Sugar-free chewing gum and dental caries: a systematic review

The effect of xylitol chewing gums and candies on caries occurrence in children: a systematic review with special reference to caries level at study baseline

PURPOSE

A systematic review of published data was carried out to assess the caries-preventive effects of xylitol chewing gums and candies in children.

METHODS

Electronic and hand searches were performed to find clinical studies on the effects of xylitol chewing gums and candies on dental caries in children (≤ 18 years). Prospective randomised or controlled clinical trials published before 2023 were included in the review.

RESULTS

The initial search identified 365 titles to be evaluated. After applying inclusion and exclusion criteria, 15 articles with either fair or low quality were reviewed. Nine articles studied chewing gums, five candies, and one both of them. In the ten evaluated xylitol chewing gum studies xylitol consumption significantly reduced caries occurrence when compared with no treatment or a placebo polyol gum. The effect was clinically significant in studies with high or moderate caries level at study baseline. The results also suggested that the caries-reducing effect of xylitol gums may differ from sorbitol/polyol gums. In five of the six heterogenous xylitol candy studies, no caries-reducing effect was found independent of caries level. In addition to caries level, also the daily xylitol dose was a confounding factor.

CONCLUSION

The present findings suggest that the caries-reducing effect of adding xylitol chewing gum to the daily diet has been well demonstrated in children and adolescents with high or moderate caries level at study baseline. Xylitol gum use could benefit subjects with active incipient caries lesions on smooth tooth surfaces.

Assessment of Oral Masticatory Muscle Activity With Different Chewing Gums: A Cross-Sectional Study Based on Electromyogram Analysis

BACKGROUND

Facial muscles, particularly those involved in mastication, play a pivotal role in the chewing process. Despite their influence on chewing, these muscles undergo alterations during mastication. Examining the relationship between chewed substances and muscle activity can provide insights into various pathological processes and aid in the development of therapeutic chewing techniques.

AIM

This study aimed to evaluate the impact of different commercially available chewing gums on the activity of key masticatory muscles.

METHOD

Twenty-two participants were recruited for the study. They were instructed to chew four commercially available gums: group 1 comprised sugar gum with a strong flavor; group 2 included gum containing sorbitol; group 3 consisted of gum containing xylitol; and group 4 provided sugar gum with a mild flavor. Electromyogram (EMG) recordings were utilized to assess muscle activity. Various aspects of muscle activity, including chewing time, maximum muscle potential, and coordination between different muscles, were evaluated. Data tabulation and analysis were performed using IBM SPSS software version 23.0 (IBM Corp., Armonk, NY).

RESULT

Analysis revealed that in terms of temporalis symmetry, group 2 exhibited the highest mean deviation, while for masseter symmetry, group 3 demonstrated the highest mean deviation. The total deviation for the temporalis and masseter muscles was 72.16% and 65.55%, respectively, indicating greater symmetry in the temporalis muscle. Additionally, group 3 displayed the highest mean deviation in both left and right-sided synergic activity of the muscles. The total deviation for the right and left sides was 64.34% and 65.67%, respectively.

CONCLUSION

The findings suggest that sugar-free chewing gums elicit increased muscle activity compared to sugar-containing chewing gums. Furthermore, the utilization of calorie-free chewing gums with a firm texture was associated with better-coordinated muscle activity. These results provide valuable insights into the effects of different chewing gums on masticatory muscle function and coordination, which may have implications for therapeutic interventions and oral health management.

Xylitol for the prevention of acute otitis media episodes in children aged 1-5 years: a randomised controlled trial

OBJECTIVE

To investigate the regular use of xylitol, compared with sorbitol, to prevent acute otitis media (AOM), upper respiratory tract infections (URTIs) and dental caries.

DESIGN

Blinded randomised controlled trial with a 6-month study period.

SETTING

Enrolment took place at 11 primary care practices in Ontario, Canada.

PATIENTS

Children aged 1-5 years who did not use xylitol or sorbitol at enrolment.

INTERVENTIONS

Children were randomly assigned to use a placebo syrup with sorbitol or xylitol syrup two times per day for 6 months.

MAIN OUTCOME MEASURES

Primary outcome was the number of clinician-diagnosed AOM episodes over 6 months. Secondary outcomes were caregiver-reported URTIs and dental caries.

RESULTS

Among the 250 randomised children, the mean (SD) age was 38±14 months and there were 124 girls (50%). There were three clinician-diagnosed AOM episodes in the 125 placebo group participants and six in the 125 xylitol group participants (OR 2.04; 95% CI 0.43, 12.92; p=0.50). There was no difference in number of caregiver-reported URTI episodes (rate ratio (RR) 0.88; 95% CI 0.70, 1.11) between the placebo (4.2 per participant over 6 months; 95% CI 3.6, 5.0) and xylitol (3.7; 95% CI 3.2, 4.4) groups. Dental caries were reported for four participants in the placebo group and two in the xylitol group (OR 0.42; 95% CI 0.04, 3.05; p=0.42). In a post-hoc analysis of URTIs during the COVID-19 pandemic, the rate among the 59 participants receiving placebo was 2.3 per participant over 6 months (95% CI 1.8, 3.0) and for the 55 receiving xylitol, 1.3 over 6 months (95% CI 0.92, 1.82; RR 0.56; 95% CI 0.36, 0.87). The most common adverse event was diarrhoea (28% with placebo; 34% with xylitol).

