Polyols and Oral Health

Fiona Collins BDS, MBA, MA, FPFA

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Polyols and Oral Health

Polyols occur naturally in some grains, fruits, vegetables and trees, are produced by the human body, and can be commercially synthesized.1American Dietetic Association. Position of the American Dietetic association: Use of nutritive and nonnutritive sweeteners. J Am Diet Assoc 2004;104:255-75.,2Al Humaid J. Sweetener content and cariogenic potential of pediatric oral medications: A literature. Int J Health Sci (Qassim) 2018;12(3):75-82.,3Roberts MW, Wright JT. Nonnutritive, low caloric substitutes for food sugars: Clinical implications for addressing the incidence of dental caries and overweight/obesity. Int J Dent 2012;Article ID 625701. For example, erythritol is derived from fermented glucose and xylitol from birch, hardwood trees and fibrous vegetation.4Calorie Council. Erythritol. Available at: https://caloriecontrol.org/erythritol/. ,5Calorie Council. Xylitol. Available at: https://caloriecontrol.org/xylitol/. Primarily used as sweeteners, polyols are also known as low-digestible carbohydrates, alternative, nutritive or low-calorie sweeteners, and as sugar alcohols (while containing neither sugar nor alcohol).6U.S. Food & Drug Administration. Sugar Alcohols. Available at: https://www.accessdata.fda.gov/scripts/InteractiveNutritionFactsLabel/sugar-alcohol.html.,7Calorie Council. Polyols. Available at: https://caloriecontrol.org/wp-content/uploads/Polyols.pdf. They contain fewer calories than sugars and impart less sweetness.7Calorie Council. Polyols. Available at: https://caloriecontrol.org/wp-content/uploads/Polyols.pdf.,8Newsee. Applications and Uses of erythritol. Available at: https://www.foodsweeteners.com/applications-and-uses-of-erythritol/.,9Sugar-and-Sweetener Guide. Glycerol. Available at: http://www.sugar-and-sweetener-guide.com/glycerol.html. In addition, since they are either only partly absorbed or digested, they result in lower energy intake than sugars. (Table 1)

Table 1. FDA status, uses, sweetness and caloric value of polyols 2Al Humaid J. Sweetener content and cariogenic potential of pediatric oral medications: A literature. Int J Health Sci (Qassim) 2018;12(3):75-82.,3Roberts MW, Wright JT. Nonnutritive, low caloric substitutes for food sugars: Clinical implications for addressing the incidence of dental caries and overweight/obesity. Int J Dent 2012;Article ID 625701.,7Calorie Council. Polyols. Available at: https://caloriecontrol.org/wp-content/uploads/Polyols.pdf.,8Newsee. Applications and Uses of erythritol. Available at: https://www.foodsweeteners.com/applications-and-uses-of-erythritol/.,9Sugar-and-Sweetener Guide. Glycerol. Available at: http://www.sugar-and-sweetener-guide.com/glycerol.html.
  FDA status Sweetness compared to sugar Uses Caloric value relative to glucose 
Erythritol GRAS 70% Foods, drinks, chewing gum, table sweetener, pharmaceuticals, personal care products, agriculture  5%
Glycerol (glycerin) GRAS 60% Foods, dentifrices, lotions,  mouthwashes, cough mixtures, as a laxative, bulking agent, texturizer, stabilizer 100%
Isomalt GRAS   Foods, drinks, pharmaceuticals, candies, nutritional supplements, cough drops, throat lozenges 50%
Lactitol  GRAS 30% to 40% Foods, drinks, table sweetener 50%
Maltitol GRAS 95% Foods, drinks, candies. Creaminess enables its use to replace fat. 53%
Mannitol Food additive 50% to 70% Foods, drinks, table sweetener, pharmaceuticals 40%
Sorbitol GRAS   60% to 70% Foods, drinks,  bulk sweetener, pharmaceuticals, chewing gum, dentifrices, mouth rinses, cosmetics   65%
Xylitol Food additive (for special dietary purposes) 95% Foods, drinks, table sweetener, chewing gum, gum drops, hard candy, pharmaceuticals, oral care products, throat lozenges, cough syrups 60%  

