Sugar alcohols—which are neither sugar nor alcohol—are polyols used for sweetening. These sweeteners are not considered artificial because they occur naturally in berries and other fruits. Because sugar alcohols convert to glucose slowly, they require little, if any, insulin to be metabolized, which inhibits blood sugar spikes.1
Sugar alcohols have been used in dentistry since the 1970s and are effective in the fight against oral bacteria. The primary bacteria associated with dental disease are Streptococcus mutans, S. sobrinus, and Lactobacillus. Through the fermentation process of consumed carbohydrates, these bacteria produce acid that breaks down enamel.2
Sugar alcohols offer anticariogenic benefits because oral bacteria cannot break down sugar alcohols and use them as an energy source. Thus, the oral bacteria basically starve, which inhibits caries development.3
Sugar alcohols are also cariostatic, meaning they help suppress caries formation. Recent studies suggest they also aid in the inhibition of biofilm buildup, gingivitis, and periodontal diseases.4–7
Varying in sweetness between 60% and 100% equal to the sweetness of sucrose, sugar alcohols are comparable in taste with minimal added calories, carbohydrates, or blood sugar spikes. This makes the use of sugar alcohols in dental products appealing. Additionally, they provide a cooling sensation in the mouth, which is caused by the sugar alcohol being dissolved, thus creating a chemical reaction that causes the oral mucosa to absorb heat.8 They are also used to mask the unpleasant taste of pediatric medications.4
However, the use of sugar alcohols is not without risk. They are poorly absorbed and excessive amounts can cause gastrointestinal issues such as bloating, gas, cramps, and diarrhea. Therefore, sugar alcohols should be introduced gradually, allowing the body to adapt by increasing production of the enzymes that breakdown sugar alcohols.
Children younger than age 3 should not consume sugar alcohols.9 Xylitol, a sugar alcohol, is also extremely dangerous and potentially fatal to pets.
Following is a discussion of the most commonly used sugar alcohols, including benefits and risks (Table 1).
Mannitol occurs naturally in food such as pineapple, olives, and sweet potatoes. Its sweetness is between 50% and 70% of sucrose. Historically, it has been produced by hydrogenation of glucose and fructose.7 However in recent years, cyanobacteria have been used for production via photosynthesis.
Due to the slow rate of absorption in the intestinal tract, mannitol may have a laxative effect if more than 20 grams per day are consumed. It is resistant to oral bacteria, which helps to prevent the mouth from becoming too acidic after consumption. It also increases the efficacy of lidocaine when used in an inferior alveolar nerve block without epinephrine by increasing the anesthetic’s duration of action.10
Maltitol’s sweetness ranges between 60% to 80% to that of sucrose. It is the most commercially produced sugar substitute and is found in chewing gum and pastries. Created through the hydrogenation process of corn, potatoes, and wheat, maltitol has anticariogenic properties, a slow absorption rate, and is unlikely to cause significant intestinal discomfort. Currently, there is no research demonstrating that maltitol reduces plaque pH.3,9
Sorbitol is naturally found in many fruits such as apples, pears, and peaches, as well as dried fruits including raisins and dates. It provides approximately 60% of the sweetness of sucrose. It can be manufactured as both a crystal and liquid and provides a cooling sensation in the mouth.
Sorbitol may also be used as a humectant in low-moisture foods as well as in children’s medications to provide a sweet taste and cooling sensation while keeping the formation of bacterial plaque low.4 Due to the anticariogenic properties of sorbitol, acid formation in plaque is slow, allowing saliva to buffer and neutralize acid as it is formed.9
The sweetest of sugar alcohols, xylitol has a sweetness comparable to sucrose, in addition to the same cooling feeling as other sugar alcohols. It is used in chewing gum, which can help reduce the level of dental plaque in addition to stimulating the production of saliva.9
Xylitol decreases the risk of Candidiasis and directly inhibits the growth of S. mutans, Lactobacillus, and B-glucosidase in saliva. It also reduces plaque/bacterial metabolism, energy production, buildup, and adherence.4,9
Xylitol may also decrease acid production resulting from consumption of sucrose as well as aid in the remineralization of teeth.4,11 One clinical trial indicated that by adding 10% xylitol to fluoride toothpaste, caries incidence was reduced by an additional 13%.12 However, additional studies are needed.
