Australian Dental Journal

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1 Australian Dental Journal The official journal of the Australian Dental Association SCIENTIFIC ARTICLE Australian Dental Journal 2012; 57: doi: /j x Erosive potential of sports beverages NJ Cochrane,* Y Yuan,* GD Walker,* P Shen,* CH Chang,* C Reynolds,* EC Reynolds* *Oral Health Cooperative Research Centre, Melbourne Dental School, Bio21 Institute, The University of Melbourne, Victoria. ABSTRACT Background: Dental erosion is an increasingly prevalent problem in Australia, with the consumption of sports beverages suggested as a risk factor. The aim of this study was to compare the erosive potential of Australian sports beverages. Methods: Ten beverages were selected and analysed to determine their ph, titratable acidity and apparent degree of saturation with respect to apatite. The erosive potential of the beverages was measured by human enamel surface loss and surface softening following a 30-minute exposure. A taste testing panel was established to determine the palatability of the sports beverages. Results: All sports beverages except Sukkie and Endura produced substantial surface loss and surface softening. Compared with the other sports beverages, Sukkie and Endura had a higher ph, lower titratable acidity and higher calcium content. However, Sukkie and Endura were deemed to be less palatable than the other more acidic sports beverages. Conclusions: The majority of the sports beverages tested produced dental erosion in this in vitro model. However, two new products Sukkie and Endura have lower erosive potential but also lower palatability. Keywords: Calcium, dental erosion, ph, sports beverages, taste. Abbreviations and acronyms: CPP-ACP = casein phosphopeptide-stabilized amorphous calcium phosphate; HA = hydroxyapatite; IAP = ion activity product; VAS = Visual Analogue Scale. (Accepted for publication 24 January 2012.) INTRODUCTION Dental erosion is the chemical loss of tooth structure due to acids or chelators that are not produced by bacteria. 1 Studies show that, while the prevalence of dental caries has steadily declined over the past 30 years, 2 the prevalence of dental erosion has been increasing. 3 Deery et al. 4 examined 254, yearold adolescents from the United States and United Kingdom, and found the prevalence of erosion to be 41% and 37%, respectively. A recent Australian study showed that 68% of 714 children aged 5 15 years exhibited signs of erosion on at least one tooth. 5 Studies have identified the consumption of acidic carbonated and non-carbonated beverages as one of the main causes of dental erosion. 6,7 However, sports beverages, as a subtype of functional beverages, have received limited attention in the literature on dental erosion. Sports beverages are specially formulated carbohydrate electrolyte products designed to provide fast rehydration and better performance for athletes. 8 A Euromonitor report 9 revealed that the off-trade volume of sports beverages in the global market has increased from million litres in 2004 to million litres in 2009, which translates to an average annual increase of 5%. The Australasian region, representing only 0.4% of the global population, accounts for 1.1% of the global sports beverage market, which is disproportionately high. 10 The Australian off-trade sales of sports beverages have increased from 61.2 million litres in 2004 to 95.6 million litres in 2009, corresponding to more than a 9% average annual increase; nearly twice the global value. 11 Consumption of sports beverages has been shown to produce dental erosion intraorally. 12 Attempts to decrease the erosive potential of beverages have been made by adding calcium, 13 increasing their ph, 14 or adding ingredients such as casein phosphopeptide-stabilized amorphous calcium phosphate (CPP-ACP). 15,16 The purpose of this study was to assess the erosive potential of a range of Australian sports beverages. The null hypothesis tested was that there would be no difference in the erosive potential of any of the beverages. ª 2012 Australian Dental Association 359

