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Soft Drinks: Hard on Teeth
With soda pop decay contributing to an alarming increase in caries among young people, dentistry finds itself fighting another kind of access problem: sweetened beverages within reach 24 hours a day.
Pamela R. Erickson, D.D.S., Ph.D.*, Deanna L. Alevizos, D.D.S., M.S.**, and Darcy J. Rindelaub, D.D.S.***
oft drinks are popular beverages. These cool, bubbly drinks are being consumed everywhere. In fact, you may very well have a can sitting next to you as you read this article. In the United States, it is culturally acceptable to consume soft drinks any time of the day. Carbonated soft drinks account for
more than 27% of Americans’ beverage consumption.1 In 1997, Americans spent more than $54 billion to buy 14 billion gallons of soft drinks. Today Americans consume more than 56 gallons per year, or more than one-anda-half 12 ounce cans per day for every man, woman, and child. Dentists are becoming increasingly concerned that over-consumption of soft drinks may result in greater amounts of dental disease. In a letter copied in the December 1997 Journal of the American Dental Association, Dr. Paul
*Dr. Erickson is a pediatric dentist in private practice in Minnetonka, Minnesota. She is the immediate pastpresident of the Minnesota Association of Pediatric Dentistry. ** Dr. Alevizos is a pediatric dentist in private practice. She is a 2000 graduate of the University of Minnesota School of Dentistry. ***Dr. Rindelaub is a second year pediatric dentistry resident at the University of Minnesota School of Dentistry.
Clinical Feature Readhead from Ames, Iowa was curious to know if any other dentist had noticed significant increase in decay among teenagers and adults due to patients drinking either regular or diet Coke® or Pepsi®. Dr. Readhead noticed, looking at the ingredients of the soft drinks, that most of them, especially the colas, contain phosphoric acid, and some, citric acid. The patients he had identified who were experiencing this decay were noted to have had above average oral hygiene and very little previous decay.
Acid Versus Enamel It is well known by the medical profession that disease loves acid,2 and this is particularly true of dental caries. Dental caries, by definition, is tooth demineralization caused by acidic byproducts of the bacterial fermentation of dietary sugars. The resulting caries lesion involves gradual demineralization of subsurface enamel and
dentin, leaving the outer 20- to 50easily penetrated and dissolved by micrometer-thick surface preserved acids.4 Even in the absence of carbohy3 more or less intact. drates, soft drinks can be destructive to With the consumpteeth. These acidic, or low tion of acidic, carbohypH, beverages can condrate-rich soft drinks, tribute to the demineralChildren teenagers are at high ization of dental hard start conrisk for caries developtissues. suming soft ment, which can be Dental erosion is the loss quite aggressive (Figure of tooth structure by a drinks at a 1). Eight- to 17-year-old chemical process not remarkably children are at greatest involving bacteria.5 Initially, risk. Normally, as the enamel will demineralize young young, immature enamel and dissolve, with the surage. . . is bathed by salivary ions face appearing dull. Acids and the intercrystalline can also enter the pits and spaces fill, it becomes progressively pores of enamel and cause subsurface harder and more mature. Mature structure loss.6 The solubility of enamel appears as a very dense, less hydroxyapatite increases logarithmipenetrable, glassy hard structure that is cally with decreasing pH. fairly resistant to acid attack. Erosion may be caused by either However, enamel maturation takes intrinsic or extrinsic sources. The time. The newly erupted enamel in intrinsic causes have been documented teenagers is immature, and the crysto include cases of anorexia nervosa talline structure is porous, chalky, and and bulimia, as well as any gastrointestinal disorder that involves increased outputs of gastric acids. Extrinsic sources include acidic medicines such as vitamin C and aspirin, aerosol acid chemicals in the work environment, or the frequent consumption of acid foodstuffs or drinks. Simple pH monitors have shown that all types of soft drinks are very acidic, especially the colas, which can have a pH of 2.4 or less (Table I). In order to neutralize a glass of cola, it takes 32 glasses of high pH alkaline water.2 Exposure of enamel to Coca-Cola® for one hour leads to significant reduction in microhardness, and scanning electron microscopic evaluation has revealed surface irregularities.7
Soft Drink Consumption Photograph of a 16-year, two-month-old male with rampant caries secondary to soft drink consumption.This teenager presented for consultation after referral from a general dentist.The previous dental examination at 14 years, five months of age showed no dental caries. Contributing etiology was the consumption of three to four cans of Mountain Dew per day while at school. Patient reported starting to consume these large quantities upon entering high school, where vending machines were readily available.
