Effect of Liquid Oral Medications on the Color Stability of Restorative Materials in Pediatric Dentistry: An in Vitro Study

ABSTRACT

Objective:  To evaluate the changes in the color of dental filling materials after being immersed in pediatric syrups for a period of time.

Material and Methods:  This study had a quasi-experimental design. Three restorative materials were employed: a conventional self-curing ionomer cement, a light-curing ionomer cement, and a light-curing composite resin. Forty disc-shaped samples of each material were prepared and randomly assigned to 6 subgroups (n=20). The samples were immersed in 2 pediatric drugs: paracetamol and ferrous sulfate, for 2 min once a day for 28 days. Color stability evaluations were performed at 7, 14, 21 and 28 days. The color variation of the materials was evaluated using a digital colorimeter. The Kruskal-Wallis test was used for intraand inter-group comparisons.

Results:  In all subgroups, the total color difference values increased significantly from the first evaluation to day 28 (p < 0.05).

Conclusion:  Long-term use of pediatric syrups may affect the color stability of restorative materials. Among pediatric syrups, the composite resin showed the least color variation when immersed in paracetamol and ferrous sulfate compared to the ionomer materials.

Keywords:
Dental Materials; Pediatric Dentistry; Chronic Pain; Anemia; Iron-Deficiency.

Introduction

Dental materials in pediatric dentistry aim to restore the morphology, function, and esthetics of affected teeth [¹] due to dental caries, which remains a public health problem worldwide [²]. Nowadays, dental esthetics has become very important for enhancing patients' self-esteem through beauty and attractiveness [³]. This need for a natural appearance of teeth by children and their parents has led to the development of fillings that resemble natural teeth [⁴]. The success of these materials will be determined primarily by their function and aesthetics [⁵].

In pediatric dentistry, dental materials, such as resin-modified glass ionomers and composites, are esthetically attractive, match the color of the teeth being restored, enhance smiles, and reconstruct affected teeth [⁶]. If these restorative materials withstand pressures and effects of the oral environment, they will be durable for a long time [⁷].

Various extrinsic and intrinsic factors are associated with color changes in esthetic restorations, as well as in foods, soft drinks, syrups, and carbonated beverages containing dyes and some additives [⁶]. Medications administered by mouth to young children with chronic diseases can cause adverse reactions, including erosion [⁸], microhardness, roughness, and staining of primary tooth enamel [⁹], as well as dental restorations [¹⁰].

Some liquid drugs used in children over a prolonged period are vitamin supplements, such as ferrous sulfate, for the prevention and treatment of iron deficiency anemia [¹¹] and analgesics such as paracetamol, which is a first-line analgesic for adults and children experiencing mild to moderate pain, being safe in adequate and controlled doses [¹²]; however, there may be an abuse in its use due to maternal self-medication and over-the-counter sale of analgesics [¹³] and; due to an increase in the frequency of self-medication in children and adolescents [¹⁴]. According to these reports, this study was planned to compare the effect of two liquid oral medications on the color stability of three pediatric esthetic restorations.

Material and Methods

Study Design

The study of quantitative methodology and quasi-experimental design [¹⁵] included three restorative materials: Llis light-curing, Fusion I-Seal light-curing, and Ketac Molar (Table 1).

Table 1
Trade names and manufacturers of the materials used.

Trade Name	Material	Manufacturer
Llis Light-Curing	Composite Resin	FGM Dental Group, Joinville, SC, Brazil
Fusion I-Seal Light-Curing	Glass Ionomer Cement	PREVEST DenPro Ltd, Mumbai, India
Ketac Molar Self-Curing	Glass Ionomer Cement	3M ESPE AG, Seefeld, Germany

Preparations

The pediatric preparations used were: paracetamol (120 mg/5 mL) for chronic pain and ferrous sulfate (75 mg/5 mL) for the treatment of iron deficiency anemia (Table 2). A total of 120 disc-shaped specimens (8 mm × 2 mm) were obtained, 40 per filling material, as indicated. Each material was inserted in a standard plastic mold [¹⁶].

Table 2
Features of the pediatric medications.

