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American Academy of Pediatric Dentistry Policy on the Use of Xylitol in Caries Prevention

Originating Council

Council on Clinical Affairs

Adopted

2006

Review Council

Council on Clinical Affairs

Revised

2010

Purpose

The American Academy of Pediatric Dentistry (AAPD) rec- ognizes the benefits of caries preventive strategies involving sugar substitutes, particularly xylitol, on the oral health of infants, children, adolescents, and persons with special health care needs. This policy is intended to assist oral health care professionals make informed decisions about the use of xylitol-based products in caries prevention.

Methods

This policy is an update of the previous policy, adopted in 2006. The update is based upon a review of current den- tal and medical literature related to the use of xylitol in caries prevention. A MEDLINE literature search was conducted using PubMed with the following parameters: Terms: “xylitol” AND “caries prevention”; Field: all fields; Limits: within the last 10 years; humans, English; birth through 18. Two hun- dred forty articles matched these criteria; 25 papers were re- viewed at this revision. When data did not appear sufficient or were inconclusive, recommendations were based upon ex- pert and/or consensus opinion by experienced researchers and clinicians.

Background

Xylitol is a five-carbon sugar alcohol derived primarily from forest and agricultural materials. It has been used since the early 1960’s in infusion therapy for post-operative, burn, and shock patients; in the diet of diabetic patients; and, most re- cently, as a sweetener in products aimed at improved oral health.1 Dental benefits of xylitol first were recognized in Fin- land in 1970, using animal models.2 The first chewing gum developed with the aim of reducing caries and improving oral health was released in Finland in 1975 and in the United States shortly after. The first xylitol studies in humans, known as the Turku Sugar Studies,3,4 demonstrated the relationship be- tween dental plaque and xylitol, as well as the safety of xylitol for human consumption. These early studies showed the de- cayed, missing, and filled (dmf) incidence in teeth in a sucrose chewing-gum group was 2.92 compared to 1.04 in the xylitol gum group. The most comprehensive study with xylitol gum,

conducted in 1995, compared the effect on caries incidence for xylitol, sorbitol, and sucrose consumption.5 The group that received 100% xylitol gum 5 times/day had significantly low- er levels of sucrose and free sialic acid in whole saliva than at baseline and significantly lower plaque index scores.5 The xylitol group also exhibited the lowest levels of salivary lac- tobacilli at endpoint, and this group did not experience the age-related increase in Mutans streptococci (MS) as did the other groups.5

Xylitol studies show varying results in the reduction of the incidence of caries or MS levels.5-13 Studies suggest xylitol intake that consistently produces positive results ranged from 4-10 grams per day divided into 3 to 7 consumption periods.5-12 Higher amounts did not result in greater reduction in inci- dence of caries and may lead to diminishing anticariogenic results.5-13 Similarly, consumption frequency of less than 3 times per day at optimal xylitol amount showed no effect.14-16 Ab- dominal distress and osmotic diarrhea have been reported fol- lowing the ingestion of xylitol.17-18 Diarrhea has been reported in patients who have consumed 3-60 grams of xylitol per day.19-23

Xylitol reduces plaque formation and bacterial adherence (ie, is antimicrobial), inhibits enamel demineralization (ie, re- duces acid production), and has a direct inhibitory effect on MS. Prolonged use of xylitol appears to select for a “xylitol- resistant” mutant of the MS cells.24 These mutants appear to shed more easily into saliva than the parent strains,23 resulting in a reduction of MS in plaque26 and possibly hampering their transmission/colonization from mother to child. Long-lasting effects have been demonstrated up to 5 years after 2 years of using xylitol chewing gum.27-28 Use of xylitol gum by mothers (2-3 times per day starting 3 months after delivery and until the child was 2 years old) reduced the MS levels in children up to 6 years of age and was significantly better than applying fluoride varnish or chlorhexidine varnish at 6, 12, and 18 months after delivery. At 5 years of age, the xylitol group had 70% reduction in caries (dmf) as compared with the varnish and chlorhexidine groups. Fluoride varnish alone had little effect on total salivary levels of MS.27 Some studies suggest the chewing process may enhance the caries inhibitory effect of xylitol chewing gum.28-31

Xylitol currently is available in many forms (eg, gums, mints, chewable tablets, lozenges, toothpastes, mouthwashes, cough mixtures, nutraceutical products).32-33 Xylitol chewing gum has been shown to be effective as a preventive agent. The effectiveness of other xylitol products is being studied at this time.

