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Chapter 38: The Sweetener Spectrum

In which we navigate the confusing world of sugar alternatives, separate marketing from science, and discover that "sugar-free" isn't always what it claims to be

I've watched humans struggle with their sweet tooth since before recorded history. Honey was the first great temptation. Then came refined sugar, and cavities followed like wolves trailing a wounded deer. Now, standing in a modern health food store, you face an overwhelming array of alternatives—bags and packets and drops, all promising the sweetness without the consequences.

Some of these promises are true. Some are half-truths. Some are outright lies.

Let me guide you through this maze, because your teeth—and honestly, your whole body—deserve better than marketing copy.

First, Some Important Definitions

Before we proceed, I need to clarify two words that look dangerously similar but mean very different things:

Cariogenic means "causes cavities" (caries). This is our primary concern for oral health. A cariogenic substance can be fermented by mouth bacteria to produce acid, which dissolves tooth enamel.

Carcinogenic means "causes cancer." This is a systemic health concern, entirely separate from dental effects. I'll address this where relevant, but don't confuse the two—they share only their Latin roots.

Throughout this chapter, when I say a sweetener is "non-cariogenic," I mean it doesn't cause cavities. Nothing more sinister than that.

The Fundamental Question: Can Bacteria Eat It?

Here's the key to understanding sweeteners and teeth: oral bacteria can only damage your teeth if they can metabolize what you eat.

When bacteria—particularly Streptococcus mutans and Lactobacillus species—ferment sugars, they produce organic acids as metabolic byproducts. These acids drop the pH of dental plaque below the critical threshold of about 5.5, at which point enamel begins to dissolve.1

Regular sugar (sucrose) is the champion of cariogenicity. Bacteria love it. They ferment it efficiently, produce abundant acid, and—here's the really troublesome part—use it to produce sticky glucans that help them adhere to teeth and build biofilm.2

So when we evaluate sweeteners, the first question is simple: can the bacteria in your mouth metabolize this substance to produce acid?

If the answer is no, it's non-cariogenic. But that's only half the story, as we'll see.

The Sugar Alcohols (Polyols)

Sugar alcohols are neither sugars nor alcohols in the way you might think. They're carbohydrates with a chemical structure that resembles both sugar and alcohol molecules. Most occur naturally in small amounts in fruits and vegetables.

The key feature: most oral bacteria lack the enzymes to efficiently ferment them.3

Xylitol: The Gold Standard

I've discussed xylitol extensively elsewhere in this book, but it deserves mention here for comparison.

Cariogenic potential: Non-cariogenic. S. mutans cannot metabolize xylitol—in fact, the bacteria waste energy trying to process it, which inhibits their growth.4

Glycemic index: 7-13 (compared to sugar's 60-65)5

Insulin response: Minimal. Does not significantly raise blood glucose or insulin in most people.6

Evidence strength: Strong. Multiple systematic reviews support xylitol's dental benefits, particularly when used 3-5 times daily.7

Digestive tolerance: Moderate. Can cause gastrointestinal distress (gas, bloating, diarrhea) at doses above 40-50g per day. Most people adapt with regular use.8

The verdict: Remains the best-studied sugar alcohol for dental health. The active inhibition of S. mutans sets it apart from merely being "not harmful."

Erythritol: The Rising Star

Here's where things get interesting. Erythritol may actually be more effective than xylitol for some dental outcomes.

Cariogenic potential: Non-cariogenic. Like xylitol, erythritol cannot be fermented by oral bacteria to produce significant acid.9

Glycemic index: Essentially 010

Insulin response: None. Erythritol is absorbed in the small intestine and excreted unchanged in urine—it doesn't participate in metabolism.11

Evidence strength: Growing. A 2016 randomized controlled trial found erythritol superior to both xylitol and sorbitol for reducing plaque and S. mutans counts in children.12 A 2022 systematic review confirmed erythritol's non-cariogenic properties.13

Digestive tolerance: Excellent. Because erythritol is absorbed before reaching the colon, it causes significantly less gastrointestinal distress than other sugar alcohols. Most people tolerate doses up to 50g without issues—far higher than xylitol or sorbitol.14

The verdict: Erythritol deserves more attention than it gets. The combination of zero glycemic impact, excellent digestive tolerance, and emerging evidence of dental benefits makes it attractive. Its main drawback is slightly less cooling sensation than xylitol and about 70% the sweetness of sugar.15

Sorbitol: The Workhorse

Sorbitol is the most common sugar alcohol in commercial "sugar-free" products, largely because it's inexpensive.

