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THE DANGERS OF SODA POP

4 CE Credits

Gary J. Kaplowitz, DDS, MA, MEd' Michael Florman, DDS Sanford A. Aaronson, DDS, MS, JD

Was urse s, Dental Co This Dentist ntal De For itten ists, and . Wr en ts Hygi Assistan

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Introduction

Enamel is the hardest substance in the body and it protects the crowns of the teeth. But it is susceptible to demineralization from acids. Acids are produced when certain bacteria colonize the tooth surface and metabolize carbohydrates. If this process continues it may eventually lead to the development of carious lesions in the enamel and dentin. Another source of acid is dietary. Many foods and beverages contain acids that also can lead to demineralization of the enamel. Soda pop has emerged as one of the most significant dietary sources of acid capable of producing demineralization of the enamel. Many brands of soda pop also contain sugars that are fermented by bacteria that produce acid by-products. It also appears that soda pop contains other ingredients that produce demineralization independent of its content of acid content or fermentable sugars1. The danger of soda pop to demineralization of the enamel and its consequences should not be underestimated.

Soda Pop Consumption

The consumption of soda pop in the United States has increased in alarming proportions. This increase in consumption crosses all demographic boundaries.

has been recognized by a number of professional associations. Recently the American Academy of Pediatrics published a position paper to inform health care professionals, school personnel and parents about the significant dangers posed by the ever-increasing amounts of soda pop consumed by children and teenagers2. Between 56%-85% of school age children consume at least one serving of soda pop each day. Often the amount of soda pop consumed daily is much larger. At least 20% of school age children consume a minimum of four soda pop servings every day 3. Some of these trends are summarized in Figure 1. The potential ravages of soda pop caries in teenagers should not be underestimated. Some teenagers drink as many as 12 cans of soda pop a day. In one welldocumented case, a teenager who grew up drinking fluoridated water and brushing twice daily with a fluoride containing toothpaste developed caries in every one of his erupted teeth necessitating two extractions and many restorations. Diet analysis revealed that he daily consumed 6-12 cans of soda pop.4 See Figure 2 for an example of erosion. Other case reports have demonstrated similar findings among other adolescents and teenagers where chronic, high soda pop consumption is linked with

Figure 2. Photo by Dr. Peter Endo.

widespread demineralization of enamel and extensive caries in pits and fissures and in the interproximal areas5.

Soda Pop in the Schools

One new major development in this problem has been the increased access to soda pop in the schools. Figure 1. Adapted from Figure 1 in Frequency distribution of sugared soda consumption servings Many schools throughout the country have easy access to and quantities by age group. Heller K, Burt A, Eklund commercial soda pop vending machines. Students have S. Sugared soda consumption and dental caries in the United States. free and easy access to purchase soda pop at will. The amount of soda pop consumed by students in schools in Everybody is drinking more soda pop and drinking it more fact has increased dramatically and continues to increase. frequently. This has created a public health crisis, which

Some commercial soda pop vendors provide deep discounts to the schools to allow them to place their vending machines on school premises. In times of budgetary constraint these offers may be difficult to ignore. Student governments may also favor the placement of soda pop dispensing machines in schools. This has become a controversial issue in some areas. Some parent-teacher organizations have sought to have these soda pop vending machines removed from school premises. This may lead to hotly contested conflicts at meetings on various levels in the school districts. Sometimes the vending machines are removed.

Soda Pop in the Market Place

Soda pop has become a firmly entrenched staple of the American diet and as American as apple pie. The commercial soda pop manufacturers have invested a fortune in advertising and they have created one of the most successful marketing campaigns in American history. Soda pop has become an integral part of American culture. In the 1950's the typical soda pop serving size was 6.5 oz. By the 1960's this had increased to 12 oz. In the 1990's the typical serving size ballooned up to 20 oz. It is clear that not only are we drinking more soda pop but also we are buying it in ever increasing amounts. This trend is also reflected in fast food outlets, which have been steadily increasing the volume of soda pop in each of their beverage serving sizes.

A Hidden Danger

One of the concomitant problems with the increase in soda pop consumption is that it leads people into drinking less milk, which indirectly leads to a higher incidence of demineralization and caries. Milk contains calcium lactate, which stimulates remineralization of enamel6. The regular consumption of adequate quantities of milk bathes the teeth in calcium and calcium lactate and promotes remineralization 7 to combat the demineralization and erosion caused by soda pop. Thus on the one hand the means for combating enamel erosion is being compromised because people are drinking less milk and on the other hand the increased consumption of soda pop contributes to the more rapid and extensive demineralization of the enamel8.

bacteria later colonize the outer surface of the enamel, form a dental plaque and begin metabolizing carbohydrates like the sugars sucrose and fructose which cause a lowering of the pH of saliva and a consequent demineralization of the enamel. When the pH drops below 5.5 for long periods or repetitively there is a significant chance that this demineralization will lead to the development of carious lesions in the enamel. Streptococcus mutans is the most significant of the bacteria involved in the development of dental caries. Lactobacillus and Actinomyces viscosus colonize later and are also important in generating acid by-products. Enamel experiences continual cycles of demineralization and remineralization. This is a dynamic process that can proceed in either direction. Factors on either side of this equation may change, shifting the reaction in one direction or the other. For many people and in many cases, increasing the sugar content of their diet can increase the demineralization and increase the chance that this may eventually lead to the development of caries. Soda pop is most commonly sweetened by adding sucrose or high-fructose corn syrup. This yields the equivalent of 10-12 teaspoons of sugar in the typical 12oz. can of naturally sweetened soda pop. These sugars fuel the metabolism of bacteria that produce the acids, which demineralize enamel. For many people, soda pop is the single biggest source of sugar in their diet. The greater the exposure to these sugars, the more acid produced by the bacteria and the greater the chance of demineralization.

