PII: so300-5712(97)00010-9 Journal of Dentistry, Vol. 26, No. 3, pp.

209-218, 1998
Copyright 0 1998 Elsevier Science Ltd. All rights reserved
Printed in Great Britain
0300&5712/98 S19.00+0.00
ELSEVIER

Update on the nomenclature of

carbohydrates and their dental effects
P. J. Moynihan
The Dental School, Faculty of Medicine, University of Newcastle, Framlington Place, Newcastle upon Tyne, UK

ABSTRACT
Objectives: This review aims to clarify the nomenclature of carbohydrates, including novel manufactured
carbohydrates which are becoming increasingly popular within the food industry, and to summarise what
is known about the effects of different carbohydrates on dental health.
Data sources: This review compiles information from articles published in mainstream microbiological,
nutritional and dental journals that are of relevance to carbohydrates and dental health.
Study selection: The review considers literature on classification of carbohydrates by chain length, for
example mono-di-oligo-and poly-saccharides and classification for dental health purposes, namely
intrinsic: non-milk extrinsic sugars. This paper includes a comprehensive review of information on novel
carbohydrates including isomaltosaccharides, fructo-oligosaccharides and gluco-oligosaccharides, malto-
dextrins and glucose syrups. Information on polyols and non-starch polysaccharides is also presented and
current knowledge on the dental effects of all carbohydrates are discussed.
Conclusion: There is a wealth of information on dietary sugars and the effects of sugars on dental health
is established knowledge. However, the range of ‘novel’ manufactured carbohydrates which are
becomming available for food use is increasing and information regarding the cariogenicity of these
substances is sparse. Research indicates that maltodextrins and glucose syrups are cariogenic, however,
initial studies on some synthetic oligosaccharides have suggested reduced cariogenicity compared to
sucrose. Further human plaque pH and in vitro and in vivo tests of cariogenicity are required to clarify
these initial observations. 0 1998 Elsevier Science Ltd. All rights reserved

KEY WORDS: carbohydrates, novel carbohydrates, dental health

d Dent. 1998; 26: 209-218 (Received 24 July 1996; reviewed 31 October 1996; accepted 10 January 1997)

INTRODUCTION sugars and intrinsic sugars. It is therefore understand-

Carbohydrates are the most widely occurring group of
substances in foods and have been implicated in the
aetiology of dental caries. Carbohydrates appear in
foods in many guises including hydrolysed starch,
maltodextrins, glucose syrup, fructo-oligosaccharides,
non-starch polysaccharide, fruit juice concentrates and
many more. Furthermore, carbohydrates can be classi-
fied in many different ways: by chain length, for
example monosaccharides, polysaccharides; by food
source, for example fruit sugar, milk sugar; and by their
affects on dental health, that is non-milk extrinsic
Correspondence should be addressed to: P. J. Moynihan, The
Dental School Faculty of Medicine, University of Newcastle,
Framlington Place, Newcastle upon Tyne NE2 4BW, UK. Tel: (0191)
222 8241; Fax: (0191) 222 6137; e-mail: p.j.moynihan@ncl.ac.uk
able if confusion exists over the classification of carbo-
hydrates and regarding which types are harmful to
teeth. Information on the potential cariogenicity of a
carbohydrate is obtainable from a range of experiments
including: incubation studies; plaque pH studies;
enamel slab studies; animal experiments; human epi-
demiological studies and clinical trials. The cariogenic
potential of a carbohydrate can be judged using collec-
tive information from these experiments, although in
many cases, especially with regard to new and novel
carbohydrates, the picture is incomplete. This review
aims to clarify the nomenclature of carbohydrates and
to summarise what is known about the effects of
different carbohydrate types on dental health.
The different types of carbohydrates to be considered
are listed in Table I.
210 J. Dent. 1998; 26: No. 3

Table !. Different types of carbohydrates

Other common
names

Monosaccharides Glucose Dextrose

Fructose Fruit sugar
Galactose
Invert sugar
Disaccharides Sucrose Table sugar
Maltose
Lactose Milk sugar
Lactulose
Trehalose Mushroom sugar
Oligosaccharides Raffinose
Stachyose
Verbascose
Ketose
Nystose
Fructofuranosylnystose
Corn starch sweeteners Glucose syrups Corn starch syrup
Liquid glucose
Maltodextrins Glucose polymers
Dextrins
Alpha limit dextrins
hydrogenated glucose syrups Lycasin
Isomalto-oligosaccharides lsomaltose
lsomaltulose Palatinose
Panose
Gluco-oligosaccharides
Fructo-oligosaccharides Profeed, Neosugar,
Meioligo, Actilight,
Nutraflora
Raftilose Oligofructose
Polysaccharides Starch
Non-starch polysaccharide Fibre
Roughage
Polyols Sorbitol, Xylitol
Mannitol, Lactitol
Maltitol

