Dental Issue

Toothfriendly

NEWSLETTER OF TOOTHFRIENDLY INTERNATIONAL

Expert opinion: Xylitol is not a magic bullet

2/2009

toothfriendly chocolate

Belgians whip up first

Future of caries prevention: fluoridation, diet, education?

Sweet, sweeter, intense sweeter?6 10 Swiss kids groups

for healthy eating

FIRST PACIFIER

APPROVED AS TOOTHFRIENDLY

TOOTHFRIENDLY NEWS is the an-nual newsletter of the non-profit association Toothfriendly International

Toothfriendly International is dedicated to improving oral health by promoting non-cariogenic dietary habits and oral hygiene.

TOOTHFRIENDLY INTERNATIONALBundesstrasse 294054 Basel - Switzerland

Tel: +41 61 273 77 07Fax: +41 61 273 77 [email protected]

PresidentProf. Bernhard Guggenheim

Executive DirectorDr. Albert Bär

Project Manager, EditorKati Leskinen

Germany: Hedi von BerghSwitzerland: Corinne VoisardTurkey: Selda AlemdarThe Netherlands: Lisette De Jong

SCIENTIFIC ADVISORY BOARD:

Prof. Thomas ImfeldUniversity of Zürich

Prof. Lutz StösserUniversity of Jena

Prof. Cor van LoverenUniversity of Amsterdam

Prof. Elin GiertsenUniversity of Bergen

The Happy Tooth logo is one of the most widespread quality seals in the world - it is currently used on more than 100 confectionery brands worldwide.

Nearly thirty years ago Swiss dentists were looking for a symbol which would easily guide consumers to guaranteed toothfriendly products. One particularly creative dental technician came up with the design for the Happy Tooth logo: a sympathetically smiling tooth under a protective umbrella.

Today, the Happy Tooth is a paradigm for effective, globally-recognized health communica-tions. Successful confectionery brands such as Mentos or Smint use the Happy Tooth logo for a simple reason: its message is easy to understand by all consumers - also on international product labels.

The Happy Tooth is currently the only quality symbol for confectionery which is based on a recognized scientific test. This is also the reason why the Happy Tooth symbol is expected to be included in the list of accepted claims under the EU Health Claims Regulation. The new Europe-wide rule defines what constitutes legitimate nutrition and health claims, posing a challenge to the legitimacy of many commonplace claims such as “with xylitol” or “anti-cari-ogenic”.

Like regulators, also dentists would find life easier if there was a symbol for healthy eating they can trust. That is why many of us keep the dietary advice to patients as simple as pos-sible: when buying sweets, look for the Happy Tooth logo.

Prof. Stefan ZimmerUniversity of Witten/Herdecke, Germany

Prof. Stefan Zimmer teaches at the Univer-sity of Witten/Herdecke. He is also a Board Member of Toothfriendly International.

Editorial

Introducing the world’s most sympathetic tooth

2 Toothfriendly News 2/2009

Efficacy of a Novel Pacifier in the Prevention of MalocclusionS. ZIMMER*, R. LJUBICIC, M. BIZHANG, W. H.-M. RAAB Dept. of Operative and Preventive Dentistry and Endodontics Heinrich Heine University Duesseldorf, Germany

Objectives: To evaluate the efficacy of a novel pacifier in preventing malocclusion.Methods: In the University Hospital of Duesseldorf/Germany, 129 new born children whose parents had decided to use pacifiers were randomly attrib-uted to two experimental groups (D=Dentistar, n=56, Novatex, Pattensen, Germany; N=NUK, n=73, Mapa, Zeven, Germany). Parents were advised to use only the allocated pacifier. Children (n=42) who did not use a pacifier served as control (C). Exclusion criteria were preterm birth (<8th month pregnancy), congenital maxillofacial defects and systemic diseases of the infant. At an age of 10 - 26 months, the children were re-examined (operator blind) with re-spect to occlusion and existence of an anterior open bite. SPSS 15.0 served for statistical analysis. Results: 121 toddlers (66 female, 55 male) were included in the final analysis (D: n=43; N: n=42; C: n=36). The mean age was 15.9 (SD 3.9) months (D=17.0; N=15.3; C=15.4, ANOVA: n.s.). In group D two children (4.7%) showed an anterior open bite. The respective values were 16 (38.1%) for N and 0 for C. The incidence of open bites was significantly less in group D and C when compared to N (chi2-test, p<0.001). No significant difference was found between D and C. Normal occlusion (Angle’s class I) was found in 35 (81.4%) subjects in group D, 14 (33.3%) in N, and 31 (86.1%) in C. The incidence of normal occlusion was significantly higher in group D and C when compared to N (chi2-test, p<0.001), but not significantly different between D and C. Conclusion: In comparison to a commonly used pacifier, the novel one may prevent the occurrence of anterior open bites and may lead to a higher incidence of normal occlusion in 16 months old children.

