Xylitol in Xerostomia
What is Xylitol?
Xylitol is a Sugar Alcohol, known since 1891, manufactured by a German chemist. It’s Chemical Formula is C5H12O5 & can be produced by the hydrogenation of Xylose to Xylitol.
Pure Xylitol has a White Crystalline Appearance and it is stable at Room Temperature.
Xylitol is water soluble and it looks & tastes like sugar. It is about 20-25% sweeter than sugar & even does not caramelize at elevated temperatures
Xylitol has 40% less calories than sugar & only about 1/3rd of the Absorbed Xylitol Gets Metabolized in the Body. The Remaining 2/3rd is Broken Down by Gut Bacteria into Short-chain Fatty Acids in the Intestinal Tract.
Xylitol has a Low Glycemic Index (GI: 7 for Xylitol against GI of Sugar: 68).
1. Xylitol is Effective in The Prevention of Dental Caries:
The Dental Benefits of Xylitol are the Most Well Researched & have been examined thoroughly. The available Scientific Literature Provides Evidence that Xylitol has Anti-cariogenic Properties
2. It does not have any Serious Side Effects & it is Not Toxic:
3. It can be used by Diabetics: Having a low Glycemic Index, Xylitol is a suitable sugar alternative for diabetics and can help people cut down on sugar.
4. It has been demonstrated in several studies that a Low GI and GL diet can help the prevention of Type 2 diabetes. That means that replacing sugar with xylitol may reduce the risk of type 2 diabetes.
One more benefit, is that xylitol has 40% less calories compared to sugar. This may not be a huge difference but its use instead of sugar can help diabetics reduce their daily calorie intake and lose weight or control their weight, which is essential for the management of diabetes.
(Schulze MB, Liu S, Rimm EB, Manson JE, Willett WC, Hu FB. Glycemic index, glycemic load, and dietary fiber intake and incidence of type 2 diabetes in younger and middle-aged women: Am J Clin Nutr., 2004 Aug;80(2):348-56).
5. It can Prevent Acute Otitis Media: A number of studies suggest that it can be a prophylaxis for Acute Otitis Media in children.
Thus with low GI, Anti-Cariogenic activity, Xylitol appears to be a good alternative to sugar.
- Xylitol is not a carbohydrate. Hence it has a Glycemic Load (GL) = 0, & it is Metabolized Independently of Insulin.
- The Glycemic Load is a measure of both the quality & the quantity of a carbohydrate and is calculated using the formula:
GL = (GI x the amount of available carbohydrate)/100.
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Salivary Flow Rate:
1. Normal Un-stimulated (resting) = 0.3-0.4 ml/min.
2. Xerostomia, abnormal <0.1ml/min
3. Simulated (chewing-taste-psychological): 1-2 ml/min (ab <0.5)
If Saliva Production is reduced, an Individual’s Oral Bacteria Levels Can Increase 10 timesover normal levels.
Flow rate Decreases with the Following:
2. Radiation to Salivary Glands,
3. Some Medicines,
4. Tumor of Salivary Gland,
5. Thyroid Deficiency,
6. Sjorgrens Disease
- The use of Xylitol-Containing Salivary Stimulants such as Biotene gum or Trident gum Can Help Stimulate Salivary Flow In Patients Having Remaining Functional Salivary Tissue. (CME: A Peer-Reviewed CE Activity by Dentistry Today, Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. June 1, 2009 to May 31, 2011, AGD Pace approval number: 309062 ; Sjögren’s Syndrome: Dental Considerations, Authored by Medha Singh, BDS, MS; Carole Palmer, EdD, RD; and Athena S. Papas, DMD, PhD,)
- Xylitol interferes with the growth of cariogenic bacteria; it is safe and approved as a therapeutic sweetener by the US Food and Drug Administration. (Brennan M, Fox P, eds, Singh M, Contributing author. Clinician’s Guide: Salivary Gland and Chemosensory Disorders. 1st ed. Edmonds, WA: American Academy of Oral Medicine; 2009).
Medscape Review Criteria:
A literature search was performed on 20th April 2009 using MEDLINE and EMBASE
Terms Used for Search: Dry Mouth & Xerostomia in Combination with Diagnosis, Management, Investigations & Treatment.
Articles published in the English language were selected & reviewed. Suitable references from these articles were also reviewed.
Disturbance of salivary flow: Xerostomia – Management
- Preventive therapy: 1) Florid rinses & gel, 2) Oral hygiene
- Symptomatic treatment: 1) Water, 2) Artificial saliva, 3) Avoid products containing sugar, alcohol, Vaseline ointment to relief cracking, Topical antifungal, Regular check ups
- Salivary stimulation: Local / topical stimulation (detectable salivary gland function)
- Chewing (flavoured, sugar free, Xylitol), 2) Systemic stimulation by Cholinergic Drugs (Pilocrpine HCl or Cevimeline).