Type of Medication	General Name	Brand Name	Manufacturer	Color	Ingredients	pH
Analgesic	Acetaminophen	Paracetamol	Portugal S.R.L., Peru	Light red	5 mL of Paracetamol contains: Paracetamol 120 mg, Hydromellose, Sodium Citrate dihydrate, Hydrogenated Castor Oil, Polyoxylated 40, Raspberry Essence, Vanilla, Sodium Saccharin dehydrated, Glycerol, Propylene Glycol, Citric Acid anhydrous, Potassium Sorbate, Red Coloring No. 40 CI 16035, Peach Essence, Purified Water	4.5
Antianemic	Ferrous sulfate	Sulfato Ferroso	Portugal S.R.L., Peru	Brown yellow	5 mL of Ferrous sulfate contains: Ferrous sulfate heptahydrate 75mg (equivalent to 15 mg of elemental iron). Excipients: Raspberry essence, Propylparaben, Sodium saccharin, Benzoic acid, Alcohol, Glycerin, Propylene glycol, Ascorbic acid, Citric acid anhydrous, Sorbitol non-crystallizable solution, Methylparaben, Purified water.	3.9

The self-curing glass ionomer cement was allowed to set at room temperature for 10 min. The Fusion I-Seal glass ionomer and resin were polymerized on the glass slide using a halogen curing unit (Optilux 501, Kerr Corporation, Pomona, CA, USA) at 500 mW/cm². After removal from the mould, the specimens were polished using polishing discs (Sof-lex, 3M ESPE AG, Seefeld, Germany). The discs were applied dry for 60 seconds using a contra-angle handpiece and micromotor. The groups were made up as follows: 40 conventional glass ionomer (20 specimens for paracetamol and 20 specimens for ferrous sulfate), 40 light-cured ionomer (20 specimens for paracetamol and 20 specimens for ferrous sulfate), and 40 light-cured resin (20 specimens for paracetamol and 20 specimens for ferrous sulfate).

The immersion protocol involved immersion in 10 mL of the mentioned syrups, according to the group, for 2 min per day, with 24 h intervals between immersion cycles [¹⁷]. After each cycle, the samples were washed and stored in distilled water until the next cycle. The pediatric preparations were renewed before each immersion.

The baseline color values were calculated using the CIE (International Commission on Illumination) L*a*b* system. After 7 days, ∆E values were calculated. The total color difference from the initial day was evaluated at 7, 14, 21, and 28 days. The color stability test was performed with a set of each specimen, which was measured with a digital colorimeter (Shenzhen Wave Optoelectronics Technology Co., Ltd, Shenzhen, China) under a standard illuminant. The equipment was calibrated before the measurements with its own special calibration tool and positioned in the center of each specimen. These tests were carried out in the High Technology Laboratory Certificate S.A.C, Lima, Peru.

Data Analysis

Data were analyzed using the Kruskal-Wallis test for intraand inter-group comparisons. Friedman and Kruskal-Wallis post hoc tests were performed. The software used was the Statistical Package for the Social Sciences (SPSS), version 23 (IBM Corp., Armonk, NY, USA), with a significance level set at less than 0.05 (p<0.05).

Results

This study examined the color variation of restorative materials used in pediatric dentistry subjected to two syrups. When the materials were subjected to ferrous sulfate, it was observed that the one with the greatest color difference from the first day to 28 days was the self-curing ionomer, followed by the light-curing ionomer. The light-curing resin showed less color variation than the ionomers (Figure 1).

Figure 1
Total color difference of materials subjected to ferrous sulfate.

When the materials were subjected to Paracetamol syrup (Figure 2), there was a total color difference, mostly from the initial day to 28 days in the self-cured ionomer, with this change being progressive from day 7, followed by the light-cured ionomer. The light-cured resin showed less color variation at 28 days after paracetamol treatment.

Figure 2
Total color difference of materials subjected to paracetamol.

According to the Kruskal-Wallis analysis, the three groups of restoration materials subjected to paracetamol syrup show statistically significant differences as the days of exposure pass, with color variation from the initial day to 28 days (p= 0.026; p= 0.007; p= 0.007). An intergroup evaluation showed that, among the three materials treated with paracetamol syrup, the Self-healing ionomer had the greatest color variation, with this difference being statistically significant at 28 days (p = 0.012).

