- Continuing Education
OK, so now let's talk about patient positioning. So we already talked about operator positioning, right, we're putting ourselves first now. And I know that that's a concept that's hard for a lot of us because we're caretakers and we want to take care of our patients. But we have to take care of ourselves first. So it disclaimer about this first section of images or patient positioning. I would say that this works for about 80% of the population. We will talk about challenging situations after this first section. So just know that I will talk about patients who can't or won't get into these positions, but most patients can and will get into these positions. Honestly, I think a lot of it comes down to us and how we're framing things with our patient and also cushions, those are a really big thing that have helped me. So we have full supine, so that is typically used for the upper arch, and that's when the patient’s body is parallel to the floor. And then we have semi supine. So that's when the patient chair back is raised about 20 to 30 degrees from that full supine and that's used for the lower arch. So let's go back to the upper arch. So when you have your patient sit in the chair and then you recline them back into full supine, the first thing you want to do is have them scoot all the way to the end of the chair. This is, you want to look at a couple things here. You want the top of their head to be in line with the top of the head rest, and then you want the top of their shoulders in line with the top of the back rest. This does a couple things, so if you have a chair that has one of those adjustable headrests, again it can really be your friend when you're positioning, depending on what arch you're working on. But the whole head has to be on that head rest. If it's only halfway on the headrest, it's not really gonna do a whole lot for you. Plus we're eliminating the dead space. And what I mean by that is if you, let's say I'm at 12 o'clock with my patient and I'm looking down, if I see any visible head rest between the top of their head and the top of the headrest, that's called dead space. It could be an inch or a few inches, but it might not seem like a lot, but that's gonna be inches that you have to make up for when you're at 12 o'clock reaching around to your patient. So we wanna have them scoot all the way to the end of the chair.
Something that can really help with this, because I understand that this can position can be scary for some patients and it can be uncomfortable for them. But using a cushion, a cervical cushion just to plug in there. Like if you look at the at the slide here, you do see some space in between her neck and the headrest. You could easily slide a cushion there that will help support the cervical spine. And I can tell you once you start using these cushions on a regular basis, it's almost like a magic trick. The patient relaxes. They just want their neck to be supported, and then you can tip them all the way back and I'll show some photos of that here in a minute. Something that can help you with controlling the maxillary occlusal plane is the head rest. So you want to decline that headrest down towards the ground so that it naturally causes the patients chin to raise up towards the ceiling. You can also ask the patient, please raise your chin up towards the ceiling. Honestly, the more the better. So what we want is the maxillary plane of occlusion to be behind the vertical plane. So if you look at this photo and just imagine a straight line going through her mouth, you want those maxillary teeth to be behind that line. And if you think about it, if I'm at 12 o'clock and these are the maxillary teeth, I want them pointed back towards me because that's gonna really reduce the amount that I'm having to lean or reach my arms forward. If those teeth are in front of the vertical plane, that's when you really are starting to lean and hunch and reach forward, so we wanna bring those teeth to us. And then once you've got the position, the headrest position down and the occlusal plane where you want it to be, then you just need to adjust the vertical height of the patient chair so that you can keep your arms nice and neutral. Now let's go to the lower arch. So here, if we're going from full supine, you want to raise the patient chair back about 20 to 30 degrees. The head rest, because ideally for the lower arch, you want the chin to be slightly pointed down so the head rest instead of it being declined, you actually want to incline it and sometimes you want to push it into the back of the patients head. So it'll force their chin to nod down towards their chest. You can also ask the patient, “please nod your chin towards your chest” and then the cushions again. So I use a cushion that's contoured. I have one side that's great for the maxillary arch, and then I flip it and then that other side is good for the mandibular arch. So again, these cushions are a game changer, I promise you. But now, now that you've got the mouth where you need it to be, we've raised the level of the patient's mouth, right, so it's no longer at the level of our elbows. So then you need to lower the patient chair down vertically so that the mouth is again at the level of your elbows. Now this can be problematic for some of the more petite clinicians like that are 5’5” and under, because the chair literally does not go down far enough and then they're forced to do this. So don't do that. There are some options. One, you can stand. It's not uncommon for me to stand for the lower arch. It just it's more comfortable for me. You could use a saddle stool, which will raise you up higher, so you have a little bit more play or you can leave the patient in that full supine. You can just leave them in full supine, adjust the headrest, push it into the head, use the cushion and then ask the patient “please nod your chin down towards your chest”. And this is where you want the mandibular plane of occlusion. So if you imagine instead of the vertical line this time you want to imagine a horizontal line going through her. You want them mandibular teeth to be about 20 degrees elevated from that horizontal plane, and really just to put it simply, for the upper arch, you want the chin way up for the lower arch, you want the chin more towards the chest. So this is the difference as far as the occlusal planes when we're talking about the upper versus the lower arch. It's very different and we really need to start being mindful of how we're positioning our patients because honestly how our patients are positioned will dictate our positioning and we want to have healthy position, right. So we really need to focus on our patient positioning. When I go into offices a lot of times, not all the time, but some most of the time the clinician will tip the patient back into whatever position and then the patient doesn't move for the entire appointment. The patient doesn't move their head side to side, they don't move it up and down the headrest, doesn't move, the chair doesn't move, which is great for the patient, it's very comfortable and convenient for them, but it's not great for us. That's when we start doing all of these crazy postures and acrobatics and orders to try and see. So depending