CONCLUSIONS

Regular use of xylitol did not prevent AOM, URTIs or dental caries in a trial with limited statistical power. A post-hoc analysis indicated that URTIs were less common with xylitol exposure during the COVID-19 pandemic, but this finding could be spurious.

TRIAL REGISTRATION NUMBER

NCT03055091.

Effects of probiotic yogurt, casein phosphopeptide-amorphous calcium phosphate, and xylitol chewing gums on the salivary count of Streptococcus mutans: A single-blinded randomized controlled clinical trial

Background

Dental caries is a preventable multifactorial disease, with Streptococcus mutans being suggested to be its primary pathogen. Our study aim was to compare the effects of three different low-cost and easy-to-use regimens with that of the gold standard (chlorhexidine [CHX] mouthwash) on the count of salivary S. mutans in dental students over 30 days.

Materials and Methods

In this single-blinded parallel randomized controlled clinical trial, a total of 120 dental students were included and randomly allocated into four intervention groups: (1) CHX mouthwash (control(, (2) probiotic yogurt, (3) casein phosphopeptide-amorphous calcium phosphate chewing gum, and (4) xylitol chewing gum. Salivary S. mutans counts were evaluated at baseline, 15 days, and 30 days after initiation of the study and compared at different times and among different groups using the repeated measures analysis of variance design analysis and least significant difference test with SPSS software version 20. The level of significance was determined to be 0.05.

Results

The microorganism count variable at baseline, first, and second follow-ups was significantly different for all groups except the probiotic yogurt group (P = 0.340). S. mutans count was significantly different when comparing the first follow-up and baseline values in the CHX and xylitol gum groups (P = 0.027, P = 0.037). When comparing the second follow-up with baseline values, a significant difference was observed in the xylitol gum group (P = 0.003).

Conclusion

Xylitol chewing gum seems to be a viable alternative to the gold standard (CHX mouthwash) in reducing the salivary count of S. mutans.

Laboratory evaluation of anti-plaque and remineralization efficacy of sugarless probiotic jelly candy supplemented with natural nano prebiotic additive

We evaluated the anti-cariogenic effect of an experimental synbiotic compound containing probiotic Lacticaseibacillus rhamnosus (NRRL B-442)-based jelly candy supplemented with natural prebiotic grape seed extract (GSE) in a nanoemulsion formula on the colonization and establishment of Streptococcus mutans (ATCC 25175) and Actinomyces viscosus (ATTCC 19246) biofilms through counting colony forming units, scanning electron microscopy (SEM), and transmission electron microscopy (TEM). We were then analysing the remineralizing effect of synbiotic jelly candy on human enamel surface lesions using Vickers microhardness testers, atomic force microscopy (AFM), SEM, energy-dispersive X-ray spectroscopy (EDAX), and confocal laser scanning microscopy (CLSM) at three stages (sound, after demineralization, and after pH cycling). We found after 21 days of treatment of the pH-cycled enamel discs with jelly candy for 10 min twice daily, a 68% decrease in S. mutans colony formation, reducing biofilm development, trapping S. mutans visualized in jelly candy under SEM examination, and significantly altering the morphological structure of these bacteria under TEM analysis. For remineralization measurements, statistically significant differences in microhardness integrated mineral loss, and lesion depth through CLSM between demineralization and treatment stages. These findings provide an effective anti-cariogenic synbiotic compound of grape seed extract and probiotic jelly candy with potential remineralizing activity.

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.

The economic benefits of increased sugar-free chewing gum in China: a budget impact analysis

Background

To analyze the potential cost savings in dental care associated with increased sugar-free gum (SFG) use among Chinese teenagers and adults.

Methods

The amount of SFG chewed per year and decayed, missing and filled teeth (DMFT) was collected from a cross-sectional survey to create a dose–response curve assumption. A cost analysis of dental restoration costs was carried out. A budget impact analysis was performed to model the decrease in DMFT and the subsequent cost savings for dental care. Three different scenarios for the increase in the number of SFG were calculated.

Results

The average cost savings per person in the Chinese population due to increasing SFG use ranged from 45.95 RMB (6.94 USD) per year to 67.41 RMB (10.19 USD) per year. It was estimated that 21.51–31.55 billion RMB (3.25–4.77 billion USD) could be saved annually if all SFG chewers among Chinese teenagers and adults chewed SFG regularly.

