All They Don’t Know: Dealing With Knowledge Gaps Among Younger Dentists

At some point, every lab has been at the receiving end of a dentist’s ire about a misfitting crown or problems with a prosthetic. And sure, labs make mistakes; we’re all only human after all. But often, perhaps the finger is being pointed at the wrong human.

The long-term complaint that any problem with a bridge or removable is the lab’s doing probably isn’t one that (unfortunately) is going to go away any time soon, particularly because the disconnect seems to be growing. With changes in how dental school programs are run, the emergence of digital technology, out-of-country outsourcing, and increases in chairside milling, rifts between labs and dentists seem to run deeper than ever. And it’s starting earlier and earlier.

Beginning in dental school, dentists aren’t getting the same exposure to the laboratory as they once did. While many dental schools used to have labs on-site, those days have mostly come to an end because of the cost of running a lab and the increase in product outsourcing outside the country. And losing this opportunity to see firsthand how lab technicians work has contributed to a gap in understanding exactly how labs create final products.

“Dynamics in dental school have changed; they no longer have to make a certain number of dentures in school,” says Thomas Zaleske, owner of Matrix Dental Laboratory in Crown Point, Indiana. “And since they’ve removed dental laboratories from schools, students are no longer able to just go down and watch what is going on in the lab; they don’t have that opportunity anymore. That creates a gap because they can’t see how it all comes together, except on a screen. I think that really handicaps them because they can’t experience the full benefit of the manual way of doing it.”

As a result, many dental schools don’t afford burgeoning dentists the opportunity to collaborate alongside lab technicians, doing away with the chance to not only learn about the process, but also develop critical communication skills necessary to a productive lab/dentist relationship.

“I think a big challenge for younger dentists is going from learning and working in a clinical environment to working in practice, where you have to be able to communicate and connect with their patients and their counterparts on the lab side of the patient,” says Marybeth Starr, head of brand promise for Harvest Dental.

And recently, even the face of this transition to practice has changed, with the rise of dental service organizations (DSOs). With more young dentists going to work for DSOs, fewer are joining small practices as associates. And this can often close the door on another opportunity for knowledge transfer.

“Transitioning to a single-doctor practice as an associate used to be the normal transition, but it’s rarer than it used to be,” Zaleske says. “In those settings, older dentists were able to mentor and train the people coming into their practice in the traditional ways, so to speak, of doing things. So there’s a gap in what they’re learning when they don’t get that mentorship.”

Without this mentorship, many young dentists are missing out on important lessons in lab relationships as well as the analog skills required to provide good scans or models. And as technology increases and analog skills are lost to the past, knowledge gaps in young dentists are increasing as well.

Technology, for Better or Worse

Technology has changed the game and the dental industry as a whole. It has reshaped the dental workflow, expedited treatment, and simplified things like impressions and scanning. It’s pushing the industry forward, and the young dentists—and lab techs—embracing it are at the forefront of the field.

“Technology is a great thing and the younger dentists who are coming into the industry are so savvy with that side of the business—it’s a beautiful thing,” Starr says. “The younger generation on both the lab and clinical sides have changed the industry all around. We live in a digital world and they both understand it well.”

But while both sides are recognizing the benefits of such a digital world, technology is also creating disconnect, and allowing for greater knowledge gaps in younger dentists.

“I think that there is a bit of collegiality between both dentists and labs when it comes to technology because both are eager to learn it,” Zaleske says. “But when you start to dive into the deeper reasons, I think that’s where the deviations are, where the separation begins. They can both agree that the technology is going to create a faster product and it’s going to eliminate some steps and they both have to learn it together. But it does create a gap between the two, because at a certain point, it’s always boiled down to who touched it last. It’s still always going to be the lab’s fault because you can’t blame the machine; the machine is finite.”

The issue becomes this: If both the dentist and the machine are as infallible as some seem to believe, the blame must surely fall squarely on the lab’s shoulders, even if perhaps the real issue isn’t the lab or the machine, but user error.

