- Email: [email protected]
Dental office design and layout
8 2 /3 4 4 • THE J O U R N A L OF THE A M E R IC A N DENTAL A S S O C IA T IO N
much. Whether painting or cleaning, care should be taken to see that the open ings on the tile remain unclogged. SUM M ARY
Acoustical materials are highly functional and decorative, are available in a variety of materials and designs, and require no involved processes or expensive equip
D e n ta l
ment for installation or maintenance. If it is agreed that an attractive, quiet en vironment is desirable for dental offices, it will be found that sound conditioning will do much to achieve that end. 335 East Forty-fifth Street
Illu s tra tio n s courtesy o f A rm s tro n g C o rk C o . ‘ President, A c o u s tic a l M a te ria ls A sso ciation .
o ffic e
d e sig n
a n d
la y o u t
John A. Anderson, D.D.S., Chicago
Better dentistry— faster and easier—is the challenge of today. Increasing produc tion without increasing the unit cost to the patient is a realistic and modern approach. Optimum dental health for the many must be achieved with com fort, efficiency, economy and satisfaction to the patient. Equally important, m od ern dentistry must be performed in such a fashion as to minimize fatigue and reduce the health hazards of the dental operator. Eliminating waste time and motion is a fascinating problem, more so with the advent of dynamic changes in modern dental operative procedures. T he greater efficiency of instruments has relegated cavity preparation— the once tedious task of restorative dentistry— to a fractional part of dental procedure time requirements. O f equal importance is the elimination of waste time and motion in all phases of dental care. Why should dentists exclude themselves from
the many advantages to be found in increased efficiency? Why must the dental profession con cern itself with increased production through greater efficiency? Unprece dented population growth, plus a more dental health conscious public, require increased production facilities. The num ber of dental graduates is not sufficient to maintain a proper population-dentist ratio.1 T he dental profession has the dual responsibility of developing its own par ticular competence according to the high est standards and of adapting that com petence to the needs and demands of the people. T he profession has met this first responsibility through progressive and scientific efforts to improve the qual ity of dental care. It is meeting its second responsibility through an effective dental health education program .2 Until the last decade, if dentists wished to serve more patients, it was necessary
ANDERSON . . .VOLUME 60, MARCH I960 • 83/345
to work longer hours to do so. Today, thanks to high-speed cutting technics, washed field procedures, organized rou tines, new impression methods, controlled casting technics, and trained auxiliary help, mouths can be restored to function much more rapidly. M any hours of chair time have been eliminated fo r both oper ator and patient. W hen a dentist treats a patient, he not only treats his physical condition, but must be concerned with his psychological welfare as well. T h e proper psychological approach is important in order to pro vide pleasant, rather than disruptive, emotional experiences for the patient. Inefficient operative procedures are not only annoying to the patient but usually result in increased discomfort, either dur ing the operation because o f unnecessary delays, or postoperatively because of mis handling o f mouth tissues. Most people do not regard having dental work done as a particularly pleasurable experience, and anything that improves their com fort, physical and psychic, during this experience is an important contribution to better patient-dentist relationships, and the production of an increased amount o f dental services. In developing methods fo r greater effi ciency in operative technics there is the danger o f automatism and this could be physically and psychologically dam aging. Therefore the operator’s comfort, the elimination o f fatigue and the main tenance o f health must be a major con sideration in any time and motion study. For example, the dentist’s posture, oper ating as he does for hours at a time, demands careful consideration. In such consideration, careful engineering o f the physical operating room layout is para mount, as is the design and selection of the equipment he uses daily. T h e purpose o f this report is three fold: 1. T o eliminate waste time and mo tion at the chair. 2. T o describe a method leading to
ward improved patient and operator comfort. 3. T o apply basic principles to engi neering operatory layout and equipment design. MOTION AND TIME STUDY
M otion and time study deals with the scientific determination o f preferable work methods; the appraisal, in terms of time, o f the value o f work involving human activity, and the development of material required to make practical use o f these data.3 In any activity or occu pation, motion and time study can help to find a preferable way of doing the work. There usually are numerous ways to perform any task, but with the knowl edge obtainable at any one time, one method is usually superior to the others, and a scientific method3 o f solving prob lems is more productive o f better work methods than is undisciplined ingenuity. T h e scientific method o f solving prob lems involving the determination o f a preferred way o f doing a job requires the application o f a logical procedure con sisting o f the follow ing seven steps: 1. A im — establishing objective criteria fo r evaluating success. 2. Analysis— subdividing work steps pertinent to the job.
and into
3. Criticism •— application o f basic principles or check-lists to the analysis. 4. Innovation— formulation o f a new suggested procedure for performing work. 5. Test— testing, by means o f data used in Step 3, o f the desirability o f method formulated in Step 4, in respect to ob jectives in Step 1. 6. T rial— sample application o f method tested in Step 5, to check completeness of all variables to be taken into account. 7. Application— final standardization and installation o f improved work method. One very important factor must be considered in setting up any new plan—
84/346 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
PREFERRED WORK AREA
*
'
\\ \V
.O v \
,«
\
„«M i
/ sK f Il
^ is K f - A u L
V.
