J Dent Hyg Sci Vol. 14, No. 4, 2014, pp.597-609❙ http://dx.doi.org/10.17135/jdhs.2014.14.4.597❙ RESEARCH ARTICLE

A Study on the Enamel Erosion Caused by Energy Drinks

Moon-Jin Jeong, Soon-Jeong Jeong1, Jung-Hui Son2, Sung-Kyun Chung3, A-Reum Kim4, Eun-Ju Kang5, Eun-Ju Kim5, Hye-In Kim5, Ko-Eun Jang5, Min-Hee Cho5, Ye-Ji Cheon5, Hyo-Jung Choi5 and Do-Seon Lim4,5† Department of Oral Histology and Developmental Biology, School of Dentistry, Chosun University, Gwangju 501-759, 1Department of Dental Hygiene, College of Health Science, Youngsan University, Yangsan 626-790, 2Department of Dental Hygiene, Daewon University College, Jecheon 390-702, 3Department of Dental Hygiene, College of Health Science, Shinhan University, Uijeongbu 480-701, 4Department of Dental Hygiene, Graduate School of Public Health Science, Eulji University, Seongnam 461-713, 5Department of Dental Hygiene, College of Health Science, Eulji University, Seongnam 461-713, Korea

시판되는 에너지음료의 법랑질 침식효과에 대한 연구

정문진ㆍ정순정1ㆍ손정희2ㆍ정성균3ㆍ김아름4ㆍ강은주5ㆍ김은주5ㆍ김혜인5ㆍ장고은5ㆍ조민희5ㆍ천예지5ㆍ최효정5ㆍ임도선4,5† 조선대학교 치과대학 구강조직발생학교실, 1영산대학교 보건의료대학 치위생학과, 2대원대학교 치위생과, 3신한대학교 보건과학대학 치위생학과, 4을지대학교 보건대학원 치위생학과, 5을지대학교 보건과학대학 치위생학과

To find out the effect of commercially available energy drinks on tooth enamel erosion, analyzed pH, buffering capacity, and the content of some of the inorganic components selecting 4 energy drinks that has high affinity of the products currently being sold. In addition, by observing the degree of erosion before and after immersion in energy drink by surface microhardness and scanning electron microscope (SEM) the results were as follows: Acidity of energy drink ʻBurn Intenseʼ was the lowest as 2.78±0.01 highest on distilled water as 6.475±0.01. ʻBurn Intenseʼ buffering capacity was 3.48±0.155 at pH 5.5, 1.88±0.15 at pH 7.0 which is the highest, and ʻHot6ʼ was 1.71±0.37, 1.23±0.35 on each of it showing the lowest points. Ca content on energy drink was the highest at ʻVolt Energyʼ as (77.21±2.70 mg/kg), the lowest at ʻHot6ʼ as (0.98±0.05 mg/kg). P content was the highest on ʻHot6ʼ(1.34±0.05 mg/kg) and detected at ʻRed Bullʼ. Enamel surface hardness variation of the energy drinks before and after immersion showed rapid decrease at ʻRed Bullʼ (66.65±35.60), and ʻVolt Energyʼ (61.96±31.42), ʻBurn Intenseʼ (58.53±24.84), ʻHot6ʼ (53.99±60.26) was in order. Distilled water, the control group, showed significant difference with the experimental group (p＜0.05). But there was no significant difference between energy drinks. At SEM observation and analysis, ʻBurn Intenseʼ was the most severe demineralization, ʻVolt Energyʼ, ʻHot6ʼ, ʻRed Bullʼ, distilled water was in order. In the above results, taken together there were no statistically differences between energy drinks but significant difference in comparison with distilled water. In addition, at SEM observation and analysis all energy drink caused dental erosion, especially ʻBurn Intenseʼ, has the lowest acidity, was serious. Thus, it is believed to provide a variety of oral health education and information about energy drinks that can affect the erosion of the teeth so public have the right to be recognized and reasonable dental care.

Key Words: Buffering capacity, Energy drink, Erosion, pH, Scanning electron microscope

Received: November 13, 2014, Revised: December 1, 2014, Accepted: December 1, 2014 ISSN 1598-4478 (Print) / ISSN 2233-7679 (Online) †Correspondence to: Do-Seon Lim Department of Dental Hygiene, College of Health Science, Eulji University, 553, Sanseong-daero, Sujeong-gu, Seongnam 461-713, Korea Tel: +82-31-740-7229, Fax: +82-31-740-7352, E-mail: [email protected]

Copyright © 2014 by the Korean Society of Dental Hygiene Science This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. J Dent Hyg Sci Vol. 14, No. 4, 2014

