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Using Xylitol Products and MI Paste to Reduce Oral Biofilm in Long-Term Care Residents
Affiliations:
Ms. Gutkowski is an international speaker, writer, and practiced general hygienist. She is also a clinical advisor for the American Association for Long Term Care Nursing.
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Oral health is becoming a topic of great concern in the long-term care (LTC) setting as an increasing number of dependent people are arriving to these facilities with most or all of their teeth intact. There is no question that the biomass that accumulates on the teeth and in the oral vestibule (ie, the space between the cheek/lips and the teeth) contributes to acute and chronic diseases. In fact, more than a decade ago, the US Surgeon General issued a significant report that provided an evidence-based argument for the importance of optimal oral care, describing how diseases and conditions that affect the face, mouth, and teeth are connected to overall health and well-being in all age groups.1 Yet in LTC facilities, little time is often spent on assisting residents with oral care, and many residents rarely receive regular dental care. In a study by Simons and colleagues,2 only 5% of residents in LTC facilities who requested assistance with oral hygiene received help.
Because I have personally observed a variety of oral care challenges in LTC residents, I conducted a small cohort pilot study with another clinical dental hygienist to determine if there was a less labor-intensive way than mechanical means (eg, brushing teeth, dental cleanings) to alter oral biofilm accumulation. I surmised that regular use of xylitol-based chewing gum and mints in combination with a mineral paste to strengthen tooth enamel might be another healthful way to reduce and remove the accumulation of oral biofilm in nursing home residents.
Why Xylitol?
Xylitol is a five-carbon sugar alcohol that naturally occurs in most plant material, including many fruits and vegetables. Globally, xylitol has been shown to reduce oral pathogens associated with dental decay and has reduced the incidence of caries among children.3-8 In an in vitro model of oral biofilm, xylitol was efficient not only in inhibiting the acid production of cariogenic bacteria, but also in preventing the formation of a multispecies biofilm.9
Xylitol acts by confusing the early biofilm colonizers, which generally includes Streptococcus mutans and other acidophilic bacteria. These bacteria use host-ingested simple carbohydrates (eg, sucrose, fructose) to manufacture a protective sticky coating consisting of polysaccharides; however, unlike sucrose’s six-carbon atoms, xylitol’s five-carbon structure is stable and does not link together with other sugars. Subsequently, these bacteria cannot metabolize this five-carbon delicacy, making it difficult for this and other early biofilm colonizers to perform the functions necessary for survival, which includes expression of glycocalyx slime and production of the acids necessary to break down tooth enamel. In addition, xylitol’s neutral pH contributes to an oral environment that is hostile to other acidophilic bacteria, fostering the growth of gram-positive basophilic bacteria, which are less associated with dental and respiratory diseases.
Use of Xylitol in Long-Term Care Facilities
Outcomes of poor oral care tend to be more dire for LTC residents than for small children. Although both populations can experience pain from tooth decay and become malnourished due to difficulty eating, older adults may become more susceptible to life-threatening illnesses. For example, a 2010 systematic review reported that good oral hygiene practices might prevent the death of about one in 10 elderly nursing home residents due to healthcare-associated pneumonia.10 Overgrowth of oral biofilm can also lead to difficulty with glucose management, accelerate acute conditions, and lead to oral malodor and/or oral Candida infection (ie, thrush), all of which can significantly reduce quality of life.
Because the consequences of poor oral hygiene in the LTC setting are becoming better understood, some facilities are seeking to find ways to improve the oral hygiene of their residents; however, many barriers continue to exist. A recent European qualitative study found that in addition to previously well-reported barriers, such as lack of time and staffing resources to take on additional oral care duties, there were several new barriers, such as nurses’ desires to respect their residents’ wishes and nurses basing their provision of oral care on their own experiences.11 When oral care interventions have been implemented, the emphasis has been on providing education to help nursing staff, typically certified nursing assistants (CNAs), to assist with mechanical cleaning of residents’ teeth. Although this is an important intervention, some residents may refuse it and time constraints may hamper these efforts long-term. Therefore, my colleague and I sought to determine if a less invasive strategy using xylitol-based products might prove beneficial in this setting, similar to what has been observed with the use of these products in children.3-8 Use of such products is rarely considered a viable option in LTC facilities, which may be due to the lack of dental knowledge in these facilities, as dental hygienists are rarely employed there.
Our Intervention
Our small pilot study was mounted to evaluate the effects of xylitol in combination with a mineral paste on residents’ oral biofilm levels over a 3-month period. During this time, the CNAs were asked to provide six residents with xylitol gum twice per day and offer the residents a mineral paste adjunct, called MI Paste, twice per day; the gum and mineral paste were donated by Xlear and GC America, respectively. The mineral paste has a complex of casein phosphopeptide–coated amorphous calcium and phosphorus as its active ingredient, which serve to offer salivary components that help remineralize the teeth, preventing tooth decay. Besides these two interventions, no other oral care changes occurred. The nursing assistants were asked to continue providing the same level of oral care as they had always done, and no oral care training on proper toothbrushing techniques was conducted.
