Hygiene Instrumentation: Dental professionals comment on patients' influence over choice

A slight majority of dental professionals believe patients should choose whether ultrasonic scaling or hand instrumentation is used during dental hygiene procedures, according to a survey in RDH eVillage.

The survey was published in the Sept. 28 issue of RDH eVillage, and 53% said the type of hygiene instrumentation should be influenced by the patient’s choice. The survey was open to all dental professionals, but dental hygienists provided 721 of the 750 responses.

READ:The Tale Of Two Hygienists
READ:So you think you can scale?
READ:What are your favorite instruments?

The survey primarily solicited comments from participants about hygiene instrumentation. The comments below reflect a selection of the broad range of comments offered.

Trust in Clinicians' Skills

• I do want to hear their preferences. If I feel that I need to do something differently for any reason, I will explain what the clinical differences and indications are according to my strengths. I explain that each RDH has his or her own skill set that could be stronger in one modality over the over. If one modality was good in one RDH's hands (assuming the tools/equipment are of sufficient quality), that doesn't necessarily mean that it will be the best modality in another RDH's hands.
• The clinician should be the one to determine which mode of treatment is indicated. If your physician recommended an MRI, would he allow the patient to have a different type of test done? No. We are in a position to determine what is the best method for the patient.
• The hygienist should be evaluating patients to determine what instrumentation is best qualified for each patient. If instrumentation causes discomfort, there should be options that may include anesthesia.
• For most of my patients, I use ultrasonic scaling first, then follow up with any necessary fine scale with hand instruments. I feel that most (adult) patients benefit greatly from this regimen, especially if there is periodontitis, gingivitis, or challenges to home care (ortho, crowns, poorly motivated or uncoordinated, etc.) because of the unique benefits of lavage and accessibility that it provides. Occasionally, whether for reasons of sensitivity or other issues, the patient prefers only hand instruments. The clinician needs to decide which is in the patient's best interest, but if the patient is generally periodontally healthy with good home care, then skilled scaling with hand instruments should be sufficient for their needs. If they are in this category and hate the ultrasonic, then there is no need to use it. The clinician makes the recommendation and works to get the patient to agree to the treatment modality, but the patient has to feel that their needs are being addressed. Would you go back to a doctor or hygienist who ignored your concerns about sensitivity and hurt you “for your own good”? I know I wouldn't.
• The patient does not have the choice of the high-speed handpiece for restorative work; it is the same for an ultrasonic.
• If the patient had a bad experience with either of the procedures, they should voice their concern. But then the hygienist needs to educate the patient on why she or he chooses the method of cleaning the teeth. If the patient is so uncomfortable with your delivery, there are other solutions as anesthetic or another hygienist. You choose the best method for the patient, not what the patient chooses.
• That would be like a patient telling their heart surgeon how to perform heart surgery.
• I have had patients refuse ultrasonic scaling on numerous occasions. I have also had patients tell me they prefer I only use ultrasonic and not hand scale. I do believe it does change their outcomes in some cases. We choose our instruments on a case-by-case basis for very specific reasons. If we are limited in these choices based on the patient’s choice, we are limiting our ability to effectively treat them.

Pro-Instrumentation Choice

• Hygienists should always be ready to use an alternate method in order to achieve the goal of removing pathogens as comfortably and completely as possible. We hygienists are serving the patients, not the other way around. When the use of the ultrasonic is vital, a patient will usually tolerate it if they understand its value. Offer a form of anesthetic for support.
• I want my patients to be comfortable and at ease. I treat each patient as an individual. The amount of calculus, fear, discomfort, etc., varies greatly per individual. Whether I use ultrasonics or hand scale, the end results are the same. I will encourage a patient to try something new. Of they don't like it, that's OK.
• I accommodate my patients preferences whenever possible. But once I identify the reasons for their objections of hand vs. ultrasonic scaling, then I can usually make modifications to make them comfortable
• The dental hygienist should choose the appropriate method with patient comfort considered. I work at a VA Medical Center. Not all my patients can tolerate certain noises or coldness; it stimulates triggers we try to avoid.
• It is always key to gauge the comfort level of our patient. For example, if the patient states a preference for hand scaling because ultrasonic scaling causes hypersensitivity or too much water accumulation, then that is something we can accommodate. It is also important to educate the patient as always, as to why we choose a certain method of instrumentation. Ultimately, a positive patient experience is what we aim to provide so tailoring the method of scaling to each individual is a sure way of doing that.
• It is their choice clearly. If the hygienist is gifted and skilled in communication, they might suggest a compromise and agree to try the best treatment.

