Dental Insider Blog

Observation and Commentary On the Dental Industry

Where Has the Quality Gone?

Posted by dentalinsider on May 9, 2007

Recently the dental laboratory magazine LMT ran an article called “LMT’s 2007 Crown Experiment: Not in my mouth!” They sent out 9 impressions to 6 domestic laboratories and 3 foreign laboratories. They were sent out as if they were coming from any “Regular Joe” Dentist, the labs were unaware they were taking part in this experiment. Once LMT received the crowns back from the labs they took them to two well known dental schools, NYU and UCONN, where they were evaluated by 11 different faculty members. You can find all the details, including a blog, at www.lmtcommunications.com, so in the interest of keeping this short I will get right to the point. The title of the article says it all; none of the crowns that were reviewed were rated as acceptable according to their scale. In fact everything was rated on a scale of 1 through 10, and none of the crowns scored above a 5 overall. Not that it matters but 10 was the good side of the scale. The evaluators went even further as those who were dentists said they would never place any of the crowns that were reviewed. (As a side note the foreign labs scored at or just below the domestic labs)

This experiment is being repeated as many cried out that it did not reflect a good cross section of the industry. Almost 300 labs will be taking place in the next experiment. However, this 2 nd experiment is tainted, since the laboratories will know they are producing for a contest. You see what many did not get from results the experiment, what they did not fully grasp, was that these 9 crowns were from 9 different labs that operate and send out work every day. That means that this work is being seated in the mouths of patients every day. This work that was graded as unacceptable by experts, that showed obvious flaws even visible in the photographs, that was from 2 large lab, 2 medium sized labs, 2 small labs and 3 foreign labs is getting placed by dentists every day. Patients are receiving sub-par work every day. They are getting restorations that were evaluated low quality, poor fitting, not fit for placement work every day, every week and every month of the year.

Let’s do a simple math equation. The 2 large labs produce 100 units per day each for a total of 200, the medium sized labs produce 50 units per day for a total of 100, the small labs produce 25 units per day for a total of 50 units. That means that just from the domestic labs that over 350 units are being sent to dental offices every day. When you factor the foreign labs in, we could be talking about 500 – 800 units every day.

Now we have estimated the number of units, but how about the number of dentists that are accepting this work and seating it in their patient’s mouths? There has to be some responsibility somewhere, and why are the clients of these labs not demanding better, and if the labs can’t produce better what are they doing in business still? The fact is that the doctors either do not know better or they are so driven by profit they do not care. One way or the other it is wrong. But this will continue to happen as long as patients do not ask questions, educate themselves and because the simple fact is that dental work is rarely a life threatening situation. Unlike the medical community where a procedure gone wrong can cost someone their life or cause them further pain and suffering, in dental you go back in two years, the dentist tells you the crown needs replaced and he collects another $1000 from you.

So who is responsible for these problems? Who is to blame and who can make a change? Does the government need to become more involved? Is self regulation working? What is the NADL doing to solve these problems? What is the ADA‘s position on this problem? So many questions, but the fact is that that unless people wake up and recognize these quality issues nothing will ever change. The dentists are making money, the labs are trying to make money, and the patients trust their dentists to give them the best quality restorations, while not knowing any better.

The simple fact is that unless something major happens this is what will continue to happen and the type of work many more than 9 labs will continue to deliver. Is this acceptable; is this the best this industry has to offer? Will this get better or worse as technology advances?

So many questions, so few answers. What are your thoughts?

Associate Q

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16 Responses to “Where Has the Quality Gone?”

  1. Miss Kad said

    I think it comes down to public awareness. The end user is the patient. If they do not know they can get something better, they will just take what they are given, even though everyone I know complains about how much crowns cost. The public needs to demand higher quality from the dentists. The dentist then needs to demand higher quality from the labs.

    There are many many high quality labs out there, but I bet there are more labs that aren’t involved in education or improving their work. They’ve been doing this for 20+ years. They know everything and say that the Dr’s won’t pay for better work, they will just leave the lab and go to someone cheaper. This is true because the average patient doesn’t want to pay more.

    Why don’t they want to pay more? Because the patient doesn’t think the garbage they are getting is worth the high price they are already paying. But if they were shown they could get something much better I wonder if they would pay.