Polyols are also used as bulking agents, flavor retainers/maskers, humectants, stabilizers, anti-crystallizing agents, and for systemic and oral health benefits.6U.S. Food & Drug Administration. Sugar Alcohols. Available at: https://www.accessdata.fda.gov/scripts/InteractiveNutritionFactsLabel/sugar-alcohol.html.,7Calorie Council. Polyols. Available at: https://caloriecontrol.org/wp-content/uploads/Polyols.pdf.,10Mäkinen KK. Biochemical principles of the use of xylitol in medicine and nutrition with special consideration of dental aspects. Experientia Suppl 1978;30:1-160. In the United States, mannitol and xylitol (for special dietary needs) are regulated as food additives, while polyols are otherwise ‘Generally Regarded As Safe’ (GRAS) (i.e., also recognized among experts as safe for their intended use). The focus of this article is primarily on xylitol and oral health.

Polyols occur naturally in some grains, fruits, vegetables and trees, are produced by the human body, and can be commercially synthesized.

Polyols and Oral Health

Evidence supports the non-cariogenicity of xylitol, and polyols generally.1American Dietetic Association. Position of the American Dietetic association: Use of nutritive and nonnutritive sweeteners. J Am Diet Assoc 2004;104:255-75.,3Roberts MW, Wright JT. Nonnutritive, low caloric substitutes for food sugars: Clinical implications for addressing the incidence of dental caries and overweight/obesity. Int J Dent 2012;Article ID 625701.,8Newsee. Applications and Uses of erythritol. Available at: https://www.foodsweeteners.com/applications-and-uses-of-erythritol/.,11Fontana M, González-Cabezas C. Are we ready for definitive clinical guidelines on xylitol/polyol use? Adv Dent Res 2012;24(2):123-8. Polyols are not/poorly metabolized by cariogenic bacteria,2Al Humaid J. Sweetener content and cariogenic potential of pediatric oral medications: A literature. Int J Health Sci (Qassim) 2018;12(3):75-82.,7Calorie Council. Polyols. Available at: https://caloriecontrol.org/wp-content/uploads/Polyols.pdf. resulting in no/little bacterial acid production and reduced risk of demineralization of tooth structure. The majority of studies have evaluated xylitol chewing gum.

Studies on Reductions in Cariogenic Bacteria

In one randomized controlled study, children used xylitol or xylitol/sorbitol chewing gum four times daily on school days.12Mäkinen KK, Alanen P, Isokangas P, Isotupa K, Söderling E, Mäkinen 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. Significant reductions in mutans streptococci (MS) and salivary lactobacilli (LB) were found at 24 and 39 months compared to no chewing gum, particularly for xylitol gum. In a second study, reductions in plaque Streptococcus mutans (S. mutans) were found following use of 6g/day of xylitol or sorbitol chewing gum for 5 weeks.13Söderling E, Elsalhy M, Honkala E, Fontana M, Flannagan S, Eckert G, Kokaras A, Paster B, Tolvanen M, Honkala S. Effects of short-term xylitol gum chewing on the oral microbiome. Clin Oral Investig 2015;19(2):237-44. In another randomized, controlled double-blind study adolescents chewed 1 of 4 gums (total dose 10 g/day) for 30 days.14Thabuis C, Cheng CY, Wang X, Pochat M, Han A, Miller L, Wils D, Guerin-Deremaux L. Effects of maltitol and xylitol chewing-gums on parameters involved in dental caries development. Eur J Paediatr Dent 2013;14(4):303-8. Compared to no gum, use of xylitol or mannitol gum and to a lesser extent a gum base (i.e., containing no polyol or sweetener), resulted in significant decreases in plaque growth and levels of cariogenic bacteria. In a fourth study, patients wearing fixed orthodontic appliances chewed gum containing xylitol, sorbitol, or one of two xylitol-sorbitol mixtures, 6 times daily (total 10.5 g/day) for 28 days.15Isotupa KP, Gunn S, Chen CY, Lopatin D, Mäkinen KK. Effect of polyol gums on dental plaque in orthodontic patients. Am J Orthod Dentofacial Orthop 1995;107(5):497-504. Plaque reductions at measured sites (gingival margin to the bracket’s edge) were found for individuals using a polyol gum, especially xylitol. Only xylitol gum resulted in significant reductions in salivary and plaque MS. Additional studies support the use of xylitol gum to reduce cariogenic bacteria.16American Academy of Pediatric Dentistry. Policy on the Use of Xylitol. Available at: https://www.aapd.org/research/oral-health-policies--recommendations/use-of-xylitol/. Reductions in cariogenic bacteria have also been found following use of xylitol gummy bears and chewable tablets.17Ly KA, Riedy CA, Milgrom P, Rothen M, Roberts MC, Zhou L. Xylitol gummy bear snacks: a school-based randomized clinical trial. BMC Oral Health 2008;8:20.,18Mäkinen KK, Saag M, Isotupa KP, Olak J, Nõmmela R, Söderling E, Mäkinen PL. Similarity of the effects of erythritol and xylitol on some risk factors of dental caries. Caries Res 2005;39(3):207-15.