2 NJ Cochrane et al. METHODS Beverage selection and preparation A range of commercially available sports drinks and powders were purchased for analysis (Table 1). Coca- Cola and Mount Franklin bottled water were selected as positive and negative controls, respectively. The powders were mixed with distilled deionized water as per the manufacturers instructions. A total of eight commercially available sports drinks were tested. Chemical analysis Freshly opened or prepared beverages were analysed in triplicate to determine their ph and titratable acidity using a TitraLab titration manager (TIM 856, Radiometer Analytical, France) at room temperature. Values for titratable acidity were determined as the volumes of 0.05 M NaOH required to increase the ph of 20 ml of the beverage to 5.5 and 7.0. These values were converted to mmol of OH ) required to adjust the ph of 1 L of beverage. The calcium, inorganic phosphate, sodium and chloride content of the beverages were determined using an automatic ion chromatography system (Dionex Corporation, CA, USA) equipped with two columns for both cation (IonPac CS12) and anion (IonPac AS18) analysis using two conductivity detectors (ICS3000). Samples were diluted with distilled deionized water, filtered through a 0.2 lm filter (Minisart, Sartorius, Victoria, Australia), and compared against a combined seven-anion and six-cation standard (Dionex Corporation, CA, USA). The calcium, inorganic phosphate, sodium, chloride and hydrogen ion concentrations were used in an iterative computational procedure with the expanded Debye-Huckel equation to calculate ion activity fugacities. 17 The ion activities were then used to determine the apparent ion activity product (IAP) for hydroxyapatite (HA). The solubility product (Ksp) for HA 18 and the respective IAP was then used to determine the degree of saturation with respect to HA using the equation: DS = (IAP Ksp) 1 n, where n equals the number of ions in a unit cell. 17 Erosion analysis Preparation of enamel blocks Seventy extracted human molars were collected from the Royal Dental Hospital of Melbourne with ethics approval from the University of Melbourne Human Table 1. Beverages selected for analysis, their manufacturer, ingredients and instructions for dilution Brand Manufacturer Flavour Ingredient (as listed by manufacturer) Weight Manufacturer recommended dilution (g L) Liquids Mount Franklin Mineral Water Coca-Cola n.a Australian spring water (100%): contains (mg l): sodium = 8, bicarbonate = 20, calcium = 2, chloride = 10, magnesium = 3, potassium = 1 carbonated purified water, cane sugar, colour Coca-Cola Coca-Cola n.a (caramel 150 d), food acid (338), flavour, caffeine Gatorade Pepsi Lemon-Lime water, sucrose, glucose, food acids (330, 331), monopotassium phosphate, sodium chloride, flavour, colour (102) Powerade Coca-Cola Blackcurrant water, sucrose, maltodextrin, food acids (330, 331), flavour, tripotassium citrate, sodium chloride, tripotassium phosphate, colours (122, 133) Powders Gatorade Pepsi Lemon-Lime sucrose, glucose, food acid (330, 331), monopotassium phosphate, sodium chloride, flavour, calcium silicate (552), colour (102) Powerade Coca-Cola Blackcurrant sucrose, dextrose, food acid (330), trisodium citrate, monopotassium phosphate, sodium chloride, flavour, colour (129, 122, 133) Staminade Steric Pty Ltd Lemon lime sucrose, glucose, food acid (330), sodium chloride, monopotassium phosphate, magnesium lactate, silicon dioxide, flavours, colours (133, 102) Sukkie Sukkie Lemon maltodextrin, fructose, calcium lactate, potassium chloride, sodium chloride, lemon lime flavour (0.1%), vegetable powder, food acid (ascorbic acid) Berry maltodextrin, fructose, calcium lactate, potassium chloride, sodium chloride, raspberry flavour (0.2%), vegetable powder, food acid (ascorbic acid) Endura Endura Raspberry maltodextrin, fructose, malic acid, magnesium amino acid chelate, calcium amino acid chelate, monopotassium phosphate, sodium chloride, colour (beta vulgaris root powder), flavour 600 ml n.a 300 ml n.a 600 ml n.a 600 ml n.a 560 g g g g g g 125 Food Colour: 102 = Tartrazine; 110 = Sunset yellow FCF; 122 = Azorubine Carmoisine; 129 = Allura red AC; 133 = Brilliant blue FCF. Food Acid: 330 = Citric acid; 331 = Sodium citrate; 338 = Phosphoric acid. 360 ª 2012 Australian Dental Association

