ON THE EROSIVE EFFECT OF SOME BEVERAGES FOR SPORTSMEN UPON DENTAL ENAMEL

Odontology ON THE EROSIVE EFFECT OF SOME BEVERAGES FOR SPORTSMEN UPON DENTAL ENAMEL Cosmin ARNĂUŢEANU 1, Sorin ANDRIAN 2, Gianina IOVAN 3, Andrei GEORGESCU 4, Simona STOLERIU 5 1 PhD Student, Department of Odontology-Periodontology, Fixed Restorations, Faculty of Dental Medicine, Gr.T. Popa UMPh Iaşi, 2 Professor, Department of Odontology-Periodontology, Fixed Restorations, Faculty of Dental Medicine, Gr.T. Popa UMPh Iaşi, 3 Associate Professor, Department of Odontology-Periodontology, Fixed Restorations, Faculty of Dental Medicine, Gr.T. Popa UMPh Iaşi, 4 Univ. Assistant, Department of Odontology-Periodontology, Fixed Restorations, Faculty of Dental Medicine, Gr.T. Popa UMPh Iaşi, 5 Lecturer, Department of Odontology-Periodontology, Fixed Restorations, Faculty of Dental Medicine, Gr.T. Popa UMPh Iaşi, Corresponding author: cosmin.arnauteanu@yahoo.com Abstract The aim of the study was to compare the surface morphology of enamel and the variation of the mineral ions concentration after the manifestation of the erosive effect determined by various commercial beverages for athletes. 14 premolars extracted from orthodontic reasons have been cut in two halves. On each section, an enamel surface of 3x3 mm was preserved for investigations. The samples have been divided into 4 groups. In the control group, the 7 sections were kept in artificial saliva while, in the other 3 groups, the sections were introduced in 3 beverages for athletes: Gatorade Citron (Pepsi Cola Co.), 5-hour Energy (Living Essentials), Powerade Cherry (Coca Cola Co.). The samples were analyzed on an electronic microscope with Vega II LSH scanning device, coupled with EDX Quantax QX2 detector. SEM analysis evidenced erosion zones at the level of enamel, which appears pinched in the samples subjected to the action of acid beverages. A decreasing tendency of the average values of calcium ion concentrations was observed in the batches in which the enamel samples had been subjected to the action of beverages for athletes. The highest relative variations of calcium and phosphorous ions (10%, respectively 8%) were recorded for Gatorade, followed, in decreasing order, by Powerade, for which variations of 9%, respectively 6%, were noticed, and by the 5-hour Energy beverage, in which the relative losses were of 5%, respectively 3%. All beverages for athletes tested in the present study showed erosion potential upon the dental enamel. Gatorade appeared as the most aggressive beverage for athletes followed by Powerade and 5-hour Energy. Keywords: erosion, enamel, beverages for athletes, SEM, EDX. 1. INTRODUCTION Dental erosion is provoked by agents with acid character, coming not from bacterial sources but from the external environment (most usually from food) or from the inside of the organism (most frequently - the gastro-oesophagian reflux and nutrition disorders). Among the exogenous sources, mention should be made of the beverages for athletes, whose popularity has constantly increased, as the population is encouraged to adopt a more healthy style of life, involving essentially physical exercises practiced on a regular basis [1]. Many of these products contain acids from fruits or acid components, which may contribute to dental erosion. Apart from this, numerous athletes, mainly practicing sports which require efforts made for long time periods, suffer from hyposalivation, known as increasing the risk of dental erosion, due to a lower salivary flow, inducing reduction of the buffer capacity and increase of the clearence time of the acids contacting the dental surfaces [2]. The prevalence of erosion among regular consumers of beverages for athletes was according to some studies of about 36.5% [3]. Even if a precise comparison of the results obtained is difficult to obtain if considering the different indices involved in evaluation, the type of studies, the diagnosis criteria and the dental surfaces under examination - similar values were reported in other studies [4-6]. Some researches demonstrated that the beverages for athletes consumed during physical exercises could not be associated with the erosive lesions observed in the investigated groups [7], International Journal of Medical Dentistry 143

