Results from the Xylitol for Adult Caries Trial (X-ACT)

Is xylitol effective in the prevention of dental caries? A systematic review

Background

Xylitol is a sugar alcohol increasingly used in dentistry as a preventative measure against dental caries. The objective of this systematic review was to assess xylitol's efficacy in caries prevention through the reduction of the most commonly associated bacteria: Streptococcus mutans.

Material and Methods

This systematic review followed PRISMA guidelines. A literature search was conducted in PubMed, Cochrane and Google Scholar databases. The search algorithm included the following key words: xylitol, dental caries, tooth demineralization, Streptococcus mutans, and prevention. The CASPe tool was used to assess risk of bias in the articles reviewed.

Results

After the search and selection processes, nine clinical trials (some of them placebo-controlled) in humans were included in the review. The objective proposed - to assess the efficacy of xylitol in caries prevention - was not fulfilled conclusively in all the works. Little heterogeneity was observed among the trials, as the study groups, evaluation periods, daily doses of xylitol etc. varied considerably between the works.

Conclusions

According to the present findings, the preventative effect of xylitol against dental caries cannot be confirmed. The results also highlight the need for further research with standardized protocols. Key words:Xylitol, dental caries, dental demineralization, Streptococcus mutans, prevention.

Effectiveness of New Isomalt-Containing Toothpaste Formulations in Preventing Dental Caries: A Microbial Study

This study investigated the efficacy of Isomalt-containing toothpaste in preventing development of dental caries.

METHODS

Human dental enamel slabs were allocated to six groups (30/group) at random: De-ionized distilled water (DDW), and toothpaste containing 10% Isomalt, 1100 ppm fluoride, 0.05% cetylpyridinium chloride [CPC] (ICT); 10% Isomalt, 1100 ppm fluoride (IT); 10% Isomalt, 1100 ppm fluoride, 1.5% Sodium lauryl sulfate [SLS] (IST); 1100 ppm fluoride only (FT); 1100 ppm fluoride with SLS (FST). The enamel slabs were exposed to caries development via plaque growth in a Microbial Caries Model for 7 days. Toothpastes were applied as slurries (one toothpaste-three DDW) for 2 min twice daily. Demineralization was measured as the change in surface microhardness (ΔSMH) and amount of mineral lost (∆Z), and these metrics were assessed using Transverse Microradiography. Intra-group (SMH) and intergroup (%∆SMH and ∆Z) comparisons were paired t-test and Tukey's test (α = 0.05), respectively.

RESULTS

With SMH, demineralization was found to be significant (p < 0.001) in all groups compared to sound enamel baseline, except ICT group. With %ΔSMH, all other groups had significantly (p < 0.001) less demineralization compared to DDW. Significantly (p < 0.001) greater demineralization was observed in IT, FT and FST compared to ICT, and no significant difference was observed between IST and ICT or FT. With ∆Z, relative to the DDW group, the inhibition of demineralization was significant (p < 0.0001) in all groups at varying percentages.

CONCLUSIONS

Toothpaste containing 10% Isomalt, 1100 ppm fluoride, and 0.05% CPC demonstrated greater efficacy in inhibiting caries development amid dental plaque compared to toothpaste containing only 1100 ppm fluoride.

A bivariate zero-inflated negative binomial model and its applications to biomedical settings

The zero-inflated negative binomial distribution has been widely used for count data analyses in various biomedical settings due to its capacity of modeling excess zeros and overdispersion. When there are correlated count variables, a bivariate model is essential for understanding their full distributional features. Examples include measuring correlation of two genes in sparse single-cell RNA sequencing data and modeling dental caries count indices on two different tooth surface types. For these purposes, we develop a richly parametrized bivariate zero-inflated negative binomial model that has a simple latent variable framework and eight free parameters with intuitive interpretations. In the scRNA-seq data example, the correlation is estimated after adjusting for the effects of dropout events represented by excess zeros. In the dental caries data, we analyze how the treatment with Xylitol lozenges affects the marginal mean and other patterns of response manifested in the two dental caries traits. An R package "bzinb" is available on Comprehensive R Archive Network.

