The effect of xylitol chewing gums and candies on caries occurrence in children: a systematic review with special reference to caries level at study baseline

PURPOSE

A systematic review of published data was carried out to assess the caries-preventive effects of xylitol chewing gums and candies in children.

METHODS

Electronic and hand searches were performed to find clinical studies on the effects of xylitol chewing gums and candies on dental caries in children (≤ 18 years). Prospective randomised or controlled clinical trials published before 2023 were included in the review.

RESULTS

The initial search identified 365 titles to be evaluated. After applying inclusion and exclusion criteria, 15 articles with either fair or low quality were reviewed. Nine articles studied chewing gums, five candies, and one both of them. In the ten evaluated xylitol chewing gum studies xylitol consumption significantly reduced caries occurrence when compared with no treatment or a placebo polyol gum. The effect was clinically significant in studies with high or moderate caries level at study baseline. The results also suggested that the caries-reducing effect of xylitol gums may differ from sorbitol/polyol gums. In five of the six heterogenous xylitol candy studies, no caries-reducing effect was found independent of caries level. In addition to caries level, also the daily xylitol dose was a confounding factor.

CONCLUSION

The present findings suggest that the caries-reducing effect of adding xylitol chewing gum to the daily diet has been well demonstrated in children and adolescents with high or moderate caries level at study baseline. Xylitol gum use could benefit subjects with active incipient caries lesions on smooth tooth surfaces.

Effect of polydopamine and fluoride ion coating on dental enamel remineralization: an in vitro study

BACKGROUND

Fluoride treatment is one of the most effective dental caries prevention methods. To continuously prevent dental caries, stably immobilizing the fluoride on the tooth enamel is highly desirable. This study aimed to evaluate the remineralization of tooth enamels by one-pot coating using polydopamine and fluoride ions.

METHODS

To prepare the enamel specimens for polydopamine- and fluoride ion-coating, they were treated with polydopamine- and fluoride-containing gels. The enamel specimens were collected from human molars in a blind manner (n = 100) and were randomized into five treatment groups (n = 20, each): 1) untreated, 2) polydopamine-coated, 3) fluoride-containing gel-treated, 4) F varnish-treated, and 5) polydopamine- and fluoride ion-coated enamels. Vickers hardness number (VHN), morphology, and fluoride contents of the specimens were measured before and after the pH-cycling regimen.

RESULTS

Polydopamine- and fluoride ion-coated enamels showed the highest fluoride content and lowest VHN reduction among the samples. The fluoride content of the polydopamine/fluoride ion (PD/F)-coated enamel was increased to 182 ± 6.6%, which was far higher than that of the uncoated enamel (112.3 ± 32.8%, P < 0.05). The changes in the VHN values (ΔVHN) of PD/F-coated enamel substrates showed a slight reduction in the VHN (-3.6%, P < 0.05), which was far lower than that in the control group (-18.9%, P < 0.05). In addition, scanning electron microscopy clearly supported the effect of polydopamine- and fluoride ion-coatings on the remineralization of enamel specimens.

CONCLUSION

Our findings suggest that one-pot treatments with polydopamine and fluoride ions could significantly enhance remineralization by inhibiting enamel demineralization through the prolonged retention of fluoride ions.

Prevalence, correlates and treatment needs of dental caries in patients attending a diabetic clinic in rural southwestern Uganda: a cross-sectional study

BACKGROUND

Diabetes mellitus is a complex heterogeneous metabolic disorder known to lead to several pathogenic disorders, and has a bidirectional relationship with oral health conditions. This study aimed at estimating the prevalence, treatment needs and correlates of dental caries among adult patients attending a diabetic clinic in Uganda.

METHODS

This was a cross-sectional study that used questionnaires to collect data on socio-demographic factors, diabetes history, oral health status, dental health care, dietary factors, lifestyle factors, and dental examination guided by the modified World Health Organization oral health questionnaire for adults.

RESULTS

We enrolled 239 participants, prevalence of dental caries was 71.6%, treatment need was nearly 100%, and mean DMFT was 3.82 (SD = 5.46). Dental caries experience was associated with being widowed.

CONCLUSION

We found a high prevalence of dental caries experience and large treatment need among our participants. We recommend integration of oral health care into routine diabetic services in rural sub Saharan Africa.

