The Open Anesthesia Journal


Formerly: The Open Anesthesiology Journal

ISSN: 2589-6458 ― Volume 13, 2019
REVIEW ARTICLE

Chewing Gum Use in the Perioperative Period



D. John Doyle1, 2, *
1 Department of General Anesthesiology, Cleveland Clinic, Abu Dhabi, UAE
2 Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA

Abstract

A synopsis of the latest research on the perioperative use of chewing gum by surgical patients is presented, focusing on the preoperative and postoperative periods. Current data now suggest that the preoperative use of chewing gum does not adversely affect gastric emptying and that the postoperative use of chewing gum may actually aid recovery from some forms of major surgery. Additionally, the use of chewing gum may increase alertness and serve to reduce stress, as well as offer important oral health benefits.

Keywords: Aspiration risk, Chewing gum, Gastric emptying, Gastric volume, Gastric ultrasonography, Postoperative ileus.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 13
First Page: 40
Last Page: 43
Publisher Id: TOATJ-13-40
DOI: 10.2174/2589645801913010040

Article History:

Received Date: 21/02/2019
Revision Received Date: 14/05/2019
Acceptance Date: 22/05/2019
Electronic publication date: 26/06/2019
Collection year: 2019

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© 2019 D. John Doyle.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at Department of General Anesthesiology, Cleveland Clinic, Abu Dhabi, UAE & Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA; Tel: -971 52 699 7627;
Email: djdoyle@hotmail.com





1. INTRODUCTION

Commercialization of chewing gum took place around 170 years ago. This brief review presents a synopsis of the latest research on the use of chewing gum by surgical patients, focusing on the preoperative and postoperative periods. It appears that the preoperative use of chewing gum does not adversely affect gastric emptying and that the postoperative use of chewing gum may actually aid bowel recovery following some forms of major surgery.

2. PREVENTION OF GASTRIC ASPIRATION

One major concern of all anesthesiologists is the possibility that their patients may aspirate gastric contents during general anesthesia. This is because several pulmonary syndromes may occur following aspiration, depending on the amount and nature of the aspirated material, the host's immune response to the aspirated material and other factors [1Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med 2001; 344(9): 665-71.[http://dx.doi.org/10.1056/NEJM200103013440908] [PMID: 112282 82] ]. Perhaps, the best known of these syndromes are aspiration pneumonitis (Mendelson's syndrome in Fig. (1)), which is principally a chemical injury to the lung parenchyma, and aspiration pneumonia, which is an infectious process related the inhalation of oropharyngeal secretions rich in pathogenic bacteria. In a study of medical malpractice cases resulting from aspiration, Eltorai et al. [2Eltorai AS. Periprocedural pulmonary aspiration: An analysis of medical malpractice cases and alleged causative factors. J Eval Clin Pract 2018.[http://dx.doi.org/10.1111/jep.13086] [PMID: 30548370] ] found that the most common alleged malpractice did not secure the airway with an endotracheal tube when faced with an elevated aspiration risk, and with “failure to perform a proper rapid-sequence induction and/or place a nasogastric tube” for the purposes of gastric decompression prior to the induction of anesthesia.

Fig. (1)
Chest X-ray of an 83 year old man showing radiological changes in the right lower lobe believed to be a consequence of having aspired gastric contents. The clinical and radiological manifestations of aspiration may vary from simple asymptomatic inflammation with minimal radiological findings all the way to severe life-threatening disease manifesting as ARDS. Image source: https://commons. wikimedia.org/wiki/File:Aspiration_pneumonia201711-3264.jpg used under the Creative Commons Attribution-Share Alike 4.0 International license.


Table 1
American Society of Anesthesiologists (ASA) recommended minimum fasting guidelines for elective surgery. Note that these fasting intervals may not be possible in some emergency situations, in which case a “rapid sequence induction” is often carried out to reduce the risk of pulmonary aspiration. This table is based on the following publications: Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2017 Mar;126(3):376-393. doi: 10.1097/ALN.0000000000001452. PubMed PMID:28045707.


