Inside Dental Technology
February 2011, Volume 2, Issue 2
Published by AEGIS Communications
Fast Forward 2020
Envisioning the next decade in dental technology and the dental laboratory of the future.
By Pam Johnson
How will dental technology evolve over the next 10 years? What will the industry and the profession look like in 2020? Ask 10 industry professionals these questions, and you will likely get 10 distinct answers. However, they agree that one thing is certain—the dental landscape will look considerably different a decade from now. The consensus is that the coming years will be more complex and uncertain, there will be fewer laboratory businesses servicing the dental industry, and new technologies will play an even larger role in shaping the industry’s future. For laboratory owners who can adapt to these changes, the next decade will provide incredible new business opportunities.
“If we are smart as an industry, learn from those industries that have undergone a similar transformation, and take advantage of what they did correctly, then I think this industry has unlimited opportunities,” says Buddy Pickle, chief executive officer of Dental Services Group, headquartered in Minneapolis, Minnesota.
But those opportunities will come at a price. Most believe the effects of the Great Recession will continue to reverberate globally in the next decade.
This aftershock promises to keep growth slow, credit tight, and uncertainty deep-seated in the marketplace, which will keep the driver of dentistry, the consumer, on edge and holding on desperately to the shrinking dollar. Smaller laboratory operations will have difficulty keeping pace with the colossal shift from labor- to capital-intensive production and continued downward price pressures from offshore and larger, high-volume operations. And new capital from outside the industry will do battle with large dental manufacturers for position and market share.
“The traditional competitive strategy and competitive advantage links between supplier/client and client/customer formed over the last 50 years in dentistry are breaking down and re-forming,” says Patrick Tessier, BSME, MBA, chief executive officer of Modern Dental Laboratory in Bellevue, Washington. “We are seeing history in the making.” And as businesses shift to re-form and reconnect these links, a new industry structure will emerge.
The next decade will bring information and computing power that is even more accessible and affordable. Markets will become increasingly interconnected, and with that, small businesses will find opportunity in specialized products and service niches to satisfy client demands that are more customized. “Smaller businesses will need to form alliances with larger corporations to stay in business and maintain a competitive edge,” says Kim Bradshaw, chief executive officer of Dental Technologies Inc in Dublin, California.
Small businesses will provide larger operations with a more in-depth knowledge of the customer base, which will enable them to expand existing markets and also to create new ones. In return, the smaller partner will reap the benefits of access to capital, marketing power, and business growth. The larger operations will grow ever bigger to compete effectively in a global economy where the customer becomes less concerned about where goods and services originate or who produces them.
Underlying and enabling all of these changes are advances in technology. New high-tech innovations will become more complex, more intuitive, and more robust and will integrate with one another to offer seamless operation and function. Large laboratories and laboratory networks will invest millions of dollars in equipment and engineering expertise over the next decade to hone manufacturing efficiencies to a level competitive with offshore production and pricing. “Digital technologies will allow us to curb the flow of products going overseas and bring that production back stateside,” says Josh Green, president and chief operating officer of National Dentex, the largest owner and operator of dental laboratories in the US.
New materials and techniques will also emerge to simplify production processes, decrease production times, and reduce the price of the finished product. “I think we are on the tip of the iceberg in terms of the range of materials these CAD/CAM technologies can and will be producing in the future,” says Paul L. Child, Jr., DMD, CDT, the chief executive officer of the CR Foundation.
Regardless of which path dental technology and dentistry will take to reach the next phase in their evolution, all of these industry leaders agree the “business as usual” mindset is not a sustainable strategy for survival. The future will call for a new type of dental technologist—one who is highly educated, demonstrates a knowledge of material science and a keen business acumen, and possesses a broader skill set that is more in tune with the digital environment.
Industry in Transition
The industry is out of balance and looking for equilibrium. The traditional power base of small, single-proprietor businesses is losing ground to the high-volume domestic and overseas producers. Meanwhile, the mid-sized operations are struggling to catch up with the established mega producers, start specializing, or be consumed. The laboratory’s customer base is beginning to evolve and stratify as more group practices, associate and corporate dental clinics, and specialized practices are springing up and changing the clinical landscape.
