Scale. Sharpen. Recontour. Inevitably, our favorite curettes succumb to this repetitive cycle. What are we to do when the working end resembles either a skinny needle or a puny nub? Retip it? Entomb it in the dead instrument drawer?
Heidi Emmerling Jones RDH, BS
Valid arguments sound out on both sides of the retipping controversy. Safety and quality control seem to be the recurring disclaimers against retipping. Convincing counter responses are stated by retippers, including cost savings and environmental concerns.
In order to better understand the retipping controversy, let`s review how instruments are manufactured. Much effort goes in to assembling a new instrument. A Gracey 13/14, for example, doesn`t just pop out of some Gracey 13/14 machine as one solid piece of metal.
The handles are formed from a brass tube, a stainless steel tube, or a solid piece of stainless steel with holes bored into the end to accept the points. The knurl pattern (cross hatch, herring bone, lines, etc.) is then rolled into the metal with a very hard steel wheel called a "knurl," sort of like how car tires leave tread patterns in the mud. Knurling places the handle under a lot of stress and, if done incorrectly, can cause it to crack or split.
The instrument points are turned from a solid piece of stainless steel. Several different turns are used to create the various shapes of instrument designs - Gracey 13/14s, Barnhart 5/6s, etc. The steel points are slightly larger (0.001 inch) than the bore in the handles to form an interference or mechanical fit. The point is then sealed into the handle with a high-temperature anaerobic sealer.
Retipping is basically rebuilding an old instrument by recycling the handle. When instruments are retipped, the worn working ends of the instrument are removed from the handles. A number of techniques accomplish this.
The method used by Pru-Dent Mfg. Co., a maker of new instruments and the first to retip dental hygiene instruments, begins with heating the handle to more than 500 degrees F to release the sealer. The point is then removed with their Soft Touch equipment. The handles are also inspected for cracks or other damage before the points are pulled, as well as after the instruments have been reassembled and polished.
The insides of the handles are cleaned to ensure proper sealing. Then new tips are placed, usually using an anaerobic sealing compound - the same type used in manufacturing new instruments. Some retippers solder the new tip in place. The point alignments are checked to ensure proper balance. Finally, the retipper`s name is stamped into the handles.
When tiny cracks become dangerous
Some instrument manufacturers are opposed to retipping. Hu-Friedy does not retip nor recommend retipping and is one of the most vocal opponents of the procedure.
Phyllis Martina, RDH, product manager of periodontal products at Hu-Friedy maintains that retipping procedures affect the safety, function, and quality of the instrument. "Retipping is equivalent to using a pencil until there is only the eraser remaining," she explains. "While the eraser has many uses left, does it make sense to attach a new pencil to a used eraser?"
First, she explains, there is a concern that removing the worn tip causes the handle to crack. She said the cracks weaken the instrument and provide openings for contamination as well as the potential for inadequate sterilization.
Cracked handles are a big issue. Everyone, whether they agree on the cause or not, mentions this problem and the resultant inadequate sterilization.
However, retippers claim that removing the tip does not crack the handle. Rather, they say it is more likely a result of a number of other factors such as the knurling process in manufacturing the new handle or stress created by heating up and then cooling the instrument (autoclaving).
As elementary physics teaches us, different materials expand and contract at different rates. On a grand scale, the phenomenon is known as erosion, which levels mountains and creates potholes in our roads. And, because the more expensive steel used for making the tips is different from the steel used for the handles, this same phenomenon is responsible for cracking instrument handles.
According to John H. Prusaitis, president of Pru-Dent, certain handle designs are more vulnerable to cracking. When asked which shapes are more likely to crack, he answers, "Anything with flat sides. Draw a circle in an octagon, and you will see eight thin spots, weak areas where the stress of autoclaving can cause a crack. If you want to reduce the chances of handle failure, you should use round handles, stainless steel handles, or both."
Prusaitis urges hygienists to inspect the handles for cracks on new instruments and to inspect the handles for cracks after each autoclaving. "This is something I have been trying to convince the dental community to do since 1978."
