ADHA Access July 2012 : Page 22

Xylitol to the Rescue By Judith M. Stein, RDH hether decay is incipient, recurrent, interproximal or on the root surface, having to note it in the patient chart is frus-trating for dental health professionals from recent graduates to veteran practitioners. Any patient can be affected, regardless of age, gender or nationality. Fortunately, they and their health care providers have a powerful ally in the form of xylitol. Xylitol, a five-carbon sugar alcohol, is a natural sweetener found primarily in birch wood chips and other agricultural products such as straw, corncobs, fruit, vegetables, cereals, mushrooms and some seaweed. 1 The human body also pro-duces trace amounts of xylitol as a byproduct of metabolism, making it compatible as an additive to our diets. To date, there are no known adverse interactions between xylitol and other foods or drugs, making this supplement widely accepted by both traditional and naturopathic medical practice. As with any supplement or drug, xylitol must not be overused. Although the U.S. government has deemed it a safe food additive, if it is ingested all at once in large amounts (30 to 40 grams), it could produce intestinal gas and/or diarrhea. 1 Xylitol was first discovered in 1891 by Emil Fischer, a Ger -man chemist 2 who was awarded the Nobel Prize in chemis-try in 1902. 3 The emergence of xylitol into general use was slow to follow; it became widely accepted in the early 1940s during WWII. Finland was the first to begin using xylitol when sucrose, or table sugar, was in short supply because of the war. In the 1960s, it became a more common choice in Germany, Switzerland, the Soviet Union and Japan. It wasn’t until 1963 that xylitol was finally approved by the Food and Drug Administration (FDA) in the United States and recog-nized as safe to use in foods. It was at this point in history that xylitol was more com-monly utilized in the medical community for diabetes man-agement. Xylitol has become a recognized alternative for the patient with diabetes. Xylitol has less effect on blood sugar and insulin than regular sucrose has, providing more variety and healthier lifestyle choices for those with diabetes. 1 Xyli-tol’s effect extends to improving the oral condition of patients with diabetes, as well. W Two-Year Turku Sugar Study, 1970s Type of sugar sweetener Sucrose only Fructose only Xylitol only Discontinued participants Number of Participants 35 38 52 10 Mean increment of decayed, missing and filled tooth surfaces 7.2 3.8 0.0 Not available In 1995, another comprehensive study was conducted that compared the occurrence of dental caries and the effects pa-tients experienced using xylitol, sorbitol and sucrose. Results included: 6 • The group that received 100 percent xylitol chewing gum five times a day experienced lower levels of sucrose and free sialic acid in their whole saliva. • The xylitol group exhibited the lowest levels of lactoba -cilli compared to the sucrose and sorbitol groups. • The xylitol group did not experience an increase in Streptococcus mutans compared to the other groups. Xylitol functions in two ways against dental caries. 1) It reduces plaque formation and 2) it reduces bacterial adher-ence. 6 These are major interruptions in the caries process. Any time plaque formation is reduced, there is the poten-tial for reduction in dental caries. Plaque reduction occurs because bacteria in the mouth will not ferment xylitol, and therefore cannot produce the acids that cause dental caries. 1 There is also the potential for a reduction in dental car-ies when bacterial adherence is altered. Whenever the cilia extending from the bacterial cell membrane are impaired, the bacterial biofilm they latch onto is altered and the caries process is reduced. Six to 10 grams of xylitol a day is the op-timum dosage and the one that daily intake experts continue to encourage. Mechanical plaque removal, fluoride applica -tions and nutritional counseling are also critical components in the war against dental caries. There is no disputing the importance of these routines. Today, thanks to the research about xylitol, oral health care professionals can add this natu-ral sugar substitute to our armamentarium. As research has indicated and as FDA has approved, xylitol can now be applied in several medical and dental situ-ations. As previously mentioned, the diabetic community has incorporated xylitol into their food choices. Today, we can expect to find xylitol in food products such as hard candies, cookies, chewing gums, soft drinks and throat lozenges. 1 These items can be located in chain grocery stores, online sites and organic food stores as well. There is also a wealth of non-food products containing xylitol, including toothpaste, that are readily available to the general public. Research is also being conducted on xylitol’s influence in treating and preventing ear infections among children. At the University of Toronto, a group of children below age 12 were given eight to 10 grams of xylitol on a daily basis. At the end of this investigation, 25 percent of these children had fewer ear infections compared to another group of children who re-ceived a different sweetener. 7 These results indicate potential far-reaching health benefits for many people in the future. { Xylitol functions in two ways against dental caries. 1) It reduces plaque formation and 2) it reduces bacterial adherence. In the 1970s, the dental community became interested in xylitol’s effect against dental caries when over 20 research reports were published on the results of a two-year study conducted in Finland. These 20 research reports collectively became known as the “Turku Sugar Study.” 4 This study ob-served the influence sucrose, fructose and xylitol had on den -tal caries. There were 35 subjects in the sucrose-only group, 38 in the fructose group, and 52 in the xylitol group. During the entire study, 10 subjects discontinued or were excluded from participation. After two years, the mean increment of decayed, missed and filled tooth surfaces was 7.2 in the su -crose group, 3.8 in the fructose group, and 0.0 in the xylitol group. 5 This research alerted the dental community to the benefits xylitol could provide in the war against dental caries. 22 JUL 2012 access

