Journal of Conservative Dentistry
Home About us Editorial Board Instructions Submission Subscribe Advertise Contact e-Alerts Login 
Users Online: 1299
Print this page  Email this page Bookmark this page Small font sizeDefault font sizeIncrease font size

Table of Contents   
Year : 2015  |  Volume : 18  |  Issue : 3  |  Page : 192-195
The effect of two types chewing gum containing casein phosphopeptide-amorphous calcium phosphate and xylitol on salivary Streptococcus mutans

1 Department of Operative Dentistry, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Clinical Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Iranian Center for Endodontic Research, Shahid Beheshti University of Medical Sciences, Tehran, Iran
4 Department of Basic Sciences, School of Rehabilitation, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Click here for correspondence address and email

Date of Submission25-Jan-2015
Date of Decision16-Mar-2015
Date of Acceptance20-Apr-2015
Date of Web Publication19-May-2015


Aim: The aim was to evaluate the effect of sugar-free chewing gum containing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and xylitol on salivary Streptococcus mutans.
Materials and Methods: A total of 60 dental students of 20-25 years old, who volunteered after checking their health condition and signing an informed consent, were randomly allocated to receive one of the following interventions: (A) Chewing gum containing CPP-ACP; (B) containing xylitol. Subjects within the experimental groups were taken the gums 3 times daily, after each meal for a period of 3 weeks. Pre- and post-intervention unstimulated saliva samples were quantified for S. mutans counts.
Results: A statistically significant reduction of salivary S. mutans was displayed in both groups A and B after the intervention when compared with baseline (P < 0.001), and group A shows more statistically significant reduction of salivary S. mutans than group B (P = 0.011).
Conclusion: Daily consumption of chewing gum containing CPP-ACP and xylitol significantly reduces the level of salivary S. mutans, but chewing gum containing CPP-ACP can reduce the level of salivary S. mutans in more than xylitol chewing gum.

Keywords: Caries; casein phosphopeptide-amorphous calcium phosphate; chewing gum; Streptococcus mutans; xylitol

How to cite this article:
Emamieh S, Khaterizadeh Y, Goudarzi H, Ghasemi A, Baghban AA, Torabzadeh H. The effect of two types chewing gum containing casein phosphopeptide-amorphous calcium phosphate and xylitol on salivary Streptococcus mutans. J Conserv Dent 2015;18:192-5

How to cite this URL:
Emamieh S, Khaterizadeh Y, Goudarzi H, Ghasemi A, Baghban AA, Torabzadeh H. The effect of two types chewing gum containing casein phosphopeptide-amorphous calcium phosphate and xylitol on salivary Streptococcus mutans. J Conserv Dent [serial online] 2015 [cited 2023 Dec 2];18:192-5. Available from:

   Introduction Top

Bacterial plaque that accumulated on teeth surfaces and composed of native oral flora is the primary etiological agent for periodontal disease and dental caries which may result in teeth loss if left untreated. [1],[2] Dental caries is the destruction of dental structures by acid product as a product of carbohydrate metabolism by cariogenic bacteria. [3] Streptococcus mutans, commonly found in human dental plaque, are the primary species associated with dental caries. [4] S. mutans is now considered to play an important role in the development of dental caries in animals and humans. Extensive research on this microorganism has been done during the last 10 years. [5]

Chewing gum is known to be a useful adjunct to common oral hygiene because of stimulation of salivary flow rate. It is effective in raising plaque pH. The chewing of sugar-free gums after meals and snacks can promote remineralization of enamel and reduce S. mutans rate. [6]

In recent years, casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) noncomplexes have also been demonstrated to have anticariogenic properties in both laboratory animal and human in situ experiments. [7],[8] CPP containing the cluster sequence −Ser(p)-Ser(p)-Ser(p)-Glu-Glu- has a remarkable ability to stabilize ACP in metastable solution. [9] When delivered in sugar-free chewing gum, CPP-ACP has also been shown to remineralize enamel subsurface lesion and reduce S. mutans in vivo, independent of chewing frequency and duration. [10],[11]

Xylitol, a five-carbon natural sugar alcohol, is widely used as a noncariogenic sweetener, which is not fermentable by most oral bacteria. [12] Several studies have shown that xylitol can also reduce dental plaque as the number of S. mutans (in vivo and in vitro). [13] The aim of the present study was, therefore, to compare the effect of xylitol and CPP-ACP chewing gums, on the level of S. mutans in the saliva of young adults.

