Dental Research

Effect of gum chewing following food ingestion on the pH of interproximal dental plaque
Ignatius K, Lee* / Charles F. Schachtele** Recent publications have suggested that chewing sorbitol- or sucrose-containing gum after a snack or meal can reduce development of caries by neutralizing dental plaque acids at interproximal sites in the dentition. To confirm these findings four volunteers wore appliances containing a miniature pH electrode. After plaque accumtdation, subjects ingested a bowl of sugar-coated cereal with milk and 20 minutes later chewed a sorbitol-containing gum, a sucrose-containing gum, or did not chew anything for 20 minutes. After exposure to the cereal, the plaque pH fell within 20 minutes from approximately 6.4 to 4.8. Sorbitol gum caused the pH to rise to 5.5, while the sucrose gum caused the pH to rise to only 5.1, After cessation of chewing, the pH in all cases dropped to 4.5 or lower. No statistically significant difference could be shown between plaque pH changes with the various protocols. Gum chewing after eating caused only a transient elevation in plaque pH. (Quintessence Int 1992:23:455-459.)

Introduction A comprehensive review of the role of chewing gum in dental health has recently been presented.' There is a continuing controversy coneeming effects of this activity on the development of cades in humans. The cariogenie potential of suero se-containing gums, the noncariogenic or possible anticariogenic activities of sorbitol- and/or xylitol-coutaining gums, and the role of enhanced saliva flow from gum chewing on removal of harmful plaque products and enamel remineralization are all issues that need further study. One aspect of chewing gum research that has received significant recent attention involves studies that empiiasized the effect of stimulation of saliva now by

Assistant Professor, Department of Restorative Sciences. University of Minnesota, School of Dentistry, 4-215 Malcolm Moos Health Sciences Tower, 515 Delaware Street SE. Minneapolis, Minnesota 55455. Protessor, Department of Oral Sciens, Director, Dental Research Institute. University of Minnesota, School of Dentistry, lS-104 Malcolm Moos Health Sciences Tower.

gum chewing on the presence in dental plaque of acids with enamel-demineralizing potential.^"^ It has been suggested that ehewing of either sugarless or sugared gum for at least 20 minutes after a meal or snack has an anticariogenic effect because of the neutralization or removal of plaque acids produced by the fermentation of the previously ingested carbohydrate,'' A key observation made in these investigations was that after the pH was lowered by food ingestion the elevated pH that was aehieved by gum chewing remained at the new level, close to pH 7.0, for at least 100 minutes/ Although the phenomenon of stimulation of saliva flow during chewing.'' followed by increases in plaque pH,*''^ is not new or unexpected, the capacity of gum chewing after eating solid foods to completely eliminate subsequent drops in plaque pH implies that gum chewing causes the removal of fermentable carbohydrate and/or plaque from interproximal sites or in some manner prevents normal interactions between plaque bacteria and residual carbohydrate. It is important that the technology used in the chewing gum studies^"^ involved in-dwelling microelectrodes positioned at interproximal sites in the dentition where food can be impacted and retained. This technology has been acknowledged by consensus as appropriate for these types of investigations.**

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Table I Salivary flow rate of human subjects Flaw(g/min) Subject No. 1
2 3 4

Unstimulated
1.1 0.8 0.5 0.7

Stimulated
1.8 2.1 1.8 1.8

The heavy reliance of several chewing gum manufacturers on results from interproximal plaque pH telemetry methods for their promotional materials and our previous observations that aeids produced by plaque fermentation in retentive sites in the dentition remain for prolonged intervals,^'*' apparently because of limited diffusion within plaque,"'^ encouraged us to perform additional investigations. An ion-sensitive field-effect transistor (ISFET) telemetry system''"" has been successfully used for many years in our laboratory'"''^ and was ideally suited to study the effect of gum chewing after eating on the pH of interproximal plaque.

electrode were secluded within the appliance by a piece of gutta-percha. Plaque was allowed to accumulate on the electrodes for 4 days, aud subjects reported having ingested only water for the previous 4 hours. The electrode was connected to a meter (Kuraray model KR-500), which was attached to a strip-chart recorder (Model 2210, LKB). A miniature reference electrode (Kuraray type 8010) was attached to the side of the appliance. Vinyl polysiloxane impression material (Express, 3M Dental Products Div) was used to fill the space housing the wires. After the baseline pH was obtained, the subject ingested, over a 10-minute interval, 50 g of a sugarcoated corn flake cereal with 150 mL of lowfat (2%) milk. Twenty minutes after initiation of eereal ingestion, a piece of sorbitol- or sucrose-containing gum was chewed for 20 minutes with the subject alternating chewing between each side of the mouth. After the gum was removed, the pH was recorded for an additional 30 minutes. In control experiments, subjects ate cereal with milk and the plaque pH was followed for a total of 70 minutes. After each session, plaque was removed from the electrodes, and they were calibrated by placement of the apphance into standard 7.0 and 4.0 buffer solutions (Baxter Scientific Products). Each of the protocols was repeated for each of the subjects. The pH values at 1-minute intervals were transferred to a computer from the strip-chart pH recording with a digitizer and electromagnetic tablet (Sigma-Scan, Jandel Scientific). Tracings were used to determine the meau pH at specific times. A statistical program (Statview) was used to analyze the data.
Results

