Purchasing Dental Equipment and Supplies
There are several options for applying dental sealants in a school setting: (1) setting up a dental clinic within a school-based health center, (2) outfitting a mobile van with dental equipment, or (3) using portable dental equipment in the school.
Some health centers are located at schools. These centers are designed to serve students who have limited access to care as well as those from families with low incomes who are uninsured or underinsured. Services provided in school-based health centers emphasize prevention as well as early identification and treatment of physical and behavioral health concerns. Each school-based health program is different, but services may include
- Care for acute illness and injury
- Care for chronic conditions such as asthma and diabetes
- Physical examinations
- Sports physicals
Dental clinics have been set up on a permanent and semi-permanent basis in some school-based health centers. Often, clinics provide preventive and restorative oral health care (including dental sealants) to students enrolled in the school, thereby serving as a dental home. Permanent dental clinics usually use traditional equipment similar to that found in a private dental practice. Semi-permanent clinics can be outfitted with portable equipment or a combination of traditional and portable equipment.
The cost of outfitting a dental sealant program in a school-based dental clinic is comparable to if not slightly less expensive than that of outfitting a portable school-based dental sealant program. Often the equipment in a clinic is secondhand or donated, particularly if traditional equipment is used. As noted previously, however, permanent and semi-permanent school-based clinics often provide preventive and restorative oral healthcare. A dentist must be on site to provide restorative care, and additional equipment and supplies are needed (e.g., handpieces, X-ray machines, filling material). These added requirements significantly increase program costs.
Working conditions in a permanent or semi-permanent school-based dental clinic tend to be better than those in a portable school-based dental sealant program, where the dental sealant team often work in hallways, gymnasiums, or other high-traffic locations. In a permanent or semi-permanent school-based dental clinic, equipment does not have to be transferred from one school to another, which reduces the likelihood that equipment will be lost or damaged and eliminates the extra time needed to set it up and break it down.
However, permanent and semi-permanent school-based dental clinics lack the flexibility of school-based dental sealant programs. Students from other schools in the district must be transported to a permanent or semi-permanent clinic for placement of dental sealants, which requires escorting them on foot or transporting them by bus or van. Usually, students are transported to the clinic at one time, and they stay at the clinic until every student’s work is complete. This allows for an efficient workflow within the dental clinic, but it keeps students outside the classroom for a much longer period of time that would be necessary if sealants were applied in their home school using portable equipment.
To improve access to oral health care for disadvantaged populations, some school-based dental sealant programs have outfitted mobile vans with dental equipment to make a fully functioning operatory on wheels. Most mobile vans are large enough to hold two dental chairs and all the equipment needed to apply dental sealants, and some make it possible for staff to provide additional preventive and restorative care. Some advantages to mobile dental vans are that they eliminate the need to find space in a school and to set up, break down, and pack up equipment. They also reduce the likelihood that dental equipment will be damaged en route from one school to another, and they keep the dental clinic environment under the control of the dental team.
There are, however, disadvantages to mobile dental vans. The cost of outfitting a van is more than 10 times greater than the cost of purchasing portable dental equipment, and the annual cost of operating a mobile van is approximately twice as high as using portable dental equipment in a school. In addition, movement of students to and from the van may be more complex than moving them within the school. For a school-based dental sealant program to operate effectively from a mobile van, the following conditions must be met:
- A special electrical hookup receptacle must be available at each school, or the van may be operated using a generator that requires fuel, which is more expensive than electric power.
- A steady temperature must be maintained in the van at all times to ensure the stability of the liquid and chemical dental supplies and to prevent equipment damage.
- Equipment must be regularly maintained to prevent mechanical failure.
- The van must be insured, and when it is not in use, it must be stored.
- Space must be available for students’ outerwear during cold or wet weather.
The Mobile-Portable Dental Manual provides additional information that may be useful to those interested in learning more about this option.
