Cspd san fran2011

DDS, CNC, ND “ Sweet Success with Xylitol” Thank You CSPD! San Francisco April 9 th 2011 DDS, CNC, ND

My Contact Information [email_address] 208-478-5437

Sucrose sugar is the standard for comparison “ sugar substitutes” Attempt to duplicate the taste And some functional properties

Sucrose “ Sugar” on food ingredients labels, ordinary table sugar, cane sugar, beet sugar disaccharide 12-carbon

Glucose (D-glucose, dextrose, corn sugar, blood sugar, monosaccharide, 6-carbon) Fructose (fruit sugar) monosaccharide, 6-carbon)

M altose (malt sugar) disaccharide, 12-carbon) Glucose (D-glucose, dextrose, corn sugar, blood sugar) monosaccharide, 6-carbon)

Maltodextrin Oligosaccharide 3 – 19 glucose units

Starch Polymer, Polysaccharide, Amylose 200 – 1000 glucose units

Sugar alcohols are reduction products of sugars MonoSaccharides Di or Poly Saccs Sugar Glucose (dextrose) Fructose (fruit sugar) Galactose Xylose (wood sugar) Maltose (malt sugar) Sucrose (table sugar) Lactose (milk sugar) Starch Hydrolysate Polyol Sorbitol Mannitol Galactitol Xylitol Maltitol (glu-sorbitol) Isomalt (glu-mann/sor) Lactitol (glu-galactose) HSH (hydrogenated SH)

Sweeteners Bulk -- Functional Properties Sugars (mono- and di-saccharides) Polyols (Sugar alcohols) Intense -- High Potency Artificial Natural

Sweeteners Intense (High potency super sweeteners) Aspartame (200x) Sucralose (600x) Saccharine (400x) Acesulfame Potassium (Ace K) (200x) Licorice (glycyrrhizin) (30-50x) Stevia (steviosides, reboudisides)(300x) Neotame (up to 13,000 x)

Sugar “-ose” by Other Names “ ose” ending (major dietary sugars are sucrose, glucose, fructose, lactose) Syrup (sugars dissolved in water) Corn syrup HFCS High Fructose Corn Syrup Starch (processed and cooked) Maltodextrin

Corn Syrup Water, glucose High Fructose Corn Syrup Glucose converted to fructose by enzymes Water, glucose, fructose (42-95%)

Fructose Fast sugar Most water soluble Liver metabolic bottleneck Maillard reaction rapid non-enzymatic browning

Glycation Non-enzymatic glycosylation Maillard Reaction: Modification of protein =browning Leads to formation of (AGE’s Advanced Glycation End-products)

AGE’s Toast Glycated hemoglobin (diabetes) Hba1c test Collagen -- wrinkles

Why is sucrose so harmful? Energy Acid Food storage

Watch for “Hidden Sugar” Cough Drops Chewable vitamins Breath mints Fruit juices Dried fruits Sports Drinks Syrup medicines

But Don’t Forget the Obvious

Way to Much Sugar Germs Sugar Acid Plaque

Way Way Way to Much Sugar … . But

American Heart Association Recommends less than 100 calories from added sugars (6.2 sugar cubes) per day for adult women

From sugar cane or sugar beets It’s all just Sugar

Conflicts of Interest Spry Dental – Consultant 2001-2004 My Xylitol www.myxylitol.com Academy of Dental Resources www.adrdental.com Designs for Health www.designsforhealth.com

Professional Education Dental Practice 1978-1995 General 1997-present Children only Education General Dentist – Practice limited to Kids CCN – Certified Nutritional Consultant NART – Nutrition Autonomic Response Testing ND – Naturopathic Doctor ACIMD American College of Integrative Medicine and Dentistry Publications Practical Application of Xylitol Finnish Dental Journal Supplement 1,2006

My Personal Xylitol History Fall of 1999 Dr. Russ Misner KlearChoice Chewing Gum 2001-2003 Xlear Dental Consultants 2002 Developed ToothGel 2004 Created ADR Xylitol CE Course 2005-2007 Patent pending gels and TP’s 2004-2009 Office Implementation 2011 Orthodontic Module Release

Our Xylitol Journey Begins 1999 Dr. Larry Bybee Dr. Russ Misner

KlearChoice 1999-2000 They packaged the gum with our label We spoke with individual dental offices Pretty soon we were moving 500-600 tubs a month

Xylitol Consultants 2001 Teamed with Xlear 15-20 Dental show per year Tons of fun but a lot of travel

Toothgel 2002 Formulated in Dr. Misner’s Kitchen = + Calcium Glycerylphosphate Xylitol + +

ADR CE Course on Xylitol DVD’s Manual Forms CD Brochures

Orthodontic Module Release all 2011 (I Hope  )

Changing Ideas and Concepts In a learning environment you don’t need to agree with anything that is said…. We learn from each other by listening and doing, NOT from argument.

