Start building your ideal dream dental office!
For more information on seeing Howard speak at this event:
11th Annual Mega’Gen International Symposium
267-291-1150
http://vizstara-professional.cdeworld.com/events/130
5/1/2015
New York, New York
Grand Hyatt Hotel
109 E. 42nd Street
New York, NY 10017
Dr. Farran’s Seminar Coordinator is:
Rebecca Parent
rebecca@farranmedia.com
I had active Townie Dr. Sameer Puri come to my practice to train my staff on a new CAD/CAM software last month. Why? Because I wanted my assistants to know how to use the system just as well, if not better, than I do. I know that 90 percent of the questions asked by patients are fielded by the front desk and the assistants, not me or the other doctors. And because of this, I want all my staff to know what they’re doing!
So many doctors go to CE courses or conferences alone. They’ll do in-office training alone. They’ll never teach their staff the software or systems or procedures. This doesn’t make any sense. You don’t work alone. You don’t run your practice alone. Why would you attend a conference to learn how to better your practice and then not bring your staff along? That just doesn’t make sense.
I sat down with Sam to ask him about CAD/CAM implementation. Our office has it already, but not all offices do. I wanted to see what he had to say about the technology and how he helps doctors successfully implement the machine into their offices. Here are some of his tips:
Train Your Team
The key with any office utilizing CAD/CAM is getting your team on board. At one point, there was a lot of debate about whether the technology worked or was worth it. I think that’s over. There have been offices—single doctor, one assistant, one front desk—that have been successful and there have been multi-doctor, multi-staff offices that have integrated it efficiently.
Once you get your team trained with how to use CAD/CAM properly, the dentist really just needs to do what he or she has been doing with a lab. The dentist should numb the patient, prep the tooth and then leave. With CAD/CAM, the team can take over (depending on the laws of the state) and nearly the entire process can be done without the supervision of the dentist. The dentist can be in the other room being productive. And when the restoration is done, come back in to check the work and cement it. If the team member takes the impression, designs the restoration, mills it and either polishes or glazes it, it saves the doctor a lot of time he or she can spend in another operatory. The key is that you have to have your team trained. You have to help them learn how to utilize the machine.
Don’t Let it Be Disruptive
Introducing a new piece of equipment into the office can be huge. Change doesn’t have to be overwhelming. I hear from dentists all the time, “We’re really busy. I don’t know if we have the time for it.” Well, it’s no different whether you have a well-functioning office using CAD/CAM or if you’re sending your restorations to a lab. The doctor does not have to be heavily involved in the design of the restoration…if you train your team.
Integrating CAD/CAM doesn’t have to be disruptive. You should adapt the system to your practice, not adapt your practice to the system. No matter how big or small your practice, you have a certain flow in your office that obviously works for you. Make the machine accommodate the flow of your office. Things don’t have to change drastically.
Yes, you’ll have to learn how to take a good digital impression. But that’s easy with the current generation of CAD/CAM systems. The impression gives you a lot of feedback. You instantly know whether you have a good prep or not, whether you’ve reduced enough, whether you need to do a reduction coping or spot the opposing. You know instantly whether you’ve captured the margins and whether you’ve prepared the tooth properly.
If the team member is doing all that work for you and they say, “I can’t quite see the margins.” He or she simply calls the dentist back, the dentist makes the appropriate modifications and you proceed.
Recognize the Need for Same-day Dentistry
When it comes to implementing the technology, the biggest mistake that offices make is they forget that there is a person attached to those teeth. They’ll say, “My lab is great. My temporaries fit well. My patients don’t mind coming back for a second visit.” This is utter nonsense. I have never met a patient who would prefer to have a restoration done in two visits instead of one. It’s crazy to believe that your patients have all this free time and can come back for multiple appointments.
Discover CAD/CAM’s Potential
When CAD/CAM first entered the mainstream market, many offices bought a CAD/CAM but they didn’t know how to use it to its full potential. This was common because the learning curve was significant. Twenty years ago you had to spend time doing 50 to 100 restorations just to learn how to do a simple inlay. You had 2D software. You had to manipulate a bunch of lines on the screen and imagine that would be a restoration. Today, with proper training, a dentist can do 30 restorations his first month. The learning curve is significantly reduced. The return rate (those who buy the machine and say it doesn’t work out) has dropped exponentially too, because the machine, the software and the results are so good.
