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ORIGINAL ARTICLE
Year : 2017  |  Volume : 35  |  Issue : 4  |  Page : 332-337
 

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


Department of Pedodontics and Preventive Dentistry, Bharati Vidyapeeth Deemed University Dental College and Hospital, Navi Mumbai, Maharashtra, India

Date of Web Publication15-Sep-2017

Correspondence Address:
Rahul J Hegde
Bharati Vidyapeeth Deemed University Dental College and Hospital, Sector - 7, CBD, Belpada, Navi Mumbai - 400 614, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_147_17

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   Abstract 


Aim: This study aimed to compare and evaluate the changes in the salivary flow rate, pH, and buffering capacity before and after chewing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and xylitol-containing chewing gums in children. Materials and Methods: Sixty children aged between 8 and 12 years were selected for the study. They were randomly divided into Group 1 (CPP-ACP chewing gum) and Group 2 (xylitol-containing chewing gum) comprising thirty children each. Unstimulated and stimulated saliva samples at 15 and 30 min interval were collected from all children. All the saliva samples were estimated for salivary flow rate, pH, and buffering capacity. Results: Significant increase in salivary flow rate, pH, and buffering capacity from baseline to immediately after spitting the chewing gum was found in both the study groups. No significant difference was found between the two study groups with respect to salivary flow rate and pH. Intergroup comparison indicated a significant increase in salivary buffer capacity in Group 1 when compared to Group 2. Conclusion: Chewing gums containing CPP-ACP and xylitol can significantly increase the physiochemical properties of saliva. These physiochemical properties of saliva have a definite relation with caries activity in children.


Keywords: Buffer capacity, casein-phosphopeptide amorphous calcium phosphate, pH, salivary flow rate, xylitol


How to cite this article:
Hegde 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

How to cite this URL:
Hegde 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 [serial online] 2017 [cited 2019 Nov 13];35:332-7. Available from: http://www.jisppd.com/text.asp?2017/35/4/332/214914





   Introduction Top


The chewing of non-food items for pleasure has a long history. Tree resins were chewed by the ancient Egyptians, the Mayan Indians, and the early American Indians. The first commercial chewing gum, State of Maine Pure Spruce Gum, appeared in 1848. Interestingly, the first patent for a chewing gum was issued to a dentist, Dr. W.F. Semple, Mount Vernon, Ohio, in 1869.[1]

Chewing gums are known to be a useful adjunct to common oral hygiene because of stimulation of salivary flow rate. Important defining aspects are the ability to use sugar substitutes in gum manufacturing. The chewing of sugar-free gums after meals and snacks can promote remineralization of enamel.[2],[3] Chewing gums also have the potential of being an effective vehicle for delivering therapeutic agents to dentition because they permit protracted contact of the agent with the teeth with minimal efforts on the part of the patient.[4]

One of the most widely used sugar alcohols is xylitol.[5] The American Academy of Pediatric Dentistry (AAPD) “supports the use of xylitol as part of a preventive strategy aimed specifically at long-term caries pathogen suppression and caries reduction in higher risk populations.”[6]

In the recent years, addition of casein phosphopeptide- amorphous calcium phosphate (CPP-ACP) noncomplexes to sugar-free chewing gum has been demonstrated to enhance remineralization of enamel subsurface lesions in a dose-related manner, independent of gum weight or type in various in vivo studies.[7]

Although the usefulness of xylitol for preventing dental caries, especially in children, has been documented in various studies, so far, the effects of CPP-ACP and xylitol-containing chewing gums on salivary flow rate, pH, and buffering capacity have not been compared clinically. Therefore, this study was undertaken to compare the effects of sugar-free chewing gum containing CPP-ACP and xylitol on physiochemical properties of saliva in children.


   Materials and Methods Top


The present study was conducted in the Department of Pedodontics and Preventive Dentistry. Sixty school children from Kharghar region, Navi Mumbai, were selected for the study.

The study was approved by the Institutional Ethical Committee and Review Board. All the children were verbally informed, and written informed consent signed by the parents was obtained for participation in the study.

