CEREC: Myth or Magic?

Have you ever observed an illusionist perform an act where he or she uses a variety of movements, colors, lights, and smoke to confuse your senses in such a manner that you lose focus on what’s really happening? You are lured into believing what he or she wants you to perceive. Well, that’s exactly how I found myself after reading the article written by Dr. Chris Pescatore, DMD (October DE, page 110).

As a user of CEREC in my private practice for the majority of the past decade, I pride myself in understanding the benefits of successfully integrating this technology into the daily practice of dentistry. However, even I had difficulty following Dr. Pescatore’s train of thought. The vast assortment of opinions were spinning in so many different directions that it was dizzying. So, I would like to try and put things back on track if I may.

First, let me consider the issue of cost comparison. He stated that the initial cost of the machine could be offset within just 15 months using lab savings alone. What he failed to mention was that after that point in time, the lack of lab expenditures becomes pure profit.

Although the figure used by Dr. Pescatore may not be reasonable for every dentist, his opinions would suggest that CEREC dentists would realize a $7,000 per month reduction in lab overhead once their machines were paid off. Using his figures and deductive reasoning, that represents an increase in net profitability of $84,000 annually.

Secondly, there is no licensing fee per restoration as reported in his article when using the chairside CEREC system. There may be some confusion in his research here with regard to the CEREC In-Lab system. These are two completely different technologies. If I understand that the scope of his article was to compare the single-visit chairside system with a traditional laboratory-fabricated restoration, those figures have no validity in this discussion.

If we believe his figures regarding the cost of blocks and burs totaling a maximum proposed expense of $27 per restoration, I could use the newfound profits to purchase more than 3,000 CEREC porcelain blocks and still have $9,000 left over to buy burs and cover extraneous operational costs and maintenance. If I were to place an average of 50 restorations a month, it would take me five years to use up that CEREC stock pile.

Furthermore, we are led to believe that the only two costs associated with a traditional lab-fabricated crown are the lab fee and a $10 cost for final impression materials. What about the cost of materials for temporization? Usually, a preliminary impression of some sort would be needed to fabricate the temporary as well. All these materials require some sort of tray with adhesive for delivery. Retraction cords, bite registrations, and hemostatic agents are a typical part of traditional crown and bridge as well. And, of course, we always get a perfect impression on the first try, don’t we?

So, before Dr. Pescatore alleges that all things are not equal, he might want to more carefully consider the cost of traditional lab restorations. He might find that their costs far exceed the $27 I supposedly pay for each CEREC restoration.

Dentists also should consider the cost of their time when comparing CEREC to the lab-based process. The time taken to prepare the teeth is similar. In the same time it takes to make an impression and a bite registration for a traditional lab restoration, a CEREC optical impression can be made and a restoration designed. If we are to believe that the milling, polishing, porcelain preparation, and cementation process all take about 45 minutes as suggested, then this appointment would have lasted somewhere around 60 to 70 minutes. This supports the “hype” that CEREC restorations are more convenient for patients and efficient for dentists.

Since we are on the topic of cost-efficiency, I found the most glaring example of smoke and mirrors in the use of production-per-hour figures. If we are to believe that the average dentist desires an hourly production gross of $750 an hour, I would like the opportunity to apply this same math to the traditional laboratory restoration.

If a traditional crown requires up to 1.5 hours for the first appointment and a follow-up seating appointment of 30 minutes, this represents a total of two hours of chair time. Therefore, this crown would cost the patient in the neighborhood of $1,500. I don’t know many places in this country that can support a dentist who charges that kind of fee for a crown.

The most common rebuttal to this figure is the claim that the dentist would not be in the room for the entire two hours. An efficient dental office has well-trained dental auxiliary staff members who would perform many of the tasks required during the traditional crown procedure, allowing the dentist to move on to other operatories.

To quote Dr. Pescatore, “Of course, a dentist can pay an assistant to do the extra work. But this would involve significant training and monitoring for quality control.” He goes on to suggest that you may even have to hire extra staff, because the assistant is going to manage a portion of the CEREC procedure. Does anyone smell smoke?

The truth is that a CEREC dentist can also operate multiple operatories if he or she desires. The pesky milling time mentioned by Dr. Pescatore is often the perfect opportunity to complete hygiene examinations or begin a second procedure in another operatory.

And don’t forget - the CEREC acquisition unit is mobile, so it is not incomprehensible that a CEREC dentist can complete two restorations in a two-hour period. If we apply the $750 per hour figures quoted earlier, these restorations are half the cost of the lab crown example mentioned. This makes the CEREC dentist twice as competitive in the market Dr. Pescatore has created for us.

So, once the smoke clears, we can get down to the real issue: Can a CEREC restoration compete with the esthetic and functional quality of a lab-fabricated restoration? It is fairly obvious what Dr. Pescatore’s opinion is. And that’s just what it is - an opinion.

CEREC is one of - if not the most - researched dental technologies ever. The facts overwhelmingly confirm that CEREC is a sound restorative option. Marginal integrity, material consistency, and many other facets of this technology have withstood the most intense scrutiny during the past 20 years. There are few, if any, other technologies in dentistry which can boast such a track record.

