Research Brief

Can a Licorice Lollipop Decrease Cariogenic Bacteria in

Nursing Home Residents?
Janet C. Mentes, PhD, APRN, BC, FGSA; Sarah Kang, MSN, RN; Sue Spackman, DDS; and
Janet Bauer, DDS

ABSTRACT

The purpose of this pilot study was to examine whether an herbal lollipop containing licorice root decreases Streptococcus mutans (S. mutans) bacteria that cause dental caries in nursing home residents. A
total of 8 residents (5 women, 3 men; mean age = 85) consented to participate in this study. Participants
were offered two lollipops per day for 21 days. Saliva samples were collected at baseline and Days 1, 3, 7,
14, and 21, then analyzed for numbers of S. mutans. Using linear mixed-models analysis with difference in
numbers of S. mutans from baseline to any time point as the dependent variable, and number of lollipops
consumed with effect of time controlled as the predictor variable, participants who consumed more lollipops during the 21-day time period were more likely to have fewer numbers of S. mutans (b = 8.703, p
= 0.067). There was a trend toward reduction of S. mutans with consumption of more lollipops during the
21-day period. Recruiting a larger sample for future research may demonstrate a significant reduction.

Consistently providing routine oral hygiene remains a

significant problem for caregivers of nursing home (NH)
residents. Residents specific disabilities, including dementia, dysphagia, and extreme physical frailty, as well as time
constraints on caregivers, makes maintaining oral hygiene
exceptionally difficult (Bauer, Spackman, Chiappelli, &
Prolo, 2008; Coleman & Watson, 2006). Inadequate oral
hygiene has been linked to declines in overall health, specifically between disease found in the oral cavity and that

found systemically throughout the body (Stein & Henry,

2009). Specifically, inflammation-driven diseases, such as
cardiovascular, cerebrovascular, and infectious pathologies,
have been associated with oral disease (Maupom, Gullion,
White, Wyatt, & Williams, 2003; Mojon, Rentsch, BudtzJrgensen, & Baehni, 1998). Additionally, inadequate oral
hygiene influences the nutrition and hydration status of NH
residents, which is an important index of health (Mentes,
2006; U.S. Department of Health & Human Services, 2000).

Dr. Mentes is Associate Professor, School of Nursing, Dr. Spackman is Lecturer and Co-Director, and Dr. Bauer is Professor and Director, June
and Paul Ehrlich Endowed Program in Geriatric Dentistry, School of Dentistry, University of California Los Angeles, and Ms. Kang is CN1, Cedars
Sinai Medical Center, Los Angeles, California.
The authors have disclosed no potential conflicts of interest, financial or otherwise. Dr. Mentes acknowledges a grant from Delta Dental. The
authors gratefully acknowledge the support of Dr. Michelle Eslami for help in recruiting study participants and Dr. Wenyuan Shi and his laboratory
staff for help with the saliva analysis.
Address correspondence to Janet C. Mentes, PhD, APRN, BC, FGSA, Associate Professor, School of Nursing, University of California Los Angeles, 700
Tiverton Avenue, Box 956919, Los Angeles, CA 90095-6919; e-mail: Jmentes@sonnet.ucla.edu.
Received: May 1, 2011; Accepted: January 27, 2012; Posted: September 17, 2012
doi:10.3928/19404921-20120906-07

Research in Gerontological Nursing Vol. x, No. x, 20xx

Mentes et al.

