Xylitol and caries prevention--is it a magic bullet?

Kinetic Behavior of Candida guilliermondii Yeast during Xylitol Production from Brewerapos;s Spent Grain Hemicellulosic Hydrolysate

Brewer's spent grain, the main byproduct of breweries, was hydrolyzed with dilute sulfuric acid to produce a hemicellulosic hydrolysate (containing xylose as the main sugar). The obtained hydrolysate was used as cultivation medium by Candidaguilliermondii yeast in the raw form (containing 20 g/L xylose) and after concentration (85 g/L xylose), and the kinetic behavior of the yeast during xylitol production was evaluated in both media. Assays in semisynthetic media were also performed to compare the yeast performance in media without toxic compounds. According to the results, the kinetic behavior of the yeast cultivated in raw hydrolysate was as effective as in semisynthetic medium containing 20 g/L xylose. However, in concentrated hydrolysate medium, the xylitol production efficiency was 30.6% and 42.6% lower than in raw hydrolysate and semisynthetic medium containing 85 g/L xylose, respectively. In other words, the xylose-to-xylitol bioconversion from hydrolysate medium was strongly affected when the initial xylose concentration was increased; however, similar behavior did not occur from semisynthetic media. The lowest efficiency of xylitol production from concentrated hydrolysate can be attributed to the high concentration of toxic compounds present in this medium, resulting from the hydrolysate concentration process.

Xylitol gummy bear snacks: a school-based randomized clinical trial

BACKGROUND

Habitual consumption of xylitol reduces mutans streptococci (MS) levels but the effect on Lactobacillus spp. is less clear. Reduction is dependent on daily dose and frequency of consumption. For xylitol to be successfully used in prevention programs to reduce MS and prevent caries, effective xylitol delivery methods must be identified. This study examines the response of MS, specifically S. mutans/sobrinus and Lactobacillus spp., levels to xylitol delivered via gummy bears at optimal exposures.

METHODS

Children, first to fifth grade (n = 154), from two elementary schools in rural Washington State, USA, were randomized to xylitol 15.6 g/day (X16, n = 53) or 11.7 g/day (X12, n = 49), or maltitol 44.7 g/day (M45, n = 52). Gummy bear snacks were pre-packaged in unit-doses, labeled with ID numbers, and distributed three times/day during school hours. No snacks were sent home. Plaque was sampled at baseline and six weeks and cultured on modified Mitis Salivarius agar for S. mutans/sobrinus and Rogosa SL agar for Lactobacillus spp. enumeration.

RESULTS

There were no differences in S. mutans/sobrinus and Lactobacillus spp. levels in plaque between the groups at baseline. At six weeks, log10 S. mutans/sobrinus levels showed significant reductions for all groups (p = 0.0001): X16 = 1.13 (SD = 1.65); X12 = 0.89 (SD = 1.11); M45 = 0.91 (SD = 1.46). Reductions were not statistically different between groups. Results for Lactobacillus spp. were mixed. Group X16 and M45 showed 0.31 (SD = 2.35), and 0.52 (SD = 2.41) log10 reductions, respectively, while X12 showed a 0.11 (SD = 2.26) log10 increase. These changes were not significant. Post-study discussions with school staff indicated that it is feasible to implement an in-classroom gummy bear snack program. Parents are accepting and children willing to consume gummy bear snacks daily.

CONCLUSION

Reductions in S. mutans/sobrinus levels were observed after six weeks of gummy bear snack consumption containing xylitol at 11.7 or 15.6 g/day or maltitol at 44.7 g/day divided in three exposures. Lactobacillus spp. levels were essentially unchanged in all groups. These results suggest that a xylitol gummy bear snack may be an alternative to xylitol chewing gum for dental caries prevention. Positive results with high dose maltitol limit the validity of xylitol findings. A larger clinical trial is needed to confirm the xylitol results.

TRIAL REGISTRATION

[ISRCTN63160504].

Effect of xylitol and fluoride on enamel erosion in vitro

This study aimed to determine the anti-erosive effects of xylitol, fluoride and a xylitol/fluoride combination used as an additive in an acidic drink or as mouthrinse after enamel was exposed to an acidic drink, in vitro. Human third molars were divided into 7 groups (A-G). Samples from groups A to D were immersed for 5 min in orange juice only (A), orange juice plus either 25% xylitol (B), F(-) 1 ppm (C) or a 25% xylitol/F(-) 1 ppm combination (D), respectively. Samples from groups E to G were immersed in orange juice for 5 min and then in either 40% xylitol (E), F(-) 227 ppm (F) or a 40% xylitol/F(-) 227 ppm combination (G), for 1 min respectively. This process was performed four times daily for 14 days. Mineral loss was determined from the lesion depth and surface hardness. Erosion depth progressively increased in all groups, except E, where erosion depth was significantly lower than group A. Surface microhardness progressively decreased in all groups, except E, where hardness was significantly higher than group A. This study demonstrated that addition of xylitol, fluoride or a xylitol/fluoride combination to an acidic drink or post-treatment with fluoride or a xylitol/fluoride combination could reduce, but not prevent, enamel erosion.

