Analyzing a regimen that's ready to fight pathogenic biofilm
By Debbie Z. Sabatini, RDH
Biofilm is the buzzword circulating the pages and airways of every health-related resource I stumble upon or subscribe to. Thousands and thousands of words are dedicated to defining what biofilm is, does, and why and how to treat it.
Those of us who keep up on biofilm are seeing more articles, products, and programs on surface disinfection, sterilization, and OSHA recommendations on biofilm in our water lines, and the importance of treating the inner surfaces of that toxic tube.
For the purpose of this article, we will focus on the toxic biofilm matrix that coats the structures of the teeth and gums. My goal for this article is that we change our conversations and the words we use among our patients and ourselves by not minimizing pathogenic biofilm and its damaging effects simply by calling it plaque.
Bacterial plaque biofilm is defined by the free dictionary as: (noun) a thick grouping of microorganisms that are very resistant to antibiotics and antimicrobial agents that live on the gingival tissues, teeth, and restorations, causing caries and periodontal diseases.
Actually, what I find perplexing is that the effects of the bacterial plaque biofilm, which are damaging and often irreversible, are the very things that are so undercommunicated to the patient.
What do you suppose the patient's response would be if we truthfully communicated the exact definition of pathogenic biofilm during the data collection portion of our risk assessment appointment? I believe it would finally put to rest the circulating fable that bacterial plaque accumulation is just from "not brushing or flossing enough." What would the reaction be if we changed the words we use to define the action or reaction of toxic biofilm to the patient's overall health?
Let's find the time to explain that the pathogenic biofilm that overpowers protective and preventive beneficial bacteria in our mouths eventually breaks down enamel by the release of lactic acid. Caries is an infection, a bacterial invasion of the tooth structure; it is not a cavity (a cavity is a hole caused by pathogenic biofilm releasing lactic acid). Pathogenic biofilm affecting the epithelial layer is a disease diagnosed as gingivitis; it is much more than bleeding gums. Let's explain that chronic biofilm exposure eats bone that supports natural teeth, a denture, partial, or an implant. This bacterial infection sadly has reached epidemic proportions, yet we still commonly refer to its generic term as periodontal disease.
Probiotics ready to fight
This is serious! The statistics of underdiagnosed and undertreated periodontal disease are staggering. Our dialogue and actions must adapt and lead us to applying personalized medicine protocols and identifying risks in long-term health or chronic illness to our clients-not to mention the added value and expertise we provide as a professional! Do you think if we articulated this position that patients would respond, "Honey, just clean my teeth"? I'm not naïve enough to say that some won't. We need to be resolved in our execution of therapy with them. Fortunately, in my experience, the majority of responses we receive is, "Why didn't someone tell me about this sooner? And how fast can we get rid of it?"
There are many forms of biofilm disruption protocols that offices try to integrate, too numerous to discuss in this article. What I do want to share, as I do in all of my seminars, is the "why" of the disease. Identifying specific species of pathogenic biofilm via noninvasive saliva testing is quick and painless. The more information you can get on the patient's specific inflammatory burden, the more predictable your treatment outcomes will become. It makes what we do medically necessary and our therapies measurably more beneficial.
So how does understanding biofilm and identifying the specific biofilm that affects tooth structure or epithelial tissue relate to probiotics? Simply put, our highly developed immune system is designed to be on guard and readily available to fight disease and safeguard itself against pathogenic biofilm. When the oral ecosystem is out of equilibrium, symptoms of inflammation, caries, and bleeding will ultimately present themselves. In identifying the imbalance, we can support its repair by selecting a supplemental product that repopulates beneficial probiotic levels found naturally in our immune system when we are healthy.
The term "probiotics" comes from Latin and Greek words literally meaning "for life." The World Health Organization's 2001 definition of probiotics is "the use of live microorganisms which, when administered in adequate amounts, confer a health beneﬁt on the host." For those who have integrated dietary probiotics into their health regimen, it has recently been published that you may already be benefiting from the therapeutic potential and inhibition of periodontal pathogens, specifically Porphyromonas gingivalis, Prevotella intermedia, Fusobacterium nucleatum, and Aggregatibacter actinomycetemcomitans.1 This means there is a bidirectional effect on probiotics taken orally and oral care probiotics, which we will address now.
Science backs up products
Oral care probiotics are probiotics intended for the oral cavity to help maintain healthy oral flora. One of the most studied and accepted oral care probiotics is EvoraPro by Oragenics. While most probiotics are ingested orally, they are not intended to confer an oral benefit. EvoraPro's patented blend of probiotic strains (ProBiora3) naturally derive from the pockets of healthy mouths and are intended to impart an oral benefit. ProBiora3 is Streptococcus oralis (S. oralis KJ3) and Streptococcus uberis (S. uberis KJ2), which are both associated with gingival tissue health, as well as Streptococcus rattus (S. rattus JH145), which is specific to tooth health. These probiotic bacteria synergistically work as antagonists to undesirable oral bacteria associated with rampant caries, bad breath, and oral infections, all challenges dental health providers and patients face indiscriminately.