    Dentists need to understand that the labs they use are a reflection of thier own reputation.

    All labs need to understand that they need to continue to raise prices. Some labs go years with out raising prices. Do suppliers do this? Do the shipping companies do this? Do the dentists do this? NO NO NO. Costs go up, so should the lab. That is why there are cheaper labs, they use cheap products, cut corners and don’t raise prices.

    Patient awareness is the bottom line!!

  2. Associate Q said

    I agree 100%, patient awareness is the only way. But every time I bring this up to anyone they say “the patient won’t care until something dramatic happens”. That is just BS. The fact is that the patient would care if someone was to expose what is going on in this indsutry. Maybe it needs to be on 20/20, maybe it needs to be said loud and clear that they are getting crapola.

    The NADL is underfunded, under-run and is always being outfoxed by the ADA. I am not blaming the NADL, I merely saying they are a housecat, and the ADA is a friggin cougar. In my opinion it rests upon the shoulders of the association representing the manufacturers of the crowns to get the public involved.

    But it gets even deeper because as you said, the labs the doc uses are a reflection upon their practice. Maybe the ADA and NADL need to work together to raise the level of quality. Wishful thinking but once can hope. I think everyone is at a point where they are saying “don’t rock the boat”. I know a lab right down the road who has not raised their prices 1 cent in 5 years. But I can tell you that they are paying more for the materials they use to make that product.

    Any how Miss Kad I agree, it all comes back to patient awareness. How that gets accomplished is what is missing.

  3. Miss Kad said

    The public doesn’t even know that technicians exist usually. They think the dentist waves a wand and the crown appears. I agree it must be full blown publicity, not just a TV reality based make over show. Our industry is so big to us, but no one really knows about it. It’s like I work for the CIA! 20/20 here we come!
    LMT did a promotion of public awareness years ago, “Dental Technicians build smiles one tooth at a time” we need to keep this going outside our industry and make it much bigger!!

  4. The Boss said

    Well, I take the results of that test with a grain of salt. Having a bunch of pointy headed beard scratchers evaluate the work was not necessarily the best route to take. I would love to turn the tables and let those same ivory tower geeks, evaluate the impressions, study models (if existing) digital photos, (if existing) working instructions (if existing) and preps. GIGO.

    Some of that work was crap, no doubt about it. However, I can’t see how a few of them scored so low. In some cases, you could see the opaque showing through on the occlusion. Why? Under reduced? Metal too thick? Also, single posterior units are the #1 outsourced crown in the US (and world wide). For all we know, ALL of them may have been done off shore, only 3 admitted it, and the others didn’t!!!

    Let’s see the same team of evaluators review the average CEREC unit done on a daily basis, without special attention- Ha –

  5. Associate Q said

    Boss, I completely agree. The quality of impressions and preps is something that needs to be discussed as well. As for study models, photos, instructions – What are those? How about facebow measurements? Occlusion simply is not of importance and as far as most are concerned it can be ground in with a 1557 bur.

    As far as the outsourcing, 3 of the labs were foreign labs. Meaning the work was actually sent overseas by LMT. Now as far as the other 6, you are correct they could have been outsourced as well. You never know, one lab could have done all the work. Although I doubt that to be true, my question still stands, will the doctors continue to seat this work and will the labs continue to produce it?

    We can debate all day long about impressions, preps, and so on. But if the impression was bad, I say the lab should have sent it back. I know, I know, that is a hard thing for a lab to do but someone, somewhere, somehow, has to take a stand. We all know that there is junk getting put into the mouth of the average Joe every day, and just because the other guy is doing it does not make it right. Maybe that is how people justify it to themselves, but in my book 2 wrongs still don’t make a right.

    Don’t even get me started on the Cerec.

  6. The Boss said

    Junk is a relative term. I’ve seen work that makes my toes curl, but from a clinical standpoint is perfectly acceptable. For example, if the margins are sealed, and verified via bitewing, the contacts are broad and tight, the occlusion, ugly, but functional, and the shade is off, is it a bad crown?

    I have only gold in my own mouth. I’m more concerned about clinical performance than esthetics. Beauty is in the eye of the beholder, however, clinical results are totally quntifiable. In that test for example, one lab lost points because the model was broken. That might have happened in transit, or even dropped by the person who unpacked the case. Who knows?

