See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/301733291

Efficacy of a sugar-free herbal lollipop for reducing salivary Streptococcus

mutans levels: a randomized controlled trial

Article  in  Clinical Oral Investigations · April 2016

DOI: 10.1007/s00784-016-1827-y

CITATIONS READS

7 272

4 authors:

Merve Erkmen Almaz Işıl S Sonmez

Kirikkale University Aydın Adnan Menderes University
22 PUBLICATIONS   107 CITATIONS    55 PUBLICATIONS   678 CITATIONS   

SEE PROFILE SEE PROFILE

Zeynep Okte Aylin Akbay Oba

Ankara University Kirikkale University
16 PUBLICATIONS   376 CITATIONS    14 PUBLICATIONS   171 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Effects of deep sedation on behaviors and side effects in children undergoing different dental procedures View project

All content following this page was uploaded by Merve Erkmen Almaz on 09 July 2018.

The user has requested enhancement of the downloaded file.

Clin Oral Invest
DOI 10.1007/s00784-016-1827-y
ORIGINAL ARTICLE
Efficacy of a sugar-free herbal lollipop for reducing salivary
Streptococcus mutans levels: a randomized controlled trial
Merve Erkmen Almaz 1 & Işıl Şaroğlu Sönmez 2 & Zeynep Ökte 3 & Aylin Akbay Oba 1
Received: 23 June 2015 / Accepted: 17 April 2016
# Springer-Verlag Berlin Heidelberg 2016
Abstract
Objective The aim of our study was to evaluate the efficacy of
an herbal lollipop containing licorice root extract on salivary
Streptococcus mutans in caries-free and high-caries-risk
children.
Materials and methods The study was conducted in caries-
free and high-caries-risk children, aged 5–11 years (n = 108).
The groups were caries-free children (group A); high-caries-
risk children whose dental treatment was completed before
lollipop use (group B); and high-caries-risk children who did
not comply with dental treatment (group C). The groups were
divided into two subgroups: herbal (A-1, B-1, C-1) and pla-
cebo lollipops (A-2, B-2, C-2). Saliva samples were taken
before dental treatment, before and after consuming lollipops,
and at 3 months after consuming lollipops. The results were
statistically analyzed with chi-squared test.
Results Only in group C-1 (high-risk, using herbal lollipops)
that significant reduction was observed in salivary S. mutans
levels after lollipop use (p = 0.033), and only in the same
Electronic supplementary material The online version of this article
(doi:10.1007/s00784-016-1827-y) contains supplementary material,
which is available to authorized users.
* Merve Erkmen Almaz
dt.merveerkmen@gmail.com
1
Department of Pediatric Dentistry, Faculty of Dentistry, Kırıkkale
University, Kırıkkale, Turkey
2
Department of Pediatric Dentistry, Faculty of Dentistry, Adnan
Menderes University, Aydın, Turkey
3
Department of Pediatric Dentistry, Faculty of Dentistry, Ankara
University, Ankara, Turkey
group (C-1), there was significant difference between after
lollipop use and third month levels (p = 0.006).
Conclusions Herbal lollipops could be recommended to chil-
dren with high-caries risk who do not comply with dental
treatment in place of high-carbohydrate snacks.
Clinical relevance The paper provides a perspective on using
herbal products in high-risk children for reducing salivary S.
mutans counts.
Keywords Herbal therapy . Dental caries . Licorice . Saliva .
Streptococcus mutans
Introduction
Dental caries is one of the most common diseases of child-
hood [1]. Caries depends on specific dietary habits, and it is
caused by a specific group of cariogenic bacteria [2–4]. The
production of acid resulting from sugar metabolism by these
bacteria and the subsequent decrease in environmental pH are
responsible for demineralization of the tooth surface and for-
mation of dental caries [5].
According to the ecological plaque hypothesis, dental plaque
is a dynamic microbial ecosystem in which non-mutans bacte-
ria (mainly non-mutans streptococci and Actinomyces) are the
key players for maintaining the dynamic stability of the medi-
um, i.e., a natural pH cycle. When the environment has become
acidic, the number of mutans streptococci (MS) and other
aciduric bacteria may increase and promote lesion development
by causing Bnet mineral loss^ [6].
In the review of Takahashi and Nyvad [6], the authors have
stated that caries lesion development changes the microflora
on the tooth surface, from dominance of non-mutans strepto-
cocci and Actinomyces to the dominance of MS and other non-
mutans bacteria, including lactobacilli and Bifidobacterium.

