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The use of hand instruments in dental hygiene is a lost art.

The lost art of hand instrumentation

March 16, 2024
Hand instruments are not stressed much in dental hygiene anymore, but incorporating them into your armamentarium will lead to better patient care.

Periodontal instrumentation is a fine motor skill that aids in the diagnosis and treatment of the periodontium. This skill uses special­ized tools to remove hard and soft deposits such as biofilm and calcu­lus from the crown and root surfaces of the teeth.

Upon graduation, many dental hy­gienists are just starting to develop proficiency in their instrumentation skills. However, with consistent prac­tice, staying rooted in basic skills, and participating in hands-on workshops that enhances these skills and intro­duces techniques beyond the scope of their initial training, hygienists can become highly skilled in periodontal instrumentation.

At RDH Under One Roof 2023, Jessica Atkinson, Shelley Brown, and I led an in­strumentation lecture called Raiders of the Lost Art. Our presentation drew at­tention to the waning interest in hand instrumentation due to updated tech­nologies, which include ultrasonics, sub­gingival air polishers, and diode lasers.

Although these advancements can contribute to improved patient out­comes, there could be situations where they may not be suitable. As such, hand instrumentation continues to hold sig­nificance in today's dental hygiene prac­tice. Key aspects of the presentation encompassed the technical nuances of hand instrumentation and other influ­encing factors concerning its application.

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Ergonomics holds a vital position in dental hygiene practice, particularly in improving proficiency in hand in­strumentation. Having a solid under­standing of ergonomics is vital for maintaining sound proper postural mechanics. This approach is critical to prevent musculoskeletal disorders (MSDs) and ensure career longevity.

Clinicians with good postural mechan­ics maintain the natural curve of their spine, use correct form during physical activity such as instrumentation, and bal­ance muscle use. Ergonomics is not limited to the way one sits; it also takes into ac­count the equipment and tools used, such as hand instruments. Here are some rec­ommendations for choosing ergonomically designed hand instruments:

  • Handle width >11 mm
  • Handle weight <15 g
  • Tapering near the shank
  • Texturing and knurling on the handle

These features are designed to reduce pinch force, a crucial factor contributing to MSDs. Furthermore, the use of sharp tools helps reduce the amount of lateral pressure required, offering several ben­efits. These include decreased burnish­ing, reduced tissue trauma, enhanced efficiency, and the requirement for fewer strokes, ultimately resulting in decreased operator fatigue.

Glove fit

Ill-fitting gloves can result in exces­sive lateral pressure, which not only increases the risk of MSDs, but also sig­nificantly impacts performance. When selecting gloves, it's important to con­sider multiple factors, such as finger length, the length from finger tips to the cuff, overall comfort and feel of the material, and how well the glove fits across the palm.

There’s a new glove made with poly­chloroprene, which offers the softness of latex and the strength of nitrile without sacrificing comfort or dexterity. This new material is latex-free, made with a synthetic rubber that is safe for those with a latex allergy or sensitivity.

AAP guidelines and instrumentation selection

The updated guidelines from the American Academy of Periodontology (AAP) offer valuable insights for instru­ment selection. These guidelines suggest that a clinician's aramentarium should be influenced by factors such as clinical attachment level and the tenacity of the deposit. My cospeakers and I discussed protocols for selecting instruments and highlighted various designs including a range of sickles, area-specifics, and uni­versal curets.

Additionally, we provided detailed explanations on the appropriate use of each instrument, taking into account the patient's condition. We addressed key questions of how, where, and why each tool should be used to enhance patient outcomes and boost operator proficiency.

We also introduced modified instru­ment designs that include tools with miniature working ends, extended shanks, and hybrid designs.

Stroke dynamics

Stroke dynamics underscore the im­portance of conserving the cemen­tum during instrumentation. A few of the tenets of stroke dynamics include angulation, activation, and adapta­tion, which comprise the following key aspects:

  • Angulation: Ideal 70–80 degrees
  • Adaptation: 2–3 mm of insert/tip against the tooth structure
  • Activation: Short 1–2 mm overlapping strokes in either a horizontal, vertical, or oblique adaptation

These guidelines enhance precision and efficiency in dental hygiene instru­mentation. While discussing activation, the speakers stressed “slow down to speed up” to help clinicians remember that strokes must be kept between 1–2 mm in length to ensure effective and complete calculus removal.

Reinforcement scaling, although not traditionally taught in dental hygiene programs, is gaining recognition for its significant benefits such as additional instrument stability when applying additional lateral pressure and miti­gating the risk of repetitive stress inju­ries (RSIs). 

With the reinforcement technique, a clinician is unable to hold a mirror in their nondominant hand. The domi­nant hand adapts and angulates the blade against the tooth surface while the thumb or index finger from the non­dominant hand is placed on the shank. Both hands exert control over the in­strument stroke.

Know your hand instruments

Many of the new instrument designs benefit from advancements in cryo­genic processing and metallurgy, which has led to instruments that stay sharper longer or are sharpen-free. These are offered by HuFriedy Group, American Eagle Instruments, PDT, Premier, Nordent Manufacturing, and LM.

How long do instruments last? Both stainless-steel and sharpen-free in­struments have an expiration date. The problem in dentistry is that many cli­nicians use instruments, particularly stainless-steel designs, beyond their functional use. Variables affecting in­strument lifespan include frequency of use, type of deposit, use of ultrasonics, frequency and proficiency of sharpening, and whether the instrument is used for its intended purpose. Traditional scalers and curets have a lifespan ranging from six months to one year, while scalers and curets made with advanced technology can last from 12 to 18 months.

Maintain your skills

Periodontal instrumentation is a criti­cal skill in dental hygiene. Despite the rise in advanced technologies, the art of hand instrumentation remains rele­vant and necessary and should be honed throughout a dental hygienist’s career. Mastery of this technique can greatly enhance the precision and effectiveness of patient care.

While many dental hygienists start their careers with a basic level of com­petence, dedicated practice, continual learning, and hands-on training can help them become experts. The focus should not solely be on incorporating the latest technological advancements but also on refining fundamental skills and knowing when to utilize them for optimal patient results. In a rapidly evolving field like dental hygiene, the significance of these skills cannot be overstated.

Editor's note: This article appeared in the March 2024 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

Joy D. Void-Holmes, DHSc, BSDH, RDH, is a hygienist with 25 years of clinical experience, founder of Dr. Joy, RDH, and creator of the Dental Hygiene Student Planner. She is program chair  of the Fortis College dental hygiene program, holds a faculty position at the American Denturist School, and is a professional speaker and published author. She has presented continuing education courses nationally and internationally in the areas of instrumentation, ultrasonics, infection control, nutrition, and biochemistry, along with her signature keynote, Confidence and Courage.