The dentist who is starting a new practice or who is upgrading a new practice is faced with many decisions. Many dentists agonize over the choices in dental chairs, cabinetry, delivery systems, and a host of many other related issues. As technology and technology systems have become more commonplace in the modern dental practice, the need to incorporate computers, networks, and digital imaging systems has turned out to be one of the most important and expensive issues to be considered.

There are many matters that have to be considered when choosing technology systems. Some of the more obvious include cost, practice management software, computers, wired and wireless networks, intraoral and extraoral digital cameras, and digital radiography. The one factor, though, that is often overlooked is how to position and use these systems without causing stress and strain to our bodies. Dental operatories are small spaces, often being 10’ X 10’, or less is some cases. By the time you add a dental chair, cabinets, delivery systems, and stools for the doctor and assistant, space is at a premium. How you position the computers, monitors, and input devices like keyboards and mice will make a huge difference in how well these systems can be used. In this article, I will examine some of the issues that must be considered, and talk about some methods of dealing with these obstacles.

Computer Systems

In most cases, the dentist should attempt to place the computer where it will be unseen by patients. Most offices use either a side-delivery or rear-delivery cabinet for storing dental supplies and handpieces, and this is often the ideal location for the computer system. Dentists who are building a new office or who are doing a complete overhaul of their operatories have the luxury of either custom-designing their cabinets or purchasing cabinets with computer space built-in. Most major computer manufacturers publish the physical dimensions of their systems online, making it easier to choose computers that fit into pre-existing or stock cabinets. In many cases, though, there is simply not enough room to place a traditional computer, so other solutions must be found.

Many computer dealers now produce a line of smaller computers. PC Power and Cooling and made their Sleekline computers for a number of years. These desktop systems are often the size of a large notebook and are only a couple of inches thick. They can easily be mounted underneath a counter-top, attached to the side of the cabinet, or underneath the computer monitor. Even Dell now has a line of computers that address these issues; their systems are called Small Form Factor computers. One concern for dentists considering these systems is that they cannot be upgraded with traditional expansion cards, like PCI or SCSI devices. While this isn’t a concern for some offices, this will limit the ability to add certain features to the computer, such as dual-display video cards, video capture cards for intraoral cameras, or some of the proprietary cards used by companies to interface with digital radiography systems.

Another method that is often employed with traditional systems is to use a special mounting bracket and to mount the computer flush on one of the walls. Both ICW and Ergotron make special brackets that can hold even large computers. I’ve often found that a computer that is mounted just below the arm of the x-ray head will be unobtrusive and will not detract greatly from the esthetics of the operatory room. The important point to remember is that the computer will need to be accessed to load programs, and in some cases, will need to be situated close to other devices. For example, offices that use certain types of digital x-ray systems must position those systems no more than 6 feet from a computer due to limitations in the length of the connecting cable.

In some cases, when placement of a desktop system is not an option, then dentists should consider using a laptop in the operatory. In the past, I was never a huge fan of laptops in the treatment rooms for various reasons. Laptops are significantly more expensive than a desktop computer with equal specifications, often two to three times the price. The speed of the top laptop is about two generations behind the fastest desktop. The screens are typically smaller and have less resolution than traditional monitors. The keyboards are cramped and in most clinical settings, typing can be difficult. Anyone who has worked with a laptop on a counter knows how easy it is to accidentally knock over the laptop. And, if you wanted to be connected to a network, you had to deal with an Ethernet cable that stretched the definition of the laptop being “portable”. Two recent advances, though, have helped to change my opinions of laptops in the operatories, under certain conditions.

First, most laptops sold today come with built-in wireless connectivity. The 802.11b standard of 11 MB/s is fast enough for almost any dental application except streaming video. With the purchase of a simple wireless access point and wireless PC Card, a dentist can spend less than $200 and have a wireless connection to his network and the Internet. With wireless, there is no longer a need to disconnect and reconnect network cables. And, with the laptop being truly portable, it is much easier to move it from room to room and to position it in front of a patient. The other new advance that is very exciting is the advent of Tablet PCs. Tablets are a cross between a conventional laptop and a Palm or Pocket PC. They use a combination of a touch screen for data input and handwriting recognition. This opens up many possibilities for dentists. We can now easily draw and annotate digital camera images or x-rays, and print out those images with the notes for the patient. We can now enter chart notes in out own handwriting and have it recognized and converted into text. The Tablets come in two flavors: slate, and convertible. The slate is a true tablet; it comes with an external keyboard and mouse that can be connected to the USB port, but it’s designed to be used by the digital stylus. The convertible is a hybrid of slate and laptop. It features a keyboard and touch pad like all other laptops. The difference is that the screen can be swiveled 180 degrees, and then folded back over the keyboard, converting it into a slate, albeit a bit thicker than the pure slate computers.

