Dental plaque, what has been re-termed “oral biofilm”, has long been connected with periodontal problems and to a lesser extent caries related to the bacteria contained within it. Oral bacteria have long been ignored for any effects outside the oral cavity. Yet, research has been accumulating directly connecting a link between oral health and systemic health, with 200 possible connections between systemic diseases and oral disease reported by The American Dental Association.1 Accumulating evidence has linked periodontal disease and chronic oral inflammation to multiple health conditions, including cardiovascular and renal issues, diabetes, osteoporosis, pulmonary disorders, Alzheimer’s and other systemic conditions. With that research in mind, oral biofilm has been recognized as a more complex environment than previously understood.2,3
Oral biofilm is a community of microorganisms found on the tooth surface or within the sulcus (periodontal pocket) which are embedded in a matrix of polymers of host and bacterial origin. Typically, more than 700 different species of bacteria naturally reside in the mouth, with most considered innocuous, but some of these microorganisms have been identified as pathogenic. As bacteria increase in number, they quickly create an intricate network of protective layers (matrix) and channels that develop into a biofilm; this is the major cause of periodontal disease. The bacteria in the biofilm are less susceptible to antimicrobial agents, either locally applied or systemically administered. It has been long demonstrated that these microbial communities can display enhanced pathogenicity (pathogenic synergism).4,5 Additionally, the structure of the biofilm might restrict penetration of antimicrobial agents, while bacteria growing on a surface (planktonic) are susceptible to antimicrobial agents.6 The aggregation of bacteria works together as a community, producing specific proteins and enzymes by way of quorum sensing, utilizing oral fluids as the vector for transmission.7 Bacteria in these oral environments have evolved as part of multispecies biofilms and may require interaction with other bacterial species to grow, forming complex bio-environments.8
Initially the biome of the biofilm consists of mostly gram-positive cocci bacteria (Streptococcus mutans, Streptococcus mitis, Streptococcus sanguis, Streptococcus oralis, Rothia dentocariosa, and Staphylococcus epidermidis), followed by some gram-positive rods and fillaments (Actinomyces viscosus, Actinomyces israelis, Actinomyces gerencseriae and Corynebacterium species) and a very small number of gram-negative cocci. Veillonella parvula and Neisseria species making up some of the gram-negative cocci, are aerobes or facultative aerobes. This early biofilm is able to withstand frequent mechanisms of the oral bacterial removal such as chewing, swallowing and salivary fluid flow. These early colonizers are also able to survive in the high oxygen concentrations present in the oral cavity. This initial biofilm, always present orally, forms immediately after cleaning. Co-adhesion of later bacterial colonizers to the initial biofilm continues to involve specific interactions between bacterial receptors; this builds up the biofilm creating a more complex and diverse environment. These diverse bacterial species create synergistic and antagonistic biochemical interactions amongst the colony’s inhabitants. This may contribute metabolically to other bacteria that are located physically close to them. When obligate aerobes and anaerobes are involved in co-adhesion, these interactions can ensure the anaerobic bacteria’s survival in the oxygen-rich oral cavity. The bacteria continue to divide until a three-dimensional mixed-culture biofilm forms that is specially and functionally organized. Polymer production causes development of an extracellular matrix. This matrix is a key structural aspect of the biofilm offering the inhabitants protection from external factors. As the biofilm thickens and becomes more mature, these anaerobic bacteria are able to live deeper within the biofilm, further protecting them from the oxygen-rich environment within the oral cavity. So, management of oral biofilm is important from an oral as well as systemic standpoint for optimized health.
