Xylitol chewing gums and caries rates: a 40-month cohort study

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.

Screening, Referral, Behavioral Counseling, and Preventive Interventions for Oral Health in Children and Adolescents Aged 5 to 17 Years: A Systematic Review for the US Preventive Services Task Force

Importance

Dental caries is common in children and adolescents aged 5 to 17 years and potentially amenable to primary care screening and prevention.

Objective

To systematically review the evidence on primary care screening and prevention of dental caries in children and adolescents aged 5 to 17 years to inform the US Preventive Services Task Force.

Data Sources

MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews (to October 3, 2022); surveillance through July 21, 2023.

Study Selection

Diagnostic accuracy of primary care screening instruments and oral examination; randomized and nonrandomized trials of screening and preventive interventions and systematic reviews of such studies; cohort studies on primary care oral health screening and preventive intervention harms.

Data Extraction and Synthesis

One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Random-effects meta-analysis was performed for fluoride supplements and xylitol; for other preventive interventions, pooled estimates were used from good-quality systematic reviews.

Main Outcomes and Measures

Dental caries, morbidity, functional status, quality of life, harms; diagnostic test accuracy.

Results

Three systematic reviews (total 20 684 participants) and 19 randomized clinical trials, 3 nonrandomized trials, and 1 observational study (total 15 026 participants) were included. No study compared screening vs no screening. When administered by dental professionals or in school settings, fluoride supplements compared with placebo or no intervention were associated with decreased change from baseline in the number of decayed, missing, or filled permanent teeth (DMFT index) or decayed or filled permanent teeth (DFT index) (mean difference, -0.73 [95% CI, -1.30 to -0.19]) at 1.5 to 3 years (6 trials; n = 1395). Fluoride gels were associated with a DMFT- or DFT-prevented fraction of 0.18 (95% CI, 0.09-0.27) at outcomes closest to 3 years (4 trials; n = 1525), fluoride varnish was associated with a DMFT- or DFT-prevented fraction of 0.44 (95% CI, 0.11-0.76) at 1 to 4.5 years (5 trials; n = 3902), and resin-based sealants were associated with decreased risk of carious first molars (odds ratio, 0.21 [95% CI, 0.16-0.28]) at 48 to 54 months (4 trials; n = 440). No trial evaluated primary care counseling or dental referral. Evidence on screening accuracy, silver diamine fluoride, xylitol, and harms was very limited, although serious harms were not reported.

Conclusions and Relevance

Administration of fluoride supplements, fluoride gels, varnish, and sealants in dental or school settings improved caries outcomes. Research is needed on the effectiveness of oral health preventive interventions in primary care settings and to determine the benefits and harms of screening.

Antimicrobial Effect of Low-Fluoride Toothpastes Containing Polyphosphate and Polyols: An In Vitro Assessment of Inhibition Zones

This study evaluated the antimicrobial effect of toothpastes containing 200 ppm fluoride (200F), xylitol (X, 16%), erythritol (E, 4%), and sodium trimetaphosphate (TMP, 0.25%), alone or in different associations, against Streptococcus mutans (SM), Lactobacillus casei (LC), Actinomyces israelii (AI), and Candida albicans (CA). Suspensions of the micro-organisms were added to a BHI Agar medium. Five wells were made on each plate to receive toothpaste suspensions at different dilutions. Toothpastes containing no actives (placebo) or 1100 ppm F (1100F) were used as negative and positive controls. Two-way ANOVA and Tukey's HDS test were used (p < 0.05). For SM, the largest halo was for 200F+TMP at all dilutions, followed by the 200F+X+E toothpaste (p < 0.001). For LC, the overall trend showed that the polyols effectively inhibited microbial growth, and the association with the other compounds enhanced such effects (p < 0.001). For AI, a less-defined trend was observed. For CA, the experimental toothpaste (200F+X+E+TMP) was consistently more effective than the other treatments, followed by 200F+X+E (p < 0.001). The association of polyols and TMP in a low-fluoride toothpaste effectively reduced the growth of cariogenic micro-organisms (SM, CA, and LC), suggesting that this formulation could be an interesting alternative for children due to its low fluoride content.

Resin infiltration in white spot lesions caused by orthodontic hypomineralisation: a minimally invasive therapy

Objective White spot lesions are characterised by the presence of clinically detectable opaque lesions due to enamel demineralisation. These frequently present in patients following fixed orthodontic treatment, mostly due to the prolonged accumulation of bacterial plaque on the dental surface. When remineralisation is not achieved through good oral hygiene and prophylaxis with fluoride products, the infiltration of lesions with low-viscosity photopolymerised resin has proved to be a valid micro-invasive alternative compared to traditional conservative therapy.Clinical considerations A case series will be presented, where the chosen approach was resin infiltration, a micro-invasive and aesthetic technique.Clinical significance Infiltrative resin therapies are single-session procedures that reduce the need for more invasive therapies such as the use of rotary instruments for greater patient comfort. The need for periodic fluoride applications is also avoided. This approach increases the durability of the infiltrated lesion without compromising its mechanical properties and impedes the development of recurrent or secondary caries.Conclusions Resin infiltration might be considered as a routine procedure in the treatment of post-eruptive hypomineralised lesions. This follows the line of thought of minimally invasive dentistry, is an excellent treatment option and prevents the lesion's progression.

