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Inside Dentistry
July 2018
Volume 14, Issue 7

Form Follows Function

Integrating new technology into your everyday practice

Jason Mazda

That new piece of digital equipment is paid for and in transit to your office. You researched the options for hours, comparing specifications and capabilities while considering prices and technical support. You calculated the return on investment, and you came to terms with the need to learn new processes and workflows. You're excited. But are you ready?

Placing your new milling unit wherever there happens to be open counter space is not likely to optimize the effectiveness of the technology. Neither will storing your intraoral scanner in a closet at the other end of the hall from your operatories. Whether you are adding equipment to an existing facility or outfitting a new one, maximizing the positive impact of new technology on your practice means carefully considering factors such as space, workflow, noise, cleanliness, accessibility, and more.

"If your equipment is not positioned in the best way for you, your assistants, and your patients, then you will not get the most out of it," says Michael Scherer, DMD, MS, a private practitioner, educator, and digital mentor based in Sonora, California. "It starts with the core fundamentals of the office. When someone says that they want to integrate digital technology into an office, my question is ‘what does that mean?' To start from the top, it really begins with a systems-based assessment of the entire workflow."

Different offices have different needs, so it is incumbent upon the dentist to plan for whatever specific technology has been purchased. For example, a high-production mill or 3-dimensional printer will require different considerations than something that fits on a countertop.

"It is best to consider the needs of the equipment before completing the design and to build the office around the equipment," says Jake Jones, an equipment specialist for Henry Schein. "The biggest problem that I see on a routine basis is failure to prioritize the parameters of efficiency, flow, and ergonomics."

Very few, if any, universal solutions exist. However, countless dentists have put their own innovative ideas into action. Whether it is to directly duplicate or simply draw loose inspiration from some of these solutions, dentists integrating new technology into their practices can benefit from the experiences of those who have already successfully accomplished it.

A Good First Impression

One of the first steps of the restorative process is obtaining an impression, and in a digital workflow, this can be accomplished with an intraoral scanner. Although most of the units on the market include a cart with a small display screen on it and a handpiece connected by a wire, recent innovations from some manufacturers include a wireless handpiece and a portable tablet display. Regardless of the portability of the unit, different office setups and business models present varying challenges to the efficiency of scanning.

Anthony LaVacca, DMD, a private practitioner in Naperville, Illinois, built a custom cart that he calls "the COW" (ie, computer on wheels). The COW has a custom display for patients and also functions as a mobile CAD station.

"The ability to move from room to room and design wherever the COW goes allows us to maximize our efficiency," LaVacca says.

Most manufacturers provide their own carts for the scanners. According to Scherer, key considerations include the length of the power cable and availability of battery power. "I have a scanner with an 18-foot cable that I can move between our four operatories, but for another scanner, I had to install a battery backup so I could easily move it between power sources without shutting down the wand and turning the computer off each time," Scherer says.

Many dentists opt for what Jones calls a "high-tech parking lot," or an area in the hallway to park the impression scanner(s) in order to maximize accessibility for all rooms as well as make them visible to patients walking past. "That technology needs to be readily available, so many dentists carve out a special area rather than simply putting it in the corner of an operatory," Jones says.

On the other end of the spectrum are dentists who opt to create one state-of-the-art scanning room. Alan Jurim, DDS, who co-owns integratedDENTAL in Woodbury, New York, with his sister Barbara Jurim, DDS, says they decided that a dedicated room was necessary to maximize the use of their technology, so they renovated their consultation room to include a chair with a scanner built into it. "The physical process of taking a scan is not very taxing on the patient or technique sensitive; for the majority of our patients, the most significant hindrance to scanning efficiency was setting up the scanner in the operatory," Jurim says. "Now we always have a scanner already integrated into the consult chair and ready to go."

Jurim's scan room has design elements to make it appear less clinical, including a floor-to-ceiling waterfall feature. It also features high-definition screens, which display live scans, that face the patient and anyone who may accompany them to their consultation, so they can view the intraoral scans in real time. "The patient's ability to participate in the scanning process is important," Jurim says. "They need to understand the process visually, which helps them build trust and confidence in our team."

That notion can extend to digital design as well. Erik Mendelsohn, DMD, a private practitioner in Egg Harbor Township, New Jersey, has his design station set up behind the patient with a 32-inch screen in front of the chair.

"I like to let patients watch the crown being designed for a few minutes, just so they know what we are doing, and then we change that screen to Netflix," Mendelsohn says.

Different variations of that setup may be preferable for each practice. For example, Mona N. Patel, DMD, a private practitioner in Abington, Pennsylvania, prefers to have all of the screens behind the chairs.

"Patients feel more comfortable when we swing them around to the screen," says Patel. "It is as if they are no longer in the dentist's chair; they feel more in control."