Dentistar - a five-star pacifier for baby teeth

Dentistar has a unique spoon-like shape which leaves more space for the tongue than any conventional pacifier on the market,. The rub-ber neck of the pacifier is thin and shaped according to a child’s natural bite. This special design allows the front teeth to develop without any significant misalignments, and pro-motes the natural jaw development.

German pacifier manufacturer Novatex has developed the first pacifier with no known detrimental effect on teeth and jaw develop-ment. The pacifier named as “Dentistar” has been granted the recognized ‘Happy Tooth’ quality seal from the dental experts of Tooth-friendly International. A comparative 2-year study with 129 newborn children conducted at the Heinrich Heine University of Düssel-dorf shows that children using Dentistar have a normal occlusion and do not develop anterior open bites which often develops as a consequence of the continued use of a tra-ditional pacifier.

“Dentists welcome the first toothfriendly pacifier”, says Dr. Albert Bär of Toothfriendly International. “In comparison to regular pa-

cifiers, Dentistar has a special, flat design which helps prevent dental misalignments.”

Pacifiers have long been a source of debate among dentists. Experts agree that consist-ent sucking habit may cause dental abnor-malities if continued after the age of two.

Dr. Bär points out that pacifiers are contro-versial items not only for dentists but for many parents as well. “Studies show that more than half of mothers worry that paci-fiers may cause bucked teeth. And yet, paci-fiers have also undeniably positive effects. Most significantly, pacifiers havebeen shown to decrease the risk of Sudden Infant Death Syndrome. It is unrealistic and pointless to ban all pacifiers.”

First toothfriendly pacifier obtains dentists endorsement

PRODUCT OF THE MONTH

Toothfriendly News 2/2009 3


“We are delighted to see that Dutch con-sumers find the ‘Happy Tooth’ symbol so at-tractive”, says Kati Leskinen of Toothfriendly International. “If consumers began to check confectionery labels and choose products which are guaranteed toothfriendly, it would help cut down the frequency of sugar con-sumption”.

The Happy Tooth symbol was introduced in 1982 as an initiative of Swiss Dental In-stitutes. The aim of the Happy Tooth logo is to enable easy recognition for guaranteed toothfriendly products. Toothfriendly Inter-national was established in 1989 as a second stage of the campaign to encourage confec-tionery manufacturers create healthier alter-natives for sugar confectionery.

Today, more than 100 brands worldwide carry the symbol, including confectionery, medicinal products, beverage and oral care products. Most products with the Happy Tooth logo can be found on the Swiss mar-ket, where the logo enjoys a spentaneous awareness of 83% across the population.

The first soft drink to make an explicit con-nection to healthy teeth are introduced in March in Switzerland. Swiss Migros is world-wide the first retailer to roll out a toothfriend-ly ice tea. The product is nearly acid-free and sweetened with isomaltulose, a novel sugar which is kind to teeth. Plaque pH-tests at the University of Zurich demonstrated that the ice tea has no risk for caries, as it does not de-press the plaque-pH below the critical level of 5.7. It also does not promote dental ero-sion.

““A non-erosive soft drink is a real innova-tion.”, says Dr. Albert Bär of Toothfriendly International. He points out that until now, most attempts to develop toothfriendly bev-erages have failed – mainly due to excessive acidity. Acids which are commonly used in soft drinks for taste and for ensuring micro-bial stability have a demineralizing effect on the tooth surface which may develop to den-tal erosion.

Happy Tooth logo helps identify toothfriendly products, say consumers

First non-erosive soft drink on the market

Nine in ten (86%) consumers say the ‘Happy Tooth’ logo would help them to easily iden-tify guaranteed toothfriendly products, ac-cording to consumer survey conducted in Utrecht, the Netherlands.

Most consumers (95%) find that the ‘Happy Tooth’ logo has a self-explanatory design which ensures that even illiterate children understand the meaning of the eye-catching symbol. Nine out of ten respondents say that the quality seal should be plcaed on the front label rather on the back-side of a packaging in order to enable easy recognition.

News

Consumers opt for sugar-free candy worldwide, say market researchSugar-free candies are up 18 per cent in the UK as health conscious consumers continue to opt for toothfriendly alterna-tives., according to recent AC Nielsen market figures. Since 2007, sugarless sweets have risen by 18 percent in the UK, bringing the market to 11 per-cent, while the sales of sugary candy fell by 5 percent.

