PREVENTION AND MANAGEMENT OF SCALE AND POLISH DAMAGE TO RESIN COMPOSITE RESTORATIONS NAIRN HF WILSON1 CHRISTOPHER D LYNCH2
BACKGROUND The use of resin composite in the restoration of, in particular, posterior teeth is increasing. This trend is set to continue, with the momentum-gathering shift towards minimal-intervention direct approaches to the restoration of diseased, damaged and worn teeth, and subsequent to the signing of the Minamata Convention, aimed, amongst other measures, at ‘phasing down’ the use of dental amalgam.1-3 As a result, members of the dental team should, it is suggested, give consideration to the prevention and management of the damage that routine scaling and polishing may cause to the margins and surfaces of restorations of resin composite, or indeed restorations of other tooth-coloured restorative systems. Such damage may compromise the aesthetic qualities and reduce the life expectancy of tooth-coloured restorations. This article focuses on the prevention and management of scale and polish damage to resin composite restorations.
Scaling Scaling, using hand or mechanical scalers, may cause clinically significant iatrogenic damage to the margins and surfaces of resin composite restorations. The extent and severity of this damage may, amongst other factors, depend on the nature of the composite forming the restoration, the type and condition of the scaling instrument, and the scaling technique employed. In removing deposits and related material in the vicinity of margins of composite restoration,
it is all too easy to inflict unnecessary damage to the restoration. As the effective edge or tip of a scaler approaches the margin of a resin composite restoration, the operating pressure should be reduced and the instrument drawn away to prevent it damaging the cavosurface margin and adjacent surface of the composite, possibly chipping a bevel finish or digging into the restoration surface or tooth-restoration interface, forming a defect which subsequently accumulates plaque and stains.
If a restoration is found to have flash excess, it is better to use some form of resin composite finishing instrument to carefully remove the ‘flash’, rather than use the scaler to chip, fracture or plane away the excess in what is typically a rather crude, haphazard manner. When such an approach is used to deal with flash excess, the restoration may be left with marginal steps and defects which may accumulate plaque and stains, often resulting in a marginal discolouration halo effect, affecting part or most of the cavosurface margin of the restoration. In the event of deposits extending over the margin and adjacent surface of a resin composite restoration, as may be seen in patients with extensive calculus build-up, a mechanical scaler should be used to carefully remove the unwanted material, avoiding contact with the surface of the restoration, wherever possible. If deposits resist removal from an underlying resin composite surface, it is better to remove them carefully with a composite finishing instrument than to persevere with a scaler, used with increasing vigour and operating pressure. If the margin or surface of an otherwise clinically satisfactory resin composite restoration is damaged during scaling, it may be refurbished or repaired, depending on the nature and extent of the damage. However, restoration replacement may be indicated in some cases.Obtaining consent from the patient should take account of such untoward effects.
Polishing 1
Nairn HF Wilson
Professor of Dentistry, King’s College London 2
Christopher D Lynch
Reader/consultant in Restorative Dentistry, School of Dentistry, Cardiff University
70
The use of an abrasive prophylaxis paste, applied on the surface of a composite restoration by means of a cup or stiff polishing brush, as may occur when attempting to, for example, remove recalcitrant stain, will cause surface roughening, usually in the form of multiple, overlapping scratches. Such roughening,
P R I M A R Y D E N TA L J O U R N A L
in addition to encouraging new stain deposition, reduces the reflectance of the composite surface, making the restoration look dull and possibly somewhat opaque, rather than aesthetically pleasing. Following scaling, teeth including composite restorations may be polished with prophylaxis paste, away from the margins and surfaces of the restoration, and by means of composite finishing and polishing systems in the vicinity of the restoration. If the use of such finishing and polishing systems is extended to include all of the exposed surfaces of the restoration, possibly dulled by erosion, overzealous use of an abrasive dentifrice or bleaching, this will have the added advantage of concurrent refurbishment of the restoration, as an adjunct to the outcome of the scaling and polishing procedure. Alternatively, if a prophylaxis paste with an abrasivity less than that required to scratch the surface of a composite is used, teeth and restorations may be simultaneously polished. However, the use of such a prophylaxis paste may be found to have certain limitations in removing stubborn residual tooth surface stains, and may not be effective in the refurbishment of composite restorations dulled in clinical service. If using both an abrasive prophylaxis paste and a less aggressive polishing agent to complete the scale and polish of teeth including composite restorations, it is important to carefully clean, or preferably replace, the polishing cup or brush, particularly between the use of the prophylaxis paste and the polishing agent. As may be found during the finishing of newly placed restorations of resin composite, the use of a composite
polishing system will, at best, remove superficial irregularities and defects only in the limiting layer of resin composite. To remove deeper irregularities and defects, as may be caused by injudicious scaling, contouring instruments must be used prior to polishing. If in the process of recontouring the restoration loses form and function, replacement of the restoration may be indicated. In this regard, special attention must be paid to restored proximal surfaces, particularly gingival margins and the adjacent root surfaces, which are especially prone to secondary caries.
