Slow down everyone—dentistry does not need to be done at speed—Part 1

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At the White Clinic, we do not cut corners, we see fewer patients a day per chair, and since late 1999, we have not booked more than one patient per hour per chair. (Image: White Clinic)

Mon. 16. August 2021

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Dentistry in many parts of the world is being taken over by financially driven practices, and there seems to be a growing number of clinics that are focused only on the bottom line and, as such, see the largest number of patients possible a day, putting themselves and their patients at risk. How? By not taking the appropriate amount of time to process patients’ information, properly discuss treatment options with them and prepare the
operatory for therapy and in many cases by not placing a dental dam when needed.

Currently on the website of one of the largest producers of toothpaste globally, Colgate-Palmolive, is the following statement on the use of the dental dam: “The downsides to using rubber dams are practical and psychological. According to the Journal of Clinical and Diagnostic Research study, some dental professionals report that they are reluctant to use dams due to the added time and cost, [and] their lack of training around this dental tool.” I think that we need to seriously change this unacceptable state of affairs. For me and all of the dentists who are part of our global network, the use of dental dams should be mandatory, as it is there not to protect the dentist, but to protect the patient! It should be a basic right for dental patients.

A Slow Dentistry clinic usually works with less stress and is more focused on creating long-lasting relationships with its patients. (Image: White Clinic)

Slow Dentistry is aimed at creating a global network of like-minded dentists, practice managers, small business owners and hygienists who are committed to practising a form of dentistry that is patient-centric in terms of hygiene and safety, thereby distinguishing themselves from their peers in their region. For that, four very simple and universally accepted cornerstones were created that could be applied in any country, under any circumstances, and require no technology or special training. The premise was for Slow Dentistry to be able to be as ubiquitous as possible and to allow the largest number of people to join. We believe that dentists who practise according to these four simple cornerstones, taught in every school around the world, care a little bit more for themselves, their team and their patients and, as such, practise higher standards of care. They are different from those who focus simply on filling out paperwork and doing treatments just to make profit. A Slow Dentistry clinic usually works with less stress and is more focused on creating long-lasting relationships with its patients based on the ethical premise that goes back to the Hippocratic oath to do no harm.

Often, we are so focused on the mechanics of dentistry and the major tasks that we forget the little ones, and as the famous saying goes, “the devil is in the details”. One of the most important details in dentistry is treatment room disinfection between appointments—proper disinfection, not simply tidying up the treatment room as happens regularly around the world. Who can claim that they have not cut corners on this important step when in a rush? Consider that apparently some dentists actually feel comfortable saying that they do not place dental dams because it takes too much time and skill, knowing full well how important it is for safety, not to mention the overall outcome and longevity of restorative dentistry and most importantly root canal therapy.

Slow Dentistry aims at improving the patient experience and the overall quality of care. (Image: White Clinic)

When I started my private practice at the end of 1999, I had no real benchmark, and no guidelines were given to me, as I took over an old practice that had not really changed its modus operandi since the 1970s. I wanted to be modern, and I wanted to be good! So when I set up the White Clinic, I established protocols of safety and security and even the workow that is still in place today. This meant that I had to do my homework and talk to the technicians who set up the treatment rooms and the sales representatives who sold me the disinfection products and have them teach me what would be the ideal way to disinfect the dental unit and used rotary instruments. I learned, quite frankly, that if you follow the guidelines it is virtually impossible to properly disinfect the treatment room, all surfaces and the floor and clear the air (open a window) after performing a treatment, whether with or without the generation of aerosols, in under 10 minutes. Therefore, when clinics are seeing in excess of 20 patients per chair a day, I always wonder what is going on with room disinfection. Or when I see dentists doing 20 or 30 restorations a day, I wonder if they are really taking the time to place dental dams.

So how do we do it at the White Clinic?

