SCIENTIFIC ARTICLE

Australian Dental Journal 2002;47:(3):228-236

Acidic diet and dental erosion among athletes

V Sirimaharaj,* L Brearley Messer, MV Morgan

Abstract Background: The consumption of acidic foods and drinks is increasing in popularity. The purposes of the present study were to investigate the consumption patterns of acidic foods and drinks among several sport groups and to examine any relationships between consumption patterns and dental erosion. Methods: A questionnaire of oral health habits, diet and dental health was developed. Thirty-two sports clubs (690 members) of the University of Melbourne participated in a survey. A total of 508 usable questionnaires were received (74.9 per cent response). Descriptive statistics were prepared and logistic regression was used to explore relationships between dental erosion (dependent variable) and the independent variables. Results: Dental erosion was reported by 25.4 per cent of respondents, particularly among athletes of the Martial arts (affecting 37.4 per cent). The consumption of acidic foods and drinks was frequent among most athletes. No significant associations were identified between dental erosion and the frequency of drinking soft drinks or sports drinks. Statistically significant associations were found between dental erosion and age group (p=0.004), frequency of drinking juices (p=0.05), and tooth sensitivity (p=0.001). Conclusion: Athletes may be placing themselves unintentionally at risk of dental erosion and dentists could counsel athletes to control and reduce the effect of potentially erosive foods and drinks.
Key words: Athletes, acid, diet, dental erosion. (Accepted for publication 10 June 2001.)

INTRODUCTION Dental erosion is a non-carious, pathological loss of tooth surface, distinct from abrasion and attrition, and is defined as the irreversible loss of dental hard tissue by

*Department of Paediatric Dentistry, Faculty of Dentistry, Chiangmai University, Thailand. Formerly postgraduate student in Paediatric Dentistry, School of Dental Science, The University of Melbourne, and honorary dental officer, Royal Childrens Hospital, Melbourne. School of Dental Science, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne.
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a chemical process not involving bacteria.1 Over the last two decades, tooth erosion has become a significant clinical problem.2,3 Dental erosion may have a multifactorial etiology, attributable to intrinsic and extrinsic causes. The intrinsic causes are associated with gastric acids, and may present intra-orally following vomiting, regurgitation, gastro-oesophageal reflux or rumination.4,5 The extrinsic factors involved in erosion include environmental factors, dietary factors, medications and lifestyle. Associations between diet and dental erosion have received considerable attention, especially in relation to acidic foods and drinks, and clinical studies have identified some particular foods and drinks as etiological factors in erosion.4,6,7 Popular literature and media suggest an increased interest in healthy and slimness lifestyles that involve regular exercise and a healthy diet. A person engaged in strenuous sports may be at risk for dental erosion due to the frequent ingestion of acidic sports drinks which provide carbohydrate, electrolytes and fluid replacement. The loss of body fluids and decreased salivary flow from exercise may increase the risk to the dentition when there is a high intake of low pH drinks.8,9 Unusual drinking habits, e.g., swishing or holding acidic drinks in the mouth for prolonged periods also have been linked to erosion.10,11 Dental erosion in athletes is a growing concern. The frequent intake of sports drinks and carbonated mineral water, and sipping habits have been implicated in tooth erosion.12 In 1997, an association between erosive tooth wear and sports drink consumption was studied in 25 competitive swimmers and 20 cyclists.12 A questionnaire identified the type of sports drinks consumed and the patterns of consumption. The pH, titratable acidity, and concentrations of calcium, phosphate and fluoride, and viscosity of the sport drinks were analyzed. The cyclists had significantly more maxillary palatal tooth wear (p<0.001), and greater consumption of sports drinks (p<0.05), than the swimmers. Although no association between erosion and sports drinks consumption was found in either group, most sports drinks have pH levels below the critical pH of 5.5 for enamel demineralization and consequently have the potential to be erosive.
Australian Dental Journal 2002;47:3.

