Download effect of mouth rinsing with solutions containing different

Open Access Journal
Indian Journal of Medical Research and Pharmaceutical Sciences
May 2017; 4(5)
DOI: 10.5281/zenodo.572580
ISSN: ISSN: 2349-5340
Impact Factor: 3.052
EFFECT OF MOUTH RINSING WITH SOLUTIONS CONTAINING
DIFFERENT COMMERCIALLY AVAILABLE SUGAR SUBSTITUTES
ON SALIVARY PH- AN IN VIVO RANDOMIZED CONTROLLED TRIAL.
Tanushri MD, Puja CY.
*
Post graduate student, Department of Public Health Dentistry, Bapuji Dental Collage and Hospital, Davangere,
India.
Professor, Department of Public Health Dentistry, Bapuji Dental College and Hospital, Davangere, India.
Abstract
Keywords:
salivary pH, stevia
rebaudiana, sucrose, mouth
rinsing, sugar substitutes.
Background: Nowadays sugar free food and drinks have become very popular
because of increased concerns related to obesity and overweight; as it is well known
that sucrose has a negative impact on both general as well as oral health. These
artificial sweeteners also have some side-effects when consumed in excess. In recent
decade, stevia rebaudiana, a plant derived sugar is considered as a natural and healthy
alternative to sugar and artificial sweeteners. Literature pertaining to the salivary pH
changes related to stevia is limited.
Objective: to assess the effect of mouth rinsing with solutions containing different
commercially available sugar substitutes on salivary pH.
Method: the present study is a randomized controlled trial with concurrent parallel
design. 85 female students aged 20-25 years were randomly allocated to four different
groups. Salivary pH assessments were performed at baseline and after mouth rinsing
with different sugar solutions containing Aspartame, Sucralose, Saccharin, Stevia and
distilled water at 1, 20 and 60 minutes respectively. One way Analysis of variance
and repeated measures Analysis of variance followed by Tukey’s post hoc tests were
employed to analyze the data.
Results: The results indicated that there was a statistical significant difference in the
salivary pH values between group C (Stevia) and group E (Distilled water) after
mouth rinsing at 20 minutes. In group C (Stevia) there was a significant rise in the
salivary pH from baseline value to 1 min (p = 0.001) and 20 minutes (p = 0.005).
Conclusions: Pattern of salivary pH changes after mouth rinsing with Stevia was
similar to other artificial sweetener solutions which indicates that Stevia rebaudina
can act as an excellent natural sugar substitute replacing the current artificial
sweeteners and refined sugars and thereby help in tackling their side effects.
Introduction
The term intense sweeteners (IS) refers to various substances of plant origin or obtained by chemical synthesis, used
in the food industry for their sweetening power and their low caloric value.1 Their sweetening power is a hundred to
thousand times higher than that of sucrose. Sugars are recognized as the most important dietary factor in the
development of dental caries. Furthermore, the role of acid fermented products of sugars in enamel dissolution by
the action of bacteria, such as Streptococcus mutans and Lactobacillus casei, is clear. 2 The use and consumption of
intense sweeteners have risen sharply over the last decades, probably due to the concerns linked to the doubling of
prevalence of overweight and obesity. Numerous studies have shown that the form in which sugars are ingested and
the frequency of their consumption are directly related to the prevalence of caries. 3,4,5 Nowadays sugar free food are
© Indian Journal of Medical Research and Pharmaceutical Sciences
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Open Access Journal
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May 2017; 4(5)
DOI: 10.5281/zenodo.572580
ISSN: ISSN: 2349-5340
Impact Factor: 3.052
very much popular because of their less calorie content. The use of sucrose substitutes in sweets is believed to have
contributed in part to the decline in the prevalence of dental caries in industrialized countries.6 These sugars tend to
have desirable sweetness but are not metabolized in the human body and therefore do not provide calorie intake. A
sweetener is a food additive, which mimics the effect of sugar on taste. Therefore, they are called as sugar
substitutes.7 Research for alternatives to sucrose have resulted in the development of synthetic sweeteners, many of
which are considered safe for teeth, such as Aspartame, Saccharin, Cyclamate, Xylitol, and Mannitol. However, in
addition to their benefits, animal studies have shown that artificial sweeteners are associated with weight gain, brain
tumors, bladder cancers and many other health hazards. Advancing research in this area has oriented towards
discovery and evaluation of natural non-cariogenic sweeteners. Stevioside is one such natural non-cariogenic
sweetener, it is a steviol glycoside extracted from stevia rebaudina.
