Use of xylitol chewing gum among Finnish schoolchildren

The preventive, and partly the remineralizing, effect of xylitol was shown in Finland in the Turku Sugar Studies in 1971-73. Since then, several clinical trials in many countries have confirmed these results. In Finland, oral health personnel have recommended daily use of xylitol chewing gum in their dental health education. Moreover, commercial companies have advertised xylitol, emphasizing in particular its caries preventive effects. All Nordic dental associations have given their recommendations for xylitol use. The aim of this study was to describe how this health habit has been adopted by Finnish schoolchildren. The study was part of the comprehensive cross-national survey on Health Behavior in School-aged Children (HBSC Study) - a WHO Collaborative Study. The data were collected using standardized questionnaires to which pupils in grades 5 (11 years), 7 (13 years) and 9 (15 years) responded anonymously in school classrooms during the spring term 1998. The response rate varied between 87% (15-year-old boys) and 94% (11- and 13-year-old girls). Among boys, the percentages of daily users of xylitol chewing gum were 47% (11 years), 46% (13 years), and 44% (15 years), and among girls, 57% (11 years), 65% (13 years), and 69% (15 years), respectively. Use of sugar-sweetened chewing gum was very rare (1%), as also was use of chewing gum with other artificial sweeteners (1%). It may be concluded that since 1991 the use of xylitol chewing gum has further increased in Finland and currently more than a half of all schoolchildren benefit from it.     

Use of xylitol chewing gum among Finnish schoolchildren

The preventive, and partly the remineralizing, effect of xylitol was shown in Finland in the Turku Sugar Studies in 1971-73. Since then, several clinical trials in many countries have confirmed these results. In Finland, oral health personnel have recommended daily use of xylitol chewing gum in their dental health education. Moreover, commercial companies have advertised xylitol, emphasizing in particular its caries preventive effects. All Nordic dental associations have given their recommendations for xylitol use. The aim of this study was to describe how this health habit has been adopted by Finnish schoolchildren. The study was part of the comprehensive cross-national survey on Health Behavior in School-aged Children (HBSC Study)--a WHO Collaborative Study. The data were collected using standardized questionnaires to which pupils in grades 5 (11 years), 7 (13 years) and 9 (15 years) responded anonymously in school classrooms during the spring term 1998. The response rate varied between 87% (15-year-old boys) and 94% (11- and 13-year-old girls). Among boys, the percentages of daily users of xylitol chewing gum were 47% (11 years), 46% (13 years), and 44% (15 years), and among girls, 57% (11 years), 65% (13 years), and 69% (15 years), respectively. Use of sugar-sweetened chewing gum was very rare (1%), as also was use of chewing gum with other artificial sweeteners (1%). It may be concluded that since 1991 the use of xylitol chewing gum has further increased in Finland and currently more than a half of all schoolchildren benefit from it.     

The potential of dental-protective chewing gum in oral health interventions

BACKGROUND: The authors provide an overview of chewing gum as a delivery vehicle for dental-protective agents, highlighting xylitol and its potential application in caries-prevention programs for children. TYPES OF STUDIES REVIEWED: The authors reviewed selected clinical investigations and previous reviews associated with chewing gum containing substances such as calcium, bicarbonate, carbamide, chlorhexidine, fluoride and xylitol and their effects on reducing caries. They searched the MEDLINE database by using the key words "dental caries," "oral health," "calcium," "bicarbonate," "carbamide," "chlorhexidine," "fluoride" and "xylitol." RESULTS: Chewing gum is being used as a delivery vehicle for substances such as calcium, bicarbonate, carbamide, chlorhexidine, fluoride and xylitol to improve oral health and reduce caries. These substances exhibit properties that are protective of the oral environment and mediate common oral diseases. The debate for advocating xylitol use in caries prevention is advancing; however, chewing gum use by young schoolchildren in the United States is hindered by choking hazard concerns and lack of specific xylitol dosing recommendations. CLINICAL IMPLICATIONS: The use of chewing gum containing dental-protective substances, particularly xylitol, in caries-prevention programs can reduce the tooth decay epidemic. Chewing gum use by children in the school setting should be reconsidered.     

