Coronal Polishing Chapter 58 Copyright 2009 2006 by

Chapter 58 Lesson 58. 1 Copyright © 2009, 2006 by Saunders, an imprint of

Learning Objectives Pronounce, define, and spell the Key Terms. Explain the difference between prophylaxis and coronal polishing. Explain the indications for and contraindications to coronal polishing. Name and describe the types of extrinsic stains. Name and describe the two categories of intrinsic stains. Describe types of abrasives used for polishing the teeth. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Introduction Coronal polishing is a technique used to remove plaque and stains from the coronal surfaces of the teeth. Polishing the crowns of the teeth is considered mainly cosmetic, but there are instances in which coronal polishing has therapeutic value as well. In some states, coronal polishing is delegated to registered or expanded-function dental assistants who have had special training in this procedure. Coronal polishing is strictly limited to the clinical crowns of the teeth. Coronal polishing is not a substitute for oral prophylaxis. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Selective Polishing Selective polishing is a procedure in which only those teeth or surfaces with stain are polished. The purpose of selective polishing is to avoid removing even small amounts of surface enamel unnecessarily. In some individuals, stain removal may cause dentinal hypersensitivity during and after the appointment. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Coronal Polishing and Fluoride Application Historically teeth were polished to remove all soft deposits and stains before the application of fluoride because it was believed that there would be greater uptake of the fluoride into the enamel. As scientific knowledge has evolved, it has been shown that polishing does not improve the uptake of professionally applied fluoride. Therefore polishing is no longer necessary before fluoride application. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Benefits of Coronal Polishing Polishing prepares the teeth for the placement of dental sealants. Smooth tooth surfaces are easier for the patient to keep clean. The formation of new deposits is slowed. Patients appreciate the smooth feeling and clean appearance. Polishing prepares the teeth for the placement of orthodontic brackets and bands. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Dental Stains of the teeth occur in three basic ways: A stain adheres directly to the surface of the tooth. Ø A stain is embedded in calculus and plaque deposits. Ø A stain is incorporated into the tooth’s structure. Ø It is important to distinguish between the types of stains before coronal polishing is undertaken to remove them. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Dental Stains are primarily an aesthetic problem. Some types of stains can be removed, and others cannot. It is important for the dental assistant to be able to correctly identify stains. There are other treatment options for patients with stains that cannot be removed. These include professional and at-home bleaching procedures, enamel microabrasion, and cosmetic restorative procedures such as laminate veneers and composite restorations. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Types of Dental Stains Dental stains are categorized as either endogenous or exogenous: Endogenous stains originate within the tooth as a result of developmental and systemic disturbances. Ø Exogenous stains originate outside the tooth in response to environmental agents. Ø Exogenous stains are those stains caused by an environmental source: Ø They are subdivided even further as extrinsic or intrinsic stains, depending on whether the stain can be removed. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Extrinsic and Intrinsic Stains Extrinsic stains are stains on the exterior of the tooth that can be removed. Examples include staining from food, drink, and tobacco. The source of the stain is external and the stain may be removed. Intrinsic stains are caused by an environmental source but cannot be removed because the stain has become incorporated into the structure of the tooth. Examples are tobacco stain from smoking, chewing, or dipping and stains from dental amalgam that has become incorporated into the tooth’s structure. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 58 -2 Endogenous developmental stain: tetracycline. (Courtesy of Santa Rosa Junior College, Santa Rosa, Calif. ) Notice how the stained area corresponds to the period of tooth development and the time at which the drug was taken. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 58 -3 Endogenous developmental stain: enamel hypoplasia. (From Daniel SJ, Harfst SA, Wilder R: Mosby’s dental hygiene: concepts, cases and competencies, ed 2, St Louis, 2008, Mosby. Courtesy of Dr. George Taybos, Jackson, Miss. ) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 58 -4 Endogenous developmental stain: dental fluorosis. (From Daniel SJ, Harfst SA, Wilder R: Mosby’s dental hygiene: concepts, cases and competencies, ed 2, St Louis, 2008, Mosby. Courtesy of Dr. George Taybos, Jackson, Miss. ) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 58 -5 Endogenous developmental stain: secondary caries. (From Daniel SJ, Harfst SA, Wilder R: Mosby’s dental hygiene: concepts, cases and competencies, ed 2, St Louis, 2008, Mosby. Courtesy of Dr. George Taybos, Jackson, Miss. ) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 58 - 6 Endogenous stain: amalgam restoration. (From Daniel SJ, Harfst SA, Wilder R: Mosby’s dental hygiene: concepts, cases and competencies, ed 2, St Louis, 2008, Mosby. Courtesy of Dr. George Taybos, Jackson, Miss. ) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Methods of Removing Plaque and Stain Air-powder polishing Ø The air-powder polishing technique involves the use of a specially designed handpiece with a nozzle that delivers a high-pressure stream of warm water and sodium bicarbonate. Rubber-cup polishing This is the most common technique for removing stains and plaque and polishing the teeth. Ø A rubber polishing cup is rotated slowly and carefully by means of a prophylactic angle attached to the slow-speed handpiece. Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Rotary Equipment for Coronal Polishing cups Ø Soft webbed polishing cups are used to clean and polish the smooth surfaces of the teeth. The polishing cup is attached to the reusable prophylaxis angle by means of a snap-on or screw -on attachment. Prophylaxis angle Commonly called a prophy angle, this tool attaches to the slow-speed handpiece. Ø The reusable prophy angle must be properly cleaned and sterilized after each use. Ø A disposable angle is discarded after a single use. Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 58 -1 Bristle brush (top) rubber polishing cup (bottom), sterilizable prophy angle (center), and disposable prophy angle (right). Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Bristle Brushes Bristle brushes, made of natural or synthetic materials, may be used to remove stains from deep pits and fissures of the enamel surfaces. Bristle brushes can cause severe gingival lacerations and must be used with special care. Brushes are not recommended for use on exposed cementum or dentin because these surfaces are soft and are easily grooved. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Abrasives Dental abrasives (polishing materials) are used to remove stain and to polish natural teeth, prosthetic appliances, restorations, and castings. They are available in extra coarse, medium, fine, and extra fine grits. The coarser the agent, the more abrasive the surface. Even a fine-grit agent removes small amounts of the enamel’s surface. The goal is to always use the abrasive agent that will produce the least amount of abrasion to the tooth surface. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Factors That Influence the Rate of Abrasion The more agent used, the greater the degree of abrasion. The lighter the pressure, the less abrasion. The slower the rotation of the cup, the less abrasion. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Chapter 58 Lesson 58. 2 Copyright © 2009, 2006 by Saunders, an imprint of