Reframing From “manage the damage or drill and fill” to health promotion and self care decay prevention From helpless victim to proactive self-care

We sometimes find ourselves changing our mind without any resistance or heavy emotion, but if we are told we are wrong we resent the imputation and harden our hearts. We are incredibly heedless in the formation of our beliefs but find ourselves filled with an illicit passion for them if someone should rob us of their companionship. It is obviously not the ideas themselves that are dear to us but our self esteem that is threatened.

We like to continue to believe what we have been accustomed to accept as true and the resentment aroused when doubt is cast upon any of our assumptions leads to seek out every manner of excuse to continue clinging to them. The result is that much of our so called reasoning consists in finding arguments to go on believing as we already do. James Harvey Robinson

Why Xylitol? Tastes good Delightful sugary taste Cooling effect It works Helps prevent dental caries and upper respiratory infections

What is Xylitol? Carbohydrate with uncommon structure Five carbon atoms Found in small amounts in a wide variety of fruits and vegetables Metabolic intermediate Used as a substitute for sugar

Sorbitol (polyol) 6-carbon Xylitol (polyol) 5-carbon

When 1891 – Emil Fischer 1950 – Identified in Human Metab. 1963 – Approved by FDA for special dietary purposes 1969 – Used intravenously in Australia 1970-1988 Studied Safe for Teeth 1990-Present Reduces Dental Decay

Other Xylitol Properties Hydrophilic – Draws Moisture Increases Salivary Flow Decreases acid strength in the Mouth Low Glycemic Index (Diabetic Safe) Yeasts and Fungus Can’t Grow in Xylitol Cooling and Refreshing

Xylitol Is Non- Cariogenic: Does not cause cavities Cariostatic: Arrests or Halts the decay Process Anti-Cariogenic: Can reverse the caries Process and Repair Incipient Decay

Things To Remember Xylitol Tastes Good, Like Sugar Lower Calorie = Less Weight Lower Glycemic = Weight Loss Can Replace All or Part of Your Sugar Good For Teeth Prevents Tooth Decay Prevents Ear Infections Too Much = Laxative Effect

I only Ate the Parts with Xylitol YUMMY

Xylitol can help keep them smiling!

Where Finland – From Wood China – From Corn Stocks USA – New Source Discovered Very Recently in Lead North Dakota

No Matter How you Stack it Xylitol is Good for Teeth

Dental Caries Process General Plaque Hypothesis Specific Plaque Hypothesis Ecological Plaque Hypothesis

Ecological Plaque Hypothesis Dental plaque is a biofilm: attach, multiply, organize, adapt Organized, diverse multi-specie microbial community in a polymer matrix Biofilms less susceptible to antimicrobials

Ecological Plaque Hypothesis Bacterial competition – more than 600 varieties Acidic conditions favor harmful bacterial communities (only about two dozen harmful) “ Acid Germs” tolerate acid “ Acid Germs” process sugars and generate acid Repeated sugar/acid cycles demineralize teeth and select for harmful “Acid Germs”

Plaque Planktonic Free Floating Single Cell Easier to remove Bio-film Organized Community Hard to kill 1000X Antibiotics

Polysaccharide Intracellular Food Storage Give them Xylitol Gorge them Wear them out Extracellular Plaque Acid Formation Give Them Xylitol (Slicky instead of Sticky)

Xylitol Keeps Unwanted Bugs Out

Effects of xylitol on plaque… Xylitol is not easily metabolized by Bacteria Non-Cariogenic Cariostatic Anti-Cariogenic Reduces MS levels Söderling et al., 1997

Effects of xylitol on plaque: "xylitol-plaque" is thinner than regular plaque, contains less adhesive polysaccharides courtesy of Eva Soderling

Tooth Eruption Xylitol Enhances Early Mineralization. Xylitol Inhibits Initial Colonization by MS. An Opportunity To Establish Long-Term Protection

How much? How often? It depends. Daily range is between 4 grams (teaspoon) and 12 grams (tablespoon). Use at least 3 times each day. Strive for 5

How much? How often? Frequency more important than amount Strive for five uses each day After each meal and snack Toothpaste morning and night

Mouth & Nose Xylitol reduces bacterial adhesion in the mouth (oral care products) & nose (nasal spray) Xylitol enhances natural defenses Where Health Begins

Dental Disease & Health Studies show a correlation between poor dental health and cardiovascular disease Many systemic health problems averted with good dental health

Xylitol supports our natural defenses by promoting protective factors stimulates saliva increases salivary pH promotes remineralization suppresses acid bacteria such as mutans strep (MS)

Glycemic Index Xylitol supplies a steady flow of energy Adapted from SS Natah et al Am J Clin Nutr (65) 1997

Xylitol’s Role in Diabetes Good Taste-Refreshing and Cooling Displacing Equal Amounts of Fast Sugars Low Glycemic Index Fewer Calories – Zero Net Carbs Lowers Serum Fatty Acid Levels No Known Harmful Effect on CNS, Hormones

Don’t Eat the Yellow Xylitol

Who Can Use Xylitol Orthodontic Patients Adults and Elderly Persons with Disabilities Persons with Dry Mouth Athletes Increases Fat Utilzation Fights Muscle Fatigue Everyone Except mans best friend

Hey Dogs Xylitol is NOT for YOU!