In the past, dentists were limited by the materials they could use. We only had one material: feldspathic porcelain, which is a relatively weak porcelain. We had to use that everywhere. Today, a dentist has anywhere from six to ten different types of blocks they can mill—from composite to zirconia to lithium disilicate to feldspathic porcelain. We can do inlays, onlays, implant abutments, bridges…we’re not talking about just a simple little machine anymore. We’re talking about a robust piece of equipment that can serve as a center of the practice doing many different types of restorations.
What’s your experience with CAD/CAM? Have you integrated it? Are you ready to do so? Let’s continue to talk about this massive evolution of technology at Dentaltown.com. – See more at: http://www.dentaltown.com/MessageBoard/thread.aspx?s=2&f=2680&t=233712#sthash.teltjuS7.dpuf
Everyone’s buzzing about online reviews as if they’re something new and different. The fact is, we’ve always had reviews. They just haven’t always been posted online for everyone to see. Online reviews are a digital version of an analog voice, and everyone reacts to them differently.
Here are some facts about online reviews:
Humans don’t like transparency, but when humans aren’t transparent, bad things happen. I raised four boys. Whenever they all went into one of the bedrooms and shut the door, I knew something bad was going to happen. It was a red flag that definitely made me go check out what was going on.
Online reviews facilitate transparency. They’re a digital platform for checks and balances, and reviews can be your best ally if you handle them right.
Sometimes patients will make a comment about how great their experience in our office has been. Ask patients who you know are happy to write an online review for your practice! Most of the time, they love to be asked. Don’t show them how to do it from your office computer. Google is watching and if they see your reviews coming from your IP address, it might affect your SEO optimization. The patients can, however, post a review from their cell phones.
There are hundreds of review sites out there—Yelp, HealthGrades, Yahoo—but don’t waste your time on these; Google drives the whole industry. Google and YouTube (which is owned by Google) are the two most-used search engines. If you Google a dentist and they have a website of any kind, he or she will come up on Google’s search results. This means the doc’s reviews also come up (Fig. 2).
In my practice, we give out “Review us on Google” cards (Fig. 1). These cards are included with new patient gifts, in recall goodie bags and are also available in all the operatories. The card not only reminds patients to write a review after they leave the office but it also guides them through the process of writing one.
Occasionally patients might have a bad experience and surprise you with a nasty online review. Say this happens. You’ve made a woman so mad that she’s gone home and registered on Google+ (which she might have had to read instructions or watch a YouTube video to learn to set up) and she’s gone through the process of writing several paragraphs about her practice experience. This probably took her the better part of an hour start to finish.
For many dentists, their first response is to hire a lawyer or try to get Google to take down the review. But you should be going the opposite way! This is an awesome opportunity. First of all, how many patients who don’t come back take the time to write a letter telling you what you can do better? Not too many!
Second of all, can you imagine if this woman, with the amount of energy and determination she has, was rallying for your practice instead of working against it? If you can rectify her bad experience, she’s a walking marketing campaign for your practice.
The best way to deal with a bad online review, whether it’s a minor complaint or an absolute disaster, is to call the patient. There are often posters on Dentaltown who will ask what to do about bad reviews. The initial answer seems to always be to show it to your malpractice carrier. Really?
This patient is already in confrontation mode. Why isn’t your first response to call the patient? Say: “Hey Sally. You are mad. Can you come down to the office and we can go to lunch and talk about it?” Most the time, the bad reviewer just wants to be heard. And by doing whatever you can to fix the situation, you’re not only addressing that patient’s complaint but also creating good rapport for your practice overall.
In addition to online reviews, I’ve found exit interviews to be very effective for getting feedback. Call all the people who haven’t been in to the office in 24 months. See why. It’s important to keep track of why patients leave. Do you really think they all died or moved? Who are you kidding? You’ll find some of them have moved, some of them changed because of insurance policies or better scheduling. But what if you find out that a substantial number of patients decided not to return because they hate one of your hygienists? What if you find out a front office person is unwelcoming?
Most of your new patients are just old patients from the dentist across the street, which means you need to ask them why they left their old dentist. When a new patient comes in to the office, the person fills out a health history. Why don’t you include a question about why they left their last dental office?
Sometimes you’ll get answers like: They didn’t take my insurance or they didn’t provide nitrous oxide as an option or they weren’t open on evenings or Saturdays. You might learn their previous dentist was unapproachable or talked down to patients or created a culture of “don’t ask questions.”