    The test was less than scientific, and I don’t think it’s the responsibility of the ADA or the NADL to try and “correct it”. The individual doctor decides what the marketabilty and quality standards are for his own individual practice, and then find a lab who satifies his needs. Obviously, if these labs are legitimate ongoing enterprises, they’ve found enough work to stay in business.

    Two wrongs don’t make a right, but it still takes two to tango!

  7. Associate Q said

    Yea, the broken model was a little too much for me to handle. The test was not scientific at all, but I still think it was enlightening.

    As for the ADA and NADL I am merely saying that the public should be involved, these associations should promote the quality work that is being done and they should help weed out some of the garbage. It is wishful thinking but one can hope. But most places it is crap in, crap out.

    As for gold, I agree 100%, I will go gold all the way to 1st Bi. Function over esthetics any day. Plus, something about the fact that gold has been used for dental restorations for thousands of years that makes me feel more comfortable. I mean come one, that is some pretty good clinical testing.

    Although we all know that this type of work exists, and happens every day I beleive if the public were aware that they can get better, often time for the same cost, they woudl demand better results. My only point int he end is that the patient deserves better. But again better is a relative term too.

  8. Miss Kad said

    You took the words out of my mouth!

    I was thinking this morning about beauty being in the eyes of the beholder. The beholder really is the patient. But the shade should match if the patient chooses a Porcelain crown. However a crown can look A+ but if it doesn’t function then it’s still a bad crown. It’s the dentist that knows it will function or not for the patient. How could the patient possibly know?

    I agree, I have gold too. But again, that has to do with education. We are educated that gold is better and why.

    Remember dentists are in sales too. If the crown doesn’t function, what will happen? The patient comes back! More $$$$. I’ve heard many friends say they have heard stories about dentists practicing this way. Doing work that doesn’t need to be done or not doing it right in the first place.

    Do patients get 2nd opinions about dental work like they would a medical decision? Not usually.

    I think all around everyone needs to seek higher standards. The dentist and the Lab NEED to work as a TEAM! They NEED to not be afraid of asking each other to redo work. That doesn’t mean it should be done for free! And poor work shouldn’t be done on purpose just to make more money!

  9. Dental Guy said

    Well Miss Kad, quality is a HUGE problem in dentistry. Dentists don’t have any quality control. Most practice independently. So, they are their own checks and balances, and in many cases they do a terrible job. On top of that, you have many dentists that are only concerned about esthetics and not proper form and function.

    It’s very unfortunate that many dentists do unnecessary work. I have heard many stories, and have experienced dentists attempt and sometimes succeed in taking advantage of me. In fact, my current dentist just over charged me for a flouride treatment, and he knows that I am in the industry!! So, I am done with him.

    I think the problem of unnecessary dental work has become such a huge problem becuase many dentists honestly think the work is necessary even if it isn’t. It makes me wonder why so many are compelled to go in and do all this work since the first rule of dentistry is to minimize damage to the tooth structure.

    In addition to continuing education, the ADA should require dentists to recertify periodically throughout their career. This would benefit the entire profession because it would provide some oversight to all these dentists that are their own bosses. Unfortunately, the bureaucracy of the ADA will never do something like that.

  10. just a complaint: visited a new dentist this february for a cleaning. never got it. instead the dentist asked me if i liked the way my teeth looked, to which i replied “no”. you see, i had chipped and gapped teeth and always wanted to have them crowned or capped.

    my new dentist explained that he could put crown on my teeth and improve my smile. that was all i needed to hear. his assistant took x-rays of my teeth and i made an appointment to have my teeth cleaned at the next appointment.

    once there the dentist was busy with another patient and i had to wait. the assistant was sent in and she started to prep me for what i thought was a cleaning, instead it was for the crown preparation. finally the dentist came in and i asked him about the cleaning and he replied that he would do the crowns first then later on he would do a deep cleaning. a mold of my teeth was created. i explained to the denist that i didn’t want to look like a mule (big teeth) and i didn’t want to look like bucky beaver either.

