Probiotics as a Preventative Treatment for Dental Caries

Probiotics as a Preventative Treatment for Dental Caries

Evidence Position Paper
By: Laura Martin, Sarah Dunsby and Lisa Goodwin
Due: July 29th, 2016

Probiotics as a Preventative Treatment for Dental Caries

Introduction
Probiotics have been used to treat a variety of health problems due to its properties that
help promote immunity and protect against infectious bacteria (Lee and Kim, 2014). Probiotics
are now being used in all sorts of products including milk and yogurt as well as over the counter
probiotics to help with digestive problems (Lee & Kim, 2014). Probiotics work by balancing the
microbial flora within the body and helping restore normal body functions (Anusha, Umar,
Basheer & Baroudi, 2015).
Recently, probiotics have been researched as being effective in the treatment of caries and
periodontal disease. Probiotics have been studied in the treatment of periodontal disease and
have shown to reduce intraoral levels of Bacteroides sp., Actinomyces sp., Candida albicans, and
Staphylococcus intermedius (Lee and Kim, 2014). Probiotics have also been studied in the use of
reducing yeast levels (Lee and Kim, 2014). However, more research needs to be conducted
before its full potential can be determined.
Probiotics research is an up and coming area of study that has captured the attention of
the dental world. With the increased use of antibiotics, the potential that probiotics can be used to
treat various oral conditions, including periodontal disease and dental caries is intriguing and this
paper will explain to readers the current research that is available regarding the use of probiotics
in the treatment of dental caries. More specifically, this paper will discuss the use of probiotics to
reduce streptococci mutans counts within the oral cavity and how probiotics can help reduce the
potential for the bacteria to grow within the oral biofilm.
Opposing Points
A review completed by Anusha, Umar, Basheer and Baroudi (2015) summarized many
studies aimed at determining the current potential of probiotics in dentistry. The area within the

Probiotics as a Preventative Treatment for Dental Caries

review that focused on the effects of probiotics on dental caries is fairly small due to the lack of
evidence. Only a small amount of studies has been completed which show the effectiveness of
probiotics against the caries causing bacteria S. mutans. These studies used a variety of
lactobacillus probiotics to see their effects on the S. mutans bacteria. All studies showed
promising results but many more randomized control trails are required before the use of
probiotics against dental caries can be considered a promising option.
Another study conducted by Hasslof, West, Videhult, Brandelius and Stecksen-Blicks
(2013) tested the long-term effects of a probiotic on caries experience in infants and the results
were measured once the study participants were 9 years old. The DMFS/dmfs scores of the
children in the probiotic group did not differ from those in the control group. This indicates that
the long-term effect of probiotic use has no benefit in children.
Lactobacilli have been used as a probiotic that is used to treat several diseases, commonly
for digestion purposes (Ehrlich, 2015). However, when the dental effects are considered
Lactobacilli are linked to the development of caries (Badet et al. 2008). One study, conducted by
Montalto et al. (2004), aimed to evaluate whether the use of probiotics, in liquid and capsule
form, would change the salivary count of lactobacilli. This study was conducted as a doubleblind, randomized, controlled study where thirty-five healthy individuals (divided into 3 groups)
were used over the span of 45 days. The results of this study showed that when given the
probiotic (either in liquid or capsule form), it significantly increases the salivary counts of
lactobacilli, while the S. mutans numbers were not significantly affected. From these results we
can determine that the use of probiotics, no matter the route of administration, can increase the
number of lactobacilli in the oral cavity.

