Wine, Alcohol, and Oral Health, with Special Emphasis on Dental Erosion

Wine, alcohol, and oral health, with special emphasis on dental erosion

Jukka H. Meurman, MD, PhD, Dr OdontVMaarit Vesterinen, DDS^

Wine ¡s an essenfial component of the Mediferranean diet. Its consumpfion is increasing in many indusfrialized countries due fo effecfive marketing. Wine may also have etfecfs in the orai cavify mainly due fo Its acidity and alcohoi contenf. This article brieliy describes some effects of wine, both bénéficiai and detnmentai, on oral and gênerai heaifh. In particular, fhe effect cf wine on toofh enamel is demon- sfrafed, (Quintessence int2000:31-.729-733)

Keywords: alcohol, dental erosion, oral health, wine

the application of 70% ethanoî directly on oral CLINICAL RELEVANCE: Wine is claimed fo have benefi- mucosa has been shown to cause epithelial desquama- cial effecfs on heaifh. Regular consumpfion of wine may tion in the rabbit- and hamster,^ Alcohol is a signifi- reduce cardiovascular disease morbidify. However, most cant risk factor of oral cancer'' and may also play a wines are acidic and may cause dental erosion, Aiso, alco- role in the etiology of oral leukoplakia. Although holic pafients suffer from a variety of metabolic problems ethanol itself has not been shown to be carcinogenic, fhat may affect dental treatment. Particularly, bleeding dis- many alcoholic drinks contain carcinogens,^ Alcohol orders are common and should be taken into account. seems to mediate or transport carcinogens through the epithelium, and the additive effect of alcohol and tobacco is well established in this respect,"'* ost health effects of wine are related to its alco- Recently, a new hypothesis was presented to Mhol content. By definition, alcoholic beverages explain the pathogenic mechanisms behind alcohol- are drinks that contain tnore than 2,8°''o ethanol. Wines associated carcinogenesis in the upper gastrointestinal contain %% to 14% alcohol, France leads the eonsump- tract, Acetaldehyde, a toxic and carcinogenic metabo- tion rate with an annual figure of 10,9 L/capita of lite of alcohol, has been sbown to be metabolized in 100% alcohol, while the respective annual consump- high levels by oxidation of ethanol by the oral tion rate of pure alcohol in the United States is 6,6 microflora,^ This may increase the production of L/capita- In the US,' 7,4 L of wine and 38,2 L of beer acetaldehyde by mucosal alcohol dehydrogenase, is being consumed per person each year. Use of alco- which is thought to play a key role in alcohol-associ- hol affects orai health in many ways. ated carcinogenesis,'" Future research will show whether poor orai hygiene, whicb is strongly linked with alcohol abuse and oral cancer, migbt contribute to carcinogenesis. Therefore, maintaining good oral ALCOHOL AND ORAL MUCOSA health should be emphasized, even in this scenario. The association of alcohol with oral mucosal pathol- ogy is well known. Concentrated alcohoi solutions cause a chemical burn in the mucosa. For example. WINE AND CORONARY HEART DISEASE Wine is also known to exert beneficial health effects, which are strongly emphasized in its global marketing. In particular, moderate but frequent consumption has 'Protessor, University of Helsinki, Helsinki, Finland, been shown to lower tbe incidence of coronary heart ^Post graduate sfudent. University ot Heisinki, Helsinki, Finland. disease (CHD)," Tbis is thought to be due to the Reprinf Requesls; Dr Jukka H, Meurman, Universify of Helsinki, PB 41 ethanol content of wine, which increases HDL choles- (Mannerheimintie f72¡, FIN-O00f4, Heisinki, Finland, E-mail: terol and decreases platelet reactivity.'^ Recently, Jukka,Meurman @ Helsinki,R

