Xylitol and caries: the collaborative WHO oral disease preventive programme in Hungary

The aim of this study was to assess the practical value of peroral xylitol at low to moderate dosage as a caries preventive measure. The trial was planned as a field study to test the feasibility of partial sucrose substitution in the relatively uniform conditions expected to occur in institutionalized children. The caries increment in the experimental group (X-group) was compared with the increments in other groups following the systemic administration of fluoride in milk or drinking water (F-group), and conventional dental treatment procedures alone (C-group). Conventional treatment was also provided for children in the X- and F-groups who used in an unsupervised manner a fluoride-containing dentifrice. The dentifrice used by the X-group also contained 10 per cent xylitol. The C-group used predominantly fluoride-free dentifrices. At baseline there were 990 children in the study. At the end of the 3-year study period there were 689 subjects. The caries scoring into four main categories was carried out yearly according to WHO criteria. The analysis of the data showed highly significant differences between the X-, F- and C-groups when measuring caries activity as the increment of DMF teeth and tooth surfaces, and also as the increment rate assessing the true caries incidence in a biostatistical sense. These results were obtained in conditions where caries prevalence and incidence continued to be high. The observations indicate that peroral xylitol has a cariostatic effect.     

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 sucrose and xylitol diets on dentin formation and caries in rat molars

To investigate the effects of a high sucrose diet and xylitol on secondary dentinogenesis and dentinal caries, a part of the sucrose in a high-cariogenic diet was replaced by xylitol. Fifty-four 3-wk-old Wistar rats were labeled with tetracycline and divided into groups. One group received a high sucrose diet (43% sucrose). In two other groups 5% and 20% of the sucrose was replaced by xylitol. A control group received non-cariogenic food. Six weeks later the mandibles were sectioned sagittally. Schiff staining was used to classify the caries, and the areas of dentin formed during the experiment and dentinal caries in first and second molars were measured planimetrically. The high sucrose diet reduced dentin formation of the molars, and this reduction was further increased by xylitol. Caries initiation and dentinal caries progression were significantly reduced by 20% xylitol, whereas only a slight reduction in caries progression was observed with 5% xylitol. Also, a negative correlation between the dentin formation and dentinal caries progression was observed in the high sucrose and 5% xylitol groups. In conclusion, xylitol together with high sucrose reduced dentin formation and dentinal caries progression, and the effect was dose-dependent.     

Turku sugar studies XX. Microbiological findings and plaque index values in relation to 1-year use of xylitol chewing gum.

The aim was to study possible alterations in the microbial flora of plaque and saliva in relation to partial substitution of dietary sucrose with xylitol. The development of plaque index values was observed simultaneously. These observations were carried out during a 1-year clinical trial, the effects of sucrose (S) and xylitol (X) chewing gum on the incidence of dental caries being observed in 100 young adults. Paraffin-stimulated saliva samples were diluted stepwise and cultivated on Rogosa S.L. agar and Sabouraud agar aerobically. Lyophilized dental plaque samples were cultivated on phenol red agar under anaerobic and aerobic conditions. The pH-values were measured after incubating the mixed plaque flora for 1 and 7 days in the presence of various sugars. Both the arithmetic and geometric means of the total CFU values on Rogosa S.L. agar decreased in the S-group at the 6-month phase but returned to the starting level after one year, whereas in the X-group they decreased or remained on the starting level. At the 6-month phase the difference between the groups was significant (U-test, p = 0.0013) and almost significant (U-test, p = 0.0569) at the end of the study. No significant differences or changes could be seen between or within the groups on Sabouraud agar. The geometric mean values of S. sanguis and S. mutans as well as the total CFU values on phenol red agar decreased considerably in both the S- and X-groups, but no significant differences could be detected in any of the streptococcal counts between the groups. The pH of the carbohydrate-containing culture media infected with mixed dental plaque significantly decreased, with the exception of the xylitol containing ones in which the pH values were not lowered even after 7 days' incubation. A significant decrease in plaque formation in relation of chewing per se was demonstrable. The difference in the plaque index values equalling or exceeding 2 was significant between the S- and X-groups. No bacterial adaptation to utilize xylitol occurred during the trial.     

Collaborative WHO xylitol field studies in Hungary. VII. Two-year caries incidence in 976 institutionalized children

The aim was to assess caries increment as influenced by partial substitution of sucrose by xylitol (X group) over a 2-year period in comparison with systemic fluoride (F group) and restorative treatment only (C group). The study differed from the 3-year field study of the same series primarily in that existing base-line differences were eliminated because the protocol required that all the new subjects entering the institutions in the 1st year were to be included for a 2-year trial. During this period the number of dropouts was 243 (19.9% of all subjects), the final material consisting of 976 children (6-12 years old). The 2-year DMFS increment was 3.8 in the X group, 4.8 in the F group, and 6.0 in the C group. The corresponding ratio (RS) between caries incidence and the tooth surface population at risk was RSX, 4.5; RSF, 5.5; and RSC, 7.5. The xylitol regimen resulted in a lower increment of caries than measured in the F and C groups (p less than 0.001; convariance analysis, with base-line prevalence, number of permanent teeth, and visible plaque index as covariants.     

