Cariogenic traits in xylitol-resistant and xylitol-sensitive mutans streptococci

Dietary Carbohydrates Modulate Streptococcus mutans Adherence and Bacterial Proteome

INTRODUCTION

Streptococcus mutans adherence to the tooth surface and subsequent biofilm development is modulated by the carbohydrate source, but the corresponding effect on bacterial proteome has not been previously studied. This study aimed to assess the effect of different carbohydrates on S. mutans viability and bacterial proteome at 2 time points, early attachment (8 h) and biofilm maturation (24 h).

METHODS

Hydroxyapatite (HAp) discs coated with parotid saliva proteins were inoculated with S. mutans UA159 in tryptone soy broth without dextrose supplemented with one of the following carbohydrates (n = 12/treatment/time point): 1% sucrose; 0.525% glucose + 0.525% fructose; 10% xylitol; 10% xylitol + 1% sucrose; or culture medium without supplementation as negative control. Once inoculated, HAp discs were incubated for 8 h or 24 h at 37°C and 10% CO2. After each incubation period, adhered bacteria were quantified using the plate-counting method for 6 HAp discs/group, and the remaining 6 HAp discs/group were used to extract bacterial cell wall proteins. Extracted proteins were analyzed using liquid chromatography coupled with mass spectrometry and then classified by their biological process. The study was conducted in three independent assays, and the number of bacteria adhered to the HAp discs was determined at each time point and analyzed by two-way ANOVA followed by Bonferroni test (α = 5%).

RESULTS

The results suggest that xylitol significantly repressed bacterial adherence and metabolism at 8 h and 24 h; however, bacterial adherence and metabolism were significantly enhanced when xylitol was combined with sucrose, showing no negative effect on S. mutans at both time points. Bacterial proteome was modulated by the carbohydrate source.

CONCLUSION

The cariogenicity of S. mutans biofilms may be reduced by the alternative sweetener xylitol; however, the combination with fermentable sugars may inhibit such a beneficial effect.

Cyclic Di-adenosine Monophosphate Regulates Metabolism and Growth in the Oral Commensal Streptococcus mitis

Cyclic di-adenosine monophosphate (c-di-AMP) has emerged as an important bacterial signaling molecule that functions both as an intracellular second messenger in bacterial cells and an extracellular ligand involved in bacteria-host cross-talk. In this study, we identify and characterize proteins involved in controlling the c-di-AMP concentration in the oral commensal and opportunistic pathogen Streptococcusmitis (S. mitis). We identified three known types of c-di-AMP turnover proteins in the genome of S. mitis CCUG31611: a CdaA-type diadenylate cyclase as well as GdpP-, and DhhP-type phosphodiesterases. Biochemical analyses of purified proteins demonstrated that CdaA synthesizes c-di-AMP from ATP whereas both phosphodiesterases can utilize c-di-AMP as well as the intermediary metabolite of c-di-AMP hydrolysis 5'-phosphadenylyl-adenosine (pApA) as substrate to generate AMP, albeit at different catalytic efficiency. Using deletion mutants of each of the genes encoding c-di-AMP turnover proteins, we show by high resolution MS/MS that the intracellular concentration of c-di-AMP is increased in deletion mutants of the phosphodiesterases and non-detectable in the cdaA-mutant. We also detected pApA in mutants of the DhhP-type phosphodiesterase. Low and high levels of c-di-AMP were associated with longer and shorter chains of S. mitis, respectively indicating a role in regulation of cell division. The deletion mutant of the DhhP-type phosphodiesterase displayed slow growth and reduced rate of glucose metabolism.

Effect of Probiotic Yogurt and Xylitol-Containing Chewing Gums on Salivary S Mutans Count

BACKGROUND AND AIMS

In addition to improving gastrointestinal health and intestinal microflora, probiotic bacteria have been recently suggested to decrease cariogenic agents in the oral cavity. The aim of this study was to investigate the effects of probiotic yogurt and xylitol-containing chewing gums on reducing salivary Streptococcus mutans levels.

