A Life in the Day: Germany

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In the series commissioned by Eschmann, Dr Jens Nolte discusses a “Life in the Day” of a typical German dental practice

On average I see approximately 20 patients per day and the hygienists see around 40 patients between them. My mornings usually comprise of one to three appointments involving preparations for crowns or bridges, while I reserve the afternoons for more routine check-ups and dental fillings. Dental crowns and bridges are very common treatments throughout Germany, although, as a specialist in aesthetics, I probably see more than general dental practitioners. I don’t perform surgery myself, so I will provide prosthetics for implants but refer the surgical procedures elsewhere.

The biggest challenge currently faced by dentists in Germany is the daily struggle of dealing with the hundreds of different insurance companies. It is not so much the problem of whether we can provide clinical treatments, but of discussion and securing payments while confirming patients are entitled to procedures. In my experience, 90-95% of patients are completely covered by the public insurance company, so they get everything except aesthetic treatments for free. However, the quality/convenience of the procedures they have access to are not always the highest – graded between ‘A’ to ‘F’, patients will often only receive the equivalent of a ‘D’ level of treatment. For the latest procedures with enhanced aesthetic and long-term outcomes, it is for the patient to pay the extra costs. This causes difficulties, hence the regular discussions with insurance companies and a huge amount of paperwork.

Infection control
There are many regulations governing the practices of dentistry in Germany, but my practice manager is well-organised and so deals with our compliance on a daily basis. Various systems and protocols are in place to ensure these regulations are met by all members of the team. All infection control guidelines are provided by the Robert Koch Institute (RKI), which regulates all hospitals, clinics and healthcare providers in Germany. As I’m sure many professionals around the world would agree, some of the rules set are imperative for the safety of everyone in the practice, while others seem much less necessary.
For example, we use disinfection sprays to decontaminate various surfaces in the surgery such as the dental chairs. We buy the disinfectant in five or 10 litre containers. As these are clearly too big to use on a daily basis, smaller 0.5 litre containers are routinely filled and used instead. According to one of the regulations stipulated, a pharmacist should transfer the liquid from one container to the next – which is clearly not possible in a dental practice every morning. We therefore allocate the task to one member of staff who is responsible for this process each day.

Otherwise, we follow the normal protocols in place throughout Europe, ensuring safe sterilisation and storage of reusable instruments, effective decontamination of surfaces etc. We must meet the European Directive 98/83 for drinking water, ensuring fewer than 100 cfu/ml (colony forming unit / millimetre) in all output water sources, and my staff wear all the applicable protective clothing from gloves to face masks. As we do little surgery in our practice, the decontamination process is not quite as elaborate as others, but we still of course have standard protocols to follow between patients, at lunchtime and at the end of the day.

In terms of decontamination equipment within the practice, we use a vacuum autoclave and ultrasonic bath to sterilise instruments. The consumables we use are usually chosen based on their cost-efficiency or personal preference. It is very difficult to attain the CE mark in Germany so we feel confident about the safety of all products on the market.

In addition to our infection control processes we have an external inspector visit the practice once a year to complete an independent audit. This is not mandatory for practices, but we do this to ensure high standards are maintained and staff training is updated. She scrutinises aspects that are not visible to the naked eye, using an ultraviolet light to identify the passage of germs from tray to chair, and right out to the kitchen. We are also subject to periodical inspections from the German Dental Association, but, as in the UK, this is a random event. With just under 70,000 dentists registered in Germany these inspections are fairly infrequent.

I don’t think our patients are especially aware of the decontamination processes followed in a healthcare setting. Every new patient is shown around the clinic, and when we tell them about our infection control measures and decontamination, they rarely have any previous knowledge about them. We demonstrate what we do and why, and explain that the 10-15 minutes between appointments is thanks to the cleaning and disinfection processes implemented for their safety.

Dr Nolte runs a practice in Bad Segeberg in Northern Germany. As is typical throughout the country, Dr Nolte is the sole dentist operating within the practice, but in contrast to the norm he works alongside four dental hygienists, as well as managerial and administrative staff and dental trainees.
The practice consists of five surgeries – three for the hygienists and two from which Dr Nolte works – as well as a separate decontamination area.