Similarity of the effects of erythritol and xylitol on some risk factors of dental caries

Several sugar alcohols (polyols) have been promoted as potential sugar substitutes in caries limitation. However, differences in the effects of simple alditol-type sugar alcohol homologues on dental plaque have not been compared in clinical tests. The effects of 6-month use of erythritol (a sugar alcohol of the tetritol type), xylitol (a pentitol) and D-glucitol (sorbitol, a hexitol) were investigated in a cohort of 136 teenage subjects assigned to the respective polyol groups or to an untreated control group (n = 30-36 per group). The daily use of the polyols was 7.0 g in the form of chewable tablets, supplemented by twice-a-day use of a dentifrice containing those polyols. The use of erythritol and xylitol was associated with a statistically significant reduction (p < 0.001 in most cases) in the plaque and saliva levels of mutans streptococci. The amount of dental plaque was also significantly reduced in subjects receiving erythritol and xylitol. Such effects were not observed in other experimental groups. Chemical analyses showed D-glucitol to be a normal finding in dental plaque while xylitol was less consistently detected. Erythritol was detected in measurable amounts only in the plaque of subjects receiving this polyol. Erythritol and xylitol may exert similar effects on some risk factors of dental caries, although the biochemical mechanism of the effects may differ. These in vivo studies were supported by cultivation experiments in which xylitol, and especially erythritol, inhibited the growth of several strains of mutans streptococci.     

Dietary factors in the prevention of dental caries: a systematic review

The aim of this study was, systematically, to evaluate the effect of dietary changes in the prevention of dental caries. A search and analysis strategy was followed, as suggested by the Swedish Council on Technology Assessment in Health Care (SBU). The search strategy for articles published in 1966-2003 was performed using electronic databases and reference lists of articles and selected textbooks. Out of 714 articles originally identified, 18 met the inclusion criteria for a randomized or controlled clinical trial--at least 2 years' follow-up and caries increment as a primary endpoint. This included the total or partial substitution of sucrose with sugar substitutes or the addition of protective foods to chewing gum. No study was found evaluating the effect of information designed to reduce sugar intake/frequency as a single preventive measure. It is suggested that the evidence for the use of sorbitol or xylitol in chewing gum, or for the use of invert sugar, is inconclusive. No caries-preventive effect was found from adding calcium phosphate or dicalcium phosphate dihydrate to chewing gums. The review dearly demonstrates the need for well-designed randomized clinical studies with adequate control groups and high compliance.     

Dietary factors in the prevention of dental caries: a systematic review

The aim of this study was, systematically, to evaluate the effect of dietary changes in the prevention of dental caries. A search and analysis strategy was followed, as suggested by the Swedish Council on Technology Assessment in Health Care (SBU). The search strategy for articles published in 1966–2003 was performed using electronic databases and reference lists of articles and selected textbooks. Out of 714 articles originally identified, 18 met the inclusion criteria for a randomized or controlled clinical trial—at least 2 years' follow‐up and caries increment as a primary endpoint. This included the total or partial substitution of sucrose with sugar substitutes or the addition of protective foods to chewing gum. No study was found evaluating the effect of information designed to reduce sugar intake/frequency as a single preventive measure. It is suggested that the evidence for the use of sorbitol or xylitol in chewing gum, or for the use of invert sugar, is inconclusive. No caries‐preventive effect was found from adding calcium phosphate or dicalcium phosphate dihydrate to chewing gums. The review clearly demonstrates the need for well‐designed randomized clinical studies with adequate control groups and high compliance.     

Dietary factors and dental caries

DATA SOURCES: Articles were sourced using Medline, the Cochrane Library, reference lists of identified articles and selected textbooks. STUDY SELECTION: Studies chosen for inclusion in the review were randomised or controlled clinical trials of at least 2 years' duration that used caries increment in the permanent or primary dentition as the end point. Publications in Danish, English, French, German, Italian, Norwegian, Spanish or Swedish were included. For multiply reported trials the one with the longest follow-up period was included. DATA EXTRACTION AND SYNTHESIS: Inclusion decisions and grading of the studies was carried out independently by two of the authors. The main outcome was caries increment and the measure of treatment effect was either relative risk reduction or prevented faction. A qualitative synthesis of the included studies was conducted. RESULTS: Eighteen studies met the inclusion criteria. They included the total or partial substitution of sucrose with sugar substitutes or the addition of protective foods to chewing gum. No study could be found that had evaluated the effect of information designed to reduce sugar intake/frequency as a single preventive measure. It is suggested that the evidence for the use of sorbitol or xylitol in chewing gum, or for the use of invert sugar, is inconclusive. No caries-preventive effect was found from adding calcium phosphate or dicalcium phosphate dihydrate to chewing gums. CONCLUSIONS: The review dearly demonstrates the need for well-designed randomised clinical studies, with adequate control groups and high compliance, looking at the effect of dietary measures on dental caries.     

