Cspd san fran2011

“Sweet Success with Xylitol”

Thank You CSPD! San Francisco April 9th 2011

DDS, CNC, ND

My Contact InformationMy Contact Information

[email protected] 208-478-5437208-478-5437

Sugar

Sucrose sugar is the Sucrose sugar is the standard for comparisonstandard for comparison

““sugar substitutes”sugar substitutes”

Attempt to duplicate the taste Attempt to duplicate the taste

And some functional And some functional propertiesproperties

Sucrose “Sugar” on food ingredients labels,

ordinary table sugar, cane sugar, beet sugar disaccharide 12-carbon

Glucose (D-glucose, dextrose, corn sugar, blood sugar, monosaccharide, 6-carbon)

Fructose (fruit sugar) monosaccharide, 6-carbon)

Maltose (malt sugar) disaccharide, 12-carbon)

Glucose (D-glucose, dextrose, corn sugar, blood sugar) monosaccharide, 6-carbon)

Maltodextrin

Oligosaccharide 3 – 19 glucose units

StarchStarch

Polymer, Polysaccharide, Amylose200 – 1000 glucose units

SugarSugar

Glucose (dextrose)Glucose (dextrose)

Fructose (fruit sugar)Fructose (fruit sugar)

GalactoseGalactose

Xylose (wood sugar)Xylose (wood sugar)

Maltose (malt sugar)Maltose (malt sugar)

Sucrose (table sugar)Sucrose (table sugar)

Lactose (milk sugar)Lactose (milk sugar)

Starch HydrolysateStarch Hydrolysate

PolyolPolyol

SorbitolSorbitol

MannitolMannitol

GalactitolGalactitol

XylitolXylitol

Maltitol (glu-sorbitol)Maltitol (glu-sorbitol)

Isomalt (glu-mann/sor)Isomalt (glu-mann/sor)

Lactitol (glu-galactose)Lactitol (glu-galactose)

HSH (hydrogenated SH)HSH (hydrogenated SH)

Sugar alcohols are reduction products of sugars

MonoSaccharides

Di or Poly Saccs

SweetenersSweeteners

• Bulk -- Functional PropertiesBulk -- Functional Properties• Sugars (mono- and di-saccharides)Sugars (mono- and di-saccharides)• Polyols (Sugar alcohols)Polyols (Sugar alcohols)

• Intense -- Intense -- High PotencyHigh Potency• ArtificialArtificial• NaturalNatural

SweetenersSweeteners

Intense (High potency super sweeteners)Intense (High potency super sweeteners)•Aspartame (200x)Aspartame (200x)•Sucralose (600x)Sucralose (600x)•Saccharine (400x)Saccharine (400x)•Acesulfame Potassium (Ace K) (200x)Acesulfame Potassium (Ace K) (200x)•Licorice (glycyrrhizin) (30-50x)Licorice (glycyrrhizin) (30-50x)•Stevia (steviosides, reboudisides)(300x)Stevia (steviosides, reboudisides)(300x)•Neotame (up to 13,000 x)Neotame (up to 13,000 x)

Sugar “-ose” by Other NamesSugar “-ose” by Other Names

““ose” ending (major dietary sugars are ose” ending (major dietary sugars are sucrose, glucose, fructose, lactose)sucrose, glucose, fructose, lactose)

Syrup (sugars dissolved in water)Syrup (sugars dissolved in water) Corn syrup Corn syrup HFCS High Fructose Corn SyrupHFCS High Fructose Corn Syrup Starch (processed and cooked)Starch (processed and cooked) MaltodextrinMaltodextrin

Corn SyrupWater, glucose

High Fructose Corn SyrupGlucose converted to fructose by enzymes

Water, glucose, fructose (42-95%)

FructoseFructose

Fast sugarFast sugar Most water solubleMost water soluble Liver metabolic bottleneckLiver metabolic bottleneck Maillard reaction rapid non-Maillard reaction rapid non-

enzymatic browningenzymatic browning

GlycationGlycation

Non-enzymatic glycosylationNon-enzymatic glycosylation

Maillard Reaction: Modification of Maillard Reaction: Modification of protein =browningprotein =browning

Leads to formation of (AGE’s Leads to formation of (AGE’s Advanced Glycation End-products)Advanced Glycation End-products)

AGE’sAGE’s

ToastToast

Glycated hemoglobin (diabetes) Glycated hemoglobin (diabetes) • Hba1c testHba1c test

Collagen -- wrinklesCollagen -- wrinkles

Why is sucrose so Why is sucrose so harmful?harmful?

EnergyEnergy

AcidAcid

Food storageFood storage

Sugar Increases the BugsSugar Increases the Bugs

Watch for “Hidden Sugar”Watch for “Hidden Sugar”

Cough Drops

Chewable vitamins

Breath mints

Fruit juices

Dried fruits

Sports Drinks

Syrup medicines

But Don’t Forget the ObviousBut Don’t Forget the Obvious

Too Much SugarToo Much Sugar

Way to Much SugarWay to Much Sugar

GermsGerms SugarSugar

AcidAcid PlaquePlaque

Way Way Way to Much SugarWay Way Way to Much Sugar

…. But

On TeethOn TeethIt is all just SugarIt is all just Sugar

American Heart American Heart AssociationAssociation

Recommends less than 100 calories from Recommends less than 100 calories from added sugars (6.2 sugar cubes) per day for added sugars (6.2 sugar cubes) per day for

adult women adult women

From sugar cane From sugar cane or sugar beetsor sugar beets

It’s all just SugarIt’s all just Sugar

Conflicts of InterestConflicts of Interest

Spry Dental – Consultant 2001-2004Spry Dental – Consultant 2001-2004 My Xylitol My Xylitol

• www.myxylitol.com Academy of Dental ResourcesAcademy of Dental Resources

• www.adrdental.com Designs for HealthDesigns for Health

• www.designsforhealth.com

Professional Education Professional Education Dental Practice 1978-1995 General 1997-Dental Practice 1978-1995 General 1997-

present Children onlypresent Children only EducationEducation

• General Dentist – Practice limited to KidsGeneral Dentist – Practice limited to Kids• CCN – Certified Nutritional ConsultantCCN – Certified Nutritional Consultant• NART – Nutrition Autonomic Response TestingNART – Nutrition Autonomic Response Testing• ND – Naturopathic DoctorND – Naturopathic Doctor• ACIMD American College of Integrative ACIMD American College of Integrative

Medicine and DentistryMedicine and Dentistry PublicationsPublications

• Practical Application of XylitolPractical Application of Xylitol• Finnish Dental Journal Supplement 1,2006Finnish Dental Journal Supplement 1,2006

My Personal Xylitol HistoryMy Personal Xylitol History

Fall of 1999 Dr. Russ MisnerFall of 1999 Dr. Russ Misner KlearChoice Chewing GumKlearChoice Chewing Gum 2001-2003 Xlear Dental Consultants2001-2003 Xlear Dental Consultants 2002 Developed ToothGel2002 Developed ToothGel 2004 Created ADR Xylitol CE Course2004 Created ADR Xylitol CE Course 2005-2007 Patent pending gels and TP’s2005-2007 Patent pending gels and TP’s 2004-2009 Office Implementation2004-2009 Office Implementation 2011 Orthodontic Module Release2011 Orthodontic Module Release

Our Xylitol Journey Begins 1999Our Xylitol Journey Begins 1999

Dr. Larry Bybee

Dr. Russ Misner

KlearChoice KlearChoice

1999-20001999-2000 They packaged the gum with our They packaged the gum with our

labellabel We spoke with individual dental We spoke with individual dental

officesoffices Pretty soon we were moving 500-600 Pretty soon we were moving 500-600

tubs a monthtubs a month

Xylitol ConsultantsXylitol Consultants

2001 2001 Teamed with XlearTeamed with Xlear 15-20 Dental show per year15-20 Dental show per year Tons of fun but a lot of travelTons of fun but a lot of travel

Toothgel 2002Toothgel 2002

Formulated in Dr. Misner’s KitchenFormulated in Dr. Misner’s Kitchen

=

+

Calcium Glycerylphosphate

Xylitol +

+

Today's PackagingToday's Packaging

ADRADR

CE Course on XylitolCE Course on Xylitol DVD’sDVD’s ManualManual Forms CDForms CD BrochuresBrochures

Orthodontic Module ReleaseOrthodontic Module Releaseall 2011 all 2011

(I Hope (I Hope ))

Sweet Success with Sweet Success with XylitolXylitol

Changing Ideas and ConceptsChanging Ideas and Concepts

In a learning environment you don’t need to agree with anything that is said….

We learn from each other by listening and doing, NOT from argument.

ReframingReframing

From “manage the damage or drill From “manage the damage or drill and fill” to health promotion and and fill” to health promotion and

self care decay preventionself care decay prevention

From helpless victim to proactive From helpless victim to proactive self-careself-care

We sometimes find ourselvesWe sometimes find ourselves changing our mind changing our mind without any resistance or heavy emotion, but if we without any resistance or heavy emotion, but if we are told we are wrong we resent the imputation and are told we are wrong we resent the imputation and harden our hearts. We are incredibly heedless in harden our hearts. We are incredibly heedless in the formation of our beliefs but find ourselves filled the formation of our beliefs but find ourselves filled with an illicit passion for them if someone should with an illicit passion for them if someone should rob us of their companionship. It is obviously not rob us of their companionship. It is obviously not the ideas themselves that are dear to us but our the ideas themselves that are dear to us but our self esteem that is threatened.self esteem that is threatened.

We like to continue to believe what we have We like to continue to believe what we have been accustomed to accept as true and the been accustomed to accept as true and the resentment aroused when doubt is cast resentment aroused when doubt is cast upon any of our assumptions leads to seek upon any of our assumptions leads to seek out every manner of excuse to continue out every manner of excuse to continue clinging to them. The result is that much of clinging to them. The result is that much of our so called reasoning consists in finding our so called reasoning consists in finding arguments to go on believing as we already arguments to go on believing as we already do.do.

James Harvey RobinsonJames Harvey Robinson

DEMODEMO

Why Xylitol?Why Xylitol?

Tastes goodTastes good• Delightful sugary tasteDelightful sugary taste• Cooling effect Cooling effect

It worksIt works• Helps prevent dental cariesHelps prevent dental caries• and upper respiratory infectionsand upper respiratory infections

What is Xylitol?What is Xylitol?

