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36 Dental Tribune Middle East & Africa Edition | February 2015ORAL HEALTH By Michael WJ Dodds, BDS, PhD,Wm.WrigleyJr.Company Excerpt from paper originally published in the Journal of the Irish Dental Association T he use of sugar-free gum provides a proven anti- caries benefit, but other oral health effects are less clear- ly elucidated. Oral health, par- ticularly caries-reducing, bene- fits of sugar-free chewing gums have been well documented in many studies and reviews.1-6 In addition, chewing gum is in- creasingly being viewed as a delivery system for active agents that could potentially provide direct oral care benefits. Chew- ing sugar-free chewing gum promotes a strong flow of stimu- lated saliva, which helps provide a number of dental benefits: • the higher flow rate promotes more rapid oral clearance of sugars; • the high pH and buffering ca- pacity of the stimulated saliva help neutralise plaque pH after a sugar challenge; • studies have shown enhanced remineralisation of early car- ies-like lesions and ultimately prospective clinical trials have shown reduced caries incidence in children chewing sugar-free gum. Scientific evidence shows that chewing gum has a place as an additional mode of dental dis- ease prevention to be used in conjunction with the more tradi- tional preventive methods. Benefits of chewing sugar-free gum Oral clearance and saliva stim- ulation, plaque pH neutralisa- tion The major benefits of sugar- free chewing gum are mediated through oral physiology: stimu- lation of the salivary glands to produce a strong flow of saliva (a 10-12 fold increase over un- stimulated saliva) is elicited by a combination of masticatory and gustatory stimuli.7 Although sali- va flow rates are highest during the first five to seven minutes of chewing, when the sweeten- ers and flavour release is maxi- mal, a two-fold increase in flow rate (over unstimulated flow) is maintained for as long as the gum continues to be chewed.8 One of the immediate short- term effects of this enhanced sa- liva flow is the increased clear- ance of sugars and food debris from the oral cavity.9 The higher flow rate, pH and buffer capac- ity of stimulated saliva further help neutralise acids found in the mouth, and in particular help raise the plaque pH.10,11 The short-term neutralisation of plaque pH out of the deminerali- sation danger zone can also be supplemented by medium-term benefits, as it has been shown that frequent chewing increases baseline (unstimulated) saliva flow rate and increases the rest- ing plaque pH and subsequent ability of the plaque to form acid from sugar.12, 13 Some stud- ies have suggested that chew- ing gum is better tolerated than artificial saliva for symptomatic relief of xerostomia.14, 15 Remineralisation and clinical caries reductions In addition to the pH neutralis- ing effect, the increased rate of delivery of soluble calcium and phosphate ions from the stimu- lated saliva helps to remineral- ise surface enamel lesions, as shown in a number of in situ remineralisation studies.16-19 Clinical studies conducted in children who chewed gum at least three times daily for two or three years show that they have significantly lower rates of decay than children who do not chew gum.20-22 Furthermore, these caries-reducing effects have been confirmed by systematic reviews.2, 5, 23 Indeed, the Ameri- can Dental Association has re- cently provided clinical guide- lines for the use of sucrose-free polyol chewing gums in high caries-risk children and adults.23 Extrinsic stain reduction Chewing gum can reduce ex- trinsic tooth stain, either by re- moving existing stain or inhib- iting its formation,24 whilst the addition of specific active agents (typically polyphosphates) may provide additional efficacy.25, 26 However, it should be noted that these types of claims are cos- metic and do not directly affect oral health, and the magnitude of the effect is small compared to bleaching therapies. On the oth- er hand, accelerated oral clear- ance of staining agents such as tea or coffee, by chewing gum stimulated saliva could conceiv- ably reduce the formation of ex- trinsic stain over time and help prolong the benefits of a dental prophylaxis. Interestingly, chew- ing gum has been found to coun- teract the short-term sensitivity associated with professionally- applied bleaching treatments,27 although the mechanism of this effect is not clear. Effects on plaque and gingivitis There is evidence that regular use of chewing gum, in con- junction with normal oral hy- giene procedures, provides a slight, but significant, reduction in plaque scores,28-30 although one other study did not show this effect.31 In addition, two of these studies showed effects on inflammatory parameters, such as bleeding score or gingival index.29, 30 A recent systematic review concluded that chew- ing 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 potential adjunctive ef- fect, not intended to substitute chewing gum as an alternative to regular brushing and flossing. Active agents for remineralisa- tion/caries There have been many attempts to improve the inherent remin- eralising effect of chewing gum- stimulated saliva through the addition of specific active ingre- dients. See an overview of some of these actives below. Specific polyol effects Sugar-free gums are usually sweetened with polyol (sugar alcohol) sweeteners, such as sorbitol, mannitol, xylitol, or maltitol. These polyols have all been certified as safe for teeth by appropriate plaque pH test- ing; thus, while their inherent sweetness 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 superior efficacy, but a re- cent 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 phosphate salts to sup- plement the natural calcium and phosphate levels of saliva, rais- ing the level of saturation of the immediate tooth environment with respect to these ions to aid Oral health benefits of chewing gum > Page 37 For more information contact your local dealer website: www.acesurgical.com • email: info@acesurgical.com A COMPLETE DENTAL SOLUTION Infinity Implants from ACE Surgical deliver a truly compatible dental implant solution at a price that makes sense for your practice. 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