hygiene and prevention

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by John Peldyak, DMD This print or PDF course is a written self-instructional article with adjunct images and is designated for 1.5 hours of CE credit by Farran Media.

1 by John Peldyak, DMD This print or PDF course is a written self-instructional article with adjunct images and is designated for 1.5 hours of CE credit by Farran Media. Participants will receive verification shortly after Farran Media receives the completed post-test. See instructions on page 95. AGD Code: 432 Farran Media is an ADA CERP Recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. 1/1/2013 to 12/31/2015 Provider ID# JUNE 2013» dentaltown.com

2 Abstract Dental caries is a transmissible infectious disease triggered by mutans streptococci bacteria. Mothers, as the primary caregivers, are the principal source of these bacteria as early colonizers of infants mouths. The window of infectivity associated with mutans streptococci colonization also offers a window of opportunity to break the dental caries transmission cycle. A twopronged approach utilizing xylitol for mothers and their babies can yield impressive dental health benefits. Educational Objectives At the end of the course, participants will be able to: 1. Describe the window of infectivity relating to oral mutans streptococci. 2. Explain the results of mother-child xylitol research trials. 3. List the benefits of daily xylitol use for mothers, infants and children. 4. Understand the long-term impact of xylitol use on oral health. 5. Recognize the many benefits of xylitol nasal spray. Long-Term Protection with Xylitol One of the main features to arise from earlier xylitol prevention trials was the recognition of a long-lasting caries-protective effect of habitual xylitol use. A follow-up five years after discontinuation of a xylitol chewing gum trial in Ylivieska, Finland, showed that the preventive effect persisted. The subjects of the Belize trials in Central America showed a similar persistence of the xylitol-preventive effect at a five-year recheck. The very best results, more than 90 percent caries reduction, were observed in teeth that erupted during the second year of habitual xylitol use. Theoretical explanations suggest that new teeth erupting into a cleaner environment experience initial colonization by cariogenic bacteria being blocked and the new enamel becoming optimally mineralized. This established the concept that the time prior to and during tooth eruption is the ideal time to use xylitol to achieve the best preventive effect. Mothers Use Xylitol, Babies Benefit A field trial was conducted in Finland in the early 1990s to see if xylitol use by mothers could affect the transmission of mutans streptococci from the mothers to their babies. Mothers chewed 100 percent xylitol-sweetened gum four times a day (about seven grams of xylitol per day), from the time their babies were three months old, and discontinued at 24 months of age. Control groups received either chlorhexidine or fluoride varnish. Colonization by mutans streptococci at age two years was three- to five-times higher in the children whose mothers did not use xylitol. At the age of five years, the children of the xylitol-using mothers had a 70 percent lower caries experience. Follow-ups on this trial were continued for 10 years. A detailed economic analysis found the mothers xylitol use was effective in reducing the costs of dental treatment for their children. Other benefits were noted such as missing fewer school days and avoiding the inconvenience, discomfort and pain associated with tooth decay. A similar mother-child trial was conducted in Sweden where the control groups also chewed gum. The results mirrored the Finland experience: the children of mothers who used xylitol had significantly reduced colonization by mutans streptococci and a lower occurrence of dental caries. Mothers who express a high level of dental anxiety tend to avoid routine professional dental visits and have less effective oral hygiene habits. A group of anxious mothers were given xylitol lozenges to use when their children were between the ages of three and 36 months. The xylitol use was well accepted and found to prevent or at least delay mutans streptococci colonization in their children. Xylitol in Pregnancy A trial in Japan began the xylitol use during pregnancy in a group of women identified as being at high risk for tooth decay. Xylitol chewing gum was used four times each day for 13 months, although they reported lower actual use than the recommended levels. Improved oral health with decreased caries activity was noted in the women of the xylitol group. These xylitol mothers had lower counts of mutans streptococci resulting in reduced colonization of their babies teeth and about 70 percent reduced risk of early childhood caries. Xylitol for the Infant One recent double-blind randomized trial by researchers at the University of Washcontinued on page 92 dentaltown.com «JUNE

continued from page 91 ington in Seattle shows just how effective xylitol is for preventing caries when used directly on the teeth of infants between nine and 15 months for a treatment period of one

The test groups got xylitol syrup at least twice per day and the control group received sorbitol syrup twice a day and xylitol syrup only once a day.

