Ask the Doctor is a question and answer forum where you can submit questions directly Dr. Coburn about your treatment room thoughts, intentions, ergonomics, or any related topics you would like to discuss. Please submit your questions through email at: info@coburndental.com With your permission, your questions and answers may be added below for fellow practitioners to read. The following Q&A’s are questions that have been discussed recently.
Q - Don, what first prompted you to begin to seek a different system for the dental treatment room?
Following the introduction of higher speed dental drills and washed field-operating techniques in the 1960’s, dental teams became interested in fourhanded dentistry and at the same time began to recognize the need for change in the set up of the dental treatment room. It seemed natural and desirable for the dental team to be seated and to work on a fully reclined patient. The problem was that the patient’s head location was now too remote from the cabinet, the instrument tray and the surgical cuspidor. This presented a challenge.
Our dental team with little informed guidance, began to re-arrange the elements of our treatment room, trying to find a better answer. We eventually realized that re-arranging would not be enough. It would be necessary to go to the drawing board, think it through and try our hand at redesigning some of the elements. We noticed that even when we started with a clean sheet, and carefully thought through our design intentions, we would still very often not have a completely adequate solution. And so---we would try again and again and---again. For each small step forward, there would be a reward. It would feel better, be more efficient or contribute some how to our understanding.
Gardiner suggested that design is a dialogue with the environment. Michael Schrage, a research associate at the MIT Media lab referred to this kind of repetitious enquiry and design activity as 'serious play’ in his book Serious Play. Well known business author, Tom Peters, in the forward to this book said, “I love this book! It is absolutely an original…. And it is absolutely right. Peters continued, “The book is about serious work: how the world’s leading companies model, prototype and simulate to innovate”. Schrage’s story helped us understand our own experience: when we worked zealously developing a design and then built a prototype, there was almost always a surprise; we would see that some aspect of the design could be improved. The prototype allowed us to work in a better, i.e. healthier, more comfortable, more efficient and perhaps more natural way. This understanding made it possible to move to a higher level --and to design a still better prototype. The challenge was and continues to be to think clearly about preferred teamwork patterns and then to shape the environment to encourage or dictate these preferences.
Q - What research did you do to validate your design decisions?
With the help of a grant from the Design Branch of the Canadian Dept. of Industry and assistance from Industrial Engineers of Stelco in Hamilton, we carried out a memo motion study of ten dentists, each in their own environments, each team doing a two- surface amalgam in an upper left bicuspid. Using memo motion photography and an analyst projector, we measured, recorded and calculated the percentage of total operating room time that each operator focused on the work area of the mouth. The degree to which each treatment environment was team supportive was obviously critical to that team’s focus.
The individual results varied from a little over 50% at the low end to 89.6% at the top end. The top two achievers, with the highest focus on the mouth, were teams working with the Cox Chairside Systems.
Incidentally I would like to give credit to others such as T.Ron Cox with whom I co-founded Cox Systems later called The Group at Cox and to David Jenkins Industrial Designer and to Wilson Southam and the Group at Cox.
Q - What are your criteria for the optimum dental environment?
This would vary according to the specific values, needs and goals of the each dental team. I had the pleasure of working for much of my 43 practice years in an environment that continued to evolve according to our team’s current understanding of our own needs. I have always understood that the process of work-place design is and will continue to be a journey. The current Coburn Treatment Room System represents our current thinking and recognizes that the requirement that the system needs to be open, flexible and adaptable enough to support new and evolving technology and philosophy.
Q - Does the Coburn System allow for the complete digitalization of the dental office?
The Coburn System offers generous team supportive work surfaces and interconnected storage units.
The furniture elements have been designed with a myriad of factors in mind, e.g. the monitor/keyboard location is said to be ideal. The seated assistant easily accesses the stowed monitor and keyboard with excellent posture by rotating slightly to the right and pulling out the keyboard tray. This movement and posture is clearly a balance to assistant’s typical operating posture. The monitor on its monitor arm is easily repositioned for a seated dentist or hygienist, critically viewing digital images. We believe the location of the patient monitor, just beyond the operator’s sink unit, is ideal to support patient/operator dialogue. This would be an upright patient with his or her eyes at the same level as the operator’s. Wireless keyboards add to flexibility and versatility.
