|Year : 2013 | Volume
| Issue : 1 | Page : 7-12
Effect of probiotic mouthrinse on dental plaque accumulation: A randomized controlled trial
Parthkumar K Thakkar, Md Imranulla, PG Naveen Kumar, GM Prashant, B Sakeenabi, VH Sushanth
Department of Public Health Dentistry, College of Dental Sciences, Davangere, Karnataka, India
|Date of Web Publication||14-Jan-2014|
Parthkumar K Thakkar
Department of Public Health Dentistry, Room No. 5, College of Dental Sciences, Davangere 577 004, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Dental caries and inflammatory periodontal diseases result from the accumulation of many different bacteria that form dental plaque, a naturally acquired bacterial biofilm that develops on the teeth. Periodontal diseases are one of the most prevalent oral diseases affecting more than 50% of Indian community. Materials and Method: A two months randomised controlled trial was conducted among ninety school children aged between 13 and 15 years, from a hostel located in Davangere city. The 90 study subjects who fulfilled inclusion and exclusion criteria were randomly divided into 3 groups namely Placebo, Chlorhexidine and Probiotic groups. Plaque scores were recorded at baseline (0 day), on 15 th day (after 14 days of intervention) and 3 weeks (after discontinuation of intervention). Statistical analysis was done using one way ANOVA and paired 't' test and P value less than 0.05 was considered statistically significant. Results: There was no statistically significant difference between groups at baseline. On 15 th day and after 3 weeks, plaque scores were significantly higher in placebo group compared to probiotic group. On 15 th day and after 3 weeks, plaque scores were higher in chlorhexidine group compared to probiotic group but difference was not statistically significant. Conclusion: Probiotic mouth rinse was more effective for inhibition of dental plaque accumulation after 14 days of intervention and also after 3 weeks of discontinuation of intervention.
Keywords: Chlorhexidine, darolac, probiotic, plaque index
|How to cite this article:|
Thakkar PK, Imranulla M, Naveen Kumar P G, Prashant G M, Sakeenabi B, Sushanth V H. Effect of probiotic mouthrinse on dental plaque accumulation: A randomized controlled trial. Dent Med Res 2013;1:7-12
|How to cite this URL:|
Thakkar PK, Imranulla M, Naveen Kumar P G, Prashant G M, Sakeenabi B, Sushanth V H. Effect of probiotic mouthrinse on dental plaque accumulation: A randomized controlled trial. Dent Med Res [serial online] 2013 [cited 2019 May 25];1:7-12. Available from: http://www.dmrjournal.org/text.asp?2013/1/1/7/124988
| Introduction|| |
The term probiotic, which literally means "for life" was first coined in the 1960s by Lilly and Stillwell.  World Health Organization (WHO) defined probiotics as 'live microorganisms which when administered in adequate amounts confer a health benefit on the host'.  Probiotic technology represents a breakthrough approach for maintaining oral health as well as natural defense against those bacteria thought to be harmful to teeth and gums.  Dental caries and inflammatory periodontal diseases result from the accumulation of many different bacteria that form dental plaque, a naturally acquired bacterial biofilm that develops on the teeth. Periodontal diseases are one of the most prevalent oral diseases affecting more than 50% of Indian community.  As the mouth represents the first part of the gastrointestinal tract there is every reason to believe that at least some probiotic mechanisms may also play a role in that part of the system.  For probiotic administration, most of the studies used either a dairy vehicle or a specially formulated mode of administration as lozenges or chewing gum, but none of these formulations are readily available for oral healthcare in India. Periodontal disease affects the majority of Indians and follows a similar trend as dental caries, where the prevalence increases as age increases.  So there exists a need to explore an easily available measure.  Hence, the present study aimed to explore the comparative effect of oral use of commercially available probiotic preparation (Darolac) and chlorhexidine mouthrinses on dental plaque accumulation; thus, assessing oral probiotic as a preventive tool against the development of dental caries and periodontal disease.
| Materials and Method|| |
The study was carried out at a hostel in Davangere city, Karnataka, India during the period of July-August 2013. The hostel had strength of 210 students aged 13-15 years for a period of 2 months. All children were examined for inclusion and exclusion criteria and among those who fulfilled the criteria, 90 children were selected by the simple random sampling method. Necessary permissions were obtained from the hostel authorities for conducting the study and ethical clearance was obtained from Institutional Review Board, College of Dental Sciences, Davangere.
