1. Coronal Polishing Chapter 58 1
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1

2. Chapter 58
Lesson 58.1
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2

3. Learning Objectives Pronounce, define, and spell the Key Terms.
Explain the difference between prophylaxis and coronal polishing.
Explain the indications for and contraindications to coronal polishing.
Name and describe the types of extrinsic stains.
Name and describe the two categories of intrinsic stains.
Describe types of abrasives used for polishing the teeth.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3

4. Introduction
Coronal polishing is a technique used to remove plaque and stains from the coronal surfaces of the teeth. Polishing the crowns of the teeth is considered mainly cosmetic, but there are instances in which coronal polishing has therapeutic value as well.
In some states, coronal polishing is delegated to registered or expanded-function dental assistants who have had special training in this procedure. Coronal polishing is strictly limited to the clinical crowns of the teeth. Coronal polishing is not a substitute for oral prophylaxis.
Even if an assistant is not required to perform coronal polishing, the assistant should become familiar with it because it is likely he or she will have to set up for and assist with such a procedure.
Removal of coronal plaque after prophylaxis helps reinforce to patients what their teeth should feel like after proper brushing and flossing, as well as brushing of the tongue.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4

5. Selective Polishing
Selective polishing is a procedure in which only those teeth or surfaces with stain are polished.
The purpose of selective polishing is to avoid removing even small amounts of surface enamel unnecessarily.
In some individuals, stain removal may cause dentinal hypersensitivity during and after the appointment.
Discuss with the dentist what should and should not be polished so that you are in agreement.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5

6. Coronal Polishing and Fluoride Application
Historically teeth were polished to remove all soft deposits and stains before the application of fluoride because it was believed that there would be greater uptake of the fluoride into the enamel.
As scientific knowledge has evolved, it has been shown that polishing does not improve the uptake of professionally applied fluoride.
Therefore polishing is no longer necessary before fluoride application.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6

7. Benefits of Coronal Polishing
Polishing prepares the teeth for the placement of dental sealants.
Smooth tooth surfaces are easier for the patient to keep clean.
The formation of new deposits is slowed.
Patients appreciate the smooth feeling and clean appearance.
Polishing prepares the teeth for the placement of orthodontic brackets and bands.
Polishing with pumice, a nonfluoridated abrasive, is important before sealant placement.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7

8. Dental Stains Stains of the teeth occur in three basic ways:
A stain adheres directly to the surface of the tooth.
A stain is embedded in calculus and plaque deposits.
A stain is incorporated into the tooth’s structure.
It is important to distinguish between the types of stains before coronal polishing is undertaken to remove them.
Only exogenous, extrinsic stains may be removed with the use of coronal polishing. Endogenous or intrinsically incorporated exogenous stains are not removed.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8

9. Dental Stains Stains are primarily an aesthetic problem.
Some types of stains can be removed, and others cannot. It is important for the dental assistant to be able to correctly identify stains.
There are other treatment options for patients with stains that cannot be removed.
These include professional and at-home bleaching procedures, enamel microabrasion, and cosmetic restorative procedures such as laminate veneers and composite restorations.
Before veneer placement a patient is often instructed to perform at-home bleaching so that the other areas of the teeth are adequately brightened to match the new color chosen for the veneers.
Some endogenous or intrinsic stains are found in conjunction with surface alterations in the enamel, and bleaching alone will not remove them.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9

10. Types of Dental Stains
Dental stains are categorized as either endogenous or exogenous:
Endogenous stains originate within the tooth as a result of developmental and systemic disturbances.
Exogenous stains originate outside the tooth in response to environmental agents.
Exogenous stains are those stains caused by an environmental source:
They are subdivided even further as extrinsic or intrinsic stains, depending on whether the stain can be removed.
What are some examples of causes of exogenous stains?
What are some examples of causes of endogenous stains?
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10

11. Extrinsic and Intrinsic Stains
Extrinsic stains are stains on the exterior of the tooth that can be removed. Examples include staining from food, drink, and tobacco. The source of the stain is external and the stain may be removed.
Intrinsic stains are caused by an environmental source but cannot be removed because the stain has become incorporated into the structure of the tooth. Examples are tobacco stain from smoking, chewing, or dipping and stains from dental amalgam that has become incorporated into the tooth’s structure.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11