Table 1. The distribution of questionnaires and responses of participants of 38 participating clubs by two methods of distribution
Distribution of clubs and questionnaires Distribution of sport clubs (n=38) Direct distribution by investigator Aikido, Athletics, Basketball (F)* Basketball (M), Boat (F), Boxing, Cricket (F), Cycling, Football (M), Hang Gliding, Hockey, Horseriding, Karate, Kendo, Kung Fu, Rifle, Mountaineering, Softball, Squash, Table Tennis, Triathlon Tae Kwon Do, Volleyball (M), Waterpolo, Waterski, Weight/Powerlifting 445 445 (100%) 436 (98%) Distribution via sport clubs mailbox Badminton, Boa (M), Cricket (M), Fencing, Football (F), Netball, Sailing/Windsurfing, Soccer (M), Surfriding, Taichi/Wushu, Tennis, Underwater

Distribution of questionnaires (n=690) Distribution of questionnaire responses (n=517) Distribution of usable questionnaires responses (n=508) *F=Female. M=Male. Per cent of questionnaires distributed. Per cent of questionnaires responses.

245 72 (29.4%) 72 (100%)

Based on the above observations, it was hypothesized that an association between the consumption of acidic foods and drinks and dental erosion could be occurring in athletes. A crosssectional, questionnaire-based study of athletes was designed, to investigate the pattern of consumption of acidic foods and drinks in members of several sports groups of the University of Melbourne, Australia. The aims of the study were three-fold: (i) to describe the consumption of acidic foods and drinks by these athletes; (ii) to record their experience of dental erosion as told to them by their dentist; and (iii) to investigate the relationship between the patterns of consumption and dental erosion. M AT E R I A L S A N D M E T H O D S Ethical approval was obtained from the Ethics Committee of the University of Melbourne. A questionnaire comprising 32 items was developed, with questions on oral health habits (n=7); dental health (n=6); and diet (n=19). The participants gender, age, ethnic background, occupation and sports activity were recorded. The specific items and rating methods are detailed in the results section below. An explanatory letter and a consent form were attached to the questionnaire.

The study was conducted during August-November, 1998. Forty-six of 53 registered sports clubs in the Sport Clubs Association of the University of Melbourne were accessed. The aims and survey process were explained to the president/secretary of each club and also at a meeting of the Sport Clubs Association Council in 1998; 38 clubs agreed to participate (Table 1). Twentysix clubs allowed the investigator to distribute questionnaires at practice venues or meetings, and 12 clubs distributed the questionnaires via the club mail boxes (Table 1). In the mailbox group, the president/secretary of each club was asked to return the completed questionnaires to the investigator by the due date and two reminders were made by telephone thereafter. The clubs were sorted into eight groups based on similarity of athletic activity. Occupations of respondents were classified into seven groups using a modification of the Australian Standard Classification of Occupations.13 Statistical analysis The information collected from the questionnaires was verified, entered into Excel spreadsheets, and exported into the Statistical Package for Social Sciences (SPSS).14 Descriptive statistics were prepared for the

Table 2. Distribution of respondents by sport groups and sport types

Sport groups* Athletics Running and ball Martial arts Racquet and ball Watersports Field sports Swords sports Ungrouped Type of sport Athletics, Cycling, Triathlon Basketball (F), Basketball (M), Football (F), Football (M), Softball, Volleyball Aikido, Karate, KungFu, Tae Kwon Do, TaiChi/Wushu Badminton, Squash, Table tennis Boat (F), Surfriding, Underwater, Waterski, Waterpolo Cricket (F), Hockey (M) Fencing, Kendo Boxing, Hang gliding, Horseriding, Rifle, Mountaineering, Weight/Powerlifting Distribution of respondent athletes (n=508) (%) 60 (11.8) 102 (20.1) 91 (17.9) 44 (8.7)1 68 (13.4) 28 (5.5)1 35 (6.9)1 80 (15.7)

*Based on similarity of athletic activity. F=Female. M=Male.

