Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation PDF

Quick Find Guide 1 Ergonomics and Periodontal Instrumentation 2 Clinician Position in Relation to the Treatment Area 3 Instrument Grasp 4 Use o Dental Mouth Mirror 5 Finger Rests in the Anterior Sextants 6 Finger Rests in Mandibular Posterior Sextants 7 Finger Rests in Maxillary Posterior Sextants 8 Instrument Design and Classi cation 9 Technique Essentials: Movement and Orientation to Tooth Sur ace 10 Technique Essentials: Adaptation 11 Technique Essentials: Instrumentation Strokes 12 Periodontal Probes and Basic Probing Technique 13 Explorers 14 Technique Essentials: Supragingival Calculus Removal 15 Sickle Scalers 16 Technique Essentials: Subgingival Calculus Removal 17 Universal Curets 18 Advanced Probing Techniques 19 Area-Speci c Curets 20 Specialized Periodontal Instruments 21 Advanced Techniques or Root Instrumentation 22 Fictitious Patient Cases: Communication and Planning or Success 23 Concepts or Instrument Sharpening 24 Instrument Sharpening Techniques 25 Pain Control During Periodontal Instrumentation 26 Powered Instrument Design and Function 27 Air Polishing or Bio lm Management Appendix: Problem Identi cation: Dif culties in Instrumentation Online @ 1B. Getting Ready or Instrumentation: Mathematical Principles & Anatomical Descriptors thePoint 20B. Dental Implants 21B. Alternate Clock Positions 26B. Cosmetic Polishing Procedures 27B. Set-Up o Air Polishing Devices Glossary Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation EiGHt H EDit iOn J ll S. Gehr g, RDH, MA Dean Emeritus, Division of Allied H ealth & Public Service Education Asheville-Buncombe Technical Community College Asheville, N orth Carolina Rebecca Sroda, RDH, MS Dean, H ealth Sciences South Florida State College Avon Park, Florida Darle e Saccuzzo, CDA, RDH, BASDH Professor, Dental Education South Florida State College Avon Park, Florida A cquisitions Editor: Jonathan Joyce Product D evelopm ent Editor: John Larkin Editorial A ssistant: Tish Rogers M ark eting M anager: Leah Thomson Production Project M anager: David Saltzberg D esign Coordinator: Joan Wendt M anufacturing Coordinator: M argie O rzech Prepress Vendor: Aptara, Inc. Eighth edition Copyright © 2017 Wolters Kluwer. Copyright © 2001, 2005, 2008, 2011 Wolters Kluwer Health / Lippincott Williams & Wilkins. All rights reserved. This book is protected by copyright. N o part o this book may be reproduced or transmitted in any orm or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any in ormation storage and retrieval system without written permission rom the copyright owner, except or brie quotations embodied in critical articles and reviews. M aterials appearing in this book prepared by individuals as part o their o f cial duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 M arket Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China Library of Congress Cataloging-in-Publication Data N ames: Gehrig, Jill S. (Jill Shi er), author. | Sroda, Rebecca, author. | Saccuzzo, Darlene, author. Title: Fundamentals o periodontal instrumentation & advanced root instrumentation / Jill S. Gehrig, Rebecca Sroda, Darlene Saccuzzo. O ther titles: Fundamentals o periodontal instrumentation and advanced root instrumentation Description: Eighth edition. | Philadelphia : Wolters Kluwer, 2016. | Includes bibliographical re erences and index. Identif ers: LCCN 2015037519 | ISBN 9781496320209 Subjects: | M ESH : Dental Prophylaxis—instrumentation. | Dental Prophylaxis—methods. | Root Planing—instrumentation. | Root Planing—methods. Classif cation: LCC RK681 | N LM WU 113 | DDC 617.6/01—dc23 LC record available at http://lccn.loc.gov/2015037519 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency o the content o this work. This work is no substitute or individual patient assessment based upon healthcare pro essionals’ examination o each patient and consideration o , among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other actors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a re erence tool. H ealthcare pro essionals, and not the publisher, are solely responsible or the use o this work including all medical judgments and or any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health in ormation, independent pro essional verif cation o medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare pro essionals should consult a variety o sources. When prescribing medication, healthcare pro essionals are advised to consult the product in ormation sheet (the manu acturer’s package insert) accompanying each drug to veri y, among other things, conditions o use, warnings and side e ects and identi y any changes in dosage schedule or contraindications, particularly i the medication to be administered is new, in requently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher or any injury and/or damage to persons or property, as a matter o products liability, negligence law or otherwise, or rom any re erence to or use by any person o this work. LWW.com Contributors Chris i e Domi ick, CDA, RDH, MEd Kimberly n aso , MSDH Associate Professor Instructor, Dental Education Program Forsyth School of Dental H ygiene South Florida State College M assachusetts College of Pharmacy and Avon Park, Florida H ealth Sciences Boston, M assachusetts Lydia t. Pierce, LPt Physical M edicine and Rehabilitation Richard Fos er, DMD Asheville, N orth Carolina Dental Director Guilford Technical Community College Bobby A. Sco yers, BA, CDA Jamestown, N orth Carolina Professor, Dental Education South Florida State College Cy hia Biro Leisica, RDH, EMt , MS Avon Park, Florida President, DH M eth-Ed, Inc. Dental H ygiene M ethodology Cherie M. S eve s, PhD Tallahassee, Florida Professor, Computer Science South Florida State College Sharo Logue, RDH, MPH Avon Park, Florida Virginia Department of H ealth Dental H ealth Program Do ald E. Willma , DDS, MS Richmond, Virginia Professor Emeritus, Department of Periodontics Robi B. Ma lof , RDH, BSDH, JD University of Texas H ealth Science Center Professor, Dental H ygiene Program at San Antonio M ount Ida College San Antonio, Texas N ewton, M assachusetts Reviewers De ise Avru ik Joyce Hudso Pamela Qui Ly A Brya Susa Je ki s Shaw a Roh er Michelle Ezzell Mark Kacerik Rebecca Smi h Ja e Gray Michelle Kle k Daw Smi h Co ie Grossma Co ie Preiser Debbie Zuer v Preface for Course Instructors Fundam entals of Periodontal Instrum entation & A dvanced R oot Instrum entation, Eighth Edition is an instructional guide to periodontal instrumentation that takes students rom the basic skills—patient positioning, intraoral f nger rests, and basic instrumentation—all the way to advanced techniques—assessment o periodontal patients and instrumentation o the root branches o multirooted teeth, root concavities, and urcation areas. The oremost instructional goal o Fundam entals is to make it easy or students to learn and aculty to teach instrumentation. The eighth edition retains the eatures that have made it the market-leading textbook on periodontal instrumentation and adds new eatures and content organization designed to acilitate learning and teaching. ONLINE INSTRUCTOR TEACHING RESOURCES The online Faculty Resource section has a collection o instructional aids or use in teaching instrumentation. These resources are located online at thePoint website (http://thePoint.lww.com/GehrigFundamentals8e). 1. PowerPoint Slides. The PowerPoint slides were designed so as to be user- riendly or wide variety o so tware versions and equipment. The PowerPoint presentations may be customized by saving the slides to your computer hard drive and using the ormatting eatures o your slide presentation so tware. Special e ects, such as progressive disclosure, may be added to the slide presentations using the custom animation eatures o your slide presentation so tware. In addition, individual slides may be deleted and new instructor-created slides added to the presentations. 2. Test Bank. The test bank questions can be used or quizzes, combined to make up unit tests, or combined to create midterm and f nal examinations. 3. Instructor Guide. The instructor guide includes: Suggestions or leading classroom discussions. A list o phrases that acilitate the teaching o instrumentation. Teaching tips or instruction, as well as, sources or periodontal typodonts. Guidelines or introduction o alternate and advanced techniques. 4. Module Evaluation Forms. Evaluation orms or instructor grading are now located online in two ormats. Evaluations or Computerized Grading. These orms are designed to allow the instructor to enter grades and comments directly on a computer. Evaluations or Paper Grading. These orms are designed to be printed out and used or “paper and pen” manual grading. Paper orms include evaluation orms or each module. vi Preface for Course Instructors v COn t En t ORGAn iZAt iOn From an instructional viewpoint, it is important to note that each m ajor instrum ent classif cation is addressed in a stand-alone m odule—sickle scalers, universal curets, and area-speci c curets. Each stand-alone module provides complete step-by-step instruction in the use o an instrument classi cation. For example, the module on universal curets provides complete instruction on the use o universal curets. This chapter does not rely on the student having studied the previous module on sickle scalers be ore beginning the universal curet module. This stand-alone module structure means that it is not necessary to cover the instrument modules in any particular order or even to include all o the modules. I sickle scalers, or example, are not part o the school’s instrument kit, this module does not need to be included in the course outline. t EXt BOOK FEAt URES 1. Module outlines. Each chapter begins with a module outline that provides an overview o content and makes it easier to locate material within the module. The outline provides the reader with an organizational ramework with which to approach new material. 