This Biofilm Message Needs to Stick

Getting patients to understand just what biofilm is and why it’s so important to consider in their daily lives.

For me, a day of writing is equivalent to a day of sunshine, especially when I’m writing about a topic that grabs my attention. I’ll never forget the day I was introduced to biofilm.

A booklet arrived in my mailbox and I think it may have been a dental magazine insert. The year was 2002 and the title was “Emerging Trends in Oral Care: Biofilm Revolution” by Scientific American Inc. and Philips Electronics. A Bozeman Symposium in 2003 by the Center for Biofilm Engineering at Montana State University further clarified new understandings of how biofilms develop and propagate. From that moment I became interested in chronic wound care and learned about biofilm that lives on the surface of chronic wounds, preventing antibiotics from fully penetrating them or failing to attack bacteria that live in these films.

Wound care nurses at Emory University taught me that biofilm plays a crucial role in delaying wound healing and ultrasonic debridement, among other treatments, is used for wound biofilm removal and suppression. That was when a light bulb went off in my head and I continued to follow the research, already knowing that dental plaque is a biofilm.

The late J. William Costerton wrote The Biofilm Primer (2007) which was an introduction to the field of biofilms. Bill (as he liked to be called) is recognized as the founding father of the field of biofilms. A Canadian microbiologist, he was naturally curious about directly observing living complex microbial communities like dental plaque on teeth. In reading his book, I learned how biofilms attach to surfaces and how they flourish in natural environments (on rocks in streams, for example or teeth) or engineered environments like shower walls or toilets.

Now my mind was racing, and I wanted to know more about oral biofilm formation on teeth and root surfaces and the role of oral biofilm in dental caries and periodontal diseases. There is a ton of research on the role of microbial biofilm communities in the pathogenesis of periodontitis and dental caries.

Maximizing the “Stickiness” of an Oral Health Message

Educational messages to patients need to “stick” and I’ve met a several dental professionals in my life who can take an oral health message and make it stand out. Let’s talk about a couple of them who are good at it. 

Paul H. Keyes, DDS, MS:

Dr Keyes was a practicing dentist and an award-winning dental researcher who passed in 2017, a few months shy of his 100th birthday. Dr Keyes is best known for advocating anti-infective agents and microbiological testing in nonsurgical periodontal therapy and his professional background was very impressive.1 Before he passed, Dr Keyes sent me a packet of materials including photos, CDs, research reports, magazine excerpts, hand-written notes to me, and newspaper articles. I admired Dr Keyes for many reasons, and he was a great friend of dental hygiene because he recognized the potential of the dental hygienist in the prevention and early treatment of dental diseases like gingivitis, periodontitis, and dental caries. In his prime, Dr Keyes was unpopular with periodontists which may have been because, as his supporters have said, his detractors (periodontists) had a vested interested in more expensive dental surgery.2

I suspect that Dr Keyes liked being controversial because he understood it would take a simple, inexpensive, and emotional messaging to grab a patient’s attention. One of his messages was this, “brush with soda every day and you’ll never lose teeth.” His nonsurgical periodontal therapy regimen came in 2 parts: microscopic analysis which he called MMPT followed by meticulous SRP, systemic antibiotics for more severe or refractory cases and a “salt-and-soda” regimen in addition to other self-care procedures.2

Sandy Sheffler, RDH

Sandy Sheffler, RDH practices with a phase-contrast microscope and she and I greatly admired Dr Keyes. Although we now know that periodontal diseases result from an interaction between a microbial challenge (from pathogens in subgingival biofilms) and host response, Sandy likes taking biofilm samples to motivate patients based on the educational value of various specimens on the viewing screen.

When patients see WBCs, spirochetes, and motile rods floating by on the screen it captures their attention. Sandy uses the phase contrast microscope as a score card to attain a diminution of microbes.3 Sandy has been practicing with a phase contrast microscope for 35 years and this year marks 50 years in dental hygiene practice! Sandy told me on the phone today that she plans on retiring from clinical hygiene at the end of 2023 and hopes to become a patient coordinator. In this role, she hopes to continue to educate patients and strongly believes that dental hygienists are “healthcare providers and not just someone who scrapes something off of teeth.” I’ve known Sandy for a very long time and have always admired her grit and determination to educate her patients to the best of her ability.

The term dental plaque has been replaced by biofilm by some individuals including me. Dental plaque is a biofilm and there’s nothing wrong with using the term “dental plaque” but research on biofilms creates an opportunity for dental professionals to tell a new story. As technology continues to advance, identification of infectious bacteria responsible for biofilm-associated infections is more challenging due to the complex and heterogeneous biofilm matrix.4

In medicine, research continues to create sensors to detect and identify biofilms.5 Since periodontitis is associated with dysbiotic biofilms in a susceptible host, perhaps at-risk individuals with early inflammation will be marked someday by sensor technology that can identify specific biofilms. There is a small percentage of patients with a more aggressive form of periodontitis who might benefit from more accurate diagnosis.

Stick-Worthy Messages for Today’s RDH

I’ve finally read a book I purchased last year on making public health and other messages stick.5 The book gives suggestions on how to get our ideas across to patients in a way that grabs their attention. I recently talked to a new patient about biofilm. The patient, a highly educated adult male from California, had never heard the term “biofilm,” but he was all ears and I had so much fun explaining how biofilm “disruption” is a critical component of oral hygiene care. I compared biofilm to the black ring on his toilet and his eyes opened even wider! He wanted more information about biofilm and our conversation eventually concluded with a customized plan to suppress biofilm formation.

Here are some valuable suggestions for anyone who wants to create sticky, memorable biofilm messages that every patient you meet will remember you by:

  • Keep it simple, sweetie. Ideas must be simple, yet profound. I tend to use a lot of metaphors and with biofilm it’s relatively easy to do. Teach your patient to become a biofilm-buster.
  • Surprise the patient to get their attention. Go back to using the 2-tone disclosing solution and then tell the patient they’ve been exchanging biofilm with their love interest when they kiss!
  • Our brains are wired to soak up sensory information. Show the patient a 3D image of a growing biofilm and tell them how long it takes for it to grow.
  • Sticky ideas need credentials to be believed. As a journalist, it was easy for me to do this, but you need to brag about yourself and show that patient that you have expertise and self-confidence.
  • Make the patient feel that their mouth is unhealthy if that’s the case. It’s easy to do with food debris, disclosed biofilm or even white spot lesions or holes in the teeth. Up your game and give the patient your full attention.
  • Tell stories. Telling success stories about other patients (with emotion) works! For example, tell the patient you picked up a slimy rock in a stream and then sniffed it and realized there was life in the “slime” called biofilm. That’s how biofilm was discovered as explained by the late Bill Costerton in his Biofilm Primer book.
  1. Paul Keyes Obituary. The Washington Post. Published 2017. Accessed February 8, 2023.
  2. Keyes PH. Microbiologically monitored and modulated periodontal therapy. Gen Dent. 1985;33(2):105-113.
  3. Sheffler, S. How a microscope changed my career. RDH magazine. Published Oct 1, 2004. Accessed February 8, 2023.
  4. ACS Sens. 2022, 7, 2, 347–357. Published February 16, 2022.
  5. Heath C and Heath D. Made to stick: why some ideas survive and others die. NY. Random House (2007)