Concluding remarks The margins and surfaces of resin composite restorations, in both anterior and posterior teeth, may be damaged in the process of routine oral healthcare maintenance, specifically during scaling and polishing. Such damage may be limited, if not prevented, by careful scaling and avoiding the use of an abrasive prophylaxis paste on the surfaces of the resin composite. Damage caused to a resin composite restoration during scaling and polishing may be corrected by means of refurbishment or repair techniques.
LETTER TO THE EDITOR Dear Sir, I enjoyed reading the article in your February issue on the often neglected role of the escort following intravenous sedation (Escorts’ Knowledge of their Duty of Care to Patients who have Undergone Intravenous Sedation). I would, however, wish to point out that the authors appear to have misunderstood one aspect of the 2003 Department of Health guidelines (Conscious Sedation in the Provision of Dental Care). As the authors of your article correctly write, the guidance states: “A responsible adult escort must accompany the patient home or to a suitable place of care after treatment under conscious sedation and assume responsibility for the post-sedation care for the rest of the day.” However, on page 68 the authors write: “One hundred per cent of escorts should… [l]ook after the patient for the next 24 hours, or have made arrangements for this to happen.” They go on to write: “Patients are required to be looked after by an adult for 24 hours following intravenous sedation” and quote the 2003 guidance as a reference. Clearly there is a discrepancy here. The 2003 guidance specifically states that the escort must look after the patient for “the rest of the day” which is somewhat different to looking after the patient for 24 hours following IV sedation. The Expert Group were, I believe, mindful of the difficulties in expecting an escort to look after someone for an entire 24-hour period, and the “rest of the day” guidance reflects this. I would appreciate it if this small but important clarification could be made in the next edition of the journal. Yours sincerely,
REFERENCES 1
2
3
United Nations Environment Programme. Minamata Convention Agreed by Nations. UNEP website. Available at: http://tinyurl.com/bkkekac. Accessed: 14 April 2014. Lynch CD, Wilson NHF. Managing the phase-down of amalgam (Part I): educational and training issues. Br Dent J 2013;215:109–113. Lynch CD, Wilson NHF. Managing the phase-down of amalgam (Part II): implications for practising arrangements and lessons from Norway. Br Dent J 2013;215:159-162.
V O L 3 N O 2 M AY 2 0 1 4
Robert Bland BDS MJDF MMedSci FFGDP(UK) Dear Dr Bland, Thank you for your comments regarding our paper. As you point out, the Standing Committee on Sedation for Dentistry’s guidelines do state that the patient escort must “assume responsibility for the post-sedation care for the rest of the day.” The standard set for the reported audit was based on our departmental protocol, where we ask patients to be cared for over a 24-hour period, and this should have been stated more clearly in the paper. William Thompson
71
n your k
ge owled
A Antimicrobial Presscribing
f General Dental Practitioners for
This essential text gives clearr,, simple sim mple and practical advice on when to prescribe, what to o prescribe, in what dose and for how long. Thiis publication is intended to complement the Dental P Practitioners’ ra actitioners’ Formularyy and will be reviewed regularly r and revised as new information becomes available. ailable. This new edition reflects changes to recom mmendations since the previous update. For the first tim me, this edition also includes dosage recommendations for children. This revised edition the leading authority uthority on prescribing for dental professionals, and is an invaluable asset to any dentist’s library.
!
No otice of
Ameendments
In its March 2014 update, the British National Formulary has amended the recommended ded amoxicillin dosages for children. These amendments are in addition to amendments made in Septtember 2013. The FGDP(UK) seeks to identify and inform members of all changes to the BNF that supersede the information in our published guidelines. Such changes are posted on the FGDP(UK) web w page for the book of Antimicrobial Prescribing for General Dental Practitioners; Practitioners; howeverr,, we also urge urrge members to check each update to the BNF as a matter of course. The recommended dosages are now: &KLOGPRQWKV PJWLPHVGDLO\ LQFUHDVHGLIQHFHVVDU\XSWRPJNJWLPHVGDLO\ &KLOG\HDUV PJWLPHVGDLO\ LQFUHDVHGLIQHFHVVDU\XSWRPJNJWLPHVGDLO\ &KLOG\HDUV PJWLPHVGDLO\ LQFUHDVHGLIQHFHVVDU\ U\XSWRPJNJ PD[J WLPHVGDLO\ &KLOG\HDUV PJWLPHVGDLO\ LQVHYHUHLQIHFWLRQJWLPHVGDLO\
For a q quick k and easy way to purcha ase p publications, visitt o our online o shop p via the Faculty y web bsite.