2. Learning objectives assist students in recognizing and studying important concepts in each chapter. 3. Step-by-step format. The clear, step-by-step sel -instructional ormat allows the learner to work independently— ostering student autonomy and decision-making skills. The learner is ree to work at his or her own pace spending more time on a skill that he or she nds di cult and moving on when a skill comes easily. The sel -instructional ormat relieves the instructor rom the task o endlessly repeating basic in ormation, and rees him or her to demonstrate instrumentation techniques, observe student practice, and acilitate the process o skill acquisition. 4. Key terms are listed at the start o each module. O ne o the most challenging tasks or any student is learning a whole new dental vocabulary and gaining the con dence to use new terms with accuracy and ease. The key terms list assists students in this task by identi ying important terminology and acilitating the study and review o terminology in each instructional module. 5. Study aids—boxes, tables, and f ow charts—visually highlight and rein orce important content and permit quick re erence during technique practice and at-home review. 6. Critical thinking activities—in the Practical Focus sections o the book—encourage students to apply concepts to clinical situations, acilitate classroom discussion, and promote the development o student problem-solving skills. 7. Case-based patient experiences allow students to apply instrumentation concepts to patient cases. 8. The glossary of instrumentation terms provides quick access to instrumentation terminology. 9. Student self-evaluation checklists guide practice, promote sel -assessment skills, and provide benchmarks or aculty evaluation o skill attainment. Use o the student sel - evaluation portion o the evaluation orms should be encouraged. The sel -evaluation process helps students to develop the ability to assess their own level o competence rather than relying on instructor con rmation o skill attainment. viii Preface for Course Instructors ONLINE CONTENT In addition to the Student and Instructor Resources, the following resources are located online at thePoint website (http:/ / thePoint.lww.com/ GehrigFundamentals8e). 1B. Getting Ready for Instrumentation: M athematical Principles & Anatomical Descriptors 20B. Instrumentation of Dental Implants 21B. Alternate Clock Positions 26B. Cosmetic Polishing Procedures 27B. Set-Up of H u-Friedy/EM S Air Flow Polishing Devices I appreciate the enthusiastic comments and suggestions from educators and students about previous editions of Fundam entals, and welcome continued input. M astering the psychomotor skill of periodontal instrumentation is a very challenging process. It is my sincere hope that this textbook will help students to acquire the psychomotor skills that—combined with clinical experience—will lead to excellence in periodontal instrumentation. Jill S. Gehrig, RDH, MA Acknowledgments It is grati ying to be members o a pro ession that includes so many individuals who strive or excellence in teaching. We are most grate ul to all o the outstanding educators who shared their comments and suggestions or improving this edition. We thank all who generously gave their time, ideas, and resources, and grate ully acknowledge the special contributions o the ollowing individuals: Charles D. Whitehead and Holly R. Fischer, M FA, the highly skilled medical illustrators, who created all the wonder ul illustrations or the book. Kevin Dietz, a colleague and riend or his vision and guidance or this book. And f nally, and with great thanks, my wonder ul team at Lippincott Williams and Wilkins, without whose guidance and support this book would not have been possible: Jonathan Joyce, John Larkin, and Jennifer Clements. Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo ix Contents Module 1 ERGOn OMiCS An D PERiODOn t AL in St RUMEn t At iOn 1 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Ergonomic Risk Factors Associated with Periodontal Instrumentation 3 Foundational Skills or Periodontal Instrumentation 9 Ergonomic Dos and Don’ts or Seated Posture 11 Application o Ergonomic Principles: Seated Posture 14 Application o Ergonomic Principles: Positioning the Patient 19 Application o Ergonomic Principles: Adjusting the O verhead Light and Instrument Tray 23 Application o Ergonomic Principles: Adjusting the Patient to Facilitate Clinician Posture 25 Ancillary Equipment 28 Skill Application 36 Module 2 CLin iCiAn POSit iOn in RELAt iOn t O t HE t REAt MEn t AREA 39 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Clock Positions or Instrumentation 41 Positioning or the RIGH T-H anded Clinician 43 Positioning or the LEFT-H anded Clinician 54 M odif ed Positioning: Working rom a Standing Position 65 Skill Application 66 Module 3 in St RUMEn t GRASP 69 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Grasp or Periodontal Instrumentation 71 Grasp Variations 76 Predisposing Conditions or H and Injuries 78 Exercises or Improved H and Strength 82 Skill Application 86 x Contents x Module 4 USE OF t HE DEn t AL MOUt H MiRROR 89 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Fundamentals o M irror Use 91 Is Achieving Direct Vision Really Best? 96 Technique Practice: RIGH T-H anded Clinician 98 Technique Practice: LEFT-H anded Clinician 103 Skill Application 109 Module 5 Fin GER RESt S in t HE An t ERiOR SEXt An t S 110 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo The Intraoral Fulcrum 112 Wrist Position or Instrumentation 114 Technique Practice: RIGH T-H anded Clinician 118 Technique Practice: LEFT-H anded Clinician 131 Skill Application 145 Module 6 Fin GER RESt S in MAn DiBULAR POSt ERiOR SEXt An t S 147 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Building Blocks or Posterior Sextants 149 Technique Practice: RIGH T-H anded Clinician 151 Technique Practice: LEFT-H anded Clinician 158 Skill Application 166 Module 7 Fin GER RESt S in MAXiLLARy POSt ERiOR SEXt An t S 169 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Building Blocks or Posterior Sextants 171 Technique Practice: RIGH T-H anded Clinician 173 Technique Practice: LEFT-H anded Clinician 180 Preventive Strategies: Stretches 187 Skill Application 190 Module 8 in St RUMEn t DESiGn An D CLASSiFiCAt iOn 193 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Design Characteristics o Instrument H andle 195 Design Characteristics o Instrument Shank 198 Design Characteristics o Instrument Working-End 202 Introduction to Instrument Classif cation 207 Skill Application 210 Module 9 t ECHn iQUE ESSEn t iALS: MOv EMEn t An D ORiEn t At iOn t O t OOt H SURFACE 213 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Learning Periodontal Instrumentation 215 M oving the Instrument’s Working-End 219 Rolling the Instrument H andle 223 x Contents Pivoting on the Fulcrum 224 O rientation of Instrument to Tooth Surface 225 Skill Application 231 Module 10 t ECHn iQUE ESSEn t iALS: ADAPt At iOn 232 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Adaptation of the Working-End 234 Ergonomics of the H andle Roll for Adaptation 237 Selecting the Correct Working-End 240 Skill Application 243 Module 11 t ECHn iQUE ESSEn t iALS: in St RUMEn t At iOn St ROKES 246 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo The Instrumentation Stroke 248 Use of Pressure During Instrumentation 253 Skill Application 258 Module 12 PERiODOn t AL PROBES An D BASiC PROBin G t ECHn iQUE 260 Jill S. Gehrig, Robin Matloff, Rebecca Sroda, and Darlene Saccuzzo The Periodontal Probe 262 Assessing Tissue H ealth 266 Reading and Recording Depth M easurements 269 Probing Technique 272 Informed Consent for Periodontal Instrumentation 281 Skill Application 284 Module 13 EXPLORERS 286 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Explorers 288 Technique Practice—Anterior Teeth 293 Technique Practice—Posterior Teeth 300 Technique Alerts 307 Detection of Dental Calculus Deposits 309 Detection of Dental Caries 314 Skill Application 318 Module 14 t ECHn iQUE ESSEn t iALS: SUPRAGin Giv AL CALCULUS REMOv AL 321 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Supragingival Calculus Deposits 323 Relationship of the Instrument Face to the Tooth Surface 324 Application of Force for Calculus Removal 327 Stroke Pattern for Supragingival Calculus Removal 329 Skill Application 332 Contents x Module 15 SiCKLE SCALERS 333 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Sickle Scalers 335 Calculus Removal Concepts 338 Technique Practice—Anterior Teeth 341 M aintaining Adaptation to Proximal Sur aces 345 Technique Practice—Posterior Teeth 349 Technique Practice—Primary Teeth 356 Skill Application 359 Module 16 t ECHn iQUE ESSEn t iALS: SUBGin Giv AL CALCULUS REMOv AL 362 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo The Sense o Touch or Subgingival Instrumentation 364 Inserting a Curet Beneath the Gingival M argin 366 The Theory Behind Subgingival Instrumentation 372 Systematic Pattern or Subgingival Calculus Removal 375 Production o a Calculus Removal Stroke 378 Skill Application 384 Module 17 Un iv ERSAL CUREt S 385 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Universal Curets 387 Calculus Removal Concepts 390 Technique Practice—Posterior Teeth 392 Technique Alert—Lower Shank Position 403 Technique Practice—Anterior Teeth 405 Technique Alert—H orizontal Strokes 410 Skill Application 412 Module 18 ADv An CED PROBin G t ECHn iQUES 415 Jill S. Gehrig, Rebecca Sroda, Darlene Saccuzzo and Christine Dominick The Periodontal Attachment System 417 Assessments with Calibrated Probes 420 Assessments that Require Calculations 427 Assessments