FROM ENGINEERING TO DENTISTRY: MANAGEMENT AND

APPLICATION OF TQM PRINCIPLES AND TOOLS AS A RESULT

LEVERAGE

ELIANA N. C. SILVA1; MARA T. SALLES1

1
Professional Master in Management Systems
Laboratory of Technology, Business and Environment Management
Fluminense Federal University
R. Passo da Pátria, 156/329-A, 24210-240-Niterói RJ, Brasil - (21) 2717-6390.
e-mail: elinapoleao@ig.com.br; mara@civil.uff.br

TQM is not new to industry and medicine. In dentistry, information on the topic is still
insufficient. Our objective is to show tools that originate from industry, which are applied in
dentistry with the intention of offering the Dental Surgeon conditions to improve performance
in search of excellence in the practice.

Keywords: Total Quality Management, Dentistry, Excellence

1 - INTRODUCTION

Dentistry in the 20th century became more efficient due to great scientific and
technological advances that revolutionized the practice of the professional DS (Dental
Surgeon). Stating some of the inventions and techniques: the photoactive resins, which made
esthetic restorations possible; micro-abrasion and laser for cavity tissue removal that can also
be used for dental diagnosis and lightening; digital radiology with reduction of radiation and
live image revelations on computer screens; the intra-oral camera, which, among other things,
makes possible for the client/patient to accompany treatment at the time of performance.

Beyond all of this scientific and technological evolution, the challenge for the
professional DS has been elevating considerably, these micro-entrepreneurs are increasingly
under pressure: through globalization, which brought profound and irreversible changes in
economics and in the behavior of people, through the market that demands reduction of costs
and gains in efficiency, through the exasperated competition and the growing exigency of
potential and final clients, and having these professionals, to find competitive differentials
that guarantee long-term survival.

Nowadays, the importance of Quality, which initiated in the factory industry and is
expanding, in large steps, and the service rendering sector, is no longer questionable, and it is
this evidence that gives the spark in the actual competitive process in the dental segment,
demanding that all are capacitated in tracing strategies and structured action plans in data and
factual analysis, which will serve as a guide on the decisions on the resource and improved
techniques application, to develop a system of modern management, that attends the needs
and expectations of the client/patient and others.

This requires the identification of opportunities, the study of competition and market
tendencies following a methodology. This is the reason why the introduction of TQM (Total
Quality Management) techniques in a company, even if the company is a small service
business like a dental office, is so important.

Total Quality Management in dentistry is equal to the sum of the technical quality of
the professional plus the quality perceived by the client, through the knowledge and respect of
their creed and values, seeking results with the strengthening of the existing credibility
between the professional and the community. Credibility reached and sustained by continual
learning and compromise with constant improvement.
 That means that knowing everything about dentistry isn’t enough. For the
professional, quality can have something to do with the technical-professional aspects, but for
the client, quality has to do with their own level of personal satisfaction.

In the new competitive context, inside the dental segment, there is still little
understanding of the true impact of a non-fundamental decision on information and focus
analysis. The idea of working with management through the TQM concepts and tools is not
disseminated.

2 - OBJECTIVE
The object of this article is to show some tools that originated from the factory
industry, applied in day-to-day dentistry as information generating sources, that, combined
with the implicit knowledge of the professional DS (dental surgeon) and assistant, and the
interaction with the clients, will make possible the creation of knowledge, the incorporation to
the rendered service, providing the Dental Surgeon and the learning organization with
continuous improvement and innovation power, like in resources for performance sustaining
and optimization in search of excellence in the practice.

3 –THEORETICAL ESTABLISHMENT
The dental office, even as a small service business, can be compared to a craft
industry. The products for sale are the dental procedures that have the necessity of a logistic
for the purchase of raw material and negotiation power with the supplier. The manager,
besides updated techno-scientific abilities, should still create a competitive differential with
the competitors, have professional competence to deal with client information, internal and
external, resources and market, and knowledge of methodological practices that help in
strategic decision making, through the analysis of information, statistical mapping, and raising
of the processes/procedures, which will serve as a support augmenting the basis of
knowledge. This article consists, mostly, in converting information into knowledge that
makes possible the innovation in business administration to overcome the current challenges
imposed to the practice of the dental profession and to maintain competitiveness. To create
an environment where the innovating spirit and the undertaking becomes indispensable for a
TQM-based strategy.
 According to JURAN, the new superiority in planning is a consequence, in part, of the
process capacity quantification use, becoming imperious to adopt quantification as a tool for
the competition in Quality planning (design for quality).
The Quality function is a planning methodology, which integrates tools and
technologies to put the whole organization aiming client satisfaction and company demand. It
follows a systematic sequence, in a way to transform the clients’ needs into requirements,
which can be integrated to the service development process.
David Kearns (1992), affirms that Total Quality Management and it’s diverse tools are
indispensable assistants for professionals, independent of the practice area, which seeks
excellence in the practice and searches client satisfaction through a service that attends, or
even overcomes, expectations. The TQM practice does not seek an objective in it’s own
context. It should be constantly perfected through training and development of new practices
that associate value to the business, generating competitive advantage.
To GARVIN, companies that learn, like, Honda, Corning, and General Electric, use
construction blocks, where one of the five pillars is the use of simple statistic tools (Pareto
graphs, correlations, histograms, cause and effect or Ishikawa diagrams) to organize data and
extract inferences. It affirms that “the managers have known for a long time that what is not
measurable is not manageable.”
According to SVEIBY, to the “knowledge organization” it is very important that there
is an interaction between information (transferring knowledge in an indirect form, making
data and facts explicit), and tradition (transferring knowledge in a direct form, from person to
person, learning by practice), among explicit knowledge and tacit. Tradition must be used to
transfer knowledge.
DAVENPORT and PRUSAK, affirm that, while the organizations interact with the
environment, absorbing and transforming information into knowledge, they start to act with
basis on these concepts, combined with experiences, values, and internal rules.
Through the study realized between the 28th of October and the 15th of November
2001- in the application of 80 questionnaires for dentistry professionals in the city of Niterói,
in the state of Rio de Janeiro, with the objective to identify the level of TQM knowledge,
application, and interest, it was verified that there is a gap of knowledge that makes this
segment work with tools and methodologies that lead to structured decisions in data analysis
in the internal and external environment possible. Of the 80 interviewed, 85% showed
interest in obtaining more information on the methodology, also in learning and using the
tools to optimize their work.
4 – APPLICATION IN DENTISTRY