Inclusion criteria

  • Children aged between 8 and 12 years
  • No report of use of antibiotics 3 months prior to the beginning of the study
  • Children with decayed, missing and filled teeth (DMFT/dmft) ≤1


Exclusion criteria

  • Children with special health-care needs
  • Children undergoing orthodontic treatment.


Children selected were randomly divided into Group 1: CPP-ACP-containing chewing gum-spearmint flavor (Trident XTRA CARE with Recaldent ®) and Group 2: xylitol-containing chewing gum-spearmint flavor (Spry Xylitol), comprising thirty children each [Figure 1].
Figure 1: Chewing gums used for the study

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At the onset, the procedure was explained and demonstrated to the children. The children were recalled after 24 h with instructions not to eat and drink anything for at least 2 h prior to collection of the saliva sample. Collection of samples was done in the afternoon hours (12:00–1:00 pm).

The children in Group 1 were first instructed to expectorate saliva in a preweighed graduated container by drooling method for exactly 5 min. Later, the children were given one pellet of sugar-free chewing gum containing CPP-ACP and asked to chew under supervision for a period of 10 min. After 10 min, the chewing gum was discarded. The stimulated saliva samples were collected from each child immediately by the same procedure and at intervals of 15 and 30 min [Figure 2].
Figure 2: Collection of saliva sample

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Similarly, the procedure was carried out in all the selected thirty children of Group 2 (all the children were given one pellet of sugar-free chewing gum containing xylitol). All the saliva samples were taken immediately to the biochemistry laboratory for salivary analysis.

Salivary analysis

Salivary flow rate was estimated by asking the child to spit into a sample-collecting container for 5 min and was determined gravimetrically (1 g = 1 ml). To calculate the weight of the saliva, the containers were weighed before and after gathering saliva, using digital scales, with a precision of 0.01 g. Then, the total volume of the saliva collected was noted and divided by 5 to obtain the flow rate of saliva in ml/min [Figure 3].
Figure 3: Saliva sample being weighed to determine salivary flow rate

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Salivary pH was measured using a calibrated digital pH meter (Toshcone CL-54). The electrode was placed in the sample and the pH was recorded to two decimal places [Figure 4].
Figure 4: Salivary pH measured using digital pH meter

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Salivary buffering capacity was estimated according to Ericsson Y (1959) method – 1 ml of saliva was mixed with 3 ml of 0.005 M HCL acid. This solution was manually stirred and allowed to stand in an open tube for 10 min to eliminate CO2. The final pH was then measured using a calibrated digital pH meter.

Statistical analysis

The results were tabulated and statistically analyzed using repeated measure analysis of variance, paired t-test, and unpaired t-test, with the type of chewing gum as the main factor.


   Results Top


In Group 1, the mean age of the children was 10.70 years, and in Group 2, mean age was 10.36 years [Table 1]. Gender-wise distribution of the study groups included 43.33% males and 56.67% females in Group 1 and Group 2, respectively [Table 2].
Table 1: Mean age (years) of the children

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Table 2: Gender-wise distribution of the children

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A significant increase in mean salivary flow rate was observed from baseline (Group 1: 0.5633 ± 0.3324 and Group 2: 0.6703 ± 0.3341) to immediately after spitting the chewing gum (Group 1: 0.9061 ± 0.3427 and Group 2: 0.8685 ± 0.3141) in both the study groups (P < 0.001). Intergroup comparison for salivary flow rate indicated no statistically significant difference in the stimulation of the salivary flow (P > 0.05) [Table 3].
Table 3: Intergroup comparison for salivary flow rate (ml/min)

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The results with respect to mean salivary pH showed significant increase from baseline (Group 1: 7.1613 ± 0.4795 and Group 2: 7.2300 ± 0.4743) to immediately after spitting (Group 1: 7.851 ± 0.3246 and Group 2: 7.7450 ± 0.2844), followed by 30 min (Group 1: 7.7287 ± 0.3349 and Group 2: 7.6810 ± 0.3041) and 15 min (Group 1: 7.5263 ± 0.3761 and Group 2: 7.5050 ± 0.3242) after spitting the chewing gum in both the study groups (P < 0.001). Intergroup comparison for salivary pH indicated no statistically significant difference in stimulated saliva samples at various time intervals (P > 0.05) [Table 4].
Table 4: Intergroup comparison for salivary pH

