Comparison of Salivary pH Changes after Original Article Consumption of Two Sweetened Malaysian Local Drinks among Individuals with Low Caries Experience: A Pilot Study Eswara UMA1, KAN Sze Theng2, Lynndy LIM Huan Yi3, LOW Hong Yun4, Eby VARGHESE1, Htoo Htoo Kyaw SOE5 1 Submitted: 07 Aug 2017 Department of Pediatric Dentistry, Faculty of Dentistry, Melaka Manipal Accepted: 12 Jul 2018 Medical College (MMMC), Manipal Academy of Higher Education (MAHE), Online: 30 Aug 2018 Malaysia 2 Tiew Dental Clinic, Petaling Jaya, Kuala Lumpur, Malaysia 3 Dental Clinic Bandar Maharani, Muar, Johor, Malaysia 4 Dental Clinic Yong Peng, Johor, Malaysia 5 Research Methodology and Biostatistics Unit, Department of Community Medicine, Faculty of Medicine, Melaka Manipal Medical College (MMMC), Manipal Academy of Higher Education (MAHE), Malaysia To cite this article: Uma E, Kan ST, Lim LHY, Low HY, Varghese E, Soe HHK. Comparison of salivary pH changes after consumption of two sweetened Malaysian local drinks among individuals with low caries experience: a pilot study. Malays J Med Sci. 2018;25(4):100–111. https://doi.org/10.21315/mjms2018.25.4.10 To link to this article: https://doi.org/10.21315/mjms2018.25.4.10 Abstract Background: Regular consumption of sweetened beverages has been associated with dental caries, which is mediated through salivary pH. The salivary pH changes among individuals with low caries experience after consumption of two local sweetened drinks is compared. Methods: In this block randomised controlled parallel group, an open-label pilot study of 49 participants aged 21–25 were selected. The participants were randomised into three groups: mineral water, chocolate drink and sirap bandung. One day prior to the test, scaling was done and the participants did not eat or drink anything on the test day till the saliva sample collection was done. Salivary pH was measured at baseline and after the consumption of the drinks with a glass electrode digital pH meter at five-minute interval for half an hour. The statistical significance was assessed at the level of 5%. Results: After consumption of chocolate drink and sirap bandung, the salivary pH dropped from a baseline of 7.09 for chocolate drink and 7.13 for sirap bandung to 6.69 for chocolate and 6.86 for sirap bandung. This difference was statistically significantP ( < 0.001). Conclusion: Sweetened milk based local drinks can increase the caries susceptibility. In the community, information about limiting the intake of sweetened drinks should be reinforced. Keywords: saliva, pH, beverage, soft drinks Introduction respect to the integrity of teeth, salivary composition, pH and plaque formation, nutrition Diet and nutrition play a major has a systemic effect (1). Sugars, in the form of multifactorial role in the etiology and carbohydrates, are the principal components of pathogenesis of oral diseases. While the diet an individual’s diet and classified as “intrinsic exerts a local effect on the oral health with sugars” (naturally integrated into the cellular Malays J Med Sci. Jul–Aug 2018; 25(4): 100–111 www.mjms.usm.my © Penerbit Universiti Sains Malaysia, 2018 100 This work is licensed under the terms of the Creative Commons Attribution (CC BY) (http://creativecommons.org/licenses/by/4.0/). Original Article | Salivary pH changes structure of food; for example, fruits) and beverages are also perceived to be healthy as they “extrinsic sugars” (occur as free molecules or have milk as the main ingredient as opposed to are added to the food). Milk sugars along with the aerated beverages. non-milk extrinsic sugar (NMES), which include Previous studies have shown an irreversible fruit juices, honey and added sugars especially effect of fruit juices and aerated beverages on during manufacture, in recipe sugars and in the teeth (9–11), while milk exerts a protective table sugars, are extrinsic sugar sub-group. effect (12) that is attributed to its remarkably Interestingly, foods high in NMES are the ones lower fermentation by oral bacteria as compared consumed frequently; for example, sweetened to that of sucrose. In addition, the fermentation beverages between meals (2). Some studies product of lactose in milk, lactic acid, inhibits showed an increased role of refined sugars, the growth of several pathogenic microbes (13). such as sucrose, an extrinsic sugar, in causing Although the literature describes the effects of diseases ranging from dental caries to delinquent aerated beverages and juices on the salivary behaviour as well unhealthy lifestyle, especially and plaque pH, the effect of locally prepared in young adults (2–4). and popular milk-based sweetened drinks Since Miller’s chemoparasitic theory such as sirap bandung and chocolate drink, that described the cause of dental caries, both containing NMES (14), have not yet been several modifying factors have been identified elucidated. that render a complex etiology for the dental Despite several preventive measures caries model. The modifying factors include instituted by the government, the prevalence of saliva, the