Why is Biofilm Disclosing so important?
Interview with dental Hygienist Faye Donald
When did you start disclosing biofilm and plaque on your patients?
At university we were taught to use disclosing solutions to help us record the patient’s plaque scores prior to giving oral hygiene advice. It was considered an adjunctive measure to toothbrushing instructions with the focus on highlighting plaque deposits for patients who would otherwise struggle to see the areas where biofilm tends to accumulate. At the time (1999 to 2001) the focus of treatment for periodontal disease still revolved around the removal of calculus deposits and what the profession thought was ‘contaminated’ cementum.
The discloser was very much for the patients benefit as it was considered an added help for the clinician, who could now see what he needed to see (calculus and stain) above the gum line and feel what they needed to feel beneath the gum line via tactile sensation.
As soon as I finished university and was faced with the time pressures that general practice brought, the number of patients I used disclosing solution on dramatically decreased as my attention was turned to scaling and polishing with less and less time dedicated to data collection and adequate oral hygiene instruction. The recording of plaque indices was virtually stopped and I could shave valuable minutes off the time that I took for oral hygiene instruction if I didn’t use the disclosing solution. At the time, I had only 20 minutes to complete the appointment, disclosing felt like an unnecessary “add-on exercise” that I simply didn’t have time to indulge in. Also, removing disclosed plaque was time consuming and it was far easier to turn a blind eye to the remaining biofilm if I hadn’t made it obviously apparent with the disclosing solution.
If you did not start immediately after beginning your professional career, why did you decide to disclose patients?
It was a couple of years later when conclusive findings emerged supporting the theory that plaque (biofilm) and the host response were the dominant factors in managing periodontal disease that my focus shifted and I started to place more emphasis on biofilm disruption. Patient education became the primary focus of my attention and naturally I searched for tools to help patients develop their home care techniques as well as tools that could help me to stay focused.
Disclosing solutions were the obvious answer but at this stage I was still using it solely for the purpose of patient education and only for those patients I felt would benefit from making changes to their home care regime. Stable patients or patients whom I deemed were already doing the best they could, were not disclosed. It never occurred to me that I might not be adequately disrupting all of the biofilm and it didn’t occur to me to check otherwise. I just presumed I was. It wasn’t until I discovered Guided Biofilm Therapy that the true advantages of disclosing every patient were unveiled to me.
Which, in your opinion, are the main advantages of disclosing for the patient?
Disclosing solution breaks down many barriers to communication. We all have different learning styles (often called sensory receivers) with ‘visual’ being one of the main receivers. Visual learners don’t tend to take in much of what we say. They need visual aids before they can absorb the messages. By disclosing patients prior to oral hygiene instruction, we can tune into those learners who need visual support in order to process new information.
We also engage those patients who are mistaken about how well they clean their teeth. Often patients are disillusioned, especially those who’ve invested in expensive brushes and regularly use interdental aids. These patients think they do enough and it doesn’t occur to them that there might be areas that they missed. Disclosing solutions are the quickest way to demonstrate that technique plays as much of a role as the oral hygiene itself. Patients can’t ignore evidence presented to them right in front of their eyes. It’s factual, indisputable and it’s personal to them. It means I can move away from generic advice and give site specific, tailor made instructions that are personal to my patient’s own mouth. They’re often genuinely surprised to see evidence that their efforts have fallen short of the standard required to maintain oral health. It’s a very effective way to engage patients.
What about advantages for the clinician?
If you think about our training, fundamentally we are taught to remove deposits from teeth, whatever they might be, be it calculus, stain or biofilm. We want as much of it gone as is realistically achievable to leave behind a clean surface. We now know that biofilm plays a bigger role than calculus in the disease process and yet much of it isn’t visible to the naked eye. I believe one of the reasons we’re drawn to calculus and stains is that we can see it and it’s in our clinical nature to remove anything that shouldn’t be there. When we disclose biofilm suddenly we can see it; bright pink and staring back at us. I’m yet to meet a dental hygienist who would knowingly leave pink stain on a patient’s teeth but they may unknowingly leave behind biofilm that they couldn’t see.
Disclosing solution focuses our attention and it focuses it on the root cause of disease: biofilm. Once visible it has to be removed. There’s no other way to guarantee we’ve removed 100% of the biofilm other than if we can physically see it has disappeared. Without it being disclosed we have to guess. We have to assume that it’s gone. Remember teeth aren’t flat. We’re not cleaning a uniformed surface and access is difficult with soft tissues often getting in the way, opening restrictions and natural resistance from patients. Had I not used a disclosing solution, the biofilm in these sites would have gone undetected.
