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Introduction.
Since ancient times, humanity has shown a marked
preference for sweet food
1
. The most widely used
sweetener historically is sucrose, which provides a high-
quality sweet taste, has a texture and acceptable shape,
and due to this, it has maintained as the most popular
sweetener
2
. However, with the passage of the years,
several researches have proven that sucrose has led to
various nutritional and medical problems
3
. Its persistent
consumption is highly related to the increase of weight,
percentage of body fat, risk of development of cardio-
vascular disease, type 2 diabetes at adult age
4-6
, breast
7-9
,
Journal of
Oral Research
ISSN Print 0719-2460
ISSN Online 0719-2479
www.joralres.com
REVIEW
Anticariogenic properties and effects on
periodontal structures of Stevia rebaudiana
Bertoni. Narrative review.
Contreras S. Anticariogenic properties and effects on periodontal structures of
Stevia rebaudiana Bertoni. Narrative review. J Oral Res 2013; 2(3): 158-166.
Abstract: Introduction: Stevia rebaudiana Bertoni is a natural non-caloric sweetener, with
more sweetness than sucrose, without adverse effects, which has demonstrated to have
multiples benefits to the systemic health and recently to the oral health. This review’s
objective is to describe anti-cariogenic and anti-periodontophatics properties of its
extracts. Results: Stevioside and rebaudioside A are the most important glycosides of
the Stevia and none is cariogenic. In vitro researches 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. In vivo and in vitro it has been observed that the production of bacterial
acids decrease attributing it a low acidogenic potential and a lesser effect of the
demineralization of the enamel in comparison with others sweeteners. Furthermore,
in vivo it has been proved an anti-plaque effect mainly due to a decrease in the production
of bacterial insoluble polymers. These characteristics in combination with anti-
inflammatory properties could result potentially effective in the treatment of periodontal
diseases in significant numbers, as it has been observed in studies conducted in animals.
Conclusion: Stevia presents properties that potentially are anti-caries and anti periodontal-
diseases. However, in vivo studies are necessary to confirm these assumptions and provide
a greater understanding of the mechanisms of action of this plant and the components
involved. Notwithstanding, with the existing background, this sweetener can be postulated
as a potential therapeutic complement in the odontological care, especially in patients
that present base conditions such as obesity, diabetes and high blood pressure.
Keywords: "Stevia" [MeSH], "Sweetening agents" [MeSH], "Tooth decay" [MeSH],
"Periodontal disease" [MeSH].
Propiedades anticariogénicas y efectos a nivel periodontal
de Stevia rebaudiana Bertoni. Revisión narrativa.
Resumen: Introducción: Stevia rebaudiana bertoni es un edulcorante natural no calórico,
con mayor dulzor que la sacarosa, sin efectos adversos, que ha demostrado tener múltiples
beneficiosos para la salud sistémica y recientemente para la salud oral. El objetivo de esta
revisión es describir propiedades anticariogénicas y antiperiodontopáticas de sus extractos.
Resultados: Esteviósido y rebaudiósido A son los glicósidos más importantes de Stevia
y ninguno es cariogénico. Estudios in vitro han demostrado que extractos de Stevia presentan
actividad antibacteriana sobre Streptococcus mutans, Streptococcus sobrinus y Lactobacillus acidophillus,
organismos estrechamente relacionados en la producción y desarrollo de caries. In vivo e
in vitro se ha observado que disminuye la producción de ácidos bacterianos atribuyéndosele
un bajo potencial acidogénico y un menor efecto de desmineralización del esmalte en
comparación con otros edulcorantes. Además, in vivo se ha comprobado un efecto anti-
placa principalmente debido a una disminución en la producción de polímeros insolubles
bacterianos. Estas características, más sus propiedades antiinflamatorias y cicatrizantes,
podrían resultar potencialmente efectivas en el tratamiento de enfermedades periodontales
en cifras significativas, como se ha observado en estudios desarrollados en animales.