3. PREOPERATIVE CHEWING GUM AND GASTRIC EMPTYING

One concern related to gastric aspiration sometimes raised is that allowing patients to chew gum in the preoperative fasting period increases gastric secretions, thereby theoretically increasing the risk of aspirationi. While perioperative fasting guidelines from the ASA [3Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: An updated report by the American society of anesthesiologists task force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology 2017; 126(3): 376-93.[http://dx.doi.org/10.1097/ALN.0000000000001452] [PMID: 280457 07] ] (Table 1) and other agencies are helpful in guiding the management of patients through the perioperative period, experts still differ widely in their recommendations concerning the use of chewing gum in the preoperative period, with some past experts recommending delaying the surgery and others who would allow it to proceed on the basis of recent research findings such as those discussed next.

In a bedside gastric ultrasoundii study by Valencia et al. [4Valencia JA, Cubillos J, Romero D, et al. Chewing gum for 1 h does not change gastric volume in healthy fasting subjects. A prospective observational study. J Clin Anesth 2019; 56: 100-5.[http://dx.doi.org/10.1016/j.jclinane.2019.01.021] [PMID: 30731390] ], 55 healthy volunteers chewed gum for an hour, with gastric volumes assessed by ultrasonography at baseline and then hourly. The investigators found that “the proportion of subjects who presented a completely empty stomach (Grade 0 antrum) was similar at baseline and after 1 h of gum-chewing [81% vs. 84%, p = 0.19, CI 95% (-12%, 16%)]” and that “among those subjects who had visible fluid at baseline, the volume remained unchanged throughout the study period.”

In another ultrasound-based study by Bouvet et al. [5Bouvet L, Loubradou E, Desgranges FP, Chassard D. Effect of gum chewing on gastric volume and emptying: a prospective randomized crossover study. Br J Anaesth 2017; 119(5): 928-33.[http://dx.doi.org/10.1093/bja/aex270] [PMID: 29077816] ], the authors carried out a randomized crossover trial on 20 healthy volunteers. Each crossover session started with an ultrasound antral assessment, followed by drinking 250 ml of water. The subjects then either chewed a sugared gum for 45 min or did not (control group). The half-time to gastric emptying, the total gastric emptying time, and other measurements were taken via ultrasonography. The authors concluded that “chewing gum does not affect gastric emptying of water and does not change gastric fluid volume measured 2 h after ingestion of water.”

In a study by Dubin et al. [6Dubin SA, Jense HG, McCranie JM, Zubar V. Sugarless gum chewing before surgery does not increase gastric fluid volume or acidity. Can J Anaesth 1994; 41(7): 603-6.[http://dx.doi.org/10.1007/BF03010000] [PMID: 8087909] ], 77 patients were randomly assigned to get sugarless gum or to serve as a control subject. On the basis of their findings, the authors concluded that surgery need not be delayed if a patient arrives in the OR chewing sugarless gum.

Ouanes et al. [7Ouanes J-PP, Bicket MC, Togioka B, Tomas VG, Wu CL, Murphy JD. The role of perioperative chewing gum on gastric fluid volume and gastric pH: a meta-analysis. J Clin Anesth 2015; 27(2): 146-52.[http://dx.doi.org/10.1016/j.jclinane.2014.07.005] [PMID: 25442242] ] conducted a systematic review and meta-analysis involving 287 patients to determine whether preoperative gum chewing affects gastric pH and gastric fluid volume. They found that “the presence of chewing gum was associated with small but statistically significant increases in gastric fluid volume” but that changes in gastric pH were not found. The authors concluded that “elective surgery should not necessarily be canceled or delayed in healthy patients who accidentally chew gum preoperatively.”

