How much effect do fruit juice drinks have on tooth enamel erosion in children?
We all know that it is important to brush our teeth regularly, preferably after every meal. We also should try and limit the frequency of sweet foods and drinks as it is this constant attack that can overwhelm the defences of our teeth and cause tooth decay. Both these effects are amplified in small children whose teeth are more susceptible to decay.
So, how concerned should we be about our children's teeth? After all didn't we eat sweets and drink squash or juice as children?
A recent family visit to the dentist has left me in no doubt that the increasing amounts of fruit juice in my daughter's frequent drinks have left her teeth damaged. It's that simple.
My youngest is currently about three years old and is a prolific drinker of milk and fruit juice. We used to view that as a blessing as the eldest child has to be forced to drink even a small cup of water per day. However, the eldest daughters teeth are showing no current signs of erosion but the youngest are already starting to show signs of acid erosion. After a quick discussion on her lifestyle habits the dentist pointed the finger at us in giving her so many 'healthy' drinks.
In a typical day my daughter may consume anywhere between 5 and 10 beakers or cups of diluted fruit juice. This is usually either apple or orange juice from concentrate which has been diluted down with tap water. When she first moved off a milk drink diet during the day we tried her with a variety of drinks but highly diluted fruit juice went down the best. When I say diluted, we used to put less than 1 part in 10 fruit juice to water. This probably wouldn't have been an issue had we kept to those concentration levels and at low frequency. She has, however, never ceased to amaze us at how often she'll ask for drink (and no there isn't anything else wrong with her that we know of, the local doctor is unconcerned). What has happened is that the frequency of drinks reached a plateau at its current high level and then the concentration of fruit juice gradually increased. Currently, it may be as high as 1:4 at times. Are we evil parents? Maybe, but this hasn't happened over night, but rather over the course of a year or more. In the same way you find yourself having stronger coffee or more sugar or salt my daughter has ‘needed' more fruit juice and we have steadily bowed to her demands without really knowing what we were doing (a statement that is generally true of most parents!). God we sound awful now...
To make matters worse she has, until today, always had a bottle of milk to finish off in bed with her - after she has brushed her teeth. Milk, what's wrong with that, it helps build stronger bones and healthier teeth? Yes, but it also contains a type of sugar which will sit on the teeth most of the night, a period when you are producing little saliva.
What is tooth erosion?
Tooth decay and tooth erosion are classified as different things by dentists. Tooth decay is caused by encouraging the growth of bacteria in the mouth (through poor dental hygiene and eating too many sources of food for bacteria like sugary drinks) and results in a localised hole in the enamel/dentine called a cavity.
Tooth erosion or non-carious dental condition or tooth surface loss (TSL) is a widespread attack on the tooth enamel (and possibly dentine underneath) caused by eating or drinking too many acidic foods and drinks.
With both items it is the length of time that the teeth are under attack that is critical. The saliva in the mouth contains calcium and PH buffers which can repair minor enamel loss due to acid attack but only if there is a let up in the bombardment.
How common is it?
In the UK the 2003 Children's Dental Health Survey showed that over half of 5 year olds surveyed showed some signs of TSL. This figure hadn't increased since the previous survey 10 years prior, which is good, but just shows how prevalent a problem this is!
Which juices from foods and drinks need monitoring?
Unfortunately, what we now consider as a healthy diet introduces your child to lots of sources of acid. Citrus fruits contain large amounts of acid and eating two portions of citrus fruit a day massively increases the risk of tooth erosion.
Fruit juice drinks again contain lots of citric acid. Even when diluted down, the concentration of acid can be high enough to cause a small, but cumulative, amount of damage.
Soft drinks, such as cola's, may be an obvious target but it is again the fruit based drinks that can potentially cause more damage.
Can different drinks be rated against each other to determine which is the worst and if possible should be avoided at least on a regular basis? Well, it isn't just the acidity of the drink/juice that matters, but rather the titratable acidity.
One of the things the saliva tries to do is to buffer the PH of the fluid in your mouth to be at a PH neutral or 7.0. In the mouth any PH below 5.5 can cause tooth enamel erosion. The titratable acidity (TA) is based on how much alkali needs adding to make the mouth PH neutral in one study on tooth erosion due to drinks and above 5.5 in another study. It is different from normal ‘acidity' as it only counts the available acidity of the liquid. Hence, the lower the TA of the liquid the greater the risk of acid erosion.
