Coronal Polishing PDF

58 Coronal Polishing L E A R N I N G A N D P E R F O R M A N C E O U TCO M E S Learning Outcomes On completion of this chapter, the student will be able to achieve the following objectives: 1. Pronounce, define, and spell the key terms. 5. Explain the importance of selec...

58 Coronal Polishing L E A R N I N G A N D P E R F O R M A N C E O U TCO M E S Learning Outcomes On completion of this chapter, the student will be able to achieve the following objectives: 1. Pronounce, define, and spell the key terms. 5. Explain the importance of selecting an appropriate polishing 2. Discuss coronal polishing, which includes: agent. The difference between prophylaxis and coronal polishing. 6. Discuss polishing esthetic restorations, which includes: Indications for and contraindications to a coronal polish. Materials to avoid when polishing esthetic restorations. The principal of selective polishing. The technique used for polishing esthetic restorations. 3. Name and describe the types of extrinsic stains, the two 7. Discuss the steps of coronal polishing, including safety categories of intrinsic stains, and the methods used to remove precautions, correct sequence, flossing after polishing, and plaque and stains. evaluation of polishing. 4. Name the handpieces and attachments used for coronal polishing. Performance Outcomes On completion of this chapter, the student will be able to meet competency standards in the following skills: Demonstrate the handpiece grasp and positioning for the Be able to determine that the teeth are free from stains and prophy angle. plaque. Demonstrate the fulcrum or finger rest used in each quadrant Complete coronal polishing without causing tissue trauma. during a coronal polish procedure. Demonstrate the proper seating positions for the operator and the assistant during a coronal polish procedure. KEY TERMS calculus (KAL-kyoo-lus) plaque adhered to tooth structure that fulcrum (FUL-krum) finger rest used when an instrument or becomes mineralized by calcium and phosphate salts from handpiece is held for a specified time saliva intrinsic (in-TRIN-zik) stains stains that occur within the tooth clinical crown that portion of the tooth that is visible in the oral structure that may not be removed by polishing cavity Nasmyth’s (NAS-miths) membrane residue from epithelial tissue coronal (kuh-ROE-nuhl) polishing technique used to remove on the crowns of newly erupted teeth that may become plaque and stains from the coronal surfaces of the teeth extrinsically stained endogenous (en-DOJ-en-us) stains stains developed from within oral prophylaxis (proe-fi-LAK-sis) the complete removal of the structure of the tooth calculus, debris, stain, and plaque from the teeth exogenous (ek-SOJ-uh-nus) stains stains developed from prophy paste commercial premixed abrasive paste used for external sources polishing teeth and restorations extrinsic (ek-STRIN-zik) stains stains that occur on the external rubber cup polishing technique that is used to remove plaque surfaces of the teeth that may be removed by polishing and stains from the coronal surfaces of the teeth Coronal Polishing In addition, patients like the feel of smooth, polished teeth. Coronal polishing is completed with the use of a low-speed Coronal polishing is a procedure that removes plaque and stains dental handpiece with a prophy angle (Fig. 58.1), a rubber from the coronal surfaces of the teeth. (Refer to Chapter 15 for cup, and a polishing material (abrasive agent). Specific indica- a discussion of dental plaque.) A smooth tooth surface is less likely tions for and contraindications to a coronal polish are listed in to retain plaque, calculus, and stain. Box 58.1. 907 908 PART 10 Assisting in Comprehensive Dental Care BOX 58.1 Indications for and Contraindications to Coronal Polishing Indications Before placement of dental sealants Before placement of the dental dam A Before cementation of orthodontic bands Before application of acid etching solution on enamel (if indicated by the manufacturer’s instructions) Before cementation of crowns and bridges B Contraindications When no stain is present Patients who are at high risk for dental caries, such as nursing bottle C D caries, root caries, or areas of thin demineralized enamel (because small amounts of enamel are removed during the polishing procedure) Sensitive teeth (because abrasive agents can increase the areas of Fig. 58.1 (A) Bristle brush. (B) Rubber polishing cup. (C) Reusable prophy sensitivity) angle. (D) Disposable prophy angle. Newly erupted teeth (because mineralization of the surfaces may be incomplete) Coronal polishing is strictly limited to the clinical crowns of the teeth. (The clinical crown is that portion of the tooth that is visible within the oral cavity.) In some states, coronal polishing is BOX 58.2 Possible Damaging Effects of Coronal delegated to registered dental assistants/expanded-functions dental Polishing assistants (RDAs/EFDAs) who have had special training in this procedure. Tooth Surfaces It is important to understand the difference between a prophylaxis Newly erupted teeth are incompletely mineralized, and excessive polishing and coronal polishing. A coronal polish is not a substitute for an with an abrasive could remove a small amount of surface enamel. Avoid polishing exposed cementum in areas of recession because oral prophylaxis. An oral prophylaxis, commonly known as a cementum is softer than enamel and is removed more easily. prophy or a cleaning, is the complete removal of calculus (calculus Avoid polishing areas of demineralization because of the possibility of loss is a