Running Time: 42 min
Review current concept on dental biofilm properties and composition Discuss the role of host response and modulation to biofilm burden Understand the role of risk assessment in patient management Discuss clinical strategies for biofilm management Release: 9/26/2014 | Expires: 9/26/2017
Release Date: September 30, 2014Subtitle:
Welcome to the module on the Dental Biochemistry, the Role of Dental Biofilm. My name is Karima Bapoo-Mohamed. I’m a dental hygienist from Edmonton, Alberta, Canada, and an associate clinical professor at the University of Alberta in Edmonton. Biofilms. Biofilms exist everywhere in nature. And they are, actually, part of the natural habitat of the environment, and actually form a critical role in the food chain of a lot of the organisms. This module will actually review the concept and the exciting new discovery of plaque actually being a dental biofilm. So what are some of the properties and composition of the dental biofilm? What is the role of the host response? And how do we modulate against this biofilm? Another objective for this course today will also be getting an understanding of risk assessment in our patients, and how do we then manage the risk for our patients? And finish off with some clinical strategies for biofilm management. The study by Centers for Disease Control and Prevention, the CDC, estimates that 45% of American adults have some form of periodontal disease. It’s mild, moderate, or severe. And it has been shown by scientific methods, that actually dental plaque is now viewed as a biofilm. We will define what a biofilm is as we move along. Which actually explains now that we have an understanding of dental plaque being biofilm, that the delivery of antimicrobials in the past, like tetracyclines and what have you, were just not effective in fighting periodontal disease. So really, viewing plaque as a biofilm has really helped us in the management, prevention, and actually treatment of periodontal disease, in a lot of ways. Biofilms are actually an oral microflora. It has a wide variety of composition, usually subgingivally located. There’s about over 300 species of bacteria, or species, in these periodontal pockets, in different individuals, of course. Nonsurgical, mechanical perio treatment is still effective against reducing the number of these microorganisms. Some of these microorganisms will actually reestablish themselves, rapidly, and especially with patients who have past history of biofilm formation. So what is a biofilm? Well, what it is, a complex microorganism colony. And it’s very cooperative, in that it was arranged in a certain way. It’s a micro colony, with a lot of channels in between them. So really they’re connected to these channels. There’s a protective matrix over it, which actually is very critical. Because it is resistant to a lot of the measures that we subject the biofilm to. It has a primitive communication system as well. So really, the gene expression also defers from a microorganism that exists in a biofilm, as opposed to a microorganism that exists free floating, or without the protective matrix of a biofilm. So this makes it quite a force to contend with, now that we understand what the dental biofilm properties are. It is composed of a wide variety, as we mentioned, of microorganisms. But it also has that ability to re-establish itself as well. Some of the significant microorganisms are actually the P. Gingivalis, the AA, as well as the T. Forsythia. And of course, there’s other links such as T. Denticola as well. Why the P. Gingivalis? Well, that’s an interesting microorganism, because it has a very low end of toxicity, which means that it doesn’t incite a full-fledged detection by the host. It’s also very virulent, in that it can invade and attach very easily on there. It does have this core aggregation property. And it actually attaches onto the host by using fimbriae or pili, which is the fingerlike tentacles you see surrounding the structures on the surface parameter of the P gingivalis. A very pivotal study by Socransky shows that it’s not so much that there’s a plaque– yes, plaque matures, and there will be colonization, especially in the subgingival area– but it’s not so much the amount of plaque, but actually what’s critical is the composition of the plaque. So the mix of the microorganisms that are habitating in this community becomes way more critical in understanding this dental biofilm. And of course, it’s different for every patient. The general makeup of this biofilm, as we mentioned, it is different from normal health. And it has an open architecture, which means it can actually move and shift very easily. It is anchored right onto the whole surface, right there. And they do have inter-cell communication, as primitive as it may be. They do communicate by a chemical signal called quorum sensing. Now, it is fairly rudimentary, but seems to prove very effective in the colonization and proliferation of a dental biofilm. The biofilm matrix does have that protective barrier, so really, when we’re mechanically doing the plaque control, when we’re giving our patients oral hygiene instructions, it’s very possible they’re not penetrating this protective barrier, which can actually reform fairly