Dental plaque formation and salivary mutans streptococci in schoolchildren after use of xylitol-containing chewing gum

Clinical Effects of Sugar Substitutes on Cariogenic Bacteria: A Systematic Review and Meta-Analysis

BACKGROUND

The use of sugar substitutes in food products has recently increased. Limited information regarding the role of various sugar substitutes in caries prevention was found. This systematic review and meta-analysis was conducted to investigate the effects of sugar substitute consumption on reducing cariogenic bacteria in dental plaque and saliva.

METHODS

We systematically searched PubMed, EMBASE, and Web of Science (inception to July 2023) for prospective controlled trials published in English and investigated the effects of sugar substitute consumption on cariogenic bacteria in dental plaque and saliva. The primary outcome was the changes in cariogenic bacteria. Two independent reviewers screened the papers. Quality was assessed using the Cochrane risk-of-bias tools.

RESULTS

From 977 studies identified, 32 trials were included. Almost half (14/32, 44%) of the included studies had a high risk of bias. Almost all (31/32, 96.88%) were investigations of xylitol and other sugar alcohols (low-intensity sweeteners), such as sorbitol, erythritol, and maltitol. Only one trial investigated stevia, a high-intensity sweetener, whereas no studies on other high-intensity sweeteners, such as sucralose, saccharin, or aspartame, were found. Almost all studies (30/32, 93.75%) showed the consumption of low-intensity sweeteners led to a significant reduction of different types of cariogenic bacteria. The results of the meta-analysis showed that consumption of low-intensity sweeteners led to a significant reduction of cariogenic bacteria in both dental plaque and saliva compared to no treatment.

CONCLUSION

The consumption of low-intensity sweeteners helps reduce cariogenic bacteria in dental plaque and saliva. There is limited clinical evidence regarding the role of high-intensity sweeteners in reducing cariogenic bacteria.

Changes in the Composition of Unstimulated and Stimulated Saliva Due to Chewing Sour Cherry Gum and a Toothbrush Change

BACKGROUND

Our previous studies demonstrated that sour cherry anthocyanins (AC) reduce the salivary count of Streptococcus mutans and inhibit salivary amylase activity within 30 minutes after chewing AC gum. AC gum and changing toothbrushes after scaling reduced the Gram-negative species in the unstimulated salivary microbiota. The present study examined the effect of AC gums on salivary factors, including changes in microbiome.

METHODS

The study was conducted over three weeks with two groups; young adults (18-30) and adults (30-45). Ten participants changed their toothbrushes, while the other 10 participants did not change after the control period. After scaling, all participants received three doses of AC gum daily. The salivary mRNA and protein levels of cytokines, mucins, melatonin, and the microbiota of unstimulated and stimulated saliva were determined by polymerase chain reaction, enzyme-linked immunosorbent assay, and 16S rRNA gene sequencing.

RESULTS

Significantly higher levels of tumor necrosis factor α (TNFα), interleukin-1β (IL-1β), mucin5B (MUC5B), mucin7 (MUC7), and melatonin were detected in stimulated saliva. Correlation analysis of these factors with the microbiota showed positive correlations with the genera Lachnospiraceae, Eikenella, Saccharibacteria_(TM7), Streptococcus, Prevotella, and Haemophilus.

CONCLUSIONS

AC chewing gum has a beneficial effect on the composition of the oral microbiome, and toothbrush replacement leads to changes in the levels of salivary pro-inflammatory cytokines.

High-Throughput Sequencing Analysis of the Changes in the Salivary Microbiota of Hungarian Young and Adult Subpopulation by an Anthocyanin Chewing Gum and Toothbrush Change

The sour cherry contains anthocyanins, which have bactericide action against some oral bacteria (Klebsiella pneumoniae, Pseudomonas aeruginosa). Sour cherry also has antibiofilm action against Streptococcus mutans, Candida albicans, and Fusobacterium nucleatum. Our earlier research proved that chewing sour cherry anthocyanin gum significantly reduces the amount of human salivary alpha-amylase and Streptococcus mutans levels. The microbiota of a toothbrush affects oral health and regular toothbrush change is recommended. A total of 20 healthy participants were selected for the study. We analysed saliva samples with 16S rRNA sequencing to investigate the effect of 2 weeks (daily three times, after main meals) of chewing sour cherry anthocyanin gum-supplemented by toothbrush change in half of our case-control study cohort-after scaling on human oral microbiota. A more stable and diverse microbiome could be observed after scaling by the anthocyanin gum. Significant differences between groups (NBR: not toothbrush changing; BR: toothbrush changing) were evaluated by log₂ proportion analysis of the most abundant family and genera. The analysis showed that lower level of some Gram-negative anaerobic (Prevotella melaninogenica, Porphyromonas pasteri, Fusobacterium nucleatum subsp. vincentii) and Gram-positive (Rothia mucilaginosa) bacteria could be observed in the case group (BR), accompanied by build-up of health-associated Streptococcal network connections.

Effect of chewing gum containing Xylitol and blackberry powder on oral bacteria: A randomized controlled crossover trial

OBJECTIVE

The aim was to determine the effect of chewing gum containing xylitol and freeze-dried blackberry powder on oral bacteria.

