Peer-reviewed systematic reviews indicate that ingesting xylitol through consumption of foods like chewing gum or candies reduces the levels of cariogenic bacteria and helps prevent dental caries.
<h4>Purpose</h4>A systematic review of published data was carried out to assess the caries-preventive effects of xylitol chewing gums and candies in children.<h4>Methods</h4>Electronic and hand searches were performed to find clinical studies on the effects of xylitol chewing gums and candies on dental caries in children (≤ 18 years). Prospective randomised or controlled clinical trials published before 2023 were included in the review.<h4>Results</h4>The initial search identified 365 titles to be evaluated. After applying inclusion and exclusion criteria, 15 articles with either fair or low quality were reviewed. Nine articles studied chewing gums, five candies, and one both of them. In the ten evaluated xylitol chewing gum studies xylitol consumption significantly reduced caries occurrence when compared with no treatment or a placebo polyol gum. The effect was clinically significant in studies with high or moderate caries level at study baseline. The results also suggested that the caries-reducing effect of xylitol gums may differ from sorbitol/polyol gums. In five of the six heterogenous xylitol candy studies, no caries-reducing effect was found independent of caries level. In addition to caries level, also the daily xylitol dose was a confounding factor.<h4>Conclusion</h4>The present findings suggest that the caries-reducing effect of adding xylitol chewing gum to the daily diet has been well demonstrated in children and adolescents with high or moderate caries level at study baseline. Xylitol gum use could benefit subjects with active incipient caries lesions on smooth tooth surfaces.
Xylitol gum use could benefit subjects with active incipient caries lesions on smooth tooth surfaces. Keywords Dental caries Xylitol Polyol Chewing gum Caries prevention University of Turku (including Turku University Central Hospital) Open Access funding provided by University of Turku (including Turku University Central Hospital).
This effect is shared by other polyol sweeteners such as sorbitol and maltitol. However, xylitol differs from them in that it is not fermented by the oral microbiota (Havenaar et al. 1978 ). Xylitol consumption has also been shown to reduce the acid production potential of plaque (Campus et al. 2009 ; Splieth et al. 2009 ). Several randomised clinical trials suggest that habitual xylitol chewing gum consumption is likely to decrease counts of caries-associated mutans streptococci and that the reduction differs from that found for sorbitol/polyol gum (Milgrom et al. 2006
Habitual xylitol gum chewing appears also to reduce the amount of dental plaque (Nasseripour et al. 2022 , Söderling and Pienihäkkinen 2022 ). These specific “xylitol-effects” have been attributed, amongst others, to growth inhibition of mutans streptococci and less adhesive plaque due to reduced amounts extracellular polysaccharides in the plaque (Söderling 2009 ). Also, the mother–child studies, demonstrating a decrease in the early transmission of mutans streptococci and caries occurrence in the children following maternal xylitol consumption, suggest specific effects for xylitol (Li and Tanner 2015 ).
On a tooth surface level, caries on smooth surfaces decreases first and the most, whereas the caries on the occlusal surfaces of first molars seems to be reduced the least. As a result, in low-caries conditions, tooth decay in children and adolescents is largely a phenomenon of occlusal pits and fissures of the posterior teeth (Selwitz et al. 2007 ; Nørrisgaard et al. 2016 ). Our aim was to describe and evaluate the literature published during 1974–2022 in relation to the caries-preventive effect of xylitol chewing gums and candies in children.
With this systematic review we aimed to answer the defined research questions: (1) can the consumption of xylitol chewing gum and/or candies reduce occurrence of dental caries in children, (2) what is the importance of the caries level of the children for the outcome, and (3) are the effects specific to xylitol? Materials and methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al. 2021 :PRISMA STATEMENT) was used as a guideline in the present systematic review. The review was registered in PROSPERO (CRD42022376771) before starting the data collection.
