The introduction of mechanical debridement of biofilm to illicit host immune response has remained the longtime gold standard of care for most oral diseases of biofilm origin. This gold standard is taught in dental hygiene school where preclinical hand skills focus on minute psychomotor work targeting impossibly microscopic furcations, concavities, depressions, and anatomical variations. We lose sleep over the clinical board examinations we are required to take, proving to the world that we know how to remove debris with anxiety-ridden strokes.
We then proudly enter the profession, ensuring we polish up our hand skills while keeping up with the cutting edge (pun intended) of new hygiene therapies. In turn, the dental hygienist has lovingly become known as “the cleaning lady” (or lord, as it were) despite the wildly diverse education, advanced therapeutic concepts, and comprehensively layered approaches required to provide complete dental hygiene therapy in the 21st century.
How to improve your patients' oral health without harping on brushing and flossing
Dental hygienists have served the community well as plaque-slaying, saliva-suctioning clinicians whose skills extend well beyond the modified pen grasp of “the free cleaning my insurance covers,” and so, let me begin by thanking you for your tireless years of service. I’d ask you to applaud yourselves, but most of you are currently experiencing musculoskeletal challenges from years of chairside care. Nevertheless, you all must be celebrated.
But now it’s time to retire the one-dimensional role society has unknowingly established as an insult to our profession, and with it, let’s also retire the methodologies that branded us as anything other than highly educated midlevel preventive specialists.
The future of host modulation therapy
It is well understood that biofilm is the causative agent of several oral diseases, and without hesitation, our foundational training has encouraged us to integrate any means necessary to either mechanically remove biofilm or utilize antibiotics to address the presence of pathogenic microorganisms. Yet, emerging research has identified consistent trends around achieving oral health associated with preserving an optimal oral microflora.
The medical profession has observed these trends for years through the use of probiotics. Conceivably, the future of oral health management begins not simply with the complete removal of all oral microorganisms, but perhaps by carefully administering health-associated microorganisms to patients.
The most studied probiotic in dentistry
The brief mention of probiotics in our foundational learning typically lingers somewhere between our nutrition coursework and pharmacology. We are taught broad-stroke fundamentals around how probiotics can be beneficial to the diversification of the gut flora and may prove to be an excellent adjunct to reduce the occasional yeast infection or diarrhea associated with prescribing systemic antibiotics.
Our foundational education does not focus on why the specific strain is critical to the efficacy of probiotic usage, or more importantly, the vast role strain-specific probiotics play in managing oral disease.
Probiotics loosely translate to “for life” (antibiotics translate to “against life”) and are defined as live microorganisms that, when administered in adequate amounts, confer a health benefit on the host. Prodentis by BioGaia contains two active strains of microorganisms isolated from humans: the Lactobacillus reuteri DSM 17938 isolated from the breast milk of a Peruvian mother and the L. reuteri ATCC PTA5289 isolated from the saliva of a Japanese woman with optimal oral health despite poor oral hygiene.
As a result, both strains were integrated into drops and tablets of Prodentis by BioGaia, the first and most studied probiotic in dentistry. In turn, the combination of both strains has demonstrated statistically significant positive effects on oral manifestations associated with plaque, gingivitis, periodontitis, peri-implant disease, oral Candida, and caries.* Let’s explore what we now know about the oral health properties of the L. reuteri-specific strains found in BioGaia’s Prodentis.
Plaque. The use of L. reuteri strains has demonstrated a positive impact on plaque accumulation. Of note, L. reuteri users experienced a 71% reduction in moderate to severe plaque conditions when compared with a placebo group.1 It is believed that the rationale lies in the competitive properties of the L. reuteri strain, in which these health-producing microorganisms rival the attachment mechanism of common disease-producing microorganisms found in mature biofilms.
Gingivitis. Patients placed on L. reuteri strains for active gingivitis experience an 85% reduction in bleeding upon probing scores and a four times reduction in inflammation.1 This data was further evaluated within a unique study that measured inflammation independent of plaque biofilm accumulation.
As part of the study, 72 sailors were sent out to sea for six weeks without oral hygiene instruction of any kind. The hypothesis inquired if providing a control group of 36 sailors with the L. reuteri strains would provide a significant outcome in the presence of oral inflammation when compared to the 36 sailors who received a placebo.2
The results: bleeding on probing scores began to dramatically sink (pun, once again, intended), as the L. reuteri group experienced an extreme decline in bleeding scores within 14 days of sailing.2 By day 42, the use of L. reuteri Prodentis reduced BOP despite a lack of optimal oral hygiene.
Periodontitis. Active periodontal patients who received L. reuteri Prodentis demonstrated a statistically significant reduction in periodontal pocket depths, which was well observed 180-plus days posttreatment.3 Impressively, L. reuteri Prodentis dramatically lowers concentrations of periopathogenic microorganisms, noting a 90% reduction in bacterial loads of Prevotella intermedia, Porphyromonas gingivalis, and Aggregatibacter actinomycetemcomitans.4
As a result of this reduction in bacterial load, periodontal patients experience a significant reduction in sulcular bleeding1 and inflammatory cytokines, particularly TNF-alpha, IL-1, and IL-7 within the gingival crevicular fluid.5
Probiotic strains of L. reuteri have demonstrated their efficacy particularly in patients with advanced periodontal pocket depths, noting that periodontal cases with moderate and advanced pocket depth readings of 7-plus mm responded favorably to the use of probiotic therapy. Finally, studies concluded that chronic periodontitis patients who are administered L. reuteri Prodentis as an adjunct to scaling and root planing (SRP) present with 47% fewer periodontal sites in need of surgery when compared with placebo use.4
Peri-implant disease. Notably, experiencing a greater progression of disease when compared with natural teeth, dental implant management requires critical and comprehensive patient considerations.6 Additionally, peri-implant diseases are quickly exacerbated by high concentrations of inflammatory mediators affiliated with large deposits of biofilm.7
Strains of L. reuteri offer an adjunctive solution for peri-implant mucositis cases as observed in the reduction in plaque index and probing depth, the positive impact on gingival inflammation, and subsequent reduction in pro-inflammatory mediators, particularly IL-1, IL-6, and IL-8.8
Caries. It is well understood that dental caries, like periodontitis, are the sequelae of a bacterial infection. The unique species responsible for releasing lactic acid and chewing away at the hardest substance in the body is Streptococcus mutans.