DESIGN

This was a randomized, controlled, cross-over study (RCT #: NCT05133557). Fifty participants chewed gum over an 8 h period, four times for 20 min at 2-hour intervals, containing 700 mg xylitol (CG) with or without 50 mg blackberry powder (BG), while wearing a stent containing a sterile enamel chip. After a 1 week washout, participants chewed gum from the other group following the same protocol. The primary outcome was the amount of nine oral bacteria in saliva as determined by quantitative PCR. The secondary outcome was bacteria formed on enamel chips.

RESULTS

Chewing BG for four twenty-minute intervals reduced mean total bacteria load and the relative abundance of six of the nine bacteria studied in saliva (p < 0.05). In comparison, only four bacteria were reduced in abundance in the CG group. After gum chewing and regardless of group, S. sanguinis and A. naeslundii were the predominant bacteria adherent to enamel, with S. mutans representing < 1 % of the total bacteria on enamel.

CONCLUSION

Bacterial loads in saliva were rapidly, differentially, and significantly reduced after one day of chewing BG.

A Comparative Evaluation of Xylitol Chewing Gum and a Combination of IgY + Xylitol Chewable Tablet on Salivary Streptococcus mutans Count in Children: A Double-blind Randomized Controlled Trial

Aim

The study was designed for evaluation and comparison of the efficacy of Xylitol chewing gum and a combination of IgY + Xylitol chewable tablet (Nodecay ^TM) against the “salivary Streptococcus mutans ” count in children.

Materials and methods

About 120 children belonging to 6-12 years age-group were enrolled into this “double-blind randomized control clinical trial” according to the selection criteria. They were randomly assigned to three groups of 40 each: Group I-Xylitol chewing gum, Group II-IgY + Xylitol Chewable tablet (Nodecay ^TM), and Group III-Control. Children in all the groups had to chew the gum/tablet twice daily for 5 minutes during the 15-day period. The salivary samples at baseline, 15 days, 1, 2, and 3 months were inoculated on mitis salivarius bacitracin agar with potassium tellurite medium and the number of colony-forming units (CFUs) of Streptococcus mutans were determined. The data obtained was subjected to statistical analysis.

Result

There was a “significant” difference in the number of “S. mutans CFUs” amongst the three groups at 15 days, 1st month, 2nd month, 3rd month with highest levels of S. mutans CFUs in Group III-Control and least in Group II-IgY + Xylitol (Nodecay^TM).

Conclusion

The combination of IgY + Xylitol (Nodecay^TM) when administered for 15 days had significant efficacy against “S. mutans” when compared to Xylitol and control group.

Clinical significance

Passive immunization with immunoglobulin Y is known not only to decrease the S. mutans count but also confers extended immunity by preventing recolonization of the tooth surface by persistence of the antibodies in saliva.

How to cite this article

Jain RL, Tandon S, Rai TS, et al. A Comparative Evaluation of Xylitol Chewing Gum and a Combination of IgY + Xylitol Chewable Tablet on Salivary Streptococcus mutans Count in Children: A Double-blind Randomized Controlled Trial. Int J Clin Pediatr Dent 2022;15(S-2):S212-S220.

Effects of xylitol chewing gum and candies on the accumulation of dental plaque: a systematic review

OBJECTIVES

A systematic review of published data was conducted with the aim of assessing the effects of xylitol consumption on the amount of dental plaque.

MATERIALS AND METHODS

Electronic and hand searches were performed to find clinical studies concerning the effects of xylitol chewing gum or candies on dental plaque. Prospective randomized controlled clinical trials published between 1971 and 2020 conducted in healthy subjects were included in the review.

RESULTS

The initial search identified 424 xylitol articles. After applying inclusion and exclusion criteria, altogether 14 articles (16 studies) were reviewed. The review identified 12 of the total of 14 xylitol chewing gum studies as having fair or high quality. In 13 of the 14 chewing gum studies, xylitol gum decreased plaque accumulation. In six studies, xylitol gum chewing decreased plaque compared to sorbitol gum, and in three studies compared to gum base/no gum. In three fair-quality studies conducted with xylitol candies, plaque accumulation did not change.

CONCLUSIONS

Habitual xylitol gum chewing appears to show plaque-reducing effects that differ from those of sorbitol gum. This suggests specific effects for xylitol on plaque accumulation. Xylitol candies appear not to decrease plaque. The heterogeneity of the studies warrants further research. Clinical relevance Habitual xylitol gum chewing is likely to decrease plaque.

Effects of xylitol and erythritol consumption on mutans streptococci and the oral microbiota: a systematic review

OBJECTIVE

A systematic review of published data was conducted with the aim of assessing effects of xylitol and erythritol consumption on levels of mutans streptococci (MS) and the oral microbiota.

MATERIALS AND METHODS

Electronic and hand searches were performed to find clinical microbiological studies concerning the consumption of xylitol and erythritol chewing gum or candies, and published between 2000 and 2019. Prospective randomized controlled clinical trials conducted in healthy subjects were included in the review.

RESULTS

The initial search identified 561 xylitol and 83 erythritol studies. After applying inclusion and exclusion criteria, 21 xylitol studies and one erythritol study were reviewed. The review identified nine xylitol studies with a fair or high quality, four conducted in children and five in adults, all demonstrating a decrease in MS levels in association with habitual consumption of xylitol. The three microbiota studies employing multispecies probe approaches revealed no effects for xylitol on the microbiota. The only erythritol study fulfilling the inclusion criteria showed no consistent effects on MS levels.

