Terri Lively

When it comes to a dental practice, is it better to own or lease the property? We spoke to a real estate expert and a financial adviser to help you decide for yourself.

Colin Carr, CEO of national real estate firm CARR, which represents healthcare tenants and buyers exclusively, said providers can benefit greatly from ownership because they increase their net worth every month by paying for an asset whose value is likely to appreciate.

Real estate markets go up and down, of course, but despite the inherent risk, commercial real estate is a solid investment that increases in value by a couple of percentage points a year over a period of 10 to 20 years. And when providers own the space, 75% of the time it sells for more than the practice itself. “You can have a practice selling for $1 million,” Carr noted, but “the real estate will sell for more than that, three-fourths of the time.”

Phil Roberts, CFP®, CLU®, ChFC®, RICP®, a financial planner at Capstone Partners, agreed, pointing to a dental client in California who sold his practice and building last year. The client had saved $400,000 in an IRA, sold his practice for around $350,000 and the building for $700,000. “That inserted…money into his portfolio that he otherwise wouldn’t have had if he didn’t own the building, and [it] made his retirement much more stable,” Roberts observed.

But dentists don’t have to sell. They can lease the space to the practice buyer to receive a monthly income and diversify their cash flow in retirement. “Having your Social Security income, asset-based income, and real estate income can create a strong retirement…position,” Roberts said.

What Is Happening in Commercial Real Estate?

Although real estate is a long-term investment, knowing what is taking place in the short term is also essential, and experts are forecasting a challenging 2023. In predicting a recession, JP Morgan cites several factors:

, like the war in Ukraine and the sanctions against Russia, have driven up the cost of food, shelter, and energy.

, as high as 7.75% in late 2022, resulted in rent increases of nearly 7% compared with 2021.

 will continue to rise in 2023 and could have a negative impact on commercial real estate owners.

CBRE, a global leader in commercial real estate services and investment, says it will be a difficult year because of high interest rates and a looming recession. As the Federal Reserve raises rates to control inflation, the higher cost of capital lowers asset values.

Capital costs are quite high, per Fundera by Nerd Wallet. Interests on commercial real estate loans range between 3.5% and 20%, and many factors affect those rates, like the property in question, the borrower’s creditworthiness, and the type of lender. Loans backed by the US Small Business Administration have the lowest rates, ranging from 3.5% to 6% for a 20- to 25-year term for amounts between $50,000 and $20 million and from 7% to 9% for 25-year terms on loans of $5000 to $5 million. Banks rates start at 3.75% for loans over $25,000 for 10-to 15-year terms.

In addition, Carr explained, ownership confers tax benefits, such as for depreciation. The IRS allows owners to take a deduction to recover the cost (or other basis) of a property’s wear and tear, deterioration, and obsolescence provided the deduction is only for the owner, the property is used for business or income-producing activity, it has a definite useful life, and is meant to last for more than a year.

Owners can depreciate everything but the value of the land on commercial properties over a period of 39 years. The Hartford insurance company recommends working with an accountant on this, as IRS rules change frequently. Properly executing a depreciation schedule allows dentists to match expenses to revenue and keep an accurate record of the practice’s business costs for a given accounting period as well as a realistic idea of its assets.

According to Carr, owners can also speed up or do a bonus depreciation through a cost segregation study. They can deem some of the improvements made to the property to have a shorter lifespan and write these off faster. For example, owners can depreciate some upgrades over 10 or 15 years and others over 5 years. “So, you can pick up even more tax deductions if you are inclined to,” Carr stressed.

In addition to the tax advantages of depreciation, owners can write off maintenance expenses, origination fees, and closing costs, said Austin Lee, CFPTM, founder of Lee Financial Group, LLC. When they need to move, they can sell the property and use the proceeds to invest in the next building within a year without paying capital gains or a 1031 exchange.

Some restrictions apply, however. A 1031 exchange works only with a building that will be used for the same purpose, and a third party must hold the proceeds in escrow until the new building is purchased. The properties must also be “like-kind,” that is, of a similar nature.

So, why wouldn’t every dentist buy a property? Sometimes, Carr indicated, there is nothing available in the area where they want to practice, they don’t have the down payment, or they have cash flow problems that make monthly payments unaffordable. Finally, some dentists may not want to worry about upkeep and management, like snow removal, landscaping, and maintenance.

“The cost of ownership is time and money,” Lee acknowledged. “You pay for…remodeling, repairs, and maintenance. On the time side, if a problem…needs to be attended to, you are the one to attend to it.”

There are also opportunity costs involved, he said; for instance, buying a commercial building is a significant investment. And spending money on a building means one cannot spend it on dental equipment, marketing, or staff salaries. “That opportunity goes away when you have to put…money into buying the building itself.”

In such cases, leasing might be the way to go, Carr said. With a lease, not only are there many more options available, but there are also fewer obstacles to entry and a much smaller startup cost—usually a security deposit and a month’s rent. Plus, many landlords offer incentives like free rent while the dentist builds out the space, which can offset moving costs, and sometimes even contribute money for build-out expenses in exchange for a longer lease.

Another significant benefit of leasing is flexibility. Those who lease can relocate in a few years if they need more space, something that’s not as easy for owners. “If you outgrow your space, you can always move on to a larger space or even work with the management company or the…own[er]…to see if you can grow into…vacant spaces nearby,” Lee pointed out.