12. Fig. 58-2 Endogenous developmental stain: tetracycline
Fig Endogenous developmental stain: tetracycline. (Courtesy of Santa Rosa Junior College, Santa Rosa, Calif.) Notice how the stained area corresponds to the period of tooth development and the time at which the drug was taken.
Notice the light-green to dark-yellow and gray-brown endogenous stains in teeth that were systemically exposed to tetracycline antibiotics during their development.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12

13. Fig. 58-3 Endogenous developmental stain: enamel hypoplasia
Fig Endogenous developmental stain: enamel hypoplasia. (From Daniel SJ, Harfst SA, Wilder R: Mosby’s dental hygiene: concepts, cases and competencies, ed 2, St Louis, 2008, Mosby. Courtesy of Dr. George Taybos, Jackson, Miss.)
This photograph shows incisal areas that have diffuse white opaque enamel when compared with the rest of the clinical crown. Pitting or grooving is also seen, in combination with a partial or total lack of enamel.
Enamel hypoplasia is developmental; it is frequently found in individuals with a wide range of congenital abnormalities that may involve other mineralization defects.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13

14. Fig. 58-4 Endogenous developmental stain: dental fluorosis
Fig Endogenous developmental stain: dental fluorosis. (From Daniel SJ, Harfst SA, Wilder R: Mosby’s dental hygiene: concepts, cases and competencies, ed 2, St Louis, 2008, Mosby. Courtesy of Dr. George Taybos, Jackson, Miss.)
This staining pattern, called “dental fluorosis,” may also be termed “mottled enamel.” It occurs when fluoride consumption from all sources (e.g., water, fluoride supplements, food sources, toothpaste consumption) exceeds 1 ppm.
Cosmetic procedures may involve veneers or crowns.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14

15. Fig. 58-5 Endogenous developmental stain: secondary caries
Fig Endogenous developmental stain: secondary caries. (From Daniel SJ, Harfst SA, Wilder R: Mosby’s dental hygiene: concepts, cases and competencies, ed 2, St Louis, 2008, Mosby. Courtesy of Dr. George Taybos, Jackson, Miss.)
This photograph depicts teeth being reflected by means of indirect vision in a dental mouth mirror.
The centrally located tooth, a second permanent premolar, is next to a first molar with an amalgam restoration over the occlusal and distal.
Secondary or recurrent decay is visible on the interproximal aspect of the premolar with the amalgam because of the altered, more opaque color of the enamel.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15

16. Fig. 58- 6 Endogenous stain: amalgam restoration
Fig Endogenous stain: amalgam restoration. (From Daniel SJ, Harfst SA, Wilder R: Mosby’s dental hygiene: concepts, cases and competencies, ed 2, St Louis, 2008, Mosby. Courtesy of Dr. George Taybos, Jackson, Miss.)
This photograph shows multiple teeth (among them a maxillary molar and two premolars) that have had amalgam restorations placed in the past.
This is an example of an endogenous source of stain that has been incorporated intrinsically into the tooth.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 16

17. Methods of Removing Plaque and Stain
Air-powder polishing
The air-powder polishing technique involves the use of a specially designed handpiece with a nozzle that delivers a high-pressure stream of warm water and sodium bicarbonate.
Rubber-cup polishing
This is the most common technique for removing stains and plaque and polishing the teeth.
A rubber polishing cup is rotated slowly and carefully by means of a prophylactic angle attached to the slow-speed handpiece.
The use of air-powder polishing can be an efficient way to remove stains quickly and thoroughly. The operator can control the flow rate, leading to differences in abrasion.
The rate at which appropriately chosen stain and plaque are removed depends on the abrasiveness of the polishing paste, the pressure applied to the rubber cup against the tooth, the length of time required for polishing, and the technique used to perform the polishing.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 17

18. Rotary Equipment for Coronal Polishing
Polishing cups
Soft webbed polishing cups are used to clean and polish the smooth surfaces of the teeth. The polishing cup is attached to the reusable prophylaxis angle by means of a snap-on or screw-on attachment.
Prophylaxis angle
Commonly called a prophy angle, this tool attaches to the slow-speed handpiece.
The reusable prophy angle must be properly cleaned and sterilized after each use.
A disposable angle is discarded after a single use.
Polishing cups come already attached to a disposable prophy angle or must be newly attached to the reusable resterilized prophy angle heads for each use.
Disposable prophy angles with attached cups come in a variety of shapes, colors, sizes, and materials.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 18