% \
'A
■S’
--------- > é---------------43" {----------------------- 6 4 -------------------------- 7 NORMAL WORK AREA
Fiq. I • Norm al and preferred work areas
the dentist himself. W hat is his philosophy o f the practice of dentistry? Does he limit his practice to any o f the special ized services? I f a dentist were to spe cialize in roentgenology, his office layout and equipment would be different from that required by a pedodontist. A perio dontist’s arrangement would not lend it self to an efficient practice o f prosthodontics, and so on. Does the dentist wish to render complete service, or is his phi losophy one o f “ patch and pull” ? His temperament— whether he has claustro phobic tendencies, or whether he dislikes additional personnel in the office— all these factors have a decided bearing on the layout and work patterns which would be most desirable fo r him. His physical dimensions are an important considera tion also. Studies o f normal work areas show the preferred areas for work re quiring visual direction, and for work with low visual requirements (Fig. 1). Placement o f instruments or operating equipment outside o f these areas results in gross bodily movements such as twist ing and turning o f the trunk or reaching. For easier and more efficient work pat terns, these motions should be avoided wherever possible. T h e use o f auxiliary personnel to bring things to within these preferred work areas increases the effi ciency o f operation and w ill be discussed in detail later. Types o f motions may
be classified into the following five groups: Class I — fingers only; Class I I — fingers and wrist; Class I I I — fingers, wrist and forearm ; Class IV-— full arm; Class V — gross bodily motion (turning, twisting, reaching). By decreasing the number and extent o f the Clas*s I V and V motions, the over-all activity is simplified and ease and efficiency are gained in any type of work. W ith the present design of dental operating equipment, storage and work cabinets, and the present ideas regarding use o f personnel, it is a practical impos sibility to reduce to any extent the great number o f Class I V and V motions that most dentists employ unless some changes are made in layout. T o make any intelli gent change the dentist should analyze his problem by referring to a check-list o f basic principles (see table). T o im prove the work method for any job, it may be necesssary to begin by introduc ing innovations or changes in any one of the follow ing areas that affect its per formance. These areas are: 1. Hand and body motions— the par ticular motions, their sequence, and the nature may be changed to ease or im prove the task. 2. Operating layout, or equipment— the design o f the room layout or equip ment used fo r any part o f the task may be modified. 3. Process or work sequence — the order in which the work is done may be changed to facilitate the flow o f work. 4. End product— may be m odified; however, no lowering o f quality or serv ice can be tolerated. 5. Character o f supplies or material— may require change in form, condition, or specification in order to be more easily utilized in the operation. W hat are practical steps that a dentist who wishes to act (change) may follow to achieve his goal? These might be the investigation and adaptation o f the fol lowing :
ANDERSON . . . VOLUME 60. MARCH I960 • 85/347
1. Instrument tray set-ups. 2. H igh speed operating where indi cated. 3. Washed field technics. 4. Properly designed equipment. 5. Properly engineered office layouts. 6. W ell trained auxiliary personnel. 7. Effective dentist-patient psychology. TRAY SET-U PS
Any plan o f treatment must include not only what must be done and how it is to be done, but also the sequence of operative procedures. N o treatment pro cedures should be undertaken until their sequence is analyzed and clearly under stood. A little time spent studying the effect o f one treatment procedure on the next w ill forestall wasted time and mo tion and prevent mistakes. Operating from prepared instrument tray set-ups is a proved time and tension saver for both the dentist and his assistants. When the dentist has analyzed his step-by-step procedures, it will be possible for him to standardize his routine so that the assistant may hand him the proper in
T a b le
Basic A. B. C. D.
strument in the proper sequence at the proper time, just because they are .laid out in the correct order on the tray. Th e dentist w ill then use this instrument on every tooth on which he is operating, after which it is returned to the assistant, and exchanged for the next instrument in the sequence. I f properly studied, and after much thought, it is possible to elim inate all but the essential instruments and to produce a smooth, continuous flow o f motion. HIGH SPEED
Th e use o f high speeds o f low torque is not new in other industries, particularly in the jewelry and stone cutting indus tries, but their use in dentistry has lagged. I t has been estimated that only five years ago, less than 5 per cent o f the dental profession was using increased handpiece speeds, whereas today most dentists are employing so-called “ high speeds” and modern instruments in some capacity. This sudden transition has pro duced a feeling o f confusion, indecision, and even bewilderment in the profession,
• Check-iist fo r analysis
principles Eliminate C o m b in e R ea rran ge Simplify
1. C a n a. b. c. d. e.
any As By By By By
step b e elim inated? u n n ecessary n ew equipm ent ch an gin g p la c e w h e r e it is d o n e ch an gin g o r d e r o f w ork ch an gin g end p r o d u c t
(Ask, (Ask, (Ask, (Ask, (Ask,
“ W hy “ W hy “ W hy “ W hy “ W hy
is is is is is
it d o n e ? ” ) p re se n t equipm ent u s e d ?") it d o n e t h e r e ? “ ) this d o n e in its presen t o r d e r ? ” ) it d o n e as it is?“ )
2. C a n an y step b e co m b in e d with a n o th e r? A r e th ere an y p o ss ib le c h a n g e s that w o u ld make this fe a s ib le in: a . W o r k p la c e (C h a n g e s in la y o u t? C h an gin g p la c e s w h e r e things a r e kept?) b. Equipment (N e w o r d ifferen t? C o u ld g ro u p in g b e b e tte r?) c . O r d e r o f steps (M o r e k n o w le d g e o n part o f w ork ers?) 3. C a n an y steps b e r e a r r a n g e d s o a s to make them an y sh orter o r e a s ie r ? a . Each step should h a v e an id e a l p la c e in s e q u e n c e (Ask, “ W h e r e ? 1') 4. C a n a n y step b e m ade ea sie r ? a . By leavin g o u t u n n ecessary o p e r a tio n s . b. C a n planning make co n tin u ou s activ ity at e a c h task p o s s ib le fo r a lo n g e r p e r io d o f time? c . W o u l d a redistribution o f w o rk a m on g the auxiliary p e rs o n n e l in c re a s e o v e r - a ll e ffe ctiv e n e ss?
86/348 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
for what appears to be a practical solu tion to problems today is obsolete to morrow. One wise researcher has stated that “ I f it works, it is already obsolete.” T h e dental profession is repeatedly guilty of accepting at face value new mate rials and new apparatus which commer cial interests proclaim with much fanfare as timesavers. Unfortunately, too little time is devoted to a mature evaluation of their merits. Without question, higher speed rotary instruments offer great advantages and contribute materially to increased oper ating efficiency. H owever, these advan tages must be considered carefully. Den tists must be aware that there are hazards as well as advantages to the use o f these new instruments. Dentistry’s goal is not merely the achieving o f speed in cutting tooth structure but should be an im proved dental service o f an increasingly higher quality, with attention directed toward the comfort o f the patient and toward the conservation o f time and energy for the operator. Any transition in operative procedures should be in stituted with extreme caution, and only be undertaken in the best interest of the patient. W ith high rotary speed instru ments, it is imperative that the new con cept be one o f thinking first, and then cutting, instead o f cutting and then think ing. I t would be questionable judgment, too, to make a change from 3,000 to 6,000 rpm to over 200,000 rpm without first mastering the use and control o f ro tary instruments at intermediate speeds.4 This report will not deal with specific instrumentation for rotary instruments using increased speeds, as this topic has been well covered in the literature by such renowned investigators as Ingraham and Tanner.5, 6 Thoughtful consideration, though, will reveal the necessity o f having a combination of equipment or equip ment sufficiently adaptable to provide speeds in the upper and lower ranges, without the disadvantage o f tedious ad justment and change. A low range of
speeds will probably always be necessary for excavating caries, and for certain re fining and finishing procedures. Th e ul tra-speed range (100,000 rpm and over) which is above the vibration perception range o f the patient, produces a very favorable response from the patient be cause o f the smoothness o f cut and the absence of the usual instrument pressures. It also enables the operator to use only a light “ feather-like” touch which re duces his digital fatigue, an important consideration in extensive reconstruction procedures.7 WASHED FIELD TECHNICS
