- Email: [email protected]
Effects of xylitol mouthrinse on Streptococcus mutans
journal of dentistry 40 (2012) 1151–1154
Available online at www.sciencedirect.com
journal homepage: www.intl.elsevierhealth.com/journals/jden
Short communication
Effects of xylitol mouthrinse on Streptococcus mutans M. ElSalhy, I. Sayed Zahid, E. Honkala * Faculty of Dentistry, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait
article info
abstract
Article history:
Objectives: This study aimed to measure the effect of xylitol mouthrinse on salivary Strepto-
Received 23 February 2012
coccus mutans counts.
Received in revised form
Methods: Subjects in the study group (n = 25) used xylitol mouthrinse for 4 weeks, while
13 August 2012
another group (n = 25) used saccharine mouthrinse. S. mutans were measured before and
Accepted 27 August 2012
after intervention. Results: At the baseline the mean S. mutans scores were 3.9 (SE = 0.03) and 3.9 (0.04) for the xylitol group and control group respectively, while the scores were 2.8 (0.13) and 3.9 (0.07)
Keywords:
after the intervention. Significant reductions ( p < 0.01) in the scores of S. mutans were found
Xylitol
after the four week use of xylitol mouthrinse.
Streptococcus mutans
Conclusions: Significant reductions in the scores of S. mutans were found after the four week
Polyols
use of 20% xylitol mouthrinse. The bacteriostatic effect of xylitol mouthrinse on S. mutans
Caries risk
may be comparable to other xylitol products. Further studies are needed to confirm both the short and long term effects of xylitol mouthrinse. # 2012 Elsevier Ltd. All rights reserved.
1.
Introduction
The bacteriostatic effect of xylitol products on Streptococcus mutans has been documented in several clinical trials. Many clinical studies have shown that xylitol consumption reduces the incidence of dental caries through reduction of growth and acid production of S. mutans.1–5 Chewing xylitol-containing gum causes a significant decrease in salivary S. mutans after two months.6 Also, twelve pieces of xylitol gum for twenty-five days resulted in a significant decrease in salivary S. mutans.7 Similarly, chewing xylitol gum for four weeks caused a significant reduction in salivary levels and plaque proportions of S. mutans compared with pre-treatment values.8 Xylitol gum taken three times a day for three weeks causes reduction in salivary S. mutans levels in preschool children.9 Also, significant reductions of S. mutants counts after chewing 100% and 55% xylitol gum for 90
days.10 A six-month polyol chewing-gum programme in kindergarten-age children showed statistically significant reductions of S. mutans in the interproximal plaque in the xylitol group.11 Although many studies have evaluated the effects of xylitol chewing gum on caries prevention, there are virtually no studies examining the effect of xylitol mouthrinse on oral S. mutans. Xylitol mouthrinse may be introduced as a possible alternative of xylitol products that can aid in caries prevention. The aim of this study was to determine the effect xylitol mouthrinse on salivary levels of S. mutans.
2.
Materials and methods
Seventy-two male children of ten to twelve years of age were screened for S. mutans counts. The 50 subjects with the highest bacterial counts (CRT scores of 3 and 4) were selected to
* Corresponding author. Tel.: +965 66857788; fax: +965 25326049. E-mail address: [email protected] (E. Honkala). 0300-5712/$ – see front matter # 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jdent.2012.08.014
1152
journal of dentistry 40 (2012) 1151–1154
Table 1 – Distribution of salivary S. mutans scores. Experimental group
Number of subjects
S. mutans score category
Baseline SM distribution
After 4 weeks SM distribution
Control group
25
1 2 3 4
0 0 4 21
0 0 8 17
Xylitol group
25
1 2 3 4
0 0 2 23
0 7 14 4
S. mutans scores are determined as described in the manufacturer’s (Ivoclar Vivadent1) manual on paraffin-stimulated whole saliva of all subjects in experimental groups.