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Table 3. Age, gender, ethnic background, and occupation characteristics of respondents (n=508)
Characteristics of respondents Gender Male Female Age 18-20 yr 21-30 yr 31-60 yr Ethnic background Australian European Asian and African Occupation* Manager/administrators Professional Para-professional Tradespersons Clerks Salespersons/personal services workers University students No of respondents (n=508) (%) 309 (60.8) 199 (39.2) 192 (37.8) 268 (52.8) 48 (9.4)1 339 (66.7) 69 (13.6) 100 (19.7) 3 54 15 3 15 (0.6)1 (10.6) (2.9)1 (0.6)1 (2.9)1

association for this type of data are odds ratios with 95 per cent confidence intervals (CI) to test the significance of each variable. The interactions between the independent variables were also investigated by logistic regression.14,15 R E S U LT S Distribution of questionnaires A total of 690 questionnaires were distributed, 445 directly and 245 indirectly via mailboxes (Table 1). Of these, 517 questionnaires were returned, 100 per cent from those distributed directly and 29.4 per cent from the mailbox distribution (74.9 per cent total response). Of the 508 usable questionnaires returned, 436 came from direct distribution, and 72 from indirect distribution (Table 1). Distribution of respondents Of the 508 respondents, the largest groups were Running and ball (n=102), followed by Martial arts (n=91) and Ungrouped (n=80); the smallest groups were the Swords sports (n=35) and Field sports (n=28) (Table 2). The predominant group of respondents were male, aged 18-30 years, Australian, and university students (Table 3). Patterns of oral health habits and dental health Of the 508 respondents, 69.3 per cent brushed their teeth 2 times/day, 46.5 per cent brushed their teeth after both breakfast and dinner, 80.1 per cent used a combination brushing technique, 77.5 per cent used a soft/medium toothbrush and most respondents never or

8 (1.6)1 410 (80.7)

*Modified from Australian Standard Classification of Occupations.12

independent variables (age, oral health habits, diet and dental health). Reported dental erosion was the dependent variable. Statistical analyses were performed on SPSS for MS Windows version 8.14 Stepwise logistic regressions (backward and forward stepwise regression) were used to determine relationships between the independent variables and the dependent variable.15 All independent variables were analyzed, then several models were tested to confirm and construct the final models. Three separate regression analyses were conducted: two multivariate and one univariate. Measurements of

Table 4. Patterns of oral health habits and dental health of the 508 respondents
Oral hygiene habits Frequency of tooth brushing: 1 time/day 1 time/day 2 times /day Timing of tooth brushing: Never, rarely Either after breakfast/dinner After both breakfast and dinner After every meal Tooth brushing technique: Horizontal Vertical Combination Don't know Tooth brushing type: Soft Medium Hard Dont know Frequency of mouth rinsing: Never or rarely 1-2 times/week 1-2 times/day Distribution of respondents n=508 (%) 32 (6.3)1 124 (24.4) 352 (69.3) 91 151 236 30 26 57 407 18 149 245 59 55 (17.9) (29.7) (46.5) 1(5.9) (5.1)1 (11.2) (80.1) (3.5)1 (29.3) (48.2) (11.6) (10.8) Dental health Suffer regurgitation: Yes No Acidic taste in the mouth: Yes No Tooth sensitivity from hot/cold foods or drinks: Not at all Seldom, rarely Sometimes On all occasions Dental erosion: Yes No Wear plastic mouthguard at night: Yes No Sometimes Grind/clench teeth at night: Yes No Dont know Distribution of respondents n=508 (%) 25 (4.9)1 483 (95.1) 234 (46.1) 274 (53.9)

131 205 134 38

(25.6) (40.3) (26.4) (7.5)1

129 (25.4) 379 (74.6) 17 (3.3)1 478 (94.1) 13 (2.6)1 93 (18.3) 282 (55.5) 133 (26.2)

367 (72.4) 78 (15.3) 63 (12.3)

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Australian Dental Journal 2002;47:3.

