|
 
 |
| REVIEW ARTICLE |
|
| Year : 2021 | Volume
: 7
| Issue : 1 | Page : 21-25 |
|
Role of probiotics in the prevention of early childhood caries
Rachita Kole1, Uma B Dixit2
1 Department of Pedodontics and Preventive Dentistry, DY Patil University, School of Dentistry, Navi Mumbai, Maharashtra, India
2 Former Professor and Head, Department of Pedodontics and Preventive Dentistry, DY Patil University, School of Dentistry, Navi Mumbai, Maharashtra, India
| Date of Submission | 03-Apr-2021 |
| Date of Decision | 03-May-2021 |
| Date of Acceptance | 04-May-2021 |
| Date of Web Publication | 12-Jul-2021 |
Correspondence Address:
Dr. Rachita Kole
Department of Pedodontics and Preventive Dentistry, School of Dentistry, DY Patil University, Navi Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijohr.ijohr_7_21
Early childhood caries (ECC) is the most common childhood disease, deemed as a chronic, infectious, and preventable disease. The etiology of ECC is complex and multifactorial; hence, early preventive measures should be implemented. Several strategies have been investigated in the past for ECC prevention. The use of probiotics in the management of gastrointestinal diseases has shown promising results. In this context, effectiveness of probiotic bacteria to re-establish a balanced oral microbiota has gained interest in the dental research community during recent years, with focus on caries prevention. To our knowledge, there is only one review, published in 2016, on the prevention of ECC with probiotic bacteria. This paper aims to present an in-depth review of probiotics as a preventive strategy for ECC. The efficacy of probiotic bacteria may be strain specific. Results of the studies investigating the effect of probiotic administration on reduction of caries risk are contradictory, with some showing reduction in Mutans streptococcus and Lactobacillus counts, while others showing no change. Long-term studies also have reported contradictory findings, with either no difference or decrease in the prevalence of caries when evaluated later in life following early administration of probiotics. As these studies offer ample evidence of the potential of probiotics in the prevention of ECC, further long-term, controlled studies should be planned to study the benefits. Keywords: Caries prevention, dental caries, early childhood caries, early childhood caries prevention, probiotics
How to cite this article:
Kole R, Dixit UB. Role of probiotics in the prevention of early childhood caries. Indian J Oral Health Res 2021;7:21-5 |
| Introduction | |  |
Early childhood caries (ECC) remains a highly prevalent worldwide disease that impacts the lives of children and their families.[1] In a recent systematic review, the mean global caries prevalence for 1 year olds was 17%, 36% in 2 year olds, and 43%, 55%, and 63%, respectively in 3, 4, and 5 year olds.[2] The overall prevalence of ECC in India is 49.6%.[3]
The etiology of ECC is multifactorial and complex that includes environmental, behavioral, socioeconomic, and biological factors. Certain unique risk factors exist in children, as oral microbial flora and host defense mechanisms are still in the developing stage. Infection with Mutans streptococci (MS) plays an important role in cariogenesis mainly because these bacteria are acidogenic, aciduric, and produce specific intra- and extracellular polysaccharides that facilitate microbial adherence on teeth.[4]
Various measures have been used to prevent ECC. They are directed toward primary prevention of ECC, prevention of new carious lesions in an already caries-affected child, and prevention of progression of the incipient lesions.[2] Despite several developments in the field of ECC prediction and prevention, ECC remains in demand of effective preventive approach.[5]
There are a few reviews published on the use of probiotics in the prevention of caries[6],[7],[8],[9],[10],[11],[12] and promotion of oral health.[13],[14],[15] One published review on efficacy of probiotics in prevention of ECC was published in 2016.[16] This lacunae in the literature motivated us to write this paper which aims to present an in-depth review of probiotics as a preventive strategy for ECC.
| Introduction to Probiotics | | |
Probiotics are live microorganisms which, when administered in adequate amounts, confer a health benefit to the host.[17] The concept of using food fermented with microorganisms as a therapeutic agent can be traced back to Romans.[18] In 1907, Metchnikoff proposed that the lactic acid-producing strain Lactobacillus bulgaricus was able to displace pathological intestinal microbiota.[19] The term “probiotic” was first used in 1965, by Lilly and Stillwell to represent “substances secreted by one organism which stimulate the growth of another.”[20] The word “probiotic” is derived from the Latin word “pro” and the Greek word “bios,” meaning, for life.