Policy statement

The AAPD: 1. supports the use of xylitol as part of a preventive strat-

egy aimed specifically at long term caries pathogen suppression and caries (dmf ) reduction in higher risk populations.

2. recommends that, as further research and evidence-based knowledge is available, protocols be established to further clarify the impact of delivery vehicles, the frequency of exposure, and the optimal dosage to reduce caries and improve the oral health of children.

3. encourages xylitol-containing products be labeled clear- ly with regard to their xylitol content to enable dentists and consumers to ensure therapeutic levels of exposure.31

References

1. Mäkinen KK. Biochemical principles of the use of xylitol in medicine and nutrition with special consideration of dental aspects. Experientia Suppl 1978;30:1-160.

2. Muhlemann HR, Regolati B, Marthaler TM. The effect on rat fissure caries of xylitol and sorbitol. Helv Odontol Acta 1970;14(1):48-50.

3. Scheinin A, Mäkinen KK, Tammisalo E, Rekola M. Turku sugar studies. XVIII. Incidence of dental caries in relation to 1-year consumption of xylitol chewing gum. Acta Odontol Scand 1975;33(5):269-78.

4. Scheinin A, Mäkinen KK, Ylitalo K. Turku sugar stud- ies. V. Final report on the effect of sucrose, fructose and xylitol diets on caries incidence in man. Acta Odontol Scand 1976;34(4):179-216.

5. Mäkinen KK, Benett CA, Hujoel PP, et al. Xylitol chew- ing gums and caries rates: A 40-month cohort study. J Dent Res 1995;74(12):1904-13.

6. Mäkinen KK, Hujoel PP, Bennett CA, et al. A descriptive report of the effects of a 16-month xylitol chewing-gum programme subsequent to a 40-month sucrose gum pro- gramme. Caries Res 1998;32(2):107-12.

7. Milgrom P, Ly KA, Roberts M, Rothen M, Mueller G, Yamaguchi DK. Mutans Streptococci dose response to Xylitol chewing gum. J Dent Res 2006;85(2):177-81.

8. Hujoel PP, Mäkinen KK, Bennett CA, et al. The opti- mum time to initiate habitual xylitol gum-chewing for obtaining long-term caries prevention. J Dent Res 1999; 78(3):797-803.

9. Mäkinen KK. The rocky road of xylitol to its clinical ap- plication. J Dent Res 2000;79(6):1352-5.

10. Mäkinen KK, Chiego DJ Jr, Allen P, et al. Physical, chemical, and histologic changes in dentin caries lesions of primary teeth induced by regular use of polyol chewing gums. Acta Odontol Scand 1998;56(3):148-56.

11. Mäkinen KK, Mäkinen PL, Pape HR, et al. Conclusion and review of the Michigan Xylitol Programme (1986- 1995) for the prevention of dental caries. Int Dent J 1996;46(1):22-34.

12. Deshpande A, Jadad AR. The impact of polyol-containing chewing gums on dental caries: A systematic review of original randomized controlled trials and observational studies. J Am Dent Assoc 2008;139(12):1602-14.

13. Stecksén-Blicks C, Holgerson PL, Twetman S. Effect of xylitol and xylitol-fluoride lozenges on approximal caries development in high caries-risk children. Int J Paediatr Dent 2008;18(3):170-7.

14. Isokangas P. Xylitol chewing gum in caries prevention. A longitudinal study on Finnish school children. Proc Finn Dent Soc 1987;83(suppl 1):1-117.

