Tallahassee, Fla. Dental patients have more to worry about than flossing and brushing daily—the restorations they put in their mouths have a direct impact on their overall health. As a result, the...See more National Association of Dental Laboratories (NADL) is promoting transparency in dentistry and the role and value of trained dental technicians with the release of its new website and social media outlets. NADL will use its new website and social media platforms to serve as the foundation for its ongoing public awareness campaign, "What's In Your Mouth?" "It's important for dentists and patients to have a full understanding of where their dental restorations are coming from and what materials are used in the process," said Henry Martin, CDT, NADL President. "Restorations from certified dental labs meet national and industry standards. Problems occur when restorations are not made in certified dental labs." Poorly-made dental restorations—whether made in America or abroad—can lead to a range of health consequences for patients, and in turn, legal consequences for dentists. Growing demand for dental work in America has created a market that features both high-end and economy-priced work. Dental restorations increasingly are being imported from countries like China, India and Vietnam. Depending on the country, those dental laboratories may not be subject to the same scrutiny that domestic laboratories receive from the U.S. Food and Drug Administration. Domestic labs remain unregulated in more than 40 states. Prior to launching its campaign, NADL spent 18 months facilitating a series of focus group meetings and conducted national surveys with the dental laboratory industry to gather information about the current status of dental laboratories and their products. The purpose of the "What's in Your Mouth?" campaign is to provide dental consumers, dentists and the dental laboratory community with the knowledge they need to make important purchasing decisions. NADL launched its new website (www.whatsinyourmouth.us) and created a YouTube page for its informational videos (https://www.youtube.com/user/WIYMCampaign/videos) this month. "We are excited about the formal launch of our new website and YouTube videos," said Gary Iocco, NADL President Elect and Co-Chair of NADL's Public Awareness Committee. "We hope to use social media to spread awareness about the critical role of the certified dental technician." "It's our hope that the public will hear our message and share our videos and website with their friends and followers," said Leon Hermanides, CDT, NADL Board Member and Co-Chair of NADL's Public Awareness Committee. For information on the campaign, please visit the NADL website: www.nadl.org.
New analysis released by the American Dental Association indicates that overall spending on dental care has remained flat in recent years, despite the fact that per patient dental spending by Baby Boomers...See more and seniors increased. Two research briefs released by the ADA's Health Policy Resources Center bolster previous statistics showing that adult dental visits have been declining from 2000 to 2010, leading to less spending on dentistry and oral care. Significantly, the declines in both dental spending and visits predate the economic crisis of 2008. "Our results suggest very strongly that the dental economy is in a major transition," wrote Dr. Marko Vujicic, Ph. D., managing vice president of the HPRC and lead author of the briefs. "Dental spending has not rebounded since the end of the Great Recession and has been stagnant, on a per capita basis, since 2008." In 2011, dental spending accounted for 4 percent of overall national health expenditures, down from 4.5 percent in 2000, according to HPRC analysis of data gathered from the Center for Medicare and Medicaid Services, the Bureau of Economic Analysis and the U.S. Census Bureau. The rate of growth of dental spending has also slowed in recent years. Between 1990 and 2002, per capita dental spending grew by 3.9 percent per year after adjusting for inflation, a rate that fell to 1.8 percent between 2002 and 2008. Since 2008, the per capita dental expenditure growth rate declined 0.3 percent while overall health spending grew by 1.6 percent. According to a previous HPRC brief, in 2003 41 percent of adults reported going to the dentist during the prior year. That figure declined to 37 percent in 2010. Children, however, visited dentists more often between 2003 and 2010, but since their dental care tends to be less expensive than adults', it did not result in greater dental spending overall. While overall dental expenditures have remained flat, the HPRC analysis shows there's more to the story -spending by Baby Boomers and the elderly is on the rise. Between 2000 and 2010, seniors' annual spending on their dental care increased from $655 to $796. The HPRC credits the increase to advances in preventive and restorative dental care, leading to greater numbers of elderly retaining their teeth. "Thanks to greater understanding of the importance of oral health and mouth healthy measures such as water fluoridation, the dental well-being of Americans has improved in recent decades," said Dr. ADA President Dr. Robert A. Faiella. "According to the Centers for Disease Control, the number of adults missing all or some of their teeth dropped from 50.2 percent in 1999 to 43.6 percent in 2010. But as positive as this trend is, the fact fewer adults are utilizing dental care jeopardizes that progress. Financial barriers to care are up among young adults, and the number of people who visit the ER for their dental care is rising. We need to find creative solutions to improve access to care for millions of Americans and reverse these recent trends." To read the full research briefs, visit www.ada.org/1442.aspx.