The literature search revealed very few studies which have assessed and compared the salivay pH changes after
consumption of different commercially available natural and artificial sugar substitutes such as Stevia, Aspartame,
Sucralose, and Saccharin. So, study is planned to evaluate and compare the effect of mouth rinsing with solutions
containing different commercially available natural and artificial sugar substitutes on salivary pH. The present study
wants to evaluate whether there is a difference in salivary pH changes after mouth rinsing with solutions containing
commercially available sugar substitutes Sugar free Gold (Aspartame), Sugar Free Natura (Sucralose), Apollo
Pharmacy Stevia (Stevia) and Saccharin Helios Pharmaceuticals (Saccharin). Null hypothesis states that there is no
difference in salivary pH changes after mouth rinsing with solutions containing commercially available sugar
substitutes Sugar free Gold (Aspartame), sugar free Natura (Sucralose), Apollo Pharmacy Stevia (Stevia) and
Saccharin Helios Pharmaceuticals (Saccharin).
Materials and methods
An Experimental, in vivo, concurrent parallel study was planned. Sample size was determined using sample size and
power calculator software with R code application on www.http://powerandsamplesize.com/Calculators/Compare-2Proportions/2-Sample-Equality website. (powerandsamplesize.com)8
sample size was calculated using the formula9
2
n=
2
z1−α/(2τ)+z1−β
σ
μA−μB
based on values from the study by Steinberg L 10, where
µA is group A mean = 6.04
µB is group B mean = 5.35
Standard deviation σ = 1.13
Power of the study (1- β) =0.8
Type 1 error rate (α ) =0.05
Overall, sample size was estimated to be 83 which was rounded off to 85 (17 in each group.)
Sampling frame comprised of female undergraduate students aged 20-25 years of Bapuji Dental College and
Hospital, Davangere. A sample of 85 undergraduate female students who fulfilled the eligibility criteria were
randomly selected. Subjects who were on medications systemic diseases that affected their salivary flow rate and
who were unable to comply with the study appointment schedules were excluded and the study was conducted at the
clinical premises of Department of Public Health Dentistry, Bapuji Dental College and Hospital, Davangere. Ethical
clearance was obtained from the Institutional Review Board of Bapuji Dental College and Hospital, Davangere.
Voluntary informed consent was obtained from the study participants prior to the start of the study after informing
about the research details through a participant information form. Investigator and participants were blinded.
Interventional groups:
1. Group A -20ml of distilled water with one tablet of Sugar free Gold (Aspartame)
2. Group B -20ml of distilled water with one tablet of Sugar free Natura (Sucralose)
3. Group C -20ml of distilled water with one tablet of Apollo Pharmacy Stevia (Stevia)
4. Group D-20ml of distilled water with one tablet of Saccharin Helios pharmaceuticals (Saccharin)
5. Group E -20ml of distilled water
Random allocation: Concealed randomization method was followed
© Indian Journal of Medical Research and Pharmaceutical Sciences
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Open Access Journal
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May 2017; 4(5)
DOI: 10.5281/zenodo.572580
ISSN: ISSN: 2349-5340
Impact Factor: 3.052
Random assignment of the participants to five interventional groups was done by a separate person not involved in
the study using computer assisted software for generating random numbers.(random no table)11
Preparation of the test solutions:The test solutions were prepared by using commercially available sugar substitutes
which are Sugar free Gold containing Aspartame, Sugar free Natura containing Sucralose, Apollo Pharmacy Stevia
containing Stevia and Saccharin in form of tablets. One tablet of each commercial sugar substitute was added
separately to 20 ml of distilled water and stirred (10 seconds) until it completely dissolved in it. The test solutions
were then given to each subject for mouth rinsing.
