Imagine you are sitting in a lecture hall. You have checked
your e-mail on your cell phone three times in the last two
minutes. The lecturer, talking in monotone, hides behind the
podium, projecting slides with too many words on them. The
room is dark. There are no windows to gaze out of, and the
people on either side of you are equally uninterested.
Now, instead, imagine a room with eight tables and several
chairs filled with dental supplies, equipment and interesting
paraphernalia, each monitored by a representative of a
dental supply or manufacturing company. During the animated,
audience-involved lecture and PowerPoint presentation
you learn why each product is useful, how it works and
when it is applicable. The lecturer calls one or two volunteer
participants to the front of the room to demo each product.
The day ends with "circuit training." During the final two
or three hours, you are assigned your workstation sequence,
which reminds you of circuit training in a gym. You pair up
with a colleague and go to each table in turn. You touch and
handle the equipment and use it on your partner under the
careful guidance of the representative. After you have completed
each task to your satisfaction, your partner applies it on
you using sterile supplies.
As a presenter of participation courses, I have found circuit
training to be a very effective way of teaching dentists
and staff new skills and exposing them to tools, supplies and
equipment with which most are unfamiliar. At the end of
each module, I ask attendees to articulate one valuable finding
- a "take-home pearl."
A typical PowerPoint lecture caters only to learners with
aural and visual learning styles. Involving participants in
demos that allow them to touch and manipulate threedimensional
objects adds kinesthetic and linguistic learning
styles to the mix, allowing participants to better retain concepts
(and avoid falling asleep).
My teaching philosophy is based on the Confucian directive:
"Tell me, and I will forget; show me and I may remember;
involve me, and I will understand." The attendance in
my participation courses is typically 20-45, comprised
mostly of dentists but include dental students, hygienists and
There are endless topics that can be taught with the circuit
training model. Since I work primarily with treating special-
needs patients, I've included one such class as an example
for this article. Each of the eight workstations tries to answer
a question in practical way, reinforcing the slides and demo
seen during the lecture part of the course. Take this example
and apply the method to your area of expertise.
Question: How can you get uncooperative patients to sit
without kicking or flailing their arms?
Answer: Use body wraps, knee/leg stabilizers and forehead
I demo this equipment by selecting the largest man in the
group, wrapping him up and challenging him to get out of the
For the workstation sequence,
a chair is placed next to a table covered
with Rainbow body wraps -
colorful, washable and inexpensive
mesh adjustable with Velcro, made
in the U.S. by Specialized Care Co.
(Fig. 1). The wraps come in seven
different sizes and are non-threatening.
They are extremely effective
in gently restraining any patient's
arms and legs.
The attendee who is playing patient sits on the chair, and
the attendee who is playing dentist is asked to wrap him or her
up. Once wrapped, the dentist further immobilizes the patient
with Velcro knee and leg stabilizers and then with forehead stabilizers.
The patient is then asked to wiggle and try to kick the
dentist or to injure him or herself. If the dentist has properly
applied the equipment, the patient will be unsuccessful.
Question: How can you open the mouths of uncooperative
Answer: Use mouth props.
After the patient is wrapped and restrained, the dentist
explores several different mouth props on the patient. During
the lecture the attendees are taught several techniques to open
the patient's mouth, not commonly known or used in dental
offices, which they can now practice.
The first technique is to hold the patient's nose with two
fingers, while the dentist's other hand (or an assistant's) hovers
near the mouth with the Open Wide mouth rest (Fig. 2),
made of two tongue depressors wrapped in foam. When the
patient opens his mouth to breathe, the prop is gently and
The second technique is to use one finger to firmly push
the middle of the chin down at a 45-degree angle, applying
vibrating pressure to the acupuncture meridian point
Once the patient's mouth is open with the mouth rest in
place, the dentist inserts a unilateral Molt Mouth Gag manufactured
by Hu-Friedy on the opposite side (Fig. 3). The dentist
then withdraws the foam mouth rest and slowly ratchets
open the Molt Gag, which is made of metal and two short rubber
hoses. The mouth is now comfortably wide open.
The dentist then inserts a bilateral Jennings mouth prop
(Fig. 4) in the patient's mouth, contacting all the premolars to
expose all 12 anterior teeth. This all-metal appliance is commonly
used by ENT specialists to examine and treat tonsils,
but can also be used by dentists to isolate and treat front teeth.
The dentist then inserts
the Isolite five-in-one device
in the patient's mouth, learning
how to select the proper
size or to modify it accordingly
(Fig. 5 & 6). This timesaving
tool is a mouth prop,
high-velocity saliva ejector, lip
retractor, tongue retractor and three-level light source. The
Isolite device isolates, illuminates and dries an area during
restorative procedures. Its use in our practice has virtually eliminated
no-charge redos of sealants or composites.
At the end of this leg of the circuit training each attendee
will have experienced these props from the patient's vantage
point, and learned how to properly apply them. Feedback
received from peers ("You're hurting my TMJ!" or "You nipped
my lip!") is immediate and honest, which leads to improved
chairside application of props.