Pro-Ultrasonics

• I firmly believe in ultrasonic scaling as the standard of care. If a patient objects, I will do all I can to help them understand why I feel as strongly as I do about the benefits of ultrasonic scaling vs. hand scaling. I find that once educated, most comply. Still, there are those obstinate few who, for whatever reason, insist on hand scaling and as I do not wish to deal with an assault and battery charge, I must comply.
• Sometimes the patient doesn't want to be inconvenienced. Or if they are sensitive, that is the time to numb them up! If the patient has active disease, the ultrasonic will help flush the debris and help the hygienist remove calculus.
• Yes, I use the ultrasonic on EVERY single patient I see. It can be mastered without much discomfort.
• I use my Cavitron at all appointments unless a patient asks if it is possible to hand scale. Noise seems to be the main problem. If they have a lot of stain, they will usually let me use it on anteriors (smile area stain).
• It's not the patient’s hand that's hurting after hand scaling all day long!
• I don't change if I think using an instrument would get the results. I have told patients if they don't want me to use a certain instrument, then keep the oral cavity free of calculus, food debris, plaque, etc.

What Other Dental Professionals Say

• Office Manager: Patients may have a preference and we try to follow that; but they do not know what is best and why it is best. We educate and lead the patient to making the best choice for themselves.
• Office Manager: It is always good for patients to be able to express their thoughts. If a patient expresses a preference in hand instrumentation, we encourage our RDHs to speak with them about the benefit of ultrasonic scaling, and then to finish with some hand instrumentation. Most patients will accept this approach.
• Dentist: If you are a good scaler you'll have pretty good results. So many hygienists want to get done fast and use ultrasonic for this reason. There are many cases though where the tips are totally helpful and that should be explained to the patient perhaps changing their mind.
• Dentist: Yes, there is always a choice. The hygienist is not in a position to dictate treatment. If there is resistance to one modality over the other, educating your patient is your best defense. In addition, communicate with your patient to find out why they prefer one over the other. It may be simply comfort vs. a bad experience from improper technique they experienced from a previous hygienist. Regardless of which camp you are from, both provide good care if the hygienist is adequately trained/skilled in both modalities, especially for routine continuing care). Yes, there are times when someone comes in with a tremendous amount of tenacious calculus. With the proper communication skills, a patient usually can be persuaded to allow ultrasonics, which may have been declined on the onset. Regardless, patients are paying clients, and they still have the right to decline one modality over the other. As a professional, you need to honor their request. Documentation is necessary especially if you are not able to remove all the calculus/stain due to time constraints or accessibility as well as informing the patient of the situation. Unfortunately, in my experience with many hygienists, several rely too much on the ultrasonics and are not proficient when it comes to sharpening or hand scaling.
• Dentist: Understanding there may some discomfort depending on the patients’ sensitivity, but unless the patient is also a dental professional, the patient does not/may not understand why we have to use the instruments that we use. The tip of an ultrasonic scaler may not be able to reach the area that needs to be treated and hand scaling may be best. Alternatively, hand scaling may take too long or be too burdensome to get some calculus that may be present and the ultrasonic is needed. I have had patients request topical or I have used Oraqix and everything has worked out fine.
• Dentist: We always are concerned about the patient's request and routinely ask, What questions or concerns do you have today? And is there anything I can do to make your appointment easier for you today? But ultimately it is up to the hygienist and dentist to insure proper care for the patient.
• Educator: I am a dental hygiene educator, and we stress to our students that the patient should never dictate treatment. We express how important it is that we as professionals practice to our standard of care, which may sometimes lead to uncomfortable treatment for the patient. The patient should be given the option to have anesthesia if need be. If ultrasonics are needed to successfully remove calculus deposits and will cause less operatory fatigue and better end results then that should be the instrument of choice. The patient is often times uneducated when it comes to making certain decisions (such as in this case) and therefore it is up to the professional to choose the right instrument. With that being said, the patient by all means has a right to autonomy and has a right to choose their course of treatment, however, whenever it falls below the standard of care, that hygienist is putting themselves at risk for a lawsuit and is better off not treating the patient at all.

