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Profile in Oral Health Trisha E. O’Hehir, RDH, MS Editorial Director, Hygienetown

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Xylitol is no longer a new topic. Journal articles cover the science and speakers endorse the preventive benefits of xylitol. Hygienetown even has a free online CE course titled: Xylitol, The Good Sugar. Xylitol is an essential ingredient in CAMBRA protocols to prevent caries. The research has been accumulating for 40 years, yet translating the science into quick and easy recommendations patients will follow is more elusive.

It's easy to give patients information and reasons why xylitol should be part of their daily oral health program, but getting follow-through is not always as easy. It requires a repeatable and predictable plan of action, resulting in patient compliance with product purchases outside the dental office. A few practices stock products for their patients and sell them directly, but the majority prefer their patients to purchase recommended products outside the dental office. Recommendation to patients should include these three simple steps:
  1. Use 100 percent xylitol sweetened products,
  2. Strive for five xylitol exposures each day; and
  3. Shop for xylitol products in a health food store.
A History Lesson
It all began in Finland during World War II. The ports were blocked so no sugar made it to Finland. The government asked scientists what other sugars might be available in Finland and were told that the bark from birch trees contained xylitol. The government built the factory to extract xylitol from the cellulose in the tree bark and provide a natural sugar to their citizens. After the war, it was decided that importing sugar was cheaper than extracting xylitol, so the country went back to cane sugar. Years later, dentists noticed that children whose teeth erupted during the time xylitol was used had fewer caries than children before or after. A few more comparisons with other Scandinavian countries confirmed that indeed something good happened when xylitol replaced sugar. With this information, researchers began investigating how xylitol impacted oral bacteria and the caries process.

Early Studies
In two short pilot studies, researchers asked subjects to refrain from all oral hygiene and gave them xylitol several times a day as a sweetener in coffee, caramels and sweet rolls. In just four days, plaque levels were reduced by 50 percent. When the study was repeated over five days, the results were the same – 50 percent reduction in plaque. As a dental hygienist, this finding is amazing. Oral hygiene instructions don't always deliver a 50 percent reduction in plaque levels. Imagine getting this result with several exposures to xylitol each day. Sweet success.

Next were the complete sugar replacement studies, to replicate the wartime xylitol diet and compare it to a traditional sucrose diet, as well as a fructose diet. Providing and monitoring food intake for subjects over a two-year period was an enormous and expensive undertaking. Results of the Turku Sugar Studies showed an amazing 85 percent reduction in caries for those in the xylitol group. Researchers then wondered how chewing xylitol sweetened chewing gum several times a day would compare to results of the meal replacement studies. Dropping the total daily intake of xylitol from 67 grams to 6.7 grams produced the same results, 85 percent reduction in caries after one year compared to sucrose chewing gum. Researchers were amazed and excited with this finding.

Long-term studies are essential to confirm the outcomes of shorter studies. These studies are difficult and expensive to perform. Researchers from Finland and the University of Michigan undertook a 40-month study in Belize City, Belize, including every fourth grader in the city. Several chewing gums were tested – 100 percent xylitol-sweetened gum, sorbitol-sweetened gum, sucrose-sweetened gum and a combination of xylitol and sorbitol in a chewing gum. The study results confirmed the caries preventive benefits of 100 percent xylitol-sweetened chewing gum were better than sucrose, sorbitol and xylitol plus sorbitol. Both sucrose and sorbitol provide a nutrient source for bacteria, allowing bacteria to produce the acid necessary to stick together in a biofilm on the teeth and to dissolve enamel leading to caries.

These early studies created a foundation for a wide variety of xylitol studies and repeatedly showed chewing gums and other candies and products sweetened with only xylitol provided the greatest caries prevention. Products with only a small amount of xylitol will not provide the benefits reported for 100 percent xylitol-sweetened gums and candies. This is a key point to remember when recommending xylitol products, be sure they are sweetened only with xylitol.

Mothers, Children and Xylitol Use
Preventing the very first carious lesion is our goal. To do that, a mother's oral flora needs to be low in strep mutans and high in lactobacillus. Several studies confirm that 100 percent xylitol chewing gum used by mothers for a period of two years, prior to tooth eruption in their infants, leads to 70 percent less need for restorative care. When researchers went back several years after completion of the study, a long-term effect was measured. The children of mothers who chewed 100 percent xylitol-sweetened gum were five times less likely to have strep mutans colonized in their mouths and still had 70 percent less caries than children whose mothers received several applications of either a fluoride or chlorhexidine varnish over two years. Chewing gum sweetened only with xylitol provided on oral flora conducive to health for both the mothers and their children. Looking across the board at many xylitol chewing gum studies, caries rates are reduced from 40 percent to 85 percent. Many factors will influence study results, including compliance and frequency of xylitol consumption each day.

