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Tooth polishing: The current status

Article  in  Journal of Indian Society of Periodontology · February 2015

DOI: 10.4103/0972-124X.154170

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Review Article

Tooth polishing: The current status

Madhuri Alankar Sawai, Ashu Bhardwaj, Zeba Jafri, Nishat Sultan, Anika Daing

Department of Abstract:
Periodontology, Faculty Healthy teeth and gums make a person feel confident and fit. As people go about their daily routines
of Dentistry, Jamia Millia and with different eating and drinking habits, the tooth enamel turns yellowish or gets stained. Polishing
Islamia, New Delhi, traditionally has been associated with the prophylaxis procedure in most dental practices, which patients
India know and expect. However, with overzealous use of polishing procedure, there is wearing of the superficial
tooth structure. This would lead to more accumulation of local deposits. Also, it takes a long time for the
formation of the fluoride-rich layer of the tooth again. Hence, now-a-days, polishing is not advised as a
part of routine oral prophylaxis procedure but is done selectively based on the patients’ need. The article
here, gives an insight on the different aspects of the polishing process along with the different methods and
agents used for the same.
Key words:
Abrasives, mechanical aids, polishing, tooth staining

INTRODUCTION hence, removal of stains was for esthetic, not for

health reason.[3] Hence, polishing was then used

Access this article online

T ooth polishing is a procedure carried out
as a part of oral prophylaxis in most dental
practices. It is an act of smoothening the tooth
Website:
surfaces to make it glossy and lustrous. Although
www.jisponline.com
the term polishing has been used to describe the
DOI:
professional removal of soft deposits and stains
10.4103/0972-124X.154170
from the tooth surfaces, in reality, this includes
Quick Response Code:
both cleaning and polishing.[1] During polishing,
plaque, biofilm, stains and acquired pellicle are
removed.
It is important to understand the patients’
expectations when considering tooth polishing.
They simply like the look and feel of polished
teeth. Taste and smell are the next important
factors from the patient’s point of view. Patients
prefer this procedure over debridement with
instruments for many reasons. An important
factor is that patients respond positively to the
smooth and clean feel that polishing produces.
Furthermore, it is less painful and stressful than
scaling; and easier for the patient to understand
and tolerate. Polishing produces tangible
benefits, which the patients can see and feel.
Though, the history of tooth polishing was
Address for mentioned in the Roman and Greek writings,
correspondence: it was only with Pierre Fauchard, the Father of
Dr. Madhuri Alankar Sawai, Modern Dentistry, who introduced it for removal
Department of of dental stains with the use of finely ground
Periodontology, coral, egg shells, ginger, or salt.[2] The techniques
Faculty of Dentistry, and modalities for tooth polishing have evolved
Jamia Millia Islamia,
over the years. Dr. Fones, the Founder of
New Delhi ‑ 110 025, India.
E‑mail: msawai@jmi.ac.in Dental Hygiene, started training his auxiliaries
to provide coronal tooth polishing in the last
Submission: 11-03-2014 century. It was observed that stains were not the
Accepted: 14‑02‑2015 etiologic factor for any destructive process and
as a selective process by Wilkins.[3] Before 1970s,
patients expected polishing as a necessary part
of the dental appointment.[4] During the 1990s
and 2000s, further evidence has supported the
adoption of selective polishing.[5] However, the
concept of full mouth polishing is still used in
many – if not most – dental hygiene practices. But
worldwide, many dental hygiene schools now
recommend selective polishing as a standard
protocol instead of including polishing at every
professional maintenance appointment.
Several terms are being used in relation to
the practice of cleansing and polishing teeth.
However, when oral health professionals use
the word “polishing,” they are typically referring
to the dual process known as “cleaning” and
“polishing.” The American Dental Hygienists
Association position paper on polishing
procedures sufficiently distinguishes between
these closely related terms‑defining “cleansing”
as “the ability to remove debris and extraneous
matter from the teeth,” and “polishing” as “the
implementation of making the tooth surface
smooth and lustrous.” The American Academy
of Periodontology defines tooth polishing  (in
relation to oral prophylaxis) 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.”[6,7]
Other terms, which are commonly used are:
1. Therapeutic polishing ‑ Refers to “the
polishing of the root surfaces that are exposed
during surgery to reduce endotoxin and
microflora on the cementum.”[7]

