|Year : 2016 | Volume
| Issue : 7 | Page : 1-6
Probiotics and its insinuation in oral health
Apexa B Patel1, B Patel Advaita2, Baldev V Patel3
1 College of Dental Sciences and Research Centre, School of Sciences, Gujarat University, Ahmedabad, Gujarat, India
2 Department of Pharmaceutical Chemistry, Kalol Institute of Pharmacy, Kalol, Gujarat, India
3 Department of Microbiology, School of Sciences, Gujarat University, Ahmedabad, Gujarat, India
|Date of Web Publication||28-Jul-2016|
Apexa B Patel
College of Dental Sciences and Research Centre, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
For some years now, bacteria known as probiotics have been added to various foods because of their beneficial effects in human health. Probiotics are microorganisms, principally bacteria, which confer health benefits beyond basic nutrition when ingested. Probiotics have been studied for their health-promoting effects. The mechanism of action of probiotics is related to their ability to compete with pathogenic microorganisms for adhesion sites, to antagonize these pathogens or to modulate the host's immune response. The main field of research has been always focused on the gastrointestinal tract. However, recently, probiotics have also been investigated from an oral health perspective, and their use has shown promising results with respect to control of chronic conditions such as dental caries, periodontitis, halitosis and candidal infections, acquired immunodeficiency syndrome, and in voice prosthesis. The potential application of probiotics for oral health has recently attracted the attention of researchers. Although only a few clinical studies have been conducted so far. This article summarizes the current status of using probiotics and its insinuation in oral health.
Keywords: Bacteria, microorganisms, oral health, probiotics, Streptococcus mutans
|How to cite this article:|
Patel AB, Advaita B P, Patel BV. Probiotics and its insinuation in oral health. N Niger J Clin Res 2016;5:1-6
| Introduction|| |
The role of diet in health and well-being is universally acknowledged. With the evolution of the science of nutrition, research is now being directed toward improving the understanding of specific physiologic effects of the diet beyond its nutritional effect. In this aspect, probiotics are the subject of intense and widespread research in food and nutritional science and in oral health. 
According to the currently adopted definition by FAO/WHO, probiotics are defined as: "Living microorganisms, principally bacteria, safe for human consumption and when ingested in sufficient quantities, have beneficial effects on human health, beyond basic nutrition."  The term prebiotic was introduced by Gibson and Roberfroid.  A prebiotic is a nondigestible food ingredient conferring benefits on the host by selectively stimulating the growth and/or activity of one species of bacteria or group of bacteria in the colon, thus improving the host's health. In the oral cavity, probiotics can create a biofilm, acting as a protective lining for oral tissues against oral diseases. Such a biofilm keeps bacterial pathogens off oral tissues, by filling a space which pathogens would otherwise invade, and by competing with cariogenic bacteria and growth of periodontal pathogens. The term synbiotic is used when a product contains both probiotics and prebiotics. As the word alludes to synergism, this term should be reserved for products in which the prebiotic compound selectively favors the probiotic compound.  The term replacement therapy, also called bacteriotherapy or bacterial interference, is sometimes used interchangeably with the term probiotics. Although both treatment modalities use live bacteria for the prevention or treatment of infectious diseases, there are some slight differences. Replacement therapy involves the direct application of the effector strain to the site of infection, and it is directed at displacing or preventing colonization by a pathogen. Probiotics are generally used as dietary supplements and act indirectly in preventing colonization by pathogens. 
| Probiotics Derivatives|| |
Probiotics are basically derived from:
- A culture concentrate added to a beverage or food, for example, fruit juice
- Inoculated into prebiotic fibers
- Inoculants into a milk-based food, for example, dairy products such as milk, milk drink, yogurt, cheese, kefir, and biodrink sauerkraut, kvass, natto, kombucha [Figure 1]
- As concentrated and dried cells packaged as dietary supplements (nondairy products) such as powder, capsule, and gelatin tablets. ,
| Composition of Probiotics|| |
Probiotics can be yeast, bacteria, or molds. Most commonly they are bacteria. 