Method and materials

Four women with at least one missing mandibular tooth were studied. Subjects were 25, 30, 51, and 55 years old with decayed, missing, and filled surface scores, determined by visual and tactile examination, of 49, 40, 66. and 79, respectively. Stimulated and unstimulated salivary flow rates were determined for ail four subjects by collecting saliva for 5 minutes with or without chewing of neutral paraffin wax (Parafilm, American Can Co). All subjects were in good general health, and this study was approved by the University of Minnesota Committee on the Use of Human Subjects in Research. Informed consent was obtained from each subject. Appliances containing an ISFET pH electrode (type 6010, Kuraray Co) were constructed with minor modification of the method described previously."^ A simulated interproximal space was created with bovine enamel in the missing tooth area of the appUance. The sensing tip of the pH electrode was positioned on the proximal surface just gingival to the contact area. When placed into the mouth, the wires from the pH

Table 1 summarizes the unstimulated and stimulated saliva flow rates of the four human subjects who participated in this study. The flow rates were elevated 1.7-, 2.6-, 3.6- and 2.6-fold by the chewing of Parafilm. Figures 1 to 3 illustrate the mean changes in plaque pH over time for the human subjects following the three protocols. After consumption of sugar-coated cereal, the resting pH fell from a mean of 6.4 to 4.8 after 20 minutes and continued to drop to a final pH of 4.4 after 70 minutes (Fig 1). In contrast, when the subjects began to chew sorbltol-containing gum 20 minutes after eating the cereal, the pH quickly rose to 5.5 within 8 minutes. The pH remained near this level until the gum was removed after an additional 12

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(mini

Fig 1 Mean change in interproximal plaque pH of four human subjects during and following ingestion ot cereal with milk.

Fig 2 Mean change in interproximal plaque pH during end foliowing ingestion ot cereal and chewing ot sorbitol gum for 20 minutes.

Table2 Interproximal plaque pH at various times toUowitig cereal and gum chewing Plaque pH (mean SD) Experimental condition Cereal Cereal+ sorbitol gum Cereal+ sucrose gtjm 0 Min 20 Min 28 Min 70 Min

6.4 + 0.4 4.8 + 0.5 4.5 + 0.5 4.4 + 0.4 6.30,3 4.8 + 0.5 5.5+0,8 4.5 + 0.5 6,20.4 4.7 + 0.4 5.1 + 0.8 4.40,4

minutes. After gum removal, the pH quickly dropped to 4.5 at a Tte similar to the initial pH drop following cereal ingestion (Fig 2). The sugar-containing gum showed similar results, except that after initiation of gum chewing the pH was elevated to only 5.1. After cessation of sugar gum chewing, the pH quickly decreased to 4.4 at 70 minutes after initiation of the experiment (Fig 3). The mean pH values and standard deviation at specific times during the experiments for each of the protocols are summarized in Table 2. At times 0, 20, and

Fig 3 Mean change in interproximal plaque pH during and following ingestion of cereal and chewing of sucrose gum for 20 minutes.

