Efficacy of Fluoride, Xylitol, and Motivational Interventions for Preventing Dental Caries in the Pediatric Population:
A Systematic Review

by Emory Page, Biology

Dental caries is a major oral health issue that affects children across the globe. There are various preventive methods that have been developed over time, but there is still need for identification of the most effective method available. This systematic review evaluates the efficacy of xylitol, fluoride, and motivational interventions in preventing dental caries among children. A comprehensive search of PubMed was performed to select twelve studies published in the last twenty-two years including only those in the pediatric population. Each study analyzed one of these interventions on pediatric dental caries reduction. Findings indicate that fluoride-based products, including water fluoridation, salt fluoridation, and varnishes, were the most effective, achieving a consistent caries reduction rate of 17–36% and even up to 66.3%. Xylitol, although somewhat effective, demonstrated a lower reduction than fluoride in caries prevention. Motivational interventions aimed at promoting oral hygiene behaviors showed inconsistent effects on caries reduction; however, they proved beneficial as supportive measures, enhancing adherence to other preventive practices. The evidence suggests that fluoride interventions remain the most effective method for caries prevention in children, with a clear advantage in caries reduction over other methods. In contrast, xylitol could potentially serve as a supportive preventive option, and motivational interventions are best used as complementary tools that enhance the effects of clinical treatments like fluoride. In summary, this review supports prioritizing fluoride products in pediatric dental care to maximize caries prevention, with xylitol and motivational approaches as potential adjuncts to optimize patient adherence and outcomes.

pediatric dental caries, caries prevention, caries reduction, fluoride interventions, xylitol products, motivational interventions

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Introduction

Dental caries, commonly known as tooth decay, are one of the most prevalent oral diseases in children. This disease poses a difficult public health issue, especially in the younger population, leading to severe pain and tooth loss. According to the CDC, nearly 46% of children, ages 2–19, have been affected by dental caries at some point in their life [1]. Instilling proper oral health techniques and implementing the most effective preventive methods is imperative for long-term oral health during formative stages of dental development.

Dental caries is a disease formed by a combination of factors, including behavioral and biological factors. This oral disease involves adherent cariogenic bacteria that metabolizes sugars left on teeth. The metabolism of these sugars forms acids on the surface of teeth that eventually demineralize the tooth leading to decay. This process can be hindered through multiple means including dietary changes, behavioral changes, and means of inhibiting cariogenic bacteria.

Many studies and reviews have been published to identify preventive methods, but there has not yet been a comparative review to identify the most effective and efficacious method available. There are three very common preventive methods used to prevent dental caries in children, including Xylitol products, fluoride, and motivational interviews. Many studies and reviews have analyzed the benefits and efficacy of these three methods individually [2, 3, 4], proving that fluoride, Xylitol products, and motivational interviews aid in the prevention of dental caries for younger populations in various ways. While these methods have been available for years, the question of which preventive method is the most effective for children has not yet been answered.

Xylitol is a sugar alcohol that has gained popularity as a preventive method for dental caries in recent years. This alcohol is used as a substitute for sugar in many commonly used products such as mints, chewing gum, sweets, and even milk [5]. Cariogenic bacteria do not metabolize this sugar substitute, which means that acids typically formed from sugars do not form to have their demineralizing effects on teeth [5]. More studies have shown the positive effects of Xylitol, such as reduction of bacteria and prevention of tooth decay, resulting in its increasing popularity [6]. However, some continue to question Xylitol as a caries preventive method due to some inconsistencies of its effectiveness when used to inhibit the development of caries [6]. As a more recently discovered method, questions still remain about the proper dosages and modalities to reap the most benefits from Xylitol products.

Fluoride has been a key player in the prevention of dental caries across all age groups for years [7]. Fluoride benefits teeth in a variety of ways including strengthening tooth enamel, inhibiting cariogenic bacteria, and enhancing remineralization. This compound has been administered in many ways such as toothpaste, mouth wash, water, and varnish. A variety of studies and reviews have shown the positive impact of fluoride on the prevention of dental caries, especially in pediatric patients [2, 7]. Despite the benefits of fluoride on teeth, many have refrained from using fluoride due to the belief that fluoride can impair brain development in young children. Many also worry about the overuse and implementation of fluoride that can lead to fluorosis, or brown speckles on the surface of teeth [8]. These issues have led to many communities refusing to implement water fluoridation and other fluoride modalities.

