J Indian Soc Pedo Prev Dent December (2002) 20 (4) : 144-151 ISSN 0970-4388 A Comparison of oral hygiene status and Dental Caries in children on Long term liquid oral medications to those not administered with such Medications. SahgalJ. a Sood P.B. b Raju O.S. C. a. Tutor Govt. Dental College and Hospital, Ahmedabad b. Prof, and H.O.D., Dept. of Pedodontics and Preventive Dentistry, c. Asso. Prof. Dept. Pedodontics and Preventive Dentistry, Bapuji Dental College and Hospital, Davangere. Young chronically ill children receive a greater sugar load from liquid medications than do healthy children. They receive variety of oral liquid medications that healthy children do not. This study was planned to know the levels of oral hygiene and Dental caries in children on long term liquid oral medicines (LOM) and to know out if any difference existed between these and children not on LOM. 51 children on LOM were compared to 54 not on LOM after equalising for age, oral hygiene and diet intake. Highly significant difference was found for dmft and dmfs in 2-6 year age group and dmft+ DMFT for 6-13 years age group, mostly posterior teeth were affected and for this the difference was statistically significant in 2-6 year old children. Percentage of childen with dmft>5 significantly increased in 2-6 years old children on LOM, when compared to that of control. Percentage of various grades of lesions (relating to the severity) also increased with an increase in the duration of LOM. Key words : LOM (liquid oral medications ), Dental caries, Chronically ill children, Fermentable carbohydrates. INTRODUCTION Pleasant tasting syrups have a long history of use in pediatric medicine to aid complaince with medication. While dental caries is a multifactorial disease, role of fermentable carbohydrate in the production of caries is well documented. Young chronically ill children receive variety of oral liquid medication that healthy children do not. Syrups sweetened with sucrose or fructose or with a combination of fructose and sorbitol produced a mark and long term drop in plaque ph. These products are acidogenic like the foods and drinks sweetened with these sugars. The cariogenic potential of pediatric liquid medications is due to high concentration of fermentable carbohydrates and their acidogenicity 1,2. MATERIALS & METHODS Children were selected from O.P.D of pediatrics and pediatric wards of Bapuji Hospital and Chigateri General Hospital, Davangere. Children for study group were identified as being on long term LOM i.e. for 3 months or longer in the past and atleast for 1 month continuously at the time of examination. Children were grouped as follows: Group - I = 2-6 years old study group, n=26 Group - II = 2-6 years old control group, n=25 Group - III = 6-13 years old study group, n=25 Group - IV = 6-13 years old control group, n= 29 Dental examination was done under battery light from a 4.5 V torch. Clinical examination was done with the help of mouth mirror and a probe was used only when in doubt or with minimal pressure to remove debris. Oral hygiene was assessed using the OHI-S by Greene & vermillion 3 - No disclosing solution was used. Dental caries was recorded using DMFT & S for permanent and dmft & s for primary dentition. Visual criteria used for diagnosing caries : Score 2-4 of the criteria used by Ekstrand et al 4.
Sahgal Jyoti, Sood P.B., Raju O.S. 145 For Pre-cavitated lesions : 2- opacity or discoloration distinctly visible without air drying. For cavitated lesion : 3- localized enamel breakdown in opaque or discoloured enamel and / or grayish discolouration from the underlying dentine. 4- Cavitation in opaque or discoloured enamel exposing the dentine. Tactile criteria for diagnosing caries : (WHO Oral Health Survey 1987) Caries was recorded as present when a lesion in a pit or fissure or on a smooth surface has a detectabiy softened floor, undermined enamel or softened wall. A tooth with temporary filling or filled tooth with decay were also recorded under this category. Identification of medicines used by study group and collection of other information relevant to the study was collected using a medical questionnaire and describing current and past medication schedules. Place of residence from birth was recorded to calculate exposure to fluoridated water. Use of fluoride supplements, tooth paste, tooth brushing frequency, parents occupation (for social class), infact feeding and sleeping habits were recorded as possible confounding factors. Dietary assessment was done with the help of a diet chart (food stuffs consumed on an average day) which included the frequency of beverages with amount of sugar added, sugared drinks during the day, sugared snacks and fruits consumed (bananas / apple / grapes / oranges / others.) Statistical analysis - students T test was used to compare the means of two groups and chi-square test for