Care should be taken while polishing.

• Proper technique should be used to minimize abrasion to the tooth surfaces with the appropriate amount of force, pressure, time, and speed.
• The least abrasive polishing agent must be used but must be effective enough to remove the stains.
• Restorations must be polished with an agent that is softer than the restoration itself [7].

Manual Devices

Porte Polisher

A porte polisher rubs the abrasive agent against the tooth surface with a wedge-shaped, tapered, orange-wooden point.

It is noiseless with minimum aerosol production, portable, accessible on various aspects of the teeth, and hence can be used on malpositioned teeth and generates minimal heat. But it has the disadvantage that is time-consuming and requires more force.

Polishing Strips

These are for interproximal regions and line angles of teeth. Since they are very abrasive, the soft tissue in the interproximal areas must be protected. They come in various colors and sizes of abrasive agents.

Engine-Driven Devices

These are widely used and need either a straight or a contra-angled handpiece. A polishing brush or a rubber cup is attached to the handpiece used at a velocity of 2500 to 3000 rpm. It is estimated that the average speed used by dental hygienists is 2500 rpm [13]. The motion used for polishing in clinical practice is patting motion, and the device should be a slow speed handpiece always rotated at the lowest rpm. The rubber cups or the polishing brushes are either autoclavable or disposable. Most tooth surfaces require 2 to 5 seconds to get polished with the rubber cup contacting the tooth for 4.5 seconds [7][13]. The pressure needed to be applied 20 psi since too much pressure generates heat. They are the most frequently used in clinical practice.

Air-Powder Polishers

These are generally used for supragingival plaque removal as they reach the inaccessible areas where the rotary devices cannot reach like furcations, flutings, close root proximities [14]. They use a slurry of water and sodium bicarbonate under air and water pressure along with certain abrasive agents like aluminum trihydroxide, calcium sodium phosphosilicate, calcium carbonate, and glycine.

The air powder polisher can also be used with an ultrasonic scaler or directly with the air/water connector or separately. It works with foot control. The nozzle of the handpiece has to be held 3 to 4 mm from the tooth as it propels the slurry of water and sodium bicarbonate on the tooth. The motion used in air powder polishers is a paintbrush motion at an angle of 60 degrees for anterior teeth, an 80-degree angle for posterior teeth, and 90-degree on the occlusal surfaces. It should be directed at the middle thirds of the tooth in a circular motion with an air pressure of 40 to 100 psi and inlet water pressure 20 to 60 psi [7]. Adjusting the water flow and the distance between the instrument and the tooth helps to adjust abrasive forces. They are generally safe for exogenous stains removal except for exposed dentin or cementum regions, which can be damaged because of the abrasives in the air-powder polishers [15].

Advantages

The main advantage of air-powder polishers is their ability to efficiently remove biofilm, without harming the periodontal soft tissues and the hard tissue structures. It is a faster method, and there is more patient comfort.

1. It saves time, and hence, it can prevent patient and operator fatigue.
2. It can be used in orthodontically bracketed teeth as it does not physically damage and disturb the bands and the wires and also does not disturb the bonding cement.
3. It reduces dentinal sensitivity by blocking the tubular opening with bicarbonate crystals.
4. It reaches the inaccessible areas that cannot be reached by rotary devices [14].

Disadvantages

Since they use sodium bicarbonate in the slurry, it should be cautiously used in patients with restricted sodium diets. Non-sodium prophy powder can be used, which contains aluminum trihydroxide in such cases.

1. It should be carefully used in patients with respiratory, renal, or metabolic disease, diuretics, or long-term steroid therapy, those having titanium implants, or with children and in patients with infectious diseases.
2. Infection control is a problem with these devices since they produce aerosols. Hence, pretreatment washes are recommended [14].
3. There is a risk of subcutaneous emphysema intraorally. It is important to follow the manufacturer's instructions to avoid such complications [7].

Air polishers are generally used in the supragingival surfaces, but, glycine powder air polishers are used for removing sub-gingival biofilm that results in less erosion of the soft tissues and an 80% reduction in abrasion of the root surface as compared to hand instrumentation or sodium bicarbonate air polishing [7].

Vector System

These use a polishing fluid, which causes minimum damage to the cementum surface. The polishing fluid contains hydroxyapatite or an abrasive fluid containing silicon carbide with a resonating device that deflects the forces directed toward the tooth and hence protects the tooth. The plaque is removed by fluid dynamics and gives effective control of inflammation [7].

When polishing pastes with coarse or medium size particles are used, they may cause abrasion and damage to the tooth surface by scratching the enamel. A less polished appearance will be seen, and this will increase bacterial plaque retention [7]. Manual devices are time-consuming, and there is no control over the force applied, and they require more patient compliance. With engine-driven polishers, there is higher aerosol production, heat generation, and damage to the soft tissue if not attended properly.

Extrinsic stains are widespread in dental practice because they can be caused by tobacco smoking or simply drinking too much coffee or tea.

The tooth polishing devices are selected according to each case, and treatment plans are selectively designed, taking into account the patients' needs and with concern about minimal damage to the teeth and periodontal structures.

Extrinsic stains are one of the factors that influence tooth color assessment. Performing professional dental prophylaxis before composite or ceramic color selection in anterior teeth restorations could increase treatment predictability [16].

When the nature of dental stains has been identified as exogenous, selective tooth polishing is the initial and most straightforward alternative to remove them after scaling, and oral debridement is complete [7]. Dental professionals, including dentists, hygienists, and dental nurses, must be aware of the different alternatives when selecting a polishing paste and devices and adjust them to each clinical case.