Modern Ultrasonic Debridement and Aerosol Management

Episode #347 with Chrissy Ford, RDH

Aerosol management is vital during COVID-19. And the limits on ultrasonics and other aerosol-producing procedures creates a perfect opportunity for clinicians to relearn forgotten protocols for hand instruments and ultrasonics. Today’s expert, Chrissy Ford, founder and CEO of Advanced Hygiene Solutions, shares tips, techniques, and things to consider when returning to manual procedures. She also shares advice for effectively and efficiently using ultrasonics to maximize comfort and hygiene for patients. For the best practices on getting the most out of ultrasonics for COVID-19 and beyond, listen to Episode 347 of The Best Practices Show!

Main Takeaways:

Aerosol capture should be the number-one consideration during COVID-19.

Now, more than ever, the quality of hand instruments is very important.

Returning to hand instruments, ergonomics for hygienists should be considered.

There is a lack of ultrasonic insert selection in most clinics.

Many hygienists are not using the correct ultrasonic inserts for each case.

They are also using a higher power setting than necessary, which creates more aerosols.

Hygienists are forgetting to check their inserts for wear, which reduces clinical performance.

ReLeaf, DryShield, and Isodry is not recommended for primary aerosol capture.

When used correctly, HVE can be 90% to 98% effective in aerosol reduction.

Quotes:

“What is hygiene going to look like during COVID-19 and beyond? Obviously, none of us have that crystal ball. Some of us are back to work, so some people have that sense a little bit more than others, what it’s going to look like. Obviously, it’s going to look different for different people, depending on where you are, depending on what your state and your provincial guidelines are going to allow you to be doing. I think it’s safe to say that the majority of us are going to be limiting our aerosol-producing procedures for a while. So, our polishing, our airflow debridement, our ultrasonic scaling, is going to be set aside for a little bit.” (00:57—01:31)

“Many hygienists are cringing at the thought of hand scaling only. And don't get me wrong, I'm right there with you. But we have to persevere through that and push through and know that we’re going to be doing this for our patients. And they need us.” (01:33—01:47)

“Life without ultrasonics, que the tear down my face. I know a lot of hygienists are feeling the same. We rely on our ultrasonics a lot. And what is that going to mean for our hygiene appointments? It is going to mean an increased time to get that same job done. So, obviously, we know we’re not going back to business as normal, seeing eight patients a day. But we’re going to need longer to get the same job done, and hand scaling takes longer than our ultrasonic use on heavier cases.” (02:00—02:28)

“We want to be thinking about ergonomics for the hygienist and that clinical strain. Our bodies have been off work for a while, and that muscle memory has been gone. And now, we’re hand scaling. And it’s hard, ergonomically.” (02:29—02:41)

“When we get to that point that we can pick up our ultrasonic scalers again, we want to make sure that we’re going to be using them effectively and efficiently, not only to minimize the exposure of our risk with aerosols during COVID-19 but, obviously, we want to make sure that we’re going to be having good clinical outcomes while we’re doing that, and also for patient comfort as well.” (04:21—04:40)

“How are we going to get the most out of our ultrasonics? Lots of different factors with this, but it is essential for the clinicians to operate the ultrasonic scaling device at a minimum effective power for the task at hand. Proper tip selection is a critical step in the implementation of effective and efficient debridement without having unnecessary root damage.” (04:42—05:08)

“One thing that I want to talk about is what I notice when I work with teams, with clinicians, when I'm doing my coaching and consulting. There's just a lack of insert selection in most clinics. Now, I don't know if this is because maybe there just isn't the budget for our clinicians to be getting the instruments that they're wanting and requiring. Maybe it’s just a fact that our clinicians just don't know what they don't know. Maybe they’ve gotten in their comfort zone. They're using an insert that they're comfortable with and they just haven't stepped out of that comfort zone, and they forget that our varying instruments are of importance.” (05:39—06:15)

“One thing that I see on both sides of the continuum, a hygienist might only be using the standard [insert] and using a selection that's meant for moderate to heavy calculus, and they're using it on all of their patients, even on those light calculus and biofilm patients. Or vice versa, on a heavy case, they're only using their slim lines. Which, we know we need to be stepping up in that insert.” (06:16—06:38)

“Geometry is probably, in my opinion, the greatest concern when choosing your insert. We are aware we have a straight or a curved. Now, this affects a clinician’s ability to access the treatment site and to make adequate contact with the surface to be treated. So, what does that mean? It means if we’re not choosing the right geometry for the area at hand, then we’re not going to be able to adapt and get into where we’re thinking.” (09:12—09:36)