For dentists who want to digitize analog impressions, the model scanners that laboratories have utilized for years can be useful. Kent J. Howell, DMD, MS, a private practitioner in Mesa, Arizona, keeps a desktop scanner in his personal office set up along with a CAD station across from his desk.

"I prefer to scan and design in a space that is not too dusty," says Howell. "With this setup, I can just swivel my chair around to move from business tasks to digital design."

Alternatively, Mendelsohn uses his cone-beam computed tomography (CBCT) scanner to scan extraoral objects, such as dentures that need to be duplicated. "Most CBCT scanners can do what desktop scanners can do," says Mendelsohn.

Of course, CBCT scanners have broader capabilities as well, but with a CBCT scanner comes significant space considerations. For example, David L. Guichet, DDS, and his brother needed to completely renovate the x-ray room of their father's practice when they acquired a CBCT unit. "The equipment required reinforcement of the walls, and our space was limited as well, so we even needed to remodel the drywall," Guichet says. "It was a lot of work."

Similarly, when Patel purchased a CBCT unit 5 years ago, it required renovation of what had been a consultation room immediately adjacent to the reception area. "Having a designated room for the CBCT unit provides privacy," Patel says. "This adds value to the process in the patient's eyes."

Some dentists prefer to take the opposite approach. Javier Vasquez, DMD, CDT, a private practitioner, educator, and dental laboratory technician in Miami, Florida, expanded the main room of his facility when he added his CBCT scanner. "It was important to us to have the machine in an open space connected with the operatories," Vasquez says. "We do not want patients to feel as if they are in a hospital, so we avoid closing off too many spaces."

Regardless of whether it is out in the open or closed off, creating that space is important. "I cannot tell you how many times I have seen a panoramic or CBCT unit stuck in the dentist's personal office or the sterilization center," Scherer says. "For larger equipment, you need a dedicated space."

Don't Just Mill Around

Milling machines come in various shapes and sizes, but many dentists agree that they should have a dedicated space as well.

Larger milling machines make more noise; therefore, they may be best positioned further away from patients. Howell utilizes a high-production mill and does a significant amount of in-house, full-arch work, so he has a dedicated laboratory space for it.

"Depending on what is being milled, with a high-performance machine, the noise can be obnoxious," Howell says. "Wet mills are messy as well-especially ones that use high volumes of water. I understand the benefits of having a mill on display for patients, but for the type of milling that I do, I need a bigger, more dedicated space."

Although Jurim uses smaller mills, he keeps them near the back of the office so his in-house laboratory technicians can use and maintain them without the noise adversely affecting the patient experience. However, in order to still "wow" his patients with the technology, he has cameras set up that allow them to watch their crowns being milled from other rooms. "The cameras also allow me to monitor the machines," he says, "and they let the assistants know when the restorations are complete."

Other dentists prioritize putting the technology on display for patients. Mendelsohn refers to it as free marketing.

Patel, whose office is in a 135-year-old building, converted what had been a coffee nook toward the front of the main hallway into a spot for her mill. She installed a sliding glass door that dulls the noise without obscuring the machine from view and painted the walls in the nook lime green. "The walls are intended to be eye-catching," Patel says. "I want patients to stop and ask about the machine."

Sometimes, Patel even allows patients to load the material blocks into the machines. "They get excited and tell their friends that they got to make their own crown," Patel says.

Similarly, LaVacca keeps multiple mills in a closet with sliding glass doors. "Part of the reason for this decision was the functional aspect-I did not want the mills in our in-house laboratory where there was dust," LaVacca says. "Also, it serves to increase the patient "wow factor," especially with same-day restorations. When a patient can see his or her crown being milled, it is impressive."

Thinking in 3D

Prominently displaying 3D printers in a dental office can achieve the same effect.

Mendelsohn positions his printers on a countertop with lighting and a backsplash. "We incorporated the lighting that shines on our 3D print center to call patients' attention to the machines as we walk them through the office," he says.

Regardless of where they are located, 3D printers must be placed on a stable surface. Another often-overlooked consideration is the amount of space required to open the lids. Nate Farley, DDS, MS, FACP, a prosthodontist for Gunderson Health System in La Crosse, Wisconsin, says he needed to remove some of the cabinetry above his countertops to accommodate his 3D printers.

"The size of the lids surprise some people who assume they can just place their printers on any countertop," Farley says. "Additionally, it often makes sense to have a separate tray for each resin, and each one either needs to be stored in a dark cabinet or have a lid on it to avoid unintentional light curing. Cleaning tools and other supplementary items also must be kept near a printer, so storing everything in a cabinet below the machine can be a good idea."

Patel is planning to add 3D printers to her practice soon, and she intends to renovate a room to accommodate them. Although it will be near the back of the office, Patel plans to bring patients to see it, so the room will be designed for public display.

