Non-Cochrane · intervention · PM38599933
Clinical Effects of Sugar Substitutes on Cariogenic Bacteria: A Systematic Review and Meta-Analysis.
Liang Nicky Linlin, Luo Bella Weijia, Sun Ivy Guofang, et al. · International dental journal · 2024 · PubMed · doi:10.1016/j.identj.2024.02.008
Full textEvery question was extracted from the full text, figures and supplements by two independent LLM extractors, disagreements adjudicated. Rows cite where in the review the value comes from.
Questions
8
current version
GRADE rated
0
No studies
1
Included studies
49
linked below
No studies 1 · 12.5%Ungraded 7 · 87.5%Very low 0 · 0%Low 0 · 0%Moderate 0 · 0%High 0 · 0%
Ungraded means an effect was reported without a GRADE rating; it is not a gap. No studies means the review found nothing to answer the question. The six categories are a display order, not a score.
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | All age groups; generally healthy participants | 32 trials; all generally healthy; ages 1 month to 98 years; per-study n 20 to 892; children/adolescents in 23 studies and adults in 9 (n=32 studies) |
| Intervention | All types of sugar substitutes in food products: low-intensity sweeteners (xylitol, sorbitol, maltitol, mannitol, erythritol) and high-intensity sweeteners (aspartame, sucralose, saccharin, stevia); any form, amount, concentration, or frequency | Low-intensity sweeteners (xylitol, sorbitol, maltitol, erythritol) in 31/32 studies, xylitol most studied; only stevia among high-intensity sweeteners (1 study); forms: chewing gum, milk, candy, tablets (n=31 low-intensity) |
| Comparison | No treatment, sugary products, or other types of sugar substitutes | No treatment/no gum, sorbitol, other sugars (sucrose, fructose), maltitol, fluoride or chlorhexidine varnish/gum |
| Outcomes | Changes in cariogenic bacteria in dental plaque and saliva (bacterial count, mean % change, prevalence lowering MS level, composition) | Change in Mutans streptococci (MS) in dental plaque (16 studies) and saliva (16 studies); a few reported Lactobacilli or other bacteria (n=32 for MS) |
| Study designs | Prospective controlled trials (RCTs and CCTs), published in English | 30 RCTs, 2 CCTs (n=32) |
| Timing | Not specified (any duration; inception to July 2023) | Study durations 2 weeks to 39 months |
Search date: 7 July 2023 (databases searched from inception to); 22 September 2023 noted in Discussion. Databases: PubMed, EMBASE, Web of Science
Questions and results
Xylitol chewing gum vs No treatment (no gum / no intervention)
Population: Generally healthy individuals across all age groups (infants to elderly)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Change in Mutans streptococci (MS) count in saliva Post-consumption endpoint (varied durations across trials) · Xylitol chewing gum vs no intervention/no gum (3 studies) Xylitol significantly reduced Mutans streptococci in saliva compared with no intervention (SMD -1.47, 95% CI -1.94 to -0.99; 3 trials), though heterogeneity was very high (I2=98%); not GRADE-rated. Source: Results 'Results of studies in saliva' (Figure 6); Abstract · same question in other reviews | SMD -1.47 [-1.94, -0.99] | 3 studies · 136 participants | Ungraded |
Change in Mutans streptococci (MS) count in dental plaque Post-consumption endpoint (trial durations 2 wk to 6 mo) · Xylitol gum vs no treatment (5 studies, mixed ages) Xylitol significantly reduced Mutans streptococci in dental plaque compared with no treatment (SMD -0.73, 95% CI -1.09 to -0.37; 5 trials, I2=53%; not GRADE-rated). Source: Results 'Results of studies in dental plaque' (Figure 4); Abstract · same question in other reviews | SMD -0.73 [-1.09, -0.37] | 5 studies · 308 participants | Ungraded |
