In the Mouth Sugar and teeth is a bad combi- nation, we’ve been saying it for years. We almost believe it by now but, saying it doesn’t make it true. There are some who still insist that the benefit of chewing xylitol gum rests solely on the increased saliva, a mountain of evidence exists to show that xylitol has medicinal properties as well. As a preventive measure and as a cure, xylitol works. The facts are that sugar and sucrose stimulates the bacteria in the mouth to create the sticky substance that makes plaque biofilm stick to teeth.3 Other sugars, like simple and complex carbohy- drates, stimulate acid production by the biofilm. It’s the acid that dissolves the enamel making first a white spot then a hole.4 Xylitol gets in the way of the bacteria’s ability to produce acid and that sticky substance that allows the germs to attach to the teeth.5 The cavity-causing bacteria will gravitate towards the xylitol in the presence of nearly all other sugars. Fructose is the only sugar that trumps xylitol. In a mixture of xyli- tol and fructose, acids will still be produced, but not the sticky coat- ing.6 Interestingly, caries and DMF (decayed, missing and filled) rates decrease without eliminating high fructose corn syrup (HFC) from the diet. Current studies do not identify HFC as a confounding factor, it’s just never been mentioned. Orthodontic patients using xylitol have a high pH and therefore a lower risk for enamel breakdown.7, 8 The best time to incorporate xyli- tol is pretty straight forward - one year before anything happens. For instance, one year before the first or second molar erupts or one year before brackets and bands are placed.9 The second best time for orthodontic patients is at the time of treatment. Recommending that patients brush with toothpaste that contains xylitol, sprinkle xylitol on their morning cereal or in their morning drink, chew xylitol gum after lunch and dinner, sprinkle xylitol in the water jet device, and perhaps using xylitol one other time during the day will do a world of good. This nearly magical ingredient has another fantastic attribute: longevity. Many of the xylitol stud- ies found much less decay and much less bacteria in the study participants years after the interven- tion with xylitol ended. The ground breaking study reporting the affects xylitol use by the mother on their child showed over 70% less decay in the children whose mother’s chewed xylitol gum even three years after the study ended. Four years after, the children in the control group had more cavity-caus- ing bacteria present in their mouth than the children in the study group. Other studies show the same level of longevity.10, 11, 12, 13, 14 The use of xylitol for young mothers is always in the discussion of when to start. The current think- ing is that pregnant women have a heightened air of responsibility about taking care of their infant and asking them to chew xylitol gum during pregnancy or early post-partum is a good time. However, the children who are highest risk for decay are not in mothers who have high self-esteem or who are caring. Those at high risk are in people who engage in risky behavior, sexual or otherwise. Endorsing xylitol for all 14-year-old teenagers may be a better start. The benefits of asking the mother to chew xylitol sweetened gum have benefits that reach into the fourth year after the study. Subsequent siblings were not considered in any of the studies, no one re-evaluated the study any further out, but there is every reason to suspect that children whose mothers used xylitol even before conception can have a lower incidence of cavity-causing bacteria even if the child is born five or more years after. Xylitol is safe and easy to use. It’s found in gum and candies and oral care products. The studies that showed the best outcome used gum sweetened exclusively with xylitol and current recommendations are to use about 6 servings of 100% xylitol sweetened products distributed throughout the day. Using all of the servings at one sitting isn’t as helpful. New studies are looking at the duration needed. The study with the mother-child pairs had the mothers using xylitol gum for 18 months. Other studies have people using xylitol products for as little as six weeks. It could be that a person may only need to use xylitol products for a month and still get the same benefits years down the road. Currently, there are no good reasons to stop using xylitol - there are plenty of good reasons to start.15 Don’t think for a minute that mechanical plaque biofilm removal using traditional means is obsolete. For the age range of young people traditionally having appliances on their teeth, xylitol use is an adjunct to brushing and flossing.16 The truth is that most people with braces are not mentally, physically or emotion- ally ready to care for their teeth the way we’d like them to and using xylitol can impact their oral health proactively with something that is sweet and satisfying. There are many ways to incorpo- rate xylitol into the daily regimen of the orthodontic patient. Gums and mints are probably the best known. Gum has the added benefit of increasing cognition and the speed of thinking.17 So, chewing gum with xylitol multiple times a day is helpful on numerous levels. Imagine recommending sugar to your orthodontic patients. How would those conversations look? Out of the Mouth Some kids are in braces because of airway difficulties. Nasal restric- tions due to chronic sinus infec- tions or allergies force the mouth to be open for good air exchange. This manifests in a narrow upper arch. Dark circles under the eyes are also indicative of problems with air exchange. Sinus infections are caused by two major groups of bacteria, Mutans streptococci pneumoniae and Haemophilus influenzae. Using a saline solution with xylitol in it can help to open the sinuses. The hardened skeptic can argue that saline alone can help flush out the www.orthodontics.com May/June 2010 37
Journal of the American Orthodontic Society May-June 2010: Page 37
