Table of Contents

Question of the Month
Cover Story
Practice Building
View Point
Continuing Education
Endodontics
Restorative

Inside Dentistry

August 2014, Volume 10, Issue 8
Published by AEGIS Communications

The Perfect Lab Partner

Like iconic dance partners, successful dentist-lab relationships elevate the routine into art.

Ellen Meyer, MBA

The pace of evolution—some would say revolution—of the dental industry has accelerated dramatically in recent years. New materials and technology—including practice management systems, digital cameras, and scanners—have transformed all but the most modest of dental practices, and, with the advent of chairside digital dentistry, CAD/CAM fabrication of a portion of restorations once sent out to a laboratory are increasingly done in-house. It is no coincidence that the number and types of laboratories, too, have also undergone radical changes. Clearly, all this turmoil has implications for the way dentists and their laboratories can best work together.

An Overview of the Industry

Bennett Napier, CAE, chief staff executive, National Association of Dental Laboratories (NADL), paints a picture of an industry that if not in disarray, is very much in transition. He says at its peak, there were 13,500 domestic dental laboratories, but that number has now dwindled to fewer than 9,000 and is expected to drop further still—to the 7,000 range, according to NADL market research, government trends, and census data.

However, he explains, behind those numbers is not so much an exodus of technicians, as a consolidation of businesses. “Ten years ago the average-sized dental lab was 3.4 employees; today it’s 13.” This trend, he says, is due to a variety of factors, which boil down to barriers to entry and survival in an industry once dominated by small labs that could be set up for less than $10,000 and sustained by business requiring traditional methods and materials from a handful of dentists. “For a laboratory to be truly competitive based on the technology and material choices, entering at the low end would require an investment of at least $50,000 to $60,000, although it’s more commonly in the $150,000 range,” he says.

Then there is the competition from dentists themselves, such as Fort Collins, Colorado, practice partners Michael McDill, DDS, and Todd Rosenzweig, DDS, MDS, who are now milling some 85% of their crowns and bridges in-house.

Also related to this changing marketplace has been the emergence of the offshore laboratory, which enables laboratories to offer services—usually at a significantly lower price point than the domestic labs based on lower labor costs—and often without the client dentist’s awareness.

It is mainly for these reasons, notes Inside Dental Technology editor, Pam Johnson, that general dentists practicing in the more regional areas may very well find that that the local lab partner they have known in the past it is no longer available “either because it has closed or been swallowed up by another outside group or lab conglomeration.”

Finding a Niche

Looking to the left and right in the current environment is sobering, all right. But 16-year veteran Jessica Birrell, CDT, who has been the owner of a small boutique laboratory in Sarasota Springs, Utah, for 5 years, is not overly concerned. “We’ve seen a shift in our industry as large laboratories are becoming larger, some midsize laboratories have slowly dissolved, and a large number of laboratory owners are nearing retirement. But boutique labs like ours, which trade on their artistry and quality, aren’t in competition with production labs; they complement each other.” Birrell’s laboratory works with about 10 practices that prize her attention to detail and artistic esthetics. “Most come to me with challenging cases, desiring the extra attention to detail through every step that boutique laboratories can offer and that some of the larger labs have a hard time handling.”

Although Birrell’s lab services are specialized and limited in scope, she makes a point of being both a partner and resource for her clients. “At our lab, we don’t offer everything, so being educated in other services that are available—even if you don’t provide them—makes you a better partner. I want to know what their business is, what it means to them, and how I can help them—how we can help both of our businesses succeed.”

Dene LeBeau, who owns LeBeau Precision Aesthetics, in Renton, Washington, likewise is comfortable in the niche he occupies, offering fixed restorative dental solutions from a single crown, to a full-mouth rehabilitation. “There is a dental technologic skill involved in designing and milling, and with certainty I can say that the best esthetics will always require a good ceramist, and few practices have a highly skilled one in their office.”

He considers the size of his laboratory—a total of 11 including office personnel, technicians, IT, and graphic design—to be ideal. “Our size and workforce is very intentional and we have worked hard on blending people and skills together for the digital lab environment.”

