Lending a Hand

“You can fortify the position of your business when you are able to become a valuable resource to your client base,” says Thomas Zaleske, AS, who owns Matrix Dental Laboratory in Crown Point, Indiana, and also works as a consultant. “Your fees should then be based not only on what you fabricate; they should reflect the value you bring to the case. Once I provide my clients with sound advice, and if they accept and act on that advice for a successful case outcome, they buy in completely to the value of a consultative relationship.”

Sometimes extensive research and additional education are necessary to act in a consultative role. Other times, it is simply a matter of recognizing when and where you can step in to secure the success of a case.

“Technicians have a tremendous amount of knowledge about so many things that dentists do not even think about,” says Ricki Braswell, CAE, President and CEO of The Pankey Institute. “It is an area that needs further exploration on the part of the dental technology industry.”

A dentist was once asked why he sends his work to Al Fillastre, CDT, owner of Ceram-O-Arts in Lakeland, Florida, considering Fillastre charges twice what some other laboratories do.

“Because he’s an indispensable asset to my practice. I get triple the value out of what he knows and what he does for me,” the dentist said, according to Fillastre. “Al helps me avoid costly mistakes with great feedback and very open communication. He is always available. If I have a patient in the chair and an issue or question arises, I can call Al for help.”

Fillastre does not just sit by the phone, though; he is proactive, whether it is in the treatment planning phase of a case or saving them chairtime with a simple solution. Digital technology has opened the door to many value-added services, and allows him to easily produce diagnostics that aid in everything from proper tissue contouring for improved implant outcomes, to full-contour mock-ups and orthotics, to helping dentists sell cases by allowing patients to easily visualize outcomes. Milling a diagnostic PMMA "shell" to bond onto deficient temps to improve them without the need to remove and remake them can help immensely.

Sometimes, a dentist needs assistance when trying to use a new tool chairside, which gives technicians the opportunity to demonstrate or walk the dentist through its use and gain that case control. Removables specialist Brian Carson, CDT, owner of Signature Dental Studio in Fayetteville, North Carolina, says dentists can be overwhelmed by trying to use tools such as papillameters.

“A lot of dentists want to progress in the area of instrumentation because it can improve their outcomes, but cannot afford to risk the chair time,” Carson says. “If a technician can master these instrumentations and explain them to the dentist, that will help cure their apprehension.”

Similarly, dentists can be uncomfortable trying new materials. Braswell says at the Pankey Institute she has observed dentists having a difficult time keeping up with the latest millable materials, for example. Restorative materials are involved in almost everything a laboratory does, but they are only a small part of a dentist’s job.

“Technicians are materials science experts,” Braswell says. “They have a much better handle on the indications and contraindications of these materials. Whether the materials are intended for anterior or posterior restorations, technicians understand the esthetic parameters and the limitations and can advise on the long-term durability as well as the chances for esthetic success. Little things can trip up dentists, such as not understanding to take a stump shade when prescribing an all-ceramic restoration. If the dentist is accustomed to prescribing PFMs and only provides the laboratory with the finish shade, the laboratory does not know if there might be underlying staining, yellowing, discoloration, or banding on the prepped tooth, and this leads to the prospect of not being able to produce a restoration that esthetically blends with adjacent natural teeth.”

Just as laboratories can share the knowledge they glean from working extensively with a wide array of materials, they also can take advantage of the knowledge gathered from working with a large client base on a regular basis. Feedback received from clients, whether positive or negative, can be passed on to other clients who may be less comfortable in a given area.

“You can capitalize on your relationships,” Carson says. “If you are seeing particularly good results from one dentist’s impressions, call and inquire about what impression material he is using. It is a chance to compliment him, and then pass that valuable information on to other clients as well.”

Sharing acquired knowledge can extend beyond clinical topics. One of the areas where many dentists feel uncomfortable is simply dealing with difficult patient issues. While technicians generally do not work directly with patients, they still can offer valuable advice.

Zaleske, a removables specialist, said many of his clients have told him they are uncomfortable dealing with denture patients because of the more demanding clientele and the complexity of issues that arise. He offers them a possible solution that draws on his previous experience in sales.

“Working with unhappy, older edentulous patients who have not been able to eat, chew, or smile for 15 years is time-consuming and difficult. To schedule these patients in the midst of routine patient visits requires that the dentist constantly changes demeanor and mindset,” Zaleske says. “I always suggest that my clients see denture patients only 1 day per week. That way you do not need to switch back and forth. You have complete focus and know what to expect on that day.”

Sundeep Rawal, DMD, a prosthodontist practicing in Merritt Island, Florida, says the laboratory also can help ease the discomfort with patient care in a practical way, by expediting certain processes when it comes to complex implant-retained prostheses.

“The biggest area where dentists do not feel comfortable is managing the patient's restorative needs on the day of surgery,” Rawal says. “Trying to deliver some sort of conversion for a fixed interim prosthesis is a challenge. The laboratory becomes an invaluable resource that the restorative dentist and later the surgeon can lean on significantly.”

Rawal tells the story of a double-arch, implant-retained case for a severely mentally challenged young woman who had lost her teeth and was not very responsive to anything he tried while she was awake. When the patient was sedated in the surgeon’s office, though, the laboratory helped make sure everything could be completed as efficiently as possible.

“The laboratory went above and beyond to not only facilitate taking dentures and converting them into fixed provisional restorations,” Rawal says. “We also took the time to make impressions, make jaw relationship records, do bite blocks, set teeth, and really almost go to the final definitive steps of the case, so that I wouldn’t have to do multiple steps with a patient who was not cooperative.”

