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Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Digital Esthetics. He is also the author of 18 technology books, including the award-winning Green IT: Reduce Your Information System's Environmental Impact While Adding to the Bottom Line. As such, he’s particularly interested in the technological side of dentistry.
The impact of thoughtful design throughout a dental practice.
Architect Louis Sullivan, the “father of skyscrapers” and mentor to iconic designer Frank Lloyd Wright, famously said, “Form follows function.”
That axiom was originally applied to architecture, but the notion lends itself to all design situations-even in the dental practice. In fact, good design concepts can be applied almost universally in a dental setting.
The principles of design can be applied to everything from crafting and creating restorations, to setting up the physical spaces in a dental practice, to planning clinical and patient workflows, to designing the way the business of the practice operates.
Restorations must both be esthetic and functional. The operatory should be practical but not frightening. Employees must do an efficient job while looking professional.
Good design can either stand out or blend in, as the situation requires, but it should always find balance and harmony with its environment.
Consider direct restorations. Those seemingly straightforward cases are the dental practice’s bread-and-butter, but they’re not without skill and artistry. Patients want their restorations to both look good and work properly.
“If you’re looking at an anterior tooth, form and esthetics are important,” says Dr. Jeffrey Lineberry, DDS, a general dentist in Mooresville, North Carolina. “You can make a tooth that’s durable and fills the functional need, but if it doesn’t look right, your patient isn’t going to be happy.”
To strike the right balance between form and function, Dr. Lineberry notes it’s necessary to, first, get a sense of what’s going on with the patient.
“Form follows function, so to speak,” Dr. Lineberry says. “They play off of one another. The thing is, when you’re designing something, you have to look at the big picture of things. Not only the restoration at hand, but, for instance, if you have a tooth that has wear on it or is chipped, you have to look at how it fits in to what is there and why it happened. Those are the things that I start looking at when we talk about form and function because they’re definitely tied together.”
The best way to achieve that balance and, ultimately, the best restoration, is to start at the end.
“The best thing is to envision it with the end in mind,” Dr. Lineberry says. “You have to know where you’re going with things before you start to rebuild something with a direct restoration. You have to understand the limitations of your materials as well. If it’s four restorations that include multiple surfaces, then you want to have a matrix system or a system to support placement of the restoration properly, so you can get ideal contours and contacts.”
Digital design and CAD/CAM is a faster, more efficient and more reproducible workflow that leverages digital capabilities and computer learning to automate parts of the restoration design process.
By scanning the tooth, crafting the restoration on the computer and then sending it to an in-house mill, clinicians need not involve laboratories for common cases.
Dr. Michael Moroni, DDS, is a general dentist from Castle Rock, Colorado, who utilizes CEREC and the Planmeca FIT CAD/CAM system in his digital workflow.
“It’s night and day,” he says. “If the scan isn’t where I needed to be and I make the restoration, and I’m trying it in at the end, if I need to add more on the buccal or the lingual or add a cusp or there’s no contacts, I can go back to the software and I can extend what I need to, and then remill it. It saves additional appointment time. Say the laboratory made the same mistake-I can’t do that with the laboratory-manufactured crown. I have to take another impression and send it back. I can do it all in the office and make the corrections and remill it, and I may have lost, maybe, 10 minutes, as opposed to a whole day.”
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At its heart, digital design is no different than any other restoration design.
“That’s part of dentistry, right?” Dr. Moroni says. “You have to know what you’re looking at and make sure it’s correct.”
The big benefit of digital dentistry is letting the computer do the heavy lifting.
“Say a tooth does need a crown, or the patient needs several crowns, or whatever, the software is so intuitive nowadays, it’s come so far, if you scan and put the correct data into the computer, the software is intuitive enough to basically do 99 percent of what a good restoration is,” Dr. Moroni observes.