Primarily research on probiotics developed for the use in the gastrointestinal ailments. Research on efficacy of probiotics in prevention of caries was first conducted by Näse et al. (2001) using Lactobacillus rhamnosus GG in vivo.[21] Use of probiotics has remained a topic of interest for prevention of oral diseases ever since. The probiotics used for oral health belong to the genera Lactobacillus, Streptococcus, and Bifidobacterium. The effects of probiotics are strain specific.[22]
Products such as milk, curd, ice cream, cheese, yoghurt, tablets, lozenges, candies, gum, powders, straws, slow-release pacifiers, and cereals have been used as vehicles of probiotic delivery.[23] Ideally, probiotics should have the ability to adhere to oral biofilm, be tolerant to oral environmental stress factors, compete for existing binding sites, colonize surfaces in the oral cavity, and have an antimicrobial activity against oral pathogens.[24],[25]
The mechanism by which probiotics influence the oral cavity is partially understood. Probiotics re-establish ecological balance in oral biofilms as a result of combined effect of local and systemic actions.[26],[27]
| Clinical Studies on Prevention of Early Childhood Caries | | |
Immediate effects of probiotics
How the administration of probiotics affects the oral microflora has intrigued many researchers. Näse et al.[21] compared caries risk between children aged 1–6 years who drank milk containing L. rhamnosus GG ATCC 53103 (5–10 × 105 CFU/ml), 5 days a week for 7 months with those drinking milk without probiotics. The results showed that the intervention with LGG significantly reduced caries risk owing to significantly lower MS counts found in those children [Table 1]. | Table 1: Summary of the in vivo studies conducted in children with prevention of caries as an endpoint
Click here to view |
Lower Streptococcus mutans levels, although statistically not significant, were reported in children subjected to an intervention of milk supplemented with probiotics L. rhamnosus and Bifidobacterium longum after 9 months when compared to the control children drinking standard milk. Lactobacillus counts showed statistically significant differences.[28] Similar results of significantly lower increase in the MS level at 3–4 months and significantly lower caries increment at 6 months were found in children aged 1.5–5 years following administration of probiotic Lactobacillus paracasei standard deviation (SD).[29] Significant decrease in S. mutans counts was found in children subjected to probiotic milk containing L. paracasei SD 1 for 6 months, with a significant increase in the Lactobacilli (LB) counts at 6 months and 12 months follow-up.[30]
Another study found a significant continuous decrease in the MS count from baseline till 30 days following daily consumption of Probiora tablet for 2 weeks in children aged 4–6 years with a high risk of caries.[31] A statistically significant reduction in MS and LB counts was also detected by Alamoudi et al.[32] with lozenges containing Limosilactobacillus reuteri DSM 17938 and L. reuteri ATCC PTA 5289 administered for 28 days and in S mutans counts alone by Tehrani et al.[33] with probiotic drops containing L. rhamnosus ATCC 15820 (1 × 1010 cfu/mL), L. reuteri ATCC 55730 (2 × 109 cfu/mL), and B. longum infantis ATCC 15697 (1.5 × 109 cfu/mL) administered for 2 weeks in children aged 3–6 years.
