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Profile in Oral Health Trisha E. O'Hehir, RDH, BS Editorial Director, Hygienetown Magazine

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by Trisha E. O'Hehir, RDH, BS
Hygienetown Editorial Director

People either love or hate 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 an opportunity to educate people about how clean teeth should feel. It's also an opportunity to provide valuable therapeutic and cosmetic benefits with new polishing pastes formulated to reduce sensitivity, remineralize tooth surfaces and safely bring shine and luster back to restorative materials.

Regardless of well-meaning claims that polishing is damaging to tooth surfaces, there is no scientific research that substantiates the notion that polishing does so. Enamel is in a constant state of flux — demineralization/remineralization. Whatever insignificant microscopic layer of "fluoride rich enamel" is removed by polishing, it will quickly be replaced by salivary minerals. There is however, evidence that polishing with coarse abrasives will damage restorative materials. Today we have new polishing pastes made specifically to protect restorative materials.

Polishing is a hot topic on the Hygienetown.com message boards. To date, more than 35 discussions directly address the changing concepts of polishing. Some deal with the new polishing paste formulations that are applied prior to instrumentation to desensitize root surfaces. Others discuss formulations now available to remineralize tooth surfaces and reverse early carious lesions. Some discussions raise questions about how to polish the interproximal surfaces that are at greatest risk for dental disease. One of the hotter topics is about polishing first, which has brought out a variety of views regarding this concept. Polishing has moved beyond the basic goal of stain removal. It is changing and evolving on both cosmetic and therapeutic levels.


Polishing Restorative and Cosmetic Restorations
For routine polishing of tooth surfaces during dental hygiene visits, polishing pastes are selected based on grit, flavor and splatter potential. In addition to a vast array of traditional polishing pastes, new formulations have entered the market. Today a wide range of restorative and cosmetic materials are used in dentistry and dictate new polishing formulations to preserve the surface and luster of restorations and also dictate a new approach to polishing. Hygienists are wise to devise a "polishing treatment plan" by identifying the various restorative materials present in each person's mouth. Gold is quickly seen, but not all tooth-colored restorations are so easily identified. Sometimes radiographs are needed to determine which teeth have been restored.

Hygienists need polishing pastes that restore the luster of restorations without scratching or damaging them. Many polishing pastes are made specifically for the new restorative materials hygienists now encounter (see chart on page 82). Aluminum-oxide and white sapphire are the primary ingredients in cosmetic restorative polishing paste made for dental hygiene use with rubber cups. Other, more expensive polishing pastes are available that use diamond powder and indicate that polishing should be done with a felt wheel.

Polishing to Desensitize
Root surface sensitivity is often due to open dentinal tubules. Occluding those tubules stops the sensitivity, but treating sensitivity at the end of a dental hygiene visit makes for painful instrumentation during the appointment. Sensitivity can be treated prior to instrumentation with prophy pastes formulated with NovaMin, Recaldent or CaviStat.

NovaMin, used in NUPRO Nusolutions by Dentsply is composed of calcium, phosphorus, silica and sodium. It was developed as an extension of bioactive glass research creating surgical bone replacement technology. When the NovaMin particle is exposed to saliva it releases billions of mineral ions that combine with naturally occurring ions in saliva to form hydroxyapatite crystals to close dentinal tubules.

Recaldent, used in MI Paste formulations by GC America is a combination of casein phosphopeptide (CPP) and amorphous calcium phosphate (ACP). Recaldent is beneficial for both sensitivity and remineralization. The ACP molecule is surrounded by CPP, a sticky milk protein that provides substantivity of approximately six hours.

SensiStat, used in DenClude, is considered a "super saliva" desensitizing complex and is the result of 30 years of salivary research. The ingredients, arginine bicarbonate and calcium carbonate, mimic saliva's protective and reparative properties. The highly soluble arginine bicarbonate surrounds the less soluble calcium carbonate forming a "super saliva spackle" that blocks open dentinal tubules. Calcium blocks the tubules and arginine, a saliva-based amino acid, is used by oral bacteria to produce alkali, a basic ionic salt which protects tooth surfaces by raising the pH of saliva.

Polishing to Remineralize
Polishing is one part of a complete diagnostic and treatment strategy to prevent and reverse early stages of the caries process. Scientific evidence confirms that caries is an infectious disease that can be prevented and that early stages can actually be reversed, thus avoiding a break in tooth enamel (see page 8 of the July/August 2008 issue of Hygienetown Magazine for an in-depth article on the new approach to caries control).

Caries begins at the atomic level as a molecule of organic acid diffuses through the enamel to the crystal surface of carbonated hydroxyapatite below. Loss of calcium, phosphate, and carbonate occurs from specific sites in the crystal. Reversal of demineralization also occurs at the atomic level as calcium, phosphate, and fluoride combine to build a new surface. Subsurface demineralization takes place before a break in enamel happens, allowing for reversal of the caries process with remineralization.

Demineralization/remineralization is a dynamic process that happens several times each day and can occur in dentin and cementum as well as enamel. Remineralization occurs when the saliva neutralizes the acid and salivary minerals are redeposited into the enamel surface. This dynamic process begins as soon as the teeth erupt and can be enhanced by polishing with prophy pastes containing the necessary minerals.

