Hygiene & Prevention Profile in Oral Health

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hygiene & prevention proﬁle in oral health

There is growing concern that increasingly heavy and fre- sugars, polysaccharides and sugar alcohols all have unique fea- quent consumption of sugars is contributing to an epidemic of tures. We can maximize benefits and minimize harm by better obesity with serious related health problems, in addition to the understanding and appropriate selection. For example, starch acknowledged contribution to dental diseases. rapidly breaks down to glucose monosaccharide whereas cellu- Taking action to reverse this disturbing trend requires some lose, also a glucose polysaccharide is resistant to digestion. understanding and awareness of the amount, the quality and the Starches can be combined with fibrous carbohydrates or sugar frequency of sugar overload. alcohols to reduce blood sugar spikes. Sugar alcohols can substi- tute for fast-acting sugars such as glucose (high-glycemic), fruc- Reducing Amounts of Sugar tose (high triglycerides, fat and AGEs) and sucrose (tooth decay). Some sources of sugar excess are obvious (cookies, pies, cakes, donuts, etc.) and can easily be reduced to help bring What Are Sugar Alcohols? down overall calorie burdens. Unless specifically labeled “sugar- Sugar alcohols (or “polyols” – polyhydric alcohols because of free,” syrups are mostly just concentrated mixtures of sugars and –OH groups) are hydrogenated versions of sugars, and can in water – this includes honey, molasses, agave and maple syrup. turn be oxidized to sugars by dehydrogenation. For example sor- “Hidden” sugars can add up in prepared foods, medicines, bitol can be made commercially by the reduction of glucose, and sauces, dressings and various condiments. sorbitol is dehydrogenated to fructose as the first step in its Heavily sweetened beverages are a major source of added metabolism. Polyols tend to be less reactive, safer for teeth and sugars. A daily soda habit (regular or diet), as well as other foods more slowly absorbed and metabolized, thus yielding fewer calo- or drinks high in fructose, is associated with increased risk for ries than their corresponding sugars. Polyols behave partly like weight gain, the metabolic syndrome and even cardiovascular dietary fiber, and overconsumption can lead to gastrointestinal events – heart attack and stroke! Eliminating or drastically distress such as flatulence and loose stools. reducing soda consumption can make a decisive difference in bringing down added sugars and associated health risks. Why Use Sugar Alcohols (Polyols)? Metabolic syndrome is a cluster of risk factors for diabetes, heart Added sugars can be displaced partially or entirely by sugar attack and stroke and yields the following effects: alcohols in certain applications. Sugar alcohols are commonly • Visceral fat used to reduce sugar, calories and glycemic index in specialty • Elevated cholesterol processed foods. Polyols can also completely replace sugars in • High triglycerides dentally safe treats and oral care products. As with sugars, differ- • Inflammation ent polyols have unique features: • Insulin resistance • Sweetness • Glucose intolerance High Intensity Sweeteners > fructose > HFCS(55) > Waist measurements of more than 35 inches for women and sucrose = xylitol > maltitol > glucose > erythritol > 40 inches for men indicate probable metabolic syndrome. sorbitol = mannitol > maltose > lactose • Glycemic Index Improving Properties of Sweeteners Glucose > sucrose > maltitol > fructose > sorbitol = Different carbohydrates have different properties: different xylitol > erythritol

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proﬁle in oral health hygiene & prevention

by Dr. John Peldyak

• 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 con- sumer. 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. continued on page 112

