There's a surge of interest in high-end dentistry and progressive laboratory owners are riding the crest of the wave. Fueled in part by patients' increasing awareness and expectations, this movement is also a result of the growing number of educational programs that emphasize the dentist/technician partnership and a move away from insurance-based dentistry.
"It's incredible what's going on right now," says Lee Culp, CDT. "More and more educators are telling dentists they've got to rethink their practices. They're saying, 'slow down, develop patient relationships, offer value to your patients - and you'll be able to charge what you're worth,'" says Culp, owner of Mosaic Studios and the Institute of Oral Art and Design in Bradenton, Florida.
Some laboratory owners have realized that by applying that same advice - slow down, develop relationships, offer value - they can partner with the doctors who are turned on by this approach to dentistry, which focuses on a higher degree of planning, constant communication between the dentist and laboratory and more sophisticated techniques. While there are some small laboratories who completely cater to this market, a new approach for larger labs is to incorporate a separate, high-end department. These labs are providing two types of restorative service - one conventional and straightforward and the other more comprehensive - in one laboratory operation.
Although combining two types of service under one roof can be challenging, these laboratories are fired up about the opportunities available with high-end dentistry. "Doing this kind of work is just so much fun," says Robert Ingrassio, CDT, owner of CQC Prosthodontics, Rochester, New York. "You can see it in the doctors' faces: once they get involved in high-end work, they get excited about dentistry again - we all do. It's contagious."
While some say that offering two levels of service is a transition - although perhaps a long one - and hope to eventually do only high-end work, others say there will always be room for both and want to be sure their clients have options. "These laboratories realize that right now, only about 15% of dentists are practicing high-end dentistry on a regular basis," says Culp, who supplies training and consulting services to many of the laboratories implementing a high-end service.
High-end vs. conventional
The difference between the two levels of service lies mostly in the process. Since high-end cases are usually more complex, technicians are heavily involved in treatment planning, and then are in constant contact throughout the case, either on the telephone or in person at the dental office. "The dentist may do study models and send them to us for evaluation or meet with us to plan the case," says John Haupt, owner of 25-pereson Haupt Dental Laboratory, Brea, California. "The focus is on making the final outcome of these complex cases esthetic and orthognathically correct."
A quadrant impression and simple prescription don't fly here: rather, dentists must provide a full arch impression, upper and lower preoperative casts, a series of photographs of the patient and his smile, and a detailed explanation of the patient's esthetic expectations. At the laboratory, the same materials are usually used in both the conventional and high-end departments. However, since the turnaround time is longer, the technician has more time to spend on the case, fabricating diagnostic waxups and incorporating advanced waxing, buildup, characterization and staining techniques.
"Fabrication time can be two to three times longer for a high-end case, compared to a similar case being done conventionally," says Richard Willes, owner of Utah Valley Dental Laboratory, Provo, Utah, whose high-end caseload comprises 60% of his overall business. "Laboratories have often looked for ways to control labor costs - using quadrant articulators and check-bite trays or dipping copings, for example. That's fine, but when we start doing bigger cases or have dentists and patients with higher expectations, we can't cut corners."
Depending on the size and type of case, the technician may also provide a number of tools to the dentist such as try-in stents, prep stents, silicone matrices and custom guide tables. But these technicians stress that it's the enhanced communication, not just the technique, that results in a high-end restoration. "You see the benefits of that communication when the restoration fits without adjustments or is a superior match to the natural teeth," says Kris VanLaanen, vice president of Lord's Dental Studio, Green Bay, Wisconsin. "It's the kind of restoration that should make the patient say, 'doctor, this is exactly what I wanted.'"
Opting for High End
Restorations fabricated in these laboratory's high-end departments are priced 50%-100% higher than those done in the conventional portion of the laboratory. When do dentists opt for the higher price tag?
Some dentists, so enthusiastic about this type of dentistry, have committed their entire practices to it and therefore use their laboratories' high-end services for all of their work. "These are the dentists who are always thinking about the patient, always looking to produce the best product," says Pat Rector, CDT, noting the client who called from his cell phone - during his morning jog - to discuss a case. "I admire these doctors for that because we want the best product too." Rector, along with Dennis Riegel, CDT, manages the Advanced Team at BonaDent Dental Laboratories, Seneca Falls, New York.
For other dentists, the complexity of the case - full mouth reconstructions, large implant cases, multi-disciplinary cases, for example - dictates whether they use the laboratory's high-end or conventional service. "We do have clients who use our laboratory strictly for their challenging cases and send everything else to other labs. However, most of our accounts cross over when needed. When they prescribe a conventional case, it's because that's all that's needed. When they send us a high-end case, they expect to pay more because of the challenges of the case," says Haupt.