Protecting Man’s Best Friend From Xylitol is exhausting Break Time

Susceptible Tooth Attacked and Demineralized By Acid Made by Germs From the fermentation of sugars Decay Process: result is cavities – holes in the teeth

Mutans streptococci on enamel

De-Mineralization (Caries v. Cavities)

Caries? Cavities? Caries is the disease process initiated predominately by the Strept Mutans bacteria Cavities are the result of the caries disease process

Caries vs. Cavities Caries Process Presence of Bacteria Mutans Strept Lactobacillus Low Salivary Flow Low Salivary ph Gingival Bleeding Cavities Physical manifestation of the caries process

Caries to Cavities Progression 1- Healthy Tooth 2- White Spot Lesion The Caries Process 3- Caries Process with Cavitation 4- Filling with Caries Process and Cavitation 5- Continued Demineralization and Undermined Enamel 6- Fractured Tooth 1996-2002 production by Douglas Bratthall

Damaging vs. Protective Sugar and Fermentable Carbohydrate Acid Xerostomia Virulent “Acid” Bacteria Xylitol Neutral, alkaline pH Saliva Calcium, Fluoride Non-Acidogenic Bacteria

Damaging vs. Protective Factors Demineralization Remineralization

Tooth decay progresses when damaging factors prevail over protective factors More demineralization than remineralization

Factors of Dental Disease A pH of 6.3 to 6.7 is a cautionary environment A pH of ≤6.2 is a red light (Non-stimulated salivary flow). GBI > 3-4 Primary or Permanent OHI of Poor or Fair High def – dMf – DMF Negative Periodontal Assessment Localized or Generalized Gingivitis or worse Salivary Flow rate of <0.7 ml/min History of Cavities or Periodontal problems Active Caries Process Noted (Staining) (Diagnodent)

High Risk Factors of Decay for Kids Systemic Diseases Compromised Immune System Mouth Breathing Use of Xlear Nasal Wash to maintain patent airway Gums Bleed when Brushing Sweetened Medicines Family members with Cavities Insufficient Fluoride in non fluoridated areas Irregular Dental Visits Deep unsealed teeth – Primary and Permanent Bottles and Sippy Cups filled with milk and sugary liquids High intake of fermentable high density Carbs between meals Raisins – Cereals - Sugar treats between meals History of ECC History of Fillings

Eruption Period – Early Mixed Dentition

Eruption Period – Late Mixed Dentition

High Risk Factors of Decay for Adults Systemic Diseases Compromised Immune System Mouth Breathing Gums Bleed when Brushing Orthodontic Appliances White spot lesions or incipient lesions on X-Rays Sporadic Dental Visits Failing Restorations High Family Caries Rate Disease Poor Dexterity Inadequate Fluoride Use Frequent Intake of Fermentable High Density Carbohydrates More than two cavities in the last year or active caries. Use of Chewing Tobacco Xerostomia by itself or with Exposed Root Surfaces Radiation Therapy

The Caries Risk Test aids in establishing Risk Inactive/No Disease: (Caries -) (Cavities -) Low Risk Post-Manifest Disease: (Caries -) (Cavities +) Moderate Risk Pre-Manifest Disease: (Caries +) (Cavities -) High Risk Manifest Disease: (Caries +) (Cavities +) High Risk

Caries Risk Levels 1 & 2 Level 1 Inactive No Disease (Caries -) (Cavities -) Anticipatory Guidance Home Care and Regular Dental Check-ups Level 2 Post-Manifest Disease (Caries -) ( Cavities + ) Maintain suppression of caries process Restore Lesions

Caries Risk Levels 3 & 4 Level 3 Pre-Manifest Disease ( Caries+) (Cavities -) Arrest Caries Process prior to Cavitation Level 4 Manifest Disease ( Caries +) (Cavities + ) ART Arrest and Restore Caries Removal, Mutans Cultures, Anticipatory guidance Counseling / Instruction Restoration or Other

