Effect of Xylitol-Containing Chewing Gums on Oral Microflora: A Systematic Review and Meta-Analysis

ABSTRACT

Objective:  To assess the quality and effect of xylitol-containing chewing gums on oral microflora.

Material and Methods:  A systematic review was conducted utilizing a database from 2016 to 2023. The PICO question implemented through this research was “Does xylitol-containing chewing gums show any effect on oral microflora?”. A total of 372 articles were found, and after eliminating duplicates, 48 articles were retrieved. By applying inclusion and exclusion criteria, a total of 10 RCTs were identified. Quality assessment was done using the CONSORT checklist, and the Risk of Bias was assessed using the RoB 2 tool (A revised Cochrane risk-of-bias tool for randomized trials). Meta-analysis was performed using the Comprehensive Meta-analysis version 4 software for 4 RCTs.

Results:  A total of 1003 subjects who are aged between 3 and 63 years were included in the randomized trials with a follow-up period ranging from 2 days to 2 years. All the included studies have shown reduced mutans streptococci count after using xylitol chewing gums. On performing Meta-analysis, a significant difference was found between the experimental (xylitol) and control (Polyol) groups with a Standard Mean Difference (SMD) of -0.559, 95% Confidence Interval (CI): -0.860 to -0.258 (p=0.001).

Conclusion:  Regular use of xylitol chewing gum will reduce the count of mutans streptococci.

Keywords:
Sugar Alcohols; Streptococcus mutans; Chewing Gum; Study Characteristics.

Introduction

According to the World Health Organization (WHO), oral disease ranks third among the other serious diseases in the world, after cancer and cardiovascular disease [¹]. Dental caries is the most prevalent chronic disease worldwide [²]. It is caused by three main factors: the host, fermentable carbohydrates, and acid-producing bacteria, which decalcify the inorganic component and destroy the organic matrix of the teeth [²,³].

The human oral cavity offers a distinctive ecology. Its temperature range, moist habitat, and availability of both endogenous and modern concepts of cariogram demonstrate microorganisms as one of the major etiological factors, apart from dietary and host factors, in the formation of dental caries. Numerous bacterial species, particularly large populations of the acidogenic and aciduric species Lactobacillus, Streptococcus mutans, and Streptococcus sobrinus, which can produce and survive in an acidic environment, have been linked to the cariogenic process [⁴].

One cause for the buildup of these germs and their detrimental activities is inadequate dental hygiene. To prevent dental plaque buildup and maintain oral health, effective oral hygiene is crucial [⁵]. The literature has described various mechanical and chemical methods for enhancing regular oral hygiene [⁵]. One such substance that has been suggested to have anticarcinogenic qualities is sugar substitutes. The regularly used sugar substitutes in food include lactitol, maltitol, mannitol, sorbitol, isomalt, and xylitol [⁶]. Now, chewing gums containing sugar substitutes like xylitol are found in the market.

It has been demonstrated that regular chewing of sugar-free gum has an inhibitory effect on dental caries. In fact, it has been noted that consuming sugar gum increases the incidence of dental caries. Collectively, this implies that the sweetening component of chewing gum plays a significant role in its cariogenicity [⁷].

Xylitol is aptly called a "magic bullet," as many studies have demonstrated its powerful antimicrobial action against salivary mutans streptococci (MS) [⁸]. It is a naturally occurring five-carbon polyalcohol derivative that is non-cariogenic and anticariogenic [⁹]. Xylitol was found to act by starving Streptococcus mutans due to its inhibitory effect on glycolysis. The inhibition of glycolysis has been linked to the intracellular accumulation of xylitol-5-phosphate after xylitol is taken up by a constitutive fructose-specific phosphotransferase mechanism. Due to this, the amount of acid that is produced from glucose is decreased, which in turn leads to a decrease in mutans streptococci count [⁶].