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.     

Effect of xylitol gum on the level of oral mutans streptococci of preschoolers: block-randomised trial

Objectives: To assess the influence of xylitol chewing gum consumption on mutans streptococci level of 3–4 years old Japanese preschoolers. Methods: 248 participants were examined regarding caries‐related factors at baseline and were followed up at 6, 9, and 12 months after the baseline: assessors were blinded, subjects were open labelled and blocked parallel randomised; 142 were selected to use xylitol gum for 3 months (from months 6 to 9) and 106 were controls. Results: 161 participants were analysed (xylitol n = 76, control n = 85). Nineteen caries‐related variables, including xylitol gum consumption, were analysed for any association with the main outcome, plaque mutans streptococci scores development within the intervention period, by logistic regression. Six showed statistically significant associations by univariate analysis (P < 0.05). However, only xylitol gum consumption remained a significant negative association (P < 0.05) by multiple analyses. Interestingly, over 10% xylitol group children experienced diarrhoea, which was larger than previous investigations. Conclusion: Xylitol gum is effective in avoiding increased plaque mutans streptococci in young children.     

Three-year Root Caries Increments: Implications for Clinical Trials

Seven hundred and ninety-six adult subjects (mean age, 39.9 years) received visual-tactile examinations for root caries over a three-year period. All subjects were employed or were the spouses of employees and resided in fluoride-deficient communities on Long Island, New York. During the three-year observation period, 81.4 percent of the subjects did not develop root caries. The 18.6 percent who developed root caries averaged 0.8 DFS/year. The subjects' ages and baseline root DFS status were associated with the development of a root DFS increment. The older the patient, especially aged 45 and older, the greater was the risk of developing root lesions or having root fillings placed. Subjects who had a root DFS score at baseline also were more likely to experience a root DFS increment. It is recommended that when designing clinical trials of agents purported to inhibit root caries, preselection criteria for the study population should consider the subjects' ages and past history of root lesions.     

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.     

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 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.     

乳牙菌斑液短链有机酸含量与龋易感性的研究分析

目的:检测并研究蔗糖溶液漱口前后乳牙菌斑液乳酸、乙酸、丙酸含量与龋病易感性的关系。方法:32名3～5岁完整乳牙列幼儿,无龋组12例(dft=0且CSI=0),有龋组20例(dft(0且CSI(0)。用高效液相色谱仪分离测定10%蔗糖溶液漱口前后菌斑液中乳酸、乙酸、丙酸浓度。结果:10%蔗糖溶液漱口前后,有龋组与无龋组比较,菌斑液乳酸浓度差值有统计学意义(P<0.01)。有龋组漱口前后菌斑液乳酸浓度差值与dft、CSI呈正相关关系(r=0.455,P<0.05;r=0.474,P<0.05)。结论:蔗糖溶液漱口前后乳牙菌斑液乳酸含量的变化与个体龋易感性相关。     

Collaborative WHO xylitol field studies in Hungary. I. Three-year caries activity in institutionalized children

The aim of this 3-year field study was to assess the value of partial substitution of sucrose with peroral xylitol (14-20 g/day) as a caries-preventive measure (X group) in comparison with systemic administration of fluoride (F group) and restorative treatment procedures solely (C group). An F dentifrice was used unsupervised in the X and F groups, the former containing 10% xylitol. The C group used customary, predominantly F-free dentifrices distributed by the local health authorities. The final material consisted of 689 institutionalized children (6-11 years). Caries was scored yearly in duplicate by two continuously calibrated teams. At base line the X group had a significantly higher caries prevalence than the F and C groups. The 3-year DMFS increment was 4.2 in the X group, 6.5 in the F group, and 7.7 in the C group. The corresponding ratio (RS) between caries incidence and the tooth surface population at risk was RSx, 4.9; RSF, 6.6; and RSC, 8.6. It is concluded that dietary xylitol in solid sweets resulted in a lower increment of caries than obtained in the F and C groups (p less than 0.001, covariance analysis, with base-line prevalence, number of permanent teeth, and visible plaque index as covariants).     

The effect of non-cariogenic sweeteners on the prevention of dental caries: a review of the evidence.

The role of sugar substitutes such as xylitol and sorbitol in the prevention of dental caries has been investigated in several clinical studies. The purpose of this report is to review the current published evidence regarding the relationship between sugar substitutes and dental caries. A literature search was conducted using MEDLINE and EMBASE and included studies published from 1966 to 2001. Studies that included human subjects and were published in English were included in this review. A total of fourteen clinical studies were reviewed that evaluated the effect of sorbitol or xylitol or the combination of both sugar substitutes on the incidence of dental caries. Most of the reports were of studies conducted with children outside of the United States. These studies demonstrated a consistent decrease in dental caries, ranging from 30 to 60 percent, among subjects using sugar substitutes as compared to subjects in a control group. These caries rate reductions were observed in subjects using xylitol or sorbitol as the sugar substitute in chewing gum or toothpaste. The highest caries reductions were observed in subjects using xylitol. These findings suggest that the replacement of sucrose with sorbitol and xylitol may significantly decrease the incidence of dental caries.     

