New Dentist Spring 2018 by The New Dentist

THE #1 RESOURCE FOR NEW DENTISTS

IMPROVING CASE ACCEPTANCE PLUS Key Practice Indicators Delaying Practice Purchase Dental Lights SPRING 2018

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FROM THE PUBLISHER’S DESK Dear Readers, Welcome to the Spring issue of The New Dentist™ magazine.

o be a successful dentist, you need to establish goals early in your career. If you don’t have goals, objectives or measurement systems in place, profits and productivity will become stagnate and even start to decline. Simply put, no goals equals no growth. There are certain benchmarks, or goals, that every practice should strive to reach. For example, collections should be 98% of the dentistry produced while case acceptance should be 85%. Hygiene should account for 33% of practice production and 85% of emergency patients should be converted to comprehensive exams. It takes work to meet these benchmarks, which is why putting protocols in place and establishing measurements is so vital to your success. Multiple practice systems affect your profitability, so determining where to start can seem overwhelming. That’s why I suggest looking at it in terms of four broad categories—Service, Staff, Profit and Growth. Service. The quality of the service you provide has a direct impact on case acceptance, collections, hygiene production, emergency patient conversion and broken appointments. I recommend establishing specific goals focused on providing exceptional customer service. Put together a team to examine the patient experience and determine where it can be improved. Ask patients for feedback and take their concerns seriously. Create an experience that makes patients want to come to your practice. Staff. Successful dentists have strong teams behind them. It’s important to establish goals that help you attract and retain the best and brightest. If you’re experiencing high turnover rates, it might be because of your hiring process, insufficient training or other system weaknesses. Hire people who are right for the job and then give them the guidance they need to succeed, which includes detailed job descriptions and continual feedback. Remember, unresolved staff issues lead to conflict, which does nothing but damage a practice. Profit. Establish goals to monitor and improve profitability. If specific practice management systems are in place, you should be able to increase profits each year. Take a close look at your practice management system reports, including the Unscheduled Treatment Report. These are available through your practice management software. Growth. Improving patient retention is the key to practice growth. Offering new services is one way to keep patients loyal to your practice. This might include interceptive perio, endodontics, veneers, whitening, and implants. You’ll not only attract more patients to your practice, you’ll stay passionate about dentistry throughout your career. In this issue… We want to help you grow your practice, and the articles in this issue are designed to do just that. If you’re ready to improve case acceptance, turn to page 6 for an overview of products that help get patients excited about treatment, and then to page 10 to read about how board member Dr. Dennis Frazee gets patients to say yes to treatment. On page 22, Dr. Paul Feuerstein gives the lowdown on LED lights, and Dr. Jose-Luis Ruiz discusses why full crowns may not be the standard of care for badly damaged teeth on page 18. We break down key practice indicators on page 12, and Dr. Tom Snyder explains why you shouldn’t put off your first practice purchase on page 20.

Here to help,

Sally McKenzie, Publisher

2 THENEWDENTIST.NET S P R I N G 2 0 1 8

Advisory Board

Christopher Banks, DDS Inwood, WV WVU, 2011

Rebecca Berry, DMD Oakland, ME Tufts, 2011

Julie Boerger, DMD Patchogue, NY University of Montreal, 2010

David Carter, DMD Zachary, LA University of Mississippi Medical Center, 2014

Hal Cohen, DMD Haverford, PA Temple University, 2010

Larry Dougherty, DMD San Antonio, TX Nova Southeastern, 2008

Dennis Frazee, DDS Mooresville, IN Indiana University, 2012

Lindsay M. Goss, DMD, MPH Chandler, AZ ASDOH, 2010

Erica Haskett, DDS New York, NY NYU, 2008

Crystal Johnson, DDS Powder Springs, GA University of Tennessee College of Dentistry, 2009

Aaron Layton, DDS Fort Collins, CO Indiana University, 2010

Leah Massoud, DMD San Jose, CA Tufts, 2009

Michael Potter, DDS Quincy, WA University of Minnesota, 2014

Tyler Scott, DDS Loudonville, OH Ohio State, 2009

Matthew Silverstein, DMD, MPH West Hartford, CT University of Pittsburgh, 2012

Nicole Smith, DDS Newport Beach, CA NYU, 2009

Gregory Snevel, DDS Cleveland, OH Ohio State, 2011

Bryan Stimmler, DDS Brooklyn, NY University of Southern California School of Dentistry, 2009

TABLE OF CONTENTS

SPRING 2018 S P R I N G 2 018 PUBLISHER

Sally McKenzie Sally@thenewdentist.net DESIGN AND PRODUCTION

Picante Creative www.picantecreative.com EDITOR

Renee Knight renee@thenewdentist.net PHOTO COURTESY OF XLDENT

SALES AND MARKETING

12 FE AT U R ES Products That Improve Case Acceptance The Yes Factor

Disclaimer — The New Dentist™ does not verify any claims or other information appearing in any of the advertisements contained in the publication and cannot take responsibility for any losses or other damages incurred by readers’ reliance on such content. The New Dentist™ cannot be held responsible for the safekeeping or return of solicited or unsolicited articles, manuscripts, photographs, illustrations, or other materials. The opinions, beliefs, and viewpoints expressed by the various authors and contributors in this magazine or on the companion website, www.thenewdentist.net, do not necessarily reflect the opinions, beliefs, and viewpoints of The New Dentist™ magazine or The McKenzie Management Company, LLC.

