Do you recommend polishing or not?

RE: To polish or not to polish?

Evelyn Barbour-Hill — Tue, 12 May 2020 16:52:22 GMT

[quote userid="2235" url="~/001/veterinary-clinical/small-animal/dentistry/f/expert-help/29063/to-polish-or-not-to-polish/222219"]This is such a good question that a whole edition of the BVDA journal was dedicated to it a couple of years ago. If you ask very nicely Evelyn Barbour-Hill may be able to supply with with a copy for a modest fee....[/quote]

All copies printed are long gone. However I still have the Quark Express document on the computer, so if you are interested I could email it to you as a set of pdfs. It would be my pleasure. I just need your email address. PM me if you like.

RE: To polish or not to polish?

Evelyn Barbour-Hill — Tue, 12 May 2020 16:12:51 GMT

I suspect polishing is going to be one of those controversial subjects that chronically infest fora.

We do need to be clear about what we are trying to achieve with polishing, if we do it.

Let us be quite clear, polishing the crown of the tooth more than a millimetre above the gum line is entirely cosmetic. Nothing wrong with a bit of cosmesis, but be honest with yourself about it

It always used to be said that the object of polishing was to remove the scratches left by the scaler. Well, perhaps in the days of relatively crude ultrasonic scalers or hand scaling with horrible triangular "tartar scrapers", it did do that. Certainly there were electron micrographs that purported to demonstrate it. But scaling is, with good modern devices like the Odontoson (I can't say about the cheap ones, I haven't used them for thirty-odd years) now much more scientific, refined and gentle and shouldn't damage enamel. Such modern electron microscopy studies as I have seen, and there don't seem to be many, don't suggest so.

As Rachel says, if you were polishing out scratches you would need to remove enamel to the depth of the scratches: highly unwise in the dog or cat which have very thin enamel compare with the human.

Then if you are polishing with a fine softish paste you won't remove scratches anyway.

However I do believe that polishing near and below the gum line does have some benefits by smoothing the surface of minor irregularities, microscopic tartar remnants and so on. And a dog or cat should, if the veterinary surgeon is doing a good job, be getting a "scale and polish" maybe twice in its whole life. The idea of the "routine annual dental" is to be condemned.

I also believe that polishing the teeth of the cat, or the smaller ones of the dog, with a human-size polishing cup (and there is no other size!) is probably pretty ineffective except on the more prominent bits, even though it makes the operator feel good.

Yes, I do polish most teeth more often than not.,because every little I can do to help plaque control has got to be good. But I don't lose any sleep if I don't polish. I don't polish in the vicinity of any completed surgery, because I certainly don't want paste working its way into incisions.

RE: To polish or not to polish?

Rachel Perry — Tue, 05 May 2020 12:31:37 GMT

In the majority of patients, but not all

RE: To polish or not to polish?

Rob Davis — Tue, 05 May 2020 11:09:45 GMT

[quote userid="2161" url="~/001/veterinary-clinical/small-animal/dentistry/f/expert-help/29063/to-polish-or-not-to-polish/222272"] There are no health benefits to routine scaling and polishing - see the Cochrane systematic review:here[/quote]

Can we just clarify that the above review shows no health benefits to scaling and polishing in human patients with no severe periodontitis who were regular attenders at dental appointments. This is a group of people with relatively good oral health who are likely to be performing regular homecare to a level we can only dream of in our patients. I would hate anybody to get the impression that scaling is not useful in our patients. I would agree that a blanket policy of advising annual "prophies" for all patients is probably inappropriate.

Do you routinely polish, Rachel? (your patients, not yourself..)

RE: To polish or not to polish?

Rachel Perry — Tue, 05 May 2020 10:31:47 GMT

That's great comment about speed, Paul. It's difficult for us to know the difference between 15000 and 30000 rpm in practice unless you have a fancy unit which tells you the exact speed. Bearing in mind most practices won't, then the pitch is a useful indicator. When I teach this in practicals, I alter the speed and ask delegates to tell me what speed to polish at. Most can detect the correct pitch. Think cat purring, not cat screaming! If in doubt, practice polishing your fingernail- it shouldn't hurt. If it does (and you will know within a second), it's too fast.

RE: To polish or not to polish?

Paul Cooper — Tue, 05 May 2020 10:26:19 GMT

I would add to Rachel's point that although plaque will build up again quickly, by not polishing we are making a subjective judgement on our client's willingness/ ability to institute homecare after the dental procedure. We should always aim to do the best for our patients, and then educate them about the on-going maintenance required (preferably BEFORE the procedure!). Do not assume they will not start homecare, even if they have not so far. How can we expect clients to brush teeth if we do not give them the best start. I have often been surprised at the number of clients who do actually brush their pets teeth, even if only to avoid another bill for further dental work in the future.

Most veterinary practices use an air motor to run a 'prophy angle' to polish teeth. Virtually none know how to alter the speed (and direction) using the knurled ring at the base of the air motor - in some practices the ring is immoveable due to years of gunge building up and never being used! Please turn the speed of these air motors down - they run at 30,000rpm at full speed, polishing should never be more than 15,000, and some experts recommend even slower.