Sugar-free sales in Italy and Australia have increased by 9 and 10 percent respectively. Worldwide, Spain has the larg-est sugar-free market with 50% of the candies sold containing no sugar.

Toothfriendly Resource Packs up for grabsToothfriendly International of-fers dental practices free edu-cational material and product samples to support the Oral Health Month initiative. The resource pack contains patient leaflets and a yummy selection of sugar-free freebies. To claim your free pack, please send your name, job title and delivery ad-dress at [email protected]


British Dental Conference

Belgians whip uptoothfriendly chocolate

Dieticians launch healthy food wheel for kidsEveryone knows Food Pyramid, the visual guide to remember the healthiest foods to eat. Swiss dieti-cians have now modified the pyra-mid into a wheel targeted at 5-12-year-old kids. The wheel shows at a glance the principles of healthy eating. It gives tips also for parents and educators. The wheel can be downloaded at www.sge-ssn.ch

Here at Toothfriendly International, we have already started ticking off the days on our calender until the next British Dental Conference, which takes place in Glasgow from 4th to 6th June 2009.

The theme for UK’s major dental event of 2009 is ‘Securing your future; real-ising your potential’ and will feature motivational, expert speakers who will inspire you to develop new ideas and grow your career.

There will be a range of sessions focus-ing on career paths, setting up in prac-tice, and business planning. If you are thinking of diversifying into areas such as botox, whitening, smoking ces-sation and implants, the workshops will help you explore opportunities in these areas.

Meet the Toothfriendly team also at:

IDS Dental ShowCologne - 24-28 March 2009

Sino-DentalBeijing - 10-13 June 2009

International Pediatric Dental CongressMunich 17-20 June 2009

FDI World Dental CongressSingapore - 2-5 September 2009

Running alongside the comprehen-sive conference programme will be the popular exhibition, which is set to be the largest yet.

Toothfriendly International has a stand (C 28) at the event - you can meet our team, pick up toothfriendly samples and patient leaflets, as well as learn about new products.

The 2009 exhibition will take place in the Scotish Exhibition and Confer-ence Centre’s largest hall, Hall 4. This is set to be our biggest Exhibition to date and with increased numbers of delegates attending year on year we anticipate this year to be buzzing full of excitement. The exhibition hall will contain a variety of caterng points, feature areas, exhibition hall seminars and an internet cafe.

It looks like chocolate, it tastes like choco-late, and it is chocolate – but it wont rot your teeth. Two Belgian chocolate specialists, Chocolaterie Smet and Daskalides, have just launched the first toothfriendly chocolate products. Also Barry Callebaut, the world’s largest chocolate manufacturer, knows the secret of dentist-friendly chocolate.

“Toothfriendly chocolate is sweetened with isomaltulose”, explains Marijke De Brouwer, Innovation Officer at Barry Callebaut. “Iso-maltulose belongs to the same group of sug-ars as sucrose. However, the bacteria in the mouth cannot use isomaltulose as a source of energy. Unlike sucrose, isomaltulose does not promote cavities.”

So a different type of sugar is the secret of toothfriendly chocolate. But does it taste any different?

“In our blind tests 82% of the kids said they liked it a lot”, says De Brouwer. “But I think the only proof that they really like something is when they ask for a second piece. And they did”.

The first two toothfriendly chocolate prod-ucts are now available in Belgium. Choco-laterie Smet is producing a range of hollow chocolate figures, while peer Daskalides has developed toothfriendly chocolate bars with hazelnut filling. Both products have been ap-proved by Toothfriendly International, and both carry the Happy Tooth quality seal.

“We only give the Happy Tooth seal of ap-proval to products which are guaranteed safe for teeth”, says Dr. Albert Bär of Tooth-friendly International. “All products which carry this logo have been tested by academic institutes for oral health.”

News


Sweet , sweeter, intense sweetener?A glance at the supermarket shelves indicates that “sugar-free” is becoming a standard in several product categories. Sugar substitutes are better for teeth, waistline and blood sug-ar levels, claim food manufacturers. Consum-ers often tend to think that sugar substitutes are something “artificial” – yet they provide many benefits to sugar, at least in confec-tionery and soft drink categories.

People have an inborn desire for sweet taste, one of the four fundamental taste sensations. Honey and fruits have long been sought out for their sweet taste; however, since it was first refined some 600 years ago, table sugar (sucrose) has been the standard for sweet-ness. Until recent decades, sucrose was vir-tually the only sweetener in general use. After the second world war, other alternative sweeteners became popular, first among diabetics and later on by calorie-conscious consumers.

