PREBIOTICS, PROBIOTICS

AND SYNBIOTICS
IN PERIODONTAL HEALTH
INTRODUCTION
The term Probiotic' = "for life.(Greek)
First used in 1965, by Lilly and Stillwell
- for describing substances secreted by one organism
which stimulate the growth of another.
An expert panel commissioned by the Food and
Agriculture Organization (FAO) and the World Health
Organization (WHO) defined Probiotics as:
"live micro-organisms", which when administered in
adequate amounts confer a health benefit on the host.
The bacterial genera most commonly used in probiotic
preparations are Lactobacillus and Bifidobacterium .
INTRODUCTION
Periodontics has entered the saga of major shifts in
treatment paradigm from nonspecific to specific
approach.
Now treatment options propose altering ecology of
niches, in order to modify pathological plaque to a
bioflim of commensalisms.
Probiotics are live microorganisms administered in
adequate amounts with beneficial health effects on
the host.
Probiotics nano soldiers refer to genera of
organisms, which play a crucial role in halting,
altering, or delaying periodontal diseases.



Traditionally, probiotics have been associated with gut
health.
Last decade an increasing number of established and
proposed health effects of probiotic bacteria have been
reported,including :
enhancement of the adaptive immune response,
treatment or prevention of urogenital and respiratory tract
infections, and prevention or alleviation of allergies and
atopic disease in infants.
Recently, their beneficial effects on oral health have been
suggested.
A few reports have suggested the role of lactobacilli and
bifidobacteria in the prevention of oral infectious diseases
such as caries and periodontal disease
Probiotics poses a great potential in arena of
periodontics in terms of :
plaque modification,
halitosis management,
altering anerobic bacteria colonization,
improvement of pocket depth, and
clinical attachment loss.
TYPES OF PROBIOTICS
Probiotics are broadly categorised in two genus :
Lactobaccilus and Bifidobacterium.
While other microorganisms also classified into this
group includes yeast and moulds e.g.,
Saccharomyces cerevisiae, Aspergillus niger,
Aspergillus oryzae, Sochromyces boulardii.

DESIRED FEATURES OF A GOOD PROBIOTIC
1. It should be a strain which is capable of exerting a
beneficial effect on the host animal.
2. It should be non pathogenic and non-toxic.
3. It should be capable of surviving and metabolising
in the gut environment, and should be able to
maintain genetic stability in oral microflora.
4. It should be present as viable cells, preferably in
large numbers.
5. It should be stable and capable of remaining
viable for periods under storage and field
conditions.
PROPOSED MECHANICS OF PROBOTICS:

Various mechanisms have been proposed for
probiotic actions.
Probiotics have been documented to modulate
host immunity both systemically and locally.
Recently, Oral lymphoid foci have been identified
in interdental papillae, which provides site for local
immune modulation.
These were earlier thought to act on
gastrointestinal tract mucosa only
1. Probiotics stimulate dendritic cells (antigen
presenting cells) resulting in expression of Th1 (T-
helper cell 1) or Th2 (T-helper cell 2) response,
which modulates immunity.
Probiotics enhances innate immunity and modulate
pathogen induced inflammation through Toll-like
receptors on dendritic cell. Intracellular pathogens
are phagocytosed by Th1 response, while
extracellular pathogens are taken care by Th2
response.
Probiotics can mimic response similar to a
pathogen but without periodontal destruction
2. Other proposed mechanisms include Glycoprotein
carbohydrate cell surface interaction mediated
by inter species interactions.
Lactobacillus casei, Lactobacillus bulgaricus,
Lactobacillus rhamnosus, Lactobacillus acidophilus
co-aggregate with Fusobacterium nucleatum.
Lactobacillus rhamnosus, and Lactobacillus
paracasei have strong binding activity to primary
pellicle. Lactobacillus rhamnosus, Lactobacillus
casei shirota, Lactobacillus casei ATCC 11578
prevent adherence of bacteria to salivary pellicle by
altering its composition.

