DIAGNOSIS/TREATMENT/PROGNOSIS
ARTICLE ANALYSIS & EVALUATION ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Effect of erythritol and xylitol on dental caries prevention in children. Honkala S, Runnel R, Saag M, Olak J, N~ ommela R, Russak S, M€akinen PL, Vahlberg T, Falony G, M€akinen K, Honkala E. Caries Res 2014;48(5):482-90.
REVIEWER Jaana Gold, DDS, PhD
PURPOSE/QUESTION To determine the efficacy of daily consumption of erythritol, xylitol, and sorbitol candies by first- and second-graders on the development of enamel and dentin caries lesions.
SOURCE OF FUNDING Cargill R&D Center Europe (Vilvoorde, Belgium), manufacturer of sweeteners
TYPE OF STUDY/DESIGN Double-blind, cluster randomized clinical trial
LEVEL OF EVIDENCE Level 2: Limited-quality, patient-oriented evidence
STRENGTH OF RECOMMENDATION GRADE Not Applicable
J Evid Base Dent Pract 2014;14:185-187 1532-3382/$36.00 Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jebdp.2014.10.007
Erythritol May Reduce Dental Caries in High-Risk School Children SUMMARY Subjects The 485 first- and second-graders from 10 schools in southeastern Estonia had a mean age of 9.1 years in the erythritol group and 8.7 years in the xylitol and sorbitol groups. The percentage of girls was 43.0% in the erythritol group, 45.5% in the xylitol group, and 48.2% in the sorbitol group. Only children whose parents/caregivers returned the signed informed consent form were included in the study. Randomization was carried out by clusters of classrooms, according to computer-generated random numbers. Inside the schools, the firstgraders were allocated to a different group than the second-graders. Samples consisted of 2 to 5 classrooms per school. Children were assigned from 6 schools/9 classrooms to the erythritol group, from 9 schools/10 classrooms to the xylitol group, and from 9 schools/11 classrooms to the sorbitol group. Concealment of allocation was maintained by the Cargill R&D Center Europe (manufacturer and the provider of the candies). Teachers distributed and supervised the use of the candies. A group of investigators made three annual site visits to the schools during the trial to enhance compliance. The surface-specific data were collected from baseline (n = 485) and follow-up examinations at 12 months (n = 436), 24 months (n = 401), and 36 months (n = 374) by using the International Caries Detection and Assessment System (ICDAS) II. The ICDAS II codes 1-3 were combined for enamel caries, and codes 4-6 were combined for dentin caries. At baseline, the mean (SEM) number of decayed, missing, and filled surfaces for the primary and permanent dentition (dmfs þ DMFS) was 11.61 (0.65) for the erythritol group (n = 165), 11.22 (0.74) for the xylitol group (n = 156), and 12.71 (0.80) for the sorbitol group (n = 164).
Key Exposure/Study Factor The children consumed 4 erythritol, xylitol, or sorbitol candies 3 to 4 times per day during 200 school days for 36 months. The candies contained about 90% of erythritol, xylitol, or sorbitol; the daily intake of polyol was about 7.5 g.
Main Outcome Measure The main study outcome was cumulative decayed (Dd) and filled (Ff) teeth and surface increments for the mixed dentition (threshold for caries was defined as combined ICDAS codes 1–3 for enamel and 4–6 for dentin) from baseline through the three follow-up examinations. Caries indices were calculated as the sum of decayed, missing, and filled teeth (D4–6MFT þ d4–6mft) and surfaces (D4–6MFS þ d4–6mfs). Double-blinded clinical examinations of the children in all groups were completed 4 times (at baseline and at 12, 24, and 36 months) by four trained and calibrated investigators. The calibration of investigators was performed during 2 days before every annual examination. Consistency
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
of use of the ICDAS II codes by each examiner and between the examiners was reported as high (k > 0.9).
Main Results The xylitol group had a significantly higher number of decayed teeth (relative risk = 1.96; 95% confidence interval [CI], 1.24–3.10) and surfaces (relative risk = 2.33; 95% CI, 1.37–3.98) than the erythritol group at 24 months and a higher number of decayed surfaces (relative risk = 1.93; 95% CI, 1.12–3.33) at 36 months. The time for decayed (enamel and dentin) lesions to develop was significantly longer in the erythritol group compared to the other groups. Over the 36-month time period, 4.6% of tooth surfaces in the erythritol group developed enamel or dentin caries compared with 5.8% in the xylitol group and 5.5% in the sorbitol group (p < 0.001).
Conclusions The authors concluded that after 24 and 36 months, erythritol candies reduced the number of decayed teeth and surfaces in the mixed dentition compared with the xylitol and sorbitol candies. Further, the time for the caries lesions to develop was longer for children who consumed erythritol candies, and sorbitol had a better caries-preventive effect than xylitol.