Previous research demonstrates that daily oral hygiene

regimens positively affect the overall health of older adults
(Meurman & Hmlinen, 2006) and NH residents (Samson, Berven, & Strand, 2009; Sjgren, Kullberg, Hoogstraate,
Johansson, Herbst, & Forsell, 2010). However, studies indicate that adequate daily oral self-care is not routinely delivered to this population (Coleman & Watson, 2006). The
lack of oral hygiene is particularly troublesome because not
only are older adults at greater risk for dental caries, respiratory pathogens aspirated from the oropharangeal cavity
have been shown to be major risk factors for pneumonia in
older adults, especially frail older adults who have swallowing difficulties or other functional disabilities (Nishiyama,
Inaba, Uematsu, & Senpuku, 2010; Ohrui, 2005). Yet, many
issues prevent proper adherence with oral care requirements
for NH residents. First, low staffing and little or no training about oral care strategies limit staff members ability to
provide necessary and adequate daily oral care for NH residents. Second, NH caregivers, specifically certified nursing
assistants, may be concerned about being injured while providing care, especially to residents with dementia (Jablonski, Munro, Grap, & Elswick, 2005; Reed, Broder, Jenkins,
Spivack, & Janal, 2006). Thus, there is a need for a simple
adjunctive aid that can be used alone or in addition to oral
care regimens for this population that can eliminate oral
pathogens and preserve normal oral flora for optimal health.
We hypothesized that an herbal lollipop containing whole
licorice extract that demonstrated antimicrobial properties in laboratory studies could potentially help reduce oral
bacterial loads, leading to improvements in the oral health
of NH residents (He, Chen, Heber, Shi, & Lu, 2006; Hu et
al., 2011). The active ingredient in licorice, glycyrrhizin, has
demonstrated many health benefits, including antibacterial
properties, specifically against cariogenic bacteria such as
Streptococcus mutans (S. mutans) (He et al., 2006; Thorne
Research, Inc., 2005). S. mutans are colonized in dental
plaque that naturally occurs on the smooth surfaces of teeth.
When colonized, S. mutans become pathogenic and are
therefore associated with the development of dental caries.
While licorice consumption is rated Generally Recognized as Safe by the U.S. Food and Drug Administration
(1974), with consumption of 1 to 5 grams of licorice per
day considered safe in reasonably healthy adults (Thorne
Research, Inc., 2005), several case reports (age range = 67
to 80) have indicated hypertensive side effects of unmonitored higher amounts of licorice intake from candy or herbal
supplements in older adults (Breidthardt, Namdar, & Hess,
2006; Janse, van Irsel, Hoefnagels, & Olde Rikker, 2005). At
30 mg per day, the amount of glycyrrhizin in the lollipops

used in this study was considered safe and thus provided a

desirable antibacterial tool with a novel delivery system.
The purpose of this pilot study was to evaluate the use
of an herbal lollipop consumed twice per day on the number of S. mutans in the oral cavity of NH residents. A secondary purpose was to assess the feasibility of offering this
intervention to NH residents.

METHOD
A single-group, repeated measures design was used to
evaluate the ability of an herbal lollipop to decrease the S. mutans bacteria counts in the oral cavity of frail NH residents.
Setting and Sample
Residents from two proprietary NHs located in the greater
Los Angeles area participated in the study. The first home had
87 beds and is part of a chain of 37 health care centers offering
complex medical care; rehabilitation, subacute, skilled nursing, Alzheimers disease, and long-term skilled nursing care;
and assisted living centers. The second nursing facility had
144 beds and provides both rehabilitative and long-term care.
Each participant or his or her legal guardian gave written informed consent to participate in this study, which
was approved by the Universitys Institutional Review
Board and appropriate individuals at each NH. Inclusion
criteria for the study were: (a) age 65 or older, (b) dentate,
and (c) speaks or understands English. Exclusion criteria
for the study were: (a) terminal diagnosis, (b) needing a
feeding tube, (c) oral or esophageal cancer, (d) diagnosed
renal failure, (e) diagnosed uncontrolled hypertension,
(f) late-stage dementia, (g) severe periodontal disease, (h)
current long-term antibiotic agent use, (i) dose of warfarin
(Coumadin) adjusted in the 2 months prior to study enrollment, or (j) allergies to dyes or licorice.
Materials
A sugar-free herbal tooth pop containing 2 mg extract of
Sophora flavescens and 15 mg of licorice extract as the active
ingredients was used in this study (Hu et al., 2011). Other inactive ingredients included hydrogenated starch hydrolysate
(solidifying agent); citric acid and mint (flavoring agents);
FD&C blue 1 and 2, red 3 and 40, yellow 5 and 6 (coloring
agents); and acesulfame potassium (noncaloric sweetener).
Procedure
After receiving informed consent, a baseline saliva
specimen was obtained from each study participant. A
registered dental hygienist then performed a dental prophylaxis that included debridement, scaling, and polishing

