Prevention of mother-childPrevention of mother-child transmission of mutans transmission of mutans streptococci with xylitolstreptococci with xylitol

Eva SöderlingEva Söderling

Institute of Dentistry, University of Institute of Dentistry, University of Turku, Turku, FinlandTurku, Turku, Finland

ContentsContents

Xylitol and dental cariesXylitol and dental cariesMechanisms of action of xylitolMechanisms of action of xylitolMother-child transmission of Mother-child transmission of

mutans streptococcimutans streptococciMother-child study: study Mother-child study: study

design and resultsdesign and results

Diet and dental cariesDiet and dental caries

A healthy diet as A healthy diet as such is no threat such is no threat to teethto teeth

Constant Constant snacking is a risk snacking is a risk to dental health!to dental health!

Diet and dental caries…Diet and dental caries…

Sugarfree products Sugarfree products are useful in are useful in improving poor improving poor snacking habitssnacking habits

Xylitol is the most Xylitol is the most beneficial sugar beneficial sugar substitute – suitable substitute – suitable for self-care!for self-care!

Xylitol/clinical studiesXylitol/clinical studies

Xylitol is most effective in the caries Xylitol is most effective in the caries prevention of eruptive teeth (Ylivieska prevention of eruptive teeth (Ylivieska 1988, Belize 1996, Estonia 2000)1988, Belize 1996, Estonia 2000)

The ”therapeutic” effects of xylitol appear The ”therapeutic” effects of xylitol appear only in habitual use and with high enough only in habitual use and with high enough frequencies/dosesfrequencies/doses

Estonian xylitol studyEstonian xylitol study(Alanen et al. 2000)(Alanen et al. 2000)

8

7

6

5

4

3

2

110 11 12 13

Age (years)

control

candy

gum

Xylitol adds to caries prevention Xylitol adds to caries prevention obtained with fluorides, advice on obtained with fluorides, advice on

diet and oral hygienediet and oral hygiene

ContentsContentsXylitol and dental cariesXylitol and dental cariesMechanisms of action of Mechanisms of action of

xylitolxylitolMother-child transmission of Mother-child transmission of

mutans streptococcimutans streptococciMother-child study: study Mother-child study: study

design and resultsdesign and results

Xylitol: a 5-carbon polyolXylitol: a 5-carbon polyol

Xylitol is found in Xylitol is found in nature; fruits, berries...nature; fruits, berries...

Sweetness equal to Sweetness equal to sucrosesucrose

Natural component of Natural component of the human metabolic the human metabolic pathwayspathways

Mechanisms of actionMechanisms of action

No acid productionNo acid production Reduces plaque by Reduces plaque by

suppressing formation suppressing formation of adhesive of adhesive macromolecules, macromolecules, especially glucansespecially glucans

Selects for less Selects for less virulent mutans virulent mutans streptococci (oral streptococci (oral flora?)flora?)

Xylitol:C5

No acid production from xylitolNo acid production from xylitol

No acid production in No acid production in plaque even after plaque even after long-term long-term consumptionconsumption

Creates conditions Creates conditions favouring favouring remineralisation remineralisation

specific effects on specific effects on remineralisation?remineralisation?

Xylitol:C5

No acid production from xylitolNo acid production from xylitol

No acid production from xylitolNo acid production from xylitol

The amount of plaqueThe amount of plaque

Xylitol reduces plaque Xylitol reduces plaque ””Xylitol-plaque” shows low adhesiveness to Xylitol-plaque” shows low adhesiveness to

the teeth, xylitol makes plaque easier to the teeth, xylitol makes plaque easier to brush offbrush off

Xylitol suppresses formation of adhesive Xylitol suppresses formation of adhesive macromolecules, especially glucansmacromolecules, especially glucans

Xylitol reduces plaque

Xylitol reduces plaque formationXylitol reduces plaque formation

Mean plaque scores following use of chlorhexidine-, xylitol-, and sorbitol-containingchewing gum in absence of mechanical plaque control measures for 6 days.

Tellefsen et al., 1996

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0CHX XYLITOL SORBITOL

Xylitol chewing gum does not Xylitol chewing gum does not replace toothbrushingreplace toothbrushing

Mutans streptococciMutans streptococci

Xylitol selectively Xylitol selectively suppresses mutans suppresses mutans streptococcistreptococci

The effect on mutans The effect on mutans streptococci is streptococci is transienttransient

Xylitol selects for less Xylitol selects for less virulent mutans virulent mutans streptococcistreptococci

Xylitol inhibits growth of mutans Xylitol inhibits growth of mutans streptococcistreptococci

pts

pts exp

per

XYLITOL

XYLITOL-5-P

XYLULOSE-5-P

Pi

Effect of xylitol pulsing on oral streptococci

S.milleri

S.mutans

ADJ, 1991,36,213-5

Xylitol selects for mutans Xylitol selects for mutans streptococci not inhibited by streptococci not inhibited by

xylitolxylitol Naturally occuring ms which do not form Naturally occuring ms which do not form

xylitol-5-P from xylitol can ”ignore” xylitolxylitol-5-P from xylitol can ”ignore” xylitol These Xr cells form a small percentage of These Xr cells form a small percentage of

the ms if no xylitol is consumedthe ms if no xylitol is consumed During regular xylitol consumption the Xr During regular xylitol consumption the Xr

ms can multiply normally while ms ms can multiply normally while ms inhibited by xylitol (Xs cells) decreaseinhibited by xylitol (Xs cells) decrease

Xr less virulent than Xs??Xr less virulent than Xs??