Straumann reported stable net revenues of CHF 519 million (-1% in local currencies) in the first nine-months of 2012. North America was the key driver throughout accompanied by strong growth in China and...See more Latin America. However, these solid performances were not enough to compensate for sluggish sales elsewhere - particularly in Europe, where the tooth replacement market has suffered from further deterioration in the economic environment. In the third quarter, sales in local currencies were generally slower with the exception of the 'Rest of the World' region. As a result, Group net revenue for the quarter was 2% off the prior year level. In Swiss francs, however, the top line grew 4%, lifted by positive currency effects. In addition to the business results, the Group announced further initiatives in its strategy for digital dentistry. Straumann plans to strengthen its collaboration with Dental Wings by transferring its software development teams and increasing its stake in Dental Wings by the end of 2012. The Group also announced resizing targets as it adapts to the current economic environment. These will lead to a reduction of approximately 150 positions worldwide by early 2013, of which about 90 will be redundancies. Straumann's President & CEO, Beat Spalinger commented: "With our margins reaching unacceptable levels in the first half of the year, we scrutinized our cost structure and determined substantial, balanced resizing measures that will not compromise our growth prospects. The initiatives we are announcing today will help restore decent margins, even if the market remains sluggish. Unfortunately, we won't be able to achieve the necessary reductions without redundancies, which the Group pledges to carry out with full regard to its social responsibilities and obligations. We are also announcing important initiatives that usher in the next phase of our digital strategy. In view of the integration of our CARES software into the DWOS open platform, we have agreed with Dental Wings to combine our software development teams to support and drive leading-edge software solutions. To underpin this strengthened partnership, Straumann will increase its stake in Dental Wings to around 45%." BUSINESS AND REGIONAL PERFORMANCES Straumann's core implant business posted the same level of sales over the nine-month period, year on year. Difficult market conditions in Europe (owing to the poor economy) and in Japan (due to negative media publicity) prevented a return to growth. The Group's CADCAM/digital business was expectedly slower than in the comparative period of 2011, which benefited from new scanner roll-outs. Straumann's smallest unit, Regeneratives, again posted double-digit growth, driven by bone augmentation products and the launch of Emdogain 015. Patience needed for turnaround in Europe The European tooth-replacement market relies on patients' ability to finance non-reimbursed procedures and thus continues to suffer from the weak economic environment. With austerity measures deepening the dents in consumer confidence, the regional market dipped further, pushing Straumann's revenues down 5% (l.c.) both in Q3 and over the nine-month period. Net revenue in the respective periods reached CHF 82 million and CHF 284 million, corresponding to 55% of the Group. The weakness of the Euro against the Swiss franc resulted in a negative currency impact of almost 2 percentage points over nine months. However, thanks to the Swiss National Bank's implementation of a minimum exchange rate for the Euro since September 2011, the currency effect on Straumann's European revenue turned positive in Q3 2012, for the first time in many quarters. The region was weighed down in Q3 by Iberia, the Netherlands and Sweden. Germany was also unable to repeat the prior year's performance in contrast to France and the UK, which both continued to perform well. Solid growth in North America Straumann's second largest region, North America, achieved strong growth of 9% (l.c.) over the first nine months. Sales continued to grow in the third quarter, albeit at a slower rate. The reason why momentum has eased over the past two quarters of this year is twofold: first the market was softer in general, and second, the Group benefitted from the introduction of new scanners in 2011. This means that the solid third quarter growth (+5% l.c.) this year was driven by strong performances in Implants and Regeneratives. The appreciation of the US dollar against the Swiss franc lifted nine-month sales growth by 6 percentage points to 15% in Swiss francs. As a result, North America achieved revenue of CHF 131 million (CHF 42 million in Q3) corresponding to a quarter of Group net revenue. Revenues maintained in Asia/Pacific The Asia/Pacific region remained stable over nine months and contracted 2% (l.c.) in Q3, with respective revenues reaching CHF 80 million and CHF 26 million, corresponding to approximately 15% of Group sales. The region's largest market, Japan, was constrained by the contracting economy and was tainted by negative media reports. As noted previously, dynamic growth in China was the region's key performance driver in Q3, complemented by a pick-up in Australia. Strong growth in parts of the Rest of the World In the 'Rest of the World', net revenue in the first nine months declined 1% in l.c. or 5% in Swiss francs. Strong expansion in Latin America was not able to offset the uncertainty in the Middle East. With net revenue reaching CHF 24 million over the nine-month period and CHF 7 million in Q3, the region contributed 5% to the Group total. STRATEGIC AND OPERATIONAL PROGRESS Straumann's digital dentistry strategy enters next phase Insights from Straumann's Vision 2020 project indicate that implant surgery and prosthetic planning will converge into one software solution in the future. For the past two years, Straumann has been working together with Dental Wings on the integration of its CARES® prosthetic planning software onto the open Dental Wings platform (DWOS). This integration will be concluded with the release of the new CARES 8.0 software early in 2013. In order to drive development to the next level, the two companies have announced their plans to combine their resources further. Straumann's guided surgery business, including