Dental and laboratory experts weigh in on what dental technicians need to know about the new workflow.
When you think about it, the process of creating a restoration is sort of a miracle. The fact that a piece of human anatomy can be replicated quickly and at reasonable expense is nothing short of astounding.
But when you add new technology and materials-like CAD/CAM and monolithics-producing better, faster, cheaper restorations becomes even more impressive.
It’s not really a miracle, though. It’s hard work between the clinician and the laboratory. To optimize the endeavors of both parties, they must be able to work together smoothly.
What Your Doctors Want You To Know
Doctors say the same thing as lab owners when it comes to having a fruitful relationship-they want effective communication.
“What I’m looking for in a lab is a partner,” says Dr. John Flucke, DDS, technology editor for Dental Products Report. “I’m a firm believer in relationships. What I want is a lab that knows what it’s doing, has good employees and then I can count on it to do the right thing and to help me.”
Staying on top of your working relationship is very important. You can learn what’s working and what needs to be worked on.
“The number one thing on the lab side would be to reach out,” says Dr. Bob Mongrain, DMD, at Berkshire Dental Group in Broken Arrow, Okla. “If you’re not hearing anything and the cases keep coming, reach out anyway. Be proactive in talking to the doctor.”
“I would almost imagine that an average dentist is going to change labs probably between five and 20 times in his or her career,” says Dr. John Comisi, DDS, president and CEO of Dental Care With a Difference in Ithica, N.Y. “That happens for many different reasons; number one, of course, communication, is certainly a challenge. Sometimes what is communicated from the doctor to the lab and/or from the lab to the doctor can be paramount to a successful, long-term relationship.”
Next page: Specific needs of communication with your clients ...
Another component of communication is checking in with your doctors from time to time. Even if every case sent back to the doctor is received and given to the patient without incident, the occasional call ensures you continue delivering what the doctor wants.
“Call every so often and just ask, ‘Hey, are the contacts too tight? Are they not tight enough? Is the occlusion off on a consistent basis? What are we learning?’” Dr. Mongrain notes. “In that case, you’re not going to have regular communication. It’s more like there’ll be periodic check-ins to see how things are going.”
More intricate cases will necessitate more interaction.
“It’s more of the bigger cases or something complex or you have a question about something-that’s where you would reach out to the lab and have a conversation,” Dr. Mongrain says. “That would just be occasionally, depending on the practice.”
The act of reaching out to doctors not only reveals problems but is also important in bolstering that relationship.
“If people are calling from the lab-which they should be-then the doctor sees the lab trying to reach out and do as good as they can,” says Shaun Keating, owner of Keating Dental Arts in Irvine, Calif. “Doctors respect that, and I think they want to see that nowadays.”
Keating notes solid relationships are what keep dentists with their labs.
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“We try to touch base with the doctors every two weeks minimum,” Keating says. “Those doctors are getting solicited 20 or 30 times a week from labs via email, mail and journals with print ads. There are lots of temptations for dentists that don’t really have that relationship with their labs. At the end of the day, we’re all sort of doing the same thing, so what sets you apart? Is it the low price? Is it the quality? Is it going to be the service? It’s a little bit of all of that, but, at the end of the day, the big thing is the relationship.”
Building a solid relationship also affords you a certain measure of protection if-and when-problems occur.
“That way, when you do screw up the case-mess it up bad-you won’t have a guy bouncing every week to another lab because there’s a relationship,” Keating observes.
Next page: How you can take the lead with your dental clients ...
Taking the Lead With New Products
Introducing a new product or material into the doctor/laboratory relationship can occur in several different ways. In some cases, the lab takes the lead.
“Generally, it’s the laboratory because it’s in its best interest to be able to continue to receive work from a doctor that’s made the switch to technology,” says Ryan Faufau, director of CAD/CAM Resources at Custom Milling Center in Arvada, Colo. “One of the fears I see with most labs is that everything’s going digital and doctors aren’t taking impressions today. How do [labs] maintain this working relationship with the clinician to continue to receive work and keep control of the account?”