Effect of habitual xylitol Effect of habitual xylitol consumption on plaque vs. saliva consumption on plaque vs. saliva

mutans streptococci levelsmutans streptococci levels

2

4

6

8

Baseline 1 month 2 months 3 months 4 months

Plaque Saliva

Log CFU

Xylitol makes mutans streptococci Xylitol makes mutans streptococci to shed more easily to the salivato shed more easily to the saliva

ContentsContents

Xylitol and dental cariesXylitol and dental cariesMechanisms of action of xylitolMechanisms of action of xylitolMother-child transmission of Mother-child transmission of

mutans streptococcimutans streptococciMother-child study: study Mother-child study: study

design and resultsdesign and results

S.mutansS.mutans infection in infants infection in infants60

50

40

30

20

10

0Never 3 mths 6 mths 3 & 6 mths

S.mutans infection

Total with ODN* Total without ODN

*p<0.001

S. Mutans infection in infants with and without oral development nodules (ODN). N children with nodules = 103, N without nodules = 85.

Wan et al. JDR 2001.

25

20

15

10

5

00 12 24 36 48 60 months

S. sanguis

S. salivarius

S. mutans

Lactobacilli

Initial colonization of the oral cavity

Birth

MS5 y

N = 38First Tooth6.8 ± 1.4 mo.

19 33

The Window of Infectivity for MS.(Caufield, Pediatric Dentistry 1997, 19: 491-8)

26

The window of infectivity for mutansstreptococci

Cumulative probability of infection.(Caufield, Pediatric Dentistry 1997, 19: 491-8)

Months

Months

0.8

0.5

0.2

0.00 20 40 60 80

0 20 40 60 80

50

40

30

20

10

0

The earlier the mutans The earlier the mutans streptococci are colonised, the streptococci are colonised, the

higher is the risk for carieshigher is the risk for caries

Mean dmft values in 5 yr-olds

The level of MS-strip test from plaque at the age of 2

Jokela, 1997

2.00

1.80

1.60

1.40

1.20

1.00

0.80

0.60

0.40

0.20

0.00

MS=0 MS=1 MS=2 MS=3

Transmission of mutans Transmission of mutans streptococcistreptococci

The mother (infecting The mother (infecting person) has high person) has high salivary mutans salivary mutans streptococci countsstreptococci counts

Several daily saliva Several daily saliva contacts between the contacts between the child and the mother child and the mother must take placemust take place

Maternal salivary level subgroups

Berkowitz et al., 1982

Relationship of maternal salivarylevels of Strep. mutans to theproportion of infant infection

0.60

0.55

0.50

0.45

0.40

0.35

0.30

0.25

0.20

0.15

0.10

0.05

0.00

CFU > 105

1 2 3 4

ms: 0 / low levels

Reducing mutans streptococci Reducing mutans streptococci in the mother during eruption in the mother during eruption

of primary teeth:of primary teeth:

Reduces on long-term basis the the mother-Reduces on long-term basis the the mother-child transmission of mutans streptococcichild transmission of mutans streptococci

Influences beneficially the future caries Influences beneficially the future caries experience of the childexperience of the child

Methods to prevent the Methods to prevent the acquisition of mutans acquisition of mutans

streptococcistreptococci Information on mother-child transmission Information on mother-child transmission

of ms, advice on diet and oral hygieneof ms, advice on diet and oral hygiene Chemical methods (chlorhexidine)Chemical methods (chlorhexidine) XylitolXylitol

ContentsContents

Xylitol and dental cariesXylitol and dental cariesMechanisms of action of xylitolMechanisms of action of xylitolMother-child transmission of Mother-child transmission of

mutans streptococcimutans streptococciMother-child study: study Mother-child study: study

design and resultsdesign and results

Mother-child studyMother-child study

Eva Söderling and Pauli IsokangasEva Söderling and Pauli Isokangas

Institute of Dentistry, TurkuInstitute of Dentistry, Turku

Ylivieska Health Centre, YlivieskaYlivieska Health Centre, Ylivieska

SubjectsSubjects

At baseline 195 At baseline 195 mothers with high mothers with high salivary ms countssalivary ms counts

2-year examination: 2-year examination: 169 mother-child pairs169 mother-child pairs

6-year examination: 6-year examination: 147 children 147 children

Study groupsStudy groups

Xylitol group: xylitol chewing gum (65%) Xylitol group: xylitol chewing gum (65%) appr.4 times a dayappr.4 times a day

Fluoride (F; control) group: fluoride varnish Fluoride (F; control) group: fluoride varnish (2.26%) treatments 2 times a year(2.26%) treatments 2 times a year