Soda Pop And Acid

In the past the focus of the deleterious effects of soda pop has been on its sugar content and its role in sustaining bacterial growth and acid by-products. However it is clear now that there are two significant threats posed by soda pop. The sugar content certainly does fuel the bacteria that produce acidic by-products, which does have a significant effect on the demineralization of enamel and development of caries. But soda pop also exerts a profound deleterious effect by bathing the teeth in acid that also is capable of producing demineralization. There is no question that enamel can be demineralized by exposure to soda pop10. Depending on the kind and brand, soda pop may contain carbonic, phosphoric, malic, citric and tartaric acids and have an Bacteria Produce Acids that Demineralize acidic pH.11 Some soda pops, which have an acidic pH, are listed in Table 112. Repeated exposure to these acids Enamel produces demineralization and erosion of the enamel. Dental caries is an infectious, chronic, multifactorial Demineralization of enamel is inversely related to the pH disease9. The disease process is initiated when bacteria of the soda pop. The more acidic the soda pop, (i.e., the are passed from the parent to the infant or toddler. These

lower its pH), the more rapid and profound the anhydrase, found in saliva, catalyzes the reaction between the free hydrogen ions from the acid and the bicarbonate demineralization of the enamel13. ion18. The end products of this reaction are water and Table 1. Soda pop with acidic pH carbon dioxide gas, which is released from the oral cavity as depicted in Figure 3. As more free hydrogen ions Ginger Ale 2-4 combine with bicarbonate ions, the pH begins to rise and the saliva begins to return to normal pH levels19. Coca-Cola 2.7 The buffering capacity of saliva varies from person Root beer 3.0 to person. Patients whose saliva has a depressed buffering Orange Crush 3.1 capacity are more susceptible to erosion from acid20. Pepsi Cola 3.3 Salivary flow also determines the capacity of saliva to 7-Up 3.5 buffer against acid. The greater the salivary flow the more bicarbonate ions available for combining with free Brands of soda pop that contain artificial sweeteners still hydrogen ions. When acid is introduced into the oral pose a significant threat because of their acidic content. cavity salivary flow is stimulated and increases within While they may not contain sucrose or fructose or other minutes. Normal salivary flow rates are generally between fermentable carbohydrates their acidic content will 0.1-0.6 ml per minute21. Salivary flow less than 0.1 ml contribute to the demineralization of enamel. Their threat per minute is considered low22. The chemical reaction between the hydrogen ions may not be as great but they are still capable of producing demineralization. In any case these brands of soda pop released from acids and the bicarbonate ions in saliva protects the enamel from demineralization. Without this only account for 14% of the market share14. Long-term consumption of soda pop has a protective buffering capacity of saliva, enamel would be significant cumulative effect on the demineralization demineralized and lost. But this buffering capacity of enamel15. The older a person is and the longer that person saliva is limited and can be overwhelmed by frequent or has been drinking soda pop the more likely that person will long-term exposure to acids. have a higher than expected DMFS16. In people 25 or older there is a statistically significant association between The Dangers of Softened Enamel long-term soda pop consumption and higher than expected DMFS. As more people are living longer, more teeth will be experiencing this long-term cumulative exposure to soda pop and we can expect more and more chemical erosion of the enamel with consequent demineralization and dissolution of tooth structure and development of caries.

How Saliva Buffers Acids

One of the body's most effective means for protecting the enamel of the teeth against acid is saliva. Saliva contains many components such as calcium ions, phosphorous ions, proteins, enzymes and bicarbonates. One of its most important functions is to bathe the teeth in a supersaturated solution of calcium and phosphorous so that the enamel of the teeth is constantly exposed to replace any loss of tooth structure due to demineralization. A second function of saliva is to buffer the pH of saliva to prevent the oral environment from becoming too acidic17. Normal salivary pH is about 6.3. When the pH of saliva drops below 5.5, demineralization usually ensues. The mechanism for the buffering effect of saliva involves the activity of the bicarbonate ions. As the acid content of saliva increases, the concentration of hydrogen ions increases which lowers the pH. The enzyme carbonic

Figure 3. Adapted from Figure 1 in Perkins S, Wetmore M. Acid induced erosion of teeth. Dentistry Today 2001;20:82-87.

When enamel is softened by exposure to soda pop it is in increased danger of being worn away or abraded. This may result in a synergism with other causes of tooth loss such as from vigorous tooth brushing with a hard-bristle toothbrush or from bruxism.

Recognizing the Signs of Soda Pop Erosion

Patients with soda pop erosion present with certain changes in the morphology and surface characteristics of their teeth. Smooth surface enamel may develop broad shiny concavities. The teeth may even have a glazed appearance. Mandibular premolars and molars commonly develop these wide concavities on their buccal surfaces in the cervical third. These may terminate at the free gingival margin producing a characteristic enamel cuff at the free gingival margin or they may extend on to the root surface if the roots are exposed. The occlusal surfaces of premolars and molars may be punctuated by deep shiny concavities that may extend down to dentin. The occlusal surfaces that have been partially restored may

The major salivary glands should be palpated and milked. Gentle massaging of the parotid gland should result in the free flow of saliva from Stenson's duct. The submandibular gland should also be gently massaged and saliva should flow freely from Wharton's duct. The saliva should be clear and flow freely. Low salivary flow can be caused by medical conditions that affect the function of the salivary glands and by certain drug therapies. Some of the more common medical conditions which cause diminished salivary flow include radiation therapy to head and neck and Sjogrens syndrome. Some of the more common drugs that produce diminished salivary flow include alpha blockers and antihistamines. Some of these patients with xerostomia or diminished salivary flow may sip soda all day long to combat the sensation of dryness in their mouth. This continuous or repeated exposure to soda pop in the absence of the protective effects of saliva can be devastating.

