The American Dental Hygienists'
Association (ADHA) takes the following position regarding polishing
procedures:
- Only a licensed dental hygienist or dentist
is qualified to determine the need for polishing procedures.
- Polishing should be performed only as needed
and not be considered a routine procedure.
Background
Historically, polishing has been a routine part of the prophylaxis appointment.
It was believed to be important to have smooth, stain-free tooth surfaces
in order to impede the buildup of new plaque. Patients/clients expected
that their teeth be polished after scaling and root planing to smooth
the tooth surface and remove stains. Recent literature, however, has
changed the way the polishing procedure is viewed.
Today, polishing is viewed as a cosmetic procedure
with little therapeutic benefit.(1,2) Unfortunately, many consumers
do equate polishing with the oral prophylaxis. Nevertheless, polishing
is not essential to the prophylaxis, as once thought. In fact, it is
considered poor oral health care to provide polishing services only
and have a patient/client believe he/she is "getting their teeth cleaned."
"Polishing" involves making a surface smooth; "cleaning"
involves removing debris and extraneous matter from the teeth.(1) "Oral
prophylaxis", then, is defined by the American Academy of Periodontology
as the "removal of plaque, calculus, and stains from the exposed and
unexposed surfaces of the teeth by scaling and polishing as a preventive
measure for the control of local irritational factors."(3) The prophylaxis
procedure as stated here is performed on the healthy mouth to prevent
periodontal disease.
Recent literature shows that thorough brushing
and flossing at home can produce the same effect as polishing.(4) Therefore,
one can conclude that polishing of coronal surfaces on a routine basis
provides no additional benefit to the patient/client. It is also argued
in the literature that continuous polishing can, over time,; cause morphological
changes in the teeth by abrading tooth structure away.(5) Additionally,
the fluoride in the outer layers of enamel is removed through polishing.(1)
Thus, researchers agree that polishing is no longer considered to be
necessary on a routine basis. The dental hygienist/dentist must assess
each patient for the amount, type, and location of stain present to
determine the need for polishing.
Another reason polishing was considered important
in the past was to remove plaque and stain prior to a fluoride treatment
to insure adequate uptake of fluoride in the enamel. Research now shows
that polishing does not improve the uptake prior to a professionally
applied fluoride treatment.(6,7) Steele's and Tinanoff's studies in
1982 and 1974 respectively showed that brushing and flossing were adequate
methods of plaque removal prior to fluoride treatments, and fluoride
uptake was not adversely affected by lack of a rubber cup polishing.
Polishing prior to sealant application is another
area of recent debate. Formerly, it was believed that it was necessary
to polish tooth surfaces prior to sealant placement to insure proper
acid etching and sealant penetration. However, several recent studies
have shown other methods of plaque removal to be equally efficient.
They include use of an explorer and forceful rinsing with water, tooth
brushing with toothpaste, hydrogen peroxide, and use of an air polisher.(8-11)
Air polishing was introduced in the 1980s and
has been found to be especially useful in certain instances. In addition
to being used during the prophylaxis, it has been found to be useful
for orthodontic patients, root detoxification during periodontal surgery,
and sealant procedures.(11-13) However, with any procedure, appropriate
knowledge and technique are important. The clinician must be aware of
its limitations, contraindications, and most importantly, its proper
use. Generally, it is indicated on patients with heavy amounts of stain,
especially chlorhexidine. There are numerous contraindications and other
concerns, however, that prohibit indiscriminate use of the air polisher
in certain patient groups.(14)
- Patients with restricted sodium diets - Patients
with respiratory, renal, or metabolic disease - Patients with infectious
disease - Children - Patients on diuretics or long-term steroid therapy
- Patients with titanium implants (Research is still needed in this
area)
Air polishers also should not be used on patients/clients
with exposed cementum or dentin. A study by Galloway and Pashley in
1986 showed the air polisher can cause clinically significant loss of
tooth structure if used excessively.(15) In addition, an air polisher
should be avoided around most types of restorative materials due to
the possibility of scratching, eroding, pitting, or margin leakage.(1)
Legislation
Currently, approximately 23 states allow dental assistants to perform
coronal polishing.(16) This raises a concern because only about half
of these states require education or examination in polishing for dental
assistants There is also a lack of standardization for education, examination,
or certification for dental assistants among states. Another concern,
to insurance companies as well as consumers, is the potential for fraud
by billings for a prophylaxis when only a polishing is performed. Coupled
with many states' legislative attempts to allow dental assistants to
perform supragingival scaling, this puts the consumer's oral health
at serious risk. Incomplete removal of deposits from above and below
the gumline can lead to several problems: 1) If bacteria-laden deposits
are not completely removed, the bacteria continue to multiply and the
disease process is not stopped. 2) When deposits are not removed from
the base of the pocket, the tissue will shrink and tighten around the
neck of the tooth, and bacterial toxins are trapped in the pocket. This
can result in a periodontal abscess. 3) When healing and tissue shrinkage
occur at the neck of the tooth, the tissue becomes tighter, and it is
more difficult to place an instrument in the pocket for removal of remaining
deposits.(17)
Conclusion
Polishing should not be considered a routine part of the oral prophylaxis.