Studies support the use of xylitol gum to reduce cariogenic bacteria.

Maternal Consumption of Xylitol

In a review of 11 studies, it was concluded that significantly reduced transmission of MS occurs when mothers with high MS levels use xylitol.19Yates C, Duane B. Maternal xylitol and mutans streptococci transmission. Evid Based Dent 2015;16(2):41-2. Results of individual studies vary. In one study, high-caries-risk mothers used xylitol gum daily from 3 to 24 months post-partum. MS colonization was reduced in their infants and, subsequently, an increased mean caries-free age was found for these children compared to the control.20Laitala ML, Alanen P, Isokangas P, Söderling E, Pienihäkkinen K. Long-term effects of maternal prevention on children’s dental decay and need for restorative treatment. Community Dent Oral Epidemiol 2013;41(6):534-40. In another study with mothers and children with high levels of S. mutans, the mothers chewed xylitol gum three times daily for three months or received fluoride varnish treatment.21Alamoudi NM, Hanno AG, Sabbagh HJ, Masoud MI, Almushayt AS, El Derwi DA. Impact of maternal xylitol consumption on mutans streptococci, plaque and caries levels in children. J Clin Pediatr Dent 2012;37(2):163-6. At 18 months, significantly lower levels of S. mutans were found for children whose mothers had used xylitol gum. No significant between-group differences were found for plaque levels or dmft compared to baseline.21Alamoudi NM, Hanno AG, Sabbagh HJ, Masoud MI, Almushayt AS, El Derwi DA. Impact of maternal xylitol consumption on mutans streptococci, plaque and caries levels in children. J Clin Pediatr Dent 2012;37(2):163-6. Further, in a 1-year double-blind randomized controlled trial, no significant differences in MS and LB levels were found for children (age range 6 to 35 months) whose mothers had used xylitol wipes or placebo wipes and had also used a corresponding wipe on their children’s teeth.22Zhan L, Cheng J, Chang P, Ngo M, DenBesten PK, Hoover CI, Featherstone JDB. Effects of xylitol wipes on cariogenic bacteria and caries in young children. J Dent Res 2012; 91(7 Suppl): S85–S90.

Reductions in Caries

In a systematic review of 10 randomized controlled studies, insufficient evidence was found to determine whether xylitol-containing products conferred any caries reduction benefit, with the exception of xylitol-containing fluoride dentifrices for which a low level of evidence was found.23Riley 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;(3):CD010743. In a meta-analysis of 14 randomized or observational studies, a caries preventive effect was found for combination xylitol-sorbitol and xylitol-mannitol chewing gums.24Deshpande A, Jadad AR. The impact of polyol-containing chewing gums on dental caries: a systematic review of original randomized controlled trials and observational studies. J Am Dent Assoc 2008;139:16021614. An earlier review assessed polyols, primarily xylitol and sorbitol.25Van Loveren C. Sugar alcohols: what is the evidence for caries-preventive and caries-therapeutic effects? Caries Res 2004;38(3):286-93. It was concluded that long-term use of polyol chewing gum three times daily may reduce the incidence of caries and that xylitol candies might be effective. In 2 of 4 studies, xylitol was more effective than sorbitol. Numerous studies have been conducted on chewing gums. In a two-year study in 6-year-olds, compared to use of polyol-free gum, significant caries reductions were found for children using xylitol or sorbitol gum, or both, five times daily.26Mäkinen KK, Hujoel PP, Bennett CA, Isotupa KP, Mäkinen PL, Allen P. Polyol chewing gums and caries rates in primary dentition: a 24-month cohort study. Caries Res 1996;30(6):408-17.

