Oulun ammattikorkeakoulu
ePooki 49/2019

Xylitol and its Benefits on Oral Health

Metatiedot

Nimeke: Xylitol and its Benefits on Oral Health. In A-L. Jussila & M. Oinonen (eds.) Oral Health Promotion

Tekijä: Boricheva Ekaterina; Elsilä Saara; Häkkilä Eveliina; Karjalainen Laura; Kinnunen Elina; Laapotti Laura; Ballardin Lisa; Jussila Aino-Liisa

Aihe, asiasanat: ksylitoli, suun terveys, xylitol, oral health

Tiivistelmä: This article focuses on the oral health benefits of xylitol – a sugar alcohol found to prevent caries. This article worked as a theory base for our health promotion event that took part in Oulu International School.

Xylitol is a natural sweetener that has unique chemical structure making it caries preventative rather than cariogenic like other common sweeteners like sugar. Xylitol can be found from various plant sources such as fruits and vegetables. Xylitol works by disrupting the energy metabolism of bacteria found in oral plaque.

Xylitol is safe and well tolerated, except for its tendency to cause stomach pain for some people. It is especially beneficial for young infants and their mothers, children and adults with increased caries risk.

Julkaisija: Oulun ammattikorkeakoulu, Oamk

Aikamääre: Julkaistu 2019-06-28

Pysyvä osoite: http://urn.fi/urn:nbn:fi-fe2019061019850

Kieli: englanti

Suhde: http://urn.fi/URN:ISSN:1798-2022, ePooki - Oulun ammattikorkeakoulun tutkimus- ja kehitystyön julkaisut

Oikeudet: CC BY-NC-ND 4.0

Näin viittaat tähän julkaisuun

Boricheva, E., Elsilä, S., Häkkilä, E., Karjalainen, L., Kinnunen, E., Laapotti, L., Ballardin, L. & Jussila, A-L. 2019. Xylitol and its Benefits on Oral Health. In A-L. Jussila & M. Oinonen (eds.) Oral Health Promotion. ePooki. Oulun ammattikorkeakoulun tutkimus- ja kehitystyön julkaisut 49. Hakupäivä 14.12.2019. http://urn.fi/urn:nbn:fi-fe2019061019850.

Xylitol is a product found from plants and it can prevent tooth decay. Natural products such as vegetables, fruits and birch bark contain xylitol. Xylitol can also be added into many products. Using xylitol chewing gum or pastilles after every meal is an easy way to stop acid attack and keep teeth to remain healthy. Recommended daily dosage of xylitol is five grams which equates about six pieces of chewing gum. For getting the best results xylitol products should be used regularly.

Introduction

In this article the studies about xylitol and its benefits on oral health is reviewed. In addition, the oral health promotion event in Oulu International School for 9th graders is described. The aim of the event was to clarify the effects of xylitol to oral health. At our stand (photo 1) the pupils were given information about the benefits of using xylitol and making small experiment with saliva's pH-levels, acid attack and xylitol gum. With the experiment the pupils were shown how effectively xylitol can help producing saliva and stopping acid attack after eating or drinking. The pupils already knew a lot about the benefits of xylitol, but after the event they knew more detailed information and explanations how and why xylitol works. 

PHOTO 1. Giving information about benefits of using xylitol in Oulu International School (photo: Kinnunen Elina)

Xylitol is a natural sugar alcohol that can be found from plants. It can be produced for commercial use like chewing gums and pastilles. For example this meta-analysis Chandrashekar Janakiram, C.V., Deepan, K. & Joe, J. 2019. Xylitol in preventing dental caries: A systematic review and meta-analyses. Journal of Natural Science, Biology and Medicine 8 (1), 16–21. Referred 13.6.2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5320817/ show that xylitol has oral health benefits. Bacteria that causes tooth decay cannot use xylitol as their nutrition. It also helps to increase the secretion of saliva. Xylitol is recommended especially for children and people with increased caries risk as it reduces oral count of mutans streptococci. People who suffer from dry mouth also benefit from xylitol.

What is Xylitol?