Intervention details: After selection of the students, they will be randomly allocated to different groups and their
unstimulated salivary sample will be collected at the baseline and pH will be determined with the help of salivary
pH indicator strips. After determination of baseline pH, the subjects will be instructed to mouth rinse with test
solutions for 30 seconds12 by swishing the entire content in the mouth at once and expectorate after which the
unstimulated salivary pH will be again assessed at 1, 20 and 60 min respectively.13
Method of saliva collection: All subjects were given clear instructions to refrain from eating for one hour before
collection of saliva. Passive drool method of saliva collection was followed. The subjects were instructed to let
saliva pool in the floor of the mouth for at least 1 minute and then expectorate into a sterile disposable cup.14
Salivary pH estimation: Salivary pH was checked using dental salivary pH indicator strips (GC company). The pH
strip was dipped into the collected saliva and taken out immediately and observed for 10 seconds for the colour
change. The change in colour was compared with the reference given by the manufacturer and readings were
entered.15 Salivary pH was recorded at baseline and then after mouth rinsing with the sugar substitute containing
solutions at one minute, 20 minutes and 60 minutes respectively.
Statistical Analysis: The data obtained during the course of the study was systematically entered in Microsoft Excel
sheet. Data analysis was performed using SPSS software version 20. Data was normally distributed, so parametric
tests have been employed. Repeated measures analysis of variance was employed to compare the means of salivary
pH within the group at different time intervals. One way analysis of variance was employed to compare the means
of salivary pH between the groups. Post hoc Tukey’s test was performed as significant difference was found
between the groups and within the groups at different time intervals.
Results
There was a significant difference in mean salivary pH between groups after mouth rinsing with solutions containing
Aspartame (group A), Sucralose (group B), Stevia (group C), Saccharin (group D) and distilled water (group E) at
20 minutes. Table 1 (p = 0.040). At baseline, there was no statistical difference in mean salivary pH values between
the interventional groups allowing for valid comparisons between groups post intervention (table 1). At 20 minutes
post mouth rinsing, there was a statistically significant difference (p = 0.040) between the mean salivary pH values
of Stevia (group C) and Distilled water (group E). No significant difference in mean salivary pH values was
observed between interventional groups at different time intervals (Tables 1, 2). Tukey’s Post-hoc comparisons of
ANOVA test between the groups at different time intervals showed a statistically significant difference between
Stevia (group C) and Distilled water (group E) at 1 minute (p=0.046) and 20 minutes time interval (p= 0.037),
(Table 2).There was an initial rise in the salivary pH after mouth rinsing with all five groups at one minute which
was not statistically significant followed by a gradual drop from 1 minute to 20 minutes in all the groups among
which the mean salivary pH drop was less in group C (table 1, graph 1). From 20 minutes to 60 minutes, there was a
gradual drop in the mean salivary pH values in all the groups and it remained above the baseline value at the end of
60 minutes after mouth rinsing with respective solutions. In group C (Stevia) there was a significant rise in the
salivary pH from baseline value to 1 minute and 20 minutes (p = 0.005), (tables 3, 4, graph 1). At the end of 60
minutes, the mean salivary pH remained above normal in all the five interventional groups (table 4, graph 1).
There were no adverse outcomes or unintended effects reported during and after the study.