with Furcation Probes 432 Skill Application 444 Module 19 AREA-SPECiFiC CUREt S 450 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Area-Specif c Curets 452 Technique Practice—Anterior Teeth 459 Technique Practice—Posterior Teeth 463 Instrumentation Techniques on Root Sur aces 474 Production o a Root Debridement Stroke 477 x Contents Design O verview: Scalers and Curets 479 Skill Application 481 Module 2 0 SPECiALiZED PERiODOn t AL in St RUMEn t S 487 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Periodontal Files 489 M odif ed Langer Curets 497 M odif ed Gracey Curets or Advanced Root Instrumentation 499 Q uétin, O ’H ehir, DeM arco Curets and Diamond-Coated Instruments 507 Subgingival Dental Endoscope 513 Skill Application 516 Module 21 ADv An CED t ECHn iQUES FOR ROOt in St RUMEn t At iOn 518 Jill S. Gehrig, Cynthia Biron Leisica, Rebecca Sroda, and Darlene Saccuzzo Anatomical Features that Complicate Instrumentation o Root Sur aces 521 Introduction to Root Instrumentation 529 Advanced Intraoral Techniques or Root Instrumentation 533 Advanced Extraoral Fulcruming Techniques 536 Technique Practice: Extraoral Finger Rests or Right-H anded Clinicians 542 Technique Practice: H orizontal Strokes or Right-H anded Clinicians 549 Technique Practice: Extraoral Finger Rests or Le t-Handed Clinicians 552 Technique Practice: H orizontal Strokes or Le t-H anded Clinicians 559 Skill Application 563 Module 22 FiCt it iOUS PAt iEn t CASES: COMMUn iCAt iOn An D PLAn n in G FOR SUCCESS 564 Jill S. Gehrig, Rebecca Sroda, Darlene Saccuzzo Understanding and Explaining Instrumentation 566 Planning or Calculus Removal 571 Practical Focus—Fictitious Patient Cases 574 Module 23 COn CEPt S FOR in St RUMEn t SHARPEn in G 592 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Introduction to Sharpening Concepts 594 Preserving Working-End Design 599 Planning or Instrument M aintenance 604 Sharpening Armamentarium 605 Skill Application 609 Module 24 in St RUMEn t SHARPEn in G t ECHn iQUES 610 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Removing M etal to Restore a Sharp Cutting Edge 612 The M oving Instrum ent Technique 616 The M oving Stone Technique 624 Evaluating Sharpness 636 Contents x Sharpening a Periodontal File 637 Skill Application 639 Module 25 PAin COn t ROL DURin G PERiODOn t AL in St RUMEn t At iOn 640 Donald E. Willmann Pain Control During Dental H ygiene Care 642 Strategies to Allay the Fear o Pain During Periodontal Instrumentation 644 Using Local Anesthesia or Pain Control During Periodontal Instrumentation 647 Module 26 POWERED in St RUMEn t DESiGn An D FUn Ct iOn 657 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Introduction to Powered Instrumentation 660 Powered Working-End Design 676 Adaptation—O rientation o Working-End to Tooth 682 Transverse Working-End O rientation or Calculus Removal rom Coronal Sur aces and Slightly Below the Gingival M argin 685 Vertical Working-End O rientation or Use in Periodontal Pockets 689 Instrumentation Challenges 691 Technique H ints or Powered Instrumentation 695 Set-Up o an Ultrasonic Unit 699 Skill Application 702 Module 27 AiR POLiSHin G FOR BiOFiLM MAn AGEMEn t An D St Ain REMOv AL 709 Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo The Signif cance o Biof lm M anagement 711 M ethods o Biof lm M anagement 712 Clinical Evidence or Subgingival Air Polishing 720 Supragingival Polishing: Using a Standard N ozzle and Conventional Sodium Bicarbonate Powder 721 Subgingival Polishing Using a Standard M etal N ozzle and Glycine-Based Powder 723 Subgingival Polishing Using a Flexible Plastic Tip and Glycine-Based Powder 726 Posttreatment Precautions and Instructions 732 Skill Application 733 Appe d x PROBLEM iDEn t iFiCAt iOn : DiFFiCULt iES in in St RUMEn t At iOn 737 Jill S.Gehrig x Contents On Lin E COn t En t (h p:// hepo.lww.com/Gehr gFu dame als8e) Module 1B GEt t in G READy FOR in St RUMEn t At iOn : MAt HEMAt iCAL PRin CiPLES An D An At OMiC DESCRiPt ORS Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Module 20B DEBRiDEMEn t OF DEn t AL iMPLAn t S Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Module 21B ALt ERn At E CLOCK POSit iOn S Cynthia Biron Leisica Module 26B COSMEt iC POLiSHin G PROCEDURES Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Module 27B SEt -UP OF AiR POLiSHin G DEv iCES Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo St UDEn t An D in St RUCt OR RESOURCES Sharon Logue, Rebecca Sroda, and Jill S. Gehrig, Rebecca Sroda, and Darlene Saccuzzo Glossar Index 745 e l u d o M 1 Ergonomics and Periodontal Instrumentation Module Overview This m intr c s th princip s p siti ning r p ri nta instr m ntati n. C rr ct p siti ning t chniq s h p t (1) pr v nt c inician isc m rt an inj ry, (2) p rmit a c ar vi w th t th b ing w rk n, (3) a w asy acc ss t th t th ring instr m ntati n, an (4) aci itat f ci nt tr atm nt th pati nt. Prior to beginning this module, readers should review the online resource: Getting Rea dy for Instrumenta tion: Ma thema tica l Principles a nd Ana tomica l Descriptors. Module Outline Section 1 Ergonomic Risk Factors Associated with Periodontal Instrumentation 3 What is Ergonomics and Why Should Hygienists Care? Ergonomic Hazards for Dental Hygienists Musculoskeletal Problems Common in Dental Hygienists Section 2 Foundational Skills for Periodontal Instrumentation 9 Section 3 Ergonomic Dos and Don’ts for Seated Posture 11 Neutral Position for the Clinician Section 4 Application of Ergonomic Principles: Seated Posture 14 Skill Building. Neutral Seated Position for the Clinician, p. 14 Skill Building. The Masking Tape Trick, p. 17 Important Elements of the Seated Position Section 5 Application of Ergonomic Principles: Positioning the Patient 19 Supine and Semi-Supine Patient Position Patient Head Position Patient Head Adjustment for Optimal Visibility Section 6 Application of Ergonomic Principles: Adjusting the Overhead Light and Instrument Tray 23 Positioning the Overhead Dental Light Positioning the Instrument Tray 1 Section 7 Application of Ergonomic Principles: Adjusting the Patient to Facilitate Clinician Posture 25 Skill Building. Establishing the Height of the Patient Chair, p. 27 Section 8 Ancillary Equipment 28 Dental Headlights: Coaxial Illumination Magnif cation Loupes Section 9 Skill Application 36 Practical Focus: Selecting a Clinician Stool Online Module Skill Evaluations Student Sel -Evaluation Module 1: Position Acc ss th onlin mo ul , Getting Ready for Instrumentation: Mathematical Principles and Anatomical Descriptors. This mo ul can b vi w at http://th point.lww.com/ G hrigFun am ntals8 Key Terms ergonomics R p titiv task d ntal h a lights Musculosk l tal Supin position Magnif cation loup s isor r S mi-supin position Working istanc Postur Chin-up position Angl o clination N utral postur Chin- own position d pth o f l Static postur Coaxial illumination Fi l o vi w Forc sourc s Blin zon Learning Objectives d f n th t rm rgonomics an iscuss how rgonomic principl s ar h lp ul in th practic o ntal hygi n. d f n th t rm musculosk l tal isor r (MSd ) an iscuss th signif canc o MSd s in th practic o ntal hygi n. Nam our rgonomic hazar s or ntal hygi nists. d v lop an un rstan ing an appr ciation or rgonomic gui lin s to minimiz th xposur o ntal hygi nists to musculosk l tal str ss. I nti y musculosk l tal isor rs commonly xp ri nc by ntal h alth pro ssionals, th ir caus s an pr v ntion. d iscuss an monstrat th l m nts o n utral s at postur or th clinician. d monstrat corr ct pati nt position r lativ to th clinician an positioning o ntal quipm nt so that it nhanc s n utral clinician postur. Stat th r ason why it is important that th top o th pati nt’s h a is v n with top g o th chair h a r st. d monstrat how to corr ctly position a short in ivi ual an a chil in th ntal chair so that (1) th pati nt is com ortabl an (2) th clinician has goo vision an acc ss to th oral cavity. In th pr clinical or clinical s tting, s l - valuat to i nti y th us o incorr ct rgonomic principl s an monstrat how to corr ct th probl m(s). Module 1 Ergonomics and Periodontal Instrumentation 3 Se ctio n 1 Ergonomic Risk Factors Associated with Periodontal Instrumentation WHAT IS ERGONOMICS AND WHY SHOULD HYGIENISTS CARE? 1. Ergonomics is an applied science concerned with the ‘ t’ between people and their technological tools and environments (1). A. In application, ergonomics is a discipline focused on making products and tasks comfortable and ef cient for the user. 1. A primary ergonomic principle is that equipment—such as computer keyboards and workstations—should be designed to t the user instead of forcing the user to t the equipment. 2. Ergonomics is the science of making things ef cient. Ef ciency is quite simply making something easier to do. B. Poor Ergonomic Working Conditions and Working Practices. When the t between an individual and his or her tools and working environment is less than optimal studies show that worker comfort, productivity, and workplace safety all suffer (1). For dental hygienists the work environment includes the dental of ce layout, dental equipment, and instruments. 2. Musculoskeletal Stresses and the Dental Professional. The dental literature indicates that both dentists and hygienists are exposed to ergonomic risk factors that often lead to discomfort, pain, and even disability. A. A musculoskeletal disorder (MSD) is a condition where parts of the musculoskeletal system—muscles, tendons, nerves—are injured over time. 1. MSDs occur when too much stress is exerted on a body part resulting in pain. When a body part is overused repeatedly the constant stress causes damage. 