4-HANDED DENTISTRY
In my previous articles I have asked you to reconsider the way you think
about ergonomic design of surgeries, bad habits and posture. Now let’s
consider practical 4-Handed dentistry.
The Norm
How often do we see nurses standing up to aspirate so they can see and
when aspirating only using one hand working with the aspirator tip whilst the
other one is redundant.
The dentist is crowding the mouth by going in first, setting in position, trying to
retract soft tissues, use the mirror and the drill all at the same time with the
nurse using Limbo positions to aspirate.
There has to be a better way of working – the clue is in the title 4-handed
Dentistry
Your Mirror
Unfortunately by holding the mirror in its most natural position i.e. half way
down the handle it obstructs your nurse’s vision and she has to bend lower in
order to see where to aspirate.
If you hold the mirror delicately at its handle end and position the reflecting
end in the opposing sulcus you will still see the relevant teeth and hey, guess
what, your nurse can actually see too.
A No. 4 mirror head is the norm but why not try a No. 2 size, after all you only
need to see the one tooth you are working on and plus two relevant halves of
adjacent teeth and it makes it far easier to position in the opposing sulcus as it
is smaller.
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Aspiration
The first thing to remember is that we are not only looking to remove water
and debris from the mouth but also to retract and protect the soft tissues using
the 3 in 1 syringe or, if you haven't got, one a reversed mirror head.
Perhaps the most important thing to say is that we dentists should hold back,
not dive in with the hand piece but allow our nurse to go into the mouth first.
This will enable them to retract the tissues and get into a nice balanced
position for aspiration, which will give much better vision to all of us.
Remember the rule: NURSE ALWAYS FIRST IN AND LAST OUT OF THE MOUT
Let's start with the Upper Left
You are aiming to use your retraction instrument to give you some space for
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your aspirator. Thus you retract the lip first, then place the aspirator alongside,
at quite an angle pulling the cheek just gently out and bring the retraction
down so you are actually opening up the whole side of the cheek rather than
just a small area where your suction is in place.
This makes it so much easier for your dentist to see what he/she is doing, as
all the shadows cast by the lip are gone. Dentists can now work by direct or
indirect vision using the mirror down in the lingual sulcus of the lower teeth or
actually outside the mouth in the dry zone.
Now - the Lower Left
The same as before, retract the lip first and place your suction tip right
alongside the tooth being worked on and now gently slide your retraction
forward quite a long way and you will see how it eliminates the shadows.
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Remember you need to sit really close to the patient as well as the dentist.
Dentists hold your mirror in the normal way, swivel by rolling it round and hold
using 4 fingers against thumb.
Now tuck your elbow in across your chest place the reversed mirror head on
top of the tongue and rather than retract it, depress the tongue right alongside
the tooth you are working on.
Now - Upper Right
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This is the one place where you sometimes swap and use your left hand to
aspirate, as you don't need to retract here as the dentist often does it.
Occasionally if the lower lip is causing a shadow you can swap back and
retract it. Remember to stay in position until the dentist is out of the mouth and
you can remove the excess water and avoid the patient gulping down the last
mouthful.
Your dentists will work using the direct or indirect vision retracting the lip with
one of his/her fingers and using the mirror as before but in the lower buccal
sulcus this time.
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Now - Lower Right
Again start with retraction of the lip and then place your suction on the lingual
side whilst protecting the tongue at the same time - again the lip retraction
eliminates shadows to give your dentist better vision.
This is the easy one for a dentist who just retracts with one finger or a mirror if
necessary and uses direct vision.
What are the benefits of these positions?
 The benefit to dentists is that they get much better vision and maintain
good posture.
 The benefit to patients is that they are far more comfortable and not full
of water and debris.
 The benefit to nurses is that they can enjoy a more active role and
maintain good posture.
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Instrument Exchange
How you hold your instruments is personal, but ideally we dentists should hold
the instrument fairly close to the working end enabling good instrument control
and leaving the other end of the instrument free for exchanging.
Your nurse should exchange instruments using her left hand, passing it using
her finger and thumb approximated at the end of the instrument and a forward
horizontal movement of her arm, and collecting it using her little finger to
grasp the instrument and a backward horizontal movement of her arm.
The essence of safe efficient exchange is to teach your nurse to hand over an
instrument so that you just have to close your hand in your favourite grip to
retrieve it and all exchange should be in the safe zone as taught.
To do this you simply hold an instrument passively and allow your nurse to
take it from you. She can now hand it back to you. All it takes is practice and
patience but can be very slick and efficient when done well. It becomes a
Strictly Come Dentistry scenario!
We call this parallel instrument exchange and it works for ALL procedures.
Conclusions
I don’t imagine you will do all of these techniques as described above
although my nurses and I do use them every day. Even if you just think about
what you could do differently it may improve your health and working life.
New cross infection control best practice and new CQC regulations and
control will radically change our working practices. So, for example new ways
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of delivering instruments to a surgery via hatchways or through the back of
cabinets will become the norm.
What will we be able to keep in our surgeries? Not a lot.
I suspect we will have minimalistic surgeries where very little is stored so
cabinetry will need to be redesigned, tub systems for materials will be utilised
and our surgeries will look like pods surrounding a central sterilisation area.
Change is difficult and often forced upon us so let’s at least be positive and
use it to make us rethink how we work together on our patients.
Going back to basic principles, forgetting our past baggage, ignoring what we
do now and just thinking how we would like to work ergonomically, with job
satisfaction and patient comfort we can come up with some new ideas.
If you do take these ideas on board then the results are “amazing” as they say
on X-Factor!!
You will be able to: 





Increase your productivity and enhance efficiency
Eliminate bad habits and improve your posture
Motivate your nurse who will be more involved
Improve the patient experience and safety
See more clearly and use loupes effectively
Achieve your UDA’s and earn more money more efficiently
In other words
Work Smarter Not Harder
To learn more about these techniques in a practical, safe and fun way we do
offer private courses for dentists and nurses to attend at A-dec showrooms in
London or Nuneaton, or indeed at your own practice. Should you be
interested in a course please contact us on: -
Telephone
01327 310770
E-mail at
martyn@dynamicdentistry.co.uk
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Website
http://www.dynamicdentistry.co.uk
Martyn Amsel and Sally Chadwick have been running courses on 4-Handed
dentistry to hundreds of dentists and their nurses for the last 20 years.
With General practice groups they get excellent feedback from both dentists
and nurses.
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