Addition of Povidone-Iodine to Fluoride Varnish for Dental Caries: A Randomized Clinical Trial.

INTRODUCTION: Dental caries is the most common chronic childhood disease. Products of metabolism by bacteria populating the tooth surface induce development and progression of cavities. OBJECTIVES: We sought to determine whether a polyvinylpyrrolidone-iodine (PVP-I; povidone-iodine) and NaF topical varnish was superior to one containing only NaF in prevention of new dental caries lesions in a single-center randomized active-controlled trial based on a double-blind, parallel-group design. METHODS: The site was Pohnpei State, Federated States of Micronesia. The study population was healthy children 49 to 84 mo old who were enrolled in early childhood education: 284 were randomized (1:1 allocation), and 273 were included in year 1 analysis and 262 in year 2. The test varnish contained 10% PVP-I and 5.0% NaF. The comparator contained only 5.0% NaF but was otherwise identical. Varnishes were applied every 3 mo during 2 y. The primary outcome was the surface-level primary molar caries lesion increment (d2-4mfs) at 2 y. Caries lesion increments from baseline to year 1 and year 2 were compared between conditions with log-linear regression, adjusting for age and sex and whether the tooth was sound at baseline (free of caries lesions). RESULTS: At year 1, the caries lesion increment for primary molars sound at baseline was 0.9 surfaces (SD = 1.5) for the test varnish versus 1.8 (SD = 2.2) for the comparator varnish with fluoride alone (adjusted rate ratio, 0.50; 95% CI, 0.31 to 0.81; P = .005). At year 2, the caries lesion increment for primary molars sound at baseline was 2.3 surfaces (SD = 2.8) for the test varnish as compared with 3.3 (SD = 2.7) for the comparator (adjusted rate ratio, 0.74; 95% CI, 0.52 to 1.03; P = .073). Teeth that were already cavitated at baseline did not show a preventive effect. There were no harms. CONCLUSIONS: A dental varnish containing PVP-I and NaF is effective in the primary prevention of cavities in the primary dentition (NCT03082196). KNOWLEDGE TRANSFER STATEMENT: This study demonstrates that periodic application of a varnish containing NaF and PVP-I is effective in prevention of caries lesions and useful in assessing the potential of combined treatment.

Streptococcus gordonii's sequenced strain CH1 glucosyltransferase determines persistent but not initial colonization of teeth of rats.

OBJECTIVE: Extracellular glucan synthesis from sucrose by Streptococcus gordonii, a major dental plaque biofilm bacterium, is assumed important for colonization of teeth; but this hypothesis is un-tested in vivo. METHODS: To do so, we studied an isogenic glucosyltransferase (Gtf)-negative mutant (strain AMS12, gtfG(-)) of S. gordonii sequenced wild type (WT, strain Challis CH1, gtfG(+)), comparing their in vitro abilities to grow in the presence of glucose and sucrose and, in vivo, to colonize and persist on teeth and induce caries in rats. Weanling rats of two breeding colonies, TAN:SPFOM(OM)BR and TAN:SPFOM(OMASF)BR, eating high sucrose diet, were inoculated with either the WT (gtfG(+)), its isogenic gtfG(-) mutant, or reference strains of Streptococcus mutans. Control animals were not inoculated. RESULTS: In vitro, the gtfG(-) strain grew at least as rapidly in the presence of sucrose as its WT gtfG(+) progenitor, but formed soft colonies on sucrose agar, consistent with its lack of insoluble glucan synthesis. It also had a higher growth yield due apparently to its inability to channel carbon flow into extracellular glucan. In vivo, the gtfG(-) mutant initially colonized as did the WT but, unlike the WT, failed to persist on the teeth as shown over time. By comparison to three S. mutans strains, S. gordonii WT, despite its comparable ecological success on the teeth, was associated with only modest caries induction. Failure of the gtfG(-) mutant to persistently colonize was associated with slight diminution of caries scores by comparison with its gtfG(+) WT. CONCLUSIONS: Initial S. gordonii colonization does not depend on Gtf-G synthesis; rather, Gtf-G production determines S. gordonii's ability to persist on the teeth of sucrose-fed rats. S. gordonii appears weakly cariogenic by comparison with S. mutans reference strains.