hard-mineralized deposit that is attached to the teeth) debris, of surface enamel. stain, and plaque from the teeth with the use of hand instruments, ultrasonic scaling, and coronal polishing. In almost every state, Gingival Tissues the dentist and the registered dental hygienist are the members of Gingival tissue may be damaged if the cup is run at a high speed and/or is the dental team who are licensed to perform an oral prophylaxis. applied too long. Fast rotation may force particles of the polishing agent into the sulcus, thereby creating a source of irritation. BENEFITS OF CORONAL POLISHING Restorations Polishing prepares the teeth for placement of dental sealants. Abrasive pastes can leave scratches or rough surfaces on gold, composite Smooth tooth surfaces are easier for the patient to keep clean. restorations, acrylic veneers, and porcelain surfaces. Formation of new deposits is slowed. From Robinson D, Bird D: Essentials of dental assisting, ed 6, St Louis, 2017, Saunders. Patients appreciate the smooth feeling and clean appearance. Polishing prepares the teeth for placement of orthodontic brackets and/ or bands. chooses to have it done, you should use a very fine abrasive such as a commercial toothpaste. Selective Polishing Historically, teeth were polished to remove all soft deposits and stains before fluoride was applied because it was thought Selective polishing is a procedure in which only those teeth or that uptake of the fluoride into the enamel would be increased. surfaces with stain are polished. Studies have shown that the abrasive As scientific knowledge has evolved, it has been shown that agent used during coronal polishing removes a small amount of polishing does not improve the uptake of professionally applied the fluoride-rich outer enamel layer. The purpose of selective fluoride. Therefore polishing is no longer necessary before fluoride polishing is to avoid unnecessary removal of even small amounts is applied. of surface enamel. Therefore, when the stain is very light and is In addition to cosmetic value, coronal polishing can have not of esthetic concern to the patient, selective polishing should therapeutic value. Therapeutic polishing refers to polishing of the be considered. The basic principle of selective polishing is that root surfaces that have been exposed during periodontal surgery. teeth should not be polished unless it is necessary. For some (Refer to Chapter 55 for a review of periodontal surgery.) Polishing individuals, stain removal may cause dentinal hypersensitivity during reduces the endotoxins and the bacteria on the cementum. Whether and after the appointment. The needs of the patient must always polishing for cosmetic or therapeutic purposes, it is important to be reviewed before stain removal. If you encounter a patient who understand the polishing process and its effects on the tooth surface does not have visible stain but is accustomed to polishing and (Box 58.2).  CHAPTER 58 Coronal Polishing 909 Dental Stains Intrinsic stains are those that are caused by an environmental source but cannot be removed because the stain has become Stains are primarily an esthetic problem. Some types of stains can incorporated into the structure of the tooth. Examples include be removed, whereas others cannot. It is important for the dental tobacco stains from smoking, chewing, or dipping, and stains from assistant to be able to correctly identify stains, to provide the dental amalgam that have become incorporated into the tooth patient with accurate information about the cause of the stains structure. The dental assistant must be able to recognize these and possible options for removing them. For stains that cannot conditions because these stains cannot be removed by polishing be removed, other treatment options are available. These include or scaling (Table 58.2). professional and at-home bleaching procedures, enamel microabra- sion, and cosmetic restorative procedures such as laminate veneers and composite restorations. Types of Stains Dental stains are categorized as endogenous or exogenous. Endogenous stains originate within the tooth through devel- opmental and systemic disturbances. Types of endogenous stains include those caused by an excessive amount of fluoride during formation of the tooth. Another example of an endogenous stain would be that resulting from medications taken by the mother or the child during tooth development. Tetracycline is an example of a medication that is known to cause developmental staining. Endogenous stains may be seen in both deciduous and perma- nent dentitions and cannot be removed by polishing (Figs. 58.2 through 58.7). Fig. 58.3 Endogenous developmental stain: enamel hypoplasia. (Cour- Exogenous stains are those that originate outside the tooth tesy Dr. George Taybos, Jackson, MS.) and are caused by environmental agents. These can be subdivided even further into extrinsic and intrinsic stains, depending on whether or not the stain can be removed. Extrinsic stains are those stains that appear on the exterior of the tooth and can be removed. Examples include staining from food, drink, and tobacco. There is another type of extrinsic stain that can occur during the eruption process. Nasmyth’s membrane is a residue from the oral epithelium on the newly erupted enamel. This residue is easily stained from food and drink and can be difficult to remove with toothbrushing. However, it can be removed by selective polishing of those teeth (see Fig. 58.7). In these cases, the source of the stain is external, and the stain may be removed (Table 58.1). Fig. 58.4 Endogenous developmental stain: dental fluorosis. (Courtesy Dr. George Taybos, Jackson, MS.) Fig. 58.2 Endogenous developmental stain: tetracycline. Note how the stained area corresponds to the period of tooth development and the time the drug was taken. (Courtesy Santa Rosa Junior College, Santa Fig. 58.5 Endogenous developmental stain: secondary caries. (Courtesy Rosa, CA.) Dr. George Taybos, Jackson, MS.) 910 PART 10 Assisting in Comprehensive Dental Care Fig. 58.6Exogenous stain: amalgam restoration. (Courtesy Dr. George Taybos, Jackson, MS.) Fig. 58.7 Staining of Nasmyth’s membrane after eruption of the teeth. TOOTH STAINS The entire crown area of the primary dentition is affected. (Courtesy Mar- Stains of the teeth occur in three basic ways: garet J. Fehrenbach, RDH, MS, Seattle, WA.) 1. The stain adheres directly to the surface of the tooth. 