Guided Biofilm Threrapy

A New Approach And A Real Game Changer

For many years little has changed in the approach to the prevention of dental decay and gum disease and the treatment of gum disease.  The simple message for all patients has always been, and must remain, “eat less sugars and clean teeth better”.

While this message remains constant, at NQ Surgical Dentistry, the mode of delivery for preventive dental careis about to change forever and become

• far more comfortable,
• minimally invasive
• more effective
• reducing anxiety for many patients.

Treatment in the past (up to late 1980’s)

Many patients remember the days of dentists and hygienists scaling your teeth using hand instruments.  This was called dental prophylaxis or a “prophy”.

These hand-scalers had sharp edges used to “scrape off” plaque and tartar from the tooth and root surfaces.  It was often uncomfortable, always noisy, scratched tooth and filling surfaces, and frequently resulted in bleeding from the gums and discomfort that took some days to resolve.  This was considered normal until the 1990’s.   Thankfully this approach can now be confined to history.

The Biological Price

Once this hand instrument cleaning or “mechanical debridement” was finished, the tooth surfaces were polished using either rotating rubber cups or brushes with an abrasive polishing paste to remove the residual stains.  This tooth polishing was only effective on the accessible smooth surfaces of teeth, but was completely ineffective in the more inaccessible sites located under the gum margins or between teeth.  Sadly the patient experience was uncomfortable and it was rarely described as pleasant, providing little incentive for the patient to repeat the ordeal.

The clinical outcome of clean teeth satisfied the dentist or hygienist, but the “biological price” paid by the patient in terms of pain, bleeding and anxiety was not worth the degree of benefit, perceived by the patient.

The result was patients often did not come back, so their mouths returned to the same state as before with a build-up of plaque and calculus, new decay and continued gum disease and infection.

Recent treatment  (1990-2015)

With the development of high frequency vibrating instruments available since the 1990’s, the use of hand instruments had been largely replaced.

Firstly came the ultrasonic scalers in the 1980’s, then the air-scalers from the 1990’s, these finally being replaced with the next generation of instruments known as piezo-scalers.  The aim of all these instruments was to provide a very high frequency vibration of the instrument tip.  This vibration offers mechanical disruption of the plaque and tartar, also known as calculus.

After the removal of tartar was completed, some stain would still be present on the teeth requiring rotating rubber cups and brushes with polishing paste.  This would remove the remaining “accessible” stains, although usually leaving behind stains that could be accessed and usually cannot be seen.

Those surfaces with remaining calculus, biofilm or stain, would still be rough and provide the ideal surface to attract new plaque and begin the development of more matured, disease-forming bacterial plaque and calculus once again.

Modern treatment approach (2018-)

Nowadays, we are moving towards a truly“patient-focused” system that allows us to avoid the use of instruments that cause damage to the tooth, root, fillings, implant surfaces or even the soft tissues of the surrounding gum margins.  Modern techniques offer care without discomfort reducing patient anxiety. 

We now have both new technologies and new rationalesfor what we do that genuinely focus on the patient and their experience. Using airjet technology and Piezo-scalers with ultra-high frequency vibration and highly developed intuitive technology to optimise their effectiveness and comfort, they can deliver the optimal degree of energy output required to remove calculus while blocking pain sensation and minimising power to avoid damaging the tooth surface.

Dental cleaning using the most modern equipment and techniques should only be a relaxing and pleasant procedure.

THE ENEMY OF A HEALTHY MOUTH

The oft-heard word “plaque” describes “the soft, live accumulations of bacteria that live on all the surfaces in the mouth in a sticky film”.

Plaque is derived from a combination of bacteria that live in the mouth and the protein is derived from saliva.  This protein provides the “matrix” or glue that gives structure to the bacterial accumulation binding all the bacteria together.  It also sticks the plaque film to the teeth and other surfaces.  It has been reported that there are up to 700 different bacterial species present in the human mouth.

This plaque film is called a “biofilm”​

It is extremely adherent to the teeth, gums, cheeks, tongue, fillings, dentures, orthodontic brackets, indeed anything that is found in the mouth.

Biofilm is the root of all evil in the mouth 

Biofilm is the cause of dental decay, gum disease and infections like wisdom tooth associated infections.

Biofilm removal can be extremely challenging primarily because it is so adherent to whatever surface it sticks to.  Incorrect or inefficient tooth brushing often leaves considerable quantities of biofilm still attached in the mouth.  However, because it is difficult to see, patients are often unaware of its presence, but its damage and disease activity continues.

Biofilm protects the bacteria

The biofilm also offers the oral bacteria an enormous degree of protection against both mechanical disruption and antibiotic and antimicrobial attack.