Strength in Numbers

Other laboratories have found success through business approaches that include growth and consolidation. In this laboratory model, Napier says, the printing/milling of restorations are typically handled at a limited number of production centers and shipped back to a satellite lab/customer service center—many of which were previously full-service laboratories purchased by the corporation.

Bigger does not mean that quality or service suffers, however. Such is the case with Peoria, Illinois-based Dental Arts Laboratories, Inc. (DAL), which employs 375 employees at 9 Illinois-area locations. Despite the size that comes with multiple locations, Jeff Stubblefield, manager of DAL Signature Restorations, a division of Dental Arts Laboratory, Inc. dedicated to the occlusal-esthetic principles of the Dawson Academy, says the family-owned company seeks to preserve the high-performance quality and customer service relationships that have been so important throughout its 80-year history.

Stubblefield explains that this is due in part to its ability not only to keep intact but also enhance the service and quality aspects of the smaller regional laboratories it has acquired in recent years. Many of the these regional laboratories offer specialized services while serving as a local representative for the complete range of services fabricated at both DAL, the main digital manufacturing laboratory with 175 technicians, and the boutique 18-technician Signature Laboratory that handles the high-end, esthetic zone restorations.

“I see dentistry as a business that is both relationship-driven and solution-based, with the end result being a consistent, high-quality product that meets the needs of doctors and their patients,” Stubblefield says. For example, because there are numerous locations, a laboratory focused on removables can offer a complete line of state-of-the-art, digitally-milled fixed restoratives, implant prosthetics, or sleep appliance options that that it would otherwise not have been in the financial or technical position to offer its client base. This opens the door for the local regional laboratory to service their customers from both a personal level as well as an enhanced technical level.

MicroDental (previously DTI) has 17 laboratories located across North America. The majority of its technicians are concentrated mainly where the milling is done—at its main campus in Dublin, California, and a new all-digital Raleigh, North Carolina, facility. Chief of Technology Lee Culp, CDT, a high-profile dental technician who has been affiliated with CAD/CAM nearly since the technology was first introduced, was hired specifically to change MicroDental from an analog to a digital manufacturing platform, and then to further the digital evolution, to launch the new Raleigh lab, where all restorations are digitally designed and fabricated. Culp says the laboratory focuses on producing “higher-end and implant-based restorations” in the digital environment. “We do everything digitally, so although we have ceramists, the artistry comes mainly from the design.”

He says the 20 other labs vary in size and services—some do shade modifications and adjustments; others are basically customer service centers.

Albensi Laboratories owner Don Albensi, CDT, is well familiar with the struggle for survival among domestic laboratories. Ten years ago, his Irwin, Pennsylvania, laboratory was nearly sunk by pressure to create competitively priced restorations. What enabled him to save, then grow, his business, explains Albensi, was to first reinvent it by going offshore to offer the lower priced restorations his customers were seeking through a sister company called Innovative Dental Arts. He then set about competing with his own offshore enterprise by investing in technology to create competitively priced restorations at home, at a new facility with six mills and a staff of 100, including 70 technicians.

Designed to maximize efficiency and quality, this laboratory has a sales team that manages the upfront relationship with the doctor, while a QC8 Certified (Quality Control) program is used to manage the production workflow. “We don’t have one specific technician working on the case, because every time that case completes a step in our production process, it gets quality control checked to make sure all components of that case leading up to finishing that step are acceptable and complete—then it moves on to the next step in the production process.”

This quality control process, he say, is effective in managing the expectations of the doctor mainly because it is overseen by a laboratory manager responsible for handling concerns that arise along the way. “This is the person who is making the call if the there are problems, such as an insufficient impression or with overall questions about what the doctor is try to achieve.”

Choosing Among Them

nearly all dentists agree that they need the right laboratory to be able to offer their patients the best available options. In fact, Theodore Constantine, DDS, a Northbrook, Illinois, private practitioner, regards an excellent laboratory much like a carefully guarded family recipe—a competitive advantage that helps practitioners stand out among their colleagues.

Depending on their own resources and needs, practitioners select laboratories in various ways using different criteria, and most use at least two different laboratories.