Clinical Feature

Judith M. Stein

Whether decay is incipient, recurrent, interproximal or on the root surface, having to note it in the patient chart is frustrating for dental health professionals from recent graduates to veteran practitioners. Any patient can be affected, regardless of age, gender or nationality. Fortunately, they and their health care providers have a powerful ally in the form of xylitol. Xylitol, a five-carbon sugar alcohol, is a natural sweetener found primarily in birch wood chips and other agricultural products such as straw, corncobs, fruit, vegetables, cereals, mushrooms and some seaweed.1 The human body also produces trace amounts of xylitol as a byproduct of metabolism, making it compatible as an additive to our diets. To date, there are no known adverse interactions between xylitol and other foods or drugs, making this supplement widely accepted by both traditional and naturopathic medical practice. As with any supplement or drug, xylitol must not be overused. Although the U.S. government has deemed it a safe food additive, if it is ingested all at once in large amounts (30 to 40 grams), it could produce intestinal gas and/or diarrhea.1 Xylitol was first discovered in 1891 by Emil Fischer, a German chemist2 who was awarded the Nobel Prize in chemistry in 1902.3 The emergence of xylitol into general use was slow to follow; it became widely accepted in the early 1940s during WWII. Finland was the first to begin using xylitol when sucrose, or table sugar, was in short supply because of the war. In the 1960s, it became a more common choice in Germany, Switzerland, the Soviet Union and Japan. It wasn’t until 1963 that xylitol was finally approved by the Food and Drug Administration (FDA) in the United States and recognized as safe to use in foods. It was at this point in history that xylitol was more commonly utilized in the medical community for diabetes management. Xylitol has become a recognized alternative for the patient with diabetes. Xylitol has less effect on blood sugar and insulin than regular sucrose has, providing more variety and healthier lifestyle choices for those with diabetes.1 Xylitol’s effect extends to improving the oral condition of patients with diabetes, as well. In the 1970s, the dental community became interested in xylitol’s effect against dental caries when over 20 research reports were published on the results of a two-year study conducted in Finland. These 20 research reports collectively became known as the “Turku Sugar Study.”4 This study observed the influence sucrose, fructose and xylitol had on dental caries. There were 35 subjects in the sucrose-only group, 38 in the fructose group, and 52 in the xylitol group. During the entire study, 10 subjects discontinued or were excluded from participation. After two years, the mean increment of decayed, missed and filled tooth surfaces was 7.2 in the sucrose group, 3.8 in the fructose group, and 0.0 in the xylitol group.5 This research alerted the dental community to the benefits xylitol could provide in the war against dental caries. In 1995, another comprehensive study was conducted that compared the occurrence of dental caries and the effects patients experienced using xylitol, sorbitol and sucrose. Results included:6 • The group that received 100 percent xylitol chewing gum five times a day experienced lower levels of sucrose and free sialic acid in their whole saliva. • The xylitol group exhibited the lowest levels of lactobacilli compared to the sucrose and sorbitol groups. • The xylitol group did not experience an increase in Streptococcus mutans compared to the other groups. Xylitol functions in two ways against dental caries. 1) It reduces plaque formation and 2) it reduces bacterial adherence. 6 These are major interruptions in the caries process. Any time plaque formation is reduced, there is the potential for reduction in dental caries. Plaque reduction occurs because bacteria in the mouth will not ferment xylitol, and therefore cannot produce the acids that cause dental caries.1 There is also the potential for a reduction in dental caries when bacterial adherence is altered. Whenever the cilia extending from the bacterial cell membrane are impaired, the bacterial biofilm they latch onto is altered and the caries process is reduced. Six to 10 grams of xylitol a day is the optimum dosage and the one that daily intake experts continue to encourage. Mechanical plaque removal, fluoride applications and nutritional counseling are also critical components in the war against dental caries. There is no disputing the importance of these routines. Today, thanks to the research about xylitol, oral health care professionals can add this natural sugar substitute to our