Authors:
Prof. Dr Ulrich P. Saxer Dr René B. A. Sanderink Dr Gail Steimer
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Caring for health of the oral-intestinal microbiome is key for oral health and health status in general. Even when the microbiome is struggling, it can be greatly improved through a series of lifestyle and oral care changes.
There is little doubt among scientists that modern life most often has detrimental effects on the eubiotic balance of the oral-intestinal microbiota. The oral-intestinal microbiota represents a virtual endocrine organ with the metabolic capacity to produce and regulate multiple compounds for reaching the circulation and thereby influencing the function of distal organs and systems. In the long run, a dysbiotic microbiota disturbs the immune system, increasing the risk of non-communicable diseases (NCDs).
Microbiota or microbiome?
While the terms microbiota and microbiome are often used interchangeably, they have distinct meanings. Microbiota refers to a collection of microorganisms – including bacteria, fungi and viruses. Microbiome encompasses not only the organisms (microbiota), but also their genetic material, metabolic products, and interactions with the host and each other.
These lifestyle-associated non-communicable diseases (NCDs) include cardiometabolic, neurodegenerative, autoimmune, and malignant diseases as well as other inflammation-related disorders such as obesity, insulin resistance, allergies, and also oral biofilm infections – in particular caries, periodontitis, and peri-implantitis. Many of these diseases have been linked to pathobiontic organisms of the oral microbiota, such as Porphyromonas gingivalis, Fusobacterium nucleatum, and Treponema denticola.
Various authors have shown that dietary preference is the primary influencer of the microbiome and the nervous system which reciprocally plays a paramount role – as illustrated in the image below from the book Oral Preventive Medicine, (Sanderink et al. 2022 Fig 1) [10].
A clear link also exists between tooth loss and life expectancy, as shown by Friedman & Lamster in 2016 [4] – illustrating higher death rates in patients with severe periodontal disease. Predictably, solid ties have been shown to exist between periodontal disease, heart and metabolic diseases, including other non-communicable diseases (NCDs).
Unfortunately, despite the overwhelming evidence, progress in adopting and applying microbiota-based approaches in clinical medicine – referred to as therapeutic microbiology – has been underappreciated. Accordingly, considering the central role of orointestinal microbial endocrine organ in human disease, future medicine must target gut microbes for prevention and to eventually pave new ways to implement cardio-vascular disease (CVDs) drugs.
As dental professionals who grew up in Post-WWII-Switzerland, we benefited from advantageous training in a progressive dental atmosphere featuring pioneers in preventive dentistry, namely Mühlemann, König and Marthaler – who in the early 1960s introduced successful preventive concepts for caries and periodontitis, thereby establishing effective treatment strategies while strengthening our conviction regarding the importance of health and the principles of prevention (Beikler et al. 2004) [3]. We are therefore strongly convinced that the orointestinal microbiome – within the framework of the immune system and synergistic with the enteric nervous system – embodies crucial interfaces for general health.
Establishing programs for the prevention of oral diseases plays a key role in overall success. Mothers as trainees were educated on implementing prevention protocols in school classes. The training was focused on teaching children how to clean their teeth properly, the use of fluoride products, and health-providing nutritional aspects – especially through limiting general sugar consumption.
This approach reduced tooth decay in young people by over 95%, and also had proven positive through impacting adults as well. The principles outlined by these researchers were proven safe and effective in countless follow-up studies – clearly demonstrating that the combination of restoring microbial homeostasis through easy-to-follow recommendations and thorough oral hygiene significantly contribute to a reduction in oral diseases. Based on these observations, teaching programs in schools today should be reevaluated to include more of the lifestyle factors mentioned.
As periodontists who have collaborated for many years with dental hygienists trained in Switzerland, we have repeatedly observed an interesting experience in our professional practice. After successful periodontitis treatment, patients with a wide range of non-communicable diseases (NCDs) often showed improvements in their general health status and a reduction in disease symptoms despite having an underlying dysbiotic condition. Such effects have only gradually become more widely understood since the 1990s. Thereafter, it became increasingly apparent – especially in medical literature – that oral keystone pathogens are definitely also involved in various diseases.
