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Soft drinks and dental health: A review of the


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Journal of Dentistry (2006) 34, 2–11

www.intl.elsevierhealth.com/journals/jden

Soft drinks and dental health: A review


of the current literature
J.F. Tahmassebi*, M.S. Duggal, G. Malik-Kotru, M.E.J. Curzon

Department of Paediatric Dentistry, Leeds Dental Institute, Clarendon Way, Leeds LS2 9LU, UK

Received 24 May 2004; received in revised form 25 October 2004; accepted 5 November 2004

KEYWORDS Summary In recent years there has been increased interest in the role of
Soft drinks; commercial soft drinks in dental diseases namely as dental caries and erosion. The
Erosion; objective of this paper has been to review the past and current literature to
Dental caries determine the present knowledge on this subject. The literature related to dental
caries, erosion, drinks, soft drinks and fruit juices was reviewed. The literature shows
efforts have been taken to modify soft drinks by either adding or deleting certain
components so as to reduce their harmful effects on teeth. A rational protocol to
encourage the sensible use of drinks and the modification of drinks to render them
less harmful would be advisable.
q 2004 Elsevier Ltd. All rights reserved.

Introduction reference to the paediatric population. This paper


reviews the background to the use of these drinks,
Soft drinks, excluding milk and water, have been findings and recommendations of the past studies
suggested as causing damage to the teeth for two and discusses the modification made accordingly to
reasons. Firstly, the low pH and high titratable the composition of the soft drinks that are present
acidity of some drinks may lead to erosion of on the market.
enamel surface. Secondly the sugars in drinks are
metabolized by plaque microorganisms to generate Background
organic acids that bring about demineralization
leading to dental caries. Over the years efforts have In 1990 in an article titled ‘Soft drinks, infants’ fruit
been made by manufactures to try and modify the drinks and dental health’ Grenby1 wrote “a lot of
composition of drinks so as to reduce these research has been done on the influence of various
potentially harmful effects on teeth. Literature kinds of solid foods on dental health, but compara-
pertaining to the use of soft drinks and dental tively little has been published on the effects of
health is reviewed using MEDLINE with particular drinks”. Since this article almost 14 years ago there
has been many studies conducted to determine any
potentially harmful effects of soft drinks on teeth.
* Corresponding author. Tel.: C44 113 343 6138; fax: C44 113
343 6140.
The commercial sale of soft drinks has increased
E-mail address: jinoustahmassebi@bramhopedentalclinic. by 56% over the last 10 years and it is now estimated
com.uk (J.F. Tahmassebi). that they will keep rising at about 2–3% a year.2
0300-5712/$ - see front matter q 2004 Elsevier Ltd. All rights reserved.
Soft drinks—a review 3