Introduction On a study about acidic drinks, When often drinks high acid beverage, erosion may cause on enamel17), Attin et Dental erosion and dental caries are typical disease al.18) reported that the enamel loss observed in the causing dental hard tissue damage. Recently, tooth erosion Coca-Cola and orange juice. Birkhed19) said about sport increases have been reported due to the influence of a lot beverage, Brunton and Hussain20) reported tea and herb of acidic drinks. Dental caries means the loss of the tooth tea, and Sim et al.21) reported fermented milk cause dental hard tissue by inorganic acid produced by the oral erosion. Snchez et al.22) said lower pH beverage you drink, bacteria1). Dental erosion means the loss of the irreversible aspect of dental erosion increase. Muller and Gortner23) dental hard tissue due to the chemical action of the acid reported aspect of enamel demineralization may appear without the involvement of bacteria2). differently depending on the pH of the beverage and kinds Dental erosion begins due to the demineralization of the of acid of beverage. Maupome et al.10) said the biggest enamel surface. When abrasion action is added, loss of factor that reduce the strength of the tooth surface when dental hard tissue accelerates and after the dentin is beverage applied to the primary and permanent teeth, if exposed, more severe hemorrhoids get loss. When teeth composition of long-time storage and frequent oral intake weakened by erosion, attrition and abrasion can cause of drinks appear. Also on a study about degree of acidic serious damage if the combination of action2). Dental beverages, concentration of the carbohydrate, Ca and P erosion, caused by frequent contact between the corrosive concentrations, potential of demineralization, product of acid and tooth surface, can be divided to exogenous and the acid, and termination about oral microorganism, endogenous factors by contact path3). Grenby et al.11) reported acid affects more on erosion than Endogenous factors, gastric reflux to stomach through caries and proper pH gives more effect on the erosion than esophagus to cause tooth erosion4-6), could cause serious pH in beverage. Not only was that the fruity or damage when gastric it contacts on tooth because of low carbonate-containing mineral in the water-induced salivary buffering capacity and flow. On exogenous fac- erosion24). tors, frequent intake of acidic foods and drinks7-11), acid On the otherwise, Johansson et al.25) said the longer the oral hygiene products12), and long-term use of acidic retention time of the drink the larger dental erosion drugs13) are the typical examples. In addition, when wo- increases especially carbonated drinks such as cola is rkers of battery factory exposed to sulfuric acid or workers associated on dental erosion. Ahn et al.26) reported when of galvanizing factory exposed to hydracid chloride, primary teeth specimens immersed in acidic beverages dental erosion occurs14). measured by surface micro-hardness reduction in the Among many factors that may cause dental erosion, hourly, surface microhardness decreased like 16.90% after acidic food and beverage is emerging as a new and impor- five minutes, 25.11% after ten minutes, and 41.62% after tant concern. In some advanced industrialized countries, 60 minutes. And among them, the reduction of flavored since dental erosion problem has emerged, it is argued that carbonated beverage was the largest. Also, Lussi et al.7) when acidic beverage consumption has steadily increased, observed surface hardness of personsʼ premolar immersed dental erosion will be more problematic clinically. But for 20 minutes to beverage, when compare a before and various acidic beverage was developed to continue, being after beverage treatment, after the treatment dental erosion able to access more easily, so consumption is increasing caused especially on a drink with a fruit acid. Venables et day by day. Also, it is a big problem that major consumer al.8) and Hooper et al.9) reported the type of beverage that groups are children and adolescents15). It is well known is consumed gives the biggest effect on enamel loss as a that most of the beverage on the market is acid. In Korea, result of attaching the removable device on human tooth on a study of Choi and Shin16), measuring pH of various enamel erosion effect of the drink. In addition, Ahn et al.27) commercial beverage, which is 158 kinds, Most of beve- said on a study of erosion of the enamel surface species of rage, except milk products, showed lower than pH 4.0. soft drinks, the four types of soft drink except for the milk

