1. Delivering Dental Care
Chapter 33
Delivering Dental Care

2. Delivering Dental Care
Lesson 33.1
Delivering Dental Care
Pronounce, define, and spell the Key Terms.
Discuss how to prepare for a patient appointment, including:
Describe how to prepare the dental treatment area for a patient’s arrival.
Discuss the importance of preparing a dental treatment room for a procedure.
Discuss the concept of team dentistry, and the principles of team positioning, including:
Describe how the operator is positioned during treatment.
Describe how the assistant is positioned during treatment.

3. Delivering Dental Care
Lesson 33.1
Delivering Dental Care
Explain the classification of motions.
Define each of the operating zones.
Explain instrument transfer, including:
Specify three grasps used by the operator.
Specify four items that have to be transferred differently because of design or use.
Discuss the differences between one-handed and two-handed instrument transfer techniques.
Identify five areas in which the assistant must have competency when practicing expanded functions.

4. Introduction
Business assistant, clinical assistant, dental hygienist, and dentist must follow a specific routine:
Review the patient record
Have knowledge of upcoming procedures
Have supplies and equipment ready
What is four-handed dentistry? (Process by which the operator and assistant work together to perform clinical procedures in an ergonomically structured environment)
What might result from a failure to meet standards for these tasks? (Loss of productivity for the dentist, inconvenience or discomfort for the patient, and unnecessary stress for everyone.)

5. Knowing your Patients
One of the best ways to know your patients and to be better prepared for the day is to have a brief meeting or review of the day before your patients arrive
Discuss
Change in schedule or procedure
Change in the patient’s health that could alter dental treatment
Additional supplies or equipment that may be needed
Preparation for the apprehensive patient
Assignment of expanded functions
Once a patient enters the reception area, it is essential that his or her presence be acknowledged immediately.
Some of the issues that should be discussed by the dental team include changes in patients’ dental histories, additional supplies or equipment that may be needed, preparations for the apprehensive patient, and assignments of expanded functions.
What are some of the tasks that should be completed during preparation for the apprehensive patient? (Scheduling a longer appointment, using premedication, and using pain-control measures such as nitrous oxide)

6. Reviewing the Patient Record
Several sections of a patient record are reviewed at each patient visit
Administrative staff
Check for changes in personal information, such as address or phone number change
Clinical staff
Check for health problems that may alter dental treatment
Look for medical alerts
Review progress notes for the planned treatment for the day
Would a chairside assistant be considered administrative staff or clinical staff? (Clinical staff)

7. Preparing the Treatment Area
Treatment room clean, disinfected, and ready for the next patient
Patient records, radiographs, and laboratory results in place
Sterile preset tray and other supplies in place
Dental chair positioned to seat the patient
Additional equipment moved out of the way for the patient and dental team
Is the use of personal protective equipment (PPE) recommended for the cleaning and disinfection of the treatment room? (Yes)
List the appropriate PPE. (Safety eyewear, lab jacket with long cuffed sleeves, gloves, face mask)
Where should radiographs be placed? (Illuminated view box)
When should the sterile preset tray be opened? (After the patient is seated and before treatment)
What is the proper position of the dental chair for receiving the patient? (Upright and at the lowest height)

8. Greeting and Seating the Patient
Pleasantly greet the patient by name in the reception area
Escort the patient to the treatment area
Place the patient’s personal items in a safe place, out of the way of the procedure
Initiate conversation with the patient
Ask whether the patient has any questions about the treatment for the day that you might be able to answer
Refer students to Procedure 33-1 for more information on greeting and seating patients (pp ).

9. Team Dentistry Components of work simplification:
Decreased number of instruments; ergonomically correct equipment
Sequencing of instruments on the tray by their use
Correct positioning of the patient, dentist, and assistant to minimize fatigue
Use of appropriate moisture-control techniques
Transfer of instruments and dental materials as necessary
Use of the least possible amount of motion
Performance of expanded functions by the assistant
Team dentistry is a standard of performance that has been taught to dental students and dental-assisting students over the past 40 years.
What are the main goals of this concept? (To deliver the best and most effective care to the patient and to increase productivity)
How does ergonomics play a role in team dentistry? (Using proper ergonomics helps reduce fatigue, stress, and injury during procedures, making them go more smoothly and efficiently.)
How do the appropriate moisture-control techniques simplify work? (Visibility of the work field in the mouth is increased)
Expanded functions allow the dentist to use time more effectively and efficiently.

