Setting Site on Biofilm: Technologies and Techniques to Help Patients Eliminate Biofilm Buildup

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How do you describe biofilm construction to your patients?

I often compare it to building a house. I like to illustrate that the bacteria first on scene build the foundation, then the framers show up, followed by drywallers. Last to the work site are the painters who also happen to be the most virulent microbes.

This works well because the comparison describes the process, inspires “at home” biofilm disruption, and reinforces the need for regular professional dental hygiene care. I really like multipurpose analogies, please send me a new one that has worked well for you!

For quick reference, here is a review of the more scientifically accurate description of the life cycle of biofilm:

• The acquired pellicle attaches to a surface
• Microbes begin to arrive and colonize the area
• More plaque with microbes connect with one another (co-adhesion)
• Biofilm matures and alerts the immune system
• Biofilm detaches and launches into other areas of the mouth and body
• The immune system realizes it has work to do and begins to respond to the invasion with a myriad of fluid, cells, and techniques
• Biofilm is removed by a person with their homecare or via professional dental hygiene care
• Biofilm begins to reform immediately upon removal
  (Insert favorite curse word here).

What are we to do with this never-ending biofilm building process? It is like the dang laundry. It starts building up the moment it is done being removed. In college, I used to sit sans clothes for a few just so the laundry could be done for five stinking minutes. Because being naked won’t help reduce oral bacteria and isn’t appropriate to recommend to our patients, let’s jump into how we can help them mitigate this biofilm issue.

First, we must give them a clean slate at the office. This is our chance to do a stellar job with our awesome clinical skills. Recent research has shown that ultrasonic instrumentation removes fifty percent more biofilm than hand instrumentation alone. The crowd favorite response is, “That’s why we use the blended approach.” However, did you know that hand instruments remove 10 times more cementum than ultrasonic instrumentation? These two pieces of evidence have been the impetus for a complete reconstruction of my clinical routine.^1,2 Now, I do my very best to use ultrasonic instrumentation only. I hope you will give this a go too. The increased speed, decreased tax on the hygienist’s body, increased biofilm elimination, and decreased cementum removal is incredibly enjoyable and effective.

Gaining confidence to let go of my precious hand instruments and the “blended approach” most of us learned in school was difficult. However, as the evidence kept coming into my view, I felt I had no choice but to practice Maya Angelou’s advice, “Do the best you can with what you know. Then when you know better, do better.”

Here is the recipe I use to ensure an efficient and effective prophylaxis, scale and root plane service, or periodontal maintenance:

Choose the Correct Ultrasonic Tip for the Type and Volume of Deposit Present

Test your choice by tapping and swiping that tartar! If the calculus comes off easily, you know that you have the correct combination. Ultrasonic the lower anterior teeth until you believe they are completely free of deposit. Move on to the surfaces toward, and finish with surfaces away. Rinse and repeat for the maxillary teeth. Then switch ultrasonic tips to a slim or thin attachment and proceed to use it like an explorer. If, and when you find a deposit that the first tip missed, simply activate this thinner tip. Stay with the calculus until it is completely removed. Floss the teeth as an additional round of exploration. Voila! Hygiene routine elevated and simplified!

Use at least two ultrasonic tips per patient. As more complicated conditions present themselves, use the appropriate tip styles and as many different tips as you need to complete the task well.

Wondering why I didn’t recommend a new piece of equipment or some magical product? Certainly, the very best tool (in this case the ultrasonic) is the one you already have. My only limitation to this statement is that the ultrasonic unit must be in working order with appropriate tips that are less than 50% worn.

The research regarding ultrasonic instrumentation is irrefutable and has decades backing it up. No gimmicks needed. Just great information for utilizing what we already have. Additionally, I truly have not seen anything show better, more repeatable, long-term results. Perhaps it is due to the lack of research and time on the market of the newer technologies. While many of these are showing promising signs of biofilm disruption and removal, I believe it is a mistake to avoid addressing the need to maximize our ultrasonic use.

Getting Patients to Help Themselves

Now that we have our part done let’s strategize how to guide our patients in between appointments. Before you recommend a tool or a technique for their home care, assess whether your words will fall upon open ears. I often find that brushing, flossing, water flossing, interdental brushing, and the like are counterproductive to recommend. Sounds crazy, I know, but hang with me for just a second.

Our wonderful patients are whole human beings, and they regularly have no idea that their oral health is connected to (i.e. the same thing as) their overall health. Ergo, I have better luck grabbing their attention and inspiring a change when I discuss anti-inflammatory living to support their gum health. More people are inspired to buy a power toothbrush (and use it) when they find out the positive effects of adding a veggie to every meal. Seems a bit disjointed, but it has been a predictably repeatable occurrence. I believe the reason this works better than recommending our favorite electric toothbrush is that it disrupts their thinking pattern. It is a conversation our patients aren’t expecting. It gains our patients’ attention and motivates them to act. Another fabulous reason to talk about overall wellness as a support to their gum health is that it shows that we care deeply about them as a whole human being.

What if they have open ears? Or better yet, what if they ask us what to use? Yee-haw! Time to have some fun. Never underestimate the power of recommending what you choose for your own mouth. The dental homecare market is incredibly robust right now. If we tell them to go research options, it is likely analysis paralysis will set in. If this happens our patient will show back up to their next recare appointment with the same routine they were using before this conversation happened. Best to give them specific recommendations.

