Board Certified Periodontist

42 – Miscellaneous Tips to Consider

Hi there. This is The Perio Hygienist Patient Podcast, a podcast for my professional colleagues and anyone else who cares to listen. My name is Dr. Ben Young and I am a periodontist living and working alongside many of you in the beautiful city of San Antonio, in the great state of Texas.

Today’s podcast is entitled: Miscellaneous Tips to Consider

Do you ever get to the point where you have more you want to say on more topics than you care to think about? Some of these tips have been with me a long time and I have tried to figure out how to present them. I hope someone finds them useful, and if you do, let me know. Also, if they generate questions or other ideas, let me know this as well.

So let’s start with the some clinical tips.

Tip #1.

Let’s talk about how to remove heavy calculus without injuring your wrist. Carple tunnel syndrome is common with dental hygienists and can be traced back to repetitive muscle strain as a result of attempting to remove heavy calculus.

First of all, like I am sure you do, begin with ultrasonics. Now I don’t know what you were taught, and if you would like to share this with me, please leave it in the comments to this podcast. But oftentimes, we are instructed to not injure the root surface. For this reason, we are to avoid the tip of instruments, both ultrasonics and hand instruments. I would like to modify this idea just a little. First of all, I know it is tempting to remove calculus in large chucks. It’s visually entertaining and satisfying, but it is the wrong approach. Instead, think of it this way. If you continually scratch the surface of the calculus with the tip of your instrument, not trying to get under or hook it to dislodge it from the root, but to scratch it’s surface, what will happen is that eventually, the calculus will fracture and fall off. It might not fall off entirely, but this is not important, you simply continue to scratch with the tip. Now think of it this way, using the tip or point of the instrument to scratch the calculus, which means you are turned perpendicular to the root surface – and if there was nothing there you would certainly be scratching the root surface, which is not recommended – you control the amount of pressure applied, and the least is required to break up the calculus when compared with the side of the instrument.

So let’s simply think about the lingual of the lower anterior teeth and you have a bridge of calculus that runs from tooth 22 to 27. You begin with an ultrasonic tip and you use it like a little jackhammer to create lines in the calculus. As the calculus breaks off, you continue this method until you are now seeing the root surface. Now you can begin to use the side of the ultrasonic tip to move over the top of the calculus until it for the most part disappears. Where you cannot see the calculus under the gums, you do the best you can to remove bumps on the surface of the root. You always need to go back and plane with an instrument.

Tip #2

Now let’s talk a moment about sharpening the hand instruments. It’s nice to have a sharp edge, but sharpness, like it does with scalpels and razorblades, dulls very quickly. So my question is, how sharp does the instrument have to be? This is a thought question. Something to think about. Isn’t it true that an extremely sharp instrument can cut into the dentin and injure the surface more than a duller instrument might assuming the same pressure applied? In other words, if you have an extremely sharp instrument you have to be careful not to apply too much force. If you have a reasonably sharp instrument, then you might have to apply slightly greater force, but will likely have a lower risk to injuring the root.

Now, I think I have stated this before on a podcast about scaling and root planing, that you go to achieve smoothness, but you have no idea what the response to the tissues will be until after the area has healed for a few weeks. Also some subgingival calculus will become visible at the next visit and then can be easily removed at that time.

So, to review, I’m challenging you to think about instrument tips and sharpness of instruments a little differently than you may have been taught. Let me know what you think.

Tip #3

Next, let me comment on scaling and root planing instrument selection. How many hand instruments do you need? I use four.

In general, there are two types of scalers or curettes we use. We talk about them as either being Universal or Area Specific. The universal instruments are designed to enable both sides of a sharpened tip to be used in procedures. Area Specific instruments which for the most part (I’m sure there are exceptions out there) are the Gracey Instruments. These may have sharp edges on both sides (because they are made by shaving half the metal off a small round stock to create what in cross section looks like two sharp edges, on flat surface and one round surface. The idea is that the round surface of the instrument protects the soft tissue side while the flat end faces the root. There is only one edge that is supposed to be used with this instrument and it is the edge furthest from the center axis of most terminal part of the instrument. What this means practically, is that for all Gracey instruments, except the Gracey 13-14, if you hold the instrument with the handle perpendicular to the instrument table, the edge furthest from the handle is the edge to be used. With the Gracey 13-14, this doesn’t work. When you hold the terminal extension of the instrument where the stock has been shaved to create the current, you will find that the edge furthest from this terminal part is also the edge closes to the handle of the instrument. This allows this particular instrument to scale and root plane distal surface of teeth.