Recognizing Destructive Habits

Some patients have destructive habits involving the consumption of soda pop. For example some patients derive pleasure from holding soda pop in their mouth and allowing it to bathe certain teeth. Some may actually swish the soda pop around and around for several minutes Figure 4 Photo by Dr. Peter Endo. before swallowing. The carbonation and effervescence of the soda pop produces a pleasure sensation. This can demonstrate loss of enamel around the occlusal aspect lead to excessive erosion of particular teeth in particular of the restoration so that it appears to rise above the areas25. existing occlusal surface. The maxillary central incisors may appear thinner with an increase in incisal translucency. The surface appears polished and smooth and distinctive Orthodontics Demineralization and caries have been traditional surface characteristics are missing. In the primary dentition there is a loss of surface dangers with cemented brackets in fixed orthodontics. definition and details. The enamel and dentin layers are Patients undergoing this mode of therapy must practice much thinner than in the permanent dentition and there meticulous oral hygiene in order to protect their teeth. is an increased chance of erosion leading to pulp exposure. Increased soda pop consumption poses a significant threat Erosion of the occlusal surface of permanent first molars to the development of caries around fixed orthodontic may result in sealants appearing to rise above the occlusal appliances. In one case report a teenager who consumed 2-4 liters of cola soda pop per day presented with surface24. significant demineralization around and under fixed cemented brackets. In some cases the demineralization Recognizing Patients at High Risk led to a loss of 0.5 millimeters of enamel26. Patients with Diminished Salivary Flow and Xerostomia orthodontic bands have significantly higher prevalence Low salivary flow means less saliva available to of Streptococcus mutans.27 Meticulous oral hygiene and homecare is essential rinse soda pop off the teeth and less bicarbonate ions to buffer the acids in soda pop and the acids produced by the to protect teeth with bands or bonded brackets. The fermentation of sugars. Some of the more common signs hygienist or dentist may consider the added protection of low salivary flow include dryness of the lips and buccal of placing sealant around the margins of the bands or mucosa. The dorsum of the tongue may also appear dry brackets to enhance the sealing effect of the cement.28 and cracked.

Role of Hygienist

The hygienist spends more chair time with the typical dental patient than any other member of the dental team. This affords the hygienist an excellent opportunity to really get to know the patient and to establish rapport. The hygienist is in an excellent position to formulate a realistic risk assessment of the patient. One of the most effective techniques for identifying patients with a high risk of soda pop is to assess how often and how much is consumed. The patient can be asked how often and how much soda pop they drink. Some patients only drink soda pop at meals, some inbetween meals as well and some all day long. Patients may also be able to describe how much soda pop they drink in a day or week. The patient should be asked about the kinds of soda pop they drink. Some soda pops are more acidic than others and some contain more sugar. Some soda pops contain artificial sweeteners and so do not pose a threat from the perspective of bacteria metabolizing sugars. Home care and oral hygiene should be assessed. The hygienist should ask the patient how many times they brush and which brand of tooth paste they use. The patient should also be asked if they use a fluoride mouth rinses. Many patients will also know if their water source is fluoridated.

Therapies to Increase Fluoride

Increasing the patient's exposure to fluorides is one means of combating the demineralizing effect of soda pop. The topical effects of fluoride exposure on erupted teeth has been well documented.31 When patients present for scheduled oral prophylaxis, fluoride should be applied in relatively high doses by the hygienist in the dental office. The hygienist should also counsel the patient to use a fluoride mouth rinses and fluoride toothpaste as part of their regular homecare. Repeated exposure to fluoride within safe limits stimulates remineralization and prevents further demineralization and erosion.

Professionally Applied Fluoride

When the patient presents for oral prophylaxis the hygienist should apply fluoride in the form of a foam, gel or rinse. The controlled application of relatively high doses of fluoride on a regular basis is one significant advantage for patients to present for professional oral prophylaxis by a dental hygienist. The traditional means of application involves a fluoride gel in an applicator tray or swabbed on the teeth. Fluoride can also be applied using a foam vehicle that decreases the chance of the patient swallowing excess fluoride. The foam is applied by tray or swabbed on the teeth. Some common gel and foam products are listed in Table 2.

Diet Counseling

One of the most important things a hygienist can do is diet counseling. Children and adolescents should be counseled to avoid consuming large amounts of soda pop.29 They should be counseled to drink more alternative beverages that contain less sugar and acid such as water, milk and 100% fruit juice. Their parents should also be informed and counseled and should understand how to stock their refrigerators and to replace fruit drinks with high sugar contents with 100% fruit juices and encourage their children to drink these instead. Parents must become informed and involved and must be proactive in encouraging their children to develop more healthful habits. Adults should be counseled on the dangers of soda pop consumption and should be encouraged to drink more healthful beverages. Destructive habits such as sipping soda pop all day long at work should be identified and discouraged. The hygienist can also counsel the patient to rinse with water after drinking soda pop to evacuate the oral cavity of any remaining vestiges of soda pop, which might prolong exposure to the enamel.30

Rinsing with a mouthwash containing fluoride reduces the incidence of caries and stimulates remineralization. In fluoride deficient areas rinsing once a week with 0.2% sodium fluoride or daily with 0.05% sodium fluoride both significantly reduced the incidence of caries in children.32 In one school-based preventive dental program, rinsing once a week with 0.2% sodium fluoride resulted in a reduction of 85% in the incidence of caries on proximal surfaces.33 There are numerous mouth rinses with 0.05% sodium fluoride that can be purchased over the counter that can be recommended to the patient. Patients should be advised to use once daily as a regular part of their home care oral hygiene regimen. For patients with higher risk, the hygienist can request that the dentist write a prescription for a mouth rinse with 0.2% sodium fluoride and instruct the patient to rinse once a week.