3 continued from page 91 ington in Seattle shows just how effective xylitol is for preventing caries when used directly on the teeth of infants between nine and 15 months for a treatment period of one year. There were two xylitol groups and a control group. The test groups got xylitol syrup at least twice per day and the control group received sorbitol syrup twice a day and xylitol syrup only once a day. While more than half of the children in the control group had tooth decay after 10 months, there were significantly fewer caries in both of the xylitol groups. The authors concluded providing xylitol syrup to infants at least twice a day (total 8gm per day) could reduce early childhood decay by more than 70 percent. Now there are commercial gels available that contain a high concentration of xylitol and are safe to swallow. Combining Mother and Child Use Often research must focus on one piece of the comprehensive puzzle. We have seen that xylitol can be an effective adjunct in breaking the mother-to-child transmission cycle when the mother chews xylitol gum or when xylitol is applied directly to the child s teeth. Why not use both approaches together? We should have more information soon. There was a recently completed trial using xylitol for both mothers and their babies at a Public Health Center in Finland. Infants received xylitol topically on their available tooth surfaces from the age of approximately six months. The mothers were also using xylitol regularly. The preliminary bacteriological reports suggest a favorable trend. Most mothers continued breast-feeding until the child was approximately 12 months old. Milk was not analyzed, but no harmful effects were observed in the infants as result of the intervention. The infants mutans streptococci levels and caries rates decreased significantly. This experiment is currently in press and will be published in the International Dental Journal. Xylitol and Ear Infections Xylitol in chewing gum or syrup has been shown to reduce the incidence of ear infections by up to 40 percent. It was found that xylitol reduces the adherence of important upper respiratory pathogens, particularly Streptococcus pneunomiae and hemophilus influenza, to epithelial cells. A physician in private practice, Dr. Lon Jones, used this information to develop a saline xylitol nasal wash for babies. He noted a dramatic reduction of ear infections with a related decrease in antibiotic use. Dr. Jones recommends preventive use of saline/xylitol nasal spray routinely, such as after diaper changes. He suggests that nasal xylitol helps to keep the nasal airway open, encourages proper nasal breathing and leads to more ideal development of the palate and dental arches. Safety of Perinatal Xylitol In amounts required for dental benefits, xylitol has a long history of safety. During the Turku Sugar Studies in the early 1970s, six of the volunteers in the xylitol-feeding group were pregnant. They were consuming about ten times more xylitol than dental recommendations, with no untoward health effects. There were no negative effects reported on mothers, births or the infants. In Ylivieska, Finland, 91 mothers were breastfeeding regularly through several months of the trial, with no reports of any adverse effects. The Swedish study was very similar in this respect. In Japan 51 pregnant women regularly used xylitol without any negative side effects on them or their children. Professors Kauko Mäkinen and Pentti Alanen at the Institute of Dentistry, in Turku, Finland, tell us that in Finland, where the awareness of xylitol is universal, thousands of breastfeeding mothers use xylitol habitually. Consumers simply consider xylitol as part of their normal life. Other Co-factors Xylitol forms weak complexes with calcium in solution and can function as a carrier for minerals. Saliva production is stimulated by xylitol. This stimulated saliva has a higher ph and greater mineralization potential than resting saliva. A series of studies carried out at Tokyo Dental College demonstrated greater saliva-mediated remineralization with regular xylitol use. They also showed deeper, more complete mineralization occurred with a calcium buffer added to xylitol. Fluoride and xylitol have a combined effect. Toothpaste containing both fluoride and xylitol should be encouraged for 92 JUNE 2013» dentaltown.com

maternal use. Erythritol is a four-carbon polyol. Preliminary evidence suggests some dental benefits similar to xylitol, with different mechanisms involved.