So with all of this in mind about Gracey’s and Universals, I find that I use a few of both. The Universals I use are McCall 13-14 and McCall 17-18. The Gracey’s I use are 11-12 and 13-14. What about the anterior Graceys? I have them around but not in every kit. The combination of these four instruments as well as ultrasonics, are what I use to provide most of my scaling and root planing. And don’t think for a second that the 11-12 Gracey can’t be use to scaling and root plane anterior teeth. Give it a try and see what you think.

Tip #4

This one is about lip and cheek retraction. When probing labial side of the lower anterior teeth, I have found that the mirror is sometimes a bit uncomfortable for the patient. So I use my finger to retract. This is especially useful when the patient has the protective response to use their lip to cover the teeth. By putting my gloved finger of the hand that would be holding the mirror between their lip and teeth, I can gently with just a bit of firmness, pull the lip down and away. Sometimes I have to wait just a moment for the lip to relax and then I probe.

And here’s a bonus retraction tip. One of the most common surgical retractors is called the Minnesota retractor. It’s inexpensive. Which is nice. I put one of these retractors in my examination kit in order to retract the cheek closes to where I am sitting. It does a better job than the mouth mirror does. Give it a try and see what you think.

Tip #5

I just got a survey asking me what I think about dental hygienists providing local anesthesia. I am in favor of it. I understand where the concern lies. It is with anesthetic blocks. The idea is that if dental hygienists are given permits to provide local anesthesia they might have problems when delivering a block anesthetic. These might result in hematomas or nerve injuries.

What is so interesting to me is that in my career I have found that infiltration anesthesia is the most predictable, (meaning frankly that we dentists miss a lot of blocks all the time – why? Because people’s anatomy isn’t all the same – there are big variations. Also blocking large nerves may miss small ones coming from other directions.

So, I reverse my anesthesia delivery to providing the infiltration anesthesia first, and then, if necessary, the block second. Here is my logic. If I miss the block, what will I do next? Infiltration, most likely. So I just do it first. Also, Septocaine is a better anesthetic compared with Lidocaine. And Septocaine is very profound even with 1:200,000 epineprhine.

Tip # 6

This has to do with suturing, which I know, isn’t something dental hygienists do, but I’m dropping this one out there for residents as well as general dentists.

One of the biggest problems with suturing using a needle holder to tie the knot has to do with what to do with the excess suture string.

First of all, with a sterile gloved hand, once the needle has gone through the soft tissue and you are now at the moment to tie the knot, take the suture needle and place it between your thumb and first finger. Now I know, for some at first, these may seem risky, but it is the most protective thing you can do to avoid needle puncture. A dangling needle is a dangerous needle. Placing it between your thumb and first finger, is, in my opinion, the safest thing you can do.

Next, begin to wrap the suture around the middle finger of the same hand holding the needle until you have a few inches left at the end of the sutures. Now tie your knot.

I have two tips left. One is a marketing tip and the other is an interpersonal tip.

Tip #7

The best marketing has nothing to do with you or  me – the ones who want to market, promote or sell. It has to do with someone else – not everyone else, which is impossible anyway, but someone else. If this is the case, and I think it is, then all marketing is personal, all marketing involves a relationship.

But what a lot of marketing is today is style, color, cleverness. You know what I mean. Instead, what it needs to be is honest and real. It should invite longer conversations that then deepen relationships – and yet marketing by the numbers sometimes can attract someone into the office and then repel them based on how they feel about the behaviour they then experience. And what is true when you have a friend or loved one who is going through a hard time (like the embarrassment they feel having neglected their teeth for so long and now having to face people in a dental office) the best thing you can do is listen. They want to feel safe and they don’t want a lecture. They will certainly, when they are ready to do so, ask for advice and recommendations.

So the best marketing comes through your office and involves patients connecting with the team – which then means that team health is critical – which is another way of saying that we all have to learn to interact with others who are not like us. Which brings me to tip number 8.

Tip #8

To provide you with the evidence you need to take this next tip seriously, I have to admit a personal failure of a sense. I have been divorced since 2016 and it came in our 39th year of marriage – and it wasn’t infidelity from either of us. If I had to boil it down, I would have to say we could never end a disagreement. This does not mean we were always arguing, but when critical important issues would come up, we could not resolve them – which meant that old wounds and hurts would sometimes come alive like ghosts and haunt our current disagreement whatever it was. Bringing up old stuff is generally a strategy of leverage. It is trying to get the other to change their behavior because of some cited problem in the past. It is also a very clever way of changing any subject. Now, as you listen to this, please avoid one common mistake. Don’t believe that you happen to have the answer to our problem. You don’t. You can’t. Which brings me to tip #8.