Are Full Crowns Still 18 The Standard of Care to Repair Badly Damaged Teeth? Why Delaying a Practice Purchase May Be a Big Mistake A Look at Lights

22 DEPARTMENTS 2 Publisher’s Message

PHOTO COURTESY OF DR. JOSE-LUIS RUIZ

4 THENEWDENTIST.NET S P R I N G 2 0 1 8

The New Dentist™ magazine is published quarterly by The McKenzie Management Company, LLC (302 N. Chestnut St., Barnesville, OH 43713) on a controlled/complimentary basis to dentists in the first 10 years of practice in the United States. Single copies may be purchased for $8 U.S., $12 international (prepaid U.S. dollars only). Copyright ©2018 The McKenzie Management Company, LLC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without permission in writing from the publisher. Authorization to photocopy items for internal or personal use is granted by The McKenzie Management Company, LLC for libraries and other users registered with the Copyright Clearance Center.

Tracking Key Practice Indicators

Contact Melissa Rataiczak at melissa@thenewdentist.net or 877-777-6151. Visit our digital media book at www.thenewdentist.net/ mediabook.htm

24 Skinny on the Street 24 Index of Advertisers

Contact Us — Questions, comments, and letters to the editor should be sent to renee@thenewdentist.net. For advertising information, contact ads@thenewdentist.net or 877.777.6151. Visit our website at www. thenewdentist.net to download a media kit.

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Products That

IMPROVE

CASE ACCEPTANCE By Renee Knight, Editor

o matter how much experience you have as a dentist, getting patients to accept treatment can be challenging. Patients are always looking for reasons to say no, and often convince themselves they don’t need what you’re recommending, or that it can wait. This can be frustrating, and certainly doesn’t do much to grow your practice or your bottom line. How can you improve case acceptance in your practice? From third party financing to patient education to technologies that improve the overall experience, there are plenty of products on the market that can help boost your numbers—you just have to make sure you’re investing in the right ones.

THIRD PARTY FINANCING Cost is one of the most common reasons patients say “no” to treatment when the dentistry they need requires an out-ofpocket investment. Most people typically need to set money aside for dentistry, and families may have other financial responsibilities, needs and wants. So, if their insurance benefits don’t cover all the cost, they may decline or delay care because they choose to prioritize another purchase over treatment. With third-party financing from companies like CareCredit, more patients with out-of-pocket costs may no longer have to choose between dentistry and another financial need or want. Instead, they can choose both. “Offering patients the opportunity to pay over time should be part of every dental practice’s business plan from the beginning,” said Sameer Bhasin, Vice President, CareCredit. “Everything in a practice should be focused on giving patients every opportunity to accept care, including providing ways that make it easier for them to pay out-of-pocket costs.” One easy way is offering third party financing as another payment option. Instead of writing one large check, patients can break up payments into smaller monthly amounts (subject to credit approval), which can make accepting treatment more financially manageable and comfortable. 6 THENEWDENTIST.NET S P R I N G 2 0 1 8

Think about what kind of practice you want to have, Bhasin said. If you only educate patients on what their insurance will cover, the dentistry you provide will be mostly insurance based. But, if you share with patients treatment that is in the best interests of their oral health and share the benefits of third party financing, it will be easier for them to see how treatment fits within their family’s financial situation. Instead of basing decisions on what insurance will cover, they may be more likely to choose what’s best for their health. “Using monthly payments to pay for larger out-ofpocket purchases is something patients understand,” Bhasin said. “They can budget for the payment each month as they do other bills. And the conversation about family finances can be very different. If someone needs $5,000 right now for treatment and there are other important and immediate financial responsibilities, that treatment may not end up being a priority. But, if monthly payments are an option, the focus of the conversation is on fitting care into the budget.”

PATIENT EDUCATION VIDEOS The more patients value dentistry, the more likely they are to accept treatment. If you educate them about their condition and treatment options, they’ll see more value in the care you offer. Providing clear, consistent education also helps you earn their trust and improve your creditability. There are plenty of patient education videos on the market, you just need to decide which best fits your practice. GURU, which is run through Dentrix practice management software, is one. Dentists can upload patients’ x-rays and images into the software and highlight areas of interest, as well as show short, interactive videos that explain procedures. “It’s not about dentistry, it’s about dentist me,” said Lee Allen of GURU. “It’s not my problem as a dentist. I’m not talking to you about science, I’m talking to you about your health condition. This is your tooth, your x-ray. You also can show them why it hurts and explain the different treatment options.” CONTINUED ON PAGE 8 >>

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Case Acceptance continued from page 6

Once you’ve done that, the conversation you just had can be emailed, Allen said. This enables patients to easily share the information with their spouse. Together, they can go through each option and make a decision that isn’t solely based on price. Consult-PRO is another option that offers education in three main areas. Dentists can link to the company’s video library on their website; they can play CP TV, which mimics a local news program, in the reception area; and they can show patients customized videos chairside, Account Manager Alex Pulec said. The videos, which can include their images and your annotations, are easy to send via email, as are the treatment plans you can create through the software. Karen Young, an implant treatment coordinator, has used Consult-PRO for years. The videos help her keep messaging consistent and to explain conditions and procedures to patients in layman’s terms, which is something dentists often struggle with. “There’s just better understanding and clarity,” Young said. “And when patients have a better understanding of what’s happening and own their issues, they make better decisions. When patients make better decisions for themselves, they’re more compliant and more successful.” Curve Dental also provides patient education through CurveEd.com, a website that features about 60 free videos that dentists can show chairside as well as email directly to patients. The videos are typically about two minutes. “It’s going to increase patient acceptance. It’s going to build trust with the doctor,” Curve VP of Marketing Andy Jensen said. “Any doctor can say you need a crown, but that doesn’t build a relationship. The doctor needs to sit down, explain what’s going on and involve the patient. That builds trust.”

