Impact of Diet and Nutrition on Oral Health
Zohoori FV, Duckworth RM (eds): The Impact of Nutrition and Diet on Oral Health.
Monogr Oral Sci. Basel, Karger, 2020, vol 28, pp 91–98 (DOI: 10.1159/000455376)
Chapter 9: Acidic Beverages and Foods Associated
with Dental Erosion and Erosive Tooth Wear
Thiago Saads Carvalho  · Adrian Lussi
Department of Restorative, Preventive and Paediatric Dentistry, School of Dental Medicine, University of Bern, Bern, Switzerland
Abstract
Dental erosion is the partial demineralisation of the tooth
surface caused by repeated exposure to acids. The loss
of surface tissue, which results from simultaneous and/
or subsequent exposure to mechanical forces is known
as erosive tooth wear (ETW). Excessive consumption of
acidic beverages and foods has been the main focus of
research into erosion. Enamel dissolution is significantly
associated with chemical parameters: pH, buffer capaci-
ty, titratable acidity, viscosity, as well as calcium, phos-
phate and fluoride concentrations in the beverages and
foods. Some of these parameters are used to calculate
the degree of saturation of a given substance, which rep-
resents its driving force to demineralise dental hard tis-
sues. Undersaturated substances with low pH and high
titratable acidity and high buffer capacity have greater
erosive potential, while substances with high concentra-
tions of Ca2+ and phosphate cause less demineralisation.
Other physical parameters also modulate the deminer-
alisation processes. Swishing drinks in the mouth tends
to cause more erosion, since the Nernst layer is continu-
ously renewed and does not reach saturation. Recent sys-
tematic reviews confirm that frequent consumption of
carbonated/soft drinks are the main dietary factor associ-
ated with ETW. Vitamin C and frequent consumption of
natural fruit juices and acidic snacks or sweets are also
significantly associated with more ETW; whereas higher
consumption of milk and yoghurt is a protecting factor.
Patients presenting with ETW should have their dietary
habits assessed by recording their complete dietary in-
take in a diet record sheet. Dentists should assess the
erosive potential of the different beverages and foods, as
well as the frequency of ingestion, then elaborate spe-
cific preventive measures and dietary interventions indi-
vidually tailored to each patient.
© 2020 S. Karger AG, Basel
Acidic Beverages and Foods Associated with
Dental Erosion
When dental hard tissues come into contact with
acidic substances, they lose structural integrity
and experience changes in physical properties,
which lead to a softening of the tooth surface and
subsequent loss of tooth structure, namely dental
erosion [1]. Clinically, however, the loss of dental
hard tissues also takes place very often in associa-
tion with mechanical forces; it is a chemical-me-
chanical process, not involving bacteria, which is
referred to as erosive tooth wear (ETW) [2]. This
chapter describes how diet influences ETW, and
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discusses the different chemical and physical fac-
tors in beverages and foodstuffs associated with
dental erosion.
ETW is triggered by repetitive contact be-
tween the tooth and acidic substances together
with mechanical impacts. When an acidic sub-
stance comes into the oral cavity, it first has to
diffuse through the acquired enamel pellicle
(AEP). The AEP is a thin acellular biofilm com-
posed of proteins, enzymes, glycoproteins, carbo-
hydrates and lipids [3, 4]. Once the acid diffuses
through the AEP, its hydrogen ions (H+) start dis-
solving the enamel crystals. The repeated contact
with acidic substances leads to an initial deminer-
alisation of the enamel surface, characterised by a
loss of hardness (softening) and a greater suscep-
tibility to the adverse effects of physical impacts.
The acidic substances responsible for dental
erosion can have either an intrinsic or extrinsic
origin, or both. The most important source of ex-
trinsic acids is the diet, where acidic beverages
and foods can demineralise the dental hard tis-
sues.
Consumption of acidic beverages and foods
has changed over time, and the worldwide con-
sumption of soft drinks, fruit juices, sports and
energy drinks has increased in recent decades.
Over the last 20 years, soft drink consumption in-
creased 300% in the USA [5], with increasing
serving sizes from 185 g in the 1950s to over 550 g
in the late 1990s. In 2007, the worldwide annual
consumption of soft drinks reached 552 billion L,
the equivalent of just under 83 L per person per
year. The annual consumption of sports and en-
ergy drinks per person is also increasing. Europe
is the leading consumer of energy drinks, while
the USA is the leading consumer of sports drinks.