CONCLUSIONS

Xylitol consumption is likely to decrease MS counts but it may not change the overall microbiota. Xylitol shows thus properties of an oral prebiotic. More studies are needed to demonstrate the effects of erythritol on MS.

Comparative evaluation of Stevia and Xylitol chewing gum on salivary Streptococcus mutans count - A pilot study

Background

Stevia is a natural sweetener which is used as sugar substitute. It has been suggested that stevia may be anticariogenic. However, there is limited research in this regard. Hence, the present study was designed to assess reduction in S. mutans in stevia and xylitol chewing gums. The aim of this study is to evaluate the effectiveness of stevia and xylitol chewing gums on salivary Streptococcus mutans count.

Material and Methods

A randomized triple blinded clinical study with a crossover design included twenty healthy children aged 8-13 years with decayed, missing, and filled teeth (dmft)/DMFT index score ≥ 3. Before the test, unstimulated saliva was collected. Children divided into Group I and II were given Stevia and Xylitol chewing gums respectively. Saliva samples were then collected at 15 min (just after spitting) and after 1 h. The amount of S. mutans in saliva was evaluated using a selective media (TYCSB). The data were subjected to statistical analysis using statistical software IBM SPSS statistics 20.0 (IBM Corporation, Armonk, NY, USA).

Results

Reduction in S. mutans was seen from baseline to 1 hour in both groups in trial and crossover design though intergroup comparison was not statistically significant. There was reduction seen from baseline to 15 minutes and 15 minutes to 1 hour in xylitol and stevia group both in trial and crossover design which was statistically significant.

Conclusions

Stevia containing chewing gum is equally effective to Xylitol chewing gum in reducing salivary S. mutans counts. Key words:Stevia, Xylitol , S. mutans.

Effect of Polyols and Selected Dental Materials on the Ability to Create a Cariogenic Biofilm-On Children Caries-Associated Streptococcus Mutans Isolates

Secondary caries is a disease associated with the formation of biofilm on the border of the tooth and dental filling. Its development is strongly influenced by the dietary sweet foods and the type of dental material. The aim of the study was to assess the effect of sweeteners on the ability of clinical Streptococcus mutans strains to form biofilm on dental materials. Strains were isolated from plaque samples from 40 pediatric patients from the 3-6 ICADS II group. The ability to form biofilm was tested on composite and glass ionomer dental materials used for milk teeth filling in the presence of sucrose, xylitol, sorbitol, and erythritol. The bacterial film mass after 12, 24, 48, and 72 h and the number of bacterial colonies significantly decreased (p < 0.01) compared to the initial value for 5% erythritol and sorbitol on examined materials. A greater inhibitory effect was noted for glass ionomers compared to composites. Sucrose and xylitol supported biofilm formation, while erythritol had the best inhibitory effect. The use of fluoride-releasing glass ionomers exerted an effect synergistic to erythritol, i.e., inhibited plaque formation and the amount of cariogenic S. mutans. Selection of proper type of dental material together with replacing sucrose with polyols can significantly decrease risk of secondary caries development. Erithritol in combination with glass ionomer seems to be the most effective in secondary caries prevention.

A review of polyols - biotechnological production, food applications, regulation, labeling and health effects

Food research is constantly searching for new ways to replace sugar. This is due to the negative connotations of sugar consumption on health which has driven consumer demand for healthier products and is reflected on a national level by the taxation of sugary beverages. Sugar alcohols, a class of polyols, are present in varying levels in many fruits and vegetables and are also added to foods as low calorific sweeteners. The most commonly used polyols in food include sorbitol, mannitol, xylitol, erythritol, maltitol, lactitol and isomalt. Of these, microorganisms can produce sorbitol, mannitol, xylitol and erythritol either naturally or through genetic engineering. Production of polyols by microbes has been the focus of a lot of research for its potential as an alternative to current industrial scale production by chemical synthesis but can also be used for in situ production of natural sweeteners in fermented products using microbes approved for use in foods. This review on the generation of these natural sweetening compounds by microorganisms examines the current understanding and methods of microbial production of polyols that are applicable in the food industry. The review also considers the health benefits and effects of polyol usage and discusses regulations which are applicable to polyol use.

Rebalancing the Caries Microbiome Dysbiosis: Targeted Treatment and Sugar Alcohols

Dental caries is a disease that results from microbiome dysbiosis with the involvement of multiple cariogenic species, including mutans streptococci (MS), lactobacilli, Scardovia wiggsiae, and several Actinomyces species that have the cariogenic traits of acid production and acid tolerance. Sugar consumption also plays an important role interacting with microbiome dysbiosis, determining the fate of caries development. In addition, the MS transmission that encompasses multiple sources can have long-term impacts on the oral microbiome and caries development in children. Intervention in MS transmission in early childhood may promote effective long-term caries prevention. Anticaries regimens aimed against the above mechanisms will be important for successful caries management. Xylitol and erythritol may serve as good components of anticaries regimens as oral microbiome modifiers, sugar substitutes, and agents to prevent MS transmission in early childhood with both oral and systemic benefits. Further studies are needed to elucidate the mechanism of the anticaries effects of xylitol and erythritol with consideration of their impacts on the microbiome and bacterial virulence, in addition to cariogenic bacteria levels as well as their benefits for overall health. On the other hand, the anticaries agent C16G2, specifically targeting Streptococcus mutans, the most common cariogenic bacterial species, has shown good safety for short-term oral topical use and promising effects in reducing S. mutans in vitro and in vivo with the promotion of oral commensal bacteria. Future study on its anticaries effect will need to include its long-term impact on the oral microbiome and effects on other important cariogenic bacteria.