Finally, Poulton [8Poulton TJ. Gum chewing during pre-anesthetic fasting. Paediatr Anaesth 2012; 22(3): 288-96.[http://dx.doi.org/10.1111/j.1460-9592.2011.03751.x] [PMID: 221716 75] ] found “no evidence that gum chewing during pre-anesthetic fasting increases the volume or acidity of gastric juice in a manner that increases risk” but instead suggested that preoperative gum chewing may be beneficial in that “gum chewing promotes gastrointestinal motility and physiologic gastric emptying.” His recommendation is that “gum chewing should cease when sedatives are given and all patients should be instructed to remove any chewing gum from the mouth immediately prior to anesthetic induction.” The last part of this recommendation is nicely reinforced by several case reports of chewing gum contributing to airway misadventures [9Haftoura E, Pourzitaki C, Logotheti H, Aroni F, Arambatzis P. Preoperative chewing gum and foreign body airway obstruction. J Anesth 2008; 22(4): 479-80.[http://dx.doi.org/10.1007/s00540-008-0662-y] [PMID: 19011795] -11Bevacqua BK, Cleary WF. An unusual case of endotracheal tube cuff dysfunction. J Clin Anesth 1993; 5(3): 237-9.[http://dx.doi.org/10.1016/0952-8180(93)90022-7] [PMID: 8318244] ].

4. POSTOPERATIVE CHEWING GUM TO IMPROVE BOWEL FUNCTION

Ertas et al. [12Ertas IE, Gungorduk K, Ozdemir A, Solmaz U, Dogan A, Yildirim Y. Influence of gum chewing on postoperative bowel activity after complete staging surgery for gynecological malignancies: A randomized controlled trial. Gynecol Oncol 2013; 131(1): 118-22.[http://dx.doi.org/10.1016/j.ygyno.2013.07.098] [PMID: 23906657] ] studied whether gum chewing influences the return of bowel function after gynecologic staging surgery. Patients undergoing complete staging surgery for gynecological malignancies were randomly assigned either to repeated gum-chewing (n = 74) or to a control group (n = 75). The authors found that the time to flatus, time to defecation, time to tolerate diet and length of hospital stay were on average “significantly reduced in patients that chewed gum compared with controls.” Additionally, ileus symptoms were less frequent in the gum-chewing group. The authors concluded that early postoperative gum chewing after “elective total abdominal hysterectomy and systematic retroperitoneal lymphadenectomy hasten the time to bowel motility and the ability to tolerate feedings” and that this treatment is sufficiently effective that it “should be added as an adjunct in postoperative care of gynecologic oncology”.

Vásquez et al. [13Vásquez W, Hernández AV, Garcia-Sabrido JL. Is gum chewing useful for ileus after elective colorectal surgery? A systematic review and meta-analysis of randomized clinical trials. J Gastrointest Surg 2009; 13(4): 649-56.[http://dx.doi.org/10.1007/s11605-008-0756-8] [PMID: 19050983] ] performed a meta-analysis of randomized clinical trials (6 trials/244 patients) to better understand the effect of gum chewing on ileus after colorectal surgery. The authors concluded that in patients suffering from ileus after colonic surgery, “gum chewing in addition to standard treatment significantly reduces the time to first flatus and the time to first passage of feces when compared to standard treatment alone” and advocated for gum chewing being added to the routine management of these patients.

5. CHEWING GUM FOR THE TREATMENT OF POSTOPERATIVE NAUSEA AND VOMITING

Darvall et al. [14Darvall JN, Handscombe M, Leslie K. Chewing gum for the treatment of postoperative nausea and vomiting: A pilot randomized controlled trial. Br J Anaesth 2017; 118(1): 83-9.[http://dx.doi.org/10.1093/bja/aew375] [PMID: 28039245] ] conducted a pilot study of 94 female patients undergoing laparoscopic or breast surgery. Patients experiencing Postoperative Nausea or Vomiting (PONV) in the Postanesthesia Care Unit (PACU) received either ondansetron 4 mg i.v. or chewing gum. It was found that chewing gum was “not inferior” to ondansetron to relieving PONV in this setting.

