Effect of chewing gum on thirst: an integrative review

Integrative review, guided by the question: “What is the scientific evidence about the effects of chewing gum on adult’s thirst?” LILACS, PubMed, Scopus and Web of Science were the databases consulted.

Results:

Of a total of 2,414 articles found, 12 papers were selected whose publications varied between 1991 and 2016. The use of chewing gum resulted in increased salivary volume (five studies), xerostomia relief (seven studies), and thirst reduction (four studies). It was not possible to establish the number of chewing gums per day, being frequent the recommendation to use as desired. There was a predominance of studies with patients under dialysis and with cancer.

Conclusion:

Chewing gum is an effective strategy to reduce thirst discomfort in adults.

Descriptors:
Thirst; Salivation; Mastication; Chewing Gum; Xerostomia

Cross references of databases - from January to February, 2017
LILACS	PUBMED	SCOPUS	WEB OF SCIENCE
Goma de mascar OR chicletes AND saliva	Chewing gum OR gum of chew OR bubble gum AND saliva	Chewing gum OR gum of chew OR bubble gum AND saliva	Chewing gum AND saliva
Goma de mascar OR chicletes AND intervenção	Chewing gum OR gum of chew OR bubble gum AND paraffin	Chewing gum OR gum of chew OR bubble gum AND paraffin	Chewing gum AND mastication
Goma de mascar OR chicletes AND mastigação	Chewing gum OR gum of chew OR bubble gum AND mastication	Chewing gum OR gum of chew OR bubble gum AND mastication	Chewing gum AND paraffin
Goma de mascar OR chicletes AND estratégias	Chewing gum OR gum of chew OR bubble gum AND salivary glands	Chewing gum OR gum of chew OR bubble gum AND salivary glands	Chewing gum AND salivary glands
Goma de mascar OR chicletes AND utilização	Chewing gum OR gum of chew OR bubble gum AND salivary flow	Chewing gum OR gum of chew OR bubble gum AND salivary flow	Chewing gum AND salivary flow
Goma de mascar OR chicletes AND xerostomia	Chewing gum OR gum of chew OR bubble gum AND xerostomia	Chewing gum OR gum of chew OR bubble gum AND xerostomia	Chewing gum AND xerostomia
Goma de mascar OR chicletes AND concentração de íons de hidrogênio	Chewing gum OR gum of chew OR bubble gum AND hydrogen ion concentration	Chewing gum OR gum of chew OR bubble gum AND hydrogen-ion concentration	Chewing gum AND hydrogen-ion concentration
Goma de mascar OR chicletes AND salivação	Chewing gum OR gum of chew OR bubble gum AND salivation	Chewing gum OR gum of chew OR bubble gum AND salivation	Chewing gum AND salivation
Goma de mascar OR chicletes AND saliva artificial	Chewing gum OR gum of chew OR bubble gum AND artificial saliva	Chewing gum OR gum of chew OR bubble gum AND artificial saliva	Chewing gum AND artificial saliva

