How to design optimal operatories

Dental Products ReportDental Products Report July 2019
Volume 53
Issue 7

Why where you work affects how you work.

For many of us, the experience in the dental operatory has changed significantly throughout our lives. The dentist office we visit today is vastly improved from the ones we visited when we were children.

Don Hobbs, vice president of equipment sales for Henry Schein, remembers visiting dental practices when he was a kid, an experience that had some areas of opportunity.

“Going to the dentist was definitely not a pleasant experience when we were kids,” Hobbs says, laughing. “It was that one dentist, two treatment rooms, and they did all their own hygiene. They did everything.”

Today, the patient experience has evolved immensely. A visit to the dentist no longer causes the fear or anxiety it once did. Hobbs says most dentists want the patient to walk into an experience comparable to a spa.

“When you go to your dentist now, you can get treated for sleep. You go in there for BOTOX. You can go in there for so many different things that are not even dentistry because today it is all about the patient experience,” Hobbs says.

Back when he was a kid, Hobbs says most people went to the dentist when they had an emergency. However, starting in the 1970s, more of the population became concerned about regular dental hygiene and overall oral health. Then, operatory design changed, moving to two treatment rooms and three hygiene rooms, even for a solo practitioner. If at first the dentist couldn’t fill all the rooms, then he or she just left one unbooked, which came in handy when people arrived with an emergency.

“The last thing you want in your waiting room with other people there is the Vincent van Gogh image of the person sitting there with the ice pack on their face wrapped in bandages. You wanted to get them into that unbooked operatory,” Hobbs says. However, Hobbs says operatory design has changed to benefit the doctor as well, especially concerning ergonomics and efficiency.

So, what is the optimal operatory and how does it benefit patients and dental professionals? What new trends are emerging, and what can we expect next? Let’s take a closer look at optimal operatories and what our experts have to say about them.

Operatory design that benefits the three Es

John Cox, vice president of technology sales at Henry Schein, says his team looks at today’s operatory design with the perspective of the three Es:

  • Experience: The patient should experience a spa-like environment and esthetics, and the operatory design should bring the patient into the decision making for his or her care.

  • Efficiency: The design should respond to tremendous pressure on dental professionals to do more dentistry in the same hours to recoup their expenses and respect patients’ time, who likely don’t want to sit around a dental office.

  • Ergonomics: An operatory design should facilitate better working postures and body positions to prevent injury and prolong the careers of the dental professionals who use it.

“The three Es are what drive operatory design today and are the difference between today’s operatory versus 50 years ago,” Cox says.

Stephane Leduc, product manager for treatment centers at Dentsply Sirona, says his team believes having a fully integrated treatment center gives much flexibility in the room design. It also allows the doctor to move wherever he or she wants.

“You remove the link between the patient and the rear cabinets, utilizing the rear cabinet as support and storage. Then, during treatment, it allows you a little bit more flexibility for the clinical team around the oral cavity,” Leduc says.

The treatment center team is also focused on the experience, including the ergonomics for the assistant, the doctor and other dental professionals. Delivering a comfortable and excellent patient experience is also a goal. 

“We want patients to have the best experience possible in a very safe manner,” Leduc says.

Leduc also thinks operatory design should include more patient communication. He likes to design ways for the patient to see what the dentist sees. The more the patient understands, the more he or she is willing to accept treatment.

“If you can show the patient what’s going to happen, they understand, and it prevents them from having to Google everything when they go home and find a better price for it at the same time,” Leduc says.

Jeff Rohde, MS, DDS, practices in Santa Barbara, California, and has much experience designing operatories. He recently built out a new practice with 12 operatories, nine designed for adult treatment and three for children. This build-out follows a practice expansion he recently completed at his former location five years ago where he grew from six operatories to nine with a total 800-square-foot expansion.

Dr. Rohde says in the past, when you looked at an operatory, doctors tended to see it as a little workshop, or a construction zone, with tools surrounding the chair. However, he changed the way he approached the design with his latest operatories, starting with access to the chair.  He took the “see better, do better” approach.

