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NUTRITION
Sugar content, cariogenicity, and
dental concerns with commonly
used medications
Mark Donaldson, BSP, RPH, PharmD, FASHP, FACHE;
Jason H. Goodchild, DMD;
Joel B. Epstein, DMD, MSD, FRCD(C), FDS, RCS(Edin)
Because of the bitter taste of many medications,
sugar (sucrose) is often combined with other
ingredients to provide more palatable forms
that may improve patient compliance.
1-3
Su-
crose provides other functional properties in addition to
sweetness; it also acts indirectly as a solvent, demulcent,
and bulking agent.
4
Unfortunately, the biofilm covering
teeth (plaque) contains over 500 species of bacteria that
consume carbohydrates such as sucrose, creating acid as
a by-product. If there is ongoing exposure to sucrose, an
acidic environment is created that can decalcify tooth
enamel, leading to carious lesions. Left untreated, caries
can lead to pulp infection and potential tooth loss; hence,
alternative sweeteners such as sorbitol and xylitol are
increasingly common in medicinal preparations in lieu of
sucrose.
5,6
Dr. Donaldson is the director of pharmacy services, Kalispell Regional
Healthcare, Kalispell, MT; a clinical professor, Skaggs School of
Pharmacy, University of Montana, Missoula, MT; and a clinical assistant
professor, School of Dentistry, Oregon Health & Sciences University,
Portland, OR. Address correspondence to Dr. Donaldson, 310 Sunnyview
Lane, Kalispell, MT 59901, e-mail mdonaldson@krmc.org.
Dr. Goodchild is a clinical associate professor, Department of Oral
Medicine, University of Pennsylvania School of Dental Medicine,
Philadelphia, PA; an adjunct assistant professor, Division of Oral
Diagnosis, Department of Diagnostic Sciences, Rutgers School of Dental
Medicine, Newark, NJ; and a private practitioner, Havertown, PA.
Dr. Epstein is a diplomat, American Academy of Oral Medicine,
Edmonds, WA; consulting staff, Division of Otolaryngology and Head and
Neck Surgery, City of Hope National Medical Center, Duarte, CA; and a
collaborative member, Samuel Oschin Comprehensive Cancer Institute,
Cedars Sinai Medical Center, Los Angeles, CA.
Copyright ª2015 American Dental Association. All rights reserved.
ABSTRACT
Background and Overview. Oral adverse events such
as cariogenicity are often overlooked as drug-associated
effects because the sugar content of many medications may
be negligible compared with the patients’overall dietary
intake of sugar. There are, however, several liquid formu-
lations of medications with significantly high sugar content
that are commonly used in patients with swallowing diffi-
culties. These medications may be associated with negative
oral health sequelae and should be considered part of the
oral health care providers’differential diagnosis of oral
pathologies.
Methods. We reviewed the literature regarding the sugar
content of oral liquid medications commonly prescribed by
oral health care providers, with consideration to their caries
potential. Where not available via public sources, phar-
maceutical companies were contacted directly for addi-
tional information on the sugar (carbohydrate) content of
these oral liquid medication formulations.
Results. Over 50 commonly used oral liquid medications
prescribed for patients with swallowing difficulties were
reviewed and found to contain sugar in varying amounts up
to 4 grams per dose (usually 1 teaspoon or 5 milliliters).
Patients who are required to take multiple doses per day of
these sugar-containing oral liquid medications may be at
increased risk for caries and associated oral health
consequences.
Conclusions and Practical Implications. Recogni-
tion and avoidance of sugar-containing oral liquid medi-
cations can help clinicians optimize patient treatment,
decreasing the risk for potential drug-induced caries while
emphasizing patient safety and improved oral health.
Key Words. Drugs; dental care; cariogenicity; patient
safety; sugar content.
