Guided Biofilm Therapy: Dr. Pam Maragliano on Fixing the 6-Month Recall Myth

Dr. Melissa Seibert: Welcome to Dental Digest. This is a podcast with a mission of enabling you to stay on the cutting edge of evidence-based dentistry. I'm your host, Dr. Melissa Seibert. Today, I'm joined by Dr. Pam Maragliano. Dr. Maragliano is a board-certified prosthodontist, internationally recognized speaker, and a leading voice in aesthetic and adhesive dentistry. She maintains a private practice at Salem Dental Arts in Massachusetts with a focus on advanced restorative dentistry, minimally invasive, and aesthetic care. In addition to her clinical work, she serves as the Chief Editor of Dental Economics and lectures nationally and internationally on composite artistry, anterior aesthetics, and practical clinical workflows. Dr. Maragliano is widely respected for her ability to translate complex concepts into everyday practice, helping dentists elevate both their clinical outcomes and confidence.

In this first half of our conversation, we start with a candid discussion around practice ownership, associateship, and what it actually takes to build a practice you enjoy being in. We also get into the realities of different practice models, what you can learn from DSOs, and how to think about growth early in your career. From there, we transition into clinical philosophy — specifically how to evaluate materials, navigate the world of adhesives, and maintain integrity when it comes to product endorsement and decision-making in your practice.

Dr. Seibert: You have a rare perspective as both a clinician and an editor, and also a former hygienist and now a prosthodontist. How do you critically evaluate claims surrounding new adhesive systems, universal adhesives, and cutting-edge materials when the literature is still immature?

Dr. Maragliano: Oh my goodness, good question. I have to say I'm one of those people that relies on our friends. I like going to the aesthetic meeting, the restorative meeting, the LA Dental Symposium, and listening to the people who know a whole lot more than I do about adhesive systems. I'm a little biased towards the bottle systems, definitely. I like to see a nice shiny dentin before I do any bonding. That said, I have used Adhese Universal and other universal-type bonding agents as well. I think if you utilize a proper technique, you're probably going to be fine. But I do rely on the people that do their research and lecture on the topic and really can break it down for us from an educational standpoint — not an influencer standpoint.

Dr. Seibert: With such a powerful background that you have as an editor, sometimes it's really easy to have a little bit of industry pressure to endorse things or accept things. And likewise, a lot of dentists feel this pressure — they might have reps coming into their office. What are some red flags or indicators that you might not want to adopt a certain material?

Dr. Maragliano: So for example, I am reticent to adopt brand-new technology, especially if it hasn't been extensively researched. I'm still not permanently delivering and utilizing 3D printed restorations. I'll use them as temps, but not as a permanent restoration. There was a lot of pressure on dentists a few years ago to adopt this. I think the industry has really kind of slowed down — private equity is really not investing in 3D printers the way it once did.

How do I critically appraise new technology? I do a few different things. I am very, very specific about what hat I'm wearing in a moment. Yes, there is some overlap because I obviously utilize certain products in my practice, and I can endorse those because I use them on a regular basis. If I'm wearing my Dental Economics hat and somebody asks me to write something, I can't write it about my practice. I'm going to encourage them to have a key opinion leader that uses their product all the time write something. It'll be more meaningful than me going through a piece of marketing and writing "efficient, works great, easy cleanup." I think there's more meaningful literature to be made by somebody who can do it genuinely.

I won't write an endorsement on a product or service that I know nothing about. There are times where I can test something in my practice — depending on what it is, I'm very careful. If it's a material that could have an adverse reaction on a patient, it's a no for me. I don't have a guinea pig tank in my practice. If it's an appointment reminder software or reactivation software, something where you're not going to hurt anybody — sure, I'll test it. If it's a material that I could play with on a lab bench, happy to do it. If it's something provisional, definitely happy. But for me to make a solid endorsement, it has to be something I'm utilizing in my practice on a regular basis and something I'm comfortable talking about. I try to keep a distinct line in the sand between my editorial life, my lecture life, and my practice life.