Does the presence of xylitol in a sorbitol-containing chewing gum affect the adaptation to sorbitol by dental plaque?

It is known that xylitol inhibits sorbitol metabolism in some bacteria in vitro. The effect of xylitol/sorbitol-containing chewing gum on sorbitol adaptation of dental plaque was therefore examined. Ten subjects used this chewing gum for 12 wk, and plaque was collected before (control plaque) and after (test plaque) the exposure to sorbitol/xylitol. The metabolism of sorbitol by the plaque was examined with ^l4C-labeled sorbitol, and the radioactive metabolites were detected by high-performance liquid chromatography (HPLC). A considerable individual variation in acid formation was found. The mean values of total acids in the test plaque increased, as compared with the control plaque. An adaptation of dental plaque to sorbitol thus occurred in spite of the presence of xylitol in the chewing gum. The concentration of acetic acid predominated over other acids in both the control and test plaques. The proportions of acids expressed in percentage of total acids differed only slightly. Thus, long-term use of xylitol/sorbitol-containing chewing gum did not eliminate the adaptation of dental plaque to sorbitol.     

Caries preventive effect of sugar-substituted chewing gum

OBJECTIVES: The aim of this 3-year community intervention trial was to determine the caries preventive effect of sugar-substituted chewing gum among Lithuanian school children, and to assess compliance with the instructions for gum use. METHODS: A total of 602 children, aged 9-14 years, from 28 school classes in five secondary schools in Kaunas, Lithuania, were given a baseline clinical and radiographic caries examination. The schools were randomly allocated to receive one of the following interventions: sorbitol/carbamide gum; sorbitol gum; xylitol gum; control gum; and no gum. Children in the four active intervention groups were asked to chew at least five pieces of gum per day, preferably after meals. The children were reexamined clinically after 1, 2 and 3 years, and radiographically after 3 years. Self-reported compliance was monitored anonymously four times during the study. RESULTS: A total of 432 children were available at the 3-year clinical follow-up examination. The crude mean 3-year caries increments (DMFS--all stages of lesion formation) were 11.8 for the sorbitol/carbamide gum group; 9.0 for the sorbitol gum group; 8.1 for the xylitol gum group; 8.3 for the control gum group; and 12.4 for the no gum group. The adjusted 3-year caries increments were statistically significantly lower in the sorbitol gum group, the xylitol gum group and the control gum group than in the no gum group, whereas no statistically significant difference was seen between the no gum group and the sorbitol/carbamide gum group. Adjusted 3-year caries increments in the xylitol gum group and the sorbitol gum group did not differ statistically significantly from the caries increments in the control gum group. Compliance with the study protocol was better in School C (xylitol gum) than in the other schools. In all schools, compliance decreased over time. CONCLUSION: The results indicate that the caries preventive effect of chewing sugar-free gum is related to the chewing process itself rather than being an effect of gum sweeteners or additives, such as polyols and carbamide.     

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.     

A 24-month clinical study of the incidence and progression of dental caries in relation to consumption of chewing gum containing xylitol in school preventive programs

The effect of chewing gum containing xylitol on the incidence and progression of dental caries was tested in a sample of 274 children, aged eight and nine years, of low socio-economic status and high caries rate. They were divided into two experimental groups (15% and 65% xylitol chewing gum distributed three times a day at school) and one control group (without chewing gum). The three groups were exposed to the same basic preventive program. Children who chewed gum had a significantly lower net progression of decay (progressions-reversals) over a 24-month period than did the controls. Results for the two groups chewing gum were similar. Chewing xylitol gum had a beneficial effect on the caries process for all types of tooth surfaces, and especially for bucco-lingual surfaces. The two experimental groups had a DMF(S) increment of 2.24 surfaces, compared with 6.06 surfaces for the control group. For this indicator, there was no difference between the two experimental groups. Results for the plaque index were in agreement with those of the DMF(S) increment and the net progression of decay.     