The average daily requirement for water in man is Dental caries


2–3 l, of which, in Western countries, more than
half comes from soft drinks.3 In many so-called Soft drinks and dental caries
advanced societies, the use of milk as a main liquid
source for children, is declining while consumers The literature on dental caries and soft drinks now
drink greater amounts of soft drinks, including fruit dates back to the 1940’s when studies by Bibby and
juices and carbonated beverages.3 others5,6 looked at the consumption of such drinks
compared with dental caries prevalence. Compari-
sons were made using reported consumption of soft
Historical aspects of soft drinks
drinks by states in the USA with dental caries data,
state by state, collected from recruits to the armed
No such drinks occurred until the latter half of the
forces. No relationship could be found. Indeed the
nineteenth century. Before that time drinks, as
highest soft drink consumption per head of
refreshments, mostly included well water, milk, population was associated with the lowest dental
ciders (fermented apple juice), ales and beers, and caries prevalence.
at certain times of the year drinks known as A more recent study in the USA showed a positive
cordials, such as lemonade and dandelion and relationship between cumulative caries scores and
burdock. The latter were made out of water and the frequency of mealtime and between-meal use
extracts from various fruits. But they were very of carbonated beverages.7 However, the strength
limited in their availability being seasonal. of this conclusion was weakened by the use of only a
Changes started to occur in the 1890s when one-day diet analysis to represent the foods and
entrepreneurs developed alternative drinks based drinks used over the period of up to 20 years during
on cola and sarsaparilla extracts. The earliest such which the observed caries developed.
drink is thought to be Moxie made by a drugstore
(chemist) owner in Lisbon Falls (Maine, USA) in The susceptibility of enamel to dissolution
1884.4 The drink was based on cola extract,
sarsaparilla and carbonated and believed to have Young, immature enamel is porous and more easily
medicinal properties. Soon afterwards other very dissolved by acids until the final intra-oral maturation
similar drinks were developed including Coco-Cola of the surface enamel has occurred.8 Normally as the
and Pepsi-Cola. Industrial production of these immature enamel is bathed by salivary ions, it
drinks together with the development of preserva- becomes progressively harder, less penetrable and
tives made so called ‘soft drinks’ more widely fairly resistant to acid attack.9 However, enamel
available, particularly in the USA. Other drinks maturation takes time and therefore young children
based on different flavours, lime, lemon, orange, are at greater risk of dental caries if the acidogenic
aniseed, etc. were introduced so that today there is challenge is excessive. Attempts to overcome this
a plethora of soft drinks available. By the time of problem with new drinks, such as herbal drinks, have
World War I, researchers at the Agricultural not met with a great deal of success.10 Therefore, it is
Research Centre (Bristol, UK) were developing the time period after eruption of the primary and
cordials based on different fruits as sources of permanent teeth and the intra-oral milieu that is
Vitamin C. With the outbreak of war one fruit crucial as to whether a tooth is damaged by an
cordial in particular, based on blackcurrant juice, acidogenic or cariogenic challenge. These time
was manufactured for distribution to children to periods are confined to the very young, less than 3
ensure that they had a sufficient intake of years of age and school age until the completion of
Vitamin C. After the war the product license was the normal complement of permanent teeth. That is
sold and then manufactured as ‘Ribena’. Soft drinks why the concern about soft drinks and teeth is largely
based on fruit cordials are now widely popular focussed on children. However, in recent years
because of their refreshing taste. another factor, of erosion in older populations has
A further aspect of importance, however, is that attracted attention as evidence of damage to the
these soft drinks and cordials can be bottled and are older dentition comes to the fore.11
free from contamination when many natural water
sources might not be. It is sometimes forgotten that Soft drinks: acidogenic and cariogenic
widely available and reliable safe drinking water is potential
only relatively recent and still not common in much
of the world. Besides being safe, these drinks are When oral acids are produced by the sugars or are
also easily assimilated energy source. inherent in a food or drink their ability to damage
4 J.F. Tahmassebi et al.

