Xylitol, Sweeteners, and Dental Caries

Kiet A. Ly, MD, MPH1 Peter Milgrom, DDS2 Marilynn Rothen, BS, RDH3

Abstract
The purpose of this report was to provide an overview of xylitol and other polyol sweeteners
and dental caries for clinicians and to discuss current applications for dental practice and
potential community-based public health interventions. Xylitol, like other polyol sweet-
eners, is a naturally occurring sugar alcohol. Studies suggest polyols are noncariogenic.
Furthermore, studies indicate that xylitol can decrease mutans streptococci levels in plaque
and saliva and can reduce dental caries in young children, mothers, and in children via
their mothers. Food products containing xylitol are now available and have the potential
to be widely accessible to consumers to help control rampant decay. Determining whether
products contain adequate xylitol amounts for practical use towards prevention is chal-
lenging, however, because xylitol content is not clearly labeled. Sufcient evidence exists to
support the use of xylitol to reduce caries. Clinicians and dental associations should push
for clear recommendations of efcacious dose and frequency of xylitol use and for clear
labeling of xylitol content in products to help consumers choose appropriately. (Pediatr
Dent 2006;28:154-163)
KEYWORDS: PREVENTIVE DENTISTRY, DENTAL CARIES, XYLITOL, SWEETENING AGENTS

X
ylitol is a sugar substitute with sweetness equal to Xylitol has been approved by the FDA since the 1960s
that of table sugar (sucrose), but with 40% fewer and is safe for use with children.7 Similar to many other
calories.1 It is a member of the sugar alcohol or polyols, it is most commonly used as a sweetener in foods
polyol family, which includes other common dietary in the United States. There has been, however, a recent
sweeteners such as sorbitol, mannitol, and maltitol. Xyli- explosion of xylitol use in the food, pharmaceuticals, and
tol is produced commercially from birch trees and other nutraceuticals industries. Polyols are absorbed slowly by
hardwoods containing xylan. More recently, to reduce the human gastrointestinal tract. The main side effect
production cost, commercial xylitol is being produced from associated with most polyol consumption is osmotic diar-
corn cobs2,3 and the waste of sugarcane or other bers4-6 us- rheawhich, for xylitol, only occurs when it is consumed
ing biotechnology. Xylitol can be found in small quantities in large quantities, 4 to 5 times that needed for the pre-
in fruits and vegetables and is produced as part of human vention of dental caries.7,8 Tables 2 and 3 provide lists of
metabolic processes. commercially available products containing xylitol as well
Sorbitol, mannitol, and maltitol are also naturally occur- as information on their xylitol content. Note that these lists
ring substances found in many trees, plants, and fruits and are not exhaustive. Many products were not included, as an
are produced commercially. They are less sweet than xylitol overwhelming majority use xylitol along with other polyols
but are widely used in sugar-free products such as chewing as sweeteners and often do not contain sufcient xylitol to
gums, candies, and toothpastes because they are cheaper. prevent dental caries. Furthermore, most products do not
Polyol sweeteners are frequently combined together with specically state the xylitol content in the packaging, mak-
small amounts of high intensity articial sweeteners such as ing it impossible for consumers to make informed decisions
saccharin or aspartame to improve the avor and sweetness about which product to purchase and consume for dental
of products. The US Food and Drug Administration (FDA) caries prevention.
allows sugar-free labeling of products sweetened only with
sugar alcohols, articial sweeteners, or a combination of Sugar alcohols and tooth decay
these sweeteners (Table 1). Sugar alcohols have been shown to be noncariogenic. Con-
sumption does not promote tooth decay.9 Furthermore,
1
Dr. Ly is assistant professor and 2Dr. Milgrom is professor in the De- xylitol has been shown to have a protective effect and to
partment of Dental Public Health Sciences, the Northwest/Alaska Cen- reduce tooth decay in part by reducing the levels of Strep-
ter to Reduce Oral Health Disparities, and 3Ms. Rothen is the clinical tococcus mutans in plaque and saliva and by reducing the
manager of the Regional Clinical Dental Research Center, University
of Washington, Seattle, Wash. level of lactic acid produced by these bacteria.
Correspond with Dr. Milgrom at dfrc@[Link].

154 Ly et al. Xylitol, Sweeteners, and Dental Caries Pediatric Dentistry 28:2 2006
Table 1. Properties of Natural Sugars and Sugar Substitutes
Nutritive value Sugar-free label
(calories/g) Cariogenic (noncariogenic) Sweetness*
Natural sugars
Sucrose 4 Yes No 1.0
Glucose 4 Yes No .7
Fructose 4 Yes No 1.5
Lactose 4 Yes No .2
Sugar substitutes
Sugar alcohols/polyols
Xylitol 2.4 No Yes 1.0
Sorbitol 2.6 No Yes .6
Mannitol 1.6 No Yes .5
Maltitol 2.1 No Yes .9
Artificial sweeteners
Aspartame (NutriSweet, Equal) 0.0 No Yes 180
Saccharin (Sweet N Low) 0.0 No Yes 300
Sucralose (SPLENDA) 0.0 No Yes 600
Acesulfame potassium (Sunett) 0.0 No Yes 200
*Sucrose (table sugar) is the standard for sweetness comparison and is given the sweetness value of 1.
Aspartame is technically a nutritive sweetener. Because of its intense sweetness, however, it is used in such small amounts that its nutritive
value is negligible.