Dental caries can be prevented by means other than medicinal modalities. Behavioral and dietary changes can have a long-term effect on the prevention of tooth decay for younger populations [9]. Motivational interviewing is a form of counseling used to instill motivation for changes in behavior. This technique uses multiple principles to help patients take control of their health. In this case, motivational interviewing is used to inform people of proper oral health tactics such as brushing teeth, flossing, and using other oral health products to maintain a healthy oral environment. Similarly, parents can inform and motivate their children to attend dental visits regularly and avoid a sugary diet in an effort to prevent demineralization of teeth in the long-term. Motivational interviewing, for many, can be an effective preventive method for dental caries [4], but questions of its efficacy still remain among dental professionals [9].

With new studies and literature on Xylitol products, fluoride, and motivational interviewing, more knowledge on the efficacy and proper modalities of each method is available. The need to identify the most effective of these methods still remains as there has not been a review directly comparing these methods on the efficacy of preventing dental caries in children. Tooth decay continues to be a public health issue among pediatric populations, so it has become even more imperative to identify the most efficacious of these methods. This review aims to analyze relevant scientific literature pertaining to these methods to examine both strengths and weaknesses of each method. In doing so, it will be possible to identify the best method or methods for the prevention of tooth decay in young populations. This review will contribute to future research and clinical practices, hopefully, to develop a more cost effective and accessible caries intervention for pediatric patients across the world. As more families have the ability to access these methods, the public health issue of dental caries will decrease dramatically.

Methods

2.1  Search Strategy

Electronic databases such as PubMed were searched during the data collection process. Google Scholar and other databases were not included in the search as they do not have the same reliability as PubMed. The initial search included terms such as “dental caries,” “fluoride,” “Xylitol,” “motivational interventions,” and “dental caries in children.” Information and data related to these terms included clinical studies, controlled clinical trials, and surveys. Clinical studies and controlled trials tended to provide more data for the effects of fluoride and Xylitol, while surveys tended to provide more data for motivational interviews. The only language in which these data were considered was English; no other language was considered for this review. In order to develop a nuanced review, only scientific literature between 2010 and to present was used.

2.2  Eligibility Criteria

In this systematic review, subjects from all sexes and races were included, however, the age range was specific to children and adolescents. This review focuses on preventive methods for dental caries in children, so sex and race were no factor to be considered. Similarly, there were no further restrictions such as those on socioeconomic class and geographical location.

Only clinical studies and controlled clinical trials involving preventive methods for dental caries were included, while literature for other oral diseases was omitted. Due to the small number of articles on certain preventive methods for dental caries in children, the form in which a certain method was administered was not considered. Xylitol, fluoride, and motivational interventions can be administered and applied in various ways, so all methods were considered and included.

2.3  Data Extraction

The data extraction process consisted of sample size, study design, treatment type, and outcomes of treatment. The samples sizes were only accepted if they included 500 or more participants, however, one exception was made for a trial consisting of slightly over 100 participants due to lack of trials available. Fluoride, Xylitol, and motivational interviews were analyzed by comparing the outcomes they had on preventing dental caries in children. This data includes the percentage of children with dental caries after the treatment was administered and the percentage of children without dental caries after the treatment. Four articles pertaining to each of the preventive methods were selected resulting in a culmination of twelve articles for this review. Again, a lack of available trials led to the use of only four articles for each treatment method in order maintain a fair data collection process. The literature used in this review was ensured to be reliable by obtaining data from PubMed, a reputable database, rather than sources such as Google Scholar.

Results

3.1 Study Selection and Characteristics

The PubMed search resulted in the accumulation of twelve studies; four studies pertaining to each method were selected. These studies consisted of three clinical trials [11, 15, 22], five randomized controlled trials [12, 14, 17, 19, 20], two randomized double-blind trials [16, 21], one controlled survey [13], and one field trial [18] that evaluated the efficacy of xylitol, fluoride, and motivational interventions in preventing dental caries in children. The studies ranged in sample size with seven studies consisting of around 100–450 participants [13, 15, 17, 18, 20, 21, 22], four studies including 500–1000 [11, 12, 16, 19], and one study including over 100,000 participants [14]. The location of each study differed as well with included study from Australia, Brazil, England, Estonia, Kuwait, Republic of Marshall Islands, The Gambia, and The United States. The participants of these studies were all <18 years old, but many studies focused primarily on children aged two to six years of age [11, 12, 13, 21, 22].

