British Journal of Nutrition (2012), 107, 252–262
q The Authors 2011
doi:10.1017/S0007114511002820
Analysis of the erosive effect of different dietary substances and medications
Adrian Lussi*, Brigitte Megert, Robert Peter Shellis and Xiaojie Wang
Department of Preventive, Restorative and Pediatric Dentistry, School of Dental Medicine, University of Bern, Freiburgstrasse
7, CH-3010 Bern, Switzerland
British Journal of Nutrition
(Received 15 October 2010 – Revised 15 April 2011 – Accepted 15 April 2011 – First published online 30 June 2011)
Abstract
Excessive consumption of acidic drinks and foods contributes to tooth erosion. The aims of the present in vitro study were twofold: (1) to
assess the erosive potential of different dietary substances and medications; (2) to determine the chemical properties with an impact on the
erosive potential. We selected sixty agents: soft drinks, an energy drink, sports drinks, alcoholic drinks, juice, fruit, mineral water, yogurt,
tea, coffee, salad dressing and medications. The erosive potential of the tested agents was quantified as the changes in surface hardness
(DSH) of enamel specimens within the first 2 min (DSH2 – 0 ¼ SH2 min 2 SHbaseline) and the second 2 min exposure (DSH4 – 2 ¼ SH4 min 2
SH2 min). To characterise these agents, various chemical properties, e.g. pH, concentrations of Ca, Pi and F, titratable acidity to pH 7·0
and buffering capacity at the original pH value (b), as well as degree of saturation (pK 2 pI) with respect to hydroxyapatite (HAP) and
fluorapatite (FAP), were determined. Erosive challenge caused a statistically significant reduction in SH for all agents except for coffee,
some medications and alcoholic drinks, and non-flavoured mineral waters, teas and yogurts (P,0·01). By multiple linear regression
analysis, 52 % of the variation in DSH after 2 min and 61 % after 4 min immersion were explained by pH, b and concentrations of F and
Ca (P,0·05). pH was the variable with the highest impact in multiple regression and bivariate correlation analyses. Furthermore, a
high bivariate correlation was also obtained between (pK 2 pI)HAP, (pK 2 pI)FAP and DSH.
Key words: Tooth erosion: Erosive potential: Dietary substances: Medications: Chemical properties: Hardness
There is increasing evidence, from in vitro and in situ studies,
that the excessive consumption of acidic drinks and foods
poses a risk to dental hard tissues(1 – 8). Tooth surface is
softened in the early stage, and subsequently bulk material
is dissolved, layer by layer, from the tooth surface. This type
of tooth wear is defined as tooth erosion and is caused by
acids (extrinsic and intrinsic) or chelating agents not involving
bacterial action. There is a trend towards the increased consumption of acidic drinks and foods. In 2007, the worldwide
annual consumption of soft drinks reached 552 billion litres,
the equivalent of just under 83 litres/person per year, and
this is projected to increase to 95 litres/person per year by
2012. However, the figure had already reached an average
of 212 litres/person per year in the USA in 2009(9). To decrease
extrinsic erosive tooth wear, the emphasis should be on preventive strategies that mainly aim at reducing the exposure
of teeth to potentially erosive agents.
As a prerequisite, it is essential for medical personnel and
patients to have a thorough knowledge of the erosive
potential of popular dietary substances. In the past several
decades, studies investigating the erosive potential of different
dietary substances and medications have been performed in
different countries(3 – 8,10). A wide range of drinks, foods and
medications, such as soft drinks, sports drinks, juices, salad
dressings, candies, herbal teas, alcoholic drinks, vinegar,
vitamin C tablets etc., were recognised to be associated with
the increase in erosion. Normally, soft drinks are mainly composed of filtered water, artificial additives and refined sugar.
Thus, they offer limited nutritional benefit, but energy.
Sports drinks, which are designed to replenish fluids lost
during activity, typically contain water, electrolytes and
sugar. Energy drinks are basically soft drinks that contain
some forms of vitamins and other chemicals that boost
energy for a very short span.
Various chemical properties of a potentially erosive agent,
such as pH value, titratable acidity, buffering capacity, the
concentrations of Ca, Pi and F, have been identified in the literature to be potentially important in determining the erosive
potential(4,5,7,11,12). However, to the best of our knowledge, no
thorough analyses of the effects of a wide range of erosive
agents have been undertaken. Buffering capacity is associated
with the undissociated acid in a solution, and maintains the
Hþ concentration and driving force for demineralisation at
the site of dissolution(13,14). The greater the buffering capacity
Abbreviations: FAP, fluorapatite; HAP, hydroxyapatite; pK 2 pI, degree of saturation; DSH, changes in surface hardness; SH, surface hardness.
* Corresponding author: Professor A. Lussi, fax þ41 31 632 98 75, email adrian.lussi@zmk.unibe.ch
Erosive effect of dietary substances and medications
of the solution, the longer it will take for saliva to neutralise
the acid, and as a result the more tooth mineral may be dissolved before a safe pH value is reached and the dissolution
ceases. It is important to distinguish buffering capacity from
titratable acidity. The latter measures total available Hþ over
a wide range of pH values, whereas the former is defined at
a certain pH value.
The aims of the present in vitro study were twofold: (1) to
evaluate the erosive potential of different drinks, foods and
medications; (2) to determine those chemical properties that
have an impact on the erosive potential.
Materials and methods
British Journal of Nutrition
Preparation of enamel specimens
From a pool of extracted teeth, six hundred caries-free human
premolars with no cracks on the buccal sites as viewed under
a stereomicroscope were selected. After the crowns of all
teeth were separated from the roots, the buccal sites were
ground flat under water-cooling on a LaboPol-21 rotating
polishing machine (Struers, Ballerup, Denmark) as follows:
groups of five enamel slabs were embedded into one resin
disk (Paladur, Bad Homburg, Germany) in two planar parallel
molds. Once the hardening process was complete, the thinner
mold (200 mm thick) was removed. The outer 200 mm of
enamel were ground away with a silicon carbide paper disc of
18 mm grade. Thereafter, the exposed buccal sides of enamel
slabs in the thicker mold (7 mm thick) were serially polished
on the polishing machine under constant cooling with silicon
carbide paper discs of 8 mm grade for 30 s and with 5 mm
grade for 1 min. Then, after being taken out of the molds, the
embedded resin disks, each containing five enamel slabs,
were polished for 1 min with 3 mm diamond abrasive on
DP-Mol polishing cloth (Struers). After each polishing step,
the resin disks were rinsed and sonicated for 2 min in tap
water. These preparation steps wore away 200 mm enamel substance in the centre of the window. Then all the resin disks with
embedded enamel slabs were stored in a saturated mineral solution (1·5 mM -CaCl2, 1·0 mM -KH2PO4, 50 mM -NaCl, pH 7·0)(15).