tooth enamel is described as acidogenicity. and subsequent research by Duggal and Curzon20
Similarly the ability of a food or drink to foster showed that these drinks had a similar acidogenicity
dental caries is termed cariogenicity and it has been and hence cariogenic potential, as drinks that
suggested that when it can be measured the term contained sucrose.
‘cariogenic potential index (CPI)’ may be used.12 Various newer carbohydrates have been intro-
A number of attempts have been made to rank duced in the last decade which are now found on
foods and drinks by this means, although not always many food and drink labels. Maltodextrins and
with universal agreement.13–15 glucose syrup are extensively being used and are
The potential acidity and cariogenicity of soft carbohydrates derived from maize starch, belonging
drinks consumed by young children and adolescents to a group of oligosaccharides (long chain polysac-
have been the subject of many studies in the past 30 charides) composed of glucose, three units and
years.16 While the research data have never been above in length. They are obtained by acidic and/or
completely conclusive many studies have shown that enzymatic hydrolysis of starch, with subsequent
when drinks containing sugars are consumed, there drying to make free flowing powders.21 They usually
is a drop in the pH of the dental plaque in vivo. This contain glucose, maltose, maltotriose and higher
acid is neutralised by saliva flow and salivary polymers of glucose, depending on the degree and
components so that normally within 20–30 min method of hydrolysis. Therefore, maltodextrins are
plaque pH returns to resting levels.16 A single acidic also called glucose polymers. The amount of glucose
attack is therefore of minor importance but if and maltose present in maltodextrins is relatively
repeated the ability of the saliva to deal with the low as compared with higher chain saccharides.
acid becomes less and less. Hence, the danger is the Maltodextrins are increasingly being used in the food
frequent use of soft drinks over time.11 industry especially in baby drinks and baby dried
With the frequent consumption of acidic, food as an anti-caking agent. However, there are
sugar-rich soft drinks, children are at a higher risk few data in the dental literature on the effect of
of acid demineralisation and ultimately leading to these carbohydrates on pH of dental plaque in vivo.
erosion and caries development. If the challenge is A study carried out by Moynihan et al.22 investigated
frequent enough and there are few or no protective the acidogenicity of glucose polymers as 10%
factors this damage can be quite aggressive. This is solutions in water, in cow’s milk, or in a solution of
particularly with nursing (early childhood caries, milk substitute (calogen). They reported that
ECC), caused by the frequent consumption of sugar glucose polymers caused a decrease in plaque pH
drinks (both commercial and natural as fruit juices) but to a significantly lesser extent than 10% sucrose,
when used frequently and poor oral hygiene.17 It and also the glucose polymers were equally acido-
should be noted then even natural fruit juices have genic when given in water, milk or calogen.
an acidogenic potential with non-milk extrinsic A study of the acidogenic potential of various
sugars.18 maltodextrins23 concluded that though maltodex-
Early childhood and adolescence are particular trins appeared to be significantly less acidogenic
periods in which the risk of dental caries remains than 10% sucrose, they can lead to a substantial
especially high. Many factors contribute to the drop in plaque pH and may therefore have a
initiation and progression of dental caries. One potential to cause demineralisation of enamel.
factor with the potential for being significant is high A recent study by Marshall et al.24, carrying out a
consumption of sugars and one product that tends dental examination on 695 children between 4–7
to contribute to the amount of sugars ingested is years age suggested that an increase in consump-
soft drinks. tion of regular soda beverages, powdered
beverages and to a lesser extent 100% juice, may
Natural versus other soft drinks increase dental caries rates in children. Assessment
of erosion in 14 year-old children in the UK revealed
In the late 1980s much attention was drawn to the that over 80% regularly consume soft drinks.25
detrimental effects of soft drinks on teeth mostly as
a result of media attention related to ECC. As a
result, many mothers started to use natural fruit
drinks, or newer products, sold as ‘no sugar added’ Erosion
or ‘containing natural sugars’. Natural sugars being
glucose and fructose, it was believed that these Soft drinks and dental erosion
drinks were safe for the teeth. However, Frostell19
showed that all sugars have virtually the same Erosion is due to the loss of the outermost surface
potential for acid production in plaque as sucrose of enamel and occurs when the surface pH falls
Soft drinks—a review 5