Non-active disease caries risk level L1: Low Risk Complete Oral Hygiene and Place Sealants if indicated. Recommend xylitol sweetened dental products (Tooth Gel, Chewing Gum, Mints, Toothpaste, Mouth Rinse, and/or tooth gel as a Saliva Replacer) and have them available for purchase. Recommend and prescribe appropriate fluoride containing products or have available for purchase. Reduce or eliminate fermentable high density carbohydrates between meals. We believe this makes good nutritional sense for the whole body. Evaluate their ability to maintain mechanical plaque control and make appropriate suggestion, i.e., mechanical tooth brush and other oral hygiene aids. Suggest concern for the need of disease control for immediate and close family members to decrease the probability of transmission, i.e., if other members of the family have a high propensity for dental disease it may be only a matter of time until everyone shares the problem. Maintain appropriate follow-up and/or testing to be confident that the patient or the parents are engaged in managing to maintain the non-disease state

Non-active disease caries risk level L2: Moderate Risk See that the necessary mechanical dental treatment such as fillings, sealants etc. are rendered. This will remove the source of possible re-infection locally in their mouths. Recommend appropriate xylitol sweetened dental products (Tooth Gel, Chewing Gum, Mints, Toothpaste, Mouth Rinse, and/or tooth gel as a Saliva Replacer) and have available for purchase. Recommend or prescribe appropriate fluoride containing products or have available for purchase. Have the patient reduce or eliminate fermentable high density carbohydrates (p. 99) especially between meals. This makes good nutritional sense for the whole body. Evaluate their ability to maintain mechanical plaque control and make appropriate suggestion, i.e., mechanical tooth brush and other oral hygiene aids. Suggest concern for the need of disease control for immediate and close family members to decrease the probability of transmission, i.e., if other members of the family have a high propensity for dental disease it may be only a matter of time until everyone shares the problem. Maintain appropriate follow-up and/or testing to be confident that the patient or the parents are engaged in managing to maintain a non-disease state.

Active Disease Caries Risk Level L3 or L4: High Risk Treat the disease process (caries) and the necessary mechanical dental treatment (cavities) such as fillings, sealants etc. Note: Prior to placement of orthodontic appliances make sure that the disease process is under control. Recommend appropriate xylitol sweetened dental products (Tooth Gel, Chewing Gum, Mints, Toothpaste, Mouth Rinse, and/or tooth gel as a Saliva Replacer) and have available for purchase. Recommend or prescribe appropriate fluoride containing products or have available for purchase. Treat the active caries disease process as a bacterial infection with an antimicrobial agent, (105-107) xylitol, and fluoride products. Have the patient reduce or eliminate fermentable high density carbohydrates (p.99) especially between meals. We believe this makes good nutritional sense for the whole body. Evaluate their ability to maintain mechanical plaque control and make appropriate suggestion, i.e., mechanical tooth brush and other oral hygiene aids. Suggest concern for the need of disease control for immediate and close family members to decrease the probability of transmission, i.e., if other members of the family have a high propensity for dental disease it may be only a matter of time until everyone shares the problem. Maintain appropriate follow-up and retesting until the patient or the parents are engaged in managing the disease.

Before and After Results obtained in our office with Xylitol

100% Xylitol Gum Only Before After 1 Week

100% Xylitol Gum Only Before After 3 Weeks

Xylitol Reduces Bacterial Regrowth After Oral Disinfection Hildebrandt GH, Sparks BS. Maintaining mutans streptococci suppression with xylitol chewing gum. J Am Dent Assoc. 2000;131:909-916 | 3 Months

100% Xylitol Gum and Chlorhexidine Before After 1 Week

100% Xylitol Gum and Chlorhexidine Before After 2 Weeks

AJS 2-26-2003 Initial examination with oral hygiene and xylitol recommendations

AJS 3-4-2003 After using xylitol for one week

WF 2-26-2003 Inadequate hygiene for fixed orthodontic appliances

WF 3-11-2003 Improvement after two weeks of Xylitol Hygiene

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.

Dry Mouth Many Prescription Drugs Cause Dry Mouth Uncomfortable Lack of Saliva Leads to Caries Root Caries

Factors Affecting Salivary Flow Pharmaceuticals Radiation Therapy Water Intake Xylitol

The caries controlling/preventing effect of xylitol is not based on saliva stimulation only

Staff Responsibilities Assess and Record pH Salivary Flow Gingival Bleeding Index Debris Index Calculus Index Calculate Oral Hygiene Index Brushing and Flossing Instructions

Caries Risk Test Provide a basis for evidence based Care Provide a basis for customized Treatment Evaluation Findings In Office Treatment Dental Practice Home Care Measures At Home In cooperation with the Polyclinic for Preventive Dentistry, Erfurt, Dental School, Friedrich-Schiller University of Jena, Germany VIVADENT

Caries Risk Test Based on Clinical Judgment Great Parent/Patient motivator Confirms clinical diagnosis Ivoclar/Vivadent incubator Test Kit – CRT Bacteria Standard Salivary Flow Rate Mutans Strep Lactobacillus

Mutans Strep ≥ 100,000 Colony Forming Units Caries Risk Test

Lactobacillus ≥100,000 Colony Forming Units Caries Risk Test

Gold Standard in Clinical Trials (MS) Growth medium Bacitrasin SM-strips Paraffin Ten tests Flossette