3 Sports beverage erosive potential Research Ethics Committee (HREC # ) and were randomly allocated into groups of seven. The teeth were sectioned to produce blocks with a volume of approximately 3 mm 3 (Minitom, Struers, Denmark), which were embedded in epoxy resin (EpoFix, Struers, Denmark). The enamel surface was exposed by lapping on a RotoPol 21 system (Struers, Denmark) with SiC paper (1200, 2400 grit: Struers, Denmark) and diamond polishing pastes (3 lm, 1 lm: Struers, Denmark). All blocks were pre-scanned using a white light non-contact surface profilometer (Altisurf 500, Cotec, France) and only included in the study if the roughness was <0.1 lm. The enamel was coated with clear nail varnish (All-In-One, Manicare, Australia) leaving a 1 mm 2 mm enamel window that was exposed to the beverages. Erosive challenge Each block was attached to the lid of a polypropylene tube with sticky wax (Model Cement, Kemdent, UK) and suspended in 50 ml of freshly opened prepared beverage. The 30-minute exposure was conducted in an incubator shaker at room temperature (HT infors, Minitron, Switzerland, 120 rpm). Enamel surface loss was determined by duplicate scanning of each exposed enamel surface with the white light non-contact surface profilometer (300 lm Z-axis depth probe, AltiSurf 500, Cotec-CCA, France, 300 Hz sampling rate, 250 lm s measurement speed, 2 lm spacing). Profiles were opened in PaperMap (3.1, Cotec-CCA, France) and the average depth of the enamel loss measured relative to the varnish protected enamel edges. Defects less than 0.1 lm could not be detected. Surface softening was determined by measuring the change in enamel microhardness. Triplicate Knoop microhardness measurements were taken of the sound enamel and the enamel exposed to the beverage using a microhardness tester (402 MVD, Wolpert Wilson, Germany, 50 g, 10-second dwell) fitted with a digital colour camera (DFC420, Leica, Germany) connected to a computer. Images were acquired using a Leica application suite and images analysed using Image J (National Institutes of Health, USA). Taste testing Twenty healthy adults were recruited and gave written consent to participate in the taste test. Each participant tasted nine different beverages with one (Gatorade Liquid) tested twice. The powdered drinks were made fresh on the day of the test with distilled deionized water according to the manufacturers instructions. The participants consumed 15 ml of each beverage with a two-minute waiting period between each, during which they rinsed with tap water to remove traces of the beverage and scored the pleasantness or unpleasantness by marking a point on a 10 cm continuous line (Visual Analogue Scale (VAS)) with 0 for most unpleasant to 10 cm for most pleasant. The participants were blinded to the identity of the beverages and their taste sequences were randomized. A blinded examiner measured the VAS score for each drinkparticipant combination. Statistical analysis Differences in surface loss produced by exposure to the different beverages were determined using a one-way ANOVA with Scheffe post hoc multiple comparison tests. Differences in surface softening produced by exposure to the different beverages were determined using a Kruskal Wallis test and comparisons between beverages were conducted with Wilcoxon Rank-Sum tests with a Bonferroni correction. For both comparisons, the overall p-value for differences between products was < Differences in the mean VAS scores for each of the 10 drinks, including the Gatorade liquid duplicates, were analysed using