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Prize Winning Essay

Biofilms: A microbial home

Rita Chandki, Priyank Banthia, Ruchi Banthia

Department of Abstract:
Periodontics, Microbial biofilms are mainly implicated in etiopathogenesis of caries and periodontal disease. Owing to its
Modern Dental College properties, these pose great challenges. Continuous and regular disruption of these biofilms is imperative for
and Research Centre, prevention and management of oral diseases. This essay provides a detailed insight into properties, mechanisms
Indore, Madhya of etiopathogenesis, detection and removal of these microbial biofilms.
Pradesh, India Key words:
Biofilm, microbes, periodontal disease

INTRODUCTION dates back to the 17th century, when Anton Von

Leeuwenhoek - the inventor of the Microscope,

O ral cavity is an open growth system with

an uninterrupted introduction and removal
of microbes and their nutrients. It offers diverse
saw microbial aggregates (now known to be
Biofilms) on scrapings of plaque from his teeth.

habitats where-in different species of micro-
organisms can prosper. The primary requisite
for any group of microbes to flourish in a niche
is their ability to adhere to the tooth surfaces
Access this article online and multiply in shielded environments like
Website: periodontal pockets and tooth crevices. Such an
www.jisponline.com aggregation of microbes on tooth surfaces has
DOI:
been traditionally referred to as ‘plaque’ because
10.4103/0972-124X.84377 of its yellowish color, reminiscent of mucosal
Quick Response Code:
plaques caused by syphilis.
Dental plaque has been defined as “a specific
but highly variable structural entity consisting of
micro-organisms and their products embedded
in a highly organized intercellular matrix.”
It represents a true biofilm consisting of a
variety of micro-organisms involved in a wide
range of physical, metabolic and molecular
interactions. The cooperative nature of a
microbial community provides advantages to
the participating organisms such as a broader
habitat range for growth, enhanced resistance
to antimicrobial agents and host defenses and
enhanced pathogenicity.[1]
Biofilms have been implicated as the chief culprit
in the etiopathogenesis of dental caries and
periodontal disease. Though uncalcified biofilms
Address for can be removed by routine oral hygiene aids or
professional dental instruments, they have the
correspondence:
potential to calcify into dental calculus making
Dr. Ruchi Banthia,
814, Jagriti Nagar, Near their removal difficult. Hence, these biofilms
Dev Shree Talkies, pose a great challenge to the dental clinician in
Indore, Madhya the control and eradication of biofilm-associated
Pradesh - 452 001, India. diseases.
E-mail: bruchi2008@
yahoo.com
HISTORICAL PERSPECTIVE
Submission: 25-11-2009
Accepted: 11-04-2010 Biofilms are nothing new. The first description
The term ‘Biofilm’ was coined by Bill Costerton
in 1978.
In 2002, Donlan and Costerton offered the
most salient description of a biofilm. They
stated that biofilm is “a microbially derived
sessile community characterized by cells that
are irreversibly attached to a substratum or
interface or to each other, embedded in a matrix
of extracellular polymeric substances that they
have produced, and exhibit an altered phenotype
with respect to growth rate and gene
transcription.”[2]
WHAT IS A BIOFILM?
The term Biofilm (Wilderer and Charaklis 1989)
describes the relatively indefinable microbial
community associated with a tooth surface or
any other hard non-shedding material, randomly
distributed in a shaped matrix or glycocalyx.[2]
In the lower layers of a biofilm, microbes are
bound together in a polysaccharide matrix with
other organic and inorganic materials. Above it,
is a loose amorphous layer extending into the
surrounding medium. The fluid layer bordering
the biofilm has stationary and dynamic sub
layers.
CLASSIFICATION OF BIOFILMS
*On basis of its location[3]
1. Supragingival - Present coronal to the gingival
margin
2. Subgingival - Present apical to the gingival
margin

