The increasing sales and use of in-office computer-aided design/computer-aided manufacturing (CAD/CAM) imaging and milling devices in U.S. dental practices and the many continuing education courses being delivered on the subject are evidence that this concept is becoming more popular in the profession. Is in-office CAD/CAM significantly influencing dental patient care? Is it a practical financial concept for typical dental practices? In speaking with people throughout the country who have purchased CAD/CAM devices, I have found strong advocates of the concept, as well as those who are more pessimistic about its value in typical practices. However, I would say the overall feeling about it among practitioners is optimistic.
Two devices are available from manufacturers. Various versions of the CEREC device made by Sirona (Bensheim, Germany, and Charlotte, N.C.) have been used for more than 20 years. There are about 9,000 users in the United States and 23,000 users in offices around the world (R. MacLeod, director, Clinical CAD/CAM, Sirona, oral communication, August 2008). The E4D device made by D4D (Richardson, Texas) has been available since December 2007. Both CAD/CAM devices, with the direction of dentists and staff members, provide the ability to make images of tooth preparations and to mill restorations while the patient remains in the office. The accuracy of the concept and the acceptability of the restorations produced have been well-documented.1–6 I previously offered my own critique and optimism concerning the in-office CAD/CAM concept.7 Fabrication and seating of an indirect restoration in one appointment appears to be a characteristic of in-office CAD/CAM that is attractive to most patients.
As with most restorative dentistry practices, two types of practice models in which in-office CAD/CAM is used are identifiable, judging from comments I receive from continuing education instructors and practicing clinical advocates of in-office CAD/CAM. One practice model suggests treating only a few patients per clinical day, having a small number of staff members working in the office, and charging higher-than-average fees. The other practice model suggests treating many patients per practice day, having many staff members accomplishing expanded clinical functions (including CAD/CAM), and charging standard, moderate fees.
In this column, I state and examine my observations on the characteristics of dentists and dental practices in which in-office CAD/CAM is working successfully from both clinical and financial standpoints. I also make suggestions for dentists considering incorporating in-office CAD/CAM into their typical dental practices—practices with many patients per day that charge reasonable fees.
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NECESSARY PRODUCTION TO MEET OVERHEAD COSTS
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Dentists who use in-office CAD/CAM must be aware of the need to produce at least an identifiable, specific number of restorations per month to pay the approximately $2,000 lease payment for either of the devices currently available (B. Bodily, CEREC specialist, Patterson Dental, oral communication, July 7, 2008). The dentist can calculate the number of CAD/CAM restorations needed to be produced per month on the basis of the usual amount paid by the dental practice to dental laboratories for fabrication of crowns.
As an example, if a typical laboratory fee for a single porcelain-fused-to-metal crown is $150, the dentist must make about 14 restorations per month ($150 x 14 restorations = $2,100) to equal the monthly amount paid for the CAD/CAM device. Additional restorations made after that number involve only the cost of the ceramic or polymer block from which the restoration is milled and the few necessary supplies (estimated at about $25 per restoration) (B. Bodily, CEREC specialist, Patterson Dental, St. Paul, Minn., oral communication, July 7, 2008). Of course, if laboratory fees are higher than the example stated, fewer restorations would need to be made per month to make the lease payment worthwhile. The ongoing monthly charge for having the CAD/CAM device in a practice may or may not be a negative factor for dentists who are considering incorporating this concept into their practices, depending on the restorative activity of the practice, the enthusiasm of the dentist and staff members, and the frequency of use of the device.
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FEW-PATIENTS-PER-DAY/ HIGH-FEE PRACTICE MODEL
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This practice model is one often promoted in dental practice management continuing education courses—and one that some dentists aspire to develop. In my opinion, the primary negative characteristic of this model is that these practices serve only a few patients. If all dentists used this practice model, the dental profession would not be able to serve the needs of much of the public. This model provides a more slowly paced, more comfortable work environment than do multipatient, multioperatory practices. Usually, such practices have only a few staff members. Such dentists accomplish more of the clinical procedures compared with the workflow in practices in which multiple patients are seen at the same time. Because of the high fees charged in these practices, supporting an in-office CAD/CAM device may not be a challenge.
Continuing education speakers talking about CAD/ CAM often espouse this practice model, which may discourage typical dental practitioners from looking seriously at CAD/CAM for use in their offices, as not all communities can support a high-fee practice. This model is not the norm in U.S. dentistry, and in the remainder of this column, I will describe my views regarding how to incorporate in-office CAD/CAM into typical U.S. dental practice.