Cariogenic potential: Low, but not zero. Unlike xylitol and erythritol, some oral bacteria can slowly ferment sorbitol, though acid production is much less than with sucrose.16 It's "reduced cariogenic" rather than truly non-cariogenic.

Glycemic index: Approximately 917

Insulin response: Low but present. Sorbitol is partially metabolized and does produce a small glycemic response.18

Evidence strength: Moderate. Sorbitol-sweetened products are clearly better for teeth than sugar-sweetened ones, but direct comparisons show xylitol and erythritol are more protective.19

Digestive tolerance: Poor. Sorbitol is notorious for causing gastrointestinal symptoms. The dose threshold for distress is lower than other polyols.20

The verdict: Better than sugar, worse than xylitol or erythritol. Commonly used in sugar-free gum because it's cheap, but not the optimal choice for those seeking maximum dental protection.

Maltitol: The Trap

Now we arrive at what I consider a genuine problem in the "sugar-free" market.

Cariogenic potential: Low to moderate. Maltitol can be fermented by some oral bacteria, though less efficiently than sucrose. It's better than sugar but worse than other polyols.21

Glycemic index: 35-52 depending on form (maltitol syrup has higher GI than crystalline maltitol)22

Insulin response: Significant. Maltitol produces about 50-75% of the glycemic response of sugar.23 This is NOT a low-glycemic sweetener despite what marketing suggests.

The trap: Maltitol is heavily used in "sugar-free" chocolates, candies, and baked goods because it has similar bulk and texture to sugar. Products proudly labeled "sugar-free" or "diabetic-friendly" often contain maltitol—and people with diabetes who trust that label may find their blood sugar spiking unexpectedly.

Digestive tolerance: Poor. Like sorbitol, maltitol frequently causes gastrointestinal distress.24

The verdict: I cannot recommend maltitol with enthusiasm. For oral health, it's mediocre. For glycemic control, it's actively misleading. If you see maltitol on a label, know that you're not getting the benefits of true sugar-free products.

Isomalt: The Baking Sugar Alcohol

Cariogenic potential: Very low. Isomalt is poorly fermented by oral bacteria.25

Glycemic index: 2-926

Insulin response: Minimal.

Evidence strength: Moderate. Used in some dental products and "tooth-friendly" candies in Europe.

Digestive tolerance: Moderate to poor. Like other sugar alcohols, can cause GI distress.27

The verdict: A reasonable choice when bulk is needed (baking, candies), but gastrointestinal effects limit intake.

Sugar Alcohol Summary Table

Sweetener Cariogenic GI Digestive Tolerance Notes
Xylitol No (inhibits bacteria) 7-13 Moderate Best studied for dental benefits
Erythritol No ~0 Excellent May outperform xylitol for plaque
Sorbitol Low (slow fermentation) ~9 Poor Common but not optimal
Maltitol Low-moderate 35-52 Poor Misleadingly marketed; avoid for glycemic control
Isomalt Very low 2-9 Moderate Useful for bulk in recipes

High-Intensity Natural Sweeteners

These sweeteners provide intense sweetness in tiny amounts—hundreds of times sweeter than sugar. Because so little is used, they contribute essentially no calories or carbohydrates.

Stevia (Steviol Glycosides)

Stevia comes from the leaves of Stevia rebaudiana, a plant native to South America that's been used as a sweetener for centuries.

Cariogenic potential: Non-cariogenic. Steviol glycosides cannot be fermented by oral bacteria.28 Some research suggests stevia may actually inhibit bacterial growth and biofilm formation, though evidence is preliminary.29

Glycemic index: 030

Insulin response: None from the steviol glycosides themselves. Pure stevia does not raise blood glucose or stimulate insulin secretion.31

Evidence strength: Moderate for dental effects. Strong for safety (extensively studied for regulatory approval).

Taste considerations: Stevia has a characteristic aftertaste that some people find unpleasant—bitter, licorice-like, or metallic. Different steviol glycosides (Rebaudioside A, Rebaudioside M, etc.) have different taste profiles. Reb M is generally considered the cleanest-tasting.32

The product problem: Pure stevia is so intensely sweet that it's impractical to measure for home use. Most consumer stevia products are bulked with fillers—and here's where it gets problematic. Common fillers include:

  • Maltodextrin: A carbohydrate with a GI of 85-105—higher than sugar itself33
  • Dextrose: Just glucose by another name
  • Lactose: A fermentable sugar that IS cariogenic

So that "stevia" packet you're pouring in your coffee might be mostly maltodextrin with a tiny amount of stevia. Read labels carefully.