STUDY DESIGN

This randomized clinical trial recruited 50 female students with over 10⁵ colony forming units S. mutans per milliliter of their saliva. The participants were randomly allocated to two equal groups to receive either probiotic yogurt containing Lactobacillus acidophilus ATCC 4356 andBifidobacteriumbifidum ATCC 29521 (200 g daily) or xylitol-containing chewing gums (two gums three times daily after each meal; total xylitol content: 5.58 g daily) for three weeks. At baseline and one day, two weeks, and four weeks after the interventions, saliva samples were cultured on mitis-salivarius-bacitracin agar and salivary S. mutans counts were determined. Data were analyzed with independent t-tests, analysis of variance, and Fisher's least significant difference test.

RESULTS

In both groups, S. mutans counts on the first day, second week, and fourth weeks after the intervention were significantly lower than baseline values (P < 0.05). The greatest level of reduction in both groups was observed in the second week after the intervention. Moreover, although the reduction was greater in probiotic yogurt consumers, the difference between the two groups was not statistically significant.

CONCLUSION

Probiotic yogurt and xylitol-containing chewing gums seem to be as effective in reduction of salivary S. mutans levels. Their constant long-term consumption is thus recommended to prevent caries.

Comparative evaluation of 0.2% Chlorhexidine Mouthwash, Xylitol Chewing Gum, and Combination of 0.2% Chlorhexidine Mouthwash and Xylitol Chewing Gum on Salivary Streptococcus mutans and Biofilm Levels in 8- to 12-Year-Old Children

AIM

To assess the effect of combining 0.2% chlorhexidine (CHX) mouthwash with xylitol (XYL) chewing gum on Streptococcus mutans and biofilm levels among 8- to 12-year-old children.

MATERIALS AND METHODS

Sixty children aged 8 to 12 years were selected with moderate and high salivary S. mutans levels. They were divided into three groups of 20 children each: (1) XYL group where the subjects chewed XYL twice daily; (2) CHX where rinsing was done twice daily; and (3) combination of XYL and CHX group (XYL+CHX) where both the agents were used once daily. The S. mutans colony-forming units (CFUs) were counted by using the mitis salivarius agar plate at the beginning of the study and at 15 days, 1, 2, and 6 months from the start of the study.

RESULTS

The XYL+CHX group showed the maximum reduction in both the biofilm and S. mutans scores throughout the study period.

CONCLUSION

The XYL+CHX combination reduced both the biofilm and S. mutans score significantly better than either XYL chewing gums or CHX mouthwash used alone.

HOW TO CITE THIS ARTICLE

Syed M, Chopra R, Shrivastava V, Sachdev V. Comparative evaluation of 0.2% Chlorhexidine Mouthwash, Xylitol Chewing Gum, and Combination of 0.2% Chlorhexidine Mouthwash and Xylitol Chewing Gum on Salivary Streptococcus mutans and Biofilm Levels in 8- to 12-Year-Old Children. Int J Clin Pediatr Dent 2016;9(4):313-319.

Xylitol-containing products for preventing dental caries in children and adults

BACKGROUND

Dental caries is a highly prevalent chronic disease which affects the majority of people. It has been postulated that the consumption of xylitol could help to prevent caries. The evidence on the effects of xylitol products is not clear and therefore it is important to summarise the available evidence to determine its effectiveness and safety.

OBJECTIVES

To assess the effects of different xylitol-containing products for the prevention of dental caries in children and adults.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 14 August 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2014, Issue 7), MEDLINE via OVID (1946 to 14 August 2014), EMBASE via OVID (1980 to 14 August 2014), CINAHL via EBSCO (1980 to 14 August 2014), Web of Science Conference Proceedings (1990 to 14 August 2014), Proquest Dissertations and Theses (1861 to 14 August 2014). We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials assessing the effects of xylitol products on dental caries in children and adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference and 95% confidence interval (CI). We used the continuous data to calculate prevented fractions (PF) and 95% CIs to summarise the percentage reduction in caries. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. As there were less than four studies included in the meta-analysis, we used a fixed-effect model. We planned to use a random-effects model in the event that there were four or more studies in a meta-analysis.