100 90 80 80 72.7 Distribution of respondents (%) 70 62.6 60 50 37.4 40 27.3 30 20 20 10 0 Athletics Running and ball Martial arts Racquet ball Watersports Sports groups Field sport Sword sport Ungrouped Total 23.5 18.6 14.3 25 30 25.4 81.4 76.5 75 70 74.6 Yes No

85.7

Fig 1. The distribution of respondents reporting tooth erosion by sport groups (n=508).

rarely used a mouth rinse (72.4 per cent; Table 4). Most respondents did not suffer regular regurgitation of stomach contents (95.1 per cent) or an acidic taste in the mouth (53.9 per cent). Over 74 per cent experienced some tooth sensitivity from hot/cold foods or drinks. A total of 129 respondents (25.4 per cent) reported being advised by their dentist that they had dental erosion; 18 per cent reported grinding/clenching their teeth at night and 6 per cent wore a plastic mouth guard at night. The Martial arts group had the highest proportion of respondents reporting dental erosion (37.4 per cent) and the Swords sport group had the least (14.3 per cent; Fig 1). Patterns of dietary habits Most respondents ate spicy foods and spicy sauces frequently (Table 5). A high proportion of respondents ate spicy sauces sometimes (45.3 per cent), snacked between meals 1-2 times/day (46.5 per cent), ate sweets 1-2 times/day (34.8 per cent), and ate citrus fruits 1-2 times/day (40.3 per cent) typically between meals (60.4 per cent). Yoghurt was consumed infrequently. The most frequent consumers of spicy foods were the Martial arts group (49.4 per cent), followed by those in the Swords sport group (42.8 per cent); the least frequent consumers were those in the Athletics group (6.6 per cent; Fig 2). Among all respondents, fruit juices were the most frequently-consumed drinks (94.3 per cent), followed by soft drinks (88.5 per cent), wine (69.3 per cent) and sports drinks (55.3 per cent; Table 5). The Running and ball and Field sport groups were the most frequent consumers of fruit juices, soft drinks and sports drinks (Fig 3). Most typical patterns were for wine to be consumed with meals (53.5 per cent); juices both with
Australian Dental Journal 2002;47:3.

and between meals (94.3 per cent); soft drinks both with and between meals (88.5 per cent), and sports drinks between meals (48.8 per cent). Soft drinks were consumed typically by straw/sipping (37 per cent) or quick swallowing (31.9 per cent); sports drinks were consumed typically by quick swallowing (31.9 per cent; Table 5). Associations between oral health habits, dietary habits and dental erosion To examine the associations between oral health habits, dietary habits and dental erosion, a multivariate logistic regression model was used. Several different models were tested to construct the final models, which showed no change in the order of importance of the variables. No significant interactions between the independent variables were found (Table 6). Statistically significant associations were noted between dental erosion and age group (p=0.004), and between dental erosion and frequency of drinking fruit juices (p=0.05). No significant associations were identified between dental erosion and the consumption of soft drinks or sports drinks; the frequency of eating spicy foods, spicy sauces, snack foods or citrus fruit; or tooth brushing frequency (Table 6). Associations between regurgitation, acidic taste in mouth, tooth sensitivity and dental erosion No significant associations were noted in multivariate logistic regression between dental erosion and regurgitation of stomach contents or acidic taste in the mouth (Table 7). A significant association was noted in univariate analysis between dental erosion and the frequency of tooth sensitivity when consuming hot or cold foods/drinks (p=0.001). Where tooth sensitivity
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Table 5. Patterns of dietary habits of the 508 respondents