Conclusión: Stevia presenta propiedades potencialmente anti-caries y anti-enfermedades
periodontales. Sin embargo, son necesarios estudios in vivo que confirmen estos postulados
y proporcionen una mayor comprensión de sus mecanismos de acción y de los componentes
que intervienen. No obstante, con los antecedentes existentes, se puede postular a este
edulcorante como un potencial complemento terapéutico en la atención odontológica, sobre
todo en pacientes que presentan condiciones de base como obesidad, diabetes e hipertensión.
Palabras clave: Stevia, agentes endulzantes, caries dental, periodontitis.
Soledad Contreras.
Private practice, Chile.
Recibido: 27/09/13
Revisado: 16/10/13
Aceptado: 29/10/13
Online: 29/10/13
Contacto: Dr. María Soledad Contreras.
Address: Las Minas 671, Tomé. Phone
number: +56 9 86488576. Email:
solecontreras90@gmail.com.
158
pancreas
10
and colon cancer
11
, risk of developing
ulcerative colitis, Crohn disease
12
and inflammatory
bowel disease
13
.
At oral level, sucrose is an important factor that
contributes the formation and development of the
bacterial plaque. This is easily metabolized by oral
bacteria
14
forming glucan, which promotes bacterial
adhesion to the teeth
15
. The metabolic activity of the
microbiota in the mouth not only is involved in cario-
genic and periodontopathic phenomena, but also in
the development of tumors in the mouth
16
. In addition,
sucrose exhibits the greatest promotion of adhesion
to Candida albicans and Candida tropicalis
17
, helping to
the emergence of the candidiasis.
Most part of the diseases in the mouth begins with
the formation of dental plaque, therefore both tooth
decay and periodontal diseases could be controlled if
the formation of dental plaque is reduced
14
. However,
eating habits are hard to change, especially when it is
associated with the consumption of sweet products
14
.
That's why, that the increase in the availability of safe
and effective substitutes for the sucrose in the diet
during critical periods of tooth development is vital
for public health at long term
18
. In this way is how
substitutes of sucrose have arisen, additives-food which
is able to simulate the presence of sugar
1
.
The sweeteners that are used in the food industry
are divided into two groups: Carbohydrate sweeteners
or nutritious and no-carbohydrate sweeteners or not
nutritious
1
.
The first group is composed by sucrose, several
oligosaccharides (palatinosa, fructo-oligosaccharides,
galacto-oligosaccharides, lacto-oligosaccharides and
xylo-oligosaccharides), starch sugars (glucose, starch
syrup, fructose, sugar, maltose, invert sugar, and fruc-
tose) and sugar alcohols (erythritol, sorbitol, mannitol,
xylitol, maltitol, lactitol, Palatinit™, and reducing starch
syrup)
2
. Most of them are neither calorie-free, nor
beneficial dietary components for those who suffer
from alteration in the metabolism for carbohydrates
and other conditions
18
. Besides, sugar alcohols generally
trigger side effects such as abdominal discomfort,
flatulence, softened stools and diarrhea when they are
consumed in excess
2
.
The members of the second group are divided into
chemically synthesized sweeteners and those obtained
from plants. The first include saccharin, aspartame and
sucralose
2
, which are associated with a greater probability
of increased caloric intake
18
, this is because they present
a low power of satiety
19
, interfering in the energy
balance
19, 20
, with the consequent incapacity to achieve
or maintain a healthy body weight
18
. In addition, they
don’t offer health benefits
18
. Those obtained from
plants include, stevioside (Stevia-glucoside), thaumatins,
and monellin
2
.
With the increase of the incidence of diabetes and
obesity and also because of the growing concern for
the safety of some chemical sweeteners such as aspar-
tame, alitame, cyclamate, saccharin, sucralose, among
others, the need of natural non-caloric sweeteners with
acceptable taste and relatively safe, is exigent
2
. Stevia
rebaurdiana bertoni is a natural sweetener that has shown,
in several publications
2, 14, 18, 21-25
, respond to these needs
and also submit beneficial properties for general and
oral health.
