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The dental practice has a flow and function that can be optimized to better serve both the dental staff and the patients.
Looking around an old home, one might be perplexed to discover a little iron door leading to the basement, a tiny alcove built into a wall or a small staircase, tucked out of sight. These are old design trends from years gone by (a coal chute, telephone niche, and a servant staircase, respectively) and not something that you would see in modern houses.
Like home design, dental practices take their cues from trends in both function and fashion. A practice that was designed in the 1950s, while utilitarian then, likely needs an overhaul to make it functional for modern-day dentists. But it’s not just practices from the 1950s that need renovation. The way dentists work is very different today than how they did 70 years ago, and even a couple of years ago.
“What’s your perspective of what an optimal office was and what it is now?” Jeff Carter, DDS, owner of dental practice design firm Practice Design Group asks. “Our design understanding of an optimal office 10 years ago is probably significantly different than yours or anybody else’s. Are we contrasting an office of 2022, versus 2017, versus 2010, versus 2000?”
It’s not easy to see the changing faces of form and function. Doctors who may not be aware of those trends my wake up one day and suddenly feel behind the times.
Stephanie Woeste, Midmark’s director of dental marketing, observes that doctors seem to be more open to recommendations and advice.
“We’re seeing that doctors who are looking at either significant remodels or new builds are really paying attention to best practice recommendations – even more so than they ever have,” she says. “They realize that this is a big investment of not only money, but of time. It’s a lot to manage while they’re practicing and keeping their patient flow going. What we’re offering is design services that complement their practice, and that’s really what it’s all about – not just adopting new trends, so to speak, but really focusing on what is going to best fit their practice and their needs.
“The first question to ask is, ‘Are you trying to expand your capacity to see more patients?’” she continues. “Are you incorporating other doctors – like visiting specialists – into your practice? That’s a big trend. Are you adopting new technology that you must accommodate? There’s a lot to really think through – from an objective standpoint. What are you trying to achieve and then hone in on? What new trends might apply to what you’re trying to achieve and going from there.”
One of the current trends that many practices are embracing is bringing a lab or specialist in-house. This makes those partners more apparent and conspicuous to patients.
“One of the biggest shifts we are seeing in our designs is increasing the size of the lab or even showcasing the lab and procedures within,” Jen Rhode, Senior Design Manager, Henry Schein says. “For many years, labs were something that housed a small workstation with small-footprint equipment like lathes, model trimmers, and such. We typically would tuck a lab away from patient view, down a private hall or in a closed room off sterilization as they could easily become messy and create noise that wasn’t the most appealing for the passerby. With the addition of scanners, 3D printers, and milling units, the amount of tech, especially high-investment tech, has moved labs to the forefront in planning for efficient workflow and marketing of the practice.
“Another trend we see in practice design is combination specialties or accommodating for a visiting specialist,” she continues. “The more procedures you can keep ‘in-house,’ the more desirable the practice becomes to the patient. This symbiotic relationship also benefits the practitioner in sharing real estate and staff, especially for front-office processes. If a practice is not looking to completely split a space, we have also seen requests for 1 or 2 larger flex treatment rooms that are suited for specialty procedures. Incorporating a small room with a basic workstation in or around the private zone can also act as a temporary private office for a specialist, or as a space for teledentistry appointments.”
How dynamic is practice design? That is, is it something that changes every year? Every f5 years? Every 10 years?
“It depends on the practice, because if the practice is structured in an optimal way – if you have a really good workflow, if you have good safety practices set up – then the things that you need to change might be, perhaps, to accommodate new technology,” Woeste says. “It doesn’t have to be a dramatic change. It’s really, ‘What do you need to change?’ ‘What’s in your practice?’ And that would facilitate a change, because like what we were seeing during COVID, is that if doctors had a good structure – an adequate workflow, adequate safety setup, and practice processes – then the things that they needed to change were more minor in scope. So, perhaps they needed to focus on air quality, because of aerosols. Some of that could be more simply executed. Or perhaps they had to take away some patient amenities for a while – you don’t want the magazines sitting out, that type of thing. But as far as major practice design changes, I think it just depends on if the practice’s needs and goals are changing.”
Overall, design needs and trends tend not to be seismic shifts, but rather small, subtle adjustments.
“At its base, dental practice design has not really changed in over 20 years,” Rhode says. “The general zoning, adjacencies, and patient-staff workflow remains the same. This is not to say there have been no adjustments or recommendations as to what treatment room layout is most efficient, or what configuration of sterilization is best. This varies mostly from doctor to doctor and can be dependent on location or demographic. It is most important for doctors to analyze their changing demographics in patient-base and community every few years to see what design trends and philosophy may align with their needs most.”
The Times They Are A-Changin’
A dental practice that is designed and built today would likely differ from a practice that was designed and built 20, 10, or even 5 years ago. Technology, space usage, and esthetics are all drivers for change. But so too are the ergonomic concerns of the people who work there.
