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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 11  |  Issue : 2  |  Page : 136-145

To evaluate the effect of probiotics on the prevalence of oral Candida organisms in denture wearers: An in vivo study


1 Department of Prosthodontics and Crown and Bridge, Kahe's KLE V. K. Institute of Dental Sciences, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
2 Department of Microbiology, Kahe's JNMC, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India

Date of Web Publication18-May-2018

Correspondence Address:
Dr. Deepali Jagadeesh Rane
Department of Prosthodontics and Crown and Bridge, Kahe's KLE V. K. Institute of Dental Sciences, KLE Academy of Higher Education and Research, Nehru Nagar, Belagavi - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_240_17

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  Abstract 


STATEMENT OF PROBLEM: Candida species are the major human fungal pathogens that cause both mucosal and deep-tissue infections. Fungal infections have been successfully treated by systemic antifungal agents for a very long time. The toxicity of available antifungals and resistance to these drugs are a concern; thus, the use of probiotics has emerged as an alternative therapeutic technique for treating Candida infections.
PURPOSE: The purpose of this study was to evaluate the effect of probiotics on the prevalence of oral Candida organisms in denture wearers with different age groups.
MATERIALS AND METHODS: Sixty completely edentulous denture wearers were divided into three groups: 50–59 years (Group A), 60–69 years (Group B), and 70 years and above (Group C). The sample collected from the denture surface and palatal mucosa pre- and postprobiotic usage were subjected to CHROMagar followed by Germ tube test and then Corn meal agar for identification and counting the number of Candida colonies. The attributed scores were tabulated and submitted for statistical analysis using Kruskal–Wallis ANOVA test, Mann–Whitney U-test, Wilcoxon matched pairs test, and paired t-test.
RESULTS: Reduction in the number of Candida colonies was statistically significant in Group A and Group B on the denture surface as compared to that of Group C. However, there was no significant difference observed in all the three groups in the number of Candida colonies on the palatal mucosa.
CONCLUSION: The study shows that multispecies probiotic product may represent as an alternative treatment for reduction of Candida infections in the oral cavity of elderly denture wearers.

Keywords: Candida albicans, Candida glabrata, Candida tropicalis, denture surface, palatal mucosa, probiotic


How to cite this article:
Rane DJ, Nayakar R, Harakuni S, Patil R. To evaluate the effect of probiotics on the prevalence of oral Candida organisms in denture wearers: An in vivo study. Indian J Health Sci Biomed Res 2018;11:136-45

How to cite this URL:
Rane DJ, Nayakar R, Harakuni S, Patil R. To evaluate the effect of probiotics on the prevalence of oral Candida organisms in denture wearers: An in vivo study. Indian J Health Sci Biomed Res [serial online] 2018 [cited 2018 Sep 22];11:136-45. Available from: http://www.ijournalhs.org/text.asp?2018/11/2/136/232687




  Introduction Top


Candida is a normal commensal organism in the oral cavity of healthy people. Candida can adhere to the mucosal surfaces as well as to the prosthetic materials.[1] Poor oral hygiene and ill-adapted dentures facilitate the adhesion and penetration of the yeast resulting in increased permeability of the epithelium to toxins produced by Candida.[1],[2]

Elderly people are vulnerable to candidiasis which is provoked by chronic diseases, medication, poor oral hygiene, reduced salivary flow, impairment of the immune system, and breakdown of the ability of natural suppression of yeast.[3],[4]

In clinical practice, the diagnosis of Candida infection is a problem leading to therapeutic errors, indiscriminate use of antifungal drugs, and consequent resistance to antimicrobial agents. Therefore, it is desirable to promote health by natural or alternative therapies, such as by using probiotics.[2],[4] Probiotics are available in medicinal preparations as mouth rinses, tablets, capsules, powder, and lozenges or in the form of functional foods in the form of culture concentrations added to beverages such as juices, inoculated in prebiotic fibers, dairy products such as yogurt and fermented milk, and fermented nondairy products such as kimchi and kombucha.[5] The dietary probiotics do not show tolerance to both low pH and bile salts. Low pH decreases their survival because of the changes in the cytoplasmic pH. The commercially available probiotics, in the form of tablets or capsules, are used as pharmaceutical vehicle which not only survive and contain bacteria and protect them from the external environment, but also multiply, at least temporarily, and improve their adaptive capacity to adverse conditions within the body. This is the reason for the need of commercial probiotics over probiotics available in functional food forms.[6] The mechanisms of probiotics against oral Candida organisms involve a combination of factors, such as competition for adhesion sites and nutrients, production of antimicrobial compounds, production of hydrogen peroxide and antifungal peptides, stimulation of cytokine production, induction of IgA secretion, and modulation of innate and adaptive immune responses.[2] The ability of probiotics to fight infections supersedes that of antibiotics as they are a healthier alternative to the latter. They act as prophylactic as well as adjunctive therapy against candidiasis.[5],[7] Thus, considering the significance of the use of natural supplements in the management of oral Candida, this study was undertaken to investigate the effect of probiotics on the prevalence of oral Candida in denture wearers.


