Tooth Polishing and Whitening

Tooth Polishing and Whitening

Introduction

  • Patients often seek solutions for teeth appearance dissatisfaction.

  • If staining is the problem, the dental hygienist determines the cause.

  • If tooth polishing and/or whitening can address the stain, the dental hygienist selects the least damaging method.

  • Dental hygienists sometimes perform tooth polishing for therapeutic reasons.

Extrinsic Stain Management

  • Two primary procedures:

    • Rubber-cup polishing: No therapeutic value in terms of periodontal health.

    • Air polishing.

  • Tooth stain is not a pathologic condition.

Rubber-Cup Tooth Polishing

  • Uses a low-speed dental handpiece, a prophylaxis angle with rubber cup or bristle brush, and prophylaxis paste.

  • Effective for removal of extrinsic tooth stains.

  • Good patient acceptance.

  • Easy to learn and perform.

  • Five variables influence efficiency, effectiveness, and tooth structure loss during rubber cup polishing:

    • Abrasiveness of the prophylaxis paste.

    • Quantity of abrasive agent.

    • Contact time on the tooth surface.

    • Speed of the rubber cup.

    • Applied pressure on the tooth surface.

Adverse Effects of Improper Polishing

  • On teeth:

    • Root surfaces.

    • Newly erupted teeth.

    • White spots.

  • On restorations: Rough surfaces.

  • On soft tissues:

    • Irritation.

    • Trauma.

    • Heat generation.

    • Discomfort.

  • On the environment:

    • Aerosol production.

    • Clinician occupational injury.

Prophylaxis Angle and Dental Handpiece Technique

  • Head of prophylaxis angle has a rubber cup or flat or pointed bristle brush.

  • Rubber cups can use prophylaxis paste, or paste-free abrasive impregnated prophylaxis polishing cups are available for use without paste.

  • Handpieces with prophy angle and prophy cup or brush are used with pen grasp.

Hand-Activated and Sonic or Ultrasonic Scaling

  • Hand-activated instruments (curets and sickle scalers) are designed primarily for calculus removal; can also be used for extrinsic stain removal.

  • As much stain as possible should be removed during scaling and debridement.

  • Sonic and ultrasonic instruments remove less tooth structure but leave a rough surface.

Air Polishing

  • Efficient and effective method of extrinsic stain removal, including pits and fissures before placement of sealants.

  • Advantages:

    • Requires less time than traditional rubber cup polishing.

    • Removes stain three times as fast as hand scaling.

    • Creates less operator fatigue.

  • Caution: Do not use on patients with respiratory diseases.

  • Effects on oral and dental tissues:

    • Intact enamel surfaces are not damaged.

    • Prolonged use on cementum and dentin can remove significant tooth structure.

    • Gingival bleeding and abrasion.

    • Taste.

Choosing an Air-Polishing Device and Powder

  • Not all air-polishing devices can accommodate all powder options.

  • Must choose appropriate prophy powder:

    • Sodium bicarbonate.

    • Calcium carbonate.

    • Aluminum trihydroxide.

    • Calcium sodium phosphosilicate.

    • Glycine.

    • Erythritol.

Effects on Oral and Dental Tissues (Air Polishing)

  • Air polishing may be less damaging and more efficient means of removing stain on enamel when comparing with rubber-cup polishing.

  • Most common soft-tissue effects of air polishing:

    • Gingival bleeding.

    • Abrasion.

Effects on Restorations and Titanium Implants

  • Avoid extended use of air polishing on all restorative dental materials.

  • Avoid air polishing on or near the following:

    • Amalgam alloy and other metal restorations.

    • Composite restorations.

    • Porcelain, gold alloy, and glass ionomer restorations.

    • Sapphire and pure titanium implants.

    • Dental implants.

Air Polishing Safety Issues

  • Patient concerns include:

    • Systemic problems from absorption of sodium bicarbonate prophy powder.

    • Respiratory difficulties and potential infection from inhaling contaminated aerosols.

    • Stinging of the lips from concentrated spray.

    • Eye problems from spray entering eyes.

  • Aerosol health hazard concerns:

    • Clinician needs to wear a well-fitting mask.

    • Patient needs to rinse with preprocedural antimicrobial rinse.

    • Use high-volume evacuation.

    • Disinfect contaminated surfaces as far away as 6 feet from treatment area.

Air Polishing Technique

  • Assemble device, high-speed evacuation, and saliva ejector; use appropriate PPE.

  • Use a modified pen grasp with the handpiece resting in the “V” of the hand.

  • Use external soft-tissue fulcrums.

  • Activate foot pedal by pushing halfway down for water and fully down for combined air-water-powder spray.

  • Hold tip of device about 3 to 4 mm from tooth surface at correct angulation.

  • Use constant circular sweeping motions from proximal to proximal.

  • Polish several teeth for 1 to 2 seconds each and rinse.

  • Document completion of service.

Client Education and Motivation

  • Before extrinsic stain removal procedures, dental hygienist encourages patients to remove all visible plaque biofilm.

  • All patients with tooth stains can benefit from individualized education linking tooth stains with lifestyle, diet, and oral hygiene practices.

  • Effective interventions for improving oral hygiene and related behaviors:

    • Goal setting.

    • Self-monitoring.

    • Planning.

Intrinsic Stain Management

  • Discolorations incorporated within tooth structure cannot be removed by scaling or polishing.

  • Intrinsic tooth stain severity and patient’s level of concern about tooth color and appearance usually determine which stain management method is recommended.

Tooth Whitening

  • Tooth whitening is a viable alternative for stain management when tooth stains are intrinsic.

  • Product active ingredients:

    • Hydrogen peroxide.