below 5.5.26 It is important to emphasise that the inevitably result in prolonged period of oral acidity
erosion of dentine becomes extremely relevant and, therefore, may play an important part in the
once the enamel has been breached. The 1993 erosion process.33
National Survey of Child Dental Health conducted in
the United Kingdom reported over half of the 5 and Diet soft drinks
6 year-olds had erosion, 25% with dentinal involve-
ment of the primary dentition. In the 11–14 year age Because of the concern in recent years over weight
group, almost 25% had erosion, 2% with dentinal and the perceived need to slim, diet drinks were
involvement in the permanent dentition.27 developed. These drinks are also marketed as
Erosion may be caused by extrinsic or intrinsic ‘sugar free’ drinks. They are based on using
acids or combination of extrinsic and intrinsic acids. artificial sweeteners so as to reduce the caloric
Extrinsic acids include acidic beverages, snacks or content of the drinks.34 But these drinks have an
environmental exposure.28 Intrinsic erosion is erosive potential that may enhance enamel demi-
caused by gastric acids and includes indigestion neralisation. In addition, there appears to be a
and recurrent vomiting as part of an eating rebound phenomenon whereby having consumed a
disorder. Although the hydrochloric acid from the diet drink the body anticipates an intake of calories
stomach is responsible for intrinsic erosion, extrin- which is not forth coming. Accordingly the satiety
sic erosion is often caused by extrinsic acids, many reflex is not induced and the individual then eats or
of which come from fruit or fruit-based drinks. The drinks more.35 There are also a number of health
reported incidence of tooth erosion associated with concerns with regard to consumption of artificial
the use of acidic soft drinks has been increasingly sweeteners.36
documented.11 The erosive potential of beverages
is thought to involve several factors, including low
pH and the buffering capacity of the drink. Soft Acidogenicity and erosion
drinks may contain several different types of acid
that contribute to the low pH value. Some may be It has been traditionally understood that acidity,
inherent and derived from the natural components the measured pH, is an accurate indicator of the
used in manufacture. Thus fruit juices and fruit erosive potential of a food or drink.37 Baseline pH
flavoured drinks are made from a concentrated values give only a measure of the initial hydrogen
source of fruit and consist of organic acids derived ion concentration and provide, therefore, no
from the fruit such as citric acid from oranges, indication as to the presence of undissociated
tartaric acid from grapes and malic acid from acid. It is now thought that the total titratable
apples.29 It is important to mention that fruit teas acidity is a more accurate measure of the total acid
which are based on dried fruit products have also content of a drink, and may, therefore be more
erosive effect on enamel.30 realistic means of predicting erosive potential.38,39
Other acids will come about during the manu-
facturing process designed to improve organo- Reduction in erosive potential
leptic properties of the drink, such as carbonation.
Carbonated beverages will contain carbonic acid Interest in dental erosion has led to increasing
formed by carbon dioxide in solution. Even when attention to ways in which the erosive potential of
the carbon dioxide has been blown off and the soft drinks and other foods might be modified.40
drinks have become ‘flat’ the pH remains low.31 One way in which the effects of acidic drinks may be
This shows that soft drinks have an inherent acidity combated is by modifying their composition so as to
due to other acids that are added to stimulate reduce their demineralisation action. As erosion is a
taste. These other acids include phosphoric and consequence of acid attack, an obvious way of
citric acids present in cola-type drinks and other curbing it is by lowering the acid content of the
acids that provide flavour and also carbonic acid drinks. However, this raises formulation difficul-
under pressure in sparkling drinks.32 ties, as the taste perception of the drinks is related
Finally, preservatives, such as added vitamin C to their tangy flavour and acidity.
(ascorbic acid), may also contribute to the acidity Another way to reduce the erosive properties of
of soft drinks.29 Fruit acids and additives such as soft drinks is by diluting the drinks with water.
phosphoric acid are not all equally erosive, and as Cairns et al.,41 investigated the potential dental
would be expected from measurements of their effects of diluting juices by measuring their acidity
acidity, there is wide variation between different levels. Their results showed that while dilution had
fruit juices. The ability of a drink to resist pH very little effect on the measured pH values, the
changes brought about by salivary buffering may titratable acidity reduced as the drink became
6 J.F. Tahmassebi et al.