Mother – Child Transmission What do the Clinical Trials Show

Stefan’s Curve Breakfast Lunch Dinner Snacks

Why are mutans streptococci (MS) so important? The caries bacteria MS form sticky plaque and produce efficiently acids Mutans streptococci on enamel

Xylitol consumption decreases amounts and the adhesivity of MS. Mutans streptococci of habitual xylitol consumers are easily shed to the saliva. Söderling et al., 1991; Trahan et al., 1992 courtesy of Eva Soderling

The effects of xylitol on MS are based on its 5-carbon structure Clinical studies support the idea that MS is targeted by xylitol (Vadeboncoeur et al., 1983; Loesche et al., 1984) The MS counts remain low as long as the use of xylitol lasts Xylitol

Effects of xylitol on mother-child transmission of mutans streptococci SWEDEN FINLAND

, February 2011) Japan Finland Sweden Finnish, Swedish, Japanese Studies (Courtesy of Eva Soderling Feb. 2011

Protect Your Child with Xylitol – It’s Pretty Cool Stuff Protected Child

Xylitol gel in pacifier for baby Mother uses xylitol chewing gum

Caufield et al., 1993 The window of infectivity for mutans streptococci Caries as an infectious disease: Early colonisation of mutans streptococci (caries bacteria) increases the risk of caries occurence in the future! courtesy of Eva Soderling

Transmission of mutans streptococci The timing of the window of infectivíty can differ in different populations (Florio et al., 2004) Factors affecting the transmission: The mutans counts of the "infecting" person (>100 000 per ml saliva – common!) Number of daily saliva contacts Individual susceptibitily of the child (Smith et al., 1998), mode of delivery (Li et al., 2005) courtesy of Eva Soderling

If we can reduce the risk of this transmission could we lower tooth decay in children? Lets look at some of the Studies to find out.

Finland:Effects of xylitol on mother-child transmission of mutans streptococI YES!

Finland: Effects of xylitol on childhood caries Isokangas et al., 2000 Caries occurence until 5 yrs YES!

Mother’s Dental Care Soderling E, IsokangasP, PienhakkinenK, Tenovuo J. Influence of maternal xylitol consumption on acquisition of mutans streptococci by infants. J Dent Res. 200;79:1885-9 Chlorhexidine YES!

Soft Banana brush with xylitol gel

When Mothers Use Xylitol, Children Have Fewer Cavities Isokangas P, Soderling E, Pienikakkinen, Alanen P. Occurrence of dental decay in children after maternal consumption of xylitol chewing gum, a follow-up from 0-5 years of age. J Dent Res. 2000;79:1885-9 YES!

Xylitol Reduces Bacterial Regrowth After Oral Disinfection Hildebrandt GH, Sparks BS. Maintaining mutans streptococci suppression with xylitol chewing gum. J Am Dent Assoc. 2000;131:909-916 | 3 Months YES!

Baby gets cariogenic bacteria from mother Mothers who use xylitol transmit non-cariogenic microflora

With All this Xylitol Your Teeth are Safe

XYLITOL’S Role in Re-mineralization

Remineralization / Cosmetic Enhancement Invention Hypomineralized areas on #8,9 Status before any treatment Status immediately following treatment Example # 1 Treatment Time: 5-7 minutes

Status before any treatment Status immediately following treatment Example #2

Status before treatment. # 8, 9 are to be treated. Note generalized demineralization on maxillary posteriors that will not be professionally treated. Example #3 - Slide 1 of 2 Status of # 8,9 immediately following professional treatment. Please note no change to hypo-mineralized areas in Maxillary posteriors.

of 2 5 months after initial professional treatment to # 8,9. Patient was instructed to use an at-home solution daily. Please note remineralization effects of home solution on maxillary posteriors.

Photos illustrating possible treatment process ~ Slide 1 of 2 Status before any treatment Slight microabrasion of surface

of 2 Chemical Etch Status immediately following treatment

Same Day After In Office Treatment

“ Xylitol gum enhanced remineralization reduced plaque and improved gingival health.” Steinberg LM, Odusola F, Mandel ID: Remineralizing potential, and plaque and anti-gingivitis effect of xylitol and sorbitol sweetened chewing gum Clinical Nutrition (supplement) 1995 pp. 275-283.

