| Abstract|| |
Introduction: The complications of soft drink consumption during orthodontic treatment includes degradation of enamel, reduction in the shear bond strength of orthodontic brackets, and also corrosion of orthodontic wires. The main objective of this review is to discuss the adverse effects of carbonated soft drink (CSD) consumption on patients undergoing fixed orthodontic treatment. Methods: A search of studies in MEDLINE (via PubMed), the Cochrane library, Web of science, IndMED, EMBASE, Google scholar and limited grey literature on the effects of consumption of CSDs was conducted. All pertinent abstracts were reviewed for inclusion. Full articles were retrieved for abstracts or titles that met the initial inclusion criteria or lacked sufficient detail for immediate exclusion. Results: Out of the 4484 results obtained from search, 16 articles were selected based on title and 6 articles were eliminated after reading the abstracts. 10 articles were selected for systematic review which included 6 invitro studies, 1 animal study, 1 observational study and 2 invivo studies. Of these, six studies evaluated the effects of carbonated drinks on the shear bond strength of brackets on enamel of which two evaluated the microhardness of enamel, two studies evaluated the mechanical and chemical properties of wires, one evaluated tooth movement and one study focussed on white spot lesions. The results from the selected articles showed that with the consumption of carbonated drinks, there was reduced shear bond strength of orthodontic brackets, altered enamel characteristics, alteration of mechanical and physical properties of orthodontic wires and decrease in rate of orthodontic tooth movement. Conclusion: Based on the available evidence, CSD consumption during orthodontic treatment definitely has an effect on orthodontic appliances, enamel and possibly on tooth movement.
Keywords: Carbonated drinks and orthodontics, carbonated drinks systematic review, shear bond strength, properties of orthodontic archwires
|How to cite this article:|
Venkatesan K, Srinivasan B, Padmanabhan S. Adverse effect of consumption of carbonated soft drinks on orthodontic treatment – A systematic review. Indian J Dent Res 2021;32:505-13
|How to cite this URL:|
Venkatesan K, Srinivasan B, Padmanabhan S. Adverse effect of consumption of carbonated soft drinks on orthodontic treatment – A systematic review. Indian J Dent Res [serial online] 2021 [cited 2022 Jun 29];32:505-13. Available from: https://www.ijdr.in/text.asp?2021/32/4/505/345429
| Introduction|| |
Orthodontics plays a major role in aligning the teeth within the periodontal ligament and thereby improving the aesthetics and function as well as maintaining the structural balance. In recent years, there has been an increase in the frequency of carbonated soft drink (CSD) consumption among children and adolescents. Many cross-sectional studies in the United States have shown that the increased consumption of these drinks has led to obesity in children and adults. The frequent use of cola and sweetened beverages is correlated with an increased risk of type II diabetes. Hypocalcaemia is also another controversial side effect of these drinks. Some studies have reported a higher risk of cardiovascular disease in females with consumption of CSDs. Cola consumption is also a risk factor for metabolic disease in the middle-aged individuals. Long-term consumption of soft drinks affects the total protein intake. It has been reported that the intake of cola beverage has a negative effect on bone healing in rat models.
One major concern during orthodontic treatment which usually lasts for 1–2 years is enamel demineralisation leading to increased risk of dental caries. Various forms of topical fluorides have been used conventionally to reduce the risk of caries during orthodontic treatment. Recently, newer methods have been proposed to reduce the risk of caries and promote remineralisation such as nanoparticles, bioactive glass, MI paste.,,,
Another challenge posed during the duration of orthodontic treatment time is by the consumption of CSDs, which may be expected to have adverse effects on oral cavity and the fixed appliances. The intake of CSDs causes an increase in acidic pH and the adverse effect can be categorized as effects on tooth structure and effect on orthodontic appliance (brackets and wire). The main objective of this review is to discuss the negative consequences of CSD consumption on patients undergoing fixed orthodontic treatment.