its development and operations units in Chemnitz, Germany, is to be transferred to Dental Wings effective as of 1 January 2013. So too will Straumann's prosthetic software development team based in Berlin. Over time, Straumann's guided surgery software and treatment planning shall be integrated in Dental Wings' software core. The transfer will considerably strengthen Dental Wings as a software power-house in digital dentistry and will add critical mass to the development of treatment planning solutions. While Dental Wings will provide the core technology, Straumann will concentrate on the digital workflow and solutions that add value for customers - both in terms of products and services. The Group will continue to promote guided surgery software and to provide first-level customer support. It will also continue to develop, sell and support proprietary implant-borne and tooth-borne restoration work-flows. Increased participation in Dental Wings As a further confirmation of its commitment to digital dentistry and the DWOS open standard software platform, Straumann announced its intention to increase its participation in Dental Wings from 30% to around 45% by year-end for an undisclosed sum. The two companies will continue to collaborate with 3M ESPE to establish DWOS as the standard software of choice in dentistry. Straumann's increased stake in Dental Wings is not intended to make the partnership exclusive. On the contrary, the partners welcome additional participants to join the open software standardization initiative. Distribution of intraoral scanning hardware discontinued As announced on 18 October, Straumann has decided to step back from distributing the iTero intra-oral scanner globally. While the company firmly believes iTero is one of the best scanners available and that intra-oral scanning will have an increasingly central position in daily dental practice, it does not consider the business case for operating as a hardware distributor to be viable in the present economic environment. Having built a digital prosthetics platform that is open to multiple scanners, Straumann's ambition is to attract business from users of other scanners, in addition to iTero. Focusing on essentials and resizing Based on insights from Straumann's Vision 2020, and to adapt to market developments, the Group has reviewed its entire cost structure to question what is essential. Apart from discontinuing the distribution of iTero scanners, the company has identified various measures to optimize costs, including streamlining and focusing its development portfolio, adapting its sales organization in markets that are heavily affected by the economic slowdown, and by optimizing its service functions. The primary goal is to restore acceptable margin levels - even if the markets remain sluggish - without compromising the Group's ability to capture market potential, to achieve sustainable growth, and to attain its Vision 2020 targets. The combination of all the above initiatives (including the discontinuation of intra-oral scanner distribution and the transfer of personnel to Dental Wings) will lead to a reduction of approximately 150 positions worldwide by early 2013, corresponding to approximately 6% of the Group's global workforce, which stood at 2 575 on 30 September. This will be achieved as far as possible through transfers or natural fluctuation, although a substantial portion will be through redundancies. Straumann is fully aware of its social responsibilities in this respect and will offer affected staff the appropriate redundancy package and outplacement support. These initiatives are expected to result in an annualized EBIT improvement of CHF 35-40 million by 2014 and an exceptional charge of CHF 15-20 million in 2012. OUTLOOK (barring unforeseen circumstances) The Group confirmed its outlook for the full-year 2012. It continues to expect challenging developments - especially in parts of Europe and Asia, while the outlook for North America and emerging markets is more optimistic. Current macroeconomic indicators suggest that the aggregated global market for tooth replacement may remain soft and thus flat, at best, over the full year. For 2012, the Group is confident that it can achieve full-year revenues in line with the 2011 level - excluding currency effects, which Straumann expects to be positive for 2012 as a whole. As the cost savings will only have minor impact in 2012, Straumann still expects the 2012 full-year EBIT margin to be similar to the reported first-half level, excluding exceptional costs in the second half related to the initiatives announced today.
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In October 1985, amidst rumblings that U.S. laboratories were farming work out to offshore laboratories, LMT brought the issue out into the open. Our interview with Jerry Doviack, CDT, Owner of California-based...See more Continental Dental Ceramics, took readers inside Interdent, his facility in the Philippines and sparked intense industry debate. In the interview, Doviack explained his strategy behind setting up offshore production to provide outsourcing services to laboratories around the world, saying it wouldn’t take jobs away because the local laboratory would still provide a vital service to its dentist-clients. Still, readers spoke out about what they perceived as a threat to their businesses and their employees, as well as concern about the American economy. Today, Interdent in Manila has grown to a staff of 700 and services several hundred labs in more than 75 countries. And, although the debate rages on, offshore outsourcing has come out of the shadows with many other offshore laboratories marketing their services and more laboratory owners openly acknowledging their use of these services. Visit LMTmag.com tomorrow for another LMT Memorable Moment.
To stay viable in today's increasingly price-sensitive, competitive market, 7% of respondents send work offshore—an average of 24% of their caseloads&mdashmost often using a U.S.-based broker....See more Overall, laboratory owners' sentiments on the topic of offshoring are still split; 55%&mdashup from 31% in 2005&mdashfeel it's un-American and unfair to their employees, and another 30% say it's just part of the globalization of our economy.
