MICRODELEGATION: Chair-side-assistance DUO work.

Microdelegation means assistance by the practical work in the mouth of the patient. The assistant places instruments and materials in the hand of the dentist according to the protocolle of the clinic. (fourhanded dentistry)

FOCUS AT PATIENT

A good organized clinic has alwas a strong focus at the patient. The organisation of the clinic is made so a maximum of time of dentist, assistants and hygienists is used caring for the patient.

Time for preparing for treatments. steels time from assistant. The organisation has therefore the objective to reduce time used for preparing the different treatments.

 DUO, DUO-SOLO AND SOLO 

It my aim to help you working in a better way in your dental clinic. These are nice words, but what does it mean and how is this applied in the daily work at the clinic.

The objectives I use teaching and training ergonomics are following.

SIT WELL    Work in good positions without discomfort or longtime risk for your health- and

SAVE TIME AND ENERGY.
Almost everyone can agree in these objectives.

The problem is however, that most dentists are not conscious about how they perform the practical work in the clinic. They are not aware of what they are doing,   Of course this make a analysis of working method difficult. Thefore - if you want to improve working methods - you - for a time - have to be very aware of what you are doing.

SEPARATE WORK WITH ASSISTANT, DUO,  FROM WORKING ALONE, SOLO.
According to my observations visiting many dental clinics, quite many dentists- and in some countries most dentists have rather small advantages of working with assistant. In spite of the assistant is sitting beside the patient, the dentist him/herseft takes handinstruments, change burs, contraangles etc, takes unitinstruments. Every time he/she has to look away from the patient to pick up and replace the instruments. This is more or less solo-dentistry with assistant

Here are some considerations you should make before you order your working-place.t.

1. I WANT TO WORK DUO, WITH ASSISTANT ALL THE TIME?
        
     a. I want to work fourhanded, this means assistant place handinstruments and materials in
          my  hand, change contraangles, burs, diamonds etc . Objective: I can maintain hands and vision
          by the object of my work, and work continiously without "lost time"

         Instrumenttable should be placed at upper left side of the head of the patient. Here the assistant
          can take handinstrument and pass them to dentist.  And with a special technique you can
          yourself easily pickup the instruments. You can email me to send a description with illustrations.
          Look please at the section at this website "Working place of assistant" and in "Flex userinfo":,
          "Four basic manuel techniques"   Click left.  
         Aspirationtube-holder should be placed on and at left side of the unit-bridge.   

          NB NB NB
          Take much care, that the working place for the assistant is very good and very well
          organized, so your assistant  can win time for continous assistance. The workingplace for the
          assistant is very often insufficient as to support four handed dentistry. 
      
                  COURSES IN ERGONOMICS,  
        WORK EFFICIENT, SAVE TIME AND ENERGY, AND SIT WELL.    
         To learn everything in a fast and efficient manner you could participate in a course in
         ergonomics.         
          
         A practical training course organize in your clinic -- may be together with colleges 
         (You may write me  or emalil about this. I understand English, German, French, Italian, Spanish 
         and the 3 lScandinavian languages)

    b. I want to take handinstruments myself like by SOLO work
 
         Instrumenttable may permanently be placed at the unitbridge under the right side of the
         unitinstruments. You are suggested to have a second instrumenttable to the upper left side
         of the head of the patient, as by fourhanded denstistry.
         Aspirationtube-holder should be placed on and at the left side of the unit-bridge or in the working module.

      
2.  I WANT TO WORK SOLO ALL THE TIME (rather common in Belgium and France)

      Instrumenttable should be placed at the unit-bridge under the right side of the unitinstruments
        Aspirationtube-holder should be mounted at the chair if you want do move unitbridge to a
        '"parking"position to the "lower" right side of the patient.
        The holder may be mounted at the left side of the unitbridge IF you want to use a "parking" position
       at the left side of the patients (as when working with assistant.

