Dental with one hand on the light looking into the camera

EDITOR'S NOTE: The original May 14 article included in inaccurate image showing a hygiene team member whose surgical mask left her mouth and nose uncovered beneath a protective shield. The article was updated to reflect the standard for personal protective equipment (PPE) in the dental practice.

While this is a stressful time for everyone, it's also an important time to bring your hygienists into post-pandemic planning and provide them with an opportunity to be key contributors to change.

In preparing your practice recovery strategy, remember:

  • Inside your hygienist's 10x10 is where patient relationships are nurtured.
  • Hygienists provide a second set of clinical eyes.
  • Hygienists are instrumental in building value and case acceptance.
  • Patient periodontal health is restored and maintained by hygienists.

Work together for the best outcomes for your practice and your patients. Dental hygienists will soon be on the front lines of health care, so it's important to consider options for selective polishing, or no polishing.


PRACTICE RECOVERY: Spear Online members can begin Practice Recovery now and discover the “4 Key Initiatives” for break-even strategies to mitigate the financial strain and align your team to treat patients in this unprecedented time.


New protocols, new polishing?

When strategizing, consider what is sacred to your patients and practice since attention to personal protective equipment (PPE) and environmental tasks will dominate your practice's post-pandemic world and add time to appointments.

Production goals for the hygiene department are heavily time-dependent. In many practices, the hygiene department is under scrutiny to get the job done quickly and efficiently.

Polishing is performed to remove extrinsic stain from tea, coffee, food coloring, etc. If there is no stain present on the teeth, is polishing really necessary? Perhaps polishing every tooth at every visit could be considered cosmetic, rather than therapeutic? Do polishing risks outweigh the benefits? This goes beyond saving time.

The case for selective polishing

What are some reasons to avoid the prophy cup?

  • Absence of stain
  • Demineralized spots
  • Exposed cementum or dentin
  • Gold, composite - many materials in cosmetic restorations
  • Reintroduction of bacteria immediately after SRP
  • Patients with respiratory and infectious diseases
  • Intrinsic stain
  • Demineralized areas or thin enamel
  • Newly erupted teeth as the surfaces have not been fully mineralized

The Mohs Hardness Scale shows the discrepancy between common ingredients of prophy paste and the surfaces to which they are applied. Very minimal polishing was shown to cause definitive abrasion on the root surface.

Caution should be exercised when polishing at or beyond the CEJ. Considering stain often recurs on mandibular anterior root surfaces, additional research into alternative, nonmechanical methods of stain removal might be helpful. Individualized polishing has a place in dentistry – many dental surfaces can be damaged by polishing.1

In tests at the Clinical Research Associates (CRA) laboratory in Provo, Utah, Dr. Rella Christensen and her colleagues tested different abrasives in commercially available prophy pastes obtainable in the late 1980s.

Her research shows less than a 1-micron loss of enamel regardless of the abrasives used. Using impressions, photography scanning electron microscope, and assays, her team determined that any effect to the enamel that had occurred from the abrasive was resolved in 90 days. The mild arching or semicircular pattern of erosion unique to spinning abrasives became less and less over time.

The story is different when it comes to cementum, dentin and composite/cosmetic restorations. Therefore, polishing is contradicted on some dental restorations.

Selective or no polishing can be a choice that meets the standard of care, does the least harm, reduces aerosols and saves production time.

If the assessment of the potential polish of a restoration is beyond a paste's indications and the hygienist's time allotted and comfort zone, it may be an option for a stand-alone appointment for the dentist or hygienist to utilize porcelain polishing kits that use various grits of abrasives in the form of wheels, points and cups to reach the definitive treatment goals.

In general, be cautious about the products used to maintain the restored esthetic smile. The goal is to maintain and protect the longevity of the restorations for the patient.2

The American Dental Hygienists Association endorses selective polishing, limiting polishing to areas of stain that cannot be removed by other methods. Prominent dental hygiene textbooks also support it and most dental hygiene programs teach selective polishing in their curricula. However, the common perception is licensed dental hygienists and dentists are reluctant to employ selective polishing in their clinical practice.3

Dental plaque has been identified as a biofilm. The nature of the biofilm enhances the component bacteria's resistance to the host's defense system and antimicrobials.