Dietary habits Frequency of eating spicy foods: Never 1 time/month 1 time/week Several times/week Frequency of eating spicy sauces: Never Rarely Sometimes Every time Frequency of eating snack foods: Never <1 time/day 1-2 times/day >2 times/day Frequency of eating sweets: Never <1 time/day 1-2 times/day >2 times/day Frequency of eating citrus fruits: Never <1 time/day 1-2 times/day >2 times/day Timing of eating citrus fruits: Not related to meal With meals Between meals With meals and between meals Frequency of eating yoghurt: Never <1 time/day 1 time/day Frequency of drinking wine: Never <1 time/day 1 times/day Timing of drinking wine: Never Usually with meals Usually between meals Both with meals and between meals Distribution of respondents n=508 (%) 49 137 164 158 102 162 230 14 18 131 236 123 16 272 177 43 28 233 205 42 28 101 307 72 (9.6)1 (27.0) (32.3) (31.1) (20.1) (31.9) (45.3) (2.7)1 (3.5)1 (25.8) (46.5) (24.2) (3.1)1 (53.5) (34.8) (8.5)1 (5.5)1 (45.9) (40.3) (8.3)1 (5.5)1 (19.9) (60.4) (14.2) Dietary habits Frequency of drinking fruit juices: Never <1 time/day 1-2 times/day >2 times/day Timing of drinking fruit juices: Usually with meals Usually between meals With meals and between meals Frequency of drinking soft drinks: Never <1 time/day 1-2 times/day >2 times/day Timing of drinking soft drinks: Never Usually with meals Usually between meals With meals and between meals Habits for drinking soft drinks: Never Sipping/straw Quick swallow Holding/swishing Frequency of drinking sports drinks: Never <1 time/day 1 times/day Timing of drinking sports drinks: Never Usually with meals Usually between meals With meals and between meals Habits for drinking sports drinks: Never Sipping/straw Quick swallow Holding/swishing Distribution of respondents n=508 (%) 29 207 216 56 (5.7)1 (40.7) (42.5) (11.0)

222 (43.7) 169 (33.3) 117 (23.0) 58 306 112 32 58 127 208 115 58 188 162 100 (11.4) (60.2) (22.0) (6.3)1 (11.4) (25.0) (40.9) (22.6) (11.4) (37.0) (31.9) (19.7)

227 (44.7) 254 (50.0) 27 (5.3)1 227 15 248 18 227 68 162 51 (44.7) (2.9)1 (48.8) (3.5)1 (44.7) (13.4) (31.9) (10.0)

121 (23.8) 304 (59.8) 83 (16.3) 156 (30.7) 340 (66.9) 12 (2.4)1 156 272 32 48 (30.7) (53.5) (6.3)1 (9.4)1

was reported on all occasions, respondents were 6.6 times more likely to report erosion than those who had never had tooth sensitivity (Table 7). DISCUSSION Direct distribution of the questionnaires resulted in an excellent return of usable responses, whereas indirect distribution by mailboxes resulted in a very low response rate from both clubs and participants. The low response rate may have been due to a lack of interest of the presidents/secretaries and members, and inconvenience associated with distributing and collecting questionnaires. Although not significantly associated with the consumption of soft drinks or sports drinks, the odds ratios reported in the present study increased when the frequency of eating spicy foods, snack foods, citrus fruit and yoghurt increased, and the Martial arts group demonstrated the highest consumption of spicy foods. In this group, 40 per cent of the respondents were of Asian background (the highest percentage of Asian
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respondents in any group). Many Asian foods are hot and spicy, and are eaten frequently by Asian people. The Martial arts group also showed the highest proportion of respondents reporting tooth erosion and tooth sensitivity. Study of a larger sample size than was possible here may demonstrate a correlation between reported tooth erosion and the high consumption of spicy foods or acidic foods, concurring with other reports.4-6,16 Acidic foods and drinks appeared to be consumed frequently by the respondents in this study, particularly fruit juices (consumed by 94.3 per cent of respondents), following by soft drinks (88.6 per cent), wine (69.3 per cent), and sports drinks (55.3 per cent). It should be noted that the questionnaire item fruit juices did not differentiate between drinks containing 100 or 25-35 per cent juice, added citric acid or added vitamin C. Similarly, the questionnaire item soft drinks did not differentiate between citrus type drinks or colas (fruit acid 338). Several of these drinks have been associated significantly with dental erosion, and to have low pH values (2.9-5.3) below the critical level (5.5) at which enamel demineralization occurs.2,6,12,16-20 For example,
Australian Dental Journal 2002;47:3.

