December 11, 2018
by Jacques Véronneau, DMD, MSc, PhD
Even with the declining prevalence of dental caries in industrialized countries during the past decades, predominately due to fluoride use, 1 dental caries is still a major problem in most industrialized countries, affecting 60% to 90% of children, and the vast majority of adults. 2 Also, there is mounting international evidence that this decline is ending 3 and that many dental patients are still highly infected with cariogenic bacteria (105 Streptococcus mutans/mL of saliva).
Dental caries remains a significant health problem 4 and is still the predominant reason for tooth loss in almost all age groups. 5 Although dental caries is a largely preventable disease, untreated cavitated carious lesions in permanent teeth are still the most prevalent health condition globally. In primary teeth, it also a very common condition 6, with the possibility of many dental, medical, social, and quality of life sequalae. 7 At the same time, real effectiveness of curative and preventive approaches on high risk caries patients are being questioned in many countries. 8,9
Since 1952, sodium fluoride in toothpaste has been the most widely used therapeutic agent. It has the potential to remineralize, but might not change the patient’s caries risk and may not offer optimal removal of cariogenic bacteria. This is why, more than 12 years ago, I tried to identify a therapeutic agent able to control the disease and reduce the cariogenic bacteria load. I conducted many studies, the most significant being with 202 Kosovar children, to confirm the efficacy of a new 25% xylitol toothpaste formulation. This therapeutic concentration was tested as an antibacterial agent to reduce the cariogenic bacteria load and as a therapeutic agent to prevent cavitated and non-cavitated carious lesions and as a remineralizer. The present paper presents the results of this research, and the development of the new X-PUR CariØ toothpaste with 25% xylitol.
Current Treatment Strategies
Many authors suggested medical strategies aimed at controlling cariogenic bacteria colonization instead of conventional approaches. 10 The Tanzer et al. review 11 identified that the main pathogenic bacteria involved in the caries process are Streptococcus mutans (SM) and Lactobacilli (L). SM/L are seen 12 as a prerequisite for the caries process and their increase is responsible for the pathological shift within the caries biofilm. Clinical key threshold of SM/L contamination for critical pathological shift is ≥ 105/ml of saliva. 13,14 Modern caries antibacterial treatments such as toothpastes, oral rinses and others vehicles should always be tested to convert infection level under this 105 threshold (Table 1).
Specifically, SM are associated with dental tissue destruction in rampant lesions 15 to caries lesions prevalence in children 16 in adolescents, 17 in adult 18 and in the elderly. 19
This SM association has been also documented for caries incidence 20 in early childhood, 21 among children 22 attending primary or secondary schools, 23 in young adults, 24 in adults 25 and in the elderly 26 and in lesions progression. 27-29 The presence of cariogenic bacteria has also been used successfully as a marker in risk assessment for any age, 29,30 as well as in monitoring the outcome of caries prevention. 11 In the end, cariogenic bacteria prevalence seems to affect the real efficacy of topical fluorides. 31
Modern Caries Process Considering Cariogenic Bacteria. 34
Limitations of Sodium Fluoride Toothpastes
Unfortunately for patients, most dental products such as sodium fluoride toothpastes do not change the patient’s caries risk. They intervene at the end of the caries process, trying to minimize tissue damage. This is termed: tertiary prevention. Fluoride toothpaste does not create significant antibacterial – conversion under the key threshold on cariogenic bacteria in high caries risk individuals. Primary prevention action on the caries process is needed to change the patient’s caries risk.
Mechanism of Xylitol Action on Dental Caries
Xylitol was discovered in 1890 by Fisher and Stahe in Germany as a sugar-alcohol and later used as natural sugar substitute during WWII in Finland. 35 It is produced naturally in the human body (between five to fifteen grams of daily production). On a commercial scale, xylitol can be produced by chemical and biotechnological processes mainly from birch trees or corn cobs. 36 Industrial xylitol production reproduces the same molecular structure of the natural one. 37 Two main hypotheses explain the bacterial effect of xylitol on the caries process 39: either by a chewing 38 movement, related to xylitol, producing saliva or as a sweetener substitute which is essentially not fermentable by the caries-inductive oral microflora. 40 Xylitol’s principal mechanism is in its early action in the caries process and thereby, in the prevention of carious lesions 40 (Fig. 1).