Xylitol (low-intensity sweetener/sugar alcohol) in food products (chewing gum, milk, candy, or tablets) vs Sorbitol (low-intensity sweetener)
Population: Generally healthy individuals across all age groups (infants to elderly)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Change in Mutans streptococci (MS) count in saliva Post-consumption endpoint (varied durations across trials) · Xylitol gum vs sorbitol gum (2 studies) Xylitol and sorbitol did not differ significantly for Mutans streptococci in saliva (SMD -0.16, 95% CI -0.44 to 0.12; 2 trials, P=.25); not GRADE-rated. Source: Results 'Results of studies in saliva' (Figure 7) · same question in other reviews | SMD -0.16 [-0.44, 0.12] | 2 studies · 201 participants | Ungraded |
Change in Mutans streptococci (MS) count in dental plaque Post-consumption endpoint (varied durations across trials) · Xylitol vs sorbitol (4 studies) Xylitol reduced Mutans streptococci in dental plaque more than sorbitol (SMD -0.45, 95% CI -0.69 to -0.21; 4 trials, I2=7%); not GRADE-rated. Source: Results 'Results of studies in dental plaque' (Figure 5) · same question in other reviews | SMD -0.45 [-0.69, -0.21] | 4 studies · 323 participants | Ungraded |
High-intensity sweeteners other than stevia (aspartame, sucralose, saccharin) in food products vs Any comparator (dietary sugar, no treatment, or other sweetener)
Population: Generally healthy individuals across all age groups
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Effects of non-stevia high-intensity sweeteners (aspartame, sucralose, saccharin) on cariogenic bacteria in dental plaque or saliva No eligible studies evaluated high-intensity sweeteners such as aspartame, sucralose, or saccharin for their effect on cariogenic bacteria. Source: Abstract; Results 'Study selection' / Discussion; Conclusion · same question in other reviews | No studies on high-intensity sweeteners such as sucralose, saccharin, or aspartame were found; the review located no eligible trials of these sweeteners on cariogenic bacteria. | 0 studies | No studies |
Stevia (high-intensity/non-nutritive sweetener) in a daily snack vs Baseline (within-group change); white sugar snack is a parallel arm with no between-group effect size reported
Population: Schoolchildren (6-9 years), high caries risk
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Change in Mutans streptococci (MS) and Lactobacilli in saliva 42 days · Single study (Cocco 2019); not pooled The single stevia trial (Cocco 2019) reported a significant reduction in salivary Mutans streptococci and lactobacilli, but gave no effect size and was not GRADE-rated. Source: Results 'Results of studies in saliva' (Cocco et al 2019); Table 2; Discussion · same question in other reviews | Cocco 2019 (the only high-intensity sweetener trial): the stevia snack showed a significant decrease in MS (P < .01) and in lactobacilli (P = .03) versus baseline, whereas the white-sugar snack showed no significant… | 1 study · 271 participants | Ungraded |
Comparison
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Change in prevalence of salivary Streptococcus sobrinus Single study (Stsepetova et al. 2019), erythritol and xylitol vs sorbitol, not pooled | Narrative (no effect size) Erythritol and xylitol significantly reduced the prevalence of salivary S. sobrinus | 1 study | Ungraded |
Change in Lactobacillus spp. in dental plaque Single study (Ly et al. 2008), xylitol or maltitol, not pooled | Narrative (no effect size) No significant change in Lactobacillus spp. after xylitol or maltitol consumption | 1 study | Ungraded |
AMSTAR 2 appraisal
Two independent extractors rated each item. Their ratings are shown side by side because they have not been reconciled yet. The overall rating follows Shea et al. 2017: one critical flaw gives Low, more than one gives Critically Low.