Journal of Indian Society of Periodontology - Vol 19, Issue 4, Jul-Aug 2015 375
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Sawai, et al.: Tooth polishing
2. Coronal or cosmetic polishing ‑ Is defined as “a procedure
designed to make the tooth free of plaque and extrinsic
stains.”[7] The process of achieving a smooth, mirror‑like
enamel or material surface that reflects light and is
characterized as having a high luster; accomplished with
a fine to extra fine grit abrasive agent so that the surface
scratches are smaller than the wavelength of visible
light (<0.05 µm). The term coronal polishing may also
encompass cleansing.[7]
3. Superficial polishing ‑ it is a term related to the polishing of
the crown of the tooth. It is now considered as a cosmetic
procedure with minimal therapeutic benefit.
4. Selective polishing ‑ is another word often used by
hygienists. It is used to indicate that cleansing and
polishing procedures are only provided when justified
by the tooth surfaces that have visible stains after
scaling, and oral debridement is complete. Selective
polishing is also known as extrinsic stain removal
or selective stain removal. The most accurate term
for all of these procedures is selective stain removal,
which indicates the removal of extrinsic stains after
professional scaling, using a rubber cup, bristle brush,
and/or an air‑powder polishing system; though
everything depends on the assessed needs of the
patient. It means cleansing and polishing are omitted
on surfaces already stain free. [7]
Today the focus of tooth polishing is to give a highly polished
and aesthetic appearance by removing bacterial plaque
biofilms and extrinsic stains. But before we do polishing, one
needs to identify the type of stains and also understand the
contraindications for tooth polishing.
Identifying stain
It is very important to identify the type of stain so as to
determine which stains can be removed and which product
to use. Stains can be broadly classified into‑endogenous
and exogenous stains. Endogenous stains can be further
divided into developmental, drug induced, environmental
or due to enamel hypoplasia. The exogenous stains are due
to various foods and harmful habits and are usually seen
as different colors: Green, orange, brown and black. The
endogenous stains cannot be removed by simple polishing.
However, the exogenous stains can be removed by scaling
and polishing.
Contraindications for use of oral prophylaxis polishing
paste[8,9]
1. Absence of extrinsic stains
2. Acute gingival and periodontal infection
3. Esthetic restorations
4. Allergy to paste ingredients
5. Dental caries
6. Decalcification
7. Enamel hypoplasia
8. Exposed dentin or cementum
9. Hypomineralization
10. Newly erupted teeth
11. Patients with respiratory problems
12. Recessions
13. Tooth sensitivity
14. Xerostomia.
376 Journal of Indian Society of Periodontology - Vol 19, Issue 4, Jul-Aug 2015
During the process of tooth polishing, following things have
to be taken care of:
1. Use proper technique to reduce unnecessary abrasion on
the exposed enamel and dentine surfaces
2. Select a least abrasive polishing agent that will remove
plaque biofilm and stain
3. Control the time, speed and pressure during the procedure
4. When polishing a restorative material, care has to be
taken to use a softer abrasive particle than the restorative
material.[1]
CHOOSING A PROPHYLAXIS PASTE
As prophylaxis paste can cause incidental damage while
removing the dental stains, they should be chosen carefully.
Those with a larger particle size, that is, coarse or medium,
are very effective in extrinsic stain removal, but they can also
cause the most abrasion and damage to the tooth surface. In
fact, excessive abrasion scratches the enamel, resulting in a