Year/Country/ Database Author/ Method/ Sample/ Level of Evidence (LoE)	Objectives/ Method	Intervention studied/ Measuring tools	Outcomes/Conclusions
2016 Greece Web of Science Kaae, Stenfeldt, Eriksen⁽²⁷27 Kaae JK, Stenfeldt L, Eriksen JG. Xerostomia after radiotherapy for oral and oropharyngeal cancer: increasing salivary flow with tasteless sugar-free chewing gum. Frontiers In Oncology [Internet]. 2016[cited 2018 Jan 25];6:111. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4853382/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾ Cohort (n = 20) LoE - 4	To investigate the possibility of mechanically stimulating the residual function of saliva using a sugar-free and flavored gum. Samples of stimulated and nonstimulated saliva were collected at baseline. During 14 days, the exposed group (patients with xerostomia after radiotherapy due to oral and oropharyngeal cancer) used the gum 3 to 5 times a day, and the saliva was collected again. The nonexposed group (healthy subjects) was instructed to use the gum in the same way.	Chewing gum free of flavor and sugar.Tools: short version of the EORTC questionnaire - H&N35 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - Head and Neck Module), which evaluates the quality of life of patients with cancer. In this study, the outcomes "oral cavity" and "feeding difficulties" were evaluated, with their respective subitems.	After the intervention, it was possible to notice an increase in the salivary flow of 14 of 20 patients in at least 0.2 g at visit 1 and 2 (p = 0.008 and p = 0.05, respectively). No change in saliva production was observed in the control group. Chewing gum as mechanical stimulation may increase saliva production and relevant xerostomia relief from the second week of use.
2013 Egypt Web of Science Said, Mohammed⁽³¹31 Said H, Mohammed H. Effect of chewing gum on xerostomia, thirst and interdialytic weight gain in patients on hemodialysis. Life Sci J [Internet]. 2013[cited 2018 Jan 25];10(2):1767-77. Available from: http://www.lifesciencesite.com http://www.lifesciencesite.com... ⁾ Quasi-experimental (n = 60) LoE - 3	To analyze the effects of sugar-free chewing gum on xerostomia, thirst and interdialytic weight gain in patients under hemodialysis. GE - they chewed one to two pieces for ten minutes (six times a day or as desired). They evaluated xerostomia and salivary flow before and after each session from a questionnaire.	GC comparison - without the chewing gum use. GE - use of sugar-free chewing gum.Tools: Xerostomia Inventory (XI); Dialytic Thirst Inventory (DTI).	With the use of chewing gum, there was relief of thirst (4.4 ± 1.2 - 1.8 ± 0.8) and xerostomia (4.6 ± 0.6 - 4.3 ± 0.6), significant decrease in interdialytic weight gain (kg) (1.9 ± 0.7 - 1.8 ± 0.7) and increase in the salivary flow rate (ml) (0.4 ± 0.1 to 0.8 ± 0.2). Chewing gum is highly recommended for patients under dialysis.
2013 China PUBMED/ Web of Science Fan, Zhang, Luo, Niu, Gu⁽²⁸28 Fan WF, Zhang Q, Luo LH, Niu JY, Gu Y. Study on the clinical significance and related factors on thirst and xerostomia in maintenance hemodialysis patients. Kidney Blood Press Res [Internet]. 2013[cited 2016 Apr 12];37(4-5):464-74. Available from: http://www.karger.com/Article/Pdf/355717 http://www.karger.com/Article/Pdf/355717... ⁾ Observational Study (n = 42) LoE - 4 Crossover randomized clinical trial (n = 11) LoE - 2	To evaluate thirst relief and xerostomia in patients under hemodialysis. To analyze the clinical significance and related factors between thirst and xerostomia, as well as the relationship between thirst, xerostomia and quality of life. They received chewing gum (six to ten times a day or when they felt dry mouth and thirst) or a thin straw to suck water for two weeks. After two weeks of wash-out, the intervention was changed for another two weeks. No strategy was used in the observational study.	Comparison between chewing gum and fine straw for drinking water in patients undergoing dialysis treatment. Tools: Visual Analogue Scale (VAS) to assess thirst and xerostomia; Dialytic Thirst Inventory (DTI); Xerostomia Inventory (XI).	The use of chewing gum significantly reduced thirst (DTI, p <0.001 and VAS, p = 0.038), xerostomia (XI, p = 0.001 and VAS p = 0.001) and interdialytic weight gain (p = 0.001). While the use of the thin straw significantly reduced thirst (DTI p = 0.003 and VAS, p = 0.016) and interdialytic weight gain (p = 0.049).