It has been suggested that regular use of xylitol will lower the incidence of caries, plaque, and mutans streptococci count [¹⁰]. Xylitol pastilles and wipes have also been demonstrated to lower MS levels in addition to xylitol chewing gums [¹¹,¹²]. But oral rinses have not shown this effect, which may be due to its short exposure time [¹³]. It's interesting that xylitol consumption by mothers was linked to a significant decline in MS mother-child transmission [¹⁴]. It also acts as a prebiotic by increasing the numbers of bifidobacteria in the large intestine of humans [¹⁵].

Past examinations done on xylitol were stretched out to various types of xylitol in the prevention of dental caries; hence, this methodical survey is taken considering a single type of xylitol (chewing gum), and from among these studies, which considered a polyol-containing control group, the results are subjected to meta-analysis. With this systematic review and meta-analysis, we aimed to answer the defined research question: “Do xylitol-containing chewing gums show any effect on oral microflora?” We reviewed studies conducted regarding the impact of xylitol-containing chewing gum on oral microflora to track down a response to this inquiry.

Material and Methods

Framework and registration

A systematic literature review and meta-analysis were performed in compliance with the PRISMA guidelines (Figure 1). The PICO framework has been accustomed to executing the quest strategy. The PICO question addressed in this research was: “Does xylitol-containing chewing gums show any effect on oral microflora?”. One such methodological survey strategy was submitted to the International Prospective Register of Systematic Reviews (PROSPERO) and was assigned an enrollment number, CRD42023492793.

Figure 1
PRISMA flow diagram of database searches.

An electronic and manual search was performed on PubMed and Google Scholar databases with keywords "Xylitol", "oral microflora", and an advanced search was carried out using the Boolean operator "AND". A total of 372 articles were found, and after eliminating duplicates, 48 articles were retrieved. By applying inclusion and exclusion criteria, 10 articles were retained.

Inclusion and Exclusion Criteria

The following inclusion criteria were adopted: 1) Human randomized clinical trials; 2) Studies published in the English language showing “Effect of xylitol-containing chewing gums on oral microflora”; 3) Studies published within a time frame of 8 years (2016 to 2023). The following exclusion criteria were established: A) Abstracts, case reports, pilot studies, reviews, and letters to the editor were excluded; B) Articles published in other languages were excluded.

Quality Assessment

A total of 10 randomized clinical trials were included as per the inclusion and exclusion criteria, and all of them were assessed using the CONSORT checklist, and the risk of bias was assessed using the robvis tool (Risk-Of-Bias VISualization).

Statistical Analysis

Meta-analysis was done using Comprehensive Meta-analysis Statistical Software version 4, and Random effects models were chosen as heterogeneity was present between the studies.

Results

All 10 articles [¹⁶-²⁵] were published between 2016 and 2023 and conducted in 6 different countries. A total of 1003 subjects who are aged between 3 and 63 years were included in the randomized trials with a follow-up period ranging from 2 days to 2 years. All of them were focused on the effect of xylitol on the mutans streptococci count in common. The basic characteristics of all the included studies are shown in Table 1.

Table 1
Characteristics of included studies.