MONOSACCHARIDES AND Sometimes monosaccharides and disaccharides are

DISACCHARIDES
Monosaccharides are single carbohydrate molecules in-
cluding glucose, fructose and galactose whereas disac-
charides are composed of two carbohydrate molecules,
thus sucroseis formed from the condensation of glucose
with fructose; maltose is formed from the condensation
of two glucosemolecules; and lactose is formed from the
condensation of glucose with galactose. A disaccharide
composed of galactose and fructose called lactulose, is
manufactured as a laxative preparation. Trehalose is a
disaccharide composed of two molecules of glucose
(a-l-l glycosidic link) and is only consumed in very
small quantities, but may become more important in the
future as a cryopreservative.
Hydrolysis of sucrose results in the formation of
equal quantities of glucose and fructose which is called
‘invert sugar’. The name invert sugar relates to the
inversion of the direction of the specific rotation of the
sugar’.
identified according to the food in which they are
found, for example ‘milk sugar’ refers to lactose, ‘fruit
sugar’ refers to fructose and ‘mushroom sugar’ refers to
trehalose, although other sugars are also present in
these foods. A summary of foods in which these mono-
and disaccharides occur is given in Table ZZ.
Mono- and disaccharides and dental health
Dental plaque bacteria, predominantly Streptococcus
mutans (S. mutans) are able to take up mono- and
disaccharides readily and metabolise them to acid. The
subsequent fall in pH at the plaque-enamel inter-
face favours the demineralisation of dental enamel and
the development of dental caries. Studies have indicated
that sucrose appears to be the most cariogenic sugar,
although glucose, fructose and maltose may be
only marginally less so2-5 and, of all the mono- and
disaccharides, lactose and galactose are the least
 Moynihan: Carbohydrates: nomenclature and dental health 211

