A Historical Perspective Regarding Extraoral Fulcrums

Many of the traditional rules of manual instrumentation, such as maintaining the exclusive use of intraoral finger rests, are legacies from the era when most scaling was done supragingivally. In the early 1900s, the first dental hygienists were educated to perform a “prophylaxis” as a preventive procedure to remove supragingival deposits in a relatively healthy mouth of a child or young adult. Consequently, most patients received only supragingival scaling and the periodontal needs of many adult patients were not adequately met.

Now we have an aging population with a higher percentage of older individuals. General dentists and dental hygienists must be prepared to identify, treat, and manage the patients in this growing segment of the population. Many clinicians and educators still use and continue to teach manual instrumentation techniques that were originally intended for supragingival calculus removal. Clinical education should incorporate approaches that adequately prepare graduates to provide more advanced therapeutic periodontal care.

In dental hygiene, the development of advanced periodontal instrumentation has been thwarted by two main factors: 1) an insistence to rigidly adhere to old rules of supragingival instrumentation using only intraoral fulcrums and 2) the inability of dental hygienists in many states to administer local anesthesia. Beginning in 1971, hygienists in many states began to use local anesthesia to treat more involved periodontal patients. As they treated more of these patients with deeper pockets, they developed extraoral and alternative fulcrums out of the need to overcome the limitations of traditional intraoral fulcrums and positions. Today, 36 out of 50 states allow dental hygienists to administer local anesthesia. As more hygienists use local anesthesia, the transition from traditional intraoral finger rests to more advanced fulcrums and positions is gradually occurring.

Given an aging population, the responsibility for nonsurgical treatment and maintenance falls on the dental hygienist. The following factors will help our profession meet the growing periodontal needs of the public:

1. Relinquishing the strict adherence to traditional rules of manual instrumentation and allowing incorporation of alternative fulcrums and positioning.
2. Progressive legislation allowing dental hygienists to administer local anesthesia, which is essential to facilitate access for thorough instrumentation.

From Dimensions of Dental Hygiene. October 2004;2(10):20, 21-23.