XYLITOL’S Role in Maintenance

Medical Model Medical Model information Adapted from A Comprehensive Review of Pediatric Dentistry Manual , San Diego September 2002. Diagnosis Treat Caries Treat Cavities Maintenance Home / Professional Health Caries+ Cavities + Cavities - Caries - Cavities - Cavities + L1 L2 L3 L4 L4

Elements of Management Date Eruption Periods Salivary ph GBI - Gingival Bleeding Index Decayed, missing, filled DI/CI – Debris Index/Calculus OHI - Oral health Index BFI/Pro-Flo Brushing, Flossing Instructions/ Prophy Caries Risk Periodontal Condition Photographs CRT/SF Caries Risk Test/ Salivary Flow CRT Mutans Strep/Lacto Bac 100% Xylitol Chewing Gum 100% Xylitol Product Reco’s Fluoride Reco’s CHX – Chlorhexidine Nutritional Information Treat Cavities Follow-up Treatment Date Referral

Maintenance Regular xylitol use should be encouraged as a routine healthy habit, a continuing part of a normal oral hygiene regimen. “ The best use of xylitol is as an addition to other oral hygiene recommendations.” Peldyak, John DMD; Makinen, Kauko K. PhD: Xylitol for Caries Prevention. Journal of Dental Hygiene Volume 67 Number IV Fall 2002, pp. 276-285.

How To Use Xylitol “ Xylitol should be used immediately after every meal and snack. 3-5 Times a Day Gum or Mint should be used for at least 3-5 minutes Can be Used at any other time you desire. Peldyak, John DMD; Makinen, Kauko K. PhD: Xylitol for Caries Prevention. Journal of Dental Hygiene Volume 67 Number IV Fall 2002, pp. 276-285.

Long-term effect of xylitol. When Used for 2 Years Cavity Reducing Effect lasts for 3-5 Years Peldyak John DMD, Makinen Kauko K PhD: Xylitol for Caries Prevention. Journal of Dental Hygiene Volume 76 Number IV Fall 2002; pp. 276-285.

Who Can Use Xylitol Orthodontic Patients Adults and Elderly Persons with Disabilities Persons with Dry Mouth Athletes Increases Fat Utilization Fights Muscle Fatigue Everyone Except Dogs

Caries process successfully managed when Salivary Mutans stays low. No gingival inflammation. Caries excavation complete, lesion appearance changed (arrested). Patients or Parents of patients engaged in managing disease.

Historical factors for low risk. Opposite of high risk factors Dental health awareness. No cavities within the last year or two. Regular dental visits. History of few cavities in the rest of the family. For adults and children no tobacco use. Good regular use of fluoride products. Adequately restored surfaces on a minimal number of teeth no foiling or creeping restorations. Deep pit and fissures are sealed. Low dietary intake of Fermentable High Density Carbohydrates. In Children no history of Early Childhood Caries, no or little history of medicines high in sucrose or syrup, no fluids in bottle or sippy cups that contain any form of sugar especially between regular feedings or left in bed with bottle or allowed to carry the vessel around except with water.

Carbonated drinks are the single biggest source of refined sugars in the American diet. According to dietary surveys, soda pop provides the average American with 7 teaspoons of sugars per day, out of a total of about 20 teaspoons. Teenage boys get 44 percent of their 34 teaspoons of refined sugars a day from soft drinks. Teenage girls get 40 percent of their 24 teaspoons of sugars from soft drinks. Because some people drink little or no soda pop, the percentage of refined sugars provided by pop is higher among actual drinkers.

Would You Like To Significantly: Decrease Decay In Your Mouth? Decrease Decay In Your Kids Mouths? Decrease Decay In Your Grandkids Mouths?

Benefits of Xylitol for Patients Effective Convenient Enjoyable Result is improved cooperation and excellent oral hygiene Xylitol on a picnic… Xylitol at the big game

Product Types Toothpaste Oral Rinse Dental Cleansing Gel Mints Gum Moisturizing breath freshener

Show ’em the door Makes plaque Slicky instead of Sticky

Slam it shut Xylitol Lives Here

Xylitol blocks the tooth-damaging factors

Xylitol Features Sweet, cooling, no aftertaste Naturally-occurring in human metabolism Low calorie (40% less than sugar) Low Glycemic (about 10% of Glucose) Low insulin usage to metabolize No Maillard reaction Slows stomach emptying – increases satiety (feelings of fullness) Energy source (Used in IV Nutrition) Enhances Calcium absorption Helps prevent tooth decay Helps prevents ear and upper respiratory infections

How much? How often? Frequency more important than amount 4 to 12 grams (teaspoon is 4 grams) 6 to 10 pieces of gum/day Active Strep Mutans infections in adults require at least 6 grams (8 or more pieces of gum) Aim for five uses each day After each meal and snack Toothpaste morning and night

5 Levels of Caries Control Remineralization Disinfect Oral Hygiene Xylitol Environment

Environment, Whole Food and Whole Food Supplements Xylitol protocols and Products Office Oral Hygiene Program Oral Disinfection Remineralization Ease of Management Effect on Oral Health Least Most Easy Hard

Whole Food – Level 1 Diet – Real Food Less Processed Products Supplements And Environment Toxins Air Water Stress Change in habits and life style

Adapted from the book: From Here to Longevity by Dr. Mitra Ray Ph.D. with Patricia Cannon Childs

Saliva Calcium Phosphorus Xylitol Gum

Adapted with permission from the book: From Here to Longevity by Dr. Mitra Ray Ph.D. with Patricia Cannon Childs

Essential Nutrient Needs of Our Bodies Macro Nutrients: Air, Water, Protein, Fats, Carbohydrates, and Fiber. Micro Nutrients: Vitamins, Minerals, Essential Fatty Acids, Amino Acids, Enzymes, Pre and Pro Biotics.

