Effect_of_conventional_and_sugar_free_pediatric_sy

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ABSTRACT
Objectives: To assess and compare the effect 
of conventional and sugar free pediatric syrup 
formulations on primary tooth enamel hardness over 
a period of 14 days. Materials and Methods: An in 
vitro study was done on 40 noncarious deciduous 
teeth. 10 teeth in each group were dipped in 4 pediatric 
medicinal syrups (1 sugarfree and 3 conventional) for 
1 min thrice daily for 14 days and the enamel surface 
micro hardness was checked at baseline, 7th day and 
14th day by Vickers hardness testing machine. The pH, 
titratable acidity and buffering capacity of the syrups 
were assessed. Results: The pH of syrups were above 
critical pH for demineralization of the tooth but tiratable 
acidity and buffering capacity differed. ANOVA test 
indicated that the reduction in mean micro hardness 
was maximum in Group D (Conventional Analgesic 
syrup) and least in Group A (Sugarfree cough syrup) 
on 7th and 14th day. On intergroup comparison there 
was no difference (P > 0.05) in micro hardness between 
Group B (Conventional Cough syrup) and Group C 
(Conventional Antibiotic). However, highly significant 
(P < 0.01) difference between the either pair of Group B 
with Group D, and Group C with Group D on 14th day. 
The percentage reduction in micro hardness on 14th day 
was maximum for Group D (24.4 ± 2.2) and minimum 
for Group A (14.0 ± 1.3) which was statistically 
significant (P < 0.01). Conclusion: Sugar free pediatric 
medicines can be effective in reducing dental erosion 
and efforts should be made to incorporate sugar 
substitutes in formulation of pediatric medicines.
KEYWORDS: Micro hardness, pediatric syrup, 
primary teeth, sorbitol
Effect of conventional and sugar free pediatric syrup 
formulations on primary tooth enamel hardness: 
An in vitro study
Gaurao Vasant Mali, Arun Suresh Dodamani, Gundabaktha Nagappa Karibasappa, 
Prashanth Vishwakarma Kumar, Vardhaman Mulchand Jain
Department of Public Health Dentistry, ACPM Dental College, Dhule, Maharashtra, India
the mirror of our body, and oral health is essential for 
children’s growth, development, and general health. 
Dental caries is the common oral disease and the most 
prevalent infectious disease in the oral cavity. Among 
the theories that explain caries onset, universally 
accepted is the action of acids produced by bacterial 
fermentation of carbohydrates (sugars) from the diet. 
However, some diseases or medications may increase 
the risk or severity of caries, and dental erosion is one 
of them.[1]
Dental erosion is defined as a progressive loss of 
dental hard tissues by chemical dissolution without 
Address for correspondence: 
Dr. Gaurao Vasant Mali, 
ACPM Dental College, Opp. Jawahar Sootgirni, Sakri Road, 
Dhule - 424 001, Maharashtra, India. 
E-mail: gauraomali2005@gmail.com
Original Article
How to cite this article: Mali GV, Dodamani AS, Karibasappa 
GN, Kumar PV, Jain V! M. Effect of conventional and sugar 
free pediatric syrup formulations on primary tooth enamel 
hardness: An in vitro study. J Indian Soc Pedod Prev Dent 
2015;33:331-6.