Author and Year	Study Area	Study Population	Results	Conclusion
Syed et al. [16] (2016)	India	60 children (males 35, females 25) in the age range of 8 to 12 years were selected from a nearby school after examination	Significant reduction was found in S. mutans CFU’s at all intervals with the maximum reduction seen in group III (100%) followed by group II (79%), and least reduction was seen in group I (69%). There was significant difference in the reduction of biofilm scores between all the groups at all time intervals with maximum reduction seen in group III at 15 days (64%), 1 month (78%), 2 months (98%), and 6 months (100%).	The use of the XYL+CHX combination reduces both the biofilm and S. mutans scores significantly better when compared to XYL chewing gums or CHX mouthwash alone.
Takenchi et al. [17] (2017)	Japan	82 healthy men aged ≥20 years were recruited from the Japan Ground Self-Defense Force.	The test group follow-up samples showed significantly lower total salivary bacteria counts (8.5) than the control group (8.7) follow-up samples (p=0.004) and no difference in the number of OTUs in the saliva samples was found between the groups.	Xylitol-containing chewing gum inhibits the increase in total salivary bacteria count without changing salivary microbial composition.
Cocco et al. [18] (2017)	Italy	130 subjects aged 30-45 years living in the town of Sassari	Statistically significant difference was found between the groups during the gum use period, i.e.; for initial caries lesions (polyol 0.09 ± 0.15 and xylitol 0.05 ± 0.12, p=0.01), for extensive caries lesions (polyol 0.18 ± 0.38 and xylitol 0.11 ± 0.12, p=0.02) and no statistically significant difference (p=0.18) was found for moderate caries lesions between groups. The comparison between groups was statistically significant (p=0.04) in terms of AUC. A statistically significant reduction (5.41 ± 0.35 to 5.15 ± 0.64; p<0.01) was found in mutans streptococci count in the xylitol group.	Long-term usage of xylitol chewing gums with low polyol concentration offers an efficient method of caries disease prevention, which is due to a reduction in cariogenic bacterial concentration and plaque acidogenicity.
Ghasemi et al. [19] (2017)	Iran	60 volunteers from female dormitory residents aged 19-27 years	Reduction in salivary mutans streptococci count was seen in both the groups, but the difference between the groups was not statistically significant (Yogurt group: 66.7 ± 42.0; xylitol group: 59.4 ± 37.0; p=0.59).	Xylitol-containing chewing gums and probiotic yogurt are both as effective in reducing salivary mutans streptococci count. Their long-term consumption is thus recommended as a safe and effective measure for caries prevention.
Oza et al. [20] (2018)	India	80 undergraduate students, aged 18-24 years, residing in a hostel.	A high statistically significant difference was found between the groups on the 30th day in mutans streptococci count (xylitol: 2.20 ± 0.4, Sorbitol: 2.75 ± 0.63, p=0.00). No statistically significant difference was found between the groups at all time intervals in terms of L. bacilli count, plaque index score, and gingival index score.	The use of xylitol gum showed a greater decrease in salivary mutans streptococci count when compared to sorbitol gum. However, the chewing gum can not be used as an effective adjunct for regular oral hygiene practice.
Abdelwahab et al. [21] (2018)	Egypt	42 preschool and school-age Egyptian children, aged 3-12 years.	In the case of mutans streptococci count, xylitol gum (23.8%) showed better reduction when compared to polyol gum (9.5%). In the case of LB count, no change was observed.	The use of xylitol shows an effective reduction in S. mutans count compared to polyol and both are comparable in reducing L. Bacilli count.
Aluckal et al. [22] (2018)	India	60 children aged between 12 and 15 years from three residential hostels	Significant difference was found in the mutans streptococci count between all the groups at all time intervals (at 30 days: p=0.019, at 60 days: p=0.003), with maximum reduction seen in the xylitol group.	Xylitol-containing chewing gums can be used as an adjunct to regular home care preventive procedures to prevent dental caries.
Elmokanen et al. [23] (2019)	Egypt	98 patients were recruited from intensive care units (ICU)	Intra-group comparisons and inter-group comparisons showed a significant difference in salivary and Interdental plaque S. mutans CFUs. Statistically significant difference was found in the intra-group Salivary pH value, whereas no significant difference was found in the inter-group salivary pH value.	Both xylitol dissolving chewable tablets and xylitol chewing gum have potent antibacterial effects and enhanced salivary pH in geriatric bedridden patients.
Cagettiet al. [24] (2020)	Switzerland	271 subjects aged between 30 and 45 years living in Sassari area, Italy	The caries increment was always found to be lower in the xylitol plus Magnolia group and Plaque pH measured as AUC has been shown to be more decreased in the Xly+Mag group. Significant decrease in mutans streptococci count was found in Xyl+Mag group and Xyl group (p<0.01 for both)	A combination of xylitol and magnolia has a higher preventive effect when compared to Xylitol alone
Jain et al. [25] (2022)	India	120 children belonging to the 6-12 years age	Significant difference in the number of S. mutans CFU’s amongst the three groups at different time intervals with maximum reduction seen in IgY+Xylitol group (Baseline: 190,421.05 to 3rd month: 99,552.63)	A combination of IgY + xylitol had a significant benefit against “salivary S. mutans” when compared to xylitol alone.

