Journal of Pediatric Dentistry

: 2017  |  Volume : 5  |  Issue : 1  |  Page : 14--20

Surface changes of primary tooth enamel by commonly used pediatric liquid medicaments: A scanning electron microscope study

Sudhir Mittal1, Bhanu Pratap Singh1, Amit Kumar Sharma1, Kavita Mittal2, Ashish Justa1, Pulkit Vaid1,  
1 Department of Pedodontics, Himachal Dental College, Sunder Nagar, Himachal Pradesh, India
2 Department of Pedodontics and Preventive Dentistry, Punjab Institute of Medical Sciences, Jalandhar, Punjab, India

Correspondence Address:
Sudhir Mittal
Department of Pedodontics, Himachal Dental College, Sunder Nagar - 175 002, Himachal Pradesh


The present in-vitro study was conducted in primary teeth in order to evaluate the erosive potential of eight commonly used pediatric liquid medications (PLMs) using scanning electron microscope. 8 most commonly used Pediatric Liquid Medicaments and 27 extracted teeth that were near to exfoliation were collected. The endogenous pH of all the Pediatric Liquid Medications was measured using a pH electrode meter. The 27 teeth were divided into two groups, the control group (n = 3) and the study group (n = 24). Three teeth in Control group were immersed in artificial saliva for three different time intervals 1 min, 10 mins. and 8 hours. In experimental group, 24 teeth were also maintained for 1 min., 10 min. and 8 hours in 8 different pediatric liquid medicaments with 3 teeth in each medicine for three different time intervals. For all the teeth of both groups ,the primary enamel surface changes were then observed under Scanning electron microscope. When viewed under Scanning Electron Microscope, all the PLM's showed an erosive effect on the Primary Enamel Surface. Crater formation was found with most of the medications followed by etched prism pattern and sporadic rod ends. Acidic pH was seen with most of the pediatric liquid medicaments used in this study which causes dental erosion. Dental erosion eventually predisposes to dental caries, so it is important to educate professionals and parents regarding use of Pediatric Liquid Medicaments in children.

How to cite this article:
Mittal S, Singh BP, Sharma AK, Mittal K, Justa A, Vaid P. Surface changes of primary tooth enamel by commonly used pediatric liquid medicaments: A scanning electron microscope study.J Pediatr Dent 2017;5:14-20

How to cite this URL:
Mittal S, Singh BP, Sharma AK, Mittal K, Justa A, Vaid P. Surface changes of primary tooth enamel by commonly used pediatric liquid medicaments: A scanning electron microscope study. J Pediatr Dent [serial online] 2017 [cited 2019 Jul 16 ];5:14-20
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Tooth wear has long been recognized phenomenon in adults and ascribed to the triumvirate of attrition, abrasion, and erosion. Increasing dental erosion is one of the commonly encountered problems in children compared to attrition and abrasion.[1] Imfeld defined attrition as “the physiological wearing away of dental hard tissues through tooth-to-tooth contact, without the intervention of foreign substances” whereas abrasion as “the pathological wearing away of dental hard tissue through abnormal mechanical processes involving foreign objects or substances repeatedly introduced in the mouth and contacting the teeth.”[2]

Dental erosion (perimylolysis) has been defined as the irreversible loss of dental hard tissue by a chemical process not involving bacteria and not directly associated with traumatic or mechanical factors or with dental caries.[3] Erosion can lead to substantial loss of enamel and exposure of softer dentin which is more susceptible to abrasion and attrition that will accelerate tooth tissue loss. The clinical erosive lesion is smooth, polished, and rounded with the loss of tooth surface characteristics.[4]

Erosive tooth wear is a multifactorial irreversible process may be caused by intrinsic, extrinsic, or idiopathic factors. The intrinsic etiologic factors are related to the contact of tooth tissues with stomach acids (i.e., regurgitation and reflux disorders). Primary extrinsic source is increased consumption of acidic food and drinks along with acidic medicines. Behavioral factors have also been identified as extrinsic etiologic factors in dental erosion.[5] As in deciduous teeth, enamel is less calcified and porous which is more easily dissolved by acids. Hence, erosion can be a particular problem for young children as the enamel and the dentin layer of primary dentition are much thinner than those of the permanent teeth.[6]