This literature review seeks to describe this natural
sweetener giving emphasis to its anti-periodontophatic
and anti-cariogenic properties, putting forward possible
uses in dental care.
Origins and composition.
Its scientific name is Stevia rebaudiana Bertoni, com-
monly is known as sweet grass or paraguayan sweet-
grass; but the native people call it kaa hee, caa ehe, kaa-
jee
26
. The Stevia plant is a perennial grass and belongs
to the Asteraceae family
27
. It comes from certain parts
of South America, mostly in Paraguay and Brazil
28
. It
was used for centuries by the Guarani natives as a
sweetener to counteract the bitter taste of medicines
based on different plants and drinks, and for medicinal
purposes that include the regulation of glycemia (blood
sugar levels) and hypertension
29
.
In 1887 a South American naturalist scientist, Dr.
Moisés Santiago Bertoni, director of the College of
agriculture in Asunción
30
, described it for the first time.
In 1900, the Paraguayan chemist Ovidio Rebaudi,
managed to isolate the active ingredients responsible
for sweetness
31
.
It is estimated that there are more than 80 species
of Stevia that grow in the wild in the American conti-
nent; of these species, only Stevia rebaudiana Bertoni and
another species already extinct seem to possess the
natural sweetness which differentiates them
30
. Its
sweeteners, mostly concentrated in the leaves, are
synthesized, at least in the initial stages, using the same
route as the gibberellic acid from the mevalonate
32, 33
.
Stevia has two main glycosides that are stevioside
(110-270 times sweeter than sugar) and rebaudioside
A (180-400 times sweeter than sugar), the last one with
higher comercial valuable
34
, because it shows a nice
flavor profile
35
, unlike artificial sweeteners that have
metallic taste
25
or the same stevioside that has a subtle
bitter flavor
36
. The difference between these glycosides
lies only in the presence of a glucose
37, 38
and its fraction
of weight in the tissues of the plant is 5-10% for
stevioside and 2-4% for rebaudioside A
39-41
. These have
a sweetness of higher quality than the sugar in terms
of smoothness and freshness
42
and tend to produce
an instantaneous sweet taste lower than sucrose, but
159
Contreras S. Anticariogenic properties and effects on periodontal estructures of Stevia rebaudiana Bertoni. Narrative review.
J Oral Res 2013; 2(3): 158-166.
long term
42
.
The full chemical composition of the Stevia is not
available yet
24
, but several of its components have been
described. The fresh leaves contain a high amount of
water (80 to 85%). Aside from the mentioned compo-
nents (glycosides), the leaves contain ascorbic acid, ß-
carotene, chromium, cobalt, magnesium, iron, potassi-
um, phosphorus, riboflavin, thiamin, tin, zinc, among
others. Among the chemicals products found are
apigenin, austroinilina, avicularin, ß-sitosterol, caffeic
acid, campesterol, caryophyllene, centaureidin, chloro-
genic acid, chlorophyll, kaempferol, luteolin, quercetin,
stigmasterol, among others
43
.
It is considered a "noble molecule", because it is
100% natural, has no calories, the leaves can be used
in their natural state and only small quantities are
required
44
. About a quarter of a teaspoon of leaves is
equivalent to one sugar tea spoon
25
.
The dispersion of the Stevia's phenomenon is huge:
It started being cultivated in Japan
30
and today it is
widely used in China, Russia, Korea, Indonesia, Malaysia,
Australia, New Zealand, Singapore, Taiwan, Thailand,
United States. USA, Canada, Europe and South
America
45
among others. The entry into the Chilean
market is recent, in 2009
46
.
Properties.
There is a global consensus of Stevia's advantages
to the human health
47
. In addition to its sweetener
properties, Stevia has important health effects
31
, many
of them detected in animals and in vitro studies. Among
them have been described:
Antihypertensive: Stevia can be considered as an
alternative or complementary therapy for patients with
hypertension
23
. Significant diminishments in systolic
and diastolic pressure have been reported in subject
with mild hypertension
48
. It has been described that
the hypotensor effect of stevioside is due to the inhi-
bition of the influence of calcium from the extra-
celular fluid
49
. Plus, it has been shown that stevioside
and steviol induce diuresis and natriuresis, without a
significant change in glomerular filtration rate or renal
plasma flow
50
. All this. without any adverse effect on
cardiac frequency or the levels of catecholamine in
serum
23
.