Children start consuming soft drinks at a remarkably young age, and consumption increases through young adulthood. Twenty percent of oneand two-year-old children consume soft drinks.8 Those toddlers drink an
average of seven ounces — nearly one cup — per day. The consumption of soft drinks has increased in the United States over the past decades. United States Department of Agriculture Food Consumption Surveys (1977-1978, 1987-88, 1994-96) have found that almost half of all children between six and eleven years of age consume soft drinks, with the average child consuming 15 ounces per day, up slightly from 12 ounces in 1977-78. The most avid consumers are 12- to 29-year-old males. Boys between 12 and 19 years of age who consume soft drinks take in an average of almost two 12 ounce sodas (28.5 ounces) per day. Teenage girls also drink large amounts (20 ounces/day), although slightly less than their male counterparts. Another analysis9 found that one fourth of males 13 to 18 years old drank two or more cans of soft drinks a day, while one out of 20 drank five or more cans per day. One-fourth of 13- to 18-year-old females drank two cans per day, and one out of 20 drank three or more cans per day.
Nutritional Impact Soft drink vending machines have added to this substantial increase in soft drink consumption. Comparison of the results of the 1965-66 USDA Food Consumption Survey with those one decade later showed that the percentage of toddlers who consumed soft drinks increased from 30% to 40%. Furthermore, in the 1977-78 survey, the typical (50th percentile) teenager drank about one half of the current consumption. Data from the USDA surveys indicate that the proportion of adolescent boys and girls consuming soft drinks on any given day increased by 74% and 65%, respectively.10 Concomitantly, milk consumption has dropped in children over this same period. For example, the proportion of adolescent girls drinking milk dropped March-April 2001
from 72% in 1977-79 to 57% in 1994.10 teenagers. Furthermore, children who Data from national surveys indicate consume more than 26 ounces of soft that calcium intakes of a drinks per day were four considerable proportimes more likely to contion of U.S. children, sume less than eight Milk conteenagers in particular, ounces of milk per day.14 sumption are well below the Nearly a tenth of the Recommended Daily calories consumed by has dropped Allowance (RDA).11 For American teenagers in children instance, data from a come from nutrition1989 survey indicated a l l y e m p t y sodas, over this that just 39.5% of girls which they drink at the same aged 12-18 were conexpense of calcium rich suming 75% or more of milk. As a result, many period. the RDA for calcium.12 young Americans today Guenther13 found that are reaching the age of soft drink intake was negatively associmaximum bone growth with bones ated with milk, calcium, magnesium, vithighly prone to osteoporosis. amin A, and vitamin C intake in U.S. Soft drinks and fruit juices have
Table I. pH and Sugar Content of a Variety of Soft Drinks and Other Popular Beverages. Beverage
Clinical Feature minimal nutritional content. All contain negligible amounts of the RDA for vitamins, minerals, and protein.14 Nutritionists warn that sweetened beverages can curb a child’s appetite and displace protein and calcium rich foods needed for proper growth. High soft drink consumption can also lead to excessive energy (caloric) intake, which may contribute to childhood obesity, a growing problem among our children.15 Sodas are the largest single source of added sugars. A 12-ounce soft drink contains on average 150 dietary calories. The percentage of overweight youths aged 6 to 17 years has more than doubled in the past 30 years.16 It is estimated that approximately 11% of U.S. youths are now seriously overweight.16 Food acceptance by young children has been shown to be largely dependent upon two characteristics: sweetness and familiarity.17 There is evidence that continuous exposure to sweets
Soft Drinks are Hard on Teeth: Minimize the Risk • Drink carbonated soft drinks and sweetened liquids (like fruit juice) in moderation. • Drink fluoridated water and use a fluoride toothpaste. • Swish out your mouth with water to dilute the sugar and acid. • Use a straw to keep sugars and acids away from your teeth. • Never consume soft drinks or juice at bedtime. (The liquid pools in your mouth and coats your tongue and teeth.) • Throw the cap away to prevent ongoing sipping. • Read the labels — sweetened drinks are high in sugar. • Get regular dental cleanings to remove plaque (bacteria) build-up on your teeth.