Tab/e II. Natural food sources of glucose, fraCtOSe, lactose and of high fruit consumers may vary in other aspects which
sucrose influence dental caries. Some studies have shown fruit
to have the potential to be cariogenic. The banana is a
Sugars content g/l00 g
fruit rich in intrinsic sugars (21 g per 100 g) and in a
Food source Glucose Fructose Lactose Sucrose series of plaque pH studies which ranked foods accord-
ing to acidogenicity, bananas fell into the same rank
Apples 1.7 6.2 0 3.9
5.0 0 11.1
as cream cakes and carbonated beverages13. Studies in
Bananas 4.8
Oranges 2.2 2.4 0 3.9 rats have shown that apples and grapes give rise to
Raisins 34.5 34.8 0 Trace caries14,15, and bananas have been shown to produce
Carrot 2.3 1.9 0 3.2 more caries than sucrose and chocolate16. So in exper-
Onion 2.1 1.6 0 1.9
imental conditions, with the fruit being a major dietary
Sweetcorn 1.4 0.5 0 0.3
Turnip 2.3 1.7 0 0 constituent, fruits may cause caries, however, as con-
Milk full fat 0 0 4.8 0 sumed as part of the mixed human diet there is no
Milk skimmed 0 0 5.0 0 evidence to support its cariogenicity. The 1989 COMA
Natural yogurt 0 0 4.7 0 report recommended that the intake of NMES should
Cheddar cheese 0 0 0.1 0
be decreased and replaced with intrinsic sugars and
Single cream 0 0 4.1 0
Double cream 0 0 2.7 0
starch. The impact of this recommendation on caries
levels remains to be observed.
Evidence shows that milk sugars exhibit low cario-
genicity4s5 and do not pose a threat to dental health’,
cariogenic4,‘. To review extensively the vast body of therefore the extensive evidence that suggests that
literature concerning the cariogenicity of monosaccha- dental caries is positively related to the amount of
rides and disaccharides is beyond the scope of this sugars17-19 in the diet and the frequency of their
review, however, comprehensive reviews of the subject consumption 20+22largely applies to non-milk extrinsic
have been published6,7. sugars. The concentration of NME sugar present in a
In 1989, the Department of Health set up a COMA food stuff, the amount consumed, the frequency of
committee (committee on medical aspects of food consumption and the retention of food in the oral
policy) who reported on the role of dietary sugars in cavity will determine the cariogenicity of a foodstuff.
human disease, including dental caries. The COMA Priority should be given to reducing the amount and
panel re-classified sugars for dental health purposes into frequency of consumption of foods richest in NME
intrinsic sugars, milk sugars and non-milk extrinsic sugars which tend to be consumed between meals, such
sugars (NME sugars)8. as confectionery and soft drinks.
Extrinsic sugars are sugars not located within the
cellular structure of a food, and are of two types. First,
milk sugars, namely those naturally present in milk and NATURALLY OCCURRING
milk products (almost entirely lactose) and second, OLIGOSACCHARIDES
non-milk extrinsic sugars (NME sugars) which are
extrinsic sugars other than milk sugars. NME sugars Oligosaccharides are usually defined as glycosidic
include those added to foods by food manufacturers, chains of 3-10 units in length (tri-, tetra-, penta-
cooks and consumers, as well as fruit juices and saccharides etc.), although disaccharides are sometimes
honey. Rich sources of NME sugars in the diet include included in this group of carbohydrates, for example
confectionery, soft drinks, biscuits and cakes. trehalose. Naturally occurring oligosaccharides are
Intrinsic sugars are sugars forming an integral part of oligomers of monosaccharides and may be homo- or
unprocessed food for example those naturally present in heterogenous in nature (e.g. contain one type or several
cereals, fruits and vegetables. The COMA panel re- types of monosaccharide molecules) and they exhibit
ported that due to their location within the structure of some sweetness. The number of possible oligosacchar-
the food, intrinsic sugars are not a threat to dental ides is very large but only a few are found in significant
health. Foods which contain intrinsic sugars also tend quantities in foods23. Examples of common oligo-
to require more mastication which mechanically stimu- saccharides occurring in foods include raffinose
lates saliva flow thereby increasing the ability to (galactose-glucose-fructose), stachyose (galactose-
neutralise plaque acid. However, it may be argued that galactose-glucose-fructose) and verbascose (galactose-
intrinsic sugars which are readily released from the galactose-galactose-glucose-fructose). Raffinose and
plant structures containing them are potentially cario- stachyose are found in molasses and beans and are not
genie. Observations from human observational studies digested in the upper intestine but are fermented by the
shown a negative relationship between fruit consump- colonic bacteria. Fructo-oligosaccharides (FOSS) are
tion and the incidence of dental caries9-12, which oligosaccharides naturally present in plant foods which
supports the view that intrinsic sugars are of low consist of sucrose to which one (ketose), two (nystose)
