So you think you can scale?

BY MADALYN ROSENBLUTH, RDH, BS
POSTSCRIPT BY SUSAN P. BURZYNSKI, RDH, MSEd

We have all watched some of the reality shows … American Idol, America's Got Talent, Dancing with the Stars, So You Think You Can Dance? ... that are so popular these days. Some of us love them and some of us can leave them, especially early on in the season, but there is no doubt that we all enjoy the end-of-season talent that is developed with the help of coaches and countless hours of rehearsal. It's the progression of a talent with practice ... just like our own reality show -- the art of performing debridement on our patients.

This is your career. You are a professional clinician who performs preventive oral hygiene procedures. How proficient do you wish to become? Do you want to be the best? Do you have a coach? Are you continually striving to progress in your talent and techniques? Are you willing to exercise repetition for perfection?

The ultrasonic unit along with our inserts are our essential instruments in performing debridement. Articles on ultrasonic scaling are too numerous to count, so why is this article different? Because this one is going to get you moving with precision and purpose. Just like the dancer, vocalist, or musician, every artist must know the basic skills to go on to become a great performer.

You will gain practical information and basic moves that, with practice, will help you progress in your everyday performance, and your patients will love and applaud you!

What unit do you use? Know your equipment. Is it magnetostrictive or piezo? 25k, 30k, or a dual-frequency unit? Is it an automatic or tunable unit? Knowledge of your unit's qualities is essential in your usage of them. Many of us don't know anything about what we are using to generate unparalleled power inside our patients' mouths. There are optimum ways of operating along with tip choices depending on your specific unit. Take a hands-on class in ultrasonic instrumentation to use various units and insert/tips to discover how to maximize your unit's full potential and explore other options in the world of ultrasonic generators.

Is the unit in good working order? Do you have it tuned up every couple of years for optimum performance? You have your car serviced more than your unit and yet you put fewer demands on your car.

What condition is your handpiece in? Is it leaking, are wires exposed, curled up and dried out, or crushed? Handpieces transfer electrical energy and water to provide power and irrigation to our ultrasonic inserts and tips. Handpieces have to be in excellent working order so that our scaling is safe, effectual, and comfortable not only for our patients but for us. They need to be rebuilt or replaced every few years as the internal wiring and lines become twisted and dried out from usage. How about those swivel handpieces? They are a great innovation by DENTSPLY/Cavitron as they take the twist out of your work and prevent damage to the handpiece assembly. Is one in your future?

Why do you have the power turned all the way up? Are your inserts/tips worn or bent? When was the last time you checked the tip length on an efficiency indicator card? Wear and loss of just 2 mm to 3mm in the length of the tip reduces the working power by 50%. That wears on you ergonomically. That's just a starting point of gathering the right tools in proper condition before we start rehearsing.

Once you have the proper equipment in great working order, you can implement the art of debridement with your ultrasonic armamentarium. Just as a dancer takes basic steps, so shall the clinician! Let's review some basic moves for successful performances.

The unit's power level should be on the lowest power settings, with inserts that have little to no wear and are maintained in good condition. If you find yourself using high power levels, your inserts are worn or are of poor quality.

Choose the correct style of insert for the debridement task at hand. With so many different styles of inserts available for various patient applications in calculus and biofilm removal, you should have a selection of different inserts. This is no one-size-fits-all scenario. Expand your selection and use appropriate inserts/tips for the location to be scaled and the amount of accumulation for removal.

Before activating, place your insert into the handpiece while holding it vertical. I know it seems silly to review this after many years of clinical practice, but I can assure you this is the right way for the health of your handpiece/equipment. Electronics inside a handpiece burn out if not in contact with the stack of an insert. Keeping the handpiece vertical over the cuspidor for just a couple of seconds (you'll see a spurt and then a stream of water flow off the tip) will ensure that it will never overheat as water will fill the stack completely. How many of us have complained of a hot insert or handpiece? You are practicing incorrectly when you don't allow the water to fill up the entire length of the stack. What happens is an air bubble forms inside and the water does not cool the entire length of the stack, resulting in overheating and damage. Use a rapid steam of water off of your insert's tip. Irrigation is what makes ultrasonic scaling so beneficial (approximately 50 cc of water per minute).