| Item | Extractor A | Extractor B | Agree |
|---|---|---|---|
| 1Research question includes PICO components | Yes | Yes | yes |
| 2Protocol established before the reviewcritical | No | No | yes |
| 3Choice of study designs explained | No | No | yes |
| 4Comprehensive literature searchcritical | Partial Yes | Partial Yes | yes |
| 5Study selection in duplicate | Yes | Yes | yes |
| 6Data extraction in duplicate | No | No | yes |
| 7List of excluded studies with reasonscritical | No | No | yes |
| 8Included studies described in detail | Partial Yes | Yes | no |
| 9Risk of bias assessed satisfactorilycritical | NRSI: Yes · RCT: Yes | NRSI: Yes · RCT: Yes | yes |
| 10Funding of included studies reported | No | No | yes |
| 11Appropriate meta-analysis methodscritical | RCT: Yes · NRSI: No | RCT: Yes · NRSI: No | yes |
| 12Impact of risk of bias on the pooled results | No | No | yes |
| 13Risk of bias accounted for in interpretationcritical | No | No | yes |
| 14Heterogeneity explained | Yes | No | no |
| 15Publication bias investigatedcritical | No | No | yes |
| 16Conflicts of interest reported | Yes | Yes | yes |
| Overall | Critically Low | Critically Low | yes |
Included primary studies 49
Open as a trial list| Study | Also included by | Outcomes it informs here | Trial PICO | Results |
|---|---|---|---|---|
| Haresaku et al. 2007 Long-Term Effect of Xylitol Gum Use on Mutans Streptococci in Adults DOI:10.1159/000099318 | 1 other review | Change in Mutans streptococci (MS) count in dental plaque | not extracted yet | not extracted yet |
| Simons et al. 1997 The Effect of Chlorhexidine/Xylitol Chewing-Gum on Cariogenic Salivary Microflora: A Clinical Trial in Elderly Patients DOI:10.1159/000262382 | 1 other review | not stated | not extracted yet | not extracted yet |
| Wang et al. 2006 matched by author and year (probable) | 1 other review | Change in Mutans streptococci (MS) count in dental plaque | not extracted yet | not extracted yet |
| Alamoudi 2012 Impact of maternal xylitol consumption on mutans streptococci, plaque and caries levels in children. PMID:23534323 | this review only | not stated | not extracted yet | not extracted yet |
| Alamoudi et al. 2012 (J Clin Pediatr Dent) Impact of Maternal Xylitol Consumption on Mutans Streptococci, Plaque and Caries Levels in Children DOI:10.17796/jcpd.37.2.261782tq73k4414x | this review only | not stated | not extracted yet | not extracted yet |
| Alamoudi et al. 2012 (Saudi Med J) Effects of xylitol on salivary mutans streptococcus, plaque level, and caries activity in a group of Saudi mother-child pairs. An 18-month… PMID:22327761 | this review only | not stated | not extracted yet | not extracted yet |
| Alamoudi et al. 2014 Early prevention of childhood caries with maternal xylitol consumption. PMID:24888659 | this review only | not stated | not extracted yet | not extracted yet |
| Aluckal 2018 Effectiveness of xylitol and polyol chewing gum on salivary streptococcus mutans in children: A randomized controlled trial. PMID:30127194 | this review only | not stated | not extracted yet | not extracted yet |
| Aluckal et al. 2018 Effectiveness of xylitol and polyol chewing gum on salivary streptococcus mutans in children: A randomized controlled trial DOI:10.4103/ijdr.ijdr_307_16 | this review only | Change in Mutans streptococci (MS) count in saliva | not extracted yet | not extracted yet |
| Autio et al. 2002 Effect of xylitol chewing gum on salivary Streptococcus mutans in preschool children. PMID:12119821 | this review only | not stated | not extracted yet | not extracted yet |
| Caglar 2007 Effect of chewing gums containing xylitol or probiotic bacteria on salivary mutans streptococci and lactobacilli. PMID:17574481 | this review only | not stated | not extracted yet | not extracted yet |
| Caglar et al. 2007 Effect of chewing gums containing xylitol or probiotic bacteria on salivary mutans streptococci and lactobacilli DOI:10.1007/s00784-007-0129-9 | this review only | not stated | not extracted yet | not extracted yet |