“We need to remember that not all teeth are created equal. If you have a look at that odontogram, reminding yourself that anterior teeth and posterior teeth are two, totally different anatomy and morphology, reminding yourselves where all of those furcations are. So, again, think of that concept. Would we scale the entire mouth with only one instrument? We could, but we sure wouldn't do a very good job. So, think of that with your ultrasonic inserts. Obviously, a straight tip is going to be great for straight anatomy, and our curved is going to contour really well around our curvature of posterior root areas.” (09:56—10:30)

“When I ask clinicians, ‘What is the reason that you're not using your left and rights?’ there are always two answers. Number one, it’s either that they don't have any and they just said, ‘I don't know. We just have never ordered them. I used to use them at my other office, but we don't have them here.’ And the second answer is, and this is usually the more common answer, ‘Well, actually, we have them. They're in the drawer. But I don't feel confident or comfortable using them.’ That's concerning to me because, in my mind, I feel like, okay, we obviously need some better education out there. We need some hands-on education for hygienists to be learning why they need to be using these left and rights and how to use them so that they're confident and they're comfortable.” (11:16—11:58)

“There are a small percentage of clinicians that are utilizing the left and rights, but they're actually utilizing them backwards. And it’s always quite eye-opening. A clinician has an aha moment in a hands-on course where I hear them whispering, ‘Oh my god! I've been using these backwards all these years!’ So, again, I recommend and implore clinicians to, when we can get back to hands-on courses together, search for a course that you can have some hands-on work and you can feel comfortable and confident in utilizing these in your practice.” (12:10—12:42)

“A lot of times, I get the question, ‘What is better, ultrasonic scaling or hand instrumentation?’ And to be honest, my answer is in terms of clinical ability. They're both going to do a good job, except in furcations. So, we need to understand that in some furcations, the opening of the furcation width is actually smaller than what our Gracey or a standard instrument can get into. So, in that situation, I absolutely believe that the ultrasonic scaler is going to adapt and get into those areas better. Otherwise, I recommend ultrasonic scaling over hand instrumentation. Obviously, to use in conjunction. But why hand scale everything when it’s better ergonomically and a little bit easier on our bodies to combine the two.” (12:47—13:27)

“For clinicians, and I see it all the time, they're like, ‘Oh, I love my triple bend. It’s my favorite. I use it everywhere.’ And I say, ‘So, you're going in right now into that five or six-millimeter pocket with your triple bend.’ We need to understand that is limited because its length is reduced. Our triple bend is meant for shallow pockets and supragingival areas, and a lot of clinicians are not putting those concepts together.” (14:10—14:34)

“[When you don't use the proper tools], you feel like you're sub-g, and you're working, and you're along there, and you feel like, ‘I'm doing a good job.’ But if you could flap away those tissues and really have an eye-opening experience into where that's adapting, you are not going to be getting into those posterior deep pockets where you should be.” (14:35—14:50)

“It’s very, very important, the angulation of your technique. We want to be between zero to 15 degrees to the tooth surface. Now, as close to zero degrees as we can, but never over 15. We want to make sure that we’re having light pressure and that it’s constant, and it’s varied in direction.” (15:54—16:11)

“In order to optimize the effectiveness of the ultrasonic action or your scaling, the working stroke needs to be deliberate and methodical in intent to make contact with every square millimeter of that root and tooth surface. So, I find incomplete channeling is usually the reason for insufficient calculus removal.” (17:21—17:39)

“It can take 30 to 60 seconds for proper biofilm debridement at low power after you've done your ultrasonic scaling for deposit removal. Again, a concept that not a lot of clinicians are thinking about. They're powering through and they're thinking about their calculus removal, and that biofilm debridement is really the important part when we’re thinking every square millimeter. That ultrasonic insert needs to be adapted to disrupt that biofilm properly.” (17:47—18:11)

“Monitoring the wear of your ultrasonic insert is key to ensuring its optimal performance. When you have an insert and it is beyond two millimeters of wear, you've lost 50% of that active area. You're, at that point, at a 50% loss of efficiency. So, again, quite a common thing that I find when I'm working with teams. I can actually sometimes tell from across the room, I can see that that ultrasonic insert should've been recycled a while ago. So, I feel like hygienists are forgetting to check their inserts, or maybe they just don't have a program or protocol in place. Or maybe it’s that they know they need to be replaced, and again, they just don't have the availability to order new ones.” (18:16—18:56)