Oftentimes, doctors are too busy to keep up with what’s new, so the lab brings it up.
“If the doctor is reading journals and literature, they’re going to be finding out about the new materials, but sometimes the day is too packed and crammed to know about all the different things that are out there,” Dr. Comisi says. “Many labs will send out brochures and leaflets regarding new techniques and materials that are available, and most of them say, ‘Call us to learn more about this material, how to work with it and what you can do.’ Technicians can give some great information. If the technicians are staying up to date and they are trained on these things, you can’t get a better insight and a better team member.”
The opportunity for a new product or material often arises when the doctor is advised by his or her lab on improving a case.
“That’s when a lot of folks, including myself, get some insights into things,” Dr. Comisi says. “I talk to my lab on a regular basis. I say, ‘Can I use this material here?’ and they’re going to tell me yes or no and why one material might be better than another. Or, even better, they might suggest an alternative that I’m not even aware of. The more we talk, the more we will be able to learn and probably be able to do a better job as we go forward.”
“Our client services people may bring it up to an account,” adds Bob Savage, CFO at Drake Precision Dental Lab in Charlotte, N.C. “Our technical people, as they’re talking about a case, say maybe they’re having a problem on this case with a material and maybe this new material is a good option or, ‘Hey, maybe on your next case similar to this we have this XYZ product that may really fit into that particular modality of the case.’”
Next page: Helping doctors navigate the worlds of materials and technologies ...
It isn’t always the lab taking the lead. Labs will often respond to their doctors’ inquiries about new products and materials.
“You have your clinicians that see a product and they want to try it or they have a case where it makes sense to try to use that product, so we get solicitations that way, as well as if we believe in the product,” Savage says. “Drake has always taken a proactive approach. We don’t want to take on products unless we feel they’re going to be good for our clients. We’re not always the early adopters sometimes because we want to do our due diligence on introducing new materials and new products into our market space.”
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It is in the lab’s best interests to keep up on what is out there, so it can advise its clinicians appropriately.
“It’s really what the doctors are requesting, but our position is if we believe in a product, invest in the product and then educate, I think that’s really where Custom Milling Center takes a step forward and makes an initial investment and just makes our client base more aware of the direction of the industry and then also what new products have hit the market and the process of delivering the final restoration from that,” Faufau says.
Responding to the doctors’ inquiries can be beneficial for the lab because others may also be interested in the product.
“‘I heard about this e.max material. Do you guys do it?’” illustrates Jason Obrokta, director of technical marketing, fixed prosthetics at Ivoclar Vivadent. “The lab’ll say yes or no, and if it’s no, it’ll say, ‘Maybe I should look into this because my doctors are asking for it.’ Laboratories, by and large, tend to be very reactive to what the doctors are asking for, which is why we put a lot of emphasis on educating the doctor on material options.”
Step-by-step: IPS e.max in action:
“What I see is primarily manufacturers and key opinion leader speakers that start talking about a new material and then the labs follow behind them to introduce them to use their clients,” Dr. Mongrain adds. “They’re usually talking to me before I’m talking to them.”
The type of product also is a factor in who introduces it into the relationship.
“In my case, when it’s a device like a scanner, I’ll often bring that to the attention of my lab,” Dr. Flucke says. “As far as materials, [the lab] will bring that to my attention because it is more versed in the materials than I am, but I’m a bit of an outlier from the device standpoint because I’m a gearhead and I’m always looking for gadgets and stuff to try.”
Next page: Digital helps them-and you ...
New Equipment, New Work Methods
With new products and techniques, there are new ways to handle the workflow between doctor and laboratory.
