28 BrJ Sports Med 1997;31:28-30 Original articles Br J Sports Med: first published as 10.1136/bjsm.31.1.28 on 1 March 1997. Downloaded from Sports drinks hazard to teeth A Milosevic Abstract from extrinsic sources within the diet or from Objective-To determine the dental haz- intrinsic gastric acid being brought "back ards associated with sports supplement up"-for example, gastric reflux, self induced drinks by investigating the chemicophysi- vomiting in bulimia nervosa.' Low pH extrinsic cal properties of eight brands of sports dietary sources are fresh citrus fruits or their drinks. fruit juices, acidulated carbonated beverages, Methods-The pH and titratable acidity and sports supplement drinks, many of which against O.lM NaOH was measured. Cal- contain citric acid. Meurman et al' reported cium, phosphate, and fluoride concentra- that nine out of 13 sports drinks contained cit- tions and viscosities of Carbolode, ric acid, two contained malic acid, and two Gatorade, High Five, Isostar, Lucozade contained an unknown acid. Furthermore, the Sport Lemon, Lucozade Sport Orange, citric acid based drinks were more erosive than Maxim, and PSP22 were determined. the malic acid containing drinks, the erosion Results-The pH values of the drinks being inversely related to the pH of the drink. ranged from 4.46 (Maxim) to 2.38 (Iso- However, the titratable acidity was believed to star) and therefore were below the critical be a better indicator of erosive potential, pH value (5.5) for enamel demineralisa- because this indicates the total amount of H' tion. Both Lucozade varieties had high able to dissociate rather than just the H' titratable acidities (16.30 ml 0.lM NaOH concentration of the solution.34 The degree of to neutrality) with Gatorade, High Five, saturation of calcium, phosphate, and fluoride and Isostar displaying intermediate titrat- in the drinks with respect to tooth mineral will http://bjsm.bmj.com/ able acidity, although Isostar had 74.5 also influence erosive potential.' Furthermore, ppm calcium and 63.6 ppm phosphate. the more adhesive or "stickier" the drink to the The fluoride concentration of all drinks tooth, the greater the propensity for erosion to was low, and none of the drinks was occur, although Lucozade Sport Orange was particularly viscous (range 3.1-1.4 reported to exhibit the lowest adhesion to mPa.s). enamel when compared with blackcurrant Coca and natural orange Conclusions-The chemicophysical analy- squashes, Cola, on September 30, 2021 by guest. Protected copyright. ses indicate that all the sports drinks in this juice. study have erosive potential. However, All the monosaccharides (including glucose drinks with higher pH, lower titratable and fructose) and disaccharides (including acidity, and higher concentrations of cal- sucrose, maltose, and lactose) are highly cium, phosphate, and fluoride will reduce cariogenic. Therefore, since the sports supple- this erosive potential. ment drinks are mainly carbohydrate (usually (BrJSports Med 1997;31:28-30) glucose, maltose, or dextrose), dental decay may be potentiated in sports men and women Keywords: caries; dental erosion; sports drinks. who do not maintain a good standard ofplaque control with frequent use of fluoride tooth- paste. Sports drinks had the same cariogenicity as fruit juice and carbonated beverages.7 How- The regular and frequent use of sports supple- ever, levels of decay were not significantly Department of Clinical ment drinks by sports men and women can different between a group of Swedish school Dental Sciences, The potentially lead to increased caries experience athletes and a non-athletic control group.7 The School of Dentistry, (dental decay) and to dental erosion. Dental effect that these sugars and organic acids may The University of decay is a disease caused by dental plaque, a have on the dental health of sports men and Liverpool, Liverpool bacterial film on the tooth surface, which women has received scant attention in the Brit- L69 3BX, United ish dental or sports literature. The Medline Kingdom ferments carbohydrates, thereby producing A Milosevic acidic byproducts of metabolism such as database did not have one reference with the lactate, acetate, propionate, and formate. keywords sports drinks, caries and erosion Correspondence to: Major loss of tooth mineral normally occurs from 1990 up until the end of 1995. A Milosevic. below the pH value of 5.5. Dental erosion, on The clinical presentation of an athlete with not since and the and Accepted for publication the other hand, does involve bacteria, dental erosion is described, pH 1 1 September 1996 the erosion is caused by the inherently low pH titratable acid, the calcium, phosphate, and Sports drinks hazard to teeth 29 incisal edge of his top front teeth which were also