Learning Objectives Describe the types of abrasives used for porcelain aesthetic restorations. Name materials to avoid when polishing aesthetic restorations. Describe the technique for polishing aesthetic restorations. Demonstrate the handpiece grasp and positioning for the prophy angle. Demonstrate the fulcrum or finger rest used in each quadrant during a coronal polishing procedure. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives (Cont’d) Demonstrate the proper seating positions for the operator and the assistant during a coronal polishing procedure. Demonstrate safety precautions to be taken during coronal polishing. In states where it is legal, demonstrate coronal polishing technique. Complete coronal polishing without causing tissue trauma. Be able to determine that the teeth are free of stains and plaque. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Polishing Esthetic Type Restorations Many patients have crown and bridge restorations and are having cosmetic resin, composite, bonding, and veneers placed to enhance their smiles. Improper oral care can quickly damage many of these types of restorations. Coarse polishing paste, use of acidulated phosphate fluorides, and even hard brushing with abrasive toothpaste can be destructive to the surfaces of restorative materials. A diamond, aluminum oxide, or low-abrasion toothpaste should be used for these restorations. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 58 -8 A, It can be difficult to detect esthetic restorations. Two of these teeth have crowns. (Courtesy of Dr. Peter Pang, Sonoma, Calif. ) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Polishing Strokes Fill the polishing cup with the polishing agent and spread it over several teeth in the areas to be polished. Establish a finger rest and place the cup almost in contact with the tooth. The stroke should reach from the gingival third to the incisal third of the tooth. Using the slowest speed, lightly apply the revolving cup to the tooth surface for 1 or 2 seconds. Use light pressure to make the edges of the polishing cup flare slightly. Use a patting, wiping motion and an overlapping stroke. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 58 -9 Close-up of hand with handpiece and proper grip. Copyright © 2009,

Fig. 58 -10 Use overlapping strokes to ensure complete coverage of the tooth. Copyright