How do you get feedback in your office? Sign on to Dentaltown.com and visit the Howard Speaks article for this issue. I’d love to hear about what you do to receive and track feedback. – See more at: http://www.dentaltown.com/Dentaltown/Article.aspx?i=357&aid=4863#sthash.pqxdvVBG.dpuf
Made popular by author Horace Greeley in the mid-1800s, the quote, “go west, young man,” was a proclamation to embrace new opportunity in the new western country. Granted, today I’d personally have to travel 1,457 miles east to get to St. Louis – the gateway to the west – from where I live in Phoenix, negating any literal meaning of the quote, but even so, it still has significance today. If you want to take advantage of new opportunities and possibilities, it might be necessary for you to move to an entirely new area or change your practice to accommodate a certain demographic.
In late November 2013, I started a message board thread on Dentaltown.com, which links to an article in The Denver Post titled, “Flood of new dental patients in Colorado meets trickle of caregivers” (Editor’s note: To view the thread, please visit www.dentaltown.com/ColoradoPatients). The article explains the new dental benefits Coloradans will receive via Obamacare and Medicaid, but that dentists are concerned that they won’t get paid enough to treat these new patients and keep their doors open. Also in the article, nine Colorado counties are listed as having no dentists in them whatsoever. In just a few days, this thread generated more than 130 posts from Townies. I invite you to check out this particular message board. It’s a pretty touchy issue, but I feel the concerns of some dentists surrounding this issue aren’t correct.
One of the arguments I hear is that those nine counties in Colorado have no money, hence, no reason for a dentist to open up a practice there. That’s ridiculous. Were that true, there wouldn’t be any Wal-Marts or McDonald’s in those counties either (and there are). If Wal-Mart and McDonald’s are in those counties, why can’t there exist a dental practice? For 25 years I’ve said all major businesses start with this equation:
Price – Profit = Budget
And I’ve always said that dentists seem to arrive at their price backwards:
Cost + Profit = Price
Ford Motor Co. has no problem starting with the average price of a Ford Taurus (at around $26,000 minimum average), from which they will subtract their profit, and from which the engineers will work off of the budget. Similarly, if they are designing a lower cost Ford Escort, they will say, “Here is what we are selling a Ford Escort for, we will subtract the profit we need to remain healthy, and then we will arrive at a budget.” Dentists don’t do that. Dentists don’t think they have two distinct markets. They will go into an area that has less income, taking HMOs and PPOs, but they won’t do amalgam. They’ll insist on doing composite. They won’t use a lowcost lab – they’ll go with some high-end cosmetic lab. They’ll insist on providing high-cost dentistry that much of the poulation of that town cannot afford.
These are the dentists who say, “I refuse to do dentistry on my patients that I wouldn’t do on myself.” That’s very altruistic of you, doc, but let’s get real here. The dentistry you would do on yourself is high-cost, high-quality dentistry only the upper class could afford. If that’s the way you think, you have to stay in the upper-half of the market and only that section of the market. You can’t be everything to anyone because eventually you will become nothing to no one. If you cannot figure out that there is lowcost dentistry, and that some people get amalgams and extractions and flippers and partials and dentures, and you need to use a low-cost lab, then you need to stay away from that geographic zone and let another dentist in who will make a killing offering low-cost dentistry. If all you offer is high-end dentistry, you’re going to make money on some patients and lose money on others – it will be a wash. You might as well pick low or high, run off half of your patients and only focus on the demographic you want to treat.
Also, consider the underserved areas themselves. No, they are not San Diego, Manhattan, Florida or Arizona where everyone seems to want to practice these days, but you have to remember those areas are already oversaturated with dentists. If it was always your goal to become a dentist and practice somewhere warm, you’re going to need to do something major to differentiate yourself from the rest of the pack. It takes a lot of work to practice in a saturated area. On the other hand, if you’re the only dentist in an entire county, people are going to flock to your practice in droves. When you serve the masses you dine with the classes, and that’s what will happen if you practice in an underserved area of the country. Do you really want to practice in San Francisco now, when you can make a killer living in a part of the country with no dentists and visit San Fran any time you want? Think about it.
There are already practices that are moving into underserved areas – corporate practices like Aspen or Heartland – and they’re doing it the right way. You know, the scariest question being asked around the dental profession is, “Is dentistry going to go the way of Walgreens and CVS the way pharmacies did?” Mom-and-Pop pharmacies collapsed because all the profit margin came from the buying power to purchase the pills. Group purchasing of drugs by Walgreens and CVS was everything that the small independent pharmacist couldn’t do. Secondly, there was not a single continuing education class pharmacists could take that would differentiate them from other pharmacists. We all know what happens when a dentist goes through Pankey or LVI or the Misch institute; we all know how dentists who take tons of CE each year for a decade can differentiate themselves from their competitors so much they’re almost playing a different game.
