|Year : 2020 | Volume
| Issue : 3 | Page : 111-116
Effect of probiotics on Candida in diabetic and nondiabetic complete denture wearers – An In vivo study
Bonda Rajasekhar1, Anil Kumar Gujjari1, Ranjitha Shankaregowda2, Karteek Durbakula3
1 Department of Prosthodontics and Crown and Bridge, JSS Dental College and Hospital, Mysore, Karnataka, India
2 Department of Microbiology, JSS Medical College and Hospital, Mysore, Karnataka, India
3 Department of Oral Pathology and Microbiology, Mamata Dental College, Khammam, Telengana, India
|Date of Submission||10-Jun-2020|
|Date of Acceptance||01-Oct-2020|
|Date of Web Publication||21-Dec-2020|
Dr. Karteek Durbakula
Department of Oral Pathology and Microbiology, Mamata Dental College, Khammam, Telengana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: To evaluate the effectiveness of probiotics on Candida albicans in diabetic and nondiabetic complete denture wearers. Study Design: Twenty complete denture wearers with dentures aging more than 6 months were selected randomly and divided into two groups (controlled diabetic and nondiabetic) based on their blood glucose levels and medical history. Materials and Methods: Probiotics were prescribed for all the subjects for the duration of 30 days. Microbial swab was collected from their dentures at 0, 15th, and 30th days and incubated in Sabouraud's dextrose agar broth. C. albicans colony-forming units (CFU/ml) were counted. Statistical Analysis: The candidial CFUs were compared using statistical analyses such as descriptive statistics, paired samples t-test, independent samples t-test, and repeated-measures ANOVA test and P < 0.05 was considered as statistically significant. Results: C. albicans count reduced in both the groups during the usage of probiotics, but the reduction was more in controlled diabetic subjects which showed statistically significant results. Conclusion: Probiotics can be used as an alternative therapy for the management of oral candidiasis in denture wearers particularly in controlled diabetic patients.
Keywords: Candida, denture, diabetes, glucose, probiotics
|How to cite this article:|
Rajasekhar B, Gujjari AK, Shankaregowda R, Durbakula K. Effect of probiotics on Candida in diabetic and nondiabetic complete denture wearers – An In vivo study. J Interdiscip Dentistry 2020;10:111-6
|How to cite this URL:|
Rajasekhar B, Gujjari AK, Shankaregowda R, Durbakula K. Effect of probiotics on Candida in diabetic and nondiabetic complete denture wearers – An In vivo study. J Interdiscip Dentistry [serial online] 2020 [cited 2021 Sep 18];10:111-6. Available from: https://www.jidonline.com/text.asp?2020/10/3/111/304156
| Clinical Relevance to Interdisciplinary Dentistry|| |
- Oral candidiasis is a common disease seen in diabetic denture wearers and use of antifungal medications leads to the development of antifungal resistance.
- Probiotics can be used as an alternative treatment modality for oral candidiasis in denture wearers with controlled diabetes, as it reduces the development of antifungal resistance and restores the balance in the oral microflora.
| Introduction|| |
Diabetes mellitus (DM) is one of the most prevalent diseases affecting 8.5% of adult population worldwide and more than 90% of them have oral health-related problems. Patients diagnosed with DM present multiple symptoms including higher susceptibility (66%–75%) to oral infections like candidiasis., In denture wearers, candidiasis is aggravated by the adhesion of Candida albicans to the tissue surface of the maxillary denture base, which serves as an effective reservoir for microorganisms.
Studies reveal that the colonization and carriage of C. albicans in the oral cavity was higher in diabetic denture wearers than in nondiabetic denture wearers., Probiotics are defined as microorganisms that promote benefits to host health, mainly by regulating resident microbiota. Disequilibrium in the normal flora can favor the growth of opportunist microorganisms and the development of pathologies, like candidiasis caused by yeasts of the Candida genus.
Recent developments in the treatment of oral candidiasis include the use of probiotic bacteria which are known to reduce the growth of pathogenic microbes. There is very sparse literature regarding the effects of probiotics on C. albicans in controlled diabetic denture wearers. Hence, this in vivo study was conducted to evaluate the effect of probiotics on C. albicans in controlled diabetic denture wearers and to compare the same with nondiabetic denture wearers.
| Materials and Methods|| |
The present study was conducted at the Department of Prosthodontics, Crown and Bridge, J. S. S. Dental College and Hospital, Mysore. The details of the study were explained to the complete denture wearers visiting the department. After recording the personal details including age, gender, and occupation, a detailed oral examination was done using clinical diagnostic instruments.
The inclusion criteria for the study were completely edentulous patients aged between 45 and 65 years, who are not under antibiotic or antifungal medication, who are using complete denture from the past 6 months and who are willing to participate in the study. The patients with uncontrolled diabetes and immunosuppressive disorders, who are using antibiotics or antifungal medications, with dentures aged <6-month duration, and who are not willing to participate were excluded from the study.