2. Almost all occupations require workers to use their arms and hands. Therefore, most M SDs affect the hands, wrists, elbows, neck, and shoulders. B. Prevalence of Musculoskeletal Problems in Dental Professionals 1. M any studies have investigated the prevalence of M SDs among dental professionals. A systemic review on this topic found that the prevalence of M SDs ranged as high as 64% to 93% (2). 2. Despite this high prevalence, there is a lack of evidence regarding the ef cacy of preventive measure for M SDs for the dental hygiene profession (3). A complete understanding of the progression of M SDs in dental hygienists is still far from being realized, due to the lack of longitudinal studies and standardized research techniques (3–5). C. Causes of Musculoskeletal Pain in Dental Professionals 1. The literature indicates that the causes of M SDs among periodontists and dental hygienists include excessive use of small hand muscles, forceful repetitive motions while maintaining muscles in same position during application of force, tight grips, and a xed work position (maintaining the body in one position for extended periods) (2–13). 2. The result is injury to the muscles, nerves, and tendon sheaths of the back, shoulders, neck, arms, elbows, wrists, and hands that can cause loss of strength, impairment of motor control, tingling, numbness, or pain. 4 Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation 3. Given the high incidence of musculoskeletal pain, it is important for clinicians to understand the causes of M SDs and to take actions to prevent them. D. Ergonomic Guidelines in Dentistry 1. It is important that dental hygiene students complete instructional modules on ergonomic principles during their education and training (3,5). 2. Research shows that among practicing hygienists, education on patient and clinician positioning can help reduce the risk of M SDs (4,14,15). 3. It is possible to de ne ergonomic guidelines to minimize exposure of dental healthcare providers to musculoskeletal stress. ERGONOMIC HAZARDS FOR DENTAL HYGIENISTS Four signi cant ergonomic hazards during periodontal instrumentation are (1) awkward clinician posture, static ( xed) working position, the force placed on a body part, and (4) repetitive movements. Figure 1-1 summarizes these hazards that can lead to musculoskeletal injury. 1. Awkward Postures. Posture is a term for the position of various parts of the body during an activity. A. For most joints, ideal or neutral posture means that the joint is being used near the middle of its full range of motion. B. The further a joint moves away from neutral posture, the more strain is placed on the muscles, tendons, and ligaments around the joint (37). For example, if an individual stands with his or her arms outstretched in front of the body, the elbow and shoulder joints are at their range of motion. If the individual pulls or lifts repeatedly in this outstretched position—versus held close to the body—there is a high risk of injury. C. The literature con rms the presence of awkward postures speci cally in the neck, shoulders, back, wrist, and hand for dental hygienists. Awkward postures often are adopted due to improper adjustment of the clinician’s chair, improper patient position in relation to the clinician, and poor work techniques. D. When dental hygienists use their bodies in awkward positions, the muscles must generate higher forces to accomplish a task than when muscles are used in a neutral position (38). E. A common awkward posture in dental hygienists is wrist exion, which results in stress to neurovascular structures and ligaments. Poor wrist positioning can diminish grip strength (39). Figure 1-2 shows the reduction in strength that occurs as the wrist deviates further away from its neutral posture (37). Ac kward Po s ture s Fixe d wo rking po s itio ns (s tatic po s ture s ) Fo rc e Re pe titive mo ve me nts Figure 1-1. Ergonomic Hazards for Dental Hygienists. The dental hygienist has a high risk of musculoskeletal injury when awkward postures, static postures, and repetitive motions are combined with forceful movements (42–45). Module 1 Ergonomics and Periodontal Instrumentation 5 75% full s tre ng th Ne utral po s ture 100% full s tre ng th Figure 1-2. Ef ect o Poor Positioning on Wrist 60% full s tre ng th Strength. This illustration shows the reduction in strength that occurs as the wrist deviates away from 40% full s tre ng th its neutral position (37). 2. Static Postures A. A static posture is de ned as a xed working position (maintaining the body in one position for an extended period of time) (1). The human body was not designed to maintain the same body position—prolonged static posture—hour after hour, day after day. In a static position, tensed muscles compress the blood vessels and reduce blood ow decreasing the oxygen and energy supply to the muscles. Waste products from the muscles accumulate causing muscle fatigue and eventually pain (1). B. Dental clinicians have been observed statically holding postures that require greater than 50% of the body’s musculature to contract (37). C. Static gripping of instrument handles for durations exceeding 20 minutes is common during periodontal instrumentation (40). 3. Force A. Force refers to the amount of effort created by the muscles, as well as, the amount of pressure placed on a body part. B. H olding a small instrument for a prolonged period of time is an example of a gripping task requiring high force application. This task is commonly performed with a pinch grip where the ngers are on one side of the object and the thumb is on the other. This form of gripping is undesirable, as it requires a much greater force application than holding an object in the palm of the hand. C. Researchers suggest that excessive use of a pinch grip is the greatest contributing risk factor in the development of M SDs among dental hygienists (40,41). 4. Repetitive Movements A. Silverstein (42), in an article in the British Journal of Industrial M edicine, de ned a repetitive task as a task that involves the same fundamental movement for more than 50% of the work cycle. Periodontal instrumentation would certainly be categorized as a repetitive task under this de nition. B. The human body was not designed to engage in ne hand movements hour after hour, day after day. The risk of developing an MSD increases when the same or similar parts of the body are used continuously, with few breaks or changes for rest (37). C. Periodontal instrumentation requires excessive upper-body immobility while the tendons and muscles of the forearms, hands, and ngers overwork. Three critical components to consider with repetitive motions include: 1. Frequency: how many times an action is repeated; such as how many instruments are gripped by one hand throughout the day. 2. Duration: how long an action is performed; such as the length of time sitting in a static posture during the workday. 3. Recovery time: periods of rest that break a repetitive cycle, such as time spent doing muscle stretches between patients. 6 Fundamentals o Periodontal Instrumentation & Advanced Root Instrumentation MUSCULOSKELETAL PROBLEMS COMMON IN DENTAL HYGIENISTS M SDs commonly experienced by dental hygienists and periodontists are illustrated in Figures 1-3 to 1-10. Figure 1-3. Thoracic Outlet Syndrome 1. Def nition A painful disorder of the ngers, hand, and/ or wrist due to the compression of the brachial Th o ra c ic o u t le t nerve plexus and vessels between the neck and Bra c h ia l n e rve p le xu s shoulder Bra c h ia l a rt e ry 2. Causes Tilting the head forward, hunching the shoulders forward, and continuously reaching overhead 3. Symptoms N umbness, tingling, and/or pain in the ngers, hand, or wrist S ub a c ro m ia l b urs a C la v ic le Figure 1-4. Rotator Cuf Tendinitis 1. Def nition A painful in ammation of the muscle tendons in the shoulder region 2. Causes Te n d o n s H olding the elbow above waist level and holding the upper arm away from the body 3. Symptoms Severe pain and impaired function of the shoulder joint Figure 1-5. Pronator Syndrome 1. Def nition A painful disorder of the wrist and hand caused by compression of the median nerve between the two heads of the pronator teres muscle 2. Causes H olding the lower arm away from the body Me d ia n P rona tor te re s 3. Symptoms ne rve mus c le Similar to those of carpal tunnel syndrome Module 1 Ergonomics and Periodontal Instrumentation 7 Figure 1-6. Extensor Wad Strain 1. Def nition A painful disorder of the ngers due to injury of the extensor muscles of the thumb and ngers Ext e n s o r m u s c le s 2. Causes Extending the ngers independently of each other 3. Symptoms N umbness, pain, and loss of strength in the ngers Figure 1-7. Carpal Tunnel Syndrome (CTS) 1. Def nition A painful disorder of the wrist and hand caused by compression of the median nerve within the carpal tunnel of the wrist Uln a r 2. Causes n e rve The nerve bers of the median nerve originate in the spinal cord in the neck; therefore, poor C a rp a l posture can cause symptoms of CTS. O ther lig a m e n t causes include repeatedly bending the hand up, down, or from side-to-side at the wrist and Me d ia n n e rve continuously pinch-gripping an instrument C a rp a l without resting the muscles b one s Fle xo r t e n d o n s 3. Symptoms N umbness, pain, tingling in the thumb, index, and middle ngers Figure 1-8. Ulnar Nerve Entrapment 1. Def nition A painful disorder of the lower arm and wrist caused by compression of the ulnar nerve of the arm as it passes through the wrist 2. Causes Bending the hand up, down, or from side-to- side at the wrist and holding the little nger a full span away from the hand 3. Symptoms Uln a r N umbness, tingling, and/or loss of strength in n e rve the lower arm or wrist 8 Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation Figure 1-9. Tenosynovitis 1. Def nition A painful in ammation of the tendons on the side of the wrist and at the base of the thumb 2. Causes Te n d o n s H and