Chlorhexidine (CHX) group: CHX varnish Chlorhexidine (CHX) group: CHX varnish (40%) treatments 2 times a year(40%) treatments 2 times a year

All interventions discontinued when the All interventions discontinued when the child was 2 years old child was 2 years old

Xylitol chewing gumXylitol chewing gum

CHX and F varnishesCHX and F varnishes

Study designStudy design

Child 3 months: xylitol consumption starts Child 3 months: xylitol consumption starts in Xylitol groupin Xylitol group

Biannually: F or CHX varnish treatments in Biannually: F or CHX varnish treatments in the F and CHX groupsthe F and CHX groups

Child 2 years: Xyl/F/CHX interventions Child 2 years: Xyl/F/CHX interventions discontinuediscontinue

Annual follow-up of dental healthAnnual follow-up of dental health Microbiological follow-up Microbiological follow-up

Microbiological methodsMicrobiological methods

Saliva/mothers and Saliva/mothers and plaque/children plaque/children annually until theannually until the

3-year examination3-year examination Saliva/children at the Saliva/children at the

6-year examination6-year examination Plate culturing on Plate culturing on

MSB agar of both MSB agar of both salivary and plaque salivary and plaque mutans streptococcimutans streptococci

ResultsResults

Mutans streptococci of the Mutans streptococci of the mothers:mothers:

High salivary mutans High salivary mutans streptococci counts in streptococci counts in all groups throughout all groups throughout the studythe study

No differences No differences between the study between the study groupsgroups

7.5

7.0

6.5

6.0

5.5

5.0

4.5

4.0

Pregnancy 0.5 1 2

Age of child (years)

FCHXXyl

Mother-child transmission of Mother-child transmission of mutans streptococcimutans streptococci

At two years of age, the children in the At two years of age, the children in the Xylitol group showed significantly less ms Xylitol group showed significantly less ms colonisation as compared to the control colonisation as compared to the control groupsgroups

At six-year of age, the Xylitol group still At six-year of age, the Xylitol group still showed the lowest ms countsshowed the lowest ms counts

60

50

40

30

20

10

0Controlgroup

CHXgroup

Xylitolgroup

n=33 n=28 n=103

2 years

At 2 years of age the child’s risk of having MS colonization in thedentition was 5-fold in the F group and 3-fold in the CHX group ascompared to the Xylitol group.

Söderling et al., J Dent Res 79, 2000, 882-887

Children showing mutans streptococci colonisation (%)

Childrens salivary mutans Childrens salivary mutans streptococci counts at 6 yearsstreptococci counts at 6 years

0

10

20

30

40

50

60

Xyl F CHX

% CFU/ml = 0 CFU/ml > 0, < 105 CFU/ml 105

Söderling et al.,2001

The results of plate culturing of The results of plate culturing of mutans streptococci and the mutans streptococci and the

chairside SM Strip mutans test chairside SM Strip mutans test were in good agreementwere in good agreement

Dental healthDental health

The differences between the groups found The differences between the groups found in the early ms colonisation (2 years) were in the early ms colonisation (2 years) were reflected in the caries occurencereflected in the caries occurence

At the age of 5 years the need of restorative At the age of 5 years the need of restorative treatment was 71-74% lower in the Xylitol treatment was 71-74% lower in the Xylitol group as compared to the F and CHX group as compared to the F and CHX groupsgroups

CHX was not effective in the study design CHX was not effective in the study design usedused

Isokangas et al., J Dent Res,2000, 79, 1885-1889

CARIES OCCURENCE IN CHILDREN

CHX

Control

Xylitol

Age

3

2

1

00 1 2 3 4 5 6

Results of the mother-child Results of the mother-child study have been confirmed by study have been confirmed by an independent, also federally an independent, also federally

funded study from Sweden funded study from Sweden (unpublished)(unpublished)

Xylitol recommendations:

Recommended target groupsRecommended target groups

Children with erupting teethChildren with erupting teeth Subjects with high caries riskSubjects with high caries risk Caries-active individualsCaries-active individuals Elderly dentate subjectsElderly dentate subjects Patients with xerostomiaPatients with xerostomia Mothers of infantsMothers of infants

Recommended intake of Recommended intake of xylitol:xylitol:

forms and frequencyforms and frequency Chewing gums and lozenges give maximal Chewing gums and lozenges give maximal

oral retention and contain no components oral retention and contain no components ”disturbing” the effects of xylitol”disturbing” the effects of xylitol

Products with a high xylitol concentration Products with a high xylitol concentration recommendablerecommendable

For optimal preventive effects 3-5 daily For optimal preventive effects 3-5 daily intakes, preferably after each mealintakes, preferably after each meal

Recommended intake of Recommended intake of xylitol: xylitol:

chewing gumchewing gum Chewing until the Chewing until the

sweet taste disappears sweet taste disappears (appr. 5 min)(appr. 5 min)

Children: one chewing Children: one chewing gum pellet 3-5 times a gum pellet 3-5 times a dayday

Adults: two chewing Adults: two chewing gum pellets 3-5 times gum pellets 3-5 times a daya day

Thank you! Kam-Sa-Ham-Ni-Da! Kiitos!

Institute of Dentistry, Turku