Antioxidant: Its use has been associated with an
improvement of the antioxidant defense in the adipose
tissue and the vascular wall, which leads to the inhibition
of the development of the atherosclerotic plaque and
stabilization of the induction plaque
51
.
Anti-tumor y anti-carcinogenic: It has been dem-
onstrated that there are inhibitory effects of extracts
of Stevia's leaf and its polyphenolic constituents, on
promotion and initiation of tumors
52
. This is because
the stevioside has a similar activity to many triterpenoids
in the promotion of 12-O-tetradecanoyl-phorbol-13-
acetate (TPA tumors)
53
. At an experimental level, it
was observed an inhibition of inflammation induced
by TPA in a dose-dependent way
52
, with the significant
inhibition of the mouse skin's carcinogenesis
54
.
Anti-inflamatory and inmunomodulator: It has been
demonstrated that stevioside significantly decreases
the production of TNF-R and IL-1a and slightly
decreases the production of NO in stimulated cells
with LPS and THP-1. It is presented as an immuno-
modulator agent acting through the stimulation of
humoral immunity, phagocytic function and cellular
immunity
55
.
Anti-diarrheal: It has demonstrated to feature anti-
inflammatory effects on epithelial cells from the colon
45
.
Stevioside inhibits the contraction and stimulation of
intestinal smooth muscle, which are linked to the
hypermobility-associated diarrhea
56
. In addition, the
dihydroisosteviol reduces intestinal fluid secretion
23
.
Dihydroisosteviol and similar have been postulated as
a new kind of CFTR inhibitors that may be useful for
the development of antidiarrheal agents
23
.
At brain and psychological level: It keeps the feel
of vitality and wellbeing as well as decreases the desire
of eat sweets and fatty food
25
. Others indicate that its
consumption reduces the desire of tobacco and alco-
holic drinks
25
. It has been observed recently that
stevioside has antiamnesia properties declaring a pre-
servative memory effect in cognitive deficits of rats
57
.
Cicatrizant: Reports indicate that when a few drops
are applied in places where there are cuts and scrapes,
they heal quickly
58
. It is used as a topical wound
dressing
59
, elasticizing of the skin, and to eliminate
blemishes and acne
58
.
Anti-diabetic: Steviol glycosides do not induce a
glycemic response when it is ingested, which makes
them attractive as zero or low-calories natural sweeteners
to diabetics and other people with carbohydrate-
controlled diets
23
. Study’s results demonstrated that the
treatment with Stevia increased the tolerance to glucose
and decreased concentrations of plasmatic glucose
60
.
The evidence suggests that stevioside improves secretion
and sensitivity to insulin
18
. Besides, it generates the
concomitant suppression of glucagon's secretion
18
and
the decline in the renal tubular reabsorption of glucose
50
.
Anti-viral: Stevia has an anti human-rotavirus effect
(HRV)
61
because it inhibits the binding of the antibody
monoclonal anti-VP7 to MA104 cells infected with
HRV
61
.
Anti-bacterial and anti-fungal: It has been found
that inhibitory activity in vitro of extracts from leaves
of Stevia in solvents like water, methanol, ethyl acetate
and hexane against four gram-positive cells (B. subtilis,
160
Contreras S. Anticariogenic properties and effects on periodontal estructures of Stevia rebaudiana Bertoni. Narrative review.
J Oral Res 2013; 2(3): 158-166.
S. aureus, M. letus, B. megaterium), four gram-negative
cells (S. marcensens, P. aeruginosa, E. coli, P. valgaris) and
fungus such as R. oligosporus and A. niger
30
.
