Battling the In-Office Crown

What do you do?

Mike Dominguez, CDT encountered this situation approximately five years ago when one of his largest accounts, a good friend, nervously revealed that he had purchased a milling machine. Dominguez, owner of Kymata Dental Arts in Seattle, Washington, had a decision to make.

“A fight-or-flight reaction would be to get upset and tell the dentist that in the long run the ROI might not work out the way you have been told it will,” Dominguez says. “While I do believe that to be true, telling the dentist that will not help salvage our relationship after he has spent $100,000 on a machine.”

Instead, Dominguez put a smile on his face. He immediately began talking to the dentist about how their relationship could move forward, and he even offered to train the dentist’s staff on color theory so that the monolithic crowns they fabricated in the office could be as close to laboratory quality as possible. Kymata Dental Arts’ mission and mindset from the beginning was to focus on more esthetic cases, complex cases, and implant cases, and the dentist still was not looking to mill those.

“We ended up producing his abutments and still working on bridges, anteriors, and some other cases for him — cases that his mill couldn’t do and that he didn’t want to do,” Dominguez says. “He started sending me more work, and as of recently, he is spending close to the amount of money with us that he was previously.”

Many laboratories have faced this situation in recent years. Industry experts estimated in 2013 that 10-15% of dental offices in the US had chairside milling systems,¹ and it would not be unreasonable to project that percentage to eventually reach 40-50%, says Edward Shellard, DMD, Vice President of Sales and Marketing for Carestream Dental, which sells a milling machine for dentists. Carestream Dental, Sirona Dental, Planmeca CAD/CAM Solutions, IOS Technologies, and Roland DGA were among the manufacturers whose mills were on display for dentists at the 2015 Greater New York Dental Meeting in December.

Despite its negative connotation, laboratory owners say that in-office milling can be an opportunity to actually stimulate and improve their business if they approach the situation in a forward-thinking manner, several laboratory owners say.

“Laboratories need to embrace this change and realize this can be a good thing for their business,” says Dena Lanier, Owner of The Lab 2000 Inc., in Columbus, Georgia.

From billable auxiliary services to goodwill efforts that pay off long-term, laboratories already are finding various ways to regain some of the profits that were taken from them via chairside milling. The common thread in all of these business strategies is that the purchase of an in-office mill does not need to signal the end of a dentist-technician relationship; rather, it can be a new beginning.

Michael Keeter, DTG, CDT, literally needed a new beginning for his laboratory. Approximately five years ago, Keeter closed his removables laboratory in Roanoke Rapids, North Carolina and reopened Realtime Dental Laboratory as a CAD/CAM crown and bridge facility in Knightdale, North Carolina. To build a client list, he targeted dentists who used digital impression technology and in-office milling.

“I heard so many technicians speaking negatively about chairside milling that I decided to take the complete opposite approach,” Keeter says. “I knew dentists were milling inlays, onlays, and single units almost exclusively. I told them, ‘I’m here to help.’ If I could gain their trust and friendship and be a resource for them, then I could persuade them to send me the work that they were not milling in-house. That is how I built my laboratory.”

Keeter held study clubs and staining/glazing training sessions for dentists and their staff. He did not charge fees, but he ended up getting paid — in the first year, he says, he picked up approximately 30-40 accounts and went from one employee to three. He reached a point where he actually had to stop holding the training sessions because he was getting too much work and wanted to spend more time with his wife and three children; he plans to start the study clubs back up this year, however. He now has six technicians in the laboratory and has incorporated four design stations and 5-axis milling. Realtime specializes in implants and digital technology, and after five years the majority of its clients still have milling machines in their offices.

“The manufacturers have created a sandbox, and dentists are playing in it,” Keeter says. “We have a choice: Either sit outside the sandbox and complain about it while the work slowly disappears, or figure out how to work within it. The sandbox is not going to disappear. I have experienced tremendous success working within it. In this industry, we must be able to meet the demands of our clients. So if your clients are buying into the technology, you either get onboard or get new clients.”

