Review of Symptoms
- Vital signs
- Blood pressure: 140/86 mmHg
- Pulse: 74 beats/min
- Respiration: 15 breaths/min
The medical history reveals weight gain over the past two years and an increase in BP over the last six months. The patient is not on medication for high blood pressure. Currently the patient is seeing her physician to monitor blood pressure and has increased walking and began a low carbohydrate diet one month ago. She and her physician are hoping to lower blood pressure through a healthier lifestyle. The patient takes over‐the‐counter (OTC) medication for osteoarthritis in her right knee.
The patient has never smoked. She drinks two to three glasses of white wine, or a beer on weekends, and drinks two to three cups of tea daily
No significant findings
The intraoral exam reveals a slightly enlarged uvula and localized gingival recession of 2 mm on teeth #6, #22, and #27. Periodontal charting was completed and reveals two areas of probing depths 4 mm or greater, #1 with a distal‐lingual reading of 5 mm and #16, mesial‐lingual with a reading of 5 mm.
Dental examination reveals a Class III distal composite and Class IV mesial‐incisal chip on tooth # 8 (see Figure 8.2.1), tooth #9 presents with a Class IV mesial‐incisal composite with, mesial‐incisal fracture, and irregular margins and a Class III distal composite with irregular margins and excess composite
The patient presents with generalized stain, most evident on lingual and facial surfaces of anterior teeth.
The patient’s oral hygiene is good. She brushes twice daily, and flosses once daily.
Class I occlusion, with a slight overbite
Four bitewings were prescribed and one periapical was prescribed of teeth #8 and #9. Tooth #8 reveals NSF in regards to caries, tooth 9 reveals a Class IV Mesial incisal with mesial incisal chip with no recurrent caries, the CL III distal presents with excess composite and rough margins (see Figures 8.2.2).
Diagnosis and Prognosis
The patient’s general oral health is good. Localized inflammation is present in the areas of teeth #1 and #16.
Gingival recession present on teeth # 6, #11, and #22
Teeth present with moderate yellow extrinsic stain due to age, tea, and wine
Some localized brown extrinsic stain on mandibular lingual of anterior teeth and occlusal of posterior teeth due to tea drinking
Dental Hygiene Diagnosis
|Problems||Related to Risks and Etiology|
|#8 Class IV mesial‐incisal composite with mesial fracture||Sharp edge on incisal, further loss of tooth structure|
|# 9 Class IV mesial‐incisal fractured composite with irregular margins||open margin, future recurrent caries, biofilm, excess material not removed, improper finishing, and polishing of restoration,|
|#9 Class III, distal composite with irregular margins and excess composite||open margin, future caries, loss of tooth structure, biofilm, excess material not removed, improper finishing and polishing of restoration,|
|Gingival recession on #6, #11, and #27||Use of medium toothbrush utilizing scrubbing technique|
|Bleeding on probing||Localized periodontal disease, difficulty removing biofilm in maxillary third molar areas|
|5 mm periodontal pockets on #1 and #16||Localized periodontal disease, difficulty removing biofilm in maxillary third molar areas|
|Generalized and localized staining||Tea and wine consumption|
|Clinical||Educational/Counseling||Oral Hygiene Instructions|
|Evaluate soft and hard tissue
Localized scaling and root
planing with 4 to 6 week periodontal re‐evaluation
After localized SRP, prophy with polishing to remove extrinsic stain
Refer to DDS for Tooth #8, placement of Cl IV mesial‐incisal composite, #9, Cl IV mesial‐incisal re‐do of composite, possible future laminates
Smooth and polish #8 Cl III distal to determine that margins are sealed,
finish and polish restoration, removal of excess composite distal #9
|Encourage brushing daily and flossing once daily, avoid further gingival recession through use of soft bristle toothbrush and proper technique
Stress importance of maintaining recare visits, continued flossing daily and brushing twice daily
Reduce tea consumption, increase brushing to three times daily
Instruct patient that whitening should be done before redo of composite, since composite restorations will not whiten. Recommend use of dentifrice containing evidence based desensitizing agents (potassium nitrate, calcium sulfate) beginning 3 weeks before in–office whitening procedure and continued for 2 weeks after
While resin and porcelain restorations are both durable and esthetic, care of esthetic restorations is still critical to enhance durability, function, and esthetics
minimize attachment of bio‐film and enhance esthetics of restoration
|Soft bristle brush/ Modified Bass technique, Modified Stillman technique in areas of recession
Emphasize importance of flossing and accessing third molar areas when brushing and flossing
OTC whitening dentifrice with fluoride, after consuming tea and wine, rinse mouth with water
Do not eat or drink for 1 hour after, avoid anything that can stain a white t‐shirt for 1 week, reduce tea and wine intake, rinse mouth with water after consuming any foods with color
Avoid biting into hard foods such as apples, instead, cut into smaller pieces to avoid fracture of resin/porcelain materials
Emphasize use of soft bristle brush on teeth with restorations, utilizing Modified Bass technique
Discussion: Polishing Restored and Natural Teeth
Should we polish or not, and if yes, what should we use? These are the questions asked so often and discussed by many dental professionals. If you were to do a literature review you would find a variety of opinions and thoughts on the topic as related to the polishing of natural teeth, as a final step in dental prophylaxis, or as a necessary step in the finishing of a resin based restoration. Perhaps the following section will shed some light and address/answer your concerns and questions.