Dental erosion in young age attributed to the regular use of products with low endogenous pH, high acidity and absence or low concentration of ions that include calcium, fluoride, and phosphate in their composition.[7] Children with chronic diseases such as asthma, cardiopathies, epilepsy, and chronic renal failure as well as those with recurrent benign pathologies such as flu, cold, tonsillitis, otitis, allergic rhinitis, and sinusitis may require several liquid medications on a daily basis. Most common sugar-containing medications regularly used by young children are the antibiotics and antitussives.[8] Most of the pediatric liquid medicaments may contain inactive ingredients which can cause harmful effects to the teeth. Among these components, the most common ones are fermentable sugar and acids. Sugar is combined with other ingredients to give a more pleasant taste to the medication to increase acceptance and compliance of the pediatric patients.[9] Pediatric liquid medications not only contain sweetening agents but also acids. The acids are added as buffering agents, and acidic nature is necessary for drug dispersion, maintenance of chemical stability, to improve flavor to enhance the patient compliance, and to ensure physiological compatibility. Apart from the benefits derived, there are associated detrimental effects of acids. That is why pediatric liquid medicament can be related as one of the major causes for dental erosion.[10]

Hence, the purpose of the present in vitro study was to analyze the effect of commercially available polarized light microscopes (PLMs) on the primary enamel surface of primary teeth using scanning electron microscope (SEM) and to measure the endogenous pH of these medications.

 Materials and Methods

For the study, 27 extracted teeth that were near to exfoliation were obtained from the Department of Pedodontics that were devoid of any restoration, cracks or fractures in the enamel, caries, hypoplastic lesion, stains, and white spot lesions. Teeth were stored in saline at room temperature (37°C) till the experiment was performed. Eight most commonly used pediatric liquid medicaments were selected for the study.

The endogenous pH of each medication was measured using a digital pH meter (Eutech pH 700) placed directly into each solution at room temperature. The pH meter accurate to 0.1 was first calibrated according to the manufacturer's instructions, using buffer standards of pH 7 and pH 4. As much of 10 mL of each medication was placed in a beaker, the pH meter was immersed into the syrup and the value was recorded.

Three teeth in Group 1, i.e., control group were immersed in artificial saliva for three different time intervals 1 min, 10 min, and 8 h. In Group 2, i.e., experimental group, 24 teeth were also maintained for 1 min, 10 min, and 8 h in eight different pediatric liquid medicaments with three teeth in each medicine for three different time intervals [Table 1]. The specimens were examined under the SEM (NOVA NANOSEM 450) in low vacuum mode, and the backscattered electrons were analyzed. The specimens were analyzed under ×1500 magnifications to observe changes in detail for all the teeth of both the groups; the primary enamel surface changes were compared using the following parameters: (1) sporadic rod ends, (2) etched prism pattern, and (3) crater formation.{Table 1}


pH of the pediatric liquid medicaments

The pH of each pediatric liquid medicament was measured using a pH electrode meter. The pH ranged between 4.3 (Kidicare) to 7.4 (Sinarest). Only antitussive group showed basic pH, i.e., Phenergan (7.2) and Sinarest (7.4), respectively, whereas rest of the pediatric liquid medicaments showed acidic pH [Table 2].{Table 2}

Surface changes of primary enamel

Primary enamel surface treated with various PLMs, and artificial saliva was observed under the SEM at 1 min, 10 min, and 8 h.

