Is Xylitol Safe for Your Smile?

Xylitol has health benefits for your teeth. Unfortunately, recent research reveals that xylitol (and its cousin erythritol) can increase your risk of major adverse cardiovascular events, particularly impacting your blood clotting abilities.

As many holistic dentists recommend xylitol, I do not recommend sugar alcohols as a sugar substitute. Instead, I encourage my patients to balance their oral microbiome to strengthen their body’s natural healing properties.

Keep reading to figure out the exact science behind xylitol’s benefits and drawbacks.

I’m Gerry Curatola, DDS. I’m a leading biologic dentist, founder of prebiotic toothpaste Revitin, and author of The Mouth-Body Connection, emphasizing oral health’s correlation with your whole-body health. Check out my book for a biologic healthcare professional’s POV.

What Other Dentists Say

Holistic and conventional dentists generally agree that xylitol works on your oral health, restoring tooth enamel and remineralizing cavities, without spiking blood sugar levels. I don’t believe that’s the whole story, but more on that in the next section.

For many years now, xylitol has been touted by both alternative dentists and mainstream experts. Conventional scientists and big companies like Mentos and Extra Gum seldom buy into holistic health products as a dental health boon. But xylitol confounds this pattern.

Many studies show the benefits of xylitol to dental health, such as starving dental plaque buildup that causes tooth decay. Xylitol specifically targets Streptococcus mutans, meaning it does not indiscriminately kill the beneficial bacteria in your oral cavity — another plus in xylitol’s column.

Learn More: Why Is the Saliva-Teeth Microbial Complex Important?

However, recent studies show that sugar alcohols like xylitol and erythritol can increase your risk of heart disease and major cardiovascular events. And all these xylitol fans and sugar-free gum companies have not changed their marketing or sales approach.

A Biologic Dentist’s Perspective

As a biologic dentist focused on whole-body health, I cannot recommend xylitol. I am open to future studies showing that the infamous Cleveland Clinic study was flawed and there are no real heart risks, but I cannot recommend xylitol at this time.

First of all, everyone agrees that xylitol leads to gastrointestinal distress.

This adverse effect is connected with xylitol being a nearly zero-calorie sugar alternative. Sugar alcohols are not digested, meaning they don’t contribute to calories, but they also may cause bloating or diarrhea.

Some are more sensitive to xylitol than others, but gastrointestinal issues can affect anyone, decreasing quality of life and impacting your gut microbiome.

The digestive issues are likely why many in the pediatric dentistry field do not recommend xylitol for young children. I would go further and suggest that young children avoid xylitol due to blood clotting issues.

Secondly, recent research has shown that sugar alcohols (polyols like xylitol) may accelerate clotting and increase the risk of major adverse cardiovascular events (MACE).

A 2024 Cleveland Clinic study shows that increased blood xylitol levels are associated with an increase in the 3-year incidence of MACE, such as heart attack and stroke. I’ll go into detail on what the study says in the next section.

This evidence demands that more research be conducted into xylitol’s impact on heart health and whole-body wellness. I would not recommend that any of my patients consume xylitol in any form until more research shows that it is safe.

In the meantime, I recommend the following people should definitely not consume xylitol in gums, candies, drinks, or any food or drink:

• People with heart health issues

• People with a family history of cardiovascular health problems

• Anyone with blood clotting conditions (e.g., hypercoagulation, thrombophilia)

The Xylitol-Erythritol and Blood Clot Connection

In one extensive study, xylitol levels in your blood have been linked to increased major adverse cardiovascular events (MACE) risk. The Cleveland Clinic study is really multiple experiments at once.

The test subjects were 56 to 72 years old, overweight or obese, and had elevated cholesterol. Around 76%-78% had a history of cardiovascular disease, and 72% had high blood pressure.

Read Next: Is Nano Hydroxyapatite Toothpaste Safe?

Part 1: Measuring Xylitol Levels and MACE Risk

In the first experiment, researchers conducted untargeted metabolomics. They concluded that individuals with elevated xylitol measured in their blood (top third of participants) had a 64% higher chance of MACE risk than the participants with the lowest third of blood xylitol.

Untargeted metabolomics cannot reliably distinguish xylitol from its isomers, so the lab conducted targeted, precise measurements on a new cohort of similar subjects.

They found a 57% higher chance of MACE over 3 years between the top third and bottom third of participants, organized by blood xylitol levels. Specifically, they found a higher risk of blood clotting problems.

Higher xylitol levels make your blood clot faster.

Do elevated xylitol levels reliably predict MACE risk? Or are people’s natural xylitol levels elevated when you’re at high MACE risk? Remember, our bodies naturally produce some xylitol as a normal part of carbohydrate metabolism.

Part 2: Does Dietary Intake of Xylitol Impact MACE Risk?

Here’s the important part: To assess whether xylitol dietary intake affects MACE risk, they gave 10 healthy individuals 30 grams of xylitol in water.

30 grams is a lot of xylitol for some people — that’s like eating an entire pack of sugar-free gum in one sitting. However, researchers came to this high amount based on a serving of keto ice cream or baked goods cooked with xylitol instead of sugar.

A half hour after ingestion, xylitol levels spiked 1,000-fold more than median baseline levels. After 4-6 hours, blood xylitol returned to normal levels.

