Summary of: Are sugar-free confections really beneficial for dental health?

Abstract

Various sugar substitutes have been introduced and are widely used in confections and beverages to avoid tooth decay from sugar and other fermentable carbohydrates. One group of sugar substitutes are sugar alcohols or polyols. They have been specifically used in foods for diabetic patients because polyols are not readily absorbed in the intestine and blood stream, preventing post-prandial elevation of glucose level. Additionally they may lower caloric intake.
We searched PubMed, Cochrane Controlled Trials Registry, Cochrane Oral Health Review, Centre for Reviews and Dissemination in the UK, National Library for Public Health and a Centre for Evidence Based Dentistry website up to the end of October 2010, using the search terms 'sugar alcohol' or 'sugar-free' or 'polyols' and combined with a search with terms 'dental caries' or 'dental erosion'.
Xylitol, a polyol, has been approved by the US Food and Drug Administration for its non-cariogenic properties that actually reduce the risk of dental decay and recently, the European Union also officially approved a health claim about xylitol as a 'tooth friendly' component in chewing gums. Although the presence of acidic flavourings and preservatives in sugar-free products has received less attention, these additives may have adverse dental health effects, such as dental erosion. Furthermore, the term sugar-free may generate false security because people may automatically believe that sugar-free products are safe on teeth.
We concluded that polyol-based sugar-free products may decrease dental caries incidence but they may bring another dental health risk, dental erosion, if they contain acidic flavouring. There is a need for properly conducted clinical studies in this area.

Full text

Are sugar-free confections
really benecial for
dental health?
H. Nadimi,1 H. Wesamaa,2 S.-J. Janket,3 P. Bollu,4 and J. H. Meurman5
a million years and caries is still widely
observed in developing countries.2
Sugars and other fermentable dietary
carbohydrates are substrates to microor‑
ganisms that ferment carbohydrates and
generate acids. The acidity causes demin‑
eralisation of the tooth enamel which is the
initial step in dental caries lesions. Hence,
blocking any of the aetiological factors
will decrease caries activity. These include
suppressing acidogenic bacteria in the
mouth by maintaining good oral hygiene
and limiting consumption of fermentable
carbohydrates. In addition, use of uoride,
which reduces enamel liability to acid dis‑
solution, leads to less dental caries.3
Sugar substitutes have been introduced
and widely investigated in limiting the
dietary source of caries hazards.4 Of these,
the sugar alcohol polyols are most popular
today in many foods and beverages. Most
notably, they have been used in chewing
gums and candies as well as in soft drinks
and sports drinks. Furthermore, polyols are
less likely to exacerbate diabetes because
INTRODUCTION
Dental caries is one of the most prevalent
health issues affecting a large proportion
of the world population and is considered
to be the most common form of chronic
disease among schoolchildren. In adults,
untreated tooth decay is seen in 28% of
people aged 35‑44and 18% of people aged
65years and older.1 Caries dates back over
Background Various sugar substitutes have been introduced and are widely used in confections and beverages to avoid
tooth decay from sugar and other fermentable carbohydrates. One group of sugar substitutes are sugar alcohols or polyols.
They have been specically used in foods for diabetic patients because polyols are not readily absorbed in the intestine and
blood stream, preventing post-prandial elevation of glucose level. Additionally they may lower caloric intake. Methods We
searched PubMed, Cochrane Controlled Trials Registry, Cochrane Oral Health Review, Centre for Reviews and Dissemination
in the UK, National Library for Public Health and a Centre for Evidence Based Dentistry website up to the end of October
2010, using the search terms ‘sugar alcohol’ or ‘sugar-free’ or ‘polyols’ and combined with a search with terms ‘dental caries’
or ‘dental erosion’. Results Xylitol, a polyol, has been approved by the US Food and Drug Administration for its non-cari-
ogenic properties that actually reduce the risk of dental decay and recently, the European Union also ofcially approved a
health claim about xylitol as a ‘tooth friendly’ component in chewing gums. Although the presence of acidic avourings and
preservatives in sugar-free products has received less attention, these additives may have adverse dental health effects, such
as dental erosion. Furthermore, the term sugar-free may generate false security because people may automatically believe
that sugar-free products are safe on teeth. Conclusion We concluded that polyol-based sugar-free products may decrease
dental caries incidence but they may bring another dental health risk, dental erosion, if they contain acidic avouring. There
is a need for properly conducted clinical studies in this area.
