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Short Communication

Clinical Efficacy of Probiotic Mouthwash in the Treatment of Gingivitis

Patients in Himachal Population
Vikas Jindal, Neha Mahajan, Amit Goel, Rupinder Kaur, Atin Mahajan, Puja Thakur Malhotra

Department of Periodontics, This study was conducted to analyze the changes in gingival health in patients
Abstract
Himachal Dental College,
Sundernagar, Himachal
treated with probiotic containing mouth rinse. Thirty volunteers between
Pradesh, India 20 and 35 years were randomly divided into two groups. While one group
was given placebos, the other was given probiotic mouth rinse for 14 days.
The volunteers were instructed to swish the mouth rinse for 60 s twice a day.
Intergroup comparison of the plaque scores (baseline‑14 days) showed there was
statistically significant difference in the mean plaque scores between the placebos
group (0.14) (P  ≤  0.05) and the test group  (0.42)  (P  ≤  0.05) and a statistically
significant difference in the mean gingival scores from baseline‑14  days between
the placebos group (0.9) (P  ≤  0.05) and the test group  (0.38) with  (P  ≤  0.05).
Despite the short period for which the probiotics mouthwash was used by the
patients, substantial improvement in gingival health of patients was observed in
the study.
Received: April, 2016.
Accepted: November, 2016. Keywords: Clinical efficacy, gingivitis, placebos, probiotics

Introduction
T he oral cavity is a rather intricate environment
that harbors a diverse array of bacterial species
with each environment within, supporting distinct yet
overlapping communities of hundreds of species. It
is estimated that more than 500 different species are
capable of colonizing the adult mouth and that any
individual typically harbors 150 or more different
species.[1] Furthermore, the microbiota of the tongue
surface is one of the most complex niches in human
ecology, and approximately one‑third of the bacterial
population in the oral cavity is found on the tongue
and not on other oral sites.[2] The balance of all these
microorganisms can easily be disturbed and a prevalence
of pathogenic organisms can lead to various oral health
problems including dental caries, periodontitis, and
halitosis.
Various studies done in the past have shown that
probiotics can tilt the balance of the oral flora toward
the beneficial species, reducing gingivitis.[3] The term
“probiotic” is derived from the Greek word meaning
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“for life.”[4] This term was first used in 1965, by Lilly
and Stillwell for describing substances secreted by one
organism which stimulates the growth of another.[5]
By the turn of 20th century Nobel Prize, Laureate Ilye
Metchnikoff was the first to state the role of beneficial
bacteria on health and proposed that Bulgarian people
had a longer longevity due to fermented milk containing
viable bacteria.[6] As defined by the World Health
Organization, probiotics have been defined as “Live
microorganisms, if administered in adequate amounts,
confer a health benefit on the host”.[7]
The concept of replacing pathogenic bacteria with
beneficial bacteria has gained much acceptance in
Address for correspondence: Dr. Puja Thakur Malhotra,
Department of Periodontics,
Himachal Dental College, Sundernagar,
Himachal Pradesh, India.
E‑mail: drpujatmalhotra1977@gmail.com
This is an open access article distributed under the terms of the Creative Commons
Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak,
and build upon the work non-commercially, as long as the author is credited and the new
creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

How to cite this article: Jindal V, Mahajan N, Goel A, Kaur R, Mahajan A,

Malhotra PT. Clinical efficacy of probiotic mouthwash in the treatment
DOI: 10.4103/2231-0754.207386 of gingivitis patients in Himachal population. J Int Clin Dent Res Organ
2017;9:41-4.

