August 2012, Volume 8, Issue 8
Published by AEGIS Communications
Building Better Partnerships
Laboratory technicians expand their services in order to become stronger partners for clinicians.
Tom Wiand, CDT, sees no way around it. Unless dental laboratory owners expand their offerings to include services such as chairside consulting, the combined onslaught of overseas competition and automation is sure to render US dental technicians obsolete, says the owner of Wiand Dental Laboratory in Scottsdale, Arizona.
“Off-shore trading with China continues to grow, and I see machines doing more and more laboratory work,” continues Wiand, who provides dentists with in-office guidance on immediate-load implant procedures. “So if we don’t offer dentists something such as chairside consulting, our survival is threatened. The last frontier we have as dental laboratories are the services we can provide.”
Technicians’ Expanding Repertoire
Nor is Wiand a lone crusader. Intent on honing their competitiveness and boosting their bottom line, dental laboratory owners across the country are adding chairside consulting to their repertoire. Their in-office assistance to dentists on esthetic and restorative procedures ranges from collaborating—defined as providing professional input on treatments—to guidance, as in the case of consulting with dentists and specialists on the placement of immediate-load implant procedures.
For some laboratory technologists, chairside consulting has become an integral component of their business model, either as an add-on value or a specific billable service. And while their dentist-clients embrace laboratory technologists’ expanded services, some in the profession raise concerns about the role of technicians venturing too far into the clinical realm, citing their lack of formal dental education (see sidebar on page 95).
Yet there is no question that dentists have become increasingly reliant on the expertise of their laboratory partners, especially since dental schools have winnowed restorative procedures from their curricula. “In the late 1980s, we started seeing dental schools cut back on restorative dental laboratory procedures,” says Bennett Napier, executive director of the National Association of Dental Laboratories, in Tallahassee, Florida. “With all the subject matter that the schools needed to cover in four years, restorative dentistry just kept getting cut to the point where it’s become a small part of their curriculum.”
The fabrication of crowns and inlays and other restorative devices largely has become the sole province of dental laboratory technologists. In turn, an increasing number of laboratory technicians today often serve as ad hoc educators to dentists on restorative dentistry fundamentals.
“The growth of chairside consulting seemed to start around 2002,” Napier continues. “That’s when we began to hear from laboratory technicians who said they were being called upon to be in dental offices for restorative procedures.”
Though NADL has no statistics on the number of laboratory technicians offering chairside services, Napier adds that it seems to have gained momentum during the last four years as more technicians have started helping dentists provide immediate-load implants.
To explore this in depth—to illustrate the various needs technicians fill today, how some of their in-office assistance has evolved, and the challenges they encounter—five dental laboratory owners and managers who provide these services, along with their dentist-clients, share their stories with Inside Dentistry.
Leonard Marotta, CDT, PhD, finally decided that the only way to handle the mounting requests for chairside assistance would be to build operatories at his Marotta Dental Studio in Farmingdale, New York, so that dentists could bring their patients to him.
When Marotta opened his laboratory in 1980, which he co-owns with his brother-in-law, Steven Pigliacelli, CDT, much of his chairside advising focused on implants. “Doctors who needed help with implants would call me and say, ‘I don’t know some of the materials. I don’t know how I’m going to get the implant to fit or retrofitted. Can you come to my office?’ And that’s how it all started,” says Marotta, who also serves as a clinical professor in the departments of Implant Dentistry, Restorative and Prosthetic Science, and Biomaterials and Biomimetics at New York University College of Dentistry in New York City.
When calls for chairside help became overwhelming, Marotta knew he needed to act. “That’s when we decided to build two operatories in our facility,” he says. “Now about 75% of our chairside consulting, which we provide as an add-on value, is done in-house.”
“When the doctors come here, especially for immediate-load implants,” adds Pigliacelli, “they know that they have a full laboratory on the premises should anything go wrong. So we can always make the case work.”
“We do case-planning with the surgeon and provide a surgical guide for placing the implants,” says Pigliacelli. “I’ll suggest where they should go for the best restorative outcome.”
