|Year : 2015 | Volume
| Issue : 6 | Page : 633-639
A comparative evaluation of the efficacy of probiotic and chlorhexidine mouthrinses on clinical inflammatory parameters of gingivitis: A randomized controlled clinical study
Purnima Vidyesh Nadkerny, Potluri Leela Ravishankar, Virupapuram Pramod, Lavanya Abhay Agarwal, Saurabh Bhandari
Department of Periodontics, New Horizon Dental College and Research Institute, Sakri, Bilaspur, Chhattisgarh, India
|Date of Web Publication||28-Dec-2015|
Purnima Vidyesh Nadkerny
“Mohini” 4-B, Cotto, Sanguem, Goa - 403 704
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The aim of our clinical trial was to assess and compare the antiplaque and anti-inflammatory potential of a probiotic mouthwash with 0.2% chlorhexidine and saline. Materials and Methods: A randomized parallel group study was designed for a period of 4 weeks on 45 systemically healthy subjects between 20 and 30 years having chronic gingivitis. The study population was divided into three groups. Group A - 15 subjects were advised experimental (probiotic) mouthwash. Group B - 15 subjects were advised positive control (chlorhexidine) mouthwash and Group C - 15 subjects into a negative control group (normal saline). Oral prophylaxis was done for all groups at baseline. After the proper oral hygiene instructions, all the three groups were instructed to rinse their mouth with 10 ml of their respective mouthrinse, undiluted for 1 min twice daily, 30 min after brushing. Clinical parameters such as plaque index (PI), gingival index (GI), and oral hygiene index simplified (OHI-S) were assessed at baseline, 2 weeks and 4 weeks, respectively. Results: At day 28, the PI, GI, and OHI-S were significantly reduced by all treatment modalities ranking probiotic and chlorhexidine is greater than saline. Conclusion: The probiotic mouthrinses tested was effectively used as an adjunct to mechanical plaque control in the prevention of plaque and gingivitis. Thus, the probiotic mouthrinse has a great therapeutic potential.
Keywords: Chlorhexidine, gingivitis, mouthrinse, probiotic
|How to cite this article:|
Nadkerny PV, Ravishankar PL, Pramod V, Agarwal LA, Bhandari S. A comparative evaluation of the efficacy of probiotic and chlorhexidine mouthrinses on clinical inflammatory parameters of gingivitis: A randomized controlled clinical study. J Indian Soc Periodontol 2015;19:633-9
|How to cite this URL:|
Nadkerny PV, Ravishankar PL, Pramod V, Agarwal LA, Bhandari S. A comparative evaluation of the efficacy of probiotic and chlorhexidine mouthrinses on clinical inflammatory parameters of gingivitis: A randomized controlled clinical study. J Indian Soc Periodontol [serial online] 2015 [cited 2020 Apr 2];19:633-9. Available from: http://www.jisponline.com/text.asp?2015/19/6/633/168491
| Introduction|| |
The treatment of periodontal diseases has now moved toward an antimicrobial model of disease management. With the threat of widespread antibiotic resistance rendering many antibiotics useless against important diseases, there is an increased necessity not only to minimize antibiotic use and develop novel nonantibiotic-based treatments, but also to raise the profile of disease prevention.
Probiotics may be a promising area of research in periodontal therapy. Probiotics are defined as “live microorganisms that when administered in adequate amounts confer health benefits on the host.” They repopulate the beneficial bacteria, which can help kill pathogenic bacteria and fight against infection. Probiotics administered orally may benefit oral health by preventing the growth of harmful microbiota or by modulating mucosal immunity in the oral cavity.
Mechanical removal of supragingival plaque is the most effective tool to prevent gingivitis (Loe et al. 1965) but most individuals do not adequately control plaque accumulation and gingivitis continues to be prevalent. To overcome this hindrance, antimicrobial products in the form of dentifrices or mouthwashes have been tested for their adjunctive efficacy in reducing plaque and gingivitis. Among them, chlorhexidine is regarded as a gold standard in dentistry for the prevention of dental plaque. Though very effective, it has certain side effects such as brown discoloration of teeth, oral mucosal erosion, and bitter taste. As an alternative preventive tool, the use of probiotics has been proposed. However, only a few clinical studies have been so far conducted on the use of probiotics in the prevention of oral diseases. Thus taking into consideration, all these above facts and claims, this study was carried out to test the potential antiplaque and anti-inflammatory properties of probiotic in the form of a mouthwash.
| Materials and Methods|| |
A total of 45 systemically healthy subjects (29 males and 16 females) visiting the Department of Periodontology, at the New Horizon Dental College and Research Institute Bilaspur, Chhattisgarh, were recruited for the study.