19. Fig Bristle brush (top) rubber polishing cup (bottom), sterilizable prophy angle (center), and disposable prophy angle (right).
This photograph shows the bristle brush (on the top left) and the rubber polishing cup (on the bottom left) that must be attached as appropriate to the reusable prophy head.
On the right, a disposable prophy head (white) with the polishing cup (green) already attached is shown.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 19

20. Bristle Brushes
Bristle brushes, made of natural or synthetic materials, may be used to remove stains from deep pits and fissures of the enamel surfaces.
Bristle brushes can cause severe gingival lacerations and must be used with special care.
Brushes are not recommended for use on exposed cementum or dentin because these surfaces are soft and are easily grooved.
Always make sure that the patient’s cheeks and lips are properly retracted so that they are not traumatized by the revolving bristle brush.
Bristle brushes should only be used on sound enamel.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 20

21. Abrasives
Dental abrasives (polishing materials) are used to remove stain and to polish natural teeth, prosthetic appliances, restorations, and castings.
They are available in extra coarse, coarse, medium, fine, and extra fine grits. The coarser the agent, the more abrasive the surface.
Even a fine-grit agent removes small amounts of the enamel’s surface.
The goal is to always use the abrasive agent that will produce the least amount of abrasion to the tooth surface.
In choosing the appropriate abrasive, the dental assistant must try to select the one that will be the least harmful to the enamel or restorative surface while still providing enough abrasion to remove the targeted stain and plaque.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 21

22. Factors That Influence the Rate of Abrasion
The more agent used, the greater the degree of abrasion.
The lighter the pressure, the less abrasion.
The slower the rotation of the cup, the less abrasion.
Using a fulcrum on a nearby tooth will help the operator control the amount of pressure used.
Rheostats have varying sensitivities. Test the sensitivity of the rheostat in controlling the handpiece speed outside of the mouth and away from the patient first.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 22

23. Chapter 58
Lesson 58.2
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 23

24. Learning Objectives
Describe the types of abrasives used for porcelain aesthetic restorations.
Name materials to avoid when polishing aesthetic restorations.
Describe the technique for polishing aesthetic restorations.
Demonstrate the handpiece grasp and positioning for the prophy angle.
Demonstrate the fulcrum or finger rest used in each quadrant during a coronal polishing procedure.
(Cont’d)
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 24

25. Learning Objectives
(Cont’d)
Demonstrate the proper seating positions for the operator and the assistant during a coronal polishing procedure.
Demonstrate safety precautions to be taken during coronal polishing.
In states where it is legal, demonstrate coronal polishing technique.
Complete coronal polishing without causing tissue trauma.
Be able to determine that the teeth are free of stains and plaque.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 25

26. Polishing Esthetic Type Restorations
Many patients have crown and bridge restorations and are having cosmetic resin, composite, bonding, and veneers placed to enhance their smiles.
Improper oral care can quickly damage many of these types of restorations.
Coarse polishing paste, use of acidulated phosphate fluorides, and even hard brushing with abrasive toothpaste can be destructive to the surfaces of restorative materials.
A diamond, aluminum oxide, or low-abrasion toothpaste should be used for these restorations.
Should indirect and direct aesthetic restorations be polished first? If the answer is yes, why?
Removal of some exogenous sources of staining, in addition to plaque, from these restorations may not be effectively accomplished by means of polishing.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 26

27. Fig. 58-8 A, It can be difficult to detect esthetic restorations
Fig A, It can be difficult to detect esthetic restorations. Two of these teeth have crowns. (Courtesy of Dr. Peter Pang, Sonoma, Calif.)
Teeth 8, 9, and 10 show moderate gingival recession. Avoid polishing the exposed root cementum.
Although they are well disguised, gingival recession makes aesthetic restorations to teeth 8 and 9 more noticeable. These restorations should be polished with the use of a low-abrasion polish.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 27

28. Polishing Strokes
Fill the polishing cup with the polishing agent and spread it over several teeth in the areas to be polished.
Establish a finger rest and place the cup almost in contact with the tooth.
The stroke should reach from the gingival third to the incisal third of the tooth.
Using the slowest speed, lightly apply the revolving cup to the tooth surface for 1 or 2 seconds.
Use light pressure to make the edges of the polishing cup flare slightly.
Use a patting, wiping motion and an overlapping stroke.
It is very important for the dental assistant to place the fulcrum finger close to the tooth on which he or she is working for better control of the handpiece.
The cup should be flared to adapt to contours, especially in the interproximal areas where most plaque and stain tends to build up.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 28