The BSP (British Society of Periodontology) guidelines require us to record plaque indices for every patient with a BPE code of 1 and above. This is almost every single patient I see. Disclosing facilitates this data collection and speeds up the process by making it easily detectable by sight alone.
I used to think disclosing slowed me down but I’ve changed that opinion as it became part of my routine. Because it eliminates any guess work, I now work more efficiently and avoid over instrumentation. Routine disclosing prior to oral hygiene instructions has also led to better engagement with patients. This in turn, has allowed me to see a reduction in plaque and bleeding scores and improved my patient’s overall oral health.
When you started, were you confronted with resistance from your patients? Did they refuse to “get disclosed”?
Initially yes. Until recent years there’s been somewhat of a stigma attached to adults having their teeth disclosed. Here in the UK, disclosing solutions were originally introduced and widely used as a teaching aid for children. Disclosing tablets are still available to buy in high street shops and are almost exclusively marketed towards children with packaging that influences the trend.
Patients know this and therefore it’s reputation that precedes it. Patients associate having their teeth disclosed with being treated like a child in the UK. Some may even remember the procedure from going to see their dental professional when they were a kid. I know I certainly do, along with pink water as a rinse and stickers for good behaviour. It’s understandable how patients might feel patronised and associate disclosers with being ‘told off’. Using a solution rather than tablets has helped me to eliminate some of the stigma and preconceived ideas but patients still sometimes ask “is this the stuff I used to have as a child?”
Naturally, communication is key here. Patients need to be made aware that the disclosing solution is there for the clinical benefits. As soon as I changed the language I used and explained I was using a dye that helped me to see all of the bacteria which in turn would ensure I removed it thoroughly, much of the resistance dissipated and uptake was no longer an issue.
I think it’s in our human nature to resist change, particularly in an environment in which threat or danger is often perceived. We like familiarity. Change makes us feel less comfortable. But we‘re also adaptable and patients have now come to expect the procedure. Getting the message right first time is key. It’s part of what happens during their appointment now. Patients know it’s necessary for me to ensure I’ve done what they're paying me to do and they no longer question it.
What kind of disclosing agent were you using when you started disclosing patients? Tablets? A liquid solution applicable with a brush? Pre-soaked pellets?
As detailed above, initially it was tablets but some patients found them unpleasant to chew on. They’re also more time consuming and rely on the patient thoroughly licking the solution across every surface which often they don’t do. In more recent years I switched to liquid solutions. It’s quicker to apply but it didn’t come without its disadvantages: I tried various ways of applying it but never found one that didn’t involve waste. The impact of plastic waste on our planet is really important to me and I try wherever possible to limit its use. Needing a plastic dampening pot plus a plastic handled brush for every patient seemed wasteful; not to say messy.
I switched to dropping a cotton wool pellet into the solution and using tweezers to smear it around the teeth. We still needed to squeeze the solution into a plastic dampening pot first but it was a less wasteful alternative. That said, we seemed to go through the bottles of discloser more quickly this way because of the volume of solution needed to fully penetrate the cotton wool pellet. The solution dries out quickly if left out in open air, so the pellets couldn’t be pre-soaked - they needed to be prepared for each patient just before they came in for their appointment. This is where it sometimes got messy. The solution would splash as I dropped it into the pot.
Have you tried the new disclosing agent marketed by EMS, the Biofilm Discloser?
Yes. I was introduced to it at the IDS in Cologne earlier this year.
How does it differ from other products available in the UK?
It eliminates much of the mess as the little sponges are pre-soaked so there’s no liquid solution involved and hence no splashing. There’s no prep involved either so they’re quick to use. I can simply take one from the pot with a clean pair of tweezers each time I need one and apply directly to the teeth. The sponges have a good size and contain ample solution for the job. One is always enough to do a full mouth. More importantly for me: there’s no excess plastic waste which reduces our financial outlay on consumables, helping me do my bit for our planet.
Will you continue to use Biofilm Discloser for all your Guided Biofilm Therapy treatments?
Absolutely. Disclosing patients is a crucial part of the Guided Biofilm Therapy and the new Biofilm Discloser is the most time efficient and cost effective way for me to carry out the procedure.