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Original Research

Effect of Chewing Gums Containing Probiotics and Xylitol on

Oral Health in Children: A Randomized Controlled Trial
Kanwardeep Kaur1, Sridhar Nekkanti1, Mridula Madiyal2, Prashant Choudhary3
1
Department of Pedodontics and Preventive Dentistry, Manipal College of Dental Sciences, 2Department of Microbiology, Kasturba Medical College, Manipal,
Karnataka, India, 3Faculty of Dentistry, SEGi University, Kota Damanasara, Petaling Jaya, Selengor, Malaysia

Abstract
Aims: Probiotics have been proven to be beneficial for general and systemic health. Many in vitro and in vivo studies have investigated the use
of probiotics for the prevention or treatment of dental caries and gingival diseases. Lactobacillus reuteri is believed to possess anti‑microbial and
anti‑inflammatory properties. The aim of our randomized controlled trial was to evaluate the effect of chewing gums containing probiotics and
xylitol on the salivary Streptococcus mutans counts, plaque, and gingival scores after the intervention. Materials and Methods: In our 3‑week,
short‑term trial, 40 healthy 7–12‑year‑old children consumed two commercially available chewing gums; Group 1 (BioGaia™ ProDentis)
and Group 2 (Orbit®Gum, Wrigley’s). Individuals consumed three chewing gums daily, immediately after major meals for 20 min each. The
probiotic gum contained two strains of L. reuteri (ATCC 55730 and ATCC PTA 5282) along with artificial sweetener, sorbitol, and the xylitol
gum consisted of both xylitol and sorbitol. Pre‑ and post‑intervention whole unstimulated saliva samples were collected and cultured on Mitis
Salivarius Bacitracin agar plates to check for colony forming units/ml of Streptococcus mutans. Plaque and gingival scores were also recorded
at pre‑ and post‑intervention appointments. Results: Following the intervention, the salivary Streptococcus mutans counts decreased in both
groups. There was a significant reduction in plaque and gingival scores at postintervention examination. Conclusion: Probiotics can be used
as an alternative to xylitol in the preventive regimen for dental caries or control in case of high caries risk.

Keywords: Dental caries, gingival index, plaque index, probiotics, xylitol

Introduction The oral cavity is home to over 250 microbial species and

The prevalence of dental caries has significantly reduced in the
past few decades owing to the use of fluoride and popularity
of dentifrices. While the developed nations have preventive
protocols, organized dental homes, and awareness programs,
industrialized nations such as India still face the burden of
oral diseases.
Fejerskov and Nyvad, 2003[1] redefined dental caries as, “A
complex microbiologic disease caused by an imbalance in the
physiologic equilibrium between tooth mineral and biofilm
fluid.” Based on studies conducted by various authors and data
collected over the years, the American Academy of Pediatric
Dentistry, 2016[2] has enumerated following risk factors for
dental caries: High levels of salivary Streptococcus mutans and
lactobacilli, low buffering capacity of the saliva, low fluoride
levels in plaque and saliva, presence of plaque on teeth, and
low socioeconomic status.
the dental hard tissue with its pits and fissures, and other
inaccessible areas are the safe haven of these microbes. These
species colonize the oral cavity in a methodical manner, from
adhesion and succession to progression.[3] Once the biofilms
are formed, caries develop in those regions where they are
allowed to mature and remain undisturbed for prolonged
periods of time. Even among a plethora of microorganisms in
the oral cavity, acidogenic organisms such as Streptococcus
mutans have been found to play a major role in causing dental
caries. These acidogenic organisms produce acid during
metabolism of dietary carbohydrates. The acids thereby formed
can dissolve the tooth mineral through a complex cycle of
Address for correspondence: Prof. Sridhar Nekkanti,
Department of Pedodontics and Preventive Dentistry, Manipal College of
Dental Sciences, Manipal ‑ 576 104, Karnataka, India.
E‑mail: drsri.pedo@gmail.com

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DOI: How to cite this article: Kaur K, Nekkanti S, Madiyal M, Choudhary P.

