Long-Term Effect of Xylitol Gum Use on Mutans Streptococci in Adults

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.

Effects of sugar-free polyol chewing gums on gingival inflammation: a systematic review

OBJECTIVES

A systematic review of published data was conducted with the aim of assessing the effects of sugar-free polyol chewing gums on gingival inflammation.

MATERIALS AND METHODS

Electronic and hand searches were performed to find clinical studies concerning the effects of sugar-free chewing gums on gingival scores. Prospective randomized controlled clinical trials published between 1971 and 2021 were included in the review.

RESULTS

The initial search identified 46 erythritol, 102 xylitol, 23 sorbitol, and nine maltitol chewing gum articles. After applying inclusion and exclusion criteria, seven xylitol chewing gum studies, one sorbitol, and one maltitol chewing gum study with either high or fair quality were reviewed. In five out of the seven xylitol studies, xylitol gum decreased gingival scores. In two studies, xylitol decreased gingival scores compared to a polyol gum, and in three studies compared to no gum/gum base. As for sorbitol and maltitol, only sorbitol gum chewing showed a small decrease in gingival scores compared to the controls.

CONCLUSIONS

Habitual xylitol gum chewing may reduce gingival inflammation. The low number of studies and their heterogeneity provide clear indications that the effects of sugar-free polyol chewing gums on gingival inflammation need further, well-controlled studies.

CLINICAL RELEVANCE

Sugar-free chewing gums, especially xylitol gum, may function as adjuncts to toothbrushing for reducing gingival inflammation, but the evidence so far is inconclusive.

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.

Erythritol inhibits the growth of periodontal-disease-associated bacteria isolated from canine oral cavity

Periodontal disease (PD) is the most common oral disease that is caused by infection with periodontal-disease-associated bacteria (PDAB) such as Porphyromonas gulae and Porphyromonas macacae in dogs as well as in humans. Unlike humans, most dogs do not follow daily oral hygiene routine, and this results in many dogs being affected by PD. Thus, to prevent PD, it is important to control PDAB. Xylitol is a sugar alcohol that inhibits the growth of oral bacteria in humans. However, xylitol is poisonous to dogs and can lead to hypoglycemia and hepatic failure. Herein, we show the inhibitory effect of erythritol, a sugar alcohol that can be used safely in dogs, on the growth of PDAB isolated from dogs with PD. Oral bacteria were isolated from the oral cavities of dogs with PD, and the distribution of PDAB was evaluated. Interestingly, Porphyromonas gingivalis, a bacterium typically responsible for PD in humans, was not isolated from dog samples. The bacteriostatic effect of erythritol supplementation was investigated on isolated PDAB in vitro. Our results show that erythritol exert bacteriostatic effects on PDAB comparable to xylitol. Thus, application of erythritol can be suggested to control PDAB in dogs in the future.

A Systematic Review and Meta-Analysis of the Role of Sugar-Free Chewing Gum on Plaque Quantity in the Oral Cavity

Background

The aim of this systematic review of published literature was to answer the research question, “What is the difference in the level of plaque quantity, in adults and children who chew sugar-free gum (SFG), compared with those who do not chew SFG, who do not chew gum, or who use alternatives such as probiotics or fluoride varnish?”.

Methods

The systematic review [registered on PROSPERO 2018 (CRD42018094676)] included studies on adults and children with chewing of SFG as the main intervention, where “sugar” referred to monosaccharides and disaccharides. Included studies were in English and corresponded to primary research published between 1946 and 2020. The search conducted spanned all relevant databases using both Medical Subject Headings (MESH) and free text with combinations of “chewing gum,” “sugar-free,” “caries,” “xerostomia,” “periodontal disease.”

Results

Eight articles included plaque quantity as part of their outcomes. Meta-analysis showed that SFG significantly reduced plaque quantity (effect size−0.778; 95% CI−1.167 to−0.39). The correlation between the baseline and the end of study data was assumed to be 0.95 for the control and 0.65 for the SFG group. A sensitivity analysis was conducted with the pre- to post-test correlation, set at 0.95 for the SFG group. This gave an effect size of−1.098 (95% CI−1.539 to−0.656) with I² = 89.73%. When looking more specifically at xylitol gum, the results of the meta-analysis showed that it significantly reduced plaque quantity (effect size−0.743; 95% CI−1.148 to−0.338). There was a high degree of heterogeneity between studies with I² = 86.0%.