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The results with respect to mean salivary buffer capacity showed significant increase from baseline (Group 1: 3.0927 ± 0.4521 and Group 2: 3.1647 ± 0.5047) to immediately after spitting the chewing gum (Group 1: 4.7377 ± 0.6341 and Group 2: 4.1537 ± 0.5715) in both the study groups (P < 0.001). Intergroup comparison for salivary buffer capacity indicated statistically significant increase in mean salivary buffer capacity of stimulated saliva samples in Group 1 when compared with Group 2 (P < 0.001) [Table 5].
Table 5: Intergroup comparison for salivary buffer capacity

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   Discussion Top


Salivary composition is an important factor in determining the prevalence of caries. For relative protection against dental caries, salivary flow rate, pH, and buffer capacity are essential. The saliva circulating in the mouth at any given time is termed as whole saliva and comprises a mixture of secretions from the major, minor salivary glands and traces from the gingival crevicular fluid. Since this fluid constantly bathes the teeth and oral mucosa, it acts as a cleansing solution, a lubricant, buffer, and ion reservoir of calcium and phosphate, which is essential for remineralization of initial carious lesion.[8]

To gain more evidence for the potential benefits of salivary stimulation in caries prevention, research has been focused on clearance, buffering, and saturation.[9] In the present study, an attempt was made to evaluate the changes in physiochemical properties of saliva, i.e. salivary flow rate, pH, buffering capacity after chewing CPP-ACP, and xylitol-containing chewing gums in children.

The american academy of pediatrics (AAP) does not recommend the use of chewing gum, mints, or hard candy by children <4 years of age due to the risk of choking.[6] Therefore, in accordance to the AAP, the age range selected for children who participated in the study was 8–12 years.

The time for collection of samples was in the afternoon hours (12:00–1:00 pm) to minimize the effect of circadian variation in the flow rates of saliva from all glands. The time for collection of saliva samples was in accordance with the study by Peck (1959) and Chauncey, Feller and Shannon (1963) who have recorded higher flow rates in the afternoon than in the morning.[10],[11]

Various studies have demonstrated that gum's taste can also affect the salivary flow rate and pH. Hence, the chewing gums selected for the present study were of same flavor (spearmint).[12]

In the present study, no statistically significant difference between the two groups, with respect to mean salivary flow rate of the stimulated saliva, was observed [Table 3]. The results are in accordance with Ribelles Llop et al. (2010), who found that the act of chewing is essential to increase salivary flow rate, which leads to the prevention of dental caries, independent of the sweetener contained in the chewing gum.[13]

Maximum peak rise in salivary pH was observed immediately after spitting the gum, followed by a drop in pH at 15 min time interval and again a rise in pH was observed 30 min after spitting the chewing gum. The increase in salivary pH was gradual but persisted through the 30 min observation period. The observation that the increase in salivary pH can be sustained for as long as 30 min could have an important oral health implication.[14] A xylitol-containing gum with CPP-ACP has also been shown to produce a dose-related increase in the salivary pH, thereby enhancing the remineralization of the white spot lesions. Marchisio et al. in an in vivo evaluation of CPP-ACP (Recaldent ® molecule) concluded that 48% of patients had an increase in plaque and salivary pH level.[15]

There was no statistically significant difference observed in mean salivary pH between the two groups at different time intervals [Table 4]. Results of this study are in accordance with that of Dawes and Kubieniec (2004) who showed that prolonged chewing of gum led to an increase in pH due to the increase in stimulated saliva, independent of the type of sugar-free chewing gum used.[16]

Results indicated statistically significant increase in the mean salivary buffer capacity of stimulated saliva in Group 1 when compared to Group 2 [Table 5]. This significant increase in the buffer capacity is due to the fact that CPP-ACP has been found to increase the levels of calcium and phosphate in plaque up to 5 fold, thereby acting as a calcium phosphate reservoir. Hence, a state of supersaturation with respect to enamel mineral is maintained, thereby depressing enamel demineralization and enhancing remineralization mechanism.[7],[17],[18],[19]

Based on the results of this study, we believe that the act of chewing is a more essential factor in the anticaries effect of chewing gum. Irrespective of the type of sugar-free chewing gum used, there is an increase in salivary flow, leading to an increase in pH and buffering capacity and thus facilitating remineralization.


