Interview with Gary Iocco, President,
National Association of Dental Laboratories
By: Michael W Davis, DDS
Dr. Michael W. Davis maintains a private general practice in Santa Fe, NM. He chairs the Santa Fe District Dental Society Peer-Review Committee. Dr. Davis is active in dental care for disadvantaged citizens. His publications are on ethical issues within the dental profession, as well as numbers of clinical research papers.
Gary Iocco is the current president of the National Association of Dental Laboratories (NADL). The NADL promotes the highest standards in the dental laboratory industry through education of its members, advancing technology, raising standards, and serving the public interest. Communication with dentists and the public is also an important role of the NADL.
NADL Website http://www.nadl.org/home-page.cfm
National Board of Certification in Dental Laboratory Technology http:///www.nbccert.org
The Foundation for Dental Laboratory Technology http://www.dentallabfoundation.org
NADL What’s in Your Mouth http://www.whatsinyourmouth.us
Dr. Davis: Many in the general public may not know the vital role of the dental technician, within the dental team. From my perspective as a restorative dentist, a dental technician can make me look like a superstar, or a nitwit. What exactly does a dental technician do, and why is that so critical in successful clinical results for patients?
Mr. Iocco: As dental laboratory technology professionals we transform the dentist’s directions from the prescription or work order and create the actual treatment option that the dentist has chosen to provide their patient. Quality dental laboratory professionals employ knowledge of modern materials and available technologies to provide our dentist clients with a restoration that is consistent with the high standard of care and esthetics that our dentists expect to provide for their patients.
This is only possible if there is sufficient communication and understanding and a mutual knowledge of and commitment to what is required for a quality outcome.
While good communication is always important, the more complex or involved a case is the earlier in the planning process a dentist should bring their dental laboratory technology professional into the conversation.
Highly skilled and experienced dentists will tell you that to provide the standard of care and esthetics that they seek for their patients restorations, they work closely with a quality dental laboratory.
Dr. Davis: European nations have adopted numbers of regulatory oversight mechanisms for the dental technology industry, all to serve the public interest. In the USA, only four states even require registration of dental laboratories. Few require doctors or patients be advised of the country of origin, of fabricated dental prosthetics (crowns, bridges, dentures, etc.). What regulatory changes would the NADL like to see, to better protect and serve doctors and patients?
Mr. Iocco: NADL actively supports and works for the implementation of the ADA current policies on dental laboratories. NADL’s regulatory goals are the implementation at the state level of the ADA policies on:
- Disclosure to the dentist of materials and point of origin;
- Education of dental laboratory technicians; and,
- Registration of dental laboratories with the state board of dentistry.
Many recognize the importance of well trained technicians and requiring dental laboratories to disclose to the dentist the point-of-origin and the material content of patient contact materials used in dental restorations as dentists need this information to protect the safety of their patients.
However, unless disclosure is coupled with a registration requirement, disclosure requirements ring hollow as there is no formal record of a dental laboratory’s address or even the name of whom a letter should be addressed to. In states without registration, even if they are found out, those that would misrepresent or provide false disclosure information are only risking the loss of a single customer.
When dental laboratories are required to register with the State Board of Dentistry any bad actors would be at risk to lose their registration and with it their ability to do dental laboratory work for any dentist in the entire state. The resulting increased accountability and compliance will help to ensure that dentists receive the information they need to continue providing the highest standard of care and safety for their patients.
NADL’s pursuit of basic minimum standards for dental laboratories at the state level is consistent with many years of ADA policy. It may surprise some to find that dental laboratory association efforts to secure the state dental society support to implement ADA policy has not seen swifter progress. However, for organizations often accustomed to governing through consensus, any dissent such as dental board staff resistance to taking on additional responsibility can often land a proposal on the back burner.
For example, both the California Dental Association and the Virginia Dental Association have passed broadly supported formal resolutions through their House of Delegates calling for laboratory registration and disclosure to the dentist of materials content and point of origin. Unfortunately, the California Dental Association, despite working on the issue since 2008 and passing a resolution in 2011, was unable to achieve consensus with the State Board of Dentistry and has yet to move forward with a bill to implement their resolution and establish disclosure requirements and registration of dental laboratories with the state dental board.
Similarly, in Virginia, despite the outstanding leadership of two very engaged and articulate dentists, one of whom served as Chair of the Task Force, the Virginia Dental Association bill stalled when the Staff at the Virginia Board of Dentistry balked at assuming any jurisdiction over dental laboratories.
Even with the addition of my state, Minnesota, there are only 7 states that require basic dental laboratory registration and disclosure. However, much more and faster progress is necessary.
Recognizing this growing need, the ADA Council on Dental Practice (CDP) and the ADA House of Delegates took action and adopted Resolution 52RC specifically urging all state dental boards to register dental laboratories at the 2013 ADA annual meeting. Perhaps ADA Resolution 52 will spark renewed focus in California and Virginia and will generate some momentum in other state dental societies to take action to establish basic minimum laboratory standards in their respective states.
This will not occur unless the leaders of the state dental societies make establishing basic dental laboratory standards on disclosure, education and registration a priority.
I find it difficult to understand why some are against registration, material content and country of origin disclosure.
Dr. Davis: Today, approximately 40% of all dental prosthetics delivered to the US public originates from offshore laboratories (generally the far East). We know verified stories of one corporate dental chain, which had lead in dental crowns, which were fabricated in China. http://www.drbicuspid.com/index.aspx?sec=sup&sub=pmt&pag=dis&ItemID=301262
We have also have reports of radioactive materials originating from offshore dental labs, as well dental prosthetics contaminated with fecal bacteria. Rarely are US patients advised of the nation of origin. Doctors may also be in the dark, if their US dental laboratory jobs out work overseas, like a clearinghouse. If the doctor is employed by a corporate dental chain, they may have limited or no option in laboratory selection for their patients. What are the potential risks to doctors and patients, as you see them? What specifically should be done for full disclosure, to benefit doctors and patients?
