Collaborative WHO xylitol field studies in Hungary. VII. Two-year caries incidence in 976 institutionalized children

Screening, Referral, Behavioral Counseling, and Preventive Interventions for Oral Health in Children and Adolescents Aged 5 to 17 Years: A Systematic Review for the US Preventive Services Task Force

Importance

Dental caries is common in children and adolescents aged 5 to 17 years and potentially amenable to primary care screening and prevention.

Objective

To systematically review the evidence on primary care screening and prevention of dental caries in children and adolescents aged 5 to 17 years to inform the US Preventive Services Task Force.

Data Sources

MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews (to October 3, 2022); surveillance through July 21, 2023.

Study Selection

Diagnostic accuracy of primary care screening instruments and oral examination; randomized and nonrandomized trials of screening and preventive interventions and systematic reviews of such studies; cohort studies on primary care oral health screening and preventive intervention harms.

Data Extraction and Synthesis

One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Random-effects meta-analysis was performed for fluoride supplements and xylitol; for other preventive interventions, pooled estimates were used from good-quality systematic reviews.

Main Outcomes and Measures

Dental caries, morbidity, functional status, quality of life, harms; diagnostic test accuracy.

Results

Three systematic reviews (total 20 684 participants) and 19 randomized clinical trials, 3 nonrandomized trials, and 1 observational study (total 15 026 participants) were included. No study compared screening vs no screening. When administered by dental professionals or in school settings, fluoride supplements compared with placebo or no intervention were associated with decreased change from baseline in the number of decayed, missing, or filled permanent teeth (DMFT index) or decayed or filled permanent teeth (DFT index) (mean difference, -0.73 [95% CI, -1.30 to -0.19]) at 1.5 to 3 years (6 trials; n = 1395). Fluoride gels were associated with a DMFT- or DFT-prevented fraction of 0.18 (95% CI, 0.09-0.27) at outcomes closest to 3 years (4 trials; n = 1525), fluoride varnish was associated with a DMFT- or DFT-prevented fraction of 0.44 (95% CI, 0.11-0.76) at 1 to 4.5 years (5 trials; n = 3902), and resin-based sealants were associated with decreased risk of carious first molars (odds ratio, 0.21 [95% CI, 0.16-0.28]) at 48 to 54 months (4 trials; n = 440). No trial evaluated primary care counseling or dental referral. Evidence on screening accuracy, silver diamine fluoride, xylitol, and harms was very limited, although serious harms were not reported.

Conclusions and Relevance

Administration of fluoride supplements, fluoride gels, varnish, and sealants in dental or school settings improved caries outcomes. Research is needed on the effectiveness of oral health preventive interventions in primary care settings and to determine the benefits and harms of screening.

The Effectiveness of Xylitol in a School-Based Cluster-Randomized Clinical Trial

Objective: The purpose of this double-blind, cluster-randomized clinical trial was to examine the effects of xylitol gummy bear snacks on dental caries progression in primary and permanent teeth of inner-city school children. Methods: A total of 562 children aged 5-6 years were recruited from five elementary schools in East Cleveland, Ohio. Children were randomized by classroom to receive xylitol (7.8 g/day) or placebo (inulin fiber 20 g/day) gummy bears. Gummy bears were given three times per day for the 9-month kindergarten year within a supervised school environment. Children in both groups also received oral health education, toothbrush and fluoridated toothpaste, topical fluoride varnish treatment and dental sealants. The numbers of new decayed, missing, and filled surfaces for primary teeth (dmfs) and permanent teeth (DMFS) from baseline to the middle of 2nd grade (exit exam) were compared between the treatment (xylitol/placebo) groups using an optimally-weighted permutation test for cluster-randomized data. Results: The mean new d3-6mfs at the exit exam was 5.0 ± 7.6 and 4.0 ± 6.5 for the xylitol and placebo group, respectively. Similarly, the mean new D3-6MFS was 0.38 ± 0.88 and 0.48 ± 1.39 for the xylitol and placebo group, respectively. The adjusted mean difference between the two groups was not statistically significant: new d3-6mfs: mean 0.4, 95% CI -0.25, 0.8), and new D3-6MFS: mean 0.16, 95% CI -0.16, 0.43. Conclusion: Xylitol consumption did not have additional benefit beyond other preventive measures. Caries progression in the permanent teeth of both groups was minimal, suggesting that other simultaneous prevention modalities may have masked the possible beneficial effects of xylitol in this trial. © 2014 S. Karger AG, Basel

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.