While the majority of Marotta Dental Studio’s chairside consulting initially centered on implants, that emphasis has shifted, continues Pigliacelli. “It seems dentists just out of school these days are asking more general questions about restorative dentistry,” he said. “They want to know how crowns are made, for example. Most of our consulting today focuses on restorative procedures.”
But chairside advising extends beyond filling the gaps in dentists’ educational curricula, points out Scott Holsinger, CDT, owner of Quartz Dental Laboratory in Centennial, Colorado. In-office assistance can also be essential to providing optimal dentistry, he says, citing a recent case of an inadequate veneer preparation for a woman in her 20s who had been treated for pulpitis and had history of trauma to tooth No. 8.
In early December 2011, as Dr. Brittany Bevis of nearby Larkspur, Colorado, devised her treatment plan for the patient, prime among her priorities was to salvage as much tooth structure as possible. “I didn’t want to do a full-coverage crown in case she needed endodontic treatment in the future,” Dr. Bevis explains. “I also wanted to keep her occlusion stable because she had had orthodontics and her smile was gorgeous. So I prepared tooth No. 8 for what I hoped would be a conservative veneer.”
She then sent the impression of the preparation to Holsinger, who immediately saw that it would not work. “I needed an additional 1 mm removed from the middle third of the tooth so that I could get my material in to block out discoloration and provide proper contour,” says Holsinger, a Master Technician at the Las Vegas Institute for Advanced Dental Studies.
Dr. Bevis recalls, “I then asked Scott to come in chairside with the patient so that he could see the case and I could explain my limitations as far as the patient’s age and pulp condition.” In the operatory, Holsinger underscored the need for re-preparing. “I asked Dr. Bevis to break contact on the mesial and distal and provide a little more room. Otherwise, the tooth would be a bit bulky and we’d probably have to schedule the patient for another appointment to remedy that.”
Dr. Bevis agreed to re-prepare, but held fast to removing minimal tooth structure. Instead of the 1 mm Holsinger requested, she shaved the facial just 0.5 mm. “But that proved to be enough,” Holsinger recalls.
“That was the first time in the 10 years I’ve been practicing that I’ve had to re-prepare something, but it was for a valid reason,” Dr. Bevis says. “The patient and her mother were very excited with the result.”
Helping dentists provide optimal dentistry also is the focus of chairside consulting at Gagliano Dental Laboratory in Tampa, Florida. For about 20 years after he opened his laboratory, James Gagliano, CDT, handled the laboratory work for about 38 clients. Then in 1998, he decided to concentrate on providing only high-end restorative and esthetic devices and services, including consulting, for a client base of six general dentists also committed to using only the highest-quality laboratory products available.
“I decided to promote my laboratory and my accounts as offices that provide the type of dentistry people don’t get anywhere else,” he says. “I’ve been successful with my approach; I haven’t had to worry about off-shore competition. And I’ve yet to see CAD/CAM technology match the quality of handmade products.”
Gagliano provides chairside consulting to his clients every day. Dentists call him in for all cases dealing with patients’ anterior teeth. “I may take a shade, visit a patient for the first time, or offer input on whether a patient is a candidate for restoring. Sometimes, for example, I might suggest that instead of restoring we provide a patient with Invisalign.”
When one of Gagliano’s clients refers a patient to a surgeon for implant placement, Gagliano is also present for the procedure. He says he typically consults with the surgeon on the optimal placement of the implant, then returns with the patient to the restorative dentist and advises on abutment selection.
Gagliano, who has continually taken continuing education courses on esthetic dentistry and dental materials, does not have a specific fee schedule for different consulting services. But he does justify the time spent at offices by increasing the price of his products. However, that does not deter his dentist-clients. “Jim provides great treatment-planning advice from a prosthetics standpoint,” says Dr. Marc Tindell in North Tampa. “He’s very knowledgeable about crown-and-bridge, for instance, and can help determine whether a tooth is a good candidate for an abutment. Also, his interaction with patients helps him learn details about their case that we might not have picked up on. And he sometimes recommends procedures, such as whitening or another tooth restoration, that may extend treatment for patients.”
Jeff Stronk, CDT, owner of Treasure Dental Studio in Salt Lake City, Utah, has no doubt that his chairside consulting for implant cases has been key to his company remaining profitable during the recession. Specifically, he points out that consulting has distinguished his laboratory from that of his competition, while also allowing “us to keep our price points a little higher.”