2. The stain is embedded in calculus and plaque deposits. 3. The stain is incorporated within the tooth structure. TABLE 58.1 Extrinsic Stains Type of Stain Appearance Cause Black stain Thin black line on the teeth near the gingival Caused by natural tendencies. margin. More common in girls. Frequently found in clean mouths. Difficult to remove. Tobacco stain A very tenacious dark brown or black stain. Caused by the products of coal tar in tobacco and by the penetration of tobacco juices into pits and fissures, enamel, and dentin of the teeth. Use of any tobacco-containing products causes tobacco stains on the teeth and restorations. Brown or yellow stain Most commonly found on the buccal surfaces of Caused by poor oral hygiene or by the use of a toothpaste with the maxillary molars and the lingual surfaces inadequate cleansing action. of the lower anterior incisors. Green stain Appears as a green or green-yellow stain, Caused by poor oral hygiene when bacteria or fungi are retained usually on the facial surfaces of the maxillary in bacterial plaque. anterior teeth. Most common stain in children. Dental plaque agents Reddish-brown stain appears on the Caused by using prescription mouth rinses that contain interproximal and cervical areas of the teeth. chlorhexidine. (Chlorhexidine is a disinfectant with broad Also can appear on restorations, in plaque, antibacterial action.) and on the surface of the tongue. Food and drink Light brownish stain. Stain is lessened with good Caused by tea, coffee, colas, soy sauce, berries, and other oral hygiene. foodstuffs. Nasmyth’s membrane Light green or brownish stain that is removed Caused by food stains in the residue of epithelium during tooth with gentle polishing. eruption. Modified from Robinson D, Bird D: Essentials of dental assisting, ed 6, St Louis, 2017, Saunders.  CHAPTER 58 Coronal Polishing 911 TABLE 58.2 Intrinsic Stains Type of Stain Appearance Cause Pulpless teeth Not all pulpless teeth discolor. A wide range of colors Blood and pulpal tissues break down as a result of exist: light yellow, gray, reddish brown, dark bleeding in the pulp chamber or death of pulp tissue. brown, or black; sometimes an orange or greenish Pigments from the blood and tissue penetrate the color is seen. dentin and show through the enamel. Tetracycline antibiotics Light green to dark yellow or a gray brown. Can occur in the child when the mother is given Discoloration depends on the dosage, the length tetracycline during the third trimester of pregnancy, or of time the drug was used, and the type of when this agent is given in infancy or early childhood. tetracycline given. Dental fluorosis Also referred to as mottled enamel; results from Varying degrees of discoloration ranging from a few ingestion of excessive fluoride during the white spots to extensive white areas or distinct mineralization period of tooth development. brown stains. Imperfect tooth development Teeth are yellowish brown or gray brown. Teeth May result from genetic abnormality or environmental appear translucent or opalescent and vary in color. influences during development. Silver amalgam Appears as a gray or black discoloration around a Metallic ions from the amalgam penetrate the dentin restoration. and enamel. Other systemic causes Appear as a yellowish or greenish discoloration of Conditions of prolonged jaundice early in life and the teeth. erythroblastosis fetalis (Rh incompatibility). From Robinson D, Bird D: Essentials of dental assisting, ed 6, St Louis, 2017, Saunders. RECALL BOX 58.3 Indications for and Contraindications to 1. What is a coronal polish? Air Polishing Use 2. What is the difference between a coronal polish and an oral Indications prophylaxis? Cleaning of pits and fissures before sealant placement 3. What is the purpose of selective polishing? Removal of temporary cement residues 4. What is an extrinsic stain? Cleaning of bands and brackets inside the mouth 5. What is an intrinsic stain? Surface cleaning (for exact tooth color selection before selection from the shade guide) Removal of difficult stain Methods of Removing Plaque and Stains Contraindications Two methods of stain removal are air-powder polishing and rubber Patients with restricted sodium diets cup polishing. Patients with respiratory, renal, or metabolic disease With any type of stain and plaque removal procedure, you Children Areas of exposed cementum or dentin must be careful (1) not to remove the surface enamel of the tooth Prolonged polishing of root surfaces and (2) to avoid trauma to the gingiva. Remember, you must check the regulations in your state regard- ing whether coronal polishing is delegated to qualified dental assistants and, if so, which technique is permitted. Rubber Cup Polishing Air Polishing The most common technique for removing stains