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Dental Tribune United Kingdom Edition | 1+2/2016 16 TRENDS&APPLICATIONS There is a reason that the health departments of Italy,Japan and Fin- land recommend the use of xylitol for active oral care. An increasing number of national dental associa- tions in Europe have also begun to follow that recommendation. What is so special about xylitol? Is there any evidence to support its claimed properties, such as being anti-cariogenicandabletoadvance enamel remineralisation? These and other questions are matters of current debate among experts. It is fact that that the very extensive Turku study, which was conducted between 1970 and 1976 (Table I), showed a 85 per cent reduction in caries in patients consuming xyli- tolcomparedwithacontrolgroup.1 These results sparked a wave of follow-up studies. Many studies conducted under the umbrella of the World Health Organization have since confirmed a significant caries reduction of between 50 and 85 per cent.2–4 Whythenhasxylitolnotbecome commonplace by now and why is it still being debated? In addition to lack of awareness, a possible ex- planation could lie in economics. Xylitolasarawmaterialis20times more expensive than sugar in pro- duction and much more costly than other sugar substitutes. Pro- cessingismorelabourintensive,as well as more costly, and therefore less attractive for manufacturers. Incontrasttosyntheticsweeteners likeaspartameandacesulfame,the taste of xylitol is not prolonged. Compared with gum containing other sweeteners, chewing gum only sweetened with xylitol loses its natural flavour after about five minutes. Therefore, synthetically sweetened gums hold more value for the industry. From a medical perspective, chewing gum sweet- ened with xylitol becomes effec- tive after five minutes by neutral- ising the significantly reduced pH value resulting from food con- sumption. Despite the above- mentionedevidence-basedstudies on xylitol, there is need for more research regarding the known positive properties of this sweet miracle. For example, Park et al. have found that xylitol reduces inflammation in the case of Por- phyromonas gingivalis.5 Uittamo et al. have described the effective- ness of xylitol against Candida albicansandthecarcinogeniceffect of acetaldehyde in the oral cavity,6 which could be of interest to smokers particularly. Xylitol cannot replace fluoride entirely. It should rather be re- garded as a valuable addition to dental prophylaxis. Critics of xyli- tol often point to the effectiveness of fluoride, but may not consider that both substances complement each other perfectly. Xylitol is within reach even when no tooth- brush is around. It is for a reason that the European Food Safety Authority (EFSA) has confirmed health claims that chewing gum onlysweetenedwithxylitolisanti- cariogenic7 and highly effective against caries. As a rule, as many products containing xylitol as possible should be used in daily practice. In order to achieve ex- traordinary results in patients, the use of chewing gum sweetened only with xylitol is recommended. Studies evaluatedby the EFSAcon- firm this. The latest analysis by German consumer watchdog publication ÖKO-TEST (September 2015 issue) of a variety of chewing gums only rated brands containing xylitol as “good” or “very good”, while some of the global competing products containing other sweeteners were rated only “fair” or “poor”. There are plenty of good alternatives to chewing gum, such as boiled sweets and xylitol powder, which compares almost one to one to granulated sugar in its sweetness. In order to benefit fully from its positive properties, five grams of xylitol a day is generally recom- mended. An intake of 50 grams for adults and 30 grams for chil- dren is well tolerated. In order to ensure that products only contain xylitol and no other sweeteners, the list of ingredients should be checked. Editorialnote:Alistofreferencesisavail- able from the publisher DrDeborahHorch is a practising dentist in Kor- schenbroich in Germany.Shecan be contacted at de.horch@gmx.de. The sweet miracle of xylitol By Dr Deborah Horch,Germany Research center Duration in years Dose g / day Reduction of caries incidence % 1. Turku, Finland 2 67 > 85 2. USSR 2 30 73 3. WHO – Thailand Polynesia Hungary 2.3–2.7 3 2–3 20 bis 20 14–20 – – – 58–68 37–45 4. Montreal, Cananda 1–2 1–3,9 52 5. Ylivieska, Finland 3 7–10 59–84 6. Dayton, OH1 1.8 bis 8.5 80 7. Ylivieska, Finland „Von der Mutter – Kind“ 21 months 6–7 70 Table I: Overview of relevant studies. 1 Root surface caries Fig. 1: Xylitol was originally harvested from birch bark. “Xylitol cannot replace fluoride entirely. It should rather be regarded as a valuable addition to dental prophylaxis.” Glycaemic Index Xylitol Milk Muesli Sugar Honey 0 20 40 60 80 100 4 5 Control Xylitol Years 0 1 2 0 100 200 300 400 500 Plaque amount Strep. Mutans (CFU x 10 3) 2 3 Fig. 2: Xylitol blocks streptococcus mutans. © Mäkinen KK, et al. (1989) Caries Res 23, 261-267—Fig. 3: miradent Dental Care Chewing Gum sweetened with 100% xylitol. © Hager & Werken—Fig. 4: Molecular structure of xylitol—Fig. 5: Xylitol is also favoured by diabetics.© D.Fritsche:„Diabetes:Der Ernährungskompass“,Gräfe und UnzerVerlag,Germany (2008) DTUK0116_16_Horch 25.02.16 15:11 Seite 1 1. Turku, Finland 267 > 85 2. USSR 23073 4. Montreal, Cananda 1–21–3,952 5. Ylivieska, Finland 37–1059–84 1.8 bis 8.580 21 months 6–770 020406080100 45 Years 012 23 DTUK0116_16_Horch 25.02.1615:11 Seite 1