these molecules are not readily absorbed
into the blood stream.5
Sugar alcohols produce less acid from
fermentation of carbohydrate by oral
microbiota.6 Any acidity surrounding the
tooth, especially a pH below the critical
value of approximately pH 5.5of dental
enamel, may induce chemical dissolution
or erosion.7,8 Dental erosion is a slowly
progressing condition described as the
irreversible loss of dental hard tissue due
to a chemical process without involvement
of microorganisms.9
Acids are frequently added as avour‑
ing and preservative agents in confections
and beverages but their role in dental
health has not been thoroughly studied.10
Depending on whether the acidic com‑
pound is in liquid or solid form, the loca‑
tion of dental defects may differ. Acidic
liquids preferentially seem to cause ero‑
sion of the anterior maxillary and man‑
dibular teeth. Erosion from solid acids
such as in candies manifests mainly on
posterior teeth with smooth, silky‑glazed
1Dental Student, 3*Research A ssociate Professor in
General Dentistry/Research Assistant Professor in
Periodontology and Oral Biology, Henry M. Goldman
School of Dental Medicine, Boston University, 100 East
Newton Street, Boston, MA 02118, USA; 2Institute of
Dentistry, University of Helsinki, FI-00 014, Helsinki,
Finland; 4Assistant Professor and Research Coordina-
tor, College of Dental Medicine, University of Southern
Nevada, 11 Sunset Way, Henderson, N V 89014, USA;
5Professor of Oral Infectious Diseases, Institute of
Dentistry, University of Helsinki/Department of Oral
and Maxillofacial Diseases, Helsinki Universit y Central
Hospital, Helsinki, Finland
*Correspondence to: Dr Sok-Ja Janket
Email: skjanket@bu.edu
Online article number E15
Refereed Paper - accepted 7 April 2011
DOI: 10.1038/sj.bdj.2011.823
©British Dental Journal 2011; 211: E15
• Sugar-free does not mean calorie-free.
Some sugar-free products generate nearly
50% of calories produced by table sugar.
• In general, sugar-free products may help
prevent dental caries. However, if they
contain acidic additives, it may increase
the probabilit y of demineralising enamel,
thus causing dental erosion.
• Avoiding acid-containing, usually fruit-
avoured sugar-free products may be
benecial.
IN BRIEF
RESEARCH
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RESEARCH
appearance of enamel and cupping of the
occlusal surfaces of posterior teeth.10
In comparison to what is known about
the fermentation of sucrose and other
fermentable sugars, data regarding oral
health consequences of polyols are sparse.
The present review is mainly based on a
PubMed literature search up to the end
of October 2010 resulting in the collec‑
tion of 471 references with the keywords
‘sugar alcohol’ or ‘sugar free’ or ‘polyols’
and combined with a search using the
terms ‘dental caries’ or ‘dental erosion’. We
also searched Cochrane Controlled Trials
Registry, Cochrane Oral Health Review,
Centre for Reviews and Dissemination
in the UK, American Dental Association
Library and National Library for Public
Health, and a Centre for Evidence Based
Dentistry (CEBD) website, but did not
nd any additional literature. The lack
of well‑conducted studies or randomised
trials on the topic prohibited us from
conducting a meta‑analysis and quanti‑
fying dental erosion. The review is thus
mainly descriptive.
POLYOLS
Polyols are naturally found in fruits and
vegetables but are also manufactured from
inorganic sources.5 Polyols are hydrogen‑
ated forms of carbohydrates whose car‑
bonyl group has been reduced to primary
or secondary hydroxyl group with struc‑
tural similarities to sugars and/or alcohols.