Streptococcus mutans: fructose transport, xylitol resistance, and virulence.

Streptococcus mutans, the primary etiological agent of human dental caries, possesses at least two fructose phosphotransferase systems (PTSs), encoded by fruI and fruCD. fruI is also responsible for xylitol transport. We hypothesized that fructose and xylitol transport systems do not affect virulence. Thus, colonization and cariogenicity of fruI(-) and fruCD(-) single and double mutants, their WT (UA159), and xylitol resistance (X(r)) of S. mutans were studied in rats fed a high-sucrose diet. A sucrose phosphorylase (gtfA(-)) mutant and a reference strain (NCTC-10449S) were additional controls. Recoveries of fruI mutant from the teeth were decreased, unlike those for the other strains. The fruCD mutation was associated with a slight loss of cariogenicity on enamel, whereas mutation of fruI was associated with a loss of cariogenicity in dentin. These results also suggest why xylitol inhibition of caries is paradoxically associated with spontaneous emergence of so-called X(r) S. mutans in habitual human xylitol users.

Sucrose transport by Streptococcus mutans. Evidence for multiple transport systems.

The transport of sucrose by selected mutant and wild-type cells of Streptococcus mutans was studied using washed cocci harvested at appropriate phases of growth, incubated in the presence of fluoride and appropriately labelled substrates. The rapid sucrose uptake observed cannot be ascribed to possible extracellular formation of hexoses from sucrose and their subsequent transport, formation of intracellular glycogen-like polysaccharide, or binding of sucrose or extracellular glucans to the cocci. Rather, there are at least three discrete transport systems for sucrose, two of which are phosphoenolpyruvate-dependent phosphotransferases with relatively low apparent Km values and the other a non-phosphotransferase (non-PTS) third transport system (termed TTS) with a relatively high apparent Km. For strain 6715-13 mutant 33, the Km values are 6.25 X 10(-5) M, 2.4 X 10(-4) M, and 3.0 X 10(-3) M, respectively: strain NCTC-10449, the Km values are 7.1 X 10(-5) M, 2.5 X 10(-4) M and 3.3 X 10(-3) M, respectively. The two lower Km systems could not be demonstrated in mid-log phase glucose-adapted cocci, a condition known to repress sucrose-specific phosphotransferase activity, but under these conditions the highest Km system persists. Also, a mutant devoid of sucrose-specific phosphotransferase activity fails to evidence the two high affinity (low apparent Km) systems, but still has the lowest affinity (highest Km) system. There was essentially no uptake at 4 degrees C indicating these processes are energy dependent. The third transport system, whose nature is unknown, appears to function under conditions of sucrose abundance and rapid growth which are known to repress phosphoenolpyruvate-dependent sucrose-specific phosphotransferase activity in S. mutans. These multiple transport systems seem well-adapted to S. mutans which is faced with fluctuating supplies of sucrose in its natural habitat on the surfaces of teeth.

Identification of several rod loci and cloning of the rodD locus of Streptococcus mutans.

Previous work has shown that Streptococcus mutans is normally a short rod or a sphere, depending on its environment. This paper describes two distinct genetic approaches used to identify multiple loci and isolate one locus, rodD, controlling S. mutans rod shape. The first method involved isolation of a group of rod- mutants caused by transposon Tn916 insertion, and analysis of the inactivated genes by Southern hybridization. The second method involved mutagenesis via a shotgun insertion-duplication technique, isolation of a rod- mutant, and cloning the intact rod locus, employing an integration shuttle plasmid, pVA891. These approaches have led to the identification of multiple rod loci involved in determining the rod shape of S. mutans, and also cloning of one rod locus, rodD. The cloning strategy may also be useful for cloning other streptococcal genes which cannot be detected by their expression in Escherichia coli.