Community interventions and strategies for caries control in Latin American and Caribbean countries

Dental caries remains highly prevalent in Latin American and Caribbean countries (LACC). However, this disease can be controlled through interventions that implement evidence-based strategies in an affordable manner and that target all population groups instead of the most affluent only. Therefore, the aim of this report was to summarize the main scientifically documented community interventions and strategies based on restriction of sugars consumption, use of fluoride, and the use of occlusal sealants for caries control in LACC. A critical literature review was carried out in a systematic manner that included defined search strategies, independent review of the identified publications, and compilation of results in this report. Three systematic searches were conducted using the PubMed, LILACS, and SciELO databases to identify studies related to community interventions and strategies for caries control in LACC. Of the 37 publications identified, twenty-six focused on fluoride use, eight on occlusal sealant use, and three on the restriction of sugar consumption. Documented community interventions for sugars restriction were scarce in the region and were based on food supplementation, sugar replacement, and education. Thus, local and/or national policies should prioritize investment in upstream, coherent, and integrated population-wide policies such as taxes on sugary drinks and stronger regulation of advertising and promotion of sugary foods and drinks mainly targeting children. The main fluoride-based strategies used drinking water, refined domestic salt, cow milk, toothpaste and, to a lesser extent, mouth-rinses, acidulated phosphate fluoride (APF) gels, and varnishes to deliver fluoride to the population. Evidence of fluoride use was seen in Argentina, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Uruguay, and Venezuela. Studies reporting the use of occlusal sealants were mainly located in Brazil, Chile, Colombia, Costa Rica, Peru, Mexico, and Venezuela. Community interventions restricting sugar consumption should be implemented at the individual level and through public policies. The use of fluoride must be monitored at the local, regional, and national levels so as to achieve maximum anti-caries effect while also minimizing the risk of dental fluorosis. Moreover, fluoridated water and salt programs, used as a mutually exclusive community level strategy for caries control, should expand their benefits to reach non-covered areas of the LACC while also simultaneously providing adequate surveillance of the fluoride concentration delivered to the population. Regulating the concentration of soluble fluoride (for anti-caries effect) in dentifrice formulations is also necessary in order to provide the population with an effective strategy for disease control. Targeting culturally appropriate, economically sustainable caries control interventions to rural populations and native ethnic groups such as indigenous people, quilombolas (African-origin), and riverside Amazonian people remains a crucial challenge.

[Pilot Project for Occupational Dental Prevention]

AIM OF THE STUDY

To investigate the feasibility and effectiveness of a low-threshold disease prevention offer in a pilot project for employees Methodology: Employees of a company working in office or on production (n=144; 90 women, 54 men) with an average age of 39.25 (StA 11.5) years were interviewed and clinically examined using a questionnaire on habits and knowledge in the prevention of dental diseases. The oral hygiene indices Papillae Bleeding Index (PBI) and the modified Approximal Plaque Index (mAPI) as well as exploratory depth measurements (STM) were collected. Subsequently, a training in dental disease prevention was carried out with a specially produced video as well as the provision of sugar-free chewing gum and mouthwash solutions for twice daily use for a period of one year. After one year, the questionnaire was again issued and the clinical parameters were collected. The study was approved by the UW/H Ethics Committee. Statistical analysis was carried out with SPSS 26.

RESULTS

85 patients with an average age of 39.23 (StD 11.3) years could be examined after one year (59 women, 26 men). The analysis of the questionnaire showed a significant improvement in oral health behavior. The corresponding total score improved from 10.68 (1.93) to 9.97 (1.60) (p<0.05). The PBI improved from 0.43 (0.40) to 0.31 (0.36) (p<0.05), the mAPI from 1.54 (0.51) to 1.35 (0.39) (p<0.01). The STM was reduced from 1.83 (0.39) to 1.56 (0.36) (p<0.001).

CONCLUSION

The dental disease prevention program for employees appears suitable for implementation at workplace and has shown significant improvements in oral health behavior as well as in clinical parameters.

Dental Caries Preventive Considerations: Awareness of Undergraduate Dental Students

The aim of this study was to assess awareness and knowledge of undergraduate dental students of common caries-related preventive considerations and to highlight these factors in a concise manner to act as a guide for dental practitioners. A sample of 118 undergraduate students at a local government dental school was included. An interactive survey that contains questions related to common preventive strategies against dental caries was presented to the students. The survey contained 22 questions concerning dietary and therapeutic strategies. Students casted their votes using their mobile cellphones. The correct answer for each question was shown to the students, and further discussion was held. Data was collected, and the statistical analysis was conducted using one-sample z- and chi-squared tests at 0.05 significance level. The students answered the questions related to oral hygiene practices, xylitol, and the common knowledge regarding fluoride. The questions related to the use of chlorhexidine, dietary factors, and fluoride formulations were answered mostly incorrectly. The students seemed to grasp details of important concepts of flossing, brushing, reducing frequency of sugar exposure, and the use of fluoride products. Still, more emphasis should be given to increase students’ awareness of dietary guidelines for caries prevention, since adequate knowledge of these modalities is paramount for graduating dentists.

A Systematic Review and Meta-Analysis of the Role of Sugar-Free Chewing Gum in Dental Caries

OBJECTIVE

To determine the difference in level of dental caries in adults and children who chew sugar-free gum (SFG), compared with those who do not chew SFG or use alternatives such as lozenges, candies, rinses, tablets, and other nonchewing controls.

METHODS

Systematic review of published literature.