“If you know the exact location and the exact square footage you’re going to need and want for the next 20 years, then…purchasing can make sense,” Carr observed. “But often it makes sense for a startup or a younger practice to lease for a season and, once established, look at purchasing.”

Newer dentists “can generally lease in a nicer area” than the one they can buy in, Lee noted, “so, depending on what type of clientele you’re trying to attract, that could boost the practice.” Plus, “a higher cash flow does help your credit rating.”

There are drawbacks to leasing as well, Carr added. Dentists who lease forfeit the asset building and increased net worth that results from owning. They cannot control rent increases, although they can negotiate, particularly with the help of a professional, but they often don’t have a say in who else leases nearby.

A pediatric dentist, for example, wouldn’t want a vape shop or liquor store next door. Professional guidance during lease negotiations can prevent these situations with stipulations in the lease as to who can be next to you, Carr said.

Lee concurred, adding that owning the building means the dentist decides who the neighbors are. “You get to choose…your tenants. So, if you are an endodontist, maybe you want a general practitioner in the building,” he explained. “You also have control over what happens to the property if you want to make improvements.”

In contrast, when leasing, dentists have little control. The rent can increase, and sometimes the property manager or owner decides not to renew, which means having to move. If there’s nothing available within the dentist’s price range, there can be a lot of uncertainty as to the future. “You are also at the mercy of the landlord for timeliness and quality of…repair[s],” Lee added. “So, if there’s something wrong, it’s only fixed when the landlord wants to fix it.”

According to Lee, there are 3 questions a dentist should consider when deciding whether to lease or own. First, how long can he or she commit to the building or the location? In the short term, leasing is more cost-effective. However, if a provider can be in the same place for more than 7 years, buying might make more sense.

“If you are planning on staying put for at least that long, your business is very well established, and you don’t see yourself retiring in the next 7 years, then you ought to look at buying,” Lee said.

Next, dentists should determine how fast their business is growing. If the practice size is relatively stable, the dentist can probably buy a space that will accommodate it for years. But if the plan is to grow significantly in the short term, leasing is best until the projected goals are reached.

Finally, a dentist should get a feel for the local economy. A great location can become a poor one over time, whereas established neighborhoods are safer places in which to put down roots. “If it’s an up-and-coming community, it might be hard to tell,” Lee said, so “it may make sense to lease and…stay flexible.”

Roberts begins the decision-making process with clients by reviewing financial models that show the numbers for both options. However, psychology also comes into play. When dentists buy real estate, they “save” money each month by paying the principal on an asset that is appreciating.

“You don’t have to make a new decision every month to put money into savings because you just pay your mortgage every month,” Roberts said. “Then, over time, you build hundreds of thousands of dollars of equity in the property because you paid the mortgage and the property appreciated.”

Another way to accrue net worth is to lease and invest the difference between the mortgage and the rent. The amount saved could be similar or higher, depending on the return on investment and the appreciation of real estate in the area where the practice is located. However, Roberts noted, most people don’t save the difference; they spend it. Therefore, owning is more likely to build net worth.

“At some point, we all have to come to grips with our human nature and our proclivity to spend [the] money we have,” he remarked.

Carr agreed that professional advisers should discuss the pros and cons of each situation, including the property itself, its benefits, expenses, and the effects on the bottom line. “You’re going to start with a plethora of information that will help you narrow your options,” Carr said. “It’s got to make sense esthetically and emotionally, meaning you want to be there for the next 15 or 20 years, but then it also has to make sense financially.”

Roberts’ advice? “Sit down with a professional, do the math, and model out the lease versus purchase. Talk to your financial person or find a good financial person that…can simulate, if you were to buy this property, how that will look over the next 10, 20, and 30 years and [how it will look] if you were to lease it.”

Carr cautioned against taking a do-it-yourself approach with what could be a multimillion-dollar transaction. A bad decision, he pointed out, can have serious financial implications. “You want to go into any transaction with that amount of money on the line with a team of people who can help you across the board,” he said, “It will save you time and a significant amount of money and help you avoid costly pitfalls and complications.”

Roberts thinks leasing is excellent for dentists who are still building their practice. However, once a dentist has enough for a down payment, he or she should consider investing in real estate.

“If you’re somebody that wants to build equity and net worth with the things that you’re doing…you might as well build that equity and net worth in your real estate, too, rather than letting someone else build equity and net worth off of your back.”

Brooks, A. 2023 commercial real estate outlook. JP Morgan Chase & Co. December 2, 2022. Accessed 7 March 2023. 

https://www.jpmorgan.com/commercial-banking/insights/2023-commercial-real-estate-trends

Barkham R. U.S. real estate market outlook 2023: opportunities amid a slowing economy. CBRE.com. December 7, 2022. Accessed March 7, 2023. 

https://www.cbre.com/insights/books/us-real-estate-market-outlook-2023

Prakash P. The best commercial real estate loan rates. Fundera by NerdWallet. January 23, 2023. Accessed March 7, 2023. 

https://www.fundera.com/business-loans/guides/commercial-real-estate-loan-rate

Publication 946 (2022), how to depreciate property

. Updated February 24, 2023. Accessed March 7, 2023. 

