Army's "Look for Xylitol First" program

Dental Assistant, The, March-April, 2004 by Pamila Richter, Jeffrey Chaffin

Abstract: Xylitol is a sugar substitute not well known in the United States. This sugar substitute is not only low in calories but can also help prevent dental caries. The U.S. Army Dental Command's Health Promotion Program is constantly seeking additional prevention measures to enhance the oral health of America's Army. The Dental Command has created the "Look for Xylitol First" initiative aimed at training all members of the dental care team on the positive benefits of xylitol and to teach patients how to be smart consumers and evaluate products for their xylitol content.

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Prevention of dental caries is fundamental to any Oral Health Promotion and Prevention Program. The U.S. Army Dental Command (DENCOM) utilizes a prevention toolbox that includes, but is not limited to, sealants, fluoride, diet modification, oral hygiene instruction, and the use of chemotherapeutics such as chlorhexidine. The purpose of this article is to introduce the use of xylitol as another useful adjunct for our prevention program.

Few Americans know that regular use of a sugar substitute called xylitol (pronounced zi-la-tol) helps prevent caries, but this product has been widely used in Europe and Asia over the last 20 years. One advantage of xylitol is that it tastes good and patients can enjoy a positive health impact while simply chewing gum or eating mints. Oral health professionals know that xylitol is not a panacea, but can be a very useful adjunct as a part of an oral health prevention program. The DENCOM has created the "Look for Xylitol First" initiative, and its first objective is to train all members of the dental care team on the positive benefits of xylitol. Secondly, it is to teach patients how to be smart consumers and evaluate products for their xylitol content.

What Is Xylitol?

Xylitol is a Food and Drug Administration approved, polyol sweetener (sometimes called a sugar alcohol, although it has no alcohol content) that has caries reducing properties over and above sugar replacements. (1) Xylitol is the only naturally occurring sugar alternative and can be found in raspberries, cauliflower and organic substances, even hardwood. Xylitol was originally produced in Finland through an extraction process using birch wood and has been part of the natural foods market for decades. Now manufactured in several countries, including the United States, it is being used in many new health and personal care products. Xylitol contains two-thirds the calories of sugar, but is digested slowly as a carbohydrate outside of the insulin loop, making it ideal for diabetics. It tastes as sweet as sugar, but has no aftertaste usually associated with sugar replacements. Plus it has a refreshing quality that gives the sensation of cooling in the mouth.

How Does Xylitol Reduce Caries?

Xylitol affects the mutans streptococci bacteria associated with dental caries but not through an antibiotic mechanism such as chlorhexedine. Xylitol is ingested by mutans streptococci, just as the bacteria would ordinarily ingest any sugar entering the oral cavity. However, the plaque-producing streptococcus bacteria are unable to process the xylitol and die, thereby lowering the number and strength of the oral bacteria load. (2) With regular use, chewing xylitol gum 3-5 times daily for about five minutes has been shown to reduce caries rates by between 35-70% in caries-prone patients. (3) Other benefits of xylitol use are:

* Xylitol maintains a neutral pH in dental plaque, avoiding decay promoting acids, probably by enhancing salivary flow and buffer capacity.

* Xylitol inhibits growth, adhesion and metabolism of mutans streptococci bacteria.

* Xylitol use helps to reduce oral plaque levels.

* Xylitol suppresses mutans streptococci bacteria even with sugar intake.

* Xylitol promotes remineralization of initial enamel lesions.

* While fluoride strengthens enamel surfaces, xylitol acts on the mutans streptococci and with a resultant synergistic caries reduction.

How to Talk to Patients About Xylitol

For your patients who chew gum, you can help them find xylitol in highly appealing chewing gums available at the candy counter of most grocery stores, convenience stores or discount retailers. Proper counseling is important since getting the right amount of xylitol per serving is key to unlocking its protective properties. Approximately 1.65g of xylitol per serving is considered to be efficacious in caries prevention. It can be difficult for consumers to determine if a product has enough xylitol. The Army is encouraging patients to read the ingredients list, and look for xylitol as the first ingredient. When xylitol appears before "gum base," you know that there is a sufficient amount of xylitol in that gum. This is in line with the U.S. Army's prevention initiative "Look for Xylitol First" that was designed for educating service personnel at risk for caries. A small handout (Figure 1) was created similar to a prescription pad detailing the benefits of xylitol and how to read the label, as well as posters for patient education (Figure 2).