less polished appearance and ultimately, contributing to an
increased rate of exogenous stain reformation and bacterial
plaque retention.[4] In contrast, prophylaxis paste with a smaller
particle size, such as those found in fine paste, will increase
tooth surface cleanliness, luster and smoothness, making the
surface more resistant to subsequent stain, plaque and calculus
formation.[4] Some professionals consider polishing with fine
prophylaxis paste to be less effective as they have to apply more
pressure and invest more time to remove the same stains than
when using coarse prophylaxis pastes.
The factors that contribute to the overall efficiency of stain
removal from the tooth surfaces include:
1. Rotations per minute (rpm) of the rubber cup polisher
2. Prophy paste coarseness
3. Rubber cup‑to‑tooth pressure or load, and
4. The time spent polishing each stained area.[10]
Unfortunately, each of these factors contributes directly to the
tooth enamel and dentin damage via abrasion.
ABRASIVE AGENTS
The purpose of the abrasive agent is to clean and to make
the tooth surfaces smooth. The abrasive agents present in the
polishing paste are usually the same as those in dentifrices.
However, the major difference being the particle size of the
abrasive; where the size is more in professional prophylaxis
pastes as compared to dentifrices. Prophylaxis polishing pastes
available in the market usually combine abrasives with a
binder, humectants, coloring agent, preservative, and flavoring
agent.[3] They are available in varying sizes of abrasive particles,
ranging from coarse, medium to fine. Harder, rough‑shaped,
large, particle size compounds produce more abrasive action
than particles that are soft, smooth‑shaped and small.
The most commonly used abrasives in polishing pastes are flour
of pumice and calcium carbonate. Other abrasive particles used
in commercial prophylaxis polishing pastes include aluminum
oxide (alumina), silicon carbide, aluminum silicate, silicon
dioxide, carbide compounds, garnet, feldspar, zirconium
silicate, zirconium oxide, boron, and calcium carbonate. Others
include the emery, silica, and perlite.
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Sawai, et al.: Tooth polishing
Pumice is a light gray, highly siliceous material produced by
volcanic activity. The flour of pumice is a very finely grounded
derivative which is used for polishing of tooth enamel, gold
foil, dental amalgam and acrylic resins.[11] Calcium carbonate,
commonly known as chalk is less abrasive then pumice. It
produces minimal scratches and results in a highly reflective
surface.[1] Zirconium silicate is also used for polishing and
is available as an off‑white mineral on abrasive disks and
strips. However, it is frequently used as a component of
dental prophylaxis paste. Manufacturers generally do not
disclose the amount of ingredients in their polishing pastes.
However, it is generally known that pumice and glycerin are
the most commonly used ingredients in commercially prepared
polishing pastes. Some commercially prepared polishing
pastes may contain fluorides, while some may have added
advantages [Table 1].
Pumice flour has been tested for its effectiveness in stain
removal on enamel. The mean abrasive depth of enamel
with pumice flour is significant (12.1 µm on a scale ranging
from 15.6 µm to 1 µm) and it has an average polishing
score when compared with other agents like Nupro Fine,
Procare, Zircate, etc.[12] Calcium carbonate produces minimal
scratches and results in a smooth, polished surface.[13] Very
few agents are available which initially function as cleansing
agent and then alters to become a polishing agent e.g.,
cleanic and zircate. These abrasives have been compared
to conventional abrasive agents. Lutz et  al. [14] in 1993
