|Year : 2018 | Volume
| 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 Publication||31-Dec-2018|
Dr. Avijit Avasthi
Bhojia Dental College and Hospital, Budh (Baddi), Solan - 173 205, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
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 Jul 21];8:106-10. Available from: http://www.ijmdent.com/text.asp?2018/8/2/106/249121
| Introduction|| |
Dental erosion is defined as irreversible loss of dental hard tissue by a chemical process that does not involve bacteria. 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., 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.,
| Determinants of Erosion|| |
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.
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?|| |
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, when compared to adults although progression of erosion is at a similar rate for both primary and permanent teeth.
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.,, 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.,, 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.
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. 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|| |
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. 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.
| Damaging Consequences of Additives to Polyols|| |
The presence of acidic additives in sugar-free products alters the chemical constituents of various sweeteners, which subsequently result in erosion. Some of the acidic additives added in sugar-free candies and gums are responsible for dental erosion.,,, 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.,,,
| Role of Method of Drinking on Dental Erosion|| |
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.
| Agents Preventing Dental Erosion|| |
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.,,,, 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].,,,
|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., Another novel strategy for preventing dental erosion would be addition of milk into sugar-free products., 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|
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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.,, 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.
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.
| Role of Polyols in the Prevention of Dental Caries|| |
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.,,, 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. Another low-cariogenic sweetener of significance is xylitol, which when used in sugar-free gums suppresses dental caries. 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. 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. 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.
| How to Recognize and Manage Dental Erosion?|| |
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.
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.
Esthetic restoration of extensively worn out dentition could be considered by placing direct and indirect composite restorative materials through clinical judgment of dentist. The placement of occlusal sealants and resin-bonded restorations reduces dentin hypersensitivity and aids mechanical protection for affected surfaces. Bicarbonate-containing toothpaste rubbed on teeth with fingertip can substantially reduce acid challenge.
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Imfeld T. Dental erosion. Definition, classification and links. Eur J Oral Sci 1996;104:151-5.
de Moor RJ. Eating disorder-induced dental complications: A case report. J Oral Rehabil 2004;31:725-32.
Bahal P, Djemal S. Dental erosion from an excess of Vitamin C. Case Rep Dent 2014;2014:485387.
Stefański T, Postek-Stefańska L. Possible ways of reducing dental erosive potential of acidic beverages. Aust Dent J 2014;59:280-8.
Kumar S, Acharya S, Mishra P, Debnath N, Vasthare R. Prevalence and risk factors for dental erosion among 11- to 14-year-old school children in South India. J Oral Sci 2013;55:329-36.
Sinha P, Abdullah S, Saha S, Verma A. Prevalence of dental erosion in 12-year-old schoolchildren of Lucknow city. J Indian Assoc Public Health Dent 2016;14:409-12. [Full text]
Johansson AK, Omar R, Carlsson GE, Johansson A. Dental erosion and its growing importance in clinical practice: From past to present. Int J Dent 2012;2012:632907.
Alanen P, Isokangas P, Gutmann K. Xylitol candies in caries prevention: Results of a field study in Estonian children. Community Dent Oral Epidemiol 2000;28:218-24.
Gardner C, Wylie-Rosett J, Gidding SS, Steffen LM, Johnson RK, Reader D, et al.
Nonnutritive sweeteners: Current use and health perspectives: A scientific statement from the American Heart Association and the American Diabetes Association. Circulation 2012;126:509-19.
Hayes C. The effect of non-cariogenic sweeteners on the prevention of dental caries: A review of the evidence. J Dent Educ 2001;65:1106-9.
Mäkinen KK. Sugar alcohol sweeteners as alternatives to sugar with special consideration of xylitol. Med Princ Pract 2011;20:303-20.
Livesey G. Health potential of polyols as sugar replacers, with emphasis on low glycaemic properties. Nutr Res Rev 2003;16:163-91.
Grenby T. Dental aspects of the use of sweeteners. Pure Appl Chem 1997;69:709-14.
Sugar Substitutes Market by Type (HIS, LIS, HFS), Composition (Stevia, Aspartame, Cyclamate, Sucralose, Saccharin, AceK, D-Tagarose, Sorbitol, Maltitol, Xylitol, Mannitol), Application (Beverages, Food, Health & Personal Care) & by Region – Forecast to 2020. Top Market Reports; 2016. Available from: http://www.marketsandmarkets.com
. [Last updated on 2015 Nov 05; Last accessed on 2016 Mar 30].
Patra F, Tomar SK, Arora S. Technological and functional applications of low-calorie sweeteners from lactic acid bacteria. J Food Sci 2009;74:R16-23.
Nadimi H, Wesamaa H, Janket SJ, Bollu P, Meurman JH. Are sugar-free confections really beneficial for dental health? Br Dent J 2011;211:E15.
Shen P, Walker GD, Yuan Y, Reynolds C, Stacey MA, Reynolds EC, et al.
Food acid content and erosive potential of sugar-free confections. Aust Dent J 2017;62:215-22.
Gambon DL, Brand HS, Nieuw Amerongen AV. The erosive potential of candy sprays. Br Dent J 2009;206:E20.
Kleber CJ, Putt MS, Muhler JC. Enamel dissolution by various food acidulants in a sorbitol candy. J Dent Res 1978;57:447-51.
