tooth polishing is no longer considered to be necessary

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Dental Hygienist News

Selective Polishing

Selective polishing is the process of rubber-cup polishing only those areas of remaining stain after scaling and root planing. Plaque deposits can be removed effectively by the clinician or the patient with a toothbrush.

WHAT ARE THE BENEFITS?

Selective polishing minimizes the irreversible loss of enamel during rubber-cup polishing. Approximately 4 microns of enamel are lost each time a tooth is polished with a rubber-cup and prophy paste.

Selective polishing prevents damage to restorative surfaces, such as composite fillings, veneers, and porcelain crowns.

Since selective polishing requires less time, the clinician can spend more time educating the patient about plaque removal with the daily use of a toothbrush.

Indications
Presence of stain after scaling and/or root planing.

Contraindications

Absence of stain
Acute gingival inflammation
Newly erupted teeth
Composite restorations
Decalcification
Porcelain crowns and veneers
Enamel hypoplasia
Titanium implants
Exposed root surfaces
Xerostomia
Areas of hypersensitivity
Respiratory problems
Rampant caries
Prophy paste allergy


Limited polishing is recommended for patients with a communicable disease.

The American Dental Hygienists' Association (ADHA) takes the following position regarding polishing procedures:

- Only a licensed dental hygienist or dentist is qualified to determine the need for polishing procedures.

- Polishing should be performed only as needed and not be considered a routine procedure.

Background
Historically, polishing has been a routine part of the prophylaxis appointment. It was believed to be important to have smooth, stain-free tooth surfaces in order to impede the buildup of new plaque. Patients/clients expected that their teeth be polished after scaling and root planing to smooth the tooth surface and remove stains. Recent literature, however, has changed the way the polishing procedure is viewed.

Today, polishing is viewed as a cosmetic procedure with little therapeutic benefit.(1,2) Unfortunately, many consumers do equate polishing with the oral prophylaxis. Nevertheless, polishing is not essential to the prophylaxis, as once thought. In fact, it is considered poor oral health care to provide polishing services only and have a patient/client believe he/she is "getting their teeth cleaned." "Polishing" involves making a surface smooth; "cleaning" involves removing debris and extraneous matter from the teeth.(1) "Oral prophylaxis", then, is defined by the American Academy of Periodontology as the "removal of plaque, calculus, and stains from the exposed and unexposed surfaces of the teeth by scaling and polishing as a preventive measure for the control of local irritational factors."(3) The prophylaxis procedure as stated here is performed on the healthy mouth to prevent periodontal disease.

Recent literature shows that thorough brushing and flossing at home can produce the same effect as polishing.(4) Therefore, one can conclude that polishing of coronal surfaces on a routine basis provides no additional benefit to the patient/client. It is also argued in the literature that continuous polishing can, over time,; cause morphological changes in the teeth by abrading tooth structure away.(5) Additionally, the fluoride in the outer layers of enamel is removed through polishing.(1) Thus, researchers agree that polishing is no longer considered to be necessary on a routine basis. The dental hygienist/dentist must assess each patient for the amount, type, and location of stain present to determine the need for polishing.

Another reason polishing was considered important in the past was to remove plaque and stain prior to a fluoride treatment to insure adequate uptake of fluoride in the enamel. Research now shows that polishing does not improve the uptake prior to a professionally applied fluoride treatment.(6,7) Steele's and Tinanoff's studies in 1982 and 1974 respectively showed that brushing and flossing were adequate methods of plaque removal prior to fluoride treatments, and fluoride uptake was not adversely affected by lack of a rubber cup polishing.

Polishing prior to sealant application is another area of recent debate. Formerly, it was believed that it was necessary to polish tooth surfaces prior to sealant placement to insure proper acid etching and sealant penetration. However, several recent studies have shown other methods of plaque removal to be equally efficient. They include use of an explorer and forceful rinsing with water, tooth brushing with toothpaste, hydrogen peroxide, and use of an air polisher.(8-11)

Air polishing was introduced in the 1980s and has been found to be especially useful in certain instances. In addition to being used during the prophylaxis, it has been found to be useful for orthodontic patients, root detoxification during periodontal surgery, and sealant procedures.(11-13) However, with any procedure, appropriate knowledge and technique are important. The clinician must be aware of its limitations, contraindications, and most importantly, its proper use. Generally, it is indicated on patients with heavy amounts of stain, especially chlorhexidine. There are numerous contraindications and other concerns, however, that prohibit indiscriminate use of the air polisher in certain patient groups.(14)

- Patients with restricted sodium diets - Patients with respiratory, renal, or metabolic disease - Patients with infectious disease - Children - Patients on diuretics or long-term steroid therapy - Patients with titanium implants (Research is still needed in this area)

Air polishers also should not be used on patients/clients with exposed cementum or dentin. A study by Galloway and Pashley in 1986 showed the air polisher can cause clinically significant loss of tooth structure if used excessively.(15) In addition, an air polisher should be avoided around most types of restorative materials due to the possibility of scratching, eroding, pitting, or margin leakage.(1)

Legislation
Currently, approximately 23 states allow dental assistants to perform coronal polishing.(16) This raises a concern because only about half of these states require education or examination in polishing for dental assistants There is also a lack of standardization for education, examination, or certification for dental assistants among states. Another concern, to insurance companies as well as consumers, is the potential for fraud by billings for a prophylaxis when only a polishing is performed. Coupled with many states' legislative attempts to allow dental assistants to perform supragingival scaling, this puts the consumer's oral health at serious risk. Incomplete removal of deposits from above and below the gumline can lead to several problems: 1) If bacteria-laden deposits are not completely removed, the bacteria continue to multiply and the disease process is not stopped. 2) When deposits are not removed from the base of the pocket, the tissue will shrink and tighten around the neck of the tooth, and bacterial toxins are trapped in the pocket. This can result in a periodontal abscess. 3) When healing and tissue shrinkage occur at the neck of the tooth, the tissue becomes tighter, and it is more difficult to place an instrument in the pocket for removal of remaining deposits.(17)

Conclusion
Polishing should not be considered a routine part of the oral prophylaxis. The licensed dental hygienist or dentist is the best qualified to determine the need for polishing. The ability to judge appropriately which patients/clients should or shouldn't be polished is compromised if a practitioner is not knowledgeable. ADHA believes that licensed dental hygienists and dentists are the best qualified to perform polishing procedures.

