***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The aim of this study was to investigate whether DMFS increment can be decreased among children with active initial caries by oral hygiene and dietary counseling and by using noninvasive preventive measures . Except for mentally disabled and h and icapped children attending special schools , all 11- to 12-year-olds in Pori , Finl and , with at least one active initial caries lesion were invited to participate in the study and were then r and omized into two groups . Children in the experimental group ( n = 250 ) were offered an individually design ed patient-centered preventive program aim ed at identifying and eliminating factors that had led to the presence of active caries . The program included counseling sessions with emphasis on enhancing use of the children ’s own re sources in everyday life . Toothbrushes , fluoride toothpaste and fluoride and xylitol lozenges were distributed to the children . They also received applications of fluoride/chlorhexidine varnish .  The children in the control group ( n = 247 ) received basic prevention offered as st and ard in the public dental clinics in Pori . For both groups , the average follow-up period was 3.4 years . A community level program of oral health promotion was run in Pori throughout this period . Mean DMFS increments for the experimental and control groups were 2.56 ( 95 % CI 2.07 , 3.05 ) and 4.60 ( 3.99 , 5.21 ) , respectively ( p < 0.0001 ) : prevented fraction 44.3 % ( 30.2 % , 56.4 % ) . The results show that by using a regimen that includes multiple measures for preventing dental decay , caries increment can be significantly reduced among caries-active children living in an area where the overall level of caries experience is low OBJECTIVES The aim of this 3-year community intervention trial was to determine the caries preventive effect of sugar-substituted chewing gum among Lithuanian school children , and to assess compliance with the instructions for gum use . METHODS A total of 602 children , aged 9 - 14 years , from 28 school classes in five secondary schools in Kaunas , Lithuania , were given a baseline clinical and radiographic caries examination . The schools were r and omly allocated to receive one of the following interventions : sorbitol/carbamide gum ; sorbitol gum ; xylitol gum ; control gum ; and no gum . Children in the four active intervention groups were asked to chew at least five pieces of gum per day , preferably after meals . The children were reexamined clinical ly after 1 , 2 and 3 years , and radiographically after 3 years . Self-reported compliance was monitored anonymously four times during the study . RESULTS A total of 432 children were available at the 3-year clinical follow-up examination . The crude mean 3-year caries increments ( DMFS -- all stages of lesion formation ) were 11.8 for the sorbitol/carbamide gum group ; 9.0 for the sorbitol gum group ; 8.1 for the xylitol gum group ; 8.3 for the control gum group ; and 12.4 for the no gum group . The adjusted 3-year caries increments were statistically significantly lower in the sorbitol gum group , the xylitol gum group and the control gum group than in the no gum group , whereas no statistically significant difference was seen between the no gum group and the sorbitol/carbamide gum group . Adjusted 3-year caries increments in the xylitol gum group and the sorbitol gum group did not differ statistically significantly from the caries increments in the control gum group . Compliance with the study protocol was better in School C ( xylitol gum ) than in the other schools . In all schools , compliance decreased over time . CONCLUSION The results indicate that the caries preventive effect of chewing sugar-free gum is related to the chewing process itself rather than being an effect of gum sweeteners or additives , such as polyols and carbamide Background Habitual consumption of xylitol reduces mutans streptococci ( MS ) levels but the effect on Lactobacillus spp . is less clear . Reduction is dependent on daily dose and frequency of consumption . For xylitol to be successfully used in prevention programs to reduce MS and prevent caries , effective xylitol delivery methods must be identified . This study examines the response of MS , specifically S. mutans/sobrinus and Lactobacillus spp . , levels to xylitol delivered via gummy bears at optimal exposures . Methods Children , first to fifth grade ( n = 154 ) , from two elementary schools in rural Washington State , USA , were r and omized to xylitol 15.6 g/day ( X16 , n = 53 ) or 11.7 g/day  ( X12 , n = 49 ) , or maltitol 44.7 g/day ( M45 , n = 52 ) . Gummy bear snacks were pre-packaged in unit-doses , labeled with ID numbers , and distributed three times/day during school hours . No snacks were sent home . Plaque was sample d at baseline and six weeks and cultured on modified Mitis Salivarius agar for S. mutans/sobrinus and Rogosa SL agar for Lactobacillus spp . enumeration . Results There were no differences in S. mutans/sobrinus and Lactobacillus spp . levels in plaque between the groups at baseline . At six weeks , log10S . mutans/sobrinus levels showed significant reductions for all groups ( p = 0.0001 ) : X16 = 1.13 ( SD = 1.65 ) ; X12 = 0.89 ( SD = 1.11 ) ; M45 = 0.91 ( SD = 1.46 ) . Reductions were not statistically different between groups . Results for Lactobacillus spp . were mixed . Group X16 and M45 showed 0.31 ( SD = 2.35 ) , and 0.52 ( SD = 2.41 ) log10 reductions , respectively , while X12 showed a 0.11 ( SD = 2.26 ) log10 increase . These changes were not significant . Post- study discussion s with school staff indicated that it is feasible to implement an in-classroom gummy bear snack program . Parents are accepting and children willing to consume gummy bear snacks daily . Conclusion Reductions in S. mutans/sobrinus levels were observed after six weeks of gummy bear snack consumption containing xylitol at 11.7 or 15.6 g/day or maltitol at 44.7 g/day divided in three exposures . Lactobacillus spp . levels were essentially unchanged in all groups . These results suggest that a xylitol gummy bear snack may be an alternative to xylitol chewing gum