29. Fig. 58-9 Close-up of hand with handpiece and proper grip.
Notice that proper infection control technique, including covering the cuffs of the laboratory coat with the gloves, is being used.
What type of prophy angle is shown in this photograph?
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 29

30. Fig. 58-10 Use overlapping strokes to ensure complete coverage of the tooth.
This diagram of a molar demonstrates multiple overlapping strokes, always initiated gingivally and directed occlusally.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 30

31. Fig. 58-11 Stroke from the gingival third with just enough pressure to cause the cup to flare.
This photograph demonstrates proper flaring of the prophy cup.
Remnants of disclosing solution may be seen on the maxillary labial mucosa.
What is being used to retract the cheek? (Dental mouth mirror.)
What tooth is the fulcrum on? (The canine.)
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 31

32. Positioning the Patient
Adjust the dental chair so that the patient is approximately parallel to the floor with the back of the chair raised slightly.
Adjust the headrest for patient comfort and operator visibility.
For the mandibular arch, position the patient's head with the chin down. When the mouth is open, the lower jaw should be parallel to the floor.
For access to the maxillary arch, position the patient's head with the chin up.
Positioning the mandibular arch parallel to the floor when open for instrumentation purposes allows for better placement of the light and for direct vision in some areas.
Positioning the maxillary arch for instrumentation with the chin up almost places the maxilla perpendicular to the floor, allowing better light placement and access for instrumentation.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 32

33. Fig For the mandibular arch, the patient’s head is positioned so that the lower jaw is parallel to the floor when the mouth is open.
This photograph depicts the recommended placement of the head when the maxillary arch is being polished.
Notice that the chin is directed upward and the maxilla is almost perpendicular to the floor.
Notice that the patient is wearing safety glasses to protect her from any potential splatter from the polishing agent. There is also a headrest covering.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 33

34. Fig. 58-13 For access to the maxillary arch, position the patient’s head with the chin up.
Polishing of what arch requires this head positioning? (Mandibular arch.)
Notice that the mandible has been placed parallel to the floor.
This permits ideal instrumentation and illumination.
A patient napkin is present to protect the patient’s clothes from debris.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 34

35. Fig. 58-14 The right-handed operator is seated at the 9 o’clock position.
Remember that the operator may rotate from the 8 o’clock through the 12 o’clock position as appropriate during treatment.
What position would the left-handed operator take?
Notice that the operator has placed the patient at her waist level.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 35

36. The Handpiece Grasp
The handpiece and prophylaxis angle are held in a pen grasp with the handle resting in the V-shaped area of the hand between the thumb and index finger.
Proper grasp is important because if the grasp is not secure and comfortable, the weight and balance of the handpiece can cause hand and wrist fatigue.
A proper grasp is important for control of the handpiece and the pressure that is exerted on each tooth.
Ask students to practice this pen grasp with a fulcrum with the pens they are using to take notes in class.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 36

37. Fig Handpiece grasp.
This is a photograph of the proper hand grasp for a right-handed operator.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 37

38. Handpiece Operation
The rheostat (foot pedal) controls the speed (revolutions per minute) of the handpiece.
The toe is used to activate the rheostat. The sole remains flat on the floor.
Apply a steady pressure with the toe on the rheostat to produce a slow, even speed.
Use a low-speed handpiece that operates to a maximum of 20,000 rpm.
Release the rheostat to prevent debris from splattering when the handpiece is removed from the tooth for more than a moment.
Make sure that the rheostat is placed conveniently close so it can be reached with the foot. If the rheostat is placed too far away, the operator will have to strain to reach it.
Release the rheostat between teeth to ensure that the revolving prophy cup or brush tip is not caught on a patient’s intraoral soft tissues.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 38

39. The Fulcrum/Finger Rest
The fulcrum provides stability for the operator and must be placed in such a way as to allow for movement of the wrist and forearm.
The fulcrum is repositioned throughout the procedure as necessary.
The fulcrum may be either intraoral or extraoral, depending on a variety of circumstances such as:
The presence or absence of teeth
The area of the mouth being polished
How wide the patient can open his or her mouth
The operator should always try to position the fulcrum close to the tooth being worked on.
The operator should be sure to change the fulcrum position as needed with each tooth so as not to strain his or her fingers and to provide the best support possible to the handpiece.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 39

