Caught Between Sucrose and Sucralose: A Dentist’s Dilemma

There is no doubt that Americans have a serious sweet tooth. You could even call it an outright sugar addiction.

To put this problem in perspective, the average person in the U.S. consumes 126 grams of sugar per day (amounting to approximately 500 calories). That's more than two times the amount the World Health Organization (WHO) recommends.

It's the Sugars, Stupid

The impact of sugar consumption on oral health is no mystery; it has long been a known offender when it comes to dental caries. One study recently published in the Journal of Dental Research charges that the role of sugars in the caries epidemic is underemphasized, and suggests that both research and public health policy has been misguided due to influence by the sugar industry.

...[R]esearchers mistakenly consider caries to be a multifactorial disease; they also concentrate mainly on mitigating factors, particularly fluoride. However, this is to misunderstand that the only cause of caries is dietary sugars…. The long-standing failure to identify the need for drastic national reductions in sugars intakes reflects scientific confusion partly induced by pressure from major industrial sugar interests.

Drastic reductions in sugars intake is great in theory, but getting Americans to kick their sugar habits for the sake of immediate and long-term oral health poses a serious challenge.

Artificial Sweeteners Are Even Worse

What about artificial sweeteners, you may be wondering. All the sweetness anyone could ask for but without the calories or cariogenicity... if only it were so easy.

Artificial sweeteners have been lauded as sugar's best replacement and their use has skyrocketed over the last two decades. Sucralose and aspartame are two of the most commonly used artificial sweeteners, in addition to acesulfame potassium and neotame. Diet sodas are loaded with them.

The problem with artificial sweeteners was most recently summarized in a General Dentistry clinical article entitled "What every dentist should know about artificial sweeteners and their effects" (May/June 2015, p. 22-25).

Artificial sweeteners, seemingly harmless food additives, preferentially activate a reward pathway [in the brain] for sweet flavors. Activation of this pathway can cause compensatory overeating that may nullify the rationale for artificial sweetener use. Artificial sweeteners may also increase the risk for developing obesity, Type 2 diabetes, and other manifestations of metabolic disorders due to their ability to influence gut microflora...

These findings—though rich in irony—leave the dental and medical communities with drastically fewer alternatives to sugar.

The authors of the General Dentistry article have the following recommendations for dentists:

[D]entists should share this information and provide personalized counseling to those patients who must monitor their glucose levels or are at high risk for caries…. Dentists should emphasize consumption in moderation and a preference for sweeteners from natural sources.

It is important to note that naturally-derived sugar alcohols, such as xylitol and mannitol, are not categorized as artificial sweeteners, and thus still have potential to be healthy sugar substitutes.

Just How Much Sugar?

Despite pressure from a whole host of health organizations, the USDA has not issued a specific recommended daily allowance for sugar. Instead, the USDA 2010 dietary guidelines lump together fats and added sugar and suggest a combined limit of five to 15 percent of total daily calories, which leaves a lot of guesswork for individuals.

WHO's 2015 "Guideline: Sugars intake for adults and children" advises adults and children to restrict the consumption of free sugars to "less than 10% of total energy intake;" they go on stating "A further reduction to below 5% of total energy intake would provide additional health benefits." Based on a 2,000 calorie per day diet, that equates to about 50 grams of sugar to meet the baseline WHO recommendation—less than 25 grams to get those "additional health benefits."

The American Heart Association's recommendations allow for no more than 100 calories (approximately 25 grams) for women and 150 calories (~37.5 grams) for men per day. By contrast, a single 12-ounce can of Coca-Cola contains 39 grams.

A study published in 2014 recommends reducing sugar intake to 2-3 percent throughout life, citing that life-long sugar intake has an accumulative effect, resulting in adults with a higher incidence of caries.

Let's be Practical Here

Experts are talking about a decrease in sugar consumption that would be Draconian by American standards. Telling the average American to go from 126 to 25 grams of sugar per day overnight is an exercise in futility. It just isn't going to happen quickly on a large scale.

So, where do we begin? Start with information. It goes without saying that educating patients on the effects of consuming too much sugar and artificial sweeteners, and backing it up with evidence from contemporary research and studies, is a good first step. Advising patients to actively try to reduce their added sugars intake and avoid artificial sweeteners as much as possible comes next. We can only hope that public health policies and campaigns eventually catch up and reinforce the message.

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