The Definition of Polishing

For some, the porte polisher is a distant memory from dental hygiene school. For others, it is pure history. The first dental hygienists used orange wood sticks inserted into the porte polisher and pumice, mixed with mouthwash for polishing the teeth. In 1902, when the idea of today’s “dental hygienist” was being discussed in the dental literature, Dr. C. M. Wright of Cincinnati, Ohio, suggested that refined ladies receive college training and certification to “…polish the teeth and care for the mouth. With this training and dental college certificate, these ladies may be employed by dentists for this special work, or may practice at parlors of their own, or at the homes of patients.”

“Have porte polisher, will travel” might have been the motto of the first hygienists if Dr. Wright had has his way. Polishing was the focus, and the portability of the porte polisher would have allowed for work outside the traditional dental office setting.

After the porte polisher came the belt-driven handpieces and prophy angles. You might remember the belt-driven handpiece, especially if you got your hair caught in it or it blackened your cap. The orangewood sticks were replaced with rubber cups, prophy brushes and polishing points. Pumice and mouthwash were mixed in a Dappen Dish for polishing. Commercially available jars of premixed prophy paste were the next polishing advent. A small amount was dipped out of the jar for each patient. After that came the individual cups of dry powder to mix with mouthwash or water. Today, we have a wide variety of unit dose prophy pastes in an ever-increasing array of flavors and colors.

From the beginning, polishing was considered an essential part of the dental hygiene visit. In fact, many patients actually considered polishing to be the “cleaning” rather than the instrumentation, which takes place prior to the polishing. People either love or hate the polishing. Some look forward to the slippery clean feeling polishing produces. Others complain about the “grit” leftover after the polishing. Despite what patients think about polishing, it is still seen as an opportunity to educate people about clean teeth. According to Caren Barnes, professor of dental hygiene and coordinator of clinical research at University of Nebraska Medical Center in Lincoln, Nebraska, “Polishing removes the acquired pellicle and helps people know what a clean mouth feels like.”

Selective Polishing

“Selective polishing” was introduced by Dr. Esther Wilkins in her textbook Clinical Practice of the Dental Hygienist. Quoting only an abstract about tooth surface removal, polishing as we knew it was condemned for damaging tooth surfaces. To date, there is no scientific research that substantiates the notion that polishing damages tooth surfaces.

Those supporting the concept of “selective polishing” believe toothbrushing and polishing to be the same thing. Patients should be encouraged to remove plaque with a toothbrush and dental floss, and therefore it is not considered necessary for hygienists to polish, except to remove stain. Selective polishing is based on the theory that polishing at every dental hygiene visit is dangerous and unnecessary.

The ADHA Position Paper on Polishing Procedures, published in 1997, stated: “Polishing procedures are considered cosmetic in nature and have no therapeutic value.” Only one reference from 1979 was used to support the claim that polishing was dangerous for tooth surfaces. Caren Barnes said, “There is no compelling evidence to avoid polishing.”

Dental hygiene textbooks still include selective polishing, and this approach is still being taught to dental hygiene students, despite the lack of scientific evidence. According to the recent Hygienetown poll on polishing, 50 percent of 418 respondents reported being taught “selective polishing” in school and only 19 percent of the 421 respondents report following “selective polishing” guidelines. Science doesn’t support the claims that polishing is dangerous and 81 percent of those taking the poll believe that as well by their actions.

Since dentin is much softer than enamel, that should be our concern, despite the fact that so little exposed dentin is encountered in clinical practice. In a study published in the Journal of Clinical Periodon-tology in 2005, Dr. S. Zimmer and colleagues estimated that during a rubber cup polishing, 4.5 seconds are spent to clean a single surface. To determine the effects of polishing with either a prophy brush or rubber cup, they measured dentin removal on extracted teeth after 37 seconds of polishing. This time frame equates to eight professional polishings. Both prophy brushes and cups were used with a variety of prophy pastes, including coarse grit pastes. Even though the prophy brush with coarse prophy paste removed the most dentin, very little dentin was removed with polishing. In fact based on these findings, it would take 69 years to polish away 0.1 mm of dentin. You can’t even see one-tenth of a millimeter change in the root surface. If very little dentin is removed with repeated polishings, it’s clear that polishing at each dental hygiene visit will not harm the enamel, a much harder surface. The message here is that you should use the least abrasive prophy paste necessary to achieve your goals. There is no need to use coarse prophy paste on all patients.

More appropriately, polishing with coarse paste will damage certain restorative materials, but not enamel. Enamel is in a constant state of mineralization flux – demineralization/remineralization. Whatever microscopic layer of “fluoride rich enamel” is removed by polishing; it will be replaced by the minerals in saliva or a topical fluoride treatment.