buyy on l ine
ww ww w.fgdp. f .org.uk
BACKGROUND The use of resin composite in the restoration of, in particular, posterior teeth is increasing. This trend is set to continue, with the momentum-gathering shift towards minimal-intervention direct approaches to the restoration of diseased, damaged and worn teeth, and subsequent to the signing of the Minamata Convention, aimed, amongst other measures, at ‘phasing down’ the use of dental amalgam.1-3 As a result, members of the dental team should, it is suggested, give consideration to the prevention and management of the damage that routine scaling and polishing may cause to the margins and surfaces of restorations of resin composite, or indeed restorations of other tooth-coloured restorative systems. Such damage may compromise the aesthetic qualities and reduce the life expectancy of tooth-coloured restorations. This article focuses on the prevention and management of scale and polish damage to resin composite restorations.
Scaling Scaling, using hand or mechanical scalers, may cause clinically significant iatrogenic damage to the margins and surfaces of resin composite restorations. The extent and severity of this damage may, amongst other factors, depend on the nature of the composite forming the restoration, the type and condition of the scaling instrument, and the scaling technique employed. In removing deposits and related material in the vicinity of margins of composite restoration,
it is all too easy to inflict unnecessary damage to the restoration. As the effective edge or tip of a scaler approaches the margin of a resin composite restoration, the operating pressure should be reduced and the instrument drawn away to prevent it damaging the cavosurface margin and adjacent surface of the composite, possibly chipping a bevel finish or digging into the restoration surface or tooth-restoration interface, forming a defect which subsequently accumulates plaque and stains.
If a restoration is found to have flash excess, it is better to use some form of resin composite finishing instrument to carefully remove the ‘flash’, rather than use the scaler to chip, fracture or plane away the excess in what is typically a rather crude, haphazard manner. When such an approach is used to deal with flash excess, the restoration may be left with marginal steps and defects which may accumulate plaque and stains, often resulting in a marginal discolouration halo effect, affecting part or most of the cavosurface margin of the restoration. In the event of deposits extending over the margin and adjacent surface of a resin composite restoration, as may be seen in patients with extensive calculus build-up, a mechanical scaler should be used to carefully remove the unwanted material, avoiding contact with the surface of the restoration, wherever possible. If deposits resist removal from an underlying resin composite surface, it is better to remove them carefully with a composite finishing instrument than to persevere with a scaler, used with increasing vigour and operating pressure. If the margin or surface of an otherwise clinically satisfactory resin composite restoration is damaged during scaling, it may be refurbished or repaired, depending on the nature and extent of the damage. However, restoration replacement may be indicated in some cases.Obtaining consent from the patient should take account of such untoward effects.
Polishing 1
Nairn HF Wilson
Professor of Dentistry, King’s College London 2
Christopher D Lynch
Reader/consultant in Restorative Dentistry, School of Dentistry, Cardiff University
70
The use of an abrasive prophylaxis paste, applied on the surface of a composite restoration by means of a cup or stiff polishing brush, as may occur when attempting to, for example, remove recalcitrant stain, will cause surface roughening, usually in the form of multiple, overlapping scratches. Such roughening,
P R I M A R Y D E N TA L J O U R N A L
in addition to encouraging new stain deposition, reduces the reflectance of the composite surface, making the restoration look dull and possibly somewhat opaque, rather than aesthetically pleasing. Following scaling, teeth including composite restorations may be polished with prophylaxis paste, away from the margins and surfaces of the restoration, and by means of composite finishing and polishing systems in the vicinity of the restoration. If the use of such finishing and polishing systems is extended to include all of the exposed surfaces of the restoration, possibly dulled by erosion, overzealous use of an abrasive dentifrice or bleaching, this will have the added advantage of concurrent refurbishment of the restoration, as an adjunct to the outcome of the scaling and polishing procedure. Alternatively, if a prophylaxis paste with an abrasivity less than that required to scratch the surface of a composite is used, teeth and restorations may be simultaneously polished. However, the use of such a prophylaxis paste may be found to have certain limitations in removing stubborn residual tooth surface stains, and may not be effective in the refurbishment of composite restorations dulled in clinical service. If using both an abrasive prophylaxis paste and a less aggressive polishing agent to complete the scale and polish of teeth including composite restorations, it is important to carefully clean, or preferably replace, the polishing cup or brush, particularly between the use of the prophylaxis paste and the polishing agent. As may be found during the finishing of newly placed restorations of resin composite, the use of a composite
polishing system will, at best, remove superficial irregularities and defects only in the limiting layer of resin composite. To remove deeper irregularities and defects, as may be caused by injudicious scaling, contouring instruments must be used prior to polishing. If in the process of recontouring the restoration loses form and function, replacement of the restoration may be indicated. In this regard, special attention must be paid to restored proximal surfaces, particularly gingival margins and the adjacent root surfaces, which are especially prone to secondary caries.