In relation to the ferrous sulfate syrup, color variation was also observed, being greater at 28 days; these differences were statistically significant (p= 0.024; p= 0.011; p= 0.011). Of the three restoration materials, the self-healing ionomer had the greatest color variation at 28 days, and this difference was statistically significant (p= 0.010) (Table 3).

Table 3
Comparison of the effect of liquid oral medications on the color variation of restorative materials.

Medication	Initial 7 Days	Initial 14 Days	Initial 21 Days	Initial 28 Days	p-value
	∆E (Mean ± SD)	∆E (Mean ± SD)	∆E (Mean ± SD)	∆E (Mean ± SD)
Paracetamol
Light-Cured Resin	2.07 ± 0.53	2.64 ± 0.52	2.48 ± 0.88	2.93 ± 0.43	0.026*
Light-Cured Ionomer	2.15 ± 0.46	2.94 ± 0.59	4.33 ± 0.40	6.11 ± 0.56	0.007*
Self-Healing Ionomer	7.02 ± 2.02	8.18 ± 1.97	8.44 ± 2.04	9.05 ± 2.37	0.007*
p-value	0.024**	0.018**	0.007**	0.012**
Ferrous Sulfate
Light-Cured Resin	1.57 ± 0.55	2.35 ± 0.61	2.48 ± 0.84	2.72 ± 0.89	0.024*
Light-Cured Ionomer	2.67 ± 0.15	3.41 ± 0.65	4.05 ± 0.85	5.27 ± 1.66	0.011*
Self-Healing Ionomer	9.91 ± 1.83	10.35 ± 1.71	11.84 ± 2.64	14.03 ± 2.98	0.011*
p-value	0.007**	0.012**	0.011**	0.010**

• SD: Standard Deviation;
• ^*
  Friedman test;
• ^**
  Kruskal-Wallis test; Significance level (p < 0.05).

According to post-hoc Kruskal-Wallis tests, there are differences between light-curing resin and self-curing ionomer on all days and between light-curing ionomer and self-curing ionomer on days 7 and 14 when used with ferrous sulphate. There are differences between light-curing resin and self-curing ionomer on all days when used with Paracetamol (Table 4).

Table 4
Comparison of colour between materials per day post-hoc test for the Kruskal-Wallis test.

Medication	7 Days	14 Days	21 Days	28 Days
Ferrous Sulfate
Photocured resin - Photocured ionomer	0.844	0.433	0.117	0.078
Photocured resin - Self-healing ionomer	0.014	0.006	0.002	0.003
Photocured ionomer - Self-healing ionomer	0.024	0.050	0.117	0.239
Paracetamol
Photocured resin - Photocured ionomer	0.117	0.239	0.202	0.170
Photocured resin - Self-healing ionomer	0.002	0.003	0.003	0.002
Photocured ionomer - Self-healing ionomer	0.117	0.078	0.086	0.096

According to post-hoc Friedman tests, there are differences between days 7 - 14, 7 - 28, 14 - 28, and 21 - 28 for the light-curing resin and between all days for the light-curing ionomer and the self-curing ionomer with ferrous sulphate. There are differences between all days 7-28 for the light-curing resin and the light-curing ionomer and between days 7-28 and 14-28 for the self-curing ionomer with Paracetamol (Table 5).

Table 5
Comparison of colour between materials per day post-hoc test for the Friedman test.

Medication	Photocured Resin	Photocured Ionomer	Self-Healing Ionomer
Ferrous Sulfate
7 days - 14 days	0.046	0.046	0.046
7 days - 21 days	0.317	0.046	0.046
7 days - 28 days	0.046	0.046	0.046
14 days - 21 days	0.317	0.046	0.046
14 days - 28 days	0.046	0.046	0.046
21 days - 28 days	0.046	0.046	0.046
Paracetamol
7 days - 14 days	0.218	0.171	0.584
7 days - 21 days	0.218	0.055	0.055
7 days - 28 days	0.003	0.001	0.003
14 days - 21 days	1.000	0.584	0.171
14 days - 28 days	0.075	0.055	0.014
21 days - 28 days	0.075	0.171	0.273

Discussion

In pediatric dentistry, a variety of esthetic restorative materials can be used, including composite resins, glass ionomer cements, and resin-modified glass ionomer [¹⁷]. These are characterized by their esthetic, functional, mechanical, and adaptability properties [¹⁸]. Several aspects can affect the durability, appearance, or longevity of the same [¹⁹,²⁰].

