The Natural Sweetener Stevia: An Updated Review on its Phytochemistry, Health Benefits, and Anti-diabetic Study

Stevia rebaudiana Bertoni is one of the significant high qualities of non-caloric sugar substitute sweetener plants against diabetes disease. Diabetes mellitus is one of the most common metabolic diseases caused by insulin secretion defects, insulin resistance in peripheral tissues, or both. Stevia rebaudiana is a perennial shrub of the Compositae family that is grown in several places around the world. It contains a plethora of different bioactive constituents which are responsible for several activities and sweetness. This sweetness is due to the presence of steviol glycosides which is 100-300 times sweeter than sucrose. Furthermore, stevia reduces oxidative stress, lowering the risk of diabetes. Its leaves have been used to control and treat diabetes and a variety of other metabolic diseases. This review summarizes the history, bioactive constituents of S. rebaudiana extract, pharmacology, anti-diabetic activity, and its application, especially in food supplements.

The dietary sweetener sucralose is a negative modulator of T cell-mediated responses

Artificial sweeteners are used as calorie-free sugar substitutes in many food products and their consumption has increased substantially over the past years1. Although generally regarded as safe, some concerns have been raised about the long-term safety of the consumption of certain sweeteners2-5. In this study, we show that the intake of high doses of sucralose in mice results in immunomodulatory effects by limiting T cell proliferation and T cell differentiation. Mechanistically, sucralose affects the membrane order of T cells, accompanied by a reduced efficiency of T cell receptor signalling and intracellular calcium mobilization. Mice given sucralose show decreased CD8+ T cell antigen-specific responses in subcutaneous cancer models and bacterial infection models, and reduced T cell function in models of T cell-mediated autoimmunity. Overall, these findings suggest that a high intake of sucralose can dampen T cell-mediated responses, an effect that could be used in therapy to mitigate T cell-dependent autoimmune disorders.

The Crashing Toxicology Patient

This article examines, using an organ-systems based approach, rapid diagnosis, resuscitation, and critical care management of the crashing poisoned patient in the emergency department. The topics discussed in this article include seizures and status epilepticus, respiratory failure, cardiovascular collapse and mechanical circulatory support, antidotes and drug-specific therapies, acute liver failure, and extracorporeal toxin removal.

Effects of short-term xylitol chewing gum on pro-inflammatory cytokines and Streptococcus mutans: A randomised, placebo-controlled trial

INTRODUCTION

Dental caries is an infectious disease with predominantly of cariogenic bacteria such as Streptococcus mutans (S mutans). Xylitol is considered as one of the effective agents that can limit this dental infection. In this randomised, placebo-controlled trial, we aimed to evaluate the potential reflection of short-term xylitol consumption on pro-inflammatory cytokines (TNF-α, IL-6 and IL-8) and S mutans counts by ELISA and qPCR (Quantitative real-time PCR), respectively.

METHODS

In this study, 154 participants were assigned to two groups, control and xylitol. Dental examination, saliva and swab samples were done at baseline and at 3-week for clinical and microbiological assessment.

RESULTS

In xylitol group at the end of 3-week, gingival and plaque index scores were significantly decreased with respect to baseline values (P < .001 and P < .05, respectively). The salivary concentration of TNF-α, IL-6 and IL-8 were statistically declined at 3-week, more so than those at baseline in xylitol group (P < .001). S mutans expression was reduced about fivefold at 3-week use of xylitol and it was a statistically significant difference compared to baseline (P < .001).

CONCLUSION

Intriguingly, even short-term consumption of xylitol might play a favourable role in maintaining the oral health status, possibly as a result of decreasing the release of pro-inflammatory cytokines and the counts of S mutans. Nonetheless, this investigation warrants further endorsement.

Therapeutic challenges in the management of osmotic demyelination syndrome: A case report of a favorable outcome from a tertiary center

RATIONALE

There is an increasing and compelling need for early recognition of features of osmotic demyelination syndrome (ODS), and a further attempt at correcting this even where presentation is late.

PATIENT CONCERNS

A 49-year-old male admitted into the emergency department with a complaint of lethargy and severe hyponatremia, with subsequent ODS supervening on initial attempts at correction.

DIAGNOSIS

Rapid rise in serum sodium concentration (121 mmol/L in 8 hours from a nadir of 101 mmol/L), concomitant deterioration in patient's conscious level support the diagnosis of ODS.

INTERVENTION

Concomitant administration of 5% dextrose water with desmopressin with a therapeutic objective of gradual relowering of serum sodium concentration.

OUTCOMES

Significant improvement in patients' conscious level and motor function with the commencement of sodium relowering therapy. The patient was eventually discharged home.

LESSONS

Regardless of the temporal profile of neurologic sequelae following ODS due to hyponatremia, its worthwhile attempting initial sodium relowering with dextrose 5% and desmopressin and then monitoring of biochemical and neurologic markers.

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.

Ultrasound-guided perineural injection with dextrose for treatment of radial nerve palsy: A case report

RATIONALE

Perineural injection with dextrose could be a novel intervention for peripheral entrapment neuropathy. However, this intervention has not been reported for treating radial nerve palsy (RNP). Here, we present a case with RNP having outstanding improvement after 2 sessions of ultrasound-guided perineural injection with 5% dextrose (D5W).