War Stories About Patients

• Some patients do not like the ultrasonic. Most will allow it to be used once explain that it is the recommended method to flush biofilm and remove deposits more easily, helping to promote healing. But some just refuse its use. Did have a patient had heavy deposits and was informed it would require more appointment time and charges due to his refusal to allow the best method to complete his perio appointments. He was OK with it because he could just not handle the ultrasonic. It was a win-win situation for us both. I did not have to kill my hands, and he was less irritated by the sound and feel of the ultrasonic.
• I have been in transition in the last four years — unemployed, under-employed, or doing temp work. I have had to "adapt" a lot. But I have clearly seen that the ones who are weak in hand instrumentation and detection skills tend to wave the Cavitron around like it's a magic wand. They are burnishing calculus all over the place, and that is never a good thing to leave calculus behind. They have created very difficult situations for me to follow in their heels or to work beside them. I usually find the burnished calculus that they don't know is even there. Unfortunately, I have encountered too many doctors in recent years that don't want to deal with it. These practices prefer the "party girl" who always makes the visit fun and easy. Patients don't want the "rough" one who speaks truth about disease and the need for more definitive treatment. You cannot expect to have long-term health in the presence of burnished calculus. Tissue may appear to be tight and firm, but will eventually become a bigger problem. Fortunately, I am happy to say that I have finally landed in a practice where the doctor and patients want "thorough" treatment and address the oral systemic connection risks and want to actually do something about it.
• There are those few who will not be convinced. I have actually scaled one lower quadrant with the ultrasonic and the left by hand to demonstrate the potential difference at a three-month recall. When the patient saw the difference in tissue tone and the amount of hemorrhage on the left he opted to allow ultrasonic scaling and was a believer.
• There have been times when a patient has absolutely refused ultrasonic scaling, so I used hand instruments. I follow up the scaling with Peridex pocket irrigation, and the clinical outcome seems to be the same.
• A patient had extreme sensitivity and several areas of class V caries, but he thought he could handle the ultrasonic scaler. I thoroughly explained to him that the machine vibrates and uses water to clean around the teeth, almost like a pressure washer for your mouth. He said "Okay, let's try it. I am here for you to get the job done." We began on the lower anteriors supragingivally and he started to wince. I immediately stopped, asked if he was OK and he said, "Keep going." I rubbed some topical around the area I was working. After noticing that the topical was not helping, I stopped and shared my concerns with the patient. I then went to the dentist and he said, "Stop using the ultrasonic scaler and get at as much calculus off supragingivally, and we will bring him back for SRPs." Patient returned a week later for the upper arch SRP (and an extraction) and was still sensitive but not as bad. He was very pleased with the outcome and cannot wait to return for the lower arch SRP. Although my original clinical outcome had to be adjusted, my main concern was my patient's comfort. I am not a heavy-handed hygienist and my patients love me for that! When I see a patient in pain, I know that it's not me and that it's my job to make them as comfortable as possible.
• Absolutely the outcome was not as good if I had my preference. There is one man that has heavy stain and calculus and he refuses to allow me or anyone else in the practice to use the ultrasonic. He said he just didn't think it did as good a job. Then I showed him on the computer screen how much more quickly and easily I could remove the deposits. Then he changed is explanation and said, "I just don't like it and I don't want you to use it." He gets the best I can do with the limitations he places on me, but it's not the BEST that I can do.
• Had a patient that was having hearing problems and did not want me to use the Cavitron because of this issue. I didn't use it, but knew that it would have been the preferred device to clean his teeth.
