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 Table of Contents  
Year : 2018  |  Volume : 10  |  Issue : 3  |  Page : 132-137

The effect of oral probiotic consumption on the caries risk factors among high-risk caries population

1 Department of Oral Biology; Department of Dental Hygiene Program, Faculty of Dentistry, Universitas Gadjah Mada, Yogyakarta, Indonesia
2 Department of Dental Hygiene Program, Faculty of Dentistry, Universitas Gadjah Mada, Yogyakarta, Indonesia
3 Department of Oral Medicine, Faculty of Dentistry, Universitas Gadjah Mada, Yogyakarta, Indonesia
4 Department of Interdisciplinary Medicine, School of Medicine, University of Bari Aldo Moro, Bari, Italy

Date of Web Publication14-Jun-2018

Correspondence Address:
Dr. Rajiv Saini
Department of Interdisciplinary Medicine, School of Medicine, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124 Bari
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jioh.jioh_82_18

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Aim: Oral health plays an important role in maintaining overall systemic health, and therefore, good oral health is essential for the well-being of humans. Dental caries prevalence continues to increase in many populations worldwide. Recent years, dental caries continues to be common chronic oral diseases worldwide including many Asian countries. This aim of this study was to investigate the effect of utilizing oral probiotics on the caries risk factors among high-risk caries population. Materials and Methods: Thirty-six participants who had a high risk of caries were randomized under control and probiotic administered test group for 60 days. Caries experience, oral hygiene status, plaque accumulation, and saliva parameters related to caries were measured at days 0, 30, and 60. Results: Among all variables, ANOVA analysis showed that oral probiotic consumption significantly reduced the plaque accumulation between days of observation in the treated group (P < 0.05) While calculus index was significantly differing from day 0 to 30 and plaque index from day 0 to 60 in the paired t-test (P < 0.05). Nonsignificant difference was found when comparing both variables in the treated group to the untreated group (P ≥ 0.05). Conclusion: The results indicate that the regular use of oral probiotics reduces the plaque accumulation and calculus formation among the treated participants, and its application could be proposed as an effective agent to inhibit dental plaque accumulation as well as calculus in high caries risk participants.

Keywords: Calculus, caries, hyperbiotics, oral probiotics, plaque

How to cite this article:
Tandelilin RT, Widita E, Agustina D, Saini R. The effect of oral probiotic consumption on the caries risk factors among high-risk caries population. J Int Oral Health 2018;10:132-7

How to cite this URL:
Tandelilin RT, Widita E, Agustina D, Saini R. The effect of oral probiotic consumption on the caries risk factors among high-risk caries population. J Int Oral Health [serial online] 2018 [cited 2022 Dec 6];10:132-7. Available from:

  Introduction Top

Oral health plays an important role in maintaining overall systemic health, and therefore, good oral health is essential for the well-being of humans.[1],[2] The overgrowth and disequilibrium of pathogenic microorganism species both native and nonnative to the oral cavity may manifest into a numerous variety of oral diseases including caries, gingivitis, pharyngitis, halitosis, and candidiasis.[3],[4] Recent years, dental caries continues to be common chronic oral diseases worldwide particularly in Indonesia.[5],[6] Expression of the disease is characterized initially by the breakdown of tooth enamel and dentin. Multifaceted disease process is involved in caries development through the interaction of host, bacteria, and nutrient which are required to produce organic acids and subsequent demineralization activity. Several researchers have been developing probiotic methods to threat the caries infection by interfering with the oral colonization of cariogenic pathogens.[3]

