Scaling techniques vary from one dental hygienist to another. Typically, the techniques learned in dental hygiene school are what dental hygienists employ in their private practice. After all, what was learned in school is expected to be “the standard,” isn’t it? But what exactly is the standard for periodontal instrumentation and does that standard differ from one school to another?
Undoubtedly, hygiene instrumentation techniques have dramatically improved throughout the years to prevent musculoskeletal injuries and permanent disability. However, what do we know about these new innovative techniques? Dare to “Dentalcompare” the various fulcrums, which stabilize the clinician’s hand during instrumentation coupled with the newer scaling techniques that can make a difference in scaling efficacy and career longevity!
Conventional Intraoral Fulcrums: A closer look at the standard
Conventional Fulcruming Technique
The most commonly used fulcrum is the conventional intraoral fulcrum or finger rest, which is established on tooth surfaces close to the working area. A stable intraoral fulcrum is dependent on the relationship between the working area and the location of the finger rest. A mirror is incorporated for retraction and illumination with the non-dominant hand; therefore, one-handed scaling is employed.
This technique for scaling was, and still continues to be, the pioneer standard in the dental hygiene profession. Today, dental hygiene schools continue to introduce the intraoral conventional scaling technique in pre-clinical courses to set the foundation for instrumentation technique. This is important because advanced periodontal instrumentation does utilize some intraoral fulcrum rests.
A problem with conventional intraoral scaling is the failure to obtain parallelism of the lower shank to second and third molar tooth surfaces, which in turn prevents obtaining access into deep periodontal pockets. Intraoral fulcrums are adequate for supragingival or shallow subgingival instrumentation. Access to maxillary second and third molars is extremely difficult and awkward. In conjunction to the awkward hand positions in trying to gain access, the risk for musculoskeletal injuries is increased due to hyperextension and flexion of the hands and wrists.
Extraoral Fulcrums: Heading towards a new standard
Extraoral Fulcrming Technique
Extraoral fulcrum techniques require greater clinician skill. Many experienced clinicians use extraoral fulcrums routinely and believe that they are essential for advanced periodontal instrumentation. The extraoral fulcrum requires stabilization of the clinician’s dominant hand outside the patient’s mouth against the cheeks, jaws, or chin. This enhances proper instrumentation placement, an extended grasp, accurate angulation; and allows the hand, wrist and arm to be in a neutral position and work as a unit while scaling.
With the increased control of having both hands work as a unit, the extraoral fulcrum also facilitates precise stroke pressure against the tooth surface and maximizes hand power and protection. All of these positive characteristics also decreases the likelihood of injury to the patient, should the patient move unexpectedly during the scaling procedure.
The extraoral fulcrum should definitely be implemented if the intraoral fulcrum is not effective. Other reasons to utilize an extraoral fulcrum include ease of instrumentation placement, protective ergonomic implementation, and increased power and strength that occurs from using a pull stroke with the larger muscle groups in the arm which in turn reduces the physical demand from the hand and wrist. Advanced instrumentation courses given for dental hygienists in private practice highlight extraoral fulcrums that incorporate opposite arch, cross-arch and reinforced fulcrums. The one problem that is encountered when teaching new techniques is that change is difficult for clinicians.
Clinicians who are accustomed to utilizing intraoral fulcrums are at first reluctant to use an extraoral fulcrum with an extended grasp. The misconception is that instrument control is facilitated with a choked-up grasp that is close to the working end of the instrument. Hence, clinicians who primarily use conventional scaling techniques should be open minded to change in order to learn more current, innovative instrumentation skills. The good news is that it is never too late to change! Efficacy is dependent on the skill, technique, and knowledge of the clinician.
Reinforced Fulcrums: Approaching a protective innovative standard
Reinforced fulcrums may vary, but ideally the technique involves utilizing both hands while scaling. Hence, using both hands to scale is considered an advanced approach to instrumentation technique. Dental hygiene programs incorporate reinforced fulcrum techniques when teaching extaoral fulcrums. Using reinforced techniques, however, requires the operator to use direct vision while scaling with both hands. These techniques require the non-dominant hand to assist and reinforce the dominant hand while primarily using extraoral fulcrums. Implementing both extraoral fulcrums and reinforced scaling also allows implementation of protective ergonomic hand, wrist and arm positions.
Utilizing reinforced instrumentation techniques can help reduce the incidence of injury and enhance scaling techniques by providing the following benefits:
- Allows both hands to work as a unit
- Provides more strength and power
- Enhances lateral pressure of the blade against the tooth surface
- Provides more stability to the working hand
- Allows the clinician to use larger muscle groups (instead of smaller more delicate muscle groups that are prone to injury with repetition)
- Incorporates a stable fulcrum
- Helps prevent hand/arm fatigue and injury while scaling
The incorporation of the non-dominant hand will help assist and reinforce the dominant hand in many ways. The index finger and the thumb are primarily utilized and can provide the following benefits:
• Index finger gently retracts patient’s cheek while utilizing an extraoral fulcrum
• Index finger presses on shank for increased lateral pressure
• Index finger behind shank supporting the instrument
• Index finger and thumb pinching shank for additional reinforcement and control
Pinching Shank Reinforced
• Thumb-to-thumb bridging together for reinforcement and control
Thumb to Thumb
• Thumb presses on instrument shank for additional lateral pressure
Thumb on Shank
• Cupping hands for increased control while index finger presses on shank
If the dental care provider has had a prior injury, using extraoral fulcrums and reinforced instrumentation strategies will help prevent the occurrence of additional work-related injuries. Dental hygienists are at risk for musculoskeletal injuries if reinforced techniques are not employed, especially when treating patients with heavy calculus deposits on a routine basis.
No longer is scaling exclusively about calculus removal. It is about calculus removal and protecting oneself from injury. Knowing and incorporating protective advanced scaling techniques are important when the student or dental care provider is having difficulty using the one-handed conventional technique. New protective reinforced instrumentation techniques are available that help prevent pain, work loss, and chronic long-term disability.
It does take an open mind, however, to adapt to new protective innovative techniques not learned in school. Scaling techniques have advanced, so dare to ‘Dentalcompare’ the various fulcrums and instrumentation reinforcements and see for yourself that even though change is difficult, it’s never too late to change!