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Hand instrumentation a shift in paradigms.

There is great ownership in the way each dental hygienist views her or his instrumentation techniques. Because of this, the recommendation of a new method of instrumentation can be met with great resistance--that is, until a clinician has a "hands-on" experience that proves that there is an easier way to perform periodontal instrumentation. Recommending a new technique in an article such as this should not be misinterpreted as an indication that the current methods used by many are incorrect; such is not the case. Every day, the dental hygiene care given to patients in our country is superb. Yet, there is a way to meet the same treatment goals with less physical demand on the clinician and less removal of the patient's cementum.

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Years of thorough study of the procedures conducted by this author have given rise to the discovery of new techniques. This article shares an introduction to the new techniques to provide insight to all who might welcome new perspectives.

Treatment for periodontally involved patients has been changing rapidly due to recent research. Since our treatment modalities are patient centered and evidence based, we are no longer trying to remove cementum to produce glassy, smooth roots. We are trying to preserve cementum while disrupting biofilms and thoroughly removing calcareous deposits. (1) This shift in treatment goals has presented a significant challenge for clinicians whose instrumentation instruction may have been focused on more aggressive root instrumentation.

Since muscle has memory and competency leads to an automatic performance, changing a technique that has been years in the making is no easy feat. Seasoned clinicians are confident about their skills and comfortable in their routines, yet many agree that they are experiencing work-related pain and injuries. (2) There is no shortage of attendees in instrumentation seminars. (3) Those in attendance are hoping for new techniques that will not only meet the need for evidence-based care, but simultaneously spare the clinician as well.

While some say a complete switch to ultrasonic and sonic instrumentation is the answer, research is saying it is not. (4) There is a need for a combination of power-driven instruments and hand instrumentation. (4) The scope of this article is not to compare and contrast indications for either power driven instruments or hand instruments, but to introduce new techniques in hand instrumentation. It is, by far, just an introduction since there is much more information than can be provided in just one article.

In several hands-on workshops, a new hand instrumentation technique utilizing a "press-open stroke" was presented to a total of 247 clinicians, consisting of 228 dental hygiene educators, five dentists, two periodontists and 12 practicing hygienists. Each workshop was limited to 30 attendees in eight- to 12-hour sessions. The workshops were scheduled twice a year over a span of five years. The ratio of instructors to attendees was one instructor to every five attendees. (3) As clinicians were introduced to new techniques, they were amazed at the effortless stroke that is a result of precision in instrument placement, movement and application of physics. At first, it was difficult for the attendees to keep from going back into "automatic pilot" (the way they are used to doing it), but once they got the feel for the new techniques, they were amazed at how effortless they were, and they wanted to master them. The testimonies from the attendees have been overwhelmingly positive. (3)

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The difference between the standard and the new techniques can be most dramatically seen in the elements of the working stroke, which has been called the scaling stroke or "pull-stroke." The new scaling technique is a press-open stroke. (3) The new root-planing stroke has changed from its original technique only in that it is a much lighter stroke used for smoothing root surfaces while preserving cementum. The root-smoothing technique is used after using power driven instruments and/or the new press-open stroke technique.

To perform the press-open stroke, the clinician must realize that you no longer open the blade before beginning the stroke, even with the off-set angle of the Gracey curets. (5) With the new press-open stroke technique, after inserting at zero degrees, you open only enough to cup the deposit by locking on the toe third of the instrument underneath it (Figure 1). So prior to activating (making the stroke), the terminal shank is not parallel to the long axis of the tooth, but braced against and slightly diagonal to the long axis of the tooth. This helps lock the toe third of the instrument under the deposit.

For example, if you are working on Quadrant I facial and you are scaling on the distal surface of tooth #3, the terminal shank of the Gracey 13/14 is diagonal, not parallel, to the long axis of the tooth and braced against the convexity of the facial aspect when the stroke is initiated (Figure 2). The stroke ends with the terminal shank parallel to the long axis of the tooth, but it does not begin that way. There is no scraping sound with the press-open stroke. The sound is a tiny "click" or "ping" where the instrument starts and almost immediately stops in a discrete 1-2 mm bite. The stroke starts out with a more closed angle. When you make the stroke, the handle moves slightly away from the tooth, and the stroke ends with the terminal shank parallel to the long axis of the tooth. (5)

You actually use lateral pressure to open the blade during the tiny bite. It is like a miniscule scoop. So you "stroke-open," you don't "open-stroke." Those who open the blade prior to the stroke are using what is known as a standard pull-stroke. (5) Although the pull-stroke can and should be performed with the whole hand functioning as a unit, the majority of the clinicians in the workshops were using their thumb and index finger to perform the pull-stroke. (3)

The press-open stroke produces a discrete lift, instead of a pull. It is performed with the whole hand. The thumb is kept still and used only to hold the instrument in the pen grasp. The press-open stroke lifts and separates the deposit from the tooth, leaving cementum intact. (5) Since the discrete 1-2 mm stroke is performed by the whole hand and arm, the effort is placed on the larger muscles of the palm, not the fingers or thumb.

