**Probiotics and Oral Health**

#### Harini Priya Vishnu

*Department of Pedodontics and Preventive Dentistry, Vydehi Institute of Dental Sciences and Research Centre, Bangalore India* 

#### **1. Introduction**

194 Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices

[11] Hahn-Berg CI, Properties of interfacial proteinaceous films with emphasis on oral

*University, Lund, 2003* 

systems, *PhD thesis, Inst Surface Chem, Stockholm and Dept Food Technol, Lund* 

*All great thoughts have already been thought; what is necessary is only to try to think them again.... Johann Wolfgang* 

Man is the most intelligent animal on the earth, as he is the only species gifted with the power of thinking and reasoning. He always manages to come up with solutions for *most problems* on earth. Ironically, most problems on earth are directly or indirectly created by Man himself. That's the reason he is most often referred to as an *intelligent fool*.

*The man-made problem* prevailing across the field of medicine is the development of *antibiotic resistance,* largely contributed by us, the health professionals. The indiscriminate and reckless use of antibiotics has led to the emergence of multi-resistant strains of bacteria. This unfortunate development has led scientists to seek other means of fighting infections. [1]

The good-old but forgotten concept of *bacteriotherapy* seem to offer innovative tools for the treatment of infectious diseases. Hence, rightly quoted "All great thoughts have already been thought; what is necessary is only to try to think them again".

*Bacteriotherapy is the administration of naturally occurring bacteria of human origin as a therapeutic manipulation of the bacterial microenvironment in the patient's body.* [1] The Basic principle is to use good bacteria to compete against pathogenic bacteria. Bacteriotherapy has been studied and tested to control infectious diseases, particularly in the GI tract. Recent studies have shown that this therapeutic method may be used to influence body function in other systems too, beyond the intestine. [1, 2, 3]

#### **2. History**

It was in the first decade of 1900, the beginning of the 20th century when the Ukrainianborn Nobel prize laureate Elie Metchnikoff observed the positive beneficial effect of some bacteria on the human health and suggested that these beneficial bacteria can be used to replace harmful microbes in the body. He reported that Bulgarians lived longer than other population which was due to their consumption of Bulgarian yoghurt which contained lactic acid bacteria.[4] Metchnikoff worked at the Pasteur Institute in Paris and had discovered Lactobacillus bulgarius, a strain he later introduced into commercial production of sour-milk products in France and throughout Europe. He devoted the last decade of his life to the study of lactic-acid producing bacteria as a means of increasing human longevity. [5] He developed a theory stating that senility is caused by poisoning of

Probiotics and Oral Health 197

with potential inhibitory activity against different bacterial species including cariogenic

The various means of administration of probiotics for oral health purpose that has been

An essential requirement for an organism to be "an oral probiotic" is its ability to adhere to and colonize surfaces in the oral cavity. Microorganisms generally considered as probiotics may not have oral cavity as their inherent habitat, so their possibility to confer benefit on oral health is then questionable. [6]The suggested mechanisms of probiotic action are drawn entirely from gastrointestinal studies. Since, mouth is the gateway of the GI tract, there is every reason to believe that atleast some probiotic mechanisms may play a role in the oral cavity. [1]

• Lactobacilli play an important role in maintaining the microecological balance in the

• Involvement in binding of oral micro-organisms to proteins [interference in formation

• Action on plaque formation and on its complex ecosystem by competing and

• Involvement in metabolism of substrate and production of chemicals that inhibit oral

Immune inductive sites in the oral cavity are within the diffuse lymphoid aggregates of the Waldeyer's ring. Lingual and pharyngeal tonsils and adenoids contain most of the lymphatic tissue. Dentritic cells in the mucosal surfaces play vital role in antigen presentation and in activating T-cell responses. Depending on the signals from dendritic cells either immune tolerance or active immune response toward a specific antigen may occur. [6] However, more studies investigating the role probiotics on activation of the oral

Some of the hypothetical mechanisms of probiotic action in the oral cavity are:

**6. Vehicles for probiotic administration for oral health purpose** 

**7. Mechanisms of probiotic action on oral health** 

Streptoccus species. [1]

oral cavity.[11]

of acquired pellicle]

bacteria.[12, 13]

• Effect on local immunity.

• Direct interaction in dental plaque

intervening with bacterial attachments.

Indirect probiotic actions are also featured such as • Modulating systemic immune function.

• Regulation of mucosal permeability.

• Effect on non-immunologic defense mechanisms.

• Probiotics as an antioxidants and produce antioxidants.

• Prevent plaque formation by neutralizing the free electrons. [14, 15, 16]

immune inductive sites are required before further conclusions are drawn.

studies are: • Lozenges • Tablets • Cheese • Yoghurt • Mouth rinse • Capsule, Liquid

the body by the products of some of the bacteria for which he proposed a diet containing milk fermented by lactobacilli producing lactic acid to prevent the multiplication of these organisms. [6] The concept of probiotics was thus born and a new field of microbiology came into light.

