‘Work smarter, not harder’ – Four-handed dentistry

Four-handed dentistry is synonymous with the term close support dentistry. This concept is built around increasing efficiency during treatment, increasing patient care, reducing stress and fatigue of both the operator and the dental nurse, and maximising the skills of the dental team.

The whole idea of dentistry is to offer patients treatment in a safe, non-threatening environment, providing them with a pleasant and efficient dental visit.

So often I have observed a dentist hunched over a patient, working alone, while the dental nurse is off completing other duties such as answering the telephone, sterilising instruments or retrieving things. My query is, WHY? Without the operator and the dental nurse seated throughout each complete dental procedure, the team is not working to its maximised efficiency and the patient is not receiving the best care possible.

The time that is saved by treating the patients in a more efficient manner will allow time for extra duties in the surgery, such as seeing more patients, team meetings, medical emergency simulations or other tasks.

The aim of four-handed dentistry is to implement time and motion principles effectively, which allows for more time in what is a traditionally stressful and time strained environment.

The practice of four-handed dentistry requires excellent communication, teamwork, organisation and respect for each member of the dental team. The dental team needs to take the following into consideration during the implementation of four-handed dentistry:

• Patient, dentist and dental nurse position

• Equipment design

• Organisation of the units and the dental nurse

• The appropriate usage of the dental nurse’s time.

The main benefits of four-handed dentistry are:

• Efficiency

• Speed

• Inclusiveness of the dental team

• Visibility for both the dentist and dental nurse

• Reduced strain and stress

• Comfort and safety for the patient.


Both the dentist and the dental nurse need to be positioned so they can both be involved with dental treatment. Both parties need to see! The dentist needs to provide treatment, and the dental nurse needs to see so he/she can assist the dentist. If the dental nurse is more aware of the bald spot on the top of the dentist’s head, you are in the wrong position!


The operator needs to have both feet flat on the floor and their thighs parallel to the floor. If an operator’s legs are crossed, this adds to the stress in their posture, possibly limiting the dental nurse’s ability to see and assist the operator. The back must be straight, with the forearms parallel to the floor.

The dental nurse

The dental nurse must also adhere to the appropriate principles of balance and proper posture. His/her chair must have a foot bar on the bottom, as he/she needs to be positioned 1.5 heads higher than the operator.

Without a foot bar, the nurse will not feel balanced at an appropriate height while looking into the patient’s mouth. His/her chair should also have an adjustable bar at the level of the rib cage, allowing movement in front of the nurse and the elbows to be rested to help with the balance while assisting.

Without the appropriate chair, the dental nurse will not be able to position himself/herself comfortably and balanced, which will restrict their view.

The patient

The patient is most often positioned in the supine position, except in the circumstances that they cannot tolerate it. The dental team must try to position the head of the patient to suit their own position. Remember, the patient only needs to be in this position for a short while; the dental team must hold their positions for the complete working day.

It is very common for members of the dental team to have soreness that is related to poor posture while working. Every effort should be made to have good posture throughout the day. The patient position needs to be adjusted according to which arch the operator is working in.

Working positions

The correct positioning of the dental nurse, the dentist and the patient are imperative to maximise the benefits of four-handed dentistry.

If you think of the working zone that includes the dental nurse, the dentist and the patient as the face of the clock, this helps to visualise the best patient position.

The dentist needs to be positioned in such a way that allows for unobstructed access to the patient’s oral cavity. The dental nurse should be positioned so that he/she has good visibility of the oral cavity, can reach instruments, materials and sundries necessary, and is able to transfer these to the operator in the transfer zone.

The patient should always be at the 12 o’clock position, with the operator between 7 and 12 o’clock, and the dental nurse 2 to 4 o’clock. These positions must be modified for a left-handed operator. The area between 12 and 2 o’clock is the area that is referred to as the static zone, which will allow room for extra equipment necessary for treatment. The area from 4 to 7 o’clock is the transfer zone and is the area where the dental nurse will transfer instruments, materialss and sundries to the operator.