Fig. 58 -11 Stroke from the gingival third with just enough pressure to cause

Positioning the Patient Adjust the dental chair so that the patient is approximately parallel to the floor with the back of the chair raised slightly. Adjust the headrest for patient comfort and operator visibility. For the mandibular arch, position the patient's head with the chin down. When the mouth is open, the lower jaw should be parallel to the floor. For access to the maxillary arch, position the patient's head with the chin up. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 58 -12 For the mandibular arch, the patient’s head is positioned so that the lower jaw is parallel to the floor when the mouth is open. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 58 -13 For access to the maxillary arch, position the patient’s head with

Fig. 58 -14 The right-handed operator is seated at the 9 o’clock position. Copyright

The Handpiece Grasp The handpiece and prophylaxis angle are held in a pen grasp with the handle resting in the V-shaped area of the hand between the thumb and index finger. Proper grasp is important because if the grasp is not secure and comfortable, the weight and balance of the handpiece can cause hand wrist fatigue. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 58 -9 Handpiece grasp. Copyright © 2009, 2006 by Saunders, an imprint of

Handpiece Operation The rheostat (foot pedal) controls the speed (revolutions per minute) of the handpiece. The toe is used to activate the rheostat. The sole remains flat on the floor. Apply a steady pressure with the toe on the rheostat to produce a slow, even speed. Use a low-speed handpiece that operates to a maximum of 20, 000 rpm. Release the rheostat to prevent debris from splattering when the handpiece is removed from the tooth for more than a moment. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

The Fulcrum/Finger Rest The fulcrum provides stability for the operator and must be placed in such a way as to allow for movement of the wrist and forearm. The fulcrum is repositioned throughout the procedure as necessary. The fulcrum may be either intraoral or extraoral, depending on a variety of circumstances such as: • The presence or absence of teeth • The area of the mouth being polished • How wide the patient can open his or her mouth Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Positioning of the Operator The operator should keep his or her feet flat on the floor and the thighs parallel to the floor. The operator's arms should be at waist level and even with the patient’s mouth. When performing a coronal polish procedure, the right-handed operator generally begins by seating himself or herself in an 8 to 9 o’clock position. When performing a coronal polish procedure, the lefthanded operator generally begins by seating himself or herself in the 3 to 4 o’clock position. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

The Sequence of Polishing Full mouth coronal polishing must be performed in a predetermined sequence to be certain that no area is missed. The best sequence is based on the operator's preference and the individual needs of the patient. Aesthetic and porcelain restorations should be polished first, after which the remaining teeth may be polished with the use of the appropriate methods for any stain that is present. This reduces the possibility that a coarse abrasive will remain in the rubber cup when aesthetic restorations are being polished. The positions and fulcrums described in the following slides are for a right-handed operator. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Setup for Coronal Polishing Copyright © 2009, 2006 by Saunders, an imprint of Elsevier

Patient Preparation Check the patient's medical history for any contraindications to the coronal polishing procedure. Seat the patient and him or her with a waterproof napkin. Ask the patient to remove any dental prosthetic appliances he or she may be wearing. Provide the patient with protective eyewear. Explain the procedure to the patient and answer any questions. Inspect oral cavity for lesions, missing teeth, tori, and so on. Apply a disclosing agent to identify areas of plaque. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Application of a Disclosing Agent Copyright © 2009, 2006 by Saunders, an imprint of

Maxillary Right Posterior Quadrant, Buccal Aspect Sit in the 8 to 9 o’clock position. Have the patient tilt his head up and turn slightly away from you. Hold the dental mirror in your left hand. Use it to retract the cheek or for indirect vision of the more posterior teeth. Establish a fulcrum on the maxillary right incisors. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Polishing the Buccal Surfaces of the Maxillary Right Quadrant Copyright © 2009, 2006 by

Maxillary Right Posterior Quadrant, Lingual Aspect Remain seated in the 8 to 9 o’clock position. Have the patient turn his head up and toward you. Hold the dental mirror in your left hand. Direct vision in this position and the mirror provides a view of the distal surfaces. Establish a fulcrum on the lower incisors and reach up to polish the lingual surfaces. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Maxillary Anterior Teeth, Facial Aspect Remain in the 8 to 9 o’clock position. Position the patient’s head tipped up slightly and facing straight ahead. Make necessary adjustments by turning the patient's head slightly either toward or away from you. Use direct vision in this area. Establish a fulcrum on the incisal edge of the teeth adjacent to the ones being polished. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Polishing the Facial Surfaces of the Maxillary Anterior Teeth Copyright © 2009, 2006 by