“The expectation level changes a bit,” Savage says. “You used to box an impression up, and you get it the next day. With digital, I think there’s a growing expectation of immediate access. That impression is now in our hands. Is it good while the patient’s still in the chair? It sets a different expectation level for us. I don’t think the communication really changes, but I think it speeds it up, and I think it’s up to the lab to be responsive to that in understanding that, going forward, as more digital impressions and CAD/CAM type restorations enter into a lab, you have to be cognizant of that expectation change.”
Dr. Comisi has gone from traditional impression techniques to using a 3Shape scanner for an all-digital workflow.
“It’s made me, in my opinion, a better doctor overall simply because as I’m preparing, after I’ve scanned, I can really scrutinize,” Dr. Comisi says. “I can blow that picture up and see were my margin is, or even worse, not see where my margin is. And I can correct it before I send that off to the lab. Since I’ve gone digital, I’m just looking at this, and I say, ‘Oh my gosh, I see things that I wouldn’t have seen otherwise,’ and it’s really remarkable.”
And while scanning has been an aid for doctors, that doesn’t mean they can be sloppy.
“If you don’t scrutinize whatever type of impression or whatever type of work that you’ve done on the preparation for the laboratory case, and you don’t give yourself your own critique, the lab is going to have less of an ability to create something of value to you,” Dr. Comisi says.
The ability to send the case electronically helps not only in terms of speed and efficiency but also gives the lab a chance to look at it while the patient is still in the chair.
“The communication there is instantaneous,” Dr. Comisi says. “Once I send an STL file to the laboratory, it’s got it within minutes. The technicians who open up the file look at the case, and, shortly thereafter, I get a notification that the case has been accepted or not so I know right away if there’s a problem with my case. That’s great because I may have that notice before I dismiss the patient, and I can correct the problem. That’s really the great thing that goes on for most of these but especially with the mobile apps that are available with many of the systems. You get a notice on your telephone that something’s going on on the Trios app, and they look at it and say, ‘OK,’ and the lab has communicated with you. Then you type back and you tell it what you want or you ask it to clarify it more, or you just get on the horn and you talk.”
To facilitate that exchange of data, labs and doctors use online portals.
“If the doctor has a chairside scanner, how does he or she get that data submitted over to the laboratory, and how do we make this as easy as possible?” Faufau asks. “One of the things that we do at CMC is we help laboratories set up this workflow between the laboratory and the doctor. We use the program called DDX, which is Dentrix-it’s actually an online web-based program that enables the clinician to create an account through its website, and the laboratory would create account, and this is how they both would connect. The clinician would be able to simply pull up the web browser, attach the file and submit the case to the laboratory without purchasing additional software.”
Tools like DDX not only facilitate the exchange of information, they also ensure regulatory compliance.
“I think it’s becoming more common because one of the things we also have to look at when we’re sending Rx’s and patient information over the web is, ‘Is this HIPAA-compliant?’” Faufau says. “‘Is it following patient privacy?’ And DDX follows all those guidelines, which I think is something that might be [overlooked] in the industry today, especially when it comes to electronic submission.”
Taking advantage of the benefits afforded by digital dentistry can be a great opportunity for both doctors and labs.
“Right now, we are seeing a big influx of digital technology being put into the laboratories, and it’s taken a long time to get to this point,” Obrokta says. “But the labs are starting to realize, ‘I see the benefits now. It’s a reduction in my labor costs so it helps me to produce a more efficient and more reproducible restoration, and I can do it with a little bit less cost for my doctors. It’s something that will look nice, perform well and net me a little bit of extra money in the end.’”
CAD/CAM has really come into its own in recent years, and many labs have realized that.
“Most laboratories are of the mindset that if they’re not involved in some sort of digital technology, they should be,” Obrokta says. “As to whether or not they feel definitively that what’s out there today is going to be the answer in the future, I think there’s still some trepidation about that. A lot of labs are in that wait-and-see approach to see what technology is going to pan out to be the ultimate technology that everybody adopts.
