Does chewing gum reduce orthodontic pain?

Does chewing gum reduce orthodontic pain?

One of the most common side-effect of orthodontic treatment is pain immediately following the placement or adjustment of appliances. This  affects 70- 95% of children at frequent time periods during their orthodontic treatment. If there was a method of reducing this pain without taking analgesics, I am sure that this would be of great benefit to our patients. Some people have suggested that chewing gum may help. This new trial has looked at the effect of chewing gum on orthodontic pain.

A team based in the South West of England (where the sun always shines) did this study. It was recently published in the AJO-DDO.

bracespainComparative assessment of chewing gum and ibuprofen in the management of orthodontic pain with fixed appliances: A pragmatic multicenter randomized controlled trial
Ireland A et al
Am J Orthod Dentofacial Orthop 2016;150:220-7

http://dx.doi.org/10.1016/j.ajodo.2016.02.018

They wrote a really nice introduction on orthodontic pain and its management and highlighted that largely anecdotal evidence has suggested that chewing gum may provide some pain relief and reduce the need for analgesics. They also mentioned that the results of two small randomised trials that concluded that chewing gum reduces both pain and analgesic consumption.

Their study was a larger trial to investigate the effect of using a sugar-free chewing gum on reported pain and analgesic intake.

What did they do?

This was a prospective multicentre randomised controlled trial  carried out in nine orthodontic departments in the South-West of England. The primary outcome measure was pain experienced on the day of appliance placement and the secondary outcomes were pain experienced in the subsequent three days and after the first arch wire change.

They enrolled 1000 consecutive patients, aged between 11 and 17 years, who were about to have upper and lower fixed appliances placed. Each patient was randomly allocated to either the experimental group (chewing gum) or to the control group (ibuprofen analgesics)

They asked the children who were allocated the chewing gum to use the gum for pain relief, if required, after the fitting of their appliances. There also told them that they could take ibuprofen for pain relief if the chewing gum did not work.

In the control group the patients were given Ibuprofen and they asked them to use it for pain relief.

Each group of patients recorded their experience of using a standardised questionnaire. They recorded this information at the following points;

  • 2 hours after appliance placement
  • 6 hours after placement
  • bedtime on the day of the appointments
  • bedtime two days after the appointment
  • 3 days after the appointment

At the next routine appointment when they changed the arch wire, reinforced the same analgesic regime and asked them to complete another pain questionnaire. They also recorded appliance breakages.

The sample size calculation randomisation, concealment and relevant blinding was good.

They analysed the data using an intention-to-treat principle.  They imputed missing data and analysed it with complex and appropriate statistical analysis.

What did they find?

They wrote a detailed data and statistical analysis. They interpreted the data very clearly and they found that;

  • There was no difference in pain between the chewing gum and analgesic group.
  • When they looked at analgesic use they found that the chewing gum group used less analgesics than the control group. 82% of the patients in the chewing gum group and 91% in the control group used analgesics after the bond up. After the follow-up visit these figures were 42% and 60% respectively.
  • Interestingly they showed that there was no difference between the groups in appliance breakages. For example, following bond up, 7% of the chewing group and 8% of the ibuprofen group broke their appliance.

Screen Shot 2016-08-19 at 11.43.37

What did I think?

I thought that this was a really good, well-managed, large-scale study that provided us with useful clinical information. The major strengths was the large sample size and its multi-centre nature with all types of orthodontic treatment being included. This means that the findings are generalisable to most orthodontic practice.

It was also very interesting that the results did not agree with the findings of two smaller trials which concluded that chewing gum reduced pain in orthodontic patients. This was a great illustration of how the findings from larger studies may be more likely to identify the true effects of an intervention, rather than a small study.

One concern that we may have with their findings  is that there was a risk of “cross contamination” between the two groups. For example, those in the analgesic group may have used chewing gum. I do not feel that this is a problem, as this simply reflects the “real world” setting of the study.