He recommends returning cracked instruments to the original manufacturer or to the retipper, if it has been retipped. He feels so strongly about the "cracked handle" issue that his company guarantees other manufacturers` handles that have been retipped by Pru-Dent to be free from cracks for 30 days from the invoice.
Is it still a perfect fit?
Tony Izzo from Premier Dental Products points out a potential for the tips to fall out of retipped instruments. Izzo maintains that, because the tip is larger than the bore in the handle, removing the tip causes the diameter of the handle to become larger, thus loosening the mechanical fit when a new tip is inserted.
"We`re not opposed to retipping merely to sell people new instruments. It`s just that loose tips are dangerous. When you get a retipped instrument back, always check to make sure that it`s not loose. We do not retip instruments and the only way we can sanction others retipping is if the new tips are soldered in place."
Others disagree. Charlene Brittain, vice president of Den Tips, a retipping service, sees no advantage of soldering over using an interference fit combined with a sealing compound. She claims her points, sealed with the anaerobic compound, often stay in better than some "original" instruments.
"I`ve been in this business for ten years and have never had a problem with our tips falling out of handle," Brittain said.
Paulette Kenney, manager of M.O. Yale retipping service, said their company does solder points. "If you try retipping, you`ll be pleased," she said. "And it`s safe. I don`t claim my product is superior to anyone else`s. Our claim is superior service. Eighty-five percent of my business is for repeat clientele."
Balance is another issue. Balance refers to a design feature where the working ends are centered on a line running through the long axis of the handle. Dredging up Physics 101 again, we know that a balanced instrument increases the effectiveness of the scaling stroke by transmitting the pressure applied to the scaler handle directly to the blade. Unbalanced instruments can cause strain on the hand muscles.
Hu-Friedy`s Martina notes that retipped instruments often have different angles, making scaling strokes less effective and more uncomfortable.
Roselyn Wilson, RDH, owner and operator of Prophy Power, a retipping service, agrees that the angles differ. In fact, she also claims angles differ between newly manufactured instruments as well. For example, a Gracey 1/2 from Company A is likely to have a different angle than a Gracey 1/2 from Company B.
"However," she maintains, "just because the angles differ does not necessarily make one company `right` and the other `wrong.` It`s a matter of what we`re used to and whether or not we want to make a change. We learn how to scale with a certain instrument in dental hygiene school. When we get out in practice, we`re exposed to other options."
Maintaining high standards
Another concern related to retipping is instrument durability. Martina said Hu-Friedy`s instruments meet or exceed International Standards Organization (ISO) specifications that define the acceptable raw materials, design elements, and ability to withstand the pressures applied during the use of the instruments. She maintains that most retippers do not conform to ISO specifications.
Retippers counter that ISO standards are for assembly-line, mass-produced products, not for those who are involved in every step of the manufacturing process. Retippers are able to check each "instrument" they make for quality control. Furthermore, Brittain explains that the steel used in her points is the same material that is used by big-name instrument manufacturers.
Martina points out that instrument manufacturers and retippers are required to follow practices that regulate manufacturing processes and control training and complaint handling to ensure the safety and efficacy of the product. She states that, while some retippers comply with the code, many do not.
Wilson confirms that retippers must be FDA approved, just like any manufacturer. "Today`s customers are looking for a good value. Services and businesses with bad products or poor practices will go out of business," she said. "The true test of a good business is the marketplace. My customers are my best advertisers."
Unfortunately, retipping an instrument leads to a goal familiar to all consumers: You need to be careful, and you need to deal with honest, reputable people. Prusaitis recommends you ask the following questions when considering a retipper:
- How long have they been in business?
- Do they manufacture their own points? If not, where do they get them?
- What is their warranty and what do you do if you have a problem?
- Do they re-sharpen instruments?
- What is their turn-around time?
- What is the cost?
- Are there any hidden costs?
- Are there any brands they can`t retip?
Prusaitis urges hygienists to complain if there is a problem, standing up for their rights as consumers.