JADA 2015:146(2):129-133
http://dx.doi.org/10.1016/j.adaj.2014.10.009
ORIGINAL CONTRIBUTIONS
JADA 146(2) http://jada.ada.org February 2015 129
Encapsulating medicines in solid oral dose forms
such as capsules or tablets is an effective method to
avoid unpleasant medication tastes, but these formula-
tions can be problematic for patients who have trouble
swallowing. Patients with pathologies that are aggra-
vated by medications that irritate the oral mucosa (such
as patients undergoing radiotherapy to the oral cavity
or chemotherapy), those with feeding tubes in place,
or patients who simply cannot swallow tablets or cap-
sules may be better suited for liquid formulations of
medications, such as oral
solutions or suspensions.
These patients pose a
significant challenge for
oral health care providers
(OHCPs), who may pre-
scribe (or who may treat
patients who have been
prescribed) sugar-
containing oral liquid
medications.
Here we review the
sugar content of oral
liquid medications
commonly prescribed by
OHCPs with consider-
ation to their caries po-
tential. Because the oral
cavity is a potential
source of sepsis, early
and definitive dental
intervention, compre-
hensive oral hygiene
measures, and elimina-
tion of the cause will
reduce the risk for oral
and associated systemic
complications.
7-10
We
focus specifically on
some of the most com-
mon sugar-containing
oral liquid medications
patients may be exposed
to; we review their oral
health implications; and
we provide guidance for
contemporary dental
practice.
DISCUSSION
OHCPs who are pre-
pared with evidence-
based information about
the formulation of liquid
medications can advise
their patients regarding
optimal medication therapy, potentially helping to
ensure healthy outcomes. We based this literature re-
view on searches of the following knowledge-based re-
sources without any restrictions on dates of publication:
Medline, PubMed, Embase, and the Cochrane Database
of Systematic Reviews. The search terms were “dental
care”and “dentistry”;“cariogenicity”and “sugar
TAB L E 1
Sugar-containing oral liquid medications commonly
prescribed by oral health care providers.
11-15
MEDICATION ACTIVE INGREDIENT
CONCENTRATION
AVAILABLE, mg*/5 mL
†
USUAL ADU LT DOSE SUCROSE
CONTENT,
g
‡
/5 mL
Antibiotics
Amoxicillin 125, 200, 250, 400 250-500 mg every 8 h 1.70, 1.68, 1.85, 1.88
Amoxicillin–clavulanic
acid
125-31.25, 250-62.5 250-500 mg every 8 h or
875 mg every 12 h
0.53, 0.67
Azithromycin 100, 200 250-500 mg once daily 3.86, 3.87
Bactrim 200-40 4 mL every 12 h 3.2
Cefaclor
§
125, 250, 375 250-500 mg every 8 h 2.3, 2.1, 2.0
Cefadroxil
§
250, 500 500-1,000 mg every 12 h 2.2, 1.9
Cefdinir 125, 250 300 mg every 12 h 2.9, 2.7
Cefpodoxime
§
50, 100 100-400 mg every 12 h 3.0, 3.1
Cefprozil
§
125, 250 500 mg every 12-24 h 2.2, 2.0
Cefuroxime
§
125, 250 125-500 mg every 12 h 3.2, 2.4
Cephalexin 125, 250 250-1,000 mg every 6-12 h 3.0, 3.0
Ciprofloxacin
§
250, 500 250-750 mg every 12 h 1.4, 1.3
Clarithromycin
§
125, 250 250-500 mg every 12 h 2.4, 2.4
Clindamycin 75 150-450 mg every 6-8 h 1.5
Doxycycline
§
25 (suspension), 25 (syrup) 100 mg every 12 h 1.7, 4.4
Erythromycin 200, 400 250-500 mg every 6 h 3.0, 3.0
Levofloxacin
§
125 250-750 mg daily 2.5
Penicillin VK
¶
125, 250 250-500 mg every 6-8 h 2.7, 2.7
Analgesics and
Anti-inflammatories
Acetaminophen 160 325-650 mg every 6-8 h 2.5
Acetaminophen with
codeine
120-12 325-650 mg every 6-8 h
(acetaminophen)
3.0
Codeine 30 15-60 mg every 4 h as needed 4.3
Ibuprofen 100 200-400 mg every 4-6 h 1.6
Miscellaneous
Diphenhydramine 12.5 25-50 mg every 6-8 h 0.42
Dexamethasone 0.5, 5 4-10 mg every 12 h 1.7, 3.2
Nystatin 500,000 U/5 mL 1-5 mL every 6 h 2.5
Prednisolone 15 Titrated to the individual 1.9
Prednisone 5 Titrated to the individual 0.8
* mg: Milligram.
