Article: A practical guide on talking to patients about sugarfree gum

This article was previously published in a supplement for Dentistry magazine in the UK.

To chew or not to chew? Is chewing gum the dental patient’s friend or foe? Simon M Roland BDS LDSRCS investigates

How to describe to our patients how sugarfree gum works. It is really all about saliva.

• Firstly it increases saliva flow by up to 10 times. This stimulated saliva can more readily get to work washing away food debris. The bicarbonate from this stimulated saliva is much more effective than resting saliva at neutralising the acid produced by plaque bacteria.
• The increased saliva flow substantially enhances the remineralisation process. What the plaque acids take out, the extra saliva puts back.
• It is important to chew the gum immediately and for 20 minutes after sugary meals, as the pH drops quite rapidly and remains low for some time. The chewing action stimulates far more saliva, which rapidly brings the pH levels back up to normal levels. Indeed chewing other products such as peanuts or cheese can achieve the same results but could lead to an unacceptable increase in dietary fat. Sugarfree gum has virtually no calories and no fat, and is therefore far more acceptable from a nutritional standpoint.
• Xerostomia, (dry mouth) is a common side effect with many medications from beta blockers to antidepressants, as well as in sufferers of Sjögren’s syndrome and following radiotherapy of the head and neck region. Stimulating the remaining or underperforming salivary tissues to pump out what saliva they can is achieved by chewing sugarfree gum. As a result, coupled with a rigorous oral hygiene programme, a much more palatable and comfortable mouth with reduced risks of caries can be attained.

There are those who have concerns over of any sort of chewing gum. The questions that may be asked include:

• Can swallowing gum be dangerous, as our grandmothers always warned? Gum is basically roughage with flavouring agents and passes through the gut as does any other roughage. It is important not to choke on gum or inhale it accidentally, and therefore should be limited to over six-year-olds and avoided during vigorous physical or contact sports.
• Does it cause ulcers by over-stimulating stomach acid production? Stomach acid is stimulated by a food bolus in the mouth and not by the chewing process itself. In fact, the additional bicarbonate produced by stimulated saliva helps neutralise acid production. Patients with existing ulcers appear to be able to chew gum without any exacerbation of their problem.
• How do you stop people littering the environment with spent gum? The message is simple: put your gum in the bin when you have finished with it.
• Does chewing gum cause TMD (temporomandibular disorders)? There is no scientific evidence to show that it does but it may be that with an existing TMD it is best to limit any jaw habit that might stress or perpetuate the muscular or joint dysfunction.
• Are there psychological effects from chewing gum? There is evidence that regional blood flow in the brain is increased and brain bio-electrical activity is influenced by chewing gum. Studies have shown that this can result in an increase in perceived relaxation and a reduction in stress.
• Why do people who give up smoking end up chewing gum incessantly? Chewing gum is an excellent mechanism for assisting smoking cessation either as a distraction or as a form of oral gratification without a negative dietary effect and as a vehicle for nicotine substitutive remedies.

It is now pretty much beyond question that chewing sugarfree gum is beneficial to dental health.

Numerous studies have shown the therapeutic use of sugarfree gum, such as Wrigley’s ORBIT, in caries prevention, as well as in patients with dry mouth and in stain reduction. I have referred to and referenced a small selection below.

The advice we give to our patients is so much more powerful when it is evidence-based rather than anecdotal. As professionals and clinicians, we should be aware of the scientific research that gives credence to the day-to-day information that we impart to our patients. Without wishing to blind them with science or, for that matter, bore them to insensibility, it can be very effective to give some meat to the expressions: ‘it is a well known fact…’ or ‘scientific studies have shown…’.

Published studies

A recently published study by Szoke, Banoczy and Proskin (2001) showed reductions of 40% in dental caries in a Hungarian population of medium to low-risk school children who chewed gum for 20 minutes after meals.

Very much higher risk children in sugar cane rich Belize were the subjects in Makinen et al’s studies (1995) where chewing various chewing gums after meals produced highly statistically significant results of up to a 73% reduction in the risk of developing caries with regular chewing of a xylitol-containing gum. In this study, not only were there substantial reductions in the numbers of carious lesions apparent over a number of years, they showed there was also a positive remineralisation of existing lesions when the artificial sweetener xylitol was incorporated into the gum.

Edgar (1990) has shown that it is the sugarfree gum causing increased stimulation of saliva with its myriad of beneficial actions that is causing the therapeutic effects. One might say that nature intended us to lick our wounds with very good reason.

Yankell and Emling’s (1997) study showed that chewing sugarfree gum helped to reduce the superficial staining when tested in patients using chlorhexidine mouthwash.

Communicating with confidence

With this evidence to hand, we have the ammunition to tell our patients with confidence that the use of Wrigley’s ORBIT sugarfree gum as part of routine oral hygiene programmes is backed up by scientific research. In addition, because of the very strong evidence, we should be specifically prescribing sugarfree gum as a therapeutic measure to any patient with active carious lesions.

Similarly, any patient suffering from dry mouth caused by drug therapy, radiation damage, Sjögren’s syndrome or other causes should be prescribed sugarfree gum as a major part of their treatment to try to alleviate what can be a very distressing condition.

Focus on prescribing

It is the concept of prescribing on which we should focus.

The power of the prescription is a very potent tool in our professional armamentarium. Patients are always seeking a magic pill for their medical needs and there is a psychological boost when a specific course of action is advised by a trusted professional rather than gleaned from an impersonal advertisement, read in a magazine or by anecdotal recommendations from friends or family.

Of course the placebo effect is extremely powerful and not to be taken lightly, but also very potent is a clinician’s prescription, preferably supported by evidence. This evidence, when presented to the patient in a clear, concise and user-friendly way, demonstrates to the patient that the efficacy of the therapy is completely accepted by authoritative dental bodies; as a result the patient’s compliance will be significantly improved.

References

Edgar WM(1990) Chewing gum and dental health – a  review. Br Dent. J. Oral Biology: 173-177

Makinen KK, Bennett CA, Hujoel PP, Isokangas PJ, Isotupa KP, Pape HR, Makinen PJ (1995) Xylitol chewing gums and caries rates: a 40-month cohort study. J Dent Res 74(12): 1904-13

Szoke J, Banoczy J, Prodkin HM (2001) Effect of after-meal sucrose-free gum chewing on clinical caries. J Dent Res 80(8): 1725-1729

Yankell SL, Emling RC (1997) J Clin Dent 8: 169-172