Fluoride Toothpastes and Gels

Fluoride Mouth Rinses

Patients should brush with any of the fluoride containing toothpastes on the market. For patients at higher risk the hygienist can request that the dentist write a prescription for a toothpaste with a higher fluoride

content like PreviDent 5000 Plus (Colgate), which has 5000 ppm fluoride.

Sealants

Sealants may not be a longterm effective barrier to the demineralizing effects of soda pop. In one in vitro study teeth were etched and sealed and then immersed in nine different dark cola soda pops. All teeth showed complete or incomplete loss of sealant and significant demineralization.34

Public Awareness

Numerous articles have appeared in newspapers and magazines informing the public of the dangers of soda pop to teeth and to general health.35 Some articles focus on the dangers of consuming too much soda pop and recommend alternative beverages.36 Some articles describe in detail how soda pop produces demineralization and caries.37 Some articles describe new patterns of caries that are becoming more common with increased and chronic consumption of soda pop.38 A great deal of information about the dangers of soda pop can be accessed on the internet. Many articles on this subject appear in many websites. The abclocalgo website has an article describing the dangers of chronic consumption of Mountain Dew in what it calls `mountain dew mouth". 39 WebMD also has an excellent article on soda pop and caries.40

References

1. Von Fraunhofer J, Rogers M. Dissolution of dental enamel in soft drinks. General Dentistry 2004;52:308-312. 2. American Academy of Pediatrics Committee on School Health. Pediatrics 2004;113:152-154. 3. Gleason P, Suitor C. Children's diets in the mid 1990s: Dietary intake and its relationship with school meal participation. Alexandria, VA: US Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and Evaluation;2001. 4. Brimacombe C. The effect of extensive consumption of soda pop on the permanent dentition: A case report. Northwest Dentistry 2001;80:23-25.

5. Majewski R. Dental caries in adolescents associated with caffeinated carbonated beverages. Pediatric Dentistry 2001;23:198-203. 6. Beiraghi S, et. al. Effect of calcium lactate in erosion and S. mutans in rats when added to CocaCola. Pediatric Dentistry 1989;11:312-315. 7. Gedalia I, et. al. Enamel softening with Coca-Cola and rehardening with milk or saliva. American Journal of Dentistry 1991;4:120-122. 8. Grenby T, Andrews A, Mistry M, Williams R. Dental caries-protective agents in milk and milk products: investigations in vitro. Journal of Dentistry 2001;29:83-92. 9. Adair S, et. al. Recommendations for using fluoride to prevent and control dental caries in the United States. Mortality and Morbidity Weekly Review 2001;:50:1-42. 10. Gedalia I, et. al. Tooth enamel softening with a cola type drink and rehardening with hard cheese or stimulated saliva in situ. Journal of Oral Rehabilitation 1991;18:501-506. 11. Roos E, Donly K. In vivo dental plaque pH variation with regular and diet soft drinks. Pediatric Dentistry 2002;24:350-353. 12. Clark D, et. al. The influence of frequent ingestion of acids in the diet on treatment for dentin sensitivity. Journal of the Canadian Dental Association 1990;1101-1103. 13. Larsen M, Nyvard B. Enamel erosion by some soft drinks and orange juices relative to their buffering effect and contents of calcium phosphate. Caries Research 1999;33:81-87. 14. Harnack L, Stang J, Story M. Soft drink consumption among US children and adolescents: Nutritional consequences. Journal of the American Dietetic Association 1999;99:436-444. 15. Heller K, Burt B, Eklund S. Sugared soda consumption and dental caries in the United States. Journal of Dental Research 2001;80:1949-1953. 16. US Department of Health and Human Services (USDHHS). National Center for Health Statistics (1997). National Health and Nutrition Examination Survey III, 1988-1994, Series 11, No. 1A, Hyattsville, M; Center for Disease Control and Prevention. 17. Tenovo J, ed. Human Saliva: Clinical Chemistry and Microbiology, vol. 1. Boca Raton: CRC Press;1989:44-59. 18. Kivela J, et. al. Salivary carbonic anhydrase isoenzyme VI. Journal of Physiology 1999;520:315320. 19. Perkins S, Wetmore M. Acid-induced erosion of teeth. Dentistry today 2001;20:82-87. 20. Gudmundsson K, et. al. Tooth erosion, gastroesophageal reflux and salivary buffer capacity. Oral Surgery Oral Medicine and Oral Pathology 1995;79:185-189. 21. Janvinen V, Rytomaa I, Heinonen O. Risk factors in dental erosion. Journal of Dental Research 1991;70:942-947. 22. Navazesh M, Christensen C, Brightman V. Clinical criteris for the diagnosis of salivary gland hypofunction. Journal of Dental Research 1992;71:1363-1369. 23. Lussi A, Jaeggi T, Zero D. The role of diet in the aetiology of dental erosion. Caries Research 2004;38:34-44. 24. Milosevic A. Tooth wear: An aetiological and diagnostic problem. European Journal of Prosthodontics and Restorative Dentistry 1993;1:173-178. 25. Gandara B, Truelove. Diagnosis and management of dental erosion. The Journal of Contemporary Dental Practice 1999;1:1-15. 26. Prietsch J, de Souza M, de Souza G. Case report: unusual dental erosion caused by a cola drink. Journal of Clinical Orthodontics 2002;36:549552. 27. Corbett J, et. al. Comparison of Streptococcus mutans concentrations in non-banded and banded orthodontic patients. Journal of Dental Research 1981;60:1936-1942. 28. Liebenberg W. Quintessence International. 1994;25:303-312. 29. Krebs-Smith S. Choose beverages and foods to moderate your intake of sugars: Measurement requires quantification. Journal of Nutrition 2001;131:5275-5355. 30. Larsen M. Erosive drinks and pH of the tongue saliva. International Association of Dental Research 2004, Abstract 2050. 31. Limeback H. A re-examination of the preeruptive and post-eruptive mechanism of the anticaries effects of fluoride: Is there any anti-caries benefit from swallowing fluoride? Community Dentistry and Oral Epidemiology 1999;27:62-71. 32. Heifetz S, et. al. A comparison of the anticaries effectiveness of daily and weekly rinsing with sodium fluoride solutions: Final results after three years Pediatric Dentistry 1983;4:300-303.