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DOI: 
10.4103/0970-4388.165707 
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Introduction
Children are future of our society and ensuring their 
overall good health is of utmost importance. Mouth is 
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Mali, et al.: Sugarfree pediatric syrup and tooth enamel microhardness
Journal of Indian Society of Pedodontics and Preventive Dentistry | Oct-Dec 2015 | Vol 33 | Issue 4 |332
bacterial involvement.[2] In modern society, the 
changing lifestyle has contributed to an increased 
incidence of dental erosion, especially in children 
and adolescents.[3,4] Erosive tooth wear is a multi-
factorial irreversible process that may be caused by 
intrinsic, extrinsic, or idiopathic factors.[4] The intrinsic 
etiologic factors are related to the contact of tooth 
tissues with stomach acids (i.e., regurgitation and 
reflux disorders).[5] Increased acidic food and drink 
consumption has become the primary extrinsic source 
of dental erosive agents, although acidic medicines, 
and behavioral factors have also been identified as 
extrinsic etiologic factors in dental erosion.[6-9]
Liquid oral medications are usually prescribed for 
children in order to avoid the difficulty encountered 
in taking medicines in other forms.[8] Furthermore, 
these medicines are acidic preparations as they are 
often necessary for drug dispersion, chemical stability 
maintenance, to ensure physiological compatibility, and 
to improve flavor. In addition to the acidic components, 
other factors such as prolonged and frequent ingestion 
(i.e., two or more times daily), bedtime and between 
meals consumption, high viscosity, and the collateral 
effect of reduced salivary flow, may contribute to 
increase the risk for medication-induced dental 
erosion.[2,3,9]
Few in vitro researches reported that medications can 
affect enamel hardness, and cause morphological 
alterations. Nevertheless, the results of these studies 
are limited to a small number of medicines, and 
the literature is scarce that investigate the effect of 
medications on permanent and deciduous tooth 
enamel.[9]
Several liquid medications can be part of the daily 
routine of children with chronic diseases.[10] Antibiotics 
and cough syrups are the most common sugar-
containing medications regularly used for young 
children.[11]
Off late, various sugar substitutes have been 
introduced and are widely used in food products to 
avoid tooth decay from sugar and other fermentable 
carbohydrates. Many studies have shown sugar 
substitutes to be noncariogenic.[12] The use of sugar 
substitutes in preparation of pediatric medicines is still 
at very minimal level. However, there is an increased 
use of oral medicines by children for prolonged periods, 
especially those with chronic diseases, thus, the aim of 
the present study was to assess in vitro, with stating 
null hypothesis that there is no effect of conventional 
and sugar free pediatric syrup formulations on primary 
tooth enamel hardness.[11]
Materials and Methods
Ethical clearance for the study was obtained from 
Institutional Ethical Review Board of A.C.P.M. 
Dental College Dhule, Maharashtra. The present 
study was an in vitro study to assess and compare the 
effect of conventional and sugar-free pediatric drug 
formulations in syrup form on primary tooth enamel 
hardness. List of all the commonly prescribed pediatric 
syrup medications were collected from Indian 
Medical Association Branch Dhule, Maharashtra. 3 
conventional and 1 sugar-free syrups were randomly 
selected and tested for initial pH, titratable acidity, and 
buffering capacity.
Study design
Preparation of specimens
First step
Noncarious deciduous teeth (40 incisors and molars) 
were collected from the Department of Pedodontics, 
A.C.P.M Dental College Dhule. Prior to the study, the 
teeth were cleaned using pumice-water slurry and 0.3-
µm alumina paste with a polishing brush at low-speed 
handpiece (5000 rpm) to remove any debris or calculus 
deposited on to the teeth.[13] Then, they were preserved 
in artificial saliva and transported to microhardness 
testing laboratory.
Each crown was fixed with plastic wax in the central 
orifice of an acrylic plate. The tooth was placed and 
stabilized with red wax with a buccal surface facing 
upwards using a parallelometer (ElQuip, São Carlos, 
SP, Brazil) to secure theflattest region of the buccal 
surface parallel to the plate. The specimens had their 
buccal enamel surfaces flattened with 600 and 1200-grit 
Al2O3 abrasive papers (Buehler Ltd.), polished with 
0.3-μm alumina paste (Alpha and Gamma Micropolish; 
Buehler Ltd.,) and felt paper using a water-cooled 
low-speed polishing machine (Politriz DP-9U2; Struers 
A/S, Copenhagen, Denmark). The specimens were 
ultrasonically cleaned in deionized water for 10 min. 
The test sites were demarcated by attaching a piece 
of insulating tape with a 2-mm diameter central hole 
on each surface. The tooth/plate sets were rendered 
acid-proof by coating them with 2 layers of cosmetic nail 
polish. The previously delimited circular area on the 
flattest region of the buccal surface was left uncoated. 
Then, the specimens were stored at 37°C in a 100% 
relative humidity environment in artificial saliva.[13]
Assessment of the initial enamel surface microhardness 
was done using Vickers hardness testing machine 
(Digital display microhardness tester HVS-1000A) 
at microhardness testing laboratory at Metallurgical 
Services Ghatkopar, Mumbai. The force of 25 g was 
applied with the diamond indenter on to the enamel 
surface at three points 100 µm apart, and the average 
of the readings was obtained as Vickers hardness 
number.[13]
Second step
After the assessment of baseline microhardness, 
the teeth specimens were demounted and 
randomly 10 teeth in each group were allocated 
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Mali, et al.: Sugarfree pediatric syrup and tooth enamel microhardness
Journal of Indian Society of Pedodontics and Preventive Dentistry | Oct-Dec 2015 | Vol 33 | Issue 4 | 333
into four groups — Group A (sugarfree cough 
syrup — M solvin, contents — guaiphenesin, 
ambroxol hydrochloride, terbutaline, sorbitol, Ipca 
laboratories Ltd.), Group B (conventional cough 
syrup — trustyl M, contents — guaiphenesin, ambroxol 
hydrochloride, terbutaline, abbot laboratories Ltd.), 
Group C (conventional antibiotic — althrocin liquid, 
contents-erythromycin estolate, alembic pharmaceuticals 
Ltd.), Group D (conventional analgesic — zukamin cold 
syrup, contents — paracetamol, chlorpheniramine, 
alkem laboratories Ltd.,). 10 teeth in each group were 
immersed into the 10 ml undiluted syrup in test tube 
and agitated for 1 min thrice daily for 7 days.[14] The 
teeth were preserved in artificial saliva and transported 
to microhardness testing laboratory, there teeth were 
remounted, and their surface enamel microhardness 
was measured.