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If these added sugars and acids are confined to mealtimes, extending the extracellular polysaccharide matrix but helping to then a non-acidogenic saliva stimulant used at the end of the disrupt bacterial and fungal cohesion and adhesion. meal can help protect teeth. Among suggestions are fibrous veg- Xylitol is practically non-fermentable by oral bacteria. It etables, nuts or aged cheese. The most practical and promising even has specific inhibitory effects against S. mutans and P. gin- strategy along these lines is to finish a meal or snack with a givalis, important caries and periodontal pathogens. (In con- candy or chewing gum sweetened with xylitol. trast, sorbitol and mannitol can be utilized by S. mutans as an energy source, but acid production is slight.) Over time, consis- Why Xylitol? tent xylitol use makes dental plaque less adhesive, less acidic, less Any polyol used after sugars in meals or snacks would be inflammatory and less harmful. In several long-term field trials helpful. But over the past 40 years, xylitol has been demon- xylitol use dramatically reduced the incidence of tooth decay. strated to have the greatest dental benefits. Xylitol promotes and supports natural protective factors. Xylitol is a versatile sweetener that can be used in many Through similar mechanisms, xylitol can also prevent upper res- applications to completely or partially replace sucrose. Because piratory infections. xylitol is found in most plants and fruits, it has always been a It is effective and convenient to add xylitol to any oral part of the human diet. Whereas most of our dietary sugars are hygiene program. Xylitol use is compatible with and comple- based on 6-carbon units, xylitol has a structure of 5-carbon mentary to other oral hygiene strategies including brushing, atoms. In metabolism, these 5-carbon sugars are critical compo- flossing and antimicrobials. Xylitol and fluoride might have an nents of energy (ATP) and nucleic acid molecules (RNA, additive protective effect. DNA). Our bodies generate about a tablespoon of xylitol every An early trial in Finland took all the added sugars out of the day as a metabolic intermediate helping to link up 5- and 6-car- diet and replaced them with xylitol. The result was the (almost) bon pathways. elimination of new cavities without any metabolic harm (gas- Because xylitol has a delightful sugary taste, but is low- trointestinal tolerance developed rapidly). But this strategy glycemic and low-calorie, it found early use as a premium natu- would be very expensive and impractical. ral sweetener in the diabetic diet, and as a supplemental energy Thankfully it was found that only tiny amounts of xylitol – source in intravenous nutrition for patients with impaired about a rounded teaspoon each day – are needed for dental glucose tolerance. health if used after eating. The number of exposures to xylitol is More recently xylitol has gained attention as an anti-biofilm critically important. Three uses are effective, but strive for five agent. Xylitol has no reactive double-bond carbonyl group so it xylitol uses each day. This is easy with so many xylitol products does not link with other sugars or amino acids, thereby not available now. Simple advice would be to brush morning and

Sugar Polyol

Monosaccharides Glucose (dextrose, blood sugar) Sorbitol (6-carbon atoms) Fructose (fruit sugar) Mannitol (6-carbon) Galactose Galactitol (6-carbon) Xylose (wood sugar) Xylitol (5-carbon) Erythrose Erythritol (4-carbon)

Disaccharides Maltose (glucose-glucose, malt sugar) Maltitol (glucose-sorbitol) Sucrose (glucose-fructose, table sugar, beet sugar, cane sugar) Isomalt (glucose-mannitol/sorbitol) Lactose (glucose-galactose, milk sugar) Lactitol (glucose-galactitol) Polysaccharides (linked glucose)

Maltodextrin (oligosaccharide) HSH (hydrogenated starch hydrolysate) Starch (amylose, amylopectin)

Mixture mono-, di-, higher saccharides Starch hydrolysate (corn syrup solids)

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proﬁle in oral health hygiene & prevention