PATIENT CONCERNS

A 62-year-old woman presented with difficulty and weakness in extension of her left wrist and fingers after she slept with the arm compressed against her body.

DIAGNOSES

On the basis of the findings of electrophysiological study and ultrasonography, the RNP with axonal injury was diagnosed.

INTERVENTIONS

Initially, the patient received 2-months conservative treatments without any improvement. Two sessions of ultrasound-guided perineural injection with total 15cc D5W with an interval of 1 month were performed 2 months after symptom onset.

OUTCOMES

A noteworthy improvement in sensory and motor functions was observed after ultrasound-guided perineural injection with D5W.

LESSONS

This case shows that ultrasound-guided perineural injection with D5W may be an effective and novel intervention for RNP.

Efficacy of Chlorhexidine, Xylitol, and Chlorhexidine + Xylitol against Dental Plaque, Gingivitis, and Salivary Streptococcus mutans Load: A Randomised Controlled Trial

PURPOSE

To compare the antiplaque, antigingivitis and antibacterial efficacy of chlorhexidine (CHX), XYL and a mouthwash combining CHX and XYL against Streptococcus mutans (S. mutans).

MATERIALS AND METHODS

A parallel design, randomised controlled trial was conducted among 75 dental students. Participants were randomised into CHX, CHX+XYL and XYL-only groups using the lottery method. Subjects were instructed to use 10 ml of the provided mouthwash for 15 s twice daily for 3 weeks. All the outcome measures, gingival index (GI), plaque index (PI) and number of salivary S. mutans CFU were recorded at baseline and 3 weeks post intervention. Nonparametric tests were used for inferential statistics.

RESULTS

All outcome variables (GI, PI scores and log10 salivary S. mutans counts) decreased significantly from baseline compared to post intervention among all three groups. Intergroup comparison demonstrated that reduction in GI was not significantly different among the three groups. The decrease in PI scores was found to be significantly higher in the XYL group, while the decrease in the log10 salivary S. mutans count was significantly higher in the CHX+XYL group.

CONCLUSION

The present study provided sufficient data to suggest that all the three mouthwashes are effective against plaque, gingivitis and S. mutans load in saliva. Further investigations should be carried out to confirm the results and develop strategies for using such products to prevent tooth decay.

Xylitol-containing Chewing Gum for Caries Prevention in Students with Disabilities: A Randomised Trial

PURPOSE

This cluster randomised controlled trial evaluated the effectiveness of a school-based xylitol chewing-gum programme on caries prevention among students with visual or hearing impairment.

MATERIALS AND METHODS

The study compared xylitol gum plus oral health education (intervention group, n = 93) with oral health education alone (control group, n = 81) among students aged 7-18 years in special needs schools in Khon Kaen, Thailand. The primary outcome was caries onset rate measured as the change in caries onset on tooth surfaces. The secondary outcome was plaque index. Between-group differences were determined using generalised estimated equations and a general linear model under the intention-to-treat approach.

RESULTS

After 1 year, there was a significantly lower caries rate in the primary dentition among the intervention group compared to the control group (0.08 vs 0.12 surfaces per surface-year, respectively; adjusted relative risk = 0.64, 95% confidence interval 0.44-0.96; p = 0.03), but there was no significant difference in the caries rates for the permanent dentition. Remineralisation also occurred more in the intervention vs the control group in the primary dentition only. Oral hygiene was significantly improved in the intervention but not in the control group (p = 0.001).

CONCLUSION

This programme reduced the caries rate and enhanced remineralisation in primary dentition, and improved oral hygiene in students with disabilities.

D-Tagatose Is a Promising Sweetener to Control Glycaemia: A New Functional Food

The objective of the current research was to review and update evidence on the dietary effect of the consumption of tagatose in type 2 diabetes, as well as to elucidate the current approach that exists on its production and biotechnological utility in functional food for diabetics. Articles published before July 1, 2017, were included in the databases PubMed, EBSCO, Google Scholar, and Scielo, including the terms "Tagatose", "Sweeteners", "Diabetes Mellitus type 2", "Sweeteners", "D-Tag". D-Tagatose (D-tag) is an isomer of fructose which is approximately 90% sweeter than sucrose. Preliminary studies in animals and preclinical studies showed that D-tag decreased glucose levels, which generated great interest in the scientific community. Recent studies indicate that tagatose has low glycemic index, a potent hypoglycemic effect, and eventually could be associated with important benefits for the treatment of obesity. The authors concluded that D-tag is promising as a sweetener without major adverse effects observed in these clinical studies.

Noncaloric Sweeteners in Children: A Controversial Theme

Noncaloric sweeteners (NCS) are food additives used to provide sweetness without adding calories. Their consumption has become more widespread around the world in all age groups, including children. The aim of this study is to show the state of the art about the intake of noncaloric sweeteners in children, as well as their benefits and consumption risk. Scientific searchers were used (PUBMED, Scopus, and Scielo) to analyze articles that included keywords (noncaloric sweeteners/saccharin/cyclamate/acesulfame potassium/aspartame/sucralose/stevia/children) in English, Spanish, and Portuguese. Authors conclude that it is imperative that health professionals judiciously and individually evaluate the overall benefits and risks of NCS use in consumers before recommending their use. Different subgroups of the population incorporate products containing NCS in their diet with different objectives, which should be considered when recommending a diet plan for the consumer. In childhood, in earlier age groups, this type of additives should be used as a dietary alternative when other forms of prevention in obesity are not sufficient.