After measurement of microhardness, the teeth were 
demounted and further immersed into the 10 ml 
syrup for 1 min thrice daily for next 7 days and 
again transported and mounted for microhardness 
measurement. Intermittently, after immersion of the 
teeth for 1 min in the syrups they were washed with 
distilled water and preserved in artificial saliva with 
daily change of the solution.
Preparation of artificial saliva
Artificial saliva was prepared at the Department of 
Chemistry, S.S.V.P.S Arts, Commerce and Science 
College Dhule, Maharashtra.
Composition of artificial saliva
Methylhydroxybenzoate 2.0 g, carboxymethylcellulose 
10.0 g, KCl 0.625 g, MgCl2.6H2O 0.059 g, CaCl2.2H2O 
0.166 g, K2HPO4 0.804 g, and KH2PO4 0.326 g in 1000 
ml of deionized water.[13]
pH measure and buffering capacity
The pH value of the syrups used for the immersion of 
the teeth and the amount of base required to raise the 
pH to 7.0 (titratable acidity) were measured with a pH 
meter (Reena Instruments Co. Pvt. Ltd., Delhi, Water 
and Soil Analysis kit). To measure titratable acidity, 
20 g of each drink or solution was titrated with 0.5 M 
NaOH in 0.02 ml increments at 25°C. The buffering 
capacity (β) was calculated with the following 
equation: β = −ΔC/ΔpH in which ΔC is the amount of 
base used and ΔpH is the change in pH caused by the 
addition of the base.[13]
Statistical analysis
All statistical procedures were performed using 
Statistical Package for Social Sciences (SPSS) 20.0 
software (IBM, Armonk, NY, United States of America). 
The data exhibited a normal and homogeneous 
distribution; thus, microhardness was analyzed using 
mean VHN score employing ANOVA and Tukey’s 
least significant difference multiple-comparison test 
with time and medication as study parameters.
Results
Before the start of the study the pH, titratable acidities 
and buffering capacities of the syrups were calculated 
and the readings were tabulated [Table 1].
Microhardness of the tooth specimens were assessed at 
baseline, 7th and 14th day. The mean hardness was least 
in Group D and maximum in Group A on 7th and 14th 
day [Table 2].
On 7th day mean surface hardness of B, C, and 
D was lower than A difference was statistically 
significant (P < 0.05). There was no significant 
(P > 0.05) difference in mean hardness between B, 
C, and D group [Table 3]. However, on 14th day 
surface hardness of group B, C, and D was lower 
than A (P < 0.01). There was no difference (P > 0.05) 
in between B and C group and highly significant 
difference (P < 0.01) between B and D, and between 
Table 3: Intergroup comparison of surface 
hardness of tooth in between four groups 
at baseline, 7th and 14th day
Baseline 7 day 14 day
A versus B (NS) A versus B* A versus B**
A versus C (NS) A versus C* A versus C**
A versus D (NS) A versus D** A versus D**
B versus C (NS) B versus C (NS) B versus C (NS)
B versus D (NS) B versus D (NS) B versus D**
C versus D (NS) C versus D (NS) C versus D**
Multiple comparison LSD test, *Mean difference is significant at the 
0.05 level, **Mean difference is significant at the 0.01 level, LSD = Least 
significant difference, NS = Not significant
Table 2: Surface hardness of tooth in four 
groups at baseline, 7th and 14th day
Group Mean ± SD
Baseline 7 days 14 days
A 419.3±7.0 372.0±7.7 360.5±7.3
B 417.7±8.1 364.1±8.9 342.6±8.3
C 416.4±7.5 364.4±6.4 346.1±5.0
D 417.0±7.1 359.5±4.9 315.3±8.4
ANOVA test P 0.838 <0.01 <0.01
Group A = Sugarfree cough syrup, Group B = Conventional cough syrup, 
Group C = Conventional antibiotic, Group D = Conventional analgesic. 