A surrogate method for comparison analysis of salivary concentrations of Xylitol-containing products

Background

Xylitol chewing gum has been shown to reduce Streptococcus mutans levels and decay. Two studies examined the presence and time course of salivary xylitol concentrations delivered via xylitol-containing pellet gum and compared them to other xylitol-containing products.

Methods

A within-subjects design was used for both studies. Study 1, adults (N = 15) received three xylitol-containing products (pellet gum (2.6 g), gummy bears (2.6 g), and commercially available stick gum (Koolerz, 3.0 g)); Study 2, a second group of adults (N = 15) received three xylitol-containing products (pellet gum, gummy bears, and a 33% xylitol syrup (2.67 g). For both studies subjects consumed one xylitol product per visit with a 7-day washout between each product. A standardized protocol was followed for each product visit. Product order was randomly determined at the initial visit. Saliva samples (0.5 mL to 1.0 mL) were collected at baseline and up to 10 time points (~16 min in length) after product consumption initiated. Concentration of xylitol in saliva samples was analyzed using high-performance liquid chromatography. Area under the curve (AUC) for determining the average xylitol concentration in saliva over the total sampling period was calculated for each product.

Results

In both studies all three xylitol products (Study 1: pellet gum, gummy bears, and stick gum; Study 2: pellet gum, gummy bears, and syrup) had similar time curves with two xylitol concentration peaks during the sampling period. Study 1 had its highest mean peaks at the 4 min sampling point while Study 2 had its highest mean peaks between 13 to 16 minutes. Salivary xylitol levels returned to baseline at about 18 minutes for all forms tested. Additionally, for both studies the total AUC for the xylitol products were similar compared to the pellet gum (Study 1: pellet gum – 51.3 μg.min/mL, gummy bears – 59.6 μg.min/mL, and stick gum – 46.4 μg.min/mL; Study 2: pellet gum – 63.0 μg.min/mL, gummy bears – 55.9 μg.min/mL, and syrup – 59.0 μg.min/mL).

Conclusion

The comparison method demonstrated high reliability and validity. In both studies other xylitol-containing products had time curves and mean xylitol concentration peaks similar to xylitol pellet gum suggesting this test may be a surrogate for longer studies comparing various products.

Growth inhibition of Streptococcus mutans with low xylitol concentrations

No studies on the concentration dependency of the inhibition of Streptococcus mutans with xylitol are available. We studied xylitol-induced growth inhibition of two type strains, S. mutans NCTC 10449 and Ingbritt, and three clinical isolates of S. mutans. The strains were grown in Brain Hearth Infusion Medium in the presence of 0.001% (0.066 mM), 0.005% (0.33 mM), 0.01% (0.66 mM), 0.1% (6.6 mM), and 1% (66 mM) xylitol. Growth was followed by measuring the absorbance at a wavelength of 660 nm. The highest xylitol concentration tested in this study, 1%, showed mean inhibition percentages ranging from 61% to 76% when the growth inhibition of the five strains was compared to the control without xylitol at log-phase. For 0.1% xylitol, the inhibition percentages ranged from 22% to 59%. A concentration dependency was seen in the growth inhibition, with 0.01% xylitol being the lowest xylitol concentration inhibiting all five strains significantly (p < 0.001). The growth inhibition percentages determined for 0.01% xylitol, however, were low, and the inhibition was significantly weaker as compared to 0.1% and 1% xylitol. Our results suggest that low xylitol concentrations of 0.1% (6.6 mM) could inhibit mutans streptococci in vivo but even lower xylitol concentrations may be inhibitory.

Dental plaque formation and salivary mutans streptococci in schoolchildren after use of xylitol-containing chewing gum

OBJECTIVE

The aim of this study was to investigate the effect of a fixed daily dose of xylitol on mutans streptococci in saliva and the amount of visible dental plaque. A second aim was to explore if the possible effects differed between children with and without caries experience.