MAIN RESULTS

We included 10 studies that analysed a total of 5903 participants. One study was assessed as being at low risk of bias, two were assessed as being at unclear risk of bias, with the remaining seven being at high risk of bias.The main finding of the review was that, over 2.5 to 3 years of use, a fluoride toothpaste containing 10% xylitol may reduce caries by 13% when compared to a fluoride-only toothpaste (PF -0.13, 95% CI -0.18 to -0.08, 4216 children analysed, low-quality evidence).The remaining evidence on children, from small single studies with risk of bias issues and great uncertainty associated with the effect estimates, was insufficient to determine a benefit from xylitol products. One study reported that xylitol syrup (8 g per day) reduced caries by 58% (95% CI 33% to 83%, 94 infants analysed, low quality evidence) when compared to a low-dose xylitol syrup (2.67 g per day) consumed for 1 year.The following results had 95% CIs that were compatible with both a reduction and an increase in caries associated with xylitol: xylitol lozenges versus no treatment in children (very low quality body of evidence); xylitol sucking tablets versus no treatment in infants (very low quality body of evidence); xylitol tablets versus control (sorbitol) tablets in infants (very low quality body of evidence); xylitol wipes versus control wipes in infants (low quality body of evidence).There was only one study investigating the effects of xylitol lozenges, when compared to control lozenges, in adults (low quality body of evidence). The effect estimate had a 95% CI that was compatible with both a reduction and an increase in caries associated with xylitol.Four studies reported that there were no adverse effects from any of the interventions. Two studies reported similar rates of adverse effects between study arms. The remaining studies either mentioned adverse effects but did not report any usable data, or did not mention them at all. Adverse effects include sores in the mouth, cramps, bloating, constipation, flatulence, and loose stool or diarrhoea.

AUTHORS' CONCLUSIONS

We found some low quality evidence to suggest that fluoride toothpaste containing xylitol may be more effective than fluoride-only toothpaste for preventing caries in the permanent teeth of children, and that there are no associated adverse-effects from such toothpastes. The effect estimate should be interpreted with caution due to high risk of bias and the fact that it results from two studies that were carried out by the same authors in the same population. The remaining evidence we found is of low to very low quality and is insufficient to determine whether any other xylitol-containing products can prevent caries in infants, older children, or adults.

Synergistic inhibition of Streptococcal biofilm by ribose and xylitol

Streptococcus mutans and Streptococcus sobrinus are the major causative agents of human dental caries. Therefore, the removal or inhibition of these streptococcal biofilms is essential for dental caries prevention. In the present study, we evaluated the effects of ribose treatment alone or in combination with xylitol on streptococcal biofilm formation for both species. Furthermore, we examined the expression of genes responsible for dextran-dependent aggregation (DDAG). In addition, we investigated whether ribose affects the biofilm formation of xylitol-insensitive streptococci, which results from long-term exposure to xylitol. The viability of streptococci biofilms formed in a 24-well polystyrene plate was quantified by fluorescent staining with the LIVE/DEAD bacterial viability and counting kit, which was followed by fluorescence activated cell sorting analysis. The effects of ribose and/or xylitol on the mRNA expression of DDAG-responsible genes, gbpC and dblB, was evaluated by RT-qPCR. Our data showed that ribose and other pentose molecules significantly inhibited streptococcal biofilm formation and the expression of DDAG-responsible genes. In addition, co-treatment with ribose and xylitol decreased streptococcal biofilm formation to a further extent than ribose or xylitol treatment alone in both streptococcal species. Furthermore, ribose attenuated the increase of xylitol-insensitive streptococcal biofilm, which results in the reduced difference of biofilm formation between S. mutans that are sensitive and insensitive to xylitol. These data suggest that pentose may be used as an additive for teeth-protective materials or in sweets. Furthermore, ribose co-treatment with xylitol might help to increase the anti-cariogenic efficacy of xylitol.

