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Xylitol and Dental Caries: An Overview for Clinicians
Abstract An overview of studies about xylitol and dental caries suggests potential clinical dental applications for xylitol. Xylitol is a naturally occurring, low-calorie sugar substitute with anticariogenic properties. Data from recent studies indicate that xylitol can reduce the occurrence of dental caries in young children, schoolchildren, and mothers, and in chil-dren via their mothers. Xylitol, a sugar alcohol, is derived mainly from birch and other hardwood trees. Short-term consumption of xylitol is associated with decreased Streptococcus mutans levels in saliva and plaque. Aside from decreasing dental caries, xylitol may also decrease the transmission of S. mutans from mothers to children. Commercial xylitol-containing products may be used to help control rampant decay in primary dentition. Studies of schoolchildren in Belize and Estonia, along with data from the University of Washington, indicate that xylitol gum, candy, ice pops, cookies, puddings, etc., in combination with other dental therapies, are associated with the arrest of carious lesions. A prospective trial in Finland has demonstrated that children of mothers treated with xylitol had lower levels of S. mutans than children of mothers treated with hlorhexidine or fluoride varnish. Food products containing xylitol are available commercially and through specialized manufacturers, and have the potential to be widely accessible to consumers. Sugar Alcohols Xylitol is a sugar substitute with sweetness equal to that of table sugar. I It is a member of the group of compounds known as sugar alcohols, which includes other common dietary sweeteners such as sorbitol and mannitol. Xylitol is produced commercially from birch trees and other hardwoods containing xylan. It can also be found in small quantities in fruits and vegetables. In contrast, sorbitol commonly found in sugar-free products such as chewing gum, candies, and toothpaste - is less sweet than sucrose and is generally combined with other sweeteners such as saccharine or aspartame as well as xylitol to improve the flavor of the product. Xylitol contains 40 percent fewer calories than sucrose. Because xylitol is absorbed slowly by the human gastrointestinal tract, the main side effect associated with its consumption is osmotic diarrhea. This usually occurs only when xylitol is consumed in large quantities, four to five times those needed for the prevention of dental caries.2 \ This side effect is common to all sugar alcohols. Xylitol and Streptococcus Mutans Microorganisms do not readily metabolize xylitol, and its consumption has minimal effect on plaque ph.1 However, xylitol does accumulate intracellularly in S. mutans. This accumulation inhibits the bacteria's growth. This has been demonstrated in vitro and may contribute to a reduction of S. mutans levels in the plaque and saliva of those consuming xylitol. In addition, xylitol has a number of effects on S. lilt/tails that may account for some of its clinical effects in caries reduction. Short-term both saliva and plaque.' Long-term habitual consumption of xylitol appears to have a selective effect on S. mutans, resulting in selection for populations less adherent to tooth surfaces. These colonies, therefore, are shed more easily from plaque into saliva." This effect may not only be important to the individual's decay experience, but may also influence the transmission of S. mutans from mothers who consume xylitol to their children. A clinician can recommend adding xylitol to the diet without asking patients to make additional alterations to their dietary patterns. Clinical Applications Children at High Risk for Caries There are surprisingly few well studied strategies available to clinicians to prevent and control high rates of caries in the primary dentition. In the absence of water fluoridation, fluoridated toothpaste and topical fluoride varnish are the mainstays in the United States. For older children, sealants are added to the regimen. Effective strategies to reduce risk by modifying the diet of children are not significant effort. As a result, the use of xylitol is particularly attractive because its action is not dependent upon reducing the amount of other sugars in the diet. Thus, a clinician can recommend adding xylitol to the diet without asking patients to make additional alterations to their dietary patterns. Xylitol containing products have the potential to improve success in controlling the problem of rampant decay in the primary dentition. A number of studies conducted among schoolchildren of various ages have shown that consumption of gum containing xylitol reduces the rates of dental decay in the treatment groups (relative risks ranging from 0.27 to 0.56). Increasing use and higher doses led to greater reductions. One study conducted among school children in Belize with very high rates of dentine caries showed that consumption of xylitol gum was associated with arrest of carious lesions and, as expected, that the highest dose of xylitol had the greatest effect. The number of lesions that re-hardened ranged from 9 percent to 27 percent in all groups and from 12 percent to 27 percent in the 