|Year : 2022 | Volume
| Issue : 1 | Page : 19-22
Estimating the effectiveness of lollipops containing xylitol and erythritol on salivary pH in 3–6 years olds: A randomized controlled trial
Sakshi Jain, Shivani Mathur
Department of Pediatric and Preventive Dentistry, ITS-CDSR, Ghaziabad, Uttar Pradesh, India
|Date of Submission||11-Feb-2021|
|Date of Decision||09-Jan-2022|
|Date of Acceptance||03-Feb-2022|
|Date of Web Publication||13-Apr-2022|
Dr. Sakshi Jain
Department of Pediatric and Preventive Dentistry, ITS-CDSR, Muradnagar, Ghaziabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Prevention of dental caries is important for nutrition and health of the child. Sucrose being considered an arch criminal, various substitutes are recommended. Xylitol is an artificial sweetener which cannot be metabolized by bacteria. Thus, it seems to be a promising method in prevention of dental caries. Materials and Methods: Fifty children between the age of 3–6 years were randomly divided into two groups; Group 1: Control group (without lollipops) and Group 2: Experimental group (with sugar substitute lollipops). The saliva sample was collected at four different time intervals, and pH of saliva was determined using universal pH indicator. Results: There was a significant drop in the pH after drinking sweetened beverages in both the groups, but there was a significant rise in pH after having xylitol + erythritol lollipops which almost returned to baseline after 15 min. Conclusion: Lollipops containing xylitol and erythritol can be used in small children and it has potential to increase salivary pH, thus not allowing the pH to fall below the critical value.
Keywords: Dental caries, erythritol, prevention, xylitol
|How to cite this article:|
Jain S, Mathur S. Estimating the effectiveness of lollipops containing xylitol and erythritol on salivary pH in 3–6 years olds: A randomized controlled trial. J Indian Soc Pedod Prev Dent 2022;40:19-22
|How to cite this URL:|
Jain S, Mathur S. Estimating the effectiveness of lollipops containing xylitol and erythritol on salivary pH in 3–6 years olds: A randomized controlled trial. J Indian Soc Pedod Prev Dent [serial online] 2022 [cited 2022 May 23];40:19-22. Available from: https://www.jisppd.com/text.asp?2022/40/1/19/343021
| Introduction|| |
Dental caries are the most common oral disease in children. It is a multifactorial disease where saliva and its constituents play an important role in the development of caries. Prevention of dental caries is important as caries influences mastication, nutrition, self-esteem, and health of the child., The most common cause of caries in children is sucrose consumption. There is drop in the salivary pH for a period of time to acidic levels after ingestion of food, especially sucrose. This drop in pH amplifies the demineralization of teeth which contributes to caries development. There are various strategies that are being used to combat caries over the years, however, the most promising caries control strategy is the substitution therapy (replacement of sucrose consumption).
Sugar substitutes (polyols) do not contribute to the formation of organic acid and plaque matrix leading to dental caries are considered more tooth-friendly. Xylitol is a five-carbon natural sugar alcohol and is used as an artificial sweetener (sugar substitute) with its sweetness equal to that of table sugar. It is commercially produced from the birch trees and other hardwood containing xylan and cannot be metabolized by oral bacteria. It is being used for more than 30 years and has been approved and considered safe to use for children by the Food and Drug Administration, since the 1960s.
In recent times, erythritol (four-carbon polyol) has also gained popularity. The properties of erythritol are similar to that of other polyols such as sorbitol and xylitol. The only differentiating feature is that it is commercially produced using fermentation. It is noncaloric and also completely lacks any adverse effects.
Various studies have been conducted on xylitol and erythritol containing chewing gums which concluded that xylitol chewing gums increase the salivary pH and also the salivary flow rate but it cannot be given in young children due to fear of ingestion. Thus, the aim of this study was to estimate the effectiveness of lollipops containing xylitol and erythritol on salivary pH in 3–6-year-old children.
| Materials and Methods|| |
It was a single-blinded randomized controlled field trial. The study was conducted in nongovernmental organization (NGO)-”Teens of God,” Gurugram, India. Fifty children between the age of 3–6 years who have not taken any meal for 2 h and without any systemic illness were included in the study. Prior ethical approval was taken by internal ethical committee (Ref No. L/2020/046) and CTRI registration was done (CTRI/2020/04/024583). The abovementioned sample size was calculated from the previous studies conducted using the following formula:
Where n = sample size of groups, σ1 = standard deviation of Group 1 = 0.41, σ2 = standard deviation of Group 2 = 0.48, Z1-α2= two-sided Z value (e.g., Z = 1.96 for 95% confidence interval), Z1-β = power = 80%, Δ = difference in group means.
A letter providing all the information of the study was given to the parent/guardian and they were considered after receiving the written consent. The children were randomly divided using lottery method into two groups (25 children in each group); Group 1: Control group (without lollipops) and Group 2: Experimental group (with sugar substitute lollipops). Lollipops used in the study are commercially available under the name as Zollipops-The Clean Teeth Pops (USA). The investigator visited the study site obtaining baseline information and performed the clinical examination and saliva collection from the selected children according to the protocol.