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.

Sugar alcohol sweeteners as alternatives to sugar with special consideration of xylitol

INTRODUCTION

Dental caries is a diet-associated disease which continues to be a serious health problem in most industrialized and developing countries. Strategies to maximize caries prevention should automatically consider the use of sugar substitutes. It is important that public health authorities are made cognizant of the availability of new polyol-type sugar substitutes.

REVIEW SUMMARY

Clinical studies have shown that xylitol, a natural, physiologic sugar alcohol of the pentitol type, can be used as a safe and effective caries-limiting sweetener. Habitual use of xylitol-containing food and oral hygiene adjuvants has been shown to reduce the growth of dental plaque, to interfere with the growth of caries-associated bacteria, to decrease the incidence of dental caries, and to be associated with remineralization of caries lesions. Numerous public regulatory bodies have endorsed the use of xylitol as a caries-limiting agent. Other sugar alcohols that have been successfully used as sugar substitutes include D-glucitol (sorbitol), which, however, owing to its hexitol nature, normally has no strong effect on the mass and adhesiveness of bacterial plaque and on the growth of mutans streptococci. A tetritol-type alditol, erythritol, has shown potential as a non-cariogenic sugar substitute. Combinations of xylitol and erythritol may reduce the incidence of caries more effectively than either alditol alone.

CONCLUSIONS

Partial sugar substitution with polyols is an important dietary tool in the prevention of dental caries that should be used to enhance existing fluoride-based caries prevention programmes. The most effective method of conveying this information to the public is through a proper health claim for these alditols in food labelling. The present review summarizes clinical and biochemical aspects of the above three dietary polyols and emphasizes the role of sugar substitution as a potential health-promoting strategy.

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.

Determinants of Dropout in a Community Intervention Trial on the Caries-preventive Effect of Chewing Gums

OBJECTIVES

This study describes determinants of dropout in a three-year community intervention trial of the effects of sugar-substituted chewing gums on caries progression rates.

METHODS

A total of 602 children aged 9-14 years from 28 school classes in five secondary schools in Kaunas, Lithuania, were given a clinical and radiographic baseline caries examination. The schools were assigned randomly to one of the following interventions: sorbitol/carbamide gum, sorbitol gum, xylitol gum, placebo gum, or no gum. Children in the four intervention schools were asked to chew at least five pieces of chewing gum per day, preferably after meals. The children were reexamined clinically after one, two, and three years of study, and radiographically after three years.

RESULTS

A total of 33 children (6%) had dropped out before the one-year clinical examination, an additional 29 children (5%) dropped out before the two-year examination, and a further 108 children (18%) dropped out before the final three-year clinical examination. A total of 230 children (39%) were not available or refused to participate in the three-year radiographic examination. Analyses using random effect logit models showed that, irrespective of time of follow-up, most of the cluster variation in dropout was related to school classes within the primary randomization units, the schools. The most important predictors of individual dropout were age and baseline caries experience, whereas sex was not associated with dropout.

CONCLUSIONS

The results show that a community intervention trial of chewing gums carried out among schoolchildren is subject to cluster effects. Dropout was not primarily related to the randomization units themselves, i.e. the schools, but rather to subclusters of classes within the schools. These findings should be considered when designing community intervention trials and practical preventive programs among schoolchildren.

Carbamide-containing polyol chewing gum and prevention of dental caries in schoolchildren in Madagascar

The objective of this investigation was to evaluate the effect on dental caries experience of using carbamide polyol chewing gum as a supplement to standard oral hygiene procedures for schoolchildren in a developing country (Madagascar). In 1994, grades 1 and 4 children of demonstration schools were allocated to experimental and control groups; all children participated in a school-based oral health education programme, including daily toothbrushing supervised by the classroom teacher. At grade 1, the test group (n = 125) also used chewing gum (V6: 55.5 per cent sorbitol, 4.3 per cent xylitol, 2 per cent carbamide) three times a day. At grade 4, one test group (n = 177) had chewing gum three times a day and an additional test group (n = 74) had chewing gum five times a day. The control groups included 117 children at grade 1 and 209 at grade 4. Dental caries was registered in 1994 and 1997 according to the Recording System for the Danish Child Dental Services. In grade 1 children, the preventive effect of the total DMFS was not statistically significant except for occlusal caries (-0.65 DMFS, P < 0.01). In the grade 4 test groups, non-significant reductions of dental caries experience were found when compared with controls. The present community trial indicates that the use of polyol chewing gum may be considered a supplement to the control of occlusal dental caries in young primary schoolchildren, particularly in developing countries with limited resources for dental care.