Written by Erik K. Curtis, DDS, MA, MAGD and reprinted with permission from AGD Impact, October 2012. (c)Academy of General Dentistry. All rights reserved. On the Web at www.agd.org. License #37166 America...See more loves big business. Never mind the warnings of philosophers and other naysayers. For every Occupy Wall Street curmudgeon huddling under a leaky tent to protest stratospheric CEO incomes, a million of his compatriots get in line at the local Apple store to purchase the company's latest and greatest products. For every crusader decrying the ethics of the bottom line, an army of analysts crisply counters that an entrepreneurial, creative private sector is what makes this country great. For every science fiction movie featuring an evil corporation bent on taking over the world, there is a corporate cinema screening that very film. Big Oil, Big Pharma, Big Media, even Big Chocolate: For most of us, big organizations mean the security of efficiency, reliability, consistency, and cost control. And now, medicine has gotten in line. In an Aug. 13, 2012, New Yorker piece titled "Big Med," American surgeon and Harvard public health professor Atul Gawande, MD, discusses U.S. Bureau of Labor Statistics data, which reveal that, in a single decade, most physicians have gone from practice owners to employees. Dr. Gawande does not decry the shift. In fact, he argues, medicine should become even more conglomerated, more systematized, and more standardized—in short, more like the restaurant chain The Cheesecake Factory. Dr. Gawande asks his readers not to scoff. "Big chains thrive," he writes, "because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key. It gives them buying power, lets them centralize common functions, and allows them to adopt and diffuse innovations faster than they could if they were a bunch of small, independent operations." While many other industries have followed this thinking—often with profitable outcomes—health care has only recently began to follow suit, albeit cautiously. Dentistry is one of the last health care fields to venture into the world of corporately driven professional services. Though big business has thrived throughout America, its success in dentistry has yet to be determined by both its patients/consumers and dentists alike. The Rise of 'Big Dentistry' Dentistry is experiencing a big-box trend of its own. According to the ADA's Health Policy Resources Center and an April 9, 2012, article from the ADA News, "ADA Explores Growth of Large Group Practices," 76% of dentists in 2006 were solo practitioners; by 2010, the number had fallen to 69%. Additionally, since 2010, the number of large dental group practices has jumped 25%, from 2,000 to 2,500. A May 2012 Bloomberg financial news article by Sydney Freeberg ("Dental Abuse Seen Driven by Private Equity Investments") reports the emergence in the last 10 years of at least 25 dental management services companies bankrolled by private-equity firms—which together account for the management or employment of approximately 8% of all U.S. dentists. In some instances, dentists contract with the companies—known as dental management organizations (DMOs) or dental service organizations (DSOs)—for business support. In others, where local laws permit, the corporations own the practices and hire their own dentists. Freeberg notes that dental practices have become "a favored investment of the private equity industry," and even quotes one dental management CEO who calls dentistry "a fragmented cottage industry ripe for outside management." "The corporate view is that dentistry is ripe for takeover," explains North Carolina AGD President Jerry W. Caudill, DMD, MAGD, of Fayetteville, NC, who is a former national dental director of a 120-office, multi-state dental management group. He explains, "Outside investors and dental corporations are interested in dentistry because our margins are much better than those of medical group practices, which have been severely reined in." Corporate dentistry doesn't just appeal to the large corporations moving in on this health care service; it also appeals to the health care providers it employs. Corporate Dentistry's Appeal Management companies can offer dentists potentially impressive advantages, including staff recruitment, patient scheduling, and marketing. Corporations enjoy deep-pocket capital, media clout, and the size to vertically integrate supplies, equipment, and technology. They can negotiate deals with dental laboratories and third-party payers that solo practitioners can't begin to match. They can organize convenient in-house specialist consultations and referrals. Employees boast about generous salaries, benefits, and bonus incentives. And, although a treating dentist still must answer to the dental board for a patient complaint, the company assumes financial responsibility for malpractice cases. Corporations promise relief from many of the traditional burdens of solo practice. "Solo practitioners have to be available to patients 24/7," says AGD Vice President W. Carter Brown, DMD, FAGD, of Greenville, SC. He continues, "Solo practitioners also have to create their own retirement, which means they must produce extra income. They have to own the building and equipment and pay the taxes. They must cover insurance costs and their employees' expenses. A corporate model has a structure to deal with all of that." Corporations also may act as a de facto private dental society, providing a broad range of benefits and perks to dentist partners and associates and promoting the group's interests in community and political arenas. "As a DSO, we were even able to arrange and offer continuing education courses," says Dr. Caudill. Some believe corporate dentistry also offers patients the comfort of a "brand." "Patients might view a dental chain as the big-box store of dentistry," Dr. Brown explains. "A patient might think, 'I am dealing with a corporation, so therefore, it must be able to offer me the same product for less money.'" Dr. Brown notes that, because money is a powerful motivator, patients often do not give dentistry the same priority as they do for medical care. "Most Americans view medical care as something that is paid for by someone else—insurance, government, or other programs," he says. "In dentistry, there is a significantly larger percentage of out-of-pocket expense than you see for typical medical care." In fact, Dr. Brown notes, dentistry receives very little government or other external support, dental insurance is woefully underfunded, and patients see dental care as expensive. (Ironically, according to Dr. Brown, the nationwide per-capita cost for dental care last year was only a little over a dollar per day.) "The reality is that, for many, dental care is not a health priority," he says. Operating in such a fiscally sensitive environment, corporate marketers sometimes send artfully contradictory messages to patients and dentists when it comes to costs and salaries, respectively. Patients hear, "You will get the best/easiest/most