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Effects of a Licorice Lollipop on S. Mutans

of teeth so each participant would begin the study with a

reduced S. mutans load. Then the study dentist completed
an examination of the participants oral cavity, specifically
evaluating debris, calculus, caries, and condition of the
periodontium, as well as completing the Index of the Activities of Daily Oral Hygiene (ADOH).
Trained research assistants delivered lollipops twice per
day to participants at the NH; collected saliva samples at baseline and at Days 1, 3, 7, 14, and 21; and regularly monitored
participants blood pressure. To collect the saliva, research assistants instructed participants to spit into a cup and pipetted
at least 0.5 mL of saliva into tubes with a preserving fixant.
For the few participants who were unable to spit, the research
assistants gently suctioned the saliva from participants oral
cavity with a pipette. The saliva was collected at least an hour
after meals or brushing of teeth and sent to a laboratory within 24 hours for analysis. Blood pressure measurements were
completed twice per week to ensure there were no untoward
effects for participants from consuming the lollipop. A followup dental examination was completed at the end of the study.
Data Collection Instruments
Participant demographic characteristics collected
from the NH charts included age, sex, marital status, race/
ethnicity, medical diagnoses, number of teeth, and current
medications.
Scales that measured the functional status of each participant included the Activities of Daily Living (ADL) Hierarchy Scale (Morris, Fries, & Morris, 1999), Cognitive
Performance Scale (CPS, Morris et al., 1994), and the Index
of ADOH (Bauer, 2001), which assesses participants ability to manipulate aids used in daily oral self-care regimens.
The ADL Hierarchy Scale and CPS data were abstracted
from the NH residents most recent Minimum Data Set
(MDS) assessment, which has demonstrated stability over
a 7-day assessment period (Graney & Engle, 2000) and is
independently associated with staff time involved in resident care (Morris et al., 1999). For this study, the MDS
ADL Hierarchy Scale was scored from 0 (independence) to
6 (total dependence) in four areas: personal hygiene, toileting, locomotion, and eating. The ADL Hierarchy Scale
determines the participants level of assistance required to
complete ADLs and is determined by an algorithm.
The CPS algorithm is scored from 0 (cognitively intact)
to 6 (very severe cognitive impairment) and has been validated against the Mini-Mental State Examination (MMSE,
Folstein, Folstein, & McHugh, 1975). The CPS showed substantial agreement with the MMSE in the identification of
cognitive impairment with a sensitivity of 0.94 (95% con-

Research in Gerontological Nursing Vol. x, No. x, 20xx

fidence interval [CI]: 0.90, 0.98) and a specificity of 0.94

(95% CI: 0.87, 0.96) (Hartmaier et al., 1995).
The Index of ADOH, developed by a dentist specializing
in geriatric dentistry, assesses the level of assistance needed
for the individual to successfully accomplish oral hygiene
routines (Bauer, 2001). Specifically, it measures older adults
ability to manipulate aids involved in flossing, tooth or denture brushing, topical fluoride application, and the use of
oral rinses. The residents abilities were assessed and scored
on a scale ranging from 0 (complete independence) to 4 (total
dependence). The total Index of ADOH score is 16 points
for dentate residents and 8 points for non-dentate residents.
In a previous study, the Index of ADOH was significantly
associated to the Barthel General Index, an index measuring performance in variables describing ADLs and mobility
(Ruiz-Medina, Bravo, Gil-Montoya, & Montero, 2005).

RESULTS
Demographic Data
Eight dentate NH residents participated in this study.
Their mean age was 85 (age range = 68 to 95). The sample was
mostly women (62.5%, n = 5; mean age = 82.2) versus men
(37.5%, n = 3; mean age = 89.7). Of the 8 study participants, 2
identified themselves as Black/African American, 5 as White/
Caucasian, and 1 as Asian/Pacific Islander. The mean number
of medical diagnoses per participant was 4.7, and the mean
number of medication categories prescribed per participant
was 8.2. Of these medication categories, participants were
receiving, on average, four medications that could cause dry
mouth. The most commonly prescribed medications contributing to dry mouth were antihypertensive agents. The mean
number of teeth for all participants was 15, with a higher
mean for women (18.4) compared with men (9.7).
Level of Functioning
The total mean MDS ADL Hierarchy Scale score was 4.1,
signifying total dependence in one or more of the four ADLs
(i.e., personal hygiene, toileting, locomotion, eating), with
women demonstrating a better functioning mean score (3.6)
versus men (5). Similarly, women exhibited a better cognitive functioning score (CPS mean score = 2) than men (CPS
mean score = 3.5), while the total CPS mean score was 2.38
(i.e., between mild and moderate impairment).
Based on the results of the Index of ADOH, 25% of participants (n = 2) required assistance with rinsing and brushing, and 88% (n = 7) required assistance with fluoride application. The greatest variability in function was observed
in participants ability to floss, ranging from independent (n
= 2), to requiring assistance (n = 5), to total dependence (n