The various adverse effects of soft drink consumption in the oral cavity of patients undergoing fixed orthodontic treatment reported in literature include calcium release from enamel surface,, increased risk of caries, decreased enamel microhardness reduction in the shear bond strength of orthodontic brackets,,,, and also corrosion of orthodontic wires.,,
Erosive nature of CSDs is greater than noncarbonated beverages because of the additional carbonic acid content. The pH value of the mouth decreases to below 5.5 on consumption of soft drinks,,, and hence, it contributes to the adverse effects. Bacteria converts retained plaque and food into acids near the gingival margins and prolonged exposure to acids during orthodontic treatment can cause dental caries. Dental caries as a result of orthodontic treatment has also been related to the demineralization of enamel caused by soft drink consumption.
Metals in the oral environment are always challenged by acidic, warm and wet environments. An acidic pH of the oral cavity can also hasten the corrosion process of orthodontic wires, leading to negative consequences ranging from lower forces being delivered to the teeth to wire fractures.
The corrosion of stainless steel, cobalt–chromium and Ni–Ti wire is prevented by formation of a passive surface oxide film and is accelerated by acidic conditions in oral cavity and formation of chloride ions.
Various studies have reported the effect of CSD on orthodontic treatment and tooth surface, but so far there is no systematic review in literature on the effects of CSD consumption on orthodontic treatment.
The aim of this systematic review is to evaluate the effect of CSD consumption on patients undergoing fixed orthodontic treatment with particular reference to enamel and orthodontic appliances.
| Materials and Methods|| |
Eligibility criteria: The studies which satisfied the following eligibility criteria were included in the systematic review.
- Participants – pre- and post-treatment records of orthodontically treated patients, sample size, age and sex
- Intervention – consumption of CSDs
- Control – samples were immersed in water/distilled water.
- Outcome – CSD consumption in patients undergoing fixed orthodontic treatment causes demineralization of enamel, increased risk of caries, reduction in shear bond strength of brackets and corrosion of orthodontic wires
- Study design – in vitro and in vivo observational study.
Inclusion Criteria included in-vitro studies, in-vivo studies during orthodontic treatment, randomized controlled trials, clinical control studies, cohort studies and studies analysing the effect of carbonated drinks on intact enamel.
Exclusion criteria included congenital enamel defects, dental fluorosis and review, editorial, case reports and letters to editor.
The primary outcomes assessed were the effects of carbonated drinks on orthodontic wires, shear bond strength of orthodontic brackets and on the enamel surface.
The design of each study was assessed using Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0.
Unpublished data was not taken into consideration for the review. Studies published from 1975 to 2016 were sought for review.
The literature for this review was searched independently by two authors, in the following database: MEDLINE (1975- 2017), IndMED, Web of science (1975–2017), Cochrane (1975–2017), EMBASE (1975–2017) and Google scholar (1975–-2017). Grey literature was sought from Greynet and OVID. Only English language articles were included.
The following search strategies (with limits) was used in MEDLINE Mesh terms used were
- Effects of carbonated drinks on orthodontics,
- Carbonated drinks on teeth,
- Carbonated drinks on brackets,
- Carbonated drinks on orthodontic wires,
- Carbonated drinks on orthodontic treatment and
- Carbonated drinks on enamel surface.
Search results from all the databases were assessed. Duplicate records of the same report were excluded. Titles and abstracts were examined to remove the reports that were obviously irrelevant. Full texts of the potentially relevant studies were sought. Individual studies were assessed for compliance on the proposed eligibility criteria. The articles which did not satisfy the eligibility criteria were excluded for the respective reasons. The reports included for review were used to proceed with data collection.
Data collection process and data items
Data was extracted independently by two authors using a data collection form. Details from the articles were collected on the variables such as study method, participants, intervention and outcome. This process was also discussed with the third author in order to prevent interobserver disagreement.
