Components of an Instrument

HANDLE

 Diameter: large diameter handles (10 mm) can provide better control and decrease muscle
fatigue.
+ Round shape is ideal
+ Hollow to transmit vibrations from the working end to the clinician’s fingers.
 Taper: tapered ends where the handle is grasped helps prevent finger slippage and requires
less pinch force during instrumentation.
 Texture: rougher surfaces (called knurling) can provide better grip.
 Weight: lightweight handles put less stress on the hand (and fingers) while enhancing tactile
sensitivity.
+ Ideal weight for periodontal instrumentation is 15g or less

SHANK

 Terminal (lower) shank: portion of the functional shank closest to the working end, between
the working end and the first bend.
+ It is normally parallel to the tooth surface that is to be instrumented. This is a helpful
visual clue when identifying the correct working end.
+ Longer, or extended, lower shanks are used in deeper pockets and posterior teeth.
+ An extended lower shank is 3mm longer than a standard lower shank.
 Simple shank: has only one bend. With the working end facing the clinician, the shank is
straight.
+ Used on anterior teeth and on easily accessible areas.
 Complex (angled or curved) shank: has multiple bends. With the working end tip facing the
clinician, the shank has a zigzag shape.
+ Commonly used on posterior teeth, but may also be adapted for anteriors. The bends
allow the instrument to access hard to reach areas and adapt to bulkier crowns.
 Flexibility: varies depending on the task of the instrument, metal used, and shank diameter.
+ Thinner, flexible shanks allow greater tactile sensitivity.
+ Thicker, rigid shanks allow greater strength.

WORKING END

 Working end refers to the part of the instrument that does the function, such as an explorer tip,
a mirror, and also blades.
 Cutting edge is formed by the junction of the face and the lateral sides.
 Some instruments have two working ends (paired), while others have only one.
 Cross section of a working end determines whether the instrument can be used subgingivally
or supragingivally.
+ Sickle scalers have a triangular cross-sectional shape and have a pointed back and tip.
They are used supragingivally.
+ Curettes have a semi-circular cross-sectional shape and have a rounded back and toe.
They are used subgingivally and supragingivally.
 Principles of Instrumentation

FULCRUM

 Mechanical leverage created using support, point of rest.

 Fulcrum finger should be strong and stable to allow instruments to be rolled easily.

 Activate the wrist and hand, not the fingers, to allow leverage that will provide greater force
and lateral pressure. This will also minimize clinician fatigue.

 Intraoral fulcrum: finger rest inside the mouth, near the tooth being treated.

 Extraoral fulcrum: finger rest outside of mouth, such as cheek or chin.

+ Used in difficult to access areas, e.g., maxillary posteriors.

 Alternative fulcrum: when intraoral or extraoral fulcrum is not accessible.

+ Cotton roll: for edentulous patients. The index finger of non-dominant hand can be placed
on the cotton roll too.
+ Light pressure for mobile teeth. General rule: avoid fulcruming on a mobile tooth.
+ Finger-on-finger rest: index finger of non-dominant hand is on the occlusal surface of
teeth near the working area, and dominant hand fulcrum is placed on top.
+ Reinforced finger rest: index finger of non-dominant hand is on the occlusal surface of
teeth near the working area, thumb (of the non-dominant hand) is on the instrument. This
creates greater strength.

TACTILE SENSITIVITY AND MODIFIED PEN GRASP

 Modified pen grasp: recommended grasp for periodontal instruments.

+ Enables precision and control of the working end and reduces musculoskeletal injury.
 Finger placement: The fingers are in a soft C-shape on the handle which allows the
instrument to be rolled to help maintain adaptation on the tooth surface.
+ Thumb and index finger: are placed opposite from each other on the handle. A small
space should remain in between- avoid overlapping.
+ Middle finger: instrument shank rests lightly on one side of the finger pad. The other side
of the finger pad rests against the ring finger
+ Ring finger: is advanced ahead of the other fingers and acts as the fulcrum to support
the weight of the hand.
+ Little finger: kept relaxed next to the ring finger.
+ Splitting the fingers apart in the grasp should be avoided.
 Tactile sensitivity: ability to feel vibrations from the instruments’ working end. The pad of
the middle finger is used to feel vibrations. Avoid gripping with fingernails, and the grasp
should be light.