598 Moon-Jin Jeong, et al：A Study on the Enamel Erosion Caused by Energy Drinks

products, caused demineralization of the tooth surface and concern. But most of the studies have been limited to intensified in accordance with the time of exposure. high-caffeine beverage intake that targets a specific layer Additionally, energy drink which has strong recognize as a of empirical research on youth and energy drinks erode healthy drink due to ads, sparkling water with low acidity, tooth situation is almost incomplete. drinks containing citric acid known to be effective in Therefore, this study was conducted for the purpose of relieving fatigue, and orange juice is reported has a analysis and investigation on the effect of these energy connection with dental erosion24,28,29). drinks on enamel erosion. First of all selects four kinds of Recently, this is a situation that changes in diet and the energy drinks commercially available on domestic, analy- consumption of various types of signs demand for food ze acidity, buffering capacity, and the content of the main increases as per the processing technology improves the inorganic component and measure the surface hardness standard of living and food development. Among them and erosion of the enamel specimens. high caffeine drinks, called ʻenergy drinksʼ have become very popular in teenagers, college students and office Materials and Methods workers. Energy drinks are favorites of candidates, college students, and office workers have been lot of stress cause 1. Experimental materials improve concentration and fatigue effects. They are grow- ing rapidly on domestic and foreign markets30). 1) Tooth and beverage selection Domestic previous studies on energy drinks began in The permanent premolars, did not exceed 2 weeks after earnest at 2003 with research for caffeine-containing extracted for purposes of orthodontics, were observed with foods by Korea Health Industry Development Institute the eye. Second select 75 excepting tooth decay, cracks, status and display system improvement as the center. As fractures, abrasion etc. Finally, immersed in distilled water the beverage market aimed at children expands, the (Daihan Pharm Co., Seoul, Korea) and kept refrigerated. dangers of reckless caffeine ingestion in children with Energy drink used in experiment as an experiment group drinks on the market were reported in children survey on a was four kinds of products have high market share on its drinks with caffeine intake31). In recent years, problems market and distilled water was a control group (Table 1). caused by the increase of young people who consume energy drinks reported, focus of studies moved high 2) Specimen fabrication caffeinated beverages to energy drinks. Intake of energy Put extracted premolar in 5% NaOCl solution for 24 drinks in Seoul middle school students by Ko32), intake of hours, remove the surface of soft tissue, cleaned it on a caffeine drinks with middle school students of Daejeon by distilled water. Cut horizontally at the enamel-dentin Ju33), intakes of functional beverage in Daegu high school junction removing the root, the enamel fragments were and university students by Moon34) have been reported. collected each size of 4×4 mm from 75 premolar crown, Also Kim35) reported on a study of intake of high caffeina- using cutting disc. After that, diameter 10 mm, height 10 ted beverages on youth, correct understanding of the high mm of epoxy resin mold fabricated cylindrical position caffeine and taurine, mixed drinks education is desperately enamel surface is perpendicular to the long axis of the needed to young people. Likewise, many studies have been reported on the situation in after 2013, including a Table 1. Energy Drinks Used in Experiment high intake of caffeine drinks energy drinks. Thus, the supply of various kinds of drinks, both quali- Beverage Manufacturer Hot6 Lotte Chilsung Beverage Co. tative and quantitative expansion has now a lot of people Red Bull Red Bull GmbH Co. consume on a daily basis. In particular, in many cases Burn Intense Coca-Cola Korea Co. growth of children and young people are the main Volt Energy Haitai Beverage Co. consumers of the drinking frequency reached a level of Distilled water (control) Daihan Pharm Co.

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cylindrical and Only exposed enamel surface was em- prior to use for use in maintaining the same pH. Each bedded. To make the flat surface of the exposed enamel beverage was dispensed using the same vessel by 50 ml specimens prepared used by #80, #600, #1,000, #1,500, each drink was induced for 30 minutes soak erosion. #2,000 grit sand paper (Matador, Edinburgh, Germany) on (2) Surface microhardness measurements ground. Specimens, immersed in a drink to recover when the 30 minutes have elapsed, cleaned it with distilled water for 1 2. Experimental method minute. And measured a surface hardness at three adjacent region who measured before treatment areas using surface 1) Analysis of energy drinks micro-hardness tester. (1) Acidity (pH) and the buffering capacity measurement (3) Observation and analysis though a scanning The solution was left at room temperature for 6 hours electron microscope and dispensed 50 ml beaker. After correcting the measured After exposed specimens were washed with distilled value of the pH meter (P25; pH Meter EcoMet, Seoul, water, they were dehydrated with a graded ethanol series Korea), the pH was measured in each group. Buffering for 15 minutes in each step. After that, they were dried capacity is added by 0.1 ml a 1 M NaOH to 50 ml drink with a critical point dryer (HCP-2; Hitachi, Tokyo, Japan). and uniformly mixed with a electronic stirrer and After that, they were coated with platinum in thickness of measuring value of the stabilized pH, measured the NaOH 20 nm by using the ion sputter (E-1030; Hithchi) and amount varies when the pH of the beverage turns 5.5 to observed at 10 kV with a SEM (S-4700; Hitachi). And 7.0. The acidity and buffering capacity three times SEM analysis of the surface roughness, cracking of the measured in the same way by the average value was surface, the expose of the fistula, which was determined in calculated. four of the items of the minerals lost. Roughness of the (2) Calcium, phosphorus concentration measurement surface was determined by the degree of unevenness eye In calcium concentration is Inductively Coupled Plasma- bore, a crack in the surface took on the basis of deter- Atomic Emission Spectroscopy (Optima 7300DV: Perkin mining the presence or absence of holes in the exposed Elmer, Seoul, Korea), the concentration is quantitatively surface of the tooth is determined, the cracks of the tooth analyzed in the Ion Chromatography (Agilent LC-1100 surface fistula. Inorganic dissipation took the wear of the Series; High Performance Liquid Chromatography, Santa teeth on the basis of the judgment. Show how observation Clara, CA, USA). is as follows (Table 2).