Erythritol: An In-Depth Discussion of Its Potential to Be a Beneficial Dietary Component

The sugar alcohol erythritol is a relatively new food ingredient. It is naturally occurring in plants, however, produced commercially by fermentation. It is also produced endogenously via the pentose phosphate pathway (PPP). Consumers perceive erythritol as less healthy than sweeteners extracted from plants, including sucrose. This review evaluates that perspective by summarizing current literature regarding erythritol's safety, production, metabolism, and health effects. Dietary erythritol is 30% less sweet than sucrose, but contains negligible energy. Because it is almost fully absorbed and excreted in urine, it is better tolerated than other sugar alcohols. Evidence shows erythritol has potential as a beneficial replacement for sugar in healthy and diabetic subjects as it exerts no effects on glucose or insulin and induces gut hormone secretions that modulate satiety to promote weight loss. Long-term rodent studies show erythritol consumption lowers body weight or adiposity. However, observational studies indicate positive association between plasma erythritol and obesity and cardiometabolic disease. It is unlikely that dietary erythritol is mediating these associations, rather they reflect dysregulated PPP due to impaired glycemia or glucose-rich diet. However, long-term clinical trials investigating the effects of chronic erythritol consumption on body weight and risk for metabolic diseases are needed. Current evidence suggests these studies will document beneficial effects of dietary erythritol compared to caloric sugars and allay consumer misperceptions.

The Role of D-allulose and Erythritol on the Activity of the Gut Sweet Taste Receptor and Gastrointestinal Satiation Hormone Release in Humans: A Randomized, Controlled Trial

BACKGROUND

Glucose induces the release of gastrointestinal (GI) satiation hormones, such as glucagon-like peptide 1 (GLP-1) and peptide tyrosine tyrosine (PYY), in part via the activation of the gut sweet taste receptor (T1R2/T1R3).

OBJECTIVES

The primary objective was to investigate the importance of T1R2/T1R3 for the release of cholecystokinin (CCK), GLP-1, and PYY in response to D-allulose and erythritol by assessing the effect of the T1R2/T1R3 antagonist lactisole on these responses and as secondary objectives to study the effect of the T1R2/T1R3 blockade on gastric emptying, appetite-related sensations, and GI symptoms.

METHODS

In this randomized, controlled, double-blind, crossover study, 18 participants (5 men) with a mean ± SD BMI (in kg/m2) of 21.9 ± 1.7 and aged 24 ± 4 y received an intragastric administration of 25 g D-allulose, 50 g erythritol, or tap water, with or without 450 parts per million (ppm) lactisole, respectively, in 6 different sessions. 13C-sodium acetate was added to all solutions to determine gastric emptying. At fixed time intervals, blood and breath samples were collected, and appetite-related sensations and GI symptoms were assessed. Data were analyzed with linear mixed-model analysis.

RESULTS

D-allulose and erythritol induced a significant release of CCK, GLP-1, and PYY compared with tap water (all PHolm < 0.0001, dz >1). Lactisole did not affect the D-allulose- and erythritol-induced release of CCK, GLP-1, and PYY (all PHolm > 0.1). Erythritol significantly delayed gastric emptying, increased fullness, and decreased prospective food consumption compared with tap water (PHolm = 0.0002, dz = -1.05; PHolm = 0.0190, dz = 0.69; and PHolm = 0.0442, dz = -0.62, respectively).

CONCLUSIONS

D-allulose and erythritol stimulate the secretion of GI satiation hormones in humans. Lactisole had no effect on CCK, GLP-1, and PYY release, indicating that D-allulose- and erythritol-induced GI satiation hormone release is not mediated via T1R2/T1R3 in the gut.

Effect of a Chronic Intake of the Natural Sweeteners Xylitol and Erythritol on Glucose Absorption in Humans with Obesity

In patients with obesity, accelerated nutrients absorption is observed. Xylitol and erythritol are of interest as alternative sweeteners, and it has been shown in rodent models that their acute ingestion reduces intestinal glucose absorption. This study aims to investigate whether a chronic intake of xylitol and erythritol impacts glucose absorption in humans with obesity. Forty-six participants were randomized to take either 8 g of xylitol or 12 g of erythritol three times a day for five to seven weeks, or to be part of the control group (no substance). Before and after the intervention, intestinal glucose absorption was assessed during an oral glucose tolerance test with 3-Ortho-methyl-glucose (3-OMG). The effect of xylitol or erythritol intake on the area under the curve for 3-OMG concentration was not significant. Neither the time (pre or post intervention), nor the group (control, xylitol, or erythritol), nor the time-by-group interaction effects were significant (p = 0.829, p = 0.821, and p = 0.572, respectively). Therefore, our results show that a chronic intake of the natural sweeteners xylitol and erythritol does not affect intestinal glucose absorption in humans with obesity.

