9/9/2016 1 By Kathleen Bokrossy, RDH, AAS & Jennifer Turner, RDH, BSc. Advanced Hand Instrumentation & Optimal Instrument Maintenance Today we will: • Discuss improving maintaining instruments so that you always work with instruments that are in optimal condition • Discover a variety of designs of instruments that are unique which aid in advanced instrumentation • Revisit exploratory techniques for accurate calculus detection • Re-evaluate the periodontal examination Disclosure Statement • Jennifer Turner is not representing the College of Dental Hygienists of Ontario in any manner throughout this presentation. • Jennifer is here today as a dental hygienist, educator, researcher and to share her passion of instrumentation in dental hygiene.
Transcript
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By Kathleen Bokrossy, RDH, AAS &
Jennifer Turner, RDH, BSc.
Advanced Hand Instrumentation&
Optimal Instrument Maintenance
Today we will:
• Discuss improving maintaining instruments so that you always work with instruments that are in optimal condition
• Discover a variety of designs of instruments that are unique which aid in advanced instrumentation
• Revisit exploratory techniques for accurate calculus detection
• Re-evaluate the periodontal examination
Disclosure Statement
• Jennifer Turner is not representing the College of Dental Hygienists of Ontario in any manner throughout this presentation.
• Jennifer is here today as a dental hygienist, educator, researcher and to share her passion of instrumentation in dental hygiene.
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The benefits of sharpening…
The Client• Client Safety and Comfort
• Quality of care is improved
• Quality of treatment
• Less post-treatment discomfort
• Pleasant experience (clients notice the difference if the clinician is using dull instruments versus sharp instruments)
• Efficient appointment (less time in the chair)
• Decrease chance of instrument slipping and damaging tissue.
• Less chance of having burnished calculus
The benefits of sharpening…
The Clinician• Client Safety and Comfort• Decrease in Lateral Pressure• Working Efficiently• Greater instrument control• Fewer lighter strokes to remove deposits • Decrease in burnished calculus• Increased tactile sensitivity• Improved speed• Helps prevent repetitive strain injuries• Decrease fatigue• Instruments last longer
The benefits of sharpening…
The Practice• Client Safety and Comfort• Increases efficiency• Less fatigued clinicians • Fewer sick days for the clinician (due to Repetitive Strain Injury) • More thorough appointment (effective treatment)• Better client experience • Increase retention and referral rate• Instruments last longer when properly maintained (saves
money).
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The goal of instrument sharpening…
• To produce a sharp cutting edge that is easily attained and sustained
• To use a method that is quick and easy and cost effective
• To maintain the original shape and design of the instrument
• How often should I sharpen?• When should I sharpen? • How often should I purchase new instruments or re-tip?• We are so disorganized with our instruments? Which ones are
sharp…which need to be replaced…what do we do with all the old instruments?
• I don’t like other hygienists sharpening my instruments. What can I do? • My employer doesn’t want to spend money on instruments! Any
suggestions? • I am opening my own practice and need to watch what I spend on
instruments, can you help me?• I temp in many offices and I am always left with the worst instruments
that you could find in the practice!!!
When Should I Sharpen?• First sign of dullness• Prior to treatment• During a longer appointment• Alberta’s new Infection Control Guidelines mandates
that RDH’s DO NOT sharpen chairside immediately before or during treatment
Professionally Sharpen• Extend the life of your instrument• Re-shape/re-sharpen• Instruments become beveled at approximately 4
months
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Sharpen-free Instruments
Looking for ways to save money?
Re-Tip (Introducing new tips to an existing handle)• Save on waste (re-uses existing handle)
• Safe process
• 440A Surgical Stainless Steel tips (North American Certified Steel)
Trade-in Old Instruments
• Many companies offer trade-in specials
• Trade-in old instruments (octagonal, plastic or if you do not want to re-tip)
• Save money on new purchase
• Old instruments can be refurbished and donated to Missionary Groups
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Recycle Program
• Many companies offer a recycle program• Saves the environment: Do your part in helping to
preserve our environment. Disposing of non-renewable resources, such as steel, is a waste of energy and material. More energy and resources are required to produce a complete instrument versus what is required to simply change out the tips on quality instrument handles.
• Saves on waste
Instrument Management Programs
Designed for practices seeking to provide optimal instrumentation, to better manage their dental hygiene instruments and to reduce instrument costs.
