ORIGINAL RESEARCH

https://doi.org/10.5005/jp-journals-10077-3239
Journal of South Asian Association of Pediatric Dentistry
Volume 5 | Issue 3 | Year 2022

Comparative Evaluation of Antifungal Efficacy of Different Pediatric Toothpastes on Candida albicans in Children with and without Early Childhood Caries

Purna Sai Prasad Kolavali¹ https://orcid.org/0000-0002-4651-4731, BV Thimma Reddy², Uday Chowdary Birapu³, Raichurkar Hemanth Kumar⁴, Kanamarlapudi Venkata Saikiran⁵, Gunde Veronica⁶

^1-4,6Department of Pediatric and Preventive Dentistry, SVS Institute of Dental Sciences, Mahabubnagar, Telangana, India

⁵Department of Pediatric and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India

Corresponding Author: Purna Sai Prasad Kolavali, Department of Pediatric and Preventive Dentistry, SVS Institute of Dental Sciences, Mahabubnagar, Telangana, India, Phone: +91 7799812057, e-mail: prasadkolavali@gmail.com

Received on: 19 July 2022; Accepted on: 30 October 2022; Published on: 26 December 2022

ABSTRACT

Aim: To evaluate the antifungal efficacy of four commercially available pediatric toothpaste on Candida albicans in children with and without early childhood caries (ECC).

Materials and methods: A total of 40 children were randomly divided into two groups; group I: ECC and group II: non-ECC, with 20 children in each group. After that, sterile cotton swabs were used to collect plaque samples from the tooth surface, and the samples were inoculated on Sabouraud dextrose agar (SDA) and incubated for 72 hours. After the growth was confirmed, four commercially available dentifrices were divided into four subgroups Kidodent®, Cheerio gel®, Pediflor®, and Colgate kids toothpaste® were titrated to a 1:1 dilution to identify the antifungal activity of C.albicans. Four wells, each of 4 mm in depth and 6 mm in diameter, were punched on the agar surface and filled with 0.02 mL of dentifrice solution using a microtiter pipette. Agar plates were incubated at 37°C for 48 hours, and the mean diameter of the zone of inhibition was measured and recorded. The collected data were tabulated and statistically analyzed using the chi-square and analysis of variance (ANOVA) tests.

Results: Kidodent® in the ECC group had a maximum zone of inhibition (35.15 ± 5.75) with a significant difference when compared with Pediflor® and Colgate kids® (p < 0.001). In the non-ECC group, Cheerio gel® (14.95 ± 1.80) showed the maximum zone of inhibition, and no significant difference was seen with the other toothpastes (p > 0.001).

Conclusion: Kidodent® toothpaste showed maximum antifungal efficacy for the ECC group and Cheerio gel® toothpaste showed maximum antifungal efficacy for the non-ECC group.

How to cite this article: Kolavali PSP, Thimma Reddy BV, Birapu UC, et al. Comparative Evaluation of Antifungal Efficacy of Different Pediatric Toothpastes on Candida albicans in Children with and without Early Childhood Caries. J South Asian Assoc Pediatr Dent 2022;5(3):127-131.

Source of support: Nil

Conflict of interest: None

Keywords: Candida albicans, Dentifrice, Early childhood caries

INTRODUCTION

Early childhood caries (ECC) is an aggressive and destructive form of dental caries affecting children younger than 6 years of age. Streptococcus mutans have been implicated as the pioneer microorganism in the initiation of ECC. These microorganisms are acidogenic and acidic, which makes the plaque cariogenic. This low pH leads to a change in the ecology of microorganisms to more acidophilic species, such as Veillonella,Lactobacilli, and Candida species.¹

The presence of Candida has been shown to enhance the adherence of S. mutans to oral biofilm and carious tooth substance by various in vitro studies in the literature. Due to an immature immune system, children are more susceptible to opportunistic microbial colonization of Candida. C. albicans does not colonize teeth effectively on its own but adheres to the oral mucosa, thereby interacting with commensal streptococci. Candida species are also acidogenic in nature and have the ability to ferment carbohydrates, which is relevant for ECC formation.²^,³

Biofilm is caused by plaque-associated microorganisms, and brushing with toothpaste is the best preventive measure currently considered.³ Various toothpastes are available for children that contain different chemotherapeutic agents to maintain good oral health by inhibiting plaque formation and its colonization. Commercially available toothpastes have their own composition and concentration of ingredients for their efficacy.⁴ These toothpastes claim to have antimicrobial properties, but more research is needed to evaluate the effectiveness of dentifrices on C. albicans. Hence, the present study was conducted to assess and compare the antifungal efficacy of four different toothpastes in children with and without ECC.