Long-term use of polyol chewing gum three times daily may reduce the incidence of caries.

In a double-blind, 40-month cohort study, chewing gum was used 3 or 5 times daily.27Mäkinen KK, Bennett CA, Hujoel PP, Isokangas PJ, Isotupa KP, Pape HR Jr, Mäkinen PL. Xylitol chewing gums and caries rates: a 40-month cohort study. J Dent Res 1995;74(12):1904-13. At 40 months, caries reductions were greatest for xylitol gum (total 8g/day) used five times daily (p<0.01; n =1,100). After adjusting for gender, age, and sound surfaces at baseline, compared to no gum use the relative risk (RR) for caries was 0.27 and 0.42, respectively, for a xylitol pellet gum used 5 or 3 times daily (total 8.5 g and 4.3 g/day). The RR was 0.44 and 0.48 for sticks of xylitol gum used 5 or 3 times daily, respectively (total 10.3 g and 6.1 g/day). For five-times daily use of gum containing a 3:2 ratio of xylitol and sorbitol (total mix 9.7 g/day) or sorbitol (9 g/day), the RR was 0.57 and 0.75, respectively. (Figure 1) The researchers also concluded that the large effect made it difficult to assume any bias due to unknown confounding factors.27Mäkinen KK, Bennett CA, Hujoel PP, Isokangas PJ, Isotupa KP, Pape HR Jr, Mäkinen PL. Xylitol chewing gums and caries rates: a 40-month cohort study. J Dent Res 1995;74(12):1904-13. In another randomized trial, 6-month use of xylitol chewing gum by high-risk schoolchildren was found to reduce incremental caries in first permanent molars and levels of salivary MS and LB at 2 years.28Campus G, Cagetti MG, Sale S, Petruzzi M, Solinas G, Strohmenger L, Lingström P. Six months of high-dose xylitol in high-risk caries subjects—a 2-year randomised, clinical trial. Clin Oral Investig 2013;17(3):785-91.

Figure 1. Relative risk for caries by intervention compared to no gum27Mäkinen KK, Bennett CA, Hujoel PP, Isokangas PJ, Isotupa KP, Pape HR Jr, Mäkinen PL. Xylitol chewing gums and caries rates: a 40-month cohort study. J Dent Res 1995;74(12):1904-13.


Caries reductions were also found for use of xylitol syrup (8g/day xylitol) in a study in infants, with no significant difference for use two/three times daily.29Milgrom P, Ly KA, Tut OK, Mancl L, Roberts MC, Briand K, Gancio MJ. Xylitol pediatric topical oral syrup to prevent dental caries: a double-blind randomized clinical trial of efficacy. Arch Pediatr Adolesc Med 2009;163(7):601-7. In another study, a 45% xylitol solution was applied once/twice daily to tooth surfaces in infants 6 to 8 months of age until age 3.30Mäkinen KK, Järvinen KL, Anttila CH, Luntamo LM, Vahlberg T. Topical xylitol administration by parents for the promotion of oral health in infants: a caries prevention experiment at a Finnish Public Health Centre. Int Dent J 2013;63(4):210-24. Compared to no intervention, lower levels of MS and significant reductions in caries were found at ages 5 through 7. In contrast, in a double-blind cluster-randomized study in 10-year-olds from a low-caries-risk population, no reduction in caries was found following use of xylitol/maltitol or erythritol/maltitol lozenges three times daily on school days for 1 or 2 years.31Lenkkeri AM, Pienihäkkinen K, Hurme 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):180-90. It was concluded that school-based use of these lozenges would not reduce caries in low-risk individuals.