Some of these bacterial species include:
Microorganisms considered to be probiotics are shown in [Table 1].
- Lactic acid producing bacteria (LAB): Lactobacillus, Bifidobacterium, Streptococcus
- Non-LAB species: Bacillus, Propionibacterium
- Nonpathogenic yeasts: Saccharomyces
- Nonspore-forming and nonflagellated rod or Coccobacilli.,,
Characteristics of Classic Probiotic Microorganisms
- Should have beneficial effect on host animal
- Should be nonpathogenic and nontoxic
- Should replace and resist the intestinal microflora
- Should be capable of surviving and metabolizing in the gut environment, for example: Resistant to low pH
- Should remain viable under storage for duration
- Should be safe for human consumption and beneficial physiological effects should be scientifically demonstrable
- Should be stable in acidic and alkaline environments
- Should be microbiologically characterized and to have been subjected to randomized clinical trials
- Should be able to adhere to the intestinal mucosa or the target tissue
- Should demonstrate high stability at room temperature, either separately or when mixed with other ingredients
- Should have no potential to develop diseases. ,,
| Mechanism of Action|| |
The mechanism of action of probiotics in oral health is by two mechanisms shown in [Table 2]. ,
- Direct Action
- Indirect Action.
| Probiotics and Dental Caries|| |
- Dental caries is a multifactorial disease of bacterial origin that is characterized by acid demineralization of the tooth enamel. ,, Streptococcus mutans is one of main causative organism for dental caries. Elevated levels of Streptococcus counts are strongly associated with increased risk of dental caries ,
- Nikawa et al. reported that consumption of yogurt containing Lactobacillus reuteri over a period of 2 weeks reduced the concentration of S. mutans in the saliva by up to 80%. Comparable results were obtained by incorporating probiotics into chewing gum or lozenges 
- Dental caries is one of the most common oral diseases that needs early prevention and intervention. To remove cariogenic bacteria from the teeth surface to fight against dental caries. First, a probiotic must be able to adhere to dental surfaces and integrate into the bacterial communities making up the dental biofilm. Second, they must become a part of the biofilm that develops on teeth. Finally, they must compete with cariogenic bacteria. All these effects of probiotics help in a drastic reduction of the levels of cariogenic bacterial growth ,
- Probiotics incorporated into dairy products neutralize acidic conditions. For example, it has been reported that cheese prevents demineralization of the enamel and promotes its remineralization ,
- In other studies, one strain of Lactobacillus rhamnosus and the species Lactobacillus casei inhibited in vitro growth of two important cariogenic streptococci, S. mutans, and S. sobrinus,
- More recently, Petti et al. reported that yogurt containing Streptococcus thermophilus and Lactobacillus bulgaricus had selective bactericidal effects on streptococci of the mutans group. Recent clinical studies have demonstrated that regular consumption of yogurt, milk, or cheese containing probiotics led to a decrease in the number of cariogenic streptococci in the saliva and a reduction in dental plaque ,,,,
- In 2001, Näse et al.  published the results of an l7-month study of 594 children 1-6 years of age that evaluated the effects on dental caries of consuming milk supplemented with a strain of L. rhamnosus. They concluded that children consuming milk containing this probiotic, particularly those 3-4 years of age, had significantly fewer dental caries and lower salivary counts of S. mutans than controls. With the diversity of the oral microflora and the mechanisms of action of beneficial bacteria, it seems plausible that probiotics would have a favorable effect on the reduction of dental caries. 