Table 1. Summary of twelve included studies on prevention of dental caries in children.

3.2 Fluoride-Based Interventions

Table 2. Summary of included fluoride intervention studies on dental caries of children.

Fluoride-based interventions, primarily administered in the form of fluoride varnishes and water fluoridation, were analyzed in four studies [11, 12, 13, 14]. These studies [11, 12, 13, 14], showed that fluoride was associated with a 17–66.3% reduction in caries prevalence, depending on the mode of administering and prior caries risk. Fluoride varnish, when applied biannually, was found to be effective, with caries reduction rates of up to 36% observed in high-risk populations [11]. Silver diamine fluoride also showed high caries reduction with a 54% caries reduction [12]. Water fluoridation showed a decreasing trend of dental caries in children as its implementation prevented 17%-28% of caries and decreased 56% of dental extraction procedures [14]. Salt fluoridation showed a much larger reduction of dental caries, most likely stemming from the sample population including preschool children with a high risk of dental caries [13]. Long-term follow-up in all included studies [11, 12, 13, 14] demonstrated sustained effects of fluoride even after cessation of intervention.

3.3 Xylitol-Based Interventions

Table 3. Summary of included xylitol intervention studies on dental caries of children.

Four studies were used to investigate xylitol-based interventions, involving the administering of candies, oral syrup, and chewing gum for the prevention of dental caries [15, 16, 17, 18]. All of the studies demonstrated a reduction in caries formation in the xylitol groups compared to control groups [15, 16, 17, 18]. The reported caries reduction for all studies ranged from 13.4% to 60% over periods of six months up to three years. Most of the studies [16, 17, 18] placed emphasis on the dosage used with products containing a range of five grams up to 11.6 grams of xylitol, signifying that xylitol-based products are more effective in specific dosages.

3.4 Motivational Interventions

Table 4. Summary of included motivational intervention studies on dental caries of children.

Motivational interventions, including oral health education and behavior change strategies aimed at improving dental hygiene practices, were analyzed in four studies [19, 20, 21, 22]. The findings were mixed, with some studies showing no reduction of dental caries [19], one study showing a slight reduction of 7.9% [22], and two studies showing a reduction in caries incidence of 47.1% and 64.3% [20, 21]. In most studies [21], the efficacy of motivational interventions was dependent on the level of risk of the children and, in most cases, motivational interventions only improved knowledge of healthy habits, but did not increase implementation of these habits. Based on the large range of data obtained from the four studies [19, 20, 21, 22], the consistency of effectiveness of motivational interventions is unclear. Motivational interventions alone were generally less efficacious than xylitol or fluoride-based methods and would be more beneficial if combined with fluoride or xylitol interventions.

3.5 Summary of Findings

Table 5. Summary of all included intervention studies on dental caries of children.

In summary, fluoride-based interventions appear to be the most efficacious method for preventing dental caries in children, with caries reduction rates consistently surpassing those of xylitol and motivational interventions in most studies. The range for percentage of caries prevention for fluoride interventions was 17%–66.3%, while range for xylitol interventions was only 8.8%–60%. Xylitol-based interventions, in many cases, were moderately effective, while motivational interventions showed the least caries reduction when applied independently.

Discussion

This systematic review includes 12 studies from the last 22 years examining the efficacy of fluoride, xylitol, and motivational interventions in preventing dental caries in children. Fluoride-based interventions, including varnish, water fluoridation, and salt fluoridation, emerged as the most effective method, consistently inhibiting demineralization and enhancing remineralization. Three of the four studies on fluoride-based interventions incorporated randomization, increasing the reliability of the evidence [11, 12, 13]. The efficacy of fluoride interventions ranged from 17–36% caries reduction in two studies [11, 14] to 54–66.3% in two others [12, 13], with the highest reduction reported across all included studies. Fluoride’s consistent effectiveness and high ceiling of benefit when used to prevent dental caries strongly supports fluoride as the most efficacious method. In contrast to xylitol and motivational interventions, fluoride showed less variability in outcomes and more consistent positive effects across different application methods. The overall range of caries reduction for fluoride, 17–66.3%, includes both moderate and high levels of efficacy, reflecting its adaptability across diverse contexts [11, 12, 13, 14].