Novel sucrose-dependent adhesion co-factors in Streptococcus mutans.

Streptococcus mutans glucosyltransferases form extracellular glucans from sucrose to promote adhesion to the teeth. We tested whether additional factors are involved in S. mutans sucrose-dependent adhesion. By screening a pVA891-insertion mutant library of S. mutans LT11, we isolated four clones deficient in adhesion to glass in the presence of sucrose, but normal in glucosyltransferase activities. The genetic loci flanking the insertion sites were retrieved and identified. They encode glycerol-3-phosphate dehydrogenase, an ABC transporter, a multidrug-efflux pump, and either the ribulose monophosphate operon or ascorbate metabolism operon. The four mutants were analyzed for their phenotypic expression and in vivo colonization in rats. The multidrug efflux pump mutant failed to colonize the rats. Three other mutants colonized the rats by reverting to the wild type. Therefore, these four factors may contribute to S. mutans sucrose-dependent adhesion.

Statistical relationship of morsal to bucco-lingual, approximal and sulcal caries in rats.

The correlation of morsal with sulcal, bucco-lingual and approximal caries scores of rats was compared. The morsal with bucco-lingual plus approximal correlation was significantly better than the morsal with sulcal correlation. When reporting rat caries, sulcal scores should be reported alone; morsal scores should be grouped with bucco-lingual and approximal to demonstrate total smooth surface lesions.

Statistical relationship of morsal to bucco-lingual, approximal and sulcal caries in rats.

The correlation of morsal with sulcal, bucco-lingual and approximal caries scores of rats was compared. The morsal and bucco-lingual plus approximal correlation was significantly better than the morsal with sulcal correlation. When reporting rat caries, sulcal scores should be reported alone; morsal scores should be grouped with bucco-lingual and approximal to demonstrate total smooth surface lesions.

Bicarbonate-based dental powder, fluoride, and saccharin inhibition of dental caries associated with Streptococcus mutans infection of rats.

The effects of NaHCO3-based dental powder containing NaF and sodium saccharin on dental caries and Streptococcus mutans recoveries in rats were studied. Weanling specific-pathogen-free Osborne-Mendel (SPFOM) rats were inoculated with S. mutans NCTC-10449S. Four infected groups were topically treated with either demineralized water (DW), a dental powder suspended such that there was 1 part solid per 2 parts DW, 0.073% NaF, or a combination of 0.073% NaF and 0.5% Na-saccharin (Nas). NaF-supplemented DW (at 10 ppm F-) was provided to a 5th group of infected rats as a positive treatment control, but this group was otherwise untreated. A sixth but uninfected group was topically treated with DW. All topical treatments were given once for 1 min daily per rat, for 5 days per week. Animals' teeth were swabbed for recovery of 10449S and total recoverable flora. Recoveries of 10449S were lower from powder-treated rats than from DW-treated rats. This difference approached but did not reach statistical significance. Total caries scores were 51% lower for the dental powder, 36% lower for the topical NaF, 34% lower for the combined NaF-Nas, and 54% lower for the NaF-supplemented drinking water group, all p less than 0.001. While all of the treatments inhibited smooth-surface caries, the dental powder effects, like those for the combined NaF-Nas, and NaF drinking water, were evident in fissure tooth surfaces as well.(ABSTRACT TRUNCATED AT 250 WORDS)

Transformation efficiency of EMS-induced mutants of Streptococcus mutans of altered cell shape.

