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Sweetened medicines and hospitalization: caries risk factors in children with and without special needs L. POMARICO*, I.P.R. SOUZA**, L.F. RANGEL TURA* ABSTRACT. Aim This was to evaluate caries risk factors: medicine consumption level, oral hygiene frequency and oral hygiene habits during hospitalization of children with and without special needs. Methods A cross-sectional study was carried out using a pre-tested form, interviews were conducted with guardians of children with (G1116) and without special needs (G2-86), from a public day nursery in Rio de Janeiro (Brazil). Results Average use of medications was at 21.8 months for G1- 24.5 and G2- 7.2 (Mann-Whitney: p-value = 0.0009). In the total sample, medicines were taken usually at night; 8.4% of parents sweetened them before ingestion and the majority of children did not brush their teeth after taking medicines. More than half (61.9%) had been hospitalized with an average duration of 21.8 days; 83 (66.4%) had had few hospitalizations; G1- 62.8% and G2 -77.4%. Some 81.6% of the sample reported no tooth brushing while in hospital. Statistics The data were entered in the EPI INFO 6.04d program, and the tests used were Fisher Exact, Mann-Whitney, Kruskal-Wallis and Chi-square with a 5% significance level. Conclusions Poor oral hygiene habits when taking medicines and during hospitalizations were observed, mainly among children with special needs. KEYWORDS: Oral health, Oral hygiene, Children, Disabled, Dental health education, Medicines, Sugars.
Introduction Children with special needs are those “who necessitate special care for an indefinite length of time or for part of their lives, and their dental treatment depends on eliminating or skirting the difficulties inherent to their condition, be their limitation in the emotional, intellectual or social area” [Lannes and Vilhena-Moraes, 1995]. Dental caries, gingivitis and lesions in the oral mucosa, although present in individuals without systemic involvement, are more frequent in patients with some systemic disease [Donatsky et al., 1980; Dens et al., 1995; Hede, 1995; Franco et al., 1996; Souza et al., 1996]. At present, dentistry focuses on prevention and education in oral hygiene. To that end, bacterial plaque control programs should be introduced to maintain a satisfactory level of oral hygiene [Weddell et al., 2001], as plaque accumulation is the principal cause of caries and gingivitis, particularly in patients with systemic involvement. Very often, due to anxiety over their general condition, the parents or guardians end up Depts. of Paediatric Dentistry, *Veiga de Almeida University, **Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
[email protected]
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neglecting other health facets of the disabled child [Roberts and Roberts, 1979]. The greatest oral health threat of these patients may be related to risk factors, such as inadequate oral health in children hospitalized for a long time [Willershausen et al., 1998], or to medicines they take during prolonged periods [Maguire et al., 1996] which contain sucrose, owing either to addition by parents [Marques et al., 2000] or to the composition of the medicament [Kenny and Somaya, 1989]. Furthermore, additional factors may be related to the aetiology of dental caries, such as a hypercaloric diet [Howell and Houpt, 1991], salivary alterations [Madigan et al., 1996] and lessening of salivary A immunoglobulins in patients infected with AIDS [Castro et al., 2004]. Such children may be considered a risk group for oral diseases. Therefore, the aim of this study was to evaluate medicine consumption level, oral hygiene frequency and habits during hospitalization of children with and without special needs.