twisting, forceful gripping, bending the hand back or to the side Lig a m e n t 3. Symptoms S yn o via l s he a ths Pain on the side of the wrist and the base of the thumb; sometimes movement of the wrist yields a crackling noise Figure 1-10. Tendinitis 1. Def nition A painful in ammation of the tendons of the Te nd ons wrist resulting from strain 2. Causes Repeatedly extending the hand up or down at the wrist 3. Symptoms Synovia l s he a ths Pain in the wrist, especially on the outer edges of the hand, rather than through the center of Liga me nt the wrist Module 1 Ergonomics and Periodontal Instrumentation 9 Se ctio n 2 Foundational Skills for Periodontal Instrumentation Periodontal instrumentation is a complex psychomotor skill that involves the precise execution of many individual component skills. Swinging a golf club is an everyday example of a complex psychomotor skill that involves many component skills, for example, proper stance, grip on the club handle, position of the golfer’s head, and movement to swing the golf club. 1. Foundational Building Blocks of Periodontal Instrumentation. M any building blocks—individual skill components—are involved in periodontal instrumentation. These building blocks are discussed below and illustrated in Figure 1-11. A. Building Block 1: Position. The building block of “ positioning” entails the proper use of equipment, as well as, positioning the patient and clinician. B. Building Block 2: Instrument Grasp. This building block involves the way in which the clinician holds a periodontal instrument. C. Building Block 3: Mirror Use. A dental mirror allows a clinician to view tooth surfaces or other oral structures that are obscured from direct viewing. D. Building Block 4: Finger Rests. This building block entails the manner in which the clinician stabilizes his or her hand in the oral cavity during periodontal instrumentation. E. Building Block 5: Stroke Production. This building block refers to the manner in which the working-end of a periodontal instrument is moved against the tooth surface. Stroke production is a complex skill that involves several smaller component skills—activation, adaptation, and angulation—that are discussed later in this book. S t ro k e Fin g e r R e s ts Mirro r Gra s p P o s it io n Figure 1-11. Building Blocks for Periodontal Instrumentation. Success ul periodontal instrumentation requires the mastery the individual skill components o position, grasp, mirror use, f nger rests, and stroke production. 10 Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation 2. Signif cance o the Building Blocks or Periodontal Instrumentation A. Precise Per ormance. 1. Precise, accurate performance of the building blocks is essential if periodontal instrumentation is to be effective, ef cient, safe for the patient, and comfortable for the clinician. 2. Research on psychomotor skill acquisition indicates that a high level of mastery in the performance of skill building blocks is essential to successful mastery of periodontal instrumentation. a. The building block skills are the foundation that “ supports” successful periodontal instrumentation. b. These skills should be mastered one-by-one. c. Each skill should be overlearned until it can be performed easily and without hesitation. It is impossible to devote too much time to the practice of these building block skills. d. If the building block skills are mastered, then the use of any periodontal instrument will be relatively easy to learn. The building block skills are the same no matter which periodontal instrument is used. B. Faulty Per ormance. Incorrect performance of even one of the building blocks means that at the very least periodontal instrumentation will be inef cient. M ost likely faulty performance results in ineffective calculus removal, unnecessary discomfort for the patient, and musculoskeletal stress to the clinician. 3. Sequencing o Building Block Skills A. The modules (chapters) in this book are sequenced to allow beginning clinicians to practice the building blocks to periodontal instrumentation one-by-one. B. Each building block should be practiced until it is easy to perform from memory before attempting the next building block in the skill sequence. BUILDING BLOCK SKILLS. The puzzle piece shown here appears throughout the book to alert clinicians to the individual skill compo- nents of periodontal instrumentation. Module 1 Ergonomics and Periodontal Instrumentation 11 Se ctio n 3 Ergonomic Dos and Don’ts for Seated Posture NEUTRAL POSITION FOR THE CLINICIAN 1. Ergonomic Do’s and Don’ts A. Ergonomic Don’ts 1. When a dental hygienist alters his or her body position or equipment in a manner that is uncomfortable or painful just to “ get the job done,” musculoskeletal stress is the result. 2. A mindset that it is acceptable to assume an uncomfortable position “ just for 15 minutes while performing periodontal instrumentation on these two teeth” is destined to lead to M SDs. 3. Pain and injury results when the body’s natural spinal curves are not maintained in a seated position. B. Ergonomic Do’s 1. For a healthy and productive career, f rst, the dental hygienist assumes a neutral, balanced body position and then alters the patient’s chair and dental equipment to complete periodontal instrumentation. 2. Good posture requires the seated dental hygienist to use a neutral spine position that maintains the natural curves of the spine (Fig. 1-12). 2. N eutral Body Position A. Spine Basics: The Curves of a Healthy Back 1. The spine is made up of three segments: the cervical, thoracic, and lumbar sections. 2. The spine has three natural curves that form an S-shape (46). When the three natural curves are properly aligned, the ears, shoulders, and hips are in a straight line. a. When viewed from the side, the cervical and lumbar segments have a slight inward curve (lordosis). b. When viewed from the side, the thoracic segment of the spine has a gentle outward curve (kyphosis). B. N eutral Body Position for the Clinician. Figures 1-13 to 1-19 illustrate the characteristics of neutral body position for the clinician. Ce rvic a l s p ine (Lo rd os is ) Thora c ic s p ine (Kyp ho s is ) Lumb a r s p ine (Lo rd os is ) Figure 1-12. Three Curves of a Healthy Back. The spine has three natural curves: cervical, thoracic, and lumbar curves. The cervical and Sa c rum a nd c oc c yx lumbar segments have a gentle inward curve. The thoracic segment has a slight outward curve. 12 Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation 20 OK AV OI D Figure 1-13. Neutral Neck Position Goal: H ead tilt of 0 to 20 degrees The line from eyes to the treatment area should be as near to vertical as possible Avoid: H ead tipped too far forward H ead tilted to one side OK AV O ID Figure 1-14. Neutral Back Position Goal: Lean forward slightly from the hips (hinge at hips) Trunk exion of 0 to 20 degrees Avoid: O ver exion of the spine (curved back) Figure 1-15. Neutral Torso Position Goal: Torso in line with long axis of the body Avoid: Leaning torso to one side Twisting the torso AVOID AVOID Figure 1-16. Neutral Shoulder Position OK Goal: Shoulders in horizontal line Weight evenly balanced when seated Avoid: Shoulders lifted up toward ears OK Shoulders hunched forward AVOID AVOID Sitting with weight on one hip Module 1 Ergonomics and Periodontal Instrumentation 13 Figure 1-17. Neutral Upper Arm Position Goal: Upper arms hang parallel to the long axis of torso Elbows at waist level held slightly away from body Avoid: Greater than 20 degrees of elbow abduction away A VO ID I O from the body D OK OK AV Elbows held above waist level AVOID Figure 1-18. Neutral Forearm Position Goal: H eld parallel to the oor Raised or lowered, if necessary, by pivoting at the OK elbow joint Avoid: Angle between forearm and upper arm of less than 60 degrees Figure 1-19. Neutral Hand Position Goal: Little nger-side of palm is slightly lower than thumb- side of palm Wrist aligned with forearm Avoid: AVOID Thumb-side of palm rotated down so that palm is parallel to oor OK H and and wrist bent up or down 14 Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation Se ctio n 4 Application of Ergonomic Principles: Seated Posture Ergonomic principles can reduce the risk of developing an M SD by reducing muscle forces during periodontal instrumentation. Attention to the principles for neutral seated clinician posture can minimize the amount of physical stress that occurs during instrumentation. SKILL BUILDING Neutral Seated Posture for the Clinician Directions: Practice the neutral clinician posture by following the steps 1 to 9 as illustrated in Figures 1-20 to 1-28. The ideal seated position for the clinician is called the neutral seated position. Adjust the clinician stool f rst. A common mistake clinicians make is positioning the patient f rst and then adjusting the clinician stool to accommodate the patient. Figure 1-20. Step 1. Position the buttocks all the way back in the chair. Distribute the body’s weight evenly on both hips. Figure 1-21. Step 2. Adjust seat height so the feet rest at on the oor. Establish a “ wide base of support” with feet on oor at least shoulder-width apart and in front of the hips (19). Legs should not dangle or be crossed at the knees or ankles. Dangling legs or crossing them puts pressure on the back of the thighs and restricts blood ow. Module 1 Ergonomics and Periodontal Instrumentation 15 Figure 1-22. Step 3. Adjust the seat tilt so that the back is about an inch higher than the front (hips slightly higher than the knees) (16,17,19,20,22–24). The seat tilt helps to maintain the natural lower curve of the spine and relaxes the bend of the knees. The seat tilt should only be about 5 degrees; overtilting it can cause too much low back curve. N ote: Chairs without a tilt feature can be retro tted with an ergonomic wedge-shaped cushion. Figure 1-23. Step 4. With buttocks seated all the way back in the chair, adjust the lumbar depth by moving the backrest closer or farther from the seat pan until the backrest nestles against the lower back. The unsupported lower back tends to straighten rather than maintain a healthy curve (21,24). Figure 1-24. Step 5. Adjust the lumbar height by moving the backrest up or down until it nestles in the natural lumbar curve of the lower back. This helps to support the natural curve of the spine (21). Figure 1-25. Step 6. Raise the tailbone up to establish correct spinal...Ta ilb o n e u p curves. All three normal back curves should be present while sitting. Studies of the seated body show that the position of the pelvis determines the shape of the spine (23). 