Table 4 contains an overview of selected clinical studies litol use is associated with greater reduction in caries and
in which xylitol chewing gum was included in the study suggested that a frequency of less than 3 times per day may
design and where the results showed either a reduction in not be effective.11,12
S mutans levels in plaque or saliva or a reduction in tooth
decay. In some of these studies, xylitol and sorbitol were Xylitol and mutans streptococci
included, independently or in combinations. Overall re- Microorganisms do not readily metabolize xylitol into en-
sults showed that participants in groups consuming 100% ergy sources, and its consumption has a minimal effect on
xylitol had greater reductions in caries or S mutans levels plaque pH.13 Xylitol, however, is absorbed and accumulates
than participants in groups that consumed a combination intracellularly in S mutans. Xylitol competes with sucrose for
of xylitol and sorbitol. In turn, the participants in this latter its cell-wall transporter and its intracellular metabolic pro-
group experienced greater reductions in tooth decay than cesses. Unlike the metabolism of sucrose, which produces
those in groups that consumed sorbitol alone. energy and promotes bacterial growth, S mutans expends
This suggests that, although polyol sweeteners used in energy to break down the accumulated xylitol without yield-
combination can reduce caries, the amount of xylitol in the ing energy in return. Furthermore, the energy-producing
combination determines the degree of reduction observed. intermediates are consumed and not reproduced by xylitol
The presence of other polyol sweeteners may enhance, but metabolism.14 This has been demonstrated in vitro and
does not reduce, xylitols effectiveness. Furthermore, the may contribute to a reduction of S mutans levels in plaque
consumption of greater amounts of xylitol per day has been and saliva and a reduction in acid production among those
associated with a larger reduction in tooth decay. Xylitol consuming xylitol.15
consumption of less than 5 g per day, however, has often In addition, xylitol has a number of other effects on
been found to be no more effective than consumption of S mutans that may account for some of its clinical effects
sorbitol alone (Table 4). in caries reduction. Short-term consumption of xylitol is
There also appears to be a ceiling effect for xylitol. In associated with decreased S mutans levels in both saliva
an intensive xylitol chewing gum treatment study where and plaque.15 Long-term habitual consumption of xylitol
a maximum of 14 g per day of xylitol was consumed, the appears to have a selective effect on S mutans strains. This
study reported a reduction in DMFS score. This reduc- results in selection for populations that are less virulent
tion, however, was not signicantly different from that of and less capable of adhering to tooth surfaces and, thus, are
the group that consumed 10 g per day.10 Two retrospective shed more easily from plaque into saliva.16 This effect may
studies have reported that increasing the frequency of xy- not only be important to the individuals decay experience,

Pediatric Dentistry 28:2 2006 Xylitol, Sweeteners, and Dental Caries Ly et al. 155
Table 2. Xylitol-containing Gums and Mints Available in US Markets,
Their Xylitol Content, Preventive Potential, and Approximate Cost*
Xylitol per piece (g) Pieces for Preventive Approximate
Products [total polyols (g)] 6 (10) g/d Potential Cost/10 pieces
Gums
Epicxylitol gum (various flavors) 1.05 6 (10) Yes $0.70$1.00 online
Clen-Dent/Xponent gum (various flavors) 0.67 10 (15) Yes $1.60$1.70 retail
Fennobon Oy XyliMax Gum 0.86 7 (12) Yes $0.80$1.00 online
Hershey Carefree Koolerz Gum
1.50 4 (7) Yes $0.95$1.50 retail
(various flavors)
Lottexylitol gum (various flavors) 0.65 9 (15) Yes $0.70$0.80 online
Omnii Theragum 0.70 9 (14) Yes $1.25$1.50 online
Spry Xylitol gum (various flavors) 0.72 8 (14) Yes $0.70$0.90 online
Tundra Trading XyliChew Gum 0.80 8 (13) Yes $1.50$1.65 retail
Vitamin Research Unique Sweet Gum 0.72 9 (14) Yes $1.00 online
WellDent Xylitol Gum 0.70 9 (14) Yes $0.90$1.00 online
Altoids Sugar-Free Chewing Gum First of 3 polyols (1.0) NC Maybe $0.90$1.00 retail
B-FRESH Gums (various flavors) First of 2 polyols (1.0) NC Maybe $0.70 online
Starbucks After Coffee Gum Peppermint First of 2 polyols (1.0) NC Maybe $1.00 retail
Arm & Hammer Dental Care
Second of 3 polyols (1.0) NC No $0.80$1.00 retail
Baking Soda Gum
Arm & Hammer Advance White
Second of 3 polyols (1.0) NC No $1.00$1.30 retail
Icy Mint Gum
Biotene Dental Gum and Dry Mouth Gum Second of 2 polyols (1.0) NC No $1.00$1.40 retail
Eco-Dent Between Dental Gum
0.35 17 (29) No $1.05$1.40 online
(various flavors)
Warner-Lambert Trident Gum with Xylitol Second of 3 polyols (1.0) NC No $0.60$0.70 retail
Warner-Lambert Trident for Kids Gum Third of 3 polyols (1.0) NC No $1.20$1.40 retail
Wrigley Orbit Sugar-Free Gum Third of 3 polyols (1.0) NC No $0.45 REI online
Ford Gum Xtreme Xylitol Gums NC NC NC $0.65$0.85 online
Wrigley Everest Mint Gum NC NC NC $0.45 REI online
Mints
Clen-Dent/Xponent Mints 0.67 9 (15) Yes $0.62$0.70 online
Epic Xylitol Mints 0.50 0.50 12 (20) Maybe $0.35$0.50 online
Omnii Theramints 0.50 12 (20) Maybe $0.45 online
Spry Mints 0.50 12 (20) Maybe $0.38$0.49 online
Tundra Trading XyliChew Mints 0.55 11 (18) Maybe $0.35$0.50 retail
VitaDent Mints/Unique Sweet Mints 0.50 12 (20) Maybe $0.62$0.65 online
WellDent Xylitol Mints 0.55 11 (18) Maybe $0.38 online
Smint Mints <0.20 30 (50) No $0.35$0.40 retail
Brown & Haley Zingos Caffeinated
Second of 2 polyols NC No $0.40$0.50 retail
Peppermints
Oxyfresh Breath Mints Second of 2 polyols NC No $0.35$0.40 online
Starbucks After Coffee Mints Second of 2 polyols NC No $0.20 Starbucks
Tic Tac Silvers NC NC No $0.35$0.40 online
Xleardent Mints NC NC No $0.20 Starbucks
*Cost varies based on retail, convenience stores, and Internet vendors. Stated cost based on a few Seattle retailers or Internet vendors.
Product list is not exhaustive. Xylitol market is rapidly changing and new xylitol containing products appear frequently.
Yes, no, or maybe are based on the potential a person is willing to consume 2 to 3 pieces, 3 to 5 times per day to meet the effective
dose range of 6 to 10 g per day. Products with a potential for effectiveness, but for which xylitol dose is either unknown or required con-
sumption, is >10 pieces/day to provide 6 g of xylitol are assigned maybe.
N/C=not certain. Information cannot be derived from Internet vendor or market packaging, or authors unsuccessful in obtaining infor-
mation from vendors information representatives.

