As a clinician, have you ever observed a stain at the margins of composite restorations or even the dreaded "little black line" at the interface between tooth structure and composite? Don't look at these "ugly contours" as a restorative failure - instead, begin to think about them as opportunities. These discrepancies, sometimes seen near tooth-colored restoration margins, should propel your thinking to the prospect that as a hygienist you can renew the composite restoration and preserve tooth structure. We no longer have to remove this functional filling and replace it with a larger one, just because the esthetics may be deteriorating.
An hygienist can increase the longevity of composite restorations and return them to a beautiful luster by learning some contemporary techniques that involve "polishing to preserve." The purposes for becoming aware and implementing these innovative services include:
- Improving gingival health and less plaque retention
- Preserving the integrity of interface between restoration and tooth structure
- Improving cleansing by the client (in other words, a smooth surface)
- Increasing the longevity and decreasing the wear of the restoration
- Increasing the luster or beauty of the restoration and/or a "renewed brightness"
- Establishing the practices' commitment to excellence and value, by providing services that boost the longevity of the clients' investment
- Expanding clinical services for hygienists
Step one: Identify. Clinicians must first identify between natural tooth structure and the type of restorations.
•Micro-hybrid, hybrid, microfill, porcelain, ceramic, and so on
•Color-code chart with a sticker (such as blue for composite, green for porcelain)
Step two: Radiographic/digital radiography assessment. Radiographs are an important tool for viewing interproximal areas, bone loss, and restorations. Develop a "radiographic assessment" depending on your client's needs and location of restorative therapy:
•Four vertical posterior bitewing X-rays every one to two years
•Three vertical anterior bitewing X-rays every one to two years
•Series of seven vertical (anterior and posterior) bitewing X-rays every one to two years
•Full-mouth radiographic series every three to five years
Step three: Visual assessment. Use magnification devices such as Orascoptic telescopes (www.kerrdental. com) and Perioscopy (www.dentalview.com) to evaluate definitive restorations. Evaluate for the following:
•Plaque and calculus accumulation
•Staining (both slight to moderate surface stain and gross stain)
•The integrity of margins in labial/palatal restorations (must be contiguous with resin margin and anatomic form). The margin may show visible crevice/discrepancies or obvious crevice/discrepancies
Step four: Therapeutic instrumentation. Minimal instrumentation.
•Hand scalers with a sharp, well-maintained edge such as the DISC sharpening system (www.premusa.com) or PerioStar (www.kerrdental.com).
•Plastic probes and instruments such as Implant-Prophy+ (www.aitdental.com) or Perio WiseRegistered an implant scaler (www.premusa.com)
•Air polishing instruments. However, sodium bicarbonate creates an increase of roughness so this is contraindicated for composite polishing services
•Ultrasonics. Research recommends avoiding the use of ultrasonics on the margins of any restoration, tooth-colored or amalgam. Apical or coronal to the margin may be acceptable if the clinician is proficiently trained in effective ultrasonic debridement techniques.
Step five: Polishing systems. Due to the differences in composite materials, one system may be incapable of creating a high shine for all materials. Polishing devices must be selected according to the type of material used. For example, a tooth/restoration that exhibits little or no stain still has its luster, and the only goal is slight stain removal or plaque removal - the device would be a gentle tooth/polishing paste such as Opalescence Whitening Toothpaste (www.ultradent.com), Rembrandt (www.rem brandt.com) or Clinpro (www.3MESPE.com).
A protocol for slight stain removal on composite is as follows:
- Distribute polish adequately over the entire surface (via buffing cup or bristles) and use a light intermittent stroke contacting the restorative/tooth surface for no more than 15 to 30 seconds each. Remember to continually add water to the buffing cup/brush during polishing.
- Carry paste interproximally with floss and rinse to clear area before re-examining.
For a tooth/composite restoration that exhibits medium to heavy stain, and no longer has its luster, various polishing mediums such as carbide burs, diamond burs, rubber polishing devices, brushes, and material-specific pastes are available:
•Polish with aluminum oxide or a small particle diamond, such as Enamelize (www.cosmedent.com), Proxyt (www.ivoclarvivadent.us.com), Diamond Polish (www. ultradent.com), and OneGloss PS (www.shofu.com).
•Discs, points, foam/buff cups, brushes such as ICB, Jiffy (www.ultradent.com), Sof-Lex (www.3MESPE. com), Super Snap Singles (www.shofu.com) and Occlubrush (www.kerrdental.com).
A protocol for medium or heavy stain removal on composite incorporates more aggressive devices in progression.
•Device selections include higher grit pastes, rotary rubber polishing instruments, points, discs, and strips all in grades ranging from extra-fine through coarse.
•Rinse away polishing agents/particles between levels of coarseness to avoid continually abrading the surface.
•Remember, the goal is for restoration polishing, not recontouring or margin obliteration.
•Once stain removal is achieved, reverse the process and complete polishing with the least abrasive polish/instrument.
•Use aluminum oxide polishing strips to remove interproximal stain. Options include Epitex (www. gcamerica.com), FlexiStrips, (www.cosmedent.com) and Sof-Lex Strips (www.3MESPE.com). Start with the finest grade and graduate to the next coarsest grade until the stain is gone. Complete the process by reversing the sequence and step down to the finest grade until the restoration is smooth interproximally.
Step Six: Increasing vitality and longevity. Once either the stain removal or polishing procedure is complete, apply a composite sealant to the composite surface. This vital step reduces wear, marginal breakdown, and microleakage, while further preserving the "glaze" and increasing the longevity of the restoration. Sealants include PermaSeal (www.ultradent.com), Fortify Plus (www.bisco.com) and OptiGuard (www.kerrdental.com).
Administer a neutral sodium fluoride application and or sodium fluoride varnish. Choices include Minute-Foam and Funtrays (www.oralb.com), All Solutions (www.professional.dentsply.com), Flouridex (www.discus dental.com), CavityShield (www.omniipharma.com), and Duraphat (www.colgateprofessional.com).
Kristine A. Hodsdon, RDH, BS, is a coach with Hygiene Mastery, as well as an international speaker, author, and software developer. She can be contacted about speaking or coaching at (888) 347-4785 or by e-mail at [email protected] or [email protected]. Visit her on the Web at www.pre-d.com and www.hygienemastery.com.