Synergistic effect of xylitol and ursolic acid combination on oral biofilms

Objectives

This study was designed to evaluate the synergistic antibacterial effect of xylitol and ursolic acid (UA) against oral biofilms in vitro.

Materials and Methods

S. mutans UA 159 (wild type), S. mutans KCOM 1207, KCOM 1128 and S. sobrinus ATCC 33478 were used. The susceptibility of S. mutans to UA and xylitol was evaluated using a broth microdilution method. Based on the results, combined susceptibility was evaluated using optimal inhibitory combinations (OIC), optimal bactericidal combinations (OBC), and fractional inhibitory concentrations (FIC). The anti-biofilm activity of xylitol and UA on Streptococcus spp. was evaluated by growing cells in 24-well polystyrene microtiter plates for the biofilm assay. Significant mean differences among experimental groups were determined by Fisher's Least Significant Difference (p < 0.05).

Results

The synergistic interactions between xylitol and UA were observed against all tested strains, showing the FICs < 1. The combined treatment of xylitol and UA inhibited the biofilm formation significantly and also prevented pH decline to critical value of 5.5 effectively. The biofilm disassembly was substantially influenced by different age of biofilm when exposed to the combined treatment of xylitol and UA. Comparing to the single strain, relatively higher concentration of xylitol and UA was needed for inhibiting and disassembling biofilm formed by a mixed culture of S. mutans 159 and S. sobrinus 33478.

Conclusions

This study demonstrated that xylitol and UA, synergistic inhibitors, can be a potential agent for enhancing the antimicrobial and anti-biofilm efficacy against S. mutans and S. sobrinus in the oral environment.

Clinical Efficacy and Effects of Xylitol Wipes on Bacterial Virulence

The aim of the study was to investigate whether xylitol-wipe use in young children prevented caries by affecting bacterial virulence. In a double-blinded randomized controlled clinical trial, 44 mother-child pairs were randomized to xylitol-wipe or placebo-wipe groups. Salivary mutans streptococci levels were enumerated at baseline, 6 months, and one year. Ten mutans streptococci colonies were isolated and genotyped from each saliva sample. Genotype-colonization stability, xylitol sensitivity, and biofilm formation of these isolates were studied. Despite a significant reduction in new caries at one year in the xylitol-wipe group, no significant differences were found between the two groups in levels of mutans streptococci. Children in the xylitol-wipe group had significantly fewer retained genotypes (p = 0.06) and more transient genotypes of mutans streptococci (p = 0.05) than those in the placebo-wipe group. At one year, there was no significant difference in the prevalence of xylitol-resistant genotypes or in biofilm formation ability of mutans streptococci isolates between the two groups. The mechanism of the caries-preventive effect of xylitol-wipe use may be related to the stability of mutans streptococci colonization. Further studies with genomic characterization methods are needed to determine specific gene(s) that account for the caries-preventive effect of xylitol.

Six months of high-dose xylitol in high-risk caries subjects--a 2-year randomised, clinical trial

Objectives

The hypothesis was that the daily use of a high dose of a xylitol chewing gum for 6 months would reduce the increment of decayed permanent first molar surfaces (ΔD₆S) in high-risk schoolchildren after 2 years.

Methods

In this randomised, clinical trial, 204 schoolchildren with a high caries risk were assigned to two experimental groups, xylitol and non-xylitol. Caries status, salivary mutans streptococci, and lactobacilli were re-evaluated 2 years later in 74 xylitol-treated and 83 non-xylitol-treated schoolchildren. Differences in mean ∆D₆S between groups registered at baseline and at follow-up were evaluated using the nonparametric Mann–Whitney U test.

