132 29 Stain Management and Tooth Whitening EQUIPMENT Polishing paste, esthetic restoration polishing paste, and low-abrasive toothpaste Prophylaxis angle and toothbrush Dental fl oss or tape Floss threader (if needed) Rubber cups and pointed bristle brushes Low-speed handpiece Gauze squares Mouth mirror, air-water syringe Disclosing solution Preprocedural antimicrobial mouth rinse Saliva ejector or high-volume evacuation (HVE) tip Safety glasses for client Personal protective equipment (PPE) STEPS RATIONALES PREPARATION AND POSITIONING 1. Evaluate client’s health and pharmacologic history to Ensures protection from health risks. determine need for antibiotic premedication. 2. Identify tooth surfaces indicated and contraindicated Prevents unnecessary removal of tooth structure; maintains for polishing. Always polish esthetic restorations first, esthetic dental material by using specially designed then polish teeth. nonabrasive polishing parts; ensures protection from health risks. 3. Educate client about selective polishing procedure. Facilitates client acceptance. 4. Select polishing abrasive based on type of stain and Prevents unnecessary removal of tooth structure. oral restorations and assemble basic setup ( Figure 27-1 ). 5. Wear appropriate PPE and provide protective eyewear Prevents cross-contamination; protects client’s eyes from for client. spatter. 6. Provide client with a preprocedural antimicrobial rinse Reduces aerosol microorganisms; minimizes occurrence of polishing. bacteremia in at-risk clients. 7. Have client tilt head up and turn slightly away when Enhances access and visibility; prevents occupational injury. polishing maxillary and mandibular right buccal surfaces of posterior teeth (left buccal if left-handed practitioner) and maxillary and mandibular left lingual surfaces of posterior teeth (right lingual if left-handed practitioner). Procedure 27-1 RUBBER-CUP POLISHING Figure 27-1. Examples of commercial prophylaxis pastes in unit doses. (Courtesy DENTSPLY Preventive Care Divi- sion, York, Pennsylvania.) Copyright © 2015, 2010, 2003, 1995 by Saunders, an affiliate of Elsevier, Inc. 133 Dental Hygiene Procedures ■ PART I GRASP 8. Use modifi ed pen grasp ( Figure 27-2 ). Facilitates movement of handpiece. 9. Rest handpiece in V of hand. Transfers handpiece weight from fingers to hand to decrease fatigue. 10. Have all fingers in contact as a unit. Facilitates wrist-forearm motion. FULCRUM 11. Establish intraoral fulcrum close to working area. Enhances control of handpiece. 12. Fulcrum on ring fi nger. Facilitates pivoting for wrist-forearm motion. 13. Use moderate fulcrum pressure. Enhances stabilization. ADAPTATION 14. Angle rubber cup to fl are at gingival margin. Enhances stain removal at cervical third of tooth. 15. Adapt rubber cup to reach distal, facial and lingual, or mesial surfaces. Ensures access to all surfaces with extrinsic stain. 16. Adapt cup to tooth by rotating handpiece or pivoting on fulcrum as necessary. Decreases tissue trauma; provides adequate tooth coverage. 17. Adapt brush to occlusal surface. Removes extrinsic stain from pits and grooves. STROKE 18. Fill cup with paste and evenly apply to surfaces to be polished. Ensures adequate and even distribution of paste. 19. Place cup on tooth; activate handpiece by gently stepping on rheostat. Stroke from the gingival third to the incisal third with just enough pressure to make the cup fl are while using wrist-forearm motion to polish the teeth. Controls speed of handpiece; reduces finger fatigue. 20. Use low speed and intermittent, dabbing, overlapping strokes with light to moderate pressure in a cervical to occlusal or incisal direction ( Figure 27-3 ). Dissipates heat, reduces abrasion, ensures complete coverage where needed. 