“I think a big gap in [younger dentists’] knowledge comes from the fact that they don’t have to use their hands to do anything,” Zaleske says. “They’re taught from the get-go that digital will cure or remedy any situations or problems, instead of understanding that digital technology has its limitations. It’s like more emphasis is being placed on learning to use the calculator rather than the actual math.

This does not work well with dentistry. “Once you take out the understanding of the math and all you learn is how to use the calculator, and you’ve never had any kind of manual comparison, well, that becomes a very tough problem to solve,” Zaleske says. “You start to rely on the information being supplied by digital tools, and you don’t investigate further.”

In his own experience with removable prosthetics, Zaleske sees this manifest regularly in a lack of understanding of what constitutes a successful complete capture of soft tissues and biologic landmarks—the factors that ensure successful denture delivery and treatment. He gives the example of locating a vibrating line.

“We learned (or the dentist used to learn) how to palpate the mouth and find that vibrating line instead of using a default fovea location for locating it,” Zaleske says. “That knowledge has gone away because the scan will identify the fovea, and use that as a default marking location, and the dentist will never explore any deeper on how to make it a better location (or how to find a better location).”

This manual learning process is something that has historically allowed dentists to better understand preparations for successful production. For example, dentists who bake their own crowns have a better understanding of what a preparation requires in order to create a successful crown. By doing it from both sides, dentists gain a deeper understanding so that when a problem arises, it’s much easier to solve, since they’ve already done it and know what they’re trying to accomplish.

This translates to digital. If a dentist understands what goes into a successful impression, they’ll understand what information a scan needs to impart.

“Everyone wants to take digital denture impressions,” Zaleske says. “Anybody who takes good denture impressions clinically understands that there are extensions and flowing of material that a digital scan around the periphery can’t accomplish. But if you’ve never done a manual impression, then you don’t understand what could be accomplished or what’s not being accomplished by the digital means.”

And incomplete or lacking digital scans can result in a poor-quality end product, ultimately hurting the patient. This makes it imperative for dentists to be careful about how heavily they rely on digital technology to do the job for them.

“The difference between artificial intelligence (AI) and a human is that a human actually cares about what’s being produced to go in the patient’s mouth,” says John “Johnny O” Orfanidis, CDT. “Dentists should understand who they are. You’re a dentist. You are a doctor of the mouth. And the only way you can get really good at it as an artist and as an expert is by putting hours into your hands. The only way you can get good is by putting in the time. You want to be the top dentist in the world charging $10,000 per crown? You can do that. But you can’t do it in a day.”

“Digital technology is just a tool, not a replacement for knowledge and an understanding of what constitutes good successful treatment,” Zaleske adds. “Dentists need to understand the legacy skill sets to provide the best treatment for their patients.”

The Industry Allure

It’s not hard to understand the pull of digital technology. Convenience, simplification, speed, and, presumably, accuracy are selling points that are hard to refuse. And this is the battle cry of the digital world, to dentists, labs, and patients alike—a battle cry that manufacturers have doubled down on.

Take digital dentures, for example. They’re touted as the most convenient thing. There’s a file on hand, so if a dog eats the dentures, the dentures can be immediately reproduced without starting from scratch. However, while this sounds appealing (and it certainly would be in the event of a denture-eating dog), it’s not the most likely of scenarios.

“I don’t know that any dogs are getting together and saying, ‘Hey, let’s eat dentures,’” Zaleske says. “Sure, it may happen, but not often. But manufacturers like to emphasize those kinds of things, rather than the longevity of the old way of doing it. There’s a lot of longevity and personalization that occurs without all the extra nuances that they have to teach you in order to get what you need for the patient. But younger dentists aren’t being told that from the manufacturers.

However, the allure presented by the manufacturers is hard to resist, and the potential gains a dentist can get from the latest and greatest technology are enticing. Quicker turnaround means higher production, which means more money. Manufacturers tell dentists that technology, such as chairside, saves time, getting more patients in the chair per hour.

“I think it’s sad because it puts a young dentist in a bad situation because they have to pay those debts off,” Zaleske says. “And they have to do that, so the promise of doing things quicker is a no-brainer for them. And I understand that. But at the end of the day, it’s not always the best choice for treatment in many cases.”