A patient's high level of expectation may also make a dentist opt to use the high-end service, even for a smaller case. "Dentists have to be able to communicate with the patient and ascertain to what extent he wants his smile changed and what kind of results he's looking for," says VanLaanen. "Dentistry is moving from a "need-base" to a "want-base," so there will be patients who walk in and want the very best."
Although working with quality-conscious dentists and being compensated for taking the time to perfect every nuance of every case may sound like paradise, offering this level of service - and particularly two levels under one roof - requires a tremendous amount of time, energy and discipline. Here are some of the key issues that come into play:
- Do you have - or can you find - clients who are interested in this approach to dentistry and are willing to pay more for it? Although some laboratories were approached by current customers interested in this service, others met high-end dentists through their involvement in advanced education (for examples, see "Where do dentists go for high-end education?" below).
- Before moving ahead with its idea for a high-end department, Lord's Dental Studio outlined the service and fabricated sample restorations to share with its Dentist Council, a group of its clients that acts as a sounding board. The response was enthusiastic. However, the dentists stressed that, in order to use the high-end services, they would first like to have a higher level of education available locally. As a result, Lord's is working on implementing training programs at a new facility being built at nearby Marquette University School of Dentistry.
Offering this kind of service requires an enormous training effort. "Even for technicians with years of experience, it takes a lot of training to reach the level we needed them to," says Willes, who spent $65,000 on education during the 16-month period of implementing the department.
And, since staying abreast of sophisticated techniques is crucial for technicians doing high-end work, the commitment to education must be ongoing. "We've had to quadruple our training budget," says Bob Edmonds, owner of 85-person Edmonds Dental Prosthetics, Springfield Missouri. "In fact, in addition to sending technicians to educational programs outside the laboratory, we've hired a full-time, in-house trainer."
- Technicians in high-end departments do have one training advantage: since they're not under heavy production, they have time to practice and fine-tune what they've learned. "Traditionally, when you send a technician for training, he comes back and immediately has deadlines to meet," says Bruce Bonafiglia, owner of BonaDent. "Having the higher fee allows him a little more time to cultivate his craft."
- Most laboratory owners say that it's essential that the high-end team just focuses on that type of dentistry; having them do both high-end and conventional cases blurs the line between the two services. "It's very difficult to switch gears. A technician would have to say, 'ok, on this case, I'll apply everything I've learned and take my time with it, and now for this one, I'll ease up,'" says Bonafiglia.
- Some labs choose to physically separate the high-end team into its own room or area because it further helps differentiate the two services and is more efficient. For others, it works better to have their high-end technicians sitting in the main part of the facility with the conventional technicians. "We felt that segregating the team would be missing an opportunity to advance the technical and creative environment of the entire laboratory," says CQC's Ingrassio. "As a result, everyone is doing better work."
Risk of alienating technicians.
- When setting up a high-end department, you must tread carefully so that you don't offend those who work in the conventional part of your laboratory. To do this well, your laboratory culture must be such that no one feels undervalued, and everyone sees the addition of high-end business as a benefit to the business - and indirectly to each of them.
- It helps if technicians see that, as the high end caseload grows, there will be increased opportunities for them to advance their training and participate in those kinds of cases. "Having a set of prerequisites that technicians must master before going on to more sophisticated training helps them set goals and see their way there," says Edmonds. "Our technicians must have the skills to handle all phases of a restoration, the ability to communicate with dentists comfortably and articulately and pay superior attention to detail." Edmonds' ART (Advanced Restorative Technologies) Department is currently staffed by nine technicians and accounts for 10% of his overall business.
- Laboratory owners say that it's critical to stick to the procedures and requirements you've set up for high-end work. "There's sometimes a temptation to step away from the rigid protocol, especially as the department gets busier. For example, a dentist may want a quicker turnaround time or tell you to 'go with what you've got' when you call for another impression," says Ingrassio. "In those cases, I explain to the doctor again that if you elect to do this type of restoration, this is what we require. If he refuses to comply, then the case becomes part of our conventional work flow and is no longer high-end." About 35% of CQC's caseload is high-end, including its TeK-ArT fixed restorations and PRS (Predictable Removable Systems) removable line.
Patience and persistence.
- This approach entails adopting a new mindset, getting comfortable with the time that technicians may spend out of the laboratory consulting with clients, and being ready to make the time and financial commitments to extensive, advanced training. Just as you couldn't implement this kind of service overnight, you can't expect to reap its benefits immediately either. But laboratories who have done it are focused on the long-term opportunities. "Right now our high-end restorations aren't as profitable as conventional restorations even though they're priced higher," says Bonafiglia. "But that's o.k. We're optimistic about the direction in which we're headed; the future is bright."