The other and most widely used equipment option for school-based dental sealant programs is portable dental equipment. The type and amount of portable dental equipment needed depends upon the size of the program (e.g., the number of students receiving dental sealants), the number of dentists and dental hygienists applying sealants, and the type of sealant material used (e.g., self-cure, light-cure).
There are a number of types of portable dental equipment that a school-based dental sealant program can use. Most programs purchase portable equipment from a variety of manufacturers.
Portable dental equipment may exhibit more variation in cost and quality than traditional dental equipment. School-based dental sealant program administrators, therefore, must be informed consumers.
Before purchasing equipment, program directors may wish to ask manufacturers for contact information for recent customers and to ask these customers about their experience with the equipment. Also, manufacturers often exhibit at public health conferences, where potential purchasers can test equipment.
Types of Portable Dental Equipment
All school-based dental sealant programs need the following portable equipment:
- Dental unit
- Air compressor
- Dental chair
- Dental light
- Dental hygienist and assistant stools
- Ultrasonic cleaner
Following are descriptions of each type of portable dental equipment and a discussion of factors to consider in choosing each one. Individual program needs and the type of vehicle that will be used to transport the equipment from school to school should be considered when making equipment selections.
The dental unit should contain high-speed evacuation and an air-and-water syringe with a self-contained water source. Handpieces are not necessary for school-based dental sealant programs since unfilled dental sealants and toothbrush prophylaxes are used. Consideration should be given to the unit’s weight, cost, ease of mobility, ease of use, ergonomic compatibility, maintenance requirements, and whether it has a stand. A tripod stand will prevent the unit from wobbling on uneven floors.
Figure 4.2. Portable Dental Unit,
Example #1. Unit manufactured by DNTLworks.
Figure 4.3. Portable Dental Unit, Example #2. Unit manufactured by A-dec.
Figure 4.4. Portable Dental Unit, Example #3. Unit manufactured by Aseptico.
Dry, oil-free air is important for all dental procedures and is essential for the successful application and retention of dental sealants. Most compressors used in dental offices have dryers to ensure that the air used for dental procedures is free of moisture and oil.
Some portable compressors use oil, and others are oilless. Oilless compressors are light and easy to move, but can be noisy. It’s best to place them as far away from the operatory as possible to reduce the noise level while the compressor is running. When possible, compressors can be located in an adjacent room (extra-long hoses that attach the compressor to the unit can be ordered).
Oil compressors can be heavy and must be loaded and transported carefully, but they are quiet. When transporting an oil compressor, care must be taken to make sure that the oil does not leak into and contaminate the air chamber.
In addition to selecting a compressor type, it is important to consider cost, horsepower, and air chamber size.
Compressors with smaller air-storage chambers are lighter and smaller than those with larger air storage chambers. Compressors with larger air-storage chambers recycle the air less frequently than those with smaller chambers, and they consequently produce less noise.
The dental chair should be durable, stable, light, easily foldable, and adjustable in seat height and chair back tilt. It should also have a carrying case. Program directors should check the chair’s seat height to make sure it can be adjusted to a level that allows staff to work comfortably. It may be necessary to purchase a heavier chair to obtain one that is ergonomically appropriate. The chair should also allow operators to work from either side, depending upon whether the individual is left- or right-handed. Adjustable headrests can be helpful.
Figure 4.7. Dental Chair, Example
#1. Unit Manufactured by Aseptico.
Figure 4.8. Dental Chair, Example #2. Unit manufactured by DNTLworks.
Figure 4.9. Dental Chair, Example #3. Unit manufactured by A-dec.
An intense dental light is important for school-based dental sealant programs, because the lighting in the room where the program is located may be poor. The intensity of dental lights can be assessed by comparing the foot candles of light they produce (a unit of measure of the intensity of light falling on a surface). Cost, weight, adjustability, ease of bulb replacement, and cost of bulbs are also important considerations. The heat generated from the light is a consideration as well, since school-based dental sealant programs often are located in spaces without air conditioning.