This last property in conjunction with the anti-
inflammatory and cicatrizant capacity will give the
starting point to the oral benefits that produces. In this
way, Stevia could become a contributing element in
the treatment of tooth decay and periodontal disease,
both conditions are considered as the most prevalent
diseases generated throughout the stomatognathic
territory.
Anti-cariogenic properties.
Dental caries are considered to be a localized disease
which results from the metabolic processes of the
biomass in contact with the tooth surface, and the diet
provides nutritional requirements and therefore the
energy to the microorganisms of the oral microbiota
30
.
It is believed that the use of substitutes for sucrose
in candy have contributed in part to the decrease in
the prevalence of tooth decay in industrialized
countries
2
. However, researches about the effect on
teeth of the commercial sweeteners currently available,
is rather insufficient
62
. It is important to highlight that,
most of the available research of an anti-caries effect
or not presumptive cariogenic of the sweetener comes
from the pure chemical compound. Information about
the cariogenicity of sweeteners when they are combined
with filling carbohydrates is more limited and may be
important in enamel and dentin caries
62
.
Being the Stevia a sweetener added and investigated
recently, it has been observed that it's not cariogenic
17,
45, 63
. Das et al. did a in vivo study about rats to assess
the cariogenic potential of stevioside and rebaudioside
A with prolonged use. The rats were fed a diet con-
taining 0.5% of stevioside or 0.5% rebaudioside A for
5 weeks. Neither of these compounds showed the
potential to increase the risk of the development of
dental caries
63
.
Since the first signs of its anti-cariogenic properties
until today, several studies have been done. These
studies confirms this property and describes the mech-
anisms of how this happen. In general, it is possible
to group these mechanisms into three groups:
1° Antibacterial effect on microorganisms associated
to the production of teeth decay: The complexity of
the bacterial community found on the surfaces of the
teeth makes difficult to associate specific groups of
bacteria as the cause of teeth decay. However, Strepto-
coccus mutans and Lactobacillus acidophillus are found in
almost all tooth decay lesions, and their proportion in
the plaque and saliva is positively related to the frequency
and activity of tooth decay
64
. It is also known that the
Streptococcus sobrinus is involved in the development of
tooth decay
65
.
The in vitro effect was observed in extracts of Stevia
in different solvents on Streptococcus mutans using tetra-
cycline 1% as a positive control. The extracts of Stevia
in acetone, ethanol and methanol had a dose-dependent
anti-bacterial activity, being the two first the ones that
present the largest inhibition zone against that bacterium
reaching values of 28.7 mm (acetone) and 27.0 mm
(ethanol), both in a 100 mg/ml concentration, compared
to the positive control which had an inhibition zone
of 10 mm
28
.
Buitrago et al. evaluated the antimicrobial effect of
Stevia extracts in methanol and concluded that con-
centrations starting from 200 mg/ml lead to an inhib-
itory effect on Streptococcus mutans
66
.
In experiments of tooth decay in rats, significant
differences were found in the count of sulcal caries
and Streptococcus sobrinus between the group of sucrose
and the group of Stevia sweeteners. There were no
significant differences between stevioside and rebaudi-
oside A. The study came to the conclusion that neither
of them is cariogenic
63
.
Noting the in vitro effect of the extracts of Stevia
to 20% on Streptococcus sobrinus it registered an inhibition
in the growth rate (50% inhibition) and a diminishment
in the production rate of the acid of the bacteria. It
was concluded that Stevia extract had an inhibitory
effect on the caries-producing properties of Streptococcus
sobrinus
67
.
It was found that Streptococcus mutans experiments
higher growth suppression when it is grown in mediums
that contain stevioside, than when it’s grown in mediums
with sucrose, glucose or fructose
68
.