ADAPTATION AND ANGULATION

 Adaptation: tip (or toe) third (1 o 2 mm) of the working end is always against the tooth to
avoid injuries to the tissues. Pivot on the fulcrum finger and roll the handle to maintain
adaptation as the instrument moves along the tooth surface.
 Angulation: formed between the face of the instrument and the tooth surface.
  Periodontal probe is positioned parallel to the tooth surface. In the col, the probe is positioned
at 20° to 30° for better access.
 Removal instruments:
+ For insertion into the sulcus/pocket, position the face of the instrument as flat against the
tooth surface as possible (0-40°).
+ For scaling, the face of the instrument is at 45°-90° with the ideal angle being 60°-80° to
the tooth surface.
+ Angles less than 45° will burnish hard deposits (burnished deposits are difficult to detect
and remove, and are plaque-biofilm retentive).
+ For soft tissue curettage, the face of the instrument is at an angle greater than 90° and
the cutting edge is directed towards the lining of the pocket.

STROKES

 Exploratory or assessment strokes: feather-like strokes using a light grasp with no lateral
pressure. This allows vibrations to be detected.
+ Overlapping, multidirectional, fluid, and longer strokes are used.
+ Use light touch in soft areas such as carious lesions to prevent further cavitation.
 Walking (bobbing) strokes: a series of small bobbing strokes made 1 to 2 mm apart to
advance the probe. Repeatedly reinserting the probe into the pocket can traumatize the tissue.
+ Use 10-20 g of pressure.
 Working stroke: calculus removal/scaling stroke. Use moderate to firm grasp during removal.
+ Overlapping, multidirectional, and shorter biting strokes are used.
+ Provides more complete coverage of areas.
+ Vertical, oblique, and horizontal strokes are also possible.
+ Lateral pressure: pressure applied by the index finger and thumb inward on the handle
to press the working end against a hard deposit or tooth surface.
+ Applied prior to and throughout a calculus removal stroke.
+ After each calculus removal stroke, pause and use a light exploratory stroke to assess if
the calculus deposit has been completely removed.
+ For roots, use longer strokes with less pressure (dentin is less mineralized) to preserve
the cementum.
+ Large calculus deposits should be removed in sections (channeling) rather than layers to
minimize burnishing.
+ For roots, use longer strokes with less pressure (dentin is less mineralized) to preserve
the cementum.
+ Removal stroke should not be used on calculus-free surfaces.

Instrument Types

MIRROR

 Provide visual access to surfaces of the teeth and structures of the oral cavity. Fulcrum is
needed for stability.
 Indirect vision: observe reflected image when direct vision is not possible (e.g., lingual of
mandibular anteriors, distal of maxillary posteriors, etc.).
 Indirect illumination: light bounces from the face of the mirror onto dark areas of the mouth.
 Transillumination: light passes through the desired area to observe shadowing. Useful to
detect caries and calculus.
 Retraction: can be used to retract tissues such as the cheek and tongue.
EXPLORER

 Functions:
+ Assessment of calculus (use the side of the explorer tip, not the direct tip).
+ Identification of tooth anatomy such as concavities, and margins of restorations.
+ Detection of carious lesions.
 Design: thin working end tapered to a point, circular in cross section. The last 1-2 mm of the
explorer tip is used.
 Types:
+ Shepherd’s hook (#23): hook-like shape, single-ended. Used supragingivally and is best
for caries detection. Also used to evaluate restorations. It is too thick for good tactile
sensitivity, and its design prohibits good adaptation in pockets or interproximal areas.
+ Area-specific (#11/12): long complex shank, tip is at right angle to the lower shank,
paired working ends. Used to explore healthy sulci and deep periodontal pockets.
+ Orban (#17): tip is at right angle to the lower shank, single-ended. Mainly used on
anteriors. A good adaptation is needed on curved surfaces.
+ Pigtail: curved shank, paired working-ends. Best for hard deposits and exploration of
healthy sulci as the tip cannot reach deep pockets. Also used for caries detection.