Carbohydrate with uncommon structure

Five carbon atoms

Found in small amounts in a wide variety of fruits and vegetables

Metabolic intermediate

Used as a substitute for sugar

xylitol

Xylitol (polyol) 5-carbon

PropertiesProperties

Relative SweetnessRelative Sweetness

010

20

30

4050

60

70

8090

100

Xylitol Sucrose Maltitol Sorbitol Isomalt Lactitol

Other Xylitol PropertiesOther Xylitol Properties

Hydrophilic – Draws MoistureHydrophilic – Draws Moisture Increases Salivary FlowIncreases Salivary Flow Decreases acid strength in the MouthDecreases acid strength in the Mouth Low Glycemic Index (Diabetic Safe)Low Glycemic Index (Diabetic Safe) Yeasts and Fungus Can’t Grow in Yeasts and Fungus Can’t Grow in

XylitolXylitol Cooling and RefreshingCooling and Refreshing

Xylitol Is HydrophilicXylitol Is Hydrophilic

Cooling and RefreshingCooling and Refreshing

Xylitol IsXylitol Is

Non- Cariogenic: Non- Cariogenic: Does not cause cavitiesDoes not cause cavities

Cariostatic: Cariostatic: Arrests or Halts the decay ProcessArrests or Halts the decay Process

Anti-Cariogenic: Anti-Cariogenic: Can reverse the caries Can reverse the caries Process and Repair Incipient DecayProcess and Repair Incipient Decay

Things To RememberThings To Remember

Xylitol Tastes Good, Like SugarXylitol Tastes Good, Like Sugar Lower Calorie = Less WeightLower Calorie = Less Weight Lower Glycemic = Weight LossLower Glycemic = Weight Loss Can Replace All or Part of Your SugarCan Replace All or Part of Your Sugar Good For TeethGood For Teeth Prevents Tooth DecayPrevents Tooth Decay Prevents Ear InfectionsPrevents Ear Infections Too Much = Laxative EffectToo Much = Laxative Effect

I only Ate the Parts with XylitolI only Ate the Parts with Xylitol

YUMMY

Xylitol can help keep them Xylitol can help keep them smiling!smiling!

WhereWhere

Finland – From WoodFinland – From Wood China – From Corn StocksChina – From Corn Stocks USA – New Source Discovered Very USA – New Source Discovered Very

Recently in Lead North DakotaRecently in Lead North Dakota

Xylitol HarvestXylitol Harvest

Wow! Xylitol is Everywhere Wow! Xylitol is Everywhere

Xylitol WonderlandXylitol Wonderland

Plant Mangers HomePlant Mangers Home

Xylitol Makes You SmileXylitol Makes You Smile

No Matter How you Stack it Xylitol No Matter How you Stack it Xylitol is Good for Teethis Good for Teeth



Dental Caries ProcessDental Caries Process

General Plaque HypothesisGeneral Plaque Hypothesis

Specific Plaque HypothesisSpecific Plaque Hypothesis

Ecological Plaque HypothesisEcological Plaque Hypothesis

Ecological Plaque HypothesisEcological Plaque Hypothesis Dental plaque is a biofilm: attach, Dental plaque is a biofilm: attach,

multiply, organize, adaptmultiply, organize, adapt

Organized, diverse multi-specie Organized, diverse multi-specie microbial community in a polymer microbial community in a polymer matrixmatrix

Biofilms less susceptible to Biofilms less susceptible to antimicrobialsantimicrobials

Ecological Plaque HypothesisEcological Plaque Hypothesis Bacterial competition – more than 600 Bacterial competition – more than 600

varieties varieties

Acidic conditions favor harmful bacterial Acidic conditions favor harmful bacterial communities (only about two dozen communities (only about two dozen harmful)harmful)

““Acid Germs” tolerate acid Acid Germs” tolerate acid

““Acid Germs” process sugars and generate Acid Germs” process sugars and generate acidacid

Repeated sugar/acid cycles demineralize Repeated sugar/acid cycles demineralize teeth and select for harmful “Acid Germs”teeth and select for harmful “Acid Germs”

PlaquePlaque

PlanktonicPlanktonic• Free FloatingFree Floating• Single CellSingle Cell• Easier to removeEasier to remove

Bio-filmBio-film• Organized Organized

CommunityCommunity• Hard to killHard to kill• 1000X Antibiotics1000X Antibiotics

Biofilm DevelopmentBiofilm Development

Why is sucrose so Why is sucrose so harmful?harmful?

EnergyEnergy

AcidAcid

Food storageFood storage

PolysaccharidePolysaccharide

IntracellularIntracellular• Food StorageFood Storage• Give them XylitolGive them Xylitol

Gorge themGorge them Wear them outWear them out

ExtracellularExtracellular• PlaquePlaque• Acid FormationAcid Formation• Give Them Xylitol Give Them Xylitol (Slicky instead of Sticky)(Slicky instead of Sticky)

Xylitol Keeps Unwanted Bugs OutXylitol Keeps Unwanted Bugs Out

Effects of xylitol on plaque…Effects of xylitol on plaque…

Xylitol is not easily Xylitol is not easily metabolized by metabolized by BacteriaBacteria

Non-CariogenicNon-Cariogenic CariostaticCariostatic Anti-CariogenicAnti-Cariogenic Reduces MS levelsReduces MS levels

Söderling et al., 1997

Effects of xylitol on plaque: "xylitol-plaque" is Effects of xylitol on plaque: "xylitol-plaque" is thinner than regular plaque, contains less thinner than regular plaque, contains less

adhesive polysaccharidesadhesive polysaccharides

courtesy of Eva Soderling

Tooth EruptionTooth Eruption

Xylitol Enhances Early Xylitol Enhances Early Mineralization.Mineralization.

Xylitol Inhibits Initial Colonization Xylitol Inhibits Initial Colonization by MS.by MS.

An Opportunity To Establish Long-Term Protection

How much? How often?How much? How often?

It depends.It depends. Daily range is between 4 grams Daily range is between 4 grams

(teaspoon) and 12 grams (teaspoon) and 12 grams (tablespoon).(tablespoon).

Use at least 3 times each day.Use at least 3 times each day. Strive for 5Strive for 5


Frequency more important than Frequency more important than amountamount

Strive for five uses each dayStrive for five uses each day

After each meal and snackAfter each meal and snack

Toothpaste morning and nightToothpaste morning and night

Mouth & NoseMouth & Nose

Xylitol reduces Xylitol reduces bacterial adhesion in bacterial adhesion in the mouth (oral care the mouth (oral care products) & nose products) & nose (nasal spray)(nasal spray)

Xylitol enhances Xylitol enhances natural defensesnatural defenses

Where Health Begins

Dental Disease & HealthDental Disease & Health

Studies show a correlation between poor Studies show a correlation between poor dental health and dental health and cardiovascular diseasecardiovascular disease

Many systemic health problems averted Many systemic health problems averted with good dental healthwith good dental health

XylitolXylitol supports our natural defenses supports our natural defensesby promoting protective factorsby promoting protective factors

stimulates saliva

increases salivary pH

promotes remineralization

suppresses acid bacteria such as mutans strep (MS)

Glycemic IndexGlycemic IndexBlood Sugar Response

0

1

2

3

4

5

6

-30 0 30 60 90 120 150 180

Time (minutes)

<Blo

od G

luco

se>

Glucose

Xylitol

Xylitol supplies a steady flow of energy

Adapted from SS Natah et alAm J Clin Nutr (65) 1997

Xylitol’s Role in DiabetesXylitol’s Role in Diabetes

Good Taste-Refreshing and CoolingGood Taste-Refreshing and Cooling Displacing Equal Amounts of Fast Displacing Equal Amounts of Fast

SugarsSugars Low Glycemic IndexLow Glycemic Index Fewer Calories – Zero Net CarbsFewer Calories – Zero Net Carbs Lowers Serum Fatty Acid LevelsLowers Serum Fatty Acid Levels No Known Harmful Effect on CNS, No Known Harmful Effect on CNS,

HormonesHormones

SafetySafety

Don’t overdo a good thingDon’t overdo a good thing

This is Overdoing ItThis is Overdoing It

This is Too Much!!This is Too Much!!

Don’t Eat the Yellow XylitolDon’t Eat the Yellow Xylitol

Don’t make lemonadeDon’t make lemonade

Xylitol Is HydrophilicXylitol Is Hydrophilic

Who Can Use XylitolWho Can Use Xylitol

Orthodontic PatientsOrthodontic Patients Adults and ElderlyAdults and Elderly Persons with DisabilitiesPersons with Disabilities Persons with Dry MouthPersons with Dry Mouth AthletesAthletes

• Increases Fat UtilzationIncreases Fat Utilzation• Fights Muscle FatigueFights Muscle Fatigue

Everyone Except mans best friendEveryone Except mans best friend

Don’t give to dogsDon’t give to dogs

Hey Dogs Xylitol is NOT for YOU!Hey Dogs Xylitol is NOT for YOU!

Good DoggieGood Doggie

Thanks for Keeping Me SafeThanks for Keeping Me Safe

Make New Friends with XylitolMake New Friends with Xylitol

Protecting Man’s Best Friend From Protecting Man’s Best Friend From Xylitol is exhaustingXylitol is exhausting

Break Time

Xylitol ReviewXylitol Review

Susceptible ToothAttacked and DemineralizedBy AcidMade by Germs From the fermentation of sugars

Decay Process:

result is cavities – holes in the teeth

Mutans streptococci on enamel

De-Mineralization De-Mineralization (Caries v. Cavities)(Caries v. Cavities)

Caries? Cavities?Caries? Cavities?