21. Remove rubber cup from tooth at completion of stroke; readapt cup for next stroke. Dissipates heat. 22. Hold mirror in nondominant hand to retract buccal mucosa. Instruct client to close mouth halfway and to tilt head slightly toward the ceiling. Polish buccal surfaces of maxillary right posterior quadrant (Figure 27-4). Mirror use facilitates access and direct observation of buccal and mesial surfaces and indirect observation of distal surfaces. Procedure 27-1 RUBBER-CUP POLISHING— cont’d STEPS— cont’d RATIONALES— cont’d Figure 27-2. Handpiece grasp. Figure 27-3. Overlapping strokes to ensure complete coverage of the tooth as needed. (From Bird DL, Robin- son DS: Torres and Ehrlich modern dental assisting, ed 9, St Louis, 2009, Saunders.) (Continued) Copyright © 2015, 2010, 2003, 1995 by Saunders, an affiliate of Elsevier, Inc. 134 Procedures Manual to Accompany Dental Hygiene 23. Polish facial surfaces of maxillary anterior teeth. Palm mirror and retract lip with fi ngers of nondominant hand ( Figure 27-5 ). Allows for direct vision; keeps mirror accessible. 24. Hold mirror in nondominant hand to retract buccal mucosa. Instruct client to close mouth halfway and to tilt head slightly toward the ceiling. Polish buccal surfaces of maxillary left posterior quadrant ( Figure 27-6 ). Mirror use facilitates access, direct view of buccal and mesial surfaces, and indirect view of distal surfaces. Figure 27-4. Polishing the buccal surfaces of the maxillary right posterior quadrant. Figure 27-5. Polishing the facial surfaces of the maxillary anterior teeth. Figure 27-6. Polishing the buccal surfaces of the maxillary left posterior quadrant. Procedure 27-1 RUBBER-CUP POLISHING— cont’d STEPS— cont’d RATIONALES— cont’d Copyright © 2015, 2010, 2003, 1995 by Saunders, an affiliate of Elsevier, Inc. 135 Dental Hygiene Procedures ■ PART I 25. Polish lingual surfaces of maxillary right posterior quadrant. Use mirror for indirect view and indirect lighting ( Figure 27-7 ). Use of indirect vision promotes good posture and visibility of lingual surfaces. Using the mirror to reflect additional light improves visibility. 26. Polish lingual surfaces of maxillary anterior teeth. Use mirror for indirect vision ( Figure 27-8 ). Use of indirect vision promotes good posture and visibility of lingual surfaces. 27. Polish lingual surfaces of maxillary left posterior quadrant. Use mirror for indirect vision ( Figure 27-9 ). Use of indirect vision promotes good posture and good visibility of lingual surfaces. Using the mirror to reflect additional light improves visibility. Procedure 27-1 RUBBER-CUP POLISHING— cont’d STEPS— cont’d RATIONALES— cont’d Figure 27-7. Polishing the lingual surfaces of the maxillary right posterior quadrant. Figure 27-8. Polishing the lingual surfaces of the maxil- lary anterior teeth. Figure 27-9. Polishing the lingual surfaces of the maxil- lary left posterior quadrant. (Continued) Copyright © 2015, 2010, 2003, 1995 by Saunders, an affiliate of Elsevier, Inc. 136 Procedures Manual to Accompany Dental Hygiene 28. Rinse client’s teeth. Removes prophylaxis paste from client’s mouth. 29. Hold mirror in nondominant hand to retract right buccal mucosa. Polish buccal surfaces of mandibular right posterior quadrant ( Figure 27-10 ). Retracting buccal mucosa with mirror facilitates access, direct view of buccal and mesial tooth surfaces, and indirect view of distal surfaces. 30. Palm grasp mirror and retract lip with fingers of nondominant hand. Polish facial surfaces of mandibular anterior teeth ( Figure 27-11 ). Allows for direct vision; palm grasp of mirror handle keeps mirror accessible. 31. Retract buccal mucosa with mirror and polish buccal surfaces of mandibular left posterior quadrant ( Figure 27-12 ). Allows for direct view of buccal and mesial surfaces and indirect view of distal surfaces. 