156 Ly et al. Xylitol, Sweeteners, and Dental Caries Pediatric Dentistry 28:2 2006
Table 3. Xylitol-containing Diet, Oral Hygiene, and Health Care Products
Available in US Markets and Their Xylitol Content
Products* Xylitol content Cost/unit Availability
Energy bars and food
Buddha Bars 4-5 g/bar $3.00/bar Online
E EnterprisesE Bar 14 g/bar $2.00/bar Online
Fran Gares Decadent Desserts Mix 15-25 g/30 g serving $7.00/canister Online
(various types)
Jay Robb Enterprise Jaybar 13 g/bar $3.00/bar Online
Kraft Jell-O Pudding Sugar Free Chocolate 7 g/serving $0.65/serving unit Retail
Natures HollowSugar Free Jam (various flavors) 4.5 g/20 g serving $6.00/10 oz Online
Natures HollowSugar Free Syrup 2.5 g/40 ml serving (7%) $5.40/8.5 oz Online
(various flavors)
Natures HollowSugar Free Ketchup .8 g/20 g serving (4%) $5.50/10 oz Online
Natures HollowSugar Free Honey 1.2 g/20 g serving (8%) $5.50/10 oz Online
Biochem Ultimate LoCarb 2 bars Second of 2 polyols $2.00/bar Retail and online
Richardson Labs Carb Solutions Third of 3 polyols (13 g) $1.50/bar Retail and online
Creamy Chocolate
Oral hygiene
Biotene Dry Mouth Toothpaste (Calcium) 10% $6.00-$7.00/4.5oz Retail and online
Crest Multicare Cool Mint Toothpaste 10% $3.50-$4.50/8 oz Retail and online
Epic Toothpaste (fluoride free) 25% (no fluoride) $4.50-$5.00/4.9 oz Online
Epic Toothpaste with fluoride 35% $7.00-$8.00/4.9 oz Online
Squigle Enamel Saver Toothpaste 36% (.24% sodium fluoride) $7.25-$8.00/4 oz Online
Topex Toothpaste Take Home Care, 10% (1.1% sodium fluoride) $4.50-$5.50/2 oz Dental office and
White Care online
Rembrandt Toothpaste For Canker Sore Only sweetener $6.50-$7.50/3 oz Retail and online
(fourth ingredient)
Spry Toothpaste MaxXylitol and Aloe N/C only polyol (no fluoride) $4.50-$5.00/4 oz Online

Toms of Maine Baking Soda Toothpaste line N/C (varies in ingredient list) $3.50-$4.50/6 oz Retail and online

Toms of Maine Natural Toothpaste line N/C (varies in ingredient list) $3.50-$4.50/6 oz Retail and online
Toms of Maine Sensitive Toothpaste line N/C (varies in ingredient list) $3.50-$4.50/6 oz Retail and online
XyliWhite Toothpaste (fluoride free) 25% (no fluoride) $3.50/6.4 oz Online
Biotene First Teeth Infant Toothpaste First of 2 polyols $5.00-$6.00/1.4 oz Retail and online
Gerber Tooth and Gum Cleanser Second of 2 polyols $5.00-$5.50/1.4 oz Retail and online
(sixth ingredient)
Spry Infant Tooth Gel N/C only polyol (no fluoride) $4.50-$5.50/2 oz Online
Biotene Oral Balance Dry mouth gel Second of 2 polyols $5.00-$6.00/1.5 oz Retail and online
Biotene Mouthwash First of 2 polyols $6.00-$7.00/16 oz Retail and online
Epic Oral Rinse 25% $7.50-$8.50/16 oz Online
Oxyfresh Mouthrinse Only sugar (second ingredient) $9.00-$10.00/16 oz Online
Rembrandt Dazzling Breathdrops Only sugar (second ingredient) $1.00-$1.50/.22 oz Retail and online
Spry Oral Rinse First of 2 polyols (no fluoride) $5.00-$5.50/16 oz Online
Toms of Maine Natural Mouthwash line N/C (varies in ingredient list) $4.00-$6.00/16 oz Retail and online