33. Leske G, et. al. Post-treatment benefits in a school-based fluoride mouth rinsing program. Clinical Preventive Dentistry 1986;8:19-23. 34. Steffen J. The effects of soft drinks on etched and sealed enamel. The Angle Orthodontist 1996;66:449-456. 35. MacDonald Sue. Tooth decay and the soda factor. The Cincinnati Enquirer April 7, 1999. 36. La Duca D. Are we drinking too much soda pop? Colorado State University Food Stamp Nutrition Education Program. August 21, 2001. 37. Mendenhall D. The Pittsburgh Post Gazette September 4, 2001. 38. Dental association blames children's tooth decay on too much soda pop. The Detroit News April 1, 2000. 39. Teen tooth decay linked to sugary soda. http://abclocal.go.com/kabc/health/090501_hs_soda_ cavity.html 40. Davis J. Too much soda taking its toll on kids' teeth. http://www.webmd.com/content/article/33/1728_8358

Questions

1. What is the hardest substance in the body

a. Cortical bone b. Cancellous bone c. Enamel d. Dentin

2. When certain bacteria colonize the surface of teeth they can metabolize carbohydrates to produce

a. Proteins b. Acids c. Bases d. Salts

3. Soda pop contains

a. Flavoring agents b. Water c. Acids d. All the above

4. The consumption of soda pop in the United States is

a. Decreasing b. Leveling off c. Increasing d. Dropping dramatically

5. A teenager may drink as many as how many cans of soda pop a day

a. Two b. Six c. Eight d. Twelve

6. At least 20% of school age children drink a minimum of how many soda pop servings a day

a. One b. Two c. Three d. Four

7. Among adolescents and teenagers, increased soda pop consumption has been linked with

a. Increased caries b. Increased pit and fissure caries c. Increased interproximal caries d. All of the above

15. Many patients drink less milk because they drink so much soda pop

a. True b. False

24. The threat of demineralization from soda pop has traditionally been attributed to

8. Soda pop vending machines are present in many schools throughout the nation

a. True b. False

16. Increasing soda pop consumption and decreasing milk consumption can lead to

a. No changes b. Increased remineralization c. Increased demineralization d. Equilibrium in enamel remineralization and demineralization a. True b. False

a. Acids produced by bacteria which colonize the tooth surfaces b. Bases produced by bacteria which colonize the tooth surfaces c. Acids and bases produced by bacteria which colonize the tooth surfaces d. None of the above

25. Soda pop contains acids which can

9. Public opposition to soda pop vending machines in the schools has resulted in

a. More soda pop vending machines being installed in the schools b. Some soda pop vending machines being removed c. First amendment law suits d. No results

17. Dental caries is a disease

a. Produce demineralization b. Produce remineralization c. Produce demineralization and remineralization d. None of the above

18. Dental caries can be characterized as

a. Infectious b. Chronic c. Multifactorial d. All of the above

26. Some of the acids in soda pop are

a.Carbonic acid b. Phosphoric acid c. Tartaric acid d. All of the above

10. The soda pop marketing campaign can be described as

a. Unsuccessful b. A disaster c. One of the most unsuccessful advertising campaigns in history d. One of the most successful advertising campaigns in history

19. When the pH of saliva drops below _____ level there is a significant tendency for demineralization to occur

a. 4.5 b. 5.5 c. 6.0 d. 7.0

27. The pH of soda pop may be as low as

a. 1 b. 2 c. 3 d. 4

11. In the 1950's the typical soda pop serving size was

a. 6.5 oz. b. 12 oz. c. 20 oz. d. 32 oz.

28. Soda pop with artificial sweeteners is a threat to enamel

demineralization because

a. It contains sucrose b .It contains fructose c. It contains corn-syrup d. It contains acids

20. The most significant of the bacteria involved in the development of dental caries is

a. Staphylococcus aureus b. Streptococcus mutans c. Prevotella intermedius d. All of the above

12. In the 1960's the typical soda pop serving size was

a. 6.5 oz. b. 12 oz. c. 20 oz. d. 32 oz..

29. Soda pop with artificial sweeteners accounts for what percentage of the market share

a. 10% b. 14% c. 20% d. 30%

21. Enamel experiences continual cycles of demineralization and remineralization

a. True b. False

13. In the 1990's the typical soda pop serving size was

a. 6.5 oz. b. 12 oz. c. 20 oz. d. 32 oz.

