Breaking Through the Wall

Inside Dental Technology: Breaking down barriers between professions can be difficult because technicians and dentists may have different backgrounds and perspectives. What are the barriers between technician and dentist in the delivery of care and solving a problem?

David Avery, CDT: A significant disparity exists between the educational levels of technicians and dentists in the United States. Internationally and in Canada, a much higher level of education is available to technicians. In the United States, our shrinking pool of educational opportunity includes fewer than 20 2-year programs with an associate’s degree. Dentists, of course, have 4 years of undergraduate training and 4 years or more of postgraduate training, depending on whether they do residencies after completion of dental school.

I firmly believe this disparity can lead to attitude clashes with a professional who may appear to not respect the technician, or a technician who may be defensive due to a perceived lack of respect by the dentist. Either of these scenarios, whether real or imagined, can make effective communication almost impossible.

Gregg A. Helvey, DDS, MAGD, CDT: With some dentists, a certain ego factor exists because of the advanced number of years of education. Most laboratory technicians did not attend dental school, so some dentists do not appreciate taking instructions from them. When I give lectures to audiences of dentists, because I command their respect as a fellow dentist, I am able to better express to them the challenges involved with being a laboratory technician and working in a laboratory.

Cheryl A. Pearson, DDS: As a dentist, we go through our education and we think we know a fair amount about laboratories and how technicians work, but in reality we do not know that much. We need to depend on them a lot more now than in the past.

Pinhas Adar, MDT, CDT: The curse of knowledge is that we know so much, but we don’t use what we know. Each person must ask, ‘Do I use those things that I know?’ The fact that we know so much does not by itself mean anything. The second question is, ‘Are you a master at that?’ Quite often, it takes about 10,000 hours to master any skill. So are you a master, or do you just do it halfway? The third question is, ‘Do I have results to show for it?’

Avery: The boundaries are largely self-imposed from the technician’s perspective. It stems from insecurity, although no one wants to admit that. I have learned in my many years of lecturing and teaching that there are basic elements of human nature that motivate us either positively or negatively. Fear is a primary motivator that holds people back from learning and from asking questions.

That insecurity is especially rampant in dentistry. People will fake it, or do the best they can without calling and having conversations, based on a fear of admitting to the dentist that they do not know something or they do not understand the information.

This can stem from a lack of basic communication skills, with which many people struggle. Technicians classically are introverted personalities anyway. If they excel at staring at something the size of their thumbnail all day, they do not tend to be good communicators. Inherently, technicians have to work to develop those skills, unless they are blessed with being good communicators from birth.

Pearson: For a laboratory technician, one barrier can be intimidation, because of the difference in educational levels. Many dentists feel as if they know everything. In reality, we can learn so much by utilizing and working with the technician. The technician I work with has helped me and advanced my ability tremendously with patient care. We have developed a relationship in which he can say to me, ‘This is in your patient’s best interest, and this is the importance of the particular data that I need.’ I am very much willing to listen. The laboratory technician needs to develop that confidence to communicate with the dentist and say, ‘I cannot do this unless you provide this data.’ If we can come together and communicate at a higher level, it would help our patients, and that is always the primary goal.

Helvey: I host a class called, ‘What Your Lab Technician Would Love to Tell You But Is Afraid to Say.’ After that lecture, so many dentists say, ‘I never knew that.’ So many dentists think that technicians can perform miracles, and a lot of them expect that. Technicians sometimes receive cases and scratch their heads, wondering, ‘What do you want me to do with this?’

The left hand does not know what the right hand is doing, and if they could come together somehow, perhaps by visiting each other’s workplaces, that would help.

Apeksha Pole, DMD: Not enough communication occurs to respect the patient’s desires, demands, and expectations. Most of the patient’s interaction is solely with the dentist. The laboratory technician fabricates the final prosthesis without ever having met that person who will be receiving, living, and functioning with the prosthesis. That is one of the biggest barriers involved with giving the patient a product that is functional and esthetic, something that they can live with and enjoy. Communication with respect to that is the biggest challenge, mainly because dentists interact with laboratory technicians as a bridge to the patient. We write down a laboratory prescription, and along with a couple models or impressions, that is all that the technician receives. To them, the patient might seem to be just a bunch of models, impressions, or a prescription. The patient’s expectations must be communicated effectively, and with just those pieces of information, you can express only a limited amount. A good relationship with the laboratory technician really helps this process because both the technician and dentist need to be on the same page in terms of delivering a certain quality and a certain standard of prosthesis.

However, we do not always have the luxury of working with the people we know well or working with the same people on a regular basis. Bigger laboratories have many technicians, and you do not know who is fabricating each prosthesis. A lot of the specific advice or information may get lost in translation, or the technician may not interpret it correctly.