For preventing/controlling dental caries, targeted therapies
against cavity-causing bacteria are considered to be effective
[7]. As one of the important pathogens of dental caries, re-
searchers have studied on the elimination of Streptococcus
mutans [8–14].
Recently, herbal products have been reported as promising
agents that can be used for the prevention of dental caries. In
many studies, herbal products have been reported to reduce
the number of S. mutans in the oral cavity [4, 7–9, 15].
Natural products, such as cocoa, miswak, propolis, and tea
leaves, have been shown to have anti-caries effects [7]. In
addition, in many studies, the efficacy of licorice extract and
its active components have been evaluated in oro-dental dis-
eases [16]. In several studies, these components have been
reported to dose-dependently inhibit the glycosyltransferase
activity of S. mutans [17], reduce dental plaque formation
[18], and demonstrate antibacterial activity against S. mutans,
Streptococcus sobrinus, Porphyromonas gingivalis, and
Prevotella intermedia species [19].
The University of California, Los Angeles (UCLA) re-
searchers have created a tooth-friendly candy in a new sug-
ar-free, orange-flavored lollipop (Dr. John’s herbal lollipops)
containing an extract of licorice root that has shown promise
in targeting and killing S. mutans.
The main purpose of introducing herbal lollipops was to
deliver a simple and effective way of fighting decay for young
children who are at high-caries risk [1].
There are few studies that have evaluated the efficacy of
herbal lollipops on S. mutans counts. We aimed to evaluate the
efficacy of herbal lollipops on salivary S. mutans in caries-free
and high-caries-risk children compared with a placebo control
group. The following null hypotheses were tested: sugar-free
herbal lollipops are effective to reducing salivary S. mutans
levels in high-caries-risk children who had no dental treatment
and placebo lollipops have no effect on salivary S. mutans
levels.
Materials and methods
Study group
The study was carried out in healthy, caries-free and high-
caries risk children (ds/DS ≥10 and salivary S. mutans levels
>105 CFU/ml), aged 5–11 years in the mixed dentition, who
had been examined at different kindergartens and primary
schools in Kırıkkale, Turkey. Examination was performed
by a research assistant (M.E.A.) in the Department of
Pediatric Dentistry in accordance with criteria outlined by
the World Health Organization [20] and expressed as decayed
(cavitated), missing, and filled surfaces (dmfs).The children
were randomly selected with exclusion criteria as follows: (1)
history of chronic disease (such as epilepsy, ectodermal
Clin Oral Invest
dysplasia, and cardiac anomalies), (2) use of any orthodontic
appliances, and (3) use of any drugs that reduce salivary flow
or antibiotics in the last 4 weeks.
A total of 204 children were invited to Kırıkkale University
School of Dentistry, Department of Pediatric Dentistry. After
clinical and radiographical examination and determination of
S. mutans levels, caries-free and high-caries risk children were
recruited for the study. All of the children with caries were
scheduled for dental treatment. Group B comprised children
whose dental treatment could be completed. Group C com-
prised children who did not comply with dental treatment in
clinical conditions and were referred for dental treatment un-
der sedation or general anesthesia.
A total sample size of 84 (14 per subgroup) was required to
detect 0.8 estimated effect size that allowed for power calcu-
lation (with a power of 80 % at the 5 % significance level). On
considering the loss to follow-up, it was decided to set a base-
line sample of 18 children per subgroup (108 participants).
Sample size estimation was performed by using the
G*Power version 3.0.10 (Kiel, Germany © 1992–2008)
software.
Study design
The study was a randomized, double-blind, controlled study
with parallel groups. The study was conducted with approval
by the ethical committee, and the informed consent form was
signed by all individual participants’ parents or guardians in-
cluded in the study.
The groups were comprised as follows: group A: caries-
free children (n = 36), group B: children with high-caries risk
whose dental treatment was completed before lollipop use
(n = 36), and group C: children with high-caries risk who did
not comply with dental treatment (n = 36). The subjects were
requested to pick red- or green-colored papers. The groups
were randomly divided into two subgroups (A-1, A-2, B-1,
B-2, C-1, and C-2) according to lollipop type (herbal and
placebo lollipops) (Fig. 1).
Under the control of the experienced dentist (M.E.A.), al-
location was implemented by simple randomization by the
assistant of the dentist. The children were told to choose red
or green papers for determining the groups. The children who
had chosen red papers were recorded as placebo group, while
the green paper pickers were recorded as herbal group. The
children were unaware of their allocation to the respective
groups.
The assistant was also responsible from distributing lolli-
pops to children according to the groups. So the dentist, the
children, and the parents/guardians of the children were
blinded to the group division.
Oral hygiene instructions were given to all children at the
start of the study.
Clin Oral Invest