SD = Standard deviation
Table 1: pH, titratable acidities, and buffering 
capacities
Group pH Titratable acidity Buffering capacity
A 5.92 115.2 96
B 5.77 100.8 56.2
C 6.4 175 131.57
D 6.12 127.2 144.5
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Mali, et al.: Sugarfree pediatric syrup and tooth enamel microhardness
Journal of Indian Society of Pedodontics and Preventive Dentistry | Oct-Dec 2015 | Vol 33 | Issue 4 |334
C and D group on 14th day [Table 3]. There was a 
reduction in microhardness of the teeth on 7th day 
and 14th day, but on comparing percentage reduction 
in microhardness between 7th and 14th day maximum 
percentage reduction was in Group D (24.4 ± 2.2) 
and minimum for Group A (14.0 ± 1.3) and was 
statistically significant (P < 0.01) [Table 4].
Discussion
The present research provides evidence that the studied 
medicines could potentially erode deciduous tooth 
enamel after successive immersion cycles. The surface 
enamel microhardness of the teeth was decreased after 
14 days in all the four groups of medicinal syrups, 
however, the teeth immersed in Group A (Sugar 
free cough syrup) showed the least reduction in 
microhardness as compared to other three groups.
Acids are added to drug formulations as buffering 
agents to maintain chemical stability, control tonicity, 
physiological compatibility, to enhance flavor, and 
thereby increasing the palatability to children.[7] Citric 
acid is the most commonly used primary acid in the 
oral medicines, despite being a weak acid, citric acid is 
a potent erosive agent.[3,14] These acids were present in 
the medicinal syrups used in this study and pH of all the 
syrups were above the critical pH of demineralization. 
Few authors have reported, as the pH decreases, thepotential of enamel erosion increases.[2,5,15]
Nevertheless, the erosive potential of a substance is 
not exclusively dependent on pH value. The erosion 
potential is also strongly influenced by titratable acidity, 
buffering capacity, calcium chelation properties, 
mineral content, and adhesion to the dental surface. 
Hence, titratable acidities and buffering capacities 
were the physicochemical properties analyzed in this 
study. Titratable acidity represents the total content of 
acids and is considered as an indication of the strength 
of the erosive potential of the syrup and buffering 
capacity is the time taken by saliva to neutralize the 
acid in the syrup.[3,15,16] A previous study that was done 
revealed high titratable acidity in liquid medications 
confirming their erosive nature.[7]
In current study, the titratable acidities and buffering 
capacities of the syrups differed. Group C (conventional 
antibiotic) exhibited the largest titratable acidity (175 
mmol/L), and Group D (conventional analgesic) 
exhibited the maximum buffering capacity (144.5 
mmol/L) [Table 1]. The most probable reason attributed 
for this difference could be due to the compositions 
of the syrups, the alcohols added, the viscosity, the 
surface tension of syrups, the acids present in their 
formulations (citric, phosphoric, hydrochloric, tartaric, 
benzoic, etc.), and the buffering agents (citrate buffers) 
added in their preparations. The properties of the 
different constituents present in the syrup may have 
also caused a difference in the buffering capacities.[13]
There was microhardness reduction seen in all the 
four groups on the 7th day and 14th day as compared 
to baseline values, and sugar-free syrup showed the 
least reduction in microhardness and was statistically 
significant. Conventional syrup group comparison 
on 7th day showed no statistical significant difference 
[Tables 2 and 3]. The reason for more reduction in 
microhardness on the 14th day as compared to 7th 
day could be due to longer duration of exposure to 
medicinal syrups [Table 3].
In the present study, there was a linear percentage 
reduction in microhardness of all groups from baseline 
to the 14th day. Moreover the reduction was more 
pronounced in a conventional group than sugar-free 
group after 7th day onward. This difference observed 
in different groups might be due to their different 
titratable acidity, buffering capacity, pH, the acids 
used, the buffers added, and the compositions of the 
medicinal syrups [Table 4].[13] Similar findings were 
seen by Scatena et al.[13]
Studies on deciduous tooth substrates are of scientific 
relevance because structural and morphological 
differences between deciduous and permanent 
substrates have been observed. Furthermore, differences 
in the chemical composition, rate of formation and 
ultrastructural appearance between the pellicle on 
primary and permanent teeth have been reported.[13] 
In vitro studies have observed the erosive potential of 
medicines and have reported alterations in enamel surface 
microhardness and tooth morphology. However, most 
of the studies were performed on a permanent tooth 
substrate.[13] There were very few studies that evaluated 
the enamel erosive effects of the medications on 
deciduous teeth. Hence, deciduous teeth were selected 
in this study to check for their microhardness.