  Materials and Methods Top


Source of data

This in vivo study was conducted on complete denture patients between the age group of 50 years and above. Written informed consent of all the study participants in their own language was obtained. This study evaluated the effect of probiotics on the prevalence of oral Candida organisms in denture wearers.

Method of collection of data

Sample size

Sixty healthy completely edentulous individuals wearing dentures for at least 1 year and having no medical history were randomly selected for the study. The participants were divided into three groups according to their age as follows:

  • Group A consisted of twenty denture wearers in the age group of 50–59 years
  • Group B consisted of twenty denture wearers in the age group of 60–69 years
  • Group C consisted of twenty denture wearers in the age group of 70 years and above.


Inclusion criteria

Complete denture wearers without a history of any systemic conditions, a history of denture wearing at least since the past 1 year, and all patients should be ambulatory and healthy.

Exclusion criteria

Patients with underlying systemic conditions, use of any systemic medications, use of antifungal agents and/or use of mouth rinses, history of consumption of commercially available probiotics, and an inability to perform/understand the experimental procedures were excluded from the study.

Methodology

The study was conducted on completely edentulous patients wearing dentures at least since the past 1 year. These old denture wearers were divided into three groups as follows:

  • Group A – Twenty individuals between 50 and 59 years of age
  • Group B – Twenty individuals between 60 and 69 years of age
  • Group C – Twenty individuals aged 70 years and above.


Samples were collected by passing sterile cotton swabs across the palatal mucosa and tissue fitting palatal surface of maxillary denture of each test individual [Figures 1 - 3]. They were then placed in the plugged test tubes and sent to the laboratory for plating within 4 h [Figures 4a and b].
Figure 1: Materials used in the study

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Figure 2: Sample collection from the denture surface

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Figure 3: Sample collection from the palatal mucosa

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Figure 4: (a) Swabs transported to the laboratory (swab from the denture surface). (b) Swabs transported to the laboratory (swab from the palatal mucosa)

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Identification of Candida using CHROMagar

The swab was gently rolled over the surface of CHROMagar plate along its diameter. A sterile inoculation loop was used to spread the sample over the surface to get a lawn culture, [Table 1] and [Table 2]. Plates were then incubated in biological oxygen demand (BOD) at 25°C ± 2°C for 24 h [Figure 5].[8] For the identification of Candida colonies, the inoculated agar plates had been divided into two parts as denture surface and palatal mucosa. After which, the number of colonies was scored as colonies forming per unit (colony-forming unit [CFU]), and the color identification of different Candida organisms such as Candida albicans, Candida tropicalis, and Candida glabrata was done on CHROMagar plates. CHROMagar is a special medium that yields microbial colonies of varying pigmentation, which is due to the chromogenic substrates that react with the enzymes secreted by the Candida species. Speciation of Candida was done by the color that was exhibited by each species on CHROMagar plate.[9] The light green colonies were suspected of C. albicans [Figure 6] and [Figure 7], metallic blue colonies with or without halo suggested of C. tropicalis [Figure 8] and [Figure 9], and white-to-light pink colonies suggested of C. glabrata [Figure 10] and 11].[8],[10] Presumptive identification was made by color and morphology of the colonies as per the manufacturer's instructions. These isolates were also further identified on the basis of Germ tube test as this test helped in differentiation between C. albicans and non-C. albicans species.[8] Germ tube test was used as a rapid test for presumptive identification of C. albicans.[11]
Table 1: Materials used in the study

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Table 2: Armamentarium used in the study

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Figure 5: Incubator used for the incubation of agar plates

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Figure 6: Identification of Candida albicans (light green colonies) on the denture surface and palatal mucosa using CHROMagar (preusage of probiotics)