†mL: Milliliter.
‡g: Gram.
§ Personal communication from the manufacturer.
¶ Can be brand specific (Stada brand ¼2.6 g/5 mL and 2.6 g/5 mL, respectively; Bristol-Myers Squibb brand ¼
3.5 g/5 mL and 3.5 g/5 mL, respectively).
ABBREVIATION KEY. OHCP: Oral health care provider.
ORIGINAL CONTRIBUTIONS
130 JADA 146(2) http://jada.ada.org February 2015
content”; and “patient safety.”
In addition, we also evaluated
journals, Web sites, textbooks,
studies, reports, conference
proceedings, consensus state-
ments, and abstracts pub-
lished in English. Multiple
pharmaceutical manufac-
turers were contacted directly
with a request to help by
providing missing or unpub-
lished data points.
Table 1lists sugar-
containing oral liquid medi-
cations commonly prescribed
by OHCPs. These medica-
tions may be ideal for patients
with swallowing difficulties
who cannot manage solid oral
dosage formulations; howev-
er, each medication listed may
contain sugar in varying
amounts, up to 4grams per
dose (usually 1teaspoon or 5
milliliters). It should be noted
that 1teaspoon of granulated
white sugar equals 4gof
carbohydrates. Because car-
bohydrates have 4calories per
gram, this equals 16 calories.
In a patient who may con-
sume 1,600 calories per day
and takes such a medication 4
times a day, then 64 calories
per day, or 4% of his or her
total daily energy (E) intake,
is from the sugar in this
medication. A recent meta-
analysis suggests that sugar
consumption should be
limited to <5% E to mini-
mize the risk of dental caries
throughout a patients’life.
15
Patients who are required
to take multiple doses per day of these sugar-containing
oral liquid medications may be at high risk for drug-
induced cariogenicity and associated oral health con-
sequences as a result of the consumption of these
medicines and the unknown ingestion of several extra
teaspoons of sugar per day.
Table 2lists sugar-containing oral liquid medications
that are not commonly prescribed by OHCPs but that
are commonly prescribed by physicians for patients
whom OHCPs may be treating for oral health care
concerns, such as caries. Given the nature of
some diagnoses (for example, patients with head and
neck cancers undergoing radiotherapy, organ transplant
recipients, patients with human immunodeficiency
virus infections, and patients with Sjögren syndrome),
oral adverse events such as cariogenicity may be over-
looked as drug-associated effects because these patients
are typically immunocompromised and the sugar con-
tent of many medications is assumed to be negligible
compared with the patients’overall dietary intake of
sugar. Three minicases are included as examples
(Boxes 1-3).
Because the oral cavity can be a source of sepsis,
early and definitive dental intervention, comprehen-
sive oral hygiene measures, and elimination of the
cause of caries will reduce the risk for oral and
associated systemic complications.
7-10
OHCPs may
TAB LE 2
Sugar-containing oral liquid medications not commonly
prescribed by oral health care providers.