Polyols are typically used in conjunction
with other articial sweeteners because
they tend to have lower sweetness than
natural sugars. Some of the common sugar
alcohols include xylitol (5‑carbon sugar
alcohol), sorbitol (6‑carbon sugar alcohol),
maltitol (12‑carbon sugar alcohol), man‑
nitol (6‑carbon sugar alcohol), and isomalt
(12‑carbon sugar alcohol).
The primary indication for polyols has
been in the production of foods for peo‑
ple suffering from diabetes because unlike
sugars, polyols are not readily absorbed in
the intestine. This prevents post‑prandial
uctuation of the blood glucose levels and
helps in achieving lower caloric intake.
However, polyols are not calorie‑free,
as shown in Table1. Sorbitol generates
nearly 65% of the calories from the same
amount of sucrose, and the lowest calories
are generated by lactitol and isomalt, with
50% of the calories that sucrose generates.
Therefore, high levels of polyol intake may
still have deleterious effects on the blood
sugar level although to a lesser extent
than other caloric sweeteners. In addition,
because polyols are not well‑absorbed in
the intestine, accumulation of unabsorbed
polyols may cause gastro‑intestinal distur‑
bance and osmotic diarrhoea, which is not
within the scope of this review.
Polyols and oral health
There have been particularly many studies
analysing the effects of xylitol in chew‑
ing gum.11–13 Xylitol has been approved
by the U.S. Food and Drug Administration
(FDA) for its non‑cariogenic properties that
actually reduce the risk of dental decay.14
Recently, the European Commission also
approved a health claim of xylitol on
‘tooth friendliness’ when used in chewing
gum.15
Oral bacteria are unable to ferment
xylitol. Studies have also shown that
xylitol chewing gum can increase salivary
ow leading to improved buffering effects
of the saliva.16 Furthermore, xylitol has the
ability to reduce the growth of oral bacte‑
ria by inhibiting glycolysis. When xylitol
is taken up by oral bacteria, it is incorpo‑
rated as xylitol 5‑phosphate which inhib‑
its the enzymes involved in metabolism.17
Sugar alcohols have been termed as non‑
fermentable sugars in the literature, yet
some oral bacteria can metabolise certain
sugar alcohols.18 For example, maltitol and
sorbitol appear to have variable ferment‑
ability depending on the species of bacteria
involved. Among polyols, scientic evi‑
dence indicates that xylitol demonstrates
the strongest caries prevention effect.19,20
The oral microorganism that displays
strong acidogenicity is Streptococcus
mutans.21 Unlike other species of the
viridans streptococci family, S.mutans
is capable of fermenting mannitol and
sorbitol.22 Lyon showed the various types
of carbohydrates that can be metabolised
by S.mutans and other strains of microor‑
ganisms.11 He also showed that S.mutans
ferments mannitol but not xylitol. Thus,
xylitol shows superior anticariogenic
properties in this regard.11
There are three notable properties of
xylitol that have made it an important
sugar alcohol in the dental perspective:
1) xylitol is not readily fermented by oral
bacteria, especially by streptococci; 2) it
has been shown to reduce the numbers of
S.mutans in the oral cavity by limiting
the source of fermentable substrates for
their survival; and 3) xylitol can induce
the production of salivary enzymes which
lead to the growth inhibition of bacteria
in plaque.13 Together, these mechanisms
are important in reducing dental caries
incidence in patients. The effective dose
of xylitol appears to be between 6.44g and
10.32g xylitol per day. Furthermore, lower
doses of xylitol have also been shown to be
efcient in caries prevention.23,24
The most commonly used polyol in
several sugar‑free chewing gums in the
United States, however, is sorbitol. This
is mainly due to its low cost compared
to xylitol.25 Since sorbitol is fermented by
mutans streptococci, thereby increasing
the acid production in plaque, it should
be considered low‑cariogenic rather than
non‑cariogenic.26 Animal studies have also
shown that microorganisms can learn to
metabolise sorbitol when the fermentable
sugar supply is restricted.27
EVIDENCE OF CARIES REDUCTION
Clinical trials with xylitol
The effect of xylitol chewing gum has
been extensively studied over the past
30 years.28 Blocking the early mother‑
child transmission of S.mutans is also an
important step in caries prevention since
the early S.mutans colonisation is con‑
nected with early childhood caries. The
effect of maternal use of xylitol chewing
gum on caries and on mutans streptococci
in children has been shown to be benecial
in caries reduction, with signicantly less
Table 1 Caloric content of various
sugar alcohols
Name Caloric content (kcal/g)
Sucrose 4
Sorbitol 2.6
Mannitol 1.6
Maltitol 2.1
Lactitol 2
Xylitol 2.4
Isomalt 2
Source: Food Insight sugar alcohols factsheet. Available
at http://www.foodinsight.org/Resources/Detail.
