Erosion in Sports

Fig. 10.1

Ubiquitous nature of sports drinks: Marketing. Sports drinks are big business (8 billion dollar per year) and are found in grocery stores, drug stores, and convenience stores, and anywhere soft drinks are found. Aggressive marketing grows market share at the expense of teeth. a Above shows a major pharmacy’s stock of sports and energy drinks. The same store had end caps and other sites for sports drinks as well. b Shows marketing for popular Gatorade sports drink at a Minnesota convenience store. (Photo credit: Mark Roettger DDS)

10.3 Extrinsic Erosion: Sports and Energy Drinks

As previously stated, sports drinks were originally created for and marketed to sports teams as a replacement for carbohydrates and electrolytes that were lost during competition. These athletes were engaging in intense activity lasting longer than 1 h. As time has passed since the creation of sports drinks and they have become more popular among consumers, the beverages are now being marketed to and consumed by those that are not involved in endurance sports or strenuous exercise. Whereas the consumption of carbohydrates during prolonged exercise can lead to an increase in endurance capacity, the average consumer of sports drinks does not necessarily derive a benefit to hydration or performance that water wouldn’t fulfill. Consequently, there are negative effects on the dentition that can manifest as dental erosion or caries due to the acidic nature and sugar content of the drinks (◘ Fig. 10.2).

Fig. 10.2

a Clinical erosion from sports drinks. b Clinical erosion from sports drink use. a Clinical photos of a 24-year-old female athlete with severe erosion and secondary dental caries resulting from multiple years of drinking 3–5 sports drinks per day. Treatment required multiple extractions, endodontic treatments, and restorative procedures on nearly every tooth. b Is the full-mouth radiographs of the same patient. Both show the incredible damage partially caused by abuse of sports drinks. (Photo credit: Mark Roettger DDS)

Dental erosion is the irreversible loss of tooth structure that can occur as a result of frequent consumption of acidic sports drinks, soft drinks, or energy drinks. The exposure of tooth structure to the drinks leads to demineralization of enamel and dentin surfaces. The optimal pH of saliva is between 6.5 and 7.5, whereas the critical pH that results in the demineralization of tooth structure is 5.5 [12]. An influencing factor is the pH of what is being consumed. As the pH level at the surface of the tooth decreases as a result of acidic exposure, calcium and phosphate ions are released from the tooth, resulting in demineralization. Popular sports and energy drinks such as Gatorade (pH = 2.95), Powerade (pH = 2.78), and Red Bull (pH = 3.32) all have a low pH that results in a high level of acidity at the tooth surface [13].

pH of Popular Drinks



5 Optimal oral pH


5 Demineralization critical pH


5 Water


5 Gatorade


5 Powerade


5 Red Bull


5 Cola


Despite a similarly acidic pH, it has been shown that the demineralization of enamel from sports and energy drinks is 3–11 times greater than that of cola, which has a pH of 2.16.

Erosion Potency of Sports Drinks [12]

All tested drinks were compared to black tea and erosion ratio figured

1. Coke

7.94 × more erosive than tea

2. AMP energy drink

40.03 × more erosive than tea

3. Gatorade

57.29 × more erosive than tea

4. KMX energy drink

84.80 × more erosive than tea

5. Powerade

48.51 × more erosive than tea

6. Red Bull energy drink

61.14 × more erosive than tea

Black tea 0.35 mg/cm2—standard

This difference is likely due to the large amounts of citric acid in sports and energy drinks as compared to the presence of phosphoric acid that is found in cola drinks. Citric acid has a greater buffering capacity and is able to bind with calcium that is released from the tooth structure during demineralization. The chelation of calcium leads to a reduction in the positive effects of calcium to reduce acidity, which ultimately would lead to remineralization. The perpetuation of a low pH after the acid exposure results in a greater potential for erosive damage to tooth structure. That being said, research has shown that there appears to be less of a correlation between the pH of a beverage and the amount of enamel demineralization. One study found that beverages with a greater composition of acid that could chelate calcium determined the severity of enamel demineralization more so than the pH of the beverage [12]. This is consistent with sports and energy drinks exhibiting a greater propensity for enamel demineralization than cola, which is just as acidic.