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Figure 7: Identification of Candida albicans (light green colonies) on the denture surface and palatal mucosa using CHROMagar (postusage of probiotics)

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Figure 8: Identification of Candida tropicalis (metallic blue colonies) on the denture surface and palatal mucosa using CHROMagar (preusage of probiotics)

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Figure 9: Identification of Candida tropicalis (metallic blue colonies) on the denture surface and palatal mucosa using CHROMagar (postusage of probiotics)

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Figure 10: Identification of Candida glabrata (white-to-light pink colonies) on the denture surface and palatal mucosa using CHROMagar (preusage of probiotics)

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Figure 11: Identification of Candida glabrata (white-to-light pink colonies) on the denture surface and palatal mucosa using CHROMagar (postusage of probiotics)

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Identification of Candida using Germ tube test

A small portion of the isolated colony of the yeast was suspended in a Kahn tube containing 0.5 ml of human pooled serum [Figure 12]. The test tube was then incubated at 37°C for 2 h. A drop of yeast–serum suspension was placed on a microscopic slide, overlaid with a cover slip, and was examined under the microscope [Figure 13]. The germ tubes were seen as filamentous extensions from the yeast cell that were about half the width and three to four times the length of the cell, with no constriction at the point of origin suggestive of C. albicans [Figure 14]. These isolates then further underwent identification on the basis of microscopic morphological features of the growth of Candida species that were obtained on Corn meal agar.[11]
Figure 12: Identification of Candida albicans using Germ tube test (performing Germ tube test)

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Figure 13: Identification of Candida albicans using Germ tube test (compound microscope)

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Figure 14: Identification of Candida albicans using Germ tube test (microscopic view showing germ tubes)

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Identification of Candida using Corn meal agar

Pure distinctive colonies obtained from CHROMagar plates were inoculated on Corn meal agar on an area of about 1 cm × 1 cm which was covered by placing sterile coverslip over it [Figure 15]. The plate was then incubated at 25°C in BOD for 24–48 h. Finally, all the yeast isolates were subjected to identification for the development of different phenotypic colonies with the aid of a compound microscope.[11]C. albicans showed chlamydospores that appear as terminal double-walled spheres on the pseudohyphae [Figure 16], C. tropicalis showed long pseudohyphae and blastoconidia all along the hyphae [Figure 17], whereas C. glabrata showed only yeast cells with no hyphae [Figure 18].[11]
Figure 15: Identification of Candida colonies using Corn meal agar

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Figure 16: Identification of Candida albicans using Corn meal agar

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Figure 17: Identification of Candida tropicalis using Corn meal agar

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Figure 18: Identification of Candida glabrata using Corn meal agar

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These old denture wearers in all the three age groups were then subjected to probiotic usage.

Probiotic usage

They were instructed to pour the capsule contents of probiotic (Probiotic immune, Zenith nutrition) in the palatal region of the cleaned maxillary denture and to use the denture in close contact with the mucosa of the palate. Test individuals were then asked to use the probiotic once daily for 5 weeks. Follow-up of the patient was done after 5 weeks. To study the colonization, sample collection and microbiological procedures in the participants in all the three age groups were carried out in a similar manner as explained earlier. The resultant colonies were counted and tabulated among the three test groups which formed the basic data for the study. The resultant data were then subjected to statistical analysis to draw a conclusion from the experimental data.


  Results Top


The resultant values of pre- and postusage of probiotics on the denture surface and palatal mucosa of Group A, Group B, and Group C were subjected to statistical analysis to draw a conclusion from the experimental data. Descriptive statistical measures such as mean and standard deviation were computed for all the study groups. In order to collectively compare the means of the study groups, Kruskal–Wallis ANOVA test was used (P < 0.05), pair-wise comparison of the test group was done using Mann–Whitney U-test, comparison in between the pre- and postusage of probiotics in the three groups was done using Wilcoxon matched pairs test, and comparison of the incidence of multispecies Candida on pre- and postusage of probiotics was done using paired t-test.