Studies in adults

There is a paucity of studies in adults. In a recent randomized, controlled multi-center 33-month trial, almost 700 adults at risk for caries (21 to 80 years-of-age) used 1 g xylitol or placebo lozenges five times daily.32Bader JD, Vollmer WM, Shugars DA, Gilbert GH, Amaechi BT, Brown JP, Laws RL, Funkhouser KA, Makhija SK, Ritter AV, Leo MC. Results from the xylitol for adult caries trial (X-ACT). J Am Dent Assoc 2013;144(1):21-30. No overall statistically significant caries reduction was observed. However, while no significant reductions were found for smooth, approximal or occlusal surfaces, use of xylitol lozenges was found to reduce root caries by 40%.33Ritter AV, Bader JD, Leo MC, Preisser JS, Shugars DA, Vollmer WM, Amaechi BT, Holland JC. Tooth-surface-specific effects of xylitol: randomized trial results. J Dent Res 2013;92(6):512-7.

In a randomized, controlled multi-center trial, use of xylitol lozenges five times daily was found to reduce root caries by 40%.

Xylitol in Dentifrices

Xylitol and sorbitol are used as humectants and sweeteners in dentifrices. In a three-month study, twice-daily use of a dentifrice containing 9.9% xylitol or 20% sorbitol resulted in MS reductions only for the dentifrice containing xylitol.34Svanberg M, Birkhed D. Effect of dentifrices containing either xylitol and glycerol or sorbitol on mutans streptococci in saliva. Caries Res 1991;25(6):449-53. In another study, adding 10% xylitol to an enzyme-containing dentifrice was found to significantly reduce levels of S. mutans.35Jannesson L, Renvert S, Birkhed D. Effect of xylitol in an enzyme-containing dentifrice without sodium lauryl sulfate on mutans streptococci in vivo. Acta Odontol Scand 1997;55(4):212-6. In double-blind studies, 10% xylitol was added to a 0.243% sodium fluoride dentifrice and an 1,1000 ppm sodium monofluorophosphate dentifrice.36Sintes JL, Escalante C, Stewart B, McCool JJ, Garcia L, Volpe AR, Triol C. Enhanced anticaries efficacy of a 0.243% sodium fluoride/10% xylitol/silica dentifrice: 3-year clinical results. Am J Dent 1995;8(5):231-5.,37Sintes JL, Elías-Boneta A, Stewart B, Volpe AR, Lovett J. Anticaries efficacy of a sodium monofluorophosphate dentifrice containing xylitol in a dicalcium phosphate dihydrate base. A 30-month caries clinical study in Costa Rica. Am J Dent 2002;15(4):215-9. At 30 months, compared to the same dentifrices without xylitol, 12% and 10% greater caries reductions, respectively, were found. In contrast, the addition of 31% xylitol or sorbitol to a 1,400 ppm fluoride toothpaste did not provide any incremental reduction in early childhood caries in a single-blind six-month study.38Chi DL, Tut O, Milgrom P. Cluster-randomized xylitol toothpaste trial for early childhood caries prevention. J Dent Child (Chic) 2014;81(1):27-32. In the United States, xylitol is not accepted as an anti-caries agent in dentifrices under the FDA Final Monograph for Anticaries Drug Products for Over-the-Counter Human Use.39US Food & Drug Administration. Anticaries drug products for over-the-counter human use; final monograph. Available at: https://www.govinfo.gov/content/pkg/FR-1995-10-06/pdf/95-24693.pdf.

In the United States, xylitol is not accepted as an anti-caries agent in dentifrices.