Naturally, the body has a biologic defense in the form of saliva that can help combat the erosive nature of acidic sports drinks. Two important protective features of saliva are the flow rate and the buffering capacity. The presence of saliva leads to the dilution of erosive beverages when they are present in the oral environment. As previously discussed, prolonged exercise leads to a significant loss of fluids through perspiration, ultimately leading to dehydration. As dehydration progresses, salivary flow rate decreases, and the resulting xerostomia leads to a slower rate of clearance of the erosive beverage that is less diluted. Saliva also has the ability to neutralize and buffer acidic substances. The calcium and phosphate in saliva can help combat the drop in pH and encourage remineralization at the tooth surface. This was demonstrated by a study that measured the salivary pH, flow rate, and buffering capacity of saliva in children. It was discovered that children with erosive lesions had a low salivary buffering capacity compared with those without lesions [14]. As a result, it has been proposed that adding calcium and phosphate to sports drinks and soft drinks may reduce the erosive nature of the beverages.

In an attempt to combat the negative aspects of sports drinks on the dentition, studies have examined the effect of attempting to lower the pH of the beverage as well as adding calcium and phosphate. It was found that this could reduce the amount of erosion that is seen on enamel surfaces. One such study involved a prototype carbohydrate and electrolyte drink that was compared to a commercially available sports drink, as well as water. The prototype drink had a less acidic pH and a greater content of calcium (pH of 3.81 and 355 mg/L of calcium) than the sports drink that was commercially available (pH of 3.16 and 2.8 mg/L of calcium). The researchers found that the amount of enamel lost from subjects that consumed the prototype sports drink was the same as the group that consumed water. In contrast, the amount of erosion observed in the group that consumed the commercially available sports drink was almost 30 times greater than the other 2 groups [15]. The challenge with adding calcium and phosphate to sports drinks to reduce the erosive effect lies in the taste. It has been determined that people prefer the taste of beverages with a lower pH and attribute a repulsive taste to those drinks with an increased pH and calcium content [16]. The palatability problems have made a more favorable formulation to the dentition more challenging.

As it is impossible to reconstitute the ingredients of all sports drinks, consumers must develop good habits when it comes to drinking these beverages. Dentists have an important role, as they may be the first to notice the erosive changes to the dentition that may be unknown to the patient. Early diagnosis and behavior modification are essential. First and foremost, sports drinks should not be substituted for water, as a majority of people consuming these beverages will derive no greater benefit to hydration that water will not provide. If sports drinks are to be consumed, the method of consumption can be modified to reduce the erosive effects on the dentition, specifically the amount of time the drink spends in contact with the teeth. Slowly sipping the beverage, or swishing a drink in the mouth, leads to the dentition being exposed to a lower pH and acidic conditions for a longer period of time. To avoid this, consumers can attempt to rapidly swallow or gulp a sports drink to minimize the amount of time the liquid is in contact with the dentition.

Finally, in addition to sports drinks, some athletes are consuming energy drinks prior to competition, mainly for the effect of caffeine and increased alertness. Like sports drinks, energy drinks also have an erosive effect on the dentition; however, these drinks carry no benefits in regard to hydration or the replenishment of carbohydrates and electrolytes. The dangers of energy drinks lie in the ingredients. Energy drinks contain caffeine along with other ingredients and herbal supplements, such as taurine, guarana, ginseng, and B vitamins that all claim to provide an increase in energy. Despite being banned by the International Olympic Committee, consuming caffeine before exercise has been found to be safe; however when combined with the other ingredients in energy drinks, there is not enough evidence to determine safety [3].

Possible Ingredients of Energy Drinks

  • Caffeine (high dose): cardiovascular effects

  • Taurine: amino acid—anxiolytic

  • Guarana: (more caffeine) cardiovascular effects

  • Ginseng: cardiovascular effects

  • Yohimbe: cardiovascular effects

  • β-phenylethylamine: weight loss

    Many ingredients of energy drinks have effects on the cardiovascular system including heart rate and blood pressure. Their use is not encouraged for sports performance.

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Aug 25, 2019 | Posted by in General Dentistry | Comments Off on Erosion in Sports
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