3. Aggregation alteration is another important
proposed mechanics as Hetrofermentative
Lactobacillus is the strongest inhibitor of
Aggregatibacter actinomycetem comitans,
Porphyromonas gingivalis and Prevotella
intermedia.
Fusobacterium nucleatum aggregate with
Weissella ciberia in preference to Treponema
denticola and Porphyromonas gingivalis.
Lactobacillus rhamnosus co-aggregates with
Fusobacterium nucleatum.

4. Apoptosis is another proposed mechanism.
Probiotics stimulate apoptosis of tumor cells
through end product formation.
Probiotic mixture has also been reported to protect
epithelium barrier by maintaining tight junction
protein expression and prevent apoptosis of
mucous membrane.
The oral anerobic bacteria exhibit a higher degree
of susceptibility to hydrogen peroxide than do other
genera of aerobic or facultative anerobic bacteria.
Weissella cibaria isolates generated a substantial
quantity of hydrogen peroxide, which was sufficient
to inhibit the proliferation of Fusobacterium
nucleatum.



5. Decrease in pro inflammatory cytokines by
probiotics ingestion is another mode of action as
seen in the GCF of patients on chewing gum
containing Lactobacillus reutri.
Lactobacillus salivaris and Lactobacillus gasseri
show strong inhibition of periopathogenic bacteria.
Secretion of bacteriocins by Lactobacillus reutri,
e.g., reutrin and reutricyclin inhibits growth of
pathogens and has high affinity for host tissue and
has anti- inflammatory effect by inhibition of
proinflamatory mediators.

PROBIOTICS IN PERIODONTAL DISEASE

Various studies have reported lactic acid inhibition
of oral bacteria suggesting a promising role in
combating periodontal diseases:
Lactobacillus reuteri was evaluated by Krasse et al.
in recurrent gingivitis case. Lactobacillus reuteri
strains were administered via chewing gum twice a
day for 2 weeks at a concentration of 110
8
CFU
along with Scaling and root planning.
After 2 weeks, the clinical parameters were
improved in group consuming probiotics chewing
gum.

A parallel,
double-blind,
randomized,
placebo-
controlled
study with 59
patients
having
moderate-to-
severe
gingivitis

In a one-way crossover, open-label placebo-
controlled study Kang et al.included 72 volunteers.
Subjects rinsed in morning twice with 15 ml rinse
containing probiotics strain. Rinsing was repeated
in the afternoon and in the evening, after brushing.
There was a significant, 20% reduction in plaque
scores when the Weissella cibaria CMS1-
containing rinse was used. These results indicate
that the Weissella cibaria isolates possess the
ability to inhibit biofilm formation.

Another parallel open label placebo controlled study
by Hillman et al. on 24 gnotobiotic rats, including
single baseline application resulted significant
decrease levels of Aggregatebacter actinomycetum
comitans when compared with placebo groups.
Another study by Grudianov et al. using mixture of
probiotics also reported improvement of clinical sign
of gingivitis. Probiotics have also been employed as
antimutagenic and anticarigenic agents.

The initial studies of the use of probiotics for enhancing
oral health were for the treatment of periodontal
inflammation.
Lactobacillus reuteri brought about a significant reduction
in gingivitis in a study done by Krasse et al.
o The oral administration of tablet containing L. salivarius
WB21 was found to be able to decrease the periodontal
index and pocket probing depth (PD) in smokers
specifically.




Recently, an in vitro study done by Nara et al. on
Lactobacillus helveticus demonstrated release of
short peptide stimulate osteoblast to promote bone
formation, thus proposing important role in repair of
periodontal bone destruction
Increase in remission period upto 1012 weeks was
reported in periodontal dressing containing
Lactobacillus casei was reported by Volozhin.
A parallel open label study by Ishikawa enrolled 84
subjects; consuming tablets containing
Lactobacillus salivaris T1 2711 strain 5 times a day
for 8 weeks resulted in decrease in black
pigmented anerobic rods.
A similar study by Matsuka reported decrease
bleeding on probing and decrease in
Porphyromonas gingivalis count.

