Introduction
Why Grinding Your Teeth Can Cause Migraines
Much focus in dentistry has been given to teeth grinding, better known as bruxism.
Bruxism can be classified as awake or sleep bruxism. Awake bruxism involves tooth clenching or tapping and jaw bracing, with or without tooth contact. Grinding is rarely noted during waking hours. Sleep bruxism involves tooth grinding with rhythmic, sustained, or mixed jaw muscle contractions. The overall prevalance of awake clenching is about 20% in the adult population with more women reporting clenching awareness than men. It has been estimated that 8% of adults in the general population are aware of teeth grinding during sleep, usually reported by their sleep partners or roommates. According to parental reports, the incident of teeth grinding noises during sleep in children younger than 11 years of age is between 14-20%. Dental signs of bruxism can be seen in approximately 10-20% of children. In a 24-hour period it is estimated that tooth contact occurs for 17.5 minutes. During a 7-8 hour sleep cycle, bruxism-related muscle activity occurs for approximately 8 minutes and does not always occur with tooth contact. Grinding noises however, only occur in approximately 44% of sleep bruxism. Patients with bruxism are 3-4 times more likely to experience jaw pain and limitation of movement than people who do not experience sleep bruxism.The greatest maximum voluntary clenching force has been measured to be 975 pounds per square inch so it is of little wonder that we witness tooth destruction due to bruxism. Many sleep bruxism patients complain of morning jaw stiffness, and a worsening of symptoms as the day progresses. Up 65% of sleep bruxism patients report frequent headaches. Symptoms of bruxism include nonspecific jaw pain, masseter muscle stiffness, neck pain, back pain, episode and daily headaches and migraines. An oral appliance (guard), covering a full or patial dental arch (anterior or posterior), has been the traditional option for patients who are frequent and severe grinders or clenchers. Full arch coverage appliances are designed to spread the load across the teeth more evenly and require more bulk in the posterior area to prevent fracturing of the material during clenching or grinding with molar teeth. The Nociceptive Trigeminal Inhibition Tension Suppression System, or NTI-tss, is a partial anterior appliance created by James P. Boyd, DDS, that specifically treats and prevents medically diagnosed migraine pain, tension-type headaches and temporomandibular
joint (TMJ) disorders. For the majority of cases, the NTI-tss is designed to be worn only at night and can provide patients with significant relief. The NTI-tss, is as surprisingly simple as it is effective: 82% of migraine and headache sufferers who use the device experience an average 77% reduction of migraine pain attacks within two months. The device is easily fit at the dentist’s office, involves no surgery, and has no risk of side effects compared to pharmaceutical migraine treatments. Hoye Dental is now offering the NTI-tss. If you or someone you know is suffering from tension or migraine headaches and are interested in trying the NTI-tss, the first step is to set up a consultation appointment. At this appointment we will check for any telltale signs of tooth clenching and get a better idea if this therapy could help. The total cost of NTI-tss therapy more than likely offsets the cost of medication or missed days at work. If you are interested in learning more about how the NTI-tss can help you, please call us today. Information from "Occlusion, Function and Parafunction: Understanding the Dynamics of a Healthy Stomataznathic System," by Stephen D. Bender, DDS. To learn more about the NTI-tss, please click here.
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New Patient Referral Program
Smile! It's our way to thank you for your referrals. We value our patients and work hard to provide a warm and inviting environment that makes you feel comfortable. That is why we want to show you our appreciation for referring new patients to Hoye Dental. Tell your family, friends and coworkers about Hoye Dental, and if they become new patients, you and your referred patient(s) will each be eligible to receive free upper and lower bleaching trays, and 1 tube of bleach (a $300 value). For a limited time only, all new patients are eligible for the bleaching tray offer. . Call us today! To learn more about our patient referral program, please click here.
M
simultaneous and continuous exploitation
of several strategies. Fluoride-based procedures
are the cornerstone of successful prevention. Rigorous,
long-term restriction of cariogenic sugars undoubtedly
also results in signifi cant caries reduction. However,
considering people’s preferences for sweet food items,
restricting cariogenic sugars without offering alternatives
is impractical.
situations such as rampant caries, profoundly cariessusceptible
tooth structure, poor diet, hyposalivation,
and amelogenesis imperfecta, the use of noncariogenic
sugar substitutes should automatically be considered.
aximized prevention of dental caries presumes1 Therefore, in clinically diffi cult
Xylitol and Caries Prevention
JANAINA HANSON
LINDA CAMPBELL
Ms. Hanson and Ms. Campbell are students in the dental hygiene program at Cape Cod Community College.
