The Value of Making Oral Appliance Labs Part of Your Team by Steve Marinkovich, DDS

The value of a good working relationship with your dental lab cannot be overestimated. Long before I started treating Dental Sleep Medicine patients, I became aware that a lab could make or break a dental practice. In the past for me, it was crowns, bridges, night guards and removable prosthetics. Now it’s Oral Appliances for Sleep Apnea and Snoring. However, what I learned in those earlier years serves me well now.
Let’s start with the size and location of the lab. I was never one to use large or distant labs in those days. I always liked to keep it local and small. My intent was to have as much control over the final product as possible without going to the time and expense of having an in house lab. I physically spent much time at the lab, not to mention almost daily phone contact. However, once I converted to Sleep Appliances, that type of interaction was not possible in my community.
It became necessary to change my approach and find a lab out of the area. I could no longer run down the street and have face to face contact with my lab person. I felt that the company that designed a particular appliance would be the best place to have it made. First, I decided which appliance I wanted to use, and then found who would do the best job making it. I’ve discovered that many labs have the expertise to perform quality work on several different Oral Appliance designs.
I had to develop new ways to communicate, but in this day and age that was not a big problem. I still wanted, however, to build relationships with the lab techs that were directly associated with fabricating my appliances. Many of the larger labs had local reps and they could introduce me, over the phone, to the actual techs that were responsible for my cases. When that was not possible, the alternative was to speak to supervisors who had direct contact with the lab techs. This was not what I was used to, but I could make this work. Many of these lab techs are, in fact, very knowledgeable because they have worked with dentists who have made many more appliances than I have.
I have always sought out techs that were not only experienced, but easy to communicate with, and accessible. When either of those two factors were not working out, and did not seem rectifiable, I would find a new lab. Incidentally, if you are just getting started, ask other more experienced dentists who they would recommend.
In terms of communication, I have even gone to the extent of drawing detailed diagrams of exactly how I want ball clasps placed in the appliances for added retention. I look for labs that are consistent and reliable in quality. Also, having appliances delivered on time is vitally important. You cannot have your patient show up for a delivery and the Oral Appliance not be on hand.
More than once, I have found that labs that are doing well for a while by all my criteria, would deteriorate over time. This becomes particularly frustrating but must be considered part of an ongoing process of continued open communication. My theory is that labs decline periodically because they have trouble estimating how many OAs will come in at any given time. Plus, more dentists are beginning to treat Sleep Apnea. Thus, labs get overwhelmed and the quality can suffer. They hire/train techs, but underestimate the learning curve involved in making a good Oral Appliance.
It is my thought that a lab will try much harder in the early working relationship and this will sometimes decrease over time. More than once I have worked with a lab, moved on to another lab, and then gone back to the first. This is, of course, not the best business model but it must be considered as a possibility. Techs in larger labs change over time and thus so does the quality. To help them help us, we must always strive to be consistent from our end as well.
For better dealing with lab techs and companies, find those that are willing to have constructive conversations. That said, I must be able to take constructive criticism myself, and this can be very difficult for dentists to do. It’s called TEAMWORK and it’s the only way for a relationship to survive.
There are other responsibilities on the part of the dental office. First, and foremost, is providing the lab with excellent study models (impressions scanned or not). I prefer to take standard impressions and pour the models myself at my office. How to accomplish this is fodder for another column, but suffice it to say you have NO leeway in this responsibility.
For most appliances, you will also be providing an accurate bite registration, which provides the lab a starting position for the Oral Appliance. This needs to be accompanied by clear, concise instructions which often need to go beyond just checking off some boxes on the standard Rx forms. Take no shortcuts here. You must have the ability to explain precisely what you expect.
It would be nice to think that the lab keeps a log of your likes and dislikes, and hopefully many do. Do not assume that this is universally true. Take the particular lab slip for each lab, add your specific preferences to it. Then make copies, and use those with each case. That way you do not need to keep writing the same added instructions on each Rx.
For me, these added notes include: Do not place ball clasps between last two teeth in the arch (more chance of opening contacts), advice on particular starting position with the advancement mechanism (i.e. start at 0.5 mm advancement, which leaves the possibility of backing up the OA slightly if necessary), wrap the distal of the last tooth in the arch when impression permits and cover at least the mesial marginal ridge of the third molars, if erupted.
Many times I will add additional notes when I deem it necessary. Another example would be on cases where, for one reason (short, unretentive teeth) or another, I think retention will be an issue. With those cases, I suggest a way to handle the situation, or ask them to call me to discuss options.
To some degree, it helps to learn what obstacles the labs face with regard to materials and procedures. Do not expect the lab to get it right every time, and be willing to admit when the problem originates at your dental office.
Don’t get everything right up to mailing the case and then do a poor job of packing the models (for non-scanned cases). That creates the chance that they will arrive at the lab damaged.
Always leave the door open for timely contact and conversation. This starts with interviewing the lab with which you hope to work. If you get bad vibes early on, or they don’t even have time for conversation, it’s best to keep looking.
While writing this article, I interviewed a long time lab tech with a large US lab to get his perspective on where he thought things tend to go wrong. Here is a synopsis of that conversation.

