Professor Fuad Al- Sabri, PhD

Department of Conservative Dentistry

In preparation for a clinical procedure,
it is important to ensure that
patient and operator positions are properly
selected, that instrument exchange between the
dentist and assistant is efficient, and that
magnification is used if needed.
 Efficient patient and operator positions are beneficial
for the welfare of both individuals.

 A patient who is in a comfortable position is more relaxed,

has less muscular tension, and is more capable of
cooperating with the dentist.

 By using proper operating positions and good posture, the

operator experiences less physical strain
and fatigue and reduces the possibility of developing
musculoskeletal disorders.
 When the back and chest are held in an upright
position with the shoulders squared, proper
breathing and circulation are promoted.

 At times, circumstances prevent maintaining this

position while operating, but it should be the
basic body position.

 Proper balance and weight distribution on both

feet is essential when operating from a standing
position. .
 Modern dental chairs are designed to provide total
body support in any chair position.

 Chair design and adjustment permit maximal operator

access to the work area.

 The adjustment control switches should be

conveniently located.

 Some chairs also are equipped with programmable

operating positions.
A. Right front. B. Right.

C. Right rear. D. Direct rear.

 To improve infection control, chairs with a foot switch for
patient positioning are recommended.

 The patient should have direct access to the chair.

The chair height should be low, the backrest upright, and
the armrest adjusted to allow the patient to get into the
chair.

 After the patient is seated, the armrest is returned to its

normal position. The headrest cushion is positioned to
support the head and elevate the chin slightly away from
the chest. In this position, neck muscle strain is minimal,
and swallowing is facilitated.

 The chair is adjusted to place the patient in a reclining

position.
 The most common patient positions for operative
dentistry are almost supine or reclined 45 degrees.

 The choice of patient position varies with the

operator, the type of procedure, and the area of the
mouth involved in the operation.

 In the almost supine position, the patient’s head,

knees, and feet are approximately the same level.
 The patient’s head should not be lower than the feet;

 The head should be positioned lower than the feet only in an emergency,

 As when the patient is in syncope.

 Operating positions may be described by the location of
the operator or by the location of the operator’s arms in
relation to patient position.

 For a right-handed operator, there are essentially three

positions—right front, right, and right rear.
These are sometimes referred to as the 7-o’clock, 9-o’clock,
and 11-o’clock positions
 A fourth position, direct rear or a 12 o’clock position, has
application for certain areas of the mouth
 As a rule, the teeth being treated should be
at the same level as the operator’s elbow.
 The right front position facilitates examination and work
on mandibular anterior teeth and maxillary anterior teeth.

 It is often advantageous to have the patient’s head rotated

slightly toward the operator.
 This position is convenient for operating on the facial
surfaces of the maxillary and mandibular right posterior
teeth and the occlusal surfaces of the mandibular right
posterior teeth.
 The right rear position is the position of choice for most
operations.
 Most areas of the mouth are accessible and can be viewed
directly or indirectly using a mouth mirror.
 The operator is behind and slightly to the right of the
patient.
 The left arm is positioned around the patient’s head
 When operating from this position, the lingual and
incisal (occlusal) surfaces of the maxillary teeth are
viewed in the mouth mirror.
 Direct vision may be used on mandibular teeth
 The direct rear position has limited application and is used
primarily for operating on the lingual surfaces of mandibular
anterior teeth.
 The operator is located directly behind the patient and
looks down over the patient’s head
 As a rule, when operating in the maxillary arch, the
maxillary occlusal surfaces should be oriented
approximately perpendicular to the floor.

 When operating in the mandibular arch, the mandibular

occlusal surfaces should be oriented approximately 45
degrees to the floor.
 Another important aspect of proper operating
position is to minimize body contact with the patient.

A proper operator does not rest forearms on the

patient’s shoulders or hands on the patient’s face or
forehead.

 The patient’s chest should not be used as an

instrument tray.
 From most positions, the left hand should be free to
hold the mouth mirror to reflect light onto the operating
field to view the tooth preparation indirectly or to retract
the cheek or tongue.
 The stool should be on casters for mobility.
 It should be sturdy and well balanced to prevent tipping or
gliding away from the dental chair.

 The seat should be well padded with smooth cushion edges

and should be adjustable up and down.

 The assistant’s stool should have a foot ring to permit

proper leg position.
 The operator should sit back on the cushion, using the
entire seat and not just the front edge.

 The thighs should be parallel to the floor, and the lower

legs should be perpendicular to the floor.

 Feet should be flat on the floor.

 The seated work position for the assistant is
essentially the same as for the operator except that the
stool is
4 to 6 inches higher for maximal visual access.

 It is important that the stool for the assistant have an

adequate footrest so that a parallel thigh position can
be maintained with good foot support.
 All instrument exchanges between the operator and
assistant should occur in the exchange zone below the
patient’s chin and several inches above the patient’s
chest.

 Instruments should not be exchanged

over the patient’s face.
 Any sharp instrument should be exchanged with
appropriate deliberation.
The assistant should take the instrument from the
operator

 Each person should be sure that the other has a firm grasp
on the instrument before it is released.

 To maximize operating efficiency, whether treating one

tooth or several, each instrument should be used
completely before proceeding to the next instrument; this
minimizes the number of instrument exchanges necessary
for each procedure.
 The operator must be able to see clearly to attend to the
details of each procedure.

 Normal accommodation of the operator’s eyes is necessary

to maintain proper working distance.

 After the age of 40, operators may require magnifying

lenses to compensate for this loss.