rapidly and quickly. Micro-environments are also formed within the colony of the biofilm and what’s neat about that is it has different pH’s and different parts of the colony. Also the amount of nutrients that are available in different parts of the colony can vary, as well as the oxygen concentration. So it’s pretty sophisticated, the more we learn about it, it’s actually quite fascinating, as to what goes on subgingivally in our mouth. And it is primarily dominated by a gram-negative anaerobes. So let’s talk about the host response and host modulation for this dental biofilm burden that the patients are experiencing. We’ve heard or learned about the nonspecific plaque hypothesis, which says that, really, the self-care regimen and strategies we give our patients, for brushing, flossing, rubber-tipping, interdental cleaning is actually adequate for this, because plaque is nonspecific. We now know otherwise, that there are specific components of the plaque. But it actually helps explain why some patients, who are fairly healthy, will have, actually, really advanced periodontal issues. And then you have patients who don’t take that much care, for their home care maintenance or oral [INAUDIBLE] therapy maintenance at home, that they do have fairly healthy mouths. So really it’s to do with that specific plaque theory. Factors that really affect the host, well, there’s a multitude of factors, ranging from stress, hormonal changes. We’re going to discuss this in a few slides over. But really, the host response, the key message with this slide, is that the host response changes continually, not just through the life, but from hour to hour, from week to week, literally, the host response can change. So it doesn’t matter how unstressed or stressed you are, the episodic occurrence of periodontal disease may not be related at all, with the way the patient’s home care performance or effectiveness is. Here’s a list of some of the risk factors we mentioned earlier. Genetics, the IL1 gene we’ve talked about, is definitely an indicator of high risk for periodontal disease. Diabetes, you want to look not only for the glycemic index, such as the blood sugar levels, but really focusing on what is their A1C level in their last blood test. Autoimmune diseases, like arthritis and lupus, absolutely are a risk assessment, criteria for us to clue in. Curious about patient’s nutrition and how much of processed foods are they having, and how is their antioxidant intake, really, will affect the general health and well being of your oral tissues as well as your general health tissues. How much sleep are you getting? That absolutely affects your immune system. And you are only as good as your immune system is. Because your immune system is a shield that’s protecting you against diseases. So having adequate sleep, lots of water is also the other thing we mention to patients. Obesity is also linked as a risk factor for biofilm load, for oral hygiene, of course, and smoking and alcohol has a multiplier effect as well. So let’s talk about this exponential effect. If you have a patient with two risk factors, the way the exponential effect works is you multiply the two numbers. So two risk factors give you a risk factor of four. However, if your patient has three risk factors, for example, maybe they’ve been recently diagnosed with Type 2 diabetes and they’re a smoker, and genetics– well, their dad had dentures, because they lost all their teeth from periodontal disease– that’s now giving you three risk factors. And three risk factors have just multiplied your overall risk to 27%. And if you add a fourth risk factor, that changes the number to 256 times. So lots of studies done on this exponential effect. The big message for us, as hygienists, is watch out for these risk factors, understand what they are. And then, if there’s one or two risk factors, I may decide to put the patient in a three to four months recall. But if there are more than two risk factors, I might choose a different protocol, depending on the patient’s manual dexterity, dental IQ. So really, the significance is customizing it for them, and having, maybe, more frequent recall visits to the office. I mentioned the nonspecific plaque theory earlier on, that it is the hypothesis that shows, or holds, the proposition, that the entire bacterial flora in the plaque plays a role in periodontal destruction, rather than any specific bacteria, that all plaque is viewed as bad plaque, and that the more plaque you have, the more chances of disease you’re going to have. So really, with the non-specific plaque theory, plaque control was viewed as essential in limiting the progression of periodontal disease and inflammation related to periodontal destruction. This is another stylized image of what the dental biofilm looks like. And it’s fascinating to see the fluid channels, which not only provide the nutrients and oxygen to the bacterial microcolony that’s inhabiting in this area, but it’s actually excreting all the waste product, so that there’s no toxin accumulation within this microcolony, fairly fascinating research, and amazing to see how sophisticated and how organized these bacteria are. And these bacterial microcolonies actually use the chemical signals that we