Xylitol is one of the better all natural sugar substitutes. It is considered to be one of the nutritious sweeteners that provide energy. Its sweetness is similar to sucrose, but less caloric. And it has a benefit in preventing dental cavities.

Xylitol is a sugar substitute with sweetness equal to that of table sugar. It is a member of the group of compounds known as sugar alcohols, which includes other common dietary sweeteners such as sorbitol and mannitol. Xylitol is produced commercially from birch trees and other hardwoods containing xylan.

Dentists became interested in xylitol after data on “Turku sugar studies” was published in the 1970’s, which turned out to be promising in cavity reduction. After 2 years starting from the moment when sucrose was replaced by xylitol in  adults, it was proven that no caries were observed, thus a conclusion was drawn that the non-cariogenic properties of xylitol are related to not being metabolized by salivary and plaque bacteria. Next in a double blind study lasting 40 months, the impact on dental caries resulting from the use of chewing gums with xylitol, sorbitol and sucrose by children was compared. The lowest incidence of dental caries was found in the xylitol group. Currently, xylitol is recognized to be a safe dental cavity preventative compound.

Xylitol possesses properties that reduce the levels of Streptococcus mutans bacteria in the dental plaque and saliva due to the disruption of the energy production process leading to bacterial cell death, adhesions reduction to the teeth and less lactic acid production.

Xylitol can also cause the disruption of bacterial protein synthesis. Its impact on the remineralization process results from the formation of polyol-Ca complexes, constituting a calcium carrier that leads to a raised level of calcium in dental plaque, where the additional calcium increases remineralization instead of plaque mineralization.

During dissolution in saliva, similarly to mint, produces a cool feeling in the oral cavity. This feeling results from the fact that xylitol absorbs more heat in the process of dissolutions in water than sucrose does.

Currently, xylitol is mostly used in chewing gum, chewable or soluble tablets, syrups, mints, mouth-wash liquids and wipes.  The AAPD recommends the use of xylitol as a part of a preventative strategy aimed to achieve long term suppression of cariogenic pathogens and a reduction of caries development in moderate and high caries risk subjects. However, to obtain those goals, a therapeutic dose is needed.

Ingested xylitol is absorbed by the body only partially, then it is either metabolized (generally by insulin-independent mechanisms) or excreted via the urinary tract, with the unabsorbed compound partially fermented in the colon and excreted through that process. A high level of consumption (45 grams per day in children,100 g per day in adults) may result in a laxative effect causing osmotic diarrhea.

Prolonged use of xylitol results in an increase in the number of S. mutans strains that are xylitol-resistant. This resistance originates from the fact that these microorganisms can change fructose absorption system and are unable to transport xylitol to the bacterial cell in which, after accumulation, it would exhibit a toxic effect.

When it comes to medical applications, xylitol has been used for a long time in infusion therapy in the patients during post-surgery recovery, as well as in patients suffering from severe burns or shock and in the diet of patients suffering from diabetes.

Specially designed pacifiers with a special “pocket”, where a xylitol tablet is placed, constitute a new form of administration of the medicine to the child’s oral cavity.

In the article titled Effectiveness of Xylitol in Caries Prevention” published by the Department of Conservative and Pediatric Dentistry, Wroclaw Medical University, Wroclaw, Poland, researcher Alamoudi, et al, studying mothers of 10-36 old children, which were using a chewing gum with 1.8 g. of xylitol three times a day for 3 months, found a significant increase of S. mutans number in saliva, as well as no increase in the DMFT value in their children compared to the children of the mothers who were given a fluoride solution. However, no difference in plaque in the children was found. Therefore, a beneficial impact of xylitol consumption by the mother on caries development and S. mutans level in children, in comparison to fluoride varnish application, was found.

The study carried out by Laitala et al showed that the reduced transmission of S.mutans bacteria from a mother to a child, had a long lasting, beneficial effect on children’s dental condition. Retrospective evaluation of the dental condition of children aged 10, whose mothers with a high caries risk used xylitol chewing gum within the period when their children were at the of 2 to 24 months, revealed that these children remained caries-free for a longer period of time in comparison to the control group (8.2 vs. 5.8 years).

However, Thorlid et al. did not find a long-term, beneficial effect regarding the dental condition of 10-year-old children, the mothers of women used xylitol chewing gum for a year (throughout the period when their children were aged 6 to 18 months), in comparison to the children of mothers using chewing gum with chlorhexidine, xylitol and sorbitol fluoride, xylitol and sorbitol.

A study based on numerous group of adults aged 21-80, who received chewable tablets containing 1 g of xylitol over a period of 33 months, 5 times a day, showed a 40% reduction of root caries and 10% reduction (statistically insignificant) of coronal caries compared to the placebo control group. This data leads to the conclusion that the caries preventive effect of xylitol is mainly caused by its impact on dental plaque and cariogenic bacteria.

However, continuous and long term exposure of teeth to xylitol is required, regardless of the carrier used. The most common form of xylitol administration is use of a chewing gum. Not only does this carrier release xylitol gradually, and thus the teeth are in contact with the substance for a longer period of time, but it also provides mechanical and taste stimulation, which in turn increases the salivary secretion, which increases its buffering capacity, and this can help in caries reduction. The dentist should recommend a suitable form of xylitol for a given patient and the clinical situation e.g. chewing gum is not recommended for children under 4 and for patients suffering from temporomandibular joint disorders. According to AADP guidelines, chewing gum should not be recommended for children less than 4 years of age, due to the risk of choking.

The Academy also stresses the fact that, according to the current state of the art, the total daily dose should be in the range of 3 to 8 g in order to obtain the cariostatic effect, with the use of the currently applied forms of supply (syrup, chewing gum, mints, lozenges. The dose should be administered at least twice a day and not exceed 8 g per day.

Xylitol is a naturally occurring compound found in many fruits, vegetables and grains. Which we should be consuming more of daily. But the low levels of xylitol occurring naturally in foods aren’t significantly more than the small amount naturally occurring in fruits, vegetables and grains. Unlike sugar, xylitol doesn’t encourage cavity-causing bacteria to produce acid. In fact, its molecular structure may actually inhibit the growth of these harmful bacteria. This helps you maintain a neutral pH, keeping the outer layer of your teeth intact.

In conclusion, one may state that in light of the current state of the art, xylitol use is a proven and effective complementary measure of caries prevention at any level among subjects with moderate and high caries risk, especially in pediatric patients.