Materials and methods Subjects. The cross-sectional study consisted of a survey of the attitudes towards oral health adopted by 197
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guardians for children with (G1) and without special needs (G2), enrolled in a day nursery of a municipal foundation of Rio de Janeiro, Brazil. This is one of the chief institutions in the city that receive children with special needs, from families in the low socioeconomic stratum. This institution includes, besides the day nursery, the Stimulation Center. The day nursery is open full-time and 312 children attend with and without special needs, divided into 15 classes according to age group. Children with special needs attend this day nursery up to the age of 6 years, and the others up to the age of 4 years. The Stimulation Center also works full-time, and at the time of the survey 170 children with special needs were being cared for, 42 of which also attended the day nursery. The stimulation activities are oriented by 1 music therapist, 2 psychologists, 1 psycho pedagogue, 6 speech therapists, 3 physiotherapists, 2 rehabilitation technicians and 4 occupational therapists, for small groups of children with special needs. The children are organized according to their general development and independence level, among other parameters. For these activities the children attend the Stimulation Center once or twice a week, and the sessions last one hour. Questionnaire. This was pre-tested by guardians of 10 children with special needs, patients at the Special Patient Pediatric Clinic, and contained 63 questions (37 open and 26 closed). A single examiner interviewed 202 parents/guardians, consisting of 116 from G1 and 86 from G2. The guardians were chosen to participate in the study by a convenience criterion. Those selected attended day nursery and Stimulation Center on the weekdays when the examiner herself was present at the institution, over a period of six months, and who voluntarily accepted to participate in the study. All participants signed an informed consent. With the purpose of putting the participants more at ease to answer the proposed questions according to their knowledge and educational level, it was stated in the text of the informed consent that there were no right or wrong answers. After pre-testing, it was necessary to modify 2 questions, eliminate 3 and add 2 others. All alterations pertained to information about the child's systemic condition. For this study, a part of the original questionnaire was selected. The questions aimed at determining the level of medicine consumption, addition of any kind of sucrose to the medicines, frequency of hospitalization, tooth brushing habits during hospitalization and each child's personal identification. The information obtained was complemented by indirect documentation 198
from the children's clinical files at the institution. Statistical analysis. Comparisons between groups were made with the total sample, including the five and six-year-old children who attended the day nursery and the Stimulation Center. For other analyses, the groups were matched by age and the comparisons made with up to four-year-old children, which constituted a sample with 169 individuals, 83 in G1 and 86 in G2. The answers were inserted into the EPI INFO 6.04d program, and for the statistical analyses the tests used were Exact Fisher, Mann-Whitney, Kruskal-Wallis and Chi-square, with a significance level of 5%.
Results Subjects. The children’s ages varied from 7 to 83 months (mean 37.3 months); mean ages by group were G1 45.8 months and G2 26.0 months (MannWhitney: p-value < 0.0001). Analyzing G1 only with children of up to 4 years of age, the average age was 36.9 months, also presenting statistical difference in relation to G2 (Kruskal-Wallis: p-value < 0.0001). Regarding gender, 55.4% were male and this percentage per group was 56.9% (G1) and 53.5% (G2). Medicines. Of the children who were on medication (n=83), the average time during which they took medicines (syrup form only) was 21.8 months and in groups G1 and G2 it was 24.5 and 7.2 months respectively (Mann-Whitney: p-value = 0.0009). Comparing the matched groups (n= 57) the average period of medication use was 18.5 months, and 21.9 months was the value for G1 (Kruskal-Wallis: p-value = 0.0023). The principal medicines used by the children were vitamins, anticonvulsants, antihistamines, anxsiolytics, antibiotics, anti-depressives, antihypothyroids, antiviral, antihypertensive, cardiological and homeopathic medicines. However, group G2 reported taking only the first three and only one child took anticonvulsants and another antihistamines. Figure 1 shows the ingestion times of these medicines, predominantly at night (after supper and before sleeping). When the guardians of the children were asked whether they usually sweetened medicines for ingestion, 76 (91.6%) said no and only 7 (8.4%) said yes. Table 1 shows the answers according to groups. The substances most used to sweeten them were water with sugar, milk, condensed milk, juice and honey. Hospitalization. Of the sample, more than half (61.9%; n = 125) had already been in hospital and the figures per groups were G1 81.0% (n = 94) and G2 36.0% (n = 31), χ 2: p-value < 0.0001). EUROPEAN JOURNAL OF PAEDIATRIC
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FIG. 1 - Reported times in the day when children took medicines according to the guardians of groups of children with special needs (G1) and without (G2) special neeeds in Rio de Janeiro (Brazil).
