The professions of dentistry and dental laboratory technology
Improving the interface
THOMAS J. McGARRY, D.D.S. and
THEODORE E. JACOBSON, D.D.S.
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ABSTRACT
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Background. Dentistry’s mission to provide rehabilitation services to patients who experienced dental disease is being jeopardized through the continual reduction of critical to quality skills and knowledge in dental laboratory technology being offered in dental and dental laboratory technician education. These reductions are creating a shortage of knowledgeable dentists and dental laboratory technicians who will be needed to address the projected public demand for laboratory-fabricated tooth replacements and restorations.
Methods. Demographic trend analysis supports a hypothesis that without immediate action by dentistry, substantial patient needs will not be met owing to inadequate levels of dental laboratory support for general dentists.
Results. The sophistication of laboratory-based rehabilitative and elective therapies demand closer cooperation between dentists and dental laboratory technologists.
Conclusions. Dentistry must not abdicate its responsibilities in dental technology as it pursues a path away from rehabilitation services toward a projected future of prevention services. With decreasing educational exposure and training in dental laboratory procedures, dentists will have difficulty participating with dental laboratory technologists to fabricate laboratory-based rehabilitative and elective therapies. Without significant guidance from dental professionals in establishing laboratory standards in both education and practice, proprietary interests and commercial biases may set the laboratory and clinical standards of the future.
Clinical Implications. Dentists will have limited experience or background to evaluate the dental laboratory technology offered in the marketplace and will be subject to the marketing of the industry. A shortage of educationally trained dental laboratory technologists will create a clinical and an economic burden on both dentists and patients.
Dentistry has begun a slow journey away from its roots as a primarily rehabilitative health care profession by reducing—both in education and practice—its involvement in dental laboratory technology. Perhaps an even more ominous trend is the practical abandonment of the profession’s relationships with dental laboratory technologists and the laboratory technology industry. These trends were noted in the ADA’s Future of Dentistry report, and these problems were addressed in the report in four of the six expert panels: clinical practice management, financing and access to dental services, education and licensure and the regulation of dental professionals.1 The section of the report titled Vision and Recommendations delineated these problems:1(p13)
Dentistry needs to rededicate itself to its responsibility of supporting all aspects of dental laboratory technology.
The dentist must remain the repository of laboratory skill and knowledge. The laboratory industry should not become the authority on laboratory procedures. Abdication of the dentist’s role in the laboratory phase due to educational cost /convenience must not create a vacuum of knowledge in the profession. Dental school curriculums must maintain sufficient focus and resources to continue to prepare dentists to provide prosthodontic/restorative therapies that continue to constitute the majority of the service component of a general practice.
There are limited national standards for dental laboratory technicians and accredited programs are decreasing. A shortage of qualified dental laboratory technicians will create a risk situation in the areas of access and quality of care, especially for the financially disadvantaged populations.
This dilemma also was addressed in an editorial in the Journal of Prosthodontics by Lloyd.2 He foresaw a crisis in the number of dental laboratory technologists enrolled in and graduating from ADA-accredited educational programs. He envisions a higher standard of care for patients if the most gifted and educated dental laboratory technologists remain in the profession and if the dental profession dedicates the necessary resources to support dental laboratory education. In the Winter 2002 issue of Journal of the American College of Dentists, four articles provided perspectives from laboratory owners, dental laboratory technicians, dental manufacturers and dentists concerning this dilemma.3–6
Surprisingly, in the ADA’s Future of Dentistry report, none of the 30 recommendations for dental education addressed the need for dentists to be technically knowledgeable or competent. Within dental education, curriculum reform proposals recommend even further reduction in clinical exposure for dental students.7,8 If, in fact, the trend of reduced laboratory education, experience and skills for dentists is the future of the profession, then it is critical that the dental profession work vigorously to create and maintain relationships with dental technologists and the dental laboratory industry. Unfortunately, many of the relationships involving dental technology and the dental profession have withered (Box 1
).
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CURRENT ENVIRONMENT
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Historically, dentists have interacted with dental laboratory technicians through multiple interfaces:
- – dental technology schools;
- – knowledge of dental laboratory techniques and technology;
- – state board–regulated rules regarding laboratory work authorizations;
- – undergraduate dental education and in-school dental laboratories and technicians;
- – use of laboratories in close physical proximity to dentists;
- – in-practice dental laboratories and technicians.
