An in-depth view of oral probiotics

Shirley Gutkowski, RDH, offers an explanation about why probiotics are so important to dental care.

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By Shirley Gutkowski, RDH, BSDH

We’ve been hearing about probiotics for some time — most notably for digestive health of the human body. What’s new is oral probiotics that help manage oral biofilm. Let’s take an in-depth look at how all of this works and how it works together with oral health.

As you look at the term probiotic, the Latin/medical language corner of your brain will spike some activity. Rickity dendrites will twitch, and the myelin-coated axons will quiver. The root word, pro, will certainly kick off some neurotransmitter juice, since it means before. Before the neurons go back to a dormant “wait for later” slump, the term biotic will stimulate some further activity. Another root word, bio becomes obvious. Whoo hoo! Two words, both Latin/medical prefixes. Before Life-tic. Ok, well, that stopped working pretty quickly. Now what?

Let me help you. According to the American Journal of Clinical Nutrition: A probiotic is defined classically as a viable microbial dietary supplement that beneficially affects the host through its effects in the intestinal tract. Or more succinctly: a live microbial food ingredient that is beneficial to health.(1)

The National Institutes of Health have a site called National Center for Complementary and Alternative Medicine (NCCAM). The NCCAM defines probiotics as live microorganisms (in most cases, bacteria) that are similar to beneficial microorganisms found in the human gut. They are also called "friendly bacteria" or "good bacteria." Probiotics are available to consumers mainly in the form of dietary supplements and foods. Yogurt and other fermented foods are the main sources of naturally occurring probiotic bacteria in the American diet.

The yogurt aisle is the first place most people ever hear about probiotics. Unless someone frequented a health food store, probiotics were not on the map of the American mind until the Dannon company started making Dannon Activa with probiotics. Few people know that yogurt has always been filled with probiotics, particularly Dannon (Remember the phrase “live active cultures?”). The fresher the yogurt, the more viable bacteria it contains. The virtues of yogurt are associated with, among other things, bacterial action in the intestines, making bacterial presence in a sufficient number important. Yogurt must by law contain at least 10 million bacteria per gram at the time it is marketed to make the claim active cultures.(2)

As they started to gain popularity in the 1980s (125 brands of yogurt were alive and well in the United States in 1985), some yogurts had no live cultures. The fresher the yogurt, the more viable bacteria it contains, and there was no real way to know if it was fresh or not. We had to read the labels. Magnifying glass in hand, those who knew the difference looked for brands with live cultures and became loyal to them.

Bacteria don’t often get called “good.” The bacteria in the yogurt are what metabolize the lactose in pasteurized low-fat milk, causing the milk to thicken and become yogurt. Those active cultures helped replace beneficial bacteria after antibiotic therapy and helped the human digestive system work better. Those were the original probiotics; the addition of more specific bacteria has taken a giant leap in food science. Today, the inclusion of different strains of bacteria into the yogurt without the intention of making the yogurt itself better has really evolved.

Yogurt isn’t the only food with naturally occurring probiotics. WebMD has quite a list on their site. To save you some time, they included other fermented milks such as buttermilk and kefir. Also included are sauerkraut, miso soup, sourdough bread, and Gouda cheese. It’s easy to get probiotics in your diet if you’re looking for a healthy gut.

On the other hand, a prebiotic is altogether different. They have only a tangential relationship with bacterial cultures. The American Journal of Clinical Nutrition again: A prebiotic is defined as a non-digestible food ingredient that beneficially affects the host by selectively stimulating the growth and/or activity of one or a limited number of bacteria in the colon. Prebiotics in the colon can select for microflora that is potentially health promoting. Those would be, surprisingly, lactobacilli and bifidobacteria, the two main ingredients in digestive probiotics.

The Livestrong.com Web site lists these foods as good sources of prebiotics: chicory root, oats, barley, legumes, greens, and garlic. WebMD adds: asparagus, Jerusalem artichokes, bananas, oatmeal, red wine, honey, and maple syrup. In the world of probiotics, prebiotics have a place in providing energy for the type of bacteria the body is trying to support. But they are not a necessary component of a probiotic supplement. So, for gut or digestive health past the stomach, prebiotics may be as important as probiotics(1) in developing friendly gut bacteria. Look for companies that add specific prebiotics like inulin to simulate growth of their probiotic. We won’t be seeing the term prebiotics as they pertain to the first part of digestion, the mouth. If the term does show up, you won’t be caught off guard because you read this article.

Oral Probiotics

Probiotics for oral health are not that prolific. The term oral probiotics seems innocuous enough. The term may be a little misleading because all probiotics are taken by mouth; they’re very rarely administered via injection, enema, or colonics. Probiotics almost all function in the gut, though. The oral probiotics of this article refer to those bacteria that are intended to work in the mouth to alter the oral biofilm to be more healthful. Yes, it’s possible to have a more healthful biofilm.

