Xylitol Use and Prevention
of Tooth Decay
Feasibility and Impact of Twice Daily
Tooth brushing at Head Start
Presented By:
Charles Hill, Director for Kittitas Co. Head Start
Elizabeth Webb-Beeles, Health Manager for Kittitas Co. Head Start
Dr. Kiet Ly, Clinical Assistant Professor and Researcher at Northwest
Center to Reduce Oral Health Disparities, University of Washington
Topics for this Session
 Oral health
 Human diet and sugars
 Causes of tooth decay
 Xylitol: What? Where? How?
 Northwest Center to Reduce Oral Health
Disparities, University of Washington
 Kittitas County Head Start feasibility project
 Future study
Oral Health
 A healthy mouth is integral to an
individual’s total health.
 America’s oral health has
improved over the past 50 years.
 Yet, tooth decay remains the single most
common chronic childhood disease.
 Worse, tooth decay is rising in preschoolers
 Over 51 million hours of school are lost each
year to dental problems.
The Great Fluoride Debate
 Fluoride prevents tooth decay
 Possible adverse side effect


Mottling of permanent teeth due to the
swallowing of excessive fluoride by young children
(dental fluorosis)
Benefit to health
in preventing
decay outweigh
the risk?
Progression of
fluorosis
Increased Risk
 Poor & Minority children suffer:


Twice as many tooth decay as their
more affluent peers, and their disease is more
likely to be untreated.
12 times more restricted-activity days than
children from higher-income families.
 Poor & ethnic minority groups experience
more oral health problems.
 Individuals with medical or physical disabilities
are also at greater risk.
Human Diet and Sugars
135 lbs. of sugar per
person per year
Cause of Dental Caries
 Streptococcus mutans (S. mutans) bacteria is
the leading cause of tooth decay.
 Plaque is a sticky film on teeth
 Bacteria like S. mutans feast on sugars and
starches found on teeth.
 Bacteria metabolism produce
acids that “eat away” teeth
surfaces causing weak spots
that can become cavities.
What is Xylitol?
 Naturally occurring sweetener in the same
class as sorbitol, maltitol, mannitol, erythritol.
 Found in fibers of trees, fruits,
and vegetables.
 The human body produces
several grams of xylitol a day.
 FDA approved as a food
additive (sweetener) in 1963.
How Xylitol Works
 Cannot be fermented by plaque bacteria.

Microorganisms like S. Mutans do not readily
metabolize xylitol into energy sources.
 Inhibits
growth and metabolism of
S. mutans and reduces dental plaque.
 Thus reduces S. mutans levels in plaque and
saliva =


Reduction in acid production
Reduction in dental caries
Xylitol Prevents Tooth Decay
 1975: First study on the effects of xylitol
conducted in Turku, Finland.
 One year study, 102 subjects
 Chewing Gum Each Day


S-group: 4 pieces of Sucrose gum
X-group: 4.5 pieces of Xylitol gum
 The mean increment of decayed, missing and
filled tooth surfaces:

S-group: 2.92 > X-group: 1.04
Xylitol Prevents Tooth Decay II
 2002: Swedish study on the effects of xylitol
toothpaste on the reduction of S. mutans.
 6 month study, 155 subjects.
 Toothpaste and brushing Twice Daily



Colgate Total with 10% xylitol
Colgate Total with triclosan (no xylitol)
Colgate Total without triclosan or xylitol
(Placebo)
 Four saliva and plaque samples gathered:

Baseline, 2 months, 4 months, 6 months
Xylitol Field Trial
 1994: Estonia school study on xylitol gum.
 3-year long period, 740 children (10 year olds).
 Xylitol or “Control” gum groups.
 Daily dose of 5 grams of xylitol in xylitol group.
 Xylitol groups showed
35-60% reduction in
caries incidence.
Significant difference
from control.
How Much Xylitol?
 Research suggests 5 to 10 grams of xylitol per
day for effectiveness.
 Humans tolerate up to
approx. 45 grams/day.
 5% may have cramps,
some have loose stools.
 Humans adapt, start slowly.
 Symptoms should disappear.
 Sorbitol is worse than xylitol.
Where Can You Find Xylitol?
Who Has Endorsed Xylitol for Caries
Prevention?
 1988 –Finnish Dental Association
 1989 – Swedish
 1990 – Norwegian
 1992 – British
 1993 – Irish & Canadian
 1995 – Estonia
 Many others since
 Most recently, the Dental Hygienist
Association in Arizona and Hawaii
Northwest Center to Reduce Oral
Health Disparities
 Oral health disparity means a
disproportionate burden and risk
of poor dental health in a particular population.
 Mission: The Northwest Center to Reduce Oral
Health Disparities conducts community-based
research. We focus on solutions to dental and
oral health disparities among vulnerable, rural,
or under-served groups, particularly lowincome families with children.
Disparities Center Xylitol Studies
 Xylitol