The effect of adding calcium lactate to xylitol chewing gum on remineralization of enamel lesions

The purpose of the study was to determine whether adding calcium lactate to chewing gum containing xylitol enhances remineralization of enamel surfaces using an early caries lesion model. Enamel slabs were cut from human extracted sound teeth and artificial subsurface lesions created within each. Half the enamel slabs were used as controls and stored in a humidifier while half were mounted into oral appliances worn by 10 volunteers (22-27 years old, 2 males and 8 females) in a three-leg trial, during which they wore the appliance without chewing gum, chewed gum containing xylitol + calcium lactate or chewed gum containing only xylitol 4 times a day for 2 weeks. Calcium concentrations in the enamel surfaces of control and test slabs were measured by X-ray spectrometry and degrees of remineralization were calculated. The mean degree of remineralization was greater after chewing xylitol-Ca gum (0.46 +/- 0.10) than after no gum (0.16 +/- 0.14) or after chewing xylitol gum (0.33 +/- 0.10) (p < 0.01). In conclusion, chewing gum containing xylitol + calcium lactate could enhance remineralization of enamel surface compared to chewing gum containing only xylitol or no gum chewing.     

Field trials of preventive regimens in Thailand and French Polynesia

Field demonstration trials of preventive agents or methods are needed so that the effectiveness and acceptability of such methods can be evaluated when used as part of the prevailing system and life style in a particular community. Agents so tested should have already been shown in a clinical trial to have a positive effect. Field demonstration trials differ from clinical trials in having no traditional control group; the study is not 'blind'; there is no special supervision and there is no special selection of participants. Results of two field demonstration trials, one in a population in Thailand with moderate but increasing caries severity and the other in French Polynesia, where caries severity is very high, are reported. The trials compared the effectiveness of various chewing gum formulations with the effectiveness of a fortnightly supervised sodium fluoride rinse. One gum formulation contained fluoride and was sweetened with sucrose or xylitol and sorbitol, the other was fluoride free and was sweetened with xylitol and sorbitol. The important information from these field trials is that a fluoride-containing chewing gum sweetened with xylitol/sorbitol appears to be effective in controlling caries experience even in communities apparently experiencing an increase of the disease; and that the apparent effectiveness was achieved in a field situation subject to all the problems of a programme not under a rigid clinical trial type of control. The fluoride-containing chewing gum-sucrose regime, in both the trials, and the non-fluoride chewing gum-xylitol/sorbitol regime in the French Polynesia trial failed to exhibit any notable preventive effect.     

Xylitol candies in caries prevention: results of a field study in Estonian children

All field studies have unequivocally reported significant reductions in dental caries occurrence associated with the use of chewing gum containing xylitol. No other xylitol products besides chewing gum have so far been tested in field trials. A 5-year follow-up study with 2- or 3-year xylitol consumption periods began in Estonia in 1994 with 740 10-year-old children in 12 schools at baseline examinations. For the study, 3 clusters each including 3-5 schools were formed on the basis of baseline caries experience. The products were used under the supervision of the teachers 3 times per day during school days but not during weekends or during the 3-month summer holiday. The daily dose of xylitol was 5 g in all groups. The children were examined every year in September by two experienced clinicians. Dental caries was recorded according to WHO criteria. After 3 years, all xylitol groups showed a highly significant 35%-60% reduction in caries incident, compared with the corresponding control groups. The differences between candies, between candies and chewing gum, and between 2- and 3-year users in the xylitol groups were non-systematic, indicating no trends between the groups. The results suggest that not only xylitol chewing gum but also xylitol candies are effective in caries prevention, and that a school-based delivery system seems to offer a practical way to distribute and control the use of the xylitol products.     