Friedman s test. Post hoc comparisons between beverages were conducted with Wilcoxon Signed Rank-Sum tests with a Bonferroni correction. For all statistical tests, the significance level was set at a = All statistical analyses were performed using SPSS version 17 (Statistical Package for the Social Sciences, SPSS Inc.). RESULTS The beverages purchased for analysis are shown in Table 1. Of the beverages purchased, two were liquid sports drinks, six were powdered sports drinks, the positive control was Coca-Cola and the negative control was Mount Franklin water. Chemical parameters The ph and titratable acidity for each beverage are shown in Table 2. Coca-Cola had the lowest ph (2.45) and Mount Franklin water had the highest ph (7.56). Of the sports beverages, the Sukkie and Endura powdered drinks had the highest ph (Table 2). The Sukkie powdered drinks had the lowest titratable acidity of all beverages tested. The calcium and inorganic phosphate content is shown in Table 2. The Sukkie and Endura beverages contained higher levels of calcium than the other products. All beverages listing phosphate as an ingredient (Table 1) were found to contain notable levels of inorganic phosphate (Table 2). The apparent degree of saturation with respect to hydroxyapatite was close to or in excess of 1 for Mount Franklin water, Endura and Sukkie beverages (Table 2). ª 2012 Australian Dental Association 361

4 NJ Cochrane et al. Table 2. The ph and titratable acidity of the various beverages (mean ± SD) Brand Flavour ph Titratable acidity Calcium (mm) Inorganic phosphate (mm) mmol OH ) L mmol OH ) L to ph 5.5 to ph 7.0 DS HA^ Liquids Mount Spring 7.56 ± 0.10 n a n a 0.19 ± ± Franklin Water Coca-Cola Original 2.45 ± ± ± ± ± Gatorade Lemon Lime 3.28 ± ± ± ± ± Powerade Blackcurrant 3.24 ± ± ± ± ± Powders Gatorade Lemon Lime 3.30 ± ± ± ± ± Powerade Blackcurrant 3.55 ± ± ± ± ± Staminade Lemon Lime 2.81 ± ± ± ± ± Sukkie Lemon 4.93 ± ± ± ± ± Berry 4.90 ± ± ± ± ± Endura Raspberry 4.85 ± ± ± ± ± ^Apparent degree of saturation with respect to hydroxyapatite. Surface loss The erosive potential of the beverages as measured by surface profilometry is shown in Table 3. Coca-Cola produced the highest amount of surface loss. Water and three other products (Sukkie (both flavours) and Endura) did not produce detectable surface loss. All other sports drinks produced measurable surface loss. The Gatorade and Powerade liquids and powders of the same flavour had similar erosive potential (p > 0.05). Surface softening The erosive potential of the beverages as measured by changes in Knoop hardness values is shown in Table 3. The mean hardness of the enamel samples tested was 348 ± 26. Coca-Cola and the majority of the sports beverages caused the enamel hardness to decrease by approximately 30% to 50%. The water produced no change in surface microhardness whereas Sukkie products and Endura produced a small change in surface microhardness (approximately 10% decrease for each). Taste preferences The mean VAS scores for the two duplicate Gatorade liquid samples (5.70 and 6.16) were not significantly different (p > 0.05). The mean VAS scores (range ) for the three sports beverages with higher ph values (Endura, Sukkie lemon and Sukkie berry) were all significantly lower than the mean VAS scores (range ) for the majority of products with lower ph values (Coca-Cola, Gatorade liquid and powder, and Powerade liquid and powder). The mean VAS scores for Endura and Sukkie beverages were not significantly different from those of Staminade (p > 0.05). There were no significant differences between the mean VAS Table 3. Surface loss and change in Knoop hardness after exposure to the various beverages and preferences of a testing panel for the different beverages (mean ± sd) Brand Flavour Surface loss (lm)* Surface softening (D Knoop hardness number)^, ** Taste *** Liquids Mount Franklin Spring Water nd # 8±24 1 Not tested Coca-Cola Original 3.22 ± 0.52 abc )178 ± 22 2, ± 2.57 a Gatorade Lemon Lime 2.00 ± 0.29 a )188 ± ± 2.19 a 6.16 ± 2.35 a Powerade Blackcurrant 1.59 ± 0.40 bde )155 ± ± 2.43 a Powders Gatorade Lemon Lime 2.50 ± 0.52 df )116 ± ± 1.93 a Powerade Blackcurrant 1.18 ± 0.37 cfg )99 ± ± 2.09 a Staminade Lemon Lime 2.55 ± 0.60 eg )113 ± ± 2.96 Sukkie Lemon nd )28 ± ± 1.65 b Berry nd )23 ± ± 2.59 b Endura Raspberry nd )28 ± ± 2.01 b ^mean hardness of sound enamel samples was 348 ± taste assessed on a 0 10 VAS where 0 was most unpleasant and 10 was most pleasant. # nd = no detectable change in surface profile (below the limits of detection). *Surface loss values marked with same superscript letters are significantly different (p < 0.05). **Surface softening values marked with same superscript numbers are not significantly (p > 0.05). ***Taste preference scores marked with same superscript symbols are not significantly different (p > 0.05). Additionally, Staminade was not significantly different to any of the other beverages (p > 0.05). 362 ª 2012 Australian Dental Association

5 Sports beverage erosive potential scores for products with low ph values (Coca-Cola, Gatorade liquid and powder, and Powerade liquid and powder) nor were there significant differences between the mean VAS scores for drinks with higher ph values (Endura, Sukkie lemon and berry). The results showed that the participants clearly preferred the taste of the beverages with lower ph values. DISCUSSION The positive (Coca-Cola) and negative control beverages (Mount Franklin water) produced the greatest and least erosion, respectively. This agrees with previous in vitro studies comparing the erosive potential of beverages. 19 The null hypothesis was rejected as differences existed between the erosive potential of the different sports drinks. All sports drinks that were found to be substantially undersaturated with respect to hydroxyapatite (Table 2) were found to produce enamel surface loss and surface softening (Gatorade, Powerade and Staminade) (Table 3). The apparent degree of saturation with respect to hydroxyapatite takes into consideration the ph, calcium ion activity and inorganic phosphate ion activity of the beverage. Despite some beverages containing more than 5 mm inorganic phosphate (Table 2), they remained undersaturated with respect to hydroxyapatite and had erosive potential (Table 3). The products with erosive potential had ph values ranging from 2.81 to 3.55, titratable acidity (to ph 7.0) from to mmol OH ) L and low levels of calcium ( 0.19 mm). The high titratable acidity can be attributed to the high content of citric acid and sodium citrate contained in these beverages (Table 1). Citric acid is particularly damaging to the teeth as the citrate anion is able to chelate calcium in addition to the erosive effect of the protons released. 20 Previous in situ testing of Gatorade powder and liquid showed that these drinks eroded enamel intraorally. 12 Therefore, given the Euromontior data indicating that Australians consume large quantities of these drinks and that these sales are growing, dental care providers should be aware that regular consumption of these beverages may contribute to the non-carious loss of tooth structure. The sports drinks produced by Sukkie and Endura all had a significantly lower erosive potential than the other sports drinks and powders tested (p < 0.05). Both Sukkie and Endura had a higher ph (approximately 4.9) and higher calcium content compared with the other sports drinks (Table 2). This resulted in Sukkie and Endura having an apparent degree of saturation with respect to hydroxyapatite that approximated 1. This is consistent with the finding that both of these sports drinks did not produce measurable surface loss and only minimal surface softening (Table 3). Unfortunately, the taste of both of these drinks was rated as relatively unpleasant. This may be attributed to the high calcium content (calcium lactate in Sukkie and calcium amino acid chelate in Endura) and or the higher ph (approximately 4.9). Given that Sukkie and