The mean, standard deviation, and coefficient of variation were calculated for the number of Candida colonies on pre- and postusage of probiotics on the denture surface in each of the three groups [Table 3] and [Graph 1]. The mean value of the change in the number of Candida colonies between the pre- and postusage of probiotics on the denture surface in Group A was 76.90 CFU (±222.83), higher than that of Group B which was 38.35 CFU (±66.47), and that of Group C which was 46.65 CFU (±216.61).
Table 3: Comparison of three groups (A, B, and C) with respect to pre- and postusage of probiotics on the denture surface by Kruskal–Wallis ANOVA test

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Kruskal–Wallis ANOVA test for significance (P < 0.005) of the three groups indicated that there was a significant difference in the number of colonies in the postusage of probiotics on the denture surface (P < 0.005) as compared to preusage of probiotics on the denture surface (H = 10.6120, P = 0.0050*) [Table 3].

Pair-wise comparison of three Groups (A, B, and C) with respect to pre- and postusage of probiotics on the denture surface using Mann–Whitney U-test [Table 4] shows that there were statistically significant differences in the number of colonies postusage of probiotics among the Group A and Group B (P = 0.0315*) and among Group A and Group C (P = 0.0133*), whereas there was no statistically significant difference among Group B and Group C (P = 0.5518).
Table 4: Pair-wise comparison of three groups (A, B, and C) with respect to pre- and postusage of probiotics on the denture surface by Mann–Whitney U-test

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On comparison between the pre- and postusage of probiotics on the denture surface in between the three groups using Wilcoxon matched pairs test [Table 5], statistically significant differences were found in the number of colonies in Group A (P = 0.0166*) and Group B (P = 0.0303*), but not in Group C (P = 0.6496).
Table 5: Comparison of pre- and postusage of probiotics on the denture surface in three groups (A, B, and C) by Wilcoxon matched pairs test

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The mean, standard deviation, and coefficient of variation were calculated for the number of colonies of Candida on pre- and postusage of probiotics on the palatal mucosa in each of the three groups [Table 6] and [Graph 2]. The mean value of the change in the number of Candida colonies between the pre- and postusage of probiotics on the palatal mucosa in Group A was 2.00 CFU (±46.18), higher than that of Group B which was –5.50 CFU (±43.81) and that of Group C which was 2.05 CFU (±16.25).
Table 6: Comparison of three groups (A, B, and C) with respect to pre- and postusage on the palatal mucosa by Kruskal–Wallis ANOVA test

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Kruskal–Wallis ANOVA test for significance (P < 0.005) of the three groups indicated that there was no statistically significant difference in the number of colonies in the postusage of probiotic on the palatal mucosa (P < 0.005) as compared to preusage of probiotic on the palatal mucosa (H = 2.3220, P = 0.3130) [Table 6].

On pair-wise comparison of three Groups (A, B, and C) with respect to pre- and postusage of probiotics on the palatal mucosa by Mann–Whitney U-test [Table 7], there were no statistically significant differences in the number of colonies among the three groups.
Table 7: Pair-wise comparison of three groups (A, B, and C) with respect to pre- and postusage of probiotics on the palatal mucosa by Mann–Whitney U-test

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On comparison between the pre- and postusage of probiotics on the palatal mucosa in between the three groups using Wilcoxon matched pairs test [Table 8], there were no statistically significant differences that were found in the number of colonies among the three groups. Paired t-test showed a statistically significant change in the number of colonies of C. albicans on the denture surface pre- and postusage of probiotics (P = 0.0277) as compared to C. tropicalis, C. glabrata, and other Candida species on both the denture surface and palatal mucosa [Table 9].
Table 8: Comparison of pre- and postusage of probiotics scores in three groups (A, B, and C) on palatal mucosa by Wilcoxon matched pairs test

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Table 9: Comparison of the incidence of multispecies Candida on pre- and postusage of probiotics on the denture surface and palatal mucosa using paired t-test

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The results of the study indicated that the prevalence of Candida species was statistically significant in both Group A and Group B on the denture surface as compared to Group C. The results also revealed that there was statistically significant difference in the number of colonies postprobiotic usage on the denture surface among Group A and Group B and among Group A and Group C.

The mean reduction in the number of Candida colonies postusage of probiotics on the denture surface in Group A (CFU: 76.90) was higher than Group B (CFU: 38.35) and Group C (CFU: 46.65).

It means that there were statistically significant differences in the number of colonies on the denture surface pre- and postprobiotic usage among Group A and Group B (P = 0.0315*) and among Group A and Group C (P = 0.0133*), whereas there was no statistically significant difference among Group B and Group C (P = 0.5518).

