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Unformatted text preview: Operative Dentistry Dissolution of dental enamel in soft drinks
J. Anthony von Fraunhofer, MSc, PhD, FADM, FRSC | Matthew M. Rogers, DDS A high percentage of the population consumes a variety of soft drinks on a daily basis.
Many of these soft drinks contain sugar and various additives and have a low pH.
This study compares enamel dissolution from both regular and diet beverages.
Received: February 25, 2004 The consumption of soft drinks has increased dramatically over past several
decades; the soft drink industry is reported to produce 10 billion 192-ounce cases
per year.1 Over a 50-year period, annual
soft drink production appears to have increased fivefold, from 100 12-ounce cans
per person in 1947 to nearly 600 12ounce cans per person in 1997. Looking
at it another way, the average person in
1947 consumed approximately two cans
of soft drinks per week, while the average
person in 1997 consumed approximately
12 cans of soft drinks per week, or nearly
two cans per day.
The greatest increase in soft drink
consumption has occurred among children and adolescents; nearly 40% of preschool children drink more than 250 mL
(8.0 ounces) of soft drinks per day.2 The
average consumption of soft drinks in the
U.S. in 2002 was approximately 53 gallons per year, or 16 ounces per day, which
represents 24% of the recommended daily fluid intake of 67 ounces.3 Although
no distinction is made between regular
and diet soft drinks, recent figures (examining the period from 1994–1996) indicate that soft drink consumption
among 12-to-19-year-old boys is 28
ounces (800 mL) per day; among 12-to19-year-old girls, the rate of consumption is 21 ounces (600 mL) per day.4
In recent years, diet (that is, reducedcalorie) versions of popular drinks have
increased in relation to their regular beverage counterparts (that is, those containing sucrose or fructose). In 1997, artificially-sweetened diet sodas accounted
for 24% of soft-drink sales, an increase of
16% since 1970.5 There also is a growing
trend within North America (and perhaps throughout the developed world)
toward increased consumption of noncola drinks and nontraditional beverages
(for example, pre-packaged coffees and 308 General Dentistry Accepted: March 29, 2004 teas).1 There also has been an upward
trend in the consumption of sports
drinks, although these may have a sugar
content as high as 20%.1
Anecdotal reports of rampant dental
caries related to frequent consumption
of soft drinks are increasingly common.1
In 2002, a young man who consumed
three to four 32-ounce beverages per day
while working at a computer terminal reported a case of rampant dental decay.6
The induction of dental caries by refined
sugars is well-established, although
prevalence is affected by numerous factors, including the foodstuff ’s cariogenicity and frequency of ingestion, the
oral levels of cariogenic bacteria (for example, Streptococcus mutans), water
fluoridation, frequency of toothbrushing
and dentifrice use, general dietary variables, and the inherent variability in oral
Ideally, the pH of saliva lies within the
range of 5.5–6.5; a pH of 5.5 generally is
accepted as the threshold level for the development of dental caries.7 While the
oral cavity may recover when the pH
within the oral cavity drops below this
threshold, prolonged exposure to this pH
or frequent cycling from the optimal
(that is, neutral) pH to a value below the
threshold can result in a more rapid demineralization of enamel. Lowered salivary pH often is a consequence of bacterial digestion of sucrose, fructose, and
similar carbohydrates, causing acidic
byproducts to form in dental plaque.
Tooth demineralization, however, also
may occur due to dental erosion.