Stronk began in-office advising on implants more than 20 years ago, just as the technology began making headway in the marketplace. Educated about implant dentistry through CE courses sponsored by DENTSPLY and Nobel Biocare, Stronk saw that his knowledge of restorative fabrication and the prerequisites for a successful outcome could make him an important part of the implant team.
“I worked as a liaison between the surgeon and the restorative dentist to make sure the case went smoothly,” he said. “I would assist the surgeon chairside with case designs, advise on implant placement for the type of restoration that the restorative doctor was planning to use, and make sure they had the components they needed. A lot of implant representatives at that time knew all about the pieces and parts of implants, but didn’t know how to integrate it all into a final restoration. That’s where I stepped in.”
Two years ago, Stronk expanded his in-office consulting to include helping dentists provide immediate-load implants. He supplies surgeons with a surgical guide for implant placement, performs all necessary laboratory work in the operatory the day of surgery with his mobile laboratory kit, and consults with surgeons to ensure the procedure runs smoothly. He lists this service as “chairside transition” and charges $600.
“It’s very important to have Jeff available to handle any questions that come up,” says Dr. A. J. Stosich, an oral and maxillofacial surgeon in Salt Lake City. “I might ask, for example, whether a certain implant will work prosthetically, or whether he can use an abutment at a certain angle. Also, there are times when you might be planning to place an implant in a certain position, but because of poor bone quality or lack of bone, you have to change plans. In those instances it is very valuable to have him there to ask about an alternative placement site.” Dr. Stosich adds that if he is working with a restorative dentist that is new to immediate-load implants, Stronk will help guide the dentist on attaining correct occlusion and seating the denture to the implant.
Stronk says the big challenge of advising on immediate-load implants is keeping up with the demand. When he started, he handled all of the consulting requests, but has since appointed two more staff members to share the workload.
Immediate-load implant consulting has proved a boon for Tom Wiand as well. He says that since he began in-office consultations four years ago, his bottom line has grown consistently despite the recession. His chairside service consists of consulting with surgeons on implant placement and alignment and completing on-site laboratory work, ie, providing the provisional immediately after surgery and, later, the final prosthesis.
He attributes the growing demand for his services to the popularity of implant centers that promise patients new teeth in a single day. Local surgeons and restorative dentists aiming to compete with the implant centers needed laboratory technicians who could complete the requisite laboratory work in the operatory the day of surgery.
“When I started this, I had no interest in going to a dental office and providing assistance to doctors,” he said. “I thought the operatory was not the place for a technician. But I also knew that if I didn’t do it, other laboratories would. And that prediction proved correct—a few laboratories around here are now consulting as well.”
Patients pay between $25,000 to $30,000 per arch for the provisional, surgery, implant placement, and final restoration, says Wiand. He adds that his laboratory bill is about $5,000 (his consulting fee is part of the overall service charge). Because the surgeons and dentists typically are unfamiliar with the immediate-load procedures, they are naturally wary of making mistakes on such big-ticket procedures, and thus turn to him for guidance, Wiand says.
“The surgeon, of course, knows how to place implants conventionally, and the restorative dentist understands how to restore these final cases, which are basically implant-supported dentures,” Wiand emphasizes. “But they need someone to help them determine how much space will be needed to restore and then to do the actual conversion the day of surgery. There’s a certain amount of room we need to get in all the implant hardware as well as the prosthesis, and the surgeon has to create that space by reducing bone.”
Wiand supplies a surgical measuring guide used to ensure sufficient bone reduction. “After the surgeon performs the osteotomy, we use a drill guide to determine the location of the implant. At that point I might ask the doctor to move the implant more toward the palate or more distally. Of course, he might not be able to do that because a nerve may be present, so he makes the final decision. But I try to get everything in the ideal position for the restorative dentist.”
The major challenge of his chairside consulting, says Wiand, is to ensure surgeons accurately perform immediate-load procedures, which “are counterintuitive to how they traditionally provide implants.”
While conventional implant procedures stress bone preservation, he explains, the immediate-load devices require added interocclusal space to accommodate the fixed detachable hybrid. Removing added bone for immediate-load implants necessarily entails excising additional tissue, which surgeons aim to avoid during standard implant procedures.