Perhaps the reason the dental profession has been so slow in accepting the de parture from a routine established 50 years ago is that it requires the intro duction o f another principle— wet field operating (not a damp or moist field but one washed with copious amounts of liq u id ). It is unfortunate that some oper ative dentists continue to' carry on the debate o f wet field versus dry field and high speed versus slow speed. Th e advo cates o f dry field-slow speed w ill throw up the question, “ W hat is happening to the dental pulp with all this high speed?” T h e truth o f the matter is that less is happening to the pulp than happens when the tooth is desiccated under a rub ber dam and the dentin is over-heated with steel burs.8 During operative procedures, the re maining tooth structure should be pre served in the most favorable physiologic condition, with a minimum o f trauma. Th e majority o f the dental profession now recognizes that the application of a suitable coolant represents acceptable practice, and with ultra-high operating speeds, the use o f coolants is regarded as even more essential.9 There is no reason why dentists should not practice humane dental surgery on teeth, and follow simple biologic procedures which do not injure the dental pulp. Avoiding
ANDERSON . . . VOLUME 60, MARCH I960 • 87/349
pressures, heat and desiccation in re moving tooth structure during restorative procedures is only humane operating, and maintaining body temperatures o f dentin with a constant flow o f lubricant is a biologic concept beyond reproach, to say nothing of the fact that the lubricant also debrides the interspaces o f the cut ting tool, increasing its efficiency and diminishing its burnishing and dulling action. Recently, an important addition to the dental armamentarium has appeared which has become such an integral part o f the “ high speed” picture that it has changed many o f the ideas o f dental operating.10 This is a high velocity, low negative pressure, air-flow mechanism which can evacuate rapidly any amount o f water from the patient’s mouth that may be employed as a lubricant during rapid cutting o f tooth structure. It is generally conceded that it is much easier to operate by direct vision than by indirect mirror vision. T o be able to place the patient in such a position that the den tist may see directly to even the most pos terior portion o f the upper arch is a de cided advantage, and this is made possible by this evacuating mechanism. When in struments and other equipment are avail able to facilitate holding the patient’s head still throughout an entire operation, ideas concerning cabinet, chair, and equipment design and positioning must be changed. N o longer need the position o f the dental chair, cabinets, or instru ment tray be dictated by the cuspidor. As a matter o f fact, the cuspidor is fast becoming an unnecessary piece o f equip ment. W ith the need for the cuspidor largely eliminated, the chair assistant and the operator can be seated comfortably at the patient’s side, and achieve their potential as a true surgical team. AUXILIARY PERSONNEL
Mem o-m otion photography11 graphic ally shows the paramount importance of
locating equipment as close as possible to the area in which it is being used. Most manufacturers o f dental equipment will agree that the dental unit, as it is known today, has been designed to func tion most appropriately for the dentist who wishes to work standing and with out assistance. W hen the dental profession is con vinced o f the need for the economizing o f time, energy, and money, and of the greater service potential to be realized by the increased use o f assistants, then and then only will the dental assistants assume their place as an integral part o f a health service team. Also, when members o f the profession realize that almost 60 per cent o f the total available time o f a dentist who works alone is wasted, or is nonproductive of dental services,12 they will see that they must change their method o f operating to one of greater utilization of auxiliary per sonnel. Th e ratio of auxiliary personnel to dentist is an individual problem; this varies with the type o f practice and the personal philosophy o f the dentist. OPERATORY LAYOUT
Granting, then, that the use of dental auxiliary personnel is not only advan tageous but essential in the modern den tal practice, it now becomes necessary to reappraise the dental operatory layout and equipment design. Random sampling analyses13 and memo-motion photog raphy revealed the inefficient arrange ment o f the conventional operatory and the lack o f regard for motion patterns o f the dentist and his assistant. Violation o f work areas, excessive Class I V and V motions, and over-all gross activity are apparent immediately, all because instru ments, materials, and medicaments are not stored near the area o f the operation, which o f course is the patient’s head. Whether the dentist desires to rearrange cabinet storage areas so as to locate things nearer the operating area or
88/350 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
whether he prefers to have them brought to the area by auxiliary personnel at the proper time is a matter o f personal prefer ence so far as efficiency o f the actual operation is concerned. Dentists must, however, also be concerned with the saving of motion and energy and of time o f the auxiliary personnel as well as o f their own time, so it behooves them to locate the materials she will be using as close to her preferable work area as possible. An experimental layout utilizing these principles is shown in Figure 2 with instruments and cabinets located as close as possible to the work area. Cognizance was taken o f the fact that the room is occupied not only by the dentist but by two assistants— one chairside assistant, and one “ roving” or “ circulating” assist ant. Th e chairside assistant acts as an other pair of hands and eyes fo r the dentist, which is essential when full use is made of the washed field technics.10 Th e “ circulating” assistant prepares, or makes ready, and carries out all o f the other duties which are necessary in the operatory, such as loading hydrocolloid impression trays at the proper time, pour ing impressions, m ixing alloy or cements, and so on, and the cleaning o f the room in preparation for the next patient. She can also assist the dental hygienist in the duties which can be delegated such as processing roentgenograms, clean-up duties between patients, or even actually assisting at the hygienist’s chair during scaling and prophylaxis by using the Vacudent with a flushing stream o f iso thermic water. TRAFFIC PATTERNS
Attention was given traffic flow when laying out the operatory shown in Figure 2 so that no traffic patterns would be through the work area. Patients enter and go to the chair directly, and the traffic pattern o f the “ circulating assist ant” also is in a noncritical area. A ll of
the materials, medicaments and instru ments used by the assistants are placed on their side o f the chair and to the rear of the patient’s head. By using a “ sur gical team” technic o f having the assist ant give the surgeon the proper instru ment at the proper time and take it from him when he is finished with it, it is no longer necessary to have the bracket table as part o f the unit hover ing over and in front o f the patient’s face. Utilizing the tray set-up procedure as described makes this ideal a prac tical possibility, even with new, untrained assistants. T o o long dentists have been punish ing their legs and backs needlessly by working all day in a standing position beside the chair. N ow , with the advent of the washed field technics and Vacu dent, it is possible to work in a comfort able seated position and operate with full direct vision. T h e chairside assistant, as well as the dentist, should be seated, which permits the patient to recline in an almost horizontal position while the dentist is working on the upper arch. Th e conventional dental chair was not designed with this position in mind as a normal position, or one to be assumed for any length o f time, and, as anyone can attest, it becomes uncomfortable dur ing prolonged restorative procedures. TH E DENTAL CHAIR
An early experiment by the author several years ago14 in increasing patient comfort involved the redesigning and adaptation of a contour chair which gave complete support to the entire body, alleviating “ tail-bone” pressures and blood vessel pressures by raising and supporting the legs and feet. In this comfort-cradle posi tion the patient could relax completely, and this relaxation makes for a patient on whom it is easier to operate. T o pro mote this feeling o f relaxation further, a mild vibration o f the chair was pro vided. As successful as this chair was
ANDERSON . . . VOLUME 60, MARCH I960 • 89/351
from the patient’s viewpoint, it left some thing to be desired for the operator as far as adjustability o f the back and head area was concerned. It was felt that it would be advantageous to be able to recline the back area, independently of the seat area, and still give proper sup port to the entire back and neck. Further research and experimentation has been in progress, and now an im proved version o f this chair is commer
cially available (Fig. 3 ). Complete and independent adjustability o f the back and seat area through motorized controls en ables the dentist to place his patient in any position he desires for best access and visibility, with profound comfort for the patient at the same time. T h e bulk o f the chair is materially reduced which allows the operator to seat himself under the back and headrest area and place the patient’s head in the preferred work area.