10.4103/jioh.jioh_170_18 Effect of chewing gums containing probiotics and xylitol on oral health in
children: A randomized controlled trial. J Int Oral Health 2018;10:237-43.

© 2018 Journal of International Oral Health | Published by Wolters Kluwer - Medknow 237
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Kaur, et al.: Effect of probiotics and xylitol in on oral health
demineralization and remineralization and eventually take part
in causing dental caries.[4]
Over the past decade, scientists have been working on more
conservative treatments and dentistry has seen a paradigm shift
from its traditional “mechanics‑based surgical” model to a
“biologically‑based medical” model.[3] Although “drill and fill”
still occupies a major place in our regimen, scientists are on
the lookout for newer techniques to alter the oral environment
and shift the balance toward protective factors. The new age
treatment is aimed to be preventive rather than therapeutic.
Fluoride has remained as the mainstay of preventive dentistry
since the past few decades. Other methods such as caries
vaccine and remineralizing agents have been discussed
in literature at length. At present, alternatives such as
bacteriotherapy and use of sugar substitutes are being studied.
Among sugar substitutes, the role of natural sugar, xylitol in
targeting oral microflora has been well established. Xylitol
is known to inhibit the growth and metabolism of mutans
Streptococcus group.[5] Xylitol is not readily metabolized by
bacteria and hence has been claimed to be anti‑cariogenic.[6]
While the caries‑preventive and cariostatic effect of xylitol
is proven, its role in actively antagonizing caries is still
controversial. Nevertheless, xylitol chewing gums are widely
used commercially. Several in vivo trials have proven the
effectiveness of xylitol in the reduction of Streptococcus
mutans counts in plaque and saliva, but one of the latest
systematic reviews has concluded that there is insufficient and
low‑quality evidence regarding its effectiveness.[7]
Over the years, many more antimicrobials have been studied
and the anti‑cariogenic role of “probiotics” is now being
thoroughly researched. As defined by International Scientific
Association for Probiotics and Prebiotics, probiotics are
“live microorganisms, which when administered in adequate
amounts, confer a health benefit on the host.” Both in vitro
and clinical studies have confirmed the positive association
between Lactobacilli and oral health. Clinical trials have
proven that probiotic bacterium, Lactobacillus reuteri can
reduce salivary Streptococcus mutans levels.[8] Probiotics may
have many direct and indirect effects in the oral cavity such
as competitive inhibition of streptococci by replacement and
direct contact with the oral tissues. An in vitro study[9] found
out that probiotics interfere with Streptococcus mutans biofilm
formation. Many more possible mechanisms have also been
proposed.
Although the role of xylitol in caries prevention is still
questionable, most commercially available caries preventing
agents such as chewing gums widely employ it. Probiotic
bacteriotherapy, on the other hand, is rather new, and although
several studies have confirmed its effectiveness, there is
insufficient literature regarding its success.
The aim of this study was to determine the effect of chewing
gums containing Probiotic Bacteria, and Xylitol on salivary
Streptococcus mutans counts in 7–12‑year‑old children and
238 Journal of International Oral Health  ¦  Volume 10  ¦  Issue 5  ¦  September-October 2018
also to assess whether there is a change in plaque and gingival
scores after chewing the aforementioned gums for 3 weeks.
Hypothesis: (1) Chewing gums containing Probiotics and
Xylitol have no effect on the salivary Streptococcus mutans
counts in 7–12‑year‑old children. (2) There is no difference
between the plaque and gingival scores before and after
intervention with chewing gums containing probiotics and
xylitol.
Materials and Methods
To be able to detect a difference between the two groups, a
sample size of 16 was calculated with the power of study being
80% at a significance level of 0.05. To allow for dropouts and
anticipating a “loss of follow‑up” of up to 25%, additional four
individuals were recruited in each group, making it a total of 40
individuals (n = 20). This investigation was a double‑blinded
randomized controlled trial in accordance with Consolidated
Standards of Reporting Trials and Helsinki Declaration of
Human Rights [Figure 1].
The individuals were screened from a group of children
who visited the Department of Pedodontics and Preventive
Dentistry, Manipal College of Dental Sciences, Manipal as
a part of the institution’s school health program initiative.