and plaque and Air polishing is an alternative to traditional rubber cup polishing for polishing the teeth is the use of an abrasive polishing agent in (Box 58.3). The air-powder polishing technique uses a specially a rubber polishing cup that is rotated slowly and carefully by a designed handpiece with a nozzle that delivers a slurry of warm prophy angle attached to the slow-speed handpiece. This is the water and sodium bicarbonate (Fig. 58.8). This slurry will remove form of coronal polishing that is described in detail in this chapter. surface stains, plaque, and other soft deposits such as food particles trapped in between teeth. Under pressure, the slurry of water and Handpieces and Attachments for sodium bicarbonate removes stains rapidly and efficiently. The flow rate of the sodium bicarbonate powder is adjusted to control Coronal Polishing the rate of abrasion. Air polishing is also recommended for cleaning Polishing Cups and removing extrinsic stain from pits and fissures before placement of sealants. The manufacturer’s instructions caution against the Soft, webbed polishing cups are used to clean and polish the smooth use of air polishing for patients with respiratory diseases because surfaces of the teeth. The polishing cup attaches to the reusable of the potential for aspiration. prophy angle with a snap-on or screw-on attachment. 912 PART 10 Assisting in Comprehensive Dental Care Fig. 58.9 Close-up of hand with handpiece and proper grasp. Fig. 58.8 Air polisher unit (left) and magnetostrictive scaler (right). (Cour- tesy Dentsply Professional Division, York, PA.) use. The disposable angle is manufactured with a polishing cup or a brush already attached. When attaching the polishing cup or the brush to the reusable Polishing cups are made from natural or synthetic rubber. Natural type of prophy angle, you must ensure that the polishing cup or rubber polishing cups are more resilient and do not stain the teeth. brush is securely fastened. If a polishing cup or brush falls off Synthetic polishing cups are stiffer than natural polishing cups. during the procedure, the patient could swallow or aspirate it. Synthetic polishing cups should be used for patients with latex allergies. Grasping the Handpiece The handpiece and the prophylaxis angle are held in a pen grasp with the handle resting in the U-shaped area of the hand between Bristle Brushes the thumb and the index finger (Fig. 58.9). Bristle brushes are made from natural or synthetic materials and Proper grasp is important; if the grasp is not secure and comfort- may be used to remove stains from the deep pits and fissures of able, the weight and balance of the handpiece can cause loss of enamel surfaces. Bristle brushes can cause cuts on the gingivae control, possibly resulting in hand and wrist fatigue. and must be used with special care. Brushes are not recommended for use on exposed cementum or dentin because these surfaces are Handpiece Operation soft and are easily grooved. A low-speed handpiece that operates at a maximum of 20,000 revolutions per minute (rpm) is recommended. The low speed Bristle-Brush Polishing Stroke minimizes frictional heat and gingival trauma caused by the If necessary, soak stiff brushes in hot water to soften them. polishing cup. Apply a mild abrasive polishing agent to the brush and, using The rheostat (foot pedal) is used to control the speed (rpm) of a light wiping stroke, spread the polishing agent over the occlusal the handpiece. surfaces to be polished. The toe of the foot is used to activate the rheostat. The sole of Use the free hand and fingers to retract and protect the cheek the foot remains flat on the floor, similar to its position when and tongue from the revolving brush. one is operating a gas pedal on a car. Establish a firm finger rest and bring the brush almost into Apply steady pressure with the toe on the rheostat to produce contact with the tooth surface before activating the brush. a slow, even speed. Release the rheostat immediately when the Using the slowest speed, apply the revolving brush lightly to handpiece is removed from the tooth for longer than a moment. the occlusal surfaces. Take care to avoid contacting the gingiva. This prevents splattering of prophy paste and saliva. Use a short-stroke brushing motion, moving from the inclined Use intermittent pressure on the tooth to allow the heat that planes to the cusps of the tooth. is generated to dissipate between strokes. Constant pressure of Move frequently from tooth to tooth to avoid generating the rubber cup or the brush on the tooth builds up frictional frictional heat. heat that may cause discomfort and possible pulpal damage. Frequently replenish the supply of polishing agent to minimize The speed of the cup is important in minimizing frictional heat frictional heat. and in polishing effectively. Operating the cup at high speeds may be harmful and ineffective. Prophylaxis Angle and Handpiece The Fulcrum and Finger Rest The prophylaxis angle, commonly called a prophy angle, attaches The terms fulcrum and finger rest are used interchangeably to to the low-speed handpiece (see Chapter 35). describe the placement of the third, or ring, finger of the hand, The two basic types of prophy angles are reusable and disposable. which holds the instrument or handpiece. The reusable type of prophy angle must be properly cleaned and The fulcrum provides stability for the operator and must be sterilized after each use. (Handpiece maintenance is discussed in placed in such a way as to allow movement of the wrist and Chapter 35.) The disposable angle is simply discarded after a single