Case Study: Xylitol’s Role in the 4Ds of Smoking Cessation

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Xylitol has resurfaced in recent years as a natural sugar (derived from birch bark, corn cob, raspberries, and even strawberries) that inhibits bacterial repopulation in the oral cavity. We are seeing it added to toothpaste, fluoride varnishes, gum, and mints and promoted to aid improved oral health.

We have been made aware of its xerostomia benefits, as well as nasal congestion relief. Could xylitol in the form of mints or gum be used as an adjunct to the 4D’s in assisting with smoking cessation?

This is a question that I pondered as I did an action research project with O’Hehir University a few years ago. Having patients who simply could not stop smoking despite their desire, led me to do my own clinical action research to see if xylitol would/could indeed be part of the link that assists patients to reduce or even quit smoking.

Aiding Smokers to Quit

Oral health professionals are in a prime position to screen patients who are smokers and offer assistance in their struggle for smoking cessation. Most smokers are not offered smoking cessation advice often enough. Their options are limited. Perhaps if smoking cessation options were offered more routinely in dental offices, we could make a positive impact on reducing the smoking rate in America.

Consider the fact that we see these patients two to four times a year when they may see their physician once a year, if that. We need to push ourselves to think outside the box when it comes to smoking cessation strategies.

Studies have proven that the oral consequences of smoking include increased risk of oral cancer and increased risk of periodontal disease. However, many patients are contentedly unaware of these risk factors.1 This shows how widespread a problem smoking is and that we need to offer differing cessation choices to smokers.

As a seasoned dental hygienist, I can attest to other oral factors that contributed to smoking, such as xerostomia, root caries, and constricted blood flow; ever notice how a smoker with a 7mm pocket does not bleed? Not to mention, the impossible-to-remove tar infestation supra- and subgingivally. This is backed by studies indicating that long-term smoking significantly reduces salivary flow, which increases oral and dental disorders associated with dry mouth, especially cervical caries, gingivitis, tooth mobility, calculus (tar), and halitosis.2

Smoking is an oral habit driven by nicotine addiction. We all know how difficult bad habits are to break. This is especially true when nicotine is involved. Hence, we need to discover if new supplemental healthy oral habits − in this case, xylitol usage − can aid in curbing the negative oral habit of smoking.

Xylitol, a Healthy Habit

How does xylitol work? Xylitol is a natural sweetener which has properties that have been shown to prevent tooth decay and increase salivary production, thereby reducing the growth of bad bacteria in the oral cavity.3 Strive for five exposures of xylitol a day to greatly inhibit bacterial growth in the oral cavity. Instead of bad oral bacteria multiplying each day exponentially, it is reduced at a significant rate.4

In simple terms, bacteria are attracted to xylitol as a sugar, but cannot metabolize the 5-carbon molecule, hence staving repopulation. Knowing that sweeteners such as fructose, glucose, and sorbitol are 6-carbon molecules and enable bacteria to metabolize makes xylitol the sweetener of choice for bacterial reduction.

Why suggest xylitol gum/mints as an adjunct aid in smoking cessation? Systemic usage of xylitol has been suggested to reduce caries and increase salivary output more effectively than sorbitol.5 Since most gum/mints contain sorbitol, or other sweeteners, the additional xylitol benefits make it a healthier option. This case study is focused on xylitol and the 4D’s as an adjunct to smoking cessation when other methods of smoking cessation may not have been successful. Xylitol gum/mints are cost-effective, easily attainable, user-friendly, has a pleasant taste, and freshens breath. With the added benefit of caries reduction and increased salivary output, it is worth investigating.

Xylitol + The 4D’s = Reduced Smoking?

I proposed the addition of the 4D’s as an adjunct to a xylitol gum/mint regimen to aid in a gradual reduction of cigarette intake. The 4D’s include: Delay, Deep Breath, Drink Water, and Do Something Else.6 Since conventional methods of smoking cessation are not always successful, it seems integral to provide new methods to patients in their quest for a smoke-free life.

Keeping this in mind, the proposition of the 4D’s of quitting (in addition to xylitol gum/mints) should be presented to patients with smoking addiction. This creates a change in behavior, which may break a link in the nicotine addiction chain.

To suppress a nicotine urge, suggest the 4D’s:

Drink Water – get a drink before anything else.

Do Something Else – have a goody bag handy of other things to do. This could be a crossword puzzle, a book, or my proposal of xylitol gum/mints. This will take the smoker’s mind off smoking for the present time.

Deep Breath – take at least 10 deep breaths to calm anxious nerves.

Delay – the urge to smoke may pass.

In my opinion, the Do Something Else, and the Delay part of the 4D’s may work best if used together, and the addition of xylitol gum/mints may help the smoker successfully quit or at least reduce smoking intake. A 2009 University of Birmingham study found that gradual nicotine replacement therapy could be effective in smoking cessation.7

Keeping this in mind, I proposed adding xylitol gum/mints as a gradual replacement (Delay and Doing Something Else) to a cigarette up to five times a day, changing the habit of grabbing a cigarette with every craving for nicotine. The idea of this method is to allow the smoker a gradual nicotine reduction as he/she will be doing this substitution up to five times daily.

