TOOTHWEAR
The
potential of
By S. M. Blacker1 and R. G. Chadwick2
Dental erosion
Dental erosion has been defined as the loss of
tooth tissue by a chemical process not involving
bacteria.1 In this condition, contact of the tooth
structure with acids results in its dissolution.
The complications of dental erosion range from
minimal tooth surface loss, leading to
sensitivity and pain, to
excessive loss of
clinical crown
height,
loss
of vitality and poor dental aesthetics.
Management of the condition ranges from
the application of simple preventive measures
and monitoring of their impact, to restoration
with composite filling materials or extensive
treatment with indirect restorations such as
onlays and crowns. This therefore can be a
very time consuming and expensive condition
to treat.2,3
Acids of intrinsic and extrinsic origin are
thought to be the main aetiological factors for
dental erosion.4 For many years exposure of
the teeth to extrinsic acids in the diet have been
seen to be a major contributory factor to the
development of dental erosion. Many studies
have identified both fruit-based drinks
and carbonated drinks to be
potentially erosive.3,5-8
iStockphoto/Thinkstock
Five a day
The UK governments five a
day campaign has encouraged
the public to consume at
least fiveportions of fruit
and vegetables per day9 to
reduce the likelihood of
developing serious medical
conditions. Many patients see
consuming fruit smoothies as
a way of achieving this and this is
reinforced further by the way such
drinks are marketed internationally.
30 vital
Clinical Lecturer in Restorative Dentistry,
2
Clinical Senior Lecturer in Restorative
Dentistry and Honorary Consultant in
Restorative Dentistry, The Dental School
and Hospital, Park Place, Dundee,
DD1 4HN
Volume 10 summer 2013
2013 Macmillan Publishers Limited. All rights reserved
TOOTHWEAR
Oneserving of fruit smoothie can be counted
as up to twoof an individuals five a day.10,11
The consumption of shop-bought smoothies
has risen dramatically, from 6.3millionlitres
in 2001 to 34millionlitres in 2006, with
consumption projected to treble over the next
fiveyears.12 However, the true level of smoothie
consumption is not actually known as these
figures exclude consumption of homemade
smoothies and those made and purchased in
cafs and juice bars.
Historically, fruit smoothies appear to have
originated in Brazil as a product of juicing
fruit.13 They first appeared in the UK in 1994
and have steadily increased their share of the
soft drinks market.
Table 1 The drinks investigated in this study
Drink
Manufacturer
Contents (compiled from carton
contents labels)
Smooth orange juice
(positive control)
Tropicana
Juice of fresh oranges
Still mineral water
(negative control)
Volvic
Still mineral water
22 crushed strawberries
2 pressed apples
Strawberries and
bananas fruit
smoothie
Innocent
2 mashed bananas
1 squeezed oranges
21 pressed red and white grapes
A squeeze of fresh lime juice
Smoothies and thickies
Legally there is no definition of a fruit smoothie,
but it is well accepted in the soft drinks industry
that fruit smoothies are made only from
pure fruit blended with 100% pure fruit juice
(not from concentrate), with no other added
ingredients, that is dairy, sugar, sweeteners or
water.14 There are thus many varieties of fruit
smoothies, made using different combinations
of various fruits and these by their nature
contain a variety of organic acids such as citric,
malic, phosphoric, oxalic and tartaric. Exposure
to such acids has the potential to cause dental
erosion.15 There is nothing to suggest that
the increased consumption of smoothies is
limited to the UK, thus giving the potential
risk of developing dental erosion from their
consumption an international dimension.
A variation of the smoothie, though a distinct
entity, is the thickie. Thickies contain dairy
in some form, usually in the form of yoghurt,
with or without fruit. In the production of
these drinks yoghurt is deliberately soured or
milk curdled by adding bacteria (for example,
Lactobacillus acidophilus), which breaks
down the milks lactose forming lactic acid.16
Although the resultant yoghurt has a low pH,
it has no erosive potential due to high levels
of calcium and phosphate within it.17 In the
2008 UK soft drinks report18 juice and dairy
containing drinks were highlighted as being set
to hit the spotlight in the future as they were
considered health targeted products. They
identified that drinks containing dairy cultures
conferred gut health benefits18 as some of the
yoghurts used are probiotic and help digestion.