Corporate dental practices like Aspen and Heartland are making some very smart moves. They’re opening up practices in rural, underserved areas where there are few or even zero dental practices, and they’re making a killing. We’ve all heard why corporate dentistry is dominating – buying power for supplies and lab costs, and better marketing. But its Achilles Heel will always be staff turnover. How many dentists who sell their practices to corporate chains are still there three, four or even five years later? In my backyard, they are all gone. And when the dentist leaves, the patients stand around wondering what happened, and they become a lot less loyal. Staff turnover trumps brand name every time. While writing this column, I asked my office manager Sandy how big a blow it would be to our practice if we let Jan, my assistant of 25 years, go, and Sandy literally gasped. It would have a devastating impact on our patients and our practice.
There is a lot of opportunity out there, doc. You don’t have to sit in an oversaturated area spinning your wheels trying to figure out how you’re going to get your next new patient. Take a look at demographics in your own state or states around you. Figure out where the underserved live. “Go west!” – See more at: http://www.dentaltown.com/MessageBoard/thread.aspx?s=2&f=2606&t=219440#sthash.ba2IC3ce.dpuf
In 1980, when I was a freshman at Creighton University, one of our professors told us we’d earn 10 extra credit points if we went to see Warren Buffett speak when he visited our campus. One of the clearest things I remember Buffett say to the crowd was when someone pitches him an idea for something in which they wanted him to invest, he would hand that person a 4×6 recipe card and a No. 2 pencil and ask them to explain their entire idea on the card. He said 90 percent of those people couldn’t do it.
This doesn’t just apply to investing, gang – this applies to dentistry! Dental manufacturers will call my practice and try to sell their products to us. We’ll tell them, “For a product to be successful, it has to meet four criteria; it has to be faster, easier, higher in quality and lower in cost.” Many of them can’t explain their products to me with those four simple criteria in mind. In fact a few weeks ago, just out of morbid curiosity, I listened to someone pitch an idea for one hour and 45 minutes. Even after all the time my team and I spent with the salesman we still had no idea what the value proposition was. It blew my mind! It doesn’t just stop at dental manufacturers, though – this also applies to treatment plans. If you can’t explain to your patients what they need on a 4×6 index card, you fail at presenting treatments. Period.
Effectively presenting a treatment plan to your patients is one of the most serious aspects of dentistry. It can be the difference between a dentist who treats one-third of the caries in his or her practice to a dentist who treats twothirds or better. In the best dental practices, treatment plan presentations are typically done by a staff member; someone who can speak your patients’ language and sell the necessary dentistry. In other practices, what you often see are dentists rambling on, trying to explain what’s going on in their patients’ mouths. The patient has a toothache and the dentist says, “You have irreversible pulpitis. You’ll need endodontic therapy, post build-up and a fullcoverage restoration.” And then the dentist opens up a computer program and jumps into a giant, in-depth, scientific lecture about what a root canal is, what it does, what can go wrong, etc. Forty-five minutes later, the dentist asks, “Any questions?” and the patient looks like she got run over by a truck with no real comprehension of what just occurred.
The best treatment plans are simple and explained in ways patients can understand them. The reason Christianity thrived was because the religion was recited in short, simple, understandable parables – and there was a point to each one of them! Stop complicating things and get someone on your team to explain treatment plans to your patients in the simplest terms.
Your treatment plan also needs to be interactive. You need to follow your patients’ cues. When you talk to someone and they break eye contact with you, it means their mind is processing. When they do this, you need to stop what you’re saying and let them process. More often than not, they’ll respond with one of the following: “How much is it?” “Will my insurance pay for it?” “When would you do it?” “How long will it take?” “Will it hurt?” or “Will I need antibiotics?” What matters is you listen to their concerns, explain it in plain English and cut to the chase. I have had several patients come to my practice after they visited other offices to address their loose-fitting denture. In literally two minutes, I present the choices by saying, “Well you’ve got just a few options here. One, we can do nothing. Two, we can re-line it. With a reline, you drop it off at eight in the morning and you come back and pick it up at the end of the day. Three, we can make you a new denture. The fourth option, which would be a lot better, involves implants. We can put two of these little titanium screws into your jaw where the denture snaps on and stays in place. Better yet, we can put four implants in there and then the denture would really snap-on nicely. Or we can put six implants in there and that denture wouldn’t even come out of your mouth. Which one of those options sounds best for you? Let’s have Dawn, our treatment coordinator, go over the fees for these different options and assist you with reserving a time to get started.” What I just wrote would literally take you two minutes to recite. It was simple, explanatory and to the point. Why can’t we all do this?!
