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Critical Issues: Even as we rely on microscopic techniques to visualize biofilms, they are entities which are patchy and dispersed rather than confluent, particularly on biotic surfaces. Consequently, detection of selleck chemicals biofilms by microscopic techniques alone can lead to frequent false-negative results. Furthermore, visual identification using the naked eye of a pathogenic biofilm on a macroscopic level on the wound will not be possible, unlike with biofilms on abiotic surfaces. Future Direction: Lacking specific biomarkers to demonstrate microscopic, nonconfluent, virulent biofilms in wounds, the present focus on biofilm research should be placed on changing clinical practice. This is best done by utilizing an anti-biofilm toolbox approach, rather than speculating on unscientific approaches to identifying biofilms, with or without staining, in wounds with the naked eye. The approach to controlling biofilm should include initial wound cleansing, periodic debridement, followed by the application of appropriate antimicrobial wound dressings. This approach appears to be effective in removing pathogenic biofilms. Steven L. Percival, PhD Scope and Significance In chronic wounds an underlying and fundamental risk factor preventing healing, and increasing the propensity for infection, is the development of a ��pathogenic�� or ��highly virulent�� biofilm. Such a biofilm is one that is upregulated genetically and biochemically, compared to more ��dormant,�� ��commensal,�� and ��relatively nonpathogenic�� mature biofilms, such as those found on the skin or in the gastrointestinal tract. These nonpathogenic biofilms help protect the human body from infection and disease i.e., they provide colonization resistance, but they can revert quickly to pathogenic or virulent biofilm during periods of stress. Compared to nonpathogenic biofilms, the higher number of upregulated genes in pathogenic biofilms lead to: excessive development of degrading enzymes (matrix metalloproteinases); enhanced production of extracellular polymeric substance (EPS); greater generation of quorum sensing molecules; and, increased microbial proliferation and dissemination. These genetic and biochemical effects within a pathogenic biofilm result in more vigorous immune responses, thus leading to chronic inflammation. These two forms of biofilms require different management strategies. Although biofilms develop in all chronic wounds, it is the pathogenic biofilms that constitute the true risk to nonhealing chronic wounds. With this in mind, the essential, but as of yet unanswered, question remains why some biofilm-infected wounds heal whereas others do not. The most basic response is that all biofilms are not the same, whether they are in a wound or in any other anatomical site of the human body.