In 2013, a study showed that the consumption of
energy drinks in the European Union is highest
among adolescents, with an average of 68% of
teenagers having consumed energy drinks at least
once in the previous year. Moreover, a total of
30% of adults, 19% of children aged 6–10, and 2%
of younger children aged 3–5 years, had all con-
92
sumed energy drinks. Remarkably, 16% of chil-
dren were already considered as high chronic
consumers, ingesting energy drinks 3 or more
times per week [6].
The excessive consumption of these acidic
drinks has been the main focus of research re-
garding the extrinsic acids associated with ETW
[7–9], especially among children and adolescents.
It has been reported that patients who frequently
consume soft drinks during adolescence, still
show a frequent consumption in early adulthood
[10]. O’Sullivan and Curzon [11] noted that chil-
dren who exhibited ETW lesions also had a great-
er daily consumption of carbonated drinks, fresh
fruit juices and diluted cordial.
Association between Diet and ETW
Diet is the most extensively studied aetiological
factor in dental erosion. The excessive consump-
tion of acidic beverages and food has been de-
scribed as the most important extrinsic factor for
dental erosion [7–9, 12]. However, the precise as-
sociation of dietary factors with ETW is still un-
der investigation.
A PubMed search with the terms (“systematic
review” OR meta-analysis) AND (dental erosion
OR ETW) yielded 37 hits: 4 studies mentioned
diet and ETW, and 2 more studies specifically re-
ported on the association between dietary factors
and dental erosion/ETW.
From the 4 systematic reviews mentioning
diet: van’t Spijker et al. [13] were not able to in-
clude diet in their regression analysis, because
very few studies reported on this variable; Kreulen
et al. [14] reviewed the prevalence of tooth wear
in children and adolescents, including 29 studies
in their analyses, from which 14 studies reported
the relationship between diet and tooth wear (6
showed a significant relationship, 8 reported no
relationship); in the Cochrane review by Harris et
al. [15], investigating one-to-one diet interven-
tion, the authors found no studies aimed at pre-
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venting tooth erosion; lastly, Corica and Caprio-
glio [16] included 3 studies in their review on the
prevalence of tooth wear in the primary dentition,
and they could not explain the role of diet on the
basis of their data.
Two systematic reviews, by Li et al. [17] and by
Salas et al. [18], specifically reported the associa-
tion of diet and erosion. Both studies identified
carbonated/soft drinks as the main dietary factor
associated with ETW. In the meta-analysis by Li
et al. [17], the authors showed a twofold increase
in the risk of ETW (OR 2.41, 95% CI 2.03–2.85)
associated with the consumption of soft drinks.
Likewise, a similar association was shown in the
meta-analysis and meta-regression by Salas et al.
[18] (OR 1.61, 95% CI 1.29–2.01).
Interestingly, although juice, sports drinks,
milk or yoghurt were not associated with dental
erosion, Li et al. [17] observed that chewing vita-
min C tablets increased the risk of ETW (OR 1.16,
95% CI 1.10–1.22). In the study by Salas et al. [18],
the authors were able to demonstrate that fre-
quent consumption of natural fruit juices (OR
1.20, 95% CI 1.02–1.42) and acidic snacks or
sweets (OR 2.24, 95% CI 1.16–4.34) are also sig-
nificantly associated with a greater risk of tooth
erosion, whereas the higher consumption of dairy
products, like milk (OR 0.96, 95% CI 0.92–0.99)
and yoghurt (OR 0.77, 95% CI 0.64–0.91) can be
considered as a protecting factor.
It is important to bear in mind that these as-
sociations are related to how frequent the prod-
ucts are consumed. This is particularly impor-
tant when considering the data related to vita-
min C chewable tablets and natural fruit juices,
where their frequent consumption increases the
odds of developing erosion by only 16 and 20%,
respectively. Higher odds are observed for the
intake of acidic snacks/sweets and carbonated/
soft drinks. Although these studies do not spec-
ify the frequency, other studies have observed
that, in general, ETW is associated with four or
more servings of acidic products per day [11,
19].
Acidic Beverages and Dental Erosion
In addition, the different results in these re-
views could be related to other patient-related
conditions. Gastro-oesophageal reflux is seldom
considered in such studies, and it is an impor-
tant factor in the majority of patients with den-
tal erosion [20]. Some patients have no appar-
ent symptoms for reflux, or they may not even
be aware that they suffer from this condition.
These patients, therefore, present silent reflux,
and this condition is only detected by a special-
ist. Further studies on the association between
ETW and diet should also consider other pa-
tient-related (confounding) variables. More-
over, further studies on sports/energy drinks
are still encouraged, especially considering the
increased popularity of these drinks among
children and adolescents. An urgent additional
reason for such research is that high consump-
tion of such drinks by young people could result
in more serious health issues, such as calcium
deficiency, which could jeopardise the accrual
of maximal peak bone mass at a critical time of
life [21].