Sugar alcohols: what is the evidence for caries-preventive and caries-therapeutic effects?

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

Microbiological aspects of some caloric sugar substitutes

Several caloric sugar substitutes are available today, e.g. maltitol, Lycasin, sorbitol, xylitol, palatinit, sorbose, coupling sugar, palatinose, fructose and invert sugar. When evaluating the cariogenicity of these sugar substitutes from a bacteriological point of view, different analytical procedures should be considered. In vitro studies on the capacity of pure oral bacterial strains and dental plaque material to decompose the substitute to acid. Studies on the catabolism of the substitute. Possible adaptation of the oral microflora to metabolize the substitute in vivo as well as in vitro. Studies on any inhibitory effect of the substitute on the microbial activities in dental plaque and on the oral microflora. The capacity of oral bacteria, e.g. Streptococcus mutans, to induce caries in animal experiments should also be considered. Results from such microbiological studies make it possible to classify the caloric sugar substitutes into different groups. The first, most suitable, group seems to consist of xylitol and sorbose. These substitutes are fermented by few oral bacteria and no negative adaptation of the oral flora has been observed. A reducing effect upon dental plaque formation and on acid production from glucose has been reported. A second group consists of maltitol, palatinite, palatinose, sorbitol and Lycasin. These substitutes are fermented by certain groups of organisms within the oral genera Actinomyces, Lactobacillus and Streptococcus. Adaptation of oral bacteria to palatinose and to sorbitol, resulting in a more pronounced acid production, has been observed. No inhibitory effects have been reported. The results from experimental studies suggest that these sugar substitutes have no or little cariogenic action in rodents inoculated with S. mutans.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of long-term, peroral administration of sugar alcohols on man

Certain sugar alcohols (polyols), notably mannitol, sorbitol and xylitol have gained use in food manufacturing for sweetening and technical purposes. These compounds are natural polyols that occur in small amounts in animals and plants. Some sugar alcohols, like xylitol, appear as normal intermediates in the carbohydrate metabolism. Exogenous mannitol, sorbitol and xylitol are metabolized in the human body along pre-existing, physiological pathways. Moderate doses of least xylitol and sorbitol are almost totally absorbed and metabolized, chiefly in the liver cells, thereby eventually contributing to the formation of glucose and liver glycogen. Various slowly absorbed carbohydrates, including sugar alcohols, when taken in orally in large quantities, can give rise to osmotic diarrhea. The available data indicate that the severity of such gastro-intestinal disturbances, induced by large doses of polyols, decrease in the following order: mannitol, sorbitol, xylitol. This osmotic diarrhea resembles that caused by lactose in subjects with restricted or frank lactose intolerance. The quantities of xylitol, for example, required to elicit diarrhea are so high that the consumption of xylitol for dental purposes does not cause any problems in children or adults. Long-term feeding trials and peroral loading experiments on human subjects have been unable to show any clinically significant differences between chronic users of xylitol and comparative human material in factors related to various metabolic functions of the body. These subjects have not shown any delayed or acute reactions which could be distinguished from those caused by the consumption of a sucrose diet. The available clinical data generally suggest that moderate consumption of the above polyols is not harmful to human metabolism.     

Diet and dental caries.

Dental caries is a diet-related disease that continues to be a problem for certain dental patients. Frequent consumption of fermentable carbohydrates that have low oral clearance rates increases the risk for enamel caries and perhaps is even more dangerous for root surfaces. Highly acidogenic snack foods should be consumed at mealtimes to reduce the risk, and between-meal snacks should be either nonacidogenic (such as xylitol products) or hypoacidogenic (such as sorbitol and HSH products). Cheeses present a naturally occurring situation that may provide anticariogenic effects from the diet. Certain additives as well as sugar substitutes show great promise for the provision of between-meal snack foods that reduce the risk of dental caries. The dental team should thoroughly understand the relationship of diet to caries and conscientiously apply that knowledge to educate the patients in general as well as counsel specific high-risk individuals. Further emphasis should be placed on the acquisition of sound scientific data for counseling caries patients concerning diet and dental caries.     

