Drs. Brian J. and Tracie E. Keller

	CAD/CAM dental offices have the opportunity to use the system’s excess capacity and the practice’s existing dental staff to develop another revenue source. With the pieces already in place to produce state-of-the-art dental restorations, it is possible-through a boutique commercial dental lab-to profit from those underachieving periods during a normal day. These doctor labs can operate within the existing dental practice without disrupting patient treatment. Revenue generated from the accounts the dental lab takes on adds benefit to the practice’s bottom line.

	That’s exactly what we’ve done in our office through The2thDox Dental Lab. This boutique lab helps us make full use of our time and technology, which motivates both doctors and staff members. This excitement translates to our patients, who are impressed and comforted that their doctors provide this service to other doctors. 

	Our decision to purchase a CAD/CAM system was based on the return on investment with our existing patient load. At the time, we had no intention of beginning an outside dental lab. Like many dental offices we immediately saw increased revenue in our restorative practice after we purchased our E4D CAD/CAM system from 

. Our patients were impressed and the staff was excited as we worked our way through the CAD/CAM learning curve. We quickly gained confidence and comfort with our new technology.

	The process of fabricating and delivering a crown to a patient became so enjoyable we told all our dental friends about it, including a relative who wanted to see the result first hand. We made him a single-unit crown for his hygienist. She was thrilled, he was hooked and we secured our first account.

	Today, we have a handful of accounts and we’re growing through word of mouth. We have had the E4D system in office for about 18 months and have been doing crowns, inlays, onlays and implant crowns for outside accounts for almost a year. Starting slowly, we have now completed more than 500 units for our clients. As we have developed efficiency and comfort in this venture, the number of units we produce continues to increase each month.

	With our current case load, we can complete a single unit in 48 hours or less. Our clients also can schedule in advance for Same Day Service. For a nominal fee doctor clients can provide their patients a crown in a single day as if they had in-office CAD/CAM themselves. This service allows our dentist clients to compete with the growing number of “Same Day” dentists, while at the same time energizing their own patient base. If there is a need for an “emergency crown,” we normally work it into our schedule. We know how valuable this can be for the doctors and their patients.

	We can deliver a product that is equal to what a commercial lab can do. Typically, a dentist who invests in CAD/CAM technology is innovative and educated. The type of dentist who has chosen to practice in-office CAD/CAM dentistry likely has the knowledge and skill to accept this new profit stream into his or her office. If the dentist is already successful with in-office CAD/CAM dentistry, the foundation is in place to accept “outside work.”

	Dentists have the unique ability to understand what the client doctor struggles with. In our 26 years in practice, we likely have experienced most every situation. We can advise our colleagues and help them make it work for the patient. As professionals ourselves, our client doctors can be assured we have their best interests, and ultimately the patients’ best interests, at heart.

Articles

 CAD/CAM dental offices have the opportunity to use the system’s excess capacity and the practice’s existing dental staff to develop another revenue source. With the pieces already in place to produce state-of-the-art dental restorations, it is possible-through a boutique commercial dental lab-to profit from those underachieving periods during a normal day. These doctor labs can operate within the existing dental practice without disrupting patient treatment.

Is in-office CAD/CAM hurting your bottom line?

	Our decision to purchase a CAD/CAM system was based on the return on investment with our existing patient load. At the time, we had no intention of beginning an outside dental lab. Like many dental offices we immediately saw increased revenue in our restorative practice after we purchased our E4D CAD/CAM system from D4D Technologies. Our patients were impressed and the staff was excited as we worked our way through the CAD/CAM learning curve. We quickly gained confidence and comfort with our new technology.

	It is important that the doctors you work with understand proper preparation and tissue management. It is difficult, if not impossible, to make up for inadequate quality of treatment. This may require visiting doctors for a quick lesson on the essentials before taking them on as clients. Many doctors don’t consider what is necessary in fabricating a restoration from the lab perspective.  Simply sending cases to commercial labs and letting them take care of it does little to improve results. In the typical commercial setting who is the lab person to tell the doctor his or her job? In our setting colleagues work together, learning happens and good results follow. Dentists genuinely wish to learn to improve what they provide their patients. There are many dentists in the community who are frustrated with the same old outcomes from those big commercial labs.

	It is our contention that throughout the office there is enough staff down time during the day that a small hand full of crowns can be produced with little, if any, disruption to the daily schedule. With just a little extra effort, you can begin to imagine Benjamins floating right down to your practice’s bottom line each month.

	Sound like something you’d like to do? Here’s how we incorporated it into our daily routine, and what we’ve learned along the way.

	Before you can begin, you and your team must have a high degree of competence in creating restorations. Everyone involved must be competent with his or her task. Remember, proper training is critical; mistakes reduce profit margins and decrease confidence in the product. Only staff members who are detail oriented and who have been properly trained should be involved. The “too many cooks” rule is always in effect.

	To make this work, your practice must be organized with a current practice schedule designed to use “gap time” for outside casework. Efficient scheduling provides valuable minutes for lab work. Office staff must understand that down time should be used, rather than lost in nonproductive pursuits. 

