Professional Documents
Culture Documents
Dental Issue
Dental Issue
Dental Issue
2/2009
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Editorial
Today, the Happy Tooth is a paradigm for effective, globally-recognized health communications. 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-cariogenic. 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 possible: when buying sweets, look for the Happy Tooth logo.
Prof. Stefan Zimmer teaches at the University of Witten/Herdecke. He is also a Board Member of Toothfriendly International.
News
First non-erosive soft drink on the market
The first soft drink to make an explicit connection to healthy teeth are introduced in March in Switzerland. Swiss Migros is worldwide the first retailer to roll out a toothfriendly 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 depress the plaque-pH below the critical level of 5.7. It also does not promote dental erosion. A non-erosive soft drink is a real innovation., says Dr. Albert Br of Toothfriendly International. He points out that until now, most attempts to develop toothfriendly beverages have failed mainly due to excessive acidity. Acids which are commonly used in soft drinks for taste and for ensuring microbial stability have a demineralizing effect on the tooth surface which may develop to dental erosion.
News
S we e t , sweeter,
in t e n s e 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 sugar levels, claim food manufacturers. Consumers often tend to think that sugar substitutes are something artificial yet they provide many benefits to sugar, at least in confectionery 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 sweetness. Until recent decades, sucrose was virtually 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 sugarfree soft drink sweetened with cyclamate. In 1980s, the discovery of new, improved sugar substitutes fuelled the development of sugar-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 culprit 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. Nearly twenty different sweeteners are currently authorized by the European Food Safety Authority (EFSA) for food production. Consumers often regard sugar substitutes as one homogenous group of artificial sweeteners. 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, varies greatly.
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.
Intense sweeteners provide sweet taste without 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, aspartame, acesulfame K, neohesperidine DC, thaumatin, sucralose and alitame have been
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
Toothfriendly sugars?
In addition to polyols and intense sweeteners, a third group of so-called non-cariogenic sugars has emerged. Isomaltulose and tagatose are examples of toothfriendly sugars derived from beet sugar and milk sugar, respectively. 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 having a much lower GI value than sucrose.
SWEETENERS
SUGARS
Sucrose Glucose Fructose Lactose Maltose Isomaltose Tagatose
POLYOLS
Xylitol Sorbitol Isomalt Maltitol Mannitol Erythritol Lactitol
INTENSE SWEETENERS
Cyclamate Aspartame Acesulfame-K ToothNeohesperidine DC friendly Sucralose Saccharin Thaumatin Alitame
Cariogenic
Toothfriendly
What is...
Sugar-free? Products which contain maximum 0.5g sugars may be labelled as sugarfree. Note: The claim sugar-free does not automatically mean that a product is safe for teeth. Sugar.-free foods with high quantities 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
Source
Derived and processed from sugar beet, corn, malt, wood pulp
Source
Chemically processed from acids. Only sucralose is processed from sugar beet.
Source
Caloric value
Caloric value
As intense sweeteners are used in minimal amounts, they provide practically 0 calories.
Caloric value
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 guaranteed toothfriendly, as they have undergone a stringent telemetry testing procedure.
Properties
Sugars are a good source of energy, but should not be consumed in excess. Isomaltulose and tagatose are toothfriendly, all other sugars are cariogenic.
- Toothfriendly - Suitable for diabetics - Less calories - Low GI - Excessive consumption (>50g) may cause laxative effects
Properties
Properties
Expert Opinion
FDI World Den t a l Fe d e r a t i o n Po l i c y St a t e m e n t : T h e a n t i c a r i o g e n i c e f f e c t o f polyols has yet to be sup p o r t e d by e v i d e n c e - b a s e d d a t a . Howe ve r, t h e e n h a n c e m e n t o f s alivar y flow may have a c a r i e s - p re ve n t a t i ve e f f e c t . Toothfriendly In t e r n a t i o n a l : W h e t h e r t h e p ro d u c t c o n t a i n s a n y s o - c a l l e d a c t ive ingredients e.g . x y l i t o l i s m u c h l e s s i m p o r t a n t t h a n t h e f a c t t h a t t h e re c o m mended product is guara n t e e d t o o t h f r i e n d l y. T h e e s s e n c e o f a l l d e n t a l d i e t a r y a d v i c e i s to cut down the freque n c y o f s u g a r c o n s u m p t i o n .
The statement 100%-xylitol chewing gum reduces the risk of caries is somewhat misleading. While certain studies point out that caries risk reduction can be obtained by consuming 2 3 g of chewing gum sweetened with 100% xylitol at least three times per day after the meals, a fair amount of clinical studies point out that the same beneficial effect can also be obtained with other non-cariogenic sugar substitutes. The World Dental Federation (FDI) has adopted a new Policy Statement on sugar substitutes and their role in caries prevention saying that the regular use of chewing gum containing non-cariogenic sweeteners such as xylitol, has a role to play in preventing dental caries because of its non-cariogenic nature and its salivary stimulatory effect. The policy also states that enhancement 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 experts 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. Lingstrm et al., 2003; Burt, 2006).
The caries risk reduction claim for chewing gum with 100% xylitol suggests to consumers that other similar products with a lower content of xylitol or with other polyols have inferior properties. In the light of current expert opinions, this is wrong and indeed misleading.
Conclusions
Any caries risk reduction claims for chewing gum with 100% xylitol bears a significant risk of being misinterpreted as demonstrating that xylitol exerts an anti-cariogenic effect. Whether sugar-free chewing gum and sweets contain any so-called .active ingredients - e.g. xylitol - is much less important than the fact that the recommended product is toothfriendly. The essence of all dietary advice is to cut down the frequency of sugar consumption.
References:
Burt B.A. (2006). The use of sorbitol- and xylitolsweetened chewing gum in caries control. JADA 137: 190-196. Imfeld T.N. (1994). Clinical caries studies with polyalcohols. Schweiz. Monatsschr. Zahnmed. 104: 941-945. Lingstrm P., Holm A.K., Mejre I., Twetman S., Sder B., Norlund A., Axelsson S., Lgerlf F., Nordenram G., Petersson L.G., Dahlgren H. and Kllestal C. (2003). Dietary factors in the prevention 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 cariestherapeutic effects? Caries Res. 38: 286-293. Zero D.T. (2008). Are sugar substitutes also anticariogenic? JADA 139: 9S-10S.
Dr. Albert Br received his Ph.D. in biochemistry from the Swiss Federal Institute of Technology (ETH) in 1974. Prior to forming Bioresco Ltd. in 1986, Mr. Br served for six years as Director, Research 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.
Top project
O ver 5000 k ids across Switzer land are par ticipating in the Toothfr iendly Playgroup program to help fight childhood cavities and promote healthy lifest yle among children. The educational campaign encourages children, parents and educators to adopt healthier snack ing habits.
teacher received story books and other material 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. Sugary snacks are consequently forbidden in the lunch boxes - except on special occasions.
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 nations 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. Switzerland 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 voluntary training courses on oral health prophylaxis to play group teachers. In addition to diverse course material, each playgroup
Toothfriendly-certified educators work according 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 message 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 motivated 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.
Note: Sugar is not bad per se. The problem emerges only when sugar becomes a staple in a childs diet, replacing healthy foods that contain vital nutrients.
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Last word
Fluoride: Salt fluoridation is a beneficial and costeffective strategy for developing countries.
Dietary habits: Sugar should not be bedevilled - consumers are likely to follow positive advice.
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