Question: How can you
relax anxious patients?
Answer: Use nitrous oxide
Nitrous oxide anxiolysis is
covered in a lively lecture, and
I demonstrate proper mask
application on an attendee. For many patients, sedation drugs
alone are just not enough to allow the needed dental care to be
completed. I present videos of several patients experiencing
During the circuit training the dentist learns how to properly
select and fit a mask on the patient. The nitrous oxide system
available to attendees is one by Porter Instrument (Fig. 7).
Its representative demonstrates more effective ways of securing
the mask and reducing air leakage. No actual gas is used in the
classroom setting - that would cause us all to lose focus for the
rest of the course! - but merely handling the mask helps each
attendee experience what it might feel like to be both the dentist
and the patient.
Question: How can you easily obtain X-rays on specialneeds
patients when you have a computer loaded with sensor
Answer: Use a handheld portable X-ray unit and a digital
The presentation includes slides illustrating the versatility
of the NOMAD and the even smaller Nomad-Pro, manufactured
by Aribex, in a wide variety of settings. I point out how
images can be made without requiring electricity. The
Nomad-Pro (Fig. 8), the DEXIS sensor (Fig. 9) nor my laptop
need to be plugged in to a wall outlet, and no Internet connection
is required. This system can be used in waiting rooms,
patients' homes, nursing homes, hospitals, institutions and
even lecture rooms.
During the demo I illustrate taking an X-ray with the fivepound
Nomad-Pro and my laptop, installed with DEXIS
instant digital imaging software and hooked up to the sensor. I
use an extracted tooth and project the X-ray image on the large
screen for all to see instantly.
During the circuit training, attendees use the Nomad-Pro
to take an X-ray of an extracted tooth or piece of metal of their
own (ring, earring), guided by Aribex and DEXIS representatives.
The reps then ask each attendee to promptly take a second
image - pretending that the first image missed the apex. A
second image instantly appears on the laptop screen, replacing
the original image, which is archived, not overwritten.
Although lead aprons may not be considered necessary for
the operator, we always have them available at our courses for
anyone who requests them. Aprons can provide an extra level
of protection from scatter radiation, should an attendee who is
learning the system not properly line up the cone at 90 degrees
to the object and sensor.
Question: How can you easily obtain X-rays on specialneeds
patients without a computer?
Answer: Use a handheld portable X-ray unit and self-developing
If I don't have access to the DEXIS system for any reason -
computer malfunction being the prime one - my fallback is
Ergonom-X self-developing film (Fig. 10), also called Dental
Film. Ergonom-X has bailed
us out of more emergencies
than I care to admit.
In my demonstration I use
the Nomad-Pro by Aribex to
expose an extracted tooth
onto the dental film, and
show attendees how to process
the image. All it takes is to
gently massage the packet's
internal chemicals onto the film for 60-90 seconds. Then I remove the film from the
packet and rinse it off in water. The image can be viewed while
it is still wet (Figs. 11 & 12).
During the circuit training, attendees develop two films
previously exposed by my office staff with different mystery
objects. They are asked to identify the objects, and place the
developed films on a hanger to dry.
Attendees then use the Nomad-Pro to take new images of
an extracted tooth or piece of metal of their own (ring, earring)
onto two fresh film packets, under the helpful guidance of the
Aribex and/or Ergonom-X representative.
Question: How can you treat patients outside the dental
Answer: Use a portable or mobile dental cart (and have a
To demo a lightweight portable cart (Fig.13), I often use an
Aseptico unit. I demo a fully assembled unit in operation, turn Use a portable or mobile dental cart (and have a
To demo a lightweight portable cart (Fig.13), I often use an
Aseptico unit. I demo a fully assembled unit in operation, turn it off, break it down, prepare
it for transport and finally
The second category of
portable tools I demo is
headlights. Not all portable
or mobile carts have lights
attached. I provide a variety
of headlights for attendees to
explore. Dental practitioners
who already use headlights
requiring an electrical outlet
are delighted to learn about
options for lightweight battery-
Before demonstrating the
Sheer Vision (Fig. 14a), Ultralight
Optics or other commercial
headlamps, I don my $15
Panther Vision PowerCap
my wife picked up at Lowes
(Fig. 14b). These handy caps
have three inconspicuous light sources and we use them in the
dental office as well as during home blackouts or out-of-the
house emergencies. I have used these inexpensive lifesavers
while camping, hiking, fishing, and reading on buses and cars.
During the circuit training, teams of attendees begin with
a fully set up portable dental cart. They dismantle the suction,
water canister, electric plug and close the boxes. They then
reassemble it to the original condition. We don't ask attendees
to clean out the suction, replace the water or oil or lubricate
the unit, but they get the idea from dissembling and reassembling
The teams then explore the different headlights. The dentist
dons the headlight and the patient is asked to squirm in the
chair. The dentist is asked to rotate his head to keep the mouth
of the patient in their field of vision and direct light.
