Oral Health and the Role of Dietary Supplements

Gargle some mouthwash, brush and floss your teeth, and drop into the dentist’s chair a couple times each year. Sound familiar? Even if many people fall short of following it, the conventional wisdom for maintaining good oral health has become fairly ubiquitous. However, there may be more to the story.

The supplement world has produced a deluge of research, applications, and products relating to oral health in the last few years. From probiotic strains working to cultivate the proper bacterial climate, to omega-3 ingredients fighting periodontitis, there’s a mouthful of options for a market that may be gradually moving “beyond dental.” A mix of cost-efficiency, natural appeal, and promising research are all driving the hype.

A Bacteria Balancing Act

One crucial element of oral health that conventional measures often fail to address is maintaining a healthy microbial balance. Most mouthwashes strive to rid the mouth of harmful bacteria that contribute to tooth decay and gingivitis, but do they go too far?

The problem with antimicrobial rinses and mouthwashes is that they “inhibit the growth and functioning of beneficial strains of bacteria that help protect the oral cavity from colonization by the pathogenic strains,” says Nena Dockery, technical support manager, Stratum Nutrition (St. Charles, MO). Beyond contributing to tooth decay and bad breath, these harmful strains may also infect the throat and upper respiratory tract.

To that end, the BLIS M18 and K12 probiotic strains from Stratum Nutrition are designed to restore protective bacteria in the oral cavity. Derived from Streptococcus salivarius, a naturally occurring oral bacteria, both strains are meant to “protect the oral cavity from occupancy by deleterious strains of bacteria through competitive inhibition,” says Dockery. But each strain takes a slightly different approach.

BLIS M18 for Periodontal Health

With three bacteriocins targeting harmful Streptococcus mutans, BLIS M18 is intended to improve gum and tooth condition, especially among patients with poor periodontal health. Study results¹ announced in January suggest Stratum may well be on the right track with this strain.

Researchers at the A.J. Institute of Dental Sciences (Mangalore, India) conducted a study of BLIS M18 probiotic lozenges on 28 participants aged 20-60 years who suffered from “varying degrees of poor periodontal health,” according to a press release. An experimental group took the lozenges every day for 30 days and was then examined at 15-day intervals for 60 days in comparison with a control group. All the participants underwent professional scaling and root planing at the outset of the study.

By the end of the 30-day probiotic administration period, “the M18 supplement group showed a significant reduction in all clinical parameters, including plaque index, gingival index, modified sulcular bleeding index, and probing pocket depth when compared to that of the control group,” says Dockery. At 60 days, the experimental group still scored higher on these parameters, but the periodontal health benefits did gradually decline after the probiotic administration stopped, reported the researchers. Dockery points out that “regular supplementation” would be necessary to sustain the possible benefits.

BLIS M18 also produces enzymes that are meant to neutralize acidic conditions that can wear down tooth enamel and degrade dextran, a component of dental plaque, says Dockery.

BLIS K12 for Children

Although it acts by a similar mechanism, Stratum’s BLIS K12 targets a different harmful strain, Streptococcus pyogenes, which can cause pharyngeal infections. K12 produces two bacteriocins that are meant to inhibit S. pyogenes, among other harmful strains, says Dockery.

A clinical study² published in Drug, Healthcare and Patient Safety in February 2014 explored possible benefits of K12 supplementation among children who suffer from recurrent oral streptococcal disorders. Thirty children aged 3-13 were treated for 90 days with a daily, slow-release oral tablet containing at least 1 billion colony-forming units/tablet of S. salivarius K12. The experimental group was compared with a control group of 30 untreated children. It was a multicenter, open, nonrandomized, controlled clinical trial.

By the end of the 90-day period, the treated group experienced a 96.79% reduction of pharynogtonsilitis episodes caused by S. pyogenes, and near-perfect patient tolerability and compliance. While the control group spent a combined 900 days taking antibiotics and missed 228 days of school or preschool, the BLIS K12 group spent only 30 combined days under antibiotics and missed just 16 days of school.

Beyond showing “excellent tolerability and ease of compliance of K12 supplementation,” this research “built upon prior studies showing that the K12 strain can be a valid therapeutic solution in the prevention of infections of the oral cavity, whether of streptococcal or viral etiology, and in particular those of a recurrent nature,” says Dockery.

