Digitising your implant practice

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CBCT volume to aid in planning for mandibular implant placement. (Image: Dr Ross Cutts)

Thu. 3. May 2018

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Undoubtedly, digital dentistry is the current topic. Over the last five years, the entire digital workflow has progressed in leaps and bounds. There are so many different digital applications that it is sometimes difficult to keep up with all the advances. Many dentists are excited about the advantages of new technologies, but there are an equal number who doubt that the improved clinical workflow justifies the expense.

I have many times heard the argument that there is no need to try to fix something that is not broken. It is so true that impressions have their place and there are certainly limitations to the digital workflow that anyone using the technology should be aware of. For me, however, the benefits of digital far outweigh the disadvantages. In fact, the disadvantages are the same as with conventional techniques.

Chairside CAD/CAM single-visit restorations have been possible for over 20 years, but it was only recently that we became able to mill chairside implant crown restorations after the release of Variobase (Straumann) and similar abutments. I made my first CEREC crown (Dentsply Sirona) back in 2003 with a powdered scanner, and the difference from what I remember then to how we can make IPS e.max stained and glazed restorations (Ivoclar Vivadent) now is amazing.

An investment not an expense

The results of a survey regarding the use of CAD/ CAM technology were published online in the British Dental Journal on 18 November 2016. Over a thousand dentists were approached online to take part in the survey and the 385 who replied gave very interesting responses. The majority did not use CAD/CAM technology, and the main barriers were initial cost and a lack of perceived advantage over conventional methods.

Thirty per cent of the respondents reported being concerned about the quality of the chairside CAD/CAM restorations. This is a valid point. We must not let ourselves lose focus that our aim should always be to provide the best level of dentistry possible. For me, digital dentistry is not about a quick fix; it is about raising our performance and improving predictability levels by reducing human error.

In the survey, 89 per cent also said they believed CAD/CAM technology had a major role to play in the future of dentistry. I really cannot imagine that once a dentist has begun using digital processes that he or she would revert to conventional techniques.

What is digital implant dentistry?

Many implant clinicians have probably been using CAD/CAM workflows without even realising it, as many laboratories were early adopters, substituting the lost-wax technique and the expense of gold for fully customised cobalt–chromium milled abutments (Fig. 1).

One of my most important goals in seeking to be a successful implantologist is to provide a dental implant solution that is durable. We have seen a massive rise in the incident of peri-implantitis and have found that a large proportion of these cases can be attributed to cement inclusion from poorly designed cement-retained restorations (Fig. 2). Even well designed fully customised abutments and crowns can have cement inclusion if the restoration is not carefully fitted (Fig. 3). This has led to a massive rise in retrievability of implant restorations, with screw-retained crowns and bridges now being the goal. However, making screw-retained prostheses places even greater emphasis on treatment planning and correct implant angulation.

With laboratories as early adopters, we have been milling titanium or zirconia customised abutments for over ten years (Fig. 4). What has changed recently in the digital revolution is the rise of the intraoral scanner. We now have a workflow in which we can take a preoperative intraoral scan and combine this with a CT scan using coDiagnostiX (Dental Wings) in order to plan an implant placement accurately and safely. We can also create a surgical guide to aid in accurate implant placement, have a temporary crown prefabricated for the planned implant position and then take a final scan of the precise implant position for the final prosthesis.

Accuracy of intraoral scanners

Figures 4 to13 show the workflow for preoperative scanning, which includes the implant design, guide fabrication and surgical placement of two fixtures. Intraoral scanners have improved over the last few years, and their accuracy and speed provide a viable alternative to conventional impression taking. The digital scan image comes up in real time and you can evaluate your preparation and quality of the scan on the screen immediately. Seeing the preparation blown up in size no doubt improves the technical quality of your tooth preparations. The scan can then be sent directly to the laboratory for processing.

While we do not think of intraoral scanners as being any more accurate than good-quality conventional impressions, there are many benefits of scanning, such as no more postage to be paid for impressions, vastly reduced cost of impression materials, almost zero re-impression rates and absolute predictability.

Of course, there are steep learning curves with the techniques, but once a clinician has learnt the workflow, there really is no looking back.

