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9Dental Tribune Middle East & Africa Edition | September - October 2013 oral HYGiene ies showed effects on inflammatory parameters, such as bleeding score or gingival index.29, 30 A recent system- atic review concluded that chewing sugar-free gum provides a small but significant reduction in plaque scores when used as an adjunct to normal plaque control measures.32 Therefore, any claims regarding effects of sugar- free gum without actives on plaque should be interpreted only as a poten- tial adjunctive effect, not intended to substitute chewing gum as an alterna- tive to regular brushing and flossing. active agents for remineralisation/ caries There have been many attempts to improve the inherent remineralising effect of chewing gum-stimulated sa- liva through the addition of specific active ingredients. See an overview of some of these actives below. specific polyol effects Sugar-free gums are usually sweet- ened with polyol (sugar alcohol) sweeteners, such as sorbitol, man- nitol, xylitol, or maltitol. These poly- ols have all been certified as safe for teeth by appropriate plaque pH test- ing; thus, while their inherent sweet- ness helps stimulate saliva, their rate of metabolism and acid production by the oral (plaque) bacteria is slow and does not cause an effective drop in the plaque pH, so the net effect is an increase in the plaque pH. There has been considerable research to test whether certain polyols show supe- rior efficacy, but a recent systematic review23 stated it was not possible to distinguish between benefits derived from chewing versus those associated with specific polyol effects. calcium and Phosphate salts Other approaches to improving the inherent anti-caries effect of sugar free gums have focused on the use of suitable calcium or calcium phos- phate salts to supplement the natu- ral calcium and phosphate levels of saliva, raising the level of saturation of the immediate tooth environ- ment with respect to these ions to aid remineralisation.33, 34 Calcium lactate added to chewing gum has also been shown to provide an enhanced rem- ineralisation benefit.35, 36 Potential negative effects of chew- ing gum It is worth acknowledging that there are some concerns over chewing gum use, including its potential to be a choking hazard in young children, be subject to littering, and exert a laxative effect. Consumers should be reminded not to give gum to chil- dren younger than school age and to dispose of chewed gum responsibly. The laxative threshold of most polyol sweeteners used in gum is typically more than 15 g/day, which would require consumption of 10 or more sticks of chewing gum per day to achieve. conclusion The scientific evidence supporting the non-specific benefits of chewing sugar-free gum has been reviewed and endorsed by key dental organi- zations across the globe including FDI (World Dental Federation), the ADA (American Dental Association) and the EFSA (European Food Safety Authority). Traditionally, preven- tive dentistry has focused on sugar restriction, plaque removal/oral hy- giene, fluoride usage, fissure sealants and education. More recently, these approaches have been modified by improved diagnostic methods to al- low early identification of disease, together with an accurate assess- ment of disease activity. There is an opportunity for chewing gum to be considered as another preventive mo- dality to provide an additional layer of prevention by helping maintain the oral ecology in high and lower risk individuals and populations. Whilst it is not the intention of this article to provide clinical guidelines for the use of sugar-free chewing gum, the aim is to inform practitioners so they can accurately answer his or her patients’ questions regarding this topic and be able to provide appropriate guidance about chewing sugar-free gum and it’s oral health benefits when used as a complement to usual oral care regimens. While chewing gum may not be a treatment for oral diseases, by helping generate a healthy flow of saliva, it may help offset the perturba- tions in the oral ecology that lead to clinical disease states. references 1. Burt BA. The use of sorbitol- and xylitol-sweetened chewing gum in caries control. J Am Dent Assoc. 2006 Feb;137(2):190-6. 2. Deshpande A, Jadad AR. The impact of polyol-containing chewing gums on dental caries: a systematic review of original randomized controlled trials and observational studies. J Am Dent Assoc. 2008 Dec;139(12):1602-14. 3. Edgar WM. Sugar substitutes, chew- ing gum and dental caries--a review. Br Dent J. 1998 Jan 10;184(1):29-32. 4. Imfeld T. Chewing gum--facts and fiction: a review of gum-chewing and oral health. Crit Rev Oral Biol Med. 1999;10(3):405-19. 5. Mickenautsch S, Leal SC, Yengopal V, Bezerra AC, Cruvinel V. Sugar-free chewing gum and dental caries: a sys- tematic review. J Appl Oral Sci. 2007 Apr;15(2):83-8. 6. Twetman S. Consistent evidence to support the use of xylitol- and sorb- itol-containing chewing gum to pre- vent dental caries. Evid Based Dent. 2009;10(1):10-1. 7. Dawes C, Macpherson LM. Effects of nine different chewing-gums and lozenges on salivary flow rate and pH. Caries Res. 1992;26(3):176-82. 8. Dawes C, Kubieniec K. The effects of prolonged gum chewing on salivary flow rate and composition. Arch Oral Biol. 2004 Aug;49(8):665-9. 9. Fu Y, Li X, Ma H, Yin W, Que K, Hu D, Dodds MWJ, Tian M. Assess- ment of chewing sugar-free gums for oral debris reduction: a randomized controlled crossover clinical trial. Am J Dent. 2012;25(2):118-22. 10. Manning RH, Edgar WM. pH changes in plaque after eating snacks and meals, and their modification by chewing sugared- or sugar-free gum. Br Dent J. 1993 Apr 10;174(7):241-4. 11. Park KK, Schemehorn BR, Bolton JW, Stookey GK. Effect of sorbitol gum chewing on plaque pH response after ingesting snacks containing predomi- nantly sucrose or starch. Am J Dent. 1990 Oct;3(5):185-91. 12. Dodds MWJ, Hsieh SC, Johnson DA. The effect of increased mastica- tion by daily gum-chewing on sali- vary gland output and dental plaque acidogenicity. J Dent Res. 1991 Dec;70(12):1474-8. 13. Jenkins GN, Edgar WM. The ef- fect of daily gum-chewing on salivary flow rates in man. J Dent Res. 1989 May;68(5):786-90. 14. Bots CP, Brand HS, Veerman EC, Valentijn-Benz M, Van Amerongen BM, Nieuw Amerongen AV, Valen- tijn RM, Vos PF, Bijlsma JA, Bezemer PD, ter Wee PM. The management of xerostomia in patients on haemodi- alysis: comparison of artificial saliva and chewing gum. Palliat Med. 2005 Apr;19(3):202-7. 15. Davies AN. A comparison of ar- tificial saliva and chewing gum in the management of xerostomia in patients with advanced cancer. Palliat Med. 2000 May;14(3):197-203. 16. Creanor SL, Strang R, Gilmour WH, Foye RH, Brown J, Geddes DA, Hall AF. The effect of chew- ing gum use on in situ enamel lesion remineralization. J Dent Res. 1992 Dec;71(12):1895-900. Full list of references is available from the author. www.wrigleyoralcare.com