Cosmin ARNAUTEANU, Sorin ANDRIAN, Gianina IOVAN, Andrei GEORGESCU, Simona STOLERIU while other studies reported a 4 time higher risk of such lesions, when this type of beverages is consumed on a regular basis [8]. The aim of the study was to compare the surface morphology of enamel and the mineral loss provoked by the erosive effect determined by various commercial beverages for athletes. 2. MATERIALS AND METHOD 14 premolars extracted from orthodontic reasons, with no carious or distrophic lesions, were selected for the study. Until the beginning of the investigation, the teeth were kept in distilled water at a temperature of 4º, followed by mesio-distal sectioning with active diamond discs (Gebr. Brasseler GmbH&Co, Germany), under continuous cooling with water to avoid over-heating. The surface of the vestibular and oral surfaces was covered with an acid-resistant varnish (Resist and shine, L Oreal, Paris), with the exception of a 3mm x 3 mm window, preserved for analysis. The samples were randomly divided into 4 groups, as follows: the control batch included 7 dental halves kept in 20 ml artificial saliva (AFNOR NF S90-701), whereas each of the other 3 groups contained 7 dental halves, introduced daily - for 2 minutes each time 4 times, along one single hour, in 3 beverages for athletes: Gatorade Citron, 5-hour Energy, Powerade Cherry. The composition of the here analyzed beverages is given in Table 1. For the immersion of each sample, 20 ml of each beverage were employed. Between the action periods of beverages, the samples were kept in artificial saliva. The samples were introduced in the beverages under analysis for 14 days. Following the last immersion in acid beverages, the samples were washed with distilled water and dried. The dental sections were analyzed morphologically, on a Vega II LSH (Tescan, Czeck Republic) electronic microscope equipped with a scanner. The calcium and phosphorus ion concentrations in the enamel were determined with an EDX Quantax QX2 (Bruker/Roentec, Germany) detector. The values of these concentrations were recorded for each sample (expressed as weight percent) and the mean concentration value was calculated for each group in part. The mineral loss was reported as relative variation of calcium (Δr Ca) and phosphorus (Δr P) ion concentrations, with formula : Δr = mean value of ion concentration in the control batch - mean value of ion concentration after immersion in the tested beverages/mean value of ion concentration in the control group x 100. Table 1. Composition of the analyzed beverages Beverage Composition Producer Gatorade 5-hour Energy Powerade water, sugar, maltodextrin, citric acid, mineral salts (0.2%) (sodium chloride, sodium citrate, potassium phosphate, magnesium oxide), stabilizers (E414, E445), ascorbic acid, natural aroma, sucrose, acesulfame potassium, beta caroten Vitamines B1, B12, niacin, folic acid, citicoline, tyrosine, phenylalanine, taurine, malic acid, glucuronolactone, caffeine water, glucose, fructose, citric acid, potassium chloride, potassium citrate, magnesium chloride, calcium chloride, potassium phosphate, gum arabic, glyceric esters of wood resin, acesulfame potassium, sucrose, aromas, colouring agents Pepsi Cola Co. Living Essential Coca Cola Co. 144 Volume 5 Issue 2 April / June 2015

ON THE EROSIVE EFFECT OF SOME BEVERAGES FOR SPORTSMEN UPON DENTAL ENAMEL 3. RESULTS SEM aspects of surface morphology, in some samples from the control group and also in the three experimental groups, are illustrated in Fig. 1 a-d. Erosion zones may be observed at enamel level, with a pinched aspect in the samples subjected to the action of acid beverages, along with zones of interprismatic demineralization, more obvious in the samples immersed in Gatorade (Fig. 1.b). a. SEM x500 b. SEM x500 c. Sem x 500 d. SEM x500 Fig. 1. a. Sample from the control batch; b. Sample from the batch tested against Gatorade; c. Sample from the batch tested against Powerade; d. Sample from the batch tested against 5-hour Energy