Depreciation defined. The Hartford. Accessed March 7, 2023. 

https://www.thehartford.com/business-insurance/strategy/depreciating-assets/depreciation-defined

Wood R. What is a 1031 exchange? Know the rules

. Investopedia. Updated July 19, 2022. Accessed March 7, 2023. 

https://www.investopedia.com/financial-edge/0110/10-things-to-know-about-1031-exchanges.aspx

Articles

Property ownership can mean time and money spent, but there can be some upsides to owning your own practice. 


Does It Pay to Be Your Own Landlord?

International speaker and mentor Ankur Gupta, DDS, a general dentist in private practice in North Ridgeville, Ohio, constantly strives to provide the best possible solutions for his patients. As a result, he enjoys fierce loyalty from his patients. His Be Better Seminars help other dentists learn how to avoid failures and achieve success with step-by-step strategies to attain the goals dentists want for their practice. However, even Dr Gupta has cases that haunt him, including this one from 5 years ago.

The patient presented to the office initially to achieve improved esthetics after years of nocturnal and daytime bruxism had caused severe occlusal attrition. At that time, because of financial limitations, the practice agreed to only restore her upper teeth by using posterior porcelain-fused-to-metal crowns to increase occlusal vertical dimension (OVD). This was followed by lithium disilicate anterior crowns. The practice provided the patient with daytime and nighttime occlusal guards, but she had a difficult time with regular adherence.



A long-time patient, aged 37 years, presented with a complaint that her teeth didn’t show enough when she smiled. A self-described bruxer, she asked whether Dr Gupta could fix it.


The Solution:
Dr Gupta thought he could put crowns on the back teeth to open the bite and regain some of the lost vertical from the grinding. He then planned to put zirconia crowns on the front teeth to improve esthetics but no crowns on the bottom front teeth because they didn’t show when she smiled (and to make the treatment more affordable). Finally, he would prescribe a night guard for maintenance to prevent any damage to the crowns.


A mere 2 years later, the upper restorations had decimated the lower teeth. The occlusal wear on teeth 23 to 26 was so severe that it had extended to the pulp and resulted in periapical pathology.



Not long after the completion of treatment, the patient returned with a new problem. The bottom teeth that hadn’t received zirconia crowns were ground down to what Dr Gupta described as pancakes. In addition, teeth 24 and 25 had developed pulp pathology.

The Next Solution:
Dr Gupta crowned the lower incisors (23 to 26) with zirconia and made a bridge, again intending to increase the vertical lost to grinding.


Although the new lower restorations looked nice, it didn’t take long to determine that they would decimate the upper crowns. “Rather than determining the etiology of her severe bruxism, made the unwise decision to simply increase her OVD with posterior lower crowns and thereby provide the room for a lower bridge,” Dr Gupta says.



The patient returned later with significant wear on the original upper crowns from grinding against the lower crowns. Dr Gupta describes the whole case as a disaster. “Imagine this patient. She has dumped so much money into this treatment and put so much trust in me, and I haven’t delivered for her. That’s what haunts me,” Dr Gupta says.


What He Would Have Done Differently:
Looking back, Dr Gupta thinks he oversimplified the solution to the bruxing problem and related esthetic concerns. The first thing he would have done differently was to determine why the patient ground her teeth, a discussion they never had.

“I had a 37-year-old [patient] who had ground her teeth down into tiny nubs, and I wanted to fix her problem,” Dr Gupta says. “I’m guilty of what a lot of dentists are guilty of. It will occur when we fix problems without assessing why that person had that problem.”

The second thing he would have done differently was not relying so much on an occlusal guard. Some patients might receive an occlusal guard, wear it as directed, and have it for the rest of their lives. However, some patients might not be this adherent. Still others might try to wear it but remove it (consciously or unconsciously) in the middle of the night if it isn’t comfortable for them.

In this case, the night guard wasn’t enough, he said. “That’s a big problem I never took the time to solve,” Dr Gupta says, adding that he might have given her an easily replaceable clear plastic retainer that would have been more comfortable. “It’s important for us to realize that they won’t follow all the rules. So, it’s up to us to give them as many tools as possible.”

Additionally, Dr Gupta would have altered his occlusal design so that the brunt of occlusal forces would have focused on the posterior teeth, which would have meant either base metal or gold occlusal surfaces. That way, if the patient had worn through the metal or gold crowns, he could have replaced the posterior crowns rather than remake them in the esthetic zone.

Perhaps most importantly, Dr Gupta would have referred the patient to a prosthodontist. He thinks a prosthodontist would have had a better understanding of occlusion than he does as a general dentist.


Where Is the Case Now?
Dr Gupta says he sent the patient for a sleep study after her top crowns suffered loss from grinding. His patient was diagnosed with obstructive sleep apnea and began using continuous positive airway pressure to improve her breathing, which was the cause of her grinding.

Is she suing him? Thankfully, no. “She still totally loves me, and I don’t deserve it,” Dr Gupta says.

Case #1—Ankur Gupta, DDS

Speaker and educator Jeffrey Lineberry, DDS, AAACD,FAGD, FICOI, owner of the Carolina Center for Comprehensive Dentistry in Mooresville, North Carolina, focuses on complex cosmetic and restorative dentistry. It’s not unusual for him to work on full-mouth restorative cases for his patients. So when a patient wanted Dr Lineberry to fix her smile, he was sure he could help. However, the way he helped her wasn’t his first choice of treatment plan.

The patient, aged mid- to late 50s, presented with missing teeth from the canines to the premolars on the upper left. She already had a removable partial denture but wanted a new solution.