2011 Poland Web of Science Jagodzinska, Zimmer-Nowicka, Nowicki⁽²⁹29 Jagodzińska M, Zimmer-Nowicka J, Nowicki M. Three months of regular gum chewing neither alleviates xerostomia nor reduces over hydration in chronic hemodialysis patients. journal of renal nutrition [Internet]. 2011[cited 2018 Jan 25];21(5):410-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21185739 https://www.ncbi.nlm.nih.gov/pubmed/2118... ⁾ Prospective pre/post-test (n = 38) LoE - 3	To examine the effect of regular use of chewing gum on xerostomia, thirst and hydration status in patients under dialysis. The patients used the gum for three months, three times a day, after the main meals (or when they felt xerostomia or thirst); received a diary where they noted the number of gums used and flakes of liquid ingested.	Artificially-sweetened chewing gum with aspartame and sorbitol in patients under dialysis. Tools: Xerostomia and Thirst Questionnaire.	Patients did not report changes in thirst and xerostomia. There was no change in interdialytic weight gain, besides the total body water content evaluated with bioimpedance did not decrease. After four weeks of the end of the interventions, there were no significant changes in thirst and xerostomia.
2005a Holland PubMed/Web of Science Bots, Brand, Veerman, Korevaar, Valentijn-Benz, Bezemer, Valentijn, Vos, Bejesma, Wee, Van Amerongen, Nieuw Amerongen⁽¹⁶16 Bots CP, Brand HS, Veerman EC, Korevaar JC, Valentijn Benz M, Bezemer PD, et al. Chewing gum and a saliva substitute alleviate thirst and xerostomia in patients on haemodialysis. Nephrol Dial Transplant [Internet]. 2005[cited 2016 May 10];20(3):578-84. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15665029 https://www.ncbi.nlm.nih.gov/pubmed/1566... ⁾ Crossover randomized clinical trial (n = 65) LoE - 2	To investigate the effect of the use of chewing gum and artificial saliva for xerostomia, thirst and weight gain in patients under hemodialysis. Chewing gum or artificial saliva was used for two weeks, the wash-out period, and then the other regimen. Xerostomia, thirst, and rates of weight gain were assessed at baseline and after each treatment period.	Comparison between chewing gum and artificial saliva. Tools: Xerostomia Inventory (XI); Dialytic Thirst Inventory (DTI).	The use of gum decreased the XI from 29.0 to 28.1 (p <0.05). The gum and the salivary substitute had effects on the reduction of the DTI. However, no intervention was successful in the change in interdialytic weight gain.
2005b Holland PubMed/Web of Science Bots, Brand, Veerman, Valentijn-Benz, Van Amerongen, Nieuw Amerongen⁽¹⁷17 Bots CP, Brand HS, Veerman EC, Valentijn-Benz M, Van Amerongen BM, Nieuw Amerongen AVN, et al. The management of xerostomia in patients on haemodialysis: comparison of artificial saliva and chewing gum. Palliative Medicine [Internet]. 2005[cited 2018 Jan 25];19:202-207 b. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15920934 https://www.ncbi.nlm.nih.gov/pubmed/1592... ⁾ Crossover randomized clinical trial (n = 65) LoE - 2	To evaluate chewing gum compared to artificial saliva in xerostomia relief in patients under chronic hemodialysis. Each intervention was used for two weeks with a two-week wash-out period. The chewing gum was used one to two units, six times a day, for ten minutes and as desired. Artificial saliva - three sprays six times a day and when desired throughout the day.	Comparison between chewing gum (Freedent White T) and xanthan-based artificial saliva (XialineT). Tools: Xerostomia Inventory (XI) evaluates xerostomia and dry mouth; Visual Analogue Scale (VAS) assessed the efficacy, preference, and side effects of treatment.	60% of patients preferred chewing gum when compared to artificial saliva. Chewing gum was more effective than artificial saliva in relieving thirst and dry mouth (p <0.001). The efficacy of chewing gum on the relief of xerostomia and thirst was greater due to the ability to stimulate the salivary glands, with consequent increase in salivary flow.