The licensed dental hygienist or dentist is the best qualified to determine
the need for polishing. The ability to judge appropriately which patients/clients
should or shouldn't be polished is compromised if a practitioner is
not knowledgeable. ADHA believes that licensed dental hygienists and
dentists are the best qualified to perform polishing procedures.
Notes
1. Woodall IR: _Comprehensive Dental Hygiene Care",
4th edition. St. Louis, Mosby-Year Book, Inc., 1993, pp. 648, 660.
2. Walsh MM, Heckman B. et al.: Effect of a rubber cup polish after
scaling. "Dental Hygiene" 1985;59(11):494-498.
3. American Academy of Periodontology: "Glossary of Periodontic
Terms", 3rd edition. Chicago, American Academy of Periodontology,
1992, p. 40.
4. Waring MB, Horn ML, et al.: Plaque reaccumulation following engine
polishing or tooth brushing—a 90-day clinical trial. "Dental Hygiene"
1988;62:282-285.
5. Swan RW: Dimensional changes in a tooth root incident to various
polishing and root planing procedures. "Dental Hygiene" 1979;53:17-19.
6. Steele RC, Waltner AW, Bawden JW: The effect of tooth cleaning procedures
on fluoride uptake in enamel. "Pediatric Dentistry" 1982;4:228-233.
7. Tinanoff N, Wei SHY, Parkins FM: Effect of a pumice prophylaxis on
fLuoride uptake in tooth enamel. "Journal of the American Dental
Association" 1974;88:384-389.
8. Donnan MF, Ball IA: A double-blind clinical trial to determine the
importance of pumice prophylaxis on fissure sealant retention. "British
Dental Journal" 1988;165(8):283
9. Houpt M, Shey Z: The effectiveness of a fissure sealant after six
years. "Pediatric Dentistry" 1983;5(2):104-106.
10. Christensen CJ: Fluoride made it: Why haven't sealants? "Journal
of the American Dental Association" 1992;123(2):89-90.
11. Brocklehurst PR, Joshi RI, Northeast SE: The effect of airpolishing
occlusal surfaces on the penetration of fissures by a sealant. "International
Journal of Pediatric Dentistry" 1992;2:157-162.
12. Gerbo LR, Barnes CM, Leinfelder KF: Applications of the air-powder
polisher in clinical orthodontics. "American Journal of Orthodontics
and Dentofacial Orthopedics" 1993:103(1):71-73.
13. Horning GM, Cobb CM, Killoy WI: Effect of an air-powder abrasive
system on root surfaces in periodontal surgery. "Journal of Clinical
Periodontology" 1987;14:213.
14. Brown SM: A scientific foundation for the clinical use of air polishing
systems, Part II: Technique. "Practical Hygiene" 1995;4(6):14-19.
15. Galloway SE, Pashley DH: Rate of removal of root structure by the
use of the prophyjet device. "Journal of Periodontology" 1986;58(7):464-469.
16. American Dental Association: "Legal Provisions for Delegating
Functions to Dental Assistants and Dental Hygienists". Chicago,
American Dental Association, 1993, p. 16.
17. O'Hehir TE: Gross scaling: An antiquated concept. "Dental Hygiene
News" 1994;7(1):19-20.American Dental Hygienists’ Association Position
on Polishing Procedures
