Being a dental hygienist, the topic of biofilm is extremely interesting to me. Maybe more interesting then I care to admit! Clinically, my role is to remove it and educate patients how to prevent its re-accumulation in order to prevent disease or disease progression.
But the truth is, even after removing 100% of biofilm, within approximately 20 minutes of treatment the early colonisers start to re-populate on the tooth surfaces. Eventually, the biofilm becomes established and the disease process starts again. For this reason, I call biofilm a nemesis, which is defined as something that is impossible to defeat. As soon as it is removed it starts the process of re-accumulation again. A cycle which never stops.
How to beat biofilm?
Beating biofilm is therefore not an easy feat. It’s a constant battle undertaken by the patient on a daily basis and by the hygienist at bespoke intervals set according to the patients’ clinical findings. Because of how biofilm accumulates and matures, to control it requires a multifaceted and teamwork approach between both clinician and patient.
To appreciate this concept, you must first understand the complex and highly intelligent nature of the biofilm itself.
Studies show that biofilm adapts to its environment and that oral biofilm is the most advanced biofilm in nature. This is because of the continuous stresses placed upon it. From saliva flow, to mastication, to the mechanical forces placed on it from brushing; the biofilm on tooth surfaces have to withstand these stresses to survive. It constantly adapts to its environment and in different sites may possess different characteristics based on the particular stress it is placed under.
To enable it to do so, it adheres to surfaces extremely well by creating and using a matrix of sticky extracellular polymeric substances (EPS). This matrix keeps the micro-organisms in close proximity and allows cohesive interactions to occur.
The matrix of oral biofilm protects the inhabiting micro-organisms from harm and disruption, including these brushing forces, but also antibacterial products, antibiotics and even host immune defences. Unless it is removed mechanically or disrupted it will remain, going on to cause gingivitis and the potential to cause caries and periodontal disease.
Mechanical Plaque Control
Emphasis is therefore placed on mechanical plaque control. This is and will always be, the best way to remove the biofilm physically. Electric toothbrushing and interdental cleaning daily is clinically proven to be the best management.
We should also always aim to create a dentition that has a low risk of biofilm accumulation by way of plaque retentive factors, as far as we possibly can. Removing restoration overhangs, choosing options that limit biofilm accumulation marginally, allow easy interproximal access and even suggesting the reduction of over-crowding and imbrication to make access easier for biofilm removal at home.
These steps are essential, but reducing biofilm should be a multifaceted approach, which includes its physical removal alongside adjuncts that aim to reduce the ability for it to reform a reliable matrix.
Polyols, such as erythritol and xylitol, can help to reduce biofilm metabolism and maturation, affecting the adhesion and cohesion within it. This may then help, alongside other modalities, in the fight to prevent periodontal deterioration as well as caries progression. This can be found in the form of sweeteners, or Dr Heff’s Mints, a supplement mint that can be bought specifically for biofilm control.
Guided Biofilm Therapy
Guided Biofilm Therapy (GBT) is a protocol created by EMS which uses a polyol called erythritol within its process, in order to manage and remove sub and supra-gingival biofilm. We achieve this by way of using Airflow and Perioflow as part of the treatment itself. This is a great tool to remove 100% of biofilm in the dental chair, allowing the hygienist to press the ‘reset’ button for the patient at regular recalls.
Another adjunct for patients which present with periodontitis, is creating an unfavourable environment in which the subgingival biofilm cannot flourish. Introducing oxygen into periodontal pocketing can prevent the ability for anaerobic bacterial growth. An example would be advising patients to use interproximal brushes with a mouthwash containing hydrogen peroxide, which allows oxygen bubbles to accumulate around the gingival margin and enter pockets as far as possible.
Similarly, chlorohexidine can be used in this way (with interdental brushes), to get the antibacterial effects to be of benefit around the gingival margin alongside a mechanical technique. This is best for short term use in biofilm control.
I am a huge fan of stannous. Specific toothpastes on the market contain a stabilised stannous complex which is proven to kill bacteria and prevent its metabolism, reducing its ability to create an effective matrix. This is good for long term use with good evidence supporting it.
Education is key
The main thing to note here though, is the most important factor of all- educating the patient. Using a waiting room TV service such as Envisage Dental TV is the ideal solution. It will help the patient understand the mechanics of their disease. Understanding their susceptibility is an important part of the behaviour change process. According to the Health Belief Model, if a patient doesn’t feel they are susceptible to disease they won’t make the necessary changes we advise. Understanding how biofilm accumulates and matures, how this subsequently leads to dental disease and appreciating that absolutely no one escapes this process, allows patients to make an informed choice about their biofilm control.
Biofilm management and control should therefore be carried out using a multifaceted approach, demonstrating teamwork between patient and clinician. Remember, it is a nemesis displaying a cycle which will never stop, making it impossible to defeat without this mindset.