The Solution:
Dr Lineberry told his patient she was a candidate for dental implants, but she refused this option. With a partial denture and implants off the table, Dr Lineberry would do a multiunit bridge abutted to the lateral on the central, replacing the canine and 2 premolars. The entire treatment, which would involve removing existing crowns and placing the bridge, would be complete in 1 day.


The patient suffered from dental anxiety, so she took Valium to help her relax for the treatment. She drove herself to the office, which was not something Dr Lineberry had advised. This situation tipped him off that the day wasn’t going to go as smoothly as he had hoped. “When your patient drives themselves to the visit—which was against our advice and not following our direction—and they seem unaffected by several milligrams of Valium, that’s a bad thing, especially when they’re already an anxious patient,” Dr Lineberry says.



Once he began the treatment, Dr Lineberry saw that the patient had poor gum health and was experiencing heavy bleeding. Moreover, his patient was moving in the chair, adding to the challenge, and there were still hours to go before completion.

Eventually, the bridge was placed along with all the other restorations, and everything worked out. Despite testing the limitations of the bridge and force load on the adjacent teeth, the outcome was satisfactory for Dr Lineberry and the patient. But the process? Not so much. “It was one of those 8-to-5 days of torturing yourself and the patient,” Dr Lineberry says. “It’s about the best way of describing it.”


What He Would Have Done Differently:
This case occurred early in Dr Lineberry’s career, almost 20 years ago. Dr Lineberry says he would have changed a few things about how he delivered that treatment. First, he would have offered more medication before attempting to alleviate the patient’s discomfort. Second, he would have ensured her gums were healthier and encouraged the patient to improve her oral health before initiating treatment. Finally, he might have convinced her to go with a different solution. “Each time she came in, I kept looking at the case wondering when it was going to fail, because everything you read in the prosthodontic books says it will fail,” Dr Lineberry says.

Dr Lineberry also learned that with extensive case management, communication is critical. Not only will it make clear whether the patient’s desired option is not ideal, but it will also allow them to be part of the solution. With many cases (not just this one), Dr Lineberry sees that patients do not take enough ownership of their role in their oral health.

“They show up in our office, and they want us to fix things, but then they don’t want to change anything that got them there,” Dr Lineberry says. “I tell them upfront, ‘If we do this, then this is how we need to manage it.’ If they don’t want to manage it and do things the right way and it breaks, I tell them they get to pay me to fix that crown again because I told them what would happen.

“It’s the most frustrating thing I have when it comes to complex cases,” Dr Lineberry continues. “They don’t do what they’re supposed to, follow through, and take ownership in their own oral health, [which] directly affects the outcome.

These up-front conversations often help when something breaks, Dr Lineberry says. When he reminds patients of their earlier conversation, they understand how their role played a part in the outcome.

Even the best intentions can result in a less-than-optimal outcome. Two clinicians share restorative cases that still haunt them and what they learned from their experiences.

The Restorative Case That Still Haunts Me

Tag teams are not usually what one pictures in a dental office. Reserved for the rowdier environs of a wrestling ring, tag teams usually involve wrestlers bouncing off each other to improve the match outcome. However, when it comes to tag-team implant planning, it is helpful to picture dental professionals bouncing ideas off each other to improve the implant restoration outcome instead.

A movement exists to change the existing implant planning process to allow for collaborations between oral surgeons, restorative dentists, and dental laboratories to improve final prosthetic outcomes. Today we look at the benefits of labs "tagging in" to implant planning earlier, how to make that work with your clients and their patients, and what technology can help.

Historically, the bone available for implant insertion drove the position and number of implants. These factors also affect the final prosthesis design and limit what prosthesis is possible in many cases.

However, a shift is happening in implant dentistry. Instead of making implant placement decisions based on bone availability alone, some research indicates that starting with a comprehensive evaluation of the final prosthetic options for treatment should be included in those decisions.

Matt Vrhovac, Senior Guided Surgery Specialist for NavaGation Precision Guidance, says that what their team calls Crown-Down Planning was the one missing link in the past.

“By treatment planning these cases on the front end with the final prosthesis in mind, we are not left with unnecessary and unexpected challenges on the back end when it is time to restore,” Vrhovac says.

“The alternative to that is the old approach,” André Grace, CDT, Director of NavaGation Precision Guidance and Organizational Development Office at Absolute Dental Services, Inc., says, “which would have been starting with the implant placement first without any idea of what the final result is going to be. Leaving the restorative phase of these cases compensating for that lack of preparation in the beginning.”

“When we first started, it was because we were tired of getting substandard work to try to put high-quality prosthetics on, and it just doesn’t work,” Vrhovac adds. “At the end of the day, it ended up being our and the restorative doctor’s responsibility to fix it.”

There are numerous benefits to end-to-end collaboration on implant cases. By allowing the team—the specialist, restorative dentist, and the lab—to plan the case from the desired prosthetic standpoint rather than designing the prosthetic around the technical limitations based on the implant placement, the cases have better outcomes.

Journal of International Society of Preventive & Community Dentistry

 suggests that these collaborations occur immediately following the initial consultation, which gathers the diagnostic information necessary. Having collaborative-treatment planning at this point presents an opportunity for the team to share the diagnostics and discuss what is bothering the patient, what the patient would like to see afterward, the patient's medical history, and current medical and dental situation. Including this information in the overall planning discussion allows the collaborators to formulate a detailed plan.

