Probiotic Supplements and Oral Health

The use of probiotic supplements to benefit various oral health conditions has been assessed in the literature and provides an all-natural addition to the oral health armamentarium. While probiotic use is well known for promoting gastrointestinal health, it may also offer oral health benefits.

Probiotics are live cultures of bacteria that may stabilize the diverse oral microbiome when taken in appropriate doses.¹ Stabilization of the oral microbiome may provide treatment options to assist with periodontal diseases, dental caries, and oral malodor. Research suggests probiotics work by helping restore homeostasis by eliminating specific oral bacteria; they also can alter the microorganisms within the oral cavity.^1,2

With the increasing risk of antibiotic resistance, probiotics could provide a more biological approach to treating and/​or preventing oral diseases, even for patients reporting good oral self-care practices.¹ Oral probiotics are available over the counter and include lozenges, chewable tablets, gum, mouthrinse, adhesive gels, drops, and tablets.

The goal of microbial homeostasis — a balanced microbiome to promote health and salivary pH — begins with the removal of plaque biofilm to prevent microbial dysbiosis or an imbalanced microbiome.^1,2 The breakdown of microbial homeostasis can lead to an increase in pathogenic bacteria, causing gingivitis, periodontitis, and caries. Probiotics increase beneficial bacteria and restore the balance of the microbiota. In addition, probiotics may decrease plaque biofilm formation by eliminating bacterial cohesion.²

Oral health professionals should be informed on the clinical research related to probiotic use in order to provide recommendations tailored to each patient’s specific treatment needs.

Periodontal Diseases

Periodontal diseases, including gingivitis, involve a change in the microbiota associated with Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans that leads to inflammation and bone loss.^1,2 Probiotics may help reduce the risk of periodontal diseases by maintaining microbial homeostasis and quelling inflammation through elimination or attack of disease-causing bacteria.^2,3

Clinical studies indicate probiotic use alone has provided some level of reduction of bleeding and probing depths.⁴ Studies show, however, that the use of probiotics in addition to periodontal treatment (including scaling and root planing) results in greater improvement of disease when compared to the use of probiotics alone.^1,5-7

A systematic review of 21 clinical trials that assessed the role of probiotic supplements in conjunction with professional biofilm removal in combatting periodontal diseases found that the supplements containing Lactobacillus acidophilus had the most significant impact on periodontal health.²

One clinical study assessed the use of a probiotic lozenge containing Limosilactobacillus reuteri on the treatment of periodontal diseases. Results showed a statistically significant reduction in P. gingivalis within the oral microbiota.⁷ This finding indicates probiotics have the potential to alter both subgingival and supragingival plaque.¹

The use of a L. reuteri-containing lozenge in combination with clinical periodontal treatment showed reduced inflammatory cytokine levels when assessing the gingival crevicular fluid and improved clinical findings within gingival bleeding index scores and probe readings compared to clinical treatments alone.⁸

L. reuteri has also been shown to decrease P. gingivalis and A. actinomycetemcomitans in subgingival plaque; however, after 4 weeks, the plaque levels returned to predisease state.⁹ An increase in the number of healthy bacteria was found in supragingival plaque after a 12-week course of probiotics containing L. reuteri; however, at the 1-month follow up, the bacteria had returned to baseline readings of disease.¹⁰

A systematic review of 14 clinical trials investigating the impact of probiotics on gingivitis concluded that probiotics could provide increased gingival health when used long term, but more research is needed to determine if plaque removal should occur prior to or after probiotic use for best results.² The role of probiotics must be further assessed to determine appropriate dose, duration, probiotic strain used, and mode of treatment.¹¹

Dental Caries

Dental caries involves a change in the microbiota associated with Streptococcus bacteria, plaque biofilm, and the immune response. Research on the efficacy of probiotics in hindering caries-causing bacteria is limited.¹

Probiotic strains, including Lacticaseibacillus rhamnosus, L. casei, L. reuteri, and Bifidobacterium spp. may interfere with caries-causing bacteria. To be effective, research suggests that various probiotic strains must be taken together.¹

Some studies show that probiotics have long-term effects among children.^12,13 A retrospective study using the decayed, missing, filled teeth index and caries management by risk assessment scores indicated a statistically significant caries reduction in caries-causing bacteria 3 years post-probiotic treatment. The probiotic strains included in the supplements studied were L. reuteri, S. oralis KJ3, S. uberis KJ2, and S. rattus JH145.¹³ This retrospective research indicated that a 1-month regimen of probiotic supplements resulted in long-term benefits to participants at high caries risk.¹³ Probiotic supplementation may provide a natural approach to reducing caries-causing bacteria among those at high risk of tooth decay and those who consume high amounts of fermentable carbohydrates.

A systematic review assessed 17 clinical trials in children and six in adults and found that the bacterial plaque in children with high caries risk was more easily modified with short-term probiotic supplementation than the bacteria of adults.² The supplements studied were L. acidophilus, L. reuteri, S. dentisani, S. salivarius, B. lactis, and L. paracasei and results showed they were effective when used in collaboration with at-home oral hygiene regimens and nutritional counseling among children at high caries risk.² Many of these probiotic strains are found in dairy products, which can be a highly successful administrative route for children as well as offering additional beneficial nutrients.