TR A Y ST O RA G E M O B IL E C A B IN ET
O RY HEAT STERILIZER SP O T WELDER A N D S O L D E R IN G M A C H IN E
A S S IS T A N T 'S S I N K WITH F O O T PED ALS
DRAWER FO R PLIERS
P O L IS H IN G LATHE IN ST R U M E N T SH ARPENER DRAWER FOR M E D IC A M E N T S A N D RESTO RATIVE M ATERIALS! DRAWER FO R PRO STHETIC M A T E R IA L S
B U N S E N BURNER
L A BO RA TO R Y V A C U D E N T B U N S E N BURNER
H Y D R O C O L L O ID C O N D IT IO N E R
D O C T O R 'S S I N K WITH F O O T PED ALS
C A B IN E T H O U S IN G FO R V A C U D E N T FILTER SY STE M R A O IO SU R G A IR TURBINE LUBRICATO R HO T WATER HEATER AIR A N D WATER SY R IN G E S SL O W SPEED M O T O R TH ERM EX C O N T R O L S
“C O N T O U R TYPE“ C H AIR
S T O R A G E FOR D IA G N O S T IC M O D E L S DENTURE TEETH TO W ELS H Y D R O C O L L O ID ETC .
V A C U U M PUMP
F iq.
2
• Experimental layout for operatory
90/352 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
Fig. 3 • Im proved version of dental chair
TIIE
D E N T A L
UNIT
Suspending the extraoral operating lights from the ceiling and concealing the den tal engine and handpiece in a cabinet on the wall, as well as eliminating the need for a cuspidor and bracket table, has eliminated the need for the conven tional dental unit. A compromise was the installation and use of a “ unette” to provide a water source for cooling hydro colloid impressions and a cuspidor for the occasional use o f those habit-condi tioned patients who absolutely must empty their own mouths. A fter several years of operating with this equipment layout, it was obvious that the number of times the cuspidor was needed were so few, that it could be eliminated com pletely, especially with the introduction of the “ Vacu-cup,” an accessory to the Vacudent (Fig. 4 ). Soft colors and soothing music, as well as the elimination of “ fearsome” dental equipment, and the elimination o f pain through use o f anesthetics and humane dental procedures, have a wonderful psychic effect on the patient and promote confidence in the dentist and his methods of operating. PRACTICE
ADMINISTRATION
A fter dentists have considered efficiency in restorative procedures, and designed
Fig. 4
• Position of Vacu-cup
their offices to permit them to render an improved service to more comfortable patients, they are capable o f rendering a better health service to more people in a shorter period o f time. It therefore becomes most imperative that attention be directed toward the principles of sound practice management. I f patients do not want what dentists have to offer, of what avail is all of the foregoing preparation? It is impossible to separate good dentistry from good practice admin istration; they go hand in hand. Th e importance of a complete examination, diagnosis, and treatment planning can not be over-stressed, with attention di rected toward education o f the patient to understand his problem, and to want and appreciate the necessary dental treat ment; so much so, that he will become a missionary for good, thorough, com plete dentistry. S U M M A R Y
Th e scientific method requires the appli cation of a logical procedure which con sists of the following steps: 1. Th e appraisal and comparison of individual work methods with preferable work methods. 2. Proper sequence of operational pro cedures. 3. The individual need for and usage of :
ANDERSON
a. b. c. d. e.
Tray set-ups. H igh speed where indicated. Washed field technics. Properly designed equipment. Properly engineered office lay outs. f . W ell trained auxiliary personnel. g. Effective dentist-patient rela tions. In conclusion, what will the elimina tion o f waste time and motion at the chair and changes in office surroundings that are conducive to comfort and effi ciency do for the dentist? 1. H e will be able to increase his pro duction and the quality o f service with less fatigue and tension for himself and his patients. 2. , H e will be able to reduce the unit cost o f dentistry to his patients. 3. H e can capitalize on the fact that efficient people are invariably happy peo ple, and that efficient offices invariably attract the best patients. 4. By answering the public dental problem with better dentistry, faster, and for more people, with reasonable fees, the profession can be protected against
.VOLUME 60, MARCH I960 • 91/353
the inroads of socialism, and dentists can enjoy the benefits that follow the pleasure and pride o f rendering capable profes sional services. 2 7 58 W est F oster A v e n u e 1. Moen, B. D. Population growth and dental man power. J.A .D .A . 56:780 June 1958. 2. Friedrich, R. H. Dental practice during next ten years. J.A .D .A . 56:795 June 1958. 3. Mundel, M. E. M otion and tim e study, ed. 2. New York, Prentice-Hall, Inc., 1955. 4. Ingraham, Rex. Report o f C om m ittee on Scientific Investigation of Am erican Academy of Restorative Den tistry. Part I lk an evaluation of recent progress^ in field of increased speeds and modern instrument design J. Pros. Den. 7:833 Nov. 1957. 5. Ingraham, Rex, and Tanner, H. M. A d aptation of modern instruments and increased operating speeds to restorative procedures. J.A .D .A . 47:311 Sept. 1953. 6. Tanner, H. M. Greater efficiency through modern instruments and higher speeds. Ann. Den. 15:34 June 1956. - 7. H artley, J. L. C om parative evaluation of newer devices and techniques fo r removal of tooth structure. J. Pros. Den. 8:170 Jan. 1958. 8. Robinson, H. B. G. Pu I pat effects of operative dentistry. J. Pros. Den. 7:282 March 1957. 9. Peyton, F. A . Effectiveness of water coolants with rotary cutting instruments. J.A .D .A . 56:664 May 1958. 10. Thompson, E. O. C lin ica l application o f washed field technic in dentistry. J.A .D .A . 51:703 Dec. 1955. 11. Mundel, M. E. Uses o f motion pictures fo r estab lishing motion times. Proceedings llth annual tim e and motion study clinic. Industrial Management Society, Chicago, 1947. 12. Hoffman, D. A. Time and motion study in den tistry. Bui. G reater Milwaukee D.A. 23:101 July 1957. 13. Morrow, R. L. Time study and motion economy. New York, Morrow Press, 1946. 14. Anderson, J. A . Efficient operative procedures performed in a washed fie ld . Unpublished.
