Prevention of mother- Prevention of mother- child child transmission of transmission of mutans streptococci mutans streptococci with xylitol with xylitol Eva Söderling Eva Söderling Institute of Dentistry, Institute of Dentistry, University of Turku, University of Turku, Turku, Finland Turku, Finland
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Prevention of mother-child transmission of mutans streptococci with xylitol Eva Söderling Institute of Dentistry, University of Turku, Turku, Finland.
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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
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
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
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
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
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