Dental erosion is the irreversible, usually painless, loss of dental hard tissue
that occurs due to a chemical process,
such as dissolution or chelation, without
the involvement of micro-organisms.1,9-13
Although susceptibility to dental erosion
varies among individuals due to such fac- www.agd.org tors as pH, salivary flow, buffering capacity, and pellicle formation, it appears that
the consumption of citrus fruits and soft
drinks may be a major factor in the etiology of the disease.14-16 Soft drinks, which
tend to be carbonated, have a low pH,
and contain sugar and a variety of other
additives, may subject dental enamel to
acid dissolution and/or erosion.14-16
In the same way that frequency of ingestion is a factor in food cariogenicity,
the frequency of soft drink consumption
is an important factor in dental erosion.6,17,18 Typically, soft drinks consumed
at meal times are less injurious than those
consumed alone and continuous sipping
is considered more harmful to dentition
than consuming an entire beverage at
once.1,6 However, it has been reported
that certain soft drinks (notably cola beverages) are retained on dental enamel and
are less likely than other beverages to be
removed by saliva, resulting in an increased cariogenicity.19
The underlying acidity of beverages is
believed to be the primary factor in the
development of dental erosion; this total
acid level (known as titratable acid),
rather than the pH, is thought to be an
important factor in erosion because it determines the actual hydrogen ion availability for interaction with the tooth surface.20,21 The measurement of a beverage’s
total acid content may be a more realistic
and more accurate method for predicting
erosive potential.22-25 Other important
factors concerning the erosive quality of
beverages include the type of acid and its
calcium chelating properties and exposure time and temperature.19,20
Most soft drinks contain one or more
food acidulants; phosphoric and citric
acid are common but malic, tartaric, and
other organic acids also may be present.26
The presence of these polybasic acids in
beverages is important because their ability to chelate calcium at higher pHs
means they can be very erosive to dental
enamel.25 In addition, polybasic acids exhibit buffering capacity that can maintain
the pH below the threshold value (that is,
at low or acidic pH values), even with
marked dilution.24 Table. Beverages utilized in this study. Beverage Container Coca-Cola
Diet Dr. Pepper
Diet Mountain Dew
Canada Dry ginger ale
A&W root beer
Arizona iced tea
Brewed black tea
Brewed black coffee
Tap water (control) pH Bottle
6.70 14-day weight
1.39 ± 0.34
1.49 ± 0.29
1.40 ± 0.22
1.46 ± 0.23
1.72 ± 0.36
1.52 ± 1.00
6.17 ± 1.13
8.01 ± 1.46
3.93 ± 1.30
3.65 ± 1.27
3.48 ± 0.71
–0.01 ± 0.12
4.86 ± 0.59
0.22 ± 0.07
0.19 ± 0.03
–0.02 ± 0.08 14-day weight
2.78 ± 0.71
3.07 ± 0.06
3.31 ± 0.43
3.22 ± 0.26
3.21 ± 0.24
2.99 ± 1.24
14.31 ± 0.94
14.82 ± 2.23
8.60 ± 1.94
6.43 ± 0.37
6.31 ± 0.65
–0.03 ± 0.28
9.03 ± 1.21
0.35 ± 0.12
0.34 ± 0.03
–0.05 ± 0.13 5
Mountain Dew Sprite
Diet Coca-Cola 3
Weight loss (%) Attrition and abfraction are two other
important factors with regard to enamel
erosion.27 Abfraction is believed to predispose enamel to erosion and/or contribute to the erosive process.28 Lesions
caused by acid eroding dental enamel
have a zone of softened enamel at their
base that is a few microns deep and is
highly susceptible to physical wear.27
Enamel is subject to both erosion and attrition at low pH levels (<6.0). Although
attrition increases with pH elevation, the
degree of attack depends on the pH of the
medium, the applied load, and the duration of contact between the affected surfaces. Erosion is virtually nonexistent at
a pH of 7.0 or higher.27,29
When wear between enamel surfaces
occurs at low pH, stress cracks are generated and propagate within the enamel,
releasing particles. This particulate debris becomes trapped between the contacting surfaces, causing the two-body
abrading system to transform into a
high-wear, three-body abrasion system.
This transformation does not appear to
happen in low-pH media because the opposing surfaces have a smoothed appearance; in fact, it appears that erosion modulates attrition to the extent that wear is
reduced by an apparent polishing effect
on the contacting surfaces. Degradation
of enamel clearly is a complex phenomenon but erosion appears to be the predominating factor at low pH levels.