Still, the opinion of some is that the public needs to be educated about the intricacies associated with the translucency, “natural-looking whiteness,” and color variations in enamel. In their view, the value of a restoration depends upon convincing the public that stained grooves are reality, and therefore preferred. Who are we kidding? For the American public today, reality is unacceptable. Tooth whitening is more popular than ever. Plastic surgery is commonplace. Even dentists have ventured into the arena of Botox injections and collagen lip enhancements. Why on earth are we still determined to force stained and characterized restorations on patients?

If realistic characterization is the final hurdle that CEREC must conquer, then I guess the CEREC dentist will just have to use a portion of that $84,000 increase in profit to reinvest in a porcelain oven, materials, and training in order to produce restorations that will impress other dentists.

Realistically, it takes very little time and effort to stain and glaze a restoration rather than just polish. And, many dentists already own porcelain ovens because the reality is that many lab-fabricated restorations call for modifications which require the dentist to either acquire the ability to do them in the office, or schedule the patient for another appointment.

A CEREC dentist with a simple understanding of staining and glazing techniques has the clear advantage in creating esthetic restorations, because he or she can make immediate comparisons and modifications to their work. After all, it is fairly complicated to communicate a clear picture of hue, value, and chroma, much less intricate characterizations, via lab slip. I know there are some nice cameras and photography techniques available to allow dentists to better communicate with their labs, but wouldn’t that require an additional investment which would have to be passed on to the patient in the form of an even higher fee?

I guess my chief concern is this: If a clinical lecturer who speaks on topics such as state-of-the-art esthetic procedures, techniques, and materials, and who is featured at an institute which boasts advanced dental studies can produce an article so devoid of factual content, it proves one thing - everyone is entitled to his or her opinion.

In my opinion, CEREC is a truly magical way of practicing dentistry.

Bradley W. Willis, DMD
Montgomery, Ala.

Seeing is believing

I was surprised and shocked to read Dr. Chris Pescatore’s article, “CEREC vs. the laboratory.” I have rarely seen an article with so much misinformation that I have to wonder if someone else wrote it and put Chris’s name on it. I know Chris and respect him, and this does not sound like him.

Nevertheless, I would like to address some statements to correct some ill-informed messages it portrays about CEREC. Dr. Pescatore said, “I expect dentists to become increasingly skeptical about CEREC’s advantages … and lower doctor costs.”

The fact is, dentists are becoming less skeptical about CEREC and its advantages. There is greater patient convenience, comparable quality, and lower doctor costs.

If national/international surveys were done on patients, if given the choice, do you think the vast majority of patients would prefer one appointment per procedure or two? I submit they would say one. I know mine do.

He states that in analyzing the financial aspects of CAD/CAM vs. traditional, “This answer ignores the impact different methods generally have on patient satisfaction.” Again, to the contrary, it addresses the impact that this new method has on satisfaction, and that satisfaction rating is very high. He further states, “The wear on milling burs costs about $2 per block.” I have often achieved up to 40 mills before having to change a bur - do you think I pay $80 per diamond?

Chris later states, “The esthetic and functional quality … affects customer satisfaction more than anything else.” He is absolutely right, but in the next sentence he says, “If patients believe a two-visit procedure will improve quality, they will likely sacrifice one-visit convenience.” That is so wrong! I have never met a patient in 41 years of practice who wants to spend more time in a dental chair.

He then states, “In terms of quality, a first-class lab surpasses even the most talented CEREC dentist.” I challenge Chris on this point, and suggest he speak to two of the most talented technicians in North America, Lee Culp and Nelson Rego, who have embraced CAD/CAM technology. They feel the majority of their work in the future will be done by CAD/CAM, adding their artistic talent to produce restorations superior to traditional methods. A dentist can match quality produced by many technicians, and the best technicians and the best dentists will always outperform the “average” with anything they do.

Click here to enlarge image

I refer Chris to a new book, “Highly Esthetic CEREC Restorations” by Dr. Richard Masek, if he wants to see excellence in CEREC restorations. I humbly submit an onlay I did for a dentist colleague recently that was done in one hour, 30 minutes from the time the patient sat in the chair. So I ask Chris - does this not represent excellence in dentistry? This restoration was not stained or glazed; no characterization placed anywhere - it was only polished. It was designed in three minutes using Lee Culp anatomy in the database (my favorite), milled for 10 minutes, 23 seconds; polished, conditioned, and bonded into place - with absolutely no sensitivity.

In summary, CEREC is a fantastic, exciting piece of technology; obviously not for everyone. But please learn all the facts before you criticize.

Ken A. Neuman, DMD (a CEREC user for four years)
Vancouver, BC, Canada

Mutual affection key to winning teams

I just finished reading Kirsten Brancheau’s Viewpoint about her disdain over “dental teams” (October DE, page 14). My first thought was that we are all very lucky - there are so many different types of offices that it should be possible for people to find the perfect office for them. And it sounds like she has - she’s been there for 10 years!

I think “team” describes what we have created here; it defines what we are trying to do. Yes, everyone has his or her position. But isn’t it nice to know that someone will back you up when the going gets tough? If one team member is busy, another will offer to help with a task or even complete it if needed. The possibilities are endless.

In our office, I think it is more often based on the affection they all have for each other. And we expect them to look out for each other. The loners either adapt or, eventually, leave. New hires quickly sense the culture; most are thrilled to be part of it. Why wouldn’t they be?

I do agree that dentists who want a team in name only are kidding themselves as well as everyone else in the practice. As for me, when things are humming, it’s always because of the team.

Steven H. Schwartz, DMD
Budd Lake, N.J.

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