INTRODUCTION
The control of biofilm is probably the most important factor in a patient’s oral health. The control of biofilm is probably the most important factor in a patient’s oral health. Yes, you read that twice because it is that important; however, as dental professionals and patients, we tend to use the same mechanical methods of controlling biofilm. Brushing, flossing, and professional cleanings are not helping us to decrease periodontal disease. As our patients age, we see a rise in gum disease: up to 70% over the age of 65 and in almost half (47.2%) of adults over the age of 30. From this, we can conclude that we have to equip our patients with better tools to help regularly reduce biofilm, which is one of the main factors contributing to the progression of poor gum health and systemic health. A rinse can be this tool to help!
WHAT IS BIOFILM, AND WHY SHOULD WE CARE?
Biofilm is an assemblage of surface-associated microbial cells that is enclosed in an extracellular polymeric substance matrix. In the mouth, we call this dental plaque. Biofilm formation is an important adaptation and survival strategy commonly employed by bacteria. Bacteria in the biofilm are protected from adverse environmental factors and immune responses.
Compared to free-living cells, cells in a microbial biofilm are much less susceptible to antimicrobial agents. This decreased susceptibility has a considerable impact on the treatment of biofilm-related infections. Biofilm formation is often considered to be the underlying reason why treatment with an antimicrobial agent fails. As an estimated 65% to 80% of all chronic infections are thought to be biofilm-related, this presents a serious challenge.
Over the past 10 years, more and more data has emerged linking oral biofilm to systemic illnesses, either causing them to begin with or making them worse. The patient’s health must be viewed as a whole-body system, with linkages that may start in the mouth and influence different parts of the body at different times.
Oral biofilm micro-organisms and their by-products have been linked to several aspects of systemic health. These include rheumatoid arthritis; diabetes; lung conditions; and prostate, colon, and pancreatic cancers, and they also include erectile dysfunction, Alzheimer’s disease, and preterm pregnancies.
In the oral cavity, biofilm has a major role in many oral diseases, such as dental caries and periodontal disease. Biofilm can be found in easy-to-reach places like the surfaces of the teeth and in tough-to-remove areas, like a gingival sulcus.
MECHANICAL VS THERAPEUTIC METHODS
Whether with home care or professional cleanings, our only method of fighting biofilm is mechanical. We diligently educate our patients on brushing and flossing and hope they do so on a regular basis. However, even when they do brush and floss, it is still only mechanical. Perhaps you’re lucky and have patients who are great brushers and flossers, but even then, they are really only cleaning about 22% of their mouths. If they just brush (like most patients I know), you can essentially cut that number in half and deduct that only 11% of the whole mouth is being cleaned. They only brush half of the tooth, leaving areas for biofilm to proliferate. These mechanical methods are simply detaching some of the biofilm from the tooth, adding it to our saliva, mixing it with some toothpaste, and then spitting it all out. It doesn’t do anything to help the patient fight an active infection, nor does it kill any microbes that cause disease, and it does nothing to prevent more biofilm from forming.
Therapeutic products (rinses) work differently. Most just focus on killing the bacteria, which has little effect on biofilm. Professional rinses try to break up or penetrate the biofilm, kill the bacteria, and prevent biofilm from forming. There are clinical studies that suggest that rinsing can be 4 times as effective as flossing. However, it is important to note that the criteria for choosing rinses should be rigorous because not all rinses have all of these abilities, nor can they all be used long-term. For example, chlorhexidine is great at killing bacteria but does nothing to break up biofilm or prevent biofilm from forming. In fact, chlorhexidine, because of substantivity, can actually increase biofilm buildup.
THE TRIAD
To properly fight biofilm, you must have these 3 criteria: You must break up/penetrate the biofilm, kill the bacteria and other microbes in the biofilm, and prevent new biofilm from forming. The product OraCare addresses all 3 by combining chlorine dioxide and poloxamer 407. Let’s take a look at both of these compounds and how they work to fight biofilm.
CHLORINE DIOXIDE
Chlorine dioxide is a powerful, selective oxidizing biocide. It attacks micro-organisms by disrupting the cell’s ability to create essential proteins. This oxidizing property makes chlorine dioxide an efficient and effective antimicrobial that is used for a variety of sterilization, disinfection, and decontamination purposes in the food, beverage, water disinfection, industrial water treatment, and agriculture markets. First discovered in 1811, its antimicrobial properties have been known since about 1900, and it has been used in the United States to disinfect public drinking water for more than 70 years. Chlorine dioxide kills many strains of bacteria, viruses, and fungi, all of which can be found in biofilm, and has a role in oral health diseases.