In an in vitro study, Vitery et al. compared the effect
of different concentrations of Stevia extracts, in water,
methanol, ethanol, hexane and ethyl acetate, on strains
of Streptococcus mutans and Lactobacillus acidophilus using
vancomycin as positive control. The Stevia extract that
showed the best results in the inhibition of growth,
both for Streptococcus mutans and Lactobacillus acidophilus,
was the hexanoic, in which after 48 hours, inhibition
halos were formed with an average of 14.5 mm with
Streptococcus mutans and 15.5 mm of Lactobacillus acidophilus
at a concentration of 50 mg/ml. The other solvents
also show activity against the studied bacteria, it is clear
that to achieve this, it was necessary to increase the
concentrations. This study verifies the antibacterial
activity of Stevia, against Streptococcus mutans and Lacto-
bacillus acidophilus
30
.
This study is matches the one made by Gamboa et
al. where it evaluated the antibacterial effect of extracts
from leaves of Stevia in hexane, methanol, ethanol,
ethyl acetate and chloroform on 12 strains of strepto-
coccus (including Streptococcus mutans) and 4 strains of
161
Contreras S. Anticariogenic properties and effects on periodontal estructures of Stevia rebaudiana Bertoni. Narrative review.
J Oral Res 2013; 2(3): 158-166.
lactobacillus (including Lactobacillus acidophilus), using
vancomycin as positive control (180 µg\/ml) and
azithromycin (150 µg/ml) which managed inhibition
zones with values between 18 mm and 25 mm. The
zones of inhibition produced by the 5 extracts in the
minimum inhibitory concentration (MIC) for the 16
strains were variable, with figures ranging from 9 mm
to 17.3 mm. The best performance was found for the
hexanoic extract whose MIC was 30 mg/ml, which
had similar values to the one achieved with ethanol
and methanol (MIC = 120 mg/ml)
69
.
Giacaman et al. with an experimental work with
commercial sweeteners and its cariogenic potential,
observed that Stevia, sucralose and saccharin leave
significantly less viable cells (Streptococcus mutans) in
biofilms if they are compared with other sweeteners
with similar counts than the negative control (NaCl).
Plus, Stevia and sucralose have tendency to induce less
biomass
62
.
2° Low acidogen potential: Sucrose is easily metab-
olized by oral bacteria, that are found in the dental
plaque and the result is the release of acids. These
acids are responsible for the demineralization of dental
tissues in the dynamic process of caries
70
.
In an in vivo study was evaluated the cariogenic
potential of rebaudioside A. In which It was com-
pared the effect on the pH of a solution of rebau-
dioside A and sucrose, both with 4.7%. The rinse
with Rebaudioside A showed a minimum pH of
6.92, which was significantly higher than the sucrose
5.62, verifying a low acidogenic potential and com-
plying with the criteria established by the FDA for
a not cariogenic sweetener
71
.
Giacaman et al. also noted that saccharin, Stevia
and sucralose induced a significantly lower acidogenicity
throughout the entire experiment. Regarding enamel
demineralization, all the tested sweeteners, including
Stevia, showed a statistically significant lower percentage
of loss of surface hardness compared to the positive
control, sucrose.
It has seen that Streptococcus mutans generates a
lower production of acid when are grown on medium
that contain Stevioside in comparation with the ones
that are grown in sucrose, glucose or fructose
68
.
3° Anti-plaque effect: Most of the diseases in the
mouth begin with the formation of dental plaque
14
,
which are complex structures that are associated to
similar microorganisms and different bacterial species
72
.
In an in vivo research it was measured the accumu-
lation of dental plaque after mouthwashes with a
solution of sucrose and one of Stevia for 5 days. The
accumulation of plaque after the mouthwashes with
Stevia was 57.82% less than with the sucrose mouth-
washes when it was measured with the Silness - Lo
index and 10.40% less when it was measured with the
O'Leary index
14
.
In two in vitro experiments which aimed to register
the inhibitory effect of Stevia extracts to 10% and 20%
of Streptococcus sobrinus, it was noted a decrease in the
hydrophobicity of the surface, the inhibition of the
extracellular polysaccharides production and the adhe-
sion of bacteria to the plaques coated with saliva
67, 73
.
Giacaman et al. also revealed a decrease in the
production of intra-cellular polysaccharides (IPS) and
extra-cellular polysaccharides (EPS) in statistically
significant numbers, by Streptococcus mutans.