It is a program that will put systems in place to ensure that all the dental hygienists in the practice are always using optimal instruments.
Benefits of creating an Instrument Management Program
• Consistency within your practice
• Improves client care/treatment
• Reduces cost
• Low maintenance required
• Helps with ordering
• Reduces waste (reduces old instrument disposal)
• Ensures that all dental hygienists are always using optimal instruments
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Within Your Own Practice:
• Team up with other dental hygienists in your practice
• Do frequent instrument inspection TOGETHER
• Frequent professional sharpening/ replacement
• A systemized approach to sharpening in the office
• Replace/sharpen ALL instruments at the same time
• No ID on instrument, therefore colour code
Different options for sharpening…
Chairside• Better control of speed, angle and
pressure• Minimum loss of instrument surface• Chairside sharpen throughout
treatment or if in Alberta an easy way to sharpen in your operatory
• Results in using sharp instruments throughout treatment
• Greater comfort for the client• Greater efficiency and comfort for
the clinician
Power• Requires training• Instrument surface loss is greater• Will go through instruments faster• Cost• Set time aside• Takes up space• Cannot do chairside throughout
hygiene treatment• Benefit: quick sharp results if used
properly
Chairside Sharpening
Three Main Techniques1. Active Stone & Stabilized Instrument2. Active Instrument & Stabilized Stone3. Active Stone on Face of Blade
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Sharpening Stone Criteria
• The grit of the stone is the most important criteria. Finer grit stones produce edges that are maintained longer. Coarse grit is need to re-shape/re-contour
• Edges maintained with a fine stone by sharpening at the first sign of dullness, are restored to sharpness quickly with minimal burs & projections.
Sharpening Stones - Natural
Natural Sharpening Stones
• Example Arkansas or India Stone
• Conical stone – for sharpening the face of the blade – not best practice –weakens the blade
• Natural pits and voids which fill with metal shavings which creates a glassy surface, not conducive for effective sharpening
• Metal becomes lodged
• Hard on instrument edge
• Inconsistent grit throughout
Sharpening Stone - Synthetic
Sharpenator Stones/Edgemate
• Aluminum oxide• Consistent grit throughout• Metal does not become lodged in stone• Variety of shapes and sizes• Small size for kits and the smaller hand• Medium size for average to larger size hands • Better grip and control of the stone with medium size• Easily sterilized – wash/scrub and sterilize with instruments• Variety of grits (fine, medium, coarse) Edge II is our most popular –
coarse on one side and fine/med on the other• Attains a sharp edge quick!
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Sharpening Depends on Angulation
Sharpening is dependent on correct angulation
• Correct angulation = maximum sharpness & longevity
Sharpening Depends on Angulation
• Not enough angulation (ie <110*) (most common error) = creates sharpness but dulls rapidly and is difficult to restore to correct angle
Sharpening Depends on Angulation
• Too much angulation = (>110*) Creates weakened edge, pre-mature dulling & decreases instrument life
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Sharpening Depends on Angulation
Test for Sharpness…
Assess Sharpness
• To avoid over sharpening and under sharpening
• To prolong the life of the instrument
• Determine with glare test, acrylic test stick or sound test
• Use magnification
Test for Sharpness…
Glare Test
• A sharp edge will form a fine line and not reflect light
• A dull edge will reflect light because of its beveled edge
Acrylic Test Stick
• Adapt instrument to the test stick as you would a tooth surface
• A dull edge will slide over the test stick
• A sharp edge will grab the test stick
Sound Test
• On the tooth surface
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What’s needed to sharpen?
• Stable work surface• Magnification – many dental hygienists are not aware of magnification in
instrument sharpening. It speeds both assessment of edge quality & attainment of edge sharpness. A small light microscope provides optimal vision but any magnification is better than none!
