Probiotics and Oral Health
How to get patients on the path to a healthy microbiome
Fred W. Michmershuizen
Probiotic therapy can help in the prevention and treatment of oral disease by adding helpful bacteria to inhibit the overabundance of pathogenic strains. According to the experts, most dental patients can benefit from probiotics. There are many different delivery methods to choose from, and there are several key points that hygienists should keep in mind when discussing the use of these products with their patients.
In general terms, probiotic therapy, or the addition of "good" bacteria to a person's diet, can help stem the profusion of harmful microbes-usually anaerobic bacteria-that lead to caries and gum disease.
"Probiotics, or beneficial bacteria, have been well documented as immune regulators-inhibitors of pathogenic bacteria-either by direct competition for colonization sites, by production of bacteriocin-like inhibitory substances (BLIS), or by the production of hydrogen peroxide, which is effective against the obligatory anaerobes," says Mark Cannon, DDS, MS, a professor at the Feinberg School of Medicine at Northwestern University in Chicago, and who has been in private practice in Long Grove, Illinois, for over 40 years. Cannon has studied the issue extensively and can cite many different studies on the subject. 1-6
Maria L. Geisinger, DDS, MS, a professor in the periodontology department at the University of Alabama at Birmingham, has also studied the use of probiotics as well as prebiotics, which are nutrients that promote the establishment of good bacteria. According to Geisinger, who recently presented a webinar on this topic, "The Pros and Cons of Probiotics and Prebiotics for Optimal Periodontal Health" (available at idh.cdeworld.com/webinars), probiotics can be a useful tool in achieving and maintaining good oral health. Geisinger says that while the traditional treatments for the eradication and prevention of oral disease have focused on elimination of biofilm, it's becoming evident that the real culprit is oral dysbiosis, or an imbalance in the oral microbiome.
Geisinger says in her webinar that probiotics and prebiotics, when used in tandem with biofilm elimination, can be useful when treating patients with periodontitis, and that use of probiotics can also help promote good overall dental health and prevent the development of periodontal disease.
Another way of explaining the usefulness of probiotics comes from Arizona-based dental hygienist and educator Katrina M. Sanders, RDH, BSDH, MEd, RF. "The big problem comes when the good bacteria are outbalanced or outweighed by the bad bacteria, and so this is where we start to see the development of oral disease," Sanders says. "This is where we start to see gingivitis, periodontitis, oral candidiasis, and decay."
"When we talk about the use of a probiotic, we're talking about introducing health-producing bacteria back into the oral cavity," Sanders says. "These health-producing bacteria are very conditioned already. They are programmed to provide protective layers, to stabilize the pH in the oral cavity, and to help promote health-producing cells in the oral cavity. ‘Pro' means ‘for.' ‘Probiotics' is ‘for life,' for the development and sustainability of life, versus an antibiotic, which kills bacteria. So, probiotics are a very gentle way of us being able to diversify the flora in the oral cavity and, in many cases, in the gut flora as well."
Most patients can benefit
Patients who have taken antibiotics and patients with xerostomia are among those who can most benefit from probiotic therapy, according to Cannon. "Sadly, anti-microbials are a two-edge sward," he says. "Beneficial bacteria are often decreased by antibiotics with devastating long-term effects."
"Patients with xerostomia often suffer from increased dental disease, so they should be on probiotics to prevent caries and periodontal disease," Cannon says. "Unfortunately, I see many adolescents on ADD/ADHD medications that cause xerostomia, and their dental disease greatly affects their quality of life. Dentists need to ask patients if they are taking any new medications that can decrease saliva production."
Sanders says that patients often begin taking probiotics because of gastrointestinal issues they may be experiencing such as stomach discomfort or constipation, but that almost everybody can use probiotics to improve their oral health as well. "I compare it to knowing whether a patient is going to benefit from using toothpaste," she says.
"The statistics right now indicate that approximately one in two adults who walk in and out of our doors every day have the irreversible form of periodontal disease, and, within the remaining patient population, the vast majority of those people have gingivitis," Sanders says. "We know that dental decay is an extremely prevalent disease process."
Sanders says anyone with oral disease has a dysbiosis. "If you see a patient who has oral disease, chances are they will be a terrific candidate for probiotics," she says.