40. Positioning of the Operator
The operator should keep his or her feet flat on the floor and the thighs parallel to the floor.
The operator's arms should be at waist level and even with the patient’s mouth.
When performing a coronal polish procedure, the right-handed operator generally begins by seating himself or herself in an 8 to 9 o’clock position.
When performing a coronal polish procedure, the left-handed operator generally begins by seating himself or herself in the 3 to 4 o’clock position.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 40

41. The Sequence of Polishing
Full mouth coronal polishing must be performed in a predetermined sequence to be certain that no area is missed.
The best sequence is based on the operator's preference and the individual needs of the patient.
Aesthetic and porcelain restorations should be polished first, after which the remaining teeth may be polished with the use of the appropriate methods for any stain that is present. This reduces the possibility that a coarse abrasive will remain in the rubber cup when aesthetic restorations are being polished.
The positions and fulcrums described in the following slides are for a right-handed operator.
It is best to complete one arch before the other, if possible, because of the different headrest adjustments that are needed.
It is also recommended that all buccal or lingual surfaces of one quadrant or sextant be polished before the dental assistant advances to the next surface, because the various surfaces require different positioning.
Remember to polish the aesthetic restorations first, with the finer polishing agent, before completing the rest of the mouth.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 41

42. Setup for Coronal Polishing
This photograph illustrates some of the disposable materials that should be available for coronal polishing.
What is shown in this photograph?
What are some of the other materials that would be desirable for this procedure?
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 42

43. Patient Preparation
Check the patient's medical history for any contraindications to the coronal polishing procedure.
Seat the patient and and him or her with a waterproof napkin. Ask the patient to remove any dental prosthetic appliances he or she may be wearing. Provide the patient with protective eyewear.
Explain the procedure to the patient and answer any questions.
Inspect oral cavity for lesions, missing teeth, tori, and so on.
Apply a disclosing agent to identify areas of plaque.
If a patient is wearing a removable denture or partial plate, this may be a good time to offer a complimentary cleaning of the prosthesis by placing it in the ultrasonic cleaner.
“Always inform before you perform.” The dental assistant should report any suspicious intraoral lesions to the dentist. Some lesions may need further follow-up, and others may be contraindications to coronal polishing at that time.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 43

44. Application of a Disclosing Agent
Once this solution is rinsed off, tooth surfaces bearing plaque will remain stained, resulting of better visibility of areas needing attention.
This also serves as a tool for patient education: The dental assistant can have the patient look in a hand mirror while showing him or her the areas with plaque buildup that should receive more attention during home care.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 44

45. Maxillary Right Posterior Quadrant, Buccal Aspect
Sit in the 8 to 9 o’clock position.
Have the patient tilt his head up and turn slightly away from you.
Hold the dental mirror in your left hand. Use it to retract the cheek or for indirect vision of the more posterior teeth.
Establish a fulcrum on the maxillary right incisors.
The following slides follow Procedure 58-1 in the textbook and offer one example of a sequence that may be used for systematic coronal polishing by the right-handed operator.
The mirror is used for cheek retraction because the buccal surfaces of the right maxilla can usually be seen by means of direct vision.
The dental assistant should be positioned for the best possible comfort, control, and visibility.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 45

46. Polishing the Buccal Surfaces of the Maxillary Right Quadrant
Notice the disclosing agent that remains, highlighting areas of plaque or tooth structure that naturally attract plaque or stain.
Be sure to warn the patient if you will be using a disclosing agent. Some patients may not want it to be used because it may stain other oral tissues for a few hours after the appointment, which may not be desirable in their activities for that day.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 46

47. Maxillary Right Posterior Quadrant, Lingual Aspect
Remain seated in the 8 to 9 o’clock position.
Have the patient turn his head up and toward you.
Hold the dental mirror in your left hand. Direct vision in this position and the mirror provides a view of the distal surfaces.
Establish a fulcrum on the lower incisors and reach up to polish the lingual surfaces.
Only slight adjustments are needed to move next to the maxillary right posterior lingual surfaces.
The patients should be asked to turn his or her head toward the operator.
Use of the mirror will help with indirect vision, especially of the posterior surfaces. The operator may need to redirect the light source as well.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 47