convenient care for less money." Potential client or employee dentists hear, "You'll make more money with less responsibility." Corporate dentistry knows the challenges that private practitioners face. Marketing messages are tailored around those challenges—and how corporate dentistry doesn't have them. "Corporations do a really good job of making their services sound very appealing to doctors," says Dr. Caudill. "For example, we would say something like, 'Doctor, you're trained to be a great dentist. Let us handle the staff, the bookwork, and the tax preparations. We'll order supplies, equipment, and maintenance. You can go home at five and relax. Go have a great life with your spouse and children.'" For dentists who are bogged down with all of the business aspects of dentistry that they have to do on their own, a corporation that says it will handle all of those responsibilities can be very enticing. "It's a good draw," he says. Corporate Dentistry's Growing Labor Force Many dentists view corporate dentistry as a good draw, indeed. Corporations go nowhere without willing labor, and there seems to be no shortage of dentists willing to take the corporate plunge. Dr. Brown believes that the rise of corporations is due in part to the financial pressures that new graduates and young dentists face. One must consider the increasing cost of dental education: "The cost of dental education is one of the highest among medical professions," Dr. Brown says. "With no vigorous scholarship mechanism in place, students rely on loans and personal funds, which often lead to $200,000 and $300,000 of debt." On top of the student loan debt, new dentists incur even more debt as they begin practicing—and they don't have many places to turn for help these days. Previous generations of young dentists could count on bank loans or associateships with established practitioners to help them with these costs. But the current recession is squeezing traditional practice entry points and bank support has dwindled. "Doctors are coming out of school $200,000 in debt into a bad economy, in which long-time dentists are going bankrupt and banks are balking at making loans. It's much harder now to come up with the money to buy or set up a private practice, which could cost $500,000 to $1 million," says Dr. Caudill. It's not surprising that many young dentists are looking to other options, including corporate dentistry. Even if young dentists had the funding to buy a practice, Dr. Brown notes, fewer practices are available for purchase, because many older dentists are practicing longer. (Interestingly, as mature dentists approach retirement, many of them are finding that fewer younger practitioners can afford to buy them out—but corporations can.) Associateships also are more difficult to secure. For one thing, there may not be enough established practices to take the graduates that are churned out by dental schools each year. "As long as we continue to graduate more dentists than the marketplace can absorb," Richard Dycus, DDS, MAGD, of Cookeville, TN, says, "corporate dentistry will scoop up the new graduates who need a job." What's more, traditional solo practitioners, strapped by lower patient traffic and less production, may be less willing to take on the burden of supporting the financial needs of younger dentists. "Many new grads need a sizeable income just to cover their loans," says Dr. Brown. "They may not be able to wait while helping to grow the practice." Only scant employment opportunities exist otherwise for dentists who want to practice. Positions in public health clinics are relatively rare and the potential for hospital positions are slim. There is another, less obvious dynamic that also may make corporate dentistry appealing to new dentists. "People are less oriented to coming out of school and starting their own practices," Dr. Caudill says. "They are losing the desire for entrepreneurship." Dr. Brown agrees that the desire for private practice has changed over the years. "Different life and career expectations come into play among the generations," he says. "The model for a lifelong, successful career has many looks now, and each generation wants different mixes of ownership, time with family, professional growth, and community involvement." Young dentists may not want to ever own a practice. Many new dentists are more interested in having a balanced work-home life. According to a 2011 American Dental Education Association report, "Reasons Why Students Pursue a Dental Career," 64% cite "control of time" as the reason why they enter the profession. And, while it still is a high percentage, only 55% cite "self-employed" as the reason for becoming a dentist. This could be related to the fact that education today focuses on more group work, social interactions, and constant communication via technology, which affects the way in which younger people work and interact after they graduate. According to a 2005 article from the EDUCAUSE Network, "Learning, Learners & Technology," "Interaction and social networks are essential. Young people prefer group work and online contact with others (e.g., Facebook)." Further, the new generation of young people, who are referred to as Generation C, or the "Connected Generation," are constantly connecting with their peers. A white paper and accompanying video, "Who Are the Class of 2015?" from the social media agency Mr. Youth, reports that 59% of college students update their Facebook status while sitting in class. More than half of students are on Twitter, and more than 75% send more than 20 text messages per day—they are constantly connecting with others. Dr. Caudill says, "The new generation of dentists also is growing up with social media. With the likes of Facebook and Twitter, this is a much more social group than the lone wolves of yesteryear. They thrive in a group environment." For this reason, solo practices may no longer be very appealing to younger dentists. Criticisms of Dental Corporations In spite of their appeal to segments of patient and dentist populations alike, some dental service organizations have generated serious operational and ethical complaints. Amid well-publicized accusations of patient abuse, unlicensed practice of dentistry, and fraud, six states currently are reviewing or auditing dental corporation business practices. Additionally, these management companies also are the subject of a U.S. Senate inquiry launched earlier this year by Sens. Max Baucus (D-Mont.) and Charles Grassley (R-Iowa). This inquiry is looking into allegations of overtreatment and low-quality care delivered with "assembly-line service" by a number of American dental corporations. Further, in recent years, Dr. Caudill describes seeing what he calls the "big-boxification" of dentistry, in which dental corporations set up shop in a given area, bombard the local media outlets with advertising, cut service prices, run mom-and-pop practices out of business, and then raise fees. "Corporate dental groups come in and saturate an area, opening multiple offices, and