MATERIALS AND METHODS

The present study was conducted in the Department of Pediatric and Preventive Dentistry. Ethical clearance was obtained from the Institutional Ethical Committee (SVSIDS/PEDO/4/2019), and the study period was from June to October 2021.

The sample power was estimated in the G* Power 3.1.9.6 program (Universität Kiel, D) and the test applied was t-test for two independent means. The study effect size was estimated from the 10 children recruited for the pilot study, and these 10 children were not part of the final sample. After obtaining the results from the pilot study, the effect was determined as 0.92 by taking α error of 0.05 and β as 0.80, and a final sample of 40 was determined.

The children were recruited based on the following inclusion criteria:

Children in the age range of 3–6 years.
Children with and without ECC.
Children are willing to participate in the study.
Children whose parents gave informed written consent.

Exclusion Criteria

Children who underwent recent administration of topical or systemic antimicrobial medication for any reason.
Children who refused to participate in the study.
Children who are unable to cope with the procedure.

Procedure

Signed informed consent was obtained from all the parents after explaining the procedure performed in the trial. After obtaining the baseline demographic data (age and gender), the caries experience for all the children was carried out using type III examination (inspection using mouth mirror, explorer, and adequate illumination). Caries index was recorded using a decayed-extracted-filled teeth score. All the clinical examinations were performed by a single trained and calibrated examiner. Later, the total sample was randomly divided into two groups (20 ECC and 20 non-ECC) using adaptive randomization. Plaque samples were obtained with sterile cotton by swabbing on the four surfaces of the tooth (buccal, lingual, mesial, and distal) and the collected swabs were placed into labeled test tubes. Later, these specimens were transferred to the laboratory for microbiological analysis.

The obtained samples were transferred into petri dishes containing SDA supplemented with 1% chloramphenicol at pH 6.6 for the prevention of bacterial contamination, and the plates were incubated at 37°C for 24–72 hours. After 72 hours of incubation, the cultures were said to be positive if smooth, creamy colonies with moldy odors were noticed in 1–2 days (Fig. 1). Whereas, whereas the cultures were considered negative if there was a complete absence of any growth. The positive cultured growth was kept in SDA vials stock, and the identification of species was made by corn meal agar test and germ tube test. After obtaining the positive growth of C. albicans, four commercially available dentifrices were evaluated for antifungal activity in the following subgroups: subgroup I: Kidodent®, subgroup II: Pediflor®, subgroup III: Cheerio gel® and subgroup IV: Colgate kids toothpaste®.

Fig. 1: Positive culture of C. albicans

A dentifrices solution of 1:1 dilution was prepared by mixing 3 gm of each study paste in 3 mL of distilled water. After that, 5 mL of sterile saline solution was added to the positive cultured growth, forming a suspension of C. albicans, and the turbidity of the inoculum was set to the McFarland 0.5 standard. Later, 0.1 mL of inoculum was spread over the entire surface of the petri dish with a sterile glass applicator.

After that, four wells were created in each petri dish plate with a depth of 4 mm and diameter of 6 mm, punched equidistantly from each other. After that, these are filled with a test solution of dentifrice of about 0.02 mL using a microtiter pipette. Finally, the incubation of agar plates was done at 37°C for 2 days, and the average diameter for the zone of inhibition was calculated using digital vernier calipers by a single trained pediatric dentist, and the values were recorded (Fig. 2). The data was entered into the Microsoft Excel spreadsheet 2016. The statistical analysis was evaluated using the Statistical Package for the Social Sciences 21.0 version for Windows (Chicago, Illinois, United States of America). The chi-squared test was used to identify the difference in the distribution of children among both groups. The normality of the data was assessed using the Shapiro–Wilk test. The difference between the four different kinds of toothpaste was assessed using ANOVA. The level of significance was set at 0.05.

Fig. 2: Zone of inhibition

RESULTS

Among the 40 children, 22 were boys, and 18 were girls, with a mean age of 4.59 ± 1.32 years and 4.74 ± 1.06 years, respectively, with no significant difference.