48. Maxillary Anterior Teeth, Facial Aspect
Remain in the 8 to 9 o’clock position.
Position the patient’s head tipped up slightly and facing straight ahead. Make necessary adjustments by turning the patient's head slightly either toward or away from you.
Use direct vision in this area.
Establish a fulcrum on the incisal edge of the teeth adjacent to the ones being polished.
The operator should remember to add more polishing agent as needed and to be careful not to harm the gingiva.
Some operators may wish to operate from the 11 o’clock to 12 o’clock position for this area.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 48

49. Polishing the Facial Surfaces of the Maxillary Anterior Teeth
Notice that the operator has established a fulcrum on an adjacent incisor.
Notice the remnants of the disclosing solution.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 49

50. Maxillary Anterior Teeth, Lingual Aspect
Remain in the 8 to 9 o’clock position or move to the 11 to 12 o’clock position.
Position the patient’s head so that it is tipped slightly upward.
Use the mouth mirror for indirect vision and to reflect light on the area.
Establish a fulcrum on the incisal edge of the teeth adjacent to the ones being polished.
The most noticeable difference for the lingual aspect of the maxillary teeth is that indirect vision with the mirror is needed.
The operator should be aware of a variety of developmental lingual pits in the cingulum areas of these teeth, which tend to trap stain and plaque.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 50

51. Polishing the Lingual Surfaces of the Maxillary Anterior Teeth
Notice the use of the mirror for indirect vision.
Notice the fulcrum on the upper right first premolar.
Light should be redirected for optimal illumination.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 51

52. Maxillary Left Posterior Quadrant, Buccal Aspect
Sit in the 9 o’clock position.
Tip the patient's head upward and turn it slightly toward you to improve visibility.
Use the mirror to retract the cheek and for indirect vision.
Rest your fulcrum finger on the buccal occlusal surface of the teeth toward the front of the quadrant.
Alternative: Rest your fulcrum finger on the lower premolars and reach up to the maxillary posterior teeth.
The patient’s head should be tipped slightly toward the operator when the operator is polishing surfaces that are located opposite the operator.
The patient’s napkin should be secured to adequately cover his or her shirt during polishing to avoid unnecessary staining of the patient’s clothes.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 52

53. Maxillary Left Posterior Quadrant, Lingual Aspect
Remain in the 8 to 9 o’clock position.
Have the patient turn his or her head away from you.
Use direct vision in this position. Hold the mirror in your left hand and use for a combination of retraction and reflecting light.
Establish a fulcrum on the buccal surfaces of the maxillary left posterior teeth or on the occlusal surfaces of the mandibular left teeth.
The patient should turn away from the right-handed operator when the operator polishes surfaces that face the operator.
What are all of the posterior surfaces that face a right-handed operator when the operator is seated in the 9 o’clock position?
What are all of the posterior surfaces that face away from a right-handed operator when the operator is seated in the 9 o’clock position?
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 53

54. Mandibular Left Posterior Quadrant, Buccal Aspect
Sit in the 8 to 9 o’clock position.
Have the patient turn his or her head slightly toward you.
Use the mirror to retract the cheek and for indirect vision of distal and buccal surfaces.
Establish a fulcrum on the incisal surfaces of the mandibular left anterior teeth and reach back to the posterior teeth.
How would operator and patient positioning change for a left-handed operator polishing these surfaces?
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 54

55. Mandibular Left Posterior Quadrant, Lingual Aspect
Remain in the 9 o’clock position.
Have the patient turn his or her head slightly away from you.
For direct vision, use the mirror to retract the tongue and reflect more light to the working area.
Establish a fulcrum on the mandibular anterior teeth and reach back to the posterior teeth.
When polishing the mandibular lingual surfaces, the operator may wish to place a saliva ejector in the area. Saliva tends to pool in these areas during polishing and dilutes the polishing agent or makes the area too slippery to polish.
The operator may also wish to polish the most posterior teeth first immediately after suctioning the area, moving anteriorly thereafter.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 55

56. Polishing the Lingual Surfaces of the Mandibular Left Quadrant
This operator has chosen a fulcrum position on the mandibular left lateral incisor area.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 56

