Learning to Survive - How will the dental technology industry endure in an education crisis?

Now consider the number of enrollees in dental laboratory programs (see Table 1) and the number of new dental technicians who graduate each year (see Table 2). Collectively, the 20 accredited dental technology programs in the United States graduate an average of 240 to 360 students a year, a number that cannot sustain a retirement exodus. They also have an aging faculty, with nearly 50% of full-time instructors at or near retirement age.² The industry is graying, with fewer entering the field than leaving.

While most college counselors and students are well acquainted with the services dentists provide, the dental technology profession is not on their radar.

Businesses hungry to hire employees with dental technician knowledge quickly snap up the few students who do complete 2-year dental technology programs though they are hardly prepared for the mass production and high-tech environment of the modern dental laboratory. Nor are they ready for the expanded roles dental technicians have had to assume—as advisors to clients in areas where technology and new clinical protocols have outpaced instruction in dental schools or as technical consultants to a client base underexposed to laboratory technical procedures in dental school.

The impending technician vacuum and knowledge erosion that looms on the horizon of dental technology in America has not gone unnoticed. The fact that the United States accounts for 35% of all indirect restorations fabricated in the world³ has even the most remote corners of the globe gearing up to fill the void. It has stirred enough concern stateside for the National Association of Dental Laboratories (NADL) and an ad hoc group of industry professionals to call for changes in American Dental Association (ADA) policy and the Commission on Dental Accreditation (CODA) educational standards.

So what is being done to fix a system that is clearly in serious trouble?

Elizabeth Curran, CDT, RDT, the NADL-nominated commissioner and chair of the CODA Dental Laboratory Technology committee, believes one of the solutions is an educational system that supports accredited, specialized education beyond the current 2-year curriculum.

“The educational programs in place now do a very good job teaching the basics, but the needs of the industry are no longer entry-level technicians,” explained Curran, assistant professor, director of laboratory services at A.T. Still University, Arizona School of Dentistry and Oral Health in Meza, Arizona. “Patient cases are becoming more complex, treatment planning more sophisticated, technology more advanced, and patients more demanding in the expected outcome.” She supports a mandated minimum 3-year formal education program plus an elective fourth and fifth year with a clinical interface to learn advanced prosthetics or to specialize in skill areas such as dentures, implants, or technology. Graduates from these programs would have the professional skill level to compete on a global scale and immediately open their own businesses. However, Curran admits such a drastic change in dental technology education may take more time than the profession has.

“Even if we were able to recruit and fill all our existing formal 2-year education programs today, the number of graduates and the time it takes for those graduates to have the level of experience they need to meet the needs of the dental industry will not be sufficient to fill the current void created by the technicians leaving the field,” she explained.

Jim Mahan, chief executive officer of Productivity Training Corp suggests that schools could graduate more well-rounded technicians with higher earning potential if the existing 2-year programs could condense the basics into a single year and use the second year to concentrate on skills with modern relevancy such as CAD/CAM, implants, and advanced denture prosthetics. This approach would enable schools to graduate competently trained technicians in the shortest amount of time.

“We can’t devote 2 years in our schools to teach the fundamentals,” Mahan said. “The industry is changing so rapidly, our schools can’t keep up.” If all dental technology programs adopted a standardized method of teaching the basics, then at minimum every graduate would be at the same skill level.”

“Currently, students in the 20 different accredited programs are receiving over-the-shoulder training by 20 different instructors, learning perhaps as many as 20 different ways to wax a crown, depending on that instructor’s approach,” Mahan added. Because of the lack of standardization among the educational programs, laboratories looking to hire have no baseline for the graduate’s skill level or ability to produce. Therefore, most lab owners feel the need to retrain so they can evaluate and manage performance.

“We need standardized education so that graduates can be predictably productive the minute they get hired,” Mahan said. “This might also keep many recent graduates from being placed in lower-paying starting positions, which hinders them from learning advanced on-the-job skills so they can move up the ladder.”

Another area that needs to be addressed is an incumbent workforce that has had no formal training. The industry needs to find ways to tap into the 40,000+ technicians in this country to provide them with basic and advanced opportunities for education.

“We need an educational platform that is able to deliver core knowledge and quality education to technicians while they maintain employment,” Curran said. “Half of those employed in this industry have no formal dental technology education, only on-the-job training, and 75% have not obtained NBC certification status.”

