Knowledge, Attitude, and Practice of Pediatricians Regarding Pediatric Liquid Medicaments on Long-Term Oral Health: A Cross-sectional Study in Bhubaneswar, Odisha.

BACKGROUND: A pediatrician is supposed to be one of the first clinician who sees a child from infancy through adolescence. This study was carried for pediatricians serving in medical colleges and tertiary hospitals in Bhubaneswar City, Odisha, India.
MATERIALS AND METHODS: A questionnaire was distributed among 30 pediatricians serving in various medical colleges and tertiary hospitals in Bhubaneswar City area. It consisted of questions regarding knowledge of pediatricians on the awareness of detrimental effects of long-term liquid medicaments use on oral cavity, including delivery of oral hygiene instructions and regular dental checkup. The data as obtained were subjected to statistical analysis using Statistical Package for the Social Sciences (SPSS) software, version 17.0, for Microsoft Windows (Chicago, Illinois).
RESULTS: The results showed that there is a good amount of awareness among the pediatricians working in medical colleges in Bhubaneswar regarding pediatric liquid medication and their ill effects on teeth. Most pediatricians considered age and body weight of the child (87%). Sixty five percent of pediatricians were aware that pediatric liquid medication (PLM) can cause dental caries. Ninety five percent of them were aware of PLMs with sugar substitutes are available in market.
CONCLUSION: The overall awareness among the pediatricians regarding the ill effects of pediatric liquid medications on teeth is satisfactory. Copyright:

Introduction

A pediatrician is supposed to be one of the first clinician who sees a child from infancy through adolescence.[1] Oral health care is an integral part of overall health. However, the pediatricians have minimal exposure to oral health examination as that part is supposed to be taken care of by dental health experts and pediatric dentists.[2] The parents along with the child, initially are frequent visitor to the pediatricians for routine medical examination. This is not the scenario in case for routine dental checkup and the parents take the child to a pediatric dentist only when the child has an emergency situation, such as trauma or pain in the tooth.[3] It is presumed that the pediatricians would provide oral health care instructions to the primary caregivers of the infants and children visiting them on a routine basis.[4] However, that does not happen as the pediatricians, either do not have time to discuss oral health or have poor knowledge to express the highlights of good oral hygiene in infants.[5] Moreover, children taking long-term liquid oral medications have deleterious oral effects but majority of them do not receive preventive instructions from the presumptive peers. In the long run, the child presents with dental caries and erosion seen at a later stage of life.[6] With the development of newer technologies and access to information on oral health practices, it might be possible for pediatricians to obtain sufficient knowledge and thereby incorporate this knowledge into routine practice. Apart from this, the related academies and associations in pediatrics often come out with policies, which highlight the topics that are of need and in vogue.[7] Thus, the pediatricians can always gain knowledge about infant oral health and children oral health needs from the vast resources they have in their hands.[7] However, still there are conflicting reports on the knowledge, attitude, and practices of pediatricians on the oral health needs of children, and it varies in different geographical locations.[89] No study has been reported from Odisha, and this was the first study conducted to know the knowledge among pediatricians regarding PLM and dental caries.

This survey was conducted among the pediatricians working in various medical colleges of Bhubaneswar, Odisha, India, regarding their knowledge, attitude, and practice in pediatric liquid medications (PLMs) and the deleterious effects they have on the long-term oral health of children.

Materials and Methods

This was a cross-sectional study conducted in Bhubaneswar, Odisha, among the pediatricians working at various medical colleges (three in number) and tertiary care hospitals (four in number). A questionnaire was randomly distributed among 30 pediatricians working in medical colleges and tertiary hospitals (seven in total) in Bhubaneswar City. There are 32 pediatricians working in these medical colleges and hospitals, of which 30 were present on the day of survey. Thus all the pediatricians were included in the study. The ethical clearance was taken from institutional ethical review board, Siksha ‘O’ Anusandhan (deemed to be) University. The questionnaires were handed out personally after explaining the motive behind the survey to pediatricians and they were requested to fill the questionnaire. The validity of the questionnaire was carried out both by pediatricians and pedodontists after conducting a pilot study. The questionnaire consisted of two parts, personal details and specific information. The first part of the questionnaire consisted of questions related to age, gender, years of practice, affiliations, and so on. The second part of the questionnaire, which had 18 questions, containing questions regarding the use of pediatric liquid medicaments, awareness of their ill effects on oral cavity in long-term use, and oral hygiene maintenance.

