Dentists: Do You Trust Your Dental Lab?

May 13, 2008 By Jim Du Molin 15 Comments

The Hidden Costs of a $40 Dental Crown

The relationship between dentists and their dental labs is a close one – but is it close enough?

The other shoe has dropped. The lead scandal, a story that The Wealthy Dentist has been covering for the last two months, has now gone national. ABC’s Good Morning America ran a segment about this potential crisis on May 8th. Doctor, you better have your story straight when you patients start asking you where your lab work in being done.

Dental labs have been in the spotlight due to the recent scare over lead apparently finding its way into dental restorations such as crowns and bridges. Dentists are realizing that they are ethically (and possibly legally) responsible for the quality of their dental lab’s work.

How much do you really know about dental labs?

The following information was provided by the National Association of Dental Labs (NADL). All numbers apply to the US.

$80 billion: Annual revenue generated by dentistry
$7 billion: Annual dental lab sales
12,000: Total number of dental laboratories
5,000: Number of those that are single-technician labs
48,000: Number of full and part-time dental technicians
11,000: Number of dental technicians predicted to leave the profession by 2014
68%: Percent of surveyed NADL labs outsourcing at least some work to domestic labs
5%: Percent of surveyed labs outsourcing overseas

There are a number of holes in the current system. Allow me to point out just a few…

Start at the beginning

Once upon a time, would-be dentists studied alongside would-be dental technicians. The two professions are inextricably connected, and each would do well to understand the needs of the other. How better to foster this relationship than by educating students together?

Today, however, that is certainly not the case. At most schools, dental students and lab students have little to no exposure to each other. The communication gap that begins in school tends to continue into the working world.

“Most dentists don’t meet a technician until after they graduate and that’s criminal. The pre-clinical students and dental laboratory technology students are able to learn from each other, which helps them hone the skills they have and build new ones.”
- Bob Schneider, DDS, University of Iowa Hospitals and Clinics Professor (Journal of Dental Technology, June/July 2006)

Bridge the communication gap

One of the biggest complaints dental lab technicians have about dentists is that they often don’t give the lab all the information they’re supposed to. A proper prescription for a dental prosthesis includes detailed information about the materials to be used in its construction. When the dentist doesn’t provide all the details, it’s up to the technician to make these important decisions.

“Most dentists rely on the dental technician to choose the materials needed for the fabrication of the prosthesis. With lack of adequate information, all too often the design, fabrication, and completion of the case is left up to the technician. Therefore, our results indicate an apparent trend to which technicians are left to make crucial decisions for dentists.”
- Z. Afsharzand, DMD et al. (from the Journal of Prosthodontics, Vol 15. No 2 March-April 2006 pgs 123-28)

Know your partners

One dentist will have been working with the mom-and-pop dental lab down the street for thirty years. Another will use a major domestic lab after personally visiting the premises. Another will prefer the US-based chain with the lowest prices. Another will go online to find a Chinese lab that offers crowns for $39.95.

The dentist’s relationship with his or her lab isn’t something the patient can see. It’s not even something most patients would think to ask about. But even if it’s invisible to the patient, it’s likely to be the factor that best predicts the quality of the dental work they receive.

Patients deserve disclosure

In the US, dentists are not required to tell patients if their dental prosthetic was manufactured outside of the country. In fact, dental labs are not always required to tell dentists where the device was manufactured. (And since many US labs use partners overseas, a domestic return address is no guarantee.)

However, expect the laws to start changing soon. A number of states are already considering legislation mandating that labs inform dentists and/or dentists inform patients of work fabricated outside of the country. In Canada, for example, patients must sign an informed consent form before receiving any foreign dental work.

Keep on working

It may be as long as year before the ADA announces the results of their testing. Perhaps it’s a big fuss over nothing; perhaps we’re all slowly dying of lead poisoning. I can’t predict what the science will say. But I can definitely predict this: you, the dentist, are going to be held responsible for your dental lab work. Here’s hoping you can be proud to stand by your restorations.