Guided Biofilm Therapy (GBT)
To successfully collaborate in oral biofilm management in order to provide long-term health and stability of the dentition and its associated structures (soft and hard tissues), the dentist and hygienist need to first identify any risk factors that inhibit a successful procedure through all steps. Whether natural teeth, implants, or a combination of the two are present oral biofilm needs to be identified and removed clinically by the dental team to create a stable environment that will help in maximizing oral and systemic health. With regard to implants, understanding the integrity of the implant surface is key to long-term maintenance of the implants intraorally; optimized in office therapies can be provided by the dental team and maintained by the patient with homecare protocols. The goal is to minimize iatrogenic damage to the implant surface which can occur with the use of metal hand or ultrasonic instruments, and to diminish pathogenic biofilm adhesion to the implant surfaces.
Once these goals, around the natural teeth and implants has been achieved, the patient should be enrolled in long-term biofilm therapy to ensure comprehensive preventive management of their teeth, implants and restorations. The GBT Compass, optimizes the patient/ clinician appointment time in a synchronized manner to enhance assessment, patient motivation and homecare protocols as well as more effective, non-invasive biofilm therapy with both patient and clinician comfort. (Fig. 1)
Disclosing to improve recall prophy maintenance and initial care
Dental healthcare professionals often equate the use of disclosing solution as undesirable as it can be time-consuming, difficult to manage, limited to pediatric patients or merely utilized in an academic clinical setting. However, the application of disclosing solution as part of a preventive maintenance workflow is an essential step in identifying biofilm and is beneficial for both the patient and clinician to see where biofilm is accumulating on the visible portions of the dentition. As the saying goes “seeing is believing”. Patients often feel they are doing an adequate job with biofilm removal with their homecare. But unless the biofilm is colored to illustrate where it is being missed, the patient is not likely to improve their homecare. This is important not only at recare appointments but also at the initial appointment when periodontal evaluation or care is rendered. Medical science has well documented the impact oral biofilm has on long-term oral health and stability of the teeth and implants. Facilitating biofilm management strategies in oral maintenance protocols is a critical component of the dental hygiene process of care.9-11
Disclosing products have improved over the years, which has simplified the application process and aligns with vital patient education to aid in improving patient homecare compliance. The application of a disclosing solution has improved for ease of use and the ability to identify different maturity levels of biofilm and the bacteria they contain. Contemporary disclosing solutions come in gel form, pre-loaded applicators, and pre-soaked sponges. Those products include: GC Tri-Plaque ID Gel (GC America, Alsip, IL), Hurriview II Two-tone pre-loaded disclosing solution applicator (Beutlich Pharmaceuticals, Bunnell, FL) and EMS Dental GBT Biofilm Discloser (EMS, Nyon, Switzerland). The gel solution form may be applied with a cotton applicator, applicator brush or toothbrush. (Fig. 2) Once the disclosing solution is applied, have the patient rinse, and then review the results with them to help illustrate what areas are being missed with their homecare. (Fig. 3) Educating the patient on the different colors related to the age and virulence of bacteria enables an understanding of periodontal and peri-implant disease etiology. Allowing the patient to visualize where biofilm is accumulating and being missed aids homecare instructions before debridement. After the demonstration of what areas are being missed with their current homecare, provide them with techniques to better reach those missed areas. Once education and home care instructions are complete, then debridement procedures can begin. This small shift in the clinical workflow will ensure that critical patient education is routinely included in maintenance appointments, thus leading to improved patient outcomes, and increased oral health and success.