This technology seduction that gets people to invest is successful because the potential seems so great. But, Zaleske says, this can be a trap.

“Companies always like to compare the worst of their competition with the best of what they can produce, and I think that’s a disservice to the profession,” he says. “Because there are some really good benefits for digital technology in certain applications. But there are others that are basically saying that a hammer can do everything. And that leads to buy-in from new dentists because of the potential that they won’t have to learn to do this or that.

“And potential is one thing, but you’ve got to understand the basics before you understand the potential,” Zaleske continues. “The people who are successful with the digital technology are the ones that already have a solid baseline of how to do it. But what happens is everyone is looking for the quick fix.”

Closing the Gaps

Perhaps one of the biggest gaps that needs to be closed is that many of today’s dentists simply don’t understand what it takes to create successful lab products, the processes that are required to do so, and what the clinician needs to contribute to ensure a smooth case workflow.

“I do think they understand to a certain extent what goes into lab work, but really none of us knows about lab but the lab technicians,” Starr says. “I believe they understand the lab industry, but they also may underestimate the work that it takes case by case.

Orfanidis agrees.

“We have a big disconnect in the dental industry,” he says. “Dentists just want to send the case to the lab, have it taken care of, and if it’s not perfect, often the lab gets burned.”

Perhaps the lack of understanding of the information necessary for each case is one of the biggest hurdles in these situations. Since younger dentists haven’t done manual impressions or don’t understand what a lab needs beyond a point-and-click scan, the potential for error increases exponentially.

“The day-to-day is a grind and there are variables on every case—not one is the same and that is the challenge for the lab,” Starr says. “How do you bring on a new dentist and cover every variable? The answer is in open communication and building that relationship.”

This communication is an intrinsic part of closing the gaps, and while dentists may not have received the benefits of mentorship from another clinician, the lab has a unique opportunity to provide education that may have been missed along the way.

“Number one, be honest with them,” Orfanidis says. “Don’t be afraid. It is a difficult industry that we’re in, and the only way you can help them to do better dentistry is by telling them it’s insufficient. Because you’re not doing the best job you can if you don’t have the information you need. Most lab guys, if they see a margin, they’ll hit it perfectly. But you need to get those margins from the dentist, and if you’re not, no one is doing their best work.”

No one likes to be told they are doing things incorrectly, however, so Zaleske recommends a light touch.

“If a new doctor comes into my office, I know the smartest thing to do is to not barrage them with a ton of different things to change, right?” he says. “I can’t give them all that information off the bat, but I kind of spoon-feed them things that can give immediate results. This also helps instill confidence in my suggestions, which is a benefit down the road.

Zaleske also ensures his dentists aren’t just taking his word for things, but backs his suggestions up by sending his dentists peer-reviewed articles (by other dentists) that are making the point he’s trying to emphasize. He’ll send physical articles or links to the dentist along with the case and allow that information to marinate so that the dentist can be educated and come to the (hopefully correct) conclusion.

“I send articles peer-reviewed by dentists so that it’s not the world according to the laboratory, but the world according to dentistry,” he says. “I think that by and large, dentists have more respect for those in their own profession than they do laboratory technicians. They respect us to a certain degree as far as our technical knowledge goes, but when we start to convince them that they have to change something in the clinical environment, they need to see somebody that works in the clinical environment making the suggestion. I’ve found that they respond better to that and it’s a good way to convince them, or at least encourage them to investigate.”

Communications like these don’t only improve cases, but also can improve relationships.

“It is all about communication and building relationships and building those relationships in different ways: in person, webinars, newsletters, tips and tricks—getting their attention in a positive way,” Starr says. “The challenge may lie in interpersonal communication and, in particular, on cases that are more analog in nature, but this may give the dentist and the lab an opportunity to bond.”

Ultimately, dentists are always going to have knowledge gaps, particularly as technology continues to literally take more work out of their hands. But as frustrating as it may be, labs can weather the storm. It all comes down to good communication, continued education, and perhaps, most importantly, a healthy dose of patience.