It’s been a while since I’ve written, as I have been busy and rather uninspired. But, two days ago, I was interviewed on Howard Farran’s podcast. It was me… one-on-one with Dr. Howard Farran, the founder of DentalTown. And, let me tell you… It takes some real energy to keep up with him! 🙂
We discussed number of topics, and I’ll touch on that, along with a link, when the podcast is published. Stay tuned! But, we discussed one thing in particular that has also come up in some Facebook and Dentaltown threads. We talked a bit about technology in dentistry. I think we’ll all agree that recent advances in dental technology have been impressive and a boon to dentistry.
Watch out for the rocks!
But, I also believe that the siren call of dental technology can be a problem for dentists. As dentists, most of us are “gadget geeks.” We love gadgets, gizmos, and toys. Dentistry is the perfect profession for technology lovers. While I fall squarely in that category, age and experience has also infused me with a healthy dose of skepticism. I’ve participated in online dental social media going back to 1992-ish on Compuserve. It was there I learned an aphorism that has proven to be very useful throughout my career. My long-time online friend, Dr. Sam Feinstein said, “It’s a solution to a problem I don’t have.” That’s practice management gold.
Below the standard of care?
Dentistry is FULL of such solutions. Mind you, I’m not disparaging or discounting many of the outstanding technologies that have come to dentistry. My point is that we don’t all need all of them. 
I’ll repeat… We don’t ALL need ALL of them. It seems the more a dentist spends on a given technology, the more evangelical he becomes in advocating for it. Worse, when you get a gaggle of dentists who have bought into the latest gizmo that costs five to six figures, they will go so far as shaming dentists who have not joined the cult. The fanbois will even declare their chosen technology is the “new standard of care.” My goodness! What dentist would continue to practice “below the standard of care???” It’s the ultimate litmus test of competency and a compelling argument to write the check, right? Of course, they are misappropriating the term “standard of care.” To be clear, “standard of care” is NOT necessarily defined by “state of the art.” Hover over those two links to see brief definitions in a convenient pop-up box. Click them, if you are interested in delving further into their meanings.
Better, stronger, faster.
One of the themes of this blog is to review dental products and technologies that offer “bang for the buck.” If a gizmo makes my life easier, treatment outcomes better and more expeditious or efficient, patients more comfortable… AND doesn’t require a dentist to take out a loan or consult with a financial adviser (or spouse as the case may be)… I’m interested. It doesn’t mean I’m not interested in the bigger ticket items. But, they have a MUCH higher bar to clear before I jump in on the “deal.”
Your mileage may vary.
If I dare risk stirring up a hornet’s nest, I’m going to use an example that we’ve all likely encountered. It relates to CAD/CAM dentistry. More specifically, I’m talking about the complete scanning and milling systems that allow for “1-visit crowns.” I should mention that I have actually used one in the context of a continuing education course, and it was WAY COOL. Being able to dial in the level of proximal contacts and occlusion was very slick. Furthermore, the result was impressive in terms of the marginal fit. Neat stuff! But, we’re looking at $140,000++!
When I brought up the significant price of admission to that club, the advocates argued, “Don’t think of it as $140,000. Think of it as a $2500 a month payment. You’re probably paying at least that much to your lab now. So, instead of paying your lab, you’ll be paying for the CEREC / E4D. Eventually, it will be paid for, and your cost per restoration will go down.”
Sounds good, eh? Makes sense, perhaps? Here’s my admittedly simplistic refutation of that argument: If I’m not happy with my lab, I can take my ball and find another game. I can “fire” the lab. If I’m not happy with my $140,000 crown-making gizmo, it will sit in the corner, and I’ve still got to cover the nut. I can’t fire it. And, the company that sold it to me won’t take it back. So, I can’t help but think of it as a six-figure commitment, which it IS. And, that doesn’t include maintenance and needed updates.
That doesn’t mean it is categorically a bad decision for all dentists. I am not saying that at all. It just means it’s not for me. Not once in my 27-year career has a patient raised an objection to having a crown restoration based on it requiring two visits rather than one. Not once has one said, “Well… I’d do it if you could do it in one visit rather than two.” It really IS a VERY expensive solution to a problem I don’t have. Is it for you? Your mileage may vary.
It’s the new standard of care!