“It’s just that the doc needs to come and tweak it or the staff needs to come and tweak it; maybe change the contacts; maybe do a little contour here, or a contour there; maybe do a little smoothing here; a higher contact, inter-proximally; and then mill it,” he continues. “The biggest thing that docs do or staff does, and they don’t really need to do it, is mess around with the original proposal. The software does an amazing job, so they just have to let it do its job.”
Because the computer is able to do such reliable design, the doctor may find him or herself not having to be as involved in case design.
“I feel 100 percent confident in letting my team do it,” Dr. Moroni says. “If you train your team to finish the design from the proposal the software gives you, I’m comfortable in leaving the operatory and having my assistant come in and finish the design and mill it.
“Once they are trained enough to do that, then I don’t have to be in the room. If they have a problem doing it or they have a question, they can always find me and I can tweak it, if I need to. But if not, then I’m okay coming in when it’s time to seat the preparation.”
Dr. Moroni advises those who are new to digital design to block off some time to learn the technology.
“If they’re just getting started in it, just jump in and do it,” he says. “It’s kind of like the first iPhone or the first computer they had. They’ve got to get comfortable with it. They’ve got to get comfortable with the software and they’ve got to get comfortable with the scanning. You’ve got to build your confidence up, prior to when a patient is there, because when a patient is there, that’s the wrong time to try and figure stuff out.
“They have to understand that if it’s a new technology for them, it’s going to take longer to do that first crown than it would, say, me, who’s been doing this for 12 or 13 years,” Dr. Moroni continues. “Them knowing that and knowing the limitations of themselves with the software and equipment is just going to take longer. They can do it, it’s just a matter of going through the steps and making sure it’s a good restoration and it’s a positive experience for the team, the doctor and the patient.”
And when the doctor is ready to go live with his or her digital workflow, he advises blocking out extra time.
“Preparing for it, clinically, is one thing,” Dr. Moroni says. “Preparing for it on the admin side and how they schedule it is pretty important. They don’t want to be rushed when they do their first couple of cases. They want to take their time, they want to block out the schedule and have just that one patient that they’re dealing with.
That way they don’t feel rushed, they don’t feel like time is a factor. They’re going to take their time. They’re going to go through the software. They’re going to do a nice scan. They can make a nice restoration. And then, as they get better, as they get more proficient, then that timeframe actually decreases. It’s good to get your feet wet first and then really go for it.”
Designing an equipment plan
Dentistry has always benefited from cutting-edge materials and technology. While barbaric now, it could be argued the animal teeth used by 700 B.C. Etruscans to create dentures was out-of-the-box thinking. In 1895, Dr. Otto Walkhoff, a dentist from Braunschweig, Germany, adapted X-ray technology to help the cause of dentistry. In 2019, CAD/CAM is the current “it” technology, helping to bring ease and predictability to dentistry.
And while dentists continue to embrace technology, there’s an element of finesse and balance involved designing its inclusion in the practice.
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“I like technology,” says Dr. Roger Levin, DDS, CEO and chairman of dental practice consulting firm the Levin Group in Owings Mills, Maryland. “I think technology has a lot of great benefits. But here’s the problem with technology: You don’t get it all at once.
“In dentistry, we tend to buy technologies one at a time,” he continues. “They don’t all match up. They don’t all work together. They are different generations. The first problem with technology is offices tend to buy one-off technologies instead of having a technology plan.
“We don’t really have technology consulting firms, other than the sales reps, who will give you a technology plan to follow with budgeting and how you can bring it in,” Dr. Levin adds. “You’ve got one technology that does one thing, another technology that does another; they don’t always talk to each other. If it doesn’t match up, it’s going to have limitations.”
Like so many things, money matters. With new technologies, costs can be prohibitive.