The demonstration of the two TQM tools that can be very useful in dentistry is
pertinent. They are:
Flowchart - It is an illustrative summary of the various operations of a process,
detailed in all of the involved steps. It may be better understood in Michael Brassard (1992).
In dentistry, the flowchart is an important tool for planning and also for perfecting
processes, identifying the ideal current flow permitting critical analysis and alterations, also
facilitating the visualization of the diverse linked steps, allowing to meet those that deserve
greater attention, and still, facilitating the orientation/instruction of the professional assistant
and other collaborators involved in the process.
In the day-to-day of the dentistry professional, the flowchart can be used for, for
example, describing step-to-step the execution process of an esthetic restoration, from the
client’s position on the clinic chair, to the final polishing of the restoration.
 Example of a Flowchart in the Restoration Process with compound resin according to the adaptation of the operational tactic of
Baratieri/Cols (1991)

ARRIVAL OF CLIENT TO A
CLINIC ROOM

Cavity Prepare
Position of client on
clinic chair

YES Cavity cleaning and

Pulp
YES protection Pulp protection
Is anesthesia Necessary?
necessary? Proceed anesthesia

NO

NO
Acid conditioning

Prophylaxis of
Teeth
Wash and dry
Operating area

Selection of resin
Resin use
and color

Isolation Photo-polimerization

Finishing and polishing

A

Liberation
Of client

FIGURE 1 – Flowchart of Compound Resin Restoration Process

Cause and Effect or Ishikawa Diagram, is explained by Michael Brassard (1992) as a

graphic technique that permits organizing information, identifying possible causes of a certain
problem or effect, showing the principal causes of an action, leading to the final result.
In dentistry, it can be used with the finality of identifying the possible causes of a
problem, obtaining better visualization of the cause and effect relation, diagnosing the causes
that are originating an effect or problem. The causes can still be divided into sub-causes,
facilitating the determination of specific actions for each one of them.
 Compound Photopolimerization
Resin

Less light than Uncalibrated

Change of recomended Photo polimizer
Supplier and o In application
Inadequate resin because of manufacturer
Technical information Resin Tempurature
insufficiency

Distance and direction of light

Source to the resin surface
Irregular resin package
Unsatisfactory
Color
color in the
unstaisfactory
anterior esthetic
nasrestorations
tooth
restaurações
class V
ig estéticas
Inadquate Visual fat de dentes
ue
Lamps for office Not enough artificial antsriores
illumination Illumination to make Necessity tipo
do CLASSE
Up absence of natural to V
illumination Selection of color Recycle
W ith dental element
Absence of dehydrated
Natural illumination
Reflector with inadquate
lamp
Failure in selection of
Restoration material

Inadquate
illumination
Dental Surgeon

FIGURE 2 – Cause and Effect or Ishikawa Diagram. For the identification of possible
causes of non-conformity levels in Anterior Esthetic Restorations type class V.

5 – PRACTICAL APPLICATION
The first initial case of TQM concept, tool, and application use began originally in a
small organization – a private dental office in the State of Rio de Janeiro, Brazil.
The data or sampling (frequency of dental procedure occurrences) were collected in a
period of 7 months, from October 1999 to April 2000, to map dental procedures and factual
analyses, with the goal to promote better distribution of grants spent on maintenance and
acquisition of consumption materials, facilitating logistics, and consequentially raising the
negotiation power with the suppliers.
The procedures were calibrated monthly with the help of a verification sheet adapted
for the organization in question. With basis on the information in the verification sheet, from
October to April, it was possible to construct a table, according to the proposed objectives,
named the TABLE OF PROCEDURES PER PERIOD, where the processes/procedures are
shown.
TABLE 1 – Table of Procedures per Period