The National Board of Certification (NBC) has helped address this issue in part by instituting a modularization program for incumbent workers that encompasses the five dental technology specialties—crown and bridge, ceramics, partial dentures, complete dentures, and orthodontics. It allows technicians currently working in the field to test their skills and knowledge in any of the 12 competency areas within the specialties. Technicians must pass written and practical exams administered by an independent proctor in a location of their choosing, which could even be their home lab. A dentist or certified dental technician verifies the practical exam before submitting to the NBC via mail. Although successful candidates receive a certificate of competency, passing the exams does not qualify them to receive CDT certification. That is something Curran would like to see changed.

“I would like to see it structured so that a technician who has been in the field for 15 years and successfully tests out of a NBC module receives CDT status in that module,” Curran said.

What about those who want to move beyond CDT status and receive advanced education while employed? Currently, there are no night classes or distance-learning programs that teach accredited core or curriculum knowledge. Nor does CODA allow for advanced placement within the dental laboratory technology educational standards. And without advanced placement, Curran said, there is no way to develop relationships between the workplace and formal educational programs. CODA will need to revisit the dental technology standards and revise them to better fit the way the dental technology profession operates.

“We need modernization of the curriculum. Without an educational mandate, this industry has always been a knowledge-on-demand profession,” Curran said. “One of the ways to help a knowledge-on-demand industry gain value and independent assessment is through developing relationships with dental education.”

Three years ago, the NADL launched a monumental initiative to bring education to the masses and help financially strapped educational programs. For years the association has been aware of the crisis facing dental technology programs and the severe shortage of qualified technicians and has voiced these concerns numerous times to the ADA Council on Dental Practice.

“We finally realized no one was going to save dental technology education,” said Ricki Braswell, co-executive director of the NADL. “If it were to be saved, we would have to do it ourselves.”

In December 2007, the NADL established the Foundation for Dental Laboratory Technology. Its mission is to address industry-driven needs and provide solutions relevant and accessible to dental technicians and other dental team members. Education is one of the major challenges facing the industry that the foundation has decided to tackle. Spearheaded by co-executive directors Braswell and Adrienne Segundo, the non-profit foundation is committed to raising awareness about the need to improve educational opportunities, develop a web-based national education curriculum, and create a grant program that would roll out in 2011. The program would offer financial assistance to existing educational facilities to buy much-needed modern equipment or to revitalize and upgrade their program curricula. It would also help individual technicians to obtain certification status through the NADL Pillar scholarship program.

Funded by donations from suppliers, laboratories, and even individuals, the foundation is also developing online outreach programs that laboratory owners, program instructors, and other involved professionals can use to raise awareness about the dental technology profession in local high schools and community colleges located near accredited and non-accredited dental technology programs.

“Before we established the foundation, the NADL believed it was important to have a mandate from the industry we are serving,” Braswell said. “So we surveyed our CDT and non-CDT membership to determine whether they thought it is necessary to have a formally educated workforce or if on-the-job training is enough.” Seventy-five percent of both survey groups agreed that the industry needs formally educated, competent technicians.

The foundation is currently working with the NBC to assess the results of the NBC 2010 Job Task Analysis survey. They will compare the results to the NADL Competency Standards and the European Federation of Dental Laboratories DOSAM Occupational Standards to identify and develop current and emerging international occupational standards for dental technology that link to the CDT and modularization program assessments. Once that is completed, they can develop educational curricula and materials to elevate dental technology education in the United States to an international level.

Much like Curran, Braswell would like to see a multi-tiered approach to dental technology education. “We could take a lesson from other parts of healthcare where they focus on equating the level of responsibility with the level of competency,” she said. “Nursing has multiple degree levels from an associate’s degree as a minimum to a bachelor’s degree to a master’s degree for a physician assistant. Why couldn’t we consider something similar?”

For those who do not complete an associate’s degree program, Braswell suggests there could be a place in the profession for a laboratory assistant. It could be a supervised position in a single department, much like a medical technician in a clinic who takes vital signs and draws blood. And for graduates who wanted to continue their education after completing a basic 2-year program and externship, they could enroll in advanced 2-year programs including specialty tracks such as business, material science, implants, or technology.