Post your comments about dental labs

Filed Under: Dental Editorials, Dental Safety, Practice Management Tagged With: dental labs, dentist, dentistry, dentists, lead

About Jim Du Molin

Jim Du Molin is a leading Internet marketing expert for dentists in North America. He has helped hundreds of doctors make more money in their practices using his proven Internet marketing techniques. +Jim Du Molin

CaliLab

I am a lab that outsources. The lab in China that we have has more certifications and quality controls systems in place than any lab I have ever worked for in the US, we’ve been there many times(china). They are both ISO and TUV certified.
I was a sales rep for a dental company a while back and visited/serviced hundreds of labs in the US, places I was scared to walk in for sanitary reasons with workpans on the shelves, someone was sending them work. With crowns from the US there is NO guarantee of quality or content, unfortunately. Stamped made in the USA means nothing in this industry. The biggest lab in the world, based in California, has secondary labs in Mexico and Costa Rica currently.

Anyhow, here is the official response a few weeks ago from the Center for Disease Control regarding lead in dental crowns. Amounts reported are extremely unlikely to cause adverse effects. Also, it states that even greater amounts would not be. http://www.ada.org/prof/advocacy/cdc_response_080417.pdf

-CL-
Patrick Tessier

Your kidding yourself if you think made in the USA equals quality & safety. Some of the worst labs in the world are right here in the USA. Remember the story in LA about the dental lab buying alloy melted down from car bumpers?

The only thing separating the scary labs from the best ones is conformance to international standards. ISO 13485 certification is absolutely the best and DAMAS is a least something. Zero labs in the US are ISO 13485 certified and only 16 are DAMAS certified. That leaves 13984 labs that are scary.

Some of the finest labs in the world are located in China and are ISO 13485 certified. Quality an Safety are not determined by borders. They are determined by conformance to international standards in manufacturing.

Dr. DuMolin, you should help you readers understand this. It would help them choose their lab based on documented evidence, not protectionist hype from the media.
http://n/a Mark Boles, CDT

Mark Boles, CDT, lab tech 33 years
Owner, Alternative Dental Lab, Marina, CA
C&B Zirconium and Titanium PFM’s

I stumbled on your blog researching the lead scare. Thank you for the information. It made me think about…

RE: The long standing “semi-precious” metal lab fraud

Alexander of Macedon upon meeting the ascetic philosopher Diogenes introduced himself, “I am Alexander the Great.”

To which the philosopher replied, “I am Diogenes the Cynic.”

Would anyone like to hear from an insider about a dental metal problem that makes the lead scare pale by seriousness and scope?

I ask this rhetorically first because the few times I have brought this up (6 times in 33 years) I have a near perfect record of incensing the dentists I have told.

Example (last time I tried 10 years ago):
I know a dentist socially who was being scammed by a lab I knew intimately (not me!). I mentioned the exposure to him and his patronizing reply was, “Mark, I am afraid you are becoming jaded. If what you say is true and this lab is doing this bad thing they would not be able to stay in business.” I quietly slunk back to by corner but thought that by this logic the Mafia would not be able to stay in business either.

Here I go again:

Many dentists are not aware that there are only 4 real dental alloy classifications:
Base
Noble
High noble
And now the new ADA class: Titanium

There is no such thing as the metal class called “semi-precious”. It is NEVER found in any mainstream dental metal catalog but if you call and ask for it you will be directed to something cheap that sounds rich. If you press for a definition you will get a lot of tap-dancing.

“Semi-precious” is a very convenient euphemism that the industry uses on the lab RX that appears to be noble or high noble but is anything they want it to be. If you ask the dental metal companies (and a lot of dentists) to define “semi-precious” the reply definition will be all over the place. I have heard high noble, noble, high palladium alloy, contains gold and many more. And my favorite by a dental metal company ad for labs, “Finally an alloy that you don’t have to cal non-precious.” I called them. After some hem-hawing they said that the metal was 2% gold and yes, it was predominantly base …”…but we don’t like to call it that.”

