Polishing Update

Polishing with a rubber cup and prophy paste using a low-speed dental handpiece is typically utilized by dental hygienists to remove extrinsic stains after appropriate scaling has been completed. In the dental hygiene profession today, there are many different opinions regarding polishing, including whether it is a necessary component of the prophylaxis appointment.

Because patients can remove plaque from their own teeth via mechanical disruption of dental biofilm—and due to some research that demonstrated polishing may damage the tooth surface—the idea of selective polishing was born. This theory, which was introduced in the late 1970s, asserts that polishing should be performed only on teeth with extrinsic stain.¹ The selective polishing theory was initially supported by research that showed polishing could abrade the tooth structure.² However, the validity of this research has been questioned due to sample sizes, uncontrolled variables, and other issues.^1,3 Variation in methods and materials, including in vivo vs in vitro experiments, bovine vs human specimens, exposure time, pressure, revolutions per minute, and abrasive agent used, have cast doubt upon the supposed danger to the tooth surface caused by polishing.³ No scientific evidence demonstrates how much enamel is removed during polishing procedures, if any is removed at all.¹ Consequently, oral health professionals began to rethink the concept of selective polishing.

Accumulation and retention of dental biofilm on teeth can affect the roughness of enamel. Therefore, tooth polishing is important, as the roughness may interfere directly with the esthetics of the teeth and the health of the supporting tissues.⁴ Polishing after scaling creates a smooth surface on teeth and restorations, which decreases the adherence of oral accretions while removing residual dental biofilm that may otherwise cause gingival inflammation.

In clinical dental hygiene practice, patients assume they will have their teeth polished and expect to have that smooth feeling when they leave the oral prophylaxis appointment.⁵ In today’s appearance-conscious society, tooth discoloration represents a common dental complaint, and a prophylaxis polishing can effectively address extrinsic stain. As such, selective polishing is no longer purported as the correct protocol, and dental hygienists are free to polish their patients’ full dentitions.¹

ARMAMENTARIUM

There are myriad agents available for polishing and extrinsic stain removal, and many factors to consider when incorporating polishing into the prophylaxis appointment. Relevant considerations include the handpiece’s rotation speed, level of pressure applied, and duration of the procedure. These factors influence the effectiveness of polishing with a rubber cup and prophy paste.⁵ Prophy pastes differ in grit size (fine, medium, coarse, and extra coarse), while pumice-based paste particles decrease in size during polishing. One study reported the characteristics of prophylaxis pastes are still controversial, principally due to the size of the particles in the paste and the amount of enamel roughness they may cause.⁶

ADVANCEMENTS IN MATERIALS

Selecting a prophy paste is no longer a straightforward process in today’s polishing realm. There is an overabundance of cleansing agents, prophy pastes, and polishing devices on the market. Oral health care providers need to remain up-to-date on new materials in order to best serve the individual needs of their patients. Stain removal is routinely the most important aspect of the prophylaxis appointment to patients because the teeth look and feel cleaner and smoother once they have been polished.

A new development in the polishing armamentarium is a prophy angle that does not require the addition of prophy paste. This hybrid-polishing concept is a disposable, paste-free prophy angle with a nonfluoridated polishing agent incorporated into the cup. This eliminates the need to repeatedly stop and apply paste, which may reduce spatter, save time, and reduce abrasiveness on enamel and restorations. The prophy cup has a soft, padded grip that reduces vibration on the enamel and is impregnated with fine silica, which polishes without additional prophy paste. When utilizing paste-free prophy angles, begin in an upper quadrant, where moisture from the parotid saliva duct will soften the cup for better adaptation.

TREATING DENTINAL HYPERSENSITIVITY

Prophy pastes with therapeutic additives are another addition to the market. As dentinal hypersensitivity is one of the most commonly encountered clinical problems, two pastes incorporate additives to help reduce this problem. Dentinal hypersensitivity is an exaggerated response to the application of stimuli to exposed dentin, regardless of its location. It affects one in three adults and is found in 60% to 98% of patients with periodontal diseases.⁷

Arginine-calcium carbonate has been added to a paste that can be used for polishing. This paste contains 8% arginine (an amino acid normally found in saliva), bicarbonate, calcium carbonate, and a pH buffer. The positively-charged arginine ions in the prophy paste attract the negatively-charged calcium and phosphate ions in saliva. The arginine compound acts like saliva, and deposits calcium and phosphate ions into open dentin tubules. The calcium and phosphate ions fill the tubules.⁸ As a result, dentinal tubules are sealed from the oral environment, and a protective coating of salivary glycoproteins and calcium phosphate is formed. The arginine and calcium carbonate paste is designed to provide rapid and lasting relief of dentin hypersensitivity.⁹ Interestingly, two of its key components—arginine and calcium—are found naturally in saliva. The arginine and calcium carbonate work collaboratively to accelerate the natural mechanisms of occlusion to deposit a dentin-like mineral, containing calcium and phosphate, within the dentin tubules and in a protective layer on the dentin surface.⁹