The EPS are responsible for 40% of the compo-
sition of the dental biofilm, and are one of the main
virulence factors of the bacterial consortium, as
they enable the adhesion of the bacterial cell to the
acquired film, they are used as scaffolding for the
maturation of biofilm and increase the porosity of
the structure allowing the diffusion of sugar within
the biofilm
74
.
Possible explanations for these properties are
based on its contents. This plant is rich in flavonoids
and terpenes. The phytochemicals present in Stevia
are austroinullin, ß-carotene, dulcoside, niacin, oxides
rebaudi, riboflavin, steviol, stevioside and thiamine
75
.
These nutritious substances affect the microbial
flora of the mouth
76
, and also, the content of tannin,
xanthines (theobromine and caffeine) and flavonoids
have anti-plaque
70
activity. In addition, the leaf
extracts of Stevia and its major polyphenolic con-
stituents, stevioside and rebaudioside A, are not
cariogenics
18
. Stevioside has a slight effect on the
enzymes that are responsible for the decomposition
of sugars, a discreet inactivation of the dextran-
sucrase and a light static-effect on the cariogenics
bacteria
77
.
Findings on Stevia rebaudiana bertoni utility
at periodontal level.
The chronic marginal periodontitis and gingivitis
are diseases that affect the periodontium of protection
and/or insertion. The presence of bacterial plaque is
relevant within its etiology. These oral pathologies
acquire significance at level of general health and vice
versa. In recent years, it is known that the condition
of oral hygiene is associated with chronic diseases: the
periodontopathies are considered as a risk factor for
heart diseases
78
. At the same time, a high amount of
evidence suggests that diabetes is associated with an
increase in prevalence, extension, and severity of
gingivitis and periodontitis
79
. There is a constant feed-
back between the mouth and the rest of the body.
162
Contreras S. Anticariogenic properties and effects on periodontal estructures of Stevia rebaudiana Bertoni. Narrative review.
J Oral Res 2013; 2(3): 158-166.
Gingivitis is the inflammation of the gums as a
result of the activity of bacteria located at the height
of the gingival margin and is considered to be the most
common form of periodontal disease. Clinical signs
of inflammation, including changes in the outline,
color and consistency of the gum, are associated with
a tissue of stable inclusion level
80
.
Stevia ability to inhibit the growth of certain bacteria
helps to explain the traditional use in the treatment of
wounds, sores and gum disease
81
, besides this contributes
its anti-inflammatory effect and antiplaque
82
.
De Slavutzky in his study of the effect about the
formation of bacterial plaque, owing to sucrose and
Stevia, managed to observe a significant reduction of
biofilm in patients who used a mouthwash with Stevia.
In this study, they conclude that this natural sweetener
can act as an anti-cariogenic and anti-gingivitis product
14
.
Chronic marginal periodontitis is an infectious
disease that leads to a slow and progressive loss of the
union of the teeth. Within the signs and characteristic
symptoms of the disease we can find clinical insertion
loss, loss of alveolar bone, periodontal pockets and
gingival inflammation
80
.
Within the many benefits that describe the Stevia
there is also healing property, to complement the
existing procedures of scraping, smoothing and peri-
odontal surgery, to improve the oral health of people
with periodontal disease
58
.
The effects of extracts of Stevia in periodontal
disease were observed in an experimental study on
dogs. It showed a significant reduction in the rate of
gingival hemorrhage that initially ranged from 65% to
80% and after the treatment was reduced from 12%
to 10%. It was reduced significantly reduced the depth
of the periodontal pockets reaching differences of 4
mm. It decreased the gingival inflammation of 66%
to 33%. At histological level significant improvements
were shown where chronic inflammation is confined
to the basal lamina and there is presence of squamous
epithelium stratified with hyperplasia in postsurgical
biopsy. In control cases there were no significant
improvements
58
.
Metabolism and toxicity.