© 2017 Journal of the International Clinical Dental Research Organization | Published by Wolters Kluwer - Medknow 41
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Jindal, et al.: Probiotic mouthwash and gingivitis
recent years where antibiotic resistance is an increasing
global problem. Given the potent paradigm shift that
this phenomenon of oral probiotics can give rise to the
field of periodontal healthcare, probiotics might offer an
opportunity as an alternative approach in reducing bacterial
mediated oral diseases as gingivitis. Considering this, the
present study was conducted to evaluate the clinical effect
of short‑term administration of probiotic product darolac
as a mouth rinse in reducing plaque and gingivitis.
Materials and Methods
This comparative double‑blind prospective study was
conducted on sample size of thirty gingivitis patients.
The patients were selected from Himachal population.
Approval for the study was obtained from the Ethical
Committee. All data were reviewed to confirm criteria
for inclusion and exclusion. The eligible patients who
satisfied the inclusion criteria of 20–35  years of age
with no recent antibiotic therapy (within 4 weeks) were
included in the study. The exclusion criteria included
patients suffering from any systemic illness or using
any other commercially available mouth rinse, probiotic
products, or any other oral hygiene aids other than
routine teeth brushing. Patients undergoing orthodontic
treatment were also excluded from the study. All
participants were informed about the nature of the study
and their informed consent was taken.
The participants and the examiner were blinded
regarding the product allocation. The mouth rinse and
the placebo (distilled water) were prepared in similar
50 ml bottles by one of the study coordinators, who
marked the code number of each bottle and kept the
record. Commercially available probiotic product
Darolac (Aristo pharmaceuticals, India, 23 A, Shah
Industrial Estate, Off Veera Desai Road, Andheri West,
Mumbai 400053, Maharashtra, India) containing 1 g
powder of 1.25 billion freeze‑dried combination, of
a mixture of Lactobacillus acidophilus, Lactobacillus
rhamnosus, Bifidobacterium longum, and Saccharomyces
boulardii was used. Each sachet powder was dissolved
in 20 ml of distilled water measured with a measuring
cup and used as a mouth rinse. The placebos mouth
rinse was prepared using distilled water.
When the participants volunteered for the study and
before they received a bottle containing mouth rinse and
instruction for use, baseline plaque index Silness and
Loe (1964) and gingival index Loe and Silness (1963),
in which the gingivae scored on a 4‑point scale from
0  (absence of inflammation) to 3  (severe inflammation)
were noted.
Each participant was given one of the test products with
a given code according to the assigned group. Twenty
42 Journal of the International Clinical Dental Research Organization | Volume 9 | Issue 1 | January-June 2017
milliliters of mouth rinse were dispensed for each
individual using a measuring cup and participants were
instructed to swish the mouth rinse for 60 s and then
expectorate. The procedure was performed twice daily,
for the first time in the morning, and to be repeated
before retiring to bed at night for the next 14 days.
During the intervention period, no influence on personal
oral hygiene procedure was exerted, the participants
were encouraged to maintain routine oral hygiene and
also instructed to maintain strict compliance. A day after
the 14 days of intervention, gingival and plaque indices
were recorded using same indices by same examiner.
Clinical monitoring was performed by single examiner
at baseline and 14th day.
The monitoring of compliance was assessed by
instructing the participants to return the old bottles
containing mouth rinses who received a new bottle of
mouth rinse. Record of the allocation list was kept with
one of the study coordinators. The mouth rinses were
decoded after the completion of the study. Data were
collected and analyzed.
Results
Fifty‑two patients between the ages of 21 and 34 years
(mean age 28 years) were screened for their eligibility
to participate in this study. Twelve patients did not meet
the inclusion criteria, and ten did not complete the study
protocol. Twenty patients received probiotic mouth
rinse (test group) and twenty patients received placebo
mouth rinse (control group). At the end of the study, a
total of thirty participants of both the control and test
group could be evaluated for the results. After 14 days,
the test (15/20) and the control (15/20) groups were
analyzed for the various parameters.
On the basis of statistical analysis, following results
were drawn. Intragroup comparison of plaque scores
from baseline to 14th day showed an increase in the
mean plaque score for the control group that was not
statistically significant, with the mean difference of
0.14 (P  ≤  0.05) and a statistically significant reduction
in the mean plaque score for the test group with a mean
difference of 0.42 (P  ≤  0.05). Intragroup comparison of
gingival scores from baseline to 14 days showed there
was no statistically significant increase in the mean
gingival score in placebo with mean differences of
0.1 (P  > 0.05) and a statistically significant reduction in
the mean plaque score for the test group with a mean
difference of 0.38 (P ≤ 0.05).
On intergroup comparison of the plaque
scores (baseline‑14 days), there was a statistically
significant difference in the mean plaque scores
between the placebos group 0.14 (P  ≤  0.05) and
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Jindal, et al.: Probiotic mouthwash and gingivitis
the test group 0.42 (P  ≤  0.05) and there was a
statistically significant difference in the mean gingival