Effectiveness of the Lorodent Probiotic Lozenge in Reducing Plaque and Streptococcus mutans Levels in Orthodontic Patients: A Double-Blind Randomized Control Trial

Orthodontic patients are at a significant risk for oral diseases due to increased plaque accumulation and oral bacterial dysbiosis. We aimed to determine the efficacy of the commercially available Lorodent Probiotic Complex at reducing plaque accumulation and Streptococcus mutans bacterial levels in adolescent orthodontic patients. Sixty adolescents undergoing fixed orthodontic treatment for a minimum of 6 months were recruited in a randomized, double-blind, parallel-group, placebo-controlled trial. They received either Lorodent probiotic lozenge (intervention, n = 30) or placebo lozenge (control, n = 30) orally every day for a 28-day administration period. Participants were assessed at four appointments (T1–T4) over a total of 56 days. Compliance and lozenge satisfaction were monitored. Saliva samples and supragingival plaques were collected for evaluation of S. mutans levels. Clinical assessment using a Plaque Index (PI) was used. Compliance with lozenge intake of all participants was over 90%. There was no significant change in the PI and composite PI scores in both placebo and probiotic groups at each time frame (all p &gt; 0.05) or the relative S. mutans DNA levels in the saliva and plaque between the probiotic and placebo groups. The findings of high compliance and satisfaction with the probiotic lozenges combined with the study's rigorous design offer a baseline for subsequent testing of further potential probiotics (of varying formulations, concentrations), especially in adolescents.

Is there a preferable management for root caries in middle-aged and older adults? A systematic review

Aim This systematic review aimed to critically summarise the results of clinical studies investigating agents able to: stop the progression of carious lesions; stop the development of new root carious lesions; preserve the vitality of the infected dental tissues; and increase the surface hardness or change of surface texture, in middle-age and older adults.Methods PubMed, Scopus, and Web of Science were searched systematically, following PRISMA guidelines. Clinical trials published from 2011 to 2020 (March) were included. This systematic review is registered in the PROSPERO database (CRD42018104399). Languages were restricted to English.Results Thirteen of 312 studies were eligible for this review. Eight agents were identified in the studies and their efficacy was assessed using different methods. The agents that presented valuable results on preventing or arresting root caries were 38% silver diamine fluoride (SDF), arginine-containing toothpaste and high-fluoride toothpastes.Conclusions Based on the selected studies' findings, annual applications of 38% SDF could be the most effective treatment for root caries in older adults. In addition, the daily use of a 1.5% arginine toothpaste or a high-fluoride toothpaste could also be recommended. More research on root caries-specific diagnostic methods, especially at very early stages, is necessary.

Inhibition of Streptococcus mutans, antioxidant property and cytotoxicity of novel nano-zinc oxide varnish

OBJECTIVE

Zinc is a potent antimicrobial against cariogenic bacteria and effective anti-plaque agent. The present study investigated the efficacy of zinc oxide nanoparticles (ZnO-NP) varnish to inhibit S. mutans growth, biofilm, acid production, and its antioxidant potential and cytotoxicity.

DESIGN

Green synthesized ZnO-NP were characterized using ultraviolet-visible spectroscopy, x-ray diffraction spectroscopy, and transmission electron microscopy. Secondary metabolites were assessed using fourier transform infrared spectroscopy. Anti-oxidant potential was ascertained using 2,2-diphenyl-2-picrylhydrazyl hydrate (DDPH) assay and cytotoxicity of synthesized nanoparticles was evaluated on human liver cancer (Hep G2) and human embryonic kidney 293 (HEK-293T) cell lines.

RESULTS

Synthesized ZnO-NP showed excellent antimicrobial properties against S. mutans, as the minimum inhibitory and bactericidal concentrations were 0.53 μg/mL, and 1.3 μg/mL respectively. ZnO-NP at 0.1 mg/μl concentration had the greatest zone of inhibition (24 mm), followed by 0.05 mg/μl ZnO-NP (23 mm) and 0.05 mg/μl ampicillin (21 mm). Further, 0.1 mg/μl ZnO-NP varnish inhibited 90 % of S. mutans biofilms and reduced 24 h acid production closest to that of baseline and it also exhibited antioxidant capacity in a dose dependent manner (94 % inhibition-100 μg/mL). Biocompatibility of ZnO-NP varnish was evaluated on Hep G2 and HEK-293T cell lines; and the highest concentration of 0.1 mg/μl ZnO-NP used caused very low cytotoxicity to Hep G2 cells and was non-cytotoxic to HEK-293T cells.