To Determine the Effect of Chewing Gum Containing Xylitol and Sorbitol on Mutans Streptococci and Lactobacilli Count in Saliva, Plaque, and Gingival Health and to Compare the Efficacy of Chewing Gums

Aims and Objective:

The aim of the study is to determine the effect of chewing gum containing xylitol and sorbitol on mutans streptococci and Lactobacilli count in saliva, plaque, and gingival health and to compare the efficacy of chewing gums.

Materials and Methods:

The study was designed as a double-blinded randomized uncontrolled clinical trial with two parallel arms. A total of 80 students consented and completed the study. The test group (X) received corresponding pellets with xylitol and the control group (S) was given pellets containing sorbitol and maltitol three times daily for 30 days. Clinical scoring and saliva samples were collected at three different intervals, at baseline, 15^th, and 30^th day of the study. The outcome measure was plaque index score, gingival index score, salivary mutans streptococci, and Lactobacilli counts. Data collected were analyzed using Statistical Package for the Social Sciences (SPSS version 19.0).

Results:

There was no statistically significant difference between the mean of mutans streptococci count of test and control group at baseline and 15^th day, but there was statistically highly significant difference (P = 0.00) between the mean of mutans streptococci count in test and control group on the 30^th day. The mean of Lactobacilli count, plaque index, and gingival index score between test and control group showed no statistically significant difference at baseline, 15^th day, and 30^th day.

Conclusion:

The results suggest that only xylitol gum may interfere with the mutans streptococci composition and reduce it after continuous use of 30 days effectively as compared to sorbitol gum, but both the gums are equally effective on salivary Lactobacilli, plaque, and gingiva at different intervals.

Effect of Probiotic Yogurt and Xylitol-Containing Chewing Gums on Salivary S Mutans Count

BACKGROUND AND AIMS

In addition to improving gastrointestinal health and intestinal microflora, probiotic bacteria have been recently suggested to decrease cariogenic agents in the oral cavity. The aim of this study was to investigate the effects of probiotic yogurt and xylitol-containing chewing gums on reducing salivary Streptococcus mutans levels.

STUDY DESIGN

This randomized clinical trial recruited 50 female students with over 10⁵ colony forming units S. mutans per milliliter of their saliva. The participants were randomly allocated to two equal groups to receive either probiotic yogurt containing Lactobacillus acidophilus ATCC 4356 andBifidobacteriumbifidum ATCC 29521 (200 g daily) or xylitol-containing chewing gums (two gums three times daily after each meal; total xylitol content: 5.58 g daily) for three weeks. At baseline and one day, two weeks, and four weeks after the interventions, saliva samples were cultured on mitis-salivarius-bacitracin agar and salivary S. mutans counts were determined. Data were analyzed with independent t-tests, analysis of variance, and Fisher's least significant difference test.

RESULTS

In both groups, S. mutans counts on the first day, second week, and fourth weeks after the intervention were significantly lower than baseline values (P < 0.05). The greatest level of reduction in both groups was observed in the second week after the intervention. Moreover, although the reduction was greater in probiotic yogurt consumers, the difference between the two groups was not statistically significant.

CONCLUSION

Probiotic yogurt and xylitol-containing chewing gums seem to be as effective in reduction of salivary S. mutans levels. Their constant long-term consumption is thus recommended to prevent caries.

Effect of Chewing Xylitol Containing and Herbal Chewing Gums on Salivary Mutans Streptococcus Count among School Children

Background:

The present study aims to assess and compare the reduction in salivary Mutans Streptococci counts after chewing Xylitol, herbal and placebo gums among high school children.

Methods:

The study was conducted among 72 school children (12–15 years) from 3 randomly selected schools (blocks). Xylitol, herbal and placebo gums were randomly allocated to 3 blocks. Subjects were instructed to chew one pellet four times a day for 21 days. The mean reduction in salivary Streptococcus mutans count was assessed.

Results:

The 100% Xylitol sweetened chewing gum “Xylitol”has shown statistically significant reduction in salivary Mutans Streptococci colony forming units at the end of 21 days (P < 0.01). The reduction was not statistically significant in herbal and placebo chewing gum.

Conclusions:

Hundred percentage Xylitol sweetened chewing gum was found to be more effective in reducing salivary Mutans Streptococci count when compared to herbal and placebo chewing gums.

The effects of funoran-containing xylitol chewing gum on dental plaque

The aim of the study was to investigate the efficacy of the addition of funoran to xylitol chewing gum in dental plaque. In a double-blinded randomized controlled clinical trial, 36 health adults (21–30 years old), who volunteered after informed consent, with >105 colony-forming units/ml mutans streptococci (MS) at baseline, were assigned randomly into one of three parallel study groups: xylitol+funoran gum (group A), sucrose gum group (group B), and control group (no gum have been provided; group C). The pH value, flash weight, and MS of dental plaque were recorded at baseline and after 2 weeks of treatment. A statistically significant reduction (p<0.05) of salivary MS was displayed in group A after the intervention when compared with baseline. The weight of plaque was reduced after 2 weeks of treatment (p=0.032) in group A. There was no significance in plaque pH value before and after the treatment in any group. Daily funoran-containing xylitol chewing gum application significantly reduced the dental plaque volume and caries pathogen counts in the oral cavity, suggesting that the use of funoran-containing xylitol chewing gum may be a useful adjunct for caries control.