Hundreds of xylitol research studies over the past 40 years demonstrate the ability of 100 percent xylitol-sweetened products used several times each day reduce both caries and periodontal pathogens, stimulate salivation, enhance remineralization, and reduce bad breath.

Strive for Five Xylitol Exposures Each Day
The key to achieving the results reported in the research is to use products sweetened only with xylitol and to use these products several times throughout the day. Research has demonstrated that it's not the total amount consumed, but rather the frequency of exposure throughout the day. Xylitol molecules have a five-carbon structure rather than six carbons, helping them to easily pass through the outer membrane of bacteria, blocking entry for the sugar molecules. However, the bacteria cannot digest the xylitol and must use its own energy to pump the xylitol molecule out, where it repeats the process, using up valuable energy of the bacteria with no acid production. With no acid production, the bacteria can't maintain the biofilm structure, cannot remain attached to the teeth and cannot dissolve enamel. The bacteria are simply flushed off the teeth down the digestive tract. The same is true for Xlear xylitol nasal rinse. Bacteria, dust, dirt and other irritants are simply flushed from nasal passages, preventing ear infections in children and colds, sinus infections and even asthma.

Target Groups in Your Practice
There are several target groups in your practice that will benefit from adding 100 percent xylitol-sweetened products several times each day. Begin with pregnant patients. By changing their oral flora, they will pass on a healthy balance of bacteria to their new baby when teeth are erupting. Infants benefit from Xlear Nasal Rinse, squirted in their noses to prevent ear infections. Children can use xylitol gel to prevent caries. Xylitol use will raise the pH of the mouth, reducing the potential for caries.

Adults will benefit from a reduction of oral pathogens associated with both caries and periodontal disease. Those suffering with xerostomia will experience stimulated salivation and a reduction in plaque levels, providing preventive benefits. Patients investing in restorative and cosmetic dentistry will protect their investment with xylitol products that prevent recurrent caries around restoration margins. The elderly are the least able to perform adequate oral hygiene on a daily basis, so xylitol products will help them reduce bacterial biofilm levels, stimulate saliva flow, raise oral pH and reduce bad breath.

Shop for Xylitol Products in Health Food Stores
Chewing gums available at the grocery store checkout are not sweetened with 100 percent xylitol. These chewing gums do not contain enough xylitol to achieve the benefits reported in research. These popular chewing gums advertise xylitol on their packaging, but the list of ingredients that will often read sorbitol, mannitol, aspartame, acesculfame K, and sucralose, often listed before xylitol. In some products, xylitol is listed as less than 2 percent. These chewing gums do not reduce plaque formation, but instead provide a nutrient source for the bacteria and the acid production continues. The benefit of other "sugar-free" chewing gums is salivary stimulation, not bacterial reduction. Chewing gums, candies and other oral health products sweetened with only xylitol are available in health food stores, not grocery or drug stores. Find a good health food store in your area, visit them and see if they carry 100 percent xylitol-sweetened products such as Spry or Xlear products. You can also visit www.xlear.com and type in your zip code to get a list of health food stores in your area that carry Spry and Xlear products. Have this store information ready for your patients when you recommend 100 percent xylitol-sweetened products. You might also include this information in your office newsletter or on your practice Web site. Share the exciting xylitol science with patients and tell them about www.xylitol.org, where they can read more about this sweet ingredient for oral health. This independent Web site provides information, videos, science and product recommendations for consumers as well as medical and dental professionals.

Conclusion
Xylitol is an exciting ingredient that will make dental disease prevention both easy and sweet. Try it yourself. Use your tongue to feel the plaque accumulating along the mandibular lingual surfaces of the posterior teeth and the facial surfaces of the maxillary posterior teeth. Chew Spry 100-percent xylitol-sweetened chewing gum after meals and snacks and on the first day, you'll feel a reduction in bacterial biofilm accumulation on these tooth surfaces As Townie Erika Feltham said in a xylitol message board: "Use Spry and let your mouth tell you why!"
Dentaltown Magazine
September 2025
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