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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

Soft drinks, excluding milk and water, have been
suggested as causing damage to the teeth for two
reasons. Firstly, the low pH and high titratable
acidity of some drinks may lead to erosion of
enamel surface. Secondly the sugars in drinks are
metabolized by plaque microorganisms to generate
organic acids that bring about demineralization
leading to dental caries. Over the years efforts have
been made by manufactures to try and modify the
composition of drinks so as to reduce these
potentially harmful effects on teeth. Literature
pertaining to the use of soft drinks and dental
health is reviewed using MEDLINE with particular
* Corresponding author. Tel.: C44 113 343 6138; fax: C44 113
343 6140.
E-mail address: jinoustahmassebi@bramhopedentalclinic.
com.uk (J.F. Tahmassebi).
0300-5712/$ - see front matter q 2004 Elsevier Ltd. All rights reserved.
reviews the background to the use of these drinks,
findings and recommendations of the past studies
and discusses the modification made accordingly to
the composition of the soft drinks that are present
on the market.
Background
In 1990 in an article titled ‘Soft drinks, infants’ fruit
drinks and dental health’ Grenby1 wrote “a lot of
research has been done on the influence of various
kinds of solid foods on dental health, but compara-
tively little has been published on the effects of
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.
The commercial sale of soft drinks has increased
by 56% over the last 10 years and it is now estimated
that they will keep rising at about 2–3% a year.2
Soft drinks—a review
The average daily requirement for water in man is
2–3 l, of which, in Western countries, more than
half comes from soft drinks.3 In many so-called
advanced societies, the use of milk as a main liquid
source for children, is declining while consumers
drink greater amounts of soft drinks, including fruit
juices and carbonated beverages.3
Historical aspects of soft drinks
No such drinks occurred until the latter half of the
nineteenth century. Before that time drinks, as
refreshments, mostly included well water, milk,
ciders (fermented apple juice), ales and beers, and
at certain times of the year drinks known as
cordials, such as lemonade and dandelion and
burdock. The latter were made out of water and
extracts from various fruits. But they were very
limited in their availability being seasonal.
Changes started to occur in the 1890s when
entrepreneurs developed alternative drinks based
on cola and sarsaparilla extracts. The earliest such
drink is thought to be Moxie made by a drugstore
(chemist) owner in Lisbon Falls (Maine, USA) in
1884.4 The drink was based on cola extract,
sarsaparilla and carbonated and believed to have
medicinal properties. Soon afterwards other very
similar drinks were developed including Coco-Cola
and Pepsi-Cola. Industrial production of these
drinks together with the development of preserva-
tives made so called ‘soft drinks’ more widely
available, particularly in the USA. Other drinks
based on different flavours, lime, lemon, orange,
aniseed, etc. were introduced so that today there is
a plethora of soft drinks available. By the time of
World War I, researchers at the Agricultural
Research Centre (Bristol, UK) were developing
cordials based on different fruits as sources of
Vitamin C. With the outbreak of war one fruit
cordial in particular, based on blackcurrant juice,
was manufactured for distribution to children to
ensure that they had a sufficient intake of
Vitamin C. After the war the product license was
sold and then manufactured as ‘Ribena’. Soft drinks
based on fruit cordials are now widely popular
because of their refreshing taste.
A further aspect of importance, however, is that
these soft drinks and cordials can be bottled and are
free from contamination when many natural water
sources might not be. It is sometimes forgotten that
widely available and reliable safe drinking water is
only relatively recent and still not common in much
of the world. Besides being safe, these drinks are
also easily assimilated energy source.
3
Dental caries
Soft drinks and dental caries
The literature on dental caries and soft drinks now
dates back to the 1940’s when studies by Bibby and
others5,6 looked at the consumption of such drinks
compared with dental caries prevalence. Compari-
sons were made using reported consumption of soft
drinks by states in the USA with dental caries data,
state by state, collected from recruits to the armed
forces. No relationship could be found. Indeed the
highest soft drink consumption per head of
population was associated with the lowest dental
caries prevalence.
A more recent study in the USA showed a positive
relationship between cumulative caries scores and
the frequency of mealtime and between-meal use
of carbonated beverages.7 However, the strength
of this conclusion was weakened by the use of only a
one-day diet analysis to represent the foods and
drinks used over the period of up to 20 years during
which the observed caries developed.