The first clinical trials were performed in the 1930s on the effect of probiotics on constipation. Ever since then, different microorganisms have been used for their ability to prevent and cure diseases. [7]

In 1994, the WHO deemed probiotics to be the next-most important immune defence system when commonly prescribed antibiotics are rendered useless by antibiotic resistance. The use of probiotics in antibiotic resistance is termed as *microbial interference therapy*. [7]

The literature on the possible role of probiotics on oral and dental health is scarce and the studies on probiotics v/s oral health are still in their cradle. [6]

#### **3. What are Probiotics?**

The term probiotic means 'for life', was first coined by Lilly and Stillwell. [8]

### **4. Definition**

*[Adopted by the International Scientific Association for Probiotics and Prebiotics term]*  Probiotics are defined as "Live microorganisms, which when administered in adequate amounts, confer a health benefit on the host" (Guarner et al 2005) [9]

### **5. Oral probiotic organisms [7]**

The most common probiotic strains belong to the genera Lactobacillus and Bifidobacterium. Bacterial strains that have been tested for probiotic action in the oral cavity include:


Table 1.

L. rhamnosus GG, ATCC 53103 (LGG) is the most widely studied probiotic bacterium. Named after the discoverers, Sherwood Gorbach and Barry Goldin, produces a substance

the body by the products of some of the bacteria for which he proposed a diet containing milk fermented by lactobacilli producing lactic acid to prevent the multiplication of these organisms. [6] The concept of probiotics was thus born and a new field of microbiology

The first clinical trials were performed in the 1930s on the effect of probiotics on constipation. Ever since then, different microorganisms have been used for their ability to

In 1994, the WHO deemed probiotics to be the next-most important immune defence system when commonly prescribed antibiotics are rendered useless by antibiotic resistance. The use

The literature on the possible role of probiotics on oral and dental health is scarce and the

Probiotics are defined as "Live microorganisms, which when administered in adequate

The most common probiotic strains belong to the genera Lactobacillus and Bifidobacterium.

LACTOBACILLI SPECIES BIFIDOBACTERIUM SPECIES OTHERS

L. rhamnosus GG, ATCC 53103 (LGG) is the most widely studied probiotic bacterium. Named after the discoverers, Sherwood Gorbach and Barry Goldin, produces a substance

• Bifidobacterium DN-173 010

• S. salivarius • W. cibaria

• •

• B. bifidum • B. longum • B. infantis

Bacterial strains that have been tested for probiotic action in the oral cavity include:

of probiotics in antibiotic resistance is termed as *microbial interference therapy*. [7]

The term probiotic means 'for life', was first coined by Lilly and Stillwell. [8]

*[Adopted by the International Scientific Association for Probiotics and Prebiotics term]* 

amounts, confer a health benefit on the host" (Guarner et al 2005) [9]

studies on probiotics v/s oral health are still in their cradle. [6]

came into light.

**4. Definition** 

• L. acidophilus

• L. johnsonii

• L. rhamnosus

• L. casei

• L. gasseri • L. reuteri • L. paracasei

Table 1.

• L. rhamnosus GG

prevent and cure diseases. [7]

**3. What are Probiotics?** 

**5. Oral probiotic organisms [7]** 

with potential inhibitory activity against different bacterial species including cariogenic Streptoccus species. [1]

#### **6. Vehicles for probiotic administration for oral health purpose**

The various means of administration of probiotics for oral health purpose that has been studies are:


#### **7. Mechanisms of probiotic action on oral health**

An essential requirement for an organism to be "an oral probiotic" is its ability to adhere to and colonize surfaces in the oral cavity. Microorganisms generally considered as probiotics may not have oral cavity as their inherent habitat, so their possibility to confer benefit on oral health is then questionable. [6]The suggested mechanisms of probiotic action are drawn entirely from gastrointestinal studies. Since, mouth is the gateway of the GI tract, there is every reason to believe that atleast some probiotic mechanisms may play a role in the oral cavity. [1] Some of the hypothetical mechanisms of probiotic action in the oral cavity are:


Indirect probiotic actions are also featured such as


Immune inductive sites in the oral cavity are within the diffuse lymphoid aggregates of the Waldeyer's ring. Lingual and pharyngeal tonsils and adenoids contain most of the lymphatic tissue. Dentritic cells in the mucosal surfaces play vital role in antigen presentation and in activating T-cell responses. Depending on the signals from dendritic cells either immune tolerance or active immune response toward a specific antigen may occur. [6] However, more studies investigating the role probiotics on activation of the oral immune inductive sites are required before further conclusions are drawn.