There is no question that erosion
causes significant damage to dental
enamel, particularly among young people.6,13,30-32 Although altering drinking
habits may prevent erosion by reducing
the intake of acidic foods and beverages,
such an adjustment cannot always be
achieved. However, recent work suggests
that modifying beverages (for example,
by the addition of citrate ions) alters the
acidogenic potential, effectively reducing
Although the literature has addressed
enamel erosion resulting from soft drink
consumption in some depth, there appears to be limited data regarding the relative aggressive quality of the very wide
variety of soft drinks available to the average consumer. The pilot study described
in this article examined relative rates of
enamel dissolution in a variety of carbonated soft drinks (both regular and diet versions) to establish some parameters for
more detailed beverage evaluations. 2 1 0 -1 50 100 150
Immersion time (h) 250 300 350 Fig. 1. Enamel dissolution in various beverages (weight loss in %). Methods and materials
The 20 test teeth were sound (caries-free)
human molars and premolars extracted
for orthodontic or periodontal reasons.
After sterilization in a 5% sodium
hypochlorite (NaClO) solution, the buccal and lingual enamel walls were sectioned into blocks (approximately 7.0
mm x 5.0 mm x 2.5 mm) using a medium
grit diamond bur in a high-speed handpiece under water cooling. Each specimen was weighed to 0.01 mg on a Mettler
H20 decicentimilligram balance (Mettler-Toledo, Inc., Columbus, OH; 800. 638.8537) and the dimensions were
measured to 0.01 mm with digital
calipers. At that point, two enamel blocks
were assigned at random to each beverage in the study. The control for the
study was tap water. All studies were
performed at room temperature.
The test beverages (see the table)
were placed in 5.0 mL screw-cap plastic
containers and the specimens were
weighed at 24–48 hour intervals for a total of 14 days (336 hours). Prior to
weighing, the specimens were blotted
dry and air-syringed. At each weighing, July-August 2004 309 Discussion
This pilot study exposed caries-free dental enamel to a variety of popular beverages continuously over a period of 14
days (336 hours). Two criticisms can be
leveled at this pilot study: the small sample size used for each beverage and the
long exposure time. Although large sample sizes are preferable in any study, this
pilot study was designed to indicate and
possibly identify which types of soft 310 General Dentistry 2.5
1.5 Coca-Cola Pepsi-Cola Diet Regular Diet Regular 0 Diet 0.5 Regular 1.0 Dr. Pepper Fig. 2. Enamel dissolution from cola beverages at 14 days. 16 12 8 Mountain Dew Sprite Regular Diet Regular 0 Diet 4
Regular Tap water, root beer, brewed black tea,
and black coffee all showed minimal
enamel dissolution (< 0.4 mg/cm2) (see
the table). All other media exhibited a
progressive attack on dental enamel,
with a linear or straight line relationship between enamel dissolution and
exposure time over the test period.
Typical dissolution curves are shown in
Regression analysis indicated no correlation between enamel dissolution and
beverage pH (r = 0.477, p > 0.05); in addition, the enamel dissolution showed no
difference (p > 0.05) between the regular
and diet versions of cola and non-cola
beverages from the same manufacturer
(Fig. 2 and 3). It was noted that the
enamel dissolution was similar for all
cola drinks over the 14-day test period
(approximately 3.0 mg/cm2).
The enamel dissolution was two to
five times greater (p < 0.05) among noncola drinks than among cola beverages
(Fig. 4). In addition, enamel dissolution
in canned iced tea was some 30 times
greater than that produced by brewed
black tea and coffee (Fig. 5).
The amount of enamel dissolution
from coffee and brewed black tea was seven times greater than that of both water
and root beer, while cola drinks dissolved
enamel 55–65 times more than both water and root beer. Enamel dissolution
from non-cola drinks was 90–180 times
greater than dissolution from water. 3.0
Weight loss (mg/cm2) Results 3.5 Weight loss (mg/cm2) the beverage was replaced in the container. Mean percentage weight losses
and weight losses per unit area were calculated for each set of enamel specimens
and beverages. The pH of each beverage
was measured at the start of the study.
The enamel dissolution data were subjected to ANOVA and post hoc Scheffé
testing at an a priori α = 0.05. Ginger ale Fig. 3. Enamel dissolution from non-cola beverages at 14 days. drink are potentially the most aggressive
toward dental hard tissues. These objectives were achieved, as noted below.
Regarding the length of the test period, it has to be recognized that realistic
testing of enamel dissolution in soft
drinks is demanding because it is difficult
to determine the extent of oral exposure
to soft drinks except among those who sip
them continuously. Nevertheless, it is
possible to make certain projections.
