Hidden Risks in Patients’ Diets
Dental assistants can help increase awareness of acid erosion
By Melissa Tennen
Every dietary choice—from a grapefruit in the morning to a sports beverage at noon to chocolate chip cookies at 8 PM—can begin to add up and cause acid erosion of teeth.
Acid erosion is the loss of enamel and dentin caused by acid.1,2 Although erosion can be caused by gastric acids, in most cases, dietary acids from foods and beverages account for this loss of tooth structure.2
The common misconception is that junk food is the only culprit in this problem. Although high-sugar foods are certainly a major part of the acid erosion problem, all kinds of “healthy” food can contribute to tooth erosion, depending on their acidity strength.3 Even acidic medications such as vitamin C and aspirin can contribute to dental erosion if chewed or held in the mouth before swallowing.4
In addition, eating small meals or snacks throughout the day can cause damage to teeth by not allowing teeth enough time to be fully remineralized by saliva between meals.3 Foods that are eaten as part of a meal cause less harm than when eaten as snacks because more saliva is released during the meal, which rinses the mouth and reduces the effects of acids.5
One risk factor is the frequency of exposure to acidic sources. Dietary acids cause an immediate drop in oral pH, which is the measure of the amount of hydrogen ions in a solution. After saliva has neutralized the acids, the pH returns to physiologic pH 7 within minutes.1 This suggests that the frequency of acid consumption is important—holding acids (such as soda) before swallowing, holding fruit against the incisors, or snacking throughout the day are all significant examples of continual exposure.1 Studies have shown that the cariogenicity of sugary foods and beverages is higher when consumed between meals when compared with consumption during a meal.6
People often sip coffee, tea, soda, sports drinks, and carbonated beverages throughout the day. Half the US population older than 2 years consumes sugary drinks (including sweetened waters and fruit beverages) daily, with male teens being the most common—they drink 252 to 273 calories a day.7 Prolonged exposure prevents saliva from neutralizing the acidity or remineralizing enamel. Saliva has calcium and phosphorus, which helps inhibit demineralization of the tooth structure.3
A typical 20-ounce bottle of soda has 16 teaspoons of sugar, 240 calories, 91 mg of caffeine, and a pH of 3 or lower, with no minerals, vitamins, or calcium. Most commercial beverages are acidic. Cola has a pH of 2.5, iced tea and sports drinks have a pH of 2.8, and energy drinks have a pH of 3.3.6 Normal salivary pH level is 6.3, and loss of tooth enamel occurs at a pH level of 4.0.8
Diet soda has more acidity than regular soda because of the acetic and carbonic acids used to help with flavoring.9 Sports and energy beverages also can lead to erosion. Any degree of damage from these drinks depends on the pattern of consumption, salivary flow rates, saliva buffering capacity, and other factors.10
The pH and titrability of an acid, or the amount of alkali needed for neutralization, are important indicators for risk (Table 1).1 The erosion risk of a grapefruit is higher than that of a soda because more alkali is needed to neutralize the acid in the grapefruit.1 So it’s important to identify in your patients what the source of erosion is.
A diet with high levels of sucrose is cariogenic, particularly if citric acid is consumed. Candies with citric acid or fruity flavors have a 2.0 to 3.0 pH level. Advise patients to read food labels carefully for added sugars, such as high fructose corn syrup, fructose, sucrose, glucose, or dextrose (Table 2).4
Signs
Acid erosion is slow and may be hard to notice at first. As enamel wears off, teeth may seem shiny. As enamel continues to thin, teeth may appear yellow due to the underlying dentin. Then, incisors may be more translucent as incisal edges thin. Eventually, the structure and form of teeth may be damaged—from small cracks and fractures to notch-shaped spaces, cupping, and cratering.3
A complication of erosion is dentin hypersensitivity, which can indicate when acid erosion is active.1,2 Ask the patient about any incidents of hypersensitivity.
Water, Water
Many patients do not drink enough water—water helps wash away and neutralize some of the acidic residue.9 Dental professionals recommend patients drink water after they consume acidic foods and beverages as part of their dental hygiene practices.5
For children—even those participating in sports—experts recommend plain water instead of sports drinks, which contain extra calories that children really don’t need and take a toll on teeth. Children should also be consuming the recommended intake of juice and milk.10
Toothbrushing
The risk for the combination of erosion and abrasion is much higher if toothbrushing is performed too soon after consuming an acidic food.2 Advise patients to wait at least 30 minutes before they brush their teeth. Brushing before meals, however, may help protect teeth because this treats the tooth surface with fluoride.2
The Fine Line
It is not possible or desirable to avoid sugar completely: all foods, including vegetables, contain sugar, and a healthy diet includes fruits and vegetables as the foundation for daily intake. Good nutrition is essential to help prevent problems, such as type 2 diabetes and obesity. A nutrient-poor diet may increase the risk of infection, including periodontal disease;5 some researchers believe that the disease progresses faster and is more severe in patients with poor diets (Table 3).5
The bottom line? Encourage patients to eat a variety of foods, from each of the five major food groups. Patients can go to www.choosemyplate.gov for food menus and to track their eating habits.
Conclusion
Tooth erosion is typically slow and destructive. Patients may not realize that foods and beverages consumed throughout the day set the stage for erosive patterns. Increasing patient awareness of the problem will help patients maintain their tooth structure. Dental assistants can help by encouraging healthy eating and water consumption, in addition to regular dental examinations and appropriate dental hygiene practices.
References
1. Bartlett D. Etiology and prevention of acid erosion. Compend Contin Educ Dent. 2009;30(9):616-620.
2. Bartlett D. Acid erosion: why is it important to your patients? Inside Dentistry. https://www.dentalaegis.com/id/2009/02/focus-on-acid-erosion-why-is-it-important-to-your-patients. February 2009. Accessed April 22, 2012.
3. Nickolson S. Who is at risk for acid wear? Inside Dentistry. https://www.dentalaegis.com/id/2007/08/update-on-patient-care-who-is-at-risk-for-acid-wear. July/August 2007. Accessed April 22, 2012.
4. Moffitt AR. Tooth wear and erosion. Inside Dentistry. https://www.dentalaegis.com/id/2008/01/update-on-patient-care-tooth-wear-and-erosion. January 2008. Accessed April 22, 2012.
5. Diet and oral health. American Dental Association Web site. www.ada.org/2984.apsx?currentTab=1#opposesoftdrinks. Accessed April 22, 2012.
6. Waldo B. Oral health means more than just healthy teeth. Inside Dental Assisting. https://www.cdeworld.com/courses/4399. June 2009. Accessed April 22, 2012.
7. Park M. Half of Americans sip sugary drinks daily. CNN Web site. https://www.cnn.com/2011/08/31/health/soda-drinking-habits/index.html. August 31, 2011. Accessed April 22, 2012.
8. Moffitt AR, Moffitt JM. Preventing tooth decay rather than treating it. Inside Dentistry. https://www.dentalaegis.com/id/2008/09/update-on-patient-care-preventing-tooth-decay-rather-than-treating-it. September 2008. Accessed April 22, 2012.
9. Margeas R. Worn out: how Americans are damaging their teeth. Inside Dentistry. https://www.dentalaegis.com/id/2007/09/update-on-patient-care-worn-out-how-americans-are-damaging-their-teeth. September 2007. Accessed April 22, 2012.
10. AAP: kids should not consume energy drinks. American Dental Association Web site. https://www.ada.org/news/5970.aspx. June 20, 2011. Accessed April 22, 2012.