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TABLE 1 Carbohydrate content and pH of TABLE 2 The tested wines and their characteristics different alcoholic beverages Acid Phosphate Alcoholic beverage Carbohydrate content (%) pH Type and Country content content brand name of origin pH (mEq/L) {|jg/mL) Beer 3,0-5.0 4,1-4.5 Wine 0.0-12.0 2.8-3.8 Dry white wine, Italy 3.16 84 440 Sweet liquor 30 0-31.0 3.3-3.9 Soave Bol i a Strong aioohol 0.0-1.2 6,5-6.9 Berry wine, Finland 3.29 63 340 Karativihedelmaviini Sv^eel wnite vjine. Chile 3 29 89 2010 Late Harvest Sauuignon Bianc Red wine. Spam 3.40 75 960 Sangre de Toro

de Lorgerii and Salen'' reported a linear correlation of wine is associated with the risk of dental ero- hetween the consumption of wine and plateiet aggre- sion,"-" tcoth discoloration,^''^^ and dentin hypersen- gation in men with CHD following a Western-type sitivity.^^ Alcoholics, in particular, have been reported diet. A negative correlation was found atnong those to be prone to erosion as a resuh of frequent vomiting following the Mediterranean diet with a low intake of and consumption of acidic drinks.^-' Professional wine saturated fats and a high intake of omega-3 fatty acids tasters have been examined, and tbe prevalence of and antioxidants. The platelet aggregation was thought erosion appears to correlate significantly to the num- to be low in the Mediterranean group particularly ber of years spent in that profession,-^ The mechanism hecause of the diet and in the Western group because by whicb wine causes erosion is linked to its acidity. of wine. The antioxidant content of red wine, Caries, however, does not seem to be associated with flavonoids in particular, has often been cited when tbe consumption of wine, although alcoholics tend to discussing the health-promoting cbaracteristics of have a higher incidence of caries than the general moderate consumption."-'*' population,^*' This, however, may be due to neglected daily oral hygiene and metabolic disturbances in salivary buffering ratber tban to tbe nature of the drinks SYSTEMIC EFFECTS OF ALCOHOL ABUSE consumed. Table 1 gives tbe carbohydrate contents and pH vaiues of sornc commonly used alcoholic bev- Hématologie disorders and nutritional imbalances erages. Frequent use of sweet liquor also increases tbe caused hy chronic alcohoi use have severe implica- risk of caries. tions in oral health partly because of the systemic effects. Alcohol is to.xic to hematopoiesis and func- tions of the liver. If the daily consumption is > 80 g EROSION EXPERIMENT ethanol, anemia and/or megaloblastic bone marrow alterations are seen in 20% to 30% of tbe cases, and We tested tbe erosive effect of 4 different types of wine sideroblastic anemia develops in 30% to SO^/o of alco- on enamel using an in vitro model system on extracted holics.'' Alcohoi-caused malfunctions and diseases of buman teeth. Tbe metbod bas been described by the liver decrease serum fibrinogen concentration and Sorvari et aF' and Meurman et al.=* Immediately after thrombocyte counts with resulting bleeding problems. extraction, the test teeth were mechanically cleaned and It is obvious tbat these disturbances affect oral health put into 60% propanol. A total of 30 enamel blocks, 3 in many ways and also eomplicate the treatment of X 3 mm, was prepared by using a diamond saw in a certain patients, whose surgical intervention must be dental bandpiece. The specimen surfaces were ground carried out with caution. The decreased resistance to even with 300 to 600 grit sandpapers, rinsed in distilled infection, such as periodontal disease, must be taken water, air dried, and checked under a stereomicroscope into account when treating alcoholic patients.'* to choose sound and even surfaces for the experiment. The specimens were stored in a refrigerator at 4°C. Freshly purchased bottles of wine that had been WINE AND DENTAL HEALTH bottled in 1997 were used. The pH of cacb wine was measured, and the buffering capacity was assessed by There are no reported beneficial effects of wine titration of 50 mL of each wine with 0.1 mol/L sodium regarding dental bealtb. On the contrary, consumption hydroxide until pH 7.0 was reached (Table 2).

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Fig 1 Scanning electrón, micrograph (SEM) siiowmg distincliy Fig 2 Enamel specimen alter 30-mmute immersion in red wine eroded enamel surtace and characteristic honey-combed struc- Siighliy eroded surface is visibie. ture afier 30-minute immersion ol study specimen in dry white wine.

Fig 3 Eriamei specimen afier 30-minute immeision in sweet Fig 4 Enamei specimen after 30-minute immersion m be'ry vjine while wine Slightly eroded surface is visible Slightly eroded suriace is visibie. Bar = 20 pm. The scale relates to Figs 1 !o 4.