12-15
MEDICATION ACTIVE INGREDIENT
CONCENTRATION
AVAILABLE, mg*/5 mL
†
USUAL ADU LT DOSE SUCROSE
CONTENT,
g
‡
/5 mL
Alendronate 70 70 mg weekly None
Amantadine 50 100-400 mg 2 times a day 2.2
Aripiprazole 5 10-30 mg daily 2.0
Bicitra (Sodium
Citrate–Citric Acid)
5 milliequivalents/5 mL 10-30 mL 4 times a day 1.15
Carbamazepine 100 100-400 mg 2 to 4 times a day 3.4
Cetirizine 5 5-10 mg daily 2.0
Diazepam 5 Titrated to the individual 1.0
Famotidine 40 20 mg 2 times a day 1.2
Fluconazole 50, 200 200-400 mg daily 2.9, 2.7
Fluoxetine
§
20 20-80 mg daily 4.0
Levetiracetam 500 500-1,500 mg 2 times a day 1.0
Loratadine 5 10 mg daily 3.0
Maalox Suspension 500-500 10-20 mL 4 times a day as needed 0.4
Methadone
Concentrate
10 mg/mL Titrated to the individual 0.9
Methadone Sugar-
Free Oral Concentrate
10 mg/mL Titrated to the individual None
Milk of Magnesia 100 5-15 mL 4 times a day as needed None
NyQuil 216-10 30 mL every 6 h as needed 3.1
Oxybutynin 5 5 mg 2 to 4 times a day 2.4
Paroxetine 5 20-50 mg daily 2.0
Pseudoephedrine 30 60 mg every 4-6 h as needed 2.2
Ranitidine 75 150 mg 2 times a day 0.5
Risperidone 5 Titrated to the individual None
Robitussin 100 200-400 mg every 4 h as needed 2.3
Robitussin DM 100-10 10-20 mL every 4 h as needed 2.3
Senna 8.8 15 mg daily 3.8
Valproic Acid
¶
250 250 mg 2 to 4 times a day 2.8
#
* mg: Milligrams.
†mL: Milliliters.
‡g: Grams.
§ Can be brand specific (Pharmaceutical Associates brand ¼4.0 g/5 mL; Dista brand ¼3.0 g/5 mL).
¶ Personal communication from the manufacturer.
# Can be brand specific (Wockhardt brand ¼3.0 g/5 mL; Abbott brand ¼4.3 g/5 mL).
ORIGINAL CONTRIBUTIONS
JADA 146(2) http://jada.ada.org February 2015 131
prescribe antibiotics to patients, or they may be treating
patients who are already receiving antibiotics. In patients
who have recently received antibiotic therapy and who
have developed opportunistic infections such as oral
candidiasis, treatment with an antifungal agent may be
indicated. In the case of cancer patients with significant
pain, opioid and nonopioid-based analgesics are often
required for disease management. In each of these ex-
amples, sugar-containing oral liquid medications may
be prescribed, especially if these patients have swal-
lowing difficulties.
Because of the complexity of some patients’diag-
noses (including immunocompromised oncology
patients, transplant recipients, and patients with human
immunodeficiency virus, Parkinson disease, and
Alzheimer disease), the patients may have difficulties
practicing effective oral hygiene. These challenges can
result in oral adverse events such as cariogenicity being
overlooked as drug-associated effects because the sugar
content of many medications is assumed to be negligible
compared with the patients’overall dietary intake of
sugar. There are, however, several medications with a
significantly high sugar content that may be associated
with negative oral health sequelae, and these should be
considered as part of the OHCPs’differential diagnosis
of oral pathologies (Tables 1and 2). If dry mouth is an
additional confounder, many of the medications pre-
sented here do have xerostomia as an adverse effect,
which can further complicate this disease burden.
20
Some physicians may not be aware that frequently
used medications with high sugar content can have a
high cariogenic risk. We found over 50 commonly used
oral liquid medications to contain varying amounts of
sugar, up to 4g per dose (usually 1teaspoon or 5mL).
Patients who are required to take multiple doses per day
of these sugar-containing oral liquid medications
because of swallowing issues may be at the highest risk
for drug-induced cariogenicity and associated oral
health consequences. Although alternative sweeteners
such as sorbitol and xylitol are increasingly common in
medicinal preparations in lieu of sucrose,
5
some of these
noncariogenic sweeteners, such as saccharin, aspartame,
and cyclamate, have a bitter or metallic taste.
6
Regard-
less, OHCPs may want to consider suggesting sugarless
or alternative-sweetener–containing oral liquid prepa-
rations if they are available for patients who present
with these iatrogenic findings. In lieu of commercially
available alternatives, compounding pharmacies are an
excellent resource for creating nonsugar-containing oral
liquid medications. Patients should also be counseled to
rinse their mouths with water or brush their teeth after
each dose of these medications to help mitigate cario-
genic risk.