The saliva sample for determination of pH was collected at the following four time intervals, i.e., baseline before having beverage (T1), after having the beverage (Frooti-Parle Agro Pvt Ltd) (T2), after having zollipops in experimental group and rinsing in control group (T3), and then, fourth sample was collected after 15 min (T4).
Children were seated with their head slightly down, and were asked not to swallow or move their tongue or lips during the collection period. Saliva was allowed to accumulate in their mouth for 2 min, and then the children were asked to spit the accumulated saliva into Eppendorf tube.
For measuring pH, universal pH indicator was used, following specifications of the manufacturer and change in pH were observed at each time interval.
| Results|| |
The obtained data were compiled systematically, and statistical analysis was done by Statistical Package for the Social Sciences (SPSS) software package (SPSS 16 Inc, Chicago IL, USA). The level of significance and confidence interval was 5% and 95%, respectively, i.e., P < 0.05. The differences between the control and experimental groups were analyzed by independent Student's t-test, and intragroup comparison was done using paired t-test.
The mean pH at baseline of Group 1 and Group 2 was 6.656 and 6.276, respectively [Table 1]. There was a significant drop in the pH after drinking sweetened beverages in both the groups. In Group 1, there was slight increase in the pH after rinsing, but in Group 2, there was a significant increase in the salivary pH after having xylitol + erythritol lollipops. After 15 min, in both the groups, the pH almost reached the baseline levels [Graph 1], however, Group 1 showed nonsignificant results when sample 1 was compared with sample 4 but Group 2 showed significant difference in sample 1 and sample 4 [Table 2].
|Table 1: Mean values of salivary pH and inter-group comparison at different time intervals|
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|Table 2: Intra-group comparison of salivary pH at different time intervals|
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| Discussion|| |
Dental caries are a result of irreversible imbalance between the remineralization and demineralization processes and this process is dependent on the chemical status of saliva and plaque., To establish the role of preventive agents against dental caries, various studies have been carried out in past and many are still going on.
Sucrose being considered the arch criminal, various studies have been conducted to determine the cariogenic potential of sweeteners. On substantial evidence, it is seen that xylitol and erythritol are the most promising sweeteners as they cannot be fermented by most of the bacteria. Dental plaque does not significantly degrade xylitol into acidic end-products. Furthermore, xylitol induces the stimulation of salivary flow and there is an increase in buffering capacity enhancing the protective properties of saliva. In stimulated saliva, bicarbonate and phosphate ion concentration is higher resulting in sudden increase in the salivary pH and prevention of demineralization of sound enamel and remineralization of decalcified sites., Xylitol also inhibits plaque accumulation and accumulation of cariogenic bacteria. Hegde and Thakkar also concluded that xylitol significantly increases the physiochemical properties of saliva.
Erythritol has an additional growth, reducing effects of Streptococcus mutans by passively crossing the cell membrane and inhibits growth through interfering with some of the enzymatic pathways involved in the growth of S. mutans. Park et al. (2014) reported that both erythritol and xylitol significantly decreased the expression of 3 GTF genes and 1 FTF gene in S. mutans (P < 0.05) compared to sucrose. These genes promotes adhesion of bacteria and are involved in sucrose metabolism.
Most of the studies conducted in past involved higher age group and was done using chewing gum. However, chewing gums have a risk of choking in children, thus the present study included the use of lollipops. A lollipop is a hard candy which is mounted on a stick and is intended for sucking or licking.
In the present study, the effect of xylitol lollipops was evaluated at four different time intervals. The results of a study by Dawes (1969) concluded that as the time progresses, there is continuous changes in the concentration of ions in saliva.
The results of the present study show that there is a significant drop in pH immediately after having beverages. A slight increase in pH was observed in control group, but a significant increase of salivary pH was seen in the experimental group, and after 15 min, the salivary pH almost returned to its baseline value. The results of the present study are in accordance with Khan et al. and Muralikrishnan et al. who concluded that increase in salivary pH was observed after the use of xylitol chewing gums. Kumar et al. also showed similar results and concluded that xylitol chewing gums are a good way to promote dental health. Vantipalli et al. observed that with use of xylitol chewing gums, there is a linear increase in salivary flow rate and salivary pH in both caries free and caries active children and thus concluded that xylitol may lead to reduction in caries activity. Runnel et al. conducted a study to the evaluate effectiveness of erythritol and concluded that use of erythritol results in reduced counts salivary and plaque S. mutans counts. Yadav et al. also observed reduction in S. mutans counts after using xylitol containing fluoride varnish.
This study has its limitation as it was conducted in NGO with low socioeconomic children, so the samples do not generalize the larger population. Furthermore, the results are a combination of xylitol and erythritol, thus, the effectiveness of individual agent is not clear. It is suggestive that further studies should be performed to determine the appropriate age to start and its frequency of consumption of xylitol and erythritol, effective mode of delivery and also any additives to be added to give better results such as addition of optimum concentration of fluoride.
| Conclusion|| |
A combination of xylitol and erythritol lollipops can be used in small children and it has potential to increase salivary pH, thus not allowing the pH to fall below the critical value. However, further studies should be conducted by adding the already available materials such as fluoride, casein phosphopeptide-amorphous calcium phosphate to sugar substitute to promote better oral health.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]