2) Surface microhardness measurements 4) Statistical analysis The polished sample is then added to the load of the The paired t-test was used to compare the enamel vertical surface in 10 seconds 200 gm in enamel surface hardness before and 30 minutes after immersion of microhardness meter (HMV-2; Shimadzu, Kyoto, Japan) the enamel specimens into the drink. To compare the per specimen were measured surface microhardness average surface hardness of enamel according to the drink (Vickerʼs hardness number, VHN) in three portions. After, groups, used one-way ANOVA. Dunnett T3 was used for 75 specimens, enamel surface hardness 280∼320, were post-test. Statistical analyzes were analyzed using IBM selected and assigned to each 5 group equally.

Table 2. Scanning Electron Microscope Criteria 3) Test after an immersion and before immersion in Notation Criteria Grade energy drinks － Non observed 0 (1) Immersion on energy drinks ＋ Very little or 1∼5 observation 1 Drink was opened immediately prior to immersion of ＋＋ Intermittently sparse observation 2 the specimen and was used to measure pH immediately ＋＋＋ Whole surface evenly observed 3

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SPSS Statistics 19.0 (IBM Co., Armonk, NY, USA) 2.78±0.01 highest on distilled water as 6.475± 0.01. ʻBurn statistical program. Intenseʼ buffering capacity was 3.48±0.155 at pH 5.5,

Results Table 4. Ca, P Content in Energy Drink (mg/kg) Group Ca P 1. Energy drink analysis Red Bull 1.75±0.06 0.49±0.02 Burn Intense 1.33±0.06 0.41±0.01 Volt Energy 77.21±2.70 ＜0.01 1) Acidity and buffering capacity Hot6 0.98±0.05 1.34±0.05 Four kinds used in the experiment (Hot6 [Lotte Distilled water 8.00±0.01 0.0 Chilsung Co., Seoul, Korea], Red Bull [Red bull GmbH Values are presented as mean±standard deviation. Co., Vienna, Austria], Burn Intense [Coca-Cola Co.,

Georgia, Atlanta, USA], Bolt Energy [Haitai Co., Seoul, Table 5. Change of Enamel Surface Hardness before and after Korea]), energy drinks all of citric acid had been added. Immersion in Energy Drinks (VHN) Acidity of energy drink ʻBurn Intenseʼ was the lowest as Treatment Group n ΔVHN Before (0 min) After (30 min) Red Bull 15 307.96±8.92 241.30±33.89 66.65±35.60* Table 3. Energy Drink Acidity and Buffering Capacity Burn 15 303.52±21.44 244.99±54.64 58.53±24.84* Intense Group pH pH 5.5 pH 7.0 Volt Energy 15 303.97±9.69 242.01±27.77 61.96±31.42* Red Bull 3.63±0.007 3.23±0.49 1.38±0.63 Hot6 15 305.00±14.08 251.02±54.64 53.99±60.26* Burn Intense 2.78±0.01 3.48±0.155 1.88±0.15 Distilled 15 301.94±10.05 300.29±10.21 1.65±2.05* Volt Energy 2.98±0.11 2.91±1.25 1.70±0.115 water Hot6 3.43±0.025 1.71±0.37 1.23±0.35 Values are presented as mean±standard deviation. Distilled water 6.475±0.01 - - VHN: Vickerʼs hardness number. Values are presented as mean±standard deviation. *p＜0.05.

Table 6. Energy Drinks Group Differences the Enamel Surface Hardness after the Immersion (Vickerʼs hardness number) Beverage I Beverage II Average difference (I∼II) Standard error Significance probability Hot6 Burn Intense －4.54667 16.82802 1.000 Red Bull －12.66667 18.07021 0.998 Volt Energy －7.97333 17.54598 1.000 Distilled water 53.24000* 15.55817 0.037 Burn Intense Hot6 －4.54667 16.82802 1.000 Red Bull －8.12000 11.20777 0.997 Volt Energy －3.42667 10.34132 1.000 Distilled water 57.78667* 6.41390 ＜0.001 Red Bull Hot6 12.66667 18.07021 0.998 Burn Intense 8.12000 11.20777 0.997 Volt Energy 4.69333 12.25941 1.000 Distilled water 65.90667* 9.19175 ＜0.001 Volt Energy Hot6 7.97333 17.54598 1.000 Burn Intense 3.42667 10.34132 1.000 Red Bull －4.69333 12.25941 1.000 Distilled water 61.21333* 8.11278 ＜0.001 Distilled water Hot6 －53.24000* 15.55817 0.037 Burn Intense －57.78667* 6.41390 ＜0.001 Red Bull －65.90667* 9.19175 ＜0.001 Volt Energy －61.21333* 8.11278 ＜0.001 *p＜0.05.