PROBE

 Functions:
+ Evaluate the health of the periodontium by measuring pocket depth.
+ Used as a “ruler” when measuring the dimension of:
+ Gingival recession, overgrowth, clinical attachment levels (CAL), etc.
+ Overjet (horizontal dimension), overbite (vertical dimension).
+ Intraoral and extraoral lesions.
+ Detect bleeding on probing (BOP) and suppuration (pus).
+ Detect hard deposits and roughness in conjunction with the explorer.
 Design: blunt tip, calibrated in mm markings. Can be circular or rectangular in cross-section.
 Types:
+ Marquis: 3-6-9-12 mm markings. Black band at 3-6 mm and 9-12 mm.
+ Williams: 1-2-3-5-7-8-9-10 mm markings. No marking at 4, 6 mm.
+ Michigan O: 3-6-8 mm markings.
+ UNC 12 (or 15): 1-2-3-4-5-6-7-8-9-10-11-12-(13-14-15) markings. Black band at 4-5 mm,
9-10 mm (and 14-15 mm).
+ WHO: 0.5 mm ball tip, 3.5, 5.5, 8.5 and 11.15 mm markings with a color band from 3.5-
5.5 mm.
+ Used for periodontal screening (PSR).
+ Goldman Fox: flat tip design (beavertail), 1-2-3-5-7-8-9-10 mm markings. No marking at
4, 6 mm.
+ Novatech: right-angle bend with mm markings at 3, 6, 9, and 12 mm. Allows easier
access to posterior teeth.
+ Naber’s: double-ended with paired, mirror image, working-ends, curved design with 3
mm intervals markings. Used to assess furcations.
+ Florida: computerized probing. Can provide more accurate readings as the same amount
of force is applied and depth is measured to the tenth millimeter.
 Marquis, University of Michigan, Williams, UNC, Naber's, plastic probes

 Probing technique:
+ Record 6 measurements per tooth, the deepest reading per site (distofacial, facial,
mesiofacial, distolingual, lingual, mesiolingual).
+ Use Assessment stroke- Light strokes, no lateral pressure.
+ Once the probe is inserted into the periodontal pocket, the working end is kept parallel to
the root surface.
+ Insert at the distofacial line angle and probe the distal side of the tooth. Reinsert at
the distofacial line angle and probe the facial and mesial surface. For lingual surfaces, use the
same sequence starting at the distolingual line angle.
+ Adapt the probe to the surface and curvature of the tooth.
+ For interproximal contacts, slightly tilt the tip to reach the center of the col.
+ Use Walking stroke- a series of small bobbing strokes 1 to 2 mm apart.
+ Gently press down to touch junctional epithelium.
+ Stop at each current point and take measurement.
+ Measurements are recorded to the nearest full millimeter.

SCALER

 Function: removal of medium-to large-

sized supragingival calculus deposits (some sources
indicate that a scaler can be used 1-2 mm below the
gingival margin).
 Design: two cutting edges per working end that come
together into a point at the back and tip.
+ Cross-sectional view is triangular.
+ Shank can be straight or complex.
+ Instrument face is perpendicular to the terminal
shank.
+ Anterior scaler: designed to be used in anterior
sextants, with a straight shank, and single or paired
working-ends.
+ Universal scaler: treat all surfaces, therefore an
efficient tool if time is limited. Its strong rigid shank helps
remove heavy deposits more easily.
CURET

 Most versatile removal instrument used supra and subgingivally.