“If I can position the patient where I could see what I’m doing better, then maybe my dentistry would be better,” Dr. Rohde says.

Dr. Rohde also sees the chair as a way to preserve a doctor’s body. Sitting in a better ergonomic position, rather than bending over at the waist or wrenching his neck around, would allow the design of his operatory to be better too. Patient comfort is a third area he emphasizes with chairs.

“If we’re going to have the patient in the chair for 30, 60 or 90 minutes, how do we get them to be able to relax?” Dr. Rohde says.

Dr. Rohde designed his operatory for patient comfort. He avoids triggers that remind the patient where he or she is, such as the bright light in the face, the smell of disinfectant, the noise of the handpiece and other reminders of poor past experiences.

Dr. Rohde admires Fred Joyal’s book, "Everything is Marketing: The Ultimate Strategy for Dental Practice Growth," which describes how everything the patient sees, feels, smells, hears or experiences creates a perception of the practice and the doctor who runs it. Dr. Rohde encourages doctors to sit in the chair and look around at what the patient sees.

“Do they see cabinets full of dusty old equipment with wires running all over the place? Then, there are some dusty old nitrous tanks leaning against the wall and a laser you don’t use anymore. A lot of it is scary,” he says.

Dr. Rohde also wants his office to look high-tech and clean. His goal is to make the patient feel like he or she is the first person who has ever been in the room.

“When they’re sitting in the chair, and they’re looking around, they literally can’t see anything but their feet, a clean sink and a screen, and maybe outside into the morning,” he says.

He will display a laser in the operatory as a conversation starter about laser dentistry and its benefits to the patient. The CEREC is also on display at times, but Dr. Rohde keeps it mobile because all of the practitioners want to use it all day.

“What patients can see is what I want them to see, and I don’t want them to see all the other stuff. I don’t want them to see the syringe holding a needle, even if I’m going to use it for some reason because I don’t want them to think about it,” Dr. Rohde explains.

Annie Roy is the product manager for CORE equipment at Planmeca, Inc., a new position for her but a complement to her 20 years of treatment design experience. Roy thinks there are many benefits of an operatory that’s using connected equipment, particularly for gathering significant amounts of data for analysis that could facilitate drastic improvements to clinical efficiency.

“Having access to data like the total time every patient is seated in the chair, chair positioning most often used, which handpieces are used, and tracking the instruments and materials going into the patient’s mouth is important information that is available now,” Roy says. “It could be used to optimize the dental treatment and practice.”

Big data in the world of Google and Apple takes the information provided by their users to provide a better user experience. Roy says the technology in the operatory is following the same path but with a different volume of users because of the difference in the size of the dental field. 

“More and more we’re going to get data and learn how to use that data,” Roy says. “For the moment, we realize we have even too much data to manage, but we are confident we will quickly be able to identify the important data that can and will influence the dental procedure.”

Roy says time will show which data is the best through research and clinical observations. Also, the dental industry will determine what the most useful application will be for it.

“It will always evolve, and new data or new things may arise that we don’t even think about right now,” she says.

A deeper dive into ergonomics

Bethany Valachi, PT, DPT, MS, CEAS, a dental ergonomic speaker and professor of ergonomics at the Oregon Health Sciences University School of Dentistry, says the human body was made to move in certain anatomical planes. When we change the position of our bodies and move out of these planes, we can start to create damage in the joints. 

“When the body is in a non-neutral position for prolonged periods of time, it causes accelerated wear and tear on the body and musculoskeletal strain can lead to disc herniation and a number of different things,” Dr. Valachi says.

Dr. Valachi says resolving ergonomic challenges in the operatory that compromise posture must be a priority for any dental professional. Also, there’s the aspect of efficiency. She says the dental assistant should have things within a certain comfortable radius. If not, then the assistant can’t make efficient transfers.

“All of the most used equipment should be within that forearm-length sweep, so they don’t have to get up and retrieve them,” Dr. Valachi says.

