Introduction

Tooth polishing is an oral prophylactic procedure that involves the smoothening of the tooth surface, making it glossy and lustrous, reducing plaque deposition, therefore maintaining periodontal health. The term tooth polishing is typically used by professionals to refer to a dual procedure of cleaning and polishing, even though the American Dental Hygienists Association clearly distinguishes between these two terms. Cleaning is described as the ability to remove debris and extraneous matter from the teeth, and polishing is the implementation of making the tooth surface smooth and lustrous.

According to the American Academy of Periodontology, tooth polishing eliminates plaque, calculus, and stains from exposed and unexposed tooth surfaces through scaling and polishing as a preventive measure to control local irritation.[1][2][3]

Since excessive polishing may cause wear of the tooth surface, dental professionals nowadays prefer to polish the teeth depending on the patients’ needs and not as a routine procedure.[4][5][6]

The term selective polishing then emerges. This procedure is not performed on stain-free surfaces and is only provided when there are visible extrinsic stains after scaling and oral debridement is complete.[7]

Anatomy and Physiology

Extrinsic stains vary in color according to their origin and may be green, brown, orange, or black.[7] Brown stains are usually caused by tobacco; some beverages like tea, red wine, and coffee; and excessive use of chlorhexidine. Black stains are more commonly caused by chemicals like silver, iron, manganese, and betel quid chewing. Green stains are associated with copper and nickel metals, whereas orange stains result from chromogenic bacteria.

Indications

Polishing can only remove extrinsic stains. They can be caused by various dietary and environmental factors, like tobacco smoking, betel quid chewing, coffee, tea, and wine drinking.[8] Intrinsic stains that occurred during teeth development cannot be removed by polishing. The etiology of these stains can be developmental, drug-induced, and environmental.

Furcation areas, root proximities, near restorations, orthodontic brackets, among others, can be polished using different types of devices suited to individual needs.[9][10][7][11]

Contraindications

Tooth polishing is contraindicated in the case of intrinsic stains that may be caused by developmental defects, environmental or drug-induced factors, such as the following:

• Enamel hypoplasia
• Hypomineralization
• Dentigoneses imperfecta
• Amelogenesis imperfecta
• Dental fluorosis
• Tetracyclines stains [12]

Other contraindications include:

• Acute diseases of the gingiva and periodontal structures
• Gingival recessions
• Sensitive teeth
• Newly erupted teeth
• Xerostomia
• Allergy to paste ingredients [7]

Equipment

Abrasive agents are used for polishing to make the teeth lustrous and give smooth and shiny surfaces. Abrasive agents are included in dentifrices and polishing pastes, with the difference that the particles are bigger in the latter.

Polishing pastes contain binders, humectants, flavoring agents, coloring agents, and preservatives to increase patient motivation. They are available in various sizes, coarse, large-sized particles, medium particles, and fine particles that are smooth and small.

Pastes with small particle sizes will increase the smoothness and cleanliness of teeth, making them more resistant to plaque accumulation. A polishing agent should be selected so that its hardness is less than the hardness of the surface to be polished.[7]

Commonly-Used Pastes

The most frequently utilized is the flour of pumice and calcium carbonate.

• Feldspar: Used on tooth and restorations.
• Pumice: Used for polishing of tooth enamel, gold foil, amalgam, acrylic resins are siliceous materials. The disadvantage of pumice is its significant abrasive depth and average polishing capacity compared to other polishing agents.
• Calcium carbonate: Less abrasive than pumice, produces minimum scratches and a highly reflective surface.
• Perlite: A fluoride-containing abrasive agent.
• Aluminum silicate: An excellent stain remover, great taste, easy to rinse-off, excellent polishing capacity, fluoride-releasing.
• Xylitol-containing products: Help in saliva production and reduce dry mouth, thus helping to reduce decay, acid, and biofilm production in the mouth. They can be used in kids and are available in various sizes.
• Novamin containing products: Reduce the sensitivity and help in stain removal.
• Zirconium silicate: Used on discs and strips, prophylactic polishing pastes.[7]

Polishing Devices

• Manual: Handheld devices
• Engine-driven: Require handpieces

Preparation

Care should be taken while polishing.

• Proper technique should be used to minimize abrasion to the tooth surfaces with the appropriate amount of force, pressure, time, and speed.
• The least abrasive polishing agent must be used but must be effective enough to remove the stains.
• Restorations must be polished with an agent that is softer than the restoration itself.[7]

Technique or Treatment

Selective Polishing

Routine tooth polishing is still the standard practice among most dental care professionals on the basis that a smooth and lustrous surface is less likely to be colonized by bacteria. Regular tooth polishing using the traditional method (rubber-cup with prophylaxis paste) removes the enamel’s superficial layer and causes morphological changes in the tooth structure over time.[13][14] The external enamel layer takes three months to rebuild, and bacteria colonize the enamel surface after 30 minutes regardless of being polished or not.[7] For all these reasons polishing should only be performed on dental surfaces that remain stained after scaling: selective polishing.

Manual Devices

Porte Polisher

A porte polisher rubs the abrasive agent against the tooth surface with a wedge-shaped, tapered, orange-wooden point.