A fantastic first place to begin is with that power toothbrush we talked about earlier. Repeatedly we see power brushes remove more plaque and biofilm than manual toothbrushes. Electric toothbrushes also cause less damage to the soft tissue. The biofilm is effectively disrupted by the mechanical action of the toothbrush. Any of the brushes that use sonic technology are extra awesome because the waves of energy emitted disrupt the outer layer of the biofilm. When the biofilm is disrupted, it must repair itself. We would rather the biofilm be working on building itself than being mature and able to detach and launch to other areas.¹

If your patient already has brushing down, we can move to the interdental space. I prefer floss and use “Reach Clean Burst” on myself. If asked, I share that piece of information. If I am not asked, it is useful to find out more about our patient’s daily routine. If we can figure out a habit they do every day that we could pair flossing, floss picking, soft picking, or interdental brushing with, we will be more likely to have compliance.

For example, Johnny has a 20-minute commute to work every day that he uses for his Zen time. Heavy metal blasting first thing in the morning puts him in a great headspace for a productive workday. This is our chance to say, “I love Metallica too! Reminds me of the cruise in high school. Johnny, you might love throwing some floss picks in your truck and busting them out during Nothing Else Matters. If we can kick out the bacteria that are growing in between your teeth, we will see your gums and body heal. Talk about increasing Zen!” Did you catch what we did there? We related to him as a human, recommended something easy, and habit-paired it for optimal success potential.

None of it: Rocket science.

All of it: Well thought out and tailored to his specific needs.

Another oral physiotherapy aid that is very effective is the water flosser. This is great for your patients with hard-to-reach areas that enjoy something new and different. Water flosser use is a fun conversation to have because we get to share that many people prefer to skip the mess and use their cordless water flosser in the shower. I think people visualize themselves doing this and it almost always produces a giggle. It is common knowledge that laughing enhances information retention, so I am all for promoting that giggle!

Water flossing is of utmost value to our patients with braces. Blasting water around brackets is an extremely helpful tool against all that extra material in the mouth for biofilm to build on.

I swear my teenagers still have teeth because of this gem of an oral care aid. It is also highly handy if you are recommending medicaments/mouthwashes/bleach therapy to your patients. It is quite simple to have them add the solution of your recommendation to the water reservoir and complete 2 tasks at once.

Speaking of mouthwashes, the conflicting information has turned into quite a can of worms for us, hasn’t it? I am a hygienist raised on essential oil/anti-septic mouthwashes such as Listerine and antimicrobials like Chlorhexidine (CHX). However, the newest data shows that we might not want to use these rinses because they disrupt the good bacteria too.

We used to recommend 2 weeks of CHX after scaling and root planning, but there is some argument that CHX disrupts the precious fibroblasts we want to be active for quick healing of the newly treated gingival tissue. We are learning that antibiotic-resistant or “super-bugs” are being created in some of these environments. We know that treating superbugs is difficult and can become dangerous. Most often, good brushing and interdental cleaning habits seem to be adequate in achieving the desired results without adding mouthwash. The simpler we can keep a hygiene routine, the more likely our patients will be to demolish their biofilm.

Might I qualify the above recommendation to skip mouthwashes? If your patient has a specific ailment that needs addressing, a mouthwash specially designed for them can be incredibly useful. Dry mouthwashes have been instrumental in helping patients going through chemotherapy, radiation, Sjogren’s Syndrome, medication/age-related xerostomia, and the like. Additionally, pH-neutralizing rinses are showing promising results for our patients with highly acidic mouths due to internal and external factors such as GERD and their diet. Because we are focusing on biofilm removal today, it was pertinent to share that the mouthwash may not be the saving grace. However, there are many occasions where mouthwashes are very helpful.

Do you ever feel as though people are looking for a new magic wand or pill to solve their problems? They often want it to take no time and be cheap if not free. As you can imagine, we are still searching for such wands and pills. In my experience, mastering the use of the underutilized tools we already have has provided the most predictably positive results. This applies to at the office and at home when getting rid of the pesky, never-ending biofilm.

The options, technologies, and techniques for eliminating biofilm continue to expand. Let’s challenge one another to do the best we can with the tools and strategies we know work well. Let’s use our ultrasonic to the best of its capability. Let’s encourage amazing biofilm removal at home. Finally, let’s join in promoting anti-inflammatory living. Together, we can make a profound and lasting impact on the lives of our patients one well-completed hygiene appointment at a time. Cheers to great biofilm elimination in and out of the dental office.

References:

1. Johnston W, Rosier BT, Artacho A, Paterson M, Piela K, Delaney C, Brown JL, Ramage G, Mira A, Culshaw S. Mechanical biofilm disruption causes microbial and immunological shifts in periodontitis patients. Sci Rep. 2021 May 7;11(1):9796. doi: 10.1038/s41598-021-89002-z. PMID: 33963212; PMCID: PMC8105330.
2. Ritz L, Hefti AF, Rateitschak KH. An in vitro investigation on the loss of root substance in scaling with various instruments. J Clin Periodontol. 1991 Oct;18(9):643-7. doi: 10.1111/j.1600-051x.1991.tb00104.x. PMID: 1960232.