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Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Digital Esthetics. He is also the author of 18 technology books, including the award-winning Green IT: Reduce Your Information System's Environmental Impact While Adding to the Bottom Line. As such, he’s particularly interested in the technological side of dentistry.
Chairside dentistry has been touted as the next evolution in dentistry-and it’s whispered about among dental technicians as something to be feared. What’s the reality of this burgeoning technology?
From a purely technological perspective, chairside dentistry is, undoubtedly, an exciting new stage in CAD/CAM evolution. If you’re a tech geek who loves to learn about how digital tools are shifting dentistry, you’ve probably done more than your share of research into these powerful chairside tools. The technology is so new and exciting, however, that only a small percentage of dentists utilize it.
And even more dynamic is the fact that there doesn’t seem to be any hard and fast rules about what a doctor should do chairside and when that case should be sent to the lab.
But chairside dentistry is one of the biggest question marks for labs and dentists-if work can be done chairside, what will happen to dental labs? If dentists are doing their own restorative work, will patients be satisfied with their esthetics and fit? Can everything even be done chairside? And what are new technologies doing to this fledgling workflow?
Of course, a lot of it depends on the individual doctor and his or her comfort level, but what sorts of guidelines should doctors follow to get the best results?
Where we are now
There are no professional standards or guidelines for when doctors should send cases to the lab. It is mostly a judgment call on the restorative dentist’s part.
“I think there’s sort of a fuzziness and I think it’s a fairly recent fuzziness, because everything has gone so digital in the last five years or so,” says Dr. John Flucke, DDS, Dental Products Report Technology Editor. “It used to be all very straightforward and it had been done the same way for an extended period of time. There’s a lot more digital stuff going on both on the lab end of it and on the dental office end of it. But even if the dental office isn’t embracing the digital aspect of it, a lot of labs are, and a lot of doctors don’t realize they’re sending impressions to a lab and the lab is scanning those impressions and doing a lot of digital things on their end.”
Dr. Paresh Patel, DDS, an implant specialist at Implants by Paresh in Lake Norman, North Carolina, recognizes his limitations and sends cases to the lab when he knows he can’t achieve the esthetic look that he needs.
“Our rule of thumb is, if I don’t have, in my mind’s eye, a very clear picture of how to apply stains to make it look as esthetic as possible, or if it’s a high-value case, where I may want to have laboratory cut back and hand-layer porcelain over the top of the CAD-milled coping or frame, I’m definitely going to go to the laboratory for that,” he says. “And some of that is just that I don’t have the skill of the laboratory technician to get that done.”
Not all doctors have that self-awareness, and their results may have been better achieved had they used a lab.
“I have seen several lectures where dentists proudly show chairside restorations that are esthetically quite poor,” Bob Cohen, Executive Director, Product Development and Clinical Education at Custom Automated Prosthetics in Stoneham, Massachusetts, says. “I have also attended meetings where others show great-looking work. I would suggest that there are dentists in each group.”
Training and education are important determinants of how well chairside restorations are fabricated.
“With the right training and support, nearly anything is possible via in-office fabrication with CAD/CAM dentistry,” Adam Busch, CEREC Product Marketing Manager, says. “Certainly, there are many non-CAD/CAM users who think that it must be difficult to fabricate quality, long-lasting restorations chairside. It is not until they try a good system for themselves that the ease of use can be clearly seen and experienced.”
Chairside is a moving target and it is something clinicians should keep an eye on.
“It seems like new chairside technologies and materials are being developed every day,” Jason Atwood, CDT, Senior Digital Solutions Adviser, Core3dcentres, says. “Many manufacturers are trying to push the limits of what can be done chairside, coming out with more and more offerings for dentists to do in-house. The sales pitch is that in-house manufacturing is more cost effective, but that is debatable.”
Next: How is this evolving?
Level of involvement
What doctors are able to do really depends on how much time they want to spend crafting cases.
“This really depends on training, finances and desire,” Cohen observes. “Some dentists love the lab end, enjoy the CAD, CAM and milling and some quiet time away from patients. If they are properly trained and have the right equipment, the sky’s the limit. That said, the cost of CAD/CAM components associated with producing advanced inductions will likely not work well for a single practitioner from an ROI perspective. For those in this group, I would suggest it’s almost a hobby. Lastly, I think this group is a very small percentage of dentists. More prevalent is the dentist that has an assistant design, mill and polish a posterior restoration.”