Assessment of Methodological Quality

The robvis tool was used to assess the quality of the selected RCTs and the risk of bias. Figures 2 and 3 show the events of methodologic quality assessments. It was observed that there is a lower risk of bias in all the enclosed studies in the measurement of the outcome. In total, two studies showed High risk of bias and four studies showed some concerns and other four studies showed Low risk of bias.

Figure 2
Traffic light plot showing risk of bias according to the robvis tool.

Figure 3
Summary plot for risk of bias according to robvis tool.

Meta Analysis

Only four studies were selected for meta-analysis as all of them used polyol in the control group and xylitol in the experimental group. Significant heterogeneity was found between four clinical studies when they were pooled (Q = 5.950, degrees of freedom = 3, p=0.114, I2 = 50%). Therefore, the random-effects model was used for the meta-analysis, and a significant difference was found between the experimental (xylitol) and control (Polyol) groups as shown in Figure 4 with Standard Mean Difference (SMD) = -0.559, 95% Confidence Interval (CI): -0.860 to -0.258 (p=0.001).

Figure 4
Forest plot of the meta-analysis for evaluating the effect of xylitol vs. polyol-containing chewing gums on mutans streptococci count.

Discussion

Dental caries is a multifactorial microbial infectious disease characterized by demineralization of the inorganic and destruction of the organic substance of the tooth [²⁶]. It was thought to be caused by oral bacteria that can ferment carbohydrates into lactic acid. They primarily belong to the Streptococcus, Lactobacillus and Actinomyces families of bacteria, whereas S. mutans is most common. This bacteria has great acidogenicity (ability to produce acids), good acid resistance, and the capacity to form extracellular and intracellular polysaccharides, the primary component of dental plaque, which is thought to be the primary cause of tooth decay. Therefore, steps must be taken reduce the S. mutans bacteria in the oral environment to lower the risk of tooth decay [²⁷].

Xylitol can be obtained in different forms like candies, chewing gums, lozenges, syrup and wipes and all these forms have shown a significant effect on reducing dental caries [²⁸]. But chewing gums, which are consumed by a substantial section of the population, have recently received a lot of attention in caries prevention. This is mostly because they can increase salivation, and as saliva is a "Magical Fluid" with many protective properties, it may help to ward off oral illnesses. Elevated buffering capacity of saliva and improved fermentation of fermentable carbohydrates in the oral cavity allow stimulated saliva to have an elevated bicarbonate concentration, which neutralizes low pH [³]. Additionally, the supersaturation of minerals in the stimulated saliva encourages the remineralization of the enamel [²⁹]. Xylitol chewing gums have gained much popularity in recent times. It was discovered that xylitol can reduce the mutans streptococci count through a variety of ways [³⁰,³¹].

The results of the Turku sugar trials made up the first investigation into how xylitol consumption affected MS numbers [³²]. Following that, the impact of xylitol consumption on MS numbers was examined in a number of trials with various study designs. Although not all of them have supported it, most have hypothesized that xylitol may reduce MS [³³]. Fewer articles have been published in recent years using saliva or plaque MS as the primary outcome measure due to the introduction of multispecies microbiota analysis methodologies [³⁴]. But recently, particularly Indian research organizations have released several articles on the impacts of xylitol chewing gums and other xylitol vehicles on MS numbers in children and adults. Xylitol's mode of delivery affects how much it inhibits bacterial growth. While replacing sugar with xylitol during food preparation cannot reduce salivary mutans streptococci count [³⁵]. Hence, reducing S. mutans levels requires the frequent and long-lasting effects of xylitol in the form of candies or gums [³⁶].