 Design: two cutting edges come together as a rounded toe and
back.
+ Rounded back.
+ Rounded toe.
+ Half-moon (semi-circular) shape in cross-section.
+ Shank can be straight or complex.
+ Longer shanks allow better access to root surfaces.
 Universal curets
+ Blade form 90° with terminal (lower) shank. The lower shank
needs to be tilted toward the tooth for correct angulation.
+ Has two parallel cutting edges per working end, therefore one
instrument can be use to treat all surfaces in a shorter amount of
time.
+ Strong rigid shank allows small-to medium sized hard deposits
to be removed more easily on crowns and root surfaces.
+ May be difficult to insert/adapt interproximally in areas where
tissue is tight.

 Area-specific curets
+ One cutting edge per working-end, the lower edge is used.
+ Blade face is angulated at 60° to 70° to terminal (lower) shank.
When the lower shank is parallel to the tooth surface, the cutting edge is
at the correct angulation.
+ Paired, mirror-imaged working ends (matched sets, e.g., #11/12,
#13/14).
+ Gracey curets are the most popular.
+ Gracey 1/2, 3/4, 5/6, 7/8: used for all anterior surfaces (5/6, 7/8 is
suitable for all surfaces on premolars).
+ Gracey 9/10: used for premolars (all surfaces) and posteriors (facial
and lingual surfaces).
+ Gracey 11/12, 15/16: used for posteriors (mesial/direct surfaces).
+ Gracey 13/14, 17/18: used for posteriors (distal surfaces).
+ Used for light to moderate deposit removal.

 Specialized curets
+ After five: shank is extended by 3 mm. Provides
better access to deeper pockets and furcations.
+ Micro-mini and mini-five: working-end width is
smaller, shank is extended. Provides better access in very
narrow areas such as furcations.
+ Vision: working end is shortened by half.
+ O’Heir: tiny circular disc at the working end. Useful for
furcations.
+ Diamond coating: working end of instrument is
covered with fine diamond grit and has no cutting edges
(e.g., diamond coated Naber’s furcation probes.). Work with light pressure.
HOE

 Function: used to remove heavy bulky supragingival calculus. It is especially effective on

lingual surfaces of mandibular anteriors.
 Design: bulky working end gives great strength. Subgingival access and adaptation may be
difficult.
 Technique: use vertical pull strokes.

FILE

 Functions:
+ Used to “crush” calculus for the preparation of
removal with other instruments especially on burnished
areas.
+ Smooths overhangs.
+ Helpful in deep, narrow pockets because of its small
size and flat working end. Use caution as it can stretch the
tissue excessively.
 Design
+ Series of fine short blades are present on the side of
the head, and the back is rounded to facilitate subgingival
insertion.
+ Thick shank gives strength but also limits tactile
sensitivity.
 Technique
+ Use vertical pull strokes while adapting the entire
face against the deposit.

A. Curet, B. Sickle, C. File, D. Hoe

IMPLANT MAINTENANCE

 Avoid metal instruments against titanium implants.

 There are many materials used as alternatives to metal curets, including plastic, graphite,
Telfon-coasted, gold-coated, titanium-coated, and solid titanium allow.
 Evidence supports the used of nonmetal instruments.
 Plastic instruments can leave debris. However, textbooks and many resources may suggest
plastic as an option, research in this area is still developing.
 Use light lateral pressure only (calculus on and around the implant are not as tenaciously
attached to the surfaces).
+ Specialized ultrasonic tips materials include:
+ Teflon-coated shank
+ Carbon-coated shank
+ Titanium-coated shank
+ Removable polyetheretheketone (PEEK) tip
 Instrument Sharpening

PURPOSE

 Sharper edges provide more effective instrumentation. Clinician can use fewer strokes and
less pressure. This reduces clinician fatigue and increases patient comfort.
 Sharper edges also prevent burnishing of calculus.
 Removes wire edges by sharpening the instrument’s face.
 Precaution is needed so as not to over-sharpen the face and weaken the instrument.
 Sterilization in autoclaves (especially with steam sterilization) gradually dulls sharp
instruments.
 Probe and explorers should not be sharpened.