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Chandki, et al.: Biofilms – A microbial home
*On basis of pathogenicity
1. Cariogenic - Generally acidogenic and gram-positive
2. Periopathogenic - Mostly basophilic and gram-negative
FORMATION OF A BIOFILM
Formation of a biofilm is a complex process that follows several
distinct phases, beginning with adsorption on to the tooth
surface of a conditioning film derived from bacterial and host
molecules, which forms immediately following tooth eruption
or tooth cleaning. This adsorption is followed by passive
transport of bacteria mediated by weak long-range forces of
attraction. Covalent and hydrogen bonds create strong, short-
range forces that result in irreversible attachment.
The primary colonizers form a biofilm by autoaggregation
(attraction between same species) and coaggregation
(attraction between different species). Coaggregation[4] results
in a functional organization of plaque bacteria and formation
of different morphologic structures such as Corncobs and
Rosettes. The microenvironment now changes from aerobic/
capnophilic to facultative anaerobic. The attached bacteria
multiply and secrete an extracellular matrix, which results in
a mature mixed-population biofilm.
After one day, the term Biofilm is fully deserved because
organization takes place within it. Transmission occurs from
other sites, leading to incorporation of new members into the
biofilm and the formation of a climax community. The thickness
of the plaque increases slowly with time, increasing to 20 to 30
µm after three days.
Four stages of dental plaque biofilm growth (as shown in
Figure 1)
Stage I - Attachment (lag - not inert, but metabolically
reduced)
Stage II - Growth (log - exponential growth)
Stage III - Maturity (stationary)
Stage IV - Dispersal (death)
Figure 1: Showing growth of biofilm
112 Journal of Indian Society of Periodontology - Vol 15, Issue 2, Apr-Jun 2011
MICROBIOLOGY OF BIOFILMS
Plaque biofilm consists of different complexes of periodontal
microorganisms which are based on the frequency with which
microorganisms are recovered together. These complexes have
been depicted in Figure 2.
PROPERTIES OF BIOFILMS
Biofilms are ubiquitous; they form on virtually all surfaces
immersed in natural aqueous environments. A biofilm confers
certain properties to bacteria that are not seen in the planktonic
state, a fact that justifies recognition of dental plaque as a
biofilm.
A major advantage is the protection that biofilm provides
to the colonizing species from competing micro-organisms,
environmental factors such as host defense mechanisms and
potentially toxic substances like lethal chemicals or antibiotics.
Biofilms also facilitate processing and uptake of nutrients,
cross feeding and removal of potentially harmful metabolic
products through the voids or water channels between the
micro-colonies, acting as a primitive circulatory system. [1] They
also create an appropriate physicochemical environment such
as a properly reduced oxidation reduction potential.
An important characteristic seen in Biofilm-associated
bacteria is Quorum sensing, or cell density mediated gene
expression.[5] This involves the regulation of expression of
specific genes through the accumulation of signaling compounds
that mediate intercellular communication. Quorum sensing
may give biofilms their distinct properties. Eg.- Expression of
genes for antibiotic resistance at high cell densities may provide
protection. It also has the potential to influence community
structure by encouraging the growth of species beneficial to the
biofilm and discouraging the growth of competitors.
Another important characteristic of biofilm associated bacteria
is the gene transfer[6] through which bacteria communicates
with each other. In S. mutans, quorum sensing is mediated by
PURPLE COMPLEX
Veillonella
Actinomyces
YELLOW COMPLEX
Streptococcus mitis RED COMPLEX
Streptococcus oralis
Porphyromonas gingivalis
Streptococcus sanguis
Treponema denticola
Tannerella forsythia
ORANGE COMPLEX
Prevotella
Peptostreptococcus
Campylobacter
GREEN COMPLEX
Fusobacterium
Eikenella corrodens Eubacterium
Capnocytophaga
Aggregatibacter
actinomycetemcomitans
Figure 2: Showing microbiology of biofilms
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Chandki, et al.: Biofilms – A microbial home