A case–control study conducted by Eden et al.,[34] evaluated the effects of consumption of probiotic yogurt containing B. longum BB536, Bifidobacterium Bifidum Bb12, and L. rhamnosus HN001 consumed once daily for 3 weeks on pH, buffering capacity, S. mutans, LB, and sIgA levels in the saliva of 6–8-month-old infants. The control group consumed homemade yogurt without supplemental probiotic bacterial species. The results showed that there was a statistically significant increase in the buffering capacity of saliva in the probiotic group, although other parameters showed no significant change in both the groups.
Salama and Abobakr[35] evaluated the effects of yogurt supplemented with or without probiotic strain Bifidobacterium animalis  i> on the salivary S. mutans and LB colonies counts in children of age 3–6 years. After 2 weeks, a significant reduction in salivary S. mutans colonies and a nonsignificant increase in LB level count were observed in the probiotic group in comparison to the control group.
On the contrary, Pohjavuori et al.[36] found no statistically significant differences in S. mutans counts and caries risk at different time periods between the probiotic (LGG-CaLG) and the control groups.
In a study by Angarita-Díaz et al.,[37] nonsignificant decrease in the concentration of S. mutans and pH variation after sugar rinse was found in children consuming milk supplemented with probiotic L. rhamnosus GG and B. longum as compared to the control children consuming standard milk. Surprisingly, however, remineralization of 64.2% carious lesions was noted in the control group as compared to 39.4% in the probiotic group. The authors attributed this difference to higher concentration of calcium in the standard milk.
A study compared the caries-preventive effect of daily intake of milk supplemented with the probiotic bacteria L. rhamnosus LB21 (107 CFU/mL) and fluoride (2.5 mg F/L) in preschool children (1–5 years) as compared to those given standard milk for 21 months.[38] At 21 months, there was a statistically significant difference in caries increment between the groups with the children in the probiotic group showing a caries prevented fraction of 75%. There were no significant differences in the prevalence of MS and LB at the end of the study. Similarly, it was found that children who drank milk supplemented with probiotic L. rhamnosus SP1 had significantly lower cavitated lesions as compared to those from the control group (9.7% vs. 24.3%) after 10 months of intervention.[39]
Significantly lower caries prevalence (24% vs. 47%) and caries increment (0.2% vs. 0.8%) at 1-year follow-up were reported in children consuming a chewable Probiora tablet (108 total CFU of Streptococcus uberis KJ2, Streptococcus oralis KJ3, and Streptococcus rattus JH145) daily for 1 year as compared to control children.[40]
Long-term effects of probiotics
Oral cavity is colonized with microorganisms soon after birth, which form the indigenous microflora that may persist for life and prevent growth of other bacteria.[41] Devine and Marsh[42] hypothesized that altering caries-associated microbiota at the time of colonization may result in a permanent incorporation of the probiotic species. Our literature search revealed four studies that evaluated the effects of probiotics on caries experience later in life following probiotic supplements given during their 1st year of life.
In a study by Taipale et al.,[43] following administration of B. animalis subsp. lactis BB-12 with xylitol twice daily from the age of 1–2 months until 24 months of age, plaque samples collected at the 2-year follow-up showed 6.3% of the children harboring MS in the probiotic group. The percentage was statistically lower as compared to the xylitol control group (31.4%) but did not differ from the sorbitol control group (10.3%). At the 4-year follow-up, no statistically significant differences were detected between the groups in the occurrence of caries and MS colonization.[44]
From the randomized controlled trial conducted by Hasslöf et al.,[45] where daily administration of probiotic L. paracasei F19 was given to infants from 4 months to 13 months of age, the authors reported no statistically significant differences in caries experience, MS and LB levels evaluated at age 9 years.
In contradiction, following daily supplementation with L. reuteri during the 1st year of life, Stensson et al.[46] reported that the probiotic group showed significantly higher percent of caries-free children (82% vs. 58%) and significantly lower mean of approximal caries lesions (0.67 ± 1.61 vs. 1.53 ± 2.64) as compared to that from the placebo group at a follow-up conducted at the age of 9 years.
