One Case, One Mind

“My technicians have been part of each reconstruction, from diagnosis to conception to sequencing to constructing to the conclusion,” Kobren says. “I cannot imagine being able to accomplish what I accomplish without that intimacy.”

Dentist-technician teams that do not have the benefit of working in the same office, however, face a steep challenge: Delivering a restoration that pleases the patient despite separately performing each step of the process while miles apart. Even if technicians never get to meet the patient in person, they are expected to fabricate precision-fitting restorations that meet the patient’s subjective esthetic expectations—and if they don’t get it right the first time, the laboratory’s profit margins are negatively affected.

This challenge is not new. However, the most successful dentists and technicians have developed methods and strategies to establish an effective collaborative culture as if they were working in the same office, even if they are hundreds of miles apart. Whether utilizing new technologies or tried-and-true tactics, the common theme among these dental professionals is that they manage to think and operate as one, as if the technician is in the operatory and the dentist in the laboratory.

“The dentist and technician must be calibrated together,” says Thomas McDonald, DMD, who practices in Athens, Georgia. “Collaboration benefits everyone: the dentist, the technician, and most importantly the patient.”

Paul Federico, MDT, CDT, shared a building with a dental practice before moving to another facility. Federico fondly recalls daily meetings when he and the dentist sat in front of a computer, looking at pictures and discussing cases. Now, he struggles just to get dentists to email him photos; even when they do, the discussion is fragmented.

“Dentists rarely have time to analyze pictures while on the phone with the laboratory,” Federico says. “The ideal situation would be to make a comment and receive an instant reply. Instead, sometimes I look at a picture and make a suggestion, and I don’t find out until later that it’s not an option due to the patient’s wishes. Not being able to banter back and forth makes a real difference.”

To make the best of a challenging situation, Federico coaches his clients to take photos that tell as much as possible. Closeups of teeth do not show him much more than he can see on the model; the patient’s face can provide much more information. Federico says he convinces dentists to send full-face photos by “asking them questions they cannot answer.”

“I will say, ‘I see the two centrals in your picture, and No. 8 is longer than No. 9. Which one looks better in the face?’” he says. “They usually do not have an answer, because they were not able to spend enough time with the patient to make that determination, but strong photos would have allowed us to perform that analysis. The incisal plane sets up the whole case; if you do not know where those teeth are, you are basically guessing. Once dentists realize this, they start taking more comprehensive photos.”

Steve Hoofard, CDT, AAACD, Lab Manager for MicroDental Northwest Laboratory in Kennewick, Washington, says he has gone so far as to purchase high-quality cameras for clients to use in their offices.

“The investment is worth it because it helps me obtain the information needed, and it also shows my clients the value in the relationship,” Hoofard says. “It demonstrates that I am committed to the relationship and to delivering cases that meet or exceed the expectations of the dentist and the patient.”

Sivan Finkel, DMD, who specializes in esthetic dentistry at his practice, The Dental Parlour in New York City, says he recently collaborated on a single-central crown with Connecticut-based ceramist Cristiana Fragoso of Oral Design Connecticut, and they produced a successful restoration on the first attempt.

“By sending her the necessary photos with the proper lighting and a detailed written description, I was able to provide her with enough information to compensate for the fact that we were in different states,” Finkel says. “Typically, we expect single-central restorations to require more than one try-in visit and the ceramist usually needs to see the patient in person. It is exciting that we can successfully fabricate these restorations without doing that.”

While some laboratories host patients for custom shade matching, Finkel noted that if the dentist is capable of taking his or her own high-quality photographs in the office, then that is a preferable option.

“The restorations will be judged based on the atmospheric lighting in my operatory,” he says, “so basing our work on photographs taken in that environment is best if possible. Additionally, this saves the patient a visit to the laboratory, which can be inconvenient.”

Dene LeBeau, CDT, owner of LeBeau Dental Laboratory in Renton, Washington, says he compels his clients to send the case photography on the same day the case is shipped.