| Probiotics and Periodontal Disease|| |
- Periodontal disease is classified into two types: Gingivitis and periodontitis. Gingivitis is characterized by inflammation limited to the unattached gingiva, whereas periodontitis is a progressive, destructive disease that affects all supporting tissues of the teeth including the alveolar bone. The main pathogenic agents associated with periodontitis are Porphyromonas gingivalis, Treponema denticola, Tannerella forsythia, and Aggregatibacter actinomycetemcomitans,
- Twetman et al. used L. reuteri-containing chewing gum in 42 healthy patients and assessed the effects on crevicular fluid volume, cytokine (interleukin-1ß, interleukin-6, interleukin-10, and tumor necrosis factor-alpha [TNF-α]) levels, and bleeding on probing. He found crevicular fluid volume, the levels of TNF-α and interleukin-8 and bleeding were all significantly reduced 
- The primary etiological factors for the development of periodontal diseases are bacteria in supra and subgingival biofilms. Mucosal immune responses may be invoked by probiotic immunization. A proposed mechanism of action of probiotics is the strengthening of the mucosal barrier via topical effects on the epithelium, and the stimulation of both the innate and adaptive immune systems. A decrease in gingival bleeding and reduced gingivitis has been observed by Krasse et al. with the ingestion of L. reuteri
- According to Koll-Klais et al. probiotics containing Lactobacillus effected an 82% and 65% inhibition in growth in, respectively, P. gingivalis and Prevotella intermedia
- Riccia et al. used lozenges into which L. brevis was incorporated to study its anti-inflammatory effects in a group of patients with chronic periodontitis. The study showed significant improvement, not only in the plaque index, gingival index, and bleeding on probing for all patients but also a significant reduction in gingival inflammation 
- Probiotic strains included in periodontal dressings at optimal concentrations of 108 CFU/mL were shown to diminish the number of the most frequently isolated periodontal pathogens: Bacteroides spp., Actinomyces spp., and S. intermedius and also Candida albicans
- Probiotic bacteria may favor periodontal health and may even recolonize a gingival pocket after scaling and root planing if they are able to establish themselves in the oral biofilm. However, further longitudinal studies are required to confirm these findings. ,,,,,
| Probiotics and Halitosis|| |
- Halitosis (bad breath) affects the large proportion of the population. It is a common problem with multiple local and systemic etiological factors. The main oral causes include periodontitis, poor plaque control, deep dental caries, tongue coating and faulty restorations, along with gastrointestinal, and lung infections
- Halitosis can be caused by sulfur-containing gases (hydrogen sulfide, methyl mercaptan, and dimethyl sulfide), which are derived from the bacterial degradation of sulfur-containing amino acids in the oropharynx predominantly from Gram-negative anaerobes. Most of the pathology causing halitosis lies within the oropharynx (tongue coating, gingivitis, periodontitis, and tonsillitis) ,
- L. salivarius TI2711 bacteria have been shown to reduce the count of the oral black-pigmented bacteroides, the bacteria strongly associated with production of the volatile sulfur compounds (VSC's) responsible for halitosis 
- Halitosis is a condition normally ascribed to disturbed commensal microflora equilibrium. It has recently been positively affected by regular administration of probiotics. Kang et al. have shown a definite inhibitory effect on the production of VSC's by Fusobacterium nucleatum after ingestion of Weissella cibaria both in vitro and in vivo
- However, the few studies published on the role of probiotics in the treatment of halitosis do not confirm any evidence-based conclusions. It may be that this is where probiotic therapy could indeed bring something new, if there is confirmation of preliminary observations on the "balancing" effect of probiotics on the oral microflora which generate VSCs. Randomized, blinded, and placebo-controlled studies with large enough sample sizes are also needed in this endeavor. ,
| Probiotics and Oral Candidiasis|| |
- C. albicans is among the most common infectious agents present in the oral cavity. Consumption of probiotic cheese containing L. rhamnosus GG and Propionibacterium freudenreichii ssp. Shermanii JS shown decrease in C. albicans count ,
- It is important to extend research on yeast infections with respect to probiotics. Analyzing the molecular mechanisms of probiotic activity might further broaden the field of potential applications. 