COMMENTARY AND ANALYSIS The reviewed study addressed a need to test the efficacy of daily consumption of erythritol and xylitol candies, compared with sorbitol candy, on the development of enamel and dentin caries lesions among high-risk school children. The authors provided an informative rationale for the trial. The methods were described well, and the statistical analyses seemed reasonable. The compliance in the study was assumed to be good; however, no data on compliance are presented. A conflict of interest existed with the sponsoring manufacturer of the tested products. The positive caries preventive effect of xylitol chewing gum has been reported in several studies, but interpretation of the data has been controversial, mostly because of variations in study designs, outcomes, or formulations/ doses tested.1 To reduce the confounding effect of chewing and increased saliva flow from chewing, caries trials using candies to test the effect of sugar alcohol are justified. Xylitol candies or lozenges have shown some potential in reducing caries; however, existing studies have been shown to have bias or heterogeneity or are sparse.2 In a previous study by Honkala et al.,3 xylitol candies reduced decayed surfaces in disabled school students compared with a control group (no candy). In a study of Estonian schoolchildren, a daily dose of 5 g of xylitol candy resulted in a caries reduction of about 50% compared with a control (no gum or candy).4 In a study by Lenkkeri et al.,5 xylitol/maltitol or erythritol/maltitol 186
lozenges did not have a caries-preventive effect, but the children in that study had a low risk for caries. According to the evidence-based recommendations of the American Dental Association, the daily use of xylitol-containing lozenges or candies (5–8 g/day in 2–3 doses) may reduce the incidence of coronal caries in children; however, the level of evidence is ‘‘expert opinion’’ because of the limited number and quality of available studies.6 Although the erythritol group in the reviewed study had statistically less enamel and dentin caries over the 36-month study period, the clinical significance is questionable. As stated by the study authors, all the children received health education and dental treatment, and few dental lesions developed in all groups. Further, their results suggested that sugar alcohols did not have the preventive effect previously claimed or that the dose and frequency in this study were not effective enough. Even though the reviewed study was cluster randomized, differences in the caries determinants between the schools may have had a confounding effect on the outcome, especially if the sample size was too small to invalidate the confounding effect. In the reviewed study, xylitol and sorbitol groups had more children in the younger age group (
ARTICLE ANALYSIS & EVALUATION ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Effect of erythritol and xylitol on dental caries prevention in children. Honkala S, Runnel R, Saag M, Olak J, N~ ommela R, Russak S, M€akinen PL, Vahlberg T, Falony G, M€akinen K, Honkala E. Caries Res 2014;48(5):482-90.
REVIEWER Jaana Gold, DDS, PhD
PURPOSE/QUESTION To determine the efficacy of daily consumption of erythritol, xylitol, and sorbitol candies by first- and second-graders on the development of enamel and dentin caries lesions.
SOURCE OF FUNDING Cargill R&D Center Europe (Vilvoorde, Belgium), manufacturer of sweeteners
TYPE OF STUDY/DESIGN Double-blind, cluster randomized clinical trial
LEVEL OF EVIDENCE Level 2: Limited-quality, patient-oriented evidence
STRENGTH OF RECOMMENDATION GRADE Not Applicable
J Evid Base Dent Pract 2014;14:185-187 1532-3382/$36.00 Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jebdp.2014.10.007
Erythritol May Reduce Dental Caries in High-Risk School Children SUMMARY Subjects The 485 first- and second-graders from 10 schools in southeastern Estonia had a mean age of 9.1 years in the erythritol group and 8.7 years in the xylitol and sorbitol groups. The percentage of girls was 43.0% in the erythritol group, 45.5% in the xylitol group, and 48.2% in the sorbitol group. Only children whose parents/caregivers returned the signed informed consent form were included in the study. Randomization was carried out by clusters of classrooms, according to computer-generated random numbers. Inside the schools, the firstgraders were allocated to a different group than the second-graders. Samples consisted of 2 to 5 classrooms per school. Children were assigned from 6 schools/9 classrooms to the erythritol group, from 9 schools/10 classrooms to the xylitol group, and from 9 schools/11 classrooms to the sorbitol group. Concealment of allocation was maintained by the Cargill R&D Center Europe (manufacturer and the provider of the candies). Teachers distributed and supervised the use of the candies. A group of investigators made three annual site visits to the schools during the trial to enhance compliance. The surface-specific data were collected from baseline (n = 485) and follow-up examinations at 12 months (n = 436), 24 months (n = 401), and 36 months (n = 374) by using the International Caries Detection and Assessment System (ICDAS) II. The ICDAS II codes 1-3 were combined for enamel caries, and codes 4-6 were combined for dentin caries. At baseline, the mean (SEM) number of decayed, missing, and filled surfaces for the primary and permanent dentition (dmfs þ DMFS) was 11.61 (0.65) for the erythritol group (n = 165), 11.22 (0.74) for the xylitol group (n = 156), and 12.71 (0.80) for the sorbitol group (n = 164).
