Combatting biofilms – Arifa Sultana

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  Posted by: Dental Design      11th April 2019

The oral cavity has many surfaces, each coated with hundreds of species of bacteria. Some bacteria are free-floating but for the most part, they multiply and flourish within a complex living community or biofilm. Here they are held together and nourished in a self-supporting network, which attaches and adheres to surfaces and is protected by an outer matrix or extracellular slime layer that is extremely resistant to antibiotics, antimicrobials and human defence mechanisms.[1],[2]

Dental plaque is recognised as a biofilm that adheres to tooth surfaces, restorations, dental implants and prostheses. It is present in the oral environment of healthy individuals but if left to accumulate, the teeth and gingival tissues may be subjected to high concentrations of bacterial metabolites, which can result in dental disease and decay. It is notoriously difficult to completely destroy biofilms and as dental professionals are aware, continuous and regular disruption is the only effective method for controlling biofilm growth, maintaining oral health and preventing oral disease progression.

Biofilms also form in the sinuses and adenoids, at the back of the mouth cavity and behind it, for example in the crypts at the base of the tongue, around the pharynx and on the palatine tonsils. Interestingly, it has recently been suggested that as well as offering first line defence against viral, bacterial, and food antigens, the palatine tonsils may also influence the growth and control of bacteria.[3],[4]Certainly, these soft tissues have natural folds and pockets where debris such as dead cells, food particles, mucus and large concentrations of bacteria can become trapped, and if left undisturbed, can form calcified concretionscalledtonsilloliths or tonsil stones.

In general, tonsil stones are considered to be fairly harmless. Often they are only detected incidentally on X-rays or CT scans and do not cause any noticeable symptoms. Some tonsilloliths, however, can appear as white or cream coloured lumps on the soft tissues at the back of the throat, which may cause irritation or the feeling that there is a constant obstruction in the throat. Depending on their size and location tonsil stones can also cause difficulty or pain when swallowing and some patients may experience referred pain in the ear. Often patients report a metallic taste in the mouth and symptoms vary from individual to individual. Nevertheless, tonsilloliths are living biofilms comprising of a significantly high number and density of bacteria and most patients with tonsil stones experience extremely unpleasant smelling breath.[5]

Tonsil stones comprise of large amounts of anaerobic bacteria including Eubacterium, Fusobacterium, Megasphaera, Porphyromonas, Prevotella, Selenomonasand Tannerella, which according to research, all appearto be associated with the production of volatile sulphur compounds.[6]To explain,

volatile sulphur compounds, or VSCs, are foul smelling gases formed as by-products during the interaction and microbial putrefaction of food debris, cells, saliva and blood, which are expelled in the breath.[7]Primarily, VSCs are composed of hydrogen sulphide, which has the odour of rotting eggs, methyl mercaptan with a barnyard smell and dimethyl sulphide, which smells of rotting cabbage or garlic.

Research has revealed that tonsilloliths are 10 times more likely to produce elevated levels of VSCs in the breath.5 Therefore, to effectively prevent the build up of bacterial biofilm and the production of VSCs, patients need to implement a regular and thorough oral hygiene routine with brushing and flossing to physically disrupt bacterial growth, and a specifically prepared mouthwash containing Chlorhexidine (CHX).CHX is bacteriostatic (inhibits bacterial growth) and bactericidal (kills bacteria). It works rapidly and binds to the oral tissues, allowing its antimicrobial effects to be sustained for several hours. In low concentrations CHX is able to damage bacterial cell walls, attack the inner membranes causing component leakage and, subsequently, cause cell death.[8]It can inhibit the adherence of microorganisms to a surface and prevent the growth and development of biofilms.

CB12 mouthwash was developed by dentists and has a patented formula containing CHX and zinc acetate, which specifically targets and neutralise foul smelling oral gases. This mouthwash successfully converts the offensive sulphur content of VSCs into odourless, insoluble sulphides. The active ingredients in CB12 are also able to chemically bind to the tissues of the oral cavity where it continues to neutralise gases and prevent oral malodour for up to 12 hours.[9]In addition, CB12 mouthwash contains fluoride to help strengthen the teeth and prevent dental decay.

Destroying problematic biofilms within the oral cavity can be challenging. However, these microbial communities can be inhibited considerably by physical cleaning and rinsing away bacteria and debris as often as possible. The emphasis is on prevention, with a good oral hygiene routine and the use of effective, clinically proven oral health products.


For more information about CB12 and how it could benefit your patients, please visit






[1]Nield-Gehrig J.S, RDH, MA Dental Plaque Biofilms.[Accessed 6th November 2018]

[2]Jamal M. et al. Bacterial biofilm and associated infections. Journal of Chinese Medical Assoication. 81 (2018) 7-11.[Accessed 6thNovember 2018]

[3]Bernstein J.M. Mucosal Immunology of the Upper Respiratory Tract.

Respiration 1992; 59:3–13.[Accessed 6th November 2018]

[4]Weise J.B. et al. A newly discovered function of palatine tonsils in immune defence: the expression of defensins. The Polish Ontolaryngology. 2002 56(4) 409-413.[Accessed 6th November 2018]

[5]Ferguson M. et al. Halitosis and the Tonsils: A Review of Management . Otolaryngol Head Neck Surg 2014, 151(2): 0194599814544881.[Accessed 6th November 2018]

[6]Tsuneishi M. et al. Composition of the bacterial flora in tonsilloliths. Microbes Infect. 2006 Aug;8(9-10): 2384-9. {Accessed 6th November 2018]

[7]Uğur Aylıkcı B. et al. Halitosis: From diagnosis to management. J Nat Sci Biol Med. 2013 Jan-Jun; 4(1): 14–23.[Accessed 6th November 2018]

[8]Chlorhexidine Facts. About Chlorhexidine: Mechanism of Action.[Accessed 6th November 2018]

[9]Thrane PS et al. Zn and CHX mouthwash effective against VSCs responsible for halitosis for up to 12 hours. Journal of the British Society of Dental Hygiene and Therapy, Dental Health Vol 48 2009 No 3 of 6.[Accessed 6th November 2018]



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