The Risk of Using Chewing Gum Whilst Participating In Sports Activities

Preamble

Chewing gum, the soft, sticky, pliable substance which is designed to be chewed without being swallowed, typically comes in the form of a flavoured tablet, pellet or “stick”. Its use by athletes and referees in many sports, for whom there are perceived psychological and physiological benefits, is now commonplace.

Benefits

Athletes use the gum as an anxiolytic to help reduce the nervousness or tension they experience prior the start of a competition. The substance is also used to increase the production of saliva from the parotid, submandibular and sublingual salivary glands and stimulate its flow in the oral cavity; beneficial when the mouth becomes dry as a result of anxiety or when exercising with an open mouth.

Additionally, this increased salivation may contribute to improved dental health by helping to remove food particles and bacteria around the teeth and washing out the mouth; bacteria which is associated with halitosis (bad breath). Flavoured chewing gum is regarded as having breath-freshening capabilities to alleviate this bad breath. The nutritional value derived from its use is negligible.

Of note is a review by Onyper et al. (2011) that found evidence of short-lived improvement in brain function, i.e. memory, after a period of chewing gum, although the precise mechanism is not well understood. However, there is no scientific validation to support its use as an aid to enhance performance.

Risks

Despite the benefits, athletes may be oblivious to the potential risks associated with participation in physical activity whilst a substance is retained in the mouth. There have been instances of athletes who have encountered significant respiratory difficulties caused by partial blockage of the airway by chewing gum; a choking episode.

Although rare, individuals have died due to asphyxiation from aspiration of gum that has fallen into the pharynx and been inhaled into the larynx causing complete airway obstruction. The malleable nature of the substance and its ability to conform to the specific anatomical structure of an individual’s airway presents a significant and particular challenge to its removal.

Possible mechanisms which may precipitate airway blockage with chewing gum are when an athlete (i) has contact with an opponent or is struck by a ball and they are concussed and rendered unconscious, (ii) collapses and becomes unconscious without any form of contact, e.g. cardiac arrest, or (iii) simply fails to remember the presence of the gum in their mouth and inadvertently inhales it.

Urgency

Airway obstruction requires a time-critical response; any delay in removing the object may have a fatal outcome.

Individuals who have a ‘first responder’ role need to have the ability to assess, recognise and manage a compromised airway.

In terms of chewing gum use, a number of questions immediately arise when assessing the athlete:

- is the athlete known to use gum during activity?

- if so, has it been ejected, i.e. is it on the ground, or is it still in the mouth?

- if in the mouth, where is it?

- would changing the athlete’s position increase the risk of the gum going further down the airway?

- does the gum appear to be affecting the athlete’s breathing?

In a conscious individual, any substance which obstructs the airway and results in a ‘mild’ choking episode, is in most instances expelled with a forceful cough. For more resistant objects, and a case of ‘severe’ choking, a cycle of ‘back blows’ and ‘abdominal thrusts’ may be required.

In an unconscious individual, before any airway-opening manoeuvre is performed, or an airway adjunct is inserted, the oral cavity needs to be inspected. If the gum is not clearly visible, where is it now located? A thorough inspection may reveal it to be found ‘sublabially’ (between either the upper or lower lip and the gingiva), ‘sublingually’ (on the floor of the mouth beneath the tongue), or in one of the cavities between inside of the cheeks and the adjacent teeth, where it can be removed either manually or with the appropriate instrument. Or is it in the pharyngeal or laryngeal space where it will not be visible and beyond the point of retrieval? In cases where the offending object cannot be recovered, and there is complete airway obstruction and an absence of normal breathing, cardio-pulmonary resuscitation will need to be to be performed.

Education and Advice

It is vitally important that athletes and referees, of all ages and at all levels, be alerted to the risks associated with the use of chewing gum whilst engaged in physical activity, whether in competition or when training. The potential challenges that may be encountered by those who will need to manage their airway, particularly if they are rendered unconscious, should also be acknowledged. Armed with this information, those who use chewing gum will be able to make an informed decision about whether or not to use the substance. Pragmatically, to eliminate the risks, the use of gum should be discouraged.

Equally all medical personnel, coaching staff and volunteers who support sports activities should be aware of the potential dangers of chewing gum use, know how to assess and recognise airway obstruction, and be fully conversant with the initial urgent steps and manoeuvres which need to be taken should an athlete experience breathing difficulties as a result of airway compromise.

References

Onyper S, Carr T, Farrar J, Floyd B; (2011). "Cognitive advantages of chewing gum. Now you see them, now you don't". Appetite. 57 (2): 321–28.

Copyright Sports ER Ltd Jul 2023