Gouveia Farias MM, de Oliveira MM, Eger Schmitt BH, da Silveira EG, de Araújo SM. Erosive potential of sugar-free hard candies dissolved in water and artificial saliva. Braz J Oral Sci 2016;15:75-8.
Johansson AK, Lingström P, Imfeld T, Birkhed D. Influence of drinking method on tooth-surface pH in relation to dental erosion. Eur J Oral Sci 2004;112:484-9.
Iijima Y, Cai F, Shen P, Walker G, Reynolds C, Reynolds EC, et al
. Acid resistance of enamel subsurface lesions remineralized by a sugar-free chewing gum containing casein phosphopeptide-amorphous calcium phosphate. Caries Res 2004;38:551-6.
Barbour ME, Shellis RP, Parker DM, Allen GC, Addy M. Inhibition of hydroxyapatite dissolution by whole casein: The effects of pH, protein concentration, calcium, and ionic strength. Eur J Oral Sci 2008;116:473-8.
Al-Janabi SZ, Al-Dahan ZA. The effects of nano-hydroxyapatite and casein phosphopeptide -amorphous calcium phosphate in preventing loss of minerals from teeth after exposure to an acidic beverage (an in vitro
study). J Bagh Coll Dent 2015;27:132-7.
Cai F, Shen P, Morgan MV, Reynolds EC. Remineralization of enamel subsurface lesions in situ
by sugar-free lozenges containing casein phosphopeptide-amorphous calcium phosphate. Aust Dent J 2003;48:240-3.
Manton DJ, Cai F, Yuan Y, Walker GD, Cochrane NJ, Reynolds C, et al.
Effect of casein phosphopeptide-amorphous calcium phosphate added to acidic beverages on enamel erosion in vitro
. Aust Dent J 2010;55:275-9.
Min JH, Kwon HK, Kim BI. Prevention of dental erosion of a sports drink by nano-sized hydroxyapatite in situ
study. Int J Paediatr Dent 2015;25:61-9.
Jager DH, Vissink A, Timmer CJ, Bronkhorst E, Vieira AM, Huysmans MC, et al.
Reduction of erosion by protein-containing toothpastes. Caries Res 2013;47:135-40.
Hemingway CA, White AJ, Shellis RP, Addy M, Parker DM, Barbour ME, et al.
Enamel erosion in dietary acids: Inhibition by food proteins in vitro
. Caries Res 2010;44:525-30.
Barbour ME, Shellis RP, Parker DM, Allen GC, Addy M. An investigation of some food-approved polymers as agents to inhibit hydroxyapatite dissolution. Eur J Oral Sci 2005;113:457-61.
West NX, Hughes JA, Parker D, Weaver LJ, Moohan M, De'Ath J, et al.
Modification of soft drinks with xanthan gum to minimise erosion: A study in situ
. Br Dent J 2004;196:478-81.
Syed J, Chadwick RG. A laboratory investigation of consumer addition of UHT milk to lessen the erosive potential of fizzy drinks. Br Dent J 2009;206:E6.
Magalhães AC, Levy FM, Souza BM, Cardoso CA, Cassiano LP, Pessan JP, et al.
Inhibition of tooth erosion by milk containing different fluoride concentrations: An in vitro
study. J Dent 2014;42:498-502.
Ganss C, Schlueter N, Hardt M, Schattenberg P, Klimek J. Effect of fluoride compounds on enamel erosion in vitro
: A comparison of amine, sodium and stannous fluoride. Caries Res 2008;42:2-7.
Schlueter N, Hardt M, Lussi A, Engelmann F, Klimek J, Ganss C, et al.
Tin-containing fluoride solutions as anti-erosive agents in enamel: An in vitro
tin-uptake, tissue-loss, and scanning electron micrograph study. Eur J Oral Sci 2009;117:427-34.
Wiegand A, Waldheim E, Sener B, Magalhães AC, Attin T. Comparison of the effects of tiF4 and NaF solutions at pH 1.2 and 3.5 on enamel erosion in vitro
. Caries Res 2009;43:269-77.
Robyn RL, Robert JM, John DR. Pucker up: The effects of sour candy on your patients' oral health. A review of the dental erosion literature and pH values for popular candies. Northwest Dent 2008;87:20-1, 24-5, 28-9.
Van Loveren C. Sugar alcohols: What is the evidence for caries-preventive and caries-therapeutic effects? Caries Res 2004;38:286-93.
Kashket S, Yaskell T, Lopez LR. Prevention of sucrose-induced demineralization of tooth enamel by chewing sorbitol gum. J Dent Res 1989;68:460-2.
Beiswanger BB, Boneta AE, Mau MS, Katz BP, Proskin HM, Stookey GK, et al.
The effect of chewing sugar-free gum after meals on clinical caries incidence. J Am Dent Assoc 1998;129:1623-6.
Leach SA, Lee GT, Edgar WM. Remineralization of artificial caries-like lesions in human enamel in situ
by chewing sorbitol gum. J Dent Res 1989;68:1064-8.
Mäkinen KK, Bennett CA, Hujoel PP, Isokangas PJ, Isotupa KP, Pape HR Jr., et al.
Xylitol chewing gums and caries rates: A 40-month cohort study. J Dent Res 1995;74:1904-13.
Honkala S, Runnel R, Saag M, Olak J, Nõmmela R, Russak S, et al.
Effect of erythritol and xylitol on dental caries prevention in children. Caries Res 2014;48:482-90.
[Table 1], [Table 2], [Table 3]