Chemical Parameters Associated with ETW
Human dental enamel is made up mostly of cal-
cium (Ca2+), phosphate (PO43–), hydroxide
(OH– ), fluoride (F–), carbonate (CO32–) and so-
dium (Na+) ions [22]. It is represented by the sim-
plified chemical formula: Ca10–xNax(PO4)6–y
(CO3)z(OH)2–uFu, which is slightly different from
pure hydroxyapatite (HAP): Ca10(PO4)6(OH)2
[22–24]. In the oral cavity, enamel is in a constant
equilibrium with its surrounding fluids. So, the
de- and re-mineralisation processes on the enam-
el surface are mediated by the continuous ionic
exchange between the enamel and the oral envi-
ronment.
Under normal (healthy) circumstances, the
outer surfaces of the enamel are surrounded by
saliva, which is rich in Ca2+, PO43–, and OH–. So
the enamel crystals remain in equilibrium with
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the saliva, and they do not lose Ca2+, PO43–, or
OH– to the environment; in other words, they do
not demineralise. However, when the surround-
ing fluid is depleted in Ca2+ and PO43– ions and
rich in H+ ions (such as most erosive substances),
the enamel and its surrounding fluids will no lon-
ger be in equilibrium, so the H+ ions from the acid
will react with the different sites on the enamel
surface. In turn, Ca2+, PO43–, and OH– will dis-
solve out of the enamel to the surrounding fluids
in an attempt to restore the equilibrium; in other
words, the enamel will demineralise [22].
Throughout our lifetime, the teeth are con-
stantly subjected to acidic environments, and the
rate of enamel demineralisation will depend on
the pH and the mineral ion concentration in the
surrounding fluids [22, 25]. When the teeth are
exposed to substances with low pH and a low con-
centration of Ca2+, PO43–, and OH–, there is a ten-
dency for enamel to release more of these ions to
the environment, and the demineralisation is
more intense. If the substances have a higher pH
or higher concentration of these ions, the demin-
eralisation proceeds more slowly, or does not oc-
cur at all.
The most important chemical factors modu-
lating erosive demineralisation are pH and Ca2+
concentration and, to a lesser extent, phosphates
and F– concentrations, as well as titratable acid-
ity and buffer capacity [26, 27]. pH is a measure
of acidity of a substance. Substances with low pH
values have higher H+ concentrations, thus elic-
iting more rapid enamel demineralisation. Both
titratable acidity and buffer capacity are closely
related to pH, and they are determined by the
type of acid and pH value. Buffering of a solution
is determined by its buffer capacity or its titrat-
able acidity. The first is measured at a specific
pH, and it is determined by how much base the
solution can withstand without changing its pH
value. The latter, on the other hand, is a measure
of the total buffering effect of the solution, and it
is determined by the total amount of base neces-
sary to change the pH of the solution from its
94
native value to a defined higher value [22]. The
titratable acidity and buffer capacity both reflect
the ability of the solution to be neutralised by sa-
liva [2]. It depends on the concentration of the
undissociated form of the acid [22], especially
organic acids, which acts as a supplier of protons
(H+ ions).
Organic acids can be generally expressed by
the chemical formula R-COOH. In solution,
these acids are in equilibrium, according to the
equation:
R-COOH (aq) ⇄ R-COO– (aq) + H+ (aq).
This means that a proportion of the acid mole-
cules are able to remain in their undissociated
form (R-COOH), while a proportion of the acid
molecules dissociate (R-COO– + H+), leaving
the H+ free in solution. Once the free H+ ions
start reacting with the enamel surface, more of
the undissociated form of the acid will dissoci-
ate, shifting the equilibrium equation to the
right, and, consequently, releasing more H+ ions
into the solution. This means that the pH of the
acid will remain low for longer (buffered), and
the enamel dissolution will continue to advance
[28, 29]. In other words, substances with higher
titratable acidity and buffer capacity present
greater erosive potential. Still, it is important not
to judge the erosive potential of beverages and
foods only by their pH, for there is no “critical
pH” related to erosion. If a beverage or food has
an acidic pH, it does not necessarily mean that it
will cause enamel dissolution. Its erosive poten-
tial will firmly depend on its Ca2+ and phosphate
content.