Probiotics as a Preventative Treatment for Dental Caries

Another article to take into consideration when making an informed decision about
offering proper advice on the subject of dental caries in the relation to probiotics is written by the
Journal of Dentistry of Tehran University of Medical Sciences. This article is a double blind,
randomized controlled clinical trial. It includes a two-phase in-vivo study. The study was
completed by Acharya et al in 2015 and included a total of thirty-three schoolchildren between
twelve to fifteen years. They were randomly designated into to three groups. Group A consisted
of eleven, children using freeze dried Lactobacillus acidophilus, Bifidobacterium longum,
Bifidobacterium bifidum and Bifidobacterium lactis. The second group (Group B) included
another eleven children of the thirty-three using freeze-dried lactic acid bacillus only. The third
and final group (Group C) included the final eleven children using placebo powder.
The study consisted of a three-week time frame with examination and sampling of the
subjects was done on days zero, seven, fourteen and twenty-one. The results recoded up to the
second week concluded a reduction in groups A and B, in salivary mutans streptococci counts.
The control group (Group C), Streptococcus mutans count did not show any significant reduction
between baseline and the first week, second week and third week.
Although the results of this study suggest a short term decrease in the caries causing
bacteria S. mutans between the groups receiving the probiotics (groups A & B), doesnt mean the
information is accurate enough to suggest probiotics as a dental care intervention (Acharya et al.,
2015). The reason that this study is not a viable resource is due to the location and study group
(Acharya et al., 2015). The location of this trial includes a rural area with school children
(Acharya et al., 2015). In order to prove the probiotics are a viable source in reducing S. mutans
for dental clients the study needs to include a generalized study to the entire population as this
study was conducted on rural schoolchildren (Acharya et al., 2015). Further randomized

Probiotics as a Preventative Treatment for Dental Caries

controlled trials on different population groups are warranted to confirm or refute the long-term
effects, means of administering probiotics and the dosages needed to achieve different preventive
or therapeutic purposes (Acharya et al., 2015).
As Dental professionals we are to make informed decisions in the best interest of our
clients and communicate our findings to them. These articles should be taken into consideration
when deciding to give or not give probiotics as a treatment option for caries. Below are articles
discussing why we should use probiotics as a preventative treatment for dental caries.
Why Choose Probiotics for Dental Caries Treatment?
According to a study conducted by Sirvastava, Saha, Kumari and Mohd (2016), probiotic
curds have been shown to significantly decrease the amount of streptococcus mutans present in
the oral cavity. The probiotic curd was also able to increase the average pH of the oral cavity by
the end of the 7-day trial period. As well, by using the curd as the delivery system for the
probiotics, the probiotics can stay in the oral cavity for longer due to its semisolid state. The
curd, being a diary product, also contains casein phosphopeptides that help with the
remineralization process of tooth enamel helping prevent dental caries.
A study conducted by Caglar et. al, 2009 aimed to determine the best route of
administration of probiotics. A group of 120 healthy volunteers between the ages of 21-24 were
selected for the trial. The subjects were then split into four groups: group A was given water that
had been treated with the probiotic and given a straw, group B had a placebo straw, group C was
given a probiotic tablet and group D received a placebo tablet. After using Lactobacillus reuteri
ATCC 55730 in their study, they were able to conclude that a short-term daily ingestion of
lactobacilli-derived probiotics delivered by prepared straws or lozenges reduced the levels of
salivary mutans streptococci in young adults.

Probiotics as a Preventative Treatment for Dental Caries

A study conducted by Lee and Kim (2014), investigated the effects of various probiotics
on the oral biofilm and their inhibitory affect on biofilm formation. The study showed that the
lactobacillus strain of probiotics was able to inhibit bacteria growth significantly more than other
probiotics, with S. mutans to be significantly susceptible. The specific strains L. acidophilus, L.
casei and L. rhamnosus were able to decrease the S. mutans count when present in the salivary
biofilm model, with L. rhamnosus inhibiting the bacteria significantly more than L. acidophilus
and L. casei. The study concluded by stating that L. rhamnosus can be a good candidate for
probiotic treatment for dental caries.
The study Screening of Probiotic Candidates in Human Oral Bacteria for the
Prevention of Dental Disease aimed to determine the specific bacteria that could be utilized for
the prevention of caries without causing other systemic health issues. This study included criteria
such as; must show no enamel demineralization, must not decrease the pH below 5.5, and
determining which surfaces the bacteria adhered to the best. The results showed that
L. crispatus YIT 12319, L. fermentum YIT 12320, L. gasseri YIT 12321, and S. mitis YIT
12322 showed neither enamel demineralization, decrease of pH below 5.5 and concluded that
the low cariogenic potential was due to the fact that they did not adhere to the tooth surface. In
the conclusion, the screening determined 4 strains that could be considered as candidates for
probiotic use in preventing caries.
In the study written by Teanpaisan and Piwat (2014), the aim of the study was to
determine the effects of a specific lactobacillus probiotic L. paracasei on the growth of S.
mutans. Although it was not able to increase the salivary pH after the 4-week period, the
probiotic was able to significantly decrease the amount of streptococci mutans present within the
oral cavity.