reported that all the three ideal requirements of a polishing
paste, that is, good cleansing ability, minimal abrasion,
and simultaneous polishing, which are fulfilled by perilite
containing polishing paste. Similarly, it was reported that a
paste containing perlite can polish teeth by removing surface
stains without causing damage to either the tooth structure
or to the soft tissues.[15]
The process of polishing has to proceed from coarse
abrasion (cleaning) to fine abrasion (polishing), with the use of
a series of finer and finer abrasives. Fine grit is used routinely;
medium or coarse pastes are only needed in situations of
heavy stain. As the polishing process proceeds from coarse to
fine abrasion, scratches smaller than 0.5 mcm are produced.
These scratches appear smooth and shiny as they are smaller
than the wavelength of visible light.[1] Even then, the degree of
Table 1: Some ready-to-use prophy pastes are
Component Trade name
Feldspar Procare® powder
Pumice Young dental’s D‑Lish® Prophy paste, can
be made chair side into a polishing paste
Perlite ClinPro™ Prophy paste
Aluminum silicate Pac‑Dent’s ProPaste™
Zirconium silicate Zircon‑F® paste
Amorphous calcium Enamel ProTM
phosphate
Xylitol containing products Proxyl®, SparkleTM
Xylitol containing products KolorzTM
Novamin containing products Nupro® Nu solutionsTM
Journal of Indian Society of Periodontology - Vol 19, Issue 4, Jul-Aug 2015 377
abrasiveness is dependent on clinicians’ technique and tooth
surface integrity.[13]
A single polishing agent cannot be used for all surfaces like
tooth enamel, root surfaces or restorations, as they all have
different hardness values. A polishing agent should be selected
on the basis of their hardness in such a way that the hardness
of the polishing agent should be less than that of the surface
to be polished [Table 2]. However, many of the abrasives used
in prophylaxis pastes are 10 times (or more) harder than the
surfaces they are used to polish.[1]
MECHANICAL DEVICES FOR POLISHING
Different polishers are available: Manual and engine driven.
The manual polishers are hand‑held devices whereas; the
engine driven uses hand pieces to do polishing. The most
commonly used method of tooth polishing is with the use of a
mechanical device along with the polishing agent.
Many polishers available are:
Porte polisher
It is a hand‑held device with an orange‑wood point. This
instrument can be used on various aspects of teeth. It rubs the
abrasive agent against the tooth surface with a wedge‑shaped,
tapered, or pointed wooden point.[1]
Advantages
1. Portable
2. Can be accessible to malpositioned tooth surfaces
3. Generates minimal thermal heat
4. Does not produce noise like rotary instruments
5. Minimal bacterial aerosol.[1]
Drawbacks
It requires more hand strength for instrumentation and takes
a longer time for polishing teeth.[16]
Polishing strips
They are a good option for interproximal areas and line angles.
However, they are highly abrasive. Care has to be taken to
avoid cutting or abrading the surrounding soft tissues during
polishing.[16]
Benefits
It can be used on tooth as well as restorations.[1]
The abrasive breaks down while in use from coarse to fine
size, contains fluorides
Exceptional polishing and stain‑removal ability, releases
fluoride, great taste and easy rinse‑off
Improves the tooth surface smoothness
Improves the health of teeth, stimulates saliva production,
alleviate dry mouth, reduce tooth decay,[17] reduction of acid
and biofilm production in the mouth.[18]
Available in splatter‑free and gluten‑free formulas, can be used
in kids, available as fine, medium, coarse and x coarse grits
Tooth desensitization, tubule occlusion and stain removal.[18]
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Sawai, et al.: Tooth polishing