“The change is incremental in that the principles that they came up with in the 60s and 70s, by and large, still hold today,” Dr Carter observes. “There’s no radical thing. All those flow principles hold to a high degree, except for things that incrementally expanded in size. People are bigger. There’s more equipment. If you were to look at a floor plan from 30 or 40 years ago, a lot of the flow would look the same. But if we went in and put a ruler on the operatories, for example, we used to do nine-foot wide operatories and nine foot six operatories. Well, now we’re all the way up to about 10-feet five wide, because people are bigger. We’re bringing in a lot more mobile accessories – digitization, scanning units – stuff like that.”
Changes do occur, but they tend to be subtle.
“If you were to look at floor plan from 20- or 30-years ago and one today, you would see that things that have expanded, they’ve been tweaked,” he highlights. “For example, one of the simplest things is how do you get into and out of an operatory? There are only so many entry points. How do you get in and out of it most efficiently? They would run studies, but there’s no question what they call ‘dual-head entry’, where at the head end of the operatory, there are two openings – one on the right side, one on the left side. So, if I’m the doctor or assistant, I have my own opening to come in and out of the operatory, then the patient faces towards the foot end of the operatory. And, ideally, they have a nice big window where they can look outside and get natural light and that relaxes them, but that’s just highly efficient.”
Some of that change, too, has evolved from the way dentists work. The concept of “4-handed dentistry” necessarily changed the size needs of an operatory.
“The emphasis and the understanding and the appreciation of what 4-handed dentistry was supposed to do was slowly getting away from us,” Dr Carter says. “In the early 2000s, things were getting larger, but we were using the principles that had evolved many years later. We were incrementally increasing the size of things, adding space in certain rooms to get a little more function and flow.
“But we were seeing people not understanding the 4-handed dentistry concepts,” he continues. “We were hearing, ‘Well, I don’t do that anyway.’ So, we were getting pushback and we were getting frustrated that some of these principles were misunderstood. It was becoming a challenge to get people to understand and appreciate them.”
The way dentists work has evolved over time, and that drives design change.
“My dentist stood up,” Dr Carter says. “They had belt-driven hand pieces. They worked by themselves. They might have a receptionist, they might have somebody that came in and helped them clean the room, but they worked literally 95% of the time by themselves. Everything was big, high counters. The dental chair looked like a barber stool. They had horrible, horrible back neck, wrist, elbow, shoulder, repetitive stress injuries, because they were so contorted trying to hunch over to look in your mouth and do stuff. Legions of dentists from the 40s, 50s, and 60s just suffered. Part of this design evolution was the transformation to sit down. Four-handed dentistry was supposed to help and alleviate the repetitive stress injuries. My dentist, George, was a great athlete in high school, a great baseball player. I remember my dad telling me that by the time he was in his forties, he had such back issues, he could hardly play golf. A lot of that stuff was to fix that, and it did for a while. It helped with some of that. That was the birth of four-handed dentistry.”
One of the things that practice designed didn’t factor in 10-, 20-, especially 50-years ago, is the current state of technology. All these new scanners, printers, and milling units require space.
“Current trends in dental design come from the intricacies of incorporating new dental equipment and technology,” Rhode says. “As mentioned previously, the advancements made with lasers, scanners, printers, and milling units require increased space in the lab and additional storage nooks for carts to dock and charge. At the beginning of the pandemic, there were many changes implemented by practicing doctors and those that were currently designing with our team due to the insecurity of the future. The major change we saw and continue to see is the elimination of large waiting rooms. In locations that found patients and staff preferred a virtual or streamlined check-in process, waiting rooms continue to be reduced to a few stylish lounge chairs or comfortable bench seat. The paperless office management systems continue to increase in prevalence through kiosk or online applications for managing appointments, checking in or out, and payment. This allows for more space to dedicate to consultation, private zone spaces for the doctor or staff, and of course, treatment rooms. For the offices that had a waiting room before the pandemic, often they opted for an additional treatment room.”
Just like anything else these days, we can’t talk about practice design without talking about the pandemic. Safety concerns are also a driver for practice design.
“I do think the pandemic brought a spotlight on safety,” Woeste says. “So, as an example, we have a lot more activity, questions, a desire for education around sterilization. The instrument processing area – because that is so critically important as part of patient safety and staff safety – is a key concern. Air quality is a consideration. So, you want to make sure that aerosols are contained and there are many ways to accomplish that. Make sure that if you are redesigning, that you’re looking at surfaces that are easily disinfected and are commercial grade, as well. There’s consumer-grade and there’s commercial-grade, and just based on the amount of steam, water, all the things that happen in a dental practice, if a doctor doesn’t choose the right materials, it’s really going to lead them to more money down the road, having to replace those things, because they need to be clean and in good repair at all times to maintain safety.”