Acid production from sugars and sugar alcohols by probiotic lactobacilli and bifidobacteria in vitro

Some probiotic bacterial strains have been suggested to improve oral health. However, lactobacilli and bifidobacteria are associated with the progression of dental caries. The pH fall caused by 14 probiotic and dairy bacterial strains from glucose, lactose, sucrose, sorbitol and xylitol was followed. All strains used glucose, nine lactose and seven sucrose. Six of the lactobacilli caused a small decrease in pH with sorbitol and two with xylitol. None of the bifidobacteria fermented sugar alcohols. As all the strains could be considered acidogenic, more long-term clinical trials are needed before recommendations for oral health purposes can be made.     

Correlation between caries incidence and frequency of chewing gum sweetened with sucrose or xylitol

The effect on caries incidence of the daily consumption of chewing gum sweetened with sucrose or xylitol was measured in 100 subjects included in the 1-year chewing gum study (Scheinin et al. 1975, Turku sugar Studies XVIII). The subjects were divided retrospectively into groups consuming 2-8 chewing gum pieces per day and their caries incidence was compared. With chewing gum sweetened with sucrose, the caries incidence increased in relation to the daily consumption of gum. In contrast, chewing gum sweetened with xylitol reduced the incidence of caries with increasing consumption.     

Xylitol and dental caries: an overview for clinicians

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 children 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 chlorhexidine or fluoride varnish. Food products containing xylitol are available commercially and through specialized manufacturers, and have the potential to be widely accessible to consumers.     

Caries preventive effects of xylitol-based candies and lozenges: a systematic review

Objective: A systematic review of published data was conducted with the aim of assessing the caries preventive effect of consuming xylitol‐based candies and lozenges. Methods: Electronic and hand searches were performed to find clinical trials concerning the consumption of products containing xylitol, published up to November 2009. The studies must have had the following characteristics: a) a comparison of caries progression in subjects who either did or did not consume candies or lozenges containing xylitol during a minimum follow‐up period of 1 year; and b) a concurrent comparison of the percentage of caries progression according to the World Health Organization criteria. The caries preventive effect of xylitol was assessed by calculating the prevented fraction. Results: The initial search identified 127 references. Six studies met the initial eligibility criteria, but three were excluded after thorough analysis. Two more articles were selected after hand searching, but they were excluded due to the presence of chewing gum in the experimental group. Of the three selected studies, two found a lower caries increment in the treatment groups. Although the findings of the analyzed studies suggest that the use of xylitol‐based candies and lozenges could favor a reduction in caries increment, in general, their consumption did not seem to be effective on the proximal surfaces. Nevertheless, these findings are not supported by strong evidence. Conclusion: This research demonstrates the need for well‐designed randomized clinical studies with adequate control groups and high compliance by the subjects.     

Effects of xylitol, sorbitol and fluoride mouthrinses on glucose clearance in adolescents

The present work describes and analyzes the results of a randomized clinical trial on 98 healthy adolescents (age 18 +/- 0.7 years) in order to evaluate the effects of a 14 days treatment with mouthrinses containing xylitol (0.2%; 0.5% and 1%), sorbitol (1%), NaF (0.1% respectively) on salivary glucose clearance. In all volunteers oral glucose clearance followed an exponential curve as a function of time, which fitted almost exactly to the equation log Ct = log Co - bt from 1 to 16 minutes after sugar rinsing. Xylitol treatment provoked an increase in oral glucose clearance, which was proportional to its concentration in the mouthrinse formula. The average AUC (area under curve) decrease was 9.1% in subjects rinsing with 0.2% xylitol; 21.5% with 0.5% xylitol and 40.0% with 1% xylitol. 1% sorbitol or 0.1% NaF did not modify any of the pharmacokinetical parameters over the same treatment time. The mouthrinses containing 1% xylitol and 0.1% NaF produced the same results as 1% xylitol alone on oral glucose clearance. No significant changes in the salivary flow rate nor in oral health parameters were observed concomitant to the faster oral glucose clearance by xylitol treatment. Since the sugars salivary clearance is part of a process intended to prevent dental caries, our results suggest that xylitol adds another mechanism of action to its well known cariostatic and anticaries properties.     

Fermentation of sugars and sugar alcohols by plaque Lactobacillus strains

Objective

The objective was to analyse the ability of Lactobacillus strains isolated from supragingival plaque of subjects with hyposalivation and from healthy controls to ferment sugars and sugar alcohols.

