Oral Health Probiotics

L. acidophilus is sometimes blamed for tooth cavities

Oral health probiotics may seem unnecessary since maintaining oral health seems easy enough: brush, floss and use mouthwash and your teeth will be pearly white and your breath minty fresh. But is it that simple? Of course not. If it were that simple, gingivitis, periodontitis, and cavities would not exist.

Gingivitis, periodontitis, and cavities are common problems in the mouth that can influence overall health. Gingivitis is a common and mild form of gum disease that causes irritation, redness, swelling, and often bleeding upon brushing of your gingiva, the part of your gum around the base of your teeth. The most common cause of gingivitis is poor oral hygiene that results from a bacterial imbalance and plaque buildup that irritates a person's gums, resulting in inflammation, discoloration, and pain. Other causes of gingivitis are bacterial, viral, or fungal infections or an allergic reaction to an oral device such as dentures. Oral health probiotics can support the body's response to gingivitis.

If not treated promptly, gingivitis can lead to a much more serious gum disease called periodontitis. Periodontal disease is a chronic inflammatory disease in the mouth that can destroy the periodontal ligaments and alveolar bone, resulting in damage to the supportive tissues surrounding the teeth and eventual tooth loss. The prevalence of periodontitis was an incredible 46% worldwide in 2010. According to the 2016 Global Burden of Disease Study, periodontal disease is the 11th most prevalent disease worldwide. What is clear from research is that periodontitis requires an imbalance in the oral microbiome and a susceptible host. Oral health probiotics can help with imbalances in microbes and immune responses to them.

Many people are familiar with cavities. Cavities, also known as dental caries, are small holes in tooth enamel that can happen when decay-causing bacteria in your mouth make acids that attack the tooth's surface. If tooth decay is not treated, it can cause pain, infection, and even tooth loss. Cavities also show the presence of a microbial imbalance. Oral health probiotics can help.

The toll on the body from oral disease is not limited to the mouth, however. Oral disease states such as periodontal disease are associated with disease states throughout the body. Some of the ways this happens are:

  • Oral cavity-associated microbes translocate and have been found in organs far away from the mouth, such as the small intestine, lungs, heart, placenta and brain
  • Toxins produced by some oral microbes enter circulation causing inflammation
  • And/or systemic inflammation results as an immune response to oral microbes.

For instance, it is known that periodontal disease is associated with cardiovascular disease and high blood pressure, as well as oral, esophageal, pancreatic, and colorectal cancers, and also inflammatory bowel disease and rheumatoid arthritis. It is also known that periodontal disease-related pathogens play a role in adverse pregnancy outcomes such as preterm delivery, stillbirth, and preeclampsia.

Periodontal disease and a pathogen associated with it are also identified as significant risk factors for the development of beta amyloid plaques, dementia, and Alzheimer's disease. Oral pathogens may also make you more susceptible to viruses.

Conversely, some disease states in the body, such as diabetes, can affect the oral microbiome. Chronic psychological stress, depression, and anxiety are also risk factors for periodontal disease.

The benefits of oral health probiotics may affect the entire body!

What Constitutes a Healthy Mouth?

A healthy mouth has:

  • pink, firm gums with whitish areas
  • no visible plaque or tartar
  • no cavities
  • adequate saliva
  • a clean tongue
  • non-offensive breath, and
  • no bleeding during routine home hygiene or cleaning

On the other hand, an unhealthy mouth with signs of dysbiosis has: red, puffy, smooth gums; visible plaque or tartar, visible cavities, dry mouth, a coated tongue, bad breath, and bleeding during routine home hygiene or cleaning.

Adequate saliva is important because it contains protective immunoglobulins and other immune molecules, controls the pH balance in the mouth, feeds oral microbes, and helps to maintain homeostasis in the mouth.

Mouthwash And Oral Health Probiotics

The composition of the oral microbiome changes throughout life in response to genetics, maternal microbial transmission, diet, oral hygiene, saliva volume, medications, stress, alcohol intake, smoking, aging, and the health-state of the body, such as previously-mentioned diabetes. It is no surprise that smoking skews the oral bacteria balance to an unhealthy status!

The composition of the oral microbiome is also influenced by those with whom we kiss and share food and drinks.

The mouth is a dynamic environment with exposure to foods, drinks, air, environment, and anything breathed in or consumed. It also contains microenvironments in different areas, such as the teeth, gums, tongue, tonsils, palate, and mucosa, that are better suited for different communities of microbes.

All this talk about microbes may make you think that having that minty feeling in your mouth from mouthwash makes your mouth is as fresh and clean as can be. The truth is, it may be too clean. Conventional antibacterial mouthwash does what it is supposed to do, inhibit bacteria in the mouth. However, by doing so, it may reduce not only the pathogenic bacteria but also the beneficial oral health probiotics or commensals ones, too.

Alcohol-based mouthwash contains approximately 25% alcohol that can slowly degrade the mucus layer in your mouth and may make bad breath worse by reducing saliva production. Alcohol is a known antibacterial agent.

