Systems for Clinical Efficiency

Corporate management gurus spend a great deal of time talking and writing about continuous process improvement, or CPI.

Corporate management gurus spend a great deal of time talking and writing about continuous process improvement, or CPI. The Japanese call it “kaizen.” It is a system involving an entire organization, and its purpose is to make things better. This concept is one that has tremendous applicability to dentistry, since many of our procedures are repetitious and easily evaluated for inefficiencies or opportunities for improvement. You might wonder how to get started with CPI. Begin by asking yourself how efficient you are in the tasks you perform every day. Do the tasks cause you stress? Does the way you perform these tasks help or hinder productivity? Are your team members consistently looking for ways to improve the systems, enhance productivity, and improve patient care? Process improvement should become a management system and will initially take time to implement. Investing your time in this process, however, will be a worthwhile effort.

The keys to implementing any systems or processes in a practice are excellent communications, and scheduling the time to assess, discuss, and refine the systems. Scheduling time for team meetings is critical to implementation of CPI and to the growth of the practice. Make a commitment to meet for several hours weekly or monthly, depending on the amount of work that needs to be done to organize your practice. You may need to meet more frequently in the beginning. Later, as you become more organized, the frequency can be decreased. The investment in time will pay huge dividends to the practice in the form of decreased stress and increased production. When conducting team meetings, here are some key systems to evaluate:

Instrument management Managing instruments in the safest, most efficient manner is a key element in productive days, since patient treatment is so heavily dependent upon instruments. In my experience as a clinician and a consultant, I have found that instrument cassettes are by far the best method of organizing instruments and setups. There are a variety of cassettes available, in sizes and materials to accommodate virtually any type of practice. These cassettes hold all of the instruments needed for a specific procedure and serve as the delivery system during treatment, the transport system to the sterilization area after treatment, and the means of keeping instruments together and protected during cleaning and sterilization. The time that the clinical team spends handling individual instruments during cleaning and preparation is greatly reduced and safety is enhanced, since the sharp, contaminated ends of the instruments are enclosed in the cassette. A practice can realize a return on its investment in the instrument cassettes within a very short time. Instead of spending time handling individual instruments for cleaning, and then sorting and placing individual instruments into packages for sterilization, the clinical team handles only one cassette per procedure. The time saved can be more productively spent with patients.

Instrument management systems to consider are: IMS cassettes from Hu-Friedy, Steri-System cassettes from Dux Dental, Instrument Delivery Cassettes from L&R Manufacturing, and Compact Cassettes and Steri-Containers from Zirc.

Materials management Organizing materials is just as important as organizing instruments. Utilizing tubs is an optimal method for keeping all items needed for a procedure in one place that is easy to set up when preparing the treatment room. A tub should be set up in each treatment room, for each type of procedure performed (e.g., composite, amalgam, crown and bridge, endo). The tubs can be configured in many different ways, depending on the types of products to be stored, and covers can be purchased for the tubs to help prevent contamination from aerosols during treatment. Storage racks are available to stack the tubs for easy access in the treatment rooms. The tubs can also be color-coded by procedure.

Inventory control In addition to instruments, patient treatment is also heavily dependent upon materials and other supplies. Nothing causes chaos in the schedule quicker than not having or running out of materials needed for a procedure. A well-maintained inventory control system not only helps to avoid such incidents, but assists in controlling supply costs as well. Most dental supply companies provide computer-based inventory control systems for the products that you order from them. Many of these systems also include the convenience of online ordering directly from the inventory management system. The systems can compare prices, and notify practices of special promotions on frequently used items. Some practice-management software systems also have the ability to track inventory and supplies. If you order supplies from more than one supplier, this may be more effective. The key is to have a master list of all the supplies that the practice uses and a method of managing orders, tracking frequency of use, pricing of supplies, and the value of products on hand. Using computer-based systems makes this a much more streamlined and manageable task.

Instrument sharpening For hygienists, an instrument sharpening system is vitally important to productivity. The ability to quickly and easily remove deposits and stains from teeth is directly affected by the sharpness of the instruments. Many hygienists comment that they are “not very good” at free-hand instrument sharpening, and because of this they avoid it. In addition, making time in the schedule to sharpen instruments can be challenging. A mechanical sharpening system that produces consistent, precise cutting edges on instruments is a good investment in efficiency, and the task often can be delegated to a member of the clinical team other than the hygienist.