participate in this study. The aim and the procedures of the study were fully explained to the subjects and their parents. A written informed consent was obtained from the parents at the beginning of the study. The research protocol and informed consent forms were reviewed and approved by the Ethical Committee of the Faculty of Dentistry, Kuwait University. Materials used in this study were 20% xylitol and 16% saccharine mouthrinses. Both solutions have approximately similar sweetness. Selected children were randomly assigned either into the control (saccharine) or into xylitol groups (25 each). The study group used 20% xylitol mouthrinse five times a day for 4 weeks; while the control group used similarly the saccharine mouthrinse of same sweetness. No eating or drinking for 20 min after rinsing was advised. Subjects were instructed not to change their oral hygiene habits. S. mutans counts were measured by CRT bacteria (Ivoclar Vivadent1) at the baseline and after 4 weeks of intervention. Stimulated saliva was collected for 5 min during paraffin-wax chewing. The saliva was transferred to a selective culture medium in glass tubes and then was incubated at 37 8C for 48 h. After incubation, the colony forming units score of S. mutans was obtained by comparing the test strip with an evaluation chart provided by the manufacturer. Two examiners read the CRT bacterial strips independently; the average of both readings was taken. Numbers of 1.0, 2.0, 3.0, and 4.0 were used as an indication of the bacterial count. The estimated levels were described as equivalent by a level of S. mutans of scores of 1.0 = <104, 2.0 = 104–105, 3.0 = 105–106, and 4.0 = >106 CFU of S. mutans/ml of saliva. According to the manufacturer, scores of 1.0 and 2.0 are considered of low caries risk, while 3.0 and 4.0 are high caries risk scores. Data were collected on specially designed study forms, entered, and evaluated using SPSS 15 software. Chi-square analysis was used to evaluate differences between the groups at baseline and after four weeks.
3.
Results
All subjects reported that they rinsed with their allocated mouthrinses at all designated times over the four week study period according to both subjects and their parents. Each child rinsed five times a day for 1 min. No adverse effects were reported during the four week period.
The mean S. mutans scores were 3.9 (SE = 0.03) at the baseline for the study group and 3.9 (0.04) for the control, while the scores were 2.8 (0.13) for the xylitol group and 3.8 (0.07) for the control group after the intervention. S. mutans scores at the baseline and after four weeks are shown in Table 1. No statistically significant differences in the distribution of salivary S. mutans could be seen between the xylitol and the control group at baseline (Chi-square, p = 0.713). However, significant reductions in the scores were noted after four weeks of intervention in the xylitol group ( p = 0.002), while no significant reductions were observed in the control group. The overall change in S. mutans scores after four weeks for each subject was also evaluated. The shift to lower scores in the xylitol group was greater than in the control group. In the xylitol group, 76% of subjects had decreased level of S. mutans; 48% decreased by only one score, while 28% decreased by two scores. However, most of the children (72%) in the control group remained having the same values.
4.
Discussion
The effectiveness of xylitol gum in the reduction of S. mutans, as shown in many long term and short term studies, was also noticed in this study using xylitol as a mouthrinse. S. mutans is considered to be the main pathogen responsible for dental caries.12 Numerous studies have shown an association between the number of carious lesions and the levels of S. mutans in both adults and children.13,14 Also, a significant correlation between caries and S. mutans was found.9 In the current study, a significant change from higher S. mutans scores to lower scores was noticed after using xylitol mouthrinse. The significance of shifting of the bacterial counts to lower scores is that it may also lead to a lower caries experience. Numerous clinical studies have shown that the consumption of xylitol reduces the incidence of caries; the most significant effect demonstrated so far is its ability to reduce the growth and acid production of S. mutans.1–5 In addition, the salivary concentration of S. mutans was crucial for colonization in the fissures.15 Since the highest caries prevalence is seen in children with higher S. mutans values, reducing the S. mutans levels is important in high-risk populations.9,14,15 The effects of long
journal of dentistry 40 (2012) 1151–1154