more dilute. However, the authors mentioned that who compared cola drink with a cola drink
it remains unlikely that the drinks would ever be supplemented with 5% calcium lactate in a group
consumed at a ‘safe’ level of dilution due to of rats. Their results showed that supplementation
diminished taste and colour. of the cola drink significantly reduced the scores for
erosion to a level no different from that of a third
group which drank only distilled water.
Larsen and Nyvad48 compared the pH and the
Modification of soft drink formulations buffering effect of various soft drinks that were
available on the Danish market. The pH and the
Efforts have been taken to modify soft drinks by
concentrations of calcium, phosphate and fluoride
either adding or deleting certain components so as
were determined. The buffering effect was deter-
to reduce their harmful effects on teeth. One
mined by titration with sodium hydroxide. Human
approach has been to reduce the total sugar
teeth (nZ54) covered with nail varnish except for
concentration in the drinks. The total sugar
3!4 mm windows were exposed to 1.5 l of the drink
concentration of most fruit drinks is usually
for either 7 days or 24 h under constant agitation.
between 7 and 10%.42 However Imfeld43 reported
They reported that the dissolution of enamel
that even very low sucrose concentrations, around
increased logarithmically inversely with the pH of
0.1–1%, can cause acidogenic response in plaque. In
the drink and parallel with the solubility of enamel
a study by Toumba and Duggal44 two new formu-
apatite. The results showed that orange juice with
lation of a blackcurrant drink (7% juice with 0.49%
pH of 4.0, supplemented with 40 mmol/l calcium
and 10% juice with 0.65% sugars concentration,
and 30 mmol/l phosphate did not erode the enamel
respectively) were compared with an apple and
as the calcium and phosphate saturated the drink
blackcurrant drink with no added sugar (0.8%), and
with respect to apatite.
a mixed citrus drink with a higher carbohydrate
Hughes et al.,49,50 in a series of published studies
concentration (4.5% w/v). It was concluded by the
have demonstrated the ability to create an extre-
authors that the two new formulations with low
levels of carbohydrate had a low acidogenic mely low erosive beverage to enamel in situ by
potential and did not depress the plaque pH below product modification with respect to raising the pH,
the critical level and their consumption could not lowering the titratable acidity and addition of
be considered to pose a significant risk for enamel calcium (Ribena ToothKind). They mention that
demineralisation. This drink was manufactured as whilst these modifications have resulted in a
‘Ribena ToothKind’. product with very low erosive properties, other
characteristics such as consumer acceptability and
stability of the ingredients could be enhanced. The
Modifying agents: calcium and/or phosphate most recent study by West et al.51 has shown that
supplements addition of xanthan gum to the Ribena Toothkind
will retain the low erosive properties of the drink
One of the earliest studies to report that the with additional benefits of taste flexibility and
addition of calcium and phosphate ions to acid beverage stability.
solutions had an effect on the appearance of acid Barlett et al.,52 investigated the effect of a
attack on human enamel was in 1953 by Besic.45 It modified version of a popular soft drink that claimed
was observed that as the concentration of calcium to reduce the potential for dental erosion. The study
and phosphate ions increased in acidic solutions compared the plaque pH response to the modified
they became more protective. In a later study, Hills and the original formula soft drink in 15 subjects
and Sullivan46 reported that saturation of the without erosion. The modified drink had a reported
demineralising medium with calcium and phosphate pH of 3.8, a titratable acidity of 0.182 and a calcium
prevented enamel dissolving at pH 7.0–4.0, but content of 195 ppm, compared with the unmodified
exact details of the calcium phospshate used were drink’s pH of 2.85, 0.2 titratable acidy and 20 ppm of
lacking. In an experiment by Reussner et al.,47 using calcium. They reported that, although the erosive
rats, monocalcium phosphate at 0.15 or 0.3% potential had been reduced by modifying the soft
reduced erosion effectively when added to a drink, it had not been eliminated.
grape powder beverage mix, reconstituted frozen
orange juice, and reconstituted orange-flavoured
beverage mix. The authors commented that this Modifying agents: citrate
compound has good solubility and no taste draw-
backs. Another interesting trial which was con- Another approach has been the supplementation of
ducted on a calcium salt was by Beiraghi et al.,40 drinks with citrate. Duke et al.,53 conducted a study
Soft drinks—a review 7