| Probiotics and HIV|| |
- Recently, the role of probiotics to slow down the progression of acquired immunodeficiency syndrome has been postulated by Lin Tao et al. (2008). A screening of saliva taken from hundreds of volunteers showed that some Lactobacillus strains produced proteins capable of binding a particular type of sugar, called mannose, found on HIV envelope
- The binding of the sugar enables the bacteria to stick to the mucosal lining of the mouth and digestive tract and colonize them. One of the strain showed abundant mannose-binding protein particles into its surroundings which binded to the sugar coating and hence neutralized HIV
- They also observed that immune cells trapped by lactobacilli formed a clump. This configuration would any immune cells harboring HIV and prevent them from infecting other cells. 
| Probiotics and Voice Prosthesis|| |
- It should be noted that there is no research regarding the relationship between dental restorative materials and probiotics. However, in larynx, the second barrier after oropharynx, probiotics strongly reduce the occurrence of pathogenic bacteria in voice prosthetic biofilms ,
- There is anecdotal evidence among patients in the Netherlands that the consumption of buttermilk, which contains Lactococcus cremoris, Lactococcus lactis ssp. that can produce antimycotics and other substances, prolongs the lifetime of indwelling voice prostheses
- Recent research has suggested that consumption of 2 kg/day of Turkish yogurt effectively eliminates biofilm formation on indwelling voice prostheses, possibly related to the presence of S. thermophilus and L. bulgaricus in Turkish yogurt. Lactobacilli have long been known for their capacity to interfere with the adhesion of uropathogens to epithelial cells and catheter materials, whereas S. thermophilus can effectively compete with yeasts in their adhesion to substratum surfaces such as silicone rubber. Further research should be carried out to determine if it will be possible to treat other infections of the upper digestive tract, such as esophagitis, with probiotic containing dairy products rather than with antibiotics. ,
| Role of Probiotics in General Health|| |
Studies have shown that probiotics are used to treat various health problems such as inflammatory bowel disease and gastrointestinal disorders in treating antibiotic-associated and traveler's diarrhea, in delaying the onset of cancer, to treat lactose intolerance and elevated cholesterol. They are also used to treat alcoholic liver diseases, ulcerative colitis, in individuals with an allergy to milk protein, asthma, hepatic encephalopathy, juvenile chronic arthritis, hypertension, urogenital infections, and to aid in calcium absorption. ,
| Administration Methods of Probiotics|| |
Milk products, supplemented with probiotics, are natural means of oral administration and can be easily adopted in most dietary regimens. However, for the purposes of prevention or treatment of oral diseases, it is specifically targeted applications, formulas, devices, or carriers with slow release of probiotics, which will be needed. Montalto et al. administered probiotic mixtures, both in capsules and in liquid form, without observing statistically significant differences in the S. mutans counts between the two test groups. ,,
The different vehicles used to administer probiotics are as shown in [Figure 2]. 
| Safety Measures Concerns Regarding Probiotics|| |
Due to increased probiotics supplementation of different food products, safety measures are a major concern. Probiotics are often regulated as dietary supplements rather than as pharmaceutical or biological products. For the safety purpose, probiotic microorganisms should not be pathogenic, should not have any growth stimulating effects on bacteria causing diarrhea, should not have an ability to transfer antibiotic resistance genes, and should not cause sepsis or bacteremia. The probiotic should maintain genetic stability in oral microflora. ,,
Lactobacillus-induced bacteremia is a relatively rare condition, with approximately 180 cases reported over the last 30 years. Clinical characteristics of Lactobacillus-induced bacteremia are highly variable, ranging from asymptomatic to serious septic conditions. However, these symptoms are particularly seen in individuals who have severe underlying diseases, or who are immunocompromised. Careful monitoring of patients is mandatory for this potentially serious condition. ,,,,