on what area we're working on or the arch we're working on, we really need to be mindful at the positioning. And then this is just showing the different headrest positions. Again, it's much different. So for the lower arch you want it almost like flat or even pushed forward into the patient's head for the OR for the upper arch, you want that head rest declined. So it's raising the patients chin up towards the ceiling. Okay, so that's for most patients and I can tell you whether you believe me or not, I don't think that I have any more cooperative patients than anyone else. But I can get most of my patients probably more than 80% into these more extreme positions because of how I'm talking to them. Like my confidence and being firm and also using cushions. But let's talk about how maybe we don't have ideal situations. So we have pedo patients and their little bodies just don't fit into these big chairs that we have, right. But the rules are the same whether you're working on a tiny human or a regular sized human. So when you lay the patient all the way back, you wanna have them scoot all the way to the end of the chair. Now, if you're talking about a little one sometime, I mean, it looks weird, but sometimes they're entire body is on that the back of the patient chair. But that's okay, they are flexible, they don't have mobility issues, yet they're able to get, they don't have vertigo, you know, they're able to get into these positions. So do not feel bad for having your patient scoot all the way up. I both love and I don't love this photo, so I love the patient positioning. It's great. The head is all the way on the headrest. The headrest is declined. The top of the shoulders are in line with the top of the back rest. She's even using a little booster cushion. This is really good for not just the little ones, but even petite adults because once you have, if you have a more petite person or a little one scoot all the way up in the chair. The contours of the chair don't fit the contours of their body anymore, and it could be really uncomfortable for them. That's when cushions come in. So you could use a booster cushion like this. There's even some lumbar cushion or knee cushions that can help kind of plug in those gaps for when the chair isn't supporting their body anymore. I don't love her position, so we don't, let's just not look at that but her patient positioning is great. And then we have elderly patients, so opposite end of the spectrum. And I would say elderly patients, they're my most difficult, not that they're difficult, but it's they've typically got some body changes or maybe medical conditions that make it very difficult for them to lay all the way back in the chair. So I use cushions. I would I use cushions most of the time anyways, but especially for my elderly patients. So if you have a patient that is coming in like this, that has that excessive curvature right, that kyphosis and then forward head posture. They actually have these cushions. They're called osteo cushions that can really help support their neck. I have people well into their 90’s that if I'm supporting their neck with a cervical cushion, they will get all the way back into full supine. I promise you, it's a game changer. If I have a patient that, for whatever reason, cannot lay back into full supine, maybe they've got COPD, they literally can't breathe if I lay them down or they've got vertigo or fusions or whatever. I will stand for them. I stand a lot anyways, but especially in those situations. Standing as a great alternative if you have a pregnant patient or a more full bodied patient as well, it just gives you a little bit more play with your posture. But there's a couple tips that I want to share with you that can help and this isn't just for elderly patients, this can be for all patients. But the first tip is pre-reclining the patient chair so this is before you even get your patient from the waiting room. You're going to tip the patient chair back just 20 or 30 degrees just a little bit. Not all the way back to where they have to like lay down, but just a little bit. Because once they come and sit in the chair there already, and this is a subconscious thing, but they're already subconsciously getting used to not being fully upright. As you're just talking to them, or maybe taking their blood pressure or whatever it is. Then when you go to tip them all the way back, it's less of a distance to go. So I know with me when I sit in the dental chair and I'm a hygienist, I know it's coming. I'm not, I'm certainly not going to complain, you know. But when I go from full upright to all the way back into full supine within the span of a few seconds, that's even disorienting for me, and I know what's coming. So then if we have a patient that comes in that's nervous, that's fearful, that's apprehensive. And then we do that same thing, of course, it's going to be uncomfortable for them. So by pre-reclining the patient chair, you have less of a distance to go, so it can be less jarring for them. Now there's another trick, and it's the slow, I call it the slow, lean back. This is just something that I learned over the years. So when I first see my patient, I'm typically talking to them. I'm. I'm having a dialogue with them. I'm maybe I'm asking them about their home care, or maybe I'm just chatting them up, doing small talk. But I wanna make sure that I'm asking them questions that require an answer. So open-ended questions I want to make sure that they're focused on me, but they're not focused on is what I'm doing, which is slowly tipping them back and it could be a a set of like 10 little tips back. So I asked them a question, they're talking to me, I tip them back. I asked him another question, they answer, I'm tipping in the back a little bit. And by the time the conversation is done, they are all the way back into full supine and they haven't even noticed what I've been doing. So that can be something that's really helpful too. But I just want you guys to know it's not going to be perfect all the time. We are gonna have patients that either psychologically or physically cannot lean back in the chair. But what we wanna do, most patients can and will, so we wanna make sure that we are being as perfect as we can with about 80% of our patients. So that when we have these patients that come in that can't we have a little bit of gas left in the tank because we're not so tired of breaking our posture from all of the patients that came before them. These are the cushions that can really help so that I would say all the time I use a cervical cushion. Sometimes the the thicker one for people with forward head posture, my elderly patients or just a regular one. They have lumbar cushions that are really nice also and then knee cushions. But these cushions can be they can actually be very beneficial when you are trying to position especially the cervical cushion for positioning the occlusal planes. But if you're offering your patient pillows and cushions, it also makes them feel pampered and makes them feel special, and that they're taking care of right. And so they typically when you do that are more app to cooperate with you, especially when you have to tip them back into some of these more extreme positions.