The susceptibility of enamel to dissolution
Young, immature enamel is porous and more easily
dissolved by acids until the final intra-oral maturation
of the surface enamel has occurred.8 Normally as the
immature enamel is bathed by salivary ions, it
becomes progressively harder, less penetrable and
fairly resistant to acid attack.9 However, enamel
maturation takes time and therefore young children
are at greater risk of dental caries if the acidogenic
challenge is excessive. Attempts to overcome this
problem with new drinks, such as herbal drinks, have
not met with a great deal of success.10 Therefore, it is
the time period after eruption of the primary and
permanent teeth and the intra-oral milieu that is
crucial as to whether a tooth is damaged by an
acidogenic or cariogenic challenge. These time
periods are confined to the very young, less than 3
years of age and school age until the completion of
the normal complement of permanent teeth. That is
why the concern about soft drinks and teeth is largely
focussed on children. However, in recent years
another factor, of erosion in older populations has
attracted attention as evidence of damage to the
older dentition comes to the fore.11
Soft drinks: acidogenic and cariogenic
potential
When oral acids are produced by the sugars or are
inherent in a food or drink their ability to damage
4 J.F. Tahmassebi et al.
tooth enamel is described as acidogenicity.
Similarly the ability of a food or drink to foster
dental caries is termed cariogenicity and it has been
suggested that when it can be measured the term
‘cariogenic potential index (CPI)’ may be used.12
A number of attempts have been made to rank
foods and drinks by this means, although not always
with universal agreement.13–15
The potential acidity and cariogenicity of soft
drinks consumed by young children and adolescents
have been the subject of many studies in the past 30
years.16 While the research data have never been
completely conclusive many studies have shown that
when drinks containing sugars are consumed, there
is a drop in the pH of the dental plaque in vivo. This
acid is neutralised by saliva flow and salivary
components so that normally within 20–30 min
plaque pH returns to resting levels.16 A single acidic
attack is therefore of minor importance but if
repeated the ability of the saliva to deal with the
acid becomes less and less. Hence, the danger is the
frequent use of soft drinks over time.11
With the frequent consumption of acidic,
sugar-rich soft drinks, children are at a higher risk
of acid demineralisation and ultimately leading to
erosion and caries development. If the challenge is
frequent enough and there are few or no protective
factors this damage can be quite aggressive. This is
particularly with nursing (early childhood caries,
ECC), caused by the frequent consumption of sugar
drinks (both commercial and natural as fruit juices)
when used frequently and poor oral hygiene.17 It
should be noted then even natural fruit juices have
an acidogenic potential with non-milk extrinsic
sugars.18
Early childhood and adolescence are particular
periods in which the risk of dental caries remains
especially high. Many factors contribute to the
initiation and progression of dental caries. One
factor with the potential for being significant is high
consumption of sugars and one product that tends
to contribute to the amount of sugars ingested is
soft drinks.
Natural versus other soft drinks
In the late 1980s much attention was drawn to the
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’
or ‘containing natural sugars’. Natural sugars being
glucose and fructose, it was believed that these
drinks were safe for the teeth. However, Frostell19
showed that all sugars have virtually the same
potential for acid production in plaque as sucrose
and subsequent research by Duggal and Curzon20
showed that these drinks had a similar acidogenicity
and hence cariogenic potential, as drinks that
contained sucrose.
Various newer carbohydrates have been intro-
duced in the last decade which are now found on
many food and drink labels. Maltodextrins and
glucose syrup are extensively being used and are
carbohydrates derived from maize starch, belonging
to a group of oligosaccharides (long chain polysac-
charides) composed of glucose, three units and
above in length. They are obtained by acidic and/or
enzymatic hydrolysis of starch, with subsequent
drying to make free flowing powders.21 They usually
contain glucose, maltose, maltotriose and higher
polymers of glucose, depending on the degree and
method of hydrolysis. Therefore, maltodextrins are
also called glucose polymers. The amount of glucose
and maltose present in maltodextrins is relatively
low as compared with higher chain saccharides.
