To Polish or Not to Polish?

Many of the techniques and modalities used by dental hygienists have evolved over the years. However, coronal tooth polishing has remained a staple of the dental hygiene appointment even though its use has been controversial since the 1970s. Patients have come to expect polishing as a necessary part of the dental appointment.¹ But dental hygiene schools now recommend selective polishing as standard protocol instead of including polishing at every professional maintenance appointment.

At the turn of the last century, Dr. Alfred Civilion Fones began training his female auxiliaries to provide coronal tooth polishing.² By the 1970s, Esther M. Wilkins, RDH, DMD, author of the widely used textbook The Clinical Practice of the Dental Hygienist, was promoting polishing as a selective process due to its removal of surface enamel.³ In the 1990s and 2000s, further evidence has supported the adoption of selective polishing.^4,5 However, the concept of full-mouth polishing is still used in many—if not most—dental hygiene practices.

TECHNIQUE

The traditional method of polishing consists of applying a rubber tip with prophy paste to the supragingival enamel surfaces to remove plaque and stain.⁶ Some research shows that polishing can remove 4 micrometers of tooth surface during a 30-second pumice polishing procedure.^3,7 With frequent polishings, tooth surfaces may be damaged due to the loss of fluoriderich enamel surface levels. However, the minerals contained in saliva consistently work to remineralize tooth surfaces.⁸ The current recommendation is to use a slow speed handpiece with prophylaxis polishing paste for 1 to 2 seconds with a light touch while gently flaring the cup to remove extrinsic stain.^6,9

PATIENT EVALUATION

After a scaling or debridement, the dental hygienist should evaluate the patient’s enamel surfaces. If no stain exists, polishing may not be necessary. Polishing is needed when extrinsic stains are visible on enamel, cementum, dentin, or restorations.⁶ Only the necessary crown surfaces should be polished to remove extrinsic stain and dental biofilm.⁶ Stain removal is not essential for healthy teeth but is an important esthetic procedure. Rubber cup polishing is not the only means of removing stain. Hand scaling, sonic and ultrasonic instrumentation, and air polishers also remove stain.⁹ New pumice-free polishing cups that eliminate the need for polishing paste are also available.

CONSIDERATIONS FOR PROPHYLAXIS PASTES

If polishing is indicated, the characteristics of the abrasive particles—including shape, hardness, body strength, attrition resistance, and particle size (grit)—should be considered when selecting prophylaxis paste for patients. Each characteristic will determine the effects on the coronal surfaces. See Table 1.

Some common abrasive agents are listed in Table 2. Abrasive agents vary in grade—from fine to coarse—with each designed for a particular use. Superfine grades are available for polishing enamel surfaces and metallic restorations while laboratory procedures use a coarser grade. The abrasive agent should be chosen based on frequency of use, eg, toothpaste for daily use = superfine, prophy paste = less fine for periodic use.⁶

Cleaning agents in polishing pastes differ in shape and hardness and include alkaline and aluminum silicate.⁶

Dental hygienists should have a variety of pastes in their armamentarium to accommodate the different tooth surfaces when polishing.⁶ Polishing pastes now contain various enhancing additives to perform special functions, such as adding to the mineral surface of enamel (calcium phosphate), adding fluoride, decreasing dentin hypersensitivity, or tooth whitening. Calcium phosphate works to stimulate remineralization causing original hydroxyapatite to form a stronger enamel, enhancing tooth smoothness and increasing enamel luster.⁶

POSSIBLE CONTRAINDICATIONS

Polishing is not necessary prior to fluoride application since the uptake of fluoride is not inhibited by plaque biofilm.^3,6,8 Three Danish study groups consisting of 160 children each found that topical applications of acidulated phosphate fluoride are effective caries prevention measures and fluoride applications for caries prevention are not impacted by prior prophylaxis.¹⁰

A possible contraindication for polishing is that the abrasive pastes may scratch the outer surfaces of materials used for restorations such as composite resin, amalgams, and gold restorations.⁸ See Tables 1 and 2. Other concerns are bacteremia and damage to the pulp of the teeth due to the heat generated by a powerdriven prophy angle.⁸

PATIENT EDUCATION

As dental professionals, we need to begin re-educating our patients on healthy procedures. First, the meaning of selective polishing should be explained along with the evidence that shows why polishing may not be necessary at every appointment when daily care is effective. Finally, patients should understand that even with the removal of stains and biofilm, acquired pellicle begins reformation within minutes.⁶

CONCLUSION

Dr. Fones stated in 1934, “The greatest service (the dental hygienist) can perform is the persistent education of the public in mouth hygiene and the allied branches of general hygiene.”¹¹ Coronal polishing should be reviewed with every patient. Do I polish for cosmetics or to make my patient feel good? May I just brush to complete the removal of biofilm? Use your evidence-based knowledge to determine what is best for each of your patients. In addition, keep in mind that other products used during the polishing procedure may indeed help remineralize tooth surfaces and alleviate sensitivity. New products may change concepts about selective polishing and the jury is still out.

REFERENCES

1. Daniel SJ, Harfst SA, Wilder RS. Mosby’s Dental Hygiene Concepts, Cases, and Competencies. 2nd ed. St. Louis: Mosby Elsevier; 2008.
2. Peterson SA. The Dentist and His Assistant. 3rd ed. St. Louis: Mosby; 1972.
3. Wilkins EW. Clinical Practice of the Dental Hygienist. 4th ed. St. Louis: Lea & Febiger; 1976.
4. Redford-Badwal DA, Nainar SM. Assessment of evidence-based dental prophylaxis education in postdoctoral pediatric dentistry programs. J Dent Educ. 2002;66:1044-1048.
5. Barnes CM. Protocol for polishing. Dimensions of Dental Hygiene. 2004;2:26-32.
6. Wilkins EW. Clinical Practice of the Dental Hygienist. 10th ed. St. Louis: Lippincott Williams and Wilkins; 2009.
7. Vrbic V, Brudevold F, McCann HG. Acquisition of fluoride by enamel from fluoride pumice paste. J Dent Res. 1956;35:420.
8. Perry DA, Beemsterboer PL. Periodontology for the Dental Hygienist. 3rd Ed. St. Louis: Saunders Elsevier; 2007.
9. Darby ML, Walsh MM. Dental Hygiene Theory and Practice. 2nd ed. St. Louis: Saunders; 2003.
10. Bijella MF, Bijella VT, Lopes ES, Bastos JR.. Comparison of dental prophylaxis and toothbrushing prior to topical APF applications. Community Dent Oral Epidemiol. 1985;13:208- 211.
11. Fones AC. Mouth Hygiene. 4th Ed. Philadelphia: Lea & Febiger; 1934.

From Dimensions of Dental Hygiene. March 2009; 7(3): 32, 35.