Table 2: Knoop hardness values[1] The air powder polisher handpiece attaches either directly
Tooth structures KH number to the air/water connector on the dental unit or as a separate
Enamel 355-461
unit or in combination with ultrasonic scalers. By activating
Dentin 68 the foot control, the handpiece nozzle would propel the slurry
Cementum 40 on the tooth surface. The nozzle should be held 3–4 mm from
Resin composites the tooth surface. Holding the nozzle farther from the tooth
Anterior 46-48 surface minimizes the abrasive action and increases the aerosol.
Posterior 45-64 The tip should be angled diagonally, with the spray directed
Microfilled 18.7-57.6
towards the middle one third of the exposed tooth, using
Hybrid 51.1-64.8
Glass ionomer 18-31 a constant circular motion, interproximal to interproximal
Metal reinforced 14-24 sweeping or paint brush motion.[1] For anterior teeth, the tip
Porcelain 14 should be directed at a 60° angle; for posterior teeth, 80° angle
Abrasives used in prophylaxis pastes and dentifrices and for occlusal surfaces a 90° angle is appropriate.[1] Most of
Calcium carbonate 135 the equipment are operated using inlet air pressure between 40
Pumice 590 and 100 psi and inlet water pressure between 20 and 60 psi.[3]
Aluminum oxide 2100
Silicon carbide 2780 However, Francis and Barnes mention that the psi produced
depends on the type of air powder polisher being used.[1] These
are usually safe to use and effective methods for extrinsic stain
Engine‑driven polishers removal and plaque removal. However, studies have reported
These are widely used amongst dental professionals and that exposed cementum and dentin structures are vulnerable to
dental hygienists for their efficiency and efficacy. These loss with the use of air powder polisher.[21,22] By adjusting the
polishers are attached to the appropriate hand piece or amount of water flow and the distance of the instrument to the
prophy‑angle, which has either straight or contra‑angled tooth, the abrasive forces can be reduced. Petersilka et al. has
shanks. They can be either disposable or reusable after noted that by changing the physical properties of air‑polishing
sterilization. A rubber cup or brush is attached to the agents, the abrasive effects on the root surfaces can be reduced
prophy‑angle. The handpiece should always be used at along with complete removal of extrinsic stains.[23]
a steady slow pace of 2500–3000 rpm.[16] Christensen and
Bangerter reported in an in vivo clinical study that the average Earlier, air dent machine which uses alumina or dolomite was
speed used by dental hygienists was 2500 rpm.[10] Because it is used. However, currently the redesigned air‑polishing device
difficult to estimate the rpm in clinical practice, the slow speed (APD), the prophy‑jet, which uses a pressurized slurry of
handpiece is always rotated at the lowest rpm possible. The sodium bicarbonate with tri‑calcium phosphate (added up to
rpm is too great if “whining” or high pitched sound occurs.[13] 0.8% of weight to improve flow characteristics) in warm water
Most of the surfaces can be polished in 2–5 s with the use of on to the tooth surface, at a suggested distance of 4–5 mm and
a light, steady speed in a patting motion. Christensen and angulations of around 60° is used.[22] Powder‑water setting,
Bangerter identified that the rubber cup contacted each tooth the distance of the jet from the treated surface and the shape
surface for an average of 4.5 s.[10] It was reported by Miller and and size of the particles used, control the effectiveness of the
Hodges that it took 10 min (3.4 s per tooth) to treat the entire device.[20] APD is an effective means for removal of plaque
mouth when standardizing polishing time in a research study from orthodontically bracketed teeth as it does not disturb the
comparing rubber cup and air‑polishing.[13] The pressure wires or rubber bands and also is not detrimental to the zinc
applied should be approximately 20 psi.[1] When a rubber cup phosphate or resin cement which are used to attach brackets
does not adequately remove occlusal stains, a brush should and bands.
be used taking care not to traumatize the soft tissue as they
are difficult to control. Advantages
1. It minimizes the operator and patient fatigue.
Indications 2. It is time saving and effective.
They can be used in most clinical applications as patient 3. Dentinal sensitivity is diminished following the use
compliance and acceptance are high. of prophy‑jet, which may be explained by the fact that
bicarbonate crystals may block the tubular opening
Contraindications 4. It removes plaque from areas that are otherwise difficult to
In patients having allergies to latex or fluorides; rubber‑cup reach like furcations, flutings and close root proximities.[19]
latex free products, prophy pastes and pumice slurry without
fluoride should be used. Disadvantages
1. They should be cautiously used in patients with restricted
Air‑powder polisher sodium diets, respiratory, renal or metabolic disease,
Nowadays, air powder polishing devices have overcome infectious disease, children, diuretics or long term steroid
conventional rubber cup polishing paste systems for therapy, and those having titanium implants. Owing to
supragingival plaque removal as it reaches surfaces that are the limitation of prophy‑jet in individuals with sodium
inaccessible to a rotary device.[19,20] These polishers use slurry restricted diets, nonsodium prophy powder, containing
of water and sodium bicarbonate under air and water pressure. aluminum trihydroxide (cavitron, jet‑fresh) instead of
Abrasives like aluminum trihydroxide, calcium sodium sodium bicarbonate can be used
phosphosilicate, calcium carbonate and glycine are also used 2. Another drawback is the aerosols generated by air‑polishing
in air polishers. may present an infection control hazard. Hence, a