SHARPENING STONES

 Arkansas stone: natural stone with fine to medium grit. Lubricated with oil.
 Ceramic stone: synthetic stone with fine grit. Lubricated with water or no lubrication is
needed.
 India stone: synthetic stone with fine to coarse grit, considered most abrasive. Lubricated
with water or oil.
 Lubrication reduces friction and prevents metal shavings from embedding into the stone.
 Stones should be sterilized before and after use.

TECHNIQUE

 Stationary technique: most common technique. Instrument is held steady in the non-dominant
hand while stone is moved up and down with the dominant hand.
 Sharpen from heel to tip (or toe).
 Use up and down strokes but end with a downstroke to prevent metal burs/wire edge.
 It is preferable to sharpen the instruments when they are sterile.
 Internal angle of 70° to 80° for both curettes and scalers should be achieved (internal angle
refers to the angle between the face and the lateral surfaces).
 Angle from face of the curette or scaler to stone is 100° to 110° (visible angle).
 Position the instrument vertically with blade to be sharpened at 6:00.
 Sickle and universal curette: terminal shank of instrument at 12:00, stone at 1:00 (11:00 for
left-handed clinicians).
+ For the opposite blade, turn the tip away and maintain terminal shank at 12:00 with the
stone at 1:00 (11:00 for left-handed clinicians).
 Areas specific including Gracey curettes: only the lower blade should be sharpened (face is
offset at 70°).
+ Odd-numbered blades, point the toe towards the clinician. Terminal shank at 11:00 (1:00
for left-handed clinicians), stone at 1:00 (11:00 for left-handed clinicians). This is done to
position the face parallel to the floor.
+ Even-numbered blades, point the toe away from the clinician. Terminal shank
at 11:00 (1:00 for left-handed clinicians), stone at 1:00 (11:00 for left-handed clinicians).
+ Opposite for left-handed clinicians. Odd-numbered blades point away, and even-
numbered blades point towards the clinician. Shank at 1:00 and stone at 11:00.
TEST STICK

 Sharp instrument should “bite” the stick with light pressure and makes a metallic sound. If the
cutting edge slides, it indicates that the blade is still dull. Test along the entire length of the
blade.
 Stick should be sterilized after use.

Power-Driven Scaling Instruments

FUNCTIONS

 Periodontal debridement (includes scaling and root planing), periodontal maintenance, and
irrigation of pockets.
 Smooth overhangs.
 Remove orthodontic cement and stain.

TYPES

 Sonic scaler: uses compressed air to create movements.

+ Compared to other types of scalers, it is considered small, light, and inexpensive.
+ 3000-8000 cycles/sec (cps). Less effective removal because of low power.
+ All sides are active and tip moves in an elliptical motion.
+ Does not generate heat but water is still needed to reduce friction.
 Ultrasonic scalers
+ Magnetostrictive scaler: uses magnetic oscillations within metal stack to
convert electricity to movement.
+ 18,000 to 45,000 cycles/sec (cps).
+ Tip moves in an elliptical motion with all parts of the tip active.
+ Heat is produced, therefore water is needed.
+ The point has the highest power and should never be directed towards the tooth surface.
+ The face is the second most powerful surface.
+ The back is less powerful than the face.
+ The sides are the least powerful.
 Piezoelectric scaler: uses ceramic discs or quartz plates to convert electricity to movement.
+ 25,000 to 50,000 cycles/sec (cps).
+ Tip moves in a linear pattern (front and back).
+ Two sides of the tip are active.
+ Heat is produced, therefore water is needed.