• The structure of biofilm protects the oral bacteria from toothbrush disruption due to its strong adherence to the tooth surface.
• The biofilm also offers a protective barrier against chemicals incorporated into toothpastes and mouthwashes, to help patients achieve good oral hygiene.
• Finally, biofilm acts like a barrier protecting the bacteria against antibiotics being used to control infection.

 

Biofilm is the enemy of a healthy mouth.

A NEW APPROACH

GUIDED BIOFILM THERAPY

Before we outline the order of treatment, let’s consider why it is difficult to remove all the small deposits of calculus from the teeth and the root surfaces.

Clearly, one reason is that we cannot easily see these small deposits of calculus because they are covered in a layer of biofilm.  Therefore the first task should be to remove the biofilm as much as possible making identification of calculus as easy as possible and thereby improve our effectiveness at its removal.

What does biofilm look like?

Biofilm is a creamy coloured, gel-like material, closely matching the colour of the underlying tooth or root surface.  It is therefore difficult to see it, but it can effectively obscure the underlying calculus deposits, stain and even areas of dental decay.

In the past the dentist or hygienist first cleaned the teeth with the hand or ultrasonic/piezo-scaler and then finally polished all the teeth to remove any residual staining.

A more logical & modern approach is now available

The most logical first treatment step would be to make the biofilm more visible, then remove the biofilm, thereby revealing the calculus deposits beneath, to allow for their effective removal and the identification of any previously hidden dental decay.  This is what is described as “Guided biofilm therapy”.   This approach is outlined below.

STAGE 1: Examination and diagnosis

“for all patients to maintain a healthy mouth”

A correct dental examination includes the observation of all structures in the mouth including the teeth, the tooth supporting structures including the gums and the bone around the teeth, and finally all the oral soft tissues including the cheeks, floor of the mouth, tongue and the lips.  Part of this screening should involve periodontal probing examination.  Diagnosis of any of the following may be the outcome:  health, dental decay, gingivitis, periodontitis, peri-implant mucositis or peri-implantitis.

STAGE 2: Plaque disclosure

“for all patients to maintain a healthy mouth”

To better identify the biofilm, it must be disclosed using a dye. This allows the dentist or hygienist to demonstrate the presence of the now highly visible biofilm clearly, in a mirror or using an intra-oral camera or video, to the patient.  After all, if you haven’t seen it, why would you believe there is a sufficient quantity to cause dental disease?

STAGE 3: Motivation and oral hygiene instruction

“for all patients to maintain a healthy mouth” 

The next stage is to ensure the patient understands why their past methods of cleaning have allowed biofilm to develop causing disease.  Advice on home care should include a demonstration of high frequency vibratory brushing on a model initially at consultation but in the patient’s own mouth at the time of dental hygienist therapy.

High frequency home brushing is the key

What is required is thorough biofilm disruption on a daily basis.  The use of high frequency vibratory tooth brushing is fundamental, both to preventing dental decay, successful treatment of gum disease and the maintenance of a healthy mouth.

Generally vibration frequencies in excess of 30,000 times a minute are required to effectively disrupt and remove biofilm.  There are very few brushes available that can achieve this frequency.  Currently we advocate the use of the Colgate 1500 or the Philips Sonicare brushes.  They are all effective at varying costs.  The dentist or hygienist can then support the patient in their learning this new technique so they can initiate the new cleaning at home after the appointment and continue to use this technique into the future.

 

 

STAGE 4:  Use of the EMS AIRFLOW  

“for all patients to maintain a healthy mouth”

Now the EMS AIRFLOW can be used to remove all the disclosed, visible and accessible biofilm, stains and immature calculusfrom the tooth surfaces using a water jet and powder system containing either SODIUM BICARBONATE (EMS AIR-FLOW SUPRAGINGIVAL  – 40microns) or ERYTHRITOL (EMS AIR-FLOW PLUS – 14microns).

This jet can access all sites around teeth, fillings, orthodontic brackets, in the tooth pits and fissures, and around rough tooth edges where enamel fractures have occurred.  It can safely be used just under the gum margins up to a depth of 4mm completely pain-free.

There is no need for rotating rubber cups or brushes with an abrasive polishing paste after AIRFLOW as the powder and water polishes at the same time.  This greatly reduces the time required for treatment.  We understand that less time in the chair is greatly appreciated by all patients and greater comfort means recall appointments are no longer something to fear.

There are 3 sound reasons to accept this new approach: 

1. It’s quicker,
2. it’s more comfortable and
3. it’s more effective.  

STAGE 5:  Use of the EMS PERIOFLOW

“for all patients who have suffered destructive gum disease with bone loss”

The next stage is to remove any plaque and calculus off the root surfaces that are located in pockets around teeth deeper than 3-4mm.

