by Kendra Haynes, RDH, BS
While most dental hygienists feel polishing is an important part of the patient's dental appointment, there still is some controversy in the profession about whether or not to polish patients' teeth. The ADHA's position on polishing states, "Polishing should be performed only as needed and not be considered a routine procedure." Documented research states that polishing can be excessive and damaging to certain restorative materials.
However, patients have come to expect polishing. They like the way their teeth feel after the procedure and feel it is a necessary part of their appointment. Of course, as dental professionals, we know that we could brush our patient's teeth to remove plaque or, better yet, have them brush their teeth until all plaque is removed without ever polishing. The problem is that many patients have a significant amount of stain. I work in a periodontal practice, and I see lots of stain, so I lean toward polishing my patient's teeth.
Is stain damaging to teeth or gums? No, but a vast majority of patients want whiter teeth and generally prefer to have as much stain removed as possible. Surface stains on the teeth are generally dark brown and are caused by strong discoloring agents such a coffee, tea, or tobacco. Is stain removal my main objective? No! My main objective is to remove bacterial plaque and calculus both supragingivally and subgingivally. Since stain removal is tedious, I utilize several techniques so I can spend my time where it is most needed, removing bacteria and toxins.
So when is the best time to polish? I prefer to polish at the beginning of the appointment. I seat my patient, review their medical and dental history, take any necessary vitals, and perform an intra/extra oral exam. I then proceed by looking for plaque and stain. I review oral hygiene and then polish my patient's teeth.
Removing plaque prior to periodontal probing is an advantage because I can see the probe readings more accurately. It also minimizes the necessity of repeatedly cleaning my instruments (saving time). I also prefer to polish stain off as opposed to scaling or using the ultrasonic to remove stain. Many patients with root exposure are sensitive to excessive ultrasonics and/or hand scaling.
Do I only polish with a slow-speed handpiece to remove stain?
No, I use a combination of ultrasonics, hand scaling, and polishing with a slow speed. No one method seems to remove all of the stain on those patients with heavy tar-like stain. Generally, I will polish the patient's entire mouth if needed and then return to the most heavily stained areas, usually the mandibular anteriors and, occasionally, the maxillary anteriors. I will then alternate ultrasonic and hand scaling.
I like to use the Hu-Friedy H6H7 anterior scaler to remove stain interproximally. I also like the Hu-Friedy model for stain removal on the direct lingual surfaces. At this point, I may polish again. Clinpro™ Prophy Paste (3M ESPE) is least abrasive and leaves a nice smooth surface. It is not a pumice-based polishing paste but contains a "perlite particle" that breaks down to smaller particles, which results in less abrasion to dentin and enamel. Patients seem to like it too, because it feels less gritty and has a refreshing taste.
Do I always remove all of the stain? No. If there is a significant amount of root exposure, repeated scaling and polishing can compromise the integrity of the tooth structure causing an effect called "Riffeling." The riffle effect was named for an early periodondist named Riffel because mandibular anterior teeth of his patient's were hourglass or Coke bottle shaped due to excessive scaling and root planing.
I feel it is okay to leave stain to prevent structural damage to the root surface especially if the patient is on a three-month maintenance schedule. There even is a patient in our practice on whom we hygienists leave supragingival calculus because he already has the hourglass shaped teeth.
Why not use a prophy jet to remove stain and plaque? Prophy jets also can compromise and damage restorative materials and are contraindicated for glass ionomer and composite resin restorations. Aerosols produced by the prophy jet also can remain in the air for a substantial amount of time. When used on several patients a day, fine particles in the powder linger in the aerosol produced and hygienists may be in danger of developing chronic respiratory conditions from inhaling the particles over time.
I feel it is most important that our patients understand that cosmetic stain removal is not the main issue. Removal of bacterial toxins to maintain and control their periodontal health is why we do an oral prophylaxis. I tell the patient that I will remove as much stain as possible, but I will allocate most of my time to their periodontal health.
Kendra Haynes, RDH, BS, received her dental hygiene degree at University of Nebraska Medical Center College of Dentistry in 1991. She has since completed a bachelor's degree and an associate's degree in surgical technology. Haynes worked as a clinical instructor at the UNMC College of Dentistry from 1992-93. She is a member of the American Dental Hygienists' Association and is extremely active in her state dental hygiene association, serving as state president, vice president, legislative chair, delegate component president and fundraiser chair. In 1998 she was awarded the Nebraska State Hygienist of the Year and Component Hygienist of the Year. She currently consults for 3M ESPE and is on its Dental Hygiene Advisory Panel.Here some tips the author and other hygienists use to reduce stain for patients in between visits:
• Powered toothbrushes
• Sending home a few containers of prophy paste and have patients use with a toothpick or an end tuft brush two or three times a month only in the affected areas.
• Use floss with whitening toothpaste