Xylitol Use and Prevention Xylitol Use and Prevention of Tooth Decayof Tooth DecayFeasibility and Impact of Twice Daily Feasibility and Impact of Twice Daily Tooth brushing at Head StartTooth brushing at Head Start

Presented By:Presented By:Charles Hill, Director for Kittitas Co. Head StartCharles Hill, Director for Kittitas Co. Head StartElizabeth Webb-Beeles, Health Manager for Kittitas Co. Head StartElizabeth Webb-Beeles, Health Manager for Kittitas Co. Head StartDr. Kiet Ly, Clinical Assistant Professor and Researcher at Northwest Dr. Kiet Ly, Clinical Assistant Professor and Researcher at Northwest Center to Reduce Oral Health Disparities, University of WashingtonCenter to Reduce Oral Health Disparities, University of Washington

Topics for this SessionTopics for this Session

Oral healthOral health Human diet and sugarsHuman diet and sugars Causes of tooth decayCauses of tooth decay Xylitol: What? Where? How?Xylitol: What? Where? How? Northwest Center to Reduce Oral Health Northwest Center to Reduce Oral Health

Disparities, University of WashingtonDisparities, University of Washington Kittitas County Head Start feasibility projectKittitas County Head Start feasibility project Future studyFuture study

Oral HealthOral Health

A healthy mouth is integral to an A healthy mouth is integral to an individual’s total health.individual’s total health.

America’s oral health has America’s oral health has improved over the past 50 years.improved over the past 50 years.

Yet, Yet, tooth decaytooth decay remains the single most remains the single most common chronic childhood disease.common chronic childhood disease.

Worse, Worse, tooth decay tooth decay is rising in preschoolersis rising in preschoolers Over 51 million hours of school are lost each Over 51 million hours of school are lost each

year to dental problems.year to dental problems.

The Great Fluoride DebateThe Great Fluoride Debate Fluoride prevents tooth decayFluoride prevents tooth decay Possible adverse side effectPossible adverse side effect

Mottling of permanent teeth due to the Mottling of permanent teeth due to the swallowing of excessive fluoride by young children swallowing of excessive fluoride by young children (dental fluorosis)(dental fluorosis)

Benefit to health Benefit to health in preventing in preventing decay outweigh decay outweigh the risk?the risk?

Progression of fluorosis

Increased RiskIncreased Risk Poor & Minority children suffer:Poor & Minority children suffer:

Twice as many tooth decay as their Twice as many tooth decay as their more affluent peers, and their disease is more more affluent peers, and their disease is more likely to be untreated.likely to be untreated.

12 times more restricted-activity days than 12 times more restricted-activity days than children from higher-income families.children from higher-income families.

Poor & ethnic minority groups experience Poor & ethnic minority groups experience more oral health problems.more oral health problems.

Individuals with medical or physical disabilities Individuals with medical or physical disabilities are also at greater risk.are also at greater risk.

Human Diet and SugarsHuman Diet and Sugars

135 lbs. of sugar per 135 lbs. of sugar per person per yearperson per year

Cause of Dental CariesCause of Dental Caries

Streptococcus mutans Streptococcus mutans ((S. mutans) S. mutans) bacteria is bacteria is the leading cause of tooth decay.the leading cause of tooth decay.

Plaque is a sticky film on teeth Plaque is a sticky film on teeth Bacteria like Bacteria like S. mutans S. mutans feast on sugars and feast on sugars and

starches found on teeth.starches found on teeth. Bacteria metabolism produceBacteria metabolism produce

acids that “eat away” teeth acids that “eat away” teeth surfaces causing weak spots surfaces causing weak spots that can become cavities. that can become cavities.

What is Xylitol?What is Xylitol?

Naturally occurring sweetener in the same Naturally occurring sweetener in the same class as sorbitol, maltitol, mannitol, erythritol.class as sorbitol, maltitol, mannitol, erythritol.