My point is that many technologies are being pushed and sold as “the new standard of care,” and there is considerable “peer pressure” to buy these technologies. Keeping up with the Greenbergs is a nearly universal dental obsession. Consider CAD/CAM and CT (Cone Beam) technologies. They enjoy a very vocal minority of dentists advocating their use. No doubt, they are the pinnacle of dental technology today. But, just those two “gizmos” will cost a dentist a cool $250,000 to implement in his office. Of course, that’s just the price of admission. Then there are the costs of maintenance, updates, and even replacement with the newest, better gizmo. Such technologies fall victim to obsolescence, usually within only a few years. It’s a quarter million dollars JUST to get STARTED with just those two technologies.
For a solo-practice dentist, that’s a daunting expense to have hanging over your head. On the other hand, a large group practice can absorb the cost and leverage the ROI with multiple users. “Just sayin’.”
Don’t get me wrong. CBCT and CAD/CAM are some cool shit! So are hard tissue lasers and lasers that purport to reverse periodontal disease. And, they have their place. Believe it or not, I haven’t yet converted to digital x-rays, much to the consternation of some of my colleagues. The question is whether they are worth the price of admission? Are you basing your decision on sound business principles? Or, are you getting caught up in the excitement?
Do you NEED it? Will it pay dividends in YOUR practice? Only you know what’s right for your practice. The other dentists don’t know what’s best for YOU.
One of us! One of us!
Maybe all the “cool” dentists have bought the gizmo and are extolling its virtues all over social media. Peer pressure in the dental world can be keen. We could coin a new term, “Dental Tech Shaming.” I would encourage you to resist it and conduct your own due diligence when it comes to these big ticket items. Does it REALLY make sense? For YOU?
Here’s a quick story about how peer pressure can rear its ugly head on dental social media. Several years ago, I was a very active member of a particular online dental group. In that group, many dentists had bought into a marketing gizmo. The company, called “Brican America,” provided a large flat screen monitor that was placed in the reception area and played a continuous video / slideshow loop promoting your practice. The content of the video was customized to your practice any way you wanted. Production quality appeared to be decent.
This was the “deal” (going from memory, which may not have the exact figures right). The dentist would pay about $500 / month to Brican for 5 years. BUT, if the dentist allowed Brican to insert an ad for a LASIK (by an ophthalmology firm) every 20 minutes in the loop, the dentist would get a “rebate” of $475 / month (to be paid back quarterly, if I recall). So, the “net” cost to the dentist was a mere $25 / month. The folks on the dental forum were all raving about it. What a deal! $25 a month! Cheap!
A local dentist friend of mine was looking into it, and she had a copy of the contract. I read it carefully. I’m not a lawyer, but something jumped out at me. There was no provision to cancel the $500 / month X 5 year contract with Brican, should the LASIK company default on their end of the deal (the quarterly rebate). I read it several times. Nope. Nothing about that. If the LASIK company bails, you continue to pay your monthly fee in full! Nobody will be picking up the slack on the promised rebates!
When I rang the alarm bell with my online group, I was ROUNDLY excoriated by my friends. I was reminded that I was “always the skeptic.” I explained that signing the contract could put dentists on the hook for what amounted to a $30,000 flat screen TV (if the LASIK dudes didn’t pay up). It was implied that I should just shut up, if I had nothing good to say or positive to contribute.
Well, whattaya know? I was RIGHT! I was the asshole who was RIGHT! The LASIK dudes bailed on the deal, and the dentists were stuck paying for a $30,000 flat screen TV. Some dentists tried to organize a class action suit. I don’t know where that ended up going. It’s been several years since this happened. Editing to update… Click on: 674 Dentists Win Judgment/Brican America
This story was a bit tangential, but it is a good example of the social forces at work within the dental profession and how it can influence dentists considering the purchase of technology.
I will conclude this blog article by simply saying to new dentists and experienced… Do the math. Your OWN math, not the sales dude’s math or another dentist’s math. Do the numbers REALLY work? Assess your needs and your patients’ needs. Is it a solution to a problem you’re having? Or is it a solution seeking a problem? What will be the NET result?
Chime in below with your comments! Have you regretted buying an expensive gizmo for your practice?