Another significant consideration is the lighting, which has changed in recent years. Dr. Valachi says for years the recommendation for overhead lighting has been to have it angled up over the patient’s chest for the upper arch and over the patient’s head for the lower arch. She says Dr. Lance Rucker’s research at the UBC School of Dentistry no longer supports those outdated guidelines.

“So, now we need to look at overhead lighting that can reach behind the dentist, so the light source can parallel the doctor’s line of sight,” she says. “Most older lighting systems don’t do that. They either don’t have ceiling tracks positioned to allow the light to reach that far, or the light arm itself is too short to position the light behind the doctor’s head.”

Dr. Valachi also has an online video course, “Positioning for Success in Dentistry,” that instructs dentists on the 10-step patient positioning sequence (for upper and lower arches). Her goal is dental ergonomic education to prevent pain and extend the careers of dental practitioners.

Dr. Valachi says dentists should use the tooth surface’s position in the mouth to dictate where they sit. She uses a clock-position system when educating doctors about where to sit to work on a particular tooth surface in the area of the mouth. The correct clock-position that coordinates with the tooth will ensure proper posture and working pose for the doctor.

“Dentists that sit in the 10 o’clock position and try to treat all the teeth in the mouth from that position are going to be contorting much more than someone who is positioning themselves correctly for the occlusal of tooth #3 in the 12 o’clock position, and then in the 9 o’clock position for the lingual of tooth #19, for instance,” she says.

Patient positioning is another area Dr. Valachi sees where doctors practice poor ergonomics. For example, dentists often accommodate patients who are reluctant to recline. It’s great for patient experience but poor for career longevity.

For example, when a dentist is treating the upper arch, if he or she doesn’t get the occlusal plane behind the vertical, then he or she is going to be hunching forward over the patient. However, getting the occlusal plane behind the vertical sometimes means reclining the patient quite far. Dr. Valachi says this can be uncomfortable for some people.

“There’s a very easy solution to this, however, support the cervical curve, because that’s what causes patients to freak out, not having the cervical curve supported,” she says. “It can be done by proper positioning with a double-articulating headrest or with contoured dental cushions.”

Most patients who have concerns about laying back feel comfortable fully reclined with proper cervical support. However, Dr. Valachi says few dentists learn in dental school the appropriate way to adjust a double-articulating headrest for the upper and lower arch versus a flat headrest.

“There’s a big difference in how you position the patient for each headrest and that generally determines how tolerant the patient is to be reclined,” Dr. Valachi explains.

Hobbs says ergonomics are designed into the equipment that goes in an operatory. The first thing the Schein team teaches doctors at trade shows is the importance of sitting in a dental stool with proper ergonomic design. However, you get what you pay for, Hobbs says, and he encourages dentists not to save their way to prosperity in the treatment room.

“This is where you are going to spend eight hours of your day,” Hobbs says. “There’s so much that goes into that ergonomic discussion from eye movements to arm movements to shoulder to repetition, and equipment selection is paramount to a long-term healthy career for a practicing dentist.”

Stools and chairs are crucial in this equation, Hobbs says. Ergonomics experts and equipment designers want the dentist to manipulate the patient and not bend over to get to the upper quadrants in the patient’s mouth, which is why they design the headrests the way they do.

“What we’re trying to avoid is the doctor bending themselves to get to the oral cavity,” Hobbs explains. “We want the oral cavity to be brought to the doctor.”

When it comes to ergonomics in the operatory, Dr. Valachi says you should consider the delivery system. For example, rear delivery is the most popular style in the U.S. However, Dr. Valachi says most doctors don’t use it correctly and are repeatedly twisting to retrieve equipment, instruments and handpieces.

“Studies show repeated twisting of the trunk in one direction leads to low back pain,” Dr. Valachi says.

She thinks doctors who choose rear delivery should utilize their assistants more. The assistant should undertake all the transfers and change all the burrs so the doctor isn’t twisting to one side.