The respective data were collected, entered, and cleaned in Microsoft Excel before statistical analysis. The entire data were statistically analyzed using the Statistical Package for the Social Sciences (SPSS, version 17.0, Chicago, Illinois) for Microsoft Windows. Pearson’s chi-square test was applied for the analysis of the data.

Results

A total number of 23 pediatricians completed the questionnaires. There were 12 male (52%) and 11 female (48%) pediatricians, and the age varied from 30 years to 58 years with mean age of 43.3 years. They considered age and body weight of the child (87%), body weight (39%), and cost of medicine (22%) to be relevant while prescribing PLM [Table 1]. None of them prescribed tetracycline, which shows that all of them were aware of the ill effects of this medication. All the pediatricians (100%) preferred oral route of drug administration for children and prescribed syrup form (78%). Although 82% of pediatricians knew that the PLM was sweet in nature, 65% said that they can cause dental caries. Eighty-two percent of pediatricians stated that the dental decay is due to the combination of pH, viscosity, and stickiness of the syrups and could not pinpoint a single property to cause caries. A large number of respondents (65%) thought that PLM caused decay of teeth, whereas 34% said PLM caused erosion. Although 86% of pediatricians were aware of the hidden sugars present in PLM, only 65% of them provided oral health instructions following their intake. Concerning the sweetening agents added in PLM, pediatricians cited corn syrup (65%), sucrose (26%), fructose (8%), sugar substitutes (26%), and glucose (4%).

Table 1

Knowledge, attitude, and practice of pediatricians regarding sugar-containing pediatric liquid medicaments

		N	N%
Q01	a. Cost of the medicine	5	21.7
	b. Patients preference	4	17.4
	c. Body weight of the child	9	39.1
	d. Age and body weight of the child	20	87.0
	e. Pharmaceutical company	0	0.0
	f. Type of sugar present	4	17.4
Q02	a. Yes	0	0.0
	b. No	30	100.0
Q03	a. Oral	30	100.0
	b. Intramuscular	2	8.7
	c. Intravenous	4	17.4
	d. Rectal	2	8.7
	e. Others (please mention)	1	4.3
Q04	a. Yes	17	73.9
	b. No	6	26.1
Q05	a. Syrups	18	78.3
	b. Dispersible tablets	5	21.7
	c. Both	8	34.8
Q06	a. Sweet	19	82.6
	b. Acidic	2	8.7
	c. Bitter	4	17.4
Q07	a. Viscosity	0	0.0
	b. pH	1	4.3
	c. Stickiness or adherence	3	13.0
	d. Sugar content	0	0.0
	e. All of the above	19	82.6
Q08	a. Yes	19	86.4
	b. No	3	13.6
Q09	a. Glucose	1	4.3
	b. Fructose	2	8.7
	c. Sugar substitutes	6	26.1
	d. Sucrose	6	26.1
	e. Corn syrup	15	65.2
Q10	a. Erosion	8	34.8
	b. Decay	15	65.2
	c. Stain	2	8.7
Q11	a. Yes	11	47.8
	b. No	12	52.2
Q12	a. Yes	15	65.2
	b. No	8	17.2
	If yes
	a. Brushing	4	8.7
	b. Rinsing	6	26.1

All the statistics applied and the tables.

1. To find a correlation between genders

2. Between age groups

3. Significance in experience

Questionnaire for Table 1

Part A

Age: Gender: Experience:

What factor do you consider before prescribing medication to the children?

Cost of the medicine

Patients preference

Body weight of the child

Age and body weight of the child

Pharmaceutical company

Type of sugar present

Do you prescribe tetracycline to children?

Yes

No

Which route of drug administration do you prefer for children?

Oral

Intramuscular

Intravenous

Rectal

Others (please mention)

Do you dispense or offer the choice of form of medicine?

Yes

No

For a young patient (1–6 years), do you prefer to prescribe?

Syrups

Dispersible tablets

Both

Are PLM (pediatric liquid medication) sweet/acidic/bitter?

Sweet

Acidic

Bitter?

Which property of PLM, do you feel causes deleterious effects on teeth?

Viscosity

pH

Stickiness or adherence

Sugar content

All of the above

Are you aware of the hidden sugars present in PLM?

Yes

No

Name of the commonly used sweetening agent(s) present in PLM?

Glucose

Fructose

Sugar substitutes

Sucrose

Corn syrup

Can PLM cause tooth erosion or decay or stains?

Erosion

Decay

Stain

Do you inform and guide child’s parents about the risk of dental caries associated with PLM?