Conclusion

There is some evidence that chewing sugar-free gum, in particular xylitol SFG, reduces the quantity of plaque in the oral cavity in comparison to non SFG chewing or no chewing controls. Further research with improved design, lengthier timeframes and higher number of participants should be considered.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=94676.

A systematic review and meta-analysis of the role of sugar-free chewing gum on Streptococcus mutans

Background

Preventive strategies targeting Streptococcus mutans may be effective in reducing the global burden of caries. The aim of the current systematic review of published literature was to determine the difference in level of Streptococcus mutans in adults and children who chew sugar-free gum (SFG), compared with those who did not chew gum, who chewed a control gum or received alternatives such as probiotics or fluoride varnish.

Methods

Systematic review (PROSPERO registration No. CRD42018094676) of controlled trials with adult and child participants where chewing of SFG was the main intervention. Databases searched (1 Jan 1946 to 31 August 2020): MEDLINE, EMBASE, PsycINFO, Scopus, Web of Science, Allied and Complimentary Medicine Database, Cochrane Central Register of Controlled Trials (CENTRAL), Open Grey, PROSPERO and the Cochrane library of systematic reviews. ‘Search terms included Medical Subject Headings, and free text to cover the following range of constructs: chewing gum, sugar free, oral health, caries, xerostomia, periodontal disease. Data extraction and Risk of Bias assessment was undertaken by three researchers using a modified version of the Cochrane RoB tool (version 1). Data synthesis was conducted using meta-analysis in STATA.

Results

Thirteen studies of SFG with micro-organisms as outcomes were identified. The use of SFG significantly reduced the load of Streptococcus mutans (effect size − 0.42; 95% CI − 0.60 to − 0.25) compared to all controls. In seven of the 13 studies the confidence intervals of the effect size estimate included zero, suggesting no effect of the intervention. Twelve trials used xylitol gum only as the basis of the intervention; xylitol gum significantly reduced the load of Streptococcus mutans (effect size − 0.46; 95% CI − 0.64 to − 0.28) in comparison to all controls. There was a moderate level of heterogeneity across the included studies. No adverse effects were recorded.

Conclusion

Chewing SFG reduces the load of Streptococcus mutans in the oral cavity in comparison to non-chewing controls. Considering the degree of variability in the effect and the moderate quality of the trials included, there is a need for future research exploring the use SFG as a preventive measure for reducing the cariogenic oral bacterial load.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01517-z.

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.

Anticariogenic potential of white cheese, xylitol chewing gum, and black tea

Objective

This study aimed to examine the effects of these foods on plaque pH and the potential development of tooth decay.

Materials and Methods

Plaque pH was measured using the sampling method before and after 1, 5, 10, 20, 30, 45, and 60 min following consumption of these foods individually and after rinsing with a 10% sucrose solution. Statistical analysis was performed using one-way ANOVA and Tukey honestly significant difference post hoc tests (α = 0.05).

Results

Although there were statistically significant differences in all test groups except the BT (P = 0.620) and sucrose + XCG (P = 0.550) groups in time, none of the participants chosen for this study were having a plaque pH value anywhere close to the critical value (pH = 5.5).

Conclusion

WC, BT, and XCG are advisable as anticariogenic foods because pH values are not below critical value.

Effect of three different compositions of topical fluoride varnishes with and without prior oral prophylaxis on Streptococcus mutans count in biofilm samples of children aged 2-8 years: A randomized controlled trial

BACKGROUND

Various strategies for controlling caries focus on disrupting the interaction between risk factors. Of these, fluoride varnish has been shown to reduce the colony-forming (CFU) units and water-insoluble extracellular polysaccharide amount. Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and xylitol-containing fluoride varnishes have recently gained importance as caries-protective fluoride varnishes.