Xylitol is a pentahydroxy sugar alcohol which exists in a very low quantity in fruits and vegetables (plums, strawberries, cauliflower and pumpkin). On commercial scale, xylitol can be produced by chemical and biotechnological processes. Ur-Rehman, S., Mushtaq, Z., Zahoor, T., Jamil, A. & Murtaza M. A. 2015. Xylitol: A Review on Bioproduction, Application, Health Benefits, and Related Safety Issues. Critical Reviews in Food Science and Nutrition 55 (11), 1514–28. Referred 22.5.2019. https://www.tandfonline.com/doi/full/10.1080/10408398.2012.702288 The chemical production of this sugar is quite expensive and it requires intensive process. The name xylitol relates to the word xylose (wood sugar) from which xylitol was first made, and which is in turn derived from the particular structure (xylene) of hardwood from which xylose can be obtained Peldyak, J. & Mäkinen, K. K. 2002. Xylitol for caries prevention. Journal of Dental Hygiene 76 (4), 276–85.. Xylitol was discovered at least from the 1890's by German and French Mäkinen, K. K. History, Safety, and Dental Properties of Xylitol. Referred 22.5.2019. https://pdfs.semanticscholar.org/079b/1341d26e02123a2dcf37f55f9d3048e8325d.pdf.

The use of xylitol is relatively common in several European countries like Finland, German and Italy. It is also known among Chinese and Japanese researchers. Compared with glucose in healthy subjects, xylitol causes a much smaller increase in serum insulin and blood glucose levels with no "rebound" hypoglycemia (glycemic index: xylitol=7, glucose=100). Peldyak, J. & Mäkinen, K. K. 2002. Xylitol for caries prevention. Journal of Dental Hygiene 76 (4), 276–85.

Xylitol replaces the sucrose of different food to avoid caries in the oral health. It reduces the levels of mutant streptococci and lactobacilli, and it can be protective against periodontal diseases. Rafeek, R., Carrington, C. V. F., Gomez, A., Harkins, D., Torralba, M., Kuelbs, C., Addae, J., Moustafa, A. & Nelson, K. E. 2019. Xylitol and sorbitol effects on the microbiome of saliva and plaque. Journal of Oral Microbiology 11 (1), 1536181. Referred 23.5.2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6225370 For this reason, xylitol can be contained in toothpaste (also with fluoride) for preventing caries in permanent teeth of children. Duane, B. 2015. Xylitol and caries prevention. Evidence-Based Dentistry 16, 37–38. Referred 23.5.2019. https://www.nature.com/articles/6401088

Products with xylitol can be divided into two groups. First group consist of natural products, which contain xylitol such as vegetables, fruits and birch bark. The second group includes products to which xylitol has been added by humans. The most common and popular among them is chewing gum. Alternative to chewing gum are pastilles, tablets, dragées (for example for patients with bite problems). Xylitol can also be included in toothpastes, mouthwashes, sprays, gels, 'artificial saliva' and even in candies. Mäkinen, K. K. 2011. Sugar Alcohol Sweeteners as Alternatives to Sugar with Special Consideration of Xylitol. Medical Principles and Practice 20, 303–320. Referred 6.2.2019. https://www.karger.com/Article/Pdf/324534

How does it work?

Xylitol has several chemical and biological properties and reactions which are caries preventative. Due to its pentitol nature, xylitol does not support dental plaque growth. Xylitol can form chemical complexes with calcium ion in saliva, which contribute to the remineralization of already existing caries lesions. Xylitol decreases the growth of mutans streptococci by affecting the bacteria's structure and acid production. Ur-Rehman, S., Mushtaq, Z., Zahoor, T., Jamil, A. & Murtaza M. A. 2015. Xylitol: A Review on Bioproduction, Application, Health Benefits, and Related Safety Issues. Critical Reviews in Food Science and Nutrition 55 (11), 1514–28. Referred 22.5.2019. https://www.tandfonline.com/doi/full/10.1080/10408398.2012.702288 It disrupts the energy production of mutans streptococci, leading to futile energy cycle and cell death. Mäkinen, K. K. History, Safety, and Dental Properties of Xylitol. Referred 22.5.2019. https://pdfs.semanticscholar.org/079b/1341d26e02123a2dcf37f55f9d3048e8325d.pdf It reduces the cariogenicity of plaque by decreasing the metabolism of all carbohydrates. With the long-term usage of xylitol, dental plaque becomes less adhesive to itself and tooth surfaces. Xylitol usage among infants' mothers as been found to prevent the transmission of caries from mother to child. Ur-Rehman, S., Mushtaq, Z., Zahoor, T., Jamil, A. & Murtaza M. A. 2015. Xylitol: A Review on Bioproduction, Application, Health Benefits, and Related Safety Issues. Critical Reviews in Food Science and Nutrition 55 (11), 1514–28. Referred 22.5.2019. https://www.tandfonline.com/doi/full/10.1080/10408398.2012.702288