10. Principles of Team Positioning
The dentist and dental assistant should develop positioning habits that allow access to and visualization of all areas of the oral cavity
Whenever the dentist and the assistant must stretch to reach for an instrument or gain access to an area of the mouth, stress is placed on the body
Accumulated strain contributes to lower back pain, circulatory problems, and muscle aches and pains
Correct positioning of the dental team is essential, otherwise careers can be shortened.

11. Concept of Four-Handed Dentistry
How does four-handed dentistry affect ergonomics and the concept of team dentistry? (The use of proper four-handed procedures enhances the treatment process by reducing stress and fatigue of both dentist and dental assistant. Four-handed dentistry also better uses the time of the dental team, increasing productivity.)

12. Positioning the Patient
Once the patient has been escorted to the treatment area and seated, he or she is:
Lowered to the supine position
Asked to slide up in the chair until the top of the head is even with the top of the headrest
Asked to turn his or her head to the right or the left to allow easier access to a specific area of the mouth
The operator makes final adjustments to the chair to establish proper working distance
The correct distance should be approximately 12 to 14 inches
Why is correct positioning of the dental team essential in the clinical area? (Correct positioning allows access and visibility to all areas of the patient’s mouth while providing maximum comfort and support to the dentist and dental assistant.)
What occurs when the dentist or dental assistant stretches to reach an instrument or gain access to the patient’s mouth? (Accumulated stress contributes to circulatory problems, lower-back pain, and other muscle aches and pain.)
What can you ask the patient to do to make access to specific areas of the mouth easier? (Turn his or her head to the left or right)

13. Positioning the Operator
Seated as far back as possible
Thighs parallel to the floor or knees slightly lower than the hips
Feet flat on the floor
Backrest of the chair positioned to support the lower portion or small of the back
Operator’s forearms bent at the elbow and parallel to the floor
What are the most essential requirements for the operator? (Access and vision)

14. Position of the Operator When Seated Correctly
Is this operator positioned correctly? (Yes)
Note the neutral elbow position.
Note how the weight of the operator is supported by the straight back and feet that are flat on the floor.

15. Positioning the Dental Assistant
Seated back on the stool
Feet on the base or foot ring of the stool
Positioned as close as possible to the dental chair
Legs parallel to the patient’s chair
Eye level 4 to 6 inches above the eye level of the operator
The dental assistant has to anticipate the needs of the dentist during treatment and maintain access to the area of concentration.

16. Position of the Dental Assistant When Seated Correctly
Is the dental assistant positioned correctly? (Yes)
This position will allow the dental assistant to sit 4 to 6 inches above the clinician to allow the assistant to have access to the concentration area.
Note the neutral elbow position.
Note how the feet are supported by the ring at the base of the stool.

17. Motion Economy
Classification of motions: 5 categories according to extent of movement
Class I: Movement of fingers only
Class II: Movement of fingers and wrist
Class III: Movement of fingers, wrist, and elbow
Class IV: Use of the entire arm and shoulder
Class V: Use of the entire upper torso
What area of the body is most likely to be fatigued by the end of the day? (The lower back)
This occurs because too much reaching, twisting, and turning goes on while seated in their work position.

18. Operating Zones
Basic concept required for the efficient, comfortable practice of team dentistry
Operator’s zone
Transfer zone
Assistant’s zone
Static zone
Operating zones are based on the “clock” concept. This concept is the best way to identify the working position of the dental team, dental equipment, and supplies needed to perform a procedure.
What affects the operator’s position within the operating zone? (The location of the zones changes according to whether the operator is right-handed or left-handed. The operator’s position varies within that zone, depending on the treatment to be delivered.)
The operator’s zone is the zone in which the clinician is positioned.
The transfer zone is the zone in which instruments and dental materials are exchanged between the clinician and the dental assistant.
The assistant’s zone is the area in which the assistant is positioned.
The static zone is directly behind the patient. This is the area with rear delivery or a unit that holds the handpieces, air-water syringe, and additional counter space.

19. Operating Zones for a Right-Handed Operator
What is the operator zone for a right-handed clinician? (12 o’clock to 5 o’clock.)
What is the transfer zone for a right-handed clinician? (4 o’clock to 7 o’clock.)
What is the assistant’s zone for a right-handed clinician? (2 o’clock to 4 o’clock.)
What is the static zone for a right-handed clinician? (12 o’clock to 2 o’clock.)