RESULTS

Twelve studies of interventions of SFG for dental caries outcomes were included. SFGs were found to significantly reduce caries increment, giving a preventative fraction (PF) of 28% (95% CI, 7% to 48%). Including the 8 trials that used xylitol gum only as the basis of the intervention, the PF was 33% (95% CI, 4% to 61%). No adverse effects were recorded. There was a high level of heterogeneity among the trials included.

CONCLUSION

The findings of this review provide tentative evidence that chewing SFG reduces caries increment in comparison to nonchewing controls. However, there is a considerable degree of variability in the effect and the trials included were generally of moderate quality. There is a need for future research to explore the acceptability and feasibility of the use of SFG as a public health intervention (PROSPERO 2018 CRD42018094676).

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by clinicians when deciding how best to implement dental caries prevention regimes for their patients. With consideration of cost and patient preference, this information could help to develop national policy directives on caries prevention and dictate the direction of future clinical research.

Randomized controlled study of aerosolized hypertonic xylitol versus hypertonic saline in hospitalized patients with pulmonary exacerbation of cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) lung disease is characterized by chronic bacterial infection and recurrent pulmonary exacerbations. Xylitol is a 5-carbon sugar that can lower the airway surface salt concentration and augment innate immunity. We examined the safety and efficacy of aerosolized xylitol use for 2 weeks in subjects hospitalized with a pulmonary exacerbation of CF.

METHODS

In a 2-week study, 60 subjects with cystic fibrosis and FEV₁ > 30% predicted were enrolled to receive aerosolized 7% hypertonic saline (4 ml) or 15% xylitol (5 ml) twice a day for 14 days. Outcomes assessed included change from baseline in FEV₁% predicted, change in sputum microbial density, revised CF quality of life questionnaire including the respiratory symptom score, time to next hospitalization for a pulmonary exacerbation, and frequency of adverse events.

RESULTS

59 subjects completed the study (one subject in the saline group withdrew before any study product administration). No significant differences were noted between the 2 arms in mean changes in lung function, sputum microbial density for Pseudomonas aeruginosa and Staphylococcus aureus, body weight, quality of life, and frequency of adverse events.

CONCLUSIONS

Aerosolized hypertonic xylitol was well-tolerated among subjects hospitalized for CF pulmonary exacerbation. Future studies examining efficacy for long term use in patients with CF lung disease would be worthwhile. The clinical trial registration number for this study is NCT00928135.

Oral and Systemic Effects of Xylitol Consumption

Recent results of randomized trials testing the efficacy of xylitol in caries prevention have been conflicting. This narrative review reveals the sources of discrepancy. The following databases were searched for the terms "xylitol" or "artificial sweeteners" restricted to the English language: PubMed, Web of Science, Evidenced-Based Medicine, Scopus, and the Cochrane database. In a separate search, the terms "dental caries" or "cariogenicity" or "glucosyltransferase" or "low glycemic" or "low insulinemic" or "dysbiosis" or "gut microbiome" were used and then combined. In section I, findings regarding the role of xylitol in dental caries prevention, the appropriateness of research methods, and the causes for potential biases are summarized. In section II, the systemic effects of xylitol on gut microbiota as well as low-glycemic/insulinogenic systemic effects are evaluated and summarized. The substitution of a carbonyl group with an alcohol radical in xylitol hinders its absorption and slowly releases sugar into the bloodstream. This quality of xylitol is beneficial for diabetic patients to maintain a constant glucose level. Although this quality of xylitol has been proven in in vitro and animal studies, it has yet to be proven in humans. Paradoxically, recent animal studies reported hyperglycemia and intestinal dysbiosis with artificial sweetener consumption. Upon careful inspection of evidence, it was revealed that these reports may be due to misinterpretation of original references or flaws in study methodology. Any systemic benefits of xylitol intake must be weighed in consideration with the well-established adverse gastrointestinal consequences. The contribution of xylitol to gut dysbiosis that may affect systemic immunity warrants further research.

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.

Qualitative assessment of knowledge transfer regarding preterm birth in Malawi following the implementation of targeted health messages over 3 years

Background

In 2012, we performed a needs assessment and gap analysis to qualitatively assess providers’ and patients’ knowledge and perceptions regarding preterm birth (PTB). During the study, we identified knowledge gaps surrounding methods to reduce the risk of occurrence of PTB and management options if preterm labor/birth occur. We targeted health messages toward these gaps. The objective of the present study was to assess the impact of our community health worker-based patient education program 3 years after it was implemented.

Methods

Fifteen focus groups including 70 participants were included in the study. The groups comprised either patients/patient couples or health providers. A minimum of two facilitators led each group using 22 a priori designed and standardized lead-in prompts for participants with four additional prompts for providers only. A single researcher recorded responses, and transcript notes were reviewed by the facilitators and interpreters immediately following each group discussion to ensure accuracy.

Results

The understanding of term vs preterm gestation was generally accurate. Every participant knew of women who had experienced PTB, and the general perception was that two to three women out of every ten had this experience. The majority of respondents thought that women should present to their local health clinic if they experience preterm contractions; few were aware of the use of antenatal steroids for promoting fetal lung maturity, but many acknowledged that the neonate may be able to receive life-sustaining treatment if born at a higher level of care facility. The majority of participants were aware that PTB could recur in subsequent pregnancies. All respondents were able to list ways that women could potentially reduce the risk of PTB.

Conclusion

After employing targeted health messages, the majority of participants expressed improved understanding of the definition of PTB, methods to prevent risk of PTB, and management options for preterm labor or PTB.