My lab does not list “semi-precious” as a choice on my lab RX. Our default gold alloy is high noble. I can’t tell you how many times dentists have challenged me on this on the premise that my competitor’s default “semi-precious” is much cheaper than mine and I need to get in line. When I remind them about the real metal categories it elicits irritation and one dentist even challenged me saying, “I know you are wrong because my dental school instructor used this term.” (semi-precious).
So “I quietly slunk back to by corner…”

Metal sales people tell me candidly that the difference between the high noble that they sell to labs and what is ultimately billed to patients/insurance is about 50%. Due to the fact that a patient would have to get their hands on a crown they wanted tested (unlikely), that the crown would have to be sent for gas spectrographic analysis (unlikely) and that the dentist would have to be shown to be knowingly low-balling the metal – “Oh, I thought semi-precious meant high noble…” (more unlikely…) we can see that up until now many hundreds of thousands of crowns have been misrepresented.

I have no problem with a base metal crown that is made under 10X and fits well, but what would the patient say if they (and their lawyer) knew the truth? And what will eventually happen when some hungry lawyer firm finally stumbles on this huge reservoir of potential prey? Will the example of the Ohio lead case start a review of the actual metal content you have been getting? And would a lab dare to swap a high noble metal dental I.D. sticker for a low or no gold alloy? Labs not being truthful….now I’m really getting jaded, huh!?

The dental labs I have witnessed over the many years have often been a very dark business, indeed. Until there is a major expose’ (and dare I suggest lab tech licensure) the storm clouds continue to gather. It is obvious that there is a significant amount of dentist complicity in this but I can’t help but believe there must be a number of Diogenes Dentists (unconditional honesty) that are not aware of the scam ….but I will tell you by long experience the truth is expensive! I wonder if the fact I work 75-80 hours a week could be related…nah!”

My lab is largely heading toward zirconium and we seem to be one of the few west coast labs that have mastered titanium pfms so perhaps there is hope for us yet! No gold metal… no temptation….and no expensive honesty.

Alexander the Great to Diogenes, “What can I do for you?”
Diogenes replied to Alexander the Great, “Get out of my sunshine.”

Wishing you all the sunshine you can handle, I thank you for your time. Or pay no attention to the man behind the curtain. This vent should be good for another 10 years…

Mark Boles, CDT, lab tech 33 years
Owner, Alternative Dental Lab, Marina, CA
C&B Zirconium and Titanium PFM’s
http://www.badteeth.net Thea Paul

Dear Mr. Boles,
Thank you so much for posting this. I recently had some crowns made. My dentist certified “high-noble” for payment. I suffered an allergic reaction. When I requested a copy of the lab prescription, I was told that it would not be released to me. Upon subpoena, I discovered that he wrote: “use precious or semi- whichever is less costly”! So, it’s very interesting to know that precious and semi-precious are not even classifications. Would you surmise that reference to the metals as precious and semi-precious indicate medical malpractice or a violation of dental standard?

There was room to mark high noble, but from his comments, I think it was clear that he wanted to increase his profit margin.

Thanks so much for your post. It was very helpful. As a way to help others, I have posted a very basic, informational website at http://www.badteeth.net.

Best regards,
Thea Paul
Josh

Hi All:
I wish to see a contact of a lab that does similar tests like ADA approval. I am am planning to make toothpaste in USA and want an ADA approval; but before I give my product to ADA for approval I wish to run a test outside first.

Please let me know.

