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Technological advances and specialist shortages have altered the practice-lab relationship.
In the past, dentists and dental labs had very clearly defined roles: A restorative case would start with the dentist's tooth (or teeth) preparation and an impression, and then the case it would be sent to an outside lab for completion.
In recent years, those roles have become somewhat blurred. Dentists are able to use in-house milling systems so that patients can get crowns the same day. In some cases, practices have their own on-site labs, providing an element of cost savings and convenience.
But are those models a threat to labs? Do labs still make sense in this day and age?
No matter where the tech works - as an in-house technician, a small lab, or a large lab - they must embrace 21stCentury skills, especially as CAD/CAM has become a driving force. But it’s not just nascent computer skills that are asked of lab techs. Their roles have evolved from simply making a restoration to becoming an active member of the dental team.
“I would describe a lot of lab technicians today more as dental engineers… as essentially a pharmacy, where the doctor sends in a prescription, [technicians] fill it and send them a product…” says Travis Zick, CDL, Apex Dental Laboratory Group VP and COO. Zick is also the National Association of Dental Laboratories (NADL) president. “In today’s lab world, there is far more collaboration. I would definitely describe today’s dental labs as partners with their clients. I think we are a valuable part of our clients’ teams, and we’re relied on more than ever to… ensure that there’s a positive outcome.”
Those new duties, Zick says, are because there are so many more opportunities available - choices that doctors might have a hard time keeping up with.
“There are so many more options available today to the dentist in terms of treating their patients,” Zick says. “There’s a vast array of material options available. Our clients rely on us to give them feedback and give them information about what types of materials are available, when and where they should use the different materials that are available and the different treatment planning options. Whereas, traditionally, the options may have been a denture or bridge, today there are 25 different treatment options that we can present to that same patient.”
That abundance of knowledge and opportunity, while great for dentists, can be challenging for lab technicians who work apart from a larger lab. For instance, Dan Elfring, master CDT, is an in-house lab technician for Pickle Prosthodontics in Colorado Springs, Colo. Recently, he and his doctor made the leap to CAD/CAM. It is such uncharted territory, that educational resources have been hard to come by.
“I can tell from my recent CAD/CAM training that it’s going to be a challenge to do what we want to do, because in the denture arena, there are not as many trained technicians to provide the training,” Elfring says.
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Not only are there ever-improving restorative options, but the products that labs have relied on making for so long are being made more inexpensively by other sources. The cases that remain can only be made by a qualified, skilled lab.
“You keep that relationship good with your doctors,” advises Shaun Keating, CDT, owner of Keating Dental Arts in Irvine, California. “You’re not going to get as much from them, but if you’re a good lab and in good standing with that account, they’re doing a lot of inlays, onlays, are doing singles, onesies, twosies… but for some of the bigger bridges and some of the different removable and fixed cases, they’re going to need a lab.”
Sheer volume alone can be prohibitive for those doctors who try to do it on their own.
“I have doctors that do [10 to 15] crowns and see 20 patients a day - it’s just not a good business model for them to try to do that in their office because it takes an average of about two hours per unit.” He also says that some doctors may think they are saving money by performing all of this work in-house, when the true savings may be less than envisioned.
“The single posterior restoration has really become a commodity in our industry,” Zick says. “That’s the product that you typically see produced in-office... going overseas, going off-shore. It’s more about price than anything else, so we’ve had to adjust to that. We’ve had to bring more value to the table to fight the commoditization.”
Everybody plays a role
No matter where the technician works - in the office or as part of an independent lab - they have a well-defined role on the restorative team.
“We just bought digital equipment to start doing some digital planning and digital denture work, but it still needs a technician to design and print and put it all together,” Elfring observes. “To me, the best business model is the doctor doing doctor things and the technician doing technician things.” Elfring has observed practices where the dentists and assistances perform the developments themselves, which he says often results in subpar products given a lack of that particular technical training.
While there are certainly doctors who embrace chairside milling, Zick says most of the digital dentists he sees are really just incorporating intraoral scanning, leaving the actual restorative craftsmanship to the labs.
“We’re seeing far more interest in digital impression devices than in-office milling,” he says.
Being responsible for an in-house system - whether the doctor tries to do it him or herself or relies on an on-site technician - can pose a financial burden.
“The doctors who mill chairside are getting frustrated with the continual prices of updates – the new blue camera, the new next best thing,” Keating says. “They’re kind of a big investment at $150,000 to get a system. There’s a lot of doctors that have tried it and it’s just not a fit for them.”
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The biggest attractors to in-office labs -price and convenience - are no longer the province of digital dentists. Conventional labs can also be just as competitive and convenient.
“Traditionally, the biggest reasons for in-office milling were cost savings and turnaround time,” Zick says. “Today, you can match both of those. If a doctor sends us a digital impression file in the morning… we can have a crown back to their office within a couple of hours, assuming that they’re reasonably close by.”
“Dentists are very, very frugal people,” Keating adds. “They don’t like to pay three dollars extra on shipping, if they don’t have to, let alone to have to update a program on their mill, or the CAD software.”
Dentists who have chosen to embrace in-office restorations had to come to terms with the price of that equipment as well as ongoing costs.
Supply and demand
Dentists who want to bring a lab in-house will find themselves challenged with finding suitable personnel.
“Technicians are pretty scarce,” Zick says. “We have very few accredited dental technology programs left in the United States.”
Technicians need more skill and ability than simply being able to point and click a computer mouse.
“A lot of labs think they can do it by getting someone off the street, just using the library, milling it out, and sending it off to the doctors,” Keating says. “But a lot of doctors that practice good dentistry want to see something that is functional and esthetic, but also, having contact circles, having proper emergence profiles, having the dissectional grooves of secondary anatomy dialed in.”
Technicians that work for a dentist need the same fundamental skills as any technician, but they will also need skills specific to the type of dentist for whom they work.
Ultimately, it depends on how much energy doctors want to expend doing in-house lab work. Those offering in-house technician services are the anomaly of dental practices.
“I still see the in-house technicians as a luxury, especially for a general dentist,” Elfring says. “I work for a prosthodontist, and those would be the ones that would have an in-house laboratory technician, but I don’t see a general dentist, unless it was a group practice. They may have a technician on staff to support the local needs, repairs, daily things that come up, but the workload would dictate that.”
For now, dental technicians remain a luxury that only a certain number of practices can afford.