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.

Hydrothermal extraction of hemicellulose: from lab to pilot scale

A flow-through reactor for hemicelluloses extraction with hot pressurized water was scaled with a factor of 73. System performance was evaluated by comparing the temperature profile, extraction yield and kinetics of the two systems, performing experiments at 160 and 170°C, 11barg for 90min, using catalpa wood as raw material. Hemicellulose yields were 33.9% and 38.8% (lab scale 160°C and 170°C) and 35.7% and 41.7% (pilot scale 160°C and 170°C). The pilot reactor was upgraded by designing a manifold system capable to provide samples with different liquid residence time during the same experiment. Tests at 140, 150, 160 and 170°C were carried for 90min. Increasing yields (9.3-40.6%) and decreasing molecular weights (4078-1417Da) were obtained at increasing the temperature. Biomass/water ratio of 1/27 gave total average concentration of xylose of 0.4g/L (140°C) to 1.8g/L (170°C).

Streptococcus mutans forms xylitol-resistant biofilm on excess adhesive flash in novel ex-vivo orthodontic bracket model

INTRODUCTION

During orthodontic bonding procedures, excess adhesive is invariably left on the tooth surface at the interface between the bracket and the enamel junction; it is called excess adhesive flash (EAF). We comparatively evaluated the biofilm formation of Streptococcus mutans on EAF produced by 2 adhesives and examined the therapeutic efficacy of xylitol on S mutans formed on EAF.

METHODS

First, we investigated the biofilm formation of S mutans on 3 orthodontic bracket types: stainless steel preadjusted edgewise, ceramic preadjusted edgewise, and stainless steel self-ligating. Subsequently, tooth-colored Transbond XT (3M Unitek, Monrovia, Calif) and green Grengloo (Ormco, Glendora, Calif) adhesives were used for bonding ceramic brackets to extracted teeth. S mutans biofilms on EAF produced by the adhesives were studied using the crystal violet assay and scanning electron microscopy. Surface roughness and surface energy of the EAF were examined. The therapeutic efficacies of different concentrations of xylitol were tested on S mutans biofilms.

RESULTS

Significantly higher biofilms were formed on the ceramic preadjusted edgewise brackets (P = 0.003). Transbond XT had significantly higher S mutans biofilms compared with Grengloo surfaces (P = 0.007). There was no significant difference in surface roughness between Transbond XT and Grengloo surfaces (P >0.05). Surface energy of Transbond XT had a considerably smaller contact angle than did Grengloo, suggesting that Transbond XT is a more hydrophilic material. Xylitol at low concentrations had no significant effect on the reduction of S mutans biofilms on orthodontic adhesives (P = 0.016).

CONCLUSIONS

Transbond XT orthodontic adhesive resulted in more S mutans biofilm compared with Grengloo adhesive on ceramic brackets. Surface energy seemed to play a more important role than surface roughness for the formation of S mutans biofilm on EAF. Xylitol does not appear to have a therapeutic effect on mature S mutans biofilm.

Ameliorating Effect of Dietary Xylitol on Human Respiratory Syncytial Virus (hRSV) Infection

Human respiratory syncytial virus (hRSV) is the most common cause of bronchiolitis and pneumonia in infants. The lack of proper prophylactics and therapeutics for controlling hRSV infection has been of great concern worldwide. Xylitol is a well-known sugar substitute and its effect against bacteria in the oral cavity is well known. However, little is known of its effect on viral infections. In this study, the effect of dietary xylitol on hRSV infection was investigated in a mouse model for the first time. Mice received xylitol for 14 d prior to virus challenge and for a further 3 d post challenge. Significantly larger reductions in lung virus titers were observed in the mice receiving xylitol than in the controls receiving phosphate-buffered saline (PBS). In addition, fewer CD3(+) and CD3(+)CD8(+) lymphocytes, whose numbers reflect inflammatory status, were recruited in the mice receiving xylitol. These results indicate that dietary xylitol can ameliorate hRSV infections and reduce inflammation-associated immune responses to hRSV infection.

Dental Flossing and Interproximal Caries: a Systematic Review

Our aim was to assess, systematically, the effect of flossing on interproximal caries risk. Six trials involving 808 subjects, ages 4 to 13 years, were identified. There were significant study-to-study differences and a moderate to large potential for bias. Professional flossing performed on school days for 1.7 years on predominantly primary teeth in children was associated with a 40% caries risk reduction (relative risk, 0.60; 95% confidence interval, 0.48–0.76; p-value, < 0.001). Both three-monthly professional flossing for 3 years (relative risk, 0.93; 95% confidence interval, 0.73–1.19; p-value, 0.32) and self-performed flossing in young adolescents for 2 years (relative risk, 1.01; 95% confidence interval, 0.85–1.20; p-value, 0.93) did not reduce caries risk. No flossing trials in adults or under unsupervised conditions could be identified. Professional flossing in children with low fluoride exposures is highly effective in reducing interproximal caries risk. These findings should be extrapolated to more typical floss-users with care, since self-flossing has failed to show an effect.

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.

Effect of maternal use of chewing gums containing xylitol on transmission of mutans streptococci in children: a meta-analysis of randomized controlled trials

BACKGROUND

Mutans streptococci (MS) are the major causative bacteria involved in human dental decay. Habitual consumption of xylitol has been proved to reduce MS levels in saliva and plaque.