Many reading this may say, "That is exactly what I do!" It may or may not be. Here is a way you can conduct a self-assessment. Insert a Gracey 1/2 curet subgingivally at zero degrees on the distal surface (proximal) of tooth #8. Watch as you make the working (scaling) stroke:

* If the handle of the instrument is moving toward the tooth during the stroke, you are performing the standard pull-stroke.

* If the handle of the instrument is moving away from the tooth during the stroke, you are performing the press-open stroke; and if the terminal shank is parallel to the long axis of the tooth when the stroke ends, you are performing the press-open stroke perfectly!

The press-open stroke does not begin the stroke with the terminal shank parallel to the long axis of the tooth unless the size of the deposit dictates it. You must use the size of the deposit as the determining factor for the degree of angulation on activation (Figure 1). Table I compares the pull-stroke to the press-open stroke.

The only time the handle of the instrument should move toward the tooth is during the root-smoothing stroke. Vertical and oblique strokes are the only strokes used for press-open strokes. Horizontal and circumferential strokes are finishing strokes that are longer and lighter and used when root smoothing.

Fulcrums

The Ring Finger

The ring finger of the dominant hand serves as the basic fulcrum. It is used to initiate, support, control and stop the stroke. The ring finger is advanced beyond the other fingers in the hand, and it is straight and rigid at all times. (1) Proper placement of the fulcrum finger enables the clinician to improve leverage and parallelism for access into deeper pockets. Without adequate parallelism for proper access to the bottom of the pocket, no instrument, regardless of length and complexity of shank, can get under the deposits that are located in a deep pocket. (6)

The Whole-Hand Fulcrum

The side of the whole hand may function as a fulcrum in the extraoral fulcrum technique. Extraoral fulcrums are used for improving parallelism when working on maxillary posterior areas of the mouth. For maxillary third molars, this is often the only means of gaining the parallelism for access to the bottom of the pocket. (6) Since the whole-hand fulcrum has an extraoral placement, it requires the clinician to hold the handle of the instrument further away from the shank. As a result, the middle finger is not on the side of the shank, and there is less control of the lateral pressure on the toe third of the instrument.

The Facilitated Fulcrum

Facilitated fulcrums are used to provide greater access and lift to the press-open stroke. Facilitated fulcrums are not just finger-on-finger fulcrums, since during a facilitated fulcrum the finger of the non-dominant hand is never placed on the occlusal surfaces of the teeth; it is placed in the mucobuccal fold (Figures 3-4). The facilitated fulcrum permits the clinician to keep the side of the middle finger against the shank for more control of the instrument tip. This placement also provides a more apical fulcrum position to aid in accessing and lifting off deep deposits with the press-open stroke. (6) In addition to providing increased parallelism, the facilitated fulcrums allow the clinician to use vertical strokes instead of other stroke directions. Vertical strokes are the most effective scaling strokes for lifting deposits. (6) Basic physics of fulcrum pressure versus stroke direction is related to opposition in forces. Aligning the fulcrum point with the direction of the lateral pressure of the stroke provides peak efficiency in the opposition of forces, known as dynamic equilibrium, as stated in Newton's Laws. (7)

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Instruments for Advanced Root Instrumentation

Gracey curets with longer terminal shanks (called After-Fives) are available to assist the clinician in gaining access to deep pockets. For furcation areas and areas of narrow root proximity, the After Fives are also available as "Minis," the working end of which is 50 percent shorter. Other instruments with shorter blades are the Sub-Zero Vision Curvettes, Langer Miniature curets, Turgeon Modified Gracey curets, and the latest of the mini-curets are the Micro-Mini and Micro-Mini Five, featuring ultra-slender blades with enhanced shank rigidity. O'Hehir Debridement curets have circular disc tips with longer, lower shanks. They are exceptional for making multi-directional strokes since the entire circumference of the disc has a sharp cutting edge. Quetin Furcation curets are available in 0.9 mm or 1.3 mm hoe-shaped tips that enable the clinician to remove deposits with a vertical pull-stroke. The new DiamondTec Files are extraordinary for root smoothing, especially with the Nabors probe design, which provides perfect adaptation to furcations. The technique used with DiamondTec instruments consists of back-and-forth smoothing strokes. (8)

Perioscopy

An endoscope for visual inspection for calculus deposits has been shown to be an aid to clinicians in removing subgingival deposits from single-rooted teeth. However, recent research has shown that the endoscope as an adjunct to removal of calculus in multirooted molar teeth provided no significant improvement over traditional scaling and root-planing procedures without an endoscope. (9)

Comparison of Treatment Modalities

A comparison of three common treatment modalities for chronic periodontitis showed that no one modality had a clinically relevant advantage over the others. (10-12) They are:

1. Full-mouth debridement with antiseptics

2. Full-mouth debridement without antiseptics

3. Quadrant scalings without antiseptics

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Quality assurance in patient care suggests that decision-making for scaling and root planing debridement procedures are patient centered and evidenced based. If a full-mouth debridement is physically taxing to the clinician, it should not be the treatment of choice, especially when the evidence shows that quadrant scalings are equally effective. Clinicians have the opportunity to choose a treatment plan, as well as the armamentarium and methods that serve both the patient and the clinician equally well.