This article originally appeared as a student presentation at Yankee Dental Congress 36 in January 2011.
Background
Xylitol is a sweet crystalline carbohydrate that has been known
to science for nearly 100 years. The name relates to the word
xylose” (wood sugar) from which xylitol was fi rst made, and
which is, in turn, derived from the particular structure (xylene)
of hardwood from which xylose can be obtained. Later studies
showed that xylitol occurs freely in fruits and other plant parts,
and in virtually all products made of fruits. Xylitol is also present
in human metabolism as a normal metabolic intermediate (in
the glucuronate-xylulose cycle). In chemical nomenclature, xylitol
is classifi ed similarly to sorbitol and maltitol (i.e., as a sugar
alcohol or a polyol). The theoretical calorie value of xylitol is the
same as with other dietary carbohydrates (i.e., about 4 kcal/g).
In practice, however, the caloric utilization of xylitol by the human
body may be lower owing to the slow and incomplete absorption
of xylitol, especially if larger quantities are consumed.
On food labels, the U.S. Food and Drug Administration (FDA)
allows a reduced calorie claim for xylitol (2.3 kcal/g). Xylitol is
currently manufactured from various xylan-rich plant materials;
xylan is the natural polysaccharide that consists of xylose units.
Although xylitol occurs freely in nature, it is more economical to
use certain plant parts as starting material, such as birchwood,
corn residues, straw, seed hulls, and nut shells.
Clinical studies carried out during the past 25 years strongly
indicate that xylitol can decisively improve caries prevention.
The purpose of this article is to briefl y review the most important
clinical studies carried out on xylitol, and to discuss practical
aspects of the usage of xylitol in caries limitation. The aim
is to emphasize the strong position the xylitol-based prevention
concept has attained, and the endorsements this strategy has received
within the public health sector.
It can be said that Americans have acquired a taste for
sweets. Since World War I, the public’s sugar consumption has
continued to creep upward. It now exceeds 120 pounds (54.5
kg) per person each year.
from excessive sugar consumption, such as diabetes, has
emerged as a priority among many public health initiatives. In
some cases, communities have attempted to restrict the sale of
soda and sugary beverages in public schools. Dentists and dental
hygienists can help bolster public awareness of the benefi ts
of replacing sugar with a regimen of non-sugar sweeteners for
improved oral and digestive health.
Several of the studies reviewed for this article include special
features that may be important to consider in clinical practice
and in disseminating the necessary information to patients.
Some of these aspects are: long-term effects of xylitol, hyposalivation,
and dry mouth syndrome; stabilization of rampant caries;
prevention of root surface caries; the mother-child relationship
from the cariologic point of view; and implementation of
school prevention programs. It is also important to emphasize
the advantage that patients will gain from systematic usage of
xylitol-containing saliva stimulants. Even in the case of total
absence of caries, xylitol is still dentally safer than fermentable
sugars, such as regular table sugar (sucrose).
Xylitol Beyond Caries Prevention
Kontiokari et al. reported that “the usage of xylitol chewing gum
or syrup by young daycare center subjects was associated with
reduced rate of acute otitis media [middle ear infections] and
with a lowered nasopharyngeal carriage rate of pneumococci.”
3,4
Another important application of xylitol is its use as a source of
energy in parenteral nutrition (infusion therapy).
Makinen reported that German physicians have used xylitol in
substantial quantities for intravenous feeding of patients with
impaired glucose tolerance, and when administered in this fashion,
xylitol was found to have a strong anticatabolic musclesparing
effect.
5 Peldyak and6
Dental hygienists mainly focus on basic prevention measures,
which include professional cleaning and oral hygiene instructions,
and the promotion of sugar-restrictive strategies often
fail because the benefi ts and solutions are not always clearly
understood by the public at large. The fundamental goal of providing
good oral hygiene instruction is to encourage better practices;
a sound understanding of the topic supported with this
evidence produces convincing instruction.
Impact of Xylitol Gum on Maternal Transmission
of
Mutans Streptococci
Research reveals that xylitol can reduce mother-child transmission
of the bacterial disease that causes caries:
mutans streptococci
(MS). The results show that xylitol is versatile and effective
among several delivery methods. We looked at the range of
xylitol doses that produced an effective response. To effectively
prevent caries, a patient needs to take xylitol with regularity.
Compliance plays a major contributing factor for xylitol effi
cacy.
Participants (
trial conducted over 28 months to confi rm the effectiveness
of chewing xylitol gum beginning in the third to fi fth months
of pregnancy for reducing mother-child transmission of MS.
n = 107) were block randomized in a controlled7
The investigators were looking to see if the chewing of xylitol
gum by pregnant Japanese women would reveal similar effects
demonstrated by maternal xylitol gum chewing in Nordic countries.