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1.88±0.15 at pH 7.0 which is the highest, and ʻHot6ʼ was 2) Ca, P content in energy drink 1.71±0.37, 1.23±0.35 on each of it showing the lowest Ca content on energy drink was the highest at ʻVolt points (Table 3). Energyʼ as 77.21±2.70 mg/kg, the lowest at ʻHot6ʼ as

Fig. 1. Change of enamel surface before and after immersion in distilled water and energy drink (1: distilled water, 2: Red Bull, 3: Hot6, 4: Volt Energy, 5: Burn Intense, A: before immersion, B: after immersion) (×1,000).

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0.98±0.05 mg/kg. P content was the highest on ʻHot6ʼ as ʻHot6ʼ 53.99±60.26 VHN, ʻdistilled waterʼ 1.65±2.05 VHN 1.34±0.05 mg/kg, ʻRed Bullʼ 0.49±0.02 mg/kg, ʻBurn in the order (p＜0.01, Table 5). Intenseʼ 0.41±0.01 mg/kg in the order (Table 4). 3. Energy drinks group differences the enamel surface 2. Variation of enamel surface hardness before and hardness after the immersion after immersion in energy drinks Distilled water, the control group, showed significant Before immersion, enamel surface hardness was 301.94 difference with the experimental group. ʻHot6ʼ was－53.24000, ʻ VHN on distilled water, 303.52∼307.96 VHN on energy Burn Intenseʼ－57.78667, ʻRed Bullʼ－65.90667, ʻVolt drink so there were no significant differences between the Energyʼ－61.21333, all were statistically significant. But groups. But after immersing in energy drink for 30 mi- there was no significant difference between the groups nutes, enamel surface hardness was significantly decrea- (Table 6). sed in all groups compared statistically before immersion (p＜0.01, Table 5). 4. SEM observation and analysis After immersing in energy drink for 30 minutes was the lowest on ʻRed Bullʼ as 66.65±35.60 VHN, ʻVolt Energyʼ 1) SEM observation as 61.96±31.42 VHN, ʻBurn Intenseʼ 58.53±24.84 VHN, Before and after immersion in distilled water was found

Fig. 1. Continued.

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Table 7. Analysis of Enamel Surface after Immersion in Energy Drink Beverage Roughness Crack of surface Exposure of the fistula Mineral loss Red Bull ＋＋＋＋＋＋ Burn Intense ＋＋＋ ＋＋＋ ＋＋＋ ＋＋＋ Volt Energy ＋＋ ＋ ＋＋＋ ＋＋＋ Hot6 ＋ ＋＋＋＋＋＋ Distilled water ＋－＋－

to be flat smooth surface without lost. ʻRed Bullʼ and ʻHot6ʼ as demineralization which starts from by the lower surface observed similar pattern, after immersion due to erosion and formating cavity by the action of acid generated by surface was rough could find fine crack between crystals. microorganism in dental plaque38). On ʻVolt Energyʼ, erosion is worse than ʻRed Bullʼ and Research that acidic fruit juices and drinks cause tooth ʻHot6ʼ recessed fistula was partially observed. On ʻBurn erosion has been reported in the early years. In early Intenseʼ case, compared to all the groups, surface is badly 1970s, since Levine39) reported increase of drinking fruit eroded could observe on all enamel surface crack and juice could be a clinical problems causing dental erosion, round, deep indented fistula (Fig. 1). acidic drinks have been more trend to diversification and the emergence of new consumption surged by various fruit 2) SEM analysis juices and sports drinks. Most of this drinks pH is 2∼4, The control group, distilled water, got 1 point on strong acid40), Rytomaa et al.41) reported critical pH of roughness and fistula, and 0 point in each crack and enamel dissolution occurs is pH 5.5, and acid food that is mineral loss. In the experimental group, ʻBurn Intenseʼ lower than pH 4 is more dangerous could cause more showed the highest point, 3, in all four contents. ʻVolt dental erosion. Gregory-Head and Curtis42) said the Energyʼ, ʻHot6ʼ, ʻRed Bullʼ was in order (Table 7). solubility of teeth increases 7∼8 fold whenever the one (pH 1.0) from the normal pH of the mouth which is pH 6.5 Discussion gets lower. In addition to the factors affecting dental erosion is a drink of flourine, calcium and phosphorus Dental erosion is the gradual loss of tooth hard tissue content as well as the type of acid and titratable acidity. As and generated by the chemical process regardless of the an affect of these factors, dental erosion occurs or may activity of the bacteria. Dental erosion is distinguished cause remineralization43). In this study, pH of the from abrasion and attrition. Attrition is a physical pheno- beverage, buffering capacity, and measured the concen- menon caused by the contact between teeth and abrasion is tration of calcium and phosphorus considering these fac- a pathological phenomenon caused by the abnormal tors. Also except for control group, energy drinks used in mechanical action36). Clinical aspects of dental erosion is the experiment, such as Red Bull, Burn Intense, Volt shown by the number of teeth by bilateral, does not repre- Energy, Hot6, was respectively 3.23, 2.78, 2.98, 3.43 and sent a rough surface or chalk that is accompanied by decal- was consistent with reports of previous investigators, so cification process, lubricant and peripheral surface of the that it can be fully demineralized. enamel is smooth transition to the normal surface is known Like a pH of beverage, buffering capacity is also a that there is no color change37). Also, dental erosion is important variables. Edwards et al.44) defined a buffering caused by direct contact between tooth surfaces and acid capacity as a the nature of the acidic drink to resist change which demineralizes tooth surfaces and without formating in pH. Tahmassebi et al.45) said beverage acidity can be lesions below the surface, enamel rods peripheral places seen in the total amount of the acid is possible, more get softened. In addition, whereas dental erosion is a phe- accurately show the erosion of the actual drink because the nomena at the tooth surface, dental caries is characterized pH of the beverage does not describe as to present only the

