Children's dental health and medicines that contain sugarBMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.6998.141 (Published 15 July 1995) Cite this as: BMJ 1995;311:141
- Iain C Mackie, Senior lecturer
- Department of Oral Health and Development University of Manchester Dental Hospital, Manchester M15 6FH
Doctors must take the lead by prescribing sugar free medicines whenever possible
Dental caries is a multifactorial disease, but the primary aetiological agent is sugar. To help children and their parents control dental caries the frequency of sugar consumption must be reduced. Many people equate this with cutting down on sweets, but they are often unaware of the sugars in foods and drinks such as biscuits, cakes, breakfast cereals, baby drinks, cordials, and soya milk. Another commonly used product that contains sugar and is given to children regularly is liquid medicine.
Since 1984 the British National Formulary has warned that “Although liquid preparations are particularly suitable for children, many contain sucrose which encourages dental decay.”1 In view of this harmful effect, doctors have been recommended to prescribe sugar free medicines whenever possible. Previously such advice was difficult to follow because only a few sugar free medicines were available, but the pharmaceutical industry has responded by reformulating old preparations and producing new varieties that do not contain sugar. The British National Formulary and MIMS (the monthly index of medical specialties) specifically indicate medicines that are sugar free; the drug dictionaries on some computerised prescribing systems also indicate preparations that are sugar free. Despite these positive steps, medicines that contain sugar are still the ones most commonly prescribed by doctors and sold by pharmacists.2
To promote the use of sugar free medicines a campaign was organised in the north west of England, targeting doctors, pharmacists, health visitors, and mothers with young children.3 The pharmacists showed great enthusiasm for this campaign, but when questioned they highlighted two problems. Firstly, doctors usually prescribed medicines containing sugar and rarely offered sugar free alternatives. Secondly, the act of prescribing medicines containing sugar was seen as endorsing their use. The pharmacists reported that they would have liked to give a sugar free medicine when dispensing a prescription but current regulations forbade them. If a doctor prescribes a generic medicine and does not specify SF on the prescription then a drug that contains sugar has to be dispensed even if both the pharmacist and the parent would prefer a sugar free preparation. This impasse could be remedied if doctors could be persuaded to write SF on their prescription.
When doctors in the north west of England were questioned about prescribing sugar free medicines some expressed concern about their palatability: poor palatability might compromise compliance.4 This does not seem to be a problem, especially if a child starts off by taking sugar free medicines and is not allowed to develop a taste for a particular sugary medicine. Other doctors mentioned that they did not always have the time to look through the British National Formulary or MIMS to find a sugar free variety—but, in these days of prescriptions that are issued by computer, quickly scanning the drug dictionary held in the computer's memory to identify a sugar free alternative is possible. Software manufacturers could therefore have a leading role in promoting sugar free medicines by ensuring that these are listed before the ones that contain sugar, or by highlighting the sugar free preparations.
To minimise the harmful effects of those medicines that are available only in the sugar form it is recommended that, whenever possible, they should be taken at mealtimes, not between meals, and definitely not last thing at night or during the night.4 The flow of saliva is greatly curtailed at night, so the protective cleansing and buffering actions are lost; hence a sugary medicine taken at this time is particularly damaging to teeth.
A relatively new concern has been the recognition of the detrimental effects on dental health of children who are taking liquid nutritional supplements—for example, young patients who are intolerant of lactose or protein. These preparations are listed in the section on borderline substances in the British National Formulary. Many of them are listed as being lactose free; in addition, the formulary indicates that they are also sucrose or fructose free. This implies that they are “sugar free,” but they usually contain glucose as the source of carbohydrate. Although sucrose is the most cariogenic sugar, glucose runs a close second, and if they are taken regularly between meals or in a bottle as a comforter last thing at night destruction of the teeth is common.
Parents should be advised that these borderline substances are rich in sugar and are as harmful to the teeth as any other drink that contains sugar and should be used as food intakes at set times, not as drinks to be taken at will or as comforters. Young patients taking drugs containing sugar long term should be prescribed a fluoride supplement and advised to register with a dentist for routine screening and advice.
If the tradition of giving children medicines that contain sugar is to be broken it is essential that doctors take the lead by prescribing sugar free medicines whenever possible.