FREQUENCY OF DENTAL PROCEDURES

PROCEDURE MONTH
Oct/99 Nov/99 Dec/99 Jan2000 Feb/2000 Mar/2000 Apr/2000 TOTAL
Prophylaxis and Fluoride Application 14 11 17 15 8 13 14 92
Prophylaxis and Seal 4 8 8 10 0 7 5 42
Supra/sub Gum Scraping 6 8 18 3 4 8 15 62
Almagam Restoration 3 10 14 4 3 11 13 58
Photo polimerizable Restoration 16 13 14 9 6 18 9 85
Exodonty 8 12 16 8 0 3 1 48
Enlargement of clinical crown 2 4 3 1 0 3 1 14
Endo unirradicular Treatment 3 0 2 0 0 0 3 8
Endo birradicular Treatment 0 0 2 0 0 1 0 3
Endo trirradicular Treatment 1 0 3 2 1 3 5 15
Pulpotomy / Pulpectomy 0 0 2 0 1 2 0 5
Steel crown 0 0 2 1 0 1 1 5
Space maintainer 0 0 0 2 0 0 0 2
Total prosthesis 0 6 5 0 0 1 1 13
Roach 0 4 8 2 0 0 1 15
Fused metallic nucleus 2 3 4 3 0 2 3 17
Jacket crown 1 1 2 4 2 2 2 14
Fused metallic restoration 2 2 1 3 1 3 2 14
Temporary crown 3 6 6 9 3 4 8 39
Fixed bridge 1 2 1 1 0 1 3 9
Artglass crown 0 3 2 1 0 0 1 7
Rx 11 7 15 8 8 9 14 72
TOTAL 77 100 145 86 37 92 102 639

Table 2 presents the dental procedures, grouped and divided by codes from A to G,
according to the practice area and organizational interest, permitting graphic representation.

TABLE 2 – Procedure Grouping by Codes

Code A Prevention Procedures

Code B Restoring Procedures
Code C Prosthetic Procedures
Code D Radiological Procedures
Code E Surgical Procedures
Code F Endodontical Procedures
Code G Individualized Surgical Procedures
 Figure 3 graphically represents the distribution of the procedures.

QUANTITY

G
F
E
A
D

C
B

FIGURE 3 – Graphic representation of the distribution of procedures

In figure 4 is used the Pareto diagram to identify the dental processes/procedures

responsible for consumer behavior.

OBS.: A+B+C = 74.18%

Q
250 35.0 P
30.67
U 30.0 E
200
A 22.38 25.0 R
150 21.13 C
N 20.0
E
T 100 15.0
11.27 N
I 10.0 T
7.51
T 50 A
4.85 5.0
Y 2.19
G
0 0.0
E
A B C D E F G
CODE

FIGURE 4 – Pareto Diagram

The diagram above shows, in decreasing order, that the code A, B, and C procedures
are responsible for 74.18% of the consumer behavior.
6 – CONCLUSION AND SUGGESTIONS

According to the quality plan, by JURAN, we have parted from a goal, identifying the
clients’ needs, followed by developing the service characteristics and procedure conformity,
inside the quality standards, according to the budget planning. Lastly, establishing the
procedure control following a systematic sequence in a way to transform the clients’ needs
into requirements and these becoming an integrated part of the final service.
With basis on the mapping and analyses of facts and data (frequency of dental
procedure occurrences), it was possible to prioritize with coherence and aligned to the budget
proposal, the acquisition of consumption material (raw material) for the organization
following a quality standard and service conformity.
In this article, the tacit knowledge of the professional Dental Surgeon orientated for
procedure, based on the belief of external resource (TQM tools and methods application) use,
combined with ability and experience, proceeding in social network, inside a culture that
values learning and knowledge, was the answer to a more economic and balanced budget
proposal, in a way to make the organization more competitive attending the clients’
exigencies and needs, inside a pre-established standard of quality and conformity.
The following described steps made possible a real experience, besides realizing
interactive improvements to reach higher quality levels:
• Process identification and mapping – communicating and measuring;
• Participation, mobilization, and initiative development – people;
• Consolidation – operational integration;
• TQM monitoring and adjustments.

It is important to emphasize that the professional DS can use TQM tools to accompany
processes, such as:

• Procedures – quantity produced, differentiation, performance, number of re-work

(repetition), and motive;
• Client data – in relation to the preferences of time and service environment (with or
without music, TV, etc.), of the materials used in treatment (esthetic – resins, porcelain,
metals – gold, silver links), satisfaction, suggestions, complaints...
• Principal supplier data – price negotiations, form of payment, and punctuality of product
delivery, equipment and/or medication;
• Market – participation;
• People – performance and satisfaction;
• Establish cost-benefit relation of the organization.
Each tool can and should be adapted to the reality of the organization and the
information should be collected according to the proposed objectives. There is no such thing
as a prewritten model, each organization will have to, parting from various analyses, create
the ideal method to implant and manage the processes based on the quality methodology. In
the TQM world, the existence of processes based on a matrix from one end of the
organization to the other is indispensable so it could be well succeeded reaching competitive
advantage.
The quality management and administration is not only a strategy, it is a working
style, and therefore infinite.
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