By Richard H. Nagelberg, DDS
There is an entire category of products that is underutilized in the dental profession — oral probiotics. In fact, they are a category unto themselves. Oral probiotics have the potential to make a significant impact on the oral health of our patients, and systemic health by extension. While not a therapeutic modality that we could include in a periodontal patient’s active phase of treatment, oral probiotics are among the best options we can use for patients in differing states of disease or health.
True oral probiotics use oral bacteria rather than intestinal bacteria, and these bacteria are nonpathogenic. Probiotics work by replacing existing disease-causing bacteria with harmless bacteria. The company Oragenics markets an oral probiotic called EvoraPro. Its development was the culmination of decades of research at the Harvard-affiliated Forsyth Institute in Boston.
The beauty of this oral probiotic is the simple, commonsense manner in which it works. EvoraPro has three naturally occurring live bacteria, freeze-dried in a mint. The mint contains three different species of Streptococcus, which are natural colonizers of a healthy mouth, rather than genetically engineered. The patient dissolves one mint in the mouth per day. The bacteria are released and compete with various pathogenic bacteria for binding sites. The sites on the teeth and gums occupied by the probiotic bacteria reduce the surface area available for disease-causing bacterial colonization. Furthermore, they also compete for nutrients.
The three species of bacteria are non-acid-producing, so when they crowd out S. mutans and other cariogenic bacteria, caries incidence is reduced. The probiotic bacteria colonize supra- and subgingival sites, and a by-product of their metabolism is hydrogen peroxide. These bacteria release a continuous, low dose of hydrogen peroxide, which is toxic to anaerobic bacteria, including the periodontal pathogens. Reducing the availability of attachment sites for the periodontal pathogens is also important, because they can only cause disease when they are in direct contact with the gingival epithelium. If they are in contact with the tooth or surfaces other than the gingival epithelium, or if they are freely floating in the mouth, they cannot cause periodontal disease.
Antimicrobial agents — including therapeutic doses of systemic and locally applied antibiotics, mouthwashes, subgingival irrigants, etc. — will kill probiotic bacteria. This is why they are not used during active periodontal therapy. One of the ideal situations in which oral probiotics are used is immediately following successful periodontal treatment. Reducing the repopulation of caries-causing and periodontal bacteria gives the patient a fighting chance to remain healthy. Probiotics are also ideally used in periodontally healthy patients, especially those with a family history of periodontal disease. The optimal time to take the probiotic mint is in the evening, following the use of all biofilm-control devices.
The patient’s health and family history are sources of considerable impactful information. A patient with a strong family history of diseases and conditions such as cardiovascular disease, diabetes, periodontal disease, high blood pressure, and rheumatoid arthritis, among many others, has a potentially heightened risk for these diseases as well. A large body of research has demonstrated several different mechanisms of oral-systemic associations. One is the effect of the chronic inflammatory properties of periodontal disease on various diseases and conditions. Another is the effect of the periodontal pathogens on cardiovascular diseases and events, independent of periodontal disease. There is also the increase in insulin resistance from the inflammatory and infectious components of periodontal disease. Insulin resistance is the biggest root cause of atherosclerosis, which is the initiating event for heart attacks and strokes. Reducing the number of pathogenic bacteria, along with the oral contribution to the total inflammatory burden in the body, by consistently and effectively controlling periodontal disease can only result in better patient health.
As clinicians, it is important to take these risk elements into account when evaluating a patient and developing a treatment plan for periodontal disease. The maintenance phase of periodontal therapy, along with the effectiveness of the patient’s home care, determines how long a perio patient will remain healed. Using all the tools at our disposal, including oral probiotics, will help to optimize our patients’ oral and general health.
Richard Nagelberg, DDS, has practiced general dentistry in suburban Philadelphia for more than 30 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations, and lecturer on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at [email protected].
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