Be sharp!

Are you on the cutting edge?

by Janet Hagerman, RDH, BS

Ask any hygienist if they like to sharpen instruments, and the reply will be a resounding “No!” Ask any dentist if they like to see their hygienist spending time sharpening instruments. Again, “No!” Doctors want hygienists to be producing or on the phone filling schedules in order to produce. Understandable. It’s a dilemma. A study conducted by RDH eVillage newsletter found that 25% of hygienists sharpen their instruments less frequently than once per month, and half of those quarterly or less.

Here are some reasons to be sharp, and strategies to stay sharp!

While advances in ultrasonic instrumentation now account for much of the periodontal scaling performed, when hand instrumentation is needed, being sharp is critical! Considering that much scaling (SRP) occurs hidden from vision beneath gingiva, entirely dependent upon a very sensitive tactile touch, the quality of instrument maintenance becomes essential. Dull instruments are dangerous — not only to the patient, but for the hygienist as well.

According to Darby/Walsh,1 dull instruments decrease tactile sensitivity, working efficiency and control, and patient comfort and safety, while increasing lateral pressure and possibility of burnished calculus.

Dull instruments:

Make calculus removal more difficult, requiring more strokes and thereby contributing to longer patient appointments
Interfere with effective instrumentation manipulation, creating the possibility of soft tissue damage
Decrease the comfort level of both the patient and the operator by having to work harder to remove dental deposits
Unnecessarily increase the hygienist’s amount, duration, and pressure of working strokes, thus contributing to repetitive wrist injuries and conditions
Slip over tooth surfaces and calculus more easily, often leaving undetected burnished calculus, which then becomes even more difficult to remove and further encourages biolfilm proliferation

Endoscopic evaluation of residual pockets that are evident by continued bleeding and/or purulence on probing often reveals residual calculus. Even tiny pieces of burnished calculus can perpetuate the inflammation/ulceration process.

Clearly, the goal for any periodontal therapist is to create a root surface that is biocompatible with tissue by avoiding burnishing and thoroughly removing subgingival calculus.

Hawaii periodontal therapist, Diane Brucato-Thomas, RDH, EF, BS, FAADH, utilizes endoscopically-assisted therapy for periodontal patients with great success.

Diane reports, “Endoscopy routinely reveals deep, residual calculus that is often burnished so smooth that it defies manual detection. Unless thoroughly removed, the root surface remains incompatible with the tissue and healing is hampered. Utilizing thin or micro ultrasonic instruments or using very sharp hand curettes best facilitates thorough calculus removal and minimizes leaving burnished calculus behind.”

While many of us do not have the luxury of endoscopic technology, we all do have the ability to be sure we use and maintain properly sharpened hand instruments.

Sharpening should occur at the first sign of instrument dullness, which is often. Hygiene instruments can be sharpened by a variety of methods, including sharpening stones, sharpening “gadgets” and machines, and sharpening services. The challenge is always to restore blade sharpness while preserving the original contours and angles of the instrument.

There is a real art to instrument sharpening, and improperly sharpened instruments will shorten the life of the instrument as well as pose a patient danger of possible subgingival tip breakage. While some hygienists are emphatic and diligent about continual manual sharpening, many more are not. A good option is to use a machine that locks in the instrument and guides the process with the correct angulation. Better yet, use a sharpening service which will assure correct blade angles and let you know when an instrument is too thin to be safely sharpened. The cost of a good service may well be the better use of a hygienist’s time, freeing her or him to be more productive with patient care.