Furthermore, when applying the Guided Biofilm Therapy (GBT) eight-step protocol, debridement outcomes improve for both natural teeth as well as implants as the clinician has a roadmap for biofilm and calculus removal via disclosing solution. (Figs. 4-6) The GBT protocol allows for more thoroughness of care, that is less labor-intensive for the clinician, and a minimally invasive approach to maintaining teeth and implant surface integrity while providing more comfort for the patient during the appointment.12
Air polishing–Improving oral biofilm in-office removal
Air polishing with glycine powder may be considered a better method to remove plaque from dental implants, as glycine is less aggressive than sodium bicarbonate powder on the surface of the implant that is supracrestal to the bone. This helps ensure that the implant surface is not inadvertently roughened, which may happen with sodium bicarbonate, and can potentially increase biofilm accumulation on that surface. The use of glycine powder moreover seems to have an active role with inhibition of bacterial recolonization of implants in a short test period (24 h).13 Additional studies have indicated that glycine powder assists in the reduction of bleeding upon probing after non-surgical therapy. This can be a key point in the dental team to patient communication of the advantages of this noninvasive therapy to reduce bleeding.14
Recent indications for the use of air polishing technology have been expanded from supragingival use (Airflow®) to subgingival air polishing (Perioflow®) with the development of new low-abrasive glycine-based powders and devices with a subgingival nozzle. Several studies on subgingival use of air polishing have been completed. In June of 2012, during the Europerio 7 Congress in Vienna, a consensus conference on mechanical biofilm management was held, aiming to review the current evidence from the literature on the clinical relevance of the subgingival use of air polishing and to make practical recommendations for the clinician.15 Their consensus concluded that:
- Oral disease is caused by biofilm
- Mechanical bacterial biofilm management is essential to the longevity of teeth and implants
- Air polishing devices are effective in removing supra and subgingival biofilm and stain
- Air polishing devices shorten the treatment time
- Air polishing diminishes root sensitivity compared to stainless steel curettes
This was supported by a more recent consensus (2017)16 where they reported that: at probing depths of 5 mm to 9 mm, using a subgingival nozzle, glycine powder air polishing was more effective at removing subgingival biofilm than manual or ultrasonic instrumentation. And in pocket depths of 1 mm to 4 mm, glycine-powder air polishing, using a standard air-polishing nozzle, is more effective at removing subgingival biofilm than manual or ultrasonic instruments. Further, they confirmed that supra- and subgingival air polishing using glycine powder is safe and effective for removal of biofilms from natural tooth structure and restorative materials. No evidence of soft-tissue abrasion when using glycine powder in an air-polishing device was reported.
Traditional air polishers use higher pressure, but more recent units have been developed that utilize very low air pressure, so potential issues previously encountered and reported with the older units are not observed. In the past air polishers have been limited to bicarbonate or glycine. One of the benefits of Airflow® (EMS), is the use of Erythritol powder. Erythritol is a polyol (sugar alcohol) that has a smaller particle size of 14µm in comparison to sodium bicarbonate (40µm) or glycine (25µm). Due to the smaller particle size and decreased abrasively, Erythritol in GBT allows the clinician to comfortably deliver supra and subgingival airflow therapy with increased comfort to the patient, without damaging the cementum or negatively affecting the implant surface. Erythritol’s hardness factor and smaller particle size also allows the clinician to remove more stain with less powder volume than glycine, which cuts down on per treatment costs. Additionally, Erythritol has been shown to have an antimicrobial inhibition factor for S.gordonii and P.gingivalis 17. Usage around implants that lie supracrestally, allows more thorough removal of biofilm on the surfaces without the potential for roughening the exposed titanium and becoming a future biofilm accumulation area. (Fig. 7A) Additionally, Airflow can reach areas not easily accessible between the tissue side of the prosthesis and the underlying soft tissue. (Fig. 7B)
Peri-implantitis is being increasingly identified and connected to implant failure when intervention is not initiated early enough. Recent scientific data has reported that depending on the clinical and radiographic criteria that are adopted, it can affect from 20% to 40% of subjects restored with dental implants.18