Some Streptococcus mutans strains change shape from bacillary to coccal or ellipsoid form in response to the ratio of bicarbonate to potassium or of borate to potassium in growth media. So that insight into determinants of shape of these streptococci could be gained, and future genetic studies facilitated, the shapes of a series of transformable and nontransformable strains of S. mutans were studied and attempts made to isolate a mutant of augmented transformability. Several strains were mutagenized by ethylmethane sulfonate and mutants with altered colonial and cellular morphologies isolated. Cell shapes were studied by Gram stain and Nomarski interference microscopy, and by scanning and transmission electron microscopy. Diverse shape-altered mutants were isolated from seven transformable and two nontransformable strains of S. mutans. Among these, length-to-width ratios ranged from > 10 to about 0.25. Regulation of timing of cell division, septum formation, or septum completion events may have been altered in these mutants. While most mutants substantially or completely lost transformability, mutant LT11 had transformation efficiency of 1.3 x 10(-4) to 2.3 x 10(-3), more than two to three orders of magnitude greater than its parental UA159 and the well-known transformable strain GS5(HK), respectively. There was no evidence of production of competence factor by LT11. Competence of LT11 was maintained for at least six months upon storage at -70 degrees C, facilitating its use for genetic studies. While the morphologies of several shape-altered mutants were no longer responsive to changes of the bicarbonate/potassium, unlike those of their parentals, the morphology of LT11 persisted in its response to this condition.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of bicarbonate-based dental powder, fluoride, and saccharin on dental caries and on Streptococcus sobrinus recoveries in rats.

The effects of NaHCO3-based dental powder containing NaF and sodium saccharin on dental caries and Streptococcus sobrinus recoveries in rats were studied. Weanling specific-pathogen-free Osborne-Mendel (SPFOM) rats were inoculated with S. sobrinus 6715-13WT. One of six infected groups was topically treated with either demineralized water (DW), a dental powder suspended such that there was 1 part solid per 2 parts DW, 0.073% NaF, 0.5% Na-saccharin (Nas), or a combination of NaF and Nas at the same concentrations. NaF-supplemented DW (at 10 ppm F-) was provided to the 6th group of infected rats as a positive treatment control, but this group was otherwise untreated. A seventh but uninfected group was topically treated with DW. All topical treatments were given once for one min daily per rat, for five days per week. Animals' teeth were swabbed for recovery of 6715-13WT and total recoverable flora. At 37 days after start of treatment, S. sobrinus recoveries were lower only for those rats topically treated with the dental powder (p less than 0.05) by comparison with recoveries from the infected, topical DW-treated group. Caries scores, however, were 42% lower for the groups receiving the dental powder (p less than 0.005), 30% lower for those treated with the combined NaF-Nas (p less than 0.005), and 47% lower for the NaF-supplemented drinking water group (p less than 0.005). The dental powder effects, like those for the combined NaF-Nas and NaF drinking water, were evident on both smooth and fissure tooth surfaces. Both the 10 ppm F- drinking water and the dental powder significantly (p less than 0.005) reduced fissure caries scores below the level elicited by the indigenous mutans-free flora in the DW-treated uninfected rats; however, these reduction were not significantly different from one another. Thus, the 10 ppm F- drinking water and the dental powder equally inhibited not only the S. sobrinus-attributable component of caries but probably also the component of caries attributable to the indigenous oral flora.

In vitro studies of growth and competition between S. salivarius TOVE-R and mutans streptococci.

Streptococcus salivarius TOVE-R has previously been reported as a successful competitor with Streptococcus mutans 10449S and Streptococcus sobrinus 6715-13 WT on the teeth of rats. We studied, in vitro, some possible bases for this competition, including hydrogen peroxide or catalase production, bacteriocin or enocin production, and growth rates. Growth rates were measured spectrophotometrically in both complex and defined media. We studied conditions of aerobic and anaerobic incubation; glucose and sucrose medium supplementation at three concentrations each; various initial pH's; singly- or doubly-inoculated cultures; and half-strength, normal, or double-strength broth used both fresh and as culture filtrates. TOVE-R grew as well as did mutans streptococci at acid pH, decidedly better at alkaline pH, and nearly twice as fast near neutral pH. The average doubling time for TOVE-R was about 0.5 hr, while that for the mutans streptococci was about 1.0 hr. When TOVE-R was grown together with a mutans streptococcus, the growth rate observed for the doubly-inoculated culture was equal to or less than that of TOVE-R alone, never greater. The presence and proportions of both organisms in mixed cultures were confirmed by plate counts, direct specific immunofluorescence, and Nomarski interference microscopy. There was no evidence, by any of the methods employed, to indicate the production of an inhibitory substance against mutans streptococci by TOVE-R, or vice versa. Also, there was no evidence that the faster growth rate of TOVE-R could be attributed to nutrient limitation of the mutans streptococci.(ABSTRACT TRUNCATED AT 250 WORDS)