Q - What qualifies your design as ergonomic?
ERGONOMICS = FITTING THE ENVIRONMENT TO HUMAN ENDEAVOR
Conventional dental cabinetry and counters are often rectangular. We think of free flowing landscaped designs and organic shapes defined by curves rather than straight lines to encourage comfortable, natural movement and posture. We must continue to ask throughout design or prototype evaluation “How should this procedure be performed physically?” When we think we have the answer, we then try to encourage and support this behaviour with appropriate design.
Q - What type of dental lighting do you recommend?
We favour track lighting because it assures flexibility, and freedom from interference when positioning x-ray arms, operating lights and patient monitors. Track lighting is technically and aesthetically attractive, integrating visually with the ceiling and suggesting a sense of order and architecture.
Q - I have been researching delivery systems and found claims to support all types. What are your thoughts on CHAIR MOUNTED systems?
Thank you for directing me to the marketing materials that support your question. While some extol the advantages of this system, let’s explore these claims:
Claim – Chair-mounted systems offer the easiest and widest range of hand piece placement
Response on “easiest”: Easiest - on what basis? It may be easy but perhaps not as easy or patient considerate as a 2 o’clock system where hand pieces are located within team members’ comfortable peripheral vision and reach and within the same general lighting as the patient’s head. The operator’s stealthy left hand effortlessly drops down to pick up the hand piece. This is then pre-positioned and transferred to the right hand. This can happen without losing eye contact with the patient. Contrast this with a right-handed pick up of the hand piece, where the right hand is lifted in view of the patient to either pick up the hand piece or to rest on it until conversation is complete. Over-the-patient hand piece and tray delivery systems are within the patient’s view and raise the possibility of patient intimidation and a sense of claustrophobia.
Response on “widest range”:
There is no argument here, it can certainly be moved almost anywhere in the room. One school of thought says, “If you don’t know where to put something, put it on wheels or on a moveable arm.” This means that the important and unanswered question, Where is it best located? has to be answered each time you sit down to work. This gets in the way of efficiency and productivity and may in the long run get tedious. Ideally the operating team would agree on best possible deployment locations and share this understanding. Well-informed design offers freedom from choice as a greater benefit than freedom of choice.
Claim – Chair-mounted systems. Simple integrated design
Response: with too many undesirable and unnecessary positioning possibilities. (See above.) One really has to ask if, in their best and final choice of tray elements and hand piece locations, they are able to match the informed deployment location, the intelligently and deliberately restrained flexibility of the air water/syringe/suction elements that are part of the unique Coburn design.
Claim – Chair mounted systems support right hand and left hand positioning for multiple operators
Response: So does a tennis racquet. Not so with a golf club. Also, not so with a Coburn System, with its “L”model dedicated exclusively to a left-handed operator or “R”model to a right-handed operator. Deploying elements in exactly the right place for R or L offers a structural advantage to dental teams. With a dedicated system, you happily get along without the leftovers of the stand up era, e.g. a dysfunctional cuspidor or a dominant and mechanical service-oriented dental unit. With a dedicated right or dedicated left, less is a great deal more. Our system focuses on the patient’s oral cavity, not on the plumbing. The “plumbing” should serve our best design intentions. . (i.e. It is all about the people not the plumbing).
Claim – 12 o’clock instrumentation s offers easy access to instrumentation and work surfaces.
Comment: The Coburn two o’clock delivery system (10 o’clock for left-handed) evolved from the Cox Chairside System that was based on the early Cox/Coburn
12 o’clock delivery system. We learned from this system. The remarkable advantage of the 2’clock orientation is a unique tubing management and deployment system that is simple, effective, tangle-free and team friendly.
Some current trays are square or round. Arbitrary shapes are likely not as functionally valid as ours, based as it is on the Common Work Area. In addition to the common work area/team tray, we have the adjacent facility of keyboard, monitor storage, extra corner support area for the assistant and the dentist desk/ mini lab. This is more functional than a cart or a tray each of which is a moving target trying simultaneously to be all things to left and right-handed people (dentists and assistants).