term rinsing with xylitol mouthrinse should be evaluated in further studies. In some xylitol studies, few subjects reported some abdominal discomfort after consumption of xylitol products.9,11 In this study, no side effects were observed by using topical application of xylitol as a mouthrinse. Both the parents and the children had been asked weather they had experienced abnormal diarrhoea or any other abdominal problems. None of the subjects reported any inconvenience or side effects. Cyclamate, saccharine and aspartame are non-caloric sweeteners that cannot be metabolized into acids by oral microorganisms. This makes them excellent control materials for this kind of studies. Saccharine mouthrinse was chosen to be the control solution in this study. It is commercially available and considered safe. Saccharine is commonly used in alternative food products without extrinsic sugar.16 Mouthrinses were prepared to an approximately similar sweetness to eliminate any possible effects of taste differences on the subjects’ compliance. One weakness of this study was its short duration. However, the purpose was to collect pilot data in a high-risk population. Nonetheless, this study demonstrated that even after four weeks of rinsing, the saliva levels of S. mutans were significantly reduced in the study group rinsing with xylitol, with no significant changes in the saccharine group. A largescale clinical trial would require a high number of subjects and considerable resources and may be indicated to confirm the results of this pilot investigation. Chair-side evaluation of salivary S. mutans levels (e.g. Dentocult-SM1 or CRT1 bacteria) has been used in several studies. The practicality of the test in children has been evaluated and was found to be accurate. In addition, the counts on the strip have been found to be a good indicator of infection.17 It suggested that salivary tests are generally more usable than the tests based on plaque, because the collection and handling of plaque tests are often more demanding.4 Also, plaque does not give a whole mouth average, which is more often desirable.17 Further studies are needed to evaluate the short and longterm effects of xylitol mouthrinse. Since xylitol delivered by xylitol gums has several biologic effects, these effects are also expected to be seen with xylitol mouthrinse. It has been suggested that xylitol gum has long-term preventive effect by reducing caries risk for several years after habitual chewing had ended.18,19 Xylitol mouthrinse may have a similar effect. This, however, needs to be confirmed in long-term studies. Moreover, a mouthrinse may be considered very safe for children to use, because swallowing of xylitol will be minimal. In this case, there will be no harm in using other xylitol products at the same period. Children generally can tolerate daily doses up to 45 g with no side effects.20 Furthermore, statistically significant association were found between intensive gum chewing and muscle sensitivity.5 In conclusion, significant reductions in the scores of S. mutans were found after the four week use of 20% xylitol mouthrinse in this study. One third of the subjects showed reduction from the high caries risk S. mutans scores to the low ones. The bacteriostatic effect of xylitol mouthrinse on S. mutans may be comparable to other xylitol products. Further
1153
studies are needed to confirm both the short and long term effects of xylitol mouthrinse.
Conflict of interest There are no conflicts of interest by any of the author.
Acknowledgement We acknowledge the administration of Al-Ghadeer Islamic Youth Center for their facilitations and cooperation during the study.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.jdent.2012.08.014.
references
1. Akerblom HK, Koivukangas T, Puukka R. The tolerance of increasing amounts of dietary xylitol in children. International Journal for Vitamin and Nutrition Research 1982;22:53–66. 2. Alaluusua S, Kleemola E, Gronros L, Eva¨lahti M. Salivary caries related tests as predictors of future caries increment in teenagers: a three-years longitudinal study. Oral Microbiology and Immunology 1990;5:77–81. 3. Autio JT. Effect of xylitol chewing gum on salivary Streptococcus mutans in preschool children. ASDC Journal of Dentistry for Children 2002;69:81–6. 4. Beighton D. The value of salivary bacterial counts in the prediction of caries activity. Journal of Dental Research 1982;68:1242–6. 5. Gavish A, Halachmi M, Winocur E, Gazit E. Oral habits and their association with signs and symptoms of temporomandibular disorders in adolescent girls. Journal of Oral Rehabilitation 2000;27:22–32. 6. Hildebrandt GH, Sparks BS. Maintaining mutans streptococci suppression with xylitol chewing gum. Journal of the American Dental Association 2000;131:909–16. 7. Hujoel PP, Ma¨kinen KK, Bennett CA. The optimum time to initiate habitual xylitol gum-chewing for obtaining longterm caries prevention. Journal of Dental Research 1999;78:797–803. 8. Isokangas R, Ma¨kinen KK, Tiekso J. Long-term effect of xylitol chewing gum in the prevention of dental caries. A follow-up 5 years after termination of a prevention program. Caries Research 1993;27:495–8. 9. Leverett DH, Proskin HM, Featherstone JD. Caries risk assessment in a longitudinal discrimination study. Journal of Dental Research 1993;72:538–43. 10. Loesche WJ, Grossman NS, Earnest R, Corpron R. The effect of chewing xylitol gum on the plaque and saliva levels of Streptococcus mutans. Journal of the American Dental Association 1984;108:587–92. 11. Loesche WJ. Role of Streptococcus mutans in human dental decay. Microbiological Reviews 1986;50:353–80.