- Low TA drinks - Beer, lager (now that would be bad parenting!), water
- Medium TA drinks - Cola, fizzy orange
- High TA drinks - Apple, orange and the king of them all grapefruit juice
One of daughter's favourite fruits, even when very young, is grapefruit...
Another source of acids in the diets are vinegar containing foods such as sauces and pickles.
An interesting note from this is that it is that from a point of view of acid erosion - only - it is better to drink cola than orange juice by about a factor of two in terms of potential tooth erosion!
It should also be pointed out that some in-vitro studies of dental erosion suggest that it isn't the titratable PH that matters but rather just the PH. Though I'm not sure how easy it is to correlate the effects of drinks on teeth in a test tube with that of a PH feedback system in the mouth. At least we know what happens to the teeth the tooth fairy takes though - she works for a big pharmaceutical company!
Identifying Acid Erosion
- The main way to identify if your child (or you for that matter) has tooth erosion is to have regular visits to a dentist.
- If your child starts having sensitivity to hot or cold drinks than there may be an issue.
- The dentine underneath the enamel is darker in colour and can give the teeth a slightly yellow tinge. In my daughters case this is most visible on the back teeth. This is most obvious when we are brushing her teeth, but is admittedly hard to see anything in the mouth of a toddler if they don't want you to.
What can be done and what are we planning/doing to solve this issue?
- We've had to get serious about this now we realise how much of a problem it is.
- We have reduced the concentration of the fruit juices back to the least our child will tolerate without it looking like water.
- We have stopped the bottle of milk in bed and made sure she drinks it before she has her teeth brushed at night.
- We are limiting the amount of citrus fruits she is getting per day.
Another point and one we are not currently addressing is that you shouldn't brush your teeth straight after having an acidic drink or food. The reason is that the acid has just weakened the outside layer of your teeth and brushing your teeth now could remove some of the enamel through abrasion.
Beware the acid erosion potential of fruit juices on young children's teeth. Continual sipping, slupring or gulping of healthy drinks can cause serious damage to the tooth enamel. Minimize the concentration and frequency of juice drinks and never give them a juice to drink (or milk for that matter) to take to bed with them.
We will monitor the problem in our daughter and hopefully see some improvement or at least no worsening of the problem at the next dentist visit.
Update 23rd February 2009
Went for a check up a couple of weeks ago (have had others since article was written) and her teeth are still deteriorating. The back teeth have visible holes in though they don't yet need fixing. The dentist says she doesn't want to do anything to them and would rather wait and see (as in the next couple of years she will start getting her adult teeth). We are continuing to minimize any fruit juice based drinks, closely monitoring the brushing of her teeth and she is using a childrens mouth wash in an attempt to strengthen the back teeth.
Our other childs teeth are completely fine.
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"I've just come back from the dentist with my sons,aged 7 and 10 and had a very similar report about the 10 yr old's teeth. The dentist said there is something acidic in his diet that has caused some of the enamel on his adult teeth to wear away, and the surface of his baby teeth to become quite eroded and flat. This really took me by surprise as I think he has quite a healthy diet. However, in the previous visit to the dentist there was no mention of damage from acidic food and drinks, and upon reflection, between that visit and this one, we have certainly increased the amount of fruit juices we buy and consume. This began with the increased play dates, and my sons' friends asking if we have juice to drink with dinner. I felt bad for not being able to offer any, and so started buying more and more. My older son loves the juices and the effect is now obvious on his teeth. My younger son is not so keen on fruit juice and his teeth are fine. Our dentis offered the same advice...cut down on acidic foods and drinks, use a children's mouth wash, and of course, brush well! She also suggested keeping a food diary."
"my child had six teeth removed after swishing smoothies.It has caused me a great deal of worry and concern and i cant wait for his second teeth to come through as im constantly worried about his remaining teeth.I would suggest any parent with a child with this problem to get them to drink water after anything sugery."