Tested dietary substances and medications
In the present study, sixty popular drinks, foods and medications in Switzerland were included (Table 1). According
to their constituents and applications, these agents were
divided into twelve groups: soft drinks, an energy drink,
sports drinks, alcoholic drinks, juice, fresh fruit, mineral
water, yogurt, tea, coffee, salad dressing and medications.
Immediately before the experiment started, the fruits were
crushed, and the pulps and seeds were removed by centrifugation; medication tablets and powders were dissolved in tap
water according to the suggestions of the manufacturers.
Chemical analysis of tested agents
The pH value and the amount of base needed to raise the pH
to 7·0 (titratable acidity) were measured with a titrator (Toledo
253
DL 53, Mettler Toledo, Electrode DG 101-SC, Software: LabX
pro, Schwerzenbach, Switzerland). To measure titratable
acidity, 10 g of each drink or solution were titrated with
0·5 M -NaOH in steps of 0·02 ml at a temperature of 308C. The
buffering capacity (b) was calculated by using the following
equation: b ¼ 2DC/DpH, where DC is the amount of base
used and DpH is the change in pH caused by the addition
of the base. In the present study, the buffering capacity at
the original pH of the tested products was calculated.
All the tested agents were further analysed for Ca by
standard atomic absorption using an atomic absorption spectrometer with an air/acetylene flame. Lanthanum was added
to all the products and standards to suppress Pi interference.
Total Pi concentration was analysed by the ammonium
molybdate method of Chen et al.(16). F concentration was
determined using a F ion-specific electrode (Orion 960900,
Boston, MA, USA). Before F measurement, all products and
standard solutions were mixed with total ionic strength adjustment buffer (TISAB). The concentrations of Ca and Pi are
expressed in mmol/l and those of F in mg/l.
The degree of saturation (pK 2 pI) with respect to hydroxyapatite (HAP) and fluorapatite (FAP) was calculated from
the pH and the concentrations of Ca, Pi and F using a computer program(17). This program assumes a solubility product for
HAP of 10258·5 and for FAP 10259·6(18,19).
Before the experiment, carbonated drinks were degassed
by stirring at room temperature to avoid the adherence of
bubbles to the enamel surface, which will affect the chemical
analyses and hardness measurements. The concentrations of
Ca, Pi and F, the pH and the titratable acidity were measured
in duplicate, and for further calculations of buffering capacity
and pK 2 pI, the mean was determined.
Surface hardness measurement
Surface hardness (SH) of the enamel specimens was determined with a Vickers diamond under a pressure of 50 mN for
15 s (Fischerscope HM 2000 XYp; Helmut Fischer, Hünenberg,
Switzerland). A total of six baseline indentations were made
at intervals of 70 mm. Further indentations next to the previous
indentations were made following the experimental procedure.
Vickers hardness was calculated from the dimensions of the
indentations. The load resolution was #0·04 mN and the
indentation depth was 600 nm for sound enamel and
, 1000 nm for most softened specimens. The device allowed
fully automatic measurements using a programmable x, y
stage. The WIN-HCU software calculated and illustrated SH.
Study design
After polishing the exposed enamel surface of resin disks (five
enamel slabs each) with a 3 mm diamond abrasive, six baseline
indentations per specimen were made and measured. The
mean SH for each resin disk, i.e. the average SH of five
enamel samples, was then calculated. According to the SH
distribution, two disks, with a total of ten enamel samples,
were assigned to one of sixty groups. Thus, the average SH
of each pair of disks was similar. Just before the experimental
British Journal of Nutrition
Tested agents
Soft drinks
Carpe Diem
Kombucha fresh
Coca-Cola
Brand
name/producer
Flavour
NA
NA
Ice tea lemon
n/a /Coop
(supermarket in
Switzerland)
Lipton/Unilever
Lemon
Ice tea peach
Lipton/Unilever
Peach
Pepsi Cola
Pepsi Cola/Pepsi
Company, Inc.
Pepsi Cola/Pepsi
Company, Inc.
Rivella/Rivella
International AG
Cola
Rivella green
Rivella/Rivella
International AG
Green tea
Rivella red
Rivella/Rivella
International AG
Sinalco/Sinalco
International
NA
Sprite/Coca-Cola
Company
Sour
Red Bull/Red
Bull GmbH
Coca-Cola light
Fanta regular
orange
Ice tea classic
Pepsi Cola light
Rivella blue
Sinalco
Sprite
Energy drink
Red Bull
Sports drinks
Gatorade
Isostar
Powerade
Juice
Apple juice
pH
mmol OH-/l
to pH 7·0
b (mmol/l
£ pH)
[Ca]
(mmol/l)
[Pi]
(mmol/l)
[F]
(mg/l)
(pK 2 pI)HAP
(pK 2 pI)FAP
Herbal tea extract and
carbonic acid
Phosphoric acid
and flavours
Phosphoric acid, citric
acid and flavours
Orange fruit, citric acid,
flavours and
acidity regulator
Black tea extract
3·00
39·0
17·6
3·30
0·07
0·39
2 19·0
2 12·0
2·45
17·5
9·6
1·08
5·04
0·22
2 20·0
2 13·1
2·60
19·0
7·3
0·82
4·85
0·22
2 19·4
2 12·5
2·67
52·5
15·8
0·48
0·08
0·04
2 25·2
2 19·1
2·94
26·5
15·0
0·45
0·04
0·76
2 24·2
2 16·9
Black tea extract and
lemon juice
Black tea extract and
peach juice
Phosphoric acid, citric
acid and flavours
Phosphoric acid, citric acid
and flavours
Milk serum, carbonic acid,
citric acid
and flavours
Milk serum, green tea
extract, carbonic
acid, citric acid
and flavours
Milk serum, carbonic acid,
citric acid and flavours
Orange juice, carbonic acid,
citric acid, mandarin juice,
lemon juice, ascorbic acid
and flavours
Carbonic acid, citric acid,
acidity regulator
and flavours
3·03
24·0
9·4
0·18
0·12
0·58
2 24·0
2 16·8
2·94
21·5
8·5
0·12
0·15
0·53
2 25·2
2 18·0
2·39
19·0
11·7
0·33
4·93
0·04
2 23·0
2 16·9
2·77
15·0
7·4
0·29
4·68
0·04
2 20·4
2 14·3
3·31
38·0
37·9
4·00
2·17
0·08
2 12·0
2 5·9
3·22
44
37·5
3·30
2·41
0·09
2 12·9
2 6·6
3·28
41·5
35·4
3·13
2·28
0·08
2 12·6
2 6·5
3·12
36·0
10·1
1·14
0·10
0·06
2 19·7
2 13·5
2·54
39·0
15·0
0·30
0·02
0·02
2 28·8
2 23·0
NA
Taurine and B vitamins
3·30
98·0
45·5
1·94
, 0·01
0·11
2 26·4
2 20·1
Gatorade/Pepsi
Company, Inc.