Maxillary Anterior Teeth, Lingual Aspect Remain in the 8 to 9 o’clock position or move to the 11 to 12 o’clock position. Position the patient’s head so that it is tipped slightly upward. Use the mouth mirror for indirect vision and to reflect light on the area. Establish a fulcrum on the incisal edge of the teeth adjacent to the ones being polished. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Polishing the Lingual Surfaces of the Maxillary Anterior Teeth Copyright © 2009, 2006 by

Maxillary Left Posterior Quadrant, Buccal Aspect Sit in the 9 o’clock position. Tip the patient's head upward and turn it slightly toward you to improve visibility. Use the mirror to retract the cheek and for indirect vision. Rest your fulcrum finger on the buccal occlusal surface of the teeth toward the front of the quadrant. Alternative: Rest your fulcrum finger on the lower premolars and reach up to the maxillary posterior teeth. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Maxillary Left Posterior Quadrant, Lingual Aspect Remain in the 8 to 9 o’clock position. Have the patient turn his or head away from you. Use direct vision in this position. Hold the mirror in your left hand use for a combination of retraction and reflecting light. Establish a fulcrum on the buccal surfaces of the maxillary left posterior teeth or on the occlusal surfaces of the mandibular left teeth. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Mandibular Left Posterior Quadrant, Buccal Aspect Sit in the 8 to 9 o’clock position. Have the patient turn his or head slightly toward you. Use the mirror to retract the cheek and for indirect vision of distal and buccal surfaces. Establish a fulcrum on the incisal surfaces of the mandibular left anterior teeth and reach back to the posterior teeth. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Mandibular Left Posterior Quadrant, Lingual Aspect Remain in the 9 o’clock position. Have the patient turn his or head slightly away from you. For direct vision, use the mirror to retract the tongue and reflect more light to the working area. Establish a fulcrum on the mandibular anterior teeth and reach back to the posterior teeth. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Polishing the Lingual Surfaces of the Mandibular Left Quadrant Copyright © 2009, 2006 by

Mandibular Anterior Teeth, Facial Aspect Sit in either the 8 to 9 o’clock position or in the 11 to 12 o’clock position. As necessary, instruct the patient to make adjustments in head position by turning either toward or away from you or by tilting his head up or down. Use your left index finger to retract the lower lip. Both direct and indirect vision can be used in this area. Establish a fulcrum on the incisal edges of the teeth adjacent to the ones being polished. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Mandibular Anterior Teeth, Lingual Aspect Sit in either the 8 to 9 o’clock position or at the 11 to 12 o’clock position. As necessary, instruct the patient to make adjustments in head position by turning either toward or away from you or by tilting the head up or down. Use the mirror for indirect vision, to retract the tongue, and to reflect light onto the teeth. Direct vision is often used in this area when the operator is seated in the 12 o’clock position, but indirect vision can also be helpful. Establish a fulcrum on the mandibular cuspid incisal area. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Polishing the Lingual Surfaces of the Mandibular Anterior Teeth Copyright © 2009, 2006 by

Mandibular Right Quadrant, Buccal Aspect Sit in the 8 o’clock position. Have the patient turn his or head slightly away from you. Use the mirror to retract tissue and reflect light. The mirror may also be used to view the distal surfaces in this area. Establish a fulcrum on the lower incisors. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Polishing the Mandibular Right Quadrant, Buccal Aspect Copyright © 2009, 2006 by Saunders, an

Mandibular Right Quadrant, Lingual Aspect Remain in the 8 o’clock position. Have the patient turn his or head slightly toward you. Retract the tongue with the use of the mirror. Establish a fulcrum on the lower incisors. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Flossing After Coronal Polishing Dental floss and tape have two purposes after coronal polishing. The first is to polish the interproximal tooth surfaces. Ø The second is to remove any abrasive agent or debris that may be lodged in the contact area. Ø Place abrasive on the contact area between the teeth and work the floss or tape through the contact area, using a back-andforth motion. A floss threader can be used to pass the floss under any fixed bridgework to gain access to the abutment teeth. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Evaluation of Polishing There is no remaining disclosing agent on any of the tooth surfaces. The teeth are glossy and reflect light from the mirror uniformly. There is no evidence of trauma to the gingival margins or any other soft tissues in the mouth. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Patient Instructions Most patients are self-conscious about stains on their teeth and appreciate any tips you can give them on how to keep their teeth as white as possible. It is important to educate patients about the causes of stains. When stains are intrinsic, the dentist may want you to discuss possible cosmetic dental care options to satisfy their desire for attractive and stain-free teeth. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.