4 maternal use. Erythritol is a four-carbon polyol. Preliminary evidence suggests some dental benefits similar to xylitol, with different mechanisms involved. Although this is speculative, there is a good possibility that xylitol and erythritol are complementary. Used together or sequentially they could have an additive or even synergistic effect. Introducing oral probiotic bacteria to erupting teeth is a relatively new concept. Harmless or even helpful oral bacteria could possibly get established early to block or crowd out the harmful varieties. Xylitol could be an indifferent bystander or possibly a prebiotic agent that would favor the probiotics while suppressing the virulent strains. There are several groups of oral bacteria that are said to be xylitol-resistant. In effect, habitual use of xylitol leads to less adhesive, less acidogenic, less inflammatory oral flora that can maintain a long-term peaceful co-existence with the host. Delivery Systems Mothers, family members and caregivers are encouraged to use xylitol in three to five divided servings throughout the day. Chewing gum is considered an ideal delivery system for xylitol, especially immediately after meals or snacks. Xylitol mints or candy can be effective where chewing gum is not practical. Additionally, xylitol toothpaste or mouthrinse can be part of routine daily home care. Xylitol nasal drops or sprays can be used with babies. By the age of six months or even before the first teeth begin to erupt, babies can be given xylitol syrup or gel. The xylitol can be squirted, brushed or wiped on the teeth by mother after feeding. Pacifiers have been developed with a reservoir to slowly release xylitol over a period of time. Well-designed pacifiers can have a beneficial orthopedic effect for the proper development of the palate and dental arches. Conclusion A simple strategy of mothers chewing xylitol gum during pregnancy and after delivery, along with their babies receiving xylitol in nasal sprays and tooth gels could effectively block or delay early transmission of pathogenic bacteria. Additionally, xylitol assists optimal mineralization of newly erupted tooth surfaces. In conjunction with standard prevention strategies and optimized nutrition, using xylitol could have a profound benefit in reducing childhood dental caries, ear infections and antibiotic overuse. n References: 1. Scheinin, A. Mäkinen, K. (eds) The Turku Sugar Studies, I-XXI Acta Odontologica Scandinavia, vol. 33, supplement 70, Uhari, T. Kontiokari, M. Koskela, M. Niemelä, Xylitol chewing gum in prevention of acute otitis media: double blind randomised trial. British Medical Journal vol. 313, no. 7066, pp , Kontiokari, M. Uhari, M. Koskela, Antiadhesive effects of xylitol on otopathogenic bacteria, Journal of Antimicrobial Chemotherapy vol. 41, no. 5, pp , May, Söderling, P. Isokangas, Pienihäkkinen, J. Tenovuo, Influence of maternal xylitol consumption on acquisition of mutans streptococci by infants, Journal Dental Research vol. 79, pp , Isokangas, E. Söderling, K. Pienihäkkinen, P. Alanen, Occurrence of dental decay in children after maternal consumption of xylitol chewing gum, a follow-up from 0 to 5 years of age, Journal of Dental Research, vol. 79, no. 11, pp , Aaltonen, J. T. Suhonen, J. Tenovuo, I. Inkilä-Saari, Efficacy of a slow-release device containing fluoride, xylitol and sorbitol in preventing infant caries Acta Odontologica Scandinavica, vol. 58, no. 6, pp , Takahashi, M. Saeki, Y. Miake,Y. Yanagisawa, T., Effects of sugar alcohols and calcium compounds on remineralization, Shikwa Gakuho, vol. 100, pp , Thorild, B. Lindau, S. Twetman, Effect of maternal use of chewing gums containing xylitol, chlorhexidine or fluoride on mutans streptococci colonization in the mothers infant children, Oral Health Preventive Dentistry, vol. 1, no. 1, pp , Thorild, B. Lindau, S. Twetman, Caries in 4-year-old children after maternal chewing of gums containing combinations of xylitol, sorbitol, chlorhexidine and fluoride, European Archives of Paediatric Dentistry, vol. 7, no. 4, pp , Söderling, Xylitol reduces mother-child transmission of mutans streptococci, Finnish Dental Journal, supplement 1, pp. 8-11, Nakai, Influence of maternal xylitol consumption on mother-child transmission of cariogenic bacteria during and after pregnancy a promising strategy against initiation of caries, Finnish Dental Journal, supplement 1, pp , Vernacchio, R. M. Vezina, A. A. Mitchell, Tolerability of oral xylitol solution in young children: implications for otitis media prophylaxis, International Journal of Pediatric Otorhinolargology vol. 71, no. 1, pp , Coldwell, T. K. Oswald, D. R. Reed, A marker of growth differs between adolescents with high vs. low sugar preference, Behavior Physiologyvol. 96, no. 23, pp , March, Fontana, D. Catt, G. J. Eckert, S. Ofner, M. Toro, R. L. Gregory, A. F. Zandona, H. Eggertsson, R. Jackson, J. Chin, D. Zero, C. H. Sissons, Xylitol: effects on the acquisition of cariogenic species in infants, Pediatric Dentistry, vol. 31, no. 3, pp , Milgrom, K. A. Ly, O. K. Tut, L. Mancl, M. C. Roberts, K. Briand, M. J. Gancio, Xylitol pediatric topical oral syrup to prevent dental caries a double-blind randomized clinical trial of efficacy, Archives of Pediatrics and Adolescent Medicine, vol. 163, no. 7, pp , Nakai, C. Shinga-Ishihara, M. Kaji, K. Murakami-Yamanaka, M. Takimura, Xylitol gum and maternal transmission of mutans streptococci, Journal of Dental Research vol. 89, no. 1, pp , Laitala, Dental Health in Primary Teeth After Prevention of Mother-Child Transmission of Mutans Streptococci A Historical Cohort Study on Restorative Visits and Maternal Prevention Costs, Academic Dissertation presented at the University of Turku Institute of Dentistry, September 24, Olak, M. Saag, T. Vahlberg, E. Söderling, S. Karjalainen, Caries prevention with xylitol lozenges in children related to maternal anxiety, Eur Arch Paediatr Dent 13:64-69, Makinen, M. Jarvinen, K., Antilla, C., Luntamo, L. Vahlberg, T. "Topical xylitol administration by parents for the promotion of oral health in infants: a caries prevention experiment at a Finnish Public Health Centre,"* International Dental Journal, doi: /idj.12038* Author s Bio Dr. John Peldyak is a general dentist in Michigan. He received his DMD degree from Southern Illinois University in 1980 and was a member of professor Kauko Mäkinen s University of Michigan xylitol research group on sugar substitutes from Dr. Peldyak is also a founding member of the American Academy of Oral Systemic Health. Disclosure: The author declares that neither he nor any member of his family have a financial arrangement or affiliation with any corporate organization offering financial support or grant monies for this continuing education program. Although commercially available products are discussed, no financial arrangements exist between the manufacturers and the author. continued on page 94 dentaltown.com «JUNE