Risk of bias assessment
Risk of bias assessment was done using OHAT (Office of Health Assessment and Translation) Risk of Bias Rating Tool for Human and Animal Studies, January 2015 for eight articles, namely, six in vitro studies, one animal study and one observational study. Risk of bias assessment was done using 'A Cochrane Risk Of Bias Assessment Tool: for Non-Randomized Studies of Interventions (ACROBAT-NRSI), Version 1.0.0, 24 September 2014', for two articles that were in vivo studies.
| Results|| |
This systematic review was executed based on the PRISMA, 2009 statement. The results of the search strategy are described in [Figure 1]. Published literature pertaining to the review was accessed through various database including MEDLINE, COCHRANE, Google Scholar, IndMED, Web of science, EMBASE, and total of 4484 results were obtained. Records identified through database search gave 60 articles from MEDLINE, 24 from COCHRANE and 4400 articles from Google Scholar. IndMED, Web of Science and EMBASE databases did not throw up any results. The search was further extended by cross searching the reference articles in the databases and two more studies were retrieved.
The identified articles were then screened and 30 studies were filtered out after reading the title and abstract. Among these records, 14 duplicates were eliminated. At this juncture, inclusion criteria were applied to assess for eligibility, as a result of which six studies were eliminated. Ultimately, after streamlining the search, 10 studies were included for this systematic review and subjected to data collection.
The study design of each article was assessed independently by the two authors using Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. Each article was described based on the following premises.
All articles were in vitro and in vivo observational studies. The following study characteristics were elicited from each article: participant information, pre- and post-treatment records of orthodontically treated patients, sample size, age, sex; usage of CSDs, control group characteristics; and outcomes assessed were CSD consumption in patients undergoing fixed orthodontic treatment causes demineralization of enamel, increased risk of caries, reduction in shear bond strength of brackets and corrosion of orthodontic wires.
The results of the study characteristics are presented in [Table 1].
Risk of bias for individual studies
Risk of bias for each study was assessed using OHAT Risk of Bias Rating Tool for Human and Animal Studies, January 2015. [Table 2] gives risk of bias eight articles, namely, six in vitro studies, one animal study and one observational study.
Risk of bias assessment was done using 'A Cochrane Risk of Bias Assessment Tool: for Non-Randomized Studies of Interventions (ACROBAT-NRSI), Version 1.0.0, 24 September 2014'. [Table 3] gives risk of bias for two articles that were in vivo studies.
Results of individual studies
Results of individual studies are presented in [Table 4]. The studies taken for review assessed one or more of these outcomes, that is, consumption of soft drinks during orthodontic treatment resulted in increased damage to enamel, reduced bond strength of brackets and effect on the mechanical properties of the orthodontic wire.
Among the studies included in systematic review, majority of them proved that there was greater enamel demineralization, reduced shear bond strength and degradation of mechanical and physical properties of orthodontic wire with consumption of carbonated drinks. However, majority of the selected studies were in vitro studies.
All the studies included had an experimental group and a control group. A study by Mikulewicz had a continuous flow system; this had experimental groups, hence was chosen for the review.
| Discussion|| |
Summary of evidence
This systematic review discusses the adverse effects caused by the consumption of CSDs. Records from various databases were screened and 4484 articles were obtained. After the exclusion of articles based on criteria formulated for our review, we had 10 articles for qualitative synthesis. The literature search revealed lack of randomized control trials in this area of research. Although randomized controlled trials are considered as the gold standard among all research design in the evidence pyramid, it is probably not possible to assess the effects of CSD consumption due to ethical considerations. Hence, this review had to rely on in vitro and observational clinical studies.
Literature has shown that the consumption of CSDs during orthodontic treatment has deleterious effects on the tooth enamel; it affects orthodontic tooth movement and also causes metal ions release from wires.,
Four studies evaluated shear bond strength of brackets on enamel,,,, two studies evaluated bond strength of brackets and microhardness of enamel, two articles evaluated the effects of mechanical and chemical properties of wires,, one study evaluated the rate of tooth movement and one study evaluated the formation of white spot lesion.
Various authors used different methods to evaluate the bond strength of brackets, bond strength of enamel and microhardness.