[Table 5] shows statistically significant differences in the number of colonies on the denture surface in Group A (P = 0.0166) and Group B (P = 0.0303) as compared to Group C (P = 0.6496) pre- and postprobiotic usage.

The mean reduction in the number of Candida colonies postusage of probiotics on the palatal mucosa in Group C (CFU: 2.05) was higher than Group A (CFU: 2.00) and Group B (CFU: −5.50).

[Table 7] shows that there was no statistically significant difference in the number of colonies on the palatal mucosa with respect to pre- and postprobiotic usage among the three groups (A, B, and C).

[Table 8] shows that there were no statistically significant differences in the number of colonies on the palatal mucosa in the three groups (A, B, and C) pre- and postprobiotic usage.

[Table 9] shows statistically significant change in the number of colonies of C. albicans (P = 0.0277) on the denture surface pre- and postusage of probiotics (P < 0.05) as compared to C. tropicalis, C. glabrata, and other Candida species on both the denture surface and palatal mucosa.


  Discussion Top


The results of the present study revealed that all the three groups (A, B, and C) showed that the mean reduction in the number of colonies on the denture surface after probiotic usage ranged between 76.90 and 38.35 CFUs. Group A showed the highest reduction in the number of Candida colonies on the denture surface after using probiotics followed by Group C and the least change is seen in Group B. Upon intragroup comparison, it was seen that there was statistically significant difference in the reduction of Candida colonization on the denture surface in both Group A and Group B but not in Group C. The statistically significant differences were also found in the number of colonies postusage of probiotics among Group A and Group B and among Group A and Group C, whereas there was no statistically significant difference found among Group B and Group C.

In case of the palatal mucosa, the mean reduction in the number of colony count after probiotic usage ranged from 2.05 to − 5.50 CFU. Group A showed the highest reduction in the number of Candida colonies on the palatal mucosa after using probiotics followed by Group B and the least change is seen in Group C. There was neither statistically significant difference seen in the reduction of Candida colonization on the palatal mucosa nor any statistically significant difference among the three groups.

In this present study, mean reduction in the number of colonies in Group C after probiotic usage was not statistically significant which may be because of hampered cleansing ability due to advanced old age, not properly following the instructions of probiotic capsule application, or not interested in maintaining proper oral hygiene. These findings were in accordance with a study by Lockhart et al., which suggested that the frequency and intensity of Candida colonization increase with increasing age in the elderly and reduction in salivary flow, which may be some of the additional reasons for not so marked reduction in the number of Candida colonies as the age advances.[3]

The results related to the increase in the number of colonies observed on the palatal mucosa in Group B which is probably due to poor oral hygiene maintenance, roughness of the prosthesis, drug intake which was not mentioned, or not following the instructions of probiotic application, which could have affected the results. These findings are in accordance with the reasons which have been cited by Ishikawa et al. in their randomized placebo-controlled trial.[2],[12],[13],[14]

Results indicate that the denture surface showed more reduction in the number of Candida colonies after probiotic usage as compared to palatal mucosa which may be because the direct application of probiotic product was done on the denture surface. These findings were in contrary to the findings reported by Pattanaik et al. in their systematic review.[15]

The present study showed that C. albicans was the most prevalent species in the oral cavity of elderly complete denture wearers. It also suggested that the decrease in the number of colonies after probiotic usage was observed more with C. albicans as compared to other Candida species. Several multispecies were isolated such as C. tropicalis, C. glabrata, Candida krusei, Candida parapsilosis, and Candida kefyr. These findings were in accordance with the studies conducted by Sumitra Devi and Maheshwari, Lockhart et al., Kraft-Bodi et al., and Hatakka et al.[3],[4],[10],[16]

This study demonstrated that locally administered probiotic capsules reduce the prevalence of Candida present in elderly edentulous complete denture patients. This was in accordance with the previous studies by Ishikawa et al., Ujaoney et al., Hatakka et al., Kraft-Bodi et al., and Stamatova and Meurman.[2],[4],[16],[17],[18]

Based on the above findings, this study showed that the tested probiotic product may represent an alternative method to reduce Candida colonization, thus preventing Candida infections.[2]