© Indian Journal of Medical Research and Pharmaceutical Sciences
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Open Access Journal
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DOI: 10.5281/zenodo.572580
ISSN: ISSN: 2349-5340
Impact Factor: 3.052
Schematic representation of random allocation:
Fig (1)
Study plan and hypothesis formulation
Ethical clearance obtained from Institutional Review Board of Bapuji Dental College and Hospital,
Davangere
Female students aged 20 – 25 years of Bapuji Dental College and Hospital, Davangere city
were invited to participate in the study
Excluded - not meeting inclusion
criteria, declined to participate
85 female students who fulfilled the eligibility criteria were the study sample
Random allocation
Sugar free Gold
(Aspartame) with
distilled water
n
n= 17
n- Group A
Sugar free Natura
(Sucralose) with
distilled water
Apollo Stevia
(Stevia) with distilled
water
n= 17
n= 17
Group B
Group C
Saccharin Helios
Pharmaceuticlas
(Saccharin) with
distilled water
n= 17
Group D
Distilled water
n= 17
Group E
Salivary pH was assessed at baseline, 1 min, 20 min, 60 min
Compilation, analysis and reporting of results
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Open Access Journal
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DOI: 10.5281/zenodo.572580
ISSN: ISSN: 2349-5340
Impact Factor: 3.052
Tables:
Table 1: Comparison of salivary pH at baseline and different time intervals between interventional groups
Interventional
groups
Mean salivary pH
and
Standard
Deviation
at
baseline
6.82±0.39
Mean salivary pH
and
Standard
Deviation at 1
minute
7.05±0.44
Distilled
Water
With Aspartame
(Group A)
7.08±0.42
Distilled
Water 6.84±0.39
With
Sucralose
(Group B)
7.17±0.44
Distilled
Water 6.72±0.19
With
Stevia
(Group C)
7.04±0.36
Distilled
Water 6.83±0.37
With
Saccharin
(Group D)
6.78±0.30
Distilled
Water 6.74±0.19
(Group E)
0.498
2.215
F Value
(One Way Anova)
0.737
0.075
Probability
(P Value)
‘A’ denotes between groups statistically significant at p < 0.01
Mean salivary pH
and
Standard
Deviation at 20
minutes
6.81±0.14
Mean salivary pH
and
Standard
Deviation at 60
minutes
6.88±0.17
7.01±0.34
7.04±0.43
7.12±0.41A
6.98±0.19
6.94±0.29
6.83±0.26
6.82±0.26A
6.85±0.20
2.633
1.900
0.040
0.119
Table 2: Tukey’s post hoc comparison of ANOVA to find significant difference in mean salivary pH values in
the interventional groups at different time intervals
Interventional
groups
Aspartame vs
Sucralose (A vs B)
Aspartame vs
stevia
(A vs C)
Aspartame vs
Saccharin
(A vs D)
Aspartame vs
Distilled water
( A vs E)
Sucralose vs stevia
(B vs C)
Sucralose vs
Saccharin (B vs D)
Baseline (p value)
1 minute (p value)
1.00
1.00
0.666
0.401
0.915
0.912
0.110
0.788
1.00
1.00
0.962
0.987
0.66
0.291
0.992
0.999
0.828
0.959
0.796
0.970
1.000
0.999
© Indian Journal of Medical Research and Pharmaceutical Sciences
20 minutes (p
value)
0.962
60 minutes (p
value)
0.166
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DOI: 10.5281/zenodo.572580
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Sucralose vs
0.876
Distilled water (B
vs E)
Stevia vs Saccharin
0.876
(C vs D)
Stevia vs Distilled
1.000
water (C vs E)
Saccharin vs
0.915
Distilled water (D
vs E)
p value –probability value
* Statistically significant at p =0.01 (2-tailed).
0.214
0.387
0.268
0.880
0.387
0.478
0.046*
0.037*
0.638
0.035*
0.796
0.999
Table 3: Comparison of mean salivary pH at different time intervals within the groups.