Xylitol in caries prevention: what is the evidence for clinical efficacy?

Xylitol has attracted much attention as an alternative sweetener. Essentially all clinical studies concerning the effect of xylitol on caries development consent to its non-cariogenicity and to the beneficial effect of substituting sucrose with xylitol in chewing gums and sweets. However, claims of anti-caries or therapeutic effects, and superiority of xylitol over other polyols are still to be confirmed by well designed and conducted studies from independent research groups.

Xylitol chewing gums and caries rates: a 40-month cohort study

Dental caries is a pandemic infectious disease which can affect the quality of life and consumes considerable health care resources. The chewing of xylitol, sorbitol, and even sugar gum has been suggested to reduce caries rates. No clinical study has simultaneously investigated the effectiveness of these gums when compared with a group receiving no chewing gum. A 40-month double-blind cohort study on the relationship between the use of chewing gum and dental caries was performed in 1989-1993 in Belize, Central America. One thousand two hundred and seventy-seven subjects (mean age, 10.2 years) were assigned to nine treatment groups: one control group (no supervised gum use), four xylitol groups (range of supervised xylitol consumption: 4.3 to 9.0 g/day), two xylitol-sorbitol groups (range of supervised consumption of total polyols: 8.0 to 9.7 g/day), one sorbitol group (supervised consumption: 9.0 g/day). The gum use during school hours was supervised. Four calibrated dentists performed the caries registrations by means of a modified WHO procedure. The primary endpoint was the development of an unequivocal caries lesion on a non-cavitated tooth surface. Compared with the no-gum group, sucrose gum usage resulted in a marginal increase in the caries rate (relative risk, 1.20; 95% confidence interval,0.96 to 1.49; p = 0.1128). Sorbitol gum significantly reduced caries rates (relative risk 0.74; 95% confidence interval, 0.6 to 0.92 ; p = 0.0074). The four xylitol gums were most effective in reducing caries rates, the most effective agent being a 100% xylitol pellet gum (relative risk, 0.27; 95% confidence interval, 0.20 to 0.36; p = 0.0001). This gum was superior to any other gum (p < 0.01). The xylitol-sorbitol mixtures were less effective than xylitol, but they reduced caries rates significantly compared with the no-gum group. DMFS analyses were consistent with these conclusions. The results suggest that systematic usage of polyol-based chewing gums reduces caries rates in young subjects, with xylitol gums being more effective than sorbitol gums.

A dietary procedure for preventing dental caries in young adults

Significant improvement in the dental caries status of children in the United States has been seen in recent decades. The percentage of children who are free from dental caries, however, rapidly decreases with age. By the time young people enter colleges or universities, only a few are caries free. Colleges and universities are places where the young are simultaneously, and perhaps for the last time, reachable as large cohorts before their lives undergo further "individualization." This makes college age a time that is crucial for channeling information about proper oral health practices by organizing mass-directed strategies for prevention of dental caries. It is now clear that dental caries can effectively be prevented. This calls for placing strong emphasis on dietary behavior and on the use of sugar substitutes as part of the strategy. Scientific evidence also suggests that the addition of small daily quantities of xylitol, a natural carbohydrate sweetener, to the diet of children and young adults causes significant reduction in the incidence of dental caries. On the basis of detailed long-term clinical trials carried out during the past 20 years, it appears that a reduction ranging from 30% to more than 85% in dental caries can be achieved simply by using a few xylitol chewing gums daily over a period of 1 to 3 years. In individual cases, virtually total, long-term protection against caries has been observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term effect of xylitol chewing gum on dental caries

About 85% (n = 269) of the subjects who participated in the Ylivieska follow-up studies on the effect of xylitol chewing gum on dental caries during 1982-84 or 1982-85 were re-examined in 1987 for the analysis of possible long-term preventive effects. Further caries reduction was found 2 or 3 yr after the discontinuation of the use of xylitol. The effect was especially marked in girls; the reduction in caries increment in the post-use years was 60% for the 2-yr users, suggesting that more pronounced caries reduction was associated with the most regular use of xylitol. In teeth erupting during the first year of the use of xylitol gum the long-term preventive effect was greater than in other teeth. Several explanations are suggested: lasting effect of the microbiological changes in the mouth, bacterial colonization on newly erupted teeth by organisms other than S. mutans, and/or thorough maturation of the teeth under favorable physico-chemical circumstances. The results suggest that the value of xylitol in caries prevention depends on the timing of the treatment in relation to the development of the dentition.