 The use of magnification before loss of accommodation

facilitates attention to detail,
 Several types of magnification devices are available,
including bifocal eyeglasses, loupes, and surgical
telescopes
 Injection is used to achieve local anesthesia in
restorative dentistry.

 To administer effective anesthesia, the dentist must

have a thorough knowledge of the patient’s physical
and emotional status ,and

an understanding of the effects of the drug to be

injected and the advantages and disadvantages of
adding vasoconstrictors.
A therapeutic dose of a drug:
Is the smallest amount that is effective when properly
administered and does not cause adverse reactions.

An overdose of a drug:
Is an excessive amount that results in an overly
elevated local accumulation or blood level of the drug,
which causes adverse reactions.
 The normal healthy patient can safely receive
five to eight cartridges of anesthetic per appointment.

 Each 1.8-mL cartridge contains anesthetic, with or

without a vasoconstrictor
(e.g., lidocaine 2% [anesthetic] with epinephrine 1:100,000
[vasoconstrictor], lidocaine 2% plain [no vasoconstrictor]).
Cardiovascular System.
 Before administering any drug, the condition of the
cardiovascular system (heart and blood vessels)must be
assessed.

 At minimum, blood pressure, heart rate, and rhythm should be

evaluated and recorded for all patients.

According to the latest guidelines, patients with a systolic

pressure less than 160 mm Hg and a diastolic pressure less than
100 mm Hg
(stage 1 hypertension) are good candidates for all dental
procedures
Patients with blood pressure
consistently greater than the aforementioned numbers
(stage 2 hypertension)
should be referred to their physicians, particularly if the
elevation is greater than 20 mm Hg.

 It is suggested that any resting patient with a pulse rate

less than 60 beats/min or greater than 110 beats/min
be questioned further.

 the lower heart rate may indicate a heart block

 The central nervous system (CNS) is more easily
affected by an overdose of injected anesthetic drugs
than the cardiovascular system.

 At minimal to moderate overdose levels, depression

is manifested in excitation

(e.g., talkativeness, apprehension, sweating, elevated

blood pressure and heart rate, elevated respiratory
rate) or drowsiness.
Allergy
• Reproducible allergy is an absolute contraindication
for administration of local anesthetic.

• When a patient reports a history of “sensitivity” or

“reaction” to an injected dental anesthetic, the dentist
must believe the patient until further investigation
disproves the patient’s claim.
 Cooperative Patient.
When a local anesthetic appropriate for the procedure is
properly administered, patient anxiety and tension should be
minimal.
 The appreciation and trust of the patient for the dentist (and
dental assistant) are expressed in a more relaxed and cooperative
attitude.
Physically and emotionally, the patient and the dentist benefit
from a relatively calm environment.

 Salivation Control.
Saliva control is a primary reason for desiring profound anesthesia
for most patients.
 Hemostasis.
The term hemostasis, as used in operative dentistry, refers to the
temporary reduction in blood flow and volume in tissue
(ischemia)

 The principal function of a vasoconstrictor in operative dentistry

is the prolongation of anesthesia because of reduced blood flow
to and from the anesthetized site.

 Without epinephrine, anesthesia from 1 mL of lidocaine 2% lasts

only 5 to 10 minutes; with epinephrine, the anesthesia lasts 40 to
60 minutes.
 Local anesthesia greatly benefits the dentist and the patient
and is beneficial for successful tooth preparation and
restoration.

 It improves operator efficiency and usually the patient is

calmer and more cooperative.

 This increased cooperation may reinforce the dentist’s

confidence and calmness, which may promote more
efficient
Psychology.
Patients have varying degrees of concern about receiving an
intraoral injection.

 The operator must use a kind, considerate, and

understanding approach.
Every assurance should be made that comfort of the patient
is paramount .

 The art of tactfully keeping the syringe and needle

from view of the patient should be practiced.
 Injection into infected tissue should be avoided
because of the risk of spreading the infection.

 Also, the anesthetic becomes less effective because

the tissue is acidic rather than basic.

 Alternative approaches, such as nerve block, should

be used.
 The needle must be sufficiently long that its full length is
never out of sight (never completely within tissue).

This means that in the unlikely event a needle breaks at the

hub junction, some of the needle is exposed for grasping and
withdrawal.

 Needles of 27-gauge are generally recommended, although

some operators prefer the 30-gauge,

short needle for infiltration anesthesia of the maxillary teeth.

 Before needle entry, the mucosa at the injection site should be
wiped free of debris and saliva by a sterile gauze.

 After wiping, a lidocaine topical anesthetic ointment is applied

for a minimum of 1 to 2 minutes to the proposed entry spot
(using a cotton-tipped swab, limiting the area of application to
the swab dimension).

 This procedure often is started immediately after positioning

the patient in the chair and following the gauze
Good injection techniques including a
slow deposition rate
(approximately 60 seconds per cartridge),
a warmed cartridge, and the use of sharp
needles are more important factors in a
painless injection than the use of topical
anesthetic.
 Slow deposition is the most important safety procedure
for the prevention of adverse reactions because of high
blood levels of anesthetic or epinephrine.

 Aspiration is second in importance.

 A 1-minute rate for 1.8 mL of anesthetic

(30 seconds for 1 mL, or half a cartridge)
would not cause tissue damage and would not lead to
serious overdose reactions, even if accidentally injected
intravascularly.
 Disposal of Needle and Cartridge.
Proper disposal of the needle and cartridge is crucial.

 Removal and disposal of the sheathed, used needle is

done by the dental assistant, whose shield-protected
hand carefully unscrews the sheathed needle from
the syringe