Interventional
groups
Mean
salivary pH
and
Standard
Deviation at
baseline
6.82±0.39
Mean
salivary pH
and
Standard
Deviation at
1 minute
7.05±0.44
Mean
salivary pH
and
Standard
Deviation at
20 minutes
6.81±0.14
Distilled Water
With Aspartame
(Group A)
6.84±0.39
7.08±0.42
7.01±0.34
Distilled Water
With Sucralose
(Group B)
6.72±0.19
7.17±0.44
7.12±0.41A
Distilled Water
With Stevia
(Group C)
6.83±0.37
7.04±0.36
6.94±0.29
Distilled Water
With Saccharin
(Group D)
6.74±0.19
6.78±0.30
6.82±0.26A
Distilled Water
(Group E)
** Statistically highest significant at p < 0.01 (2-tailed).
Mean
salivary pH
and
Standard
Deviation at
60 minutes
6.88±0.17
F Value
(Repeated
Measures
ANOVA)
Probability
(P Value)
2.021
0.120
7.04±0.43
1.402
0.250
6.98±0.19
5.690
0.002**
6.83±0.26
1.542
0.212
6.85±0.20
1.604
0.370
Table 4: Tukey’s post hoc comparisons of repeated measures ANOVA to find significant difference in mean
salivary pH between different time intervals of different interventional groups
Time intervals
Baseline vs 1
minute
Baseline vs 20
minutes
Baseline vs one
hour
Distilled Water
With Aspartame
(Group A)
0.104
Distilled Water
With Sucralose
(Group B)
0.286
Distilled Water
With Stevia
(Group C)
0.002*
Distilled Water
With Saccharin
(Group D)
0.192
Distilled
Water
(Group E)
0.551
0.970
0.522
0.006**
0.529
0.339
0.909
0.328
0.120
0.930
0.702
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1 minute vs 20
minutes
1 minute vs 1
hour
20 minutes vs 1
ISSN: ISSN: 2349-5340
Impact Factor: 3.052
0.262
0.976
0.990
0.915
0.984
0.370
1.000
0.483
0.509
0.995
0.996
0.987
0.674
0.880
0.993
hour
* Statistically significant at p < 0.05 (2-tailed).
** Statistically highly significant at p < 0.01 (2-tailed)
Line graph 1: Depicting the Salivary pH changes at different time intervals in five Interventional
groups
7.30
7.20
aspartame
7.10
7.00
sucralose
6.90
stevia
6.80
6.70
saccharin
6.60
distilled
water
6.50
6.40
0
10
20
30
40
50
60
Discussion
The present study assessed and compared the baseline salivary pH changes after mouth rinsing with commercially
available sugar substitutes (Aspartame, Sucralose, Stevia and Saccharin) at one minute, twenty minutes and one
hour. To the author’s best knowledge, this is the first study of its kind to compare salivary pH changes between
commercially available natural and artificial sugar substitutes. The results indicated that there was a statistically
significant rise in the salivary pH values in Stevia group (group C) at 20 minutes after mouth rinsing with the
respective solutions. This result is in accordance with the study result of Goodson J et al.16 where statistically
significant rise in plaque pH was found in stevia oral rinse group when compared with sucrose oral rinse group. In
the present study, there was a rise in the salivary pH in all the groups post mouth rinsing with commercially
available sugar substitutes from baseline to 1 minute. Between one to twenty minutes there was a gradual decline in
the salivary pH in all the 5 groups out of which the salivary pH drop in group C (Stevia) was less than other groups
and it was statistically significant. From 20 minutes to 60 minutes; the salivary pH values further decreased for
aspartame and stevia group as compared to sucralose, saccharin and distilled water but the pH remained above the
baseline for all groups and the pH change was not statistically significant. Our study findings are concurrent with
those of Stephan and Kumar et al 17 in which the study participants were given 10 ml (20%) of sucrose solution and
the salivary pH reduced gradually to a point and then increased gradually toward the baseline level, which was not
reached even 60 minutes after sucrose exposure. They suggested that although organisms in the saliva may be
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Impact Factor: 3.052
producing some acid, the acids arising in the dental plaque or from bacteria colonizing on the tongue and other soft
tissues might appear in the saliva, giving rise to a 'Salivary Stephan Curve'. In the present study, in stevia group,
there was drop in mean salivary pH from 20 minutes to 60 minutes but didn’t reach the baseline mean salivary pH
value even at the end of one hour. The pattern of salivary pH changes in the stevia group was similar to all other