The enamel specimens were sonicated for 5 minutes ance of honey-combed surfaces. Examples of SEM in distilied water and randomiy placed into 5-mL findings are shown in Figs 1 to 4. aiiquots of the wines, with 6 specimens in each \vine. The release of phosphate due to dissoiution of Six additional specimens were left intact for controls. enamel caused by the wines is shown in Fig 5. There The irrmiersion times in each wine were 15, 30. and 60 was no statistically significant difference between the minutes, and the experiment was carried out on a mix- wines in this respect. ing tabie at 20°C. After the immersion, specimens were Ail the wines tested were potenfiaiiy erosive, but dif- rinsed again in distilled water and prepared for scan- ferences hetween the various types of wines did exist. ning electron microscopy (SEIVl) using critical-point The highiy acidic dry white wine appeared to be most drying and platinum sputtering methods. The specimens detrimental to teetii in tiiis series. Finally, it should be were then investigated in a Zeiss Digitai SEM 962 oper- emphasized that no protective factors such as saliva ating at 10 kV accelerating voltage. were used in the model system. Thus, in reality, the The phosphate content of each test wine was ana- erosive effect of wine may not be as strong as shown lyzed before and after the erosion experiment. The here. Saliva is known to modify erosion by causing the Fiske-Subbarow method was tised, and the results formation of an enamel pellicle, which protects the were analyzed statistically. surface from dissolution." Nevertheless, the present The results showed ali the wines to cause erosion ohservations give an explanation for why professional after 30 minutes of immersion, but only tbe dry white wine tasters who frequentiy keep wine in their mouths wine caused erosion at 15 minutes. In all of the develop gross erosion after a iengthy tasting career." severely eroded specimens, the lesions characteristi- These extreme cases should also be kept in mind when cally reveaied enamel prism structures and the appear- counseling wine lovers about oral health. In alcoholics.

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Fig 5 Release of phosphate i^oi^, ^«n m^niUer'" mens after immersion in wines for Jp » °^

•*• Dry white wine i -*- Barry wine -e- Sweet white wine -Û- Red wine

45 Time (min)

frequent vomiting and alterations in saliva add to the Franco EL, Kowalski LP, Oliveira BV, Pereira RN, Silva risk of dental erosion, when not only the extrinsic but ME, Fava AS, Torloni H, Risk factors for oral cancer in Braïil: A case-control study. Int J Cancer 1989;43: also the intrinsic causes of erosion challenge the dental 992-1000. health of these patients. Cawson RA, Eweson JW. Oral patiiology and diagnosis. Heinemann: London, 1987:136-137 Eiwood JM, Pearson JCG, Skippen DH, Jaeson SM, CONCLUSION Aicohol, smoking, sociai and occupationai factors in the aetioiogy of cancer of the oral cavity, pharynx and iarynx, Int J Cancer 1984;34:603-612, Although alcohol may have beneficial effects on general health, particularly regarding CHD, the detrimen- Squier CA, Cox P, Haii BK. Enhanced penetration of nitro- sonornicotine across oral mucosa in the presence of tal effects on mouth mucosa and dental hard tissue etbanoi. J Orai Pathol 1986:15:276-279, must be emphasized in oral health care. Alcohol is sta- Squier CA, Lesch CA. Penetration pathways of different tistically linked with the development of oral cancer, compounds through epidermis and orai epithelia, J Oral and all acidic beverages, including alcoholic beverages Pathol 1988:17:512-516, like wine, are potential risk factors of dental erosion. Homann N, Jousimies-Somer H, Jokelainen K, Heine R, Therefore, dentists should be alert because of the Saiaspuro M High acetaldehyde levéis in saliva after increasing consumption of wine among the public. ethanol consumption: Methodological aspects and patho- Wine is becoming a common lifestyle factor because genetic implications. Carcinogenesis 1997:18:1739-1743, of effective marketing in countries other than the tra- Joiíelainen K, Heiititonen E, Roine R, Lehtonen H, Saiaspuro M, increased acetaldehyde production by mouth- ditional wine-producing countries. Dentists, liiie washings from patients with oral cavity, laryngeal or pKa- physicians, should use every opportunity to educate ryngeal cancer. Alcohol Ciin Exp Res 1996;20:1206-1210, patients about the risks of alcohol use and abuse,^" Rimm EB, Eilison RC, Alcobol in tbe Mediterranean diet. Am J Clin Nutr 1995;61:1378--1382. Meade TW, Vickers MV, Thompson SG, Stirling Y, Miller REFERENCES GJ, Epidgmiological characteristics of platelet aggregability, Br Med J 1985;290:428-432, 1. World Drinii Trends, Madison, Wl: Nationai Institutes of de Lorgcril M, Salen P, Wine etbanoi, platelets, and Healtii, NTC Publications, 1998, Mediterranean diet. Lancet 1999:353:1067 2. Müiler P, Hepiie B, Meldan V, Raabe G, Tissue damage in Puddley IB, Croft KD, Abdu-Amsha Caccetta R Beilin LI the rabbit oral mucosa by acute and chronic direct tosic Alcohol, free radicals and antioxidants, Novartis Found action of different alcohol concentrations, Exp Patiiol 1983; Symp 1998;2ie:51-62, 24:171-181, Soleas GJ, Diamandis EP, Goldberg DM, Wine as a bioiogi- 3. Margarone JE, Thines TJ, Drinnen AJ, Ciancio SG. The cal fluid: History, production, and role in disease preven- effects of alcohoi and cetyipyridinium chioride on tbe buc- tion, J Clin Lab Anal 1997;11:287-313. cal mucosa of the hamsters. J Orai Maxiliofac Surg 1984; 16. Heller FR, Descamps O, Hondekijn JC. LDL oxidation: 42:111-113, Therapeutic perspectives. Atherosclerosis 1998;137:25-31,

