Brush more, floss more, use automated toothbrushes, a water pik, or place sulcular antibiotics?
What regimens are you currently recommending in your office for your patients’ oral hygiene maintenance and prevention? What if I told you that mechanical removal of bad bacteria might not be enough to ensure optimal oral health in all of your patients? After all, if simple removal of bacteria was beneficial then mouth washes would rein supreme chemical adjunct to mechanical removal. The problem is that this chemical warfare kills all types of oral bacteria, including the good!
The potential issue is that problems can become worse because good bacteria are targeted and reduced and numbers can decline to levels that allow bad bacteria to take over. What if the war on bad bacteria could be won with target warfare by out numbering them! It is time to consider adding friendly bacteria to the mix.
There is an entire category of products that is underutilized in the dental profession — oral probiotics. In fact, they are a category unto themselves.
Oral probiotics have the potential to make a significant impact on the oral health of our patients, and systemic health by extension. While not yet a therapeutic modality that we could include in a periodontal patient’s active phase of treatment, oral probiotics are among the best options we can use for patients in differing states of disease or health.
According to the current ad- opted definition by the World Health Organization, probiotics are: “Live microorganisms which when administered in adequate amounts confer a health benefit on the host.”
Lactic acid bacteria (lactobacillus), Streptococcus and Bifido- bacteria are the most common types of microbes used as pro- biotics and have been widely accepted in the medical profession. Some benefits of probiotics are decreased hypertension, managing lactose intolerance, lowering cholesterol, overall GI health and soon to be added is improved oral health and caries prevention.
The beauty of oral probiotics are the simple, commonsense manner in which it works. All oral probiotics are naturally occurring live bacteria, freeze-dried and delivered to the mouth in different ways, i.e. mouthwash and lozenges. These products contain different species of oral probiotics, which are natural colonizers of a healthy mouth, rather than genetically engineered. The patient dissolves one mint in the mouth per day. The bacteria are released and compete with various pathogenic bacteria for binding sites. The sites on the teeth and gums occupied by the probiotic bacteria reduce the surface area available for dis- ease-causing bacterial colonization. Furthermore, they also compete for nutrients.
Use of oral probiotics
As dentists we advise patients to avoid sugar to pre- vent caries. Have you ever wondered why some patients’ diets are loaded with sugar, and yet they are relatively caries free, while others partake in a diet only light with sugar (substrate) and they are highly caries active? How do you respond to this patient amongst team members? “They are drinking more soda then they are telling us” or “eating more sugar-filled snacks then they let on.” Here is the truth when it comes to caries: It isn’t the sugar that causes cavities but how streptococcus bacteria use sugar and produce lactic acid that causes decay. The ecological plaque hypothesis states that caries and periodontitis, the 2 most common biofilm- associated diseases in the world, originate from a disturbance in the balance and diversity in the biofilm. Contributing causes may be inadequate oral hygiene, incorrect diet, stress and/or other factors which determine the micro- ecology. Caries is caused by the presence of acidogenic and aciduric bacteria (mainly mutans streptococci) metabolizing dietary sugars to create a low local pH environment which can de-mineralize enamel. Thus patients whose bacteria war is being won by the bad bacteria will have more decay than those where the bad bacteria is kept at lower levels. How can we help?
Oral probiotics are able to naturally alter the oral ph levels and because they are early biofilm colonizers and nonaciduric, they build a much smaller bio- film.
Streptococcus rattus JH145 is a unique strain of streptococcus that does not produce lac- tic acid, and has been shown to successfully compete for nutrients and space on tooth surfaces with the native strain of streptococcus that produces lactic acid. The result is a reduction in decay despite the potential presence of sugar (sub- strate) in the oral environment.
