Ian Shuman, DDS
The past decade's swell of profit centers for dental practices — everything from whiter teeth to fresher breath — has been overwhelming. Yes, these wonderful add-ons have boosted our practice's bottom line, but have we ignored the greatest potential for truly breathtaking income? I think so.
Crown and bridge treatment options have grown incredibly, and range from traditional cast gold, porcelain-to-metal, and stacked porcelain to the more exotic stuff of pressed ceramics, 24-karat gold alloy substructures, and glass-filled composite resins. Tooth preparation can range from the simple, circumferential, full-reduction champfer margin (aka: the traditional crown preparation) to the complex, reverse three-quarter shoulder margin anterior preparation (aka: the porcelain veneer preparation). In addition, the increased alternatives that implant therapy provides have given the restorative playing field limitless potential. Just leave it to your imagination! Without a doubt, there is now an answer for every fixed restorative need, needs that are growing at a fast and furious pace. Here's why: The majority of full-coverage restorative cases come from teeth that were restored with amalgams as old and large as the Grateful Dead (the Baby Boom generation to all of you Gen X, Y and Z'ers). Add to this mix the "Gee doc, can't you just fill it?" pothole patchwork, fractured cusps and marginal ridges, and post-endodontic therapy means patients who have significant needs.
So how do these needs become profit centers in your practice? More to the point, what can you do differently to increase the number of crown and bridge cases? It all comes down to the "S" word. Most of us cringe at the very mention of this dirty little four-letter word, but it is the very gas that fuels our practices. That's right: Sell.
If they see it, you can sell it
We live in a five-minute-info-clip, give-me-the-bottom line world where information is dished out like fast food. (In fact, I'm willing to bet that while you are reading this issue of Dental Economics, you are parked in front of the tube, watching and eating, reading and resting.) Our patients have grown fond of the eye-candy commercialism that TV and the media dish out on a daily basis. Dentists must heed their desires and duplicate this perfection in their offices. The first step is the process of co-diagnosis through visualization — simply taking a picture of the tooth in question and showing it to the patient. In our practice, we use the Vistacam intraoral camera by Air Techniques and pop a quick image on the wall-mounted monitor. We have an ironclad rule in my practice: We leave the operatory, and not a word is spoken. None! Patients digest the miserable condition of their teeth in complete silence and solitude. A moment of reflection, a moment of oral meditation, and a moment to realize: "Yuck! That's my tooth!" After several uncomfortable minutes, we return to the operatory and allow the patient to speak first. The usual comments are "Wow, I didn't know it was that bad," and, "What is that black stuff around my filling?" and even, "When can we get started?" — when a treatment plan and fees have yet to be discussed.
The next step is to X-ray the tooth in question. For the most accurate diagnostics with simultaneous visual dazzle, digital radiography offers the best that technology can offer. With lower radiation requirements than traditional X-ray film, a virtually instant image, and a picture as large as your computer screen, you and the patient can view the problem from the inside out. Trex Trophy from PracticeWorks, one of the most popular digital radiography systems, uses unique software that allows the image to be colorized, providing a spectral view that even impresses dental professionals. Caries is clearly delineated, as is any other anomaly present. With this system and its super-loaded features, patients can become instant armchair radiologists. Once we have their undivided attention, it's time to educate them about the next step: treatment.
If you used to enjoy explaining the need and benefit of treatment but are now burned out on the subject, be careful; patients will pick up on your attitude. Instead, let them watch a perfect stream of images coupled with a soothing voice that easily explain treatment needs. Whether you have a DVD player or a DVD drive in your computer, CAESY is a great patient-education system.
Besides educating your patients within two minutes per procedural clip, you can document that they have viewed the item (unlike a verbal explanation that varies from patient to patient). Once they have viewed the crown, bridge, veneer, or implant segment on CAESY, ask if they have any questions. Typically, the next question is, "How much is this going to cost?" This is where your skilled office manager takes over.
