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Several companies produce probiotics for the oral environment. Recently, Oragenics Inc. introduced a probiotic for children, EvoraKids, which offers a different probiotic blend than the adult product known as EvoraPlus.

Dr. Jeffrey Hillman, the chief scientific officer at Oragenics, developed both products. Dr. Hillman
is the company’s founder, a project initiated after 25 years of research on caries and other oral diseases at the Forsyth Institute and the University of Florida of Dentistry. An author of more than 125 articles and textbook chapters, he earned his dental degree from Harvard, as well as a doctorate from the Harvard Medical School.

He was kind enough to answer some questions that I had about probiotics, and I would like to share his responses. In his comments below, he refers to Probiora3, which is the proprietary blend developed by Oragenics. More information about it can be viewed at www.evoraplus.com.

Hartley: Since probiotics in dentistry are still a relatively new option, what do you think most dental professionals need to understand about incorporating probiotics as part of a patient’s home care regimen?

Dr. Hillman: Probiotics, in general, are new to most Americans. In this regard, we lag behind much of the world by failing to appreciate that not all germs are bad. Most dentists are taught that, among the hundreds of species that form our dental plaque, there is a small, select group of bacteria that are responsible for tooth decay and gum disease. These pathogens are present in almost everyone’s mouth most of the time, but cause disease only sporadically. To understand and appreciate probiotics for the oral cavity, the dentist needs to learn just two things.

First, the reason that the pathogenic species don’t cause more disease than they do is that there are beneficial species of bacteria normally present in dental plaque, which inhibit the growth of the pathogens to keep them below the threshold number required for them to initiate the disease process.

Secondly, for unknown reasons, the beneficial bacteria sometimes disappear from a particular site, which leads to the outgrowth of the pathogen.

The whole point of oral probiotics is to introduce the beneficial bacteria on a daily basis to make certain that the microflora is balanced in favor of health. The fact that the beneficial bacteria involved in maintaining gum health exert their effect on the pathogens through hydrogen peroxide production provides an additional benefit — tooth whitening.

Hartley: In medicine, there have been cases of where probiotics made a patient more susceptible to the disease that it was supposed to prevent? In other cases, it remains questionable if whether a probiotic can replace natural flora when the latter has been killed off for a specific reason. In terms of thinking of probiotics as being a resource for dental patients, should dental professionals be more
vigorous in screening patients to determine the best candidates for probiotics? If so, in what way?

Dr. Hillman: Probiotics intended for gastrointestinal health or to boost immunity are very difficult to
study relative to oral probiotics for the simple reason that it’s very much harder to sample the microenvironment of the bowel than the oral cavity. For this reason, we feel that we have been able to obtain much more compelling evidence for the safety and efficacy of Probiora3 than other probiotic applications that are vouchsafed as being safe and effective through more anecdotal evidence.

The other consideration is the importance of strain differences; it’s empirically clear that different strains of Lactobacillus reuteri have different effectiveness and, likely, safety profiles. This is the major reason that the big probiotic companies trademark their strains and the informed public is aware of the importance of choosing quality brands for this reason.

Hartley: I’m a little confused. Evora is touted as being chewable, yet there are other reminders that it should “melt” on the tongue. Can you clarify the most effective way for young patients to derive the most benefit from Evora?

Dr. Hillman: It doesn’t really matter if the tablet is chewed or allowed to dissolve in saliva. I personally prefer the former since it releases the active ingredients — the probiotic strains — more quickly. But the important thing is that the probiotic cells have time — 30 seconds is sufficient
— for them to attach to the tooth surfaces. A little swishing, if the child is old enough to perform that step, also helps to obtain a more uniform distribution of the cells over the surfaces of the teeth.

For more information about EvoraKids, visit www.evorakids.com. Dental hygienists can email questions about probiotics to info@EvoraPro.com.

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Comment by Mary Jane RDH BS on August 2, 2010 at 6:54pm
Challenging...
Comment by Ted Anibal on August 2, 2010 at 9:09am
Wonderful; I'm glad someone is paying attention. Of course you are absolutely correct. I think the mouthwash manufacturers should include a couple of paragraphs of fine print on the label that explains the limitations of their product. You know the one that claims it can replace flossing just by rinsing with it? The fine print should say, "Not really, but it'll make you feel better until your next checkup." Biofilms are complex communities and research is ongoing to determine the mechanisms of communication. Crevicular fluids with free-floating cells may succumb to certain mouthwashes, but no, not the ones bound together within the biofilm, and not the ones in the sulci. The use of a pulsating water-jet device that includes mouthwash may produce a better result, but not substantially better than water alone.

If these new oral probiotics are to be effective in their mission, it would seem necessary for them to affect the sulcular biofilm, where the bad anerobic critters live. Therefore, a thorough flossing and brushing should be done before the probiotic is applied. Ah, there's the rub -- making a kid do that every morning!
Comment by Mary Jane RDH BS on August 2, 2010 at 6:58am
Most of the pathogens are anaerobes..cannot live in the presence of oxygen. They are in the sulcus (thus the need for flossing, floss picks, etc.) or surrounded by those that can survive in oxygen. The biofilm communicate with each other..live very nicely in a symbiotic fashion..until some big bad piece of floss comes along or some ultrasonic wave shatters their cell walls. Mouth rinses are adjuncts..they do kill some bacteria..somewhat helpful..some of the newer products are more than helpful..but the biofilm has the capability of clinging to the tooth, root surface, etc. and the rinse cannot force it off. It can only kill the ones on the outside or the free floating bacteria which might be perfectly innocent. As with all environments, which recolonize first? On average, bacteria replicate every twenty minutes..those in a protected area i.e. sulcus might be just a little ahead.
Comment by Ted Anibal on August 2, 2010 at 4:54am
So do all the ADA-accepted mouthwashes kill only the pathogenic bacteria and spare the beneficial varieties? If so, how do they differentiate among them? Have any studies been done on that?
And, if 99.9 percent of germs are killed (assuming that's not 100 percent marketing hype), which bacteria -- the good guys or the bad guys -- re-colonize first? Can that process be guided to favor the good guys with this product? Or is that even a good idea -- do the good guys need the bad guys in order to exist?
Comment by Mary Jane RDH BS on August 1, 2010 at 6:42pm
There are only about twenty-five or so pathogens in the oral cavity. This is not new information; nor is the concept of beneficial bacteria new. The balance of bacteria in the mouth, as all environments, is very important. Historically, destroying the biofilm has been the answer,,maybe advancement in this concept will give us bigger guns.
Comment by Ted Anibal on August 1, 2010 at 4:14pm
We are in a brave new world of beneficial germs, and it is fascinating. All of my life, the emphasis has been on eradicating ALL germs -- we were on a mission to disinfect the world. We eagerly bought aerosols and mouthwashes that "Kills germs on contact!"

So this concept of not only letting the right ones live but also flooding our mouths with them is entirely contrary to everything we humans have been taught ever since germ theory went mainstream more than 100 years ago. So my question is: In light of this knowledge of beneficial bacteria in the oral environment, bacteria that should not be killed, but nurtured, what are dental schools and dental hygiene schools doing to recognize this and retrain professors and instructors? Further, how are dental professionals relearning the proper treatment of the proper germs? Any CE courses yet?

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