Gum and Tooth Health
What do you make of patients who brush and floss, their plaque indices are down, and yet their periodontal health continues to slump? Can the same be true of these patients? Despite their commitment to mechanically remove bacteria, chemically the bad is still winning the war. Research has revealed that even after the aggressive process of scaling to clean out the periodontal pockets, the future oral health of the patient is determined by the type of bacteria that colonizes first in the base of that clean pocket. If the harmful bacteria are first to colonize, the disease condition will quickly return. If the beneficial bacteria are first, then good oral health will be established and the dental of- fice procedure will have been successful (Socransky and Hafajee, 1992, J. Perio, p. 322).
Pathogenic biofilm has a couple of requisites, and one is a low pH. So a biofilm with early colonizers that doesn’t make acid has a harder time harboring the bacteria that we associate with dental disease. Harnessing this pH characteristic of biofilm goes right up into the face of traditional methods -brush ‘n’ floss. Adjusting the pH allows your patients a way to manage their biofilm without having the dexterity and laser- focused education of a dental hygienist.
When giving brush ‘n’ floss directions, we end up focusing only on the teeth, and we miss the elephant in the room – the tongue. Tongue coating is not innocuous, nor is it only a cosmetic concern. Biofilm on the tongue releases plank- tonic bacteria in what’s called a planktonic storm. A coated tongue sends new biofilm to the rest of the mouth.
So it’s time for the tongue to be included in discussions about biofilm management and prophylaxis and it is here that pro biotics plays a very important role due to their activity in all oral biofilm.
Probiotic bacteria like Streptococcus oralis KJ3, and Streptococcus uberis KJ2 colonise supra and sub gingival sites and produce hydrogen peroxide, which aids in inhibition of periodontal pathogens. The ability to reduce these types of harmful bacteria in return results in a reduction of pathogenic bio- film on the teeth because they can only cause disease when they are in direct contact with the gingival epithelium. If they are in contact with the tooth or surfaces other than the gingival epithelium, or if they are freely floating in the mouth, they cannot cause periodontal disease. The patients who suffer from refractory periodontal disease, or who have poor results from traditional periodontal treatment now have a new conservative approach which might provide them results they were previously unable to achieve with contemporary treatments alone. The story of oral probiotics gets better! This way of biofilm management is not the wave of the future any longer. Recommending oral probiotics with natural strains from healthy mouths may be the ticket for patients who can- not or will not remove their own biofilm to dental hygienist standards.
Antimicrobial agents including therapeutic doses of systemic and locally applied antibiotics, mouthwashes, sub- gingival irrigates, etc. — will kill probiotic bacteria. This is why they are not used during active periodontal therapy. One of the ideal situations in which oral probiotics are used is immediately following successful periodontal treatment. Reducing the repopulation of caries- causing and periodontal bacteria gives the patient a fighting chance to remain healthy. Probiotics are also ideally used in periodontally healthy patients, especially those with a family history of periodontal disease. The optimal time to take the probiotic mint is in the evening, following the use of all biofilm- control devices.
In general, amino acids are the main substrate for the production of oral malodorous com- pounds. As freshly secreted human saliva contains low levels of free amino acids, halitosis occurs as a result of bacterial putrefaction by several anaerobic species found in the oral cavity. The most widely used strategies in the treatment of halitosis are comprehensive oral hygiene, including tongue scraping and brushing, as well as the use of mouth rinses containing antibacterial agents. Antibacterial mouthwashes and breath fresheners promote killing up to 99.9% of bacteria and germs in the mouth. These products indiscriminately wipe out both the essential, good bacteria along with the harmful bacteria. Within several hours after using an antibacterial mouthwash or breath freshener, the surviving .1% of the bacteria remaining in the mouth will repopulate the full level of harmful bacteria that was present in the mouth be- fore the product was used. This indiscriminate destruction of bacteria creates ongoing imbalances in the microflora that naturally inhabit the oral cavity. Antibacterial mouthwashes and breath fresheners simply mask the malodor and can never effectively address the issue on the causal level.
Oral probiotics are natural antagonists to the malodor-creating bacteria, quickly colonizing to create a healthy balance of micro flora and resulting in longer lasting, truly fresher breath.