Similarly, Scherer chooses not to put his printers in or near the waiting room, but he has cameras trained on them so patients can see from there.

"Approximately 50% of digital technology implementation is in how you market it," Scherer says. "It is important to show off your technology with passion. It makes a big impact when a clinician says, ‘Let me show you how cool this is' to a patient."

Laser Focus on Accessibility

Just as important as making technology visible is keeping it accessible. Mills and printers are generally stationary, but one trend Jones has observed in offices he has worked with is to make smaller devices available in nearly every room.

"We try to make equipment such as intraoral cameras, sensors, and lasers accessible at the dentists' fingertips," Jones says. "Dentists want to incorporate these devices into all of their operatories instead of just having one room dedicated for each procedure. Being able to do any procedure in any room at any time increases efficiency."

One way this is being accomplished, he says, is by incorporating intraoral cameras and lasers into the operatories' treatment centers.

Mendelsohn has only three lasers, but utilizes six power cords (ie, one for each of his operatories), so they can be easily plugged in as they are moved from room to room. "We found that just adding a few extra cords saved us a significant amount of time," Mendelsohn says.

Minimally, Jones recommends designing every room to be able to accommodate the air and power requirements of a large laser. "If air and power are accessible in every room," he says, "then it is a quick process to connect, use, disconnect, and then move a laser to the next room for another patient."

A Digital Ecosystem

It is not difficult to imagine a future in which technology is accessible in every room without the need for such measures as adding extra cords. Manufacturers are developing various ways to improve portability.

"The ideal office would feature a simple integration of your systems in which you do not necessarily need carts, you do not need to move things around, and you do not need to connect or boot up machines or equipment for each use," Scherer says.

Jurim has created what he calls his office's central nervous system-a server room that is the heart and soul of the practice's network.

"As we acquire more and more devices that communicate over networks, we have the ability to enable them work together to change the experience and what you can and cannot do. I call that my ‘digital ecosystem,'" says Jurim, who also minored in computer communications when he was in college. "If my CBCT scanner is integrated into the same network as my 3D printer, design computers, and scan computers, the information is already digitized, and I am able to access it in many different ways from many different places. All of that happens through the information technology (IT) brain of the building or the network wiring."

The nature of each individual piece of equipment in this network is important as well, because some are more difficult than others to integrate.

"You need specificity in the technology that you select because each piece complements the others," Vasquez says.

That can mean implementing multiple technologies from the same manufacturer, even if it is not a closed system, or it can simply mean ensuring in advance that equipment from different companies will work together as planned.

"As more and more companies enter the market, dentists have so many more choices," Patel says. "I would like to see each piece of technology designed to flow together so it is not necessary to be limited to one company in order to implement all of the capabilities that you want."

The next step would involve integrating these diagnostic and CAD/CAM technologies with the dental office's practice management software, but opinions vary on the viability of that. Scherer and some others believe that this could unnecessarily complicate things by exposing clinicians to new possibilities for malfunctions, such as a scan being interrupted by a problem with the office's scheduling system. However, there would also be benefits to complete integration.

"Ideally, integrating our CAD/CAM system with our practice management software would be fantastic," Howell says. "Being able to go straight to your operatory hardware and/or network would greatly increase efficiency."

The Bottom Line

When implementing digital technology, improved efficiency is one of the most significant goals of nearly every dentist, but if the integration itself is inefficient or incomplete, then the effectiveness of that technology will suffer.

"When you have invested, oftentimes, hundreds of thousands of dollars into this equipment," Jones says, "it is very important to utilize design principles to optimize its accessibility, which improves both your productivity and your patients' awareness of your investment and commitment."

With existing facilities, creativity can be necessary, and Patel recommends thinking big. "In order to grow your practice to pay for a technology, you need to attract patients who value that technology," Patel says. "So when you are planning your purchases, you need to think about how you intend to use each piece of technology, where you want to put it, and how it will affect the flow of your office. You do not want to just put a new piece of technology in a corner; however, if you need to start with that and then figure out a better way to arrange your office, then that is OK."

Scherer recommends partnering with a digital mentor who has experience implementing new technology into a dental office. "Trying to build a digital office alone can be very confusing, especially for less technologically savvy people," Scherer says. "The major distributors do a good job of guiding clinicians in this process, and other options are available as well."

The most important fact to remember, perhaps, is that technology is constantly evolving, so the perfect solution today may be obsolete in the future. This should be a primary consideration in any renovation or reorganization. A cabinet that is the perfect size for a new milling machine now may be 1 inch too narrow for the next generation of equipment that is released in a few years.

"Building out is important, but beware of being so detailed and intimate in your buildout that you cannot adapt it further in the future," Scherer says. "The moral of the story is that you just need to focus on the technology."

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