Xylitol‐containing products for preventing dental caries in children and adults

Philip Riley; Deborah Moore; Farooq Ahmed; Mohammad O Sharif; Helen V Worthington

doi:10.1002/14651858.CD010743.pub2

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Adults: xylitol lozenges versus control lozenges, Outcome 1 Caries increment at 33 months follow‐up (DFS).

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Analysis 2.1

Comparison 2 Children: xylitol lozenges versus no treatment, Outcome 1 Caries increment at 4 years follow‐up (DMFS).

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Analysis 2.2

Comparison 2 Children: xylitol lozenges versus no treatment, Outcome 2 Number with caries increment at 4 years follow‐up (as opposed to none/no change).

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Analysis 3.1

Comparison 3 Children: xylitol topical oral syrup versus control syrup (very low dose xylitol), Outcome 1 Number of decayed primary teeth at 1 year follow‐up.

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Analysis 4.1

Comparison 4 Children: xylitol sucking tablets versus no treatment, Outcome 1 Caries increment at 2 years follow‐up (dmfs).

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Analysis 4.2

Comparison 4 Children: xylitol sucking tablets versus no treatment, Outcome 2 Number with caries increment at 2 years follow‐up (as opposed to none/no change).

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Analysis 5.1

Comparison 5 Children: xylitol plus fluoride toothpaste versus fluoride toothpaste, Outcome 1 Caries increment at 2.5 to 3 years follow‐up (Prevented Fraction).

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Analysis 5.2

Comparison 5 Children: xylitol plus fluoride toothpaste versus fluoride toothpaste, Outcome 2 Caries increment at 2.5 to 3 years follow‐up (DFS).

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Analysis 6.1

Comparison 6 Children: xylitol tablets versus control (sorbitol) tablets, Outcome 1 Number with caries increment at 4 years follow‐up (as opposed to none/no change).

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Analysis 7.1

Comparison 7 Children: xylitol wipes versus control wipes, Outcome 1 Number with caries increment at 1 year follow‐up (as opposed to none/no change).

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Summary of findings for the main comparison. Xylitol toothpaste versus control toothpaste for preventing dental caries

Xylitol toothpaste compared with control toothpaste for preventing dental caries
Patient or population: children with permanent teeth Settings: schools Intervention: fluoride toothpaste containing 10% xylitol Comparison: fluoride toothpaste
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Xylitol
Caries: increment (DFS) prevented fraction (PF) at 2.5 to 3 years follow‐up (higher DFS score indicates worse caries)	The (weighted) mean caries increment for control groups was 2.1	The mean caries increment in the xylitol groups was 0.28 lower (0.42 to 0.14 lower)	PF¹ = 0.13 (0.08 to 0.18)	4216 (2 studies)	⊕⊕⊝⊝ low²	The PF of 0.13 means that there was a 13% reduction in caries in the xylitol group There is no compelling evidence, from other comparisons in this systematic review, to support the use of xylitol products. The body of evidence for all other comparisons and caries outcomes is rated as being low to very low quality. This is because they are single studies with imprecision mostly due to very small sample sizes, and most of which have a high risk of bias
Adverse effects	Both studies reported that there were no adverse effects in either the xylitol or control group
CI: Confidence interval; DFS: decayed filled surfaces; PF: prevented fraction
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ The prevented fraction (PF) is calculated as follows: the mean increment in the controls minus the mean increment in the treated group divided by the mean increment in the controls ² Downgraded due to high risk of bias in the included studies (due to high attrition) and both studies were conducted by the same authors in the same population

Summary of findings for the main comparison. Xylitol toothpaste versus control toothpaste for preventing dental caries

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Table 1. Prevented fractions (PF) for caries incremental data