cariogenicity. However: the type of diets and lifestyles or three (fructofuranosylnystose) additional fructose
212 J. Dent. 1998; 26: No. 3
units are adjoined by a p-2-1 glycosidic link. Food
rich in natural FOSS include banana, garlic, barley
and honey24. Manufactured oligosaccharides will be
considered later in this review.
Natural oligosaccharides and dental health
Little is known about the fermentation of oligosacchar-
ides by oral micro-organisms but recently it has been
shown that 5’. mutanshas a transport system involved in
the uptake of oligosaccharides25,26. Intracellularly these
may be degraded further with the release of monosac-
charides, and subsequently metabolism to acid. Most
oligosaccharides are resistant to digestion in the upper
gastrointestinal tract, although, this does not necessar-
ily imply that they are not metabolised by the bacteria
in dental plaque, many of which are similar to species
found in the large intestine (e.g. bifido bacteria; lacto-
bacilli). Nonetheless, in practice oligosaccharides are
consumed in very small amounts, and are often located
intrinsically within the food and so it is therefore very
unlikely that, as consumed, they are harmful to teeth.
‘NOVEL’ MANUFACTURED
CARBOHYDRATESUBSTANCES
Production of synthetic disaccharides and oligosacchar-
ides of glucose, fructose and galactose has increased
dramatically over the past 10 years and these carbo-
hydrates are increasingly being used in everyday food
products. It is therefore important that the dental
effects of these novel carbohydrate substances are
known so that correct advice concerning the cariogenic-
ity of these carbohydrates reaches health professionals
and the general public.
LACTULOSE
Lactulose, the disaccharide of galactose and fructose, is
principally used in the laxative product ‘Lactulose
Solution BP’ (Sandoz Pharmaceuticals; Boots). This
preparation contains approximately 67% of the disac-
charide lactulose and 27% of lactose, galactose and
other ketose sugars. Although lactulose is resistant to
digestion in the upper intestine, lactulose is metabolised
by bacteria in the colon to produce acid27. Experiments
carried out in vitro have shown that lactulose is metabo-
lised by lactobacilli to produce acetic, lactic and butyric
acids2’ and it is therefore possible that lactulose is
capable of being metabolised by plaque bacteria
thereby depressing the pH. Studies carried out in vitro
have shown that lactulose is metabolised by both
S. mutans and lactobacilli (Moynihan et al., unpub-
lished data). The clinical significance of lactulose
metabolism by bacteria present in dental plaque needs
to be determined.
HYDROLYSED STARCH PRODUCTS
Heterogeneous hydrolysed starch products including
glucose syrups (liquid glucose) and maltodextrins (glu-
cose polymers) are produced by the acid hydrolysis of
starch (from corn, maize, wheat or potato). Hydrolysis
of starch results in a mixture of mono-, di-, tri-, tetra-,
penta-, hexa- and heptasaccharides The degree of de-
polymerisation is expressed as the dextrose equivalent
(DE) which is the amount of total reducing sugars
expressed as dextrose and calculated as a percentage of
the total dry matter. Glucose syrups have a DE of 20 or
more, whereas maltodextrins are relatively more com-
plex in nature and have a DE of less than 20. The higher
the DE of a hydrolysed starch product the more the
more reducing sugars it will contain and consequently
the more readily the product will be metabolised by the
oral bacteria. Glucose syrups should not be confused
with ‘hydrogenated glucose syrups’ (the trade name for
which is ‘Lycasin’) which is a bulk non-sugar sweetener
which is safe for teeth29,6.
Hydrolysed starch products have an increasingly
important role in the food industry. Glucose syrups and
maltodextrins are added to soft drinks, including baby
drinks and sports drinks, desserts and confectionery.
Manufacturers seem to be reluctant to declare the
amount of maltodextin present in their products, al-
though the order in which it appears on the ingredients
label gives some indication of the quantity present.
Products containing glucose syrups and maltodextrins
are also available on prescription as energy supplements
and as a component of proprietary nutritionally com-
plete feeds for use in dietetic practice. Nutritionally
complete feeds contain approximately 35% malto-
dextrins, whereas carbohydrate energy supplements
contain on average 85% maltodextrins or glucose syrup.
Maltodextrins are also found in dried infant desserts for
technological as well as nutritional reasons.
Hydrolysed starch products are composed of glucose
units linked together by a-14 bonds, which form
straight chain polysaccharides, and a-1-6 bonds, which
form branching points in the polysaccharide chain.
Starch cannot be completely hydrolysed to glucose
because a-amylase cannot break the a-l-6 bonds and
the a-14 bonds immediately adjacent to the branch
point. Hydrolysis of starch therefore results in a
number of short branched chain products called a-limit
dextrins. Alpha limit dextrins range from three to seven
glucose units and are present in glucose syrups and
