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Understanding Offshore Lab Resurgence

Last month, a friend of mine told me his revenues were 30% over last year. He isn’t a technician and has almost no equipment. In fact, his 10 person sales force outnumbers his technical team, 10 to 1. His single technician only performs small corrections because my friend sends all cases offshore.

In the past 10 years, the number of dental labs has fallen more than 50%, lab fees have remained mostly flat or down, while the percentage of units sent offshore has continued to rise. Certainly, many are doing better this year due to lab attrition and the improved economy. But, why are some offshore labs outgrowing domestic labs?

Why the Revenue Shift

Dental technology has given every high production lab an edge, especially offshore, where dentists can find “Good enough” restorations for 30 – 50% cheaper fees.

Dental technicians are a part of healthcare, making “body parts” (medical devices) to help patients restore and maintain their health. However, unlike larger, more sophisticated “medical device” companies and their industries, unorganized, and generally unregulated dental laboratories are forced to compete with well-run, FDA and ISO certified offshore labs that produce lower cost “Good enough” from the same materials and equipment as domestic labs. Furthermore, when intra oral scanners gain larger market share, there’s a risk this disparity could increase.

Why it is Happening

There are four reasons why offshore labs are growing revenues 20 – 30%. First, digital technology and globalization has made offshore restorations more consistent and largely indistinguishable from domestic restorations.

The second reason is due to large dental office chains, DSOs. Their increasing numbers of locations and marketing are eroding private practice revenues in much the same way pharmacy chains have destroyed small pharmacies, and Home Depot has forced small hardware stores to close. Additionally, and unlike lab and dentist professional associations, the DSOs coordinate sophisticated marketing and political support through a highly effective national DSO organization, that unlike our organizations, is making strides with a laser-like focus on business. While some DSO offices work with domestic labs, much of their work goes offshore.

The third reason stems from insurance influence. Insurance companies own, control, and distribute up to 75% of dental patients, forcing 90% of dentists to join PPOs and agree to set fees at 1996-2002 levels. Insurance companies increase their profits by forcing a reduction in the number and value (fees) of clinical procedures, essentially controlling the flow [reduction] of revenue for the entire dental industry, including manufacturers and distributors. The combined effects of DSOs and insurance has helped lower annual dentist income to 1976 levels, and influenced their laboratory decisions.

With income pressures at an all-time high, it should not be surprising that more work is being sent offshore, especially if restorations are meeting the same or better standards at a lower cost. But there is a fourth reason that offers the most opportunity. To seize it, we must first get past Einstein’s definition of “insanity,” and stop continually doing the same things and expecting different results.

How to Fix It

Many would like to blame dental organizations, such as the American Dental Association (ADA) and the National Association of Dental Laboratories (NADL). While we can argue they have provided little help on the business side of things, especially compared to DSOs and insurance organizations, we need to consider that we are the ADA and the NADL, even if we aren’t members. Whatever they are or become, we either caused it or allowed it.

Einstein’s comments about insanity suggests that if we don’t like what is going on, we need to change. In contemplating change, there are three questions each of us must answer:

  1. What do I need to do?
  2. How will I do it?
  3. Will I do it?

We’ll begin to answer these questions in our next monthly article. Until then, please remember this: Improvements are the result of change. Without change, nothing will improve.

Nacera Ant Stained

Staining Zirconia and its Impact on Strength

Photo: Nacera Zirconia (Nacera.US), ceraMotion® (Dentaurum), by Carlo Paoletti, Odt

 

For dental purposes, the consistency of zirconia and its strength have made it a reliable and highly popular material for fixed prosthetics. Fortunately, we’re able to mask the high value nature of sintered zirconia with coloring liquids to make it more esthetic. However, some have begun to ask if the penetrating stains will weaken the structure of zirconia, and if so, how much and in which ways.

Background

It has been reported that stains for ceramics rely on a multitude of metal ions for colorations. Theil and Stephan explained the following color sources in a patent application: Iron (Fe) for brown, erbium (Er) for light violet, neodynium (Nd) for light pink, cerium (Ce) for cream or orange, terbium (Tb) only for light orange, manganese (Mn) for black, and praseodymium (Pr) for dark yellow. Unfortunately, coloring ions have the potential to become impurities in zirconia that can adversely affect its properties. Some studies have reported a decrease in flexural strength, while others have reported no effects. The different results on strength, however, might be due not on whether or not stain has been applied, but instead, its concentration, as reported by Sutter et al. An alternative type of esthetic stain, reported by Holand et al in 2012, avoids metal ions by adding metal oxides to zirconia powder prior to its pressing. Unfortunately, oxides have proven to be sometimes unreliable when used for darker shades, and can lead to surface pitting.