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MULTIPATIENT-PER-DAY/STANDARD-FEE MODEL—OR, THE TYPICAL U.S. PRACTICE MODEL
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Assuming that the dentist and staff members are convinced that they want to incorporate CAD/CAM into their practice, carrying out the following steps will allow them to integrate the system relatively easily into their practice, satisfying restorative needs in terms of both quality and quantity and meeting financial requirements as well.
Identify staff members interested in the concept.
Interested staff members become the main implementers of the CAD/CAM concept for a typical practice. They can be computer-competent dental hygienists, dental assistants or even business personnel who want to become skilled in CAD/CAM tasks. Without adequate delegation to staff members, the dentist must accomplish most of the CAD/CAM procedure, and the financial feasibility of CAD/CAM in a busy numerous-patients-per-day practice becomes questionable. If the dentist does not delegate tasks to staff members and will not or cannot change to the previously described few-patients-per-day practice model, CAD/ CAM may not be practical. Delegation of some of the CAD/CAM tasks appears to be mandatory for a typical practice.
Obtain training and education in CAD/CAM use.
Various continuing education programs are available in several locales for the CEREC system. Continuing education for the E4D system is available at the D4D education facility in Richardson, Texas.
Become competent in the necessary clinical and milling tasks.
These tasks are best learned by means of repetition. I suggest learning the clinical and milling tasks after practice hours or during practice times that do not interfere with the flow of patients in the practice’s typical revenue-producing schedule.
Implement the CAD/CAM procedures in the revenue-producing hours of the practice.
Any new procedure should be integrated into the practice at times of lower stress. In that way, if problems are encountered, the overall patient schedule is not influenced. One opportune time to use CAD/ CAM in treatment is at the end of the clinical day.
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MAKING CAD/CAM A ROUTINE PROCEDURE
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The following are my suggestions about delegating the various steps of the procedure to qualified, educated, motivated staff members, which will help the practice to best meet both the clinical and financial expectations of in-office CAD/CAM. I have surveyed numerous long-time users in typical dental practices and, on the basis of the results of these surveys, I make the following suggestions about the characteristics of the CAD/CAM appointment in typical dental practices.
Patient education.
Dentists, dental hygienists, dental assistants and business personnel should learn about the CAD/CAM concept adequately to allow them to educate patients about the desirability of in-office CAD/CAM dentistry.
Anesthetic delivery.
Dentists or dental hygienists deliver the local anesthetic. Dental hygienists’ legal ability to deliver local anesthetic is an advantage of having them involved with this procedure, thus sparing the dentist this task.
Tooth preparation.
The dentist makes the tooth preparations.
Imaging prepared teeth.
Opinions of users vary regarding the best person to perform this task. Some dentists prefer to do this task themselves; others delegate it.
Milling restorations.
Most dentists delegate the supervision of this procedure to staff members. It requires a few minutes or as long as 20 minutes, depending on the milling device used, the speed setting used and the size and complexity of the restoration.
Maintenance of the milling device.
This task should be delegated to staff members. Both of the available milling devices require only minimal maintenance, but it must be done on a routine basis to produce optimum restorative results.
Fitting restorations.
Opinions vary as to who should accomplish this task. Experienced staff members legally can carry it out, thus freeing the dentist to treat other patients. Both devices mill restorations for properly imaged tooth preparations that require only minimal adjusting in the mouth. Therefore, there is little clinical involvement before the restoration is seated.
Staining and glazing restorations.
Staff members can use staining ovens to place any necessary superficial stains and glazes on the restorations. This step is not mandatory for many restorations.
Cementing restorations.
In most areas, the dentist, by law, must accomplish this task.
Removal of excess cement and postoperative patient education.
This step may be performed by staff members.
Patient education and final instructions.
Most dentists prefer to conclude the appointment with some suggestions and instructions.
The described steps for making a one-appointment CAD/CAM restoration demonstrate that a significant portion of the procedure can be delegated to staff members. With careful delegation, the dentist is free to treat other patients while the assigned steps in the procedure are being accomplished by staff members, thus making the concept financially feasible in the context of charging standard moderate fees. The choice of staff members to whom the appropriate CAD/CAM procedures are delegated is extremely important. Those chosen must be responsible, self-starting, outgoing, organized people who know how to accomplish the respective tasks well and who have the public relations skills to educate patients regarding the value of the CAD/CAM concept.
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SUMMARY
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Research results have shown that the in-office CAD/CAM concept can produce restorations that are equal or superior to laboratory-made restorations.1–6 Some dentists have expressed concern about the financial feasibility of the concept in typical, multipatient-per-day, average-fee practices. In this article, I have described the steps that can be delegated to qualified, responsible staff members to make in-office CAD/CAM dentistry feasible in a typical restorative dentistry–oriented dental practice.
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NECESSARY PRODUCTION TO MEET...
FEW-PATIENTS-PER-DAY/ HIGH-FEE...