Fiberoptic lights are ideal for school-based dental sealant programs. Although they are costly, they allow for maximum visibility, which can improve sealant quality.
Care must be taken when transporting fiberoptic lights, as they can be easily damaged. If the bundles in the light’s arm are bent too far or mishandled, they can be broken, which reduces the intensity of the light over time. If program administrators feel that fiberoptic lights are too costly or fragile, halogen lights may be a better option.
A significant change in portable dental lights has been the introduction of light-emitting diode (LED) lights. They produce a true white light that is up to 40 percent brighter than halogen lamps. The bulbs have a 12–25 year life compared to halogen’s 3–6 month life. LED lights are energy efficient and produce no heat in the beam, which improves dental sealant staff and patient comfort.
Portable dental lights are available in multiple configurations. The three most comon are lights that are mounted to a stand, headband, or loupe. Stand-mounted versions typically have a focused-beam light on a strong, flexible, gooseneck arm. Headband-mounted and loupe-mounted light sources are worn by the dental team. These provide a line-of-sight light that reduces eyestrain and the need to reposition the overhead light. All come with a power cord or battery pack.
|Figure 4.12. LED Loup-mounted light, Example #3. Unit manufactured by SheerVision|
Figure 4.10. Halogen Light, Example
#1. Unit Manufactured by Aseptico.
Figure 4.11. Fiberoptic Light, Example #2. Unit manufactured by DNTLworks.
Figure 4.12a. LED Headband-mounted light, Example #4. Unit manufactured by DNTLworks.
Dental Hygienist and Assistant Stools
Dental hygienist and assistant stools should be light and comfortable and should have adjustable seat and back heights. Ergonomically sound equipment is worth the extra cost, since it impacts staff health, comfort, and productivity, and ultimately, satisfaction and retention.
A few styles of stools fold into carrying cases. If there is sufficient space in the vehicle used to transport equipment, small, lightweight stools that are not specifically designed for portable dental programs can be purchased from dental suppliers. These are less expensive than foldable styles. It is also more convenient to not have to break down and reassemble the stools every time the program moves.
If possible, before purchasing dental hygienist and assistant stools, program administrators should allow dental hygienists and assistants to try them out to determine whether the stools adjust properly and don’t tip over when rolled on uneven surfaces. Stools with five casters are more stable than those with four. If stools need to be disassembled for packing, administrators should try to disassemble and reassemble them before purchasing to make sure the process is manageable.
There are no sterilizers manufactured specifically for portable dental programs. To ensure proper sterilization, school-based dental sealant programs should use only sterilizers manufactured for medical or dental instruments and supplies. These can be acquired from dental-equipment suppliers. There are a variety of sterilizers available: steam under pressure (also called autoclaves) and dry heat.
Steam-under-pressure sterilizers. Steam-under-pressure sterilizers allow for the sterilization of a wide range of materials. Temperature, pressure, and time are the main factors in this process. The higher the temperature, the greater the pressure, and the shorter the sterilization cycle. There are two basic types of steam sterilizers—gravity displacement and pre- and post-vacuum.
Gravity displacement sterilizers generate steam within the chamber and force air out through an escape valve. This process forms the moist heat that kills microorganisms. During the sterilization process, cool air pockets can form and prevent the sterilizer from reaching the required temperature for complete sterilization. In addition, gravity-displacement sterilizers may cause instruments to corrode. Furthermore, if sterilized instrument packs are handled before they are completely dry, the instruments can become contaminated from microorganisms that penetrate the wet pack. Wet instrument packs can also be torn or punctured easily.
Pre-and post-vacuum sterilizers, sometimes referred to as pre-vacuum sterilizers, pump air out of the chamber before the steam enters, creating an environment that allows faster and more thorough steam penetration than gravity-displacement steam sterilizers. Pre-vacuum sterilizers also include a cycle that removes moisture, resulting in a dry instrument pack, thereby reducing chances that instruments will be contaminated.