A longer time of xylitol use does not significantly reduce the number of MS in the saliva when compared to a control group of non-users [³⁷] in contrast to the results obtained with short periods of use [³⁸]. It is said that the reduction in salivary mutans streptococci persists for a specific period after instituting the chewing of xylitol-containing gums. The organisms then become resistant to xylitol and will be followed by an increase in the quantity of salivary mutans streptococci and these germs are less adherent to the tooth surface hence less pathogenic (cariogenic) thus providing long term effect anti‑caries effect.

Mäkinen et al. [³⁹] demonstrated that habitual use of polyol-containing chewing gums can reduce mutans streptococcus counts, with xylitol showing better results compared to other polyols, thereby helping to reduce dental caries. Additionally, Milgrom et al. [⁴⁰] concluded that the use of a xylitol dose greater than 10.32 g/day did not show any increase in efficacy. In comparison, a dose of 3.44 g/day or less did not show any change in mutans streptococcus counts [⁴⁰]. All studies included in this review have demonstrated that the use of xylitol reduces the count of mutans streptococci, which in turn affects reducing dental caries among different age groups.

Several studies have analyzed the action of xylitol. Some authors have shown that the use of a XYL+CHX combination reduces both the biofilm and S. mutans scores more significantly than either XYL chewing gums or CHX mouthwash used alone [¹⁶]. Takeuchi et al. [¹⁷] found that the use of xylitol-containing chewing gum inhibits the increase in total salivary bacteria over a short time without changing the salivary microbial composition. Cocco et al. [¹⁸] found that there was a decrease in mutans streptococci count after using xylitol, along with a decrease in AUC. On the other hand, Ghasemi et al. [¹⁹] found that the use of probiotic yogurt and xylitol has shown the same effect in reducing mutans streptococci count. Oza et al. [²⁰] found that the use of xylitol gum may interfere with the mutans streptococci composition and reduce it effectively after 30 days of continuous use, when compared to sorbitol gum. Both gums were equally effective in reducing the Lactobacilli count. Abdelwahab et al. [²¹] found that xylitol was more effective in reducing MS compared to the polyol group, and both gums were equally effective in reducing LB count. Aluckal et al. [²²] found that the use of xylitol can reduce dental caries occurrence when used along with regular home care, while Elmokanen et al. [²³] demonstrated that the use of both xylitol chewing gums and xylitol chewable tablets has shown an effect on reducing microbial count in geriatric bedridden patients. Finally, Grazia et al. [²⁴] found that the use of xylitol along with magnolia has shown better effect in reducing MS when compared to the use of xylitol alone, and Jain et al. [²⁵] demonstrated that the combination of IgY + xylitol has reduced mutans streptococci CFUs more when compared to the use of xylitol alone.

The present review has identified ten RCTs on xylitol and mutans streptococci count, with these results showing the effect of xylitol on mutans streptococci count, with one study suggesting that xylitol affects only mutans streptococci count without affecting the oral microbiota composition. The studies included were heterogeneous in terms of subjects, methods, and study designs. Out of 10 studies, only four were selected for performing a meta-analysis as they had a common polyol for the control group in all the studies. On performing meta-analysis, the results showed that there was a significant difference in the reduction of mutans streptococci count between both the groups, i.e., xylitol and polyol groups.

Conclusion

It has been identified that regular use of xylitol in the form of chewing gum will reduce the count of mutans streptococci in the oral cavity by increasing salivary flow and oral cavity pH, without altering the overall oral microbiome composition, which helps reduce dental caries. Hence, xylitol can be considered an oral prebiotic, as Prebiotics are traditionally defined as promoters of the growth of beneficial microorganisms. But still more studies are needed to demonstrate the effects of xylitol on oral microflora.

• Financial Support
  None.

Data Availability

The data used to support the findings of this study can be made available upon request to the corresponding author.

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Edited by

• Academic Editor:
  Alessandro Leite Cavalcanti

Publication Dates

• Publication in this collection
  08 Dec 2025
• Date of issue
  2026

History

• Received
  05 Mar 2024
• Reviewed
  18 Nov 2024
• Accepted
  06 Jan 2025