        The planning of the treatmentroom should be made for 100 % SOLO dentistry, with working-
        surfaces and storage-place very close to dentist. Se examples of treatment-room plans in the
        "Clinic planning Report" You can order it by your Flex Dealer or be Flex Dental, Denmark

 3. I WANT TO CHANGE BETWEEN WORKING  DUO and SOLO.
        This combines the many advantages of working DUO with assistant with the flexibility that you can
        work alone SOLO, as well. This is the typical working method, if your assistant due to other  
        tasks do cannot stay all the time by you and you therefor at part of the time have to work SOLO
        DUO-SOLO work is a an option for dentists in Germany, who wants to reduce costs.      

        It is essential that you separate the to different working-concepts.  Work either DUO or SOLO, and
        change the workingplace between the two concepts in 7 seconds.

        The unique DUO-SOLO working-place of Flex offers you this advantage.

        Instrumenttable should be placed at upper left side of the head of the patient. Here the assistant
        can take handinstrument and pass them to dentist.  And with a special technique you can
        yourself easily pickup the instruments.
       
        Aspirationtube-holder should be placed on and at left side of the unit-bridge.  
        The position of the holder can be changed between DUO og SOLO- position in 2 seconds.
       
     

THE WORKING PLACE FOR PATIENT TREATMENT

 The design of the treatment room, the working place around the patient

 The design of the working place in the treatment room has a large influence at the work of the dentist and assistant. It may support or seriously disturb good functions. My experience is, that dentists unfortunately generally are not conscious about this. Therefore it is very important to develop at good knowledge and ergonomics and ergonometrics before you make a design of your working-place, which influences you during many years.

 The objectives are at first to define the functions of the working-place around the patient, and then- afterwards make design, which fulfil these objectives.

IT IS MORE DIFFICULT THAN YOU THINK TO DESIGN A GOOD WORKING-PLACE

First you have to realize all the functions of the working-place.  It is too late after the design is made.

TAKE CARE:

My experience is that dentists very often underestimate the complexity of time-cost efficient practical work.   The working- methods are often non-conscious, and therefore even obvious unpractical working-methods may be repeated during decades of years. And what you don’t know, what you are non-conscious about you cannot change or improved. You adapt yourself to a insufficient or bad working-place and don't realize the problems it causes in form of poor working-positions and loss of time and energy, because few things are within reach of dentist or assistant

OBJECTIVES FOR THE PRACTICAL WORK

The objectives for the working-place is decided by the space necessary to allow the dentist without limitations to work in different positions between 9 and 12 o'clock as well as to allow the assistant to reach "everything" without moving away from the patient.

These are the conditions for fulfilling the objectives for working-method for dentist and assistant:

Free choice of sitting-positions according to the actual direction of vision to avoid twisting the spine.

Dentist keeps hands and eyes by the mouth of the patient.

BE CRITICAL AND STAND HARD ON THE FUNCTIONALITY

Most of the cabinet arrangements made don’t have an acceptable functionality.

Unfortunately are many working places in the treatment-room of lower “ergonomy-quality” than during the past years.

That the assistant needs a working-place for working in sitting position is apparently forgotten. Instead it has been common to copy kitchen-arrangements- which are made for working in standing position may be with a small "drawer" for mixing materials.

Here are some examples why kitchen-arrangements of cabinets create a poor working-place for dentist and assistant.

1. HANDINSTRUMENTS CANNOT BE REACHED BY THE ASSISTANT.

A handinstrumenttable on the unit doesn't work for  work with assistant, because the assistant cannot reach the handinstruments

2. THE DENTIST CANNOT WORK IN 12 O'CLOCK POSITION

40 – 45 cm between the headrest of the patient-chair and the cabinets behind the chair does not allow enough space for enabling the dentist to work in 12 o'clock – position. This means that den dentist has to twist neck and back to look at the left side of the teeth of the patient. (There has to bee at least 60 cm between headrest and the modules behind the patient chair.)

3. NO TABLE TOP  - WORKING TABLE – FOR THE SITTING ASSISTANT.

For working in sitting position, there has to be a tabletop about 75 – 80 cm above the floor. A "kitchen-table" of 90 cm cannot be used as working-table for a sitting person.