2004 Holland Web of Science Bots, Brand, Veerman, Van Amerongen, Nieuw Amerongen⁽²²22 Bots CP, Brand HS, Veerman ECI, Van Amerongen BM, Nieuw Amerongen AV. Preferences and saliva stimulation of eight different chewing gums. Int Dental J [Internet]. 2004[cited 2018 Jan 25];54:143-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15218894 https://www.ncbi.nlm.nih.gov/pubmed/1521... ⁾ 1^st step (n = 83) 2^nd step (n = 112) Randomized clinical trial for both studies LoE - 2	To examine the use of chewing gum in order to stimulate the salivary flow of healthy and sick individuals, taking into account the preference of the patients for different gums, evaluating the pH and salivary flow rate. 1^st step - Mechanically stimulated saliva was collected for 5 minutes; after a 15-minute break, subjects received different chewing gum types for 10 minutes, collecting the saliva 4 times in that period to evaluate pH and flow. 2^nd step - Each of the 112 subjects received one type of chewing gum to use as preferred for 2 days; on the third day they should respond to the tools of data collection. Then another type of gum was distributed; thus, each individual tested three of the eight types of chewing gum.	First step: chewing gum compared to paraffin. The volume was measured from the collection of saliva stimulated by paraffin; then by the chewing gum. Tools: did not use. Second step: eight different chewing gums evaluating the preference of participants. Tools: Visual Analogue Scale to evaluate the preference between gums; Ten-item taste questionnaire.	An increase in salivary flow and pH was observed in all subjects. The mean increase in flow rate was 187% during the 1^st minute of mastication compared to paraffin stimulation. Gums have also stimulated salivary flow, but taste and shape, according to patient preference, may influence long-term outcomes. There were differences in taste preferences and flavor. Gender relations were observed for taste (p = 0.019), total evaluation (p = 0.047) and willingness to use gum for several weeks (p = 0.037).
2000 England Web of Science Davies⁽³⁰30 Davies AN. A comparison of artificial saliva and chewing gum in the management of xerostomia in patients with advanced cancer. Palliat Medicine [Internet]. 2000[cited 2018 Jan 25];14(3):197-203. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10858827 https://www.ncbi.nlm.nih.gov/pubmed/1085... ⁾ Crossover randomized clinical trial (n = 43) LoE - 2	To compare sugar-free chewing gum with artificial mucin-based saliva to relieve xerostomia in patients with an advanced-stage cancer. Patients received chewing gum or artificial saliva to be used before meals and before bed (or when they felt the need) for ten minutes. Each intervention lasted five days with each product and a two-day wash-out period.	Comparison between sugar-free chewing gum (Freedent™) and artificial mucin-based saliva (Saliva Orthana™). Tools: Visual Analogue Scale (VAS); Questionnaire on the side effects of the two products.	The chewing gum and the artificial saliva showed effectiveness in the relief of xerostomia in patients with advanced-stage cancer. Of the patients, 90% said that gum improved xerostomia, and 86% wanted to continue using it after the study. Gum was more effective (69%). However, chewing gum presented side effects in three patients (two with nausea and one with irritations in the oral cavity). Patients preferred chewing gum. There was no statistically significant difference between treatments (p = 0.33).
1998 USA PUBMED Stewart, Jones, Bates, Sandow, Pink, Stillwell⁽²³23 Stewart CM, Jones AC, Bates RE, Sandow P, Pink F, Stillwell J. Comparison between saliva stimulants and a saliva substitute in patients with xerostomia and hyposalivation. Spec Care Dentistry [Internet]. 1998[cited 2018 Jan 25];18(4):142-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10218061 https://www.ncbi.nlm.nih.gov/pubmed/1021... ⁾ Crossover randomized clinical trial (n = 80) LoE - 2	To analyze the preference and efficacy of chewing gum, lemon balm and artificial saliva, all presenting sorbitol and xylitol, for the relief of xerostomia in patients with low salivary flow. Each product was used for two weeks; among products, there was a one-week wash-out.	Comparison between three products: chewing gum, lemon peel and artificial saliva. All containing sorbitol and xylitol in the composition.Tools: Product classification questionnaire; Dry mouth questionnaire.	The Kruskal-Wallis tests did not reveal statistical significance (p> 0.589) among the products. No product demonstrated efficacy in the stimulation of salivary production. ANOVA analysis followed by the Tukey HSD test revealed no significant difference between the mean flow rate stimulated by artificial saliva and the flow rates stimulated by gums and pellets. In relation to xerostomia, only a brief relief was obtained.