16 Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation Figure 1-26. Step 7. Stabilize the low back curve by pulling the stomach muscles toward the spine (25). Figure 1-27. Step 8. Relax your shoulders so that they are down and back (16). If your stool has armrests, adjust the height of each arm so the arms are supported. This helps take the weight off the shoulders. Figure 1-28. Step 9. Position the upper arms parallel to the long axis of the torso with elbows held near the body. M aintain a trunk position such that an imaginary straight line can be drawn connecting from the ear, shoulder, and hips (19). Module 1 Ergonomics and Periodontal Instrumentation 17 SKILL BUILDING The Masking Tape Trick An easy way to monitor back position while practicing instrumentation in a preclinical setting is to use the “ masking tape trick.” While sitting with your back in a neutral position, have a friend apply a strip of masking tape down the center of your back, along your spinal column. Figure 1-29 shows how the masking tape will appear when a clinician is seated in neutral position. If a clinician bends forward, out of neutral position, the masking tape breaks as shown in Figure 1-30. Figure 1-29. Correct Position—Neutral Back Figure 1-30. Incorrect Position—Rounded Position. Maintain a neutral back position Back Position. The masking tape strip will while practicing positioning or perio ontal tear if you ben over, roun ing your back instrumentation an the strip of masking tape while practicing positioning or perio ontal remains intact an straight. (Photo courtesy instrumentation. Torn masking tape will alert of d r. Richar Foster, Guilfor Technical you to problems with your seate position. Community College, Jamestown, NC.) (Photo courtesy of d r. Richar Foster, Guilfor Technical Community College, Jamestown, NC.) 18 Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation IMPORTANT ELEMENTS OF THE SEATED POSITION Figures 1-31 and 1-32 depict important elements of the seated clinician position. Figure 1-31. Correct Feet Position. The eet shoul be positione to create a “wi e base o support” or the seate clinician. That is, the eet shoul be f at on the f oor about a shoul er’s wi th apart or i eal balance while seate. Figure 1-32. Incorrect Feet Position for Seated Clinician A. Narrow Base of Support. A narrow base o support with the eet together or tucke un er the chair inter eres with the clinician’s balance an can limit his or her range o motion uring instrumentation. B. Crossed Legs. Crossing the legs at the knees or ankles restricts bloo f ow to the legs an eet. In a ition, this position places more weight on one si e o the hip an inter eres with the clinician’s balance uring perio ontal instrumentation. (Photos courtesy o d r. Richar Foster, Guil or Technical Community College, Jamestown, NC.) Module 1 Ergonomics and Periodontal Instrumentation 19 Se ctio n 5 Application o Ergonomic Principles: Positioning the Patient SUPINE AND SEMI-SUPINE PATIENT POSITION The recommended patient position for dental treatment is with the patient lying on his or her back. For maxillary treatment areas, the back of the dental chair is nearly parallel to the oor in a supine position (Table 1-1, Fig. 1-33). For mandibular treatment areas, the back of the dental chair is slightly upright in a semi-supine position (Table 1-2, Fig. 1-34). TABLE 1 -1. POSITION FOR MAx ILLARY TREATMENT AREAS Figure 1 33. Patient Position or the Ma illary Arch. Body The patient’s eet should be even with or slightly higher than the tip o his or her nose. Chair Back The chair back should be nearly parallel to the f oor for maxillary treatment areas. Head The top o the patient’s head should be even with the upper edge o the headrest. If necessary, ask the patient to slide up in the chair to assume this position. Headrest Adjust the headrest so that the patient’s head is in a chin up position, with the patient’s nose and chin level. Patient head position is discussed in more detail later in this chapter. 20 Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation TABLE 1 -2. POSITION FOR MANDIBULAR TREATMENT AREAS 15 Figure 1 34. Patient Position for the Mandibular Arch. Body The patient’s feet should be even with or slightly higher than the tip of his or her nose. Chair Back The chair back should be slightly raised above the parallel position at a 15- to 20-degree angle to the f oor (24) Head The top of the patient’s head should be even with the upper edge of the head rest. I necessary, ask the patient to slide up in the chair to assume this position. Headrest Raise the headrest slightly so that the patient’s head is in a chin down position, with the patient’s chin lower than the nose. Patient head position is discussed in greater detail later in this chapter. Module 1 Ergonomics and Periodontal Instrumentation 21 PATIENT HEAD POSITION The patient’s head position is an important factor in determining whether the clinician can see and access the teeth in a treatment area. Unfortunately, a clinician may ignore this important aspect of patient positioning, contorting his or her body into an uncomfortable position instead of asking the patient to change head positions. Working in this manner not only causes stress on the musculoskeletal system, but also makes it dif cult to see the treatment area. Remember that the patient is only in the chair for a limited period of time while the clinician spends hours at chairside day after day. The patient should be asked to adjust his or her head position to provide the clinician with the best view of the treatment area. The patient’s head should be positioned at the upper edge of the headrest. This position permits maximal visibility and access to the oral cavity. Figure 1-35A and B depicts correct patient head position for an adult and a young child. Incorrect head position is shown in Figure 1-36. Figure 1-35. Correct Position. A. Adult Patient. o nce the patient chair is in a supine r semi-supine p siti n, ask the patient t slide up until his r her head is even with the t p edge f the headrest. B. Young Child. Asking a y ung child t bend the knees and cr ss the legs may be helpful in keeping him r her fr m sliding d wn in the chair. Figure 1-36. Incorrect Position. The patient may slide d wn in the chair when the patient chair is reclined. If patient’s head is n t even with the upper edge f the headrest, access and visibility f the ral cavity is restricted. 22 Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation PATIENT HEAD ADJUSTMENT FOR OPTIMAL VISIBILITY O nce the patient is comfortably lying in a reclined position, the next objective is to ask the patient to adjust his of her head position to attain an optimal view of the treatment area. The patient can (1) tilt the head up or down, (2) rotate the head toward or away from the clinician, and (3) bend the head to the side (Figs. 1-37 to 1-40). Articulating (adjustable) headrests facilitate adjustment of the patient’s head. Cervical rolls can be used with nonarticulating headrests to maintain patient head position. Figure 1-37. Patient Head Tilt for Maxillary Arch. Angle the headrest up into the back of the patient’s head (occipital area) so that the nose and chin are approximately level (48). The upper arch needs to be angled backward past the vertical plane. This patient head position is known as the chin-up position. Figure 1-38. Patient Head Tilt for Mandibular Arch. Angle the headrest forward and down, so that the chin is lower than nose level (48). The occlusal or incisal surfaces of the treatment area should approximately parallel to the oor. This patient head position is known as the chin- down position. Figure 1-39. Patient Head Rotation for Both Arches. Ask the patient to rotate his or her head for easy access to the treatment area. Positions include turning toward the clinician, looking straight ahead, and turning slightly away from the clinician. Figure 1-40. Bending the Head to the Side. If the patient chair has a at, nonarticulated headrest, it is helpful to ask the patient to side- bend the head toward the clinician and then turn his or her head for the treatment area. This technique can position the oral cavity 2 to 3 in closer to the clinician and enhance viewing of the treatment area. Module 1 Ergonomics and Periodontal Instrumentation 23 Se ctio n 6 Application of Ergonomic Principles: Adjusting the Overhead Light and Instrument Tray POSITIONING THE OVERHEAD DENTAL LIGHT Ideally, the overhead dental light is positioned so that the light beam is parallel to the clinician’s line of sight (22,24,49). For mandibular treatment areas, the overhead dental light is positioned so that the light beam is approximately perpendicular to the oor (Fig. 1-41). For maxillary treatment areas, it usually is not possible to direct the light beam identically to the clinician’s line of sight. For maxillary areas, it often is necessary to move the dental light above the patient’s neck and angle the light beam into the mouth (Fig. 1-42). It is signi cant to