639

Journal of Oral Science, Vol. 59, No. 4, 639-643, 2017

Original

Sports drink consumption and dental erosion among

amateur runners
Leonardo S. Antunes1), Lais Veiga2), Victor S. Nery2),
Caio C. Nery2), and Lívia A. Antunes1)
1)Department of Specific Formation, School of Dentistry, Fluminense Federal University, Nova Friburgo,
RJ, Brazil
2)School of Dentistry, Fluminense Federal University, Nova Friburgo, RJ, Brazil

(Received August 16, 2016; Accepted January 30, 2017)

Abstract: This cross-sectional study assessed the

prevalence and potential risk factors for dental
erosion in amateur athletes at running events. After
a sample calculation, 108 runners from the state of
Rio de Janeiro, Brazil, were selected and examined
for dental wear by a single trained and calibrated
evaluator (kappa = 1.00). To identify risk factors, the
runners were interviewed by using a standardized,
semi-structured questionnaire. The average (SD) age
of the runners was 34.2 (11.45), and the prevalence of
dental erosion was 19.4%. Gastroesophageal reflux,
running frequency per week, and time expended
during competition were associated with dental
erosion (P < 0.05). The association between use of
isotonic drinks and dental erosion was not significant
(P > 0.05). In conclusion, dental erosion was not asso-
ciated with use of isotonic drinks. However, frequency
of exercise per week and gastroesophageal reflux were
risk factors for dental erosion.
Keywords: dental erosion; sports drinks; exercise;
sports; running.
Correspondence to Dr. Leonardo Santos Antunes, Department
of Specific Formation, School of Dentistry, Fluminense Federal
University, Rua Doutor Silvio Henrique Braune, 22 Centro, Nova
Friburgo, Rio de Janeiro 28625-650, Brazil
Fax: +55-22-25287168 E-mail: leonardoantunes@id.uff.br
doi.org/10.2334/josnusd.16-0611
DN/JST.JSTAGE/josnusd/16-0611
Introduction
Oral abnormalities can adversely affect general health
and interfere with well-being and quality of life (1). The
relationship between oral health and sports has been
investigated (2,3): a systematic review reported that
athletes had high prevalences of oral diseases, including
dental caries (15-75%), moderate-to-severe periodontitis
(≤15%), dental erosion (36-85%), and pericoronitis/
impacted third molars (5-39%) (3). Among the oral
diseases that affect athletes, dental erosion is defined as
progressive, irreversible loss of tooth tissue due to acid
dissolution, without bacterial involvement (4). It results
when a tooth is in frequent contact with acid (5).
Dental erosion can be caused by extrinsic or intrinsic
sources. Intrinsic causes are essentially exposure to
gastric contents, such as in gastric reflux or spontaneous
or induced vomiting. Such exposure causes a number
of medical problems and may result in extensive dental
erosion when it persists in a susceptible individual (6).
Extrinsic causes include an individual’s environment,
medications, diet, and lifestyle (7). Environmental
extrinsic exposures are seen in dynamite factory
workers (sulfuric and nitric acid), battery industry
workers (sulfuric acid), workers in galvanizing plants
(hydrochloric acid), and workers in factories involved in
cleaning processes and acid (sulfuric and hydrochloric
acid) (7). A number of medications may cause dental
erosion, mostly vitamin C tablets and iron formulations
that are too acidic, especially when in chewable form (6).
A lifestyle that emphasizes a “healthy” diet and exercise
with regular, continuous use of isotonic drinks could
640
potentially lead to increased dental erosion (4,6).
The greatest loss of tooth minerals typically occurs at
a pH of 5.5 (8). Extrinsic sources with a low pH include
fresh citrus fruit and their juices, acidulated carbonated
beverages, and sports supplement drinks, many of which
contain citric acid (8,9). Furthermore, high consumption
of drinks by athletes during exercise, along with transient
xerostomia resulting in inadequate rinsing and subse-
quent demineralization of the tooth surface by acids, may
lead to erosive lesions on teeth (9-11). Dental erosion in
athletes is a growing concern, and a number of studies
have investigated the occurrence of dental erosion in
relation to consumption of isotonic drinks during swim-
ming practice, college sports, and cycling (12,13).
This study estimated the prevalence of dental erosion,
evaluated potential risk factors for erosive tooth wear,
and investigated if consumption of isotonic drinks was
associated with increased dental erosion in amateur
athletes participating in racing events. Our hypotheses
were that the prevalence of dental erosion would be high
among amateur runners and that sports drink consump-
tion would influence dental erosion.
Materials and Methods
Participants and study design
The sample was calculated by estimating the prevalence
of dental erosion, which was reported to be 30.4%
(14), with a 10% error and 95% confidence interval.
To compensate for a possible cluster effect, the sample
size was increased by 20% (design effect = 1.2), which
yielded a total sample size of 98 participants. This
value was then increased by 10% to compensate for any
withdrawals. The minimum sample size was thus 108
subjects. One hundred and eight amateur runners were
randomly selected during running events, to ensure they
were representative of the original population.
The assessment tool used in this study was a face-
to-face questionnaire administered after running events
during the period from August to November 2015. Our
questionnaire was adapted, applied, and evaluated for
ease of comprehension in a pretest of 10 athletes and
administered a second time, 1 month later. These 10
athletes were not included in the final sample. The pretests
were administered outside the study area and resulted in
a number of minor modifications to the wording.
The questionnaire contained items on age, sex, infor-
mation on sports practice (frequency, activity time, time
spent in training, time spent in competitions), use of
isotonic drinks, potential risk factors linked to everyday
athletic routine (work in factories, swimming in chlo-
rinated swimming pools, acidic drinks, tooth brushing
time, type of toothbrush bristle and paste, and brushing
duration), and potential systemic risk factors for dental
erosion (vomiting, regurgitation, gastroesophageal reflux,
gastroesophageal reflux disease, bulimia, anorexia, xero-
stomia, radiotherapy, and hemodialysis).
This study was approved by the Committee for
Ethical Research of the Fluminense Federal University
(830.318). In accordance with ethical guidelines, this
study was preceded by a detailed explanation for the
amateur runners. Informed consent was obtained from all
participants. This cross-sectional study enrolled athletes
after running events in Nova Friburgo, a city in the Rio
de Janeiro state of Brazil. Runners who were unwilling
to participate in the study, those who did not sign the
informed consent form, and those who did not provide
completed questionnaires were excluded from the study.
Clinical examination
A spatula, gauze, disposable gloves, and headlamp were
used for examinations after running events, with both
the athlete and examiner seated on chairs. The training
exercise for evaluation of dental wear was done by using
images of different clinical situations. Intra-rater reli-
ability was assessed with weighted (dental wear) kappa
statistics for two separate dental examinations. There
was a 1-week interval between sessions for 10 subjects
(not part of the study population). The kappa value for
intra-examiner reliability in the assessment of dental
wear was 1.00.
During the clinical examination, the following clinical
data regarding dental erosion were collected: dental wear
(dental morphology was observed in both tooth arches
and classified as absent or present) and type (class I-III)
(15).
Statistical analysis
For quantitative analysis of the results, the data were
entered into the Statistical Package for Social Sciences
version 16.0 (SPSS Inc., Chicago, IL, USA) in a single
session and then tabulated. This method increases the
reliability and credibility of the study. Frequencies
were calculated, and associations were assessed with
the Student t-test, chi-square test, or Fisher exact test
and odds ratios. A P value of ≤0.05 was considered to
indicate statistical significance.
Results
A sample of 108 amateur runners from Rio de Janeiro,
Brazil, participated in the study; 62% were male. Mean
(SD) age was 34.1 (11.07) years (range 18-60 years).
Sports drinks were consumed regularly by 38.9% of
 641