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Great article Mike and I agree 100%! You might be surprised that I actually own a CEREC (since 1999) and a Cone Beam but I couldn’t agree more with your viewpoint. The key is to analyze your practice and your commitment to these procedures and devices and how they will or won’t be utilized in your practice. For me it made sense but I fear many buy these things just as you say because they are made to feel it is the standard of care or something when it is not.
Ken
Thanks for your comments, Ken! What Howard Farran said about owning and using a CEREC in his podcast with me was VERY interesting. But, I won’t spoil it. Stay tuned for that.
I think implementing something as significant as CAD/CAM or CBCT (and their related BIG investment) successfully would involve a LOT of planning and education AHEAD of time. Dropping six figures on a gizmo willy-nilly, hoping it will magically transform a practice is folly. And, a LOT of dentists have been down that road. The evidence is on Ebay and similar sites.
Looking forward to your episode.
I’m not sure if you listen to his podcast semi-regularly or at all, but he talks about CBCT/Cerec and asks almost every one of his guests whether they think a new dentist or any dentist needs it, so his views (which I agree with almost 100%) are definitely well established and consistent for regular listeners to his show.
I have had at least 3 people who I’ve recommended crowns to in the past 12 months ask if it was a 1 day procedure now. I don’t have this tech by the way. I know I have had at least one person tell me they would get several of the cracked teeth in their mouth crowned that i’ve been showing them pictures of if it meant it could get done in one sitting and they didn’t have to make a second trip. Meanwhile I assume they won’t move forward with me until one of them breaks.
So the desire is out there for the tech.. but I agree that wearing a temp and having 2 visits isn’t keeping very many patients from treatment acceptance that I’m aware of.
Again… not once in all my years, have I had a patient even ASK for a 1-day crown… or refuse to go through treatment because of a 2nd visit. I think folks may be surprised to hear what HF says about his patients, given a choice between a “same day” crown vs a lab-processed “2-visit” crown. 🙂 But, I’ve had MANY patients come from another practice REGRETTING their “same day” crown. Click here for a recent case.
I purchased a scanning and milling unit but no matter what we did, the unit would not consistently perform as advertised. And on those few occasions that it did complete a crown, the crown looked like it was produced in a third world nation by a third world technician.
I had it picked up and received a refund.
A very timely article for those who have been around for decades and watched things come and go.
Thanks, Gerald!
Here’s a CEREC crown I removed this week. Patient had it done about a year ago in another state. It has been sensitive ever since it was placed. The concerned patient returned to the dentist, who reportedly told her, “it’s fine.” The decay on the facial went about 3-mm deep, requiring a “block-out / build-up.”
Admittedly, this result could have just as easily occurred with a lab-made crown. This thing was a “beotch” to cut off! And, the tooth was not “happy” making anesthesia a challenge. Given the open margins and the thickness of the cement, I suspect the crown didn’t get seated all the way at the delivery.
How long after your purchase were you able to return your system? Yours is the first story of a successful return that I’ve heard.
Nice blog Mike. I agree wholeheartedly. I have been looking for an excuse to buy just a scanner, but with initial investment and more importantly the monthly data fee I just can’t make the numbers add up just yet. Getting closer though. I have used the “solution for a problem I don’t have” many times. As a member of the white hair society I tend to be more skeptical. I have digital xrays and pan but I could justify those numbers. Not to plug it ,but one piece of technology I have found to be a big asset in my practice is the cari-vue. Minimal investment but I find it invaluable in diagnosing interproximal decay and helpful with fractures.(Of course I may just stink at reading x-rays 🙂 )
Hi Pat,
I do see myself scanning preps in the future (when the cost comes down to the point of making it a no-brainer). I’m simply not interested in milling crowns and becoming a lab tech to custom stain them (which never looks anywhere close to a layered crown). When we are printing crowns, they will look better.
Tell me more about Cari-Vue. I admit to knowing nothing about it. I’ve had a Diagnodent since they became available in the U.S. I don’t use it a lot, but it comes in handy occasionally.
Mike,
Nice article, like usual. I guess I’m the least sharp of your readers.. but can you explain who Greenberg is/are? Is he/she the “keeping up with Joneses” of the dental world?
On a related note, just went to a CE dinner last night on cone beam technology for GPs. They recommend purchasing a machine and then of course getting a scan on every one of your patients. I simply don’t understand how you can justify that radiation… along with getting all your patients to pay for it! Your post was dead on as I read it this morning after that lecture.