We continually see data that suggests dentists treat only 38 cavities for every 100 cavities diagnosed. That’s a terrible statistic. You might be earning your FAGD or your MAGD and think you’re on your way to total dental enlightenment, but I’ll let you in on a little secret – you’re not. Why? Because two of every three kids come into your office with caries and you don’t remove them. I don’t care if you’re using composite or amalgam – you need to treat as many cavities as you can. It’s your sacred and sovereign duty! Easiest way to do this is to get your staff involved in the treatment plans. It’s one thing for a patient to try to trust the guy who’s presenting a treatment plan in Latin (that’s rare), but it’s another thing for the patient to implicitly trust the entire staff standing behind the dentist nodding their heads in agreement and better explaining the treatment plan.
When you and/or your staff can explain a treatment plan in plain English and combine it with some great visuals from your digital X-ray system, every single one of your patients is going to fully understand what’s going on in their mouths and will want you to do something about it. It’s impossible for your patients to grasp what you’re trying to explain to them on a one-inch by one-inch X-ray film. I still can’t believe there are dental practices that do not employ digital X-rays in 2013. You want to explain something to your patient? Blow up the image on screen and do some teaching. Better yet, print off their X-ray on a piece of paper and circle the trouble spots, then give them the printout to take home as a reminder of what they need to have fixed.
Every single dental practice consultant I’ve ever met has told me when they walk into an office and pull up the report generator on the practice management software, 80 percent of all of the reports have never been run once. So, maybe you are only treating a third of the diagnosed dentistry, or maybe you’re doing a better job than that… or maybe you aren’t. You’d never know because you don’t know what the score is. You don’t know what your close rate is. You don’t track it. When you start tracking the dentistry you’re doing against the dentistry you’re diagnosing, you start to become a much better dentist. You start to realize you might not be the best person in the practice to sell dentistry to your patients. Your close rate will improve and your patients will be much happier with healthy mouths. You owe it to yourself, your practice and your patients to start running your treatment plan reports and actively reviewing them to help identify your monthly close rate. It’s time you start taking the selling process more seriously. Taking 500 hours of CE and earning your MAGD is completely useless if you’re not going to treat two-thirds of the people who come through your doors.
Humans are social animals. Social animals exist in tribes, and for the survival of every tribe you need order. For there to be order, there needs to be control. Social animals are hard wired for control, and because of this a lot of businesses become unsuccessful because the owner or CEO abhors delegation and feels the strong need to control everything. How does the CEO of a Fortune 500 company run her operation of 100,000 employees if she doesn’t delegate anything? It would be impossible! The leaders who rise to the top don’t fear risk or delegation – they retain and attract quality key people, give them responsibilities and then get out of their way. Success is counterintuitive to how humans operate.
Another great example is how most dentists imagine the way they are going to retire and sell their practices at age 65. At age 55 they start thinking, “Well, I’m going to retire in 10 years, so the last thing I’m going to do with this practice is invest in any new equipment or new technologies or implement any new techniques into my repertoire.” They’re content with milking the cow dry and refuse to feed it anymore oats, grass, grain or water. But here’s the amusing part: when it comes time for that dentist to sell her practice, she thinks it is going to sell for some huge amount, but it’s not going to happen. Nothing in the practice has been updated, new patients have dwindled to zero and it has become a business that nobody in their right mind would purchase at the price in the dentist’s head.
You have to realize the final 10 years that you are in practice are the most important years to double down on your business bet! In this time you can’t be milking your practice of what it’s currently worth only to sell it for pennies on the dollar. You need to modernize your practice. You need to move it from a lousy 1,000 square foot rental space on the third floor of a medical building to a premium 4,000 square foot building right out on Main Street with a huge sign. This is the time for you to upgrade from 2D X-rays to 3D cone beam computed tomography! This is the time to invest in CAD/CAM! In dentistry the only dogs that can’t learn new tricks are dead dogs!
If your practice is neglected because you milked it for the last 10 years, you will end up with an illiquid asset. You have to get your business poised for growth. You can’t sell a sinking ship. Just like with the sale of a home, when a window breaks, you don’t say, “Let’s just wait until two other windows break and then we’ll fix it.” No way.