to assess whether drinks formulated with relatively


Table 1 Summary of factors considered to modify
low levels of citrates and citric acid exhibited a
soft drinks to reduce their harmful effects on teeth.
reduced acidogenic response in the plaque. They
concluded that moderate levels of citrate in sugar- Reduce the total sugar concentration
based drinks reduced the level of the pH of plaque Diluting the drinks by addition of water
and thus reduced potential cariogenicity. However, Addition of calcium and/or phosphate supplements
it has been pointed out that the theory that citrate Addition of a moderate levels of citrate
Addition of Fluoride
could be beneficial is erroneous because of its
strong chelating properties. On the other hand, *Modified drinks are unsuitable for infants.
attention has been drawn to the fact that the
chelating properties of citrate should be of little Reussner et al.,47 noted the inhibition of erosion
importance at the low pH levels of acidic drinks.54 in rats by sodium monofluorophosphate in one of
In a study by Pollard et al.,55, addition of 0.1–02% their four experiments, in which three other
citrate to a 10% sucrose solution significantly phosphates and calcium chloride as additives to a
reduced the acidogenic response in the plaque reconstitute powdered beverage, were ineffective.
and 0.103% citrate was also effective as a sup- The anti-erosive action of 15 ppm fluoride added to
plement in a blackcurrant drink.56 Speculation on a sports drink mixture, diluted to give a sugars
this observed beneficial effect was based on some content of 6%, pH 3.2 and given to rats ad libitum,
known properties of citrate. Acid citrate and citric was reported by Sorvari et al.,59. In a recent study
acid at relatively low concentrations are known to by Larsen60 very little effect of 4–6 ppm ionic
inhibit phosphofructokinase.57 Due to this inhibition fluoride dissolved in the soft drinks was observed
of glycolytic enzymes, it may, therefore, reduce and the author concluded that the acidic soft drinks
the acid which forms in the dental plaque by are capable of dissolving considerable amounts of
bacterial fermentation of sugars. Another comment calcium fluoride and the erosion preventive effect
made was that the stimulation of salivary flow by of even high fluoride concentrations is limited. In
citrate may lead to quicker clearance of acid after another study, Larsen and Richards61 reported that
an acidogenic challenge. Although raising the non-carbonated fruit-flavoured drinks contain con-
concentration of citrate might increase the erosive siderable amounts of acids which in vitro, induce
potential of drinks, it was felt that at low erosion in teeth similar to those induced by
concentrations it might help to buffer the acids in carbonated soft drinks. Their results also showed
fruit based drinks, by this means reducing their that drinks with pH above 3, saturated with CaF2,
erosiveness. Thus the usefulness of citrate in reduced the in vitro development of erosion by 28%.
curbing erosion is unclear. However, in drinks with pH below 3, erosion were
not affected, despite total fluoride concentrations
Modifying agents: fluoride of 20 ppm. These authors concluded that it does not
seem advisable in a product for consumption to
Fluoride has been used successfully in the preven- increase the fluoride concentration any further in
tion of dental caries. Although there remains some an attempt to obtain a note worthy erosion
differences of opinion as to its main mechanism of prevention.
Fluoride has also been tested as an addition to a
action, it is known to improve the acid resistance of
pure citrus (orange) drink in a study by Gedalia
enamel when incorporated into the enamel apatite
et al.,62. The main object of this study was the
structure. It is however, an open question whether
suppression of caries. Groups of 6–9 year-old
fluoride can prevent, at least to some extent,
children were given the supplemented and control
erosion of the enamel caused by acidic soft drinks
drinks for 3 years. The results showed 30% reduction
and fruit juices. Taking into consideration the low
in the caries incremental rate. A summary of
pH of the soft drinks and the high solubility of both
modifying factors are shown in Table 1.
hydroxyapetite and fluorapetite at such low pH and
absence of calcium, it seems difficult to imagine
conditions by which saturation with respect to
fluorapatite or hydroxyapatite can be established. Discussion
However, Lussi et al.,58 observed that fluoride
levels in a range of juices and drinks were Soft drink intake has been negatively associated
statistically correlated with their potential erosive- with milk, calcium, magnesium, vitamin A, and
ness in vitro, measured by surface hardness and vitamin C intake in teenagers living in the USA.63
iodide permeability. Most soft drinks and fruit juices have minimal
8 J.F. Tahmassebi et al.