22. Soda pop is most commonly sweetened by adding

a. Sucrose b. Fructose c. High-fructose corn syrup d. All of the above

30. Long-term consumption of soda pop appears to has a significant cumulative effect on the demineralization of the enamel

a. True b.False

14. Milk contains what agent that stimulates remineralization of enamel

a. Carbonate b. Anhydrase c. Lipase d. Calcium lactate

23. The typical 12-oz can of soda pop may have the equivalent of how many teaspoons of sugar

a. 6 b. 8 c. 10-12 d. 16

THE DANGERS OF SODA POP

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Excellent=4 to Poor=0 1. 2. 3. The content was valuable: 4 3 2 1 0 The questions were relevant: 4 3 2 1 0 The course gave you a better understanding of the topic: 4 3 2 1 0 Rate the overall value to you: 4 3 2 1 0 Would you participate in a program similar to this one in the future on a different topic of interest: _____ Yes _____ No

q MasterCard q Visa q Discover q American Express

Account # _________________________________ Exp. Date__________

4. 5.

6. What additional CE Topics would you like to receive? _______________________________________________ Any additional comments or criticisms: _____________ ____________________________________________

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

A A A A A A A A A A A A A A A

B B B B B B B B B B B B B B B

C C C C C C C C C C C C C C C

D D D D D D D D D D D D D D D

E E E E E E E E E E E E E E E

16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

A A A A A A A A A A A A A A A

B B B B B B B B B B B B B B B

C C C C C C C C C C C C C C C

D D D D D D D D D D D D D D D

E E E E E E E E E E E E E E E

q

Check this box to receive score with certificate.

Author(s) Gary J. Kaplowitz, DDS, MA, MEd' Michael Florman, DDS Sanford A. Aaronson, DDS, MS, JD COURSE CREDITS/COST All participants scoring at least 70% (answering 26 or more questions correctly) on the examination will receive a certificate verifying 4 CEUs. The ADTS is an ADA CERP Recognized Provider. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. The current term of acceptance extends through 12/31/2004. After 12/31/2004, please contact ADTS for current term of acceptance. "DANB Approval" indicates that a continuing education course appears to meet certain specifications as described in the DANB Recertification Guidelines. DANB does not, however, endorse or recommend any particular continuing education course and is not responsible for the quality of any course content. Participants are urged to contact their state dental boards for continuing education requirements. The cost for this course is $55.00. EDUCATIONAL DISCLAIMER The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the courses and do not necessarily reflect those of the ADTS. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. PARTICIPANT FEEDBACK Please e-mail all questions to: [email protected] Or, fax questions to: 216-398-7922. RECORD KEEPING The ADTS maintains records of your successful completion of any exam. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt. REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting the Academy of Dental Therapeutics and Stomatology in writing. COURSE EVALUATION We encourage participant feedback pertaining to all courses. Please be sure to complete the attached survey included with the answer sheet.

EDUCATIONAL OBJECTIVES This continuing dental education course has been written to review the dangers of soda pop consumption and its effect on oral health. INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a certificate. Certificates will be mailed within two weeks after taking and examination. SPONSOR/PROVIDER The Academy of Dental Therapeutics and Stomatology, Inc. (ADTS) is the only sponsor/provider. This course was made possible through an unrestricted educational grant from Colgate. No manufacturer or third party has had any input into the development of course content. All content has been derived from references listed, and the opinions of clinicians. Please direct all questions pertaining to the ADTS or the administration of this course to the current director, Michael Florman, D.D.S.: P. O. Box 116, Chesterland, OH 44026 or [email protected]