Comparison (number)	Increment (Study)	PF (95% CI)	Notes
Adults
Xylitol lozenges versus control lozenges (1.1)	33‐month caries increment (Bader 2013)	0.08 (–0.03 to 0.20)	8% reduction in caries in test group
Children
Xylitol lozenges versus no treatment (2.1)	4 year caries increment (Lenkkeri 2012)	‐0.10 (‐0.59 to 0.39)	10% increase in caries in test group compared to control

Xylitol topical oral syrup versus control syrup (3.1)	Caries in primary teeth over 1 year follow‐up (Milgrom 2009)	0.58 (0.33 to 0.83)	58% reduction in caries in test group

Xylitol sucking tablets versus no treatment (4.1)	2 year caries increment (Oscarson 2006)	0.53 (0.001 to 1.04)	53% reduction in caries in test group

Xylitol plus fluoride toothpaste versus fluoride toothpaste (5.1)	2.5 to 3 year caries increment (Sintes 1995)	0.12 (0.06 to 0.18)	12% reduction in caries in test group
	2.5 to 3 year caries increment (Sintes 2002)	0.14 (0.05 to 0.23)	14% reduction in caries in test group
CI = confidence interval

Table 1. Prevented fractions (PF) for caries incremental data

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Comparison 1. Adults: xylitol lozenges versus control lozenges

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Caries increment at 33 months follow‐up (DFS) Show forest plot	1	669	Mean Difference (IV, Fixed, 95% CI)	‐0.64 [‐1.58, 0.30]

Comparison 1. Adults: xylitol lozenges versus control lozenges

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Comparison 2. Children: xylitol lozenges versus no treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Caries increment at 4 years follow‐up (DMFS) Show forest plot	1	97	Mean Difference (IV, Fixed, 95% CI)	0.28 [‐0.99, 1.55]

2 Number with caries increment at 4 years follow‐up (as opposed to none/no change) Show forest plot	1	97	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.83, 1.26]

Comparison 2. Children: xylitol lozenges versus no treatment

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Comparison 3. Children: xylitol topical oral syrup versus control syrup (very low dose xylitol)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number of decayed primary teeth at 1 year follow‐up Show forest plot	1	94	Mean Difference (IV, Fixed, 95% CI)	‐1.10 [‐2.03, ‐0.18]

Comparison 3. Children: xylitol topical oral syrup versus control syrup (very low dose xylitol)

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Comparison 4. Children: xylitol sucking tablets versus no treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Caries increment at 2 years follow‐up (dmfs) Show forest plot	1	118	Mean Difference (IV, Fixed, 95% CI)	‐0.42 [‐1.12, 0.28]

2 Number with caries increment at 2 years follow‐up (as opposed to none/no change) Show forest plot	1	118	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.35, 1.45]

Comparison 4. Children: xylitol sucking tablets versus no treatment

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Comparison 5. Children: xylitol plus fluoride toothpaste versus fluoride toothpaste

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Caries increment at 2.5 to 3 years follow‐up (Prevented Fraction) Show forest plot	2		Prevented Fraction (Fixed, 95% CI)	0.13 [0.08, 0.18]

2 Caries increment at 2.5 to 3 years follow‐up (DFS) Show forest plot	2	4216	Mean Difference (IV, Fixed, 95% CI)	‐0.28 [‐0.42, ‐0.14]

Comparison 5. Children: xylitol plus fluoride toothpaste versus fluoride toothpaste

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Comparison 6. Children: xylitol tablets versus control (sorbitol) tablets

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number with caries increment at 4 years follow‐up (as opposed to none/no change) Show forest plot	1	62	Risk Ratio (M‐H, Fixed, 95% CI)	3.08 [0.69, 13.65]

Comparison 6. Children: xylitol tablets versus control (sorbitol) tablets

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Comparison 7. Children: xylitol wipes versus control wipes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number with caries increment at 1 year follow‐up (as opposed to none/no change) Show forest plot	1	44	Risk Ratio (M‐H, Fixed, 95% CI)	0.14 [0.02, 1.07]

Comparison 7. Children: xylitol wipes versus control wipes

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