| Future Prospectives of Probiotics in Oral Health|| |
Many researchers have reported significant benefits in oral health on administration of probiotics. Genetic engineering and the recombinant DNA technology can further improve the probiotic characteristics. Lactic acid production by acidogenic bacteria has been considered to be the major cause for the production of caries lesion. The probiotic acidogenic bacteria can be engineered genetically to prevent dental caries. , Mutations can be induced to create the mutants with increased bacteriocin production. Such mutant strains displace the indigenous strains and colonize the oral cavity. Still many in vitro and in vivo tests for the presence of the desirable characteristics must be carried out, and various random trials need to be performed to find out the most potent probiotics organisms for oral health and the most effective ways of their administration. In future, probiotics application can be extended to cure many health-related problems. The critical steps in wider application will be to make products available that are safer and clinically proven in a specific formulation, which should be easily accessible to physician and consumers. In India, sporlac, i.e. Sporolactobacilli is commonly used probiotic. Recently, Bacillus mesentericus is used as an alternate to B-complex. Genetically, modified LAB have been proposed as a vehicle to deliver vaccines in the gastrointestinal tract. ,,,,
| Conclusion|| |
Probiotics represent a new area of research in oral health, the examination of the close relationships between food and oral health. Preliminary data obtained by various research laboratories have been encouraging, but numerous randomized clinical studies will be required to clearly establish the potential of probiotics in preventing and treating oral infections. Such studies will allow identification of the probiotics that are best suited to oral use, as well as the most appropriate vehicles: Food products (cheese, milk, and yogurt) or supplements (chewing gum and lozenges). The existence of probiotics in the indigenous oral microflora of humans warrants exploration because these bacteria offer the advantage of being perfectly adapted to the human oral ecosystem. ,,,,,,,,,,,,,,,,,,,
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Reddy JJ, Sampathkumar N, Aradhya S. Probiotics in dentistry: Review of the current status. Rev Clín Pesq Odontol 2010;6:261-7.
Ross RP, Desmond C, Fitzgerald GF, Stanton C. Overcoming the technological hurdles in the development of probiotic foods. J Appl Microbiol 2005;98:1410-7.
Gibson GR, Roberfroid MB. Dietary modulation of the human colonic microbiota: Introducing the concept of prebiotics. J Nutr 1995;125:1401-12.
Schrezenmeir J, de Vrese M. Probiotics, prebiotics, and synbiotics - Approaching a definition. Am J Clin Nutr 2001;73 2 Suppl: 361S-4S.
Pradeep K, Kuttappa MA, Prasana KR. Probiotics and oral health: An update. SADJ 2014;69:20-4.
Singh T, Majumdar S, Ghosh AK, Pal SP, Waghle SR, Dakchiyani MB. Probiotics in oral health: A review. J Adv Med Dent Sci Res 2014;2:62-5.
Caglar E, Kargul B, Tanboga I. Bacteriotherapy and probiotics' role on oral health. Oral Dis 2005;11:131-7.
Jain P, Sharma P. Probiotics and their efficacy in improving oral health: A review. J Appl Pharm Sci 2012;2:151-63.
Babaji P, Keswani K, Lau H, Lau M, Sharma N, Punga R. Role of probiotics in oral health: A review of the literature. J Educ Ethics Dent 2012;2:52-5.
Parvez S, Malik KA, Ah Kang S, Kim HY. Probiotics and their fermented food products are beneficial for health. J Appl Microbiol 2006;100:1171-85.
Nikawa H, Makihira S, Fukushima H, Nishimura H, Ozaki Y, Ishida K, et al. Lactobacillus reuteri
in bovine milk fermented decreases the oral carriage of mutans streptococci. Int J Food Microbiol 2004;95:219-23.
Stamatova I, Meurman JH. Probiotics: Health benefits in the mouth. Am J Dent 2009;22:329-38.
Reddy RS, Swapna LA, Ramesh T, Singh TR, Vijayalaxmi N, Lavanya R. Bacteria in oral health - Probiotics and prebiotics a review. Int J Biol Med Res 2011;2:1226-33.
Gedalia I, Ionat-Bendat D, Ben-Mosheh S, Shapira L. Tooth enamel softening with a cola type drink and rehardening with hard cheese or stimulated saliva in situ
. J Oral Rehabil 1991;18:501-6.
Jensen ME, Wefel JS. Effects of processed cheese on human plaque pH and demineralization and remineralization. Am J Dent 1990;3:217-23.