Pearson: Respect is paramount. I have as much
respect for my technician as I do for all colleagues, including specialists and general dentists. If you do not have that respect, you just cannot work together well. When something goes wrong, you cannot immediately blame it on someone else. I sometimes look back and see that I did not get the data exactly the way I should have. Sometimes I take an impression and think it looks really good, but the laboratory points out a problem. It is important to be humble and realize that when dealing with so many variables, we have to work together.

Avery: In my years in the industry, I have spent a lot of time consulting and training within the laboratory community. I invariably try to convince technicians that they need to communicate with dentists and make suggestions and explain to them when cases are compromised. Technicians tell me they do not bother because the dentists will not listen to their suggestions.

It reminds me of my first year in the business. The best removable prosthetic technician I have ever known had worked primarily with prosthodontists but then opened a commercial laboratory. I began picking up models from impressions that came from general practitioners, and the quality of the impressions that we received varied greatly. One day, I went to his bench and showed him a model that was obviously inadequate, and I asked if he was going to call the dentist. He said, ‘Why should I bother? They are just going to tell me to do the best I can.’ It was shocking to me. I inherently knew that was wrong and that we should all be working toward the best care for the patient.

So in my early stages of ignorance, before I had a lot of experience in the laboratory industry, I encountered that apathy and was convinced that I would not work that way. For my entire career, I have made it a point to be proactive and make sure the dentist knows if we have a compromised case.

IDT: How do you overcome the barriers and work as an efficient and effective team?

Adar: It’s all about relationships and how we can effectively communicate with words, images, or any tools that we have. Quite often, we have not learned those skills in dental school or laboratory school. The physical skills we learn are not enough, especially today, because technology is advancing and everything is changing quickly. We have an information overload, and we need to interpret that information and process it. My passion is teaching communication skills to professional dentists as well as non-dental professionals. People think communication skills are only for public speakers, but when you leave your house, you are speaking publicly. How effective you are with your words is crucial to any success in life or business. Once you open your mouth, the world knows who you are. We have to be careful about how we portray ourselves.

We also face the challenges of communicating with patients effectively. Every patient communicates differently.

Avery: Building relationships takes work. Inevitably, if the technician is prepared to be a resource of information for the dentist, a much better opportunity will exist to build a solid relationship. When we receive cases in the laboratory, we have a responsibility to perform quality control on the impressions, bite registrations, preparations, and other materials that must be utilized to develop that restoration. If we have any question or concern, and we proactively pick up the phone and ask the question, it is only a reason for concern. If we mention the problem after the fact when there is a failure, it is an excuse.

Not everybody wants help. Not everybody realizes they need help. We have a professional role to try to broaden the horizon of the clinician as far as our knowledge base and sharing information with them to help us all accomplish a better result.

Pearson: I do not need help looking bad; I can do that myself. I need a technician who makes me look really good. When you find a really good technician, hang on to them. Be good to them. Try to do the things that they need. They will appreciate you more as well. It makes for a better situation in every way.

Adar: Solving a problem involves not doing more of the same thing and hoping for different results. We just need to get better. As the author Jim Rohn once said, ‘For things to improve, you have to improve. For things to change, you have to change.’ We have to learn from people who have done it and have track records as far as being effective in communication. The best way to change is to have 2 parties work together. For example, if you work with dentists who are also on the path of growth and trying to be more effective, it is better to work together and learn that skill. No matter how good you are, if your verbiage is not right, you are not going to be successful.

Helvey: For complicated cases, the entire treatment team should discuss necessities before starting the case. Too many times, a technician receives a case from the dentist and has suggestions regarding what could have been done differently. Communication should occur before starting a complex case.

Avery: If technicians have limited clinical knowledge and do not fully understand what is happening in the operatory relative to the prosthesis they are trying to produce, they often do not feel comfortable calling the dentist and asking for something different. It is very important that we as technicians know as much as humanly possible about clinical processes and procedures, because we obviously will have a stronger knowledge base of what happens in the laboratory than the average dentist does. In the last 10 to 12 years, dental-school graduates have had far less hands-on, direct training in prosthetic procedures, and therefore they truly do not understand what we are doing in the laboratory and cannot appreciate what it takes to get it done. Inherently, we have the advantage where that is concerned. We just have to prepare ourselves to be strong in our knowledge base clinically so that we understand the full scope of treatment.

IDT: How has technology helped bridge the gap?

Pole: I am not just trying to give the technician the information to fabricate a tooth or a denture; I am trying to get something for the patient that functions so they can live their life. I am trying to give them something to improve their quality of life. When you are dealing with a person like this, communication technology makes such a difference because now we are both treating it. That trend of being able to virtually see patients is the future, because that is what we really need in order to relay that information to each other.