forearm. The fulcrum is repositioned throughout the procedure  CHAPTER 58 Coronal Polishing 913 TABLE 58.3 Commonly Used Abrasives Agent Action A Silex Fairly abrasive; used for cleaning more heavily stained tooth surfaces. Superfine Silex Used for removal of light stains on tooth enamel. Fine pumice Mildly abrasive; used for more persistent stains, such as tobacco stains. Zirconium Used for cleaning and polishing tooth surfaces silicate (this material is highly effective and does not B C D E abrade tooth enamel). Chalk Also known as whiting; chalk is precipitated Fig. 58.10 Prophy pastes and equipment. (A) Finger ring that holds the calcium carbonate (frequently incorporated individual container of prophy paste. (B) Mild grit. (C) Medium grit. (D) into toothpaste and polishing pastes to whiten Coarse grit. (E) Soft polishing paste for esthetic restorations. the teeth). Commercial Contain an abrasive, water, a humectant (to keep premixed the preparation moist), a binder (to prevent as necessary and usually is maintained as close as possible to the preparations separation of the ingredients), flavoring working area. The fulcrum may be intraoral or extraoral, depending agents, and color. Commercial preparations on a variety of circumstances: are available in small plastic containers or The presence or absence of teeth individual packets. These are available in a variety of grits; some are made especially for The area of the mouth that is being treated esthetic restorations. The patient’s ability to widen the mouth when open When possible, an intraoral fulcrum is preferable. Improper Fluoride Replace some of the fluoride that is lost from the positioning of the hand and fingers greatly increases operator fatigue prophylaxis surface layer during the polishing process. and can cause painful inflammation of the ligaments and nerves pastes These pastes are not a substitute for topical of the wrist over time. application of fluoride. Use of fluoride paste is contraindicated before acid etching of the enamel when followed by bonding of sealants Polishing Agents or other bonded materials. Selecting an appropriate polishing agent is important. The recom- mended polishing pastes are those with high polish and low abrasion levels. All polishing materials are abrasives, and it is through a process of abrasion that they reduce scratches, remove stains, and polishing, the dental assistant must be able to differentiate between smooth surfaces. tooth structure and the restorative material by carefully examining Polishing agents (abrasives) are available in various grits. (Grit the margins and the outline of the tooth surface with an explorer refers to the degree of coarseness of an agent.) These agents are and relying on tactile sensitivity. Radiographs and reflection of available in extra coarse, coarse, medium, fine, and extra fine. The light with the mouth mirror also can help in identifying the location coarser the agent, the greater is the abrasion to the surface. of a restoration (Fig. 58.11). A review of the patient’s dental record Even a fine-grit agent removes small amounts of enamel surface. can reveal the locations of esthetic restorations. The goal is to always use the abrasive agent that will produce the Improper oral care can quickly damage many of these types of least amount of abrasion to the tooth surface. restorations. Dental assistants who perform rubber cup coronal Polishing agents are available as commercial premixed pastes polishing must understand the maintenance requirements associated (prophy paste) or as powders mixed with water or mouthwash with esthetic dentistry. to form slurry used on the polishing cup. Powder abrasives should Regular prophy paste generally is not recommended for polishing be as wet as possible (i.e., the texture should be similar to moist most esthetic restorations. Low-abrasive pastes such as micron-fine cake mix) to minimize frictional heat. If the mixture is too wet, sapphire or diamond paste or aluminum oxide paste should be spatter will occur, and it will be difficult to keep the material inside used for these restorations. The polishing agent should be applied the cup. The commercial type of premixed paste is available in directly to the restoration and then polished thoroughly with the ready-to-use packages (Fig. 58.10 and Table 58.3). use of a rubber cup for 30 seconds. Sapphire or diamond polishing paste is suggested when only porcelain is being polished. Aluminum Polishing Esthetic Restorations oxide paste is recommended for use on filled hybrid composites and resin restorations. Always follow the manufacturer’s suggestions Esthetic dentistry has become an important part of today’s dental regarding polishing of esthetic restorations. practice, and this trend will continue to grow. Many patients have Esthetic and porcelain restorations should be polished first. crown and bridge restorations, and many are choosing to have Then, the remaining teeth may be polished with the use of appropri- cosmetic resin, composite, bonding, and veneers placed to enhance ate methods for any stain present. This is done to reduce the their smile. Identifying esthetic restorations can be challenging possibility that a coarse abrasive may remain in the rubber cup because tooth-colored restorations are not easy to recognize. Before when one is polishing esthetic restorations. 