AIM

To evaluate the effect of the maternal use of xylitol gum on MS reduction in infants.

DESIGN

A structured literature review and meta-analysis. A random effects model was used to assess the relative risks of the incidence of MS in the saliva or plaque of children who were 6, 9, 12, 18, and 24 months old.

RESULTS

We reviewed 11 RCTs derived from 5 research teams that included 601 mothers. Our results indicated that the incidence of MS in the saliva or plaque of the infants was significantly reduced in the xylitol group (risk ratio: 0.54; 95% confidence interval: 0.39-0.73, at 12-18 months) and (risk ratio: 0.56; 95% confidence interval: 0.40-0.79, at 36 months) compared with the control groups. The long-term effect of maternal xylitol gum exposure on their children's dental caries was controversial.

CONCLUSION

Habitual xylitol consumption by mothers with high MS levels was associated with a significant reduction in the mother-child transmission of salivary MS.

Long-term clinical and bacterial effects of xylitol on patients with fixed orthodontic appliances

Background

The objective of this study was to evaluate long-term clinical and bacterial effects of using 6 g of xylitol per day for 3 months on patients with full fixed orthodontic appliances.

Methods

The study was a pilot clinical trial that included 41 subjects who were undergoing orthodontic treatment. The subjects were randomly divided into three groups. Group A received xylitol chewing gum, group B received xylitol dissolvable chewable tablets, and Group C served as the control group and did not receive xylitol gums or tablets. Clinical examination and the collection of plaque and saliva samples were carried out at baseline and 3, 6, and 12 months. All three groups were given oral hygiene instruction and were put on a 6-month cleaning and topical fluoride schedule. Plaque scores and bacterial counts were used to evaluate the effectiveness of the different approaches at reducing the caries risk.

Results

Xylitol groups did not experience any more reduction in plaque score, plaque MS counts, or salivary MS counts than the control group nor did they have lower values at any of the time points. Chewing gum did not significantly increase the incidence of debonded brackets over the other groups.

Conclusions

Xylitol does not have a clinical or bacterial benefit in patients with fixed orthodontic appliances. Oral hygiene instructions and 6-month topical fluoride application were effective at reducing plaque scores and bacterial counts in patients with full fixed appliances regardless of whether or not xylitol was used.

Effect of Chewing Xylitol Containing and Herbal Chewing Gums on Salivary Mutans Streptococcus Count among School Children

Background:

The present study aims to assess and compare the reduction in salivary Mutans Streptococci counts after chewing Xylitol, herbal and placebo gums among high school children.

Methods:

The study was conducted among 72 school children (12–15 years) from 3 randomly selected schools (blocks). Xylitol, herbal and placebo gums were randomly allocated to 3 blocks. Subjects were instructed to chew one pellet four times a day for 21 days. The mean reduction in salivary Streptococcus mutans count was assessed.

Results:

The 100% Xylitol sweetened chewing gum “Xylitol”has shown statistically significant reduction in salivary Mutans Streptococci colony forming units at the end of 21 days (P < 0.01). The reduction was not statistically significant in herbal and placebo chewing gum.

Conclusions:

Hundred percentage Xylitol sweetened chewing gum was found to be more effective in reducing salivary Mutans Streptococci count when compared to herbal and placebo chewing gums.

The Effectiveness of Xylitol in a School-Based Cluster-Randomized Clinical Trial

Objective: The purpose of this double-blind, cluster-randomized clinical trial was to examine the effects of xylitol gummy bear snacks on dental caries progression in primary and permanent teeth of inner-city school children. Methods: A total of 562 children aged 5-6 years were recruited from five elementary schools in East Cleveland, Ohio. Children were randomized by classroom to receive xylitol (7.8 g/day) or placebo (inulin fiber 20 g/day) gummy bears. Gummy bears were given three times per day for the 9-month kindergarten year within a supervised school environment. Children in both groups also received oral health education, toothbrush and fluoridated toothpaste, topical fluoride varnish treatment and dental sealants. The numbers of new decayed, missing, and filled surfaces for primary teeth (dmfs) and permanent teeth (DMFS) from baseline to the middle of 2nd grade (exit exam) were compared between the treatment (xylitol/placebo) groups using an optimally-weighted permutation test for cluster-randomized data. Results: The mean new d3-6mfs at the exit exam was 5.0 ± 7.6 and 4.0 ± 6.5 for the xylitol and placebo group, respectively. Similarly, the mean new D3-6MFS was 0.38 ± 0.88 and 0.48 ± 1.39 for the xylitol and placebo group, respectively. The adjusted mean difference between the two groups was not statistically significant: new d3-6mfs: mean 0.4, 95% CI -0.25, 0.8), and new D3-6MFS: mean 0.16, 95% CI -0.16, 0.43. Conclusion: Xylitol consumption did not have additional benefit beyond other preventive measures. Caries progression in the permanent teeth of both groups was minimal, suggesting that other simultaneous prevention modalities may have masked the possible beneficial effects of xylitol in this trial. © 2014 S. Karger AG, Basel

Diet as a risk factor for pneumococcal carriage and otitis media: a cross-sectional study among children in day care centers

Background

Pharyngeal bacteria are exposed to different sugar conditions depending on the diet of the child. We hypothesized that dietary factors such as daily intake of carbohydrates could be associated with pneumococcal carriage and the occurrence of otitis media in children.