Conclusion

This study suggests that dental care costs could be significantly reduced if SFG use increased in the Chinese population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01786-8.

A Systematic Review and Meta-Analysis of the Role of Sugar-Free Chewing Gum in Dental Caries

OBJECTIVE

To determine the difference in level of dental caries in adults and children who chew sugar-free gum (SFG), compared with those who do not chew SFG or use alternatives such as lozenges, candies, rinses, tablets, and other nonchewing controls.

METHODS

Systematic review of published literature.

RESULTS

Twelve studies of interventions of SFG for dental caries outcomes were included. SFGs were found to significantly reduce caries increment, giving a preventative fraction (PF) of 28% (95% CI, 7% to 48%). Including the 8 trials that used xylitol gum only as the basis of the intervention, the PF was 33% (95% CI, 4% to 61%). No adverse effects were recorded. There was a high level of heterogeneity among the trials included.

CONCLUSION

The findings of this review provide tentative evidence that chewing SFG reduces caries increment in comparison to nonchewing controls. However, there is a considerable degree of variability in the effect and the trials included were generally of moderate quality. There is a need for future research to explore the acceptability and feasibility of the use of SFG as a public health intervention (PROSPERO 2018 CRD42018094676).

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by clinicians when deciding how best to implement dental caries prevention regimes for their patients. With consideration of cost and patient preference, this information could help to develop national policy directives on caries prevention and dictate the direction of future clinical research.

Medical Model in Caries Management

The current mode of dental caries management mainly operates through irreversible and symptomatic treatment by means of drilling and filling, while caries prevention is largely overlooked or omitted. Focus should be redirected through a medical model towards elimination of the disease through tackling its causes and risk factors to address current and future caries initiation. Caries is the demineralisation of dental hard tissues by bacterial acids when periodically exposed to fermentable carbohydrates. The medical model of caries management is a philosophy that steers sustainable caries management through controlling bacterial infection, a reduction of risk levels, remineralisation of teeth and long-term follow-up. Its goal is to prevent new and recurrent caries, arrest ongoing caries processes by alteration of the cariogenic environment, and support the healing of remineralisable enamel and dentine. The mechanism involves dietary counselling and plaque control, placement of dental sealants, administration of fluoride agents and chemotherapeutic medications and use of chewing gum. This paradigm shift from a surgical to a medical model aims to pursue the ultimate intention of maintaining a caries-free dentition and is anticipated to promote true oral health-related quality of life. The objective of this paper is to discuss the medical model of caries management.

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.

Xylitol for the prevention of acute otitis media episodes in children aged 2-4 years: protocol for a pragmatic randomised controlled trial

INTRODUCTION

Xylitol (or 'birch sugar') is a naturally occurring sugar with antibacterial properties that has been used as a natural non-sugar sweetener in chewing gums, confectionery, toothpaste and medicines. In this preventative randomised trial, xylitol will be tested for the prevention of acute otitis media (AOM), a common and costly condition in young children. The primary outcome will be the incidence of AOM. Secondary outcomes will include upper respiratory tract infections (URTIs) and dental caries.

METHODS AND ANALYSIS

This study will be a pragmatic, blinded (participant and parents, practitioners and analyst), two-armed superiority, placebo-controlled randomised trial with 1:1 allocation, stratified by clinical site. The trial will be conducted in the 11 primary care group practices participating in the TARGet Kids! research network in Canada. Eligible participants between the ages of 2-4 years will be randomly assigned to the intervention arm of regular xylitol syrup use or the control arm of regular sorbitol use for 6 months. We expect to recruit 236 participants, per treatment arm, to detect a 20% relative risk reduction in AOM episodes. AOM will be identified through chart review. The secondary outcomes of URTIs and dental caries will be identified through monthly phone calls with specified questions.

ETHICS AND DISSEMINATION

Ethics approval from the Research Ethics Boards at the Hospital for Sick Children and St. Michael's Hospital has been obtained for this study and also for the TARGet Kids! research network. Results will be submitted for publication to a peer-reviewed journal and will be discussed with decision makers.

TRIAL REGISTRATION NUMBER

NCT03055091; Pre-results.

Does reduced mastication influence cognitive and systemic health during aging?

There is a growing body of literature which suggests that oral health and mastication can influence cognitive and systemic health during aging. However, it is currently unclear whether oral health, masticatory efficiency, cognitive health and systemic health merely deteriorate independently with age, or whether mechanisms exist linking mastication to cognitive and systemic health directly. The aim of this paper is to review the extent to which reduced mastication influences cognitive and systemic health during aging because this knowledge may underpin future interventions that improve quality of life. Current evidence suggests that a deterioration in mastication and oral health during aging can have: 1) direct effects on systemic health through mechanisms such as the migration of the oral microbiota into the systemic environment, and 2) indirect effects on systemic health through changes nutrient intake. A loss of teeth and reduction in masticatory efficiency during aging can have: 1) direct effects on cognitive performance and potentially impact cognitive health through mechanisms such as enhanced adult hippocampal neurogenesis, and 2) indirect effects on cognitive health through changes in nutrient intake. It is concluded that oral health and masticatory efficiency are modifiable factors which influence the risk poor cognitive and systemic health during aging, although it is currently premature to propose chewing-based interventions to slow the rate of cognitive decline and improve cognitive health during aging. Future research should include large-scale longitudinal studies which control for the types of confounding factors which concurrently influence the association between mastication and cognitive and systemic health.

