Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2022  |  Volume : 40  |  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

Correspondence Address:
Dr. Sakshi Jain
Department of Pediatric and Preventive Dentistry, ITS-CDSR, Muradnagar, Ghaziabad, Uttar Pradesh
India

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.



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 Jul 7 ];40:19-22
Available from: https://www.jisppd.com/text.asp?2022/40/1/19/343021


Full Text



 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.[1] Prevention of dental caries is important as caries influences mastication, nutrition, self-esteem, and health of the child.[2],[3] 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.[4] 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).[5]

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.[5]

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.[6]

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:

[INLINE:1]

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.

Saliva collection

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}{Table 2}[INLINE:2]

 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.[4],[7] To establish the role of preventive agents against dental caries, various studies have been carried out in past and many are still going on.[5]

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.[5] 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.[8] 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.[5],[9] Xylitol also inhibits plaque accumulation and accumulation of cariogenic bacteria. Hegde and Thakkar[10] 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.[11] Park et al.[12] (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.[12]

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)[13] 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.[1] and Muralikrishnan et al.[5] who concluded that increase in salivary pH was observed after the use of xylitol chewing gums. Kumar et al.[14] also showed similar results and concluded that xylitol chewing gums are a good way to promote dental health. Vantipalli et al.[15] 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.[16] 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.[17] 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

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Khan M, Bhat SS, Bhat VS, Hegde KS. Comparative evaluation of the effects of xylitol sugar free chewing gum and recaldent sugar free chewing gum on salivary pH in children. Int J Oral Health Med Res 2017;3:45-8.
2Aluckal E, Ankola AV. Effectiveness of xylitol and polyol chewing gum on salivary streptococcus mutans in children: A randomized controlled trial. Indian J Dent Res 2018;29:445-9.
3Hildebrandt GH, Sparks BS. Maintaining mutans Streptococci suppression with xylitol chewing gum. J Am Dent Assoc 2000;131:909-16.
4Rokaya D, Manipal S, Bajracharya M. Use of chewing gum to increase the pH of saliva. J Nepal Dent Assoc 2013;13:22-5.
5Muralikrishnan K, Asokan S, Priya PR. Effect of different chewing gums on dental plaque pH, salivary pH, and buffering capacity in children: A randomized controlled trial. SRM J Res Dent Sci 2018;9:158-63.
6de Cock P, Mäkinen K, Honkala E, Saag M, Kennepohl E, Eapen A. Erythritol is more effective than xylitol and sorbitol in managing oral health endpoints. Int J Dent 2016;6.1-15.
7Cristina Nuca CA. Clinical Study Regarding the Influence of the Sugared and Sugar Free Chewing Gum on the Salivary pH and Flow. Oral Health Dent Manag 2004;3:12-18.
8Goswami M, Saha S, Chaitra TR. Latest developments in non-fluoridated remineralizing technologies. J Indian Soc Pedod Prev Dent 2012;30:2-6.
9Makinen KK. Dietary prevention of dental caries by xylitol-clinical effectiveness and safety. J Am Nutr 1992;44:16-28.
10Hegde RJ, Thakkar JB. Comparative evaluation of the effects of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and xylitol-containing chewing gum on salivary flow rate, pH and buffering capacity in children: An in vivo study. J Indian Soc Pedod Prev Dent 2017;35:332-7.
11Hashino E, Kuboniwa M, Alghamdi SA, Yamaguchi M, Yamamoto R, Cho H, et al. Erythritol alters microstructure and metabolomic profiles of biofilm composed of Streptococcus gordonii and Porphyromonas gingivalis. Mol Oral Microbiol 2013;28:435-51.
12Park YN, Jeong SS, Zeng J, Kim SH, Hong SJ, Ohk S, et al. Anti cariogenic effects of erythritol on growth and adhesion of Streptococcus mutans. Food Sci Biotechnol 2014;23:1587-91.
13Dawes C. The effects of flow rate and duration of stimulation on the condentrations of protein and the main electrolytes in human parotid saliva. Arch Oral Biol 1969;14:277-94.
14Kumar S, Sogi SH, Indushekar KR. Comparative evaluation of the effects of xylitol and sugar-free chewing gums on salivary and dental plaque pH in children. J Indian Soc Pedod Prev Dent 2013;31:240-4.
15Vantipalli UK, Avula SS, Enuganti S, Bandi S, Kakarla P, Kuravadi RV. Effect of three commercially available chewing gums on salivary flow rate and pH in caries-active and caries-free children: An in vivo study. J Indian Soc Pedod Prev Dent 2017;35:254-9.
16Runnel R, Mäkinen KK, Honkala S, Olak J, Makinen PL, Nommela R, et al. Effect of three year consumption of erythritol, xylitol and sorbitol candies on various plaque and salivary caries related variables. J Dent 2013;41:1236 44.
17Yadav S, Sachdev V, Malik M, Chopra R. Effect of three different compositions of topical fluoride varnishes with and without prior oral prophylaxis on Streptococcus mutans count in biofilm samples of children aged 2-8 years: Arandomized controlled trial. J Indian Soc Pedod Prev Dent 2019;37:286-91.