New safer concepts are emerging in enamel polishing
By Shirley Gutkowski, RDH, BDH
The story of prophylaxis polish is about progress, not just change.
Although today's polish is still mostly pumice based-and the top-selling grit is coarse followed by extra coarse-a number of changes show the industry's attempt to provide us with a polish that will remove stain while keeping the enamel and root surface intact. The most critical polishing time is before the prophylaxis when removing biomass from the enamel and root surfaces. The benefits of polishing then are pretty obvious. The downside is that the enamel is softest at the interface where the biomass is accumulated; using coarse paste may be too damaging to the enamel, and the enamel may not recover.
That's the big issue here-preserving enamel. It seems enamel heals provided it gets the minerals it needs from saliva or added topical agents. This little secret is not a license to use overly coarse minerals during the polish. We are still obligated to use the least damaging agent to remove stain. Or, we provide the enamel a supportive salivary replacement that is built into the polish.
Let's start with categorizing polishes into two camps: pastes and powders. Pastes are applied with an angle, and powders are applied with an air-polishing unit. Pastes with remineralizing agents have been around awhile; what's new in paste delivery are double cups.
Double the polish
Remineralizing agents in the pastes are either a bioactive glass called NovaMin (Dentsply Nupro), an amorphous calcium phosphate (ACP) (Premier Dental), or NuFluor, a proprietary fluoride with calcium and phosphate (Preventech's MAXmin). Unless you look for a polish specifically without fluoride, all polishes contain sodium fluoride to help the remineralization. These smart polishes can be used on every patient at every appointment. For specific cases, they're a must.
For regular patients with regular stain from morning coffee or tea, for example, a double cup of fine and medium polish can save enamel and contribute to a beautiful end product. Most hygienists don't like the idea of using two cups; most practice owners aren't big on it either, which is why the double cup design is so awesome (Young Dental's SmartSelect). There are two schools of thought about how to use the grits. One is to use the coarse first, and then the fine grit.
Another way to use a double cup is to start with the smaller particles, polish all the teeth, and then polish the leftover stain with the coarser polish. Either way is good if the patient has saliva to replenish the enamel.
If your patient doesn't have saliva, a quick swipe of a remineralizing paste-containing hydroxyapatite (Voco's Remin Pro, Carifree HA Paste) or Recaldent (GC America's MI Paste)-would be a great service after polishing. Saliva is the determining factor for your choice of polishing pastes, unless your patient has a lot of esthetic prostheses. The higher the grit, the more chance of losing the gloss and turning your dentist's beautiful work into a yellow sesame seed filling.
Patients with mixed enamel and cosmetic restorations have special needs too. For special esthetic cases, the choices are pretty broad. The proper way to polish the teeth in that type of condition is to polish the prosthesis first with the nonabrasive polish, then use the pumice paste on the enamel. Why make a point of this point? Because you'll likely use just one prophy angle or cup; you don't want to have leftover pumice in the cup and damage the prosthesis without realizing it when going back to polish the fillings.
Seems the industry has settled on pumice as the abrasive. There is no standard for pumice size for the grit. One company's fine may be another's medium. Rest assured, though, that pumice crushes as you polish. So whatever grit size you start with becomes smaller. Perlite is also available. Perlite doesn't start with sharp edges such as pumice, and it crushes faster (3M's Clinpro). Another new product is a traditional paste with baking soda (sodium bicarbonate) (Young Dental's Vera). Acting as a buffering agent, the sodium bicarbonate improves pH and removes stain without being abrasive.
Clinicians also have control over the safety of polishing by adjusting the speed of the cup and the amount of pressure applied to the tooth while polishing. An increase in either can leave more distinctive marks on the enamel. This is where air polishing takes the lead in polishing, adjusting the amount of powder for each area on a tooth is pretty easy, as is adjusting the water to powder ratio.
This may be a place for a discussion about gluten. Gluten is not used in the manufacturing of polishing pastes. However, that is not to say that gluten is not a part of some of the ingredients that are used in the making of polishing paste. If soda is made in an area with fluoridated water, even cola beverages contain fluoride. Some polish makers went through the expense and effort of testing their brands and flavors to ensure a gluten-free style of polish. This is a major selling point, so when you're ordering, check the ad (Young Dental's D-Lish and Vera, Preventech's Nada, and Denticator's SureClean).