Recent studies have shown that a portion of stevi-
oside is absorbed and degraded to steviol, which seems
to undergo an additional metabolism
83
. Other studies
indicate that none of the digestive enzymes in the
gastrointestinal tract of different animals and the man
are able to degrading stevioside in steviol
84, 85
. It is
established that eventually is excreted by renal and
biliary system
86
.
There are no reports in the medical literature of
any adverse effects by using Stevia, because it is recog-
nized that it has a wide margin of safety
30
. One of the
most obvious indicators of safety from Stevia is that
there is no adverse effect reported in more than 1500
years of continuous use by the Paraguayans
87
. About
1000 tons of Stevia extract are consumed in Japan,
and at the moment there haven't been reported toxic
effects by the Japanese Food and Drug Safety Center.
This fact has taken on vital importance due to the
comments arised from the use of other synthetic
sweeteners such as aspartame, which initially would
not have the same safety margin
88
.
In September, 1995 the U.S. Food & Drug Admin-
istration (FDA) approved Stevia as a dietary
complement
30
. It was recently approved for its com-
mercial use by Joint Food and Agriculture Organization
(World Health Organization Expert Committee on
Food Additives, 2005) and more recently the approval
of generally recognized as safe (GRAS) of the Food
& Drug Administration
89
.
The Joint FAO/WHO Expert Committee on Food
Additives (JECFA) at their 68
th
and 69
th
meetings in
2008, established an admissible daily intake (IDA) for
steviol glycosides of 0-4 mg per kg of body weight
per day, expressed as steviol
89
, additionally available
data support the conclusion that the daily human intake
of 5 mg to 6 mg of leaf of Stevia's extract as a dietary
sweetener per kg of body weight is safe
90
.
The 70% of world production is used for processing
crystals of stevioside, while 30% is earmarked for
herbal uses
91
. Glycosides are sold in its natural form
as dry leaves (6-15% of glycosides), and processed, in
the form of extracts (liquid or powder) and combina-
tions in tablets, whose concentrations of glycosides
vary according to the manufacturer in a range that goes
from 7%
92
to 97% glycoside content
91
.
Future of Stevia in Dentistry.
The application of Stevia in the dental treatment
is a barely explored field. In order to materialize their
contribution to this area, further studies are needed
on the isolation, characterization and identification of
substances present in the extracts
69
. It has to be found
the solvent that achieve the best use of the active
components of this plant and make it biocompatible;
the concentration has to be selected to suits the stan-
dards of acceptable daily intake and make it effective
at the same time, and has to be found a mean of
administration considering the time spent at the site
of action so that the active compound will achieve the
desired effect.
The massification of Stevia in the food industry
and as a sweetener, enhances the importance of inves-
tigating its effectiveness in combination with other
substances (other sweeteners and filler items), which
163
Contreras S. Anticariogenic properties and effects on periodontal estructures of Stevia rebaudiana Bertoni. Narrative review.
J Oral Res 2013; 2(3): 158-166.
is the form that is delivered to the public in the majority
of commercial shapes.
Conclusion.
The research about Stevia have left in manifest a
potential anti-cariogenic and anti-periodontopathic
role, result of its ability to reduce the bacterial load,
the formation of biofilm, avoiding high pH decreases,
and acting as an anti-inflammatory and healing agent
at the periodontium level.
The evidence regarding a possible anti-cariogenic
role is used as a base to support future research,
especially randomized controlled clinical trials of which
there is no constancy. Studies about a possible anti-
periodontophatic role are insufficient to assert benefits
in humans, but the research lines are promising and
thus, in vivo and in vitro studies become necessaries to
continue investigating about this property.
If deeper studies are done regarding this subject,
Stevia rebaudiana Bertoni could become a complement
to oral care used in the form of mouthwashes, tooth-
pastes, chewing gum, artificial saliva, chewable tablets,
among others, being especially beneficial in patients
with obesity, diabetes and hypertension.
164
Contreras S. Anticariogenic properties and effects on periodontal estructures of Stevia rebaudiana Bertoni. Narrative review.
J Oral Res 2013; 2(3): 158-166.
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