If a reputable company says, "Hey, would you mind trying this composite? Tell me what you think, take a few photos" — sure, that's something I'd absolutely do. Am I going to promise I'm going to buy it for the rest of my life? Probably not. But would I try it? Absolutely. If somebody said, "There's this new classification of this material that we're just about ready to get FDA approval" — probably not for me.

Dr. Seibert: This also brings to mind a question that's not really a clinical question. With the many hats that you wear, you've probably faced pressure to do things that didn't make you comfortable, weren't in alignment. It doesn't even have to do with industry — it can just be as a clinician. I talk to a lot of women in dentistry, I get a lot of messages from female clinicians about patients pressuring them to do X and Y. What kind of encouragement would you have to people that feel like they can't comfortably uphold their boundaries?

Dr. Maragliano: I would say: get comfortable. And I know that sounds a little aggressive or maybe a little assertive. This is your practice, your license, your life. If you're doing something out of feeling pressured to, and it doesn't align with your value system, your skill set, or your morals — don't do it. It's very simple. There's nothing wrong with saying no. There's nothing wrong with saying no with no explanation. There's also nothing wrong with saying "no, I'm not comfortable" and ending the discussion right there.

It's different if you're going to try something new and you feel pressure because it's pushing yourself out of your comfort zone to grow — totally different thing. But if it's something that really doesn't align well with your value system or something you're comfortable with, I say don't do it. You're the one who's got to live with yourself.

Dr. Seibert: Fair. Across your publications, you stress the importance of restorative maintenance beyond simple prophy visits. What does an evidence-based recall protocol look like for patients restored with modern ceramics, bioactive resins, or adhesive rehabilitation?

Dr. Maragliano: One piece of literature that dates back to 1979 from Jan Lindhe discusses biofilm and how biofilm matures — and the maturation rate of biofilm. Biofilm takes three months to mature. So while we seem to be married as an industry to this concept of a six-month recall, that came about in the 1950s from a toothpaste commercial, believe it or not. There was this toothpaste commercial and they said, "by the way, visit your dentist every six months or twice a year." Somehow, whoever that marketer is must have been a genius — because here we are in 2025 and 2026 still clinging to the six-month recall that has literally no research behind it. It's got a 1950s commercial behind it, and that's what we've clung to.

When you mention evidence-based hygiene protocols or preventive protocols, the first thing to do is abandon the six-month recall as a standard with our patients. If you have somebody that's super healthy, low risk from the standpoint of perio and caries, with great compliance — fine, knock yourself out, throw them on a six-month recall. I would argue they probably still have some bleeding on probing and inflammation somewhere. We also live in a world now where a little inflammation is not acceptable, because if there's inflammation in your mouth, there's inflammation probably elsewhere in your body that can be exacerbated by the oral biofilm that's there.

My first standard for preventive maintenance is to get people on a tighter recall — three months, four months if they're pretty good. Now think about this: you're a cosmetic restorative dentist. I am as well. Most of our patients have restorations in their mouth. If you look at the CAMBRA documents from 2007 — we're pushing 20-year information here — patients with 10 or more restored surfaces, which isn't that many restorations, are deemed high caries risk. They're deemed high risk because most likely those restorations are going to fail due to caries at the cavo-surface margin or the restorative-tooth interface. So there's risk everywhere on our patients. My goal is to try to minimize risk, enhance outcomes, elongate the longevity of the restorations, but also not destroy the restorations that we have.

My protocols include a tighter recall — three or four months — Guided Biofilm Therapy, a really great evidence-based approach to the preventive visits. What I love about that is there's just such a push toward education and motivation and empowerment on the part of the patients. Yes, there's technology associated with it too. But what that's done to my practice and for my patients has been immeasurable, both for getting them healthy and for building my dental hygiene department.