Table 1 Characteristics of participating athletes, by dental erosion status

Univariate logistic model
Total (n = 108) Presence of erosion (n = 21) Absence of erosion (n = 87) P value
Odds ratio
Age (DP) 34.1 (11.07) 36.2 (12.16) 33.6 (10.80) — 0.37*
Sex (%)
Female 41 (37.96) 10 (47.62) 31 (35.63)
1.64 (0.57-4.76) 0.31**
Male 67 (62.04) 11 (52.38) 56 (64.37)
Running frequency during a week (%)
1 to 3 times 72 (66.67) 10 (47.62) 62 (71.26)
0.37 (0.12-1.08) 0.04**
4 or more 36 (33.33) 11 (52.38) 25 (28.74)
Number of years of sports activity (%)
Up to 2 years 56 (51.85) 10 (47.62) 46 (52.82)
0.81 (0.28-2.32) 0.67**
Over 2 years 52 (48.15) 11 (52.38) 41 (47.13)
Time expended during training (%)
Up to 1 h 70 (64.81) 11 (52.38) 59 (67.82)
Up to 2 h 26 (24.07) 8 (38.10) 18 (20.69) — 0.25**
Up to 3 h 12 (11.11) 2 (9.52) 10 (11.49)
Time expended during competition (%)
Up to 1 h 91 (84.26) 14 (66.67) 77 (88.50)
Up to 2 h 11 (10.19) 6 (28.57) 5 (5.75) — 0.01**
Up to 3 h 6 (5.55) 1 (4.76) 5 (5.75)
Sports drinks (%)
Yes 42 (38.89) 9 (42.86) 33 (37.93)
1.23 (0.42-3.56) 0.68**
No 66 (61.11) 12 (57.14) 54 (62.07)
*Student t-test; **Chi-square test or Fisher exact, according to the minimum number of expected values per cell. Bold text indicates statistical significance (P ≤ 0.05).