CONCLUSIONS

Within the limits of this study, ZnO-NP varnish was effective in inhibiting S. mutans and holds great potential as an effective anticaries agent.

Erosive assessment of dry mouth lozenges and tablets on enamel and dentin

OBJECTIVES

To assess the erosive potential of dry mouth lozenges and tablets on enamel and dentin.

MATERIALS AND METHODS

The following lozenges and tablets were tested: Salese, Oracoat Xylimelts, Cotton Mouth, TheraBreath, DenTek OraMoist, SmartMouth, ACT, CVS Health, Rite Aid, Med Active, and Hager Pharma. pH Analysis: Each lozenge or tablet was crushed with a pestle and mortar and 5 g of the resultant powder was dissolved in 10 ml of distilled water (pH 7.02) The pH of each lozenge solution was assessed by using a calibrated pH meter. Titratable Acidity (TA) was determined by adding 0.1 M of NaOH to each homogenous tablet solution until the pH reached 7.0. Gravimetric Analysis was measured with freshly extracted molars crown/roots were sectioned at the CEJ and enamel and dentin specimens were fabricated. The specimens were then submerged in 5 ml of solution containing 2.5 gm of crushed tablets for 24 h, 48 h, 96 h and 14 days with measurements performed at each interval after drying. The solutions were renewed at each interval.

RESULTS

Significant correlation between pH and TA was observed for lozenges and tablets evaluated (p < 0.0001). Both variables were strongly correlated with enamel and dentin loss (p < 0.0001). For enamel, DenTek resulted in significantly more substance loss (p < 0.05) than with the other tested products, while Xylimelts presented the lowest percentage of substance loss. For dentin, Cotton Mouth resulted in the highest substance loss, and Xylimelts presented the lowest percentage of substance loss.

CONCLUSIONS

There is a strong correlation between the pH, tritatable aciditiy, and erosive potential of these products. DenTek and Cotton Mouth reported erosive effect to the enamel and dentin, respectively. Xylimelts performed better than the rest of the products in relationship to enamel and dentin.

METHODS FOR CARIES PREVENTION IN ADULTS AMONG DENTISTS FROM A BRAZILIAN COMMUNITY: Adult' caries prevention among Brazilian dentists

Little is known about dental practice patterns of caries prevention in adults among Brazilian dentists.

OBJECTIVE

To quantify procedures used for caries prevention for adult patients among dentists from a Brazilian community.

METHODS

Dentists (n=197) who reported that at least 10% of their patients are more than 18 years old participated in the first Brazilian study that used a translated version of the "Assessment of Caries Diagnosis and Caries Treatment" from the U.S. National Dental Practice-Based Research Network. A questionnaire about characteristics of their practice and patient population were also completed by the dentists. Generalized linear regression models and a hierarchal clustering procedure were used (p<0.05).

RESULTS

In-office fluoride application was the preventive method most often reported. The main predictors for recommending some preventive agent were: female dentist (dental sealant; in-office fluoride; non-prescription fluoride) and percentage of patients interested in caries prevention (dental sealant; in-office fluoride; non-prescription fluoride). Other predictors included private practice (dental sealant), percentage of patients 65 years or older (in-office fluoride), graduation from a private dental school (non-prescription fluoride), years since dental school graduation (chlorhexidine rinse) and using a preventive method (recommending sealant/fluoride/chlorhexidine rinse/sugarless, xylitol gum). Cluster analysis showed that dentists in the largest subgroup seldom used any of the preventive agents.

CONCLUSION

Dentists most often reported in-office fluoride as a method for caries prevention in adults. Some practitioner, practice and patients' characteristics were positively associated with more-frequent use of a preventive agent.

Using big data to promote precision oral health in the context of a learning healthcare system

There has been a call for evidence-based oral healthcare guidelines, to improve precision dentistry and oral healthcare delivery. The main challenges to this goal are the current lack of up-to-date evidence, the limited integrative analytical data sets, and the slow translations to routine care delivery. Overcoming these issues requires knowledge discovery pipelines based on big data and health analytics, intelligent integrative informatics approaches, and learning health systems. This article examines how this can be accomplished by utilizing big data. These data can be gathered from four major streams: patients, clinical data, biological data, and normative data sets. All these must then be uniformly combined for analysis and modelling and the meaningful findings can be implemented clinically. By executing data capture cycles and integrating the subsequent findings, practitioners are able to improve public oral health and care delivery.