Results

Outcome was the development of detectable carious lesions initial (D₁–D₂) and manifest (D₃) in the permanent first molars. In the xylitol group, the difference in proportion of children with decayed first permanent molars at baseline and follow-up was 1.43 % for manifest lesion and 2.86 % for initial lesions; while in the non-xylitol group was 10.26 % (p < 0.01) and 16.66 % (p < 0.01), respectively. A statistically significant difference regarding means was also observed in the non-xylitol group: the ∆D₆S for manifest lesion was 0.18 (p = 0.03) and 0.67 (p = 0.02) for initial lesion.

Conclusion

The use of a chewing gum containing a high dose of xylitol for a period of 6 months has been shown to produce a long-term effect on caries development in high caries-risk children.

Clinical relevance

A school-based preventive programme based on 6 months’ administration of a high dose of xylitol via chewing gum proved to be efficacious in controlling caries increment in high-risk children.

Randomized controlled trial to evaluate tooth stain reduction with nicotine replacement gum during a smoking cessation program

BACKGROUND

In addition to its general and periodontal health effects smoking causes tooth staining. Smoking cessation support interventions with an added stain removal or tooth whitening effect may increase motivation to quit smoking. Oral health professionals are well placed to provide smoking cessation advice and support to patients. The objective of the present study was to evaluate the effect of Nicorette(®) Freshmint Gum used in a smoking cessation programme administered in a dental setting, on extrinsic stain and tooth shade among smokers.

METHODS

An evaluator-blinded, randomized, 12-week parallel-group controlled trial was conducted among 200 daily smokers motivated to quit smoking. Participants were randomised to use either the Nicorette(®) Freshmint Gum or Nicorette(®) Microtab (tablet). Tooth staining and shade were rated using the modified Lobene Stain Index and the Vita(®) Shade Guide at baseline, weeks 2, 6 and 12. To maintain consistency with other whitening studies, the primary end-point was the mean change in stain index between baseline and week 6. Secondary variables included changes in stain measurements and tooth shade at the other time points the number of gums or tablets used per day and throughout the trial period; and the number of cigarettes smoked per day. Treatments were compared using analysis of covariance (ANCOVA), using treatment and nicotine dependence as factors and the corresponding baseline measurement as a covariate. Each comparison (modified intention-to-treat) was tested at the 0.05 level, two-sided. Within-treatment changes from baseline were compared using a paired t-test.

RESULTS

At week 6, the gum-group experienced a reduction in mean stain scores whilst the tablet-group experienced an increase with mean changes of -0.14 and +0.12 respectively, (p = 0.005, ANCOVA). The change in mean tooth shade scores was statistically significantly greater in the gum-group than in the tablet group at 2 (p = 0.015), 6 (p = 0.011) and 12 weeks (p = 0.003) with greater lightening in the gum-group at each examination period.

CONCLUSION

These results support the efficacy of the tested nicotine replacement gum in stain reduction and shade lightening. These findings may help dentists to motivate those wishing to quit smoking using a nicotine replacement gum.

TRIAL REGISTRATION

NCT01440985.

Use of chewing gum containing 15% of xylitol and reduction in mutans streptococci salivary levels

Frequent use of Xylitol may decrease the S. mutans levels. However, very little is known about whether this effect on the levels of cariogenic bacteria is maintained after the interruption of short-term usage of xylitol. This study aimed at evaluating changes in mutans streptococci (MS) salivary levels after using a chewing gum containing xylitol. Twelve volunteers harboring > or = 10(5) CFU MS/ml saliva levels were asked to chew Happydent-xylit for 5 minutes, 5 X/day, for 30 days. Saliva samples were collected at baseline, at 30 days after xylitol usage began, and at 30 days beyond its interruption. MS salivary levels were estimated. The average salivary levels of MS in the ten subjects who completed the study were 13.17 (NL-CFU) at baseline (A). After the 30 days experimental period (B), this average decreased to 9.45 (NL-CFU). Nine of ten subjects studied showed a reduction in MS salivary levels in relation to baseline, whereas salivary levels were maintained in the remaining subject. At thirty days beyond the interruption of xylitol usage (C), the average levels of MS were still reduced to 10.31 (NL-CFU). Multiple sample comparison using the Bonferroni test revealed that the decrease in MS levels observed from baseline (A) to the time immediately after 30 days of xylitol usage (B) was statistically significant (p < 0.05), and those levels were still decreased between baseline and 30 days beyond the interruption of xylitol usage (C). So, the use of xylitol induced a reduction in MS salivary levels after a short period of usage which persisted beyond its interruption.