The depreciation of dental technology education and the transition from hand artistry to machine-produced restorations has caused a subtle shift in the perception that some general dentists hold about the domestic dental laboratory industry. Unfortunately, some see it becoming a less-educated, blue-collar manufacturing entity, Dr. Child says. He laments the decision some universities have made to move dental technology programs offsite, reduce or eliminate laboratory procedures in the dental school curriculum, and eradicate the valuable face-to-face interaction with dental technicians. “It has exacerbated the devaluation of the technician’s collaborative role for the general dentist,” Dr. Child says. “It’s also resulted in the average general dentist’s inability to speak intelligently to a technician, take a respectable impression, or properly prep a tooth. I’m disappointed in the direction the industry is moving on both sides of the spectrum.”
As technicians in the US have begun to place less value on education, some see a chasm forming between the educated and the uneducated, the step worker versus the highly trained, skilled technologist, and the high production mega-manufacturing facility as opposed to the boutique or specialized laboratory. Daniel Alter, BS, MDT, CDT, a professor at the New York City College of Technology, believes the créme de la créme of dental technologists will become highly paid consultants to the dental community in the future. Working from stand-alone business offices, these professionals will sit behind a desk outfitted with sophisticated communication technologies or consult onsite with dentist clients on complex cases at their practices. The technologist would then CAD-design a case before sending the digital design file to a manufacturing center, where in-line production technicians would manufacture the final product.
“The future for technologists with advanced training looks bright,” says Dana Cohen, CDT, who is a professor of Dental Science and the department chair of Dental Technology at Los Angeles City College. “The need for highly educated technologists will always be there and play an even larger role in helping our clients plan and execute complex cases in the future,” he says. However, those who are formally educated in this industry currently represent only about 5% to 10% of the laboratory technologists in the US. And that is problematic for an aging industry that is struggling to attract, educate, and graduate technicians.
Sophisticated cases, however, are not the backbone of this industry. What about the simple posterior single- and three-unit bridge cases that make up the lion’s share of the industry’s workload? Driven by a stressed economy and the lower value that dentists and patients place on posterior restorations, many believe these crowns and bridges are destined to move from the small and mid-sized labor-intensive laboratories to large industrialized centers where they will be produced by machines or to overseas operations where labor is cheap.
“Unfortunately, I see a mass exodus of restorative work from the US going overseas,” Dr. Child says. “To me, it’s a simple matter of supply and demand.” He believes domestic laboratories cannot possibly meet the future demands of dentistry in this country. That is because more than half of the industry comprises small one-and two-man laboratories. Not only are these US-based businesses reducing in number, but most of those remaining do not have the financial means to acquire expensive high-production milling technology. If the industry does not have the ability to produce in volume, demand in this country will always exceed supply. “As long as the labor costs remain low overseas compared to the high cost of automation, automation will never be able to meet or beat that offshore threat,” Dr. Child predicts.
Move to Restructure
With small businesses finding access to funding and technology difficult in this economic climate, undercapitalized laboratories should be thinking about partnerships with larger corporations that have horsepower, Bradshaw says. Otherwise, it is inevitable that the industry will shrink. “The forward-thinking business owner who seeks shelter and builds an alliance today could potentially weather the storm,” she suggests.
This is a viable solution, Green says, if the smaller operators can change their production mindset. He sees a healthy financial and competitive future for those that utilize the restorative resources of larger laboratories to supplement what they produce locally. “They can provide their customers with a better product, faster, on time, every time,” Green says.
Tessier sees the beginnings of this movement happening already. “You’re seeing businesses band together or cooperate in a much more structured manner in order to share the costs of capital and the capital risk associated with the changeover to a capital-intensive industry,” he says.
Along with this shift, even more private equity funds will be injected into the industry to take it to the next level. “This is a market ripe for value creation,” Pickle says. “You will see a pent-up private equity demand look at this market because it is so disaggregated. Even the market leaders in this industry own such a small market share.”
