International Dental Journal (2010) 60, 200-203

Biofilm dynamics at the gingival

frontier
Sebastian Ciancio
Center of Dental Studies , State University of New York ( SUNY) , Buffalo, USA

Microbial biofilms are common in the human body and in the environment. In recent
years, dental plaque has been identified as a biofilm, and the structure, microbiology,
and pathophysiology of dental biofilms have been characterised. The nature of the biofilm
enhances the component bacterias’ resistance to both the host’s defence system and an-
timicrobials. If not removed regularly the biofilm undergoes maturation, resulting in dental
caries, gingivitis, and periodontitis. The control of biofilm accumulation on teeth has been
the cornerstone of periodontal disease prevention for decades. However, the widespread
prevalence of gingivitis suggests the inefficiency of self-performed mechanical plaque
control in preventing gingival inflammation. Studies indicate that effective antiseptic mouth-
washes can provide significant gingivitis reduction beyond what can be accomplished with
only brushing and flossing. Particularly, mouthrinses containing essential oils have well
documented clinical antiplaque and antigingivitis effects. These mouthrinses have a posi-
tive track record of safety and their use does not increase the levels of resistant species.
In summary, use of a well-established, essential oil mouthrinse can be recommended for
daily use as an adjunct to mechanical methods of plaque control.

Key words: Plaque, biofilm periodontal disease

Biofilms are complex arrangements of bacteria which
are ubiquitous and are potentially found in a variety
of sites within the human body. In areas related
to oral health care, bacterial biofilms are found on
tooth surfaces, dental prosthetic appliances and oral
mucous membranes, and are referred to as ‘dental
plaques’. Biofilm in the form of supragingival and
subgingival plaque is the aetiologic agent in dental car-
ies and periodontal diseases1-4. The pathogenicity of
the dental plaque biofilm is enhanced by the fact that
the component bacteria have increased resistance to
antimicrobials and are less able to be phagocytised by
host inflammatory cells. Therefore, control of dental
plaque biofilm is a major objective of dental profes-
sionals and critical to the maintenance of optimal oral
health. This article reviews the dental biofilm, its role
in the aetiology of periodontal diseases, and provides
an overview of strategies for controlling the biofilm
to promote oral health.
Besides being a prerequisite for caries occur-
rence5.6, dental biofilm is the direct cause of gingivi-
tis7. In a classical study of experimental gingivitis, the
withdrawal of all measures of oral hygiene resulted
in the accumulation of abundant biofilm and the
© 2010 FDI/World Dental Press
0020-6539/10/03200-04 (Supplement 1)
development of marginal gingivitis8. As some patients
may improve oral hygiene just before a dental appoint-
ment, the assessment of the gingival condition seems
to be a reliable and valid measure relative to the quality
of biofilm control9.
Overview of dental plaque development
The growth and development of biofilms are charac-
terised by four stages: initial adherence, lag phase, rapid
growth, and steady state. Biofilm formation begins with
the adherence of bacteria to a tooth surface, followed by
a lag phase in which changes in gene expression occur. A
period of rapid growth then occurs, and an exopolysac-
charide matrix is produced. During the steady state, the
biofilm reaches growth equilibrium. Surface detachment
and sloughing occur, and new bacteria are acquired.
The most prevalent oral biofilm, i.e. dental plaque,
exists as a complex multispecies entity, consisting of
more than 700 bacterial species on the tooth surface.
The bacteria in the biofilm deposit on the teeth by
attaching to host-derived glycoproteins, mucins and
other proteins coating the tooth surface10. These sali-
vary proteins are deposited within minutes on a clean
doi:10.1922/IDJ_2557Ciancio