| Chi et al. 2016 Milk Sweetened with Xylitol: A Proof-of-Principle Caries Prevention Randomized Clinical Trial. PMID:28327266 | this review only | Change in Mutans streptococci (MS) count in dental plaque | not extracted yet | not extracted yet |
| Cocco 2019 Effect of a Daily Dose of Snacks Containing Maltitol or Stevia rebaudiana as Sweeteners in High Caries Risk Schoolchildren. A Double-blind… PMID:31641701 | this review only | not stated | not extracted yet | not extracted yet |
| Cocco et al. 2019 DOI:10.3290/j.ohpd.a43329 | this review only | Change in Mutans streptococci (MS) and Lactobacilli in saliva | not extracted yet | not extracted yet |
| Emamieh et al. 2015 The effect of two types chewing gum containing casein phosphopeptide-amorphous calcium phosphate and xylitol on salivary Streptococcus… PMID:26069402 | this review only | not stated | not extracted yet | not extracted yet |
| Fontana et al. 2009 Xylitol: effects on the acquisition of cariogenic species in infants. PMID:19552232 | this review only | not stated | not extracted yet | not extracted yet |
| Haresaku 2007 Long-term effect of xylitol gum use on mutans streptococci in adults. PMID:17426399 | this review only | not stated | not extracted yet | not extracted yet |
| Holgerson 2007 Dental plaque formation and salivary mutans streptococci in schoolchildren after use of xylitol-containing chewing gum. PMID:17263856 | this review only | not stated | not extracted yet | not extracted yet |
| Holgerson et al. 2006 Dental plaque formation and salivary mutans streptococci in schoolchildren after use of xylitol‐containing chewing gum DOI:10.1111/j.1365-263x.2006.00808.x | this review only | Change in Mutans streptococci (MS) count in saliva | not extracted yet | not extracted yet |
| Isotupa 1995 Effect of polyol gums on dental plaque in orthodontic patients. PMID:7733059 | this review only | not stated | not extracted yet | not extracted yet |
| Isotupa et al. 1995 Effect of polyol gums on dental plaque in orthodontic patients DOI:10.1016/s0889-5406(95)70117-6 | this review only | Change in Mutans streptococci (MS) count in dental plaque | not extracted yet | not extracted yet |
| Jain et al. 2022 A Comparative Evaluation of Xylitol Chewing Gum and a Combination of IgY + Xylitol Chewable Tablet on Salivary Streptococcus mutans Count… PMID:35645521 | this review only | Change in Mutans streptococci (MS) count in saliva | not extracted yet | not extracted yet |
| Lee 2009 Morphological changes in Streptococcus mutans after chewing gum containing xylitol for twelve months. PMID:19085034 | this review only | not stated | not extracted yet | not extracted yet |
| Lee et al. 2009 Morphological Changes in Streptococcus mutans After Chewing Gum Containing Xylitol for Twelve Months DOI:10.1007/s00284-008-9332-4 | this review only | Change in Mutans streptococci (MS) count in saliva | not extracted yet | not extracted yet |
| Loesche 1984 The effect of chewing xylitol gum on the plaque and saliva levels of Streptococcus mutans. PMID:6427315 | this review only | not stated | not extracted yet | not extracted yet |
| Loesche et al. 1984 The effect of chewing xylitol gum on the plaque and saliva levels of Streptococcus mutans DOI:10.14219/jada.archive.1984.0390 | this review only | not stated | not extracted yet | not extracted yet |
| Ly et al. 2006 Linear response of mutans streptococci to increasing frequency of xylitol chewing gum use: a randomized controlled trial [ISRCTN43479664]. PMID:16556326 | this review only | not stated | not extracted yet | not extracted yet |
| Ly et al. 2008 Xylitol gummy bear snacks: a school-based randomized clinical trial. PMID:18657266 | this review only | not stated | not extracted yet | not extracted yet |
| Mäkinen 2005 Six-month polyol chewing-gum programme in kindergarten-age children: a feasibility study focusing on mutans streptococci and dental plaque. PMID:15880962 | this review only | not stated | not extracted yet | not extracted yet |
| Makinen 2008 Thirty-nine-month xylitol chewing-gum programme in initially 8-year-old school children: a feasibility study focusing on mutans… PMID:18350853 | this review only | not stated | not extracted yet | not extracted yet |