70 minutes, the average plaque pH values obtained from tbe strip-chart recordings were between 6.24 and 6.37, 4.66 and 4.83, and 4.38 and 4.55, respectively.
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Statistical analysis using repeated-measures analysis of variance did noi show any significant differences at any of the time intervals. With both types of gum, 28 minutes represented the time at whicb tbe highest pH was achieved. Although there was a 1-pH unit difference at 28 minutes between the cereal alone and cereal followed by sorbitol gum and a O.^pH unit difference between the sorbitol and sucrose gums, analysis using repeated-measures analysis of variance failed to detect any significant difference between the values. Discussion The average stimulated saliva flow rate of 1.9 g/min of the four subjects who participated in this study was similar to results presented from previous studies in tbis laboratory"' and to tbose obtained by otbcrs in studies of larger populations using a variety of techniques. Based on the many measurements made in this and other laboratories, the results presented in this current study were obtained with individuals whose salivary flow rates were within tbe range of what might be considered "normal" for healthy subjects. The resting interproximal plaque pH values obtained in tbe subjects were almost identical to those presented previously in similar studies, in wbich tbe resting pH value from eight telemetry runs was 6.3 0.2"* and from 16 telemetry runs was 6.4 0.3.'*'Although these values were slightly lower than those presented by others,""' it should be emphasized tbat in our studies the subjects had not fasted overnight but had simply refrained from eating for approximately 4 hours and chewed Parafilm for several minutes prior to initiation of each experimental run. The dramatic decrease in pH immediately after the initiation of food ingestion is typical of what is normally obtained with interproximal plaque pH telemetry systems. In a previous study, in which the ingested food was a toffee, the pH declined to 4.3 + 0.3 (n = 8) and 4.5 0.3 (n = 8).'^ In addition, previous studies using glass microelectrodes demonstrated that a similar toffee product caused the interproximal plaque pH to drop to a minimum of approximately 4.4 within 20 minutes of ingestion"' and 4.1 within 30 minutes of ingestion.^^ Thus, the results obtained during the first 20 minutes of this study were consistent with those of previous investigations in this and other laboratories. A basic observation made during the pioneering 458 plaque pH studies in Zurich, Switzerland, was that the lowering of plaque pH by the fermentation of food car.bohydrates could be alleviated by stimulating the flow of saliva by chewing a pliable, inert product such as ^g^ h,23-27 ii^ addition. Von Maiwald et a P demonstrated that chewing gum that contains sorbitol causes a rapid rise in interproximal plaque pH, 20 minutes after ingestion of a sucrose-containing product. Similar effects were found in our laboratory with a sorbitol gum alone and a gum that contained sodium bicarbonate."' These observations bave been expanded on by Jensen""'* at the University of Iowa. The present results on the effect of gum chewing on the pH of interproximal plaque are consistent with the resuhs of all of these investigations. The present results markedly differed from those of previous studies,"* however, in the pH of interproximal plaque after the cessation of gum chewing. In contrast to the investigations that demonstrated that after cessation of gum chewing, the elevated interproximal plaque remains near pH 7,-"* the present Study consistently revealed a subsequent drop in pH to levels that might be considered barmful to the dentition. The results presented in this paper represent the third trial with these protocols; the only difference was the type of food ingested. In every case, the same basic observations were made after cessation of gum chewing. Tbere are several possible explanations for the differences seen between these studies and those of Jensen.-"* The human subjects, apphances, electrodes, or the associated electronics could be responsible for tbe differences. As discussed, the plaque pH responses of tbe present subjects were consistent with those in other subjects in many previous studies. With regard to the telemetry system, a direct comparison of ISFET and glass electrodes in interproximal plaque pH telemetry studies of ingested sucrose and wheat starch provided almost identical results.''' Another key point is that when studies of liquid substrates, such as 10% solutions of sucrose or glucose, are performed with our system, it is possible to consistently demonstrate that the pH can be raised to close to 7.0 by gum chewing and that the pH remains at this level after removal of the gum (data not shown). However, when solid foods that contain fermentable carbohydrate are ingested, there is always a drop in pH after the cessation of gum chewitig. We believe this decrease represents fermentation of residual carbohydrate that is not removed by the chewing of gum for 20 minutes. We are not aware of studies demonstrating the removal of impacted foods from interproximal

