James Goolnik reveals everything dental professionals need to know about sweeteners and what to advise to patients.
Human brains have evolved to enjoy sweet tastes, and food manufacturers take advantage of this to sell their products. The focus on sugar in public health has led manufacturers to reduce calories through non-calorific sweeteners, keeping the same sweet taste but allegedly negating the harms of too much sugar.
Can we then get away with eating whatever sugar-free products we fancy? Sweeteners are ingredients that are added to food and drinks to enhance sweetness, but they can be broken down into a few different classifications. One division that is often drawn is between is natural and artificial sweeteners.
However, a more useful way of grouping sweeteners is to look at those that have nutritive value (ie, nutritive sweeteners) and those without nutritive value (ie, non-nutritive or ‘low-calorie’ sweeteners).
Nutritive sweeteners
There are many types of nutritive sweeteners, but they all contain carbohydrate and provide calories.
On packaging, you will see them labelled as ‘sugars’ or ‘added sugar’. Examples include glucose, fructose, sucrose and honey.
Polyols, such as xylitol, are a type of nutritive sweetener called sugar alcohols. They have fewer calories and affect your blood glucose levels less than sucrose. Polyols are used in a lot of dental products, including toothpaste and tooth mousse.
Non-nutritive sweeteners
The first non-nutritive or artificial sweetener was saccharin, first synthesised in 1879. You may recognise others such as aspartame, stevia and stevia derivatives.
The whole area of artificial sweeteners is quite controversial. To the industry, they are potentially a good way to avoid the damage that sugar is known to cause. As a consumer, it feels like we can potentially ‘have our cake and eat it too’.
Enjoying the sweetness that we crave without a downside is an attractive prospect for many. But this might not be the whole story.
In May, the World Health Organization (WHO) released new guidelines advising against the use of artificial sweeteners for weight control. They highlighted the possibility of negative effects on health including an increased risk of type 2 diabetes, cardiovascular diseases and mortality in adults.
The WHO advises the use of other ways to reduce free sugar intake, such as consuming foods with naturally occurring sugars, like fruit, or unsweetened foods and beverages.
Low-calorie swaps
When considered as a straight swap, diet and low-calorie products seem to make sense. For example, switching a full-sugar cola for a diet version results in a net reduction in calories – a saving of 97 calories for each substitution made.
Similarly, switching three sugars in a cup of tea to a sweetener will save 46 calories. But this is not quite as good as it seems. The catch is that artificial sweeteners still do not reduce appetite (Bellisle and Drewnowski, 2007). Hence, the drivers of overeating are maintained.
This makes it harder to lose weight if that is your goal, as the calories saved can be quickly wiped out if accompanied by a binge. This is probably why studies into sweetener consumption show zero to modest reduction in weight and a higher incidence of obesity, hypertension, metabolic syndrome, type 2 diabetes and cardiovascular events.
From a dental health perspective, diet drinks are still a problem, as the drink itself is corrosive to tooth enamel (Korte et al, 2019) irrespective of the fact that it doesn’t contain sugar. Many ‘tooth friendly’ products contain acidic flavouring that is known to erode teeth.
An important factor here is exposure time. We often tell our patients to drink through a straw, rinse mouths with water afterwards or chew sugar-free gum to try and neutralise that acid.
Finally, sweet receptors are still overstimulated by artificial sweeteners as with sugar. This means normal foods like vegetables will taste bitter. Consuming artificial sweeteners alters your palate over time to increase the desire for more sweet foods.
The first step
We advise our patients to switch to an artificial sweetener as the first step in the right direction. They can then slowly reduce the amount of sweetener until they do not use it at all.
Dental teams are best placed to help our patients by slowly reducing the overall sweetness in their diets as a whole. Use of diet sheets and working closely with a registered nutritionist gives the best sustainable results.
The fact that patients save money on future dental bills if they can stop the caries process is an added bonus.
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