As a dentist, I get asked a lot about sugar. But as it turns out, sugar isn’t actually the worst thing for your teeth. Sugar also isn’t the cause of tooth decay; acid is. The most cavity-causing food is crackers and breads, not candy.

As someone with a major sweet tooth myself, I’ve wondered many of the same things: How bad is sugar, really? How much sugar can we get away with?

Sugar also doesn’t just impact oral health; it impacts overall health too. New research is starting to find that our levels of sugar consumption are making sugar a toxin that could be a driving force behind many diseases, such as heart disease, diabetes, Alzheimer’s, and breast, endometrial, and colon cancers.

I aim to answer all of your questions about sugar in this blog post, as well as share my tips for how to indulge a sweet tooth healthily and safely. If you still have a question by the end of this blog post, let me know in the comments and I’ll be glad to answer it! I read each and every one.

How does sugar cause cavities?

This is actually a myth. Acid causes cavities. When you eat something with sugar, bacteria that naturally reside in your mouth consume this sugar as well. Bacteria’s waste product is acid, so after they have a meal, they excrete acid. Acid is what causes problems for teeth. Enamel is strong, but not strong enough to resist acid. Acid decalcifies or demineralizes tooth enamel by taking away its structure, creating decay.

My pediatric patients are very impressed when I tell them that cavities are caused by bacteria “pooping” in their mouth. Whatever helps you remember!

Is sugar the only cause of cavities?

No! In fact, the number one most cavity-causing food is crackers. Goldfish and saltine crackers are the worst. That’s because they’re fermentable carbohydrates. What does that mean? It means foods that are easily broken down in the mouth, instead of later on down the digestive tract. Fermentable carbohydrates allow the bacteria in your mouth to have a feast, and thus, increase the acid attack on your teeth more than other foods.

How can I minimize the effect of sugar?

Optimize remineralization. Teeth don’t just sit there and dissolve; there’s an ongoing process of a tooth losing minerals and regaining minerals. You prevent tooth decay when the tooth regains minerals more than it loses minerals. How does a tooth regain minerals? This is a process called remineralization and it happens naturally in your mouth. You can optimize this process by having a good pH in your mouth and plenty of saliva (no dry mouth). Fluoride, vitamin D, and dark chocolate (yes, you read that correctly!) all encourage remineralization as well.

Stick to a grain-free diet. Some studies show that this is one of the best preventive strategies for reducing cavities.

Get orthodontic treatment. Having straight teeth can also help minimize tooth decay since straight teeth make for fewer nooks and crannies where sticky foods can get stuck. People with a proper bite have far fewer cavities than those with crooked teeth.

Eat what you like, but keep it to mealtime. If you sip soda or sweetened coffee throughout the day, snack, or suck on hard candies, you’re providing your mouth bacteria with a steady food supply to produce acid nearly constantly. Studies show that people who snack have more cavities than those who eat the same amount of sweets, but keep it to mealtime.

Have cheese for dessert. The Europeans have cheese for dessert, which is a great way to buffer the acids in your mouth after a meal. Acids have a low pH, so you can neutralize them with things with a higher pH. Water, cheese, and vegetables all have a neutral to basic pH that can help neutralize acid and lesson the attack on your teeth.

Chew gum with xylitol. Choose a gum that’s sugarless and that contains xylitol, which has been shown to reduce mouth bacteria and help buffer acids in the mouth to protect from tooth decay. Chewing on gum also produces more saliva in your mouth, which neutralizes acids as well. Just be careful with gum since it can easily bring on jaw pain and TMD symptoms.

Swish with water after sticky foods. The longer food stays stuck in your teeth, the longer bacteria can feast and the more acids will be produced. This is why dried fruit and Goldfish crackers are the worst; they get stuck in your teeth. After you eat something sticky, swish vigorously with water to try to dislodge as much of the food from your teeth as possible before your next floss and brush session.

drink water to neutralize acid in the mouth

Help your kids develop their taste buds. Would you believe they even add sugar to baby food now? Help your kids appreciate the delicious natural sweetness of sugar snap peas and carrots. Get rid of the Goldfish, fruit juice, saltine crackers, and sugary cereals.

Eat it, don’t drink it. Soda and special Starbucks drinks often contain as much, if not more sugar than a slice of cake. I’d much rather have the cake and at least feel satiated! Some of my favorite indulgences: chocolate sacher torte, chocolate bars, and milkshakes. These are a rare treat, they make me feel satiated, and they don’t sneak their way into my day-to-day diet.  It’s also hard to go overboard on natural sugars present in apples, bananas, and some veggies. Orange juice will spike your blood sugar and won’t make you feel satiated, but eating a real orange will.