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sites in the human dentition by the chewing of gum. Clarification of the proposed role of sorbitol- or stigarcontaining chewing gum in human caries prevention or development will require appropriate clinical studies with various products. Conclusions This study failed to replicate the results of previous studies, in which the chewing of gum after the ingestion of solid food that contains fermentable carbohydrate results in stable interproximal plaque pH values close to 7,0, The differences in results do not appear to be due to the subjects used in the study or the appliances and electrodes utilized. Clearly, tlie phenomenon of alteration by chewing gtim of acid accumulation at interproximal sites following food ingestion will require additional investigations. At this time it is difficult to envision how gum chewing can result in the removal of fermentable carbohydrate and/or plaque from interproximal sites or in some manner prevent normal interactions between plaque bacteria and residual carbohydrate. Further studies are needed on this important issue. Acknowledgments
This worIi was supported in part by Biomdical Research Support grant No. 2S1)7-RR 05322 from the US Public Health Service. The willing and timely support of the human subjects involved in (his study is acknowledged. Schachtele CF, Jensen ME: Human plaque pH studies: estimating lhe acidogenic potential of foods. Cereal Foods World 1981 ;26:14-18. Igarashi K, Lee I, Schachtele CF: Comparison of in vivo buman dental plaque pH changes within artificial fissures and al interproximal sites. Caries Res iyKy;23:417^22. Meiers JC, Schachtele CF: The effect of an antibacterial solution on the microflora of human incipient fissure caries, J Dent Res 1984 ;63:47-51. Dibdin GH: A brief survey of recent in vitro work on the diffusion of small ions and molecules in denial plaque, in Guggenheim B (ed: Carioiogy Today. Basel, Karger 1984. pp 191-198. Igarashi K. Kamiyama K, Yamada T: Measurement of pH in human dental plaque in vivo witb an ion-sensitive transistor electrode. Arch Oral Biol iy8t;26:203-207, Yamada T, Igarashi K, Mitsutomi M: Evaluation of cariogenicity of glycosylsucrose by a new method to measure pH under human dental plaque in situ. J Dent Rei 1980;59: 2157-2162Yamada T, Igarashi K, Kamiyama K: Advantages and disadvantages of using an ion-sensitive transistor electrode for measuring pH in human dental plaque in vivo, in Franli RM, Leach SA (eds): Surface and Coiloid Phenomena in the Oral Cavity: Methodological Aspects. London, IRL Press Ltd, t981, pp 157-166. Igarashi K, Lee t. Schachtele CF: Effect of cbewing gum containing sodium bicarbonate on human interproximal plaque pH. ; Dem Res 1988;67:531-535. Becks H. Wainwright WW: Human saliva, Xtll. Rate of flow of resting saliva of bealthy individuals, } Dent Res iy43;22: 391-396, Andersson R, Arvidsson E, Crossner C-G, et al: The flow rate, pH and buffer effect of mised saliva in ehildren. J Int Assoc Dent Child 1974;5:5-12. Heintze U, irkhed D, Bjorn H: Secretion rate and buffer effeei of resting and stimulated wtiole saliva as a function of age and sex. Swed Dent J 19a3;7:227-238. Crossner C-G : Salivary flow rate in children and adolescents. Swed Dco7 19R4;8:271-276. imfeldT, Mhlemann HR: Cariogenicily and acidogenicity of food confectionary and beverages. Pluinmicol Ttier Dent 1978; 3:53-68. Jensen ME, Schachtele CF: Tbe acidogenie potential of reference foods and snacks at interpro^:imal siles in the human dentition. J Denl Res 19S3;62:889-892. Graf H, Muhlemann HR: Telemetry of plaque pH from interdental areas. Heiv Odontol Aaci 1966;10:94-101. De BoeveT I, Mtihkmann HR: pH of inlerproximal plaque with regard to continuous suerose application, Helv Odontot Acta l%9;13:97-99. Mhlemann HR: Inlra-oral radio telemetry. Int DentJ 1971; 21:456^65. Imfeld T, Mhlemann HR: Evaluation of sugar substitutes in preventive carioiogy, / Prev Dent t977;4:8-14. Imfeld T: Evaluation of the cariogenieity of confeedonery by intra-oral wire-tele me try. Helv Odontol Acta t977;21:l-28. von Maiwald HJ, Banoczy J, Tetze W, et al: Die Beeinflussung des Plaquc-pH durch zuckerhaltigen und zuckerfreien Kaugummi. Zaiin Mund Kieferheitkd 1982;70:598-604. . Jensen ME: Tleme trie methods using ion-specific electrodes. Adv Dent Res Vmi.1.^1-9?.. D

References
1. EdgatWM, GeddesDAM: Chewing gum and dental health-a review. Br Dent J l9g0;t68:17J-177. 2. Jensen ME: Responses of interpro>;imal plaque pH to snack foods and effect of chewing sorbitol-containing gum. J Am Dent Assoc Ii*86;113:262-266, 3. Jensen ME: Eftecis of chewing sorbitol gum and paraffin on human interproximal plaque pH. Curies Res 1986:20:503-50!'. 4. Jensen ME, Wefel JS: Human plaque pH responses to meals and the effects of chewing gum. Br Dent J 1989; 167:204-208, 5. Dawes C: Physiological factors affecting salivary flow rate, oral sugar clearance, and the sensation of dry mouth in man, J Dent Res 1987; 66:648-653. 6. Graf H : The glycolytic activity of plaque and its relation to hard tissues pathology-recent findings from intraoral pH telemetry researcb. tnt DentJ 1971;20:426-435. 7. Imfeld T: Identification of low caries risk dietary components. Monogr Orai Sd 1983;11. 8. DePaola DP: Executive summary. Scienlific consensus conference on methods for assessmeni of the cariogenic potential of foods. J Dent Re.i 1986;65:1540-1543.

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