604 Moon-Jin Jeong, et al：A Study on the Enamel Erosion Caused by Energy Drinks

undissociated acid value of the hydrogen ion concen- croscopy50). Surface microhardness used in this experi- tration contained in the beverage. Grobler and van der ment is effective to measure the change in the surface Horst46) insisted because of the ability to resist changes in microstructure as a method for indirectly measuring the pH of the beverage by the saliva buffer capacity, the degree of demineralization of the initial lesions. Feather- acidity in the mouth is longer maintained, and thus play an stone and Mellberg1) said on a surface micro-hardness important role in the erosion process. Also, (thus), Cairns measurements are sensitive enough to 50 μm within the et al.47) said in examination of 4 species of drinks, showing depth. Lussi et al.7) immersed a premolar on acidic drink significant resistance on raising the pH is cause of high about 20 minutes to observe a surface hardness before and internal buffering capacity. Larsen and Nyvad48) said it after beverage processing. Reported dental erosion caused could cause more high erosion when acidic drink has after processing, and on other many studies reported a big lower pH or has high buffering capacity. In this study, connection between pH of drinks and dental erosion17,21). evaluated buffering capacity by the amount of NaOH Lee et al.51) said four kinds of surface hardness after needed the pH of the beverage is to reach up to 5.5 and immersion than 10 minutes to drink in the experiment of 7.0. And found out that buffering capacity which was hi- immersing the orange juice that has been reduced from ghest on among 4 species of energy drink was ʻBurn 7.2% to 11.2%. Maupome et al.10) reported about hardness Intenseʼ that has lowest pH to reach pH 5.5 and pH 7.0 variation on a differences in pH beverage treatment times needed NaOH amount was 3.48 ml, 1.88 ml. And most after plaque formated in normal enamel, enamel hardness decreased on surface hardness values after 30min, causing gets lower when 1 day intake frequency increased. more erosion when buffering capacity is high, same results Youn52), on a study of enamel erosion by some com- with Larsen and Nyvadʼs study48). mercial drinks, said showing a large tooth erosion in a There have been many previous studies that the addition mixed drink carbonated beverages group than the group of of calcium and phosphorus in acidic beverages inhibit low pH is considered to be under the influence of drink erosion. Larsen and Nyvad48) reported erision didnʼt cau- drinks there which contained in acid drinks. On Van sed on orange juice which was pH 4.0, added calcium (40 Eygen et al.ʼs coke test53), when immersed for 20 minutes, mmol/L), phosphorus (30 mmol/L). Hooper et al.49) re- 3 times in a day for a week on drinks, and immersed on ported in in situ, erosion inhibits in comparison with a artificial saliva for 1 hour, enamel surface hardness shown control group that calcium and phosphorus are added to to be statistically significant decrease. Also, at Youn et al.ʼs soft drinks has not been added. Based on these findings, it study54), when applied to beverages other than the 10 kinds seems like calcium and phosphorus is a key role on of control group to the normal enamel, enamel surface inhibiting erosion but on this study ʻVolt Energy (77.21 hardness before immersing in drinks has no significant mg/kg)ʼ that contained lot of calcium, ʻHot6 (1.34 mg/kg)ʼ difference, but after 10 minutes immersed in drink that has lot of phosphorus caused a erosion showed a significantly in both the test and control groups was difference with previous studies. These result could in- reduced. On this study, enamel surface hardness before ferred ʻVolt Energyʼ contains calcium but no phosphorus, immersing in energy drink was 301.94 VHN on distilled otherwise ʻHot6ʼ has phosphorus but not substantially water, 303.52∼307.96 VHN on energy drink, has no included calcium so it may be the result of a interaction of significant difference. But after immersing in energy drink calcium and phosphorus. Therefore, studies on the interac- for 30 minutes, enamel surface hardness is decreased by a tion on the calcium and phosphorus corrosion inhibition statistically in all groups compared before immersion and may be necessary in the future. prior studies showed similar results, but the difference in On the otherwise, a method for analyzing the state of materials and methods. tooth erosion usually used surface microhardness, SEM, Scanning electron microscopy is shaping the surface microradiography, digital image analysis, chemical analy- structure of the sample image which can be seen by an sis, iodine permeability measurements, atomic force mi- optical microscope at a much higher resolution by using an