- Children aged between 13 and 15 years
- Children with written consent of respective authority
- Children having mild to moderate or good to fair plaque scores
- Children with no active carious lesions
- Children with no recent antibiotic therapy (within 4 weeks).
- Children with known history of allergy to any mouthrinse or drug
- Children undergoing orthodontic treatment
- Children suffering from any systemic illness
- Children using any other commercially available probiotic products
- Children using any other oral hygiene aid other than routine teeth brushing.
Sample size calculation was based on the proportion of reduction in colony counts as observed in pilot study.
The sample size (n) was calculated from the following formula.
Zα = 1.96 (assuming the distribution is normal and confidence limit is 95%)
p = The proportion of reduction in colony counts as observed in pilot study (in %) = 80
q = 1 - p (in %) =20
L = Permissible error in estimation of p = 20% of p (standardized) =20% of 80 = 16
Substituting the values in the formula,
The number of subjects per group is approximately 24 thus a total sample size of 72 subjects were included in the study.
Based on the above calculations, a sample size of 30 subjects per group was used in this study considering dropouts (attrition), thus totaling to 90 subjects.
The three intervention groups are,
Group 1: Placebo mouth rinse (placebo control group, coloured distilled water)
Group 2: Chlorhexidine mouth rinse (positive control group, 0.12% Cariax® KIN S.A. Laboratory, Spain)
Group 3: Probiotic mouth rinse containing Darolac (test group)
[Figure 1] shows the distribution of participants in the study.
Preparation of probiotic mouthrinse
Probiotic mouth rinse was prepared using commercially available probiotic product Darolac (Aristo pharmaceuticals, India) 1 gm Darolac powder contains 1.25 billion freeze dried bacterial combination comprised of Lactobacillus acidophilus, Lactobacillus rhamnosus, Bifidobacterium longum, and Saccharomyces boulardii. The sachet contents were dissolved in 10 ml of distilled water which was used as a mouth rinse.
A detailed schedule which included the date of collection of salivary samples was prepared well in advance by discussing with the study subjects and hostel authorities to prevent unforeseen lapses. Type III examination of all the study subjects was done at baseline (0 day), on 15 th day morning (after 14 days of intervention), and again after 3 weeks (discontinuation of intervention). The plaque scores were recorded by using plaque index (Silness P. and Loe H., 1967). After the baseline recording of plaque scores, scaling was done in all subjects to make all groups comparable before the intervention and to evaluate the effect of all 3 mouth rinses on dental plaque accumulation. On the first day of the intervention, before bedtime all subjects performed mouth rinsing in front of the examiner and guardians were instructed to maintain strict compliance. Each subject was instructed to swish the 10 ml mouth rinse for 1 minute before spitting it. During the intervention period, each subject was given one of the test products with a given code according to the assigned group and was encouraged to maintain routine oral hygiene practices. Double blinding was ensured by keeping colour of all three mouthrinses same for subjects and principal investigator was unaware of coding. All the examinations were carried out by a single examiner and recording was done by another person, who was familiar with the pro forma. The kappa coefficient value for intraexaminer variability for plaque index (PI) was 0.89. Prior to statistical analysis, collected data was subjected for normality. Data was expressed as mean ± standard deviation (SD). For inter group comparison at different time intervals, one-way analysis of variance (ANOVA) was used followed by paired t-test for pair-wise comparison on 15 th day and after 3 weeks. The statistical analysis was performed using the software, Statistical Package for Social Sciences (SPSS; Version 21.0, Chicago, IL, USA) for MS Windows and P < 0.05 was considered statistically significant.
| Results|| |
[Table 1] shows demographic characteristics of subjects who participated in the study and [Table 2] shows distribution of samples in various mouthrinse groups at baseline (0 day), on 15 th day (after 14 days of intervention), and after 3 weeks (discontinuation of intervention) according to plaque scores. As seen in [Table 3] and [Figure 2] for plaque scores, there were statistically highly significant difference between groups on 15 th day and statistically significant difference between groups for after 3 weeks but not for baseline. On 15 th day, plaque scores were significantly lower for chlorhexidine and probiotic groups than placebo group. After 3 weeks, plaque scores were significantly higher for placebo group than chlorhexidine and probiotic groups; whereas, [Table 4] and [Figure 3] depict that there was statistically highly significant difference (P=0.001) in all groups (on 15 th day-after 3 weeks comparison) for plaque scores. When chlorhexidine and probiotic groups were compared, the plaque scores were less in probiotic group both on 15 th day of intervention and after 3 weeks after discontinuation of intervention.