Indraneel Kanaglekar, Senior Vice President, and President of Global Dental at ZimVie, a global life sciences firm, agrees that the Tag Team Approach to dental implant cases benefits the patient experience and, particularly, how they feel about the outcome.

"A lot of times, a specialist might be an excellent implant pacer, but not fully aware of the many innovative options available in prosthetic planning,” Kanaglekar says. “If you create a Tag Team Approach, you likely have a much better esthetic outcome at the end of the implant process."

In addition, the collaboration of a Tag Team Approach to implant planning improves efficiency and logistics, Kanaglekar says.

"You may have less to worry about, such as remakes or comebacks and the crown not fitting," Kanaglekar says.

David Turpin, the fourth-generation owner of Spartan Dental Lab, agrees that early collaboration alleviates setbacks for the labs when restoring, particularly regarding full arch restoration and more extensive prosthetics. Collaboration is essential, he says, because the dental team can create a predictable environment, which allows delivery of the prosthetic to go smoothly.

"Too many times implants would be placed without the final prosthetic taken into consideration. This causes many challenges later on the lab front,” Turpin says.

Miles Schuck, Head of Implant Surgery for Dandy Labs, adds that using treatment planning and surgical guides provides a significant benefit to doctors through increased predictability and accuracy. Predictable implant placement reduces appointment time and accurate placement increases the success rate of the final restoration 6 months later. Early collaboration also allows dentists to accurately place temporary provisionals like Essix retainers or temporary implant crowns, or even digitally manufactured custom healing abutments, which Schuck says are growing in popularity.

The lab benefits, too, Schuck explains. Utilizing surgical guides unlocks more predictable surgeries. For general practitioners (GPs) new to implant surgery we see more confidence in collaborating with the lab and doing guided placement.

"We can make it a much more seamless process and support the doctor and the patient by minimizing appointments and increasing cohesion there," Schuck says. "The first thing we start with is a design of the ideal final restoration."

In addition, the process is seamless. The guides are 3D printed, and the technician uses 1 of the various planning software available. Schuck says providing this service is an attractive new offering for the lab's clients.

"It allows you to capture the full scope of a patient’s implant experience rather than just the surgery or just the restorative," Schuck says.

"Seeing the full digital story of the patient on the lab side means we can create a more predictable restorativeproduct for our dentists." Andrew Bukuras, Senior Product Marketing Manager for Dandy, says. “Utilizing scan bodies in the digital workflow is a huge step forward in accuracy for dentists used to closed or open tray techniques. It’s precise, easier, and much more comfortable for the patient.”

Schuck says the first thing a lab can do to make this process work for them is to find lab technicians wanting to take on a new skill set. Ideally, these technicians are familiar with the final implant restorations and comfortable speaking to doctors.

"It's a high-touch and personal experience," Schuck says of the Tag-Team Approach to implant cases. "Each plan is reviewed live with the doctor or sent via video recording, so you develop strong relationships with practices.

In addition, Bukuras says, “Doctors who want the end-to-end control over their implant’s workflow are finding success in the tag team approach. We are seeing a rise in GPs who see the value in placing their own implants in-practice. This is where the value is fully realized.”

Also, it might require educating doctors. Bukuras suggests helping practices up-level their understanding of digital implant workflows through education, easy-modes of digital communication, and hands-on support from experienced clinical professionals.

"Most labs aren't set up for that today," Bukuras says. "Dandy is.”

Turpin leveraged his relationships with the implant companies to get into the Tag Team Approach. His implant reps had relationships with surgeons that wanted to collaborate with labs, so the sales representative suggested Turpin while talking to the surgeon. Turpin's expertise regarding digital workflow for full arch cases has been popular with surgeons and restorative dentists alike.

"Everybody's all about doing these cases digitally and how technology helps reduce appointments," Turpin says. “My reps asked me if I know anyone who can do these cases digitally and I knew how, so that’s how I got into it. After that, I saw the huge need for the team approach on full-arch cases and decided to talk about it more with clients who were doing or were interested in starting to do these types of cases.”

In cases where the restorative doctor and a surgeon are involved, Vrhovac says the restorative doctor must be involved from the beginning whenever possible to ensure the lab has buy-in on the wax-up and the implant position. The restorative dentist signing off is essential because it takes the onus off the surgeon and lab and facilitates what Vrhovac describes as multi-disciplined treatment planning.

“You’re incorporating more than 1 aspect of the entire treatment; you’re incorporating the restorative, the lab, and the surgical,” Vrhovac says.

“When you are a lab focused on the pre-and post-surgical aspect of the case, dealing with both sides, we must keep it all in mind. That’s why we need to have all parties involved in the process from the beginning,” Grace explains. “It saves us a lot of work on the back end.”

Also, having everyone involved is essential to ensure that labs don’t take too much responsibility in the treatment planning. Vrhovac says that with their team that understands both the surgical and restorative process, they have to know where the line is between making a recommendation for the treatment planning and taking over the treatment planning. He explains that labs getting into treatment planning like this have to know where their job starts and stops, which can be difficult in these relationships.

“That’s where a lot of labs make a mistake. They take too much of the onus,” Vrhovac says.