| Makinen et al. 2005 Six-month polyol chewing-gum programme in kindergarten-age children: a feasibility study focusing on mutans streptococci and dental plaque DOI:10.1111/j.1875-595x.2005.tb00038.x | this review only | not stated | not extracted yet | not extracted yet |
| Makinen et al. 2008 Thirty-nine-month xylitol chewing-gum programme in initially 8-year-old school children: a feasibility study focusing on mutans… DOI:10.1111/j.1875-595x.2008.tb00175.x | this review only | not stated | not extracted yet | not extracted yet |
| Milgrom et al. 2006 Mutans streptococci dose response to xylitol chewing gum. PMID:16434738 | this review only | Change in Mutans streptococci (MS) count in dental plaque | not extracted yet | not extracted yet |
| Nakai 2010 Xylitol gum and maternal transmission of mutans streptococci. PMID:19948944 | this review only | not stated | not extracted yet | not extracted yet |
| Nakai et al. 2010 Xylitol Gum and Maternal Transmission of Mutans Streptococci DOI:10.1177/0022034509352958 | this review only | not stated | not extracted yet | not extracted yet |
| Seki et al. 2011 Effect of xylitol gum on the level of oral mutans streptococci of preschoolers: block-randomised trial. PMID:21995376 | this review only | not stated | not extracted yet | not extracted yet |
| Simons 1997 The effect of chlorhexidine/xylitol chewing-gum on cariogenic salivary microflora: a clinical trial in elderly patients. PMID:9118190 | this review only | not stated | not extracted yet | not extracted yet |
| Söderling 2000 Influence of maternal xylitol consumption on acquisition of mutans streptococci by infants. PMID:10765964 | this review only | not stated | not extracted yet | not extracted yet |
| Soderling 2015 Effects of short-term xylitol gum chewing on the oral microbiome. PMID:24663814 | this review only | not stated | not extracted yet | not extracted yet |
| Soderling et al. 2000 Influence of Maternal Xylitol Consumption on Acquisition of Mutans Streptococci by Infants DOI:10.1177/00220345000790031601 | this review only | not stated | not extracted yet | not extracted yet |
| Soderling et al. 2015 Effects of short-term xylitol gum chewing on the oral microbiome DOI:10.1007/s00784-014-1229-y | this review only | Change in Mutans streptococci (MS) count in saliva | not extracted yet | not extracted yet |
| Stsepetova et al. 2019 Impact of polyols on Oral microbiome of Estonian schoolchildren. PMID:30999906 | this review only | not stated | not extracted yet | not extracted yet |
| Taipale 2012 Bifidobacterium animalis subsp. lactis BB-12 administration in early childhood: a randomized clinical trial of effects on oral… PMID:22327347 | this review only | not stated | not extracted yet | not extracted yet |
| Taipale et al. 2012 <i>Bifidobacterium</i><i>animalis</i> subsp. <i>lactis</i> BB-12 Administration in Early Childhood: A… DOI:10.1159/000335567 | this review only | not stated | not extracted yet | not extracted yet |
| Thaweboon et al. 2004 The effect of xylitol chewing gum on mutans streptococci in saliva and dental plaque. PMID:15916109 | this review only | Change in Mutans streptococci (MS) count in dental plaque | not extracted yet | not extracted yet |
| Thorild 2004 Salivary mutans streptococci and dental caries in three-year-old children after maternal exposure to chewing gums containing combinations… PMID:15841810 | this review only | not stated | not extracted yet | not extracted yet |
| Thorild et al. 2004 Salivary mutans streptococci and dental caries in three-year-old children after maternal exposure to chewing gums containing combinations… DOI:10.1080/00016350410001676 | this review only | not stated | not extracted yet | not extracted yet |
| Wang et al. 2014 matched by author and year (probable) | this review only | Change in Mutans streptococci (MS) count in dental plaque | not extracted yet | not extracted yet |
Overlap with other reviews
Reviews that include the same primary studies are not independent evidence. Shared counts match studies by PMID, DOI or NCT, and otherwise by author and year (a probable match).