• A good lighting source• Chair-side Guide• Sharpening Stone• Test stick• Gauze• Instrument guide or master set of instruments for comparison• Protective wear (gloves, mask, eyewear)
Review of the Basic Instrument Design
The hygiene instrument consists of:
• A working end(s)• Shank• Handle
Review of the Basic Instrument Design
Working end
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Review of the Basic Instrument Design
Working end
Review of the Basic Instrument Design
Functional Shank
Review of the Basic Instrument Design
Terminal Shank
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Review of the Basic Instrument Design
Sickle Scaler
90 DegreesCutting edge
Lateral surface
Back
FaceCutting edge
Lateral surface
Review of the Basic Instrument Design
Universal Curette
90 DegreesCutting edge
Lateral surface
Back
FaceCutting edge
Lateral surface
Review of the Basic Instrument Design
Gracey Curette
Cutting edge
Lateral surface
Back
FaceCutting edge
Lateral surface
70 degrees
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Review of the Basic Instrument Design
Gracey Curette
Cutting edge
Lateral surface
Back
Face
Cutting edge
Lateral surface
110 degrees
The Basics of Sharpening
• Position the instrument (use a sharpening guide)• Hold and stabilize the instrument in non-dominant hand• Hold the stone in dominant hand at 110*• Toe of blade facing toward you• Face of the blade parallel to the floor• Move the stone in short rhythmic strokes (.5” – 1”) up and down motion
from heel, to middle to toe keeping the design of the blade in mind• Applying light pressure (slightly heavier pressure on the down stroke)• Never lose contact of instrument and stone• Ending at tip of toe for sickles and opposite side for rounded toe for
curettes on a down stroke
Positioning the Instrument
Sickle Scaler:
• Terminal shank is at the 90* (face is parallel to the floor)
Universal Curette
• Terminal shank is at the 90* (face is parallel to the floor)
Gracey Curette
• Terminal shank is at the 110* (face is parallel to the floor)
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Positioning the Instrument
Sickle Scaler:
Terminal shank is at the 90* (face is parallel to the floor)
Positioning the Instrument
Universal Curette:
Terminal shank is at the 90* (face is parallel to the floor)
Positioning the Instrument
Gracey Curette:
Terminal shank is at the 110* (face is parallel to the floor)
– Keep face of the blade parallel to the floor and sharpen at 110*
• Dental hygiene therapy has changed over the last 30 years.
• Traditionally the successful end product of non-surgical periodontal therapy was the achievement of a glassy root surface and to remove the cementum.
• Bacterial plaque/biofilm and the host response, not calculus, is responsible to be the primary etiologic agent in the development and progression of gingival and periodontal diseases.
• The success of periodontal debridement is measured by tissue response.
• The goals of periodontal debridement include management of an oral infection, establishment of gingival health, periodontal attachment gain and maintenance of an oral environment conducive to periodontal health and a healthy host response
• Dental hygienists play an integral role in the assessment, implementation of treatment, and evaluation of periodontal diseases.
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• Mechanical removal of bacterial plaque/biofilm and calculus can be performed with the use of hand and ultrasonic instrumentation.
• Both mechanisms of plaque and calculus removal have shown comparable results following instrumentation.
• Studies have shown that the combination of both hand and ultrasonic instrumentation are not only effective in removing bacterial plaque and calculus; but also, encourages epithelial attachment and overall tissue healing.
• Hand instrumentation provides an equally acceptable alternative for the removal of deposit and periodontal maintenance procedures for clients.
• Instrument manufacturers are continually modifying current instruments to help increase the client comfort and the comfort of the clinician
• Instruments are designed to help allow ergonomic hand positioning and additional access to the dentition
.
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• Overall improved instrument design can increase effectiveness of instrumentation and reduce physical stress.
• Extended shank instruments relieve movement restrictions
• Rigid shanks withstand the force of lateral pressure and removal of more tenacious calculus
• Thinner blades improve access to restricted anatomical areas
Instrument Selection
• The hand selection of hand instrumentation is based on numerous factors. Before beginning treatment, The dental hygienist needs to consider:– The pocket depth
– Tissue consistency
– Root morphology
– Amount and type of deposits
– Furcation invasions
– And accessibility
Instrument Selection
• Using a variety of instruments helps relieve hand fatigue and can help prevent repetitive strain injuries. Materials that handles are available:– Stainless Steel
– Plastic
– Silicone
– Instruments should weigh between 10 – 15 gm
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Select Correct Working-End
11/12 Explorer
• Tip is at 90-degree angle to the lower shank
• Only the terminal 2 mm of the side tip are adapted to tooth surface
Elastic, ergonomic surface materialand optimised contouring- Comfortable, non-slip grip- Safe to autoclave, holds the
color/shade
Stylish colors and visible product names - easy identification
Special alloy metal core- lightweight, yet firm structure
Solid and reliable mounting- safe even in hard use- Firm metal-to-metal connection
New DuraGradeMAX steel- extremely wear resistant
Hand-finishing- sharp smooth cutting edge
Optimal rigidity-excellent sensitivity and efficiency
Re-care Tray Set-up
• Besides the Mirror, Explorer and Probe, only 2 instruments are required to complete a re-care appointment
Mini Syntette (Dual Gracey) & Mini Sickle
• The Dual Gracey combines the traditional Gracey 11-12 (mesial) and 13-14 (distal) curettes. With the Dual Graceyyou can conveniently move from mesial to distal surfaces without flipping the instrument and from buccal to lingual side without switching instruments
• Keep lower shank parallel to the axis while scaling (similar to Graceys)
• Mini Sickle – universal use throughout entire dentition
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PDT’s Most Popular Instrument
laatija / pvm
Are you ready to go bananas?
