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Plaque biofilm

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Plaque biofilm

Plaque biofilm is the principal local modifiable risk factor for development of gingival inflammation and periodontitis. Plaque biofilm retentive factors (e.g. calculus, local dental crowding, dentures, etc.) are also considered risk factors for disease initiation and progression as they increase the likelihood that oral hygiene will be compromised, and that plaque will accumulate. Consequently, regular removal of plaque biofilm and plaque retentive factors is essential in the prevention of periodontal diseases, and during treatment and maintenance care in those individuals with a diagnosis of periodontitis. 

Key recommendations

Advise patients (and their carers, where appropriate) to regularly remove plaque biofilm using a toothbrush, and interdental aids where required, as an effective regime to prevent and facilitate management of plaque-induced gingivitis and periodontitis.

(Strong recommendation; moderate certainty evidence)


Use behaviour change methods when providing oral hygiene instruction for patients who have sub-optimal oral hygiene.

(Conditional recommendation; low certainty evidence)

Oral hygiene

Both the BSP implementation of European S3 – level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice (BSP-S3)6 and the Delivering Better Oral Health (DBOH)7 toolkit recommend that patients be advised of the best methods of plaque biofilm removal, primarily by toothbrushing with supplemental interdental cleaning advised to control gingival inflammation. This is informed by the well-established relationship between plaque biofilm and gingivitis and supported by evidence from a meta review of systematic reviews which found that toothbrushing is effective at removing plaque biofilm.56 The evidence is considered to be of moderate certainty due to methodological issues with the systematic reviews included in the meta review. DBOH notes that professional intervention alone, in the form of dental professional delivered, in-surgery removal of plaque biofilm and calculus, is insufficient to prevent periodontal disease starting or deteriorating and recommends that patients be advised of the best methods of personal plaque biofilm removal to prevent gingivitis, and to achieve lowest risk of periodontitis and tooth loss.57, 58 

Oral hygiene instruction

It is usual practice to discuss oral hygiene routines, the effect of inadequate plaque control and to provide oral hygiene instruction as part of periodontal management. While there has been much research into methods to support patient behaviour change with regard to oral hygiene, there is to date no robust evidence to support any particular type of behaviour change intervention. There is low to moderate certainty evidence that motivational methods result in a reduction in plaque levels59 but very low to low certainty evidence with regard to a subsequent reduction in gingivitis. Factors affecting the certainty of the evidence include risk of bias, heterogeneity and limited study sizes. There is insufficient evidence to support the use of specific psychological interventions, such as motivational interviewing or cognitive behavioural therapy, to influence patients’ compliance with oral hygiene practices.33 However, building motivation and confidence are likely to be important components of successful behaviour change.

Accordingly, both the DBOH and BSP-S3 guidelines state there is insufficient evidence to support the use of any specific oral hygiene behaviour change intervention. However, both guidelines note that behaviour change approaches are viewed as being important in improving patients’ plaque control and recommend emphasizing the importance and benefits of effective oral hygiene to patients when discussing their oral health. 

Further details on the development of the recommendations in this guidance can be found in Methodology.

Oral hygiene instruction (also described as ‘coaching’):

  • should be individually tailored to suit each patient; 
  • should assist and encourage the patient to improve their oral hygiene skills as well as their understanding of the value of good self-care routines;
  • should be delivered in a manner that actively involves the patient in skill acquisition rather than passively delivering information, for example, giving the patient the opportunity to practice in their own mouth with support from the dental team.

Patients with a diagnosis of periodontitis will require additional advice and coaching on oral hygiene, including advice on the importance of cleaning interdentally. 

Patients with inadequate oral hygiene may require more frequent reinforcement of oral hygiene messages and support to acquire the necessary skills during ongoing care. 

It is important to appreciate that the motivation to change behaviour has to originate from the patient; patients must want to improve their oral hygiene, must understand why improvement is needed and the likely benefits, and must feel that they have the skills required to do this. Dental professionals have the knowledge and skills to support and encourage the patient to change and to teach the required plaque removal skills.

Advise patients to regularly remove plaque biofilm using a toothbrush, and interdental aids where required.

Provide oral hygiene instruction (coaching) to ensure patients can effectively remove plaque biofilm.

  • Assist and encourage the patient to improve their oral hygiene skills as well as their understanding of the value of good self-care routines.
  • Oral Hygiene TIPPS (see Oral hygiene and Oral Hygiene TIPPS) is an example of a behaviour change strategy that can be used to highlight the importance of effective plaque biofilm removal and to show the patient how they can achieve this.
  • For patients with extensive inflammation, begin with advice on toothbrushing then move on to advice on interdental cleaning.
  • Some patients, such as those with additional care needs, may need assistance and support in the use of oral hygiene aids.
  • Where patients have crowded teeth or dental appliances, specific help with cleaning of those areas and use of appropriate plaque biofilm removal devices will be necessary.