|Figure 2: Between group comparisons of plaque scores for various mouthrinse groups at baseline (0 day), on 15th day (after 14 days of the intervention) and after 3 weeks (discontinuation of the intervention)|
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|Figure 3: Within group comparisons of plaque scores for various mouthrinse groups at baseline (0 day), on 15th day (after 14 days of the intervention) and after 3 weeks (discontinuation of the intervention)|
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|Table 1: Demographic and clinical characteristics of subjects who participated in study |
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|Table 2: Distribution of samples in various mouthrinse groups at baseline (0 day), on 15th day (after intervention for 14 days), and after 3 weeks (discontinuation of intervention) according to plaque scores |
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|Table 3: Intergroup comparison of various mouthrinse at baseline (0 day), on 15th day (after 14 days of intervention), and after 3 weeks (discontinuation of intervention) for plaque scores |
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|Table 4: Intragroup comparison of various mouthrinse on 15th day (after 14 days of intervention) and after 3 weeks (discontinuation of intervention) for plaque scores |
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| Discussion|| |
Maintenance of good oral hygiene helps in inhibition of biofilm accumulation. The regimens targeted at modifying the ecology of the oral biofilm have not been reproducibly successful yet. The ecological plaque hypothesis of caries presents interactions between the microbiota of the oral biofilm and the environment, such that a caries-inductive environment characterized by frequent intakes of high levels of fermentable carbohydrates, poor oral hygiene, with or without diminished salivary flow gives rise to changes in the composition of the biofilm. If the oral biofilm is to be beneficially modified, it might reduce its cariogenicity at specific tooth sites. 
Some of the hypothetical mechanism of probiotics action in the oral cavity is by: Direct interaction in dental plaque, involvement in binding of oral microorganisms to proteins, action on plaque formation and on its complex ecosystem by competing and intervening with bacterial attachments, and involvement in metabolism of substrate and production of chemicals that inhibit oral bacteria. ,,,
Till date, probiotic bacteria have been used as various formulations like milk, yogurt, straws/tablets, chewing gums, controlled releasing medical devices, and also as mouthrinses; but they all had one thing in common that only single (in most studies) or two probiotic bacteria were used; but, in present study a commercially available probiotic preparation Darolac (Aristo Pharmaceuticals, India) containing 1 g powder of 1.25 billion freeze-dried bacterial combination (a mixture of, Lactobacillus acidophilus, Lactobacillus rhamnosus, Bifidobacterium longum, and Saccharomyces cereviasae) was used to prepare probiotic mouth rinse to check the local effect of multiple probiotic bacteria on dental plaque accumulation.
In the present study, 13-15-years-old children were included; as by this age, all the permanent teeth would have erupted except third molars and better compliance can be expected compared to children below 12 years and young adults.
Totally valid comparisons could not be done between our study and other studies reported in literature due to wide variations observed with respect to selected age group, applied indices, species of probiotic bacteria, vehicles for administration and materials and methods. However a sincere attempt is done to compare and discuss to the extent possible.
In the present study, there was no significant difference between the groups (Probiotic, Chlorhexidine and Placebo) at baseline (P=0.431) hence baseline comparability before the intervention was ensured. Further Scaling was done in all subjects after the baseline recording of plaque scores. There was statistically significant difference between groups on the 15 th day and after 3 weeks (P=0.001, P=0.012 respectively). On the 15 th day and after 3 weeks least plaque scores were seen in the probiotic group followed by the chlorhexidine group and placebo group. This shows that after 2 weeks of the intervention and after 3 weeks (discontinuation of the intervention) Probiotic mouth rinse was more effective than Chlorhexidine mouth rinse for inhibiting plaque formation. However, there was no statistical significant difference in the mean plaque scores between the probiotic and chlorhexidine groups on the 15 th day.
Similar results were reported by Harini and Anegundi  and Noordin and Kamin  who compared probiotic mouthrinse with placebo mouthrinse (only 32 subjects). Shimauchi et al.,  also reported similar reduction in PI scores after using probiotic (Lactobacillus salivarius WB21 strain) containing xylitol tablets compared to plain xylitol tablets. However, a study conducted by Staab et al.,  showed that PI scores were increased in both probiotic milk group and control group, which were in contrast to result of the present study. Reduction of plaque scores in present study can be due to mechanical cleansing and swishing of mouthrinse, but as Staab et al. used milk as vehicle which would not be swished and also contains milk proteins which might have increased the plaque scores.