6. CHEWING GUM FOR THE MANAGEMENT OF STRESS

There is even evidence that chewing gum may play a role in relieving stress [15Scholey A, Haskell C, Robertson B, Kennedy D, Milne A, Wetherell M. Chewing gum alleviates negative mood and reduces cortisol during acute laboratory psychological stress. Physiol Behav 2009; 97(3-4): 304-12.[http://dx.doi.org/10.1016/j.physbeh.2009.02.028] [PMID: 19268676] ] as well as in increasing alertness [16Johnson AJ, Jenks R, Miles C, Albert M, Cox M. Chewing gum moderates multi-task induced shifts in stress, mood, and alertness. A re-examination. Appetite 2011; 56(2): 408-11.[http://dx.doi.org/10.1016/j.appet.2010.12.025] [PMID: 21232569] -18Miquel S, Haddou MB, Day JEL. A systematic review and meta-analysis of the effects of mastication on sustained attention in healthy adults. Physiol Behav 2019; 202: 101-15.[http://dx.doi.org/10.1016/j.physbeh.2019.01.003] [PMID: 30611764] ] and in increasing memory performance [19Scholey A. Chewing gum and cognitive performance: A case of a functional food with function but no food? Appetite 2004; 43(2): 215-6.[http://dx.doi.org/10.1016/j.appet.2004.07.004] [PMID: 15458809] ]. One proposed mechanism for these findings is that increased activity in the Locus coeruleus may be involved [20Tramonti Fantozzi MP, De Cicco V, Barresi M, et al. Short-term effects of chewing on task performance and task-induced mydriasis: Trigeminal influence on the arousal systems. Front Neuroanat 2017; 11: 68.[http://dx.doi.org/10.3389/fnana.2017.00068] [PMID: 28848404] ].

7. CHEWING GUM FOR ORAL HEALTH

The oral health benefits of chewing gum are sometimes unappreciated. Dodds [21Dodds MWJ. The oral health benefits of chewing gum. J Ir Dent Assoc 2012; 58(5): 253-61.[PMID: 23573702] ] points out that not only does the use of sugar-free gum provide a valuable anti-caries benefit but that chewing sugar-free gum promotes saliva production, thereby providing dental benefits such as the rapid oral clearance of sugars, the neutralization of plaque pH after a sugar challenge, and remineralization of early dental lesions.

CONCLUSION

Data now exist to show that the preoperative use of chewing gum does not adversely affect gastric emptying. Also, the postoperative use of chewing gum may aid bowel function recovery after some forms of major surgery. Finally, the use of chewing gum may increase alertness and serve to reduce stress, as well as offer oral health benefits.

NOTES

ii For an introduction to gastric ultrasound, visit http://www.gastricultrasound.org/

CONSENT FOR PUBLICATION

Not applicable.

FUNDING

None.