Enrollment Assessed for eligibility (n=204)

Excluded (n= 96)

Not meeting inclusion criteria (n=73)
Declined to participate (n=18)
Other reasons (n=5)

Allocation n=108

Caries-free children – Group A (n=36) High-caries-risk children – Group B and C (n=72)

Randomized (n=36) Randomized (n=72)

Had dental treatment – Group B (n=36) Had no dental treatment – Group C(n=36)

Allocated to herbal Allocated to placebo Allocated to herbal Allocated to placebo Allocated to herbal Allocated to placebo
lollipop (n=18) lollipop (n=18) lollipop (n=18) lollipop (n=18) lollipop (n=18) lollipop (n=18)

Follow-Up n=108

Lost to follow-up (give Lost to follow-up (give Lost to follow-up Lost to follow-up Lost to follow-up Lost to follow-up
reasons) (n=1) reasons) (n=2) (give reasons) (n=1) (give reasons) (n=3) (give reasons) (n=2) (give reasons) (n=2)

Analysis n=97

Analysed (n=17) Analysed (n=16) Analysed (n=17) Analysed (n=15) Analysed (n=16) Analysed (n=16)

Fig. 1 Flow diagram showing the number of children from the study

Lollipops growth of all other oral streptococci except mutans streptococ-

The ingredients of the lollipops are listed in Table 1. Sugar-
free, orange-flavored lollipops of the same brand (Dr. John’s
Candies, sugar-free lollipops, USA) were used as a placebo in
the study. All children consumed lollipops according to the
manufacturer’s instructions, twice daily for 10 days. One lol-
lipop was consumed in the morning at school under the su-
pervision of the examiner, and one in the evening at home
under the supervision of the parent/guardian.
Parents/guardians were informed about how and when
their children will consume lollipops and were informed that
if their children refuse to consume lollipops, he/she will be
excluded from the study.
Saliva collection and interpretation of results
ci on mitis salivarius-bacitracin agar [21].
For saliva collection, each subject was instructed to chew a
paraffin pellet for 1 min. Then the rough surface of the test
strip was pressed against the saliva remaining on the patient’s
tongue, and the strip was removed gently through the patient’s
closed lips. The strips were then placed in the selective culture
broth with the smooth surfaces clipped and attached to the cap.
The vials were labeled according to each patient’s data and
incubated in an upright position at 37 °C for 48 h with the cap
one quarter of a turn open to allow growth of microorganisms.
The presence of S. mutans was confirmed by the detection
of light-blue to dark-blue raised colonies on the inoculated
surface of the strip. Two blinded independent interpreters
(M.E.A. and A.A.O.) evaluated the results according to the
manufacturer’s chart:

A dip-slide method, Dentocult SM Strip Mutans test (Orion Class 0: <10,000 CFU/ml (CFU: colony forming unit)
Diagnostica, Espoo, Finland), was used to determine the level Class 1: <100,000 CFU/ml
of S. mutans in the saliva. Dentocult is a simple chairside Class 2: 100,000–1,000,000 CFU/ml
method which is based on the fact that bacitracin inhibits the Class 3: >1,000,000 CFU/ml
 Clin Oral Invest

Table 1 Ingredients of the

lollipops according to the Herbal lollipops Sugar-free lollipops
manufacturer’s declaration
Ingredients Hydrogenated starch hydrolysate Hydrogenated starch hydrolysate
Citric acid Citric acid
Natural orange flavor Natural and artificial flavors
FD&C Yellow 6 Titanium dioxide
Glycyrrhiza uralensis FD&C Blue 1, 2; Red 3, 40; Yellow 5, 6
Acesulfame potassium Acesulfame potassium

Saliva samples were taken before and after consuming lol-
lipops and at the end of the third month in all groups. In group
B, one more saliva sample was taken after the completion of
dental treatment. After consuming lollipops, during 3 months,
all children were told to resume normal dietary and oral hy-
giene habits.
Samples of paraffin-stimulated whole saliva were collected
in the morning (between 9 a.m. and 12 a.m., at least 2 h after
breakfast) on the day before onset and 1 day after the inter-
vention period (10-day lollipop use).
Statistical methods
The results were interpreted by two independent interpreters
who were blinded about the group division. S. mutans levels
in the saliva were compared with the baseline values.
Data were analyzed using the SPSS software (SPSS Inc.,
Chicago, IL, USA, ver. 23). Comparisons were statistically
analyzed using chi-squared test.
Results
At the beginning of the study, there were 108 children who
entered into the trial, but for reasons such as school change,
moving out of town, and chronic illness, three patients from
group A, four patients from group B, and four patients from
group C were excluded from the study. The mean number of
decayed surfaces (ds/DS) and the mean age of children in each
group are shown in Table 2.
The distribution of the Dentocult SM Strip Mutans test
scores before and after lollipop use and at the third month in
all groups is shown in Table 3.
Comparison within groups
Herbal lollipop groups
During the 10-day intervention, S. mutans levels showed no
significant difference in groups A-1 and B-1 (p > 0.05). Only
in group C-1 was a significant reduction observed in salivary
S. mutans levels after lollipop use (p = 0.014).
There were no significant differences at the third month, for
groups A-1 and B-1; however, in group C-1 S. mutans levels
increased significantly (p = 0.013).
Placebo lollipop groups
In the placebo lollipop groups (A-2, B-2, and C-2), the sali-
vary S. mutans levels showed no significant difference after
lollipop use (p > 0.05).
Also, there were no significant differences in S. mutans
levels at the third month for all placebo groups (A-2, B-2,
and C-2) (p > 0.05).
Dental treatment procedure
In groups B-1 and B-2, there was significant reduction in
salivary S. mutans levels after dental treatment (p = 0.001).

Table 2 Mean number of decayed surfaces (ds/DS) and mean age of children in each group

Group n Mean Mean Mean

age ± SD ds ± SD DS ± SD

Group A-1 (caries-free, herbal lollipop) 17 6.8 ± 2.0 – –

Group A-2 (caries-free, placebo lollipop) 16 7.5 ± 1.8 – –
Group B-1 (high caries risk, treatment (+), herbal lollipop) 17 7.2 ± 0.9 18.0 ± 6.2 1.0 ± 1.9
Group B-2 (high caries risk, treatment (+), placebo lollipop) 15 7.5 ± 1.2 13.5 ± 5.5 1.6 ± 1.8
Group C-1 (high caries risk, treatment (−), herbal lollipop) 16 6.8 ± 0.9 18.0 ± 10.1 0.4 ± 0.9
Group C-2 (high caries risk, treatment (−), placebo lollipop) 16 6.6 ± 1.0 14.1 ± 4.1 0.8 ± 2.0
Clin Oral Invest