    at first the dentist would shave FOUR teeth (2 upperfront and the two beside both upperfront). the spaces in mouth, he said were larger than anticipated so now he needs to shave SIX teeth. the other 2 next to the 4 other upper teeth. i’m in the dental chair from 9;OOAM TO 1:30PM. the dentist is in and out with other patients while he has the dental assistant pack my mouth or whatever they do. more pain relief had to be injected as sometimes i could feel the pain. temporary teeth were made and seated in my mouth. i was sent home with no instruction on how to take care of my teeth because the dentist had other patients he had to attend to. i had a mild headache for about a week.

    my next appt. was for 3 wks. later. crowns had to be made. 3 wks.later one of the temporary front toothcap came off. i immediately went back to the denist and he had his assistant attach another temporary cap on my upper front tooth. the material scraped the roof of my mouth when she finished applying the cap and i told her so. her reply and the denist, was that my permanent teeth would be here tomorrow.

    next day my teeth were seated in my mouth and i looked like a mule. i said this to my denist and he said my smile was beautiful and that i just had to get used to them. in july i went back to see my denist and informed him of my dis-satifaction. i explained to him that i had an overbite and that my upper teeth were too long, and that my mouth was always dry at night. Guess what? he offered to shave them right then and there. i declined. he referred me to another denist for consultation (more money). i will not let him touch my mouth again.

    for now i will have to make do with what i have in my mouth until my dental insurance kicks in again. MY TEETH STILL HAVE NOT BEEN CLEANED. for the record… if your dentist seem irratated when you ask questions ..RUN.
    INSURANCE: i changed dental insurance from “delta insurance” to “employers dental service”, BIG mistake.

  11. Associateq said

    I am so sorry to hear this, but unfortunately this is something that is happening across the country. Speaking in broad terms, dentists are more interested in sales than patient comfort.

    In dental school these dentists now take more classes on BUSINESS SALES than they do on important things like DENTAL TECHNOLOGY. They teach them to sell patients veneers & inlays, then they sell you crowns, then they sell you a partial denture and finally they sell you full dentures. Or as many are doing these days they go straight to implants if they want the big bucks.

    To the person above you need to file a complaint with your state dental board. It sounds to me like the dentist seated veneers in your mouth. Many times Dentists will try to use veneers in place of braces. You see if you were to get braces or some of the newer orthodontic treatments they might have to send you somewhere else. (That means cash out of their pocket) So they try to fill gaps and straighten teeth with veneers and crowns. Usually they push the materials they are using way past the point of where it should be.

    Did this doctor do a study model? That is a model where he showed you a “wax-up” of what the final crowns/veneers would look like? When you told him you were unhappy did he ask you what you were unhappy with? Size, color, fit, etc? Did he offer to replace the veneers?

    I could go on and on and on and on and on. But the moral of the story is that you are the CONSUMER, the dentist is a BUSINESS. He is liable for the work he has done. If it is as bad as you say it is then you could end up with numerous issues. Problems with your gums, opposing teeth and many other problems that can cause A LOT of pain.

    Do not take this lightly. Demand your money or new work. If they resist file a complaint with the dental board. Tell your friends, family and anyone you see about this dentist. Fight back and if you need to take the a-hole to court.

    Until people demand better quality dental care we will continue to receive this SUB PAR CRAP these dentist are doing. It is all about money and the longer you are in their chair the more you are costing them.

    And to the person who says “it is horrible that dentists like this do these things, they give all dentists a bad name” I say BS. I am in the industry and I had to go to 4 dentists before I could find a dentist that could provide proper care. The others tried to push “sealings”, “all-ceramics” and all the other non-sense they try to sell. There are way more bad dentists out there then good. Plus, I talk to dental labs every day and see impressions every day, 75% is crap.

    Beneste I am sorry you had this happen, but you have rights and should fight back.

    Q

  12. kp said

    Q,
    why shouldn’t we get you started on CEREC? What is your beef with it?
    kp

  13. Associateq said

    Cerec InLab or Cerec for Dentists? Apples and oranges, but they are both rotten when not used correctly. My main issue with any new system is the lack of training. For labs let’s see, we go from no computers and not even a fax machine to a sophisticated design and milling machine. Every prototype company I have ever dealt with uses similar machines for aerospace and other industries has people with multi year degrees running these systems. A 3 day course in Brea or wherever they do it now jsut does not cut it.

    I am not going to rant, but I will leave you with a question. When is strong too strong? What type of environment should it not be subjected to? What is this mystical material that seems to be the solution to all problems?