Long-term effect of xylitol chewing gum on dental caries

About 85% (n = 269) of the subjects who participated in the Ylivieska follow-up studies on the effect of xylitol chewing gum on dental caries during 1982-84 or 1982-85 were re-examined in 1987 for the analysis of possible long-term preventive effects. Further caries reduction was found 2 or 3 yr after the discontinuation of the use of xylitol. The effect was especially marked in girls; the reduction in caries increment in the post-use years was 60% for the 2-yr users, suggesting that more pronounced caries reduction was associated with the most regular use of xylitol. In teeth erupting during the first year of the use of xylitol gum the long-term preventive effect was greater than in other teeth. Several explanations are suggested: lasting effect of the microbiological changes in the mouth, bacterial colonization on newly erupted teeth by organisms other than S. mutans, and/or thorough maturation of the teeth under favorable physico-chemical circumstances. The results suggest that the value of xylitol in caries prevention depends on the timing of the treatment in relation to the development of the dentition.     

Effect of sorbitol- and xylitol-containing chewing gum on salivary microflora, saliva, and oral sugar clearance

Abstract – The effect of frequent use of a sorbitol-containing nicotine chewing gum on saliva secretion rate and buffer capacity and some oral bacteria was studied in 27 patients at a smoking cessation clinic. The effect was compared with that obtained after frequent use of a chewing gum containing xylitol in a second study in 14 subjects. The results showed that sorbitol-containing nicotine chewing gum had no significant effect on salivary numbers of oral streptococci and lactobacilli during a 3-month period of active chewing five times a day. Chewing on xylitol-containing gum caused a significant decrease in salivary S. mutans after 2 months but not after 3 months. No change in secretion rate or buffer capacity was observed in the two studies. Oral sugar clearance time was reduced after 3 months with a statistically significant difference to baseline values in subjects consuming the sorbitol-containing nicotine chewing gum.     

Effect of sorbitol- and xylitol-containing chewing gum on salivary microflora, saliva, and oral sugar clearance

The effect of frequent use of a sorbitol-containing nicotine chewing gum on saliva secretion rate and buffer capacity and some oral bacteria was studied in 27 patients at a smoking cessation clinic. The effect was compared with that obtained after frequent use of a chewing gum containing xylitol in a second study in 14 subjects. The results showed that sorbitol-containing nicotine chewing gum had no significant effect on salivary numbers of oral streptococci and lactobacilli during a 3-month period of active chewing five times a day. Chewing on xylitol-containing gum caused a significant decrease in salivary S. mutans after 2 months but not after 3 months. No change in secretion rate or buffer capacity was observed in the two studies. Oral sugar clearance time was reduced after 3 months with a statistically significant difference to baseline values in subjects consuming the sorbitol-containing nicotine chewing gum.     

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.     

Acceptance of the xylitol chewing gum regimen by preschool children and teachers in a Head Start program: a pilot study

PURPOSE: This pilot study evaluated the acceptance and compliance of a xylitol chewing gum regimen by both children and classroom teachers in a Head Start program. METHODS: Thirty-five children chewed 100% xylitol gum (XyliFresh 100%, Leaf, Inc., 500 Field Dr., Lake Forest, IL 60045 U.S.A.) three times a day over a three week period. Children's acceptance was evaluated using a picture selection test. Teachers' acceptance was evaluated using a questionnaire. The children's and teachers' compliance was evaluated using a daily checklist that was completed by each teacher. RESULTS: Positive ratings were given for xylitol gum chewing (94%) and for taste (86%). Children's acceptance and compliance for chewing was excellent. Children chewed the gum at designated times and none of the children swallowed the gum. Teachers' acceptance of the chewing program was low. Three out of five participating teachers thought the gum chewing disturbed the classroom routine and four were not willing to participate in the program next year. Teachers' compliance was good and they followed by instructions during a three-week period. CONCLUSIONS: This study supports the suggestion that chewing xylitol gum is well accepted by children. Collaboration and education is essential to motivate teachers to adopt and supervise school-based prevention programs.     