“We are the bridge between the 2, but we don’t replace the restorative doctors,” Grace says. “It’s an ecosystem we are creating here of transferring records, communicating the outcome and challenges in the front-end stage all the way through to the end stage of restoring the case, keeping in mind the patient and restorative doctors’ expectations. So, our job as a lab is to create that ecosystem between the restorative doctor, surgeon, patient, and the lab and making sure there is a smooth, predictable transition from the surgical to the restorative phase of the case.”

“You have to allow the surgeon and the restorative doctor to make that call,” Vrhovac says. “Because, at the end of the day, it’s their plan.”

The Technology That Helps the Process, Too

Technology is critical when it comes to making the collaborative process easier for everyone. However, it is essential to understand the clinician's system before choosing which software to design the prosthetic. A study published in January 2022 that analyzed several software systems concluded that this information is essential because not every software supports every implant system.

All systems could import a virtual prosthetic setup.

All systems displayed 3D reconstructions or 2D cross-sections with different orientations that allow for virtual implant placement; users can mark the inferior alveolar nerve, allowing for the minimum distance between the nerve and the planned implant placement.

No system provides individual abutment design tools; therefore, stock abutments are the option for implant planning.

Two systems, DentalWings CoDiagnostiX™ and 3Shape's Implant Studio, provided a way for individual virtual prosthetic setups.

Four systems, Dentsply's Simplant Pro™, Swissmedia's Smop™, CoDiagnostiX and Implant Studio, provided a setup for standardized teeth.

NobelClinician™ works with conventional setups only.

A virtual articulator was only allowed by 3Shape's Implant Studio.

Software systems that had more than 50 implant systems in the library were CoDiagnostiX, Simplant Pro, and Implant Studio, and Smop had 33; Nobel Clinician had 4.

Increasing compatibility with universal import formats, like face scans or scanner-specific formats that include color information, would simplify using the systems.

to read the open-access study on prosthetic setup and virtual implant planning.

Using digital tools in the Tag Team Approach also enables precision-based surgery, which enhances the clinical performance of the restoration, Kanaglekar says, adding that ZimVie is always looking for ways to create better value for labs. However, it starts with adopting a Tag Team Approach to enable prosthetic-driven implant planning that leverages the precision of guided surgery. Building awareness about what is possible for collaboration using these tools is a significant part of this effort.

For example, ZimVie's RealGUIDE™ Software Suite offers an end-to-end solution for implant planning for the team. The cloud-based software and app also mean collaborators can access the case from any device without purchasing multiple licenses. Moreover, the software provides a free PLAN module that allows the dentist and specialist to use the design tools without investing in the lab's software. In addition, ZimVie also offers Implant Concierge™, an on-demand virtual Treatment Plan Coordinator™ that provides treatment planning and guided surgery solutions for labs that need to outsource the case because of inexperience or operational constraints.

"If they want to get into the game without having to invest money, but still maintain the relationships with their restorative dentist and surgeon, an easy way would be to leverage our service, Implant Concierge on the back end," Kanaglekar explains.

Schuck likes coDiagnostiX® 10 software for planning implant locations. Lab technicians can do the wax-ups of the finals in there and things on the restorative side. Schuck also likes 3Shape Dental System dental CAD design software for designing more significant finals, which facilitates efficiency in their workflow. For example, if Dandy is fabricating an overdenture or an all-on-X case, they can designthe restorative in 3Shape and then import that design into coDiagnostiX to plan the best implant locations.

"It involves tight coordination between different departments where the implant surgery team is working with the digital denture team to go back and forth then and work on the best possible final denture to plan the implant locations," Schuck says. "And the beauty of this system is we'll use the same denture design to fabricate the immediate denture. Then, the doctor gets a guide and the denture based on that exact same design, and they get it all in 1 package. So, it's a pretty attractive offering for doctors as well."

When the lab has all the clinical information, including the final restoration the doctor wants, this streamlines the workflow, and we can have a plan ready for review in a couple of days. Bukuras explains that the ability to transfer clinically significant information in an effortless experience for doctors is vital.

Using the CBCT from the consultation and the design mock up, Turpin uses Dentsply's Simplant ™ implant planning services and software to make a recommendation for implant placement. Then, he meets with the surgeon and restorative dentist in person or via video conference to review everything and get approval. The surgeon may make changes to the placement and has to sign off, then the file is sent to the surgeon to print.

"That way, everyone is together at the same time, and we are not having multiple meetings," Turpin explains. "We go through our design and plan, so the team knows what to expect on surgery day. This presentation is then given to the patient.”

"And" Turpin continues, laughing as he explains how he tells the team in these meetings, "I'll deliver on my end if everything's good."

“Having the right planning software is key in all of this, and many are out there. But having the right one that accommodates what you are trying to do is essential. For example, if you are planning single-tooth implants all day long, plenty of software can accommodate that, but if you’re trying to work in the full-arch arena, there are only 2, maybe 3, that will work for that,” Vrhovac says. “So, you have to look at your end goal and custom tailor the technology based on what you’re trying to achieve.”

In addition, the technology used to get patient records is essential. For example, the edentulism of the patient can dictate what records are needed preemptively to plan a case properly, Vrhovac says.

“It’s also good to be very versatile and have different types of software and equipment because many doctors coming into the space want suggestions of what to get for a scanner and software. They want to make sure that the lab they’re working with can accept it,” Grace says. “Of course, we have our preferences, and doctors have their preferences. We stay unbiased in all of that. But we do need to have the ability to accomplish anything no matter what they have. We have software we hardly use, but we keep it because we have the 1 office that just got into the space, and that’s what they have.”