On Education • The idea of what is true merit should also be often presented to youth, explain’d and impressed on their minds, as consisting in an inclination joined with an ability to serve mankind, one’s country, friends and family; which ability is (with the blessing of God) to be acquir’d or greatly encreased by true learning; and should indeed be the great aim and end of all learning. Benjamin Franklin, Proposals Relating to the Education of Youth in Pennsylvania, 1749.
much. Whether painting or cleaning, care should be taken to see that the open ings on the tile remain unclogged. SUM M ARY
Acoustical materials are highly functional and decorative, are available in a variety of materials and designs, and require no involved processes or expensive equip
D e n ta l
ment for installation or maintenance. If it is agreed that an attractive, quiet en vironment is desirable for dental offices, it will be found that sound conditioning will do much to achieve that end. 335 East Forty-fifth Street
Illu s tra tio n s courtesy o f A rm s tro n g C o rk C o . ‘ President, A c o u s tic a l M a te ria ls A sso ciation .
o ffic e
d e sig n
a n d
la y o u t
John A. Anderson, D.D.S., Chicago
Better dentistry— faster and easier—is the challenge of today. Increasing produc tion without increasing the unit cost to the patient is a realistic and modern approach. Optimum dental health for the many must be achieved with com fort, efficiency, economy and satisfaction to the patient. Equally important, m od ern dentistry must be performed in such a fashion as to minimize fatigue and reduce the health hazards of the dental operator. Eliminating waste time and motion is a fascinating problem, more so with the advent of dynamic changes in modern dental operative procedures. T he greater efficiency of instruments has relegated cavity preparation— the once tedious task of restorative dentistry— to a fractional part of dental procedure time requirements. O f equal importance is the elimination of waste time and motion in all phases of dental care. Why should dentists exclude themselves from
the many advantages to be found in increased efficiency? Why must the dental profession con cern itself with increased production through greater efficiency? Unprece dented population growth, plus a more dental health conscious public, require increased production facilities. The num ber of dental graduates is not sufficient to maintain a proper population-dentist ratio.1 T he dental profession has the dual responsibility of developing its own par ticular competence according to the high est standards and of adapting that com petence to the needs and demands of the people. T he profession has met this first responsibility through progressive and scientific efforts to improve the qual ity of dental care. It is meeting its second responsibility through an effective dental health education program .2 Until the last decade, if dentists wished to serve more patients, it was necessary
ANDERSON . . .VOLUME 60, MARCH I960 • 83/345
to work longer hours to do so. Today, thanks to high-speed cutting technics, washed field procedures, organized rou tines, new impression methods, controlled casting technics, and trained auxiliary help, mouths can be restored to function much more rapidly. M any hours of chair time have been eliminated fo r both oper ator and patient. W hen a dentist treats a patient, he not only treats his physical condition, but must be concerned with his psychological welfare as well. T h e proper psychological approach is important in order to pro vide pleasant, rather than disruptive, emotional experiences for the patient. Inefficient operative procedures are not only annoying to the patient but usually result in increased discomfort, either dur ing the operation because o f unnecessary delays, or postoperatively because of mis handling o f mouth tissues. Most people do not regard having dental work done as a particularly pleasurable experience, and anything that improves their com fort, physical and psychic, during this experience is an important contribution to better patient-dentist relationships, and the production of an increased amount o f dental services. In developing methods fo r greater effi ciency in operative technics there is the danger o f automatism and this could be physically and psychologically dam aging. Therefore the operator’s comfort, the elimination o f fatigue and the main tenance o f health must be a major con sideration in any time and motion study. For example, the dentist’s posture, oper ating as he does for hours at a time, demands careful consideration. In such consideration, careful engineering o f the physical operating room layout is para mount, as is the design and selection of the equipment he uses daily. T h e purpose o f this report is three fold: 1. T o eliminate waste time and mo tion at the chair. 2. T o describe a method leading to
ward improved patient and operator comfort. 3. T o apply basic principles to engi neering operatory layout and equipment design. MOTION AND TIME STUDY
M otion and time study deals with the scientific determination o f preferable work methods; the appraisal, in terms of time, o f the value o f work involving human activity, and the development of material required to make practical use o f these data.3 In any activity or occu pation, motion and time study can help to find a preferable way of doing the work. There usually are numerous ways to perform any task, but with the knowl edge obtainable at any one time, one method is usually superior to the others, and a scientific method3 o f solving prob lems is more productive o f better work methods than is undisciplined ingenuity. T h e scientific method o f solving prob lems involving the determination o f a preferred way o f doing a job requires the application o f a logical procedure con sisting o f the follow ing seven steps: 1. A im — establishing objective criteria fo r evaluating success. 2. Analysis— subdividing work steps pertinent to the job.
and into
3. Criticism •— application o f basic principles or check-lists to the analysis. 4. Innovation— formulation o f a new suggested procedure for performing work. 5. Test— testing, by means o f data used in Step 3, o f the desirability o f method formulated in Step 4, in respect to ob jectives in Step 1. 6. T rial— sample application o f method tested in Step 5, to check completeness of all variables to be taken into account. 7. Application— final standardization and installation o f improved work method. One very important factor must be considered in setting up any new plan—
84/346 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
PREFERRED WORK AREA
*
'
\\ \V
.O v \
,«
\
„«M i
/ sK f Il
^ is K f - A u L
V.
% \
'A
■S’
--------- > é---------------43" {----------------------- 6 4 -------------------------- 7 NORMAL WORK AREA
Fiq. I • Norm al and preferred work areas
the dentist himself. W hat is his philosophy o f the practice of dentistry? Does he limit his practice to any o f the special ized services? I f a dentist were to spe cialize in roentgenology, his office layout and equipment would be different from that required by a pedodontist. A perio dontist’s arrangement would not lend it self to an efficient practice o f prosthodontics, and so on. Does the dentist wish to render complete service, or is his phi losophy one o f “ patch and pull” ? His temperament— whether he has claustro phobic tendencies, or whether he dislikes additional personnel in the office— all these factors have a decided bearing on the layout and work patterns which would be most desirable fo r him. His physical dimensions are an important considera tion also. Studies o f normal work areas show the preferred areas for work re quiring visual direction, and for work with low visual requirements (Fig. 1). Placement o f instruments or operating equipment outside o f these areas results in gross bodily movements such as twist ing and turning o f the trunk or reaching. For easier and more efficient work pat terns, these motions should be avoided wherever possible. T h e use o f auxiliary personnel to bring things to within these preferred work areas increases the effi ciency o f operation and w ill be discussed in detail later. Types o f motions may
be classified into the following five groups: Class I — fingers only; Class I I — fingers and wrist; Class I I I — fingers, wrist and forearm ; Class IV-— full arm; Class V — gross bodily motion (turning, twisting, reaching). By decreasing the number and extent o f the Clas*s I V and V motions, the over-all activity is simplified and ease and efficiency are gained in any type of work. W ith the present design of dental operating equipment, storage and work cabinets, and the present ideas regarding use o f personnel, it is a practical impos sibility to reduce to any extent the great number o f Class I V and V motions that most dentists employ unless some changes are made in layout. T o make any intelli gent change the dentist should analyze his problem by referring to a check-list o f basic principles (see table). T o im prove the work method for any job, it may be necesssary to begin by introduc ing innovations or changes in any one of the follow ing areas that affect its per formance. These areas are: 1. Hand and body motions— the par ticular motions, their sequence, and the nature may be changed to ease or im prove the task. 2. Operating layout, or equipment— the design o f the room layout or equip ment used fo r any part o f the task may be modified. 3. Process or work sequence — the order in which the work is done may be changed to facilitate the flow o f work. 4. End product— may be m odified; however, no lowering o f quality or serv ice can be tolerated. 5. Character o f supplies or material— may require change in form, condition, or specification in order to be more easily utilized in the operation. W hat are practical steps that a dentist who wishes to act (change) may follow to achieve his goal? These might be the investigation and adaptation o f the fol lowing :
ANDERSON . . . VOLUME 60. MARCH I960 • 85/347
1. Instrument tray set-ups. 2. H igh speed operating where indi cated. 3. Washed field technics. 4. Properly designed equipment. 5. Properly engineered office layouts. 6. W ell trained auxiliary personnel. 7. Effective dentist-patient psychology. TRAY SET-U PS
Any plan o f treatment must include not only what must be done and how it is to be done, but also the sequence of operative procedures. N o treatment pro cedures should be undertaken until their sequence is analyzed and clearly under stood. A little time spent studying the effect o f one treatment procedure on the next w ill forestall wasted time and mo tion and prevent mistakes. Operating from prepared instrument tray set-ups is a proved time and tension saver for both the dentist and his assistants. When the dentist has analyzed his step-by-step procedures, it will be possible for him to standardize his routine so that the assistant may hand him the proper in
T a b le
Basic A. B. C. D.