What We’ve Learned What you eat affects the health of your mouth, body, and life That it is best to avoid sugar, white flour products, vegetables oils, and trans-fats That it is best to drink pure filtered water and eat fresh proteins, fresh vegetables, and salads That it is better for you to eat foods less processed food That it is best for you to eat foods closest to their natural state That it is essential to support your nutrition with concentrated whole food supplements, because the foods we consume today are not as nutrient dense as they were 100 years ago.

To Summarize: We believe that whole food nutrition , as close to the natural state that one can obtain, supplemented by the use of concentrated whole food supplements is the essential foundation for a healthy mouth and body.

Food to Choose (Organic) Home grown in your own garden or pasture Fresh picked (Farmers Markets) Fresh frozen Fresh as it can be in grocery store meat, fish, and produce section

Oral Hygiene – Level III Cleaning, x-rays, Exam, Fluoride 1. Report Card Presentation 2. Findings 3. Reason for follow-up 4. Objective Data and assessment 5. Provider Recommendations

1. Report Card Cavity Risk Gum Health Referral

2. Dental Exam Findings Dental Needs Head and Neck Intro Oral Soft Tissues Intra Oral Teeth X-Rays

3. Follow up Care - Recall Preventative Care Early Cavity Detection X-Rays for Cavity Detection Monitor Eruption Monitor Stained Areas Monitor Spots between Teeth Soft Tissue Check Monitor Spacers Check Crowns/Fillings

4. Objective Data and Assessment Date Eruption Period pH Bleeding Gums Plaque Oral Hygiene Instruction Cleaning and Fluoride Gum Disease Cavity Risk

5. Provider Recommendations Daily Xylitol Daily Fluoride Professional Care

Oral Disinfection – Level IV Perioguard - Chlorhexidine Betadyne – Povidone Iodine CloSysII – Chlorine Dioxide

Remineralization – Level V Ionizable minerals Calcium Lactate Calcium Citrate Calcium Glycerol Phosphate Fluoride Listerine, Act, Fluoguard…. Prevent 5000

Xylitol Is: Non-Cariogenic: Does not contribute to the caries disease process. Cariostatic: The caries disease process does not occur in the presence of Xylitol. Anti-Cariogenic: The caries disease process may be reversed through appropriate exposure to Xylitol.

Xylitol is Anti-Cariogenic “ The highest caries reduction rates were observed in subjects using Xylitol.” Hayes, Catherine D.M.D. D.M.Sc: The effect of Non-Cariogenic Sweeteners on the Prevention of Dental Caries: A review of the evidence Journal of Dental Education October 2001/Vol.65/No. 10pp. 1106-1109.

“ Studies are remarkably consistent, in the terms of the magnitude of the effect observed as well as the consistent demonstration of the superiority of Xylitol compared to sorbitol in decreasing the risk of dental caries.” Hayes, Catherine D.M.D D.M.S c: The effect of Non-Cariogenic Sweeteners on the Prevention of Dental Caries: A review of the evidence Journal of Dental Education October 2001/Vol.65/No. 10pp. 1106-1109.

Xylitol is non-acidogenic and non-cariogenic. Xylitol is essentially non-fermentable and therefore cannot be converted to acids by oral bacteria. Xylitol can be left on teeth overnight and not cause any damage. All from Peldyak John DMD: Xylitol Sweeten Your Smile ; Advanced Developments, Inc. Mt. Pleasant, MI p.8.

How Safe is Xylitol “ In the amounts needed to prevent tooth decay (less than 15 grams per day), Xylitol is safe for everyone.” Peldyak, John D.M.D, Xylitol Sweeten Your Smile Advanced Developments, Inc. Mt Pleasant, MI 48804-1010. “ Xylitol with adaptation is well tolerated and safe to levels of at least 90 grams/day, with no subjective or objective adverse findings.” Brin M, Miller ON: The safety of oral xylitol in: Sugars in Nutrition Sipple HL (ed) Academic Press New York 1974 pp. 591-605. .

Xylitol’s Main Side Effect Xylitol is very hydrophilic and a side effect may be slight gastric distress and slight osmotic diarrhea. Consider starting with a slight dose then increasing or informing the patient if they have any problem to cut back for a while and build up to level recommend as tolerated Dr. John Peldyak DMD in his book “ Xylitol Sweeten Your Smile ”; Advanced Developments, Inc. Mt. Pleasant, MI. 48804-1010, 1996, pp.5-6.