Pediatric Dentistry 28:2 2006 Xylitol, Sweeteners, and Dental Caries Ly et al. 157
Table 3 continued
Health care Xylitol content Cost/unit Availability
Bayer Flintstone VitaminsComplete N/C $15.00-$17.00/150 Retail and online
tablets
Bayer One a Day Kids VitaminsComplete N/C $5.00-$8.50/50 tablets Retail and online
Sundown Spiderman Complete Vitamins N/C $7.00-$8.00/60 tablets Retail and online
Micro Spray Vitamin Sprays N/C (2nd ingredient) $13.00-$20.00/9 ml Online
B&T Echina Spray N/C $6.00-$10.00/0.68 oz Online
Dr. Rays Products Spiffies Dental Wipes N/C (2nd ingredient) $5.50-$9.00/48 wipes Online
Nicorette GumMint N/C (last ingredient) $27.00-$33.00/40 Retail and online
pieces
Xlear Nasal Wash N/C (2nd ingredient) $13.00-$14.00/1.5 oz Retail and online
Xylifloss Pocket Dental Flosser N/C $4.00/250 uses Retail and online
*Product list is not exhaustive. Xylitol market is rapidly changing, and new xylitol-containing products appear frequently. Aside from
toothpaste, most products have not been studied or published in peer-reviewed journals; thus, the potential impact on caries reduction is
not known.
Cost varies based on retail and convenient stores. Stated cost based on a few Seattle area retailers.
N/C=not certain. Information cannot be derived from market packaging and authors unsuccessful in obtaining information from com-
pany information representative.
but may also inuence the transmission of S mutans from to be effective with chewing gum as the delivery system.
mothers who consume xylitol to their children. Future studies in this series will evaluate the effectiveness
of other xylitol-containing snack food to xylitol chewing
Xylitol dose and frequency for effectiveness gum in both adults and children.
Dosing and frequency guidelines for xylitol have not been
fully developed. This is because there have been no prospec- Clinical applications
tive studies designed to determine the minimum effective The use of polyols as sweeteners in foods and beverages to
amount and frequency of xylitol use and to specically not promote tooth decay is widespread. Sorbitol, mannitol,
determine the dose-response and frequency-response rela- and/or maltitol are most frequently used. Nevertheless,
tionship of xylitol and S mutans or dental caries. evidence supporting the role of xylitol in reducing MS in
Researchers at the University of Washington, Seattle, plaque and saliva and in reducing the incidence of tooth
Wash, conducted a series of studies with adults chewing decay is inuencing the market; xylitol is appearing in
xylitol gum to clarify the relationship of dose and frequency consumer products rapidly, sometimes purely as a sweetener
of use of xylitol to the reductions of mutans streptococci while at other times it is included to provide therapeutic
(MS) levels in plaque and saliva. In the initial study, par- levels. These xylitol-containing products, when used at
ticipants were randomly assigned to 1 of 4 groups and efcacious levels by consumers and particularly if used in
chewed 12 pellets of xylitol and/or control (sorbitol) gums well-planned dental public health programs for children at
evenly divided into four doses per day and giving varying high caries risk, may help signicantly reduce tooth decay
amounts of xylitol per group. The study concluded that MS beyond the results from currently applied strategies.
levels were reduced with increasing doses of xylitol, with
the effect leveling off between 6.88 g per day and 10.32 g Children at high risk for caries
per day. Although the smallest dose in the study, 3.44 g per There are few well-studied strategies available to clinicians
day, showed a reduction, the difference was not statistically to prevent and control the high rates of caries in the primary
signicant.17 dentition.18 In the absence of water uoridation, uoridated
In a second study, participants consumed 10.32 g per day toothpaste and topical uorides are the primary preventive
of xylitol divided into 2, 3, or 4 administrations per day. tools for clinicians. For children in mixed dentition, seal-
The results demonstrated a linear response where increasing ants are added to the regimen. Effective strategies to reduce
frequency of use is associated with decreasing levels of MS risk by modifying childrens diets are not readily applicable
in plaque and saliva. Although a reduction was observed to dental practice, nor are they typically effective without
with xylitol use of 2 times per day and the reduction was signicant effort. As such, the use of xylitol is particularly
consistent with the linear line model, however, the differ- attractive because its action is not dependent upon reducing
ence was not statistically signicant when compared to the the amount of other sugars in the diet. Thus, a clinician can
sorbitol control (unpublished data). Thus, xylitol consumed recommend adding xylitol to the diet without asking patients
twice a day was not effective in reducing MS. to make additional alterations to their dietary patterns. Xyli-
These results conrm previous suggestions regarding tol-containing products have the potential to improve success
dose and frequency. A range of 6 to10 g divided into at in controlling rampant decay in the primary dentition.
least 3 consumption periods per day is necessary for xylitol

