Purpose
The American Academy of Pediatric Dentistry (AAPD) recognizes
the benefits of caries preventive strategies involving
sugar substitutes, particularly xylitol, on the oral health of
infants, children, adolescents, and persons with special
health care needs. This policy is intended to assist oral health
care professionals make informed decisions about the use
of xylitol-based products in caries prevention.
Methods
A MEDLINE literature search was conducted using the
terms “xylitol AND dental caries”, “caries prevention”,
“plaque reduction”, “maternal Streptococcus mutans (MS)
transmission”, and “Streptococcus mutans long term suppression
with xylitol”.
Background
Xylitol is a five-carbon sugar alcohol derived primarily from
forest and agricultural materials. It has been used since the
early 1960’s in infusion therapy for post-operative, burn,
and shock patients; in the diet of diabetic patients; and, most
recently, as a sweetener in products aimed at improved oral
health.1 Dental benefits of xylitol first were recognized in
Finland in 1970, using animal models. 2 The first chewing
gum developed with the aim of reducing caries and improving
oral health was released in Finland in 1975 and in the
United States shortly after. The first xylitol studies in humans,
known as the Turku Sugar Studies,3,4 demonstrated
the relationship between dental plaque and xylitol, as well
as the safety of xylitol for human consumption. These early
studies showed the decayed, missing, and filled (dmf) incidence
in teeth in a sucrose chewing-gum group was 2.92
compared to 1.04 in the xylitol gum group.
The most comprehensive
study with xylitol gum, conducted in 1995,
compared the effect on caries incidence for xylitol, sorbitol,
and sucrose consumption.5 The group that received
100% xylitol gum 5 times/day had significantly lower levels
of sucrose and free sialic acid in whole saliva than at
baseline, and significantly lower plaque index scores.5 The
xylitol group also exhibited the lowest levels of salivary lactobacilli
at endpoint, and this group did not experience the
age-related increase in MS as did the other groups.5
Xylitol studies show varying results in the reduction of
the incidence of caries or MS levels.5-11 Studies suggest xylitol
intake that consistently produces positive results ranged
from 4-10 grams per day divided into 3 to 7 consumption
periods.5-11 Higher amounts did not result in greater reduction
in incidence of caries and may lead to diminishing
anticariogenic results.5-11 Similarly, consumption frequency
of less than 3 times per day at optimal xylitol amount
showed no effect.12-14 Abdominal distress and osmotic diarrhea
have been reported following the ingestion of
xylitol.15-16 Diarrhea has been reported in patients who have
consumed 3-60 grams of xylitol per day.17-21
Xylitol reduces plaque formation and bacterial adherence
(ie, is antimicrobial), inhibits enamel demineralization (ie,
reduces acid production), and has a direct inhibitory effect
on MS. Prolonged use of xylitol appears to select for a “xylitol-
resistant” mutant of the MS cells.22 These mutants
appear to shed more easily into saliva than the parent
strains,23 resulting in a reduction of MS in plaque24 and
possibly hampering their transmission/colonization from
mother to child. Long-lasting effects have been demonstrated
up to 5 years after 2 years of using xylitol chewing
gum.25 Use of xylitol gum by mothers (2-3 times per day)
starting 3 months after delivery and until the child was 2
years old, reduced the MS levels in children up to 6 years
of age, and was significantly better than applying fluoride
varnish or chlorhexidine varnish at 6, 12, and 18 months
after delivery. At 5 years of age, the xylitol group had 70%
reduction in caries (dmf) as compared with the varnish and
chlorhexidine groups. Fluoride varnish alone had little effect
on total salivary levels of MS.25 Some studies suggest
the chewing process may enhance the caries inhibitory effect
of xylitol chewing gum.26-29
Xylitol currently is available in many forms (eg, gums,
mints, chewable tablets, lozenges, toothpastes, mouthwashes,
cough mixtures and nutraceutical products).30
Xylitol chewing gum has been shown to be effective as a
preventive agent; however, the usefulness of other xylitol
products that have not been studied is uncertain and cannot
be recommended at this time because the delivery system
and dose/frequency of use both impact the effectiveness of
products.
Policy Statement
The AAPD:
- supports preventive strategies aimed specifically at long
term caries pathogen suppression and caries (dmf) reduction
using commercially available non-cariogenic
sugar substitutes such as xylitol.
- recommends further research on xylitol to improve the
evidence-based knowledge, the impact of delivery vehicles,
and the identification of optimal prevention
strategies to reduce caries (dmf) and improve the oral
health of children.
- encourages xylitol-containing products to be labeled
clearly to enable dentists and consumers to evaluate
fully their therapeutic value.29
References
1. Makinen KK. Biochemical principles of the use of xylitol
in medicine and nutrition with special
consideration of dental aspects. Experientia Suppl
1978;30:1-16.
2. Muhlemann HR, Regolati B, Marthaler TM. The effect
on rat fissure caries of xylitol and sorbitol. Helv
Odontol Acta 1970;141:48-50.
3. Scheinin A, Makinen KK, Tammisalo E, Rekola M.
Turku sugar studies. XVIII. Incidence of dental caries
in relation to 1-year consumption of xylitol chewing
gum. Acta Odontol Scand. 1975a;335:269-278.