talked about. So it almost feels like, if you have a habit of brushing just one way, they have a way of communicating to actually grow the way you’re not brushing, in order to survive and proliferate in your mouth. This is, again, showing the phases of plaque formation. We’re all familiar with how it starts out, with an acquired pellicle, and then we have the initial colonization. Then we have a secondary colonization. And as the plaque matures, with the volume and number increasing, it get anchored onto the whole site and producing this kind of a physical manifestation microscopically. This picture is, again, showing the different varieties of bacteria that exist in the microflora of the oral cavity. And again, the big message here is, it’s not the amount of plaque, that not all plaque is bad, but that the composition, the mixture of all these different organisms and how they are inter-reacting with each other, becomes a critical factor in understanding dental biofilm. So we talked about some of the risk assessments. Now, what are some of the things we can do to manage these risks, from a patient’s perspective, and from an operator perspective? Risk factors, really, we need to understand them. Because they affect the onset, the rate of progression, and really, the severity of the periodontal disease, in response to any therapy you’re going to give it. And really, risk factors help us determine what is the appropriate maintenance protocol. Maybe every six months isn’t going to cut it for a hygiene recall for this patient, and we need to come up with a more customized recall strategy for them. And risk assessment really is an ongoing process. Because guess what? Patient’s lives don’t stay the same. They’re constantly changing, from one recall to the other recall. So we want to be assessing them on a regular basis. So we’re going to go over the list of the risk assessment for periodontitis. And then we’re going to talk about how we can reduce some of these risks. Some of them are under our control, some are not. For example, a genetic predisposition shows that you are predisposed to periodontitis or have familial history of periodontitis, may make it difficult to control. But having knowledge, an awareness of that concept, might make you be a little bit more vigilant about your maintenance and how you look after your teeth and gums. Smoking absolutely has shown evidence, we have seen evidence of the history and frequency of smoking, will have an effect on periodontitis. Hormonal changes, specifically for pregnancy, as well as menopause, will have an effect on periodontitis. And we talked earlier, on a different module, on the systemic diseases, where we discussed diabetes, osteoporosis, immune system diseases, and also a lot of blood disorders do have– connective tissue diseases as well– have a risk factor for periodontitis. Stress, as reported by the patient, is definitely a risk factor. So patients feeling overwhelmed and stressed about life, chances are, their immune system isn’t quite up to par, and they will become a risk for developing periodontitis. Nutritional deficiencies, very important component of what does their diet look like? Medications, especially the calcium channel blockers as well as the anti-convulsant medicines, Dilantin, for example, gives us the gingival hyperplasia, will have an effect and higher risk for periodontitis. The kind of dentistry that exists in a patient’s mouth will also have an effect. Watching out for occlusal overloading, how the patient’s relating the top jaw to the bottom jaw, as well as their hygiene and home care, and past history of periodontitis. So with this list of risks, let’s talk about how do we modify the risk? I’m not sure if you’ve heard the term, perioceutics, and that’s a pharmaceutical agent that we’ve developed as an antimicrobial therapy for patients, strictly for treatment of periodontitis. So that is also an arena for prevention or management of periodontal disease. A lot of this, again, I keep mentioning, has to be dependent on the host response and host immunity, and really, the levels of enzymes and cytokines that the host is producing will really have a factor on how the risk is reduced or modified. One way to actually reduce the risk of periodontitis or reduction of the biofilm, is really having more frequent visits. If we’ve identified the patient as having two or more, as we mentioned, with the exponential effect, that you want them in the office a little bit more frequently. Smoking cessation counseling may be indicated for our patients who are on a moderate to high risk. What about patients with the hormonal variations? Perhaps we want to have them checking with a medical doctor for any modifications if possible. Patients with a systemic disease, can they improve their glycemic index? And can they control their diabetes maybe a little better? Is our osteoporotic patient doing everything possible, as far as preventing or managing the deterioration of their osteoporosis, for example, taking calcium supplements or bisphosphonate. The immune system and the hematologic disorders, absolutely, we want to make sure that that can be controlled and reduced as best as possible. Stress management, perhaps the patient needs a referral if