This article is about how fruit juices and milk can and do cause serious acid erosion of teeth. My dentist warned me and I've seen it with my own eyes. In researching this article I read dental research papers on the effects of different drinks on TEETH. I didn't just read someone else's opinion in a populist book and state it as fact.
You keep feeding your child raw foods as nature intended 1,000,000 years ago and I'll feed my child a post-stone age diet that is balanced combination of veg, fruit, meat and dairy both cooked and un-cooked."
"I am horrified by the blatant inaccuracies shared here about nutrition and certain foods, particularly fruits, juices and milk. Milk causes cassein. Cassein is carcenogenic. We only the only mammals on this planet that drink another mammal's milk. Cow's milk is not required, or intended, for human growth. It i in fact one of the biggest mucous forming agents known to man. Do you have children who suffer constantly with ear/nose/throat ailments? Look no further. The milk that makes the corporates billions of dollars and pounds a year is to blame. Onto juice: the fruit juice you are feeding your child is not fresh fruit juice unless it comes straight from the fruit. Anything else (concentrate included) is not fresh. It's that simple. And if it's not fresh, you can rest assured you will have problems affecting your child's teeth and 1000 other ailments. We have been raised in a highly commercialised world where so many truths about foods and natural nutrition are grossly distorted for commercial profit. Orange juice for example contains many mineral salts and lime, PREVENTING acidosis. We live in a world where our so called medical professionals are ignorant enough to tell us that fresh orange juice is too acidic to feed children. I took my now 1 year old son off formula when I couldn't breastfeed at 7 months old. Since then he has been on a 100% raw (fresh) fruit and veg diet. He is the only child of hundreds I know that does not suffer from any ailments whatsoever. He is the only one that sleeps contently 12 hours a night. He is vitally healthy and happy, and it's as a result of his 100% fresh diet. I'm not going to rewrite it. Read Campbell's THE CHINA STUDY. Milk is bad for humans. Meat is another conversation all of its own. We need to be eating at least a 70% raw (fresh) diet. The rest is there for sweets and treats which our powerful bodies can cope with. Don't be yet another parent who shuns something others say until YOU have done the work yourself. Do the research. To make it easy for you, THE CHINA STUDY has it all in one book. Follow that up with Harvey Diamond's FIT FOR LIFE and you will not need to rely on the unfounded, commercially driven or ignorant statements of others ever again. Take charge and responsbility of your children's lives. Read these 2 books. They can be life saving."
"This isn't as widely known as it should be. Most people are aware of the fact that sugary soda drinks like coke will harm your teeth , but I don't think people even associate drinking fruit juices with tooth decay. In fact they often take pride in the fact that they are taking such good care of themselves. I am only 24 and I went to school drinking cartons of fruit juices - now my teeth are really sensitive and there is visible enamel erosion - especially on the front teeth. My front teeth have also been chipped because the acid has caused them to be weak. Recently it has become trendy to drink Smoothies. People think that drinking these fruit smoothies will help them. Fruit isn't even that healthy - especially in the form of a juice. Oranges for instance: the only valuable thing that they contain in a worthwhile amount is Vitamin C. Kids are much better eating vegetables - they contain all the things that fruits do, in fact they offer much more nutritional value and most importantly they don't harm your teeth. It should be noted that if you are to have fruit, then forget smoothies and fruit juices - it is much better in it's raw form. The juice is held inside the cell walls meaning that the acidic juice doesn't come as much into contact with the teeth. "
"I fully understand how you feel. Last week I took my 3 year old daughter to the dentist as I was concerned about her teeth. The situation is exactly the same, plenty of apple juice throughout the day and milk at night (which she refuses to let go of)! As a parent I feel awful that she has now got tooth decay, but I have never let her have fizzy drinks or juice from a babies bottle or sweets other than a shared packet with her older sister maybe twice a week. (My oldest has to be really pushed to drink anything so we were plaesed that Frankie drank so much, just like your situation). I want mothers to become aware of the danger of fresh juices on the teeth of their little ones. I am a really capable and sensisble person and I have done all the things which we are advised to do, I had no idea that apple juice, even watered down, can cause such problems. I am pleased to have read about your article, sad you are going through the smae thing, but grateful that I am not alone in wanting to make people more aware."