Episode #310: Reshaping Dental Labs & Education, with Dr. Mike DiTolla

Labs will tell you that crowns take two weeks to make. But this isn't true — it could be made much quicker! And to teach you why you should start demanding three-day turnarounds, Kirk Behrendt brings in Dr. Mike DiTolla to explain the correlation between seating times and the need for adjustments. More adjustments mean loss of patient confidence, loss of time, and loss of opportunities. Don't just settle for “how it’s always been done”! To learn more about the benefits of a faster turnaround time, listen to Episode 310 of The Best Practices Show!

Main Takeaways:

• Seat crowns in three days instead of two weeks, and the need to adjust almost disappears.
• Dental school normalizes the two-week turnaround time — but it should be three days.
• Not many dental labs are willing to turn a crown around in three days. Start demanding it!
• Check your dental assistant’s crown work for over-polishing before dismissing the patient.
• Polish zirconia crowns instead of glazing them.

Quotes:

• “One thing that largely hasn't changed from when I graduated is the two-week turnaround time that a dentist takes from the time they prep a crown to where they seat a crown.” (14:07—14:17)
• “Going from waiting two weeks to cement a crown to three days is a game-changer. I mentioned earlier that I left and went to Sirona, where you can do same-day crowns. And that is an ideal that we should stretch for. But we’re still waiting for a really affordable value-based system that’s easy to use before most dentists dip their toe into making restorations chairside. But seating it the same day should certainly be our goal, at least for single-unit posterior crowns.” (15:17—15:47)
• “Every dentist knows that if a patient is away for six weeks, or eight weeks, or six months with a temporary on, when they come back to have that permanent crown be cemented, the chances of it fitting decreases as that time increases. And I'm here to tell younger dentists that the opposite is true, that when you start seating crowns after three days instead of two weeks, your need for adjustments almost disappears.” (15:47—16:11)
• “Most dental laboratories aren't willing to turn a crown around [in three days]. And they will actually tell you that it takes longer to fabricate a crown and make it, which just isn't true. You can make an E-MAX crown the same day. You can make a zirconia crown the same day. It needs to sinter overnight, but it’s ready on the second day. Really, what the problem is, the labs aren't hiring enough employees to be able to handle this workflow. And since dentists just have always said yes to two-week crowns, that's how it’s always been.” (16:14—16:44)
• “Any time we take a bur to a crown, even if you polish away all the scratches on the surface, there’re still tiny little microfractures under the surface that you can't see that connect over time and cause failure, and the crowns are less aesthetically pleasing. And any time a crown gets thinner, it’s more prone to break anyway, besides these microfractures that are in there. So, our goal should be not to have to touch any crowns. Our goal should be to drop a crown from a foot above the prep and it just sucks into place. And for that to happen, this three-day turnaround is really important. And there's just not that many labs willing to do this three-day turnaround, and we need to all implore our labs to do it.” (17:46—18:24)
• “Maybe we should all be heading to same-day dentistry. But that's $100,000 and a lot of training to learn how to design and make crowns. In the meantime, three-day crowns is a perfect stopgap. And it’s going to give you 90% of what you get from that same-day restoration.” (18:55—19:10)
• “It starts in dental school. In dental school, we don't even do most of our own lab work. It gets sent either to an outside laboratory or a central laboratory within the dental school. So, it might be two or three weeks till we see that. And we’re never taught in dental school, ‘Oh, by the way, this should be three days, but due to the constraints of a dental school, we can't get this done for three weeks.’ We just assume that’s the right way. In fact, there's no talk whatsoever, in my recollection, about why it is here.” (19:50—20:16)
• “You can Google it all day long and look for references, and you'll never see any research study showing that two weeks allows for the inflammation in the pulp to go down, or anything that happens good in two weeks. Nothing good happens while the temporary is on.” (20:17—20:33)
• “The best thing we could do is prep a crown and then immediately cement the crown in place, or like an hour later, with chairside CAD/CAM. So, anything we do besides that is a compromise. And the compromise just gets worse the longer that we let it go.” (20:44—20:58)
• “The issue is that our well-meaning dental assistants, especially if we don't reinforce this, they want to make sure the one part that they touch and have the final say over, in most practices it’s the temporary crown, and so a lot of dental assistants take a lot of pride in the temporary crown. But one thing they're going to do is make sure it’s insanely smooth so that it doesn't bother the patient’s tongue when they rub it up against there, or it’s not bothering their cheek or anything like that. And as a result, when they make the temporary crown, dental assistants with all the right intentions and with big hearts over-polish temporary crowns.” (20:58—21:31)
• “I noticed at Glidewell we had so many complaints about the bite was too high. I had to grind on the crown too much. And so, I started going down for the doctors who complained the most, and I would look at their cases as they went out on the FedEx trucks that day, and I checked their crowns. They were perfect on the models. And yet, the doctor would complain a week-and-a-half later that the bite was too high. And I began to realize my own assistant was [over-polishing temporary crowns] as well, because we don't reinforce the basics to them.” (21:54—22:23)
• “Follow Gordon and Rella Christensen’s recommendation . . . and that is, polish zirconia crowns instead of glazing them. So, all the crowns that you get from 38 Smiles, you get them back in three days if you send a digital impression. And the price is really good too. But also, it’s all polished zirconia. It’s not glazed, so you don't get that initial wear of the opposing tooth that you do with the glaze until the patient wears through that. I learned that from Gordon and Rella. Her SEMs have been showing that for years. But most labs won't polish zirconia crowns because it takes more time to polish in the occlusal surface. It’s way easier to spray some glaze on it and run it up in the oven while you do something else.” (25:55—26:35)
• “Frankly, dentists aren't asking for [three-day turnarounds], so there's no real reason for the labs to change. Labs didn't get Im.P.R.E.S. until dentists started asking for it. We launched Solid Zirconia, BruxZir, at Glidewell, and it wasn't until dentists started asking their labs for it that zirconia started being incorporated. So, dentists, you have a voice. You drive a lot of what the laboratory does way more so than you do with manufacturers.” (28:13—28:39)
• “The scary dentists are the ones with the 0% remake rate. If God were a dentist, he'd have a 2% remake rate, because you still can't control everything in the universe. And there’re dentists with 0% remake rates who send hundreds of units in a year to the lab, and you realize those are the dentists with no quality control filter.” (35:03—35:24)
• “For dentists who hate dentures like I do, or did — kind of still do — digital dentures represents a huge step forward. This is not just a marketing term. Digital occlusal splint, that's kind of a marketing term. But digital dentures are kind of the real deal, in the sense that from the very try-in, you're going to get something that fits way better than your old final dentures did. And so, not only is the fit going to be better, but you're going to know it right away, and you're going to be able to see. And that fit that you get initially when you try that in is going to follow you all the way to the finished product.” (41:46—42:19)