maltodextrins.
Hydrolysed starch products and dental
health
Unlike naturally occurring oligosaccharides, hydro-
lysed starch products are added to foods and are
therefore extrinsic in nature. In addition to this, they
are present in foods in much greater quantities and
 Moynihan:
are readily digested and absorbed. Hydrolysed starch
products may therefore have a cariogenic potential,
although research to show this is sparse. One study has
shown that substitution of sucrose in the diet with
glucose syrups resulted in markedly reduced plaque
scores after lo-12 weeks3’ However, there is no strong
evidence that the amount of plaque present is related to
caries development. Early studies failed to show a
difference in caries development between rats fed a diet
containing glucose syrups and rats fed a sucrose-
containing diet3’, yet glucose syrups were found to be
significantly less cariogenic than sucrose when added to
the drinking water (20% solutions) of caries active
rats32. However, recent studies have shown that rats fed
maltodextrins or glucose syrups containing between 11
and 36% sugars had higher caries scores compared to
rats fed more common dietary sugars33.
Glucose syrups are present in place of lactose in soya
infant formula, which are used for infants who are
intolerant to cow’s milk protein, lactose or both, and
this has given rise to concern regarding the cariogenicity
of these infant formulas. Standard infant milks contain
lactose which has a low cariogenicity, whereas glucose
syrups contain NME sugars (at approximately 2.5%),
however, plaque pH studies in human volunteers
showed no significant difference in indices of acido-
genicity between soya infant formula and standard
infant milk34. No long-term clinical trials to compare
the actual cariogenicity of soya infant formula com-
pared to other methods of infant feeding have yet been
conducted.
Owing to their relatively longer glycosidic chain
length, maltodextrins should be metabolised more
slowly than simple sugars, however, it has been shown
that S. mutuns is capable of intracellular uptake of
carbohydrates composed of three to four glucose
units25. Salivary amylase may also hydrolyse glycosidic
chains resulting in smaller units that are readily
metabolised by the oral bacteria. The extent of hydroly-
sis by amylase will be determined by the retention time
in the oral cavity.
The ability of the oral bacteria to metabolise a-limit
dextrins has also been investigated35 and it has been
shown that they are capable of inducing the DexB
enzyme present in S. mutans resulting in the production
of further fermentable substrate. It is possible that,
when the source of dietary sugars is scarce, the oral
bacteria are able to adapt to metabolising longer chain
and branched chain saccharides. The significance of this
to caries development remains to be determined.
Recent plaque pH studies have shown that malto-
dextrins, taken as a 10% solution in water and milk, are
able to depress plaque pH and although this was to a
lesser extent than a 10% sucrose solution, the plaque
pH of approximately half the subjects reached values
of 5.5 or below36. In view of this, advice for the use of
maltodextrins by the general population should be
along the same lines as that for NME sugars. The
Carbohydrates: nomenclature and dental health 213
importance of maltodextrins and glucose syrups in
dietetic practice must be recognised and dental advice
must not interfere with the patient’s dietary therapy. In
dietetic practice, maltodextrins and glucose syrups are
commonly added to soups, drinks, mashed potato,
porridge and puddings. From a dental point of view it is
best to advise that between meals maltodextrins are
added only to foods and drinks which are cleared from
the mouth quickly and when added to drinks it is best
to advise that they are consumed through a straw.
NOVEL MANUFACTURED
OLIGOSACCHARIDES
In the past, starch hydrolysates were very much a
heterogeneous mixture, however, more recent develop-
ments using transglucosylase enzymes have enabled the
production of more highly defined oligosaccharide
products such as isomalto-oligosaccharides, gluco-
oligosaccharides, fructo-oligosaccharides and galacto-
oligosaccharides. There is increasing interest in the
synthesis of these novel carbohydrate substance and in
isolating the enzymes which produce them, not only
because of their use in the food industry as sweetening
and bulking agents but also because their consumption
may have potential health benefits. Synthetic oligosac-
charides are only partially digested in the small intestine
and their presence in the large bowel has been shown
to encourage the growth of bifidobacteria, which are
known to reduce the growth of pathogenic micro-
organisms37. Production of ‘new’ oligosaccharides is an
exciting area of food technology since it may lead to the
isolation of carbohydrates which are not fermentable by
the oral bacteria which have a role in the prevention of
dental caries. Most studies have focused on the ability
of S. mutans and, to a lesser extent, other oral Strepto-
cocci to metabolise these carbohydrates, however, it is