15. Rekola M. Correlation between caries incidence and frequency of chewing gum sweetened with sucrose or xylitol. Proc Finn Dent Soc 1989;85(1):21-4.

16. Thaweboon S, Thaweboon B, Soo-Ampon S. The effect of xylitol chewing gum on mutans streptococci in saliva and dental plaque. Southeast Asian J Trop Med Public Health 2004;35(4):1024-7.

17. Scheie AA, Fijerskov O. Xylitol in caries prevention: What is evidence for clinical efficacy? Oral Dis 1998;4(4): 268-78.

18. Mäkinen KK. Dietary prevention of dental caries by xylitol – Clinical effectiveness and safety. J Appl Nutr 1992;44:16-28.

19. Akerblom HK, Koivukangas T, Puuka R, Mononen M. The tolerance of increasing amounts of dietary xylitol in children. Int J Vitam Nutr Res Suppl 1982;22:53-66.

20. Giertsen E, Emberland H, Scheie AA. Effects of mouth rinses with xylitol and fluoride on dental plaque and saliva. Caries Res 1999;33(1):23-31.

21. Salminen EK, Salminen SJ, Porkka L, Kwasowski P, Marks V, Koivistoinen PE. Xylitol vs glucose: Effect on the rate of gastric emptying and motilin, insulin, and gas- tric inhibitory polypeptide release. Am J Clin Nutr 1989; 49(6):1228-32.

22. Uhari M, Kontiokari T, Koskela M, Niemela M. Xylitol chewing gum in prevention of acute otitis media: Double blind randomized trial. Brit Med J 1996;313(7066): 1180-4.

23. Waler SM, Rolla G. [Xylitol, mechanisms of action and uses]. Nor Tannelaegeforen Tid 1990;100(4):140-3.

24. Trahan L, Mouton C. Selection for Streptococcus mutans with an altered xylitol transport capacity in chronic xylitol consumers. J Dent Res 1987;66(5):982-8.

25. Trahan L, Söderling E, Dréan MF, Chevrier MC, Iso- kangas P. Effect of xylitol consumption on the plaque- saliva distribution of mutans streptococci and the occur- rence and long-term survival of xylitol-resistant strains. J Dent Res 1992;71(11):1785-91. Erratum in: J Dent Res 1993;72(1):87-8.

26. Söderling E, Trahan L, Tammiala-Salonen T, Hakkinen L. Effects of xylitol, xylitol-sorbitol, and placebo chewing gums on the plaque of habitual xylitol consumers. Eur J Oral Sci 1997;105(2):170-7.

27. Söderling E, Isokangas P, Pienihakkinen K, Tenovuo J, Alanen P. Influence of maternal xylitol consumption on mother-child transmission of mutans streptococci: 6 year follow-up. Caries Res 2001;35(3):173-7.

28. Mäkinen KK, Alanen P, Isokangas P, et al. Thirty-nine month xylitol chewing gum programme in initially 8- year-old school children: A feasibility study focusing on mutans streptococci and lactobacilli. Int Dent J 2008; 58(1):41-50.

29. Machiulskiene V, Nyvad B, Baelum V. Caries preventive effect of sugar-substituted chewing gum. Community Dent Oral Epidemiol 2001;29(4):278-88.

30. Scheie AA, Fejerskov O, Danielsen B. The effects of xylitol-containing chewing gums on dental plaque and acidogenic potential. J Dent Res 1998;77(7):1547-52.

31. Van Loveren C. Sugar alcohols: What is the evidence for caries-preventive and caries-therapeutic effects? Caries Res 2004;38(3):286-93.

32. Ly KA, Milgrom P, Rothen M. Xylitol, sweeteners, and dental caries. Pediatr Dent 2006;28(2):154-63. Discussion 92-8.

33. Lynch H, Milgrom P. Xylitol and dental caries: An over- view for clinicians. J Calif Dent Assoc 2003;31:205-9.