Dental management of patients with substance use disorder

Substance use disorder (SUD) is a relapsing brain disorder characterized by compulsion and chronicity. SUD has detrimental effects on oral health. Drugs and alcohol negatively impact oral health by inducing a myriad of orofacial conditions including xerostomia, dental caries, periodontal disease, bruxism, pre-cancer and cancer, to name a few. Limited recommendations are available for dental professionals on how best to manage patients afflicted with SUD. The aim of this article is to review the oral health consequences of alcohol and commonly abused drugs to provide guidelines for the public health community and dental professionals. The United Nations estimates that a quarter billion people, representing five per cent of the global adult population, used drugs at least once in 2015. Developing public health interventions that include the participation of dental professionals and access to dental services for persons afflicted with SUD could play a critical role in improving their quality of life, their recovery, and their reintroduction into society.

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.

Remineralization Potential of Mints Containing Bioactive Agents in Artificially Induced Root Caries

This study investigated the remineralization effect of experimental mint formulations containing bioactive agents (xylitol; green tea extract, GT; and amorphous calcium phosphate, ACP) in the progression of artificially induced root caries. Root caries lesions were induced by demineralization solution (pH 4.6; 96 h; 37°C). The lesions were treated with mint A, mint B, mint C, xylitol, GT, ACP, or remineralization solution (RS; negative control). Specimens were pH-cycled through treatments (5×/day; 3 min) and 6 cycles of acidic (pH 5.0; 30 min) and neutral (pH 7.0; 10 min) buffers for 8 days. Bacterial collagenase (Clostridium histolyticum) was used overnight to simulate proteolytic challenge. Caries depth and porosity as well as mineral density were estimated using fluorescence microscopy (n = 15) and microcomputed tomography (n = 6). Analysis of variance (ANOVA, α = 0.05) showed no statistically significant difference in caries depth among all groups (p = 0.172). The highest fluorescence intensity decrease was observed for GT followed by mint C, with no significant difference between them (p = 0.868). There were significant differences among GT and mints A, B, and C when compared to RS (p < 0.001). No statistically significant differences in fluorescence intensity were observed among ACP, xylitol, and RS (p > 0.05). The mineral density of the lesions in GT, mints A, B, and C, and ACP was statistically similar (p > 0.05) and significantly higher than that in RS (p < 0.05). No significant difference was observed between xylitol and RS (p = 0.728). The experimental mints showed remineralization action on artificial root caries, and GT was found to be the main active ingredient in the investigated formulations.

The caries preventive effect of 1-year use of low-dose xylitol chewing gum. A randomized placebo-controlled clinical trial in high-caries-risk adults

Objectives

The caries preventive effect of long-term use (1 year) of low-dosage (2.5 g/die) of xylitol chewing gum in a high-caries-risk adult population was evaluated.

Materials and methods

In this randomized clinical trial, 179 high-caries-risk adults were assigned to two experimental groups, xylitol and polyols. Caries status, salivary mutans streptococci (MS), and plaque pH were re-evaluated after 2 years from baseline in 66 xylitol and 64 polyol subjects. Outcomes (the net caries increment for initial, moderate, and extensive caries lesions and for the caries experience) were evaluated using the nonparametric Mann–Whitney U test.

Results

The total caries experience increment was 1.25 ± 1.26 in the xylitol group and 1.80 ± 2.33 in the polyol group (p = 0.01). Subjects treated with xylitol chewing gums had a reduction of risk rate at tooth level of 23% with respect to those treated with polyols with a number needed to treat of 55 teeth. The area under the curve at pH 5.7 was statistically significantly lower (p = 0.02) during the experimental period in the xylitol group. A decrease of the concentration of salivary MS was noted in the xylitol group (p < 0.01).

Conclusions

Subjects using the low-dose xylitol chewing gum showed a significantly lower increment of initial and extensive caries lesions and overall a lower increment of caries experience.

Clinical relevance

One-year use of chewing gums provides an effective means for the prevention of caries disease.