Caries is the disease Caries is the disease process initiated process initiated predominately by predominately by the Strept Mutans the Strept Mutans bacteriabacteria

Cavities are the Cavities are the result of the caries result of the caries disease process disease process

Caries vs. CavitiesCaries vs. Cavities

CariesCaries• ProcessProcess• Presence of Presence of

BacteriaBacteria Mutans StreptMutans Strept LactobacillusLactobacillus

• Low Salivary FlowLow Salivary Flow• Low Salivary phLow Salivary ph• Gingival BleedingGingival Bleeding

CavitiesCavities• Physical Physical

manifestation of manifestation of the caries the caries processprocess

Cavities

Caries

Caries to Cavities ProgressionCaries to Cavities Progression 1- Healthy Tooth1- Healthy Tooth 2- White Spot Lesion The 2- White Spot Lesion The Caries Process Caries Process 3- Caries Process with 3- Caries Process with

CavitationCavitation 4- Filling with Caries 4- Filling with Caries Process and CavitationProcess and Cavitation 5- Continued5- Continued Demineralization andDemineralization and Undermined EnamelUndermined Enamel 6- Fractured Tooth6- Fractured Tooth

1996-2002 production by Douglas Bratthall

Damaging vs. ProtectiveDamaging vs. Protective Sugar and Sugar and

Fermentable Fermentable CarbohydrateCarbohydrate

AcidAcid XerostomiaXerostomia Virulent “Acid” Virulent “Acid”

BacteriaBacteria

XylitolXylitol Neutral, alkaline pHNeutral, alkaline pH SalivaSaliva Calcium, FluorideCalcium, Fluoride Non-Acidogenic Non-Acidogenic

Bacteria Bacteria

Damaging vs. Protective FactorsDamaging vs. Protective Factors

DemineralizationRemineralization

Tooth decay progresses Tooth decay progresses when damaging factors when damaging factors prevail over protective prevail over protective

factorsfactors

More More demineralization demineralization

than remineralizationthan remineralization

Risk FactorsRisk Factors

Factors of Dental DiseaseFactors of Dental Disease A pH of 6.3 to 6.7 is a cautionary environmentA pH of 6.3 to 6.7 is a cautionary environment A pH of ≤6.2 is a red light (Non-stimulated A pH of ≤6.2 is a red light (Non-stimulated

salivary flow).salivary flow). GBI > 3-4 Primary or Permanent GBI > 3-4 Primary or Permanent OHI of Poor or FairOHI of Poor or Fair High def – dMf – DMFHigh def – dMf – DMF Negative Periodontal AssessmentNegative Periodontal Assessment

• Localized or Generalized Gingivitis or worseLocalized or Generalized Gingivitis or worse Salivary Flow rate of <0.7 ml/minSalivary Flow rate of <0.7 ml/min History of Cavities or Periodontal problemsHistory of Cavities or Periodontal problems Active Caries Process Noted (Staining) Active Caries Process Noted (Staining)

(Diagnodent)(Diagnodent)

High Risk Factors of Decay for KidsHigh Risk Factors of Decay for Kids Systemic DiseasesSystemic Diseases Compromised Immune Compromised Immune

SystemSystem Mouth BreathingMouth Breathing

• Use of Xlear Nasal Wash to Use of Xlear Nasal Wash to maintain patent airwaymaintain patent airway

Gums Bleed when BrushingGums Bleed when Brushing Sweetened MedicinesSweetened Medicines Family members with Family members with

CavitiesCavities Insufficient Fluoride in non Insufficient Fluoride in non

fluoridated areasfluoridated areas Irregular Dental VisitsIrregular Dental Visits

Deep unsealed teeth – Deep unsealed teeth – Primary and PermanentPrimary and Permanent

Bottles and Sippy Cups Bottles and Sippy Cups filled with milk and filled with milk and sugary liquidssugary liquids

High intake of High intake of fermentable high density fermentable high density Carbs between mealsCarbs between meals

Raisins – Cereals - Sugar Raisins – Cereals - Sugar treats between meals treats between meals

History of ECCHistory of ECC History of FillingsHistory of Fillings

Eruption Period – Early Mixed Eruption Period – Early Mixed DentitionDentition

Eruption Period – Late Mixed Eruption Period – Late Mixed DentitionDentition

High Risk Factors of Decay for AdultsHigh Risk Factors of Decay for Adults Systemic DiseasesSystemic Diseases Compromised Immune Compromised Immune

SystemSystem Mouth BreathingMouth Breathing Gums Bleed when Gums Bleed when

Brushing Orthodontic Brushing Orthodontic AppliancesAppliances

White spot lesions or White spot lesions or incipient lesions on X-incipient lesions on X-RaysRays

Sporadic Dental VisitsSporadic Dental Visits Failing RestorationsFailing Restorations High Family Caries High Family Caries

RateRate

DiseaseDisease Poor DexterityPoor Dexterity Inadequate Fluoride UseInadequate Fluoride Use Frequent Intake of Frequent Intake of

Fermentable High Density Fermentable High Density CarbohydratesCarbohydrates

More than two cavities in the More than two cavities in the last year or active caries.last year or active caries.

Use of Chewing TobaccoUse of Chewing Tobacco Xerostomia by itself or with Xerostomia by itself or with

Exposed Root SurfacesExposed Root Surfaces Radiation TherapyRadiation Therapy

Tooth decay progresses Tooth decay progresses when damaging factors when damaging factors prevail over protective prevail over protective

factorsfactors

More More demineralization demineralization

than remineralizationthan remineralization

The Caries Risk Test aids in establishing RiskThe Caries Risk Test aids in establishing Risk

Inactive/No Disease:Inactive/No Disease:(Caries -) (Caries -) (Cavities -)(Cavities -) Low Risk Low Risk

Post-Manifest Disease: Post-Manifest Disease: (Caries -)(Caries -) (Cavities +)(Cavities +) Moderate Risk Moderate Risk

Pre-Manifest Disease: Pre-Manifest Disease: (Caries +)(Caries +) (Cavities -)(Cavities -) High Risk High Risk

Manifest Disease: Manifest Disease: (Caries +)(Caries +) (Cavities +) (Cavities +) High Risk High Risk

Caries Risk Levels 1 & 2Caries Risk Levels 1 & 2 Level 1 Inactive No Disease (Caries -) Level 1 Inactive No Disease (Caries -)

(Cavities -)(Cavities -)• Anticipatory GuidanceAnticipatory Guidance

Home Care and Regular Dental Home Care and Regular Dental Check-upsCheck-ups

Level 2 Post-Manifest Disease (Caries -) Level 2 Post-Manifest Disease (Caries -) ((Cavities +Cavities +))• Maintain suppression of caries processMaintain suppression of caries process

Restore LesionsRestore Lesions

Caries Risk Levels 3 & 4Caries Risk Levels 3 & 4 Level 3 Pre-Manifest Disease Level 3 Pre-Manifest Disease ((Caries+)Caries+) (Cavities -)(Cavities -)

• Arrest Caries Process prior to CavitationArrest Caries Process prior to Cavitation

Level 4 Manifest Disease Level 4 Manifest Disease ((Caries +)Caries +) (Cavities + (Cavities +))

• ART Arrest and RestoreART Arrest and Restore Caries Removal, Mutans Cultures, Anticipatory Caries Removal, Mutans Cultures, Anticipatory

guidanceguidance Counseling / InstructionCounseling / Instruction Restoration or OtherRestoration or Other

Non-active disease caries risk level Non-active disease caries risk level L1: L1:

Low RiskLow Risk Complete Oral Hygiene and Place Sealants if indicated. Complete Oral Hygiene and Place Sealants if indicated. Recommend xylitol sweetened dental products (Tooth Gel, Chewing Recommend xylitol sweetened dental products (Tooth Gel, Chewing

Gum, Mints, Toothpaste, Mouth Rinse, and/or tooth gel as a Saliva Gum, Mints, Toothpaste, Mouth Rinse, and/or tooth gel as a Saliva Replacer) and have them available for purchase.Replacer) and have them available for purchase.

Recommend and prescribe appropriate fluoride containing products Recommend and prescribe appropriate fluoride containing products or have available for purchase.or have available for purchase.

Reduce or eliminate fermentable high density carbohydrates Reduce or eliminate fermentable high density carbohydrates between meals. We believe this makes good nutritional sense for the between meals. We believe this makes good nutritional sense for the whole body.whole body.

Evaluate their ability to maintain mechanical plaque control and Evaluate their ability to maintain mechanical plaque control and make appropriate suggestion, i.e., mechanical tooth brush and other make appropriate suggestion, i.e., mechanical tooth brush and other oral hygiene aids.oral hygiene aids.

Suggest concern for the need of disease control for immediate and Suggest concern for the need of disease control for immediate and close family members to decrease the probability of transmission, close family members to decrease the probability of transmission, i.e., if other members of the family have a high propensity for dental i.e., if other members of the family have a high propensity for dental disease it may be only a matter of time until everyone shares the disease it may be only a matter of time until everyone shares the problem.problem.

Maintain appropriate follow-up and/or testing to be confident that Maintain appropriate follow-up and/or testing to be confident that the patient or the parents are engaged in managing to maintain the the patient or the parents are engaged in managing to maintain the non-disease state non-disease state

Non-active disease caries risk level Non-active disease caries risk level L2: L2:

Moderate RiskModerate Risk See that the necessary mechanical dental treatment such as fillings, See that the necessary mechanical dental treatment such as fillings,

sealants etc. are rendered. This will remove the source of possible re-sealants etc. are rendered. This will remove the source of possible re-infection locally in their mouths.infection locally in their mouths.

Recommend appropriate xylitol sweetened dental products (Tooth Gel, Recommend appropriate xylitol sweetened dental products (Tooth Gel, Chewing Gum, Mints, Toothpaste, Mouth Rinse, and/or tooth gel as a Chewing Gum, Mints, Toothpaste, Mouth Rinse, and/or tooth gel as a Saliva Replacer) and have available for purchase.Saliva Replacer) and have available for purchase.

Recommend or prescribe appropriate fluoride containing products or Recommend or prescribe appropriate fluoride containing products or have available for purchase.have available for purchase.

Have the patient reduce or eliminate fermentable high density Have the patient reduce or eliminate fermentable high density carbohydrates (p. 99) especially between meals. This makes good carbohydrates (p. 99) especially between meals. This makes good nutritional sense for the whole body.nutritional sense for the whole body.

Evaluate their ability to maintain mechanical plaque control and make Evaluate their ability to maintain mechanical plaque control and make appropriate suggestion, i.e., mechanical tooth brush and other oral appropriate suggestion, i.e., mechanical tooth brush and other oral hygiene aids.hygiene aids.

Suggest concern for the need of disease control for immediate and Suggest concern for the need of disease control for immediate and close family members to decrease the probability of transmission, i.e., close family members to decrease the probability of transmission, i.e., if other members of the family have a high propensity for dental disease if other members of the family have a high propensity for dental disease it may be only a matter of time until everyone shares the problem.it may be only a matter of time until everyone shares the problem.

Maintain appropriate follow-up and/or testing to be confident that the Maintain appropriate follow-up and/or testing to be confident that the patient or the parents are engaged in managing to maintain a non-patient or the parents are engaged in managing to maintain a non-disease state.disease state.