1 . (1% Sodium Fluoride) BOOSTER

h Tootpaste Prescription Strength

5000

Rx only

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Carcinogenesis,Mutagenesis,I p i m n o F r i i y I a s u y c n u t d i r d n s, o c r i o e em a r e t f e t l t : n td odce n oet n a c n g n sswa f u d i m l a d f m l m c a d f m l r t t e t d w t flu r d a d s l v l r n i g f o 4 1 t 9 1 i s o n n a e n e a e i e n e a e a s r a e i h oie t oe ees agn rm . o . m / g o b d w i h . E u v c l e i e c o c r i o e e i wa r p r e i m l r t t e t d w t 2 5 a d 4 1 g k f o y e g t q i o a v d n e f a c n g n s s s eotd n ae as rae ih . n . m / g o b d w i h . I a s c n s u y, o c r i o e e i wa osre i rt m l s o f m l s, r a e w t flug k f o y e g t n e o d t d n a c n g n s s s bevd n as, a e r e a e t e t d i h o i e u t 1 . m / g o b d w i h .E i e i l g c l d t p o i e n c e i l e i e c f r a a s c a i n b t e n rd p o 13 gk f oy egt pdmooia aa rvd o rdbe vdne o n soito ewe flurd e t e n t r l y o c r i g o a d d t d i k n wae a d r s o h m n c n e F u r d i n i n t m t g n c oie, i h r a u a l c u r n r d e o r n i g tr, n i k f u a a c r. l o i e o s o u a e i i s a d r b c e i l s s e s. t h s b e s o n t a flu r d i n h s p t n i l t i d c c r m s m a e r t o s n tnad atra ytm I a e n h w h t o i e o a o e t a o n u e h o o o e b r a i n i c l u e h m n a d r d n c l s a d s s m c h g e t a t o e t w i h h m n a e e p s d In vivo d t a e n utrd ua n oet el t oe uh ihr hn hs o hc uas r xoe. aa r c n cig S m s u i s r p r c r m s m d m g i r d n s, h l o h r s u i s u i g s m l r p o o o s r p r o flitn. o e t d e e o t h o o o e a a e n o e t w i e t e t d e s n i i a r t c l e o t ngtv rsls. o e t a a v r er p o u t v e f c so flu r d e p s r i h m n h s n t b e a e u t l e leaie eut P t n i l d e s e r d c i e f e t f o i e x o u e n u a s a o e n d q a e y va utd A v r e e f c s o r p o u t o w r r p r e f r r t m c fx a d c t l e p s d t 1 0 p m o g e t r ae. d e s f e t n e r d c i n e e e o t d o a s, i e,o, n a t e x o e o 0 p r r a e c n e t a i n o flurd i ter de o dikn wae t e s u i s c n u t d i r t d m n t a e t a l w r o c n r t o s f oie n hi it r rnig tr.O h r t d e o d c e n a s e o s r t d h t o e c n e t a i n o flu r d ( m / g o b d w i h ) d d n t r s l i i p i e f r i i y a d r p o u t v c p b l t e o c n r t o s f o i e 5 g k f o y e g t i o e u t n m a r d e t l t n e r d c i e a a i i i s. 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Nursing Mothers: I i ntkoni flu r d i e c e e i h m n m l .However, a y d u s a e e c e e i m l , t s o nw f o i e s x r t d n u a i k mn rg r xrtd n ik a d c u i n s o l b e e c s d w e p o u t c n a n n flu r d a e a m n s e e t a n r i g w m n R d c d n ato hud e xrie hn rdcs otiig oie r diitrd o usn oa. e u e m l p o u t o wa r p r e i f r - a s d f x w e t e a i a s w r f d a d e c n a n n a h g c n e t a i n i k r d c i n s eotd n amrie o hn h nml ee e it otiig ih ocnrto o flu r d ( 8 1 7 m / g o b d w i h ) N a v r e e f c s o p r u i i n lcain o ofpigwr se i rt f o i e 9 - 3 g k f o y e g t . o d e s f e t n a t r t o , atto, r fsrn ee en n as a m n s e e flu r d u t 5 m / g o b d w i h . diitrd oie p o gk f oy egt P d a r c U e T e u e o P e i e t® 5 0 B o t r i p d a r c a e g o p 6 t 1 y a s a a c r e p e e t v i e i t i s : h s f rvDn 00 ose n eiti g rus o 6 er s ais rvnie s s p o t d b p o e r n c i i a s u i s w t 1 1 s d u flu r d g l i m u h t a s i s u e t a e 1 t 1 y a s u p r e y i n e i g l n c l t d e i h . % o i m oie es n ot ry n tdns g 1 o 4 er c n u t d b E g a d r e a .2-4 S f t a d e f c i e e s i p d a r c p t e t b l w t e a e o 6 y a s h v n t b e odce y nlne t l aey n fetvns n eiti ains eo h g f er ae o en etbihd P e s r f r t t e C N R I D C I N a d W R I G s c i n salse. l a e e e o h O T A N I AT O S n A N N S e t o s. G r a r c U e O t e t t l n m e o s b e t i c i i a s u i s o 1 1 ( / ) s d u flurd 1 p r e t w r e i t i s : f h o a u b r f u j c s n l n c l t d e f . % w v o i m oie, 5 e c n e e 6 a d o e h l 1 p r e t w r 7 a d o e o oeal dfeecs i sft o efciees wr osre 5 n v r,w i e e c n e e 5 n v r.N v r l i f r n e n a e y r f e t v n s e e b e v d b t e n t e e s b e t a d y u g r s b e t a d o h r r p r e c i i a e p r e c h s n t i e t fie dfeecsi e w e h s u j c s n o n e u j c s, n t e e o t d l n c l x e i n e a o d n i d ifrne n r s o s s b t e n t e e d r y a d y u g r p t e t btgetrsniiiyo sm odridvdascno b rld e p n e e w e h l e l n o n e a i n s, u r a e e s t v t f o e l e n i i u l a n t e u e ot h s d u i k o n t b s b t n i l y e c e e b t e k d e a d t e r s o t x c r a t o s t t i d u m y b u.T i r g s n w o e u s a t a l x r t d y h i n y, n h i k f o i e c i n o h s r g a e g e t ri p t e t w t i p i e r n lf n t o .B c u ee d r yp t e t a em r l ke yt h v d c e s dr n lf n r a e n a i n s i h m a r d e a u c i n e a s l e l a i n s r o e i l o a e e r a e e a u cto, c r s o l b t ke i ds slcin a d i m y b u e u t m n t r r n l f n t o .5 in a e h u d e a n n oe eeto, n t a e s f l o o i o e a u c i n ADVERSE REACTIONS: A l r i r a t o s a d o h r i i s n r s e h v b e r r l r p r e . legc ecin n te doycais ae en aey eotd OVERDOSAG :A c d n a i g s i n o l r e a o n s o flu r d m y r s l i a u e b r i g i t e m u h a d s r E cietl neto f ag mut f oie a eut n ct unn n h ot n oe t n u N u e , vmtn, a d d a r e m y o c r s o a t r i g s i n ( i h n 3 m n t s a d a e a c m a i d b o g e. a s a o i i g n i r h a a c u o n f e n e t o w t i 0 i u e ) n r c o p n e y slvain h m t m s s, n e i a t i c a p n a d m n l p i .T e e s m t m m y p r i t f r 2 h u s.fls ai to, e a e e i a d p g s r c r m i g b o i a a n h s y p o s a e s s o 4 o r I es t a 5 m flu r d / g b d w i h ( . , l s t a 2 3 m flu r d / b b d w i h ) h v b e i g s e , g v c l i m h n g o i e k o y e g t i e. e s h n . g o i e l o y e g t a e e n n e t d i e a c u (., m l ) o a l t r l e e g s r i t s i a s m t m a d o s r e f r a f w h u s.I m r t a 5 m flu r d / g eg ik rly o eiv atonetnl ypos n bev o . e or f o e h n g oiek b d w i h ( . , m r t a 2 3 m flu r d / b b d w i h ) h v b e i g s e , i d c v m t n , gv oal sl o y e g t i e. o e h n . g o i e l o y e g t a e e n n e t d n u e o i i g ie rly oube clim ( g ml, 5 c l i m g u o a e o c l i m l c a e s l t o ) a d i m d a e y s e m d c l a s s a c l acu e., ik % a c u l c n t r a c u a t t o u i n n m e i t l e k e i a s i t n e. . F r a c d n a i g s i n o m r t a 1 m flu r d / g o b d w i h ( . , m r t a 6 9 m flu r d / b b d o c i e t l n e t o f o e h n 5 g o i e k f o y e g t i e. o e h n . g o i e l o y wih) i d c v m t n a d a m t i m d a e y t a h s i a f c l t egt, n u e o i i g n d i m e i t l o o p t l a i i y. A t e t e t d s ( t i r b o ) o P e i e t® 5 0 B o t r c n a n a p o i a e y 2 5 m flurd A 3 5 fl.z r a m n o e a h n i b n f r v D n 0 0 o s e o t i s p r x m t l . g oie. . 8 o. ( 0 m ) b t l o P e i e t® 5 0 B o t r c n a n a p o i a e y 6 7 m flurd 1 6 L o t e f r v D n 0 0 o s e o t i s p r x m t l 4 g oie. DOSAG AND ADMINISTRATION: F l o t e e i s r c i n u l s o h r i e i s r c e b y u d n a p o e E o l w h s n t u t o s n e s t e w s n t u t d y o r e t l r f ssoa: 1 A u t a d p d a r c p t e t 6 y a s o a e o o d r, p l a t i r b o o P e i e t® 5 0 B o t r t a inl . d l s n e i t i a i n s e r f g r l e a p y h n i b n f r v D n 0 0 o s e o t o h r s . B u h t o o g l o c d i y f r t o m n t s, r f r b y a b d i e, n p a e o y u r g l r t o h a t o t b u h r s h r u h y n e a l o w i u e p e e a l t e t m i l c f o r e u a o t p s e. 2 Atrue, d l s e p c o a e. o bs rsls, ontet dik o r n e f r 3 m n t s. eiti ptet a e 6 1 , . fe s a u t x e t r t F r et eut d o a, rn, r i s o 0 i u e P darc ains, g - 6 epcoae atr ue ad rne muh toogl x e t r t f e s n i s o t h r u h y. HOW SUPPLIED: 3 5 fl.z (0 m)i patcbtls . 8 o. 16 L n lsi ote S e r i t NDC 0126-0075-34 pamn: F u t s i TM NDC 0126-0076-34 riatc: STORAG : S o e a C n r l e R o T m e a u e, 0 2 C ( 8 7 F E t r t o t o l d o m e p r t r 2 - 5° 6 - 7°) . REFERENCES: 1 A e i a D n a A s c a i n c e t d D n a T e a e t c E . 4 ( h c g 1 8 ) 4 5 4 7 . m r c n e t l s o i t o ,A c p e e t l h r p u i s d 0 C i a o, 9 4 : 0 - 0 . 2 HR E g a d r e a . JADA 7 ( 9 7 : 6 8 6 4 3 HR E g a d r e a . JADA 7 ( 9 9 : 7 3 7 7 4 HR . .. n l n e t l , 5 1 6 ) 3 - 4 . . .. n l n e t l , 8 1 6 ) 8 - 8 . . .. E g a d r e a . JADA 8 ( 9 1 : 3 4 3 8 5 D t o fil.C l a e O a P a m c u i a s. nlne t l, 3 17) 5 - 5 . . a a n e o g t r l h r a e t c l