Yes… It’s a play on the “Joneses.” There was an episode of “Two and a Half Men” when Charlie threw out his back. He couldn’t remember exactly who or where his doctor was except that it was “Dr. Schwartz on Wilshire Blvd.” So, his brother Alan calls “information” (remember when you could do that?) and asks for, “Dr. Schwartz on Wilshire Blvd.” The operator replies, “Sir… we have 47 Dr. Schwartzes on Wilshire Blvd.” 🙂
Scan every patient?? Holy shit. They said that with a straight face??
That’s a funny anecdote from Two and a Half Men. And I totally believe there are 47 Dr. Schwartzes on Wilshire.
Totally straight face. The speaker was describing what he does in his practice. A lot of time was spent showing the various pathology that he was able to diagnose with 3D imaging. That was certainly impressive, and he did a great service to those specific patients, but all I could think of were the hundreds of other patients who had large amounts of radiation and who likely forked over several hundreds of dollars for a scan that was probably not needed.
So, he’s doing a full mouth scan on every patient?? What are the figures for the radiation dose (as compared to a traditional FMX)?
One thing many dentists discover the hard way, technology alone will NOT make you a better dentist. Since a couple comments here related to CEREC; A CEREC will not rescue you from mediocre dentistry.
Technology “alone” (and I stress “alone) will not make you a better dentist or rescue your work. You must commit to excellence and only then can some of these “technologies” make sense. I have seen crappy crowns from a lab just like those above. Whether CEREC or lab it’s the Indian and not the arrow used.
Absolutely! But, unfortunately, a lot of these technologies are marketed that way. And, the dentists who buy them often turn into faithful acolytes promoting them as the “new standard of care.” All BS, of course. CAD/CAM is neither “better” nor “worse” than lab-fabricated restorations.
All photographers cringe when they hear, “What kind of camera did you use? It takes great pictures!”
I agree and it’s unfortunate that many of these things are indeed marketed that way. I suppose it’s the lure of the sirens for many dentists.
Hit the nail squarely on the head as usual, Mike. Thank you for having the balls to put that out there like you did, because I am also keenly aware of how unpopular this position is. Kind of makes you feel like a leper in the dental community when you go against the tide. This is just another issue that serves to further fracture the already strained practicing dentists.
Just before I read this post, I read Fred Joyal’s most recent piece about why it pays to invest in this technology. I have great respect for Fred’s work, but I am unsettled by the implication that this is the new standard of care. He also states that young doctors may not consider purchasing a practice that doesn’t have the “bells and whistles.” All the technology cannot make up for lack of critical thinking and sure hands. At the end of the day, you still have to recognize what needs to be done clinically, and then put the bur to the tooth with your own hands. If you lack these qualities, then having a Cerec unit, for example, will allow you to only say this: ‘ with this astronomically expensive piece of equipment, I am now able to take fantastically accurate scans of my shitty preps.’
Our job is to treat the patient the best we can. The dental companies/reps job is to sell stuff. That’s it. We have to decide what is best and then have dental suppliers aid us accordingly, all the while supporting each other along the way. But as you pointed out, the reverse is the norm, and this creates a false need to jump on the bandwagon, tearing our colleagues down in the scramble. Your advice should be strongly considered by all, especially the up- and-comers who would be more prone to make some serious financial mistakes without the benefit of years of clinical and business experience.
Thanks for your thoughtful comment, Brian! Some great points there that really resonate with me (and my article).
I chuckled at, “….with this astronomically expensive piece of equipment, I am now able to take fantastically accurate scans of my shitty preps.” I was at a CE course where all the participants brought in a solid model of a single crown prep case from their practices. We would scan those and fabricate CEREC crowns. It was fun and very cool, honestly. But, to your point, I looked at some of the other models of preps. Most looked pretty good. But, some looked like a rat chewed on the tooth! Holy crap. Retention and resistance form? Who needs that?!?! Build-ups and block-outs? Meh! That takes too much time and materials! Just let the “glue” do the work! 🙁
I haven’t seen Fred’s article. I’ll try to find it.
Love your blog, Mike. I’ve been following you for a number of years; I first stumbled across something linked to you regarding firearms. I’m a marksman myself, and competed for years on the KY State high power rifle team. I always like reading your stuff; very thoughtfully written.
