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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 106-110

Role of acidic additives in noncaloric sweeteners in causation of dental erosion


Department of Public Health Dentistry, Bhojia Dental College and Hospital, Budh (Baddi), Solan, Himachal Pradesh, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Avijit Avasthi
Bhojia Dental College and Hospital, Budh (Baddi), Solan - 173 205, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmd.ijmd_34_18

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  Abstract 


Dental erosion is a nondestructive carious process, slowly dissolving tooth structure because of extrinsic, intrinsic, and idiopathic causes, resulting in painless loss of tooth structure without the involvement of microorganisms. Polyols/noncaloric sweeteners are promoted extensively owing to cariostatic action and low-glycemic response, but pose a risk of dental erosion because of acidic additives incorporated into sugar-free products which cause demineralization of enamel. Erythritol, sorbitol, mannitol, and xylitol are some of the polyols publicized in maintaining good oral health by the American Dental Association. A review of the existing literature was done by searching through databases such as PubMed, EBSCO, Hinari, and Sage on noncaloric sweeteners from February to end of May 2016 using keywords noncaloric sweetener, polyols, dental erosion, casein phosphopeptide (CPP) and amorphous calcium phosphate (ACP), nanohydroxyapatite, and prevention of erosion. Novel preventive strategies by infusing CPP ACP, milk protein casein, and fluoride into sugar-free formulations may resolve the cause of dental erosion.

Keywords: Polyol; sweetening agent; tooth erosion


How to cite this article:
Avasthi A. Role of acidic additives in noncaloric sweeteners in causation of dental erosion. Indian J Multidiscip Dent 2018;8:106-10

How to cite this URL:
Avasthi A. Role of acidic additives in noncaloric sweeteners in causation of dental erosion. Indian J Multidiscip Dent [serial online] 2018 [cited 2019 May 20];8:106-10. Available from: http://www.ijmdent.com/text.asp?2018/8/2/106/249121




  Introduction Top


Dental erosion is defined as irreversible loss of dental hard tissue by a chemical process that does not involve bacteria.[1] The dissolution of mineralized tooth structure occurs on contact with acids introduced into the oral cavity from intrinsic sources and habits (e.g., gastroesophageal reflux and vomiting) and eating disorders such as anorexia nervosa, bulimia nervosa, or extrinsic sources (e.g., citrus fruits, acidic beverages, iron tonics, and Vitamin-C chewable tablets) causing perimylolysis/smooth erosion of enamel.[1],[2] Dental erosion precipitates hypomineralization, resulting in softening of enamel, and decreases wear-resistance of both enamel and dentin. Reduced salivary secretion coupled with reduced buffered capacity of saliva decreases the concentration of calcium and inorganic phosphate in saliva, stimulating dental erosion. Softening of enamel is visible clinically, affecting palatal surfaces of maxillary teeth, which intensifies extending to occlusal surface of posterior teeth. Severe generalized erosion makes teeth hypersensitive because of dentin and pulp exposure.[2],[3]


  Determinants of Erosion Top


An interplay of biological and behavioral factors influences erosion. Reduced salivary flow rate, buffer capacity of saliva, and increase in oral clearance time of acids are biological factors influencing dental erosion. The frequency and duration of acid exposure, abnormal drinking habits, and contact time of acidic substance with tooth constitute behavioral factors.[4]

This review stressed upon the role of acidic additives incorporated in noncaloric sweeteners: confectionaries, candies, and chewing gums for flavor and taste causing dental erosion. A review of the existing literature was done by searching through databases such as PubMed, EBSCO, Hinari, and Sage on noncaloric sweeteners from February to end of May 2016 using keywords noncaloric sweetener, polyols, dental erosion, casein phosphopeptide (CPP) and amorphous calcium phosphate (ACP), nanohydroxyapatite, and prevention of erosion.