Trial registration number

NCT02310308

Evaluation of the caries-preventive effect of toothpaste containing surface prereacted glass-ionomer filler

AIM

Although fluoride interventions have the most consistent benefit in preventing caries, caries still develop in high-risk individuals. Authors have evaluated the effectiveness of toothpastes containing surface prereacted glass-ionomer (S-PRG) filler in preventing tooth demineralization.

METHODS

Human tooth enamel blocks were randomly assigned to six groups (30 blocks/group): no treatment (a), and toothpaste containing either 1500 ppm fluoride as sodium monofluorophosphate (NaMFP) (b), 0 wt% S-PRG (b), 1 wt% S-PRG (d), 5 wt% S-PRG (e), or 20 wt% S-PRG (f). Early caries developed on each block by 7-days demineralization using a microbial caries model. Mineral loss (Δz) and lesion depth (LD) were determined using transverse microradiography.

RESULTS

Relative to the control, all toothpastes, except 0% S-PRG, significantly (analysis of variance, Tukey's, P<.0001) reduced Δz and LD at varying percentages. With regard to Δz, all comparisons were significant (P<.0001), except 0% S-PRG vs the control. Otherwise, S-PRG 1%, 5%, and 20% had 0.50, 0.37, and 0.27 times Δz compared to the control, respectively, while NaMFP had 0.61 times Δz compared to the control. LD followed an almost similar trend as Δz.

CONCLUSIONS

The findings of the present study demonstrate the effectiveness of toothpaste containing S-PRG filler in inhibiting tooth demineralization in the presence of bacterial plaque, thus highlighting its potential as an effective caries-control tool for individuals at high risk of developing caries.

A BAYESIAN HIERARCHICAL SPATIAL MODEL FOR DENTAL CARIES ASSESSMENT USING NON-GAUSSIAN MARKOV RANDOM FIELDS

Research in dental caries generates data with two levels of hierarchy: that of a tooth overall and that of the different surfaces of the tooth. The outcomes often exhibit spatial referencing among neighboring teeth and surfaces, i.e., the disease status of a tooth or surface might be influenced by the status of a set of proximal teeth/surfaces. Assessments of dental caries (tooth decay) at the tooth level yield binary outcomes indicating the presence/absence of teeth, and trinary outcomes at the surface level indicating healthy, decayed, or filled surfaces. The presence of these mixed discrete responses complicates the data analysis under a unified framework. To mitigate complications, we develop a Bayesian two-level hierarchical model under suitable (spatial) Markov random field assumptions that accommodates the natural hierarchy within the mixed responses. At the first level, we utilize an autologistic model to accommodate the spatial dependence for the tooth-level binary outcomes. For the second level and conditioned on a tooth being non-missing, we utilize a Potts model to accommodate the spatial referencing for the surface-level trinary outcomes. The regression models at both levels were controlled for plausible covariates (risk factors) of caries, and remain connected through shared parameters. To tackle the computational challenges in our Bayesian estimation scheme caused due to the doubly-intractable normalizing constant, we employ a double Metropolis-Hastings sampler. We compare and contrast our model performances to the standard non-spatial (naive) model using a small simulation study, and illustrate via an application to a clinical dataset on dental caries.

Hyposalivation and Xerostomia: Etiology, Complications, and Medical Management

Saliva is one of the most versatile, multifunctional substances produced by the body and has a critical role in the preservation of the oropharyngeal health. It comprises a serous and mucinous component and is secreted by the major salivary glands. The mucins in the saliva serve to protect and lubricate the hard and soft tissues of the mouth, protecting them from chemical and mechanical damage. Hyposalivation can be managed by various salivary substitutes, peripheral sialagogues, and central sialagogues.

Comparing the efficacy of xylitol-containing and conventional chewing gums in reducing salivary counts of Streptococcus mutans: An in vivo study

Objective:

Dental caries is among the most common chronic diseases in humans. Streptococcus mutans is generally responsible for most cases of dental caries. The present study sought to compare the effects of xylitol-containing and conventional chewing gums on salivary levels of S. mutans.

Materials and Methods:

This study adopted a crossover design. Two type of chewing gums (one containing 70% xylitol and approved by the Iranian Dental Association, and another containing sucrose) were purchased. The participants were 32 individuals aged 18–35 years whose oral hygiene was categorized as moderate or poor based on a caries risk assessment table. Salivary levels of S. mutans were measured at baseline, after the first and second phases of chewing gums, and after the washout period. The measurements were performed on blood agar and mitis salivarius-bacitracin agar (MSBA). Pairwise comparisons were then used to analyze the collected data.

