|Year : 2019 | Volume
| Issue : 1 | Page : 61-66
|Effect of sugar-free chewing gum on plaque and gingivitis among 14–15-year-old school children: A randomized controlled trial
P Abdul Saheer1, Preetika Parmar2, Shanila Abdul Majid3, Mamtha Bashyam2, Pallavi Swamy Kousalya2, Tency Mathew Marriette1
1 Department of Public Health Dentistry, Al Azhar Dental College, Thodupuzha, Kerala, India
2 Department of Public Health Dentistry, Vokkaligara Sangha Dental College, Bengaluru, Karnataka, India
3 Department of OMRD, Al Azhar Dental College, Thodupuzha, Kerala, India
Click here for correspondence address and email
|Date of Web Publication||20-Mar-2019|
| Abstract|| |
Aim: The aim of the study was to find out the effect of sugar-free chewing gums (xylitol and sorbitol) on plaque and gingivitis among 14–15-year-old school children. Materials and Methods: A single center, double-blind, randomized controlled trial was conducted on 14–15-year-old children. Sample size was determined to be 48. Participants were randomly allocated to test group (xylitol [n = 12], sorbitol [n = 12]) and control group (no gum, n = 24). Duration of the study was 14 days. Baseline assessment of plaque, gingival, and bleeding score, followed by oral prophylaxis. Selected children received daily two chewing gum (1.1 g each) to chew for 20 min postbreakfast and postlunch. Follow-up was done on 15th day. Analysis was done using independent t-test, ANOVA, and post hoc test. Significance level was kept at P < 0.05. Results: There was a significant reduction in plaque, gingival, and bleeding score in test group (P < 0.05) compared to control group. Conclusion: Sugar-free gum (xylitol and sorbitol) significantly reduced the plaque, gingival, and bleeding score.
Keywords: Chewing gum, children, dental plaque, gingivitis, sorbitol, xylitol
|How to cite this article:|
Saheer P A, Parmar P, Majid SA, Bashyam M, Kousalya PS, Marriette TM. Effect of sugar-free chewing gum on plaque and gingivitis among 14–15-year-old school children: A randomized controlled trial. Indian J Dent Res 2019;30:61-6
|How to cite this URL:|
Saheer P A, Parmar P, Majid SA, Bashyam M, Kousalya PS, Marriette TM. Effect of sugar-free chewing gum on plaque and gingivitis among 14–15-year-old school children: A randomized controlled trial. Indian J Dent Res [serial online] 2019 [cited 2019 Apr 26];30:61-6. Available from: http://www.ijdr.in/text.asp?2019/30/1/61/254511
| Introduction|| |
Chewing gum is a well-accepted, enjoyable, and frequent activity for adults and children, most consumers of chewing gum are teenagers.,
Chewing a sugar-free gum can increase the initial salivary flow rate by a factor of 10. In addition to the more effective clearance of carbohydrate from the mouth, stimulated saliva contains higher concentrations of remineralizing ions and bicarbonate to buffer the acids formed from plaque.
Today, most chewing gums sold in developed countries are sweetened with sugar substitutes. The predominant sugar substitutes are polyols, which are low-caloric substances sometimes called “sugar alcohols” because their chemical structure is similar to that of both sugar and alcohol. The most common polyols in sugar-free chewing gum are sorbitol, which is a hexanol derived from glucose, and xylitol, which is a pentatol that occurs widely in nature.
Imfeld suggested that sugar-free chewing gum has no relevant mechanical tooth-cleaning effects although the saliva stimulated by mastication will effectively dissolve and remove soluble fermentable substrates from the oral cavity, increase the pH of plaque, and promote the remineralization of early carious lesions.
Various investigators using different forms of chewing gums available in the market have reported increases in salivary pH as well as reductions in dental plaque and gingivitis.,,,
The most common dietary polyols used in sugar-free chewing gum are xylitol and sorbitol. Xylitol is a sugar alcohol derived from pentose sugar xylose, and sorbitol is a sugar alcohol derived from glucose.
It has been postulated that presence of plaque, bleeding gums, and gingival inflammation is the main outcome measurements of the oral health. There is little information in the literature regarding the effect of different sugar-free chewing gum on three outcome variables simultaneously. Hence, we felt that there is a need to study the effect of chewing gum on oral health and also to understand the therapeutic effect on plaque, gingivitis, and bleeding gums.
Thus, the present study was conducted to assess the effect of xylitol and sorbitol sugar-free chewing on gingival, plaque, and bleeding score among 14–15-year school children.
| Materials and Methods|| |
A single-center, double-blind, parallel, randomized controlled trial to assess the effect of sugar-free chewing on plaque and gingivitis among 14–15-year school children.