Probiotics as a Preventative Treatment for Dental Caries

Another study completed by Kermanshahi & Tahmourespour in 2011 investigated the
ability of biofilm among mutans and non-mutans oral streptococci and to determine the effect of
the probiotic Lactobacillus acidophilus on the adhesion of selected streptococcal strains on the
surfaces. This study done included 40 isolates of oral S. mutans from dental plaque of volunteer
persons with the mean age of 25 years. In order to assess the effect of Lactobacillus acidophilus
on biofilm formation, an overnight culture of each isolate was grown in tryptic soy broth
supplemented with 1% sucrose. An overnight culture of the probiotic strain in MRS broth was
also prepared. After twenty-four hours incubation and washing three times with PBS, staining
with CV was done. The Optical density was read with ELISA reader. In conclusion an adhesion
reduction can be an effective way of decreasing cariogenic potential of oral streptococci and that
probiotic bacteria such as Lactobacillus acidophilus can affect the oral ecology.
A study done by Chuang, Huang, Lin & Ou-Yang (2010) researched the Probiotic
Lactobacillus paracasei effect on cariogenic bacterial flora. This study included eighty healthy
volunteer subjects, aged twenty to forty years, and grouped by randomization. This double-blind
method included forty-two and thirty-eight samples for the probiotic and control group. The
exclusion criteria were persons who smoke, with systemic disease, using long-term use of
antibiotics, or undergoing dental treatment including orthodontic, periodontal, endodontic, and
prosthodontic treatment. The investigation included probiotic tablets with a two-week
intervention treatment and a two-week posttreatment. In the control group there was no
difference in S. mutan counts during each treatment time. In the probiotic treatment group, the S.
mutans decreased slightly during the treatment phase and even more of a reduction shown during
the post treatment phase.

Probiotics as a Preventative Treatment for Dental Caries

Nishihara et al 2014 completed a randomized open-label clinical trial on the effects of
lactobacillus salivarius-containing tablets on caries risk factors. This study included 64
volunteers split into four groups containing probiotics for two weeks then their saliva was
collected. The aim is to reduce S. mutans utilizing the L. salivarius-containing tablets. The
results of the study concluded a reduction in caries risk in the L. salivarius-containing tablets.
One review that was conducted by Devine et al, 2009, states that there are many
considerations when studying which probiotics will work and which ones dont such as their
ability to colonize or adhere to surfaces, antagonistic capabilities, or inhibition abilities. This
review goes on to promote the use of probiotics stating that they have been shown to be effective
in protecting against caries and reducing S. mutans levels in saliva when ingested (Devine et al,
2009). However Devine does mention that some strains such as Lactobacillus spp. or L.
salivarius have been linked to the development of caries.
Conclusion
From these findings we can conclude that certain probiotics can be very beneficial to
systemic health, oral health, and even caries prevention. Selection of a probiotic must be done
carefully and after dutiful research into the specific strain being used. Without careful selection,
you may incidentally increase the risk for caries rather than achieve the goal of caries prevention.
In addition to the type of bacteria being used, the optimal mode of delivery must be found as
well. For instance, some bacteria might work better as a rinse than a tablet. In order to
completely understand and optimize the benefits of probiotics, without long-term consequences,
further research should be completed.