Avoid foods where sugar is listed as one of the first five ingredients. Ingredients in the packaging are listed in order from greatest quantity to smallest quantity, so if sugar is listed in the first five, I’d recommend avoiding it, at least for something you eat frequently. You’d be amazed at how many tomato sauces, “healthy” cereals, and energy bars have sugar as one of the first five ingredients.

Limit the frequency. When it comes to dental health, having your sweets all in one sitting is better than spreading it out by sipping a soda all morning or snacking throughout the day.

Don’t brush right afterward. After a sugary meal, wait thirty minutes to one hour before flossing and brushing. Otherwise, with all that acid present in your mouth, you risk etching away enamel.

Make a habit of limiting it. Use as little sugar as you can possibly get away with, and try to ween yourself off of it. By training your brain and your tastebuds, you protect yourself from getting addicted. A recent study suggests that sugary cookies could be as addictive as cocaine or morphine. Eating high-sugar foods lights up the same part of the brain as when a person shoots heroin. Excess sugar can cause changes in the brain and leave you feeling lethargic, anxious, and irritable. For more reading on sugar addiction and the brain, check out Dr. Nicole Avena’s book, Why Diets Fail.

harmful effects of sugar

Can I spread out my sugar consumption to reduce tooth decay?

It’s actually much better to eat a large quantity of candy all at once rather than spreading it out with a little piece here, and then another piece a half hour later. Frequency is the thing to worry more about than quantity, when it comes to your dental health at least.

How much sugar can I have?

To avoid cavities, the recommended level for sugar consumption is less than 40 grams per day, according to studies, but I would recommend aiming for less than 20 grams. The latest recommendation is that sugar be no more than 5% of your diet. That’s between 6 and 9 teaspoons, which is about the amount of sugar in half a cup of raisins!

Why do we like it so much?

We’ve only had processed sugar in our diets for a few hundred years. For most of human history, sugar was scarce, and usually meant something nutritious like berries or fruits, so we are programmed to like it and crave it. There was very little sugar in our ancestors’ diets, but this helped them stay disease-free for longer and square their life curves.

What does sugar do to our health?

Let’s shift from cavities to the rest of the body for a moment. Sugar can act like poison in high doses, according to Robert Lustig, M.D., a neuroendocrinologist at the University of California at San Francisco School of Medicine, and the amount of sugar in the typical processed food diet is beyond toxic.

How excess sugar wreaks havoc on the body:

  • Excess sugar can lead to high levels of insulin, making you feel hungry even when you’re full and triggering your brain to store glucose as belly fat.
  • Surges in insulin can eventually lead to Alzheimer’s disease, and at the very least, open the door for cravings and addiction-like neurochemistry in the brain.
  • If your cells become resistant to all this insulin production, you’re left with prediabetes or full-blown diabetes.
  • Excess sugar can also put extra load on the liver, over time, causing globules of fat to grow in the liver, which is the precursor to nonalcoholic fatty liver disease.
  • Excess sugar can also lower your “good” cholesterol and spur a type of fat called triglycerides which can migrate from the liver to the arteries, raising your risk for heart attack or stroke.
  • Your liver sends an S.O.S. for extra insulin (yep, the multi-tasker also aids liver function). Overwhelmed, your pancreas is now in overdrive, which can result in total-body inflammation that, in turn, puts you at even higher risk for obesity and diabetes.

Are certain sugars better than others?

Table sugar is sucrose, while other kinds of sugars are usually a mixture of glucose and fructose. This difference is largely irrelevant, because sucrose is converted to glucose and fructose in your stomach within minutes.

dangers of artificial sweeteners

How about artificial sweeteners like Sweet’N Low, Splenda and Equal?

Artificial sweeteners could be worse than sugar, due to the way they disrupt the body’s ability to regulate blood sugar, causing metabolic changes that are the first step toward diabetes.

Until recently, it was thought that artificial (no-calorie) sweeteners passed through the body without doing anything. Many diet foods, from soft drinks to desserts, are sweetened with these substances with the thought that they provide the sweet without any calories.

When mice were given water with Sweet’N Low, Splenda, or Equal, they developed intolerance to glucose. Mice given sugar water and regular water remained healthy. Glucose intolerance is when the body is less able to cope with large amounts of sugar and is the precursor to Type 2 diabetes and other metabolic syndromes.

The researchers believe this is all due to changes in the intestinal bacteria since they took intestinal bacteria from the mice that drank the water with artificial sweetener in it and injected it into the guts of healthy mice and those healthy mice developed the same glucose intolerance. DNA sequencing showed that Sweet’N Low had markedly changed the variety of bacteria in the guts of the mice that had it in their water.