Methods

Our study design was a cross-sectional study among 1006 children attending child day care centers. Parents filled in a food frequency questionnaire. Oropharyngeal swabs were collected from each child. The primary outcome was the occurrence of pneumococcal carriage and the secondary outcome the number of acute otitis media episodes during life. Principal component analysis was used to group dietary intake into nine factors. The models were adjusted for age, gender of the child and educational level of the mother.

Results

The dietary factor which included high consumption of sweet pastries and jam was associated with an increased risk of pneumococcal carriage (OR 1.17, 95% CI 1.01 to 1.36, P-value 0.04). The factor including frequent consumption of fruit and berries was associated with a decreased risk of acute otitis (regression coefficient −0.51, 95% CI −0.98 to −0.03, P = 0.04). A high intake of consumption of sweets and snacks (OR 1.36, 95% CI 1.03 to 1.80, P = 0.03) was associated with an increased risk of caries.

Conclusions

Diet was associated with a risk of pneumococcal carriage and the occurrence of otitis media. Diet may thus be a modifiable risk factor for the occurrence of acute otitis media.

Xylitol syrup for the prevention of acute otitis media

BACKGROUND

Acute otitis media (AOM) is a common childhood illness and the leading indication for antibiotic prescriptions for US children. Xylitol, a naturally occurring sugar alcohol, can reduce AOM when given 5 times per day as a gum or syrup, but a more convenient dosing regimen is needed for widespread adoption.

METHODS

We designed a pragmatic practice-based randomized controlled trial to determine if viscous xylitol solution at a dose of 5 g 3 times per day could reduce the occurrence of clinically diagnosed AOM among otitis-prone children 6 months through 5 years of age.

RESULTS

A total of 326 subjects were enrolled, with 160 allocated to xylitol and 166 to placebo. In the primary analysis of time to first clinically diagnosed AOM episode, the hazard ratio for xylitol versus placebo recipients was 0.88 (95% confidence interval [CI] 0.61 to 1.3). In secondary analyses, the incidence of AOM was 0.53 episodes per 90 days in the xylitol group versus 0.59 in the placebo group (difference 0.06; 95% CI -0.25 to 0.13); total antibiotic use was 6.8 days per 90 days in the xylitol group versus 6.4 in the placebo group (difference 0.4; 95% CI -1.8 to 2.7). The lack of effectiveness was not explained by nonadherence to treatment, as the hazard ratio for those taking nearly all assigned xylitol compared with those taking none was 0.93 (95% CI 0.56 to 1.57).

CONCLUSIONS

Viscous xylitol solution in a dose of 5 g 3 times per day was ineffective in reducing clinically diagnosed AOM among otitis-prone children.

Role of sugar and sugar substitutes in dental caries: a review

Dental caries is a chronic disease which can affect us at any age. The term "caries" denotes both the disease process and its consequences, that is, the damage caused by the disease process. Dental caries has a multifactorial aetiology in which there is interplay of three principal factors: the host (saliva and teeth), the microflora (plaque), and the substrate (diet), and a fourth factor: time. The role of sugar (and other fermentable carbohydrates such as highly refined flour) as a risk factor in the initiation and progression of dental caries is overwhelming. Whether this initial demineralization proceeds to clinically detectable caries or whether the lesion is remineralized by plaque minerals depends on a number of factors, of which the amount and frequency of further sugars consumption are of utmost importance. This paper reviews the role of sugar and sugar substitutes in dental caries.

Caries prevention with xylitol lozenges in children related to maternal anxiety. A demonstration project

AIM

This was to compare the effect of a prevention program between children of anxious and non-anxious mothers.

METHODS

Mothers (n=120) with high and low dental anxiety scores (DAS>15 and DAS <8, respectively), and with high levels of mutans streptococci (>10(5)cfu/mL) were recruited at a maternity clinic of Tartu, Estonia. Two groups: 30 highly anxious, and 30 non-anxious mothers used xylitol (6 g/day) for 33 months and a non-treatment group of 60 mothers, both highly and low anxious (30 in each sub-group), acted as controls. All mothers were interviewed for oral health habits and education, and their dental health was examined. Due to discontinued participation 75% of the children (n=90) were examined at 2 and at 3 years of age.

RESULTS

Anxious mothers brushed less frequently (p=0.014), had a longer time since their last dental visit (p<0.0001), and a lower level of education (p<0.0001) than their non-anxious counterparts. However, maternal anxiety had no effect on children's dental health, contrary to the caries prevention program which was effective both at 2 and at 3 years of age (p<0.01; OR 6.6, 1.8-25.0 and OR 3.9, CI 1.5-10.0, respectively).

CONCLUSION

Children benefited from the caries prevention program, irrespective of maternal anxiety.

Xylitol inhibits in vitro and in vivo angiogenesis by suppressing the NF-κB and Akt signaling pathways

Angiogenesis is an important process involved in tumor growth and metastasis. Many studies have investigated the use of natural compounds such as angiogenic inhibitors. Xylitol is a 5-carbon sugar alcohol and is an artificial sweetener that has been used in chewing gums to prevent tooth decay. Xylitol has been also known to inhibit inflammatory cytokine expression induced by lipopolysaccharide (LPS). Since angiogenesis and inflammation share a common signaling pathway, we investigated the role of xylitol in angiogenesis. Xylitol inhibited the migration, invasion and tube formation of human umbilical vein endothelial cells (HUVECs). Xylitol also inhibited in vivo angiogenesis in a mouse Matrigel plug assay. Furthermore, mRNA expression of vascular endothelial growth factor (VEGF), VEGFR-II (KDR), basic fibroblast growth factor (bFGF), bFGFR-II, matrix metalloproteinase-2 (MMP-2) and MMP-9 of HUVECs decreased following treatment with xylitol. These anti-angiogenic effects of xylitol are exerted through inhibition of NF-κB and Akt activation. Taken together, these results suggest that xylitol acts as a beneficial angiogenesis inhibitor.