   Materials and Methods Top

This was a randomized, stratified block, controlled clinical trial with parallel groups that registered at

A total of 60 young adults (37 women, 23 men) who volunteered, after signing an informed consent, were selected. Eligible persons were dental students who had healthy condition and were between the ages of 20 and 25 years old. Exclusion criteria were any abnormal oral, medical or mental condition (including any milk-related allergies and medical condition involving the kidneys), a history of systemic antibiotic or topical fluoride treatments within a 4 weeks period before baseline, individuals with a habitual use of dairy xylitol or recaldent chewing gums, any untreated caries lesions or clinical signs of either gingivitis or periodontal disease.

This clinical trial had two parallel groups (each size group = 30). Each group chewed 3 gum pellets, 3 times/day for an experimental period of 3 weeks. Subjects were randomly assigned to groups by a stratified block randomization procedure. Group A consumed three chewing gums containing CPP-ACP 3 times daily after each meal; group B was given three chewing gums containing xylitol 3 times daily after each meal. Salivary samples were collected at baseline and 1-day after the final gum consumption. During the experimental period, the subjects were strongly encouraged to reduce their carbohydrate diet and brush their teeth twice a day with fluoride toothpaste.

Each recaldent pellet (Trident Company, Thailand) contained 10% CPP-ACP plus gum base and the xylitol chewing gum (Orion Company, Rasti Lar Company, Iran) contained 55.3668% xylitol. The ingredients of the gums are listed in [Table 1]. The participants were instructed to actively chew on the assigned gums during 20 min after the meals; in the morning, at noon, and evening.
Table 1: Ingredients of the chewing gums according to the manufacturers' declaration

Click here to view

Unstimulated saliva was collected in the morning (9:00 am) on the day before onset and 1 day after the intervention period in the 1.5 cc test tube. The counts of salivary S. mutans were evaluated using mitis Salivarious agar (merk) as described. After cultivation at 37°C with CO 2 3% for 48 h, the colony forming units were identified on the basis of their morphology and counted in a stereomicroscope with 12-25 times magnification. The results were categorized in 3 scores, and the data were processed with the SPSS software (version 18, SPSS, Chicago, IL, USA).

   Results Top

All subjects completed the trial, the compliance was excellent, and no side effects were reported. The preintervention and postintervention reports are shown in [Table 2]. All subjects had detectable levels of S. mutans at baseline, and there were no statistically significant differences between the two groups concerning the distribution of scores. One day after the 3-week intervention period, significantly reduce levels (P < 0.05) of S. mutans compared to baseline in both groups A and B. Group A shows more statistically significant reduction of salivary S. mutans than group B.
Table 2: Counts of S. mutans preintervention and postintervention

Click here to view

   Discussion Top

A significant part of studies has been focused on studying the effect various substances for preventing dental caries in the primary stages. S. mutans is the effective bacteria on the beginning of the process of demineralization of enamel and consequently decays, hence using an appropriate solution for controlling or eliminating these bacteria can prevent the creation of decay.

In the present study, we assessed the effectiveness of xylitol and CPP-ACP chewing gum in reducing load of S. mutans as cariogenic agents.

Although the usefulness of xylitol for preventing dental caries especially in patients with primary caries has been documents, [14],[15],[16] But since so far the effect of these two types of chewing gums on the S. mutans rate in saliva have not been compared with each other clinically, hence the present study has been developed and conducted.