aspx?topic=Sugar_Alcohols_Fact_Sheet
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RESEARCH
S.mutans colonisation and less caries in
the children.24,29
The use of xylitol products has also been
tested on patients with high caries risk,
with xed orthodontic appliances, disabled
school children and/or veterans with high
root caries risk.30–32 Xylitol appeared to
have caries preventive effects in all but one
of these studies. However, in a two‑year
double blind trial evaluating the effect of
xylitol‑ and xylitol/uoride‑containing
lozenges on proximal caries, no statisti‑
cally signicant differences were found in
caries incidence between the experimental
groups and a control group that did not
receive lozenges.33
Milk for neonates would be a natural
vehicle for administration of anticaries
compounds. Hence, the taste of xylitol in
milk as a rst step toward measuring the
effectiveness of xylitol‑containing milk on
caries was tested in Peruvian children.34
The xylitol‑sweetened milk appeared to be
well accepted, offering a novel means for
administration. However, we question the
wisdom of introducing sweet taste sensa‑
tion at an early age which may not be
benecial.
Clinical trials with sorbitol
Sorbitol is the most commonly used polyol
in the United States because of its low cost.
However, only a few clinical trials have
been conducted on its caries‑inhibitory
action. Some trials have been conducted
with xylitol, sorbitol, and mixtures of
xylitol and sorbitol. According to the
review by Burt, chewing sorbitol‑sweet‑
ened gum no more than three times a day
had low cariogenicity compared to chewing
sugar‑sweetened gum.25 Although small
amounts of sorbitol can be fermented by
oral microorganisms, this amount does not
lower the plaque pH enough to cause dem‑
ineralisation of enamel.35 In a rat model,
however, an adaptation to sorbitol did take
place and resulted in an enhanced drop in
plaque pH following sorbitol application.27
Caries reduction with other polyols
Lactitol and maltitol have been tested
mainly in laboratory animals. Lactitol, a
lactose‑based sugar alcohol, showed anti‑
dental caries properties similar to xylitol.36
However, since it is made from lactose
and whey, lactose‑intolerant persons may
experience gastric disturbance. Maltitol
was not utilised by mutans streptococci,
nor did it produce sufcient acid to dem‑
ineralise tooth enamel. Replacement of
sucrose with maltitol in the diet resulted
in a trend towards caries reduction.37 More
recently, Mäkinen and co‑workers com‑
pared the effects of erythritol, a tetritol
(4‑carbon sugar alcohol), with xylitol
and D‑glucitol (a 6‑carbon sugar alcohol)
on the risk of dental caries.38 The use of
erythritol and xylitol resulted in a statis‑
tically signicant reduction in the plaque
and saliva levels of S.mutans (p<0.001
in most cases) and there was also a sig‑
nicant reduction in the amount of dental
plaque in groups receiving erythritol and
xylitol. Further studies are needed, how‑
ever, to verify these results.