groups which shows that it can replace other artificially available commercial sugar substitutes. Results could not be
compared with other studies as literature search revealed no studies in this regard. The drop in salivary pH in stevia
group is similar to the study findings of Giongo et al.18 and Goodson J et al 16 In the study conducted by Goodson J
et al16, rinses with stevia demonstrated a minimum pH of 6.92 ± 0.08, (mean ± SE) that was significantly higher (p
<0.0001) than that of sucrose rinse (5.62 ± 0.13). Certain in vivo studies have shown pH rise. In vitro and in vivo
studies have shown that stevia extracts have anti-bacterial activity on Streptococcus mutans, Streptococcus sobrinus
and Lactobacillus acidophilus organisms that are closely related to the production and development of tooth decay.19
Hence it can be a potential substitute to sugar. Stephan’s curve describes the changes in dental plaque pH in
response to a carbohydrate challenge over a period of time. Characteristically, the curve reveals a rapid drop in
plaque pH that is attained after consumption of sugar. It normally takes at least twenty minutes for the plaque pH to
reach its resting value.13 In some studies, the salivary pH did not return to its original baseline even at the end of one
hour and remained below baseline mean salivary pH.19 So, it was decided to check salivary pH changes at one,
twenty and sixty minutes time interval. A study done by Motamayell FA 20 showed that the pH of saliva was lower
in males as compared to females. Hence, for the purpose of standardisation, only female students were included in
the present study. A study done by Paraskevas et al.12 showed that, rinsing for 30 seconds appeared to be sufficient
for all plaque-covered surfaces of the dentition to come into contact with the mouthwash. Hence, the time duration
of mouth rinsing was set at 30 seconds for all the groups. Unstimulated whole saliva reflects basal salivary flow rate,
is present for about fourteen hours a day, and is the secretion that provides protection to oral tissues.21 Stimulated
saliva cause alterations in salivary pH hence unstimulated saliva collection was preferred. The study was done on a
small sample. So, further studies should be done involving larger sample size. Though plaque pH changes are
concurrent with salivary pH changes, it would have been better if plaque pH was assessed as the process of dental
caries starts at plaque tooth interface.
Conclusion
There was a significant rise in salivary pH after mouth rinsing with Stevia solution. Pattern of salivary pH changes
after mouth rinsing with Stevia was similar to other artificial sweetener solutions. From baseline to one minute after
mouth rinsing with the respective solutions there was a rise in the salivary pH in all the 5 groups but Stevia group
showed more rise as compared to other groups. There was a gradual fall in the salivary pH values from one minute
to 20 minutes in all the groups. From 20 minutes to 60 minutes, the salivary pH remained above the baseline values
in all the groups. The ability of stevia to avoid high salivary pH drop when consumed along with its ability to reduce
the bacterial load and formation of biofilm together with its anti-inflammatory properties point out the potential of
research towards anti-cariogenic properties of stevia. If proved effective, stevia can serve as an excellent sugar
substitute replacing the current artificial sweeteners and refined sugars thereby help in tackling the lifestyle
associated diseases like dental caries, obesity etc.
References
1.
2.
3.
4.
5.
Olivier B, Serge AH, Catherine A, Jacques B, Murielle B, Marie-Chantal CL et al. Review of the nutritional
benefits and risks related to intense sweeteners. Arch Public Health 2015 Oct 1; 73:41-6.
Sheiham A, James W.P.T. A reappraisal of the quantitative relationship between sugar intake and dental caries:
The need for new criteria for developing goals for sugar intake. BMC Public Health 2014 Sep 16; 14: 863-71.
Burt BA, Eklund SA, Morgan KJ, Larkin FE, Guire KE, Brown LO et al. The effects of sugars intake and
frequency of ingestion on dental caries increment in a three-year longitudinal study. J Dent Res 1988 Nov;
67(11):1422-429.