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.     

Field studies on sugar substitutes

Four field studies assessing the caries preventive value of partial substitution of sucrose by xylitol or a mixture of xylitol and sorbitol were recently conducted. The trials (in Thailand, Hungary and two in French Polynesia) had certain common features, i.e. protocols approved by the WHO; low intake of polyol(s); non-randomized young study populations, differing baseline caries prevalences between groups; and planned duration of 32-36 months. Analysis of the findings was facilitated through the use of rates to measure caries increments expressed as DMF teeth and surface counts in relation to the numbers of teeth at risk. Irrespective of baseline differences, all studies revealed, in comparison to known methods, that partial substitution of sucrose was associated with a preventive effect.     

Caries-preventive effect of dentifrices containing various types and concentrations of fluorides and sugar alcohols

The caries-inhibiting effect of unsupervised daily use of four different toothpastes was compared in a 3-year clinical and microbiological study: (1) 0.8% sodium monofluorophosphate (MFP) with 3% xylitol and 6% sorbitol; (2) 0.03% sodium fluoride with 3% xylitol and 6% sorbitol; (3) 0.8% MFP with 9% sorbitol, and (4) 0.03% sodium fluoride with 9% sorbitol. In all 284 children, 12-13 years old at baseline, took part in the study. After 3 years, no statistically significant differences were found between the different toothpaste groups concerning either development of initial or gross caries lesions or number of mutans streptococci and lactobacilli in saliva. However, children with no detectable approximal caries at baseline, who used the MFP toothpaste with the xylitol-sorbitol mixture, showed a lower (p less than 0.05) caries increment as compared with children who used the MFP toothpaste with sorbitol alone.     

Oral health in 5-year-old Swedish children

ABSTRACT The purpose of the study was to investigate the oral health of a group of 5-year-old children who had previously been examined in this respect at 3 and 4 years of age. The results were compared with those in an aged-matched reference group. The study included examination of caries and gingivitis, occlusion, presence of lactobacilli and C. albicans in plaque samples, flow rate, pH and buffer effect of stimulated saliva, and certain data on past prophylaxis and oral habits. Caries was found in 76 % of the children in the study group (S-group) and in 78% in the reference group (R-group). No significant differences were found in caries or gingival indices, in oral habits or prophylactic measures between the two groups. Buffer effect and pH of stimulated saliva were negatively correlated with deft and deft. Lactobacilli were demonstrated in 37 % and C. albicans in 12 % of the plaque samples. Various sucking habits were still present in 25 % of the S-group and 22 % of the R-group. Forty-nine and 46 % respectively had been given a daily supply of fluoride tablets by their parents for at least 2 years.     

Xylitol in caries prevention: what is the evidence for clinical efficacy?

Xylitol has attracted much attention as an alternative sweetener. Essentially all clinical studies concerning the effect of xylitol on caries development consent to its non-cariogenicity and to the beneficial effect of substituting sucrose with xylitol in chewing gums and sweets. However, claims of anti-caries or therapeutic effects, and superiority of xylitol over other polyols are still to be confirmed by well designed and conducted studies from independent research groups.     

The caries-preventive effect of xylitol/maltitol and erythritol/maltitol lozenges: results of a double-blinded, cluster-randomized clinical trial in an area of natural fluoridation

International Journal of Paediatric Dentistry 2012; 22: 180–190 Objective. Xylitol studies suggest caries reductions in the order of 50%. Based on animal/microbial studies, erythritol potentially has caries‐preventive properties. However, clinical studies are required to confirm this.The aim of the study was to investigate the additional caries‐preventive effect of xylitol/maltitol and erythritol/maltitol lozenges delivered at school, relative to controls receiving comprehensive prevention, in a low‐caries prevalence population. Methods. A 4‐year, cluster‐randomized, double‐blinded clinical trial. Five hundred and seventy‐nine 10‐year‐old consenting subjects from 21 schools were randomly assigned to one of five groups. Four groups used the lozenges on school days, in three teacher‐supervised sessions daily, over 1 or 2 years. The daily amount was 4.7 g/4.6 g for xylitol/maltitol and 4.5 g/4.2 g for erythritol/maltitol. The groups received free examinations and care in the public health centre. Four hundred and ninety‐six children were analysed. The main outcome measure was dentin caries increment based on a clinical examination at 4 years since the start. The groups were compared in relation to the increment using hierarchical logistic regression to adjust for potential clustering. Results. Use of xylitol/maltitol or erythritol/maltitol lozenges did not result in caries reduction. A strong relationship between baseline caries prevalence and the 4‐year increment was observed (OR = 7.38; 95% CI: 3.78–14.41). Conclusions. The results suggest that in relatively low‐caries conditions the school‐based use of xylitol/maltitol or erythritol/maltitol lozenges would not have additional caries‐preventive effect when compared with comprehensive prevention.