Are erythritol-sugar blends “healthy and tooth-friendly” ?

A quick look around my local supermarket revealed that erythritol seems to be the rising star in the sugar aisle. It is found in almost every trendy brand of blended sugars e.g. “Skinny Sugar”, “Natvia with Natvriol”, “Stevia with Monk Fruit”. Even the trusted CSR, “Australia’s premium sugar” had their own, “CSR Lite” with cane sugar, erythritol and steviol glycosides!

What is erythritol?

Erythritol is a nutritive sweetener belonging to the polyol or sugar alcohol group, along with xylitol and sorbitol.(1-3) As with other polyols, erythritol is a hydrogenated carbohydrate.(4) Erythritol has 4-carbon in its chemical structure and is a smaller molecule than the other polyols.(1-4) It is naturally occurring in fruits and vegetables but can also be produced via fermentation e.g.by fermenting corn or wheat with the help of osmophilic yeasts. Erythritol is also naturally found in humans in small amounts.(1)

What is so fantastic about erythritol?

1. Erythritol has very few calories

Erythritol only has 0.24 calorie per gram. This is fewer calories than xylitol (2.4 calories per gram) and table sugars (4 calories per gram).(2,3)

2. Erythritol has similar taste and texture to table sugar

Although erythritol is 60-80% less sweet compared to table sugar, the taste and texture are similar.(1,2) Erythritol does not have an aftertaste and may even mask the aftertaste of other more intense sweeteners such as Stevia.(4)

3. Erythritol is health-promoting

Erythritol has a low glycaemic index.(5) It does not affect blood sugar or insulin and so is suitable for individuals with diabetes.(1,2) Chukwuma and co-authors have even suggested that erythritol possesses anti-hyperglycaemic and anti-diabetic potentials by reducing small intestinal glucose absorption, increasing muscle glucose uptake and improving glucose metabolic enzymes activities, but so far this has only been demonstrated in animals.(7) Erythritol may also act as an antioxidant.(1,2,4,8)

4. Erythritol is well tolerated

Erythritol is generally well tolerated by humans.(1) Erythritol does not cause stomach upsets as easily as xylitol or sorbitol, although excess consumption of erythritol can still cause flatulence and laxation in some individuals.(1,6) Even children as young as 4yo have been reported to tolerate erythritol well at 0.73g/kg body weight, up to a maximum of 15g/day.(6)

When ingested, erythritol largely passes through the human body without being metabolized and without affecting blood glucose or insulin levels.(1,2,4) Unmodified erythritol is excreted in urine.(1-3)

5. Erythritol is tooth-friendly

Similar to other polyols, erythritol does not cause tooth decay or dental erosion. It is not metabolised by bacteria in the mouth and therefore does not produce decay-promoting acids.(1,2,4) It has been demonstrated that long-term use of erythritol inhibits decay-causing bacteria such as Streptococcus mutans, reduces build-up of dental plaque, decreases stickiness of dental plaque.(1-4)

Recent studies have further demonstrated that erythritol may be superior to xylitol and other polyols in preventing tooth decay. In particular, a daily dose of 7.5g erythritol has been shown to provide better protection than lower doses.(1,9,10) Research findings have found that due to the smaller molecular size of erythritol, it may be able to pass through bacteria more passively to suppress bacteria growth by interfering with bacterial enzymatic pathways.(1,2) Erythritol's lower solubility in the mouth and lower molecular weight than xylitol may also increase its effectiveness by dissolving more slowly to provide longer exposure and deeper diffusion into dental plaque to target decay-causing, acid-promoting oral bacteria.(1,2) Moreover, erythritol has been shown to prevent bacteria adhesion to tooth surfaces better than xylitol.(1-3,9,10)

Not only is erythritol regarded as having anti-cariogenic properties but it may also play a role in periodontal health by inhibiting bacteria such as P. gingivalisand suppressing the formation and growth of dental plaque.(1-3,11,12)  

Conclusion

It does seem worthwhile to keep an eye on erythritol. Current research findings do suggest more health benefits than adverse effects. 