they’re self diagnosing as very stressed and very maxxed out, maybe a referral to a psychologist or a psychiatrist may not be a bad idea, and actually a risk reduction for biofilm management and periodontitis. Nutritional supplementation, especially if you’re doing nutritional counseling, would be a good referral as well, maybe to a nutritionist. And again, consulting with the physician for the medications they’re on, could there be some alterations or changes? For example, if it’s a risk of xerostomia, or dry mouth syndrome, could there be an alternate medicine that could be given to the patient? And if their dentistry is impeding or impacting and creating microcolonies and opportunities for the biofilm to re-aggregate, could that dentistry be corrected? And could the occlusal adjustments be corrected, in a way that actually helps the patient maintain and manage their periodontitis, and more importantly, manage their dental biofilm on a daily basis? So really, the key is to set the patient up for success as best as we can, so that they can manage or self manage their oral hygiene care. So we’re going to talk about some of the clinical strategies. We do this on chairside and home care for our patients, for dental biofilm management. Absolutely, as part of our clinical assessment, we’re looking at the clinical tissue and we’re doing our probe readings. We’re looking for the alveolar bone support, making sure there’s no mobility. What does the recession look like? Is there any furcations? And of course, we’re good with taking our indices for plaque scores and calculus deposits. One key element we have to really focus in on is bleeding points. Every time you’re noticing an asterisk, it is cause for inflammation. Bleeding is a sign of the body raising a flag and saying, I’m here. I’m here. Come and get me. These are the microorganisms that are producing toxins, inciting an inflammatory reaction by the body. And a lot of times we’ll discount it. Sometimes while I have a dental assistant helping me out with the charting, I will actually call out the readings, when we do the probe measurement of say, 5, 3, 2, 4, 4, 4. And I will call out the bleeding points as well. And what’s interesting though, that was unnoticed to me, is the patient is listening. And as much as they may or may not understand, which I’ll explain to them later on, what the probe readings meant, they clue in on the bleeding points. And oh, so what does that mean? And again, an amazing opportunity to explain that bleeding is not normal, your gums be bleeding, showing that it’s a warning sign for your body. The parameter that we follow is, actually, greater than 15 bleeding points raises your risk for dental biofilm proliferation and, hence, periodontal disease. Why do I have a picture of a tomato in here? 15 bleeding points equates about the size of the tomato seed. So just think of that. And I use analogies like that, to explain to my patients that, if you have bleeding points the size of a tomato seed in your forearm, would you not want to do something about it? Would that not bug you? Would that not be something that would merit your attention? And so bringing it tangibly to the patient, where they can get to wrap their head around it and say, wow, this bleeding is not a good thing, and I want to help control it. What can I do? So really, that is a good strategy, in not only educating and explaining, but actually soliciting motivation and compliance from the patient. What we want to explain and really share with the patients, from your diagnosis and findings today is, where is the location of this biofilm? What’s its composition? And depending on the patient’s dental IQ, some of them really want to know, what are the properties of this dental biofilm? And I get very animated and excited about this whole microcolony of complex organisms that’s living below your gum line. And really, what are the causes and how can you prevent this infection? Absolutely you have control over some of the risk factors there. And so then, we would be a good segway to talk about personal oral hygiene, home care hygiene, and how do you control the biofilm, moving forward? The key message you want to talk about with the self performed oral hygiene– and yes, they take ownership of it. But it’s the number of species of bacteria in your biofilm, that is the key in trying to control the proliferation and the further detriment of the periodontal supporting structures, with this biofilm. So really, the main objective is to make them understand they’ve got to reduce that bacterial load and the variety of the species is a big factor for us to watch out for. We all do this, the Bass method of brushing, which is that 45 degree angle that you want to have the patient project, right into the gum line. Flossing is probably one of the strategies that is low on the compliant list for most patients. And brushing, again, with that 45-degree angle, I would recommend at least a minimum of twice a day. I’m crazy. And I some of my patients follow this regiment even five times a day. And the five times is usually like, you wake up first in the morning, before breakfast. You want to reduce that bioload of biofilm in your mouth right away. You want to do it after breakfast, after