A recent RDH eVillage survey (July 2011) investigated the sharpening habits of hygienists. The main reasons cited for not using sharp instruments (buying replacements) was lack of time, financial resources (money, budget), and lack of doctor support, citing:

Financial concerns of office, including budgets
“My bosses are nice. I don’t want to appear demanding.”
Justifying the need for instruments to employer

Interestingly, many hygienists also complained that other hygienists sharpened improperly, which destroyed their instruments. Here is a small sampling of the responses:

I will not share with other hygienists as they sharpen poorly.
Curettes looked like scalers after some hygienists sharpened them!
Differences in diligence toward maintaining a sharp edge as well as angle distortion.
I’m the only hygienist who knows how to sharpen and actually does any sharpening (without destroying the instrument).
Improper sharpening causing damage to edges of scalers.
Maintaining the right edge.
Older hygienist sharpening the wrong side of the blade.
Other hygienist oversharpens instruments.
Others ruin the cutting edge when sharpening.
People sharpen differently so the instruments are out of shape.
Some hygienists don’t know how to sharpen and ruin the instrument.
The sharpening skills of each hygienist are not the same so we tend to get worn tips much faster.
They ruin the cutting surfaces.

Clearly, there is need for improved communication between dentist and hygienist, as well as other hygienists, with the goal being to provide clinicians with the proper tools they need to do their job. The quality and the longevity of the doctor’s financial investment should be protected.

Here are some strategies to bridge this gap.

First, understand your employer’s point of view. A dental practice is a business, and budgets need to be considered.

Second, treat your hygiene department like a business. Take a complete inventory of all your instruments. Test them all for sharpness. Make a list of all your packets (instrument setups) compared to what you think you need. Now make a list of what you think you need, in terms of ongoing sharpening and new instruments. Predict what you think you will need annually and monthly. Don’t be extravagant but be realistic in your needs. Forecast your needs in the form of a proposal. Compare costs from several instrument companies and sharpening services. Then take your proposal to your employer.

Request a meeting with your doctor (and office manager or the person responsible for ordering, if appropriate) in advance, explaining the reason for your meeting request. Come prepared to the meeting with your findings and your proposal. Bring a copy of this article.

By handling this as a business meeting, you show your employer that you respect the financial and business needs of the practice. Your job will be to prove to your employer the financial advantage of keeping a sharp instrument inventory. By doing this, you will also help yourself better manage the “tools of your trade.” Additionally, you are assisting with the solution by proposing an annual “plan,” which the office can then budget for.

Because so many hygienists struggle (perceived or unperceived) with the ability to sharpen correctly, and hygiene time can be so much more productive chairside, I recommend using a professional sharpening service.

Nordent has a new system which is a win-win for all. While their sharpening service will sharpen any brand of instrument, they will sharpen their own Relyant brand for free for the life of the instrument! Then they’ll tell you when it is beyond further sharpening and discount a replacement. Their service will

also help you with an auto-ship program, making the process easy for you to incorporate into your routine.

According to Tim Irwin of Nordent, who has worked with thousands of hygienists all over the country, “The RDH eVillage survey really opened our eyes. It became apparent that for many offices regular sharpening in the office just isn’t realistic. We hope that with our Relyant System we can help clinicians work with instruments in better condition and realize all of the benefits of working with sharp instruments.”

I think this new Relyant system will be a real game changer. Most hygienists do not like to, or cannot find time to, properly sharpen hand instruments, and many do not have the skill to do this correctly. This system is a win-win for all, freeing the hygienist to concentrate on patient care and periodontal therapy. However, whatever system you choose, whether sharpening yourself or using a professional service, or a combination of both, commit yourself to using and maintaining only sharp instruments. Be sharp!

Instrument Inventory Plan

Take instrument inventory
Band (color code) all hygiene instruments appropriately
Document acceptable level of sharpness and/or need for replacement
Bag and label appropriately
Research costs and services
Prepare your proposal

Janet Hagerman, RDH, BS, is an author, international speaker, and consultant. A graduate of the Medical College of Georgia, she has practiced clinical dental hygiene for over 20 years, and helped hundreds of dental offices in her roles as coach, consultant, and clinical director. Contact Janet at (678) 371-8234, [email protected] or visit www.janethagerman.com.