Probiotics and Oral Health 199

Chung et al, 2004 showed that the probiotic strain L. fermentum found in the saliva of healthy children significantly inhibited the formation of the insoluble glucan produced by S.mutans. It did not affect the multiplication of this pathogenic strain, but it completely

Koll-Klais et al (2005) used various lactobacilli strains in their study and stated that 69% of

An increase in the number of salivary lactobacilli has also been seen in some studies. [18, 26] The products containing probiotic LGG bacteria may have beneficial effects on the dental

Stamatova et al, in their study that was in conducted in 2007 stated that L. rhamnosus & Lactobacillus bulgaricus produced inhibitory effects against P. gingivalis, Fusobacterium

Strahnic et al, 2007 conducted a study using probiotic strains L. salivarius & L. fermentum and both strains showed antagonistic activity on the growth of S. mutans and Streptococcus pneumonia. L. salivarius was able to survive an environment of low pH as that produced by

N.S.H. Mehanna et al (2009) investigated the effect of plant meswak and some probiotic bacteria on Streptococcus mutans and Porphyromonas gingivalis isolated from human oral cavity as most common oral pathogenic strains. The results of the study indicated that lactobacillus rahmonosus had a marked decreasing effect on the colonization of both

A recently published review article by Anna Haukioja in 2010 does not give a conclusive statement about the effect of probiotics on dental caries or caries related organisms since the

Encouraging results have been obtained in studies investigating the role of probiotics for the treatment of various periodontal diseases, gingivitis, plaque levels, and periodontitis. Reduction in the number of periodontopathogens in the plaque has also been observed.

Koll-Klais and team (2005) found a prevalence of Lactobacillus gasseri and L. fermentum in the oral cavity of healthy individuals compared to those with chronic periodontitis. Further to this, the same researchers have found that lactobacilli inhibit the growth of periodontopathogens, demonstrating the influence of lactobacilli in the oral cavity of a

Riccia, et al (2007) recently studied the anti-inflammatory effects of Lactobacillus brevis in a group of patients with chronic periodontitis. The treatment, which involved sucking on lozenges containing L. brevis over a period of 4 days, led to improvements in the targeted clinical parameters (plaque index, gingival index, bleeding on probing) for all patients. In that study, a significant reduction in salivary levels of prostaglandin E2 (PGE2) and matrix metalloproteinases (MMPs) was also observed. The authors suggested that the beneficial anti-inflammatory effects of L. brevis could be attributed to its capacity to prevent the production of nitric oxide and, consequently, the release of PGE2 and the activation of MMPs induced by the nitric oxide. However, L. brevis may also be antagonistic, leading to a reduction in the quantity of plaque and therefore an improvement in the gingival

health. The LGG bacteria had been shown not to ferment lactose or sucrose. [30]

inhibited the adherence onto cuvette walls. [28]

nucleatum & streptococcal species. [31]

a high number of S. mutans. [32]

**8.2 Action on periodontal diseases** 

healthy individual. [29]

index. [34]

Again, most studies have been fairly short. [10]

these strains inhibited S. mutans, 82% inhibited P. gingivalis. [29]

Streptococcus mutans and Porphyromonas gingivalis. [33]

study groups have been relatively small and of fairly shorter duration. [10]

Fig. Possible Mechanisms of Probiotic Action in the Oral Cavity [10]

#### **8. Action of probiotics on oral health**

#### **8.1 Action on organisms associated with dental caries**

Several investigations have shown reduction in the number of mutans streptococci in saliva after consumption of various probiotic products, [17 – 25] however such an effect has not been observed in all studies. [26]

 Náse et al, 2001 showed that supplementing 1-6 year old children with L. rhamnosus for 7 months significantly reduced the risk of dental caries. [17]

Comelli EM et al (2002) studied 23 dairy bacterial strains for the prevention of dental caries and reported that only two strains namely Streptococcus thermophilus and Lactcoccus lactis were able to adhere to saliva-coated hydroxyapatite and were further successfully incorporated into a biofilm similar to the dental plaque. Furthermore, they could grow together with five strains of oral bacterial species commonly found in supragingival plaque. In this system, Lactobacillus lactis was able to modulate the growth of the oral bacteria, and in particular to diminish the colonization of Streptococcus oralis, Veillonella dispar, Actinomyces naeslundii and of the cariogenic Strep.sobrinus. [27]

Fig. Possible Mechanisms of Probiotic Action in the Oral Cavity [10]

Several investigations have shown reduction in the number of mutans streptococci in saliva after consumption of various probiotic products, [17 – 25] however such an effect has not

Náse et al, 2001 showed that supplementing 1-6 year old children with L. rhamnosus for 7

Comelli EM et al (2002) studied 23 dairy bacterial strains for the prevention of dental caries and reported that only two strains namely Streptococcus thermophilus and Lactcoccus lactis were able to adhere to saliva-coated hydroxyapatite and were further successfully incorporated into a biofilm similar to the dental plaque. Furthermore, they could grow together with five strains of oral bacterial species commonly found in supragingival plaque. In this system, Lactobacillus lactis was able to modulate the growth of the oral bacteria, and in particular to diminish the colonization of Streptococcus oralis, Veillonella dispar,

**8.1 Action on organisms associated with dental caries** 

months significantly reduced the risk of dental caries. [17]