The interest in oral probiotics has been growing during the last decades.[7] Probiotic is defined as supplement which contains a discrete dose of viable good bacteria which provide benefits to individuals who receive it.[8] Broad microbiome of bacteria, fungi, and other microorganism that inhabit oral cavity may provide an essential role to oral health. Bacteria referred as “good” bacteria if the bacteria could provide benefits to the oral cavity, while “bad” bacteria might cause various diseases such as caries, periodontal disease, strep throat, and other diseases.[9] Immunomodulation and prevention of pathogen colonization are beneficial effects which produced by good bacteria. Several beneficial aspects of good bacteria which were studied by microbiologist lead to the contention of using supplements of these species for human consumption.[4]Streptococcus salivarius is one of the good bacterial species which is utilized as commercial probiotics.[10] The previous study has reported the significant benefit in the reduction of oral diseases including dental caries, periodontitis, halitosis, and oral candidiasis.[9],[11],[12] Gingivitis including supragingival plaque, gingival inflammation, sulcular bleeding, and pocket depth was reduced among participants who using M18 lozenges. Recently, only a few studies had been done to investigate the effect of oral probiotics including K12 and M18 on oral health. The majority research focuses on K12, and more research should be conducted on M18 and other S. salivarius strains which provide oral health benefits.[9] This study was aimed to investigate the effect of supplementing oral probiotics (Hyperbiotics Pro-Dental, USA) on the caries risk factors among high-risk caries population in Yogyakarta, Indonesia.

  Materials and Methods Top


The present study was conducted in a private senior high school located in Bantul District of Yogyakarta, Indonesia, which was randomly selected. Smokers and participants who were receiving prescription and using xylitol-containing products were excluded from the study. A minimum of 4 weeks since the last antibiotic treatment was also an inclusion criterion. Total 96 participants aged 15–19 years old who meet the study criterion were included in the study.

Study design

The high-risk group was determined based on the Caries Management by Risk Assessment (CAMBRA) methodology. Thirty-six participants who had previously experienced dental caries were classified as high-risk caries group. The study was a randomized and controlled study with two parallel groups. The participants were randomized into the two groups. The study consisted of 60-week periods: baseline, intervention, and posttreatment. Information about participants' health, medication, smoking habits, dental care, and use of lactic acid products were collected at baseline. The participants were not told not to use probiotic-containing products or xylitol products for 3 weeks before the study itself. The participants were given toothbrushes and fluoride toothpaste to be used during the day. They instructed to brush their teeth twice a day. Any change in health and any use of prescription were also reported. The study population was divided into two categories which comprised 18 participants each as illustrated in [Table 1]. A double-blind protocol was used to define the treatment plan and further categorization into study group. All participants were agreed to undergo oral examinations and consume oral probiotic lozenges (Hyperbiotics Pro-Dental, USA).
Table 1: Study flowchart

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The study protocol was approved by the Ethics Committee of the Faculty of Dentistry, Universitas Gadjah Mada, Indonesia (Approval No. 001264/KKEP/FKG-UGM/EC/2017). The participants were agreed and provided written consent. The parents of all participants were informed of the methodology and signed consent and privacy policy to publish the results.

Oral examination

A dentist examined the participants' oral condition before and after the study. At the first visit, clinical examination was done and recorded the numbers of decayed, missing, and filled and any new caries lesions that had occurred during the study period. Also recorded at this visit (and at the 30- and 60-day visits) were data on oral hygiene, dental plaque, and salivary parameters (pH, buffering capacity, and salivary flow rate). Those variables were used to define caries risk factors. Oral hygiene participants were examined based on parameter Oral Hygiene Index-Simplified (OHI-S) of Greene and Vermilion which consists of two components, debris index and calculus index. Each of these is based on numerical determination representing the amount of debris or calculus on index tooth surfaces. Silness-Löe plaque index was used to measure the accumulation of plaque among groups. Unstimulated saliva was collected to measure pH, buffering capacity, and salivary flow rate. The participants were instructed not to eat and drink other than mineral water before oral examination.

