Every practice has a way of doing things, a flow of tasks that makes it possible to get things done.
Every practice has systems. Each of these systems was either created with intent based on an outcome that was first visualized and deemed to be desirable, or they just happened. For most of us the thought of systems doesn’t really occur until we find ourselves not getting the outcomes we hope for in practice.
It’s easy to understand how systems just happen – they are either the leftovers of the practice we joined or bought, or they are the best attempt of a group of people recently assembled to make things work. When a team is created, each member brings their own systems, their own way of making it happen. These may be exactly what we are looking for. They could also be far from what we desire.
At Spear we are always referencing systems. Facially Generated Treatment Planning seeks to help you create a system of analysis that makes it possible to work through every patient's data in a logical and linear manner, simplifying the process and your life. Once woven into the fabric of what you do, of how you approach things, of how you think, systems make the repeatable processes in the practice occur with predictable outcomes.
Why Checklists are Crucial
I’ve written several times about checklists. Checklists are systems for which we have created a written guideline that is referred to while we “run” the system. You may have read some of my other references to “The Checklist Manifesto,” by Atule Gawande. He designed surgical protocol checklists for World Health Organization hospitals with immediate effects on their levels of morbidity and mortality. They were applied pretty quickly in many hospitals around the world following publication of the book. Their effect, while not ubiquitous, had an overall positive impact.
The following chart came out of a study by a 10-hospital group in the United Kingdom as the leaders tried to understand why the checklists did not seem to make things run more successfully in every instance. Here are the reasons they reported about why checklists might fail:
While morbidity and mortality are not usual terms applied to cementation and bonding of dental restorations, I think they actually can be applied with remarkable accuracy.
Mortality of the restorations we cement or bond is painfully evident when they come off or debond, suffering an untimely death. While all restorations are doomed to die eventually, their premature passing can and does create significant anguish for many dentists and teams. The disruption to the schedule created by de-cementation or de-bonding, and the reduction in trust that occurs when a patient returns on multiple occasions, are the unmeasured but deeply felt consequences of early death.
Morbidity of our restorations is less acute but no less painful. Early breakdown of the cement or bonding layer is an ongoing concern and the reason for many re-do restorations of teeth for which we hoped a long and useful existence. Again, while we have tried to impress our patients with the temporary nature of our restorations, the truth is both they and we are disappointed when things begin to fail.
Research has illustrated that morbidity and mortality can be impacted by the use of a checklist when complex systems are involved, and dental bonding is certainly an example of a complex system1,2. I’m not sure that cementation qualifies.
Cementation Checklists Are Not Necessary
This was the first resin-modified glass ionomer cement I ever used, and the one to which I became addicted. Originally branded Vitremer and available as a powder liquid it has cemented millions of restorations with great success. Available today as Rely-X Luting Cement from 3M, it is available under many names and many brands from many companies. Its reduction in use came about not because it did not work well in widely variable clinical applications, but because we started bonding and because it is so white.
Cementation is simple. Clean the restoration, clean the tooth, dry both restoration and tooth, apply gluma if you desire, seat the restoration, clean-up the excess, have a nice day. Any pilot and crew can and does remember that protocol. Adding the necessity of verbally (or physically) checking off a list can create push-back, as noted above, and will not usually improve the result. I don’t think there is a good reason to create a checklist for cementation. Once the team is aware of the protocol – the system – they easily reproduce the results predictably and accurately. It is not complex.
Bonding Checklists Are Necessary
Bonding is different. As noted in the previous reference, bonding is fraught with so many technical steps that flying becomes difficult to predictably repeat again and again without the assistance of a guide. Gawande showed that highly intelligent, highly trained, highly skilled individuals will believe they have completed a step when in fact they did not. The reasons for this are guessed about in his book, but the fact that it happens means we reduce the risks associated with bonding restorations when we use a checklist.
I like many bonding products and systems, and most if not all of the products out there work well. If they did not, they would gradually disappear, and this does not seem to be happening. That being said, anyone who has switched products becomes immediately aware that while the general protocol is similar, each company and product has a very distinct and directed application to insure the highest level of success. Noting this protocol in writing and “checking it off” as you seat restorations can improve your success.
Gary DeWood, D.D.S., M.S., is Executive Vice President of Spear Education and a member of Spear Resident Faculty. As one of the founding members of Spear, he directed Curriculum and Clinical Education for nearly a decade prior to joining in the launch of Spear Practice Solutions.
1. Askarian, M, Kouchak, F, Palenik, CJ. Effect of Surgical Safety Checklists on Postoperative Morbidity and Mortality Rates, Shiraz, Faghihy Hospital, a 1-Year Study. Quality Management in Health Care. 2011;20(4):293–297.
2. Frankenberger, R, Kramer, N, Petschelt, A. Effect of Application Mistakes on Bond Strength and Marginal Adaptation. Operative Dentistry. 2000;25(4):324-330