Effect of erythritol and xylitol on Streptococcus pyogenes causing peritonsillar abscesses

Polyols are effective against caries-causing streptococci but the effect on oropharynx-derived pyogenic streptococci is not well characterised. We aimed to study the effect of erythritol (ERY) and xylitol (XYL) against Streptococcus pyogenes isolated from peritonsillar abscesses (PTA). We used 31 clinical isolates and 5 throat culture collection strains. Inhibition of bacterial growth by polyols at 2.5%, 5% and 10% concentrations was studied and the results were scored. Amylase levels in PTA pus were compared to polyol effectivity scores (PES). Growth curves of four S. pyogenes isolates were analysed. Our study showed that XYL was more effective than ERY inhibiting 71–97% and 48–84% of isolates, respectively, depending of concentrations. 48% of clinical and all throat strains were inhibited by polyols in all concentrations (PES 3). PES was negative or zero in 26% of the isolates in the presence of ERY and in 19% of XYL. ERY enhanced the growth of S. pyogenes isolated from pus with high amylase levels. Polyols in all concentrations inhibited the growth in exponential phase. In conclusion, ERY and XYL are potent growth inhibitors of S. pyogenes isolated from PTA. Therefore, ERY and XYL may have potential in preventing PTA in the patients with frequent tonsillitis episodes.

The Biocompatibility of a New Erythritol-and Xyltol-Containing Fluoride Toothpaste

The basic function of toothpastes is biofilm removal in order to prevent caries and gingivitis. Toothpastes should provide maximal fluoride availability, optimal abrasivity, and ingredients that do not interfere with fluoride release but should have additional beneficial effects. Further, the effect on cells of the oral cavity is of the utmost importance. We investigated several biological parameters of a new toothpaste (AirFlow-AF) that contains fluoride, xylitol and erythritol but no sodium lauryl sulfate and compared them to commercially available toothpastes (Zendium-Ze, Sensodyne-Se, OdolMed-OM, OralB-OB). The half lethal concentration (LC50) as well as the proliferation behavior on gingival (GF), periodontal ligament (PDL), and mouse fibroblast cells (L929) were was tested. The mean LC50 values of AF on GF, PDL, and L929 were 16.2, 10.9, and 9.3, respectively. In comparison, the four other toothpastes showed mean LC50 values of 1.5 (OB), 1.2 (OM), 1.4 (Se), and 27.7 (Ze) on GF. Mean LC50 values on PDL and L929 were 1.0 and 0.2 (OB), 3.7 and 0.9 (OM), 1.2 and 0.6 (Se), and 25.4 and 5.6 (Ze), respectively. Proliferation behavior mainly confirmed the LC50 values. While cells after stimulation with AF returned to almost unimpaired proliferation behavior at 6%, cells were still strongly impaired after stimulation with all tested commercially toothpastes. AF showed high biocompatibility with different cell types.

In situ evaluation of 200 ppm fluoride toothpaste content trimetaphosphate, xylitol and erythritol on enamel demineralization and dental biofilm

OBJECTIVE

To evaluate the effect of low-fluoride (F^-) toothpaste and sodium trimetaphosphate (TMP) associated with xylitol and erythritol (XE) on enamel demineralization and biofilm composition.

METHODS

This crossover double-blind in situ study consisted of five phases (seven days each), in which 14 volunteers wore oral appliances containing four enamel bovine blocks. The cariogenic challenge was performed by exposure to a 30% sucrose solution (6x/day). The toothpaste treatments (3x/day) were as follows: placebo (no F^-/TMP/XE); 200 ppm F^- (NaF) (200F); 1,100 ppm F^- (1100F); 16% Xylitol and 4% Erythritol (XE); and 200 ppm F^-, 0.2% TMP, 16% xylitol, and 4% erythritol (200F-TMP-XE). Percentage of surface hardness loss (%SH) and integrated loss of subsurface hardness (ΔKHN), and calcium (Ca²⁺), phosphate (PO₄^3-), and F^- on enamel and biofilm were determined; as well as insoluble extracellular polysaccharide (EPS).

RESULTS

XE and 1100F groups showed no significant difference for %SH and ΔKHN values (p = 0.220 and p = 0.886), and the 200F-TMP-XE group had the lowest mineral loss (p < 0.001). Ca²⁺ and PO₄^3- in the enamel showed the highest values (p < 0.001) for the 200F-TMP-XE group. Higher values of F^- in the enamel and biofilm were observed for the 1100F group (p < 0.001). There was no difference for Ca²⁺ (p = 1.00) and EPS (p =0.918) values between XE and 200-TMP-XE groups in the biofilm, but their values were higher and lower than the 1100F (p = 0.002 and p = 0.029), respectively.

CONCLUSIONS

200F-TMP-XE promoted a greater protective effect against enamel demineralization and significantly affected the composition of biofilm formed in situ compared to 1100F toothpaste.

CLINICAL SIGNIFICANCE

Low-F^- toothpaste containing TMP and polyols can be considered an effective and safe measure to improve the oral health of individuals, especially patients with high caries activity.