Snippets:

• Dr. DiTolla’s background. (03:28—07:25)
• The craziest thing that ever happened to Dr. DiTolla while speaking. (07:55—11:22)
• A brief rant on microaggressions toward the follicularly challenged. (11:22—12:56)
• Where we’re currently at in dentistry. (13:31—19:10)
• Reshaping how people think about the lab process. (19:49—30:55)
• What lab techs would really say. (31:40—35:29)
• The economic impact of a remake. (36:15—37:40)
• The future of lab processes. (38:17—42:47)
• The future of education, AcciDental Geniuses podcast, and future events. (43:43—48:06)
• @mikeditollaislosingit. (48:07—56:22)
• The trend with audio education. (57:20—1:04:17)
• Comedians he follows, and social media. (1:05:02—1:14:04)
• How his speaking career started, and mental health. (1:14:33—1:24:54)

Reach Out to Dr. DiTolla:

Dr. DiTolla’s Facebook: https://www.facebook.com/michael.ditolla

@mdt360

Dr. DiTolla’s new Instagram: @mikeditollaislosingit https://www.instagram.com/mikeditollaislosingit/

References:

38 Smiles Dental Lab: https://38smileslab.com/

Sebastian Maniscalco (comedian): https://sebastianlive.com/home/#tour

Neal Brennan (comedian): https://www.nealbrennan.com/

Anthony Jeselnik (comedian): https://www.anthonyjeselnik.com/

Kyle Dunnigan (comedian): https://www.kyledunnigancomedy.com/

Dr. Mike DiTolla Bio:

As a dentist who practices within the largest lab in the U.S., Dr. DiTolla has access to tens of thousands of doctors’ preps and impressions on a monthly basis. As a result, he has an intimate knowledge of the common habits of the dentists getting the best restorative results. As a self-proclaimed “average dentist,” he has developed techniques that provide exceptional restorative results with a very average set of hands. His mission is to share these techniques with dentists to help them improve their preps, impressions, and restorations. When dentists perform better restorative dentistry, they are happier, more profitable, and most importantly, the patient receives excellent restorative dentistry.

Dr. DiTolla graduated from the University of the Pacific School of Dentistry in 1988. He was awarded his Fellowship in the Academy of General Dentistry in 1995. He is a graduate of the Las Vegas Institute of Cosmetic Dentistry and is also a clinical evaluator for CRA. From 2001 – 2006, he was an Instructor for PAC-Live’s Live Patient Hands-On Veneer Course. In 2001, he became Director of Clinical Research and Education at Glidewell Labs.

While writing for several journals, Dr. DiTolla has a monthly column on restorative dentistry in Dental Economics and is a contributing editor for Contemporary Esthetics and Restorative Practice. Dr. DiTolla helped launch Chairside Magazine and is the Clinical Editor of this quarterly publication that frequently presents his own clinical case studies.

Referred to as one of dentistry’s most entertaining speakers, Dr. DiTolla’s blend of humor and entertainment keeps attendees awake and helps a day of education become much more pleasant. He uses live clinical videos in his presentations to reinforce the learning and increase retention of the techniques.