60 Never 1 time/month 1 time/week Several times/week 42.8 Distribution of respondents (%) 40 35.3 29.4 30 26.7 27.5 25.3 21.5 20 16.6 13.7 11.7 10 8.8 5.7 2.3 0 Athletics Running and ball Martial arts Racquet and ball Watersports Sport groups Field sport Sword sport Ungrouped Total 13.2 10 9.6 18.7 25 34.1 30.9 29.4 26.5 40 38.6 35.7 32.1 31.2 25.7 32.3 31.1 27

50 45

49.5

Fig 2. The distribution of respondents (n=508) consuming of spicy foods.

grapefruit juice (pH 3.2) and apple juice (pH 3.9) have been associated with softening enamel and dentine.21 It is likely that the consumption frequency and period of exposure of enamel to these acidic drinks are associated with dental erosion. The frequency of drinking fruit juices in the present study showed a statistically significant association with dental erosion (p=0.05),
100 93.3 90 83.3 80 71.7 Distribution of respondents (%) 70 60 50 40 30 20 10 0 Athletics Running and ball Martial arts Racquet and ball 77.4 85.7 99 94.1 91.2 88.6 95.4 92.6

suggesting support for this relationship. In addition, respondents consuming fruit juices more than two times/day were more likely to report erosion than those not consuming fruit juices. The high consumption of acidic drinks may relate to the type of sport activity played. Some athletes have a high carbohydrate requirement (beyond that obtained
100 89.3 86.8

94.3 88.6 91.2 90

94.3 88.6

75

55.3 50 47.7 42.6 38.5 37.1

Watersports Sport groups

Field sport

Sword sport

Ungrouped

Total Fruit juices Soft drinks Sports drinks

Fig 3. The distribution of respondents (n=508) consuming potentially erosive drinks.

Australian Dental Journal 2002;47:3. 233

Table 6. Associations between reported tooth erosion and oral health habits and dietary habits (Multivariate Logistic Regression model)
Variable Age Brushing teeth Levels 18-20 yr 21-30 yr 31-60 yr <1 time/day 1 time/day 2 times/day Never, rarely Either after breakfast/dinner After both breakfast/dinner After every meal Never 1 time/month 1 time/week Several times/week Never Rarely Sometimes Every time Never <1 time/day 1-2 times/day >2 times/day Never <1 time/day 1-2 times/day >2 times/day Not related to meals Usually with meals Usually between meals Never <1 time/day 1 time/day Never <1 time/day 1-2 times/day >2 times/day Not related to meals Usually with meals Usually between meals Never <1 time/day 1-2 times/day >2 times/day Never Usually with meals Usually between meals Never <1 time/day 1 time/day Never Usually with meals Usually between meals Never Usually with meals Usually between meals With meals and between Odds ratio 1* 1.8 4.1 1 1.6 1.7 1 0.8 0.7 0.4 1 1.6 1.7 1.8 1 0.5 0.7 0.3 1 1.7 2.0 2.8 1 2.0 1.4 1.8 1 0.5 0.6 1 1.9 1.7 1 0.9 0.5 1.2 1 0.6 0.5 1 1 0.9 1.7 1 0.8 0.9 1 1.6 1.6 1 1.1 0.6 1 0.7 0.3 0.8 95% CI 1.1-2.9 1.8-9.3 0.68 0.4-6.0 0.5-6.1 0.44 0.4-1.5 0.3-1.3 0.1-1.3 0.64 0.6-4.1 0.6-4.7 0.6-4.9 0.11 0.2-1.0 0.4-1.5 0.05-1.4 0.34 0.4-6.9 0.5-7.7 0.7-11.3 0.19 0.6-6.0 0.4-4.2 0.5-6.4 0.3 0.3-1.3 0.3-1.2 0.10 1.0-3.3 0.8-3.5 0.05 0.3-2.4 0.2-1.3 0.4-3.5 0.17 0.4-1.1 0.3-1.0 0.64 0.4-2.6 0.3-2.4 0.5-5.5 0.70 0.4-1.5 0.5-1.7 0.88 0.4-6.0 0.4-7.3 0.53 0.2-5.9 0.2-1.9 0.23 0.4-1.2 0.09-1.0 0.4-1.9 p value 0.004

