Dental technology is one of the core allied

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1 Transforming Dental Technology Education: Skills, Knowledge, and Curricular Reform Anita M. Bobich, BA, CDT; Betty L. Mitchell, BS, CDT, TE Abstract: Dental technology is one of the core allied dental health professions supporting the practice of dentistry. By definition, it is the art, science, and technologies that enable the design and fabrication of dental prostheses and/or corrective devices to restore natural teeth and supporting structures to fulfill a patient s physiological and esthetic needs. Dental technology educational programs are faced with serious challenges, including rapid changes in technology, inadequate funding for educational programs, and the need to develop curricula that reflect current industry needs. Better communications between dental technologists and practitioners are needed to gain greater recognition of the contribution that technologists make to patient health. Amid these challenges, the technology workforce is dedicated to providing patients with the best possible restorative dental prostheses. This article was written as part of the project Advancing Dental Education in the 21 st Century. Prof. Bobich is Assistant Professor and Program Administrator, Department of Restorative Dentistry, Division of Health Sciences, Pasadena City College; and Prof. Mitchell is Professor and Program Director, Dental Technology Program, Allied Health Department, Kirkwood Community College. Direct correspondence to Prof. Anita M. Bobich, Division of Health Sciences, Pasadena City College, 1570 East Colorado Blvd., Pasadena, CA 91106; ; ambobich@pasadena.edu. Keywords: dental technology, prosthetic or prostheses, restorative dental technology, dental laboratory, dental technician, allied dental education Submitted for publication 1/23/17; accepted 3/15/17 doi: /JDE Dental technology is one of the core allied dental health professions supporting the practice of dentistry. By definition, it is the art and science of fabricating corrective devices and replacements for natural teeth. This article uses the term dental laboratories to describe the organizations that provide the services, the term restorative dental technologists for dental laboratory staff who graduated from Commission on Dental Accreditation (CODA)-accredited programs, and the term dental technicians for dental laboratory staff who are trained on-the-job. This article focuses on the education of restorative dental technologists. There are five major dental laboratory services provided by restorative dental technologists: 1) fixed prostheses (ceramics and fixed partial dentures); 2) removable full and partial prostheses; 3) maxillofacial prostheses (obturator, ocular, and craniofacial); 4) orthodontics and auxiliaries services (orthodontics appliances, sleep apnea devices, and mouth guards); and 5) implant-borne fixed, removable, and maxillofacial prostheses. Fixed and removable prostheses are the dominant services and account for most dental laboratory revenues. Restorative dental technologists also provide support services for dental practices, such as pre-surgical stents for implants, radiographic stents, advice on materials, fabrication of complex provisional restorations, tooth shade verification, coordination of services for cases requiring multidisciplinary restorative expertise, and treatment planning consultations before, during, and after case completion. Their work is based on written prescriptions from dentists. Restorative dental technologists work in a dental laboratory with many dental materials, dental instruments, and sophisticated laboratory equipment, such as CAD/CAM scanning, design, and milling units and 3D generative or additive printing technologies. They have extensive knowledge of teeth and supporting tissues and must have good customer service skills. In their managerial role, restorative dental technologists supervise dental laboratory staff and ensure dental laboratory compliance with state and federal regulations. The goals of this article are to examine the dental laboratory industry; review trends in restorative dental technologist education programs; and make recommendations that will strengthen restorative dental technologists educational programs to best serve the dental laboratory industry and the practice of dentistry and, most importantly, meet the oral health needs of the American people in This article was written as part of the project Advancing Dental Education in the 21 st Century. September 2017 Supplement Journal of Dental Education es59

2 Dental Laboratory Industry Total national expenditures for dental laboratory services were $7.5 billion in Average sales revenues varied greatly among small ($351,000), medium ($1.6 million), and large companies ($6.4 million). In 2015, 6,584 laboratories had a payroll, meaning the owner employed one or more restorative dental technologists and dental technicians. Another 735 laboratories were single-person operations. These 2015 data represent a 17% decline (1,113 labs) since The number of owner-operated laboratories declined the most (91% to 81%). Some 81% of laboratories in 2015 were independently owned and operated. Another 7.2% were in dental offices; 6.5% were part of a conglomerate; 2% were in military or government facilities; 1% were in dental and dental technology schools; 0.8% were in hospitals/clinics; and 0.8% were part of a manufacturer enterprise. Whether a laboratory is independently owned and operated varies by laboratory size: small (83%), medium (89%), and large (60%) in On average, total restorative dental technologist and dental technician payrolls (salaries and benefits) in 2014 were $414,599, with a median of $175, The average laboratory had 18 full- and part-time employees. With a median of six employees, most laboratories had few employees. About 75% of laboratories provide crowns, bridges, and implants. 