Quality vs. cost issues
Finally, Martina observes that Hu-Friedy`s pride in the quality and integrity of their instruments is backed by product warranties and service. But once the instrument has been retipped, all warranties are null and void. Retippers are required to stamp their names in the handles of retipped instruments. This makes it fair to the original manufacturers not to assume liability of someone else`s (the retipper`s) product.
Reputable retippers also stand behind their service and product. Prusaitis guarantees his instruments and retipping points. As a retipper, he accepts responsibility for the quality and performance of the instruments he services. He`s happy to stamp his name in the handle.
In addition to the topic of quality control, retipping prompts other issues to surface. Russ Jenkins, general manager and vice president of American Eagle Instruments, said his primary concern is that he does not want his employees handling used, potentially contaminated instruments. American Eagle does not retip instruments.
Kenney, on the other hand, points out that all instruments that come to M.O. Yale need to be in a properly sterilized pouch. As an added precaution, her workers wear gloves.
Some find retipping an appealing option for economic reasons. After all, dental professionals have no qualms about repairing other dental equipment. It costs less to rebuild a handpiece or repair Cavitrons, dental lamps, and X-ray units than it does to purchase these items new. Similarly, it costs less to retip a used instrument by recycling the handle than it does to buy an entirely new instrument.
Jenkins argues, however, that retipping is not necessarily more economical. While he acknowledges that retipping can be done for about half the price of a new instrument, he points out that hygienists can get twice the use out of a new American Eagle instrument that boasts a higher Rockwell number (the number of strokes before the instrument becomes dull).
But retippers such as Pru-Dent use high-Rockwell tips that are slightly higher than other manufacturers. Some manufacturers purposely choose lower Rockwell numbers - not so you will to need buy a new instrument sooner - because they claim the lower numbers are less likely to result in tip breakage.
Other reasons besides metal hardness can cause instruments to wear out, Den Tip`s Brittain said. Consider the variations of sharpening techniques between practitioners, for example. Retippers and sharpeners note that hygienists get quite "creative" with sharpening techniques. An edge is often created that is not even close to what the original manufacturer had in mind. Sometimes the blade is allowed to get too dull and rounded. In both circumstances, it requires the removal of extra metal to get the proper shape back, thus wearing out the tip sooner than if the tip had been sharpened correctly in the first place.
Tom Thompson Jr., president of Thompson Dental Instruments, echos sentiments about costs. He claims that the average dentist spends only $200 per year on instruments.
"That`s less than it would cost for an average staff lunch," Thompson said. "It doesn`t make sense to worry about saving a few pennies on retipping because instruments aren`t that expensive to begin with. Especially when you consider the liability involved with using retipped instruments."
Thompson does not retip instruments with the exception of large-volume retipping for schools. This is so they can recode the handles in order to track them for liability purposes. He said the retipping process on a smaller scale is not economically feasible for a large instrument manufacturer.
Another reason we might be interested in having our instruments retipped is for environmental concerns. After all, what are we supposed to do with all those "dead" instruments?
A number of instrument manufacturers have anticipated our concerns. Hu-Friedy, for example, has a recycling program called "Environdent." When you purchase 12 new Hu-Friedy or American Dental scalers, you can send them 12 used instruments (from any manufacturer) and receive a free scaler. The used scalers are recycled back into base metals that are eventually turned into supports for buildings and bridges.
Thompson Dental Instruments gives a $2 credit toward the purchase of new scalers for every used instrument returned. They then recycle the handle by regrinding, repolishing, and recoding it.
Although the increased use of ultrasonic scalers has given our curettes some relief, we still love our curettes. As long as we scale teeth with scalers and curettes, as long as we sharpen and recontour our instruments, we will be forever confronted with the retipping issue. A number of variables are considered with no clear-cut, definitive, prescriptive answers. As we have seen, there are as many different opinions as there are manufacturers and retippers.
Some folks will always eat at a Denny`s or a Burger King, places that are tried and true, places they know exactly what they`re going to get no matter when or where they order. Others are happier dining at a local cafe, someplace with a varied menu for varied tastes. Some are more comfortable going with a respected manufacturer with established industry standards. Others prefer keeping costs down, recycling, and working with a reputable retipper who offers a high-quality product and custom options.