Material and methods

Fifty strains isolated from interproximal plaque from subjects with radiation-induced hyposalivation (25 strains), subjects with primary Sjögren’s syndrome (16 strains) and from subjects with normal salivary secretion rate (9 strains) were tested. Growth and pH were determined after 24 and 48 h of anaerobic incubation in vials containing basal media with 1 % of glucose, fructose, sucrose, mannitol, sorbitol or xylitol.

Results

No differences between strains isolated from hyposalivated subjects and controls were detected. All strains lowered the pH to <5.0 from fructose and the majority of the strains from glucose and sucrose. A pH of <5.5 was seen for 52 % of the strains using mannitol, 50 % using sorbitol and 36 % using xylitol. The ability to produce acids from sugars and sugar alcohols was highest among strains of Lactobacillus rhamnosus, Lactobacillus casei and Lactobacillus paracasei and lowest among Lactobacillus fermentum strains.

Conclusion

A large number of Lactobacillus strains are able to ferment not only sugars but also the sugar substitutes mannitol, sorbitol and xylitol to pH levels critical for enamel demineralisation.

Clinical relevance

Our findings suggest that products containing mannitol, sorbitol and/or xylitol may contribute to the acidogenic potential of the dental plaque and especially in hyposalivated subjects with high numbers of lactobacilli.     

Factors associated with the acceptance of sugar and sugar substitutes by the public

Acceptance is described in both market and sensory research terminology and recent developments in the fields of applied psychology and physiology are examined for their pertinence to public acceptance of sucrose and its substitutes. Information on the function of sucrose in foods other than beverages is presented with emphasis on salivation as an acceptance factor and attention is drawn to its possible dental significance. Distinctions are made between the sweetening and bulking properties of sucrose and sugar substitutes. Factors having a bearing on the acceptance of sweet foods and the determination of their optimal sugar content are described in detail. While major decreases in sucrose intake in the US resulted from high-fructose corn-sweetener usage in soft drinks, no evidence is yet available to suggest that the use of sugar substitutes of the intense artificial sweetener type has caused any decrease in ordinary sugar consumption. Neither is the consumption of polyols (sorbitol, mannitol, xylitol) high enough in confectionery categories to cause any discernible decrease in sugar usage. The evidence suggests not so much that sugar substitutes may have stopped the growth in sucrose usage, but that new product categories such as diet foods and "sugarless' confections may have been created. These categories were never available to fermentable carbohydrate sweeteners and equivalence in acceptance to sucrose-sweetened products was not an important factor in their growth.(ABSTRACT TRUNCATED AT 250 WORDS)     

Biochemical, microbiologic, and clinical comparisons between two dentifrices that contain different mixtures of sugar alcohols

It has been customary to think that in a dentifrice only a few of its ingredients would be active and have clinically significant effects on dental caries, oral hygiene, and the levels of caries-inducive microorganisms or harmful plaque metabolic products. Therefore, most of the emphasis has been placed on the type of fluorine compounds, abrasives, or similar dentifrice ingredients. This study shows that such common dentifrice components as the humectants, which contribute to the texture, rheologic characteristics, and shelf life of the product, also may affect the type of dental plaque grown on the tooth surfaces between toothbrushings or during long-term neglect of toothbrushing or of oral hygiene. Commonly used humectants include sorbitol, a sugar alcohol of the hexitol type, which is used often in sugarless candies. This study showed that when sorbitol in a dentifrice was replaced by xylitol, a sugar alcohol of the pentitol type, the dental plaque of human subjects contained more ammonia and significantly less bacterial polysaccharides. It is accepted generally that ammonia neutralizes plaque acids and that bacterial polysaccharides are involved in promoting caries. Xylitol-containing dentifrice also reduced the saliva levels of S mutans. The results further indicated that if sorbitol and xylitol could be compared in a short-term dentifrice study that relied on subjective and coarse plaque determinations only, no differences between those dentifrices would be found necessarily. To demonstrate the differences between the experimental dentifrices used in this study, it was necessary to analyze specific plaque components and the salivary levels of S mutans.(ABSTRACT TRUNCATED AT 250 WORDS)     

Xylitol, sweeteners, and dental caries

The purpose of this report was to provide an overview of xylitol and other polyol sweeteners and dental caries for clinicians and to discuss current applications for dental practice and potential community-based public health interventions. Xylitol, like other polyol sweeteners, is a naturally occurring sugar alcohol. Studies suggest polyols are noncariogenic. Furthermore, studies indicate that xylitol can decrease mutans streptococci levels in plaque and saliva and can reduce dental caries in young children, mothers, and in children via their mothers. Food products containing xylitol are now available and have the potential to be widely accessible to consumers to help control rampant decay. Determining whether products contain adequate xylitol amounts for practical use towards prevention is challenging, however, because xylitol content is not clearly labeled. Sufficient evidence exists to support the use of xylitol to reduce caries. Clinicians and dental associations should push for clear recommendations of efficacious dose and frequency of xylitol use and for clear labeling of xylitol content in products to help consumers choose appropriately.     