In addition, Grace also uses an assortment of third-party software that facilitates the collaborative process. For example, they use Dropbox for file transfers, Calendly for appointment scheduling, and Zoom for video conferencing.

“These are all different aspects that help make that whole ecosystem work together that are sometimes overlooked,” Grace says, adding that the human element of a well-trained admin team is indispensable in these efforts also. “All of those things are essential to making it work, and they’re underestimated at times.”

1. Gowd MS, Shankar T, Ranjan R, Singh A. Prosthetic Consideration in Implant-supported Prosthesis: A Review of Literature. 

. 2017;7(Suppl 1):S1-S7. doi:10.4103/jispcd.JISPCD_149_17

 Digital implantology—a review of virtual planning software for guided implant surgery. Part II: Prosthetic setup and virtual implant planning. 

https://doi.org/10.1186/s12903-022-02057-w

Implant placement in available bone was the standard for planning in the past. But what happens to placement optimization when you add the desired prosthetic into consideration? Our experts say the answer is many great things.

Tag-Team Implant Planning: How to Work with Your Clients to Plan the Best Implant Restorations

Getting What You Need: What to Do If Your Practice Is Not Providing What You Need to Do Your Job. Image courtesy of kues1/stock.adobe.com. 


There are things that you want for your practice and things that you need to do your job. Some hygienists would argue that these are 2 ways of saying the same thing. However, your dental practice isn't always of the same mind.

So, which things do you need, how do you get them, and what do you do if you hit a brick wall? We found out from a few experts in the dental hygiene field.

Katrina Sanders, RDH, BSDH, M.Ed, RF, a practicing dental hygienist, dental hygiene educator, and international speaker, says hygienists' needs have changed since she began her career. The hygiene field has experienced a paradigm shift regarding how to treat patients and the technology used to do it.

For example, Sanders says hygienists examine more tethered oral tissues and screen for more pathologies in the mouth than before, as well as discussing sleep, airway, and TMJ complications. Also, aging patients require complete dentition maintenance as the older population lives longer and hangs on to all their teeth. Hygienists also have infection control and sterilization to consider. Furthermore, patients present with advanced disease from conditions that worsened from delayed treatment during the pandemic and now need care.

Hygienists are constantly adapting to those changes and demands, taking on additional duties while still handling the old ones, Sanders explains. Hygienists are catching up and seeing new layers of disease, new lesions, and new inflammation in their patients, trying to reframe the patient experience based on what they see. What they need is another set of hands.

Sanders has an assistant in her clinical practice that works alongside her, allowing her to deliver the standards of excellence expected from hygienists today. Her assistant is:

Preparing and auditing charts for future appointments, noting who needs imaging or advanced imaging

Taking medical histories and inputting them into the electronic health record (EHR)

Handling tasks like perio charting, intraoral and extraoral photos

Scribing clinical notes during the patient appointment

Managing patient correspondence for the hygienists

Retrieving equipment so Sanders doesn't have to change personal protective equipment (PPE)

Priming Sanders regarding patient care triggers, like queries regarding applying fluoride varnish or locally delivered antibiotics in specific areas of disease

Communicating with the dentist about initial findings or exams needed

"To provide that level of care needed by the community of patients, hygienists need an assistant," Sanders says.

A Safe and Supportive Working Environment

Speaker and presenter Caitlin Parsons, RDH, C-IAYT, wellness and ergonomic professional says hygienists need a safe working environment for practitioners and patients, from infection control protocols to the cords and equipment in the operatory, making their work safe physically, to feeling safe to express themselves regarding concerns about operations at the practice.

"If you don't feel safe to go to your doctor or manager and bring up challenges, then that practitioner is unhappy, doesn't feel supported, and probably can't do her job properly," Parsons says.

In addition, Parsons thinks good ergonomics and equipment are essential. For example, is there a protocol and budget at the practice for replacing equipment? She also feels that hygienists also need to feel there is a trusting relationship there, autonomy to do their job, and support from the practice stakeholders.

"That goes for everyone in the office," Parsons says. "The hygienists want to feel supported by the front office person, but also, it goes the other way."

Brandi Hooker Evans, RDH-ER, MHE, speaker and consultant with Stellar Outcomes, says hygienists need the courage to challenge the status quo before addressing any product, training, or adjunct they want for their practice. In addition, hygienists should feel confident about their performance in the past so they can plan for their future possibilities.

However, the future also requires good ergonomics. So, Hooker Evans thinks operatory equipment that keeps hygienists' bodies feeling good is essential, which includes magnified vision.

"A lot of hygienists still are not using loupes, and we know that can be huge," Hooker Evans says. "Even more so, the ergonomic loupes that have taken the world by storm where we don't have to lean our head forward is an incredible investment in our body."

However, investing in the future doesn't always mean buying something. Hooker Evans suggests hygienists alternate between seated and standing positions when delivering patient care. She thinks this free option is an excellent way to improve ergonomics and challenge the status quo of how they provide treatment.

"A third thing is to pick a new topic that applies to their patients. It doesn't have to be their teeth, but anything that has to do with their patients or their day at the dental office that is new and exciting that they can geek out on through the internet," Hooker Evans says. "Follow a new Instagram account about sleep apnea, take nutrition or a movement course, or learn about myofunctional therapy. One of the reasons we bet so burnt out is because we never expand our horizons."