Maltodextrins are increasingly being used in the food
industry especially in baby drinks and baby dried
food as an anti-caking agent. However, there are
few data in the dental literature on the effect of
these carbohydrates on pH of dental plaque in vivo.
A study carried out by Moynihan et al.22 investigated
the acidogenicity of glucose polymers as 10%
solutions in water, in cow’s milk, or in a solution of
milk substitute (calogen). They reported that
glucose polymers caused a decrease in plaque pH
but to a significantly lesser extent than 10% sucrose,
and also the glucose polymers were equally acido-
genic when given in water, milk or calogen.
A study of the acidogenic potential of various
maltodextrins23 concluded that though maltodex-
trins appeared to be significantly less acidogenic
than 10% sucrose, they can lead to a substantial
drop in plaque pH and may therefore have a
potential to cause demineralisation of enamel.
A recent study by Marshall et al.24, carrying out a
dental examination on 695 children between 4–7
years age suggested that an increase in consump-
tion of regular soda beverages, powdered
beverages and to a lesser extent 100% juice, may
increase dental caries rates in children. Assessment
of erosion in 14 year-old children in the UK revealed
that over 80% regularly consume soft drinks.25
Erosion
Soft drinks and dental erosion
Erosion is due to the loss of the outermost surface
of enamel and occurs when the surface pH falls
Soft drinks—a review
below 5.5.26 It is important to emphasise that the
erosion of dentine becomes extremely relevant
once the enamel has been breached. The 1993
National Survey of Child Dental Health conducted in
the United Kingdom reported over half of the 5 and
6 year-olds had erosion, 25% with dentinal involve-
ment of the primary dentition. In the 11–14 year age
group, almost 25% had erosion, 2% with dentinal
involvement in the permanent dentition.27
Erosion may be caused by extrinsic or intrinsic
acids or combination of extrinsic and intrinsic acids.
Extrinsic acids include acidic beverages, snacks or
environmental exposure.28 Intrinsic erosion is
caused by gastric acids and includes indigestion
and recurrent vomiting as part of an eating
disorder. Although the hydrochloric acid from the
stomach is responsible for intrinsic erosion, extrin-
sic erosion is often caused by extrinsic acids, many
of which come from fruit or fruit-based drinks. The
reported incidence of tooth erosion associated with
the use of acidic soft drinks has been increasingly
documented.11 The erosive potential of beverages
is thought to involve several factors, including low
pH and the buffering capacity of the drink. Soft
drinks may contain several different types of acid
that contribute to the low pH value. Some may be
inherent and derived from the natural components
used in manufacture. Thus fruit juices and fruit
flavoured drinks are made from a concentrated
source of fruit and consist of organic acids derived
from the fruit such as citric acid from oranges,
tartaric acid from grapes and malic acid from
apples.29 It is important to mention that fruit teas
which are based on dried fruit products have also
erosive effect on enamel.30
Other acids will come about during the manu-
facturing process designed to improve organo-
leptic properties of the drink, such as carbonation.
Carbonated beverages will contain carbonic acid
formed by carbon dioxide in solution. Even when
the carbon dioxide has been blown off and the
drinks have become ‘flat’ the pH remains low.31
This shows that soft drinks have an inherent acidity
due to other acids that are added to stimulate
taste. These other acids include phosphoric and
citric acids present in cola-type drinks and other
acids that provide flavour and also carbonic acid
under pressure in sparkling drinks.32
Finally, preservatives, such as added vitamin C
(ascorbic acid), may also contribute to the acidity
of soft drinks.29 Fruit acids and additives such as
phosphoric acid are not all equally erosive, and as
would be expected from measurements of their
acidity, there is wide variation between different
fruit juices. The ability of a drink to resist pH
changes brought about by salivary buffering may
5
inevitably result in prolonged period of oral acidity
and, therefore, may play an important part in the
erosion process.33
Diet soft drinks
Because of the concern in recent years over weight
and the perceived need to slim, diet drinks were
developed. These drinks are also marketed as
‘sugar free’ drinks. They are based on using
artificial sweeteners so as to reduce the caloric
content of the drinks.34 But these drinks have an
erosive potential that may enhance enamel demi-
neralisation. In addition, there appears to be a
rebound phenomenon whereby having consumed a
diet drink the body anticipates an intake of calories
which is not forth coming. Accordingly the satiety
reflex is not induced and the individual then eats or
drinks more.35 There are also a number of health
concerns with regard to consumption of artificial
sweeteners.36
Acidogenicity and erosion
It has been traditionally understood that acidity,
the measured pH, is an accurate indicator of the
erosive potential of a food or drink.37 Baseline pH
values give only a measure of the initial hydrogen
ion concentration and provide, therefore, no
indication as to the presence of undissociated
acid. It is now thought that the total titratable
acidity is a more accurate measure of the total acid
content of a drink, and may, therefore be more
realistic means of predicting erosive potential.38,39
Reduction in erosive potential
Interest in dental erosion has led to increasing
attention to ways in which the erosive potential of
soft drinks and other foods might be modified.40
One way in which the effects of acidic drinks may be
combated is by modifying their composition so as to
reduce their demineralisation action. As erosion is a
consequence of acid attack, an obvious way of
curbing it is by lowering the acid content of the
drinks. However, this raises formulation difficul-
ties, as the taste perception of the drinks is related
to their tangy flavour and acidity.