It is noiseless with minimum aerosol production, portable, accessible on various aspects of the teeth, and hence can be used on malpositioned teeth and generates minimal heat. But it has the disadvantage that is time-consuming and requires more force.

Polishing Strips

These are for interproximal regions and line angles of teeth. Since they are very abrasive, the soft tissue in the interproximal areas must be protected. They come in various colors and sizes of abrasive agents.

Engine-Driven Devices

These are widely used and need either a straight or a contra-angled handpiece. A polishing brush or a rubber cup is attached to the handpiece used at a velocity of 2500 to 3000 rpm. It is estimated that the average speed used by dental hygienists is 2500 rpm.[15] The motion used for polishing in clinical practice is patting motion, and the device should be a slow-speed handpiece always rotated at the lowest rpm. The rubber cups or the polishing brushes are either autoclavable or disposable. Most tooth surfaces require 2 to 5 seconds to get polished with the rubber cup contacting the tooth for 4.5 seconds.[7][15] The pressure needed to be applied was 20 psi since too much pressure generates heat. They are the most frequently used in clinical practice.

Air-Powder Polishers

These are generally used for supragingival plaque removal as they reach the inaccessible areas where the rotary devices cannot reach like furcations, flutings, close root proximities.[16] They use a slurry of water and sodium bicarbonate under air and water pressure along with certain abrasive agents like aluminum trihydroxide, calcium sodium phosphosilicate, calcium carbonate, and glycine.

The air powder polisher can also be used with an ultrasonic scaler or directly with the air/water connector or separately. It works with foot control. The nozzle of the handpiece has to be held 3 to 4 mm from the tooth as it propels the slurry of water and sodium bicarbonate on the tooth. The motion used in air powder polishers is a paintbrush motion at an angle of 60 degrees for anterior teeth, an 80-degree angle for posterior teeth, and 90-degree on the occlusal surfaces. It should be directed at the middle thirds of the tooth in a circular motion with an air pressure of 40 to 100 psi and inlet water pressure of 20 to 60 psi.[7] Adjusting the water flow and the distance between the instrument and the tooth helps to adjust abrasive forces. They are generally safe for exogenous stains removal except for exposed dentin or cementum regions, which can be damaged because of the abrasives in the air-powder polishers.[17]

Advantages

The main advantage of air-powder polishers is their ability to efficiently remove biofilm, without harming the periodontal soft tissues and the hard tissue structures. It is a faster method, and there is more patient comfort.

1. It saves time, and hence, it can prevent patient and operator fatigue.
2. It can be used in orthodontically bracketed teeth as it does not physically damage and disturb the bands and the wires and also does not disturb the bonding cement.
3. It reduces dentinal sensitivity by blocking the tubular opening with bicarbonate crystals.
4. It reaches inaccessible areas that cannot be reached by rotary devices.[16]

Disadvantages

Since they use sodium bicarbonate in the slurry, it should be cautiously used in patients with restricted sodium diets. Non-sodium prophy powder can be used, which contains aluminum trihydroxide in such cases.

1. It should be carefully used in patients with respiratory, renal, or metabolic disease, diuretics, or long-term steroid therapy, those having titanium implants, or with children and in patients with infectious diseases.
2. Infection control is a problem with these devices since they produce aerosols. Hence, pretreatment washes are recommended.[16]
3. There is a risk of subcutaneous emphysema intraorally. It is important to follow the manufacturer's instructions to avoid such complications.[7]

Air polishers are generally used in the supragingival surfaces, but, glycine powder air polishers are used for removing sub-gingival biofilm that results in less erosion of the soft tissues and an 80% reduction in abrasion of the root surface as compared to hand instrumentation or sodium bicarbonate air polishing.[7]

Vector System

These use a polishing fluid, which causes minimum damage to the cementum surface. The polishing fluid contains hydroxyapatite or an abrasive fluid containing silicon carbide with a resonating device that deflects the forces directed toward the tooth and hence protects the tooth. The plaque is removed by fluid dynamics and gives effective control of inflammation.[7]

Complications

When polishing pastes with coarse or medium size particles are used, they may cause abrasion and damage to the tooth surface by scratching the enamel. A less polished appearance will be seen, and this will increase bacterial plaque retention.[7] Manual devices are time-consuming, and there is no control over the force applied, and they require more patient compliance. With engine-driven polishers, there is higher aerosol production, heat generation, and damage to the soft tissue if not properly attended.

Clinical Significance

Extrinsic stains are widespread in dental practice because they can be caused by tobacco smoking or simply drinking too much coffee or tea.

The tooth polishing devices are selected according to each case, and treatment plans are selectively designed, taking into account the patients' needs and with concern about minimal damage to the teeth and periodontal structures.

Extrinsic stains are one of the factors that influence tooth color assessment. Performing professional dental prophylaxis before composite or ceramic color selection in anterior teeth restorations could increase treatment predictability.[18]

Enhancing Healthcare Team Outcomes

When the nature of dental stains has been identified as exogenous, selective tooth polishing is the initial and most straightforward alternative to remove them after scaling, and oral debridement is complete.[7] Dental professionals, including dentists, hygienists, and dental nurses, must be aware of the different alternatives when selecting a polishing paste and devices and adjust them to each clinical case.