The presence of Ca2+ and phosphate in bever-
ages and foods can be considered as a protecting
factor [30–33]. One example is yoghurt, which
can have a pH as low as around 4, yet it is not
erosive due to its high Ca2+ and phosphate con-
centrations (37.4 and 10.7 mmol/L, respectively)
[26]. Sour milk also has a high Ca2+ (69.0 mmol/L)
and phosphate (39.2 mmol/L) content, and even
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with its low pH of 4.2 it has no erosive impact on
enamel [34]. Since these mineral ions are key
protecting factors, experiments have been done
supplementing orange juice with calcium and
phosphate. Orange juice supplemented with cal-
cium (42.9 mmol/L) and phosphate (31.2
mmol/L) caused no enamel erosion despite its
low pH of 4.0, whereas the non-supplemented
orange juice caused deep erosive lesions [31].
Hemingway et al. [35] suggested that Ca2+ is re-
leased before phosphate ions from dissolving
enamel, and Ca2+ will play a more important role
in the erosive potential of a substance than phos-
phate. In solution, orthophosphate can exist as 4
different species (H3PO4, H2PO4–, HPO42– and
PO43–). The only species of importance with re-
gard to erosive potential is PO43–, since it is the
relevant species of enamel mineral (see formula
at the beginning of the chapter) [27, 35]. The
concentrations of the different species are strong-
ly influenced by pH. In erosive substances with
low pH, only a minute fraction of the phosphate
species are in the form of PO43–, so phosphate
plays a minor role in the erosive potential of bev-
erages and foods. Lastly, the literature is still con-
tradictory in relation to how F– concentrations in
the beverages and foods affect their erosive po-
tential [26, 27, 31, 36], although caution should
be taken that excess intake of fluoride is directly
linked to cases of fluorosis.
All the above mentioned chemical parameters
act in unison in the erosive potential of substanc-
es, and the interplay between these parameters
will modulate the amount of demineralisation of
the enamel. Together, these parameters can be
used to calculate the degree of saturation of a giv-
en substance with respect to HAP and fluorapa-
tite (FAP) [37]. The degree of saturation repre-
sents the driving force for whether a substance is
more or less likely to demineralise the enamel or
cause precipitation of the mineral. When a sub-
stance is undersaturated with respect to HAP and
FAP, it will cause the enamel to demineralise,
whereas substances supersaturated with respect
Acidic Beverages and Dental Erosion
to HAP and FAP will tend to precipitate salts on
the dental enamel [22]. Lussi et al. [27], Lussi and
Hellwig [34], as well as Lussi and Carvalho [26]
analyzed the effects of several beverages and
foods on deciduous and permanent enamel.
These authors further investigated different
chemical parameters of the substances and used
a multiple linear regression analysis to determine
which factors played significant roles in enamel
dissolution. A list of erosive potentials of several
beverages and foods can be found in these re-
ports [26, 27, 34].
Physical Parameters Associated with ETW
Besides chemical parameters, physical parame-
ters will also modulate the demineralisation pro-
cesses. In dentine, continued acid attacks cause a
surface demineralisation of the dentine, exposing
the dense, fibrous, organic collagen network (or-
ganic matrix). During dental erosion, this organic
matrix is retained, and it serves as a physical dif-
fusion barrier, constraining the dissolved mineral
ions largely within the liquid phase surrounding
the collagen fibres, leading to a higher concentra-
tion of these ions near the surface of the dentine
than if diffusion were unhindered. This higher
ionic concentration increases the degree of satu-
ration immediately surrounding the dentine sur-
face, markedly decreasing further mineral loss
[38].
In enamel, there is no corresponding layer of
insoluble matrix, but a diffusion process can still
occur when an erosive substance is left on the
tooth surface with no movement. In this case, the
outflow of PO43– and OH– from the enamel dur-
ing the demineralisation process will slowly neu-
tralise the H+ in the immediate vicinity of the
enamel surface. This too leads to a local rise in the
concentration of mineral ions in the semi-static
liquid layer immediately adjacent to the enamel
surface [38]. This semi-static layer is called the
“Nernst layer.” The higher concentration of these
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Table 1. Median relative surface hardness (%rSH) of deciduous enamel after 2 or 4 min immersion in different sub-
stances under gentle agitation (not swishing) or vigorous agitation (swishing)

Substance pH 2 minutes 4 minutes

† ‡
gentle vigorous p value* gentle† vigorous‡ p value*
agitation agitation agitation agitation
(%rSH) (%rSH) (%rSH) (%rSH)

Mineral water 6.5 100 99 0.335 100 99 0.642

Orange juice 3.6 97 89 0.001 90 71.5 <0.001
Apple juice 3.2 90 70 <0.001 70 47 <0.001
Coca-cola 2.6 70 70 <0.001 66 46 <0.001
Monster energy 3.4 91 72 <0.001 75 53 <0.001
Red bull 3.4 88 73 <0.001 70 48 <0.001
Sour candy 2.5 86 67 0.001 64 41 <0.001
Candy spray 2.1 39 31 0.001 18 15 0.064

† Values
calculated from Lussi and Carvalho [26].