INSERTION TIPS

 Standard tips: useful for the removal of most types of deposits and for initial debridement.
 Broad tips: useful for the removal of heavy calculus, stain, orthodontic cement. Also
called beavertail tips.
 Periodontal (slim) tips: longer and thinner (40%) than standard tips. Efficiently
remove light deposits and can reach the base of deep pockets more easily.
 Right and left (contra-angled) tips: work similarly to area-specific curettes and adapt better
to posterior teeth, furcation areas, and root concavities.
  Implant tips: made of plastic (or carbon composite) to prevent scratching of the titanium
implant.
 Replace tip that has lost 2 mm from working end.

TECHNIQUES

 Wet the O-ring if present. Water power should provide a halo effect with no excess dripping.
 Start with low power setting and increase as needed.
 Start with coronal areas then move to apical and subgingival areas (reverse for hand
instrumentation).
 Use sweeping motions.
 Tapping motions are allowed for large-sized deposits.
 High-speed suction is preferred to reduce aerosol and facilitate water evacuation.
 Last few millimeters of the tip are most powerful and should be placed against the tooth.
 Use light grasp. Heavy pressure reduces effectiveness and causes discomfort to the patient.

BENEFIT OF POWER-DRIVEN INSTRUMENTS

 Fluid lavage: water constantly flows into the pockets. It is possible to incorporate
chemotherapeutic agents to water.
 Acoustic streaming: disrupts cell walls and kills microorganisms.
 Cavitation: energy released from the small bubbles causes shock waves that can disrupt or
lyse bacterial cell walls.
 Less root structure is removed compared to manual instruments and furcation can be
effectively cleaned.
 No need for instrument sharpening.

CONTRAINDICATIONS

 Respiratory diseases such as COPD or asthma, and immunocompromised patients.

 Communicable diseases such as tuberculosis that spread through aerosol.
 Strong reflex and/or patients that may have difficulty swallowing.
 Porcelain or composite restorations. The restoration may fracture.
 Margins of restorations should be avoided unless the purpose is to remove overhang.
 Demineralized areas, sensitive roots.
 Newly erupted teeth, as they have large pulps that may be heat sensitive and the enamel is
not fully mineralized.
 Old pacemakers. New pacemakers are shielded and are not contraindicated anymore.

Polishing

SELECTIVE POLISHING

 Currently most accepted approach to polishing. Full-mouth polishing is not considered a

routine part of oral prophylaxis but can increase patient satisfaction.
 Repeated polishing can remove cementum, exposed dentin, and enamel; while increasing
surface roughness (promotes plaque reattachment).
 Indicated for the removal of extrinsic stain and to smooth rough surfaces. Tenacious stain
such as black line stain requires the use of curettes.
TECHNIQUES

 Rotary brush/cup polishing

+ Cup should be placed at a 90 degree on the tooth surface. Apply light pressure to flare
the edges of the rubber cup slightly and use the slowest rpm. Fulcrum is needed for stability.
+ Begin with the distal surface of the most posterior tooth in a quadrant and then proceed
forward toward the anterior teeth. Move the cup in a patting/brushing motion and work from the
gingival third toward the incisal third of each tooth indicated for selective polishing.
+ Bristle brush is used for occlusal surfaces and concave areas of the tooth only.
 Air powder polishing
+ Sodium bicarbonate powder, water, and air are made into a slurry and pushed toward
the tooth surface at high pressure.
+ Best for removing extrinsic stain. Also used for sealant preparation.
+ Causes less damage to the tooth surface compared to cup polishing.
+ For anteriors, tip is directed at 60° towards the facial and lingual surfaces.
+ For posteriors, tip is directed at 80° towards the facial and lingual surfaces.
+ For occlusal surfaces, tip is directed at 90° to the occlusal plane.
+ Use rapid, sweeping strokes with the tip positioned 4-5 mm away from the tooth surface.
+ Polish for 5 seconds or less per tooth and do not spray directly at the gingival margin.