Oral health promotion: the economic benefits to the NHS of increased use of sugarfree gum in the UK

INTRODUCTION

The effect of sugarfree gum (SFG) on the prevention of dental caries has been established for some time. With increased constraints placed on healthcare budgets, the importance of economic considerations in decision-making about oral health interventions has increased. The aim of this study was to demonstrate the potential cost savings in dental care associated with increased levels of SFG usage.

METHODS

The analysis examined the amount of money which would hypothetically be saved if the UK 12-year-old population chewed more SFG. The number of sticks chewed per year and the caries risk reduction were modelled to create a dose response curve. The costs of tooth restoration, tooth extraction in primary care settings and under general anaesthetic were considered, and the effects of caries reduction on these costs calculated.

RESULTS

If all members of the UK 12-year-old population chewed SFG frequently (twice a day), the potential cost savings for the cohort over the course of one year were estimated to range from £1.2 to £3.3 million and if they chewed three times a day, £8.2 million could be saved each year. Sensitivity analyses of the key parameters demonstrated that cost savings would still be likely to be observed even in scenarios with less significant increases in SFG use.

CONCLUSION

This study shows that if levels of SFG usage in the teenage population in the UK could be increased, substantial cost savings might be achieved.

Quantification and qualification of bacteria trapped in chewed gum

Chewing of gum contributes to the maintenance of oral health. Many oral diseases, including caries and periodontal disease, are caused by bacteria. However, it is unknown whether chewing of gum can remove bacteria from the oral cavity. Here, we hypothesize that chewing of gum can trap bacteria and remove them from the oral cavity. To test this hypothesis, we developed two methods to quantify numbers of bacteria trapped in chewed gum. In the first method, known numbers of bacteria were finger-chewed into gum and chewed gums were molded to standard dimensions, sonicated and plated to determine numbers of colony-forming-units incorporated, yielding calibration curves of colony-forming-units retrieved versus finger-chewed in. In a second method, calibration curves were created by finger-chewing known numbers of bacteria into gum and subsequently dissolving the gum in a mixture of chloroform and tris-ethylenediaminetetraacetic-acid (TE)-buffer. The TE-buffer was analyzed using quantitative Polymerase-Chain-Reaction (qPCR), yielding calibration curves of total numbers of bacteria versus finger-chewed in. Next, five volunteers were requested to chew gum up to 10 min after which numbers of colony-forming-units and total numbers of bacteria trapped in chewed gum were determined using the above methods. The qPCR method, involving both dead and live bacteria yielded higher numbers of retrieved bacteria than plating, involving only viable bacteria. Numbers of trapped bacteria were maximal during initial chewing after which a slow decrease over time up to 10 min was observed. Around 10(8) bacteria were detected per gum piece depending on the method and gum considered. The number of species trapped in chewed gum increased with chewing time. Trapped bacteria were clearly visualized in chewed gum using scanning-electron-microscopy. Summarizing, using novel methods to quantify and qualify oral bacteria trapped in chewed gum, the hypothesis is confirmed that chewing of gum can trap and remove bacteria from the oral cavity.

Candy consumption patterns, effects on health, and behavioral strategies to promote moderation: summary report of a roundtable discussion

Nearly all Americans (97%) report eating candy at least once per year; yet, on a given day, only approximately one-fourth of the US population aged ≥2 y consumes candy. Among all Americans, candy contributes a relatively small proportion of calories, added sugars, and saturated fat to the total diet, and recent research suggests that current levels of candy consumption are not associated with risk of weight gain and cardiovascular disease in children and adults. Providing guidance for the consumption of candy in moderation requires an understanding of various behavioral health-related factors that influence candy consumption. A roundtable of behavioral nutrition experts, researchers, and nutrition educators met to discuss recent data on intakes of candy, health outcomes associated with usual candy intake, and the impact of behavioral strategies, including restriction, education, and environmental awareness, on modifying eating behaviors to achieve moderate intakes of candy. Restricting access to palatable foods, whether self-imposed or by parental control, may have potentially negative consequences. Techniques and insight into how to adopt "moderation" in candy consumption, from effective parental practices to environmental strategies that facilitate behavior change without a high degree of effort, were identified as important next steps toward sustainable dietary guidance related to the role of candy and other treats in a healthy lifestyle.

