The term four-handed dentistry is now rooted in professional terminology
but implies no more than the importance of team effort. The
dental team normally comprises the operator and nurse (four hands),
but it is not uncommon for an additional nurse to make six.
Principles of four-handed dentistry
There are many ways in which the dental team can work efficiently,
along ergonomic principles. Nevertheless, the underlying principles
Rationalisation and standardisation. The repetitive nature of so much
in dentistry offers the ideal opportunity to ration the immediate
supply of instruments to those most commonly used and, also, to
standardise technique so that, with practice, considerably greater
efficiency will be achieved.
• Delegation. Delegation is the transfer of any task to a person who is
both qualified and capable. This remains an area in which many
dentists fail to take full advantage of the skills of the dental nurse.
• Anticipation. The experienced dental nurse will quickly learn the
individual methods of the operator and begin to anticipate almost
every situation. As a member of a regular dental team, rather than
one based on rotational duty, the advantages can be significant.
• Safety. The focus and control achieved in all the various approaches
to four-handed dentistry is undoubtedly matched by improved
safety for both patient and operator. However, while there has been
understandable concern that a supine patient may be at greater risk
of ingestion or inhalation of foreign matter, it has been shown that,
in this position, the tongue rests against the soft palate to provide a
seal2. Nevertheless, some posterior pooling of fluid will inevitably
occur and the responsibility of both nurse and operator in the
control and removal of this accumulation cannot be overstated.
In procedures carrying higher risk, such as endodontics, the
total protection of the airway utilising rubber dam is self-evident.
However, it is essential that no dental procedure should take place
without appropriate airway protection, irrespective of patient
All patients, and indeed members of the dental team, should be
provided with protective eyewear and for the supine patient, no
transfer of materials or instruments should occur over the face.
• Methods. The concept of four-handed, ergonomic dentistry is open
to varied individual approach and has been described in detail
by Paul1. However, the underlying principle demands that all
delivery, discard and transfer takes place in the area of safety and
convenience around and below the chin – the so-called ‘transfer
zone’ (Fig. 1.6). This practice demands maximal delegation to the
dental nurse and requires concerted effort and understanding.
However, the advantage to the operator, and hence the patient, of
an undistracted focus on the tooth is considerable.
A comparison is with that of the general surgeon awaiting the
appropriate instrument, correctly positioned for immediate grasp
and use. The dentist’s hands should therefore remain whenever
possible in the transfer zone, instruments and materials should be
asked for, not looked for, and be received to enable correct grasp
with no risk of injury.
If both hands are free, instrument transfer is simple but more
commonly the task must be completed in one hand. This method
of instrument retrieval by the fourth finger, rotation of the wrist,
and supply from thumb to first fingers is easily mastered and is
Therefore, it is clear that when due attention is paid to basic procedural
aspects and organisation, the clinical scenario is efficient, effective,
enjoyable and professional. On the other hand, without such discipline,
there is the potential for inefficiency, lower standards and a lost opportunity
to maximise the potential for a fulfilled professional career.