So, back to our original dilemma: To tip or not to tip. It`s the customer`s professional responsibility to do the research. It will depend on the product, the service and the customer`s needs and expectations. And ultimately it`s the customer`s prerogative.
Heidi Emmerling Jones, RDH, BS, is a consulting editor for RDH and practices dental hygiene in Sparks, Nevada.
Roselyn Wilson, RDH, is the owner and operator of Prophy Power, a retipping service.
Sharpening products simplify a despised chore
All those who love sharp instruments, say "aye!" Now, all those who love sharpening ...? Instrument sharpening seems to be one of our most despised yet most needed chores. After all, we know that the better we maintain our instruments, not allowing them to become dull, the longer they will last. We also know that sharp instruments save wear and tear on us, wear and tear on our patients, and increase our efficiency at removing deposits. But we`re always looking for an easier way. Fortunately, there are companies and products out there in a variety of price ranges that can make our lives a little easier.
Hu-Friedy has come out with an instructional sharpening video and manual called, "It`s time to get on the cutting edge." The upbeat video reviews how to test the sharpness of the instruments, specific sharpening techniques for all scalers, and how to maintain the original instrument shape. This innovative technique allows us to visualize the relationship of the instrument to the shape of the clock, making the sharpening process easy to remember. The University of Missouri, Kansas City, offers a post-test in the manual that is worth two hours of continuing education. The price for the video and manual is approximately $35.
Premier has a DISC (Dental Instrument Sharpening Companion) instrument sharpener that is designed to help you keep your instruments in optimum condition. It`s a set of two stones (one for touch up sharpening and one for recontouring) and an adjustable visual guide that allows you to maintain the original cutting angles of the blade. All you need to do is to keep the handle of the instrument parallel to the designated "Instrument Reference Lines" on the guide while sharpening. It`s nice because it avoids the variable of eyeballing where to place the stone. Once you arrange the instrument with the line, getting the proper angle on the cutting edge is virtually foolproof. It runs about $99.
The Pru-Dent Sharpening System was recently awarded a U.S. patent. "It`s so easy to use," they state. "If you can eat with a spoon, you can sharpen instruments correctly." The system includes a stainless steel sharpener, three stones of varying coarseness, test sticks, three new instruments to practice on, a coupon to retip three instruments for free, the manual, and a friendly, helpful video with continuing education credit available. There is also a toll-free help line. The sharpener holds the stone at the appropriate angle so all you have to do is hold the face horizontal while sharpening, like holding a spoonful of liquid. This is easy to use and practically guarantees the perfect cutting edge. And it is sterilizable so you will be able to use it chairside.
I had the opportunity to try out the prototype and I was impressed by how quickly and easily I could recontour my dullest curette. The cost is approximately $195 and will be available in November 1996.
If you don`t want to mess with manual sharpening, Rx Honing manufactures automatic sharpeners that provide fast sharpening, easy use, and very sharp edges. The Rx Honing Machine they term the "Cadillac" sharpener utilizes reciprocating abrasive hones. The honing restores the edge of an instrument in about 20 seconds. They are currently updating the machine to an Rx System II, the "Rolls Royce" of sharpeners. The Rx System II includes not only the reciprocating hones but also rotating disks. The disks are used to reshape damaged instruments, create ultra-fine finishing, and polish. Since you don`t need to use a lot of pressure to get the edge quickly, you end up removing less metal and the instrument life is increased. Also, any heat generated is never enough to pull temper from an instrument. The guides assure accuracy and the foot pedal leaves both hands free. A manual and video are included. The Rx Honing Machine is available for about $455. The Rx System II runs about $585. Upgrades to the original machine are available for about $150.
If you absolutely hate sharpening and don`t want to deal with any type of gadgets or stones, there are a number of companies who will sharpen your instruments for you. One company is Precision. It costs about $1.35 per end ($2.70 per double-ended instrument) plus packaging and postage. They can get the instruments back to you usually within two days.
- By Heidi Emmerling Jones, RDH, BS