Salivary flow induction by buccal permucosal pilocarpine in anesthetized beagle dogs.

We tested whether permucosal delivery of pilocarpine nitrate could be used to elicit significant salivary secretion. Pilocarpine (pKa 6.6 at 37 degrees C) was applied as solutions (pHs 5.6, 6.6, 7.6; 15 mg/mL) to the buccal mucosa (2.8 cm2) of 6 anesthetized dogs. Saliva was collected continuously from cannulated submandibular and parotid ducts and blood sampled during and after drug administration. Plasma pilocarpine levels were determined by reversed-phase HPLC. Absorption rates were determined by use of data from separate zero-order intravenous infusions to the same dogs. Pilocarpine was buccally absorbed at a constant rate of 72.9 +/- 38.5 micrograms/kg/h following its application at pH 7.6. At this pH of the drug solution, the time to appearance of pilocarpine in blood plasma was 0.31 +/- 0.08 h, and the time to appearance of salivary flow was 0.86 +/- 0.32 h. A threshold dose of 32.9 +/- 7.5 micrograms/kg was required to induce secretion with the pH 7.6 drug, the steady-state submandibular flow rate was 0.14 +/- 0.11 mL/min/gland pair. Salivary flow induction was symmetrical and reached levels as high as 0.35 mL/min/submandibular gland pair without apparent tachyphylaxis. Results at pHs 5.6, 6.6, and 7.6 were consistent with the hypothesis that pilocarpine is primarily absorbed as un-ionized drug. The data indicate that transmucosal delivery of pilocarpine, avoiding "first pass" hepatic loss, may hold promise for the treatment of xerostomia.

A pharmacokinetic and pharmacodynamic study of intravenous pilocarpine in humans.

Pilocarpine (P) is of potential utility in the treatment of xerostomia. Because optimal development of P dosage forms for humans requires that its pharmacokinetics and pharmacodynamics be defined, this intravenous study of its disposition and associated salivary responses was performed. In a hospital setting, two healthy female subjects were given a series of graded doses of intravenous P or placebo to stimulate salivary secretion. Plasma levels of P, heart rate, blood pressure, and respiratory rate were simultaneously monitored. Other objective and subjective physiological parameters were assessed. Plasma concentrations of P declined either mono- or bi-exponentially with time, and brisk initial salivation was followed by prolonged salivation at doses > or = 1 mg. At doses between 0.5 and 3.5 mg, dose-independent pharmacokinetic parameters included a small steady-state volume of distribution (2.4 to 3.0 L/kg), a high plasma clearance (0.026 to 0.03 L/kg/min), and a mean residence time of approximately 100 min. The cumulative volume of whole saliva secreted during the first 3 h post-dose was linearly related to the area under the plasma concentration-time curve. Plasma concentrations from 1 to 42 ng/mL were associated with significant levels of salivation. The pharmacokinetic linearity of the system and proportionality between the area under plasma concentration-time curves and overall salivary response have important implications for the design and utilization of pilocarpine dosage forms.

Simultaneous caries induction and calculus formation in rats.