Active Disease Caries Risk Level L3 or L4: Active Disease Caries Risk Level L3 or L4:

High RiskHigh Risk Treat the disease process (caries) and the necessary mechanical dental Treat the disease process (caries) and the necessary mechanical dental

treatment (cavities) such as fillings, sealants etc. Note: Prior to placement of treatment (cavities) such as fillings, sealants etc. Note: Prior to placement of orthodontic appliances make sure that the disease process is under control.orthodontic appliances make sure that the disease process is under control.

Recommend appropriate xylitol sweetened dental products (Tooth Gel, Recommend appropriate xylitol sweetened dental products (Tooth Gel, Chewing Gum, Mints, Toothpaste, Mouth Rinse, and/or tooth gel as a Saliva Chewing Gum, Mints, Toothpaste, Mouth Rinse, and/or tooth gel as a Saliva Replacer) and have available for purchase.Replacer) and have available for purchase.

Recommend or prescribe appropriate fluoride containing products or have Recommend or prescribe appropriate fluoride containing products or have available for purchase.available for purchase.

Treat the active caries disease process as a bacterial infection with an Treat the active caries disease process as a bacterial infection with an antimicrobial agent, (105-107) xylitol, and fluoride products.antimicrobial agent, (105-107) xylitol, and fluoride products.

Have the patient reduce or eliminate fermentable high density carbohydrates Have the patient reduce or eliminate fermentable high density carbohydrates (p.99) especially between meals. We believe this makes good nutritional (p.99) especially between meals. We believe this makes good nutritional sense for the whole body.sense for the whole body.

Evaluate their ability to maintain mechanical plaque control and make Evaluate their ability to maintain mechanical plaque control and make appropriate suggestion, i.e., mechanical tooth brush and other oral hygiene appropriate suggestion, i.e., mechanical tooth brush and other oral hygiene aids.aids.

Suggest concern for the need of disease control for immediate and close Suggest concern for the need of disease control for immediate and close family members to decrease the probability of transmission, i.e., if other family members to decrease the probability of transmission, i.e., if other members of the family have a high propensity for dental disease it may be members of the family have a high propensity for dental disease it may be only a matter of time until everyone shares the problem.only a matter of time until everyone shares the problem.

Maintain appropriate follow-up and retesting until the patient or the parents Maintain appropriate follow-up and retesting until the patient or the parents are engaged in managing the disease.are engaged in managing the disease.

Before and AfterBefore and After

Results obtained in our office Results obtained in our office with Xylitol with Xylitol

100% Xylitol Gum Only100% Xylitol Gum Only

Before After 1 Week

100% Xylitol Gum Only100% Xylitol Gum Only

Before After 3 Weeks

Xylitol Reduces Bacterial Regrowth Xylitol Reduces Bacterial Regrowth After Oral DisinfectionAfter Oral Disinfection

0

20

40

60

80

100

Time Since Oral Disinfection

Mea

n Bac

terial

Lev

els

(%

Tim

e 0)

XylitolSorbitolPlacebo

Hildebrandt GH, Sparks BS. Maintaining mutans streptococci suppression with xylitol chewing gum. J Am Dent Assoc. 2000;131:909-916

| 3 Months

100% Xylitol Gum and 100% Xylitol Gum and ChlorhexidineChlorhexidine

Before After 1 Week

100% Xylitol Gum and 100% Xylitol Gum and ChlorhexidineChlorhexidine

Before After 2 Weeks

AJS 2-26-2003

Initial examination with oral hygiene

and xylitol recommendations

AJS 3-4-2003

After using xylitol for one week

WF 2-26-2003

Inadequate hygiene for fixed orthodontic appliances

WF 3-11-2003

Improvement after two weeks of Xylitol Hygiene

PeriodonticsPeriodontics Xylitol hygiene can benefit patients with Xylitol hygiene can benefit patients with

gingivitis or periodontitis.gingivitis or periodontitis.

Regular Xylitol use helps reduce plaque Regular Xylitol use helps reduce plaque quantity.quantity.

Plaque becomes less adhesive, less acidic, less Plaque becomes less adhesive, less acidic, less inflammatory, and less harmful than sucrose inflammatory, and less harmful than sucrose plaque.plaque.

Xylitol helps block re-emergence of cariogenic Xylitol helps block re-emergence of cariogenic organisms during periodontal therapy, such as organisms during periodontal therapy, such as after full-mouth disinfection.after full-mouth disinfection.

Dry MouthDry Mouth Many Prescription Drugs Cause Dry Many Prescription Drugs Cause Dry

MouthMouth UncomfortableUncomfortable Lack of Saliva Leads to CariesLack of Saliva Leads to Caries Root CariesRoot Caries

Factors Affecting Salivary FlowFactors Affecting Salivary Flow

PharmaceuticalsPharmaceuticals Radiation TherapyRadiation Therapy Water IntakeWater Intake XylitolXylitol

• The caries controlling/preventing The caries controlling/preventing effect of xylitol is not based on effect of xylitol is not based on

saliva stimulation onlysaliva stimulation only

Effects of xylitol on plaque…Effects of xylitol on plaque…

Xylitol is not easily Xylitol is not easily metabolized by metabolized by BacteriaBacteria

Non-CariogenicNon-Cariogenic CariostaticCariostatic Anti-CariogenicAnti-Cariogenic Reduces MS levelsReduces MS levels

Söderling et al., 1997

Staff ResponsibilitiesStaff Responsibilities

Assess and RecordAssess and Record• pHpH• Salivary FlowSalivary Flow• Gingival Bleeding IndexGingival Bleeding Index• Debris IndexDebris Index• Calculus IndexCalculus Index• Calculate Oral Hygiene IndexCalculate Oral Hygiene Index

Brushing and Flossing InstructionsBrushing and Flossing Instructions

Caries Risk TestCaries Risk Test Provide a basis for evidence based CareProvide a basis for evidence based Care Provide a basis for customized Provide a basis for customized

TreatmentTreatment• EvaluationEvaluation

FindingsFindings

• In Office TreatmentIn Office Treatment Dental PracticeDental Practice

• Home Care MeasuresHome Care Measures At HomeAt Home

In cooperation with the Polyclinic for Preventive Dentistry, Erfurt, Dental School, Friedrich-Schiller University of Jena, Germany

VIVADENT

Caries Risk TestCaries Risk Test Based on Clinical Based on Clinical

JudgmentJudgment Great Parent/Patient Great Parent/Patient

motivatormotivator Confirms clinical Confirms clinical

diagnosisdiagnosis Ivoclar/Vivadent Ivoclar/Vivadent

incubatorincubator Test Kit – CRT Test Kit – CRT

Bacteria StandardBacteria Standard Salivary Flow RateSalivary Flow Rate

Mutans Strep

Lactobacillus

Mutans Strep ≥ 100,000 Colony Forming Units

Caries Risk Test

Lactobacillus ≥100,000 Colony Forming Units

Caries Risk Test

Gold Standard in Clinical Trials (MS)Gold Standard in Clinical Trials (MS)

Growth medium

Bacitrasin

SM-strips

Paraffin

Ten tests

Flossette

Mother – Child TransmissionMother – Child Transmission

What do the Clinical Trials ShowWhat do the Clinical Trials Show

Stefan’s Curve

Breakfast Lunch Dinner

Snacks

Mutans streptococci Mutans streptococci

Why are mutans streptococci Why are mutans streptococci (MS) so important?(MS) so important?

TheThe caries bacteria caries bacteria MS form sticky plaque and MS form sticky plaque and

produce efficiently acidsproduce efficiently acids

Mutans streptococci on enamel

Xylitol consumption decreases amounts and the adhesivity Xylitol consumption decreases amounts and the adhesivity of MS. Mutans streptococci of habitual xylitol consumers of MS. Mutans streptococci of habitual xylitol consumers

are easily shed to the saliva.are easily shed to the saliva.

Söderling et al., 1991; Trahan et al., 1992courtesy of Eva Soderling

The effects of xylitol on MS The effects of xylitol on MS are based on its 5-carbon are based on its 5-carbon structurestructure

Clinical studies support the Clinical studies support the idea that MS is targeted by idea that MS is targeted by xylitolxylitol (Vadeboncoeur et al., 1983; (Vadeboncoeur et al., 1983; Loesche et al., 1984)Loesche et al., 1984)

The MS counts remain low The MS counts remain low as long as the use of xylitol as long as the use of xylitol lasts lasts

Xylitol

Effects of xylitol on mother-child Effects of xylitol on mother-child transmission of mutans streptococcitransmission of mutans streptococci

SWEDEN

FINLAND

, February 2011)

Japan

Finland

Sweden

Finnish, Swedish, Japanese Studies (Courtesy of Eva Soderling Feb. 2011

Protect Your Child with Xylitol –Protect Your Child with Xylitol –It’s Pretty Cool StuffIt’s Pretty Cool Stuff

Protected Child

Xylitol gel in pacifier for babyXylitol gel in pacifier for baby

Mother uses xylitol chewing gum

Caufield et al., 1993

The window of infectivity for mutans streptococci

Caries as an infectious disease:Caries as an infectious disease: Early colonisation of mutans streptococci Early colonisation of mutans streptococci

(caries bacteria) increases the risk of caries (caries bacteria) increases the risk of caries occurence in the future!occurence in the future!


Transmission of mutans Transmission of mutans streptococcistreptococci

• The timing of the window of The timing of the window of infectivíty can differ in different infectivíty can differ in different populations populations (Florio et al., 2004)(Florio et al., 2004)

• Factors affecting the transmission: Factors affecting the transmission: 1.1. The mutans counts of the "infecting" The mutans counts of the "infecting"

person (>100 000 per ml saliva – person (>100 000 per ml saliva – common!)common!)

2.2. Number of daily saliva contactsNumber of daily saliva contacts3.3. Individual susceptibitily of the child Individual susceptibitily of the child (Smith et (Smith et

al., 1998),al., 1998), mode of delivery mode of delivery (Li et al., 2005)(Li et al., 2005)


If we can reduce the risk of this If we can reduce the risk of this transmission could we lower tooth transmission could we lower tooth decay in children?decay in children?

Lets look at some of the Studies to Lets look at some of the Studies to find out.find out.

Finland:Effects of xylitol on mother-Finland:Effects of xylitol on mother-child transmission of mutans child transmission of mutans

streptococIstreptococI

YES!