Calcium sodium phosphosilicate is another additive to prophy paste formulated to counteract dentinal hypersensitivity. It is designed to physically seal the dentin tubules. This action occurs rapidly in an aqueous environment, such as saliva, where the material immediately releases sodium ions, which, in turn, increases the local pH. This process allows for rapid precipitation of particles, and the formation of a calcium hydroxyapatite mineral layer on the dentin surface.⁷

ANGLE DESIGN

An advancement in angle design includes the introduction of an angle with special counter-clockwise, turbine-like internal fins to reduce spatter. The angle is designed to provide increased cleaning and polishing effectiveness. In addition, the cup features raised, diamond-shaped ridges on its outside wall for easier interproximal and lingual cleaning.¹⁰

For stains and areas with orthodontic brackets where prophy cups are not practical, the disposable prophy angle with tapered brush may be effective. This prophy angle consists of white nylon bristles with a tapered brush tip. This alternative to a prophy cup is flexible enough to reach into occlusal fissures and grooves to remove debris without injury. This brush may also assist in the preparation of tooth surfaces prior to sealant and orthodontic applications.

A user-friendly prophy angle intended to maximize clinician comfort also has been introduced. The innovative design facilitates cleaning of difficult-to-reach areas, such as the distals of posterior molars, and buccal and occlusal surfaces. Its smooth, rounded head was ergonomically engineered to enhance maneuverability, and its slim neck diameter makes it easier to clean areas with obstructed visibility—such as a tight buccal mucosa, third molars, and dentition in small mouths.

An alternative to the prophy angle is another option. One prophy alternative features a two-in-one design, with a prophy cup that can be removed as needed to clean remaining areas with its gentle tip. Its 100° angle is designed to provide comfort and convenience by reaching all areas of the oral cavity.¹⁰

CONCLUSION

Evidence-based practice considers the scientific evidence, patient preferences or values, clinical/patient circumstances, and clinician experience and judgment. Therefore, oral health care providers need to make informed clinical decisions regarding polishing. Very little sound enamel is actually removed by polishing,³ and it remains an important component of the dental hygiene appointment. Clinicians need to select the appropriate polishing agent, as well as the surfaces to be polished during the dental hygiene appointment. Although patients anticipate that minty clean feeling at the end of the appointment, oral health care providers must ensure that all polishing is provided according to the individual needs of patients.

REFERENCES

1. Barnes C. Shining a new light on selective polishing. Dimensions of Dental Hygiene. 2012;10(3):42–44.
2. Vrbic V, Brudevold F, McCann HG. Acquisition of fluoride by enamel from fluoride pumice paste. J Dent Res. 1956;35:420.
3. Pence S, Chambers D, VanTets I, Wolf R, Pfeiffer D. Repetitive coronal polishing yields minimal enamel loss. J Dent Hyg. 2011;85:348–357.
4. Segura A, Donly K, Wefel J, Drake D. Effect of enamel microabrasion on bacterial colonization. Am J Dent. 1997;10:272–324.
5. Barnes C. The science of polishing. Dimensions of Dental Hygiene. 2009;7(11):18–22.
6. Bertoldo C, Lima D, Fragoso L, Ambrosano G, Aguiar F, Lovadino J. Evaluation of the effect of different methods of microabrasion and polishing on surface roughness of dental enamel. Indian J Dent Res. 2014;25:290–293.
7. Milleman JL, Milleman KR, Clark CE, Mongiello KA, Simonton TC, Proskin, HM. NUPRO Sensodyne prophylaxis paste with NovaMin for the treatment of dentin hypersensitivity: a 4-week clinical study. Am J Dent. 2012;25:262–268.
8. Barnes C. The evolution of prophy paste. Dimensions of Dental Hygiene. 2011;9(3): 50–52.
9. Petrou I, Heu R, Stranick M, et al. A breakthrough therapy for dentin hypersensitivity: how dental products containing 8% arginine and calcium carbonate work to deliver effective relief of sensitive teeth. J Clin Dent. 2009;20:23–31.
10. Product Focus. Available at: dentistrytoday.com/product-focus-hygiene/6455-prophy-angles. Accessed October 21, 2014.

From Dimensions of Dental Hygiene. November 2014;12(11):42–43,46.