The studies conducted by Todkar et al.,  Charles et al.,  and Bhadbhade et al.  reported reduction in PI score in chlorhexidine group when compared to control group which was similar to present study results. Though in above mentioned studies chlorhexidine concentration and age groups were different, similar results were obtained. To conclude, irrespective of probiotic bacteria and vehicles used for administration there was significant reduction in plaque scores in study group compared to control group.
| Conclusion|| |
Probiotic mouthrinse and chlorhexidine mouthrinse caused significant inhibition of dental plaque accumulation compared to placebo mouthrinse, but probiotic mouthrinse was found to be more effective for inhibition of dental plaque accumulation after 14 days of intervention and 3 weeks after discontinuation of intervention than the chlorhexidine mouthrinse. So probiotic mouthrinse can be viewed as potential alternative to chlorhexidine mouthrinse for prevention of periodontal disease, but further long-term studies are recommended to get information on safety, side-effects, and carryover effect of such bacteriotherapy.
| References|| |
|1.||Harini PM, Anegundi RT. Efficacy of a probiotic and chlorhexidine mouth rinses: A short-term clinical study. J Indian Soc Pedod Prev Dent 2010;28:179-82. |
|2.||Jindal G, Pandey RK, Agarwal J, Singh M. A comparative evaluation of probiotics on salivary mutans streptococci counts in Indian children. Eur Arch Paediatr Dent 2011;12:211-5. |
|3.||Agarwal V, Khatri M, Singh G, Gupta G, Marya CM, Vimal K Prevalence of Periodontal Diseases in India. J Oral Health Comm Dent 2010;4(Spl):7-16. |
|4.||Parvez S, Malik KA, Ah Kang S, Kim HY. Probiotics and their fermented food products are beneficial for health. J Appl Microbiol 2006;100:1171-85. |
|5.||Lin S, Mauk A. Oral health: Addressing dental diseases in India. Implementing Public Health Interventions in Developing Countries. 2011 [Last cited on 2013 Oct 10]. Available from: http://www.ictph.org.in/tps-2011/paper4-india.html. |
|6.||Beighton D. Can the ecology of the dental biofilm be beneficially altered? Adv Dent Res 2009;21:69-73. |
|7.||Salminen MK, Tynkkynen S, Rautelin H, Saxelin M, Vaara M, Ruutu P, et al. Lactobacillus bacteremia during a rapid increase in probiotic use of Lactobacillus rhamnosus GG in Finland. Clin Infect Dis 2002;35:1155-60. |
|8.||Suvarna VC, BobyVU. Probiotics in human health: A current assessment. Curr Sci 2005;88:1744-8. |
|9.||Meurman JH. Probiotics: Do they have a role in oral medicine and dentistry? Eur J Oral Sci 2005;113:188-96. |
|10.||Huovinen P. Bacteriotherapy: The time has come. BMJ 2001;323:353-4. |
|11.||Noordin K, Kamin S. The effect of probiotic mouthrinse on plaque and gingival inflammation. Annal Dent Univ Malaya 2007;14:19-25. |
|12.||Shimauchi H, Mayanagi G, Nakaya S, Minamibuchi M, Ito Y, Yamaki K, et al. Improvement of periodontal condition by probiotics with Lactobacillus salivarius WB21: A randomized, double-blind, placebo-controlled study. J Clin Periodontol 2008;35:897-905. |
|13.||Staab B, Eick S, Knöfler G, Jentsch H. The influence of a probiotic milk drink on the development of gingivitis: A pilot study. J Clin Periodontol 2009;36:850-6. |
|14.||Todkar R, Sheikh S, Byakod G, Muglikar S. Efficacy of chlorhexidine mouthrinses with and without alcohol - a clinical study. Oral Health Prev Dent 2012;10:291-6. |
|15.||Charles CH, Mostler KM, Bartels LL, Mankodi SM. Comparative antiplaque and antigingivitis effectiveness of a chlorhexidine and an essential oil mouthrinse: 6-month clinical trial. J Clin Periodontol 2004;31:878-84. |
|16.||Bhadbhade SJ, Acharya AB, Rodrigues SV, Thakur SL. The antiplaque efficacy of pomegranate mouthrinse. Quintessence Int 2011;42:29-36. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]