Natural Sweeteners: The Relevance of Food Naturalness for Consumers, Food Security Aspects, Sustainability and Health Impacts

At a moment when the population is increasingly aware and involved in what it eats, both consumers and the food sector are showing more interest in natural foods. This review work discusses, addresses and provides details of the most important aspects of consumer's perceptions of and attitudes to natural foods and in-depth research into natural sweeteners. It also includes issues about their use and development as regards health impacts, food security and sustainability. In line with our main research outcome, we can assume that consumers are very keen on choosing foods with clean labelling, natural ingredients, preferably with other functional properties, without the loss of taste. In response to such a phenomenon, the food industry offers consumers alternative natural sweeteners with the advantage of added health benefits. It is noteworthy that Nature is a superb source of desirable substances, and many have a sweet taste, and many still need to be studied. Finally, we must stress that being natural does not necessarily guarantee market success.

A salivary metabolite signature that reflects gingival host-microbe interactions: instability predicts gingivitis susceptibility

Several proteins and peptides in saliva were shown to stimulate gingival wound repair, but the role of salivary metabolites in this process remains unexplored. In vitro gingival re-epithelialization kinetics were determined using unstimulated saliva samples from healthy individuals collected during an experimental gingivitis study. Elastic net regression with stability selection identified a specific metabolite signature in a training dataset that was associated with the observed re-epithelialization kinetics and enabled its prediction for all saliva samples obtained in the clinical study. This signature encompassed ten metabolites, including plasmalogens, diacylglycerol and amino acid derivatives, which reflect enhanced host-microbe interactions. This association is in agreement with the positive correlation of the metabolite signature with the individual’s gingival bleeding index. Remarkably, intra-individual signature-variation over time was associated with elevated risk for gingivitis development. Unravelling how these metabolites stimulate wound repair could provide novel avenues towards therapeutic approaches in patients with impaired wound healing capacity.

Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: A report from the American Dental Association

BACKGROUND

An expert panel convened by the American Dental Association Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review and formulated evidence-based clinical recommendations for the arrest or reversal of noncavitated and cavitated dental caries using nonrestorative treatments in children and adults.

TYPES OF STUDIES REVIEWED

The authors conducted a systematic search of the literature in MEDLINE and Embase via Ovid, Cochrane CENTRAL, and Cochrane database of systematic reviews to identify randomized controlled trials reporting on nonrestorative treatments for noncavitated and cavitated carious lesions. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and move from the evidence to the decisions.

RESULTS

The expert panel formulated 11 clinical recommendations, each specific to lesion type, tooth surface, and dentition. Of the most effective interventions, the panel provided recommendations for the use of 38% silver diamine fluoride, sealants, 5% sodium fluoride varnish, 1.23% acidulated phosphate fluoride gel, and 5,000 parts per million fluoride (1.1% sodium fluoride) toothpaste or gel, among others. The panel also provided a recommendation against the use of 10% casein phosphopeptide-amorphous calcium phosphate.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Although the recommended interventions are often used for caries prevention, or in conjunction with restorative treatment options, these approaches have shown to be effective in arresting or reversing carious lesions. Clinicians are encouraged to prioritize use of these interventions based on effectiveness, safety, and feasibility.

Impact of polyols on Oral microbiome of Estonian schoolchildren

BACKGROUND

Oral microbiome has significant impact on both oral and general health. Polyols have been promoted as sugar substitutes in prevention of oral diseases. We aimed to reveal the effect of candies containing erythritol, xylitol or control (sorbitol) on salivary microbiome.

METHODS

Ninety children (11.3 ± 0.6 years) consumed candies during 3 years. Microbial communities were profiled using Illumina HiSeq 2000 sequencing and real-time PCR.

RESULTS

The dominant phyla in saliva were Firmicutes (39.1%), Proteobacteria (26.1%), Bacteroidetes (14.7%), Actinobacteria (12%) and Fusobacteria (6%). The microbiome of erythritol group significantly differed from that of the other groups. Both erythritol and xylitol reduced the number of observed bacterial phylotypes in comparison to the control group. The relative abundance of the genera Veillonella, Streptococcus and Fusobacterium were higher while that of Bergeyella lower after erythritol intervention when comparing with control. The lowest prevalence of caries-related mutans streptococci corresponded with the lowest clinical caries markers in the erythritol group.

CONCLUSIONS

Daily consumption of erythritol, xylitol or control candies has a specific influence on the salivary microbiome composition in schoolchildren. Erythritol is associated with the lowest prevalence of caries-related mutans streptococci and the lowest levels of clinical caries experience.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01062633.