Xylitol also has so called passive effects, which can be found caries preventative. It increases salivation and when used as a sugar substitute, the progression of caries decreases because cariogenic organisms no longer have their normal growth substrate, sucrose. Ur-Rehman, S., Mushtaq, Z., Zahoor, T., Jamil, A. & Murtaza M. A. 2015. Xylitol: A Review on Bioproduction, Application, Health Benefits, and Related Safety Issues. Critical Reviews in Food Science and Nutrition 55 (11), 1514–28. Hakupäivä 22.5.2019. https://www.tandfonline.com/doi/full/10.1080/10408398.2012.702288

Is it safe?

Researches has proven that xylitol is safe for humans. Over the years there has been scientific studies worldwide of toxicological and nutritional safety of xylitol and long-term consumption of xylitol for diabetic people (e.g Dasgupta, D., Bandhu, S., Adhikari, DK. & Ghosh D. 2017. Challenges and prospects of xylitol production with whole cell bio-catalysis: A review. Microbiological Research 197, 9–21. Referred 13.6.2019. https://www.sciencedirect.com/science/article/pii/S094450131630708X). The conclusion of those studies has been that xylitol is safe to use. One of those studies was made in Turku during the 1970's and the purpose of that study was to test safety of xylitol on humans. Subjects consumed xylitol daily in large amounts for two years. The results showed that there were no pathological findings on blood and urine chemistry analyses and no harmful long-term side-effects were found Mäkinen, K. K. 2011. Sugar Alcohol Sweeteners as Alternatives to Sugar with Special Consideration of Xylitol. Medical Principles and Practice 20, 303–320. Referred 6.2.2019. https://www.karger.com/Article/Pdf/324534. Humans tolerate xylitol well, but for some people large consumption of it can cause stomach pain or diarrhea Nayak, P., Nayak, U. & Khandelwal, V. 2014. The effect of xylitol on dental caries and oral flora. Clinical, Cosmetic and Investigational Dentistry 6, 89–94. Referred 6.2.2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4232036/pdf/ccide-6-089.pdf.

Xylitol is safe for diabetic people too. Xylitol is slowly absorbed and metabolized by human bodies which leads to only slight changes in insulin levels. Researches has found that because of xylitol's low glycolic index it's ideal sweetener for maintaining steady levels of insulin and blood sugar Carniciu, S., Ionescu, A., Ionescu-Tirgoviste, C., Mihai, A. & Vasilescu, R. 2011. Sweeteners and metabolic diseases: xylitol as a new player. Proc. Rom. Acad., Series B, 2, 125–128. Referred 6.2.2019. https://pdfs.semanticscholar.org/83c4/e2c528390e5dee46322807f07ff15a9fadc9.pdf.

Who will benefit from xylitol?

Using xylitol from early age improves oral health of children and reduces the oral count of mutans streptococci. A caries prevention experiment in infants was demonstrated at Finnish Public Health Centre in 2002–2011. Parents of the children from the age of 6–8 months started to swab 45 % xylitol onto their children's deciduous teeth by using cotton swabs or children's toothbrush twice a day. Xylitol swabbing treatment continued until the child was 36 months old. As a result, there was a significant reduction in enamel and dentine caries compared to control group of 7- year old children Mäkinen, K., Järvinen, K., Anttila, C., Luntamo, L. & Vahlberg, T. 2013. Topical xylitol administration by parents for the promotion of oral health in infants: a caries prevention experiment at a Finnish Public Health Centre. International Dental Journal 63 (4), 210–224. Referred 7.2.2019. https://onlinelibrary.wiley.com/doi/full/10.1111/idj.12038. Besides caries, xylitol also prevents ear infections on children. Streptococcus Pneumoniae which causes acute otitis media, ear infection, cannot exploit xylitol as an energy source. Xylitol decreases these bacteria by modifying their structure and destroying them. Preventing ear infections works only when xylitol is used regularly Tapiainen, T. 2002. Microbiological effects and clinical use of xylitol in preventing acute otitis media. Väitöskirja. Oulun yliopisto. Referred 17.2.2019. http://urn.fi/urn:isbn:9514267796