At the time of commencing this work
a review of the literature failed to find any
research that had investigated the capacity of
fruit smoothies to cause dental erosion. This
invitro work therefore sought to investigate
the pH and titratable acidity of a range of fruit
smoothies and observe the effects of exposure
to them upon samples of human tooth tissue.
3 pressed apples
1/3 pressed pineapple
Kiwis, apples and
limes fruit smoothie
Innocent
2 crushed kiwis
21 pressed red and white grapes
fresh lime
A dash of spinach and nettle extract
86 pressed red and white grapes
2 mashed bananas
Pomegranates,
blueberries and aai
fruit smoothie
Innocent
1 crushed pomegranate
1 squeezed oranges
153 crushed blueberries
102 peeled aai berries
4 pressed apples
54 pressed red and white grapes
Cranberries,
blueberries and
cherries fruit smoothie
Innocent
29 crushed cherries
160 crushed cranberries
90 crushed blueberries
A squeeze of fresh lime juice
Fresh low-fat probiotic yoghurt 73%
Yoghurt, vanilla bean
and honey thickie
Innocent
pressed apple
Honey 9%
Vanilla 0.1%
450g strawberries
Homemade
strawberry and
banana fruit smoothie
(recipe adapted from
Innocent strawberries
and bananas fruit
smoothie)
200g mashed banana
315g pressed apples (juice and pulp)
Innocent
215g squeezed oranges (juice and
pulp)
125g pressed green and black grapes
(juice and pulp)
15 ml freshly squeezed lime juice
Details derived from manufacturers data.
Source: Innocent website at www.innocentdrinks.co.uk/things_we_make/smoothies/ (accessed 24 January 2011)
vital 31
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2013 Macmillan Publishers Limited. All rights reserved
TOOTHWEAR
In addition, the effects of the removal of fruit
smoothie constituents upon erosive potential
were also investigated.
THE STUDY
This was an invitro investigation in which
fivevarieties of shop-bought fruit smoothies
including a thickie were investigated, with
respect to their initial pH, titratable acidity
and effect upon exposure to the surface
microhardness and profile of extracted
human teeth.
The effect of a 60 minute exposure to
each drink was investigated using
specially prepared samples of extracted,
human buccal/palatal enamel.
Titratable acidity and initial
pH measurement
For each fruit smoothie and the positive control
drink, five100ml samples were titrated to a pH
of 7.0 using 0.1M sodium hydroxide (NaOH)
while being stirred constantly with a magnetic
stirrer set at a uniform rate. The initial pH and
the change in pH by adding increments of
0.1M NaOH were recorded using a calibrated
temperature compensated pH electrode. The
mean initial pH reading and volume of 0.1M
NaOH required to raise this to pH7.0 was
recorded. The mean and standard deviation of
these values were calculated for all the drinks.
The mean titratable acidity values were also
expressed as the standardised titratable acidity
(STA). This is the mean volume of 0.1M NaOH
required to neutralise onelitre of drink.
Stockbyte/Thinkstock
Table 1 gives details of the drinks studied
that also included positive (Tropicana smooth
orange juice) and negative (Volvic still mineral
water) control drinks, as well as a homemade
fruit smoothie made using the Innocent
strawberries and bananas fruit recipe as a
guide, sourced from the carton label of the
commercially available drink with the quantities
of fruit used converted to grammes to ensure
reproducibility. Fiveversions of this homemade
strawberry and banana smoothie were made
for testing that omitted certain key ingredients:
strawberry omitted; orange and lime omitted;
banana omitted; apple omitted; grape omitted.
For each homemade smoothie all ingredients
were placed within the jug of a commercially
available smoothie maker and blended for
120seconds.
Effect of exposure to the drinks upon
surface microhardness and contour
of tooth samples
The effect of a 60minute exposure to each
drink was investigated using specially prepared
samples of extracted, human buccal/palatal
enamel. Their fluoride history was unknown.