Results:

Salivary levels of S. mutans in both groups were significantly higher during the two stages of chewing gum than in the washout period or baseline. Moreover, comparisons between the two types of gums suggested that chewing xylitol-containing gums led to greater reductions in S. mutans counts. This effect was more apparent in subjects with poor oral hygiene than in those with moderate oral hygiene.

Conclusions:

Xylitol-containing chewing gums are more effective than conventional gums in reducing salivary levels of S. mutans in individuals with poor–moderate oral hygiene.

Developing pathways for oral care in elders: evidence-based interventions for dental caries prevention in dentate elders

BACKGROUND

Dental caries is becoming an ever-growing challenge as the number of elders maintaining their teeth increases. There is a need for low-cost, effective preventive interventions to retain natural teeth for elders.

OBJECTIVE

The purpose of this article is to evaluate evidence based interventions for dentate elders, specifically the adjunct therapies of fluoride, chlorhexidine, xylitol, casein phosphopeptide-amorphous calcium phosphate, ozone, and herbal liquorice.

RESULTS

Fluoride interventions have demonstrated prevention and remineralization of dental caries in elders. Systematic reviews of the literature are unable to establish definitive conclusions regarding the effectiveness of other adjunct therapies in dental caries prevention.

CONCLUSIONS

Further research with elders requires improved study design with well designed multi-center trials. Considerations for new strategies for research of the effectiveness of therapies to reduce dental caries include the development and evaluation of combinations of therapeutic interventions and dental caries management by risk assessment.

pH and Erosive Potential of Commonly Used Oral Moisturizers

PURPOSE

To measure the pH values of commonly used oral moisturizers and to evaluate their erosive potential using a gravimetric analysis.

MATERIALS AND METHODS

A pH analysis was performed for seven commercially available oral moisturizers using a calibrated pH meter. The pH recording was repeated three times, from three different bottles each of the same product. The gravimetric analysis was performed by submerging human dentin blocks in 5 ml of each of the moisturizers for a total of 2 weeks, with gravimetric measurements made at baseline, 24 hours, 48 hours, 96 hours, 1 week, and 15 days. Tap water was used as positive control and citric acid as the negative control. The erosive potential was descriptively analyzed, and a Spearman correlation coefficient was used to assess the relationship between the erosive potential and the pH values.

RESULTS

The average pH values are as follows: Oasis, 6.3, Bioténe Moisturizing Mouth Spray, 6.1, CTx2 Spray, 9.1, Mouth Kote, 3.0, Thayer's, 6.3, Bioténe Oral Balance, 6.6, Rain, 7.1, tap water 6.99, and citric acid 1.33. The results (% of tooth structure lost) of the gravimetric analysis were as follows: Mouth Kote, 9.6%, Bioténe Moisturizing Mouth Spray, 4.6%, Oasis, 3.2%, Thayer's, 2.0%, Bioténe Oral Balance, 0.0%, Rain, 0.0%, CTx2 Spray, 0.0%, tap water 0.0%, and citric acid 18.8%. There was a significant negative correlation between the pH values and the erosive potential (r(s) = -0.73; P ≤ 0.0001).

CONCLUSIONS

There is large variation in the composition and pH values of commonly used oral moisturizers, and there is a strong correlation between pH values and erosive potential of commonly used oral moisturizers.

CLINICAL SIGNIFICANCE

Patients with dry mouth are at increased risk for erosion and root caries. Oral moisturizing agents are often prescribed for patients with hyposalivation to be used as needed for symptomatic relief. This study shows that there is large variation in the pH values and erosive potential of commonly used oral moisturizing agents.

The dynamic behavior of the early dental caries lesion in caries-active adults and implications

OBJECTIVE

To describe the full range of behavior of the visible, noncavitated, early caries lesion in caries-active adults with substantial fluoride exposure, and to consider implications.

