In this article, Ali Lowe discusses the effects that alcohol can have on dental health—high pH levels and hidden sugar can have detrimental effects on teeth. Alcohol can also have an effect on systemic health, including liver damage, dementia, stroke and oral cancer

The past half century has seen a change in alcohol's status, propelling it from a luxury to a staple item, and doubling consumption in a large percentage of the population (Public Health England (PHE), 2014). ‘Oiled’ is the new normal: be it at home, at leisure, or interacting professionally, we feel we need alcohol to relax and socialise (Betts, 2014).

Women have largely been at the forefront of this transition due to a shift from the occasional medicinal sherry to ‘mumsnet wine ‘o clock’ and, as a result, drink is fast becoming a feminist issue. Indeed, at every age women are catching up with men in terms of consumption (National Institute on Alcohol Abuse and Alcoholism (NIAAA), 2014).

All drinkers, regardless of their age, gender or drinking status, will benefit from oral hygiene care and advice together with knowledge of the effect alcohol use may have on their oral health, for even ‘sensible’ drinkers may suffer from problems (Daniel et al, 2008).

Hidden sugar

As dental professionals, we are fully aware that sugary snacks and acidic fruit juices can be harmful to our patients' teeth but little thought is given to the hidden levels of sugar in popular alcoholic drinks. A single pint of cider contains almost as much sugar as the World Health Organization (WHO) recommends should be an average person's daily limit (WHO, 2013). Alcoholic beverages such as pina coladas, sticky liqueurs, rum and coke, alcopops and sweet sherry may be tempting but they have a high sugar content. Cocktails and mixed drinks are often both sugary and carbonated and therefore pose a threat to the enamel. Analysis of sugar levels in sherry, spirits, flavoured vodkas, rums and sloe gin found that some drinks contained as many as five teaspoons of sugar in a single serving and are therefore best avoided (, 2015).

In contrast, wines, beer and clear alcohols such as gin and vodka contain very little sugar unless they are combined with a mixer, e.g. a gin and tonic.

The World Health Organization (WHO) has recommended that a person's daily intake of added sugar should be halved to six teaspoons to help avoid growing health problems (WHO, 2013).

Also, the Chief Medical Officer has warned manufacturers to ‘ramp up’ attempts to reduce the amount of added sugar in food and drink and is reinforcing calls for a ‘sugar tax’ to be implemented (Department of Health, 2014). As PHE's (2014)Delivering Better Oral Health: An Evidence-based Toolkit for Prevention (DBOH) reminds us: ‘lowering the amount and frequency of sugars consumed will have wider health benefits, preventing weight gain and obesity, which in turn will reduce the risk of heart disease, type 2 diabetes and some cancers’. Thus, it is clear that ‘hidden’ sugar in alcohols could contribute to a series of health problems, partly because they contain high calorie levels.

Following the consumption of a sugary alcoholic beverage the drop in plaque pH usually takes no more than five minutes, whereas the recovery can take between 30 and 60 minutes depending on the acid neutralising properties of each individual's saliva (PHE, 2014). The Stephan Curve is a simple visual way of showing patients how the oral environment changes on a typical night out, highlighting the vulnerability of the tooth structure once the pH is below the critical level (5.5), particularly if this is maintained over a long period.

Unlike most packaged foods and soft drinks, manufacturers of alcoholic beverages are not required to include information about the ingredients of most alcoholic drinks on the label, meaning that consumers are unable to see how much sugar is contained in each drink. It would be helpful if tobacco style warnings on drink bottles were enforced, together with wide ranging advertising restrictions.

In addition to demineralisation and decay, consumption of alcoholic beverages is also associated with noncarious tooth surface loss due to the acidity and low pH of drinks such as alcopops, cider and wine (Robb and Smith, 1990). Indeed, many carbonated beverages are at least as acidic as orange juice. As a rule, dry sparkling wines are the worst offenders due to the bubbles that are produced by carbon dioxide. Good advice to patients would be to choose a less acidic, flat wine over prosecco or champagne. As a rule, white wine is more acidic than red. Beer, despite the bubbles, is not quite as harmful to the teeth due to its high calcium content. Keep in mind that while the pH of a drink is an indicator of its erosive potential, a measure called total titrable acidity, which gives the capacity of a liquid to dissolve enamel, is a better guide (Levine and Stillman-Lowe, 2009).