When we have a wheeled mobile cart available attendees
examine and explore the unit to gauge how effective these carts
can be in providing complete dental care in a non-office setting.
Typically, mobile carts include high- and low-speed handpieces,
fiber-optic lights, sonic scalers, air/water syringes and
X-ray viewing boxes. Popular models we have used in our
courses include DNTL, Port-Op, Aseptico and ASI.
Question: How can you modify a toothbrush for manual
Answer: Easily - use your imagination plus arts-andcrafts
During my lecture I display
photos of a few examples
of toothbrushes that were
adapted to such patients by
attendees in past courses.
When participants reach
this workstation they see several
dozen Colgate or DentalElite toothbrushes (Fig. 15) and a
wide variety of inexpensive arts and crafts supplies. The items
include Play-Doh, Velcro, bicycle handles, Styrofoam, rulers,
rubber bands, whiffle balls, different kinds of tape, and more.
I challenge attendees to modify a toothbrush so that it
can be easily used by some category of special-needs patient.
Attendees take one or more toothbrushes, enhance it with the
items on the table, and submit their creations to be judged as the
most practical and effective.
At the end of the program, attendees describe their target
population's physical challenge, demonstrate the modified
toothbrush and explain how their creation would be used by
these patients (Fig. 16). I, along with the vendors and reps
select one as "best design."
Question: How can you work on patients in a wheelchair
Answer: Use movable operatory chairs.
My practice in Maryland treats a large number of wheelchairand
gurney-bound patients. Many prefer or need to remain in
their own chairs during dental treatment. Others arrive in their
wheelchairs and need to be transferred to our operatory chairs.
We used DentalEZ J-chairs with Airglide (Figs. 17 & 18).
Since we are unable to display these heavy chairs in our
courses, I show videos instead. Attendees see accessibility features
we implemented in our office, and see DentalEZ Jchairs
with Airglide sliding across a treatment room. Other
videos show obese, quadriplegic, amputee or other physically challenged patients remaining in the comfort of their wheelchairs
or gurneys during treatment.
When this course is taught at a large dental meeting with
exhibitors, the attendees are encouraged to visit the DentalEZ
booth to see the movable operatory chairs for themselves.
Often, a DentalEZ rep is there to demonstrate and have
everyone practice with the Identafi Oral Cancer screening
light. The station exercise calls for each attendee to use the
three different colored lights to search out any abnormal soft
tissue in the person's mouth, using both the straight wand
with a disposable plastic cover and then again with a disposable
illuminated mirror. The Identafi light readily detects
enamel crazes as well as abnormal soft-tissue lesions.
Other Hands-on and Participation Activities
for Hospital Dentistry
My two-day and three-day courses include an entire day
about hospital dentistry. One of the exercises for that module
includes working on a mannequin or dentiform, similar to
those used in dental schools.
Each group of two attendees is asked to place a throat
pack (Fig. 19) (about 18" of an ace bandage) into the dentiform's
mouth, replicating what they would do on a sleeping
dental patient in the operating
room of a surgical center
or hospital. Attendees are further
asked to use a mouth gag
or prop to keep the mouth
open. Then, they perform or
simulate a dental procedure -
such as applying a Triodent
or other matrix on a tooth
on the non-propped side - as part of a mock composite
placement. Attendees experience what it would be like to
efficiently work on a propped and throat-packed mouth that
has no head or tongue movement, no saliva and no chance
A second activity for the operating room module is to
simulate creating and dictating an operative report (Fig. 20),
upon completion of a dental case under general anesthesia in
an operating room. My course handout includes three different
sample operative reports
of hospital O.R. dental treatment.
In the style of Mad
Libs, many words about specific
details and results of the
case have been replaced by
Each attendee is assigned one of the three operative
reports and fills in the blanks. Each sample operative report is
read out loud to the group, with different participants reading
successive sections. Operative case reports have ranged
from extremely technical and serious to hysterically funny
and entertaining. The only requirement is that all the blanks
be filled in to indicate a completed operative report. These
group readings are always memorable and everyone learns
from each other.
At the conclusion of my courses we go around the room
one last time to share a personal epiphany or take-home pearl.
Invariably, everyone comments on how they enjoyed the circuit
training format. This is where someone also invariably
reminds me of the promise I made at the beginning, "No one
will enjoy or learn from every single workstation, but everyone
will take home at least two pearls that they can incorporate
into their professional practice."
To date, I have not had a single person tell me that this
promise did not ring true. The course goals were met without
anyone falling asleep, and everyone benefited. This includes
the attendees, the host organizations, the co-sponsoring companies,
me and most importantly, tomorrow's patients.
I encourage you to learn from this model and adapt it to
courses you teach. Changing the format of a course from lecture
to hands-on "circuit training" allows clinicians to learn in
a different way and helps them to retain information.