In an industry that iData Research valued at an estimated $10.7 billion in 2009 and expects to reach $14.6 billion by 2014, the gold rush for market share will not go unchallenged by the establishment. To some, the more considerable move is the one that dental manufacturers are making. Many of the large, mostly international, corporations seem to be positioning themselves and preparing to go directly to the dentist. “We are going to see cross-channel competition in this industry coming from the large dental suppliers,” says Mark Jackson, RDT, owner of Precision Ceramics Dental Laboratory in Montclair, California. “The cost of restorative services can go way down if you take the laboratory out of the equation.” And what could be simpler for the dentist than to take a digital impression and push a button on his computer screen to simultaneously send the digital file and order a major crown brand from a corporate milling center? The restoration could be delivered the next day via FedEx®, or produced and delivered by a satellite corporate lab in the dentist’s area.
Supplier as competitor does not sit well with the big laboratory players in the industry—they are challenging this new competitive set with their sheer buying power. “The relationship between the laboratory and the dentist is the strongest relationship that the dentist has,” Green says. “If (the manufacturers) think they can intrude on that relationship, then we will need to rethink our purchasing strategies.”
Tessier says this is one more example of the massive changes taking place in the dental technology industry, where the traditional business links that have bound it together for the last half-century are breaking down and being re-formed. “It’s happening faster than most are comfortable with, and no one knows what the dominant strategy will be,” he says.
Business Landscape of the Future
So what will the industry structure look like a decade from now? No one can predict precisely how the jockeying for position and domination will play out. But the erosion of the one-, two-, and three-person businesses—the largest segment of the industry—is certain. Steve McGowan, CDT, believes the constriction of smaller laboratories is necessary to keep the industry healthy. “There are just too many technicians in the market who are merely dental mechanics. They produce work but don’t invest in higher education and training,” says McGowan, who owns Arcus Laboratory in Kenmore, Washington. “An uneducated workforce is not sustainable for the future needs of dentistry.”
As awareness grows within the dental community that there is a shortage of highly trained technicians in the workforce, those technicians who do invest in advanced education may find themselves employed in the practices of high-end specialists in the future. Dr. Child and his group have seen a growing trend in this direction. More technicians may also join the payrolls of group practices and large corporate dental enterprises.
For mid-sized laboratories, especially those in the 20- to 40-employee range, the challenge becomes growing the business quickly enough over the next decade to compete with large, high-volume production centers on and offshore or risk being acquired by one of the mega laboratory operations.
“I was one of those mid-size labs at risk,” Jackson admits. “My solution has been to change my business focus.” He now considers the bread-and-butter work that comes into his laboratory an added bonus. He has refocused his business to engineer large, sophisticated cases that require multiple disciplines. “We are specializing in cases that involve 3-D imaging, computer-guided surgery—what I call engineered dental technology,” Jackson says. “This is the future I see for larger mid-size laboratories that have the capital resources to invest and want to carve out a sustainable niche.”
Jeff Stronk, president of National Association of Dental Laboratories, agrees that the value of the educated dental technologist is most appreciated and needed in handling large, complicated cases. “The laboratories that value education, stay abreast of trends, technology, and material developments and become a resource for their clients will be successful in the future,” says Stronk, who co-owns Treasure Dental Studio in Salt Lake City, Utah.
Smaller five- to 10-man operations that make smart investments in scanning and design technologies will become the gorilla force of the industry, says Larry Stites, owner of Allure Dental Studio in Tracy, California. “Small operations like mine are able to be nimble, and react and adapt quickly to changes in the market,” he explains. “We can send files anywhere around the world and produce anything the big boys can.”
For the high-end boutique laboratory, the key to survival lies in education and working at the highest level of dentistry. But finding patients who will pay for that level of treatment in this economy worries some high-end technologists like Joshua Polansky, BA, MDC. “You have to fight for and value every customer and every patient that comes your way today,” says Polanksy, who owns Niche Dental Studio in Cherry Hill, New Jersey. “Because the industry is moving toward commodity-based dentistry, I think only 2% to 3% of the boutique laboratories will survive in the end.”
However, Tessier believes there will always be a market for the niche laboratory whether the restoration is being made by hand or on a computer, and the educated dental technologist will always be in demand and rewarded financially for that knowledge. “Even 10 years from now, all this technology will not be able to do everything,” he notes.