Doctors must be cognizant of the fact, however, that the more work they perform in-house is money from their pockets as they have less opportunity to see patients.
“It’s absolutely all over the map,” Mark Ferguson, General Manager, Vulcan Custom Dental, says. “Every doctor is going to want to take on a different amount of work. You’re going to get some doctors who want to tinker or do more, which is fine, but ultimately the doctor is responsible for the case. If they want to do more, that’s great. Where it kind of ends up hurting the doctor is where they want to do more, but they’re taking time away from working with a patient in the chair. The biggest issue that doctors run into is not valuing their own time. They could be saving $100 or $200 from their lab bill by working on a crown, but rather than doing that, they could be paying $100 or $200 for the lab bill and making $300 by seeing another patient in the chair, so they’re not really coming out ahead there.”
The amount of time and effort a clinician wants to put into esthetic chairside restorations is another consideration.
“Esthetics is a gray area,” Atwood says. “What may be acceptable to one may be completely unacceptable to another. I have heard it compared to ordering a steak at a restaurant: What one person considers the perfect steak would be sent back to the kitchen by the next person. That being said, I believe that the tendency is to overestimate the time that it takes to achieve a high level of esthetics. In my observance, chairside restorations can look just as good as a lab restoration, if you are willing to spend the time to do so. Some doctors may be fine with what they are able to do chairside right out of the machines, but some will want to improve the esthetics. It really becomes a question of time spent.”
Being aware of abilities and limitations is key in understanding one’s role in chairside.
“Every manufacturer is going to tell you that this is easy to do, everybody can do this and I say it’s like any other skill that you want to learn,” Dr. Patel says. “If you put in the time and the effort, I think, yes, you could create a very esthetic, lifelike restoration that probably rivals a laboratory-created restoration. But if you’re just a casual user who bought into the system thinking, ‘Hey I’m going to do this, because all I have to do is take a scan and, somehow or another, the computer miraculously makes an auto proposal design that’s perfect every time,’ then I don’t think that’s reality.”
Next: What do labs and doctors need to do?
So what should doctors do?
While comfort level and ability are cited for some advanced chairside practitioners, there does seem to be a top end to what newer chairside doctors should take on.
“It’s a question of time and skill,” Tais Clausen, 3Shape CTO and co-founder, says. “You’ve got a doctor like Alan Jurim who can do everything himself because he’s also a very skilled technician and has an in-house lab. Then you have others using a chairside system that they bought five years ago-I would think they shouldn’t be doing any implant bar or bridge work. They should probably stick to simple crowns, inlays and onlays.”
“The most advanced work that you should do chairside really depends on your experience and the amount of continuing education that you have taken,” Dr. Erinne Kennedy, DMD and GPR resident at the VA hospital in Baltimore, adds. “I would probably limit myself to a three-unit bridge in the posterior. However, I would feel really comfortable with single-unit crowns and bridges.”
“For most, I would suggest posterior inlays, onlays and full crowns,” Cohen agrees. “The rest go to the lab. There is a much smaller percent that move comfortably into anterior restorations. Lastly, there is a group that never reaches a comfort zone with chairside and ultimately abandon the workflow all together.”
There are some who may have abandoned chairside in its early days. Dr. Flucke suggests that they might want to revisit that assessment if their interest is still there.
“A lot of offices saw what you can do with the technology and they thought, ‘That’s not something I want to do,’ because it wasn’t esthetic enough for them,” Dr. Flucke says. “But I think that’s changed a bunch and, unfortunately, I think it’s just human nature that when you’ve seen something before you didn’t like it, we kind of have a tendency to think, ‘Oh, I saw that before, I tried it, did it and it didn’t work for me.’ I think that people who probably saw it more than five years ago should probably look at it again. It has changed a great deal.”
And what should labs do?
On the lab end, esthetics and case complexity seem to be their perview. After all, they’re the experts on tooth morphology, shade and placement, and it’s not like that knowledge just disappears as soon as a computer gets involved.
“Anything in the esthetics zone,” Ferguson observes, “labs are generally better-equipped to handle those sorts of cases. But because this isn’t a clear-cut case, it’s still going to be a case where a single central may go better with a doctor’s chairside mill than it would if he sent it out to a lab, because he’s got the patient there if he wants to do a custom stain and glaze job. Just like there are good and bad lab technicians, there are doctors that are better and worse at chairside milling as well.”
Dr. Patel sends his anterior cases to his lab.