nutritional content and contain negligible amounts develop a chalky taste. As noted above the
of the Recommended Daily Allowance (RDA) for organoleptic properties of a drink are crucial to
vitamins, minerals, and protein. Accordingly nutri- its use.
tionist have suggested that sweetened beverages One reason for most soft drink manufacturers
may curb a child’s appetite and displace protein concentrating on product modification with calcium
and calcium-rich foods needed for proper growth, and phosphate compounds is that there is less
although there is no scientific evidence for this. likelihood of raising regulatory obstacles than some
High soft drink consumption can also lead to of the other substances which have been con-
excessive energy intake, which may contribute to sidered. Fluoride for example, has been shown by
childhood obesity, a growing problem in children in Gedalia et al.,62 to reduce the caries incremental
some countries.64 rate by 30% when added to soft drinks. However, to
Children start consuming soft drinks at an avoid any risk of over- or uncontrolled consump-
increasingly younger age, and this increases tion, intake levels would need to be carefully
through young adulthood. Indeed it has been monitored and controlled, which would be difficult
noted that 22% of one and 2-year-old children if freely available in soft drinks. A major barrier to
consume soft drinks with an average of nearly one its application for this purpose would be the
cup per day.65 Food acceptance by young children prospect of political activist campaigns that have
has been shown to be largely dependent upon two helped to curtail fluoride use in products other than
characteristics: sweetness and familiarity. There is oral hygiene preparations.
evidence that in utero there is a preference for Other factors were felt to be more important in
sweet taste66 and that continuous exposure to considering the cariogenic potential of diets includ-
sweets sustains a neonate’s preference for this ing the use of other foods such as baked goods. A
taste. The liking for sweetness is thought to be diet does not consist of drinks alone but a complex
innate and is related to the fact that nearly all mixture of foods and drinks. In any discussion of the
sweet tasting foods and drinks are ‘non-poisonous’. use of soft drinks the total diet must be considered.
Nevertheless, some studies have shown that sweet Ismail et al., 7 in an extensive study of the
preference changes with continued exposure to relationship of diet (including soft drinks) and
sugars, and the more sugars people consume, the dental caries concluded that in modern society
higher their threshold for sweetness67, indicating a where there is extensive use of fluoride products
possible increased risk for caries.68 the role of diet has become of lesser importance.
It is mentioned that soft drink vending machines Nevertheless, where there is frequent use of
have contributed to the substantial increase in soft acidogenic and erosive drinks there has to be an
drinks consumption and are now the largest source increased risk.
of added sugars in the USA, accounting for one third As it seems very unlikely that populations can be
of total intake.69 Manufacturers of soft drinks induced to reduce their use of soft drinks so product
market their products by using the message, modification by manipulating the acidity levels has
among others, that these drinks are healthy and gained increasing attention. The addition of
may be consumed at all times of the day. The citrate, noted above, has been one aspect of this.
essence of this message is that these drinks are 90% Many products already contain citrate and modifi-
water and contain sugars found in nature often cation of citrate level in drinks has been carried
derived from fruits. With the expanding use of soft out, although there has been some scepticism over
drinks, especially in younger age-groups, there is the usefulness of citrate on account of its reputed
growing concern within the dental profession over powerful chelating properties. It must also be
the problem of their erosiveness and risk of causing pointed out that product re-formulation is no
demineralization leading to caries. There has been simple matter as many of the additives proposed
much interest in ways in which it can be reduced. could exert adverse effects on other ingredients in
Product modification is one option that has been the drinks. As the manufacturers point out, detailed
explored (see Table 1). It can be seen from the tests of flavour acceptability and organoleptic
references cited above that the main area in which properties would be needed.
there has been major activity is in addition of Other suggestions for minimizing the damaging
compounds or mixtures supplying calcium and effect of soft drinks include new formulations with
phosphate. It must not be overlooked that the low levels of sugars44 and modification to the
addition of calcium and phosphate salts to soft packaging and the route of intake. Grobler et al,29
drinks has an impact on the flavour as well as the observed that the use of a straw was the least
pH, depending on the salt used and the amount, if harmful method of drinking sugars containing drinks
calcium is not well masked, the products tend to and in a later study Tahmassebi and Duggal70
Soft drinks—a review 9

showed that drinking with a straw resulted in a less the risk. Negative admonitions to stop using these
pronounced pH drop in plaque. Accordingly, use of a drinks is not likely to be successful. Guidance for
straw for drinking potentially damaging soft drinks dental health, therefore, should follow current
should be encouraged. It should be emphasised that guidelines to limit intake of soft drinks, other than
the straw must be introduced beyond the incisor milk or water, to meal times, and to brush teeth
teeth to minimise erosion. twice daily with fluoride toothpaste. Where advice
The relationship of foods and drinks to dental on reducing soft drink consumption is not likely to
caries is a very complex one.71 A systematic review be accepted an emphasis on using modified drinks
of the literature by Burt et al.,72 concluded that the should be used. Table 2 shows a summary of
relationship between sugar consumption and caries recommendation for safe use of soft drinks.
is much weaker in the modern age of fluoride
exposure than it used to be. However they
mentioned that controlling the consumption of References
sugar remains a justifiable part of caries preven-
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