AIM

This study aims to assess and compare the reduction in Streptococcus mutans count in biofilm samples after topical application of three different fluoride varnishes and to evaluate the effect of oral prophylaxis prior to fluoride varnish application.

MATERIALS AND METHODS

Sixty healthy children with no active caries, in the age group of 2-8 years, were randomly divided into Group A = fluoride varnish containing CPP-ACP; Group B = fluoride varnish containing xylitol; and Group C = fluoride varnish with 0.9% difluorosilane; further, the groups were divided into two subgroups, namely A1, B1, and C1 with prior oral prophylaxis and A2, B2, and C2 without oral prophylaxis. Plaque samples were collected at baseline, 1^st month, and 3^rd month; cultured; and incubated, and CFU/ml was calculated.

RESULTS

Data were compiled, and CFU/ml was analyzed by independent t-test, paired t-test, and one-way ANOVA. There was no statistical difference between the fluoride groups. Furthermore, no statistically significant difference was seen between the subgroups.

CONCLUSION

Fluoride varnish containing CPP-ACP showed higher reduction in S. mutans count followed by xylitol-containing fluoride varnish and Fluor Protector^®. There was no effect of prior oral prophylaxis on the efficacy of fluoride varnish.

Comparative evaluation of 0.2% Chlorhexidine Mouthwash, Xylitol Chewing Gum, and Combination of 0.2% Chlorhexidine Mouthwash and Xylitol Chewing Gum on Salivary Streptococcus mutans and Biofilm Levels in 8- to 12-Year-Old Children

AIM

To assess the effect of combining 0.2% chlorhexidine (CHX) mouthwash with xylitol (XYL) chewing gum on Streptococcus mutans and biofilm levels among 8- to 12-year-old children.

MATERIALS AND METHODS

Sixty children aged 8 to 12 years were selected with moderate and high salivary S. mutans levels. They were divided into three groups of 20 children each: (1) XYL group where the subjects chewed XYL twice daily; (2) CHX where rinsing was done twice daily; and (3) combination of XYL and CHX group (XYL+CHX) where both the agents were used once daily. The S. mutans colony-forming units (CFUs) were counted by using the mitis salivarius agar plate at the beginning of the study and at 15 days, 1, 2, and 6 months from the start of the study.

RESULTS

The XYL+CHX group showed the maximum reduction in both the biofilm and S. mutans scores throughout the study period.

CONCLUSION

The XYL+CHX combination reduced both the biofilm and S. mutans score significantly better than either XYL chewing gums or CHX mouthwash used alone.

HOW TO CITE THIS ARTICLE

Syed M, Chopra R, Shrivastava V, Sachdev V. Comparative evaluation of 0.2% Chlorhexidine Mouthwash, Xylitol Chewing Gum, and Combination of 0.2% Chlorhexidine Mouthwash and Xylitol Chewing Gum on Salivary Streptococcus mutans and Biofilm Levels in 8- to 12-Year-Old Children. Int J Clin Pediatr Dent 2016;9(4):313-319.

Xylitol for preventing acute otitis media in children up to 12 years of age

BACKGROUND

Acute otitis media (AOM) is the most common bacterial infection among young children in the United States. There are limitations and concerns over its treatment with antibiotics and surgery and so effective preventative measures are attractive. A potential preventative measure is xylitol, a natural sugar substitute that reduces the risk of dental decay. Xylitol can reduce the adherence of Streptococcus pneumoniae (S pneumoniae) and Haemophilus influenzae (H influenzae) to nasopharyngeal cells in vitro. This is an update of a review first published in 2011.

OBJECTIVES

To assess the efficacy and safety of xylitol to prevent AOM in children aged up to 12 years.

SEARCH METHODS

We searched CENTRAL (to Issue 12, 2015), MEDLINE (1950 to January 2016), Embase (1974 to January 2016), CINAHL (1981 to January 2016), LILACS (1982 to January 2016), Web of Science (2011 to January 2016) and International Pharmaceutical Abstracts (2000 to January 2016).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs of children aged 12 years or younger where xylitol supplementation was compared with placebo or no treatment to prevent AOM.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials from search results, assessed and rated study quality and extracted relevant data for inclusion in the review. We contacted trial authors to request missing data. We noted data on any adverse events of xylitol. We extracted data on relevant outcomes and estimated the effect size by calculating risk ratio (RR), risk difference (RD) and associated 95% confidence intervals (CI).