The inclusion criteria for the study included:
- Subjects between the age group 20 and 30 years of age
- Subjects with chronic gingivitis
- Subjects are having a dentition with ≥20 evaluable teeth (minimum of five teeth per quadrant).
The exclusion criteria of the study included:
- History of systemic diseases
- Pregnant, lactating females
- History of antibiotic therapy in the past 3 months
- History of oral prophylaxis within 6 months previous to the study
- Subjects with mouth breathing habit
- Subjects with orthodontic and prosthodontic appliances
- Subjects with deleterious habit such as smoking
- History of undergoing nonsurgical and surgical periodontal therapy in the last 6 months.
Study design and clinical measurements
A randomized, parallel group clinical study was conducted on 45 systemically healthy patients reporting to the outpatient Department of Periodontics and Oral Implantology, at the New Horizon Dental College and Research Institute, Sakri, Bilaspur (Chhattisgarh) with chronic gingivitis.
The clinical parameters were recorded in a case history proforma. The subjects were assessed for plaque and gingival inflammation by recording the plaque index (PI) (Loe and Silness 1964), gingival index (GI) (Loe and Silness), and oral hygiene index-simplified (OHI-S) (Green and Vermillion) by a single investigator experienced with index system recording at baseline. Thorough scaling and polishing were performed and the patients were randomly divided into three groups consisting of 15 patients each as under:
Group A - Probiotic mouthrinse (Sporlac Plus ® [Sanzyme Ltd. India] + distilled water)
Group B - Chlorhexidine mouthwash 0.02% (Hexidine ® [ICPA])
Group C - Control (saline)
An informed written consent was obtained from each patient included in the study.
The patients in Group A were given Sporlac Plus ® Satchets (a probiotic formulation containing Lactobacillus acidophilus, Lactobacillus rhamnosus, Lactobacillus sporogenes, Bifidobacterium longum, and Saccharomyces boulardii) and 10 ml ampules of distilled water which are commercially available at the chemist as shown in [Figure 1]. The patients were demonstrated and instructed to prepare the experimental probiotic mouthwash by mixing together the contents of the sachet and 10 ml of distilled water. Emphasis was made to explain to the patient that the solution had to be stirred thoroughly until all the contents were completely dissolved in the distilled water. The formulation had to be prepared and rinsed immediately once prepared and could not be stored.
|Figure 1: Photograph showing the sporlac plus probiotic sachet, distilled water ampules, and chlorhexidine mouthwash|
Click here to view
All the three groups were advised to rinse their mouths with the respective mouthwashes prescribed to them for 15 days without any dilution for 1 min twice daily half an hour after brushing. They were advised not to eat anything for half an hour after using the mouthwash. The clinical parameters of PI, GI, and OHI-S recorded at baseline were repeated on 14th and 28th day.
Descriptive analysis was done and Independent sample t-test was employed between 2 groups. ANOVA and Tukey's tests were applied for intergroup comparison. Results were expressed as mean, standard deviation. For all tests, a P < 0.05 was considered as statistically significant. The study protocol was in accordance with the local ethical guidelines and approved by the Local Ethics Committee.
| Results|| |
The mean PI values for all three mouthrinses were 0 at baseline as scaling and polishing were done for all tooth surfaces. A PI score of 0 represented a tooth surface that was entirely free of clinically detectable plaque. Mean values of PI scores for probiotics was 0.36 ± 0.14, control 1.10 ± 0.22, and chlorhexidine 0.21 ± 0.15 as cited in [Table 1]. The degree of increment of mean PI scores was more pronounced for control rinse (saline) as compared to probiotic and chlorhexidine rinses. The differences in the increment of the mean PI scores before and after rinse for probiotic and control were significant, whereas that between probiotic and chlorhexidine were statistically insignificant. The mean GI scores were 0.45 ± 0.174 for probiotic, 1.03 ± 0.142 for control, and 0.40 ± 0.124 for chlorhexidine as cited in [Table 2]. In comparison to the baseline data, there was a significant decrease in mean GI scores of probiotic and chlorhexidine rinses as compared to the control rinses, whereas that between probiotic and chlorhexidine it was statistically insignificant. The degree of reduction of mean GI scores was more pronounced for the probiotic and chlorhexidine rinses as compared to control rinse.
The mean OHI-S values were 0.35 ± 0.106 for probiotic, 0.97 ± 0.139 for control, and 0.48 ± 0.341 for chlorhexidine, respectively, as cited in [Table 3]. In comparison to baseline data, there was a significant decrease in the OHI-S score of the probiotic and chlorhexidine group as compared to the control group.