lunch, after supper, especially before bedtime, because now your mouth is going to stay undisturbed throughout the night. And what an opportunity for you to reduce that biofilm load in your mouth. So not everybody can do five times, it’s probably not very realistic for a lot of patients. But I do put it out there as something, maybe, worthy of trying to achieve. Some patients may just– like I find my aging population, it may be tough for them to get that 45-degree angle, and so you rely on a lot of the power adjuncts, such as power toothbrushes, Waterpiks, or hydra flosses, any kind of device that doesn’t require a lot of manual dexterity. I’ve been known, actually, to show patients, take a normal toothbrush, a manual toothbrush, and just bend it, and putting it under a tap of hot water in the sink, in the dental hygiene operatory. And with the warm water, the plastic gets moldable, and I’ll just bend it. And patients think I’m a hero. Wow, you can do that? And absolutely, what you’ve done is customize and modified that angle of trajectory, for the patient to manage the biofilm on a daily basis at home. So think outside the box and think of situations that will really support your patient in maintaining their biofilm. And don’t forget, the other component which is extraoral, however, so necessary for biofilm and just general health, is having healthy food choices. So really, decreasing the sugary foods and the sodas and really increasing your fruits and vegetables, becomes very critical, along with, of course, continued care and regular hygiene visits. Flossing technique, I tell you, has got to be one of the hardest things, as I was mentioning earlier. And patients end up with two left hands, to wrap it around the middle finger, and then use the index on the thumb to make a C shape, is sometimes quite challenging. So again, what I do is, as best as we can, some patients will be very compliant– and it is effective in that mechanical removal of some of that biofilm that’s accessible to the cemento enamel junction or subgingival area. But more and more I feel I’m reliant on inter dental cleaners. And I really feel that might become a new mantra for us in dental hygiene, is the brush and floss is going to be brush and inter dental clean. Because it’s something that’s A, it’s one-handed dentistry. Patients can just pick up one of these little inter dental cleaners– there’s a whole different variety of them– and really work it in between the teeth and access a space. It’s not as good as flossing, because it doesn’t it mimic the C shape. But it’s something. And if the patient’s going to do it, something is better than nothing. So I rely on these quite heavily, lately. Plastic toothpicks, soft sticks, which have a little foamy end to it, are all excellent adjuncts for patients to then, in a very user friendly way, maintain their biofilm. This is again, showing a bent curved handle that you can easily manipulate, a lot of times, with the regular brushes. This is just showing some other examples of inter brushes. And you can see, you can have the different orientations, the Christmas tree shaped one, or really have a very narrow cylindrical one, especially with patients with braces or implants, or really, those hard to reach areas, I’m finding a lot of success and compliance for interdental cleaning, using such devices. Rubbertipping is absolutely something I recommend and do like it for my patients. What I like about it is, it’s got a real nice pencil point to it. And I tell patients, it’s like having one of my little tools at home, right? Except this is plastic and rubbery. And you’re not going to damage anything, when you go along and below the gum line. So really, use that along the gum line to clean it out. We all have evidence based on chlorhexidine and its efficacy in the mouth and its combat measures against biofilm. What I’ve done, actually, is worked with a pharmacist next door and created a formulation of gel, with some other components to it, too. So sometimes in periodontal disease areas, I’ll use it with my instruments. But very often I’ll make it available as a prescription to patients, who then use it as a take-home, daily basis gel, that they actually place right into the gum line, using the rubber tip. This is again, showing some more adjuncts, such as the wooden toothpicks or Stim-U-Dent. To be honest, I put this slide in because I’m not a big proponent of the wooden toothpicks or the Stim-U-Dents. I’ve had one patient, in my work history, where the wood actually slivered and splintered, and ended up in the mucosal tissue, giving this patient a huge infection. So I’m just not comfortable. If I’m going to give them interdental cleaner that is like a Stim-U-Dent. My preference is those cleaners, as opposed to the wooden toothpicks. What about mouthwashes? Patients will always, maybe, ask the question. Yeah, so, is mouthwashing OK? I mean, I like the feel. And I like the taste. And would it be OK to use a mouthwash? So again, mouthwashes are great, because they do reduce the bacterial count in your mouth. My worry with mouthwashes, or excessive use of mouthwash, is it’s very nonselective. So it can reduce some of the good bacteria in your mouth as well. So I give the analogy to my patients. It’s