“Within the data acquisition part of it, they’re scanning models or they’re scanning representations of the patient’s mouth to go into the digital fabrication. That technology seems to have pretty well panned out. There’s one company that seems to have the bulk of the market right now, but even that adoption rate is not 100 percent. A lot of people are still saying, ‘I want to see what else this thing can do before I invest in it.’”
Next page: Helping get your perfect restorations to the patient ...
New materials require new cements for the proper application, and your doctors might not know that.
“In the past, you had to always do this bonding procedure that required a bunch of steps and was very easy to not get completely correct,” Obrokta says. “And if you didn’t get it right, then a restoration could fall out or fail because of that, so all ceramics were a bit limited in their exposure and their penetration into the dentist market because of that. Because doctors typically would just like to put some cement on the crown and stick it in place, and that’s been the procedure they’ve had for metal-based restorations forever. That was in the past. Now, with these stronger, all-ceramic materials like zirconia and lithium disilicate, there’s more flexibility in the cementation they can do. It becomes more application-based now versus just material-based.”
It is up to the lab, ultimately, to communicate correct usage.
“Some doctors know that and understand that,” Obrokta says. “Most doctors, I feel, don’t, so it’s up to the laboratory. What ends up happening a lot of times is a doctor will get a new crown of a new material type from a new laboratory, and they get that restoration, and they’ve got the patient and they go, ‘Let’s get the lab on the phone because I don’t know what to put this thing in with.’ To that end, we’ve also done a lot of work trying to educate the laboratories on cementation so they can answer those questions. Every time there is something different that’s offered to a dentist, the dentist will say, ‘Great. What am I supposed to cement this with?’ We’ve tried to educate the laboratories so they can be a better resource for their doctors.”
Next page: The key to teamwork ...
For the best working relationship-and for the best results-clinicians and their labs must work as a team. To smooth out complex cases, Dr. Flucke brings each member of the team together.
“What I’ve seen is the lab will call me and say, ‘You know, John, we’re going to have a hard time getting this the way you want it because the surgeon or the periodontist didn’t put these where they need to be for easy restorability or for angulation or whatever,’” Dr. Flucke says. “Unfortunately, in those situations, the general dentist becomes caught in the middle. So what I’ve started doing when we get complicated things-and this is something I would really advise with cases like this-if there is a chance that it could go haywire, have a meeting.”
That meeting can be done in person or even through conference calls or online. In Dr. Flucke’s case, he built a conference room in his building with a screen so he can host meetings. He brings in the lab tech and any specialists, and puts the case on the wall so they can all go over the details together.
“We can review the X-rays, photos, everything,” Dr. Flucke says. “We can all treatment plan the case together so that we all know the nuances of it. It’s nice to do that because you end up with a case that everybody is involved with from the ground floor. I have no problem with having a big meeting and getting everybody together and making the decisions together as a group so we all know where the limitations are with different potential stopping points.”
Realizing the skills and talents of the other members of your team will help you deliver the best for the patient.
“It’s definitely an interesting time, but, regardless of whether it’s CAD/CAM or whether it’s traditional impressions, communication is a very big piece to our business,” Savage says. “We have to communicate because I think both parties bring different talents and different experiences to the table. We learn from our clients, and I hope our clients learn from us because that’s the way it should be and can really build a synergistic relationship-not be just one-way communication.”
Ultimately, a solid relationship between the clinician and lab comes down to that vital quality of a great relationship: communication.
“At the end of the day, it’s just about talking,” Savage says. “It’s two people communicating. Whether it’s a lab and a doctor or two friends talking to each other. It’s about being respectful. It’s about being positive and really showing what the general intent is. Communication is difficult and easy at the same time. It sounds easy, but, as you get into it, you can’t be afraid to talk to your clients.”
Robert Elsenpeter is a contributing writer for Dental Lab Products and Dental Products Report.
Top photo: Hero Images/Getty Images