Also, with side delivery, which Dr. Valachi says is excellent for a hygiene operatory in which they’re moving around the patient, dentists will also have problems using an assistant to his or her full potential because he or she can’t reach the other side.

“It depends what the priority is,” Dr. Valachi says. “Over-the-patient delivery is one of the most ergonomic, but then there’s the fear factor. All the instruments are right in front of them, so that’s the trade off.”

Another area of opportunity is counter height. When designing an operatory from the ground up, Dr. Valachi says very tall or very short dentists may want to consider designing the height of the counter above or below the standard height. When buying a practice, doctors should consider the height of the counters, too. Buying a practice from a taller doctor can result in shoulder problems from repeatedly reaching up to a counter that’s too high. Regarding associates, Dr. Valachi says working with a doctor with a similar height would be preferable, ergonomically speaking.

“A 6-foot-6-inch doctor should not have the same counter height as a 5-foot doctor,” Dr. Valachi says. “And if a doctor is looking for an associate doctor, a short doctor shouldn’t be partnering with a tall doctor. That’s a recipe for ergonomic disaster.”

What’s trending today?

Cox says technology brings the patient into the treatment discussion and facilitates the person’s self-diagnosis. Patients can see their smile, the defects and what issues they want to address. They’re part of the process with the dental team.

“In the old days, the dentist would come in and say, ‘Hey, here’s what we’re going to do.’ Now, the patient is involved. They understand what the issues are, what the treatment plan is going to be and how long it’s going to take. They’re very involved,” Cox says.

Cox credits technology’s communication component for enabling this involvement. Diagnostic tools and intraoral cameras make it possible to see the fracture, decay, or periodontal disease “larger than life” on a 60-inch monitor.

“It could be intraoral imaging that allows them to take an X-ray and show it up on the screen immediately, with no delay, so the whole patient interaction is streamlined and much more efficient than it’s ever been,” Cox says. 

Digital impressions and CAD/CAM have played a part in the transition of operatory design, too. With these technologies built into the practice, the dentist can now display the problem, do the procedure and deliver the final restoration in one visit. 

Cox says technology also allows the practices to do more. It can help a practice deliver more specialty-type services, such as ortho, endo, implants and sleep, which leads to more accessibility to care for people who need it.

“That level of efficiency and a great patient experience is enabled by technology that’s been brought into the dental operatory,” Cox explains.

Technology isn’t just for patients, Cox says. It’s also changing attitudes and excitement for the team. When assistants, hygienists and dentists use technology that delivers a “wow” factor for patients, it improves the team’s attitude about coming to work.

“The technology in the operatory is empowering team members to feel like they’re more part of the whole treatment experience from diagnosing to educating to delivering the treatment to a happy patient. They feel more involved,” Cox says.

Technology is also progressing the science of dentistry. Roy says Planmeca learned in a project with Columbia University over the past 18 months by assigning the chairs an IP address and connecting them with the network and a local or cloud server, they could collect data about what happens in that chair. The data is accessible remotely and delivers precise details about who used the chair and how.

“You can connect to any specific chair and know at the exact moment the position of the chair. You can know if there’s someone in the chair because there’s a seat sensor. You can know, in this case, which student is connected or logged into that chair,” Roy explains.

It also stores the data for reporting. In the educational situation, students and faculty can use it for research data. In a clinical situation, dentists can use it to calculate efficiency and where they lose time. For example, it can show how long a patient is waiting in a chair when nothing is happening after a hygiene appointment. The data will show whether you should change the scheduling to improve efficiency.

“It gives objective data you can bank on,” Roy says.

When Leduc and his team start an office design, they begin by looking to optimize workflows and organization. Often, it means starting with making instruments management as efficient as possible. They favor centralized material storage and a tub and cassette system. Although this system could mean a higher initial investment, the return on investment in efficiency is worth it, Leduc says.

“You have better organization and turnover of the room is easier because everything is always set up the same way and you can create references to that,” he says. “That leads to higher efficiency, less in-operatory storage and less need to have cabinets on all four walls. Ultimately, that also reduces the clutter and the stress level of everybody that goes in there.”