Treatment protocol

On the 1st day of the study protocol, the participants used a fluoride-containing toothpaste not containing any supplementary antibacterial agents and under the supervision of dentist brushed their teeth until all their disclosed plaque had been removed. Two hours later, the test group was asked to suck one probiotic lozenge and was instructed not to use other probiotic-containing products during the entire study period, while the control group was only asked to do daily tooth brushing without consuming oral probiotics. A supply of the appropriate probiotic lozenges (Hyperbiotics Pro-Dental, USA) was provided for home use to the treated group, while only toothpaste and toothbrushes were provided to the control group. The protocol required the treated group to suck two lozenges each day for 60 days after brushing their teeth. Recall visits were scheduled for all the participants belonging to both groups (test and control) on the day 30 and 60.

Statistical analysis

The baseline characteristics of the participants were described using mean (± standard deviation). The comparison of variables between untreated and treated group was performed using t-test and Chi-square test for grouping variable. Paired sample t-test was used to compare variables between day 0, 30, and 60 examinations. Subsequently, comparison variables between baseline and follow-up examination were done by ANOVA test. P < 0.05 was considered statistically significant. Statistical analysis was performed using SPSS for Windows (ver. 22.0; IBM Cor. Armonk, NY, USA).

  Results Top

The randomized and controlled study has been carried out on 36 participants at high risk of new dental caries development. Eighteen of these participants were treated for 60 days with oral probiotics. The baseline characteristics of participants were presented in [Table 2] where no statistical difference existed between control and test group. In the test group, in [Table 3], paired t-test showed that only plaque index was found to have significant difference between day 0 and 60. It shown that after 60 days consuming probiotic lozenges, the plaque index was significantly reduced. However, the mean value of debris index, calculus index, and OHI-S was tending to reduce in the day 60 compared to day 0 and day 30, while the mean value of pH saliva was increased from baseline to day 60. Among all variables, plaque index and calculus index were found to have significant difference between days of observation. These results showed that plaque index was found to significantly reduce from baseline to day 60 and calculus index was found to have significant difference after 30 days using the probiotic lozenge. However, the mean value of debris index and OHI-S was tending to reduce in the day 60 compared to day 0 and day 30, while the mean value of pH saliva was increased from day 0 to 60.
Table 2: Baseline characteristics of participants

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Table 3: Paired sample t-test between days of observation among variables in the treated group

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In the test group, ANOVA test showed that plaque index was a significant difference and all variables were nonsignificant difference among days of observation. All variables were found to have nonsignificant difference between days of observation in the control group [Table 4] and [Table 5]. To investigate the effect of probiotic consumption on the caries risk factors, all variables were compared between untreated and treated group at day 30 and 60. At both days of observation, no variables were not significantly affected with probiotic consumption [Table 6] and [Table 7]. However, the mean value of debris index, calculus index, and OHI-S was tending to reduce in the treated group compared to untreated group at day 60.
Table 4: Comparison of variables between days of observation in the test group

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Table 5: Comparison of variables between days of observation in the control group

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Table 6: Comparison of variables between untreated and treated group at day 30

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Table 7: Comparison of variables between untreated and treated group at day 60

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  Discussion Top

Caries risk assessment is an essential tool guiding the dental professional in obtaining a better understanding of the dental profile of individual. The CAMBRA methodology may provide an effective way in evaluating such a risk.[13],[14] The present study showed that among all variables, only plaque index and calculus index were significantly reduced after consuming two probiotic lozenges per day. These results showed that the calculus was significantly reduced after 30 days using probiotic lozenges. Therefore, the primary clinical measure of clinical efficacy of probiotics in the present study was the reduction of plaque index. The plaque score was monitored for each participant before the start of dosing and then at day 30 and 60. The significance plaque difference between day 0 and 60 in the treated group was observed which tends to reduce at the end of study period.

Dental plaque is a complex biofilm that accumulates on the hard tissues in oral cavity. A variety of adhesions and molecular interactions underline these adhesive interactions and contribute to plaque development and ultimately to diseases such as caries and periodontal disease.[15] Different probiotic regimen was previously reported to have significant effect on plaque score reduction,[11] and additionally, probiotic treatment may provide greater benefit to individuals with existing high plaque levels and may be most efficacious when used in conjunction with preliminary plaque removal procedure. While the pH of saliva was increased in test group, the salivary pH became neutral value. This study results still in line with previous studies [16] who advocated that S. salivarius M18 was also reported to have ability in releasing bacteriocins which are able to kill Streptococcus mutans and dextranase and urease enzymes that are capable of counteracting plaque formation and increasing saliva pH, respectively.