In the present research, considering the effect of caries on the number of S. mutans of saliva, those individuals with active caries have been eliminated from the study. In addition, with matching the health and nutrition programs such as do not using any other xylitol and CPP-ACP products and mouthwash and fluoride gel, it has been tried to eliminate the intervening variables as much as possible. [17]

In the current study, the time of sampling has been performed at 9 am and while fasting that this method of sampling is consistent with the sampling method in the study of Caglar et al. [17]

In this study, the patients were asked to use the provided chewing gums were used for a time period of 3 weeks, 3 times a day after eating their main meal. Researchers believe that for evaluating the effects of each chewing gum on the counts of S. mutans in saliva, the chewing gums should be used immediately after taking the main meal for 3 weeks. [18],[19]

The individuals were asked to use the chew the chewing gums every time for 20 min. According to the studies of Harris et al., and Iijima et al., after 20 min of chewing the gums, the secretion rate of saliva becomes 3 times and also due to increasing the level of pH and increasing the mineral deposition of calcium and phosphate ions present in saliva, enamel become remineralized. [11],[18]

In this study, the S. mutans rate in saliva after 3 weeks of using chewing gums containing xylitol has decreased significantly (P < 0.0011). This finding is consistent with the study of Fraga et al. [20]

The reason that xylitol has the amounts of reduced S. mutans might be due to the inability of 5-carbon sugar xylitol to be fermented by S. mutans furthermore, because chewing stimulates salivary flow, which improves the buffering of the pH drop that occurs after eating, the growth of these bacteria reduces. [20]

In so many studies, xylitol has caused the reduction of S. mutans in saliva that is consistent with the findings of the present study. [16],[21],[22],[23]

In this study, the rate of S. mutans in saliva had a significant reduction (P < 0.001) after 3 weeks of consumption of chewing gums containing CPP-ACP that this finding is in agreement with the study of Subramanian and Naidu and Vashisht et al. [24],[25]

In the present study, although in both groups the rate of S. mutans in saliva after the consumption of the chewing gums have shown a significant decrease; however, the rate of S. mutans in saliva in the group of xylitol is significantly higher comparing to CPP-ACP group that can be due to the antibacterial properties and its buffering effect on plaque and prevention of growth and attachment of Streptococcus strains to the teeth. This study has documented and demonstrated the clinical antibacterial effects of CPP-ACP and its effect as an anti-caries agent (in primary caries). [25]

All individuals, especially those who are in danger of the development of dental caries can use these substances; however, more clinical long-term studies in this regard are required.

   Conclusion Top

Daily chewing gum containing CPP-ACP and xylitol reduce the level of salivary S. mutans significantly, but chewing gum containing CPP-ACP can reduce the level of salivary S. mutans in a significant way than xylitol chewing gum.