‡ Values
calculated from Carvalho et al. [40].
* Mann-Whitney tests were used to verify significant differences between the 2 types of movements for each substance
and erosion time.

ions in the Nernst layer will also increase its de-
gree of saturation in the immediate vicinity of the
enamel, eventually becoming saturated with re-
spect to the tooth mineral, and, in turn, reducing
the demineralisation.
These parameters (collagen layer and Nernst
observed in 2 studies from our group [26, 40],
where we investigated erosion in deciduous teeth
using different agitation speeds. Both experi-
ments were conducted by immersing the decidu-
ous teeth in acidic beverages for either 2 or 4 min,
at the same temperature 30 ° C, but using 2 differ-

layer) are influenced by in vivo circumstances.
The collagen layer may be influenced by matrix
metalloproteinases from dentine and saliva, and
the Nernst layer is influenced by normal eating
and drinking movements. The latter causes a con-
tinuous flow of the acidic beverages over the
teeth, leading to a constant renewal of the Nernst
layer, which never reaches saturation with respect
to the dissolving enamel [39].
Lussi and Carvalho [30] suggested that the
process of renewing the Nernst layer is particu-
larly important when a substance is only slightly
undersaturated with respect to tooth mineral.
During greater agitation, like when patients
swish drinks in the mouth, the continuous out-
flow of Ca2+, PO43–, and OH– from the enamel
will lead to a more rapid erosive process. This was
ent kinds of agitation: in one study [26], we used
gentle agitation (similar to patients who drink
without swishing the drinks in their mouth), and
in the other study [40] we used vigorous agitation
(similar to patients who swish drinks in their
mouths). The results are presented in Table 1.
We clearly observe that vigorous agitation causes
significantly more erosion than gentle agitation
either after 2 or 4 min erosion, yet no significant
differences are observed when candy spray is
used for 4 min. Substances like candy spray are so
aggressive that a normal intake (gentle agitation)
for a slightly longer period of time (4 min) will
already cause maximum harm to the teeth. From
these results (Table 1), we can conclude that the
kind of intake plays a significant role in initial
enamel erosion, leading to distinct differences in
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enamel surface hardness loss, but this difference
diminishes when a non-erosive substance (like
mineral water) is used, or when a strong erosive
substance (like candy spray) is used for longer
erosion times.
This effect has also been observed in patients,
who adopt specific behaviours that increase the
contact time between the tooth and the acidic
substance (like swishing). In a case-control study,
O’Sullivan and Curzon [11] compared a group of
patients who presented with ETW to a group of
patients who had active caries lesions, and anoth-
er (control) group who had neither ETW nor car-
ies. The authors observed that 43% of the patients
with ETW had some kind of drinking habit, such
as holding the drinks in the mouth, sucking or
swishing; whereas, only 15% of the caries-active
patients and 3% of the control group exhibited
such habits. So during the clinical assessment of
patients with ETW, it is important to assess their
behaviours and drinking habits.
Conclusion
Since diet plays a significant role in ETW, dietary
habits should be thoroughly and routinely inves-
tigated in the clinical setting. Lussi and Hellwig
[34] advise that patients should record their com-
plete dietary intake over a course of 4 consecutive
days, taking notes specifically on the time of day,
the duration of ingestion, and the quantity of all
ingested beverages and foods. Additionally, both
weekdays and weekends should be included in
the diet record sheet, for behaviours can differ
considerably depending on the day of the week.
Dentists should use these food diaries to assess
the erosive potential of all beverages and foods, as
well as the frequency of ingestion, thus estimating
the patient’s daily acidic intake [34]. With this in-
formation, preventive measures and dietary in-
terventions individually tailored to each patient
can then be elaborated in an attempt to slow the
progression of ETW.

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Dr. Thiago Saads Carvalho
Department of Restorative, Preventive and Pediatric Dentistry
University of Bern, Freiburgstrasse 7
CH–3010 Bern (Switzerland)
E-Mail thiago.saads @ zmk.unibe.ch
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Saads Carvalho · Lussi
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