- A Muscarinic Receptor Agonist Available as 5 mg tab. It is shown to improve symptoms of RT induced xerostomia. A Maximum Dose of 30 mg/day in divided doses.
- Effects of Pilocarpine are usually immediate; Increase in Saliva Production Generally Lasts 4 hrs
- In RT-induced Xerostomia, Pilocarpine can take up to 12 weeks to Produce Effects
- Undesirable Side Effects: Perspiration, Flushing, Lacrimation, Urinary Frequency & GI Disturbances.
- Being cholinergic:
- Contraindicated In Patients With Asthma, Chronic Obstructive Airway Disease, Heart Diseases, Epilepsy, Hyperthyroidism & Parkinson’s Disease.
- Since Pilocarpine May Cause Fluctuations in the Blood Pressure or Heart Rate, the Patient Should be Closely Supervised by an M.D. Physician
Xerostomia: Causes, Symptoms & Treatment
- Common Causes: Systemic Medications, Radiotherapy (H & N Cancer) & Sjogrens syndrome.
- Symptoms: Thirst, Difficulty eating, speaking, wearing denture, Need sips of water while eating, Burning sensation of mouth, Abnormal taste & halitosis, Cracked lips and soreness of corners of mouth.
- Radiation & Xerostomia: Radiation Damages Serous Salivary Glands in Parotid Gland Resulting in Reduced Salivary Flow/Xerostomia Within 5 Weeks. Rarely Does Patient Completely Recover.
- Main Complications of Hyposalivation:
*Dental Caries (requires dental referral).
*Oral Candidiasis (requires antifungal therapy).
- Xerostomia is Associated with a High Morbidity & can be Debilitating for Patients.
Primarily Involves the Use of Salivary Substitutes and/or Stimulants. Patients Seem to Prefer Salivary Stimulants to Saliva Substitutes, therefore, the Use of Salivary Stimulants Should be Encouraged.(http://www.medscape.com/viewarticle/716205_print)
- Chew Gum or Sour Candy.
- Look for Sugarless Gum or Candy with Xylitol.
- If one Chews this Gum for ‘5 Minutes’ after Every Meal, Studies Show that One Can Reduce the Incidence of Tooth Decay by up to 62%. (http://www.medscape.com/viewarticle/716205_print)
Safety: Xylitol Side-Effects
Does xylitol have any side effects? If yes, What are Xylitol’s side effects?
- US FDA: Has Approved Xylitol for use in “Foods for Special Dietary Purposes”
- JEFCA (Joint Expert Committee on Food Additives) allocated an Acceptable Daily Intake (ADI) for Xylitol of “Not Specified”,
- Xylitol Represents the Safest Category which JEFCA can Allocate to a Food Additive.
- Approved by the EU Scientific Committee for Food for dietary uses
- Xylitol has Some Minor Side Effects that Usually Arise when it is Consumed in Large Quantities.
Children’s acceptance of milk with xylitol or sorbitol for dental caries prevention: (Castillo JL, Milgrom P, Coldwell SE, Castillo R, Lazo R, BMC Oral Health. 2005 Jul 22;5:6. Departamento Academico de Estomatología del Niño y del Adolescente, Universidad Peruana Cayetano Heredia, Honorio Delgado 430, Lima 34, Peru. [email protected])
Xylitol, a Polyol Sugar, has been Shown to Reduce Dental Caries When Mixed With Food or Chewing Gum: To Examines In A Public Health Program.
- the Taste Acceptability Of Xylitol In Milk …as a 1st Step Toward Measuring the Effectiveness of Xylitol in Milk for the Reduction of Dental Caries
Ranking from Best to Worst for the samples across categories
- 1. Xylitol (0.0.042 g/ml), 2. Sorbitol (0.042 g/ml), Xylitol (0.021 g/ml) & Milk Alone (Friedman’s ANOVA).
- Xylitol & Sorbitol Were Preferred Over Milk Alone,
- Xylitol (0.042 g/ml) was Preferred to Sorbitol (0.042 g/ml)(p < .05 sign test).
CONCLUSION: Milk sweetened with Xylitol is well accepted by Peruvian children ages 4-7 years.
Use Of Chewing Gum Containing 15% of Xylitol & Reduction In Mutans Streptococci Salivary Levels: (Cláudia Perez Trindade Fraga, Márcia Pinto Alves Mayer, Célia Regina Martins Delgado, Rodrigues), Braz Oral Res. 2010 142 Apr-Jun;24(2):142-6
- The Effect Of Xylitol Use on Caries Initiation & Progression May not be Attributed Only to its Effect on Mutans Streptococci (MS), Since Several Studies have also Shown that Other Sugar Substitutes as Sorbitol, as well as Placebo Gum, Can Exhibit Some Effect, Although Not As Relevant As Xylitol.