Had I known this one myself earlier, perhaps our marriage outcome would have been different – but it might not have been. What would definitely have been different would have been my behavior and my overall sense of peace and tranquility.

The tip is to work not to understand the other’s thoughts and behavior, but to understand that you will never understand anyone else’s thoughts and behaviors.

Let that sink in.

Sometimes, to be completely honest, I have to work to understand my own motivations for why I do what I do, so why in the world am I believing I have the capacity to read someone else’s mind and know why they do what they do?

Now if you have listened to enough of my podcasts or you know me personally, you get that I am very analytical. I like to think about things. I want to understand how they work, and this has included how others work, how they think.

Why do some patients accept care and others don’t?

Why do I get along with some people and not others – and usually I want to answer such questions by better understanding them and not myself – when, again, to repeat myself for your sake, the fact of the matter is the only one I have even a smidgen of a chance to understand is me.

Also, this means, I can’t transfer my thoughts to others. I can’t assume that others think like I do. The truth of the matter is the chances they think like I do are zero point zero.

With this in mind, how do we live with others? How do we manage disagreements – which by my point that none of us are alike – must occur. Disagreements are a normal part of life, but arguments, do not have to be.

My solution, coming out of the process of recovery – which is an on-going process of living one day at a time and staying in healthy relationships as being vital to living a happy life. Is to give everyone I interact with the respect that they are doing the best they can under their circumstances. Now I have told people this, and it doesn’t work with anyone who is at this moment dealing with the hurt and pain of injury or the betrayal of someone they trusted. I understand. But when the dust settles, and the emotions subside, there is this choice – whether to continue to hold on to resentment or let it go – not for the benefit of the other – because most certainly they are not aware of how you are thinking or feeling, and might not care even if they did – but for your own benefit, to be able to reclaim yourself. You see, one of the errors having to do with forgiveness has to do with admitting they are somehow right in what they did. It is actually, the acknowledgment that they did not do something right, otherwise, why is their a need to forgive in the first place. Think of it this way. Resentment and bitterness are poison pills we take ourselves hoping someone else will suffer and be punished. Life does not work this way.

So let’s go back over this one more time. That someone has hurt me may be true, however, when I acknowledge that they were doing the best they could under their circumstances – and the only other alternative I can think of, if this is not the case is that they are evil – what I am saying is that at the time they were yelling at me or insulting me or cheating me, or even physically harming me, they were acting under circumstances that led them to do what they did – and I don’t know what these circumstances are and I don’t have to agree with their choices. I am simply acknowledging that there is a mystery here I will not solve and it is not my job to change the behavior of another adult. We might have more influence on our young children when they are growing up but even with them, regardless the age, it is critical that we respect them as well, and understand that they too are making choices, even poor ones, based on their own circumstances, which we don’t completely understand. We may not know about the bullying by another child and the fear they are facing because they don’t see themselves succeeding in school or in a sport.

And it just so happens that many of us have never believed we had but one of two options when it came to conflict. We could fight or we could flee. I’ve done both many times. Be aggressive or shut down entirely.

So here is my tip once again. Disagreements are a way of life, but fights, conflicts, arguments take two willing participants. There is a third option, which is to learn to pause, to treat others with the respect that they are behaving in a way they see as rational and therefore, evidently, are doing the best they can. Perhaps they are locked into thinking as I once did that we have to fight or escape, and that arguments are all about winning or losing. To be able to pause and remain calm without shutting down is a discipline that has to be developed, even practiced away from conflict in order to enable it to settle in.

So the next time you find yourself heading into an argument, with a child, with a spouse, with a parent, with a friend, with a stranger, with a patient, with a boss, with an employee, is to stop, to listen, and pause, in order process our own thoughts and as well as feelings.

I have found that many times when my responses are simply put on hold, paused, by counting to ten, by counting to a hundred, whatever it takes to obtain mental clarity, that very interesting and unexpected things begin to happen. For example, I have discovered that many times, I do not have to come up with a solution to whatever problem seems to be presenting itself. That sometimes, not touching the problem at all results in it correcting itself without my involvement (or interference) at all.  Well, that’s it. Use what works for you and throw out the rest. This has been The Perio Hygienist Podcast and I am still Dr. Ben Young. Thanks for listening. Bye for now.