Information sources and research strategies The research question for the present systematic review was formulated using PICO characteristics (Patients, Intervention, Control, Outcome), as follows: in children (0–18 years) (P), are xylitol chewing gums and/or candies (I), compared with a control (no gum/candy, a placebo gum/candy) (C), effective in decreasing caries occurrence (during the follow-up the reduction in the caries increment or in the proportion of subjects/teeth/tooth surfaces with new dental decay) (O)? The search to identify all the relevant, published studies was conducted using three databases: PubMed, Embase and the Cochrane Library.
It is surprising that many reviews on effects of xylitol on caries occurrence neglect to acknowledge the caries level at baseline as a confounding factor (Mickenautsch et al. 2007 , Deshpande and Jadad 2008 ; Riley et al. 2015 ; Janakiram et al. 2017 ; Marghalani et al. 2017 ; ALHumaid and Bamashmous 2022 ; He et al. 2023 ). With decreasing caries level, the average number of decayed tooth surfaces, teeth and dentitions decrease, and the proportion of subjects with no disease and those with no new decay increases.
This knowledge may provide dental professionals with confidence in their recommendations of xylitol use to their high-caries risk patients in particular. The surface-specific analyses suggest that xylitol gum use could work with the highest benefit in subjects with active incipient caries lesions detected on buccal or lingual surfaces of teeth. Xylitol use is, anyhow, one piece in a puzzle of caries prevention to be used together with tooth brushing with fluoride toothpaste twice a day and restriction of sucrose intake.
Xylitol, a naturally occurring sugar found in plants and fruits, is becoming an increasingly important agent against tooth decay. Dominique Tillen, Founder and Direct of Brushbaby, looks further at its application in dentistry
<h4>Background</h4>Xylitol is a sugar alcohol increasingly used in dentistry as a preventative measure against dental caries. The objective of this systematic review was to assess xylitol's efficacy in caries prevention through the reduction of the most commonly associated bacteria: Streptococcus mutans.<h4>Material and methods</h4>This systematic review followed PRISMA guidelines. A literature search was conducted in PubMed, Cochrane and Google Scholar databases. The search algorithm included the following key words: xylitol, dental caries, tooth demineralization, Streptococcus mutans, and prevention. The CASPe tool was used to assess risk of bias in the articles reviewed.<h4>Results</h4>After the search and selection processes, nine clinical trials (some of them placebo-controlled) in humans were included in the review. The objective proposed - to assess the efficacy of xylitol in caries prevention - was not fulfilled conclusively in all the works. Little heterogeneity was observed among the trials, as the study groups, evaluation periods, daily doses of xylitol etc. varied considerably between the works.<h4>Conclusions</h4>According to the present findings, the preventative effect of xylitol against dental caries cannot be confirmed. The results also highlight the need for further research with standardized protocols. <b>Key words:</b>Xylitol, dental caries, dental demineralization, Streptococcus mutans, prevention.
It is characterized by having the same sweetness and volume as saccharine but with a third fewer calories and without requiring insulin for its metabolism, which contributes to its insulinemic properties and low glycemic index ( 2 ). It has been shown that xylitol is a valuable agent in dental caries prevention because it is not an attractive substrate for the bacteria that make up oral biofilm. Its consumption increases saliva flow and reduces Streptococcus mutans (SM) levels by altering its processes of energy production, leading to an unusable energy cycle and cell death.
At the same time, xylitol reduces the acidogenic potential and adhesion of these microorganisms to the tooth surfaces by increasing pH, which impedes enamel demineralization. Its main characteristic is that xylitol is practically non-fermenTable by oral bacteria ( 2 , 5 , 6 ). The safety of xylitol has been extensively investigated. While most research has reported few secondary effects, such effects are produced only after high intakes of xylitol, as high as 50 g per day, four or five times the recommended dose. These include abdominal pain and diarrhea. But at the recommended dose of 6 g per day, xylitol is considered completely safe ( 1 , 5 ).
An electronic search was made in the PubMed, Cochrane and Google Scholar databases using following MeSH (Medical Subjects Headings) terms and Boolean operators: xylitol, dental caries, tooth demineralization, Streptococcus mutans , and prevention.