Actinomyces naeslundii and of the cariogenic Strep.sobrinus. [27]

**8. Action of probiotics on oral health** 

been observed in all studies. [26]

Chung et al, 2004 showed that the probiotic strain L. fermentum found in the saliva of healthy children significantly inhibited the formation of the insoluble glucan produced by S.mutans. It did not affect the multiplication of this pathogenic strain, but it completely inhibited the adherence onto cuvette walls. [28]

Koll-Klais et al (2005) used various lactobacilli strains in their study and stated that 69% of these strains inhibited S. mutans, 82% inhibited P. gingivalis. [29]

An increase in the number of salivary lactobacilli has also been seen in some studies. [18, 26] The products containing probiotic LGG bacteria may have beneficial effects on the dental health. The LGG bacteria had been shown not to ferment lactose or sucrose. [30]

Stamatova et al, in their study that was in conducted in 2007 stated that L. rhamnosus & Lactobacillus bulgaricus produced inhibitory effects against P. gingivalis, Fusobacterium nucleatum & streptococcal species. [31]

Strahnic et al, 2007 conducted a study using probiotic strains L. salivarius & L. fermentum and both strains showed antagonistic activity on the growth of S. mutans and Streptococcus pneumonia. L. salivarius was able to survive an environment of low pH as that produced by a high number of S. mutans. [32]

N.S.H. Mehanna et al (2009) investigated the effect of plant meswak and some probiotic bacteria on Streptococcus mutans and Porphyromonas gingivalis isolated from human oral cavity as most common oral pathogenic strains. The results of the study indicated that lactobacillus rahmonosus had a marked decreasing effect on the colonization of both Streptococcus mutans and Porphyromonas gingivalis. [33]

A recently published review article by Anna Haukioja in 2010 does not give a conclusive statement about the effect of probiotics on dental caries or caries related organisms since the study groups have been relatively small and of fairly shorter duration. [10]

#### **8.2 Action on periodontal diseases**

Encouraging results have been obtained in studies investigating the role of probiotics for the treatment of various periodontal diseases, gingivitis, plaque levels, and periodontitis.

Reduction in the number of periodontopathogens in the plaque has also been observed. Again, most studies have been fairly short. [10]

Koll-Klais and team (2005) found a prevalence of Lactobacillus gasseri and L. fermentum in the oral cavity of healthy individuals compared to those with chronic periodontitis. Further to this, the same researchers have found that lactobacilli inhibit the growth of periodontopathogens, demonstrating the influence of lactobacilli in the oral cavity of a healthy individual. [29]

Riccia, et al (2007) recently studied the anti-inflammatory effects of Lactobacillus brevis in a group of patients with chronic periodontitis. The treatment, which involved sucking on lozenges containing L. brevis over a period of 4 days, led to improvements in the targeted clinical parameters (plaque index, gingival index, bleeding on probing) for all patients. In that study, a significant reduction in salivary levels of prostaglandin E2 (PGE2) and matrix metalloproteinases (MMPs) was also observed. The authors suggested that the beneficial anti-inflammatory effects of L. brevis could be attributed to its capacity to prevent the production of nitric oxide and, consequently, the release of PGE2 and the activation of MMPs induced by the nitric oxide. However, L. brevis may also be antagonistic, leading to a reduction in the quantity of plaque and therefore an improvement in the gingival index. [34]

Probiotics and Oral Health 201

Recently it has been postulated that the probiotic bacteria may slow down AIDS progression. Lin Tao and his colleagues (2008) screened hundreds of bacteria taken from the saliva of volunteers. The results showed that some Lactobacillus strains had produced proteins capable of binding a particular type of sugar found on HIV envelope, called mannose. The binding of the sugar enables the bacteria to stick to the mucosal lining of the mouth and digestive tract, forming colonization. One strain secreted abundant mannosebinding protein particles into its surroundings, neutralizing HIV by binding to its sugar coating. They also observed that immune cells trapped by lactobacilli formed a clump. This configuration would immobilize any immune cells harboring HIV and prevent them from

Residence time of probiotics in oral cavity after treatment withdrawal was studied by Çaglar et al (2006) A reduced S. mutans level was shown after a two-week use of a L. reuterienriched yogurt; effects were observed during use and for a few days after discontinuation.