Wow! This is good!Wow! This is good!

Finland: Effects of xylitol on childhood Finland: Effects of xylitol on childhood cariescaries

Isokangas et al., 2000

Caries occurence until 5 yrs

YES!

Yum!Yum!

Mother’s Dental CareMother’s Dental Care

05

101520253035404550

Perc

enta

ge C

olon

izat

ion

Fluoride Xylitol

Mothers Dental CareSoderling E, IsokangasP, PienhakkinenK, Tenovuo J. Influence of maternal xylitol consumption on acquisition of mutans streptococci by infants. J Dent Res. 200;79:1885-9

Chlorhexidine

YES!

Soft Banana brush with xylitol gelSoft Banana brush with xylitol gel

When Mothers Use Xylitol, When Mothers Use Xylitol, Children Have Fewer CavitiesChildren Have Fewer Cavities

00.5

11.52

2.53

3.54

2 3 4 5

Years

DM

F XylitolChlorhexidineFluoride

Isokangas P, Soderling E, Pienikakkinen, Alanen P. Occurrence of dental decay in children after maternal consumption of xylitol chewing gum, a follow-up from 0-5 years of age. J Dent Res. 2000;79:1885-9

YES!

She likes it!She likes it!

Xylitol Reduces Bacterial Regrowth Xylitol Reduces Bacterial Regrowth After Oral DisinfectionAfter Oral Disinfection

0

20

40

60

80

100

Time Since Oral Disinfection

Mea

n Bac

terial

Lev

els

(%

Tim

e 0)

XylitolSorbitolPlacebo

Hildebrandt GH, Sparks BS. Maintaining mutans streptococci suppression with xylitol chewing gum. J Am Dent Assoc. 2000;131:909-916

| 3 Months

YES!

Baby gets cariogenic Baby gets cariogenic bacteria from motherbacteria from mother

Mothers who use Mothers who use xylitol transmit non-xylitol transmit non-cariogenic microfloracariogenic microflora

With All this Xylitol Your Teeth are With All this Xylitol Your Teeth are SafeSafe

XYLITOL’SXYLITOL’S

Role in Re-mineralizationRole in Re-mineralization

Remineralization / Cosmetic Enhancement Remineralization / Cosmetic Enhancement InventionInvention

Hypomineralized areas on #8,9

Status before any treatment

Status immediately following treatment

Example # 1

Treatment Time: 5-7 minutes

Status before any treatment Status immediately following treatment

Example #2

Status before treatment. # 8, 9 are to be treated. Note

generalized demineralization on maxillary posteriors that will not

be professionally treated.

Example #3 - Slide 1 of 2

Status of # 8,9 immediately following professional

treatment. Please note no change to hypo-mineralized areas in Maxillary posteriors.

Slide 2 of 2

5 months after initial professional treatment to # 8,9. Patient was instructed to use an at-home solution daily. Please note

remineralization effects of home solution on maxillary posteriors.

Photos illustrating possible Photos illustrating possible treatment process ~ Slide 1 of 2treatment process ~ Slide 1 of 2

Status before any treatment Slight microabrasion of surface

Slide 2 of 2Slide 2 of 2

Chemical Etch Status immediately following treatment

Initial Condition

Same Day After In Office Treatment

““Xylitol gum enhanced remineralization Xylitol gum enhanced remineralization reduced plaque and improved gingival reduced plaque and improved gingival health.” health.”

Steinberg LM, Odusola F, Mandel ID: Remineralizing potential, Steinberg LM, Odusola F, Mandel ID: Remineralizing potential, and plaque andand plaque and

anti-gingivitis effect of xylitol and sorbitol sweetened chewing anti-gingivitis effect of xylitol and sorbitol sweetened chewing gum gum Clinical Clinical

NutritionNutrition (supplement) 1995 pp. 275-283. (supplement) 1995 pp. 275-283.

XYLITOL’SXYLITOL’S

Role in MaintenanceRole in Maintenance

Medical ModelMedical ModelDiagnosis

Treat Caries

Treat Cavities

Maintenance Home / Professional

Health

Caries+

Cavities +

Cavities -

Caries -

Cavities -Cavities +

L1L2

L3

L4

L4

Medical Model information Adapted from A Comprehensive Review of Pediatric Dentistry Manual, San Diego September 2002.

Elements of ManagementElements of Management DateDate Eruption PeriodsEruption Periods Salivary phSalivary ph GBI - Gingival Bleeding GBI - Gingival Bleeding

IndexIndex Decayed, missing, filled Decayed, missing, filled DI/CI – Debris DI/CI – Debris

Index/CalculusIndex/Calculus OHI - Oral health IndexOHI - Oral health Index BFI/Pro-Flo Brushing, BFI/Pro-Flo Brushing,

Flossing Instructions/ Flossing Instructions/ ProphyProphy

Caries RiskCaries Risk Periodontal ConditionPeriodontal Condition PhotographsPhotographs

CRT/SF Caries Risk Test/ CRT/SF Caries Risk Test/ Salivary Flow Salivary Flow

CRT Mutans Strep/Lacto CRT Mutans Strep/Lacto BacBac

100% Xylitol Chewing 100% Xylitol Chewing GumGum

100% Xylitol Product 100% Xylitol Product Reco’sReco’s

Fluoride Reco’sFluoride Reco’s CHX – ChlorhexidineCHX – Chlorhexidine Nutritional InformationNutritional Information Treat CavitiesTreat Cavities Follow-up Treatment Follow-up Treatment

DateDate ReferralReferral

MaintenanceMaintenance Regular xylitol use should be encouraged Regular xylitol use should be encouraged

as a routine healthy habit, a continuing as a routine healthy habit, a continuing part of a normal oral hygiene regimen.part of a normal oral hygiene regimen.

““The best use of xylitol is as an addition The best use of xylitol is as an addition to other oral hygiene recommendations.”to other oral hygiene recommendations.”

Peldyak, John DMD; Makinen, Kauko K. PhD: Xylitol for Caries Peldyak, John DMD; Makinen, Kauko K. PhD: Xylitol for Caries Prevention. Prevention. Journal of Dental HygieneJournal of Dental Hygiene Volume 67 Number IV Fall Volume 67 Number IV Fall 2002, pp. 276-285.2002, pp. 276-285.

How To Use XylitolHow To Use Xylitol ““Xylitol should be used immediately after Xylitol should be used immediately after

every meal and snack.every meal and snack. 3-5 Times a Day3-5 Times a Day

Gum or Mint should be used for at least 3-Gum or Mint should be used for at least 3-5 minutes5 minutes

Can be Used at any other time you desire.Can be Used at any other time you desire.

Peldyak, John DMD; Makinen, Kauko K. PhD: Xylitol for Caries Prevention. Peldyak, John DMD; Makinen, Kauko K. PhD: Xylitol for Caries Prevention.

Journal of Dental Hygiene Journal of Dental Hygiene Volume 67 Number IV Fall 2002, pp. 276-285.Volume 67 Number IV Fall 2002, pp. 276-285.

Long-term effect of xylitol.Long-term effect of xylitol.

When Used for 2 YearsWhen Used for 2 Years

Cavity Reducing Effect lasts Cavity Reducing Effect lasts for 3-5 Yearsfor 3-5 Years

Peldyak John DMD, Makinen Kauko K PhD: Xylitol for Caries Peldyak John DMD, Makinen Kauko K PhD: Xylitol for Caries Prevention. Prevention.

Journal of Dental Hygiene Volume 76 Number IV Fall 2002; pp. 276-Journal of Dental Hygiene Volume 76 Number IV Fall 2002; pp. 276-285.285.

Who Can Use XylitolWho Can Use Xylitol

Orthodontic PatientsOrthodontic Patients Adults and ElderlyAdults and Elderly Persons with DisabilitiesPersons with Disabilities Persons with Dry MouthPersons with Dry Mouth AthletesAthletes

• Increases Fat UtilizationIncreases Fat Utilization• Fights Muscle FatigueFights Muscle Fatigue

Everyone Except DogsEveryone Except Dogs

Caries process successfully Caries process successfully managed whenmanaged when

Salivary Mutans stays low.Salivary Mutans stays low. No gingival inflammation.No gingival inflammation. Caries excavation complete, Caries excavation complete,

lesion appearance changed lesion appearance changed (arrested).(arrested).

Patients or Parents of patients Patients or Parents of patients engaged in managing disease. engaged in managing disease.

Historical factors for low risk.Historical factors for low risk. Opposite of high risk factors Opposite of high risk factors Dental health awareness.Dental health awareness. No cavities within the last year or two.No cavities within the last year or two. Regular dental visits.Regular dental visits. History of few cavities in the rest of the family.History of few cavities in the rest of the family. For adults and children no tobacco use.For adults and children no tobacco use. Good regular use of fluoride products.Good regular use of fluoride products. Adequately restored surfaces on a minimal number of teeth Adequately restored surfaces on a minimal number of teeth

no foiling or creeping restorations.no foiling or creeping restorations. Deep pit and fissures are sealed.Deep pit and fissures are sealed. Low dietary intake of Fermentable High Density Low dietary intake of Fermentable High Density

Carbohydrates.Carbohydrates. In Children no history of Early Childhood Caries, no or little In Children no history of Early Childhood Caries, no or little

history of medicines high in sucrose or syrup, no fluids in history of medicines high in sucrose or syrup, no fluids in bottle or sippy cups that contain any form of sugar especially bottle or sippy cups that contain any form of sugar especially between regular feedings or left in bed with bottle or allowed between regular feedings or left in bed with bottle or allowed to carry the vessel around except with water.to carry the vessel around except with water.

Carbonated drinks are the single biggest source of refined sugars in the American diet.

According to dietary surveys, soda pop provides the average American with 7 teaspoons of sugars per day, out of a total of about 20 teaspoons.

Teenage boys get 44 percent of their 34 teaspoons of refined sugars a day from soft drinks.

Teenage girls get 40 percent of their 24 teaspoons of sugars from soft drinks.

Because some people drink little or no soda pop, the percentage of refined sugars provided by pop is higher among actual drinkers.

Would You Like To Significantly:Would You Like To Significantly:

Decrease Decay In Your Mouth?Decrease Decay In Your Mouth? Decrease Decay In Your Kids Mouths?Decrease Decay In Your Kids Mouths? Decrease Decay In Your Grandkids Decrease Decay In Your Grandkids

Mouths?Mouths?

