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Profile in Oral Health Dr. John Peldyak

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by Dr. John Peldyak

There is growing concern that increasingly heavy and frequent consumption of sugars is contributing to an epidemic of obesity with serious related health problems, in addition to the acknowledged contribution to dental diseases.

Taking action to reverse this disturbing trend requires some understanding and awareness of the amount, the quality and the frequency of sugar overload.

Reducing Amounts of Sugar
Some sources of sugar excess are obvious (cookies, pies, cakes, donuts, etc.) and can easily be reduced to help bring down overall calorie burdens. Unless specifically labeled "sugarfree," syrups are mostly just concentrated mixtures of sugars and water – this includes honey, molasses, agave and maple syrup. "Hidden" sugars can add up in prepared foods, medicines, sauces, dressings and various condiments.

Heavily sweetened beverages are a major source of added sugars. A daily soda habit (regular or diet), as well as other foods or drinks high in fructose, is associated with increased risk for weight gain, the metabolic syndrome and even cardiovascular events – heart attack and stroke! Eliminating or drastically reducing soda consumption can make a decisive difference in bringing down added sugars and associated health risks. Metabolic syndrome is a cluster of risk factors for diabetes, heart attack and stroke and yields the following effects:
  • Visceral fat
  • Elevated cholesterol
  • High triglycerides
  • Inflammation
  • Insulin resistance
  • Glucose intolerance
Waist measurements of more than 35 inches for women and 40 inches for men indicate probable metabolic syndrome.

Improving Properties of Sweeteners
Different carbohydrates have different properties: different sugars, polysaccharides and sugar alcohols all have unique features. We can maximize benefits and minimize harm by better understanding and appropriate selection. For example, starch rapidly breaks down to glucose monosaccharide whereas cellulose, also a glucose polysaccharide is resistant to digestion. Starches can be combined with fibrous carbohydrates or sugar alcohols to reduce blood sugar spikes. Sugar alcohols can substitute for fast-acting sugars such as glucose (high-glycemic), fructose (high triglycerides, fat and AGEs) and sucrose (tooth decay).

What Are Sugar Alcohols?
Sugar alcohols (or "polyols" – polyhydric alcohols because of –OH groups) are hydrogenated versions of sugars, and can in turn be oxidized to sugars by dehydrogenation. For example sorbitol can be made commercially by the reduction of glucose, and sorbitol is dehydrogenated to fructose as the first step in its metabolism. Polyols tend to be less reactive, safer for teeth and more slowly absorbed and metabolized, thus yielding fewer calories than their corresponding sugars. Polyols behave partly like dietary fiber, and overconsumption can lead to gastrointestinal distress such as flatulence and loose stools.

Why Use Sugar Alcohols (Polyols)?
Added sugars can be displaced partially or entirely by sugar alcohols in certain applications. Sugar alcohols are commonly used to reduce sugar, calories and glycemic index in specialty processed foods. Polyols can also completely replace sugars in dentally safe treats and oral care products. As with sugars, different polyols have unique features:
  • Sweetness
    High Intensity Sweeteners > fructose > HFCS(55) > sucrose = xylitol > maltitol > glucose > erythritol > sorbitol = mannitol > maltose > lactose
  • Glycemic Index
    Glucose > sucrose > maltitol > fructose > sorbitol = xylitol > erythritol
  • Cariogenicity (estimated)
    Sucrose > glucose > lactose > fructose > sorbitol = mannitol > maltitol > xylitol (non- or anti-cariogenic)
  • Gastrointestinal Tolerance
    This varies considerably between individuals, and several factors come into play even with the same consumer. Sugars are generally well-tolerated, but fructose and lactose intolerance are not rare. For polyols generally: erythritol > xylitol (with adaptation) > maltitol > sorbitol > mannitol
Some preferred uses for sugar alcohols include maltitol in chocolate, isomalt for hard candy, sorbitol to maintain creamy consistency in toothpaste, mannitol for moisture-resistant surface "dusting," erythritol in beverages because of good digestive tolerance and xylitol in oral care products. Hydrogenated starch hydrolysate (HSH) is a polyol syrup which contains mixtures of sorbitol, maltitol and higher polyols. The properties of HSH vary with the constituents.