Sugar substitutes hit the mainstream in the early 1960s with the introduction of first sugar-free chewing gum in the Unites States. In 1963, Coca Cola introduced the first sugar-free soft drink sweetened with cyclamate. In 1980s, the discovery of new, improved sugar substitutes fuelled the development of sug-ar-free lozenges, mints and candies. Today, nearly 100% of all chewing gum and over 10% of sweets sold in the UK are sugar-free.

Food manufacturers have long noticed that not only diabetics avoid eating sugar. Sugar and other carbohydrates have become a cul-prit for many health enthusiasts following a low-carb or low glycemic diet.

Sugar is also closely associated with dental cavities. According to a recent survey, most young consumers choose sugar-free sweets and chewing gum for oral health reasons - and not so much for the lack of calories.

Are sugar substitutes safe for teeth and good for the waistline, or best avoided? Kati Leskinen lays down the facts and fiction of toothfriendly sweeteners.

Nearly twenty different sweeteners are cur-rently authorized by the European Food Safety Authority (EFSA) for food production. Consumers often regard sugar substitutes as one homogenous group of “artificial sweet-eners”. In reality, sugar substitutes differ from each other by origin, chemical composition, sweetness, energy value and physiological properties. Also the glycemic index (GI), i.e. the ability to increase blood sugar level, var-ies greatly.

Sweetening agents can be devided into two main categories: polyols (bulk sweet-eners) and intense sweeteners. Polyols are carbohydrates, but unlike sugar, they are digested more slowly. They usually replace sugar in products with a ratio of about 1:1. The most common polyols used in the food production today are sorbitol, isomalt, malti-tol, mannitol and xylitol. They all have little impact on blood sugar or insulin levels, and provide less than half the calories of sucrose. The oral bacteria cannot ferment polyols, which makes them an ideal ingredient for toothfriendly sweets, chewing gum, tooth-pastes and mouth washes.

Like beans, prunes and other high-fibre foods, polyols are good for the digestive health when eaten in moderate amounts. When consumed in excess, polyols can cause discomforts such as flatulence or upset stomach. The reaction resembles an over-consumption of high-fibre foods, and is, despite its inconvenient nature, harmless for the body. An amount of 25-50g of polyol-containing products consumed throughout the day is normally well tolerated.

Intense sweeteners provide sweet taste with-out calories, or with very few calories. Due to their high sweetness intencity, only minimal amounts are needed. All intense sweetenes are non-cariogenic, i.e. safe for teeth.

The first intense sweetener, saccharin, was discovered in 1878. Since then, a number of other sweeteners including cyclamate, as-partame, acesulfame K, neohesperidine DC, thaumatin, sucralose and alitame have been

produced and used around the world, all with their own variations in terms of taste, mouthfeel and sweetness intensity.

Sucralose is one of the fastest growing in-tense sweeteners on the market today. It is a non-nutritive sweetener, which is 600 times sweeter than sugar. It is the first, and cur-rently only intense sweetener that is actually derived from beet sugar. Sucralose is now being used across a broad spectrum of food and beverage products.

In Europe, the European Food Safety Au-thority (EFSA) is controlling the safety of all sweeteners used in food production. No food additive, such as an intense sweetener, may used in food products without a strin-gent safety assessment and approval by the European Comission. The levels of intense sweeteners used in food products are based on an accepted daily intake level set by EFSA. The level is 100-fold lower than the safe dose demonstrated in studies. This conservative measure makes sure that even a frequent, daily consumption of products containing intense sweeteners is safe.

“All intense sweeteners are non-cariogenic, i.e. safe for teeth.”

More infromation on polyols:Calorie Control: www.caloriecontrol.org European Association of Polyol Producers www.polyols-eu.com Maltitol: www.maltitol-maltisorb.roquette.com Isomalt: www.beneo-palatinit.com Erythritol: www.cargillsweetness.com

More infromation on intense sweeteners:www.sweeteners.org www.aspartame.net www.sucralose.com www.acesulfamek.org www.food.gov.uk/safereating/chemsafe/additivesbranch/sweeteners/

Toothfriendly sugars?In addition to polyols and intense sweeten-ers, a third group of so-called non-cariogenic sugars has emerged. Isomaltulose and taga-tose are examples of toothfriendly sugars de-rived from beet sugar and milk sugar, respec-tively. Since isomaltulose is relatively readily digested to glucose and fructose, which are absorbed, this sugar has a higher intestinal tolerance than the polyols. Tagatose has the advantage of providing less calories and hav-ing a much lower GI value than sucrose.