Erythritol Functional Roles in Oral-Systemic Health

Erythritol belongs chemically to the family of polyols (or sugar alcohols), yet it is metabolized by animals and humans very differently compared to all other polyols. While polyols have been used traditionally (for about 80 y) to replace sugar in sweet foods to reduce demineralization of tooth enamel and to reduce postprandial blood glucose levels, benefits achieved merely through the absence of sugar, emerging evidence shows that erythritol can play a number of functional roles to actively support maintenance of oral and systemic health. Oral health studies revealed that erythritol can reduce dental plaque weight, reduce dental plaque acids, reduce counts of mutans streptococci in saliva and dental plaque, and reduce the risk for dental caries better than sorbitol and xylitol, resulting in fewer tooth restorations by dentist intervention. Systemic health studies have shown that erythritol, unlike other polyols, is readily absorbed from the small intestine, not systemically metabolized, and excreted unchanged within the urine. This metabolic profile renders erythritol to be noncaloric, to have a high gastrointestinal tolerance, and not to increase blood glucose or insulin levels. Published evidence also shows that erythritol can act as an antioxidant and that it may improve endothelial function in people with type 2 diabetes. This article reviews the key research demonstrating erythritol's oral and systemic health functionalities and underlying mechanisms.

Caries reporting in studies that used the International Caries Detection and Assessment System: A scoping review

OBJECTIVE

To explore how caries was reported in studies that employed the International Caries Detection and Assessment System (ICDAS).

METHODS

A systematic database search up to August 2017 was carried out using PubMed, Ovid MEDLINE, Cochrane library and ISI Web of Science electronic databases. Only studies that used the ICDAS for dental caries examinations were included. Studies were excluded if the examination was done only for the validation or the calibration of the ICDAS and/or if the examination was not done for the whole dentition. Measures used to report caries were considered.

RESULTS

A total of 126 papers met the inclusion criteria. Forty-four different synthesis measures were used to report caries. Most of the studies used a combination of multiple measures to report patient's caries level. These reporting measures cluster into four main groups: the number of individual ICDAS scores (ie, total counts of every score); the number of decayed surfaces/teeth (ie, total counts of combined caries scores for surfaces or teeth); measures of caries experience (ie, total counts of combined caries scores, filled and/or missing surfaces or teeth); and measures of central tendency and dispersion. The number of decayed surfaces and individual ICDAS scores were the most commonly used measures. Three studies used mean ICDAS score (ie, total ICDAS scores divided by the number of teeth), two used mean ICDAS score of carious teeth (ie, total ICDAS scores divided by the number of carious teeth) and two used the maximum ICDAS score (ie, highest ICDAS score recorded). The total ICDAS score was used only once. Many studies synthesized from the ICDAS the number of decayed, missing and filled teeth/surfaces (dmft/DMFT, dmfs/DMFS) as a measure of caries experience.

CONCLUSIONS

There are variations among studies in the utilization of the system to summarize caries. Most studies presented caries data using the categorical characteristics of the ICDAS.

Nonrestorative Treatments for Caries: Systematic Review and Network Meta-analysis

The goal of nonrestorative or non- and microinvasive caries treatment (fluoride- and nonfluoride-based interventions) is to manage the caries disease process at a lesion level and minimize the loss of sound tooth structure. The purpose of this systematic review and network meta-analysis was to summarize the available evidence on nonrestorative treatments for the outcomes of 1) arrest or reversal of noncavitated and cavitated carious lesions on primary and permanent teeth and 2) adverse events. We included parallel and split-mouth randomized controlled trials where patients were followed for any length of time. Studies were identified with MEDLINE and Embase via Ovid, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews. Pairs of reviewers independently conducted the selection of studies, data extraction, risk-of-bias assessments, and assessment of the certainty in the evidence with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Data were synthesized with a random effects model and a frequentist approach. Forty-four trials (48 reports) were eligible, which included 7,378 participants and assessed the effect of 22 interventions in arresting or reversing noncavitated or cavitated carious lesions. Four network meta-analyses suggested that sealants + 5% sodium fluoride (NaF) varnish, resin infiltration + 5% NaF varnish, and 5,000-ppm F (1.1% NaF) toothpaste or gel were the most effective for arresting or reversing noncavitated occlusal, approximal, and noncavitated and cavitated root carious lesions on primary and/or permanent teeth, respectively (low- to moderate-certainty evidence). Study-level data indicated that 5% NaF varnish was the most effective for arresting or reversing noncavitated facial/lingual carious lesions (low certainty) and that 38% silver diamine fluoride solution applied biannually was the most effective for arresting advanced cavitated carious lesions on any coronal surface (moderate to high certainty). Preventing the onset of caries is the ultimate goal of a caries management plan. However, if the disease is present, there is a variety of effective interventions to treat carious lesions nonrestoratively.

Elevating the use of sugar-free chewing gum in Germany: cost saving and caries prevention

OBJECTIVE

To analyse the lifetime monetary and health related effects of the consumption of sugar-free chewing gum.

