Throughout your dental career, reducing sugar intake will be a recurring theme in the oral health advice you give to your patients. However, some alternatives perceived as "healthy" dietary choices can bring their own oral health risk in the form of acid erosion. How can dental students help patients make positive changes without this unintended consequence?
Acid erosion involves the irreversible loss of dental hard tissues caused by non-bacterial acids. You may also hear it referred to as dental erosion or, when only the enamel is affected, enamel erosion. The acid either originates inside the body (gastric acid) and is known as intrinsic acid, or it originates from outside of the body (most commonly from acidic foods and drinks) and is referred to as extrinsic acid. The non-bacterial acid demineralizes tooth structure, softening it and making it susceptible to subsequent wear.
Enamel erosion and diet
Our patients are increasingly aware of the health risks associated with consuming sugar, including the increased risk of dental caries. As they attempt to reduce their sugar intake, patients may look to replace sweet foods and drinks with alternatives that they consider "healthy". Popular options include:
Snacking on fruit instead of candy.
Replacing soda with fruit smoothies, juice, diet sodas, or seltzers.
Drinking unsweetened coffee.
However, in one review, 93% of all commercially available drinks in the US were found to have a pH below 4.0. Some popular foods and juices also have a low pH and are highly acidic. Examples include:
Lemon juice (2.0-2.6)
Orange juice (3.3-4.19)
Fruit smoothies can have a low pH and sometimes contain added sugar, a "double whammy" that contributes to both caries risk and erosion risk. In addition, patients focused on health improvement may follow popular diets and wellness regimens that rely heavily on acidic ingredients like lemon juice or apple cider vinegar, e.g., the “master cleanse” or the ACV diet.
Helping patients make healthier choices
Patients who choose alternatives like fruit and smoothies often have no idea that they can cause acid erosion. As you counsel a patient on reducing sugar intake, it’s the perfect opportunity to make them aware of acid erosion and help them make healthy, well-informed changes to their diet. It may be helpful to frame your advice by first acknowledging your patient's efforts, then reinforcing the benefits, explaining the risks, and providing a balanced solution.
You can share advice to help the patient minimize the risk of erosion, such as:
Reducing and moderating consumption of acidic foods and drinks.
Substituting juice or seltzers with milk or fluoridated water.
Drinking milk or fluoridated water when eating acidic foods.
Having acidic foods and drinks only at mealtimes (this reduces the frequency of exposure to extrinsic acids).
Choosing higher pH-ingredients for smoothies (e.g., banana, avocado, coconut milk).
Avoiding sipping and "swishing" acidic drinks around the mouth.
Drinking through a straw to minimize contact with the teeth.
Helping to prevent and reduce enamel erosion
In addition to dietary intake and lifestyle, salivary flow, buffering capacity, and the mineral content of the tooth structure (calcium, phosphate and fluoride) play an important role. Fluoride in general has been found to be protective against acid erosion, and stannous fluoride toothpaste has been recommended for patients at risk for dental erosion. Frequent application of high-concentration fluorides may also be considered as a preventative approach.
For home oral hygiene, you may wish to consider recommending an oral care product like Colgate Total SF toothpaste, formulated to strengthen tooth enamel. Another option is a higher-level fluoride toothpaste containing 5000 ppm fluoride, such as Colgate PreviDent 5000 Enamel Protect, which strengthens enamel and protects against acid wear.
Helpful resources for patients
Finally, it may be helpful to provide your patients with resources to which they can refer back, such as:
What is Dental Erosion? (Journal of the American Dental Association)
Erosion: What You Eat and Drink Can Impact Teeth (Mouth Healthy)
Dental Erosion (Better Health Channel)
pH Values of Foods and Food Products (Arrow Scientific)
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