1154
journal of dentistry 40 (2012) 1151–1154
12. Ma¨kinen KK, Soderling E, Isokangas P. Oral biochemical status and depression of Streptococcus mutans in children during 24- to 36-month use of xylitol chewing gum. Caries Research 1989;23:261–7. 13. Ma¨kinen KK, Bennett CA, Hujoel PR. Xylitol gums and caries rates: a 40-month cohort study. Journal of Dental Research 1995;74:1904–19. 14. Ma¨kinen KK, Ma¨kinen PL, Pape Jr HR. Stabilization of rampant caries: polyol gums and arrest of dentine caries in two long-term cohort studies in young subjects. International Dental Journal 1995;45:93–107. 15. Ma¨kinen KK, Hujoel PR, Bennett CA. Polyol chewing gums and caries rates in primary dentition: a 24-month cohort study. Caries Research 1996;30:408–17. 16. Ma¨kinen KK, Isotupa KP, Ma¨kinen PL, So¨derling E, Song KB, Nam SH, et al. Six-month polyol chewing-gum programme in kindergarten-age children: a feasibility study focusing on
17.
18.
19.
20.
mutans streptococci and dental plaque. International Dental Journal 2005;55:81–8. Modesto A, Drake DR. Multiple exposures to chlorhexidine and xylitol: adhesion and biofilm formation by Streptococcus mutans. Current Microbiology 2006;52:418–23. Svanberg M, Loesche WJ. The salivary concentration of Streptococci mutans and Streptococci sanguis and their colonization of artificial tooth fissures in man. Archives of Oral Biology 1977;22:441–7. Ma¨kinen KK. Sugar alcohol sweeteners as alternatives to sugar with special consideration of xylitol. Medical Principles and Practice 2011;20:303–20. Thaweboon S, Thaweboon B, Soo-Ampon S. The effect of xylitol chewing gum on mutans streptococci in saliva and dental plaque. Southeast Asian Journal of Tropical Medicine and Public Health 2004;35:1024–7.
Available online at www.sciencedirect.com
journal homepage: www.intl.elsevierhealth.com/journals/jden
Short communication
Effects of xylitol mouthrinse on Streptococcus mutans M. ElSalhy, I. Sayed Zahid, E. Honkala * Faculty of Dentistry, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait
article info
abstract
Article history:
Objectives: This study aimed to measure the effect of xylitol mouthrinse on salivary Strepto-
Received 23 February 2012
coccus mutans counts.
Received in revised form
Methods: Subjects in the study group (n = 25) used xylitol mouthrinse for 4 weeks, while
13 August 2012
another group (n = 25) used saccharine mouthrinse. S. mutans were measured before and
Accepted 27 August 2012
after intervention. Results: At the baseline the mean S. mutans scores were 3.9 (SE = 0.03) and 3.9 (0.04) for the xylitol group and control group respectively, while the scores were 2.8 (0.13) and 3.9 (0.07)
Keywords:
after the intervention. Significant reductions ( p < 0.01) in the scores of S. mutans were found
Xylitol
after the four week use of xylitol mouthrinse.
Streptococcus mutans
Conclusions: Significant reductions in the scores of S. mutans were found after the four week
Polyols
use of 20% xylitol mouthrinse. The bacteriostatic effect of xylitol mouthrinse on S. mutans
Caries risk
may be comparable to other xylitol products. Further studies are needed to confirm both the short and long term effects of xylitol mouthrinse. # 2012 Elsevier Ltd. All rights reserved.
1.