  Who All Affected? Top


Dental erosion is found to affect both children and adults. Xerostomics with decreased salivary flow are more likelihood of developing dental erosion. The prevalence of condition is higher in children[5],[6] when compared to adults although progression of erosion is at a similar rate for both primary and permanent teeth.[7]

Over the years, change in lifestyle has profoundly impacted the dietary habits of people. Increased health awareness has driven the demand for people to switch to noncaloric sweeteners which impart sweet taste and serve in reducing dental caries proven by field clinical trials.[8],[9],[10] Noncaloric sweeteners/polyols are now dispensed in bakeries, confectionaries, chewing gums, mouthwashes, and dentifrices and are promoted for patients with diabetes mellitus or hyperglycemia and xerostomia owing to low glycemic response and decreased incidence of dental caries when compared with conventional sugar and starches.[11],[12],[13] Likewise, increase in disposable income in developing Asian countries increases the demand for noncaloric sweeteners, and commercial market is estimated to be valued at USD 13.26 billion in 2015, which is estimated to reach USD 16.53 billion by 2020.[14]

However, sugar-free products have a hidden risk of erosion because of acidic additives which impart flavor and taste. The chemical constituents of sugar-free candies, gums, and drinks can stimulate erosion.[15] Acids in sugar-free preparations comprise primarily of citric acid, followed by malic acid, phosphoric acid, fumaric acid, and tartaric acid, which enhance taste and flavor and serve as preservatives. In vitro studies provide evidence to suggest that citric acid is an important contributor to dental erosion, because of more erosiveness compared to phosphoric and malic acid.


  Pharmacokinetics of Noncaloric Sweeteners/polyols Top


Polyols tend to metabolize in different ways when compared with conventional sugars. The absorbed portion is either metabolized generally by insulin-independent mechanisms or excreted via urine. The unabsorbed polyols are metabolized to short-chain fatty acids and gases by gut microflora.[15] Polyols are naturally derived from fruits and vegetables such as pumpkins, onions, olives, apples, berries, and cherries and examples of various polyols include xylitol, mannitol, and sorbitol. The American Dental Association way back in 1998 acknowledged the role of sugar-free foods and medications in maintaining good oral health.[16]


  Damaging Consequences of Additives to Polyols Top


The presence of acidic additives in sugar-free products alters the chemical constituents of various sweeteners, which subsequently result in erosion.[17] Some of the acidic additives added in sugar-free candies and gums are responsible for dental erosion.[18],[19],[20],[21] Several in vitro studies [Table 1] have shown that acidic additives added in candies and chewing gums cause a significant drop in salivary pH, which results in dental erosion.[18],[19],[20],[21]
Table 1: Acidic additives in sugar-free formulations

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  Role of Method of Drinking on Dental Erosion Top


Dental erosion also relies on the method of drinking, which was investigated in a study where participants consumed a sugar-free carbonated beverage by various methods involving holding a drink in mouth, short sipping, long sipping, nipping, and gulping. Holding drink in the mouth before sipping resulted in drastic fall in pH. Drinking method influences dental erosion by affecting tooth surface pH; thus, dietary counseling is recommended to decrease dental erosion.[22]


  Agents Preventing Dental Erosion Top


The potentially damaging effect of acidic additives in sugar-free products prompted research toward reduction of dental erosion, with CPP and ACP emerging as the preventive strategies for dental erosion.[23],[24],[25],[26],[27] CPPs occur naturally in milk and impart stability to calcium and phosphate in solution. CPP can balance ACP, which has an additive effect compared with separate remineralization effects of CCP-ACP.In vitro studies show the role of milk protein casein, nanohydroxyphosphate, and protein-containing toothpaste in reducing dental erosion [Table 2].[25],[28],[29],[30]
Table 2: Studies supporting efficacy of casein phosphopeptide-amorphous calcium phosphate (casein phosphopeptide-amorphous calcium phosphate) and milk protein-casein in preventing dental erosion

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Addition of food-approved polymers, xanthan gum and carboxymethyl cellulose, may be beneficial as erosion reducing agents in modifying acidic drinks.[31],[32] Another novel strategy for preventing dental erosion would be addition of milk into sugar-free products.[33],[34] In vitro experiments have substantiated that adding of milk in sugar-free products lessens the capacity of dental erosion [Table 3].
Table 3: Studies supporting efficacy of milk and fluoride in preventing dental erosion

Click here to view


Although supplementing milk in sugar-free drinks could lessen the capacity of dental erosion, further research need to be undertaken to explore the in vivo effect of milk by controlled clinical trial.