armamentarium. As research has indicated and as FDA has approved, xylitol can now be applied in several medical and dental situations. As previously mentioned, the diabetic community has incorporated xylitol into their food choices. Today, we can expect to find xylitol in food products such as hard candies, cookies, chewing gums, soft drinks and throat lozenges.1 These items can be located in chain grocery stores, online sites and organic food stores as well. There is also a wealth of non-food products containing xylitol, including toothpaste, that are readily available to the general public. Research is also being conducted on xylitol’s influence in treating and preventing ear infections among children. At the University of Toronto, a group of children below age 12 were given eight to 10 grams of xylitol on a daily basis. At the end of this investigation, 25 percent of these children had fewer ear infections compared to another group of children who received a different sweetener.7 These results indicate potential far-reaching health benefits for many people in the future. In oral health care, it is exciting to see xylitol leading the way toward the elimination of dental caries. There is also new and exciting research being conducted that highlights xylitol’s effect on periodontopathic bacteria. Knowing the destruction that Porphyromonas gingivalis bacteria and inflammatory cytokines have on the gingival tissue, it is encouraging to note that xylitol is showing an inhibitory effect on the growth of P. gingivalis.8 With awareness of the inflammatory component of periodontal disease, the dental research community will continue to observe xylitol’s influence and possible applications. Use of xylitol by pregnant women has also helped improve prenatal dental care for both mother and child. Research conducted at New York University School of Medicine suggests that children acquire cavity-causing bacteria from their mothers.9 Regular use of xylitol by a mother of a newborn child has shown to provide long-lasting protection to the child as well. What an optimum time to intercede and educate an expectant mother about dental caries prevention. When both mother and child benefit from the use of xylitol products, the long-term health benefits are doubled. Today, thanks to research efforts by both the medical and dental research communities, we have begun to trust the many benefits xylitol has on the human body. Terms like incipient caries, recurrent caries, interproximal caries and root surface caries no longer sound as hopeless. We can proceed into the next decade knowing the plethora of benefits xylitol provides in the fight against dental caries, periodontal disease and childhood ear infections as well as its positive role in diabetes management and prenatal dental care. References 1. University of Michigan Health System. Xylitol. Available at: www.uofmhealth. org/health-library/hn-3983008. 2. Rothen M. Xylitol in development. Dimensions of Dental Hygiene. 2006; 4(3): 24, 26. Available at: www.dimensionsofdentalhygiene.com/ddhright. aspx?id=765. 3. The Nobel Prize in Chemistry, 1902, Emil Fischer. Available at: www.nobelprize. org/nobel_prizes/chemistry/laureates/1902/. 4. Peldyak J. Turku sugar studies. Kidds Dental website. Available at: www.Kiddsdental.com/xylitol-research/turku-sugar-studies.html. 5. Scheinin A, Mäkinen KK, Ylitalo K. Turku sugar studies. V. Final report on the effect of sucrose, fructose and xylitol diets on the caries incidence in man.Acta Odontol Scand. 1976; 34(4):179-216. Abstract available at: www.ncbi. nlm.nih.gov/pubmed/795260 6. American Academy of Pediatric Dentistry. Policy on the use of xylitol in caries prevention. Available at: www.aapd.org/media/Policies_Guidelines/P_ Xylitol.pdf. 7. Natural sweetener used in chewing gum, mint may help arrest ear infections among children. India Pharma News. Nov 12, 2011. 8. Su-Ji Han, So-Yeon Jeong, Yun-Ju Nam, et al. Xylitol inhibits inflammatory cytokine expression induced by lipopolysaccharide from porphyromonas gingivalis.Clin Diagn Lab Immunol. 2005; 12(11): 1285–91. Abstract available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1287760/. 9. New York University Langone Medical Center. Tooth decay prevention. Available at: www.med.nyu.edu/content?ChunkIID=38568. Judith M. Stein, RDH, is a 1981 graduate of Kellogg Community College, Battle Creek, Mich. She has enjoyed a variety of professional opportunities in her dental hygiene career that include a commitment to lifelong learning and contributing as a feature writer for RDH magazine. She is now employed in private practice and an active volunteer in several professional, community and faith organizations.

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