slightly sensitive (fig 1). The medical Br J Sports Med: first published as 10.1136/bjsm.31.1.28 on 1 March 1997. Downloaded from history was clear, the subject being a marathon and cross-country runner. Dental examination revealed minor erosion of the upper teeth on many surfaces, but extensive erosion through to the dentine on the palatal (inside) surfaces of the upper central incisors (fig 2). These teeth are ridged at the point where enamel meets the eroded and thinned dentine body of the crown. This ridge was bothersome to the subject. Oral hygiene was good, with few filled teeth indicating a moderate level of past caries experience. Questioning the athlete revealed regular consumption of sports supplements for over one year, and he also drank carbonated mineral water in order to quench his thirst. A five day fluid intake record showed that hot beverages were rarely consumed, the subject preferring fresh fruit juice and carbonated bev- Figure 1 Labial view of upperfront teeth. Note the loss of the incisal edges of the central erages. Although the subject did not compete incisors. during the five days, he did drink a popular brand of still isotonic sport drink from a pouch after three training sessions. Methods The chemicophysical properties of six varieties of freshly made sports supplement drinks at 10% concentration were analysed. A further two sports drinks, Lucozade Sport Orange and Lemon were analysed directly from the pouch. The titratable acidity was determined against 0.1 M NaOH to the neutral end point with phenolphthalein as indicator. The pH was measured with a calibrated pH meter and fluo- ride concentration with the fluoride specific ion electrode (Orion Research Inc). A Perkin- Elmer atomic absorption spectrophotometer http://bjsm.bmj.com/ with a nitrous oxide/acetylene flame was used to measure calcium concentration, and phos- phate was measured by the standard chemical technique of Murphy and Riley.8 Figure 2 The palatal view ofthe upperfront teeth. A ridge is present between the Viscosity analyses on 8 ml drink samples relatively intact enamel near to the gum margin and the thinned eroded body of the crown. were made with the model DV-1 Brookfield digital viscometer (Brookfield Engineering fluoride concentrations, and the viscosity (as a on September 30, 2021 by guest. Protected copyright. measure of adhesiveness) of several popular Labs Inc., Stroughton, MA, USA). Spindle varieties of sports supplement drinks were rational speed was set at 60 rpm as per manu- determined. Advice regarding "safer" drinks facturer's instructions at a shear rate of 1.32 N. and caries/erosion-reducing behaviour is also Constant viscometer readings were obtained given. after a few minutes, and this value was multiplied by the recommended factor for speed/spindle combination. All analyses were Case report made at the ambient room temperature. A 23 year old man was referred to the author by a local dental practitioner. The patient Results complained of the poor appearance of the Table 1 shows the chemicophysical properties of eight varieties of sports supplement drink. Table 1 Chemicophysical properties of 10% concentrations ofsports supplement drinks at 200 C Discussion Titratable acid All the sport drinks had pH values lower than (ml 0. JM NaOH Calcium Phosphate Fluoride Viscosity Sports drink pH to pH 7) (ppm) (ppm) (ppm) (mPa.s) the value of 5.5, below which enamel deminer- alisation mainly occurs. The titratable acidity Carbolode 3.74 1.80 0.22 0.00 0.01 2.5 varied from 16.30 ml of 0.1M NaOH for Gatorade 3.05 10.70 0.98 104.00 0.01 1.4 High 5 2.52 7.85 3.00 1.10 0.01 1.7 Lucozade Sport to 0.30 ml 0.1M NaOH for Isostar 2.38 8.50 74.50 63.60 0.05 1.4 Maxim. Lucozade Sport is ready to drink from Lucozade Sport Lemon 3.05 16.30 21.00 3.45 0.04 3.1 a pouch, whereas all the other drinks were in Lucozade Sport powdered form and subsequently mixed with Orange 3.05 16.30 25.00 12.65 0.03 2.2 water. Although Lucozade did not exhibit the Maxim 4.46 0.30 0.11 0.00 0.01 2.1 PSP 22 2.60 2.10 0.04 0.00 0.01 2.2 lowest pH, the high titratable acidity makes it potentially the most erosive. However, the 30 Milosevic presence of calcium and phosphate in the by the provision of palatal composite veneers aqueous oral fluid will influence the extent of which were bonded to the tooth with modern Br J Sports Med: first published as 10.1136/bjsm.31.1.28 on 1 March 1997. Downloaded from the demineralisation. Undersaturation of this dental adhesive resins. This is favoured by the aqueous phase with respect to hydroxyapatite author because "adhesive dentistry" is revers- and fluorapatite in vitro resulted in dental ero- ible and non-destructive of further tooth sion and not dental decay.9 Therefore the pres- substance since tooth preparation is minimal.