Weanling specific pathogen-free Osborne-Mendel rats were fed a high-calcium, high-phosphorus diet with various levels of sucrose and inoculated with Streptococcus sobrinus strain 6715-13WT and Actinomyces viscosus strain OMZ-105 in order to determine whether calculus and caries could develop simultaneously. Rats consumed diets designated RC-16-5, RC-16-25, or RC-16-50 which partially replaced the corn starch component with progressively higher levels of sucrose, thus, to 5, 25, or 50% sucrose. In general, bacterial recoveries of A. viscosus declined with higher sucrose content of the diet, but a pattern of recovery for S. sobrinus was less clear with respect to dietary sucrose. S. sobrinus, however, was recovered at higher percentages from the tooth surface flora at the later two of three sampling dates. Most calculus--identified by the brittle quality, staining characteristics, and apatitic x-ray diffraction patterns of tooth surface deposits--was formed on the maxillary molars, and most carious lesions occurred on mandibular molars. While there was minimal association of the calculus score with the amount of sucrose in the diet, calculus scores increased greatly from 23 to 43 days after infectious challenge. Caries scores, of both fissure and smooth surfaces, by contrast, increased in a dose-response fashion with increasing dietary sucrose and with time. It is thus possible to induce calculus formation and caries simultaneously in specific pathogen-free Osborne-Mendel rats consuming a high-calcium and -phosphorus diet conducive to calculus formation and containing sucrose.(ABSTRACT TRUNCATED AT 250 WORDS)

The repressible metabolism of sorbitol (D-glucitol) by intact cells of the oral plaque-forming bacterium Streptococcus mutans.

Sorbitol metabolism of Streptococcus mutans was studied. Cocci adapted to growth in sorbitol, glucose or both were challenged to grow on and to ferment those carbohydrates in pH-controlled defined media with intact cells capable of metabolic inductions and regulations. Glucose degradation when in high concentration did not depend upon induction of glucose-specific phosphoenolpyruvate-dependent phosphotransferase activity, as it did at low glucose concentrations. Sorbitol utilization was signalled by the induction of sorbitol-specific phosphoenolpyruvate-dependent phosphotransferase and sorbitol-6-phosphate dehydrogenase activities which persisted throughout the growth cycle. However, when even low levels of glucose were present, sorbitol transport and catabolic activities were rapidly repressed and they were not de-repressed until essentially all glucose had been utilized. Metabolism of sorbitol thus relies on the sorbitol phosphotransferase/sorbitol-6-phosphate dehydrogenase pathway whose activity is sensitively repressed in the presence of glucose.

Oral colonization and cariogenicity of Streptococcus gordonii in specific pathogen-free TAN:SPFOM(OM)BR rats consuming starch or sucrose diets.

The significance of Streptococcus gordonii in dental caries is undefined, as is that of other alpha-amylase-binding bacteria (ABB) commonly found in the mouth. To clarify the ecological and cariological roles of S. gordonii our specific pathogen-free Osborne-Mendel rats, TAN:SPFOM(OM)BR, were fed either diet 2000 (containing 56% confectioner's sugar, most of which is sucrose) or diet 2000CS (containing 56% cornstarch, in lieu of confectioner's sugar) and inoculated with S. gordonii strains. Uninoculated rats were free of both indigenous mutans streptococci (MS) and ABB, including S. gordonii, as shown by culture on mitis salivarius and blood agars of swabs and sonicates of dentitions after weanlings had consumed these diets for 26 days. ABB were detected by radiochemical assay using [125I]-amylase reactive to alpha-amylase-binding protein characteristic of the surface of S. gordonii and other ABB. No ABB were detected (detection limit < 1 colony-forming units in 10(6) colony-forming units). Thus the TAN:SPFOM(OM)BR colony presents a 'clean animal model' for subsequent study. Consequently, S. gordonii strains Challis or G9B were used to inoculate weanling rat groups consuming either the high-sucrose diet 2000 or the cornstarch diet 2000CS. Two additional groups fed each of these diets remained unioculated. Recoveries of inoculants were tested 12 and 26 days later by oral swabs and sonication of the molars of one hemimandible of each animal, respectively. Uninoculated animals were reconfirmed to be free of ABB and mutans streptococci, but inoculated ones eating diet 2000CS had S. gordonii recoveries of 1-10% or, if eating diet 2000, 10-30% of total colony-farming units in sonicates. There were no statistically significant differences among the inoculated and uninoculated animal groups' caries scores when they ate the cornstarch diet. Lesion scores for sucrose-eating rats were, however, from 2.4-5.1-fold higher than for cornstarch-eating rats, P < 0.001, and were still higher if animals had been inoculated with either Challis (1.41-fold) or G9B (1.64-fold), than if uninoculated, both P < 0.001, so long as the rats ate the sucrose diet. Therefore, TAN:SPFOM(OM)BR rats do not harbour ABB or S. gordonii but can be colonized by S. gordonii. Colonization levels of S. gordonii on the teeth are higher in the presence of high sucrose than with high starch-containing diets. Caries scores are augmented by sucrose compared with starch, and are further augmented by S gordonii colonization. S. gordonii is thus cariologically significant in the presence of sucrose, at least in this rat.