  Conclusion Top


Within the limitations of this in vivo study, the following conclusions were drawn. The probiotic was more efficient in reduction of the number of Candida colonies in the age groups of 50–59 years and 60–69 years as compared to 70 years and above. The probiotic product was effective in reducing the colonization of the oral cavity with Candida in elderly denture wearers. Our study shows that the use of a multispecies probiotic product may represent an alternative treatment for reduction of Candida infections in elderly denture wearers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Salerno C, Pascale M, Contaldo M, Esposito V, Busciolano M, Milillo L, et al. Candida-associated denture stomatitis. Med Oral Patol Oral Cir Bucal 2011;16:e139-43.  Back to cited text no. 1
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2.
Ishikawa KH, Mayer MP, Miyazima TY, Matsubara VH, Silva EG, Paula CR, et al. A multispecies probiotic reduces oral Candida colonization in denture wearers. J Prosthodont 2015;24:194-9.  Back to cited text no. 2
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Lockhart SR, Joly S, Vargas K, Swails-Wenger J, Enger L, Soll DR, et al. Natural defenses against Candida colonization breakdown in the oral cavities of the elderly. J Dent Res 1999;78:857-68.  Back to cited text no. 3
    
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Hatakka K, Ahola AJ, Yli-Knuuttila H. Probiotics reduce the prevalence of oral Candida in the elderly – A randomized controlled trial. J Dent Res 2007;86:125-30.  Back to cited text no. 4
    
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Menon A. Implications of probiotics on oral health: Past-to-present. J Dent Res Rev 2016;3:36-41.  Back to cited text no. 5
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Fuochi V, Petronio GP, Lissandrello E, Furneri PM. Evaluation of resistance to low pH and bile salts of human lactobacillus spp. Isolates. Int J Immunopathol Pharmacol 2015;28:426-33.  Back to cited text no. 6
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Matsubara VH, Bandara HM, Mayer MP, Samaranayake LP. Probiotics as antifungals in mucosal candidiasis. Clin Infect Dis 2016;62:1143-53.  Back to cited text no. 7
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Kumar S. Application of CHROMagar candida for identification of clinically important Candida species and their antifungal susceptibility pattern. Int J Biol Med Res 2013;4:3600-06.  Back to cited text no. 8
    
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Nayak S, Kavitha B, Sriram G, Saraswathi TR, Sivapathasundharam B, Dorothy AL, et al. Comparative study of Candida by conventional and CHROMagar method in non-denture and denture wearers by oral rinse technique. Indian J Dent Res 2012;23:490-7.  Back to cited text no. 9
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Sumitra Devi L, Maheshwari M. Speciation of Candida species isolated from clinical specimens by using chromagar and conventional methods. Int J Sci Res Publ 2014;4:2250-3153.  Back to cited text no. 10
    
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Agarwal S, Manchanda V, Verma N, Bhalla P. Yeast identification in routine clinical microbiology laboratory and its clinical relevance. Indian J Med Microbiol 2011;29:172-7.  Back to cited text no. 11
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Sutula J, Coulthwaite L, Thomas L, Verran J. The effect of a commercial probiotic drink on oral microbiota in healthy complete denture wearers. Microb Ecol Health Dis 2012;23:1-10.  Back to cited text no. 12
    
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Rathee M, Hooda A, Ghalaut P. Denture hygiene in geriatric persons. Internet J Geriatr Gerontol 2009;6:1-5.  Back to cited text no. 13
    
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Webb BC, Thomas CJ, Willcox MD, Harty DW, Knox KW. Candida-associated denture stomatitis. Aetiology and management: A review. Part 2. Oral diseases caused by Candida species. Aust Dent J 1998;43:160-6.  Back to cited text no. 14
    
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Pattanaik S, Vikas BV, Pattanaik B, Sahu S, Lodam S. Denture stomatitis: A literature review. J Indian Acad Oral Med Radiol 2010;22:136-40.  Back to cited text no. 15
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Kraft-Bodi E, Jørgensen MR, Keller MK, Kragelund C, Twetman S. Effect of probiotic bacteria on oral Candida in frail elderly. J Dent Res 2015;94:181S-6S.  Back to cited text no. 16
    
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Ujaoney S, Chandra J, Faddoul F, Chane M, Wang J, Taifour L, et al. In vitro effect of over-the-counter probiotics on the ability of Candida albicans to form biofilm on denture strips. J Dent Hyg 2014;88:183-9.  Back to cited text no. 17
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Stamatova I, Meurman JH. Probiotics: Health benefits in the mouth. Am J Dent 2009;22:329-38.  Back to cited text no. 18
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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