Chlorhexidine mouthwash caused shifts in the abundances of oral microbes after 7 days in 36 patients such that salivary pH and salivary acid-buffering capability were reduced, and salivary lactate was increased. Oddly enough, these effects of the mouthwash are associated with tooth decay and periodontal disease! Chlorhexidine also decreased the oral and plasma levels of nitrite (more about nitrite below). Additionally, it is known that chlorhexidine can result in increased tartar on teeth and staining in the mouth.

Antibacterial mouthwash can increase blood pressure. A 3-year study that focused on 540 forty- to sixty five-year old overweight/obese individuals who used over-the-counter mouthwash twice daily showed that mouthwash use was associated with a higher risk of high blood pressure independent of major risk factors for hypertension and other potentially cofounding factors. Those who used mouthwash twice per day had 85% higher risk of diagnosed hypertension compared to less-frequent users, and more than double that of non-users.

Another study involving 15 treated older hypertensive men and women was a randomized, controlled cross-over trial. Within 3 days, antibacterial mouthwash use disrupted nitrate to nitrite metabolism and increased systolic blood pressure.

Nitrate metabolism is one of the important functions of our commensal bacteria. Increased blood pressure with antibacterial mouthwash use occurs because antibacterial mouthwash disturbs the nitric oxide cycle. There is a symbiotic relationship between oral nitrate-reducing bacteria and humans. Almost 25% of the nitrate in foods we consume is transported back to the oral cavity. There, the commensal microbes reduce nitrate to nitrite. The nitrite is then swallowed and converted to nitric oxide, which is a signaling molecule that has important functions in cardiovascular health through vasodilation and antihypertensive effects.

Dysfunctions in nitric oxide or its signaling are also associated with obesity, and one study showed that frequent over-the-counter mouthwash use independently increased the risk of prediabetes/diabetes in overweight adults.

Antibacterial mouthwash also inhibits the bacteria that can buffer acids produced by cavity-associated bacteria by producing alkaline metabolic products.

Clearly, routine antibacterial mouthwash has its drawbacks. And of course, oral antibiotics have great potential to disrupt the biomes in the rest of the body, particular in the gastrointestinal tract.

Sometimes, however, it is helpful to have products to control oral pathogens and help break up or reduce formation of biofilms, yet still be gentle for sensitive teeth and not eliminate beneficial bacteria. In times like those, I like the Dentalcidin Oral Care System. Unlike antibiotics or broad antibacterial mouthwash products previously mentioned, Dentalcidin products are based on the plant-based blend of botanicals and essential oils in Biocidin that have shown the ability to act against biofilms and pathogens without decimating beneficial or probiotic microbes, but these products also provide antioxidants to neutralize damaging free radicals, support gum tissue repair, and help in plaque prevention.

Dentalcidin toothpaste and Dentalcidin LS Liposomal Rinse are made without dairy, gluten, soy, corn, animal products, artificial coloring or flavoring. Note that they do contain walnut leaf and hull.

Xylitol products are enjoyable products for oral health. Xylitol is a sugar alcohol that has been shown to prevent bacteria from attaching to teeth and gums. I like Spry products. Spry has a spray, a peppermint-y moisturizing spray sweetened with xylitol and formulated with aloe vera (soothing) and calcium glycerophosphate (pH balance and enamel protection) as a between-brushing dental freshening up. Spry is also available in chewing gum and hard lozenges in flavors like peppermint, cinnamon, spearmint, and berry, as well as toothpastes and non-alcohol mouthwashes. The hard lozenges are great for on-the-go, and I take some backpacking with me. There are products suitable for kids, too. You can find Dentalcidin and Spry products in my Wellevate and Fullscript online dispensaries. Please always check ingredients prior to purchase.

Of course, your diet and lifestyle have major effects on your oral health. One of my newsletters provided several ways to support oral health.

The Need for Oral Health Probiotics

I previously mentioned microenvironments in the mouth such as the teeth, gums, tongue, tonsils, palate, and mucosa. Some microbes are present in more than one microenvironment. Research shows that some of the same microbes found in gingival plaque are also found in subgingival (below the gumline) plaque.

Plaque is a type of biofilm, and the overabundance of these plaque microbes is the result of an imbalance in the oral microbiome. Once the community of bacteria involved in plaque formation are established, they replicate, mature, and form of a complex biofilm that can contain hundreds of species. These species arrange themselves with aerobic taxa on the periphery and anerobic taxa in the interior. Plaque protects microbes from fluctuations in their environment as well as from host defenses.

There have been over 700 species of bacteria characterized from the oral cavity, including some well-known pathogens such as Streptococcus mutans and Porphyromonas gingivalis. The oral microbiome has the largest core set of microbes found among unrelated individuals. The main genus is Streptococcus, with commensal species oralis, mitis, and peroris the most predominant. Commensals such as these are important in maintaining homeostasis in the oral microbiome.