Genetic alterations of Streptococcus mutans' virulence.

The use of mutants defective in caries-associated traits has enabled the genetic dissociation of agglutination from adhesion, the demonstration of serotype-specific contributions of IPS to virulence, the importance of glucanohydrolase to virulence to a greater degree than to plaque formation, and the apparent lack of importance of agglutination to virulence. We have also been able to demonstrate the ability of plaque formation-defective mutants and other variants both to infect and to emerge, yet not to cause disease. Additional mutants, currently under study in our laboratory include fructanase, invertase, and sucrose permease-defectives. Ultimately, the identification of key, probably surface-associated virulence factors will offer more potent and specific antigens for directed immune responses by the host.

Current trends of sugar consumption in developing societies.

This paper reviews recent data on sugar consumption in developing countries that may lead to a potential increase in caries prevalence. A search of the business, dental and nutritional literature was conducted through May 1995. There is evidence that sugar (sucrose) use was increasing in China, India, and Southeast Asia. In South and Central America (except Haiti) sugar use was either equivalent to or higher than that in most developed societies. In the Middle East, average sugar use was higher than that of other developing areas. However, it was either lower than or equivalent to the levels reported by other developed countries. Many central African countries consumed less than 15 kg of sugar/ person/year. Of particular concern is a rise in the consumption of sugar-containing carbonated beverages in a number of developing societies: China, India, Vietnam, Thailand, and other Southeast Asian countries are currently major growth markets for the soft drink industry. Consumption of high-sugar desserts and snacks may also be increasing in urban centers in some developing countries. To counteract the potential increase in the prevalence of dental caries in some developing countries, preventive and oral health promotion programs should be planned and implemented. We contend that taxation of sugar-containing products as well as efforts to reduce the level of sugar consumption to "safe" levels may be impractical, and in most countries, cannot be supported for political, economic, or health reasons. Instead, we recommend that collaboration be established between public health authorities and manufacturers/distributors of soft drinks and sweets in developing countries to establish a dental health fund that could be used to support caries preventive programs. The fund could be supported through donations from manufacturers based on the principle of the "milli-cent" (1 cent for every 1000 cents of sales). This minimal contribution would provide enough financial support for planning and implementing dental preventive and restorative programs in developing countries.

Xylitol chewing gum and dental caries.

There is an extensive peer-reviewed literature on xylitol chewing gum as it pertains to effects on tooth decay in human subjects, on human dental plaque reduction, on inhibition of dental plaque acid production, on inhibition of the growth and metabolism of the mutans group of streptococci which are the prime causative agents of tooth decay, on reduction of tooth decay in experimental animals, and on xylitol's reported contribution to the remineralisation of teeth. The literature not only supports the conclusion that xylitol is non-cariogenic but it is now strongly suggestive that xylitol is caries inhibitory, that is, anti-cariogenic in human subjects, and it supplies reasonable mechanistic explanation(s).