Steps for placing immediate-load implants versus implants for crown-and-bridge restorations also differ significantly, explains Wiand, who received training on immediate-load implants from surgeons and seminars. “During conventional implant placement, the surgeon places the implant into the extraction site, down in the long axis of the tooth apex,” he continues. “The implant engages the cortical bone in the socket. But if you were to use that same approach for the immediate-load implant, the implant would be in an undesirable esthetic position—the access hole would come out of the facial of the tooth. In order to get the hardware in the space we need to have the access hole in an ideal position, it has to be 5-mm to 7-mm lingual of the socket.”
Today, Wiand considers his chairside consulting on implants a major growth area for his laboratory. “Immediate-load implant procedures are still in their infancy,” he concludes. “With baby boomers’ increasing demand for the implants and the growing competition among surgeons wanting to handle these cases, we’re only at the tip of the iceberg.”
New Business Models for the Dental Laboratory
Communicating with dentists to keep abreast of their needs is a primary pillar in the business model at Keller Laboratories, Inc., in Fenton, Missouri. When Larry Weiss joined the lab more than 20 years ago, he brought with him an extensive background in finance. The goal of sustained growth soon became an integral part of the Keller culture. “We’ve created a very extensive set of metrics, including profitability, as well as customer and team measurements,” Weiss says. “We follow them very closely, and as soon as we’re not hitting our goals, we start to research to learn why we’re not. It’s doing that deeper dive to get answers.” Weiss provides the example of gold crowns, a big seller until gold prices skyrocketed in recent years. Dentists and their patients began demanding lower-priced products. “Surveys tell us that dentists’ income, business, and profitability are down,” Weiss observes. “So our priority is to stay relevant to the dentists as their business model changes.” Keller responded by offering monolithic crowns, which sell for around $109 versus $200 for gold crowns. Moreover, monolithic crowns provided an added advantage for Keller because they can be produced by CAD/CAM, making them more price-competitive with crowns produced offshore.
The Technological Imperative
Dentists’ requests for lower-priced products, along with their desire to practice high-tech dentistry, also prompted Jay Collins to add digital technology at his Cornerstone Dental Labs in Ivyland, Pennsylvania. Since last September, Collins has purchased 3Shape scanners and a 3-D wax printer. He is currently researching digital milling equipment.
Before the move to digital, Cornerstone was a traditional crown-and-bridge laboratory. The waxing, casting, and building was done by hand. “The market drove me to look at the technology,” Collins says. “I had conducted a survey among my clients to learn who’s knowledgeable and excited about the new technology.”
Survey results showed that Collins’ clientele, getting younger by the year, were very interested in the speedy turnarounds available only with high-tech equipment. One client asked whether Collins would be able to do a wax mockup of a case and get it back to the dental office in a day. “I knew I needed to get more technologically advanced for the dentists,” Collins says. “I firmly believe that within 3 to 5 years, 70% of their impressions will be digital. A laboratory that doesn’t have the ability to accept an STL file will have to rely on other vendors to design the case, make it into a model, print it, and send it back to the laboratory for the restoration. And all that only adds to the time and cost for the dentist.”
But Don Albensi, owner of Albensi Laboratories in Irwin, Pennsylvania, anticipates that the capital expense needed to add CAD/CAM technology to his business during the past two years will provide a long-term payback. For every restoration made at his US laboratory last summer, Albensi figures he had four produced overseas to meet the demand for lower-priced products. But the reduced labor costs and added productivity using CAD/CAM technology are helping to bring much of that work back. “I would say by this summer that for every four units we do here at Albensi Laboratories, only one will now go overseas,” Albensi notes.
The Dental Operatory: No Place for Laboratory Technicians?
Despite some dentists’ requests for chairside consulting, Dr. William D’Aiuto, chairman of the American Dental Association Subcommittee on the Future of Dental Laboratory Technology, questions the appropriateness of laboratory technicians being in the dental office with patients, except for a few limited circumstances. “I have great respect for dental laboratory technicians,” he says. “But the amount of input they can provide with the training they’ve had—beyond, say, helping with a difficult shade selection—is minimal.”
