Practical Application of Xylitol in Dentistry John Peldyak, D.M.D. Larry Bybee, D.D.S. Eric Johnson, M.S., D.D.S. Russ Misner, D.D.S.

Use of Xylitol in Modern Dental Practice General Family Practice Pediatric Periodontic Orthodontic Public Health

Why Xylitol? Mechanical Model – treating symptoms only is inadequate Medical Model – addresses causes Based on research, observation, and implementation Protocols are subject to modification Addition of Xylitol to prevention programs is guided by research and product availability

Benefits of Xylitol For the Professional Office For the Patient

For the Dental Office: Establish Respect and Trust Develop rapport with patients to improve oral and systemic health Empower patients to take responsibility for their health

Predictable results Avoiding Failures Adding Xylitol increases patient interest and compliance Xylitol can be a Practice builder

Barriers to Implementation Office Staff may be Resistant to Change Is there room for improvement? Acknowledge room for improvement Schedule training time Establish effective Doctor/Staff communication Encourage use of xylitol by office personel

Barriers for Patients Lack of awareness Provide information about xylitol Introductory DVD is entertaining Staff is able to answer questions Customizable letters provide detailed explanations and specific recommendations Concern about cost “Transfer buying” is the substitution of xylitol for common sucrose products already being used

Patients Appreciate General and Specific Xylitol Recommendations PRODUCTS Preferred products have high xylitol content. Xylitol is the first sweetener listed on the label. We favor 100% xylitol-sweetened chewing gum, mints, and small candies. We recommend brushing with Xylitol/Fluoride toothpaste. Non-fluoride Xylitol/Calcium gel is available for those who are likely to ingest toothpaste.

Frequency Use an effective amount of Xylitol several times each day. Goal is 5 uses per day, such as xylitol toothpaste morning and night plus xylitol chewing gum after each meal and snack. Higher caries risk may require more frequent applications.

Pre-Treatment Evaluation “SOAPTx” Hygiene Evaluation is essential. Patients can be categorized according to risk for dental disease (low, moderate, or high). Follow a “SOAPTx” format. Gather Subjective and Objective data. Assess data. Plan is developed. Treatment is prescribed.

Subjective Data is obtained from the patient. Some risk areas to note are: Use of sweetened medicines. Bottles and training cups filled with sugary liquids. High intake of fermentable carbohydrates between meals. Insufficient fluoride. History of dental disease. Low dental care awareness.

Objective Data is obtained by dental personel, which includes: Visual and radiographic examination. Plaque Index. Gingival Index. Periodontal pocket measurements. Dietary evaluation.

Assessment Doctor reviews risk factors and may order Caries Risk Test (CRT). Measures saliva quantity and quality (pH and buffering capacity). Bacterial count, usually Streptococcus mutans. Doctor assesses data to identify risk and target treatment accordingly.

Plan Treatment Plan is developed for in-office treatment and home care. Diminish future risk. Increase protective factors. Xylitol remains an important hygiene adjunct even for “low-risk” patients. Xylitol is a non-cariogenic alternative. Useage levels may be reduced.

Treatment We favor full-mouth disinfection at the time of oral prophylaxis and scaling. Long-term suppression of pathogenic bacteria is then maintained with the Xylitol program.

Patient Education Reinforcement is provided with take-home prevention kit, which includes: Pamphlets Customized letters Product samples.

Special Situations and Patients at Higher Risk Mother/Child Early Childhood Caries Preschool Children Mixed Dentition Orthodontics Restorative Cosmetic Xerostomia Periodontics Special Needs

Mother-Child Children generally receive oral flora from mother Preventing early colonization of pathogenic bacteria reduces caries risk. Pregnant women should be in low caries risk condition. Use of xylitol by mother can help block early pathogen colonization. Baby can use xylitol gel by the time of first tooth emergence.

Initial Dental Exam Recommended by age one. Knee to knee exam provides opportunity to discuss oral care. Xylitol program provides parents with a positive message.

Early Childhood Caries (ECC) Result of early infection and sugar abuse. Parents and caregivers should use xylitol gum, while baby receives xylitol gel. Milk and sugary liquids in bottles and training cups should be strictly controlled, particularly at bedtime.

Preschool Children Xylitol is well-accepted and effective for reducing caries risk. Additional benefit is possible reduction of ear infections. Aerosolized xylitol may help reduce upper airway infections and the need for antibiotics.

Mixed Dentition Is a “high risk” situation, and a “window of opportunity” for long-term protection. Ideally begin Xylitol hygiene one year before eruption of permanent teeth. Consider increasing consumption levels to 6 grams per day. Increase frequency of use if needed.

Orthodontics Orthodontic appliances create areas that are difficult to maintain with standard mechanical plaque control. Xylitol should be initiated, and excellent hygiene should be demonstrated before appliances are placed. Poor cooperation with hygiene predicts noncompliance during orthodontic therapy. Xylitol chewing gum is well-accepted and can help minimize enamel scarring and gingivitis. Xylitol gel can be placed inside removable appliances.

Restorative Restorative procedures repair long-term damage caused by caries process. These patients should be placed on intensive xylitol hygiene regimen. Control of caries process reduces chances of secondary caries and restorative failure. More conservative and esthetic procedures can be considered. Incipient caries can be stabilized and reversed.

Cosmetic Unsightly white spot lesions, fluorosis, and other stains may be cosmetically improved with a xylitol mineralizing solution. Lightly abrade Etch 10 seconds Apply xylitol solution in-office Continue to use xylitol at home Custom trays may be used to apply xylitol gel to reduce sensitivity caused by bleaching.

Xerostomia, a frequent complaint in older patients Is uncomfortable and potentially damaging for teeth. Xylitol stimulates saliva. Stimulated saliva has higher pH and increased protective factors. Xylitol can reduce potential for root caries and gingivitis for older patients with gingival recession. Recommendations include Xylitol/Calcium lemon lozenges, dry mouth spray, and Xylitol added to tea or water and sipped as desired.

Periodontics Xylitol hygiene can benefit patients with gingivitis or periodontitis. Regular Xylitol use helps reduce plaque quantity. Plaque becomes less adhesive, less acidic, less inflammatory, and less harmful than sucrose plaque. Xylitol helps block re-emergence of cariogenic organisms during periodontal therapy, such as after full-mouth disinfection.

Special Needs situations may suggest intensive use of Xylitol gel, gum or mints. Dexterity impairment or difficulty in controlling the swallowing reflex may make effective brushing and flossing difficult. Circumstances (hospitals and nursing care facilities) make expectorating toothpaste inconvenient.

Conclusions Patient management goals: Low pathogenic bacterial counts. Arrest of caries process. Patient maintains excellent oral hygiene and satisfactory nutritional intake. Xylitol is an essential adjunct that is complementary to all other oral hygiene and nutritional counseling strategies. Xylitol is an underutilized part of a multiple intervention approach for prevention of dental caries. Recommendations for Xylitol use can be customized to met the needs of the individual patient.