METHODS

The study was designed as a double-blind randomized controlled trial with two parallel arms. All pupils (n=149) in grades 1-6 in a comprehensive school in northern Sweden were invited, and 128 children (mean age=12.7 years) consented to participate. The children were stratified as having caries experience (DMFS/dmfs>or=1) or not before the random allocation to a test or control group. The control group (A) was given two pellets containing sorbitol and maltitol three times daily for 4 weeks, and the test group (B) received corresponding pellets with xylitol as single sweetener (total dose=6.18 g day). Clinical scoring and saliva samples were collected at baseline and immediately after the test period. The outcome measures were visible plaque index, salivary mutans streptococci counts and salivary lactic acid production.

RESULTS

The amount of visible plaque was significantly reduced in both groups after 4 weeks (P<0.05). Likewise, the sucrose-induced lactic acid formation in saliva diminished in both groups (P<0.05). The proportion of mutans streptococci decreased significantly in the test group compared to baseline, but not in the control group (P<0.05). The alterations in the test group seemed most prominent among children without previous caries experience.

CONCLUSIONS

The results suggest that chewing gum with xylitol or sorbitol/maltitol can reduce the amount of dental plaque and acid production in saliva in schoolchildren, but only the xylitol-containing gum may also interfere with the microbial composition.

Caries in 4-year-old children after maternal chewing of gums containing combinations of xylitol, sorbitol, chlorhexidine and fluoride

AIM

To evaluate the effect of maternal use of chewing gums containing combinations of xylitol, sorbitol, chlorhexidine and fluoride on caries prevalence in a group of mother's 4-year-old children.

STUDY DESIGN

Randomised controlled trial.

METHODS

After screening 416 women with newborn babies, 173 mothers with high counts of salivary mutans streptococci (MS) were randomly assigned into three experimental chewing gum groups containing A) xylitol (n=61), B) chlorhexidine/xylitol/sorbitol (n=55), and C) sodium fluoride/xylitol/sorbitol (n=57). The intervention started when each child was 6 months old, was terminated one year later. All of the mothers were instructed to chew one piece of the appropriate gum for 5 minutes, three times a day. The outcome measure was the presence of cavitated and non-cavitated (enamel) lesions in the primary dentitions of the children at the age of 4 years.

RESULTS

The drop-out rate in the experimental groups was 15-20%. The mean defs, on examination at aged 4 years was 0.4 +/-1.0 in group A, 0.7 +/-1.7 in group B and 1.4 +/-3.0 in group C. The difference between group A and C was statistically significant (p<0.05).

CONCLUSIONS

Less caries was observed in children of mothers who chewed gums with xylitol as the single sweetener during the time of eruption of the first primary teeth compared with those who used gums containing fluoride, sorbitol and lower amounts of xylitol.

Biochemical characterization of an L-Xylulose reductase from Neurospora crassa

An l-xylulose reductase identified from the genome sequence of the filamentous fungus Neurospora crassa was heterologously expressed in Escherichia coli as a His(6) tag fusion protein, purified, and characterized. The enzyme may be used in the production of xylitol from the major pentose components of hemicellulosic waste, d-xylose and l-arabinose.

Xylitol concentration in saliva and dental plaque after use of various xylitol-containing products

The study consisted of two sets of experiments, one in saliva and one in dental plaque. The xylitol concentration in saliva was determined enzymatically in 12 children (mean age 11.5 years) after a standardised use of various xylitol products: (A) chewing gums (1.3 g xylitol), (B) sucking tablets (0.8 g xylitol), (C) candy tablets (1.1 g xylitol), (D) toothpaste (0.1 g xylitol), (E) rinse (1.0 g xylitol), and (F) a non-xylitol paraffin. Unstimulated saliva was sampled 1, 3, 8, 16 and 30 min after use. The concentration in dental plaque was determined after mouthrinses with contrasting amounts of xylitol (LX = 2.0 g, HX = 6.0 g, and control) and supragingival plaque was collected and pooled after 5, 15 and 30 min. The mean xylitol concentration in saliva at baseline was approximately 0.1 mg/ml. All xylitol-containing products resulted in significantly increased levels (p < 0.05) immediately after intake and remained elevated for 8-16 min in the different groups. The highest mean value in saliva was obtained immediately after use of chewing gums (33.7 +/- 16.4 mg/ml) and the lowest was demonstrated after using toothpaste (8.2 +/- 4.9 mg/ml). No significant differences were demonstrated between chewing gums (A), sucking tablets (B), candy (C) and rinses (E). In dental plaque, the mean values were 8.6 +/- 5.4 and 5.1 +/- 4.0 mg/ml 5 min after HX and LX rinses. Concerning the higher concentration, the values remained significantly elevated (p < 0.05) during the entire 30-min follow-up. In conclusion, commonly advocated xylitol-containing products gave elevated concentrations of xylitol in unstimulated whole saliva and dental plaque for at least 8 min after intake.