Benefits of Xylitol for PatientsBenefits of Xylitol for Patients

EffectiveEffective

ConvenientConvenient

EnjoyableEnjoyable

Result is improved Result is improved cooperation and cooperation and excellent oral excellent oral hygienehygiene

Xylitol on a picnic…

Xylitol at the big game

Product TypesProduct Types

Product Types Product Types

Toothpaste

Oral Rinse

Dental Cleansing Gel

MintsGumMoisturizing

breath freshener

Spiffies Infant WipesSpiffies Infant Wipes

Banana BrushBanana Brush

Joint Venture ProductJoint Venture Product

Joint VentureJoint Venture

UltradentUltradent

EnjoyEnjoy

Old wayOld way

Find a BugFind a Bug

Use a DrugUse a Drug

New WayNew Way

With XylitolWith Xylitol

Show ’em the doorShow ’em the door

Makes plaque Slicky instead of Sticky

Slam it shutSlam it shut

Xylitol

LivesHere

Xylitol blocks the tooth-damagingXylitol blocks the tooth-damaging factorsfactors

Xylitol FeaturesXylitol Features

Sweet, cooling, no aftertasteSweet, cooling, no aftertaste Naturally-occurring in human metabolismNaturally-occurring in human metabolism Low calorie Low calorie (40% less than sugar)(40% less than sugar) Low Glycemic Low Glycemic (about 10% of Glucose)(about 10% of Glucose) Low insulin usage to metabolizeLow insulin usage to metabolize No Maillard reactionNo Maillard reaction Slows stomach emptying – increases satiety Slows stomach emptying – increases satiety (feelings (feelings

of fullness)of fullness) Energy source Energy source (Used in IV Nutrition)(Used in IV Nutrition) Enhances Calcium absorptionEnhances Calcium absorption Helps prevent tooth decayHelps prevent tooth decay Helps prevents ear and upper respiratory infectionsHelps prevents ear and upper respiratory infections




Frequency more important than amount Frequency more important than amount 4 to 12 grams 4 to 12 grams (teaspoon is 4 grams)(teaspoon is 4 grams) 6 to 10 pieces of gum/day6 to 10 pieces of gum/day

• Active Strep Mutans infections in adults Active Strep Mutans infections in adults require at least 6 grams require at least 6 grams (8 or more pieces of (8 or more pieces of gum)gum)

Aim for five uses each dayAim for five uses each day After each meal and snackAfter each meal and snack Toothpaste morning and nightToothpaste morning and night

Use 100% Xylitol ProductsUse 100% Xylitol Products

Xylitol Keeps Them SmilingXylitol Keeps Them Smiling

5 Levels of Caries Control5 Levels of Caries Control

RemineralizationRemineralization DisinfectDisinfect Oral HygieneOral Hygiene XylitolXylitol EnvironmentEnvironment

Environment, Whole Food and Whole Food Supplements

Xylitol protocols and Products

Office Oral Hygiene Program

Oral Disinfection

Remineralization

Ease of M

anagement

Effect on O

ral Health

Least

Most

Easy

Hard

Whole Food – Level 1Whole Food – Level 1

Diet – Real Food Diet – Real Food • Less Processed ProductsLess Processed Products

SupplementsSupplements And EnvironmentAnd Environment

• ToxinsToxins• AirAir• WaterWater• StressStress• Change in habits and life styleChange in habits and life style

Adapted from the book: From Here to Longevity by Dr. Mitra Ray Ph.D. with Patricia Cannon Childs

Saliva

CalciumPhosphorus

Xylitol Gum

Adapted with permission from the book: From Here to Longevity by Dr. Mitra Ray Ph.D. with Patricia Cannon Childs

S. Mutans

Essential Nutrient Needs of Our Essential Nutrient Needs of Our BodiesBodies

Macro Nutrients: Macro Nutrients: Air, Water, Protein, Fats, Air, Water, Protein, Fats, Carbohydrates, and Fiber. Carbohydrates, and Fiber.

Micro Nutrients:Micro Nutrients: Vitamins, Minerals, Essential Vitamins, Minerals, Essential Fatty Acids, Amino Acids, Fatty Acids, Amino Acids,

Enzymes, Pre and Pro Biotics.Enzymes, Pre and Pro Biotics.

What We’ve LearnedWhat We’ve Learned What you eat affects the health of your mouth, body, and What you eat affects the health of your mouth, body, and

lifelife That it is best to avoid sugar, white flour products, That it is best to avoid sugar, white flour products,

vegetables oils, and trans-fatsvegetables oils, and trans-fats That it is best to drink pure filtered water and eat fresh That it is best to drink pure filtered water and eat fresh

proteins, fresh vegetables, and saladsproteins, fresh vegetables, and salads That it is better for you to eat foods less processed foodThat it is better for you to eat foods less processed food That it is best for you to eat foods closest to their natural That it is best for you to eat foods closest to their natural

statestate That it is essential to support your nutrition with That it is essential to support your nutrition with

concentrated whole food supplements, because the foods concentrated whole food supplements, because the foods we consume today are not as nutrient dense as they were we consume today are not as nutrient dense as they were 100 years ago. 100 years ago.

To Summarize:To Summarize:

We believe that We believe that whole food nutritionwhole food nutrition, as close, as close

to the natural state that one can obtain,to the natural state that one can obtain,

supplemented by the use of supplemented by the use of concentrated concentrated

whole food supplementswhole food supplements is the essential is the essential

foundation for a healthy mouth and body.foundation for a healthy mouth and body.

Food to Choose (Organic)Food to Choose (Organic)

Home grown in your own garden or Home grown in your own garden or pasturepasture

Fresh picked (Farmers Markets)Fresh picked (Farmers Markets) Fresh frozen Fresh frozen Fresh as it can be in grocery store Fresh as it can be in grocery store

meat, fish, and produce sectionmeat, fish, and produce section

Xylitol – Level IIXylitol – Level II



Oral Hygiene – Level IIIOral Hygiene – Level III

Cleaning, x-rays, Exam, FluorideCleaning, x-rays, Exam, Fluoride• 1. Report Card Presentation1. Report Card Presentation• 2. Findings2. Findings• 3. Reason for follow-up3. Reason for follow-up• 4. Objective Data and assessment4. Objective Data and assessment• 5. Provider Recommendations5. Provider Recommendations

1. Report Card1. Report Card

Cavity RiskCavity Risk Gum HealthGum Health ReferralReferral

2. Dental Exam Findings2. Dental Exam Findings

Dental NeedsDental Needs Head and NeckHead and Neck Intro Oral Soft TissuesIntro Oral Soft Tissues Intra Oral TeethIntra Oral Teeth X-RaysX-Rays

3. Follow up Care - Recall3. Follow up Care - Recall

Preventative CarePreventative Care Early Cavity DetectionEarly Cavity Detection X-Rays for Cavity DetectionX-Rays for Cavity Detection Monitor EruptionMonitor Eruption Monitor Stained AreasMonitor Stained Areas Monitor Spots between TeethMonitor Spots between Teeth Soft Tissue CheckSoft Tissue Check Monitor SpacersMonitor Spacers Check Crowns/FillingsCheck Crowns/Fillings

4. Objective Data and Assessment4. Objective Data and Assessment

DateDate Eruption PeriodEruption Period pHpH Bleeding GumsBleeding Gums Plaque Plaque Oral Hygiene InstructionOral Hygiene Instruction Cleaning and FluorideCleaning and Fluoride Gum Disease Gum Disease Cavity RiskCavity Risk

5. Provider Recommendations5. Provider Recommendations

Daily XylitolDaily Xylitol Daily FluorideDaily Fluoride Professional CareProfessional Care

Oral Disinfection – Level IVOral Disinfection – Level IV

Perioguard - ChlorhexidinePerioguard - Chlorhexidine Betadyne – Povidone IodineBetadyne – Povidone Iodine CloSysII – Chlorine DioxideCloSysII – Chlorine Dioxide

Remineralization – Level VRemineralization – Level V

Ionizable mineralsIonizable minerals• Calcium LactateCalcium Lactate• Calcium CitrateCalcium Citrate• Calcium Glycerol PhosphateCalcium Glycerol Phosphate

FluorideFluoride• Listerine, Act, Fluoguard….Listerine, Act, Fluoguard….• Prevent 5000Prevent 5000

Slide Show ReviewSlide Show Review

Thank YouThank You

QuotesQuotes

Xylitol Is:Xylitol Is:

•Non-Cariogenic:Non-Cariogenic:

Does not contribute to the caries disease process.Does not contribute to the caries disease process.

•Cariostatic:Cariostatic:

The caries disease process does not occur in the presence ofThe caries disease process does not occur in the presence of Xylitol.Xylitol.

•Anti-Cariogenic:Anti-Cariogenic:

The caries disease process may be reversed through The caries disease process may be reversed through appropriate exposure to appropriate exposure to Xylitol.Xylitol.

Xylitol is Anti-CariogenicXylitol is Anti-Cariogenic

““The highest caries reduction The highest caries reduction rates were observed in subjects rates were observed in subjects using Xylitol.”using Xylitol.”

Hayes, Catherine D.M.D. D.M.Sc: The effect of Non-Hayes, Catherine D.M.D. D.M.Sc: The effect of Non-Cariogenic Sweeteners on the Prevention of Dental Caries: Cariogenic Sweeteners on the Prevention of Dental Caries: A review of the evidence A review of the evidence Journal of Dental EducationJournal of Dental Education October 2001/Vol.65/No. 10pp. 1106-1109. October 2001/Vol.65/No. 10pp. 1106-1109.

““Studies are remarkably consistent, in Studies are remarkably consistent, in the terms of the magnitude of the the terms of the magnitude of the effect observed as well as the effect observed as well as the consistent demonstration of the consistent demonstration of the superiority of Xylitol compared to superiority of Xylitol compared to sorbitol in decreasing the risk of sorbitol in decreasing the risk of dental caries.”dental caries.”

Hayes, Catherine D.M.D D.M.S c: The effect of Non-Cariogenic SweetenersHayes, Catherine D.M.D D.M.S c: The effect of Non-Cariogenic Sweeteners

on the Prevention of Dental Caries: A review of the evidence on the Prevention of Dental Caries: A review of the evidence Journal of Dental Journal of Dental

EducationEducation October 2001/Vol.65/No. 10pp. 1106-1109. October 2001/Vol.65/No. 10pp. 1106-1109.