Thanks
Josh
http://www.gigharborsmiles.com/ Gary

I trust my lab… I know them very well. All done in the USA!
Patti Depaola

Back in the day my porcelain crowns & bridgework were underlayed in gold. Later some more work was done I had silver underlaying because of cost. When I needed a “full” reconstruction I told my new dentist I wanted gold because I did not like the dark shadows that appeared around the gum. When my dentist was done part of my lower arch was still gold & the other dark. My dentist said he didn’t have to reconstruct the other side. My dentist also replied that he used high noble which was “gold.” When trying to ask more questions my dentist said, “Shut up!” I also ended up with TMD from that improperly positioned reconstruction. My dentist shrugged off an untreated abcessed molar for 2 years as bruxing. I’m not a bruxer. To save himself the cost of a cheap crown replacement he drilled completely thru the molar & filled it with metal amalgam. I ended up on life support with septic shock. My dentist also intentionaly filed down my teeth. He left me with a completely closed bite. I was left to look as tho I wore dentures but I did not have them in. My dentist laughed & called me “POOCH!”, “YOU LOOK LIKE YOU SHOULD HAVE A CORN COB PIPE GRAMMAW!” as he slapped the sides of my cheeks & jowls. Despicable! Why would a dentist want his patient to look grotesque? All my crowns were falling & my bridges were breaking off. All the so called high noble was black & my teeth were badly decayed. I had three abcesses. One molar was extracted with an abcess attached to its root. The oral surgeon stated he had never seen a reconstruction like this. He stated that either my teeth were improperly prepped or still decayed while the crowns & bridges were placed. I now have a dentist who works closely with the lab in the same building…NO THREE DAY TURNAROUND TIME. The lab is right there for you. I now have not only beautiful teeth but I have a beautiful smile. Today I am no longer suffering excruciating pain & ongoing fevers. That old dentist said he didnt do “ESTHETIC TEETH.” But he took my $30 thousand dollars anyway & today I’m very lucky to be alive. A great dental lab is like a magnificent sculptor of teeth. Why pay high cost chair time when many dentists say “I DONT DO ESTHETIC TEETH
Due to China’s past reputation I wouldn’t want my lab work or anything done in China.
But I do think it would no great loss to ship my old dentist off to China!
C. Mancini

My husband and I owned and operated a crown and bridge dental lab here in Florida for many years, we are now running a full service lab. We do not outsource, all work done in-house. The biggest problem we have is not with the metal issue (we don’t offer “semi-precious or precious”, but Noble and high-nobel for PFG’s), but the quality of the impressions we receive. Economy impression material, insufficient material used, quadrant trays (a lot of them more like pedo-trays), drags and voids in the impression, patient biting the trays, triple tray impressions, no study models, no pre-op models, several impressions for the same case. Always an excuse…”patient is a gagger”, “you choose the best impression, these are the best I could get”, poorly packed or non-existent cord, improper preps for the restoration requested, the list goes on. Try returning poor impressions…this does not go over well…dentists can go “down the street” to a substandard lab that will accept their work, and the quality lab suffers. We are looking for quality dentists..any takers?
Patti Depaola

To C. Mancini No one can believe what I lived through. To think dentist’s are saying they don’t do “ESTHETIC” teeth is idiotic. It’s the lab that creates esthetic teeth…beautiful teeth, beautiful smile. I don’t think anyone realizes it’s the lab not the dentist who creats a brand new beautiful smile.
Without the dental lab where would I be? The lab is the sculpture of teeth. Everyone wants perfect teeth & everyone’s whitening their teeth. Yet I found dentist’s telling me to “stain” some of my teeth to make them look more natural. My teeth are so natural that my dentist’s assistant had to inform my dentist otherwise.
Your’re absolutely right in looking for quality dentists. Here in Illinois quality dentists are also hard to find. Many are trying to earn a quick dollar sedating patients while they are unlicensed to have control substances.
Hang in there because patients like me are looking for great sculptures of teeth. Hopefully someday every state will allow patients to see a dental lab in their state instead of paying high cost chair time with a dentist who doesn’t do “esthetic teeth.”
Patti Depaola

To C. Mancini I just wanted to add while my dentist was trying to fix my failures he stated, “The lab said this wouldn’t work.” But “That’s good enough for her.” I was told by my dentist he was the best. But what I got was, “That’s good enough for her.” Looking thoothless left on life support to die of septic shock. My dentist also wrote letters & informed my medical doctor not to treat me as I was a hypochondriac. Since when does a dentist interfer with a doctor patient relationship? Also a patient of this dentist. My medical doctor’s dead but I’m luck to be alive.
Ray