Whereas clinical significance after intergroup comparison between control and chlorhexidine was P = 0.00, probiotic and chlorhexidine was P = 0.16, probiotic and control was P = 0.00 for PI. Between control and chlorhexidine, it was P = 0.00, probiotic and chlorhexidine it was P = 0.75, probiotic and control was P = 0.00 when comparison for GI was calculated. Between control and chlorhexidine, P value was at 0.00 for probiotic, and chlorhexidine P value was at 0.41 for probiotic and control P value was at 0.00, when OHI-S was calculated. This intergroup comparison shows that there is a statistically significant difference in the control group and probiotic group in the reduction of PI, GI, and OHI-S scores. However, no statistically significant difference is noted in the chlorhexidine and probiotic groups.
| Discussion|| |
Chemical agents have been increasingly used as an adjunct to mechanical control. They are intended to augment and not to replace mechanical plaque control. Chlorhexidine has been reported to have a number of local side effects. These side effects are brown discoloration of the teeth and tongue, oral mucosal erosion, and taste perturbation. Several side effects associated with its use have stimulated the search for an alternative antiplaque agent. Antibacterial mouthrinses act by nonspecifically reducing the levels of both friendly and harmful oral bacteria. In contrast, probiotic has been developed utilizing natural beneficial bacteria to promote a healthy balance of microorganisms in the mouth.
Probiotic technology represents a breakthrough approach to maintain oral health by utilizing natural beneficial bacteria commonly found in healthy mouths to provide a natural defense against those bacteria thought to be harmful to teeth and gums. Probiotic species mostly belong to the genera Lactobacillus and Bifidobacterium. To be able to exert probiotic properties in the oral cavity, however, it is essential for the microorganism to resist the oral environmental conditions and defense mechanism, to be able to colonize and grow in the mouth, and to inhibit oral pathogens. The putative probiotic species also needs to be safe for the host. The potential benefits of probiotics on systemic health and medical disorders, such as gastrointestinal diseases, have been elaborately described. The first species introduced into research were L. acidophilus and Bifidobacterium bifidum. Among a number of potential benefits that have been proposed are reduced susceptibility to infections, reductions in allergies, and lactose intolerance, as well as lowered blood pressure and serum cholesterol values. Within dentistry, the previous studies with lactobacillistrains such as L. rhamnosus, Lactobacillus. casei, Lactobacillus reuteri, or a lactobacilli mix have revealed mixed results on oral microorganisms. A variety of mechanisms have been proposed for their actions, and some effects have been stated to be systemic rather than only local. It is likely that these mechanisms vary according to the specific strain or combinations of strains used, the presence of prebiotics and the condition that is being treated, as well as the stage of the disease process in which the probiotic is administered. There are common themes emerging in studies of the modes of action of probiotics and numerous mechanisms have been proposed including prevention of adhesion of pathogens to host tissues, stimulation, and modulation of the mucosal immune system, e.g., by reducing production of pro-inflammatory cytokines through actions on NFkB pathways, increasing production of anti-inflammatory cytokines such as interleukin-10 (IL-10, and host defense peptides such as beta-defensin 2, enhancing immunoglobulin A defenses, and influencing dendritic cell maturation. Killing or inhibition of growth of pathogens through production of bacteriocins or other products, such as acid or peroxide, which are antagonistic toward pathogenic bacteria has also been reported.
The current concept concerning the etiology of periodontal disease considers three groups of factors which determine whether active periodontal disease will occur: A susceptible host, the presence of pathogenic species, and the absence of so-called “beneficial bacteria.”
It is generally accepted that the oral biofilm in association with an aerobic bacteria is the main etiological factor in periodontal disease. Few experimental studies have explored the use of probiotic in periodontal diseases.
Shimauchi et al. did a study in patients with moderate to severe gingivitis who were given either freeze-dried Lactobacillus salivarius WB21 (WB21)-containing tablets or xylitol containing placebos regularly (3 times daily for 8 weeks). The intake of tablets containing L. salivarius resulted in benefits in terms of pocket probing depth and PI in individuals at high-risk of periodontal disease (smokers) as compared to a placebo control group.
Krasse et al. did a study in patients with moderate to severe gingivitis who were given one of the two different L. reuteri formulations (LR-1 or LR-2) at a dose of 2 × 10 (8) CFU/day, or a corresponding placebo. L. reuteri was efficacious in reducing both gingivitis and plaque in patients with moderate to severe gingivitis.
