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.
Comparative 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
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.
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.