A process called “flash steam sterilization” is a method for disinfection that is available on most steam sterilizers. Flash sterilization should only be used for instruments or other solid items that will be used immediately. To avoid contamination, instruments are not wrapped and must not be transported or stored. It is also important that the instruments are adequately cleaned before they are sterilized. Flash sterilization has been used frequently in operating rooms when changes in planned surgical procedures occur, when limited instrument inventory is available, or when instruments are dropped. Because dental sealant program staff seldom face circumstances similar to those present in operating rooms and because of the high risk for instrument contamination, flash sterilization is not recommended for school-based dental sealant programs.
All steam-under-pressure sterilizers require adequate ventilation. Recent advances in steam-under-pressure sterilizers include increased use of digital instrumentation and monitors, which need to be protected from high heat and moisture. Basic, solid-state steam-under-pressure sterilizers may be more durable and reliable than more technologically advanced ones.
Dry-heat sterilizers. Dry-heat sterilizers employ high temperatures to destroy microorganisms. These sterilizers are considered effective and safe for metal instruments because the process does not cause rust or corrosion. There are two kinds of dry heat sterilizers: (1) the traditional “toaster oven” style, which take 1 hour to sterilize instruments, and (2) the COX Dry Heat Sterilizer, which can sterilize instruments in 6 minutes.
Selecting a sterilizer. In selecting a sterilizer, school-based dental sealant program directors should consider the following factors:
- Size. Smaller units cannot sterilize as many instruments in a single cycle as larger units can.
- Portability. All of the sterilizers described in this section are available in a tabletop form, which makes transport from site to site easier. Weight and size should be considered, especially if dental sealant program staff members move the equipment from site to site.
- Distilled water requirements. All steam-under-pressure-sterilizers require distilled water, which has to be carried and must be available on a daily basis. Liquids are heavy, and they spill easily.
- Cycle time (all the steps a sterilizer must go through to sterilize a load). In most instances, sterilizers with short cycles allow for more efficient use of time because staff members don’t have to wait at the end of a day for a long cycle to run. Likewise, on moving days, short cycles allow for sterilizing to be completed and the equipment cooled down before it has to be moved.
All dental instruments should be decontaminated before they are sterilized. The ultrasonic cleaner is an effective tool for removing blood, saliva, and debris from dental materials before sterilization. Size, weight, and cost are all considerations in selecting an ultrasonic cleaner.
In addition to budgeting for the equipment listed above, school-based dental sealant programs should also budget for the following items, as needed:
- If light-cured sealant material is used, curing lights are needed.
variety of containers are required for storing and moving supplies
and equipment. Eighteen-gallon storage containers are durable and
can double as counter space.
Figure 4.18. Storage Units Double as Counters. Courtesy of the Cincinnati Department of Health.
Figure 4.19. Storage Units Double as Counters. Courtesy of the Cincinnati Department of Health.
- Dollies or carts are helpful in moving portable equipment into
and out of schools.
- Because outlets are not always conveniently located, electrical
outlet strips with circuit breakers and heavy-duty extension cords
are important. In older school buildings, long extension cords
are sometimes necessary to plug equipment into outlets on different
circuits to avoid overloading electrical systems.
Figure 4.21. Dollies That Convert to Carts Are Useful in Moving Equipment. Courtesy of the Cincinnati Department of Health.
Figure 4.22. Dollies That Convert to Carts Are Useful in Moving Equipment. Courtesy of the Cincinnati Department of Health.