A loss of L. reuteri colonization was observed by Wolf et al (1995) two months after having discontinued probiotic use. [44] L. rhamnosus GG administration and oral cavity colonization was studied by Yli-Knuuttila et al in 2006. The authors concluded that permanent colonization in oral cavity was unlikely (although possible in some cases) and

 Binding strength of 17 Lactobacillus strains and 7 bifidobacteria strains to saliva and oral mucous membrane was variable in different strains, according to a study by Haukioja et al in 2006, such a strength variation caused an increased residence time of probiotic in oral cavity.[46] Latency time of probiotic S. salivarius K12, 4 tablets/day for 3 days, was assessed in several oral cavity areas in a 35-day follow-up, by Horz et al (2007) probiotic could be found on oral mucous membrane, tongue and in stimulated saliva for more than 3 weeks, with a gradually reduced S. salivarius K12 level being detected beginning 8 days after

The findings of the studies on oral colonization of probiotics did not suggest that a permanent installation can take place. However, one needs to bear in mind that most studies were conducted in adults and it may be questioned if a permanent installation readily can occur in persons with an already established microflora.[1] Therefore, it seems especially important that further research needs to be carried on infants because it is very likely that the chance of a permanent colonization of probiotics increases with a regular exposure from

The oral cavity with its diversity of microbial species has been shown to harbor strains also distinguished as probiotics as such. Further studies identifying resident probiotics in the

Probiotics are a new and interesting field of research in oral microbiology and oral medicine. Bacteriotherapy in the form of probiotics seems to be a natural way to maintain health and protect oral tissues from diseases. But, this area of research in relation to oral health is still in

mouth, and their eventual effect on the oral environment are required.

**8.5 Probiotics and HIV** 

infecting other cells. [42]

treatment withdrawal. [47]

early childhood. [3]

**10. Conclusion** 

[43]

**9. Residence time of probiotics in oral cavity** 

suggested the probiotic to be used on a regular basis. [45]

Shimazaki and colleagues (2008) used epidemiological data to assess the relationship between periodontal health and the consumption of dairy products such as cheese, milk and yogurt. The authors found that individuals, particularly nonsmokers, who regularly consumed yogurt or beverages containing lactic acid exhibited lower probing depths and less loss of clinical attachment than individuals who consumed few of these dairy products. A similar effect was not observed with milk or cheese. By controlling the growth of the pathogens responsible for periodontitis, the lactic acid bacteria present in yogurt would be in part responsible for the beneficial effects observed. [35]

Harini PM and Anegundi RT 2010 found that probiotic mouth rinse was effective in reducing plaque accumulation and gingival inflammation in 6-8 year old children. [36]

#### **8.3 Halitosis**

There are a number of reasons for the onset of halitosis (bad smelling breath) –consumption of particular foods, metabolic disorders and respiratory tract infections – but commonly it is associated with an imbalance of the commensal microflora of the oral cavity. [37]

An unbalanced oral microflora has been associated with the production of malodorous substances called volatile sulphur compounds (VSCs). These are by-products of microbial degradation of proteins, blood, mucins found in saliva, and traces of food retained on oral surfaces. Kazor and team (2003) looked at the species of bacteria found on the tongue of patients suffering from halitosis and compared the findings with subjects who were considered healthy. The species found to be most associated with halitosis were Atopobium parvulum, Eubacterium sulci, Fusobacterium periodonticum. In the same study, Streptococcus salivarius was found to be the most prevalent in the healthy subjects, and this is thought to be due to the capability of S. salivarius to produce bacteriocins which could contribute to reducing the number of bacteria that produce VSCs. [38]

Probiotics are marketed for the treatment of both mouth and gut associated halitosis.

#### **8.4 Probiotics and Candida albicans**

C. albicans is a leading cause of infection in oral cavity; it is particularly common in the elderly and in immunocompromised patients. Hatakka et al (2007) showed a reduced prevalence of C. albicans after taking probiotics in cheese containing L. rhamnosus GG and Propionibacterium freudenreichii. [39]

Results obtained by Koll et al (2008) when assessing the effects of various Lactobacillus strains in oral cavity were markedly different; most strains suppressed growth of periodontal pathogens, including actinomycetemcomitans (60 out of 67 tested strains); Porphyromona gingivalis (35 out of 42 strains), P. intermedia (26 out of 42 strains), and cariogenic S. mutans (37 out of 67 strains). No inhibition was found, however, for C.albicans growth. [40]

Hasslöf P et al (2010) investigated the ability of a selection of lactobacilli strains, used in commercially available probiotic products, to inhibit growth of oral mutans streptococci and C. albicans in vitro by agar overlay method. At concentrations ranging from 109 to 105 CFU/ml, all lactobacilli strains inhibited the growth of the mutans streptococci completely with the exception of L. acidophilus La5 that executed only a slight inhibition of some strains at concentrations corresponding to 107 and 105 CFU/ml. All the tested lactobacilli strains reduced candida growth but the effect was generally weaker than for mutans streptococci. The two L. plantarum strains and L. reuteri ATCC 55730 displayed the strongest inhibition on Candida albicans. [41]

Shimazaki and colleagues (2008) used epidemiological data to assess the relationship between periodontal health and the consumption of dairy products such as cheese, milk and yogurt. The authors found that individuals, particularly nonsmokers, who regularly consumed yogurt or beverages containing lactic acid exhibited lower probing depths and less loss of clinical attachment than individuals who consumed few of these dairy products. A similar effect was not observed with milk or cheese. By controlling the growth of the pathogens responsible for periodontitis, the lactic acid bacteria present in yogurt would be