Aspartame: Should Individuals with Type II Diabetes be Taking it?

BACKGROUND

Individuals with Type II Diabetes (T2D) have to manage blood glucose levels to sustain health and longevity. Artificial sweeteners (including aspartame) are suggested sugar alternatives for these individuals. The safety of aspartame in particular, has long been the centre of debate. Although it is such a controversial product, many clinicians recommend its use to T2D patients, during a controlled diet and as part of an intervention strategy. Aspartame is 200 times sweeter than sugar and has a negligible effect on blood glucose levels, and it is suggested for use so that T2D can control carbohydrate intake and blood glucose levels. However, research suggests that aspartame intake may lead to an increased risk of weight gain rather than weight loss, and cause impaired blood glucose tolerance in T2D.

OBJECTIVE

This review consolidates knowledge gained from studies that link aspartame consumption to the various mechanisms associated with T2D.

METHOD

We review literature that provides evidence that raise concerns that aspartame may exacerbate T2D and add to the global burden of disease.

RESULT

Aspartame may act as a chemical stressor by increasing cortisol levels, and may induce systemic oxidative stress by producing excess free radicals, and it may also alter gut microbial activity and interfere with the N-methyl D-aspartate (NMDA) receptor, resulting in insulin deficiency or resistance.

CONCLUSION

Aspartame and its metabolites are safe for T2D is still debatable due to a lack of consistent data. More research is required that provides evidence and raise concerns that aspartame may exacerbate prevalence of pathological physiology in the already stressed physiology of T2D.

Midwife or doctor local opinion leader to implement a national guideline in babies on postnatal wards (DesIGN): protocol of a cluster-randomised, blinded, controlled trial

INTRODUCTION

Neonatal hypoglycaemia is a common condition that can cause developmental delay. Treatment of neonatal hypoglycaemia with oral dextrose gel has been shown to reverse hypoglycaemia and reduce admissions to neonatal intensive care for hypoglycaemia. An evidence-based clinical practice guideline was written to guide the use of dextrose gel to treat neonatal hypoglycaemia in New Zealand. However, it is unclear what clinical discipline might most effectively lead the implementation of the guideline recommendations.

OBJECTIVE

To determine if midwife or doctor local opinion leaders are more effective in implementing a clinical practice guideline for use of oral dextrose gel to treat hypoglycaemia in babies on postnatal wards.

METHODS AND ANALYSIS

A cluster-randomised, blinded, controlled trial. New Zealand maternity hospitals that care for babies born at risk of neonatal hypoglycaemia will be randomised to having either a local midwife or doctor lead the guideline implementation at that hospital. The primary outcome will be the change in the proportion of hypoglycaemic babies treated with dextrose gel from before implementation of the guideline to 3 months after implementation.

ETHICS AND DISSEMINATION

Approved by Health and Disability Ethics Committee: 15/NTA/31. Findings will be disseminated to peer-reviewed journals, guideline developers and the public.

TRIAL REGISTRATION NUMBER

ISRCTN61154098.

Xylitol nasal irrigation in the treatment of chronic rhinosinusitis

OBJECTIVE

To evaluate the efficacy of xylitol nasal irrigation (XNI) treatment on chronic rhinosinusitis (CRS) and to investigate the effect of XNI on nasal nitric oxide (NO) and inducible nitric oxide synthase (iNOS) mRNA in maxillary sinus.

MATERIALS AND METHODS

Patients with CRS were enrolled and symptoms were assessed by Visual Analog Scale (VAS) and Sino-Nasal Outcome Test 22 (SNOT-22). Nasal NO and iNOS mRNA in the right maxillary sinus were also examined. Then, they were treated with XNI (XNI group) or saline nasal irrigation (SNI, SNI group) for 30days, after which their symptoms were reassessed using VAS and SNOT-22, and nasal NO and iNOS mRNA in the right maxillary sinus were also reexamined.

RESULTS

Twenty-five out of 30 patients completed this study. The scores of VAS and SNOT-22 were all reduced significantly after XNI treatment, but not after SNI. The concentrations of nasal NO and iNOS mRNA in the right maxillary sinus were increased significantly in XNI group. However, significant changes were not found after SNI treatment. Furthermore, there were statistical differences in the assessments of VAS and SNOT-22 and the contents of nasal NO and iNOS mRNA in the right maxillary sinus between two groups.

CONCLUSIONS

XNI results in greater improvement of symptoms of CRS and greater enhancement of nasal NO and iNOS mRNA in maxillary sinus as compared to SNI.

The Efficacy of Xylitol, Xylitol-Probiotic and Fluoride Dentifrices in Plaque Reduction and Gingival Inflammation in Children: A Randomised Controlled Clinical Trial

PURPOSE

The present prospective, randomised, placebo-controlled, clinical trial was designed to evaluate the clinical effects of a commercially available dentifrice containing fluoride, xylitol or xylitol-probiotic on the decrease of plaque and gingival inflammation in children between 13 and 15 years of age.