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17, Weksler BB, Moore A. Hematology. In: Andreoli IE, 24, Smith BG, Robb ND. Dental erosion in patients with Carpenter CCJ, Plum F, Smith LH ¡eds]. Philadelphia; chronic aleoholism, ] Dent 1989;17:219-221, Saunders, 1990:398-402, 25, Wiktorsson AM, Angmar-Mansson B. Erosive tooth wear: IS. Novacek G, Piachetzky U, Potzi R, Lentner S, Slavicek R, Prevalence and severity in Swedish winetasters. Eur J Oral GangI A, Ferenei P. Denta! atid periodontal disease in Sei 1997;105:544-550. patients with eirrhosis-role of etiology of hver disease 26, Hede B. Determinants of oral health in a group of Danish J Hepatol 1995;22:576-582. alcoholics. Eur J Oral Sei 1996;104;403-408, 19. Gray A, Ferguson MM, Waii JG. Wine tasting and dental 27, Sorvari R, Meurman JH, Prank RM, Effects of fluoride var- erosion. Case report. Aust Dent J 1998,43 32-34. nish and solution on enamel erosion in vitro. Caries Res 20. Ferguson MM, Dunbar RJ, Stnith |A, Wail JG. Enamel ero- 1994;28:227-232. sion related to wiremaking, Occup Med 1996;46;159-162, 28, Meurman JH, Sorvari R, Pelttari R, Rytömaa I, Franssila S, 21. Scguurs AH, Abraham-lnpiju L, van Straalen ]P, Hospital mouth-cleaning aids may cause dental erosion. Sastrowijoto SH, An usual case of black teeth. Oral Surg Spec Care Dentist 1996;16;247-250. Oral Med Oral Pathol 1987;64:427-431. 29, Meurman JH, Frank RM. Scanning electron microscopic 22. Oikarinen KS, Nieminen TM. Influence of acid-etched study on the effect of salivary pellicle on enamel erosion. splinting methods on discoloration of dental enamel in fuur Carles Res 1991:25;l-6. media: An in vitro study. Scand J Dent Res 1994;102 30, Bradley KA, Merrill [O. Doctor, is wine good for my heart? 313-318. Lancet 1999;353:1S15-1816, 23. Addy M, Ahsi EG, Adams D. Dentine hypersensitivity. The effects in vitro of acids and dietary substances on root- planed and hurred dentine. J Ciin Periodontol 1987;14: 274-279. HARVARD survives the test of time

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