Daily chewing of gum containing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) or xylitol can significantly reduce the level of Streptococcus mutans bacteria in saliva. A study of 60 participants who chewed gum containing either CPP-ACP or xylitol for 3 weeks found that both reduced S. mutans, but CPP-ACP gum reduced levels more than xylitol gum. CPP-ACP and xylitol have properties that inhibit the growth and attachment of S. mutans to teeth, thereby reducing the risk of dental caries.

1. The effect of two types chewing gum containing
casein phosphopeptide-amorphous calcium
phosphate and xylitol on salivary
streptococcus mutans
Shila Emamieh,Yosra Khaterizadeh, Hossein Goudarzi, Amir Ghasemi, Alireza Akbarzadeh Baghban,
HasanTorabzadeh
Journal of Conservative Dentistry | May-Jun 2015 | Vol 18 | Issu
3

2. Introduction
• Dental caries is the destruction of dental structures by acid product as a product of
carbohydrate metabolism by cariogenic bacteria.
• Streptococcus mutans, commonly found in human dental plaque, are the primary
species associated with dental caries
• Chewing gum is known to be a useful adjunct to 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.

3. • In recent years, casein phosphopeptide-amorphous calcium phosphate (CPP-ACP)
noncomplexes have also been demonstrated to have anti-cariogenic properties in
both laboratory animal and human in situ experiments.
• 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.
• Several studies have shown that xylitol, is widely used as a noncariogenic
sweetener, can also reduce the number of S. mutans (in vivo and in vitro).

4. Materials & Methods
N= 60
(Men= 23,Women 37)
Age group: 20-25 years
EXCLUSION CRITERIAS
• Abnormal oral, medical or mental condition
• 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 lesion
• clinical signs of either gingivitis or periodontal disease

5. N= 60
Salivary samples collection: unstimulated saliva
• in the morning (9:00 am) on the day before onset
• 1-day after the final gum consumption
Group A
Chewing gum
containing 10% CPP-
ACP
“Recaldent pellet”
(Trident Company,Thailand)
Group B
Chewing gum
containing 55.3668%
xylitol
(Orion Company, Rasti Lar
Company, Iran)
3 gum pellets,
3 times/day
for an experimental
period of 3 weeks

6. During the experimental period: the subjects were strongly encouraged to reduce
carbohydrate diet and brush their teeth twice a day with fluoride toothpaste
Counts of salivary S. mutans were evaluated: mitis Salivarious agar (merk)
Cultivation: 37°C with CO2 3% for 48 h
Colony Forming Units were identified using a stereomicroscope with (12-25 X)
Results: categorized in 3 scores, and the data were processed with the SPSS
software (version 18, SPSS, Chicago, IL, USA)

7. Results
Group A
Group B

8. Discussion
• 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 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.

9. • 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.
• 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.

10. • 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, increases
pH, the growth of these bacteria reduces.
• 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 anticarious agent
(in primary caries).

11. Conclusion
“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.”

12. References
1. Gib bons RJ. Adherent interactions which may affect microbial ecology in the mouth. J Dent
Res 1984;63:378-8
2. LoescheWJ. Role of Streptococcus mutans in human dental decay. Microbiol Rev 1986;50:353-
80.
3. Selwitz RH, IsmailAI, Pitts NB. Dental caries. Lancet 2007;369:51-9.
4. 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.
5. Hamada S, Slade HD. Biology, immunology, and cariogenicity of Streptococcus mutans.
Microbiol Rev 1980;44:331-84.
6. ImfeldT. Chewing gum – facts and fiction: A review of gum-chewing and oral health. Crit Rev
Oral Biol Med 1999;10:405-19.
7. 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.
8. 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.

13. 9. Reynolds EC, Black CL.Advances in enamel remineralization: Anticariogenic casein
phosphopeptide-amorphous calcium phosphate. J Clin Dent 1999;10:86-8.
10. Shen P, Cai F, Nowicki A,Vincent J, Reynolds EC. Remineralizationof enamel subsurface lesions
by sugar-free chewing gum containing casein phosphopeptide – Amorphous calcium
phosphate. J Dent Res 2003;48:240-3.
11. IijimaY, Cai F, Shen P,Walker G, Reynolds C, Reynolds EC. Acid resistance of enamel subsurface
lesions remineralized by a sugar-free
12. Trahan L. Xylitol: A review of its action on mutans streptococci and denta plaque – its
clinical significance. Int Dent J 1995;45 (1 Suppl 1):77-92
13. Söderling EM. Xylitol, mutans streptococci, and dental plaque. Adv Dent Res 2009;21:74-8
14. Suda R, SuzukiT,Takiguchi R, Egawa K, SanoT, Hasegawa K.The effect of adding calcium
lactate to xylitol chewing gum on remineralization of enamel lesions. Caries Res
2006;40:43-6
15. 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
16. 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

14. 17. 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.
18. Harris NO, Garcia-Godoy F, Nathe CN. Primary Preventive Dentistry. 6th ed. New Jersey.
Prentice Hall; 2004. p. 132-7.
19. 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.
20. 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.

15. Thank you!