The objective was to find out the effect of sugar-free chewing gum on dental plaque, gingival, and bleeding score and also to compare the effectiveness of the same among test and control group. The trial was conducted at a private school (Sajjan Rao school, Bengaluru) for a period of 14 days.
Ethical approval was obtained from the Institutional Review Board. The study protocol is in full accordance with the Helsinki Declaration (1975).
Informed consent (consent and assent) - parent consent and participant assent were obtained before the study. The permission to carry out the study in school was obtained from the Head of the school and from Block Education Officer (Bengaluru South).
Sample size estimation
Estimated sample size = (Z alpha + Z beta) 2 × 2 × S2 d2
Z alpha = 1.96 (95% confidence, two-tailed test)
Z beta = 0.84 (20% beta error, power 80%)
S = Standard deviation = 0.4 (pilot study)
Expected difference (d) =0.5
Sample size= (1.96 + 0.84) 2 × 2× 0.42 = 7.84 × 2 × 0.16 = 10.53 ≈ 11 0.52 0.25
A final sample of 12 for each group was taken
Total sample size = 48 (24 in test [sorbitol-12, xylitol-12] and 24 in control).
- Minimum of twenty natural teeth
- Age 14–15 years.
- Wearing of any intraoral prosthesis or appliances
- Oral breathing
- Chronic onychophagia (nail biting)
- Unilateral chewing predisposed by active carious lesions
- Undergoing any medication.
Pilot study - Calibration of the examiner
The pilot study was carried out with a convenience sample of five participants ranging in age from 14 to 15 years old in the Department of OMRD at V S Dental College and Hospital. The examiner was trained and calibrated to ensure uniform interpretation. Intraexaminer reliability for outcome variables was tested by repeating the examination on a group of five children of 14–15 years old at a time interval of 4–5 h. Intraexaminer reliability was found to be high (Kappa value, χ =0.80/0.84/0.88/for plaque index [PI], gingival index [GI], and bleeding index [BI], respectively).
The procedure of randomization was as follows. Selected participants were assembled in a classroom and asked to select a sealed postal cover from the box; each contains a card where the name of the group was written (Group xylitol, Group sorbitol, and Group control) and handed over to the assistant investigator. Thus, participants were allocated to test and control groups [Chart 1].
Blinding and study procedure
The double-blind study in which the principal investigator who was trained, calibrated, and blinded to group allocation performed the assessment of outcome variables (PI, GI, and BI) before and after the intervention. Oral prophylaxis was performed for all participants after the initial assessment of clinical variables to ensure baseline zero level. Assistant investigator allocated the students into various groups and distributed chewing gums to the participants every day for 14 days. Although few of the participants used to brush twice daily, all were (both test and control groups) instructed to brush once in the morning throughout the study period to avoid any of the confounding effect due to variability in frequency of cleaning. Disclosing solution (two-tone dye-DPI Alphaplac solution) was used to check any residual amount of plaque which was removed until there was no indication of plaque.
Test groups ([xylitol n = 12] and [sorbitol = 12] [n = 24])
Study participants in the xylitol group (n = 12) were given two chewing gums/day, PERFETTI'S HAPPYDENT, each gum weighs 1.1 g. Children were instructed and supervised to chew for 20 min postmeal 2 times/day (postbreakfast and postlunch) for a period of 14 days. Proper disposal of the chewing gums was carried out by the investigators themselves. The same protocol was followed for sorbitol group (n = 12) (WRIGLEY'S Orbit, each gum weighs 1.1 g) for the study period. A total of 48 (24 in each group) were given.
Control group (n = 24)
Participants were not given any intervention rather instructed to follow once daily brushing pattern.
Recording of clinical parameters
GI measured by Loe and silness criteria (1964).
PI measured using Quigley and Hein PI (1962) modified by Turesky-Gilmore-Glickman criteria (1970)
BI measured by Ainamo and Bay criteria (1975)
Data collected during the study were entered into excel sheets and were subjected to data analysis. Statistical analysis was done by Statistical Package for the Social Sciences version 19 (SPSS, Inc., Chicago, USA) for descriptive data analysis. Descriptive and Chi-square statistics were done for demographic data. The t-test, ANOVA test, and post hoc comparison was used to find the significant differences between the means of the study groups with P < 0.05.