The challenge is to repopulate the niche in the oral biofilm that holds the cariogenic bacteria. For years, the people who have been working on a caries vaccine have been trying to figure out how to do that. Their idea is to start with a sterile field, then add some early colonizers that will build the biofilm without having space for the caries causing bacteria, which are still considered to be streptococcus mutans and strep sobrinus. They needed a strain that was powerful enough to act like them, but not be aciduric, meaning they don’t pump out acid.

One savvy researcher, Dr. Jeffrey D. Hillman(3), working on a caries vaccine for over two decades noticed people in Europe supplementing their gut bacteria nearly every day with a little jug of the probiotic mixture. It dawned on him that people may be willing to supplement their oral flora daily as opposed to once as with a vaccine. He collected biofilm samples from people with healthy teeth, isolated three particular bacteria branded them with a specific number, and grouped them together with outstanding results. No, he didn’t do that all in one day. The process took a few years to get right.

That bacterial grouping is called ProBiora3 and is found in EvoraPro. This is the only probiotic with original strains cultivated from healthy people. No foods contain these strains. The mission is to provide bacteria that creates an oral ecology that favors health. The bacteria in the ProBiotic3 are Streptococcus oralis KJ3, Streptococcus uberis KJ2, and Streptococcus rattus JH145. The strep genus is the usual instigators in building the biofilm from the surface of the teeth. If the strep are mutans, or sobrinus, for instance, any amount of sugar will start the acid and slime pumps a crankin’. By crowding out that bunch with bacteria that don’t exhibit those attributes, the plaque biofilm grows much much slower above and below the gingival crest. The probiotic blend manages the biofilm.

Oral probiotics, such as ProBiora3, are freeze dried. Some of us remember freeze-dried astronaut food, Taster’s Choice freeze-dried coffee, and freeze-dried foods for campers. Freeze drying is an art. The idea is to take the moisture out of something until it it’s totally dry by freezing it. The trick is to monitor the heat that facilitates the drying, or vaporization of the water. Accidentally cooking the thing you’re trying to dry out is pretty easy when you’re dealing bacteria.

The process is to freeze the bacteria and move from the solid stage to the vapor stage by sublimation. Sublimation means shifting from solid to vapor without moving through the liquid phase. Are you ready for this? They do that by applying pressure, kind of the way an autoclave gets the water over 212 degrees -- because of the pressure.

So by applying pressure to the frozen product, the liquid vaporizes. In the case of probiotics, the water is vaporized out of the bacteria, leaving the entire bacteria intact. Their size also allows them to rehydrate and reanimate in the presence of moisture, such as saliva.

Probiotics for children are the easiest way to start a person on the way to oral health. The child between the ages of 3 to 10 years simply dissolves the lozenge in their mouth once a day. There are fewer bacteria in the lozenge for children. In adults, a tablet dissolved in the mouth is all that is required after an acclimation period of 10 days on two lozenges. The EvoraPro tablets for adults that contain the ProBiora3 formulation is intended to be dispensed by the dental office, and there are sufficient numbers in the bottle to offer the patient 90 days of coverage.

Because probiotics are so well received by the general public, it makes sense to start offering them from the office. Selecting a person who is trying everything to manage their oral health and not succeeding is the best candidate to start with.

Keep your eye toward your dental hygiene portfolio. Take some pictures of the patient’s disclosed teeth before they start and again in a month or three. Track how well they respond and their comments. Ask them if it was easy to remember to take the lozenges. Create a little chart, even on the computer in the treatment room. Charting progress can help you follow cases and find out the best way to present the case, or increase patient compliance. Publishing those cases will support the whole of dental hygiene. What a great piece of evidence you’ll have at raise time. Adding a new and exciting product to your protocols for caries management and proof of how it works is one of the things that make for a secure position.

Contraindications

Because probiotics are live bacteria, there is only one type of patient that will present to you who will not be a candidate for any probiotics — a patient who is immunocompromised. People who are undergoing chemotherapy are not candidates, as well as those who present with HIV/AIDS. Other conditions also drive down the immune system, and those patients are not good candidates either. Often, these patients need oral biofilm management, and xylitol products are a better option.
Looking at labels of probiotic mints, learn to be discerning. What sweetener is used? What type of flavoring agent is used? Where are the offered bacteria from? How is it administered? Certainly swallowing a tablet won’t do as much for the oral ecology as letting it dissolve in the mouth. As medicine alters the human physiology with medications, environmental and dietary stresses contribute to oral changes; the time is right for oral probiotics to support oral health.

Pennwell web 100 66Shirley Gutkowski, RDH, BSDH, is a clinical dental hygienist, speaker, and writer. Gutkowski is the technology coach and mentor at CareerFusion. She can be found on Facebook, YouTube, Twitter, and LinkedIn for speaking at your meeting. Her electronic portfolio can be viewed here.

References
1. Am J Clin Nutr 2000;71
2. http://www.customprobiotics.com/ Accessed March 14, 2012
3. http://www.oragenics.com/ Accessed March 14, 2012

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