Here’s another housing example tied to liquidity: a three bedroom, two bath house in Phoenix, Arizona, can easily sell within 30 days, but a 10 room house with an eight-car garage and a tennis court and Olympic-sized pool can sit there for three years because it is just not a liquid asset. Nobody wants it or can afford it. Along these same lines: the corner commercial lot on the corner of 1st and Main, you can sell in a heartbeat for premium price. But if you go just 300 yards down the street either way, you might be looking at half the price and, worse, you might never be able to sell it. I mean there are intersections in Phoenix that are still vacant from when I moved here 25 years ago because they just weren’t perfect. This is why location is key! So if you’re renting in a medical building or you aren’t set up on a great location, you need to be poised to sell, so get moving!
Here’s something else you need to think about if you’re considering retiring and selling your practice in the next 10 years: interest rates on CDs right now are at two percent, so that means for every million dollars in cash you have in the bank, in government bonds or CDs, you are going to make $20,000. Let’s say the average dentist makes $140,000 dollars a year. That means they would have to have $7 million in cash in a two percent government bond or CD at Bank of America or Chase to maintain their income. That is just not going to happen. I don’t know of too many dentists that can walk away at 65, sell their practice and have $7 million in cash earning two percent.
If you’re a renter and you sell your practice for $400,000, that’s it. That’s all you get. But if you owned your practice and you owned the building, you could sell your practice for $400,000, but keep the building, so you would charge rent to the new dentist who purchased your practice. Every year you can adjust the price of the rent based on the Consumer Price Index, and over the next 10 years, you could earn an additional $400,000. Then, maybe, at the end of the 10- year lease, the new dentist wants to buy the building. Then you finance that to the new dentist and you end up with yet another 10-year income stream. Think about it: the renter made $400,000 and gave half of it to Uncle Sam, so she’s sitting there with $200,000, which at two percent is making $4,000 a year. At that point the renter dentist is going to have to go be an associate somewhere else (at age 65) in order to live the way she did when she was practicing! So instead of continuing to rent the space for your practice, you need to get poised for growth. Buy that premium property on 1st and Main or a 4,000 square foot building right next to a WalMart, then sell your practice and rent out your building to earn revenue the smart way.
But this only applies to dentists who want to retire. Me, personally, I never want to retire. Sure, the first year of retirement is fun – you get to golf all the time and go fishing. It’s like a really long vacation. But by the second or third year of retirement, you start to see some dysfunctional behavior. There’s no passion for life. They let themselves go. They don’t have a reason to shower in the morning, let alone get out of bed. Here’s something you should consider if you’re actually considering retirement: don’t retire! I’m serious! There are 5,000 new dental school graduates entering the dental profession every year and they’re looking for a job. These kids are so desperate for a job, when the government asks them to join the military and sit on an aircraft carrier in the middle of the Pacific Ocean or Afghanistan, it sounds really enticing to them. And I hear the excuse all the time from dentists in rural areas that they can’t find an associate because they practice in Middle of Nowhere, Montana. Really? You can’t convince someone to stay in America where nobody’s shooting at them but the government can convince them to practice in Iraq? Stay in practice and be a mentor for crying out loud! Do you know what your unique selling proposition is to these new grads? Do you know what you have to sell more than anything? You! You get out there, you get poised for growth, you go to the finest finishing schools in America like The Pankey Institute or Spear, you get your practice to the very top of your game, and then you get your pickings from 5,000 graduates, some of which are seriously considering going into the military and practicing dentistry in some third world country. Instead you could just reach out and say, “Hey you, new grad, come work for me. You’ll probably look back on this decision when you are 65 years old and realize it was best decision you’ve ever made, because I’m going to teach you how dentistry gets done. It’s all going to be cool, we are going to have a good time working together and you are going to become a very successful dentist.”
Best Tips for Better Practice in 2013
Dentaltown Magazine wants to know what you’ve done this year to make your practice the best it can be! Visit www.dentaltown.com/BestTips2013 to tell us what you’ve done to improve your practice. Keep your eyes peeled for the December issue of Dentaltown Magazine and your tips could be featured in that issue. One lucky contributor will be drawn to win a copy of Dr. Howard Farran’s One-day Dental MBA DVD.