Xylitol Studies Chart, outline and references 1-15 are courtesy of Dr. John Peldyak Mt. Pleasant Michigan.

Turku, Finland (1) -- Xylitol (67g/day) replaced dietary sugar (sucrose), 1 Turku, Finland (2) -- Xylitol (6.7g/day) was used only in chewing gum.1 Soviet Union -- Control group also had more severe “deep” lesions and pulpitis.2 French Polynesia -- Both control group and xylitol group received basic oral hygiene with fluoride toothpaste. ³ Hungary -- The xylitol group also had lower caries rate than a group which received fluoride.4, 5 Montreal, Canada -- Chewing gum contained a mixture of xylitol and sorbitol.6, 7 Ylivieska, Finland -- Comprehensive prevention program was improved by the addition of xylitol gum. Long-term benefit of xylitol was established.8-10 Belize -- Chewing gum sweetened exclusively with xylitol was more effective in preventing caries than sorbitol or xylitol-sorbitol mixtures. Sucrose gum increased caries incidence.11, 12 Stann Creek -- Five year follow-up of Belize trial demonstrated lasting benefit of xylitol use.13 Dayton -- Supragingival root surface caries were studied.14 Estonia -- Xylitol candy was as effective as xylitol chewing gum in reducing caries.15

Galiullin AN: Evaluation of the caries-prevention action of xylitol . Kazan Med. J 1981:67:16-18. Kandelman D, Bär A, Hefti A: Collaborative WHO xylitol field study in French Polynesia. 1. Baseline prevalence and 32 month caries increment. Caries Res 1988; 2:55-62. Scheinin A, Banóczy J, Szóke J, et al: Three-years caries activity in institutionalized children. Acta Odont Scand 1985; 43:327-347. Scheinin A, Mäakinen KK: Turku sugar studies I-XXI. Acta Odont Scand 1975; 33:suppl 70, 1-348. Scheinin A, Pienihäkkinen K, Tiekso J, Banóczy J, et al: Collaborative WHO xylitol field studies in Hungary. VIII. Two-year caries incidence in 976 institutionalized children. Acta Odont Scand 1985; 43:381-387. Kandelman D, Gagnon G: Clinical results after 12 months from a study of the incidence and progression of dental caries in relation to consumption of chewing gums containing xylitol in school preventive programs. J Dent Res 1987; 66:1407-1411. Kandelman D, Gagnon A: A 24-month clinical study of the incidence and progression of dental caries in relation to consumption of chewing gums containing xylitol in school preventive programs. J Dent Res 1990; 69:1771-1775.

Isokangas P Alanen P, Tiekso J, Mäkinen KK: Xylitol chewing gum in caries prevention: a field study in children. J Am Dent Assoc 1988; 17:315-320 Isokangas P, Tiekso J, Alanen P, Mäkinen KK: Long-term effect of xylitol chewing gum in the prevention dental caries. Comm Dent Oral Epidemiol 1989; 17:200-203. Isokangas P, Mäkinen KK, Tiekso J, Alanen P: Long-term effect of xylitol chewing gum in the prevention dental caries: A follow-up five years after termination of a prevention program. Caries Res 1993; 27:495-498. Mäkinen KK, Bennett CA, Hujoel PH, it al: Xytiltol chewing gums and caries rates: a 40-month cohort study. J Dent Res 1995; 74 1904-1913. Mäkinen KK, Hujoel PH, Bennett CA, Isotupa KP, et al: Polyol chewing gums and caries rates in primary dentition: a 24 month cohort study. Caries Res 1996; 30:408-417. Mäkinen KK, Allen P, Bennett CA, et al: Stabilization of rampant caries: polyol gums and arrest of dentin caries in two long-term cohort studies in young subjects. Int Dent J 1995; 45: 93-107. Mäkinen KK, Pemberton D, Mäkinen P-L et al: Polyol-combinant saliva stimulants and oral health in Veterans Affairs patients--an exploratory study. Spec Care Dent 1996; 16:104-116. Alanen P, Isokangas P, Gutmann K: Xylitol candies in caries prevention: results of a field study in Estonian children. Community Dent Oral Epidemiol 2000; 28:218-224.

Findings “ Xylitol was clinically proven to be Non-Cariogenic.” Scheinin A, Mäkinen KK: Turku sugar studies I-XXI Acta Odontologica Scandinavia 33 (suppl 70): 1975

Findings “ Results suggest… that high-xylitol content chewing gum usage can retard or arrest rampant dentine caries.” Mäkinen KK, Mäkinen PL, Pape HR.: Stabilization of rampant caries: polyol gums and arrest of dentine caries in two long-term cohort studies in young subjects. Int. Dent J 1995b; 45:93-107

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