    Q

  14. Dental Guy said

    I would also like to add that some Dentists with CEREC may get a little trigger happy and place unnecessary inlays, and onlays, and other stuff. In fact, SIRONA has developed some creative definitions for inlays vs onlays, and dental insurers have decided it is a bunch of horses#!t. Right now, Dentists are trying to get insurance companies to reimburse them for CEREC procedures that don’t fit the textbook definition of what was really supposed to be done.

    Then again, dentists do this all the time anyways. So, it’s entirely fair to say that the same dentists would be wasting more time on implants, endo, lasers, and plenty of other gizmos, if they didn’t have their CEREC toy.

    For the average person that just wants needs a new crown, CEREC makes the process super easy and super fast. But for the dentist that wants to redo everything and the kitchen sink, CEREC can be a bad bad toy. I think the same thing can be said about lasers. I am never going back to my dentist, he knows I am in the industry, amd he over charged me for a stupid flouride treatment. In the same appointment, he said he wanted to “zap a spot” on my tooth the next time I am in the office. Not a cavity, a Spot = a Stain!! I think he is probably a good dentist, but some get so focused on esthetics, that the lose sight of the fact that teeth don’t have to look a specific way, and stain does not = decay.

    Any dentist that wants to remove tooth structure for something other than a bona fide cavity is fishing for $$$. Some Dentists say they are precavities, and some use the Diagnodent to measure people’s teeth and say, “oh it says 14! That means you have a cavity!” When KaVo reps will say, “18+ is when you should be concerned.” It’s kinda sad. You would think the Diagnodent would be used in a way to prevent good teeth from being drilled on, when it’s done the exact opposite because dentists are fooling their patients!!

  15. kp said

    Q,
    I was just curious overall, but I agree with you on the rotten fruit comment. I am not seasoned enough to intelligently answer your questions, so I won’t.

    Dental Guy I agree with you as well.
    As with anything, one needs to have the proper education and training in order maximize the results and care given.
    I personally think it’s an incredible piece of technology that is the future of dentistry. but that’s just me.

  16. Mike Creighan said

    Well I would certainly have to disagree with the comment, “In dental school these dentists now take more classes on BUSINESS SALES than they do on important things like DENTAL TECHNOLOGY. They teach them to sell patients veneers & inlays, then they sell you crowns, then they sell you a partial denture and finally they sell you full dentures. Or as many are doing these days they go straight to implants if they want the big bucks.”
    Obviously this is a vent from an uninformed individual with absolutly no knowledge of the information and clinics taught in most dental schools. It is unfortunate that more and more people believe this. I would propse that most Dentists are honest hard working individuals who truly care about their patients and work hard at perfecting their craft.
    The insurance industry happens to be the biggest hurdle blocking most dentist from providing optimal dental care and most patients recieving the best care and technology available.
    I have read literally thousands of complaints on the internet from unhappy patients who have undergone unnessary dental work. When I go to my dentist I always know why I am in the chair, exactly what is going to be done, the pros and cons of the treatment, potential problems and the cost regardless of my insurance contribution. I fail to understand why either dentists or patients or both don’t clarify all of this.
    It is as much the patients responsibility to ask questions as it is the dentists to explain the diagnosis,treatment plan and cost.
    I really do understand what the complaints are about..10 years ago I was diagnosed and treated for sarcoma and was told that I had about six months to live. The previous three surgeons who missed this little tidbit and would not biopsy the lump thought they were doing their best.
    If you think you have been inappropriatly treated by a dentist or any professional for that matter file a wrotten complaint with the regulatory body for that profession and it will be investigated.

    As for the Cerec, some are slapping them in where they don’t belong. Others are selecting the clinical situations that best fit the properties of the material for a properly prepared tooth. There is no single restorative material that out does all others. Experience, education and clinical judgement should decide the best material for each individual case. Dental gold, in my opinion a very beautiful and long lasting material. Not all dental golds are gold. To properly make sure you are placing long lasting, malleable and burnishable gold you must have approx. 12 carat gold (Tucker gold).

    Finally, nothing last forever not even fillings. If you find a material that will break this rule let me know and I’ll pay for 2 cars to be made out of it and give one to you.

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