Xylitol interventions demonstrated moderate efficacy by reducing cariogenic bacteria, though results were inconsistent. Two studies reported reductions of 8.8–27.8% [17, 18], while the two remaining studies showed reductions of 13.4–44.1% [15] and 35–60% [16]. Despite some higher values of caries reduction, the broad range and variability lowered confidence in the findings.

Motivational interventions, aimed at improving oral hygiene habits, showed similar inconsistent results. One study reported no reduction in caries [19], while another found a reduction of 64.3% [21]. Other studies reported reductions of 7.9% [22] and 47.1% [20], highlighting the difficulty in drawing firm conclusions. Given its consistent effectiveness among the four studies, fluoride has been identified as the most reliable of the three methods for preventing pediatric dental caries.

The studies reviewed targeted diverse pediatric age groups and included various fluoride and xylitol application methods. Of the 12 studies, 11 utilized randomization [11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22], with the single non-randomized study focusing on xylitol [18]. Evidence quality was strongest for fluoride, while xylitol and motivational approaches exhibited significant variability due to differences in dosage, application frequency, and study duration. The effectiveness of xylitol and motivational interventions largely depends on adherence, which can vary among families of different socioeconomic backgrounds. Fluoride’s proven effectiveness across multiple populations supports its role as a primary preventive measure, while further research is needed to confirm the broader impact of xylitol and motivational interventions, particularly in high-risk groups. Each xylitol study used a different dosage, making efficacy difficult to assess. Motivational interventions, reliant on self-reported parental adherence, were prone to bias, further complicating assessments of their long-term impact. Standardized study designs with consistent dosages and methodologies would improve the reliability of findings on xylitol and motivational approaches.

Future research should focus on optimizing fluoride and xylitol combinations, particularly for high-risk children, and identifying cost-effective preventive strategies. Many families lack access to these interventions due to financial constraints, making affordability a key consideration. Further studies should determine the proper xylitol dosage and application method through standardized trials across multiple pediatric populations. More rigorous research on motivational interventions is needed, particularly those using sustainable support programs that ensure consistent adherence. Investigating the cost-effectiveness of combined approaches could be valuable for underserved populations where proper oral health education is lacking.

Potential biases in this review include selection and publication bias, as only English-language studies from PubMed were included. This may have excluded relevant research from other databases or languages, limiting the generalizability of findings. The heterogeneity of study designs and outcomes, particularly for xylitol and motivational interventions, may have introduced interpretation bias. Despite efforts to minimize these limitations through thorough searches and independent assessments, they should be considered when interpreting the findings.

These results align with prior research confirming fluoride as the most reliable preventive measure for dental caries in children due to its well-documented cariostatic effects and accessibility [2, 7]. While some previous literature suggested xylitol as an effective prevention method [23], this review supports recent literature indicating its variable efficacy [6], positioning it as an adjunct rather than a primary preventive measure. Motivational interventions also showed inconsistent effectiveness, largely dependent on caretaker involvement. Overall, fluoride remains the most effective approach for preventing pediatric dental caries, while xylitol and motivational strategies provide supplementary rather than primary benefits.

Conclusion

In conclusion, this systematic review highlights fluoride-based interventions as the most effective standalone method for preventing dental caries in children, offering consistent reduction of dental caries across diverse pediatric populations. While xylitol and motivational interventions showed some potential benefits, their efficacy was less consistent, largely due to challenges with adherence, variability in study designs, and variability of dosages. Xylitol’s role appears to be complementary, primarily enhancing the effects of fluoride in high-risk children, while motivational interventions, similarly, are used as a means to instill proper oral health techniques which further enhance the benefits of fluoride. Overall, fluoride-based interventions remain the cornerstone of pediatric caries prevention, but incorporating xylitol and motivational approaches could dramatically improve outcomes, especially for high-risk populations. Further research into optimal dosages and delivery techniques, along with long-term, standardized studies to assess sustained benefits could identify xylitol or motivational interventions as more efficacious. However, fluoride remains the most effective preventive method at this time. It is imperative that more studies are performed to identify and implement effective, accessible caries prevention programs for children.

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Acknowledgements: I would like to express my gratitude to Dr. Holly Gallagher for all of her valuable insights and guidance.

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