Table 3 Distribution of the

Dentocult SM Strip Mutans test Time n Dentocult SM Strip Mutans test score p
scores before and after lollipop
use and at the 3rd month for all 0 1 2 3
groups
Group A-1 (caries-free, herbal lollipop)
Before lollipop use 17 13 3 1 0
After lollipop use 17 10 4 3 0 p2 = 0.287
Third month 17 8 6 3 0 p3 = 0.145
Group A-2 (caries-free, placebo lollipop) p4 = 0.133
Before lollipop use 16 11 1 4 0 p2 = 0.365 p5 = 0.582
After lollipop use 16 9 5 2 0 p3 = 0.544
Third month 16 4 7 5 0
Group B-1 (high-risk, treatment (+), herbal)
Before dental treatment 17 0 0 9 8 p1 = 0.000*
Before lollipop use 17 7 9 1 0 p2 = 0.287
After lollipop use 17 5 9 3 0 p3 = 0.545
Third month 17 1 8 7 1 p4 = 0.522
Group B-2 (high-risk, treatment (+), placebo) p5 = 0.020*
Before dental treatment 15 0 0 5 10 p1 = 0.000*
Before lollipop use 15 5 7 3 0 p2 = 0.409
After lollipop use 15 5 5 5 0 p3 = 0.232
Third month 15 4 9 2 0
Group C-1 (high-risk, treatment (−), herbal)
Before lollipop use 16 0 0 12 4 p2 = 0.033*
After lollipop use 16 1 3 12 0 p3 = 0.006*
Third month 16 1 3 8 4 p4 = 0.476
Group C-2 (high-risk, treatment (−), placebo) p5 = 0.544
Before lollipop use 16 0 0 11 5 p2 = 0.069
After lollipop use 16 2 1 11 2 p3 = 0.102
Third month 16 1 0 9 6

Chi-squared test p < 0.05 = statistically significant, p > 0.05 = not statistically significant
p1 p value between the pre- and post-dental treatment
p2 p value between before and after lollipop use
p3 p value between after lollipop use and third month
p4 p value between placebo and herbal group (transitions between before and after lollipop use)
p5 p value between placebo and herbal group (transitions between after lollipop use and third month)
* statistically significant

Comparison between groups
There were no statistically significant differences between the
placebo and herbal lollipop groups in the changes in salivary
S. mutans levels before and after lollipop use (p > 0.05).
When comparing the changes in salivary S. mutans levels
after lollipop use and third month, we found statistically signifi-
cant difference only between the B-1 and B-2 groups (p = 0.020).
Discussion
Recently, herbal products became popular to prevent dental
caries by reducing oral pathogens including S. mutans [7]. An
herbal lollipop comprising licorice root extract, which is de-
scribed as a promising intervention, was introduced into the
market, and it targets and disables the major organisms
(S. mutans and S. sobrinus) causing tooth decay.
This is the first randomized clinical trial that has evaluated
the efficacy of an herbal lollipop on salivary S. mutans in
caries-free and high-caries-risk children compared with a pla-
cebo control group.
Before the results are discussed, the limitations of the pres-
ent study must be presented. First of all, the distribution of
caries experience in deciduous and in permanent teeth in high-
risk groups (groups B and C) indicated that the groups have
baseline differences. If a child had ds/DS ≥10 and salivary
S. mutans levels >105 CFU/ml, he/she was included to the