Table 4.1 shows the approximate cost of equipment needed to start a school-based dental sealant program using average 2007 retail equipment costs. The table does not include “other” expenses (e.g., cotton roll holders, mirrors):
|Table 4.1. Approximate Cost of Equipment Needed to Start a School-Based Dental Sealant Program|
|Equipment||First Operatory||Second Operatory|
|Low Estimate ($)||High Estimate ($)||Low Estimate ($)||High Estimate ($)|
|Dental hygienist stool||250.00||590.00||250.00||590.00|
|Total||$7,621.00||$17,746.00||* $4,811.00||* $11,920.00|
Grand totals for first and second operatories
|* The cost per operatory is lower in two-operatory programs because only one sterilizer and one ultrasonic cleaner are needed.|
Number of Operatories Needed
Assuming that a school-based dental sealant program is to operate 6 hours a day for 5 days a week during the school year, the number of operatories needed can be determined by estimating the participation rate according to the total number of students eligible for the program. Although participation rates vary, in many programs approximately 50 percent of students eligible for the program actually participate. Given the parameters described previously, one operatory can serve 3,300 to 3,500 students. Based on a participation rate of 50 percent, approximately 1,650 to 1,750 students will actually receive dental sealants. With two operatories, 3,300 to 3,500 students will receive dental sealants. This information is useful for estimating the number of operatories needed to reach all participating students enrolled in a school district during a single school year.
Selecting Portable Dental Equipment
Regardless of the purchasing process a school-based dental sealant program is required to follow, it is important to determine which brand and model of each piece of equipment best meets the program's needs.
Some dental manufacturers sell directly to programs, and some distribute equipment through dental suppliers. All dental manufacturers publish a manufacturer's recommended retail price, which includes an established profit margin for the manufacturer, and, when appropriate, for the dental supplier. Also, some manufacturers publish discounted institutional prices for government and nonprofit agencies.
All retail prices should be considered negotiable. Institutional prices may be negotiable depending on the volume of the purchase and the profit margin the manufacturer has established.
It may be preferable to purchase as many pieces of equipment as possible from a single manufacturer. Equipment will then be standardized and interoperable, and it can be calibrated before it is shipped to the program (e.g., the dental unit’s air pressure can be properly adjusted).
Some programs are required to request formal bids from prospective vendors. If a program’s purchasing requirements do not allow it to specify manufacturer and model, then the request for bids should detail the equipment specifications (e.g., size, weight, horsepower, foot candles, portability), as specifically as possible. Otherwise, program administrators may be forced to purchase from the manufacturer that provided the lowest bid, even though the equipment does not meet program needs.
Preparing Equipment for Use
Before portable dental equipment is moved into a school-based dental sealant program, administrators should allot time to prepare the equipment for use. The equipment should be unpacked, and program administrators should read all manuals and instructions.
The dental unit and compressor will need to be adjusted to work with the proper amount of air pressure. In some instances, quick-disconnect fittings will need to be installed on the compressor hose and dental unit. A service technician from a local dental supply company can calibrate equipment and assist with any adjustments. If no local dental supply companies are available, program administrators should consult the manufacturer. In some instances, manufacturer representatives can train staff to set up, use, and maintain the equipment.
The supplies a school-based dental sealant program needs depend upon the method of sealant application selected and program administrators’ and staff’s preferences. Table 4.2 provides a list of supply categories that should be considered when making purchases:
Table 4.2. School-Based Dental Sealant Program Supplies
Staff and Student Protection
Sterilization and Disinfection
The cost of purchasing durable equipment (e.g., mouth mirrors, explorers, cotton roll holders, trash cans, dishpans, extension cords, tray tables) listed in the preceding table is approximately $3,000 to $5,000 using 2009 average retail prices. The annual cost of infection control and supplies using 2009 average retail prices is approximately $25,000.
Many manufacturers produce a variety of dental sealant materials. When selecting the dental sealant material for use in a school-based dental sealant program, program administrators should look for cost-effective materials that have prolonged retention properties, have low solubility in the oral environment, and are simple to apply. The type of sealants, bonding agents, and enamel etchants should also be considered carefully.