Isostar/Novartis
International AG
Powerade/Coca-Cola
Company
Sour
Citric acid and flavours
3·17
46·0
21·8
0·13
2·98
0·05
2 19·7
2 13·7
NA
Citric acid, flavours and
ascorbic acid
Malic acid, vitamins
B2 and B6
3·87
56·5
52·8
8·20
4·49
0·11
2 5·9
2 0·1
3·74
43·0
18·0
0·25
, 0·01
0·21
2 22·5
2 16·2
Ramseier/Ramseier
Suisse AG
Premium
3·41
72·0
43·6
1·96
1·66
0·06
2 13·0
2 7·0
Cola
Cola
Orange
Cola
NA
Orange
Lemon
Apple juice and
pear juice
A. Lussi et al.
Carpe Diem/Carpe
Diem GmbH & Co KG
Coca-Cola/Coca-Cola
company
Coca-Cola/Coca-Cola
Company
Fanta/Coca-Cola
Company
Erosion-related
ingredients
254
Table 1. Basic information and various chemical parameters of the tested agents, e.g. pH value, titratable acidity to pH 7·0, buffering capacity at the pH value, Ca, Pi, and F concentrations, degree of
saturation with respect to hydroxyapatite and fluorapatite*
British Journal of Nutrition
Table 1. Continued
Brand
name/producer
Flavour
Carrot juice
Biotta/Biotta AG
Carrot
Grapefruit juice
Orange juice,
Del Monte
n/a /Coop
n/a /Migros
(supermarket
in Switzerland)
Hohes C/Eckes AG
Tested agents
Beer, Eichhof
Champagner
Red wine, Collivo
Red wine,
Montagne
White wine
Smirnoff ice vodka
Medications
Alca-C fizzy tablet
Alcacyl 500
Alka-Seltzer fizzy
tablet
Aspirine-C fizzy
tablet
Berocca fizzy
tablet
Fluimucil 200
fizzy tablet
Neocitran
pH
mmol OH-/l
to pH 7·0
b (mmol/l
£ pH)
[Ca]
(mmol/l)
[Pi]
(mmol/l)
[F]
(mg/l)
(pK 2 pI)HAP
(pK 2 pI)FAP
4·16
70·5
55·7
4·40
1·20
0·04
2 6·6
2 1·4
Grape fruit
Orange
Carrot juice, orange juice,
agave juice,
lemon juice and
ascorbic acid
Grapefruit juice
Orange juice
3·15
3·74
168·5
108·0
71·4
66·7
2·30
2·38
2·17
2·36
0·03
0·03
2 14·2
2 9·8
2 8·4
2 4·5
Orange
Orange juice
3·56
121·0
62·5
1·98
2·57
0·03
2 11·4
2 5·8
NA
NA
NA
Apricot
Kiwi
Orange
NA
NA
NA
3·25
3·25
3·60
317·0
206·5
113·0
125·0
142·9
47·6
1·20
3·35
2·18
5·95
4·47
1·27
0·02
0·02
0·03
2 13·6
2 11·9
2 11·8
2 8·0
2 6·3
2 6·3
Bacardi/Bacardi &
Company Limited
Cynar/Campari Gruppo
Carlsberg/ Carlsberg
Group
Eichhof/Eichhof
Getränke AG
Freixenet/Grupo Freixenet
Collivo/Italia
Montagne/France
Orange
3·16
60·0
26·1
0·19
0·14
0·03
2 22·5
2 16·7
NA
NA
4·4 % alcohol and
orange juice
16·5 % alcohol
5·0 % alcohol
4·00
4·20
6·0
17·5
5·8
8·3
2·01
0·74
0·13
5·65
0·07
0·74
2 12·0
2 7·9
2 6·5
2 1·5
NA
4·9 % alcohol
4·07
18·0
8·1
1·94
9·30
0·06
2 6·3
2 0·9
NA
NA
NA
12·0 % alcohol
13·0 % alcohol
11·7 % alcohol
2·99
3·43
3·68
78·0
76·0
63·0
35·8
54·4
46·5
1·90
1·25
1·68
1·98
4·69
2·79
0·26
0·07
0·11
2 15·9
2 12·5
2 10·7
2 9·0
2 6·4
2 4·7
La Côte/France
Smirnoff/Diageo plc
NA
Lemon
12·1 % alcohol
40·0 % alcohol
and lemon juice
3·60
3·07
53·0
50·0
50·0
18·2
1·30
0·18
4·42
6·54
0·27
0·12
2 11·3
2 18·8
2 4·8
2 12·4
Alca-C/Novartis
Consumer
Health Schweiz AG
Alcacyl 500/Novartis
Consumer Health
Schweiz AG
Alka-Seltzer/Bayer
(Schweiz) AG
Aspirine-C/Bayer
(Schweiz) AG
Berocca/Bayer
(Schweiz) AG
Zambon
Orange
Acetylsalicylic acid
and ascorbic acid
4·20
53·0
45·5
9·03
0·02
0·07
2 10·2
2 4·8
Sour
Acetylsalicylic acid
6·93
0·5
3·7
1·89
, 0·01
0·07
0·4
3·1
Sour
Acetylsalicylic acid
and citric acid
Acetylsalicylic acid
and vitamin C
Vitamin C
6·23
14·0
24·9
2·06
0·03
0·08
1·5
5·0
5·51
27·5
32·8
2·04
, 0·01
0·08
2 5·7
2 1·5
4·24
59·5
57·2
15·20
0·03
0·12
2 8·9
2 3·3
4·71
19·5
13·5
1·98
, 0·01
0·06
2 12·5
2 7·6
Neocitran/Novartis
Consumer
Health Schweiz AG
Sour
Tartaric acid, citric
acid monohydrate
and flavours
Vitamin C
2·85
73·5
27·5
4·63
1·58
0·09
2 15·5
2 0·9
Sour
Orange
Orange
Erosive effect of dietary substances and medications
Orange juice,
Hohes C
Fruit
Apricot
Kiwi