57. Mandibular Anterior Teeth, Facial Aspect
Sit in either the 8 to 9 o’clock position or in the 11 to 12 o’clock position.
As necessary, instruct the patient to make adjustments in head position by turning either toward or away from you or by tilting his head up or down.
Use your left index finger to retract the lower lip. Both direct and indirect vision can be used in this area.
Establish a fulcrum on the incisal edges of the teeth adjacent to the ones being polished.
The operator can retract the lower lip with the use of a square piece of gauze.
Be sure to establish a stable fulcrum and modify it as necessary.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 57

58. Mandibular Anterior Teeth, Lingual Aspect
Sit in either the 8 to 9 o’clock position or at the 11 to 12 o’clock position.
As necessary, instruct the patient to make adjustments in head position by turning either toward or away from you or by tilting the head up or down.
Use the mirror for indirect vision, to retract the tongue, and to reflect light onto the teeth. Direct vision is often used in this area when the operator is seated in the 12 o’clock position, but indirect vision can also be helpful.
Establish a fulcrum on the mandibular cuspid incisal area.
Depending on the lingual inclination of a patient’s mandibular anterior teeth, direct vision may not be possible even with the operator seated at the 12 o’clock position.
This area of the mouth tends to see the accumulation of much stain and plaque.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 58

59. Polishing the Lingual Surfaces of the Mandibular Anterior Teeth
Notice that a fulcrum is placed on the adjacent teeth for stability while a finger from the opposite hand helps retract the lower lip.
Retraction of the lower lip also aids transillumination of the tooth.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 59

60. Mandibular Right Quadrant, Buccal Aspect
Sit in the 8 o’clock position.
Have the patient turn his or her head slightly away from you.
Use the mirror to retract tissue and reflect light. The mirror may also be used to view the distal surfaces in this area.
Establish a fulcrum on the lower incisors.
A right-handed operator should remember to have patients turn their heads away slightly for better visibility and access.
What will change in the positioning of an operator and the positioning of the patient when the operator completes these surfaces and prepares to polish the lingual surfaces?
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 60

61. Polishing the Mandibular Right Quadrant, Buccal Aspect
A fulcrum is placed more anteriorly.
The mirror is being used for retraction of the cheek.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 61

62. Mandibular Right Quadrant, Lingual Aspect
Remain in the 8 o’clock position.
Have the patient turn his or her head slightly toward you.
Retract the tongue with the use of the mirror.
Establish a fulcrum on the lower incisors.
Suction may be required when the mandibular lingual surfaces are being polished, because saliva tends to accumulate in this area.
High-speed suction may be used to simultaneously retract the tongue and provide suction if the mirror is not needed for indirect vision.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 62

63. Flossing After Coronal Polishing
Dental floss and tape have two purposes after coronal polishing.
The first is to polish the interproximal tooth surfaces.
The second is to remove any abrasive agent or debris that may be lodged in the contact area.
Place abrasive on the contact area between the teeth and work the floss or tape through the contact area, using a back-and-forth motion.
A floss threader can be used to pass the floss under any fixed bridgework to gain access to the abutment teeth.
Be sure to ask the patient whetherhe or she can feel any remaining polish between the teeth.
If a patient had a tremendous amount of plaque between his or her teeth, this may be a good time to review the proper use of floss.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 63

64. Evaluation of Polishing
There is no remaining disclosing agent on any of the tooth surfaces.
The teeth are glossy and reflect light from the mirror uniformly.
There is no evidence of trauma to the gingival margins or any other soft tissues in the mouth.
Some operators wish to reapply the disclosing agent after polishing to see whether any plaque remains that requires additional polishing before dismissal of the patient.
Ask the patient to run his or her tongue over the surfaces of the teeth to feel the difference after polishing.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 64

65. Patient Instructions
Most patients are self-conscious about stains on their teeth and appreciate any tips you can give them on how to keep their teeth as white as possible.
It is important to educate patients about the causes of stains.
When stains are intrinsic, the dentist may want you to discuss possible cosmetic dental care options to satisfy their desire for attractive and stain-free teeth.
Have the dentist discuss other alternatives, such as at-home vital bleaching, that may help the aesthetically conscious patient achieve whiter teeth.
Many patients do not realize how some foods, drinks, and tobacco contribute to initial extrinsic tooth staining. Educate the patient about these issues.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 65