Harini PM and Anegundi RT 2010 found that probiotic mouth rinse was effective in reducing plaque accumulation and gingival inflammation in 6-8 year old children. [36]

There are a number of reasons for the onset of halitosis (bad smelling breath) –consumption of particular foods, metabolic disorders and respiratory tract infections – but commonly it is

An unbalanced oral microflora has been associated with the production of malodorous substances called volatile sulphur compounds (VSCs). These are by-products of microbial degradation of proteins, blood, mucins found in saliva, and traces of food retained on oral surfaces. Kazor and team (2003) looked at the species of bacteria found on the tongue of patients suffering from halitosis and compared the findings with subjects who were considered healthy. The species found to be most associated with halitosis were Atopobium parvulum, Eubacterium sulci, Fusobacterium periodonticum. In the same study, Streptococcus salivarius was found to be the most prevalent in the healthy subjects, and this is thought to be due to the capability of S. salivarius to produce bacteriocins which could

associated with an imbalance of the commensal microflora of the oral cavity. [37]

contribute to reducing the number of bacteria that produce VSCs. [38]

**8.4 Probiotics and Candida albicans** 

Propionibacterium freudenreichii. [39]

strongest inhibition on Candida albicans. [41]

Probiotics are marketed for the treatment of both mouth and gut associated halitosis.

C. albicans is a leading cause of infection in oral cavity; it is particularly common in the elderly and in immunocompromised patients. Hatakka et al (2007) showed a reduced prevalence of C. albicans after taking probiotics in cheese containing L. rhamnosus GG and

Results obtained by Koll et al (2008) when assessing the effects of various Lactobacillus strains in oral cavity were markedly different; most strains suppressed growth of periodontal pathogens, including actinomycetemcomitans (60 out of 67 tested strains); Porphyromona gingivalis (35 out of 42 strains), P. intermedia (26 out of 42 strains), and cariogenic S. mutans

Hasslöf P et al (2010) investigated the ability of a selection of lactobacilli strains, used in commercially available probiotic products, to inhibit growth of oral mutans streptococci and C. albicans in vitro by agar overlay method. At concentrations ranging from 109 to 105 CFU/ml, all lactobacilli strains inhibited the growth of the mutans streptococci completely with the exception of L. acidophilus La5 that executed only a slight inhibition of some strains at concentrations corresponding to 107 and 105 CFU/ml. All the tested lactobacilli strains reduced candida growth but the effect was generally weaker than for mutans streptococci. The two L. plantarum strains and L. reuteri ATCC 55730 displayed the

(37 out of 67 strains). No inhibition was found, however, for C.albicans growth. [40]

in part responsible for the beneficial effects observed. [35]

**8.3 Halitosis** 

#### **8.5 Probiotics and HIV**

Recently it has been postulated that the probiotic bacteria may slow down AIDS progression. Lin Tao and his colleagues (2008) screened hundreds of bacteria taken from the saliva of volunteers. The results showed that some Lactobacillus strains had produced proteins capable of binding a particular type of sugar found on HIV envelope, called mannose. The binding of the sugar enables the bacteria to stick to the mucosal lining of the mouth and digestive tract, forming colonization. One strain secreted abundant mannosebinding protein particles into its surroundings, neutralizing HIV by binding to its sugar coating. They also observed that immune cells trapped by lactobacilli formed a clump. This configuration would immobilize any immune cells harboring HIV and prevent them from infecting other cells. [42]

#### **9. Residence time of probiotics in oral cavity**

Residence time of probiotics in oral cavity after treatment withdrawal was studied by Çaglar et al (2006) A reduced S. mutans level was shown after a two-week use of a L. reuterienriched yogurt; effects were observed during use and for a few days after discontinuation. [43]

A loss of L. reuteri colonization was observed by Wolf et al (1995) two months after having discontinued probiotic use. [44] L. rhamnosus GG administration and oral cavity colonization was studied by Yli-Knuuttila et al in 2006. The authors concluded that permanent colonization in oral cavity was unlikely (although possible in some cases) and suggested the probiotic to be used on a regular basis. [45]

 Binding strength of 17 Lactobacillus strains and 7 bifidobacteria strains to saliva and oral mucous membrane was variable in different strains, according to a study by Haukioja et al in 2006, such a strength variation caused an increased residence time of probiotic in oral cavity.[46] Latency time of probiotic S. salivarius K12, 4 tablets/day for 3 days, was assessed in several oral cavity areas in a 35-day follow-up, by Horz et al (2007) probiotic could be found on oral mucous membrane, tongue and in stimulated saliva for more than 3 weeks, with a gradually reduced S. salivarius K12 level being detected beginning 8 days after treatment withdrawal. [47]

The findings of the studies on oral colonization of probiotics did not suggest that a permanent installation can take place. However, one needs to bear in mind that most studies were conducted in adults and it may be questioned if a permanent installation readily can occur in persons with an already established microflora.[1] Therefore, it seems especially important that further research needs to be carried on infants because it is very likely that the chance of a permanent colonization of probiotics increases with a regular exposure from early childhood. [3]

#### **10. Conclusion**

The oral cavity with its diversity of microbial species has been shown to harbor strains also distinguished as probiotics as such. Further studies identifying resident probiotics in the mouth, and their eventual effect on the oral environment are required.