The verdict: Stevia itself is an excellent choice—non-cariogenic, zero glycemic impact, from a plant source. But beware of products that dilute it with cariogenic or high-GI fillers.

Monk Fruit (Luo Han Guo)

Monk fruit comes from Siraitia grosvenorii, a vine native to southern China and northern Thailand. The sweetness comes from compounds called mogrosides.

Cariogenic potential: Non-cariogenic. Mogrosides cannot be fermented by oral bacteria.34

Glycemic index: 035

Insulin response: None. Pure monk fruit extract does not raise blood glucose.36

Evidence strength: Limited for dental effects specifically, but strong for non-cariogenicity given the mechanism.

Taste considerations: Monk fruit has a cleaner taste profile than stevia for many people, with less aftertaste. It does have a slight fruity/melon note that some find pleasant and others find odd.37

The product problem: Same as stevia—most commercial monk fruit products are bulked with fillers. Erythritol is a common (and acceptable) filler; maltodextrin and dextrose are problematic ones.

The verdict: Excellent choice when pure or combined with other non-cariogenic sweeteners like erythritol. Read labels.

High-Intensity Artificial Sweeteners

These are synthetic compounds, some discovered by accident, that provide intense sweetness. They've been controversial since their introduction, but the dental science is actually quite clear.

Sucralose

Sucralose is made from sugar through a process that substitutes three chlorine atoms for three hydroxyl groups. Yes, it contains chlorine—but so does table salt (sodium chloride). The chlorine is bound within the molecule and doesn't behave like free chlorine.

Cariogenic potential: Non-cariogenic. Sucralose passes through the digestive system largely unchanged and cannot be fermented by oral bacteria.38

Glycemic index: 039

Insulin response: Controversial. Pure sucralose does not raise blood glucose, but some studies suggest it may affect insulin response or glucose tolerance through other mechanisms (gut microbiome effects, taste receptor signaling). Evidence is mixed and effects appear modest if present.40

Safety considerations: Sucralose has been extensively studied and is approved by regulatory agencies worldwide. Some research raises questions about effects on gut microbiota at high doses, but standard consumption appears safe.41

The product problem: Splenda, the most common sucralose product, is mostly maltodextrin by weight. One cup of Splenda contains about 24g of maltodextrin (with its GI of 85-105) and only about 1g of sucralose.42

The verdict: Non-cariogenic and zero-calorie, but the common commercial forms come with problematic fillers. Liquid sucralose avoids the filler issue.

Aspartame

Aspartame is a dipeptide—two amino acids (phenylalanine and aspartic acid) bonded together. It's metabolized in the body, unlike most artificial sweeteners, but the amounts are tiny.

Cariogenic potential: Non-cariogenic. Aspartame cannot be fermented by oral bacteria to produce acid.43

Glycemic index: 0 at normal serving sizes44

Insulin response: Minimal to none at typical consumption levels.45

Safety considerations and the cancer question: In 2023, the International Agency for Research on Cancer (IARC) classified aspartame as "possibly carcinogenic to humans" (Group 2B)—the same category as aloe vera extract and picked vegetables.46 This sounds alarming but requires context:

  • The classification was based on limited evidence from some observational studies
  • The Joint FAO/WHO Expert Committee on Food Additives (JECFA) simultaneously reaffirmed the acceptable daily intake of 40mg/kg body weight
  • To exceed this limit, a 70kg adult would need to consume about 9-14 cans of diet soda daily, depending on brand
  • Group 2B means "possibly carcinogenic"—the evidence is not sufficient to establish causation

For oral health purposes, aspartame is non-cariogenic. The systemic health debate continues but is beyond the scope of dental considerations.

The phenylketonuria warning: People with PKU (phenylketonuria) cannot metabolize phenylalanine and must avoid aspartame entirely. This is clearly labeled on products.

The verdict: Non-cariogenic. The cancer classification is a "possible" risk at doses far exceeding normal consumption, similar to many common substances. Individual risk tolerance varies.

Saccharin

The oldest artificial sweetener, discovered in 1879. Once feared as a carcinogen (based on flawed rat studies), saccharin was delisted as a potential carcinogen in 2000.47

Cariogenic potential: Non-cariogenic. Cannot be fermented by oral bacteria.48

Glycemic index: 0

Insulin response: None.49

Taste considerations: Saccharin has a bitter, metallic aftertaste at high concentrations, which is why it's often blended with other sweeteners.

The verdict: Non-cariogenic, though taste limits its appeal. The cancer scare has been resolved—saccharin is considered safe.