Finding from our review of literature is in agreement with earlier reviews that concluded that prevention of caries with probiotic bacteria demonstrated the low quality of evidence due to the high attrition rates of candidates and high performance and selection bias.[11],[16]
| Conclusion | | |
Our literature review on clinical efficacy of probiotics in prevention of ECC reveals conflicting evidence. Although few studies have found a reduction in MS and LB counts immediately following administration of probiotics in children, few studies have concluded otherwise. Long-term studies, where probiotics were administered in early infancy, have also offered conflicting evidence of reduction in caries risk (MS counts) or caries status at a later stage in life.
Considering the conflicting reports on the potential of probiotics in the prevention of ECC, it would be premature to advise probiotic treatment recommendations on the community level. However, as the benefits are greater than any potential harm, probiotic therapy may be considered as an adjunct to established caries preventive measures. Further long-term studies are an urgent need to reduce the conflicting results so far.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | McGrath C, Broder H, Wilson-Genderson M. Assessing the impact of oral health on the life quality of children: Implications for research and practice. Community Dent Oral Epidemiol 2004;32:81-5.  |
| 2. | Tinanoff N, Baez RJ, Diaz Guillory C, Donly KJ, Feldens CA, McGrath C, et al. Early childhood caries epidemiology, aetiology, risk assessment, societal burden, management, education, and policy: Global perspective. Int J Paediatr Dent 2019;29:238-48. |
| 3. | Ganesh A, Muthu MS, Mohan A, Kirubakaran R. Prevalence of early childhood caries in India – A systematic review. Indian J Pediatr 2019;86:276-86. |
| 4. | Thenisch NL, Bachmann LM, Imfeld T, Leisebach Minder T, Steurer J. Are mutans streptococci detected in preschool children a reliable predictive factor for dental caries risk? A systematic review. Caries Res 2006;40:366-74. |
| 5. | Xiao J, Alkhers N, Kopycka-Kedzierawski DT, Billings RJ, Wu TT, Castillo DA, et al. Prenatal oral health care and early childhood caries prevention: A systematic review and meta-analysis. Caries Res 2019;53:411-21. |
| 6. | Ramanujam P, Poorni S, Srinivasan MR, Sureshbabu NM. Probiotics in dental caries prevention. Indian J Nutr Diet 2019;56:84-91. |
| 7. | Angarita-Díaz MP. Probiotics and their relationship with caries control. A topic review. Rev Fac Odontol Univ Antioq 2016;28:179-202. |
| 8. | Shakib P, Rouhi S, Zolfaghari MR. The role of probiotics in preventing dental caries. Plant Biotechnol Pers 2020;2:55-8. |
| 9. | Sivamaruthi BS, Kesika P, Chaiyasut C. A review of the role of probiotic supplementation in dental caries. Probiotics Antimicrob Proteins 2020;12:1300-9. |
| 10. | Cagetti MG, Mastroberardino S, Milia E, Cocco F, Lingström P, Campus G. The use of probiotic strains in caries prevention: A systematic review. Nutrients 2013;5:2530-50. |
| 11. | Poorni S, Srinivasan MR, Nivedhitha MS. Probiotic Streptococcus strains in caries prevention: A systematic review. J Conserv Dent 2019;22:123-8. [ PUBMED] [Full text] |
| 12. | Zaura E, Twetman S. Critical appraisal of oral pre- and probiotics for caries prevention and care. Caries Res 2019;53:514-26. |