now recognised that other micro-organisms present in
dental plaque may play a role in the oral metabolism
of oligosaccharides. Several studies have demonstrated
the ability of the colonic microflora to metabolise
oligosaccharides but whether oral strains of bacteria
such as b$dobactevia and luctobacilli can metabolise
oligosaccharides to produce acid has not been investi-
gated. Such studies need to be carried out in order
to ascertain the full cariogenic potential of synthetic
oligosaccharides.
ISOMALTO-OLIGOSACCHARIDES
Isomalto-oligosaccharides (IMOs) are commercially
produced and are widely used in foods and drinks.
IMOs, also known as glucosyl-oligosaccharides, in-
clude: isomaltose (glucose a-1-6 glucose); Isomaltulose
(glucose a-1-6 fructose), which is also known as palati-
nose and panose (glucose a-1-6 glucose a-14 glucose).
The characteristic of these oligosaccharides is that they
214 J. Dent. 1998; 26: No. 3
are u-l-6 linked (but may contain a-1-4). IMOs have
received increased attention as food additives because
they have been shown to increase bifidobacteria and
may be less cariogenic than conventional sweeteners3*.
They are produced commercially enzymatically from
starch or sucrose. Starch is first hydrolysed to maltose
and the glucose moiety of the a-14 linked maltose
(or a-1-2 linked sucrose) is transglucosylated by U-D-
glucosidase to produce a l-6 linked oligosacchar-
ides. IMOs are found naturally in small quantities in
fermented foods and in honey.
Isomaltulose (palatinose) is a functional isomer of
sucrose which has a similar energy value (calorie con-
tent) to sucrose but is only one third as sweet. Isomal-
tulose is produced by the transglucosylation of sucrose
by a glucosyltransferase enzyme (EC 2.4. l-group).
Hydroxylation of isomaltulose produces the non-sugar
bulk sweetener ‘Isomalt’.
THEDENTALEFFECTSOF
ISOMALTO-OLIGOSACCHARIDES
IMOs are metabolised to acid to a much lesser extent
than glucose and sucrose when incubated with S.
mutans in vitro, and plaque pH studies in which IMOs
were given as drops, rinses or candy have shown that
IMO mixes are less acidogenic compared with glucose
or sucrose, but may result in a fall in pH to below 5.039.
It has been reported that IMO mixes inhibit glucan
synthesis from sucrose and also inhibit the sucrose
dependent adherence of S. mutans on the tooth surface
in vitro4’. Ooshima et ~1.~~reported on the dental effects
of a panose rich IMO mixture (‘GOS-sugar’) which
contained maltose and IMOs (G22G7) produced from
starch, with maltose (24%) and panose (43%) being the
principle components. S. rnutans and S. sobrinus did
ferment this panose rich IMO mix and produce acid in
a similar way to glucose and maltose, however, the
mixture was not a substrate for glucosyltransferase of
S. mutans or S. sobrinus and therefore did not result in
the synthesis water insoluble glucan and was shown to
inhibit significantly the synthesis of glucan from sucrose
and also inhibit adherence of growing cells to a glass
surface. Animal studies also demonstrated reduced
cariogenic potential of this panose-rich oligosaccharide
and showed that it induced significant but minimal
caries in rats which have been superinfected with either
S. mutans or S. sobrinus. These investigators also dem-
onstrated that replacement of half diet sugar with the
IMO mixture resulted in a significant reduction of
caries in rats infected with S. sobrinus.
The IMO isomaltulose is only slightly metabolised by
S. mutans and dental plaque suspensions, which sug-
gests low cariogenicity42. In vitro studies have demon-
strated that isomaltulose results in reduced production
of glucan and acid when compared with sucrose43. The
hydroxylated derivative of isomaltulose, Isomalt, does
not lower plaque pH significantly and is virtually non-
cariogenic39. The IMO panose has been shown to
reduce glucan production by S. mutans and to reduce
cellular adherence44.
GLUCO-OLIGOSACCHARIDES
Gluco-oligosaccharides (GOSS) are a new type of syn-
thesised oligosaccharide produced by a transglucosyla-
tion reaction which transfers glucose from a sucrose
donor to a maltose acceptor45. GOS are composed of
mono- to heptasaccharides and are characterised by
a-1-2 linkages (and also contain some a-1-6 linkages).
Studies have shown that only 20% of GOSS are de-
graded by endogenous enzymes in the small intestine
and that the main component of the GOS mix, a
pentasaccharide, is fully resistant to digestion46. GOSS
are fermented by bacteria present in the large intestine
and, like IMOs, improve the growth of bifidobacteria45.
The health benefits of GOSS are still under investigation
and as yet, these oligosaccharides are not used by the
food or pharmaceutical industries. The dental effects of
these carbohydrates also need to be determined as it
is not known whether S. mutans or other oral micro-
organisms are capable of metabolising carbohydrates
containing a-1-2 linkages.
FRUCTO-OLIGOSACCHARIDES
Commercially produced FOSS are produced by the
action of fructofuranosidase on sucrose or inulin24.
FOSS are also resistant to digestion in the upper gastro-