Type of Sealants
The most commonly used sealant materials are resins. They include filled, unfilled, and fluoride-releasing filled cyanocrylates; polyurethane resins; and bisphenol-A-glycidyl (bis GMA resins). In terms of retention and effectiveness, one resin type does not stand out over the others. Filled resins should not be used in school-based dental sealant programs because they do not abrade rapidly, requiring adjustments to be made to the occlusion after they are placed.1 Under most state practice acts, a dentist is the only oral health professional allowed to perform this procedure. Occlusal adjustments also require the use of a handpiece. These requirements increase the school-based program’s equipment and operating costs.
There has been an increased interest in the use of glass ionomer cements (GICs) as sealant materials because they release fluoride that may be an aid in delaying the caries process and because they can be used in fields that are difficult to keep dry (e.g., partially erupted occlusal surfaces). GICs’ retention rates are lower than rates for resin-based sealants, and GICs require frequent monitoring and reapplication.1 In school-based settings the added time needed to monitor and reapply GICs reduces efficacy and adds to the programs operating costs. For this reason they are not recommnded for use in school-based dental sealant programs.
Research on the placement of bonding agents or primers prior to sealant placement has shown improved retention rates, particularly in the buccal pits and lingual grooves.3 The use of a bonding agent, however, adds a step to the application process. This involves applying a bonding agent layer to the tooth surface and then air thinning this layer before the sealant can be placed.
The usual acid used for enamel etching is 37 percent phosphoric acid. Acceptable bonding is obtained if the etchant is in contact with clean enamel for 15 to 20 seconds. Topical fluoride treatments can be applied before sealants are placed without impairing the sealant’s retention.
Other factors to consider when selecting dental sealant materials include the following:
- Whether to use light-cured or self-cured dental sealants. Self-cured sealants come in two parts that are mixed to begin the polymerization process. Setting time can vary from 60 to 90 seconds, and the warmer the temperature, the more quickly the sealants will set. Light-cured sealants harden when exposed to a curing light. An obvious advantage of light-cured sealants is that they allow for increased working time. However, if light-cured sealants are used, a light must be purchased. Self-cured sealants can usually be applied more quickly by using a quadrant or half-mouth technique. This way, all the sealants can cure simultaneously instead of individually.
- Whether to use clear or colored dental sealants. Sealants can be clear, tinted, or opaque; some sealant material is tinted when it is applied and changes to an opaque color after it has set. Tinted or opaque sealants are easier to evaluate than clear ones during retention checks.
Since school-based dental sealant programs cannot carry large volumes of supplies from school to school, a central storage location is needed. Supplies are sent to the program from central storage weekly. For programs located in rural areas, supplies can be shipped directly to the home of a staff member. Stored supplies should be kept off the floor on palettes or shelves.
Estimated Cost of Supplies
Supply costs vary among programs because each program operates differently, selects different supplies, and uses different purchasing processes. When planning a program, however, an estimate of supply costs is helpful. For example, a program in Ohio examined 4,000 students per year from 2003 to 2006 and placed about 20,000 dental sealants on 3,600 students per year. Supply costs averaged $20,000 per year over the 3 years. Supply costs, therefore, were approximately $5.50 per student per year during this period.
- Simonsen RJ. 2002. Pit and fissure sealants: Review of the literature. Pediatric Dentistry 24(5):393-414. http://www.ncbi.nlm.nih.gov/pubmed/12412954.
- Joskow R, Barr DB, Barr JR, Calafat AM, Needham LL, Rubin C. 2006. Exposure to bisphenol A from bis-glycidyl dimethacrylate-based dental sealants. Journal of the American Dental Association. 137(3):353–362. http://jada.ada.org/content/137/3/353.full.
- Fiegal RJ, Musherure P, Gillespie B, Levy-Polack, Quelhas I, Hebling J. 2000. Improved sealant retention with bonding agents: A clinical study of two-bottle and single-bottle systems. Journal of Dental Research 79(11):1850-1856. http://www.ncbi.nlm.nih.gov/pubmed/11145354.