The formulation of L. reuteri Prodentis ensures that the drops and lozenges deliver no detrimental effects on tooth enamel9 and superior inhibition against S. mutans compared with other strains of Lactobacillus in probiotics.10
Candida. In cases of oral infections with Candida spp., probiotic bacteria easily coaggregate with Candida-infected biofilms, ensuring easier removal from the oral environment by salivary flow and swallowing. Additionally, L. reuteri Prodentis has shown to provide antifungal properties against five of the six most common Candida species.11
It is believed that L. reuteri strains expose these fungal environments to substances that halt fungal growth while also inhibiting the ability for Candida spp. to bind to and subsequently penetrate the oral epithelium, a critical aspect of Candida infections that can often lead to systemic Candidiasis.12
Where we go from here?
With both in-office and patient take-home delivery systems, L. reuteri Prodentis by BioGaia affords progressive hygienists the opportunity to provide an evidence-based modality designed to achieve ideal oral health for diseased patients by supporting an optimal immune response13 and subsequent improved clinical outcomes.*
Gone are the days of treating oral disease as a “cleaning lady.” Now more than ever, we have an opportunity to address these critical diseases as the preventive specialists we were trained to be by using evidence-based, state-of-the-art modalities designed specifically to achieve optimal health. To the “plaque-slayers” of the world: we ride at dawn; bring your probiotics and tell the others!
* FDA disclaimer: These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.
Editor's note: This article appeared in the October 2022 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
References
- Schlagenhauf U, Jakob L, Eigenthaler M, Segerer S, Jockel-Schneider Y, Rehn M. Regular consumption of Lactobacillus reuteri-containing lozenges reduces pregnancy gingivitis: an RCT. J Clin Periodontol. 2016;43(11):948-954. doi:10.1111/jcpe.12606
- Schlagenhauf U, Rehder J, Gelbrich G, Jockel-Schneider Y. Consumption of Lactobacillus reuteri-containing lozenges improves periodontal health in navy sailors at sea: a randomized controlled trial. J Periodontol. 2020;91(10):1328-1338. doi:10.1002/JPER.19-0393
- Vicario M, Santos A, Violant D, Nart J, Giner L. Clinical changes in periodontal subjects with the probiotic Lactobacillus reuteri Prodentis: a preliminary randomized clinical trial. Acta Odontol Scand. 2013;71(3-4):813-819. doi:10.3109/00016357.2012.734404
- Teughels W, Durukan A, Ozcelik O, Pauwels M, Quirynen M, Haytac MC. Clinical and microbiological effects of Lactobacillus reuteri probiotics in the treatment of chronic periodontitis: a randomized placebo-controlled study. J Clin Periodontol. 2013;40(11):1025-1035. doi:10.1111/jcpe. 12155
- Hallström H, Lindgren S, Widén C, Renvert S, Twetman S. Probiotic supplements and debridement of peri-implant mucositis: a randomized controlled trial. Acta Odontol Scand. 2016;74(1):60-66. doi:10.3109/00016357.2015.1040065
- Froum S. Dental implants fail at a rate 10 times that of natural teeth in patients with treated chronic periodontitis: new study. Perio-Implant Advisory. April 2, 2021. https://www.perioimplantadvisory.com/clinical-tips/article/14200690/dental-implants-fail-at-a-rate-10-times-that-of-natural-teeth-in-patients-with-treated-chronic-periodontitis-new-study
- Renvert S, Persson GR, Pirih FQ, Camargo PM. Peri-implant health, peri-implant mucositis, and peri-implantitis: case definitions and diagnostic considerations. J Clin Periodontol. 2018;45(Suppl 20):S278-S285.doi: 10.1111/jcpe.12956
- Flichy-Fernández AJ, Ata-Ali J, Alegre-Domingo T, et al. The effect of orally administered probiotic Lactobacillus reuteri-containing tablets in peri-implant mucositis: a double-blind randomized controlled trial. J Periodontal Res. 2015;50(6):775-785. doi:10.1111/jre.12264
- Jones SE, Versalovic J. Probiotic Lactobacillus reuteri biofilms produce antimicrobial and anti-inflammatory factors. BMC Microbiol. 2009;9(1):1-9. doi:10.1186/1471-2180-9-35
- Nikawa H, Makihira S, Fukushima H, et al. Lactobacillus reuteri in bovine milk fermented decreases the oral carriage of mutans streptococci. Int J Food Microbiol. 2004;95(2):219-223. doi:10.1016/j.ijfoodmicro.2004.03.006
- Jørgensen MR, Kragelund C, Jensen Pø, Keller MK, Twetman S. Probiotic Lactobacillus reuteri has antifungal effects on oral Candida species in vitro. J Oral Microbiol. 2017;9(1):1274582. doi:10.1080/20002297.2016.1274582
- Taylor M, Raja A. Oral Candidiasis. StatPearls Publishing; 2019.
- Alok A, Singh ID, Singh S, Kishore M, Jha PC, Iqubal MA. Probiotics: a new era of biotherapy. Adv Biomed Res. 2017;6:31. doi:10.4103/2277-9175.192625