Keeter’s mindset is becoming more widespread among laboratories, says Norbert Ulmer, Director of Laboratory CAD/CAM for Sirona Dental, Inc.

“Historically, many laboratories viewed in-office milling negatively,” Ulmer says. “However, recently we have seen many more laboratories encourage their dentists to move forward with it, and they offer to help. This strengthens the bond between dentist and laboratory, which helps the laboratory in the long-term.”

Lanier adheres to that philosophy with The Lab 2000 Inc. She holds lunch-and-learn sessions for dentists and advertises her free consulting services in a quarterly newsletter for dentists.

“Many times, dentists cannot believe that we go to their offices and teach them staining, glazing, and other techniques to improve their chairside restorations,” Lanier says. “They say, ‘Why are you doing this? We are taking work from you.’ I say, ‘This may be true, but you are able to deliver work quicker, which means you have time to do the complex cases that we are fabricating at the laboratory. You have invested in the new technology like we have, and it has only enhanced the relationship that you have with our team.’”

Dominguez, owner of Kymata Dental Arts, says he considered charging consulting fees when he first started working with dentists in this capacity, but he decided against it.

“If they are still going to send thousands of dollars worth of work to my laboratory,” Dominguez says, “then the goodwill is more valuable for me than the nominal consulting fees I could charge.”

Shellard, of Carestream Dental, compares it to the situation of endodontists. General dentists perform more than 90% of the endodontic work in the US, but the increased attention to that area has led to more endodontic work overall, and specialists have thrived.²

“Other examples exist within dentistry of specialists coexisting very well alongside the general dentist who does some limited chairside work,” Shellard says. “I equate technicians with specialists. Endodontists are viewed as trusted partners for the general practitioner in cases that involve straightforward endodontic procedures.

“Over the years, endodontists have helped general practitioners understand the limits of what they can and cannot do. Similarly, the laboratory technician can become a valued partner and can strengthen the relationship with the general practitioner.”

When cultivating and developing those relationships, two things are important for laboratories to remember, several industry professionals say: Patient service is often a more significant motivating factor for dentists than saving money on laboratory bills, and the savings on those laboratory bills are generally limited to simple cases.

Prosthodontist Steven D. Spitz, DMD, concedes that helping his bottom line was a main selling point when he purchased a milling machine four years ago for his practice, Smileboston Cosmetic and Implant Dentistry in Massachusetts. Spitz soon realized, however, that his laboratory bills were not changing significantly.

“The financial aspect has turned out to be secondary,” Spitz says. “I still send implant and complex cases to the laboratories. Considering the affordability of their single-unit crowns, the savings on crowns I fabricate in-office are minimal. However, I have found in many cases, in-house crowns are a benefit to my patients and in the end, that is the return on the investment.”

Indeed, Lanier says one of her dentist-clients last year said, “I hate to tell you this, but I fabricated 27 units this month on my mill.” Lanier responded, “That’s great!” The dentist was confused. “If you look at your laboratory bill this month,” Lanier went on, “it’s more than it was the previous month.” The impact of the single crowns was minor, and the dentist had been able to send more large cases to the laboratory — “a win-win,” Lanier says.

While the big money may lie in complex and difficult cases, there are sometimes profits to be made by laboratories even with single crowns being milled by dentists.

Lanier says she offers a design service for $15 per unit, as well as overnight sintering and other services. After seeing a landscaper distribute a flyer that said, “Did you know we also offer…,” Lanier created something similar for her laboratory and sent it to dentists with their monthly statements. She says her clients are increasingly utilizing these options.

“You need to listen to your customers and provide a service, even if it is not the same service you have been offering in the past,” Lanier says. “Their offices are changing, and your laboratory will change also.”

If several of those changing offices are located in close proximity to each other in a densely populated area, an opportunity could exist for a laboratory to offer in-office services such as staining/glazing and design, says Daniel Alter, MSc, MDT, CDT, a dental technology consultant and a Professor of Restorative Dentistry at New York City College of Technology.