The outcome measure was MS colonization in the children.
Samples were taken from two sites: the tongue dorsum and the
mucosa of the mandibular and maxillary ridges using a sterile
cotton swab to collect the unstimulated saliva. (See Figure 1.)
This trial confi rmed that xylitol gum chewing during
pregnancy is an effective early intervention period for reducing
mother-child transmission of MS. The xylitol group children
exhibited signifi cantly more non-detectable, MS-negative levels
(score 0) on the tooth ridges or tongue and the gingival ridge
at nine, 12, and 24 months. The xylitol group children were
also signifi cantly less likely to be MS-positive than the control
group children at and after nine months of age. The investigators
reported that the children whose mothers did not chew
xylitol gum acquired MS 8.8 months earlier than did those
whose mothers did chew the gum.
7
At the time, the investigators reported that the study was
the fi rst to detail the effectiveness of maternal xylitol exposure
during an earlier intervention period. The results from this trial
reveal that maternal exposure to xylitol chewing gum provides
intervention by preventing or delaying mother-child MS transmission.
From a public health viewpoint, dental practitioners
might consider informing expectant mothers about the benefi ts of
xylitol gum chewing during hygiene instruction. Similar to other
studies, several limitations involving compliance are described in
this study. The dose compliance limitation should be scrutinized
further before recommending the xylitol chewing gum as an intervention
strategy for pregnant women. Expectant mothers will
need to chew xylitol gum three to fi ve times a day, beginning in
the third to fi fth months of pregnancy, along with following basic
prevention measures in order to gain the benefi ts of reducing
mother-child transmission of MS refl ected in this study.
Dose Response from Xylitol Gum Chewing
A prospective controlled, double-blind clinical trial with four
groups of 33 participants each (
six months to determine the relationship between dose and effects
on
n = 132)
Controversies noted in this study were whether or not xylitol’s
effectiveness was attributed to the anticariogenic effect of
xylitol itself, or whether it was a result of chewing and digestion
activities of the products consumed. The researchers assert that
their results, using just syrup, more accurately refl ect the effects
of xylitol use versus the current studies conducted with gum and
lozenges that don’t take into account increased saliva fl ow, food
removal from the oral cavity, and pH of the mouth that assists
in caries reduction and prevention. Their research confi rms the
effectiveness of xylitol alone.
The study results also indicate that an alternative xylitol
vehicle has been found for young children. Toddlers, who are
one of the high-risk groups for caries development, are unable
to consume typical xylitol products, such as gum and lozenges,
due to safety and choking concerns. With only two applications
of the syrup required per day for effectiveness, compliance will
be much easier to accomplish, thereby increasing the therapeutic
effect and caries prevention. Although a xylitol syrup product is
not currently available at retail markets, there are several similar
commercially available products, such as pudding, jam, and maple
syrup, available in retail stores and online sites that provide
the therapeutic 4.0 grams or more per serving outlined in the
study.
will need to caution parents about the potential for loose
stool and diarrhea; approximately 10 percent of the study’s participants
experienced these adverse effects. The authors noted
that a gradual increase in dosage during the treatment aided
the patient’s acclimatization to xylitol and reduced the adverse
gastrointestinal problems.
10 Dentists or dental hygienists recommending this treatment
The Effectiveness of Xylitol Gummy Bear Snacks
One other study looked at the habitual consumption of xylitol
gummy bear snacks and its effectiveness in reducing MS.
six weeks of providing school-age children with gummy bear
snacks containing xylitol at 11.7 grams per day, the study revealed
signifi cant reduction in
sobrinus,
isolated from human tooth surfaces and shown to be cariogenic
in experimental animals.
11 AfterStreptococcus mutans and Streptococcusa species of gram-positive, coccoid bacteria
Tooth decay prevention programs using xylitol chewing
gum and hard candies are currently popular in Europe, Korea,
Japan, Thailand, and China; however, they have not been
adopted in the United States due to the fact that gum and candies
present a choking hazard to children and are not considered
an acceptable delivery vehicle. The results of this study, however,
have identifi ed what may be an effective alternative vehicle
Group Percentage with Decayed Teeth Number of Decayed Teeth, Mean
Control Group 51.7 1.9
Xylitol—2X per day, 4.0 g per dose 24.2 0.6
Xylitol—3X per day, 2.67 g per dose 40.6 1.0
Table 1.