   Conclusion Top


The following conclusions can be made from the present study:

  1. Statistically significant increase in salivary flow rate, pH, and buffering capacity from baseline to immediately after spitting the chewing gum was found in both the study groups
  2. No statistically significant differences were found in the stimulation of the salivary flow rate between the two study groups
  3. No statistically significant differences were found between the two study groups in terms of salivary pH at various time intervals
  4. Chewing CPP-ACP chewing gum produced statistically significant increase in salivary buffer capacity when compared to xylitol-containing chewing gum.


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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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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. 1
    
2.
Edgar WM. Sugar substitutes, chewing gum and dental caries – A review. Br Dent J 1998;184:29-32.  Back to cited text no. 2
    
3.
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.  Back to cited text no. 3
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4.
Chow LC, Takagi S, Shern RJ, Chow TH, Takagi KK, Sieck BA. Effects on whole saliva of chewing gums containing calcium phosphates. J Dent Res 1994;73:26-32.  Back to cited text no. 4
    
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Van Loveren C. Sugar alcohols: What is the evidence for caries-preventive and caries-therapeutic effects? Caries Res 2004;38:286-93.  Back to cited text no. 5
    
6.
Guideline on xylitol use in caries prevention. Am Acad Pediatr Dent 2011;36:175-8.  Back to cited text no. 6
    
7.
Gurunathan D, Somasundaram S, Kumar S. Casein phosphopeptide-amorphous calcium phosphate: A remineralizing agent of enamel. Aust Dent J 2012;57:404-8.  Back to cited text no. 7
    
8.
Animireddy D, Reddy Bekkem VT, Vallala P, Kotha SB, Ankireddy S, Mohammad N. Evaluation of pH, buffering capacity, viscosity and flow rate levels of saliva in caries-free, minimal caries and nursing caries children: An in vivo study. Contemp Clin Dent 2014;5:324-8.  Back to cited text no. 8
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9.
Edgar WM, Higham SM, Manning RH. Saliva stimulation and caries prevention. Adv Dent Res 1994;8:239-45.  Back to cited text no. 9
    
10.
Peck RE. The SHP test - an aid in the detection and measurement of depression. Archer gen. Peychiat 1959;1:35-40.  Back to cited text no. 10
    
11.
Chauncey HH, Feller R P, Shannon IL. Effect of acid solutions on human gustatory chemoreceptors as determined by parotid gland secretion rate. Proc Soc exp Biol Med 1963;112,917-23.  Back to cited text no. 11
    
12.
Karami-Nogourani M, Kowsari-Isfahan R, Hosseini-Beheshti M. The effect of chewing gum's flavor on salivary flow rate and pH. Dent Res J (Isfahan) 2011;8 Suppl 1:S71-5.  Back to cited text no. 12
    
13.
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. 13
    
14.
Polland KE, Higgins F, Orchardson R. Salivary flow rate and pH during prolonged gum chewing in humans. J Oral Rehabil 2003;30:861-5.  Back to cited text no. 14
    
15.
Marchisio O, Esposito MR, Genovesi A. Salivary pH level and bacterial plaque evaluation in orthodontic patients treated with Recaldent products. Int J Dent Hyg 2010;8:232–236.  Back to cited text no. 15
    
16.
Dawes C, Kubieniec K. The effects of prolonged gum chewing on salivary flow rate and composition. Archs Oral Biol 2004;49:665-9.  Back to cited text no. 16
    
17.
Reynolds EC. Remineralization of enamel subsurface lesions by casein phosphopeptide-stabilized calcium phosphate solutions. J Dent Res 1997;76:1587-95.  Back to cited text no. 17
    
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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 2001;80:2066-70.  Back to cited text no. 18
    
19.
de Alencar CR, Magalhães AC, de Andrade Moreira Machado MA, de Oliveira TM, Honório HM, Rios D. In situ effect of a commercial CPP-ACP chewing gum on the human enamel initial erosion. J Dent 2014;42:1502-7.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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