Patients are focused on how things look at feel. We are focused on identifying patient needs and utilizing appropriate therapies. Some marvelous products can help us provide appropriate end results for our patients.
From the very first time Irene Newman picked up a porte polisher, patients were trained to accept and expect polishing. In the minds of many patients, polishing is synonymous with getting their teeth cleaned.
The term polishing implies producing either a surface that is smooth or has a high luster. Traditionally, we have used a prophylaxis paste to achieve this outcome. The definition of a paste is a semisolid mixture with a consistency between a liquid and a solid but there is no mention of the concept of polishing until one pairs the word with the term prophylaxis.
Polishing to a gleaming shine
For the first 55 years dental hygienists focused on stain removal. Initially, we learned to remove unsightly deposits with non-swiveling belt-driven handpieces, finally graduating to heavy, air turbine handpieces attached to wrist-tugging coiled hoses.
We used coarse paste or pumice mixed with mouth wash, with little regard to the effect on restorations or delicate tooth surfaces. Patients wanted gleaming teeth, and we were expected to produce this end result with whatever technique or product it took.
Five separate events over the last twenty years are shaping the evolution in how we now view this once sacred cow standard of dental hygiene treatment.
Cosmetics - restorations, stain removal
Minimal intervention - medicament application; remineralization and desensitizing
Infection control - development of disposable angles
Ergonomics - hand awareness
Biofilm disruption - preprocedural polishing
A selective view
Several decades ago, forward thinkers in dental hygiene began to question the importance and wisdom of full mouth polishing, especially using coarse paste. This was the birth of the selective polishing movement, a technique routinely taught in most dental hygiene products today.
Rather than regularly polishing every tooth surface, students are instructed to polish off stains that are not removed by traditional hand or power scaling. The hope is to preserve as much tooth structure as possible. This is particularly important when polishing stain off of exposed dentin and cementum or working around cosmetic restorations.
The procedure becomes even more critical if one is using a coarse or extra coarse polish. According to dental distributors approximately 85 percent of all prophy paste sold is coarse to extra-coarse. While the stain may come off faster, the larger particles leave bigger and deeper microscopic scratches on delicate tooth surfaces that will pick up stain even faster.
There are two solutions to this dilemma. First, a properly used ultrasonic dental scaler can be a very efficient stain removing device; therefore a light polish with a mild or fine prophy paste can remove the final amount of residual stain.
Another approach is to use a product like the 3M ESPE Clinpro paste. Made from perlite particles that rapidly crush into a very fine paste, the Clinpro paste is much gentler to delicate tooth structure and cosmetic restorations. Research shows that this product is effective in removing surface stains but is less damaging than coarse pumice-based pastes.
The concept of minimal intervention is gaining widespread acceptance among hygienists today. This thought process fits perfectly into the goals of dental hygiene practice.
Two parallel thoughts guide minimal intervention. The first is to do as little harm as possible. Using a less coarse polish possible is an example of this. Secondly, hygienists are using a wide variety of products that help remineralize weakened tooth structure.
The number of polishing products containing compounds that assist in remineralization grows every day. In addition to remineralization, many of these products reduce tooth sensitivity. Some examples of polishing or paste products that hygienists are currently using in the clinical setting are described below.
More than 30 years of research by scientists at the University of New York
Stony Brook campus led to the development of a calcium carbonate/bicarbonate/arginine complex, which is currently incorporated into Ortek Therapeutics' product called ProClude - the first FDA approved desensitizing prophy paste. Emerging research points to the ability of this product and its companion home care paste, DenClude, to interrupt the caries process by remineralizing tooth structure, raising the pH to a more neutral state, in addition to reducing or eliminating sensitivity on exposed root structure by occluding dentinal tubules.
GC America's Prospec MI paste contains amorphous calcium phosphate combined with Recaldent, a casein polypeptide that allows the active ingredients to be released over time to strengthen teeth as well as reduce patient sensitivity. The original research was conducted in Australia and clinicians using this product, which comes in a wide variety of flavors, are reporting favorable clinical results.
Sunstar Butler's NuCare prophy paste contains NovaMin, which is a calcium sodium phosphosilicate glass that releases calcium and phosphate ions in the presence of water or saliva, resulting in an occlusion of dentinal tubules to prevent pain.
In addition to pastes that are therapeutic in nature there are specialty products marketed for particular patient needs. For example, some patients are sensitive or allergic to color and flavoring additives. Others who suffer from celiac disease are gluten intolerant, which is an ingredient in many flavors and colors. Other patients request paste without fluoride and some want a paste that is "all natural." Denticator's SureClean and Preventech's Nada pastes are made without any flavors or colors and are the perfect products for these types of situations.
The manufacturers of today's cosmetic restorations discourage the use of traditional pastes on these man-made tooth surfaces. Over time traditional pastes create damage that can alter the surface, rendering a less than ideal appearance. Dentsply's NUPRO Shimmer is an example of a specially formulated polish. It is not designed for stain removal but rather to enhance and enrich the surface of cosmetic restorations.
The effect of infection control on prophy angles
Another driving factor in changing polishing protocols was concern over infection control issues, which led to the development and subsequent popularity of disposable prophy angles, which are now the predominant form of polishing device. DPAs are one time use devices and there are pluses and minuses for using these types of products.
From a positive point of view, disposable angles weigh less, which benefits the user ergonomically. In addition, contra-angled DPAs such as Young Dental's Contra or SmartPractice's Swangle allow the user to maintain a neutral wrist position even when trying to access difficult to reach posterior areas.
The rotation in angles with a screw-in prophy cup is smoother than a DPA with a snap-on cup, which can wobble during polishing and creating unnecessary stress on the user's wrist. Soft cups do not require clinicians to use as much pressure to maintain contact on the tooth surface, and smaller cups are designed to improve access in constricted areas.
Prophy cups come in a wide variety of designs that feature ribs or webs to improve the action and distribution of prophy paste. Despite all of the design features and changes through the years, hygienists continue to be frustrated with the splatter from polishing, which is annoying, messy, and certainly an infection control issue. Splatter can be reduced by running the handpiece at a slower speed, maintaining continuous suction, and not overfilling the cup.
When to polish
Another approach to polishing takes into account that teeth are covered with biofilm and a light but complete polishing of all exposed tooth surfaces using a very fine paste can help break up this supragingival pathogenic pile of slime.
Some clinicians prefer to polish at the beginning of the appointment to reduce the bioburden on the tooth structure prior to scaling. This consideration becomes even more important with the increased use of ultrasonic dental scalers. Regardless of what type of scaler you use, there will be some amount of aerosol. Polishing before scaling will reduce the bacterial concentrations in the contaminated aerosol.
There are many reasons that polishing has changed through the years. In order to create a clinical comfort zone that address the real needs of today's patients we need to understand the unique who, what, where, when, and why of this procedure for every patient that sits in our chair.
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