CONCLUSIONS
Recognition and avoidance of sugar-containing oral
liquid medications can help clinicians optimize patient
treatment and decrease drug-induced cariogenicity risk
while emphasizing patient safety and improved oral
health. Several pharmaceutical manufacturers were
BOX 1
Minicase 1: oral liquid antibiotics
(amoxicillin and cephalexin).
An at-risk patient is scheduled for a dental procedure requiring
prophylactic antibiotics per the American Heart Association’s current
recommendations.
16,17
A one-time dose of amoxicillin is one of the
first-line agents. Further consideration is given to more aggressive,
ongoing antibiotic therapy in the presence of infection and other
comorbidities in this patient, and the typical adult dose of 500
milligrams 3 times a day for 10 days is prescribed.
If the patient has swallowing difficulties, she may be prescribed 500 mg
3 times a day of the amoxicillin 250 mg/5 milliliters oral liquid for 10
days. Each dose contains 3.7 grams of sugar (1.85 g/5 mL 10 mL).
Three doses a day would therefore equate to 11.1 g of sugar—a total of
111 g over the full course of treatment, based on the data in Table 1.
If cephalexin were substituted for amoxicillin in a patient with a potential
allergic history to penicillin-type medications, 500 mg 3 times a day of
the 250 mg/5 mL oral liquid would result in the ingestion of 12 g of
sugar per day, or a total of 120 g over the full course of treatment.
BOX 2
Minicase 2: oral liquid antifungal
(nystatin).
A patient presents to the dental office with multiple comorbidities to
include poor oral health of several years’neglect. In addition to surgical
treatment, oral thrush (candidiasis) is diagnosed, and a prescription for
the topical antifungal nystatin is written.
Nystatin oral suspension is indicated for the treatment of candidiasis
in the oral cavity. In adults, it is typically administered as a 5-milliliter
swish-and-swallow treatment that needs to be taken 4 times a day
for up to 10 days.
According to the product label, nystatin contains 50% weight per volume
of sucrose, which is the equivalent of 2.5 grams of sugar per each 5-mL
dose.
18
In this dental patient with an opportunistic infection of oral
thrush, given the high sugar content and mode of delivery, nystatin use
creates ideal conditions for causing tooth decay, including extended
presence of sugar in the oral environment—in this case, 10 milligrams
per day in addition to the patient’s regular dietary sugar intake.
BOX 3
Minicase 3: oral liquid analgesics
(codeine and methadone).
A patient presents to the dental office for surgical extraction of wisdom
teeth. The patient has multiple drug allergies and swallowing difficulties
that limit the postoperative analgesic selection to liquid narcotics only.
Codeine is a centrally acting narcotic analgesic that is often used to
manage moderately severe or severe postoperative dental pain. Codeine
sulfate oral solution (30 milligrams/5 milliliters) is available as an
orange-flavored, clear, reddish-orange to orange solution, and the usual
adult dosage is 15 to 60 mg (2.5 to 10 mL) repeated up to every 4 hours
as needed for pain. The maximum recommended 24-hour dose is
360 mg. There are 4.3 grams of sugar in every 5-mL (30-mg) dose, so the
patient receives approximately a teaspoon of sugar with every 30-mg
dose she receives.
As an alternative to codeine, methadone is also an opioid analgesic
indicated for moderate to severe pain.
19
Methadone oral liquid
(10 mg/mL) does contain 0.9 g of sugar in each 5 mL of solution;
however, it is also available as a sugar-free concentrate (10 mg/mL),
which is far less cariogenic.
ORIGINAL CONTRIBUTIONS
132 JADA 146(2) http://jada.ada.org February 2015
contacted directly for information about the sugar
content of their oral liquid formulations during the
preparation of this article. Many of the medications
listed may have more than one manufacturer, in which
case we have reported examples of differences in sugar
content, as it may vary according to brand. Some
manufacturers refused to provide this information,
citing the confidential nature of this proprietary infor-
mation. Regardless, in reviewing the literature on this
subject, we were unable to find a more comprehensive
and up-to-date compilation of these data, which may be
of high value to practicing OHCPs. n
Disclosure. None of the authors reported any disclosures.
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