It is simple. We do not cut corners, we see fewer patients a day per chair, and since late 1999, we have not booked more than one patient per hour per chair. We have seven chairs in the clinic and so that means no more than 56 patients a day. We are open for eight working hours a day from Monday to Friday and so that would be the maximum capacity allowed. The daily average of the last five years was 35 patients a day in the clinic—and that is divided over the seven dental chairs. This means that it is possible for us to really focus on our patients, creating quality relationships, to make sure that we have proper consent and that they have a clear understanding of the treatment to be performed and to give the dental assistants the necessary time to properly disinfect between appointments. Moreover, we even have a special team for sterilisation so that the dental assistants can properly focus on their tasks.

A clear example of this would be our oral hygiene appointment. It is a good example because the protocol is always the same. For 20 years, our oral hygienists have worked with a dental assistant by their side, and the time allocated to each patient is 1 hour. The actual intervention usually ends 5 to 10 minutes before the hour, and the following patient’s actual intervention will start 5 to 10 minutes after the hour, leaving roughly 45 to 50 minutes of chair time to perform a good deep cleaning procedure properly. In the time in between that, the dental assistance exchange the disinfected tips, making sure everything is properly prepared for the next appointment, and the hygienist talks to the patients, writes the clinical notes, and has some time to rest, have a glass of water and get ready for the next intervention.

The daily average of the last five years was 35 patients a day in the clinic—and that is divided over the seven dental chairs. (Image: White Clinic)

Many of my peers claim that it is impossible to do so and make any money from dentistry. I always answer, how can you practise dentistry without focusing on safety and hygiene? What are you selling at the end of the day? Is it not trust? Should we decide what is important for the patient? In the pre-COVID-19 world, I can understand fitting in as many patients a day as possible, resulting in packed waiting rooms and rushing from patient to patient. In a world after COVID-19, this is no longer possible. If your business plan is all about volume so that you can charge less and attract more patients, this is at the expense of basic safety protocols like room disinfection and placing dental dams.

Portugal is not the wealthiest country in Europe; it is actually one of the poorest countries in Europe. We do not have socialised dentistry; it is almost 99% private. Practising this way for 20 years has not always been easy, but one thing is for sure: at the end of the day, our patients feel safer with us. We had many patients return to our clinic after having left us for years to go to cheaper clinics for follow-up and maintenance and, during 2020 as a consequence of the pandemic, come back to the White Clinic because they nally understood that the premium that they paid was for hygiene and safety.

Moreover, when you work this way, there is undoubtably a great deal less stress at the end of the day for the clinical staff. Mental health is a major topic in dentistry today, and if you do your research you will probably find that, in some industrialised countries, suicide among dentists is one of the highest in any industry. Is it because the job is stressful? I do not think so! I believe that dentistry is actually a very rewarding job, as long as you are given time to practise it. I think many dentists go home overworked, undervalued and stressed because they know that at the end of the day they did not do things perfectly and safely and often did not put the patient at the centre of their care. Everything we do is founded on scientific principles and clinical evidence. The basic cornerstones of Slow Dentistry are undeniably true. No dentist needs to invest in any superior education or technology to implement them. All you have to do is slow down and understand what your priorities are. They should be to work safely, ethically and responsibly.

All you have to do is slow down and understand what your priorities are. They should be to work safely, ethically and responsibly. (Image: White Clinic)

Disclaimer

Slow Dentistry is part of the non-profit Foundation for Excellence in Dentistry, based in Switzerland. I have no financial interest in the organisation. It was created to improve dentistry as a whole, and as part of my legacy work towards the industry.
www.slowdentistry.com

Editorial note: This is the first article in a four-part series on Slow Dentistry and its principles and advantages. It was published in roots—international magazine of endodontics vol. 17, issue 1/2021.

COVID 19 Dental dam Disinfection Foundation for Excellence in Dentistry Hygiene protocol Mental health Rubber dam Slow Dentistry Treatment room disinfection Work ethics

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