competence stimulating peptide, wherein genes are responsible posterior teeth

for multiple functions - biofilm formation, competence and 3 Firmly adhered thick biofilm only on anterior or posterior
acid tolerance. teeth
4 Firmly adhered thick biofilm on anterior teeth and thin
Biofilm related Regulation of gene expression has been shown biofilm on posterior teeth, or firmly adhered thick biofilm
in certain bacteria. eg. Exposure of S. gordonii to saliva results on posterior teeth and thin biofilm on anterior teeth
in induction of genes that mediate host surface binding and 5 Firmly adhered thick biofilm on anterior and posterior
coaggregation with P. gingivalis and Actinomyces. Similarly, teeth
genes encoding glucan and fructan synthesis are differentially
regulated in Biofilm-associated S. mutans. Treatment of periodontal biofilms
As with other branches of dentistry, there is no ‘cook book’
MECHANISM OF INCREASED ANTIBIOTIC approach that works for every site in every patient. Individual
RESISTANCE IN BIOFILMS considerations must be taken care of, while treatment
planning. No matter what, biofilm control is fundamental to
Organisms in a Biofilm are 1000-1500 times more resistant to the maintenance of oral health and to the prevention of dental
antibiotics than in their planktonic state. The mechanisms[2] caries, gingivitis and periodontitis.
of this increased resistance differ from species to species,
antibiotic to antibiotic and for biofilms growing in different Possible strategies to control oral biofilms
habitats. This antibiotic resistance in bacteria is thought to be • Inhibition of bacterial colonization
affected by their nutritional status, growth rate, temperature, • Inhibition of bacterial growth and metabolism
pH and prior exposure to sub-effective concentrations of • Disruption of established plaque
antimicrobial agents. Another important mechanism appears • Modification of plaque biochemistry
to be the slower rate of growth of bacterial species in a biofilm, • Alteration of plaque ecology
which makes them less susceptible to bactericidal antibiotics.
Biofilm matrix can resist diffusion of antibiotics. Eg. strongly Clinical approaches
charged or chemically highly reactive agents can fail to reach • Mechanical plaque control[8]
the deeper zones of the biofilm as it acts as an ion exchanger - Tooth brushes
in removing such molecules from solution. - Manual
- Electrical
‘Super-resistant’ bacteria have been identified within a biofilm, - Interdental cleaning aids
which have multidrug-resistance pumps that can extrude - Dental floss
antimicrobial agents from the cell. Since these pumps place - Wooden tips
the antibiotics outside the outer membrane, the process offers - Perio-aid
protection against antibiotics that target cell wall synthesis. - Interdental brushes
Above mentioned observations are critical to the use of - Rubber tip
antimicrobials in the treatment of Biofilm-associated infections.[7] - Oral irrigation devices
• Chemical plaque control[9]
BIOFILMS AND INFECTIOUS DISEASES - Enzymes
- Mucinase
Biofilms have been found to be involved in a wide variety of - Dehydrated pancrease
microbial infections (by one estimate 80% of all infections). - Lactoperoxidase hypothiocyanate
These include dental caries, periodontal disease, otitis media, - Antibiotics
musculoskeletal infections, necrotizing fascitis, biliary tract - Penicillin
infection, osteomyelitis, bacterial prostatitis, native valve - Vancomycin
endocarditis, meloidosis, cystic fibrosis pneumonia and peri- - Erythromycin
implantitis. Salient features of these infections are persistence - Phenols
and chronicity.[2] - Thymol
- Delmopinol
MANAGEMENT PROTOCOL - Quarternary ammonium compounds
- Benzalkonium chloride
Detection and assessment of biofilms: Biofilms can only - Cetylpyridinium chloride
be revealed by staining with dyes – either basic fuschin or - Bisbiguanides
erythrosine. These are called disclosing agents.[7] Two tone - Chlorhexidine
dyes contain FDC Red no.3 and FDC Green no.3, which stain - Alexidine
immature and mature plaque respectively. Laser confocal - Bispyridines
microscopy is the latest method for plaque detection. - Octenidine
- Metallic salts
Criteria utilized in the assessment of Dental Biofilm: (Ribeiro - Zinc
et al. 1999): - Tin
0 No visible biofilm - Copper
1 Thin biofilm only on anterior teeth - Herbal extracts
2 Easily removed thin biofilm distributed on anterior and - Sanguinarine