Chlorine dioxide has a superior ability to break down the toughest micro-organisms and biofilms without corrosive action or negative impacts on the oral environment. Its efficacy is not impacted by the condition of the environment, most notably in regard to pH levels and the presence of organic matter. Chlorine dioxide is effective against bacteria, protozoa, viruses, and fungi on inanimate objects and is considered more effective against microbes than other chlorine solutions. Unlike other products, chlorine dioxide starves and kills micro-organisms by disrupting the transport of nutrients across their cell walls.
Chlorine dioxide is used in many industries to “break up biofilm,” but what it really does is penetrate the biofilm and inactivate the bacteria that are producing the biofilm, stopping the production of biofilm at the source.
Chlorine dioxide may be the perfect compound to fight oral biofilm because it is a very selective oxidizer that penetrates biofilm, kills microbes, and prevents biofilm from reproducing.
POLOXAMER 407
Poloxamer 407 is an FDA-approved polyoxyethylene polymer and a hydrophilic non-ionic surfactant. It is made up of 2 blocks of hydrophilic polyethylene glycol on either side of a central hydrophobic polypropylene glycol block. It reduces its surface tension, thereby increasing its spreading and wetting properties.
The poloxamer works with chlorine dioxide to make the surfaces of the oral cavity “slicker,” preventing biofilm from taking hold. This combination has yielded excellent results in clinical studies and clinical cases.
CLINICAL STUDY
Salus Research conducted a 6-week, randomized, examiner-blind clinical trial to evaluate the safety and efficacy of OraCare Health Rinse compared to tooth brushing alone (Table 1). One of the 4 areas evaluated was biofilm reduction using OraCare vs brushing without OraCare. We will focus on the results of this area.
Salus Research evaluated multiple surfaces of the teeth, the whole mouth, gumlines, and interproximal areas. OraCare saw an amazing 225% decrease in biofilm vs brushing alone and an astounding 307% reduction interproximally. Here is the clinical summary:
- The active treatment provided very positive outcomes toward gingival health over the 6-week period, with about 6 times the improvement seen for the control group.
- The active treatment increased healthy MGI sites to about 20 compared to less than one site for the control group.
- The active treatment provided very positive outcomes toward plaque biofilm removal over the 6-week study, with a 22% improvement in the whole mouth compared to no improvement for the control group.
- The active treatment showed a 15-times improvement in the periodontal pocket depth compared to the control group.
- The active treatment rinse showed superiority for every endpoint evaluated compared to the control group.
What this study shows us is that the combination of mechanical and therapeutic techniques far exceeds just mechanical aids.
CASE REPORTS
Case 1
The patient in this case was seen continually on a 3-month recall. The patient always had calculus buildup and inflamed gingiva. This was documented in Figure 1 on January 4, 2018. This was consistent with how the patient’s oral health looked during the 3-month recalls. After a periodontal maintenance appointment on January 4, 2018, the patient was given OraCare and was instructed to rinse twice a day. The patient returned on March 5, 2018, with considerably less calculus and inflammation (Figure 2). The only change in the patient’s oral hygiene was the addition of OraCare twice a day.
Figure 1. The patient was seen continually on a 3-month recall. The patient always had calculus buildup and inflamed gingiva.
Figure 2. The patient returned for 3-month perio maintenance after incorporating rinsing into the daily routine. The patient returned with less calculus, less inflam- mation, and increased comfort during cleaning.
Case 2
The patient in this case presented with inflammation, bleeding, moderate plaque buildup, and sensitivity due to a lack of good oral hygiene (Figure 3). If left untreated, this patient would have developed a more severe form of gum disease. Like many patients, the dentist and hygienist stressed good oral hygiene at previous appointments, including instructions on proper brushing and flossing techniques. Due to a lack of improvement, the dental team discussed the need for a potential gingivectomy. In a final attempt to improve the patient’s home care, the patient was given OraCare. After just 5 weeks of use, the patient saw a significant reduction in inflammation, bleeding, plaque accumulation, and sensitivity (Figure 4). This rinse provided the benefits that the dental team had been unable to achieve with traditional methods in a short window of time. The patient had higher compliance with rinsing compared to brushing and flossing. With this simple additional step added, the dental team decided not to move forward with the gingivectomy and continued having the patient use OraCare to aid in improving the patient’s gum health and general health.