Reducing Frequency of Sugar Exposure
Restricting added sugars to mealtimes could help reduce excess calorie consumption. It is also a core strategy for improving dental health. This can be very important for those with established soft drink habits, and even those athletes who often use sports beverages and energy gels. In addition to frequent exposures of high sugar concentrations, there is the dental burden of erosive acids potentially demineralizing tooth surfaces.

Misguided popular perception might consider fruit juice drinks between meals as "healthy," when they pose similar metabolic and dental damage as soda for very young children.

If these added sugars and acids are confined to mealtimes, then a non-acidogenic saliva stimulant used at the end of the meal can help protect teeth. Among suggestions are fibrous vegetables, nuts or aged cheese. The most practical and promising strategy along these lines is to finish a meal or snack with a candy or chewing gum sweetened with xylitol.




Why Xylitol?
Any polyol used after sugars in meals or snacks would be helpful. But over the past 40 years, xylitol has been demonstrated to have the greatest dental benefits.

Xylitol is a versatile sweetener that can be used in many applications to completely or partially replace sucrose. Because xylitol is found in most plants and fruits, it has always been a part of the human diet. Whereas most of our dietary sugars are based on 6-carbon units, xylitol has a structure of 5-carbon atoms. In metabolism, these 5-carbon sugars are critical components of energy (ATP) and nucleic acid molecules (RNA, DNA). Our bodies generate about a tablespoon of xylitol every day as a metabolic intermediate helping to link up 5- and 6-carbon pathways.

Because xylitol has a delightful sugary taste, but is lowglycemic and low-calorie, it found early use as a premium natural sweetener in the diabetic diet, and as a supplemental energy source in intravenous nutrition for patients with impaired glucose tolerance.

More recently xylitol has gained attention as an anti-biofilm agent. Xylitol has no reactive double-bond carbonyl group so it does not link with other sugars or amino acids, thereby not extending the extracellular polysaccharide matrix but helping to disrupt bacterial and fungal cohesion and adhesion.

Xylitol is practically non-fermentable by oral bacteria. It even has specific inhibitory effects against S. mutans and P. gingivalis, important caries and periodontal pathogens. (In contrast, sorbitol and mannitol can be utilized by S. mutans as an energy source, but acid production is slight.) Over time, consistent xylitol use makes dental plaque less adhesive, less acidic, less inflammatory and less harmful. In several long-term field trials xylitol use dramatically reduced the incidence of tooth decay. Xylitol promotes and supports natural protective factors. Through similar mechanisms, xylitol can also prevent upper respiratory infections.

It is effective and convenient to add xylitol to any oral hygiene program. Xylitol use is compatible with and complementary to other oral hygiene strategies including brushing, flossing and antimicrobials. Xylitol and fluoride might have an additive protective effect.

An early trial in Finland took all the added sugars out of the diet and replaced them with xylitol. The result was the (almost) elimination of new cavities without any metabolic harm (gastrointestinal tolerance developed rapidly). But this strategy would be very expensive and impractical.

Thankfully it was found that only tiny amounts of xylitol – about a rounded teaspoon each day – are needed for dental health if used after eating. The number of exposures to xylitol is critically important. Three uses are effective, but strive for five xylitol uses each day. This is easy with so many xylitol products available now. Simple advice would be to brush morning and night with xylitol/fluoride toothpaste. After brushing is a good time to use xylitol/saline nasal spray for the upper airway. Use xylitol chewing gum or candy after meals to maintain a healthy oral environment.

A striking benefit of xylitol is the long-term protection acquired by teeth that erupt during xylitol use. These teeth are particularly well-mineralized and resistant to decay. Xylitol forms weak complexes with calcium in solution and acts as a carrier to get minerals deeper into the tooth structure.

Xylitol is effective for breaking the cycle of transmission of cariogenic microflora. The concept is for mothers to use xylitol (such as chewing gum) during pregnancy and after delivery to decrease S. mutans. Their babies tend to not acquire the cariogenic organisms and maintain a low caries rate throughout the service of their primary dentition. In complementary studies, xylitol syrup applied directly to the primary teeth resulted in similar decay reduction.

It seems reasonable to advise mothers (and all close-contact caregivers) to use xylitol, and for the babies to have xylitol applied to their teeth. This combination could block MS colonization and lead to long-term dental health.

In mature adults, xylitol has been shown to remineralize enamel defects, reduce gingival inflammation and prevent root surface caries. Xylitol might be useful in difficult situations such as nursing homes because many of the products are easy to apply.