EvoraPro ideally should be taken orally every evening after normal oral hygiene routines are completed. Once activated via saliva (by chewing and swishing around the mouth, sucking on until dissolved, or crushing the tablet and placing in the mouth), ProBiora3 competes with the disease-causing pathogenic microorganisms for the same nutrient layer and space that proliferates below the gum line, deep down in the base of the pocket, and in and around the crevices of the tooth and occlusal surfaces.
In a 2009 human clinical study,2 the effects of daily usage of EvoraPro oral care probiotics over four weeks resulted in a decrease in the levels of Streptococcus mutans in 84% of the subjects tested. Across all subjects there was an average six-fold reduction, thus reducing the risk of a caries infection from moderate to low according to the CAMBRA index. Also documented was a greater than 300-fold decrease in the levels of Campylobacter rectus, a toxic gram-negative pathogenic bacterium found in patients with periodontal disease. A greater than 100-fold decrease response was also noted in Porphyromonas gingivalis among other oral pathogens within a month of use.
Imagine the impact of helping to maintain our patients' oral health by including EvoraPro as part of optimal long-term care. With the implementation of EvoraPro3 as part of the all-natural oral ecosystem hygiene protocol, we can now assist all patients in reestablishing and/or maintaining the delicate balance between oral microflora and the host to prevent the overcolonization of undesirable microorganisms that they sometimes cannot prevent on their own.
There are three other products available for the benefit of a balanced ecosystem. Sunstar provides GUM PerioBalance,3 which contains two strains of Lactobacillus reuteri (Prodentis) that is derived from dairy and the human gut. When taken on a daily basis, it helps to balance the oral environment to promote healthy teeth and gums, reduce plaque, and fight bad breath.
Another product comes from BLIS Technologies. BLIS K12 is an advanced probiotic for oral and upper respiratory tract health. It is a specific and proprietary strain of S. salivarius able to help support fresh breath naturally while supporting immune system health as it relates to the mouth and upper respiratory tract.4 S. salivarius M18 also satisfies patients' desire for fresher breath, healthy teeth, and plaque reduction.
The last product is a toothpaste from Germany called Plidenta Pro-T-Action. It is a first-of-its-kind probiotic toothpaste. Pro-T-Action is a specific probiotic (Lacobacillus paracasei), which co-aggregates Streptococcus mutans and thus reduces caries-causing bacteria in the mouth.5
Please look at the manufacturer's labels and talk with your representatives when evaluating these six factors. Together you will determine the best product for your patient's condition.
In closing, bidirectional interactions between pathogenic biofilm and probiotics have a huge potential in playing an important role in the maintenance of oral health and general well-being. Including oral care probiotics will assist the patient to naturally and consistently improve oral health and maintain a balanced ecosystem easily, effectively, and consistently in between visits.
The key to maintaining oral health is to embrace its microbial ecosystem and its unique ability to thrive from exposure at birth until death. Now, with a better understanding of biofilm and probiotics, we can proactively impact the oral health of our patients and minimize the need for invasive dental or pharmacological oral care. RDH
Which oral care probiotic should you recommend?
In researching the best probiotic regimen for you and your clients, consider these six factors:
1. Price-This is often the first concern of the clinician in anticipation of explaining the investment in dispensable items to the client.
2. Purity-The fewer the additives, flavors, impurities, the better.
3. Potency-The total count of all bacteria in the probiotic. Potency is a measure of viable bacterial or fungal cells. It is often listed as CFU or colony forming units. Read the label; it often contains "live active cultures added." Taking and storing them according to manufacturer's recommendations will ensure the percent of live cultures will be maintained.
4. Expiration date-Probiotics are most effective when they are live. Some need to be stored in the refrigerator and have a short shelf life. Others have been manufactured and freeze-dried to maintain potency for a longer time period; this is called stability.
5. Strains-Most probiotics have a combination of effective strains, which enhance the bacteria to do a specific job.
6. Compliance-How do you think your patient will integrate oral care probiotics into the oral hygiene regimen? Taking an oral care probiotic is simple and inexpensive. I suggest my clients take it when I do-30 minutes after my home-care procedures, I allow it to dissolve in my mouth before I put my bruxism appliance in.
Debbie Z. Sabatini, RDH, is the founder of the OralED Institute. She has presented continuing education for a number of programs: oral-systemic health, oral abnormality screening techniques for cancer prevention, oral HPV, effective communication, and technologies for risk assessment. In 2015, Sabatini cofounded the All.Cancer.Prevention.Coalition (ACPC.org), a nonprofit whose purpose is to support a medley of cancer causes with its focus on early detection through education and screening events, as well as to comfort and support patients and families diagnosed with cancer.
1. van Essche M, Loozen G, Godts C, Boon N, Pauwels M, Quirynen M, Teughels W. Bacterial antagonism against periodontopathogens. J Periodontol. 2013;84(6):801-811. doi: 10.1902/jop.2012.120261. Epub 2012 Aug 16.
2. Journal of Applied Microbiology. 2009;107:682-690. oragenics.com.
Thomas JG, Posey SP, Namsupak A. Probiotics: The link between beneficial oral bacteria and total health. Sherman Oaks, California. Health Point Press, 2009.