like you enter a room and it smells, because there’s a dirty diaper in the room. And what you’re doing is taking the air freshener and just spraying the room with air freshener. So it smells good for awhile. But the smell comes back, right? So mouthwash, to me, is similar to that air freshener. Unless you get into the cause of the irritation or the bad smell, you’re not solving the problem. Now before you’re in to see your hygienist for the next visit, and you’re not comfortable with how you’re feeling in the mouth, once in a while, mouthwashes are great. I would recommend you alcohol-free mouthwashes. And instead of– I would say consider this– instead of just taking a swig of it and sloshing it around in your mouth, consider using it with a dry toothbrush. And the instructions I give them is, actually, immerse the dry toothbrush into the mouthwash and then place it at that 45-degree angle along the gum line. So you’re getting a very site specific chemotherapeutic agent, with the mechanical force being applied at that area. And especially around the lingual areas, off your mandibular posteriors, for example, the tongue tends to cover it. And when patients brush, it foams up in your mouth and feels like you’ve been brushing for five minutes, when it’s only been, maybe, five seconds or the phone rings. But that area, I find, invariably gets missed by patients. So maybe having them using the brush, but with the mouthwash, even with the toothpaste I haven’t changed the routine. So just don’t be in a habit of picking up the brush– and I usually will ask the patient, are you left handed, right handed, how do you brush? Show me how you brush. And when they pick up the brush and I say, oh, do you always start from the upper right corner, for example, and maybe consider changing where you start the brushing. Because at the start of the brushing cycle, you’re probably doing a very good job. But towards the end of the brushing cycle, you’re in a rush and the toothpaste is foamy, and you will rush through it. So really, to reduce that biofilm load in the mouth, try changing up, every two weeks, where you start your brushing cycle from. So again, at the recare appointments what we want to do is review where the patient has been, how they’re brushing, what their issues are. Explain to them how many bleeding spots were evident in their mouth today, from your analysis and assessment. What does the soft tissue show you? And show it to them, share it with them, of course, as we do. Radiographs might have some evidence that there is biofilm breaking down the alveolar bone there. And so then that motivates them for this next phase, which is that home care routine that we want them to be following vigilantly. So the maintenance phase, again, after the active treatment is completed, we want to make sure that the mouth stays in a relatively healthy state. And we want to leave it in a healthy state, so that the patient can manage it on a regular basis, and really be specific on how often you want them on that maintenance phase. Is it a 45-minute appointment? Is it a one-hour appointment? How often do you want them to see, based on all the assessments of the risk factors that you just did with them? And do you want them to come back to you? Do you want to refer them to another specialty, perhaps? And what are some of the home care modifications you’re going to give your patient, based on their dexterity, based on your clinical findings of this case, based on their risk factors. And when we’re reassessing the tissue again, I want to emphasize the bleeding and the increased probe breeding, recession. Any time, now, you have recession, guess what? You have a new surface for the bacteria to colonize on. So we want to make sure we look after that and keep that as clean as possible. So with the debridement, we really want to make sure we use a physical removal of the dental plaque, biofilm, be it with our mechanical instruments, with our powered instrumentation, like-hand instrumentation, as well as rubber cup prophylaxis. That subgingival plaque, within the pockets, cannot be reached by brushes, flosses, or oral rinses. So really, we want to make sure that we’re advantaging the patient, when they exit the dental office, that we’ve cleaned it as best we can. And really setting up a frequent periodontal debridement routine for this patient, to return to our office for having these root surfaces examined carefully. So really the dental biofilm, plaque control, it is something that is real and happening. And it is something that we need to really educate our patients, based on the newest research or body of evidence that has come out on the biofilm. The risk factors for this patient should absolutely be considered very closely. And that bleeding is not a healthy sign. So that is an indication of some inflammatory process going on in your mouth. Chart the bleeding responses and really highlight them, in the patient’s mind. And this will give us an effect on what is that burden of that biofilm and relating it, then, to the risk factors and the patient’s host responses as well. Having a customized periodontal maintenance is critical, especially for our high-risk patients. And a patient with gingivitis, as mild and as benign