“In a heavily saturated area such as New York City, one building might house 20 dentists,” Alter says. “A dental technician or a laboratory can enter that space and offer those auxiliary services, and the travel time would be minimal enough to make it a viable model.”

Depending on each technician’s fees, it could be worthwhile to travel to offices around a city, region, or even around the country, as high-end ceramist Eddie Corrales does with his business, CAD Smiles.

Larry Emmott, DDS, professional speaker, author, and President of Emmott on Technology LLC, says he expects most dentists to send design work to laboratories as in-office milling becomes more prevalent.

“The future for chairside milling will be for dentists to take the digital impression, send that file to the laboratory, let the experts design that crown, inlay/onlay, or bridge, and then send the design file to my milling machine or 3D printer, whenever that is developed, and produce that restoration in-house in less than an hour,” Emmott says. “For most dentists who have embraced chairside milling, the restorative design in the software demands a huge learning curve that eats up the dentist’s chair time.”

Even for laboratories that prefer to offer free consulting on simple cases, collaboration of the sort that Emmott describes on more complex cases should provide opportunities to bring in revenue via billable services.

Alter says he recommends to his students that they give away as few free services as possible.

“That is a very deep wormhole, and I hope nobody wanders into it,” he says. “It becomes borderline abusive because you are completing that service multiple times and not getting compensated for it. The highly knowledgeable dental technician, who has dedicated the time to truly develop technical skills, can be of tremendous value to dental clients. Good dentists will appreciate that.”

Whether the laboratory is being directly compensated or not, the elephant in the room is the question of how much work will remain for technicians in the future as the technology continues to evolve and develop. What if dentists no longer are limiting their in-office milling to single posterior crowns? What if they try to cut laboratories out entirely as the milling machines become more efficient and user-friendly?

Ulmer says that is unlikely.

“The technology is not what limits dentists to single crowns,” the Sirona executive says. “Our milling machines already can handle a wide range of indications. We could do single-visit titanium bars; the question is, how long do you keep that patient in your office?”

Not only is it less enticing to keep a patient in the office for the duration of a complex case, but it is often not the best use of the dentist’s time and resources.

“In the New York area, a dentist needs to produce approximately $1,000 per hour in order to remain profitable,” Alter says. “If the dentist spends significant amounts of time designing and post-processing, that is not very cost-effective.”

Time is not the only limiting factor. More challenging cases — whether due to complexity, demand for better esthetics, or unusual variations — require skill beyond CAD/CAM. Qualified dental technicians continue to be best equipped in most cases to handle contact or occlusal issues, challenging margins, and other variables.

Shellard says Carestream Dental anticipates that most dentists will realize this even as milling technology improves.

“Our experience has not been that dentists want to mill 10 veneers, or mill a bar for a removable denture. I do not see that happening,” Shellard says. “There are a few dentists who enjoy tweaking and pushing the limits of technology — many of the early adopters of the first chairside mills. However, our experience has been that dentists purchasing mills now do not want to get into those complex situations.”

Ulmer adds, “The majority of dentists do not want to be laboratory technicians. They are dentists. Quite frankly, their time is better spent as a dentist.”

As long as that holds true, plenty of cases will continue to be fabricated by technicians, especially as the amount of dental work being done in the US increases and laboratories consolidate. A conciliatory approach to chairside milling can help retain existing clients as well as gain new business.

“When I lecture to laboratory owners and dental technician students, I tell them not to look at chairside milling as taking away business from laboratories,” Alter says. “I believe chairside milling will create new revenue streams for laboratories.”

Regardless of whether that turns out to be true, the in-office mill appears destined to become more prevalent, not less, in the coming years, so many laboratories are making the best of it.

“It is here to stay. It’s not a fad,” Shellard says. “Embracing it and figuring out ways to become a good partner with your dentists is going to make your business that much stronger.”