TREATMENT PLANS Many patients don’t accept treatment because they aren’t aware of all their options. Often, dentists only present treatment they think patients are interested in pursuing, which hurts case acceptance rates. Through Dentrix practice management software, it’s easy to show patients all the treatment they need as well as their various options, said Dr. Bill Busch, who uses the software in his practice. “Dentrix allows you to divide the treatment plan into a traffic light scenario. A red light indicates an immediate need, yellow indicates future needs and green indicates optional dentistry,” Dr. Busch said. “This organizes treatment options right off the bat. Doctors can prescribe and recommend treatment that would improve health without any reservations. They have the freedom to recommend anything the patient needs, regardless of price.” Before he puts the plan together, Dr. Busch always asks for permission, and patients usually say yes. Once the plan is complete, he can give them an overview of all their needs, making it clear which are most immediate. DEXIS imaging integrates with the Dentrix software, making it easy to copy and paste

images into the treatment plan to give patients a visual of their condition. From there, patients can make an informed decision on which treatment options to pursue. Dr. Busch has three folders, one for each level of treatment, with codes for the procedures. Once patients decide on treatment, he can go to the appropriate folder and get them scheduled. He also has patients digitally sign the treatment plan, even if they don’t go forward with any recommendations, so there’s legal documentation of what was discussed. “This gives the new dentist credibility,” he said. “They’re able to teach patients and let them understand what their needs are. They don’t just have to take the doctor’s word for it. You’re using a tool that allows you to teach your patients.” The Trx Plan Generator from DentalTrx Software offers dentists another option to make treatment plans clearer. Developed by Dr. Robert Wilkoff, the software enables clinicians to create treatment plans in three or four minutes. The program also generates a customized narrative report. To create the treatment plan, the dentist enters the patient’s name and contact information, and then selects the appropriate pre-programmed buttons to enter clinical information. It only takes a few seconds to mark each condition, and users can add notations as they go along. “With the Trx Plan Generator, there is a complete appreciation of my services and the thought process that goes into preparing a treatment plan from the simple filling or filling replacement to more complex restorations,” said Dr. Allan Miller, who uses the software in his practice. “It gives my office manager more information to help her close the case and make financial arrangements for patients.”

INTRAORAL IMAGING Many patients are visual. If you can show them what’s happening in their mouth, they’ll be more likely to trust your recommendation. Intraoral cameras and digital x-rays make that possible. Every practice should have an intraoral camera for both educational purposes and insurance documentation, said Gil Orenstein, Regional Product Manager for Intraoral Imaging at Carestream Dental, the company behind the CS 1200 and CS 1500 cameras. It’s also vital to invest in digital imaging, whether you use digital sensors or phosphor plates. Both provide a better overview of the mouth, and, when paired with intraoral cameras and/or other imaging technology, help give a complete picture. No matter what technology you invest in, the software you use, like the CS Imaging Software, should bring all the images together in one place and make them easy to access and share. It’s also important to look for sensors that offer additional features. For instance, RVG Digital Radiography Systems come with Logicon Caries Detector Software, which is an optional component that helps dentists better analyze radiographs to diagnose caries. Clinicians can take an x-ray with the RGV 6200 sensor to perform an automatic analysis of the mouth and potential for caries. CONTINUED ON PAGE 17 >>

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The

between you and your patients that creates an opportunity for them to say no to treatment. By Dr. Dennis Frazee

YES

Factor

A guide to case acceptance. et’s face it: Dentists are not the greatest at casually talking to patients, especially dentists who are fresh out of dental school. We can discuss how the anaerobic bacteria are multiplying at the apex of the tooth root that is causing compression on blood vessels and nerves all day, but when it comes to determining what motivates patients to accept treatment, we fall short. In my practice, there are three factors that allow us to really connect with our patients. Taking these steps has made patients more likely to say “yes” to treatment, which has helped our scratch practice grow exponentially in our first three years.

1. AVOID “VERBAL DIARRHEA” We all have this incredible tendency to show our patients just how much we know by talking about technical aspects of dentistry. In actuality, patients don’t really care how much you know. Sure, 5% or so of patients want to know exactly what type of bacteria causes a cavity to progress, and you can feel free to unleash your vast knowledge with these patients. The other 95% of patients who present to your office usually want to know three things: what is causing the problem that got them into your chair, what are you going to do to fix it, and how much is it going to cost. That’s it! Once you start talking about the widening of the PDL and the periapical radiolucency, patients become glassy eyed and stop listening. All you are doing is creating a separation 10 THENEWDENTIST.NET S P R I N G 2 0 1 8

2. LET PATIENTS TREATMENT PLAN THEMSELVES Okay, so I don’t mean to literally let a patient look at the x-ray or photo and say, “Well, I think that one needs a crown!” I’m talking about figuring out what treatment patients are interested in. We do this by asking every patient who comes through the door one simple question. This is usually how our initial encounter goes: Me: Hello Mrs. Jones. I’m Dr. Frazee. Thank you for coming in today! I have a few questions before we really get started that will help us make today’s appointment as efficient as possible. Mrs. Jones: That would be great! Me: Mrs. Jones, how did you hear about our office? Mrs. Jones: My sister has been here and she referred me after saying how great it was. Me: That’s great Mrs. Jones. I will be sure to thank her for that kind referral. Now Mrs. Jones, what exactly are your goals for your mouth? If you take the time to sit back and listen to their answers, this opens the door for patients to essentially treatment plan themselves. If the patient says, “Well doc, I’ve got a bunch of missing teeth and I’ve got another one broken that I would like to get out of there,” you know what kind of treatment to focus on. You probably wouldn’t spend a large amount of time talking about saving the tooth or replacing it with implants. I’m not saying not to at least bring it up to give the option, I’m just simply saying don’t spend an inordinate amount of time talking about implants to someone who just “wants the tooth out.” You don’t want to inundate patients with loads of information they couldn’t care less about. This creates an opportunity for them to say no to treatment that would fix the problem that originally brought them through your doors. Instead of overloading them with information, present the treatment plan and get the patient numb to create efficiency in the appointment. If Mrs. Jones were to reply to the question with, “Well doc, I’ve got a couple spaces in my mouth that I would like to have fixed with something that stays in place,” you know you are going to spend a little more time planning this case and going over treatment options. This allows you to create an efficient office flow where the appropriate time is spent focusing on your patients’ goals. In a dental office, time is money, and if you are spinning your wheels discussing implants with a patient who has absolutely no interest in implants, you lose 15 minutes of productive time you could have spent elsewhere. Do this 3-4 times a day and those dollar signs, not only from lost time

The products Dr. Dennis Frazee can’t practice without: but from lost opportunities in other chairs, really starts to add up.