hiring specialists who rotate among locations and cut out outsiders," Dr. Caudill says. Dr. Brown worries that these insider-only referrals are not in patients' best interest. "Mega-groups that include specialists may seem like a benefit to patients who want to only go to one location for care," he says, "but do the dentists in these groups have the option to refer to the specialist who they think would be best for that patient, whether inside or outside of the group?" Once established, Dr. Caudill says, some corporations may put doctors on production quotas, which are often strictly enforced. Under pressure to perform and produce—or risk termination—dentists may become motivated to prescribe the most expensive treatments available. "They may be encouraged to up-sell the patient," he says. Dr. Caudill explains that he was informed by a colleague from a dental corporation about incentivized up-selling procedures. If a doctor prescribes a filling, for example, and the hygienist or treatment plan coordinator can convince the patient to accept a crown, they all may receive bonuses. Dr. Caudill also describes supply quotas that result in shortages. After a previous slow month, for example, a practice can run out of supplies in the third week of a busy month. The dental corporation may refuse to send more, and the practice can't order again until the next month. This may cause disruptions in, or changes to, treatments. "I've seen doctors tempted to put in the wrong color composite because that's all they have left," Dr. Caudill says. Different Approaches to Care In addition to supply issues, DSOs and private practice dentists differ in other areas, including practice management and approaches to care. Dr. Caudill says he has encountered a variety of corner-cutting techniques in corporate dentistry, such as delaying and postponing care of capitation patients. "The goal of some DSOs may be, in theory, to not see the capitation patient at all, while continuing to collect capitation fees," he says. Additionally, Dr. Caudill says, corporate doctors often are instructed to use only a company-approved lab, which typically would be the lowest bidder, and not always the one that offers the highest quality. And even if the lab's quality is not good, doctors often are not allowed to change labs. Speed and a one-size-fits-all mentality limit a dentist's ability to treat every patient as an individual. "Some DSOs may tend to run the patients through like cattle to maximize profits," Dr. Caudill says. DSOs may win out over solo practitioners on the cost of treatment, according to some observers, but on such specific benefits as detailed, thorough, easy-to-understand descriptions of treatment plans and such broad intangibles as human connection and trust—not to mention a stable, low-turnover employee base—they inevitably come up short. Corporations, of course, have other axes to grind, constituencies outside the office to please. They must fund the checking accounts and 401(k)s of layers of people beyond just the dental team itself—particularly corporate employees and executives. They must generate a return on their investment that satisfies stockholders. So DSOs constantly struggle to find the cost savings that allow them to remain competitive. "There are companies that do it right," Dr. Caudill says. "But, there are also some very bad actors who want ROI [return on investment] so badly they will do anything to reach it. These corporations will cut everything to squeeze more profit because of the extra layers of people to feed. Once you have the pressures of stockholders to satisfy, dental practice takes on a whole new character." As a result of their broader focuses, corporations may lose sight of the needs of the people closest to the action. Dr. Caudill says, "In many DSOs, the doctors are always fighting the bean counters. Some corporations are good at making promises to both patients and dentists that they don't or can't keep. The doctors want to provide quality care, but often feel they aren't given enough time, staff, or supplies to do so." This struggle to provide intangibles like caring, thoughtful treatment and building long-standing, personal relationships with patients are reasons some argue that corporate dentistry offerings cannot compare to what private practices provide. Conflicts of Interest Treatment philosophies also come into play for all dentists—corporate and private alike. Dentists, like all doctors, always have walked a philosophical tightrope. They must balance their own best interests with those of their patients. "The best basis for creating good oral health is a solid patient-doctor relationship," Dr. Brown says. "This means that the patient and the doctor collaborate to decide the best course of treatment. The doctor informs the patient of any conditions and concerns and presents the solutions for the patient. The patient expresses his or her wishes, and a dialogue determines the best mix of solutions and potential outcomes. The patient trusts the doctor to present what is in the best interest of the patient, not the best interest of the doctor." But, for some corporations, only one bottom line exists. Above all, corporations must make a profit. "Profit-seeking corporations are not directly required by licensing laws or patient-care interest to meet a dentist's ethical responsibilities," says Gary D. Oyster, DDS, of Raleigh, NC, legislative chair of the North Carolina Dental Society. Dr. Brown is concerned that corporate dentistry encourages a commodity mind-set. "Production quotas, whether directly stated or implied, ruin the patient-doctor continuum. They can, even if subconsciously, drive doctor decision-making and abrogate patient responsibility," he says. Some believe the commoditization of dentistry also may distort patient values. "Commodity patients see dental care the same as buying tires. They want top-drawer results without cost or commitment to the personal responsibility that is the key to good oral health," Dr. Brown says. "The public health iron triangle of access to dental care says that you cannot have high-quality oral health care from a committed, caring professional and still receive all treatments at a fraction of the cost. You can't minimize cost without negatively affecting quality or availability of care." Dr. Caudill notes that, despite this, dental corporations like to position themselves as patient advocates. DSOs argue that only they have the capital to reach out to patients in rural or underserved areas. But Dr. Caudill says his experience contradicts this. "You are not going to put a fast food restaurant in an area with insufficient traffic," he explains. "DSOs make their decisions in the same way. They use population density ratios, demographic studies of socioeconomic levels, and traffic count surveys to determine where to put a new office. They are not going to open in an area unless they see a very good opportunity for corporate profits." A Test of Power One such area where dental corporations were part of a heated