MATERIALS AND METHODS

Forty-eight adolescents were randomly grouped into three groups of n = 16 each: study group A received xylitol (Xyliwhite) toothpaste; study group B received xylitol-probiotic (Periobiotic) toothpaste; and the control group C received fluoride (Colgate Max Fresh) toothpaste. The subjects were instructed to use the dentifrice determined and a modified Bass brushing technique twice a day for two minutes over a 6-week perioed. Clinical evaluation was performed using a gingival index and a plaque index at baseline and at the end of the 6-week period.

RESULTS

From day 0 to 42, reductions in the plaque index were statistically significant in all groups, Colgate Max Fresh, PerioBiotic and Xyliwhite (p-values 0.001, 0.001 and 0.035, respectively), but reductions in the gingival index were statistically significant only in the Colgate Max Fresh and PerioBiotic groups (both with p = 0.001), not in the Xyliwhite group (p = 0.116). PerioBiotic toothpaste was found to be better than Xyliwhite and Colgate Max Fresh toothpastes at reducing plaque and gingival scores. However, statistically significant differences with PerioBiotic and Colgate Max Fresh toothpaste were not observed.

CONCLUSION

It was concluded that PerioBiotic was an all-round dentifrice that produced a significant reduction in both gingivitis and plaque.

The caries preventive effect of 1-year use of low-dose xylitol chewing gum. A randomized placebo-controlled clinical trial in high-caries-risk adults

Objectives

The caries preventive effect of long-term use (1 year) of low-dosage (2.5 g/die) of xylitol chewing gum in a high-caries-risk adult population was evaluated.

Materials and methods

In this randomized clinical trial, 179 high-caries-risk adults were assigned to two experimental groups, xylitol and polyols. Caries status, salivary mutans streptococci (MS), and plaque pH were re-evaluated after 2 years from baseline in 66 xylitol and 64 polyol subjects. Outcomes (the net caries increment for initial, moderate, and extensive caries lesions and for the caries experience) were evaluated using the nonparametric Mann–Whitney U test.

Results

The total caries experience increment was 1.25 ± 1.26 in the xylitol group and 1.80 ± 2.33 in the polyol group (p = 0.01). Subjects treated with xylitol chewing gums had a reduction of risk rate at tooth level of 23% with respect to those treated with polyols with a number needed to treat of 55 teeth. The area under the curve at pH 5.7 was statistically significantly lower (p = 0.02) during the experimental period in the xylitol group. A decrease of the concentration of salivary MS was noted in the xylitol group (p < 0.01).

Conclusions

Subjects using the low-dose xylitol chewing gum showed a significantly lower increment of initial and extensive caries lesions and overall a lower increment of caries experience.

Clinical relevance

One-year use of chewing gums provides an effective means for the prevention of caries disease.

Trial registration number

NCT02310308

Prophylactic Oral Dextrose Gel for Newborn Babies at Risk of Neonatal Hypoglycaemia: A Randomised Controlled Dose-Finding Trial (the Pre-hPOD Study)

BACKGROUND

Neonatal hypoglycaemia is common, affecting up to 15% of newborns, and can cause brain damage. Currently, there are no strategies, beyond early feeding, to prevent neonatal hypoglycaemia. Our aim was to determine a dose of 40% oral dextrose gel that will prevent neonatal hypoglycaemia in newborn babies at risk.

METHODS AND FINDINGS

We conducted a randomised, double-blind, placebo-controlled dose-finding trial of buccal dextrose gel to prevent neonatal hypoglycaemia at two hospitals in New Zealand. Babies at risk of hypoglycaemia (infant of a mother with diabetes, late preterm delivery, small or large birthweight, or other risk factors) but without indication for admission to a neonatal intensive care unit (NICU) were randomly allocated either to one of four treatment groups: 40% dextrose at one of two doses (0.5 ml/kg = 200 mg/kg, or 1 ml/kg = 400 mg/kg), either once at 1 h of age or followed by three additional doses of dextrose (0.5 ml/kg before feeds in the first 12 h); or to one of four corresponding placebo groups. Treatments were administered by massaging gel into the buccal mucosa. The primary outcome was hypoglycaemia (<2.6 mM) in the first 48 h. Secondary outcomes included admission to a NICU, admission for hypoglycaemia, and breastfeeding at discharge and at 6 wk. Prespecified potential dose limitations were tolerance of gel, time taken to administer, messiness, and acceptability to parents. From August 2013 to November 2014, 416 babies were randomised. Compared to babies randomised to placebo, the risk of hypoglycaemia was lowest in babies randomised to a single dose of 200 mg/kg dextrose gel (relative risk [RR] 0.68; 95% confidence interval [CI] 0.47-0.99, p = 0.04) but was not significantly different between dose groups (p = 0.21). Compared to multiple doses, single doses of gel were better tolerated, quicker to administer, and less messy, but these limitations were not different between dextrose and placebo gel groups. Babies who received any dose of dextrose gel were less likely to develop hypoglycaemia than those who received placebo (RR 0.79; 95% CI 0.64-0.98, p = 0.03; number needed to treat = 10, 95% CI 5-115). Rates of NICU admission were similar (RR 0.64; 95% CI 0.33-1.25, p = 0.19), but admission for hypoglycaemia was less common in babies randomised to dextrose gel (RR 0.46; 95% CI 0.21-1.01, p = 0.05). Rates of breastfeeding were similar in both groups. Adverse effects were uncommon and not different between groups. A limitation of this study was that most of the babies in the trial were infants of mothers with diabetes (73%), which may reduce the applicability of the results to babies from other risk groups.