As with all trials, I have to consider whether this influences my practice. I think it is important to attempt to reduce analgesic consumption and as the use of chewing gum did not increase appliance breakages, I am going to recommend the use of chewing gum to my patients.

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  1. Many years ago we did a similar pilot study with same results. No difference in pain nor appliance breakage. However we did find increased rate of tooth movement in the chewing gum group. We hypothesized that the “jiggling” effect of the gum chewing decreased friction and pertebation between arch wires and brackets.

  2. Thanks Kevin, reading above provokes 2 questions. 1. was the study sponsored by a gum company? (even so, you say well blinded so hope no bias if it was) 2. as you state that you will be recommending chewing gum to your patients; will you explain to them the possible physiologic mechanisms behind the pain reduction? (..If you believe the analgesia to be assisted via increased blow flow within the periodontal ligament, would you be obligated to similarly condone the use of commercially available dental vibratory devices to the same end?) FYI I don’t use them for analgesia or any other purported advantage! Just wondering. VV

  3. Interesting. I ban chewing gum in my patients to reduce archwire distortion which I find can occur especially in small diamter niti, though I’ve no evidence chewy foods/gum is the cause. It might take a lot more to make me change advice I’ve been giving for 14 years!

  4. Kevin, I wrote to the authors of this paper that I enjoyed reading it, but they were 32 years late with their study. A pioneering
    study was published in the J. Clinical Orthodontics XVIII No. 8 August 1984 pp 572-574. You can also find it on my website
    under articles, and you will need the password and user name to access it. They are the same orthotx

  5. Kevin,
    Thanks as always for your efforts in keeping the orthodontic profession focused

    I was confused with the following statement in the “What did I think?” summary of the study. It reads, “It was also very interesting that the results did not agree with the findings of two smaller trials which concluded that chewing gum reduced pain in orthodontic patients.” It seems to me that the authors of this current study did conclude that chewing gum, (with analgesics), did reduce pain in orthodontic patients, even though there was not a significant difference compared with the analgesic group. Perhaps the two studies mentioned earlier only compared chewing gum to a no pain intervention control?

    I must be missing something. Show me the light!

  6. Kevin,

    I think this a really interesting piece of work; however when you state that the ‘results did not agree with the findings of two smaller trials’ I beg to differ (but I think you are used to people disagreeing with you by now). I presume you are referring to our study published in 2012 (Benson PE et al. The effect of chewing gum on the impact, pain and breakages associated with fixed orthodontic appliances: a randomized clinical trial Orthod Craniofac Res 2012;15:178–187). Firstly, we used a different primary outcome measure, the impact of fixed appliances questionnaire developed by Mandall et al, which measures aspects other than just pain. Secondly, we did find a difference in the visual analogue scores taken after 1 day; however, just as in the Bristol study (and many other pain studies) the variation was huge. Our data were quite significantly positively skewed and I am not sure how useful this single measure of pain really is, although I understand that it is widely used. In fact, if you read our discussion carefully, we do point out that several participants commented that chewing gum didn’t reduce the pain, but distracted them from it, which they found helpful. If people are interested in measuring pain then there is a validated measure that could be used in future studies (Iwasakia LR et al. Validation of a modified McGill Pain Questionnaire for orthodontic patients. Angle Orthod. 2013;83:906–912).

    Just as in the Bristol study we found no increase in breakages with fixed appliances when patients chewed gum and I have no idea where this belief comes from.

    The proposed increase in the rate of tooth movement when chewing gum is also interesting. I often find, when closing space, that one side of the arch closes more rapidly than the other. I once examined a masters dissertation, which hypothesized that space closes quicker on the patient’s preferred side of chewing. Ever since then, whenever I have observed this phenomenon, I have asked the patient which side they prefer to chew on and it invariably confirms this hypothesis. I am not sure how you would test this using RCT methodology!

    Best wishes and keep up the good work.