sustains a neonate’s preference for million on advertising, while the four sweets.18 Studies have shown that major soft drink companies spent sweet preference changes with expo$631 million. Between 1986 and 1997, sure to sugars,19 and the these companies spent more sugars people con$6.8 billion on adversume, the higher their tising.8 Soft drink threshold for sweetness, Companies make sure indicating an increased that their products are manufacturrisk for caries. always readily available. ers market Thus, in 1997, 2.8 million Marketing soft drink vending and sell Soft drink companies machines dispensed 27 their market their products by billion drinks worth sending the message that $17.5 billion.20 Cocaproducts by soft drinks are healthy to Cola® soft drinks are contracting consume at all times of sold at two million the day. A quote from M. stores, more than with school Douglas Ivester, Coca450,000 restaurants, and systems. Cola’s® chairman and 1.4 million vending CEO, defending marketing machines.21 in Africa, said, “. . . actually, The School Connection our product is quite healthy. Fluid replenishment is a key to health. . . One of the ways that soft drink manuCoca-Cola® does a great service facturers market and sell their products because it encourages people to take in is by contracting with school systems. more and more liquids.”8 Pepsi® and Coca-Cola® are the two The soft drink industry has consismain contractors in schools.22 For tently portrayed its products as being example, in November 1997, one of positively healthful, saying they are Colorado’s largest school districts 90% water and contain sugars found entered into a partnership with Pepsi® 8 in nature. A poster provided to teachand U.S. West® to build a five million ers by the National Soft Drink dollar football stadium. Within the Association states: agreement, Pepsi® obtained exclusive “As refreshing sources of needed liqrights to sell its products in the disuids and energy, soft drinks represent a trict’s 140 schools. positive addition to a well-balanced Soft drink company partnerships diet. . . These same three sugars also have become so commercial that there occur naturally, for example, in fruits. . . have been letters sent from school In your body it makes no difference officials in Colorado to their schools whether the sugar comes from a soft warning them that if their school didn’t drink or a peach.” “dramatically” increase sales, the Soft drink companies are among the district’s schools could lose significant most aggressive marketers in the revenue from their soft drink partner. world.8 Advertising budgets of soft Stating that he didn’t want to pressure drink manufacturers are enormous teachers, the administrator suggested compared to public service campaigns that the principals “allow students promoting the consumption of fruits, virtually unlimited access to the soft vegetables, healthful diets, and lowdrink machines, move them where fat milk. In 1997, Coca-Cola®, they would be accessible to the which accounts for 44% of the soft students all day, and permit students drink market in the U.S., spent $277 to purchase and consume vended
products throughout the day”, and even “consider allowing students to drink their soft drink products in the class”.22 A 1996 study of 55 high schools in a large metropolitan area found that 11% of the schools offered soft drinks in vending machines during school hours.23 As more liberal school policies have taken effect recently, this will most likely increase. We recently conducted a phone survey of Minnesota school districts and found that the vast majority do have contracts with soft drink manufacturers. The annual revenue per district is approximately $150,000, with some districts even receiving “signing bonuses”.