CONCLUSIONS

The incidence of neonatal hypoglycaemia can be reduced with a single dose of buccal 40% dextrose gel 200 mg/kg. A large randomised trial (Hypoglycaemia Prevention with Oral Dextrose [hPOD]) is under way to determine the effects on NICU admission and later outcomes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613000322730.

Milk Sweetened with Xylitol: A Proof-of-Principle Caries Prevention Randomized Clinical Trial

PURPOSE

To evaluate the efficacy of xylitol-sweetened milk as a caries-preventive strategy.

METHODS

In this nine-month prospective proof-of-principle trial, Peruvian schoolchildren were randomized to one of five different milk groups: (1) eight g of xylitol per 200 mL milk once per day; (2) four g of xylitol per 100 mL milk twice per day; (3) eight g of sorbitol per 200 mL milk once per day; (4) four g of sorbitol per 100 mL milk twice per day; or (5) eight g of sucrose per 200 mL milk once per day. The primary outcome was plaque mutans streptococci (MS) at nine months. A secondary outcome was caries incidence. We hypothesized that children in the xylitol groups would have a greater MS decline and lower caries incidence.

RESULTS

One hundred fifty-three children were randomized in the intent-to-treat analyses. Children receiving xylitol had a greater decline in MS than children receiving sucrose (P=0.02) but were not different from children receiving sorbitol (P=0.07). Dental caries incidence for xylitol once per day or twice per day was 5.3±3.4 and 4.3±4.0 surfaces, respectively, compared to sorbitol once per day, sorbitol twice per day, or sucrose (4.1±2.8, 3.7±4.2, and 3.2±3.4 surfaces, respectively). There were no differences in caries incidence between xylitol and sucrose (rate ratio [RR] = 1.51; 95 percent confidence interval [CI] = 0.88, 2.59; P=0.13) or between xylitol and sorbitol (RR = 1.28; 95 percent CI = 0.90, 1.83; P=0.16).

CONCLUSION

Xylitol-sweetened milk significantly reduced mutans streptococci levels compared to sucrose-sweetened milk, but differences in caries incidence were not detected.

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.

COMMITTEE ON FETUS AND NEWBORN and SECTION ON ANESTHESIOLOGY AND PAIN MEDICINE. Prevention and Management of Procedural Pain in the Neonate: An Update

The prevention of pain in neonates should be the goal of all pediatricians and health care professionals who work with neonates, not only because it is ethical but also because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor, yet painful procedures. Therefore, every health care facility caring for neonates should implement (1) a pain-prevention program that includes strategies for minimizing the number of painful procedures performed and (2) a pain assessment and management plan that includes routine assessment of pain, pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and measures for minimizing pain associated with surgery and other major procedures.

Is Stevia rebaudiana Bertoni a Non Cariogenic Sweetener? A Review

Stevia rebaudiana Bertoni is a small perennial shrub of the Asteraceae (Compositae) family that is native to South America, particularly Brazil and Paraguay, where it is known as "stevia" or "honey leaf" for its powerful sweetness. Several studies have suggested that in addition to their sweetness, steviosides and their related compounds, including rebaudioside A and isosteviol, may offer additional therapeutic benefits. These benefits include anti-hyperglycaemic, anti-hypertensive, anti-inflammatory, anti-tumor, anti-diarrheal, diuretic, and immunomodulatory actions. Additionally, critical analysis of the literature supports the anti-bacterial role of steviosides on oral bacteria flora. The aim of this review is to show the emerging results regarding the anti-cariogenic properties of S. rebaudiana Bertoni. Data shown in the present paper provide evidence that stevioside extracts from S. rebaudiana are not cariogenic. Future research should be focused on in vivo studies to evaluate the effects on dental caries of regular consumption of S. rebaudiana extract-based products.

Effectiveness of nasal irrigation for chronic rhinosinusitis and fatigue in patients with Gulf War illness: protocol for a randomized controlled trial

INTRODUCTION

Gulf War Illness (GWI) affects 1 in 7 returned Persian Gulf War veterans. Quality-of-life impact is large; there is no cure. Chronic sinus symptoms and fatigue are common. Nasal irrigation with saline (NI-S) or xylitol (NI-X) improve sinus symptoms and fatigue in the general population. This trial will assess the effect of NI-S and NI-X on sinus and fatigue symptoms, economic outcomes and pro-inflammatory milieu among participants with GWI.

METHODS

75 participants (age 35 to 65 years, 25 in each of three arms) with GWI will be recruited from the Veteran's Administration and the community. They will use routine care for sinus symptoms and fatigue and be randomized to continued usual care alone or additional therapy with NI-S or NI-X. Participants will be able to adjust specific elements of the NI procedure. The primary outcome (Sinonasal Outcome Test, SNOT-20) and other self-reported assessments will occur at baseline, 8 and 26 weeks; lab assessment of pro-inflammatory cellular and cytokine profiles will occur at baseline and 26 weeks. Other outcomes will include fatigue-specific and overall health-related quality of life, pro-inflammatory cellular and cytokine profiles, cost-effectiveness and participant satisfaction.

RESULTS

Baseline demographic and clinical data from the first 10 participants show effective participant recruitment, enrollment, randomization, retention and data collection.

