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Strive-the Student View Xylitol: A Dental Phenomenon Dental caries is one of the most common infectious diseases known to mankind. Although dental caries is largely preventable, it is the most common chronic disease of children ages 5 to 17 years.[1] Dental professionals receive extensive education to treat the symptoms of caries, but more emphasis should be placed on prevention and control of this infectious disease. Everyone's mouth is inhabited with bacteria. Lactobacillus acidophilus and Streptococcus mutans are the specific bacteria that cause dental caries.[2] L. acidophilus resides in the pits and fissures and S. mutans prefers to reside on the smooth surfaces of teeth. When high amounts of sugar, especially sucrose, are found in the mouth, these bacteria increase in number and cause dental caries.[3] We all know it may be impractical and nearly impossible to completely avoid sugar. However, a more realistic solution is to limit the amount of sucrose ingested and maintain good oral hygiene, using fluoride and sugar substitutes such as xylitol to control S. mutans. Importance of Xylitol
The dental significance of xylitol was discovered in Finland in the early 1970s, when scientists at Turku University showed it could prevent caries. Xylitol has the ability to[5]
Studies using xylitol as either a sugar substitute or in small amounts as a dietary supplement have demonstrated a dramatic reduction in new tooth decay, along with potential termination and even reversal of existing dental caries. The Mechanism of Action
of Xylitol Second, xylitol works by raising the oral pH to be more alkaline. When S. mutans bacteria are fed by sugar, they produce acids, which lower the pH level below 7 and slowly but surely weaken the protective tooth enamel. After sugar consumption, it takes over half an hour before the pH of plaque is restored to the normal level of around 7. If sugar is eaten several times a day, acid attacks occur, wherein salts dissolve off the enamel more and more deeply, and eventually the enamel becomes porous. Once pockets of the enamel are gone, cavities begin to form. When you ingest xylitol, the acid attack that would otherwise last for over half an hour is stopped, and because the bacteria in the mouth causing caries are unable to ferment xylitol in their metabolism, their growth is reduced. The number of acid-producing lactobacilli and streptococci may fall as much as 90%. As a result of the decrease in number of bacteria, the oral pH stays higher. When the pH of saliva is above 7, calcium and phosphate salts in saliva start to precipitate into parts of enamel where slight demineralization has occurred. Thus, soft calcium-deficient enamel sites begin to harden again. This is how xylitol helps to remineralize tooth enamel.[3] Third, xylitol stimulates saliva flow. Saliva is the mouth's natural defense against invaders like sugars, but when too much sugar is ingested too often, the saliva is unable to defend the teeth because of the acid pH resulting from sugar usage. Increased salivary flow offers protection to both the oral soft tissues and the teeth.[7] Clinical Studies Report
Clinical Efficacy of Xylitol One hundred sixty-nine mother-child pairs participated in a two-year study exploring whether the mothers' xylitol consumption could prevent mother-child transmission of S. mutans. All mothers showed high salivary levels of S. mutans during pregnancy. The mothers were recruited for the study during pregnancy and were assigned to one of three study groups. The first group of mothers chewed xylitol gum approximately four times a day up to 24 months after the child was born. The second and third groups were control groups. The mothers in the two control groups received fluoride (which does not affect S. mutans transmission, but strengthens tooth enamel) or chlorhexidine (which reduces S. mutans transmission) treatments at 6, 12, and 18 months post delivery. Otherwise, normal dietary and oral hygiene practices were maintained. The children did not chew gum or receive varnish treatments. S. mutans from the mothers' saliva were assessed at half-year intervals and from the children's plaque at the one- and two-year examinations. The S. mutans were cultured on mitis salivarius agars containing bacitracin. The amount of S. mutans in the mothers' saliva remained high and not significantly different among the three study groups throughout the study. The study measured the occurrence of tooth decay in the children at the age of two years: 9.7% of the children in the xylitol group, 28.6% in the chlorhexidine group, and 48.5% in the fluoride varnish group showed detectable level of S. mutans. Thus, the mothers' habitual use of xylitol chewing gum prevented tooth decay in their children by significantly reducing the transmission of S. mutans from mother to child in early childhood.[9] The author of the study concluded, "...Since the evidence suggests a strong caries protective effect of xylitol, it would be unethical to deprive subjects of its potential benefits."[7] Xylitol Products
The recommended dose varies upon its intended action. For the maximum prevention of dental caries, 7 to 20 grams per day are given, divided into several doses in candies or chewing gum.[10] If xylitol is used only occasionally, or even as often as once a day, it may not be effective, regardless of the amount. The consistent use of xylitol at least three and preferably five times every day is more effective. The best time to use xylitol is immediately after eating and clearing the mouth by swishing with water. Another recommendation is to replace ordinary chewing gum, breath mints or breath spray that you use between meals with comparable xylitol products. Other research shows 5 to 10 grams per day is enough. In practice, this means three to eight pieces of chewing gum a day.[10] The pieces should be chewed immediately after a meal or a snack. If you eat more snacks, you of course need more frequent ingestion of xylitol.[11] Known toxic affects of xylitol to humans arise from consuming too much, as it may have a mild laxative and cramping effect.[10] Xylitol is safe for everyone and is easy to implement anywhere and anytime. It does not raise blood pressure or blood glucose levels as most sugar substitutes do.[5] It fits right in with the most frantic schedules. You don't need to change your normal routine to use xylitol. Children love to eat a piece of candy or chew on gum and notice no difference in candy and gum that replace sucrose with xylitol. As dental hygienists, it is our responsibility to provide preventive services to our patients, and therefore it is our responsibility to recommend products containing xylitol to help our patients improve their oral health and protect their teeth.
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