immune system of the body, time, dental caries in Malaysia among 20–24 years old socio-economic status, education level of the is 81.9% (15). Among Malaysians, the frequent individual, lifestyle behaviours and the use consumption of these sweetened beverages may of fluorides (1). Saliva plays a major role in be one of the contributing factors to the high maintaining oral health. Alteration of the oral prevalence of dental caries. Thus, the present homeostasis that is maintained by saliva, leads study aimed to assess the changes in the pH of to poor oral health (5). This is primarily because saliva after the consumption of two sweetened saliva performs multiple roles within the oral Malaysian drinks among individuals with low cavity. The buffering capacity of saliva helps in caries. neutralising the acids produced from the plaque, foods and beverages. As saliva is saturated with Materials and Methods calcium and phosphate ions and is in equilibrium with enamel, the enamel dissolution does not Participants occur. When the pH of the saliva drops below the critical pH, the enamel dissolves to restore This randomised, controlled, parallel the calcium and phosphate ion equilibrium to group, open-label, pilot study was conducted normal (6). Thus, the salivary buffer is the key to in our institution. The ethical clearance from preventing dental erosion and caries (4). the institute was obtained from the Human and In Malaysia, increasing availability and Ethics committee prior to the start of the study consumption of sugars and sweeteners coupled (Ref# - MMMC/FOD/AR/B3/E C-2015(03)). with increasing sedentary lifestyles have Using purposive sampling, dental students were contributed to the rising problems of obesity invited to participate in the study. A total of and associated non-communicable diseases (3). 146 students volunteered to participate in the Frequent consumption of beverages sweetened study. The study procedure was explained to with condensed milk, chocolate, cordial the participants and informed consent obtained syrup and sugars by adults have contributed before starting the study. In addition, the history significantly towards energy intake (3, 7, 8). of each participant regarding any acute or In addition to the aerated beverages available chronic disease of the body or oral cavity as well in the market, Malaysians frequently consume as the use of any antibiotics two months before many locally prepared beverages like teh tarik, the collection of saliva samples was collected sirap bandung and soya cincau as they are by interview. The history of any deleterious prepared at the food stalls itself and sold at a habits like smoking or chewing tobacco was very affordable price. Due to the affordability and also obtained. A single examiner using a mouth ease of availability, these beverages are all-time mirror and explorer examined all the subjects. favourite drinks among the locals. Some of these The teeth were cleaned with cotton, dried using www.mjms.usm.my 101 Malays J Med Sci. Jul–Aug 2018; 25(4): 100–111 an air syringe, and examined for the presence estimation for a pilot study as well as a similar of caries. The tooth surface was probed only if previous study, a minimum sample size of 15 the visual examination was inconclusive. The participants per sweetened group was planned decayed, missing and filled teeth (DMFT) were for the present pilot study (20, 21). recorded based on the WHO criteria (16). Oral Of the 146 voluntary participants, 49 Hygiene Index–Simplified (OHI-S) comprising dental students (32 females and 17 males) with of debris index and calculus index was recorded a mean age of 23.3 ± 0.77 years were eligible for all the participants (17). Six key surfaces (four to participate in the study after applying the from posterior teeth and two from anterior teeth) inclusion and exclusion criteria. The participants were examined for debris index and calculus were randomly assigned to one of the three index. Buccal surfaces of teeth #16 and #26 groups, namely mineral water (B1), chocolate and lingual surfaces of teeth #36 and #46 were drink (B2) and sirap bandung (B3) in 1:1:1 scored. In the anterior region, the labial surfaces ratio using research randomiser. Mineral water of teeth #11 and #31 were scored. The OHI-S and chocolate drink groups consisted of 16 score was calculated after computing the debris participants each, and sirap bandung group and calculus scores. had 17 participants (Figure 1). Each selected The participants of the study included participant was assigned a code used during dental students of the institution aged 21–25 saliva collection. years. Only those students with DMFT < 3 and OHI-S < 1.2 were included in the study. Test Products Students undergoing orthodontic treatment Three beverages were selected for the (fixed or removable) and having any systemic study: mineral water (B1)-Spritzer®, chocolate illness or a history of intake of any antibiotics drink (B2)-Milo® powder, and sirap bandung or medications that could affect the salivary (B3)-rose syrup (F&N) in milk.