158 Ly et al. Xylitol, Sweeteners, and Dental Caries Pediatric Dentistry 28:2 2006
A number of studies conducted among schoolchildren public school children 7 to 12 years old who used uoride
of various ages have shown that consumption of gum con- toothpaste with or without 10% xylitol. The DFS and
taining xylitol reduces the extent of dental caries (Table 4). DFT increments for the 10% xylitol group were 1.30 and
One study conducted among schoolchildren in Belize with .69, respectively, compared to uoride-only group scores
very high rates of tooth decay showed that consumption of 1.51 and .81.25 A study conducted in Sweden among
of xylitol gum was associated with arrest of carious lesions. 155 students (average age=25 years) with high MS levels
The number of lesions that rehardened ranged from 9% to compared 3 fluoride toothpaste formulations, Colgate
27% in all groups.19 This study is important because the Total with or without triclosan (control) or with triclosan
children continued to consume very high levels of sucrose plus 10% xylitol (Colgate Oral Pharmaceuticals, Canton,
in their everyday diet. A recent study of 3- to 6-year-olds Mass). After 6 months of twice daily brushing, only the
compared xylitol chewing gum and tooth-brushing using a 10% xylitol toothpaste group demonstrated a signicant
uoridated toothpaste (.05% NaF). The children brushed reduction of MS in plaque (9-fold reduction) and saliva
once after lunch or chewed xylitol gum 3 times each day (8-fold reduction).26 Fluoride toothpaste with xylitol can be
during daycare hours. All children brushed as they normally recommended as a substitute for regular uoride toothpaste,
would at home. The study found that the xylitol gum group and other xylitol products can be recommended concur-
had better oral health status than the group that brushed.20 rently with uoridate toothpaste, topical uorides, and
Another study in Europe showed that the DMFS increment sealants. Xylitol and uoride can be used simultaneously, as
among groups of fth graders who consumed xylitol chew- they have different mechanisms of action and a potentially
ing gum either for 2 or 3 years were no different than the synergistic effect.
group that received sealants at the end of the 5-year study According to available data, there is no xylitol product
period.21 A major limitation in extending these results to the commercially available in the United States that is suitable
United States, however, is that chewing gum is not consid- for toddlers and preschool children too young to chew gum.
ered safe for very small children and is actively discouraged An ongoing study of adults at the University of Washington
in daycare and schools because of choking risk. is comparing xylitol delivered via gum to xylitol delivered via
Other xylitol-containing products have been studied. A a snack food for young children at the effective doses and fre-
eld trial of the use of xylitol-containing candy among 10- quencies. Syrups have also been developed for evaluation. In
year-old schoolchildren in Estonia showed a 33% to 59% older children, chewing gum, mints, or lozenges with xylitol
tooth decay reduction in the groups using xylitol candy and can be recommended. It should be recognized, however, that
a 54% tooth decay reduction in the group using xylitol gum most products available at local retail stores are not optimizing
relative to the control group.22 This suggests that candy may xylitol for the caries preventive effects and are likely to have
be as effective as chewing gum as a vehicle for the delivery minimal, if any, caries prevention impact.
of xylitol in caries prevention.
At the University of Washington, researchers have pro- Pregnant women and new mothers
duced and eld tested xylitol-containing popsicles, gummy A combination of good dental care, instruction to im-
bears, puddings, macaroons, and sorbet.23 They have shown prove oral hygiene, and chlorhexidine gels and uoridated
that children will readily accept such foods when offered toothpastes leads to reductions in maternal S mutans levels
as part of the daily diet and that they suffer no side effects and reduction in the extent of transmission to the child.27
from their use. Food producers are available to develop Hildebrandt and colleagues showed that the use of commer-
these snacks, but considerable work is needed to produce cially available chlorhexidine rinses for 2 weeksfollowed
commercially viable products that will be accepted. In the by the daily use of xylitol gum (2 pellets containing 1.7g xy-
future, these xylitol snack foods need to be tested with litol) in high-caries-rate adults with recent restorationsled
children to establish their effectiveness at preventing decay to major reductions in S mutans.28 A clinical trial conducted
because certain foods are better than others at delivering in Finland comparing the effects of strategies to modify
and releasing xylitol in the oral cavity. the maternal transmission of S mutans to infants demon-
Xylitol is also found in several toothpaste formulations strated that xylitol had the greatest effect.29 The mothers,
(see Table 3). Several studies have evaluated toothpaste all of whom had high S mutans levels at the beginning of
formulations with 10% xylitol. A study conducted in Costa the study, were treated with either chlorhexidine varnish,
Rica involving 2,630 children between 8 and 10 years old uoride varnish, or 100% xylitol gum chewed at least 2 to
compared sodium uoride toothpaste with and without 3 times per day for 18 to 21 months. The children were
10% xylitol. After 3 years of twice daily brushing, the not treated.
children using the xylitol toothpaste showed a 12% reduc- The children of mothers treated with xylitol had the low-
tion in decayed/lled surfaces (DFS) and 11% reduction est levels of S mutans levels during the intervention period
in decayed/lled buccal and lingual surfaces (DFS-BL) (treatment continued until the child was 2 years old) and
compared to the uoride-only toothpaste.24 In a more re- during followup.30 The percentage of colonization with S
cent study, the same author conducted a 30-month study mutans in the children in the xylitol group at 2 years old
to evaluate long-term tooth decay increment among 3,394 was 10%, compared to 29% in the chlorhexidine group and

Pediatric Dentistry 28:2 2006 Xylitol, Sweeteners, and Dental Caries Ly et al. 159
Table 4. Summary of Selected Clinical Trials that Included the Use of Xylitol Chewing Gum
and that Reported a Reduction in Streptococcus mutans, in Mutans streptococci, or in Caries
Consumption
Study Population frequency Xylitol doses (g/d) Conclusion
24 mos; 3 groups: xylitol, Adults (n=125); 1 piece, 4.5 x/d on 67 Reduction in caries
fructose, and sucrose age=27 ys (avg) avg (range=37) increment rate34
4 wks chewing, then 4 wks Children (n=80) 2 pieces, 5 x/d 5-7 Reduction in
not chewing; 3 groups: xylitol, (pedodontic clinic) unstimulated saliva and
fructose, sorbitol/mannitol plaque S mutans levels35
24 mos; 3 groups: xylitol 15%, Children (n=433); 1 piece, 3 x/d 15%=0.8 Lower DMFS increment of
xylitol 65%, no gum age=8-9 ys School days only 65%=3.4 decay in both active groups36

24 mos; retrospective study Children (n=212); 1 piece, 3 x/d 10.5 (3.5 g/piece) Lower DMFS increment with
categorized original cohort age=11-12 ys frequency of >3 x/d groups11
into 3 chewing frequencies
32 mos; 2 groups, xylitol, Children (n=468); Combination of 20 (combine Lower DMFS increment than
no xylitol snack foods age=6-12 xylitol snack foods maximum) no xylitol controls37
daily
24 mos; 2 groups: xylitol Children (n=212); 1 piece, 3 x/d 10.5 (3.5 g/piece) Lower DMFS increment
gum vs no gum Age=11-12 ys vs controls38

12 mos: retrospective study Young adults 1 piece, 4.5 x/d on 67 Greater reduction in caries
categorized original cohort (n=100); average (range=37) incidence with increased
into chewing frequencies age=22 ys (avg) frequency of use12
25 days chewing crossover; Adult (n=20); 1 piece, 12 x/d 13.4, 6.7, 3.36 Higher xylitol level associated
4 groups r: 3 xylitol groups, age=25.5 ys (avg) with lower S mutans levels in
1 sorbitol plaque and saliva; xylitol
3.36 g same as controls39
24 mos; 6 groups: 3 xylitol, Children (n=510); 1 stick or 2 pellets, x/s*=7.11, Reduction in caries rate
2 sorbitol, 1 no gum age=6 ys, 10 5 x/school days and x/s=9.68 among groups chewing
schools with 3 no nonschool days Xylitol stick=10.42 gums; 100% XylPellet
gum chewing Xylitol pelet=10.67 most effective40