MAIN RESULTS

We identified five clinical trials that involved 3405 children for inclusion. For this 2016 update, we identified one new trial for inclusion. This trial was systematically reviewed but due to several sources of heterogeneity, was not included in the meta-analysis. The remaining four trials were of adequate methodological quality. In three RCTs that involved a total of 1826 healthy Finnish children attending daycare, there is moderate quality evidence that xylitol (in any form) can reduce the risk of AOM from 30% to around 22% compared with the control group (RR 0.75, 95% CI 0.65 to 0.88). Among the reasons for dropouts, there were no significant differences in abdominal discomfort and rash between the xylitol and the control groups. Xylitol was not effective in reducing AOM among healthy children during a respiratory infection (RR 1.13, 95% CI 0.83 to 1.53; moderate quality evidence) or among otitis-prone healthy children (RR 0.90, 95% CI 0.67 to 1.21; low-quality evidence).

AUTHORS' CONCLUSIONS

There is moderate quality evidence showing that the prophylactic administration of xylitol among healthy children attending daycare centres can reduce the occurrence of AOM. There is inconclusive evidence with regard to the efficacy of xylitol in preventing AOM among children with respiratory infection, or among otitis-prone children. The meta-analysis was limited because data came from a small number of studies, and most were from the same research group.

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.

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.

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

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.

One-to-one dietary interventions undertaken in a dental setting to change dietary behaviour

BACKGROUND

The dental care setting is an appropriate place to deliver dietary assessment and advice as part of patient management. However, we do not know whether this is effective in changing dietary behaviour.

OBJECTIVES

To assess the effectiveness of one-to-one dietary interventions for all ages carried out in a dental care setting in changing dietary behaviour. The effectiveness of these interventions in the subsequent changing of oral and general health is also assessed.

SEARCH METHODS

The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 24 January 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE via OVID (1950 to 24 January 2012), EMBASE via OVID (1980 to 24 January 2012), CINAHL via EBSCO (1982 to 24 January 2012), PsycINFO via OVID (1967 to 24 January 2012), and Web of Science (1945 to 12 April 2011). We also undertook an electronic search of key conference proceedings (IADR and ORCA between 2000 and 13 July 2011). Reference lists of relevant articles, thesis publications (Dissertations Abstracts Online 1861 to 2011) were searched. The authors of eligible trials were contacted to identify any unpublished work.

SELECTION CRITERIA

Randomised controlled trials assessing the effectiveness of one-to-one dietary interventions delivered in a dental care setting.

DATA COLLECTION AND ANALYSIS

Abstract screening, eligibility screening and data extraction decisions were all carried out independently and in duplicate by two review authors. Consensus between the two opinions was achieved by discussion, or involvement of a third review author.

MAIN RESULTS

Five studies met the criteria for inclusion in the review. Two of these were multi-intervention studies where the dietary intervention was one component of a wider programme of prevention, but where data on dietary behaviour change were reported. One of the single intervention studies was concerned with dental caries prevention. The other two concerned general health outcomes. There were no studies concerned with dietary change aimed at preventing tooth erosion. In four out of the five included studies a significant change in dietary behaviour was found for at least one of the primary outcome variables.

AUTHORS' CONCLUSIONS

There is some evidence that one-to-one dietary interventions in the dental setting can change behaviour, although the evidence is greater for interventions aiming to change fruit/vegetable and alcohol consumption than for those aiming to change dietary sugar consumption. There is a need for more studies, particularly in the dental practice setting, as well as greater methodological rigour in the design, statistical analysis and reporting of such studies.

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.

Xylitol for preventing acute otitis media in children up to 12 years of age

BACKGROUND

Acute otitis media (AOM) is the most common bacterial infection among young children in the United States with limitations and concerns over its treatment with antibiotics and surgery. Therefore, effective preventative measures are attractive. A potential preventative measure is xylitol, a natural sugar substitute that reduces the risk for dental decay. Xylitol can reduce the adherence of Streptococcus pneumoniae (S. pneumoniae) and Haemophilus influenzae (H. influenzae) to nasopharyngeal cells in vitro.