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is $3,499. Imagine how efficient this is when patients get the same answer from everyone they talk to in the office. 3. CREATE PACKAGE FEES This also eliminates the potential of FOR TREATMENTS patients going line by line and questioning each cost, which leads to them Think back to the last time you questioning the treatment. were quoted for a service with In our office, simple is the multiple line items. It doesn’t matIvoclar Vivadent OptraGate solution. Our goal is to create an ter what the service was, the first atmosphere and to communicate thing you did was look at each Premier Dental Traxodent Retraction Paste with our patients in a way that easily line, determine what the cost was allows them to say “yes” to our treatment options. These are for each line item, and then question why certain line items a few of the methods we have found to work incredibly well cost what they did. You better believe that when you put all in our first 3 years, and I truly believe if you adopt some of the codes into your practice management software and print these practices early in your career, you will find that case the treatment plan for patient presentation, the first thing acceptance soars through the roof! the patient is going to do is follow each line item and start questioning costs. This just creates another barrier to the patient saying Dr. Frazee was born and raised in Northwest Indiana. “yes” to treatment. There is a very simple solution, and that’s After receiving a BA at Wabash College and a master’s to create package pricing for certain procedures. It simplifies degree from Purdue University, both in biology, Dr. Frazee graduated from IU School of Dentistry in things for you, your team and the patient. For instance, in our June 2012. He is a member of the American Dental office, if you ask any of our team members what the cost of an Association, the Indiana Dental Association, the immediate implant is, including extraction and bone grafting, Indianapolis District Dental Society, the Academy they would all be able to answer you within 3 seconds that it of General Dentistry, and the American Implant Association. n n n n n n n n

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THENEWDENTIST.NET

Tracking Key Practice Indicators

ost dentists don’t spend a lot of time focusing on key practice indicators (KPIs) or even really know what they should be tracking. As long as they have enough money in the bank to pay the bills, they think they’re doing OK.

Unfortunately, they’re usually not, and they certainly aren’t meeting their full potential as practice owners. “Think about the show Shark Tank,” said Brent Saunier, CPA with Pro-Fi 20/20, CPAs. “To be taken seriously, or to know that you are serious about growing your business, you must know your numbers. Most doctors want to avoid this and just focus on the clinical side. The doctor is the employee who practices clinical dentistry and gets a salary paycheck, but an owner is focused on the numbers, growing revenues, and making a profit.” KPIs tell you how your practice is performing, and give you the opportunity to make adjustments when needed. If you ignore them completely or only pay attention to a few, you’re missing the big picture—which means it becomes difficult to make solid business decisions that will help your practice grow. “It’s like following a road map. If you don’t follow the map, there’s no guarantee you’re going to get where you want to go,” said Nancy Caudill, Senior Consultant for McKenzie Management. “Following these indicators helps you determine if your practice is healthy and if you’re on track to meet your goals. It also helps with accountability and making sure your front desk employees are doing what they’re supposed to be doing.”

PHOTO COURTESY OF XLDENT

By Renee Knight, Editor

From Saunier: • Number of new patients per month per doctor, which should be between 20 and 25. • Acquisition cost per new patient, which is marketing spend / number of new patients. This should be $120. • Average revenue per new patient, which is total collections / total number of new patients. This should be between $1,800 and $2,000 per new patient. • Average revenue per chair, which is total collections / chairs / 12 months. This should be between $25,000 and $40,000 per month. • Production adjustments.

TRACKING THE NUMBERS Part of the reason many dentists don’t monitor KPIs is they don’t know what to track. Caudill and Saunier both have suggestions to help with that. Here are a few KPIs you should monitor each month through your practice management software:

This list is by no means all inclusive, but it should give you an idea of what needs monitored. Keep in mind you might have to include certain filters when you run reports, Caudill said, depending on what you’re tracking. Don’t be afraid to ask the practice management software manufacturer for some guidance with this, as well as with understanding how to read the reports. It’s also a good idea to reach out to a dental consulting firm like McKenzie Management for help.

From Caudill: • Net collections to net production. The goal is to be collecting 100 percent after adjustments, with no more than 2% written off for bad debt. • Accounts receivable, which should be 1X net production or less. (Make sure your accounts receivable report doesn’t include credit balances or your number won’t be accurate.) • Hygienist production, which should be three times their salary. • Gross wages, which should be 19 to 22 percent of net collections.

THE KPI DASHBOARD FROM XLDENT XLDent recently added the KPI Dashboard to their software, giving practices the ability to analyze critical numbers in real time, which can be especially beneficial for new dentists. “Establishing new patient and production goals are key to growth, as well as knowing what marketing sources are working better than others,” XLDent President Dawn Christodoulou said. “A/R age, front desk collections and write-off composition are keys to establishing financial policies, making contract decisions, and setting up standard operating procedures from the get go. Real-time KPIs for a new dentist are like a magnifying glass. They clearly report the information CONTINUED ON PAGE 14 >>

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“There are really only three phases of business: Growth, Plateau, or Decline. Which one do you always want to be in?”

Key Practice Indicators continued from page 12

critical to the establishment of the systems that will keep the organization streamlined and overhead low relative to growth.” Moira Campbell, a clinical financial manager at a Washington-based practice, has been using XLDent for about five years and the new KPI Dashboard for a few months. She, and anyone else on the team who has access to the dashboard, no longer has to wait for individual reports to be run to see key indicators, and can look at statistics in real time from a computer or a mobile device. Users also have the ability to customize how the graphs are laid out and can drill down reports for more specific information, such as the best times of day to open up spots for new patients. Team members can filter to see production numbers by provider and type of treatment, and can even make comparisons of KPIs month to month and year to year. And if they find they aren’t meeting a particular goal, they can quickly make adjustments to get back on track. “We are a pediatric practice so patients are always graduating from the office. Demographics and revenue tracking are important to us,” Campbell said. “We don’t want to see that information 30 days later. We want to see it in real time.”