    • Carbamide peroxide.

Over-the-Counter (OTC) Home-Use Whitening Products

  • OTC whitening products:

    • Toothpaste:

      • Toothpaste containing mild abrasive to remove extrinsic stains and prevent stain formation.

      • Toothpaste containing a bleaching agent.

      • Toothpaste containing titanium dioxide, which covers extrinsic stains.

    • Whitening kits:

      • Poor or improperly fitted trays.

      • Seepage of oxidizing gel out of tray can harm soft tissues.

      • Acidic prerinse can damage enamel.

      • Laypersons may not know how to deal with side effects.

      • Laypersons may ignore oral disease such as caries.

Professionally Dispensed Home-Use Whitening Products

  • In-office fabrication of custom mouth tray.

  • Need patient education.

  • Superior products control dentinal hypersensitivity and loss of enamel.

  • Lower in cost than in-office bleaching.

  • Have the most scientific evidence supporting their effectiveness.

  • Patient must adhere to protocol.

  • Degree of change in color is unpredictable.

Professionally Applied Tooth Whitening Procedures

  • In-office whitening techniques.

  • Intracoronal bleaching:

    • Thermacatalytic.

    • Walking.

  • Microabrasion:

    • Procedure that removes superficial dark stains or white spot decalcified areas of enamel.

    • More effective on mild stains than in moderate or severe cases.

Side Effects of Tooth Whitening

  • Mild thermal tooth sensitivity and gingival irritation.

  • Occasionally: sore throats, tooth pain, tingling of tissues, headaches, slight morphologic changes in enamel.

  • Overuse: can decrease enamel hardness.

  • Some restorations are more likely to experience alterations.

  • TMJ may be affected due to tray fabrication/material.

Restorative Management of Stained Teeth

  • Veneers.

  • Full-coverage crowns.

  • A dentist performs most restorative procedures, but the dental hygienist should be able to explain all procedures to the patient.

Legal and Ethical Aspects of Tooth Whitening

  • Nonmaleficence requires that all recommended guidelines on the safe use of rubber-cup, air polishing, and tooth bleaching systems must be followed.

  • Patients must be informed of and consent to procedures before they are performed.

  • Patient education includes advantages, disadvantages, risks, and potential adverse effects of treatment.

  • Risk management strategies for treating medically compromised or immunocompromised patients must be followed.

  • Know and follow state statutes.

Intrinsic Stain Management

  • Discolorations incorporated within tooth structure cannot be removed by scaling or polishing.

  • Intrinsic tooth stain severity and patient’s level of concern about tooth color and appearance usually determine which stain management method is recommended.

Tooth Whitening

  • Tooth whitening is a viable alternative for stain management when tooth stains are intrinsic.

  • Product active ingredients:

    • Hydrogen peroxide.

    • Carbamide peroxide.

Over-the-Counter (OTC) Home-Use Whitening Products

  • OTC whitening products:

    • Toothpaste:

      • Toothpaste containing mild abrasive to remove extrinsic stains and prevent stain formation.

      • Toothpaste containing a bleaching agent.

      • Toothpaste containing titanium dioxide, which covers extrinsic stains.

    • Whitening kits:

      • Poor or improperly fitted trays.

      • Seepage of oxidizing gel out of tray can harm soft tissues.

      • Acidic prerinse can damage enamel.

      • Laypersons may not know how to deal with side effects.

      • Laypersons may ignore oral disease such as caries.

Professionally Dispensed Home-Use Whitening Products

  • In-office fabrication of custom mouth tray.

  • Need patient education.

  • Superior products control dentinal hypersensitivity and loss of enamel.

  • Lower in cost than in-office bleaching.

  • Have the most scientific evidence supporting their effectiveness.

  • Patient must adhere to protocol.

  • Degree of change in color is unpredictable.

Professionally Applied Tooth Whitening Procedures

  • In-office whitening techniques.

  • Intracoronal bleaching:

    • Thermacatalytic.

    • Walking.

  • Microabrasion:

    • Procedure that removes superficial dark stains or white spot decalcified areas of enamel.

    • More effective on mild stains than in moderate or severe cases.

Side Effects of Tooth Whitening

  • Mild thermal tooth sensitivity and gingival irritation.

  • Occasionally: sore throats, tooth pain, tingling of tissues, headaches, slight morphologic changes in enamel.

  • Overuse: can decrease enamel hardness.

  • Some restorations are more likely to experience alterations.

  • TMJ may be affected due to tray fabrication/material.

Restorative Management of Stained Teeth

  • Veneers.

  • Full-coverage crowns.

  • A dentist performs most restorative procedures, but the dental hygienist should be able to explain all procedures to the patient.

Legal and Ethical Aspects of Tooth Whitening

  • Nonmaleficence requires that all recommended guidelines on the safe use of rubber-cup, air polishing, and tooth bleaching systems must be followed.

  • Patients must be informed of and consent to procedures before they are performed.

  • Patient education includes advantages, disadvantages, risks, and potential adverse effects of treatment.

  • Risk management strategies

Extrinsic Stain Management

Two primary procedures:

Rubber-cup polishing: No therapeutic value in terms of periodontal health.

Air polishing.

Tooth stain is not a pathologic condition.

Air Polishing

Efficient and effective method of extrinsic stain removal, including pits and fissures before placement of sealants.

Advantages:

Requires less time than traditional rubber cup polishing.

Removes stain three times as fast as hand scaling.

Creates less operator fatigue.

Caution: Do not use on patients with respiratory diseases.

Effects on oral and dental tissues:

Intact enamel surfaces are not damaged.

Prolonged use on cementum and dentin can remove significant tooth structure.

Gingival bleeding and abrasion.

Taste.