MATERIAL AND METHODS

Using a Markov model we assumed that the German consumption of sugar-free chewing gum (111 gums/year) could be elevated to the level of Finland (202 gums/year). The calculation was based on a model patient representing the development of oral health from the age of 12 to 74 years and clinical data on the effectiveness of chewing sugar-free gum. Lifetime and yearly costs for the 'Finland-scenario' were determined and compared with the actual German expenses of the statutory health insurance companies for dental health.

RESULTS

The actual total lifetime expenditures of the statutory health insurance companies are 17,199.96€ per capita and would be 12,188.94€ in the scenario with elevated consumption of sugar-free chewing gum in Germany. Thus, 5011.02€ per capita could be saved in a lifetime and 80.82€ per year.

CONCLUSIONS

On a national scale, the elevation of the consumption of sugar-free chewing gum in Germany to the level of Finland would lead to a considerable benefit for cost saving and oral health for the statutory health insurance companies.

Fluorides and Other Preventive Strategies for Tooth Decay

We focus on scalable public health interventions that prevent and delay the development of caries and enhance resistance to dental caries lesions. These interventions should occur throughout the life cycle, and need to be age appropriate. Mitigating disease transmission and enhancing resistance are achieved through use of various fluorides, sugar substitutes, mechanical barriers such as pit-and-fissure sealants, and antimicrobials. A key aspect is counseling and other behavioral interventions that are designed to promote use of disease transmission-inhibiting and tooth resistance-enhancing agents. Advocacy for public water fluoridation and sugar taxes is an appropriate dental public health activity.

Beyond Streptococcus mutans: clinical implications of the evolving dental caries aetiological paradigms and its associated microbiome

Aetiological concepts of dental caries have evolved over the years from being considered as a disease initiated by nonspecific microorganisms, to being regarded as an 'infectious' disease caused by specific bacteria, to the current paradigms that emphasise a 'mixed bacterial-ecological approach' as being responsible for lesion initiation and pathogenesis. These aetiological paradigms are not just intellectual concepts but have important implications on how clinicians manage this age-old disease in the twenty-first century. Despite evidence-backed recommendations for adopting more biological measures to counter the disease, a significant proportion of dentists continue following traditional caries management guidelines in their daily clinical practice. This paper will review the evolving dental caries aetiological concepts and highlight the current evidence for adopting a more ecological approach to caries prevention, risk assessment, and treatment.

Sugar-free hard confectionery with at least 90% erythritol and reduction of dental plaque which reduces the risk of dental caries: evaluation of a health claim pursuant to Article 14 of Regulation (EC) No 1924/2006

Following an application from Cargill R&D Centre Europe, submitted for authorisation of a health claim pursuant to Article 14 of Regulation (EC) No 1924/2006 via the Competent Authority of Belgium, the EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA) was asked to deliver an opinion on the scientific substantiation of a health claim related to sugar‐free hard confectionery with at least 90% erythritol and reduction of dental plaque which reduces the risk of caries. The food proposed by the applicant as the subject of the health claim, sugar‐free hard confectionery with at least 90% erythritol, is sufficiently characterised. In the context of this application, the weight of dental plaque, and/or the counts of Streptococcus mutans in dental plaque, and/or the concentration of organic acids in plaque (primarily acetic acid and lactic acid) can be considered as risk factor(s) in the development of dental caries, as long as evidence is provided that the consumption of the food that is the subject of the health claim reduces one or more of the proposed risk factors and the incidence of dental caries. One human intervention study did not show an effect of sugar‐free hard confectionery with at least 90% erythritol on the incidence of dental caries in children on either mixed or permanent dentition. The Panel concludes that a cause and effect relationship has not been established between the consumption of sugar‐free hard confectionery with at least 90% erythritol and reduction of dental plaque which reduces the risk of dental caries.

Effect of erythritol on microbial ecology of in vitro gingivitis biofilms

Gingivitis is one of the most common oral infections in humans. While sugar alcohols such as erythritol are suggested to have caries-preventive properties, it may also have beneficial effects in prevention of gingivitis by preventing maturation of oral biofilms. The aim of this study was to assess the effect of erythritol on the microbial ecology and the gingivitis phenotype of oral microcosms. Biofilms were inoculated with stimulated saliva from 20 healthy donors and grown in a gingivitis model in the continuous presence of 0 (control group), 5, and 10% erythritol. After 9 days of growth, biofilm formation, protease activity (gingivitis phenotype), and microbial profile analyses were performed. Biofilm growth was significantly reduced in the presence of erythritol, and this effect was dose dependent. Protease activity and the Shannon diversity index of the microbial profiles of the biofilms were significantly lower when erythritol was present. Microbial profile analysis revealed that presence of erythritol induced a compositional shift from periodontitis- and gingivitis-related taxa toward early colonizers. The results of this study suggest that erythritol suppresses maturation of the biofilms toward unhealthy composition. The gingivitis phenotype was suppressed and biofilm formation was reduced in the presence of erythritol. Therefore, it is concluded that erythritol may contribute to a healthy oral ecosystem in vitro.