— Brent Saunier, CPA with Pro-Fi 20/20, CPAs

NOW IS THE TIME No matter which practice management system you choose, it’s important to start tracking KPIs and making the necessary changes based on what the numbers tell you. “There are really only three phases of business: Growth, Plateau, or Decline. Which one do you always want to be in? Growth, of course. But it won’t just magically happen for you. It has to be set as a goal with defined numbers,” Saunier said. “If you truly want to be a success, you must become a student of the game, of your numbers. Focus on your business like an engine that you have to keep fueling, repairing, and maintaining. The goal is to start tracking, keep tracking, and systematize your business for repeated, predictable results.”

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VITAL SIGN NO. 1: PATIENTS New Patients: Practice specific goal Past Due Recall Patients Reactivated: Practice specific goal Emergency Patients Converted to Comprehensive Exams: 85%> Patient Retention: The practice canâ&#x20AC;&#x2122;t lose any more than 50% of the new patient total per month through recall patients not returning. VITAL SIGN NO. 2: TREATMENT Treatment Presented: Practice specific goal Treatment Accepted: 85%> Production: Dentists set production goals based on how much money is needed to meet personal and professional goals. VITAL SIGN NO. 3: FINANCIALS Accounts Receivable: < 1 x monthly net production Collection Ratio: 98%> (over 100% if over 90 days is more than 10%) Over the Counter Collections: 45%> if accept assignment from insurance, 95%> if cash practice Over 90 days Past Due: < 10% VITAL SIGN NO. 4: SCHEDULING Unscheduled Time Units Converted to Dollars Lost, Doctor and Hygiene: Less than 3, 10 minute units/day. To determine how much money is being lost in your practice, divide the practice daily goal by time units worked/day. Production Per Day: Practice specific goal Doctor and Hygiene Scheduled Out: No more than 3 weeks VITAL SIGN NO. 5: HYGIENE Perio Services to Hygiene Production: 33% Hygiene Production to Practice Production: 33% Hygienist Compensation to Production: 33% Number of Hygiene Days Needed Per Week: Practice specific goal

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VITAL SIGN NO. 6: OVERHEAD Lab: 10% Dental Supplies: 5% Facility: 5% Staff Wages: 19-22% Staff payroll taxes and benefits: 3-5% Misc.: 10%

WAX-UPS

Case Acceptance continued from page 8

“At first you might take an x-ray and the patient doesn’t immediately see what’s going on, even though you’re confident treatment should be done,” Orenstein said. “Logicon overlaying on the x-ray shows the penetration and even history. You can look at the x-ray taken from the last visit six months ago.”

OTHER TECHNOLOGIES There are many technologies you can invest in that may improve the patient experience and help boost case acceptance, including lasers, CAD/CAM and digital impressions. Dr. Blake Cameron, who is a member of the Academy of Laser Dentistry, uses the Lightwalker AT Er:Yag and Nd:Yag laser from Fotona. When he explains to patients he can perform a painless procedure without numbing them, they’re more likely to say yes to same-day or adjunctive treatment. It also helps with multiple quadrant dentistry. If patients need more than one filling, he

Wax-ups like the White Wax-Up from Arrowhead Dental are typically used to guide doctors through a case, and aren’t ordered until after a patient accepts treatment, said Peggy Nelson, Director of Sales. Some doctors, however, use the wax-ups during case presentations to help patients better visualize what their teeth will look like after the procedure. If you choose to go this route, it’s best to include the cost in the patient’s bill. can easily do them at the same time without anesthetic. Patients are more comfortable during the procedure and they don’t have to come back for a second appointment. That’s better for the patient, and more profitable for the dentist. Many patients don’t accept treatment because they’re scared. Some are needle phobic and others associate the sounds of the dental office with a bad experience. Lasers minimize those

unpleasant sounds and often eliminate the need for anesthetic, helping put patients at ease. “When those patients tell other patients about their experience, you may get patients coming in who have avoided the dentist because of fear. The laser helps change their perspective,” Dr. Cameron said. “These patients also tend to need a fair amount of work. You can help them and it’s a win/win for everybody.” Dr. Cameron also offers same-day crowns and digital impressions. Both technologies add a convenience factor, making patients more likely to accept treatment.

IMPROVING CASE ACCEPTANCE Building trust with your patients is key to improving case acceptance. These products can help, but remember it all comes back to establishing relationships and educating your patients. Make it easy for patients to accept treatment and your practice will grow.

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SPRING 201 8

THENEWDENTIST.NET

Are Full Crowns Still the Standard of Care to Repair Badly Damaged Teeth?

By Jose-Luis Ruiz, DDS

he short answer is NO! While there are many new techniques and materials, a hard look at indirect restorative clinical dentistry shows a small improvement to the patients’ and dentists’ overall experience. Teeth continue to be cut aggressively for crowns, increasing the need for root canal therapy1 and shortening the life of restorations and teeth. Difficult and unpredictable cord packing, impression and cementation of restorations with subgingival margins is the norm, with devastating effects to the periodontal health of our patients2 (Fig. 1). Supragingival dentistry has the opposite effect, making dentistry easier, faster and more predictable. Tooth conserving dentistry and partial coverage restorations are strongly advocated by most, but rarely used. As the more than 37 million CEREC or lab fabricated crowns placed yearly can attest, crowns are most popular by far.3 Why? Familiarity with the procedure is often incorrectly confused with simplicity, or quality.4 Second, the over complicated adhesive dentistry techniques advocated by educators makes adhesive dentistry appear difficult, but it is not. Third, the adherence by clinicians to the mechanically retained principles learned in school, and lack of understanding and trust in adhesion, encourages undesirable resistance and retention forms.