I am a Lab owner in Cali. for the past 15 years , the sad truth is the person suffering the most is the patient. The prices that the doctor pays his or her lab is just a drop in the bucket less then 10% SO you do the math.
I have seen myself the work from China, it is not something I would let even my enemy have! Another problem is not only outsourcing. All the lab’s in Cali do not need to have any type of certification,so any one who thinks he is a technitian may open a lab with just a simple buss. licence.
Now this is not the Lab owners fault but the State! Why you ask? You see the ADA is so powerful and lobby’s to keep it that way ,so the more labs there are the better prices the Dentist get so who looses you!
http://www.611dentalstudio.com Mike

Shrugging off China is a mistake. I have owned a cosmetic dental lab in Southern California since 1995. There are many labs who either have already made the decision or are thinking seriously about developing a relationship with an international lab. As more and more dentists purchase technology and resources that reduce the need for dental lab services, the more and more labs will become desperate to replace their income. Competition is increasing and with that comes a reduction in dental lab prices. A reputable dental tech will tell you that the intrinsic value of a high noble crown is around $40-$60 dollars. That is just the hard cost of the alloy. Do the math for yourself- $1,100 for 1 oz of gold. Hi-Noble runs about $900 an oz. There are 20 pennyweight in an ounce. That is $45 per pennyweight. Hi-Noble is a heavier metal and the average crown will approach or exceed 1 pennyweight in weight 85% of the time. If you are working with noble alloy, the cost will come in around $20 per pennyweight. However, I am aware of some strange new noble alloys being peddled by the major metal suppliers. These new alloys contain Cobalt. The cost can get down around $10-$15 per pennyweight.

Back to China- the offshoring trend will surely continue. There are quality labs in China to be sure. In fact, the work I have seen is better than most US labs whose work I have seen. In the past 15 years I have interviewed and attempted to hire nearly 40 “experienced” dental technicians. I have hired three. The rest just can’t produce a quality, natural looking dental restoration. However, our test of China labs resulted in 9 unsatisfactory restorations, 3 satisfactory restorations and 4 very sellable crowns. In addition, I was recently at Lab Day Chicago and saw work from two different China labs (case work…not samples…so they say) and the work was not bad at all. Two of the labs claim they buy all their materials from the U.S.

To my fellow dental lab brothers- you can put your head in the sand and cry and moan about the state of the industry or you can get in front of all of theses changes. My average dental restoration price is more than $140. From July of 2009 to January of 2010 our lab experienced double digit month-over-month growth (7 months). Sales slipped in February from January and we are flat in March…so far. And all this while working in arguably the most competitive dental lab market in the country. I share this with you not to boast but to encourage you. You can grow without the need to sacrifice quality of work or materials.
Patti Depaola

I’m sick & tired of inferior & toxic product imported from China. China poisons our animals, feeds our food sources (like fish…why can’t we raise tilapia?) antibiotics, creates childrens toys from lead & makes our clothes with formaldehyde. I’m sick of buying cheap products from china. The TSA uniforms are unwearable & itchy because of the formaldehyde preventing wrinkles. China’s intentionally making us sick. Wake up America!!!
Imabigskycarver

What states allow patients to see dental labs for dentures?
http://www.ndpcorp.com soft-fit

YOUR PRESENTATION IS A TRIPLE EDGED SWORD!! WHO’S TO BLAME, THE DENTIST, THE LABORATORY TECHNOLOGIST, OR THE MATERIALS THAT ARE USED IN MANUFACTURING THE PROSTHESIS!!!! THERE IS SURELY ENOUGH TO GO AROUND FOR ALL!!!!!! I FEEL SORRY FOR THE POOR PATIENT. THEY DON’T KNOWN A DAMN THING ABOUT WHAT’S HAPPENING TO THEM!!! THEY MUST TRUST THE DENTIST!!! THEY KNOWN NOTHING ABOUT DENTAL LABORATORIES & MUCH LESS ABOUT THE MATERIALS THAT ARE GOING INTO THEIR MOUTH. THE DENTIST HAS TO BE THE FOCAL POINT. EVERYTHING STARTS WITH THE (EXPERTISE) OF THE DENTIST