With current digital technology, Dr. D’Aiuto continues, even the most complicated clinical problems can be photographed and discussed with the dental technician, with mounted study models, before the restorative treatment appointment when the patient is not in the office. He adds that dentists and dental technicians will likely have a much more thorough discussion of treatment options if the patient is not present.
“After careful treatment planning, a dentist rarely requires additional expertise in the operatory,” Dr. D’Aiuto says. “The state dental practice acts of 49 states say that the only person who can do treatment planning, diagnosis, surgery, and irreversible procedures is the dentist.”
In her prosthodontic practice in Newport Beach, California, Dr. Cherilyn Sheets and her three partners employ eight dental laboratory technicians who routinely consult with doctors and patients in the operatories. Dr. Sheets makes the distinction between technicians who collaborate versus those who guide the dentist’s treatment. “Collaboration is a concept I’m very positive about,” she says, adding that dentists can benefit greatly from knowledgeable laboratory technicians’ input during both case planning and complex treatment procedures. Likewise, technicians can learn more about patients’ prosthetic needs by meeting with them compared to working with models.
But Dr. Sheets does raise concerns about laboratory technicians who provide dentists with guidance on complex treatments such as extensive implant procedures. “If you have [laboratory technicians] who are only educated at a limited number of implant manufacturers’ weekend courses who may not understand all the biological implications of the advice they are giving, and you combine that with a dentist who is a neophyte and may also not understand the biological and biomechanical implications of the advice they are getting, then you’re going to potentially have a higher rate of complications, and even failures.”
Dr. Sheets says the way to avoid these problems is to provide more multidisciplinary study clubs and hands-on courses for the dentist/dental technologist team. “That would be a great step forward for our profession,” she says.
In response, Wiand maintains that his guidance is not the equivalent of devising a treatment plan. He says he provides direction on issues such as “bone reduction to meet the space requirement necessary for the final restoration, and implant positioning for ideal spacing and position of access holes.”
Ultimately, he adds, “it is the doctor’s responsibility to understand the biological implications of the restorative choices he or she has made.”
Dr. Sheets also makes the case that “laboratory technicians’ increasing presence in the operatory points to a deeper problem in the dental profession—the lack of a standard credentialing program to ensure the quality of their input and the respectful position they deserve on the multidisciplinary oral healthcare team.”
“Dentistry in this country is missing a very important element that I believe is critical to providing quality care, and that is having knowledgeable, licensed dental technologists collaborating with dentists and helping them perform their duties,” she concludes. “There is no mandatory licensing regulatory system to give credibility to technicians who come into your office. That has to change.”
CAD/CAM, the Dental Laboratory, and the Great Recession
Ed Corrales, CDT, needed a plan to save his career. Driving home from his 15-year-old crown-and-bridge dental laboratory in San Diego one late November day in 2008, Corrales’ growing preoccupation with the country’s economic downturn—and its impact on his business—had come to a head. His profits—half of what they had been the previous year—were in a tailspin. It was eminently clear that his business strategy up to that point—a slippery mix of forbearance, toughing it out, and rootless hope—was only helping to propel his company to the edge.
“We were heading into the holidays, and I had bills but no money or cases,” Corrales recalls. “It was scary. It looked like I might have to close my Downtown Dental Designs laboratory. I knew I had to do something.”
During the next few days, Corrales took stock of his strengths. A Las Vegas Institute (LVI) master ceramist and a participant in Pacific Aesthetic Continuum (PAC) Live continuing education seminars, Corrales had extensive education and experience in smile design, including extensive use of the CEREC® chairside milling system. He knew that while about 15% of dentists in the country had a CEREC machine, few were sufficiently adept with the technology to handle anterior cases. He telephoned a nearby dentist friend who had the technology and offered to provide a complete makeover for a patient in a day. “That case turned out great,” Corrales says. “Then we did a few more, and I started posting before-and-after photos on Facebook to get the word out about my new service.” He also sent advertising postcards to dentists.
Gradually, dentists’ orders for Corrales’ service grew. Today, 2 ½ years later, he handles two same-day smile cases a week, spending about 4 hours on each patient. Profits from his new company, CadSmiles, have long since made up for his 2008 losses, and adding digital technology has helped boost business at his laboratory as well. “This same-day-smile service is pure profit,” he says. “I don’t use my equipment; my only overhead is the gas I use driving to the dentist’s office. And if I have to go out of town, the dentist covers my traveling expenses.”