Notes
1. Woodall IR: _Comprehensive Dental Hygiene Care", 4th edition. St. Louis, Mosby-Year Book, Inc., 1993, pp. 648, 660.
2. Walsh MM, Heckman B. et al.: Effect of a rubber cup polish after scaling. "Dental Hygiene" 1985;59(11):494-498.
3. American Academy of Periodontology: "Glossary of Periodontic Terms", 3rd edition. Chicago, American Academy of Periodontology, 1992, p. 40.
4. Waring MB, Horn ML, et al.: Plaque reaccumulation following engine polishing or tooth brushing—a 90-day clinical trial. "Dental Hygiene" 1988;62:282-285.
5. Swan RW: Dimensional changes in a tooth root incident to various polishing and root planing procedures. "Dental Hygiene" 1979;53:17-19.
6. Steele RC, Waltner AW, Bawden JW: The effect of tooth cleaning procedures on fluoride uptake in enamel. "Pediatric Dentistry" 1982;4:228-233.
7. Tinanoff N, Wei SHY, Parkins FM: Effect of a pumice prophylaxis on fLuoride uptake in tooth enamel. "Journal of the American Dental Association" 1974;88:384-389.
8. Donnan MF, Ball IA: A double-blind clinical trial to determine the importance of pumice prophylaxis on fissure sealant retention. "British Dental Journal" 1988;165(8):283
9. Houpt M, Shey Z: The effectiveness of a fissure sealant after six years. "Pediatric Dentistry" 1983;5(2):104-106.
10. Christensen CJ: Fluoride made it: Why haven't sealants? "Journal of the American Dental Association" 1992;123(2):89-90.
11. Brocklehurst PR, Joshi RI, Northeast SE: The effect of airpolishing occlusal surfaces on the penetration of fissures by a sealant. "International Journal of Pediatric Dentistry" 1992;2:157-162.
12. Gerbo LR, Barnes CM, Leinfelder KF: Applications of the air-powder polisher in clinical orthodontics. "American Journal of Orthodontics and Dentofacial Orthopedics" 1993:103(1):71-73.
13. Horning GM, Cobb CM, Killoy WI: Effect of an air-powder abrasive system on root surfaces in periodontal surgery. "Journal of Clinical Periodontology" 1987;14:213.
14. Brown SM: A scientific foundation for the clinical use of air polishing systems, Part II: Technique. "Practical Hygiene" 1995;4(6):14-19.
15. Galloway SE, Pashley DH: Rate of removal of root structure by the use of the prophyjet device. "Journal of Periodontology" 1986;58(7):464-469.
16. American Dental Association: "Legal Provisions for Delegating Functions to Dental Assistants and Dental Hygienists". Chicago, American Dental Association, 1993, p. 16.
17. O'Hehir TE: Gross scaling: An antiquated concept. "Dental Hygiene News" 1994;7(1):19-20.American Dental Hygienists’ Association Position on Polishing Procedures

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Dental Polishing is Now Selective

Mature enamel is the hardest calcified tissue in the human body. And even though enamel is the hardest, it can be lost forever since it is nonvital and therefore not a renewable resource. The preservation of the enamel of every tooth during the patient's lifetime is one of the goals of every dental professional. The dental professional must take into consideration the properties of enamel when deciding the cavities-risk for patients, counseling patients and communities on fluoride use, placing enamel sealants, and using and recommending polishing agents.

The type of polishing agent used by the dental professional and the patient at home is thus a very important consideration. Older toothpastes and professional polishing agents were noted for their abrasiveness of the enamel surface, removing valuable tooth layers to obtain only temporary aesthetic results. Today the use of selective polishing methods during a professional cleaning to only remove stain and also the use of less abrasive professional and recommendation of certain patient polishing agents preserves the limited enamel present on the crowns. This is possibly evident during your last professional cleaning when care was taken to not only chose the correct polishing agent but to then only polish those enamel surfaces with stain. The loss of the overall smooth, pasty and minty feeling is one thing we all need to get over since it meant in many cases the loss of enamel! If you want further information on this new consideration for your teeth, discuss it with your dental professional at your next visit.

Margaret J. Fehrenbach, RDH, MS, Educational Consultant

[malernee]

The calculated enamel loss could be a problem with repeated polishings if 4
microns of enamel are lost every polishing and the thickness of the enamel is
as little as 0.1mm. The enamel thickness in a dog or cat tooth is often much
less than a human tooth. .Assuming a cleaning schedule of 1 time/year, a 15
year life span with dentals done from the age of 1 year, this would be 15 x 4 =
60 microns. This translates to .06 mm lifetime enamel loss. In a limited
study done (Journal of Veterinary Dentistry, Sept 1995) 147 dog teeth were
sectioned (incisors, cuspids, premolars and molars) 61% of the teeth had enamel
thickness of 0.1 - 0.3 mm. 37% were 0.4 - 0.6 mm, and 2% were 0.7 -1. mm thick. If
the enamel was 0.1mm thick we would have polished off over 50% of the enamel
through the years.

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