The effect of chewing xylitol gum on the plaque and saliva levels of Streptococcus mutans

Eating foods containing sucrose between meals can be highly cariogenic. The use of sucrose substitutes that provide the hedonistic appeal of sucrose, yet are not fermented by the plaque flora to the low pHs that are associated with caries, is a reasonable approach to caries control. Xylitol, a sweet-tasting pentitol, has been reported to cause about an 80% reduction in caries increment when chewed in a gum. The present investigation was designed to determine whether the chewing of xylitol gums affected the salivary and plaque levels of S mutans and lactobacilli. The chewing of xylitol gums for four weeks caused a significant reduction in saliva levels and plaque proportions of S mutans compared with pretreatment values. The levels were also significantly reduced to values obtained by chewing either sorbitol or fructose sweetened gum. The chewing of various gums had no significant effect on the proportions of lactobacilli in the plaque. These findings suggested that the small amounts of xylitol used (about 5 gm) resulted in a suppression of S mutans.     

Turku sugar studies XXI: Xylitol-, sorbitol-, fructose- and sucrose-induced physico-chemical changes in saliva

The aim was to study eventual physico-chemical changes occurring in whole saliva due to sweetened and unsweetened stimulators. The assay was carried out in 10 female subjects with regard to changes of pH, buffering capacity and electrolytes in saliva as influenced by chewing of fructose, sucrose, sorbitol and xylitol gum, gum base and paraffin. The flow rate of saliva was measured in relation to use of xylitol and sucrose chewing gum and unsweetened gum base. These sweeteners increased significantly the salivary flow rate in comparison to the unsweetened gum base. Generally, xylitol and sorbitol on one hand, and sucrose and fructose on the other, behaved in an almost similar way. Increased buffering capacity and elevation of pH in saliva was found in the presence of the polyols tested.     

Turku sugar studies XXI. Xylitol, sorbitol-, fructose- and sucrose-induced physico-chemical changes in saliva.

The aim was to study eventual physico-chemical changes occurring in whole saliva due to sweetened and unsweetened stimulators. The assay was carried out in 10 female subjects with regard to changes of pH, buffering capacity and electrolytes in saliva as influenced by chewing of fructose, sucrose, sorbitol and xylitol gum, gum base and paraffin. The flow rate of saliva was measured in relation to use of xylitol and sucrose chewing gum and unsweetened gum base. These sweeteners increased significantly the salivary flow rate in comparison to the unsweetened gum base. Generally, xylitol and sorbitol on one hand, and sucrose and fructose on the other, behaved in an almost similar way. Increased buffering capacity and elevation of pH saliva was found in the presence of the polyols tested.     

咀嚼木糖醇口香糖对中学生牙齿矿化影响的临床研究

目的：采用激光荧光早期龋探测仪（DIAGNOdent），研究咀嚼木糖醇口香糖对青少年恒牙早期脱矿牙体组织表面再矿化效果的影响。方法：在四川省德阳市随机抽取两所农村中学的13-14岁学生，分别设为空白对照组和试验组；试验组每日餐后咀嚼木糖醇口香糖，空白对照组保持原有口腔卫生措施不变。应用DIAGNOdent分别于基线1、3和6个月观察两组磨牙再矿化情况，试验数据做方差分析。结果：试验组咀嚼木糖醇口香糖1个月后，磨牙颊（舌）面和[牙合]面DIAGNOdent读数与基线相比有显著下降，并且试验组DIAGNOdent读数在3和6个月持续下降；而对照组在1、3、6个月与基线数据比较无显著性差异。结论：应用木糖醇口香糖作为防龋手段，可以促进牙齿表面早期脱矿牙体组织再矿化。     

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.