Forty individuals were chosen from the patients visiting the department for the study. Out of them, 20 individuals were selected using random sampling technique and written consent was obtained from each selected individual. Ethical clearance for the study was obtained from the Institutional Ethics Committee of J. S. S. Dental College and Hospital, Mysore (Ref: No: JSS/ACP/Ethical/2012–13).
All the 20 subjects were tested for HbA1c, fasting plasma glucose level, and postprandial plasma glucose level. Then, they were divided into two groups based on the blood glucose levels:
- Group A: Ten patients having normal blood glucose level with no history of diabetes
- Group B: Ten patients having normal blood glucose level with a history of diabetes and under medication.
The denture was gently washed under running water and microbial smear was taken with a sterile cotton swab by rolling gently over the palatal tissue surface of the maxillary complete denture [Figure 1]a. The swab was then placed in prelabeled sterile airtight test tube and taken for microbial evaluation within 1 h of collection. Subjects were instructed to start the regimen of probiotics, FLORA-SB (Discovery, Mankind Pharmaceuticals) for 30 days once daily. They were instructed to dispense probiotic powder into drinking water and drink the same solution. The subjects were instructed to use a denture brush to maintain the denture hygiene and not to use any form of chemical disinfectants to clean the denture. Subjects were recalled after 15 days and 30 days of regimen of probiotics for collection of second and third microbial smear, respectively [Table 1].
|Figure 1: (a) Collection of microbial swab. (b) Microbial swab in Sabouraud's dextrose agar broth|
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After the collection, the swab was placed in Sabouraud's dextrose agar broth using a biological loop and inoculated at 37°C for 24 h [Figure 1]b. Gram staining was done for the culture isolates and was observed under the microscope for any yeast isolate. Germ tube test was performed to confirm the presence of Candida. The change in the count of C. albicans colony-forming units (CFU/ml) was evaluated and compared in both the groups using different statistical tests such as descriptive statistics, paired samples t-test, independent samples t-test, and repeated-measures ANOVA test. All the statistical calculations were done using SPSS - Statistical Package for Social Sciences (IBM SPSS for Windows, Version 16.0, Chicago) and P< 0.05 was considered as statistically significant.
| Results|| |
C. albicans count (CFU/ml) reduced in both the groups during the usage of probiotics [Table 2]. In nondiabetic denture wearers (Group A), there is a decrease in mean CFU/ml of C. albicans before probiotic therapy at 0 day and after probiotic therapy at 15th by 22.39% and further reduced at 30th day by 21.89%. On the whole, the decrease in mean CFU/ml of C. albicans after probiotic therapy at 30th day is 39.34% [Figure 2].
|Table 2: Candida albicans count colony-forming units/ml in different subgroups (descriptive statistics)|
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|Figure 2: (a) Colony-forming units/ml of Candida albicans in Group-A at 0 day. (b) Colony-forming units/ml of Candida albicans in Group A at 15th day. (c) Colony-forming units/ml of Candida albicans in Group A at 30th day|
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In controlled diabetic denture wearers (Group B), there is a decrease in mean CFU/ml of C. albicans before probiotic therapy at 0 day and after probiotic therapy at 15th by 32.05% and further reduced at 30th day by 29.37%. On the whole, the decrease in mean CFU/ml of C. albicans after probiotic therapy at 30th day is 52.01% [Figure 3].
|Figure 3: (a) Colony-forming units/ml of Candida albicans in Group-B at 0 day. (b) Colony-forming units/ml of Candida albicans in Group B at 15th day. (c) Colony-forming units/ml of Candida albicans in Group B at 30th day|
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A comparison of the C. albicans count between the different subgroups of Group A using paired sample t-test showed nonsignificant statistical relationship [Table 3], while the same in different subgroups of Group B showed a statistically significant result [Table 3].
|Table 3: Comparison of mean colony-forming units/ml of Candida albicans within Group A and Group B (paired sample t-test)|
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A comparison of the C. albicans count between the different subgroups of Groups A and B was done using independent samples t-test which showed a statistical significant difference between all the subgroups [Table 4].
|Table 4: Comparison of mean colony-forming units/ml of Candida albicans between Group A and Group B at 0 day, 15th day, and 30th day (independent samples t-test)|
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A comparison of the C. albicans count between the subgroups of Group A using repeated-measures ANOVA test showed nonsignificant statistical relationship, while the same in subgroups of Group B showed a statistically significant difference. ANOVA comparison at three time durations among nondiabetic denture wearers and controlled diabetic denture wearers showed statistically significant results [Table 5].
|Table 5: Comparison at three time durations among different groups and subgroups (repeated-measures ANOVA)|
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| Discussion|| |
DM is a chronic metabolic disorder characterized by hyperglycemia, associated with irregularities in the metabolism of carbohydrates, lipids, and proteins. The prevalence of diabetes is found to be more among older adults. Diabetics have an increased predisposition to the manifestations of oral diseases like candidiasis, which may be explained due to increased glucose levels in oral fluids or immune dysregulation.
