Price, quality, and volume

What does digital dentistry mean to you? Do you own an intraoral scanner? Do you have an in-office mill? Does your lab have CAD/CAM scanning, milling, and printing capabilities? If you have any of these things, chances are you invested a lot of money and time into them. Why did you invest in these systems? Perhaps it was to increase efficiency, reduce time to completion, lower costs of lab work, or maybe just to be on the cutting edge of new technology. The beautiful thing about this new technology is the ability to deliver better restorations. It enhances communication with the lab via instant feedback on impression accuracy, and it decreases waste of materials, such as impression material and alloy, in the casting process.

Unfortunately, too many dental professionals lose sight of what a wonderful restorative alternative they offer with this technology and they sell themselves short. They undersell their services and think about offering the lowest possible price. In the last few years it appears that many are racing to the bottom. “How cheap can I sell this?” is uttered too often, when in fact it makes more sense to charge more. Sure, you can scan that prep and mill a lithium disilicate crown in the office. Should it be cheaper or more expensive than one taken with impression material and sent to the lab? What do you think? Even if it’s quicker and easier, the rate of inflation, cost of rent, maintenance, and more dictate that fees remain at least the same.

Today, digital dentistry reminds me of implants in the late ’80s and early ’90s. Discussing all the cool things we can do now is fun. But inevitably the discussion evolves into price and speed. “How much will you charge me for a model-free crown just glazed?” “Can you do better than that?” “You know, so-and-so lab sells them for this much.” “Why don’t you put a mill in my office and make a satellite lab and charge me even less?” When I speak to technicians I hear, “I converted all my doctors to milled lithium disilicate even if it’s not proper prep design. I make those crowns looser so they will go down. If I have to remake, I remake.” Where is the quality in this work? Where is the pride in craftsmanship?

As an industry, we have had a three-tiered system of product and service. There’s the high-quality, high-priced, low-volume boutique practice; the good-quality, variable-priced, medium-volume practice; and the low-quality, low-priced, high-volume commercial practice. In all three categories, both the dentist and lab do their best to please the patient and produce a product that meets the financial and personal needs of the patient. I’ve spent my career trying to maintain a high-quality first-tier dental lab. It’s a lot of work and even more frustration. In no way have I ever felt that I was superior to or more noble than other labs in the middle and third tier. It’s simply a matter of what business one chooses to be in. My partner and I chose this course while others chose a different path. Ultimately, we’re all professionals running our businesses.

Dental labs work in a few ways. One way is to pay a technician by the unit. Another is to pay a salary for a set amount of work. When requiring a limited amount of work per day, the quality can remain more consistent and accurate. Technicians will work full time at a lab where they receive their benefits, vacation, and sick days. Many will stop off at another lab after work and knock out a bunch of units to earn extra money. Where they had eight hours to produce eight to 10 units, they now have three hours to produce 10 to 20 units. The difference in the quality of the work is dramatic.

What we’ve seen the last few years has been a decrease in the middle-of-the-road practices and an increase in the high-production practices for both dentists and labs. A primary reason has been the growth of dental service organizations (DSOs). Many older and retiring dentists have sold out to a corporate entity that now owns the practice and dictates the price structure and procedures offered. It’s not that these groups produce low-quality work; in fact, some are quite good. It’s the buying and bargaining power they have that enables them to purchase supplies at a low cost. This in turn allows them to produce low-cost restorations.

Dentists who are not a part of these groups may consider lowering their fees out of fear and misinformation. The problem is that they do not have the same discounts as the corporations. Separate from DSOs are the low-quality practices with aggressive marketing campaigns. These are the guys who place ads on menus and in “PennySavers” for $399 implant restorations. They aren’t using bulk discounts; they’re likely just putting out an inferior product.

Meanwhile, dental labs are either closing or being taken over by corporations. Offshoring work to China for cheap, mass-produced restorations has been a growing concern for the industry for more than a decade. Many dentists say that they can do everything themselves with in-office machinery. In turn, they might lower their fees since they’re not using a lab. The question to ask them is, “What is your time worth?” The billable hours of a dentist’s chair time versus saving a lab fee are not equal. A dentist can prep a tooth in an hour and send it out to a lab, pay a lab fee, and insert it in less than a half hour. Or, the dentist can prep the tooth, scan, design, mill, stain, and glaze in two hours and not pay a lab fee. Is the lab fee equal to an hour of chair time? Unless the dentist is charging the patient fully double what he or she would when using a lab, the dentist is not making the profit he or she could be. Working smarter pays off way better than working harder.

Like a wave that crashes on the beach and recedes back into the ocean, so shall dentistry. Just like it is inherent for people to seek low prices, it is also inherent for them to seek out the best product. We have had a three-tier system for so many years, why is it going to end now? Rebuild the middle tier! Not all patients are going to go to the cheapest dentist. When people pay top dollar for inferior work, they leave and don’t return. We have determined that between 15% and 20% of my lab’s work has been implant bridge remakes. I’ve joked around that this one dentist in particular put my daughter through college with all the cases we redid. Those who offer digital impressions with a very esthetic, properly fitting restoration will continue to prosper.

The ability of dentists to scan a prep and examine it immediately in the office increases the overall quality of that restoration. Not only is the quality of the scan being determined, but also the final success of the restoration. The dentist can see if the occlusal clearance is adequate, judge the parallelism and contacts, and determine if the emergence profile is well defined. When the dentist performs these steps, the final product can be that much better. Many dentists already employ this form of work with a chairside technician or through e-mail and services such as FaceTime. So, instead of scanning and running to the next patient, they give more time to each patient and charge for their services.

The lab then can automatically produce a better product, just by having a better impression. The number of remakes resulting from poor impressions and fudging dies is tremendous. Instead of defaulting on a monolithic zirconia crown or a pure stain-and-glaze lithium disilicate crown, the lab can produce a formfitting, minimal cutback, layered porcelain restoration. Guided surgery in conjunction with intraoral scanning requires many hours of planning to achieve the most incredible result of immediate-loading implant prosthetics. The implant, surgical, and crown-and-bridge possibilities are endless in the digital age. Digital is the next generation of dentistry. Those who perform top-of-the-line dentistry will be the most successful. So, rather than racing to the bottom and being one of many, strive to get to the top and be the high echelon in the next generation of dentists.

Steven Pigliacelli, CDT, MDT, is an instructor in postgraduate prosthodontics at New York University. He manages Marotta Dental Studio and directs the general practice residency and prosthetic resident rotation, an intensive educational program that focuses on the value of the technician-dentist relationship. He is also president of the new Association of Innovative Dentistry.