I am an unapologetic proponent of the newer versions of CEREC and CBCT. I swallowed the big pill about 3 years ago and thought I’d share my experiences with you. A 2007 graduate, I bought a prosthodontists part time practice in 2011. I worked that office only 2 days a week and struggled to make it grow in competitive east Louisville. I worked 2-3 days a week as an associate in another office an hour away. I felt that an investment in technology that nobody else in the area had might set me apart a bit. I was VERY apprehensive of the price tag. I shopped CEREC Omnicam and E4D Nevo (now PlanScan) as they were the only serious options at the time, and attended both the Accept program in Scottsdale and the hands on course in Dallas that E4D offered. I also shopped about 7 different CBCT systems. I learned a lot about CBCT in relation to radiation exposure, voxels, focal spots, etc. It took me about 6 months of evaluation to make a decision. I ended up with Sirona products all around. Let me tell you why.
First, I had a written guarantee that I could return either of them within the warranty period (1 year CEREC, 3 years XG3D) without depreciation or restocking fees. They were the only ones who offered that. While I found both E4D and CEREC made very nice crowns, I was never able to get the E4D to work fast enough to where I thought single visit crown appointments were realistic. My experience with the CEREC has been that the restorations are as good or better than what I ever got back from the lab. I was nervous about this for a while, because there are several offices around with older versions of CEREC that produce pretty horrific restorations that I frequently find myself removing and replacing. The machine makes what you tell it to make; if you get a bad outcome, you can’t “Blame it on Bob” the lab guy anymore. I won’t say it’s perfect every time, but any time I’ve had a less than ideal restoration milled I have been able to go back into the software and see where I screwed up. I would argue that it has indeed made me a better dentist. Way more thought goes into prep design; enamel conserving preps are terrific, and there are many studies available that show the ideal time to bond a restoration is as soon after the tooth is prepped as is possible. Blowing up what you think are fine preps on a monitor for the world to see can be humbling at times, and is another challenge to improve yourself. Polishing margins with ultra fine diamonds is now the norm for me. Seeing what goes into making a crown gives a glimpse of what the lab techs have to deal with, and can lead to some AHA! moments from time to time. I would also agree that it’s not for everybody. I’m a clinical trainer for CEREC now, and there’s one doc that comes to mind who is constantly struggling. We have spent probably 80 hours or more with him training, but he just can’t quite get it to work as intended. I bet he returns it, and I think that would be a good choice for him should he do so. Staining and glazing is usually a 3-5 minute affair and is honestly a non issue. Although I’ve done several full anterior cases, I find that a master ceramist does a way better job achieving the desired esthetics than I am able to do. There are some CEREC guys out there who are artists with the thing, but that’s not me. I send demanding cases to the lab via digital impression. As far as maintenance, repairs, software updates, etc., it’s also been a non issue. You do have to be “in the club” so to speak, but about $300/mo covers both pieces of tech for 7 years. I’ve had all the software updates installed at no extra cost, maintenance schedules kept, I had a bad ring motor in the CBCT taken care of, and had a failed motor in my mill replaced, all attended to within 48 hours of my phone call reporting a problem. In short, my experience is that start to finish, with training to maintenance to repairs, it has been nothing but positive.
In regards to CBCT, I would submit that it is a tough thing to compare them all in one category. Are we talking full FOV units? 16cm? 8cm? 5cm? Are we talking about intensifiers or flat panels? Are we talking about units that are basically reconfigured medical units or ground up dental units? You can compare really low radiation units like iCat or Galileos or some of the Planmeca models, but throw in Prexion, for instance, and it’s not even a remotely an apples to apples comparison. Your standard exposure of the 8cm volume on the XG3D (the one I have) has the equivalent background ionizing radiation as a flight to Australia; when is the last time you saw an airline pilot wearing a radiation badge? Prexion of 3 years ago (not sure about the current one) exposed the patient to about 40x the ionizing radiation, depending on which brochure or which sales guy you spoke to. Exposing every patient to something like that would be a sin, in my estimation. The machine I have? I expose nearly everybody, using it as a pan. The radiation dose is within a few microsieverts of my old digital pan, and nobody complained about that or shook their heads about recommending one every 5 years. There are an inordinate number of asymptomatic failed RCT teeth out there that simply do not present on 2D radiograhy, and is my #1 incidental finding. I review each scan and have found several conditions early on that would have been very bad for the patient had they not been discovered as an incidental finding; the most recent was a fungal infection in the sphenoid fossa of a young woman. The ENT I referred her to said that the early finding spared her much misery, and encouraged me to keep doing what I’m doing. I perform about 100 implant surgeries a year, which was my primary motivation for CBCT, and I’d point out that CBCT is standard of care for implant surgeries now. This statement is made in light of legal precedent at this point; the ITI and AAOMFR also have position statements that it is SOC. I find that co treatment planning implant cases using the CBCT with the patient leads to a better informed patient, vastly simplifies surgical preparation relative to the days prior to me having the tech, and has improved case acceptance.