The use of bacterial replacement therapy may produce long-term effects in reducing caries with re-application. Genetically modifying S. mutans can change the genetic sequence to remove lactic acid production associated with the bacteria, a contributing factor in caries formation.¹⁴

Oral Malodor

Oral malodor may be caused by maladies such as periodontal diseases or its origin may be the presence of physiological bacteria on the tongue, particularly in the difficult-to-access dorsal posterior surface and circumvallate papillae.¹ Other contributing factors include smoking, respiratory illness, xerostomia, imbalance of the oral microbiome, and volatile sulfur compounds (VSCs) from alteration of oral bacteria.²

Probiotics may increase the number of healthy bacteria of the tongue as well as decrease VSCs. Targeting the tongue’s papillae would require a more specific probiotic strain. In vivo studies have shown much variability in the ability of probiotic lozenges to reduce VSCs.¹

A systematic review that assessed four clinical trials on probiotics and oral malodor found that the consistent use of probiotic strains L. salivarius, S. salivarius, Weissella cibaria, and L. reuteri did reduce oral malodor when used with good oral self-care.² Future research should determine which strains can adhere to the tongue to reduce odor-causing bacteria.

Role of the Dental Hygienist

Oral health professionals need to be knowledgeable about the probiotic supplements available to improve oral health. Testing the composition of the oral microbiome prior to recommending a specific strain of supplement is supported by evidence. Patients also need to be evaluated on their willingness to comply with a probiotic supplement regimen.

Regularly reviewing systemic and meta-analyses on the use of probiotics in oral health will help oral health professionals make effective patient recommendations. Patient demographics, including diagnosis and age, should also be considered. Providing instructions on best practices for probiotic use is also imperative to increase patient acceptance and confidence.

Conclusion

The use of probiotic supplements to improve oral health can be a helpful addition to clinical dental hygiene treatment with the ultimate goal of balancing the oral microbiome.¹³ More research is needed to better understand how this therapy may help all patient populations improve their oral health.

References

1. Allaker RP, Stephen AS. Use of probiotics and oral health. Curr Oral Health Rep. 2017;4:309-318.
2. Saiz P, Taveira N, Alves R. Probiotics in oral health and disease: a systematic review. Appl Sci. 2021;11:1-19.
3. Saha S, Tomaro-Duchesneau C, Tabrizian M, Prakash S. Probiotics as oral health biotherapeutics. Expert Opin Biol Ther. 2012;12:1207–1220.
4. Teughels W, Loozen G, Quirynen M. Do probiotics offer opportunities to manipulate the periodontal oral microbiotaJ J Clin Periodontol. 2011;38(Suppl 11):159–177.
5. Bidault P, Chandad F, Grenier D. Risk of bacterial resistance associated with systemic antibiotic therapy in periodontology. J Can Dent Assoc. 2007;73:721–729.
6. Rams TE, Degener JE, van Winkelhoff AJ. Antibiotic resistance in human chronic periodontitis microbiota. J Periodontol. 2014;85:160–169.
7. Teughels W, Durukan A, Ozcelik O, et al. Clinical and microbiological effects of Lactobacillus reuteri probiotics in the treatment of chronic periodontitis:a randomized placebo-controlled study. J Clin Periodontol. 2013;40:1025–1035.
8. Szkaradkiewicz AK, Stopa J, Karpiński TM. Effect of oral administration involving a probiotic strain of Lactobacillus reuteri on proinflammatory cytokine response in patients with chronic periodontitis. Arch Immunol Ther Exp. 2014;62:495–500.
9. Iniesta M, Herrera D, Montero E, et al. Probiotic effects of orally administered Lactobacillus reuteri-containing tablets on the subgingival and salivary microbiota in patients with gingivitis. a randomized clinical trial. J Clin Periodontol. 2012;39:736–744.
10. Vestman NR, Chen T, Holgerson PL, et al. Oral microbiota shift after 12-week supplementation with Lactobacillus reuteri DSM 17938 and PTA 5289; a randomized control trial. PLoS One. 2015;10:1–18.
11. Vuotto C, Longo F, Donelli G. Probiotics to counteract biofilm associated infections: promising and conflicting data. Int J Oral Sci. 2014;6:189–194.
12. Cannon M, Trent B, Voacheck A, et al. Effectiveness of CRT at measuring the salivary level of bacteria in caries prone children with probiotic therapy. J Clin Pediatr Dent. 2013;38:55-60.
13. Cannon M, Vorachek A, Le C, et al. Retrospective review of oral probiotic therapy. J Clin Pediatr Dent. 2019;43:367-371.
14. Hillman JD, Brooks TA, Michalek SM, et al. Construction and characterization of an effector strain of Streptococcus mutans for replacement therapy of dental caries. Infect Immun. 2000;68:543–549.

From Dimensions of Dental Hygiene. April/May 2024; 22(3):14-17