Mr. Iocco: The good news is that the vast majority of work both foreign and domestic is safe. Further, in many instances, foreign dental laboratories are using FDA registered dental materials.
However, we have also had some troubling reports. Earlier this year, NADL received documented reports of zirconia powder from China containing high levels of Chromium and shockingly 4 times the level of lead that was found in the 2008 Ohio lead in crown cases.
These cases while rare illustrate how critical it is that dentists receive the most accurate information about the materials that they are using in order to protect the continued health and safety of their patients. These cases also highlight the need for requiring dental laboratories to provide dentists with written material content and point of origin disclosures coupled with requiring dental laboratories to register with the state dental board for greater compliance and accountability.
To help dentists and consumers, NADL offers an online resource at www.whatsinyourmouth.us which provides access to a number of topics on dental material safety, standards in dental laboratory technology and regulatory requirements.
Dr. Davis: During my 35 years in dentistry, I have noted a serious decline in training facilities for dental technicians, closures of numbers of labs, and layoffs in the industry. Jobs for dental technicians, like many American jobs, seem to be going away. Why is it important to the dental profession and the American public, to maintain a viable and healthy dental laboratory industry, within our nation?
Mr. Iocco: Restorative dentistry is a very important part of most dental practices, with on average 65% of practice revenue coming in from that facet of patient services. More experienced dentists tell us that that at one time there was greater emphasis on dental laboratory technology in dental schools to the extent that a dental student even learned how to wax a crown. However, the current curricular requirements do not typically include any minimum required number of clock hours be spent on actual dental laboratory technology. CODA Standards state that students be generally competent in communicating and managing dental laboratory procedures, however, there is no actual requirement for dental students to receive a minimum number of hours of instruction in dental laboratory technology in dental school.
Consequently new graduates over the last decade and more recent graduates must rely more on the dental laboratory technology professionals at the dental laboratory that they work with to gain sufficient technical understanding of materials and DLT techniques in order to provide effective supervision. This makes it all the more vital that we have well trained dental laboratory technology professionals if dentists are to maintain their current high standard of care that is the hallmark of American restorative dentistry.
More than one very knowledgeable and experienced dentist has told me that a viable and thriving practice of restorative dentistry in this country cannot exist without the availability of well-trained highly-skilled dental laboratory technology professionals and a robust domestic dental laboratory industry.
Dr. Davis: Mr. Iocco, what direction do you see the US dental laboratory industry taking, into the future? What positive changes are on the horizon?
Mr. Iocco: The three biggest developments that we have seen in the domestic dental laboratory industry over the last five years are; a frenzy of low priced foreign competition, the emergence of many new technologies and techniques, and a substantial consolidation in the number of dental laboratories and formal dental laboratory technology education programs.*
As the industry works to adapt we are seeing continued consolidation in the number of domestic dental laboratories but at a slower rate. Foreign competition has swelled to consume a very significant piece of the market but seems for the moment to have leveled. Those domestic laboratories that are able to, continue to invest in new equipment and implement new technologies and techniques to improve efficiency. Those that can’t, continue to contribute to the consolidation.
However some progress has been made and there are some positive changes on the horizon. The ADA has taken some significant steps with the recent passage of Resolution 52 and its support of other important issues and their policies on dental laboratory technology. Numerous dental colleges and societies now understand the critical state of the domestic dental laboratory industry and recognize the need to foster a robust domestic dental laboratory profession for the future of restorative dentistry.
There are some promising demographics on the horizon and if for dental practices and the quality dental laboratories that are able to survive the recent economic and competitive challenges the future outlook can be very positive.
The NADL leadership is committed to doing everything in our power to ensure a robust domestic dental laboratory industry for the future. However, the profession of dentistry is regulated at the state level through the state dental boards. Accordingly, much of this rests in the hands of the leaders of the state dental societies and their willingness to lead and take the action necessary to establish basic standards for dental laboratories today, for the viability of a bright future for restorative dentistry tomorrow.
*The number of domestic dental laboratories has gone from 13,000 in 2009 down to about 9,000 in 2013.
Currently there are only 19 accredited dental laboratory technology education programs.
Communication between doctors and lab technicians is too often problematic. Doctors too often don’t take the time or effort. This interview is a very positive step in that direction.
The valuable role played by dental technicians needs better understanding, from the dental profession and general public. If we can assist the dental laboratory industry, we all will be better served.
Mr. Iocco: We are grateful for this opportunity. Our fates are tied and we must continue to work together.
The US has the finest dentists in the world. However, change is all around us and dentistry and dental laboratory technology professionals are facing an increasingly dynamic environment. It is incumbent upon individual dentists and the leaders of organized dentistry at the national and state level to respond timely and effectively or events such as the corporatization of dentistry and the reduction in the availability of well-trained dental laboratory technology professionals will overtake the dental profession and those of us who serve dentists in less than optimal ways.
I am not suggesting gloom and doom. We are seeing the early signs of some very positive developments. We continue to be inspired by the intellect, dedication and passion displayed by individual dentists and many of the leaders of organized dentistry. However, gone are the days when an issue can be mulled over for a few years, a resolution passed a couple of years later and implemented at the state dental board level a few more years later still, if at all.
The forces of change are moving quickly and the individuals and entities driving these changes are nimble and quick to adapt. There are several already adopted current ADA policies that will make a real difference if they are implemented at the state level. State implementation will only happen if state dental societies make it a priority. If we fail to seize this moment and take too much time to act, we may find that the changes have already occurred and the opportunity to shape them in a way that is best for those served by our respective professions is lost. We must act now.