“I’m working with a young dentist right now who is going down this path of technology,” says Jim Hammon, equipment sales specialist, Henry Schein Dental. “He wants to buy all the latest and greatest tools. And I said to him, ‘Doctor, let’s make sure we build your new office with a balance of equipment and technology. Start with the basics like patient chairs, compressor, X-rays and add in the foundation technology items your practice needs to get off on the best start”
Cutting-edge technology is great, but, like form and function, an organizational balance must be struck. Without the foundational pieces in place and ready to provide support, those cutting-edge systems won’t be able to achieve their full potential for the practice.
“My suggestion is that you use technology to do one of three things: It makes you faster, more efficient, or it reduces costs,” Dr. Levin says. “For example, is there a technology that would allow an office to save time? Yes. All of the texting confirmation technologies. Now, front desk people aren’t spending an hour or two each day making confirmation calls to people they can’t reach. It’s all done by text message. That saves time. If you save enough time, you can save some labor. Are we replacing what we’re doing with technology or improving what we’re doing with technology?”
Operatory design is for everyone
Between the sound of the handpiece motor, the sight of a needle and the smell of disinfectant, operatories can be intimidating and overwhelming environments for patients. But they’re not the only ones who can be affected by an operatory’s design. Clinicians have to work comfortably and efficientlyÂ-all day-in those tiny rooms.
Dental practices are composed of different areas, says Dr. Jeff Carter, DDS, co-owner of dental practice design firm Practice Design Group There must be a clear delineation between public areas-such as the reception area-and treatment areas.
“As we feed back into the treatment areas, we never want the operatories up by the business waiting area because we call that a ‘zoning violation,’” Dr. Carter says.
“There are public activities-the waiting area, the front desk, making appointments, paying money-but we don’t want to mix that with clinical procedures where people are in chairs,” he continues. “There’s handpieces, you’re prepping teeth, you’re injecting people, if people aren’t comfortable, they’re making unusual noises-all the hubbub that’s going on in clinical activity. We don’t want to mix that with sedate public areas where there’s nonclinical activity.”
The operatories are also areas where extra attention must be paid to environmental factors.
“There’s a greater need for air conditioning in that area because there’s more dynamic activity,” Dr. Carter says. “You’ve got doctors and staff gowned up, gloved and masked. You’ve got patients who are maybe nervous or a little bit anxious and they feel hot or uncomfortable.”
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It isn’t just the patient who should feel at ease. Team members should be comfortable when they’re working, and a major consideration for that is in workflow efficiencies. It’s important to think of the specific needs of each person who will use a space when designing the different areas of a dental practice. Dr. Carter says this type of thinking leads to smart design decisions for every aspect being built into a space.
“The dentist is seated in the chair, and the average oral cavity, when they’re in a chair, fully reclined, is about 32 inches above the floor,” Dr. Carter says. “So, we put side cabinets at 32 inches above the floor. We put delivery units at 32 inches above the floor. We put the 12 o’clock cabinet at 32 inches. We’re trying to sync up supporting surfaces and equipment with the oral cavity, so we’re working on a consistent plane that is the same height. We’re not reaching way up high to get stuff, we’re not reaching way down low to get stuff, we’re working in consistent plane, and that’s more efficient.”
The first steps of practice design
Before patients even get to the chair, doctors have the opportunity to put their best foot forward with the overall design of the practice. Like the other elements in dental design, striking the right balance between form and function is critical.
There are some dentists who might elect to take on the challenge of practice design themselves, but there’s some wisdom in working collaboratively with design professionals.
For instance, Don Hobbs, vice president of equipment sales and his team at Henry Schein Dental, helps dentists with all aspects of practice design.
“When an opportunity does come our way, for instance, Dr. Smith is either building, remodeling, or moving,” Hobbs says. “Dentists, historically, move an average of two to three times in their career. Depending on if we have a relationship with that customer, or if it is a brand-new customer, we are going to take them through the whole process.”
“One of the first things is, where do you want to go? Do you have a location?” Hammon adds. “We will partner with the realtors, developers, etc., to start that process. It can be a demographic study. It could be a real estate study, but to find out where do you want to go or what town is underserved or growing.”