Näse L, Hatakka K, Savilahti E, Saxelin M, Pönkä A, Poussa T, et al.
Effect of long-term consumption of a probiotic bacterium, Lactobacillus rhamnosus
GG, in milk on dental caries and caries risk in children. Caries Res 2001;35:412-20.
Meurman JH, Antila H, Korhonen A, Salminen S. Effect of Lactobacillus rhamnosus
strain GG (ATCC 53103) on the growth of Streptococcus sobrinus in vitro
. Eur J Oral Sci 1995;103:253-8.
Petti S, Tarsitani G, Simonetti D'Arca A. Antibacterial activity of yoghurt against viridans streptococci in vitro
. Arch Oral Biol 2008;53:985-90.
Ahola AJ, Yli-Knuuttila H, Suomalainen T, Poussa T, Ahlström A, Meurman JH, et al.
Short-term consumption of probiotic-containing cheese and its effect on dental caries risk factors. Arch Oral Biol 2002;47:799-804.
Caglar E, Kavaloglu SC, Kuscu OO, Sandalli N, Holgerson PL, Twetman S. Effect of chewing gums containing xylitol or probiotic bacteria on salivary mutans streptococci and lactobacilli. Clin Oral Investig 2007;11:425-9.
Caglar E, Cildir SK, Ergeneli S, Sandalli N, Twetman S. Salivary mutans streptococci and lactobacilli levels after ingestion of the probiotic bacterium Lactobacillus reuteri
ATCC 55730 by straws or tablets. Acta Odontol Scand 2006;64:314-8.
Montalto M, Vastola M, Marigo L, Covino M, Graziosetto R, Curigliano V, et al.
Probiotic treatment increases salivary counts of lactobacilli: A double-blind, randomized, controlled study. Digestion 2004;69:53-6.
Krasse P, Carlsson B, Dahl C, Paulsson A, Nilsson A, Sinkiewicz G. Decreased gum bleeding and reduced gingivitis by the probiotic Lactobacillus reuteri. Swed Dent J 2006;30:55-60.
Persson GR. Immune responses and vaccination against periodontal infections. J Clin Periodontol 2005;32 Suppl 6:39-53.
Volozhin AI, Il'in VK, Maksimovskii IuM, Sidorenko AB, Istranov LP, Tsarev VN, et al
. Development and use of periodontal dressing of collagen and Lactobacillus casei
37 cell suspension in combined treatment of periodontal disease of inflammatory origin (a microbiological study). Stomatologiia (Mosk) 2004;83:6-8.
Flichy-Fernández AJ, Alegre-Domingo T, Peñarrocha-Oltra D, Peñarrocha-Diago M. Probiotic treatment in the oral cavity: An update. Medicina Oral Patologia Oral Cirugia Bucal. 2010;15:677-80.
Kang MS, Na HS, Oh JS. Coaggregation ability of Weissella cibaria
isolates with Fusobacterium nucleatum
and their adhesiveness to epithelial cells. FEMS Microbiol Lett 2005;253:323-9.
Busscher HJ, Free RH, Van Weissenbruch R, Albers FW, Van Der Mei HC. Preliminary observations on influence of dairy products on biofilm removal from silicone rubber voice prostheses in vitro
. J Dairy Sci 2000;83:641-7.
Narang S, Gupta R, Narang A. Probitics in oral health care - A review. Int J Sci Eng Res 2011;2:1-5.
Vanderhoof JA. Probiotics: Future directions. Am J Clin Nutr 2001;73:1152S-5S.
Hatakka K, Ahola AJ, Yli-Knuuttila H, Richardson M, Poussa T, Meurman JH, et al
. Probiotics reduce the prevalence of oral candida in the elderly - A randomized controlled trial. J Dent Res 2007;86:125-30.
Grajek W, Olejnik A, Sip A. Probiotics, prebiotics and antioxidants as functional foods. Acta Biochim Pol 2005;52:665-71.
[Figure 1], [Figure 2]
[Table 1], [Table 2]