We have three different scanners in the practice: the iTero (Align Technology), the CEREC Omnicam (Dentsply Sirona) and the Straumann CARES Intraoral Scanner (Dental Wings; Fig. 14). The CEREC Omnicam is fantastic for simple chairside CAD/CAM restorations, such as IPS e.max all-ceramic restorations on Variobase abutments. For truly aesthetic results, we, of course, still have a very close working relationship with our laboratory, but, undoubtedly, patients love the option of restoration in a day. Being able to scan an implant abutment and then an hour later (to allow for staining and glazing) fitting the definitive restoration is a game changer. Patients also love watching the production process as they see their tooth being milled from an IPS e.max block.

Figures 15–19 show the production process, including the exposure of the implant, the abutment seating, the scan flag on top of the abutment, the healing abutment during fabrication and the delivery of the final prosthesis. However, for more than single units or aesthetic single-unit cases, we use the iTero and Straumann scanners. The latter we have only had at our disposal since February. While it is a powdered system at the moment, this is due to change this month. Particularly with implant restorations, the need to apply a scanning powder is a limitation, owing to a lack of moisture control contaminating the powder. The technology, however, is superb, as is the openness of the system, which provides the advantage of being able to export files into planning software. A colleague of mine even uses it for his orthodontic cases now instead of wet impressions.

We invested in the iTero scanner five years ago and have used it for everything, from simple conventional crowns and bridges to scanning for full-mouth rehabilitations. When fabricating definitive bridgework, we use Createch Medical frameworks for screw-retained CAD/CAM-milled titanium and cobalt–chromium frameworks. Even though intraoral scanning appears extremely reproducible and accurate, I still use verification jigs where needed to ensure our frameworks are as accurate as possible. There are many intricacies that we consider and tips and techniques that we employ to make the scans more accurate that we have developed over time. The closer the scanbodies are together, the more accurate the scan is. Also, the more anatomical detail, such as palatal rugae or mucosal folds, the better the scans can be stitched together.

Figure 20 shows a CBCT volume to aid in planning for mandibular implant placement (Fig. 21) and realising the implant placement. We exposed the fixtures and placed Straumann Mono Scanbodies (Fig. 22). Then, we took an iTero scan of the fixtures in situ (Fig. 23) and made a verification jig from this (Fig. 24) to ensure passive implant positioning. The iTero models were made (Fig. 25) and a Createch titanium framework was used to support porcelain in a screw-retained design (Fig. 26). The last two figures show the excellent outcome and accurate framework seating (Figs. 27 & 28).

Choosing your workflow

There are many different systems on the market now, each offering a one-stop shop. If you are considering investing in a digital scanner, then take some advice from colleagues. One of the most important things is to ensure the system you opt for is an open one that allows you to extract the digital impression data into different software. We extract our files into CT planning software, model production software, chairside milling for stents, temporaries and definitive restorations, and now orthodontic planning software. I am convinced there will be yet more advances with time. The size of the camera is critical—some can be very cumbersome—and it is worth asking the salesperson what developments are underway.

Some companies are more on the cutting edge than others. My favourite at the moment is the Straumann scanner. Its design is light and user-friendly and it synchronises perfectly with implant planning software coDiagnostiX. Furthermore, while it offers a chairside milling unit, it also synchronises perfectly with my laboratory for larger cases.

To conclude, digital implant dentistry is the future and so why not take advantage of it and help improve your clinical outcomes?

Editorial note: A list of references is available from the publisher. This article was published in CAD/CAM - international magazine of digital dentistry No. 03/2017.

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Dental consultant Chris Barrow is advising dental professionals to raise their treatment prices sooner rather than later in order to stay profitable in the current financial situation. (Image: Khakimullin Aleksandr/Shutterstock)

Thu. 1. December 2022

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I am delighted to have been asked by Dental Tribune International to share my observations and thoughts about where we are heading over the next few years and how this affects the way that UK dental professionals run their dental businesses. There has never been a period of such disruption, not just in dentistry but for all of us—and it is against that backdrop that I want to help plan for a secure future. In this article series, I am going to review each of the five basic systems that dental professionals need to have in place and offer my guidance as to how best to prepare. This first part will focus on financial systems in dental practices.

Five basic systems

I am the proud owner of a signed 1999 edition of Michael Gerber’s The E-Myth Revisited—Why Most Small Businesses Fail and What To Do About It. Published four years earlier, The E-Myth Revisited remains a classic, whose message is as relevant today as when first penned and to which I refer all my new clients. Gerber was the first to describe the five basic systems necessary to operate all businesses, and I offer his definitions here with a dental spin to apply them to our landscape:

  1. financial systems (which I will discuss more in this article);
  2. lead generation systems (how we attract new patients and sell more to existing patients);
  3. lead conversion systems (how we enrol people as long-term patients and how we ethically explain and sell treatment to them);
  4. operational systems (how we run the business on a day-to-day basis and remain compliant);
  5. people systems (how we create, lead and manage teams and how we create a work environment in which people want to do their best).