Some mechanical instrument sharpening systems to evaluate are: PerioStar 3000® from Kerr, Sidekick from Hu-Friedy, InstRenew from Nordent, DISC from Premier, and EdgeMaker 1000 from Rx Honing Machine.

Mixing impression materials Some of the best improvements in the use of impression materials during the last several years have come in the form of mixing and dispensing systems. These automated, dynamic mixing machines prepare the materials quickly, providing homogenous, smooth mixes with a variety of materials ... with none of the air bubbles that can get incorporated during hand mixing. The auto-mix cartridge systems were certainly an improvement over hand mixing, but many of the heavier-body materials can be difficult to mix and dispense. The dynamic mixing systems make mixing quick, efficient, and easy on the hands.

Mixing systems to consider are: Pentamix from 3M ESPE, MixStar from Zenith, and Genie Magic Mix from Sultan Chemists. Another type of mixing and dispensing system worth investigating is the digit Targeted Delivery System from Dentsply Caulk. This is a unit-dose, auto-mix cartridge system for Aquasil impression material. It takes the place of the wash material that may be dispensed from a separate syringe or from a much larger and harder-to-maneuver auto-mix system.

Isolation systems There are several isolation systems available to help keep a dry field and facilitate easier placement of restorations, endodontic procedures, and in-office whitening. The traditional rubber or dental dam has been updated by several manufacturers. These include OptiDam from Kerr, Insti-Dam from Zirc, and HandiDam from Aseptico. These products are prepunched, have attached or easy-to-attach flexible frames, and are contoured for a better fit when placed. Zirc also provides Insti-Clamp single-use dam clamps.

Another innovation in isolation is the Isolite i2 from Isolite Systems. This device is called a dryfield illuminator and combines a bite block/retractor, suction, and illumination in one easy-to-place device. It can enhance visibility and efficiency for restorative and hygiene procedures.

HVE/suction systems Suctioning and retracting during any procedure are challenging at best. Several devices have been developed that can make this task easier and more efficient. One such device is the Mirror Suction from Hager Worldwide. This is a mouth mirror that can be used for retraction and light reflection, and it attaches to the HVE hose to allow for suctioning. It works very well for hygienists who are using mechanical scalers, allowing them to suction and retract at the same time. Other innovative suction devices are the Tongue, Lip, and Cheek Retractor Suction Tips from LAK Enterprises and the Grab-Free HVE from Dux Dental. These tips are designed to prevent grabbing of the tissue and to provide superior retraction. Yet another innovation is the Vacu-Spray Ex from Dynamic Dental Innovations. This device combines the suction onto the air/water syringe, with an extended tip. It allows the assistant to handle the air/water syringe and suction in one hand, which allows for more flexibility at chairside.

Infection-control systems There is no doubt that infection-control procedures add extra time to patient visits. Disinfecting surfaces in the treatment rooms can be made simpler and less time-consuming by using the many disposable barriers available for equipment. The barriers simply need to be replaced between patient visits - no disinfecting is required. If barriers are not used, then contaminated surfaces must be cleaned and disinfected after treatment. Using disinfectant wipes is the most efficient way to accomplish this task. Wipes moistened with an intermediate-level disinfectant (one that says on the label that it kills m. tuberculosis) are readily available from various manufacturers and distributors. The surfaces should be wiped first to clean and remove any debris, then wiped again (with another wipe) to reapply the disinfectant. Be sure to close the cover on the wipes between uses to prevent evaporation of the solution. Turn the container upside down (with the tab closed) periodically to rewet the wipes with the solution that has settled in the bottom of the container. The use of these wipes is not only quick and convenient, it also decreases the amount of solution that is dispersed into the air from spraying disinfectants. Current guidelines from the Centers for Disease Control and Prevention no longer recommend the “spray-wipe-spray” technique for disinfecting surfaces. Instead, the guidelines recommend cleaning first, then disinfecting.

Eye safety Protective eyewear is a critically important safety device for the clinical team. Many team members require prescription eyewear and use those glasses as their safety glasses at work. This is risky, though, since the fashion in eyeglasses tends toward small lenses, which do not provide good protection. There are several options available for safety protection that can be worn over prescription glasses. Uvex® makes safety goggles - the XC™ model - which includes an insert for prescription lenses. Googles™ Eye Shields from Dental Disposables International (DDI) are very lightweight, disposable safety shields that easily fit over prescription glasses, but aren’t heavy or bulky. DDI and Crosstex®®offers face shields that clip on to the sides of prescription eyewear, as well as disposable chin-length face shields.