Concluding remarks The margins and surfaces of resin composite restorations, in both anterior and posterior teeth, may be damaged in the process of routine oral healthcare maintenance, specifically during scaling and polishing. Such damage may be limited, if not prevented, by careful scaling and avoiding the use of an abrasive prophylaxis paste on the surfaces of the resin composite. Damage caused to a resin composite restoration during scaling and polishing may be corrected by means of refurbishment or repair techniques.
LETTER TO THE EDITOR Dear Sir, I enjoyed reading the article in your February issue on the often neglected role of the escort following intravenous sedation (Escorts’ Knowledge of their Duty of Care to Patients who have Undergone Intravenous Sedation). I would, however, wish to point out that the authors appear to have misunderstood one aspect of the 2003 Department of Health guidelines (Conscious Sedation in the Provision of Dental Care). As the authors of your article correctly write, the guidance states: “A responsible adult escort must accompany the patient home or to a suitable place of care after treatment under conscious sedation and assume responsibility for the post-sedation care for the rest of the day.” However, on page 68 the authors write: “One hundred per cent of escorts should… [l]ook after the patient for the next 24 hours, or have made arrangements for this to happen.” They go on to write: “Patients are required to be looked after by an adult for 24 hours following intravenous sedation” and quote the 2003 guidance as a reference. Clearly there is a discrepancy here. The 2003 guidance specifically states that the escort must look after the patient for “the rest of the day” which is somewhat different to looking after the patient for 24 hours following IV sedation. The Expert Group were, I believe, mindful of the difficulties in expecting an escort to look after someone for an entire 24-hour period, and the “rest of the day” guidance reflects this. I would appreciate it if this small but important clarification could be made in the next edition of the journal. Yours sincerely,
REFERENCES 1
2
3
United Nations Environment Programme. Minamata Convention Agreed by Nations. UNEP website. Available at: http://tinyurl.com/bkkekac. Accessed: 14 April 2014. Lynch CD, Wilson NHF. Managing the phase-down of amalgam (Part I): educational and training issues. Br Dent J 2013;215:109–113. Lynch CD, Wilson NHF. Managing the phase-down of amalgam (Part II): implications for practising arrangements and lessons from Norway. Br Dent J 2013;215:159-162.
V O L 3 N O 2 M AY 2 0 1 4
Robert Bland BDS MJDF MMedSci FFGDP(UK) Dear Dr Bland, Thank you for your comments regarding our paper. As you point out, the Standing Committee on Sedation for Dentistry’s guidelines do state that the patient escort must “assume responsibility for the post-sedation care for the rest of the day.” The standard set for the reported audit was based on our departmental protocol, where we ask patients to be cared for over a 24-hour period, and this should have been stated more clearly in the paper. William Thompson
71
n your k
ge owled
A Antimicrobial Presscribing
f General Dental Practitioners for
This essential text gives clearr,, simple sim mple and practical advice on when to prescribe, what to o prescribe, in what dose and for how long. Thiis publication is intended to complement the Dental P Practitioners’ ra actitioners’ Formularyy and will be reviewed regularly r and revised as new information becomes available. ailable. This new edition reflects changes to recom mmendations since the previous update. For the first tim me, this edition also includes dosage recommendations for children. This revised edition the leading authority uthority on prescribing for dental professionals, and is an invaluable asset to any dentist’s library.
!
No otice of
Ameendments
In its March 2014 update, the British National Formulary has amended the recommended ded amoxicillin dosages for children. These amendments are in addition to amendments made in Septtember 2013. The FGDP(UK) seeks to identify and inform members of all changes to the BNF that supersede the information in our published guidelines. Such changes are posted on the FGDP(UK) web w page for the book of Antimicrobial Prescribing for General Dental Practitioners; Practitioners; howeverr,, we also urge urrge members to check each update to the BNF as a matter of course. The recommended dosages are now: &KLOGPRQWKV PJWLPHVGDLO\ LQFUHDVHGLIQHFHVVDU\XSWRPJNJWLPHVGDLO\ &KLOG\HDUV PJWLPHVGDLO\ LQFUHDVHGLIQHFHVVDU\XSWRPJNJWLPHVGDLO\ &KLOG\HDUV PJWLPHVGDLO\ LQFUHDVHGLIQHFHVVDU\ U\XSWRPJNJ PD[J WLPHVGDLO\ &KLOG\HDUV PJWLPHVGDLO\ LQVHYHUHLQIHFWLRQJWLPHVGDLO\
For a q quick k and easy way to purcha ase p publications, visitt o our online o shop p via the Faculty y web bsite.
buyy on l ine
ww ww w.fgdp. f .org.uk