intestinal tract and increase the growth of bifido-
bacteria24. Two widely used FOSS are ‘Profeed’ a FOS
produced enzymatically from sucrose and marketed as
‘Neosugar’, ‘Meioligo’, ‘Actilight’ and ‘Nutraflora’47
and ‘Raftilose’ (also known as Oligo-fructose) which is
a FOS produced enzymatically from inulin. FOSS are
widely used in foods in Japan where they are considered
food ingredients rather than food additives24. FOSS
have also been used to improve the organoleptic
properties of plain unsweetened yoghurt24.
Fructo-oligosaccharides and dental health
Oral streptococci produce several fructanases which can
degrade fructans and in vitro studies have shown that
fructo-oligosaccharides are metabolised to acid follow-
ing incubation with several strains of oral streptococci
and FOSS have also been shown to induce plaque
growth in an in vitro system. These findings suggest
that FOSS are potentially cariogenic. Hartemink et al.
concluded that FOSS are potentially as cariogenic as
sucrose4’. Several studies have investigated the acido-
genicity of nystose, a component of FOS mixes, how-
ever, conflicting results have been obtained which may
be due to between-strain differences in the ability of
 Moynihan:
S. mutans to metabolise nystose. Ziesenitz and Siebert”’
reported rapid metabolism of nystose following incu-
bation with human dental plaque, however, Hirasawa
ef ~1.~’ claimed Neos LI gar (which contains nystose) to be
non-cariogenic despite some acid production by the
oral bacteria. Further studies in animals and human
plaque pH studies are required in order to determine
the cariogenic potential of these novel carbohydrates
which are becoming available in an increasing number
of foodstuffs.
The European Commission Scientific Committee on
food is currently considering the safety of novel manu-
factured oligosaccharides in foods. In general these
products are not considered to be food additives but
rather food ingredients and are therefore not subject to
statutory testing. The only legislation on their food use
which applies in the United Kingdom is the Food
Safety Act, which states that a food unfit for human
consumption may not be sold.
STRUCTURAL ISOMERS OF SUCROSE
Interest in producing structural isomers of sucrose has
arisen due to the finding that many of the isomers have
similar organoleptic properties to sucrose but have a
reduced cariogenic potentia151. Theoretically sucrose
has five structural isomers composed of glucose and
fructose which may be produced by transglycosylation
of sucrose and these are: trehalulose (glucose a-l-l-
fructose); turanose (glucose a-1-3-fructose); maltulose
(glucose a-1-4-fructose); leucrose (glucose a-1-5-
fructose) and the IMO isomaltulose (glucose a-1-6-
fructose) which has already been discussed. Minami
ef aL5* have reported that none of these isomers are
fermented to acid by S. mutans and all of them inhibit
the production of glucan from sucrose. Animal exper-
iments have shown that leucrose to be non-cariogenic in
rats53. Trehalulose is formed as a by-product in the
manufacturer of isomaltulose, it is 60% as sweet as
sucrose and is used in the confectionery industry in
Japan. Ooshima et ~1.~’ have investigated several as-
pects of the cariogenic potential of trehalulose and have
reported that S. mutans and S. sobrinus do not utilise
trehalulose and that trehalulose is not a substrate for
glucan synthesis. In animal experiments trehalulose
does not induce significant caries in rats superinfected
with S. mutans or S. sobvinus and replacement of
dietary sucrose with trehalulose resulted in fewer caries
in rats superinfected with S, sob~inus.
POLYSACCHARIDES
Polysaccharides are carbohydrate polymers which are
greater than 10 sugar units long. For nutritional pur-
poses polysaccharides can be sub-divided into starch
and non-starch polysaccharide (NSP). Starch is a
polysaccharide of glucose found as a storage carbo-
Carbohydrates: nomenclature and dental health 215
hydrate in plants and is composed of two different
polymers, amylase (linear) and amylopectin (branched).
The number of glucose units in various starches will
range from a few hundred to several thousand. Starch is
found is large amounts in a range of staple dietary items
including bread, pasta, potatoes, rice and other cereals.
STARCH AND DENTAL HEALTH
Dental plaque exhibits starch-degrading activity prob-
ably due to both salivary amylase and bacteria enzymes
such as dextrinase and amylase. S. mutans possesses
enzymes involved in the degradation of starch but does
not appear to produce acid from it irz Y&O, probably
because the starch molecule is too large to enter the
bacterial cell.
The effect of starch on dental health has been exten-
sively reviewed by Rugg-Gunn6 who, on considering all
the evidence, concluded that:
l The cariogenicity of uncooked starch is very low, but,
since this is seldom consumed by man, this finding is
of little relevance.
*Finely ground and heat treated starch can cause
dental caries, but the amount is less than that cause by
sugars.
@Cooked staple starchy foods, such as rice, pasta,
potatoes, and bread are of low cariogenicity in man.