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electron beam. It is possible to see the fine region having a between 1∼2 points with a view to fine cracks between size smaller than the wavelength of visible light through the crystal surface was slightly rough, because of the the electron beam is focused by a magnetic lens55). In erosion. But on a ʻVolt Energyʼ, erosion was hard than ʻRed addition, through the image that has taken from SEM, Bullʼ and ʻHot6ʼ, partially recorded the recessed average since analysis or useful to measure the feature cannot be two-point which is fistula observed. Especially, ʻBurn seen with an optical microscope was used in this study. On Intenseʼ, Average three points are badly eroded surface a study of erosion of enamel by some commercial drinks, compared to all groups was observed in the form of a Youn52) said mixed drink groups and soft drink groups of rounded and deeply indented fistula enamel cracks normal enamel and artificial carious enamel showed a lot throughout the first half. of rough surface due to erosion, decisions have been The most effective way to prevent dental erosion is to arranged very irregularly observed in finely crushed form. reduce the chance of contact with acid. Also, to reduce On this study, except for a case of immersed in distilled oral residence time and the frequency of acidic food intake water, control group, all experiment group, energy drink, and to increase the salivary flow rate may help reduce showed erosion similar with Youn52) result at ʻBurn erosion. These tooth erosion due to increased food should Intenseʼ which has highest pH. Grando et al.56) said on a be placed on prevention rather than treatment emphasis. case of immersed enamel on 12 hours at soft drink groups, Tell hazards and should promote an acidic beverage ever could find out destroy of sheath and head of enamel rod, developed alternative beverages to reduce the intake of and sulcus between enamel sheath and head. But on this acidic foods. Especially the children, while remaining to study, couldnʼt find sheath and head of enamel rod after prevent the intake of drinking water in the mouth for a immersion on enamel drink. The previous studies are long time thought to be, above all, it is important to be thought to have occurred less erosion because of ob- educated27). serving the surface of the immersion will constantly Taken together, the above results between energy drinks immersed for 12 hours soda. This study was for a short there was no statistically significant difference, but show- time of 30 minutes in the energy drink. On a Eisenburger ed a significant difference when compared with distilled et al.ʼs study57), 3% citric acid solution and then immersed water. Also became a cause tooth erosion in all energy for 2 hours in a result of observation by SEM, there was drinks in a scanning electron microscope observation and irregular crystals which were arranged in a predetermined analysis, especially in the most severe erosion was ob- direction and determination of the type that a flat carpet served with the lowest pH, Burn Intense. Therefore, it is was looked for covering the surface aspect. In case of considered that the general public for energy drinks that energy drinks in the present study, there was rough and can affect the tooth erosion to provide various oral health irregular crystal which is aligned in a predetermined education and information in order to have the proper direction with a fine crack and forms of decision-toed soap recognition and reasonable dental care. bubbles are showing similar results and aspects covering the whole surface. Summary On the otherwise, Kim58) said Coca-Cola, when orange juice and sports drinks after analysis of the enamel surface To find out the effect of commercially available energy treatment using SEM, Roughness, exposure and mineral drinks on tooth enamel erosion, analyzed pH, buffering loss of fistula appears two or more points in all groups on a capacity, and the content of some of the inorganic com- experimental study about influence carbonated beverage ponents selecting 4 energy drinks that has high affinity. In intake on tooth. The surface both before and after im- addition, by observing the degree of erosion before and mersion in distilled water was evaluated by the flat smooth after immersion in energy drink by surface microhardness points where no lost, also on this study. But on a case of and SEM the results were as follows. ʻRed Bullʼ and ʻHot6ʼ, energy drinks are then immersed 1. Acidity of energy drink ʻBurn Intenseʼ was the lowest