Claim – 12 o’clock instrumentation can provide left and right hand operation
Response: Yes, but in the process, it compromises the benefits of a dedicated system.
Claim – 12 o’clock instrumentation supports peripheral operatory equipment, i.e. amalgamators
Response: So do we, and all of the other peripheral equipment, such as intra-oral cameras, cavitron, electro-surge, air abrasive units, curing lights, etc.
Dr. Malios - Greece - Your site is very helpful for me in designing a more ergonomically dental office. Let me ask a question: In your designs the dynamic instruments for the operator are always in his left area (out of sight of the patient) but do you find it troublesome as the operator must take them with the left hand and pass them in the right hand?
Dr. Coburn - Yes, it is true that our dynamic instruments (dental hand pieces) are oriented at 2 o’clock for left hand pick-up of hand pieces. (i.e. for a right-handed operator). Our left-handed version is a mirror image of the right-handed version. The issue you raise is really about picking up a hand piece with your left hand, then pre-positioning it for transfer to the right hand as compared to picking it up with your right hand and then getting it properly positioned in your hand so that you are ready to operate. Once the hand piece is in your hand, we would probably agree that you keep it there, if possible, until the task is complete. This would include pausing to put in a different or fresher carbide or diamond instrument. It has been our contention that the left hand pick-up is about as fast as right-hand pick-up and there are some added benefits to left-hand pick-up, which includes the hand pieces are within easy reach of the dental assistant who may participate in getting the right instrument (drill) on the hand piece. Then towards the end of the appointment the assistant conveniently breaks down the hand pieces for sterilization without moving to the dentist’s side of the chair.
Left Hand pick-up - The operator’s left hand drops down to the hand piece to pick it up or put it back. This is physically and psychologically more comfortable than reaching up with the right hand to an over-the-patient delivery: where the hand pieces are visible to the patient. Over-the-patient delivery or ‘side delivery’ are not nearly as convenient for the dental assistant to service as is our team tray with its 2 o’clock delivery. The efficiency of comfortable assistant access to the hand pieces, in our opinion, would outweigh by far any perceived benefit to right-handed hand piece pick-up. Another article we have available, called, “Dental Team Work”, discusses the unassisted dental student where hand piece pick-up is often with the right hand. When the new graduate goes out to shop for dental equipment, the habits formed at dental school may make it difficult for the student to understand the teamwork benefits of our 2 o’clock system.
Dr. Malios - Greece - I saw the Morita units, which approach your philosophy except that the dynamics instruments are in the right area of the operator. Do you believe that this position of the dynamic instruments is more favourable? I have a dual entrance room with trans-continental delivery.
Dr. Coburn - Our single entry, dedicated right or dedicated left treatment room is able to single-mindedly support the need of each team member. The assistant’s support area allows the assistant to focus on the flow in instruments and materials. This allows the dentist to focus fully on the patient in a supportive environment that gives patients the reassurances they require about sanitary process, efficiency and technical excellence.
Assistant Support Area
This is the most important delivery/support area in any office because the well-supported dental assistant is able to handle the flow of instruments and materials so effectively that the dentist is able to fully focus on the work area of the patient’s mouth.
The second entrance as seen in many treatment rooms takes up too much of this and valuable, absolutely key work and preparation space. Our corner cabinet system provides the perfect location for keyboard and monitor, assistant’s lower drawers and CPU compartment, as well as generous set-up space for multiple procedures and focused efficient teamwork. The patients are the important customers in this equation. They feel supported and un-threatened in this environment. As the dentist enters the room and establishes contact with the reclined patient, he or she can be seated to wash hands, dispense towel, dispose of towel into counter hole, and then in turn, dispense mask and gloves. An aerosol screen protects all of the dispensed items. By design, the operator touches only the dispensed towel, and then the mask and gloves without contacting door or drawer handles or cardboard boxes. The patient’s introduction to your office and the total experience reassures them about the efficiency and sanitary standards of your office. You only get one chance to make a good first impression.
Please submit your questions through info@coburndental.com
Thank you!