Table 1.

pH levels in alcohol

DrinkpH level
Gin and tonic2.6
White wine3.3
Red wine3.4
Rose wine3.4
Dessert wine3.4
Whiskey and soda5.0

Limiting the harmful effects of alcohol

There are many ways that moderate drinkers can minimise the damage that alcohol does to their teeth:

  • ? Choose ‘skinny’ champagne; it tastes great and is sugar free

  • ? Add plenty of ice to drinks as this will dilute the harmful effects

  • ? Use a straw placed to the back of the mouth

  • ? Alternate alcoholic drinks with water or rinse with water between drinks

  • ? Always drink lots of water when you get home: even just one glass of wine can cause dehydration resulting in dry mouth and often halitosis. Patients who suffer from xerostomia will find that the problem will be exacerbated if they drink a significant amount of alcohol without being very careful to keep their water intake up (Arnold, 2013)

  • ? Carry a travel size bottle of fluoride mouthwash to rinse with as this will help to neutralise the acid

  • ? Wait at least 30 minutes before brushing teeth following an acidic drink

  • ? Chew sugar free gum as this will help to keep your mouth moist and neutralise plaque acids.

Raising awareness of the dangers of alcohol

Unfortunately not all of our patients can be classed as ‘sensible’ drinkers. About two million people in the UK drink enough to seriously endanger their health and a growing proportion of them are what most of us might regard as ‘social drinkers’: people who enjoy a drink at the end of the day to help them unwind, and who often get ‘tipsy’ around the dinner table or on nights out (Porter, 2014). Few ‘social’ drinkers realise the damage they are doing and fully believe they can ‘take it or leave it’.

Macmillan Cancer Support (2014) have revealed that the average Briton spends £50 000 on alcohol during their lifetime and a recent study published in the BMJ argued that 12 units a week—less than a pint, or large glass of wine a day—can have an adverse effect on health (Brennan et al, 2014). Also, one of the biggest mistakes our patients make is to think that their liver is the only thing that they are likely to damage, but drinking too much causes a myriad of other problems, including dementia and stroke, not to mention facial trauma, periodontal disease and mouth cancer.

Since a significant proportion of the healthy general population visit a dentist on a regular basis (Health and Social Care Information Centre, 2013), the dental team is in a unique position to provide brief advice and support to patients who are considered to be hazardous or harmful drinkers and signpost to GP and/or local alcohol services (where appropriate). Indeed, a substantial body of high quality evidence has highlighted the effectiveness of dental professionals delivering brief advice to drinkers (Kaner et al, 2007).

A variety of alcohol screening questionnaires have been developed for use in primary care settings and all have been shown to be a reliable and valid means of detecting alcohol misuse among patients (Fiellin et al, 2000) One of the most useful training resources is the AUDIT-C tool (Bush et al, 1998). This takes approximately three minutes to complete and offers direct and personalised feedback to the patient, identifying excessive drinking and providing tailored advice according to their score.

However, one of the simplest ways of advising our patients that they may have a problem is to tot up the units. Current guidelines recommend that women should drink no more than two to three units a day (with a maximum of 14 a week), while men can drink up to four units a day (but no more than 21 a week). However, it is widely accepted that the current guidelines are not based on the best evidence and were designed from the outset to err on the side of caution rather than reflect true risk (Porter, 2014).

Most medical history forms include questions related to alcohol consumption but many patients are unsure of what constitutes a ‘unit’. For this reason it can be useful to have information to hand. Basically, one unit of alcohol is 10 ml (1 cl) by volume and 8 g by weight of pure alcohol. This is equivalent to:

  • ? Half a pint of ordinary strength beer, lager or cider (3–4% alcohol by volume)

  • ? A small pub measure (25 ml) of spirits (40% alcohol by volume)

  • ? A standard pub measure (50 ml) of fortified wine such as sherry or port (20% alcohol by volume)

  • ? Half a glass (87.5 ml) of wine (12% by volume).

The Alcohol Learning Centre have produced a chart (similar to the one in Figure 1) detailing how many units are in alcoholic drinks. This is a great visual aid for use with patients as it helps them to understand how many units are in alcohol (DH, 2012).

Figure 1.Showing how many units are in alcholic drinks can help patients to understand what constitutes a unit



Alcohol use has become increasingly common in all age groups, from teenagers to the elderly. Indeed, older drinkers have been in the spotlight recently following the publication of a new report showing that alcohol-related problems are rising fast in the over 60s, with more seeking professional help than ever before (Alcohol Policy UK, 2014).

While the occasional glass of red wine may actually be beneficial and offer protection against cardiovascular disease, it is clear that excessive alcohol consumption can contribute to a series of health problems, and can result in major health, social and economic consequences (PHE, 2014). Remember that most people with a drink problem do not match the stereotypical image we all have of an alcoholic; in fact they look pretty much like you and me!

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Key points

  • ? We need to be aware of hidden sugars in alcohol—cider, cocktails and alcopops have high sugar contents.

  • ? Consumption of alcoholic beverages not only causes demineralisation and decay, but also noncarious tooth loss due to high acidity and pH levels.

  • ? The effects of alcohol can be reduced, such as drinking water in between alcoholic drinks, rinsing with fluoride mouthwash, and chewing sugar free gum.

  • ? Dental professionals can offer brief advice to drinkers, using the AUDIT-C tool and also visual aids that show how many units an alcoholic drink contains

  • ? Excessive alcohol can contribute to a series of health problems