Leave it to the bankers
Since many patients come with a dental plan crutch (notice I did not say insurance), it is important to define relationships. The only true relationship your office has is with your patient, and your patient must clearly understand that role. In this day and age of miniscule "insurance" reimbursement, rapid credit approvals and clear financial arrangements are the easiest methods for managing the store. With cases that involve fixed restorative care, price tags can run high. The fees for a full reconstruction can rival the price of a new car. However, any substantial financing can be handled by professional financing services such as CareCredit and Dental Fee Plan. After all, the sign on your door says "Dental Office," not "Dental Bank."
What to charge?
Ahh, the ever-sensitive money question. Fees can be determined through a series of complex algorithms and higher mathematics. As we all know, there are plenty of gurus who advocate these complex structuring systems. Fees also can be structured through the plain business concept of profit and loss. Simply put, calculate your overhead per hour. This should include all expenses such as team salaries, materials, lab fees, utilities, and anything else that drains your bank account. Then, add profit up to what the market will bear. "What the market will bear" is the maximum dollar amount the majority of patients are willing to pay for a given service. Those fees can be derived from the ADA, this magazine's annual survey, and other periodicals and services. If you find that after charging this magical number you aren't gaining enough profit to fuel the business, then it's time to cut costs and expenses.
Whether you are creating one restoration or 32, time is an undeniable factor in profitability. It is vitally important to accomplish your business task in as little time as possible while providing the highest quality service available. That's easy to say, and tough to do. Here's how to accomplish this step-by-step:
Time it. Do you own a timer? If not, you should. Start using a countdown timer for anything that has a setting time. That includes onset of anesthesia (traditional and intraosseous), pre- and postoperative impressions, temporization materials, and temporary and permanent cements. These tasks — if not specifically timed — are often left to "bake" too long, which squanders precious time. The only procedure that should not be defined by strict timing is tooth preparation. That task requires attention to detail and should never be rushed. However, dentists can expedite this task by using fresh burs and sequential preparation steps.
Preparation. Regardless of the number of teeth being prepared, knowing and having the end result in mind prior to tooth preparation will not only guide you, but also will provide an easy solution for interim temporization.
For single to three units — Perhaps the easiest method is to record the unit(s) prior to preparation. For single units, a triple-tray impression with a soft polyvinyl, such as Mixstar StatusBlue (Zenith DMG), can create a highly detailed, long-lasting record that can be saved and reused in the event the patient loses the temp. To mock up a missing pontic tooth, a Styrofoam pontic (Proviponts, Ivoclar) can be wedged between the abutment teeth; the opposing teeth can press the Styrofoam into proper occlusion. An impression can then be made of this as well.
Multiple units to full reconstruction — When rehabilitating cases involving more than three units, it is an absolute requirement to mount the case in the desired vertical and centric and wax it to proper specifications. If you are unsure about the amount of tooth reduction required and want guidance, or you desire a professional wax-up, there is an option known as the Dentist Diagnostic System (DDS) available from Aesthetic Porcelain Studios (800-544-9605). Your study models are duplicated twice; one will demonstrate the type of ideal preparations required and the other a newly created dentition, beautifully done in white wax. This model can then be used in patient consultations as well as for the vacuform stent for temporization fabrication.
Anesthesia. If you haven't explored anesthesia since the mid 1990s, you're missing out on some truly incredible, rapid, and profound techniques and anesthetics. For the past 20 years, the world outside the United States has enjoyed the benefits of Articaine (Septodont), an anesthetic that provides deep local anesthesia. Additionally, intraosseous anesthesia has provided practitioners with a method for anesthetizing teeth that cannot be accomplished via traditional methods or when time is of the essence. In timing these two modalities, we allow five minutes for traditional blocks and infiltration and one minute for intraosseous injections.
Tooth preparation. Tooth-structure preparation can be nearly automated. By using fresh burs and heavy irrigation, most single-tooth preparations can be accomplished quickly. Recently, a real revolution has occurred with bur development. Dentists have requested specific bur shapes and cutting efficiencies, and manufacturers have listened. One of the oldest and most innovative companies in this field is S.S. White..This company has produced some extremely unique burs. A great bur series for bulk reduction is the TDA diamond series. These medium-grit diamonds reduce tooth structure very rapidly and do not clog with tooth material. Another, more refined bur that can create a perfect margin is the Piranha diamond series (S.S. White).