This experiment shows that the use of xylitol in the diet briefly impacts blood xylitol levels. It also implies that the elevated xylitol levels in participants with higher MACE risk are not caused by diet alone.

Part 3: Xylitol Levels Enhance Blood Clotting

The Cleveland Clinic team wanted to explore the initial findings further, which were that xylitol directly impacted coagulation (AKA blood clotting).

At fasting levels, xylitol alone did not affect platelets. But when platelets were exposed to xylitol plus a submaximal dose of a known agonist, platelet activity increased significantly in a dose-dependent manner, becoming more sensitive even to normal stimuli.

This suggests even moderate increases in xylitol after eating can heighten clotting potential.

The lab conducted an artificial experiment that mimicked human blood flow. The scientists confirmed that xylitol significantly sped up platelets' adherence to collagen and calcium release, both key steps in clot formation.

Part 4: Arterial Injury in Mice

Next, researchers incised the arteries in mice. (It’s illegal to slice open human arteries for a study.)

The mice given xylitol via injection showed quicker clot formation and cessation of blood flow than the control mice.

Although quicker blood clotting is good for healing cuts, it also increases your risk of heart attack and stroke.

Part 5: Discussion and Conclusion

Animal and human trials showed that xylitol increases platelet activity and clotting. Although dietary xylitol intake produced interesting results, the Cleveland Clinic team argues that their observations “reflect endogenous xylitol levels… not recent dietary exposure.”

Although marketed as a safe and health-conscious sweetener, xylitol has direct, measurable, and concerning side effects on blood clotting. Since xylitol production has increased 40-fold in the past 40 years, further investigation is required to determine xylitol’s safety in humans.

Until more studies can elucidate whether xylitol is safe or at what amounts it should or shouldn’t be consumed, some experts (including myself) are recommending avoiding all xylitol due to its potential harm to your cardiovascular system.

Their studies suggested xylitol “will likely confer heightened thrombosis potential in the same vulnerable patients that it is marketed towards and intended to protect,” as in people with diabetes, obesity, and cardiovascular disease.

FAQs

Is xylitol better than fluoride?

Xylitol is better than fluoride since fluoride has been shown to cause systemic health problems for decades. Xylitol helps fight cavities, but not as well as fluoride. Xylitol may increase your risk of heart disease, but fluoride would almost certainly increase your risk even more.

The best oral hygiene products should not kill bacteria but nourish the natural balance of beneficial bacteria in the oral microbiome. So, steer clear of using a xylitol toothpaste. 

Should I chew gum with xylitol in it?

I recommend you avoid chewing xylitol gum. It may be better than chewing sugar gum, but the best option is not to chew any gum. Sugar can contribute to dental caries, gum disease, and obesity, while xylitol seems to contribute to cardiovascular disease risk.

Instead of trying to hack your oral health with sugar substitutes, simply empower your oral microbiome with probiotics and prebiotics.

Choose Microbiome-Supporting Oral Care

Avoid xylitol-containing products, at least for now — especially if you’re a diabetic or at risk for heart disease. Despite the oral health benefits and fewer calories, this “natural sweetener” seems to increase your risk of major adverse cardiovascular events.

Instead of artificial sweeteners and sugar alcohols like xylitol and erythritol, focus on promoting oral microbiome balance through an all-natural oral hygiene routine, including flossing, non-alcoholic mouthwashes, a microbiota-friendly toothpaste, and regular hygienist visits.

For instance, oral probiotics and prebiotic supplements are designed to add diverse beneficial bacteria into your oral cavity, empowering your mouth’s natural healing properties.

Looking for an all-natural toothpaste that supports your oral microbiome? Try Revitin, the first prebiotic toothpaste that is designed by the nation’s leading biologic dentist to balance oral health with whole-body health.

Sources

1. Gasmi Benahmed, A., Gasmi, A., Arshad, M., Shanaida, M., Lysiuk, R., Peana, M., ... & Bjørklund, G. (2020). Health benefits of xylitol. Applied Microbiology and Biotechnology, 104(17), 7225-7237.
2. Witkowski, M., Nemet, I., Alamri, H., Wilcox, J., Gupta, N., Nimer, N., ... & Hazen, S. L. (2023). The artificial sweetener erythritol and cardiovascular event risk. Nature medicine, 29(3), 710-718.
3. Nayak, P. A., Nayak, U. A., & Khandelwal, V. (2014). The effect of xylitol on dental caries and oral flora. Clinical, cosmetic and investigational dentistry, 89-94.
4. Meyer-Gerspach, A. C., Drewe, J., Verbeure, W., Roux, C. W. L., Dellatorre-Teixeira, L., Rehfeld, J. F., ... & Wölnerhanssen, B. K. (2021). Effect of the natural sweetener xylitol on gut hormone secretion and gastric emptying in humans: a pilot dose-ranging study. Nutrients, 13(1), 174.
5. Witkowski, M., Nemet, I., Li, X. S., Wilcox, J., Ferrell, M., Alamri, H., ... & Hazen, S. L. (2024). Xylitol is prothrombotic and associated with cardiovascular risk. European Heart Journal, 45(27), 2439-2452.