EVIDENCE OF HIDDEN RISK
Acids in sugar-free candies
and beverages
Addition of other ingredients such as acids
to produce an enjoyable taste is another
important aspect of sugar‑free candies and
beverages. Acids are also used in foods as
preservatives. From a dental health point
of view, acidic avouring agents have
the same detrimental effects on dental
enamel as the microorganism‑generated
acids from sugar fermentation. This is evi‑
denced by the demineralisation observed
invitro studies39 and also shown following
the consumption of sugar‑free beverages.
The effect of acids in sugar‑free products
has yet to be widely studied invivo, and
more studies are needed in this area of
research. Our literature review will next
expand to dental erosion by discussing the
acids added to sugar‑free products in this
perspective.
Dental erosion
When a patient presents with dental ero‑
sion, the possibility of frequent consump‑
tion of acidic candies should be considered
as a potential detrimental aetiologic factor.
The risk of erosion from acidic additives in
sugar‑free products has been recognised as
early as 1978 by Kleber and colleagues.40
This phenomenon may be more apparent
in paediatric patients due to low salivary
volume.41 Recently a few invivo, exvivo
and invitro studies have been published
on confections, conrming their erosive
capacity.10,41–45 According to the study by
Wagoner and co‑workers, both original
avour and sour versions of candies were
potentially erosive; generally the erosive
capacity was directly proportional to the
acidity of the candies investigated.45
In a study by Brand and co‑workers, the
erosive potential of several lollipops and
the protective effect of saliva were inves‑
tigated. Ten healthy volunteers consumed
different types of lollipops and their sali‑
vary ow rate and pH was determined. The
lollipops differed in their erosive potential
depending on their avours. Fruit and cola
avoured lollipops had a very low pH of
2.3‑2.4and showed a drop in the salivary
pH to well below the critical value of 5.5.
Strawberry yoghurt and salty liquorice lol‑
lipops had pH values of 3.8‑4.7and also
resulted in a salivary pH below 5.5.43 Hence
these products appeared to be potentially
detrimental to the teeth.46
Candies are also made in spray‑form in
Europe and some chewing gums are lled
with acidic centers.41,42 The seven candy
sprays tested by Gambon and co‑workers
had an extremely low pH of 1.9‑2.3. All
these candy sprays had erosive potential
and the effect may be even greater with
children as their salivary volume is smaller
than in adults.41 Also the longer exposure
time to these acids may increase the risk of
erosion even more.47 The acidic lling of a
chewing gum reduced the microhardness
of both primary and permanent enamel in
a study by Bolan etal. Sour sweets have
been found to be even more erosive than
orange juice, which is a well‑known ero‑
sive agent.10
Since dental erosion is an irreversible
pathology and erosive lesions on teeth are
difcult to treat, the addition of protec‑
tive ingredients such as calcium and/or
phosphate to candies has been considered.
The addition of calcium has been shown
to reduce the erosive tendency of poten‑
tially erosive candies.44,48 Salivary cal‑
cium concentration of around 15mmol/l
resulted in considerable attenuation in
the erosive potential of a candy compared
to candies without calcium (p<0.001).44
However, one recent study did not observe
any protection against erosion by adding
various minerals.49 The exact quanti‑
cation of the possible protective effect
of adding calcium into potentially ero‑
sive candies should be conducted in the
future. The erosive potential of a foodstuff
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RESEARCH
is the result of complex interactions of
many molecules where calcium chelat‑
ing properties are only one parameter.50
Table 2 presents studies where acidic
products have been tested in relation to
dental erosion.
SUMMARY
As the use of sorbitol and xylitol contain‑
ing products increases, the public should
be educated on the hidden risk of dental
erosion due to acidic additives as well as
the adverse effects of gastric disturbance
and osmotic diarrhoea. Especially in sugar‑
free products, these adverse effects may
be more insidious because the public has
blind condence that they are oral health
friendly. Also, the exposure time to such
products should be considered. Thus, hard
candies or lollipops may be more harmful
if they are slowly melted in the mouth than
candy spray.47
Adding calcium and phosphate to
the product is a promising approach to
counteract the adverse erosive effect on
teeth but more studies are needed to con‑
rm its efcacy. At present, the reports
of protective effects of uoride against
dental erosion are conflicting. Thus,
we defer further discussion until a clear
trend emerges.