Another way to reduce the erosive properties of
soft drinks is by diluting the drinks with water.
Cairns et al.,41 investigated the potential dental
effects of diluting juices by measuring their acidity
levels. Their results showed that while dilution had
very little effect on the measured pH values, the
titratable acidity reduced as the drink became
6 J.F. Tahmassebi et al.
more dilute. However, the authors mentioned that
it remains unlikely that the drinks would ever be
consumed at a ‘safe’ level of dilution due to
diminished taste and colour.
Modification of soft drink formulations
Efforts have been taken to modify soft drinks by
either adding or deleting certain components so as
to reduce their harmful effects on teeth. One
approach has been to reduce the total sugar
concentration in the drinks. The total sugar
concentration of most fruit drinks is usually
between 7 and 10%.42 However Imfeld43 reported
that even very low sucrose concentrations, around
0.1–1%, can cause acidogenic response in plaque. In
a study by Toumba and Duggal44 two new formu-
lation of a blackcurrant drink (7% juice with 0.49%
and 10% juice with 0.65% sugars concentration,
respectively) were compared with an apple and
blackcurrant drink with no added sugar (0.8%), and
a mixed citrus drink with a higher carbohydrate
concentration (4.5% w/v). It was concluded by the
authors that the two new formulations with low
levels of carbohydrate had a low acidogenic
potential and did not depress the plaque pH below
the critical level and their consumption could not
be considered to pose a significant risk for enamel
demineralisation. This drink was manufactured as
‘Ribena ToothKind’.
Modifying agents: calcium and/or phosphate
supplements
One of the earliest studies to report that the
addition of calcium and phosphate ions to acid
solutions had an effect on the appearance of acid
attack on human enamel was in 1953 by Besic.45 It
was observed that as the concentration of calcium
and phosphate ions increased in acidic solutions
they became more protective. In a later study, Hills
and Sullivan46 reported that saturation of the
demineralising medium with calcium and phosphate
prevented enamel dissolving at pH 7.0–4.0, but
exact details of the calcium phospshate used were
lacking. In an experiment by Reussner et al.,47 using
rats, monocalcium phosphate at 0.15 or 0.3%
reduced erosion effectively when added to a
grape powder beverage mix, reconstituted frozen
orange juice, and reconstituted orange-flavoured
beverage mix. The authors commented that this
compound has good solubility and no taste draw-
backs. Another interesting trial which was con-
ducted on a calcium salt was by Beiraghi et al.,40
who compared cola drink with a cola drink
supplemented with 5% calcium lactate in a group
of rats. Their results showed that supplementation
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
buffering effect of various soft drinks that were
available on the Danish market. The pH and the
concentrations of calcium, phosphate and fluoride
were determined. The buffering effect was deter-
mined by titration with sodium hydroxide. Human
teeth (nZ54) covered with nail varnish except for
3!4 mm windows were exposed to 1.5 l of the drink
for either 7 days or 24 h under constant agitation.