What is...

Sugar-free? Products which contain max-imum 0.5g sugars may be labelled as sugar-free. Note: The claim “sugar-free” does not automatically mean that a product is safe for teeth. Sugar.-free foods with high quan-tities of acid can attack dental enamel and cause erosion.. Especially many sugar-free “diet” beverages - such as light soft drinks - contain high amounts of citric aciic.

Toothfriendly? A product can be called “toothfriendly” if it is neither cariogenic nor erosive. These “toothfriendly” properties are determined by a standardized in vivo plaque pH-telemetry test. Only products with the “Happy Tooth” symbol are guaran-teed toothfriendly, as they have undergone a stringent telemetry testing procedure.

SWEETENERS

SUGARS POLYOLS INTENSE SWEETENERS

SucroseGlucoseFructoseLactoseMaltose

IsomaltoseTagatose

XylitolSorbitolIsomaltMaltitolMannitolErythritolLactitol

Cariogenic

Tooth-friendly

Cyclamate AspartameAcesulfame-KNeohesperidine DCSucraloseSaccharinThaumatinAlitame

Source

Caloric value

Source Source

Caloric value Caloric value

Tooth-friendly

Tooth-friendly

Derived from beet sugar, corn, milk sugar, fruits

Derived and processed from sugar beet, corn, malt, wood pulp

Chemically processed from acids. Only sucra-lose is processed from sugar beet.

Sucrose and fructose around 4 kcal/g, others 2-3 kcal/g.

Erythritol has a ca-loric value of 0 kcal/g, others 1-3 kcal/g.

Properties Properties

As intense sweeteners are used in minimal amounts, they provide practically 0 calories.

- Toothfriendly- Suitable for diabetics- Less calories - Low GI- Excessive consump-tion (>50g) may cause laxative effects

- Toothfriendly- Suitable for diabetics- No calories- Low GI- No laxative effects

PropertiesSugars are a good source of energy, but should not be con-sumed in excess. Isoma-ltulose and tagatose are toothfriendly, all other sugars are cariogenic.



Xylitol in caries prevention: is it a magic bullet? Confec t ioner y manufac turers around the wor ld c la im that x y l i to l -sweetened chewing gum reduces the r isk of tooth decay. Whi le i t ’s general ly recognized that x y l i to l i s an excel lent , non- car iogenic a l ternat ive to sucrose, sc ient ists remain scept ical about x yl i to l ’s therapeut ic ef fec t on teeth. Three dental profess ionals take a cr i t i -ca l look at how the consumption of x y l i to l may - or may not - benef i t ora l health .

Prof. Bernhard Guggenheim, University of Zurich.

There is a consensus that the use of poly-ols may have contributed to the decline of dental caries in many industrialized countries. As polyols are not fermented by the oral bacteria, they do not pro-mote caries. In addition, the enhance-ment of salivary flow when eating chew-ing gum, toffee, hard candies or similar confectionery sweetened with polyols, will favourably affect the remin / demin balance of the tooth surface.

Xylitol is often referred to as a superior polyol due to an alleged anti-cariogenic effect. However, comparative clinical studies have demonstrated that there is no sufficient evidence to support a supe-riority of xylitol.

Neither xylitol nor any other polyol has been shown to have an anti-caries ef-fect. The caries reductions which were observed in studies can rather be as-cribed to a reduced frequency of sugar exposure or saliva stimulation.

Prof. Vita Machiulskiene, University of Kaunas, Lithuania.

All sugar alcohols have proven to be hypo- or non-acidogenic in in-vitro tests. Those findings have stimulated in-tensive research on their possible caries preventive effect in clinical conditions.

Xylitol has often been claimed to pos-sess anti-caries properties, due to its anti-microbial potential. However, from a number of clinical studies using differ-ent treatment protocols, there is no suf-ficient evidence to support neither the superiority of xylitol, nor the direct ther-apeutic effect of any polyols. In fact, the caries-preventive effect of toothfriendly chewing gums may be related to the chewing process itself rather than any added “active” ingredients.

This conclusion is in agreement with the reports of the Scientific Committee on Medicinal Products and Medical De-vices of the EU Commission.

Prof. Lutz Stösser, University of Jena, Germany.

Under laboratory conditions, some dif-ferences in the fermentability of polyol sugar substitutes by micro organism of the dental plaque may be observed. For example, xylitol is not converted to organic acids to any significant extent and may even exert some inhibitory ef-fects on certain micro-organisms.