606 Moon-Jin Jeong, et al：A Study on the Enamel Erosion Caused by Energy Drinks

as 2.78±0.01, highest on distilled water as 6.475±0.01. 0.05), 에너지음료 간에는 유의한 차이가 없었다. ʻBurn Intenseʼ buffering capacity was 3.48±0.155 at pH 4. 주사전자현미경 관찰 및 분석에서는 번인텐스에서 탈 5.5, 1.88±0.15 at pH 7.0 which is the highest, and ʻHot6ʼ 회가 가장 심한 것으로 관찰되었으며, 그 다음으로 볼트에 was 1.71±0.37, 1.23±0.35 on each of it showing the 너지, 핫식스, 레드불, 증류수 순으로 나타났다. lowest points. 이상의 결과에서 정상법랑질에서도 pH가 낮거나 구연산 2. Ca content on energy drink was the highest at ʻVolt 을 함유한 에너지음료 섭취는 치아 표면경도를 감소시켜 치 Energyʼ, the lowest at ʻHot6ʼ. P content was the highest on ʻ 아손상을 악화시킬 수 있을 것으로 생각된다. Hot6ʼ and detected at ʻRed Bullʼ. 3. Enamel surface hardness variation of the energy Acknowledgements drinks before and after immersion showed rapid decrease at ʻRed Bullʼ, and ʻVolt Energyʼ, ʻBurn Intenseʼ, ʻHot6ʼ was This study was supported by research fund from Chosun in order. Distilled water, the control group, showed University, 2014. significant difference with the experimental group (p＜ 0.05). But there was no significant difference between References energy drinks. 4. At SEM observation and analysis, ʻBurn Intenseʼ was 1. Featherstone JD, Mellberg JR: Relative rates of progress of the most severe demineralization, ʻVolt Energyʼ, ʻHot6ʼ, artificial carious lesions in bovine, ovine and human enamel. ʻRed Bullʼ, distilled water was in order. Caries Res 15: 109-114, 1981. In the above results, low acidity or containing citric acid 2. Imfeld T: Dental erosion, definition, classification and links. energy drink intake on normal enamel could reduce the Eur J Oral Sci 104: 151-155, 1996. hardness of the tooth surface able to deteriorate the tooth 3. Jarvinen VK, Rytomaa II, Heinonen OP: Risk factors in damage. dental erosion. J Dent Res 70: 942-947, 1991. 4. Meurman J, Toskala J, Nuutinen P, Klemetti E: Oral and 요 약 dental manifestations in gastroesophageal reflux disease. Oral Surg Oral Med Oral Pathol 78: 583-589, 1994. 본 연구는 시판중인 에너지음료에 의한 치아 법랑질 침 5. Rebecca M, David B, Angela A: Dental erosion gastroeso- 식효과를 알아보기 위하여 선호도가 높은 4종의 에너지음 phageal reflux disease and saliva: how are they related? J 료를 선정하여 산도, 완충능 및 Ca, P 함량을 분석하였다. 또 Dent 32: 489-494, 2004. 한 에너지음료 침지 전ㆍ후의 법랑질의 침식 정도를 표면미 6. Moazzez R, Bartlett D, Anggiansah A: The association of 세경도와 SEM으로 관찰하여 다음과 같은 결론을 얻었다. acidic reflux above the upper oesophageal sphincter with 1. 에너지음료의 산성도는 번인텐스에서 2.78±0.01로 가 palatal tooth wear. Caries Res 39: 475-478, 2005. 장 낮았고 대조군인 증류수에서 6.475±0.01로 가장 높았다. 7. Lussi A, Jaeggi T, Jaeggi-Scharer S: Prediction of the erosive 완충능은 번인텐스가 pH 5.5에서 3.48±0.155이고, pH 7.0 potential of some beverages. Caries Res 29: 349-354, 1995. 에서는 1.88±0.15로 가장 높게 나타났고, 핫식스에서 각각 8. Venables MC, Shaw L, Jeukendrup AE, et al.: Erosive effect 1.71±0.37, 1.23±0.35로 가장 낮게 나타났다. of a new sports drink in dental enamel during exercise. Med 2. 에너지음료의 칼슘 함유량은 레드불(77.21±2.70 mg/kg) Sci Sports Exerc 37: 39-44, 2005. 에서 가장 높게 나타났고 핫식스(0.98±0.05 mg/kg)에서 가 9. Hooper S, West NX, Sharif N, et al.: A comparison of enamel 장 낮게 나타났다. 인의 함유량은 핫식스(1.34±0.05 mg/kg) erosion by a new sports drink compared to two proprietary 에서 가장 높게 나타났고, 레드불에서는 검출되지 않았다. products: a controlled, crossover study in situ. J Dent 32: 3. 에너지음료 침지 전ㆍ후의 법랑질 표면경도 변화는 레 541-545, 2004. 드불에서 가장 큰 감소가 나타났고, 다음으로 볼트에너지, 10. Maupome G, Aguilar-Avila M, Medrano-Ugalde HA, 번인텐스, 핫식스 순으로 나타났다. 대조군과 모든 에너지 Borges-Yanex A: In vitro quantitative microhardness asse- 음료 간에는 통계적으로 유의한 차이를 나타냈으나(p＜ ssment of enmel with early salivary pellicles after exposure to

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