high-risk group. Then, all children in the high-risk group
called for dental treatment. When we have reached 36 partic-
ipants who do not comply with dental treatment, they have
been included in group C: children with high caries risk, who
did not comply with dental treatment. Then, children who had
dental treatment were included in group B (n = 36). As a result,
randomization was done for intervention so that there are
some baseline differences between groups B and C.
However, all children in the high-risk groups had salivary S.
mutans levels >105 CFU/ml and we evaluated the efficacy of
the lollipops according to the levels of S. mutans. Secondly,
saliva samples were taken at the end of the third month after
lollipop use in all groups. The 3-month period is a short time
for evaluating post-treatment S. mutans levels. Maybe as the
manufacturer’s recommendation, the 10-day lollipop use
might be repeated every 3 months, and maybe the duration
of the study could be extended. However, we firstly wanted to
evaluate whether lollipops have a dramatic effect in the first 3-
month period or not. Thirdly, the children who included to the
study consumed lollipops twice a day. They consumed daily
one of the two lollipops at home, not under the supervision of
the dentist. We have tried to compensate for this limitation as
similarly done in previous studies evaluating oral health prod-
ucts such as gum, mouthrinse, etc. Information was given to
parents and the children consumed lollipops at home under the
supervision of the parents/guardian [8, 22, 23]. The parents
were asked whether their children had consumed the lollipops
regularly at home or not, and all children were reported as
consumed regularly. Also, the children have mentioned that
they liked the taste of the lollipops, compliance was well, and
no side effects or adverse events were reported.
Within the limitations of the present study, after the 10-day
herbal lollipop use, a significant decrease in S. mutans counts
was observed in high-risk children who had no dental treatment
(group C-1). In a previous study, the efficacy of an herbal lollipop
containing an extract of licorice root in preschool children was
evaluated [1], and a result similar to the present study was report-
ed. Also, as expected, in the placebo groups (A-2, B-2, and C-2),
the difference between S. mutans levels before and after lollipop
use was not statistically significant. The null hypotheses have
been accepted based on the findings of the present study.
Although a significant decrease in S. mutans counts was
observed in group C-1, statistical power was found to be lower
than expected (<80 %). For a study like this, power can be
increased by adding more subjects. Also, adding more sub-
jects might provide significant differences between placebo
and herbal groups.
Peters et al. (2010) have reported that no significant chang-
es were observed in the low S. mutans group after herbal
lollipop use [1]. Similar to the study of Peters et al. (2010),
in the present study, in groups A-1 (caries-free) and B-1 (high
caries risk, dental treatment), S. mutans levels were not signif-
icantly changed after herbal lollipop use [1]. These results
Clin Oral Invest
could be due to the low levels of salivary S. mutans which
were not affected by herbal lollipops. In group B-1, after den-
tal treatment (before lollipop use), S. mutans levels decreased
significantly similar to previous studies [10, 24, 25]. So, the
reason of observed efficacy of the herbal lollipops in group C-
1 (high caries risk, had no dental treatment) might be related to
the high levels of S. mutans before lollipop use.
The hypothesized mechanism behind the efficacy of the
herbal lollipops (licorice) was shown in several studies; inhi-
bition of bacterial glucosyltransferase activity [17, 18, 26],
reducing the growth, and acid production of Streptococcus,
Actinomyces, and Bacterionema species [27, 28] and antibac-
terial activity against cariogenic bacteria S. mutans and S.
sobrinus and periodontal pathogens Porphyromonas
gingivalis and Prevotella intermedia [17–19]. Also, licorice
being a sweet-tasting substance and acting as a gustatory stim-
ulus may increase the salivary flow and then provide a bene-