Sorbitol, on the other hand, may be fer-mented slowly over several hours. How-ever, such differences have no practical consequences as shown by comparative studies with measurement of plaque pH in human volunteers. Under real life conditions, the contact time between ingested polyols and teeth is too short to allow for any relevant acid formula-tion or for anti-plaque effects. In view of these findings and the absence of dif-ferent caries incidence in comparative human studies with xylitol and sorbitol, there is no evidence of an outstanding preventive effect of xylitol in compari-sion with other polyols.

FDI World Dental Federat ion Pol icy Statement : “ The ant i car iogenic e f f e c t o f po lyo l s has ye t to be suppor ted by ev idence-based data . However, the enhancement o f sa l ivar y f low may have a car i e s -preventat ive e f f e c t .”

Toothfr iendly International : “ Whether the product contains any so-ca l l ed “ac t ive” ingredient s – e .g . x y l i to l – i s much l e s s impor tant than the fac t that the recommended product i s guaranteed too th fr i endly. The e s s ence o f a l l denta l d ie tar y advice i s to cut down the f requency o f sugar consumption.”

Expert Opinion


The statement “100%-xylitol chewing gum reduces the risk of caries” is somewhat mis-leading. While certain studies point out that caries risk reduction can be obtained by con-suming 2 – 3 g of chewing gum sweetened with 100% xylitol at least three times per day after the meals, a fair amount of clinical stud-ies point out that the same beneficial effect can also be obtained with other non-cari-ogenic sugar substitutes.

The World Dental Federation (FDI) has adopted a new Policy Statement on sugar substitutes and their role in caries preven-tion saying that “the regular use of chewing gum containing non-cariogenic sweeteners such as xylitol, has a role to play in prevent-ing dental caries because of its non-cari-ogenic nature and its salivary stimulatory effect”. The policy also states that “enhance-ment of salivary flow when using chewing gums may have a caries-preventive effect” and “non-cariogenic sugar substitutes when used in products such as confectionery, chewing gum and drinks, reduce the risk of dental caries”. However, with regard to xylitol it maintains that “the anticariogenic effect of the sugar substitutes themselves has yet to be supported by evidence-based data”.

The new FDI Policy statement is fully in line with scientific reviews and meta-analyses of the scientific literature by renowned ex-perts in cariology (e.g., Imfeld, 1994; Moss, 1999; Van Loveren, 2004; Mickenautsch et al., 2007; Zero, 2008; Stookey, 2008). Of course, as always in science, there are reviews which deviate somewhat from the majority view in one or the other direction (e.g. Lingström et al., 2003; Burt, 2006).

Position of the dental profession: reduce the sugar consumption

The prevailing opinion in the dental profes-sion is that chewing gum and other confec-tionery products which are formulated with non-fermentable ingredients, reduce the risk of caries because they typically substitute for the consumption of corresponding prod-ucts which are sweetened with sucrose or sucrose/glucose mixtures. The caries reduc-tions, which were observed in studies with sugar-free chewing gum and candies would, therefore, be the consequence of a reduced sugar intake rather than an active interfer-ence with caries formation.

Furthermore, it is thought that the stimula-tion of salivary flow due to the consumption of confectionery promotes the reminerali-zation of the surface layer of dental enamel during periods in which the pH of the dental plaque and the oral fluid stays above the crit-ical value of 5,7. And finally, the consumption of sugarfree chewing gum and candies after meals will accelerate the clearance of dietary carbohydrates from the oral cavity and the neutralization of the dental plaque by stimu-lation of the salivary flow.

The results of the human intervention stud-ies in support of the caries risk reduction claim of chewing gum with 100% xylitol, are completely in line with this combined sugar substitution/saliva stimulation mechanism of caries prevention. So far, not a single study provides hard data on the frequency of sugar consumption in the treated groups and con-trols which would invalidate the sugar sub-stitution/saliva stimulation mode of action of chewing gum with 100% xylitol.

The caries risk reduction claim for chewing gum with 100% xylitol suggests to consum-ers that other similar products with a lower content of xylitol or with other polyols have inferior properties. In the light of current ex-pert opinions, this is wrong and indeed mis-leading.

The caries risk reduction claim for chewing gum with 100% xylitol suggests to consum-ers that other similar products with a lower content of xylitol or with other polyols have inferior properties. In the light of current ex-pert opinions, this is wrong and indeed mis-leading.