The CNAs were asked to chart the times that the xylitol gum was offered and the paste applied, but were not asked to chart brushing. Before the study was conducted, a two-tone disclosing solution (donated by Young Dental) was used to establish and document the participants’ baseline levels of oral biomass. At the midpoint and end of the 3-month study, the disclosing solution was used again to determine the participants’ biomass levels. The use of xylitol gum and application of the mineral paste reduced the oral biomass in the study participants. The Figure demonstrates the results obtained in one of our study participants, which was characteristic of our findings in the overall study population. In the photographs, the dark blue areas indicate a mature biomass (present >24 hours), whereas the more reddish areas indicate a newer biomass (present <24 hours). As shown by these photos, the mature biomasses were more common prior to study initiation. In addition, the quality of the masses was reduced by the end of the study, as demonstrated by the mass being less dense and the dark blue coloring on many teeth reverting to a lighter color intensity, with much converting to a more reddish hue, indicating the biofilm had not been on the teeth for long. As previously noted, one of the reported attributes of xylitol is that it interferes with the ability of early biofilm colonizers to produce the matrix that protects the oral biofilm inhabitants, preventing bacteria from adhering to the teeth.
There was also one unexpected consequence of the study, which was a marked reduction in oral malodor in one particular resident. His breath was so foul-smelling that his CNA had a difficult time assisting him with his activities of daily living. In addition, he had become a social outcast, often eating alone because the other residents could not bear being near him; however, during the study, his breath improved so remarkably that his CNA called us to comment on the difference in his oral malodor and his new engagement in social activities.
The xylitol and mineral paste intervention was well tolerated and there were no reported complications throughout the study. Xylitol, like other sugar alcohols, can cause gastrointestinal discomfort, including bloating, intestinal gurgling, and diarrhea, but there were no such reports by any of the study participants during the 3-month study period. All residents received approximately 3 g of xylitol per day, which is a small amount. Generally, amounts up to 50 g daily in adults appears to be safe.12
Study Limitations
The only vehicle available for tracking oral health changes was the disclosing solution. There were no funds to track oral pH changes. In addition, resources were not available to measure the participants’ saliva output or to have the CNAs physically chart the amount of biomass on the residents’ teeth. We also could not assess blood values, as we were unable to gain consent from the residents’ guardians to review the residents’ medical charts or to take blood. Obviously these things should be done were another wider, more definitive study conducted. Ideally, such a study would include multiple locations, a longer study duration, and observe changes in hospitalizations, respiratory infections, and antibiotic days, while also monitoring blood values such as C-reactive protein and glycated hemoglobin levels.
Conclusion
Acute diseases attributed to oral biomasses (eg, pneumonia, oral thrush) continue to plague LTC facilities. People who entrust their care to these facilities should have every opportunity to live the remainder of their lives with dignity and should not die because their teeth were dirty. Although having a dental hygienist on staff at every LTC facility would help ensure these objectives are met, there are still many hurdles that must be overcome before this becomes feasible. In the meantime, LTC facilities can consider providing their residents with xylitol-based gum and mints, and, if resources permit, adding a mineral paste to the oral care regimen. More studies in this area are desperately needed and this may be an area where nursing homes can initiate a quality improvement project.
References
1. Office of the Surgeon General, US Department of Health and Human Services. A National Call to Action to Promote Oral Health. 2003. Accessed November 21, 2013.
2. Simons D, Brailsford S, Kidd EA, Beighton D. Relationship between oral hygiene practices and oral status in dentate elderly people living in residential homes. Community Dent Oral Epidemiol. 2001;29(6):464-470.
3. Mäkinen KK, Järvinen KL, Anttila CH, Luntamo LM, Vahlberg T. Topical xylitol administration by parents for the promotion of oral health in infants: a caries prevention experiment at a Finnish Public Health Centre. Int Dent J. 2013;63(4):210-224.
4. Dodds MW. The oral health benefits of chewing gum. J Ir Dent Assoc. 2012;58(5):253-261.
5. Kumar S, Sogi SH, Indushekar KR. Comparative evaluation of the effects of xylitol and sugar-free chewing gums on salivary and dental plaque pH in children. J Indian Soc Pedod Prev Dent. 2013;31(4):240-244.
6. Zhan L, Cheng J, Chang P, et al. Effects of xylitol wipes on cariogenic bacteria and caries in young children. J Dent Res. 2012;91(suppl 7):85S-90S.
7. Ly KA, Milgrom P, Rothen M. The potential of dental-protective chewing gum in oral health interventions. J Am Dent Assoc. 2008;139(5):553-563.
8. Alamoudi NM, Hanno AG, Masoud MI, Sabbagh HJ, Almushayt AS, Masoud IM. Effects of xylitol on salivary mutans streptococcus, plaque level, and caries activity in a group of Saudi mother-child pairs. An 18-month clinical trial. Saudi Med J. 2012;33(2):186-192.
9. Badet C, Furiga A, Thébaud N. Effect of xylitol on an in vitro model of oral biofilm. Oral Health Prev Dent. 2008;6(4):337-341.
10. Rosenblum R Jr. Oral hygiene can reduce the incidence of and death resulting from pneumonia and respiratory tract infection. J Am Dent Assoc. 2010;141(9):1117-1118.
11. De Visschere L, de Baat C, De Meyer L, et al. The integration of oral health care into day-to-day care in nursing homes: a qualitative study. Gerodontology. Published online ahead of print June 20, 2013. doi: 10.1111/ger.12062.
12. WebMD. Xylitol side effects & safety. https://bit.ly/QfV1t5. Accessed November 25, 2013.
Disclosures: The author reports having received speaker honoraria from Xlear Inc, which manufacturers xylitol gum, and GC America, which manufactures MI Paste and other oral health products.
Address correspondence to: Shirley Gutkowski, RDH, BSDH, 2775 Shadow Trail, Sun Prairie, WI 53590; crosslinkpresent@aol.com