Percentage with Tooth Decay and Number of Decayed Teeth Among 94 Children Administered Xylitol Oral Syrup
12
received a mixture of control gum and/or xylitol gum: 3.44 g/
day (G2), 6.88 g/day (G3), or 10.32 g/day (G4). The participants
were instructed to chew three pellets four times per day. Plaque
and unstimulated saliva samples were taken at baseline. MS levels
in plaque were measured from samples taken at fi ve weeks
and in plaque and unstimulated saliva at six months. (See Figure 2.)
The investigators reported that MS levels in plaque decreased as
exposure to xylitol increased, and found what appeared to be a
plateau effect between 6.88 g/day and 10.32 g/day.
Xylitol Syrup Administered to Children
Children with early childhood caries are three times more likely
to develop tooth decay in permanent teeth than children without
childhood caries. The use of products containing xylitol has
been investigated as a way to prevent caries in children. An effective
xylitol vehicle that is acceptable and safe for toddlers has
been elusive. In addition, the effectiveness of xylitol is dependent
on a minimum daily quantity and frequency, which means that it
has limited patient compliance and, thus, effectiveness.
Milgrom et al. conducted a double-blind, randomized controlled
trial using a xylitol topical syrup to determine the effectiveness
in children.
as little as twice daily at a total daily dose of 8 grams was
found to be effective in preventing childhood caries.
mutans streptococci count (CFU/ml) 20 Journal of the Massachusetts Dental Society
for administering xylitol, one that could lead to successful oral
health prevention programs for U.S. children.
The study design was a double-blind, randomized trial using
three groups. The three groups were children who received
either 11.7 g or 15.6 g of xylitol per day, or maltitol at 44.7 g per
day. The design controlled for the frequency and the number of
gummy bears consumed. A total of 154 children per group were
selected for the study. The results showed that after six weeks
of habitual consumption of xylitol gummy bears, the levels of
S. mutans/sobrinus
baseline levels. The study also noted a plateau effect at higher
xylitol dose levels. (See Figure 3.) The authors also determined
that doses greater than 11.7 g per day did not result in a statistically
signifi cant reduction in
were signifi cantly reduced compared to theS. mutans/sobrinus levels.
Mouthrinses: Xylitol/Chlorhexidine Versus Xylitol
or Chlorhexidine Alone
In 2008, Decker et al. investigated the effect of combining xylitol
and chlorhexidine on the viability of
Streptococcus sanguis or
S. mutans
how the combination compared to xylitol and chlorhexidine
alone.
signifi cant antiviral effect on streptococci when compared
to pure xylitol or chlorhexidine used alone. This newly discovered
synergistic effect of xylitol and chlorhexidine could be used
in new caries prevention programs for high-risk caries patients
or for reducing MS transmission from mother to child.
The experiment design used
in human saliva. The suspensions were exposed to the
sodium chloride, xylitol, chlorhexidine, and xylitol/chlorhexidine
test solutions, and then allowed to attach to human enamel
slides. The vitality of the bacteria was monitored using fl uorescent
DNA stains and epifl uorescence microscopy. Total bacterial
cell counts and the growth of suspended streptococci were also
measured. The data showed that both
during the early stages of biofi lm development and12 The xylitol/chlorhexidine combination showed a statisticallyS. sanguis and S. mutans suspendedS. mutans and S. sanguis
were sensitive to the chlorhexidine and xylitol/chlorhexidine solutions,
with the most signifi cant reductions in enamel adhesion
realized by the xylitol/chlorhexidine solution. Bacterial count
results showed that
effects of chlorhexidine alone, while
more sensitive to the xylitol/chlorhexidine solution.
S. sanguis was most sensitive to the antisepticS. mutans colonies were
Conclusion
Xylitol has been shown to be effective in the prevention of caries
when consumed in quantities as little as 8 grams per day. The
range of commercially available products containing 4 grams of
xylitol or higher per serving has expanded in recent years, providing
greater opportunities for use in a wider population.
recent study
the established antibacterial agent chlorhexidine improves xylitol’s
antibiotic capabilities. Several studies have outlined successful
caries prevention program designs using xylitol for children
and toddlers,
and that present diffi cult challenges for obtaining compliance
with xylitol consumption. These new xylitol products and successful
caries prevention programs can provide the dental team
with important tools for caries management.
10 A12 has also shown that using xylitol combined with11,13 populations that have the highest risk for caries
Although underutilized and often overlooked, xylitol use
is compatible and complementary with all current oral hygiene
recommendations. Xylitol is not a panacea, but it is a convenient,
pleasant, practical, effective, and essential adjunct to stateof-
the-art caries prevention programs.
