Four university educators and one veteran administrator share their perspectives on laboratory communication.
by Jean A. Sagara
In this series, we have been examining dental laboratory communication in all of its forms. We have presented viewpoints from labs, dentists, and vendors in separate articles since January. We have covered topics such as shade-matching, implants, and cosmetic imaging, all relevant issues that impact lab communication.
Now let's go to where it all begins - to dental school ... where students are first introduced to the dental laboratory ... where residents learn to perfect the clinical subtleties of appliance prescription ... where institutions may struggle with administrative systems, divergent faculty viewpoints, and with labs. It is time for those involved with the universities to give us their input on the important topic of lab communication and tell us about their customary practices.
Participants and objectives
We interviewed an expert panel of educators and one veteran administrator who gave us their perspectives. We will disclose two facts at the outset:
We know many of these individuals professionally as leaders in the dental academic world.
A We know some of them because their schools use, or soon will use, TransLab™, an online laboratory prescription product with which we are familiar.
Our goal was to address the topic of lab communications broadly. While the topic of technology was included in our interview questions, it did not drive our conversations. Rather, technology's importance in lab communications (for example, digital radiography and electronic medical records) suggests that it needs to be the subject of a future article.
For this study, we asked representatives from each school how they select a lab, monitor the quality of work produced, teach lab communications, and manage labs within their administrative systems.
Our interview participants included these colleagues:
•Robert Chapman, DMD, professor/chairman, Department of Restorative Dentistry, Tufts University School of Dental Medicine, Boston, Mass.
•Richard Fredekind, DMD, associate dean for clinical services, University of the Pacific School of Dentistry, San Francisco, Calif.
•Anton Gotlieb, DDS, associate professor of restorative dentistry, NOVA Southeastern University College of Dental Medicine, Ft. Lauderdale, Fla.
•Ms. Nikki Nicholas, laboratory and stores manager, University of Florida College of Dentistry, Gainesville, Fla.
How labs are chosen by schools
It surprised us to discover that schools work with as many as 15 labs at any given time. Another surprise was learning that few schools utilize an RFP (Request for Proposal) or contract process to formalize lab relationships. On the other hand, all participant schools monitor work quality on a regular basis and feel no compunction about ending a lab relationship when performance suffers. They have quality managers, quality teams, and a rigorous evaluation process that is applied to every appliance received from every lab. We began to appreciate that the informal arrangement actually allowed for greater flexibility, giving schools more leverage with labs.
We asked the interviewees how a lab is deemed suitable. Again, a pragmatic approach is the norm. All schools choose their labs based on recommendations from faculty or dentist referrals. Word-of-mouth works well and is the primary method employed. Since few lab contracts exist, no standard "term of service" exists either. All labs serve at the pleasure of the schools.
Dr. Susan King of the University of Louisville states it well: "We work with a dental laboratory for as long as the relationship prospers."
Metrics for performance
Naturally, while quality of the work product is the number one basis for evaluating a lab, additional criteria also are used:
- Ability to manage seasonal changes in workload
- Production turn-around times
- Fee structures
- Remake rates
More than one school emphasized the seasonal demand changes. For many schools that have a fluctuating calendar year, a laboratory's ability to handle the uneven demand for service without compromising quality becomes key.
Dr. Richard Fredekind of the University of the Pacific summed it up: "The seasonal nature of the quantity of work is a significant problem for the labs with schools. They have to learn to manage that without compromising quality. We take a hard look at that issue in choosing and staying with a given lab."
Apparently, many labs had difficulty responding to these cycle variables at first. Now, however, the dynamic is better managed with fewer quality consequences.
Dental schools teach communication
Instruction in lab communications is carefully conceived and richly delivered at dental schools. Much attention is paid to helping the student get lab prescriptions right.
As Dr. Anton Gotlieb at NOVA Southeastern University told us, "Our greatest emphasis is on how to write the script. We have to teach the student how to ask for what he or she wants. Then, the lab has to deliver whatever was asked for, no more and no less."