“What happens if people increase the power setting to compensate for the reduction in their performance? This is ineffective, and it’s not recommended. What this does is it creates more patient sensitivity, and it reduces your clinical performance. And it actually creates more aerosols. So, if our whole concept is trying to reduce our ultrasonic use and our aerosols as much as possible, let's get the right tools for the job at hand. That way, we can achieve the best desired outcomes in a faster, more efficient way.” (19:06—19:35)

“I think when you think HVE for hygiene, there are a lot of people that are underestimating or forgetting that this always has been recommended. Some provinces and states have actually mandated that we should've been using HVE in hygiene even prior to COVID-19. So, why is it that the majority of our hygienists were always using their low-volume section? And the reason for that, and because I'm a clinician and I can absolutely agree, it’s hard as a single clinician to be using that as a single operator.” (19:46—20:15)

“The dentist has their assistant, and they have their rubber dams. So much easier to control their aerosol. But in hygiene, and I'm not going to lie, the kind of old technology that we had for HVE was poor for hygiene. It was terrible ergonomically, long term, to be using that day after day for repetitive strain. It was cumbersome. It was frustrating to use and grab the lips and cheeks. And patients got frustrated, clinicians got frustrated. So, what happened is people gave up. They put it down and they picked up their low volume again. And what I want to say right now is, we do not have the luxury to do that anymore. We have to be using our HVE in hygiene.” (20:16—21:56)

“HVE can be 90% to 98% effective in aerosol reduction. But that is only when you have your motor, your lines, and your user effectiveness all in order. So, it doesn't really matter if you pick the perfect HVE tip or management system. If the rest isn't in line, then you're not going to be effective.” (22:26—22:45)

“A lot of you are probably thinking, ‘Well, why didn't you talk about the ReLeaf or the DryShield or the Isodry?’ The reason I didn't include that is because I do not recommend these systems for your primary aerosol capture. These are great for retraction. They are great for pulling water and for saliva. But they are not meant to be used in terms of your only aerosol capture, especially for hygiene procedures.” (32:45—33:13)

“We can't use aerosols, for now. Probably, we’re going to be mostly hand scaling. What is that going to mean, and what are the considerations for hygienists right now? I want to say now is the time that we need to be evaluating your hand instruments. We need to go back to the office, we need to have a look through, we need to realize that if we can't rely on our ultrasonics right now — that is what did all the heavy work for us — we need to match our hand instruments to the job at hand.” (42:29—42:56)

“If your instruments are thin and look like they're about to break off in the mouth, we need to recycle those babies. We need to get those out of there, because we’re going to be working on heavier calculus. We’re going to be working on people that are overdue and have way more calculus than maybe they normally do. We need to match our instrument to the job.” (43:51—44:10)

Snippets:

0:00 Introduction.

0:55 What hygiene will look like during COVID-19 and beyond.

4:42 How to get the most out of ultrasonics.

7:22 Things to consider in tip selection: tip diameter, shape, and geometry.

12:45 Ultrasonic scaling versus hand instrumentation.

13:38 Things to consider in tip selection: tip profile.

15:52 Techniques: vertical and horizontal angulation.

16:54 Techniques: working stroke.

18:14 Insert tip wear.

19:40 HVE for hygiene.

21:44 Aerosol management with HVE.

23:38 Clinician testing of different HVE systems.

28:19 Purevac and Nu-Bird HVE systems.

30:45 Overview of HVEs.

33:52 Adjunctive tools: CordEze and A~flexX Assist Arm.

39:29 Q&A: CordEze use and maintenance.

40:06 How the Assist Arm works.

41:46 Chrissy’s top pick HVE.

42:24 Other considerations for hygienists.

48:41 Q&A: Difference between aerosols created from a Piezo versus Cavitron?

49:33 Q&A: How do you justify polishing if you shouldn't use Cavitron?

50:46 Q&A: Where to purchase CordEze and A~flexX Assist Arm.

Reach Out to Chrissy:

Chrissy’s CE website: https://www.advancedhygienesolutions.ca/

Chrissy’s Facebook: https://www.facebook.com/fordchrissy

Chrissy’s social media: @advancedhygiene

Chrissy Ford, RDH Bio:

Chrissy is committed to empowering dental hygienists to create strong, patient-centered, and profitable hygiene programs. The development of her successful CE and coaching programs draws from 20 years of experience in the dental field as a clinician, university instructor, treatment coordinator, and practice manager. She still enjoys working as a dental hygienist in clinical practice, but also has a passion for educating others. She enjoys hands-on mentoring and coaching dental teams on how to integrate advanced hygiene programs into their practice.