There must be free space under the tabletop for the legs of the assistant. The assistant must be able to use the working table without needing to "roll away from the patient" The reach of the arms of the assistant decides where materials etc are placed.

The front of the tabletop must- for these reasons – be placed exactly 20 behind (and to the side from-) the headrest of the patient chair. Look please at diagrams next page.

4. NO PLACE FOR MATERIALS FOR TREATMENTS WHERE MAY MATERIALS ARE NEEDED.

If the tabletop for working is as small as 45 x 45 cm (which unfortunately often is the case) there is far from enough space. For some treatments you need more than 60 –70 items.

5. DRAWERS MAY BE USELESS DURING TREATMENT.

Sometimes a "drawer-like" working-table-top blocks the use of the drawers below

6. NOT ENOUGH STORAGE SPACE WITHIN REACH.

The assistant has repeatedly to move away from the patient, with the result that assistance by the treatment is seriously disturbed.

THE CENTRAL WORKING-PLACE BY THE PATIENTCHAIR.

We need a working-place close to the patient, with a lot of space for storage within react for the assistant without she has to move around on her chair.

ERGONOMETRICS:  THE MEASURES OF THE WORKING-PLACE.

Here is an example of a working-place with correct measures, ergonometrics according to the objectives for working.

THE HANDINSTRUMENTTABLE

The handinstrumenttable supports the instrument tray + may be some other items. It is placed so the assistant can reach the handinstruments for the instrument transfer to the dentist. The dentist to can reach them with left-to- right-hand-instrument-transfer. The handinstrumenttable is mounted on an arm so it can be moved about 15 cm in all directions.

THE WORKING-TABLE-TOP

 At the illustration you can see the exact position and measures for the working-table-top. This position allows the dentist the space for 12 o'clock -position, and is at the same time so close to the assistant, so she- just with a slight turn on her stool can reach and prepare materials at the tabletop.

 The oval field describes what the assistant can reach without "rolling away" from the patient on her stool.

There is prepared for preparation, bite registration, impression and temporary for a crown. Notice that the tabletop is almost full, even if it as shown is about 130 cm long – the left part, which is " covered" by the handinstrument tray.

The length of the available part of the tabletop should be at least 100 cm.

Under the right part of the tabletop is placed one or two cabinet. The first with drawers and may be the second 25 cm of width with shelves for large trayes for materials.

The dentist can sit at 12 o'clock position.

The assistant can reach the handinstruments at tray on the handinstrumenttable.

There is a working-table-top for the assistant with enough places for all the materials for complex treatments.

The working-table-top is so close to the patient, that the assistant doesn't need to move away from the patient, when using it.

There is space for the legs of the assistant under the left side of the table.

There is a cabinet with drawers under the right side of the table.

To the right side of this cabinet there may be a cabinet for large material trays. (see later description)

There is a cabinet placed 12-15 cm above the tabletop with a lot of place for materials. Here can the most frequent used materials be placed on material-trays. If you as an example have to make a composite filling the assistant take down first the tray with "everything" for matrixes, matrix-holder, wedges ect. And the assistant take down the composite-tray with "everything" for composite. (look at later example)

The assistant saves a lot of time avoiding to collect the necessary materials at several or many different positions.

The debt if the table-top below is 90 cm which is exactly the same as a kitchenlike cabinetarrangement with a drawerlike working-plate for the assistant.

To understand how a working-place for a assistant should be you could at best imagine a office-working-table and not a kitchen.

The ergonometrics at this working-place is the same as above, but the tabletop behind the dentist is here 50 cm deep. The left cabinet could be mounted with a sink for washing hands.  

Here is the working-place seen from the front.

The assistant has space for her legs under the left side of the table. Behind the dentist there is too a working-place for the dentist, with place for the legs under the table-top.

The cabinets above the table-top are here mounted with "holders" for standard-trayes for materials and instrument-trays at the right side.

Under the right side of the table-top there are two cabinets – one with drawers and one with place for large material-trays.