Found in fibers of trees, fruits, Found in fibers of trees, fruits, and vegetables.and vegetables.

The human body produces The human body produces several grams of xylitol a day.several grams of xylitol a day.

FDA approved as a food FDA approved as a food additive (sweetener) in 1963.additive (sweetener) in 1963.

How Xylitol WorksHow Xylitol Works

Cannot be fermented by plaque bacteria. Cannot be fermented by plaque bacteria. Microorganisms like Microorganisms like S. Mutans S. Mutans do not readily do not readily

metabolize xylitol into energy sources.metabolize xylitol into energy sources. Inhibits growth and metabolism of Inhibits growth and metabolism of

S. mutans S. mutans and reduces dental plaque.and reduces dental plaque. Thus reduces Thus reduces S. mutans S. mutans levels in plaque and levels in plaque and

saliva = saliva = Reduction in acid productionReduction in acid production Reduction in dental cariesReduction in dental caries

Xylitol Prevents Tooth DecayXylitol Prevents Tooth Decay

1975: First study on the effects of xylitol 1975: First study on the effects of xylitol conducted in Turku, Finland.conducted in Turku, Finland.

One year study, 102 subjectsOne year study, 102 subjects Chewing Gum Each DayChewing Gum Each Day

S-group: 4 pieces of Sucrose gumS-group: 4 pieces of Sucrose gum X-group: 4.5 pieces of Xylitol gumX-group: 4.5 pieces of Xylitol gum

The mean increment of decayed, missing and The mean increment of decayed, missing and filled tooth surfaces:filled tooth surfaces: S-group: 2.92 > X-group: 1.04S-group: 2.92 > X-group: 1.04

Xylitol Prevents Tooth Decay IIXylitol Prevents Tooth Decay II

2002: Swedish study on the effects of xylitol 2002: Swedish study on the effects of xylitol toothpaste on the reduction of S. mutans.toothpaste on the reduction of S. mutans.

6 month study, 155 subjects. 6 month study, 155 subjects. Toothpaste and brushing Twice DailyToothpaste and brushing Twice Daily

Colgate Total with 10% xylitolColgate Total with 10% xylitol Colgate Total with triclosan (no xylitol)Colgate Total with triclosan (no xylitol) Colgate Total without triclosan or xylitolColgate Total without triclosan or xylitol

(Placebo)(Placebo)

Four saliva and plaque samples gathered:Four saliva and plaque samples gathered: Baseline, 2 months, 4 months, 6 monthsBaseline, 2 months, 4 months, 6 months

Xylitol Field TrialXylitol Field Trial

1994: Estonia school study on xylitol gum.1994: Estonia school study on xylitol gum. 3-year long period, 740 children 3-year long period, 740 children (10 year olds).(10 year olds).

Xylitol or “Control” gum groups.Xylitol or “Control” gum groups. Daily dose of 5 grams of xylitol in xylitol group.Daily dose of 5 grams of xylitol in xylitol group. Xylitol groups showed Xylitol groups showed

35-60% reduction in 35-60% reduction in caries incidence. caries incidence. Significant difference Significant difference from control.from control.

How Much Xylitol? How Much Xylitol?

Research suggests 5 to 10 grams of xylitol per Research suggests 5 to 10 grams of xylitol per day for effectiveness.day for effectiveness.

Humans tolerate up to Humans tolerate up to approx. 45 grams/day.approx. 45 grams/day.

5% may have cramps, 5% may have cramps, some have loose stools.some have loose stools.

Humans adapt, start slowly.Humans adapt, start slowly. Symptoms should disappear.Symptoms should disappear. Sorbitol is worse than xylitol.Sorbitol is worse than xylitol.

Where Can You Find Xylitol?Where Can You Find Xylitol?