Within the control batch, the values of calcium concentration varied between 28.54 wt% and 33.15 wt%, while those of phosphorus - between 11.98 wt% and 13.06 wt%. In the group formed of samples immersed in Gatorade, calcium concentration varied between 26.93 wt% and 29.06 wt%, and the phosphorus one - between 10.53 wt% and 11.36 wt%. When the samples were immersed in 5-hour Energy, the values of calcium concentration varied between 28.06 wt% and 32.20 wt%, and those of phosphorus - between 11.97 wt% and 12.64 wt%, whereas the concentration values for the samples immersed in Powerade ranged between 26.73 wt% and 29.84 wt% (for calcium), and between 11.18 wt% and 11.86 wt%, respectively (for phosphorus). A decreasing tendency was recorded in the mean values of ion calcium concentrations in the groups in which the enamel samples had been subjected to the action of beverages for athletes, from 32.34 wt% in the control group to 30.69 wt% in the group testing 5-hour Energy, to 29.35 wt% in the group testing Powerade and 28.91 wt%, respectively, in the batch testing Gatorade. The same tendency was also registered for phosphorus ions when, from a value of 12.42 wt% in the control, the mean concentration values reached 11.96 wt% in the group testing 5-hour Energy, 11.63 in that testing Powerade and 11.14 wt%, respectively, in the group testing Gatorade. The relative variation of calcium and phosphorus ions in the three experimental groups is listed in Table 2. Table 2. Relative variation (%) of the calcium and phosphorus ions from the enamel under the action of the tested beverages Gatorade 5-hour Energy Powerade Δr Ca 10 5 9 Δr P 8 3 6 The highest relative variations of calcium and phosphorus (10%, respectively 8%) ions were registered with Gatorade, followed, in decreasing order, by Powerade for which variations of 9%, respectively 6%, were recorded, and by 5-hour Energy, for which the relative losses were of 5%, respectively 3%. 4. DISCUSSION A regular and frequent consumption of beverages for athletes caused higher carious experience and dental wear in time [9]. A too frequent consumption of such beverages and, consequently, exposure to the acids present both in these liquids and/or resulted from sugars bacterial fermentation might induce both dental erosions and carious lesions. Even if these International Journal of Medical Dentistry 145

Cosmin ARNAUTEANU, Sorin ANDRIAN, Gianina IOVAN, Andrei GEORGESCU, Simona STOLERIU beverages are to be consumed by persons who make special physical efforts during intense sporting activities, they are also consumed by a much larger population segment, exceeding the consumption of water, which suggests that these beverages are much more attractive as to their organoleptic properties [10]. All beverages tested in the present study evidenced erosive potential upon the enamel, which agrees with the results of other investigations [1]. SEM analysis of the enamel samples showed obvious morphological modifications, the most important ones being observed after immersion in Gatorade. Similar aspects on the erosive effects induced by Gatorade have been mentioned by other researchers [11]. Previous researches put into evidence the erosive potential of some well-known beverages for athletes, whose ph ranged between 2.4 and 4.5, yet with a surprising variability of titrable acidity [12,13]. All beverages for athletes tested in the present study have ph values below 5.5, considered as the critical ph at which enamel demineralization begins. As known, erosion is inversely proportional with the ph of the acid solution. Other investigations attested that the ph of beverages in itself had no significant influence upon the dissolution of the enamel exposed to the action of acid beverages [14,15]. Anyway, titrable acidity is viewed as a more reliable index of the erosive potential, as it indicates rather the total amount of protons capable of dissociation than the total concentration of protons from solution. Many of the beverages for sportmen are prepared from fruits or acid components which may contribute to inducing dental erosion. The citric and phosphoric acids have a pronounced