categorical data. RESULTS The total number of children who were on long - term LOM were 51. The various medical diagnosis of these children were - Recurrent URTI, LRTI T.B. meningitis, pulmonary T.B., cerebral palsy, rheumatic heart disease, enteric fever, persistent cough, non specific post hiarrhoeal colitis, mitral regurgitation, gastroenteritis, hypoglycemia, idiopathic epilepsy and jaundice. Many of these were found in combination with each other. However most of the syrup medicines taken long term were multivitamin syrups with or without iron, enzyme preparations, expectorants and bronchodilators, most of which were not directly related to the diagnosis but were given for symptomatic treatment of the chief complaints at that particular time. OHI-S (Table -1) No statistically significant difference was found beween the medicine and the non medicine group. DECAYED, MISSING FILLED TEETH : (Table -2 ) Mean dmft for group I was 6.54 and that of group II was 2.80. At P value < 0.001, the difference was highly significant. The mean number was 6.48 for group III compared to 4.90 for group IV. (P value < 0.05) Table three depicts level of caries in children on LOM compared to control group. As age advances the number of decayed teeth were also seen increasing. However, in group i & II it was highly significant, whereas in group III & IV it was not. (Table - 3) Caries of anterior and posterior teeth (Table -4) Statistically significant difference was seen in the dmf of posterior teeth in group l&group II with mean dmft for group I at 5.3 and that of group II at 2.28, P value < 0.001 which is highly significant. For the group III and IV both the anterior and posterior teeth did not show any statistically significant difference. Decayed, Missing, Filled Surfaces : (Table-5) Statistically significant difference was seen between group I and group II with mean dmft for group I at 8.19 and group II at 3.04, P level <0.01. No, statistically significant difference was found between the group III and group IV. SWEET CONSUMPTION AND DECAYED, MISSING, FILLED TEETH : (Consumption of sweet snacks only, from general diet
Oral hygiene status and Dental Caries in Children on Liquid oral medication 146 diary) (Table 6 a and 6 b) : (Table-6a) In group I there were 15 children who did not report having any sweets on a normal day but who did have mean dmft of 5.73, the corresponding level of dmft in group II was 1.82 and the number of children not reported to have sweets was 11. Therefore, the result was highly significant at P level < 0.01. The mean dmft increased with the reported frequency of sweets i. e. with 1-3 times sweet intake daily dmft increased to 7.64 in the group I. An increase was noted in the group II also with dmft increasing to 3.57 but still the difference was found to be statistically significant between the study and the control group, (P level <0.01). The corresponding levels for the group III and group IV were found to be higher in the group III than the group IV but were not statistically significant. (Table 6b.) NON MEAL TIME EXPOSURE FOR SWEET SNACKS & DECAYED, MISING, FILLED TEETH (FROM THE 24 HOUR DIET DIARY) : (TABLE - 7a and 7 b) (The 7a) Group I mean dmft for 0 non meal time exposure was 5.41 whereas for group II was 1.87. P level for this < 0.001 therefore highly significant difference was recorded. For 1-2 non meal time exposure in group I dmft increased to 9. 29 which is significantly higher than that of the group II with mean dmft rising to 3.14. DURATION OF LOM & GRADES OF LESIONS:(Table 8) Group - I With duration of 3-4 month of LOM, 44 % of lesions were under grade 2, 49 % under grade 3 and only 7 % under grade 4. However, with more than 4 months of LOM, 28 % of the lesions were under grade 2, 30 % under grade 3 and 42 % under grade 4. Group - III With 3-4 months duration of LOM, 49% were under grade 2, 29% under grade 3, and 22% under grade 4. with more than 4 months of LOM, 13% were under grade 2,45% under grade 3 and 42% under grade 4 were found. Table No.1 : OHI-S (Greene & Vermillion) Scores in a group of children on long term liquid oral medications compared with a control group. Scores for OHI -S : Good (0.0-1.2) Fair (1.3-3.0) Poor (3.1-6.0) GROUPS
Sahgal Jyoti, Sood P.B., Raju O.S. 147 Table No.2 : Decayed, missing, filled teeth of children on LOM compared to control group. Table No.3 : Level of Caries in children on LOM compared to control group. Table No.4 : Decayed, missing, filled teeth (Anterior & Posterior) in children on LOM compared to control group. Anterior Teeth
Oral hygiene status and Dental Caries in Children on Liquid oral medication 148 Posterior Teeth Table No.5 : Decayed, missing filled surface in children on LOM compared to control group. Groups Table No.6A : Sweet consumption and dmft+ DMFT (Consumption of sweet snacks only not including any beverage intake) from general diet diary.
