Role of Probiotics As Bacteriotherapy in Dentistry: A Literature Review
Role of Probiotics As Bacteriotherapy in Dentistry: A Literature Review
Role of Probiotics As Bacteriotherapy in Dentistry: A Literature Review
a literature review
Riveros-Figueroa4
DOI: 10.22592/o2017n30a2
Abstract.
According to WHO and FAO, probiotics are “live microorganisms which when
administered in adequate amounts confer a health benefit on the host”. The aim of this
paper is to describe the beneficial effects of probiotics on oral disease prevention. The
search included the last five years in the Web of Science, PubMed and SciELO.
Results showed that probiotics can produce antimicrobials, compete for cell adhesion
sites, modulate the immune system and degrade toxins. This has led to dental studies
that focus on reducing caries incidence, improving the prognosis of periodontitis and
decreasing halitosis and candidiasis. Probiotics may be a valuable adjunct for the
prevention of oral diseases. However, there are still doubts about which are the best
bacterial strain, dose and timing of administration. Therefore, future longitudinal studies
are required.
1.
Pediatric Dentistry. PhD, Associate Professor, Department of Pediatric Dentistry,
ORCID: 0000-0002-0308-6044
2.
EDF Dentist, Cesfam Cordillera Andina, Servicio de Salud Aconcagua. Dental
ORCID:0000-0002-9532-9874
3.
Dental Surgeon. School of Dentistry, Universidad de Concepción, Chile. ORCID:
0000-0002-1954-8565
4.
Dental Surgeon. School of Dentistry, Universidad de Concepción, Chile.
ORCID:0000-0001-8842-2205
Introduction
The term “probiotics” literally means “for life” and was coined for the first time in the
1960s(1,2). According to the report of the World Health Organization (WHO) and the
Food and Agriculture Organization of the United Nations (FAO) (2002), probiotics are
benefit on the host”(3). It is from this view that the concept of bacteriotherapy emerges,
which is the term used when a harmless strain is implanted in the host’s microflora to
maintain or restore the natural microbiome through the interference and/or inhibition of
diseases, with fewer side effects than conventional drugs, and it also helps treat
disorders that seem to have no connection with the bacteria, such as asthma, obesity
and diabetes(4-6). From this perspective, scientific evidence has shown that probiotics
can improve the condition of patients with medical disorders, such as diarrhea,
gastroenteritis, short-bowel syndrome, inflammatory bowel disease, cancer,
liver diseases, infections with Helicobacter pylori, and urinary tract infections(7-9). In the
last decade, the use of probiotics has generated interest within the dental community
with the development of studies focused on reducing caries incidence, improving the
candidiasis(4,7,9).
Method
A search was conducted in the following databases: Web of Science, PubMed and
3. Language: English/Spanish
Keywords: Probiotics AND Dental Caries and Prevention: we found 75 papers, of which
Resource availability
There are several products with different probiotic bacterial strains in the market:
chewing gum, tablets or pills and dairy products such as milk, ice cream, cheese, and
yogurt. The latter are the most natural ones, easiest to find and most widely accepted
by the population, especially children(2,10,11). Several studies have compared the use of
probiotics in dairy products with placebos or probiotic products with similar functions
(fluoride, chlorhexidine, coconut oil, etc.), but very few have compared them to each
other. A study conducted by T. Madhwani et al. compared the use of probiotics in ice
cream and drinks, and showed that ice cream would be a better option as it maintains a
significant reduction of S. mutans in saliva levels after 90 days of consumption(10).
Regarding its use in dentistry, we must consider that dairy products should be the
vehicle for the administration of probiotics, since they contain casein phosphopeptides
Mechanism of action
Several mechanisms have been proposed for the potential beneficial effect of
proliferation of pathogens.
4. Degradation of toxins.
All available data show that the effects of probiotics are species- and
strain-specific(4,8,12-15). The optimal dose for dental diseases has not yet been explored,
as the dose regimens adopted so far are based on standards for the gastrointestinal
tract and for pediatric health care. However, we know there are between 75 and 100
bacterial species in the mouth of each person, and that different people have different
combinations of species. In other words there is no “one size fits all” solution, so we
may need a mixture of beneficial strains rather than a single strain as oral
The probiotic bacterial species most widely studied belong to the Lactobacillus and
oral biofilm and account for approximately 1%. Bifidobacterium are produced only in
small amounts in oral biofilm(17,18). The focus is on these species because they are
produced in the dairy industry and are rarely involved in human infections. In fact,
these bacteria have a symbiotic relationship with human beings. They are present in
the mucous membrane of intestinal epithelial cells, inhibiting the growth and
aciduric. They are generally considered cariogenic and could be considered a risk for
these bacteria counteracts their acidity(15,21). In addition, several studies have shown
that Lactobacillus are late mediators in the progression of carious lesions due to their
poor adhesion properties. Therefore, they do not increase the incidence of new lesions,
although little is known about the effect they could have on pre-existing lesions(15,17,18).
probiotics(17).