See more at: http://www.dentaltown.com/Dentaltown/Article.aspx?i=334&aid=4538#sthash.iedaYMzG.dpuf
Dr. Carl Misch, who is regarded by many as the number-one implantologist in the world today, (and who just filmed a series of four awesome online CE courses for Dentaltown.com), wrote in his book Dental Implant Prosthetics that the 15 year survival rate of implant restorations is 95 percent and for a three-unit bridge the survival rate is 74 percent. In this day and age, dentists really have to ask themselves, “If an implant and crown has a 21 percent higher success rate over a three-unit bridge, why are we doing so many three-unit bridges?”
Insurance Coverage?
Is it because insurance still doesn’t cover implants? We all know that’s not true! Twenty-five years ago, when I opened my Phoenix, Arizona, dental practice – Today’s Dental – almost zero insurance companies offered any coverage of dental implants. Today, based on the insurance plans that we have verified and have in our system at my practice, we have come up with the following percent of insurance plans that have implant coverage:
When I started my practice in 1987, implants were not a covered benefit under most insurance plans, but today, we are seeing an upward trend in insurance companies realizing the benefits of implants; such as, preserving tooth structure and making it virtually impossible for decay to form. With more and more insurance plans covering dental implants, it can’t possibly be a good enough reason to not be placing implants.
Pricing and Presentation?
Here’s another reason why we might be placing way too many three-unit bridges: price breakdown and case presentation. When I graduated from dental school in 1987, I argued with a lot of local Medicaid plans because coverage of an extraction was $2 cheaper than a filling. Moms in lower socioeconomic brackets had the economic incentive to pull their babies’ teeth instead of fixing them, just because it was cheaper. I always thought the extraction should cost $2 more than an amalgam filling, because when it comes to certain procedures for certain patients, affordability was always the key decision maker.
The same thing is happening with bridges vs. implants. Most dentists will offer their patients an exact flat fee for a bridge, and they’ll say they can prep it today and cement it in two weeks. Then when the patient asks about an implant, most dentists break it down to something like, “Well, um, it’s $1,500 for the implant and it’s $1,000 for the crown, but then we might have to do a bone graft, and we might have to do a gum procedure, and I won’t really know what we’re looking at until I pull the tooth to know how long this will take…” It’s a total confusing quagmire! The implant is the better option, but you make it so difficult for the patient to understand. I mean, I’m a dentist with an MBA and an MAGD and because of the way you present a bridge vs. an implant even I would opt for the bridge!
You need to figure out a way to explain that the cost of an implant is the same as the cost of a bridge. If you charge $3,000 for a bridge, then an implant should be $3,000 as well. Now, whether or not you have to do a bone graft or something more, that’s just the cost of doing business. Obviously some cases will be easier than others, but that’s life. It’s also the way everybody else does business. When you take your car in to fix your radiator, they’re going to do it at a flat fee. I guarantee some radiators are easier to fix than others – you’re not going to get nickel and dimed because your radiator was harder to fix than the last one they worked on.
You know what would help you place more implants in your practice? If your implants cost less than a bridge! They have a 21 percent better success rate, after all! You need to take the economic incentive to do the cheaper but less effective option out of the equation. If you tell your patients it’s cheaper to do an implant and a crown than it is to do a bridge, you’re going to be placing a ton more implants, doc!
Specialists?
I recently spoke about this issue with Dr. August de Oliveira, the author of Implants Made Easy, and he brought up a survey conducted by Straumann, which indicated the United States of America currently ranks fifth in total implants placed. More than 85 percent of general dentists in South Korea place implants, more than 50 percent of all general dentists in Europe place implants, and the most implants placed in the world is Israel. When I asked August why he thinks so many dentists still do bridges over implants he said, “It’s a loss in production if general dentists send out the implant case. Rather than learning how to do implants themselves, they do bridges and send out an occasional implant. That is changing as patients are getting educated on the benefits of an implant crown vs. a three-unit bridge.”
In America, culturally, we got into this groove where oral surgeons and periodontists place implants. GPs don’t want to do implants because it’s inconvenient, it’s a loss of revenue to send out, and you have to work with a specialist. If you’re not going to place implants yourself, you need to work with a specialist who will agree with your vision of a flat fee for all implants placed. If you charge $3,000 for a bridge, you’re going to charge $3,000 for an implant whether you place it or the specialist does. You want the safety of being able to tell your patients that they’re going to go to another doctor who will place the implant, it will be the same fee, and there will be no nickel and diming. If your specialist cannot work with the laws of averages like every other service industry does, then find another specialist! Either that or learn how to place implants. Too hard, you say?