Materials used for screening included mouth mirror, probe,
tweezers, cotton and gauze piece, disposable gloves and
mouth mask. Sterile graded cups for the collection of
unstimulated saliva samples, 2 cc syringe to transport saliva
sample, disposable gloves and mouth mask were among
the materials used for sample collection. Culturing media
used included Mitis Salivarius Bacitracin (MSB) Agar with
Potassium Tellurite (Hi‑Media®, Hi‑Media laboratories,
Mumbai, India), standard loop to streak the saliva sample
on the culture plate, and MSB agar plate. Chewing gums
used in the study were Probiotic Chewing Gums (BioGaia™
ProDentis, Sweden) containing L. reuteri DSM 17938 And
L. reuteri ATCC PTA 5289 (L. reuteri Prodentis) and Xylitol
Chewing Gums (Orbit® Gum, Wrigley’s, India). This study
was approved by Institutional Ethics Committee, Kasturba
Hospital, Manipal (Registration number: ECR/146/INST/
KA/2013) bearing number IEC 672/2015. The clinical trial
was prospectively registered with Clinical Trials Registry of
India bearing the registration number: CTRI/2017/05/008518.
A total of 200 children, 7–12‑year‑old children who visited
the Department of Pedodontics and Preventive Dentistry,
Manipal, as a part of the department’s school health program
were screened. Based on the inclusion and exclusion criteria,
40 children were selected for the study. Inclusion criteria:
healthy children in the age group of 7–12 years, children
with decayed, missing, and filled teeth/deft score more than
1, children with similar oral hygiene and dietary habits, and
those having minimal or no crowding.
Exclusion Criteria: Children suffering from any long‑term
medical conditions, children under current anti‑microbial
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Kaur, et al.: Effect of probiotics and xylitol in on oral health
Figure 1: Consolidated Standards of Reporting Trials 2010 flow diagram
therapy or those who had been on the same 1 month before
the commencement of the study, children who had large
fillings/open carious lesions on the smooth surfaces of teeth
and those with severely crowded dentition. Before recruitment
of the individuals and before the commencement of the study,
a patient information sheet was given to all the students in
English and the vernacular, Kannada. A written informed
consent designed in accordance with the guidelines of Kasturba
Hospital Ethics Committee, Manipal, was obtained from the
parents of participating children. Cluster Randomization was
done, and the students from each school were assigned a
particular chewing gum.
Unstimulated saliva was used for the assessment of
Streptococcus mutans counts before the intervention.
Individuals were asked to expectorate the saliva into sterile
graded cups which were transferred to the department of
microbiology for analysis within 20 min of collection. The
collected salivary samples were cultured on MSB Agar
quantitatively. Commercial media from Hi‑Media® (Hi‑Media
laboratories, Mumbai, India) was used for the preparation of
the media with modifications adapted as per Gold et al., 1973[10]
by adding 20% sucrose and 0.2 units/ml of bacitracin.
The samples were diluted in 100–10−2 dilutions using a standard
loop. Plates were incubated at 37°C for 48 h in CO2 incubators.
Journal of International Oral Health  ¦  Volume 10  ¦  Issue 5  ¦  September-October 2018
Streptococcus mutans was identified using the cultural
characteristics. Doubtful isolates were identified using Vitak
2 identification system. The growth was quantified taking loop
factor and dilution factor into account.
Each child in a particular school, i.e., cluster was instructed
to consume three chewing gums every day, namely morning,
afternoon, and night after the three major meals for 20 min
throughout the study period of 21 days. In Group 1, probiotic
chewing gums were given, and in Group 2 xylitol chewing
gums were administered. The chewing gums were placed in
similar white containers and coded by a third person who was
not involved in the study.
Children were advised to continue their normal diet and tooth
brushing. Before dispensing of chewing gums, a written
assent of each subject was obtained, and a log sheet for each
consumption was handed out to monitor consumption. The
school teachers were requested to supervise consumption of
chewing gums, and written notes were sent for the parents to
supervise at home and on Sundays/holidays.
At the end of 3 weeks of the use of chewing gums, the salivary
samples were taken again in a similar way as described for
the baseline readings and subjected for microbiological
analysis. Plaque and gingival scores were also recorded
postintervention.
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Kaur, et al.: Effect of probiotics and xylitol in on oral health