378 Journal of Indian Society of Periodontology - Vol 19, Issue 4, Jul-Aug 2015
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Sawai, et al.: Tooth polishing
preprocedural rinse is always recommended along with
aerosol reduction devices. Subcutaneous emphysema can
also occur whenever compressed air is employed intra‑orally.
This highlights the iatrogenic potential and reinforces the
need to follow manufacturer’s instructions appropriately.[19]
Recent introduction of glycine powder air‑polishing in
removing sub‑gingival biofilm abridge periodic sub‑gingival
instrumentation and serve as an alternative to conventional
techniques that result in less gingival erosion along with
80% reduction in abrasiveness on root surface than hand
instrumentation or sodium bicarbonate air‑polishing.[24]
Comparison of rubber cup polishing and air‑polishing methods
Result of studies comparing the effectiveness of air‑polishing
to the rubber cup polishing for bacterial plaque and
stain removal demonstrate that either method is equally
effective.[25] They reported that both methods caused some
gingival trauma.[25] However, Garcia‑Godoy and Medlock have
reported air polishers to be more effective for plaque and stain
removal in pits and fissures.[26]
Vector system
The vector system uses a polishing fluid to polish the teeth.
It removes plaque and endotoxin with minimal removal of
the cementum surface. Braun et al. demonstrated the use of a
polishing fluid containing hydroxyapatite or an abrasive fluid
containing silicon carbide which has a resonating device that
deflects vibrations directed toward the tooth surface, thereby
minimizing the forces that remove tooth substance. Thus, less
force is directed at the tooth surface as fluid dynamics removes
the plaque. This can provide effective control of inflammation
after thorough debridement of calculus and before new
deposits of calculus begin to form.[27]
EVALUATION OF COMPLETION OF POLISHING
PROCEDURE
At the end of polishing procedure, the teeth have to be
inspected thoroughly using a mouth mirror, intra‑oral light,
compressed air and disclosing solution.[1] Remaining biofilm
or stains has to be removed by either re‑instrumentation or
re‑polishing the surface. Finishing strips or dental tape rubbed
with a small amount of prophy paste before flossing assists in
the removal of residual interproximal stains.[1]
CONCLUSION
Tooth polishing used to be a standard part of a dental cleaning
appointment. The dentists used to smoothen teeth so that
plaque and bacteria which cause gingivitis, periodontitis or
cavities do not stick to the tooth easily. However, it is now
known that within 30 min, the bacteria colonize on the tooth
surface irrespective of whether teeth are polished or not. Also,
polishing removes the outer layer of tooth enamel, which takes
a period of 3 months to rebuild the fluoride‑rich layer. Hence,
selective polishing is recommended. Each patient should be
assessed individually for polishing of teeth. Teeth are polished
only if stains are present which scaling was unable to remove.
This means that during cleaning procedures either some, all
or none of the teeth may be polished.
Journal of Indian Society of Periodontology - Vol 19, Issue 4, Jul-Aug 2015 379
Currently, the dentists and hygienists have varied options
regarding the abrasive/polishing agents and type of polishers
used. They can now use different polishers and abrasives based
on the patients’ acceptance and condition, thereby providing
good care by selectively designing the treatment according to
the patients’ need and with minimum concern about the loss
of tooth structure.
REFERENCES
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Daniel SJ, Harfst SA, Wilder R, editor. Mosby’s Dental Hygiene:
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2. Ring ME. History of dental prophylaxis. J Am Dent Assoc
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3. Barnes CM. Extrinsic stain removal. In: Wilkins EW, editor.
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4. Putt MS, Kleber CJ, Muhler JC. Enamel polish and abrasion by
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16. Rethman J. Polishing angles, cups and pastes. Pract Hyg
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18. Petersilka GJ, Ehmke B, Flemmig TF. Antimicrobial effects of
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21. Petersilka GJ, Bell M, Häberlein I, Mehl A, Hickel R, Flemmig TF.
In vitro evaluation of novel low abrasive air polishing powders.
J Clin Periodontol 2003;30:9‑13.
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How to cite this article: Sawai MA, Bhardwaj A, Jafri Z, Sultan N,
Daing A. Tooth polishing: The current status. J Indian Soc Periodontol
2015;19:375-80.
Source of Support: Nil, Conflict of Interest: None declared.

380 Journal of Indian Society of Periodontology - Vol 19, Issue 4, Jul-Aug 2015

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