Polishing pastes containing ACP, Recaldent, NovaMin or SensiStat will remineralize tooth surfaces. Polishing with these products adds to and interacts with the normal remineralization process to achieve stronger molecular bonds within the hydroxyapatite layer of enamel. White spots indicating areas of advanced demineralization are prime targets for remineralization. Other target areas are surfaces at greatest risk for caries.

Polishing Interproximal Surfaces With the Profin/Profinet
Prior to prophy cups, hygienists used orange wood sticks inserted into a porte polisher and pumice mixed with mouthwash. After the porte polisher came belt driven handpieces and prophy angles. The orangewood sticks were replaced with rubber cups, prophy brushes and polishing points. Prophy cups polish facial and lingual surfaces, but they don't reach the interproximal surfaces, the surfaces at greatest risk of caries and periodontal disease. Prophy brushes access occlusal groves better than prophy cups and polishing points reach slightly into the interproximal area, but not completely.

To reach the interproximal surfaces, Dr. Per Axelsson invented the Profin and the Profinet (available from Dentatus International). These are reciprocating handpieces that use triangular shaped wedges to polish interproximal surfaces. The desensitizing, remineralizing and cosmetic/restorative polishing pastes can be easily delivered to interproximal surfaces with this system. These surfaces are often subject to greater demineralization than facial and lingual surfaces, so remineralization polishing should be directed to these surfaces.

Polishing for Deplaquing
Using a soft rubber cup and the Profinet can remove both supra and subgingival plaque. Soft rubber cups allow the cup to flare into the subgingival space, removing plaque biofilm from hard-to-reach areas. The Profinet is the only mechanical polishing system that reaches the interproximal surfaces. Many hygienists use floss and polishing paste to deplaque interproximal surfaces. However, the anatomy of interproximal surfaces, especially areas with a history of periodontal disease, has concavities that will not be reached by dental floss.

The value of polishing for deplaquing is evident in research protocols that include weekly appointments for polishing. Periodontal researchers routinely schedule weekly polishing following treatment to remove plaque and enhance tissue healing.

Polishing First
Traditional education suggests polishing after instrumentation to smooth the roughened surfaces. While many hygienists have found that polishing first has its benefits, not all dentists have heard of it. Dentaltown Townie "Nunano" posted the following question on the Dentaltown.com message boards in November 2008: "We hired a new hygienist and she asked if we were polishing before scaling at recall appointments. This was new to me. I am getting old, but is this a trend in care and if so what is the rational and/or benefit?"

Several Dentaltown and Hygienetown Townies answered this question, confirming that in their practices, polishing is done first. "Timmy G" presented the following reasons for polishing first: "1) If there is significant plaque, why would you want to waste scaling time removing something that can be removed with a rubber cup? Use scaler/ultrasonics for what it's intended to do — to remove calculus. 2) If there is significant plaque, who wants to create aerosols with ultrasonics containing all that bacteria. Now I know, it's going to occur anyway, but why make it worse then it needs to be?" Townie "rscrawfo" pointed out "For the nasty mouth polish first, swish with chlorhexidine, then use the ultrasonic."

"Suzanna-Suzanna" described the benefits: "[Polishing first] allows me to 'see' better. I do not have to try to probe through plaque, it allows me to polish any alloys that are present and see more clearly when evaluating gingival tissue, restorations, etc. It also allows me to take a better intraoral photo that clearly shows areas of concern, i.e., cracks, broken margins or restorations, gingival breakdown, etc. The benefit for the patient is that by the end of the appointment there is no gritty residue whatsoever and all they feel is a smooth 'clean' surface. They love it."

Polishing Ingredients
Besides the beneficial ingredients in prophy pastes to reduce sensitivity and remineralize enamel, product manufacturers are now stating, on packaging and in advertisements, ingredients that are not in their products: "gluten-free," "saccharine-free" and "aspartame-free." Consumers are asking about these ingredients and product manufacturers are providing the information.

Polishing provides cosmetic and therapeutic benefits beyond basic stain removal. New products and exciting new technologies allow hygienists to enhance the benefits of a procedure that was nearly eliminated from routine dental hygiene care with the introduction of selective polishing. Your patients will realize many benefits from polishing as you use new products, concepts and systems in your treatment regimen.
Specialty Polishing Pastes
Product Company Web Site Ingredient Indications
ProClude Colgate www.colgate.com CaviStat (arginine bicarbonate and calcium carbonate) Sensitivity
Enamelize Cosmedent www.cosmedent.com Aluminum oxide Restorations
NUPRO Shimmer Dentsply www.dentsply.com   Restorations
NUPRO Nusolutions Dentsply www.dentsply.com NovaMin
(calcium, phosphorus, silica, sodium)		 Sensitivity
Remineralization
MI Paste GC America www.gcamerica.com Recaldent CPP ACP
(Case Phosphopeptide)		 Sensitivity
Remineralization
CPR (Cosmetic Polishing Restorative) IC Care Inc. www.iccare.net White Sapphire Restorations
Enamel Pro Premier www.premusa.com ACP (Amorphous Calcium Phosphate) Remineralization
Soft Shine WaterPik www.waterpik.com White Sapphire Restorations
Dentaltown Magazine
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