A study done on release of pro inflammatory
cytokine on Lactobacillus brevis by Ricca et al. and
Lactobacillus reutri by Svante Twetman et al.
showed decreased levels, improving the clinical
signs of gingivitis.
Teughels et al. conducted a split mouth design
study on 32 beagle dogs with artificially created
pockets, bacterial pellets Streptococcus sanguis
KTH-4, Streptococcus salivarius TOVE, and
Streptococcus mitis BMS were applied locally in
designated periodontal pockets at baseline, 1, 2,
and 4 weeks, result showed decrease in anerobic
bacteria and Campylobacter rectus with decrease
pocket recolonization and bleeding on probing
when compared with controls.

PROBIOTICS IN GENERAL USE

Proven indication
1. Diarrhoea
2. Reduction of antibiotic associated side effect

Possible indication
1. Dental caries and periodontal health
2. Food allergies and lactose intolerance
3. Atopic eczema
4. Prevention of vaginitis
5. Urogenital infections
6. Irritable bowel disease
7. Cystic fibrosis
8. Traveller's diarrhoea
9. Enhance oral vaccine administration
10. Helicobacter pylori infection
11. Various cancers
OBSERVED EFFECTS ON HALITOSIS


Volatile sulphur compounds (VSC) are responsible
for halitosis. A probiotic strain (Weissella cibaria)
possesses the ability to
inhibit VSC production under both in vitro and in
vivo conditions. It possesses great potential as
novel probiotic for use in the periodontium. Co-
aggregation of Fusobacterium nucleatum with other
periopathogens results in secondary colonization of
biofilm and contributes substantially to VSC
production in the oral cavity
Bacteria
responsible for
VSC production
are Fusobacterium
nucleatum,
Porphyromonas
gingivalis,
Prevotella
intermedia, and
Treponema
denticola.
Lactobacillus acidophilus and Lactobacillus casei
have been determined to inhibit the in vitro
proliferation of anerobic bacteria via the production of
a strong acid.
Streptococcus salivaris produces bacteriocins, which
inhibit bacteria producing VSC.
Recently, in a study it was shown that lozenges and
gum containing Streptococcus salivaris decrease VSC
in halitosis patients.
Hydrogen
peroxide has
been
implicated in
maintenance
of a stable
ecological
system, and
protecting
against
invading
pathogens.
Hydrogen
peroxide is
known to
reduce
concentrations
of sulphur gas
significantly in
vivo
Bacteriophages, viruses that kill bacteria, have
been detected in oral pathogens, such as
Actinobacillus actinomycetemcomitans, and they
may playa role in the pathogenicity. Recently, it has
been showed experimentally that phages against
Enterococcus faecal led to reduction of bacterial
vitality in root canals infected with this organism.
To exert their action in the oral cavity, the probiotic
microorganism should :
be able to resist the oral environmental conditions and
defense mechanisms,
be able to adhere to saliva-coated surface,
colonize and grow in the mouth and to inhibit oral
pathogens.
So there is a need to develop the probiotic strain and
species that can resist oral environmental conditions and
can bring their antimicrobial action.
Prebiotics by definition are the non-digestible food
ingredient that confers benefits on the host by selectively
stimulating the growth and/activity of one bacterium or a
group of bacteria in the colon, and thus improve the host
health.
Oligosaccharides in the group of fructo-oligosaccharides
and galactosaccharides are the commonly studied
prebiotics.
They escape digestion in the upper gastrointestinal tract
so that they can be released in the lower tract and used
by beneficial microorganisms in the colon, mainly
bifidobacteria and lactobacilli.
PREBIOTICS
Prebiotics serve as a food source for probiotics.
The probiotics feed off the prebiotics and increase in number.
Different probiotics have different actions in the gut. Each
probiotic species provides a distinctive health benefit.
Therefore, an increase in the number of probiotics positively
impacts the digestive system by improving digestive health
such as reducing the symptoms of irritable bowel syndrome
and inflammatory bowel diseases (e.g. Crohnsdisease);
promoting regularity; reducing the growth of harmful
bacteria; synthesizing vitamins (primarily B vitamins);
decreasing lactose intolerance; improving serum cholesterol
levels; and decreasing the risk of certain cancers.