Probiotics are a new and interesting field of research in oral microbiology and oral medicine. Bacteriotherapy in the form of probiotics seems to be a natural way to maintain health and protect oral tissues from diseases. But, this area of research in relation to oral health is still in

Probiotics and Oral Health 203

[20] Caglar E, et al. (2005). Effect of yoghurt with Bifidobacterium DN-173010 on salivary

[21] Caglar E, et al. (2006). Salivary mutans streptococci and lactobacilli levels after ingestion

[22] Caglar E, et al. (2007). Effect of chewing gums containing xylitol or probiotic bacteria on salivary mutans streptococci and lactobacilli. Clin Oral Investig, 11:425–429. [23] Caglar E, et al. (2008). Short-term effect of ice-cream containing Bifidobacterium lactis

[24] Caglar E, et al. (2008). A probiotic lozenge administered medical device and its effect on salivary mutans streptococci and lactobacilli. Int J Paediatr Dent, 18:35–39. [25] Cildir SK,et al. (2009). Reduction of salivary mutans streptococci in orthodontic patients

[26] Montalto M, et al. (2004). Probiotic treatment increases salivary counts of lactobacilli: a

[27] Comelli EM, et al. (2002). Selection of dairy bacterial strains as probiotics for oral health.

[28] Chung J, et al. (2004). Isolation and characterization of Lactobacillus species inhibiting

[29] Koll-Klais P, et al. (2005). Oral Lactobacilli in chronic periodontitis and periodontal

[30] Meurman J, et al. (1994). Recovery of Lactobacillus strain GG (ATCC 53103) from saliva

[31] Stamatova I, et al. (2009). In vitro evaluation of yoghurt starter lactobacilli and

[32] Strahinic I, et al. (2007). Molecular and biochemical characterizations of human oral lactobacilli as putative probiotic candidates. Oral Microbiol Immunol, 22(2): 111-7. [33] N.S.H. Mehanna et al. (2009). Effect of some probiotic strains and meswak plant on

[34] Riccia DN, et al. (2007). Anti-inflammatory effects of Lactobacillus brevis (CD2) on

[35] Shimazaki Y et al. (2008). Intake of dairy products and periodontal disease: the

[36] Harini PM & Anegundi RT. (2010). Efficacy of a probiotic and chlorhexidine mouth

[37] Scully G & Greenman J. (2008). Halitosis (breath Odor). Periodontology 2000, 48: 667-75. [38] Kazor CE, et al. (2003). Diversity of bacterial populations on the tongue dorsa of patients with halitosis and healthy patients. J. Clin. Microbiol, 41(2): 558-563.

certain oral pathogenic strains. Int J of Academic Res, 1(2): 128-132.

double-blind, randomized, controlled study. Digestion. 69:53–56.

320.

Acta Odontol Scand, 64:314–318.

Scand, 66:154–158.

Eur J Oral Sci, 110(3):218-24.

Microb Ecol Health Dis, 7:295-298.

periodontal disease. Oral Dis, 13(4):376-85.

Hisayama Study. J Periodontol, 79(1): 131-7.

rinses: A short term clinical study. JISPPD, 28(3):179-182.

31:407–4011.

20(6): 354-61.

Immunol. 24:218–223.

6.

mutans streptococci and lactobacilli in young adults. Acta Odont Scand, 63:317–

of the probiotic bacterium Lactobacillus reuteri ATCC 55730 by straws or tablets.

Bb-12 on the number of salivary mutans streptococci and lactobacilli. Acta Odontol

during daily consumption of yoghurt containing probiotic bacteria. Eur J Orthod,

the formation of Streptococcus mutans biofilm. Oral Microbiol Immunol, 19(3): 214-

health: species composition and antimicrobial activity. Oral Microbiol Immunol,

of healthy volunteers after consumption of yoghurt prepared with the bacterium.

Lactobacillus rhamnosus GG adhesion to saliva-coated surfaces. Oral Microbiol

its infancy and further long term randomized controlled studies are required before definite conclusions are drawn regarding their effective action on oral health.

#### **11. References**


its infancy and further long term randomized controlled studies are required before definite

[1] Meurman JH. (2005). Probiotics: do they have a role in oral medicine and dentistry? Eur J

[2] Noordin K & Kamin S. (2007). The effect of probiotic mouthrinse on plaque and gingival

[3] Twetman S & Stecksen-Blicks C. (2008). Probiotics and oral health effects in children. Int

[4] Metchnikoff E. (1907). Lactic acid as inhibitory intestinal putrefaction. In Chalmers

[5] The Columbia Encyclopedia, (2001). 6th Ed. New York: Columbia University Press.