The fact that general health relies on a proper diet has been clearly shown by a Swiss television “Life as in the Stone Age” study. The study unquestionably revealed that within a 4-week period, participants who consumed only naturally derived nutrition and who did not practice any oral hygiene measures experienced a noticeable increase of plaque levels, but interestingly none of the subjects revealed an increase in gingivitis. On the contrary, there was a spontaneous decrease in the gingival inflammation average compared to the initial state – including a significant reduction in the presence of oral pathological keystone bacteria (view image below). It appears that the dysbiotic microbiome shifted to a eubiotic (homeostatic) state.
This leads us to the question: To what extent can coaching the microbiota – through guided modulation of lifestyle factors including nutrition and oral care changes – lead to its improvement and stabilization? Recent studies show that it is not only possible, but it is in fact very successful.
In Sweden, for example, researcher Malin Stensson and her team recommended that pregnant women take probiotics during the last month of pregnancy and continue giving probiotics to their newborns for the first year (Stensson & Koch, 2014) [14]. The results of this perinatal probiotic administration were impressive: children who received probiotics had over 50% fewer cavities and 40% less gum disease when examined ten years later (unmonitored) compared to a control group using a placebo. This shows that influencing the microbiota during pregnancy through easy therapeutic measures is possible and that it can lead to long-lasting health benefits for the-offspring.
Another example is the use of probiotics to replenish lost bacterial strains – specifically using Limosilactobacillus reuteri (LB). In a study involving Navy soldiers who were smokers, taking probiotic LB lozenges significantly reduced harmful bacteria and improved periodontal health – even though personal oral hygiene was lacking (Schlagenhauf, Jockel-Schneider et al. 2020) [12]. Ausenda et al. (2023) [1] found in a systematic revue paper that probiotics also positively affect non-surgical periodontal therapy (Martin-Cabezas et al. 2016) [6]. The longer the duration of probiotic administration was, the greater the improvement in periodontal attachment.
Optimal oral hygiene has long been known to multimodally benefit the oral-intestinal microbiota, immunity, and overall health. Oral keystone pathogens – in particularly Porphyromonas gingivalis – are often swallowed and carried to the intestine (Schmidt et al.2019) [15] – which leads to the activation of inflammatory cells and the translocation of harmful bacteria including virulence factors back into oral tissues via the bloodstream (Nagao et al. 2022) [8].
This process triggers inflammatory responses in distal organs and worsens periodontal inflammation, creating a vicious cycle. Thankfully, current hydrodynamic sonic toothbrushes are especially effective at eliminating harmful bacteria from the mouth, and therefore, from the oral-intestinal microbiome and even periodontal pockets compared to manual toothbrushes (Offenbacher et al. 2010 [9]; van der Sluijs et al. 2023) [16].
These clinical studies show that coaching the microbiome is possible and effective – even if people do not fully comply or have lapses in their routine. It is puzzling that the benefits and preventative approaches to oral diseases which also support general health and reduce healthcare costs are often neglected by health authorities. Addressing these issues with skill, empathy and expertise is a necessary step for the dentists of the future.
Prof. Dr Ulrich P. Saxer completed his studies in dentistry in Zurich, Switzerland, in 1967, and specialized in periodontology and oral prevention. He established several DH educational programs, was even the owner of a private DH School in Switzerland, gave over 100 lectures, and published as many scientific papers. He is also a scientific advisor for many companies creating oral health products, most recently with Curaden AG.
Dr René B. A. Sanderink studied in Nijmegen and Zurich, received his doctorate in Zurich under Prof. Mühlemann, and practiced in Switzerland and Germany. He is a senior oral immunology and microbiology lecturer at the University of Würzburg.
Dr Gail E. Steimer began her career by obtaining her R.D.H. from the Forsyth School for Dental Hygienists in 1969, followed by a bachelor’s degree from Columbia University’s School of Dental and Oral Surgery. After a decade of private dental hygiene practice in Zürich, she earned her DMD from the University of Zurich in 1987. She managed her own holistic dental practice in Zürich from 1988 to 2016 and continues to be involved in clinical duties and education.
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