Carbohydrate-controlled precipitation of apatite with coprecipitation of organic molecules in human saliva: stabilizing role of polyols

Addition of common dietary carbohydrates to Millipore-treated human whole saliva either enhances or inhibits the formation of salivary precipitates, some carbohydrates showing no effect. The purpose of this study was to investigate the precipitation conditions more thoroughly and to elucidate the chemical nature of the precipitates formed. D-Xylose either enhanced precipitation (in long-term incubations) or had no appreciable effect (in 10 minute incubations). Other aldo- and keto-sugars and disaccharides (maltose, sucrose, lactose) generally enhanced precipitation, whereas all polyols (xylitol, D-sorbitol, mannitol, and maltitol) retarded the formation of turbidity in saliva. Xylitol inhibited formation of precipitates also in the presence of D-xylose, dextrans, and starch. Fast protein liquid chromatography (FPLC) of EDTA-soluble pellets obtained by centrifugation of the precipitates produced two major protein fractions (I and II) with a molecular weight of 112,000 and 46,000, respectively. The carbohydrates exerted a selective effect on the relative size of I and II in that polyol incubations resulted in a I to II ratio of 1:3, whereas control incubations (without added sugars) and incubations with other carbohydrates gave ratios of 1:6 to 1:10. Both peaks contained large amounts of acidic amino acids, proline, and glycine. The saliva precipitates contained a substantial portion of a crystalline phase that had the crystal structure of apatite, the individual crystallites being extremely small (less than 1 micron) with a Ca:P ratio of 1.46. The carbohydrates had a similar effect on the overall inorganic composition of the precipitates, but they had a clearly selective effect on the rate of formation of precipitates and on the relative amount of coprecipitating salivary proteins. This selectivity indicates that these carbohydrates, when consumed habitually, may exert different effects on the precipitation of Ca-salts at mineral-deficient enamel and dentine sites.

Salivary lactobacilli and yeasts in relation to caries increment. Annually repeated measurements versus a single determination

The purpose was to compare annually repeated measurements with a single determination of salivary lactobacilli and yeasts in distinguishing subjects with high and low caries increments. The determinations were carried out using Dentocult and Oricult chair-side methods in connection with a 3-year oral health preventive program. The subjects were institutionalized Hungarian children (n = 257), ranging from six to eleven years of age. The data were analyzed by comparing the age-adjusted means of caries increment in subjects with positive and negative microbiological findings. In comparison with a single determination, two or three annual measurements of the tests proved to increase the ability to distinguish subjects with respect to the 3-year caries increment. The analysis of the repeated measurements providing longitudinal information of these microorganisms probably included the time factor required for development of caries.

Collaborative WHO xylitol field studies in Hungary. I. Three-year caries activity in institutionalized children

The aim of this 3-year field study was to assess the value of partial substitution of sucrose with peroral xylitol (14-20 g/day) as a caries-preventive measure (X group) in comparison with systemic administration of fluoride (F group) and restorative treatment procedures solely (C group). An F dentifrice was used unsupervised in the X and F groups, the former containing 10% xylitol. The C group used customary, predominantly F-free dentifrices distributed by the local health authorities. The final material consisted of 689 institutionalized children (6-11 years). Caries was scored yearly in duplicate by two continuously calibrated teams. At base line the X group had a significantly higher caries prevalence than the F and C groups. The 3-year DMFS increment was 4.2 in the X group, 6.5 in the F group, and 7.7 in the C group. The corresponding ratio (RS) between caries incidence and the tooth surface population at risk was RSx, 4.9; RSF, 6.6; and RSC, 8.6. It is concluded that dietary xylitol in solid sweets resulted in a lower increment of caries than obtained in the F and C groups (p less than 0.001, covariance analysis, with base-line prevalence, number of permanent teeth, and visible plaque index as covariants).