases by a pediatric dentist is therefore mandatory from the beginning of PLM therapy (11-13). However, the cooperation between the pediatrician and the pediatric dentist remains, for the time being, an interdisciplinary challenge.

Article written for Viața medicală and first published aici

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