“For those doctors that were actively designing with our team when the pandemic began, the uncertainty of the future lead to responsive changes in the floor plans,” Rhode adds. “Cased openings to treatment rooms were quickly replaced with doors, bays were eliminated or inflated to allow for additional distancing from chair-to-chair or the inclusion of freestanding or immovable partitions, and center-island cabinets were swapped for t-walls or private rooms. While these requests have decreased, doctors are more aware of the perception patients have regarding infection control. Bays have returned, but they more commonly include partitions. Center-island cabinets are still good solutions for increasing storage and harness valuable real estate between operatories.
“Dentistry is inherently an environment dominated by infection control procedures, so the layout and equipment designed and implemented before the pandemic still support safe practices,” she continues. “Increasing patient awareness of the safety procedures can alleviate anxiety and establish trust. We do recommend dentists consider showcasing sterilization or providing education on the sterilization processes. Any purchases made to enhance a patient’s treatment or experience are worth displaying to create an opportunity for informative conversation.”
Does all this mean that dentists must drop everything, burden themselves with million-dollar loans, and rebuild their practices from the ground up? Of course not.
“It depends on the state the practice and how it was constructed to begin with,” Woeste says. “But what we encourage doctors to do is really walk through their practice and think of it through the eyes of their patients. Many doctors come to work, and they’ll go through a side door or a back door that’s closer to their office, and they don’t walk through the front door. Take the opportunity to approach your office like a patient would and think subjectively. As you’re looking around, make sure that things are clean and in good repair. A lot of patients are noticing things like cloth seats that you can’t disinfect effectively on a regular basis.
“You’ve got clinical-grade upholsteries that can be disinfected,” she continues. “Those little details matter tremendously to patients because everyone is so sensitive to the effects of COVID, and from an esthetic standpoint. Think of it like your home. Colors can become dated. Flooring materials can become dated. And every now and then, or if the doctor doesn’t feel that confident that they have good sense in those things, bring a friend and say, ‘Help me critique this through the eyes of a potential new patient.’ It doesn’t have to be a significant remodel to really help doctors recruit and retain patients.”
It doesn’t mean that dentists must break the bank to remodel their offices, but they should be mindful of how patients see the office.
“Dental is a highly competitive field to be in,” Rhode says. “Finding an unoccupied niche in service, design, or amenity in your area is an opportunity to set yourself a level above in a patients’ eyes. I would say it is unlikely that a practice would need to do a major renovation every few years but may consider reassessing their current market and patient demographic to see what they may incorporate into the current design or workflow to increase new patient interest and retention. This could be updated interior finishes like paint, wallcovering, furnishings, or décor. In treatment this may mean upgrading or adding equipment to accommodate same-day dentistry or cosmetic procedures like teeth whitening, clear aligners, veneers, or even Botox. A demographic analysis is going to be the best informant for what services are best suited for a practice.”
How does the dentist know whether they need to renovate their facilities? A good first step is to consider were they think they are lacking.
“For an existing practice, deciding what to do, whether that be renovate, expand, build new, or move to a new lease space, can be a daunting decision,” Rhode says. “The first step is to identify what has initiated this change. Most often, it is simply a lack of space. This could mean a practice does not have the space to upgrade or add those advancements in equipment, or best case, the patient load is large and active enough to drive for a bigger, updated space. There are a few important considerations practitioners should assess before jumping into a new project.”
It may be trite, but the old real estate axiom of location, location, location is apt.
“The first is your current location,” Rhode observes. “Is the area highly desirable? Is there good signage, adequate parking or transportation routes, or a preferred demographic? Is there a good density of your ideal patient? If a doctor answers yes to most of these questions, it is probably not ideal for them to move, unless there is another available space that is comparable but larger. Another option is if there is expansion space available. This could be an adjacent unit that the practice could ‘break’ into, or if there is available land with proper zoning to build an expansion.
“If a doctor answered ‘no’ to having an ideal location,” she continues, “moving, or building new is best. With today’s costs in construction materials and labor, many are opting for buying or leasing an existing space and renovating. It is important to have a consultation with a dental-specific designer or project manager to analyze the space before committing.”
But, if a dentist is still on the fence about whether their practice is adequate for their needs, it may be time to call in a fresh set of eyes.
“Lastly, if all the above solutions are not an option, schedule time with a dental-specific designer to see what can be optimized in the current space,” Rhode says. “Other than waiting rooms, it is very common to renovate office space like consultation, private office, or business office space into additional treatment space. With today’s practice management software, more of the front-office procedures are moving back into treatment to free up square footage. Dead-end halls can become docking stations for carts or equipment. As hard as it is to give up storage closets, absorbing a storage closet into sterilization or lab may provide the necessary space for scanners, mills, or printers. If a doctor is leasing, it is important to discuss these upgrades with the landlord and potentially negotiate tenant-lease improvements to help cover costs.”