strument in the proper sequence at the proper time, just because they are .laid out in the correct order on the tray. Th e dentist w ill then use this instrument on every tooth on which he is operating, after which it is returned to the assistant, and exchanged for the next instrument in the sequence. I f properly studied, and after much thought, it is possible to elim inate all but the essential instruments and to produce a smooth, continuous flow o f motion. HIGH SPEED
Th e use o f high speeds o f low torque is not new in other industries, particularly in the jewelry and stone cutting indus tries, but their use in dentistry has lagged. I t has been estimated that only five years ago, less than 5 per cent o f the dental profession was using increased handpiece speeds, whereas today most dentists are employing so-called “ high speeds” and modern instruments in some capacity. This sudden transition has pro duced a feeling o f confusion, indecision, and even bewilderment in the profession,
• Check-iist fo r analysis
principles Eliminate C o m b in e R ea rran ge Simplify
1. C a n a. b. c. d. e.
any As By By By By
step b e elim inated? u n n ecessary n ew equipm ent ch an gin g p la c e w h e r e it is d o n e ch an gin g o r d e r o f w ork ch an gin g end p r o d u c t
(Ask, (Ask, (Ask, (Ask, (Ask,
“ W hy “ W hy “ W hy “ W hy “ W hy
is is is is is
it d o n e ? ” ) p re se n t equipm ent u s e d ?") it d o n e t h e r e ? “ ) this d o n e in its presen t o r d e r ? ” ) it d o n e as it is?“ )
2. C a n an y step b e co m b in e d with a n o th e r? A r e th ere an y p o ss ib le c h a n g e s that w o u ld make this fe a s ib le in: a . W o r k p la c e (C h a n g e s in la y o u t? C h an gin g p la c e s w h e r e things a r e kept?) b. Equipment (N e w o r d ifferen t? C o u ld g ro u p in g b e b e tte r?) c . O r d e r o f steps (M o r e k n o w le d g e o n part o f w ork ers?) 3. C a n an y steps b e r e a r r a n g e d s o a s to make them an y sh orter o r e a s ie r ? a . Each step should h a v e an id e a l p la c e in s e q u e n c e (Ask, “ W h e r e ? 1') 4. C a n a n y step b e m ade ea sie r ? a . By leavin g o u t u n n ecessary o p e r a tio n s . b. C a n planning make co n tin u ou s activ ity at e a c h task p o s s ib le fo r a lo n g e r p e r io d o f time? c . W o u l d a redistribution o f w o rk a m on g the auxiliary p e rs o n n e l in c re a s e o v e r - a ll e ffe ctiv e n e ss?
86/348 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
for what appears to be a practical solu tion to problems today is obsolete to morrow. One wise researcher has stated that “ I f it works, it is already obsolete.” T h e dental profession is repeatedly guilty of accepting at face value new mate rials and new apparatus which commer cial interests proclaim with much fanfare as timesavers. Unfortunately, too little time is devoted to a mature evaluation of their merits. Without question, higher speed rotary instruments offer great advantages and contribute materially to increased oper ating efficiency. H owever, these advan tages must be considered carefully. Den tists must be aware that there are hazards as well as advantages to the use o f these new instruments. Dentistry’s goal is not merely the achieving o f speed in cutting tooth structure but should be an im proved dental service o f an increasingly higher quality, with attention directed toward the comfort o f the patient and toward the conservation o f time and energy for the operator. Any transition in operative procedures should be in stituted with extreme caution, and only be undertaken in the best interest of the patient. W ith high rotary speed instru ments, it is imperative that the new con cept be one o f thinking first, and then cutting, instead o f cutting and then think ing. I t would be questionable judgment, too, to make a change from 3,000 to 6,000 rpm to over 200,000 rpm without first mastering the use and control o f ro tary instruments at intermediate speeds.4 This report will not deal with specific instrumentation for rotary instruments using increased speeds, as this topic has been well covered in the literature by such renowned investigators as Ingraham and Tanner.5, 6 Thoughtful consideration, though, will reveal the necessity o f having a combination of equipment or equip ment sufficiently adaptable to provide speeds in the upper and lower ranges, without the disadvantage o f tedious ad justment and change. A low range of
speeds will probably always be necessary for excavating caries, and for certain re fining and finishing procedures. Th e ul tra-speed range (100,000 rpm and over) which is above the vibration perception range o f the patient, produces a very favorable response from the patient be cause o f the smoothness o f cut and the absence of the usual instrument pressures. It also enables the operator to use only a light “ feather-like” touch which re duces his digital fatigue, an important consideration in extensive reconstruction procedures.7 WASHED FIELD TECHNICS
Perhaps the reason the dental profession has been so slow in accepting the de parture from a routine established 50 years ago is that it requires the intro duction o f another principle— wet field operating (not a damp or moist field but one washed with copious amounts of liq u id ). It is unfortunate that some oper ative dentists continue to' carry on the debate o f wet field versus dry field and high speed versus slow speed. Th e advo cates o f dry field-slow speed w ill throw up the question, “ W hat is happening to the dental pulp with all this high speed?” T h e truth o f the matter is that less is happening to the pulp than happens when the tooth is desiccated under a rub ber dam and the dentin is over-heated with steel burs.8 During operative procedures, the re maining tooth structure should be pre served in the most favorable physiologic condition, with a minimum o f trauma. Th e majority o f the dental profession now recognizes that the application of a suitable coolant represents acceptable practice, and with ultra-high operating speeds, the use o f coolants is regarded as even more essential.9 There is no reason why dentists should not practice humane dental surgery on teeth, and follow simple biologic procedures which do not injure the dental pulp. Avoiding
ANDERSON . . . VOLUME 60, MARCH I960 • 87/349
pressures, heat and desiccation in re moving tooth structure during restorative procedures is only humane operating, and maintaining body temperatures o f dentin with a constant flow o f lubricant is a biologic concept beyond reproach, to say nothing of the fact that the lubricant also debrides the interspaces o f the cut ting tool, increasing its efficiency and diminishing its burnishing and dulling action. Recently, an important addition to the dental armamentarium has appeared which has become such an integral part o f the “ high speed” picture that it has changed many o f the ideas o f dental operating.10 This is a high velocity, low negative pressure, air-flow mechanism which can evacuate rapidly any amount o f water from the patient’s mouth that may be employed as a lubricant during rapid cutting o f tooth structure. It is generally conceded that it is much easier to operate by direct vision than by indirect mirror vision. T o be able to place the patient in such a position that the den tist may see directly to even the most pos terior portion o f the upper arch is a de cided advantage, and this is made possible by this evacuating mechanism. When in struments and other equipment are avail able to facilitate holding the patient’s head still throughout an entire operation, ideas concerning cabinet, chair, and equipment design and positioning must be changed. N o longer need the position o f the dental chair, cabinets, or instru ment tray be dictated by the cuspidor. As a matter o f fact, the cuspidor is fast becoming an unnecessary piece o f equip ment. W ith the need for the cuspidor largely eliminated, the chair assistant and the operator can be seated comfortably at the patient’s side, and achieve their potential as a true surgical team. AUXILIARY PERSONNEL