Orange
Alcoholic drinks
Bacardi Breezer
orange
Cynar
Beer, Carlsberg
Erosion-related
ingredients
255
British Journal of Nutrition
256
Table 1. Continued
Tested agents
Vitamin C fizzy
tablet,
Actilife
Vitamin C fizzy
tablet,
Streuli
Siccoral
Yogurt
Kiwi Tropicana
Valser Viva
Lemon
Tea
Rose hip
Pepper mint
Black tea
Wild berries
Coffee
Espresso
Salad dressing
Thomy French
Classic
Thomy French
Light
[Ca]
(mmol/l)
[F]
(mg/l)
(pK 2 pI)HAP
(pK 2 pI)FAP
93·0
58·8
1·90
0·03
0·06
2 15·0
2 9·4
3·63
85·0
42·6
1·78
2·01
0·06
2 11·4
2 5·6
NA
5·41
2·5
2·0
0·15
0·12
0·03
2 7·4
2 3·6
3·99
Milky
Milky
Berries
Kiwi and
exotic fruits
NA
NA
Forest berries
124·5
111·1
45·83
33·82
0·04
0
5·3
3·91
4·03
3·77
120·0
133·5
159·0
95·5
100·0
200·0
43·33
56·33
45·50
34·34
38·74
36·81
0·04
0·03
0·05
2 0·6
0·8
2 1·4
4·7
5·9
4·1
Henniez/Nestlé Waters
Henniez/Nestlé Waters
Valser/Valser
Mineralquellen AG
Valser/Valser
Mineralquellen AG
NA
NA
NA
NA
NA
NA
7·68
6·13
5·63
N.A
4·0
12·5
2·0
4·2
10·9
2·48
2·40
9·93
, 0·01
, 0·01
, 0·01
0·10
0·09
0·60
2·4
2 6·2
2 2·8
4·5
2 2·6
2·1
Lemon
and herbs
Lemon
and herbs
3·31
40·0
21·1
9·75
0·08
0·63
2 14·7
2 7·6
n/a /Migros
n/a /Migors
n/a /Coop
Lipton/Unilever
Rose hip
Pepper mint
Black tea
Berries
Rose hip
Pepper mint
Black tea
Hibiscus bloom,
apple, strawberry,
currant and
blackberry
3·15
7·51
6·59
6·78
19·5
N.A
1·5
1·0
19·7
2·9
2·6
2·6
2·65
1·93
1·10
1·10
0·42
0·35
0·27
0·24
0·05
0·05
1·63
0·78
2 16·0
11·8
5·6
6·6
2 10·0
13·8
10·0
10·5
Nestlé /Nestlé
Switzerland
Coffee
NA
5·82
3·0
2·2
0·69
0·63
0·07
0·6
4·5
Thomy/Nestlé
Switzerland
Thomy/Nestlé Switzerland
Creamy
and sour
Creamy
and sour
Vinegar and
lemon juice
Vinegar
4·04
141·0
111·1
20·50
0·46
0·11
2 6·1
2 0·5
3·85
145·0
100·0
40·00
1·14
0·11
2 5·3
0·5
Flavour
Erosion-related
ingredients
Actilife/Migros
Orange
Citric acid, vitamin C
and flavours
3·86
Streuli/Streuli Pharma AG
Sour
Vitamin C
Siccoral/Drossa
Pharma GmbH
NA
Hirz/Nestlé Switzerland
Kiwi
n/a /Migros
n/a /Migros
n/a /Migros
pH
pK 2 pI, degree of saturation; HAP, hydroxyapatite; FAP, fluorapatite; NA, not available.
* Titratable acidity, mmol OH-/l to pH 7·0; b, buffering capacity at the pH value; pK 2 pI with respect to HAP and pK 2 pI with respect to FAP.
[Pi]
(mmol/l)
A. Lussi et al.
Nature
Slimline
Forest berries
Mineral water
Henniez
Henniez sparkling
Valser
mmol OH-/l
to pH 7·0
b (mmol/l
£ pH)
Brand
name/producer
British Journal of Nutrition
Erosive effect of dietary substances and medications
procedures, the resin disks were further polished with a 1 mm
diamond abrasive for 1 min (LaboPol-6, DP-Mol Polishing,
DP-Stick HQ; Struers, Copenhagen, Denmark), which assured
the removal of the possible remnants from storage.
Before the erosive challenge, enamel specimens were
immersed in 20 ml of freshly collected human saliva for 3 h
to form a salivary pellicle. The saliva, stimulated by paraffin
wax (Fluka; Sigma-Aldrich Chemie GmbH, Munich, Germany),
was collected in an ice-cooled tube from a single healthy
donor at least 1 h after any intake of drink or food(20,21). She
gave informed consent, and saliva collection was performed
in accordance with the protocol approved by the University
of Bern (Bern, Switzerland). After being carefully rinsed with
tap water for 50 s, with deionised water for 10 s and then
dried for 5 s with oil-free air, the SH baseline of the samples
was measured. Afterwards, the resin disks with five enamel
specimens each were individually placed in 60 ml (or g) of
the appropriate solution under constant agitation (95 rpm) at
308C (shaking bath Salvis; Renggli AG, Rotkreuz, Switzerland).