as it may be, it is really a gatekeeper to periodontitis. So if you have gingivitis, I explained to patients, you are sitting on the fence. It could go either way, right? So you want it to go on the side of health and not on the side of disease, which it could easily go to, now that you’ve developed gingivitis. So really explaining to the patient how can we help protect them from this production and proliferation of biofilm, and using our magnetostrictives, our piezo, as well as some air polishing, which are some of the powered instrumentation we have available in managing biofilm. Biofilm management, it’s going to be interesting now that we have a lot of research on this, that perhaps, by manipulating the oxygen concentration– because they’re anaerobic bacteria– and if we can manipulate that subgingival flora or that environment, by way of oxygen or pH, or how many nutrients are available, maybe the biofilm cannot proliferate and will not be able to colonize. Increased gingival crevicular fluid, of course, increases the nutrient supply off this biofilm. And this that subgingival biofilm that’s so anchored into it. So can we control the gingival crevicular fluid somehow? And would that have, then, a positive effect on reduction of the dental biofilm? And of course, we want to use anti-inflammatory agents, which really help inhibit this destructive pathway of anti-inflammatory diseases. So some of the possible strategies, just to recap, was controlling the nutrients, which is including, actually, the bone-generating nutrients. How about the crevicular fluid flow? Because those are related to the inflammatory agents, subgingivally. We spoke about the actual environment of the biofilm, as far as the pH goes, and some of the antimicrobial agents that may be able to affect it or change it, and controlling the redox potential of these subgingival areas, along the ways of oxygenating agents, may be a strategy as well. But overall, really we want to prevent the colonization of these selected organisms and really have enzymes that will dissolve this biofilm. It’s thought provoking, now that we have more knowledge on how sophisticated the biofilm is. So in conclusion, we do now know dental researchers have been attempting to understand this for a long time. But we now have a better understanding of this microbial nature of oral diseases, related to dental biofilm. And really, the view of the plaque has changed, in that it’s shifted. It was specific plaque hypothesis, and it went to nonspecific plaque hypothesis. And now we’re back again to the theory of specific periodontal pathogens in the plaque biofilm. And researchers now are looking and confirmed that plaque has actually qualified as a biofilm, based on its properties and characteristics that we discussed earlier. So really, an improved understanding of this biofilm really helps us, as hygienists, in the kind of strategies we’re going to develop in managing and helping our patients with biofilm management. So to recap, here are our course objectives. We started out with the concept of plaque is a biofilm, based on its properties and composition. The role of the host is critical in the modulation and proliferation of this biofilm. We discussed, briefly, some of those risk factors that will actually create in the patient higher risk for a lot of proliferation, and then how do we help the patient, in managing and controlling, based on these risk factors? And then we talked about the actual physical management of biofilm, by sharing some clinical strategies. I’d like to leave you with a quote, at the end of this module, that comes from John Wooden, one of the greatest coaches, I feel, for basketball. We all know he was a UCLA basketball coach. And he said, “it’s what you learn after you know it all that counts.” I think it’s so appropriate, because we knew, oh yeah, it’s plaque. It’s microorganisms. We got this. We know plaque. But we now know so much more, that plaque is actually a very complex organized biofilm. And it is now qualified as that. So I think it’s a constant journey of learning and growth. And it’s when you know it all, you’re doomed. My dad used to say, when you’re green, you grow. And when you’re ripe, you rot. So you always want to be green. The term, actually, the title on this slide, which says W.O.W, I have a story I’d like to share with the audience. I was working on a presentation for one of the international trips I was going. And my daughter, who was maybe about nine years old then, comes in the den and watches what I’m doing. And so here I am, I know it all. I’m a mom. So I say, hey, look what I came up with? Wow, W.O.W. means, “words of wisdom,” pretty cool, hey? Like, I came up with that acronym. And so she’s just looking at this screen, on the computer, sitting on my lap, going hmm. she’s not responding. And I’m like, do you get it? Like, W.O.W., words of wisdom. And she says, uh huh. It’s also an upside down mom. So there’s a different perspective I learned from my nine-year-old. So I think the opportunity to learn and grow and really change our perspective is continual. It’s a continual momentum. I thank you very much for joining us on this module, Dental Biofilm. We look forward to seeing you at the next module. Goodbye.