4. Scheinin A, Makinen KK, Ylitalo K. Turku sugar studies.
V. Final report on the effect of sucrose, fructose
and xylitol diets on caries incidence in man. Acta
Odontol Scand 1976;344:179-216.
5. Makinen KK, Benett CA, Hujoel PP, et al. Xylitol
chewing gums and caries rates: A 40-month cohort
study. J Dent Res 1995;7412:1904-1913.
6. Makinen KK, Hujoel PP, Bennett CA, et al. A descriptive
report of the effects of a 16-month xylitol
chewing-gum programme subsequent to a 40-month
sucrose gum programme. Caries Res 1998;322:107-
112.
7. Milgrom P, Ly KA, Roberts M, Rothen M, Mueller
G, Yamaguchi DK. Mutans Streptococci dose response
to Xylitol chewing gum. J Dent Res 2006; 85:177-181.
8. Hujoel PP, Makinen KK, Bennett CA, et al. The optimum
time to initiate habitual xylitol gum-chewing
for obtaining long-term caries prevention. J Dent Res
1999;783:797-803.
9. Makinen KK. The rocky road of xylitol to its clinical
application. J Dent Res 2000;796: 1352-1355.
10. Makinen KK, Chiego DJ, Allen P, et al. Physical,
chemical, and histologic changes in dentin caries lesions
of primary teeth induced by regular use of polyol
chewing gums. Acta Odontol Scand 1998;563:148-
156.
11. Makinen KK, Makinen PL, Pape HR, et al. Conclusion
and review of the Michigan Xylitol Programme
(1986-1995) for the prevention of dental caries. Int
Dent J 1996;461:22-34.
12. Isokangas P. Xylitol chewing gum in caries prevention.
A longitudinal study on Finnish school children. Proc
Finn Dent Soc 1987;83(Suppl 1):1-117.
13. Rekola M. Correlation between caries incidence and
frequency of chewing gum sweetened with sucrose or
xylitol. Proc Finn Dent Soc 1989;851:21-24.
14. Thaweboon S, Thaweboon B, Soo-Ampon S. The effect
of xylitol chewing gum on mutans streptococci in
saliva and dental plaque. Southeast Asian J Trop Med
Public Health 2004;354:1024-1027.
15. Scheie AA, Fijerskov O. Xylitol in caries prevention:
What is evidence for clinical efficacy? Oral Dis 1998;
4: 268-278.
16. Makinen KK. Dietary prevention of dental caries by
xylitol - Clinical effectiveness and safety. J Appl Nutr
1992;44:16-28.
17. Akerblom HK, Koivukangas T, Puuka R, Mononen
M. The tolerance of increasing amounts of dietary
xylitol in children. Int J Vitam Nutr Res Suppl
1982;22:53-66.
18. Giertsen E, Emberland H, Scheie AA. Effects of mouth
rinses with xylitol and fluoride on dental plaque and
saliva. Caries Res 1999;331:23-31.
19. Salminen EK, Salminen SJ, Porkka L, Kwasowski P,
Marks V, Koivistoinen PE. Xylitol vs glucose: Effect
on the rate of gastric emptying and motilin, insulin,
and gastric inhibitory polypeptide release. Am L Clin
Nutr 1989;496:1228-1232.
20. Uhari M, Kontiokari T, Koskela M, Niemela M. Xylitol
chewing gum in prevention of acute otitis media:
Double blind randomized trial. Brit Med J
1996;313(7066):1180-1184.
21. Waler SM, Rolla G. [Xylitol, mechanisms of action and
uses]. Nor Tannelaegeforen Tid 1990;1004:140-143.
22. Trahan L, Mouton C. Selection for Streptococcus
mutans with an altered xylitol transport capacity in
chronic xylitol consumers. J Dent Res 1987;665:982-
988.
23. Trahan L, Soderling E, Drean MF, Chevrier MC,
Isokangas P. Effect of xylitol consumption on the
plaque-saliva distribution of mutans streptococci and the
occurrence and long-term survival of xylitol-resistant
strains. J Dent Res 1992;7111: 1785-1791.
24. Soderling E, Trahan L, Tammiala-Salonen T,
Hakkinen L. Effects of xylitol, xylitol-sorbitol, and
placebo chewing gums on the plaque of habitual xylitol
consumers. Eur J Oral Sci 1997;1052:170-177.
25. Soderling E, Isokangas P, Pienihakkinen K, Tenovuo
J, Alanen P. Influence of maternal xylitol consumption
on mother-child transmission of mutans streptococci: 6
year follow-up. Caries Res 2001;353:173-177.
26. Machiulskiene V, Nyvad B, Baelum V. Caries preventive
effect of sugar-substituted chewing gum.
Community Dent Oral Epidemiol 2001;29:278-288.
27. Scheie AA, Fejerskov O, Danielsen B. The effects of
xylitol-containing chewing gums on dental plaque and
acidogenic potential. J Dent Res 1998;77:1547-1552.
28. Van Loveren C. Sugar alcohols: What is the evidence
for caries-preventive and caries-therapeutic effects?
Caries Res 2004;38:286-293.
29. Ly KA, Milgrom P, Rothen M. Xylitol, sweeteners,
and dental caries. Pediatr Dent 2006;28:154-163.
Discussion 92-98.
30. Lynch H, Milgrom P. Xylitol and dental caries: An
overview for clinicians. J Calif Dent Assoc 2003;
31:205-209.
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