Four-handed dentistry

Justin Underwood explains why four-handed dentistry is so important and what’s involved.

Which group of verbs summarise the typical working day for your nurse: straining, stretching, searching, twisting, leaning or transferring, handing, presenting, delivering and passing?

We are all self-taught when it comes to ergonomics in a dental setting and let’s face it, as young dentists we tend to think about a hundred more important other things. This, however, will all catch up with us one day.

The truth is in a busy practice there is a link with clinical inefficiency and stress. Within a dental surgery stress can be caused by running late, a disorganised nurse, poorly stocked surgery and poor patient positioning during treatments. We all know in surgery, the most unpredictable aspect to our day are emergency appointments, so why not make everything else entirely predictable? Poorly managed stress can result in burnout and this is more common than you might think.

Improving the workflow

Four-handed dentistry is an art and when performed correctly it allows the slick predictable series of events to run like clockwork to reduce not only clinical time but also mental and physical energy exertion.

Surgeons are taught about minimalisation of movements, so why aren’t dentists? The bread and butter of four-handed dentistry is down to efficient instrument exchange whereby the nurse can deliver these straight into the dentist’s hands whilst maintaining the visual field. This smooth exchange even allows the dentist’s finger rest to remain in place so the new instrument can be used immediately to continue treatment. The principles of energy saving motions becomes particularly useful when using high magnification loupes or a microscope.

Aspirating is always a challenge for nurses as dentists are generally in their way. If the nurse can sit closer such that their hips are touching the patient’s shoulder it would not only significantly improve their visibility but this closer working environment forces correct posture for the dentist too. Whilst facing in the opposite direction to the patient, the nurse can pick the next instrument or handpiece within an arm’s reach from the worktop in front of them (usually by anticipation as they can now see what’s going on) to repeatedly exchange instruments in and out of the dentist’s hands on request.

Most surgeries may not be designed for this style of dentistry so to implement it you may require to make some adjustments or compromises. An example could be to keep the nearest top drawer open for storing consumables or to invest in a removable trolley.

As a more active participant, the nurse can hold in each hand the three in one syringe and suction to blow excess water from the dentist’s mirror, whilst also aspirating, wash and dry a carious cavity, whilst the dentist is drilling, and provide much better soft tissue retraction than using one hand alone.


Dentists can’t do everything. As a side topic to four-handed dentistry, the ability of delegating duties for the nurse has relevance to clinical efficiency and teamwork and will also keep her motivated to make her day more rewarding. Some examples for nurses could be to:

  • Place amalgam directly into the cavities with the amalgam carrier
  • Dry teeth and apply fluoride varnish as the dentist isolates teeth with cotton rolls
  • Take clinical photographs
  • Prepare the rubber dam unassisted but assist during its placement
  • Replace burs on handpiece
  • Configure the correct radiograph holder for any tooth
  • Write the benefits/risks/complications in the clinical notes as you discuss it to the patient
  • Write patient details on lab forms and referrals
  • Provide oral hygiene instruction/diet advice/smoking cessation/post-operative instructions/post-operative phone calls
  • Pre-set full clinical trays for restorative procedures
  • Pre-set an endodontic tray for emergency appointments
  • Hold the endo ring, measure hand files, estimate WL from the radiograph and pre-bend the irrigation needle gauges.

Four-handed dentistry involves analysing all motions and ergonomics to ultimately prevent musculoskeletal problems and reduce stress, which overall improves speed, efficiency and comfort for the patient.

Justin Underwood

Justin Underwood

Author at Young Dentist

Justin Underwood graduated in 2011 at Cardiff University in addition to gaining an intercalated Bsc in Oral Diseases. During this year his research around dental implants was published and presented in the London’s Queen Elizabeth II Conference Centre at the International Association of Dental Research conference. Justin is currently studying towards his Msc in Endodontics and is a member of the British Endodontics Society and European Endodontology Society.

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