Implants Are Hard? Really? In 2013?
I learned how to place implants early on in my dental career. I earned my Diplomat in the International Congress of Oral Implantologists (DICOI) and my fellowship at the Misch Institute. In 1987 placing an implant was hard. You had 2D Xrays, panos and PAs, and you never truly knew what was going on until you laid a flap. Today, with 3D cone beam computed tomography (CBCT), diagnosis is twice as easy – heck, even the software that’s been developed for these systems will tell you how long and wide the implant can be to place in your particular patient. You almost don’t need to think about it. Oh, and anatomical features that scared us to death back in the day, like the inferior alveolar nerve and the sinus, are all spelled out for you in a 3D image. You know exactly what you’re looking at before you even pick up an intrument. This harkens back to my May 2013 column “Is Dentistry Getting Too Easy?” It’s twice as easy to do a root canal today (with high-speed handpiece-driven NiTi files), and it’s just as easy to place an implant with the help of 3D CBCT.
It’s time we all sit back and rethink placing implants. Placing an implant today is so much easier than pulling a wisdom tooth – yet I know more dentists who pull 10 to 30 percent of their wisdom teeth but don’t place a single implant. I think that’s completely backward (and bizarre)! That’s like saying you can repair your car but can’t fix the chain on your bicycle. You need more skill to pull a wisdom tooth than to place an implant. With the technological advancements we have at our fingertips today, it just doesn’t make any sense why dentists don’t place more implants.
Remember the 4,000lb Gorilla in the Room
When it comes to the dentistry we do, nobody likes to talk about the 4,000lb gorilla in the room – mortality. The average man dies at age 74, and the average woman dies at almost 80. When grandma and grandpa go into the nursing home to live out their remaining days, all the dentistry we’ve performed over their lifetime crumbles and rots after 18 months. I’ve been a huge proponent of there being less inert and more bacteriostatic restorative materials in the dental market – and dental implants fit that bill. When I visit nursing homes, it’s sad to say that the lucky ones are the people who have dentures and implant-supported prosthetics. The people who have their mouths full of $20,000 worth of root canals and crowns are the most unlucky, because their teeth turn to mush from root surface decay. These people are too old and brittle to do any extractions or full-mouth restorative, and their home care is essentially nonexistent. You really need to start asking yourselves, especially by the time a patient turns 60 years old, are we really going to do a root canal buildup, a crown and a three-unit bridge instead of titanium implants, which the Streptococcus mutans won’t eat? Think about it.
In Summary
While I was wrapping my head around this issue, I talked to longtime Townie, Dr. Jay B. Reznick, oral surgeon at the Southern California Center for Oral & Facial Surgery, in Tarzana, California, and founder of OnlineOralSurgery.com. He sent me an e-mail that summed up the issue of why dentists don’t place implants more than bridges quite nicely. Jay says:
“A dental implant is designed to be ‘permanent,’ however there are a lot of factors, such as hygiene, patient general health and nutrition, systemic disease, local factors, age, implant positioning, prosthetic stresses and individual variation that will reduce the longevity. I always tell my patients, ‘Dental implants are as permanent as their “permanent” teeth,’ so they understand that even what nature gave them is not always perfect and can fail under the right set of conditions. A three-unit bridge is also meant to last a long time, but dental insurance companies will pay to replace a bridge after five to 10 years (depending on the policy), so that should tell you a lot.
“There are a number of reasons why dentists may choose to do a bridge over an implant. I think the biggest is still the misconception, especially in the older practitioners, that implant dentistry is too complicated. They also feel the bridge will be delivered sooner than in the case of an implant, where the extraction site needs to heal and the implant needs time to integrate. Right behind that is the economic desire to keep all the revenue within their practice, rather than sharing the case with a surgical specialist. Of course, that model is changing rapidly, as more and more general dentists are becoming trained and placing their own implant fixtures and then restoring them.
“We are seeing an increase in the number of dental insurance carriers that are covering implant treatment. They are usually the more expensive plans for the patient or employer, and reimburse at a substantially reduced rate from usual, customary and reasonable (UCR) charges.
“The only advantage a bridge has over an implant is that it is faster. The implant helps preserve bone and soft tissue architecture, is easier for the patient to maintain, and leaves a one-tooth problem as a one-tooth problem, rather than creating a three-tooth problem (which will become a four-tooth problem, and eventually a denture).”
It’s time to change the way we think about implants and the way we present this incredible option to our patients – the future of the dentistry we provide depends on it!