4 Some 55% provide full and partial dentures and digital dentistry CAD/CAM services. Some laboratories also provide services to other laboratories. Only 21% of laboratories are Table 1. Number of full- and part-time restorative dental technologists and dental technicians employed in dental laboratories, selected years from 2001 to 2014 Year Number , , , , , , , ,798 Source: National Association of Dental Laboratories. The changing world of the dental laboratory technician At: dentallabs.org/the-changing-world-of-the-dental-laboratorytechnician/. Accessed 10 Jan full-service operations. As a general rule, larger laboratories provide a broader mix of services. Certification Dental laboratories, restorative dental technologists, and dental technicians are certified by the National Board for Certification (NBC) in Dental Laboratory Technology. The NBC is an independent not-for-profit organization affiliated with the industry trade organization, the National Association of Dental Laboratories (NADL). The certification designations are Certified Dental Laboratory (CDL) for dental laboratories, Certified Dental Technologist (CDT, TE) for restorative dental technologists, and Certified Dental Technician (CDT) for dental technicians. 5 Some 33.2% of dental laboratories are NBC-certified. 6 Another 10.9% of laboratories are certified by other organizations. Certified restorative dental technologists and dental technicians are more likely to work in certified dental laboratories, have supervisory positions, and receive higher salaries. 5 Certification also applies to the subspecialties of dental technology, including crown and bridge, ceramics, complete dentures, partial dentures, and implants. CAD/CAM is not a subspecialty at this time but is incorporated into the exam process. 7 Only four states require restorative dental technologist or dental technician certification or continuing education, although many dentists assume that most states require certification Workforce The number of full- and part-time restorative dental technologists and dental technicians employed in laboratories declined from 47,063 to 44,569 from 2001 to 2015, but employment has been relatively stable since 2011 (Table 1). 3 There are multiple reasons for the decline: less demand (33.8%), automation (19.2%), offshore competition (15.2%), and other (4.3%) in In terms of education, in 2015, 61.1% of dental laboratory technical staff were restorative dental technologists who are educated in colleges (51.2%) or the armed services (9.9%). 2 Prior to becoming restorative dental technologists, 55.9% had some college education. Only 1.9% did not have a high school degree (high school graduation is now a requirement to enter a CODA-accredited program). Dental technicians constituted 36.5% of the dental technology technical workforce that year. es60 Journal of Dental Education Volume 81, Number 9 Supplement

3 Restorative dental technologist and dental technician compensation varies by certification, years of experience, region, and subspecialty. 1,4 For those just entering the profession, the average annual salary is $33,755 in For experienced restorative dental technologists and those with a CDT, TE (about 60% of the total), the average salary is $74,941. The estimated mean salary in 2015 was $40, Restorative Dental Technologist Education Trends CODA-accredited programs have declined in number in the past 25 years. As of July 2015, there were 17 accredited programs (Table 2), producing a total national graduating class of There were also 20 non-coda-accredited programs that largely provide dental technicians with training in specific laboratory skills. These programs have no accreditation standards, curricular review, or reporting requirements. For the restorative dental technologist class of 2012, 204 of 279 enrollees completed their programs. 13 This 26.8% attrition rate is within the national attrition average for two-year college programs for many disciplines. Of the 171 graduates in 2014, dental laboratories employed 118 approximately two years after graduation. These results need further investigation due to insufficient employment data at many colleges. The average first year in-district, out-of-district, and out-of-state student costs in CODA-accredited programs were $11,438, $14,422, and $23,7293, respectively, in These costs include tuition, instruments, textbooks, uniforms, and fees but not room and board. Since 2005, in-district student costs have increased 59%. Non-accredited program student fees are substantially higher, although specific figures are not available. Table 3 shows the time restorative dental technologist students spent in various subject areas (including mandatory advanced specialties) in CODA-accredited programs in These numbers do not reflect recently implemented changes in accreditation standards. The curriculum is a mix of didactic and laboratory courses with most time spent in laboratories. The total number of hours was 2,291.7; of those, 26.9% were didactic courses Table 2. Number of restorative dental technologist and dental technician programs by type of program, 2015 Type Number of Programs Public (CODA-accredited) 17 Private 1 Private state-related 0 For-profit 20 Total 38 Source: U.S. Department of Labor, Bureau of Labor Statistics. Occupational employment statistics: occupational employment and wages, May 2015 for dental laboratory technicians. At: Accessed 12 Jan Table 3. Average clock hours of instruction in accredited restorative dental technologist programs, Didactic Mean Laboratory Mean Subject Hours Hours Communications Mathematics Business Chemistry Physics Dental materials Tooth morphology Oral anatomy Occlusion Legal, ethics, history Bloodborne diseases Hazard control Lab techniques Complete dentures Removable partials Crown and bridge Ceramics Orthodontics Practical experience Specialties Total ,674.6 Source: American Dental Association, Health Policy Institute survey of dental laboratory technology education programs. Chicago: American Dental Association, focusing on science and fabrication processes. Many programs are adding CAD/CAM and 3-D Computer Generative technology courses. This introduction is a slow process since these courses require expensive equipment that is difficult to finance. The Foundation for Dental Laboratory Technology, an affiliate of NADL, provides annual competitive grants to schools, and some private and government grants are September 2017 Supplement Journal of Dental Education es61