Conclusion As you may imagine, although the erosion and caries processes are as different as their histological appearance, the two conditions occurring concurrently could be deleterious to dental hard tissues. As dental professsionals, we need to educate our patients about the consequences of soft drink consumption and provide suggestions to minimize the risk. We also need to be active in educating school administrators on the negative impact soft drinks have on students’ teeth.
The place where children spend a great portion of their day and where they are influenced greatly by their surroundings is their school. Schools are therefore the most suitable environment to provide health information to children in order to achieve the goal of health promotion programs. It is quite a contradiction to teach principles of good nutrition in health education, then adjourn the class to the reality that the children have high accessibility to soft drinks right outside the classrooms. ■ References
8. Jacobson, M.: Liquid candy, how soft drinks are harming Americans’ health. Website: http://www.cspinet.org/sodapop/liquidcandy.html, 1999. 9. Environ Inc., 1988. 10. Borrud, L., Wilkinson, D., and Mickle, S.: What we eat: USDA surveys food consumption changes. Comm Nutr Inst 1997: 4-5, 1997. 11. Albertson,A.,Toblemann, C., Engstrom,A., and Asp, E.: Nutrient intakes of 2 to 10 year old American children: 10 year trends. J Am Diet Assoc 92: 1,492-96, 1992. 12. Kennedy, E., and Goldberg, J.: What are American children eating? Implications for public policy. Nutr Rev 53: 111-126, 1995. 13. Guenther, P.: Beverages in the diets of American teenagers. J Am Diet Assoc 86: 493-499, 1986. 14. Harnack, L., Stang, J., and Story, M.: Soft drink consumption among US children and adolescents: nutritional consequences. J Am Diet Assoc 99: 436-441, 1999. 15. Morbid Mortal Weekly Report, 1994.
1. National Soft www.nsda.org.
2. Frazier, W.: Don’t drink soft drinks (and wish you didn’t). Website: http://[email protected], 1999. 3. Larsen, M.J., and Nyvad, B.: Enamel erosion by some soft drinks and orange juices relative to their pH, buffering effect and content of calcium phosphate. Caries Res 33: 81-87, 1999. 4. Massler, M.: Teen-age cariology. Dent Clin No Am 13: 405-23, 1969. 5. Zipkin, J., and McClure, F.J.: Salivary citrate and dental erosion. J Dent Res 28: 613-626, 1949. 6. Thylstrup,A., and Fejerskow, O.: Clinical and pathological features in dental caries. Enamel surface structure. In Textbook of Clinical Cariology, Second Edition, Thylstrup, A., and Fejerskow, O., eds. Copenhagen: Munksgaard, 1994, pages 112-115. 7. Gedalia, I., Ionat-Benat, D., and Ben-Mosheh. S.: Tooth enamel softening with a cola type drink and rehardening with hard cheese or stimulated saliva in situ. J Oral Rehab 18: 501-506, 1991.
16. Troiano, R., Flegal, K., Kuczmarski, R., Campbell, S., and Johnson, C.: Overweight prevalence and trends for children and adolescents: The National Health Examination Surveys. 1963-1991. Arch Ped Adolesc Med 149: 1,085-91, 1995. 17. Drewnowski,A.: Sensory preferences for fat and sugar in adolescence and adult life. Ann NY Acad Sci 561: 243-250, 1989. 18. Beauchamp, G.M., and Moran, M.: Dietary experience and sweet taste preference in human infants. Appetite 3: 139-152, 1982. 19. Jamel, H., Sheilman, A., Watt, R., and Cowell, C.: Sweet preference, consumption of sweet tea and dental caries: studies in urban and rural Iraqi population. Int Dent J 47: 213-217, 1997. 20. Vending Times 38: 15, 21, 22, 1998. 21. Wall Street Journal, page 1, May 8, 1997. 22. Meskin, L.: Outrageous. JADA 130: 308-310, 1999. 23. Story, M., Hayes, M., and Kalina, B.: Availability of foods in high schools: is there a cause for concern? J Am Diet Assoc 96: 123-126, 1996.