Artificial sweeteners also seem to be more addictive than sugar and even hard drugs like cocaine. In another study, it was found that rats given a choice between cocaine and aspartame always chose aspartame. Even the rats programmed to be cocaine addicts chose aspartame over cocaine.

In human studies, people who normally did not use artificial sweeteners were given the maximum amount recommended by the FDA. In four of the seven volunteers, blood sugar levels were disrupted in the same way as in the mice. In another study of 381 non-diabetic participants, researchers found a correlation between use of artificial sweeteners and glucose intolerance. The gut bacteria of those who used artificial sweeteners were different from those who did not.

If you do use artificial sweeteners, I recommend you look into using probiotics. Probiotics are live bacteria that are good for your health and studies suggest they could be used to shift your gut bacteria to a population that reverses glucose intolerance. These are some great tips for boosting the good bacteria in your gut.

So, artificial sweeteners might not have any calories, but they will alter your intestinal bacteria in dangerous ways. If you have artificial sweeteners in your home, toss them; I’d much rather you add a little bit of sugar to your coffee and slowly get used to adding less and less.

Here’s a list of the most common artificial sweeteners to avoid:

Splenda

  • Sucralose
  • 1′,4,6′-Trichlorogalactosucrose
  • Trichlorosucrose
  • Equal Sucralose
  • NatraTaste Gold

Sweet’N Low

  • Saccharin
  • Acid saccharin
  • Equal Saccharin
  • Necta Sweet
  • Sodium Saccharin
  • Sweet Twin

Equal

  • Aspartame
  • Acesulfame
  • TwinSweet (Europe only)
  • APM
  • AminoSweet
  • Aspartyl-phenylalanine-1-methyl ester
  • Canderel
  • Equal Classic
  • NatraTaste Blue
  • NutraSweet

Is natural sugar better than processed sugar?

Barely. Sugar is sugar, and the body doesn’t care where it came from. Using the word “natural” is a marketing gimmick by the food industry to, ahem, sweet-talk you into overlooking sugar’s harmful effects on health.

The main difference between natural sugars and processed sugar is that natural sugars often have other components which might be good for you, like vitamins, minerals or antioxidants. But, and this is very, very important: this doesn’t make natural sugars good for you! It just makes them marginally less bad. You are far, far better off getting your vitamins, minerals and antioxidants from other, non-sweet sources.

What are the different names for sugar?

There are lots of different names for sugar!

Table sugar: this can come from sugar cane or sugar beet (which is a different plant from regular beets). Either way, it’s 99.95% pure sucrose.

Beet sugar: this is table sugar. There are a few trace compounds that are different from sugar cane-derived table sugar, but your body will not know the difference.

Brown sugar: this is also table sugar, with some molasses (sugar that’s been caramelized to have a higher carbon content). Either way, the benefits of using brown sugar instead of table sugar are negligible.

Fructose: Once touted for its low glycemic index (about 19 as opposed to 65 for table sugar and 100 for glucose), studies have linked it to increased insulin resistance, obesity, elevated LDL and triglycerides, and in extreme cases, liver disease and gout.

Honey: The ancient egyptians used honey to disinfect wounds, but its antibacterial properties don’t work after you eat it. Honey is mostly a mixture of glucose and fructose, and excess fructose is bad. One important warning: in rare cases, honey can be contaminated with a small amount of botulism, so it should not be given to infants, who do not yet have a fully functional immune system.

Maple syrup: It’s got minerals and antioxidants, but maple syrup is mostly sucrose, so it’s slightly less harmful than table sugar. I used to add just a teaspoon on top of our daughters’ oatmeal when they were young. A little goes a long way!

Cane juice: Manufacturers love this stuff, because it’s sugar, but it doesn’t have the word “sugar” in it.

High-fructose corn syrup: No digestion is required for the body to process high fructose corn syrup — it goes right to the liver and triggers the production of fats like triglycerides and cholesterol, making it a major cause of liver damage in the United States. It also triggers big spikes in insulin, leading to metabolic changes that increase appetite, weight gain, diabetes, heart disease, cancer, and dementia. For more information about HFCS, I highly recommend Dr. Hyman’s “5 Reasons High Fructose Corn Syrup Will Kill You.”

Brown rice syrup: Often found at Chinese markets, this is almost pure glucose, with a high glycemic index of 98.

Agave sweetener: Agave used to be thought of as the best “natural” sweetener thanks to its low glycemic index and is now widely used “health” products from teas to nutrition bars to energy drinks. The problem with agave is that it has even more fructose by weight than high-fructose corn syrup. Fructose is a major culprit in the rising incidence of type 2 diabetes and nonalcoholic fatty liver disease.  It may also increase risks of heart disease and cancer. This is why I recommend avoiding agave nectar.