Moreover, hygienists can help the patient take responsibility and accountability for their health. By giving patients the tools and changing the conversation, hygienists allow patients to diagnose their gum disease and own the behavior changes needed to treat it.

"Hygienists need the courage to empower their patients to be in charge of their own health," Hooker Evans says.

Tim Quirt, DDS, Senior Vice President of Clinical Operations at Heartland Dental focused on hygiene operations and development, says hygienists need work-life balance. The repetitive nature of clinical hygiene requires a good environment that supports work-life balance to be successful.

Also, viewing dental hygiene as a career and not a job is essential. Dr Quirt recommends plotting a path for career growth on the work side of that balance, so hygienists don't get bored doing the same procedures all the time.

"There are other ones out there that you should learn and should be a part of your developmental opportunities," Dr Quirt says.

These opportunities also require a robust hygienist-doctor partnership. Therefore, hygienists should find a doctor with whom their clinical philosophies mesh so that the doctor can support the hygienist in their career growth and work-life balance.

"Self-care is a big thing, too, because it's not going to be easy, and you will be doing it for quite a long time," Dr Quirt says.

Getting what you want or need requires some strategy. Sanders thinks the first step is recognizing an appropriate time to discuss getting things done, which isn't when the dentist just finished a complicated treatment.

In addition, she thinks having an ownership mindset is essential. The hygienist should research and present what they want and be prepared to defend why it is critical to the practice goals.

For example, suppose the hygienist is looking for a supportive hygiene assistant. In that case, they should be prepared to report the going rate, have a working start to the job description, and be able to clarify where the new assistant could help not only financially but also in elevating patient care.

"So, it should be things like, 'Doctor, I see that there are opportunities to do more perio. My hands are currently tied; I'm struggling to gather the correct assessments and educate patients in one sitting. But, with the use of an assistant, I believe I would have the ability to gather all of these pieces and educate the patient while empowering my assistant to get that person scheduled for treatment,'" Sanders says. "Then, the doctor, or practice owner, can see that the dental assistant becomes an extension of the hygiene team, helping to support the patients."

Parsons agrees that emotional asks are not as successful as good communication skills and research why this ask is necessary.

For example, Parsons describes herself as a people pleaser early in her career that didn't want to make waves at the practice. However, she couldn't express herself about not having what she needed, and she regretted how these frustrations ended up coming out later. Therefore, she learned to process emotions and discuss her concerns with the practice stakeholders conversationally.

Also, hygienists need to have realistic expectations about what the doctor provides. Parsons says that getting what they need might require hygienists to invest in themselves. Seeing that commitment to their career and the practice through self-investment could enhance the doctor-hygienist relationship, making the dentist more amenable to supporting the hygienists' requests.

"That collaboration allows for more freedom and less stress and confrontation," Parsons says.

In addition, Parsons thinks hygienists should research and connect with other professionals through networking groups or social media. By discovering how other hygienists manage their work environment, hygienists can advocate for themselves.

"It can feel lonely when we feel like we have no other options. But, often, there are other options that we don't think about," Parsons says. "Sometimes it's a matter of being patient and putting in the time for getting what you need. We build that trust and put in the work for them to do that for us."

For new hygienists, Dr Quirt says hygienists should know how they want to spend their clinical days and their practice philosophy. For example, is it working in a busy practice that emphasizes the prevention and treatment of periodontal disease or one that works with many kids? Or all of the above? Once hygienists know these details, finding a situation and physician that supports that philosophy of care is more straightforward.

By contrast, seasoned hygienists will want to build that physician-hygienist relationship and leverage that to get a work environment that meshes with the hygienist's philosophy. When hygienists know what stresses them out and what feels healthy, they can communicate that to the practice stakeholders.

"Especially now when it's an employee environment. You can shop around and make sure that the practice is a great fit for you," Dr Quirt says.

Hooker Evans says that hygienists first need to roll up their sleeves; none of this change is coming to your email inbox.

"When I want to change my life, my go-to step is to decide what it is I want and then, second, see if someone else has it. Then, if they do, I figure out how they got it," Hooker Evans says.

She also recommends combining the power of virtual and real-world communities. For example, use the web to find a book, blog, or article or search for an online community about your areas of interest. Also, visit with the team to find like-minded team members. When you have 3 or 4 people excited about something at the office, it gets momentum, Hooker Evans says.

"It snowballs if you allow your team to get on board with you, which is also how you're going to get it to come to fruition," Hooker Evans says.

When It Isn't Going to Happen, What's Next?

The demand for hygienists is still high after the pandemic. Dr Quirt says that hygienists are in an empowered situation right now, which isn't bad. If a practice is not meeting hygienists' needs, they can find one that does, Dr Quirt says.

"If it's not a fun office or not busy enough, or you don't feel like you are achieving the next level in your career, then it's time to consider a career move," Dr. Quirt says. "It might require finding something that's a better fit. It could be private practice, a small group, a dental support organization practice, or it could even be teaching and training. So, there's a lot out there. But, first, you've got to go back to your philosophy and determine what is making you unhappy with where you are right now."

Moreover, Dr Quirt thinks hygienists have more opportunities today than ever. There are more resources available and more types of practices to join. Hygienists could also consider getting their degrees and becoming a dentist.

There are things you want and need, and some would argue they are the same thing. So, we explore what to do if your practice is not providing what you need to do your job. 