Nutrients · 11 authors, 1 centre
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This systematic review of 19 studies (7 in vivo, 12 in vitro) confirms that carbonated soft drinks, with pH often below the critical 5.5 threshold, cause enamel erosion, increased surface roughness, and higher caries risk. The erosive potential depends on pH, exposure duration, and buffering capacity, with saliva providing some protection. Clinically, reducing soft drink consumption and promoting water intake are key preventive strategies.
**Background:** The increasing global consumption of carbonated soft drinks, especially among children and adolescents, has raised concerns about dental erosion. Enamel erosion is a non-carious loss of tooth structure caused by acids, leading to hypersensitivity, pain, and increased caries risk. The critical pH for enamel dissolution is 5.5, and many carbonated drinks have pH values as low as 2.5 due to carbonic, citric, phosphoric, and tartaric acids. This systematic review aimed to analyze the erosive potential of carbonated drinks on dental enamel.
**Methods:** A systematic review was conducted following PRISMA guidelines and registered in PROSPERO (ID: 405107). PubMed, Scopus, and Web of Science were searched from 1 January 2018 to 31 January 2023 using the Boolean keywords “soft drinks AND tooth”. Inclusion criteria were human in vivo and in vitro studies, English language, open access, randomized clinical trials, and research on effects of carbonated drinks on dentin/enamel. Exclusion criteria included animal studies, non-English languages, non-open access, case reports/series, reviews, editorials, and book chapters. The PICOS framework was used: Participants – teeth of children and adults (in vivo/in vitro); Intervention – considerable consumption of any carbonated soft drink; Comparison – no considerable consumption; Outcome – damage to dental enamel; Study – clinical trials on human teeth. Risk of bias was assessed using RevMan 5.5 and the OHAT tool for the seven in vivo studies.
**Key Results:** The initial search yielded 407 items (PubMed n=134, Scopus n=136, WOS n=137). After removing 168 duplicates, 239 articles remained. Screening removed 83 items (11 reviews, 16 not free full text, 3 animal studies, 53 off-topic). A further 137 were excluded for lack of interest, leaving 19 studies for inclusion: 7 in vivo and 12 in vitro. Risk of bias assessment for the 7 in vivo studies showed that only 2 (Hasheminejad et al. and Schmidt et al.) had low risk of bias. Randomization was performed in ~50% of papers; performance and detection bias were present in ~15% and ~40% of studies, respectively. Meta-regression was not applicable due to heterogeneity. Key findings from included studies: The probability of dental erosion in subjects who never used sugary soft drinks was 94% lower than that of daily consumers. Soft drinks with added calcium glycerophosphate (CaGP) at 2 mM to 10 mM reduced mineral loss and surface microhardness decline. Saliva buffering capacity and pellicle formation protect enamel; in vitro studies without saliva overestimate erosive potential. Surface roughness >0.2 μm promotes bacterial adhesion. Sports participation was strongly associated with erosive injuries; water sports professionals were about 14 times more likely to suffer erosion. Consuming water as main beverage reduced erosion risk by ~70%.
**Clinical Implications:** The review confirms that carbonated soft drinks cause significant enamel erosion, surface roughness, and increased caries risk, especially in children and adolescents. Saliva plays a protective role, so individuals with low salivary flow are at higher risk. Preventive strategies include reducing soft drink consumption, promoting water and milk intake, and using biomimetic hydroxyapatite-based oral care products. Health professionals should educate patients, and policy measures (marketing restrictions, pricing, reformulation) are recommended. Limitations include the predominance of in vitro studies, short time range (2018–2023), and inability to perform meta-analysis due to heterogeneity.