Introduction
The bacteriostatic effect of xylitol products on Streptococcus mutans has been documented in several clinical trials. Many clinical studies have shown that xylitol consumption reduces the incidence of dental caries through reduction of growth and acid production of S. mutans.1–5 Chewing xylitol-containing gum causes a significant decrease in salivary S. mutans after two months.6 Also, twelve pieces of xylitol gum for twenty-five days resulted in a significant decrease in salivary S. mutans.7 Similarly, chewing xylitol gum for four weeks caused a significant reduction in salivary levels and plaque proportions of S. mutans compared with pre-treatment values.8 Xylitol gum taken three times a day for three weeks causes reduction in salivary S. mutans levels in preschool children.9 Also, significant reductions of S. mutants counts after chewing 100% and 55% xylitol gum for 90
days.10 A six-month polyol chewing-gum programme in kindergarten-age children showed statistically significant reductions of S. mutans in the interproximal plaque in the xylitol group.11 Although many studies have evaluated the effects of xylitol chewing gum on caries prevention, there are virtually no studies examining the effect of xylitol mouthrinse on oral S. mutans. Xylitol mouthrinse may be introduced as a possible alternative of xylitol products that can aid in caries prevention. The aim of this study was to determine the effect xylitol mouthrinse on salivary levels of S. mutans.
2.
Materials and methods
Seventy-two male children of ten to twelve years of age were screened for S. mutans counts. The 50 subjects with the highest bacterial counts (CRT scores of 3 and 4) were selected to
* Corresponding author. Tel.: +965 66857788; fax: +965 25326049. E-mail address: [email protected] (E. Honkala). 0300-5712/$ – see front matter # 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jdent.2012.08.014
1152
journal of dentistry 40 (2012) 1151–1154
Table 1 – Distribution of salivary S. mutans scores. Experimental group
Number of subjects
S. mutans score category
Baseline SM distribution
After 4 weeks SM distribution
Control group
25
1 2 3 4
0 0 4 21
0 0 8 17
Xylitol group
25
1 2 3 4
0 0 2 23
0 7 14 4
S. mutans scores are determined as described in the manufacturer’s (Ivoclar Vivadent1) manual on paraffin-stimulated whole saliva of all subjects in experimental groups.
participate in this study. The aim and the procedures of the study were fully explained to the subjects and their parents. A written informed consent was obtained from the parents at the beginning of the study. The research protocol and informed consent forms were reviewed and approved by the Ethical Committee of the Faculty of Dentistry, Kuwait University. Materials used in this study were 20% xylitol and 16% saccharine mouthrinses. Both solutions have approximately similar sweetness. Selected children were randomly assigned either into the control (saccharine) or into xylitol groups (25 each). The study group used 20% xylitol mouthrinse five times a day for 4 weeks; while the control group used similarly the saccharine mouthrinse of same sweetness. No eating or drinking for 20 min after rinsing was advised. Subjects were instructed not to change their oral hygiene habits. S. mutans counts were measured by CRT bacteria (Ivoclar Vivadent1) at the baseline and after 4 weeks of intervention. Stimulated saliva was collected for 5 min during paraffin-wax chewing. The saliva was transferred to a selective culture medium in glass tubes and then was incubated at 37 8C for 48 h. After incubation, the colony forming units score of S. mutans was obtained by comparing the test strip with an evaluation chart provided by the manufacturer. Two examiners read the CRT bacterial strips independently; the average of both readings was taken. Numbers of 1.0, 2.0, 3.0, and 4.0 were used as an indication of the bacterial count. The estimated levels were described as equivalent by a level of S. mutans of scores of 1.0 = <104, 2.0 = 104–105, 3.0 = 105–106, and 4.0 = >106 CFU of S. mutans/ml of saliva. According to the manufacturer, scores of 1.0 and 2.0 are considered of low caries risk, while 3.0 and 4.0 are high caries risk scores. Data were collected on specially designed study forms, entered, and evaluated using SPSS 15 software. Chi-square analysis was used to evaluate differences between the groups at baseline and after four weeks.
3.
Results
All subjects reported that they rinsed with their allocated mouthrinses at all designated times over the four week study period according to both subjects and their parents. Each child rinsed five times a day for 1 min. No adverse effects were reported during the four week period.
The mean S. mutans scores were 3.9 (SE = 0.03) at the baseline for the study group and 3.9 (0.04) for the control, while the scores were 2.8 (0.13) for the xylitol group and 3.8 (0.07) for the control group after the intervention. S. mutans scores at the baseline and after four weeks are shown in Table 1. No statistically significant differences in the distribution of salivary S. mutans could be seen between the xylitol and the control group at baseline (Chi-square, p = 0.713). However, significant reductions in the scores were noted after four weeks of intervention in the xylitol group ( p = 0.002), while no significant reductions were observed in the control group. The overall change in S. mutans scores after four weeks for each subject was also evaluated. The shift to lower scores in the xylitol group was greater than in the control group. In the xylitol group, 76% of subjects had decreased level of S. mutans; 48% decreased by only one score, while 28% decreased by two scores. However, most of the children (72%) in the control group remained having the same values.