Tooth-surface-specific effects of xylitol: randomized trial results

The Xylitol for Adult Caries Trial was a three-year, double-blind, multi-center, randomized clinical trial that evaluated the effectiveness of xylitol vs. placebo lozenges in the prevention of dental caries in caries-active adults. The purpose of this secondary analysis was to investigate whether xylitol lozenges had a differential effect on cumulative caries increments on different tooth surfaces. Participants (ages 21-80 yrs) with at least one follow-up visit (n = 620) were examined at baseline, 12, 24, and 33 months. Negative binomial and zero-inflated negative binomial regression models were used to estimate incidence rate ratios (IRR) for xylitol's differential effect on cumulative caries increments on root and coronal surfaces and, among coronal surfaces, on smooth (buccal and lingual), occlusal, and proximal surfaces. Participants in the xylitol arm developed 40% fewer root caries lesions (0.23 D2FS/year) than those in the placebo arm (0.38 D2FS/year; IRR = 0.60; 95% CI [0.44, 0.81]; p < .001). There was no statistically significant difference between xylitol and control participants in the incidence of smooth-surface caries (p = .100), occlusal-surface caries (p = .408), or proximal-surface caries (p = .159). Among these caries-active adults, xylitol appears to have a caries-preventive effect on root surfaces (ClinicalTrials.gov NCT00393055).

Clinical evidence for polyol efficacy

Xylitol is a safe dental caries preventive when incorporated into chewing gum or confections used habitually. The goal of this paper is to identify and assess the work on xylitol and other polyols and dental caries since 2008. Xylitol is effective when used by the mother prenatally or after delivery to prevent mutans transmission and subsequent dental caries in the offspring. One new completed trial confirmed that children of mothers who used xylitol lozenges after delivery had less dental caries than a comparison group. A similar study confirmed that the use of xylitol gum by the mother either prevented or postponed MS transmission to the offspring. Xylitol use among schoolchildren delivered via a gummy bear confection reduced S. mutans levels, but a once per day use of xylitol-containing toothpaste did not. Randomized trials, with caries outcomes, assessing xylitol-containing lozenges in adults and xylitol-containing gummy bears in children will release results in the coming year. Other studies are ongoing but are not systematic and will fail to answer important questions about how xylitol, or other polyols, can address the global dental caries problem.

Administration of Bifidobacterium animalis subsp. lactis BB-12 in early childhood: a post-trial effect on caries occurrence at four years of age

Probiotic bifidobacteria are widely used in the prevention of childhood diseases. These bacteria are also associated with caries occurrence. The present secondary analysis in a low-caries population evaluated the effect of early administration of Bifidobacterium animalis subsp. lactis BB-12 (BB-12) on caries occurrence and identified markers of dental decay in early childhood. In the original randomized, double-blind, placebo-controlled study (NCT00638677, http://www.clinicaltrials.gov), infants (n = 106) received BB-12, xylitol or sorbitol tablets from the age of 1-2 months to 2 years with a slow-release pacifier or a spoon (daily dose of BB-12 10(10) colony-forming units, polyol 200-600 mg). The present data were collected using clinical examinations and questionnaires at the age of 4 years. The occurrence of dental caries was assessed using the International Caries Detection and Assessment System. Oral hygiene status and mutans streptococci (MS) levels were also determined. No differences were detected between the study groups in the occurrence of enamel caries (p = 0.268) or obvious dentinal caries (p = 0.201). The occurrence of caries was associated with daily consumption of sweet drinks (p = 0.028), visible plaque observed (p = 0.002) and MS detected in the dental plaque (p = 0.002). Administration of BB-12 in infancy does not seem to increase or decrease the occurrence of caries by 4 years of age in a low-caries population.

A contemporary review of white spot lesions in orthodontics

White spot lesions (WSL) associated with fixed orthodontic appliances are a common adverse effect of orthodontic treatment and represent a significant challenge to achieving esthetic excellence. The purpose of this article is to review the current evidence regarding diagnosis, risk assessment, prevention, intratreatment management, and postorthodontic treatment of WSL, and to provide clinical recommendations useful for both the orthodontist and the general dentist. Caries risk assessment should be incorporated into initial evaluations of orthodontic patients, and risk-specific prevention and management protocols can help to eliminate or minimize this clinical problem. There are multiple options for treatment of WSL, ranging from conservative to invasive techniques; the severity of lesions is a determinant of which option is most appropriate.

CLINICAL SIGNIFICANCE

White spot lesions associated with orthodontic treatment are a common problem that can be minimized with appropriate prevention, management, and treatment approaches.