ficial impact against dental caries [16].
The manufacturer of herbal lollipops recommends the use
of herbal lollipops every 3 months in high-caries risk children.
Therefore, in the present study 3-month follow-up was con-
ducted. Only in group C-1 (high caries risk, had no dental
treatment) were the S. mutans levels increased significantly
after 3 months (p = 0.006). The increase could be due to the
lack of supervision by a dentist in the 3-month period and the
children have returned to their former oral hygiene and dietary
habits.
There were no statistically significant differences between
the placebo and herbal lollipop groups in the changes in sali-
vary S. mutans levels before and after lollipop use. This was
an unexpected result of the study. At least, a significant differ-
ence was expected between the C-1 and C-2 groups, as a
statistically significant difference was observed for group C-
1. The transition of salivary S. mutans levels might be similar
in both groups, and this might explain non-significant differ-
ences in placebo and herbal groups. Only between the B-1 and
B-2 groups, there was a statistically significant difference after
lollipop use in the third month. But this finding has no effect
on explaining the efficacy of herbal lollipops.
In previous studies, herbal lollipops were considered a nov-
el tool for promoting oral health in patients of different ages
(preschool children, adults, and nursing home residents) [1, 4,
29]. Likewise, in the present study, the results are also encour-
aging to recommend herbal lollipops in high-caries risk chil-
dren (who did not comply with dental treatment) as an alter-
native to cariogenic confectionery.
In conclusion, herbal lollipops were found to be effective in
high-caries risk children (who did not comply with dental
treatment) in reducing salivary S. mutans levels. In the present
study, the efficacy of herbal lollipops was evaluated for reduc-
ing salivary S. mutans levels only. Because caries is a multi-
factorial disease (e.g., Lactobacilli counts, plaque formation),
determination of only the salivary S. mutans levels may not be
Clin Oral Invest
sufficient to evaluate the anti-caries efficacy of herbal prod-
ucts. Therefore, more extensive and comprehensive research
is needed to evaluate the efficacy of licorice root extract in
caries prevention.
Compliance with ethical standards The study was a randomized,
double-blind, controlled study with parallel groups. The study was con-
ducted with approval by the ethical committee, and the informed consent
form was signed by all individual participants’ parents or guardians in-
cluded in the study.
Funding This study was funded by Kırıkkale University Scientific
Research Projects Coordination Unit (project number 2012/98).
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All procedures performed in studies involving hu-
man participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964
Helsinki Declaration and its later amendments or comparable ethical
standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
References
1. Peters MC, Tallman JA, Braun TM, Jacobson JJ (2010) Clinical
reduction of S. mutans in pre-school children using a novel liquo-
rice root extract lollipop: a pilot study. Eur Arch Paediatr Dent
11(6):274–278
2. Huxley HG (1977) The effect of feeding frequency on rat caries. J
Dent Res 56:976
3. Beighton D, Adamson A, Rugg-Gunn A (1996) Associations be-
tween dietary intake, dental caries experience and salivary bacterial
levels in 12-year-old English schoolchildren. Arch Oral Biol 41(3):
271–280
4. Hu CH, He J, Eckert R, Wu XY, Li LN, Tian Y et al (2011)
Development and evaluation of a safe and effective sugar-free herb-
al lollipop that kills cavity-causing bacteria. Int J Oral Sci 3(1):13–
20
5. Marsh PD, Nyvad B (2008) The oral microflora and biofilms on
teeth. In: Fejerskov O, Kidd EAM (eds) Dental caries. The disease
and its clinical management, 2nd edn. Blackwell Munksgaard,
Oxford, pp 163–187
6. Takahashi N, Nyvad B (2011) The role of bacteria in the caries
process: ecological perspectives. J Dent Res 90(3):294–303
7. Jeon JG, Rosalen PL, Falsetta ML, Koo H (2011) Natural products
in caries research: current (limited) knowledge, challenges and fu-