Acesulfame Potassium (Ace-K)

Often used in combination with other sweeteners to mask aftertastes.

Cariogenic potential: Non-cariogenic.50

Glycemic index: 0

Insulin response: Some studies suggest possible effects on insulin secretion, but evidence is inconsistent.51

The verdict: Non-cariogenic. Commonly used in blends.

The Rare Sugars

These are sugars that exist in nature but in small quantities. They're technically sugars but behave very differently from sucrose or glucose.

Allulose (D-Psicose)

Allulose is a "rare sugar" found naturally in small quantities in figs, raisins, and maple syrup. It tastes almost exactly like sugar but is barely metabolized by the human body.

Cariogenic potential: Non-cariogenic. Oral bacteria cannot efficiently ferment allulose to produce acid.52

Glycemic index: 0-153

Insulin response: Does not raise blood glucose or stimulate insulin secretion. Some evidence suggests it may even blunt the glucose response when consumed with other carbohydrates.54

Evidence strength: Growing. Relatively new to the market but mechanistic evidence supports non-cariogenicity.

Taste considerations: Remarkably similar to sugar with about 70% of the sweetness. No significant aftertaste.55

Cost considerations: Currently expensive due to limited production scale.

The verdict: Perhaps the most promising sweetener for those who want sugar-like taste without cariogenic or glycemic effects. The main barrier is cost.

Tagatose

Another rare sugar with similar properties to allulose.

Cariogenic potential: Non-cariogenic to very low cariogenicity.56

Glycemic index: 357

Insulin response: Minimal.

The verdict: Similar to allulose but less widely available.

The Glycemic Index Question

You might have noticed I've been tracking glycemic index alongside cariogenic potential. Why does this matter for a book about teeth?

First, because many people seeking alternatives to sugar are doing so for multiple health reasons—diabetes management, weight control, metabolic health. A sweetener might be excellent for your teeth but problematic for your blood sugar.

Second, because insulin and glucose affect your entire body, and the mouth is part of that body. Diabetes is a significant risk factor for periodontal disease.58 Chronic hyperglycemia impairs immune function and wound healing, including in oral tissues.59 If you're choosing sweeteners to protect your health, you should consider the whole picture.

The Cephalic Phase Insulin Response: What We Actually Know

You may have heard that sweet taste alone—regardless of whether the sweetener contains calories—triggers an insulin response. This is called the cephalic phase insulin response (CPIR).

The evidence here is genuinely mixed:

Some studies show small, measurable insulin increases in response to sweet taste alone.60 Others find no effect.61 The response, when present, appears to vary between individuals and may be influenced by learned associations between sweet taste and caloric intake.62

What we can say with more confidence:

  • Pure artificial sweeteners do not raise blood glucose (because there's no glucose to raise)
  • Any insulin response to sweet taste alone is small compared to the response to actual glucose consumption
  • The clinical significance of CPIR, if it exists, is unclear

I'm presenting this nuance because you deserve accurate information, not because it should change your practical decisions. If you're managing diabetes, the glycemic index of the sweetener itself is what will affect your blood sugar readings.

The Product Problem: Reading Labels

Here's where my exasperation reaches its peak.

A sweetener can be perfectly non-cariogenic and zero-glycemic in its pure form, yet the commercial product you buy might be diluted with substances that are neither.

Common problematic fillers:

Filler GI Cariogenic? Found in
Maltodextrin 85-105 Yes Splenda packets, stevia packets
Dextrose 100 Yes Various "sugar-free" products
Lactose 46 Yes Some stevia products
Fructose 19 Yes Some "natural" blends

Better fillers:

Filler GI Cariogenic? Notes
Erythritol 0 No Common in monk fruit products
Inulin (fiber) 0 No Prebiotic, feeds beneficial bacteria

Acidic products:

Some liquid sweeteners and flavored waters contain citric acid, phosphoric acid, or other acids for flavor enhancement. These acids are directly erosive to enamel—no bacterial fermentation required. A "sugar-free" beverage can still be damaging your teeth if it's acidic.63

My recommendation: Read the full ingredient list, not just the front label. When possible, choose:

  • Pure liquid forms (no fillers needed)
  • Products bulked with erythritol or fiber rather than maltodextrin
  • Products without added acids

Practical Guidance: Matching Sweeteners to Goals

Let me boil all of this down for you in my cauldron:

If your primary goal is dental health:

Best choices: Xylitol (for active bacterial inhibition), erythritol (for excellent tolerance and plaque reduction), stevia (pure), monk fruit (pure), allulose