Mechanism of Action of Xylitol Against Streptococcus mutans.
Xylitol as an Antibacterial Agent
Chewing gum has been the most tested vehicle for xylitol delivery in clinical studies. 41 Several clinical trials 42-45 and literature reviews 46-51 have confirmed the potential of xylitol to reduce cariogenic bacteria using chewing gum. 52 This evidence has allowed Health Canada to officially recognize xylitol gums as an antibacterial agent on cariogenic bacteria, and also as a saliva stimulating agent. 53
Xylitol as a Therapeutic Agent
As a therapeutic agent, systematic xylitol use leads to impressive reductions in caries incidence. 54 This has been reported by many researchers 55,56 and in literature review. 57,58 With chewing gum, several studies show carious lesion reduction among children after exposure of 12 to 40 months 44,47,48,59-61 and systematic reviews reported some high preventive fractions on caries experiences. 44,62 Therapeutic effects were estimated from xylitol trials using menthols, candies, 52,63 syrup (8 grams/day), 64 wipes 65 and milk 66 with success. An observational study showed effectiveness of xylitol gum-lozenges on root caries lesions. 67 In 1990, two trials used toothpaste as a vehicle for xylitol 10% (0.1 g/tooth brushing). One trial combined it to NaF 68 and in the other, Sodium of Monofluorophaste 69 using a total of 4 800 school children and reported a negligible prevention fraction of 10 % and 13% respectively. The authors concluded that xylitol in toothpaste might be irrelevant.
Worldwide, the most convenient vehicle for personal hygiene and compliance of active agent, is toothpaste. 70 Natural toothpaste containing 25% of xylitol has been tested as an antibacterial and therapeutic agent on cariogenic bacteria in Eastern Europe. Study sites we selected primarily as vulnerable territories for caries prevalence by the author. Pristina in Kosovo and Cluj in Romania, respected these criteria. 71 Begzati et al. 71-73 established, for example, that SM prevalence was 98% in ECC (Early Childhood Caries) children of Pristina and the prevalence of carious lesions in children aged two to six years was 91.2%. In Kosovo, 72% of adults 74 were affected by caries experiences. 75 In Romania, among 548 six to eight-year-olds, 84.3% had caries experience.
The following are the results of the study:
Effect of 25% Xylitol Formulation Toothpaste on the Reduction of Cariogenic Bacteria Load.**Streptococcus***Lactobacillus
Effect of a 25% Xylitol Formulation Toothpaste in Reducing Cavitated and Non-Cavitated Lesions and in Remineralization. Average number of carious lesions decreases, while number of remineralized lesions increases.
X-PUR CARIØ (Oral Science), a New Fluoride-Free Toothpaste with 25% Xylitol and indicated by Health Canada to prevent cavities.
According to recent stats, the prevalence of caries in at-risk individuals increased between 1994 and 2012, despite exposure to various fluoride products. As well, patients are increasingly drawn to and are buying natural dental products even though they contain no therapeutic agents. This is contributing to a rise in carious lesions. This is the rationale behind the development and introduction of an effective caries reducing natural toothpaste containing 25% concentrated xylitol as the sole anti-caries therapeutic and anti-bacterial agent. OH
Oral Health welcomes this original article.
About the Author
Dr. Jacques Véronneau is a cariologist, researcher and speaker, working in private practice at Centres Dentaires Véronneau. He is a graduate of Montreal (DMD, MSc) and McGill (PhD) Universities and has done dental research on three continents. He has spent the last 12 years researching a more effective agent in reducing carious lesions and the cariogenic bacteria load.
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