Adults also benefit from using xylitol, especially patients with an increased risk of caries. The risk is increased by factors such as poor oral hygiene, dry mouth, different fillings and orthodontic devices. Certain medication like antipsychotic and cardiac medication influence the saliva production by reducing the flow of saliva therefore making its washing effect insufficient. The use of medication increases as person ages. Xylitol products are recommended to patients with Sjogren syndrome and patients receiving radiation therapy to head and neck area because of its stimulating effect on salivary flow due to their impaired activity of salivary glands. Gupta, A., Epstein, J. B. & Sroussi, H. 2006. Hyposalivation in Elderly Patients. J Can Dent Assoc 72 (9), 841–6. Hakupäivä 9.2.2019. http://www.cda-adc.ca/JCDA/vol-72/issue-9/841.pdf Orthodontic patients benefit from using xylitol products as orthodontic devices make cleaning the teeth harder and the devices increase attachment points for bacterial biofilm. Also, special groups like disabled people who cannot manage adequate oral hygiene due to motor difficulties will benefit from using xylitol products as a way of caries prevention. Peldyak, J. & Makinen, K. K. 2002. Xylitol for caries prevention. J Dent Hyg.76 (4), 276–85. Hakupäivä 23.5.2019. https://www.ncbi.nlm.nih.gov/pubmed/12592919

Finnish Dental Association recommends using xylitol after every meal. Recommended daily dosage of xylitol is five grams, which equates about six pieces of chewing gum. For getting the best results xylitol products should be used regularly. The more chewing gum contains xylitol, the better effect it has on dental health. Suomen hammaslääkäriliitto. 2013. Ksylitoli. Referred 24.3.2019. https://www.hammaslaakariliitto.fi/fi/suunterveys/yleistietoa-suunterveydesta/ravinto-ja-suunterveys/ksylitoli#.XJd9YygzZPY

Promoting adolescents' oral health 

The students of Health Promotion Project course held a health promotion event in Oulu International School for 9th graders. The students had a stand and they were giving information about benefits of using xylitol and making small experiment with saliva’s pH-levels, acid attack and xylitol gum. With the experiment they wanted to show pupils how effectively xylitol can help producing saliva and stop acid attack after eating or drinking. In the experiment pupils were given small cups of soda to drink at first. Soda is a carbonic drink, which lowers the pH-level of mouth below neutral and starts acid attack. After that pupils were given pH-level test to measure their saliva’s pH-level. After measurement the next step was to chew xylitol gum for few minutes. During those few minutes the pupils were told important facts about xylitol. When few minutes of chewing had passed pupils were given new pH-level tests to check how xylitol had worked. With pH-level tests pupils could concretely see how quickly pH-level can change and how xylitol can help.

In the end of the event pupils were given a quiz about all the things they had learned during the event. They were asked, "what is the recommended daily intake of xylitol" and "when should you use xylitol". The correct answers were "five grams" and "after every meal". All pupils chose correct answers. Before the event pupils already knew a lot about benefits of xylitol, but after the event they knew more detailed information and explanations on how and why xylitol works.

Conclusion

Xylitol is a natural sugar alcohol that is generally suitable for everyone to use. Even people with diabetes can safely consume it, because unlike sugar, xylitol has a negligible effect on blood sugar and insulin level. Usually xylitol is used in chewing gums and pastilles but can be also used for example in mouthwashes and toothpastes. It has several health-promoting effects and that's why it is recommended to use regularly after a meal, as it will be the most beneficial for oral health.

Xylitol inhibits the growth of bacteria in the mouth, reduces the formation of plaque, reduces the destruction of tooth enamel and reduces ear infections in children. It also stimulates the salivary flow, which neutralizes acids, removes bacteria and food debris from the mouth. Xylitol is very useful for the people in risk for caries, people with dry-mouth, children, and people with special needs, especially who have some difficulties with brushing. The use of xylitol can prevent the transmission of caries infection from mother to a child. 

Xylitol is a good adjunct to protect teeth from caries, but it does not replace brushing. Flossing and brushing are fundamental to good dental health.

References

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