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Article: Improving the dentist-technician fit
8th Oct 2010
There are more than 12,000 dental laboratories in the United States (Napier B, co-executive director, National Association of Dental Laboratories, oral communication, 7 January 2009), and their staff sizes vary from a single laboratory technician to hundreds of technicians. Many
laboratories are specialised or cater to a certain type of client, while others are full-service laboratories. However, there appears to be a common problem regardless of the size or work orientation of the laboratories and that is a lack of communication between dentists and technicians.
"Take digital photos of the patient. I prefer a relatively comprehensive series of images that competent staff members can take, but even just a few photos can be helpful for technicians"
Dr William Yancey and I convened a series of conferences, each known as The Dental Technology Summit, held each February from 2005 to 2009 in Chicago. The conferences were attended by representatives from the dental profession, the dental industry, laboratories, academic institutions, professional organisations and others.
These conferences identified most of the current problems in the dental industry. It was the consensus of the attendees that one of the major challenges facing the
laboratory industry and clinical dentistry is the lack of interaction and communication between dentists and technicians (Christensen, Yancey, 2005; Christensen, Yancey, 2005).
In addition, in a questionnaire sent to laboratory directors of 199 dental laboratories located in all 50 states, responses indicated that there is a lack of communication between dentists and laboratory technicians (Afsharzand, Rashedi, Petropoulos, 2006). That survey showed that a large percentage of respondents agreed that lack of communication by dentists to technicians is best reflected by inadequacy in work authorisation forms sent to the technician (Afsharzand, Rashedi, Petropoulos, 2006).
Other authors have pointed out the significant problems with the current state of dentist/laboratory technician communication (Kahng, 2006; Mendelson, 2006; Killian, 2006; Small, 2006; Phelan, 2002; Leith, Lowry, O'Sullivan, 2000; Davenport et al, 2000; Lang, 1999).
In this article, I will suggest several easily implemented policies that will improve dentist/laboratory interaction and communication and, subsequently, the quality of oral health services. Some of the following suggestions can be implemented whether or not your laboratory is close to your practice, and others require a close proximity of the two.
Attending courses together In my opinion, dentists and technicians' joint attendance at continuing professional development (CPD) events is one of the best methods to improve interaction and
communication between the two.
When dentists and technicians attend a course together, they hear and read the same information. Together, they discuss the course and the information provided. They determine the pertinent parts of the course related to their mutual interests, and it is quite likely that they will implement some of the information they have learned.
If the laboratory you use is far from your practice, you need to arrange a meeting together near the course location.
Hypothetical course
As an example of the significant potential value of enhancing dentist/technician communication via jointly attended CPD classes, I will describe the benefits of these professionals participating together in a course on a subject of high interest: zirconia-based crowns and fixed prostheses.
• Zirconia frameworks
Recent research demonstrated the importance of using the optimum formulation and firing temperature of superficial ceramic or precise pressing of superficial ceramic over zirconia (CR Clinicians Report, 2008). When dentists hear this information in a CPD course, yet their technicians are unaware of these important laboratory challenges, these measures are not implemented and patients suffer the results. Communication between the dentist and the
technician is mandatory to prevent these errors and is eased if they both learn the same information at the same time.
• Tooth preparations
Some manufacturers have indicated that tooth preparations for all-ceramic crowns should be the same as (or similar to) porcelain-fused-to-metal (PFM) tooth preparations. Technicians from many laboratories have reported different observations to me. Although all-ceramic crowns can be made on PFM tooth preparations, somewhat deeper tooth preparations allow for stronger and more aesthetic all-ceramic restorations by providing optimum space for both the zirconia and the superficial ceramic. Dentists cutting PFM tooth preparations for all-ceramic crowns compromise technicians' ability to provide optimum restorative results. Technicians learn this by trial and error, but dentists may never learn of it without communicating with their laboratory technicians.