The final impression. A final impression should be a thing of beauty. Those perfect margins should be visible across the room, not illegible! How to achieve this is another story, but oh-so-easily attainable. For single crowns, a triple tray is the best way to go. For multiple units, nothing beats the accuracy of full-arch mounted models, especially when it comes to the all-important holy grail of dentistry — occlusion. However, for creating truly outstanding impressions, Honigum, a unique polyvinyl, has outdone itself in this field. Its unusual chemistry allows this thixotropic material to capture and duplicate detail to an extent that is truly mind-boggling. It is the first impression material made with a microcrystalline wax matrix and reactive polysiloxanes that hardens to prevent distortion — and actually works in the presence of fluids.
Temporization. Are you still using acrylic to fabricate your provisionals? Are you using a horse and buggy to get to work? Get the idea? Despite costing pennies per use, acrylic can occupy 20 to 30 minutes of your valuable time when fabricating a single unit temp from a preoperative impression, and even longer if you use the block-temp method. A far better approach is to use the bis-acryl composites, now an old technology in the scheme of things.
Despite costing about .50 cents per unit, these very beautiful and durable temps can be churned out in less than three minutes. One of the first and still finest bis-acryl materials, Luxatemp (Zenith DMG), is ideal for this purpose. For temporary cementation, Tempocem, another Zenith product, is an easy-to-use, automix temporary cement that is dispensed from a hand-held syringe directly into the temporary unit. It is available in eugenol and noneugenol forms, sets rapidly, and cleans up without the mess that other temporary cements often leave behind.
Off to the lab. Perhaps the two most important pieces of information to transmit to the lab are shade and material type. Today, shading can be accomplished with enough precision to make an interior decorator jealous. The automation of shade selection is now easily achieved with a variety of handheld electronic measuring devices.
One of the easiest and perhaps most accurate is the ShadeVision unit manufactured by X-Rite Corporation. This company has been in the business of automated color matching and determination since the sky was blue.
After developing automated-color matching systems for companies like GE, major auto manufacturers, and printers worldwide, the company turned its attention to a truly difficult industry: tooth shade matching. Because of their prismatic nature, teeth are notoriously difficult to match. What the Shade Vision system does is capture an image of the tooth to be matched, and breaks it down into its component shades, which allows the lab to precisely match the tooth as seen through the eyes of the computer. Shade mapping can then be altered to accommodate most existing porcelains, which are selected from a list in the Shade Vision program. However, the most artistically created shading will look shabby if the wrong material is selected.
Selecting a core material for porcelain-to-metal restorations requires many factors to be considered. In areas that are not under a heavy occlusal load, a nearly pure, gold substructure such as Goldtech BIO 2000 (Argen Corp.) makes an ideal choice, especially from an aesthetic perspective.
The gold imparts a dentin-like quality, never causes black-line-at-the-gingiva disease, and is highly biocompatible. All-ceramic materials are another choice, and many options are available. To greatly simplify this issue, if the dentin core is a "pleasant" yellow, IPS Empress I is an excellent choice because it offers a translucency that mimics tooth structure like no other.
However, if the underlying dentin is dark and requires masking, feldspathic porcelain (stacked porcelain) is ideal. It can be created with an opaque base layer and requires less tooth reduction than other ceramic systems. For all else, porcelain-to-precious metal and cast gold crowns for posterior teeth have always been the workhorses of dentistry and will serve your patients for many years to come.
Final cementation. With all of the final cements on the market, how do you choose the best? Like everything else, there are several that are always at the top of the list. One of those is Fuji Cement (GC America). This resin-reinforced glass ionomer sticks to everything and contains fluoride. Enough said.
Don't forget the bumpers
Adding to the practice-building concept is an oft-forgotten adjunct to a healthy dentition — the nightguard. If a patient presents with a fractured tooth, the next logical step following restorative therapy is to protect that investment and prevent future damage. A patient can easily understand the importance of this device and its concurrent fabrication with a fixed restoration.
With all of these ideas, there should be something to help your practice boost its crown- and- bridge bottom line. Just don't be afraid to invest in the best, provide the finest care, and make the statement that only excellence will do. You won't regret it.