CONFLICT OF INTEREST

The author declares no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med 2001; 344(9): 665-71.[http://dx.doi.org/10.1056/NEJM200103013440908] [PMID: 112282 82]
[2] Eltorai AS. Periprocedural pulmonary aspiration: An analysis of medical malpractice cases and alleged causative factors. J Eval Clin Pract 2018.[http://dx.doi.org/10.1111/jep.13086] [PMID: 30548370]
[3] Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: An updated report by the American society of anesthesiologists task force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology 2017; 126(3): 376-93.[http://dx.doi.org/10.1097/ALN.0000000000001452] [PMID: 280457 07]
[4] Valencia JA, Cubillos J, Romero D, et al. Chewing gum for 1 h does not change gastric volume in healthy fasting subjects. A prospective observational study. J Clin Anesth 2019; 56: 100-5.[http://dx.doi.org/10.1016/j.jclinane.2019.01.021] [PMID: 30731390]
[5] Bouvet L, Loubradou E, Desgranges FP, Chassard D. Effect of gum chewing on gastric volume and emptying: a prospective randomized crossover study. Br J Anaesth 2017; 119(5): 928-33.[http://dx.doi.org/10.1093/bja/aex270] [PMID: 29077816]
[6] Dubin SA, Jense HG, McCranie JM, Zubar V. Sugarless gum chewing before surgery does not increase gastric fluid volume or acidity. Can J Anaesth 1994; 41(7): 603-6.[http://dx.doi.org/10.1007/BF03010000] [PMID: 8087909]
[7] Ouanes J-PP, Bicket MC, Togioka B, Tomas VG, Wu CL, Murphy JD. The role of perioperative chewing gum on gastric fluid volume and gastric pH: a meta-analysis. J Clin Anesth 2015; 27(2): 146-52.[http://dx.doi.org/10.1016/j.jclinane.2014.07.005] [PMID: 25442242]
[8] Poulton TJ. Gum chewing during pre-anesthetic fasting. Paediatr Anaesth 2012; 22(3): 288-96.[http://dx.doi.org/10.1111/j.1460-9592.2011.03751.x] [PMID: 221716 75]
[9] Haftoura E, Pourzitaki C, Logotheti H, Aroni F, Arambatzis P. Preoperative chewing gum and foreign body airway obstruction. J Anesth 2008; 22(4): 479-80.[http://dx.doi.org/10.1007/s00540-008-0662-y] [PMID: 19011795]
[10] Karuparthy V, Kaneda K, Bellinger A, Han T-H. Chewing gum: A potential cause of airway obstruction. J Anesth 2009; 23(1): 168-9.[http://dx.doi.org/10.1007/s00540-008-0683-6] [PMID: 19234850]
[11] Bevacqua BK, Cleary WF. An unusual case of endotracheal tube cuff dysfunction. J Clin Anesth 1993; 5(3): 237-9.[http://dx.doi.org/10.1016/0952-8180(93)90022-7] [PMID: 8318244]
[12] Ertas IE, Gungorduk K, Ozdemir A, Solmaz U, Dogan A, Yildirim Y. Influence of gum chewing on postoperative bowel activity after complete staging surgery for gynecological malignancies: A randomized controlled trial. Gynecol Oncol 2013; 131(1): 118-22.[http://dx.doi.org/10.1016/j.ygyno.2013.07.098] [PMID: 23906657]
[13] Vásquez W, Hernández AV, Garcia-Sabrido JL. Is gum chewing useful for ileus after elective colorectal surgery? A systematic review and meta-analysis of randomized clinical trials. J Gastrointest Surg 2009; 13(4): 649-56.[http://dx.doi.org/10.1007/s11605-008-0756-8] [PMID: 19050983]
[14] Darvall JN, Handscombe M, Leslie K. Chewing gum for the treatment of postoperative nausea and vomiting: A pilot randomized controlled trial. Br J Anaesth 2017; 118(1): 83-9.[http://dx.doi.org/10.1093/bja/aew375] [PMID: 28039245]
[15] Scholey A, Haskell C, Robertson B, Kennedy D, Milne A, Wetherell M. Chewing gum alleviates negative mood and reduces cortisol during acute laboratory psychological stress. Physiol Behav 2009; 97(3-4): 304-12.[http://dx.doi.org/10.1016/j.physbeh.2009.02.028] [PMID: 19268676]
[16] Johnson AJ, Jenks R, Miles C, Albert M, Cox M. Chewing gum moderates multi-task induced shifts in stress, mood, and alertness. A re-examination. Appetite 2011; 56(2): 408-11.[http://dx.doi.org/10.1016/j.appet.2010.12.025] [PMID: 21232569]
[17] Hirano Y, Onozuka M. Chewing and attention: A positive effect on sustained attention. BioMed Res Int 2015; 2015367026[http://dx.doi.org/10.1155/2015/367026] [PMID: 26075234]
[18] Miquel S, Haddou MB, Day JEL. A systematic review and meta-analysis of the effects of mastication on sustained attention in healthy adults. Physiol Behav 2019; 202: 101-15.[http://dx.doi.org/10.1016/j.physbeh.2019.01.003] [PMID: 30611764]
[19] Scholey A. Chewing gum and cognitive performance: A case of a functional food with function but no food? Appetite 2004; 43(2): 215-6.[http://dx.doi.org/10.1016/j.appet.2004.07.004] [PMID: 15458809]
[20] Tramonti Fantozzi MP, De Cicco V, Barresi M, et al. Short-term effects of chewing on task performance and task-induced mydriasis: Trigeminal influence on the arousal systems. Front Neuroanat 2017; 11: 68.[http://dx.doi.org/10.3389/fnana.2017.00068] [PMID: 28848404]
[21] Dodds MWJ. The oral health benefits of chewing gum. J Ir Dent Assoc 2012; 58(5): 253-61.[PMID: 23573702]

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