Bond strength assessment
Oncag et al., Pasha et al., Ulusoy et al. and Khoda et al. evaluated the shear bond strength of brackets on exposure to CSDs in intervention group and control group was artificial saliva/distilled water. The first three studies showed a reduction in bond strength, and they believe that the reason for this was the enamel erosive effect of the phosphoric acid in carbonated drinks that reduced the shear bond strength. Study by Khoda et al. showed that there was no significant difference in bond strength, and the reason for the difference they attributed it to a specific type of composite material used for bonding (Unite, self-cure).
We had also noticed that the duration of exposure to carbonated drinks and the method of testing were different in these studies. In a study by Oncag et al., Khoda et al., Ulusoy et al., the duration of exposure was the same, but in Pasha et al.'s study, teeth were kept in soft drinks for 15 days, for 15 min, 3 times a day, separated by intervals of 2 h. At other times, they were kept in artificial saliva.
Oncag et al. measured the shear bond strength using a shear tester and determined the amount and localization of erosion using SEM. Pasha et al. assessed the shear bond strength after debonding with a universal testing machine. Khoda et al. assessed debonding strength of brackets using Zwick machine.
Enamel surface assessment
The changes in enamel surface were assessed based on microhardness and SEM study to assess the bond strength.
Hammad et al. assessed the microhardness of enamel in addition to the shear bond strength of brackets.
A study by Hammad et al. assessed the enamel, after resin infiltration in intervention group and control group without resin infiltration. Bond strength was assessed using scanning electron microscopy. It was seen that the cola group without resin infiltration showed least resistance to shearing forces, and it also showed that after resin application, enamel surface was smooth and less erosive. Thus, with the sealing effect on sound enamel and the stabilization of demineralized enamel, it is conceivable that the caries infiltration technique may be beneficial as a form of pretreatment before bracket fixation.
Eygen et al. concluded that soft drink consumption caused a significant reduction in the microhardness value of enamel and that even intake for a short duration had a role on the microhardness. They assessed the hardness of enamel using a Knoop hardness tester.
Orthodontic tooth movement
Aghili performed an in vivo animal study on Sprague–Dawley rats and showed that there was a significant decrease in rate of orthodontic tooth movement on consumption of CSDs. The oral intake of high amounts of sugar leads to a rapid, statistically significant decrease of bone formation and resorption markers, osteocalcin and its carboxylated type. These drinks contain acidic components (carbon dioxide, phosphoric acid) that may alter bone metabolism towards this condition. This may influence the bone remodelling process and subsequently orthodontic tooth movements.
Effect on orthodontic materials
Mikulewicz evaluated the metal ions release on consumption of CSDs and it was seen that coca-cola caused increased release of Ni ions. The authors suggest that the low pH of these drinks promotes corrosion by activating the cathodic reaction. The proposed hypothesis by the authors is that the passivating oxide layer is further acted on by protons in acidic environment, resulting in leaching of metal ions.
Parenti et al. showed that there was no change in the physical and chemical property of Ni–Ti-based wire. This was an in vitro study, and the acidic pH of the oral environment to favour corrosion of Ni–Ti -based orthodontic wire was not present.
- Most of the studies included in the systematic review were only in vitro studies.
- Absence of randomized trials proved to be a limitation.
- Various differences in the methods of assessment could have attributed to the lack of standardization in providing results.
- Not all the studies taken for analysis had the same primary outcome.
- Scarce literature was available for the effect of CSDs on orthodontic tooth movement and the effects of carbonated drinks on the property of orthodontic wires.
More clinical research with standardized protocols might offer more substantiated information.
| Conclusion|| |
Based on the available evidence, CSD consumption during orthodontic treatment definitely have an effect on the bond strength of bracket and on the enamel surface. It was inconclusive if CSD consumption causes decrease in orthodontic tooth movement and if metal ions are released from orthodontic wires and brackets because of scarce literature that is available.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Keerthi Venkatesan
Department of Orthodontics and Dentofacial Orthopaedics, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]