note that dental hygienists whose overhead dental lights are positioned farther away from their sight lines (toward the patient’s waist) are more likely to experience lower back pain (22,24,49). It is necessary to make tiny adjustments to the light throughout periodontal instrumentation—seldom is the light positioned for an arch and left in the identical position until moving to the opposite arch. As the clinician works around a dental arch and as the patient looks toward or away from the clinician, the dental light requires minor adjustments. Figure 1-41. Light Position for Mandibular Arch. For the mandibular treatment areas, the overhead dental unit light is positioned directly over the oral cavity. Position the light at arm’s length within comfortable reach. Avoid positioning the light close to the patient’s head. The patient is in a chin-down head position. The light beam is directed approximately perpendicular to the oor. Figure 1-42. Light Position for Maxillary Arch. The maxillary treatment areas, the position of the overhead dental unit light ranges from being directly over the oral cavity to a position over the patient’s neck. Position the light at arm’s length within comfortable reach. Ideally, the light beam always would be perpendicular to the oor, but this is not always possible using an overhead dental light. This is why a coaxial illumination source is ideal. Coaxial illumination is discussed later in this chapter. The patient is in a chin-up position. The direction of the light beam ranges from perpendicular to the oor to a 60- to 90-degree angle to the oor. 24 Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation POSITIONING THE INSTRUMENT TRAY The instrument tray should be positioned within easy reach of the clinician’s dominant hand as shown in Figure 1-43. Incorrect positioning of the instrument tray as depicted in Figure 1-44 places unnecessary stress on the clinician. Figure 1-43. Correct Positioning of the Instrument Tray. A. Front/Side Delivery. Instrument tray positioned correctly for front or side delivery within easy reach of the clinician’s dominant hand. B. Rear Delivery. Instrument tray positioned correctly for rear delivery within easy reach of the clinician’s dominant hand. Figure 1-44. Incorrect Positioning of Instrument Tray. A combination of positioning errors is demonstrated in this photo. The patient’s oral cavity is positioned too high at midsternum level, instead of at the clinician’s waist-level. The bracket table is positioned too far from the clinician. She would have to stretch to reach the instrument. Module 1 Ergonomics and Periodontal Instrumentation 25 Se ctio n 7 Application of Ergonomic Principles: Adjusting the Patient to Facilitate Clinician Posture A major component in avoiding fatigue and injury is proper positioning of the patient and dental equipment in relation to the seated clinician. While working, the clinician must be able to gain access to the patient’s mouth and the dental unit without bending, stretching, or holding his or her elbows above waist level. The neutral seated position is established f rst, and then everything else—the patient chair, the patient’s head, the dental unit light, and other dental equipment are adjusted to acilitate maintenance o the neutral seated position. Box 1-1 (Fig. 1-45) provides an overview of the relationship of the patient chair to the seated clinician while Figures 1-46 and 1-47 demonstrate correct and incorrect positioning. Box 1-1 Overview: Patient Chair Position Relative to the Seated Clinician Figure 1-45 Clinician assumes a neutral seated position. The clinician establishes a “wide base o support” with eet on f oor at least shoulder-width apart and in ront o the hips. The patient chair is lowered until the tip o the patient’s nose is below the clinician’s waist. The clinician should position his or her stool close to the patient to enhance vision o the treatment area and to minimize orward bending. Whenever possible, the clinician should straddle the headrest to acilitate neutral position. 26 Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation Figure 1-46. Correct Positioning. Here the patient chair and patient’s head are positioned at the correct height in relation to the clinician. Note that the clinician holds her upper arms parallel to her torso, her arms are not raised, and her shoulders are relaxed. Figure 1-47. Incorrect Positioning—Patient Too High. A. Note how this clinician must hold her elbows up in a stress ul position in order to reach the mouth because she has positioned the patient’s chair too high. This error is o ten due to the misconception that the clinician sees better i the patient is closer to the clinician’s eyes. Actually, the reverse is true; the clinician has improved vision o the mouth when the patient is in a lower position. B. In this example, the patient is positioned too high or the clinician. As a result, the clinician’s chair is raised so the clinician can reach the mouth. The high chair position causes her to rest her eet on the rungs o the chair because she cannot touch the f oor with the soles o her shoes. Module 1 Ergonomics and Periodontal Instrumentation 27 SKILL BUILDING Establishing the Height of the Patient Chair Directions: Follow steps 1 to 5 below to practice establishing the correct height of the patient chair in relation to the seated clinician (Fig. 1-48). 1. Assume a neutral seated position. Sit next to the patient with the forearms crossed at your waist with your hand at the side at waist, not at your midsection (Fig. 1-48). 2. Position the patient chair for the treatment area (maxillary: supine; mandibular: semi- supine). 3. Position the patient’s head for the treatment area (chin-up or chin-down). 4. The patient’s open mouth should be below the point of the clinician’s elbow. 5. In this position, the clinician will be able to reach the treatment area without raising his or her elbows above waist level. Figure 1-48 28 Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation Se ctio n 8 Ancillary Equipment Ancillary equipment that may be helpful to the clinician during periodontal instrumentation includes a coaxial illumination source and magni cation loupes. DENTAL HEADLIGHTS: COAx IAL ILLUMINATION Adequate light must be present for human eyes to function effectively. In many instances, the clinician’s hands or instruments block the light from the overhead dental light causing the clinician to crane the neck and assume a poor working posture. Instead of using the overhead dental light for illumination, many clinicians use a light source attached to a headband or mounted to magni cation loupes (Fig. 1-49). Figure 1-49. CoA ial Illumination Source. A headlight mounted to eyeglass rames. Note also that magnif cation loupes are mounted to the lenses o the glasses. The battery power source or headlight is shown on the le t-hand side o this photo. (Courtesy o SurgiTel/General Scientif c Corporation.) 1. Coaxial Illumination Coaxial illumination sources are spectacle-mounted or headband-mounted miniature lights that provide a beam of light that is parallel to the clinician’s sight line (Figs. 1-50 to 1-52). In everyday terms, coaxial illumination sources are called dental headlights. 2. Advantages of Dental Headlights Coaxial illumination provides a light source that is parallel to the clinician’s line of vision that eliminates shadows produced by hands and instruments. Dental headlights provide the clinician with shadow-free light and facilitate improved posture (50). Dental professionals spend many hours per year adjusting traditional overhead dental lights. Dental headlights improve productivity because time is not wasted adjusting a traditional overhead dental light (50). Recently, Dr. Janet H arrison researched ocular hazards from dental headlights (51). Although most manufacturers advertise that their devices emit “ white” light, some dental headlights have a strong blue-light component versus the green-light component. Blue light is highly energized and is close in the color spectrum to ultraviolet light. The hazards of retinal damage with the use of high-intensity blue lights have been well-documented. There is limited research regarding the possible ocular hazards of usage of high-intensity illuminating devices. Another unexamined component is the effect of high-intensity light re ective glare and magni cation back to the practitioner’s eyes due to the use of water during dental procedures. Module 1 Ergonomics and Periodontal Instrumentation 29 Figure 1-50. Dental Headlight. A dental hygienist wearing a spectacle-m unted dental headlight. Figure 1-51. Illumination with an Overhead Light. o ten, it is dif cult t p siti n an verhead light t achieve g d illuminati n the maxillary arch. N te that the hygienist’s head is bl cking the light beams. Figure 1-52. Coaxial Illumination. The dental headlight pr vides a beam light that is parallel t the clinician’s line sight. The headlight pr vides g d illuminati n maxillary and mandibular treatment areas. And, there is n need t reach up t adjust an verhead light! 30 Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation MAGNIFICATION LOUPES 1. Magnif cation Loupes: Ergonomically Help ul or Harm ul? M agni cation through surgical telescopes—known as magnif cation loupes—may be a technological aid during periodontal instrumentation (Fig. 1-53). A. Research Evidence Concerning Magnif cation Loupes 1. While the use of loupes is often promoted as an ergonomic intervention, there is little published research to support this claim (8). a. A study by H ayes et al. (8) suggests that wearing loupes has both positive and negative effects on upper extremity M SDs among dental hygienists (22,50,53). Additional research is needed to assess the long-term e ects o loupes wear, over an extended period o time. b. A study by H oerler et al. (52) shows no statistically signi cant data to support the use of magni cation loupes to enhance indirect vision skills among dental hygiene students. 