Spicy foods

Spicy sauces

Snack food between meals Citrus fruits

Yoghurt Fruit juices

Soft drinks

Sports drinks

Wine

*Reference baseline group.

from meals) to meet the energy needs of frequent and lengthy training sessions, and require water and electrolytes to balance body fluids lost during and after exercise. Liquid carbohydrate supplements can meet these needs and can be provided by sports drinks, soft drinks and fruit juices. Sports drinks also serve to replenish post-exercise muscle and liver glycogen stores as well as restore fluids, which are important postexercise goals.22 Soft drinks and fruit juices provide carbohydrate (17-20 per cent sugars), which exacerbates dehydration. The findings of the present
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study showed that Running and ball and Field sport groups had the greatest frequency of consumption of fruit juices, soft drinks, and sports drinks. In these activities, athletes tend to use much energy, and need more carbohydrate, electrolytes, and water replacement than other sport groups. The increased need and high consumption of acidic drinks may contribute to the risk of dental erosion in these athletes. In the present study, the frequency of tooth sensitivity when consuming hot or cold foods/drinks correlated strongly with dental erosion. As a steadily
Australian Dental Journal 2002;47:3.

Table 7. Associations between reported tooth erosion and reported regurgitation, acidic taste, and tooth sensitivity
Statistical analysis Multivariate Logistic Regression model Univariate analysis Variable Suffer regurgitation of stomach contents Acidic taste in the mouth Tooth sensitivity Levels No Yes No Yes Not at all Seldom, rarely Sometimes On all occasions Odds ratio 1* 1.05 1 1.43 1 3.4 4.3 6.6 95% CI 0.42-2.59 0.08 0.95-2.14 0.001 1.8-6.7 2.2-8.4 2.8-15.6 p value 0.92

*Reference baseline group.