Comparison of the effect of two sugar-substituted chewing gums on different caries- and gingivitis-related variables: a double-blind, randomized, controlled clinical trial

OBJECTIVE

The aim of this study was to compare the effect of two sugar-substituted chewing gums besides toothbrushing on different clinical, microbiological, and biochemical caries- and gingivitis-related variables.

MATERIALS AND METHODS

The study was designed as a double-blind, randomized, controlled trial with three parallel arms. A total of 130 dental students, who volunteered after signing an informed consent, were randomly allocated to receive one of the following interventions: hexitol-sweetened gum containing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), pentitol-sweetened gum containing no CPP-ACP, and control group with no gum. Subjects within the experimental groups chewed two gum pellets for 20 min three times a day after meals. The daily consumption level of both polyols was 6.0 g. Clinical examinations and salivary samplings were conducted at baseline and after 30 days of gum use. Pre- and post-intervention stimulated whole saliva samples were quantified for calcium/phosphate ionic concentration, total facultative bacterial load, Streptococcus mutans/Lactobacillus spp. counts, and Gram-negative percentage.

RESULTS

A statistically significant reduction in visible plaque score was displayed in the hexitol/CPP-ACP gum group after the intervention when compared with baseline, but the order of the effect was in the same order as the differences between the groups at baseline. A similar tendency was seen in both the pentitol/non-CPP-ACP gum and control groups regarding total salivary facultative bacterial load and S. mutans count, but median values of these parameters were more significantly reduced in the pentitol/non-CPP-ACP gum group in comparison with those of the control group. Alterations of salivary Lactobacillus spp. were demonstrated only in the pentitol/non-CPP-ACP gum group.

CONCLUSION

Although these findings might indicate that a 30-day protocol of daily chewing of pentitol-sweetened gum containing no CPP-ACP might have some a reducing effect on the salivary levels of facultative bacteria, S. mutans and Lactobacillus spp., there was only a marginal, if any, benefit from the chewing gums under study on some microbiological caries- and gingivitis-related variables.

CLINICAL RELEVANCE

Taking into account that for transferring results into clinically relevant conclusions the findings need to be strong and consistent, adhering to single significant differences appears not appropriate. Hence, the clinical significance of chewing gums as an adjunctive tool for daily oral care remained questionable.

Xylitol concentrations in artificial saliva after application of different xylitol dental varnishes

Objective

The present study analyzed xylitol concentrations in artificial saliva over time after application of varnishes containing 10% and 20% xylitol.

Material and Methods

Fifteen bovine enamel specimens (8x4 mm) were randomly allocated to 3 groups (n=5/group), according to the type of varnish used: 10% xylitol, 20% xylitol and no xylitol (control). After varnish application (4 mg), specimens were immersed in vials containing 500 µL of artificial saliva. Saliva samples were collected in different times (1, 8, 12, 16, 24, 48 and 72 h) and xylitol concentrations were analyzed. Data were assessed by two-way repeated-measures ANOVA (p<0.05).

Results

Colorimetric analysis was not able to detect xylitol in saliva samples of the control group. Salivary xylitol concentrations were significantly higher up to 8 h after application of the 20% xylitol varnish. Thereafter, the 10% xylitol varnish released larger amounts of that polyol in artificial saliva.

Conclusions

Despite the results in short-term, sustained xylitol releases could be obtained when the 10% xylitol varnish was used. These varnishes seem to be viable alternatives to increase salivary xylitol levels, and therefore, should be clinically tested to confirm their effectiveness.

A practice-based study on the effect of a short sucrose/xylitol exposure on survival of primary teeth caries free

BACKGROUND

In a randomized double-blinded clinical trial, preschool children used sucrose or xylitol chewing gum regularly for 2 months to study the preventive effect of xylitol on acute otitis media (AOM). Salivary mutans streptococci (sm) levels of the children were measured before the exposure. Those with ≥10(5) sm CFU in 1 mL saliva were considered to have high sm levels (sm+); and those with <10(5) CFU low sm levels (sm-).

AIM

This practice-based study aims to evaluate long-term dental effects of the sucrose/xylitol exposure on primary teeth.

DESIGN

For analyses, individuals were divided into sub groups according to their study group in the original AOM trial and baseline sm levels. Outcome events owing to dental caries of their all primary teeth were followed from dental records up to 12 years. Survival of teeth caries free was determined by Kaplan-Meier method and analysed statistically by Wilcoxon testing.

RESULTS

Survival of primary teeth caries free of children with high sm levels in the sucrose group was significantly shorter compared with all other groups when followed until shedding.

CONCLUSIONS

Two months' regular exposure to sucrose was sufficient to induce dental caries in primary teeth of children with elevated sm levels at baseline.