After immersion for 2 and 4 min, the resin disks were taken
out of the solution, and the SH measurement was performed
once again.
Statistics
Wilcoxon’s signed rank tests were calculated in an attempt to
compare the SH values before and after immersion. The
relationship between the changes in SH (DSH) within the
first 2 min (DSH2 – 0 ¼ SH2 min 2 SHbaseline) and the second
2 min (DSH4 – 2 ¼ SH4 min 2 SH2 min) immersion (dependent
variables) and pH, buffering capacity, and Ca, Pi and F concentrations (independent variables) was investigated using
multiple linear regression (backward selection) analyses.
Only variables independent from each other were included.
The pK 2 pI and the titratable acidity were not eligible for
inclusion. To assess the bivariate associations between different chemical properties and DSH after 2 or 4 min exposure,
Spearman’s correlation coefficients were used. The statistical
calculations were performed using SAS Enterprise Guide 4.1
software. The significance level was set at 0·01 in Wilcoxon’s
signed rank tests and at 0·05 in multiple linear regression
and Spearman’s correlation analyses.
Results
Changes in the surface hardness of enamel
In Table 2, Wilcoxon’s signed rank tests revealed a significant
reduction (P, 0·01) of DSH2 – 0 for soft drinks, sports drinks,
the energy drink (Red Bull), juices (except for carrot juice),
fruits and salad dressings. Except for Isostar (sports drink) and
Thomy French Classic salad dressing, these substances presented a trend towards further decrease in DSH4 – 2. On the contrary, no statistically significant change was found for coffee,
most mineral waters, teas and yogurts in both DSH2 – 0 and
DSH4 – 2. Exceptions were rose hip tea, forest berries yogurt
and Valser Viva Lemon mineral water that had a similar erosive
effect as soft drinks. A complicated erosive pattern was
observed in the medication and alcoholic drink groups. For
257
example, Alca-C, Alcacyl 500 and Berocca fizzy tablets did not
induce a significant decrease in SH, while the reduction was
observable within the first 2 min for Aspirine-C fizzy tablet
and within the second 2 min for Siccoral, Alka-Seltzer and Fluimucil 200 fizzy tablets. In the alcoholic drink group, by the end
of the experiment, Cynar, Carlsberg beer and Montagne red
wine did not produce any significant changes in SH of enamel
specimens, whereas Eichhof beer demonstrated erosive potential within the second 2 min. It is worth noting that as no adjustment for multiple testing was done, the present results can only
be taken into exploratory consideration.
Influence of different chemical properties on changes
in surface hardness
Table 1 also gives an overview of the chemical properties of
all tested agents.
Coffee, teas (except for rose hip tea), mineral waters
(except for Valser Viva Lemon mineral water) and some medications (Alcacyl 500, Alka-Seltzer and Aspirine-C fizzy tablets)
had the highest pH values, above 5·5. The lowest pH values,
varying between 2·4 and 3·3, were mostly found in the soft
drinks and the energy drink (Red Bull).
The larger titratable acidity was found for fruits, salad dressings, yogurts as well as for grapefruit and orange juices
(. 100 mmol/l). The buffering capacity ranged from 2·0 to
200 mmol/l £ pH. The highest values were observed for
yogurts, fruits (except for orange) and salad dressings
(. 95 mmol/l £ pH), the lowest values for Siccoral, Henniez
mineral water, coffee and tea (except for rose hip tea)
(, 3 mmol/l £ pH).
Yogurts contained the highest concentrations of Ca
(. 43 mmol/l) and Pi (.33 mmol/l). Black tea contained the
highest concentration of F (1·63 mg/l), whereas F concentration in other agents normally varied between 0 and 1 mg/l.
Many of the test agents under study were undersaturated
with respect to both HAP and FAP. Exceptionally, Henniez
mineral water, Alcacyl 500 and Alka-Seltzer fizzy tablets,
Kiwi and Slimline yogurts, coffee and teas (except for rose
hip tea) were supersaturated with respect to both minerals.
Valser mineral water, natural and forest berries yogurts,
Thomy French Light salad dressing were undersaturated
with respect to HAP but supersaturated with respect to FAP.
Table 3 shows the chemical properties with a significant
impact on DSH after a 2 and 4 min immersion in the multiple
linear regression analysis. In this analysis, 52 % of the variation
of DSH after 2 min immersion and 61 % of the variation after
4 min immersion could be explained by pH, buffering
capacity, Ca and F concentrations (P,0·05).
There were high bivariate correlations between DSH and the
pH, the (pK 2 pI)HAP and (pK 2 pI)FAP (Table 4). However, the
concentrations of Ca, Pi and F, the titratable acidity and the buffering capacity showed small bivariate correlations with DSH.