These offer timeless wisdom that I have been interpreting on behalf of my clients in dentistry for a quarter century. However, little could have prepared any of us for the consequences that have unfolded since two unrelated events—Brexit and the COVID-19 pandemic—have changed the landscape in many ways and created dangers for the unwary.

So where are we now?

It would be easy to dwell on the bad news currently circulating in the marketplace; however, in setting the scene for this series, I want to present a balanced view—preferring to avoid doom and gloom as well as false optimism.

Twelve reasons to be miserable:

  1. the continued demise of NHS dentistry (the longest death scene in history);
  2. the recruitment crisis (nobody replies to our adverts);
  3. the retention crisis (my team members are leaving dentistry);
  4. the poaching crisis (my team members are leaving for better money in dentistry);
  5. the wages crisis (I am revising my 20-year-old key performance indicators [KPIs] on team wages from 17.5% to 25.0%);
  6. the pricing crisis (we need to put our prices up by 25% to stand still—how are we going to do that?)—more on that later;
  7. the EBITDA (earnings before interest, taxation, depreciation and amortisation) multiples crisis (the mergers of some of the largest dental groups in the UK, deflates multiples, as does the increased cost of borrowing—some have predicted a 25% reduction in goodwill values before year end);
  8. the exit crisis (more of my clients have their practices up for sale than at any time before—hardly surprising given what I have listed so far);
  9. the energy crisis;
  10. the inflation crisis (the Bank of England suggesting an inflation rate of up to 18%);
  11. the consumer confidence crisis (when all this bad news impacts patients and leads to treatment plans being delayed or not being taken up);
  12. yet another new prime minister and cabinet whose hands are going to be full.

These are enough to make an owner want to sell. I think we need some balance. Here is a list of what I see as the good news among all this doom and gloom.

Twelve reasons to be cheerful:

  1. Correctly utilised, the intra-oral scanner is the single greatest revolution in the delivery of oral health education and advice in a generation.
  2. Similarly, the intra-oral scanner is the single best treatment generator ever invented.
  3. The training of dental nurses registered with the General Dental Council (GDC) and of treatment coordinators in the use of intra-oral scanning allows greater use of the new technology to wow patients and frees up clinicians’ time to generate profitable revenue.
  4. The rise of dental deserts across the UK makes compulsory dental plan membership (and conversion) easier than at any time since 1996.
  5. Over the last six recessions (through which I have lived and worked), the sale of the very highest value and most complex dental treatment has remained robust—the more you focus on the dentistry that most dentists are either too scared or too unmotivated to invest in, the busier you will be.
  6. The effective collection of Google reviews puts automated search engine optimisation within the grasp of any practice and at no cost, thus eliminating the need for the smoke and mirrors of digital advertising.
  7. The GDC scope of practice for dental therapists opens up a whole new world in the provision of preventive maintenance on profitable terms and without the need for principals to be drowning in check-ups.
  8. The ability to grow therapist- and associate-led businesses frees the principal from the shackles of a performance-related earnout on sale.
  9. The effective and responsible use of social media generates new patients more cost-effectively than ever, resulting in decreased marketing costs.
  10. The more corporates and micro-corporates emerge amid the current recruitment and retention crisis, the more the trend towards salaried clinicians and the demise of the broken percentage/hourly rate model will continue, resulting in better profit margin management for owners.
  11. The more practices are gobbled up by corporates and micro-corporates, the less competition there is for independent owners, because corporate dental marketing is almost always poorly designed and executed.
  12. During the 2008 banking collapse, goodwill values dropped by 25% almost overnight—that lasted for 18 months before they were back and beyond their previous highest levels because there is no such thing as a crisis—there are only cycles.

So now you can decide: is your glass half-empty or half-full?