RELATION BETWEEN PREBIOTICS AND PROBIOTICS

Synbiotics are products that contain both probiotics and
prebiotics.
These products have the good bacteria (probiotics) and
the non-digestible carbohydrate source (prebiotics) to
encourage the growth of beneficial bacteria.
Fermented dairy products (yogurt and kefir) are
synbiotic because they contain live bacteria and the food
source needed for them

The synbiotic concept was first introduced, along with
prebiotics, as:
mixtures of probiotics and prebiotics that beneficially
affect the host by improving the survival and
implantation of live microbial dietary supplements in the
gastrointestinal tract, by selectively stimulating the
growth and/or by activating the metabolism of one or a
limited number of health-promoting bacteria, thus
improving host welfare (Gibson & Roberfroid 1995).
Since, there have been many in vitro and in vivo studies
focusing on the application of prebiotics, firstly in health
and gradually in disease states.
Only recently have studies on synbiotics started to
emerge with the main focus being on applications against
disease.
Probiotics improve health in different ways . The
health benefits conferred by probiotic bacteria are
strain specific . Some strains increase phagocytic
activity of peripheral blood leukocytes, others
strains promote production of mucosal antibodies
reducing the trans-mucosal transfer of antigens.
This strengthens the mucosal barrier function .
Other probiotic strains increase cytokine production
such as interleukin 6 (IL-6) .. C- reactive protein has
a relatively short half-life making it useful in
monitoring infection, inflammation and response to
treatment . IL-6 is a pro-inflammatory cytokine
which stimulates the production of acute phase
proteins (such as CRP) . It is readily detected in
serum during inflammation and indicates the
presence of infection.
MECHANISM OF ACTION OF PROBIOTICS
1. Probiotics improve colonization resistance to gut
pathogens by reinforcing the mucosal barrier and
restoring normal gut micro ecology after diarrhea.
If the intestinal micro flora is deficient, antigen
transport is increased.
Probiotics have been shown to normalize an increased
permeability. Binding is considered to be the first step
in pathogenesis, and binding of bacteria to the intestinal
mucosa or mucus may allow the colonization.
Probiotics compete with pathogens for binding sites
and available substrates.
Probiotics also seem to diminish the rate of
progression from inflammation through dysplasia to
colon cancer in experimental animals.

2. Lactobacillus acidophilus, Lactobacillus
reuteri, Lactobacillus casei GG, or
Bifidobacterium animalis in the GI-tract of mice
prolonged their survival and decreased the severity
of mucosal and systemic candidiasis by modulating
immune responses, decreasing the number of C.
albicans in the alimentary tract, and by reducing the
numbers of orogastric infections.The results
demonstrated not only that probiotics bacteria have
biotherapeutic potential for prophylaxis against and
therapy of this fungal disease, but also that
probiotic bacteria protect mice from candidiasis by
a variety of immunological (thymic and extrathymic)
and non immunological mechanisms.


3.Probiotics can also activate and modulate the
immune system, and they have been shown to
reinforce gut defence by immune exclusion, immune
elimination, and immune regulation.
The intestinal micro flora is associated with the
development of the immune system in the gut during
infancy and early childhood
PROBIOTICS, ORAL BIOFILM AND MICROFLORA
Direct interactions may include
Involvement in binding of oral microorganisms to
proteins (biofilm formation).
Action on plaque formation and on its complex
ecosystem by compromising and intervening
with bacteria to bacteria attachments.
Involvement in metabolism of substrate (competing
with oral microorganisms of substrates available)
Production of chemicals that inhibit oral bacteria
(antimicrobial substances).

