Abstract
Dental caries is an infectious-contagious disease of multifactorial origin,
which requires interference in one or more of its etiologic factors for
prevention. Within this context, the utilization of xylitol is highlighted,
which was initially studied as a sugar substitute because of its similarity
as regards the sweetening power and later was also employed in other
forms for caries prevention and control. The purpose of this study is
to describe, by means of a review of the specialized literature, how
xylitol can be used as an anticariogenic agent, demonstrating its
properties and possible mechanisms of action in the prevention and
control of dental caries. Analysis of many studies on xylitol revealed
that it is available in many forms: chewing gums or tablets, mouthrinses,
or even associated to toothpastes. Its anticariogenic properties are
related to the reduction in plaque adhesion, remineralization of incipient
carious lesions, and specific reduction of S. mutans.
Introduction
Dental caries is an infectious-contagious disease of
multifactorial origin and requires simultaneous interaction
of three factors for establishment: microorganisms, host and
diet1-3. Prevention of this pathology requires interference on
these etiologic factors by means of strengthening of the
host, which occurs in the presence of fluorides; control of
the microorganisms through professional prophylaxis and
antimicrobial agents; and restriction of dietary carbohydrates,
especially sugar.
Within this preventive context, the utilization of xylitol is
highlighted, which is a polyalcohol known by organic
chemistry since 1890. Xylitol may be found naturally in some
fruits and vegetables and may also be industrially produced4.
The dental studies concerning xylitol were initiated in 1969,
aiming at a possible substitution of sucrose because of the
similar sweetening power. Later it was also employed in other
forms for prevention, allowing interference on the metabolism
of cariogenic microorganisms and improving the protective
mechanisms of the host against tooth decay5. Xylitol is
currently available in many forms such as chewing gums 6-
10, toothpastes11-13, fluoridated mouthrinses14-15, milk16 and it
may also be associated to the use of fluoride17-18.
The utilization of xylitol in chewing gums allows an increase
in the salivary flow, yielding an increase in the buffering
capacity of saliva and a larger and faster increase in the
salivary pH, therefore making the de/remineralization process
more favorable19. The studies on the literature display
possible anticariogenic20 and cariostatic21 properties of
xylitol, which render this sweetener greatly interesting and
important to Preventive Dentistry. However, its utilization in
public services is partially impaired by one of its
disadvantages, namely the high cost21. However, this may
be overcome because of the preventive benefits it provides
to oral health, reducing the expenses with therapeutic
procedures. There is also the gastrointestinal side effect,
caused by the intake of doses above 20g, which can lead to
osmotic diarrhea. Nevertheless, it is known that high doses
of fluoride, which is currently the most widely spread and
used preventive method, can bring about even death of
individuals, a risk that xylitol22 does not present.
The aim of this work is to describe how xylitol can be used as
an anticariogenic agent by means of a review of the
specialized literature, demonstrating its properties and
possible mechanisms of action in the control and prevention
of tooth decay.Top of page.
Literature Review
Studies using xylitol in chewing gums revealed a reduction
of 40% in dental plaque, compared to a group that used
chewing gums containing sugar6.
When chewed between meals, the gums can stimulate the
natural defenses of the organism, which help in the decrease
of caries prevalence together with the non-fermentability of
xylitol by the bacteria7, besides the decrease in the speed of
progression of the lesion20 and reduction in the amount of
cariogenic bacteria23.
Comparison of xylitol chewing gums and pit and fissure
sealants demonstrated no significant difference between
these two preventive methods24.
The utilization of xylitol was also investigated in toothpastes
containing it and NaF/silica, which produced a significant
increase in the anti-caries benefit when compared to a similar
toothpaste without xylitol13. This can be attributed to the
remineralization capacity of human enamel surfaces by means
of toothpastes with fluoride and xylitol12, showing that it is
an efficient association.
Utilization of xylitol in solutions associated or not to fluoride
was also observed, and the results showed that xylitol
isolatedly did not reduce the level of demineralization, yet
such reduction was present when xylitol was associated to
fluoride14 Therefore, mouthrinses containing xylitol seem not
to have anticariogenic effects over the dental plaque25.
Further benefits were observed when xylitol was used in
pills associated to fluoride and sorbitol, which yielded a
reduction in the colonization of S. mutans, leading to a lesser
amount of plaque and less carious lesions in the deciduous
dentition. A reduction in the amount of S. mutans was also
observed when xylitol pills were used in dummies26.
The utilization of substances to avoid dental plaque
formation and adhesion to the dental structure is of great
importance for the maintenance of oral health. Within this
context, xylitol has been playing an important role because
of the following properties: non-fermentability by the
cariogenic bacteria, ability to stimulate certain natural
defenses of human beings7, reduction in the amount of
bacteria9 and their adherence27, which make it a cariostatic
and anti-cariogenic agent3.
Some disadvantages are reported, such as the high cost28
and possible gastrointestinal alterations when consumed in
high doses1.
The utilization of xylitol as a sugar substitute has been mainly
performed in chewing gums, with better results when chewed
between meals2,7 and no differences as to the total or partial
substitution of sugar. The main advantages of the chewing
gum include the great acceptability by children29-30, extended
period of contact with the teeth and saliva2 and permanence
below the critical pH for a very short period16.
The reduction in dental plaque was quantitatively
demonstrated through the utilization of xylitol chewing
gums6,27, which revealed a reduction of 40%6, collaborating
with the reduction in tooth decay8 and prevention of
periodontal disease2. Further, there was remineralization of
incipient carious lesions4,19,21.
Regarding the reduction in the levels of S. mutans, some
studies demonstrated a positive effect of xylitol4,27, differently from another on which such reduction was not observed11.
Some species of S. mutans may adapt themselves to xylitol;
however, these are less pathogenic than those that metabolize
the sucrose. The reduction in the amount of S. mutans and
Lactobacillus occur either with the isolated utilization of
xylitol28 or in association with chlorhexidine20.
The fluoride-xylitol complex demonstrated to be beneficial
for caries prevention in the deciduous dentition, by means
of the utilization of tablets with this complex in babies aged
8 to 16 months old, through the reduction in the amount of S.
mutans26,31.
Being fluoride an acknowledged relevant agent for caries
prevention, several studies were conducted to compare it to
the use of xylitol in toothpastes, which demonstrated the
induction of cariostatic mechanisms10 and provided an
optimal concentration of available fluoride32.
The three-year employment of a toothpaste containing
fluoride and xylitol reduced the number of new restored
surfaces, presenting to be better than the isolated use of
fluoride13.
When mouthrinses containing xylitol were used, a smaller
reduction in salivary pH3 was observed, however other
studies demonstrated that xylitol was not able to reduce the
level of demineralization14 nor did it have any effects on the
dental plaque15.
In conclusion, xylitol can be presented in many forms such
as chewing gums, tablets, mouthrinses, and associated to
fluoride in toothpastes. Its anticariogenic power is due to
the impairment of growth of cariogenic bacteria and
consequent reduction in the acidity of plaque. Besides, it
helps in the remineralization of initial carious lesions, is
specific to S. mutans, well accepted by children and may be
used with beneficial effects in all ages. Top of page.
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