debate is North Carolina. Dentistry in that state was thrust into the news recently with its legal debate over dental corporations. For some years, the North Carolina State Board of Dental Examiners had been pursuing expensive and strongly contested litigation against corporate violations, such as illegal ownership, fee-splitting, and false bookkeeping. In 2010, a 62-year-old dentist sold his practice to the Illinois-based corporation Heartland Dental Care Inc. However, the North Carolina Dental Practice Act ownership provision prohibited this sale as it allows only licensed dentists to own or otherwise control, manage, or supervise a practice. The dental board took legal action against Heartland Dental and the dentist. In lieu of a formal administrative hearing, the dental board settled the complaint with consent orders for both the dentist and Heartland Dental, and the parties' agreement was terminated eventually—a huge setback for corporate dentistry in North Carolina. Still, corporations continue to flex their power, and their money, too. In 2011, legislation was introduced to improve the North Carolina dental board's capacity to enforce the state's broad laws against corporate practice. The bill came to be seen as a test case on dental corporation power. A consortium of mostly out-of-state, investor-owned companies raised more than $1.1 million to fight the bill with political advertisements. The companies also hired 14 lobbyists and delivered significant campaign contributions to legislators. Organized dentistry pushed back; the North Carolina Dental Society website declared that some DSOs "have crossed the line from providing business support services to exerting control over the dental practice." By summer 2012, the legislation passed, reinforcing dental corporation statutory restrictions as valid state law and calling for further work to improve board regulation. According to Dr. Oyster, this new law demonstrated that "corporate-run—owned, supervised, or controlled—clinics are against the law and are bad for the profession." For now, at least in North Carolina, organized dentistry seems to be winning the battle against corporatization. Perceptions of Corporate Dentistry While the battle continues and becomes more of an issue for the profession, many dentists have been and will continue to form opinions about corporate dentistry. Trying to compete with and challenge corporations can be tough for solo practitioners and private practice dentists, mainly because corporations are extremely powerful—and rich. "The corporations are making huge bucks. They are not going away. They have the money and lawyers to stay the course," Dr. Caudill says. Many expect the corporate dentistry trend to continue growing at its current, accelerated rate, increasing the influence of standardized, The Cheesecake Factory-esque big business on something that many dentists feel should stay small and personal. There are dentists who vehemently oppose DSOs, and there are some who feel there can be a middle ground or practical alternative to DSOs. "I think small, space-sharing groups are a much better answer than large corporations," Dr. Brown says. "Then, you could keep the private-practice advantages for patients, while maximizing expense coverage and enjoying the built-in professional collaboration." There is also the group who feels that DSOs remain a good option for some dentists, including those just graduating from dental school. All dentists—whether they favor corporate models or not—will agree that the patient must remain the No. 1 priority. As is the case with all health care professions, transparency remains the key. "Patients have a right to know who is driving the bus, who is really calling the shots regarding their care—the doctor or the corporation," Dr. Caudill says. About the Author: Erik K. Curtis, DDS, MA, MAGD, is an adjunct associate professor at the University of the Pacific. Dr. Curtis holds a certificate in professional writing from the University of Arizona and is certified by the Board of Editors in the Life Sciences. He maintains a private general dental practice in Safford, AZ.
Steve Braykovich · January 20 at 1:57 am
How long does it take your mill to machine a (insert restoration type here)? This seems to be an area that the digital dental labs and milling centers are most concerned with and can likely be a...See more key criterion in their purchase of a milling machine. Of course machine cycle time is important but it is in reality, not a true gage of a milling machines production and effect on overall throughput and profitability. While the VersaMILL is capable of producing single unit zirconia restoration in as little as 6 minutes and titanium implant abutments in less than 20 minutes, our answer to this questions is typically: “How long do you want it to take”? This may, on the surface, appear to be a flippant answer but in reality we are quite serious. Often time sacrifices are made and indeed even tolerated in the pursuit of fast cycle times. Sacrifices that include: Decreased Cutting Tool Life Increased Manual Bench time Decreased Accuracy Inferior Surface Finish (i.e. Occlusal Surfaces) Poor Feature Definition (i.e. Margin Definition) Increased Design Time Does it make sense to be able to pull a restoration off of the milling machine in 4 minutes only to spend another 10 minutes on the bench to clean it up OR determine it is unacceptable thereby having to re-make it OR spend additional time designing the restoration to avoid machine issues OR spend additional money on expensive diamond tooling due to improper feed/speed rates, OR to sacrifice finish or detail, etc.? The achievement of high quality, in terms of work-piece dimensional accuracy, surface finish, production rate, wear on the cutting tools and economy of machining in terms of cost saving are the main challenges of modern dental manufacturing. Machine stability in terms of vibration dampening characteristics of the axes and spindle drive systems, spindle run-out, machine positional accuracy, cutting tool materials and geometry, machining parameters such as speed, feed, depth of cut and CAM programming strategies all play a factor in enabling you to reach your throughput and profitability objectives. We at Axsys not only have the PRODUCTS, we even more importantly, have the KNOWLEDGE and EXPERIENCE to maximize their effectiveness in pursuit of your goals and objectives. With our products we can provide you with the throughput you need to be competeitve while enabling you to ship superior product to your customers while yeilding high, predictable profits. You may even find that with the VersaMILL and our expertise, an extremely quick return on investment can be realized in zirconia restoration alone; thanks to the tooling cost savings associated with our extremely long tool life (in many cases over 200 units per tool) from tooling that costs a fraction of what competitive solutions offer. Contact Us today to learn more about the Axsys Advantage so we can put our experience to work for you.