If you were identified at stage 1 (examination and diagnosis) as a patient who has experienced gum disease, your dentist or hygienist will explain to you some important factors on gum disease:

1. how the bone level reduction around your teeth takes place as a result of a heightened inflammatory response,
2. and as a consequence, periodontal pockets develop that can harbour bacteria
3. and that these pockets offer a protected environment for the biofilm,
4. thereby encouraging the progression of gum disease and further bone loss around the teeth.

This detailed information is available in our leaflet entitled “Gum Disease – the basics explained”.

EMS PERIOFLOW

This uses a specially designed tip to access the pockets painlessly and apply a water jet and two streams of fine ERYTHRITOL powder (14 microns) to remove the plaque and calculus deposits from the inner surfaces of the pocket including the root surface and the adjacent soft gum surface.  Any residues of the erythritol will dissolve and be removed from the pockets naturally.

The EMS PERIOFLOW can be used to within 1-2mm of the depth of any pocket with a maximum penetration depth in deep pockets of 9mm.

Once again EMS PERIOFLOW is pain-free.  It allows patients an anxiety free appointment and improves the overall dental experience reducing anxiety over future recall visits.

STAGE 6:  Use the PIEZON PS. The PS tip is used for patients with teeth and the PIEZON PI tips are used around implants.

“for all patients with hard and adherent calculus”

For patients visiting our practice for the first time, with either untreated severe gum disease (chronic or aggressive periodontitis) or those patients who have received incomplete periodontal therapy previously, some deposits of very hard and adherent calculus may remain in pockets or around the gum margin area of teeth.   These deposits may be highly mineralised and adherent to the tooth surface and therefore a final stage is required to remove these disease-causing deposits.

STAGE 7: Quality control – re-check for residual deposits and decay

“for every patient”

After the completion of your Guided Biofilm Therapy, your on-going future susceptibility to gum disease remains unchanged as this is primarily determined by your genetic make-up.   Therefore daily home care and biofilm removal is fundamental to achieving and maintaining oral and gum health.

Home care is fundamental

Once your current active disease is stabilised and inflammation largely resolved, it is imperative that you maintain the highest standard of biofilm control at home every day.  You will also require regular professional support by your dentists and/or hygienist including preventive therapy in the future to stay healthy.

The regularity of your preventive therapy will depend on both the patient’s degree of susceptibility to periodontal disease and the standard of the home cleaning of which the patient is capable.  On-going assessment of disease activity and patient control must continue and is an important part of patients’ maintenance care by the team.

STAGE 8: SCHEDULE A RECALL ASSESSMENT

“for all patient”

All patients will benefit from this Guided Biofilm Therapy approach to achieving and maintaining a healthy mouth.  Sound professional support accompanying thorough and effective daily homecare is key to maintaining good dental health.

Once this treatment protocol has been performed, it is fundamental that on-going supportive therapy is provided on a regular basis.  How often that care is provided will depend on both the degree of susceptibility to dental disease and how effective the home biofilm control is. Your dentist or hygienist, in providing you with a future maintenance schedule, will take these factors into account.

Recall may vary from 3 to 9-12 monthly.  Your care is tailored to your specific risk factors and therefore a plan needs to be agreed with you on when the next scheduled recall appointment will be required.

STAGE 9: MAINTENANCE CARE PLAN

“for all patients to maintain a healthy mouth”

This logical, step-wise, preventive approach has been developed by the European Federation of Periodontology(EFP) combining high quality home care using high frequency brushing, tongue-care (involving brushing the tongue to remove the reservoir of bacteria that live there) and the use of floss/airfloss.

Guided Biofilm Therapy Summary

These home-based procedures must be backed up with professional supportusing the Guided Biofilm Therapysystem that has been outlined in this leaflet and can be summarised as:

• Examination and diagnosis
• Disclosure of dental plaque to identify it clearly
• Support patients to use high frequency vibratory brushing at home using Colgate 1500 or Philips Sonicare brushes
• Perform AIRFLOW on tooth surfaces and up to 4mm under gum margins
• Perform PERIOFLOW in pockets more than 4mm deep
• Perform PIEZON (PS/PI) cleaning of resistant calculus that remains
• Reassessment of the whole mouth, checking for any previously invisible signs of dental decay, then application of re-mineralising therapy to repair early decay and prevent later tooth hypersensitivity after cleaning.
• Schedule the next recall appointment
• Future regular maintenance care plan.

For more information: Dental Hygiene Therapy

contact the friendly team at NQ Surgical Dentistry today on (07) 4725 1656 or call in to see us at 183 Kings Rd, Pimlico QLD 4812