for dental caries prevention . Positive results with high dose maltitol limit the validity of xylitol findings . A larger clinical trial is needed to confirm the xylitol results .Trial registration [ IS RCT N63160504 Objective : The aim of this study was to test the efficacy of long-term , daily intake of erythritol and xylitol c and y , compared with sorbitol c and y , on the development of enamel and dentin caries lesions . Methods : The study was a double-blind r and omized controlled prospect i ve clinical trial . Altogether 485 primary school children , first- and second- grade rs at baseline , from southeastern Estonia participated in this 3-year intervention . Each child consumed four erythritol , xylitol or sorbitol ( control ) c and ies three times per school day . The daily intake of polyol was about 7.5 g. The International Caries Detection and Assessment System ( ICDAS ) was used in the clinical examinations by four calibrated examiners at baseline and at 12 , 24 and 36 months . Results : The annual examination analyses and the follow-up analyses confirmed that the number of dentin caries teeth and surfaces at 24 months follow-up and surfaces at 36 months follow-up was significantly lower in the mixed dentition in the erythritol group than in the xylitol or control group . Time of enamel/dentin caries lesions to develop and of dentin caries lesions to progress was significantly longer in the erythritol group compared to the sorbitol and xylitol groups . Also the increase in caries score was lower in the erythritol group than in the other groups . Conclusions : In the follow-up examinations , a lower number of dentin caries teeth and surfaces was found in the erythritol group than in the xylitol or control groups . Time to the development of caries lesions was longest in the erythritol group . Trial registration : Clinical Trials.gov Identifier NCT01062633 Dental caries is a p and emic infectious disease which can affect the quality of life and consumes considerable health care re sources . The chewing of xylitol , sorbitol , and even sugar gum has been suggested to reduce caries rates . No clinical study has simultaneously investigated the effectiveness of these gums when compared with a group receiving no chewing gum . A 40-month double-blind cohort study on the relationship between the use of chewing gum and dental caries was performed in 1989 - 1993 in Belize , Central America . One thous and two hundred and seventy-seven subjects ( mean age , 10.2 years ) were assigned to nine treatment groups : one control group ( no supervised gum use ) , four xylitol groups ( range of supervised xylitol consumption : 4.3 to 9.0 g/day ) , two xylitol-sorbitol groups ( range of supervised consumption of total polyols : 8.0 to 9.7 g/day ) , one sorbitol group ( supervised consumption : 9.0 g/day ) , and one sucrose group ( 9.0 g/day ) . The gum use during school hours was supervised . Four calibrated dentists performed the caries registration s by means of a modified WHO procedure . The primary endpoint was the development of an unequivocal caries lesion on a non-cavitated tooth surface . Compared with the no-gum group , sucrose gum usage result ed in a marginal increase in the caries rate ( relative risk , 1.20 ; 95 % confidence interval , 0.96 to 1.49 ; p = 0.1128 ) . Sorbitol gum significantly reduced caries rates ( relative risk , 0.74 ; 95 % confidence interval , 0.6 to 0.92 ; p = 0.0074 ) . The four xylitol gums were most effective in reducing caries rates , the most effective agent being a 100 % xylitol pellet gum ( relative risk , 0.27 ; 95 % confidence interval , 0.20 to 0.36 ; p = 0.0001 ) . This gum was superior to any other gum ( p < 0.01 ) . The xylitol-sorbitol mixtures were less effective than xylitol , but they still reduced caries rates significantly compared with the no-gum group . DMFS analyses were consistent with these conclusions . The results suggest that systematic usage of polyol-based chewing gums reduces  caries rates in young subjects , with xylitol gums being more effective than sorbitol gums OBJECTIVES To evaluate the effectiveness of a xylitol pediatric topical oral syrup to reduce the incidence of dental caries among very young children and to evaluate the effect of xylitol in reducing acute otitis media in a subsequent study . DESIGN Double-blind r and omized controlled trial . SETTING Communities in the Republic of the Marshall Isl and s. PARTICIPANTS One hundred eight children aged 9 to 15 months were screened , and 100 were enrolled . Intervention Children were r and omized to receive xylitol topical oral syrup ( administered by their parents ) twice a day ( 2 xylitol [ 4.00-g ] doses and 1 sorbitol dose ) ( Xyl-2 x group ) or thrice per day ( 3 xylitol [ 2.67-g ] doses ) ( Xyl-3x group ) vs a control syrup ( 1 xylitol [ 2.67-g ] dose and 2 sorbitol doses ) ( control group ) . MAIN OUTCOME MEASURES The primary outcome end point of the study was the number of decayed primary teeth . A secondary outcome end point was the incidence of acute otitis media for reporting in a subsequent report . RESULTS Ninety-four children ( mean [ SD ] age , 15.0 [ 2.7 ] months at r and omization ) with at least 1 follow-up examination were included in the intent-to-treat analysis . The mean ( SD ) follow-up period was 10.5 ( 2.2 ) months . Fifteen of 29 of the children in the control group ( 51.7 % ) had tooth decay compared with 13 of 32 children in the Xyl-3x group ( 40.6 % ) and eight of 33 children in the Xyl-2x group ( 24.2 % ) . The mean ( SD ) numbers of decayed teeth were 1.9 ( 2.4 ) in the control group , 1.0 ( 1.4 ) in the Xyl-3x group , and 0.6 ( 1.1 ) in the Xyl-2x group . Compared with the control group , there were significantly fewer decayed teeth in the Xyl-2x group ( relative risk , 0.30 ; 95 % confidence interval , 0.13 - 0.66 ; P = .003 ) and in the Xyl-3x group ( 0.50 ; 0.26 - 0.96 ; P = .04 ) . No statistical 
    Output:
    
The present systematic review examining the effectiveness of  xylitol on caries incidence in children showed a small effect size in r and omized controlled trials and a very low quality of evidence that makes preventive action of xylitol uncertain