   References Top

Gibbons RJ. Adherent interactions which may affect microbial ecology in the mouth. J Dent Res 1984;63:378-85.  Back to cited text no. 1
Loesche WJ. Role of Streptococcus mutans in human dental decay. Microbiol Rev 1986;50:353-80.  Back to cited text no. 2
Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet 2007;369:51-9.  Back to cited text no. 3
Aksoy A, Duran N, Koksal F. In vitro and in vivo antimicrobial effects of mastic chewing gum against Streptococcus mutans and mutans streptococci. Arch Oral Biol 2006;51:476-81.  Back to cited text no. 4
Hamada S, Slade HD. Biology, immunology, and cariogenicity of Streptococcus mutans. Microbiol Rev 1980;44:331-84.  Back to cited text no. 5
Imfeld T. Chewing gum - facts and fiction: A review of gum-chewing and oral health. Crit Rev Oral Biol Med 1999;10:405-19.  Back to cited text no. 6
Reynolds EC. The prevention of sub-surface demineralization of bovine enamel and change in plaque composition by casein in an intra-oral model. J Dent Res 1987;66:1120-7.  Back to cited text no. 7
Walker G, Cai F, Shen P, Reynolds C, Ward B, Fone C, et al. Increased remineralization of tooth enamel by milk containing added casein phosphopeptide-amorphous calcium phosphate. J Dairy Res 2006;73:74-8.  Back to cited text no. 8
Reynolds EC, Black CL. Advances in enamel remineralization: Anticariogenic casein phosphopeptide-amorphous calcium phosphate. J Clin Dent 1999;10:86-8.  Back to cited text no. 9
Shen P, Cai F, Nowicki A, Vincent J, Reynolds EC. Remineralization of enamel subsurface lesions by sugar-free chewing gum containing casein phosphopeptide - Amorphous calcium phosphate. J Dent Res 2003;48:240-3.  Back to cited text no. 10
Iijima Y, Cai F, Shen P, Walker G, Reynolds C, Reynolds EC. Acid resistance of enamel subsurface lesions remineralized by a sugar-free chewing gum containing casein phosphopeptide-amorphous calcium phosphate. Caries Res 2004;38:551-6.  Back to cited text no. 11
Trahan L. Xylitol: A review of its action on mutans streptococci and dental plaque - its clinical significance. Int Dent J 1995;45 (1 Suppl 1):77-92.  Back to cited text no. 12
Söderling EM. Xylitol, mutans streptococci, and dental plaque. Adv Dent Res 2009;21:74-8.  Back to cited text no. 13
Suda R, Suzuki T, Takiguchi R, Egawa K, Sano T, Hasegawa K. The effect of adding calcium lactate to xylitol chewing gum on remineralization of enamel lesions. Caries Res 2006;40:43-6.  Back to cited text no. 14
Milgrom P, Ly KA, Roberts MC, Rothen M, Mueller G, Yamaguchi DK. Mutans streptococci dose response to xylitol chewing gum. J Dent Res 2006;85:177-81.  Back to cited text no. 15
Söderling E, Alaräisänen L, Scheinin A, Mäkinen KK. Effect of xylitol and sorbitol on polysaccharide production by and adhesive properties of Streptococcus mutans. Caries Res 1987;21:109-16.  Back to cited text no. 16
Caglar E, Kavaloglu SC, Kuscu OO, Sandalli N, Holgerson PL, Twetman S. Effect of chewing gums containing xylitol or probiotic bacteria on salivary mutans streptococci and lactobacilli. Clin Oral Investig 2007;11:425-9.  Back to cited text no. 17
Harris NO, Garcia-Godoy F, Nathe CN. Primary Preventive Dentistry. 6 th ed. New Jersey. Prentice Hall; 2004. p. 132-7.  Back to cited text no. 18
Kolahi J, Soolari A, Ghalayani P, Varshosaz J, Fazilaty M. Newly formulated chlorhexidine gluconate chewing gum that gives both anti-plaque effectiveness and an acceptable taste: A double blind, randomized, placebo-controlled trial. J Int Acad Periodontol 2008; 10:38-44.  Back to cited text no. 19
Fraga CP, Mayer MP, Rodrigues CR. Use of chewing gum containing 15% of xylitol and reduction in mutans streptococci salivary levels. Braz Oral Res 2010;24:142-6.  Back to cited text no. 20
Thaweboon S, Thaweboon B, Soo-Ampon S. The effect of xylitol chewing gum on mutans streptococci in saliva and dental plaque. Southeast Asian J Trop Med Public Health 2004;35:1024-7.  Back to cited text no. 21
Wang YI, Chuang CY, Liao JF. Effect of xylitol in chewing gum on dental plaque and Streptococcus mutans. J Food Drug Anal 2006;14:84-8.  Back to cited text no. 22
Ribelles Llop M, Guinot Jimeno F, Mayné Acién R, Bellet Dalmau LJ. Effects of xylitol chewing gum on salivary flow rate, pH, buffering capacity and presence of Streptococcus mutans in saliva. Eur J Paediatr Dent 2010;11:9-14.  Back to cited text no. 23
Subramanian P, Naidu P. Effect of tooth mousse plus and cervitic gel on S. mutans. J Minim Interv Dent 2009;2:164-9.  Back to cited text no. 24
Vashisht R, Indira R, Ramachandran S, Kumar A, Srinivasan MR. Role of casein phosphopeptide amorphous calcium phosphate in remineralization of white spot lesions and inhibition of Streptococcus mutans? J Conserv Dent 2013;16:342-6.  Back to cited text no. 25
[PUBMED]  Medknow Journal  