40 mos; 9 groups: 6 xylitol, Children 3-5 x/school days 7.11x/s Reduction in caries increment
1 sorbitol, 1 sucrose, 1 no (n=1,227); and nonschool day mixed 3 x/d among gum groups except
gum control age=10 ys 9.68x/s sucrose; 100% xylitol pellet
mixed 5 x/d most effective19
6.25xylitol stick Saliva S mutans not increase
3 x/d with age among 100%
10.42xylitol Xylitol Pellet groups as did
stick 5 x/d other groups41
6.40xylitol pellet
3 x/d
10.67xylitol
pellet 5x/d
16 mos; intensive treatment Children (n=109); 7 x/d 14 (max) Reduction in caries onset rate
1 group (high-risk participants) age=13.5 ys(mean) and in DMFS score10

60 mos; 3 groups: 2-year 14 classrooms of 2 pieces, 3 x/d 5 No difference in DMFS

32 mos; 2 groups: xylitol, Children (n=921); 1 pieces, 3 x/d 2.5 g/d No difference in dfm between
brushing 11 daycare centers (Xylifresh) xylitol and brushing20
daycare hours
3 mos; 3 groups: xylitol Children (n=91); 2 pieces, 3 x/d 55%=5.76 g/d Reduction in saliva and
55%, xylitol 100%, no gum age=10-12 ys school days only 100%=11.88g/d plaque S mutans counts in
both treatment groups42
*x/s is a gum that contains both xylitol and sorbitol.

49% in the uoride group. These children were followed up uoride groups, respectively.31 Children of mothers treated
most recently at 6 years old and were found to still have the with xylitol also had the lowest rates of decay. Follow-up at
lowest S mutans levels52% were colonized in the xylitol 5 years of age found that dentinal caries among children in
group compared to 86% and 84% in the chlorhexidine and the xylitol group was reduced by 70%, compared to children

160 Ly et al. Xylitol, Sweeteners, and Dental Caries Pediatric Dentistry 28:2 2006
in the uoride or chlorhexidine groups.29 These studies have indicate that their product is sweetened with 100% xylitol,
been conducted only in settings in which child rearing is who list xylitol as the rst ingredient, or who indicate the
done primarily by the mother and in which mother-to-child number of grams of xylitol per piece facilitate professional
transmission is presumed. No studies have been completed evaluation and consumer knowledge.
in communities where child rearing is shared among greater Due to their size, mints often contain insignificant
numbers of people. amounts of xylitol. Specialized manufacturers aimed at the
Whether used alone or in combination with other an- dental market, however, produce a suite of productsin-
timicrobial therapies such as chlorhexidine, xylitol has an cluding gum, mints, toothpaste, and mouth rinseswith
important role in the prevention of dental decay among therapeutic levels of xylitol. Several toothpaste manufacturer
children born to mothers with high S mutans levels. This representatives have indicated to the authors that selected
is not only because of its effects on S mutans levels and products in their line contain at least a 10% level of xylitol
bacterial properties during the period of consumption, (see Table 3). Not all manufacturers of toothpaste with
but also because its benecial effect on decay reduction xylitol listed in their ingredients were forthcoming with
in these children appears to persist far beyond the period this proprietary information when the authors questioned
of consumption.30 Both chlorhexidine and xylitol may be them. Almost no research has been done on mouth rinses
used safely by pregnant women and nursing mothers.32,33 containing xylitol. There is no scientic evidence available
Currently available data suggest that twice daily use of on which to base any recommendation on the value of xyli-
chlorhexidine gluconate rinse (.12%) for 2 weeks, followed tol-containing towelettes, nasal sprays, or xylitol-sweetened
by 6 to 10 g of xylitol via chewing gum per day chewed for 5 childrens vitamins.
minutes each time, should lead to a major reduction in the Another consideration in recommending daily xylitol
mothers MS levels and tooth decay. This regimen should consumption for patients is cost and adherence. In xylitol
also benet the child. In very high-risk individuals, follow- studies to date, the vehicle (gum, candies, toothpaste) has
up periods of chlorhexidine use may be benecial. been provided to subjects and use has been closely moni-
tored. A daily xylitol chewing gum habit may cost $30 per
Deciphering xylitol product ingredients month depending on the market in which the product is
list for efcacy potential purchased. There is at least one gum aimed at children avail-
Food products containing xylitol, including chewing gums able in most retail stores that contains signicant amounts
and mints, are currently available in retail stores, through of xylitol for dental caries benet (see Table 2). Retail store
specialized manufacturers, and online (Tables 2 and 3). The gums are typically less costly than those produced by spe-
number and types of products have been proliferating at a cialty Internet vendors or products positioned as dental gum
rapid rate. There are now, for example, xylitol-containing providing therapeutic benets. Additionally, xylitol gum
avored towelettes for cleaning infants and toddlers teeth and mints are very popular in Asian countries, and these
and gums. The challenge is for clinicians to recommend products can frequently be found in Asian retail stores in
products that have been shown to be effective and deliver the United States. As the products are not often labeled in
the recommended 6 to 10 g per day. This requires a basic English, however, determining the amount of xylitol they
understanding of sugar substitutes and clear product label- contain may be challenging.
ing. Gums, mints, and other products labeled sugar-free
or does not promote tooth decay may contain 3 or 4 Conclusions
sweeteners including articial intense sweeteners with the The list of snack foods and dietary products containing
total of the sugar alcohols (polyols) listed by percent or xylitol is rapidly expanding. The overwhelming majority
weight in grams. Xylitol may not be the rst sugar alcohol of studies showed the protective effect of xylitol on tooth
listed, though the packaging may highlight its presence decay. In the face of the continuing high rate of caries in
for marketing purposes. The amount of an ingredient in some populations in the presence of current dental caries
a product decreases with the order in which it appears. prevention modalities, xylitol offers a potent tool that can
Furthermore, often the rst several ingredients make up have a signicant impact. The evidence is sufcient for
the bulk of the product. clinicians to consider including xylitol-containing products
Take a hypothetical gum for which the nutritional infor- in their clinical armamentarium for the prevention of tooth
mation indicates that one piece weighs 2 g and lists sugar decay in high-risk populations. Clinicians, consumers, and
alcohols to be 1 g. The ingredients list shows that xylitol is dental pubic health agencies should advocate for:
the second of 3 sugar alcohols listed and is the sixth ingredi- 1. clear labeling of the xylitol content in products to help
ent in the list. Therefore, the exact amount of xylitol in the consumers make well-informed decisions when using
product is unknown, but being the sixth ingredient indicates these products for the prevention of tooth decay; and
that a small proportion of the gum weight is xylitol. Being the 2. clear recommendations of efcacious dose and fre-
second sugar alcohol indicates that xylitol does not make up quency of xylitol use.
the bulk of the sugar in the gum. Consequently, only a small Prospective studies at the University of Washington
proportion, likely between 0.1 to 0.3 g, of the 1 g of sugar conrmed previous observations and retrospective studies
alcohols in the gum is xylitol. Thus, chewing this gum would and provide adequate evidence that:
unlikely yield a caries-preventive benet. Manufacturers who