Table 1 represents the mean and standard deviation (SD) of a zone of inhibition in ECC and non-ECC groups. Statistical significant differences among the four groups were appreciated in the ECC group (p < 0.001). Whereas, no significant difference was seen among the four groups in the non-ECC group (p = 0.733). Similarly, the highest zone of inhibition is observed in group I, with a mean value of 35.15 ± 5.75, and the least zone of inhibition is seen in group IV, with a mean value of 12.72 ± 1.87 for ECC children. Whereas in non-ECC children, all the groups have shown similar zone of inhibition.

**Table 1:** Mean and SD of the zone of inhibition in ECC and non-ECC
Group	ECC		Non-ECC
Group	Mean ± SD	p-value	Mean ± SD	p-value
Kidodent®	35.15 ± 5.75	<0.001*	14.32 ± 2.53	0.733 (NS)
Pediflor®	14.11 ± 2.85		14.36 ± 2.46
Cheerio gel®	31.64 ± 5.12		14.95 ± 1.80
Colgate kids®	12.72 ± 1.87		14.25 ± 1.82

*significance of p-value

Table 2 represents the mean difference and standard error of multiple comparisons in ECC between the four groups. When the group I was compared with the other groups, a statistical significant difference was seen in all the groups except group III (p = 0.049). Similarly, group II exhibited statistical significant differences among groups I and III (p <0.001). When group III was compared with other groups, a statistical significant difference was observed between groups II and IV (p < 0.001). Finally, when group IV was compared with the other three groups, a statistical significant difference was seen with group I and III (p < 0.001).

**Table 2:** *Post hoc* Tukey test values for multiple comparisons in the ECC group
Group		Mean difference	Standard error	p-value
Kidodent®	Pediflor®	21.04	1.33	<0.001*
	Cheerio gel®	3.51	1.33	0.049
	Colgate kids®	22.43	1.33	<0.001*
Pediflor®	Kidodent®	−21.04	1.33	<0.001*
	Cheerio gel®	−17.53	1.33	<0.001*
	Colgate kids®	1.38	1.33	0.725
Cheerio gel®	Kidodent®	−3.51	1.33	0.049
	Pediflor®	17.53	1.33	<0.001*
	Colgate kids®	18.92	1.33	<0.001*
Colgate kids®	Kidodent®	−22.43	1.33	<0.001*
	Pediflor®	−1.38	1.33	0.725
	Cheerio gel®	−18.92*	1.33	<0.001*

*significance of p-value

Table 3 represents the mean difference and standard error of multiple comparisons in non-ECC among the four groups. No significant difference was observed among all four groups (p > 0.001).

**Table 3:** *Post hoc* Tukey test values for multiple comparisons in non-ECC groups
Group		Mean difference	Standard error	p-value
Kidodent®	Pediflor®	−0.03	0.69	1.000
	Cheerio gel®	−0.62	0.69	0.804
	Colgate kids®	0.07	0.69	1.000
Pediflor®	Kidodent®	0.03	0.69	1.000
	Cheerio gel®	−0.58	0.69	0.830
	Colgate kids®	0.10	0.69	0.999
Cheerio gel®	Kidodent®	0.62	0.69	0.804
	Pediflor®	0.58	0.69	0.830
	Colgate kids®	0.69	0.69	0.748
Colgate kids®	Kidodent®	−0.07	0.69	1.000
	Pediflor®	−0.10	0.69	0.999
	Cheerio gel®	−0.69	0.69	0.748

DISCUSSION

Dental caries is a chronic multifactorial illness that damages the calcified tissue of the teeth, impairing their esthetic appearance and masticatory function.⁵ Cariogenic bacteria, refined carbohydrates, and plaque are the various etiologic factors that will contribute to the development of dental caries.⁶^,⁷ In the literature, various terms have been used to describe dental caries in children, including “early childhood tooth decay,” “ECC,” “bottle caries,” “nursing caries,” “night bottle mouth,” and “baby bottle tooth decay.”⁸^,⁹ The prevalence of ECC is 49.6% across India, with Andhra Pradesh having the highest incidence at 63% and Sikkim having the lowest prevalence at 41.92%.¹⁰^,¹¹

The initiation of dental caries is mainly caused by S. mutans, while the advancement of dental caries is mediated by Lactobacillus species. The presence of C. albicans in the cariogenic biofilm has been documented in various studies over the past two decades of ECC in children.¹² A study done by Wu et al. stated that the presence of C. albicans was conversely proportional to the severity of ECC in terms of decayed, missing, and filled teeth score in 3–5 years children.¹² Similarly, numerous studies have reported that children with ECC have a higher prevalence of C. albicans than children without ECC.¹³^,¹⁴

