The Clinician & the Laboratory

Ultimately, the more sound that a clinician's relationship is with his or her trusted dental laboratory, the better the end result is for the patient's well-being and the clinician's professional life. To help clinicians forge ahead and achieve the best outcomes, six industry leaders share their perspectives on the clinician/laboratory relationship and explain how to realize the greatest advantages in a way that is mutually beneficial.

An important factor for developing a good relationship is a high level of mutual respect and trust, and in the world of restorative dentistry, there needs to be a decisive level of mutual respect and trust, as well as camaraderie, for a relationship to truly be progressive and successful. According to Joshua Polansky, MDC, the owner of Niche Dental Studio in Voorhees, New Jersey, "The relationship between clinicians and modern dental laboratories has definitely changed. What I see that has changed is the clinician's perspective of the laboratory. Previously, the technician was always thought of as the ‘artist,' and the dentist rarely reached out to him or her for advice beyond esthetics." Digital technology has provided an evolution for communication, and thus, the relationship has also evolved.

The main and most important consideration is to find like-minded professionals to work with. Lee Culp, CDT, the chief executive officer of Sculpture Studio in Cary, North Carolina, says, "I often tell people that they need to decide where their space is, whether it be a relationship-based practice/laboratory synergy or a mail-order type of practice/laboratory synergy-neither of which are bad. They are both fine, and both are successful business models, but each requires a different approach and desires that must align properly for the model to truly work." Understanding where business models and philosophies align can facilitate better mutual respect and trust, leading to a greater professional and personal relationship. However, when the two parties in a relationship do not quite align, an enormous strain is created that, unless resolved, could mean the end of that relationship. Gregg Helvey, DDS, CDT, an associate professor of general dentistry at the Virginia Commonwealth University School of Dentistry and the owner of a private practice in Middleburg, Virginia, suggests, "Dentistry is kind of like the relationship between an architect and a builder. The former knows how to design but doesn't know how to build, whereas the latter knows how to build but does not know how to design appropriately. The two cannot function without having a lot of communication, so how can we expect it to be any different in dentistry?"

Both the clinician and laboratory can help in the development of a positive and productive relationship. "My laboratory relationships have been shaped over the years. One of the ways that I cultivated them was by not only sending my technicians the ‘before' pictures, but also making it a point to send them the ‘after' pictures," says Cary Goldstein, DMD, a prosthodontist in Atlanta, Georgia, and president-elect of the American Academy of Esthetic Dentistry. "This is because most technicians rarely get a chance to see their work in the mouth once it leaves the laboratory, nor do they really know whether the case was successful or to what degree it was successful." This is a very unique and powerful method of building a relationship that supports mutual growth and development. "I send them the pictures so that they can see it firsthand, and that really secures the relationship between us significantly," says Goldstein. "Having that level of a relationship with the laboratory creates a synergy in which they are sincerely committed to our practice and our patients. The laboratory technicians go out of their way because they know that we are both trying to become better together for our patients' benefit." Regarding communication, Peter Pizzi, MDT, CDT, the owner of Pizzi Dental Studio in Staten Island, New York, and the editor-in-chief of Inside Dental Technology says, "Today, I speak with dentists throughout the world, and it's like we are sitting in the same room. I would like to think that with all of these new technologies for communication, we do a better job communicating-which is true-but ultimately, the responsibility lies in the hands of both the clinicians and the laboratories. We need dentists to be great communicators, and we need laboratories to be great communicators as well." By being great communicators with one another, respect and trust can be developed, but it needs to go both ways. According to Pizzi, "We currently have the tools, we just need more dental professionals to utilize those tools to build great working relationships that provide for exceptional and fulfilling results for both patients and dental professionals."

One of the greatest ways to build a comprehensive relationship with the modern dental laboratory is through strong communications, and in today's world where technology is so readily available at our fingertips, communication couldn't get any easier. Amanda Seay, DDS, an accredited member of American Academy of Cosmetic Dentistry and the owner of a private practice in Mount Pleasant, South Carolina, asserts, "The ability to be more involved in the actual smile design is significantly important to me. Just a few years ago, I was working with a very good technician, and I would send the case along with my instructions in written form. Then, I would wait to get something back from him that I either liked or disliked." This is a cause of frustration and anxiety that many clinicians regularly encounter. However, using technology and the appropriate tools can afford us the opportunity to do more in an easier and better fashion. "Now, I can overlay tooth libraries on patients virtually and see the end results before we even begin. I can show the laboratory technician the desired shape and where I want the tooth to be. In the past, I felt like I was involved but not nearly as involved as I am now. This is all thanks to digital communication, and we are all better for it," says Seay.