In most of the medicaments, etched prism pattern and crater formation were observed on the primary enamel surface immersed in medicaments at 1 min, 10 min, and 8 h time intervals and sporadic rod ends were seen at the end of 1 min time interval in Kidicare only [Figure 1], [Figure 2], [Figure 3].{Figure 1}{Figure 2}{Figure 3}

In artificial saliva, no surface changes were observed on primary enamel surface in SEM [Figure 4].{Figure 4}

In antibiotic group (Mox, Flagyl, and Azithromycin), In Mox and Flagyl, etched prism pattern was seen after 1 min interval and crater formation was seen after 10 min and 8 h interval, respectively, whereas, in Azithromycin, nothing significant was found after 1 min interval, but etched prism pattern was seen after 10 min and crater formation was seen after 8 h interval.

In analgesics group (Crocin and Ibugesic), etched prism pattern was observed after 1 min interval and crater formation was seen after 10 min and 8 h interval in both the medicaments, respectively.

In multivitamin group (Kidicare), sporadic rod ends were seen only in this group after 1 min interval. Etched prism pattern was seen after 10 min and crater formation was seen after 8 h interval.

In antitussives group (Sinarest and Phenergan), no significant changes on primary enamel surface were found after 1 min and 10 min interval, whereas crater formation was seen after 8 h interval in both the medicaments [Table 3].{Table 3}

Mean comparison of all of the groups at different time intervals

When all the medicaments were compared together after 1 min interval, there was a statistically significant difference observed in etched prism pattern with P value 0.03 (P< 0.05), whereas statistically nonsignificant difference was observed in sporadic rod ends pattern with P = 0.351 (P > 0.05).

After 10 min interval, a significant difference was observed in crater formation with P = 0.02 (P < 0.05) and statistically nonsignificant difference was observed in etched prism pattern with P = 0.170 (P > 0.05).

After 8 h interval, no P value was computed as standard deviation was zero indicating no significant difference among various medicaments [Table 4].{Table 4}


Pediatric liquid medications are administered quite frequently to very young children and to children with low compliance of capsules and tablets. They are preferred due to their ease of administration and palatability.[11] These preparations when used abundantly and frequently are of concern, thereby providing a substrate for plaque microorganisms throughout the day.[9]

Maguire et al. conducted a study and measured the endogenous pH and titratable acidity of pediatric liquid medications and found that majority of these formulations have high erosive potential due to high titratable acidity and reported over half of the British medications have pH values significantly below the critical pH.[12] Furthermore, this erosive potential is particularly harmful when used by children suffering xerostomia or taken on a regular basis and/or at night in the treatment of a chronic condition.[13]

Sucrose is widely used due to its properties as preservative, antioxidant, solvent, and thickening agent. It is also a low cost, nonhygroscopic, easily processed substance, as well as clinician's helper in pediatric therapeutics, given that its pleasantly sweet taste encourages medicine acceptance.[14] Sugars metabolized by bacteria to acid end products, lower the pH within the bacterial plaque that is unavailable to salivary buffering. Low pH causes ionic dissolution from the hydroxyapatite crystals, leading to enamel and dentin demineralization.[15] In addition to the properties of the medications, the indiscriminate use of liquid formulations (syrups) by young children can increase the risk for the development of caries and dental erosion because the administration of liquid oral medications at bedtime frequently is not followed by proper oral hygiene after ingestion of the substance. The liquid oral medications are usually viscous syrups that penetrate into the fissures and proximal areas, which are inaccessible to the toothbrush.[8]

Imfeld[16] and Lokken et al.[17] suggested that the cariogenic potential present in medicines was due to the presence of sugar and its availability to oral plaque bacteria. Imfeld showed the deleterious effects of liquid oral medications. Studies done by Greenwood et al.,[18] Mackie and Hobson,[19] and Rekola[20] confirmed that these preparations were cariogenic and acidogenic in nature. As most liquid syrups are maintained in an acidic pH, the present study is conducted to know the acidogenic potential of commonly used PLMs in day-to-day practice and their erosive effect on the primary enamel surface of primary teeth.

The pH of the PLMs in our study ranged between 4.3 (Kidicare) and 7.4 (Sinarest). In our study, 75% of the pediatric liquid medicaments showed acidic pH.