Results Table 1: Intergroup comparison at preintervention

The statistical analysis was done using SPSS version 18 Mean (SD) P
(SPSS Inc, Illinois, Chicago, USA). A <0.05 was considered
Group 1 Group 2
statistically significant. Colony forming units (CFU) values for
Log CFU 3.81 (0.60) 4.39 (0.80) 0.083 (NS)
pre‑ and post‑intervention were transformed by Logarithmic
PI 1.49 (0.26) 1.72 (0.41) 0.066 (NS)
transformation. Mann–Whitney U test was done to compare the
GI 1.37 (0.30) 1.12 (0.41) 0.025 (significant)
log CFU/ml of Streptococcus mutans counts, plaque and gingival NS: Nonsignificant, CFU: Colony forming units, PI: Plaque index, GI:
scores between the two groups preintervention [Table 1]. The Gingival index, SD: Standard deviation
mean Log CFU of the individuals in Group 1 and Group 2
was 3.81 (standard deviation [SD]−0.60) and 4.39 (SD −0.80),
respectively. Statistically, there was no statistically significant Table 2: Intergroup comparison at postintervention
difference in the Log CFU among the two groups. The mean Mean (SD) P
plaque score in Group 1 and Group 2 was 1.49 (SD −0.26) Group 1 Group 2
and 1.72 (SD −0.26), respectively. No statistically significant Log CFU 1.91 (1.89) 2.39 (2.27) 0.404 (NS)
difference was observed between the two groups. The mean PI 1.31 (0.24) 1.38 (0.40) 0.666 (NS)
gingival score in Group 1 and Group 2 was 1.37 (SD −0.30) GI 1.16 (0.27) 0.87 (0.42) 0.006 (significant)
and 1.12  (SD  −0.41), respectively. Statistically significant NS: Nonsignificant, CFU: Colony forming units, PI: Plaque index,
difference was observed between the two groups. GI: Gingival index, SD: Standard deviation