Xylitol is non-acidogenic and non-Xylitol is non-acidogenic and non-cariogenic.cariogenic.

Xylitol is essentially non-fermentable Xylitol is essentially non-fermentable and therefore cannot be converted to and therefore cannot be converted to acids by oral bacteria.acids by oral bacteria.

Xylitol can be left on teeth overnight Xylitol can be left on teeth overnight and not cause any damage.and not cause any damage.

All from Peldyak John DMD: All from Peldyak John DMD: Xylitol Sweeten Your SmileXylitol Sweeten Your Smile; Advanced ; Advanced Developments, Inc. Mt. Pleasant, MI p.8.Developments, Inc. Mt. Pleasant, MI p.8.

How Safe is XylitolHow Safe is Xylitol ““In the amounts needed to prevent In the amounts needed to prevent

tooth decay (less than 15 grams per tooth decay (less than 15 grams per day), Xylitol is safe for everyone.”day), Xylitol is safe for everyone.”Peldyak, John D.M.D, Peldyak, John D.M.D, Xylitol Sweeten Your SmileXylitol Sweeten Your Smile Advanced Advanced Developments, Inc. Mt Pleasant, MI 48804-1010.Developments, Inc. Mt Pleasant, MI 48804-1010.

““Xylitol with adaptation is well Xylitol with adaptation is well tolerated and safe to levels of at least tolerated and safe to levels of at least 90 grams/day, with no subjective or 90 grams/day, with no subjective or objective adverse findings.”objective adverse findings.”

Brin M, Miller ON: The safety of oral xylitol in: Brin M, Miller ON: The safety of oral xylitol in: Sugars in NutritionSugars in Nutrition Sipple HL Sipple HL (ed) Academic Press New York 1974 pp. 591-605.(ed) Academic Press New York 1974 pp. 591-605.

..

““Xylitol gum enhanced Xylitol gum enhanced remineralization remineralization reduced plaque and reduced plaque and improved gingival improved gingival health.” health.”

Steinberg LM, Odusola F, Mandel ID: Remineralizing potential, Steinberg LM, Odusola F, Mandel ID: Remineralizing potential, and plaque andand plaque and

anti-gingivitis effect of xylitol and sorbitol sweetened chewing anti-gingivitis effect of xylitol and sorbitol sweetened chewing gum gum Clinical Clinical

NutritionNutrition (supplement) 1995 pp. 275-283. (supplement) 1995 pp. 275-283.

Xylitol’s Main Side EffectXylitol’s Main Side Effect

Xylitol is very hydrophilic and a Xylitol is very hydrophilic and a side effect may be slight gastric side effect may be slight gastric distress and slight osmotic distress and slight osmotic diarrhea. Consider starting with diarrhea. Consider starting with a slight dose then increasing or a slight dose then increasing or informing the patient if they informing the patient if they have any problem to cut back for have any problem to cut back for a while and build up to level a while and build up to level recommend as toleratedrecommend as tolerated

Dr. John Peldyak DMD in his book “Dr. John Peldyak DMD in his book “Xylitol Sweeten Your SmileXylitol Sweeten Your Smile”; ”; Advanced Developments, Inc. Mt. Pleasant, MI. 48804-1010, 1996, Advanced Developments, Inc. Mt. Pleasant, MI. 48804-1010, 1996, pp.5-6.pp.5-6.

Xylitol StudiesXylitol Studies

Caries prevention by xylitol compared to a control group

-90-80-70-60-50-40-30-20-10

0

% Reduction in Caries for Xylitol vs. Control

Caries prevention by xylitol compared to a control group

-90-80-70-60-50-40-30-20-10

0

% Reduction in Caries for Xylitol vs. Control

Chart, outline and references 1-15 are courtesy of Dr. John Peldyak Mt. Pleasant Michigan.

ReferencesReferences

www.ADRdental.com

1.1. Turku, Finland (1)Turku, Finland (1) -- Xylitol (67g/day) replaced dietary -- Xylitol (67g/day) replaced dietary sugar (sucrose), 1sugar (sucrose), 1

2.2. Turku, Finland (2)Turku, Finland (2) -- Xylitol (6.7g/day) was used only in -- Xylitol (6.7g/day) was used only in chewing gum.1chewing gum.1

3.3. Soviet UnionSoviet Union -- Control group also had more severe -- Control group also had more severe “deep” lesions and pulpitis.2“deep” lesions and pulpitis.2

4.4. French PolynesiaFrench Polynesia -- Both control group and xylitol group -- Both control group and xylitol group received basic oral hygiene with fluoride toothpaste. ³received basic oral hygiene with fluoride toothpaste. ³

5.5. HungaryHungary -- The xylitol group also had lower caries rate than -- The xylitol group also had lower caries rate than a group which received fluoride.4, 5a group which received fluoride.4, 5

6.6. Montreal, CanadaMontreal, Canada -- Chewing gum contained a mixture of -- Chewing gum contained a mixture of xylitol and sorbitol.6, 7 xylitol and sorbitol.6, 7

7.7. Ylivieska, FinlandYlivieska, Finland -- Comprehensive prevention program -- Comprehensive prevention program was improved by the addition of xylitol gum. Long-term was improved by the addition of xylitol gum. Long-term benefit of xylitol was established.8-10benefit of xylitol was established.8-10

8.8. BelizeBelize -- Chewing gum sweetened exclusively with xylitol -- Chewing gum sweetened exclusively with xylitol was more effective in preventing caries than sorbitol or was more effective in preventing caries than sorbitol or xylitol-sorbitol mixtures. Sucrose gum increased caries xylitol-sorbitol mixtures. Sucrose gum increased caries incidence.11, 12 incidence.11, 12

9.9. Stann CreekStann Creek -- Five year follow-up of Belize trial -- Five year follow-up of Belize trial demonstrated lasting benefit of xylitol use.13demonstrated lasting benefit of xylitol use.13

10.10. DaytonDayton -- Supragingival root surface caries were studied.14 -- Supragingival root surface caries were studied.1411.11. EstoniaEstonia -- Xylitol candy was as effective as xylitol chewing -- Xylitol candy was as effective as xylitol chewing

gum in reducing caries.15gum in reducing caries.15

1.1. Galiullin AN: Evaluation of the caries-prevention action of Galiullin AN: Evaluation of the caries-prevention action of xylitolxylitol. Kazan Med. J . Kazan Med. J 1981:67:16-18. 1981:67:16-18.

2.2. Kandelman D, Bär A, Hefti A: Collaborative WHO xylitol Kandelman D, Bär A, Hefti A: Collaborative WHO xylitol field study in French Polynesia. 1. Baseline prevalence and field study in French Polynesia. 1. Baseline prevalence and 32 month caries increment. 32 month caries increment. Caries ResCaries Res 1988; 2:55-62. 1988; 2:55-62.

3.3. Scheinin A, Banóczy J, Szóke J, et al: Three-years caries Scheinin A, Banóczy J, Szóke J, et al: Three-years caries activity in institutionalized children. activity in institutionalized children. Acta Odont ScandActa Odont Scand 1985; 43:327-347.1985; 43:327-347.

4.4. Scheinin A, Mäakinen KK: Turku sugar studies I-XXI. Scheinin A, Mäakinen KK: Turku sugar studies I-XXI. Acta Acta Odont Scand 1975; Odont Scand 1975; 33:suppl 70, 1-348.33:suppl 70, 1-348.

5.5. Scheinin A, Pienihäkkinen K, Tiekso J, Banóczy J, et al: Scheinin A, Pienihäkkinen K, Tiekso J, Banóczy J, et al: Collaborative WHO xylitol field studies in Hungary. VIII. Collaborative WHO xylitol field studies in Hungary. VIII. Two-year caries incidence in 976 institutionalized children. Two-year caries incidence in 976 institutionalized children. Acta Odont ScandActa Odont Scand 1985; 43:381-387. 1985; 43:381-387.

6.6. Kandelman D, Gagnon G: Clinical results after 12 months Kandelman D, Gagnon G: Clinical results after 12 months from a study of the incidence and progression of dental from a study of the incidence and progression of dental caries in relation to consumption of chewing gums caries in relation to consumption of chewing gums containing xylitol in school preventive programs. containing xylitol in school preventive programs. J Dent J Dent ResRes 1987; 66:1407-1411. 1987; 66:1407-1411.

7.7. Kandelman D, Gagnon A: A 24-month clinical study of the Kandelman D, Gagnon A: A 24-month clinical study of the incidence and progression of dental caries in relation to incidence and progression of dental caries in relation to consumption of chewing gums containing xylitol in school consumption of chewing gums containing xylitol in school preventive programs. preventive programs. J Dent ResJ Dent Res 1990; 69:1771-1775. 1990; 69:1771-1775.

8.8. Isokangas P Alanen P, Tiekso J, Mäkinen KK: Xylitol chewing Isokangas P Alanen P, Tiekso J, Mäkinen KK: Xylitol chewing gum in caries prevention: a field study in children. gum in caries prevention: a field study in children. J Am Dent J Am Dent AssocAssoc 1988; 17:315-320 1988; 17:315-320

9.9. Isokangas P, Tiekso J, Alanen P, Mäkinen KK: Long-term effect Isokangas P, Tiekso J, Alanen P, Mäkinen KK: Long-term effect of xylitol chewing gum in the prevention dental caries. of xylitol chewing gum in the prevention dental caries. Comm Comm Dent Oral EpidemiolDent Oral Epidemiol 1989; 17:200-203. 1989; 17:200-203.

10.10. Isokangas P, Mäkinen KK, Tiekso J, Alanen P: Long-term effect Isokangas P, Mäkinen KK, Tiekso J, Alanen P: Long-term effect of xylitol chewing gum in the prevention dental caries: A of xylitol chewing gum in the prevention dental caries: A follow-up five years after termination of a prevention program. follow-up five years after termination of a prevention program. Caries ResCaries Res 1993; 27:495-498. 1993; 27:495-498.

11.11. Mäkinen KK, Bennett CA, Hujoel PH, it al: Xytiltol chewing Mäkinen KK, Bennett CA, Hujoel PH, it al: Xytiltol chewing gums and caries rates: a 40-month cohort study. gums and caries rates: a 40-month cohort study. J Dent ResJ Dent Res 1995; 74 1904-1913.1995; 74 1904-1913.