Xylitol is also known to inhibit inflammatory responses by impeding the production of cytokines triggered by the bacterial toxin lipopolysaccharides (LPS). It can reduce the LPS secretion from Porphyromonas gingivalis, which plays a primary role in the development of periodontal diseases.13
Xylitol enhances flavor and can mask unpleasant flavors in medications. Due to the association between sugar-based medication and caries risk, xylitol provides a safe and palatable alternative with minimal adverse effects.4
Research demonstrates the efficacy of xylitol so oral health professionals can feel confident recommending it. However, children should not consume more than 8 grams per day and xylitol syrup is not indicated for children younger than age 4.9
Erythritol can be found naturally in many sources—from fruits to the bodily fluids of mammals. It is also the first polyol to be naturally produced through the fermentation process of glucose by yeast. It has 70% to 80% of the sweetness of sucrose.
Erythritol is quickly absorbed through the small intestine and most of what is absorbed passes through urine unchanged and without being metabolized.2,11 This makes it an excellent choice for individuals with diabetes and those who tend to experience intestinal upset following sugar alcohol consumption.
Erythritol has few side effects. Studies tested repeated ingestion of erythritol as 1 g/kg of body weight, finding that, even on an empty stomach, it was tolerated well and did not cause a laxative effect.11
Studies indicate that erythritol has the greatest efficacy as compared to other sugar alcohols with inhibiting growth and reducing adhesion of S. mutans. It decreases biofilm formation in vitro and may be a suitable option for the use of subgingival air polishing.11,14
Currently, erythritol can be found in lozenges, chewing gum, toothpaste, mouthrinses, and air polishing powders.
Sugar alcohols are becoming a popular option in dental products. Research shows that while they provide sweetness, they have none of sucrose’s deleterious effects on oral health. Sugar alcohols may aid in enamel remineralization and the reduction of caries and periodontal diseases.
- Yale New Haven Health. Eat Any Sugar Alcohol Lately? Available at: ynhh.o/g/services/nutrition/sugar-alcohol. Accessed February 14, 2023.
- Sachdev R. Sugar substitutes and dental health. International Journal of Basic & Clinical Pharmacology. 2018;7(9):1667–1673.
- BeMiller J. Carbohydrate Chemistry for Food Scientists. 3rd ed. Philadelphia: Elsevier; 2019.
- Al Humaid J. Sweetener content and cariogenic potential of pediatric oral medications: a literature. InJ J Health Sci (Qassim). 2018;12:75–82.
- Chan A, Ellepola K, Truong T, Balan P, Koo H, Seneviratne CJ. Inhibitory effects of xylitol and sorbitol on streptococcus mutans and candida albicans biofilms are repressed by the presence of sucrose. Arch Oral Biol. 2020;119:104886.
- Kõljalg S, Smidt I, Chakrabarti A, Bosscher D, Mandar R. Exploration of singular and synergistic effect of xylitol and erythritol on causative agents of dental caries. Sci Rep. 2020;10:6297.
- Janus MM, Minke C, Volgenant C, et al. Effect of erythritol on microbial ecology of in vitro gingivitis biofilms. J Oral Microbiol. 2017;9:1337477.
- Chéron JB, Marchal A, Fiorucci S. Natural sweeteners. In: Melton L, Fereidoon S, Varelis P, eds. Encyclopedia of Food Chemistry. Cambridge, Massachusetts: Academic Press; 2019:189–195.
- Gupta M. Sugar substitutes: mechanism, availability, current use and safety concerns-an update. Open Access Maced J Med Sci. 2018;6:1888–1894.
- Pathak PK, Singh AK, Agrawal S, Singh D, Mali DK, Kumar U. Role of 0.5 M mannitol as an adjuvant with lidocaine with or without epinephrine for inferior alveolar nerve block: a randomized control trial. J Clin Exp Dent. 2019;11:e500–e505.
- De Cock P, Mäkinen K, Honkala E, et al. Erythritol is more effective than xylitol and sorbitol in managing oral health endpoints. Int J Dent.2016;2016:9868421.
- Yu OY, Lam WYH, Wong AWY, Duangthip D, Chu CH. Nonrestorative management of dental caries. Dent J (Basel). 2021;9:121.
- Gasmi Benahmed A, Gasmi A, Arshad M, et al. Health benefits of xylitol. Appl Microbiol Biotechnol. 2020;104:7225–7237.
- Lim JH, Jeong Y, Song SH, et al. Penetration of an antimicrobial zinc-sugar alcohol complex into Streptococcus mutans biofilms. Sci Rep. 2018;8:16154.
From Dimensions of Dental Hygiene. March 2023; 21(3)16,18,21.