Proposed anti-caries mechanisms of action

Several anti-caries mechanisms of action have been proposed. Xylitol inhibits glucosyltransferase, an enzyme contributing to extracellular polysaccharide production and adhesion of S. mutans to the tooth surface.40Ren Z, Chen L, Li J, Li Y. Inhibition of Streptococcus mutans polysaccharide synthesis by molecules targeting glycosyltransferase activity. J Oral Microbiol 2016;8:31095. When exposed to xylitol or erythritol in vitro, bacterial cell adhesion was reduced and growth inhibited in one study.41Söderling EM, Hietala-Lenkkeri AM. Xylitol and erythritol decrease adherence of polysaccharide-producing oral streptococci. Curr Microbiol 2010;60(1):25-9. Erythritol has been found to inhibit the formation of a biofilm containing S. gordonii.42Hashino 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. Further, long-term xylitol use can result in xylitol-tolerant S. mutans, which is proposed to be less cariogenic than xylitol-sensitive S. mutans.43Lee SH, Choi BK, Kim YJ. The cariogenic characters of xylitol-resistant and xylitol-sensitive Streptococcus mutans in biofilm formation with salivary bacteria. Arch Oral Biol 2012;57(6):697-703.,44Trahan L. Xylitol: a review of its action on mutans streptococci and dental plaque: its clinical significance. Int Dent J 1995;45(suppl. 1):77-92.Passive replacement of fermentable carbohydrates has also been proposed.25Van Loveren C. Sugar alcohols: what is the evidence for caries-preventive and caries-therapeutic effects? Caries Res 2004;38(3):286-93. In addition, chewing gum increases salivary flow, which increases salivary buffering capacity, helps to clear fermentable carbohydrates and may provide an antimicrobial effect.24Deshpande A, Jadad AR. The impact of polyol-containing chewing gums on dental caries: a systematic review of original randomized controlled trials and observational studies. J Am Dent Assoc 2008;139:16021614.,25Van Loveren C. Sugar alcohols: what is the evidence for caries-preventive and caries-therapeutic effects? Caries Res 2004;38(3):286-93.(Table 2)

Table 2. Proposed anti-caries mechanisms of action
Inhibition of glucosyltransferase production
Reduced bacterial cell adhesion and growth
Passive replacement of fermentable carbohydrates
Effect of chewing in increasing salivary flow
Shift to xylitol-tolerant S. mutans with long-term xylitol use, which are less cariogenic than xylitol-sensitive S. mutans

Figure 2. Warning on xylitol consumption by dogs.


Source: U.S. Food & Drug Administration

Adverse Effects of Polyols

Reported side effects of polyol intake include cramps, bloating, flatulence, and diarrhea.1American Dietetic Association. Position of the American Dietetic association: Use of nutritive and nonnutritive sweeteners. J Am Diet Assoc 2004;104:255-75.,7Calorie Council. Polyols. Available at: https://caloriecontrol.org/wp-content/uploads/Polyols.pdf.,23Riley 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;(3):CD010743. These are exacerbated in patients with irritable bowel syndrome, Crohn’s disease, other GI conditions or taking medications affecting the GI tract.2Al Humaid J. Sweetener content and cariogenic potential of pediatric oral medications: A literature. Int J Health Sci (Qassim) 2018;12(3):75-82.,7Calorie Council. Polyols. Available at: https://caloriecontrol.org/wp-content/uploads/Polyols.pdf. Erythritol is reported to offer high GI tolerance.45de Cock P. Erythritol functional roles in oral-systemic health. Adv Dent Res 2018;29(1):104-109. Children and adolescents may experience a mild laxative effect at 8 to 10 g/day of xylitol or sorbitol, and this may be more severe in younger children.7Calorie Council. Polyols. Available at: https://caloriecontrol.org/wp-content/uploads/Polyols.pdf. To reduce the risk of side effects, patients can be advised to start with smaller doses and gradually increase the dose, allowing tolerance to build up.7Calorie Council. Polyols. Available at: https://caloriecontrol.org/wp-content/uploads/Polyols.pdf.

To reduce the risk of side effects, patients can be advised to start with smaller doses and gradually increase the dose.