“I’m probably a premolar-back kind of guy,” Dr. Patel says. “Anything in the anterior zone would probably be better off going to a laboratory. A little asterisk has to go out there so we don’t irritate the hardcore user that says, ‘I can make an anterior crown just as well as the laboratory technician. The e.Max material that I’m going to mill out of is the same e.Max material at the lab is going to mill it out of.’ It goes to that doctor who really knows how to design the anatomy of a crown correctly. You’re not going to be able to design a crown chairside as easily as someone who does that all day long, if you haven’t gotten the additional training.”
Next: Is chairside a threat to labs?
Is chairside a threat to labs?
The elephant in the room is, of course, to what degree chairside threatens labs’ business. That is, every crown or bridge made chairside is money out of a lab’s pocket. While chairside currently accounts for a small amount of restorations, labs must still think ahead.
“Chairside is now in about 12 percent of restorative dental practices,” Cohen observes. “From what I have heard, this number will be very slow to grow. With the pricing pressure that has occurred in the lab business, the ROI is not as good as it once was for a dentist to make the chairside investment. On another note, I do see chairside scanning now growing very rapidly. All labs should become prepared to accept digital impressions and build and print 3D digital models.”
While it may seem like a menace to business, some see it as a challenge that should encourage labs to improve their services.
“A well-equipped lab with experienced technicians can help the doctor go through some of their stumbling blocks or make sure that they are positioned for more advanced cases that may not be offered on a chairside solution,” Ferguson says. “If I’m a lab and all I do is single-unit molars, then I’m obviously going to be far more threatened by a chairside mill than if that’s not all my lab does. [Labs] should look at advanced cosmetics or full-arch, screw-retained zirconia cases, or things like that. The labs have to define what they want to do with their business plan and they have to diversify. If you’re only doing one thing, you can be the best in the world at it, but if that one thing becomes easier to get somewhere else, then there’s a major threat.”
Kassandra Braun, Marketing Manager for Laboratory CAD/CAM and Prosthetics at Dentsply Sirona agrees, noting that it affords an opportunity for labs to offer higher-value restorations.
“Chairside milling does not pose a threat to laboratories that are open to digital technology,” she says. “Every year, we see fewer dental laboratories nationwide. At the same time, the number of restorations per year is increasing. The industry, as a whole, needs to produce more restorations with fewer technicians. If doctors begin milling crowns chairside, that leaves laboratories with the increasing number of complex restorations, which are more profitable. Laboratories simply need to position themselves to take into account the changing market.”
“I think labs should embrace this,” Dr. Patel adds. “It gives them what they want, which is that we are going to leverage what we have, which is the artistic ability of our technicians. I liken it to when rotary endo came to the market, and endodontists all freaked out that, ‘I’m not going to be doing endo anymore, because rotary endo is going to make every general dentist an endodontist.’ Certainly, rotary endo has helped [general dentists] do endo more successfully, but I would say endodontists are just as busy today as they were before, because we need skilled technicians just like we need skilled specialists to handle all the cases that we can’t do chairside.”
Other experts believe labs need not feel too threatened, simply because technology can only go so far.
“In the long-term, and by long-term I mean 10 years, maybe even longer than that, we may see a fewer number of labs than what we see today,” Dr. Flucke says. “But I think we’re definitely going to have labs. Because we’re always going to have situations where you want the human element involved, and there’s probably always going to be doctors that want the human element involved. I think you’re always going to have labs, you just may not have as many, because the people that really do enjoy doing the majority of everything themselves have those options now.”
“Chairside dentistry poses some threat to labs, but I still believe that there will always be a need for dental labs,” Dr. Kennedy adds. “Especially as more of the population is retaining their teeth, aging and requiring more restorative work.”
Next: What the future holds...
What the future of lab work looks like
Labs with doctors embracing or just considering chairside services are encouraged to be a resource for those clients.
“It’s not that the lab needs to be careful because the doctor is suddenly going to produce all of his or her restorations in-house and the lab will suddenly lose all of their business,” Braun says. “Many of our lab customers have found it beneficial for their doctors to have a chairside system because it opens up so many more possibilities for profitability. In most cases, doctors only want to do single posterior cases chairside, which are the cases that are least profitable for labs. Then these doctors have increased technological capabilities and begin to send more complex cases to labs. Also, it opens up the possibility for labs to do cases model-free or to offer a design service to these doctors.”