Many oral pathologies, such as dental caries, periodontal disease, and peri-implantitis are plaque related.[17] Microorganisms in biofilms such as plaque are in close physical contact, and this can increase the probability of interactions, some of which can modulate the pathogenic potential of cariogenic bacteria.[18] The biofilm that forms and remains on tooth surfaces is the main etiological factor in caries and periodontal disease. The prevention of caries and periodontal disease must be based on means that counteract this bacterial plaque.[19] In this present study, plaque was reduced continuously up to the final study period follow-up among participants who received probiotic lozenges. While plaque index was significantly differing from day 0 to 60, calculus index from day 0 to 30.

Effective plaque control should maintain the oral microflora at levels that are compatible with health to retain the beneficial properties of the resident oral microflora, while minimizing the risk of disease. The microbial composition of oral biofilms varies depending on the site or surface because local environmental conditions dictate which organisms can colonize, grow, and be either major or minor components of the established microbial community. Antiplaque agents function by removing or disrupting biofilms or by preventing the formation of new biofilm, without necessarily killing the component microorganisms.[20] Probiotic may affect the oral ecology by specifically preventing the adherence of other bacteria and by modifying the protein composition of salivary pellicle. Probiotic bacteria could modify the protein composition of the pellicle by two different methods, namely, binding to and the degradation of salivary proteins.[21] Probiotic lowers the pH so that microorganism cannot form dental plaque and calculus that causes oral inflammation. It was found that cellular extracts of human intestinal lactic acid bacteria had a strong growth-inhibiting effect specific for  S.mutans Scientific Name Search .[22] Periodontitis is initiated by oral biofilm formation if untreated progress to gingivitis further leading to periodontal disease.[23],[24] If the plaque growth is ignored and the plaque is not cleaned, it will form a complex bacterial colony and will initiate dental caries.[25] The nature of a biofilm helps explain why periodontal diseases have been so difficult to prevent and treat.[15],[26] By contrast, no significant difference was found among variables in the untreated group. Nonstatistically significant was found when comparing the plaque reductions between untreated and treated group. Nevertheless, this outcome is considered to the anticariogenic characteristics of oral probiotics among the treated participants.

The strength of this study is the homogeneous group of high-risk caries population, allowing for the control of potential confounders including age and race. However, several limitations must be considered in interpreting the result of the present study. First, there is no positive control group and only the negative control group comprises untreated group. Second, the number of enrolled participants was rather small. Third, the observation period was taken in short period. Therefore, this study needs to be confirmed in large population which includes a long period of observation. Nevertheless, this study advocates the efficacy of oral probiotics in reducing plaque even though in short-term application. If these preliminary results can be confirmed in large study population, the practical application of probiotics could be proposed in the future as a new tool in preventing caries along with the already available strategies to be adopted in participants considered at high-risk group. Certainly, in participants defined at high risk, the addition of oral probiotics (Hyperbiotics pro-Dental, USA) could be crucial to addressing and further reducing the risk of caries. With an increasing global problem of antibiotic resistance, contributing to ineffective treatment of microbial diseases, probiotics by the natural therapy appear to be a novel approach for the prevention of oral diseases such as dental caries and periodontal diseases.

  Conclusion Top

The practical application of probiotic strain could be proposed in the future as a new tool in preventing caries along with the already available strategies, particularly among high-risk population. The research data of this study advocate that twice-daily dosing with the oral probiotic lozenges (Hyperbiotics Pro-Dental, USA) is an efficacious way of significant reduction in plaque and calculus formation among participants with high risk of developing new caries lesion.


The authors have received research grants from INNBIORES, India.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]

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