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.

Synthesis of arabinitol 1-phosphate and its use for characterization of arabinitol-phosphate dehydrogenase

D-arabinitol 1-phosphate (Ara-ol1-P), a substrate for D-arabinitol-phosphate dehydrogenase (APDH), was chemically synthesized from D-arabinonic acid in five steps (O-acetylation, chlorination, reduction, phosphorylation, and de-O-acetylation). Ara-ol1-P was used as a substrate for the characterization of APDH from Bacillus halodurans. APDH converts Ara-ol1-P to xylulose 5-phosphate in the oxidative reaction; both NAD(+) and NADP(+) were accepted as co-factors. Kinetic parameters for the oxidative and reductive reactions are consistent with a ternary complex mechanism.

Effect of xylitol on mutans streptococci and lactic acid formation in saliva and plaque from adolescents and young adults with fixed orthodontic appliances

This study aimed to investigate two dose regimens of xylitol-containing tablets on the ecology of dental plaque and saliva during treatment with fixed orthodontic appliances. The study group comprised 56 healthy patients (mean age 15.8 yr) randomly assigned into the following groups: A, (n = 23) two xylitol tablets two times a day (1.7 g xylitol d(-1)) for 18 wk; B, (n = 23) two tablets four times per day (3.4 g xylitol d(-1)) for 18 wk; and C, (n = 10) no tablets. The levels of mutans streptococci (ms) were enumerated in plaque and saliva and the proportion of xylitol-sensitive (X(S)) strains in saliva was determined by autoradiography with [(14)C]-xylitol at baseline and at 6, 12, and 18 wk. The lactic acid formation rate was assessed enzymatically in sucrose-challenged plaque suspensions. A drop in salivary ms levels was found in Group A after 6 wk but not after 12 or 18 wk. The proportion of X(S) ms was decreased after 6 wk in groups A and B and remained so during the experimental period. The lactic acid formation rates decreased slightly ( approximately 10%) in the two xylitol groups compared with baseline. In conclusion, our results showed that although an alteration of ms strains was demonstrated following a regular daily low-dose intake of xylitol, the long-term total ms counts in plaque and saliva as well as plaque acidogenicity remained unchanged.

Sugar Alcohols: What Is the Evidence for Caries-Preventive and Caries-Therapeutic Effects?

The most widely used sugar alcohols are: xylitol, sorbitol, mannitol, maltitol, lactitol and the products Lycasin and Palatinit. It is often claimed that xylitol is superior to the other sugar alcohols for caries control. This paper examines clinical studies on the caries-preventive and therapeutic effects of sugar alcohols with emphasis on sorbitol and xylitol. It is concluded that chewing sugar-free gum 3 or more times daily for prolonged periods of time may reduce caries incidence irrespective of the type of sugar alcohol used. It may be sufficient to do this only on school days. Sucking xylitol-containing candies or tablets may have a similar effect as chewing xylitol chewing gum. Clinical trials suggest greater caries reductions from chewing gums sweetened with xylitol than from gums sweetened with sorbitol. However, the superiority of xylitol was not confirmed in 2 out of 4 clinical trials comparing the caries-preventive effect of xylitol- with sorbitol-sweetened gums. The caries-preventive effects of polyol-containing gums and candies seem to be based on stimulation of the salivary flow, although an antimicrobial effect cannot be excluded. There is no evidence for a caries-therapeutic effect of xylitol. These conclusions are in line with those of recent reviews and with the conclusions of the Scientific Committee on Medicinal Products and Medical Devices of the EU Commission.