| Results|| |
Results show groups are statistically non significant regarding age, gender, and all outcome variables (PI, GI and BI) at baseline (P > 0.05) [Table 1]. Postintervention assessment of plaque score suggested that there was a significant reduction in plaque score for test (xylitol and sorbitol) group. Between-group comparison of plaque score showed that reduction was higher in xylitol group (18%) and sorbitol group (17%) compared to control (1%) group (P < 0.05) [Table 2]. Similarly, a 34% reduction in gingival score for xylitol and 27% for sorbitol was observed compared to 5% in control group (P < 0.05) [Table 3]. Similar significant reduction was observed in the test group for bleeding score as well (15%, 14% vs. 7%) [Table 4]. The plaque index showed significant reduction of 0.52 and 0.51 in xylitol and sorbitol group [Graph 1]. Similar significant reduction was seen with respect to bleeding index (0.74 and 0.58) [Graph 2]. Gingival index (0.16 and 0.13) [Graph 3] respectively.
|Table 2: Before and after comparison of plaque score within and in between group|
Click here to view
|Table 3: Before and after comparison of gingival score within and in-between group|
Click here to view
|Table 4: Before and after comparison of bleeding score within and in-between group|
Click here to view
| Discussion|| |
The present study assessed the effect of use of sugar-free chewing gum on clinical parameters such as plaque, gingival, and bleeding score over a period of 14 days. The study was conducted among a group of 48 school children in the age group of 14–15 years who were randomly distributed to study groups (xylitol and sorbitol) and a control group.
Our country is burdened by high prevalence and mortality of dental caries and associated impact of pain on quality of life and loss of school hours for the children. Chewing gum is common practice among school children; hence, the present study included 14–15-year-old school children and to have a study group with permanent teeth to avoid perplexities in recording indices.
The double-blind intervention was planned for the study as it would reduce the possibility of any bias and having a control group possibly eliminated the confounders. The present single-center, double-blind study assessed change in plaque, gingival, and bleeding score after 14 days. Participants were randomly allocated into test and control groups (test [Group 1 - xylitol, Group 2 – sorbitol] and control - Group 3) by lottery method.
Each student in the chewing gum group was given two chewing gums/day (1.1 g × 2 g = 2.2 g/day) which is in accordance with the guidelines given by American Academy of Pediatric Dentistry, which recommends 3–8 g/day for age group 4 years or older.
Baseline assessment of plaque, gingival, and bleeding score showed no statistically significant difference in the three groups suggesting similarities in the three groups. After baseline clinical oral examination, oral prophylaxis was done to remove matured plaque over the teeth and also to make all three groups similar in relation to the clinical parameters. The mechanism of action of sugar-free chewing gum is also mainly on newly formed plaque rather than on the matured ones and the effect on established plaque will be to a small extent.,
Studies done by Fure et al. and Stein berg et al. reported similar results where xylitol and sorbitol chewing gum group showed a significant reduction in plaque levels after intervention. Significant reduction of plaque score was reported by Hanham and Addy et al., Hoerman et al., Addy et al. (sorbitol vs. control) by Mouton et al. and Barnes et al. (xylitol vs. control). The mechanism of action for the observed findings has been explained as an inability of microorganism to produce lactic acid from sugar substitute.
The present study showed that, though plaque score in xylitol group was less than the sorbitol group, the difference was not statistically significant. It has been suggested that xylitol has better antibacterial properties compared to sorbitol, the latter being fermentable to a smaller level compared to xylitol. In clinical trials, xylitol gum has been found to be superior to sorbitol gum in retarding regrowth of supragingival plaque (Cronin et al., 1994; Maguire and Rugg-Gunn, 2003). On contrary, studies by Pluss et al.(1978) and Ainamao et al. showed no significant reduction in plaque score between the use of xylitol and sorbitol chewing gums.
The present study showed that, a significant reduction in gingival score within xylitol and sorbitol groups compared to control group. This is similar to Fure et al. Steinberg et al., who reported reduced gingival inflammation (using xylitol and sorbitol) whereas Loe and Sillness study reported a reduction of gingivitis only in sorbitol group, not for xylitol group compared to control group. The increased antimicrobial protein concentration of stimulated saliva due to gum chewing has anecdotally been claimed to be instrumental in reducing gingivitis.
Within-group comparison showed that there was a significant reduction in the bleeding score observed after intervention in xylitol and sorbitol group compared to control group. The reduction was 15% in xylitol group and 14% in sorbitol group compared to control (7%). A similar reduction was reported by Lingstorm et al. and Keukenmeester RS et al.
| Conclusion|| |
Thus, the present study showed a definite reduction in clinical parameters such as plaque, gingival, and bleeding score which reflects the preventive potential of sugar-free chewing gum. Thus, the chewing of tooth-friendly gum after meals and carbohydrate-containing snacks is strongly recommended if no mechanical oral hygiene can be performed. It can be used as a cost-effective measure among the high-risk target group for prevention of dental caries. The antibacterial properties of sugar-free gum in reducing the inflammation emphasize the importance of its use as an adjunct oral hygiene measure.
The limitations of the study were small sample size and short duration trial.