Monitors

The placement of computer monitors is probably the most important aspect of technology integration in the operatory. Placement will depend on a number of factors, such as whether there will be a monitor designed for patient viewing, cost considerations, type of existing lighting (pole vs. ceiling mounted), and viewing considerations. While flat panel monitors were once priced very high, they are now available for less than $400 on average and are an excellent choice. Besides being much lighter, they have a small footprint (take up very little space) and can easily be mounted from a ceiling, light pole, wall, or floor-based command console. In an ideal world, there would be two monitors in the operatory; one placed in front of the patient that can be used to show patients digital x-rays, intra- and extraoral images, or patient education DVDs. The doctor and assistant would ideally place the other monitor behind the patient’s head where it is easily viewed. This monitor would be used to access the practice management software and any other relevant data that the doctor doesn’t necessarily want the patient to see. Newer HIPPA regulations have caused many dentists to consider placing the monitor where the patient cannot see sensitive data. The need to do this should be based on what information is listed on the screen. For example, if the electronic scheduler has full patient names and medical alerts right on the schedule, then this information cannot be shown to other patients. While a monitor can be placed near a ceiling for patient’s who wish to watch a video, it will have little value in that position as a diagnostic aid for the patient.

Some of my clients also ask about whether they should use TVs or computer monitors in the treatment rooms. In most cases, I recommend using computers and computer monitors. Older analog intraoral camera systems used the RCA or S-video jack on a TV to show images. However, unless there was an expensive photo printer also hooked up to the TV, and then there was no way to save or get a hard copy of the images. With the falling prices of computers, it makes sense to consider this option first; it gives you the ability to save all images, and you can get very nice photo prints with a printer that costs less than $200.

Input

The positioning of keyboards and mice is very important since it will affect the way that both the doctor and the assistant work. A keyboard that is placed behind the doctor’s back will be uncomfortable to use and will require constant swiveling of the chair. Also, this would prevent the assistant from having access to the keyboard. Ideally, the keyboard would be placed behind the patient’s head on a rear-unit, so that both doctor and assistant could access it. Another good option is to attach a keyboard tray to either the desktop or to the monitor-mounting arm. A wireless keyboard would also be an excellent option to consider, as it will allow both the doctor and assistant the luxury of placing the keyboard in the position that is most comfortable for each of them. When it comes to mice, there are more options since more than one can be hooked to the computer at the same time. In the past, I often recommended that the doctor use a light pen, which will allow them to point out areas of interest on the patient screen, and the assistant could then use a traditional mouse or trackball to enter data for charting, scheduling, etc. The problem, though, is that light pens can only be used on CRT monitors; they don’t work on flat-screen LCD monitors.

There are still other good options for entering data or working in a Windows environment. Many keyboards come with a built-in touchpad or trackball, which would eliminate the need for a separate mouse. You can buy touchpads, similar to the ones that are used on laptops, for desktop computers. If price isn’t an object, consider a touchscreen monitor. Expect to pay about $750 for a decent 15” touchscreen monitor, and $1200 for a 17” version. Windows comes with an on-screen keyboard, just like a Palm. Since most of the data entered in the operatory is either for charting or entering treatment codes, it wouldn’t be too cumbersome to enter text this way.

While technology has greatly aided the modern dentist in providing treatment and involving the patient in co-diagnosis, care must be taken to properly plan for the ideal positioning of these devices. While it is easy to get caught up in planning the purchases and choosing the various components, dentists must spend time to decide how these different systems will be positioned and used in the dental practice. Dentists have a high occurrence of back and neck problems compared to other professions, so we must do everything we can to minimize the stresses we place on our bodies throughout the course of the typical work day. The decisions that we make before the purchases go a long way towards improving the quality of our working life.