Yes

No

Do you recommend oral hygiene measures to be taken following intake of PLM?

Yes

No

If yes

Brushing

Rinsing

The pediatricians having more than 15 years of experience were significantly more inclined to give choice to parents for route of administration of PLM (P < 0.05) than those who have less experience.

Almost all the pediatricians (95.7%) who were working in medical colleges and tertiary care hospital were aware of sugar-free medications being available [Table 2]. The source of information was medical representatives (24.5%) and health journals (20.4%). The choice to dispense sugar-free medication depended on the medical status of the patient. Although all were aware of sugar-free medications, most pediatricians (65.2%) did not want all the PLM to be sugar free. There was a significant finding of more experienced pediatricians saying sugar-free medicaments to be more expensive so a hindrance to prescribe these over sugar-containing medications.

Table 2

Awareness of pediatricians regarding sugar-free pediatric liquid medicaments

		Responses
		N	Percent (%)
Q1a	a. Yes	22	95.7
	b. No	1	4.3
Total		23	100.0
Q2a	a. Health Literature	7	14.3
	b. Professional journal	10	20.4
	c. Conference/seminars	6	12.2
	d. Postgraduate training	5	10.2
	e. Undergraduate training	3	6.1
	f. News media	3	6.1
	g. Print media	3	6.1
	h. From pharmacists, sales representatives	12	24.5
Total		49	100.0
Q3a	a. Agree	9	39.1
	b. Disagree	13	56.5
	c. Not sure	1	4.3
Total		23	100.0
Q4a	a. Agree	5	21.7
	b. Disagree	10	43.5
	c. Not sure	8	34.8
Total		23	100.0
Q5a	a. Agree	1	4.3
	b. Disagree	15	65.2
	c. Not sure	7	30.4
Q6a	a. Parental requests	4	10.5
	b. Medical status of patients	7	18.4
	c. Information from health literature	3	7.9
	d. Detailing by pharmaceutical representative	2	5.3
	e. Availability in pharmacy	2	5.3
	f. Recommendations by national health policy	10	26.3
	g. Affordability	3	7.9
	h. Mass media advertisements	1	2.6
	i. Reports of clinical trials	6	15.8

Part B: Questionnaire for Table 2

Awareness of the pediatricians regarding sugar-free pediatric medicaments

Have you heard about sugar-free medicaments?

Yes

No

What is the source of information?

Health literature

Professional journal

Conference/seminars

Postgraduate training

Undergraduate training

News media

Print media

From pharmacists, sales representatives

Others

Sugar-free medicine is not as sweet as sugar-containing medicines?

Agree

Disagree

Not sure

Sugar-free medicines are more expensive than sugar-containing medicines?

Agree

Disagree

Not sure

Should all PLM be available as sugar-free medicines?

Agree

Disagree

Not sure

What are the factors that influence your decisions to dispense sugar-free medicines if made available at your place?

Parental requests

Medical status of patients

Information from health literature

Detailing by pharmaceutical representative

Availability in pharmacy

Recommendations by national health policy

Affordability

Mass media advertisements

Reports of clinical trials

Discussion

This study found that most pediatricians considered age and body weight for prescribing medication, none of them gave any preference to pharmaceutical company or cost of medicine for prescription, which was in contrast to previous studies.[8910] The reason for not considering the cost of medication and any particular pharmaceutical company might be due to the fact that the pediatricians considered in this study were working in medical colleges and tertiary care centers. Syrup form was mostly prescribed by the pediatricians probably because most of the PLMs are sweetened to improve the palatability of children. Majority of the pediatricians knew that hidden sugars present in PLM make them palatable, they were also aware of its role in causation of dental caries and erosion, which was again different from other studies in which, although most pediatricians were aware of the hidden sugars in PLM, they did not know the deleterious effects on teeth.[1112] Most pediatricians in our study thought corn syrup is added in PLM, which was again in contrast to other studies, where most pediatricians had the knowledge of sucrose being used in syrups. High fructose corn syrups are detrimental to the teeth as they can lead to dental caries much similar to normal sugars. Although pediatricians were knowledgeable of the ill effect of tetracycline on teeth, they appeared to be unaware of the effect of liquid medicaments on dental health.[13]

In our study, pediatricians were aware of the hidden sugars in the PLM, and most of them informed children’s parents about the risk of dental caries associated with liquid medications and recommended for oral hygiene measures. This finding was in contrast with other studies, which stated that most of the pediatricians did not give oral health instructions to be followed after intake of medicines.[1014]