| 13. | Chugh P, Dutt R, Sharma A, Bhagat N, Dhar MS. A critical appraisal of the effects of probiotics on oral health. J Funct Foods 2020;70:103985. |
| 14. | Cannon ML. A review of probiotic therapy in preventive dental practice. Probiotics Antimicrob Proteins 2011;3:63-7. |
| 15. | Seminario-Amez M, López-López J, Estrugo-Devesa A, Ayuso-Montero R, Jané-Salas E. Probiotics and oral health: A systematic review. Med Oral Patol Oral Cir Bucal 2017;22:e282-8. |
| 16. | Jørgensen MR, Castiblanco G, Twetman S, Keller MK. Prevention of caries with probiotic bacteria during early childhood. Promising but inconsistent findings. Am J Dent 2016;29:127-31. |
| 17. | Araya M, Morelli L, Reid G, Sanders ME, Stanton C, Pineiro M, et al. Guidelines for the Evaluation of Probiotics in Food. Report of a Joint FAO/WHO Working Group on Drafting Guidelines for the Evaluation of Probiotics in Food, London, Ontario, Canada. Rome, Geneva: Food and Agriculture Organization of the United Nations and World Health Organization; 2002. |
| 18. | Plinius Secundus Maior G. Naturalis Historiae 77 AD. |
| 19. | Metchnikoff E. The Prolongation of Life. Optimistic Studies. New York: Putman's Sons; 1908. p. 161-83. |
| 20. | Lilly DM, Stillwell RH. Probiotics: Growth-promoting factors produced by microorganisms. Science 1965;147:747-8. |
| 21. | Näse L, Hatakka K, Savilahti E, Saxelin M, Pönkä A, Poussa T, et al. Effect of long-term consumption of a probiotic bacterium, Lactobacillus rhamnosus GG, in milk on dental caries and caries risk in children. Caries Res 2001;35:412-20. |
| 22. | Minocha A. Probiotics for preventive health. Nutr Clin Pract 2009;24:227-41. |
| 23. | Gruner D, Paris S, Schwendicke F. Probiotics for managing caries and periodontitis: Systematic review and meta-analysis. J Dent 2016;48:16-25. |
| 24. | Meurman JH, Stamatova I. Probiotics: Contributions to oral health. Oral Dis 2007;13:443-51. |
| 25. | Caglar E, Kargul B, Tanboga I. Bacteriotherapy and probiotics' role on oral health. Oral Dis 2005;11:131-7. |
| 26. | Teughels W, Loozen G, Quirynen M. Do probiotics offer opportunities to manipulate the periodontal oral microbiota? J Clin Periodontol 2011;38 Suppl 11:159-77. |
| 27. | Kang MS, Oh JS, Lee HC, Lim HS, Lee SW, Yang KH, et al. Inhibitory effect of Lactobacillus reuteri on periodontopathic and cariogenic bacteria. J Microbiol 2011;49:193-9. |
| 28. | Villavicencio J, Villegas LM, Arango MC, Arias S, Triana F. Effects of a food enriched with probiotics on Streptococcus mutans and Lactobacillus spp. salivary counts in preschool children: A cluster randomized trial. J Appl Oral Sci 2018;26:e20170318. |
| 29. | Pahumunto N, Piwat S, Chankanka O, Akkarachaneeyakorn N, Rangsitsathian K, Teanpaisan R. Reducing Mutans streptococci and caries development by Lactobacillus paracasei SD1 in preschool children: A randomized placebo-controlled trial. Acta Odontol Scand 2018;76:331-7. |
| 30. | Manmontri C, Nirunsittirat A, Piwat S, Wattanarat O, Pahumunto N, Makeudom A, et al. Reduction of Streptococcus mutans by probiotic milk: A multicenter randomized controlled trial. Clin Oral Investig 2020;24:2363-74. |
| 31. | Cortés-Dorantes N, Ruiz-Rodríguez MS, Karakowsky-Kleiman L, Garrocho-Rangel JA, Sánchez-Vargas LO, Pozos-Guillén AJ. Probiotics and their effect on oral bacteria count in children: A pilot study. Eur J Paediatr Dent 2015;16:56-60. |
