Xylitol (C5H12O5) is found naturally in corn cobs, birch trees and beech trees, and in small quantities in fruits and vegetables. It is also produced as part of human metabolism. It is therefore referred to as a nutritive sweetener and not an artificial sweetener. Chemically it is a pentitol (a type of sugar alcohol or a polyol).
Often used as a sugar substitute, xylitol has similar sweetness as sucrose but fewer calories (approx. 2.4 calories per g, 30-40% less compared to sucrose). Xylitol is listed as food additive 967. It is commonly added to processed food and drinks, confectionery, chewing gums, toothpastes and mouthrinses to enhance sweetness and flavours. Xylitol is superior to some other sugar substitutes as it does not have any unpleasant aftertaste.
Xylitol is better for oral health than sugar
Xylitol promotes oral health because it is not fermentable. As a sugar substitute, xylitol tastes like sugar but does not metabolise like sugar, therefore it does not increase the risk of tooth decay.
How does xylitol work to prevent tooth decay?
Xylitol works in the following ways to prevent tooth decay:
- Xylitol e.g. in chewing gum, increases saliva production, thereby improving oral cleansing of the mouth and rises oral pH, so that the oral environment is less acidic (therefore less welcoming for decay-causing bacteria) (Twetman & Stecksen-Blicks, 2003; van Loveren, 2004).
- Xylitol is not broken down by bacteria in the mouth to produce decay-causing acids.
- Xylitol reduces the formation of sticky extracellular polysaccharides by decay-causing bacteria, thereby helping to reduce the stickiness of dental plaque (Chi et al., 2016; Kayalvizhi et al., 2018).
- Long term regular use of xylitol is useful for rebalancing the oral microbiome so the mix of bacteria in the mouth are health promoting rather than health debilitating (Zhan, 2018).
- As decay-causing bacteria cannot use xylitol for their activities, long term use of xylitol may decrease the quantity and harmfulness (virulence) of decay-causing bacteria such as mutans streptococci, in the mouth.
However, xylitol’s ability to reduce dental decay rates and improve calcium uptake to reverse enamel demineralization that occur at the initial stages of tooth decay, are controversial (Antonio et al., 2011; Riley et al., 2015; Chi et al., 2016; Shen et al., 2017).
What are some ways to use xylitol to optimise oral health?
Xylitol needs to be used for a prolonged period of time to provide benefits for oral health. The minimum effective dose of 4-8g per day (5g is most often quoted) is needed to result in tooth decay protection in children (Makinen et al., 2005; Alanzi et al., 2016; Marghalani et al., 2017).
For the whole family
Cooking and baking with xylitol may seem the simplest way of replacing sugar in the diet without giving up on sweet tastes. However, xylitol is much more expensive than “normal” sugar, so this may not be practical or cost-effective for all families.
For infants and young children
For infants and young children’s oral health, xylitol use e.g. chewing gum, lozenges, (in the range of (1.9g to 5.3g) among mothers and mothers-to-be have been effective for reducing or delaying decay-causing bacteria in their babies’ mouths (Nakai et al., 2010; Milgrom et al., 2012; Yates & Duane, 2015; Lin et al., 2016). Xylitol works by reducing maternal decay-causing bacteria e.g. mutans streptococci levels, thereby decreasing babies’ exposure to decay-causing bacteria resulting in less quantity of and/or delay in decay-causing bacteria being transferred (Isokangas et al., 2000; Milgrom et al., 2012; Yates & Duane, 2015).
Wiping teeth / mouth with xylitol impregnated wipes e.g. Spiffies (0.7g of xylitol per wipe) several times per day has been shown to help reduce the quantity or harmfulness of decay-causing bacteria in infants’ mouths (Zhan et al., 2012a; Zhan et al., 2012b; Kayalvizhi et al., 2018). Xylitol containing teeth wipes vary greatly in the quantity of xylitol per wipe, so it is important to find out.
For older children and adults
Xylitol containing chewing gums, lozenges and confectionery, used several times per day, have shown varying results in reducing the quantity of decay-causing bacteria, and/or new decay formation (Makinen et al., 2008; Campus et al., 2009; Antonio et al., 2011; Lenkkeri et al., 2012; Bader et al., 2013; Alanzi et al., 2016).