“The ability to have a true doctor/lab relationship is here today,” Busch adds. “This relationship starts with sending the case to the lab via a secure portal, then leads to a potential conversation via the software about the case. Users can add intraoral/extraoral 2D pictures to the case along with notes to the lab. If the lab has a question, a Skype conversation via the portal is possible before the patient even leaves the chair. Now imagine the lab owner is actually in the coffee shop reviewing the 3D model of this case on an iPhone app. When they return from the coffee break, they design the restoration for the dentist and send it back through the secure portal for milling and finishing by the doctor.”
And labs are still-and will be-the experts in restoration creation.
“Obviously, some doctors are going to want to make their own restorations, for single crowns, etc.,” Clausen says. “Chairside solutions have made this very easy. Labs need to remember that they are the experts when it comes to materials and design, so they should never burn any bridges when a doctor chooses chairside. They should be there for the dentist, always available as a consultant. And as I mentioned earlier, doctors might still opt to have the lab provide design services for them.
“Moreover, if a lab hasn’t already gone digital, then I would strongly advise them to do so immediately,” he continues. “Our research shows that 50 percent of doctors in the USA are considering an intraoral scanner. So doctors are going to scan and send digital files. Plus, nowadays, the costs for going digital are not as high as they once were.”
The important thing to remember is that as doctors add chairside, it is not the death knell for a lab.
“Don’t shut out the doctor,” Ferguson says. “If the doctor brings this stuff in, a lot of times they’ll gain more appreciation for what the lab actually does, if they don’t already know. A lab that says, ‘Oh you bought a chairside mill, I don’t want to work with you anymore,’ could actually lose a good account, because they jumped the gun. I’ve known labs whose doctor bought a chairside mill and the lab has grown, because they were the lab that helped that doctor integrate that chairside mill.”
Next: Advice for doctors...
Advice for doctors
For doctors, whether they are just considering chairside or are novice users, they are encouraged not take on more than they can handle.
“Start slow and start easy,” Dr. Flucke recommends. “Do things that you’re confident you can take care of. Sometimes, as human beings, we tend to learn how to do something-for instance, we learn how to snow ski and the next thing we want to do is, ‘I want to hit the black diamond slope.’ We learn something and we think, ‘Oh, I get this. I can do a really big case, or I can do this complicated shade matching,’ but I would tell people to start out slow. Do things that you know you can do, easy things, and that will build confidence and then you’ll be able to move on and learn more and take more training if you want and you just get better and better at it.”
Dr. Kennedy notes that it is important to know your equipment.
“Remember, if you are working chairside you are now the lab,” she says. “It’s your responsibility to know your machine, calibrate your machine regularly and know the materials. Keeping on top of this will help your workflow run smoothly.”
Time, as it is said, is money. Atwood warns against taking too much time to tinker with chairside, distracting from your real revenue generators.
“These systems are sold as being ‘convenient time savers,’” Atwood observes, “that can save them money by keeping it in-house. This is true! However, in my experience, the one thing that gets overlooked is how much of their time they have to invest in these systems. The manufacturers don’t discuss who in the office has to run the machines. Someone has to load the scans, load the materials, finish and polish, etc. This all takes time. If doctors wish to do this themselves, that is time that is taken away from seeing patients, which is a loss of money coming in. If they want staff to take care of this workflow, that is also time, and wages that they have to pay out to someone to do that for them-which is a loss of money going out. There is a balance to the workflow that needs to be seriously considered.”
Using the best materials is another important consideration.
“Learning about material options is the big step toward success in my opinion,” Busch says. “Choosing a system that has the most material options available is a good choice. Not only is this is an indicator of proven technology that can meet the requirements of the materials’ manufacturers, but [it is] also a playground for the user to experiment and choose clinically proven materials that feel right in their hands for a variety of clinical situations. If a material is not comfortable to you, try something else that achieves the desired clinical outcome.”
Building one’s business is, of course, important. However, Dr. Patel observes that chairside is something that should be undertaken only if the doctor has a real interest in it, and then the money will follow.
“I would encourage doctors to consider chairside milling not to make extra money, and not to save money, not to do anything except for creating a better patient experience,” he says. “If they’re willing to invest the time to learn that this is a new skill, and a new skill demands time from the doctor and staff, and if they’re willing to put forth that time, and put forth the dollars for proper training, then I think they’re going to achieve what they want to out of it. Otherwise, I think it’s just going to end up being a dust collector in the doctor’s office.”