Caries Incidence in a Healthy Young Adult Population in Relation to Diet

In the past, epidemiological studies focused on cavitated stages of caries. The arrival of the International Caries Detection and Assessment System (ICDAS) in 2004 allowed for clinical measurements of the initial stages of enamel caries. However, since the introduction, most studies applying the ICDAS still have studied the diseased population. The objective of this cross-sectional observational study was to describe early enamel caries in a large healthy young adult population and determine the relationship with diet and oral hygiene measures. The study population consisted of 268 healthy participants without frank cavitation. The examinations were done visually and radiographically using ICDAS on all tooth surfaces. In total, 8.6% of the surfaces (occlusal > approximal > smooth) had caries, of which 92.0% were confined to enamel (28.5% ICDAS score 1, 54.0% score 2, 8.6% score 3). Thirteen percent of the occlusal and 63% of the approximal caries were found with radiography. Thus, radiography is quintessential for the diagnosis of approximal enamel lesions. We found a positive correlation between enamel caries (ICDAS 1 to 3) and the consumption of mono- and disaccharides and carbohydrates ( r = 0.226 and r = 0.188, respectively, both P < 0.01), as well as a negative correlation with alcohol consumption ( r = -0.202, P < 0.01). There was also a positive correlation between enamel caries and the energy intake from mono- and disaccharides (sugar kJ, r = 0.206, P < 0.01), which was independent of body mass index. Only 11 participants consumed less than 10% of total energy as sugar kJ, which is the recommended percentage of kJ from free sugar by the World Health Organization. No clear correlation was found with oral hygiene. In conclusion, in this healthy young adult population, caries was found in 97.8% of the subjects, mostly initial enamel caries (ICDAS 1 to 2) in the occlusal surface of molars, and was related with dietary factors.

Long-Term Effect of Erythritol on Dental Caries Development during Childhood: A Posttreatment Survival Analysis

Objective: To assess the effect of daily consumption of erythritol, xylitol, and sorbitol candies on caries development in mixed dentition during a 3-year intervention and 3 years after the intervention. Methods: 485 Estonian first- and second-grade primary school children participated. Children were randomly allocated to an erythritol, xylitol, or sorbitol (control) group. Polyol-containing candies were administered on school days with a daily polyol consumption of 3 × 2.5 g. Yearly, caries development was assessed by calibrated dentists using the ICDAS criteria. Six years after initiation of the study and 3 years after cessation of daily polyol consumption, 420 participants were re-examined to identify potential long-term effects of polyol consumption. Survival curves were generated at the end of the intervention period and 3 years after intervention. The model included age of the subjects, schools, tooth surface ages and years of surface exposure to intervention. ICDAS scoring system-based events included enamel/dentin caries development, dentin caries development, increase in caries score, and dentist intervention. Results: At the end of the intervention, time to enamel/dentin caries development, dentin caries development, increase in caries score, and dentist intervention were significantly longer in the erythritol group as compared to the sorbitol group. Except for increase in caries score, all effects persisted 3 years after cessation of daily polyol consumption. Conclusions: A caries-preventive effect of 3-year erythritol consumption as compared to sorbitol was established in children with mixed dentition. The effect persisted up to 3 years after the end of the intervention.

Gastrointestinal Disturbances Associated with the Consumption of Sugar Alcohols with Special Consideration of Xylitol: Scientific Review and Instructions for Dentists and Other Health-Care Professionals

Sugar alcohols (polyols) are used in food manufacturing and in medical tests and examinations. d-Glucitol (sorbitol) and d-mannitol were previously the most common alditols used for these purposes. After the 1960s, xylitol became a common ingredient in noncariogenic confectioneries, oral hygiene products, and diabetic food. Erythritol, a polyol of the tetritol type, can be regarded as the sweetener of the "next generation." The disaccharide polyols maltitol, lactitol, and isomalt have also been used in food manufacturing and in medical tests. Consumption of pentitol- and hexitol-type polyols and disaccharide polyols may cause gastrointestinal disturbances at least in unaccustomed subjects. The occurrence of disturbances depends on consumer properties and on the molecular size and configuration of the polyol molecule. Adaptation may take place as a result of enzyme induction in the intestinal flora. Some of the literature on xylitol has been difficult to access by health-care professionals and will be reviewed here. Research and clinical field experience have found no pathology in polyol-associated osmotic diarrhea-the intestinal mucosa having normal basic structure, except in extreme instances. Xylitol is better tolerated than hexitols or the disaccharide polyols. Erythritol, owing to its smaller molecular weight and configuration that differ from other alditols, normally avoids the gastrointestinal reactions encountered with other polyols. This review will also touch upon the FODMAPs diet concept.