4.
Discussion
The effectiveness of xylitol gum in the reduction of S. mutans, as shown in many long term and short term studies, was also noticed in this study using xylitol as a mouthrinse. S. mutans is considered to be the main pathogen responsible for dental caries.12 Numerous studies have shown an association between the number of carious lesions and the levels of S. mutans in both adults and children.13,14 Also, a significant correlation between caries and S. mutans was found.9 In the current study, a significant change from higher S. mutans scores to lower scores was noticed after using xylitol mouthrinse. The significance of shifting of the bacterial counts to lower scores is that it may also lead to a lower caries experience. Numerous clinical studies have shown that the consumption of xylitol reduces the incidence of caries; the most significant effect demonstrated so far is its ability to reduce the growth and acid production of S. mutans.1–5 In addition, the salivary concentration of S. mutans was crucial for colonization in the fissures.15 Since the highest caries prevalence is seen in children with higher S. mutans values, reducing the S. mutans levels is important in high-risk populations.9,14,15 The effects of long
journal of dentistry 40 (2012) 1151–1154
term rinsing with xylitol mouthrinse should be evaluated in further studies. In some xylitol studies, few subjects reported some abdominal discomfort after consumption of xylitol products.9,11 In this study, no side effects were observed by using topical application of xylitol as a mouthrinse. Both the parents and the children had been asked weather they had experienced abnormal diarrhoea or any other abdominal problems. None of the subjects reported any inconvenience or side effects. Cyclamate, saccharine and aspartame are non-caloric sweeteners that cannot be metabolized into acids by oral microorganisms. This makes them excellent control materials for this kind of studies. Saccharine mouthrinse was chosen to be the control solution in this study. It is commercially available and considered safe. Saccharine is commonly used in alternative food products without extrinsic sugar.16 Mouthrinses were prepared to an approximately similar sweetness to eliminate any possible effects of taste differences on the subjects’ compliance. One weakness of this study was its short duration. However, the purpose was to collect pilot data in a high-risk population. Nonetheless, this study demonstrated that even after four weeks of rinsing, the saliva levels of S. mutans were significantly reduced in the study group rinsing with xylitol, with no significant changes in the saccharine group. A largescale clinical trial would require a high number of subjects and considerable resources and may be indicated to confirm the results of this pilot investigation. Chair-side evaluation of salivary S. mutans levels (e.g. Dentocult-SM1 or CRT1 bacteria) has been used in several studies. The practicality of the test in children has been evaluated and was found to be accurate. In addition, the counts on the strip have been found to be a good indicator of infection.17 It suggested that salivary tests are generally more usable than the tests based on plaque, because the collection and handling of plaque tests are often more demanding.4 Also, plaque does not give a whole mouth average, which is more often desirable.17 Further studies are needed to evaluate the short and longterm effects of xylitol mouthrinse. Since xylitol delivered by xylitol gums has several biologic effects, these effects are also expected to be seen with xylitol mouthrinse. It has been suggested that xylitol gum has long-term preventive effect by reducing caries risk for several years after habitual chewing had ended.18,19 Xylitol mouthrinse may have a similar effect. This, however, needs to be confirmed in long-term studies. Moreover, a mouthrinse may be considered very safe for children to use, because swallowing of xylitol will be minimal. In this case, there will be no harm in using other xylitol products at the same period. Children generally can tolerate daily doses up to 45 g with no side effects.20 Furthermore, statistically significant association were found between intensive gum chewing and muscle sensitivity.5 In conclusion, significant reductions in the scores of S. mutans were found after the four week use of 20% xylitol mouthrinse in this study. One third of the subjects showed reduction from the high caries risk S. mutans scores to the low ones. The bacteriostatic effect of xylitol mouthrinse on S. mutans may be comparable to other xylitol products. Further
1153
studies are needed to confirm both the short and long term effects of xylitol mouthrinse.