The digital impression field is really taking off right now because you can instantaneously send an impression to a laboratory. I do not have to wait for UPS or a third-party delivery. I do not have to worry about a model breaking, and I know what I have is sent is exactly what I see. There are no variables, no discrepancies, and no errors introduced. We are just transmitting the information. A lot of companies have jumped on board and are working hard to instantaneously give the technician a virtual model of somebody’s mouth. Get rid of all the impression material; get rid of all the gloopy, gunky mess that we have to put in people’s mouths. We have increased accuracy and efficiency with these new technologies.

Pearson: Photography has become huge. I have been in practice for 35 years. Of course, we did not have digital photography when I started. Sending photographs and information to the laboratories was difficult. Today, digital technology offers an advantage. Sometimes when I send photographs of my patients to my laboratory technician, he sends information back asking if I noticed something in particular. We solve the problem and the patient is very happy. My technician cannot fabricate or begin anything until I answer his questions. Returning his calls personally is a high priority for me. I send him as much information as possible. It is so important to send as much as possible and not forget to respond.

Pole: Technology has come a long way in terms of the ability to give the technician more information. That is the basis for what will change the industry and enable us to do a better job: more effective, more efficient, and meeting the expectations of the patients on a regular basis. We are able to give the laboratory a lot more than just a prescription, a model, and maybe an impression. We are able to give the technician a 3D virtual tour of a patient’s mouth. We can offer digital photography and full-face images. Instead of a model and a piece of paper, the laboratory now has a patient. The dentist and technician are now seeing the same thing and relaying the same information. What I see in a patient’s mouth is now what a technician is able to see, which makes a big difference. They can see not only the teeth itself but a patient’s face. They can see how the prosthesis will look in the patient’s mouth, how it will match their character, and how it will match the esthetics that we seek. They can see what I am talking about and what I want to achieve.

When I take a virtual impression or digital impression, I can send it to the laboratory and have my technician approve it immediately. I don’t waste the patient’s time by calling them back, and I don’t waste the technician’s time because they can see what they need right away. We are able to more effectively, more efficiently get the work done.

IDT: What other tactics could improve dentist-technician relationships?

Helvey: The biggest barrier between dentists and laboratory technicians, from my perspective working in both capacities, is that the dentist is not fully versed in what the technician needs to do in order to fabricate cases that the dentist has sent to them. The basic wall to overcome is that the dentist does not know what that requires and the technician does not know what is required to prepare teeth.

There are many situations in which the laboratory receives an impression or makes a model, and it is just not quite adequate. The technicians were not present in the dentist’s office to see the challenges involved with taking this impression. Perhaps the patient was screaming, gagging, and salivating extraordinarily. The technician looks at a model, is unable to read all the margins, and wonders, ‘How does the dentist expect me to fabricate a flawless restoration when I do not have all the information that I need?’

If dentists would spend time in a laboratory and see what laboratory technicians are doing, and if technicians would spend time in the dental office to see what challenges dentists face, it might help break some of these barriers.

Pearson: How we respect each other and what we do goes 2 ways. I like for my technician to come into my office and meet my patient. Many times, I introduce my patient to the technician who fabricates the restorations. My patients enjoy that, and they connect with the person who is making the final product.

Helvey: I have been a dentist for 40 years and started doing laboratory work approximately 15 years ago, and now whenever I work on a patient, I think as a technician during the preparations. I consider what I need in the laboratory to make the case work.

I encourage my students at the Virginia Commonwealth University School of Dentistry to spend time in the laboratory in order to see what the technician’s job involves. They can look at models of prepped teeth and get an idea of how a technician finds disappearing margins. They can see how the technician picks out a shade with a discolored tooth and no stump shade picture to utilize.

Avery: One of methods I have used for many years is having a solid reference of materials to which to refer dentists. If a dentist is having problems with preparations, bite registrations, impressions, or anything else, it is crucial to be able to refer them to lectures, articles, or webcasts. It disarms the dentist from thinking, ‘A technician who does not have nearly the knowledge that I have is trying to tell me how to practice dentistry.’ Referring them to someone whom they recognize and respect should make them more willing to adapt and adjust to those suggestions.

Adar: Another important component to breaking down barriers is the OQP (Only Quality People) principle. Sometimes we work with the wrong people, and we try to change them because we want so much more for them than what they want for themselves. When a team includes dentists and laboratory technicians who have different values, they will get burned out. A crucial step is qualifying the people who work with you as people who have the same path and same vision, and then develop yourself to have the same mission so you can accomplish your goal. It is not a skill you can develop overnight. It is a process, not an event. You have to master it daily.