A Market for Oral Probiotics?

Even if oral probiotics have shown promise in recent research, is the market there? One advantage may be the acceptance that probiotics have already found in other applications.

“Most consumers now recognize the benefits of probiotics in the GI tract, so they are more receptive to understanding the role that probiotics can have in supporting oral health as well,” says Dockery. “The market is definitely growing.”

Entering the probiotic market also poses the challenge of finding ways to market specific strains and make finished products stand out, according to Heather Thompson, global marketing manager, Stratum Nutrition. Rather than a weakness, the novelty of oral probiotics may actually be a strength for suppliers looking to differentiate new products.

“We are now trying to educate on another angle with a different kind of probiotic. The mouth is a primary entry point for all bacteria-good and bad,” says Thompson. “Why not be proactive in building the positive balance within this gateway to our overall health?”

Stratum’s probiotics are not intended as replacements for daily brushing and flossing, but Thompson hopes consumers will turn to oral probiotics more and more as part of a well-rounded oral health regimen.

Fighting Plaque? There’s a PAC for That

Another relative newcomer to the oral health world is the cranberry, which has recently begun making appearances in powders, toothpastes, and chewing gums as an ingredient aimed at reducing harmful biofilm in the mouth. Could it be that the same proanthocyanidins (PACs) often claimed to provide relief from urinary tract infections (UTIs) may also reduce dental plaque?

Cranberry Toothpaste and Chewing Gum

On the basis of two promising preliminary trials, Nexira (Rouen, France) is promoting its Exocyan cranberry extract as a “natural oral care solution for decreasing dental plaque.” Just last year, Nexira launched Exocyan Cran 70S, named for the up to 70% possible standardized PAC levels in the extract.

Dental plaque arises out of the formation of a white viscous layer of harmful biofilm, but Nexira says the PACs in Exocyan disrupt the formation of this biofilm due to their anti-adhesive properties. If the PACs are able to prevent bacteria from attaching and growing in the mouth, inhibiting biofilm formation, then it may be possible to decrease the “main risk factor of gingivitis and periodontitis,” according to Nexira.

Researchers at the University of Bordeaux (Talence, France) conducted two small preliminary human studies on Exocyan’s effect on oral health in chewing gum and toothpaste. In the chewing gum study, conducted in 2008, nine participants chewed four pieces of gum every day for four weeks, with each piece of gum containing 36 mg of Exocyan PACs. According to Nexira, researchers saw an average 28% decrease in dental plaque over the course of the study, as measured by the Turesky plaque index score.

The 2011 study on PAC toothpaste involved 18 participants who brushed their teeth three times daily with toothpaste containing Exocyan. After six weeks, researchers noted a 15% decrease in plaque, also measured by the Turesky plaque index score. In both studies, the participants were healthy volunteers without cavities who were approximately 21 years old. Both study results are unpublished but currently featured in Nexira’s marketing materials.

“The natural action in oral health of Exocyan, as well as its natural origin, makes it perfectly suitable for the formulation of healthy and clean-label products,” says Vanessa Agnolutto, marketing and communication manager, Nexira. She adds that Exocyan is available in organic grade and suitable for soluble and insoluble applications.

Cranberry Powder

Cranberry ingredient supplier Fruit d’Or Nutraceuticals (Notre-Dame-de-Lourdes, QC, Canada) recently launched its own cranberry powder for oral health, called Oral Cran. Acting on the same biofilm-disrupting mechanism as Exocyan, Oral Cran is currently available in a powder that Fruit d’Or claims may help fight plaque buildup, cavities, gum bleeding, and bad breath.

A recent pilot study of 33 patients aged 33-80 showed promising potential for Oral Cran, according to Fruit d’Or. The participants all suffered from halitosis, gum bleeding, or generally poor gum condition prior to treatment. After two months of tooth brushing with Oral Cran powder, study organizer Hilary Rodrigues, PhD, reported overwhelmingly positive findings.

“The periodontal condition has improved, and in all cases bleeding from the gums has ended,” Rodrigues said in a press release. “Swelling of gums was reduced, bad breath was eliminated, and blue-tinged gums turned back to a normal pink color.”