32. Polish lingual surfaces of mandibular right posterior quadrant. Use mirror to retract tongue and for indirect vision and lighting ( Figure 27-13 ). Retracting the tongue facilitates direct and indirect vision. Figure 27-10. Polishing the buccal surfaces of the man- dibular right posterior quadrant. Figure 27-11. Polishing the facial surfaces of the man- dibular anterior teeth. Figure 27-12. Polishing the buccal surfaces of the man- dibular left posterior quadrant. Procedure 27-1 RUBBER-CUP POLISHING— cont’d STEPS— cont’d RATIONALES— cont’d Copyright © 2015, 2010, 2003, 1995 by Saunders, an affiliate of Elsevier, Inc. 137 Dental Hygiene Procedures ■ PART I 33. Polish lingual surfaces of mandibular anterior teeth ( Figure 27-14 ). Use mirror for indirect vision and indirect lighting. Avoid resting mirror on sublingual mucosa. Resting the mirror on sublingual mucosa is very uncomfortable for client. Rim of cup can be used to polish concave lingual surfaces of anterior teeth. 34. Polish lingual surfaces of mandibular left posterior quadrant (Figure 27-15). Use mirror to retract tongue and for indirect vision and lighting. Replace rubber cup with flat or pointed brush and remove occlusal stain. Use of mirror facilitates access and visibility of lingual surfaces. Brushes adapt to pits and fissures. Procedure 27-1 RUBBER-CUP POLISHING— cont’d STEPS— cont’d RATIONALES— cont’d Figure 27-14. Polishing the lingual surfaces of the man- dibular anterior teeth. Figure 27-13. Polishing the lingual surfaces of the man- dibular right posterior quadrant. Figure 27-15. Polishing the lingual surfaces of the mandibular left posterior quadrant. (From Bird DL, Robinson DS: Torres and Ehrlich modern dental assisting, ed 9, St Louis, 2009, Saunders.) (Continued) Copyright © 2015, 2010, 2003, 1995 by Saunders, an affiliate of Elsevier, Inc. 138 Procedures Manual to Accompany Dental Hygiene 35. Floss client’s teeth with abrasive agent still on teeth, then rinse. Removes prophylaxis paste from client’s mouth; facilitates the removal of interproximal stain. 36. Apply topical fl uoride therapy (see Chapter 31 in the textbook). Replaces fl uoride removed from the outer surfaces of enamel by selective polishing. 37. Document completion of service in client’s record under “Services Rendered” and date the entry— e.g.,”Removed tobacco stain with rubber-cup polishing on No. 6-11L, 22-27L; removed client oral biofi lm from remaining teeth with a soft toothbrush and fl uoride gel toothpaste. Flossed all teeth. APF topical fluoride gel treatment—tray method—provided for 4 minutes. Advised client not to eat, drink, or rinse for 30 minutes.” Ensures integrity of client’s record for client’s health and legal protection of practitioner. Procedure 27-1 RUBBER-CUP POLISHING— cont’d STEPS— cont’d RATIONALES— cont’d Photographs courtesy Dr. Margaret Walsh, University of California–San Francisco. Copyright © 2015, 2010, 2003, 1995 by Saunders, an affiliate of Elsevier, Inc. 139 Dental Hygiene Procedures ■ PART I EQUIPMENT Sodium bicarbonate powder or aluminum trihydroxide air polishing powder and low-abrasive toothpaste (Figure 27-16 ) STEPS RATIONALES PREPARATION AND POSITIONING 1. Evaluate client’s health and pharmacologic history to determine need for antibiotic premedication. Ensures safe treatment. 2. Identify tooth surfaces and restorations indicated and contraindicated for polishing and agents to be used. Prevents unnecessary removal of tooth structure. 3. Educate client about selective polishing procedure. Facilitates client acceptance of procedure. 4. Assemble high-speed evacuation and saliva ejector. Reduces amount of aerosol released into atmosphere. 