Table 2 Associations of potential exposures with dental erosion in athletes

Univariate logistic model
Total Presence of erosion (n = 21) Absence of erosion (n = 87) P value*
Odds ratio
Work in factory (%)
Yes   4 (3.70)   1 (4.76)   3 (3.45)
— 0.58
No 104 (96.30) 20 (95.24) 84 (96.55)
Swim in chlorinated pool (%)
Yes   4 (3.70)   0 (0)   4 (4.60)
0.00 (0.00-6.65) 0.42
No 104 (96.30) 21 (100) 83 (95.40)
Acidic drinks (wine, fruit juice, soda) (%)
Yes   86 (81.13) 16 (76.19) 70 (80.46)
0.78 (0.22-2.83) 0.43
No   22 (20.37)   5 (23.81) 17 (19.54)
Brushing teeth immediately after eating (%)
Yes   76 (70.37) 16 (76.19) 60 (68.97)
1.44 (0.43-5.05) 0.52
No   32 (29.63)   5 (23.81) 27 (31.03)
Stiff-bristled brush/toothpaste too gritty/duration of brushing (%)
Yes   28 (25.93)   6 (28.57) 22 (25.29)
1.18 (0.36-3.80) 0.76
No   80 (74.07) 15 (71.43) 65 (74.71)
* Chi-square test or Fisher exact test, according to the minimum number of expected values per cell. Bold text indicates statistical significance (P ≤ 0.05).

athletes. The prevalence of dental erosion was 19.4%
(n = 21 runners); 52.4% (n = 11) of runners had class I
erosion and 57.1% (n = 12) had class II erosion. In the
maxilla, the rate was 4.8% for anterior teeth and 28.6%
for posterior teeth. In the mandible, the rates were 23.8%
and 61.9%, respectively.
Dental erosion in amateur runners was significantly
associated with frequency of running per week (P =
0.04) and time expended during competition (P = 0.01).
Consumption of sports drinks was not associated with
dental erosion (Table 1). Analysis of potential risk factors
related to the daily routine of runners showed no statis-
tical significant difference in relation to the prevalence of
dental erosion (Table 2). Analysis of potential systemic
risk factors revealed that gastroesophageal reflux was
significantly associated with dental erosion (P = 0.05)
(Table 3).
Discussion
Dental erosion is an important oral health problem in
modern society. Its causes are multifactorial, and the
contributions of different etiological factors cannot be
642

Table 3 Associations of systemic risk factors with dental erosion in athletes

Univariate logistic model
Total (n = 108) Presence of erosion (n = 21) Absence of erosion (n = 87) P value*
Odds ratio
Vomiting (%)
Yes   19 (17.59)   5 (23.81) 14 (16.09)
1.63 (0.44-5.83) 0.29
No   89 (82.41) 16 (76.19) 73 (83.91)
Regurgitation (%)
Yes   3 (2.78)   2 (9.52)   1 (1.15)
9.05 (0.60-267.15) 0.09
No 105 (97.22) 19 (90.48) 86 (98.85)
Gastroesophageal reflux (%)
Yes   12 (11.11)   5 (23.81)   7 (8.05)
3.57 (0.85-14.86) 0.05
No   96 (88.89) 16 (76.19) 80 (91.95)
Gastroesophageal reflux disease (%)
Yes   3 (2.78)   2 (9.52)   1 (1.15)
9.05 (0.60-267.15) 0.10
No 105 (97.22) 19 (90.48) 86 (98.85)
Bulimia (%)
Yes   0 (0)   0 (0)   0 (0)
— —
No 108 (100) 21 (100) 87 (100)
Anorexia (%)
Yes   0 (0)   0 (0)   0 (0)
— —
No 108 (0) 21 (100) 87 (100)
Xerostomia (%)
Yes   4 (3.70)   1 (4.76)   3 (3.45)
— 0.58
No 104 (96.30) 20 (95.24) 84 (96.55)
Radiotherapy (%)
Yes   1 (0.93)   0 (0)   1 (1.15)
0.00 (0.00-74.80) 0.81
No 107 (99.07) 21 (100) 86 (98.85)
Hemodialysis (%)
Yes   0 (0)   0 (0)   0 (0)
— —
No 108 (100) 21 (100) 87 (100)
*Chi-square test or Fisher exact test, according to the minimum number of expected values per cell. Bold text indicates statistical significance (P ≤ 0.05).