The preliminary study consisted entirely of patients from Dr. Rodrigues’s private practice, and the results are unpublished, but Fruit d’Or has plans to launch a larger-scale study of Oral Cran, according to Stephen Lukawski, director, sales and business development. Lukawski also posits Oral Cran as a less expensive complement to professional teeth cleaning, especially for patients undergoing chemotherapy who are advised not to get their teeth cleaned for fear of infection.

Omega-3s: A Friend for Gums in Need?

Omega-3 fatty acids have racked up an expansive lineup of possible health benefits over the years, but we may soon be adding one more to the list. Recent research has shown omega-3s may ease several symptoms of periodontitis, possibly due to the anti-inflammatory action of the famous fatty acids.

Omega-3s and Aspirin

A randomized, double-blind, placebo-controlled trial³ published last year in the Journal of Dental Research explored the effect of omega-3 docosahexaenoic acid (DHA) on adults with moderate periodontitis. Over the course of three months, 46 participants took either 2000 mg per day of DHA or identical placebo capsules. All study participants also received 81 mg of aspirin per day, which was intended to reduce enzymatic inactivation of DHA and enhance possible “protection against inflammation-induced tissue and bone loss from periodontitis,” according to the researchers.

Although bleeding on probing and plaque index were not affected in either group, researchers at Beth Israel Deaconess Medical Center (Boston) observed a significant decrease of mean pocket depth and gingival index in the experimental group, two indicators of problematic inflammation and separation of the gum from the tooth. The proportion of DHA in red blood cell plasma membranes also increased from 3.6% to 6.2% in the omega-3 group, compared with no change among the control group.

The researchers concluded that “aspirin-triggered DHA supplementation significantly improved periodontal outcomes in people with periodontitis, indicating its potential therapeutic efficacy.”

Omega-3s Alone

Researchers at India’s Dental College and Research Centre (Kolhapur, India) also released the results of a similar study⁴ last year, except in this case aspirin was not included in the study design. For 12 weeks, 58 participants with moderate and severe chronic periodontitis were given either a 300-mg tablet of omega-3s daily or a placebo. Each omega-3 capsule contained 180 mg of eicosapentaenoic acid (EPA) and 120 mg of DHA. The trial was randomized, double-blind, and placebo-controlled.

Four parameters of gum health-gingival index, sulcus bleeding index, pocket depth, and clinical attachment levels-all saw significant reductions in the omega-3 group compared with the control group, researchers reported. They concluded that omega-3 supplementation may have “potential benefits as a host modulatory agent in the prevention and/or adjunctive management of chronic periodontitis.”

New Products?

Clearly, the research for omega-3 applications in oral health is growing, but it’s still not a “slam dunk,” says Harry Rice, PhD, vice president of regulatory and scientific affairs, Global Organization for EPA and DHA Omega-3s (Salt Lake City). Rice is also a member of Nutritional Outlook’s editorial advisory board.

In the last five years, omega-3 research has taken enormous strides in moving from animal models to human trials, says Rice, but there is still a scarcity of companies marketing omega-3 products specifically for oral health. As always, a big question is: would there be a demand among consumers?

“Perhaps the appeal would be that omega-3s have additional benefits above and beyond cardiovascular health,” says Rice, adding that periodontists would likely need to begin endorsing omega-3 products to jumpstart the market. “Provided the research builds in support of a solid benefit, there could be a demand, but I think it would be a niche market.”

With so many new and promising options, dietary supplements are poised to play an evermore important role in consumers’ oral healthcare routines.

References

1. Scariya L et al. “Probiotics in periodontal therapy.” International Journal of Pharma and Bio Sciences, vol. 6, no. 1 (January 2015): 242-250.
2. Di Pierro F et al. “Use of Streptococcus salivariusK12 in the prevention of streptococcal and viral pharyngotonsillitis in children.” Drug, Healthcare and Patient Safety. Published online February 13, 2014.
3. Naqvi AZ et al. “Docosahexaenoic acid and periodontitis in adults: a randomized controlled trial.” Journal of Dental Research,vol. 93, no. 8 (June 2014); 767-773.
4. Deore GD et al. “Omega 3 fatty acids as a host modulator in chronic periodontitis patients: a randomised, doubled-blind, palcebo-controlled, clinical trial.” Journal of Periodontal & Implant Science, vol. 44, no. 1 (February 2014): 25-32.

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