Pickle agrees but says survival for small boutique business models will require them to become even more boutique-oriented with a sharp focus on a particular customer segment, product, or demographic. “Boutique labs can’t be all things to everyone and compete with the big providers,” he says. “But no matter what size business you have, it will become ever important that you determine and sharpen your business strategy, your vision, and your value proposition to your customer base to remain competitive in this changing environment.”
Shift to Technology
And the dental environment is destined to change. The flood of high-tech production equipment, communication media, and collaboration technologies coming into the market offer laboratories and dentists new tools for delivering unprecedented precision in patient care. “Technology is changing so quickly, it’s hard to keep your sights on a moving target,” Jackson explains. “It makes it difficult to predict where you are going because yours eyes are fixed on the horizon to see what’s coming next.”
Over the next decade, hardware and software technologies will get even smarter, helping dental professionals make everyday decisions and streamline complex tasks. And not all new developments will originate from the major manufacturers. Large laboratory groups are becoming part of the creative development process, and have tapped into engineering minds to produce next-generation technologies. “We’re currently developing software that will let the dentist know in real-time, while he’s taking a digital impression, that his preparation doesn’t have enough clearance for the type of restoration he is prepping for,” Green says.
Dentistry today finds itself undergoing an industrial revolution—albeit 100 years later than most other industries, Tessier notes. Bradshaw agrees that the industry is transforming and the revolution has begun, but the transition from labor- to capital-intensive production is still in its infancy. She suggests that all thriving industries arrive at this point, where they move from manual labor, complicated techniques, and materials that are difficult to find to innovative ways to build it better, faster, and cheaper. “We have barely scratched the surface as to what is possible,” Bradshaw remarks. “Every major industry has changed with the introduction of technology, whether that is the automotive and computer industries or the healthcare system. Technology allows us to respond to the demands of the ever-changing client. Human beings don’t like to wait; we want what we want, when we want it.” Consumers drive demand, and that means giving them precisely what they want so that they do not look for another way to get it. For that reason, Bradshaw believes the dental space must flex and respond accordingly.
That is why the initiative of laboratories to supply their customers with digital impression technology makes so much sense to Pickle. “Technology advancements driven by market demand force change,” he says. “That’s why we’ve instituted a customer-driven scanner rebate program. It’s is a win-win for everyone, especially the patient.” And the faster adoption is driven, the lower the price point will become for these technologies.
Dr. Child thinks it will take longer than a decade for chairside technologies like intraoral impressioning to dominate the industry. “The technology we have now is just beginning to touch all the possibilities and must improve,” he suggests. “I think there are new technologies out there that we can’t even envision. They will evolve and trickle down from other industries.” These new developments will eliminate the shortcomings of current scan technologies and speed up the process. They will be able to simultaneously scan through tissue and teeth and differentiate the various restorative materials in the mouth. Dr. Child notes the development of ultrasound technology that “can scan the entire tooth in 1 second and create a 3-D image delineating cracks in the tooth or small lesions under existing restorations.”
Pickle believes technological advances will give laboratories that can afford them the ability to meet the two primary demands of the dental customer—consistency and ease of doing business. They will also fundamentally change the way the industry does business. Many industry professionals envision “design, assemble, and service” as the reality for laboratories in the future.
This means the role of the future technologist will evolve into more of a computer software operator and designer, says Ian Taylor, FBIDST, owner of Castle Ceramics in Staffordshire, England. In the practice, the dentist will have a range of digital technologies to perform a complete diagnostic work up of the patient—assessing, charting, and prioritizing treatment protocol from caries removal to TMJ and occlusion equilibrium analysis, orthodontics, and implant placement. The virtual patient’s digital treatment plan data will be sent to the laboratory for technicians to fabricate prototypes of the expected treatment outcome. Using biogeneric algorithms, technologists will propose the optimal esthetic and functional outcome, and provide clients with milled or printed diagnostic wax-ups and indexes for treatment acceptance and tooth preparation. Restorations will be milled, and individual tooth shade and characterization will be applied to ceramics or similar materials in a 3-D process.