Newbrun E. Frequent sugar intake-then and now: interpretation of the main results. Scand J Dent Res. 1989
Apr; 97(2):103-9.
Gupta P, Gupta N, Pawar AP, Birajdar SS, Natt AS, Singh HP et al. Role of sugar and sugar substitutes in
dental caries: A review. ISRN Dent 2013; 2013:519421.
© Indian Journal of Medical Research and Pharmaceutical Sciences
http://www.ijmprs.com/
[13]
Open Access Journal
Indian Journal of Medical Research and Pharmaceutical Sciences
May 2017; 4(5)
DOI: 10.5281/zenodo.572580
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
ISSN: ISSN: 2349-5340
Impact Factor: 3.052
Burt BA. Caries prevalence in North America. Int Dent J 1994; 44: 403-13.
Chattopadhyay S, Raychaudhuri U, Chakraborty R. Artificial sweeteners – a review. J Food Sci Technol 2014
Apr; 51(4):611-21.
Power and sample size. Available from www.http://powerandsamplesize.com/Calculators/Compare-2Proportions/2-Sample-Equality (accessed on 19 June 2016 at 11:20 AM.)
Chow S, Shao J, Wang H. Sample size calculations in clinical research. 2 nd ed. Chapman and Hall/ CRC
Biostatistics series; 2008.p.71.
Steinberg LM, Odusola F, Mandel ID. Effect of sucralose in coffee on plaque pH in human subjects. Caries Res
1996; 30(2):138-42.ROL
Random number table. Available from www.https://nist.gov/document-9635 (accessed on 15 September 2016 at
12:30 AM.)
Paraskevas S, Danser MM, Timmerman MF, Van der Velden U, van der Weijden GA. Optimal rinsing time for
intra-oral distribution (spread) of mouthwashes. J Clin Periodontol 2005 Jun;32(6):665-9
Azrak B, Willershausen B, Meyer N, Callaway A. Course of changes in salivary pH-values after intake of
different beverages in young children. Oral Health Prev Dent 2008; 6(2):159-64.
Salimetrics LL, SalivaBio LL. Saliva collection and handling advice. Available at
www.http://salimetrics.com./(Accessed on 19 July 2016 at 3:20 PM).
Animireddy D, Reddy Bekkem VT, Vallala P, Kotha SB, Ankireddy S, Mohammad N et al. 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.Topitsoglou V, Sasaki N, Takazoe I, Frostell G.
Effect of frequent rinses with isomaltulose (palatinose) solution on acid production in human dental plaque.
Caries Res 1984; 18(1):47-51.ROL
Goodson J, Cugini M, Floros C, Roberts C, Boileau A, Bell M. Effect of a Truvia™ Rebiana on Plaque pH.
Abstract presented at the International Association for Dental Research General Sessions, Barcelona; 2010 Jul
:14-17
Kumar A, Hedge R, Dixit U. Role of plaque in the clearance of salivary sucrose and its influence on salivary
pH. J Indian Soc Pedod Prev Dent 2011; 310-314.
Giongo FC, Mua B, Parolo CC, Carlén A, Maltz M. Effects of lactose-containing stevioside sweeteners on
dental biofilm acidogenicity. Braz Oral Res. 2014;28.
Contreras S. Anticariogenic properties and effects on periodontal structures of Stevia rebaudiana Bertoni.
Narrative review. J Oral Res, (2013); 2(3), 158-166.
Motamayell FA, Goodarzi MT, Hendi SS, Abdolsamadil H, Rafieian N. Evaluation of salivary flow rate, pH,
buffering capacity, calcium and total protein levels in caries free and caries active adolescence. J Dent Oral
Hyg. 2013; 5(4):35-9
Fenoll-Palomares C, Muñoz Montagud JV, Sanchiz V, Herreros B, Hernández V, Mínguez M, Benages A.
Unstimulated salivary flow rate, pH and buffer capacity of saliva in healthy volunteers. Rev Esp Enferm Dig.
2004 Nov; 96(11):773-83.
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