erosive effect upon the hard dental tissues [16,17]. In the present study, the beverages containing citric acid (Gatorade and Powerade) appeared as more erosive than the one containing malic acid (5-hour Energy). The saturation degree in calcium, phosphates and fluorine ions of beverages, comparatively with the minerals present in the hard dental tissues, will also influence the erosive potential [18]. Nevertheless, the presence of calcium and of the phosphate in the oral fluid will increase demineralization. Non-saturation of this aqueous phase towards hydroxyapatite and fluorapatite in vitro provoked dental erosion and not caries, which explains why the presence of calcium in acid beverages tended to inhibit demineralization, yet without knowing exactly at what concentration values the phenomenon definitely occurs [12]. The technology of adding calcium, accompanied by a corresponding ph adjustment an operation previously applied to carbonated and soft beverages, for reducing their erosive potential might be also applied to beverages for athletes. 5. CONCLUSIONS All beverages for athletes investigated in the present study evidenced an erosive potential upon the dental enamel. Among them, most aggressive appeared Gatorade, followed by Powerade and 5-hour Energy. References 1. Rees J, Loyn T, McAndrew R. The acidic and erosive potential of five sports drinks. Eur J Prosthodont Restor Dent. 2005; 13 (4): 186-90. 2. Woltgens JH, Vingerling P, de Blieck-Hogervorst JM, Bervoets DJ, Enamel erosion and saliva. Clin Prev Dent. 1985; 7: 8-10. 3. Mathew T, Casamassimoa PS, Hayesb JR. Relationship between Sports Drinks and Dental Erosion in 304 UniversityAthletes in Columbus. Caries Res. 2002; 36: 281 287. 4. Al-Dlaigan YH, Shaw L, Smith A. Dental erosion in a group of British 14-year-old school children. Part I: Prevalence and influence of differing socioeconomic backgrounds. Braz Dent J. 2001; 190:145 149. 5. Ganss C, Klimek J, Giese K. Dental erosion in children and adolescents: A cross-sectional and longitudinal investigation using study models. Community Dent Oral Epidemiol. 2001; 29: 264 271. 6. Deery C, Wagner ML, Longbottom C, Simon R, Nugent ZJ. The revalence of dental erosion ina United States and a United Kingdom sample of adolescents. Pediatr Dent. 2000; 22: 505 510. 7. Horswill CA, Stofan JR, Horn MK, Eddy DE, Murray R. Effect of exercise and fluid consumption on salivary flow and ph. Int J Sports Med. 2006; 27(6): 500-504 8. Jarvinen VR, Rytomaa II, Heinonen OP. Risk factors in dental erosion. J Dent Res. 1991; 70: 942-947. 9. Bryant S, McLaughlin K, Morgaine K, Drummond B. Elite Athletes and Oral Health. Int J Sports Med. 2011; 32(9): 720-724. 146 Volume 5 Issue 2 April / June 2015

ON THE EROSIVE EFFECT OF SOME BEVERAGES FOR SPORTSMEN UPON DENTAL ENAMEL 10. Coombes JS. Sports drinks and dental. Am J Dent. 2005; 18(2): 101-104. 11. Owens BM, Kitchens M. The erosive potential of soft drinks on enamel surface substrate: an in vitro scanning electron microscopy investigation. J Contemp Dent Pract. 2007; 8(7): 11-20. 12. Milosevic A. Sports drinks hazard to teeth. Br J Sports Med. 1997; 31(1): 28-30. 13. Birkhed D. Sugar content, acidity and effect on plaque ph of fruit juices,fruit drinks, carbonated beverages and sport drinks. Caries Res. 1984; 18: 120-127. 14. Jain P, Nihill P, Sobkowski J, Agustin MZ. Commercial soft drinks: ph and in vitro dissolution of enamel. Gen Dent. 2007; 55(2): 150-154. 15. von Fraunhofer JA, Rogers MM. Effects of sports drinks and other beverages on dental enamel. Gen Dent. 2005; 53(1): 28-31. 16. Stoleriu S, Iovan G, Pancu G, Georgescu A, Sandu AV, Andrian S. In vitro evaluation of acidic beverages effect in dentine and cement, with and without storage in artificial saliva. Mat Plast. 2014; 2:162-166. 17. Stoleriu S, Iovan G, Georgescu A, Sandu AV, Roşca M, Andrian S. Study Regarding the Effect of Acid Beverages and Oral Rinsing Solutions on Dental Hard Tissues. Rev Chim. 2012; 63(1): 68-73. 18. Lussi A, Jaggi T, Scharer S. The influence of different factors on in vitro enamel erosion. Caries Res. 1993; 27: 387-393. International Journal of Medical Dentistry 147