WHAT CAN ORAL PUBLIC HEALTH LEARN FROM FINLAND?

Dental caries are the most prevalent chronic childhood disease in the United States, and the burden of this condition falls heavily on socially disadvantaged children. Findings from numerous reports have demonstrated that there is an oral health gap in the United States—ethnic minorities, children of low-income families, and children whose parents have less educational attainment have the worst caries outcomes. Commonly listed reasons relate to access to care and include inability to afford preventive and therapeutic care, a shortage of minority dentists, ineffective insurance coverage, and poor diet.

In their editorial “Strengthening the Oral Health Safety Net: Delivery Models That Improve Access to Oral Health Care for Uninsured and Underserved Populations,” Formicola and colleagues state that “reducing disparities in oral health requires both institutional and health policy changes.”1 One institutional shift that could serve to improve oral health can be found in Finland—use of xylitol for caries prevention.

Xylitol, a sugar substitute that is not fermentable by oral microflora, is considered an anticariogenic agent.2 It is a 5-carbon-sugar alcohol (pentitol) approved by the US Food and Drug Administration as a food sweetener.3 Multiple clinical and field trials have demonstrated that the addition of xylitol to the diet dramatically reduces the incidence of dental caries,4–7 and this reduction seems to continue long after use of xylitol is terminated. 7 One study in Finland demonstrated that a school-based xylitol program was equal in caries prevention to a pit and fissure sealant program.8 Xylitol-based chewing gum is a mainstay for prevention in Finland, where in 1998 45% of boys and 63% of girls in a nationally representative survey of 11-, 13-, and 15-year-olds used xylitol gum daily.9

Caries prevention strategies employed in the United States, such as cleanings and application of sealants, are performed in clinical settings. Healthy People 2010 specifically calls for measures that would target oral health preventative procedures to poor inner-city children in school-based or school-linked programs.10 Distributing gum or candy to children is inherently low-tech. The xylitol research is significant because a low-cost, quickly implementable caries prevention strategy that can circumvent barriers could lessen oral health disparities in the United States.