tooth surface and are called the ‘acquired pellicle’, which
makes the surface receptive to colonisation by specific
bacteria. Acquired pellicle formation begins within min-
utes of a professional prophylaxis and within one hour,
microorganisms attach to the pellicle.
Furthermore, microorganisms on the outer surface
of biofilms are not as strongly attached within the ma-
trix and tend to grow faster than those bacteria deeper
within the biofilm. Surface microorganisms are more
susceptible to detachment, a characteristic that facilitates
travel and formation of new biofilm colonies on nearby
oral structures and tissues.
Continued development of the plaque biofilm relies
on physical interaction of bacteria of the same or dif-
ferent class through coaggregation and coadhesion11.
Many of these bacteria would not usually interact with
each other in a way that results in aggregation. However,
certain bacteria, such as Fusobacterium nucleatum, serve
as important bridges between these non-coaggregat-
ing, early colonising bacteria and the late colonisers11,
facilitating coaggregation.
Studies on the microbial aetiology of various forms
of periodontitis demonstrate that only certain micro-
organisms within the plaque complex are pathogenic.
These specific virulent bacterial species activate the
host’s immune and inflammatory responses that then
cause bone and soft tissue destruction12-14.
Biofilms can harbour mucosal surfaces throughout
the oral cavity. Microcolonies exist on oral mucosa,
the tongue, and especially the dorsum of the tongue
(because of its long papilla (flagiform papilla)), bioma-
terials used for restorations and dental appliances, and
tooth surfaces above and below the gingival margin.
As the biofilm begins to mature, there is a progressive
shift from a gram positive, aerobic flora to one pre-
dominated by gram negative, anaerobic species. This
shift is associated with the development of the biofilm
beneath the gingival surface and is strongly influenced
by supragingival plaque biofilm. However, salivary and
masticatory influences that have an impact on the su-
pragingival microflora do not have the same influence
on subgingival bacteria15. As the gingival inflammatory
process continues, additional mediators are produced,
and more inflammatory cell types such as neutrophils,
T cells, and monocytes are recruited to the area.
The result of this chronic inflammation is a break-
down of gingival collagen and accumulation of an inflam-
matory infiltrate, leading to the clinical signs of gingivitis.
In some individuals, the inflammatory process will also
lead to the breakdown of collagen in the periodontal
ligament and resorption of the supporting alveolar bone,
leading to periodontitis. Thus, controlling dental plaque
biofilm is essential to preventing and reversing gingivitis
as well as preventing and managing periodontitis.
Inorganic components are also found in dental
plaque; largely calcium and phosphorus which are
primarily derived from saliva. The inorganic content
201
of plaque is greatly increased with the development of
calculus. The process of calculus formation involves
the calcification of dental plaque. The practical con-
sequences of calculus formation are that the deposit
is significantly more difficult to remove once calcified,
and it leaves a rough surface on the root which is easily
colonised by plaque.
The extracellular matrix produced by biofilm bac-
teria encloses the microbial community and protects it
from the surrounding environment, including attacks
from chemotherapeutic agents16-19. Thus, the matrix
helps to protect bacteria deep within the biofilm from
antibiotics and antiseptics, increasing the likelihood of
the colonies’ survival. Furthermore, the extracellular
matrix keeps the bacteria banded together, so they are
not flushed away by the action of saliva and gingival
crevicular fluid. Mechanical methods, including tooth-
brushing, interdental cleaning, and professional scaling
procedures, are required to regularly and effectively
disrupt and remove the plaque biofilm. Antiseptics,
such as mouthrinses, can help to control the biofilm
but must be formulated so as to be able to penetrate the
plaque biofilm matrix and gain access to the pathogenic
bacteria.
It is important for oral health professionals to com-
municate to their patients that both dental caries and
periodontal disease are infectious diseases resulting
from dental plaque biofilm accumulation. Each of these
diseases requires specific strategies for prevention and
treatment.
Penetrating the plaque biofilm – role of
essential oil containing mouthwash