914 PART 10 Assisting in Comprehensive Dental Care A B Fig. 58.11(A) It can be difficult to detect esthetic restorations. Two of these teeth have crowns. (B) Note the opaque white line of cement on teeth #8 and #9, which shows that these teeth have porcelain crowns. (Courtesy Dr. Peter Pang, Asheville, NC.) FACTORS THAT INFLUENCE THE RATE OF ABRASION The amount of abrasive agent used (the more agent used, the greater the degree of abrasion) The amount of pressure applied to the polishing cup (the lighter the pressure, the less abrasion) The rotation speed of the polishing cup (the slower the rotation of the cup, the less abrasion) Fig. 58.12 Use overlapping strokes to ensure complete coverage of the tooth. POLISHING TIPS Use approximately one cupful of polishing agent for one or two teeth. An empty cup generates more heat. Coronal Polishing Steps Use moderate intermittent pressure to permit heat dissipation. Heavy pressure creates more heat and greater abrasion to the tooth. Polishing Stroke Use the lowest possible handpiece speed that will move the cup or Begin with the distal surface of the most posterior tooth in the brush against the tooth without stalling. A whine or whistle in the handpiece indicates excessive speed. quadrant and work forward toward the anterior. Usually 20 lb per square inch (psi) of air pressure is sufficient for stain The stroke should occur from the gingival third toward the removal. incisal third of the tooth (Fig. 58.12). Polish each tooth for approximately 3 to 5 seconds. The more time Fill the polishing cup with the polishing agent and spread it spent polishing a tooth, the greater will be the abrasive effect. over several teeth in the areas to be polished. Establish a finger rest and place the cup almost in contact with the tooth. Using the slowest speed, apply intermittent strokes with the revolving cup lightly to the tooth surface for approximately 1 RECALL to 2 seconds between strokes. Purpose: Higher speeds produce 6. Which is the most common technique for stain removal? frictional heat that can damage the tooth and burn the gingiva. 7. Which type of grasp is used to hold the handpiece? Intermittent strokes allow the heat to dissipate. 8. What is the purpose of a fulcrum? Use intermittent pressure that is sufficient to cause the edges 9. What precaution should be taken when esthetic-type restorations are of the polishing cup to flare slightly. Each tooth should be polished? completed in approximately 3 to 5 seconds (Fig. 58.13).  CHAPTER 58 Coronal Polishing 915 Fig. 58.13 Stroke from the gingival third with just enough pressure to cause the cup to flare. Move the cup to another area on the tooth, using a patting, wiping motion and an overlapping stroke. Purpose: This motion avoids creating heat that could harm the tooth. Fig. 58.14 For the mandibular arch, the patient’s head is positioned so Reapply polishing agent frequently as needed. the lower jaw is parallel to the floor when the mouth is open. Turn the handpiece to adapt the polishing cup to fit every area of the tooth. Purpose: Doing so ensures that the cup covers all areas of the tooth. If you are using two polishing agents with different degrees of coarseness, always use a separate polishing cup for each. Use the most abrasive agent first; finish with the finest (least abrasive). Always rinse between polishing agents. Purpose: The finer abrasive removes tiny scratches left by the coarser abrasive. Positioning the Patient and Operator Proper positioning of both the operator and the patient during coronal polishing procedures is necessary for maximum comfort and efficiency. Positioning the Patient The dental chair is adjusted so the patient is approximately parallel to the floor with the back of the chair raised slightly. The movable headrest is adjusted for patient comfort and operator visibility. For access to the mandibular arch, position the patient’s head Fig. 58.15 For access to the maxillary arch, position the patient’s head with the chin up. with the chin down. When the mouth is open, the lower jaw is parallel to the floor (Fig. 58.14). For access to the maxillary arch, position the patient’s head with the chin up (Fig. 58.15). Tip: For maximum support and safety, keep the fulcrum as close to the area you are polishing as possible, preferably on the Positioning the Operator same dental arch. The operator positions described in this chapter refer to the face of a clock. (This concept is discussed in Chapter 33.) Sequence of Polishing The operator should be seated comfortably at the patient’s side and must be able to move around the patient to gain access to If full-mouth coronal polishing is indicated, it must be done in a all areas of the oral cavity. predetermined sequence to be certain that no area is missed. The The seated operator’s feet should be flat on the floor with the best sequence is based on the operator’s preference and the individual thighs parallel to the floor. needs of the patient. The operator’s arms should be at waist level and even with the One very effective sequence is described in Procedure 58.1: patient’s mouth. Rubber Cup Coronal Polishing (Expanded Function). Positions When performing a coronal polish procedure, the right-handed and fulcrums described are for a right-handed operator. The concepts operator generally begins by being seated at the eight o’clock of direct and indirect vision are discussed in Chapter 33. or 9 o’clock position (Fig. 58.16). The patient’s mouth is rinsed with water from the air-water When performing a coronal polish procedure, the left-handed syringe as necessary to maintain patient comfort throughout the operator generally begins by being seated at the three o’clock procedure. The high-volume evacuator (HVE) tip is used to remove or four o’clock position. excess water and debris. 