Amanda Seay, DDS, a Mount Pleasant, South Carolina, private practitioner, especially values craftsmanship and individualization, such as the work provided by the boutique labs. Solo practitioner Michelle VanDyke-Topp, DDS, of Muskegon, Michigan, wants the feel of a small shop but the resources of a large one. Alexandra Smith, DDS, is necessarily cost conscious, but because she is a new practitioner working largely alone at a dental service organization practice, she needs a lab that is accessible and willing to educate as well as communicate. Matilda Dhima, DMD, MS, who is assistant professor and maxillofacial prosthodontist, University of Pittsburgh School of Dental Medicine, believes effective communication and the ability to monitor the progress of her cases calls for using a lab where all work is completed in a single location. Drs. McDill and Rosenzweig use their laboratory mainly for removables such as dentures, partials, and nightguards, but they also depend upon their lab for the 15% of crowns and bridges not suited to chairside fabrication.

Dr. Dhima says, “I think that it is important to learn more about what potential new labs have to offer. One of the most important things is to learn more about the lab itself, the facilities, and technicians’ expertise, knowledge, and interest in the cases you commonly treat.”

But ultimately what matters most is quality.

As Dr. VanDyke-Topp puts it, if the quality of the work isn’t at a certain level, the rest doesn’t matter. “It doesn’t matter how fast you can get it to me, if it’s a bad crown it doesn’t work for me,” she says. Adds Dr. McDill, “Even if there are errors on our end, and they aren’t communicated to us, if we’re regularly getting work back that’s not up to our standards, that’s a deal breaker for us.”

Working Together Collaboratively

dr. Seay recognizes that it is her responsibility as the dentist to provide the technician with the “core essentials to meet the patient’s functional and esthetic needs and goals,” which she says includes clear direction, good engineering, detailed photographic information, digital laboratory prescriptions, and quality dentistry such as tooth preparations and impressions. The lab technician’s role, she says, “is to understand and envision the esthetic result desired, communicate any challenges that may inhibit this outcome, and then proceed using his/her artistry and skill to do what they do best.”

Using Technology

To fulfill the requirements such as those described by Dr. Seay, Dr. Dhima expects her laboratory to be technologically adept both at both communication and fabrication—including CAD/CAM capability— to help improve esthetic outcomes and turnaround time. “The ability to share and send clinical photographs is especially important for complex esthetic cases and full-mouth rehabilitations,” she says. “Being able to provide the laboratory with crucial information such as stump shade, incisal edge position, views of teeth preparations, and the facial form of the patient helps minimize the barrier to actually seeing the case chairside together with the laboratory technician.”

Stubblefield believes that a “paradigm shift” he has observed—especially among among younger doctors—is directly related to the digitalization of dentistry. “It has also made it easier than ever to forge an effective partnership with dentists at least partly because it has made communication between labs and dentists and labs with labs so much easier.” He adds that it’s also easier to avoid and ascertain mistakes. “When things are more complete, correct, the work is more consistent, so there are fewer remakes. Everyone wins.”

Even the boutique laboratories that specialize in high-end, labor-intensive esthetic restorations consider technology a boon to the profession and essential for communication. “We have so many resources available to communicate everything we need, providing all the information necessary for creating esthetics,” says Birrell.

LeBeau says, “Being able to email questions and send screen shots of a digital design that illustrates the final outcome before the case is even completed is a never-before-dreamed-of advantage. Now a clinician and technician can see the same issues and find the most positive way to deal with case problems, both large and small. If a complex case presents functional issues or anything that needs to be seen and discussed in real time, we can use video options such as Skype or GoToMeeting.”

Although both benefit, LeBeau believes the driving force to interface digital technology between lab and dentist will mostly come from the lab, and he considers it “a real opportunity for those that accept the change and use the knowledge to help the dentist adjust to the ever-changing technical landscape.”

The Future

change is sure to continue within these segments. Birrell maintains that even small boutique laboratories like her own are likely to become involved in milling, citing the advantages of using milling software to create custom-designed restorations, while maintaining control on the final touches she is known for. “I think we’ll all be there at some point, but it won’t change the main focus of the boutique laboratory. Computers may never be able to create the irregularities that our minds see and that make dental restorations appear natural, but with a skilled technician behind the computer, the possibilities are exciting.”

Culp, who does in fact believe that the computers can deliver a level of artistry, is philosophical about the inevitability of widespread chairside dentistry delivered by dentists with the ability to design and mill their own restorations. “Dentists are going to do what they are going to do, but they can’t do everything. We want to be there for the restorations that they cannot or don’t want to do.”