• When a patient shows aversion to the ultrasonic scaler and it is needed, I will educate them on why I am utilizing it. Once I am completed with the information, I will ease into the instrumentation with the ultrasonic with going slow, tooth by tooth and being very gentle. I check in with the patient on the comfort level and I continue to discuss the benefits of ultrasonic instrumentation. Once completed, I receive the feedback from the patient and I will document the patient reaction to the service. If patient still has an issue, then I will identify the areas that would benefit the most from the treatment of an ultrasonic, let the patient know and utilize the ultrasonic in those locations at the next visit. I find an educated patient, proper instrumentation and gentleness goes a long way in patient management and disease treatment.
• I have two patients who really would benefit the most from a ultrasonic cleaning but due to issues with their inner ear they both swear that the ultrasonic makes them nauseated. They are both long time patients so I do accommodate their requests for hand scaling only. They both have agreed to come in every four months even though their insurance only pays the standard twice yearly.
• I have one patient with fair home care who had a temporary hygienist use it when I was out on sick leave one time. He thought it was great that he was in and out in 15 minutes. He loved that “power thingy!" When he requested I use it, because it was quicker, I said sure, but I would also be following up with hand instruments and assured him he would be in my chair longer than 15 minutes as I felt we had a more thorough job to accomplish. It is many years later and we have been following this routine first at the patient’s request but now he has 5 mm pocketing between the maxillary molars, which I am happy to use the ultrasonic scaler on.
• I had a patient on oxygen and the water from the ultrasonic made her choke a lot which made it hard for her to breath, so I hand scaled. She was much more comfortable and able to breath better. In her case, there was a lot of calculus to remove but her tissue and bone were not terribly affected so I feel her treatment would not have much of a different outcome either way.
• I have a patient who is an accomplished musician. The pitch of the ultrasonic is annoying for him. He prefers hand scaling so I hand scale.
• I prefer hand instrumentation over ultrasonics for most patients. I feel that with the majority of inserts available over the last 25 years of practice that calculus is left behind, especially under contacts. I also feel that most patients abhor the ultrasonic devices and will request myself or another hygienist my practice that doesn't always use it! I do always use it during scaling and root planing or for very selectively for extremely heavy deposits.
• I have a four-month recall patient who has requested that I don't use the ultrasonic scaler. Not due to discomfort but because of research she did after we used it for the first time. (She couldn't remember the source.) She is somewhat compliant at home with flossing and extremely faithful as far as keeping her appointments. Her pocket measurements remain stable, most within 2-3 mm with several molar areas remaining at 4 mm with slight bleeding. I do think if she flossed and remembered to rinse twice day with Listerine these areas would improve also. I do wonder if the ultrasonic would change these areas, but I feel her home care is the bigger stumbling block. When she flosses more regularly she has less 4 mm pockets and the bleeding is not present.
• I stood to accommodate a patient who refused to lean back. I was out of work with a bad back for the two following weeks, plus I know I did a less than adequate job. She never insisted on sitting up straight for the dentist!
• A middle-aged male asked me to use the NEW instrument that didn't "scrape" his teeth. This took more time than hand scaling because I cannot rely solely on ultrasonic to reach or feel all surfaces and completed the professional hygiene care with hand scalers. The clinical outcome was improved with less trauma to the gingiva overall and the patient felt he had ultra-modern care and was more attentive to home care instructions. Plus, he referred his friends who had been away from professional dental care. Great outcome!