night with xylitol/fluoride toothpaste. After brushing is a good Take Away time to use xylitol/saline nasal spray for the upper airway. Use There are no sweeteners that are perfect for all situations. We xylitol chewing gum or candy after meals to maintain a healthy need to be cautious about the harmful metabolic effects of too oral environment. much added sugar. Try to restrict most sugars to mealtimes to A striking benefit of xylitol is the long-term protection avoid dental harm. acquired by teeth that erupt during xylitol use. These teeth are Important practical steps are to drastically reduce soda and particularly well-mineralized and resistant to decay. Xylitol heavily sweetened beverages, especially between meals. Plain forms weak complexes with calcium in solution and acts as a car- water is great for hydration. Coffee and tea can be lightly sweet- rier to get minerals deeper into the tooth structure. ened with intense sweeteners, but erythritol or xylitol could pro- Xylitol is effective for breaking the cycle of transmission of vide extra dental protection. cariogenic microflora. The concept is for mothers to use xylitol Some added sugars can be replaced by polyols and resist- (such as chewing gum) during pregnancy and after delivery to ant starches (fiber) although such reformulation of familiar decrease S. mutans. Their babies tend to not acquire the cario- items might need intense sweeteners to approach expected fla- genic organisms and maintain a low caries rate throughout the vor. The goals are to reduce glycemic index and calories at an service of their primary dentition. In complementary studies, acceptable cost. xylitol syrup applied directly to the primary teeth resulted in For dental benefits, use a non-acidogenic saliva stimulant at similar decay reduction. the end of meals and snacks. Xylitol can be combined effectively It seems reasonable to advise mothers (and all close-contact with other sugar alcohols in suitable products that encourage caregivers) to use xylitol, and for the babies to have xylitol sucking or chewing. However, items that are fully sweetened applied to their teeth. This combination could block MS colo- with xylitol appear to provide the best results. n nization and lead to long-term dental health. In mature adults, xylitol has been shown to remineralize enamel defects, reduce gingival inflammation and prevent References root surface caries. Xylitol might be useful in difficult situa- 1. Wang YM, van Eys J. “Nutritional Significance of Fructose and Sugar Alcohols.” Annual Review of Nutrition vol.1, 437-475, July 1981. tions such as nursing homes because many of the products are 2. Gardener H, Rundek T. “Diet Soda increases vascular events.” International Stroke Conference Los easy to apply. Angeles, Feb 9 2011. 3. Gehring F. “Cariogenic Bacteria.” In Xylitol, Councell JN, ed. Applied Science 1978. Metabolically, xylitol is slowly and only partially absorbed. 4. Dhingra R, Sullivan L, et al. “Soft drink consumption and risk of developing cardiometabolic risk factors Most xylitol is processed by the liver and can be converted to and the metabolic syndrome in middle-aged adults in the community.” Circulation 116 (5) 480-488, July 2007. glucose and glucose polymer (glycogen). The impact on blood 5. Stanhope KL, Schwarz JM, et al. “Consuming fructose-sweetened, not glucose-sweetened, beverages sugar and insulin is about 90 percent less than ingested glucose. increases visceral adiposity and lipids and decreases insulin sensitivity in overweight/obese humans.” J Clin Invest 119(5):1322-1334, May 2009. Xylitol does not glycate like fructose or contribute to formation 6. Livesey G. “Glycaemic Responses and Toleration” in Sweeteners and Sugar Alternatives in Food Technology of advanced glycation end products (AGEs). 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, Some xylitol reaches the lower gut where fermentation can ed. 134-151,CRC Press 2009. occur and exert a probiotic effect. One breakdown product is 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 butyrate, which is utilized for energy by cells in the colon wall. Res, 74, 1904-1913, 1995. Butyrate is associated with healthy gut function and might have 10. Bond M, Dunning N. “Xylitol” in Sweeteners and Sugar Alternatives in Food Technology Mitchell H, ed. 295-320, Blackwell 2006. anti-cancer properties. Too much xylitol, taken rapidly espe- 11. Han SJ Jeong, SY, et al. “Xylitol inhibits inflammatory cytokine expression induced by lipopolysaccharide cially with liquids on an empty stomach can result in flatulence from Porphyromanas gingivalis.” Clinical and Diagnostic Laboratory Immunology, 12 (11) pp 1285- 1291, 2005. 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 constipa- tion without any untoward side effects. Author’s Bio Most other polyols will cause even more potential intestinal John Peldyak is a general dentist in Michigan. He received his DMD distress. An exception is erythritol (4-carbon), which is mostly degree from Southern Illinois University in 1980 and was a member eliminated in the urine and not metabolized at all. of professor Kauko Mäkinen’s University of Michigan xylitol research Mixtures of xylitol with other sweeteners, sugars and group on sugar substitutes from 1986-1992. Dr. Peldyak is also a starches might be useful in cooking to reduce overall glycemic founding member of the American Academy of Oral Systemic Health. load, reduce calories and reduce, but not eliminate dental acids.

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