Business of Dentistry

Demarcations

British industrial relations have, in the past, been notorious for strikes caused by demarcation disputes, the ‘who does what’ on the factory floor, and the concept of one man one job. This culminated, for those old enough to remember, in the winter of discontent of 1978-79, and the sea changes in the political arena that followed.

As dental students working in many clinics, we got used to doing all the procedures ourselves however time consuming that was, at the expense of more clinical experience. For that reason, when I was appointed to establish the Transitional Training Unit (now the Dental Practice Unit) in the University of Sheffield in 1980, one of the first, and to my mind most important, decisions I made was that each of the 5 surgeries was to have its own dedicated Dental Nurse. The reasons were both operational and educational. I wanted my students to experience just what it would be like in their careers to have a nurse prepare the surgery for their use and clear away, provide sterilised instruments, mix their materials etc. Educationally, I wanted them to experience just how valuable , nay essential, it was to have a dedicated nurse working with them, to learn about team working and to develop the skills of 4 handed dentistry, a concept then in its relative infancy in the UK back in the early 1980’s. I understand that the Unit has been increased to 10 surgeries recently. Whilst I am pleased that the original concept has stood the test of time, I understand that there are insufficient nurses to staff all surgeries and students work in pairs on a ‘buddy’ system. This may save money, but it can only be educationally detrimental to the following generation.

If any colleague doubts the importance of our nurses to our working lives, let us consider what happens if our nurse has to be absent from work for any reason, particularly at short notice and when no alternative cover is available. Productivity and thus fee income takes a nosedive, some procedures are impossible, patients get cancelled, planned schedules (see Tips no 4) go out the window for both us and our technicians, stress levels rise, there is no chaperone, and so on. Yes, there are some things we can do on our own, but we are no longer students.

In many US states dental nurses can legally place restorative materials in teeth and carry out a range of enhanced duties. In the UK we are limited by the conservative strictures of the General Dental Council. That said, the move to allow extended duties orthodontic nurses was one small step in the right direction.

I have always been fortunate in having excellent nurses working with me during my career. I am a firm advocate of paying well for expertise and having nurses who wanted to share their ideas to improve our working practices. Are the majority of dentists making the most of their nurses’ skills and potential contribution to the day’s workload?Are the majority of dentists willing to take on board ideas from their ancillary staff? I venture to say they are not and therefore put forward the following ideas to enhance their nurses’ contribution and interest.

Shade Taking

Whilst shade taking cameras are coming into increasing use, even then they may signal that a colour is outside the expected range and produce the nearest alternative. For many surgeries shade guides will be the norm. Quite often the choice can be narrowed down to one or two shades and your patients can easily become undecided. Your nurse’s opinion will carry a lot of weight, particularly if your patient has been attending the surgery for some time, has established a rapport with your nurse, and trusts her judgement. Similarlyat try in of denture or crown fit appointments, your nurse will be able to reinforce that this was the shade we all chose working together. Harold Wilson when he was Prime minister put it well, the doctrine of collective responsibility.

Acid Etching

Although Buonocore first described acid etching in 1955, it took 30 years before the technique came into widespread use, initially for enamel and later for dentine also. Our dental material scientists have established the optimum and critical times required for etching each component of tooth structure, dentine requiring less time than enamel. So who checks the etch time when you, the dentist are busy etching often several teeth and are concentrating you efforts in the mouth? The answer is of course your nurse. She could check timings on a surgery clock which has a minute hand. Better still, buy her a fobwatch (Fig 1) so she can keep time for you. She signals that time is up by lifting up the sucker the noise of which indicates to you that now is the time to wash off the etch and dry the tooth or teeth ready for the next stage of the restorative process.

Curing Command Set Composites

There is a common misconception that during curing command set composites cure towards the light. This is a fallacy. Composites cure towards the centre of the mass, and to achieve optimum bonding require a significantly increased curing time than that commonly applied. This will be discussed in more detail in a later article. So, who activates and holds the curing light?.I advocate that this should be devolved to your nurse. It is very hard to keep the area dry, make sure that the restoration is fully seated and hold the light yourself. Please delegate this responsibility to your nurse!

Articulating Paper

You have just fitted a crown or a denture and want to check the occlusion. So you get out the articulating paper, place in the patient’s mouth and say bite together. There is a high spot, the patient bites where they think they ought to and then you grind off the area you think is high and repeat the process, and repeat the process, etc. This is inefficiency at work again. Articulating paper works best when the area to which it is to be applied is dry. I found a paper tissue was an effective drier, and it can also be used to wipe marks off other teeth. The person who should be holding the articulating paper is your nurse definitely never the dentist. As the patient then closes together you the dentist can watch paths of mandibular closure, and by placing your hands under the patient’s chin feel what is happening intra-orally, the Dawson technique. Again Dawson will feature in a future Tips article.

In this article I have suggested several ways to improve teamwork in your surgery and enhance the work and therefore interest you delegate to your nurse. As always follow the principles described by John Hunter in the eighteenth century and try the experiment.