1
The Dental Operatory

The dental operatory is the central point where patient, veterinarian, and staff come in contact with equipment, materials, instruments, and techniques necessary to diagnose, treat, and prevent dental disease (Figures 1.1 and 1.2). The challenge is to provide an efficient area for the use and storage of dental supplies, instruments, powered equipment, radiography unit(s), computer(s), suction, illumination, general anesthesia, monitoring devices, as well as a comfortable and safe place for the dental assistant(s) and practitioner(s) to treat patients. To avoid injury and aid efficiency, every effort should be made to decrease floor-based equipment (dental delivery systems, anesthesia delivery units, dental X-ray generators, and intravenous fluid stands).

Figure 1.1 Author's multiple station dental operatory in use.

Figure 1.2 (a and b) Dentistry suite.

Source: Courtesy of Warren Chase Freedenfeld, AIA, Rauhaus Freedenfeld & Associates.

Space

If the practitioner has the luxury of planning the dental operatory versus retrofitting an already built area, an 8-ft by 10-ft area should be the minimum floor space allocated for one table. A 12-ft by 15-ft space is adequate space for at least two or more tables, storage, anesthesia, and a dental X-ray unit.

The number of operatory tables used for dentistry in a practice often is what limits the amount of dentistry that can be performed. "Dentistry" no longer is an hour or less procedure where primarily calculus (tartar) and plaque are removed from tooth crowns. The comprehensive oral prevention, assessment, and treatment (COPAT) visit includes dental scaling, polishing, irrigation, full-mouth intraoral radiographs, and care to treat pathology uncovered during the assessment. The COPAT visit commonly takes two hours or more to complete. Ideally two or three tables should be planned - one used for patients going under anesthesia, teeth cleaning, and diagnostics, while the other one or two used for dental therapy (Figure 1.3).

Figure 1.3 (a) Two-operatory table setup.

Source: Courtesy of Dr. Susan Crowder.

(b) Two-operatory table setup.

Source: Courtesy of The Animal Medical Center in New York City, note all support equipment off the floor.

(c) Author's four-table dental operatory (All Pets Dental, Weston, Florida).

The dental operatory should not be located in the same room used for general surgery or surgical pack preparation to protect from contamination of the surfaces through ultrasonic aerosolization.

When a veterinarian works alone (two-handed dentistry), considerable time is spent charting, acquiring instruments, materials, and equipment while the patient is anesthetized. Four-handed dentistry (Figure 1.4a), which is commonly practiced in human dentistry, engages a dental assistant who helps in charting and envisages needs, handing over the instruments and materials in a timely manner. In veterinary dental practice, the patient also must be monitored while anesthetized. Six-handed dentistry includes the practitioner, a dental assistant, and an anesthesia-monitoring assistant, increasing the efficiency of dental procedures performed, often decreasing the anesthetic time (Figure 1.4b).

Figure 1.4 (a) Four-handed dentistry.

Source: Courtesy of Dr. Susan Crowder.

(b) Six-handed dentistry.

Source: Courtesy of Dr. Brook Niemeic.

Electricity, Water, and Drainage

Multiple electrical grounded 110-V receptacles are recommended to power the delivery system, light curing unit, ultrasonic scaler, illumination source, computer and screens, monitoring equipment, and thermal control unit. Monitoring equipment may require a dedicated circuit to prevent interference from the ultrasonic scaler. Three four-plug grounded outlets are usually sufficient for each operatory table.

Water is dispensed under pressure from the high-speed delivery system to clear debris and prevent heat damage to surrounding tissue generated by drilling and to remove debris. A filter is recommended to decrease the sediment thereby increasing the efficiency and the life of dental handpieces. Distilled water can be used in stand-alone units or obtained from a distiller and pumped directly into the delivery system.

Over time, a bacterial biofilm forms along the internal surfaces of water lines. In human dentistry, this biofilm has been implicated for introducing pathogenic bacteria into the oral cavity. A bacterial microfilter and a chlorhexidine flushing system can be installed to decrease this biofilm. Additionally, products can be purchased to shock and clean water lines as indicated.

Ergonomics

When planning the dental operatory, attention to the mechanics of delivering dental care is important. Five ergonomic classes of motion are used to define which types of movements are desirable and which movements damage the skeleton and musculature. See Table 1.1.

Table 1.1 Five ergonomic classes and movement.

Class four on a repetitive basis can be damaging and leads to inflammatory joint disease. Class five movements are to be avoided whenever possible.

In human dentistry, the ergonomic objective is to achieve a doctor's range of motion that goes no further than a class three movement and the assistant's range of motion that goes no further than class four during 80% of the procedure time.

Activities that cause excessive reaching, bending, and twisting should be limited. In order to avoid these:

• Instruments and equipment should be arranged where they could be easily grasped. See Figure 1.5.
• Supplies and frequently used equipment should be placed as close as possible to the working area and working height to decrease stretching and bending.
• Sufficient space should be allowed to turn the whole body, using a swivel stool.

Figure 1.5 Dental operatory where the shelves of dental materials are located within easy reach.

Source: Courtesy of Dr. Ed Eisner.

Storage and retrieval of instruments, materials, and consumables (gauze, cotton, and suture) are important considerations. Consumables should be close to the operatory field and readily assessable without excessive stretching or bending. Back-up sterilized instrument packs or trays and materials can be stored in the general operatory area.

The Operatory

Ideally, the operatory dry/wet table should be 5-7?ft long, 2 1/2?ft wide, and with a height of 36?in. (head of patient) and 38?in. (tail of patient) angled downward. If possible, two or more dental stations should be planned side by side or nose to nose to allow treatment by the veterinarian on one table while an assistant cleans the teeth and completes diagnostics on the other table for delivery to the veterinarian. Peninsular stations allow the sharing of the dental radiograph unit, computer monitor, scaler/polisher, light cure unit, and dental materials. When multiple tables are used, one can be shorter to accommodate small dogs or cats. Other recommendations include:

• The working end of the table should be placed opposite from the faucet.
• Room beneath the table should be provided for the practitioner or assistant's legs/knees with access on three sides (Figure 1.6).
• An instrument and material layout area should be located within three feet of the patient's head to minimize the reach for dental instruments without the need to leave the chair or stool (Figure 1.7).

Figure 1.6 Self-contained dental delivery system.

Source: Courtesy of Midmark.

Figure 1.7 Large instrument and material layout area.

Source: Courtesy of Dr. Susan Crowder.

Adjustable Stools/Chairs

Dental procedures can be time-consuming; some practitioners and dental assistants perform dental care standing (Figure 1.8), while others prefer sitting at the patient's head treating dental pathology (Figure 1.9).

Figure 1.8 Doctor standing during dental procedures.

Source: Courtesy of Dr. Eric Davis.

Figure 1.9 Veterinarian sitting on a saddle-style stool.

Source: Courtesy of Dr. Fraser Hale.

Good posture is essential. The average human head weighs 15 pounds. Humans essentially carry a bowling ball on their shoulders....