scores (baseline‑14 days) between the placebo
group  −0.9  (P  ≤  0.05) and the test group  0.38
with (P  ≤  0.05) as shown in Table 1 and Table 2,
respectively.
Discussion
The present study was done to analyze the changes in
gingival health in patients treated with probiotic containing
mouth rinse. The results of the study showed that the
administration of probiotic containing L. acidophilus,
L.  rhamnosus, B.  Longum, and S. boulardii, when used
as an adjunct to participants’ mechanical oral hygiene
procedures, provided a better clinical improvement
compared with placebo over a period of 14 days. Parallel
to the clinical improvements, plaque and gingival index
scores also showed significant improvements in the test
participants. The outcome of the study revealed significant
reductions in plaque and gingival index in the test group
at 14 days. A statistically significant reduction in the mean
plaque score for the test group was found on the 14th day
when compared to baseline.
In our study, the choice of the probiotic used was based
on the constituent bacteria present in the product, and
its beneficial effect on the gingival tissues. Among the
various selection criteria for probiotic, adhesion of the
beneficial bacterium to the tooth surface was considered
of primary importance that further favored the expression
of probiotic activity. Various studies have been done
in the past to assess the adhesion by measuring the
attachment of bacteria to saliva‑coated hydroxyapatite
and oral epithelium and these studies have revealed
that among probiotics strains L. rhamnosus GG
exhibited the highest values of adhesion, comparable
to those of the early tooth colonizer Streptococcus
sanguinis.[8] Some probiotic bacteria were also found
Table 1: Intergroup comparison of mean palque score
from baseline to 14 days
Mean plaque difference N Mean Standard deviation P with scaled and root‑planed pockets alone (30% vs.
(Baseline‑14 days)
Group 1 15 ‑0.14 0.4 0.000*
Group 2 15 0.42 0.3
*Statistically Significant. Independent t‑test
Table 2: Intergroup comparison of mean gingival score
from baseline to 14 days
Mean gingival difference N Mean Standard deviation P
baseline ‑14 days
Group 1 15 ‑0.09 0.32 0.000*
Group 2 15 0.38 0.21
*Statistically Significant. Independent t‑test
Journal of the International Clinical Dental Research Organization | Volume 9 | Issue 1 | January-June 2017
to have immunostimulatory activity on oral epithelial
tissues. Studies in the gastrointestinal tract have
revealed that active and heat inactivated L. acidophilus
PZ, induced remarkable expressions of human
β‑defensin (hBD‑2) in Caco‑2 cells. In the oral cavity,
hBD‑2 is expressed in oral epithelium in normal
uninflamed gingival tissue presumably because of the
high level of exposure to commensal microorganisms.
Studies have also revealed positive affect and reduction
in periodontal inflammation by the administration of two
probiotic tablet forms Bifidumbacterina and Acilact b
available on the Russian market.[9]
The data in our study compare favorably with that from
the study performed by Shimauchi et al. 2008 reporting
statistically significant decreases in gingivitis index and
plaque index when compared with baseline values when
probiotics were used.[10] In contrast, the study by Staab
et al. 2009 showed a statistically significant increase
in gingivitis index when compared with baseline
values.[11] Further, various studies done in the past such
as one study by Cildir et al. 2009 have also reported
a significant decrease in bleeding upon probing when
compared with baseline values on probiotic use.[12]
Given the above‑discussed background, one of the
shortcomings of this study may be the short period
for which the effect of probiotics administration was
assessed. Studies done in the past have supported the fact
that to be able to have probiotic effects in the mouth, a
bacterium must adhere to oral surfaces and become part
of the biofilm.[9] The results of one such study done for
14 days revealed that L. rhamnosus (bacterium forming
one of the constituents in the probiotic used in the
present study) might not easily colonize the oral cavity.[3]
In this light, it may be considered that for a probiotic
to effect a shift away from periodontopathogens would
require its continuous administration. A remarkable
study performed by Teughels et al. (2011) on Beagle
dogs reported a statistically significant lower bleeding
upon probing for pockets that received multiple
applications of probiotics for 12 weeks when compared
45%, respectively). In this study, no oral hygiene was
provided to the dogs.[13]
As the use of probiotic mouth rinse for 2 weeks showed
a significant improvement of plaque and gingival
status, it seems plausible that prolonged administration
of probiotic preparations may have a preventive role
against development of plaque and gingivitis.
Conclusion
The present study aimed to evaluate the effects of
prolonged administration (2 weeks) of probiotics on
43
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Jindal, et al.: Probiotic mouthwash and gingivitis
periodontal health. The results showed a significant
improvement of plaque and gingival status in patients.
Thus, although the question of selection of probiotic
strains, the exact molecular mechanisms of their action,
dosage of probiotic administration for each indication
and the applied methodology of the studies needs to be
addressed, results from present study and a few done
in past have shown that probiotics could be effective
in improving periodontal health by manipulating the
periodontal microbiota.
Financial support and sponsorship
The probiotic sachets (Darolac) used in the study were
provided by Aristo pharmaceuticals.
Conflicts of interest
There are no conflicts of interest.
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