916 PART 10 Assisting in Comprehensive Dental Care Patient Education Most patients are self-conscious about stains on their teeth and appreciate any tips you can give them about how they can keep their teeth as white as possible. You can explain to the patient that the causes of extrinsic stains are often controllable sources, such as coffee, tea, and tobacco. Patients may then choose to eliminate the causes of these stains, or they may have you show them how to improve their oral hygiene procedures. It is important that patients understand the causes of stains on their teeth. When stains are intrinsic, the dentist may want you to mention possible cosmetic dental care options to satisfy the patient’s desire for attractive and stain-free teeth. Legal and Ethical Implications Laws regarding coronal polishing performed by dental assistants vary widely among states. In some states, the dental assistant may have to be certified or registered to perform this function. It is your responsibility to understand and comply with the regulations of your state. It is also important to remember that a coronal polish is not the same as a prophylaxis. Dental assistants are not allowed to Fig. 58.16 The right-handed operator is seated at the nine o’clock perform a prophylaxis. A dentist or a dental hygienist must complete position. this procedure. Eye to the Future RECALL Every day, patients see and hear advertisements in the media for 10. In which direction should the polishing stroke move? 11. What damage can result from use of the prophy cup at high speed? products that will clean, polish, whiten, and remove stains from 12. How should the patient’s head be positioned for access to the maxillary their teeth. Some of these products are effective; many are not. mandibular arch? This trend of consumer interest will continue to grow, and patients will look to the dental professionals who provide their care to help them make wise choices. The role of the dental healthcare profes- Flossing After Polishing sional is to help patients realize that good oral health means more than just white teeth. Dental floss or tape can be used after coronal polishing to polish the interproximal tooth surfaces and remove any abrasive agent Critical Thinking or debris that may be lodged in the contact area. To polish these areas, abrasive is placed on the contact area 1. Before performing a coronal polish on Michelle, a 16-year-old between the teeth, and floss or tape is worked through the contact girl, the certified dental assistant (CDA) notices in the health area with a back-and-forth motion. Because operators’ and patients’ history that Michelle was given the drug tetracycline as a very preferences for floss and tape vary, many types are available. When young child. Michelle states that she took the drug repeatedly used properly, floss and tape are equally effective. over several months. What, if any, conditions might the CDA After the interproximal surfaces have been polished, a fresh expect to see on Michelle’s teeth? piece of dental floss or tape is used to remove any remaining 2. The dentist asks the CDA to perform a coronal polish on a abrasive particles between the teeth. patient who will have some orthodontic brackets placed. The If necessary, a floss threader can be used to pass the floss under CDA notices some formation of light calculus on the facial fixed bridgework to gain access to the abutment teeth. Flossing surfaces of the anterior teeth. What should the CDA do? techniques are further discussed in Chapter 15. 3. You are getting ready to perform a coronal polish procedure by beginning on the facial surfaces of the maxillary right quadrant. How would you position yourself and your patient? Evaluation of Polishing When you have completed polishing and flossing, evaluate the effectiveness of your technique by reapplying the disclosing agent ELECTRONIC RESOURCES and checking for the following criteria: Additional information related to content in Chapter 58 can be After the tooth surfaces have been dried with air, no disclosing found on the companion Evolve Web site. agent remains. Practice Quiz The teeth are glossy and reflect light from the mirror uniformly. Video: Coronal Polishing No evidence of trauma to the gingival margins or to any other soft tissues in the mouth is apparent.  CHAPTER 58 Coronal Polishing 917 PROCEDURE 58.1 Rubber Cup Coronal Polishing (Expanded Function) Consider the following with this procedure: Confirm with state guidelines before performing this procedure. Personal protective equipment (PPE) is required for the healthcare team, the student is required to identify and prepare the instrument setup, ensure appropriate safety protocols are followed, and the procedure is to be documented in the patient record. Prerequisites for Performing This Procedure Mirror positioning Operator positioning Dental anatomy Fulcrum positioning Instrumentation Equipment and Supplies Prophy angle, sterile or disposable Polishing cup accessory, snap-on or screw-on Bristle brush, snap-on or screw-on Prophy paste or other abrasive in slurry High-volume evacuator (HVE) tip or saliva ejector Maxillary Right Posterior Quadrant, Buccal Aspect (Eleven o’Clock Disclosing agent (tablets, gel, or solution) or Twelve o’Clock Position May Be Used) Cotton-tip applicator (if disclosing solution is used) 6. Sit in the eight o’clock to nine o’clock position. Dental tape 7. Ask the patient to tilt the head up and turn slightly away from you. Dental floss 8. Hold the dental mirror in your left hand. Use it to retract the cheek or Bridge threader for indirect vision of the more posterior teeth. Air-water syringe and sterile tip 9. Establish a fulcrum on the maxillary right incisors. Maxillary Right Posterior Quadrant, Lingual Aspect (Eleven o’Clock or Twelve o’Clock Position May Be Used) 10. Remain seated in the eight o’clock to nine o’clock position. 