With this gradual reduction in habit and gradual reduction in nicotine, perhaps the smoker may then be able to quit cold turkey.

Offering a healthy alternative to nicotine replacement seems to be an ideal option with possible long-term health benefits. Xylitol gum/mints may make the user feel in control of his smoking cessation therapy as it is easily attainable and affordable, plus the xylitol will give the user the added benefit of a healthier and cleaner feeling mouth. Perhaps this positive push could help break the chain of addiction.

Putting the Action Research into Action

Using open-ended questions, I gained the approval of six patients to participate in a study. I first sought approval from my dentist to propose this action research to my patients. This was a four-week study with limited results.


In summary, half of my participants dropped out immediately and will most likely not change their smoking habits. One-third of the participants are continuing with the use of xylitol gum.

The xylitol gum’s pleasant taste promoted a clean feeling which helped with the “little victories” in the battle against smoking. The 4D’s, along with the xylitol gum, seemed to help guide a few participants through their cravings.

This is encouraging enough for me to continue recommending xylitol and the 4D’s as an adjunct to smoking cessation therapy.

My final thought is that the simple fact that the smoker’s dry mouth may be alleviated and feel cleaner could be enough to encourage patients who are smokers to try xylitol gum/mints and the 4D’s as a healthy adjunct to smoking cessation. If we can change even one life using alternative smoking cessation methods, we should have an open mind and suggest them as an option.

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  1. Bartold, P. Smoking – what’s in it? Australian Dental Journal. 2015; 60.3: 275-275. Retrieved from
  2. Rad, M., Kakoie, S., Brojeni, F., Pourdamghan, N. Effect of Long-Term Smoking on whole-Mouth Salivary Flow Rate and Oral Health. J Dent Res Dent Clin Prospects. December 2010; 4(4): 110-114. doi: 10.5681/joddd.2010.028. Retrieved from
  3. Velasquez, C., Narvaez, C. Effect of Xylitol Chewing Gum on Dental Plaque, Saliva Flow and Saliva Buffer Capacity in Chilean Youngsters. Int. J. Odontostomat. 2013; 7(1). Retrieved from
  4. Ly, K., Milgrom, P., Roberts, M., et al. Linear Response of Mutans Streptococci to Increasing Frequency of Xylitol Chewing Gum Use: A Randomized Controlled Trial. BMC Oral Health. 2006; 24(6): 6. Retrieved from
  5. Makinen, K., Bennet, C., Hujoel, P., Isokangas, P., Isotupa, K., Pape, H., Makinen, P. Xylitol Chewing gum and Caries Rates: A 40 Month Cohort Study. Journal of Dental Research. December 1995; 74(12): 1904-1913. doi; 10.1177/00220345950740121501. Retrieved from
  6. The American Cancer Society Medical and Content Team. Deciding to Quit Smoking and Making a Plan. American Cancer Society. Last Medical Review: April 19, 2016. Retrieved from
  7. Phend, C. Gradual Cutback with Nicotine Replacement Boosts Quit Rates. MedPage Today. 2009-04-03. Retrieved from
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Rebecca Marie Friend, BS, RDH
Rebecca Marie Friend, RDH, BS, attained her Associate of Applied Science degree in Dental Hygiene from Ferris State University, Big Rapids, Michigan, in 1987, where she also met and married her husband. She has been a practicing dental hygienist for over 30 years and has raised three sons while working as a full-time clinical dental hygienist. Rebecca currently practices in Battle Creek, Michigan. She resides in neighboring historic Marshall, Michigan. Rebecca is board certified in Nitrous Oxide and Local Anesthesia Administration and is certified in low-level laser therapy. Continuously striving to improve upon her skills and methods of forward-thinking in the dental world, she recently attained her Bachelor of Science degree in Oral Health Promotion through Action Research at O’Hehir University. She is actively involved in a mentorship with students at O’Hehir University. “I take pride in my abilities as a skilled periodontal therapist. I enjoy the patient-practitioner relationship that develops when trust and health are gained, taking mindful care of every individual that I connect with. The benefits of helping others achieve a healthy mouth and regain their confidence with a great smile and healthier self are very rewarding. Whole-body health begins with the mouth.” In her free time, Rebecca enjoys visiting the beautiful shores of Lake Michigan, where the sunsets are magical, the dunes are stunning, and the rocks are a collector’s delight. She loves to immerse herself in nature whenever she gets a chance and enjoys canoeing, kayaking, nature walks, flexibility training, yoga, and little “get-a-ways” with her husband. Family life has always been important to her, and now that her three grown sons have spread their wings, she has a little more time to spread hers.