5. Verify that slurry exits from device tip when held outside the mouth; adjust saliva ejector as necessary. Ensures adequate evacuation. 6. Use appropriate PPE and provide protective eyewear for client. Reduces risk of infection in client and practitioner. 7. Clinician, client, and equipment must be in appropriate position for each area. Enhances access and visibility; prevents occupational injury. GRASP 8. Use modifi ed pen grasp. Facilitates movement of handpiece. 9. Rest handpiece in V of hand. Transfers handpiece weight from fingers to hand to decrease fatigue. 10. Have all fi ngers in contact as a unit. Facilitates wrist-forearm motion. 11. Tuck excess cord around pinkie finger, if desired. Decreases pull from handpiece cord. FULCRUM 12. Use external soft tissue fulcrums. Facilitates access. Procedure 27-2 AIR POLISHING TECHNIQUE Figure 27-17. Prophy-Jet and ultrasonic scaler combina- tion (top unit) . (Courtesy DENTSPLY Preventive Care Divi- sion, York, Pennsylvania.) Figure 27-16. Flavored prophy powder for use in air pol- ishing device. (Courtesy DENTSPLY Preventive Care Divi- sion, York, Pennsylvania.) (Continued) Air-polisher device (Figure 27-17) and toothbrush Dental fl oss or tape Mouth mirror, air-water syringe Disclosing solution Lubricant for client’s lips Saliva ejector and high-volume evacuation (HVE) tip Safety glasses for client Personal protective equipment (PPE) Preprocedural antimicrobial mouth rinse Copyright © 2015, 2010, 2003, 1995 by Saunders, an affiliate of Elsevier, Inc. 140 Procedures Manual to Accompany Dental Hygiene ADAPTATION AND STROKE 13. Activate foot pedal by pushing halfway down for water and all the way down for combined air-water-powder spray. Provides adequate coverage of tooth surface. 14. At about 3 to 4 mm from tooth surface and at correct angulation, use constant circular sweeping motions, from proximal to proximal; pivot nozzle to surface being polished; polish several teeth for 1 to 2 seconds each and rinse. Surfaces without stain are cleaned with a toothbrush and low-abrasive toothpaste ( Figure 27-18 ). Ensures adequate stain removal; provides pleasant aftertaste; ensures adequate biofilm removal. OTHER 15. Rinse with water; fl oss all teeth (or have client do so and evaluate their flossing technique). Removes any remaining polishing paste. 16. Evaluate effectiveness with disclosing solution, compressed air, and good lighting. Ensures complete extrinsic stain removal. 17. Provide professionally applied topical fluoride treatment. Replenishes any fl uoride lost from outer fluoride-rich surface layer of enamel. 18. Dispose of single-use items according to federal, state, and local regulations. Ensures compliance with law. 19. Properly disinfect and sterilize all other equipment. Prevents cross-examination between clients. 20. Document completion of service in client’s record under “Services Rendered” and date the entry, e.g., “Removed tobacco stain with air polishing on No. 6-11L, 22-27L; removed client oral biofilm from remaining teeth with a soft toothbrush and fluoride toothpaste. Flossed all teeth. APF topical fluoride gel treatment—tray method—provided for 4 minutes. Advised client not to eat, drink, or rinse for 30 minutes.” Ensures integrity of client’s record for client’s health and legal protection of practitioner. Procedure 27-2 AIR POLISHING TECHNIQUE— cont’d STEPS— cont’d RATIONALES— Cont’d Figure 27-18. Recommended angulations of Prophy-Jet nozzle to tooth surface. (Adapted from DENTSPLY Preventive Care Division, York, Pennsylvania.) Please refer to the Evolve website ( http://evolve.elsevier.com/Darby/hygiene ) for competency forms to help evaluate your mastery of each procedure in this chapter. Copyright © 2015, 2010, 2003, 1995 by Saunders, an affiliate of Elsevier, Inc.