	Inventory control is essential. The lab must have what is necessary to produce the unit on hand. Everything from glass blocks to plastic crown boxes are important to deliver the product on time and efficiently. Rushing glass blocks by overnight delivery decreases profit margins.

	Staff and change are never good words in the same sentence, and they always cause a dentist discomfort. In this case, if you have already implemented CAD/CAM dentistry into your practice you have completed all the heavy lifting. You know by now who in your office is on board with CAD/CAM dentistry.  Maybe you have staff members who do not embrace the change. Those who cannot handle the upgrade are creating an overabundance of excess capacity. Help them find other work. Find those who are ready to share your excitement and accept this new challenge.

	Not only do you need to have the right materials and equipment, you also have to maintain them. Keep a tidy and organized lab area. Our dentist clients will come by the office to drop off and pick up cases or to discuss a case in progress. It is important to look professional to those who trust you with their patients’ treatments.

	When we receive a case we immediately place it in a casework pan. All necessary information is taken from the doctor’s prescription and the case is entered into the computer system and a workflow sheet is attached to the case pan-a must for every case. The doctor checks the case and notes how it will proceed.

	By using a workflow sheet, we can easily monitor each case for progress without having to waste time deciphering what stage the restoration is in. The sheet should include procedure check offs for team members to initial. If there are any missteps, this is an effective way to determine who is responsible and how to correct the problem. The workflow sheet also should allow space for notes to advise the treating doctor of any problems we might find during production. We never want to keep things in our heads. Good notes are important to refer to in cases that may not go as the treating doctor expects. The lab can head off potential conflict and help the treating doctor anticipate any adjustments that might be necessary upon seating the restoration. This is a marketable advantage our doctor lab can provide that may not be available from a commercial lab.

	In our office, we have two assistants who are trained and responsible for CAD/CAM production. During the day they use time between patient duties to check the workflow sheet attached to cases and perform the next step toward completion. We can’t emphasis enough how important it is for team members to note their progress on the workflow sheet.  Most tasks involved in completing a unit take only a few minutes, and between them they can turn out an impressive number of units without a dramatic change in their personal work load.

	Once the crown has been designed, it is sent to the mill where it can be milled at any time throughout the day. Cases are finished according to the prescribing doctor (polished, glazed, or custom tinted). The lab doctor always performs the final check and the case is then boxed and ready for delivery.

	We do cases for both in town and out of town offices. For in town cases, the prescribing office can deliver and pick up from our front desk or we can arrange for a courier service. For out of town cases, we keep a stack of “If it fits, it ships” Priority Mail boxes. We generally pay for shipping from the lab. The prescribing doctor is responsible for sending the case and any other overnight or special rates that may apply.

	When starting out, go at a pace you are comfortable with. Any additional crowns you mill are a positive. We have experienced record days that have pushed our comfort level, but those days always created a new benchmark in efficiency. A uniquely fun aspect of moving quickly around the lab is that, unlike a patient, a crown does not feel it was rushed. We have developed a great team effort in putting the product out.

	The economics of reimbursement requires dentists to keep lab fees as low as possible. We can charge a fee similar to the largest commercial labs and retain a reasonable profit.    

	Taking on accounts slowly also will reduce staff stress and increase acceptance of the growing workload. It may be challenging at first, but as the number of cases completed increases so does efficiency and the pride the staff takes in providing a great product.

	We can deliver a product that is equal to, or superior to, a commercial lab. Typically, a dentist who invests in CAD/CAM technology is innovative and educated. The type of dentist who has chosen to practice in-office CAD/CAM dentistry likely has the knowledge and skill to accept this new profit stream into his or her office. If the dentist is already successful with in-office CAD/CAM dentistry, the foundation is in place to accept “outside work.”  Efficient workflow is the key.

	Dentists have egos and it is a safe bet that many don’t relish the idea of another dentist critiquing their work, so don’t. Remind your dentist clients that you’ve been there, too. Remember, like you, every bad margin or under reduced occlusal is an uncooperative, hyper-hemorrhagic patient’s fault. Besides the lab person at the factory crown outlet never criticizes, and he has those glossy coupons with the ladies in big white teeth for half off your next 50 crowns.

	We always inform prescribing doctors if it is in their best interest not to proceed with a case as is. When appropriate we send notes describing suggestions for future cases. We also find it beneficial to send word when treatment was performed well so that we can share the lab perspective with the treating doctor.

	It is beneficial for CAD/CAM dentists to keep the mill running. By adding outside accounts, the mill can hum longer each day while using up excess capacity. Test this for yourself. Consider the fixed cost of producing a CAD/CAM crown and what you might pay for that same crown at a reputable commercial lab. The difference is entirely yours. Multiply this number until your excess capacity is filled and you will be pleasantly surprised and probably shocked.

	Becoming a commercial lab might require some upgrades in office efficiency, but in this economy how could that be bad? Other than ordering a gross of those little plastic crown boxes, you have all you need to begin.

	If you have a CAD/CAM dental office, you have a great opportunity to add another revenue source without a lot of extra time and work. We find the financial reward of producing to-go restorations is a great motivator, and the lab is an area where everyone works together. There is an excitement generated from how efficient we can be at getting those crowns out. So get your boutique dental laboratory started now, lose the excess capacity and say hello to extra profit.