Most of these interfaces created an intimacy between dental laboratory technicians and dentists that started in dental school and continued throughout dentists’ careers. Unfortunately, most of these interactions placed dental laboratory technicians in a subservient role because of educational and economic disadvantages. Regardless of the benevolence of dental professionals, the stature afforded dental laboratory technicians has been insufficient to create a sustainable professional career model. To cope with the demands of practicing dentists and new dental technologies, dental laboratory technicians and the laboratory industry are searching for new relationships with dental professionals.
The educational and economic imbalances of the past now are being reversed with dental technologists being the most knowledgeable members of the dentist/dental laboratory technician partnership in the area of laboratory techniques, instrumentation and materials. We need to ask ourselves how this role reversal will affect the structure of the dentist/dental laboratory technician interface in the future. Will dental technologists become manufacturers or allied health professionals or will the dental technology industry become a direct-to-the-consumer business?
We also need to investigate the forces inside of dentistry that are driving this new paradigm. At the start of dental education, exposure to the different phases of laboratory procedures is critical. In the past, dentists were required to master different levels of laboratory procedures as part of their clinical education; however, the requirements have been reduced significantly to an exposure experience versus competency.9–11 Two separate yet interdependent issues are contributing to this reduction of practical experience. First, there has been a reduction in the number of clinical procedures involving laboratory technology performed by dental students, as evidenced by the reduction of clinical prosthodontic requirements at most dental schools. This was documented in a survey of dental schools in 1999 by Jacobson (Boxes 2–6, Tables 1–3).12 There also has been a reduction in experience and skill required in the laboratory phase of rehabilitative dental procedures.
A new role advocated for dentists is as an evaluator or supervisor of laboratory procedures. However, the clinical role of dentist based on the physician-based model proposed in an Institute of Medicine study is not sufficient to provide laboratory-based prosthetic procedures.13 Prosthodontic competence cannot be achieved with a prescription pad.14 Preparation for this envisioned new role is being diminished by insufficient experience to gain competency as a supervisor.15–25
The trend of dental schools removing in-school dental laboratories also eliminates several educational opportunities for novice clinicians. Dental students cannot appreciate or observe the laboratory procedures accomplished for their patients or how their clinical performance affects the work of dental laboratory technicians. This critical interface is being lost as more dental schools use remote laboratory services, thus eliminating a valuable opportunity for students to learn how to evaluate laboratory procedures. Perhaps, more importantly, the undergraduate dental student loses a concrete visualization of the cause and effect of clinical performance on the outcome of the final restoration. This reduced experience when coupled with decreased laboratory procedure training, diminishes the ability of dentists to partner with dental laboratory technologists.
Additionally, with the economic crisis in dental education, the integration of the newest technologies in laboratory procedures is limited for dental students.1(p13) In a written communication with Dr. Charles Goodacre (dean, Loma Linda University School of Dentistry, November 2002), this educational challenge was highlighted. The loss of in-house laboratories in dental schools has been implemented largely for economic reasons, which indicates that the typical dental school administration does not fully comprehend the value of this educational experience. The additional investment to run an in-house laboratory over outsourcing the services is a small percentage of the total school budget, especially when compared with the benefits to the students. The benefits are the educational interaction of the students with dental laboratory technologists, quality of the service, speed of the service, custom processes, service to the patient (relines and repairs while the patient waits), help with shade selection and custom coloring.
An even more threatening break in the dentist/dental laboratory technician interface is the use of offshore and foreign-based dental laboratories that practically prevents the opportunity for dentists and dental laboratory technicians to discuss the needs of the patient and the design of the restoration. This is a shortsighted solution to an economic problem that creates a lack of dentist/dental laboratory technician interaction. Unfortunately, even some dental schools use offshore laboratories. This is the wrong message to send, especially to new dentists whose clinical experience is not yet fully developed.