Correspondence Address:
Dr. Shila Emamieh
Department of Operative Dentistry, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-0707.157240

Clinical trial registration IRCT2014063018296N1

Rights and Permissions


  [Table 1], [Table 2]

This article has been cited by
1 The preventive/therapeutic effect of CO2 laser and MI Paste Plus® on intact and demineralized enamel against Streptococcus mutans (In Vitro Study)
Dhuha H. Almarsomy, Fadia A. Al-khayat, Lamis A. Al-Taee
Heliyon. 2023; 9(10): e20310
[Pubmed] | [DOI]
2 Remineralization of teeth with casein phosphopeptide-amorphous calcium phosphate: analysis of salivary pH and the rate of salivary flow
Lubna Alkarad, Muaaz Alkhouli, Mayssoon Dashash
BDJ Open. 2023; 9(1)
[Pubmed] | [DOI]
3 Chewing gum base: A comprehensive review of composition, production, and assessment methods: Advances and approaches in biodegradability
Mona Kaveh, Samira Yeganehzad, Mansour Rabie Ashkezary, Mohammad Ali Hesarinejad, Aldo Todaro, Katsuyoshi Nishinari
Journal of Texture Studies. 2023;
[Pubmed] | [DOI]
4 Synthetic amorphous calcium phosphates (ACPs): preparation, structure, properties, and biomedical applications
Sergey V. Dorozhkin
Biomaterials Science. 2021; 9(23): 7748
[Pubmed] | [DOI]
5 Antibacterial efficacy and remineralization capacity of glycyrrhizic acid added casein phosphopeptide-amorphous calcium phosphate
Feride Sahin, Fatih Oznurhan
Microscopy Research and Technique. 2020; 83(7): 744
[Pubmed] | [DOI]
6 The effect of antimicrobial activity of Teucrium Polium on Oral Streptococcus Mutans: a randomized cross-over clinical trial study
Somayeh Khoramian Tusi, Ahmad Jafari, Seyed Mahmoud Amin Marashi, Salomeh Faramarzi Niknam, Malihe Farid, Mehdi Ansari
BMC Oral Health. 2020; 20(1)
[Pubmed] | [DOI]
7 The potential ecological effects of casein phosphopeptide-amorphous calcium phosphate in dental caries prevention
N Philip, L Walsh
Australian Dental Journal. 2019; 64(1): 66
[Pubmed] | [DOI]
8 Casein Phosphopeptide-Amorphous Calcium Phosphate Attenuates Virulence and Modulates Microbial Ecology of Saliva-Derived Polymicrobial Biofilms
Nebu Philip, Shaneen J. Leishman, H.M.H.N. Bandara, Laurence J. Walsh
Caries Research. 2019; 53(6): 643
[Pubmed] | [DOI]
9 Salivary Iron (Fe) Ion Levels, Serum Markers of Anemia and Caries Activity in Pregnant Women
Elisa Miranda Costa, Juliana Aires Paiva de Azevedo, Rafiza Félix Marão Martins, Vandilson Pereira Rodrigues, Cláudia Maria Coêlho Alves, Cecília Cláudia Costa Ribeiro, Erika Bárbara Abreu Fonseca Thomaz
Revista Brasileira de Ginecologia e Obstetrícia / RBGO Gynecology and Obstetrics. 2017; 39(03): 094
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  

    Materials and Me...
    Article Tables

 Article Access Statistics
    PDF Downloaded288    
    Comments [Add]    
    Cited by others 9    

Recommend this journal