Edward Lowe, DMD, and Nelson Rego, CDT
Accredited members, American Academy of Cosmetic Dentistry
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Communication between the dentist and laboratory technician forms the soul of their business relationship. While there have been amazing changes in clinical dentistry and techniques, the dentist-technician communication link has remained relatively unchanged — at least until the advent of the digital age and the Internet.
Prior to the development of these practice-altering tools, dentists and laboratory technicians were forced to rely on carbon copies of handwritten laboratory slips and an occasional phone call to address questions.
If the practice and laboratory were physically close, treatment planning could be done face-to-face. But if the offices were far apart, the telephone — no matter how ineffective — was the only available means of communication. Film-based radiographs were duplicated and written data was photocopied. The records then were sent by “snail mail“ or courier between the two parties.
Cases were picked up and delivered by either the lab owner or an employee. If a custom shade was required, either the lab owner went to the practice or the patient had to drive to the lab. Photographs had to be transferred into slide format. This took additional time at a photo lab.
When questions arose, the case often had to be returned to the dentist for review and the process was further delayed. Clearly, the dental laboratory's location was important. Local labs had the advantage of easier communication with local dentists, but small-town dentists had little nearby access to quality labs.
The introduction of the digital camera in the late 1990s marked the beginning of the modern age of communication between dentists, technicians, and patients. However, early cameras were not comparable to film in quality and were expensive.
As advances in digital single lens reflex camera technology progressed, the price decreased and the quality increased. High-quality SLR digital camera kits optimized for dentistry can be purchased today for approximately $2,000.
The price of compact flash cards or “digital film“ has decreased dramatically. It is now possible to find 16-gigabyte camera cards for less than $100. Combin this with ever-faster Internet connections and information can be exchanged instantaneously.
Who really needs information this quickly? When one takes into account that the average dentist's chairtime today is worth approximately $600 per hour, it becomes important to be as productive as possible. In the realm of indirect restorations, what do you think a doctor would pay to get a crown completed right the first time, every time?
If laboratory technicians can save a doctor a single hour's time by avoiding problems or remakes, then they have really saved the doctor $600 or more. Something as simple as communication can add significantly to the bottom line.
Before a laboratory technician fabricates a restoration, he or she must be sure that the doctor has provided adequate preparation-reduction. If not, the technician can snap a digital photo of the model, upload it to a laptop, and send it via e-mail directly to the doctor.
The doctor can recall the patient, reprepare the case, and with the patient still in the chair, take a photo and send it by e-mail to the laboratory for review. This is especially helpful when complex restorative cases are in the treatment planning or preparation phase.
If the patient is a sedation case or is from out of town, it is even more important that the case be done correctly and completed in as few appointments as possible. You only get one chance to make a great first impression!
One of the most difficult situations a dentist can encounter is matching the shade of a single anterior tooth to existing dentition. The introduction of electronic shade-matching systems enables precise shade measurement that ensures accurate shade matching of the restoration.
Advanced color meter technology (i.e., ShadeVision, X-Rite, Grandville, Mich.) electronically measures the tooth to provide an average shade, color grid, and color mapping, as well as an analysis of the hue, chroma, and saturation.
The EasyShade system (Vident, Brea, Calif.) provides an immediate digital reading of the cervical, body, and incisal shades. These systems are particularly beneficial when the laboratory is remote or when a custom chairside stain is not possible.
Video, the most promising new technology, is becoming widely available due to new fiber-optic Internet infrastructure. All that is required is an inexpensive Web camera, a computer, and an ultra high-speed Internet connection, such as Verizon FIOS.
A video chat is now possible during a patient consult. In essence, a multidisciplinary meeting takes place between the dentist, patient, orthodontist, periodontist, and technician. This type of direct communication saves everyone involved significant time and expense.
Another promising new technology is digital impressions.
It is now possible to take a series of digital images that are then sent to a milling center. While the model is being milled, the image is sent to the dental laboratory where restorations are designed and milled. A full contour waxup is fabricated and everything is pressed, even without a model!
For those dentists who own a chairside milling system (CEREC, E4D), it is possible to fabricate a working model to replace the traditional PVS impression. This is especially helpful since it allows multiple uses and helps to justify the large investment in equipment.
So let's put it all together.
The communication between a dentist and a technician for a complex case may go something like this:
A patient comes to the office to begin a comprehensive oral rehabilitation case. The dentist takes digital X-rays, pan, and photos and stores these in the patient's electronic file. A computerized tomography or Cone Beam Volumetric Tomography scan of the patient is done to plan implants.
After a thorough medical history and diagnosis is conducted, the information is transmitted to providers. Imaging is done with an imaging program to give the patient an idea of how the final outcome may look. The dentist then sends all the records by e-mail to the technician to discuss the case. In much the same way, other specialists are consulted.
A Web conference (e.g., iChat, WebEx, GoToMeeting) may be held in which the dentist, specialist, and technician discusses the case in real time. A treatment plan is presented to the patient. If questions arise, the dentist and patient may communicate with the technician or specialist via Web conference.
(The American Academy of Cosmetic Dentistry has developed a digital protocol for the accreditation process. Often this involves a mentor who helps a candidate decide which cases have promise and how to proceed with the treatment plan. The ability to immediately transmit photos by e-mail, combined with video conferencing with the restorative team, means that accreditation candidates can rapidly determine a course of action that will help lead to desired results.)
At the preparation appointment, photos of the preps and prep shades are taken digitally along with pertinent information related to the mounting of the case on an articulator. The final shade is determined using shade matching software.
These photos are sent by e-mail to the lab, and a Web conference is held between the dentist, patient, and technician if needed. An impression is taken with VPS, or digitally with scanning software, and sent to the lab.
A week later, the case is seated as expected without any glitches. Results are verified photographically.
There was a time when communication between the dentist and technician was done by assumption. The days of writing “PFM crown, shade B2“ … and hope it matches are over.
It is apparent that modern lab communication involves the triumvirate of dentist-patient-technician to achieve predictable results.
Dentists who demand quality results must find their voices and tell technicians what they want. High dental IQ patients who know what they want expect their dentist-technician teams to deliver, and they no longer accept mediocrity. Technicians must insist on complete information from their dentist clients and encourage forms of communication that take advantage of these amazing changes in technology.
Needless to say, what is considered modern technology for lab communication in 2009 may need to be revisited in a year as new advances continue to develop at an exponential rate. Today's state-of-the-art may well be on next year's craigslist. What a wonderful time to be in dentistry!
Edward Lowe, BSc, DMD, is an accredited member of the American Academy of Cosmetic Dentistry. He maintains a full time practice in Vancouver, British Columbia, Canada. You may reach him by e-mail at [email protected].
Nelson Rego, CDT, owns and operates Smile Designs by Rego, a progressive dental laboratory that specializes in ceramics in Santa Fe Springs, Calif. Nelson is an accredited member of the American Academy of Cosmetic Dentistry. You may reach him via e-mail at [email protected].