Conclusions

Any caries risk reduction claims for chewing gum with 100% xylitol bears a significant risk of being misinterpreted as demonstrat-ing that xylitol exerts an anti-cariogenic ef-fect. Whether sugar-free chewing gum and sweets contain any so-called .”active” ingre-dients - e.g. xylitol - is much less important than the fact that the recommended prod-uct is toothfriendly. The essence of all dietary advice is to cut down the frequency of sugar consumption.

There are, as of today, no c lear data to suppor t the concept that x y l i to l possesses speci f ic ef fec ts in v ivo which val idate a supe -r ior i t y over other polyols , says Dr. Alber t Bär of Toothfr iendly I nternat ional .

Why the ‘xylitol gospel’ is misleading consumers

References:Burt B.A. (2006). The use of sorbitol- and xylitol-sweetened chewing gum in caries control. JADA 137: 190-196.

Imfeld T.N. (1994). Clinical caries studies with polyalcohols. Schweiz. Monatsschr. Zahnmed. 104: 941-945.

Lingström P., Holm A.K., Mejàre I., Twetman S., Söder B., Norlund A., Axelsson S., Lägerlöf F., Nordenram G., Petersson L.G., Dahlgren H. and Källestal C. (2003). Dietary factors in the preven-tion of dental caries: a systematic review. Acta Odontol. Scand. 61(6): 331-340.

Mickenautsch S., Leal S.C., Yengopal V., Bezerra A.C. and Cruvinel V. (2007). Sugar-free chewing gum and dental caries – a systematic review. J. Appl. Oral Sci. 15(2): 83-88.

Moss S.J. (1999). Xylitol – an evaluation. Int. Dent. J. 49: 00-00.

Stookey G.K. (2008). The effect of saliva on dental caries. JADA 139: 11S-17S.

van Loveren C. (2004). Sugar alcohols: what is the evidence for caries-preventive and caries-therapeutic effects? Caries Res. 38: 286-293.

Zero D.T. (2008). Are sugar substitutes also anticariogenic? JADA 139: 9S-10S.

About the author:Dr. Albert Bär received his Ph.D. in biochemistry from the Swiss Federal Institute of Technology (ETH) in 1974. Prior to forming Bioresco Ltd. in 1986, Mr. Bär served for six years as Director, Re-search and Development, at Xyrofin Ltd and the Finnish Sugar Ltd. He is the author of numerous scientific publications. He is also the director of the non-profit association Toothfriendly International.

Xylitol was derived from Finnish birch wood only in the very early days of xylitol production. Today it is manu-factured mainly from corn cobs and other liquidified agricultural waste material.

teacher received story books and other ma-terial to make teeth a topic even with small children. Most imprtantly, however, each play group teacher is committed to promote healthy snacks - especially fruits, veggies and wholemeal sandwiches - in the group. Sug-ary snacks are consequently forbidden in the lunch boxes - except on special occasions.

“Toothfriendly”-certified educators work ac-cording to following principles: 1) They inform parents about the importance of caries prevention 2) They sensitize kids with books, games and songs 3) They promote toothfriendly snacks

“By the end of 2008, we have carried out more than 20 training courses throughout the country, and certified more than 200 groups”, says Voisard. “That makes altogether thousands of children and their parents who have been reached with the positive mes-sage of early childhood caries prevention.”

Not only dentists praise the project, but also the Swiss Association of play group teachers (SSLV) takes a positive stock of the project work. “Our women have been highly moti-vated to take part in the education courses”, says Anna Lustenberger, a Board Member of SSLV. “Healthy eating is an ongoing concern in our society, and it has been a revelation for many of us to learn that what is good for the teeth is also often good for the whole body. So not only the teeth have benefited from this project.”

O ver 5000 k ids across Switzer land are par t ic ipat ing in the Toothfr iendly Playgroup program to help f ight chi ldhood cavit ies and promote healthy l i fest y le among chi ldren. The educat ional campaign encourages chi ldren, parents and educators to adopt healthier snack ing habits .

Tips and tricks to promote toothfriendly snacks

HOW MANY SUGAR CUBES are in...

1 glas of cola drink 9100g of chocolate 191 chocolate snack bar (45g) 141 cup of fruit yogurt 91 spoon of jam 2.51 spoon of cacao 2.53.3 dl orange juice 93.3 dl apple juice 105 dl Ice Tea 9.52.2 dl flavoured milk 81 probiotic drink (125ml) 410 g ketschup 0.660 g sugared cereals 100,25 l ice cream 2025 g cacao-nut cream 51 sugary candy 2

Note: Sugar is not “bad” per se. The prob-lem emerges only when sugar becomes a staple in a child’s diet, replacing healthy foods that contain vital nutrients.