CROWN PROCEDURES CAN BE FULLY SUBSTITUTED BY USING SUPRA-GINGIVAL DENTISTRY. Supra-gingival minimally invasive dentistry is an innovative approach that assumes all damaged teeth can be restored with a partial coverage direct or indirect restoration, and most subgingival margins are preventable and counterproductive. Thus, the supra-gingival approach uses advanced adhesion, tricks and techniques for maximum preservation of tooth structure and supra-gingival margins. It is healthier to the pulp, periodontium, and makes adhesive restorations faster, easier and predictable! “The more damaged the tooth is, the more we need to cut a crown” is the old counterintuitive paradigm. The new paradigm is, “the more damaged the tooth is, the less we should cut,” using the following supra-gingival rules (Fig. 1):

18 THENEWDENTIST.NET S P R I N G 2 0 1 8

Fig. 1

First Rule: Respectful Removal of Caries and Old Material. Preservation of tooth structure, especially at the gingival margin, allows for a more simple, predictable and healthy procedure. Second Rule: Avoid Counterproductive Mechanical Retention (Trust Adhesion). Traditional preparation techniques, which include axial reduction and interproximal boxes, require extensive tooth removal, lead to subgingival margins and are counterproductive to adhesive dentistry. Third Protocol: Enamel Margin Preservation Technique. Because of the way caries spread, it is common to find preparation margins with healthy enamel but lots of caries beneath it. A basic rule of cavity preparation is removing unsupported enamel. We traditionally remove this precious enamel at the margin.5 Enamel preservation is especially important when healthy enamel allows the restoration margins to stay supra-gingival (Fig. 2). The benefits are periodontal health, simplicity, and increasing the long term seal.6 The idea of enamel preservation for esthetic or restorative benefits is not new. I’ve promoted this technique for years, and recently demonstrated it through an in-vitro test using the proper enamel preservation technique.7 With direct restorations, it’s easier to isolate supra-gingival margins, place matrix bands, seal the margin with a wedge, restore, and remove composite flash and finish. For indirect cases, supra-gingival margins make impressions easier and the adhesive cementation of onlays or veneers easier and more predictable. The unsupported enamel must be repaired using bonded composite and a careful adhesive procedure to avoid polymerization forces that could cause enamel micro-cracks. CONTINUED ON PAGE 21 >>

Fig. 2

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Why Delaying a Practice Purchase May Be a Big Mistake

n reviewing the profile of dental graduates from the class of 2016, it was reported that those graduates having any educational debt averaged $261,000. In fact, 34% of this class had educational debt in excess of $300,000! So it is no small wonder that a growing number of our recent grads are delaying practice ownership or even considering not becoming a business owner in their professional career. More and more recent grads view the associate path as the only route they can take to repay their educational debt. Therefore, practice ownership seems like a “far off” option that’s only available to them after they practice for years as an employee. This line of thinking may be a huge financial mistake in the long term. Many recent graduates also feel their high indebtedness precludes them from qualifying for a practice acquisition loan. That assumption is clearly not true. Dental lenders are in the business to make loans. They understand the financial plight of recent grads and are eager to give loans to young practitioners so they can purchase a practice or an equity interest in a partnership. However, in certain cases where the purchaser’s education debt level exceeds national averages, a lender may require the selling doctor to hold a note for a portion of the purchase price for several years. So, if you are considering a practice purchase opportunity and it demonstrates a healthy financial picture, a positive loan approval is awaiting as long as your personal credit history is good. The point? Waiting years to purchase a practice may not be in your best financial interest long term. To prove that point, let’s examine a hypothetical situation of two classmates who both purchased a dental practice, but at different times after graduation. To make this a fair comparison, we’ll make the practice’s financial profile identical.

DR. A Dr. A decided to purchase a dental practice three years after graduation. The practice brings in $900,000 in revenue and has 62% overhead, making the net profit $342,000. Let’s assume the practice sells for $630,000 and that Dr. A requests $100,000 in working capital. That makes the total practice acquisition $730,000.

20 THENEWDENTIST.NET S P R I N G 2 0 1 8

By Thomas L. Snyder, DMD, MBA

Dr. A’s loan terms are for 10 years at 5% interest, with annual principal and interest payments totaling approximately $93,000. Let’s assume the practice will grow 5% annually, but overhead will remain constant at 62%, excluding any debt service. Dr. A’s projected net income before taxes, but after debt service, will be about $249,000 in the first year of ownership.

DR. B Dr. B, one of Dr. A’s classmates, does not feel confident enough to purchase a practice so soon after graduation and decides to work as an associate for three more years. He earns an income of $130,000 initially with an annual increase of 6% during the associate phase. We’ll assume Dr. B decides to buy a similar practice grossing $900,000 with an overhead of 62%, yielding the same net profit of $342,000. We’ll also assume the purchase price is identical to Dr. A’s acquisition at $630,000 and that he has the same working capital needs of $100,000, for a total loan amount of $730,000. However, interest on the same 10-year loan increased to 6.5%, making annual practice

Full Crowns continued from page 18 NET INCOME (BEFORE TAXES) COMPARISON

Dr. A (Owner Year 1)

Dr. B. (Owner Year 4)