A recent Cochrane systematic review concluded that xylitol containing fluoride toothpaste may be effective in reducing dental decay in the permanent teeth of children, but not xylitol containing candies, lozenges, wipes or chewing gums (Riley et al., 2015). The review did not include xylitol only toothpaste. However, practically, it would be difficult to achieve a therapeutic dose of xylitol from using xylitol only toothpaste twice a day.
Any side effects?
Xylitol, when used in large quantities, may cause bloating, farting and laxative effects. This is especially common when xylitol is first introduced into the diet. Although rare, allergy to xylitol is possible.
Xylitol is toxic to dogs, and results in extreme low blood sugar and liver damage, so xylitol must be kept away from family pets.
So xylitol is good for teeth, but is xylitol good for the body?
With the exception of rare allergy and dose-related stomach upsets, xylitol is not harmful to the body. Xylitol has a low GI value, is absorbed very slowly and has negligible effects on blood sugar or insulin (Livesey, 2003). A recent Cochrane systematic review concluded that xylitol may help prevent acute otitis media in children by reducing S. penumoniae and H. influenzae from sticking to nasopharyngeal cells (Azarpazhooh et al., 2016).
In sum, what are some ways to get the most benefits out of xylitol?
- For parents and parents-to-be, chew xylitol containing chewing gum, in addition togood oral hygiene habits (flossing, toothbrushing, regular dental check-up) to reduce the transmission of decay-causing bacteria to their babies.
- For infants, start toothbrushing as soon as there are teeth, using xylitol containing toothpaste or xylitol containing fluoride toothpaste (recommended age to start using fluoride toothpaste varies from country to country). Wipe mouth with xylitol containing wipes after feeds.
- For older children and adults, use xylitol containing fluoride toothpaste, over a fluoride only or xylitol only toothpaste. Chew xylitol containing chewing gum after meals to increase saliva and oral cleansing, as well as reduce acids in the mouth.
- If lollies and chocolates are consumed, xylitol-rich, low acid and non-sticky options are preferable over sugary-sour-sticky ones.
Keep in mind that the efficacy of xylitol is significantly dependent on the quantity of xylitol available and the ability to sustain use over time (Alanzi et al., 2016).
Alanzi A, Soderling E, Varghese A, Honkala E. Xylitol chewing gums on the market: Do they prevent caries? Oral Health Prev Dent 2016;14(5):459-466. doi: 10.3290/j.ohpd.a36101.
Antonio AG, Pierro VS, Maia LC. Caries preventive effects of xylitol-based candies and lozenges: a systematic review. J Public Health Dent 2001;71(2):117-124.
Azarpazhooh A, Lawrence HP, Shah PS. Xylitol for preventing acvute otitis medida in children up to 12 years of age. Cochrane Database Syst Rev 2016; (8):CD007095. doi: 10.1002/14651858.CD007095.pub3.
Bader JD, Volimer WM, Shugars DA, Gilbert GH, Amaechi BT, Brown JP, Laws RL, Funkhouser KA. Results from the Xylitol for Adult Caries Trial (X-ACT). J am Dent Assoc 2013;144(1):21-30.
Campus G, Cagetti MG, Sacco G, Solina G, Mastroberardino S, Lingstrom P. Six month of daily high-dose xylitol in high-risk schoolchildren: a randomized clinical trial on plaque pH and salivary mutan streptococci. Caries Res 2009;43(6):455-461.
Chi DL, Zegarra G, Vasquez Huerta EC, Castillo JL, Milgrom P, Roberts MC, Cabrera-Matta AR, Merino AP. Milk sweetened with xylitol: a proof-of-principle caries prevention randomized clinical trial. J Dent Child 2016; 83(3):152-160.
Kayalvizhi G, Nivedha D, Sajeev R, Prathima GS, Suganya M, Ramesh V. Evaluating the efficacy of xylitol wipes on cariogenic bacteria in 19- to 35-month-old children: A double-blind randomized controlled trial. Int J Clin Pediatr Dent 2018; 11(1):13-17. doi: 10.5005/jp-journals-10005-1476.