[6] Meurman JH & Stamatova I. (2007) Probiotics: contributions to oral health. Oral

[7] Parvez S et al. (2006). Probiotics and their fermented food products are beneficial for

[8] Lilly DM & Stillwell RH. (1965) Probiotic growth promoting substances produced by

[9] FAO/WHO. (2001). Evaluation of health and nutritional properties of powder milk and

[11] Koll-Klais P et al. (2006) Oral lactobacilli in chronic periodontitis: species composition and antimicrobial activity. IADR Congress, Dublin, 13-16 Sept (Abstract 0081) [12] Isolauri E et al. (1993). Lactobacillus casei strain GG reverses increased intestinal

[13] Vanderhoof JA et al. (1999) Lactobacillus GG in the prevention of antibiotic associated

[14] Suvarna VC & Boby VG. (2005). Probiotics in human health - A current assessment.

[15] Izumita D. (2001). A new approach in dentistry. Clinical and Basic Medical Research on

[16] Minna KS, et al. (2002). Lactobacillus bacterium during a rapid increase in probiotic use

[17] Nase L et al. (2001). Effect of long-term consumption of a probiotic bacterium,

[18] Ahola AJ et al. (2002). Short-term consumption of probiotic-containing cheese and its

[19] Nikawa H, et al. (2004). Lactobacillus reuteri in bovine milk fermented decreases the oral carriage of mutans streptococci. Int J Food Microbiol, 95:219–223.

effects on dental caries risk factors. Arch Oral Biol, 47: 799-804.

Lactobacillus rhamnosus GG, in milk on dental caries and caries risk in children.

live lactic acid bacteria. Cordoba, Argentina: Food and Agriculture Organization of the United Nations and World Health Organization Expert Consultation Report, 1-

permeability induced by cow milk in suckling rats. Gastroenterology, 105: 1643-

Available at http://www.bartleby.com/65/me/Metchnik.html.

[10] Haukioja A. (2010). Probiotics and Oral Health. Eurp J of Dent, 4: 348-355.

Mitchell P, ed. The prolongation of life: optimistic studies. London: Heinemann,

conclusions are drawn regarding their effective action on oral health.

inflammation. Annal Dent Univ Malaya, 14: 19-25.

health. J of Appl Microbiol, 100: 1171-1185.

microorganisms. Science, 147: 747-748.

diarrhea in children. J Ped, 135: 564-568.

EM-X--A Collection of Research Papers, 2:77-81.

of L. Rhamnosus GG in Finland. CID, 35:1155-60.

Current science, 88: 1744-48

Caries Res, 35: 412-420.

**11. References** 

161-183.

34.

1650.

Oral Sci, 113: 188-196.

J of Pead Dent, 18: 3-10.

Diseases, 13: 443-451.


**12** 

*Brazil* 

**Towards Oral Health Promotion** 

What is the concept of health? What is oral health? What is the concept of health and oral health promotion? Is there a prescription to follow for any individual or a population? Can this universal prescription be refined to serve both developed and developing countries as well as populations with social deprivation characteristics? Many other questions could be raised before the discussion of oral health promotion or health promotion, yet the fact is that oral health is an important part of general health (1). Previous studies have thoroughly documented the association between oral health and other health conditions as well as also oral health's relation to quality of life (2, 3). However, health promotion cannot be targeted to only health sector efforts; intersectorial actions are necessary to make oral health more affordable. Therefore, it is not possible to improve oral health without assembling the

Would it be possible to conduct oral health promotion on a regular basis? In the first place, the concept of health and oral health should be clear to as many professionals as possible. The internationally accepted definition of the World Health Organization is a good start for clarification, because in the preamble of its constitution, it describes health as "a state of complete physical, mental and social well-being and not merely the absence of disease and

The primary concern must be professionals' idea of health as more than the absence of disease, and to do so, it is necessary for professionals to understand what would be classified as a disease or as infirmity. Although this chapter does not aim to delve deeply into the philosophy of health, illness and disease, it can help readers to understand disease

The complete state of physical, mental and social well-being would be too hard to explain in full to a person; nevertheless, this must be considered a target to health promotion practitioners. Consider this issue as a gradient of health wherein these three dimensions

Magali de Lourdes Caldana1, Luis Marcelo Aranha Camargo2, Ariadnes Nobrega Oliveira1, Ricardo Pianta Rodrigues da Silva3, Angela Xavier1, Fábio Silva de Carvalho 1 and Roosevelt da Silva Bastos1

overall as a disturbance in the balance of the health-disease process.

<sup>1</sup>*University of São Paulo/Faculty of Dentistry at Bauru, Brazil*  <sup>2</sup>*University of São Paulo/ Biomedical Sciences Institute, Brazil* 

**1. Introduction** 

**2. Oral health** 

infirmity" (4).

3*São Lucas University, Brazil*

 \*

evolution of the concept of health promotion.

José Roberto de Magalhães Bastos et al.\* *University of São Paulo/ Faculty of Dentistry at Bauru* 