2. M agni cation may reduce the tendency to lean forward in an attempt to obtain a better view of the treatment area and therefore, reduce musculoskeletal strain to the clinician’s neck, back, and shoulder muscles. B. Problems Associated with Loupes 1. As with most equipment, how the loupes are used determines whether this equipment is bene cial in reducing musculoskeletal strain (Fig. 1-54). A poorly f tted or incorrectly used magnif cation system is more likely to exacerbate musculoskeletal problems than to solve them (54–57). It is important to make sure that the magni cation system is properly tted to the clinician. 2. According to Chang (55), President and Chief Scientist of SurgiTel/General Scienti c Group, “ M any clinicians think loupes solve ergonomic problems, but loupes can create ergonomic problems. The key is to nd loupes that meet their ergonomic requirements.” a. Loupes with improper working distances and declination angles can actually cause chronic neck and upper back pain (55,57–59). b. M isalignment of the two oculars can cause eyestrain, double vision, and headaches. Clinicians should try loupes before they buy and ensure the loupes are custom- t. Figure 1-53. Flip-Up Style. Flip-up styles have the magnif cation telescopes attached to the eyeglasses by a hinged bracket. The bracket allows the clinician to obtain nonmagnif ed vision by rotating the telescopes above the eyewear. (Courtesy o SurgiTel/General Scientif c Corporation.) Module 1 Ergonomics and Periodontal Instrumentation 31 Figure 1-54. Loupes and Posture. As, this clinician’s poor position clearly demonstrates, there is no “magic, easy f x” or maintaining neutral posture. As with most equipment, how the loupes are used determines whether this equipment is benef cial in reducing musculoskeletal strain. 2. Magnif cation Loupes or Periodontal Instrumentation A. Ergonomic Criteria or Loupes Selection. Three essential considerations when selecting loupes are working distance, declination angle, depth of eld, and frame size and weight (55,59). 1. Working distance is the distance measured from the eyes to the teeth being treated. If the working distance measured for the loupes is too short, the clinician needs to assume a head-forward or hunching posture to see the treatment area. 2. Angle o declination is the angle between the temple piece of the spectacle- mounted magni cation system and the actual line of sight chosen by the clinician (Fig. 1-55). a. Each clinician has a unique optimal declination angle determined by the individual’s most balanced seated position (55,59). b. If the declination angle of the loupes is too small, the clinician will have to tip the head forward or use a hunching posture to view the treatment area through the loupes. If the declination angle is too great, the clinician will have to tilt the head backward in order to view the treatment area through the loupes. 3. Depth o Field. Depth o f eld is the distance range within which the object being viewed remains in sharp focus. a. Adequate depth of eld allows the clinician to move his or her head without the treatment area going out of focus. b. Inadequate depth of eld may cause the clinician to assume an awkward head position in order to clearly view the treatment area. 4. Sizes and Weight o Spectacle Frame a. Large frames that sit low on the cheek allow better placement of the telescopes than narrow, oval frames. In general, the lower the telescopes are in relation to the clinician’s pupils, the better the declination angle. b. The dental professional may wear magni cation loupes for many hours each day. It is important, therefore, that the frames be as light and comfortable as possible. 32 Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation Te mple pie ce Line of s ight Figure 1-55. Declination Angle. The declination angle is the angle ormed between the temple piece o spectacle-mounted magnif cation system and the clinician’s actual line o sight. 3. Important Considerations or Preclinical Periodontal Instrumentation A. Limitations on What Can Be Seen with Magnif cation 1. Limited Field o Vision with Magnif cation. The f eld o view is the total size of the object that can be viewed through the loupes. The most popular magni cation strengths for periodontal instrumentation are 2.0×, 2.5×, and 2.6× (55). The lowest level of magni cation required should be selected. Lower magni cation levels increase the depth of eld and minimize the blind zone. 2. Blind Zone with Magnif cation. The blind zone is an area of vision between the unmagni ed peripheral eld of vision and the magni ed center of the eld of vision. a. The blind zone presents the most dif culty when an instrument is being moved into or out of the magni ed eld of view. Injury to the patient or the clinician is a possibility as the instrument is moved through the blind spot. M ost clinicians simply move the loupes aside until a stable fulcrum has been established with the instrument. b. The lowest magni cation should be selected to minimize the size of the blind zone. B. Criteria or Use o Magnif cation Loupes in Preclinical Setting 1. Ability or Student Sel -Assessment a. When learning the skills of clinician position, patient position, clock positions, mirror use, and nger rests it is vital that the student clinician is able to continuously self-assess the positioning of his or her body, arms, hands, and ngers. b. Sel -assessment o these skills during the learning process means that the student clinician must have a visual f eld that includes the patient’s head and the clinician’s arms, hands, and f ngers as well as the oral cavity. c. Figure 1-56 shows the minimum eld of vision needed by the student clinician while practicing and mastering the fundamental skills of patient position, clock positions, mirror use, and nger rests. d. M agni cation loupes limit the clinician’s eld of vision to the oral cavity (60). Figure 1-57 shows the clinician’s eld of vision using with 2.5× magni cation loupes. O nce a clinician has mastered the fundamental skills of patient position, clock positions, mirror use, and nger rests, the loupes provide a eld of vision that is adequate for instrumentation. e. This magnif ed f eld o vision, however, is too restrictive to permit sel - evaluation o skills when acquiring the undamental preclinical skills o positioning and f nger rests. Module 1 Ergonomics and Periodontal Instrumentation 33 Figure 1-56. Field of Vision without Loupes. When learning and mastering the undamental skills o positioning, mirror use, and f nger rests, the student clinician needs a f eld o vision that allows him or her to continuously sel -evaluate these skills. Figure 1-57. Limited Field of Vision with Loupes. When wearing magnif cation loupes, the clinician’s f eld o vision is limited to the oral cavity. This f eld o vision is too restrictive when practicing and per ecting the undamental skills o positioning, mirror use, and f nger rests (Box 1-2). Box 1-2 No Magnif cation, Please Magnif cation loupes should not be worn when practicing and per- ecting certain undamental skills o periodontal instrumentation. The limited f eld o vision created by magnif cation loupes make it impos- sible or student clinicians to sel -evaluate undamental skills such as positioning, grasp, and f nger rests. Sel -assessment o these skills requires an unlimited f eld o vision. 34 Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation References 1. Kroemer KH. Fitting the human: introduction to ergonomics. 6th ed. Boca Raton, FL: CRC Press; 2009. xix, 437. 2. H ayes M J, Smith DR, Cockrell D. Prevalence and correlates of musculoskeletal disorders among Australian dental hygiene students. Int J D ent H yg. 2009;7(3):176–181. 3. H ayes M J, Smith DR, Taylor JA. M usculoskeletal disorders in a 3 year longitudinal cohort of dental hygiene students. J D ent H yg. 2014;88(1):36–41. 4. H ayes M J, Taylor JA, Smith DR. Predictors of work-related musculoskeletal disorders among dental hygienists. Int J D ent H yg. 2012;10(4):265–269. 5. Khan SA, Chew KY. Effect of working characteristics and taught ergonomics on the prevalence of musculoskeletal disorders amongst dental students. BM C M usculoskelet D isord. 2013;14:118. 6. Graham C. Ergonomics in dentistry, Part 1. 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Fit to sit–strategies to maximize function and minimize occupational pain. J M ich D ent A ssoc. 2008;90(5):38–45. 20. M andal AC. Balanced sitting posture on forward sloping seat. 2008. Epub M arch 17, 2008. Available online at http://www.acmandal.com on. Accessed O ctober 6, 2015. 21. Rucker L. M usculoskeletal health status in B.C. dentist and dental hygienists: Evaluation the preventive impact of surgical ergonomics training and surgical magni cation. Workers’ Compensation Board of British Columbia. 2001. 22. Rucker LM , Sunell S. Ergonomic risk factors associated with clinical dentistry. J Calif D ent A ssoc. 2002;30(2):139–148. 23. Schoberth H. Correct workplace sitting, scienti c studies, results and solutions. Der Arbeitssitz in Industriellen Produktionsbereich. Dortmund, Germany: Schriftenreihe Arbeitsschutz; 1970. 24. Valachi B, Valachi K. Preventing musculoskeletal disorders in clinical dentistry: strategies to address the mechanisms leading to musculoskeletal disorders. J A m D ent A ssoc. 2003;134(12):1604–1612. 25. Akesson I, Johnsson B, Rylander L, M oritz U, Skerfving S. M usculoskeletal disorders among female dental personnel–clinical examination and a 5-year follow-up study of symptoms. Int A rch O ccup Environ H ealth. 1999;72(6):395–403. 26. A

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