Vitamin D and dental caries in controlled clinical trials: systematic review and meta-analysis

Vitamin D has been used to prevent and treat dental caries. The objective of this study was to conduct a systematic review of controlled clinical trials (CCTs) assessing the impact of vitamin D on dental caries prevention. Random-effects and meta-regression models were used to evaluate overall and subgroup-specific relative-rate estimates. Twenty-four CCTs encompassing 2,827 children met the inclusion criteria. Twenty-two of the 24 CCTs predated modern clinical trial design, some of which nonetheless reported characteristics such as pseudo-randomization (n = 2), blinding (n = 4), or use of placebos (n = 8). The relative-rate estimates of the 24 CCTs exhibited significant heterogeneity (P < 0.0001), and there was evidence of significant publication bias (P < 0.001). The pooled relative-rate estimate of supplemental vitamin D was 0.53 (95% CI, 0.43-0.65). No robust differences were identified between the caries-preventive effects of vitamin D(2) , vitamin D(3) , and ultraviolet radiation (Prob > F = 0.22). The analysis of CCT data identified vitamin D as a promising caries-preventive agent, leading to a low-certainty conclusion that vitamin D may reduce the incidence of caries.

Binding affinity of anti-xylitol antibodies to canine hepatic vessels

Xylitol is used as a sugar substitute in food products. Dogs have been reported to experience lethal liver injury after accidental ingestion of xylitol. Because liver injury may be a serious consequence of canine immune-mediated reactions, antibodies produced against xylitol may attack the liver. Therefore, in the present study, we evaluated whether binding sites for xylitol antibodies are located at the liver or not. Anti-xylitol antibodies were generated by immunization of rabbits with a xylose-bovine serum albumin conjugate. Immunohistological examination showed that binding sites for the anti-xylitol antibodies were located in the hepatic arteries and the portal veins. Western blotting analyses by using a canine liver homogenate showed 4 protein bands with different molecular weights which reacted with anti-xylitol antibodies. Therefore, binding of anti-xylitol antibodies to the vessels may be the first step in an immune-mediated pathogenic response in xylitol toxicity. Further studies are necessary to determine the effects of anti-xylitol antibodies on the liver in the pathogenesis of xylitol toxicity.

Xylitol concentrations in artificial saliva after application of different xylitol dental varnishes

Objective

The present study analyzed xylitol concentrations in artificial saliva over time after application of varnishes containing 10% and 20% xylitol.

Material and Methods

Fifteen bovine enamel specimens (8x4 mm) were randomly allocated to 3 groups (n=5/group), according to the type of varnish used: 10% xylitol, 20% xylitol and no xylitol (control). After varnish application (4 mg), specimens were immersed in vials containing 500 µL of artificial saliva. Saliva samples were collected in different times (1, 8, 12, 16, 24, 48 and 72 h) and xylitol concentrations were analyzed. Data were assessed by two-way repeated-measures ANOVA (p<0.05).

Results

Colorimetric analysis was not able to detect xylitol in saliva samples of the control group. Salivary xylitol concentrations were significantly higher up to 8 h after application of the 20% xylitol varnish. Thereafter, the 10% xylitol varnish released larger amounts of that polyol in artificial saliva.

Conclusions

Despite the results in short-term, sustained xylitol releases could be obtained when the 10% xylitol varnish was used. These varnishes seem to be viable alternatives to increase salivary xylitol levels, and therefore, should be clinically tested to confirm their effectiveness.

A practice-based study on the effect of a short sucrose/xylitol exposure on survival of primary teeth caries free

BACKGROUND

In a randomized double-blinded clinical trial, preschool children used sucrose or xylitol chewing gum regularly for 2 months to study the preventive effect of xylitol on acute otitis media (AOM). Salivary mutans streptococci (sm) levels of the children were measured before the exposure. Those with ≥10(5) sm CFU in 1 mL saliva were considered to have high sm levels (sm+); and those with <10(5) CFU low sm levels (sm-).

AIM

This practice-based study aims to evaluate long-term dental effects of the sucrose/xylitol exposure on primary teeth.

DESIGN

For analyses, individuals were divided into sub groups according to their study group in the original AOM trial and baseline sm levels. Outcome events owing to dental caries of their all primary teeth were followed from dental records up to 12 years. Survival of teeth caries free was determined by Kaplan-Meier method and analysed statistically by Wilcoxon testing.

RESULTS

Survival of primary teeth caries free of children with high sm levels in the sucrose group was significantly shorter compared with all other groups when followed until shedding.

CONCLUSIONS

Two months' regular exposure to sucrose was sufficient to induce dental caries in primary teeth of children with elevated sm levels at baseline.

Delivery of Active Agents from Chewing Gum for Improved Remineralization

Most surrogate measures of caries were developed to test products containing fluoride, typically at relatively high and closely controlled oral concentrations. However, since the primary mechanism for the remineralization of early enamel caries lesions by chewing gum is through stimulation of saliva, delivering Ca and Pi to the demineralized enamel lesion, established methods may lack the sensitivity to detect the additional benefit of an active agent without the strong remineralizing potential of fluoride. Issues related to the release of active agents from the gum matrix, dilution in the saliva, and limited oral retention time, along with taste, safety, regulatory, and cost concerns, impose further limitations. This paper reviews the efficacy of some active agents used in chewing gum for improved remineralization and includes results from in situ testing of calcium-containing gums, including calcium lactate, tetracalcium phosphate/dicalcium phosphate anhydrous, calcium citrate/encapsulated phosphate, and a calcium lactate/sodium phosphate blend. Despite promising in vitro data from these agents, they did not provide consistently superior results from in situ testing. There is a need to develop better predictive in vitro models for chewing gum, as well as improved sensitivity of in situ models to discriminate relatively small amounts of remineralization against a background of high biological variability.