Effects of sugar-free chewing gum sweetened with xylitol or maltitol on the development of gingivitis and plaque: a randomized clinical trial

OBJECTIVE

The objective of this study was to test the effect of sugar-free chewing gum sweetened with xylitol or maltitol compared to the use of a gum base or no gum on gingivitis and plaque scores under both brushing and non-brushing circumstances.

METHODS

The design of the study was a four-group, double-blinded, randomized controlled study with a 3-week duration. In each group, the participants did not brush the teeth in the lower jaw designated to develop experimental gingivitis, while maintaining normal oral hygiene procedures in the upper jaw. After professional dental prophylaxis, the participants were allocated into one of four groups (xylitol, maltitol, gum base or no gum). Chewing gum was used five times a day for 10 min.

RESULTS

220 participants completed the study and provided evaluable data. The increase in bleeding on marginal probing (BOMP) and plaque scores (PS) in the non-brushed (lower) jaw with experimental gingivitis was significant in all groups (P < 0.001). As compared to the gum base, the increase in BOMP in the xylitol and maltitol group was significantly lower. In the brushed upper jaw, no significant changes for BOMP were observed from the baseline to the end point of the study, and there were no significant differences in BOMP and PS between the groups.

CONCLUSION

In circumstances where regular brushing is performed, no effect of chewing gum was observed on bleeding and plaque scores. In the absence of brushing, chewing xylitol or maltitol gum provided a significant inhibitory effect on gingivitis scores compared to chewing gum base. The difference when compared to the group not using gum was not significant.

Effect of chewing gums with xylitol, sorbitol and xylitol-sorbitol on the remineralization and hardness of initial enamel lesions in situ

BACKGROUND

The purpose of this study was to determine the effect of three chewing gums and paraffin on the remineralization and the hardness of demineralized enamel.

MATERIALS AND METHODS

A total of 12 subjects wore intraoral palatal appliances with two demineralized bovine enamel slabs. The study consisted of four experimental periods each lasting 21-days, during which subjects were assigned to one of three gum-chewing regimens: gum containing sorbitol, xylitol and a mixture of sorbitol and xylitol and with paraffin as control. The appliances were worn during gum-chewing for 20 min and then retained for 20 min 4 times/day. The slabs were subjected to energy dispersive X-ray spectroscopy analysis and surface microhardness measurements before in setting into the appliance and after the experimental period. The data were subjected to analysis of variance for repeated measures. A P < 0.05 was considered statistically significant.

RESULTS

Mineral analysis revealed no significant difference between the baseline and after chewing periods for all groups (P > 0.05). No significant difference was found among the groups either for the baseline measurements or after chewing periods (P > 0.05). All groups showed higher microhardness values after the chewing periods than the baseline except for the Vivident Xylit group (P < 0.05).

CONCLUSION

The chewing of gum had no effect on the Ca/P ratio of demineralized enamel surfaces. The hardening of the demineralized enamel surfaces may vary according to the type of chewing gum.

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.

[More] evidence to support oral health promotion services targeted to smokers calling tobacco quitlines in the United States

BACKGROUND

Prior research demonstrated a need and opportunity to target smokers calling a free, state-funded tobacco quitline to provide behavioral counseling for oral health promotion; however, it is unclear whether these results generalize to tobacco quitline callers of higher socioeconomic status receiving services through commercially-funded quitlines. This knowledge will inform planning for a future public oral health promotion program targeted to tobacco quitline callers.

METHODS

We surveyed smokers (n = 455) who had recently received tobacco quitline services through their medical insurance. Participants were asked about their self-reported oral health indicators, key behavioral risk factors for oral disease, motivation for changing their oral self-care behavior, and interest in future oral health promotion services. Where applicable, results were compared against those from a representative sample of callers to a free, state-funded quitline (n = 816) in the same geographic region.

RESULTS

Callers to a commercially-funded quitline had higher socioeconomic status, were more likely to have dental insurance, and reported better overall oral health indicators and routine self-care (oral hygiene, dental visits) than callers to a state-funded quitline. Nevertheless opportunities for oral health promotion were identified. Nearly 80% of commercial quitline callers failed to meet basic daily hygiene recommendations, 32.8% had not visited the dentist in more than a year, and 63.3% reported daily alcohol consumption (which reacts synergistically with tobacco to increase oral cancer risk). Nearly half (44%) were interested in learning how to improve their oral health status and, on average, moderately high levels of motivation for oral health care were reported. Many participants also had dental insurance, eliminating an important barrier to professional dental care.

CONCLUSIONS

Future public oral health promotion efforts should focus on callers to both free state-supported and commercially-funded tobacco quitlines. While differences exist between these populations, both groups report behavioral risk factors for oral disease which represent important targets for intervention.

Are we ready for definitive clinical guidelines on xylitol/polyol use?