Interestingly, it has been shown that commensal species are required for the periodontal pathogens to increase their virulence through cross-feeding. The commensals produce metabolic products such as lactic acid, which the pathogens then use to fuel their growth.

 S. mutans excels at producing biofilms, especially when dietary sucrose (sugar) is available, and is implicated in dental cavities. P gingivalis is prevalent in periodontitis, and promotes disease by exploiting the pro-inflammatory immune responses of the periodontitis patient, resulting in bone loss.

T. forsythia and T. denticola are also oral pathogens. Together with P gingivalis these bacteria are known as the "red complex" since they are found together in periodontal pockets with extensive damage. Other oral pathogens frequently involved in periodontitis are F. nucleatum, A. actinomycetemcomitans, and P. intermedia.

Scaling and root planning is the usual treatment for periodontitis. In some cases, antibiotics are given. While oral antibiotics are often given to individuals with compromised immunity during dental procedures, systemic antibiotics do little to the bacteria protected in biofilms. Locally-placed antibiotics may have a better result for periodontal pockets, but many of the oral pathogens, like other pathogens and opportunists in our bodies, are resistant to antibiotics. Thus, oral health probiotics may be the additional resource to add to conventional treatment of periodontitis.

Oral Health Probiotics

Probiotics can help to support oral health through various actions. One of these actions is to increase the alkalinity in the mouth. Another is to antagonize oral pathogens. Yet another is to modulate the immune response to pathogens with antioxidant and antiinflammatory actions. Some probiotics do all three actions and more.

A systematic review in 2021 of 91 studies showed that despite inconsistencies between clinical trials, benefits of various probiotics included reduced S. mutans counts, reduced probing depth in chronic periodontitis, reduced levels of bad breath, and soothed oral mucositis in chemotherapy-radiation cancer patients.

A 2022 meta-analysis of the efficacy of probiotics against cavities in children showed that from 43 included randomized, controlled trials, probiotics significantly reduced cavity lesions in children and reduced S. mutans.

Another 2022 meta-analysis showed that although the use of probiotics did not improve the plaque index, this meta-analysis DID show that periodontal pocket depth, clinical attachment loss, and bleeding on probing while using probiotics as an additional therapy to scaling and planing resulted in improvement in all those measurements.

Different probiotics were investigated for different oral health problems, thus there is not one single probiotic that is determined to support all aspects of oral health. However, nearly all of the probiotics studied were in the genera Lactobacillus (various species) or Streptococcus (particularly salivarius species.) Many are not available as supplements yet. Some of the probiotics were swallowed, some were in the form of a gel or lozenge, and others were swished in the mouth and then swallowed.

Here is the big takeaway: The rationale for using probiotics as adjuvant therapies should not be based on the plaque index because biofilms will form on teeth even in a healthy mouth. In fact, one probiotic was isolated from the plaque of a healthy person with a healthy mouth.

Additionally, according to one review, the actual driving force behind inflammation-promoting oral dysbiosis is not solely poor oral hygiene, but a state of systemic inflammation. Since mechanical removal of plaque and tartar is already established as a successful treatment for oral health conditions, adding probiotics specifically targeting the mouth in otherwise healthy individuals may not provide noticeable effects on oral health because their overall inflammation levels throughout their bodies are low. However, in populations with altered systemic inflammatory responses, the systemic antiinflammatory responses from probiotics may be the key to their use.

That being said, almost all of us have some level of damaging inflammation in our bodies, even if we do not have outright systemic conditions like diabetes or hypertension. Maintaining healthy gut and oral microbiota balance should be in everyone's daily routine. Easy ways to consume certain Lactobacillus species is with lacto-fermented or -cultured foods and drinks and probiotic supplements found in my online supplement dispensaries Wellevate and Fullscript.

The future of probiotics and post-biotics in oral health will continue to be investigated. Even OMT, oral microbiome transplant, may someday be a common therapy for periodontitis and other oral health problems.

Major References:
L. Sedghi et al. "The oral microbiome: Role of key organisms and complex networks in oral health and disease," Periodontol 87.1 (2021)
K. Joshipura et al. "Over-the-counter mouthwash use, nitric oxide and hypertension risk," Blood Press 29.2 (2020).
C. Bondonno et al. "Antibacterial mouthwash blunts oral nitrate reduction and increases blood pressure in treated hypertensive men and women," Am J Hypertens 28.5 (2015).
P. Saiz et al. "Probiotics in Oral Health and Disease: A Systematic Review," MDPI 11.17 (2021).
J. Shi et al. "Efficacy of probiotics against dental caries in children: a systematic review and meta-analysis," Crit Rev Food Sci Nutr (2022).
L. Hardan et al. "The Use of Probiotics as Adjuvant Therapy of Periodontal Treatment: A Systematic Review and Meta-Analysis of Clinical Trials," Pharmaceutics 14.5 (2022).
U. Schlagenhauf et al. "Probiotics in the Management of Gingivitis and Periodontitis. A Review," Front. Dent. Med 2 (2021).

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