"We have photo samples on our website for anterior and posterior teeth, so we ask that our clients generally imitate our angles, shade tab placement, and exposure," LeBeau says. "When we take the time to explain what we want and why we want it, usually clients understand and give us what we need."

Video is another valuable resource that is becoming increasingly easy to utilize with tools such as Dropbox to send large files to the laboratory in seconds. Watching patients speak on video serves two purposes: It allows the technician to get a better feel for the patient’s personality and desires, and it helps in analyzing their speech for functional purposes. Federico says ideally a dentist would have a checklist of questions and topics to cover on video.

“How does the patient make S sounds?” Federico says. “Does he or she bring the incisors into closest speaking distance and then make the S sound? Does the patient make the S sound off the tongue? That type of information can be important.”

There is, however, the risk of becoming too dependent on technology. Verbal communication and a comfortable clinician-ceramist relationship, Finkel says, will always be important.

“Sending the laboratory videos and photos and saying, ‘Do your thing,’ is not sufficient,” he says. “I still fill out an elaborate laboratory slip each time, followed up by phone calls or even Skype meetings for especially complicated cases. You cannot forget that technology is not a replacement for personal communication. No matter how talented the ceramist is, a lapse in communication leaves too much to the ceramist’s imagination, and the results become unpredictable.”

From a smile design standpoint, Finkel also warns: “In the wrong hands, technology becomes dangerous because if you show a patient digitally what you are going to do in their mouth, you’d better be able to pull it off. You still need a solid foundation of the technical skills required and an understanding of the biology involved.”

The wide range of communication avenues available today provide dentists and technicians with options to customize their interaction according to each individual’s preference.

Finkel says he uses email, text messages, Skype, Dropbox, and WhatsApp—an app that allows him to send text messages internationally without fees. When a question or idea pops into his head, he reaches out to the technician and usually receives a response much faster than if he needed to call the laboratory, speak to a receptionist, and schedule a time to speak to the technician.

“The concept of asynchronous communication has really helped dentistry,” Finkel says. “Instead of meeting requests or calls, which would require both of us to be available at the same time, asynchronous communication allows you to work around each person’s busy schedule. Chatting throughout the day needs to be the standard relationship between ceramist and clinician in 2016.”

Hoofard makes his cell phone number available to all of his clients and encourages them to text him any time.

“Texting is instant,” he says, “and I can respond either immediately if I have time, or in a few minutes. It is also a really good way to feel connected with the client, a personal touch that brings more value to the relationship.”

LeBeau has a preschedule system at his laboratory, so he encourages dentists to text or email the case details on the day the case is diagnosed. With this quick bit of case planning communication, cases usually are completed promptly when they are submitted to the laboratory; the advance notice simply helps with internal organization.

"In order to effectively collaborate, we need to be organized, which requires us to be in communication as early as possible with each case," LeBeau says.

Communication is not always that simple, however. With so much at stake, it is crucial for dentists and technicians to understand each other’s terminology.

“As technicians, we do not speak the same language as dentists,” Federico says. “We need to be taught the vocabulary of dentistry. Many technicians just do not understand the verbiage, so even though they are communicating, they are not communicating effectively. It’s like speaking a foreign language.”

Federico says even if a technician learned clinical terminology in a college program, new developments often make that education obsolete.

“The dictionary of prosthetic terms changes very rapidly,” Federico says. “Unless you keep up with it through continuing education, you are speaking a different language than the modern dentist.

Conversely, Finkel says dentists must learn laboratory terminology in order to understand exactly what technicians are saying during discussions about cases.

“Dentists need to be intimately familiar with micro-esthetic criteria such as height of contour, zeniths, axial inclinations, opalescence, and luster,” he says. “We really need to understand color concepts such as value chroma and hue, so that we’re all on the same page.

“The next step is learning your counterpart’s tendencies. You learn what certain subjective words mean to each individual. For instance, ‘slight translucency’ might mean something different to two different ceramists. You need to calibrate yourself with each individual technician, and this will strengthen the relationship over time.”