And it isn't just clinicians and laboratories that are seeing and feeling the great benefits of today's robust digital communication tools. "Patients absolutely love the level of communication-both with them and the laboratory," Helvey adds. "It is so cool, and it allows us to show patients what outcomes can be achieved for their individual cases."

Technology is an ever-evolving space that keeps innovating and finding new and easier ways of utilizing its solutions to enable us to become better and more efficient. There are many tools available to achieve this, and Seay claims that "if you are working with a dental laboratory that also has digital technology and acumen, the sky is the limit regarding communication. The capabilities of digital technology and what you can design and do are really extraordinary." Digital processes in the form of CAD/CAM have paved the way for virtual mock-up and assessment tools, and since they've been coupled with photography and videography, they've become an incredibly strong resource for both clinicians and the laboratory. "Today, communication has gotten so much better and easier," says Polansky. "In the past, it used to take so much effort, but today, as I am working up a case using CAD, I can simply take a screen shot and email it or take a picture and text it to the dentist. Providing a clearer understanding of where we are and where we need to get has become so quick and easy."

From a simple single restoration on a posterior molar to a more complex case, the better the communication and interaction between the clinician and the laboratory, the better the results can be. "When you are developing complex restorative cases, it serves the patient's best interest if the clinician communicates more," Helvey says. "The more communication between the laboratory and dental office, the better the results." Oftentimes, dental laboratories will use their experience and knowledge to offer solutions to the challenges that dentists confront. Similarly, the more that dentists know about what is happening in the laboratory, the easier the laboratory's job becomes. Helvey notes that he is all for anything that can make the job easier and less stressful, and technology can do that.

Working up a case virtually is a great way to engage with your laboratory counterparts to figure out the potential challenges and their solutions together before they even arise-all prior to having a bur touch any tooth structure. Over the years, communication has gotten so much better and easier with photographs, screen shots, emails, and all of the other resources that are readily available today. Screenshots allow the laboratory to quickly and easily share information with the clinician, such as the fact that there may not be enough room or that the margin is not clear. "It is a lot easier and much more effective to show the situation to the dentist rather than to attempt to explain it over the phone," Culp says. "A lot of these imaging technologies and software applications, including some smile design and augmented reality applications, such as IvoSmile, are phenomenal selling tools. Anything that helps patients see what can be achieved is very viable, and we do a lot of that. These communications can be accomplished in 5 minutes and have the potential to make a huge impact."

Goldstein's laboratory uses a different approach to create a similar impact with technology. "Being able to send a digital file is huge, but I still put my instructions on paper and call if need be," he says. "If I am doing a cosmetic case, the laboratory will send me a digital mock-up or a photographic mock-up. Photography is critical; I have three cameras in my office. Typically, we take photographs of every patient who walks through our door and send them to the laboratory. Within 30 minutes, we get a photographic mock-up while the patient is still in the chair. This process is phenomenal for case acceptance-20% of the photographs that we take of patients result in the patients doing the work with us." When they see in real time that their smiles could be improved, they jump at that opportunity. Goldstein does not use any particular design software in his office; he sends it all out because he believes that the laboratory does a great job. "It is so much easier and faster to have the laboratory do it while communicating with us throughout the process to get the best outcome," says Goldstein.

Seay has a similar mock-up process with her laboratory. She sends her laboratory technician photographs of her patients, and then the technician creates the smile designs, superimposes them onto her photographs, and sends them back for approval. Any necessary changes are made until both the clinician and laboratory are satisfied. The convenience is profound, and you do not even need to be in front of a computer to leverage these advances in communication. "Today, I don't even have to be at my desk. Because many of these sharing options and communication tools are mobile friendly, I can achieve so much more on my smartphone or tablet. I can be out and about with my family and still check on a design in order to keep the case moving forward."

Video transferring or screen sharing software applications are among the most popular modern technologic tools currently used to communicate between the dentist and laboratory. Platforms such as TeamViewer can provide users with the necessary password to remotely access another computer and not only view but also manipulate what is on the screen. These tools are used often and provide yet another level of engagement between the dentist and laboratory. Culp's laboratory utilizes this technology on a regular basis. "My laboratory is engaged in the relationship business model. We encounter large and complex cases, which oftentimes deal with implants. Therefore, to be successful, we must maintain a robust level of communication with the entire team. Our laboratory practically lives on TeamViewer now. When we design, all of the dentists are given the option to see it, approve of it, and communicate in real time their desired outcomes," Culp says. "This has become a standard protocol because we definitely want our clients to access the system to make sure that we are doing what they wanted us to do, especially for big cases, because if something goes wrong, it is very expensive for the dentist, the laboratory, and the patient."