For minimizing calories, erythritol-table sugar blends such as “Skinny Sugars” and “CSR Lite” are effective. 

Erythritol per se is tooth-friendly. However, when it comes to protecting against tooth decay, erythritol-table sugar blends may not be definitively effective. So, "don’t throw away the toothbrush" just yet. While minimizing sugar is definitely a tooth-friendly move, tooth decay is a complex multifactorial disease that requires an individualised “risk-based blended strategies” approach to prevent and keep under control. To find out what specific dietary modifications may be the most helpful for your oral health, do see an oral health practitioner.   

REFERENCES

1. De Cock P, Makinen K, Honkala E, Saag M, Kennepohl E, Eapen A. Erythritol is more effective than xylitol and sorbitol in managing oral health endpoints. Int J Dent 2016;2016:9868421. doi: 10.1155/2016/9868421. 
2. De Cock P. Erythritol funcational roles in oral-systemic health. Adv Dent Res 2018 Feb;29(1):104-109. doi: 10.1177/0022034517736499.
3. Makinen KK. Sugar alcohols, caries incidence, and remineralization of caries: A literature review. Int J Dent 2010;2010:981072. doi: 10.1155/2010/981072. 
4. Regnat K, Mach RL, Mach-Aigner AR. Erythritol as sweetener – wherefrom and whereto? Appl Microbiol BIotechnol 2018;102(2):587-95.https://dx.doi.org/10.1007%2Fs00253-017-8654-1.
5. Livesey G. Health potential of polyols as sugar replacers, with emphasis on low glycaemic properties. Nutr Res Rev 2003; 16(2):163-91.doi: 10.1079/NRR200371.
6. Jacqz-Aigrain E, Kassai Bm Cornu C, Cazaubiel JM, Prevel JM Bell M, Boileau A, de Cock P. Gastrointestinal tolerance of erythritol-containing beverage in young children: A double-blind, randomised controlled trial. Eur J Clin Nutr. 2015 Jun;69(6):746-51. doi: 10.1038/ejcn.2015.4.
7. Chukwuma CI, Mopouri R, Nagiah S, Chuturgoon AA, Islam MS. Erythritol reduces small intestinal glucose absorption, increases muscle glucose uptake, improves glucose metabolic enzymes activities and increases expression of Glut-4 and IRS-1 in type 2 diabetic rats. Our J Nutr 2017 Aug 2. doi: 10.1007/s00394-017-1516-x. 
8. Den Hartog GJ, Boots AW, Adam-Perrot A, Brouns F, Verkooijen IW, Weseler AR, Haenen GR, Bast A. Erythritol is a sweet antioxidant. Nutrition 2010;Apr;26(4):449-58. doi: 10.1016/j.nut.2009.05.004.
9. Runnel R, Makinen KK, Honkala S, Olak J, Makinen PL, Nommela R, Vahlberg T, Honkala E, Saag M. Effect of three-year consumption of erythritol, xylitol and sorbitol candies on various plaque and salivary caries-related variables. J Dent 2013;41(12):1236-44.doi: 10.1016/j.jdent.2013.09.007.
10. Honkala S, Runnel R, Saag M, Olak J, Nommela R, Russak S, Makinen PL, Vahlberg T, Falony G, Mainen K, Honkala E. Effect of erythritol and xylitol on dental caries prevention in children. Caries Res 2014;48(5):482-90. doi: 10.1159/000358399.
11. Hashino E, Kuboniwa M, Alghamdi SA, Yamaguchi M, Yamamoto R, Cho H, Amano A. Erythritol alters microstructure and metabolomic profiles of biofilm composed of Streptococcus gordonii and Porphyromonas gingivalis. Mol Oral Microbiol 2013;28(6):435-51.doi: 10.1111/omi.12037.
12. Janus MM, Volgenant CMC, Brandt NW, Buijs MJ, Keijser BJF, Crielaard W, Zaura E, Krom BP. Effect of erythritol on microbial ecology of in vitro gingivitis biofilms. J Oral Microbiol 2017;9(1):1337477. doi: 10.1080/20002297.2017.1337477.