For those who are sensitive to nearly everything, a paste that has nothing in it may be just what the dental hygienist ordered. No flavor, no fluoride, no gluten, no problem.
What about the clinician? Is there a way for you to be safer? There sure is. For traditional polishing, use a contra angle with a small cup. Using a cordless or angled handpiece (Young Hygiene Handpiece) will also be kinder to your wrist, shoulder, and neck.
Can you really see the buccal of the last molar on the opposite side? Probably not. It's dark back there! There's not a lot of safety in the dark. Wearing a headlight is really helpful, but until you have a light on the polishing handpiece, you're still polishing in the shadows; that's not ergonomic. So far, there's only one polishing handpiece with a light on the end, and it's on an air-polishing unit called Suvi (Coltene Whaledent's Suvi Elite). The light is also handy for visualizing during your hard- and soft-tissue exam.
The Suvi brings us into the air polishing discussion. Using an air slurry polisher is the most flexible way to polish teeth. There have been new strides in air polishing that can make polishing this way the best way to remove stain and rehab teeth. Using rehabbing polishing materials is awesome for patients with lots of biomass coating their teeth.
If a tooth has some decay on it, or a prosthesis on part of a tooth, that tooth likely has invisible areas of breakdown too. Air polishing compounds that remineralize teeth have been slow in coming. However, studies on hydroxyapatite powders and bioactive glass show improved enamel and improved root surfaces. As yet, there's no hydroxyapatite powder for air polishing. There is an available bioactive glass powder (Velopex's Sylc). The trick of the bioactive glass is in the particle size. Your patient may feel as if there's grit in the mouth after polishing, but that's just the glass particle dissolving, mixing with the saliva and healing the tooth until it's completely dissolved. Rinsing it out will not be as healthful for the tooth's surfaces as leaving it to work after your work is done.
Traditional powders are less expensive than the remineralization powders. There are still two main types of powders for air slurry polishing-calcium carbonate and sodium bicarbonate. As for paste polishes, care on the root surface is paramount. Only the bicarb has contraindications past what is normal, such as prostheses, white spot infections, or on patients with respiratory infections (all are contraindicated for paste and powder). Those on a sodium-restricted diet are also restricted from using sodium bicarbonate air polishing powder. Swapping out sodium bicarbonate for calcium carbonate can be time consuming if the powder is not easy to remove from the machine.
The air polishing powder should also be switched based on the patient in the chair, and maybe per tooth. Sometimes a tooth or an area cries out for special attention. For most machines, switching polishing powders is a time consuming activity. Dumping out the powder, cleaning out the line, and reintroducing a second powder take precious time and introduce infection control issues. Even removing the powder at the end of the day is a difficult task for most machines, and it's what keeps many clinicians from using the air polishing part of a dual scaling/polishing machine. The powder cup of the Suvi is on the outside and has a wide mouth. Just swapping cups is really all that is necessary.
Maintenance on the machines has improved quite a bit. For most, a press of a button blows out the remaining powder and gets you ready for your next patient in practically no time at all. Air slurry is quick and easy for your patients and makes it easy to keep the enamel and root surface intact.
This may sound fishy to people who have been following air polishing science for a while. Yes, there's a learning curve, as there was in school when you learned to use your angle. An early study showed root damage on teeth polished with sodium bicarbonate at 20 seconds, a long time in air polishing for a single location. The authors of that 20-second paper mentioned above didn't mention the air pressure. So, here's the scoop on air polishing that puts all the negatives into a new light: Turn the air pressure down. There's a way to turn down the pressure from the air compressor before it goes into the machine.
This simple tip reduces aerosols and fluff and improves the cleaning outcome and the patient experience. Wearing a good mask properly improves safety for all clinicians who work on patients. There are also masks for patients to protect them from all aerosols that occur during a visit with the dental hygienist.
Learning how to use today's polishing options can make an oral health provider a true patient advocate by keeping enamel sound. For whatever reason, patients like to have their teeth polished, and dental hygienists like offering it as a service. Polish like a pro... progress, that is. RDH
Shirley Gutkowski, RDH, BSDH, is a practicing dental hygienist specializing in orofacial myofunctional therapy. Her practice, Primal Air, LLC, is in Sun Prairie, Wisconsin. Ms. Gutkowski is also the host of Cross Link Radio, a podcast with timely information integrating oral and systemic health.