Isokangas P, Soderling E, Pienihakkinen K, Alanen P. Occurrence of dental decay in children after maternal consumption of xylitol chewing gum: a follow up from 0 to 5 years of age. J Dent Res 2000;79(11):1885-1889.
Lenkkeri AM, Pienihakkinen K, Hume S, Alanen P. The caries-preventive effect of xylitol/maltitol and erythritol/maltitol lozenges: results of a double-blinded, cluster-randomized clinical trial in an area of natural fluoridation. Int J Paediatr Dent 2012;22(3):180-190. doi: 10.1111/j.1365-263X.2011.01182.x.
Lin HK, Fang CE, Huang SS, Cheng HC, Huang TW, Chang HT, Tam KW. Effect of maternal use of chewing gums containing xylitol on transmission of mutans streptocci in children: a meta-analysis of randomized controlled trials. Int J Paediatr Dent 2016;26(1):35-44. doi: 10.1111/ipd.12155.
Livesey G. Health potential of polyols as sugar replacers, with emphasis on low glycaemic properties. Nutr Res Rev 2003;16(2):163-191. doi: 10.10789/NRR200371.
Marghalani AA, Guinto E, Phan M, Dhar V, Tinanoff N. Effectiveness of xylitol in reducing dental caries in children. Pediatr Dent 2017; 39(3):103-110.
Makinen KK, Isotupa KP, Makinen PL, Soderling E, Song KB, Nam SH, Jeong SH. Six-month polyol chewing-gum programme in kindergarten-age children: a feasibility study focusing on mutans streptococci and dental plaque. Int Dent J 2005;55(2):81-88.
Makinen KK, Alanen P, Isokangas P, Isotupa K, Soderling E, Makinen PL, Wenhui W, Weijian W, Xiaochi C, Yi W, Boxue Z. Thirty-nine-month xylitol chewing-gum programme in initially 8-year-old school children: a feasibility study focusing on mutans streptococci and lactobacilli. Int Dent J 2008;58(1):41-50.
Milgrom P, Soderling EM, Nelson S, Chi DL, Nakai Y. Clinical evidence for polyol efficacy. Adv Dent Res 2012;24(2):112-115. doi: 10.1177/0022034512449467.
Nakai Y, Shinga-Ishihara C, Kaji M, Moriya K, Murakami-Yamanaka K, Takimura M. Xylitol gum and maternal transmission of mutans streptococci. J Dent Res 2010;89(1):56-60. doi: 10.1177/0022034509352958.
Riley P, Moore D, Ahmed F, Sharif MO, Worthington HV. Xylitol-containing products for preventing dental caries in children and adults. Cochrane Database Syst Rev 2015; 26(3): CD10743. doi: 10.1002/14651858.CD010743.pub2.
Shen P, Walker GD, Yuan Y, Reynolds C, Renolds EC. Polyols and remineralisation of enamel subsurface lesions. J Dent 2017;66:71-75. doi: 10.1016/j.dent.2017.08.008.
Twetman S, Stecksen-Blicks C. Effect of xylitol-containing chewing gums on lactic acid production in dental plaque from caries active pre-school children. Oral Health PRev Dent 2003;1(3):195-199.
Van Loveren C. Sugar alcohols: what is the evidence for caries-preventive and caries-therapeutic effects? Caries Res 2004;38(3):286-293.
Yates C, Duane B. Maternal xylitol and mutans streptococci transmission. Evid Based Dent 2015;16(2):41-42. doi: 10.1038/sj.ebd.6401090.
Zhan L, Cheng J, Chang P, Ngo M, Besten PKD, Hoover CI, Featherstone JDB. Effects of xylitol wipes on cariogenic bacteria and caries in young children. J Dent Res 2012a; 91(7): 855-896.
Zhan L, Featherstone JD, Lo J, Krupansky C, Hoang N, DenBesten P, Huynh T. Clinical efficacy and effects of xylitol wipes on bacterial virulence. Adv Dent Res 2012b;24(2):117-122, doi: 10.1177/0022034512449835.
Zhan L. Rebalancing the caries microbiome dysbiosis: targeted treatment and sugar alcohols. Adv Dent Res 2018; 29(1):110-116. doi: 10.1177/0022034517736498.