Conflict of interest There are no conflicts of interest by any of the author.
Acknowledgement We acknowledge the administration of Al-Ghadeer Islamic Youth Center for their facilitations and cooperation during the study.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.jdent.2012.08.014.
references
1. Akerblom HK, Koivukangas T, Puukka R. The tolerance of increasing amounts of dietary xylitol in children. International Journal for Vitamin and Nutrition Research 1982;22:53–66. 2. Alaluusua S, Kleemola E, Gronros L, Eva¨lahti M. Salivary caries related tests as predictors of future caries increment in teenagers: a three-years longitudinal study. Oral Microbiology and Immunology 1990;5:77–81. 3. Autio JT. Effect of xylitol chewing gum on salivary Streptococcus mutans in preschool children. ASDC Journal of Dentistry for Children 2002;69:81–6. 4. Beighton D. The value of salivary bacterial counts in the prediction of caries activity. Journal of Dental Research 1982;68:1242–6. 5. Gavish A, Halachmi M, Winocur E, Gazit E. Oral habits and their association with signs and symptoms of temporomandibular disorders in adolescent girls. Journal of Oral Rehabilitation 2000;27:22–32. 6. Hildebrandt GH, Sparks BS. Maintaining mutans streptococci suppression with xylitol chewing gum. Journal of the American Dental Association 2000;131:909–16. 7. Hujoel PP, Ma¨kinen KK, Bennett CA. The optimum time to initiate habitual xylitol gum-chewing for obtaining longterm caries prevention. Journal of Dental Research 1999;78:797–803. 8. Isokangas R, Ma¨kinen KK, Tiekso J. Long-term effect of xylitol chewing gum in the prevention of dental caries. A follow-up 5 years after termination of a prevention program. Caries Research 1993;27:495–8. 9. Leverett DH, Proskin HM, Featherstone JD. Caries risk assessment in a longitudinal discrimination study. Journal of Dental Research 1993;72:538–43. 10. Loesche WJ, Grossman NS, Earnest R, Corpron R. The effect of chewing xylitol gum on the plaque and saliva levels of Streptococcus mutans. Journal of the American Dental Association 1984;108:587–92. 11. Loesche WJ. Role of Streptococcus mutans in human dental decay. Microbiological Reviews 1986;50:353–80.
1154
journal of dentistry 40 (2012) 1151–1154
12. Ma¨kinen KK, Soderling E, Isokangas P. Oral biochemical status and depression of Streptococcus mutans in children during 24- to 36-month use of xylitol chewing gum. Caries Research 1989;23:261–7. 13. Ma¨kinen KK, Bennett CA, Hujoel PR. Xylitol gums and caries rates: a 40-month cohort study. Journal of Dental Research 1995;74:1904–19. 14. Ma¨kinen KK, Ma¨kinen PL, Pape Jr HR. Stabilization of rampant caries: polyol gums and arrest of dentine caries in two long-term cohort studies in young subjects. International Dental Journal 1995;45:93–107. 15. Ma¨kinen KK, Hujoel PR, Bennett CA. Polyol chewing gums and caries rates in primary dentition: a 24-month cohort study. Caries Research 1996;30:408–17. 16. Ma¨kinen KK, Isotupa KP, Ma¨kinen PL, So¨derling E, Song KB, Nam SH, et al. Six-month polyol chewing-gum programme in kindergarten-age children: a feasibility study focusing on
17.
18.
19.
20.
mutans streptococci and dental plaque. International Dental Journal 2005;55:81–8. Modesto A, Drake DR. Multiple exposures to chlorhexidine and xylitol: adhesion and biofilm formation by Streptococcus mutans. Current Microbiology 2006;52:418–23. Svanberg M, Loesche WJ. The salivary concentration of Streptococci mutans and Streptococci sanguis and their colonization of artificial tooth fissures in man. Archives of Oral Biology 1977;22:441–7. Ma¨kinen KK. Sugar alcohol sweeteners as alternatives to sugar with special consideration of xylitol. Medical Principles and Practice 2011;20:303–20. Thaweboon S, Thaweboon B, Soo-Ampon S. The effect of xylitol chewing gum on mutans streptococci in saliva and dental plaque. Southeast Asian Journal of Tropical Medicine and Public Health 2004;35:1024–7.