Who Has Endorsed Xylitol for Caries Who Has Endorsed Xylitol for Caries Prevention?Prevention? 1988 –Finnish Dental Association1988 –Finnish Dental Association 1989 – Swedish1989 – Swedish 1990 – Norwegian1990 – Norwegian 1992 – British1992 – British 1993 – Irish & Canadian1993 – Irish & Canadian 1995 – Estonia1995 – Estonia Many others sinceMany others since Most recently, the Dental Hygienist Most recently, the Dental Hygienist

Association in Arizona and HawaiiAssociation in Arizona and Hawaii

Northwest Center to Reduce Oral Northwest Center to Reduce Oral Health DisparitiesHealth Disparities Oral health disparity means a Oral health disparity means a

disproportionate burden and risk disproportionate burden and risk of poor dental health in a particular population. of poor dental health in a particular population.

Mission: The Northwest Center to Reduce Oral Mission: The Northwest Center to Reduce Oral Health Disparities conducts community-based Health Disparities conducts community-based research. We focus on solutions to dental and research. We focus on solutions to dental and oral health disparities among vulnerable, rural, oral health disparities among vulnerable, rural, or under-served groups, particularly low-or under-served groups, particularly low-income families with children.income families with children.

Disparities Center Xylitol StudiesDisparities Center Xylitol Studies Xylitol Chewing Gum Xylitol Chewing Gum

Dose responseDose response Frequency responseFrequency response

Xylitol SnacksXylitol Snacks Xylitol Gummy BearsXylitol Gummy Bears Xylitol SyrupXylitol Syrup Xylitol ToothpasteXylitol Toothpaste

NOT ALL XYLITOL PRODUCTS PROVEN NOT ALL XYLITOL PRODUCTS PROVEN EFFECTIVEEFFECTIVE

Kittitas County Head Start ProjectKittitas County Head Start Project 2007-2008 Academic Year2007-2008 Academic Year Information gathering, used historical data.Information gathering, used historical data. Epic Dental Xylitol-Fluoride toothpaste.Epic Dental Xylitol-Fluoride toothpaste. SchoolSchool

Twice-daily tooth Twice-daily tooth brushing after mealsbrushing after meals

HomeHome Toothbrushes and toothpaste sent home to Toothbrushes and toothpaste sent home to

families twice during yearfamilies twice during year Encouraged brushing at homeEncouraged brushing at home

Challenges SuccessChallenges Success Preparation of suppliesPreparation of supplies Facilities Facilities TimeTime Home trackingHome tracking

Children were Children were receptivereceptive

Encouraged more Encouraged more frequent brushingfrequent brushing

Parents liked itParents liked it

Parent SurveyParent Survey

End of Study Survey, spring 2008End of Study Survey, spring 2008 57 surveys returned57 surveys returned

35 English35 English 22 Spanish22 Spanish 12% had two children in program12% had two children in program 82% were enrolled for 6 months or more82% were enrolled for 6 months or more

Survey ResultsSurvey Results Frequency of brushing at homeFrequency of brushing at home

Child: 65% brushed 2 times/dayChild: 65% brushed 2 times/day Child: 23% brushed 3 or more times/dayChild: 23% brushed 3 or more times/day Adult: 60% brushed 2 times/dayAdult: 60% brushed 2 times/day Adult: 30% brushed 3 times/dayAdult: 30% brushed 3 times/day

Use of Xylitol toothpaste at homeUse of Xylitol toothpaste at home 9% of children did not use9% of children did not use 76% of childre used it half of the time76% of childre used it half of the time 42% of parents used the toothpaste42% of parents used the toothpaste 35% of other family members used the toothpaste 35% of other family members used the toothpaste

Overall Positive ResponseOverall Positive Response

40% of the respondents would purchase 40% of the respondents would purchase xylitol toothpaste.xylitol toothpaste. 44% were not sure44% were not sure

67% of respondents would allow their child to 67% of respondents would allow their child to participate in future studies.participate in future studies. 30% said maybe30% said maybe

80% of respondents wanted more information 80% of respondents wanted more information on xylitol.on xylitol.