Addition of Sucrose
n
G1 %
G2
Yes No Total
6 64 70
8.6 91.4 100.0
n 1 12 13
Total %
n
%
7.7 92.3 100.0
7 76 83
8.4 91.6 100.0
Exact Fisher Test: p-value=1.000
TABLE 1 - Addition of sucrose to medicines for ingestion according to guardians, of groups of children with (G1) and without (G2) special needs living in Rio de Janeiro (Brazil).
Tooth Brushing
n
G1 %
n
G2 %
n
Total %
Yes No Total
20 74 94
21.3 78.7 100.0
3 28 31
9.7 90.3 100.0
23 102 125
18.4 81.6 100.0
TABLE 2 - Tooth brushing of children during hospitalization according to guardians, of groups of children with (G1) and without (G2) special needs living in Rio de Janeiro (Brazil).
Hospitalization frequency was that 83 (66.4%) had had few hospitalizations (up to 2), 32 (25.6%) from 3 to 5 episodes and 10 (8.0%) from 6 to 15. By group the results were G1 and G2: 62.8%, 26.6% and 10.6%; 77.4%, 22.6% and 0.0%, respectively. Considering only the children aged up to 4 years, the hospitalization frequency was also statistically significant (χ2: p-value = 0.0014). Of those children who had been hospitalized, most (84.8%) were accompanied by their mother, followed by the mother and another person, such as the father, aunt and grandmother and a smaller percentage stayed alone. The average duration of the hospitalization was 21.8 EUROPEAN JOURNAL OF PAEDIATRIC
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days and the distribution per group was 39.1 (G1) and 16.9 (G2). This difference was statistically significant (Mann-Whitney: p-value = 0.0042). For the group of children up to 4 years of age, this result was also statistically significant, with the average duration of 43.2 months for G1 (Mann-Whitney: p-value = 0.0018). Tooth brushing. During hospitalization, 81.6% reported they did not brush, with similar values in the two groups, although there was a higher percentage in group G2 (Table 2). As for tooth brushing after taking medicines, the majority (81.9%) answered no. There was a higher percentage (84.3%) among disabled children (Table 3). 199
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Tooth Brushing
n
G1 %
n
G2 %
n
Total %
Yes No Total
11 59 70
15.7 84.3 100.0
4 9 13
30.8 69.2 100.0
15 68 83
18.1 81.9 100.0
TABLE 3 - Reported tooth brushing after taking medicines according to guardians of groups of children with (G1) and without (G2) special needs living in Rio de Janeiro (Brazil).
Discussion Children with systemic involvement often take sweetened medicines for a long time. Taken at night they can be an aggravating condition, because during this period salivary flow rate is reduced and the time of elimination from the oral cavity rises [Fraiz, 1997]. An analysis of the most frequent times when children took medicines showed night time, with a higher percentage in G1. If ingestion after supper is added to ingestion before sleeping, there was a frequency of 80.0% in G1 and 46.2% in G2 (Figure 1). This fact is more worrying if we consider that the average duration of the G1 children’s use of such medicines was 53.5% of their lifetime at the time of the survey, while in G2 this percentage was 27.7%. Fraiz [1997] wrote that the use of home remedies or honey or sugar syrups should be discouraged, particularly at night. Furthermore, this author also considers that children who take medications for long periods have been identified as a caries risk group and therefore should receive special dental care. This is corroborated by Maguire et al. [1996] who found more caries in the primary dentition of children who took liquid medicines for a prolonged time when compared with their healthy siblings. However, Littleton and White [1964] found a lower rate of caries and gingivitis among children taking medicines when compared with the group that did not, relating this factor to better oral hygiene standards. Our findings agree with those of Karjalainen et al. [1992] and Santos-Pinto et al. [2001], who suggest that preventive dental measures must be implemented for children who take potentially cariogenic medicines. With regard to addition of sucrose to medicines by guardians, there was a low prevalence in our sample (8.4%) (Table 1), and the substances used most were water with sugar, milk, condensed milk, juice and honey. Worse results were reported by Marques et al. [2000], when they found that 65.5% of hospitalized children took medication with sugar. However, Castro et al. [2002] found that 100% of the doctors of an AIDS clinic recommended taking medicines 200