Pediatric Dentistry 28:2 2006 Xylitol, Sweeteners, and Dental Caries Ly et al. 161
1. the effective daily xylitol dose range is 6 to 10 g; 10. Makinen KK, Hujoel PP, Bennett CA, Isokangas P,
2. the effective frequency of consumption is 3 to 5 times Isotupa K, Pape HR, Jr, et al. A descriptive report
per day; and of the effects of a 16-month xylitol chewing-gum
3. the effectiveness is greater at higher frequency of con- programme subsequent to a 40-month sucrose gum
sumption as well as with a higher dose of xylitol. programme. Caries Res 1998;32:107-112.
There appears to be a ceiling effect, however, where 11. Isokangas P. Xylitol chewing gum in caries prevention.
effectiveness is not enhanced for xylitol dose beyond A longitudinal study on Finnish school children. Proc
10 g per day. Finn Dent Soc 1987;83(suppl 1):1-117.
Xylitols favorable side-effect prole, its benets as a 12. Rekola M. Correlation between caries incidence and
sugar substitute in other areas of health, and its potential frequency of chewing gum sweetened with sucrose or
to be widely acceptable to the general population add to its xylitol. Proc Finn Dent Soc 1989;85:21-24.
utility and applicability. Demand by consumers and dental 13. Edgar WM. Sugar substitutes, chewing gum and dental
professionals for less expensive xylitol-containing products cariesa review. Br Dent J 1998;184:29-32.
should make it more accessible. Development of products 14. Trahan L, Bareil M, Gauthier L, Vadeboncoeur C.
and public health programs for delivering xylitol products Transport and phosphorylation of xylitol by a fructose
routinely to high risk preschool populations should be seri- phosphotransferase system in Streptococcus mutans.
ously debated and implemented. Caries Res 1985;19:53-63.
15. Trahan L. Xylitol: a review of its action on mutans
Acknowledgments streptococci and dental plaqueits clinical signi-
Work cited in this paper was supported in part by grants cance. Int Dent J 1995;45(suppl 1):77-92.
no. 1 P50 DE14254 and no. T32 DE07132 from the 16. Trahan L, Soderling E, Drean MF, Chevrier MC,
National Institute of Dental and Craniofacial Research, Isokangas P. Effect of xylitol consumption on the
National Institutes of Health, Bethesda, Md, and grant no. plaque-saliva distribution of mutans streptococci and
R40MC03622 from the Maternal and Child Health Bureau, the occurrence and long-term survival of xylitol-resis-
Health Resources Services Administration, Rockville, Md. tant strains. J Dent Res 1992;71:1785-1791.
17. Milgrom P, Ly K, Roberts M, Rothen M, Mueller G.
References Mutans streptococci dose response to xylitol chewing
1. Lindley MG, Birch GG, Khan R. Sweetness of sucrose gum. J Dent Res 2006;85:177-181.
and xylitol. Structural considerations. J Sci Food Agric 18. Weinstein P, Harrison R, Benton T. Motivating parents
1976;27:140-144. to prevent caries in their young children: One-year
2. Tada K, Horiuchi J, Kanno T, Kobayashi M. Micro- ndings. J Am Dent Assoc 2004;135:731-738.
bial xylitol production from corn cobs using Candida 19. Makinen KK, Bennett CA, Hujoel PP, Isokangas PJ,
magnoliae. J Biosci Bioeng 2004;98:228-230. Isotupa KP, Pape HR, Jr, et al. Xylitol chewing gums
3. Latif F, Rajoka MI. Production of ethanol and xy- and caries rates: A 40-month cohort study. J Dent Res
litol from corn cobs by yeasts. Bioresour Technol 1995;74:1904-1913.
2001;77:57-63. 20. Kovari H, Pienihakkinen K, Alanen P. Use of xy-
4. Buhner J, Agblevor FA. Effect of detoxication of di- litol chewing gum in daycare centers: A follow-up
lute-acid corn ber hydrolysate on xylitol production. study in Savonlinna, Finland. Acta Odontol Scand
Appl Biochem Biotechnol 2004;119:13-30. 2003;61:367-370.
5. Dominguez JM, Gong CS, Tsao GT. Pretreatment 21. Alanen P, Holsti ML, Pienihakkinen K. Sealants and
of sugar cane bagasse hemicellulose hydrolysate for xylitol chewing gum are equal in caries prevention.
xylitol production by yeast. Appl Biochem Biotechnol Acta Odontol Scand 2000;58:279-284.
1996;57-58:49-56. 22. Alanen P, Isokangas P, Gutmann K. Xylitol candies
6. Santos JC, Pinto IR, Carvalho W, Mancilha IM, Felipe in caries prevention: Results of a eld study in Es-
MG, Silva SS. Sugarcane bagasse as raw material and tonian children. Community Dent Oral Epidemiol
immobilization support for xylitol production. Appl 2000;28:218-224.
Biochem Biotechnol 2005;121-124:673-683. 23. Lam M, Riedy CA, Coldwell SE, Milgrom P, Craig
7. Forster H, Quadbeck R, Gottstein U. Metabolic toler- R. Childrens acceptance of xylitol-based foods. Com-
ance to high doses of oral xylitol in human volunteers munity Dent Oral Epidemiol 2000;28:97-101.
not previously adapted to xylitol. Int J Vitam Nutr Res 24. Sintes JL, Escalante C, Stewart B, McCool JJ, Garcia
1982;22(suppl):67-88. L, Volpe AR, et al. Enhanced anticaries efcacy of a
8. Akerblom HK, Koivukangas T, Puukka R, Mononen 0.243% sodium uoride/10% xylitol/silica dentifrice:
M. The tolerance of increasing amounts of dietary 3-year clinical results. Am J Dent 1995;8:231-235.
xylitol in children. Int J Vitam Nutr Res 1982;22(sup- 25. Sintes JL, Elias-Boneta A, Stewart B, Volpe AR, Lovett
pl):53-66. J. Anticaries efcacy of a sodium monouorophos-
9. Hayes C. The effect of noncariogenic sweeteners on the phate dentifrice containing xylitol in a dicalcium
prevention of dental caries: A review of the evidence. phosphate dihydrate base. A 30-month caries clinical
J Dent Educ 2001;65:1106-1109. study in Costa Rica. Am J Dent 2002;15:215-219.