Those with manual tunable units will find now is the time to take the few seconds to tune each insert to optimum frequency, because each insert has a slightly different level.

Make sure you activate your insert before touching the tooth surface. The added water irrigation not only cools the tip, but it's more comfortable for the patient this way -- no sudden sensitivity as the insert meets the tooth.

Always keep moving and use the lightest touch. Staying in motion allows the insert/tip to do its work as it moves either in an elliptical or linear cycle depending on whether you use magnetostrictive or piezo energy. New and well-maintained inserts have tips that travel farther and cover a larger area more effectively. Do not press the tip against the deposit with force or you will diminish its movement. Contrary to hand instrumentation, move with a light touch and reap the ergonomic benefits of your ultrasonics. Work from the coronal area toward the root in deliberate overlapping strokes.

Stay in the sulcus. While keeping in motion, get down into the area that is the breeding ground for what we are after. Don't be afraid, and don't be a drive-by scaler. Linger while staying in motion subgingivally with the lightest grip on your handpiece, so the magic of cavitational therapy can effectively remove deposits and biofilms with simultaneous lavage.

The more practice, purpose, and attention you use in your ultrasonic therapy, the more proficient you will become.

With magnification loupes and enhanced LED portable headlamps, you will become dramatically more proficient in providing ultrasonic therapy. Add in perioscopy and it will wow you with how effective you can be in obliterating biofilm.

Invest in instruction and equipment for yourself, and your patients will be very impressed with your level of care and commitment to them. This will raise your value in everyone's mind, making you the "Ultrasonic Idol" of the practice! RDH

Postscript

BY SUSAN P. BURZYNSKI, RDH, MSEd

All of us have had patients on our schedules whom we dread due to the condition of their mouths. We have hand scaled until our hands felt like they were going to fall off from removing so much calculus and stain. Many have used ultrasonic scalers to remove thick, tenacious calculus, both supra- and subgingivally, only to have these patients return three to four months later in the same condition. Are you like me, constantly wondering if you are using your ultrasonic equipment correctly or effectively?

Tom is a patient of mine who fits the description above. He is in his fifties and has resisted our pleas over the years that he see a periodontist. His comment, when we would revisit this request, was always, "They are going to do the same thing you do and charge me more." No amount of explaining convinced Tom this would be to his benefit. I had used hand instruments and ultrasonic scalers at each of his appointments, and each time he would say, "Man, that was a workout!" Yeah! On whose part?

Thanks to PennWell's RDH Under One Roof conference, I had the opportunity to meet co-attendee Madalyn Rosenbluth, founder of MadUltrasonics. She explained to me that I didn't need to be working so hard; I just needed to work smarter with high-quality, well-maintained ultrasonic equipment. Other hygienists suggested that I purchase my own instruments to assist me in accomplishing just that. I knew it was time to make my move and purchase a new universal, beavertail, and triple bend inserts.

Tom returned for his three-month recare appointment, and this time I did not dread seeing him! I actually looked forward to trying my new ultrasonic inserts. I explained to him that I had new instruments and I needed his input. Tom was eager to help out. I started with the universal, then switched to the triple bend, and what a difference! I could use these new inserts on lower power settings and still be effective in removal of both supra- and subgingival calculus, stain, and biofilms. Tom was impressed and said that it was the first time he felt so comfortable during his hygiene appointment. Fast forward to another three-month recare appointment and surprise! Tom's oral tissues looked better than they ever had in all the years I have been treating him. He finally decided to follow the home-care directions I gave him. This visit, I only had to use my triple bend and Tom again said he felt so much more comfortable. I am finally working smarter with efficient ultrasonics, which makes my work and my patients' visits a pleasure!