As a clinician, you have to acquire new skill sets for these digital communication tools and other technologies and ensure that you fully understand them; otherwise, you are relying on technology to figure things out for you, and that is not necessarily the best approach. The diagnostics, planning, and communication technologies must be driven by the clinician in order to optimize their results. It can be difficult to keep up with all of the new technology and learn how to best utilize it under time constraints; however, Seay claims to have gained this level of education from working with laboratories and the great educators in the industry. "Personally, I've learned the most from my technicians. A technician once sat down with me and told me which vantage points and what type of lighting they need in photographs to acquire the information necessary for them to do their jobs well. This technician was the one who really opened my eyes to how to effectively use photographs in communications."

Having the benefit of the entire restorative team communicating on one platform in real time is truly remarkable. We all have to become more collaborative in our learning in order to best serve our patients. According to Pizzi, the clinician and the dental technician have to be on the same page regarding their approach to managing the oral health systems of their patients. "I think the entire team needs to be communicating well in order to achieve the best possible results for patients," he says. "This way, we have an intellectual cache that includes the unique perspectives of not only the restorative dentist and laboratory but also periodontists, orthodontists, and others regarding what we can or cannot do when approaching a patient's treatment."

In the digital world, many clinicians need help, and technicians can really provide them with an advantage. "Clinicians are involving their laboratories more often in surgical procedures, implant-supported arch cases, and esthetic cases. Through these closer relationships, technicians are stepping forward to assist with their specialized skills and knowledge," says Polansky. "Today, there are technicians teaching dentists how to scan, design, and create 3D-printed models, stents, and even digital dentures. In the past, this would be unheard of. I have dentists who consider me to be their mentor, and I am always blown away by this fact, but that's the impact of our positive relationship as dental professionals."

As more and more chairside options for scanning, milling, and 3D printing become available, how clinicians adapt to these technologies and how they might affect the clinician/laboratory relationship is on the minds of many. Although experts suggest that only a small subset of the population currently engages with these technologies, many agree that the dental professional of the future will regularly deploy them chairside. Seay believes that the final quality control would be the responsibility of the dental practice, which presents issues in that some offices are not prepared to operate in that way. "I think that this is where things are going," she says. "With truly digital dentistry, there will be scanners, mills, and 3D printers in every office, but there will also be a need for skilled technicians to help clinicians through truly digital workflows. A comprehensive and complete workflow is what we need, and a knowledgeable and skilled technician can help establish that in a dental office."

Both Culp and Polansky feel that chairside milling and printing will become commonplace. "Probably not in the very near future, but certainly during my lifetime, the posterior single units and inlays/onlays will all be done chairside," predicts Polansky. "It will be better for the patient because it creates convenience, but clinicians must know their limits and be able to care for things that are not traditionally in their wheelhouse. There has never been a better time to work as a dentist or a technician because we have so many awesome tools at our disposal as well as people who enjoy growing and learning."

And, according to Culp, "This is the evolution of dentistry. Some dentists are better than others at designing restorations that deliver excellent function and esthetics. I have embraced digital technology. If the dentist wants to do the crown, that is great, and I will help him or her as needed. If the dentist wants me to fabricate it in the laboratory, that is great too. Ultimately, any benefit should be for the patient," he says. "If we look at all of dentistry and the numbers, chairside technology has yet to really affect the restorative space in an impactful way."

Certainly, the collaborative development of a strong clinician/laboratory relationship provides for better engagement and outcomes. To successfully accomplish this, Helvey suggests that "new dentists spend some time at the dental laboratory, share their goals, see how the laboratory can help in achieving them, and learn what they can do clinically to ensure that the laboratory technicians get what they need to make cases more predictable and as successful as possible. Don't be afraid to ask questions and be open to listening to the laboratory's advice. Otherwise, how can clinicians possibly give the laboratory what it needs to get the results they desire?" At the end of the day, like any other effective relationship, the clinical/laboratory relationship is based upon strong communication, mutual respect, and trust in one another-elements that, when optimized, result in the common goal of providing the best care for patients.