Polishing of Natural Teeth, Polishing vs Cleaning Agents
“Polishing” of natural teeth is performed in conjunction with dental prophylaxis to remove any remaining stain and/or dental biofilm. Every patient is unique, and products used for stain or biofilm removal are not “one size fits all.”
The key point to keep in mind is that the least abrasive polishing agent or cleaning agent necessary to remove the remaining stains or biofilm is the product that should be used. If a very fine paste removes the stain, then that is all that is necessary.
Unlike traditional polishing paste, which contains irregularly shaped gritty particles, cleaning agents are made of nonabrasive particles, round, and flat in shape that do not scratch a surface and are able to produce a high luster. Because of their extremely low level of abrasion they can be used on natural teeth as well as restorations including implants. Cleaning agents are often made from a combination of feldspar, alkali, and aluminum silicates. The agent is mixed with water to create a slurry or flour consistency. For a patient who presents without stain, but feels that their prophy procedure has not been completed if a polishing procedure is not performed, a cleaning agent may be utilized (Barns 2013).
The use of cleaning and polishing agents for removal of stain and dental biofilm is a “selective procedure.” Polishing is “selective” in that the teeth that need to be polished and the cleaning or polishing agent used must be selected based on the patient’s individual needs (Barns 2013).
Polishing of Composite Restorations
As dental hygienists we are now caring for a population of patients who present with a scope of esthetic restorations, some which may be virtually undetectable. In fact, these restorations may look so natural; the only way to confirm that they are actually restorations will be by reviewing radiographs and the patient record (see Figures 8.2.1 and 8.2.2).
To be esthetically pleasing a composite restoration should be highly polished. This will make the restoration more lustrous and pleasing to the eye (those composites used today such as microfilled and nanofilled, are going to have the most esthetic appearance and will be most susceptible to polishing in achieving a highly lustrous finish).
A highly polished composite restoration however, has shown to provide other benefits besides enhanced esthetics; a decrease in accumulation of biofilm and reduction of staining of composite restorations has been noted (Mandikos 2007).
Some research also shows that roughness of a composite may be linked to the wear of the restoration, and by having a highly polished surface, wear incidence may be decreased (see Figure 8.2.1) (Mandikos 2007).
When a patient presents with composite restorations that exhibit stain, care should be taken to avoid roughening of the composite surface. Even a fine prophy paste can cause irregularities on the surface of a composite restoration. If necessary to remove surface stain, a cleaning agent such as a high‐quality flour of pumice can be used. Luster of the restoration can be brought back by use of fine and ultrafine composite polishing disks, or use of a diamond luster paste.
Polishing Porcelain Veneers
Porcelain veneers routinely should not need polishing (see Figure 8.2.3).
Should a patient present with veneers that appear to be stained, it should first be determined that the discoloration is in fact stain and not a defect within the veneer.
Veneers may be polished with a rubber cup and use of a fine prophy paste for stain removal.
A urethane dimethacrylate‐based point containing fine diamond powder or a ceramic finishing bur may also be utilized for polishing of the veneer (see Figure 8.2.4).
When polishing veneers, light pressure should always be used.
- For stain removal in pits and fissures of posterior teeth, prophy paste on a tapered polishing brush, instead of a rubber cup is very effective.
- When determining the presence and location of composite restorations in a patient’s mouth, light air should be utilized to dry teeth. In even the most esthetic restorations, it is easier to detect a margin on a dry tooth surface rather than wet.
- Use air and a mirror utilizing transillumination technique to check for defects within a porcelain veneer.