Dean Mersky, DDS · September 26, 2012
I find the China debate to be very interesting yet perplexing. Some continue to believe that the problems faced by today's lab owners are in some measure due to the Chinese. This is akin to standing at...See more the plate and taking a called strike while swatting a gnat. If we don't keep our eyes on the ball, the game will be over before we realized what happened. While some dental laboratories might be adversely affected by offshore products, pricing pressures are occurring industry-wide and are mostly coming from the insurance industry. Specifically, the insurance industry has depressed reimbursements to the point that many dental offices are fighting to keep their doors open. As a result, price pressures continuing downstream are falling on every domestic dental laboratory and manufacturer. Blessed with a bad economy, the insurance companies are continuing to promise purchasers even lower prices in the future while their margins remain healthy. All that, combined with inefficient laboratory business models, and we have a called strike! But the insurance companies are not entirely to blame. Dental industry silence plays a role and it comes in the absence of a unified voice sounding a singular purpose. The insurance companies have branded themselves with a single purpose cost control and now are the gateways for dental care, while we have done little. Despite the excellent leadership offered by dentist, laboratory and manufacturer organizations, the industry as a whole has been ineffective as guardians of care services. While each disparate organization has been tending to the unique needs of its members, we have failed to brand ourselves as the gateway and best keepers for patient care. As a result, the insurance industry has filled the void, wedged itself between patients and dentists, de-branded the profession and marginalized the entire dental industry. Today, the insurance industry defines itself as the keepers of quality care and the agents for dentist credentialing. It has presented itself as the "good cop" to protect beneficiaries from potential abuse and as the expert in keeping costs to a minimum. Today, thanks to our slumbering, consumers seek their dentists through insurance company websites, a clear indication of how the care brand is owned and controlled by a force we have failed to reckon with. The net result affects each sector of our industry in destructive ways and leaves consumers vulnerable to those with no experience in care delivery. I suggest a meeting of representative leadership from the aforementioned organizations to help develop a unified voice and message, and a strategy with which to deliver it, something OPT-In a national cooperative of small laboratories is currently working on. Let's take our eyes off the gnat and prepare for the next pitch. That's the only way to have any chance of remaining in the game. Dean Mersky, DDS Founder, OPT-In Dental Lab Cooperative
Claus Dampmann · June 15, 2012
A counter viewpoint to those who have concerns about the materials being used in China.
Larry Borman · April 17, 2012
Dear LMT: A recent issue of Dentistry Today featured an article, "Dental Lab Registration: Dentists Leading the Way", written by attorney and NADL Chief Staff Executive Eric Thorn, who points out some...See more interesting trends in states that are creating legislation or proposals requiring dental lab registration (including Virginia, Georgia, Minnesota, New York, New Jersey, California and Washington). Thorn says that, in many cases, the reason for the growing push for lab registration is the leadership of dentists and state dental associations. I wrote a letter to Dentistry Today in response to the article, and also wanted to share some of my sentiments with other lab owners through LMT. Are dentists really leading the way? If so, which way? Dental laboratories, I would argue, are most interested in engaging, educating and empowering both dentists and patients about choices, benefits and risks of source materials. But dental lab registration does little to accomplish those goals. If the health and well-being of patients is really at risk (and I believe it is), why does it seem that many dentists allow insurance reimbursements to dictate what they will pay for crowns and other restorations? Of equal importance, do they know which materials are used to make these restorations? Is the consumer even aware that many crowns for U.S. patients are made overseas (the majority in mainland China)? As a full service lab owner with more than 25 years experience, I know as do most lab owners, the patient is generally unaware a dental lab even exists, let alone that a patient's crown is custom made for him. In a global economy, the opportunities to buy products from many countries other than the U.S. are vast, and the reason is almost always price. Dentistry is not exempt from this. Many dentists both knowingly and unknowingly use these overseas labs. Yet dentists I have spoken to seem either unaware of or claim to be unaware of this proliferation of global providers, even though they advertise in nearly every dental journal. When I've asked dentists about this, their responses remind me of a former policy of our armed services: Don't ask, don't tell. You have to wonder why a number of the state legislative movements are requiring labs to register yet the patient still has no idea what is going in his mouth. Shouldn't the patient be aware of the origin of the product and the materials being put into his body? Why is the dentist exempt from providing the patient with options; shouldn't the patient have a choice between using an overseas laboratory versus paying a premium for a lab that follows U.S. health and safety standards? Informed consent is always important and should be here, too. I believe patients value the freedom to choose, especially when their health could be at risk. Until these fundamental questions are answered and acted upon, there is little reason for any of us in the dental profession to think we're moving ahead in the best interest of the patient by requiring the registration of dental labs. Like many lab owners, I readily accept (and embrace) the idea that all labs should voluntarily comply with origin and material disclosures. We would also welcome dentists to truly lead the way in offering the patients the ability to make an informed consent decision. ~ Larry Borman Owner Tetra Dynamics West Babylon, New York Also see Laboratory Owner Terry Fohey's Letter to the Editor, "Why is Dentistry Afraid of Transparency?" Â»