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Caries Res 1990;24:256-257

0008-65681901020101-0257

S 2.7510

Combined

Effect

of Xylitol

and Fluoride

on Enamel Demineralization

in vitro

(ShortCommunication)
I. Arendsa, I Laboratory Copenhagen. M. SmilSi, I.L. Technica, Rubena, University I. Chrislojjersenb of Groningen, The Netherlands;
b Mcdicinsk-Kcmisk Institut, Panum Instituucl

for Materia Denmark

Key Words. Caries. Enamel.

Fluoride.

Xylitol

Fluoride is the most effective agent in the prevention of dental caries nowadays. Topically applied fluoride is most likely the major cause of the decreased prevalence of enamel caries in the Western world. From the mechanistic point of view fluoride strongly reduces enamel demineralization [Arends and Christoffersen, 1982; Arends et al., 1983; Borsboom et al., 1985] while F- ions also enhance remineralization [ten Cate and Arends, 1977]. Xylitol is a pentol employed for many years as an anificial sweetener in numerous applications. A major aspect of xylitol is that it cannot be fermented by plaque bacteria [Grenby et al., 1982; Rolla et al., 1983; Tuompo et al., 1983]. Several papers have also indicated that xylitol may be effective in caries prevention because of its interaction with the enamel mineral [Makinen and Soderling, 1982; Arends et al., 19~4; Leach and Green, 1980]. The presence of xylitol reduces demineralization of enam el lesions, but most likely the mechanism of action is quite different from that of fluoride. Very few papers deal with the combined action of fluoride and xylitol. The aim of this study has been to investigate the simultaneous effect of fluoride and xylitol on in vitro enamel demineralization. The xylitol content was chosen in the range relevant for chewing gums, pastilles and toothpastes. In this study 48 freshly extracted bovine incisors were used. They were flattened as described by de Rooy and Arends [ 1981] and subsequently covered with nail varnish except for a rectangular window of about 5 x 5 mm. For demineralization the teeth were placed in an unstirred 0.1 M lactic acid/potassium lactate buffer at pH -4.5 at 37OC. The solution was made by titration of a 0.1 M lactic acid solution with 2 M KOH, after agent addition. The surface-to-liquid ratio of3 cm2 .1-1 (6 teeth per 0.5 liter solution) prevented saturation effects. The pH

and fluoride levels were verified after the demineralization experiments. After 3 weeks the pH change was less than 0.2 pH unit; the change in F level was less than 1.5 ~M F- (or 0.03 ppm F-). The demineralization periods in this experiment were 3, 8 or 21 days. The agents added to the previously described demineralization solution were xylitol (2.63 M), fluoride as NaF (0.3 mM or about 6 ppm) and both xylitol and fluoride in the concentrations mentioned. In the control situation no agents were added to the demineralization solution"; The effect of an acid attack on the enamel was evaluated using transversal microradiography. The technique and its limitations have been described in detail previously [de Josselin de Jong and ten Bosch, 1985]. The two main parameters evaluated are the lesion depth I (in ~m) and the total mineral loss ~Z (in vol% mineral. ~m). The lesion depth and mineral loss values for: no agent addition, xylitol or fluoride addition and the addition of both xylitol and fluoride are compiled in table I. A verage values over 6 samples and the standard deviations of the mean values are presented. ANOV A analysis of the data in table I after 21 days of demineralization shows that there was no statistically significant difference (p 0.05) between the F-only and the xylitol-only results. The inhibiting effect of 0.3 mM F- and also the effect of 2.63 M xylitol is in the order of 30%. The analysis shows furthermore, at p -0.05, the difference between the control, or the F-only treatment or the xylitol-only treatment and the fluoride plus xylitol treatment are all statistically significant. After 9 days a similar picture emerges. If we calculate the effect of fluoride plus xylitol after 21 days the lesion depth reduction and the mineral loss reduction are both about 68%. Therefore we assume that the effects of xylitol and fluoride (present conditions and concentrations)

Table I. Lesion depth and mineral loss (AZ) values after enamel demineralization at pH -4.5 at 37 -C after 9 and 21 days
Agent added

results obtained in this in vitro study may be quite dirferent from in vivo results, in particular because the xylitol are very difficult to determine due to the relatively low xylitol efficacy and the biological spreading in the enamel. In conclusion this model study at pH -4.5 shows that (I) 6 ppm F in solution and 2.63 M xylitol in solution have comparable effects on lesion reduction in vitro, and (2) the effects of F- and xylitol are additive under the conditions described.