The same test was done to compare the log CFU/ml of

Streptococcus mutans counts, plaque and gingival scores Table 3: Intragroup comparison between pre‑ and
between the two groups postintervention [Table 2]. The post‑intervention
mean Log CFU of the individuals in Group 1 and Group 2 Mean (SD) P
was 1.91  (SD  −1.89) and 2.39  (SD‑2.27), respectively.
Pre Post
Statistically, there was no statistically significant difference
Group 1
in the Log CFU among the two groups. The mean plaque
Log CFU 3.81 (0.60) 1.91 (1.89) 0.003 (significant)
score in Group  1 and Group  2 was 1.31  (SD  −0.24) and
PI 1.49 (0.26) 1.31 (0.24) <0.001 (significant)
1.38  (SD  −0.40), respectively. No statistically significant
GI 1.37 (0.30) 1.16 (0.27) <0.001 (significant)
difference was observed between the two groups. The mean Group 2
gingival score in Group 1 and Group 2 was 1.16 (SD −0.27) Log CFU 4.39 (0.80) 2.39 (2.27) 0.001 (significant)
and 0.86  (SD  −0.42), respectively. Statistically significant PI 1.72 (0.41) 1.38 (0.40) <0.001 (significant)
difference was observed between the two groups. GI 1.12 (0.41) 0.87 (0.42) 0.002 (significant)
CFU: Colony forming units, PI: Plaque index, GI: Gingival index,
Intragroup comparison between pre‑ and post‑intervention SD: Standard deviation
Probiotic chewing gums
Wilcoxon Signed Rank test was done to compare the means plaque score was <0.001. There was a statistically significant
of the given parameters pre‑ and post‑intervention in each difference between the pre‑ and post‑intervention plaque
of the two groups. The P value obtained for the pre‑ and scores. The P value obtained for the pre‑ and post‑intervention
post‑ intervention Streptococcus mutans counts in probiotic gingival score was <0.002. Hence, there was a statistically
group was 0.003 [Table 3]. The null hypothesis was rejected, significant difference between the pre‑ and post‑intervention
implying that there was a statistically significant difference gingival scores.
between the microbial counts pre‑ and post‑intervention
with probiotic chewing gums. The P value obtained for the
pre‑ and post‑intervention plaque score was <0.001. There Discussion
was a statistically significant difference between the pre‑ and This randomized controlled trial was carried out to assess the
post‑intervention plaque scores. The P value obtained for the effect of chewing gums containing probiotics and xylitol on
pre‑ and post‑intervention gingival score was <0.001. Hence, salivary Streptococcus counts in 7–12‑year‑old children. As a
there was a statistically significant difference between the secondary outcome measure, the clinical implications in terms
pre‑and post‑intervention gingival scores. of plaque and gingival scores were also measured before and
after the intervention period of 21 days.
Xylitol chewing gums
The log CFU counts pre‑ and post‑intervention for the xylitol Chewing gums stimulate salivary flow which results in an
group and the P value obtained was 0.001. The obtained P value increase in the buffering capacity of saliva. The masticatory
suggests that there is a statistically significant difference before and gustatory stimuli together, aid in increasing the flow rate
and after the intervention with xylitol‑containing chewing by as much as 10–12 times more than unstimulated saliva.
gums. The P value obtained for the pre‑ and post‑intervention This counterbalances the drop in plaque pH that occurs after