In the past decades, numerous studies have looked at the anticaries effects of polyols, particularly xylitol, and a great many studies have focused on xylitol's antimicrobial properties. Researched vehicles have mostly included chewing gums, followed by lozenges/candies, toothpastes, and others (e.g., syrup). Good evidence supports the claims that xylitol is non-cariogenic and has a dose-/frequency-dependent antimicrobial effect on dental plaque/mutans streptococci, and that polyol use is very safe. However, interpretation of caries data has been controversial, due in part to variability in study designs, formulations/dosages tested, and outcomes reported (e.g., many caries studies have a "no gum" control, limiting the interpretation of the polyol's benefit; few studies have compared different polyols side-by-side, or in adults). Even when the level/strength of high-quality anticaries evidence is still limited, most recent systematic reviews have consistently concluded that the habitual use of sucrose-free xylitol or polyol-combination chewing gum/ lozenges is an effective adjunct in coronal caries prevention. Consequently, many health organizations worldwide are supporting this recommendation for at-risk populations. However, most experts agree that well-designed, placebo-controlled randomized clinical trials (RCTs) (focusing on efficacy, feasibility, adherence, dosage, vehicle, synergism with other preventive strategies, and cost) are still needed in target populations worldwide to reach definitive caries-preventive/therapeutic recommendations.

Minimal intervention dentistry for managing dental caries - a review: report of a FDI task group

This publication describes the history of minimal intervention dentistry (MID) for managing dental caries and presents evidence for various carious lesion detection devices, for preventive measures, for restorative and non-restorative therapies as well as for repairing rather than replacing defective restorations. It is a follow-up to the FDI World Dental Federation publication on MID, of 2000. The dental profession currently is faced with an enormous task of how to manage the high burden of consequences of the caries process amongst the world population. If it is to manage carious lesion development and its progression, it should move away from the 'surgical' care approach and fully embrace the MID approach. The chance for MID to be successful is thought to be increased tremendously if dental caries is not considered an infectious but instead a behavioural disease with a bacterial component. Controlling the two main carious lesion development related behaviours, i.e. intake and frequency of fermentable sugars, to not more than five times daily and removing/disturbing dental plaque from all tooth surfaces using an effective fluoridated toothpaste twice daily, are the ingredients for reducing the burden of dental caries in many communities in the world. FDI's policy of reducing the need for restorative therapy by placing an even greater emphasis on caries prevention than is currently done, is therefore, worth pursuing.

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.

Delivery of Active Agents from Chewing Gum for Improved Remineralization

Most surrogate measures of caries were developed to test products containing fluoride, typically at relatively high and closely controlled oral concentrations. However, since the primary mechanism for the remineralization of early enamel caries lesions by chewing gum is through stimulation of saliva, delivering Ca and Pi to the demineralized enamel lesion, established methods may lack the sensitivity to detect the additional benefit of an active agent without the strong remineralizing potential of fluoride. Issues related to the release of active agents from the gum matrix, dilution in the saliva, and limited oral retention time, along with taste, safety, regulatory, and cost concerns, impose further limitations. This paper reviews the efficacy of some active agents used in chewing gum for improved remineralization and includes results from in situ testing of calcium-containing gums, including calcium lactate, tetracalcium phosphate/dicalcium phosphate anhydrous, calcium citrate/encapsulated phosphate, and a calcium lactate/sodium phosphate blend. Despite promising in vitro data from these agents, they did not provide consistently superior results from in situ testing. There is a need to develop better predictive in vitro models for chewing gum, as well as improved sensitivity of in situ models to discriminate relatively small amounts of remineralization against a background of high biological variability.

The effect of sugar-free chewing gum on plaque and clinical parameters of gingival inflammation: a systematic review

OBJECTIVE

The aim of this study was to systematically review the current literature on the clinical effects of sugar-free chewing gum on plaque indices and parameters of gingival inflammation.

MATERIAL AND METHODS

The MEDLINE-PubMed, Cochrane-CENTRAL and EMBASE databases were searched up to 20 April 2012 to identify any appropriate studies. Plaque indices and parameters of gingival inflammation were selected as outcome variables.

RESULTS

An independent screening of the 594 unique titles and abstracts identified six non-brushing and four brushing studies that met the eligibility criteria. In the non-brushing studies, the use of chewing gum did not significantly affect the parameters of interest. In the descriptive analysis of the brushing studies, four of five comparisons showed a statistically significant effect in favour of the sugar-free chewing gum with respect to plaque scores. The meta-analysis for the Quigley & Hein (J Am Dent Assoc 1962; 65: 26) plaque index scores in the brushing studies also showed a significant difference (DiffM -0.24, 95% CI [-0.41; -0.08]). For bleeding tendency, the descriptive analysis showed that one of the two comparisons identified a significant difference in favour of chewing gum. The meta-analysis, however, did not substantiate this difference.