Bacteria in plaque biofilms are more resistant to antimi-
crobial agents than they are in the free-floating (plank-
tonic) form. The efficacy of any antiseptic mouthwash
depends on its ability to penetrate the biofilm in addition
to its ability to kill bacteria in vivo20.
Essential oil (EO) mouthwashes kill microorgan-
isms by disrupting their cell walls and inhibiting their
enzymic activity. They prevent bacterial aggregation,
slow multiplication and extract endotoxins. Studies also
suggest that an effective mouthwash must also penetrate
the plaque biofilm.
The efficacy of oral antiseptics is usually attributed
to their bactericidal activity, but essential oils also work
by interfering with bacterial colonisation of the tooth
surface. Essential oils stop bacteria from aggregating
with gram positive pioneer species, slow bacterial mul-
tiplication, and extract endotoxins from gram negative
pathogens21. This can lead to a reduced bacterial load,
slow plaque maturation and decreased plaque mass and
pathogenicity.
The essential oils in an over-the-counter mouthwash,
Listerine (Johnson & Johnson), have demonstrated the
ability to penetrate the plaque biofilm and have also been
Ciancio: Biofilm dynamics at the gingival frontier
202
shown in vitro to kill 99.9% of oral gram positive and
gram negative bacteria, opportunistic bacteria and yeast
within a 30 second exposure22-24. The active ingredients
of this essential oil mouthwash are a fixed combina-
tion of four essential oils; thymol 0.064%, eucalyptol
0.092%, methyl salicylate 0.06%, and menthol 0.042%25-
27
. These essential oils slow plaque maturation and
decrease plaque mass and pathogenicity20,28. Listerine is
the only over-the-counter mouthwash to have received
the ADA (American Dental Association) Council on
Scientific Affairs Seal of Acceptance for control of
supragingival plaque and gingivitis.
Rinsing with essential oils could also impact the
subgingival microbiota29. The subgingival antimicrobial
effect of the mouthrinse is most likely mediated by
disruption of the contiguous supragingival biofilm29.
A regimen of twice daily rinsing with essential oils for
14 days can reduce the levels of total anaerobes, gram
negative anaerobes and volatile sulphur compound-pro-
ducing organisms in plaque and on the dorsum of the
tongue up to 12 hours after the final rinse, indicating a
certain level of substantivity24.
A study examining the adjunctive benefit of essential
oils in reducing plaque and gingivitis in subjects who
brush and floss regularly, demonstrated that in addition
to brushing, the essential oil mouthrinse group had sta-
tistically and clinically significantly lowered plaque levels,
suggesting that essential oils are an effective adjunct to
regular brushing and flossing30 or brushing alone31.
Conclusions
In summary, dental biofilm is a complex, organised mi-
crobial community that is the primary aetiologic factor
for the most frequently occurring oral diseases: dental
caries and periodontal diseases. Dental plaque accumu-
lates not only on teeth, dentures and orthodontic appli-
ances but also on oral soft tissues. This accumulation is
facilitated by the absence of adequate oral hygiene pro-
cedures. Dental plaque consists of a biofilm containing a
mass of microorganisms embedded in an organic matrix
of host and microbial origin. Consequences of plaque
include dental caries, gingivitis, periodontal disease and
denture associated problems. Thus the prevention of
plaque formation, the reduction of plaque accumulation
and the effective removal of plaque play a significant
role in maintaining optimal oral hygiene.
The goal of keeping dental biofilm growth to low
levels has been shown to be more achievable when
chemotherapeutic agents such as essential oils rinses
are used in conjunction with conventional mechanical
means of plaque reduction. Based on the evidence-base
supporting this, it is recommended that dental patients
be educated on the benefits of rinsing with an estab-
lished and clinically proven antimicrobial mouthrinse,
after brushing and interdental cleaning, in order to
achieve optimal oral hygiene levels.
International Dental Journal (2010) Vol. 60/No.3 (Supplement 1)
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Correspondence to: Sebastian Ciancio, Distinguished Service

Professor and Chair, Department of Periodontics and Endodontics,
Adjunct Professor of Pharmacology Director , Center for Dental
Studies, 250 Squire Hall, University at Buffalo, SUNY, Buffalo, NY
14212, USA. Email: ciancio@buffalo.edu

Ciancio: Biofilm dynamics at the gingival frontier