All of the schools we spoke with reported using a generic, written script - one for fixed prosthetics and one for removables - to accompany the case model. To take a closer look at how one school helps the dental undergraduate master prosthetic-treatment considerations, we talked to Dr. Richard Fredekind at the University of the Pacific, a three-year school. He detailed their teaching stages:
- For the first-year student, we use a check-box form (the same prescription form used for clinical cases), with close faculty monitoring and input for prepping the impression and writing the lab prescription for porcelain crowns fabricated for typodont preparation.
- For the second year, students deliver a crown on a real patient, with good student-to-faculty ratios that allow careful supervision of clinical and laboratory procedures.
- For the third year, aesthetic considerations are introduced with the added complexities involved in proper lab prescriptions. Students complete many clinical cases requiring communication with labs, again with generous faculty oversight, but a predominant goal of nurturing the student toward greater independence.
Dr. Fredekind amplified these remarks with a central caution that is shared by his colleagues: " … What the lab receives from a dentist will dictate the quality of the prosthesis coming back."
The labs told us the same thing, as did the practicing dentists we spoke to in earlier studies on this subject. All participants accepted their responsibility to teach students the importance of quality lab communications. They understand that good teaching provides the foundation for good practice. There must be an emphasis on curriculum content and sound techniques ... and the schools must set that high standard.
Opportunities to enrich understanding also exist. Dr. Susan King discussed the value of meeting with lab and manufacturers' representatives occasionally.
Dr. King explained that she schedules "lunch and learn" sessions at the University of Louisville School of Dentistry for faculty and students to learn about new products.
Supervision is critical
Dr. Robert Chapman of Tufts University talked about how many faculty members "sign off" on scripts done by students and about the different areas of emphasis each instructor brings to this review.
Another of our interviewees, Nikki Nicholas, lab manager from the University of Florida at Gainesville, talked about oversight and supervision. Her responsibilities include not only distribution, case and model tracking, and financial authorization, but also informal monitoring of students. She supports them with comfortable question-and-answer exchanges. Nicholas emphasizes "… the critical importance of good supervision on technique." She points out that if a student does an impression wrong, "… the lab can produce an appliance that is unsatisfactory through no fault of its own."
The schools acknowledge their responsibility to teach by example. Quality is a two-way street. Both parties in the relationship must be accountable. What you receive from a lab is directly influenced by the quality of what you give that lab - a value underscored by our interviewees again and again.
What can go wrong?
What can go wrong with lab communications? Everyone agreed that unsuccessful lab relationships usually involve miscommunicating those customized characteristics that cannot be described objectively - shade, contour, color, and shape. A typical mistake is when a student sends the wrong shade guide to the lab. A digital photo can augment subjective detail, but images do not tell the whole story. The drop-down menus and smart forms offered by programs such as TransLabtrademark are useful, according to Dr. Chapman. He has used the product at Tufts University for two years. Still, all of the schools had reservations about communicating aesthetic considerations with precision.
Participants expressed a desire for online case tracking to coordinate appliance status with patients' return appointments. At some point, we believe supply-side management solutions already in use by other industries will be adapted to the school environment. While adequate tracking systems exist, work flow is still cumbersome. There are a lot of intercept points en route, such as Q&A approval, centralized distribution, and financial authorization. Our panel expects conversion to smarter transactional reporting systems in the future.
What does the future look like?
We asked if our interviewees could foresee lab communications converting completely to a digital form. All said yes, at some point in the future, that would be an inevitability. Dr. Fredekind told us that by July, all of his students will be using laptops. The University of the Pacific also uses electronic medical charts and will begin using digital radiographs in July as well.
Dr. Chapman said that TransLabtrademark offers "… very good reinforcement of what the student is taught in the classroom," but it "… cannot adequately address certain aspects of the aesthetic considerations…" mentioned previously.
Dr. King believes the rate-limiting factor that prevents going all digital " … is still the case model. We are very proficient in impression techniques. Once we can satisfactorily accomplish this through three-dimensional configurations and an electronic transmission with all of the customized characteristics included, we can do digital communications with our labs."
Take a look at our summary table of interview highlights for additional insight.