Mem o-m otion photography11 graphic ally shows the paramount importance of
locating equipment as close as possible to the area in which it is being used. Most manufacturers o f dental equipment will agree that the dental unit, as it is known today, has been designed to func tion most appropriately for the dentist who wishes to work standing and with out assistance. W hen the dental profession is con vinced o f the need for the economizing o f time, energy, and money, and of the greater service potential to be realized by the increased use o f assistants, then and then only will the dental assistants assume their place as an integral part o f a health service team. Also, when members o f the profession realize that almost 60 per cent o f the total available time o f a dentist who works alone is wasted, or is nonproductive of dental services,12 they will see that they must change their method o f operating to one of greater utilization of auxiliary per sonnel. Th e ratio of auxiliary personnel to dentist is an individual problem; this varies with the type o f practice and the personal philosophy o f the dentist. OPERATORY LAYOUT
Granting, then, that the use of dental auxiliary personnel is not only advan tageous but essential in the modern den tal practice, it now becomes necessary to reappraise the dental operatory layout and equipment design. Random sampling analyses13 and memo-motion photog raphy revealed the inefficient arrange ment o f the conventional operatory and the lack o f regard for motion patterns o f the dentist and his assistant. Violation o f work areas, excessive Class I V and V motions, and over-all gross activity are apparent immediately, all because instru ments, materials, and medicaments are not stored near the area o f the operation, which o f course is the patient’s head. Whether the dentist desires to rearrange cabinet storage areas so as to locate things nearer the operating area or
88/350 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
whether he prefers to have them brought to the area by auxiliary personnel at the proper time is a matter o f personal prefer ence so far as efficiency o f the actual operation is concerned. Dentists must, however, also be concerned with the saving of motion and energy and of time o f the auxiliary personnel as well as o f their own time, so it behooves them to locate the materials she will be using as close to her preferable work area as possible. An experimental layout utilizing these principles is shown in Figure 2 with instruments and cabinets located as close as possible to the work area. Cognizance was taken o f the fact that the room is occupied not only by the dentist but by two assistants— one chairside assistant, and one “ roving” or “ circulating” assist ant. Th e chairside assistant acts as an other pair of hands and eyes fo r the dentist, which is essential when full use is made of the washed field technics.10 Th e “ circulating” assistant prepares, or makes ready, and carries out all o f the other duties which are necessary in the operatory, such as loading hydrocolloid impression trays at the proper time, pour ing impressions, m ixing alloy or cements, and so on, and the cleaning o f the room in preparation for the next patient. She can also assist the dental hygienist in the duties which can be delegated such as processing roentgenograms, clean-up duties between patients, or even actually assisting at the hygienist’s chair during scaling and prophylaxis by using the Vacudent with a flushing stream o f iso thermic water. TRAFFIC PATTERNS
Attention was given traffic flow when laying out the operatory shown in Figure 2 so that no traffic patterns would be through the work area. Patients enter and go to the chair directly, and the traffic pattern o f the “ circulating assist ant” also is in a noncritical area. A ll of
the materials, medicaments and instru ments used by the assistants are placed on their side o f the chair and to the rear of the patient’s head. By using a “ sur gical team” technic o f having the assist ant give the surgeon the proper instru ment at the proper time and take it from him when he is finished with it, it is no longer necessary to have the bracket table as part o f the unit hover ing over and in front o f the patient’s face. Utilizing the tray set-up procedure as described makes this ideal a prac tical possibility, even with new, untrained assistants. T o o long dentists have been punish ing their legs and backs needlessly by working all day in a standing position beside the chair. N ow , with the advent of the washed field technics and Vacu dent, it is possible to work in a comfort able seated position and operate with full direct vision. T h e chairside assistant, as well as the dentist, should be seated, which permits the patient to recline in an almost horizontal position while the dentist is working on the upper arch. Th e conventional dental chair was not designed with this position in mind as a normal position, or one to be assumed for any length o f time, and, as anyone can attest, it becomes uncomfortable dur ing prolonged restorative procedures. TH E DENTAL CHAIR
An early experiment by the author several years ago14 in increasing patient comfort involved the redesigning and adaptation of a contour chair which gave complete support to the entire body, alleviating “ tail-bone” pressures and blood vessel pressures by raising and supporting the legs and feet. In this comfort-cradle posi tion the patient could relax completely, and this relaxation makes for a patient on whom it is easier to operate. T o pro mote this feeling o f relaxation further, a mild vibration o f the chair was pro vided. As successful as this chair was
ANDERSON . . . VOLUME 60, MARCH I960 • 89/351
from the patient’s viewpoint, it left some thing to be desired for the operator as far as adjustability o f the back and head area was concerned. It was felt that it would be advantageous to be able to recline the back area, independently of the seat area, and still give proper sup port to the entire back and neck. Further research and experimentation has been in progress, and now an im proved version o f this chair is commer
cially available (Fig. 3 ). Complete and independent adjustability o f the back and seat area through motorized controls en ables the dentist to place his patient in any position he desires for best access and visibility, with profound comfort for the patient at the same time. T h e bulk o f the chair is materially reduced which allows the operator to seat himself under the back and headrest area and place the patient’s head in the preferred work area.