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Kaur, et al.: Effect of probiotics and xylitol in on oral health
eating (Burt BA, 2006).[11] Another anti‑cariogenic action
of chewing gums may be due to increase in bicarbonate
ions, which also improve the buffering capacity of saliva.[12]
Moreover, this leads to an increase in the rate of clearance
of sugars and food debris. While sugared gum is cariogenic,
gums containing non‑caloric substitutes have been used in
the caries‑control regimen since long. The most common
components of commercially available polyol chewing gums
are sorbitol and xylitol. Xylitol is a derivative of pentose
sugar, xylose whereas sorbitol is derived from glucose. The
mechanism of action of both involves stimulation of gustation
and salivary flow. Most oral bacteria cannot metabolize either
of the two to form acids. The ability of sorbitol in reducing
demineralization was demonstrated by chewing a gum
containing sorbitol for 5 min following a sucrose rinse.[13]
The fact that enhanced salivary stimulation and subsequent
remineralization can result from mastication cannot be
underestimated. Recent studies have also proven that xylitol
not only decreases bacterial load but also aids in increasing
pH of the oral cavity[14] and has a remineralizing potential.[15]
Ghasemi et al., 2017[16] in their study used xylitol chewing
gums and probiotic yogurt as vehicles. While they concluded
that both were equally effective in reducing the salivary
Streptococcus mutans counts, the use of a similar vehicle
in both groups would have eliminated the bias of salivary
stimulation on bacterial counts in the chewing gum group as
compared to the yogurt group. Mitrakul et al.,2017[17] compared
xylitol chewing gum and maltitol spray, thus creating a bias due
to the difference in vehicles. Van Loveren, 2004[18] stated that
xylitol induced reduction of dental caries could be confounded
by increased salivation due to the chewing effect. Mäkinen
et  al., 1995[19] in their 40‑month cohort trial used different
formulations of non‑sugar gums (xylitol/sorbitol) in all the
nine study groups.
The beneficial effects of probiotics for the treatment of oral
diseases such as caries, gingivitis, or periodontitis have
been proven in vitro.[11] Many in vivo studies[7,20‑24] have also
attempted to study the short‑term and long‑term effects of
probiotics in the oral cavity. Different vehicles such as curd,
ice creams, yogurt, or non‑dairy products such as drops,
straws, lozenges, tablets, and candies were used in different
studies. Caglar et al., 2007[25] also compared chewing gums
containing probiotics (L. reuteri) and xylitol in their study and
concluded that both had a significant effect on Streptococcus
mutans counts in saliva. Moreover, chewing gum as a vehicle is
attractive and acceptable for children as compared to lozenges,
yogurt, or milk.
Taking into consideration the previous studies, chewing
gums were chosen as a vehicle in our study to eliminate the
confounding bias as well as to have a similar amount of salivary
stimulation in both groups. Most of the previous studies either
compared xylitol with other polyols or with placebo. Ours
is one of the first studies in children to compare xylitol and
probiotic chewing gums.
Journal of International Oral Health  ¦  Volume 10  ¦  Issue 5  ¦  September-October 2018
Each subject was given an equal number of chewing gum
pellets of probiotics and xylitol. All the individuals had healthy,
adequate amount of saliva and were asked to chew the gum
pellets thrice daily for 20 min each. The school teachers were
explained the whole process and were requested to supervise
and monitor the children. Written forms with instructions
and daily checklists were given to all the children to check
compliance. Similar compliance calendars were followed by
Pahumunto et al., 2017[26] and Alamoudi et al., 2018.[27]
The possible effect of the duration of chewing gum on the
overall outcome of the intervention cannot be overlooked.
Edgar et  al. (1975)[12] concluded that a 5‑min duration of
chewing sugar‑free gum had little effect on the pH of plaque.
A smaller fall in the pH and a more rapid rise of the pH back to
its resting levels was noticed after a 10‑min chewing duration
by Park et al.[28] Following an acidogenic challenge, the rise in
resting pH levels was more rapid and took substantially lesser
time when a sugarless gum was chewed for at least 20 min. Park
et al.,[28] determined the optimal initiation time and duration
of chewing to achieve maximum salivary stimulation and
benefits of a chewing gum containing sorbitol. The authors
concluded that chewing a sugarless gum within the first 5 min
of eating and continuing it for a minimum of 15 min would
confer the maximum benefits. Caglar et al., 2007[25] in their
study on healthy adults used a chewing duration of 10 min
and reported a significant reduction in salivary Streptococcus
counts with both probiotics and xylitol. The European Food
Safety Authority, 2010[29] reviewed a plethora of scientific
research papers and recommended the use of 2–3 g of
sugar‑free gum for 20 min after meals. Therefore, keeping
in mind the recommendations of the European Food Safety
Authority, manufacturer recommendations, as well as the
American Dental Association guidelines, a chewing duration
of 20 min, was kept standard for both groups. Our results
showed that both probiotics and xylitol significantly reduced
the levels of Streptococcus mutans in saliva after 3 weeks
of intervention. These results are consistent with the study
conducted by Caglar et al., 2007.[25] However, the mechanism
of action of both the gums is different, and because the bias