Year 1

$ 249,000*

$ 130,000* Associate Income

Year 2

$ 266,000

$ 138,000 Associate Income

Year 3

$ 284,000

$ 146,000 Associate Income

Year 4

$ 303,000

$ 243,000 Ownership

Year 5

$ 323,000

$ 260,000 Ownership

Year 6

$ 344,000

$ 278,000 Ownership

Year 7

$ 365,000

$ 297,000 Ownership

Year 8

$ 388,000

$ 317,000 Ownership

Year 9

$ 412,000

$ 338,000 Ownership

Year 10

$ 437,000

$ 359,000 Ownership

Total Earnings

$3,371,000

$2,506,000

*Dollars rounded off for subsequent years

Fourth Protocol: Margin Elevation Technique. In cases where caries or old restorative margins are already subgingival and deeper than 1 ½ mm below the gingiva, predictability decreases dramatically. The current approach is either deal with bleeding gums (often unsuccessfully) or do a crown lengthening procedure. An alternative option is a margin elevation procedure, which has shown to increase simplicity and success with indirect restorations. Fifth Protocol: Proper Use of Translucency for Ideal Restorative Margin Blending & Esthetics. Restorative margins are often buried below the gum to hide them, usually unsuccessfully. The ability to create a beautiful margin that blends with the tooth facilitates placing restorative margins supra-gingival. Factors crucial to achieving the desirable blending are the correct choice of translucent restorative material, the cement and the underlying tooth color. All of the above techniques are explained in the book “Supragingival Minimally Invasive Dentistry” published by Wiley and authored by Dr. Ruiz. References 1.

acquisition principal and interest payments approximately $99,000. Dr. B’s net income after loan payments, but before taxes, will be $243,000 in the first year of ownership. Dr. B’s practice also will grow at a rate of 5% annually and will maintain a constant overhead ratio of 62%. If we compare the total income Dr. A earned over a 10 year period from the time he purchased his practice to Dr. B’s earnings over the comparable period, the difference amounts to more than $865,000! (See the Net Income (Before Taxes) Comparison chart above.)

A BRIGHTER FUTURE Imagine if Dr. B would have purchased a practice at the same time as Dr. A. The additional $856,000 in income (before taxes) could have helped him eliminate his dental school debt earlier, putting him in a much stronger financial position to save for retirement and other expenses. The old adage “timing is everything” is quite applicable to purchasing a dental practice. So, when considering a purchase opportunity from a timing perspective, it can make a significant financial difference! Dr. Tom Snyder is Director of Professional Practice Transitions for Henry Schein Professional Practice Transitions. He is a nationally recognized speaker, author and consultant. Dr. Snyder received his DMD from Penn Dental Medicine as well as his MBA from The Wharton School of Business at the University of Pennsylvania. He is also a member of the Faculty at Penn Dental Medicine. Dr. Snyder serves as a regular contributor to Dental Economics and The Dentists Network and is a contributing author to The New Dentist™ magazine.

2. 3. 4. 5. 6. 7.

Davis GR, Tayeb RA, Seymour KG, et al. Quantification of residual dentine thickness following crown preparation. Journal of Dentistry 2012; 40( 7): 571–576. Reitemeier B, Hänsel K, Walter MH, Kastner C, Toutenburg H. Effect of posterior crown margin placement on gingival health. J Prosthet Dent. 2002 Feb;87(2):167-72 Christensen GJ. Are tooth colored onlays viable alternatives to crowns? Clinicians Report, January 2012; 5(1):1,3 Ruiz JL, Christensen GJ. Myths vs. realities, State of the art indirect posterior restorations. Journal of Cosmetic Dentistry 2011; 27(3): 63-72 Black, G. V.: Operative Dentistry, Chicago, 1908, Medico-Dental Publishing Company, p. 115 Redwin CJ1, Stokes A, Moles DR. Influence of flowable liner and margin location on microleakage of conventional and packable class II resin composites. Oper Dent. 2005 Jan-Feb;30(1):32-8. Ruiz JL, Finger WJ. Enamel Margin Preservation and repair technique. 2016. J Dent Res Vol 95(Spec Iss 5) : abstract number, 2370749.

Readers are invited to attend a lecture, with details and step-by-step instructions. The LA Institute will sponsor the tuition for new graduates. Proof of recent graduation is required. Use promo code “TNDM” at RuizDentalSeminars.com or call 818-729-9121.

Dr. Ruiz is the Director of the Los Angeles Institute of Clinical Dentistry and Course Director of numerous CE Courses at University of Southern California (USC). He is Honorary Clinical Professor at Warwick University in England and member of the editorial board for Dentistry Today. He is also an Associate Instructor at Dr. Gordon Christensen PCC in Utah and an independent evaluator of dental products for CR (CRA). Dr. Ruiz was named as one of the “Leaders in CE 20062015” by Dentistry Today.

SPRING 201 8

THENEWDENTIST.NET

A Look at

By Dr. Paul Feuerstein

LIGHTS

Why you might want to consider LEDs for your practice. The days of incandescent and halogen bulbs are numbered. In 2007, the U.S. Government created the Energy Independence and Security Act (EISA), which basically stated that bulbs have to decrease their energy consumption. In simple terms, a typical 100 watt bulb has to deliver the same amount of light with less than 72 watts. This led to making the existing bulbs more efficient and the advent of new types of bulbs. First on the scene were Compact Fluorescent Lightbulbs (CFL) and LEDs. The issues with fluorescents are well known, including the fragility and the environmental impact. LEDs were fairly expensive at first, but as manufacturing processes as well as volume expanded, the prices plummeted. Right now, many stores sell LEDs for the home that look just like your original bulbs in wattages (40, 60, 75 and 100) for as low as $2 each. Some local power companies subsidize these and offer homes and businesses significant discounts with the end result very inexpensive lighting for the office.

