Minimal Intervention

Sept. 1, 2008
I’m sure you’ve heard of xylitol. You know it’s a five-carbon sugar that is safe for use with diabetics and those who are avoiding cavities.

Xylitol Oh Xylitol
The Powerhouse of Minimal Intervention

by Shirley Gutkowski, RDH

I’m sure you’ve heard of xylitol. You know it’s a five-carbon sugar that is safe for use with diabetics and those who are avoiding cavities. You also hear a bunch of myths about this fabulous ingredient that can really provoke hesitation among your patients. Let’s take a look at those myths and see why they’re important to squash.

Myth 1: We don’t know how xylitol works; well, we know it doesn’t feed the bacteria, but the rest is a mystery.

Xylitol works in the metabolism cycle in the bacteria. It fills the slot that is normally taken up by fructose. By blocking this sector, the metabolism is blocked entirely, and the bacterium dies. Yes, xylitol kills germs. It does not do it in the traditional dental way — killing upon contact. Xylitol stops bacteria from living by starving it, and acids are not created, which alters the pH. The rest of the acidophilic bacteria die too, leaving room for the basophilic bacteria.

Myth 2: The only vehicle that has been proven to work with respect to xylitol is gum.

Xylitol will work in any vehicle that does not have fructose as part of the makeup. Gum, mints, washes, syrups, toothpaste, nasal spray, or sprinkling sugar all affect the bacteria the same. The trick is to have the xylitol available for a long time — the longer the better. Gum chewing has been isolated as the best vehicle because it keeps the xylitol around for a while.

Myth 3: It’s not the xylitol so much as the chewing that stimulates salivary flow. That is what’s helpful against the cavity-causing bacteria.

While it is true that chewing sugarless gum can increase remineralization, xylitol has its own effect on the cariogenic bacteria. As illustrated in the answer to the first myth discussed above, we can trace the mechanism of action from the perspective of the bacteria. Not only that, studies from the 1990s show us that xylitol attracts calcium. Xylitol decreases biofilm mass by eliminating the cariogenic bacteria, and xylitol has a small part to play in remineralization too.

Myth 4: Xylitol is great only for kids.

Xylitol is great for anyone. Oral health-care providers have all seen a rash of decay starting in adults with no foreseeable reason. Xylitol is helpful for anyone with this enamel infection. Dental leaders who study xylitol don’t stop at recommending xylitol for children only.

History shows us that young adults who live away from home often have a bout with enamel infections. It’s good practice to start all 17-year-old young adults on xylitol. Another popular time for patients to develop new decay is as they near 50 and start taking medications for various health problems, often discovering xerostomia issues. Starting all people on xylitol at age 45 may be a great way to decrease the effects those medications bring.

Middle-age adults are also at higher risk for chronic and acute diseases that can affect oral health directly or indirectly. Curbing the cariogenic bacteria can make it easier for them to miss opportunities for cavities.

The sad state of oral health in dependent adults is also a great place for xylitol to come to the rescue. As patients decline in mental or physical health, oral cleanliness often suffers. Starting all patients at age 60 or 65 on xylitol can potentially help decrease the problems that come with massive biofilm accumulations.

Myth 5: Xylitol comes from very expensive trees — birch. Harvesting hardwoods for xylitol production clears forests.

Xylitol comes from plants, not just trees. If you remember your botany classes, xylose is a product of plants, any plant with a pulpy woody component, including corncobs. There is anecdotally an issue from corn-derived xylitol. There are currently no studies to support the contention that those with corn allergies have problems from xylitol made from corn. It’s easy enough to avoid xylitol in an effort to do a self-test.

Myth 6: People who use xylitol have GI issues that range from painful gas to diarrhea.

One of the largest studies on xylitol was done with children in the first grade. Each child was using over 200 grams of xylitol per day without any gastrointestinal effect. If an effect is noticed, cutting back on the dose and slowly increasing the amount of xylitol over time will usually work.

Myth 7: All xylitol comes from China and we know about the problems there.

The companies who choose to purchase their xylitol from China use a pharmaceutical grade of xylitol. They adhere to a number of standards from the American side of the pond to ensure safety.

Myth 8: The effects of xylitol are short lived.

The effects of xylitol are long lasting. Probably the best study on xylitol, surely the ground-breaking study on the total effects of xylitol, was one published in the beginning of this millennium. Mothers were asked to chew xylitol gum every day between their child’s sixth and 24th month. At 24 months, the children were tested for strep bacteria. Less than 10% of the children were infected with strep as compared to nearly 30% of the children in the control group.

The children were rounded up again when they were 5 years old, three years after the study intervention ended. Those children whose mothers chewed the experimental gum had over 70% less decayed, missing, and filled teeth than the children in the control, and a year later were found to still have less strep than the controls. The effect of xylitol lasts years. Currently there is no end-point. Reintroducing xylitol at critical times throughout life may be unnecessary. Until the studies are conclusive, it’s best to keep recommending it.

Myth 9: Chewing that much xylitol chewing gum will affect the TMJ.

The amount of chewing is a concern for those people with TMJ issues. There are studies that show chewing gum will not affect the TMJ of people who don’t already have issues. The current recommendation is to chew the gum for five minutes. Figuring that each serving has about 1 gram and the recommendation is for 6 to 10 grams per day, that’s one serving every 90 minutes or so throughout the day. Chewing for just five minutes is acceptable. If the gum has long-lasting flavor, the temptation for chewing longer is likely to cause sore facial muscles.

Myth 10: Xylitol is a sugar substitute, like Splenda, or NutraSweet.

Xylitol is a natural sugar; it is no more manufactured than regular cane sugar. With the pulpy plants mentioned above, all of the water is taken out of the pulp, yeast is added, and the metabolites of the yeast are collected. That’s the xylitol. No chemists working over a bench with bubbling beakers nearby, no huge vats of toxins. It is a very simple basic extraction from xylose in plant material to xylitol.

With all that myth-busting, most are wondering how to use xylitol in their practices. As with any product recommended by the dental practice, having the products on hand is a great service to patients/clients. It also makes it easier to track their use.

Who should use xylitol? Anyone with a bacterial infection that centers on cariogenic bacteria.

How much should they use? The current recommendation is for 6 to 10 grams per day. Any combination of products is worthwhile. Dry mouth or breath spray, candies, toothpaste, mouthwash, or any other vehicle that comes around.

How long should people use xylitol? It’s best to use it for one year. The most important time is in children aged 5 or so to potentially avoid that first cavity.

While it may sound too good to be true, you can see that xylitol is exceedingly safe and almost magically effective. Not only is it effective against caries pathogens, it’s also effective when used to avoid middle ear infections in small children, as well as for lung infections. Early studies are finding xylitol effective against bone resorption and even helps build collagen, so watch for xylitol as an adjunct to periodontal therapy. Xylitol for enteral nutrition in place of glucose has helped in the fight against sepsis. Keep watching — there may be no end to the benefits of xylitol.

About the Author

Shirley Gutkowski, RDH, BSDH, FACE, is co-director of CareerFusion and a practicing dental hygienist. She is co-author with Amy Nieves, RDH, of the best-selling book, The Purple Guide: Developing Your Clinical Dental Hygiene Career. She can be contacted at [email protected].