Implants--Nine steps to profitability with implant prosthetics

May 1, 2003
Training in dental schools typically offers little in the areas of case cost analysis and case presentation. The clinical and technical aspects of fixed and removable procedures require years of education

Samuel M. Strong, DDS

Training in dental schools typically offers little in the areas of case cost analysis and case presentation. The clinical and technical aspects of fixed and removable procedures require years of education to become proficient and competent and are offered in professional education centers.

However, we often find that clinicians graduate and practice without an organized business model for determining how to profitably run their restorative-based practices. Dental insurance UCR tables are too frequently used as a reference point or basis for establishing fees, but these figures can be flawed by being seriously out of date.

UCR rates are established statistically by insurance companies. There is no consideration given to the actual fixed and variable costs incurred by dentists in widely-divergent geographical locations with widely varying overhead costs (i.e., staff salaries, capital investments). Therefore, although they can be used as a common reference source, these UCR figures provide a poor basis for developing a profit structure that will allow the practice to grow and thrive.

The field of restorative-implant therapy adds another layer of laboratory and hardware (implant components and tooling) to the above considerations. The dentist finds that he or she is dealing with total case costs that far exceed the routine costs from natural tooth-born crown and bridge or conventional removable procedures.

An accurate preoperative determination of the cost of an implant case is essential in order to offer this exciting modality to patients while making a reasonable profit. To bring some organization to this field of financial considerations, the clinician should consider the following nine essential elements associated with implant profitability.

1. Systemize your analysis of case costs.

The restorative dentist must analyze each implant case before the surgical phase has begun. If you work in conjunction with a surgical dentist, it is incumbent for you to jointly plan the case so that you can accurately assess all potential costs. Failure to assume this responsibility increases the risk of not being able to carry through the restorative plan as anticipated.

The restorative dentist should determine the three primary areas of case costs with any variables or ranges that could be incurred:

A. Laboratory costs

B. Implant-components costs (Impression posts, analogs, abutments, etc.)

C. Overhead costs — All costs to the office incurred while the dentist is actively involved with completion of the case.

Determining the overhead costs associated with a particular implant case can be an intimidating process, especially if the clinician has never done this type of case before. However, the overhead estimate can be computed by first listing all of the appointments needed to complete the case. Next, estimate the total clinical time (chairside and dental office lab time) needed to complete each appointment. Then multiply this total clinical time (in hours) by your personal hourly overhead to gain the overhead cost figure.

For example, consider all of the activities you would do performing a transfer impression on a bar overdenture case using six maxillary implants.

Even if you have never done these procedures, the line-item display gives you the ability to estimate the time required. On the unlikely side, could you complete these procedures in 30 minutes? Probably not! How about one hour? Maybe, depending on your individual speed and expertise. How about 1.5 to 2 hours? The latter is probably more realistic, especially for the less- experienced clinician or if the patient presents with conditions that can be expected to add more time to your usual estimate.

By examining the activities involved with each appointment, you can develop at least a ballpark estimate of the time required for completion and then develop an overhead cost estimate. Because many dentists are willing to share their experience with others, discussing the case with a mentor is an excellent way to compare your case-cost estimate with someone who has already done the procedure.

2. Establish a true interdisciplinary treatment-planning protocol with your surgical dentist.

This can be accomplished either by meeting with the surgical dentist or by phone. The key element here is a review by both clinicians of the patient's mounted diagnostic casts, radiographs (Panoramic, FMX, and/or tomographic), photos, health history, chart notes, and any other pertinent diagnostic information. Much of this critical preoperative information is supplied by the restorative dentist from a diagnostic workup procedure.

The ideal and alternative treatment plans can be developed at this meeting. Pertinent subjects of discussion include whether the case will be fixed or removable, screw- or cement-retained, number of implants, width and length of each implant, bone-grafting requirements, anticipated treatment time, provisionalization needs, consideration of any obstacles to success (such as tobacco usage, diabetes, severe bruxism, etc.), and overall case prognosis.

3. Establish an interdisciplinary treatment-planning protocol with your laboratory technician.

Send the mounted casts and other workup information, along with your preliminary case plans, to the dental laboratory you expect to use for the case.