20. Operating Zones for a Left-Handed Operator
What is the operator zone for a left-handed clinician? (12 o’clock to 5 o’clock)
What is the transfer zone for a left-handed clinician? (5 o’clock to 8 o’clock)
What is the assistant’s zone for a left-handed clinician? (8 o’clock to 10 o’clock)
What is the static zone for a left-handed clinician? (10 o’clock to 12 o’clock)

21. Instrument Transfer
An ergonomically sound way to practice dentistry using the skills of the dental assistant while including work simplification techniques
Dentist relies on the clinical assistant to have the supplies, instruments, and dental materials ready for transfer into the dentist’s hands
Requires coordination, communication, and practice between the dentist and the dental assistant
What is the key term that describes the focus of four-handed dentistry? (Teamwork)
Instrument transfer or instrument exchange takes place in which zone? (Transfer zone)
What is the role of the dental assistant in four-handed dentistry? (Throughout the procedure, the dentist relies on the clinical assistant to have the supplies, instruments, and dental materials ready for transfer into the dentist’s hands.)
Who benefits from a standardized operating sequence? (Both the dentist and dental assistant, as well as the patient, benefit.)

22. Objectives of Efficient Instrument Transfer
Understand sequence of procedures and anticipate when instrument transfer is required
Transfer dental instruments and dental materials with the left hand
Transfer of instruments should be accomplished with a minimum of motion, involving only the fingers, wrist, and elbow
Instruments are transferred in their position of use
Instrument is transferred so that dentist can grasp the instrument for its appropriate use
An instrument being transferred must be positioned firmly in the dentist's hand
Instruments should be exchanged with Class I, Class II, and Class III motions. These motions only involve the fingers, wrist, and elbows.
Describe a Class I motion and give an example. (Movement of fingers only)
Describe a Class II motion and give an example. (Movement of wrist and fingers)
Describe a Class III motion and give an example. (Movement of fingers, wrist, and elbow)

23. Grasping an Instrument
Three basic grasps
Pen grasp: The instrument is held in the same manner as a pen.
Palm grasp: The instrument is held securely in the palm of the hand.
Palm-thumb grasp: The instrument is held in the palm of the hand and the thumb is used to stabilize and guide the instrument.
Can you define the term “grasp”? (Grasp is the correct way an instrument or handpiece is held.)
What affects the manner in which the operator grasps and holds an instrument? (The instrument type, the way it is used, and the area of the mouth in which it is being used)

24. Basic Instrument Grasps
A, Pen grasp.
B, Palm grasp.
C, Palm-thumb grasp.
Can you identify when each grasp would be used? (Pen grasp, explorer; palm grasp, surgical forceps; palm-thumb grasp, cotton pliers)

25. Transfer Technique
Dental assistant uses a specific, single-handed technique for efficiency
Applies to hand instruments, dental handpieces, and air-water syringes
Refer students to Procedure 33-2 for detailed information on transferring instruments with the single-handed technique (pp ).
If transfer of dental instruments is done with the dental assistant’s left hand, what is the function of the dental assistant’s right hand? (The right hand is kept free to provide suction and ready the next materials and instruments.)
When instruments are being transferred, the working end, or the position of use, is pointed downward for mandibular areas or upward for maxillary areas.
Why is it important to transfer instruments to the dentist in their position for use? (So the dentist does not have to reposition the instrument in his or her hands before use)
Assistant transfer technique is usually a single-handed technique.

26. Variations in Instrument Transfer
Mirror and explorer
Cotton pliers
Handpiece
Instruments with hinges
Refer students to Procedure 33-3 for information on transferring instruments with a two-handed technique (p. 525).
Why are different instrument-exchange procedures necessary? (Because of variations in instrument design)
The dental assistant delivers the mirror and explorer simultaneously, using a two-handed exchange.
What signal is used by the dentist to indicate the need for the mirror and explorer? (The dentist places one hand on each side of the patient’s mouth in a position ready to receive the instrument.)
The dental assistant delivers the pliers to the dentist while pinching the “beaks” to avoid dropping the item being held in the pliers.
Take care to avoid tangling the hoses during handpiece transfer.
Rubber dam forceps, surgical forceps, orthodontic pliers, and scissors should be transferred with care. Hold the instrument at the hinge and transfer by directing its handles into the dentist’s palm. (Scissors are placed over the dentist’s fingers.)