Based on an average daily consumption of
25 ounces of soft drink and a residence
time in the mouth of five seconds, the total exposure time to beverages would
equal 22,750 seconds (380 minutes or 6.3
hours) per year. However, it is more likely that the exposure time for a beverage
on the dentition is closer to 20 seconds
before salivary clearance occurs; this
would make the annual exposure of den- www.agd.org tal enamel to soft drinks approximately
90,000 seconds (that is, 1,500 minutes or
25 hours) per year. The test period of 336
hours used in this study appears comparable to approximately 13 years of normal
beverage consumption, a reasonable time
period for evaluating the potential enamel attack in children and young adults.
Despite the limitations of this pilot
study, certain conclusions may be drawn.
First, exposure to the regular and diet
versions of both cola and non-cola effervescent drinks from the same manufacturer indicate similar amounts of enamel
dissolution from both, suggesting that
the presence of simple carbohydrates
such as sugar in a soft drink (as opposed
to artificial sweeteners) has no effect on
enamel dissolution. No differences in
the amount of enamel attack were
found among the six cola drinks tested, Weight loss (mg/cm2) 16 for assessing the erosive potential of soft
drinks than the simple solution pH.19-24
This clearly requires further study. 12 Summary
8 CocaCola PepsiCola Dr. Pepper Mountain
Dew Diet Regular Diet Regular Diet Regular Diet Regular Diet 0 Regular 4 Sprite Fig. 4. Enamel dissolution by regular and diet soft drinks at 14 days. 10 Weight loss (mg/cm2) 8 6 4 The data reported here indicate that carbonated soft drinks may cause significant
long-term enamel dissolution. Carbonated beverages were markedly more aggressive toward enamel than coffee, tea,
and root beer. No differences in enamel
dissolution were found between regular
and diet versions of the same brand of
beverage or between enamel dissolution
from the different cola drinks. However,
the data clearly indicated that non-cola
beverages were far more aggressive than
cola drinks. The data suggest that enamel aggressivity is determined by beverage
composition rather than by beverage pH.
Root beer appears to be the safest soft
drink for the health of dental enamel,
while non-cola drinks and canned iced
tea exhibited the most aggressive dissolution of dental enamel. It appears that reducing the residence time of beverages in
the mouth by salivary clearance or rinsing would be beneficial. Author information
2 0 Brewed
iced tea Water Root
beer Fig. 5. Dissolution of enamel by other beverages. suggesting that comparable rates of
enamel dissolution would be observed in
this category of beverage regardless of the
manufacturer or sweetening agent. The
causative agent for enamel dissolution at
this stage is unknown.
A more interesting observation was
the marked disparity in enamel attack by
cola-based drinks as compared with noncola drinks and canned iced tea. These
differences could not be ascribed simply
to the soft drink’s pH, since no correlation could be found between beverage
pH and enamel dissolution. It should be
mentioned that the pH range for most
beverages is 2.4–3.4, well below the
threshold pH for dental caries of 5.5.
This range suggests that enhanced enamel dissolution results from effects other
than simple beverage pH, most likely the
additives within non-cola beverages that are necessary for achieving the desired
As indicated earlier, most soft drinks
contain acidulants such as phosphoric
and citric acid, along with varying
amounts of malic, tartaric, and other organic acids.26 These polybasic acids exhibit buffering capacity and can maintain
the local pH at the tooth surface below
the threshold value even with marked dilution; as a result, they can be very aggressive toward dental enamel.24 The
presence of these polybasic acids in beverages is important, as their ability to
chelate calcium at higher pH levels could
cause significant enamel dissolution
through a calcium chelation effect rather
than a simple acid attack.25 Interestingly,
recent reports in the literature suggest
that the total acid level (that is, the titratable acid) is a more realistic parameter Dr. von Fraunhofer is a professor and
Director of Biomaterials Science, Department of Oral and Maxillofacial
Surgery, University of Maryland Baltimore Dental School, where Capt Rogers
obtained his DDS degree. Capt Rogers
is stationed with the USAF Dental
Corps, 60th Dental Squadron, Travis
AFB, California. References
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