CONCLUSION

Early study conduct suggests that our participant-oriented approach will yield high rates of participant adherence and data capture, facilitating robust analysis. Results of this study will clarify the value of NI for chronic sinus symptoms and fatigue among patients with GWI.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov identifier NCT01700725.

Management of patients with active caries

This paper reports on a mechanism to manage caries as a disease and to medically intervene in the disease process to halt progression. The goal of this paper is to provide this alternative to a surgical-only approach. The management of caries begins with assessing lesion activity and the potential for arrest. This requires a clinical and radiological assessment and evaluation of risk. Hopeless teeth are extracted and large cavities filled to reduce infection. Risk reduction strategies are employed so efforts to arrest lesions can be successful. Teeth with lesions in the enamel or outer third of the dentin should be sealed, not restored, as restorations can weaken teeth and can be traumatic to pulps.

[Effects of different types and concentration of oral sweet solution on reducing neonatal pain during heel lance procedures]

OBJECTIVE

To compare the effect of different types and concentrations of sweet solutions on neonatal pain during heel lance procedure.

METHOD

Totally 560 full term neonates (male 295, female 265) were randomized into 7 groups:placebo group (plain water), 10% glucose, 25% glucose, 50% glucose, 12% sucrose, 24% sucrose and 30% sucrose groups.In each group, 2 ml corresponding oral solutions were administered through a syringe by dripping into the neonate's mouth 2 minute before heel lance. The procedure process was recorded by videos, from which to collect heart rate, oxygen saturation and pain score 1 min before puncture, 3, 5 and 10 min after puncture.

RESULT

The average heart rate increase 3, 5 and 10 min after procedure in the 25% and 50% glucose groups, 12% and 24% and 30% sucrose groups was significantly lower than those in the placebo group (P < 0.01 or 0.05). The average heart rate increase 3 min after procedure in the sucrose group was lower than that in the glucose group (P < 0.01).Neonates who received 30% sucrose has a significantly lower average heart rate increase than those who received 12% and 24% sucrose 3 min after heel lance (both P < 0.05) . The average oxygen saturation decrease 3, 5, 10 min after procedure was significantly lower than those in the placebo group (P < 0.01). The average oxygen saturation decrease 3 min after procedure in the sucrose groups was significantly lower than that in the glucose groups (P < 0.01). The average pain score 3, 5, 10 min after procedure was significantly lower than those in the placebo group (P < 0.01). The average pain score 3 min after procedure in the sucrose groups was significantly lower than that in the glucose groups (P < 0.01).

CONCLUSION

Oral administration of sweet solutions is an effective way to relieve neonatal pain on procedure, and sucrose has a better pain relief action than glucose, moreover, 30% sucrose provides better effect in control of heart rate increase 3 min after heel lance, but the best concentration of sucrose for pain relief needs further study.

Handbook of Non Drug Intervention (HANDI) Project Team. Sweet solutions for procedural pain in infants

A sweet solution, such as sucrose or glucose, can be used for analgesia for minor short term procedural pain, such as immunisation, in infants up to 12 months of age. The sweet solution is given orally and provides short term analgesia. It has National Health and Medical Research Council (NHMRC) Level I evidence of efficacy and no serious adverse effects have been reported. This article is part of a series on non drug treatments summarising indications, considerations, evidence and where clinicians and patients can get further information.

Caries prevention with xylitol lozenges in children related to maternal anxiety. A demonstration project

AIM

This was to compare the effect of a prevention program between children of anxious and non-anxious mothers.

METHODS

Mothers (n=120) with high and low dental anxiety scores (DAS>15 and DAS <8, respectively), and with high levels of mutans streptococci (>10(5)cfu/mL) were recruited at a maternity clinic of Tartu, Estonia. Two groups: 30 highly anxious, and 30 non-anxious mothers used xylitol (6 g/day) for 33 months and a non-treatment group of 60 mothers, both highly and low anxious (30 in each sub-group), acted as controls. All mothers were interviewed for oral health habits and education, and their dental health was examined. Due to discontinued participation 75% of the children (n=90) were examined at 2 and at 3 years of age.

RESULTS

Anxious mothers brushed less frequently (p=0.014), had a longer time since their last dental visit (p<0.0001), and a lower level of education (p<0.0001) than their non-anxious counterparts. However, maternal anxiety had no effect on children's dental health, contrary to the caries prevention program which was effective both at 2 and at 3 years of age (p<0.01; OR 6.6, 1.8-25.0 and OR 3.9, CI 1.5-10.0, respectively).

CONCLUSION

Children benefited from the caries prevention program, irrespective of maternal anxiety.

Evaluating the provision of oral health education material in Schools in Finland

INTERVENTIONS

The Finnish Dental Association donated new oral health education material (OHEM) to all upper comprehensive schools in 2008.

OBJECTIVE

The aim of this study was to determine whether that OHEM was noticed, received and used in schools, and whether oral health teaching and teachers' attitudes towards oral health changed after distribution of the OHEM.

METHODS

Surveys were conducted using online questionnaires for all health education teachers in upper comprehensive schools in Finland. Schools response rates were 39% in 2008, and 40% in 2009. Statistical significances between the teachers and between the schools according to background variables were analysed using a Pearson's Chi-square test for nominal data and Mantel-Haenszel Chi-square test for ordinal data. Changes between 2008 and 2009 were evaluated using percentage change and confidence intervals.