The use of benign, commensal probiotics could therefore offer a complementary and more long-term treatment strategy to combat bad breath.
A natural by-product of oral probiotics is a low-dose of hydrogen peroxide. As this good bacteria is replenished daily, it creates a gradual teeth whitening effect with the full benefits of long contact times, delivering 24- hour per day coverage of balancing and brightening. Yellowing, surface discoloration or staining are all results of lifestyle choices: tobacco use, coffee, tea, beets, etc. Anything that stains will affect the color of the teeth. Tooth enamel is porous, filled with microscopic cracks and pores that hold onto staining products. Commercial tooth whiteners employ extremely high levels of harsh, chemical hydrogen peroxide which can actually damage the tooth and create a roughness on the tooth’s surface. This increases the film that builds up on the tooth surfaces and in the micro cracks and is available to hold on to stains much bet- ter. Streptococcus oralis KJ3 binds to the surface of the teeth, crowding out harmful bacteria by competing for the same nutrients and surface spaces. In laboratory studies, the low- dose hydrogen peroxide produced by the Streptococcus oralis KJ3 created a continuous whitening benefit that did not plateau over the duration of the study. With daily use, the colonization of Streptococcus oralis KJ3 provides a constant and expanding population for gradual and continual whitening effects. The hydrogen peroxide metabolites of Streptococcus oralis KJ3 also contribute to the breath-freshening features of oral probiotics by inhibiting the growth of harmful bacteria. The decrease in these harmful bacteria results in a substantial reduction in the volatile sulfur compounds associated with bad breath. Unlike other whitening products, oral probiotics are completely safe for veneers, caps and dentures.
The patient’s health and family history are sources of considerable impactful information. A patient with a strong family history of diseases and conditions such as cardiovascular disease, diabetes, periodontal disease, high blood pressure, and rheumatoid arthritis, among many others, has a potentially heightened risk for these diseases as well. A large body of research has demonstrated several different mechanisms of oral-systemic associations. One is the effect of the chronic inflammatory properties of periodontal disease on various diseases and conditions. Another is the effect of the periodontal pathogens on cardiovascular dis- eases and events, independent of periodontal disease. There is also the increase in insulin resistance from the inflammatory and infectious components of periodontal disease. Insulin resistance is the biggest root cause of atherosclerosis, which is the initiating event for heart attacks and strokes. Reducing the number of pathogenic bacteria, along with the oral contribution to the total inflammatory burden in the body, by consistently and effectively controlling periodontal disease can only result in better patient health.
As clinicians, it is important to take these risk elements into account when evaluating a patient and developing a treatment plan for periodontal dis- ease. The maintenance phase of periodontal therapy, along with the effectiveness of the patient’s home care, determines how long a perio patient will re- main healed. Using all the tools at our disposal, including oral probiotics, will help to optimize our patients’ oral and general health.
Patients who have been susceptible to health breakdown due to age related or medically induced changes can now have conservative treatment to help reverse these issues. Patients who undergo extensive dental treatment such as implants, veneers, full mouth rehabilitations, or even are currently undergoing orthodontic therapy now have a simple treatment to aid in the protection of their dental investment. The science and research on probiotic therapy for overall health and wellbeing is constantly advancing in new areas and uncovering new benefits. The probiotic benefits for oral health are an exciting and newly expanding area of this type of therapy. The obvious patient demand for fresher breath is apparent. How about introducing them to a mint that not only tastes good and freshens breath, but allows for reduction in caries and periodontal disease.
By Jaco Smith DDS
Editor’s note: This article was originally posted in Hygiene Tribune by Dr. Jaco Smith. It is directed at dentists posing the question of what measures they recommend to their patients for optimal oral prevention and care and suggests the use of oral probiotics to be an important tool in good oral health. This information is especially important to HIV patients who run a higher risk of oral disease manifestation.