While safe for humans, xylitol consumption by dogs can induce seizures and life-threatening hypoglycemia within 10 to 60 minutes of intake.46U.S. Food & Drug Administration. Paws off xylitol; It's dangerous for dogs. Available at: https://www.fda.gov/consumers/consumer-updates/paws-xylitol-its-dangerous-dogs. Dogs suspected of consuming xylitol should immediately be taken for emergency care. While ferrets are susceptible, xylitol is less dangerous for other pets. (Figure 2)

Considerations and Current Recommendations

It is recognized that further research and robust studies are necessary to clarify the efficacy of xylitol and other polyols, as well as their relative efficacy, vehicles, optimal doses and frequency of use.11Fontana M, González-Cabezas C. Are we ready for definitive clinical guidelines on xylitol/polyol use? Adv Dent Res 2012;24(2):123-8.,16American Academy of Pediatric Dentistry. Policy on the Use of Xylitol. Available at: https://www.aapd.org/research/oral-health-policies--recommendations/use-of-xylitol/.,48Rethman MP, Beltrán-Aguilar ED, Billings RJ, Burne RA, Clark M, Donly KJ, Hujoel PP, Katz BP, Milgrom P, Sohn W, Stamm JW, Watson G, Wolff M, Wright T, Zero D, Aravamudhan K, Frantsve-Hawley J, Meyer DM; for the American Dental Association Council on Scientific Affairs Expert Panel on Nonfluoride Caries-Preventive Agents. Nonfluoride caries-preventive agents. Executive summary of evidence-based clinical recommendations. J Am Dent Assoc 2011;142(9):1065-71. In one review, 7 studies were at high, 2 at unclear and only 1 at low risk of bias.23Riley 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;(3):CD010743. Weaknesses in existing studies include variability in design, reported outcomes, and confounding factors such as diet, salivary flow, fluoride exposure, home care and lack of negative control (e.g., use of a gum base).11Fontana M, González-Cabezas C. Are we ready for definitive clinical guidelines on xylitol/polyol use? Adv Dent Res 2012;24(2):123-8.,27Mäkinen KK, Bennett CA, Hujoel PP, Isokangas PJ, Isotupa KP, Pape HR Jr, Mäkinen PL. Xylitol chewing gums and caries rates: a 40-month cohort study. J Dent Res 1995;74(12):1904-13.,47Mickenautsch S, Yengopal V. Effect of xylitol versus sorbitol: a quantitative systematic review of clinical trials. Int Dent J 2012;62(4):175-88.,48Rethman MP, Beltrán-Aguilar ED, Billings RJ, Burne RA, Clark M, Donly KJ, Hujoel PP, Katz BP, Milgrom P, Sohn W, Stamm JW, Watson G, Wolff M, Wright T, Zero D, Aravamudhan K, Frantsve-Hawley J, Meyer DM; for the American Dental Association Council on Scientific Affairs Expert Panel on Nonfluoride Caries-Preventive Agents. Nonfluoride caries-preventive agents. Executive summary of evidence-based clinical recommendations. J Am Dent Assoc 2011;142(9):1065-71.However, existing data is supportive of xylitol in particular.

The American Academy of Pediatric Dentistry supports pediatric use of xylitol and other polyols as non-cariogenic sugar substitutes, and recognizes that consistent evidence for reductions in MS and dental caries is lacking.19Yates C, Duane B. Maternal xylitol and mutans streptococci transmission. Evid Based Dent 2015;16(2):41-2. The American Dental Association has published recommendations based on the available evidence.48Rethman MP, Beltrán-Aguilar ED, Billings RJ, Burne RA, Clark M, Donly KJ, Hujoel PP, Katz BP, Milgrom P, Sohn W, Stamm JW, Watson G, Wolff M, Wright T, Zero D, Aravamudhan K, Frantsve-Hawley J, Meyer DM; for the American Dental Association Council on Scientific Affairs Expert Panel on Nonfluoride Caries-Preventive Agents. Nonfluoride caries-preventive agents. Executive summary of evidence-based clinical recommendations. J Am Dent Assoc 2011;142(9):1065-71. (Table 3) Based on these, for children age 5 and older, parents and caregivers should be advised that the incidence of coronal caries may be reduced by use of a xylitol or polyol combination chewing gum for 20 minutes after meals and by daily use of xylitol-containing lozenges/hard candies, dissolved slowly in the mouth after meals at a total daily dose of 5 to 8 grams divided into 2 or 3 doses. Adults can be advised that use of a sucrose-free chewing gum containing xylitol only or polyol combinations for 10 to 20 minutes after meals may reduce incidence of coronal caries. Insufficient evidence was found to recommend use of xylitol for children younger than 5 years-of-age. This does not necessarily mean that xylitol is ineffective, but that insufficient evidence is available to make a determination. Since 2011, the European Food Safety Agency has accepted claims related to reductions in dental plaque for high- concentration xylitol chewing gum.49Milgrom P, Söderling EM, Nelson S, Chi DL, Nakai Y. Clinical evidence for polyol efficacy. Adv Dent Res 2012; 24(2):112-6. Globally, other organizations support the use of xylitol.11Fontana M, González-Cabezas C. Are we ready for definitive clinical guidelines on xylitol/polyol use? Adv Dent Res 2012;24(2):123-8.