DemineraJiz:ltion in days period

I :t. SD I1m

~Z:tSD vol% .~m

None None
F-(0.3 mM) F-(0.3 mM) Xylilol Xylilol (2.63 M) (2.63 M)

9 21 9 21 9 21

339 :i: 25 450:i: 49

6,380 .t 893 8,880 .t 840 5,456 .t 600 6,305 .t 790 4,809.t615 6,650 .t 1,090

248 .t I S 300 .t 41 229 t 25 325 t 30

References Arends J, Christoffersen J: Progress of anificial caries lesions in

F- + xylilol (0.3 mM + 2.63 M) F- + xylilol (0.3 mM + 2.63 M) 21 137%36

142 t 20

2.845 t 484 2,820 t 930

enamel. J Dent Res 1982;61 :232. Arends J. Christoffersen J, Christoffersen ence of fluoride concentration

MR. Schuthof

J: Influ-

on the progress of demineralizaor

Mean values over 6 samples t SD of the mean are given.

tion in bovine enamel at pH 4.5. Caries Res 1983; 17:455-457. Arends J, Christorfersen J, Schuthor J, Smites Mi: Influence xylitol on demineralization or enamel. Caries

Res 1984:18:

296-301. Borsboom P. Van der Mei HC, Arends J: Enamel lesion formation with and without 0.12 ppm F in solution. Caries Res 1985: 19:

are additive.

From the mechanistic

point of view, the

396-402. ten Cate JM.

Arends

J: Remineralization

or anilicial

enamelleon tooth lesions in

additive effect of F- ions and high xylitol contents is plausible. Fluoride ions in solution most likely affect the dissolution rate of enamel mineral or form fluorapatite-Iike precipitates [Christoffersen and Arends, 1982: Arends et al., 1983; ten Cate and Duysters, 1983]. On the other hand, xylitol interaction with the enamel mineral can be explained in terms of ion-solvent interactions between Ca++ and xylitol. Xylitol is known to penetrate into dermineralized enamel [Arends et al., 1984]. In a high xylitol situation the Ca++ ions are not only hydrated by water but partly solvated by xylitol molecules. Because hydrogen is a more electronegative radical than a carbon-hydrogen group, one may expect the hydroxyl groups in xylitol to be more effective than water in solvating particularly positive ions. f{-is presumed that the above effect (together with steric effects) lowers the diffusion coefficient ofCa++ ions out of the demineralizing enamel. It is interesting to compare the relative effectiveness of F- and xylitol under the present conditions. Because the effects of high-level xylitol (2.63 M) and 0.3 mM(or 6 ppm) F are comparable and not statistically different, the effectiveness of fluoride on a molar basis is about 9,000 times greater in retarding enamel demineralization than that of xylitol. In several practical applications, pastilles, chewing gums and toothpastes xylitol is employed with concentrations comparable to the high xylitollevel used in this work. The

sions ili;vitro. Caries Res 1977: 11:277-286. ten Cate JM. Duysters PPE: Influence of F in solution demineralization. Caries Res 1983;17:193-199. Christoffersen J. Arends J: Progress or anificial carious enamel. Caries Res 1982: 16:433-440. de Rooij J F. Arends J: Phosphate diffusion

in whole bovine enamel trial to compare the

at pH 7. Caries Res 1981: 15:353-362. Grenby TH. Basharaat AH. Gey KF: A clinical effects of xylitol and sucrose chewing growth. Br Dent J 1982: 152:339-343. de Josselin de Jong E. ten Bosch JJ: Error radiographic determination of mineral

gums on dental analysis content

plaque

or the microin mineralized diets on the

tissue slices. Phys Med Bioi 1985:30: 1067-1075. Leach SA, Green RM: Effect or xylitol.supplemented progression and regression

of fissure caries in the rat. Caries

Res 1980:14:16-22. Makinen KK. Soderling E: The relative ability or simple carbohydrates to rorm Ca-complexes in vitro. J Dent Res 1982;61 :208. Rolla G. Assev S, Waler SM, Vegamd mineralization and G, Wilbanks or Teeth. J. Ciardi Oxrord, J: DeIRL Remineralization

Press, 1983, pp 77-88. Tuompo H, Meurman J. Loutnatma K. Linkola J: Effect of xylitol and other carbon sources on the cell wall of s. mulans. Scand J Dent Res 1983:91:17-23.

Received: May 11,1989 Accepted after revision: January 31, 1990 J. Arends Laboratory Antonius NL-9713

for Materia Deusinglaan A V Groningen

Technica, I

University

of Groningen

(The Netherlands)