162 Ly et al. Xylitol, Sweeteners, and Dental Caries Pediatric Dentistry 28:2 2006
26. Jannesson L, Renvert S, Kjellsdotter P, Gaffar A, 35. Loesche WJ, Grossman NS, Earnest R, Corpron R.
Nabi N, Birkhed D. Effect of a triclosan-containing The effect of chewing xylitol gum on the plaque and
toothpaste supplemented with 10% xylitol on mutans saliva levels of Streptococcus mutans. J Am Dent Assoc
streptococci in saliva and dental plaque. A 6-month 1984;108:587-592.
clinical study. Caries Res 2002;36:36-39. 36. Kandelman D, Gagnon G. A 24-month clinical study
27. Kohler B, Bratthall D, Krasse B. Preventive measures in of the incidence and progression of dental caries in
mothers inuence the establishment of the bacterium relation to consumption of chewing gum containing
Streptococcus mutans in their infants. Arch Oral Biol xylitol in school preventive programs. J Dent Res
1983;28:225-231. 1990;69:1771-1775.
28. Hildebrandt GH, Sparks BS. Maintaining mutans 37. Kandelman D, Bar A, Hefti A. Collaborative WHO
streptococci suppression with xylitol chewing gum. J xylitol eld study in French Polynesia. I. Baseline
Am Dent Assoc 2000;131:909-916. prevalence and 32-month caries increment. Caries Res
29. Isokangas P, Soderling E, Pienihakkinen K, Alanen P. 1988;22:55-62.
Occurrence of dental decay in children after maternal 38. Isokangas P, Alanen P, Tiekso J, Makinen KK. Xylitol
consumption of xylitol chewing gum: A follow-up chewing gum in caries prevention: A eld study in
from 0 to 5 years of age. J Dent Res 2000;79:1885- children. J Am Dent Assoc 1988;117:315-320.
1889. 39. Wennerholm K, Arends J, Birkhed D, Ruben J, Emil-
30. Soderling E, Isokangas P, Pienihakkinen K, Tenovuo J, son CG, Dijkman AG. Effect of xylitol and sorbitol in
Alanen P. Inuence of maternal xylitol consumption chewing gums on mutans streptococci, plaque pH, and
on mother-child transmission of mutans streptococci: mineral loss of enamel. Caries Res 1994;28:48-54.
6-year follow-up. Caries Res 2001;35:173-177. 40. Makinen KK, Hujoel PP, Bennett CA, Isotupa KP,
31. Soderling E, Isokangas P, Pienihakkinen K, Tenovuo J. Makinen PL, Allen P. Polyol chewing gums and caries
Inuence of maternal xylitol consumption on acqui- rates in primary dentition: A 24-month cohort study.
sition of mutans streptococci by infants. J Dent Res Caries Res 1996;30:408-417.
2000;79:882-887. 41. Makinen KK, Chen CY, Makinen PL, Bennett CA,
32. Brambilla E, Felloni A, Gagliani M, Malerba A, Gar- Isokangas PJ, Isotupa KP, et al. Properties of whole
cia-Godoy F, Strohmenger L. Caries prevention during saliva and dental plaque in relation to 40-month con-
pregnancy: results of a 30-month study. J Am Dent sumption of chewing gums containing xylitol, sorbitol,
Assoc 1998;129:871-877. or sucrose. Caries Res 1996;30:180-188.
33. Wang YM, van Eys J. Nutritional signicance of fruc- 42. Thaweboon S, Thaweboon B, Soo-Ampon S. The ef-
tose and sugar alcohols. Annu Rev Nutr 1981;1:437- fect of xylitol chewing gum on mutans streptococci in
475. saliva and dental plaque. Southeast Asian J Trop Med
34. Scheinin A, Makinen KK, Ylitalo K. Turku sugar stud- Public Health 2004;35:1024-1027.
ies. V. Final report on the effect of sucrose, fructose,
and xylitol diets on the caries incidence in man. Acta
Odontol Scand 1976;34:179-216.

Pediatric Dentistry 28:2 2006 Xylitol, Sweeteners, and Dental Caries Ly et al. 163