*The addition of sugar increases the cariogenicity of
cooked starchy foods. Foods containing cooked
starch and substantial amounts of sugar appear to be
as cariogenic as a similar amount of sugar.
Current dietary guidelines outlined in the 1991
COMA report on Dietary Reference Values54 and sub-
sequently in the 1994 COMA report on Nutritional
Aspects of Cardiovascular disease” recommend an
increase in the consumption of starchy foods. It was
stated that staples such as bread, rice, pasta and
potatoes should replace the energy deficit resulting from
a reduction in consumption of NME sugars and fat.
NON-STARCH POLYSACCHARIDE
NSP is commonly referred to as dietary fibre, a group of
compounds including cellulose, hemicellulose, pen-
tosans, pectic substances and gums. NSP is resistant to
digestion in the upper gastrointestinal tract, although
some colonic bacteria are capable of metabolising some
forms of NSP to short-chain fatty acids56. There is
no evidence that to show that NSP is metabolised in
the oral cavity and therefore NSP may be considered
non-cariogenic. Foods rich in NSP may in fact be
protective against dental caries because such foods
require increased mastication which increases salivary
flow and therefore oral buffering capacity. NSP rich
216 J. Dent. 1998; 26: No. 3
foods also contain inorganic and organic phosphates
and phytate, all of which have been shown to have
anti-caries effects.
POLYOLS
Polyols are not strictly carbohydrates but the alcohol
derivates of sugars. However, many sugars are con-
verted to the corresponding alcohol derivate to produce
sweeteners which are metabolised very slowly by the
oral bacteria and are therefore virtually safe for teeth.
Polyols are found naturally in fruit and vegetables in
very small quantities. Polyols were first introduced for
use in specialised diabetic products, however, they are
now used in a much wider range of sugar-free products
including chewing gum, chocolate, boiled sweets and
biscuits. Polyols which are commonly used in foods
to replace sugar include xylitol, sorbitol, mannitol,
maltitol and lactitol. Polyols are ‘bulk sweeteners’
which vary in relative sweetness compared to sucrose,
for example, xylitol is as sweet as sucrose, whereas
sorbitol is half as sweet and lactitol has only one third
the sweetness of sucrose.
Polyols and dental health
Extensive research has shown that polyols are safe for
teeth. The 1989 COMA report on dietary sugars and
human disease” summarised the evidence on non-sugar
sweeteners and dental health and concluded:
Artificial sweeteners and alternative sweeteners can be
considered non-cariogenic or virtually so and are use-
ful sugar substitutes within limits prescribed by other
expert committees. The Panel recommends that food
manufacturers produce ‘low sugars’ or ‘sugars-free’
alternatives to existing sugars-rich products, particu-
larly those for children.
Current evidence suggests that bulk sweeteners have
negligible cariogenicity compared with sugars and that
substitution of sugars with alternative sweeteners could
substantially reduce caries development. The greatest
gain would be expected to occur if they were used to
replace sugars in foods ingested frequently, such as
sweet snacks, drinks and liquid medicines.
Although it is best that people consume starchy
snacks, fruit and vegetables in replace of sugar, this is
not always practical or palatable, as sometimes there is
a preference for a sweet taste. Therefore, by advising
replacement of sugar-rich items, which tend to be
consumed in-between meals, with foods sweetened with
polyols (and other non-sugar sweeteners) the risks to
dental health can be diminished.
SUMMARY
In summary, there are a wide and increasing range of
carbohydrates to be found in food substances, not all of
which are harmful to teeth. NME sugars found outside
the cellular structure of the food are the main threat to
dental health. Novel carbohydrate sweeteners such as
hydrolysed starch products may also pose a threat to
dental health since they are extrinsic in nature and can
be metabolised by the oral bacteria. Advice with regard
to NME sugars and hydrolysed starch products (with
the exception of when used for medical purposes)
should be to limit frequency of consumption, preferably
to meal times only, and never to consume foods con-
taining these carbohydrates close to bed-time. Evidence
suggests that the carbohydrates which are less harmful
to teeth include: intrinsic sugars, such as that in fresh
fruit and vegetables; starch based staple foods; and milk
sugars and the polyols. Unrefined plant foods which are
rich in NSP contain factors which may protect against
dental caries. Consumption of foods rich in NSP should
be encouraged for general health purposes in addition
to any potential benefits for dental health. Food manu-
facturers are increasing the use of non-sugar sweeteners,
such as the polyols and it is therefore important to be
aware of the sugar-free alternatives to traditional snack
foods, which can be suggested as alternatives for
patients.
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