ABRASIVE AGENTS

 Pumice and silicone dioxide are common abrasive agents. Pumice is the primary ingredient in
prophylaxis pastes- water, humectants, flavoring agents, etc. may also be added. Some
prophylaxis pastes contain fluoride at a level that does not provide therapeutic effects.
 Size of abrasive particles determines the abrasiveness. Smallest particles are less abrasive.

CONTRAINDICATIONS

 Restorative materials.
 Should not be used immediately after SRP and NSPT to avoid reintroduction of bacteria.
Polishing can be done at succeeding appointments.
 Patients with hypertension, Addison’s disease, Cushing’s syndrome, and metabolic alkalosis
(applies to air polishing with sodium bicarbonate-based powder).
 Patients with respiratory and infectious diseases, as polishing creates aerosols.
 Unhealthy, spongy, edematous tissue.
 Intrinsic stain or no obvious extrinsic stain.
 Recession with tooth sensitivity. Abrasion can wear the root surfaces and patient may feel
pain.
 Demineralized areas or thin enamel as in amelogenesis imperfecta.
 Newly-erupted teeth as the surfaces have not been fully mineralized yet.
 Teeth with large pulp chambers, such as primary teeth (susceptible to heat).
 Positioning During Instrumentation

CLINICIAN POSITIONING

 Ergonomics: the science of adjusting the design to maximize the efficiency and quality of
work. It is important for the clinician to consider his/her ergonomics first.
 Proper positioning:
+ Neck: centered with minimal bending of the neck and minimal rotation (less than 20
degrees).
+ Chin: lightly tilted downward, eyes looking about 15-22 inches from the working area.
+ Shoulders: relaxed in a neutral position.
+ Elbows: relaxed, close to the body.
+ Elbows at waist level bent at a 90° angle; forearms are parallel to the floor.
+ Elbows are at or above the level of the patient’s mouth (or nose).
+ Wrists: aligned with hand and forearm, and minimal flexion or extension (less than 15
degrees).
+ Use forearm activation for strength.
+ Back: natural curve, tilting forward from the hips rather than curling, minimal rotation of
the torso.
+ Hips: level on clinician’s chair.
+ Knees: 105-125 angle from hips and shoulder-width apart.
+ Back of the knees should not be right against the edge of the seat.
+ Keep knees and legs apart to create a tripod effect between the two feet and the stool.
+ Feet: flat on the floor, thighs parallel to the floor, shoulder-width distance and back
against the backrest.
+ Avoid placing the legs under the back of the patient chair. This will place the patient too
high. Legs under the headrest are acceptable.

PATIENT POSITIONING

 In a supine position, the head, heart, and feet are approximately on the same plane. This
reduces the chance for syncope (fainting).
 Patient’s tip of the nose should always be lower than the clinician’s elbow.
 For maxillary procedures, the maxillary occlusal plane should be perpendicular to the floor. Ask
the patient to maintain a neutral position or a chin-up position (headrest can be titled).
+ Light is positioned over the chest, shining into the mouth at an angle.
 For mandibular procedures, the occlusal plane should be as parallel to the floor as possible.
Ask the patient to tilt the chin downward (headrest can be tilted).
+ Light positioned directly over the mouth, shining straight down.
 Relative contraindication for a supine position: congestive heart failure, respiratory problems,
pregnancy, spine injury, etc.
 Raise chair slowly to prevent orthostatic hypotension.

CLOCK POSITIONING

 8 to 9 o’clock (3 to 4 o’clock for left-handed clinicians): anterior surfaces towards the clinician,
and posterior surfaces towards the clinician.
 12 o’clock: anterior surfaces away from the clinician.
 10 to 11 o’clock (1 to 2 o’clock for left-handed clinicians): posterior surfaces away from the
clinician.