Even cooperative patients can make dentists uncomfortable when it comes to implant cases. Implant prosthetics is one of the fastest growing segments of the dental industry but also one of its most challenging. New technological advances are making implants a more viable option for a wider range of patients, but the process still requires a high level of skill and knowledge.

“More general dentists than ever are doing implant work,” Braswell says. “The timing of when the technician enters the process of an implant case makes an enormous difference in how successful that case is.”

Even if the dentist is only restoring implant cases, a technician’s input is extremely valuable on the front end of the case. Dentists’ concepts of emergence profiles, placement, and managing expectations regarding esthetics are often not as strong as those of the technician, Braswell says. Some general dentists are placing implants as well, and a technician can help them do so more confidently by being involved in the beginning with input on aspects such as the CBCT scans and which implant system is best suited for that case.

When it comes to full-arch implant-retained cases, Braswell says, dentists often are more experienced and thus more comfortable with the actual placing process. However, much of their experience has been with single units in non-esthetic zones, and full-arch cases require a deeper knowledge of occlusion. With those cases, a technician can step in and help prevent a potential catastrophe.

“Dentists are not used to looking at the occlusion as a potential cause of catastrophic failure,” Braswell says. “If you have a crown that is out of occlusion, the crown may break, the opposing may fracture, or you might have some jaw problems. However, if you have improper occlusion in an implant case, you will have significantly more serious issues that arise as a consequence.”

Removable prosthetic cases can be just as significant a source of discomfort. Zaleske says dentists today are graduating with so little knowledge of removable prosthetics that he foresees denturism being legalized in more states. Currently only 6 states regulate denturism, but 9 more are seeking regulation, according to the National Denturist Association.

Burney Croll, DDS, a prosthodontist practicing in New York City, says that with the rising 65-and-older population, the problem is serious and the laboratory’s role is crucial with dentists who lack experience with removable prosthetics.

“Many seasoned dentists have neglected maintaining competence in the removable prosthetic area, expecting everything to be solved with easy digital technologies,” Croll says. “Digital solutions have not displaced many critical steps in the removable prosthetic skill set that require the human eye, and thoughtful integration is required.”

Recent dental school graduates also are receiving less exposure to removable prosthodontic skills.

"Dental laboratories are providing continuing education in such basic areas as impression making and mounting cases appropriately on an articulator to help decrease remakes," Croll says.

While prosthetic dentistry continues as the most prevalent caseload dentists face, sleep appliances might be the next business growth area for both dentists and laboratories. Several studies over the past decade have concluded that oral appliance therapy should be considered as a viable treatment alternative for patients with mild to moderate obstructive sleep apnea syndrome.

“It is going to hit the masses,” says Philip “Sonnie” Bocala, CEO and Founding Partner for T&S Laboratory in La Mesa, California. “Many aspects of sleep medicine are not thoroughly covered in some dental schools, and that leaves a prime opportunity for laboratories to share their knowledge base of appliances and appliance therapy, and become a resource for the dentist."

Bocala says he decided approximately 8 years ago to commit to becoming a sleep apnea expert. He attends continuing education courses on the subject, even if they are geared solely toward clinicians. He has spent extensive amounts of time researching various appliances so that he can advise dentists which ones have the most value.

“We function as a large-capacity production laboratory but behave like a small laboratory in that dentists can use me as a resource directly,” Bocala says. “I have learned from both my perspective and theirs.”

The laboratory can play an important role in the sleep appliance process. Even if dentists know the proper techniques, Bocala says, they might not have time to look through the various products available on the market and which is best for a particular case. Important choices that must be made when selecting an appliance include whether to choose a digital, vacuum-formed, or acrylic appliance, and the cost considerations of each.

“There is a great deal of information to understand and absorb, and it can be overwhelming,” Bocala says. “It is up to the laboratories to educate themselves on the myriad options available."

Doing so can be the difference in retaining business as dentists search for laboratories that will help in their discomfort zones.

“They look at me not as a laboratory technician filling a prescription but as a partner,” Bocala says.

Identifying dentists’ discomfort zones and offering assistance is only part of the challenge. In many situations, persuading dentists to accept that help can be more difficult. While Bocala’s strategy with sleep appliances is to attend clinical courses, Zaleske says with removable prostheses he compiles literature to back up his recommendations.

“Dentists often are uncomfortable receiving advice from somebody who does not have the same level of education,” Zaleske says. “The first thing you need to do in order to be their technical resource is find published articles by their peers to give them the information that they need to know without allowing for that objection.”

Part of that responsibility lies with the dentists as well, though. No one is perfect in every aspect of dentistry, and it is important to acknowledge discomfort zones and accept the input and assistance of others. Rawal says he considers dental technicians to be his peers.

“Delivering restorative excellence, great patient care, and a wonderful patient experience,” Rawal says, “really depends on a team of peers who mutually respect each other, who value each other’s skills and knowledge, and who therefore can work in a synergistic way.”

At the Pankey Institute, Braswell says technicians are considered specialists. The institute offers classes on both restorative and surgical implants that feature working technicians. None of the institute’s courses have prerequisites, meaning they are all open to technicians. The cost of courses for technicians is about one-quarter of the cost for dentists, an extra incentive for technicians to join in the team education.

“You can be a really good dentist, but you will never be a great dentist without a good technician,” Braswell says. “It just will not happen.”