Because of the concern of sugar-containing PLM, pharmaceutical companies have introduced sugar-free medications into the market. Sugar-free medications are known to be as effective as sugar-containing medications and only 10% are more expensive.[15] In this study, around 95% of pediatricians were aware of the availability of sugar-free medications, which was again higher than other studies conducted so far on this subject. Their main source of information was through medical representatives, professional journals, and health literature, followed by attending conferences and seminars and training during undergraduate course. These findings suggested that there is a need for an educational input at undergraduate level and continuing training even after graduation to remain up to date with the changing situation.[16]

It is important that health professionals, particularly pediatricians and child health-care providers including pediatric dentists, be aware of the risk of oral diseases during the course of use of pediatric medications. Oral hygiene instructions are a must for children under medication. The sugar-free medicines must be suggested wherever possible. Pediatric dentists should educate parents to ensure adequate oral clearance after each dose of medication as a primary step for minimizing the risk of dental caries and erosion of dental structures.[17]

This study indicated a shift regarding the understanding of constituents in the sweetened medicaments. Initially, the awareness was focused on sucrose, but this study showed that the present day pediatricians are aware of the sugar substitutes, which pose little concerns on the oral health. Public health policies must be implemented and followed in our country to reduce the sugar content, where medicines are used on a long-term basis by children and adolescents, and therefore decrease the incidence of dental caries. Prescription practices may vary in different countries, but the basic ingredients are nearly similar in many countries. Adequate information should be provided regarding oral health in medical colleges, residency and postgraduate programs, and in continuing education programs by adding a lesson on the preventive measures on oral health care. Thus, all the medical professionals including pediatricians may be able to play an important role in improving the oral health of children.[1819]

This study also tried to establish that pediatricians who are more experienced offer the parents a choice of administration of PLMs and they are more aware of the hidden sugars in PLMs than their younger counterparts, which is something new in this study.

The factors that should be considered to determine a drug’s cariogenic potential are its sugar content, frequency, dose, and pattern of use.[20] Also, individual characteristics such as salivary flow rate and buffer capacity should be considered. The liquid medications are usually viscous syrups that penetrate and adhere into fissures and interproximal areas, which are inaccessible for brushing.[21] Children should be encouraged to rinse their mouths with water after taking liquid medications. Most parents are not aware that several foods, beverages, and pediatric medications in the form of syrups or granules have dissolved sugar in them, and they associate caries only with the consumption of chocolates and cookies.[22]

Conclusion

As the medications prescribed to children are commonly available as drops and syrups in sweetened forms, it is important that health professionals, particularly pediatricians and pediatric dentists should make an effort to make the parents aware about the ill effects of these on children’s teeth. Children under medication should be motivated to practice adequate oral hygiene measures. Despite the availability of many sugar substitutes, products in the market continue to include sweeteners with cariogenic potential. Alternative measures to improve the flavor or taste using techniques such as coating, complex formation, choice of vehicle, and adjustment of viscosity should be considered in the development of drug formulations. The pediatricians also should be made aware of the potential harm to the teeth by PLM so that they can tell the parents about the same and take adequate oral hygiene measures accordingly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Pearson chi-square tests
		Gender
Q1	Chi-square	1.917
	Sig.	0.384
Q2	Chi-square	6.983
	Sig.	0.538
Q3	Chi-square	2.545
	Sig.	0.467
Q4	Chi-square	1.732
	Sig.	0.630
Q5	Chi-square	3.160
	Sig.	0.368
Q6	Chi-square	7.505
	Sig.	0.585

Sig. = significant

Nothing significant

Pearson chi-square tests
		Age Groups
Q1	Chi-square	2.718
	Sig.	0.257
Q2	Chi-square	6.747
	Sig.	0.564
Q3	Chi-square	0.897
	Sig.	0.826
Q4	Chi-square	2.230
	Sig.	0.526
Q5	Chi-square	3.418
	Sig.	0.331
Q6	Chi-square	8.624
	Sig.	0.473

Sig. = significant

Nothing significant

Pearson chi-square tests
		Experience
Q1	Chi-square	0.915
	Sig.	0.633
Q2	Chi-square	11.205
	Sig.	0.190
Q3	Chi-square	0.518
	Sig.	0.915
Q4	Chi-square	6.416
	Sig.	0.093
Q5	Chi-square	3.560
	Sig.	0.313
Q6	Chi-square	7.497
	Sig.	0.586

Sig. = significant