Other studies have aimed to identify organisms which have the potential for probiotic action that may protect against periodontal diseases. Some oral strains oflactobacilli, streptococci,,,, and bifidobacteria  have been reported to have in vitro inhibitory activity against periodontal pathogens while others are more active against mutans streptococci.,,
Kõll-Klais et al. observed that L. gasseri strains isolated from periodontally healthy subjects were more efficient at inhibiting the growth of Aggregatibacter actinomycetemcomitans than strains from periodontally diseased subjects, and also inhibited the growth of Porphyromonas gingivalis and Porphyromonas intermedia. This correlated with an inverse relationship between carriage of homofermentative lactobacilli and subgingival colonization by A. actinomycetemcomitans, P. gingivalis, and P. intermedia.
Ishikawa et al. observed in vitro inhibition of P. gingivalis, P. intermedia, and Prevotella nigrescens by L. salivarius. Daily ingestion of L. salivarius - containing tablets resulted in reduced salivary counts of these black pigmented anaerobes.
Noordin and Kamin  conducted a trial among 90 school children and assigned them into placebo, chlorhexidine, and probiotic groups; and plaque scores were recorded at baseline (0 day), on 15th day (after 14 days of intervention), and 3 weeks (after discontinuation of intervention). Probiotic mouthrinse was more effective for inhibition of dental plaque accumulation after 14 days of intervention and also after 3 weeks of discontinuation of intervention.
Vivekananda et al. evaluated the effects of lactobacilli reuteri (prodentis) alone and in combination with scaling and root planing (SRP) in patients with chronic periodontitis for a period of 42 days. Their trial confirmed the plaque inhibition, anti-inflammatory, and antimicrobial effects of L. reuteri (prodentis) and they recommended the use of probiotic during nonsurgical and maintenance phase of periodontal treatment.
Harini and Anegundi  evaluated clinically the efficacy of a probiotic and chlorhexidine mouthrinses on plaque and gingival accumulation in children for 14 days and concluded that the probiotic mouthrinse was found effective in reducing plaque accumulation and gingival inflammation.
Teughels et al. in a randomized placebo-controlled clinical trial evaluated the effects of L. reuteri - containing probiotic lozenges and placebos as an adjunct to SRP in 30 patients with chronic periodontitis, monitored clinically, and microbiologically at baseline, 3, 6, 9, and 12 weeks after therapy. Significant improvement in all clinical parameters reduced P. gingivalis levels, more pocket depth reduction and attachment gain in moderate and deep pockets was observed in the SRP + probiotic group.
Maekawa and Hajishengallis  studied whether Lactobacillus brevis CD2 or placebo could inhibit periodontal inflammation and bone loss in experimentally induced periodontitis in mice. Mice topically treated with L. brevis CD2 displayed significantly decreased bone loss, lower expression of tumor necrosis factor, IL-1β, -6 and -17A, lower counts of anaerobic bacteria, but higher counts of aerobic bacteria as compared to placebo-treated mice. Hence, L. brevis CD2 could inhibit periodontitis through modulatory effects on the host response and the periodontal microbiota.
Purunaik et al. aimed to investigate the efficacy of Probiotic (1 g powder of 1.25 billion freeze dried combination, a mixture of L. acidophilus, L. rhamnosus, B. longum, and S. boulardii), 0.2% of chlorhexidine and placebo mouthrinses in reducing plaque and gingivitis among 90 school children aged 15–16 years. It was found that both probiotic and chlorhexidine mouthrinses were able to significantly reduce plaque and gingival levels after 14 days.
Baca-Castañón et al. did a study to test and compare in vitro antimicrobial activity of L. reuteri on pathogenic bacteria involved in the formation of dental caries: Streptococcus mutans, Streptococcus gordonii, and periodontal disease: Actinomyces naeslundii and Tannerella forsythia chlorhexidine of 0.12% was used as a positive control. L. reuteri was shown to have an inhibitory effect against S. mutans, followed by T. forsythia and S. gordonii, and a less significant effect against A. naeslundii.
Our results indicate that probiotics could be useful in the improvement/maintenance of oral health in subjects at a high-risk of periodontal disease and add to the body of data supporting the effectiveness of both chlorhexidine and probiotic as antiplaque/antigingivitis agents. The advantages of using a probiotic mouthrinse are that as it contains friendly commensals, there is no issue of antibiotic resistance, and there are no known/proven toxicities caused due to their use.
Sporlac plus sachet ® powder for oral solution is a commercially available powder containing probiotics Lactobacillus and Bifidobacterium not <1.25 billion cells (L. acidophilus, L. rhamnosus, lactic acid bacillus, B. bifidum, B. longum, and S. Boulardii) popularly used in the treatment of diarrhea of any etiology infantile, weaning, and neonatal diarrhea along with any anti-diarrheal agent. Several clinical studies have already demonstrated the effectiveness of this probiotic in the treatment of systemic diseases and infectious diseases such as acute diarrhea and Crohn's disease.