RESULTS

Of the responding teachers, 46% reported that they had received the OHEM and 33% had used it in their teaching. The number of teachers teaching oral health did not change after the OHEM, but teachers who taught oral health reported teaching all oral-health-related topics more frequently than they did before. Female teachers more often reported having received the OHEM (48% vs 32%, p=0.011) and having used it (36% vs 22%, p=0.017) than did male teachers.

CONCLUSIONS

The OHEM may not lead more teachers to teach oral health, but it provides them with the resources to teach the subject more comprehensively. The OHEM must be planned in close co-operation between schools and local dental health care professionals, to make it better known and accepted among teachers, especially male teachers.

Clinical evidence for polyol efficacy

Xylitol is a safe dental caries preventive when incorporated into chewing gum or confections used habitually. The goal of this paper is to identify and assess the work on xylitol and other polyols and dental caries since 2008. Xylitol is effective when used by the mother prenatally or after delivery to prevent mutans transmission and subsequent dental caries in the offspring. One new completed trial confirmed that children of mothers who used xylitol lozenges after delivery had less dental caries than a comparison group. A similar study confirmed that the use of xylitol gum by the mother either prevented or postponed MS transmission to the offspring. Xylitol use among schoolchildren delivered via a gummy bear confection reduced S. mutans levels, but a once per day use of xylitol-containing toothpaste did not. Randomized trials, with caries outcomes, assessing xylitol-containing lozenges in adults and xylitol-containing gummy bears in children will release results in the coming year. Other studies are ongoing but are not systematic and will fail to answer important questions about how xylitol, or other polyols, can address the global dental caries problem.

Masked hypoglycemia in the presence of icodextrin for peritoneal dialysis

BACKGROUND

Handheld glucose meters remain a rapid means of excluding hypoglycemia as a cause of altered mental status in the Emergency Department. However, emergency physicians must be alert for factors that can mask hypoglycemia at the bedside.

CASE REPORT

An 80-year-old man with diabetes mellitus and end-stage renal disease on peritoneal dialysis presents with altered mental status, hypotension, and a bedside handheld glucose meter reading of 99mg/dL. His mental status failed to improve with treatment of hypotension and the patient was intubated for airway protection. Laboratory-measured serum glucose was 29mg/dL. His mental status improved after glucose administration. It was subsequently determined that the patient used icodextrin (Extraneal(®), Baxter Healthcare Corporation, Deerfield, IL) as his peritoneal dialysate. This is partly absorbed into serum and hydrolyzed to oligosaccharides that are falsely detected as glucose by many handheld glucose meters.

CONCLUSION

The peritoneal dialysate icodextrin can produce falsely elevated bedside glucose meter values. As the prevalence of diabetic nephropathy and dialysis increases, emergency physicians must remain vigilant for such cases of unrecognized hypoglycemia.

[Glucose, ascorbic acid and hydrogen peroxide as ingredients of endoscopic hemostasis in bleeding ulcer]

Glucose and ascorbate used for endoscopic hemostasis metabolic preventive to prevent recurrent ulcer bleeding. Unacceptable joint use in endohemostasis ascorbate and hydrogen peroxide.

Risk indicators for the presence and extent of root caries among caries-active adults enrolled in the Xylitol for Adult Caries Trial (X-ACT)

OBJECTIVE

This paper uses baseline data from a randomized clinical trial to evaluate cross-sectional indicators of root caries in caries-active adults.

MATERIALS AND METHODS

Adults (21-80 years) having at least 12 erupted teeth and between one and ten caries lesions were enrolled. Participants (n = 437) received caries exams by trained, calibrated examiners and responded to baseline demographic and medical-dental questionnaires. We examined associations between baseline characteristics and (1) the presence of any root caries using Mantel-Haenszel hypothesis tests and odds ratio (OR) estimators and (2) the number of root surfaces with caries among study participants with exposed root surfaces (n = 349) using Mantel-Haenszel mean score tests and Mann-Whitney estimators.

RESULTS/CONCLUSIONS

Adjusting for study site and age, male gender [OR, 1.72; 95% confidence interval (CI), 1.08, 2.78], white race (OR, 2.39; 95% CI, 1.43, 3.98), recent dental visit (OR, 1.98; 95% CI, 1.07, 3.66), poor self-described oral health (OR, 2.65; 95% CI, 1.10, 6.39), and recent professional fluoride treatment (OR, 1.85; 95% CI, 1.06, 3.25) were significantly associated with increased odds to have any root caries, and study participants with exposed root surfaces characterized by male gender [Mann-Whitney probability estimate (MW) = 0.57; 95% CI, 0.51, 0.63), white race (MW, 0.61; 0.55, 0.68), recent dental visit (MW, 0.58; 0.50, 0.67), poor self-described oral health (MW, 0.61; 0.53, 0.69), and flossing at least once per day (MW, 0.57; 95% CI, 0.51, 0.62) were significantly more likely to have a greater number of root surfaces with caries than a randomly selected study participant from their respective complementary subgroups (female gender, non-white, etc.).

CLINICAL RELEVANCE

Our findings may help identify individuals at higher root caries risk.