Communication is so important because in the absence of direct interaction between the patient and the dental technician, the dentist serves as a middleman of sorts, and no amount of technology can substitute for cultivating a relationship to the point at which the dentist and technician think as one, making it as if the technician were in the operatory.

“Dentists and technicians who want to perform high-level, complex restorative dentistry absolutely need to invest the time it takes to develop a strong relationship,” McDonald says.

McDonald began working with technician Terry Fohey, CDT, of Nucraft Dental Arts, 31 years ago. They decided early on that it would be necessary to attend continuing education sessions together, and McDonald at one time stopped by Fohey’s laboratory every night on his way home from the office to discuss cases. The result is that now they think so similarly that they do not need to be in the same room or even use video to achieve the results they want.

“My view of an A1 shade is synchronized with Terry’s,” McDonald says. “We speak each other’s language. We understand each other’s quirky descriptions. If a tooth suddenly looks translucent, and it’s hard to describe it or even photograph it, I can say, ‘It looks like an A2 shade tab but three clicks more translucent,’ and he knows exactly what that means.”

The impact of a strong relationship between dentist and technician is especially evident to Bernadette Sawa, DDS, who works at two different practices in New York City. At her primary practice, Sawa has worked with the same technician for several years, and they frequently meet in person to discuss cases. At her other office, collaboration with technicians is rare, which she says often results in remakes and wasted chair time. There is no quick, simple solution, Sawa says.

“Developing a strong working relationship takes years,” she says. “Every case is different, so you need to learn from each one.”

Attending continuing education courses together is a popular method of developing that relationship.

“If there is an interest on the dentist’s part to move into an arena that interests me or would benefit the collaborative process, I pursue that,” Hoofard says. “I look to see what courses are available that address that topic, and I start a dialogue about attending them. It is a great way to close the gap, and then a personal relationship develops out of that as well.”

McDonald says attending education together helps in more ways than just developing a personal relationship and gaining experience with different types of cases.

“We get a chance to walk in each other’s shoes,” McDonald says. “Terry has witnessed difficult patients, so he tells his fellow technicians, ‘The next time you look at a plaster model die and complain about the job the dentist did preparing the distal margin, consider whether you could prepare a distal margin on a squirmy patient.’ Conversely, by spending time learning from the laboratory’s perspective, I could see things that I thought were perfect clinically that were not perfect under the microscope. We developed empathy for each other’s journey.”

The ultimate goal of the journey is to provide optimal patient care, but remaining viable financially is also important, and establishing a strong collaborative culture can help in that regard as well.

“There is a direct link to profitability for the dentist because I can be more precise in communicating my patients’ desires,” Finkel says. “That makes my business more profitable because I’m not spending time with remakes. Additionally, I’m building a happy patient base.”

Laboratories, in turn, can build satisfied client bases. Hoofard says strong collaboration inevitably leads to loyalty.

“The clients with whom I have that personal relationship are also the ones with the strongest business relationships,” he says.

Conversely, the consequences of a weak working relationship can negatively impact profit margins. Sawa says she sometimes spends several extra hours, including unpaid chair time, on a case due to insufficient collaborative efforts.

“My time is being wasted because the case was not communicated well enough,” Sawa says.

The first step to developing an effective collaborative culture is a willingness from both parties to contribute the necessary effort. Once that has been established, the possibilities are endless.

“When I was in dental school,” Finkel says, “the dream was to have a ceramist in-house. Now, because of technology, you no longer need to have a ceramist in the same city, state, or even country. I can work with someone in Brazil or Tokyo just as predictably as I can work with someone here in New York. It’s very liberating to realize that.”

Watching patients speak on video allows the technician to get a better feel for the patient’s personality, and it helps in analyzing their speech for functional purposes.

“We understand each other’s quirky descriptions. If a tooth suddenly looks translucent, and it’s hard to describe it or even photograph it, I can say, ‘It looks like an A2 shade tab but three clicks more translucent,’ and he knows exactly what that means.” — Thomas McDonald, DMD