Blazing New Paths
Corrales’ achievement illustrates the type of new business strategy needed to survive what industry observers claim is the most calamitous era in the history of the dental laboratory industry. For one, the recession has cut deeply into cost-conscious consumers’ demand for dental services. According to the Levin Group Inc., an international dental practice-management consulting firm, between 2006 and 2010 general dentists saw a 17.8% decline in business. Moreover, cosmetic treatments have dropped by at least 25%.
For dental laboratory owners, problems from the slackening demand for dental services are compounded by the growth of offshore trade’s capture of an ever-greater share of the US marketplace. The National Association of Dental Laboratories (NADL) reports that in 2006, offshore manufacturers made 17% of the crown-and-bridge units in the US market; by 2010, offshore laboratories had captured 38% of the market.1 Decreasing demand in this country and increasing competition from abroad have eroded the US laboratory industry. Citing US Labor Department statistics, NADL Executive Director Bennett Napier notes that during the past 36 months, both the number of commercial dental laboratories and dental laboratory workers have declined by 22%.
Survivors like Corrales emphasized taking control of their companies’ growth by adding new services, revamping their product lines to focus on profitability, incorporating new technology to boost efficiencies, reduce turnaround time, and better compete with offshore manufacturers, thus adapting marketing strategies to educate dentists about their new capabilities, and closely tracking dentists’—and their patients’—evolving needs. “The Great Recession has nailed down a new reality—dentists have no choice but to change laboratories when they need to satisfy money-strapped patients’ demands for lower-priced products,” he admits.
1. National Association of Dental Laboratories. Costs of Doing Business in 2010: Panel Survey. 2010. Tallahassee, Florida: National Association of Dental Laboratories; 2010.
Laboratories Are Now Education Centers
When laboratory owners do commit to purchasing new technology, the expense demands extra planning, they say. At Nakanishi Dental Lab in Bellevue, Washington, owner Dave Nakanishi, CDT, decided within the past year to step up his technological capabilities by adding a variety of new equipment. “The technologies we’re using today—CAD/CAM mills, laser sintering, wax milling, 3-D printing—are able to provide us with economies of scale,” Nakanishi says. “You have to make these restorations in volume; otherwise you can’t justify the cost and eventual obsolescence of the technology. Our business model today says we have to pay for equipment within 24 months, whereas it used to be 5 to 7 years.”
Camaraderie among dental laboratory owners has helped Nakanishi avoid shutdowns due to technological malfunctions. When overloaded with orders, he occasionally sends files to a nearby laboratory for milling. In addition, Leon Hermanides’ Protea Dental Lab has helped out with sintering jobs, and Nakanishi frequently undertakes work for other laboratories.
Peer support and networking have also proved a pivotal factor in helping Steve Killian, CDT, to devise a new business strategy for Killian Dental Ceramics in Irvine, California. As the recession deepened and his cosmetic cases continued to slide, Killian began searching for new opportunities. During meetings with dental laboratory working groups, other laboratory owners shared their recent successes in helping dentists provide All-on-4 dental implants. “We learned that there were a lot of potential cases out there to be had and that few dentists know how to handle them,” Killian says.
Consequently, Killian is currently devising an education campaign to help dentists sell the cases to patients. “We’re just beginning to get the word out. We have educational materials that include what the treatments entail, what they cost, and how to present them to patients.” Killian also plans to contact all the oral surgeons in the Irvine area and invite them to a “lunch n’ learn” at his laboratory, and make presentations at dentists’ study clubs. “I have been working very hard to educate myself about this treatment in order to help doctors become confident to educate their patients,” Killian says. “A lot of labs are sharing educational materials, and everyone’s talking about the opportunities.”
Given the upheaval the laboratory industry has faced in recent years, the cooperation among laboratory owners is notable. In fact, one might add “mutual aid” to the list of strategies laboratory owners are implementing to ensure their survival. Nakanishi sums it up as “great competitors working together.” He adds, “We need each other now more than ever.”