Endura did not produce measurable surface loss in vitro, they are highly unlikely to cause erosion intraorally as the presence of pellicle, plaque, salivary buffers and calcium and phosphate will all act to further reduce the erosive potential of these drinks. Of the commercially available sports drinks tested in this in vitro study, Sukkie and Endura were shown to be the best choice to help avoid dental erosion. Both beverages were mildly acidic, did not produce measurable surface loss and only caused minimal softening of the enamel surface. However, consumers would need to compromise on flavour for the oral health benefit. It must be noted that all sports drinks, even Sukkie and Endura, contained sugars that oral bacteria could ferment to produce acids. Hence, frequent consumption of any of these sports drinks could increase the risk for initiation or progression of dental caries. In conclusion, consumers should drink sports drinks in moderation and be aware of the oral health risks of consuming these beverages. REFERENCES 1. Ganss C. Definition of erosion and links to tooth wear. In: Lussi A, ed. Dental erosion: from diagnosis to therapy. Basel: Karger Publishers, 2006: Hugoson A, Koch G, Helkimo AN, Lundin SA. Caries prevalence and distribution in individuals aged 3 20 years in Jonkoping, Sweden, over a 30-year period ( ). Int J Paediatr Dent 2008;18: Nunn JH, Gordon PH, Morris AJ, Walker A. Dental erosion changing prevalence? A review of British national childrens surveys. Int J Paediatr Dent 2003;13: Deery C, Wagner ML, Longbottom C, Simon R, Nugent ZJ. The prevalence of dental erosion in a United States and a United Kingdom sample of adolescents. Pediatr Dent 2000;22: Kazoullis S, Seow WK, Holcombe T, Newman B, Ford D. Common dental conditions associated with dental erosion in schoolchildren in Australia. Pediatr Dent 2007;29: Tahmassebi JF, Duggal MS, Malik-Kotru G, Curzon MEJ. Soft drinks and dental health: a review of the current literature. J Dent 2006;34: Jarvinen VK, Rytomaa II, Heinonen OP. Risk factors in dental erosion. J Dent Res 1991;70: Shirreffs SM. Hydration in sport and exercise: water, sports drinks and other drinks. Nutrition Bulletin 2009;34: Euromonitor. Sports drinks market sizes Euromonitor. Global functional drinks opportunities Euromonitor. Functional drinks Australia Hooper SM, Hughes JA, Newcombe RG, Addy M, West NX. A methodology for testing the erosive potential of sports drinks. J Dent 2005;33: Attin T, Weiss K, Becker K, Buchalla W, Wiegand A. Impact of modified acidic soft drinks on enamel erosion. Oral Dis 2005;11:7 12. ª 2012 Australian Dental Association 363

6 NJ Cochrane et al. 14. Meurman JH, Harkonen M, Naveri H, et al. Experimental sports drinks with minimal dental erosion effect. Scand J Dent Res 1990;98: Manton DJ, Cai F, Yuan Y, et al. Effect of casein phosphopeptide-amorphous calcium phosphate added to acidic beverages on enamel erosion in vitro. Aust Dent J 2010;55: Ramalingam L, Messer LB, Reynolds EC. Adding casein phosphopeptide-amorphous calcium phosphate to sports drinks to eliminate in vitro erosion. Pediatr Dent 2005;27: Cochrane NJ, Saranathan S, Cai F, Cross KJ, Reynolds EC. Enamel subsurface lesion remineralisation with casein phosphopeptide stabilised solutions of calcium, phosphate and fluoride. Caries Res 2008;42: McDowell H, Gregory T, Brown W. Solubility of Ca 5 (PO 4 ) 3 OH in the system Ca(OH) 2 -H 3 PO 4 -H 2 O at 5, 15, 25 and 37 C. J Res Natl Bur Stds 1972;81: Cochrane NJ, Cai F, Yuan Y, Reynolds EC. Erosive potential of beverages sold in Australian schools. Aust Dent J 2009;54: ; quiz West NX, Hughes JA, Addy M. The effect of ph on the erosion of dentine and enamel by dietary acids in vitro. J Oral Rehabil 2001;28: Address for correspondence: Professor Eric C Reynolds AO Melbourne Dental School The University of Melbourne 720 Swanston Street Melbourne VIC e.reynolds@unimelb.edu.au 364 ª 2012 Australian Dental Association

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