CONCLUSION

Within the limitations of this systematic review, it may be concluded that the use of sugar-free chewing gum as an adjunct to toothbrushing provides a small but significant reduction in plaque scores. Chewing sugar-free gum showed no significant effect on gingivitis scores. In the absence of brushing, no effect on plaque and gingivitis scores could be established.

Effect of xylitol on cariogenic and beneficial oral streptococci: a randomized, double-blind crossover trial

BACKGROUND/PURPOSE

Although habitual consumption of xylitol reduces cariogenic streptococci levels, its effect on beneficial oral streptococci is less clear. The main aim of the study is to investigate the effect of short-term xylitol consumption on the oral beneficial streptococci level of saliva, Streptococcus sanguinis and S. mitis.

MATERIAL AND METHODS

Twenty four volunteers with a median age of 23.7 years (range: 20-28) harboring Streptococcus mutans, S. sobrinus, S. sanguinis and S. mitis participated in the randomized, double-blind, cross-over study. The experimental chewing gum (1.5 g/pellet) contained 70% xylitol w/w while the control gum contained 63% sorbitol w/w. Saliva samples were collected before and after two three-week test periods with a four-week washout interval. Colony-forming units (CFU)/ml were enumerated for the estimation of S. mutans levels on Mitis Salivarius-Mutans valinomycin (MS-MUTV), S. sobrinus on Mitis Salivarius-Sobrinus (MS-SOB), S. sanguinis on Modified Medium 10-Sucrose (MM10-S) and S. mitis on Mitis Salivarius Agar with Tellurite (MSAT) media.

RESULTS

The S. mutans and S. sobrinus counts of the saliva samples decreased significantly (p = 0.01 and p = 0.011, respectively) in the xylitol gum group but not in the sorbitol gum group. The salivary S. sanguinis and S. mitis counts did not decrease in both xylitol and sorbitol gum groups.

CONCLUSIONS

Based on the findings of this study, xylitol consumption reduced S. mutans and S. sobrinus counts in saliva but appeared not to effect numbers of S. sanguinis and S. mitis in saliva. So, habitual consumption of xylitol reduces cariogenic streptococci levels without any effect on beneficial sterptococci for the oral cavity.

An AMSTAR assessment of the methodological quality of systematic reviews of oral healthcare interventions published in the Journal of Applied Oral Science (JAOS)

BACKGROUND

Systematic reviews are not an assembly of anecdotes but a distillation of current best available evidence on a particular topic and as such have an important role to play in evidence-based healthcare. A substantial proportion of these systematic reviews focus on interventions, and are able to provide clinicians with the opportunity to understand and translate the best available evidence on the effects of these healthcare interventions into clinical practice. The importance of systematic reviews in summarising and identifying the gaps in evidence which might inform new research initiatives is also widely acknowledged. Their potential impact on practice and research makes their methodological quality especially important as it may directly influence their utility for clinicians, patients and policy makers. The objectives of this study were to identify systematic reviews of oral healthcare interventions published in the Journal of Applied Oral Science (JAOS) and to evaluate their methodological quality using the evaluation tool, AMSTAR.

METHODS

Potentially eligible systematic reviews in JAOS were identified through an electronic search of the Scientific Electronic Library Online (SciELO). Details of the relevant aspects of methodology as reported in these systematic reviews were extracted from the full text publications. Methodological quality was assessed independently by two reviewers using the AMSTAR questionnaire.

RESULTS

Five systematic reviews were identified, one of which was subsequently excluded as it was a review of a diagnostic test. Summary AMSTAR scores for the four included reviews were: 1, 5, 2 and 4 out of a maximum score of 11 (range 1-5, mean 3) with only one of the reviews scoring 5.

CONCLUSION

AMSTAR evaluation of the methodological quality of the relatively small number of systematic reviews published in JAOS illustrated that there was room for improvement. Pre-publication and editorial appraisal of future systematic reviews might benefit from the application of tools such as AMSTAR and is to be recommended.

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.

Translation and implementation of added sugars consumption recommendations: a conference report from the American Heart Association Added Sugars Conference 2010

BACKGROUND

A 2-day forum was convened to (1) discuss ways to translate the 2009 American Heart Association added sugars recommendations into actions in areas such as regulation, food labeling, nutrient content claims, and practical application in the American diet; (2) review surveillance methodology and metrics for tracking and understanding the impact of reducing added sugars in the diet; and (3) initiate the development of a framework for future collaboration to help Americans implement science-based guidance relative to added sugars.

METHODS AND RESULTS

More than 100 multinational participants representing scientists from academia and government and stakeholders engaged in food production, development, and processing, food manufacturing and servicing, food and nutrition policy, and nutrition recommendations for the public attended the conference. Presentations included definitions and examples of added sugars, current US and international added sugars perspectives, added sugars in diets of individuals and in the food supply, food technology behind added sugars, added sugars and health, food manufacturer perspectives, added sugars food-labeling considerations, and examples of positive approaches to improve eating behaviors and the food environment. Facilitated breakout sessions were conducted after the plenary sessions to allow participants to contribute their expertise and thoughts.