Once the location is selected, designers can help with an understanding of what the doctor hopes to achieve.
“What are we trying to do?” Dr. Carter asks. “What are we trying to accomplish? What are our needs that we’re trying to address? What, maybe in our existing facility, is not working that we want to improve? So, it’s very critical that you catalogued the essential data of ‘why are we even doing this?’”
Often designers follow the 80/20 rule, what doctors should strive for something closer to their exact needs.
“If 80 percent of the dentists show up and wanted to do a new office, they’d get six operatories and 2,200 square feet,” Dr. Carter says. “For 80 percent of the people, that’s close enough. You really want to take it further than that. You really want to explore what their specific needs are. That’s what we do. We want to explore every last thought, every last desire and vision that the doctor wants. What are we trying to accomplish in this? They have to set some kind of realistic business budget upfront. There’s a bunch of wonderful stuff that we can buy new, but what is our budget for this?”
Balancing vision and cost
Professional designers can help doctors fine-tune their wish lists into a realistic vision.
“Programming is a document,” Dr. Carter says. “It goes through all the major points in a dental office: How many front desk people are there? Do you have an office manager? How many chairs do you envision in the waiting area? They know what they want but maybe not necessarily in the context of all the parts and pieces. It’s one thing to do programming, but you need somebody with some specialized design expertise.”
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The biggest element in a project design, which should come as no surprise, is the budget.
“It’s going to sound really simplistic, but it’s always about money,” Hammon says. “Again, think about the different walks of life that we are working with, whether it’s the young person who is right out of school, whether it’s someone who’s been working somewhere for five or six years, or he’s the guy who’s 50 and says, ‘My practice is tired and old.’ We have learned, across the board, they don’t know what things cost.”
“I always joke that doctors come to us and I say, ‘What’s your budget?’ And they’re literally off by half almost every single time-and it’s usually not the good half,” Dr. Carter says. “They’re under by 50 percent because they go out in the marketplace and they get low-balled. It’s not a malicious thing, but they talked to a contractor who did a project five years ago and that was the most minimal thing to make it go.”
To help doctors understand what they can afford, Hammon asks them to look at their life budget.
“‘Okay, doctor, what are you paying in loans?’” Hammon asks. “’What’s your student loan? What’s your housing? What’s your car payment?’ You’re going to come to us, and I’m going to tell you that this project, for the next five to 10 years, depending on the length of your loan, is going to cost you another $6,000 a month.”
“Take all that, add it all up and divide it by dentistry,” he continues. “Can you produce enough dentistry in this new practice? We are trying to add all that up and get them to understand, I’m not asking you for $700,000, I’m asking you, can you afford $6,500 a month?”
Form and function are, of course, a delicate balance, and how the practice looks is a reflection-justified or not-of the clinician’s dentistry.
“What I tell the doctor is, ‘Nobody woke up in the morning doing cartwheels saying, ‘Yay! I get to go to the dentist,’” Hammon says. “If your office looks like something out of a time machine or the carpet is bare or the paint is peeling, is that really a reflection of you and your practice?”
“Have you ever gone home to your spouse or your kids and said, ‘Have you seen his crown preps? They’re amazing!’” he continues. “No. You’re going to go home and talk about, ‘It was comfortable. It was nice. It was really modern.’ No one ever goes home and talks about crown preps.
“When Mrs. Jones pulls in your parking lot, and if your flower bed is full of weeds; if the ‘E’ on your signage doesn’t light up; that first impression goes a long way. I talk to them, a lot, about the appearance of the office and taking those reservations that the patient has and trying to make them go away,” he adds.
Dr. Carter underscores the need for the doctors to be active participants in their practice design.