Key Exposure/Study Factor The children consumed 4 erythritol, xylitol, or sorbitol candies 3 to 4 times per day during 200 school days for 36 months. The candies contained about 90% of erythritol, xylitol, or sorbitol; the daily intake of polyol was about 7.5 g.
Main Outcome Measure The main study outcome was cumulative decayed (Dd) and filled (Ff) teeth and surface increments for the mixed dentition (threshold for caries was defined as combined ICDAS codes 1–3 for enamel and 4–6 for dentin) from baseline through the three follow-up examinations. Caries indices were calculated as the sum of decayed, missing, and filled teeth (D4–6MFT þ d4–6mft) and surfaces (D4–6MFS þ d4–6mfs). Double-blinded clinical examinations of the children in all groups were completed 4 times (at baseline and at 12, 24, and 36 months) by four trained and calibrated investigators. The calibration of investigators was performed during 2 days before every annual examination. Consistency
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
of use of the ICDAS II codes by each examiner and between the examiners was reported as high (k > 0.9).
Main Results The xylitol group had a significantly higher number of decayed teeth (relative risk = 1.96; 95% confidence interval [CI], 1.24–3.10) and surfaces (relative risk = 2.33; 95% CI, 1.37–3.98) than the erythritol group at 24 months and a higher number of decayed surfaces (relative risk = 1.93; 95% CI, 1.12–3.33) at 36 months. The time for decayed (enamel and dentin) lesions to develop was significantly longer in the erythritol group compared to the other groups. Over the 36-month time period, 4.6% of tooth surfaces in the erythritol group developed enamel or dentin caries compared with 5.8% in the xylitol group and 5.5% in the sorbitol group (p < 0.001).
Conclusions The authors concluded that after 24 and 36 months, erythritol candies reduced the number of decayed teeth and surfaces in the mixed dentition compared with the xylitol and sorbitol candies. Further, the time for the caries lesions to develop was longer for children who consumed erythritol candies, and sorbitol had a better caries-preventive effect than xylitol.
COMMENTARY AND ANALYSIS The reviewed study addressed a need to test the efficacy of daily consumption of erythritol and xylitol candies, compared with sorbitol candy, on the development of enamel and dentin caries lesions among high-risk school children. The authors provided an informative rationale for the trial. The methods were described well, and the statistical analyses seemed reasonable. The compliance in the study was assumed to be good; however, no data on compliance are presented. A conflict of interest existed with the sponsoring manufacturer of the tested products. The positive caries preventive effect of xylitol chewing gum has been reported in several studies, but interpretation of the data has been controversial, mostly because of variations in study designs, outcomes, or formulations/ doses tested.1 To reduce the confounding effect of chewing and increased saliva flow from chewing, caries trials using candies to test the effect of sugar alcohol are justified. Xylitol candies or lozenges have shown some potential in reducing caries; however, existing studies have been shown to have bias or heterogeneity or are sparse.2 In a previous study by Honkala et al.,3 xylitol candies reduced decayed surfaces in disabled school students compared with a control group (no candy). In a study of Estonian schoolchildren, a daily dose of 5 g of xylitol candy resulted in a caries reduction of about 50% compared with a control (no gum or candy).4 In a study by Lenkkeri et al.,5 xylitol/maltitol or erythritol/maltitol 186
lozenges did not have a caries-preventive effect, but the children in that study had a low risk for caries. According to the evidence-based recommendations of the American Dental Association, the daily use of xylitol-containing lozenges or candies (5–8 g/day in 2–3 doses) may reduce the incidence of coronal caries in children; however, the level of evidence is ‘‘expert opinion’’ because of the limited number and quality of available studies.6 Although the erythritol group in the reviewed study had statistically less enamel and dentin caries over the 36-month study period, the clinical significance is questionable. As stated by the study authors, all the children received health education and dental treatment, and few dental lesions developed in all groups. Further, their results suggested that sugar alcohols did not have the preventive effect previously claimed or that the dose and frequency in this study were not effective enough. Even though the reviewed study was cluster randomized, differences in the caries determinants between the schools may have had a confounding effect on the outcome, especially if the sample size was too small to invalidate the confounding effect. In the reviewed study, xylitol and sorbitol groups had more children in the younger age group (