Another source of dentist/dental laboratory technician interaction was dental technology training programs associated with dental schools. This avenue has been reduced by universities’ requiring that only degreed programs be offered. This university requirement prevents dentist/ dental laboratory technician educational cooperation and reduces laboratory technologists’ opportunities for academic training. The reduction of accredited dental laboratory educational programs by more than 50 percent (from 59 to 28 programs) has reached crisis levels.1(pp43,80,81,102–106) The ability to set educational standards for dental technology is being almost eliminated through the loss of academically based dental technology programs. According to the National Association of Dental Laboratories, there are 20 non–ADA-accredited technology programs. Reasons given by the programs for remaining nonaccredited include expense of teacher salaries, minimum program income and the costs associated with compliance with ADA education guidelines.26
The apparent abandonment by the dental profession of the educational process for dental laboratory technicians is forcing the dental laboratory industry to create and support their own training programs and standards for dental laboratory technicians and laboratory procedures. Independent for-profit companies now provide educational programs for more than 800 laboratories nationwide. The use of video modules and on-the-job training constitutes this type of educational experience. Though training protocols established and maintained by private industry may be valuable sources of instruction and information, the presence of bias and proprietary agendas is problematic. Training programs in laboratory technology should be based on scientific evidence and be consistent with information that is taught in dental education.
With the loss of university-based programs, the costs of developing and maintaining free-standing laboratory training facilities outside of dental schools is prohibitive. Independent programs also do not have actual clinical cases for technical training. The tuition necessary to support such training programs is high and not easily recovered by new graduates. The salary expectation of graduates of two-year dental laboratory programs is commensurate with their educational commitment and financial investment.1(p106),26 However, they usually are disappointed at the entry-level salaries because, though they are knowledgeable, they are not yet productive in a commercial environment. This imbalance in economic expectation is further reducing enrollments in existing programs.
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FUTURE DEMAND
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Manski and Moeller27 reported an analysis of 1996 data from the Medical Expenditure Panel Survey that showed the demand for laboratory-based procedures is increasing and constitutes the largest segment of reported clinical procedures after diagnostic and preventive procedures. An analysis of the data also showed that restorative and prosthetic patient visits are the second most reported patient visits after diagnostic and preventive visits. The income generated by these procedures contributes greatly toward the total production of a dental practice. In this same report, the authors noted that all endodontic, periodontic and orthodontic procedures needed to be pooled to achieve a statistically significant number of procedures, which was only 3 percent of the total number.
In clinical practice, continuing education in laboratory-based procedures is highly sought. Independent facilities such as The Pankey Institute for Advanced Dental Education (Key Biscayne, Fla.), the Las Vegas Institute for Advanced Dental Studies and the Pacific Esthetic Continuum (San Francisco) provide extensive education in laboratory-based dental procedures at significant costs to the general dentist.
Another large segment of laboratory-based dental procedure education is the dental implant manufacturing industry. This manufacturer-sponsored education is extensive and concentrates on clinical procedures requiring laboratory-based restorations. Implant prosthodontics require extensive cooperation between dentists and dental laboratory technicians. It is expected that this phase of dentistry will enjoy continued growth for many years.28,29 With the minimal amount of implant prosthodontic training in undergraduate dental education, the burden of education in this field has fallen on the dental implant manufacturers and the dental laboratory industry.30 The dental laboratory industry has taken a leading role in providing both clinical and laboratory education to dentists, as well as providing the most sophisticated dental restorations. With an estimate that there will be 60 million completely edentulous jaws by the year 2020, the need for tooth replacements created by dental technologists will be increasing.28,29 Almost 30 percent of people 65 years of age or older are completely edentulous.1(pp54,55),29 While complete edentulism has been reduced on a percentage basis, the total number of people who are completely edentulous is a serious geriatric health problem,29 as well as an access-to-care issue. Dental laboratory technologists in partnership with dentists will face serious challenges in addressing these issues. Baby boomers are approaching the stage of life at which tooth loss and damage occur at a greater rate. These patients, most of whom are financially capable and knowledgeable, will demand the most sophisticated dentistry available.31 This increasing demand for laboratory-based dental procedures is being augmented by the dental manufacturing industry and its marketing. The dental manufacturing industry has long recognized the public need and desire for laboratory-based restorations and materials and continually brings new and innovative products to the market.