Effect of xylitol-containing chewing gums on interdental plaque-pH in habitual xylitol consumers

OBJECTIVE

The aim was to investigate the effect of high and low amounts of xylitol on the interdental plaque-pH, directly and after sucrose challenge, in schoolchildren with habitual consumption.

MATERIAL AND METHODS

The study group consisted of 11 healthy children (10-15 years) with low caries risk and the experiment had a single-blind crossover (Latin square) design. After a 2-week run-in period with a daily 4.0 g xylitol intake, the children were subjected to single-dose exposures of chewing gums with (i) paraffin (CTR; no xylitol), (ii) low-dose xylitol (LX; 2.0 g xylitol), and (iii) high-dose xylitol (HX; 6.0 g xylitol) in a randomized order separated by a washout period of 1 week. Samples of chewing-stimulated whole saliva were collected prior to and after the experimental period for determination of bacterial counts. The outcome measures were in situ plaque-pH (micro-touch method) and area under the pH curve (AUC).

RESULTS

The AUC was significantly greater (p < 0.05) in the HX group compared to the LX and control groups during the first 5 min after chewing. After a 10% sucrose rinse, the interdental plaque-pH dropped in all groups but the HX regimen displayed significantly less reduction 0-5 min after chewing (p < 0.05). No significant alterations of the total viable counts or mutans streptococci levels in saliva were disclosed during the 4-week experimental period.

CONCLUSIONS

The present results suggested that a high single dose of xylitol had a short and limited beneficial effect on interdental plaque-pH in habitual xylitol consumers, while a low single dose, resembling normal chewing gum use, did not differ from the control.

Dietary factors and dental caries

DATA SOURCES

Articles were sourced using Medline, the Cochrane Library, reference lists of identified articles and selected textbooks.

STUDY SELECTION

Studies chosen for inclusion in the review were randomised or controlled clinical trials of at least 2 years' duration that used caries increment in the permanent or primary dentition as the end point. Publications in Danish, English, French, German, Italian, Norwegian, Spanish or Swedish were included. For multiply reported trials the one with the longest follow-up period was included.

DATA EXTRACTION AND SYNTHESIS

Inclusion decisions and grading of the studies was carried out independently by two of the authors. The main outcome was caries increment and the measure of treatment effect was either relative risk reduction or prevented faction. A qualitative synthesis of the included studies was conducted.

RESULTS

Eighteen studies met the inclusion criteria. They included the total or partial substitution of sucrose with sugar substitutes or the addition of protective foods to chewing gum. No study could be found that had evaluated the effect of information designed to reduce sugar intake/frequency as a single preventive measure. It is suggested that the evidence for the use of sorbitol or xylitol in chewing gum, or for the use of invert sugar, is inconclusive. No caries-preventive effect was found from adding calcium phosphate or dicalcium phosphate dihydrate to chewing gums.

CONCLUSIONS

The review dearly demonstrates the need for well-designed randomised clinical studies, with adequate control groups and high compliance, looking at the effect of dietary measures on dental caries.

Salivary mutans streptococci and dental caries in three-year-old children after maternal exposure to chewing gums containing combinations of xylitol, sorbitol, chlorhexidine, and fluoride

The aim of this study was to evaluate the effect of maternal use of chewing gums containing combinations of xylitol, sorbitol, chlorhexidine, and fluoride on salivary mutans streptococci (MS) counts and caries prevalence in the mothers' 3-year-old children. After screening 416 women with newborn babies, 173 mothers with high counts of salivary MS were randomly assigned into 3 experimental chewing gum groups containing (A) xylitol (n = 61), (B) chlorhexidine/xylitol/sorbitol (n = 55), and (C) sodium fluoride/xylitol/ sorbitol (n = 57). Mothers with low or medium MS counts formed a reference group (D) without any intervention (n = 232). The participants in the experimental groups were instructed to chew one piece of the gum for 5 min 3 times a day. The chewing regimen started when the child was 6 months old and was terminated 1 year later. The outcome measures were salivary MS counts and caries prevalence at the age of 3 years. Bacterial enumeration was carried out with a chair-side technique and caries (defs) was scored by clinical examination. Medium and high counts of salivary MS were found in 13%, 16%, and 22% in groups A, B, and C, respectively. The mean defs was 0.1 in group A, 0.2 in group B, and 0.4 in group C. The differences concerning salivary MS and caries were not statistically significant. The MS counts and caries prevalence in children of mothers with low MS counts (group D) were similar to those found in groups A and B. In conclusion, lower but non-significant levels of salivary MS and dental decay were observed in 3-year-old children to mothers who used high-content xylitol gums compared with those who used lower amounts of xylitol. The efficiency of this type of targeted intervention in a low-caries community may be questioned.