1993 Norway Web of Science Risheim, Arneberg⁽²⁴24 Risheim H, Arneberg P. Salivary stimulation by chewing gum and lozenges in rheumatic patients with xerostomia. Scand J Dent Res [Internet]. 1993[cited 2018 Jan 25];101:40-3. Available from: https://www.ncbi.nlm.nih.gov/pubmed/8441894 https://www.ncbi.nlm.nih.gov/pubmed/8441... ⁾ Crossover randomized clinical trial (n =18) LoE - 2	To evaluate the effects that chewing gum and tablets have on the signs of xerostomia in rheumatic patients, in addition to the salivary flow rate. The chewing gum was used for 30 minutes. The frequency was 2 times a day, from the 1st to the 4^th day; and 5 times a day, from the 5^th to the 14^th day. The xylitol tablet was used 4 to 8 times a day for 6 to 10 minutes for 2 weeks. Between the two interventions, there was a two week wash-out.	Comparison between chewing gum and tablets sweetened with xylitol and sorbitol.Tools: Visual Analogue Scale (VAS) applied for xerostomia signs. Sensation of dryness of the mouth assessed through questions about relief.	In one-third of participants, both strategies resulted in dry mouth relief. However, almost half of the participants did not feel any relief from the symptom. The salivary flow rate had no significant effect after the use of the strategies. Regarding preference, the patients classified the gum and the tablet as being equal. Chewing gum: good relief (n = 5), short (n = 5), no relief (n = 7). Tablet: Good relief (n = 5), short (n = 2), no relief (n = 9). Two participants dropped out. Thus, the total was 17 participants in the chewing gum group and 16 in the tablet group.
1992 Denmark Web of Science Aagaard, Godiksen, Teglers, Schiadt, Glenert⁽²⁵25 Aagaard A, Godiksenn S, Teglers PT, Schiodt M, Glenert U. Comparison between new saliva stimulants in patients with dry mouth: a placebo-controlled double-blind crossover study. J Oral Pathol Med [Internet]. 1992[cited 2018 Jan 25];21:376-80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/1403845 https://www.ncbi.nlm.nih.gov/pubmed/1403... ⁾ Crossover randomized clinical trial (n-43) LoE - 2	To evaluate the preference and the effect of two salivary stimulants in patients with chronic xerostomia. The patients were divided into three groups, and the distribution of the three types of chewing gum (mucin, carbamide and placebo) was randomized. There was guidance to use at least 1 time per day for 14 days each.	Comparison between three chewing gums: V6 (carbamide), chewing gum with mucin and taste-free gum (placebo). Tools: The effect was assessed by interviews related to dry mouth and determined by changes in stimulated and non-stimulated salivary flow rate.	There was a positive result in the relief of dry mouth symptoms in patients who used Mucin (64%), V6 (44%) and Placebo (26%). Regarding preference, 61% opted for Mucin chewing gum, 21% V6, 5% placebo product, and 13% did not know which to choose. Among patients, 50% had an increase in the rate of unstimulated salivary secretion of all products after 14 days of regular use, indicating a long-term effect.
1991 Sweden PubMed/Web of Science Olsson, Spak, Axéll⁽²⁶26 Olsson H, Spak CJ, Axéll T. The effect of a chewing gum on salivary secretion, oral mucosal friction, and the feeling of dry mouth in xerostomic patients. Acta Odontol Scandin [Internet]. 1991[cited 2018 Jan 25];49(5):273-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/1803848 https://www.ncbi.nlm.nih.gov/pubmed/1803... ⁾ Crossover randomized clinical trial (n =14) LoE - 2	To evaluate the stimulatory capacity of a chewing gum with long duration of flavor and to measure its effect on salivary secretion by comparing it with a commercially available gum. The patients with xerostomia were divided into two groups of seven: with chewing of 35 minutes for both groups, the first one used commercially available gum (V6); while the other, the new chewing gum Pinkerton Tobacco Company (PTC). Each patient participated in four experimental sessions; between each treatment, there was a wash-out day.	Comparison between chewing gum with long duration of flavor (PTC) and one commercially available (V6), both containing xylitol and sorbitol. Tools: Visual Analogue Scale (VAS) for subjective evaluations.	Long-lasting chewing gum (PTC) provided a considerable increase in salivary flow with its peak between 5 to 10 minutes, in addition to less friction of the oral mucosa when compared to the V6 gum. There was a difference between the subjective evaluations of V6 gum and PTC in relation to salivary stimulation, capacity and taste, with preference for PTC gum.

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[1] Corresponding Author: Aline Korki Arrabal Garcia E-mail: alinekorki@yahoo.com.br