The evolution of modern dentistry is being driven both by changes in technology and the advancement of dental materials.
by Suzette Marie Stines, DDS, FACDNA
For more on this topic, go to www.dentaleconomics.com and search using the following key words: CAD/CAM, practice, evolution, modern dentistry, technology, dental materials, Suzette Stines.
My first venture into dentistry was in 1969 during my high school years. I worked afternoons as a dental assistant in an upscale Berkeley, Calif., practice that specialized in gold foils. When I graduated from dental school in 1981, materials and techniques had not changed appreciably since 1969.
I entered the world of modern dental technology in 1991 when my IBM Selectric's type ball refused to return, forcing a front-office work stoppage. Despite my misgivings, I was forced to buy a computer just for the word processing capability. Before the year was out, I had computerized my front office with a shareware program I found in a sale bin. When I realized how much money had slipped through my fingers every day by generating insurance claims by hand and submitting them on paper, I became hooked on digital technology. I quickly signed up for a programming course at the local university and wrote a program to track and schedule my patients' recall appointments.
A fresh start
In 1999, I left my 18-year dental partnership and opened a solo private practice, moving from a small city to a remote rural community. I wanted to make the kind of changes in my practice that would build passion in the second half of my career. The county's population of 52,000 supported 11 practitioners. My town boasts about 2,000 people, which is not a particularly large market for the practice I envisioned. I had purchased an exceptionally dated practice with a belt-driven handpiece, no suction, and what looked like a 98-year-old X-ray head.
So, I yanked everything out, ran to the Hinman meeting, and bought every piece of technology I craved. I created a paperless, high-tech practice in a small, rural community. Computer monitors were mounted on the wall of each operatory — rectangles of light opening new windows to a world of dental technology. My practice-management software included charting capabilities; myriad digital images flashed across the screens in a dizzying array. Digital X-rays integrated with the charting program via a bridge; intraoral cameras integrated with a cosmetic-imaging program, which integrated with the charts. Patients were dazzled by "after" images of their "beautiful twins." Air abrasion kept the little ones from crying. The incessant buzzing in my ears died down with the switch to electric handpieces, and I began humming with joy. I set off on the long road to mastering digital photography, and launched my first Web page. The following year, my professional life changed forever: I bought a CEREC 3 (2D version).
As time passed, I watched my practice develop. I generated reports to track my practice numbers and formulated a marketing strategy based on emphasizing my CAD/CAM technology.
Chairside CAD/CAM's effect on patients, profit, and productivity
So, what has all this technology done for my practice? Even in this rural setting, it revealed that my patients craved modern dentistry. They wanted more than had been previously offered — they wanted tooth-colored restorations, and they wanted easier, more comfortable appointments. Chairside CAD/CAM was my "hook" to provide what they wanted. Given today's economic climate and the competitive world of dental marketing, CAD/CAM dentistry is still a great hook. Currently, only a small percentage of dental offices practice with this degree of sophisticated technology. The ability to offer in-office indirect restoratives to your patients separates your office from the pack. In terms of marketing, it is a win-win.
But what about productivity? I remember meeting with my new office staff in 1999 and setting a very modest daily production goal. I sat down, added up all of my notes (at 4% APR), added in salary and payroll figures, calculated a percentage for supplies, and guessed at a goal. I realized I had a considerable sum invested in creating the practice of my dreams, but I never forgot that technology frees up chair time — chair time is money. By a modest estimate, any practice can expect to free up chair time worth an additional $60,000 to $120,000 per year by eliminating the seating appointment for indirect laboratory fabricated restorations and replacing them with indirect chairside restorations. Even if you have a great relationship with your lab, it is just more efficient to cut a prep, scan, mill, glaze, and seat in one appointment.
Patients were amazed that they could get their crowns the same day, and they were dazzled by the computer images and fascinated by the sound of milling. They prided themselves on coming to a modern office. They complimented me on all of the changes and embraced the high-tech "bells and whistles." I loved my ability to provide esthetic, conservative restorations of the highest quality. Initially, my aim was merely to meet my daily production goal. Then my goal was to make sure I treated one CAD/CAM patient a day. At first, I primarily did full-coverage restorations (they were easier to learn). I worked hard to understand the difference between all-ceramic and gold preparations. I was then able to complete inlays and onlays in a reasonable amount of chair time. As patients discovered they didn't have to lose so much of their tooth structure unnecessarily to traditional full crown preps, referrals increased. My practice continued to grow and evolve.
Learning more every day — growing my practice in every way
I was really getting the hang of this new technology. Even today, I'm still excited by the constant improvement in the CAD/CAM software. Using CEREC became more and more habitual as the software became easier and faster to manipulate, even as the applications expanded. Quadrants of indirect CAD/CAM restorations became a regular occurrence in my appointment book. (I began to think there must have been hundreds of dedicated programmers locked in a tower somewhere in Germany working just for me!)