Figure 3. The patient presented with inflammation, bleeding, moderate plaque buildup, and sensitivity due to a lack of good oral hygiene.
Figure 4. The patient returned for re- evaluation after 5 weeks of using rinse. These were the results seen in that period of time.
Case 3
Many patients struggle with home care. They often consume staining liquids and foods like coffee, tea, fruits, red wines, and more that cause discoloration to build over a period of time. Even with more frequent recare appointments, the stain can be heavy and hard to remove. The patient in this case had been seen at 3-month intervals for an extended period of time (Figure 5). Each time, he presented with a heavy amount of stain due to his diet. The dental team counseled him on good brushing and flossing techniques and changes that would need to be made in his diet, but the staining persisted. To help prevent the accumulation of stains, the patient was given OraCare. OraCare helps to reduce plaque. Since plaque is a sticky film of bacteria that forms on the tooth surface, it can trap pigmented substances from food and beverages, leading to discoloration or staining of the teeth. With the regular use of OraCare twice per day, this patient had little to no staining upon his return at his next 3-month recare appointment (Figure 6).
Figure 5. This patient has been seen on 3-month intervals for an extended period of time. Each time, he presented with a heavy amount of stain due to his diet. The patient is not a tobacco user.
Figure 6. The patient returned to the office after 3 months of using OraCare with an incredible reduction in stain.
Figure 7. This is the same patient as in Figures 5 and 6 but with a view of the lingual area of the mouth.
Figure 8. After 3 months of using OraCare daily.
On the same patient, we view another problematic area for many to keep clean at home. The lingual of the mandibular anterior teeth is a common place for calculus to form due to the area being hard to reach and the plaque being able to mature and harden into calculus (Figure 7). This is a common place for calculus and stain to collect. The patient admitted to only brushing once daily and did not floss but began using OraCare twice daily. Notice the reduction in stain and calculus formation in just 3 months (Figure 8).
Case 4
As seen in Figure 9, this patient also struggled to clean the lingual of the mandibular anterior teeth. The patient is seen every 4 months due to heavy bleeding and calculus formation. The patient was brushing twice per day using an electric toothbrush in the morning and a manual toothbrush at night. The patient had also been using an over-the-counter mouthwash in an attempt to help with buildup and bleeding. Due to a lack of results, the patient was given OraCare with instructions to use the rinse every morning and every night. Figure 10 shows the results after 4 months of incorporating OraCare into a daily routine. There was noticeably less calculus and a reported reduction in bleeding because of the rinse’s ability to kill bacteria and break up plaque in this problematic area.
Figure 9. The patient is seen every 4 months due to heavy bleeding and calculus formation. The patient was brushing twice per day using an electric toothbrush in the morning and a manual toothbrush at night and had also been using an over-the-counter mouthwash.
Figure 10. The following visit. The patient continued to brush 2 times per day with an electric/manual brush and floss daily. The patient replaced the over-the-counter rinse with a professional rinse, which resulted in less plaque and calculus accumulation.
CONCLUSION
Biofilm is a menace when it comes to the human body, especially the oral cavity. It is a constant battle and one that we are losing when you look at the public’s general oral health. Mechanical removal of biofilm is just not enough for most people. Our hygienists do a great job of removing calcified biofilm (calculus), but patients do not brush and floss adequately. That is a fact. Most patients brush for 30 seconds or less, and many do not floss. We must give them help, and that comes in the form of a rinse that breaks up the biofilm, kills the microbes, and prevents new biofilm growth. Studies and clinical cases prove that rinses work. As stated in the beginning, control of biofilm may be the most important factor in your patients’ oral health. Incorporating rinses in their home care may be one of the best and easiest things you can do in the continued fight with biofilm.
ACKNOWLEDGMENTS
The author would like to thank Wohlers Family Dentistry and Cloudland Dental for their contribution to the cases mentioned in this article.
ABOUT THE AUTHOR
Dr. Martino earned his DDS degree from the West Virginia University School of Dentistry. Following dental school, Dr. Martino practiced dentistry in the Bridgeport and Buckhannon areas of West Virginia. He now owns and operates 7 dental practices in West Virginia, presiding as CEO of Wilmar Management Company. In 2012, Dr. Martino co-founded Dentist Select and helped launch OraCare. He is currently CEO. In 2013, Dr. Martino founded Freedom Day USA (freedomdayusa.org), a national movement to thank our active military and their immediate family members, along with our veterans. He can be reached via email at robertmartino@wilmarmanagement.com.
Disclosure: Dr. Martino reports no disclosures.
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