They reported that the dissolution of enamel
increased logarithmically inversely with the pH of
the drink and parallel with the solubility of enamel
apatite. The results showed that orange juice with
pH of 4.0, supplemented with 40 mmol/l calcium
and 30 mmol/l phosphate did not erode the enamel
as the calcium and phosphate saturated the drink
with respect to apatite.
Hughes et al.,49,50 in a series of published studies
have demonstrated the ability to create an extre-
mely low erosive beverage to enamel in situ by
product modification with respect to raising the pH,
lowering the titratable acidity and addition of
calcium (Ribena ToothKind). They mention that
whilst these modifications have resulted in a
product with very low erosive properties, other
characteristics such as consumer acceptability and
stability of the ingredients could be enhanced. The
most recent study by West et al.51 has shown that
addition of xanthan gum to the Ribena Toothkind
will retain the low erosive properties of the drink
with additional benefits of taste flexibility and
beverage stability.
Barlett et al.,52 investigated the effect of a
modified version of a popular soft drink that claimed
to reduce the potential for dental erosion. The study
compared the plaque pH response to the modified
and the original formula soft drink in 15 subjects
without erosion. The modified drink had a reported
pH of 3.8, a titratable acidity of 0.182 and a calcium
content of 195 ppm, compared with the unmodified
drink’s pH of 2.85, 0.2 titratable acidy and 20 ppm of
calcium. They reported that, although the erosive
potential had been reduced by modifying the soft
drink, it had not been eliminated.
Modifying agents: citrate
Another approach has been the supplementation of
drinks with citrate. Duke et al.,53 conducted a study
Soft drinks—a review
to assess whether drinks formulated with relatively
low levels of citrates and citric acid exhibited a
reduced acidogenic response in the plaque. They
concluded that moderate levels of citrate in sugar-
based drinks reduced the level of the pH of plaque
and thus reduced potential cariogenicity. However,
it has been pointed out that the theory that citrate
could be beneficial is erroneous because of its
strong chelating properties. On the other hand,
attention has been drawn to the fact that the
chelating properties of citrate should be of little
importance at the low pH levels of acidic drinks.54
In a study by Pollard et al.,55, addition of 0.1–02%
citrate to a 10% sucrose solution significantly
reduced the acidogenic response in the plaque
and 0.103% citrate was also effective as a sup-
plement in a blackcurrant drink.56 Speculation on
this observed beneficial effect was based on some
known properties of citrate. Acid citrate and citric
acid at relatively low concentrations are known to
inhibit phosphofructokinase.57 Due to this inhibition
of glycolytic enzymes, it may, therefore, reduce
the acid which forms in the dental plaque by
bacterial fermentation of sugars. Another comment
made was that the stimulation of salivary flow by
citrate may lead to quicker clearance of acid after
an acidogenic challenge. Although raising the
concentration of citrate might increase the erosive
potential of drinks, it was felt that at low
concentrations it might help to buffer the acids in
fruit based drinks, by this means reducing their
erosiveness. Thus the usefulness of citrate in
curbing erosion is unclear.
Modifying agents: fluoride
Fluoride has been used successfully in the preven-
tion of dental caries. Although there remains some
differences of opinion as to its main mechanism of
action, it is known to improve the acid resistance of
enamel when incorporated into the enamel apatite
structure. It is however, an open question whether
fluoride can prevent, at least to some extent,
erosion of the enamel caused by acidic soft drinks
and fruit juices. Taking into consideration the low
pH of the soft drinks and the high solubility of both
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.
However, Lussi et al.,58 observed that fluoride
levels in a range of juices and drinks were
statistically correlated with their potential erosive-
ness in vitro, measured by surface hardness and
iodide permeability.
7
Table 1 Summary of factors considered to modify
soft drinks to reduce their harmful effects on teeth.
Reduce the total sugar concentration
Diluting the drinks by addition of water
Addition of calcium and/or phosphate supplements
Addition of a moderate levels of citrate
Addition of Fluoride
*Modified drinks are unsuitable for infants.
Reussner et al.,47 noted the inhibition of erosion
in rats by sodium monofluorophosphate in one of
their four experiments, in which three other
phosphates and calcium chloride as additives to a
reconstitute powdered beverage, were ineffective.