“I don’t worry at all about dentists milling crowns in their own offices, “ says LeBeau. “My position has always been that my lab will offer the most functional esthetic restorations that we possibly can and let the market decide the winners and losers. Looking forward, I suspect that either very high quality or price will rule the day and the middle-of-the road lab or dentist may suffer. I hold out hope that there will be room for all of us!”

Offshore Labs

Bennett Napier, CAE, chief staff executive, National Association of Dental Lab­oratories (NADL) is concerned about what clinicians may not know about the restorations they provide for their patients. “By and large, an ‘economy line’ crown is is likely to be made offshore, and material disclosure is crucial.” He says the purpose of the NADL’s current “What’s in Your Mouth” campaign is a push for transparency, particularly about these lower-price products. “Dentists should ask what the differences are, what the value proposition is—so they are making an informed choice.”

As one familiar from both sides, Albensi Lab­oratories owner Don Albensi, CDT, says going offshore with Innovative Dental Arts not only enabled him to get through a rough patch, but it also remains an option for cost-conscious clients. He says doctors whose restorations are handled offshore are made fully aware of it, but notes that a 10-day turnaround largely defines offshore versus domestic laboratories, which can offer significantly shorter turnaround.

Albensi says beyond a 3-to-5 day turnaround, Albensi Laboratories clients receive daily case overview emails that provide updates on the case, which helps in facilitating patient scheduling. He says, particularly if the doctor sends a digital scan, it makes more sense to have the entire restoration done domestically. “It comes down to this. Our streamlined digital production workflow now allows us to be competitive in a shorter timeframe than the competition overseas.”

Relationship Matters

What’s the key to having a great relationship with your laboratory? According to Mark T. Murphy, DDS, the keys to all lasting relationships are basically the same and include open communication, honesty, empathy, and common goals. In the laboratory-clinician relationship, he says, the common goal of the best interests of the patients may come from different perspectives—eg, occlusion or centric relation—but they must match up in the ways that matter most—ie, “what they believe in, what they stand for.”

Unfortunately, says Dr. Murphy—who is both a laboratory technician and a dentist, as well as a highly sought after speaker—too many clinicians operate on the assumption that this is a commodity-based relationship.

This could hardly be further from the truth. As MicroDental Chief of Technology Lee Culp, CDT, explains, the relationship between the laboratory and dentist is unique among supplier-client relationships in that the supplier—ie, the laboratory—is totally dependent upon the willingness and ability of the client dentist to provide the materials and information needed to provide high quality work. “And what they need,” he asserts, “are correct impressions, preparations, diagnoses, and treatment plans.”

Dr. Murphy says there are steps technicians can take to nudge that relationship away from the commodity basis toward more of a partnership in recognition of their interdependency. He says the best time to start building a successful professional relationship is at the beginning. At the initial meeting, he suggests the laboratory technician set the stage by asking about the dentist’s preferences—hoping, of course, that the dentist will do the same. This might start with “What do you need from me so we can do our best work on behalf of the patient?” This is the opportunity to talk about different types of preparations, impression trays, and methods of communication. It can also be the time to subtly begin encouraging cooperation by using a “carrot” approach—intermittent positive re-enforcement—by pointing out what the dentist is doing right.

A once common problem for technicians—which is becoming increasingly rare—is receiving pushback from doctors when, for example, asked to replace an insufficient impression. In this situation, Albensi Laboratories owner Don Albensi, CDT, finds it is sometimes necessary to employ a strategic partner approach and work together with the practice to achieve the common goal of making sure the patient receives a top-quality restoration in a timely manner. Open communication and an evolving lab-doctor relationship makes this approach successful.

Because a great relationship is so important to the success of the work they do together, Culp says he makes a point of actively seeking out what he considers ideal dentists, those who “are always looking for continuing education—whether through one of the postgraduate series, like the Pankey Institute, or some of meetings, like AACD [American Academy of Cosmetic Dentistry].” He finds them, he says, “at venues frequented by doctors who are really committed to postgraduate education.” He says he is able to do his best work with those who share his company’s philosophy and thought processes related to restorative dentistry.