METHODS

The data were from the Xylitol for Adult Caries Trial (X-ACT) collected annually for 33 months using condensed ICDAS caries threshold criteria. Individual tooth surfaces having a noncavitated caries lesion were included, and the patterns of transition to each subsequent annual clinical examination to sound, noncavitated or cavitated, filled or crowned were determined. The resulting sets of patterns for an individual tooth surface, looking forward from its first appearance as a noncavitated lesion, were combined into one of four behavior profiles classified as reversing, stable, oscillating, or continuously progressing, or were excluded if not part of the caries continuum. The distributions of profile types were assessed using the Rao-Scott chi-square test, which adjusts for clustering of tooth surfaces within teeth.

RESULTS

Inter- and intra-examiner kappa scores demonstrated acceptable calibration at baseline and annually. 8084 tooth surfaces from 543 subjects were included. The distribution of profile types differed significantly between coronal and root surfaces. Overall, two-thirds of all coronal noncavitated lesions were first seen at baseline, half reversed, over a fifth were stable, 15% oscillated, and only 8.3% progressed to cavitation, filled, or crowned in 33 months or less (6.3% consistently Progressed plus 2.0% inconsistently, a subset of oscillating, which oscillated before progressing to cavitation). Approximal, smooth, and occlusal coronal surfaces each were significantly different in their individual distributions of profile types. Xylitol showed no significant and consistent effect on this distribution by tooth surface type. This was in keeping with the X-ACT's lack of effect of xylitol at the noncavitated plus cavitated lesion thresholds combined.

CONCLUSIONS

This study demonstrated the full dynamic range of early caries lesion behavior. The great majority were not progressive, and few (8.3%) became cavitated over 33 months in caries-active adults using fluorides. Important caries management implications favoring recorded longitudinal monitoring, prevention of active risks, and minimal restoration only after direct visual determination of cavitation are discussed.

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.

Mother-to-child transmission of Streptococcus mutans: a systematic review and meta-analysis

OBJECTIVES

A systematic review was performed with the aim of determining whether there is scientific evidence of the transmission of Streptococcus mutans from mother to child.

DATA

The eligibility criteria, based on the PECO strategy, were the following: observational human studies whose subjects were mother and child pairs (P) contaminated by S. mutans (E); comparison according to the presence or absence of S. mutans (C); and whether there is transmission (O). The qualitative analysis was performed by assessing the risk of bias of the included studies, while quantitative synthesis was performed through comprehensive Meta-Analysis software (p<0.05).

SOURCES

Two reviewers performed the database search of studies published between January 1950 and May 2014. The strategy included observational studies that assessed the vertical transmission of S. mutans from mothers to children through analyzing genetic strains.

STUDY SELECTION

It was found 166 non-duplicated studies. However, after reviewing the articles in full and applying the eligibility criteria, 36 papers were selected for qualitative analysis and 19 for quantitative analysis. The cumulative meta-analysis demonstrated vertical transmission of S. mutans from mother to child (p<0.001).

CONCLUSIONS

The present systematic review and meta-analysis demonstrated evidence of vertical transmission of S. mutans from mother to child because there was an association between S. mutans n mothers and their respective children.

CLINICAL SIGNIFICANCE

The knowledge of the S. mutans strains is important because the virulence of the microorganisms is varied; also, the virulence affects the dental caries evolution rate, being more or less aggressive.

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

Oral implications of polypharmacy in the elderly

One of the major side effects of medications prescribed to elderly patients is the qualitative and quantitative alteration of saliva (salivary hypofunction). Saliva plays a pivotal role in the homeostasis of the oral cavity because of its protective and functional properties, including facilitating speech, swallowing, enhancing taste, buffering and neutralizing intrinsic and extrinsic acid, remineralizing teeth, maintaining the oral mucosal health, preventing overgrowth of noxious microorganisms, and xerostomia. With salivary hypofunction, a plethora of complications arise, resulting in decreased quality of life. The anticholinergic effects of medications can be overcome, and the oral cavity can be restored to normalcy.

Caries: review of human genetics research

The NIH Consensus Development Program released a statement in 2001 (http://consensus.nih.gov/2001/2001DentalCaries115html.htm) and listed six major clinical caries research directions. One of these directions was the need for genetic studies to identify genes and genetic markers of diagnostic, prognostic and therapeutic value. This last decade has seen a steep increase in studies investigating the presence of genetic factors influencing individual susceptibility to caries. This review revisits recent caries human genetic studies and provides a perspective for future studies in order to fulfil their promise of revolutionizing our understanding of and the standard of care for the most prevalent bacteria-mediated non-contagious disease in the world.