Planmeca will soon release an operatory light with 48 integrated cameras. You can store still images much like you would radiography. There are two 4K cameras, so the doctor could also take a 3D image of the patient’s face and overlap it to a CBCT volume and the software. Also, the cameras can be remotely accessed, which has excellent uses in a school setting.

“Let’s say you want to see if the student is doing fine during an evaluation. You can turn on the camera, and you can see what’s happening in the mouth of the patient,” Roy says.

Also, Planmeca is adding tracking to its handpieces and instruments. When a user logs in using RFID technology, it will switch to your preferred settings on that unit. From motor speed to water spray and even the chair positions, the unit recalls all those settings to the chair.

“And if you move from a unit to another unit, it’s going to recall the same settings, which are your settings,” Roy says. 

By including RFID tags on each instrument, dental professionals can tell if they’ve been sterilized and when it occurred. Using a barcode etched on the handpiece and a reader at the sterilization area, the practice can prove a handpiece was cleaned, which might be necessary in the case of a lawsuit.

“So, for another example, the system can raise a flag and say it is time for those instruments to be sterilized again because it has been six months and it has expired,” Roy explains.

They’re also working on a reader on the back of the chair that records the instrument used for the treatment. This data will be recorded and stored, which could have implications for ordering. Roy says many schools buy thousands of the same instruments every year out of habit whether they use them or not.

“Through ranking of the instruments, we realized this specific instrument was never used or very rarely used. It changed the purchasing requirements, so now they buy what they need, which allows them to save a lot of money,” Roy says. 

Roy adds large groups with 30 different locations throughout the country can see all that’s happening at all those locations from the operations office. She and the team at Planmeca see it as a massive advantage for their operations team to get objective data that can drive their decisions moving forward.

“It’s a matter of changing habits. If we can change the habits because of the data and objective proofs, maybe it will all come together,” she says.

What’s next in operatory design?

Leduc is excited about a trend toward a medical approach, which relates a lot to privacy. Leduc thinks patients like the quiet of a private area for their treatment. Noise, he says, can be stressful for patients.

“When you have four operatories and you hear all of them at the same time, that’s more stressful than just your own. When you hear the next patient that’s 6 years old screaming and crying, that doesn’t reduce your stress level,” he says.

He has seen doctors trending toward surgical ops that are private and quiet. Leduc and his team have taken this idea and applied it to the whole office.

“We found ways to accommodate this and reduce the square footage needed for each operatory,” he says. 

Cox says he’s starting to see smart devices and digital impression scanners built into the dental delivery unit as well as HD cameras and other diagnostic tools. The technology devices are also changing with added functionality, which he describes as “smarter” devices. For example, TRIOS incorporated caries detection and transillumination into its digital scanning device, and the Planmeca Emerald™ included caries detection.

“It used to be you’d have one device that was a camera, and another device could be a diagnostic caries detection device, and another device would handle digital impressions. Now, we’re starting to see all these things come together where one device is doing all these jobs, and I think we’ll continue to see more of that moving forward,” Cox says. 

Dr. Rohde is excited about what companies such as Seiler are doing with magnification. Seiler is taking the conventional microscope and incorporating two camera systems to create true 3D. With this instrument, the doctor doesn’t wear loupes with little eyepieces but instead watches a screen in full 3D with 3D glasses on.

“That not only gives you better clarity and better ergonomics because you’re sitting up straight but also, if you want to, you could record the whole procedure to a computer if you like because it’s all digital input. That part is pretty cool,” Dr. Rohde says.

Roy compares the operatory of the future to the evolution of restaurant kitchens. Kitchen design is essential for restaurants. The trend today in kitchens is minimalistic, organized and visible. She sees the same design trends moving into the dental operatory.

“You didn’t see that 20 years ago. There is that trend for visibility in every field,” Roy says. “Maybe that visibility trend might affect dentistry, but the changes travel a little slower in our field.”