continued from page 93 Post-test Claim Your CE Credits» Answer the test in the Continuing Education Answer Sheet and submit it by mail or fax with a processing fee of $36.

5 continued from page 93 Post-test Claim Your CE Credits» Answer the test in the Continuing Education Answer Sheet and submit it by mail or fax with a processing fee of $36. We invite you to view all of our CE courses online by going to and clicking the View All Courses button. Please note: If you are not already registered on you will be prompted to do so. Registration is fast, easy and of course, free. 1. The window of infectivity for mutans streptococci colonization most likely occurs: a. prior to birth. b. before first six months of life. c. first 36 months of life. d. time between years four and six. 2. When mothers regularly use xylitol themselves: a. their children also experience dental benefits. b. their children have much earlier MS colonization. c. mothers tooth decay rates dramatically increases d. no benefits are realized. 3. Oral health benefits of xylitol have been documented even years after discontinuation of regular use. a. True b. False 4. Xylitol use during pregnancy is safe for both mother and infant. a. True b. False 5. Providing xylitol gel to infants can reduce early childhood caries by: a. 0 percent. b. less than 10 percent. c. less than 30 percent. d. up to 70 percent. 6. Xylitol/saline nasal spray reduces the adherence of pathogens to epithelial cells and: a. keeps the nasal airway open. b. encourages proper nasal breathing. c. can lead to more ideal development of the palate and dental arches. d. All of the above 7. Benefits of xylitol are maximized when: a. used only by the mother. b. used regularly by both mother and infant. c. used only by the infant. d. used without fluoride. 8. Xylitol use by breastfeeding mothers is safe with no negative side effects reported on mother or child. a. True b. False 9. Daily xylitol use should be: a. divided into three to five servings for mother and at least two for baby. b. taken all at once. c. whatever the person wants. d. taken every other day. 10. Daily xylitol use can have profound benefits in reducing: a. childhood dental caries. b. ear infections. c. antibiotic overuse. d. All of the above. Legal Disclaimer: The CE provider uses reasonable care in selecting and providing content that is accurate. The CE provider, however, does not independently verify the content or materials. The CE provider does not represent that the instructional materials are error-free or that the content or materials are comprehensive. Any opinions expressed in the materials are those of the author of the materials and not the CE provider. Completing one or more continuing education courses does not provide sufficient information to qualify participant as an expert in the field related to the course topic or in any specific technique or procedure. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, expertise, skill and judgment of a trained healthcare professional. You may be contacted by the sponsor of this course. Licensure: Continuing education credits issued for completion of online CE courses may not apply toward license renewal in all licensing jurisdictions. It is the responsibility of each registrant to verify the CE requirements of his/her licensing or regulatory agency. 94 JUNE 2013» dentaltown.com

6 Continuing Education Answer Sheet hygiene and prevention Instructions: To receive credit, complete the answer sheet and mail it, along with a check or credit card payment of $36 to: Dentaltown.com, Inc., 9633 S. 48th Street, Suite 200, Phoenix, AZ You may also fax this form to or answer the post-test questions online at This written self-instructional program is designated for 1.5 hours of CE credit by Farran Media. You will need a minimum score of 70 percent to receive your credits. Participants only pay if they wish to receive CE credits, thus no refunds are available. Please print clearly. This course is available to be taken for credit June 1, 2013 through its expiration on June 1, Your certificate will be ed to you within 3-4 weeks. Window of Opportunity for Prevention: Health Benefits of Early Xylitol Use by John Peldyak, DMD License Number AGD# Name Address City State ZIP Daytime phone (required for certificate) o Check (payable to Dentaltown.com, Inc.) o Credit Card (please complete the information below and sign; we accept Visa, MasterCard and American Express.) CE Post-test Please circle your answers. 1. a b c d 2. a b c d 3. a b 4. a b 5. a b c d 6. a b c d 7. a b c d 8. a b 9. a b c d 10. a b c d Card Number Expiration Date Month / Year / Signature Date Program Evaluation (required) Please evaluate this program by circling the corresponding numbers: (5 = Strongly Agree to 1 = Strongly Disagree) 1. Course administration was efficient and friendly Course objectives were consistent with the course as advertised COURSE OBJECTIVE #1 was adequately addressed and achieved COURSE OBJECTIVE #2 was adequately addressed and achieved COURSE OBJECTIVE #3 was adequately addressed and achieved COURSE OBJECTIVE #4 was adequately addressed and achieved COURSE OBJECTIVE #5 was adequately addressed and achieved Course material was up-to-date, well-organized, and presented in sufficient depth Instructor demonstrated a comprehensive knowledge of the subject Instructor appeared to be interested and enthusiastic about the subject Audio-visual materials used were relevant and of high quality Handout materials enhanced course content Overall, I would rate this course: Overall, I would rate this instructor: Overall, this course met my expectations Comments (positive or negative): For questions, contact Director of Continuing Education Howard Goldstein at hogo@dentaltown.com dentaltown.com «JUNE

Perio Reports Vol. 25 No. 6. Child s First Dental Visit. page 2. page 1. June Being a Pedo Dental Hygienist. Message Board, page 11

Perio Reports Vol. 25 No. 6. Child s First Dental Visit. page 2. page 1. June Being a Pedo Dental Hygienist. Message Board, page 11 Child s First Dental Visit page 1 Perio Reports Vol. 25 No. 6 page 2 June 2013 Being a Pedo Dental Hygienist Message Board, page 11 in this section Child s First Dental Visit by Trisha E. O Hehir, RDH,