4 available. The curriculum for private non-accredited dental technician programs is not available. In 2014, most faculty members (72.5%) in these programs had bachelor or associate degrees; 17.5% master s degrees; 0.8% doctoral degrees; and 4.2% dental degrees. 14 Most (55.3%) held the academic rank of instructor. About 60% were 50 years of age or older; female faculty members were considerably younger than their male counterparts. Level of knowledge and practical experience of faculty members with new advanced digital technologies is unknown. Restorative Dental Technologist Profession in 2040 Certain trends are reasonably clear, and restorative dental technologist educational programs will need to adapt to meet the needs of the industry. The two major trends that will determine the future of the dental laboratory workforce are improved oral health status and new technologies. Those and other factors will affect the future education and workforce prospects for restorative dental technologists. Trends in Oral Health and Technologies The oral health of the population is improving, especially for upper income groups that account for most prosthetic services. 15,16 Currently, the upper income 15 to 54 years age group averages less than one missing tooth per person. Even those above 45 years of age only average three missing teeth. Some unknown percentage of these missing teeth is the result of orthodontic care and does not need replacement. 15 In addition, the trend in replacing missing teeth is implants rather than fixed partial prostheses. 17 These oral health trends are certain to continue as post-fluoride and healthier cohorts become a larger percentage of dental practice patients. 17 While older lower income populations have more missing teeth, most do not have the resources to purchase prosthetic services in the private dental market. Thus, while there is a need for removable denture prosthetics among middle- and low-income Americans, this need will not be turned into demand unless public dental insurance programs (i.e., Medicaid) enroll a higher percentage of low-income adults, cover removable prosthetic services, and provide dentists adequate compensation for these services. 15 The political reality of a larger public investment in dental care for low-income adults is unknown. The bottom line is that the demand for dental laboratory services is likely to continue to decline, reducing the need for restorative dental technologists. In addition, the dental laboratory industry is undergoing a major transformation as digital technologies replace traditional methods for constructing dental prostheses. This is certain to continue as digital technologies increase in effectiveness and decline in price. According to presentations at the 2017 National Association of Dental Laboratories, Education Section Conference, this trend will lead to larger but fewer dental laboratories and will require a workforce that is experienced in these new technologies and with a solid background in dental anatomy, tooth morphology, physiology of mandibular movement, and oral and facial structures. 18 Restorative Dental Technologist Education It is beyond the scope of this article to project a detailed model of restorative dental technologist education in 2040, but the general direction is clear. The need for a well-educated restorative dental technologist workforce is apparent, and these professionals will play an important role in the future dental care system. As such, the current education system will have to undergo a major restructuring. Specifically, restorative dental technologists will require advanced education in the traditional dental sciences, digital technologies, and clinical dentistry. In all likelihood, there will be three types of restorative dental technologists qualified to design, fabricate, and troubleshoot dental prostheses: 1) restorative dental technologists with the scientific and experiential background to provide prostheses using digital and other advanced technologies; 2) restorative dental technologists who provide dental laboratory services primarily using traditional non-digital processes; and 3) restorative dental technologists who work directly in practice settings with dentists and patients, employed by practices or dental laboratories and assigned to practices. As solo dental practices continue to decline and large group dental practices grow, demand for this last type of restorative dental technologist is likely to increase. es62 Journal of Dental Education Volume 81, Number 9 Supplement