While youth caries rates have declined sig-nificantly since peaking in the mid-1970s, recent Swiss surveys found that over the past two years this progress has been stalled and may even have reversed in the toddler age group. In the city of Zurich already 13% of 2-year-old children have cavities. In 4% of tod-dlers all four incisors were rotten and had to be removed.

Such statistics served as a wake-up call for the Swiss Toothfriendly Association (Aktion Zahnfreundlich) which decided to kick off a new project targeted at the nation’s play groups consisting of kids aged 3-5 years.

“The aim is to create a long-term campaign which is fitted to the needs and abilities of small children”, explains Corinne Voisard, Project Manager of the association. “Swit-zerland has excellent school-based caries prevention, but not much has been done to reach younger children and their parents. However, caries prevention should begin as early as the first teeth erupt.”

The preliminery aim of the project was to cut down the frequency of sugary snacks eaten by small children. “Many parents are shocked to hear how many cubes of sugar many popular snacks contain”, says Voisard. “Juices and muesli bars are promoted as healthy, yet they may carry surprising amounts of sugar.”

The first step of the project was to offer vol-untary training courses on oral health proph-ylaxis to play group teachers. In addition to diverse course material, each playgroup

Visualise the amount of hidden sugar in most snacks by piling up the amount of sugar. Make a snack game by cutting pictures of healthy and unhealthy snacks, and gluing them on a piece of carton. Slice vegetables and fruits in funny shapes, make “cars” out of carrots or “elephants” out of mandarines. Browse magazines with children; look for advertisements of healthy and un-healthy snacks and make a collage of best pictures. Read product labels of common snacks and spot the amounts of hidden sugars.

Top project

Kids for carrots


Last word

Future of caries prevention Despite great improvements in ora l health , dental car ies remains a chal lenge par t icular ly among the underpr iv i leged populat ion groups. We asked three Swiss exper ts what they see for the future of car ies prevent ion.

Prof. Thomas MarthalerUniversity of Zurich (Emeritus)

Research and practical experience demonstrates that dental caries can be prevented effectively through estab-lishment of fluoride programmes. Wa-ter fluoridation, salt fluoridation, milk fluoridation and use of affordable fluor-idated toothpastes play a major role in caries prevention also in future.

I personally consider salt fluoridation a beneficial, safe and extremely cheap public health measure, particularly for developing countries. The cariostatic ef-fectiveness of fluoridated salt is equiva-lent to that of water fluoridation when implemented on a community base. The cost-benefit ratio is even better than that of water fluoridation. In many countries, the cost of introducing and running salt fluoridation was so low that many producers did not even raise the price of fluoridated salt.

All that is needed is political willpower and the unanimous support of the na-tion’s dental profession.

Dr. Albert BärToothfriendly International

The fact that dental caries is still wide-spread is not only the result of inad-equate exposure to fluorides, but also a consequence of growing sugar con-sumption. An especially relevant – and often forgotten – factor is the increas-ing frequency of sugar exposure.

For many years the simplified message to prevent tooth decay was ‘don’t eat sweets’. This advice is unrealistic and too simplistic. Small amounts of sugar and other fermentable carbohydrates eaten frequently during the day will increase caries risk more than large amounts eaten infrequently.

Positive dietary advice stresses the fact that foods that we nibble or sip often – such as sweets or soft drinks – should be replaced by toothfriendly alterna-tives. The good news is that the food industry has made great progress in the past 20 years: there is a wide range of toothfriendly confectionery available, without compromising on taste.

Esther MartinetOral Health Instructor

The Swiss model of school-based oral health education demonstrates the ef-fect of classroom prophylaxis. In the past 40 years, the consequent fluoridation and tooth brushing instruction done at Swiss primary schools has helped reduce the number of cavities found in 12-year-olds by 90%. Additionally, the preventive measures have spared the Swiss tax payers more than 250 Million Euro in dental costs annually.

Partly due to influx of foreigners, the car-ies prevalence of kindergarten children and those of 1st level primary school has increased lately. This fact draws at-tention to the significance of a uniform, continuous and systematic prevention.

In most industrialized countries, the need for qualified oral health educators will increase. In the case of Switzerland, the education of oral health instructors is expected to undergo a major revision, with the aim of professionalizing the education of the nation’s school-based oral health instructors.

Fluoride: “Salt fluoridation is a beneficial and cost-effective strategy for developing countries.”

Dietary habits: “Sugar should not be bedevilled - consum-ers are likely to follow positive advice.”

Education: “Oral health education in schools saves tax payers money.”


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