Oral Pharmaceuticals

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U.. a e t N 6 2 0 9 3 S P t n o. , 9 , 3 P037 071 Rv. 7 0 e 0/3

From your trusted name in prescription fluoride--

Works in places where a brush can't

FA S T E R D I S P E R S I O N T H A N O T H E R Rx F L U O R I D E T O O T H PA S T E S B E C A U S E O F I T S F L U I D C O N S I S T E N C Y 1

From Colgate® PreviDent® -- introducing Colgate® PreviDent® 5000 Booster, the Rx fluoride toothpaste specially developed to help patients reach areas their toothbrush can't. You can count on this patented fluid formula to deliver:

1 K Faster fluoride dissolution in saliva 2 K Patented formula provides maximum fluoride protection

K Flows between teeth to get to places your toothbrush can't reach

Colgate® PreviDent® products are available for in-office dispensing (where permitted by state law). To place an order, call 1-800-2COLGATE (226-5428) or contact your sales representative.

Effective fluoride, complete coverage

References: 1. Joziak MT, et al. Comparison of enamel fluoride update and fluoride release from liquid and paste dentifrices. J Dent Res. 2003;82(Sp. Issue). Abstract 1355. 2. US Patent 6,290,933. Please see full Prescribing Information on the following page.

To purchase product for your practice, call For additional product information, visit

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©2004 Colgate-Palmolive Company C41481 9/04

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