Ergo Access
• Specialty instruments for calculus removal from problematic areas
• The revolutionary handle design, “Access”, allows easy access to difficult-to-reach areas.
• The Blue and Green instruments are hoe-scalers, with elliptical cutting edges for removal of supra and subgingival calculus effectively, even in deep and narrow pockets and concave root surfaces. The H-Scalers can be used with both vertical and horizontal techniques. The Pink instruments is a micro scaler
• Ideal for the elderly and children clients who cannot open wide
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Ergo Access
• H-Scaler I – Distal, lingual anteriors
• The curved handle allows access to difficult-to-reach areas such as distal surfaces of molars and lingually inclined incisors
Ergo Access
• H-Scaler II – Mesial/distal, anteriors
• Provides easy access to mesial and distal surfaces of molars even with smaller aperature
Ergo Access
• Micro Sickle – Interproximal, anterior
• Similar to the 204SD scaler, great for anterior interproximal areas
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Universal
• Designed for the removal of sub and supragingival calculus
• BH 5 -6 (Barnhart)– A popular “go-to” universal for all posterior region
– Great bend angle and ideal lower shank length for optimal reach to molars
PDT “Queen of Hearts”
Queen of Hearts- PDT
• Curette
• Longer cutting edges 6 mm
• Used like a probe
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Furcator
• Fine, angled micro-size excavator
• Designed for debriding the roof and inner surfaces of furcations, as well as concavities and grooves
• Petite clinical design to access and treat Class I and II furcations and to prevent further involvement
Trisha O’Hehir
www.ohehiruniversity.com
O’Hehir Curettes
The O’Hehir Debridement curettes are a new type of area-
specific curette designed to remove light residual calculus
deposits and bacterial contaminants from the entire root
surface.
• Used with a gentle stroke pressure with either push or pull strokes.Shape of Working-End
• The working-end is a tiny circular disk.
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O’Hehir Curettes
Cutting Edge
• The entire circumference of the working-end is a cutting edge. This design allows the instrument to be used with a push or pull stroke in any direction – vertical, horizontal or oblique.
• The working-end curves into the tooth for easy adaptation in furcations, developmental grooves, and line angles.
Shank Design
• These curettes have extended lower shanks for easy access into deep periodontal pockets.
O’Hehir Curettes
Indications and Contraindications:
Entire edge is a cutting edge enabling a push or pull stroke in all directions vertical, horizontal or oblique
Shanks are extended for easy access into deep pockets
• OH 1/2 Facial and lingual surfaces of posterior teeth
• OH 3/4 Mesial and distal surfaces of posterior teeth
• OH 5/6 Anterior teeth
• OH 7/8 Anterior teeth with deep pockets
O’Hehir Debridement Curettes
• Working-end is a tiny, circular disk
• The entire circumference of the working-end is a cutting edge
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Design Features
Curet Area of Use
O’Hehir 1/2 Fa - Li of posteriors
O’Hehir 3/4 M - D of posteriors
O’Hehir 5/6 Anterior teeth
O’Hehir 7/8 Anteriors with deep pockets
Application
O’Hehir Curettes
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O’Hehir Curettes
O’Hehir Curettes
O’Hehir Curettes
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Implant Maintenance Instruments
• Titanium – gentle material but effective
• Soft titanium alloy, safe to use on abutments
• Excellent tactile sensitivity and optimal rigidity
Conclusion
When we are in dental hygiene school we are introduced to the basic design and types of instruments. As we gain experience in instrumentation we must expand our selection to aid in easier access and successful debridement.
Think Outside the Tray!
References:
• Clinical Practice of the Dental Hygienist, Wilkins, 10th
Edition• Dental Hygiene Theory and Practice, Darby & Walsh• LM-dental.com