Risk management strategies for reducing oral adverse drug events

Oral adverse drug effects negatively impact oral health, comfort and function.

BACKGROUND

Patients treated in the oral health care environment take multiple medications, many of which cause oral complications. Dental professionals are challenged with making recommendations to prevent or minimize drug-induced oral disease risks, while reducing symptoms to improve oral health quality of life.

METHODS

This paper presents a critical analysis of current evidence regarding common oral adverse drug events, and reviews existing clinical practice guidelines based upon findings from published systematic reviews.

RESULTS

There is a lack of sufficient, high quality evidence to support most recommendations for interventions to relieve signs and symptoms of drug-induced oral adverse events. Existing recommendations are largely based on data obtained from observational studies and case reports, and from randomized controlled clinical trials with significant design flaws and potential reporting bias. Outcome measures, especially those related to symptom relief and long-range benefits, are either insufficient or lacking.

CONCLUSIONS

Oral adverse drug effects are a common problem, and additional data is needed to support best practices for product recommendations to improve oral health in medicated patients.

Visual scoring of non cavitated caries lesions and clinical trial efficiency, testing xylitol in caries-active adults

OBJECTIVES

To better understand the effectiveness of xylitol in caries prevention in adults and to attempt improved clinical trial efficiency.

METHODS

As part of the Xylitol for Adult Caries Trial (X-ACT), non cavitated and cavitated caries lesions were assessed in subjects who were experiencing the disease. The trial was a test of the effectiveness of 5 g/day of xylitol, consumed by dissolving in the mouth five 1 g lozenges spaced across each day, compared with a sucralose placebo. For this analysis, seeking trial efficiency, 538 subjects aged 21-80, with complete data for four dental examinations, were selected from the 691 randomized into the 3-year trial, conducted at three sites. Acceptable inter- and intra-examiner reliability before and during the trial was quantified using the kappa statistic.

RESULTS

The mean annualized noncavitated plus cavitated lesion transition scores in coronal and root surfaces, from sound to carious favoured xylitol over placebo, during the three cumulative periods of 12, 24, and 33 months, but these clinically and statistically nonsignificant differences declined in magnitude over time. Restricting the present assessment to those subjects with a higher baseline lifetime caries experience showed possible but inconsistent benefit.

CONCLUSIONS

There was no clear and clinically relevant preventive effect of xylitol on caries in adults with adequate fluoride exposure when non cavitated plus cavitated lesions were assessed. This conformed to the X-ACT trial result assessing cavitated lesions. Including non cavitated lesion assessment in this full-scale, placebo-controlled, multisite, randomized, double-blinded clinical trial in adults experiencing dental caries did not achieve added trial efficiency or demonstrate practical benefit of xylitol.

TRIAL REGISTRATION

ClinicalTrials.Gov NCT00393055.

Predictors of coronal caries progression in adults: results from the Prevention of Adult Caries Study

OBJECTIVES

This secondary analysis of data from the Prevention of Adult Caries Study (PACS) assesses risk factors for progression of coronal caries.

METHODS

Participants (n = 983) were adults at increased caries risk with at least one cavitated and one noncavitated lesions who were enrolled in a randomized clinical trial to test the effect of a 10% w/v chlorhexidine varnish coating on caries progression. Calibrated examiners scored tooth surfaces using a modified International Caries Detection and Assessment System (ICDAS) classification at baseline and at 7 and 13 months postrandomization. Potential baseline predictors of caries risk were used in adjusted negative binomial regression models to predict net D2FS increment and in linear regression models to predict the rank-normalized net D12FS increment.

RESULTS

Mean (SD) D2FS and D12FS increments were and 2.4 (3.1) and 2.1 (6.9), respectively. In multivariate analyses, two or more baseline D2 lesions, consumption of acidic drinks, and increasing age were all significantly associated with increased D2FS and D12FS risk. Daily flossing also was associated with increased D2FS risk. More frequent dental care at baseline was associated with significantly decreased caries risk for both increments.

CONCLUSIONS

The general concordance of risk factors in the D12FS and D2FS models lends support to the hypothesis that the D1 increment is an intermediate stage in the progression to fully cavitated lesions.

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).