| 32. | Alamoudi NM, Almabadi ES, El Ashiry EA, El Derwi DA. Effect of probiotic Lactobacillus reuteri on salivary cariogenic bacterial counts among groups of preschool children in Jeddah, Saudi Arabia: A randomized clinical trial. J Clin Pediatr Dent 2018;42:331-8. |
| 33. | Tehrani MH, Akhlaghi N, Talebian L, Emami J, Keyhani SE. Effects of probiotic drop containing Lactobacillus rhamnosus, Bifidobacterium infantis, and Lactobacillus reuteri on salivary Streptococcus mutans and Lactobacillus levels. Contemp Clin Dent 2016;7:469-74. [ PUBMED] [Full text] |
| 34. | Eden E, Ak AT, Ozgenc F, Aksu G, Ergin E. Effect of short-term probiotic yogurt consumption on caries risk factors in infants. J Pediatr Res 2019;6:12-8. |
| 35. | Salama RI, Abobakr RM. The effects of probiotics on the salivary Streptococcus mutans and Lactobacilli levels among preschool children: A clinical trial. Egypt Dent J 2018;64:855-62. |
| 36. | Pohjavuori S, Ahola AJ, Yli-Knuuttila H, Piirainen L, Poussa T, Meurman JH, et al. Effect of consumption of Lactobacillus rhamnosus GG and calcium, in carrot-pineapple juice on dental caries risk in children. Int J Probiotics Prebiotics 2010;5:221-8. |
| 37. | Angarita-Díaz MP, Forero-Escobar D, Cerón-Bastidas XA, Cisneros-Hidalgo CA, Dávila-Narvaez F, Bedoya-Correa CM, et al. Effects of a functional food supplemented with probiotics on biological factors related to dental caries in children: A pilot study. Eur Arch Paediatr Dent 2020;21:161-9. |
| 38. | Stecksén-Blicks C, Sjöström I, Twetman S. Effect of long-term consumption of milk supplemented with probiotic lactobacilli and fluoride on dental caries and general health in preschool children: A cluster-randomized study. Caries Res 2009;43:374-81. |
| 39. | Rodríguez G, Ruiz B, Faleiros S, Vistoso A, Marró ML, Sánchez J, et al. Probiotic compared with standard milk for high-caries children: A cluster randomized trial. J Dent Res 2016;95:402-7. |
| 40. | Hedayati-Hajikand T, Lundberg U, Eldh C, Twetman S. Effect of probiotic chewing tablets on early childhood caries – A randomized controlled trial. BMC Oral Health 2015;15:112. |
| 41. | Meurman JH. Probiotics: Do they have a role in oral medicine and dentistry? Eur J Oral Sci 2005;113:188-96. |
| 42. | Devine DA, Marsh PD. Prospects for the development of probiotics and prebiotics for oral applications. J Oral Microbiol 2009;1:1-9. |
| 43. | Taipale T, Pienihäkkinen K, Salminen S, Jokela J, Söderling E. Bifidobacterium animalis subsp. lactis BB-12 administration in early childhood: A randomized clinical trial of effects on oral colonization by mutans streptococci and the probiotic. Caries Res 2012;46:69-77. |
| 44. | Taipale T, Pienihäkkinen K, Alanen P, Jokela J, Söderling E. Administration of Bifidobacterium animalis subsp. lactis BB-12 in early childhood: A post-trial effect on caries occurrence at four years of age. Caries Res 2013;47:364-72. |
| 45. | Hasslöf P, West CE, Videhult FK, Brandelius C, Stecksén-Blicks C. Early intervention with probiotic Lactobacillus paracasei F19 has no long-term effect on caries experience. Caries Res 2013;47:559-65. |
| 46. | Stensson M, Koch G, Coric S, Abrahamsson TR, Jenmalm MC, Birkhed D, et al. Oral administration of Lactobacillus reuteri during the first year of life reduces caries prevalence in the primary dentition at 9 years of age. Caries Res 2014;48:111-7. |
[Table 1]
|
Search Pubmed for