Chewing Gum
Dose response
Frequency response
 Xylitol
Snacks
 Xylitol Gummy Bears
 Xylitol Syrup
 Xylitol Toothpaste
NOT ALL XYLITOL PRODUCTS PROVEN
EFFECTIVE
Kittitas County Head Start Project
 2007-2008 Academic Year
 Information gathering, used historical data.
 Epic Dental Xylitol-Fluoride toothpaste.
 School

Twice-daily tooth
brushing after meals
 Home


Toothbrushes and toothpaste sent home to
families twice during year
Encouraged brushing at home
Challenges
Success
 Preparation of supplies
 Children were
 Facilities
receptive
 Encouraged more
frequent brushing
 Parents liked it
 Time
 Home tracking
Parent Survey
 End of Study Survey, spring 2008
 57 surveys returned




35 English
22 Spanish
12% had two children in program
82% were enrolled for 6 months or more
Survey Results
 Frequency of brushing at home




Child: 65% brushed 2 times/day
Child: 23% brushed 3 or more times/day
Adult: 60% brushed 2 times/day
Adult: 30% brushed 3 times/day
 Use of Xylitol toothpaste at home




9% of children did not use
76% of childre used it half of the time
42% of parents used the toothpaste
35% of other family members used the toothpaste
Overall Positive Response
 40% of the respondents would purchase
xylitol toothpaste.

44% were not sure
 67% of respondents would allow their child to
participate in future studies.

30% said maybe
 80% of respondents wanted more information
on xylitol.
Study Design
 The observational group
from 2007-2008



Fluoride and xylitol toothpaste
Tooth brushing twice a day
Sent home xylitol toothpaste and tootbrushes
 The historical control group
data gathered from 2006-2007 class


Fluoride only toothpaste
Tooth brushing once a day
Sample Size
 Small sample size limited scope of the study
 The whole program participated (123 slots -
105 Head Start, 18 ECEAP) however only:


41 children received 2 dental exams* during the
2006-2007 school year
17 children received 2 dental exams* during the
2007-2008 school year
*Excludes dental visits for follow-up treatment.
Results of the Project
 Small sample size likely cause for lack of
significant results, however trends indicate:

Less children in the xylitol-fluoride group had an
increase in dental caries than fluoride only group.
Children with 2 exams
Children with dmft increase
% children with dmft increase
Fluoride Only
41
15
37%
“dmft” = decayed, missing, filled teeth
Xylitol Fluoride
17
2
12%
Results Continued
Dental caries to increase in most children
between .5 to .7 for each year of age.
 Xylitol-fluoride toothpaste group showed less
increase in dental caries (8%) from baseline than
the fluoride only toothpaste group (34%).

Baseline Mean dmft
Follow-up Visit Mean dmft
Mean dmft Increment
% change from Baseline
T-test∆ in dmft increment
Fluoride Only
3.63
4.85
1.22
34%
Xylitol Fluoride
3.59
3.63
0.29
8%
0.019
Mean dmft Increment
Mean Baseline dmft
5.00
4.50
1.22
0.29
4.00
3.50
3.00
2.50
2.00
3.63
3.59
1.50
1.00
0.50
0.00
Fluouride only
Xylitol Fluoride
Conclusions
 Xylitol-fluoride toothpaste appears to
enhance protection from dental caries.
 It is feasible to integrate twice-daily tooth
brushing into the program.
 Families need to be encouraged to use xylitol
at home.
 Additional funds are needed for supplies
(toothbrushes, toothpaste, sinks).
Future Study
 NIH Grant, two years
 One year of data collection
 Xylitol-fluoride and Fluoride only
 Twice-daily or once-daily
 Classroom assistants to help with tooth
brushing and data collection
 New sinks and computers
Interested?
Want more information?
 Dr. Kiet Ly


Northwest Center to Reduce Oral Health Disparities
University of Washington
Health Sciences B-530
Box 357480
Seattle, WA 98195
kietaly@uw.edu
Liz Webb-Beeles

Kittitas County Head Start
PO Box 835
Ellensburg, WA 98926
lwebb@kitcohs.org