Clinical Efficacy and Effects of Xylitol Wipes on Bacterial Virulence

The aim of the study was to investigate whether xylitol-wipe use in young children prevented caries by affecting bacterial virulence. In a double-blinded randomized controlled clinical trial, 44 mother-child pairs were randomized to xylitol-wipe or placebo-wipe groups. Salivary mutans streptococci levels were enumerated at baseline, 6 months, and one year. Ten mutans streptococci colonies were isolated and genotyped from each saliva sample. Genotype-colonization stability, xylitol sensitivity, and biofilm formation of these isolates were studied. Despite a significant reduction in new caries at one year in the xylitol-wipe group, no significant differences were found between the two groups in levels of mutans streptococci. Children in the xylitol-wipe group had significantly fewer retained genotypes (p = 0.06) and more transient genotypes of mutans streptococci (p = 0.05) than those in the placebo-wipe group. At one year, there was no significant difference in the prevalence of xylitol-resistant genotypes or in biofilm formation ability of mutans streptococci isolates between the two groups. The mechanism of the caries-preventive effect of xylitol-wipe use may be related to the stability of mutans streptococci colonization. Further studies with genomic characterization methods are needed to determine specific gene(s) that account for the caries-preventive effect of xylitol.

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 a sugar-free chewing gum containing magnolia bark extract on different variables related to caries and gingivitis: a randomized controlled intervention trial

The effect of magnolia bark extract (MBE) on different variables related to caries and gingivitis administered daily through a sugar-free chewing gum was evaluated. The study was performed with healthy adult volunteers at high risk for caries as a randomized double-blind interventional study. 120 subjects with a salivary mutans streptococci (MS) concentration ≥10(5) CFU/ml and presence of bleeding on probing >25% were enrolled and divided into three groups: magnolia, xylitol and control. The study design included examinations at baseline, after 7 days, after 30 days of gum use and 7 days after the end of gum use. Plaque pH was assessed using the strip method following a sucrose challenge. Area under the curve (AUC(5.7) and AUC(6.2)) was recorded. Whole saliva was collected and the number of salivary MS (CFU/ml) was counted. Bleeding on probing was recorded as a proxy of dental plaque. Data were analyzed using ANOVA repeated measures. Magnolia gum significantly reduced plaque acidogenicity, MS salivary concentration and gingival bleeding compared to xylitol and control gums. Subjects from the magnolia and xylitol groups showed both MS concentration (p = 0.01 and 0.06, respectively) and AUC(5.7) (p = 0.01 and 0.04, respectively) to be significantly lower compared to baseline. Thirty-day use of a chewing gum containing MBE showed beneficial effects on oral health, including reduction of salivary MS, plaque acidogenicity and bleeding on probing.

Effects of orally administered lactoferrin and lactoperoxidase-containing tablets on clinical and bacteriological profiles in chronic periodontitis patients

This study was undertaken to evaluate the effect of oral administration of lactoferrin (LF) and lactoperoxidase-(LPO-)containing tablet on periodontal condition. Seventy-two individuals with chronic periodontitis were randomly assigned to take either bovine LF and LPO-containing tablets (test group, n = 37) or control tablets (control group, n = 35) every day for 12 weeks. Periodontal parameters and levels of subgingival plaque bacteria, human and bovine LF, and endotoxin in gingival crevicular fluid (GCF) were evaluated at baseline, 1 week, 4 weeks, and 12 weeks. Significant differences were observed in GCF levels of bovine LF between the test and control groups throughout the study (P < .05). However, clinical and bacteriological parameter values proved comparable between the two groups at 1 week to 12 weeks. Therefore, the effect of oral administration of LF and LPO-containing tablets might be weak on periodontal and bacteriological profile in this study.

Effects of xylitol as a sugar substitute on diabetes-related parameters in nondiabetic rats

Abstract The present study was examined the effects of xylitol feeding on diabetes-associated parameters in nondiabetic rats. Seven-week-old male Sprague-Dawley rats were randomly divided into three groups: control (five rats), sucrose (six rats), and xylitol (six rats). Animal had free access to a commercial rat pellet diet, and ad libitum water, 10% sucrose solution, and 10% xylitol solution were supplied to the control, sucrose, and xylitol groups, respectively. After 3 weeks of feeding of experimental diets, food intakes were significantly (P<.05) lower in the sucrose and xylitol groups compared with the control group. Drink intake was significantly higher in the sucrose group but significantly lower in the xylitol group compared with the control group. Body weight gain was significantly lower in the xylitol group compared with the sucrose group. Weekly nonfasting blood glucose was significantly increased, but fasting blood glucose was significantly decreased, in the sucrose group compared with the control and xylitol groups. Significantly better glucose tolerance was observed in the xylitol group compared with the control and sucrose groups. Serum insulin and fructosamine concentrations were not significantly influenced by the feeding of xylitol or sucrose. Relative liver weight and liver glycogen were significantly increased in the xylitol group compared with the sucrose group, whereas no difference was observed between the xylitol and control groups. Serum total cholesterol and low-density lipoprotein-cholesterol were significantly decreased in the sucrose and xylitol groups, and serum triglyceride of the xylitol group, but not the sucrose group, was significantly increased compared with the control group. Data of this study suggest that xylitol can be a better sweetener than sucrose to maintain diabetes-related parameters at a physiologically safer and stable condition.

Evaluation of the Antimicrobial Effectiveness and the Effect of Dosage and Frequency of Sugar-free Chewing Gums on Streptococcus mutans Count: An in vivo Microbiological Study

The aim of the present study was to evaluate the antimicrobial efficacy of sugar-free chewing gums and also to assess the effect of dosage and frequency of intake of sugar-free gums on Streptococcus mutans count.