Choosing a delivery method
When a patient seeks to add probiotics to their diet, there are many different products to choose from, beyond just the fermented milks and yogurts available at the grocery store. Other options include pills, mints, drops, lozenges, and even probiotic toothpastes and mouth rinses. There are products formulated specifically for adults and others for children.
Both Cannon and Sanders say patients should not be concerned with the number of CFUs (colony-forming units) on the labels but rather focus on which strains are present.
"Effective oral probiotics are commercially available in lozenge or mint form," Cannon says. "ProBiora has a child-friendly orange-creamsicle flavor with their ProBioraKids product. It has to taste good or kids won't use it. BioGaia has a product, Prodentis, that is available in drops for infants and toddlers."
Other companies that offer probiotic products formulated specifically for oral health include BURST Oral Care, Orasana, and others.
"I use probiotic tablets for myself, and I also like to drink kefir. My favorite is the kefir from Lifeway with 12 beneficial strains," Cannon says. "Don't worry about the ‘added sugar,' because the bacteria consume all of that. Kefir should not taste sweet. I also take a gut probiotic with 32 strains at 85 billion CFU. It is very important to know that the number is not that important. The actual strains are what really are important."
Sanders says that patients should take whichever probiotic has been clinically proven to address the clinical modality that they are concerned about. In her webinar, Geisinger lists a number of particularly beneficial microorganisms, namely Lactobacillus, Bifidobacterium, some types of Streptococcus (but not S. mutans, which is harmful!), and Weissella cibaria. There are also various recombinant probiotics, which are produced via genetic engineering, Geisinger says.
"Most patients don't realize that gut probiotics are different from oral probiotics," Cannon says. "Often, when you recommend a probiotic, they respond that they already take one. Most often, it is a no-name brand that was on sale somewhere. Please direct them to the recommended, studied, established oral probiotics."
The Bottom Line for Hygienists
In a way, the ideal oral microbiome can be compared to a lush tropical rainforest, with an abundant variety of organisms living together in balance. Sadly, that ideal environmental harmony is rare for most patients. "Almost all of us now have oral and gut dysbiosis due to the processed food that we too often eat," Cannon says. "The over-use of antibiotics has also been harmful to our eubiotic microbiome."
The key is to help patients address disease-causing dysbiosis with proactive steps. Probiotics formulated for oral health can be a useful tool. In the end, it's all about maintaining a healthy balance inside the mouth and the whole body.
Glossary of terms
Probiotics: Live microorganisms that when introduced to the body can have beneficial effects.
Prebiotics: Nutrients that can be ingested to help promote the establishment of probiotics.
Antibiotics: Medicines that kill or inhibit the growth of microorganisms.
Microbiome: The community of microorganisms present within an environment.
Dysbiosis: An imbalance between the types of microorganisms.
CFU: Colony forming unit, usually measured in the billions.
Some of the beneficial types of oral bacteria
According to the experts, the following bacteria are among those that can help foster a healthy balance inside the mouth:
Lactobacillus reuteri DSM 17938
Lactobacillus reuteri ATCC PTA 5289
Streptococcus oralis KJ3®
Streptococcus uberis KJ2®
Streptococcus rattus JH145®
Streptococcus salivarius K12
Streptococcus salivarius M18
(Sources: Mark Cannon, DDS, MS; and Maria L. Geisinger, DDS, MS)
1. Zhang J, Haines C, Watson AJM, et al. Oral antibiotic use and risk of colorectal cancer in the United Kingdom, 1989-2012: a matched case-control study. Gut. 2019;68(11):1971-1978.
2. Berkowitz RJ. Acquisition and transmission of mutans streptococci. J Calif Dent Assoc. 2003;31(2):135-138.
3. Featherstone JDB. The caries balance: contributing factors and early detection. J Calif Dent Assoc. 2003;31(2):129-133.
4. Cannon ML. A review of probiotic therapy in preventive dental practice. Probiotics Antimicrob Proteins. 2011;3(2):63-67.
5. Cannon ML, Vorachek A, Le C, White K. Retrospective review of oral probiotic therapy. J Clin Pediatr Dent. 2019;43(6):367-371.
6. Cannon ML. Clinical application of probiotic therapy. Inside Dentistry. 2011;7(6):112-115.