The anti-erosive action of 15 ppm fluoride added to
a sports drink mixture, diluted to give a sugars
content of 6%, pH 3.2 and given to rats ad libitum,
was reported by Sorvari et al.,59. In a recent study
by Larsen60 very little effect of 4–6 ppm ionic
fluoride dissolved in the soft drinks was observed
and the author concluded that the acidic soft drinks
are capable of dissolving considerable amounts of
calcium fluoride and the erosion preventive effect
of even high fluoride concentrations is limited. In
another study, Larsen and Richards61 reported that
non-carbonated fruit-flavoured drinks contain con-
siderable amounts of acids which in vitro, induce
erosion in teeth similar to those induced by
carbonated soft drinks. Their results also showed
that drinks with pH above 3, saturated with CaF2,
reduced the in vitro development of erosion by 28%.
However, in drinks with pH below 3, erosion were
not affected, despite total fluoride concentrations
of 20 ppm. These authors concluded that it does not
seem advisable in a product for consumption to
increase the fluoride concentration any further in
an attempt to obtain a note worthy erosion
prevention.
Fluoride has also been tested as an addition to a
pure citrus (orange) drink in a study by Gedalia
et al.,62. The main object of this study was the
suppression of caries. Groups of 6–9 year-old
children were given the supplemented and control
drinks for 3 years. The results showed 30% reduction
in the caries incremental rate. A summary of
modifying factors are shown in Table 1.
Discussion
Soft drink intake has been negatively associated
with milk, calcium, magnesium, vitamin A, and
vitamin C intake in teenagers living in the USA.63
Most soft drinks and fruit juices have minimal
8 J.F. Tahmassebi et al.
nutritional content and contain negligible amounts
of the Recommended Daily Allowance (RDA) for
vitamins, minerals, and protein. Accordingly nutri-
tionist have suggested that sweetened beverages
may curb a child’s appetite and displace protein
and calcium-rich foods needed for proper growth,
although there is no scientific evidence for this.
High soft drink consumption can also lead to
excessive energy intake, which may contribute to
childhood obesity, a growing problem in children in
some countries.64
Children start consuming soft drinks at an
increasingly younger age, and this increases
through young adulthood. Indeed it has been
noted that 22% of one and 2-year-old children
consume soft drinks with an average of nearly one
cup per day.65 Food acceptance by young children
has been shown to be largely dependent upon two
characteristics: sweetness and familiarity. There is
evidence that in utero there is a preference for
sweet taste66 and that continuous exposure to
sweets sustains a neonate’s preference for this
taste. The liking for sweetness is thought to be
innate and is related to the fact that nearly all
sweet tasting foods and drinks are ‘non-poisonous’.
Nevertheless, some studies have shown that sweet
preference changes with continued exposure to
sugars, and the more sugars people consume, the
higher their threshold for sweetness67, indicating a
possible increased risk for caries.68
It is mentioned that soft drink vending machines
have contributed to the substantial increase in soft
drinks consumption and are now the largest source
of added sugars in the USA, accounting for one third
of total intake.69 Manufacturers of soft drinks
market their products by using the message,
among others, that these drinks are healthy and
may be consumed at all times of the day. The
essence of this message is that these drinks are 90%
water and contain sugars found in nature often
derived from fruits. With the expanding use of soft
drinks, especially in younger age-groups, there is
growing concern within the dental profession over
the problem of their erosiveness and risk of causing
demineralization leading to caries. There has been
much interest in ways in which it can be reduced.
Product modification is one option that has been
explored (see Table 1). It can be seen from the
references cited above that the main area in which
there has been major activity is in addition of
compounds or mixtures supplying calcium and
phosphate. It must not be overlooked that the
addition of calcium and phosphate salts to soft
drinks has an impact on the flavour as well as the
pH, depending on the salt used and the amount, if
calcium is not well masked, the products tend to
develop a chalky taste. As noted above the
organoleptic properties of a drink are crucial to
its use.