Method : The sample consisted of 30 subjects, divided into two groups AI and AII. Each group consisted of 15 subjects. Group AI chewed two sugar-free chewing gum, twice daily for 20 minutes (Total four gums daily) and group AII chewed two sugar-free chewing gum, four times daily for 20 minutes (Total eight gums daily) and saliva sample was collected and agar plates were inoculated for Streptococcus mutans colony count. The study was carried for a week’s time and saliva samples collected were baseline, day 1 morning and evening, day 4 evening, day 7 morning and evening.

Results : After the gum was chewed, it was observed that the colony count started to reduce when compared with baseline in both the groups. The fall in Streptococcus mutans count was statistically highly significant with p < 0.001 in both the groups. When comparing between group AI (dosage 4 gums daily) and group AII (dosage 8 gums daily), the fall in Streptococcus mutans count for both the groups was not statistically significant with p > 0.05. It was concluded that there was reduction in the level of salivary Streptococcus mutans, but was not statistically significant by increasing the dosage and frequency of intake of sugar-free chewing gums.

Therefore, we recommend that dosage of sugar-free chewing gums can be restricted to four gums instead of eight gums per day.

Xylitol gum, plaque pH and mutans streptococci

DESIGN

This was a randomised clinical trial (note that the initial screening used a cluster randomised in part design).

INTERVENTION

A total of 176 children (7-9 years old) with high MS scores were randomised into equal groups. For 6 months the xylitol group chewed five times during the day, 11.6 grams of a mixed gum containing 36.6% xylitol and other polyols (34.5%). while the control group chewed an identical dose of a non xylitol gum sweetened with a mixture of different polyols (71.1%).

OUTCOME MEASURE

At baseline, 3 months, 6 months and 9 months (3 months after chewing) children were assessed for both plaque acidogenicity (after sucrose challenge) and salivary MS.

RESULTS

Statistically significant differences were found between both groups at 3, 6 and 9 months, in 'area under the curve' (AUC) graphs, with lower plaque pH values in the xylitol group at 3 and 6 months and decreasing difference at 9 months. There was no significant difference between the maximum pH fall in both groups, and only small differences in minimum pH values at 3 and 6 months. There was significantly lower MS level in the xylitol compared with the control group. In addition there was a significant relationship between changes in MS levels, and changes in AUC.

CONCLUSIONS

This randomised clinical trial suggests that the use of high-dose xylitol chewing gum has beneficial effects on plaque pH and MS in children at high risk of caries.

Evidence-based caries, risk assessment, and treatment

Dental caries is a dietary and host-modified biofilm disease process, transmissible early in life that, if left untreated, will cause destruction of dental hard tissues. If allowed to progress, the disease will result in the development of caries lesions on tooth surfaces, which initially are noncavitated (eg, white spots), and eventually can progress to cavitation. The "medical model," where the etiologic disease-driving agents are balanced against protective factors, in combination with risk assessment, offers the possibility of patient-centered disease prevention and management before there is irreversible damage done to the teeth. This article discusses how to use evidence supporting risk assessment and management strategies for the caries process.

The impact of polyol-containing chewing gums on dental caries: a systematic review of original randomized controlled trials and observational studies

BACKGROUND

The authors conducted a systematic review of original studies that was designed to assess the impact of polyol-containing chewing gum on dental caries compared with the effect with no chewing gum.

REVIEW METHODS

The authors searched MEDLINE, The Cochrane Library and Google Scholar up to May 2008 to identify peer-reviewed articles that compared polyol-containing chewing gum with no chewing gum. The authors extracted study characteristics, data on incremental dental caries and quality by consensus. Data on prevented fraction (PF) were pooled across studies.

RESULTS

The results of 19 articles with data from 14 study populations showed that the use of xylitol, xylitol-sorbitol blend and sorbitol were associated with mean PF (95 percent confidence interval) of 58.66 percent (35.42-81.90), 52.82 percent (39.64-66.00) and 20.01 percent (12.74-27.27), respectively. For the sorbitol-mannitol blend, it was 10.71 percent (-20.50-41.93), which was not statistically significant. Sensitivity analyses confirmed the robustness of the findings.

CLINICAL IMPLICATIONS

Although research gaps exist, particularly on optimal dosing and relative polyol efficacy, research evidence supports using polyol-containing chewing gum as part of normal oral hygiene to prevent dental caries.

Association of chlorhexidine and fluoride for plaque control and white spot lesion remineralization in primary dentition

BACKGROUND

Plaque control and caries arrest still remain a challenge for dentists.

OBJECTIVE

This study was conducted to assess the effect of the combined use of chlorhexidine varnish and fluoride varnish on the visible plaque index (VPI) and white spot lesion (WS) remineralization in primary dentition.

METHODS

A total of 80 caries-active preschool children (3-5 years) were randomly divided into four groups. Group 1 received a chlorhexidine varnish application every week during 4 weeks. Group 2 received a fluoride varnish application every week during 4 weeks. Group 3 received alternated applications of chlorhexidine and fluoride varnish during 4 weeks. Group 4 served as control (without any type of cariostatic agent).

RESULTS

There was no statistically significant difference in the VPI and WS remineralization among the groups after 1 month. However, 3 months follow-up demonstrated that group 3 (chlorhexidine + fluoride) showed significantly better results for both VPI and WS remineralization.

CONCLUSION

The combined application of chlorhexidine and fluoride varnishes is more effective on plaque and remineralization of incipient caries after 3 months than the same agents applied separately.