Include details such as whether the case is to be fixed or removable, implant types, numbers of implants to be placed with anticipated width and length of each, ridge-augmentation procedures, photos, and any other relevant data. Because the laboratories are exposed to many more implant cases than most individual clinicians, they are well-positioned to verify or suggest alternatives to the treatment plan. The lab can produce an estimate for its expenses for any treatment option, including the purchase of implant hardware from the manufacturer. Without this lab and component estimate, the restorative dentist is truly working in the dark when contemplating the case cost.

Successful dental laboratories are very efficient operations. They usually rely on profit margins that are thinner than the average dental practice. Accordingly, they cannot tolerate inefficiency or failure. Labs tend to develop their own biases toward particular implant and impression systems, types of abutments, attachments, and other technical aspects that produce the most predictable results. We, as clinicians, should heed the advice of seasoned, proficient technicians to reduce the length of our own learning curve with implant products and procedures.

4. Plan for contingencies.

As with most dental procedures, contingencies or possible complications may have to be resolved. In some cases, frameworks will not fit completely or passively require a section and solder or laser-weld correction. Additional appointments to produce shade modifications to porcelain in fixed cases or changes to the denture tooth setup in removable cases may add to the number of appointments needed for case completion. This adds to overhead costs and, in some cases, lab expenses. Uncertainty about the final sites and angulations of implants, inter-arch space, and position of the implants relative to the gingival crest can influence our decision to cement or retain the prosthesis with a screw. Because these are factors affecting case costs, we may need to develop our analysis based on a "least estimated" and "greatest estimated" case-cost basis.

Other factors such as an inability to open the mouth normally (resulting from myofacial dysfunction, arthritic conditions, or scleroderma, among others) can hamper the clinician's ability to complete procedures in a standard time format. You may need to allocate additional chairtime for this case which increases overhead costs. The patient's cooperation — or lack of it — should also be a part of the equation in estimating how long each procedure will require.

5. Determine your fee

The total case cost represents the sum of all lab, implant, and overhead costs. The final fee determination is a simple computation once the total case cost is established. From the overhead-cost evaluation, we compute how much time we expect to spend on the case. The clinician decides how much profit he or she would like to make on the case on an hourly basis. Multiplying the desired hourly profit times the number of anticipated hours for case completion gives us the case profit. The profit margin is then added to the total case cost to determine the fee estimate.

This method of evaluating the three primary elements of case costs to establish the total cost — plus the desired case profit — is the most rational and effective way to ensure a profitable result for the clinician.

6. Develop an effective case presentation.

This method of case-cost analysis and fee determination gives the restorative dentist a clearer vision of the sequential, step-by step procedures and appointments needed for each case. This should result in an improved ability to communicate the benefits of recommended treatment to the patient. Communication is extremely important in presenting the case effectively. Clinicians should practice, or role-play, their presentation to ensure that they come across as organized, methodical, and professional.

The case presentation involves use of the patient's mounted casts, photos, and radiographs, supplemented with multiple visual aids. Today, we can illustrate implant cases similar to what a particular patient may need by using flip charts, brochures, and fixed and removable sample case models. We also can use interactive computer or DVD programs to present the procedures in animated or actual clinical-case form. We can do this with the CAESY system or patient-education software such as Click and Print (Click and Print, London, Calif). I have found that documentation of your own completed cases often is the most effective and powerful method of case presentation. This confirms to the patient that the dentist actually has experience with similar cases and has successfully completed them. Digital, slide, or print documentation then can be incorporated into an office computer presentation.

Some of the elements of effective case presentation include discussing patients' existing conditions, their stated desires for correcting missing or defective dentition, surgical and restorative recommendations, hygiene maintenance requirements after restorative-implant therapy is completed, home care importance, and nonimplant options.