The Perioflow® device (EMS) provides a flexible nozzle and lightweight body permitting a minimally invasive treatment of periodontal pockets with a uniform trilateral powder spray. (Fig. 8) The flexible tip can be inserted atraumatically into the sulcus to the bottom of the pocket present. (Fig. 9) Three outlets at the tip provide comfortable decontamination of the tissue, implant and the base of the sulcus with Erythritol powder delivered with warmed water with the Perioflow® handpiece as part of GBT. It is ideal for supportive periodontal therapy (SPT), primary and secondary prevention, as well as implant maintenance and non-surgical treatment of peri-implantitis and periodontitis. Biofilm regrowth was also reported to be significantly lower when Erythritol powder was utilized with the Perioflow compared to other debridement methods.19 Erythritol air polishing seems as effective as piezoelectric ultrasonic scaling in the non-surgical treatment of peri-implantitis as has been reported and can be an adjunct when a surgical approach is required to clean the exposed implant surface prior to graft placement to ensure elimination of the present biofilm.20
Utilization of GBT for biofilm and calculus removal, a case example:
A 30-year-old female presented for recall prophylaxis. Generalized gingival inflammation and bleeding on probing was observed. (Fig. 10) Review of the medical history noted no contributory conditions were present. The patient was informed of the periodontal condition and scaling/root planning was recommended. Full mouth periodontal charting was performed to assess the state of the periodontal health. (Fig. 11) Periodontal charting noted pocket depths of 3-4mm and bleeding at the maxillary and mandibular anteriors and at the 1st-2nd molars in all quadrants, with 18 of 67 sites demonstrating bleeding. Supra and subgingival calculus was detected in the areas that were bleeding and inflamed. No mobility was noted. Treatment suggested to the patient consisted of GBT with placement on a 3-month recall schedule with GBT repeated at each recall to maintain biofilm elimination and aid tissue healing.
Local anesthetic was administered in all quadrants to provide patient comfort during GBT. The patient was disclosed and areas where she was missing in homecare were reviewed with her. Instructions were given on improving homecare maintenance. Airflow® was used to eliminate visible deposits on the dentition using the disclosed areas to aid in biofilm removal. Perioflow® was then used subgingivally, to removal subgingival biofilm attached to the sulcus lining and subgingival tooth surfaces. Piezon® was utilized to remove any residual calculus on the root surfaces; this was followed by verification of effectiveness with hand instruments. Following this treatment appointment, a reduction in the inflamed appearance to the marginal gingiva was noted, as well as cleaner appearing teeth with all stain and calculus removed by the Erythritol powder applied with Airflow® and Perioflow®. Fig. 12
The patient was placed on 3-month recall and maintained that schedule during the past 10 months with a slight delay related to the ongoing pandemic. GBT was repeated at each recall appointment and performed without local anesthetic use. At the most recent recall, no gingival inflammation was noted, nor calculus reformation. Periodontal charting was performed at 10-months to assess the health subgingivally. Fig. 13 Pockets had reduced from 4mm in many sites to 3mm with light bleeding on probing only noted in 3 isolated sites. The patient reported since the initial healing after the 1st GBT treatment she has not observed any bleeding when brushing and her mouth felt healthier.
Biofilm management is critical to oral as well as systemic health. Scaling with either hand instruments or ultrasonics is inadequate for removal of subgingival biofilm. Airflow and Perioflow with Erythritol powder have demonstrated the ability to remove that biofilm without affecting cementum on roots or harming the implant surfaces. The key to clinical success also requires improved patient homecare. When disclosing is used at the hygiene appointment, patients are able to see what areas they are missing, and they can then be educated on improved biofilm management. In office and at home management of biofilm leads to optimal and maintainable oral health and consequent benefits to systemic health.
Oral Health welcomes this original article.
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About the Author
Dr. Kurtzman is in private general practice in Silver Spring, Maryland and is a former Assistant Clinical Professor at University of Maryland. He is a former AAID Implant Maxi-Course assistant program director at Howard University College of Dentistry. He has lectured internationally and published over 760 articles. He can be reached at firstname.lastname@example.org
Debbie Zafiropoulos, is CEO of the OralED Institute, Partner in Education the Wellness Dentistry Network, MoradoASC, and certified GBT Trainer for EMS-NA. In 2016, she was recipient of the SUNSTAR Award of Distinction and in 2017 she was recognized as one of the Top 25 Women in Dentistry for research and prevention of HPV related oral cancer.