• Taper of full-crown tooth preparations for zirconia-based restorations
Often, the taper of full-crown tooth preparations is excessive because of deep previous restorations or previously over prepared teeth. If technicians allow only the manufacturer-suggested 0.3-0.5mm thickness of zirconia to be milled as the framework, the superficial ceramic required for optimum tooth anatomy may be too thick, thus inviting superficial ceramic fracture. To prevent subsequent superficial ceramic fracture, the zirconia frameworks need to be built to simulate in miniature the anatomical characteristics of the eventual crown (CR Clinicians Report, 2008). This example demonstrates the need for both dentist and technician to know this subject well and to assist each other in avoiding superficial ceramic crown fracture in clinical service.
The bottom line is this: if dentists and technicians learn the full perspective on clinical techniques and processes in CPD courses they attend together, better clinical results will ensue. Take your technician to CPD courses with you.
Holding private meetings
Meeting with your laboratory technician is valuable if your laboratory is close to your practice. Going to breakfast or lunch together allows time for discussion of mutually important points related to laboratory and clinical subjects. Such meetings build collegiality, mutual understanding and trust. They allow the dentist and the technician to discuss specific difficult cases, assess materials, compare costs and characteristics of specific types of restorations, and evaluate decisions made relative to overall and specific questions.
Developing optimal communication in laboratory orders
Insufficient communication between dentist and technician is a well-known and universal problem. As a ridiculous but common example, some laboratory orders for removable partial dentures come to technicians in terms as limited as ‘make partial – A2'. Is there any wonder why such
prostheses do not meet high quality standards? A number of American states are passing laws requiring more two-way communication between dentists and laboratories. For example, the Florida Dental Laboratory Association has developed some sample forms to help dentists and technicians comply with their state's new law.
In addition to better forms, I suggest instituting a few procedures that have the potential to increase the quality of communication.
Take digital photos of the patient. I prefer a relatively comprehensive series of images that competent staff members can take, but even just a few photos can be helpful for technicians. As an example, for an anterior fixed partial denture (FPD), I suggest at least taking photos of the following: a full face, a natural smile, the lips and cheeks retracted, and the dentist holding the selected shade tab adjacent to the remaining natural teeth.
In addition, and for a more complete series, I prefer two lateral mirror views of the teeth in occlusion and mirror views of the maxillary and mandibular arches. This series of seven photos may be too comprehensive for every dentist or every case, but the dentist should at least send a photo of the teeth showing their colour and anatomy and a shade tab held adjacent to the teeth.
In difficult cases, invite the technician to see the patient.
When the laboratory and clinical offices are close together, the technician's observation of the patient is invaluable in difficult cases. When the technician actually sees the patient's smile characteristics, the colour of the gingiva, the occlusion and any other peculiar characteristics, the clinical result will be better.
Describe the desired characteristics thoroughly. The dentist should provide a complete description of the restoration he or she desires: metal or non-metal materials, presence of ceramic or metal margins, the degree of tooth anatomy and staining preferred, and any other desired or peculiar characteristics, including pontic form.
Many dentists compromise the quality of restorations by not providing enough information to technicians. I use custom drawings of my preference for tooth anatomy, specific pontic form or any other characteristics related to the patient being treated.
Consult by telephone regarding intermediate steps. When a try-in of a denture or a framework try-in for a removable partial denture or an FPD requires some changes, the dentist should call the technician and describe the changes while the case is fresh in his or her mind. Communication by writing alone is seldom sufficient.
Incorporating technicians into your practice
At the beginning of my career, I sent almost all laboratory work to laboratories distant from my office. The results usually were adequate, but occasionally the quality of my work was compromised inadvertently because sending a prosthesis with minor problems back to the laboratory would have caused inconvenience for the patient and significant loss of income for the practice.
The tendency was to accept some laboratory work that could have been improved in a few minutes if the technician had been on the premises. Therefore, for the latter portion of my career, my practice has included in-office laboratory technicians.
In my opinion, there is absolutely no comparison in the clinical quality level attainable via the in-office laboratory versus the remote laboratory. When a laboratory technician is in the dentist's practice and sees, even momentarily, most of the patients, colour matching and occlusion
automatically improve. The technician learns how many laboratory decisions influence clinical quality, thus improving the dentist's ability to produce high-quality aesthetic results.
