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Letters to the Editor

Using Xylitol Products and MI Paste to Reduce Oral Biofilm in Long-Term Care Residents

Having worked for several years on interventions to improve mouth care for long-term care residents, we feel the need to emphasize the limitations and dangers of xylitol use in nursing homes, because they were not discussed in the article nor the accompanying editorial that appeared in the December 2013 issue of Annals of Long-Term Care: Clinical Care and Aging®.

The problem with using xylitol gum and mints is that the persons who often need the most help with oral hygiene are those with advanced dementia, stroke-related disability, and advanced incapacity due to serious acute or chronic illnesses, and these individuals tend to have swallowing difficulties that place them at significant risk of aspiration. For this reason, we declined to include xylitol gum or mints when designing the evidence-based Mouth Care Without a Battle program.

Instead of using xylitol gum or mints, we recommend regular tooth cleaning with antibacterial products and innovative supplies using methods proven to reduce resident resistance to mouth care. We feel this approach is more comprehensive and less hazardous, as it avoids the obvious risk of aspiration. These products, techniques, and practices are described in our articles1,2 and detailed in our training materials at the aforementioned website.


Philip D. Sloane, MD, MPH

Sheryl Zimmerman, PhD

Cecil G. Sheps Center for Health Services Research University of North Carolina, Chapel Hill, NC


1.     Sloane PD, Zimmerman S, Chen Xi, et al.  Effect of a person-centered mouth care intervention on care processes and outcomes in three nursing homes. J Am Geriatr Soc. 2013;61(7):1158-1163.

2.     Zimmerman S, Sloane PD, Cohen LW, Barrick AL. Changing the culture of mouth care: mouth care without a battle. Gerontologist. 2014;54(S1):S25-S34.

The author responds:

Thank you for bringing up some good points. Aspiration is always a concern, even in the application of fluoride gels. As a matter of fact, there was hesitation by the researchers in even approaching the director of nursing to start a xylitol protocol because of the aspiration potential; however, once we realized that a caregiver would be with the resident during these times, the authors of the protocol were more comfortable moving forward.

We used xylitol candies and gum because other studies used these products in children and found them to be safe and effective in reducing oral biofilm in this population. Other studies have shown them to be effective in removing biofilm in adults, and that was the primary goal of our project: reducing oral biofilm.

The other point I want to make is that having a dental hygienist on staff is critical, as there are other ways of managing oral biofilm beyond brushing and flossing, which nondental staff may not be aware of. Yet this information is especially important to understand to facilitate oral hygiene, particularly among resistant and combative residents and those with other issues that can lead to oral care challenges. In addition, several studies have shown that certified nursing assistants and other nursing staff are not comfortable mechanically removing oral biofilm. When examining the before images we provided in the article, it is easy to see the level of oral care that residents were receiving at the facility.

Compared with other healthcare professionals, only a dental hygienist is motivated by clean teeth and has spent nearly 3000 hours learning the trade.1 Having a dental hygienist on staff eliminates concerns with how to best use xylitol for each resident. For instance, pudding or ice cream made with xylitol may be an excellent replacement for the gum/mints. In addition, thickened water that includes xylitol may make the difference between a hydrated and dehydrated resident while also providing him or her with a powerful biofilm reducer.2,3 Xylitol is available in many forms, even as sprinkling sugar. With so many ways to administer xylitol, the term hazardous may be overstating the issue with xylitol application in oral health maintenance. It may be more accurate to say that adding gum and candies to the oral care protocol is unsafe for some residents.

At the same time, aspirating chunks of dental biomass is dangerous for all patients, as it is a gateway to pneumonia.4 As strains of antibiotic-resistant bacteria proliferate, the treatment of nursing home–acquired pneumonia is becoming increasingly more difficult to manage; thus, every measure should be taken to prevent these infections.5 Interestingly, in 2008, an animal study showed that xylitol-supplemented nutrition enhanced oxidative killing of bacteria and prolonged the survival of rats that had experimental pneumococcal sepsis.6 Although it is unclear whether such benefits would extend to humans, the study shows that xylitol may have additional clinical benefits and warrants further investigation.

Facilities have specialists in hair care, podiatry, eye care, dietary care, nutrition, wound care, speech, and other aspects of personal wellbeing. It is time that care of the oral cavity be maintained by specialists in the field of oral care: dental hygienists. In the meantime, functional foods and, in particular, xylitol in the daily regimen for everyone in long-term care will augment any mechanical attempts at oral biofilm removal.

Shirley Gutkowski, RDH, BSDH

Clinical advisor, American Association for Long Term Care Nursing


  1. American Dental Hygienists’ Association. Dental Hygiene Education. Accessed January 27, 2014.

2. Kurola P, Tapiainen T, Sevander J, et al. Effect of xylitol and other carbon sources on Streptococcus pneumoniae biofilm formation and gene expression in vitro. APMIS. 2011;119(2):135-142.

3. Ruiz V, Rodríguez-Cerrato V, Huelves L, et al. Adherence of Streptococcus pneumoniae to polystyrene plates and epithelial cells and the antiadhesive potential of albumin and xylitol. Pediatr Res. 2011;69(1):23-27.

4. Raghavendran K, Mylotte JM, Scannapieco FA. Nursing home-associated pneumonia, hospital-acquired pneumonia and ventilator-associated pneumonia: the contribution of dental biofilms and periodontal inflammation. Periodontol 2000. 2007;44:164-177.

5. El Solh AA, Pietrantoni C, Bhat A, Bhora M, Berbary E. Indicators of potentially drug-resistant bacteria in severe nursing home-acquired pneumonia. Clin Infect Dis. 2004;39(4):474-480.

6. Renko M, Valkonen P, Tapiainen T, et al. Xylitol-supplemented nutrition enhances bacterial killing and prolongs survival of rats in experimental pneumococcal sepsis. BMC Microbiol. 2008;8:45.




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