One reason for most soft drink manufacturers
concentrating on product modification with calcium
and phosphate compounds is that there is less
likelihood of raising regulatory obstacles than some
of the other substances which have been con-
sidered. Fluoride for example, has been shown by
Gedalia et al.,62 to reduce the caries incremental
rate by 30% when added to soft drinks. However, to
avoid any risk of over- or uncontrolled consump-
tion, intake levels would need to be carefully
monitored and controlled, which would be difficult
if freely available in soft drinks. A major barrier to
its application for this purpose would be the
prospect of political activist campaigns that have
helped to curtail fluoride use in products other than
oral hygiene preparations.
Other factors were felt to be more important in
considering the cariogenic potential of diets includ-
ing the use of other foods such as baked goods. A
diet does not consist of drinks alone but a complex
mixture of foods and drinks. In any discussion of the
use of soft drinks the total diet must be considered.
Ismail et al., 7 in an extensive study of the
relationship of diet (including soft drinks) and
dental caries concluded that in modern society
where there is extensive use of fluoride products
the role of diet has become of lesser importance.
Nevertheless, where there is frequent use of
acidogenic and erosive drinks there has to be an
increased risk.
As it seems very unlikely that populations can be
induced to reduce their use of soft drinks so product
modification by manipulating the acidity levels has
gained increasing attention. The addition of
citrate, noted above, has been one aspect of this.
Many products already contain citrate and modifi-
cation of citrate level in drinks has been carried
out, although there has been some scepticism over
the usefulness of citrate on account of its reputed
powerful chelating properties. It must also be
pointed out that product re-formulation is no
simple matter as many of the additives proposed
could exert adverse effects on other ingredients in
the drinks. As the manufacturers point out, detailed
tests of flavour acceptability and organoleptic
properties would be needed.
Other suggestions for minimizing the damaging
effect of soft drinks include new formulations with
low levels of sugars44 and modification to the
packaging and the route of intake. Grobler et al,29
observed that the use of a straw was the least
harmful method of drinking sugars containing drinks
and in a later study Tahmassebi and Duggal70
Soft drinks—a review
showed that drinking with a straw resulted in a less
pronounced pH drop in plaque. Accordingly, use of a
straw for drinking potentially damaging soft drinks
should be encouraged. It should be emphasised that
the straw must be introduced beyond the incisor
teeth to minimise erosion.
The relationship of foods and drinks to dental
caries is a very complex one.71 A systematic review
of the literature by Burt et al.,72 concluded that the
relationship between sugar consumption and caries
is much weaker in the modern age of fluoride
exposure than it used to be. However they
mentioned that controlling the consumption of
sugar remains a justifiable part of caries preven-
tion, if not always the most important aspect.
Attempts over the past 100 years to make safe foods
and drinks in a modern diet have not been overly
successful. At the same time prevention pro-
grammes based on admonishing people not to use
foods and drinks that are appealing and tasteful
have been singularly unsuccessful. A rationale
approach of encouraging the sensible use of drinks
and the modification of drinks to render them less
harmful would seem to have a greater likelihood of
achieving the aims.
Conclusion
Although the erosion and caries processes are
different in their histological appearance, the two
conditions occurring concurrently could be deleter-
ious to dental hard tissues. As dental professionals,
there is a need to educate our patients about the
consequences of frequent soft drink consumption
and provide positive suggestions to minimise
Table 2 Recommendations for the safer use of soft
drinks in dentistry.
Always follow the manufacture’s instructions on usage
and dilution
Ideally serve only at mealtimes
Keep drinking times short
Use a straw whenever possible
Cooled soft drinks have less erosive potential
Drinks should not be added to bottles or reservoir
feeders, nor given at night time
Drinks should not be swished around the mouth or held
in contact with tooth surfaces
Avoid tooth brushing immediately following con-
sumption of an acidic drink
Finish meals with something to neutralise any acids,
e.g. cheese or milk
Low erosive beverages may be a valuable alternative
to other acidic soft drinks.
9
the risk. Negative admonitions to stop using these
drinks is not likely to be successful. Guidance for
dental health, therefore, should follow current
guidelines to limit intake of soft drinks, other than
milk or water, to meal times, and to brush teeth
twice daily with fluoride toothpaste. Where advice
on reducing soft drink consumption is not likely to
be accepted an emphasis on using modified drinks
should be used. Table 2 shows a summary of
recommendation for safe use of soft drinks.
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