Discussion
In agreement with previous studies(4,5,22,23), the present study
indicated that soft drinks, energy drinks (Red Bull), sports
258
A. Lussi et al.
Table 2. Original surface hardness (SHbaseline) of specimens, and the changes within the first 2 min (DSH2 – 0 ¼ SH2 min 2
SHbaseline) and the second 2 min (DSH4 – 2 ¼ SH4 min 2 SH2 min) incubation in different dietary agents and medications
(Mean values with their standard errors)
British Journal of Nutrition
SHbaseline
Soft drinks
Carpe Diem Kombucha fresh
Coca-Cola
Coca-Cola light
Fanta regular orange
Ice tea classic
Ice tea lemon
Ice tea peach
Pepsi Cola
Pepsi Cola light
Rivella blue
Rivella green
Rivella red
Sinalco
Sprite
Energy drink
Red Bull
Sports drinks
Gatorade
Isostar
Powerade
Juice
Apple juice
Carrot juice
Grapefruit juice
Orange juice, Del Monte
Orange juice, Hohes C
Fruit
Apricot
Kiwi
Orange
Alcoholic drinks
Bacardi Breezer orange
Cynar
Beer, Carlsberg
Beer, Eichhof
Champagner, Freixenet
Red wine, Collivo
Red wine, Montagne
White wine, La Côte
Ice vodka, Smirnoff
Medications
Alca-C fizzy tablet
Alcacyl 500
Alka-Seltzer fizzy tablet
Aspirine-C fizzy tablet
Berocca fizzy tablet
Fluimucil 200 fizzy tablet
Neocitran
Vitamin C fizzy tablet, Actilife
Vitamin C fizzy tablet, Streuli
Siccoral
Yogurt
Kiwi Tropicana
Nature
Slimline
Forest berries
Mineral water
Henniez
Henniez sparkling
Valser
Valser Viva Lemon
Tea
Rose hip
Pepper mint
DSH2 – 0
DSH4 – 2
Mean
SEM
Mean
SEM
P
Mean
SEM
P
526·8
513·4
600·3
513·3
517·0
511·7
541·0
563·3
512·7
530·2
505·6
532·0
514·3
513·2
6·5
7·7
16·1
10·0
13·9
6·9
14·8
16·9
7·7
16·4
18·3
16·4
4·8
12·9
2 190·2
2 157·4
2 276·7
2 244·8
2 84·3
2 86·1
2 82·4
2 190·8
2 180·4
2 253·8
2 144·9
2 211·1
2 166·5
2 192·9
8·0
21·1
17·0
12·4
12·6
8·0
14·5
12·8
8·0
17·8
19·4
10·8
7·8
19·6
0·002*
0·002*
0·002*
0·002*
0·002*
0·002*
0·002*
0·002*
0·002*
0·002*
0·002*
0·002*
0·002*
0·002*
2 143·5
2 153·3
2 147·0
2 136·9
2 99·3
2 106·8
2 158·7
2 106·8
2 110·0
2 138·9
2 142·7
2 136·0
2 120·5
2 119·5
10·4
15·9
13·8
7·3
14·9
8·7
11·8
10·7
9·2
5·6
22·6
10·9
9·8
11·9
0·002†
0·002†
0·002†
0·002†
0·002†
0·002†
0·002†
0·002†
0·002†
0·002†
0·002†
0·002†
0·002†
0·002†
534·9
18·7
2 88·7
22·5
0·009*
2 135·7
10·2
0·002†
513·2
539·9
510·0
7·3
11·1
6·3
2 124·7
2 35·4
2 62·7
9·3
5·5
6·0
0·002*
0·002*
0·002*
2 107·5
2 0·2
2 96·3
13·6
7·6
11·9
0·002†
1·000
0·002†
560·9
531·9
491·0
500·6
590·8
26·5
12·5
8·6
6·1
11·8
2 145·4
2 13·4
2 152·8
2 35·2
2 59·8
13·6
5·5
7·6
5·4
8·7
0·004*
0·037
0·002*
0·002*
0·002*
2 145·8
2 10·5
128·9
2 72·2
2 100·3
16·1
3·4
9·7
8·6
15·0
0·002†
0·020
0·002†
0·002†
0·002†
519·1
499·8
561·2
5·9
6·2
13·1
2 120·3
2 116·8
2 97·4
9·2
9·2
7·2
0·002*
0·002*
0·002*
2 103·6
2 110·3
2 101·9
7·5
6·4
14·6
0·002†
0·002†
0·002†
572·1
519·1
511·1
520·6
531·3
543·4
556·2
505·0
565·3
17·0
8·4
10·4
10·1
8·0
22·3
12·5
8·1
11·1
2 224·9
þ1·2
2 1·6
þ0·5
2 126·9
2 31·1
2 20·5
2 24·9
2 173·9
13·3
5·4
5·5
8·0
7·3
5·6
7·4
3·9
9·0
0·002*
0·695
1·000
0·846
0·002*
0·002*
0·027
0·002*
0·002*
2 130·0
þ9·1
2 5·0
2 13·8
2 98·8
2 33·4
2 35·9
2 38·1
2 132·4
8·5
7·8
3·5
3·6
10·0
5·6
11·4
5·5
10·1
0·002†
0·275
0·124
0·006†
0·002†
0·002†
0·557
0·002†
0·002†
533·6
527·8
512·3
534·6
511·4
530·8
541·5
509·5
549·4
525·7
11·3
11·8
7·7
7·1
5·3
9·5
13·3
8·3
19·5
16·6
2 13·2
2 2·3
2 3·9
2 17·4
2 1·7
2 9·4
2 249·5
2 88·2
2 139·1
2 7·4
5·0
5·5
4·8
4·7
7·0
9·7
10·9
7·1
11·3
6·0
0·037
0·492
0·492
0·006*
0·846
0·322
0·002*
0·002*
0·002*
0·322
2 7·5
þ2·7
2 15·0
2 8·4
þ1·2
2 19·1
2 119·8
2 98·6
2 147·7
2 21·0
6·1
3·7
4·2
3·8
4·4
5·4
5·0
4·9
8·8
6·1
0·160
0·557
0·009†
0·049
0·846
0·009†
0·002†
0·002†
0·002†
0·002†
548·3
524·3
573·7
525·0
8·7
4·3
18·5
8·7
þ7·3
þ2·8
2 3·3
2 6·3
10·3
3·6
10·2
2·7
0·770
0·375
0·105
0·049
þ 18·1
2 8·5
2 3·0
2 5·6
16·1
4·3
7·1
1·8
0·492
0·160
0·275
0·009†
543·0
501·3
491·7
506·3
11·9
7·4
5·0
11·6
þ3·8
2 1·0
2 1·5
2 81·0
10·6
3·2
2·3
10·9
1·000
0·760
0·625
0·002*
2 9·5
þ0·4
2 4·3
2 89·7
5·1
3·1
3·1
6·7
0·131
0·846
0·275
0·002†
545·6
519·5
16·2
6·7
2 181·1
þ0·8
19·6
5·2
0·006*
0·922
2 117·8
þ7·2
5·9
5·0
0·006†
0·155
Erosive effect of dietary substances and medications
259
Table 2. Continued
SHbaseline
Black tea
Wild berries
Coffee
Espresso
Salad dressing
Thomy French Classic
Thomy French Light
DSH2 – 0
Mean
DSH4 – 2
Mean
SEM
507·4
603·7
8·5
9·5
2 1·2
þ2·1
5·7
7·4
1·000
0·846
þ2·4
þ5·3
2·8
5·3
0·625
0·322
516·5
7·1
þ3·7
5·0
0·492
þ0·5
5·8
0·846
548·6
509·1
9·5
14·1
2 21·2
2 32·6
5·8
4·0
0·002*
0·002*
2 4·0
2 61·4
6·7
8·5
0·492
0·002†
SEM
P
Mean
SEM
P
British Journal of Nutrition
* Mean values were significantly different in SH within the first 2 min of erosive challenge.