The other advantage of polishing is as a final check of the mouth, once you think all the calculus has been removed, and extractions performed. It allows you to properly check each tooth as you polish, and especially after the final rinse.

RE: To polish or not to polish?

Rachel Perry — Tue, 05 May 2020 07:27:33 GMT

Before we answer the question about whether we should or not, it's important to think about the purpose of polishing. The reasons for polishing have been misunderstood and twisted by the veterinary profession. Do a literature search on polishing human teeth and nowhere will you see reference to damage from scaling equipment miraculously rectified by polishing. If you think about that, in order to make the enamel surface smooth, you would need to remove enamel to the depth of the deepest defect which is not feasible nor desirable.

Polishing removes dental deposits (pellicle [the first layer to stick to a clean tooth surface], plaque and calculus) and therefore exogenous dental stain (from coffee, tea and wine drinking). It also does make the tooth surface smooth- by using a fine abrasive material scratches are formed in the enamel which are smaller than the wavelength of visible light, and therefore the tooth surface looks glossy, smooth and lustrous. Patients like this feeling and look. A dentist or hygienist would remove stain with a medium or coarse paste, and then finish with a fine or very fine paste ( a bit like sanding wood)

There has been a lot of debate over decades about routine scaling and polishing and selective polishing. There are no health benefits to routine scaling and polishing - see the Cochrane systematic review:here

So, seeing as our patients don't suffer from stain, we can argue that we are primarily performing the procedure to remove plaque. This will last less than 48hrs before a mature biolfim has built up again. Is it worth it then?

We could argue no, but are we doing our best for our patients if we don't attempt to remove all dental deposits? What about if you are charging a client for "scaling and polishing" and then only doing the scaling part? What about if the client expects you to polish their pet's teeth? Informed consent comes into this argument.

If you are going to polish teeth it is vital that you do it properly- FINE paste! Light touch, short amount of time, oscillating cups are great, but otherwise a SOFT cup (not the hard white ones)

The anecdotal statement I hear a some vets state is that once you start to scale and polish you have to do it more regularly, so why bother is probably a reflection of the procedure carried out. Inappropriate scaling causing scratched on enamel and inappropriate polishing using a coarse paste, creating more scratches. Which will inevitably lead to faster and thicker biolfilm accumulation.

RE: To polish or not to polish?

Bob Partridge — Mon, 04 May 2020 18:06:04 GMT

Rob covers the points well.

Polishing does have its detractors - personally I think the benefits outweigh the disadvantages as it should reduce retention centres for plaque post dental. The oscillating heads have the disadvantage of being 90' angle, whereas most other polishers are easier to position. That being said I have been won over to them (avoids having a Yorkie spinning around when you trap the hair!).

Simply bathing/rinsing the mouth post polishing will give little penetration subgingivally, 3-Way syringe will penetrate 30-50% of sulcular depth, water pick will give 70%.

If you are using SANOS - then need to use a non-fluoride paste & also dry the sulcus.

RE: To polish or not to polish?

Rob Davis — Sat, 02 May 2020 07:48:58 GMT

This is such a good question that a whole edition of the BVDA journal was dedicated to it a couple of years ago. If you ask very nicely Evelyn Barbour-Hill may be able to supply with with a copy for a modest fee....

In our patients the main reason for polishing is to remove the microscopic imperfections left on the enamel surface after scaling. The smoother we leave the enamel, the less plaque-retentive it will be. In humans polishing is also considered important for cosmetic purposes, but this is not really a significant consideration for out patients.

BUT polishing is not entirely benign even if performed correctly. The intention is to remove a small amount of enamel, and enamel is not replaced once the tooth has erupted. There are concerns in human dentistry that repeated polishings over many years may end up causing clinically significant thinning of the enamel. While I don't think there is any documented evidence for this occurring in cats or dogs to date, it is at least a theoretical concern. Our patient's enamel is much thinner than our own (0.1-0.6mm in dogs and 0.1-0.3 in cats vs 2-4mm in people!) so it is certainly possible that over-polishing could result in clinically significant enamel thinning.

I addition it is quite easy to perform polishing badly - too high rpm, too much pressure, staying on one area for too long, insufficiently wet prophy paste will all increase heat build up, and dental pulp is sensitive to thermal damage, so care needs to be taken.

My personal recommendations would be:

use oscillating prophy head rather than rotating -> less heat build up, doesn't snag on hair etc. Not everybody likes these, but I do.
always use fine grit prophy paste - medium or course will remove too much enamel and will leave a less smooth surface
most prophy pastes are too dry so add water from the 3-way syringe before using - should be a "slurry"
apply sufficient pressure to flare cup so that the edge polishes subgingivally - use soft cups so pressure required isn't too high.
keep the polisher head moving and don't spend too long on any single area.
Ensure you flush the sulcus afterwards - 3-way syringe works well. I tend to use chlorhexidine, but water is fine if you don't have a CLS bottle on your dental machine.