Indirect interactions may include:
modulating systemic immune function effect on
local immunity, effect on non- immunologic defence
mechanisms, regulation of mucosal permeability,
selection pressure on developing oral microflora
towards colonization by less pathogenic species.
Effect of probiotics on the induction and
maintenance of oral tolerance has been recently
studied through lactobacillus paracasei (NCC
2461), lactobacillus johnsonii (NCC 533) and
Bifidobacterium lactis Bb12 (NCC 362) on to bovine
beta-Iacto globulin (BlG) that was investigated in
mice. This study had provided evidence that
probiotics modulate the oral tolerance to BlG in
gnotobiotic mice.
DESIGNER PROBIOTICS

Probiotics bacteria equipped with genetic element
necessary to overcome stress outside host, inside host
and antagonise invading pathogens.
probiotics are engineered to express receptor mimic
structures on their surface.
Designer probiotics have been employed in treatment of
HIV, also employs as a novel vaccine delivery vehicle.
Improving the stress tolerance profile of probiotic
cultures significantly improves tolerance to processing
stress and prolongs survival during subsequent storage.
This in turn contributes to a significantly larger
proportion of the administered probiotics would reach
the desired location (e.g., the gastrointestinal
tract/periodontium) in a bioactive form.

few
studies
done are
limited to
gut,
periodont
al studies
are
lacking,
but poses
a great
potential
in this
field to
develop.
REPLACEMENT THERAPY

The term replacement therapy (also called
bacteriotherapy or bacterial interference) is
sometimes used interchangeably with probiotics.
But it differs from probiotics in following:
1. Effector strain is not ingested and is applied
directly on the site of infection.
2. Colonization of the site by the effector strain is
essential.
3. Involves dramatic and long-term change in the
indigenous microbiota and is directed at displacing
or preventing colonization of a pathogen.
4. Have a minimal immunological impact
Teughels et al. employed this term as probiotics
and conducted studies, with application of
Streptococcus salivaris, Streptococcus mitis,
Streptococcus sanguis, repeatedly on root surfaces
after scaling and root planning have resulted
decrease number of periopathogens.
It refers to the basic idea of replacing pathogenic
bacteria by supplying commensalisms, which have
same affinity for tooth surface adherence.

Some cases of bacteraemia and fungenaemia have
been reported in immunocompromised individuals
in gut syndrome and chronic diseases.
Lactobacillus endocarditis have been reported after
dental treatment in a patient taking Lactobacillus
rhamnosus.
Reported cases of infection are extremely rare
accounting to 0.050.4% of infective endocarditis
and bacteraemia.
Liver abscess was reported in an individual on
Lactobacillus rhamnosus GG.


Concerns have been
raised for lifelong use
of probiotics on having
adverse effect on risk
group, though risk
group have not been
identified. Stimulation
of immune system by
probiotics could prove
to show degradation in
autoimmune diseases,
and they could transfer
antibiotic resistance to
pathogens
SAFETY CONCERNS
. In healthy people
probiotics rarely cause
disease. The risk of
developing bacteraemia
from ingested lactobacilli
is less than 1 per 1 million
users; risk of developing
fungaemia (from
Saccharomyces Boulardii)
is less than1 per 5.6
million users . In many
studies on infants, C-
reactive protein (CRP)
and IL-6 have been used
to diagnose the early
onset of infection . CRP is
an acute phase protein,
blood levels begin to rise
to 10 1000 fold from 1
ug/ml within 46 hours at
the onset of an infective or
inflammatory process.
CONCLUSION

Probiotics are counterparts of antibiotic thus are free
from concerns for developing resistance, further they
are body's own resident flora hence are most easily
adapted to host.
With fast evolving technology and integration of
biophysics with molecular biology, designer probiotics
poses huge opportunity to treat diseases in a natural
and non invasive way.
A critical need to establish good periodontal health for
attaining good systemic health is of utmost importance
and probiotics are promising, safe, natural, and side
effects-free option, which are required to be explored in
depth for periodontal application.
Advances and accomplishments attained give us the
ability to employ these friendly bacteria (probiotics) as
nano soldiers in combating periodontal diseases

T
H
A
N
K
Y
O
U
Criteria of an ideal microorganism used as
probiotics:
1. High cell viability, resistant to low ph and acids
2. Ability to persist
3. Adhesion to cancel the flushing effect
4. Able to interact or to send signals to immune cells
5. Should be of human origin
6. Should be non pathogenic
7. Resistance to processing
8. Must have capacity to influence local metabolic
activity