In total 40teeth were used in this study. In
preparation their roots were removed and
the resultant crown sectioned longitudinally
to leave buccal and palatal halves. Each half
was mounted with their buccal/palatal face
outermost in epoxy resin mixed according to
the manufacturers instructions. Once the resin
was set this surface was finished flush with the
surrounding mounting epoxy resin using a PM5
precision lapping and polishing machine and a
32 vital
slurry of calcined aluminium oxide powder with
a particle size of 9m, for subsequent exposure
to the test drinks (fiveteeth per drink).
Before the commencement of any
experimental work, the surface microhardness
and baseline surface profiles of all specimens
were determined, following marking the
specimens so that a 2mm field of measurement
was reproducibly identifiable. To achieve this,
fourindentations were made in the mounting
epoxy resin. When joined by twoparallel lines
2mm apart a zone of measurement was defined.
Both surface hardness and profile measurements
were made at the centre of this and across it.
Following baseline measurement adhesive
masking tape was applied to the tooth
specimens to mask out their surfaces other
Volume 10 summer 2013
2013 Macmillan Publishers Limited. All rights reserved
TOOTHWEAR
than a 2mm strip as detailed by the reference
indentations. Following immersion in the
drinks, the tape was removed and measurement
of the surface microhardness and profile
was again undertaken. Before and following
immersion all specimens were stored at 37C
in distilled water to prevent desiccation of the
tooth specimens.
RESULTS
The majority of the drinks investigated had a
baseline pH below the critical pH of enamel
(5.5) and required comparable volumes of
0.1M NaOH to raise their pH to neutrality as
the positive control. Only twodrinks (Volvic
still mineral water, the negative control, and
the yoghurt, vanilla bean and honey thickie)
displayed a higher pH, though to neutralise the
thickie, a lesser quantity of alkali addition was
required. The immersion of the tooth samples
in the drinks brought about reductions in their
surface hardness but these were only significant
(p<0.001) for the cranberry, blueberry
and cherry fruit smoothie and homemade
strawberry and banana fruit smoothie. There
was no reduction in surface hardness in the case
of the teeth immersed in the thickie. Omission
of certain ingredients from the homemade
smoothie affected the magnitude of surface
hardness reductions seen. With regard to the
loss of surface contour of the tooth samples
following immersion in the drinks, as assessed
by depth loss, there were significant differences
between the drinks (p=0.0064) with the thickie
and negative control not causing depth loss and
the kiwi, apple and lime smoothie producing
most depth loss (28.26 [5.45] m).
DISCUSSION
In this work threecommonly used laboratory
tests were used to investigate the potential of
the drinks to bring about dental erosion invitro.
All the methods used in this study have the
limitation that they cannot replicate exactly the
conditions encountered in the oral environment
but they do enable onevariable at a time to be
studied under carefully controlled conditions
and their performance compared to control
drinks. As no human subjects are directly
involved in drink consumption there is minimal
risk and so longer exposure times can be used
than would be encountered invivo. In this
context it should noted that tooth substance loss
in such tests is considered to be tenfold greater
than would occur intra-orally.8
The commercial smoothies investigated in
this study were selected as they represented
world brand leaders whose constituents were
readily declared. Their inclusion did not imply
that they were considered by the researchers to
be any better/worse than competitor beverages.