Table 3. American Dental Association recommendations on polyols48Rethman MP, Beltrán-Aguilar ED, Billings RJ, Burne RA, Clark M, Donly KJ, Hujoel PP, Katz BP, Milgrom P, Sohn W, Stamm JW, Watson G, Wolff M, Wright T, Zero D, Aravamudhan K, Frantsve-Hawley J, Meyer DM; for the American Dental Association Council on Scientific Affairs Expert Panel on Nonfluoride Caries-Preventive Agents. Nonfluoride caries-preventive agents. Executive summary of evidence-based clinical recommendations. J Am Dent Assoc 2011;142(9):1065-71.
Children 5 years-of-age and older: Provide advice to parents/guardians that the incidence of coronal caries may be reduced by use of a xylitol or polyol combination chewing gum for 20 minutes after meals; and, by use of xylitol-containing lozenges/hard candies, dissolved slowly in the mouth after meals at a total daily dose of 5 to 8 grams divided into 2 or 3 doses.
Adults: Use of a sucrose-free chewing gum containing xylitol only or polyol combinations for 10 to 20 minutes after meals may reduce the incidence of coronal caries.

Source: American Dental Association

Conclusions

While more research is required on interventions using xylitol and other polyols, the available data supports their adjunctive use together with proven caries-prevention interventions.48Rethman MP, Beltrán-Aguilar ED, Billings RJ, Burne RA, Clark M, Donly KJ, Hujoel PP, Katz BP, Milgrom P, Sohn W, Stamm JW, Watson G, Wolff M, Wright T, Zero D, Aravamudhan K, Frantsve-Hawley J, Meyer DM; for the American Dental Association Council on Scientific Affairs Expert Panel on Nonfluoride Caries-Preventive Agents. Nonfluoride caries-preventive agents. Executive summary of evidence-based clinical recommendations. J Am Dent Assoc 2011;142(9):1065-71.

Dental professionals can advise patients and parents/guardians on the use and safety of xylitol and other polyols as adjuncts for preventive care. Individualized advice should be provided based on current recommendations, the patient’s age, caries risk, systemic health status and suitability of polyols as part of a strategy to reduce dental caries. Patients should also be advised to limit children’s intake of sugar-containing foods and drinks, if possible, limiting these to mealtimes.48Rethman MP, Beltrán-Aguilar ED, Billings RJ, Burne RA, Clark M, Donly KJ, Hujoel PP, Katz BP, Milgrom P, Sohn W, Stamm JW, Watson G, Wolff M, Wright T, Zero D, Aravamudhan K, Frantsve-Hawley J, Meyer DM; for the American Dental Association Council on Scientific Affairs Expert Panel on Nonfluoride Caries-Preventive Agents. Nonfluoride caries-preventive agents. Executive summary of evidence-based clinical recommendations. J Am Dent Assoc 2011;142(9):1065-71. Last but not least, pet owners should be made aware of the potentially lethal effects of xylitol in dogs and advised to check labels and keep xylitol-containing products out of their reach.

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