Connected equipment

Hobbs says smart operatories are coming through Bluetooth and cloud connectivity. Smart operatories facilitate the ability to track how many times a handpiece gets used or engage in remote troubleshooting instead of sending a technician to fix an issue with the equipment. He sees a future with smart operatories where your sterilizer, your mechanical room, your X-ray equipment and everything else you need is in the cloud. 

“There’s a couple of our suppliers right now that when you take the image of the patient, there’s someone sitting at that supplier’s headquarters that can talk to the doctor or the staff at the end of the day to give them pointers on a better position for the patients, so they get a better image,” Hobbs says.

Cox agrees the Internet of Things is going to be in every aspect of the operatory. Not only that, but all the technology will have predictive analytics. Your equipment will communicate when it needs service based on usage before it runs the risk of failure or decreased performance. 

“Those sorts of things are starting to happen now, and they’ll be more prevalent in the future,” Cox says. 

Automation of the workflow is another area Cox sees in the future operatory. The workflow of the future will eliminate many manual steps.

“So, the efficiencies, the speed of all these procedures, and the safety and efficacy for the patient will continue to improve as a result of technological advancement,” Cox says.

Leduc sees integration only going further in the future. Integrated treatment centers with implant motors and endo capabilities and Apex locators integrated into one unit already exist. With digitalization and technology, there can only be more features, workflows and peripheral equipment being integrated.

“As the future comes, everything is going to get a little smaller, a little bit easier to handle and fully integrated. So, you don’t have 12 foot pedals; you have one. You don’t have 12 different devices on your countertop; you have your treatment center,” Leduc says.

Leduc also envisions fewer overhead lights because more dentists are using lighted loupes and systems that have a light. He sees more exploration into assisted procedures that follow the guided implant example that allow the GP to do more complex procedures in his or her operatory rather than farming them out to specialists.

“We are enabling the GP to do more. Simplifying complex procedures by giving general dentists the tools to be able to do them better consistently, keeping the need for specialists for the most complex or challenging ones,” Leduc says.

Build to your personal style

Dr. Rohde wants more dentists to be more deliberate in their operatory design to reflect their philosophy of care and the mission of the practice. It’s vital for the dentist to define these details early so he or she can incorporate them into the design, he says.

“What are we trying to accomplish here on a daily basis? I would say this is a question most people don’t even ask,” Dr. Rohde says. 

For example, one part of Dr. Rohde’s mission statement is to utilize technology and the latest trends in dentistry to create an unparalleled patient experience. He then considers how the room does that. Does the laser do that? Does the DEXIS CariVu™ caries detection device do that?

Dr. Rohde says the dentist has to take all of the suggestions, prioritize them and decide which ideas to incorporate. Some solutions are going to be too far outside the mission of the practice or the budget parameters. Dr. Rohde says the doctor is the one who needs to take charge of the decision making.

Leduc thinks of operatory design as an investment to gain back your time. If you can save five minutes per procedure, that adds up and can give you time to do more on each procedure or go home a little earlier, whichever is important to you as a clinician.

“Time is money. Time is what people lack the most. Time is one thing we can’t make out of a machine,” Leduc says. “But, we can make machines better, safer and faster to give you the ability to do a little bit more, and on top of that, you’ve got that improved patient experience, too.”

Leduc also favors operatories with identical layouts to provide a consistent experience and remove the awkward feeling when you’ve got to reach three or four inches more in this room than the other one. Each operatory is precisely the same, allowing the dental team to focus on what it’s doing.

“You don’t have to think, ‘Oh, I’m in room five today,’ or ‘I’m going to check in room three, but when I go back to my operatory, I’m going to have to think a little differently on how I get everything.’ Making them all the same makes it easier for you to practice anywhere,” Leduc explains.

Leduc also believes that having the right people on your team to work with will aid the operatory design process. Sometimes, he says, you need to have a different person for every task, while other times you can have fewer people who are knowledgeable about key areas.

“One way or another, make sure the right team is there,” he says. “There are experts in every field, so why not leverage that?”

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