If a crown, FPD, removable partial denture or complete denture is slightly wrong, it requires only a
few minutes for the in-house technician to modify the restoration without forcing the patient to make a costly reappointment.
In my opinion, if a practitioner is placing 30 or more units of laboratory-made crowns or fixed prostheses per month, an in-house technician may be a better clinical and financial choice than sending laboratory work out to geographically distant laboratories. If a dentist is in a building with compatible peers, and the practices' combined number of units of fixed or removable prostheses meets the level needed to provide an adequate income for a technician or technicians, the dentists should consider bringing the laboratory into their practice or building.
Making post-operative telephone calls to technicians
While the treatment I have just completed for a patient is still in my mind, I like to call the technician to discuss what I saw clinically as the restoration was seated. Maybe a
contact area was too tight, the occlusion was slightly too high or too low, a pontic form needed to be changed, the occlusion on a partial or complete denture was too high or the border extensions were too long. Even though I corrected the problems, the technician needs to know how the restorations seated.
This communication may reduce the number of such problems in future cases. Conversely, when a restoration drops into the mouth with little or no adjustment, it takes only a brief telephone call reporting the good news to help make a happy and confident technician.
Initiating or joining inclusive organisations
For some unknown reason, dentists and technicians in America have segregated themselves into two autonomous camps when it comes to professional organisations
and even study clubs.
Seek out – or form yourself – organisations that encourage interaction between the two groups. Some of the most beneficial educational experiences in my professional life as a prosthodontist have been in such situations. We must learn from each other.
Promoting integrated education of dental and laboratory technology students
It makes sense for dental and laboratory technology students to be educated in the same environment, yet this practice seems largely to have gone by the wayside. How have we lost this concept? There are notable examples in which integrated dentist/technician educational
programmes are still functional, but most joint dentist/technician programmes have disappeared.
If you are a private practitioner, you can only encourage the establishment and continuation of such programmes.
If you are an educator, my opinion is that it should be one of your primary goals to encourage and eventually incorporate these programmes, either in the same school or by combining programmes of dental schools with technicians' programmes in nearby community colleges.
Summary
Communication between dentists and dental technicians is known to be inadequate. Reasons for this problem are clear but remedies have been slow to evolve.
I suggest the following concepts for dentists and technicians to improve dentist/technician integration and communication and, ultimately, to improve patient care:
• Increasing the quality and scope of communication in laboratory orders
• Attending CPD courses together
• Holding private meetings
• Incorporating technicians into dental practices or buildings
• Making post-operative telephone calls to technicians
• Initiating or joining study clubs or joining dental organisations that include both dentists and technicians
• Promoting integrated education of dental and laboratory technology students. Improving interaction and communication between dentists and laboratory technicians cannot be achieved without proactive change on the part of both groups.
Christensen GJ (2009) Improving dentist-technician interaction and communication. JADA 140(4): 475-78. Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission. The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association.
References
References for this article are available on request. Please email newsdesk@dentistry.co.uk.
Dr Gordon J Christensen will be speaking at Private Dentistry Live! on 12 November 2010 at the Royal College of Physicians, London. For further information, call Independent Seminars on 0800 371652 or visit www.independentseminars.co.uk
Author
Gordon Christensen
Gordon J. Christensen is Founder and Director of Practical Clinical Courses (PCC), an international continuing education organization for dental professionals initiated in 1981, and based in Provo, Utah. For many years, thousands of dentists and dental staff persons have participated in PCC courses, and viewed PCC videos. Dr. Christensen has presented over 45,000 hours of continuing education throughout the world and has published hundreds of articles or books.
Gordon and Rella Christensen, are co-founders of the non-profit Clinical Research Associates (CRA), which Rella directed for many years. Since 1976, CRA has conducted research in all areas of dentistry and published the findings to the profession in the well-known CRA Newsletter. The CRA Newsletter is now read throughout the world in ten languages.
Early in his career, Gordon helped initiate the University of Kentucky and University of Colorado Dental Schools and taught at the University of Washington.
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