5 Restorative Dental Technologist Workforce While there will always be a demand for a welleducated dental laboratory workforce, a key issue is the number of restorative dental technologists that will be needed. If the oral health, utilization, and automation trends described in this article continue, the number of restorative dental technologists required is likely to decline. This is a serious problem, because only about 245 restorative dental technologists are currently graduating per year nationally from 17 CODAaccredited programs. 12 The key question is: can the current restorative dental technologist educational system continue with so few programs and students? There is no easy answer to this question. A significant decline in students will make it difficult for many programs to continue. Different options will need to be considered such as having only a few programs educate most restorative dental technologists, merging restorative dental technology education with some other dental or medical allied health profession program, or requiring all restorative dental technologists to have a four-year bachelor s degree that includes significant university education in digital manufacturing. The latter option needs special attention because a large percentage of current restorative dental technologists already have substantial pre-enrollment college experience. A related issue is differentiating restorative dental technologists from dental technicians. At present, there is significant overlap in their roles. The future of restorative dental technologists as a health profession depends on providing them with an education that cannot be learned on-the-job. With the rapid transition to digital prosthetic technologies, it is an ideal time to make this educational commitment. There may well be a need for dental technicians in the dental laboratory workforce, but we can foresee a time when they will no longer compete with restorative dental technologists. Strengths and Weaknesses of Current Restorative Dental Technologist Education Currently, restorative dental technologist education has both strengths and weaknesses. As we look to the future of this oral health profession, both the strengths and weaknesses can help determine steps needed to move the profession forward. Strengths The first strength is that graduates of CODAaccredited restorative dental technology programs are specialists in dental anatomy, tooth morphology, physiology of mandibular movement, oral and facial structures, dental materials, and prosthetic processes. Second, curricular design includes courses in six specialties/dental technology sub-disciplines. Third, educational programs are making a substantial effort to prepare students to use new digital technologies. 18 Fourth, there is considerable demand for certified restorative dental technologists. 5 Fifth, baccalaureate programs for restorative dental technologists have been started. 18,19 Weaknesses The first weakness is that currently there are only 17 CODA-approved programs and 245 graduates per year; furthermore, both the numbers of programs and students are declining. 12 Second, the marketplace does not clearly differentiate between restorative dental technologists and dental technicians in terms of their roles in dental laboratories. Third, most restorative dental technologist educational programs do not have and cannot afford the new digital technologies needed to prepare students for their roles in dental laboratories. Furthermore, fourth, the traditional two-year restorative dental technologist educational program may not provide enough time to prepare students to use the new digital technologies. Fifth, the percentage of current restorative dental technologist faculty members who are experienced in the use of new digital technologies used to manufacture prostheses is unknown. Sixth, most dental and restorative dental technologist educational programs are not coordinated, so graduates of both programs have inadequate experience working together. 20 Seventh, few restorative dental technologist educational programs provide graduates with experience working directly with dentists and patients. 20,21 Finally, it is our opinion that non-coda-accredited programs should either obtain CODA accreditation or close. Conclusion Restorative dental technologist educational programs are at the brink of growth and development September 2017 Supplement Journal of Dental Education es63

6 or decline. The profession is challenged with many obstacles related to rapid changes in core technologies, a decline in the demand for dental prosthetic services, a curriculum that does not adequately reflect current industry needs, and an aging faculty that may not be experienced with new digital technologies. The future of the restorative dental technologist profession requires better communication between technologists and dental practitioners, and the dental profession and general public need to give greater recognition to the importance of restorative dental technologists for the effective and efficient practice of dentistry. Despite these challenges, it is encouraging to see the commitment that restorative dental technologists have to their work. Their dedication to providing patients with the best possible restorative dental prostheses that will become a permanent part of their orofacial structures and affect their short- and long-term health is significant. Not only does the profession of dentistry benefit from this dedication, but, more importantly, so do dental patients. Editor s Disclosure This article is published in an online-only supplement to the Journal of Dental Education as part of a special project that was conducted independently of the American Dental Education Association (ADEA). Manuscripts for this supplement were reviewed by the project s directors and the coordinators of the project s sections and were assessed for general content and formatting by the editorial staff. Any opinions expressed are those of the authors and do not necessarily represent the Journal of Dental Education or ADEA. REFERENCES 1. National Association of Dental Laboratories business survey: report of findings. Tallahassee, FL: Valmont Research, National Association of Dental Laboratories trends on business survey. Ventura, CA: Valmont Research, National Association of Dental Laboratories. 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