Very few studies till date have studied the basic/initial treatment for periodontal patients in terms of SRP and use of probiotic mouthwash in the reduction of clinical parameters of gingivitis in India. An initial attempt was made in this randomized, parallel clinical trial to evaluate the benefits of scaling and sporlac plus probiotic sachet in the treatment of chronic gingivitis and to compare it with chlorhexidine, which has been regarded as the “gold” standard in dentistry for the prevention of plaque and gingivitis.
In all the three groups namely chlorhexidine, probiotic, and saline, PI, GI, and OHI-S were significantly reduced within each treatment group over the 30 days, and thus, even the control had a significant effect. However, such placebo effects are known to occur as a simple consequence of the Hawthorne effect.
The results of our study are in accordance with studies done by Vivekanand et al., Harini and Anegundi, and Noordin and Kamin  showing the effect of the probiotics in the management of periodontal disease.
The combination of scaling and probiotics and scaling and chlorhexidine demonstrated a significant reduction of PI, GI, and OHI-S when compared with scaling and saline group. The effect of SRP on plaque reduction is similar to that reported by Mousques et al. and Proye et al. Thus, the plaque reduction brought about by scaling was enhanced by the use of probiotics and chlorhexidine, which is in accordance with the studies done by Krasse et al.
In the present study, using a negative (saline) and a positive control (chlorhexidine), we were able to state that the probiotic mouth wash (Sporlac plus) has shown a good potential as an antiplaque agent and its effectiveness in reducing the plaque accumulation and gingival inflammation is comparable to chlorhexidine. Considering the local side effects of chlorhexidine including brown staining, taste disturbance, enhanced supra gingival calculus formation, and less commonly desquamation of the oral mucosa. Sporlac plus probiotic mouthrinse seems a very effective and economical alternative for patients with periodontal disease.
Probiotic effects are strain-specific, thus, each individual bacterial strain needs to be tested separately, and the effects described for one strain cannot be directly applied to others. Most of the studies carried out to evaluate the effects of probiotics on periodontal disease have been associated with an individual bacterial strain., Unfortunately, mislabeling of strains in probiotic products seems to be a common problem., On the other hand, multispecies or multi-strain probiotic products can be even more effective than products with only one bacterial strain.,
In our study, we used a probiotic mouthrinse containing the combination of Lactobacillus, bifidobacterium, and Sacchromyces strains. It is possible, in the complex environment of the human mouth that probiotic “cocktail” of multiple strains would be more effective than any single probiotic agent. This combination of probiotic strain was similar to those used by Haukioja et al. and Purunaik et al. The results of our study showed a significant reduction of plaque and gingival status and were in accordance with the above-mentioned studies suggesting that combinations of probiotics strains may have synergistic adhesion effect. Though these strains tested maintained the oro-microbiological balance, their action in the oral cavity is dubious as oral mucosa is not their innate habitat. Furthermore, there is also a need to evaluate whether these lactobacilli strains are momentary or stable oral colonizers. However, it seems plausible that prolonged administration of probiotic preparations may have a preventive role against the development of plaque and gingivitis.
However, we would like to state that the major limitation of our probiotic preparation is that it needs to be used immediately once prepared and cannot be stored. Thus, we would recommend that a proper vehicle is needed for delivering probiotics so that patient compliance can be improved. Apart from the unacceptable taste, no other adverse effects on the oral mucosa such as ulcerations were noted with probiotic mouthrinse. Likewise, it would be interesting to evaluate the additional GI benefits of probiotics in studies, where the patient is instructed to ingest rather than expectorate the probiotic mouthrinse. This was not possible to evaluate in this study, since it was a comparative clinical trial assessing the efficacy of three mouthrinses. Longitudinal studies involving probiotics and further microbiological evaluation are also essential when prescribing them in place of antiseptics and antimicrobials.
| Conclusion|| |
In the recent times, when organisms are fast developing resistance to antibiotics, the emergence of probiotics appears to be a boon for the treatment of diseases. Researchers have confirmed that diseases of the periodontium are not confined to the oral cavity but have strong systemic effects. Hence, probiotics offer a natural and promising option to establish both a good oral and systemic health. In the present study, the probiotic mouthrinse tested was effective in reducing plaque accumulation and gingival inflammation. Therefore, probiotic mouth rinse has a potential therapeutic value, and further long-term studies are recommended to determine its efficacy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]