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Knowledge, Attitude and Practice of Mothers for Administration of Medicaments to Their Children and its Correlation with Dental Caries

Oral health is considered to be an important factor in a child’s overall growth and development. Dental caries being one of the major threats to children is multifactorial. It leads to decalcification of the teeth due to acid production caused by oral bacteria. The reaction between sugars in drinks, foods and bacteria in the dental biofilm present on the tooth surface causes the production of acid which is responsible for the initiation of dental caries.1,2


INTRODUCTION
Oral health is considered to be an important factor in a child's overall growth and development. Dental caries being one of the major threats to children is multifactorial. It leads to decalcification of the teeth due to acid production caused by oral bacteria. The reaction between sugars in drinks, foods and bacteria in the dental biofilm present on the tooth surface causes the production of acid which is responsible for the initiation of dental caries. 1,2 Analgesics and antibiotics along with various multivitamin supplements are commonly prescribed to children. These medications are widely available in syrup or suspension form and sweetened to increase patient compliance. Along with acceptance by the pediatric age group, medication in syrup form has good absorbability and flexibility with dosage. 3 However, long term usage of sweetened oral medication can cause amplification of risks by making patients more susceptible to dentinal caries. 4 High sucrose, fructose and glucose content in these medications along with other contributing factors like low pH, the duration and frequency and time of administration leads to an increase in caries in children. The incidence of caries can be reduced if proper precautionary and preventive measures are taken by the child's parent or guardian. Poor attitude of parents towards the oral health of children is one of the reasons for the increase in caries prevalence.
. Thus, this study is scheduled to assess the knowledge and awareness of mothers about cariogenicity of pediatric syrup medications and its correlation to dental caries.

MATERIALS AND METHODS
The study was a prospective study conducted in the Department of Pediatrics and Preventive Dentistry, Sharad Pawar Dental College and Department of Pediatrics, Acharya VinobaBhave Rural Hospital, Sawangi(Meghe), Wardha.
The study included 230 mothers of children aged between 4 to 8 years of age and mothers of immunocompromised children or those having systemic medical history were excluded from the study. A validated short questionnaire consisting of 4 multiple choice questions were used for the study. (Table  1) The questionnaire was framed in local language about awareness regarding the administration of medication to their children. The oral cavity of children of participated mothers was examined for dental caries and recorded in the study.

STATISTICAL ANALYSIS
The data obtained was calculated using descriptive statistics employing absolute distribution, percentage of measures and techniques of interferential statistics. Frequency analysis was done using SPSS software version 22.0.

RESULTS
Amongst the 230 mothers who participated in the study, 80.4% mothers preferred syrup and 1.7% mothers preferred tablets for their child while 17.8% mothers preferred medication in both forms for their children (Graph 1). 63.5% of mothers revealed that they administered medication twice daily while 34.8% of mothers used to administer medication thrice for their children (Graph 2). None of the participated mothers made their child brush post medication, however, 93.9% mentioned that their child drinks water after intake of medication and 6.1% mothers took oral hygiene measures and made their child gargle with water post medication intake (Graph 3).
The relationship between frequent consumption of medications and dental caries was not known to 78.7% mothers while 19.1% of mothers thought that these medications could not cause dental caries (Graph 4). The dental caries status of children having one carious lesion is among 33.9% whereas only 3.5% of children had more than 6 carious teeth in the mouth (Graph 5).

Graph 1:
Mothers knowledge about the form of medication delivered to her child.

Graph 2:
Mothers knowledge about the frequency of medication delivered to her child.

DISCUSSION
Lokken et al. and Imfeld et al. mentioned the presence of sucrose in medicines having cariogenic potential. This sucrose amount varied from 0-67% in pediatric liquid medication. 5 Agrawal et al. 6 observed a range of 20.62 -68.26% sucrose in Indian Pediatric liquid medication. 6 Commercially available medications for pediatric age group are mainly in sucrose based syrup forms as the liquid preparation for drug delivery are popular and easily accepted by children. 7 Historically, Roberts and Roberts first documented harmful effects on the oral health of a child due to oral medication in 1979. 8 Physicians including the Pediatricians prescribe medications for cough, fever along with medications for overall growth and well-being. Pediatric dentists are well aware of the relationship between liquid medication and dental caries. However, due to parental preference and lesser knowledge about the of non-sweetened pediatric medications availability in the market, they tend to prescribe the medication in liquid syrup form.
Mothers are unaware of the hidden sugar components in liquid medicaments and their implication on the oral and dental health of the child. Liquid medications can lead to rampant dental decay and it can be considered as one of the major etiologic factors. 9 Literature suggests an increase in caries incidence in children consuming liquid medication. It has been noted that in children consuming liquid medications, the incidence of dental caries is also increased. 10,11,12 Also, low endogenous pH of these medications is responsible for erosive and cariogenic potential in children. 13,14 Nowadays, it is seen that there is an increased usage of nonprescription and over the counter liquid medicaments for cough and cold in children. But many studies have shown that there are adverse effects associated with non-prescription drug administration. 15 Walimbe et al. 16 through his study stated that about 50% paediatrician prescribed medication in the form of syrup, whereas more than 80% parents stated that their children preferred medication in the liquid form as stated in the present study.
Mothers are often responsible for the administration and care related to the use of pediatric medicines. The medical practitioners should encourage the parents to restrict the intake of the medication to mealtimes and avoid administrating medication before sleeping. 17 In the present study, around 63.5% of parents administered medications twice daily while only 0.4% administered it four times a day. The duration has a major impact on dental caries, as Girish Babu et al. 5 stated that syrups given in 2-3 divided doses especially during the night have a deleterious effect on enamel. This can be attributed to the fact that the saliva rate decreases during the night and the oral muscular co-ordination is less leading to decrease in the oral clearance process and reduced ability to eliminated the retained particles from the mouth.
Pediatric dentists emphasize parents on seeking regular preventive oral care for their children along with a routine oral hygiene recommendation post medication administration. 7 The frequency of consumption of sugar is proportional to the experience of caries. Consumption of these liquid medicines increases the number of sugar exposure in the child's normal diet thereby increasing the risk of caries. 18 About 33.9% of children had only one carious lesion while only 3.5% has carious lesion more than six carious teeth. This can be attributed to the fact that majorly 91% of mothers mentioned that they made the child drink water post medication. This was a major oral hygiene factor practised by the mothers unknowingly, flushing the liquid medication of the teeth surface and decreasing dental caries incidence.
It is important to spread awareness amongst parents about the potential risk of inadvertent and injudicious use of these medications in which Pediatricians and Pedodontists play an important role. They should inform the parents about the sugar content of these medications, recommend limited use whenever possible, use of tablets be encouraged, advice brushing after administration, medication to be given at mealtimes rather than between meals and avoid administration at bedtime. 19 Pediatricians, Pediatric dentists and Physicians should prescribe non-sucrose medicaments and advice adequate preventive and oral hygiene measures for children on the long term use of liquid medicines. 20

CONCLUSION
The Pediatric dentist and Pediatricians should create awareness among the parents regarding caries incidence due to liquid medication. They should be encouraged to take adequate post medication measures in their children.
Acknowledgement: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.