Combinations of these (MeSH) key terms were used: (“xylitol” [MeSH terms] OR “xylitol” [All fields]) AND (“dental caries” [MeSH terms] OR “dental” [All fields] AND “caries” [All fields] OR “dental caries” [All fields]) AND (“tooth demineralization” [MeSH terms] OR “tooth” [All fields] AND “demineralization” [All fields] OR “tooth demineralization” [All fields]) AND (“ Streptococcus mutans ” [MeSH terms] OR “Streptococcus” [All fields] AND “mutans” [All fields] OR “ Streptococcus mutans ” [All fields]) AND (“prevention” [MeSH terms] OR “prevention” [All fields]). An additional manual search was made for any other articles that could be of relevance.
At the same time, no significant differences were found between the groups in terms of general bacterial composition between baseline and follow-up analyses. Jain et al . ( 13 ) set out to compare the efficacy of xylitol chewing gum with a combination of IgY (immunoglobulin Y) and chewable xylitol Tablets for reducing SM in children. Children (n=120) of both sexes, aged between 6 and 12 years were included in the trial. The subjects selected presented SM saliva counts of ≤ 105 colony forming units and all had at least one tooth with caries, either lost or in treatment.
In the xylitol group, gingival index and plaque values were significantly lower after three weeks than at baseline ( p <0.001 and p <0.05, respectively), as well as the concentration of cytokines in saliva. SM was reduced by approximately five times through the use of xylitol over the three weeks with significant difference in comparison with baseline counts. Kayalvizhi et al . (
Forty-four patients participated in the trial (22 males and 22 females) aged between 12 and 18 years (mean age 14.38 +/- 1.96 years). All patients presented Quigley Hein (modified by Turesky) plaque index scores of 1.5 or over. They were divided randomly into two groups: 22 patients used toothbrushes impregnated with xylitol (test group) and 22 used toothbrushes without xylitol (control group). They were asked to use a new tooth brush every day for 12 weeks, brushing twice a day for 2 minutes. In this way, test patients were exposed to approximately 0.02 g xylitol at each brushing.
Although caries was usually registered at the age of 7 years, caries data was also calculated at younger ages, showing significant reductions ( p < 0.001) in the incidence of enamel and dentin caries in the xylitol group compared with the control group at all time intervals. In the test group, oral SM counts decreased significantly ( p < 0.001). Discussion Caries is an infectious and multifactorial disease caused by specific bacteria that adhere to teeth, in particular Streptococcus mutans (SM), which metabolizes sugars to produce acid that over time demineralizes the dental structure. Caries prevention is based on the search for substances that reduce or eliminate SM.
(20) 271 subjects 6-8 months Mixed 26-28 months Dosage: 13.5mg daily per deciduous tooth (n=133) xylitol applied with cotton bud twice a day (n=138) control group Clinical trial
<h4>Objective</h4>A systematic review of published data was carried out to assess specific effects of xylitol chewing gum on levels of mutans streptococci (MS), dental plaque, or caries.<h4>Materials and methods</h4>Electronic and hand searches were performed to find clinical studies on levels of MS, or plaque, or caries comparing effects of xylitol gum with a polyol control gum. Prospective randomized or controlled clinical studies published before 2025 were included in the review.<h4>Results</h4>The search identified 908 titles on MS, 879 titles on plaque, and 658 on caries to be evaluated. After applying inclusion and exclusion criteria, 16 articles on MS, ten on plaque and five on caries were reviewed. In 12/14 studies xylitol gum significantly decreased MS counts compared with sorbitol gum. Plaque accumulation decreased in 6/10 studies and caries occurrence in 3/5 trials when xylitol gum was compared with sorbitol/sorbitol-containing gum. Three studies on MS and/or plaque accumulation had a maltitol gum control, but the results of the studies were conflicting.<h4>Conclusions</h4>The best evidence of specific beneficial effects for xylitol gum differing from those of sorbitol gum are found in the evaluated MS and plaque studies. The results of the reviewed caries trials are in line with this idea. Xylitol gum chewing is suggested to act as an adjunct to toothbrushing for reducing caries-associated MS and plaque accumulation to control and prevent caries occurrence in children and adults. Adults with other plaque-related diseases like periodontal disease should also benefit from xylitol gum.