† Mean values were significantly different in SH within the second 2 min of erosive challenge.
drinks, juices, fruits, and some medications and alcoholic
drinks caused statistically significant decrease in SH of
enamel samples. Yogurts, teas, mineral waters and coffee,
except for those that were flavoured with acidic additives,
did not have a detrimental effect on enamel SH.
The results highlight the role of acidic additives in increasing erosive capacity of potentially erosive agents. The fruitbased or other acidic flavourings added to ‘plain’ or ‘flat’
drinks and foods, which are intended to stimulate taste, contribute to lower acidity and, consequently, induce erosion.
Yogurt is a good example for demonstrating the effect of
acidic additives. Natural yogurt caused no erosion in spite of
its low pH value (3·91). This can be attributed to its high
(pK 2 pI)HAP resulting from high concentrations of Ca and
Pi. The addition of berries (forest berries yogurt) caused a
clinically not relevant reduction in SH within the second
2 min exposure. Even though this brand had higher Ca and
Pi concentrations than natural yogurt, its pH of 3·77 was too
low for it to be supersaturated with respect to HAP. These
findings are in accordance with other studies(24,25). Similarly,
compared with plain mineral water or tea, flavoured products,
such as Valser Viva Lemon mineral water and rose hip tea, had
much lower pH and negative (pK 2 pI)HAP, and hence caused
a statistically significant reduction in SH. Moreover, it has been
suggested that fruit-based acids might enhance the buffering
capacity(12), which perhaps explains the higher buffering
capacity and titratable acidity for the flavoured liquids (Table
1). Therefore, the above-mentioned flavoured products,
from the chemical composition point of view, should be
classified as soft drinks. Their erosive potential would be
expected to be much closer to erosive drinks than to plain
products(6,26).
The pK 2 pI with respect to tooth mineral, determined by
the pH value and the concentrations of Ca, Pi and F in a
solution, is the driving force for mineral dissolution. When
(pK 2 pI)HAP , 0, the solution is undersaturated with respect
to HAP, which chemically and structurally resembles natural
tooth(27). In acidic media, the value of the ion activity product
for HAP was a good predictor of enamel lesion(28,29). Therefore, this solution may induce demineralisation of the
enamel. When (pK 2 pI)HAP . 0, the solution is supersaturated, so favours remineralisation(30). Previous studies have
observed that (pK 2 pI)HAP plays an important role in tooth
dissolution. A small change in (pK 2 pI)HAP might result in a
marked difference in the dissolution rate of enamel(13,31,32).
As (pK 2 pI)HAP is dependent on pH and Ca and Pi concentrations, it was not included in the multiple regression analysis. However, there was a negative and strong bivariate
correlation between both (pK 2 pI)HAP and (pK 2 pI)FAP
and DSH after both 2 and 4 min. In general, bivariate analyses
may be misleading because possible interactions between
variables are neglected. Interestingly, the concentrations of
Ca, Pi and F alone had a weak correlation with DSH[0],
whereas the pK 2 pI defined by the combination of these
variables (and the pH) showed a strong correlation.
Many studies have demonstrated that pH is a good predictor
of dental erosion: as the pH of the investigated product
decreases, there is an increased amount of erosion, independent of the way in which erosion is measured(22,33). The
buffer properties (buffering capacity or titratable acidity)
have also been considered to be important(5), even more
than pH(34,35), in predicting the erosive potential because it
maintains the Hþ concentration available for the interaction
with the tooth surface(1). The effect of buffering might, however, vary with pH. Because erosive demineralisation takes
place at least partly beneath the enamel surface, buffering
capacity may become increasingly important as pH falls,
since this is accompanied by an increase in dissolution rate.
Consequently, while diffusion may be capable of supplying
sufficient Hþ ions at higher pH (slow dissolution), increased
buffering will be required at lower pH in order to maintain
the supply of Hþ ions(36). However, the relative importance
of pH and buffering properties could depend on factors
such as exposure time and the ratio of the volume of solution
to the area of exposed tooth surface. In an in vitro study using
a low ratio of solution to specimen area, Jensdottir et al.(23)
reported a significant correlation between buffer properties,
titratable acidity, buffering capacity and tooth tissue dissolution after exposure to selected soft drinks for a long time
(24 h), while after a short-term exposure (3 min), erosion
was associated with pH but not with titratable acidity(37).
They speculated, therefore, that titratable acidity was the
better predictor of erosive potential during longer erosive
challenges and pH was better for short challenges. However,
Hara & Zero(7) observed that after 2 h exposure, titratable
acidity showed a low-to-moderate correlation with enamel
demineralisation, while pH value was the best predictor for
erosion. They ascribed this result to the relatively high
260
A. Lussi et al.
Table 3. Multiple linear regression analysis of the changes in surface hardness (DSH) of all specimens after immersion in all agents for 2 and 4 min*
(b Coefficients)
pH
DSH
2
DSH2 – 0 (R 0·52)†
DSH4 – 0 (R 2 0·61)‡
Buffering capacity
Ca concentration
F concentration
Intercept
P
b
P
b
P
b
P
b
P
b
, 0·0001
, 0·0001
2 46·5
2 81·0
, 0·0001
, 0·0001
2 0·5
2 0·6
, 0·0001
, 0·0001
2 1·2
2 2·6
0·0006
0·0055
2 34·2
2 39·9
, 0·0001
, 0·0001
300·3
521·1
British Journal of Nutrition
* P values (b: estimate) are listed for those variables with a significant impact on DSH.
† DSH2 – 0 ¼ SH2 min 2 SHbaseline.
‡ DSH4 – 0 ¼ SH4 min 2 SHbaseline.
volume (30 ml) used in their study. Buffering properties are
likely to be relatively more important when a low volume of
solution is used, as the pH would be raised more easily by
mineral dissolution(7). The dependence of tooth erosion on
both pH value and buffering capacity observed in the present
study, and the lack of a significant effect of titratable acidity
could thus be due to our use of short erosive challenges
and an adequate, well-stirred volume of the test product.