The effect of Breezy candy on halitosis: a double-blind, controlled, and randomized study

Halitosis (bad breath) is a common condition that is socially crippling for vast parts of the population and results from malodorous volatile sulfur compounds, which are by-products of oral bacteria. In this doubled-blind, randomized study, 75 subjects with halitosis were evaluated. The participants were treated with or without abrasive microcapsules (candy) containing zinc gluconate 0.5%, propolis 2%, and a combination of both (zinc 0.25% and propolis 1%). The halitosis was assessed by a Halimeter, a portable instrument that measures the emission of volatile sulfur compounds at different time exposures to the treatments. Breezy candy (which is sugar-free) was found effective in the treatment of halitosis for up to 4 hours. While treatment with regular candy (group 1, traditional candy without abrasive particles) showed reduction in malodor of 10%, Breezy candy showed reduction of up to 60% in malodor (P < .0001). Since this was not a longitudinal study, the total duration of the effect was not assessed. Breezy candy in the abrasive form with zinc additive had the best potential to positively affect malodor when treating patients with halitosis. The combined effect of abrasion by microcapsules with zinc supplement represents a novel and successful approach for the treatment of halitosis.

Assessment of chewing sugar-free gums for oral debris reduction: a randomized controlled crossover clinical trial

PURPOSE

To assess the oral debris removal efficacy of two commercial sugar-free chewing gums, based on a newly developed oral debris scoring system.

METHODS

A randomized, examiner-blinded, three-arm crossover study was conducted, with a 1-week washout period between the crossover phases. 42 healthy adults were randomly assigned to sugar-free stick gum (Wrigley's Extra Freshmint), sugar-free pellet gum (Wrigley's Extra Fruit) or no-gum chewing groups. Subjects consumed a single chocolate cookie, and were examined at baseline, and at 2-, 5-, and 10-minute time points with or without gum-chewing treatment. Primary outcome measures were oral debris scores on the occlusal surface, interproximal and gingival margin areas. The entire test procedure was repeated on two subsequent visits.

RESULTS

The baseline conditions in the three groups did not differ significantly. Chewing either stick gum or pellet gum resulted in significantly lower oral debris scores (P < 0.0001) compared to the control (no-gum) treatment for all intraoral sites, while no significant difference was observed between the two chewing gum groups. Intra-examiner repeatability of the new scoring criteria was high throughout the study (Kappa > 0.90).

Short-term stability of a new generic sodium ferric gluconate in complex with sucrose

BACKGROUND

Sodium ferric gluconate in complex (SFG) is used to treat iron deficiency anemia in patients aged ≥6 years undergoing chronic hemodialysis and receiving supplemental epoetin therapy. Both the branded product (Ferrlecit, branded SFG) and a new generic version of sodium ferric gluconate in complex (Nulecit; generic SFG) are provided in 5 mL vials. SFG may be administered by slow intravenous (IV) injection of the undiluted product or by 1 h IV infusion after dilution in 100 mL 0.9% sodium chloride. This study evaluated the short-term stability of undiluted and diluted generic SFG at room temperature and under refrigeration.

METHODS

Samples of generic SFG undiluted in 10 mL syringes or diluted in IV infusion bags containing 0.9% sodium chloride solution were stored at room temperature or under refrigerated conditions (2-8°C). Samples at room temperature were stored for ≤48 h if undiluted and for ≤24 h if diluted. All refrigerated samples were stored for ≤7 days. Parameters evaluated were elemental iron (Fe) concentration and SFG apparent molecular weight. All tests were performed on two lots of the generic product.

RESULTS

Fe concentrations were identical in both lots and did not vary substantially over time under different conditions of storage or dilution. SFG apparent molecular weight varied across all samples from 306,000 to 354,000 Daltons, well within the range of 289,000 to 440,000 Daltons specified as the molecular weight in the FDA-approved prescribing information.

CONCLUSION

Iron content and SFG apparent molecular weight were stable under all experimental conditions. Undiluted generic SFG was stable for ≥2 days at room temperature and ≥7 days under refrigerated conditions, and generic SFG diluted in IV infusion bags containing 0.9% sodium chloride solution was stable for ≥1 day at room temperature and ≥7 days under refrigerated conditions.

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.

The role of remineralizing agents in dentistry: a review

Minimal intervention is a key phrase in today's dental practice. Minimal intervention dentistry (MID) focuses on the least invasive treatment options possible in order to minimize tissue loss and patient discomfort. Concentrating mainly on prevention and early intervention of caries, MID's first basic principle is the remineralization of early carious lesions, advocating a biological or therapeutic approach rather than the traditional surgical approach for early surface lesions. One of the key elements of a biological approach is the usage and application of remineralizing agents to tooth structure (enamel and dentin lesions). These agents are part of a new era of dentistry aimed at controlling the demineralization/ remineralization cycle, depending upon the microenvironment around the tooth. This article details the various agents that enhance and/or promote remineralization and discusses their clinical implications.

Caries risk assessment, prevention, and management in pediatric dental care

The recent increase in the prevalence of dental caries among young children has highlighted the need for a new approach to prevent caries in children at a younger age. New disease prevention management models call for children to have their first visit to the dentist at age 1 or when their first tooth erupts. This article addresses early childhood caries risk assessment, prevention, and management strategies in young children using the concept of the "dental home" and a simple six-step protocol to conduct an effective and comprehensive infant oral care visit.