Mentes et al.

of oral hygiene, both debris and calculus score, showed no

clinically significant change.
For the outcome of interestlevels of S. mutanswe
used a linear mixed-models analysis with difference in
numbers of S. mutans from baseline to any time point as
the dependent variable, and number of lollipops consumed
with the effect of time controlled as the predictor variable.
Participants who consumed more lollipops during the
21-day period were more likely to have fewer numbers of
S. mutans (b = 8.703, p = 0.067). The Figure illustrates the
effect of the lollipops on S. mutans load in 3 of the 8 participants. These participants began the study with a lower
S. mutans load and were able to maintain lower loads until Day 7, when bacterial loads increased for 2 of these 3
participants. This is explained by the fact that average adherence to the lollipop regimen decreased over time, from
78% during Days 1 to 3, to 62% in Days 3 to 7, and 54% in
Days 7 to 14, and then rising slightly to 60% in Days 14 to
21. Of 42 total lollipops, the range of lollipops consumed
was 9 to 28, with a mean of 22, or one lollipop per day.

DISCUSSION

Figure. Three participants S. mutans load during the 21 study days.

= 1). Although most participants were able to brush their

teeth, upon initial examination and cleaning, there was evidence of moderate debris in teeth, suggesting participants
did not brush on a regular basis, which appeared to be related to not being able to independently gather the supplies
needed for oral care. This has been identified in other studies
as well (Coleman & Watson, 2006; Woods & Mentes, 2011).
Effects of the Licorice Lollipop
Since licorice root in large amounts has been found to
increase blood pressure, blood pressure trending was completed for participants. Blood pressure remained stable
throughout the study, suggesting the relative safety of including herbal lollipops as a part of an oral care regimen
for NH residents (data not shown).
The results of the pre- and post-study dental examinations revealed that participants had generally good oral
health that persisted throughout the 21-day period. Indices

This study found promise in the effectiveness of herbal

lollipops to augment oral care health outcomes in NH residents by reducing S. mutans. Although statistical significance was not achieved due to the small scale of the study,
we found a decreasing trend of S. mutans bacteria with the
increasing consumption of licorice lollipops over time. Additional important findings from this pilot study were that
the intervention was best tolerated by NH residents over a
7- to 14-day period, rather than for 21 days. Participants
tended to fatigue with the intervention starting at Day 7. In
addition, it is interesting to note that, on average, the participants consumed one lollipop per day, rather than the
two that were prescribed as part of the protocol; yet, they
were able to maintain a lowered S. mutans load.
Concerning participants response to the intervention, we
found that the lollipops could be used with relative ease, with
little risk of injury to caregivers and residents with dysphagia
or dementia. Reasons participants refused the lollipop included dislike of the orange flavor, embarrassment over consuming a lollipop in front of peers, and being too tired to consume
it. Offering an assortment of flavors, as well as providing it in
a lozenge version, could make it more amenable to some NH
residents. The nursing staff provided positive feedback on the
novelty and simplicity of the concept, suggesting that caregivers may be willing to embrace licorice lollipops as a part of
oral care. The lollipop is also relatively inexpensive, approximately 40 cents each. All these factors demonstrate the prom-

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Effects of a Licorice Lollipop on S. Mutans

ising feasibility of implementing this intervention as a part of

the oral care regimen for NH residents.
Important limitations in this study were the small
sample, lack of a control group, and the inability of many
participants to provide enough saliva for analysis due to
medications and disease conditions.

CONCLUSION
An antimicrobial herbal lollipop could be a simple, noninvasive, nonpharmacological strategy to improve the oral
health of NH residents. Future research should encompass
a larger cohort with control and intervention groups, as well
as determine the optimal length of time for consumption of
lollipops and how often the regimen should be repeated. In
addition, although the lollipop intervention holds promise
for decreasing cariogenic bacteria, future research should
include the additive effect of a structured oral care regimen.

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