10 percent xylitol groups. This study is important because the children continued to consume very high levels of sucrose in their everyday diet. However, a major limitation in extending these results to the United States is that chewing gum is not considered safe for very small children and is actively discouraged in schools. Other xylitol-containing products have been studied. A field trial of the use of xylitol-containing candies among 10-year-old schoolchildren in Estonia showed a 33 percent to 59 per-_ cent caries reduction in the group using the candies and a 53.5 percent caries reduction in the group using the gum relative to the control group. This suggests that candy may be as effective as chewing gum as a vehicle for the delivery of xylitol in caries prevention. At the University of Washington, researchers have produced and field-tested xylitol-containing ice pops, chewy worms, puddings, macaroons, and sorbet. They have initiated studies that suggest that children will fairly readily accept such foods when offered as part of the daily diet and that suffer no side effects from their use. Food producers are available to develop these foods, hut considerable work is needed to produce commercially viable products and have them accepted. According to available data, there is no vehicle in the United States for using xylitol in toddlers and preschool children too young to chew gum. In older children, four to five pellets or sticks (1 gram of xylitol per pellet or stick) of xylitol gum per day, chewed for five minutes, should reduce dental caries activity. Xylitol, approved by the Food and Drug Administration, has been used as a sweetener in foods since the 1960s. It is sale for use with children. The use of fluoridated toothpaste, topical fluorides, and sealants should also be encouraged. Pregnant Women and New Mothers Kohler and colleagues demonstrated that the combination of good dental care, instruction to improve oral hygiene, and chlorohexidine gels and toothpastes led to reductions in maternal S. mutans levels and reduction in the extent of transmission to the child. More recently, Hildebrandt and colleagues showed that the use of commercially available chlorohexidine rinses for two weeks followed by the daily use of xylitol gum (two pellets containing 7g xylitol) in high-caries-rate adults with recent restorations led to major reductions in S. mutans. A clinical trial conducted in Finland, demonstrated that xylitol had the greatest effect. The mothers, all of whom had high S. mutans levels at the beginning of the study, were treated with either chlorhexidine varnish or fluoride varnish or 100 percent xylitol gum (65 percent xylitol by weight, chewed at least two to three times per day) for 1 to 21 months. The outcome measures were decay rates among the children and S. mutans levels in both the Dentinal caries among children in the xylitol group was reduced by 70 percent as compared with children in the fluoride or chlorhexidine groups. mothers and the children. The chi 1chen of mothers treated with xylitol had the lowest levels of S. mutans during the intervention period (treatment continued until the child was 2 years old) and during follow-up. The percentage of colonization with S. mutans in the children in the xylitol group at 2 years old was 9.7 percent. This was statistically different from the other two groups, in which 2H.6 percent were colonized in the chlorhexidine group and 4.5 percent in the fluoride group. These children when followed up most recently had the lowest S. mutans levels (51.6 percent were colonized in the xylitol group vs. H3.9 percent in the fluoride group and H6.4 percent in the chlorhexidine group). Children of mothers treated with xylitol also had the lowest rates of decay. Follow-up at 5 years of age found that dentinal caries among children in the xylitol group was reduced by 70 percent as compared with children in the fluoride or chlorhexidine groups. These studies have been conducted only in settings in which child rearing is done primarily by the mother and in which mother-to-child transmission is presumed. \10 studies have been completed in communities where child rearing is shared among greater numbers of people. The use of xylitol gum by mothers as well as other family members is currently being investigated in one such community. Whether used alone or in combination with other antimicrobial therapies such as chlorhexidine, xylitol has an important role in the prevention of dental decay among children born to mothers with high levels of S. mutans not only because of its effects on S. mutans levels and bacterial properties during the period of consumption, but also because its beneficial effect on decay reduction in these children appears to persist far beyond the period of consumption. Both chlorhexidine and xylitol may be used safely by pregnant women and nursing mothers. Currently available data suggest that twice daily use of chlorhexidine gluconate rinse (0.12 percent) for two weeks, followed by four to five sticks or pellets of xylitol gum per day chewed for five minutes each time, should lead to a major reduction in S. mutans levels in the mother and should benefit the child. |
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