These studies claim that probiotics strains can be detected in the saliva during their
consumption, but when consumption ceases, they disappear from the oral cavity within
a few weeks(6). Some of the studies were short-term clinical trials (days or weeks), and
others long-term studies (six months to one year). They used different vehicles (tablets,
milk, ice cream, cheese, and sweets) and worked with different age groups
The literature also mentions in vitro studies, where the following strains are used:
reduce the colonization of Streptococcus mutans in vitro. Both probiotics are used
in Chilean dairy products: Lactil and Chamyto respectively. Their effect was
evaluated in four different concentrations (1, 1/10, 1/100 and 1/1000), but no
significant differences were found. However, the probiotic strain Lactobacillus casei,
Lactobacillus reuteri strains ATCC PTA 5289: it adheres and forms a biofilm on
the hydroxyapatite coated with saliva, competing with Streptococcus mutans for a
place on the enamel(26). These results were obtained in an in vitro study. However a
administration ceased(19).
There are currently patented dental probiotics available that include Lactobacillus
Despite the large amount of scientific evidence, more randomized clinical trials are
needed to identify the best combinations of probiotic strains, as well as their vehicles
Terai et al. accepted the challenge and proposed new potential candidates. They
selected 14 Lactobacillus strains and 36 Streptococcus strains from 896 oral isolates
taken from 56 healthy volunteers aged between 25 and 66, based on the following
parameters: the bacteria should not produce VSC (volatile sulfur compounds), should
have antibacterial activity against pathogens that cause periodontal disease and dental
cells in vitro, should not have cariogenecity potential in an artificial mouth system, and
should not induce endocarditis in a rat model. Based on these parameters, the best
candidates to be tested in a randomized clinical trial with humans would be:
L. crispatus YIT 12319, L. fermentum YIT 12320, L. gasseri YIT 12321, 12322 and
S. mitis YIT(20).
The oral cavity is a habitat for a large diversity of microorganisms including bacteria,
yeasts and viruses; all associated with oral infections. Bacteria are dominant in this
microflora, and the diversity of species found in the oral cavity reflects the various types
of habitat for colonization and the opportunity to survive as biofilm. However, the
balance between this microflora and the host can be interrupted, resulting in diseases
Dental caries
To understand the role of probiotics in the prevention of dental caries, we must first
Hypothesis”, caries pathogens may occur (or be transmitted) in a low number in the
oral biofilm, which is compatible with oral health. However, if there is an imbalance in
this oral biofilm due to changes in local environmental conditions, there would be a
higher number of pathogens, which would cause dental caries. Some of these changes
or “ecological pressures” are: a diet rich in carbohydrates, decreased salivary flow and
low oral pH. Under these circumstances, the pathogens that compete with the
indigenous microflora reach the numerical dominance levels necessary for the disease
presents it as a complex disease. Although it starts through microbial action, the main
pathogenic species linked to its development are endogenous and not exogenous,
which significantly increase their number when there is a favorable change of the
infectious disease(21).
Therefore, dental caries can be prevented by implementing two approaches: 1) directly
responsible for pathogen selection(17). In view of this, the studies conducted in the last
the use of probiotics (first approach) and making favorable ecological changes to the
disrupted oral environment, such as increasing local pH and salivary flow (second
approach)(2.13).
There are a number of randomized clinical trials that indicate that probiotics from
mutans (the main bacterial species that causes dental caries)(8,10-13,17,19,22-25). However,
associated with fewer cavities or reduced risk of tooth decay. Attempts have been
made to combine professional dental cleaning and the use of antibacterial agents with
the use of probiotics, in order to amplify the inhibitory effect and slow the growth of the
pathogen(5,9).