The present study followed brushing trial (where study participants are allowed to follow only once daily brushing protocol) which would likely to result in Hawthorne effect in the test group.
A multicenter trial with cross-over design will be helpful in establishing difference between groups.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pizzo G, Licata ME, La Cara M, Pizzo I, Guiglia R, Melilli D, et al.
The effects of sugar-free chewing gums on dental plaque regrowth: A comparative study. J Dent 2007;35:503-8.
Keukenmeester RS, Slot DE, Rosema NA, Van Loveren C, Van der Weijden GA. Effects of sugar-free chewing gum sweetened with xylitol or maltitol on the development of gingivitis and plaque: A randomized clinical trial. Int J Dent Hyg 2014;12:238-44.
Addy M, Perriam E, Sterry A. Effects of sugared and sugar-free chewing gum on the accumulation of plaque and debris on the teeth. J Clin Periodontol 1982;9:346-54.
Imfeld T, Birkhed D, Lingström P. Effect of urea in sugar-free chewing gums on pH recovery in human dental plaque evaluated with three different methods. Caries Res 1995;29:172-80.
Edgar WM. Sugar substitutes, chewing gum and dental caries – A review. Br Dent J 1998;184:29-32.
Sharma NC, Galustians JH, Qaqish JG. An evaluation of a commercial chewing gum in combination with normal toothbrushing for reducing dental plaque and gingivitis. Compend Contin Educ Dent 2001;22:13-7.
Anderson LA, Orchardson R. The effect of chewing bicarbonate-containing gum on salivary flow rate and pH in humans. Arch Oral Biol 2003;48:201-4.
Löe H. The gingival index, the plaque index and the retention index systems. J Periodontol 1967;38 Supp l:610-6.
Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of victamine C. J Periodontol 1970;41:41-3.
Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25:229-35.
Kleber CJ, Davidson KR, Rhoades ML. An evaluation of sodium bicarbonate chewing gum as a supplement to toothbrushing for removal of dental plaque from children's teeth. Compend Contin Educ Dent 2001;22:36-42.
Fure S, Lingström P, Birkhed D. Effect of three months' frequent use of sugar-free chewing gum with and without urea on calculus formation. J Dent Res 1998;77:1630-7.
Steinberg LM, Odusola F, Mandel ID. Remineralizing potential, antiplaque and antigingivitis effects of xylitol and sorbitol sweetened chewing gum. Clin Prev Dent 1992;14:31-4.
Hanham A, Addy M. The effect of chewing sugar-free gum on plaque regrowth at smooth and occlusal surfaces. J Clin Periodontol 2001;28:255-7.
Hoerman KC, Gasior EJ, Zibell SE, Record D, Flowerdew G. Effect of gum chewing on plaque accumulation. J Clin Dent 1990;2:17-21.
Addy M, Perriam E, Sterry A. Effects of sugared and sugar-free chewing gum on the accumulation of plaque and debris on the teeth. J Clin Periodontol 1982;9:346-54.
Mouton C, Scheinin A, Mäkinen KK. Effect of a xylitol chewing gum on plaque quantity and quality. Acta Odontol Scand 1975;33:251-7.
Barnes VM, Santarpia P, Richter R, Curtis J, Xu T. Clinical evaluation of the anti-plaque effect of a commercial chewing gum. J Clin Dent 2005;16:1-5.
Cronin M, Gordon J, Reardon R, Balbo F. Three clinical trials comparing xylitol- and sorbitol-containing chewing gums for their effect on supragingival plaque accumulation. J Clin Dent 1994;5:106-9.
Maguire A, Rugg-Gunn AJ. Xylitol and caries prevention – Is it a magic bullet? Br Dent J 2003;194:429-36.
Plüss EM. Effect on plaque growth of xylitol and sucrose-containing chewing gums. J Clin Periodontol 1978;5:35-40.
Ainamo J, Asikainen S, Ainamo A, Lahtinen A, Sjöblom M. Plaque growth while chewing sorbitol and xylitol simultaneously with sucrose flavored gum. J Clin Periodontol 1979;6:397-406.
Loe H, silness J. Periodontal disease in pregnancy. Prevalence and severity. Acta Odontol Scand 1963;21:533-51.
Lingström P, Fure S, Dinitzen B, Fritzne C, Klefbom C, Birkhed D, et al.
The release of vitamin C from chewing gum and its effects on supragingival calculus formation. Eur J Oral Sci 2005;113:20-7.
Dr. P Abdul Saheer
B4/Alsa Palm Springs, RC Road, Calicut - 673 032, Kerala
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]
| Article Access Statistics|
| Viewed||200 |
| Printed||8 |
| Emailed||0 |
| PDF Downloaded||18 |
| Comments ||[Add] |