Equipment design

Much research needs to be done prior to the purchase of dental equipment for a dental surgery. This article does not aim to provide guidelines for the purchase of the equipment, more to create an awareness of the research that needs to be carried through.

Each member of the dental team needs a chair designed for their own particular needs. The dental nurse must have a stool on casters that is easily mobile, it must have a foot bar for support, and a moveable arm that aids the nurse’s stability while being involved chariside. The dental nurse’s chair must also be adjustable for height, so that they are able to work higher than the operator to aid in visibility. Both the operator’s and the dental nurse’s chairs must have a sufficiently sized and padded seat for stability and comfort, which will reduce the stress and fatigue on the muscles. The operator stool must also:

• Be on castors

• Be height adjustable

• May have back support.

Sufficient research also needs to be carried out during the purchase of the patient chair.

Units and cabinetry

The dental units and cabinetry and the position of them will also affect how the team can efficiently carry out dental treatment. Mobile units that allow repositioning to accommodate the position of the operator and the dental nurse are desirable. The dental nurse should have a unit that is on wheels and has areas for storage of sundries and materials that are used frequently. All other sundries and materials that are more infrequently used should be kept out of the area where the patient is treated as this may increase the clutter and reduce the efficiency. The unit must be tall enough that when the dental nurse is positioned, he/she can retrieve instruments and materials without causing strain or fatigue to the muscles. It is the role of the dental nurse to ensure that the dental operatory is completely prepared for each patient and that all necessary instruments, materials and sundries are prepared prior to the patient arriving. In no circumstance should a patient be seated prior to the operatory being completely set-up and before all appropriate infection control procedures have been carried out. With efficient organisation the dental nurse can stay with the operator and the patient throughout treatment, utilising their chairside and four-handed skills and ensuring the safety of the patient. It is not efficient to have the dental nurse carrying out other duties during treatment such as answering the telephone. Communication is key between the dentist and the dental nurse, so the nurse can ensure that the operatory is completely set up for the treatment planned.


The dental nurse must take responsibility for the preparedness and organisation of the dental operatory prior to the arrival of the patient.

If there is not enough time during the day to prepare, time should be made available at the beginning of the day to prepare the morning session, and again prior to the start of the second session.

Organisation includes such things as ensuring that the operatory is well stocked and preparing instrument trays (with instruments in the proper sequence) in advance.

Instrument transfer

The incorporation of safe, efficient instrument transfer techniques between the dentist and the dental nurse is imperative with the implementation of four-handed dentistry.

The dental team will have to communicate to use a sequence of hand movements so that the dental nurse can safely transfer the instruments to the operator. Instrument transfer will allow the dental nurse more involvement in the dental treatment provided and foster a team approach. The smooth working between the team will increase efficiency and instill patient confidence in the dental team. The transfer of instruments involves hand movements and anticipation of the operator’s needs by the dental nurse.

With good posture and with good visibility the dental nurse should be able to anticipate and prepare the next step of the treatment for the operator. If the operator chooses to change the ‘normal’ sequence of steps, this requires communication with the dental nurse, and will a small adjustment to the ‘regular’ routine it can be incorporated without and disruption. Without good preparation of the dental surgery and collection of all instruments and materials needed for the procedure, four-handed dentistry will not be carried out efficiently.

True four-handed dentistry – the process of the dental team implementing time and motion principles and using ergonomic equipment, with all four hands working together throughout the treatment procedure – is the only way to reduce stress and increase productivity. (Finkbeiner & Muscari, 2006).

With the proper training, communication and team work four-handed dentistry may be implemented to the benefit of the patient and the dental team.

‘These principles allow the practitioner to work smarter not harder,’ (Finkbeiner, 2000).


Finkbeiner B (2000) Four-handed denistry revisted. J Contemp Dent Pract 1(4): 74-86

Finkbeiner B, Muscari M (2006) Let ergonomics and true four-handed dentistry help you. Available from: http://rdh.pennnet.com/Articles/Article_Display.cfm?Section=ARTCL&ARTICLE_ID=256863&VERSION_NUM=2&p=55 [accessed 1 April, 2007]

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