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Chandki, et al.: Biofilms – A microbial home

- Amino alchohols of a dentist extends much beyond the removal of biofilms

- Octapenol
- Decapenol
- Other surfactants
- Sodium lauryl sulphate
• Professional oral prophylaxis
- Calculus-associated Biofilm can effectively be removed
by Scaling and Root planing and Tissue-associated
Biofilms by Gingival Curettage.
THE FUTURE
Biofilms have become a hot topic in environmental and
infectious disease microbiology as well in the popular press.
In recent years, dental researchers have begun to view plaque
as a biofilm. This shifting view on plaque has important
implications for future efforts in its prevention and treatment.
CONCLUSION
It is universally acknowledged that oral diseases are
multifactorial, with each factor exerting its own influence
thereby propelling the host towards diseased state. Even
then, dental plaque is recognized as the single most important
etiological factor. Dental health professionals have been waging
a constant battle against biofilms.
Biofilms are difficult to locate, remove and penetrate and have
an uncanny adaptive ability or to create their own environment.
The need of the hour is to supplement the conventional
treatment strategies like Scaling, Root planing and Surgery
with Chemical Plaque Control Agents, Antimicrobials (e.g.
chemically Modified Tetracyclines and Low Dose Tetracyclines),
irrigational devices and Local Drug Delivery (LDD) systems to
fight the menace of biofilms. Above all, the role of the dental
office and the patient himself in maintaining adequate plaque
control cannot be overemphasized. Conventional mechanical
plaque control methods like efficient tooth brushing and
interdental cleaning aids are still the easiest, cheapest and
the most convenient weapons against oral biofilms. The role
but encompasses educating and motivating the patient to do
so. This would go a long way in creating and maintaining a
disease-free oral environment.
REFERENCES
1. Lang NP, Mombelli A, Attstrom R. Oral Biofilms and Calculus
In Lindhe J, Lang NP, Karring T. Clinical Periodontology and
Implant Dentistry. 5th ed. Oxford: Blackswell- Munksgaard; 2008.
p. 183-267.
2. Socransky SS, Haffajee AD. Dental biofilms: difficult therapeutic
targets. Periodontol 2000 2008;28:12-55.
3. Ximénez-Fyvie LA, Haffajee AD, Socransky SS. Comparison of
microbiota of supra- and subgingival plaque in subjects in health
and periodontitis. J Clin Periodontol 2000;27:648-57.
4. Quirynen M, Teughels W, Haake SK, Newman MG. Microbiology
of Periodontal Diseases In Newman MG, Takei HH, Klokkevold
PR, Carranza FA. Carranza’s Clinical Periodontology. 10th ed. St.
Louis, Missouri: Elsevier (Saunders); 2006. p. 134-69.
5. Processor JI. Quorum Sensing in biofilms. Dental Plaque
revisitedIn: Newman HN, Wilson M, editors. Cardiff: Bioline;
1999. p. 79-88.
6. Tatakis DN, Kumar PS. Etiology and pathogenesis of periodontal
diseases in periodontology: present status and future concepts.
Dent Clin North Am 2005;49:493-7.
7. Peterson FC, Scheie AA. Chemical Plaque Control: A Comparison
of Oral Health Care Products In Busscher HJ, Evans LV. Oral
Biofilms and Plaque Control. India: Harwood Academic
Publishers; 1998. p. 277-94.
8. Petersilka GJ, Ehmke B, Flemmig TF. Antimicrobial effects of
mechanical debridement. Periodontol 2000 2008;28:56-71.
9. Quirynen M, Teughels W, De Soete M, van Steenberghe D.
Topical antiseptics and antibiotics in the initial therapy of chronic
adult periodontitis: microbiological aspects. Periodontol 2000
2008;28:72-90.
How to cite this article: Chandki R, Banthia P, Banthia R. Biofilms: A
microbial home. J Indian Soc Periodontol 2011;15:111-4.
Source of Support: Nil. Conflict of Interest: None declared.

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