Regardless of which direction these various initiatives take, dental technology education must get buy-in from all of the major players, including CODA, the ADA, the American Dental Education Association (ADEA), educators, and schools, which presents huge bureaucratic and politically-charged hurdles.

Clinicians who work side-by-side with technicians every day on highly complex cases witness the plight of the dental technology industry firsthand. They clearly see what the future holds if the technician workforce is further compromised. That is why the Prosthodontic Forum, which represents 17 dental organizations, and the Dental Technology Summit, an ad hoc group of concerned industry professionals, have been so persistent in expressing their concerns to the ADA.

A strong advocate for dental technology education, New York prosthodontist Burney Croll, DDS, is a member of the Prosthodontic Forum and executive director of the Dental Technology Summit.

“Over the past five years, we—along with the NADL and other industry leaders—have been very vocal about the quality of oral health services dentistry will be able to deliver if changes in dental and dental technology education are not instituted,” Dr. Croll said. “The majority of dentists in this country rely now more than ever before on the dental technologist’s expertise to collaborate and advise on complex casework.”

Heeding their call to action, the ADA called a special conference on August 7, 2009 to address the issues raised by the NADL, Forum, and Summit groups. The ADA Future of Dental Technology Conference centered on the reduced dental technology workforce, dental technology education, off-shore and regulatory concerns, certification of dental technicians, and general prosthodontic competence of pre-doctoral graduates.

The issues raised at the conference were passed through a subcommittee to the Council on Dental Practice, where the subcommittee’s recommendations, new resolutions, and actions were approved for submission to the ADA House of Delegates. The House will meet this month during the association’s annual session to vote on instituting the recommendations.

While not every issue raised at the conference made it to the Council on Dental Practice, Dr. Croll believes it is a great starting point for increasing dentist/technician interaction and education and curbing the use of off-shore laboratories by universities.

The recommendations, resolutions, and actions approved include:

Encouraging component dental societies to recognize the continuing education needs of certified dental technicians by inviting them to attend continuing education seminars.

Encouraging dental programs to collaborate with dental technology programs in dental schools.

Encouraging dental schools to use US laboratories for the fabrication of undergraduate and graduate prostheses in lieu of sending them abroad.

Encouraging US dental schools to use in-house laboratories whenever possible to facilitate dentist/technician interaction.

It may be a start but is it enough?

Manufacturers may be betting that it is not enough. What has not been addressed—and may never be—is the manufacturer’s involvement in the dentist/technician equation of patient care. Lily T. Garcia, DDS, MS, FACP, vice president of the American College of Prosthodontists and a member of the ADEA Board of Directors recently participated in a key opinion leader meeting held by a major manufacturer that services the dental technology industry. She was intrigued to hear differing perspectives on the future and the greater need for a broad-based involvement to develop solutions. The meeting left her concerned about the effect that having fewer highly educated technicians will have on her ability to provide specialty-level patient care and about who will deliver the millions of restorations and complex prosthetic cases the US market demands now and in the future.

“If we lose our technician base here in this country, where is dentistry left?” asked Dr. Garcia, a professor in the Department of Prosthodontics at the University of Texas Health Science Center San Antonio. “Will we be sitting in front of a computer screen prescribing and interacting virtually on a case and sending that case digitally to other parts of the world?”

That is not such a far-fetched concept. Mahan’s company receives requests from all over the globe for their PTC technician-training program. “There is an emerging market and awareness of dental technology throughout the world,” Mahan said. “We are in a world economy, and the US currently has the highest demand for dental procedures in the world.”

In most of the rest of the world, the dental technology profession is regulated, with education as the central component of that qualification, Curran said. In other countries, it is viewed as a patient-safety issue—something that has not been addressed in this country yet because the dentist is seen as the prescriber and safety net between the patient and the dental technologist. But, Curran says the truth is, most dentists in this country leave material selection up the laboratory and have no idea if the proper material science was applied in the fabrication or if the restoration was manufactured properly.

Mandated, degreed education is the foundation and future of any industry. When education suffers, so do all other aspects of a profession. Curran, Braswell, Mahan, Dr. Croll, and others will continue to keep the momentum going, pounding away at the ruling bodies of the profession to wake up and take action.

If you want your voice to be heard on this issue, write or e-mail the ADA, ADEA, CODA, and the NADL. Help those who are already committed to working toward a solution.