To make the best choices, clinicians must be willing to adopt newer techniques and equipment. This means setting aside techniques that are familiar and thought to be most reliable, and openly investigating all that may be in the best interest of not only the patient, but also the clinician.

References

(1.) Nield-Gehrig JS. Fundamentals of periodontal instrumentation and advanced root instrumentation, 6th ed. Philadelphia: Lippincott, Williams and Wilkins; 2007.

(2.) Dylla J, Forrest JL. Fit to sit-strategies to maximize function and minimize occupational pain. Access 2006; 20(3): 16-23.

(3.) Biron C. DH. Methods of Education, Inc. Available at: http://www.dhmethed.com.

(4.) Guentsch A, Preshaw PM. The use of linear oscillating device in periodontal treatment: a review. J Clin Periodontol 2008; 35(6): 514-24.

(5.) Biron C. Precision in periodontal instrumentation. 2006. Available at: http://www.dhmethed.com

(6.) Biron Leiseca C. A focus on fulcrums.2009. Available at: http://www.dhmethed.com.

(7.) Newton, Sir Isaac. Laws of dynamic equilibrium. Available at: http://www.dev.physicslab.org.

(8.) Available at: http://www.hufriedy.com.

(9.) Michaud RM, Schoolfield J, Mellonig JT, Mealey BL. The efficacy of subgingival calculus removal with endoscopy-aided scaling and root planing: a study on multirooted teeth. J Periodontol. 2007; 78(12): 2238-45.

(10.) Eberhard J, Jepsen S, Jervoe-Storm PM, et al. Full-mouth disinfection for the treatment of adult chronic periodontitis. Cochrane Database Syst Rev 2008; (1): CD004622.

(11.) Kinane DF, Papageorgakopoulos G. Full mouth disinfection versus quadrant debridement: the clinician's choice. J Int Acad Periodontol 2008; 10(1): 6-9.

(12.) Farman M, Joshi RI. Full-mouth treatment versus quadrant root surface debridement in the treatment of chronic periodontitis: a systematic review. Br Dent J 2008; 205(9): E18; discussion 496-7. Epub 2008 Oct 3.

By Cynthia Biron Leiseca, RDH, MA

Cynthia Biron Leiseca, RDH, MA, is chair of the Dental Health Programs at Tallahassee Community College, in Tallahassee, Fla. In addition to her contributions to numerous textbooks and journals, she is an international speaker and the inventor of the dental hygiene process of care computerized evaluation system, TalEval (www.taleval.com), which aids clinical instructors in evaluating each aspect of periodontal instrumentation. Her "Boot Camps in Periodontal Instrumentation" provide dental hygiene instructors and practicing dental hygienists with "hands-on" instructional sessions in the latest techniques.
Table I. Comparison of the Pull-Stroke and
Press-Open Stroke

Pull-Stroke                         Press-Open Stroke

Instrument inserted close           Same
to zero as possible

Exploratory stroke to locate        Same
calculus

Instrument repositioned under       Same
deposit

Instrument blade opened until       Instrument blade is not opened.
terminal shank is parallel to the   Terminal shank is not parallel
long access of the tooth to         at the beginning of the stroke.
establish face-to-tooth             Terminal shank is braced against
angulation of 60 degrees to 80      the convexity of the crown.
degrees.                            Face-to-tooth angulation is only
                                    opened enough to cup the deposit
                                    with the toe third.

Lateral pressure is applied after   With toe third locked on under
opening the blade and with a        the deposit, lateral pressure is
pull-stroke.                        applied before and during opening
                                    the blade and with a lift stroke
                                    that is a miniscule scoop.

Handle moves toward the tooth       Handle moves away from the tooth
during the pull-stroke, ending      during the lift stroke ending
with terminal shank against tooth   with terminal shank parallel to
and the angle closed.               the long axis of the tooth.

Whole hand or thumb and             Whole hand as a unit--lifting
index--pull

Stroke is 2+ mm long                Stroke is less than 2 mm long
(sounds like a scrape).             (sounds like a "click" or
                                    "ping"). It is tiny, controlled
                                    and discrete.

Working strokes are vertical,       Working strokes are only vertical
oblique, horizontal and             or oblique. Horizontal and
circumferential.                    circumferential strokes are only
                                    used for root smoothing.
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Title Annotation:lead story
Author:Leiseca, Cynthia Biron
Publication:Access
Article Type:Cover story
Geographic Code:1USA
Date:May 1, 2009
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