OBJECTIVES

To assess the efficacy and safety of xylitol to prevent AOM in children up to 12 years old.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1950 to August Week 1, 2011), EMBASE (1974 to August 2011), CINAHL (1982 to August 2011), Health and Psychosocial Instruments (1985 to August 2011), Healthstar (OVID) (1966 to August 2011) and International Pharmaceutical Abstracts (2000 to August 2011).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs of children aged 12 years or younger where xylitol supplementation was compared to placebo or no treatment to prevent AOM.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials from search results, assessed and rated study quality and extracted relevant data for inclusion in the review. We contacted trial authors to request missing data. We noted data on any adverse events of xylitol. We extracted data on relevant outcomes and estimated the effect size by calculating risk ratio (RR), risk difference (RD) and associated 95% confidence intervals (CI).

MAIN RESULTS

We identified four studies of adequate methodological quality that met our eligibility criteria. In three RCTs with a total of 1826 healthy Finnish children attending day care, there was a reduced risk of occurrence of AOM in the xylitol group (in any form) compared to the control group (RR 0.75; 95% CI 0.65 to 0.88). The fourth RCT included 1277 Finnish day care children with a respiratory infection and found no effect of xylitol on reducing the occurrence of AOM (RR 1.13; 95% CI 0.83 to 1.53). Xylitol chewing gum was superior to xylitol syrup in preventing AOM among healthy children (RR 0.59; 95% CI 0.39 to 0.89) but not during respiratory infection (RR 0.68; 95% CI 0.43 to 1.07). There was no difference between xylitol lozenges and xylitol syrups in preventing AOM among healthy children (RR 0.77; 95% CI 0.53 to 1.11) or among children during respiratory infection (RR 0.74; 95% CI 0.47 to 1.14). Similarly, no difference was noted between xylitol chewing gum and xylitol lozenges in preventing AOM among healthy children (RR 0.73; 95% CI 0.47 to 1.13) or among children during respiratory infection (RR 0.92; 95% CI 0.59 to 1.46). Among the reasons for drop-outs, there were no significant differences in abdominal discomfort and rash between the xylitol and the control groups.

AUTHORS' CONCLUSIONS

There is fair evidence that the prophylactic administration of xylitol among healthy children attending day care centres reduces the occurrence of AOM by 25%. This meta-analysis is limited since the data arise from a small number of studies, mainly from the same research group.

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.

Use of chewing gum containing 15% of xylitol and reduction in mutans streptococci salivary levels

Frequent use of Xylitol may decrease the S. mutans levels. However, very little is known about whether this effect on the levels of cariogenic bacteria is maintained after the interruption of short-term usage of xylitol. This study aimed at evaluating changes in mutans streptococci (MS) salivary levels after using a chewing gum containing xylitol. Twelve volunteers harboring > or = 10(5) CFU MS/ml saliva levels were asked to chew Happydent-xylit for 5 minutes, 5 X/day, for 30 days. Saliva samples were collected at baseline, at 30 days after xylitol usage began, and at 30 days beyond its interruption. MS salivary levels were estimated. The average salivary levels of MS in the ten subjects who completed the study were 13.17 (NL-CFU) at baseline (A). After the 30 days experimental period (B), this average decreased to 9.45 (NL-CFU). Nine of ten subjects studied showed a reduction in MS salivary levels in relation to baseline, whereas salivary levels were maintained in the remaining subject. At thirty days beyond the interruption of xylitol usage (C), the average levels of MS were still reduced to 10.31 (NL-CFU). Multiple sample comparison using the Bonferroni test revealed that the decrease in MS levels observed from baseline (A) to the time immediately after 30 days of xylitol usage (B) was statistically significant (p < 0.05), and those levels were still decreased between baseline and 30 days beyond the interruption of xylitol usage (C). So, the use of xylitol induced a reduction in MS salivary levels after a short period of usage which persisted beyond its interruption.

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.

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].