TR A Y ST O RA G E M O B IL E C A B IN ET
O RY HEAT STERILIZER SP O T WELDER A N D S O L D E R IN G M A C H IN E
A S S IS T A N T 'S S I N K WITH F O O T PED ALS
DRAWER FO R PLIERS
P O L IS H IN G LATHE IN ST R U M E N T SH ARPENER DRAWER FOR M E D IC A M E N T S A N D RESTO RATIVE M ATERIALS! DRAWER FO R PRO STHETIC M A T E R IA L S
B U N S E N BURNER
L A BO RA TO R Y V A C U D E N T B U N S E N BURNER
H Y D R O C O L L O ID C O N D IT IO N E R
D O C T O R 'S S I N K WITH F O O T PED ALS
C A B IN E T H O U S IN G FO R V A C U D E N T FILTER SY STE M R A O IO SU R G A IR TURBINE LUBRICATO R HO T WATER HEATER AIR A N D WATER SY R IN G E S SL O W SPEED M O T O R TH ERM EX C O N T R O L S
“C O N T O U R TYPE“ C H AIR
S T O R A G E FOR D IA G N O S T IC M O D E L S DENTURE TEETH TO W ELS H Y D R O C O L L O ID ETC .
V A C U U M PUMP
F iq.
2
• Experimental layout for operatory
90/352 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
Fig. 3 • Im proved version of dental chair
TIIE
D E N T A L
UNIT
Suspending the extraoral operating lights from the ceiling and concealing the den tal engine and handpiece in a cabinet on the wall, as well as eliminating the need for a cuspidor and bracket table, has eliminated the need for the conven tional dental unit. A compromise was the installation and use of a “ unette” to provide a water source for cooling hydro colloid impressions and a cuspidor for the occasional use o f those habit-condi tioned patients who absolutely must empty their own mouths. A fter several years of operating with this equipment layout, it was obvious that the number of times the cuspidor was needed were so few, that it could be eliminated com pletely, especially with the introduction of the “ Vacu-cup,” an accessory to the Vacudent (Fig. 4 ). Soft colors and soothing music, as well as the elimination of “ fearsome” dental equipment, and the elimination o f pain through use o f anesthetics and humane dental procedures, have a wonderful psychic effect on the patient and promote confidence in the dentist and his methods of operating. PRACTICE
ADMINISTRATION
A fter dentists have considered efficiency in restorative procedures, and designed
Fig. 4
• Position of Vacu-cup
their offices to permit them to render an improved service to more comfortable patients, they are capable o f rendering a better health service to more people in a shorter period o f time. It therefore becomes most imperative that attention be directed toward the principles of sound practice management. I f patients do not want what dentists have to offer, of what avail is all of the foregoing preparation? It is impossible to separate good dentistry from good practice admin istration; they go hand in hand. Th e importance of a complete examination, diagnosis, and treatment planning can not be over-stressed, with attention di rected toward education o f the patient to understand his problem, and to want and appreciate the necessary dental treat ment; so much so, that he will become a missionary for good, thorough, com plete dentistry. S U M M A R Y
Th e scientific method requires the appli cation of a logical procedure which con sists of the following steps: 1. Th e appraisal and comparison of individual work methods with preferable work methods. 2. Proper sequence of operational pro cedures. 3. The individual need for and usage of :
ANDERSON
a. b. c. d. e.
Tray set-ups. H igh speed where indicated. Washed field technics. Properly designed equipment. Properly engineered office lay outs. f . W ell trained auxiliary personnel. g. Effective dentist-patient rela tions. In conclusion, what will the elimina tion o f waste time and motion at the chair and changes in office surroundings that are conducive to comfort and effi ciency do for the dentist? 1. H e will be able to increase his pro duction and the quality o f service with less fatigue and tension for himself and his patients. 2. , H e will be able to reduce the unit cost o f dentistry to his patients. 3. H e can capitalize on the fact that efficient people are invariably happy peo ple, and that efficient offices invariably attract the best patients. 4. By answering the public dental problem with better dentistry, faster, and for more people, with reasonable fees, the profession can be protected against
.VOLUME 60, MARCH I960 • 91/353
the inroads of socialism, and dentists can enjoy the benefits that follow the pleasure and pride o f rendering capable profes sional services. 2 7 58 W est F oster A v e n u e 1. Moen, B. D. Population growth and dental man power. J.A .D .A . 56:780 June 1958. 2. Friedrich, R. H. Dental practice during next ten years. J.A .D .A . 56:795 June 1958. 3. Mundel, M. E. M otion and tim e study, ed. 2. New York, Prentice-Hall, Inc., 1955. 4. Ingraham, Rex. Report o f C om m ittee on Scientific Investigation of Am erican Academy of Restorative Den tistry. Part I lk an evaluation of recent progress^ in field of increased speeds and modern instrument design J. Pros. Den. 7:833 Nov. 1957. 5. Ingraham, Rex, and Tanner, H. M. A d aptation of modern instruments and increased operating speeds to restorative procedures. J.A .D .A . 47:311 Sept. 1953. 6. Tanner, H. M. Greater efficiency through modern instruments and higher speeds. Ann. Den. 15:34 June 1956. - 7. H artley, J. L. C om parative evaluation of newer devices and techniques fo r removal of tooth structure. J. Pros. Den. 8:170 Jan. 1958. 8. Robinson, H. B. G. Pu I pat effects of operative dentistry. J. Pros. Den. 7:282 March 1957. 9. Peyton, F. A . Effectiveness of water coolants with rotary cutting instruments. J.A .D .A . 56:664 May 1958. 10. Thompson, E. O. C lin ica l application o f washed field technic in dentistry. J.A .D .A . 51:703 Dec. 1955. 11. Mundel, M. E. Uses o f motion pictures fo r estab lishing motion times. Proceedings llth annual tim e and motion study clinic. Industrial Management Society, Chicago, 1947. 12. Hoffman, D. A. Time and motion study in den tistry. Bui. G reater Milwaukee D.A. 23:101 July 1957. 13. Morrow, R. L. Time study and motion economy. New York, Morrow Press, 1946. 14. Anderson, J. A . Efficient operative procedures performed in a washed fie ld . Unpublished.
On Education • The idea of what is true merit should also be often presented to youth, explain’d and impressed on their minds, as consisting in an inclination joined with an ability to serve mankind, one’s country, friends and family; which ability is (with the blessing of God) to be acquir’d or greatly encreased by true learning; and should indeed be the great aim and end of all learning. Benjamin Franklin, Proposals Relating to the Education of Youth in Pennsylvania, 1749.