Color changes in materials may be due to the accumulation of colorants from food, beverages, and syrups on their surfaces; color stability depends on physical properties, the organic matrix, filler particles, the restorative technique, and polishing [²¹].

Young children suffering from acute or chronic diseases are usually given pharmaceutical formulations in the form of syrups or suspensions. The components of these liquid formulations include sugars, acids, buffering agents and colorants. The low endogenous pH and viscosity of these drugs can lead to adverse effects such as erosion and intrinsic and extrinsic discoloration of teeth and dental restorations [¹⁰,²⁰]

The permitted colorants used in these liquid medicaments can be absorbed by the restorative materials, affecting the color stability [²²]. Composite resin was the restorative material with the least color variation after being subjected to pediatric syrups. The variation was less when subjected to Paracetamol in relation to the Ferrous sulfate syrup, coinciding with that reported by other authors [⁶,²³]; likewise, they had less color variation than ionomers; and it is that conventional ionomers due to the porosity of their glass particles, dehydration after setting, drying and microcracks allow greater staining and discoloration of the restoration [²⁴]. Likewise, the high viscosity and colorants in syrups can also affect the color stability of dental materials [²⁵]. Two pediatric oral liquids were used in this study: paracetamol, a light red liquid containing Red Coloring No. 40 (CI 16035), and ferrous sulfate, a yellow-brown liquid containing elemental iron (Table 2). Iron-based vitamin supplements cause more discoloration in restorations than other syrups. The amount of discoloration may vary depending on the iron composition of these syrups [²⁶].

The resin's color stability is affected by the presence of silane in its composition, due to its hydrophilicity, which leads to high water absorption, and also by its low concentration and larger filler particles, which tend to pigmentation [²²]. Therefore, the variation in the color of the composite resin (A Llis light-curing) is due to the proportion of silane present in the structure of the material.

The variation in color stability of the ionomer-based materials was greater when they were subjected to pediatric syrups than with the resin, consistent with a previous report [²⁷]. This may be because fluoride-releasing materials are more susceptible to staining [²⁸]. The conventional or self-curing ionomer showed greater color variation when subjected to syrups, which is attributed to the polyacid content of the material, which is related to the degradation of the metal polyacrylate salts [²⁹].

Variation in the colour stability of the material affects the longevity of dental restorations. Colour change may be due to intrinsic and extrinsic factors [²²]. There is adsorption of the colouring agent on the surface and absorption into the subsurface layer, which changes the restoration's colour [³⁰]. Aesthetic appearance is often associated with social acceptance and professional success; dental restorations are important for the treatment of caries and for the psychological and physiological development of individuals, so restorative materials must maintain long-term colour stability [¹⁰].

The results of this study may inform parents, pediatric dentists, and other members of the child's health care team about the risk of colour variation in pediatric dental restorations, which may affect their longevity. The main limitation of this study is that it is introductory. It will be important to conduct in vivo studies to evaluate the role of saliva, biofilm, and the oral environment in relation to liquid oral medications, including sugar content, pH, colorants, and their relationship with restorations in colour variation, to support our findings.

Conclusion

Pediatric syrups affect the colour stability of restorative materials, which, in turn, can influence the longevity of the restoration. Among pediatric syrups, the composite resin showed the least colour variation when immersed in paracetamol and ferrous sulfate, compared to the ionomer materials.

• Financial Support
  None.

Data Availability

The data used to support the findings of this study can be made available upon request to the corresponding author.

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Edited by

• Academic Editor:
  Catarina Ribeiro Barros de Alencar

Publication Dates

• Publication in this collection
  12 June 2026
• Date of issue
  2026

History

• Received
  16 Jan 2025
• Reviewed
  18 Mar 2025
• Accepted
  05 May 2025