We've incorporated a lot of adjunct procedures. I do what's called airflow appointments before some restorative visits. I don't treat unhealthy people periodontally if I can help it. I don't like to fight with bloody tissue when I'm trying to bond something. I don't want to fight with bloody tissue when I'm trying to create a veneer or even a class two composite. Nobody wants to do that — and we don't have to do that anymore. So I work with my hygienists very closely to get my patients healthy before they come and see me in the back of the office. We utilize the laser, Perio Protect trays, lots of different bacterial testing — different modalities we can add to the protocols. But our standard go-to is GBT.

Dr. Seibert: I want to hear all about GBT. What is it? How are you using it?

Dr. Maragliano: GBT is Guided Biofilm Therapy, and it has been coined GBT by EMS Dental. It's a whole protocol to the hygiene visit. There's an eight-step compass that's part of it. The first three steps are assess, motivate, educate the patient. So it's about collecting all of — I mean, the first part isn't that riveting, although that's where most of the preventive recommendations are made. We start with the medical history and try to identify systemic illnesses that are exacerbated by poor oral health, creating value for our patients there.

I love voice-activated periodontal charting — getting the patient involved in their perio chart and explaining what we're doing.

Dr. Seibert: Stop, wait. What is voice-activated periodontal charting?

Dr. Maragliano: So we use Florida Probe. There are a lot of different ones out there, but basically my hygienist will tell the patient: "I'm going to take six measurements on each tooth. Anything less than a three is great. Anything with four or greater we're going to discuss. I'm also going to count up bleeding points." So now the patient's listening to what's about to happen. She'll go through it — "this is what I'm about to do" — and then I'll hear "voice works on," and she'll start charting. You can chart probing depths, bleeding, suppuration, furcation, recession — pretty much everything you can chart on a periodontal chart.

Once that's done, the patient's already been listening the whole time. Back in the day, we might not even tell the patient about the probing depths — we're just probing and writing them into a chart. But now the patient's engaged. Once the hygienist has that conversation, she makes perio recommendations and recall recommendations right there. Boom, done, check, moving on.

Then we disclose.

Dr. Seibert: Tell me again — what was the name of the software? I'm guessing it's a subscription service that you pay for.

Dr. Maragliano: The one I have in my practice is called Florida Probe. What I like about Florida Probe is there's a bridge to it — I have Dentrix, so it bridges with Dentrix really easily. The hygienist can use their favorite probe — there's no special probe required. There are other systems out there — Dentrix itself has its own charting system, and there are periodontal charting systems with AI built into them. But for us, Florida Probe has been working. It's a good workhorse. My hygienists like it, and I like how it looks as soon as it's done. We have TVs in each of the hygiene ops, so my hygienist will sit the patient up and show them: "You have 20 bleeding points. We'd like to see you with zero." And now if patients have two bleeding points, they're like, "I'm going to have none next time." We're getting patients more motivated than I've ever seen.

Then we disclose, and we try to identify what is happening in the mouth from an oral hygiene standpoint. We use Tri Plaque ID from GC America. It's a really cool disclosing agent because there are three different colors that can turn up. There's pink biofilm — that's new biofilm. If you brushed your teeth in the morning, ate breakfast and lunch, pellicle and new bacteria will look pink — no big deal. There's also purple biofilm — that biofilm has been sitting undisturbed for 48 hours or longer. There's education to be had there. And there's a turquoise-blue, bright-blue biofilm that can turn up — that's aciduric biofilm. That is biofilm whose colony is in a pH of 4.5 or less.

So we can identify if this is new biofilm, old biofilm, or aciduric biofilm — and we can then educate our patients about where they're missing. That's where we'll provide oral hygiene instructions. My hygienist will often invite them to bring their electric toothbrush into the practice, or use whatever manual toothbrush, or we've got Oral-B's test drive — and show them how hard it is to remove biofilm. It's sticky, it's thick. If they've got xerostomia, it's harder to remove. At that moment we educate them on how much pressure they need to use, water flossing, whatever recommendations my hygienist makes. But now they see it.

This also serves as a guide for my hygienist to remove that biofilm. So the next part of the appointment is the therapeutic part. All of the education has taken place — hygiene recommendations, perio therapy recommendations, recall recommendations — all done. Now they just get to lay there.