In general, sugar‑free products appear
to be benecial as far as dental caries is
concerned. However, the unrecognised risk
of acidic avouring in sugar‑free candies
and beverages on dental health calls for
more studies and public awareness. Based
on research results by Kleber and Wagoner,
acidic additives lower the pH of saliva well
below the critical level of 5.5, regardless of
acid type (Fig.1). Some researchers advo‑
cate future randomized, cross‑over trials.
However, it may be unethical to expose
study subjects to irreversible harm from
dental erosion. Thus, future studies should
include in vivo assessment of pH change
with the consumption of sugar‑free con‑
fections with and without acidic avour‑
ing and exvivo assessment of erosion at
such respective pH levels.
CONCLUSIONS
Although some disagreement exists, results
from numerous studies have shown that
substitution of table sugar with sugar‑
free sweeteners is a healthier choice for
dental caries prevention. However, the
acid avouring and preservatives used in
the sugar‑free confections and beverages
cause the salivary pH to drop below the
critical value and thus may cause dental
erosion. Therefore, properly conducted
randomised controlled trials using sugar‑
free products with or without acidic addi‑
tives are needed.
Table 2 Studies testing sugar-free products with acids
Type of study Test subject/object Main result Comments Reference
Invitro,
acidulants
Bovine incisors Fumaric acid, tar-
taric acid and citric
acid showed high-
est demineralisa-
tion. There was less
erosion when these
acids were given in
sorbitol candy.
Enamel dissolution
was correlated
with the potential
of the acids to
chelate calcium.
Kleber etal.40
Exvivo and
invitro,
beverages
Five healthy women Citric acid was the
most detrimental
to enamel.
All drinks had a pH
of below 5.5.
Meurman
etal.46
Exvivo,
beverages
Bovine tooth
enamel
Most erosion
with cola, orange
beverage, sports
drink, orange juice,
diet cola. Fluoride
did not inuence
erosive depth.
Carbonated mineral
water, beer, coffee,
yoghurt and butter-
milk did not cause
surface erosion.
Lowest pH below
4.5.
Rytömaa etal.39
Invivo and
invitro,
acidic candies
20 healthy
volunteers
Modied candy
reduced the erosive
potential of acidic
candies
Critical pH may not
fully reect when
dental erosion is
expected to occur.
Jensdottir
etal.44
Invitro,
sour candies
28 different sour
candies
pH for all below 4.0,
some to 1.6and 1.8
Primary teeth
are more prone
to erosion, soft
tissue irritation
was possible.
Robyn etal.50
Invitro, acidic
centre-lled
chewing gum
80 enamel blocks The acidic lling
of gum reduced
the microhardness
of enamel
Both primary and
permanent enamel
were affected
Bolan etal.42
Invitro,
lollipops
10 healthy
volunteers
Lollipops differ in
erosive potential
Fruit and cola
avoured lollipops
have the greatest
erosive effect.
Brand etal.
200951
Invivo and
invitro,
candy sprays
Seven different
candy sprays on
adult volunteers
Candy sprays have
a very low pH of
1.9-2.3
Effect on children
may be greater
as their salivary
volumes are smaller
than adults´
Gambon etal.
200941
7
6
5
4
3
2
1
0
pH
Water
Ascorbic acid
Adipic acid
Succinic acid
Glutaric acid
Fumaric acid
Malic acid
Tartaric acid
Citric acid
Fig. 1 pH change with various acidic additives in sugar-free confections
4 BRITISH DENTAL JOURNAL
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RESEARCH
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BRITISH DENTAL JOURNAL 5
© 2011 Macmillan Publishers Limited. All rights reserved.
© 2011 Macmillan Publishers Limited. All rights reserved.
© 2011 Macmillan Publishers Limited. All rights reserved.
© 2011 Macmillan Publishers Limited. All rights reserved.