Saliva has a role in forming the salivary protein-based 
pellicle on enamel tooth surfaces, which behaves as 
a diffusion barrier to prevent direct contact between 
acids and the tooth surface, thus preventing the 
demineralization process.[3,17] Hence an artificial saliva 
medium was used between the immersion cycles for 
preservation of the teeth because of its proven ability 
to exert similar remineralizing effect as that of fresh 
human saliva and care was taken to replace it daily.[17]
Table 4: Percentage reduction of surface hardness 
of tooth in four groups at 7th and 14th day
Group Mean ± SD
7 day 14 day
A 11.3±1.6 14.0±1.3
B 12.8±2.8 17.9±3.0
C 12.5±0.5 16.9±1.1
D 13.8±0.9 24.4±2.2
ANOVA test P 0.022 <0.01
SD = Standard deviation
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Mali, et al.: Sugarfree pediatric syrup and tooth enamel microhardness
Journal of Indian Society of Pedodontics and Preventive Dentistry | Oct-Dec 2015 | Vol 33 | Issue 4 | 335
The erosive potential of an acidic challenge might also 
be related to the frequency and time of acid exposure 
as well as by the total volume of acid media ingested. 
In addition to the properties of the medications, the 
indiscriminate use of liquid formulations (syrups) by 
young children can increase the risk for dental erosion 
because the administration of liquid oral medications at 
bedtime which is not followed by proper oral hygiene 
after ingestion of the substance.[1] Therefore, the 
experimental period of 14 days was chosen for this study 
to assess the effect of medications for longer duration. 
The syrups used in this study were selected because they 
were most commonly prescribed and easily available.
In the current investigation, the protocol used was 
based on the following frequency of syrup ingestion: 
10 ml taken 3 times a day, under agitation of the 
solution during the specimen immersion period and 
this agitation was done because according to some 
authors, when a substance is ingested, a certain 
agitation occurs, which favors the substance capacity 
to cause erosion.[14]
Nowadays various sugar substitutes have been 
widely used in food products and beverages to 
avoid tooth decay from sugar and other fermentable 
carbohydrates. However, other ingredients, such as 
citric or phosphoric acids in beverages, may cause 
dental erosion. Most commonly used sugar alcohols 
are xylitol, sorbitol, etc. Studies on xylitol, carried out 
in Russia, Hungary, and Estonia, have shown that 
xylitol is noncariogenic.[13] Along with xylitol, sorbitol 
has also been proved to be effective sugar substitute in 
reduction of dental caries but very few cough syrups 
are available for pediatric use which contain sorbitol 
in their composition and very few studies have been 
carried out on the same.[18] Hence in this study a sugar-
free cough syrup containing sorbitol was used to check 
for its effect on the microhardness of teeth.
Thus, the present study emphasized to assess and 
compare the effect of conventional and sugar free 
pediatric medications on primary tooth enamel 
hardness and the importance of sorbitol-containing 
pediatric medications to minimize dental erosion. The 
parameters, titratable acidities, buffering capacities 
used in this study have an impact on the microhardness, 
but these parameters are not enough to validate the 
results of the study. Along with these parameters, the 
compositions of the syrups and the total dissolved 
sugars should also be assessed to see the exact impact 
on the microhardness.
Recommendations
Sorbitol-containing medications have proved to be 
helpful in reduction of microhardness, but they have 
to be cautiously used in pediatric patients in proper 
doses because of their proven side-effects. Further 
clinical trials are required to assess its safety and 
adverse effects on tooth enamel.
Conclusion
Sugar substitutes have been proved to be noncariogenic 
and tooth — friendly component. Though their use 
is minimal, efforts should be made to incorporate 
them in formulation of pediatric medicines by 
the pharmaceutical companies and health care 
professionals should start prescribing these sugar-free 
pediatric drug formulations keeping in mind their 
benefits and side-effects for pediatric use.
Acknowledgment
The authors would like to thank Dr. N.N. Pawar, Ph.D, 
H.O.D, Dept. of Organic Chemistry, S.S.V.P.S Arts, 
Commerce and Science College Dhule, Maharashtra 
for helping out with preparation of artificial saliva and 
measurement of pH, titratable acidities and buffering 
capacities of the medicinalsyrups and Dr. Prashant Patil, 
Biostatistician, Hire Medical College, Dhule for helping 
them with statistical analysis.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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