Air Polishing

Air polishers were introduced in the 1980s to provide an alternative to the traditional rubber cup polishing. Combining compressed air, water and a fine-grade sodium bicarbonate provides an effective alternative that removes bacterial biofilm and stains quicker and more efficiently than a rubber cup. It is especially effective around orthodontic appliances and implants, but does require skill to avoid damaging gingival tissues. Just trying it on only a couple patients or for a day or two will not convince you to trade in your rubber cups for air polishing. If you stick with the air polisher for at least a month, you will develop the necessary skills and confidence. Those who have developed proficiency with the air polisher typically do not give it up.

The Jet Shield attachment for the Dentsply Prophy-Jet was developed by Dr. Steve Harrel, a Texas periodontist. This soft, transparent, cup-shaped attachment controls the mist of sodium bicarbonate powder, protects the gingiva and provides suction. This attachment may help beginners learn to be more comfortable with the air polisher as techniques are developed. Those with more experience prefer to work without the Jet Shield.

Several companies make air polishers, either as a stand-alone device like the Dentsply Prophy-Jet and the Deldent Jet Polisher; or as handpiece attachments like the KaVo PROPHYflex, Sirona ProSmile Handy or the EMS Air-Flow system.

Deplaquing

Polishing is still considered an important part of a dental hygiene visit, especially in the subgingival and interproximal areas. Soft prophy cups can be flared to reach subgingivally and toward the interproximal areas and air polishers can be directed interproximally. The Dentatus Profinette reciprocating interproximal polishing angle provides those who want to deplaque interproximal areas with a tool to easily and effectively achieve that. The use of dental floss or tape is also used with polishing paste to deplaque interproximal surfaces.

Polishing for deplaquing reasons is done either before or after instrumentation. Those who decide to polish first, do so to remove bacterial biofilm and thus reduce the potential for bacteria in the power scaler aerosol. The majority of hygienists still polish after instrumentation.

Periodontal researchers routinely schedule patients for weekly polishings following treatment in their studies. No damage to the teeth has ever been reported from these frequent polishings. Weekly polishings are provided to remove plaque and enhance tissue healing.

Polishing Treatment Plan

Hygienists need to devise a “polishing treatment plan,” according to Air Polishing Expert Cynthia Fong, RDH, MS, and Caren Barnes, polishing researcher. Barnes points out the need to identify the various restorative materials used in each person’s mouth. Not all tooth colored restorations are easily identified. Sometimes radiographs are needed to determine which teeth have been restored.

Next, the hygienist needs to have choices available to polish restorations without scratching or damaging them. Many polishing pastes are made specifically for the new restorative materials using Perlite, aluminum oxide, or diamond powder instead of pumice. A few examples include: Nupro Shimmer, CPR, Sultan Brilliance, Waterpik SoftShine and 3M ESPE Clinpro.

Pro Care by Young Dental has been available for years and is safe for all materials as it is a non-abrasive cleaning agent. It’s a dry powder that requires mixing with water to form a paste, but it will work on any material without scratching. Devising a polishing treatment plan for each patient, based on the restorative material present in the mouth, is the way to provide effective polishing without damaging restorative materials.

The Future of Polishing

Calculus provides a reservoir for bacterial biofilm and thus subgingival instrumentation is carried out throughout the mouth at each dental hygiene visit, with either power scalers, hand instruments or a combination of both. If you ask your patients, will most of them say they’d prefer to have just the polishing if that could take the place of instrumentation? Development of low-abrasion powders for air polishing may replace curettes, power scalers and rubber cups for removal or disruption of supragingival and subgingival bacterial biofilm. Research has shown that air polishing with a new Clinpro low-abrasive air-polishing powder can safely reach subgingival surfaces without harming the gingival tissues.

This concept has the potential to change the way we provide dental hygiene maintenance care. New technology may lead to shorter visits and more time to discuss prevention, diet, and overall health.

Dr. G. Petersilka and his team at the University of Münster in Germany published in the Journal of Clinical Periodontology in 2003, a comparison of curettes and air polishing with the EMS AirFlow S1 air polisher. The tip of the air polisher was directed subgingivally for five seconds per surface and instrumentation was repeated with Gracey curettes until the instrument blade came out free of plaque. Instrumentation took more time than air polishing.

Subgingival bacterial counts were reduced more with the air polishing than with curettes. Both procedures proved to be safe for tissues and teeth when compared over several maintenance visits. When asked their preference, patients said they didn’t find the curettes painful, but they preferred the air polishing. What would your patients prefer, polishing or curettes?

When the Clinpro low abrasive polishing powder becomes available in the United States, you will have a new maintenance option for your patients. The use of power scalers and curettes will still be needed to initially treat periodontal disease. When you have returned your patients to health and coached them in effective daily oral hygiene, maintaining oral health may be as easy as subgingival deplaquing with a low abrasive air polishing powder.

Whatever your current definition of “polishing” a new definition is on the horizon. “Subgingival airpolishing,” supported by clinical research, has the potential to significantly change the way we practice dental hygiene. This is a change patients will enjoy and hygienists will support. The challenge of treating periodontal disease remains, but the routine and struggle of removing all subgingival bacterial biofilm at each maintenance visit will be made easier, faster and more efficient with new technology. Therapeutic polishing is a valuable treatment you can provide your patients.