“They should be presented options to be able to provide their input unique vision and circumstances over the design,” Dr. Carter says. “And when they show up at the end, when it’s done, then they can say, ‘Oh, I came up with that. That was my idea.’ It should be a fun, engaging, energizing process. If it’s just drudgery, ‘Oh, I’m sick of these meetings. I have to decide what kind of faucet to put in the bathrooms.’ It shouldn’t be like that. You should be energized by it, and if you’re not, then I don’t think your needs and vision are being addressed.”
Designing a dental business
Design, on the business end of a dental practice, may seem somewhat mercurial, but there’s an important balance, or élan, that goes into business strategy, and it all starts with planning.
“The first step is: What is the workflow?” Dr. Levin asks. “You need to map out every aspect of the workflow from the new patient phone call to the new patient experience to the active patient experience to case presentation to scheduling to insurance explanation to the collection process, which should also include aspects such as patient financing.”
That critical step of planning is often neglected for a very simple reason.
“Up until recent years, the reason why dentists didn’t worry about workflow is that they didn’t have to. It’s that simple,” Dr. Levin says. “Practices did well; dentists made the income that they wanted to make; they had the lifestyle they wanted to have. When you’re not under pressure, you’re not going to take the time to learn how to create a better workflow when things look like they’re working just fine.”
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Another factor is that dentists become dentists for the sake of performing dentistry, not because they want to become businesspeople.
“Dentists don’t learn business in dental school,” Dr. Levin says. “Even if they taught it, nobody would pay attention because dentists are trying to get the requirements and trying to get out. And when they’re in practice, they don’t have the experience or background to put together all stages of the workflow.”
Stumbling blocks in a practice’s business design are due, largely, to things that are overlooked.
“The missteps are parts of the systems that are left out,” Dr. Levin says. “For example, the practice is supposed to collect money following a visit. The patient comes up to the front desk and says, ‘Oops, I don’t have my credit card or checkbook.’ The patient walks out the front door, and now you have an accounts receivable factor that you may or may not collect.”
“Another example is the sooner you get a new patient in, the more efficient, the more likely they’ll show up, the more likely they’ll accept treatment,” he adds. “And yet there are still practices where a new patient will call and they put them out for five weeks, which often leads to a no show or a dropout.”
“Another example was not using all financial options,” he continues.
“There are an increasing number of patients who cannot afford treatment, so you have companies like CareCredit that will finance patients. A lot of doctors instruct their staff not to use it unless they have to because they have to pay a small portion of the fee back to the financing firm. It’s a matter of not skipping steps in the systems and the systems are the workflow process.”
Another component of that is deficiencies in the practice’s physical design.
“The patient comes up to the front desk, you’re having a financial conversation, people are waiting in the reception room because they can’t go rebuild their office to fit the most modern workflow philosophy,” Dr. Levin says. “As I like to say, right after you build your office, it becomes obsolete.”
While function seems to be the cornerstone of good business design, form also matters.
“Physically, you have to look good,” Dr. Levin says. “You can’t have five-star customer service if you don’t look good. For example, we have a client who has high fees but an unattractive office. That unattractive office is sending a message to patients, and it’s not the message you want to send, especially in a high fee environment. There was a time when that didn’t matter as much, but today it does. Everybody in business is trying to raise their game from a competitive standpoint. Physically, you want to reflect the level of customer service you want patients to perceive that you have.”
“The second part of the answer is just, simply, efficiency,” he continues. “When staff members look efficient, then the patient assumes that it is a better practice. One of the glitches that we often see is confirming insurance coverage, for example. The patient, typically, has no idea what their coverage is. There’s no software that’s housing that. It often comes across to the patient that the practice isn’t doing a good job, even though it’s not the practice’s responsibility. Efficiency, for patients, is a major factor in customer service. There is a form and function relationship. We have to get this information, but how quickly can we get it? How comfortably can we answer a patient’s question? How organized are we at the front desk to take care of the patient’s different needs, whether it’s collections, patient financing, checking their dental insurance or scheduling their next appointment? Otherwise, you could do a good job but still be perceived as a low-level customer service environment.”