associated with sweetened liquids and only 25% recommended oral hygiene after taking the medicine. This can be related to the low frequency of brushing, after taking medicine, found in this study. All the above shows the seriousness of the situation, particularly among disabled children, who face many other health problems. However, Martens et al. [2000] found that children with special needs, who did not take medicines, had significantly less help for brushing, which resulted in more risk to gingival health. In spite of the low frequency of sucrose addition to medicines, another factor to be considered is the composition of the medicines that already contain sucrose, as noted by Lima et al. [2000], who recorded that 58.3% of the medicines studied contained this sweetening agent. Kenny and Somaya [1989] and Santos-Pinto et al. [2001] also found substantial quantities of sucrose in liquid medicines taken by chronically sick children. Silva and Guimarães [2001] found that the majority of the medicines most commonly sold in the city of Maceió (Brazil) had a potential to reduce the salivary flow. Sucrose is the sweetener generally added to the medication formulas because it is a low-cost, easily processed substance [Bigeard, 2000], and has the characteristic of improving the taste of the medicaments [Kenny and Somaya, 1989]. It would be better to use sugar substitutes, such as sorbitol. Another aspect analyzed referred to the long periods of the children’s hospitalization, during which oral hygiene is often relegated to second place. This was found in the present study, in which the occurrence, duration and frequency of hospitalizations happened in a higher percentage in group G1, when the mother was the child’s principal companion. Willershausen et al. [1998] confirmed this situation when they reported a much lower level of oral health among children hospitalized for prolonged periods, compared with those who had not been hospitalized. Hede [1995] found similar results in an adult population. A lack of tooth brushing during hospitalization was found in the EUROPEAN JOURNAL OF PAEDIATRIC
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present study. In research by Costa et al. [2000], with health professionals that treated hospitalized children, however, 56.9% said that the children brushed their teeth daily, mostly in the morning. Other authors have suggested the adoption of oral health programs for hospitalized patients [Hede, 1995; Marques et al., 2000; Pajari et al., 1995].
Conclusion It is suggested that the labelling of medicines should mention their cariogenic potential and recommend oral hygiene after taking the medicine. Furthermore, oral hygiene routines should be introduced in hospitals, particularly at night. Children with special needs took medicines for longer periods and more frequently at night than children without special needs. Poor oral hygiene habits when taking these medicines and during hospitalizations were observed, mainly among these children with special needs.
Acknowledgements This research was approved by the Ethics Committee of the Nucleus of Community Health Studies (NESC) of the Federal University of Rio de Janeiro.
References Bigeard L. The role of medication and sugars in pediatric dental patients. Dent Clin North Am 2000; 44: 443-456. Castro GF, Ribeiro AA, Portela MB, Silva SLM, Souza IPR. Physician’s knowledge and practices of early dental caries in HIV infected children (Portuguese). Rev Bras Odontol 2002; 59: 19-21. Castro GF, Souza IPR, Lopes S, et al. Salivary IgA to cariogenic bacteria in HIV-positive children and its correlation with caries prevalence and levels of cariogenic microorganisms. Oral Microbiol Immunol 2004; 19: 1-8. Costa EM, Castro GF, Ramos ME, Chianca T, Souza IP. Medical dentistry project: knowledge and practice on oral health for hospitalized children (Portuguese). Revista do Centro de Estudos – FO/UERJ 2000; VI: 59-63. Dens F, Boute P, Otten J, Vinckier F, Declerck D. Dental caries, gingival health, and oral hygiene of long term survivors of pediatric malignant diseases. Arch Dis Child 1995; 72: 129-132. Donatsky O, Ahlgren P, Hansen PF. Oral health status and treatment needs in long-term medicine patients in a Copenhagen hospital department. Community Dent Oral Epidemiol 1980; 8: 103-109. Fraiz FC. Diet and dental caries in early infancy (Portuguese). In: Walter LRF, Ferelle A, Issao M (eds). Dentistry for infants. São Paulo: Artes Médicas; 1997. pp. 107-122.