The literature is contradictory with regard to the erosive
potential of acidic drinks and foods containing F(4,5,22). Previous studies have shown that the erosive capacity of different
drinks was significantly and negatively associated with their
original F concentration(4,5). This observation was confirmed
in the present study. In contrast, Larsen & Nyvad(22) reported
that F concentration in eighteen soft drinks had no effect on
the depth of tooth erosion. Furthermore, a study by Larsen
& Richards(38) showed that in drinks with pH above 3, F concentrations reduced the in vitro development of erosion by
28 %; in drinks with pH below 3, erosion was not affected,
despite total F concentrations of 20 parts per million and saturation with calcium fluoride. It is worth noting that in those
studies, severe acid attacks with surface loss was chosen,
while in the present study initial erosion (softening) caused
by various agents was assessed.
A higher concentration of the Ca and/or Pi in a solution will
increase the pK 2 pI with respect to dental mineral, so that the
presence of suitable concentrations of Ca and Pi may counteract tooth erosion caused by acidic drinks and foods. Some
studies have proved that lower levels of enamel demineralisation were found in Ca-containing drinks than in those without
Ca(23,39 – 41). The relatively higher concentrations of Ca and Pi
are most probably responsible for the less erosive effect of Isostar compared with other sports drinks. Isostar does not contain other protective ingredients, such as casein. The results of
multiple linear regression analyses indicated a significant
relationship between Ca concentration and erosion. However,
there was no evidence of a relationship between Pi and tooth
erosion. There are four species of inorganic Pi, namely H3PO4,
22
32
H2PO2
4 , HPO4 and PO4 , in a given solution and their proportions depend on the pH(42). At the pH of erosive drinks
(approximately 2 – 4), only a minute fraction of the total Pi
(of the order of 10213) is in the form of PO32
ions(42),
4
which are the only important Pi species in the ion activity product of HAP and FAP. Therefore, enormous quantities of Pi are
required to raise the degree of saturation of the solution. This
may be the reason why Pi is ineffective in the present study.
The formation of a pellicle with human saliva as well as the
exposure time scale of a few minutes used in the present study
is of particular physiological relevance and clinical interest.
First, this exposure time is comparable with clearance time
of acids in the mouth(23). Second, in the early stage, acids
diffuse into the tooth and remove Ca and Pi from the outer
few micrometres of hard tissues, forming a demineralised,
weakened layer. Remineralisation is possible in this stage,
since the remaining enamel can serve as framework in
which minerals can be deposited again(43).
The present in vitro study, however, cannot totally reproduce the clinical conditions, and should only be interpreted
as a prediction of the relative erosive potential of a dietary
substance or a medication. Erosion is a multifactorial condition, and its occurrence and development depend on
many risk and protective factors as well as on their interplay(44). In addition to the erosive potential of dietary substances and medications, a variety of factors, for example
frequency of acid intake, individual dietary habits (sipping,
gulping, frothing or use of a straw)(45), the physical properties
(the adhesiveness and displacement) of these agents(46), the
flow rate, composition and clearing capability of the saliva,
may influence the progress of tooth erosion(47). However, an
investigation of the parameters associated with the erosive
potential of dietary substances and medications could act as
a significant screening test through which dentists can provide
instructional recommendations for patients at high risk of
dental erosion. In addition, the present study covered a
wide range of tested agents with various chemical and physical properties. Some components in these agents may have an
Table 4. Spearman’s correlation coefficients: all chemical properties v.
the changes in surface hardness (DSH) and the respective P values
DSH2 – 0*
Chemical property
pH
Titratable acidity
Buffering capacity
Ca concentration
Pi concentration
F concentration
(pK 2 pI)HAP‡
(pK 2 pI)FAP§
R
2
2 0·83
0·14
0·04
2 0·27
2 0·13
2 0·11
2 0·75
2 0·70
DSH4 – 0†
P
, 0·0001
0·0006
0·321
, 0·0001
0·0009
0·006
, 0·0001
, 0·0001
R
2
2 0·86
0·16
0·06
2 0·28
2 0·14
2 0·11
2 0·78
2 0·73
pK 2 pI, degree of saturation; HAP, hydroxyapatite; FAP, fluorapatite.
* DSH2 – 0 ¼ SH2 min 2 SHbaseline.
† DSH4 – 0 ¼ SH4 min 2 SHbaseline.
‡ pK 2 pI with respect to HAP.
§ pK 2 pI with respect to FAP.
P
, 0·0001
0·0001
0·154
, 0·0001
0·0005
0·005
, 0·0001
, 0·0001
Erosive effect of dietary substances and medications
influence on salivary pellicle and thus interfere in the correct
assessment of tooth erosion. For example, black tea and red
wine have been shown to have a profound effect on in
vitro pellicle maturation, causing thickened layers of stained
material to build up, which were not readily removed. The
mechanism behind this effect was ascribed to the polyphenols
contained(48). Salivary proline-rich proteins, particularly
basic proline-rich proteins, via the proline rings(49), have a
particularly high affinity for dietary polyphenols(50,51), as do
histatins(52,53).
In conclusion, the present study confirmed the erosive
potential of a wide range of dietary substances and medications. Tooth erosion had a significant relationship with
pH, with buffering capacity, F and Ca concentrations. The
degree of saturation with respect to HAP and FAP, illustrating
the combined effect of these parameters, showed a high
bivariate correlation with tooth erosion.
11.
12.
13.
14.
15.
16.
17.
British Journal of Nutrition
18.
Acknowledgements
The present study was supported by a grant from the Swiss
Society of Odontology (project no. 222-05). A. L. designed
the protocol. B. M. conducted the experiments. X. W., R. P. S.
and A. L. analysed the data and wrote the manuscript. A. L.
had primary responsibility for the final content. All authors
read and approved the final manuscript. None of the authors
reported a conflict of interest. We thank Stefanie Hayoz, Institute of Mathematical Statistics and Actuarial Science, University
of Bern, for the statistical analysis, and also Thiago Saads Carvalho, Faculdade de Odontologia da Universidade de São
Paulo, for the help in the revision of this manuscript.
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