12.12. Mäkinen KK, Hujoel PH, Bennett CA, Isotupa KP, et al: Polyol Mäkinen KK, Hujoel PH, Bennett CA, Isotupa KP, et al: Polyol chewing gums and caries rates in primary dentition: a 24 chewing gums and caries rates in primary dentition: a 24 month cohort study. month cohort study. Caries ResCaries Res 1996; 30:408-417. 1996; 30:408-417.

13.13. Mäkinen KK, Allen P, Bennett CA, et al: Stabilization of Mäkinen KK, Allen P, Bennett CA, et al: Stabilization of rampant caries: polyol gums and arrest of dentin caries in two rampant caries: polyol gums and arrest of dentin caries in two long-term cohort studies in young subjects. long-term cohort studies in young subjects. Int Dent JInt Dent J 1995; 1995; 45: 93-107.45: 93-107.

14.14. Mäkinen KK, Pemberton D, Mäkinen P-L et al: Polyol-combinant Mäkinen KK, Pemberton D, Mäkinen P-L et al: Polyol-combinant saliva stimulants and oral health in Veterans Affairs patients--saliva stimulants and oral health in Veterans Affairs patients--an exploratory study. an exploratory study. Spec Care DentSpec Care Dent 1996; 16:104-116. 1996; 16:104-116.

15.15. Alanen P, Isokangas P, Gutmann K: Xylitol candies in caries Alanen P, Isokangas P, Gutmann K: Xylitol candies in caries prevention: results of a field study in Estonian children. prevention: results of a field study in Estonian children. Community DentCommunity Dent Oral EpidemiolOral Epidemiol 2000; 28:218-224. 2000; 28:218-224.

1.1. Turku, Finland (1)Turku, Finland (1) -- Xylitol (67g/day) replaced dietary -- Xylitol (67g/day) replaced dietary sugar (sucrose), 1sugar (sucrose), 1

2.2. Turku, Finland (2)Turku, Finland (2) -- Xylitol (6.7g/day) was used only in -- Xylitol (6.7g/day) was used only in chewing gum.1chewing gum.1

3.3. Soviet UnionSoviet Union -- Control group also had more severe -- Control group also had more severe “deep” lesions and pulpitis.2“deep” lesions and pulpitis.2

4.4. French PolynesiaFrench Polynesia -- Both control group and xylitol group -- Both control group and xylitol group received basic oral hygiene with fluoride toothpaste. ³received basic oral hygiene with fluoride toothpaste. ³

5.5. HungaryHungary -- The xylitol group also had lower caries rate than -- The xylitol group also had lower caries rate than a group which received fluoride.4, 5a group which received fluoride.4, 5

6.6. Montreal, CanadaMontreal, Canada -- Chewing gum contained a mixture of -- Chewing gum contained a mixture of xylitol and sorbitol.6, 7 xylitol and sorbitol.6, 7

7.7. Ylivieska, FinlandYlivieska, Finland -- Comprehensive prevention program -- Comprehensive prevention program was improved by the addition of xylitol gum. Long-term was improved by the addition of xylitol gum. Long-term benefit of xylitol was established.8-10benefit of xylitol was established.8-10

8.8. BelizeBelize -- Chewing gum sweetened exclusively with xylitol -- Chewing gum sweetened exclusively with xylitol was more effective in preventing caries than sorbitol or was more effective in preventing caries than sorbitol or xylitol-sorbitol mixtures. Sucrose gum increased caries xylitol-sorbitol mixtures. Sucrose gum increased caries incidence.11, 12 incidence.11, 12

9.9. Stann CreekStann Creek -- Five year follow-up of Belize trial -- Five year follow-up of Belize trial demonstrated lasting benefit of xylitol use.13demonstrated lasting benefit of xylitol use.13

10.10. DaytonDayton -- Supragingival root surface caries were studied.14 -- Supragingival root surface caries were studied.1411.11. EstoniaEstonia -- Xylitol candy was as effective as xylitol chewing -- Xylitol candy was as effective as xylitol chewing

gum in reducing caries.15gum in reducing caries.15

1.1. Galiullin AN: Evaluation of the caries-prevention action of Galiullin AN: Evaluation of the caries-prevention action of xylitolxylitol. Kazan Med. J . Kazan Med. J 1981:67:16-18. 1981:67:16-18.

2.2. Kandelman D, Bär A, Hefti A: Collaborative WHO xylitol Kandelman D, Bär A, Hefti A: Collaborative WHO xylitol field study in French Polynesia. 1. Baseline prevalence and field study in French Polynesia. 1. Baseline prevalence and 32 month caries increment. 32 month caries increment. Caries ResCaries Res 1988; 2:55-62. 1988; 2:55-62.

3.3. Scheinin A, Banóczy J, Szóke J, et al: Three-years caries Scheinin A, Banóczy J, Szóke J, et al: Three-years caries activity in institutionalized children. activity in institutionalized children. Acta Odont ScandActa Odont Scand 1985; 43:327-347.1985; 43:327-347.

4.4. Scheinin A, Mäakinen KK: Turku sugar studies I-XXI. Scheinin A, Mäakinen KK: Turku sugar studies I-XXI. Acta Acta Odont Scand 1975; Odont Scand 1975; 33:suppl 70, 1-348.33:suppl 70, 1-348.

5.5. Scheinin A, Pienihäkkinen K, Tiekso J, Banóczy J, et al: Scheinin A, Pienihäkkinen K, Tiekso J, Banóczy J, et al: Collaborative WHO xylitol field studies in Hungary. VIII. Collaborative WHO xylitol field studies in Hungary. VIII. Two-year caries incidence in 976 institutionalized children. Two-year caries incidence in 976 institutionalized children. Acta Odont ScandActa Odont Scand 1985; 43:381-387. 1985; 43:381-387.

6.6. Kandelman D, Gagnon G: Clinical results after 12 months Kandelman D, Gagnon G: Clinical results after 12 months from a study of the incidence and progression of dental from a study of the incidence and progression of dental caries in relation to consumption of chewing gums caries in relation to consumption of chewing gums containing xylitol in school preventive programs. containing xylitol in school preventive programs. J Dent J Dent ResRes 1987; 66:1407-1411. 1987; 66:1407-1411.

7.7. Kandelman D, Gagnon A: A 24-month clinical study of the Kandelman D, Gagnon A: A 24-month clinical study of the incidence and progression of dental caries in relation to incidence and progression of dental caries in relation to consumption of chewing gums containing xylitol in school consumption of chewing gums containing xylitol in school preventive programs. preventive programs. J Dent ResJ Dent Res 1990; 69:1771-1775. 1990; 69:1771-1775.

8.8. Isokangas P Alanen P, Tiekso J, Mäkinen KK: Xylitol chewing Isokangas P Alanen P, Tiekso J, Mäkinen KK: Xylitol chewing gum in caries prevention: a field study in children. gum in caries prevention: a field study in children. J Am Dent J Am Dent AssocAssoc 1988; 17:315-320 1988; 17:315-320

9.9. Isokangas P, Tiekso J, Alanen P, Mäkinen KK: Long-term effect Isokangas P, Tiekso J, Alanen P, Mäkinen KK: Long-term effect of xylitol chewing gum in the prevention dental caries. of xylitol chewing gum in the prevention dental caries. Comm Comm Dent Oral EpidemiolDent Oral Epidemiol 1989; 17:200-203. 1989; 17:200-203.

10.10. Isokangas P, Mäkinen KK, Tiekso J, Alanen P: Long-term effect Isokangas P, Mäkinen KK, Tiekso J, Alanen P: Long-term effect of xylitol chewing gum in the prevention dental caries: A of xylitol chewing gum in the prevention dental caries: A follow-up five years after termination of a prevention program. follow-up five years after termination of a prevention program. Caries ResCaries Res 1993; 27:495-498. 1993; 27:495-498.

11.11. Mäkinen KK, Bennett CA, Hujoel PH, it al: Xytiltol chewing Mäkinen KK, Bennett CA, Hujoel PH, it al: Xytiltol chewing gums and caries rates: a 40-month cohort study. gums and caries rates: a 40-month cohort study. J Dent ResJ Dent Res 1995; 74 1904-1913.1995; 74 1904-1913.

12.12. Mäkinen KK, Hujoel PH, Bennett CA, Isotupa KP, et al: Polyol Mäkinen KK, Hujoel PH, Bennett CA, Isotupa KP, et al: Polyol chewing gums and caries rates in primary dentition: a 24 chewing gums and caries rates in primary dentition: a 24 month cohort study. month cohort study. Caries ResCaries Res 1996; 30:408-417. 1996; 30:408-417.

13.13. Mäkinen KK, Allen P, Bennett CA, et al: Stabilization of Mäkinen KK, Allen P, Bennett CA, et al: Stabilization of rampant caries: polyol gums and arrest of dentin caries in two rampant caries: polyol gums and arrest of dentin caries in two long-term cohort studies in young subjects. long-term cohort studies in young subjects. Int Dent JInt Dent J 1995; 1995; 45: 93-107.45: 93-107.

14.14. Mäkinen KK, Pemberton D, Mäkinen P-L et al: Polyol-combinant Mäkinen KK, Pemberton D, Mäkinen P-L et al: Polyol-combinant saliva stimulants and oral health in Veterans Affairs patients--saliva stimulants and oral health in Veterans Affairs patients--an exploratory study. an exploratory study. Spec Care DentSpec Care Dent 1996; 16:104-116. 1996; 16:104-116.

15.15. Alanen P, Isokangas P, Gutmann K: Xylitol candies in caries Alanen P, Isokangas P, Gutmann K: Xylitol candies in caries prevention: results of a field study in Estonian children. prevention: results of a field study in Estonian children. Community DentCommunity Dent Oral EpidemiolOral Epidemiol 2000; 28:218-224. 2000; 28:218-224.

FindingsFindings

““Xylitol was clinically proven to be Non-Xylitol was clinically proven to be Non-Cariogenic.”Cariogenic.”

Scheinin A, Mäkinen KK: Turku sugar studies I-XXI Acta Odontologica Scandinavia 33 (suppl 70): 1975

FindingsFindings

““Results suggest… that high-xylitol Results suggest… that high-xylitol content chewing gum usage can content chewing gum usage can retard or arrest rampant dentine retard or arrest rampant dentine caries.”caries.”

Mäkinen KK, Mäkinen PL, Pape HR.: Stabilization of rampant caries: polyol gums and arrest of dentine caries in two long-term cohort studies in young subjects. Int. Dent J 1995b; 45:93-107

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