Fluoride therapy can be of use in preventing dental erosion. Fluoride compounds form precipitates on tooth surface, which serve barrier toward erosion. Fluoride preparations, NaF and amine fluoride, however, form calcium fluoride layers (CaF2), which readily dissolve in contact with acids.[35],[36],[37] However, to resolve the dissolution of CaF2 layer with acid, titanium tetrafluoride is another novel agent which is efficacious than sodium fluoride and amine fluoride in enhancing remineralization and has protective action against enamel erosion at low pH by forming an acid-resistant glaze-like layer.[37]

Thus, clinicians/dentists can advise their patients to reduce the intake of sugar-free substitutes blended with acidic additives, especially in children because the sudden fall in flow and volume of saliva alters salivary pH and increases the chance of dental erosion.

Intrinsic sources such as gastroesophageal reflux/frequent regurgitation require referral to a medical professional. Dietary causes of erosion could be addressed by restricting the frequency and consumption of acidic candies.[38]


  Role of Polyols in the Prevention of Dental Caries Top


Among the polyols, sorbitol is a low-cariogenic sweetener that is useful in inhibiting demineralization of enamel, stimulates salivary secretion, and enhances remineralization of carious lesions validated in several in situ studies.[39],[40],[41],[42] Sorbitol gum when chewed immediately after cariogenic diet for a minimum duration of 20 min, at least 5 times/day, has a therapeutic action in repairing caries.[42] Another low-cariogenic sweetener of significance is xylitol, which when used in sugar-free gums suppresses dental caries.[11] The cariostatic capability of xylitol was tested in a 40-month clinical trial, which scientifically proved 100% xylitol-sweetened pellets being superior to sorbitol-sweetened gums and more effective than xylitol-sorbitol mixtures in preventing caries.[43] Erythritol is another natural noncariogenic sweetener naturally found in plant products such as mushrooms, cheese, and soy sauce. It has very low calories nearing to 0.2 calories/g and is easily digested and absorbed.[44] Recently, a double-blind randomized controlled clinical trial compared the effectiveness of candies sweetened with xylitol, sorbitol, and erythritol. The study revealed that those who took erythritol candies had less progression to enamel/dentin caries when compared to those on xylitol and sorbitol.[45]


  How to Recognize and Manage Dental Erosion? Top


Early signs of erosion requiring attention include “cupping,” a concavity seen on enamel which might be with and without dentinal involvement extending on cusp tip. Development of reversed V-sign incisally on maxillary incisors is another prominent clinical sign of erosion.[7]

In clinical practice, diagnosing dental erosive wear could be done by the use of ordinal scales, which grades the severity of dental erosion seen on buccal and lingual surfaces of maxillary anterior teeth. Laser scanning method is a recent advancement, which allows better visualization of rate of tooth loss.[7]

Esthetic restoration of extensively worn out dentition could be considered by placing direct and indirect composite restorative materials through clinical judgment of dentist.[7] The placement of occlusal sealants and resin-bonded restorations reduces dentin hypersensitivity and aids mechanical protection for affected surfaces.[7] Bicarbonate-containing toothpaste rubbed on teeth with fingertip can substantially reduce acid challenge.[7]

Further research by infusing preventive agents such as CPP-ACP, fluoride compounds, and milk and in vivo studies testing newer agents which show the potential to reduce the damage inflicted by dental erosion are very much needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Introduction
Determinants of ...
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Role of Method o...
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Role of Polyols ...
How to Recognize...
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