Xylitol gummy bear snacks: a school-based randomized clinical trial

BACKGROUND

Habitual consumption of xylitol reduces mutans streptococci (MS) levels but the effect on Lactobacillus spp. is less clear. Reduction is dependent on daily dose and frequency of consumption. For xylitol to be successfully used in prevention programs to reduce MS and prevent caries, effective xylitol delivery methods must be identified. This study examines the response of MS, specifically S. mutans/sobrinus and Lactobacillus spp., levels to xylitol delivered via gummy bears at optimal exposures.

METHODS

Children, first to fifth grade (n = 154), from two elementary schools in rural Washington State, USA, were randomized to xylitol 15.6 g/day (X16, n = 53) or 11.7 g/day (X12, n = 49), or maltitol 44.7 g/day (M45, n = 52). Gummy bear snacks were pre-packaged in unit-doses, labeled with ID numbers, and distributed three times/day during school hours. No snacks were sent home. Plaque was sampled at baseline and six weeks and cultured on modified Mitis Salivarius agar for S. mutans/sobrinus and Rogosa SL agar for Lactobacillus spp. enumeration.

RESULTS

There were no differences in S. mutans/sobrinus and Lactobacillus spp. levels in plaque between the groups at baseline. At six weeks, log10 S. mutans/sobrinus levels showed significant reductions for all groups (p = 0.0001): X16 = 1.13 (SD = 1.65); X12 = 0.89 (SD = 1.11); M45 = 0.91 (SD = 1.46). Reductions were not statistically different between groups. Results for Lactobacillus spp. were mixed. Group X16 and M45 showed 0.31 (SD = 2.35), and 0.52 (SD = 2.41) log10 reductions, respectively, while X12 showed a 0.11 (SD = 2.26) log10 increase. These changes were not significant. Post-study discussions with school staff indicated that it is feasible to implement an in-classroom gummy bear snack program. Parents are accepting and children willing to consume gummy bear snacks daily.

CONCLUSION

Reductions in S. mutans/sobrinus levels were observed after six weeks of gummy bear snack consumption containing xylitol at 11.7 or 15.6 g/day or maltitol at 44.7 g/day divided in three exposures. Lactobacillus spp. levels were essentially unchanged in all groups. These results suggest that a xylitol gummy bear snack may be an alternative to xylitol chewing gum for dental caries prevention. Positive results with high dose maltitol limit the validity of xylitol findings. A larger clinical trial is needed to confirm the xylitol results.

TRIAL REGISTRATION

[ISRCTN63160504].

Effect of xylitol and xylitol-fluoride lozenges on approximal caries development in high-caries-risk children

AIM

To evaluate the effect of xylitol- and xylitol/fluoride-containing lozenges on approximal caries development in young adolescents with high caries risk.

STUDY DESIGN

A 2-year double-blind trial with two parallel arms and a nonrandomized reference group.

MATERIAL AND METHODS

One hundred and sixty healthy 10- to 12-year-old children with high caries risk were selected. After informed consent, they were randomly assigned into a xylitol and a xylitol/fluoride group. They were instructed to take two tablets three times a day (total xylitol and fluoride dose 2.5 g and 1.5 mg, respectively). The compliance was checked continuously and scored as good, fair, or poor. A reference no-tablet group was also selected (n = 70) for group comparison. The outcome measure was approximal caries incidence.

RESULTS

The dropout rate was 28%, and 41% exhibited a good compliance with the study protocol. No statistically significant differences in caries incidence could be found between the study groups (P > 0.05). Among a subgroup of children who demonstrated good compliance, the mean DeltaDMFSa value was significantly lower in the xylitol/fluoride group compared to the xylitol group, 1.0 +/- 2.3 vs. 3.3 +/- 4.6 (P < 0.05), while no difference could be displayed between any of the study groups and the reference group (P > 0.05).

CONCLUSION

The results from this 2-year trial did not support a self-administered regimen of xylitol- or xylitol/fluoride-containing lozenges for the prevention of approximal caries in young adolescents with high caries risk.

Effect of chewing gums containing xylitol or probiotic bacteria on salivary mutans streptococci and lactobacilli

The aim was to evaluate the effect of xylitol and probiotic chewing gums on salivary mutans streptococci (MS) and lactobacilli (LB). The material consisted of 80 healthy young adults (21-24 years) who volunteered after informed consent. They were assigned by random into one of four parallel study groups: A, probiotic gum group; B, xylitol gum group; C, probiotic + xylitol gum group; and D, placebo gum group. The gums were taken three times daily after meals, and the intervention period was 3 weeks. The probiotic gums contained two strains of Lactobacilli reuteri (ATCC 55730 at a dose of 1 x 10(8) CFU/gum and ATCC PTA 5289 at a dose of 1 x 10(8) CFU/gum), and each pellet of the xylitol gum contained approximately 1.0 g xylitol as single sweetener. Pretreatment and posttreatment samples of stimulated whole saliva were collected and quantified for MS and LB with chair-side kits. A statistically significant reduction (p < 0.05) of salivary MS was displayed in group A and B after the intervention when compared with baseline. A similar but nonsignificant tendency was seen in group C. No alterations of salivary LB was demonstrated in any group. In conclusion, daily chewing on gums containing probiotic bacteria or xylitol reduced the levels of salivary MS in a significant way. However, a combination of probiotic and xylitol gums did not seem to enhance this effect.