Enhancing the patient's ability to remove it regularly inhibits its ability for maturation. The resulting pathogenic bacterial complex can lead to dental caries, gingivitis and periodontitis.

A daily regimen of thorough mechanical oral hygiene procedures, including toothbrushing and interdental cleaning, is key to controlling biofilm accumulation.

Since teeth comprise only 20% of the mouth's surfaces, for optimal oral health, more research is needed in the areas of an antimicrobial mouth rinse to help control biofilm not reached by brushing and flossing, as well as biofilm bacteria contained in oral mucosal reservoirs.

Dental instrumentation

In all this prophy paste discussion, are we losing sight of what is the most important part of the procedure? It's the dental instrumentation that's most significant to clinical outcomes.

Most hygienists are reverting to hand instruments over ultrasonics. Sharp instruments become key to successful clinical outcomes and the economics of buying and maintaining instruments in these tough times is a nonnegotiable issue.

The true purpose of dental prophylaxis is to remove calculus and reduce toxins from the teeth, both supra and subgingival, to control and prevent periodontal disease.

When calculus remains at, near, or below the CEJ, inflammation and infection are more likely to ensue. When polishing occurs on the coronal and root surface in the presence of calculus, there is a clear danger of burnished calculus.

Burnished calculus is a deposit that has had its outermost layer removed, so the surface is smooth. Burnished calculus becomes difficult to remove because the cutting edge of the instrument tends to slip over the smooth surface of the deposit. It may lead to delayed healing of the periodontal tissue and possible periodontal abscesses.4

The patient experience

Why do patients expect a polish at the end of each visit?

  • They like the feeling
  • It is easier to remove fine stain
  • That's the way we've always done it
  • Plaque biofilm is removed temporarily

From a practice management and patient experience standpoint, how can selective polishing, or no polishing, be discussed with the patient?

Patients may not be aware of the effects of rubber-cup polishing on the tooth. Just as it is with all dental conditions and procedures, it's more important to educate patients on the unfamiliar – the philosophy of polishing based solely on need. Then step back and listen. Let the patient have a voice.

To my surprise, when I first introduced the concept, many patients thanked me and said polishing wasn't their favorite part of their appointment. Of course, some patients will still request the polishing procedure. In these cases, use your best judgment to comply with clinical best practices for coronal polishing, which means treatment must be individualized.

It's a choice

Selective or no polishing can be a choice that meets the standard of care, does the least harm, reduces aerosols and saves production time.

If, when, and where you choose to polish – use the least abrasive polishing agent that will remove plaque biofilm and stain. Control the time, speed and pressure during the procedure.

Full-mouth polishing is still widely practiced but selective polishing is being recommended as the gold standard at many educational institutions.

I truly believe if we hang in there and practice due diligence, this “new normal” will be temporary. Engaging your hygienists in the conversation about what this will look like inside their 10x10 not only builds a strong team, but also shows the value you place on their roles.

Redirect any downtime toward team education and ramp up competencies. If you are a Spear Online member, there are tools and resources to help you and your hygienists be ready for what's ahead, including the new Practice Recovery program.

In the meantime, “Evolve or Die” as Robin Crow describes in his book. There are optimistic solutions in this crisis to become better than you were yesterday and realize abundance at every level for personal and professional growth.

Renee Marks, R.D.H., M.S., is a member of Spear Resident Faculty.

References

1. Barnes CM. The science of polishing. Dimensions of Dental Hygiene. 2009:7(11):18-20.

2. Hodsdon KA. Postoperative care for esthetic restorations: a challenge to dental hygienists. Journal of Practical Hygiene. 1998;7:19-24

3. American Dental Hygienists' Association position paper on polishing. American Dental Hygienists' Association [Internet]. [cited 2009 May 20]. Available from: http://www.adha.org/profissues/polishingpaper.htm

4. Checchi L, Montevecchi M, Checchi V, Zappulla F. The relationship between bleeding on probing and subgingival deposits. An endoscopical evaluation. Open Dent J. 2009;28:154-160.