Baseline pH and titratable
acidity (STA)
The methods used to measure baseline pH and
the titratable acidity were similar to that used
by others.14-21 In the present study, however,
100ml of drink was used due to the thickness
of both the fruit smoothies and the yoghurt
thickie investigated. On a practical basis such
a volume promoted the efficient mixing of
drink and chemical reagents. In contrast, other
beverage studies only used 20ml of drink,
perhaps due to the lower viscosities of the drinks
under investigation.21 In the present work a
non-heating magnetic stirrer, set at the highest
stirring rate, was used to provide sufficient
momentum to permit mixing due to the drinks
thick consistencies. As Shellis etal. found,
stirring rate influences both the rate of erosion
and rate of dissolution of tooth substance so this
was kept constant in the work reported here.22
It is recommended that smoothies are stored
in a fridge and so, when determining pH and
titratable acidity, these tests were conducted as
soon as practicable, upon removal of the drink
from the fridge, which was at a temperature
of 4C. Although the quantity of 0.1M NaOH
required to bring about neutrality of the drinks
is reported in this study, the standardised
titratable acidity (STA) is also given, as
advocated by Syed and Chadwick to permit
ready inter study comparisons.23
Although much literature exists upon the
pH and titratable acidity of single fruit juices
no published work to date has examined
combinations of fruit juices, such as those found
in fruit smoothies, with one exception.21 Most
work hitherto has focused on orange, apple,
grapefruit and lemon juice and more exotic fruit
juices such as blackcurrant, guava, apricot and
grape.24-28 Although Blacker etal.20 investigated
the pH and titratable acidity of smoothies it is
difficult to compare the results with the present
work as only onefruit smoothie is common
to both studies: the shop-bought strawberry
and banana fruit smoothie. In addition, testing
was carried out in the previous study at room
temperature. Therefore, comparison between
the studies is not practicable. Increases in
temperature have been demonstrated to increase
acid dissociation with an erosive drink.27,29
In this work there were significant differences
between the drinks tested in the present study
in terms of baseline pH reading and titratable
acidity. The variations observed are probably a
reflection of the complex interplay of different
acid constituents and certainly worthy of
detailed future chemical analysis. It is interesting
to note that all the smoothies examined had
pH values less than 5.5 and titratable acidity
values approaching that of the positive control
drink. They thus had the capacity, on this basis,
to bring about dental erosion. In terms of pH
the exception to the statement was the Innocent
yoghurt, vanilla bean and honey thickie, which
had a mean baseline pH reading of 5.70. On first
examination this appears to be at odds with the
work of Bamise and Bamise who investigated
the acidic content of commercially available
yoghurt drinks in Nigeria.30 The yoghurt drinks
which they investigated, however, were fruitbased and displayed baseline pHs that ranged
from 3.51to 4.12. Such differences could be
accounted for by the fact that the Nigerian
yoghurt drinks investigated contained fruit
concentrate and stabilisers whereas the Innocent
yoghurt, vanilla bean and honey thickie
investigated in the present study did not contain
any fruit. Touyz found that products from fruits
were always acidic whether they were fresh,
juiced or dried.31 The presence of fruit would
therefore lower the pH and account for the
apparent difference seen.
In terms of titratable acidity the yoghurt,
vanilla bean and honey thickie required the
least amount of 0.1M NaOH to neutralise it
compared with the other drinks. This could be
accounted for by the fact that this drink did not
contain any source of fruit and contained dairy
products unlike the other drinks investigated.
Other invitro studies have demonstrated that
the addition of calcium to both orange juice32
and in the form of UHT milk to carbonated
beverages23 reduces titratable acidity,
thus reducing the potential to bring about
dental erosion.
Despite being of a similar recipe to the shopbought variety the homemade version of the
strawberry and banana fruit smoothie required
more than 0.1M NaOH to neutralise it. Various
reasons could account for this finding that
include the use of different fruit varieties, fruit
at different stages of ripening and also possible
heightened acid activity due to the relative
freshness of the homemade smoothie. Grobler
etal.25 found that the amount or proportion of
acids found in fruit varied from fruit to fruit,
between different varieties of the same fruit and
fruit in different stages of ripeness. It should be
pointed out that Innocent fruit smoothies do not
contain any preservatives or stabilisers but are
gently pasteurised, during which degradation of
acids may occur.33
Surface hardness and profilometry
This work sought to assess the effects of
immersion of prepared human tooth samples
upon these parameters. In discussing this it is
important to note that the fluoride history of the
teeth used, by virtue of the anonymous nature of
donation, was unknown. Fluoride incorporation
into the apatite lattice has been shown to be
protective against erosion.34
vital 33
Volume 10 summer 2013
2013 Macmillan Publishers Limited. All rights reserved
TOOTHWEAR
In relation to tooth sample preparation
a precision lapping machine was used to
flatten and polish the tooth samples tested in
preparation for pre- and post-exposure profiling.
In this process it is inevitable that the enamel
tested by both profilometry and hardness
determination was subsurface enamel and may
also have included zones of dentine. Subsequent
exposure of these samples to the drink may
therefore have resulted in an artificially elevated
measurement of tooth surface loss, as dentine
is softer than enamel and more susceptible to
softening upon acid exposure.
