Dental Tribune USA

Protective extraoral and reinforced instrumentation strategies

By Diane Millar, USA
May 27, 2014

Imagine working in your profession as a dental hygienist without ever experiencing work-related pain. Dental hygienists expect to have long careers once they enter their profession after graduation. Unfortunately, having a long career in dental hygiene can be problematic if protective reinforced instrumentation and ergonomics are not implemented.

Numerous hygienists experience pain, fatigue and injuries that lead to a shorter career. Scaling is no longer exclusively about calculus removal. It is about calculus removal and protecting oneself from injury.

Learning extraoral fulcrums to prevent injury

Utilizing protective extraoral reinforced instrumentation techniques requires scaling teeth with two hands, instead of one, to ensure optimum performance and to promote occupational health and career longevity. These techniques allow the non-dominant hand to assist and reinforce the dominant hand while primarily using extraoral fulcrums. Reinforced instrumentation techniques can extend career longevity in the field of dental hygiene, which has documented evidence of ergonomic disorders.

There are several ways to learn protective instrumentation strategies to help prevent injury if a hygienist isn’t sure how to utilize extraoral reinforced techniques. There are ‘hands-on’ courses offered at seminars for dental hygienists who want to practice on typodonts, as well as a book that was written for dental hygienists in private practice, titled ‘Reinforced Periodontal Instrumentation and Ergonomics for the Dental Care Provider,’ published by Lippincott, Williams and Wilkins in 2007. This book shows extraoral, reinforced fulcrums in every area of the oral cavity, ergonomic positioning techniques that guide the practitioner to utilize the 8 o’clock position to the 2 o’clock position around the dental chair for improved access, and stretches that can be done in the operatory for wellness and career longevity.

Unlike years ago, many dental hygiene schools are now introducing extraoral fulcrums during the first semester in pre-clinic. The primary reason for this is extraoral fulcrums need to be utilized in order to use an ultrasonic scaler correctly. There is also more of an awareness of the importance of proper hand ergonomics to prevent injury by keeping the hand, wrist and arm in a neutral position. With this awareness, dental hygiene schools utilize ultrasonic scalers, magnification loupes and protective extraoral fulcrums.

In the early 1980s and earlier, the ultrasonic scaler could only be used for heavy calculus removal in many dental hygiene programs. It was important to first and foremost learn how to scale by hand and not depend on an ultrasonic scaler. Also, scaling by hand in those days primarily was done by utilizing intraoral scaling techniques, not extraoral techniques. Extraoral fulcrums and reinforced scaling “tips” were often introduced during the second year of the dental hygiene program.

Thankfully, with the awareness of documented injury in the dental hygiene profession, proper hand ergonomics that incorporate a neutral position of the hand, wrist and arm while using extraoral techniques are being taught in many dental hygiene schools the first semester of the program.

Incorporate hand and arm exercises

Hand strength is important to successfully implement extraoral fulcrums. In fact, fulcrum pressure determines whether an instrument stroke will be appropriately controlled. Other important factors include an extended grasp and adequate pressure exerted against the patient’s cheek and jaw for support. The amount of pressure that needs to be exerted throughout the appointment and throughout the day with each patient is significant. If a dental hygienist’s hands and arms are weak and are lacking muscle tone and strength, injury can occur.

Ideally, dental hygiene schools should be implementing hand and arm exercises to increase muscle endurance, which can help prevent injury while in the hygiene program as well as in private practice. This would also set a standard of awareness to exercise one’s hands and arms on a regular basis. Using squeeze balls and light weights daily will increase strength, improve muscle tone and provide increased endurance. Hygienists who do this and graduate from dental hygiene school and enter into private practice will have the muscular strength and endurance to treat eight to nine patients per day, and will be less prone to injury.

If a dental hygienist has had a problem with carpal tunnel syndrome, tendonitis or any other upper body musculoskeletal injury, incorporating protective reinforced techniques will help reduce additional injury by utilizing both hands to scale. Coupled with that, the larger muscle groups in the arms versus the smaller muscle groups in the hands will be used.


Scaling with both hands while utilizing protective extraoral techniques will enhance scaling technique efficacy and reduce the incident for injury, especially when treating patients with heavy calculus, by providing the following benefits:

  • Allows the hands to work as a unit.
  • Provides more stability to the dominant hand.
  • Enhances the balance of both hands for instrument placement.
  • Incorporates a stable fulcrum.
  • Helps prevent hand, wrist and arm fatigue.
  • Increases control of the instrument blade.
  • Provides more power and strength.
  • Enhances lateral pressure.
  • Improves scaling efficiency.
  • Helps to prevent instrument slippage.
  • Helps to decrease hand, wrist and arm pain.
  • Prevents injury and work-related disability.

The benefits of using extraoral fulcrums in comparison to intraoral fulcrums are many. Most importantly, these protective scaling fulcrums stabilize the clinician’s hand while instrumenting. In turn, this helps the hands, wrists and arm remain in a neutral position. These added benefits help guard against injury that can occur while scaling and root planning.

Our profession requires good ergonomic techniques for career longevity as well as career satisfaction. Thus, it’s important to try new innovative scaling techniques not learned in school. The results are well worth the effort to ensure a long career as a dental hygienist.


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