Hand safety When clinical team members are cleaning treatment rooms or instruments, OSHA requires the use of utility gloves to protect hands from chemicals and punctures. Many clinical team members don’t like the utility gloves because of their bulkiness, and opt to wear exam gloves instead. Several companies offer utility gloves that provide protection and flexibility. Hu-Friedy offers the IMS Lilac Gloves and Health Sonics offers ASEP gloves. Both of these gloves provide the chemical and puncture protection required by OSHA, but with the flexibility to pick up items. Their flock lining makes them easy to put on and take off.

Exam gloves are items taken for granted in many situations, but improperly fitting gloves can increase hand fatigue and cause numbness and pain in the hands. For long procedures, right/left or hand-specific gloves are more appropriate, since they are manufactured to fit the hand while it is flexed. A variety of right/left gloves are available from Crosstex®, Smart Practice®, and RelyAid.

Respiratory protection Face masks can cause skin irritation, which prompts some clinical team members to work at chairside without proper respiratory protection. Many times, skin irritation that occurs comes from wearing masks with scratchy, coarse fibers and/or dyes on the insides. Choosing masks that are dye-free on the inside and made of very soft material should alleviate this problem. The Ultra Sensitive mask from Crosstex® and the Com-Fit® mask from Sultan Chemists meet these criteria.

Other chairside timesavers

Here are several more timesavers to consider:

Alginate and impression materials - If you mix alginate frequently for impressions, consider the Alginator II from Dux Dental, which quickly produces smooth, bubble-free mixes. Cleanup is quick with Clean and Lube Wipes from Dux Dental. These convenient wipes will remove alginate or stone residue from mixing bowls and lubricate the bowls to extend their use life.

Alginate alternatives - Looking for an alternative to alginate for some impressions? Three products to consider are Position Penta from 3M ESPE, AlgiNot from Kerr, and Status Blue® from Zenith. These are vinyl impression materials, designed for taking preliminary impressions or for study models and whitening trays. The major advantage of these materials is dimensional stability. If it’s not convenient to pour the model right away, these materials will not distort, as alginate will, over time.

Matrix band placement and removal - Placing and removing matrix bands, especially sectional matrices, is often a challenge. This task can be much simpler with DryerPliers from DryerPliers, Inc. The pliers, which come in mesial and distal versions, have tips that follow the curve of sectional matrices. The pliers have been redesigned from the original version and have shorter tips for improved access.

Garrison Dental Solutions offers its Composi-Tight® system for placement of matrix bands in composite restorations, and has recently introduced a unique Universal Composite Instrument that combines five composite instruments into one for ease of placement and adaptation of restorations.

Digital X-ray sensor positioners - As more dental practices embrace digital radiography, clinical team members sometimes struggle with sensor placement. Several new positioning devices are available that will work with most sensors and facilitate optimum positioning for exposure. The first is AnyRay from MediaDent®. It is a universal sensor holder that eliminates the need for different holders for various exposures. The Eezee-Grip Digital Sensor Holder® from Dentsply Rinn is another new device for holding most types of digital sensors. It has flexible grips for the sensor, which increases patient comfort. Another product that increases patient comfort with digital X-ray sensors is Edge-Ease® cushions from Strong Dental Products. This adhesive foam adapts to the sensors, making placement more comfortable.

There are undoubtedly many other products and devices that can boost productivity and efficiency in your practice. Those discussed here are just a start. Involve your entire team in a continuous improvement process. Evaluate your systems, standardize your procedures, and look for ways to accomplish tasks in a more time-efficient manner. Your team and patients will reap the benefits.

Mary Govoni, CDA, RDA, RDH, MBA, is a Certified and Registered Dental Assistant and a Registered Dental Hygienist with more than 34 years of experience in dentistry as a clinical assistant, office administrator, clinical hygienist, educator, consultant, and speaker. She is the founder of Clinical Dynamics, a firm that provides consulting and seminar services for dental teams both nationally and internationally. She is adjunct faculty member of the Business and Community Institute at Lansing Community College in Lansing, Mich. Govoni is a columnist for Dental Equipment & Materials® and RDH® magazines, as well as a featured speaker on the ADA Seminar Series. You may contact her at

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