of salivary stimulation was eliminated, both groups were
comparable. While probiotics, in general, may act through
several mechanisms such as host modulation, prevention of
cellular adhesion, competitive inhibition and coaggregation,
L. reuteri particularly is known to secrete two antimicrobial
agents called “Reuterin”[30] and “Reutericyclin.”[31] Our results
revealed a statistically significant difference in the pre‑ and
post‑intervention values of Log CFU in case of probiotic
chewing gums, which can be attributed to the action of saliva
and the presence of “Reuterin” and “Reutericyclin” in the
gum formulation.
In accordance with a study conducted by Krasse et al., 2006,[32]
we also observed a significant reduction (P < 0.001) in plaque
and gingival scores (P < 0.001). Our results are consistent with
Vivekananda et al., 2010[33] who conducted a split‑mouth trial
in which two quadrants were treated with scaling and root
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Kaur, et al.: Effect of probiotics and xylitol in on oral health
planing and the other two were left untreated. The individuals
were then given probiotic lozenges for 2 weeks and a
significant reduction in plaque and gingival scores was noticed.
The reduction of plaque and gingival scores in our study would
have been more if we had performed oral prophylaxis and root
planing before administration of probiotic chewing gums.
It can thus be hypothesized that the gingival and plaque scores
decreased partly because of the anti‑inflammatory action of
L. reuteri as supported by Cabana et al., 2006[34] in their in vitro
study. L. reuteri inhibits the pro‑inflammatory cytokine, IL‑8
and upregulates Nerve Growth Factor. Second, the presence of
reuterin and reutericyclin contributes toward the antimicrobial
effects of L. reuteri. Finally, it can also be assumed that some
reduction might be seen due to the daily chewing action which
increases the overall oral clearance.
Our study, therefore, confirms the anti‑inflammatory and
plaque inhibitory actions of probiotic chewing gums, although
the exact mechanism is still unclear.
In case of xylitol group, a small but significant reduction in
plaque scores was noticed in our study. This is in accordance
with the systematic review by Kukenmeester et al., 2013[35]
where plaque scores were lowered after using polyol chewing
gums. Mitrakul et  al., 2017[17] also observed a reduction in
plaque index after a 4‑week intervention with xylitol gum.
These results could be an effect of normal tooth brushing
along with a psychological component wherein children might
have been encouraged to brush their teeth more frequently
and effectively because of frequent contact with the doctor.
Alamoudi et al., 2018 reported a similar Hawthorne Effect.
Nevertheless, the reduction in gingival scores in case of xylitol
group is a controversial.
Steinberg et al.,1992[36] carried out a 6‑week single‑blinded,
crossover trial wherein the study individuals chewed five xylitol
gums daily in addition to maintaining normal oral hygiene.
They reported that there was a reduction in plaque score and
gingival inflammation after the intervention period. However,
the systematic review by Keukenmeester et al., 2013[35] could
not corroborate strong evidence for the same and questioned
the validity of the previous studies. The significant reduction
of gingival scores in the xylitol group as compared to the
probiotic group in our study is unlikely to be due to polyols
alone. It might have to do with the fact that children may not
have followed instructions of avoiding all other measures of
oral hygiene except for regular tooth brushing. Moreover, the
different tooth brushing habits of children could have played a
role in reducing gingival scores in the xylitol group more than
the probiotic group despite the anti‑inflammatory properties
of probiotics being more pronounced than that of xylitol.[35]
Among since the children were from lower socioeconomic
strata; the compliance was questionable. Despite taking
consent, assent and daily checklists, four children in the xylitol
group dropped out of the study and were not available for
postintervention records. Only one child reported of discomfort
242 Journal of International Oral Health  ¦  Volume 10  ¦  Issue 5  ¦  September-October 2018
due to probiotic chewing gum, which might have been due to
its taste and was immediately asked to discontinue intake and
was withdrawn from the study.
Further long‑term studies with larger a sample size are needed
to compare the efficacy of probiotic and xylitol chewing gums
in caries‑control regimen.
Conclusion
The effect of chewing gums containing probiotics (ProDentis,
BioGaia™, Sweden) and xylitol (Orbit® Gum, Wrigley’s,
India) on salivary Streptococcus mutans counts and plaque
and gingival scores was evaluated.
The following conclusions can be drawn from this study:
1. Both probiotic and xylitol containing gums are equally
effective in reducing Streptococcus mutans counts in
children
2. There was a small but significant reduction in plaque
deposition when regular home care hygiene methods were
continued in both, xylitol and probiotic groups
3. There was more reduction of gingival scores in case of
xylitol group
4. Chewing gums containing probiotics and xylitol can be
an alternative regimen for prevention of caries in children
in addition to fluoride supplements.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
The authors would like to thank Sebastian Nummelin (Bio
Gaia, Stockholm, Sweden) for supplying the probiotic gums
for this trial.
Conflicts of interest
There are no conflicts of interest.
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