- The Effect Of Chewing Gums On Caries May Also Be Attributed to the Stimulation & Increase of Salivary Flow & Its Resultant Increased Buffer Capacity, &
- To Increased Removal of Bacterial Substrates, Which Suggests An Influence In The Remineralization Process, Promoted By The Regular Use Of Chewing Gums.
Dose of Xylitol in the Study
- In the present study the use of a chewing gum (15% of xylitol, 5 X/day for 30 days) led to at least 10 times reduction in MS salivary levels in 9 of 10 subjects.
- Despite the low total intake of xylitol (1 g/day), the high frequency employed here (5 X/day) may possibly have influenced the MS salivary levels.
- The present data indicate that the use of 15% xylitol chewing gums, 5 times/day, even for short periods such as 30 days, resulted in reduced MS levels.
- The data also indicate that these levels were kept low for at least one month, suggesting that xylitol use should be encouraged, particularly in highly MS infected subjects.
- Other Studies Have Shown Lozenges & Mints to be Equally Effective in Saliva Stimulation
- In Elderly & very young Children Use of Chewing Gum could be hazardous, not acceptable & is not Recommended
- Chewing Gum becomes Taste-less within a Minute, Showing that Contents Released Quickly within a couple of minutes.
- Plenty of Studies Claim Increased Salivary Flow
- Anti-caries Action
- Candies, Lozenges or Mint/Toffees are Safer & as Effective in Saliva Production
- 4 to 10 g Dose per day Was Used in Many Studies for Anti-caries Action
- Brazilian Study Used a Total Dose of 1 g/day for Successful Prevention of Caries (Divided in to 5 times)
- In Actual Sample Study on SST in a Couple of Centers, SST showed Satisfactory Effect on Saliva Production in Patients Undergoing Radiation Therapy
- Xytilol thus Appears to be the Most Suited Product in Xerostomia vis-à-vis Efficacy & Safety
- June 2, 2011 (San Diego, California) — Mothers can significantly reduce caries in their babies by wiping their mouths with wipes impregnated with xylitol, even though the wipes do not kill the bacteria most often blamed for the disease, researchers reported here at the International Association of Dental Research 89th General Session and Exhibition. (http://www.medscape.com/viewcollection/31937)
- Xylitol concentration in saliva and dental plaque after use of various xylitol-containing products. Caries Res. 2006;40(5):393-7., Lif Holgerson P, Stecksén-Blicks C, Sjöström I, Oberg M, Twetman S; Source: Department of Odontology, Pediatric Dentistry, Faculty of Medicine, Umeå University, Umeå, Sweden. [email protected]. (A) Chewing gums(1.3 g xylitol), (B) sucking Tablets (0.8 g xylitol), (C) Candy tablets (1.1 g xylitol),
- All xylitol-containing products resulted in significantly increased levels (p < 0.05) immediately after intake and remained elevated for 8-16 min in the different groups.
- No significant differences were demonstrated between Chewing Gums (A), Sucking Tablets (B), Candy (C) And Rinses (E). In conclusion, commonly advocated xylitol-containing products gave elevated concentrations of xylitol in un-stimulated whole saliva and dental plaque for at least 8 min after intake.
Nan Su, BScH; et al, Caries Prevention for Patients with Dry Mouth, J Can Dent Assoc 2011;77:b85
Advice for Patients with Dry Mouth:
- Chewing xylitol gum up to 5 times a day for 5 minutes each time to reduce acid production by bacteria, and increase saliva and oral comfort
- Taking medications, including pilocarpine, bethanechol or Sialor, to induce salivary flow and increase comfort for those with residual salivary gland function
Gastrointestinal Side Effects
Bloating & Diarrhea: Two Main Gastrointestinal Side-Effects of Xylitol.
- Absorbed Incompletely from the Intestine by Passive Diffusion
- An Excessive Load Over a Person’s Laxation Threshold Can Cause Diarrhea.
- Regular Consumption can Increase One’s Laxation-threshold, (the body adapts to higher dosages).
- Since it is Incompletely Absorbed, Unabsorbed Quantities are Fermented by the Intestinal Flora, which can Cause Abdominal Gas and Bloating.
- Glycemic Index of Food Products
- Soybeans (15), Fructose (20), Cherries (23), Grapefruit (26), Kidney beans (29), Lentils (29),
- Milk (34), Yogurt (36), Chickpeas (36), Apples (39), Spaghetti (42), Grapes (45), Oranges (46), Sweet potatoes (48). All-bran (51), Oatmeal (54),
- Corn (59), Table sugar (sucrose) (59),
- Bananas (62), Raisins (64), Soft drinks (68), Bread, white (69), Potatoes (70), Candy bar (70), Bread, whole wheat (72), White rice (72),
- Refined cereals (80), Honey (87), Carrots (92)
- Glucose (100)
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