THE BENEFIT OF LEDS LEDs have many advantages over traditional bulbs, the greatest being low use of electricity, negligible heat emitted and long life (some of these bulbs claim a 10 year lifetime). An LED is basically a small electrical component, known as a diode, and has no filament or flexible parts. The bulb is not typically glass and is thus resistant to vibration and impact. We have seen these come into dentistry in several areas, including handpieces, headlights, curing lights and overhead chair lights. Fiberoptic handpieces have changed over to small LEDs in the hose near the end of the connector, eliminating the expensive and somewhat fragile cable in the hose. Headlights have benefited from this technology and now feature lights that weigh as little as 3 grams. Curing lights 22 THENEWDENTIST.NET S P R I N G 2 0 1 8

also have seen a huge change. We have gone through evolutions of bulbs, cables, guns, wands and more, all of which were cabled and featured bulbs that needed fans for cooling. These were large and bulky but also required a close watch on the light output as the bulbs degraded over time. LED curing lights have evolved as LED technology has advanced. The initial units were not bright enough and did not have a full spectrum of wavelengths to cure all the materials the predecessors did. New LEDs can be created to emit any specific wavelength, setting up a limited range or a full spectrum range. Although the frequencies and output of the LEDs themselves do not change, the lenses and other optics can. Keep in mind it is still necessary to monitor the light output to be sure your composites are completely cured.

OVERHEAD LIGHTS Overhead treatment lights have undergone an amazing transformation. They started as candles with great reflective mirrors and then moved on to the larger Ritter lights with heavy glass collimation lights. Today, they have evolved into very bright and more compact units. As we know, the older versions could get very hot; weâ&#x20AC;&#x2122;ve all had to tell curious patients not to touch the light. Changing bulbs in some of the units also was a larger production. One of the most popular lights, the Pelton & Crane Light Fantastic (LF), required a special tool to pry the contacts apart. We had to be careful not to get a fingerprint on the new bulb or, we were told, it might explode. There were also times the glass collimator broke and needed replaced. Still, that and other lights have performed over the years. When the new LED bulbs came along, Pelton & Crane kept the original basic design and used a new bulb in its place. To be honest, that reflective back, because of its parabolic design, is not sexy, but it provides a light with no shadows.

WHEN BUYING A NEW OVERHEAD LIGHT, DO SOMETHING THAT WILL BENEFIT YOUR PRACTICE AS WELL AS THE ENVIRONMENT. The flexibility the LED bulbs offer has allowed designers to become quite creative. Belmont’s Bel-Halo features bulbs around a circle, with room in the middle for an optional patient mirror. Flight Dental Systems has developed creative space age designs that are quite eye catching. In addition, there is an optional camera that can be mounted in the center of the light that sends images to an iPad or monitor. Other lights have configurations in squares, rectangles, circles and various creative designs. But buyers should not be distracted by these features and should instead focus on performance factors.

WHAT TO LOOK FOR IN AN OPERATORY LIGHT First, consider the area of focus. When evaluating a light, shine it on the dental chair back or a sheet of paper about where the patient’s head will be. Most of the lights form a rectangle image. Because the light comes from different angles, put your hand or an instrument in front of it to see if you cast a shadow. The better ones won’t. The size of the rectangle or other shape should be large enough to illuminate the entire oral cavity. The rectangle should be brighter in the center and feather out to the edges so there is not a sharp demarcation at the edges, which could cause eye fatigue. Next, look at the settings for the light color. Most come in at full spectrum or a Kelvin temperature of 5000K. This is pure white light and excellent for color matching as opposed to the yellowish hue you get from incandescent and halogen lights. There are brightness settings as well as spectrum change settings. This allows “surgical settings” (typically 4500K) that optimize color contrast of the soft tissues or lower settings (3000K for example) that do not contain the blue frequency that cures composites. Keep in mind your LED curing lights use a frequency that will set the composite that is contained in the full spectrum. Many of us use an orange filter, and some of the lights actually have an orange light “composite” so there’s no need to change the brightness or color frequency. Lights have different types of switches to adjust settings. Some are touch type on the lights (flat and easily wiped), some feature controls remotely, either on the floor or in the unit (A-Dec for example), while a few require

a mere wave of the hand to change the settings, making them truly touch-free. All lights have handles that must be cleaned. They also can be cleaned with disinfecting wipes, and some have removable handles that can be autoclaved.

WHY LEDS Keep in mind LEDs should last about 10 years. The energy used is typically less than 20 watts, compared to 150 with halogens. So while LEDs might be more expensive at the outset, they offer long-term savings. The bottom line is, when buying a new overhead light, do something that will benefit your practice as well as the environment. Paul Feuerstein, DMD, received his undergraduate training at State University of NY at Stony Brook during the 1960s and is a 1972 graduate of University of NJ Medical and Dental (now Rutgers). He maintains a general practice in Massachusetts. He is now the Technology Editor of Dentistry Today after 14 years with Dental Economics. His work with CAD/CAM helped develop the LAVA C.O.S. intraoral scanning system. He is also CDO of the Cellerant Consulting Group and is an Adjunct Assistant Professor in General Dentistry at Tufts University.

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THENEWDENTIST.NET

SKINNY

on the Street

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The American Academy of Cosmetic Dentistry’s (AACD) member benefits have recently expanded to address the specific needs of younger dentists. The AACD has partnered with SoFi, the leading student loan refinancing provider, to offer AACD members a $300 bonus for refinancing with SoFi. The new AACD Network, powered by HigherLogic, gives members an exclusive online forum for connecting, learning, getting advice and sharing ideas with seasoned AACD members (an incredibly valuable resource!). Plus, the AACD has supercharged its Find-A-Dentist directory to help more prospective patients find AACD member dentists when doing an online search.

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INDEX O F A D V E R T I S E R S Advertisers in this issue of The New Dentist™ have made it possible for you to receive this publication free of charge. Please support these companies. Contact information can be found below, or visit The New Dentist™ Resources at thenewdentist.net to receive information from more than one company. Advantage Dental Products..... 23 advantagedentalinc.com 800-388-6319 Affordable Image.....................14 affordableimage.com 866-961-4412 American Academy of Dental Sleep Medicine.......................... 9 aadsm.org 630-737-9755 Arrowhead Dental Laboratory.............................. IFC arrowheaddental.com 877-358-0285

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