Dentists communicate with their technicians (and vice versa) in a variety of ways, and on a variety of subjects. Yet in the experience of Dental Protection, many valuable opportunities to improve the quality of these communications seem to be missed. Although there has to have been some dialogue, there is often little or no tangible evidence that this was so.
The quality of dental care is likely to be maximised when dentists and technicians are communicating well. This communication may take place:
- In person (this is obviously much easier when they are working together on the same premises).
- In writing (for example, on lab tickets, in letters or by email).
- On the telephone.
- Indirectly - for example by trimming or marking dies on working models.
In order to avoid misunderstandings, information, requests and instructions must be clear and unambiguous, and each party must recognise and respect the perspectives and views of the others. Many of the problems that arise at the interface between the dental technician and the dental surgeon result from assumptions, mismatched expectations and a failure of one or both parties to develop an effective working relationship with the other.
A simple example would be a case where a patient has made it clear that they do not want any metal to be visible on a porcelain/metal bonded crown. Unfortunately, this fact is not made clear to the technician. The dentist then under-prepares the tooth, leaving insufficient occlusal space to accommodate both the metal and porcelain. The technician takes the decision (without reference to the dentist) to construct the restoration with an all-metal occlusal surface. Predictably enough, the patient is not willing to accept the finished crown and the dentist and technician end up in a dispute over who should be responsible for the cost of remaking it.
One area where problems have arisen relates to a technician’s willingness to accept an impression, or perhaps a bite registration, or a dentist’s willingness to accept (and subsequently fit) work supplied by a technician, that is not of an appropriate standard.
It is helpful to establish mutually agreed ‘terms of engagement’ where from the very outset, the responsibilities of each party are clearly set out and understood.
Included here are details such as the specification (for example, the metal content) of certain restorations, in order to avoid situations when the dentist ends up providing the patient with an inferior product, rather than the product agreed. This can have serious legal consequences and in the past Dental Protection has seen cases that included criminal charges (of fraud) and the removal of a dentist’s registration, as well as civil litigation between dentist and technician for breach of contract.
Problems of this nature could easily be overcome if a technician were to supply a written confirmation of the precise specification of the materials that would be used whenever certain restorations are requested by the dentist. The corollary is that rather than simply making assumptions regarding the metal content of restorations provided by a technician, the dentist could undertake some basic and reasonable ‘due diligence’ enquiries of the technician, to ascertain the metal content with certainty.
Another important ‘quality assurance’ aspect of communication is that of the disinfection of impressions before they are sent to a dental laboratory, and similarly, the disinfection of appliances by a technician before supplying them to the dentist. Both parties deserve the peace of mind of knowing that proper decontamination has happened, and in the case of disinfecting impressions and certain kinds of metal appliance, of knowing that the disinfection process will not itself have caused any damage that could compromise the finished product in some way (for example, some disinfectants damage/distort certain types of impression material and similarly hypochlorite can attack the surface of chrome cobalt dentures).
Here again, something as simple as a sticker on a bag containing impressions or appliances, could be used to supply this confirmation and reassurance to the recipient.
Problems can result from the date set for the return of the work from the technician to the dentist. This must be realistic and agreed mutually. Missed deadlines can lead to patient dissatisfaction, especially when it prevents treatment being completed as promised for an important occasion in the patient’s life such as a holiday, wedding, business commitment, etc. On the other hand, asking technicians to meet impossible deadlines makes it more likely that the work will be carried out under pressure, causing or the possibility that attention to detail might suffer.
The communications between dentist and technician are not always recorded in the patient’s clinical notes, although these conversations may have a direct impact upon the treatment outcome. On those occasions when a technician is directly involved in the process of shade selection, this fact should be obvious from the clinical notes; such involvement is an indication of the care and attention to detail that has been invested in the patient’s treatment.
Laboratory tickets and invoices all form part of the overall treatment records (not least, in cases where it is later alleged that the wrong materials had been used or ordered). As such, they should be stored for the same period of time.
For computerised practices it is extremely simple to scan these documents and hold them in electronic format along with the rest of the patient’s records. Where paper-based records are kept, financial records such as invoices may be stored separately (and perhaps kept for a shorter period of time).
Mutual understanding and learning
One way of building this important relationship within the dental team, is to seize any available opportunity for shared learning. Attending courses together not only provides an opportunity to learn and discuss new techniques; perhaps more importantly, it is a chance for dentists and technicians to spend time together and to build a stronger relationship and better mutual understanding.
Carry out this simple audit on a random selection of records of patients for whom you have carried out treatment that has involved laboratory work:
- Can you identify which laboratory/technician carried out the work?
- Can you establish with certainty exactly what appliances or restorations you requested, and what instructions you gave to the laboratory?
- Have you retained your laboratory tickets to assist in point 2?
- How easily can you track down the invoice for the work in question?
- In the case of (for example) a cast chrome/cobalt denture or other similar appliance, who was involved in the detailed design of the appliance? What documentation is available to support/confirm this?
Now repeat the exercise for any specific cases you can remember, where some kind of problem arose in connection with the laboratory work. Answer questions 1–5 and include these additional questions:
- When these problems arose during the treatment (for example, the need to make adjustments of occlusion or shade, or problems at the ‘fit’ stage) how well is this recorded?
- Is it clear what steps were taken to rectify/remedy the problem?
- If any conversations took place between dentist and technician, how well are they recorded in the clinical notes or elsewhere?