Nine steps to financial confidence

Against this backdrop, I intend to identify winning habits, trends and actions in this article series that are keeping my best clients at the top of their game, despite the challenges they are facing. This is a summary of the nine characteristics of dental practices whose financial systems are excellent and their owners thus confident:

  1. The owners understand their profit and loss statement, they are in receipt of updated management accounts every month (from cloud-based accountancy software) and set aside the time to review the numbers.
  2. KPIs are monitored monthly to spot trends and compare against industry benchmarks.
  3. Every year, a 12-month budget and cash flow forecast are created, and progress is monitored monthly.
  4. The average daily production of every fee earner is closely monitored and compared with industry benchmarks, and fee earners are held to account.
  5. The all-important operating cost per surgery per day becomes a key measure of the profitability of each treatment room.
  6. As a result of which, each fee earner has his or her own profitability measured on a rolling 90-day cycle.
  7. The owners fully understand EBITDA and adjusted EBITDA when it comes to an assessment of the goodwill value of their practice.
  8. The owners know the value of their goodwill and can plan their exit in a targeted manner.
  9. Prices are set accurately and reviewed regularly.

I believe pricing to be the most important of these nine steps in the current climate. I suggested to my clients in the fourth quarter of 2021 to increase their fee per item (FPI) prices by at least 20% in the first quarter of 2022. Like usual, 20% of them went ahead and 80% increased by lower amounts of 5%–15%. Without exception, all my clients reported that their patients did not bat an eyelid.

In the third quarter of 2022, I suggested to my clients to increase their FPI prices by another 20% in the fourth quarter. So far, very few of them—if any—seem to have taken the advice. My guess is that they fear the consequences, or—to put it in other words—they are fantasising about an exodus of patients and/or declined treatment plans. FEAR is Fantasy Expressed As Reality.

Let us set some context here:

  • Before any energy bills cap, energy bills are up 50%–60% this year so far.
  • We all know what is happening at petrol stations and on supermarket shelves.
  • I tried to book a standard-class one-way ticket from Stockport to Plymouth in September, and it cost over £400.
  • Last year, my wife flew premium economy from Manchester in the UK to New York in the US via Heathrow Airport for £750 return—the same journey this year will be £1,500.
  • My Amazon Prime subscription renewed last month, and it is 20% more compared with a year ago.
  • Supply chain delays are affecting every sector of the economy
  • The media are doing a fantastic marketing job for all of us now by highlighting the dental deserts I mentioned all over the UK.
  • The demand for high-value dentistry has historically been very robust in recessions (I am thinking especially of between 2008 and 2010), and the waiting lists for treatment are growing longer as scarcity creates demand.

I am certain that you will have similar examples of everything becoming more expensive, and as an aside, that is why your team members are either asking for more wages or looking around for better pay. To repeat, the KPI for wages has been 17.5% of sales for the last 25 years. I advise my clients that this will be at 25% by the first quarter of 2023 and is likely to stay there. That is 7.5% of your profits gone unless you do something about it. You have two options: first, increase the average daily production of all your fee earners, and second, increase your prices. These are not really options; you must do both and you must start now. Not doing so means less profit, and less profit does not just mean that—it also means less EBITDA in a market that now expects multiples for goodwill valuations to decline. In summary, if you are looking to grow, to sell, to keep your team together or to recruit new staff members—put your prices up.

I want to encourage you to take action, but I also want to remind you that there are four areas where you must be careful about price rises and (the good news) many more areas where you do not have to be.

The four areas of price sensitivity in dental services and products:

  1. the cost of a dental health review (check-up);
  2. the cost of a hygiene visit;
  3. the monthly cost of a dental membership plan; and
  4. your price for Invisalign.

The first three are sensitive to price because they are regular repeats and the fourth is because it is a globally commoditised product, and the public are savvy. In these four areas, you must exercise some caution, but what does caution mean? Up to 2021, caution meant keeping the rise to no more than 5% a year. In 2022, caution means a rise of no more than 10%–15% in my opinion.

For all the other treatment areas, I advise raising prices by 20%–25%. If you did not raise your prices in January, you will still be behind, but will have to catch up over the next 12 months. However, you do not need to wait until next year; nothing is going to become better or easier and more time of low profit helps nobody in your business. Have a look at your FPI price list within the next seven days, revise the prices and start as soon as possible. If there is a price list on your website, you can change it at the start of next month. There is no need to mail your patients unless you make changes to the first three points on my sensitivity list. Your financial ship is leaking profit as you read this article. Leadership requires action. Put your prices up.

In my next article, I will be looking at lead generation systems and the latest ideas on how best to attract new patients, how to sell more to existing patients and—dare I say it—how to avoid wasting money on advertising and marketing ideas that frequently just do not work.

Business Finances Inflation Practice management

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