In the area of elective esthetic dentistry, making laboratory-fabricated restorations demands the utmost in communication and partnership between dentists and dental laboratory technologists. New materials and technologies will increase the need for dental laboratory technicians to be highly educated to provide support to dentists. This is especially true for procedures such as the newest computer-aided design/computer-aided manufacturing technologies, which will demand greater cooperation between dentists and dental laboratory technicians. With dental students having little or no experience with many of the newest materials and techniques, dental laboratory technologists will be the source of information for general dentists.
The dental profession should develop strategies to maintain the dentist as a knowledgeable director of laboratory procedures to ensure the safety of the patient.
The need for laboratory-based restorations will be increased further by the increase in life expectancy.1(pp39–41,94),31–33 Since all dental restorations have a finite service life, people’s additional years of life will increase the demand for retreatment of existing restorations and new restorations.
The incongruities associated with increasing demand for laboratory-based dental procedures, reductions in clinical experiences, decreases in laboratory training for dentists, decreases in dental laboratory technician training programs and all the reductions in the dentist/dental laboratory technician interface opportunities must be recognized as immediate and critical problems, as well as future problems. To continue to reduce or eliminate opportunities for dentists and dental laboratory technicians to interact will only erode the transfer of laboratory knowledge by dentists to clinical practice.
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CREATING THE VISION
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The dental profession must help create a coherent vision of the role of laboratory technology in the delivery of care to patients. Dentistry needs to determine how dentists will remain knowledgeable in the vital procedures of laboratory-based therapies, what the relationship between dentists and dental laboratory technicians will be, and how dentists and dental laboratory technicians will overcome the myriad of challenges they now face. The creation of this new vision must include input from dental laboratory technicians, representatives of the laboratory industry, dental educators, dental manufacturers, the ADA, prosthodontists and practicing dentists. The ADA has recognized the need for action on this issue with two clinical practice recommendations in the 2001 Future of Dentistry report:
- – A study should be undertaken to address the adequacy of the number of dental laboratory technicians and to develop a strategy for attracting qualified people into that profession.
- – The dental profession should develop strategies to maintain the dentist as a knowledgeable director of laboratory procedures to ensure the safety of the patient.
The creation of this new vision requires strategies to accomplish the specific goals outlined in these recommendations. Strategies for increasing the number and stature of dental technologists include developing a national leadership conference for dental laboratory technology, developing dental technology training programs embedded in dental schools, expanding educational opportunities at dental meetings for dental technologists, receiving ADA support for certified dental technician programs and having the ADA support and expand accredited dental technology education programs in partnership with dental technology industry. Strategies for maintaining dentists’ knowledge of laboratory technology include developing simultaneous education programs for dentists and dental technologists, combining training of dentists and dental technologists in dental education and developing communication strategies in dental education between dental students and dental technologists.
Additionally, new interfaces must be established and old interfaces must be renewed. Toward this goal, an initial step has been taken by the American College of Prosthodontists. It created the Dental Technician Alliance. This program endeavors to increase the scientific interaction of dental laboratory technicians and prosthodontists through joint meetings and lectures. Prosthodontists and dental laboratory technicians have enjoyed having a close working relationship that is based on mutual respect. This alliance is designed to help the entire dental profession by creating a professional atmosphere in which dental laboratory technicians and dentists are true partners in clinical care. This first step must be followed by a concerted effort by dentistry to help create multiple interfaces with dental laboratory technicians in a mutually supportive environment.
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CONCLUSIONS
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The profession of dentistry needs to rededicate itself to its responsibility of supporting all aspects of dental laboratory technology from the education of dentists to the education of dental laboratory technicians. Dentistry also needs to create a climate of cooperation between dentists and their colleagues in dental laboratory technology to provide the public with the quality dental services they deserve. Future dental technology demands a vibrant dental technology industry to partner with the dental profession.
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Dr. McGarry is in private practice limited to prosthodontics, 4320 McAuley Blvd., Oklahoma City, Okla. 73120, e-mail, "mcgarry{at}qns.com". Address reprint requests to Dr. McGarry.
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ABSTRACT
CURRENT ENVIRONMENT