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Franco E, Saunders CP, Roberts GJ, Suwanprasit A. Dental disease, caries related microflora and salivary IgA of children with severe congenital cardiac disease: an epidemiological and oral microbial survey. Pediatr Dent 1996; 18: 228-235. Hede B. Oral health in Danish hospitalized psychiatric patients. Community Dent Oral Epidemiol 1995; 23: 44-48. Howell RB, Houpt M. More than one factor can influence caries development in HIV-positive children. Pediatr Dent 1991; 13: 247. Karjalainen S, Rekola M, Stahlberg MR. Long-term effects of syrup medications for recurrent otitis media on the dental health of 6-to-8-years-old children. Caries Res 1992; 26: 310-314. Kenny DJ, Somaya P. Sugar load of oral liquid medications on chronically ill children. J Can Dent Assoc 1989; 55: 43-46. Lannes C, Vilhena-Moraes SA. Children with special needs (Portuguese). In: Guedes-Pinto AC (ed). Paediatric Dentistry. São Paulo: Santos livraria editora; 1995. pp. 1067-1104. Lima KT, Almeida ICS, Senna ETL. Pediatric medication – sweetener agents and pH (Portuguese). J Bras Odontoped Odonto Bebe 2000; 3: 457-463. Littleton NW, White CL. Dental findings from a preliminary study of children receiving extended antibiotic therapy. J Am Dent Assoc 1964; 68: 520-525. Madigan A, Murray PA, Houpt M, Catalanotto F, Feuerman M. Caries experience and cariogenic markers in HIV-positive children and their siblings. Pediatr Dent 1996; 18: 129-136. Maguire A, Rugg-Gunn AJ, Butler TJ. Dental health of children taking antimicrobial and non-antimicrobial liquid oral medication long-term. Caries Res 1996; 30: 16-21. Marques AC, Ramos ME, Soviero VLM. Education and prevention in buccal health for hospitalized children (Portuguese). Pesqui Odontol Bras 2000; 14 suplemento: 45. Martens L, Marks L, Goffin G et al. Oral hygiene in 12-years-old disabled children in Flanders, Belgium, related to manual dexterity. Community Dent Oral Epidemiol 2000; 28: 73-80. Pajari U, Ollila P, Lanning M. Incidence of dental caries in children with acute lymphoblastic leukemia is related to the therapy used. ASDC J Dent Child 1995; 62: 349-352. Roberts IF, Roberts GJ. Relation between medicines sweetened with sucrose and dental caries. Br Med J 1979; 2: 14-16. Santos-Pinto L, Uema AP, Galassi MA, Ciuff NJ. What do pregnant women know about oral health? (Portuguese). J Bras Odontoped Odonto Bebe 2001; 4: 429-434. Silva MFA, Guimarães JA. Cariogenic potential of medicaments used for treatment of respiratory tract diseases and allergy (Portuguese). J Bras Odontoped Odonto Bebe 2001; 4: 383-386. Souza IP, Teles GS, Castro GF, et al. Caries prevalence in HIV-infected children (Portuguese). Rev Bras Odontol 1996; LIII: 49-51. Weddell JA, Sanders BJ, Jones JE. Dental problems of children with disabilities (Portuguese). In: McDonald RE and Avery DR (eds). Dentistry for the child and adolescent. Rio de Janeiro: Guanabara Koogan; 2001. pp.413-435. Willershausen B, Lenzner K, Hagedorn B, Ernst CP. Oral health status of hospitalized children with cancer: a comparative study. Eur J Med Res 1998; 3: 480-484.
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