Of all the drinks investigated, the thickie
showed the least reduction in tooth substance
surface hardness. This finding could be
explained by the presence of high calcium and
phosphate ions in the yoghurt that prevent the
dissolution of dental enamel by the law of mass
action, therefore making it more resistant to
indentation.23 Similarly Gedalia etal. found acid
softened enamel samples were rehardened after
exposure to milk.36
Upon removing the acidic constituent
of orange/lime juice from the homemade
strawberry and banana fruit smoothie there
was less reduction in surface microhardness
than when these constituents remained. This,
however, is at odds with the greater depth loss
seen when orange/lime juice was removed from
the drink.
With reference to the changes in surface
contour seen of all the fruit smoothies
investigated, the kiwi, apple and lime smoothie
produced the most tooth substance loss at
28.26m after immersion for 60minutes. This
was nearly double the amount of tooth loss
produced by the next erosive drink, which was
fresh orange juice (positive control) at 15.39m.
It is generally considered that in laboratory
tests orange juice removes 4m per hour.24
The elimination of orange/lime juice from the
homemade smoothie markedly reduced the
depth loss seen. Although apples contain citric
acid (3%), their major acid constituent is malic
acid (95%)25 and this, coupled with presence
of citric acid from the lime and kiwi fruit,
may account for the considerable reduction in
surface hardness seen for the kiwi, apple and
lime fruit smoothie. It should also be borne
in mind that assessments of erosive potential
should use a variety of tests to gain an overall
assessment, for no single test has proven to be a
reliable predictor of tooth tissue loss.35
Plain yoghurt, as used in the dairy-based
smoothie tested in this work, is a low pH food34
recognised as being non-erosive due to its
calcium and phosphate constituents and buffer
capacity. It was therefore not surprising to see
that the Innocent yoghurt, vanilla bean and
honey thickie produced no tooth surface loss
n in tooth
The thickie showed the least reductio
substance surface hardness.
or deterioration in surface microhardness. The
increases in the amount of tooth structure and
hardness seen could be the result of deposition
of organic and mineral material upon the
surface of the affected tooth samples.36
Conclusions
Although the thickie drink was not dentally
erosive in this study, it contains 29.89g of
fermentable carbohydrate per 250ml bottle
according to the manufacturers data. Such a
level of carbohydrate is classed as high (15g
per 100g) and therefore regular consumption
of such beverages, due to the risk of developing
caries, is not recommended by some.37 It may
therefore not be wise to advocate this as an
alternative type of safer smoothie in a patient
with dental erosion.
Various organisations and government
bodies have advocated the consumption of
fruit on a daily basis, citing fruit smoothies as
a valid source.38,39 A recent survey showed 60%
of parents gave their children fruit smoothies
as they felt it was an easy way for them to
consume their fruit portions.40 Recently the
World Health Organisation (WHO) developed
nutritional education guidelines to encourage
the development of nutrition education in
health promoting schools in Europe.41 In the
spirit of this the Scottish Government have
issued guidelines on what can be consumed as a
drink in school premises as part of their policy
document Healthy eating in schools - a guide to
implementing the nutritional requirements for
food and drink in schools (Scotland) Regulations
2008.42 Permitted drinks include plain water
(still or carbonated), milk drinks and drinking
yoghurts, fruit juices and blends of these. In
these regulations lunchtime consumption of
fruit juice is limited to a portion size of no
more than 200ml. It is, however, known that
other drinks are consumed in school hours
and these are either brought in lunchboxes
from home (71% of drinks consumed within
school) or purchased at school (26% of drinks
consumed within school)11 and their quantity
and consumption is therefore outside of
controlled mealtimes. It is therefore likely that
some children may snack on fruit smoothies as
they are perceived to be nutritionally healthy. If
this is frequently carried out the results of this
invitro study, with its limitations, suggests they
may be heightening their risk of developing
dental erosion. Such a practice should therefore
be discouraged and any claimed nutritional
34 vital
benefits of smoothie consumption be reaped at
mealtimes only.
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The full version of this article was published
in the BDJ on 22 February 2013 as An in
vitro investigation of the erosive potential of
smoothies (Volume 214; E9).
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