  1. Not enough information or correct information on the Rx form. Apparently, labs for Sleep OAs have been required to become medical device companies and thus must consider the prescription gospel. They cannot proceed unless everything is filled out: doctor’s name, patient’s name, device type and retention type. He said that more cases are held up for this reason, than any other.Be sure to make your instructions legible. Labs are sometimes reluctant to call to tell you they can’t read what you wrote. Plus, it just adds more time to the procedure for no real reason.
  2. Insufficient models/impressions/bites. He said many cases are stopped for poor model work, bite registrations with no verticals, no coverage of posterior teeth, rocking or deviated bites. Also, requests like, “make it work”, “open up or close the bite a little”, drive them crazy.
    This reminds me of a story from my general dentistry days when my lab tech was sent a die only and was asked to remake a crown on it. Problem: There was no impression of the approximating teeth or opposing occlusion. When the tech questioned the dentist, he said “JUST REMAKE IT! You lab guys always want to work under ideal conditions!” Seriously. That really happened.
  3. Lack of communication. Please tell the lab which is the best way to communicate with your office (email, phone, etc.) and to whom they should talk. Let them know the best time to call. Don’t just tell them what is going wrong, but also what is going right.
    I personally like labs that send questionnaires along with the cases, as long as they actually read them when I send them back. In fact, I am surprised more labs do not do this. I had a lab, in my crown and bridge days, that sent the questionnaires with their cases, and coincidentally, they were one of the best labs I ever used. Could there be a connection?

Final thoughts

Labs would agree, we are all in this together. We both want the same thing, which is to provide the best service to our patients. It is not always easy, but keeping the door open to great communication is the key. In the end, there is no use in creating a contentious relationship.
There are many dentists, and there are many labs. Finding and maintaining a good working relationship takes time. Unless the door actually closes, always (that’s always) strive for frequent contact and constructive conversation. Try not to burn bridges, because at some point you may need to come together again.
Remember, we need to all work on this very difficult healthcare problem together and our patients will all benefit. If we accomplish this, we will have a win-win-win situation.

Dr. Steve Marinkovich has been in private practice in Tacoma, WA since graduating from the University of Washington Dental School in 1976. He has spent more than 20 years as part time faculty in the Restorative Dental Department of that school. He holds fellowships in both the American and International Colleges. He also served on the Washington State Board of Dental Examiners for six years. He has practiced Dental Sleep Medicine for over twenty years and has restricted his practice to that discipline for the last three plus years. He is a Diplomate of the American Board of Dental Sleep Medicine, and his clinic is accredited by the American Academy of Dental Sleep Medicine.

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