I changed my production goal to one CAD/CAM patient in the morning and one in the afternoon. Some of these were single-unit patients, while others were quadrants of inlays, onlays, and crowns. I took an anterior course and learned to stain and glaze. I then expanded my offerings to beautiful anterior restorations! A single-tooth anterior CAD/CAM unit, properly stained and glazed, is a fantastic service to provide, and has become commonplace. Referrals really leaped for the anterior cases, and my geographic market region expanded as my practice was sought out for anterior rehabilitation. I was able to perform a six-unit anterior case in a half day, and practice revenue grew at a steady rate. Even with reducing the number of days I worked and patients I saw, my gross continued to climb. That peaceful, low-stress practice I envisioned was coming into being.
I refreshed my occlusal knowledge by taking a few courses. Now I knew that, with proper diagnosis, I could provide full-mouth rehabilitations with my CAD/CAM unit. I've become adept at opening up vertical dimension with occlusal veneers in the posterior. This is a wonderful service to offer patients, as opposed to the full-coverage restorations generally utilized to restore vertical dimension. I bought a diode laser and took some courses to become proficient at completing cases with proper tissue contouring and esthetic, all-ceramic, lifelike anteriors.
I then took an inLab course. inLab is the laboratory component of CEREC technology. I became more skilled at staining and glazing, and refreshed my ability to stack porcelain. I studied the physical properties of all the new materials we were using — zirconia, alumina, and lithium disilicate glass — while reacquainting myself with spinell. I discovered that I could mill temporary bridges in my office! Then I taught myself to do diagnostic wax-ups indirectly with CAD-Waxx. I was dazzled and amazed. I now perform more comprehensive workups on patients because I can do diagnostic wax-ups more easily. I finish them with conventional life wax, which provides a beautiful case presentation model. The full-mouth patients are referring more full mouths! And my practice continues to evolve: I just purchased an inEos scanner, which will allow further expansion of my in-office laboratory capabilities. I'll be able to e-mail designs for zirconia frames to a sintering center, and I am taking on a part-time ceramist.
I had been restoring implants for years with chairside CAD/CAM and taken countless implant classes. I finally took the leap and began placing my implants with great results. I am placing immediate-load implants where there is adequate stability, and temporizing with milled resin crowns. The final restorations are chairside CAD/CAM feldspathic porcelain or lithium disilicate glass milled in the office and placed in the same appointment. The implant patients are referring implant candidates, and the practice continues to grow.
Stepping up the pace — in peace
I invested in another milling chamber, a spiffy new MC XL high-speed unit, which mills a restoration in about three or four minutes. I began placing indirect milled resin restorations instead of stacking composite — no more polymerization shrinkage! Then I started treating pediatric patients with indirect milled resin restorations — no more stainless steel crowns! And the referrals continue to make my practice grow. I read an article describing how to make Class V restorations out of porcelain, tried it, and discovered a great service for my patients.
High-tech dentistry was surveyed in a 2006 JADA article, and evaluated all of the technology I use in my practice as "essential, desirable, or hype." The article recommends that dentists performing primarily single-tooth restorative dentistry should consider in-office CAD/CAM.1 I concur 100%. For any general practitioner, this technology enhances the quality of patient care and, amazingly, fits into any practice setting. I have a rather peaceful general practice, reserving a portion of every morning for high-revenue patients with complicated restorative needs. As the only dentist in town, I also have an emergency call each day. It is not unusual to pull my CAD/CAM out of the corner and immediately restore a broken tooth. Instead of the old IRM and follow-up appointment, I am able to finalize the restoration and collect the full fee at the first visit. I have realized my goal of seeing fewer and fewer patients each day, yet I continue to experience a steady increase in my gross revenue. I also continue to attract new patients.
The applications continue to grow and expand. This week, I found ways to utilize CAD/CAM on more than 85% of my operative patients. I've done porcelain inlays, onlays, resin Class II composites, a porcelain Class V, and an immediate-load implant crown. I fabricated a really amazing temporary bridge for a young patient who suffered a traumatic injury, following socket preservation for tooth No. 9 and root canal therapy for No. 8 with a post and core buildup. I restored bombed-out pediatric primary molars with onlays milled from resin instead of ill-fitting stainless steel crowns. I do at least one anterior unit every day, and usually more.
The new CEREC 3.0 software is so fast and easy to use that my assistant feels that when it's combined with my MC XL, it's as simple as doing a filling. In my office, a filling is most often indirect milled porcelain or resin. I never hesitate to restore a broken tooth for an emergency patient in this fashion, because I know it won't impact my schedule.
My personal growth has been amazing, my passion for dentistry is greater now than it has ever been, and I look forward to every day that I go to work. My practice growth has also been phenomenal. I have achieved my dream practice by eliminating the grueling pace that defines so many dental practices. I have achieved financial security. I have interesting work to do. My practice is productive, satisfying, and peaceful. And all of this growth was driven by CAD/CAM technology!
1. Christensen GJ. Is now the time to purchase an in-office CAD/CAM device? J Am Dent Assoc. 2006 Feb;137(2):235-6, 238.
Suzette Marie Stines, DDS, FACDNA, is a graduate of the University of North Carolina School of Dentistry, Adjunct Associate Professor UNCCH, Fellow, Academy of Computerized Dentistry of North America, and a Certified Trainer of the International Society of Computerized Dentistry. She is in private practice in Chadbourn, N.C. Dr. Stines may be reached at [email protected].