Army's "Look for Xylitol First" program.

Abstract: Xylitol is a sugar substitute not well known in the United States. This sugar substitute is not only low in calories but can also help prevent dental caries. The U.S. Army Dental Command's Health Promotion Program is constantly seeking additional prevention measures to enhance the oral health of America's Army. The Dental Command has created the "Look for Xylitol First" initiative aimed at training all members of the dental care team on the positive benefits of xylitol and to teach patients how to be smart consumers and evaluate products for their xylitol content.

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Prevention of dental caries is fundamental to any Oral Health Promotion and Prevention Program. The U.S. Army Dental Command (DENCOM) utilizes a prevention toolbox that includes, but is not limited to, sealants, fluoride, diet modification, oral hygiene instruction, and the use of chemotherapeutics such as chlorhexidine. The purpose of this article is to introduce the use of xylitol as another useful adjunct for our prevention program.

Few Americans know that regular use of a sugar substitute called xylitol (pronounced zi-la-tol) helps prevent caries, but this product has been widely used in Europe and Asia over the last 20 years. One advantage of xylitol is that it tastes good and patients can enjoy a positive health impact while simply chewing gum or eating mints. Oral health professionals know that xylitol is not a panacea, but can be a very useful adjunct as a part of an oral health prevention program. The DENCOM has created the "Look for Xylitol First" initiative, and its first objective is to train all members of the dental care team on the positive benefits of xylitol. Secondly, it is to teach patients how to be smart consumers and evaluate products for their xylitol content.

What Is Xylitol?

Xylitol is a Food and Drug Administration approved, polyol sweetener (sometimes called a sugar alcohol, although it has no alcohol content) that has caries reducing properties over and above sugar replacements. (1) Xylitol is the only naturally occurring sugar alternative and can be found in raspberries, cauliflower and organic substances, even hardwood. Xylitol was originally produced in Finland through an extraction process using birch wood and has been part of the natural foods market for decades. Now manufactured in several countries, including the United States, it is being used in many new health and personal care products. Xylitol contains two-thirds the calories of sugar, but is digested slowly as a carbohydrate outside of the insulin loop, making it ideal for diabetics. It tastes as sweet as sugar, but has no aftertaste usually associated with sugar replacements. Plus it has a refreshing quality that gives the sensation of cooling in the mouth.

How Does Xylitol Reduce Caries?

Xylitol affects the mutans streptococci bacteria associated with dental caries but not through an antibiotic mechanism such as chlorhexedine. Xylitol is ingested by mutans streptococci, just as the bacteria would ordinarily ingest any sugar entering the oral cavity. However, the plaque-producing streptococcus bacteria are unable to process the xylitol and die, thereby lowering the number and strength of the oral bacteria load. (2) With regular use, chewing xylitol gum 3-5 times daily for about five minutes has been shown to reduce caries rates by between 35-70% in caries-prone patients. (3) Other benefits of xylitol use are:

* Xylitol maintains a neutral pH in dental plaque, avoiding decay promoting acids, probably by enhancing salivary flow and buffer capacity.

* Xylitol inhibits growth, adhesion and metabolism of mutans streptococci bacteria.

* Xylitol use helps to reduce oral plaque levels.

* Xylitol suppresses mutans streptococci bacteria even with sugar intake.

* Xylitol promotes remineralization of initial enamel lesions.

* While fluoride strengthens enamel surfaces, xylitol acts on the mutans streptococci and with a resultant synergistic caries reduction.

How to Talk to Patients About Xylitol

For your patients who chew gum, you can help them find xylitol in highly appealing chewing gums available at the candy counter of most grocery stores, convenience stores or discount retailers. Proper counseling is important since getting the right amount of xylitol per serving is key to unlocking its protective properties. Approximately 1.65g of xylitol per serving is considered to be efficacious in caries prevention. It can be difficult for consumers to determine if a product has enough xylitol. The Army is encouraging patients to read the ingredients list, and look for xylitol as the first ingredient. When xylitol appears before "gum base," you know that there is a sufficient amount of xylitol in that gum. This is in line with the U.S. Army's prevention initiative "Look for Xylitol First" that was designed for educating service personnel at risk for caries. A small handout (Figure 1) was created similar to a prescription pad detailing the benefits of xylitol and how to read the label, as well as posters for patient education (Figure 2).

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Xylitol can be used in many ways such as in candy, gum, mouthwash, or toothpaste. Since companies are continually changing their formulas, it is best to teach your patients always to look at the ingredients list and not just a particular brand. What could be a great xylitol gum today can be completely changed and still wear the same brand name without xylitol. Dentifrices containing 10% xylitol sweetener have been shown to reduce caries in a number of recent studies. (4) Although it has not been studied for effectiveness, a mouthwash is available in a popular health brand line.

Who Should Use Xylitol?

While Xylitol is safe for the whole family, chewing gum in general, is not recommended for children younger than three years of age. As children approach the cavity-prone early teen years, they should be encouraged to use xylitol gum. People with dry mouth (xerostomia) as a side-effect of medications, diseases such as Sjogrens Syndrome, or age-related reduced salivary flow could benefit from regular use of xylitol chewing gum. Of course, caries-prone adults of ally age who chew gum regularly should be steered toward those containing xylitol. However, the inherent fun of chewing gum is not centered on health benefits. The unique flavor profiles in which the gum is often made, like lemon, berry and power mint, are enhanced by a cooling effect that the xylitol contributes to the product.

Why Isn't Xylitol Well Known in the United States?

Part of the problem of why xylitol is not as popular in the United States may stem from the sugar-alternatives rather unusual name. In Canada, where xylitol is used extensively in familiar, dentally positioned chewing gum, xylitol is called Dentec. The United States continues to use the chemical name, and xylitol companies have yet to give it an also-known-as handle as they have for aspartame (Nutrasweet).

The awareness about xylitol is strong in Europe and Asia. Xylitol containing sugar-free gums are the number one sellers in Japan and Korea. In Europe, where xylitol has been incorporated in the candy industry for 30 years, xylitol gums and candies are everywhere to be found often marketed to mothers who give the candies to their children.

As U.S. manufacturers expand their product lines toward healthy and low-calorie goods, and as we continue to exchange delicacies with Europe, more xylitol-containing products are sure to appear. This will be a win-win situation for the American population since caries is not promoted by the consumption of these products. Remineralization of demineralized tooth structure will also occur. Don't forget to encourage your patients to "Look for Xylitol First"!

References

(1.) Hayes C. The effect of noncariogenic sweeteners on the prevention of dental caries: A review of the evidence. J Dent Educ. 2001: 65(10); 1106-9.

(2.) Trahan L. Xylitol: a review of its action on mutans streptococci and dental plaque--its clinical significance. Int Dent J. 1995: 45; 77-92

(3.) Alanen P, et al. Xylitol candies in caries prevention: results of a field study in Estonian children. Community Dent Oral Epidemiol. 2000: 28(3);218-24.

(4.) Sintes JL, et al. Enhanced anticaries efficacy of a 0.243% sodium fluoride/10% xylitol/ silica dentifrice: three-year clinical results. Am J Dent. 1995; 8(5); 231-5.

The authors are with the Dental Corps, U.S. Army Dental Command, serving at Fort Sam Houston, Texas. Pamila Richter, RDH, is Health Promotion Director and MAJ Jeffrey Chaffin, DDS, MPH, is Public Health Dental Officer.

Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy of the U.S. Department of Defense or other departments of the U.S. Government.