Probiotics as a Preventative Treatment for Dental Caries

References
Acharya. S., Ganta. S., Nagaraj. A., Pareek. S., Sidiq. M., Singh. K., Vishnani. P., Yousuf. A.
(2015). Comparative Evaluation of Commercially Available Freeze Dried Powdered
Probiotics on Mutans Streptococci Count: A Randomized, Double Blind, Clinical Study.
J Dent (Tehran), 12(10): 729738. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4888159/
Anusha, R. L., Umar, D., Basheer, B., & Baroudi, K. (2015). The magic of magic bugs in oral
cavity: Probiotics. Journal of Advanced Pharmaceutical Technology & Research, 6(2),
43-47.
Badet, C., & Thebaud, N. . (2008). Ecology of Lactobacilli in the Oral Cavity: A Review of
Literature. The Open Microbiology Journal, 2, 3848.
http://doi.org/10.2174/1874285800802010038
Caglar, E., Cildir, S. K., Ergenell, S., Sandalli, N., & Twetman, S. (2009, July 2). Salivary
mutans streptococci and lactobacilli levels after ingestion of the probiotic bacterium
Lactobacillus reuteri ATCC 55730 by straws or tablets. Retrieved July 28, 2016, from
http://www.tandfonline.com/doi/full/10.1080/00016350600801709
Chuang. L., Huang. C. S., Lin. S., Ou-Yang, L. (2010). Probiotic Lactobacillus paracasei effect
on cariogenic bacterial flora. Springer: Clinical oral investigations. 15(4): 471476. Doi:
10.1007/s00784-010-0423-9
Devine, D. A., & Marsh, P. D. (2009). Prospects for the development of probiotics and prebiotics
for oral applications. Journal of Oral Microbiology, 1, 10.3402/jom.v1i0.1949.
http://doi.org/10.3402/jom.v1i0.1949

Probiotics as a Preventative Treatment for Dental Caries

Ehrlich, S. D., NMD. (2015, August 6). Lactobacillus acidophilus. Retrieved July 28, 2016, from
http://umm.edu/health/medical/altmed/supplement/lactobacillus-acidophilus
Hasslof, P., West, C. E., Videhult, F. K., Brandelius, C., & Stecksen-Blicks, C. (2013). Early
intervention with probiotic lactobacillus paracasei F19 has no long-term effect on caries
experience. Caries Research, 47(6), 559-565.
Kermanshahi. K. R., Tahmourespour. A. (2011). The effect of a probiotic strain (Lactobacillus
acidophilus) on the plaque formation of oral Streptococci. Bosnian Journal of Basic
Medical Sciences, 11(1): 3740. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4362563/
Lee, S., & Kim, Y. (2014). A comparative study of the effect of probiotics on cariogenic biofilm
model for preventing dental caries. Archives of Microbiology, 196, 601-609.
Montalto, M., Vastola, M., Marigo, L., Covino, M., Graziosetto, R., Curigliano, V., & Gasbarrini,
G. (2004). Probiotic treatment increases salivary counts of lactobacilli: A double-blind,
randomized, controlled study. Digestion, 69(1), 53-56.
Nishihara. T., Hirofuji. T., Suzuki. N., Yoneda. M. (2014). Effects of Lactobacillus salivariuscontaining tablets on caries risk factors: a randomized open-label clinical trial. BMC Oral
Health. 14: 110. Doi: 10.1186/1472-6831-14-110
Srivastava, S., Saha, S., Kumari, M., & Mohd, S. (2016). Effect of probiotic curd on salivary ph
and streptococci mutans: A double blind parallel randomized control trial. Journal of
Clinical and Diagnostic Research, 10(2). ZC13-ZC16.
Teanpaisan, R., & Piwat, S. (2014). Lactobacillus paracasei SD1, a novel probiotic, reduces
mutans streptococci in human volunteers: A randomized placebo-controlled trial. Clinical
Oral Investigations, 18, 857-862.

10

Probiotics as a Preventative Treatment for Dental Caries

Terai, T., Okumura, T., Imai, S., Nakao, M., Yamaji, K., Ito, M., Hanada, N. (2015). Screening
of Probiotic Candidates in Human Oral Bacteria for the Prevention of Dental
Disease. PLoS ONE, 10(6), e0128657. http://doi.org/10.1371/journal.pone.0128657

11