Study DesignStudy Design The observational group The observational group

from 2007-2008from 2007-2008 Fluoride and xylitol toothpasteFluoride and xylitol toothpaste Tooth brushing twice a dayTooth brushing twice a day Sent home xylitol toothpaste and tootbrushes Sent home xylitol toothpaste and tootbrushes

The historical control group The historical control group data gathered from 2006-2007 classdata gathered from 2006-2007 class Fluoride only toothpasteFluoride only toothpaste Tooth brushing once a dayTooth brushing once a day

Sample SizeSample Size

Small sample size limited scope of the studySmall sample size limited scope of the study The whole program participated (123 slots - The whole program participated (123 slots -

105 Head Start, 18 ECEAP) however only:105 Head Start, 18 ECEAP) however only: 41 children received 2 dental exams* during the 41 children received 2 dental exams* during the

2006-2007 school year2006-2007 school year 17 children received 2 dental exams* during the 17 children received 2 dental exams* during the

2007-2008 school year2007-2008 school year

*Excludes dental visits for follow-up treatment.

Results of the ProjectResults of the Project

Small sample size likely cause for lack of Small sample size likely cause for lack of significant results, however trends indicate:significant results, however trends indicate: Less children in the xylitol-fluoride group had an Less children in the xylitol-fluoride group had an

increase in dental caries than fluoride only group.increase in dental caries than fluoride only group.

Fluoride Only Xylitol FluorideChildren with 2 exams 41 17Children with dmft increase 15 2% children with dmft increase 37% 12%

“dmft” = decayed, missing, filled teeth

Results ContinuedResults Continued

Dental caries to increase in most children Dental caries to increase in most children between .5 to .7 for each year of age.between .5 to .7 for each year of age.

Xylitol-fluoride toothpaste group showed less Xylitol-fluoride toothpaste group showed less increase in dental caries (8%) from baseline than increase in dental caries (8%) from baseline than the fluoride only toothpaste group (34%).the fluoride only toothpaste group (34%).

Fluoride Only Xylitol FluorideBaseline Mean dmft 3.63 3.59Follow-up Visit Mean dmft 4.85 3.63Mean dmft Increment 1.22 0.29% change from Baseline 34% 8%T-test∆ in dmft increment 0.019

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

Fluouride only Xylitol Fluoride

3.63 3.59

1.22

0.29

Mean dmft Increment

Mean Baseline dmft

ConclusionsConclusions

Xylitol-fluoride toothpaste appears to Xylitol-fluoride toothpaste appears to enhance protection from dental caries.enhance protection from dental caries.

It is feasible to integrate twice-daily tooth It is feasible to integrate twice-daily tooth brushing into the program.brushing into the program.

Families need to be encouraged to use xylitol Families need to be encouraged to use xylitol at home.at home.

Additional funds are needed for supplies Additional funds are needed for supplies (toothbrushes, toothpaste, sinks).(toothbrushes, toothpaste, sinks).

Future StudyFuture Study

NIH Grant, two yearsNIH Grant, two years One year of data collectionOne year of data collection Xylitol-fluoride and Fluoride onlyXylitol-fluoride and Fluoride only Twice-daily or once-dailyTwice-daily or once-daily Classroom assistants to help with tooth Classroom assistants to help with tooth

brushing and data collectionbrushing and data collection New sinks and computersNew sinks and computers

Interested?Interested?Want more information?Want more information? Dr. Kiet LyDr. Kiet Ly

Northwest Center to Reduce Oral Health DisparitiesNorthwest Center to Reduce Oral Health DisparitiesUniversity of WashingtonUniversity of WashingtonHealth Sciences B-530Health Sciences B-530Box 357480Box 357480Seattle, WA 98195 Seattle, WA 98195 kietaly@uw.edukietaly@uw.edu

Liz Webb-BeelesLiz Webb-Beeles Kittitas County Head StartKittitas County Head Start

PO Box 835PO Box 835Ellensburg, WA 98926Ellensburg, WA 98926lwebb@kitcohs.orglwebb@kitcohs.org