27. The Expanded-Functions Dental Assistant
“Expanded function” refers to specific intraoral procedures, or part of a procedure, performed by the clinical dental assistant that have been delegated by the dentist
Advantages
Increased productivity
Less stress on the dentist
More patients seen
Increased job satisfaction
Expanded-function dental assistants (EFDAs) must be credentialed in accordance with state guidelines. Most states require formal education before a dental assistant can legally perform expanded-function duties.
What are approved educational training programs? (Accredited dental-assisting programs, programs approved by the state dental board but not accredited, specific course[s] approved by the state dental board)
Who or what dictates whether the expanded function must be under the direct or indirect supervision of the dentist? (The Dental Practice Act for that state)
What is direct supervision? (The dentist must be in the same treatment area as the EFDA for the EFDA to perform the function.)
What is indirect supervision? (The dentist must be in the dental office area, but not specifically in the same treatment room as the EFDA, and must be available to evaluate the EFDA’s expanded function.)

28. Dental Supervision Direct supervision Indirect supervision
The dentist must be in the same treatment area as the EFDA for the assistant to perform the function
Indirect supervision
The dentist must be in the dental office area but not necessarily be present in the same treatment room as the EFDA
Who determines what level of supervision is required for each particular expanded function? (The Dental Practice Act for each state dictates whether the expanded function must be directly or indirectly supervised by the dentist.)

29. Working as the Operator
Operator positioning
Developing mirror skills
Establish a working position
Establish preferred mirror-to-tooth position
Using a fulcrum
Understanding dental anatomy
Understanding cavity preparations
Adapting instrumentation
Applying dental materials
Evaluation of expanded functions
A dental assistant carrying out an expanded function assumes the role of an operator.
It is imperative that the EFDA become knowledgeable and competent in the areas listed on this slide.

30. Operator Positioning and Developing Mirror Skills
Follow all guidelines and avoid curving the spine and slumping
Mirror skills
Maintain posture, reduce eyestrain, and complete specific functions
Position yourself to gain a “straight-on” visual effect
Mirror must be kept parallel to the working surface
Refer students to Table 33-1 for more information on specific operator positioning (p. 520).
Refer students to Procedure 33-4 for detailed information on using the dental mirror intraorally (p. 526).
What is indirect vision? Why is it more difficult to use a mirror for indirect vision? (Indirect vision describes viewing an object through the use of a mirror [Fig ]. Much trial and error is involved in learning to use a mirror for indirect vision because the object is viewed in reverse (mirror image).)

31. Using a Fulcrum Fulcrum: A “finger rest” that stabilizes the hand
A fulcrum that is established within the mouth is referred to as an intraoral fulcrum.
What are some examples of functions that require proper use of a fulcrum? (Placement of a dental liner and base, removal of dental cement, placement of retraction cord, suture removal, coronal polishing, placement of sealants, placement of separators and the application of ligature and elastomeric ties)
From Baum L, Phillips R, Lund M: Textbook of operative dentistry, ed 3, Philadelphia, 1995, Saunders.

32. Understanding Dental Anatomy and Cavity Preparations
Knowledge of dental anatomy must be attained if you are to gain an understanding of a dental procedure and a delegated function
To know where to place a dental material and how to apply a matrix band and wedge, it is important for the assistant to understand specific cavity terms and classifications
What anatomical knowledge is necessary? (Patient’s occlusion of teeth to proper form and function, structures of teeth [e.g., enamel, dentin, cementum, pulp], contours of each tooth, contact and interproximal surfaces, proximal contact area and its importance, pits and fissures of each tooth, and periodontium and its importance)
Several expanded functions delegated to dental assistants are associated with operative dentistry and restoration of teeth.

33. Adapting Instrumentation
You must be able to adapt the working end of the instrument to the tooth surface, and then to go one step farther by correctly moving the instrument
By moving the hand, wrist, and forearm as a single unit for enhanced strength
By moving the fingers back and forth in a more confined or precise area
Refer students to Procedure 33-5 for more information on using an instrument intraorally (p. 527).

34. Applying Dental Materials
When you take on the function of placing a dental material into the mouth or cavity preparation, you also need to know the application process
Each dental material is unique in how it is used and where it is placed in the mouth
As a dental assistant, you have the skill to mix dental materials, and you know the materials that should appear before application.

35. Evaluation of Expanded Functions
You are accountable for your skills
You must attain the knowledge and skill needed for an expanded function through mastery of course material and also by talking with the dentist with whom you practice
The dentist will use specific ways to make a temporary tooth, remove a matrix band, or place etchant.
To learn the dentist’s preferences, engage in open communication with the dentist when new expanded functions are delegated.

36. Questions?