CONCLUSION

The American Heart Association Added Sugars Conference is the first step in an important process that facilitates collaboration across science, public health, and industry to foster innovation, partnerships, policy, and implementation of new products and services for the benefit of the health and well-being of the American public. Science has advanced in the area of added sugars and health, creating mounting pressure to use better methods for translation and dissemination of the science for consumer education and for food companies to respond by producing foods and beverages with fewer added sugars. The new science also reinforces the importance of preventing, rather than simply treating diseases, especially overweight and obesity, diabetes mellitus, high blood pressure, heart disease, and stroke. Reducing added sugars consumption is a good target for addressing obesity, along with other sources of excess calories. However, the potential unintended consequences of substituting added sugars with ingredients that may not reduce calories and of increasing other macronutrients or food groups that may not result in a net health gain must be considered. Although there are many challenges to incorporating added sugars to the food label as was discussed during the conference, disclosure of added sugars content on food and beverage labels is an essential element in consumer education and can provide the information and motivation for making healthier food choices. This conference demonstrated the value of interactive dialogue among multiple sectors and disciplines. More disciplines should be at the table to bring expertise to discuss cross-cutting issues related to public policies and offer diverse insights to finding a solution.

Treatment protocols: nonfluoride management of the caries disease process and available diagnostics

This article reviews the evidence for saliva diagnostics and some antibacterial concepts with potential to interfere with the caries process. It concludes that there is incomplete evidence to evaluate the role of chair-side tests and to recommend general topical applications of antibacterial agents to prevent caries lesions. However, such measures may be considered to control the disease in caries-active individuals. There is evidence that xylitol has antibacterial properties that alter the oral ecology but the clinical evidence for caries prevention is rated as fair. However, preventive programs should include as many complementary strategies as possible, especially when directed toward caries-active patients. Therefore, any antibacterial intervention should always be combined with a fluoride program, until stronger evidence for its use in caries prevention and management becomes available.

Sugar alcohols, caries incidence, and remineralization of caries lesions: a literature review

Remineralization of minor enamel defects is a normal physiological process that is well known to clinicians and researchers in dentistry and oral biology. This process can be facilitated by various dietary and oral hygiene procedures and may also concern dentin caries lesions. Dental caries is reversible if detected and treated sufficiently early. Habitual use of xylitol, a sugar alcohol of the pentitol type, can be associated with significant reduction in caries incidence and with tooth remineralization. Other dietary polyols that can remarkably lower the incidence of caries include erythritol which is a tetritol-type alditol. Based on known molecular parameters of simple dietary alditols, it is conceivable to predict that their efficacy in caries prevention will follow the homologous series, that is, that the number of OH-groups present in the alditol molecule will determine the efficacy as follows: erythritol >/= xylitol > sorbitol. The possible difference between erythritol and xylitol must be confirmed in future clinical trials.

Consistent evidence to support the use of xylitol- and sorbitol-containing chewing gum to prevent dental caries

DATA SOURCES

Studies were identified using searches with Medline, the Cochrane Library and Google Scholar.

STUDY SELECTION

Studies were screened independently and were included if they evaluated the effect of one or more chewing gums containing at least one polyol (xylitol, sorbitol, mannitol or maltitol) on caries development, provided they supplied original data generated by means of a comparative design (experimental or observational) and were published in English. Studies were excluded if only an abstract was available or they described only the pharmacodynamic or pharmacokinetic properties of polyols or did not include a no-treatment arm in the study. Randomised trial quality was assessed using the Jadad scale, and the US Preventive Services Task Force criteria to grade the internal validity of individual nonrandomised studies.

DATA EXTRACTION AND SYNTHESIS

Data were extracted independently with only the final outcomes of a study being recorded. It was decided that surface rather than tooth level data would be recorded. Incremental caries was converted to prevented fraction (PF; the proportional reduction in dental caries in experimental groups relative to control groups) for meta-analysis. The studies were grouped according to type of polyol and a separate meta-analysis performed. Data were pooled using both a random and a fixed-effects model and heterogeneity assessed using I2.

RESULTS

Of 231 articles identified 25 studies were initially selected with 19 being included in the review [six randomised controlled trials (RCT) of which four were cluster RCT, nine controlled clinical trials (CCT) and four cohort studies]. Two RCT had a Jadad score of three or higher. The mean preventive fraction for the four main gum types are shown in the table 1, results of all except the sorbitol -mannitol blend were statistically significant. Sensitivity analyses confirmed the robustness of the findings.

CONCLUSIONS

Although research gaps exist, particularly on optimal dosing and relative polyol efficacy, there is consistent evidence to support the use of xylitol- and sorbitol-containing chewing gum as part of normal oral hygiene to prevent dental caries.