Erythritol Is More Effective Than Xylitol and Sorbitol in Managing Oral Health Endpoints

Objective. To provide a comprehensive overview of published evidence on the impact of erythritol, a noncaloric polyol bulk sweetener, on oral health. Methods. A literature review was conducted regarding the potential effects of erythritol on dental plaque (biofilm), dental caries, and periodontal therapy. The efficacy of erythritol on oral health was compared with xylitol and sorbitol. Results. Erythritol effectively decreased weight of dental plaque and adherence of common streptococcal oral bacteria to tooth surfaces, inhibited growth and activity of associated bacteria like S. mutans, decreased expression of bacterial genes involved in sucrose metabolism, reduced the overall number of dental caries, and served as a suitable matrix for subgingival air-polishing to replace traditional root scaling. Conclusions. Important differences were reported in the effect of individual polyols on oral health. The current review provides evidence demonstrating better efficacy of erythritol compared to sorbitol and xylitol to maintain and improve oral health.

Gut hormone secretion, gastric emptying, and glycemic responses to erythritol and xylitol in lean and obese subjects

With the increasing prevalence of obesity and a possible association with increasing sucrose consumption, nonnutritive sweeteners are gaining popularity. Given that some studies indicate that artificial sweeteners might have adverse effects, alternative solutions are sought. Xylitol and erythritol have been known for a long time and their beneficial effects on caries prevention and potential health benefits in diabetic patients have been demonstrated in several studies. Glucagon-like peptide-1 (GLP-1) and cholecystokinin (CCK) are released from the gut in response to food intake, promote satiation, reduce gastric emptying (GE), and modulate glucose homeostasis. Although glucose ingestion stimulates sweet taste receptors in the gut and leads to incretin and gastrointestinal hormone release, the effects of xylitol and erythritol have not been well studied. Ten lean and 10 obese volunteers were given 75 g of glucose, 50 g of xylitol, or 75 g of erythritol in 300 ml of water or placebo (water) by a nasogastric tube. We examined plasma glucose, insulin, active GLP-1, CCK, and GE with a [(13)C]sodium acetate breath test and assessed subjective feelings of satiation. Xylitol and erythritol led to a marked increase in CCK and GLP-1, whereas insulin and plasma glucose were not (erythritol) or only slightly (xylitol) affected. Both xylitol and erythritol induced a significant retardation in GE. Subjective feelings of appetite were not significantly different after carbohydrate intake compared with placebo. In conclusion, acute ingestion of erythritol and xylitol stimulates gut hormone release and slows down gastric emptying, whereas there is no or only little effect on insulin release.

A novel strain of Yarrowia lipolytica as a platform for value-added product synthesis from glycerol

BACKGROUND

Increasing interest of non-conventional yeasts has been observed for many years due to their biochemical characteristics and potential applications. Well-studied, oleaginous yeast Y. lipolytica is an attractive host for converting a low-cost glycerol, into value-added products such as erythritol (sweetener) or citric acid. Glycerol is an important renewable feedstock and is the main co-product of biodiesel production, which is nowadays applied on a large commercial scale. To this end, we engineered the yeast Y. lipolytica to increase the productivity of this strain.

RESULTS

In this light, we enhanced glycerol assimilation by over-expression of the YALI0F00484g gene encoding glycerol kinase (GK) and gene YALI0B02948g encoding glycerol-3-P dehydrogenase (GDH). The modified strains have been tested for glycerol consumption rate and erythritol and citric acid synthesis under various conditions. Here, we show that the overexpression of GK and GDH, increased glycerol consumption resulting in rapid erythritol and citric acid synthesis. Next, we combined the two genes in the tandem gene construct for the simultaneous co-expression of GK and GDH, which further increased the desired product synthesis. The glycerol consumption was explored in a 5-L bioreactor and the engineered strains were able to utilize 150 g/L glycerol within 44-48 hours. The erythritol productivity for GK overexpression and co-expression of GK and DGH was 24 and 35 %, respectively, over the control strain. Moreover, we established conditions for the production of citric acid at pH 3.0, the engineered strains increased citric acid production 14-fold over the control.

CONCLUSION

This work demonstrates the excellent capacity of the engineered strains as a starting platform for further modification for broad-range value-added product biosynthesis from glycerol. This study presents the highest reported titer citric acid at low pH to date. The process parameters such as productivity and yield of erythritol and citric acid were significantly elevated, what is valuable for industrial applications.

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.