BY Karen Davis, RDH, BSDH
Action Point Takeaways:
1. Inform your team and your patients of the noncariogenic property of erythritol with the advantage of having zero calories and being gentle on the GI tract.
2. Experiment using erythritol crystals (available on Amazon.com) to sweeten beverages and prepare foods.
3. Seek out new studies being published on the effectiveness of erythritol in caries control, management of biofilm, and suppression of periodontal pathogens.
Clinicians all over the world are talking to patients about the benefits of xylitol and advising them to have multiple xylitol exposures daily. Some even advise patients to substitute sugar with xylitol crystals when baking. Don't stop. The use of xylitol is great clinical advice.
But, are you also aware of the benefits of erythritol? Erythritol is a natural sweetener derived from plants and is present (in low levels) in mushrooms, soy sauce, many fruits, cheeses, beers, and wines. It is common in many Japanese foods and beverages. Erythritol has some advantages over other sugar alcohols in that it has nearly zero calories (0.2 calories per gram); does not raise plasma glucose, or insulin levels; is noncariogenic; and is easy to digest. More than 90% of erythritol is absorbed in the small intestine, so minimal amounts reach the colon where some sugar alcohols can cause bloating, gas, or diarrhea. Erythritol is heat stable, so it can be used in food preparation. Manufacturers are beginning to include it as a sugar substitute in gum, pudding, beverages, condiments, and cookies. Start reading labels, and you will begin to find erythritol in products such as Swiss Miss pudding, Zevia sodas, Vitamin Water Zero, and Orbit gum.
Recently, erythritol has gained the attention of researchers for application inside the oral cavity, posing it as a potential "new best friend" for dentistry. Molecular Oral Microbiology published an interesting study in 2013 examining the efficacy of sugar alcohols for inhibiting biofilm microorganisms implicated in the caries and periodontitis process.1 This was an in-vitro study, and it would be interesting to have a similar study performed on patients, but the results were promising nonetheless. Erythritol, sorbitol, and xylitol were all evaluated for their ability to inhibit development and growth of Streptococcus gordonii and Porphyromonas gingivalis. This study found erythritol to be the most effective in suppression of these pathogens and biofilm formation.
Another interesting study published in Caries Research in 2014 evaluated over 400 first and second graders consuming four candies three times per day (that were sweetened with erythritol, sorbitol, or xylitol).2 This was a double-blind, randomized, controlled prospective clinical trial comparing the effectiveness of these candies in the prevention of enamel and dentin caries. Their daily intake of sugar alcohols was 7.5 g per day and they were evaluated over a three-year period. The time for enamel/dentin caries to develop and the time for carious lesions to progress were significantly longer in the erythritol group compared to the sorbitol and xylitol groups. This study as well as others3,4 pose a promising outlook for erythritol to be an effective sweetener for patients at high caries risk, along with the added benefits of it being noncaloric and kind to the GI tract.
How else is erythritol advantageous in the oral environment? Currently, it is a "one-stop-shopping" air-polishing powder that effectively removes biofilm above and below the gum line, and it is also effective in stain removal. Erythritol-based Air Flow PLUS powder, by Electro Medical Systems (EMS), is available in Europe and is anticipated for FDA approval soon in the U.S. for supra- and subgingival air polishing through Hu-Friedy EMS. It is the lowest-abrasive air-polishing powder available with a particle size of 14 microns compared to sodium bicarbonate particle sizes of 45-70 and glycine powder with a particle size of 25. Using an air polishing powder that can tackle stains and is safe on tooth surfaces, restorative materials, and is kind to the tissue is a significant advantage for clinicians due to its efficiency in biofilm removal. Biofilm removal with erythritol air-polishing powder is significantly faster than biofilm removal with curettes5 or ultrasonic instrumentation and is perceived to be more comfortable by patients.6 A 2014 study published in the Journal of Periodontology compared erythritol and chlorhexidine air-polishing powder to glycine powder. In-vitro results revealed a stronger antimicrobial activity of the erythritol-based powder than the glycine powder and more powerful antibiofilm activity present with the erythritol-based powder compared to glycine.7
Additionally, erythritol-based air-polishing powder has been shown safe and significantly more efficient for biofilm removal associated with peri-implantitis than ultrasonic debridement with PEEK tips and Teflon curettes.8
So, what do you think? We know that xylitol is our friend, but perhaps erythritol will soon become dentistry's new best friend. RDH
1. Hashino E, Kuboniwa M, Alghamdi S, Yamaguchi M, Yamamoto R, Cho H, Amano A. Erythritol alters microstructure and metabolomic profiles of biofilm composed of Streptococcus gordonii and Porphyromonas gingivalis. Molecular Oral Microbiology 2013:435-451.
2. Honkala S, Runnel R, Saag M, Olak J, Mömmela R, et al. Effect of erythritol and xylitol on dental caries prevention in children. Caries Research 2014;48(5):482-90.
3. Makinen K. Sugar alcohols, caries incidence, and remineralization of caries lesions: a literature review. International Journal of Dentistry 2010;981072.
4. Makinen K, Saag M, Isotupa K, et al. Similarity of the effects of erythritol and xylitol on some risk factors of dental caries. Caries Research 2005;39: 207-215.
5. Hagi T, Hofmänner P, Salvi G, Ramseier C, et al. Clinical outcomes following subgingival application of a novel erythritol powder by means of air polishing in supportive periodontal therapy: A randomized, controlled clinical study. Quintessence International 2014: 1-9.
6. Müller N, Moëne R, Cancela J, Mombelli A. Subgingival air-polishing with erythritol during periodontal maintenance. Journal of Clinical Periodontology 2014 Sept;41(9): 883-889.
7. Drago L, Del Fabbro M, Borolin M, Vanessa C, Vecchi E, Taschieri S. Biofilm removal and antimicrobial activity of two different air-polishing powders: an in vitro study. Journal of Periodontology 2014; 85:e363-e369.
8. Nastri L, Miraldi G, Ripoli R. Treatment of peri-implantitis using an air polishing device with erythritol powder or mechanical debridement: a randomized, controlled split mouth clinical study. Clinical Oral Implants Research 2014; 25 (Suppl.10) 645-646.
Karen Davis, RDH, BSDH, is the founder of Cutting Edge Concepts, an international continuing education company, and practices dental hygiene in Dallas, Texas. She is an independent consultant to the Philips Corp., Periosciences, and Hu-Friedy/EMS. She can be reached at [email protected].