Stites sees direct manufacturing of long-term temporaries and even ceramic crowns as a niche possibility for the future that has yet to be realized. “Unfortunately, all the principles of esthetics we studied with the great masters, such as tooth characterization and crack lines, are being lost on the patient and going away,” he laments. “Patients don’t know the difference, and apparently don’t appreciate the difference or want to pay for it.”
Price has always been a driving force in dentistry, as Dr. Child sees it. He points to many studies that have been done on what type of quality the public is able to discern. They show that most patients cannot make the distinction between a grade A and grade B restoration. So if the grade B restoration costs the dentist less and is easier and faster to get, then price will influence their choice.
“Patients want instant gratification and an affordable great white smile,” Jackson stresses. “Taking a month or two to create that smile is no longer acceptable for the masses.” He says dental technology has always been a mix of art and science, but as the next decade progresses, the artistry is going to fade away, and math and science will dominate the industry. This shift will bring new blood into the industry—with a completely different knowledge base and skill set and a new outlook that will take the industry to the next plateau.
Coupled with industry efforts to slow the stream of restorative work offshore, the consumer demand for affordable, yet biocompatible, esthetic restorative solutions has manufacturers working rapidly to develop newer CAD/CAM machinable and printable materials. “The money being put into material development right now is more than what is being spent on technology development,” Green says. “Our industry is about to be catapulted into the future, and we have to be prepared to take advantage of that.” There is no doubt in Green’s mind that the industry is hastening to create a range of monolithic metal-free materials that is well-suited to automated manufacture, strong, durable, and esthetically-pleasing, yet kind to opposing dentition. “These new material developments will put us on a level playing field with offshore production,” he predicts.
What the material of the future will be is a matter of opinion. Jackson believes the modified composite resins used in the defense and aeronautic industries may be candidates. As the US military pulls back from conflict areas around the globe, the companies that make these materials will search out new markets. And composite resin materials lend themselves well to 3-D printing technology, which Jackson says is infinitely more efficient for producing the end product. “You could take the digital impression and digital photo of the patient and even a face scan, forward that data along with digital color mapping of adjacent teeth to a production center, and have them print out a crown with all the gradient color and characterization,” he says.
Green thinks millable composites also make sense because they are less abrasive to mill than ceramics and require much less bur replacement. He has even seen a Kevlar material that was crafted to look tooth-like.
Dr. Child sees potential in polymers because of their high strength and low cost. “We need what Rella Christensen calls the Volkscrown—a restoration that is easy and fast to make and durable enough to hold up well in the mouth,” he says. Stites agrees that temporary materials with the same 5-year life expectancy of a porcelain-fused-to-metal could be developed at a fraction of the cost. This would provide a restorative solution for those challenged by the costs of mainstream dentistry.
Cariostatic materials, both chairside and laboratory, are in another area of development that Dr. Child believes will experience extreme growth. “These materials will help block the caries process,” he explains. “Indirect materials will be manufactured in whole or in part in the laboratory but carry a cariostatic property to improve the lifespan of that tooth.”
As new sophisticated and technique-sensitive indirect materials are introduced over the next decade, technicians will have to become much more knowledgeable about material science and adhere more strictly to fabrication and manufacturing protocols.
With more restorations being manufactured with less human intervention, Cohen is concerned about the potential to harm natural dentition. “As we push more and more all-ceramic units even faster through the production chain process, chances are the less polish the occlusal and incisal aspects of the restoration will receive,” he says. “The less polish they receive, the more they will wear opposing natural dentition.” It is just as critical if the dentist makes adjustments chairside and does not perform the final polishing afterward.
Surviving the Years Ahead
For some in the industry, the future holds great promise and exciting prospects—for others, the ongoing changes are disorienting and uncomfortable. Dentistry has always been a conservative industry that is slow to change, but pressures from the laboratory industry, the consumer, and big business are forcing a market stuck somewhere in the 20th century to move closer to the realities of the 21st century.
History tells us that surviving any change requires knowledge and a willingness to adapt. “Education wins out every time,” Tessier says. “Staying abreast of market changes, adapting to those changes, and educating yourself on the advanced segments of dental technology is the ultimate defensive weapon. It’s true in life and it’s true in business.”