Other synonyms for sugar to watch out for on ingredient labels

Watch out for these. Some sound scientific, some almost healthy, but in the end, they all mean “sugar.”

  • Barbados Sugar
  • Barley Malt Syrup
  • Blackstrap Molasses
  • Cane Crystals
  • Cane Juice Crystals
  • Castor Sugar
  • Corn Sweetener
  • Corn Syrup
  • Corn Syrup Solids
  • Crystalline Fructose
  • Date Sugar
  • Demerara Sugar
  • Dextrose
  • Evaporated Cane Juice
  • Florida Crystals
  • Fructose
  • Fruit Juice
  • Fruit Juice Concentrate
  • Galactose
  • Glucose
  • Glucose Solids
  • Golden Sugar
  • Golden Syrup
  • Granulated Sugar
  • Grape Juice Concentrate
  • Grape Sugar
  • High-Fructose Corn Syrup
  • Honey
  • Icing Sugar
  • Invert Sugar
  • Lactose
  • Malt Syrup
  • Maltodextrin
  • Maltose
  • Mannitol
  • Maple Syrup
  • Molasses
  • Muscovado Syrup
  • Organic Raw Sugar
  • Powdered Sugar
  • Raw Sugar
  • Refiners’ Syrup
  • Rice Syrup
  • Sorbitol
  • Sorghum Syrup
  • Sucrose
  • Table Sugar
  • Treacle
  • Turbinado Sugar
  • Yellow Sugar

Which sweeteners are safest?

The research on the safety and health benefits of these alternative sweeteners is very promising:

Xylitol: This is a naturally occurring modified sugar alcohol. It’s sweet, has a low glycemic index of around 11, and has been used in chewing gum lately. Some studies have found xylitol to be more effective at preventing cavities than fluoride and others have found that replacing sucrose with xylitol in the diet reduces cavities. Xylitol isn’t highly fermentable, so it doesn’t provide a food source to bacteria. Xylitol also actively inhibits the growth of cavity-causing bacteria. Xylitol forms complexes with calcium, which may aid in teeth remineralization. One word of warning for dog owners: xylitol can be toxic for canines.

Stevia: This sweetener comes from a plant, and numerous studies have shown no adverse side effects, so the FDA has given it a rating of GRAS (Generally Regarded As Safe). It has been used since pre-Columbian times in Brazil and Paraguay. It tastes sweet because it’s a glycoside, meaning it has the same shape as sugar, and your tongue can’t tell the difference.

Monk fruit: Rich in antioxidants with anti-inflammatory benefits, one study indicated that monk fruit may offer anti-cancer and anti-diabetic benefits. This is a newcomer to the world of sweeteners (in the West, at least), and I’m confident you’ll hear much more about it in the near future. Used since at least the 13th century in Thailand and China (where it’s known as luo han guo), monk fruit is a gourd that contains a glycoside (like Stevia) and is also classified as GRAS by the FDA. Splenda sells their version of monk fruit sweetener, Nectresse, but it has sugar and molasses added. Look for pure lo han sweetener with no additives.

Erythritol: Erythritol is a virtually non-caloric, aftertaste-free sugar alcohol that occurs naturally in fruits such as melons, pears, and grapes. About 70 percent as sweet as table sugar, whose taste it resembles, erythritol comes in white crystalline powder form and is a common ingredient in foods, especially baked goods, labeled as “light” and “low-calorie.” Studies show that up to 90 percent of erythritol is excreted unchanged in human urine within 24 hours of consumption, thus it’s not absorbed into the body, and that, like stevia, it does not harm teeth.

How can I bake with less sugar?

In recipes calling for white sugar, try substituting some applesauce or mashed ripe banana, puréed dates, raisins or prunes. They’ll add fiber and create a delicious, moist texture.

 

Sources

Mark Burhenne DDS

R. Ehrenberg. “Artificial sweeteners may tip scales toward metabolic problems.” Science News. Sept. 17, 2014.

T. Hampton. “Sugar Substitutes Linked to Weight Gain.” The Journal of the American Medical Association. May 14, 2008.

Suez, Jonathan. “Artificial sweeteners induce glucose intolerance by altering the gut microbiota.” Nature. 17 September 2014

Lenoir M, Serre F, Cantin L, Ahmed SH (2007) “Intense Sweetness Surpasses Cocaine Reward.” PLoS ONE 2(8): e698. doi:10.1371/journal.pone.0000698