easily distinguished. Our hypothesis that the prevalence
of dental erosion would be high among amateur runners
was not confirmed, and sports drinks did not affect dental
erosion. However, this is the first study of dental erosion
among Brazilian athletes to report that exercise frequency
was associated with dental erosion.
Current media reports and the popular literature advo-
cate healthy lifestyles involving physical exercise and a
balanced diet (16). In addition, marketing strategies for
isotonic drinks emphasize performance improvement
and replacement of fluids and electrolytes lost in sweat
during and after exercise (17). The sale and production
of these drinks is a profitable and competitive industry.
It is estimated that the market for isotonic drinks in the
US market alone is worth more than $1.5 billion a year
(18). Several studies have shown that isotonic drinks are
regularly consumed by most athletes (12,19). However,
in the present study, only 38.89% of runners consumed
such beverages. Water was the most frequently consumed
liquid (92.59%) and, in most cases, it is the appropriate
choice to maintain hydration before, during, and after
physical exercise (17).
The worldwide prevalence of dental erosion among
children and adolescents is 7.2% to 74.0% (14). This
study of amateur runners found a prevalence of 19.44%,
which is slightly lower than prevalences of dental erosion
among practitioners of other sports. A study in Lithuania
of swimmers aged 12 to 25 years reported a prevalence
of 35.6% (4). Another study, in Poland, reported that the
prevalence was greater than 26% among professional
swimmers and 10% among amateur swimmers (19).
Among athletes in a university in the US state of Ohio the
prevalence was 36.5% (12). Dental erosion was mainly
present on posterior teeth in the lower jaw and thus might
have been caused by gastroesophageal reflux disease
during intense training sessions.
No comprehensive clinical study has assessed the
effects of isotonic drinks on dental erosion among
runners or triathletes. An in vitro study of the chemical
properties of three sports drinks (Gatorade, Isostar,
Powerade) showed that pH varied from 3.17 to 3.87,
that the buffering capacity was 18.0-52.8 mmol/L × pH,
and that titratable acidity was <56.5 mmol/L. Isostar
had the highest concentrations of Ca (8.20 mmol/L) and
inorganic phosphate (4.49 mmol/L). Powerade had the
highest concentration of F (0.21 mg/L), and F concentra-

tion varied from 0.05 to 0.21 mg/L (20). We observed
no association between consumption of isotonic drinks
and dental erosion in this study of amateur runners.
Other studies, of swimmers (13), college athletes (12),
and cyclists (13), also reported no association. This lack
of an association may be attributable to the fact that
isotonic drinks have varied concentrations of calcium
and phosphate in their formulations. This maintains high
concentrations of these salts in salivary fluids, thereby
inhibiting tooth demineralization (7,20).
The present analysis of possible risk factors for dental
erosion showed that frequency of race practice, time
spent running during competition, and gastroesophageal
reflux were associated with dental erosion. Other studies
of athletes identified age (4), time and frequency of sports
practice (19), and ethnicity (12) as risk factors for dental
erosion. These past and present findings confirm the
multifactorial nature of the disease and that the frequency
and duration of sports activities are risk factors, since
athletes are exposed to adverse conditions such as pH
and salivary flow changes during sports practice. Future
studies should attempt to replicate and clarify these find-
ings.
This study had some limitations. First, assessment of
dental erosions with the Eccles Index might be biased by
diagnostic uncertainty. We tried to address this problem
by using only one calibrated examiner, thereby increasing
reliability. Second, athletes were asked to self-report their
training habits, and it is thus possible that some athletes
under- or over-reported their weekly training habits.
Our findings emphasize the importance of early diag-
nosis, accompanied by dietary advice and monitoring of
athletes, to successfully prevent and treat progression of
dental erosion. Dental surgeons should provide orienta-
tion and prevention programs for athletes, which would
reduce the adverse effects of acidic foods and potentially
erosive drinks.
In conclusion, the prevalence of dental erosion was
19.44%. Use of isotonic drinks was not associated with
the prevalence of dental erosion. However, the frequency
of exercise per week and gastroesophageal reflux were
associated with the prevalence of dental erosion.
Conflict of interest
None declared.
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