Effect of three-year consumption of erythritol,xylitol and sorbitol candies on various plaque and salivary caries-related variables

Objective

The objective of the present paper is to report results from oral biologic studies carried out in connection with a caries study.

Methods

Samples of whole-mouth saliva and dental plaque were collected from initially 7- to 8-year-old subjects who participated in a 3-year school-based programme investigating the effect of the consumption of polyol-containing candies on caries rates. The subjects were randomized in three cohorts, consumed erythritol, xylitol, or sorbitol candies. The daily polyol consumption from the candies was approximately 7.5 g.

Results

A significant reduction in dental plaque weight from baseline (p < 0.05) occurred in the erythritol group during almost all intervention years while no changes were found in xylitol and sorbitol groups. Usage of polyol candies had no significant or consistent effect on the levels of plaque protein, glucose, glycerol, or calcium, determined yearly in connection with caries examinations. After three years, the plaque of erythritol-receiving subjects contained significantly (p < 0.05) lower levels of acetic acid and propionic acid than that of subjects receiving xylitol or sorbitol. Lactic acid levels partly followed the same pattern. The consumption of erythritol was generally associated with significantly (p < 0.05) lower counts of salivary and plaque mutans streptococci compared with the other groups. There was no change in salivary Lactobacillus levels.

Conclusion

Three-year consumption of erythritol-containing candies by initially 7- to 8-year old children was associated with reduced plaque growth, lower levels of plaque acetic acid and propionic acid, and reduced oral counts of mutans streptococci compared with the consumption of xylitol or sorbitol candies.     

Can the oral flora adapt to sorbitol?

The number of non-sugar sweeteners that are approved for use in foods and drinks is increasing and manufacturers are using these as alternatives to cariogenic sugar. These non-sugar sweeteners are generally classed as non-cariogenic. The most frequently used non-sugar sweetener is sorbitol, and concern has been expressed that the oral flora may adapt to sorbitol so that it looses its 'safe for teeth' property. The purpose of this review is to describe the mechanisms whereby oral microorganisms, and mutans streptococci in particular, might metabolize sorbitol and to summarize published research into changes in plaque acid production and changes in plaque flora after exposure to sorbitol. Finally, the possibility that some groups of people may be especially 'at-risk' from adaptation of oral microorganisms to sorbitol is considered. It is concluded that frequent or long-term use of sorbitol is unlikely to present any increased risk of dental caries in normal people, but that frequent use of sorbitol may present a small cariogenic risk in people with low salivary flow.     

Sugar consumption and dental caries experience in Kenya

Introduction: There have been claims that dental caries experience and prevalence in Kenya has been increasing as a result of increased sugar consumption. A review of the literature in 1986 failed to link dental caries experience with an increase in gross national sugar consumption. Subsequently, a number of studies were conducted, necessitating further review to examine trends in dental caries experience and to relate this to changes in per capita sugar consumption. Methods: Studies conducted since 1980 for children 3–15 years of age were examined. Dental caries prevalence and experience for 3–5 years’ (deciduous teeth) and 12 years’ (permanent teeth) age groups were analysed. Calculation of per capita sugar consumption was performed using gross national annual sugar consumption for 1969–2009 national population census years. Results: There was a gradual increase in per capita sugar consumption, from 35.5 g/day in 1969 to 60.8 g/day in 2009. Dental caries experience in deciduous teeth for children 3–5 years of age increased from a decayed, missing and filled teeth/decayed and filled teeth (dmft/dft) index of 1.5 in the 1980s to 2.95 in the 2000s. At 12 years of age, caries experience for permanent teeth increased from a DMFT of 0.2 to a DMFT of 0.92 over the same period. Dental caries prevalence for both deciduous and permanent teeth also increased with time. Conclusion: These observations suggest that dental caries prevalence and experience increased with time, in parallel to an increase in per capita sugar consumption. However, a clearer understanding can be derived from longitudinal studies, based on actual household age-specific sugar consumption and dental caries incidence.Key words: Sugar, caries experience, socio-economic development