11. Ask the patient to turn the head up and toward you. 12. Hold the dental mirror in your left hand. Direct vision in this position Procedural Steps with use of the mirror provides a clear view of the distal surfaces. 13. Establish a fulcrum on the lower incisors and reach up to polish the 1. Check the patient’s medical history for any contraindications to the lingual surfaces. coronal polish procedure. 2. Seat and drape the patient with a waterproof napkin. Ask the patient to Maxillary Anterior Teeth, Facial Aspect remove any dental prosthetic appliance he or she may be wearing. 14. Remain in the eight o’clock to nine o’clock position. Provide the patient with protective eyewear. 15. Position the patient’s head tipped up slightly and facing straight ahead. 3. Explain the procedure to the patient and answer any questions. Make necessary adjustments by turning the patient’s head slightly 4. Inspect oral cavity for lesions, missing teeth, tori, and so forth. toward or away from you. 5. Apply a disclosing agent to identify areas of plaque. 16. Use direct vision in this area. Continued 918 PART 10 Assisting in Comprehensive Dental Care PROCEDURE 58.1 Rubber Cup Coronal Polishing (Expanded Function)—cont’d 17. Establish a fulcrum on the incisal edge of the teeth adjacent to the 29. Establish a fulcrum on the buccal surfaces of the maxillary left posterior ones being polished. teeth or on the occlusal surfaces of the mandibular left teeth. Mandibular Left Posterior Quadrant, Buccal Aspect (Eleven o’Clock or Twelve o’Clock Position May Be Used) 30. Sit in the eight o’clock to nine o’clock position. 31. Ask the patient to turn the head slightly toward you. 32. Use the mirror to retract the cheek and for indirect vision of distal and buccal surfaces. 33. Establish a fulcrum on the incisal surfaces of the mandibular left anterior teeth, and reach back to the posterior teeth. Mandibular Left Posterior Quadrant, Lingual Aspect 34. Remain in the nine o’clock position. 35. Ask the patient to turn the head slightly away from you. 36. For direct vision, use the mirror to retract the tongue and reflect more light to the working area. 37. Establish a fulcrum on the mandibular anterior teeth and reach back to the posterior teeth. Maxillary Anterior Teeth, Lingual Aspect 18. Remain in the eight o’clock to nine o’clock position or move to the eleven o’clock to twelve o’clock position. 19. Position the patient’s head so it is tipped slightly upward. 20. Use the mouth mirror for indirect vision and to reflect light on the area. 21. Establish a fulcrum on the incisal edge of the teeth adjacent to the ones being polished. Mandibular Anterior Teeth, Facial Aspect 38. Sit in the eight o’clock to nine o’clock position, or in the eleven o’clock to twelve o’clock position. 39. As necessary, instruct the patient to adjust the head position by turning toward or away from you or by tilting the head up or down. 40. Use your left index finger to retract the lower lip. Direct and indirect Maxillary Left Posterior Quadrant, Buccal Aspect vision can be used in this area. 22. Sit in the nine o’clock position. 41. Establish a fulcrum on the incisal edges of the teeth adjacent to the 23. Position the patient’s head tipped upward and turned slightly toward ones being polished. you to improve visibility. Mandibular Anterior Teeth, Lingual Aspect 24. Use the mirror to retract the cheek and for indirect vision. 42. Sit in the eight o’clock to nine o’clock position, or in the eleven o’clock 25. Rest your fulcrum finger on the buccal occlusal surface of the teeth to twelve o’clock position. toward the front of the sextant. 43. As necessary, instruct the patient to adjust the head position by turning ALTERNATIVE Rest your fulcrum finger on the lower premolars and toward or away from you or by tilting the head up or down. reach up to the maxillary posterior teeth. 44. Use the mirror for indirect vision, to retract the tongue, and to reflect Maxillary Left Posterior Quadrant, Lingual Aspect light onto the teeth. Direct vision often is used in this area when the 26. Remain in the eight o’clock to nine o’clock position. operator is seated in the twelve o’clock position, but indirect vision also 27. Ask the patient to turn the head away from you. can be helpful. 28. Use direct vision in this position. Hold the mirror in your left hand for a 45. Establish a fulcrum on the mandibular cuspid incisal area. combination of retraction and reflecting light.  CHAPTER 58 Coronal Polishing 919 PROCEDURE 58.1 Rubber Cup Coronal Polishing (Expanded Function)—cont’d Mandibular Right Quadrant, Lingual Aspect Mandibular Right Quadrant, Buccal Aspect 50. Remain in the eight o’clock position. 46. Sit in the eight o’clock position. 51. Ask the patient to turn the head slightly toward you. 47. Ask the patient to turn the head slightly away from you. 52. Retract the tongue with the mirror. 48. Use the mirror to retract tissue and reflect light. The mirror also may be 53. Establish a fulcrum on the lower incisors. used to view the distal surfaces in this area. Mandibular Right Quadrant, Lingual Aspect (Eleven o’Clock or 49. Establish a fulcrum on the lower incisors. Twelve o’Clock Position May Be Used) 54. Sit in the eight o’clock to nine o’clock position. 55. Ask the patient to turn the head slightly toward you. 56. Retract the tongue with the mirror. 57. Establish a fulcrum on the lower incisors. Documentation 58. Document the procedure.