Hedayati-Hajikand et al. found that the combined use of chewable tablets with
ProBiora3® (combination of S. uberis KJ2, S. oralis KJ3 and S. rattus JH145) and the
daily use of fluoride toothpaste decreased early demineralization of the enamel, but
chewable tablets presented no new caries lesions in the period under study. This
suggests that the appearance of tooth decay could be reduced through daily
preschoolers(12).
Periodontal disease
Efforts to prevent and treat periodontal disease focus mainly on reducing endogenous
epithelial barrier, thus helping reduce susceptibility to infection. Probiotic bacteria can
promote periodontal health if they can establish themselves in the oral biofilm and
inhibit the growth of periodontal pathogens and their metabolism. Less is known about
probiotics and their effect on periodontal disease than about probiotics and caries.
Efforts are being made to study the effect of probiotics on clinical parameters (plaque
(LGG) and Bifidobacterium animalis sub species lactis Bb-12 (BB-12) reduces the
amount of plaque and it is clinically relevant for the reduction of gingival inflammation.
The combination of LSG and BB-12 seems to be even more effective in comparison to
each one alone. On the whole, it would improve the periodontal condition of healthy
subjects, without affecting the composition of the adhesion properties or the oral
It has been recently shown that Lactobacillus reuteri (Periobalance®) decreases the
reducing plaque levels and gingival inflammation in subjects with moderate to severe
gingivitis. The host’s immune modulation could explain their action in improving
periodontal status, since there was no change in the oral microbiota or the adhesion
cytokines in the crevicular fluid of adults with gingival inflammation. This finding may
According to Terai et al., lactic acid bacteria (LAB) showed antibacterial activity against
Iniesta et al. conducted a literature review in the years before the period covered in this
2006: chewing gum with L. reuteri led to a statistically significant reduction in the
2008: Tablets containing L. salivarius improved plaque index and probing depth in
Halitosis
disease. It has been shown that bacteriotherapy can also improve this condition(4,9,20).
Replacing the bacteria involved in halitosis with colonization with probiotic bacterial
strains from the oral microbiota of healthy human beings may have a potential
is the origin of most malodor problems, a candidate to counter this condition must be
able to survive in this particular ecosystem. It would be ideal to have a probiotic strain
able to efficiently colonize the surface of the tongue without producing odorous
metabolic byproducts(27).
Little research has been conducted on how probiotics may reduce the levels of volatile
sulfur compounds. The strains that have been studied are: Streptococcus salivarius
and Lactobacillus salivarius in chewable tablets and Weissella cibaria in the form of
colutory. They have all obtained statistically significant reductions in the levels of
volatile sulfur compounds in patients(9). Terai et al. found, in an in vitro study, that
Lactobacillus crispatus YIT 12319 and LBS11-17 have a greater adherence to the HSC
cells from the human tongue. Their results suggest that there may be receptor-ligand
systems between the epithelial cells of the tongue and these bacteria, which would be
and is found predominantly in “healthy” human beings who are not affected by halitosis.
This strain produces two natural antibacterial peptides: salivaricin A212,13 and
salivaricin B,14. These peptides are bacteriocins that inhibit the colonization of bacteria
Candida albicans is the most common cause of fungal infections in the oral cavity.
used to modify the microfloral ecosystem and have shown some success as a
therapeutic agent for oral diseases(28). Daily consumption of cheese supplemented with
increase in salivation. This last point is interesting as we know that decreased salivary
flow is a risk factor for candida infection in older people(9). Another important factor
regarding this infection is that the colonization site for Candida albicans is provided by
the carious lesion, since acid production favors an ecological niche for this
microorganism. In addition, in vitro studies have shown that the presence of Candida
albicans improves the adherence of S. mutans to oral biofilm and carious tooth
albicans.
Conclusions
Many recent studies indicate that treatment with probiotics can be a valuable
preventive complement to measures already tested, such as the use of fluorides. Most
articles selected for this review state that, in the short term, daily consumption of
probiotics can effect changes directly in the oral microbiota, such as reducing the
number of pathogens, and indirect changes that enhance the growth of indigenous
microorganisms, and in the long term, decrease the development and growth of oral
In terms of patient compliance and costs, the fact that probiotics need to be consumed
daily is a challenge (or at least 4-5 days a week). This could be solved by adding
health measure.
To have a greater impact it would be necessary to combine the use of multiple probiotic
species that can significantly affect the levels of cariogenic bacteria in saliva and
periodontal pathogens in subgingival plaque. Finally, more clinical trials are needed to
determine the best combinations of probiotic strains, and to identify the ideal vehicles
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