The results of our study are in accordance with several other studies showing that most pediatric liquid medicaments were acidic.[8],[21],[22],[23] Neves et al.[24] conducted a study and showed that all the 23 pediatric medications used in the study showed acidic pH. Passos et al.[25] and Xavier et al.[23] found that 44% and 56% of pediatric liquid medicines had pH values below 5.5, respectively, whereas studies conducted by Subramaniam and Nandan[21] Cavalcanti et al.,[8] Neves et al.,[24] and Agrawal et al.[26] showed that 70%, 80%, 87%, and 90% of analyzed medicines were below this value.

Even though the pH of pediatric liquid medicaments is not near the critical pH of the oral cavity, erosion of primary enamel surface is evident when subjected to study under SEM. This is in agreement with the studies of Babu et al.[27] and Greenwood et al.,[18] who used SEM to evaluate the erosion potential of liquid syrup on rats enamel and human extracted primary teeth, respectively. Silverstone et al. described three basic types of etching patterns, i.e., Type 1, Type 2, and Type 3.[28] In our study, prism pattern observed on primary enamel surface is similar to Type 1 etching pattern, where the prism periphery is relatively intact, and prism core material is preferentially removed in a honeycomb prism appearance.

Enamel surface treated with Mox suspension for 1 min, Flagyl suspension for 1 min, Crocin suspension for 1 min, Ibugesic suspension for 1 min, Azithromycin suspension for 10 min, and Kidicare suspension for 10 min, all showed the etched prism pattern, but this is not of the classical appearance. Sporadic rod ends are seen only in enamel surface treated with Kidicare suspension for 1 min. The results of our study are in accordance with the results of the study conducted by Tupalli et al.[7] and Babu et al.[27]

The atypical appearance of enamel surface can be supported by the study done by Grando et al.,[29] who stated that complexity can be seen in the different patterns of loss of the enamel structure in eroded deciduous teeth.

Some of the enamel surfaces looked like large craters. This type of appearance is observed on the enamel surface treated with MOX for 10 min and 8 h, Azithromycin for 8 h, Flagyl for 10 min and 8 h, Crocin for 10 min and 8 h, Ibugesic for 10 min and 8 h, Kidicare for 8 h, and Phenergan and Sinarest for 8 h, respectively. The primary enamel surface changes observed in the study are in agreement with the findings of the Tupalli et al.,[7] who reported similar crater formation on enamel surfaces treated with most of the PLMs used in the study.

Chelation is a process by which a molecule encircles and binds to a metal and removes it from the tissue. Chelation is independent of the pH of the medium so that the removal of metallic ions such as calcium from a biological calcium-phosphorous system may occur at a neutral or even alkaline pH.[30] Morch et al.[31] and Onose and Sandham[32] reported that the chelating agents present in PLMs such as sodium salt of various amino acids (alanine, aspartame, and glutamate) and lactate, at or near neutral pH, can increase the uptake of radioactive phosphorus by loss of calcium from enamel. This factor may also be responsible for the erosive pattern seen on the surface of primary enamel surface in the present study.

In the present study, SEM analysis is used as a qualitative method to visualize erosion on primary enamel surface and is not a quantitative method which is a limitation of the study. Therefore, a step further should be taken where quantification of the erosion caused by the pediatric liquid medicaments can be analyzed. Furthermore, as the erosion in this study was induced under in vitro conditions, the results cannot be completely extrapolated to in vivo situations. Presence of pellicle is one factor which protects the teeth from acidic challenges. The amount and quality of saliva, in particular, its buffering capacity, are also important factors in the occurrence of dental erosion.


The following can be concluded from this study:

Majority of the pediatric liquid medicaments used in the study are acidic in nature with pH below 7The pediatric liquid medicaments frequently used have erosive effect on enamel of deciduous teethThere is a need to educate parents and professionals regarding the use of pediatric liquid medicaments that either they should be taken with meals or the child should rinse mouth with water after taking pediatric liquid medicament.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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