Dental practices are complex machines-there are a lot of moving parts. That machine has to operate efficiently and effectively. To that end, practice management software can help to oil the gears, so to speak.
Dan Easty, regional technology adviser with Patterson Dental, makers of Eaglesoft practice management software, observes that software facilitates effective communication within the practice.
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“That’s one of those benchmarks that people need when we look at, ‘What do I really need to run the office successfully?’” Easty says. “You’re going to need the ability to make appointments and make that manageable through the computer system. Images, radiology and diagnosing images at a grander scale has improved light years just from when I started back in 2005. There’s a lot of great advancements on that side. Look at 3D imaging. Look at the advancements of 2D, and just the ease of it, too. I plug in my sensor, I’m not having to manipulate too much on the software to get it going. Those are the things that we hear from clinicians saying, ‘I expect X. To get there, I need a simple process.’ And that’s something we provide.”
Do practices need practice management software, or can it still be done from file folders and clipboards?
“I believe that having practice management software is one of those benchmarks of running a business,” Easty says. “We’re still finding some practices that don’t, and the reason why they’re going with software now is because they’re transitioning owners, or they’re retiring, or they’re looking at selling their practice, and they need to prove, ‘I have so many patients,’ and all these benchmarks to make that happen, and it’s very difficult to do that on paper. Even nowadays, there’s a more heightened demand from patients. ‘I want to be communicated with by my cell phone. I don’t want you to call me. Just text me. Send me an email.’”
In addition to the under-the-hood mechanisms that keep the practice maintaining forward momentum, the user interface matters both from perspectives of function and form.
“One of the crucial things is when the patient is in the chair, you don’t want the patient to have the perception that you’re clicking a lot of things,” Easty says. “‘Hey, they’re clicking a lot of things. They’re spending a lot of time on the computer.’ Also, we’re putting a sensor or a phosphorus plate in their mouth and then you don’t hold still to take that image. So, there’s a time factor, too. Instead of me having to open the page and click here and click there, all I want to do is position that sensor, get the camera ready and be able to auto acquire, it’s ready for me to take, and then go for it. When we look at a workflow, and this is something that our technology advisers stress, make sure that we are working with the team and they know to prep all of that, to place that sensor in the mouth, and so we’re ready to acquire that image. Sometimes, when we take that image, we have to go back to the computer and take it again. Some softwares you don’t have to do that. It takes the image and it’s right there. Then, I can go back to the patient, readjust, reposition that for another shot until I’m done with that series. When we talk to team members, it’s really their feedback that drives development of that software.”
Practice management softwares’ communication abilities extend beyond the four walls of the practice. Thanks to third-party integration, portals allow patients to be more actively involved with the practice.
“I see that as something that’s growing,” Easty says. “With one of our third-party vendors, RevenueWell, they do have a portal that they provide for patients. It’s something that’s provided by the office that their patients can create this patient connect where they would be provided with their login account and create their appointment requests, view their bill, because a lot of that is really ownership of their account. And if we can provide patients with an ownership of their account, we’re looking at a little more engagement with the dental office. They can view when their next appointment is, or when they’re due for their next recall, which will reduce the longevity of the hygiene reappointment.”
Eaglesoft’s Patterson Intelligence Report provides practices with the ability to see where their practice might need help.
“That helps offices provide insight on current gaps, or maybe future trends, maybe something that they’re not hitting on,” Easty says. “This would show areas of preappointments, future appointments, even production. There are analytics that help offices examine their current workflow and say, ‘Are there any disruptions that I’m not aware of that I may be able to pinpoint an area for growth?’”
Form and function are essential components of any design in the dental practice-whether it be restorations, operatories, the practice, the business itself, or the workflow. Striking the appropriate balance necessitates the doctor consider a number of mission-critical variables, including patient wants and needs; the best interests of the practice; and what he or she wants to achieve from the business.