A systemic review by Xiao et al. stated that the presence of C. albicans in the saliva of ECC ranged from 24–100%, in plaque (44–80%), swab samples (14.7–44%), and in carious lesions about 60–100%. Similarly, in non-ECC, C. albicans was found in saliva (100–100%), plaque (7–19%), and swab samples (6–7%).¹⁵

Dentifrices help to clean and polish the tooth surface and act as a vehicle for antimicrobial agents, which reduces the accumulation of plaque and calculus, thereby preventing dental caries. Antimicrobial agents are added to toothpaste, which helps in maintaining the lower levels of plaque by selectively inhibiting specific growth of microorganisms that are related to periodontal disease by lowering the expression of virulence determinants.¹⁶^,¹⁷

Currently, there are several commercial toothpaste varieties with various combinations of antimicrobial and antifungal qualities available in the market. Hence, in the present study, four children’s toothpaste that is frequently recommended by dentists, namely, Kidodent®, Cheerio gel®, Pediflor®, and Colgate Kids®, were assessed for their anticandidal action. Based on the findings from the present study, Kidodent® exhibited the highest zone of inhibition when compared to other toothpaste. This increased anticandidal activity of the paste would be due to the synergistic interaction of the active components, such as sodium monofluorophosphate, triclosan, and xylitol.¹⁸ Similarly, a study conducted by Prasanth and Giuliana et al. has stated that triclosan is not only an effective antifungal agent against C. albicans but has also been shown to reduce the overall microbial count in the saliva.¹⁹^,²⁰

In comparison to Kidodent® in the current study, Cheerio gel® was found to have a higher zone of inhibition. The main contribution to it is to the active constituents, that is, sodium monofluorophosphate with 458 ppm of fluoride. A study conducted by Malhotra et al. showed that the maximum zone of inhibition was seen with 0.35% sodium monofluorophosphate when compared with 0.38%. The present study showed an approximately closer antifungal zone of inhibition with the Cheerio gel®.²¹

When compared to Kidodent® and Cheerio gel in the present study, the zone of inhibition by Pediflor® was determined to be significant. These are in accordance with a study done by Chandhru et al., which revealed a zone of inhibition values comparable to those in the current investigation.⁴ The combination of various components that comprise Pediflor® may have resulted in a smaller zone of inhibition in the current study.⁴ Finally, among the four kinds of toothpaste tested in the ECC group, Colgate Kids® had the smallest zone of inhibition. A similar result was also seen in a study by Chandhru et al. though the values were comparatively higher than the present study, the results were statistically not significant.⁴

The main difference between Kidodent® and Cheerio gel® is attributed to their composition. Kidodent® has a synergistic effect of triclosan and xylitol with sodium monofluorophosphate, whereas Cheerio gel® contains sodium monofluorophosphate alone. This might be the reason for a lower zone of inhibition for Cheerio gel® in comparison with Kidodent® in this study.

In the non-ECC group, no significant differences were seen in the zone of inhibition values among the four kinds of toothpaste. But when compared with the values of the ECC group, a significant difference was seen, which might be due to the complex ecological interactions between the toothpaste and oral microflora in the ECC and non-ECC groups.

Limitations of the Study

Further clinical studies on larger samples are required to evaluate the antifungal efficacy of these dentifrices.
The amount of xylitol is not disclosed in the commercial preparations that have an impact on the antimicrobial activity.
As ECC is multifactorial, examination of various other species should be considered.
In the present study, only four different kinds of toothpaste were compared to various commercial kinds of toothpaste available in the market.

CONCLUSION

Within the limitations of the present study, Kidodent® has shown maximum antifungal activity for which it can be prescribed for children with ECC. At the same time, Colgate Kids toothpaste has minimum antifungal activity in children with ECC. For the children with non-ECC, any of the toothpaste studied could be prescribed as no statistical significance was noted. Hence, while prescribing a dentifrice for a child, the condition of the oral cavity, as well as the status of ECC, should be taken into consideration for optimal results.

CLINICAL SIGNIFICANCE

The outcome of this study emphasizes that Kidodent and Cheerio gel toothpaste were better than Pediflor and Colgate kids toothpaste over the growth of C. albicans in reducing the severity of ECC in children.

ORCID

Purna Sai Prasad Kolavali https://orcid.org/0000-0002-4651-4731

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