My personal opinion is that CBCT is indeed for everybody, even if they are not placing implants. CADCAM, on the other hand, requires work, training, and dedication that not everybody can accommodate. How has it gone for me? I obviously never had to try out that return policy, but in short order I found myself 4 days a week in my little office and had to move about a year ago to allow room to grow. I do not like how some of the sales guys promote CADCAM as SOC; if you have a nice prep and take an accurate impression and send it to a good lab, you’ll get a nice restoration. That CADCAM/SOC thing is complete garbage. I also do not like how the sales guys (and I’m not talking just Sirona, btw but all of them) try to push a combo optical scanner and CBCT combo and tell them how easy it is to make a surgical guide that won’t let you mess up an implant surgery. Unless the doc performing has the requisite training and skill set that’s a recipe for disaster.
To close, these are just tools. They can be used to great effect, great waste, or even be detrimental to patient care; it all depends on who’s controlling their use. One might even say it depends who’s pulling the trigger.
Highest regards,
Jeremy
Thanks for your comments, Jeremy. No doubt yours is one of many success stories. But, as you said, your success was far more involved than the mere purchase of the tools. They’re tools, just like firearms… they can’t do anything autonomously. 🙂 You put a lot of time and training into the equation.
My point wasn’t to disparage nor refute the technical value of these machines. My point is that there exists significant “social” pressure within our professional community and that dentists should weigh their decisions based on their OWN circumstances. I picked on these two technologies a bit, because they are the most expensive… each six figures, totaling over a quarter million dollars. With careful planning it may work out. Or, it may be financially (and even clinically) disastrous.
I would urge all dentists to simply think for themselves. Success is not predicated on the number of toys you own.
Thanks for chiming in with your reasoned comments! And, “keep your powder dry!” 😀
I’d have to agree with your assessment, Mike. I have seen the “buzz” surrounding the introduction of new technologies on DentalTown over the years….and I do believe there is some degree of “peer pressure” to keep up with the Jones and the Greenbergs. I purchased the Cerec 3 (prior to the Windows version we enjoy now) back in 2002…and have enjoyed it very much. I”ve upgraded a couple of times over the years and now have the Cerec AC. The suggestion that the monthly cost will be negated by what you were paying your lab bill is not always true though…some months are slow and you don’t do enough single unit crowns to cover that expense. And….what they don’t say is that by the time you do get it paid off…you really can’t just enjoy the saved expense because now it’s time to upgrade to the newer version….and there goes another $75K. I’ve owned the Waterlase, the Waterlase MD, and now the Powerlase AT. All are great…and work pretty good….but NO WAY do they pay for themselves. I can’t say I’ve gotten that many new patients because of having them, either. All I can say about them is I enjoy using them and it makes coming to work that much more fun…but they don’t pay for themselves. In fact…..the ONLY piece of technology I’ve ever purchased that actually DID pay for itself was the Periolase MVP-7. It paid for itself in about 9 months. It’s the only one of the bunch that actually kept the “pays for itself” promise.
I’m much more selective in making my purchase decisions of big dollar tech these days….
DrDan
Thanks for your candid comments, DrDan!
Thanks for sharing!
Great article, thanks for sharing. It’s always funny hearing about the new standard of care in dentistry.
Hi Mike, I’m sorry to use this space for something unrelated, but what the heck
happened to the Aspen Dental blog? I noticed it was not on your site anymore. Were
you forced to remove it? Anything nefarious going on? Please say it ain’t so, because
that would make me feel like I did the day I found out there was no Santa Clause. Please let me know if you can. Thanks, Brian