Acceptable: Sorbitol, isomalt, sucralose, aspartame, saccharin (all non- or minimally cariogenic)

Avoid: Maltitol (moderate cariogenic potential), any product with maltodextrin/dextrose/lactose as primary filler

If your primary goal is blood sugar management:

Best choices: Erythritol (GI 0), stevia (GI 0), monk fruit (GI 0), allulose (GI 0-1)

Acceptable: Xylitol (GI 7-13), sorbitol (GI ~9), sucralose, aspartame, saccharin

Avoid: Maltitol (GI 35-52—this is critical), products bulked with maltodextrin (GI 85-105)

If you want the most natural option:

Plant-derived: Stevia, monk fruit, xylitol (from birch or corn), erythritol (fermented from glucose)

Rare sugars: Allulose, tagatose

Note: "Natural" doesn't automatically mean "safe" or "healthy," and "artificial" doesn't automatically mean "dangerous." These are marketing categories, not safety categories. I evaluate on evidence, not etymology.

If digestive tolerance is a concern:

Best tolerated: Erythritol (absorbed before reaching colon), stevia (used in tiny amounts), monk fruit (used in tiny amounts), allulose, sucralose, aspartame

Potentially problematic: Sorbitol, maltitol, isomalt, xylitol at high doses

The Moderation Principle

I've been collecting teeth for millennia, and if there's one lesson I've learned, it's that humans struggle with moderation. You discover that something is "healthy" or "safe" and proceed to consume it in quantities that would make even me raise an eyebrow.

Non-cariogenic sweeteners are not a license for unlimited sweet consumption. There are reasons for moderation:

Habituation: Constant intense sweetness may perpetuate cravings for sweet foods and make naturally sweet foods (fruit) seem inadequate.64 Training your palate to enjoy less sweetness has value.

Unknown unknowns: Most of these sweeteners have been consumed at current levels for only a few decades. The long-term effects of consuming large amounts of any non-nutritive sweetener are not fully known. Caution is warranted.

The diet soda paradox: Observational studies show associations between artificial sweetener consumption and weight gain or metabolic issues.65 This may be confounding (people who are already overweight may be more likely to choose diet products), or it may indicate effects we don't fully understand. Experimental evidence is less clear.

Displacement: If you're drinking sugar-free sodas, you're not drinking water. If you're eating sugar-free candy, you're not eating vegetables. The displacement of nutritious foods matters.

My advice: use these sweeteners when sweetness is needed, choose wisely based on your health goals, and don't mistake "sugar-free" for "unlimited."

A Word on Children

Children's developing teeth and metabolic systems deserve special consideration.

For dental health, xylitol has the strongest evidence in children.66 Regular xylitol exposure (through gum, mints, or syrup) can significantly reduce cavity rates.

For other sweeteners, the considerations are similar to adults, but:

  • Be especially vigilant about products marketed to children that contain maltodextrin or other cariogenic fillers
  • Sugar alcohols can cause digestive upset at doses children may encounter more easily
  • The long-term effects of high artificial sweetener consumption starting in childhood are not well studied

When possible, help children develop a palate that doesn't require intense sweetness. The best sweetener is often less sweetener.

Summary Table: The Complete Sweetener Spectrum

Sweetener Type Cariogenic GI Sweetness vs Sugar Key Considerations
Sucrose Sugar YES 60-65 1x The problem
Xylitol Sugar alcohol No (inhibits bacteria) 7-13 1x Best studied for teeth
Erythritol Sugar alcohol No 0 0.7x Best tolerance, may beat xylitol
Sorbitol Sugar alcohol Low ~9 0.6x GI issues, commonly used
Maltitol Sugar alcohol Low-moderate 35-52 0.9x AVOID for glycemic control
Isomalt Sugar alcohol Very low 2-9 0.5x Useful for baking
Stevia Natural high-intensity No 0 200-350x Watch for fillers
Monk Fruit Natural high-intensity No 0 150-200x Watch for fillers
Sucralose Artificial No 0 600x Fillers in powder form
Aspartame Artificial No 0 200x IARC 2B; PKU warning
Saccharin Artificial No 0 300-400x Cancer scare resolved
Allulose Rare sugar No 0-1 0.7x Most sugar-like; expensive

What I want you to take from this chapter is nuance. The sweetener world is not divided cleanly into "good" and "bad." It's divided into trade-offs—between dental effects and glycemic effects, between taste and tolerance, between pure forms and commercial products.

Read labels. Choose consciously. And remember that even the best sweetener is no substitute for actual food.

Your teeth will thank you. And so will I, since it means fewer collections for me to make.

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