The research has shown that wearing of complete dentures promotes the growth of candidiasis by decreasing salivary flow, lowering pH levels under the denture, and serving as reservoirs in which C. albicans can thrive. Existence of intra-oral Candida species varies from 20% to 50% in healthy edentulous population and up to 75% in denture wearers. Usually, oral candidiasis is associated with a high density of yeasts in the lesions.
The rationale for increased Candida growth in diabetics could be due to the formation of chemically reversible glycosylation products. Plasma glucose reacts with proteins in the tissues and forms these products when the blood glucose level is high. It is possible that accumulation of such glycosylation products in epithelial cells may increase the number of available receptors for Candida on the surface of epithelial cells.
C. albicans is usually susceptible to most antifungals, but mechanical disruption of a biofilm prior to antifungal application may be required. An acquired problem is that long-term exposure to antifungal agents promotes acquired resistance. The documented levels of resistance in oral Candida are indeed on the rise. Antifungal resistance is based on different mechanisms, like reduced drug intracellular accumulation, decreased target affinity for the drug, and counteraction of the drug effect.
To address these shortcomings, an alternative therapy is necessary for controlling the incidence of oral candidiasis without the need for antimicrobials using products such as probiotics. Probiotics are bacterial cultures or living microorganisms which upon ingestion exert health benefits beyond inherent general nutrition. A large number of organisms are being used in clinical practice for a variety of purposes. The most widely used and thoroughly researched organisms were Lactobacillus species (Lactobacillus acidophilus, Lactobacillus rhamnosus, Lactobacillus bulgaricus, Lactobacillus reuteri, and Lactobacillus casei) Bifidobacterium species, and Saccharomyces boulardii, a nonpathogenic yeast. However, all probiotics do not have the same efficacy. A combination of strains can enhance adherence in a synergistic manner.
Recent research has elucidated the role and importance of the oral microflora in pathogenesis. With this in mind, investigators have proposed probiotics, specifically Lactobacilli, for maintaining and regaining oral health. In vivo, several mechanisms may be involved in a successful inhibition of pathogens which include probiotic inhibition of pathogenic molecules and exopolysaccharide secretion. These are responsible for dental plaque formation which allows for accelerated growth of opportunistic organisms. They also block the pathogen adhesion sites, modulate pH of the oral cavity, and create competition for the nutrients.
A number of reports confirmed experimentally and clinically that oxidative stress are involved in the pathogenesis and progression of DM as well as the subsequent complications. In diabetes, generation of oxygen-free radicals occurs due to nonenzymatic protein glycosylation, auto-oxidation of glucose, and impaired antioxidant defense enzymes. This impaired balance of oxidants/antioxidants may lead to cellular damages, development of insulin resistance, dysfunction in a variety of enzymes, occurrence of inflammation process, and lipid peroxidation.
Probiotic foods have been reported to repress the oxidative stress. L. acidophillus and L. casei attenuate oxidative stress and have antidiabetic effects. The antioxidative mechanisms of probiotics could be assigned to reactive oxygen species scavenging, metal ion chelation, pro-oxidant enzyme inhibition, reduction activity, and inhibition of ascorbate oxidation.
In the present study, probiotics given to the subjects consisted L. acidophilus, L. rhamnosus, Bifidobacterium longum, Bifidobacterium bifidum, Saccharomyces boulardii, and Fructo-oligosaccharide. The results of the present study demonstrated a statistically significant decrease of C. albicans count with the intake of probiotics by 52.1% in controlled diabetic denture wearers. In contrast, the C. albicans count in nondiabetic denture wearers was decreased by only 39.4%, which was not statistically significant.
The results of the present study are similar to a study conducted by Hatakka et al., in which they found that the use of cheese containing probiotics reduced the prevalence and risk of high yeast counts (>104 CFU/ml) by 32% and 75%, respectively. They also found that probiotics reduced the prevalence of hyposalivation by affecting the composition of saliva, such as the concentrations of mucins and salivary immunoglobulins.
The present study results also correlate with the study conducted by Dos Santos et al., wherein individuals presenting with Candida in the oral cavity used probiotic Yakult LB for 20 days and showed a significant reduction in Candida prevalence (46%) and mean Candida CFU/ml counts (65%). They concluded that this reduction may be due to competition between the yeasts rather than by specific immune response stimulation.
Ishikawa et al. conducted a study to evaluate the effects of multispecies probiotic powder on oral Candida colonization in denture wearers. Their study results showed that the multispecies probiotic powder reduced the oral candidial colonization and proposed their usage as an alternative treatment for oral candidiasis. These results correlate with the results of the present study which showed a decrease in Candida CFU.
Chhabra et al. conducted a study to evaluate the effect of denture adhesive with probiotics on CFU of Candida in completely edentulous patients. Their study results showed a decrease in the number of CFU of Candida after using denture adhesives with probiotics. These results correlate with the results of our study.
| Conclusion|| |
Oral Candidiasis is a common disease seen in the denture wearers. Probiotics can be used as an alternative therapy for the management of oral candidiasis in denture wearers, particularly in controlled diabetic patients, as it reduces the development of antifungal resistance and helps in maintaining the balance in the oral microflora.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]