7. Offer financial options.

Because implant cases can require a patient expense varying from a few thousand dollars to significantly more — and because insurance coverage is limited, at best — you may feel uncomfortable about quoting the total fee. The dollar amount may be much higher than you are accustomed to quoting. It also typically requires the patient to make all or most of the payment "out-of-pocket." Financial options that expand beyond the office's current guidelines may be needed. Use Care Credit, Dental Fee Plan, HelpCard, or other third-party finance companies to help patients finance the cost of treatment over 6 to 12 months or longer.

Establishing the value of the service to the patients is critical to help them justify their investment in dental implant treatment. Testimonials — either written or in person — from patients who have completed treatment can be very useful in confirming the efficacy and high satisfaction rates associated with most implant cases. Gaining permission from these patients to use their comments or to personally discuss their assessment with prospective patients is necessary before utilizing their testimonials.

8. Follow up with prospective patients.

In many instances, the patient wants to have implant treatment performed, but is simply not ready to do it because of financial concerns, time, occupational restraints, or personal matters unknown to you and your staff. Follow up with prospective patients for some period of time (6 to 12 months or more) to maintain the relationship. Just reminding the patient through letters, brochures, or other printed material of the benefits of implant therapy can improve the chances that they return to your office when they are ready to proceed. We have seen patients wait two years or more before returning to review their options ... and then decide to continue on with the proposed treatment.

Establishing a "tickler file" either manually or within the computer software can be delegated to a staff person. Part of the job responsibility is to maintain periodic contact with the prospective implant patient and to monitor this contact for whatever time frame the office feels is appropriate.

9. Focus on practical scenarios.

Incorporating any new modality into the restorative practice entails a learning curve. Many clinicians find that a smooth transition into implants can be accomplished by targeting implant procedures with high success rates and, conversely, avoiding or referring out those procedures with more complexity and risk. In our experience, the implant applications with the greatest predictability include single posterior teeth; restoration of multiple implants in posterior, edentulous quadrants; and bar-retained overdentures. Obviously, there are numerous additional applications for the use of implants, but this "risk-reduction" format will increase your confidence in delivering the treatment with a high level of success.

For example, although single, anterior implant restorations can be successfully performed, the restorative result is highly dependent upon a very precise surgical placement of the fixture, along with preservation or creation of the interdental papilla. Because this is a critically important aesthetic area, small deviations from a natural appearance may be viewed as a failure by the patient. Techniques are in place for experienced surgical and restorative dentists to overcome these obstacles, but after mastering more basic, nonaesthetic zone cases. The development of increased confidence on the part of the dentist and repeated success, in turn, create an increased implant awareness and enthusiasm throughout the entire dental team. As more and more cases are predictably completed, the dentist and staff are encouraged to target more complex cases that will provide greater total revenue to the office.

Profitability with dental-implant cases presents some unique challenges to the restorative office. However, we cannot achieve profitability if the patient does not accept treatment. The coordinated efforts of the surgical and restorative dentist in learning effective communication skills, while utilizing the many adjunctive visual aids, software, and video patient-education materials can enhance your ability in this area. While implant dentistry can present a significant investment on the part of the patient, many who have completed treatment agree that the cost is well worth the final result of being able to replicate — or even exceed — the function and aesthetics of their former dentate condition.

Nine essential elements of implant profitability

1. Systemize your analysis of case costs.
2. Establish a true interdisciplinary treatment-planning protocol with your surgical dentist.
3. Establish an interdisciplinary treatment-planning protocol with your laboratory technician.
4. Plan for contingencies.
5. Determine your fee.
6. Develop an effective case presentation.
7. Offer financial options.
8. Follow up with prospective patients.
9. Focus on practical and predictable scenarios.

How long would you estimate it would take you to do the following?

1. Unscrew six healing abutments.
2. Screw in six transfer assemblies completely seated into the implants.
3. Radiograph the junction of the transfer assembly and implant to confirm that there is not a gap between them. Then, wait for the radiograph to be processed (unless you have digital radiography).
4. Border-mold your custom tray.
5. Complete the procedure using one or two consistencies of impression material, then remove the impression from the mouth.
6. Unscrew each transfer assembly.
7. Join each transfer assembly to its corresponding analog and reposition these into the impression.
8. Replace each healing abutment into the implants.
9. Reline the patient's interim denture.

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