Metabolically, xylitol is slowly and only partially absorbed. Most xylitol is processed by the liver and can be converted to glucose and glucose polymer (glycogen). The impact on blood sugar and insulin is about 90 percent less than ingested glucose. Xylitol does not glycate like fructose or contribute to formation of advanced glycation end products (AGEs).

Some xylitol reaches the lower gut where fermentation can occur and exert a probiotic effect. One breakdown product is butyrate, which is utilized for energy by cells in the colon wall. Butyrate is associated with healthy gut function and might have anti-cancer properties. Too much xylitol, taken rapidly especially with liquids on an empty stomach can result in flatulence or even loose stools from an osmotic effect. Intestinal tolerance to increasing amounts of xylitol can be developed rapidly within two or three weeks. A reasonably small amount of xylitol will help promote healthy regular elimination and prevent constipation without any untoward side effects.

Most other polyols will cause even more potential intestinal distress. An exception is erythritol (4-carbon), which is mostly eliminated in the urine and not metabolized at all.

Mixtures of xylitol with other sweeteners, sugars and starches might be useful in cooking to reduce overall glycemic load, reduce calories and reduce, but not eliminate dental acids.

Take Away
There are no sweeteners that are perfect for all situations. We need to be cautious about the harmful metabolic effects of too much added sugar. Try to restrict most sugars to mealtimes to avoid dental harm.

Important practical steps are to drastically reduce soda and heavily sweetened beverages, especially between meals. Plain water is great for hydration. Coffee and tea can be lightly sweetened with intense sweeteners, but erythritol or xylitol could provide extra dental protection.

Some added sugars can be replaced by polyols and resistant starches (fiber) although such reformulation of familiar items might need intense sweeteners to approach expected flavor. The goals are to reduce glycemic index and calories at an acceptable cost.

For dental benefits, use a non-acidogenic saliva stimulant at the end of meals and snacks. Xylitol can be combined effectively with other sugar alcohols in suitable products that encourage sucking or chewing. However, items that are fully sweetened with xylitol appear to provide the best results.

References
  1. Wang YM, van Eys J. "Nutritional Significance of Fructose and Sugar Alcohols." Annual Review of Nutrition vol.1, 437-475, July 1981.
  2. Gardener H, Rundek T. "Diet Soda increases vascular events." International Stroke Conference Los Angeles, Feb 9 2011.
  3. Gehring F. "Cariogenic Bacteria." In Xylitol, Councell JN, ed. Applied Science 1978.
  4. Dhingra R, Sullivan L, et al. "Soft drink consumption and risk of developing cardiometabolic risk factors and the metabolic syndrome in middle-aged adults in the community." Circulation 116 (5) 480-488, July 2007.
  5. Stanhope KL, Schwarz JM, et al. "Consuming fructose-sweetened, not glucose-sweetened, beverages increases visceral adiposity and lipids and decreases insulin sensitivity in overweight/obese humans." J Clin Invest 119(5):1322-1334, May 2009.
  6. Livesey G. "Glycaemic Responses and Toleration" in Sweeteners and Sugar Alternatives in Food Technology Mitchell H, ed. 295-320, Blackwell 2006.
  7. Ly KA, Milgrom P. "Sugar alcohols and dental health" in Food Constituents and Oral Health Wilson M, ed. 134-151,CRC Press 2009.
  8. Scheinin A, Makinen KK. "Turku sugar studies I-XXI" Acta Odontol Scand 33 (Suppl 70), 1-349, 1975.
  9. Makinen KK, Bennett CA, et al. "Xylitol chewing gums and caries rates: a 40-month cohort study." J Dent Res, 74, 1904-1913, 1995.
  10. Bond M, Dunning N. "Xylitol" in Sweeteners and Sugar Alternatives in Food Technology Mitchell H, ed. 295-320, Blackwell 2006.
  11. Han SJ Jeong, SY, et al. "Xylitol inhibits inflammatory cytokine expression induced by lipopolysaccharide from Porphyromanas gingivalis." Clinical and Diagnostic Laboratory Immunology, 12 (11) pp 1285- 1291, 2005.
Author’s Bio
John Peldyak is a general dentist in Michigan. He received his DMD degree from Southern Illinois University in 1980 and was a member of professor Kauko Mäkinen's University of Michigan xylitol research group on sugar substitutes from 1986-1992. Dr. Peldyak is also a founding member of the American Academy of Oral Systemic Health.
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