A hand search was conducted in the reference lists of previous systematic reviews close to the present topic. The authors have written two previous systematic reviews aiming to find out if xylitol chewing gum or candies/lozenges can reduce caries occurrence [ 9 ] or the accumulation of plaque [ 5 ]. We also wrote a systematic review on the effects of xylitol and erythritol consumption on the numbers of MS and composition of the oral microbiota [ 1 ]. In that review the abundant literature limited the search to cover papers published between 2000 and 2019.
These MS were suggested to be easily shed to saliva and be connected with a decrease in the accumulation of plaque [ 61 ]. This idea has not been supported by studies showing that xylitol chewing gum use reduces MS levels and plaque accumulation even in long-term use [ 29 , 33 , 35 , 40 , 62 ]. The degree of xylitol sensitivity also varies a lot among S. mutans strains, and in comparisons of xylitol-resistant versus xylitol-sensitive S. mutans strains, no differences in cariogenic traits were found [ 63 , 64 ]. Apart from xylitol, systematic MS decreases have not been reported for other polyols used in chewing gums [ 1 , 2 , 10 ].
with active incipient caries lesions on buccal or lingual surfaces of teeth, xerostomic patients, and elderly people in general. Also motivated adults with a history of caries and young children may reduce the early MS-transmission by consuming xylitol chewing gum. Daily xylitol doses of 5–6 g with a consumption frequency of three times a day appear to be effective in reducing MS counts, accumulation of plaque, and caries occurrence (Tables 1 , 2 , and 3 [ 22 , 30 , 31 ];). The recommended daily xylitol doses are not high, the dose is achieved with 5–6 pellet gums with a high xylitol concentration.
Xylitol chewing gum, which is suitable for self-care, can be recommended not only to patients with a high caries risk, but also to patients who suffer from gingival inflammation or periodontal disease. Xylitol chewing gum is no substitute for tooth brushing, however; any adjuncts which may support mechanical control of pathogenic biofilms and thus the prevention of periodontal disease are of importance. So far, only a few clinical trials have focused on periodontal applications of xylitol chewing gum [ 71 ]. Very recently, a novel application of xylitol chewing gum was presented by Valentine et al. [ 72 ].
According to the study results, Malawian pregnant women who chewed xylitol gum experienced fewer miscarriages compared to those who did not chew gum. This result was attributed to an improvement in periodontal health. The association between adverse pregnancy outcomes and periodontal health has been demonstrated in several studies [ 72 , 73 ]. Considering the high rates of miscarriages in Malawi, xylitol gum chewing could help to reduce the risk of periodontal disease-associated pregnancy complications. In general, the only adverse effects connected with polyol consumption are digestive disorders.
Xylitol and other polyols belong to FODMAP (fermentable oligo-, di-, monosaccharides and polyols) substances which may not be suitable for persons with digestive disorders. For dental benefits relatively small daily doses are recommended. Complaints about digestive discomfort in xylitol studies are rare [ 1 , 5 , 9 ], which is supported by results of the present review. When ingested in the form of chewing gum xylitol is absorbed from the gut and metabolized by efficient metabolic pathways [ 74 ]. Recently, the study by Witkowski et al. [ 75 ] suggested that xylitol is associated with increased cardiovascular risk.
The present review also suggests that it is likely that habitual use of xylitol chewing gum decreases plaque accumulation, a risk factor of both caries and periodontal disease. These effects are specific to xylitol chewing gum and differ from those of sorbitol chewing gum. The results of the few evaluated caries trials were in line with or at least did not contradict this idea. Xylitol chewing gum can be helpful in the prevention and control of plaque-related diseases in children and adults. It is no substitute for tooth brushing, but an effective addition to daily health routines, i.e. tooth brushing with fluoride toothpaste and restriction of sucrose intake.
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