progressive loss of tooth surface by chemical processes, erosion may be difficult to detect clinically. The earliest change in an affected tooth is enamel surface loss, followed by increasing translucency on interproximal and incisal margins. The enamel may become more translucent due to thinning and may fracture; the tooth may become sensitive and patients may present to the dentist at this stage of tooth deterioration. Tooth sensitivity may be a sign of erosion, increasing with progressive loss of tooth surface.3,17 The Martial arts group had the most respondents reporting both erosion and tooth sensitivity, suggesting an association between these two phenomena. An apparent increase in the risk of erosion when sports drinks were consumed once or more per week, or when soft drinks were consumed daily, has been reported.6 However, in the present study the frequency of drinking sports drinks or soft drinks was not related to dental erosion. Among respondents consuming these drinks, most were likely to drink these less than once per day. Only 28.3 per cent of the respondents drank soft drinks, and 5.3 per cent drank sports drinks, at least daily. The small numbers of respondents who frequently consumed sports drinks or soft drinks limit the findings of the present study. As the respondents were regularly undertaking exercise, but not necessarily competitively (where athletes tend to use much energy in a short time period), they may not have required as much nutrient and electrolyte replacement. Although no statistically significant association was reported between dental erosion and the frequency of consuming soft drinks or sports drinks, the odds ratios indicated that erosion increased with the increasing frequency of consumption of these drinks. Although not statistically significant in the present study, unusual or high consumptions of spicy foods, spicy sauces, yoghurt, wine and citrus fruit have been reported to damage tooth surfaces.4-6,16 Respondents in the present study were likely to eat spicy foods once per week or more, sometimes ate spicy sauces with meals, ate snack foods 1-2 times/day, and ate sweets, citrus fruit or yoghurt <1 time/day. At these frequencies, the consumption of these foods appears to be low or normal. Also, these foods are generally eaten at meals together with other foods, which may provide buffering and neutralization of acids, thereby lowering the erosive potential.
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In studies of dental erosion in adult populations reported in Switzerland and Saudi Arabia, the prevalence of erosion ranged from 28 per cent to 43 per cent, depending on age and diagnostic criteria.21,23 In both studies, acidic drinks were associated significantly with the presence of erosion. The findings of the present study concur with such studies, with 25.4 per cent of respondents reported being told by their dentist that they had dental erosion. Since clinical oral examinations were not used in the present study and the findings were based on potentially inaccurate selfreports, it is not possible to make direct comparisons with studies based on clinical observations. However, if the respondents reports were accurate, the high percentage reporting dental erosion reflects a need for preventive programmes and for dietary counselling for athletes in these sports groups. The prevalence of dental erosion increases with age.24 Since older persons now retain their teeth longer than in the past, older respondents were more likely to have had their teeth exposed to common foods and drinks which are acidic. The findings from the present study support this trend. The odds ratios reported here showed that older age groups had more erosion than younger age groups. The effect of gastric acid on teeth is well documented.3,9,24-26 Gastric acid in the mouth can result from voluntary or involuntary (self-induced) regurgitation.3,9,24-26 It has been noted that gastrooesophageal reflux may be associated with some forms of exercise.27 The present study asked if respondents ever suffered regular regurgitation but did not specify the time, e.g., after extreme exercise. No statistically significant association between dental erosion and regurgitation or acidic taste in the mouth was noted. However, as the study was based on self-reports, the respondents may not have understood the terms used, resulting in under-reporting. Oral hygiene practices may contribute to dental erosion. Tooth brushing immediately after exposure to acidic foods or drinks has been reported to increase mineral loss from the tooth surface.9 In the present study, more than 60 per cent of respondents in each group brushed their teeth after meals, although information was not collected as to whether this was immediate or delayed brushing. In order to study more adequately any relationships between oral hygiene
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practices and dental erosion, an intra-oral examination should be performed. It was not possible in the present study to include intra-oral examinations for logistical reasons and the study was limited to examining some potential factors contributing to erosion. It is acknowledged that a questionnaire survey cannot provide the accurate observations possible with a clinical examination. Assessing the effects of acidic foods/drinks and other related factors on dental erosion, based on questionnaire responses, may not provide accurate data. However, recalled dietary information is frequently the basis upon which dentists provide dietary advice for patients in clinical practice. An internal measure of the validity of the responses in the present study was indicated by the strong statistical association between tooth sensitivity and dental erosion. This study indicates a significant need to promote preventive programmes to athletes, particularly participants of the Martial arts, who showed high risk dietary behavior (consumption of spicy foods) and reported the most dental erosion, and also to participants in the Running and Ball and Field sports groups who reported high consumption of juices, sports drinks and soft drinks. Preventive programmes could include prescription of a regular neutral sodium fluoride mouth rinse, avoiding tooth brushing immediately after consuming acidic foods/ drinks, limiting the intake of acidic foods/drinks to meal times, and dietary advice.17,25 Further clinical studies involving direct observation of tooth surfaces should be carried out to determine the strength of the associations between dental erosion and acidic foods, drinks and consumption habits. CONCLUSION The pattern of consumption of acidic drinks among the eight sport groups was similar. Association between consumption of fruit juices may be correlated with dental erosion and athletes may be placing themselves unintentionally at risk for erosion. The findings of the present study indicate a significant need for preventive programmes and dietary counselling for young athletes to control and reduce the effect of acidic foods and drinks. Such advice could be given by dentists to patients who are at risk in competitive sports, and also by dental professionals working in conjunction with organizers of sports groups. AC K N OW L E D G E M E N T S This study was supported by the School of Dental Science Research Committee, the University of Melbourne, and the Colgate Oral Care Company, Australia. REFERENCES
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Address for correspondence/reprints: Professor Louise Brearley Messer School of Dental Science The University of Melbourne 711 Elizabeth Street Melbourne, Victoria 3000 Email: jbm@unimelb.edu.au
Australian Dental Journal 2002;47:3.