Sahgal Jyoti, Sood P.B., Raju O.S. 149 Table No.6B : Sweet consumption and dmft+ DMFT Consumption of sweet snacks only not including any beverage intake from general diet diary. Table No.7A : Non-meal time exposure for sweet snacks and dmft + DMFT (From 24 hr. diet diary) Table No.7B : Non-meal time exposure for sweet snacks and dmft + DMFT (From 24 hr. diet diary)
Oral hygiene status and Dental Caries in Children on Liquid oral medication 150 DISCUSSION Various authors have expressed concern over the presence of fermentable carbohydrates in syrup medications and their adverse effects on the oral health of children who are given these type of LOM on long term. There has been a contradictory view also regarding this, with some authors actually reporting that caries rate for most children is not markedly affected by chronic liquid medication intake. No significant difference was found in OHI-S in the present study. Therefore, the result of Roberts and Roberts (1979) 5 is in acccordance with the present study. Whereas Butler (1998) 6 had found results contrary to this result. Blasczazak (1999) 7 also found statistically significant difference in the oral hygiene of their study group (children with haemorrhagic diatheses). Kenny and somaya (1989) 1 reported median number of decayed teeth as 8 for 2-6 years age group. The statistically significant difference dmfts for (2-6 years) between study and control was also in accordance with those of Roberts and Roberts 5 who also reported a significant difference in caries experiences between study and control group (2-5 years ). The result obtained presently are also higher than those reported by Feigel 8 and Gleeson (1984). Maguire 9, Rugg-Gunn and Bulter (1996) 9 also reported much lower mean dmft in children <6 years. In the present study these difference in caries however were not observed in the DMFT + dmft for 6-13 years old children. Though the values were higher in the study group, they were not significantly different from that of the control group. This difference was also noted by Roberts and Roberts 10 (1979) who reported that majority of the decayed, filled surface were seen in children between 2-5 years. As Karjalainen, Rekola and Stahlberg (1992) 11 -also reported in their study that difference in dental health disappeared in older age group. DMF value of adenectomised children who had significantly less caries in younger age group, seemed to catch up with those of the control group. They reported that the difference disappeared after 4 years of age. A rise in dmft was recorded with the results reported by Narinder, Tewari and Chawla (1986) 12 who reported that as the number of sugar exposures increased from 1 to 2 and to 3, the relative dental caries also increased. In the present study, the number of children in group-l reported having no sweet snacks per day (meal time or non meal time) was 15 with a dmft of 5.73. This fact points to the presence of some other factor (other than the sweet snacks) which was responsible for this high figure. When compared to the control group with dmft of 1.82, the only factor is LOM which is pointed out. With an increased in duration of LOM, there is a tendency for the lesions to worsen. In the present study it was seen that the: 1. Liquid oral medications taken for a duration of 3 months or more are a risk factor for increased level of caries. 2. Posterior teeth are much more affected than anterior. 3. Significantly higher caries scores are found in 2-6 years old children (primary dentition ) on long LOM. 4. Severity of caries increases with the increase in duration of LOM. REFERENCES: 1. Kenny, J. and P. Somaya. (1989) : Sugar load of oral liquid medications on chronically ill children. J Cand Dent Ass, Jan, 1989, 55 (1) : 43-46. 2. Rekola, M (1989) : In vivo acid production from medicines in syrup form. " Caries Res : 1989, 23: 412-416. 3. Green, J. and J. Vermillion. (1964) : "The simplified oral hygiene index". JADA, 1964, Vol. 68, Jan : 26-31. 4. Ekstrand, K.R., D.N.J. Ricketts and E.A.M. Kidd. (1997): "Reproducibility and accuracy of 3 methods of assessment of demineralization depth on the occlusal surface an in vivo examination. "Caries Res; 1997, 31: 224-231. 5. Robert. G. and I.F.Robert. (1983) : "Dental disease in chronically sick children." ASDCJ of Dent for child, Sept-Oct :1983, 345-351. 6. Butler, J.C. et al (1998) : "The dental status of asthmatic British school children. "Pediatr Dent 1988, 20 : 281-87. 7. Mackie - Blaszcak, M : "Evalution of dentition status and oral hygiene in polish children and adolescents with congenital haemorrhagic diathesis." Int. J of Paed Dent. 1999, 9 : 99-103. 8. Feigal, R.J.et al (1984): "Dental caries related to liquid medication intake in young patients. "ASDC Jo Dent for child, Sept-oct: 1984, 360-362. 9. Maguire, A.,A.J. Rugg-Gunn and T.J. Bulter, : "Dental health of chil dren taking antimicrobial and non antimicrobial liquid oral medication long term." Caries Res; 1996, 30 : 16-21. 10. Roberts, G.J.and I.F. Roberts.: "Relation between medicines sweet ened with sucrose and dental disease." Br Med J, Jul 7:2 (6181) : 1979, 14-6.
Sahgal Jyoti, Sood P.B., Raju O.S. 151 11. Karjalainenm, S.,M. Rekola and M.R. Stahlberg. : Longterm effect Reprint requests to : of syrup medications for recurrent otitis media on the dental health Dr Jyoti Mathur of 6 to 8 year old children. "Caries Res; 1992, 26: 310-314. 4-Vanshree Society, Opp. Udgam School, Drive - In - Road, 12. Narinder, A. Tewari and H.S.Chawla. : Intercomparison of sugar Thaltej and dental caries relationship in urban and rural children." J Indian Ahemadabad - 380054 Soc Pedo Prev Dent. March : 1986, 52-60.