ture perspective. Caries Res 45(3):243–263
8. Agarwal P, Nagesh L (2011) Comparative evaluation of efficacy of
0.2 % chlorhexidine, listerine and tulsi extract mouth rinses on
salivary Streptococcus mutans count of high school children—
RCT. Contemp Clin Trials 32(6):802–808
9. Asokan S, Rathan J, Muthu MS, Rathna PV, Emmadi P,
Raghuraman et al (2008) Effect of oil pulling on Streptococcus
mutans count in plaque and saliva using Dentocult SM Strip
Mutans test: a randomized, controlled, triple-blind study. J Indian
Soc Pedod Prev Dent 26(1):12–17
View publication stats
10. Simratvir M, Singh N, Chopra S, Thomas AM (2010) Efficacy of
10% povidone iodine in children affected with early childhood
caries: an in vivo study. J Clin Pediatr Dent 34(3):233–238
11. Soderling E, Hirvonen A, Karjalainen S, Fontana M, Catt D, Seppa
L (2011) The effect of xylitol on the composition of the oral flora: a
pilot study. Eur J Dent 5(1):24–31
12. Thorild I, Lindau B, Twetman S (2004) Salivary mutans strepto-
cocci and dental caries in three-year-old children after maternal
exposure to chewing gums containing combinations of xylitol, sor-
bitol, chlorhexidine, and fluoride. Acta Odontol Scand 62(5):245–
250
13. Twetman S, Petersson LG (1998) Comparison of the efficacy of
three different chlorhexidine preparations in decreasing the levels
of mutans streptococci in saliva and interdental plaque. Caries Res
32(2):113–118
14. van Lunsen DM, de Soet JJ, Weerheijm KL, Groen HJ, Veerkamp
JS (2000) Effects of dental treatment and single application of a
40% chlorhexidine varnish on mutans streptococci in young chil-
dren under intravenous anaesthesia. Caries Res 34(3):268–274
15. Taheri JB, Azimi S, Rafieian N, Zanjani HA (2011) Herbs in den-
tistry. Int Dent J 61(6):287–296
16. Messier C, Epifano F, Genovese S, Grenier D (2012) Licorice and
its potential beneficial effects in common oro-dental diseases. Oral
Dis 18(1):32–39
17. Sela MN, Steinberg D, Segal R (1987) Inhibition of the activity of
glucosyltransferase from Streptococcus mutans by glycyrrhizin.
Oral Microbiol Immunol 2(3):125–128
18. Steinberg D, Sgan-Cohen HD, Stabholz A, Pizanty S, Segal R, Sela
MN (1989) The anticariogenic activity of glycyrrhizin: preliminary
clinical trials. Isr J Dent Sci 2(3):153–157
19. Gafner S, Bergeron C, Jr V, Godejohann M, Kessler P, Cardellina
JH et al (2011) Isoflavonoids and coumarins from Glycyrrhiza
uralensis: antibacterial activity against oral pathogens and conver-
sion of isoflavans into isoflavan-quinones during purification. J Nat
Prod 74(12):2514–2519
20. World Health Organization (1997) Oral health surveys, basic
methods, 4th edn. WHO, Geneva
21. Guo L, Shi W (2013) Salivary biomarkers for caries risk assess-
ment. J Calif Dent Assoc 41(2):107–118
22. Campus G, Cagetti MG, Sacco G, Solinas G, Mastroberardino S,
Lingstrom P (2009) Six months of daily high-dose xylitol in high-
risk schoolchildren: a randomized clinical trial on plaque pH and
salivary mutans streptococci. Caries Res 43(6):455–461
23. Campus G, Cocco F, Carta G, Mg C, Simark-Mattson C,
Strohmenger L et al (2014) Effect of a daily dose of Lactobacillus
brevis CD2 lozenges in high caries risk schoolchildren. Clin Oral
Investig 18(2):555–561
24. Litsas G (2010) Effect of full mouth rehabilitation on the amount of
Streptococcus mutans in children with early childhood caries. Eur J
Paediatr Dent 11(1):35–38
25. Morinushi T, Murayama M, Kinjyo S (2004) Mutans streptococci,
lactobacilli in saliva and acidity from organisms in dental plaque:
changes after restorative treatment. J Clin Pediatr Dent 28(4):327–
332
26. Isbrucker RA, Burdock GA (2006) Risk and safety assessment on
the consumption of licorice root (Glycyrrhiza sp.), its extract and
powder as a food ingredient, with emphasis on the pharmacology
and toxicology of glycyrrhizin. Regul Toxicol Pharmacol 46(3):
167–192
27. Berry CW, Henry CA (1982) Effect of glycyrrhizin on the growth
and acid production of Streptococcus mutans. J Dent Res 61:114
28. Berry CW, Henry CA (1984) Influence of glycyrrhizin on the met-
abolic activity of oral bacteria. J Dent Res 63:212
29. Mentes JC, Kang S, Spackman S, Bauer J (2012) Can a licorice
lollipop decrease cariogenic bacteria in nursing home residents?
Res Gerontol Nurs 5(4):233–237