The Research

Testing conducted at Kagoshima and Aichi Gajuin Universities provided mixed answers to how coloring affects zirconia strength. Researchers at the Universities tested four zirconia brands: “P-NANOZR (ceria-stabilized TZP and alumina nanocomposite (30 vol.% alumina)) [20]. Cercon, ZENOSTAR, and Zirkonzahn Prettau are Y-TZPs.” Test samples were made by dipping the zirconia into “six kinds of coloring liquid for 30 min at room temperature and dried in air. The immersed plates were sintered for 2 h at 1350 ºC for Cercon, at 1450 ºC for P-NANOZR and ZENOSTAR, and at 1600 ºC for Zirkonzahn Prettau…Three-point flexural strengths were determined at a span length of 16 mm. Fracture toughness was determined by an indentation method in terms of Palmqvist cracks.”

Results

Test results showed flexural strength and fracture toughness were largely unaffected by the test stains, the only exception being stains with Er ions. There were no unusual differences in x-ray diffraction patterns “with and without coloring except those for Er,” which was associated with a phase change to cubic zirconia, while the other samples remained as tetragonal zirconia. For example, a SEM of ZENOSTAR stained with Er showed a shift to cubic on its surface. Also noticed was that “the concentrations of Er and Nd increased in the large grains and that of Zr decreased.” The investigators concluded that the surface structure of these particular samples were likely cubic, which does not undergo phase toughening in the presence of micro fractures.

The content of Fe2O3 and CoO ions in the sintered zirconia after firing was too small to be detected by x-ray diffraction. Only a small amount of these ions was required for the coloration of zirconia. According to analytical results of the coloring liquids’ baking powders, the three kinds of ivory liquid mainly consist of Fe ions and a small number of Cr ions, the two violet liquids mainly consist of Co ions and small amounts of Ca, Y, Mn, and P.

Discussion

The final results showed through X-ray diffraction that a phase shift to cubic structures was associated with stains containing Er. “The formation of the cubic phase resulted in a reduction of the flexural strength and fracture toughness. It is well known that cubic zirconia is weaker than tetragonal zirconia, because, as shown by Sutter et al, the stable cubic zirconia is impossible to be strengthened by the stress- induced transformation.”

According the scholars from Japan, “It is known that both Er and Nd act as stabilizers for cubic zirconia, creating a large strain in the crystal lattice due to their substitutions because the ionic radii,” facts substantiated by Katamura and his team in 1995. The findings indicate that stains “containing Er and/or Nd should be avoided. Furthermore, coloring with Fe and Co showed no remarkable property changes, indicating little reaction with zirconia and the formation of each oxide at grain boundaries. In other words, coloration with Fe and Co ions does not appear to affect the crystalline phase or mechanical properties of the final product, as previously found by Denry and Kelly.”

We question the results found in dental laboratories. What if zirconia is exposed to these coloring liquids for far less than 30 minutes? Regardless, there have been more reports of fractured cubic zirconia in the mouth than tetragonal zirconia. However, it is our believe that this problem is more related to mismanagement of the material than the type of coloring liquids.

dentist and lady

Marketing “Why My Practice” to Consumers

One of the biggest challenges facing dentists is how to set themselves apart from the competition. Every dentist has met graduating criteria, state licensing, and practice standards. To make matters worse, insurance companies continually market to consumers (who don’t understand quality dental care) that all dentists are the same. To counter the stereotype and attract patients, dentists need an “identifiable” purpose built around what patients really want, and make it their message.

 Identify Your Purpose

Purpose statements aren’t Mission Statements explaining an area of focus. In contrast, a Purpose Statement explains Why we exist, our personal motivation, but not our goals. Without an articulated Purpose, marketing inside and outside the practice lacks a distinct message.

An example of a purpose statement that connects the heart and the head comes from Greg Ellis, former CEO and managing director of REA Group, a leading online real estate ad agency: “…to make the property process simple, efficient, and stress free for people buying and selling a property.” Other examples include the financial company ING: “Empowering people to stay a step ahead in life and in business”, the insurance company, IAG: “To help people manage risk and recover from the hardship of unexpected loss”, and General Electric: “GE people worldwide are dedicated to turning imaginative ideas into leading products and services that help solve some of the world’s toughest problems.”

 

“An Extraordinary Business

Starts with Extraordinary People

Extraordinary People Start with Purpose”

Jesper Lowgren, business author

According to Simon Sinek, continuously sharing our Purpose with like-minded consumers, “Solidifies your brand with whom you share your values. When you share the core beliefs of your business with like-minded people, a natural connection is made. People whose beliefs are in line with your own automatically retain your business as part of their community.  More importantly, because your business feels right, these clients will become walking advocates, sharing your business with other like-minded people in their network. The result is a natural, self-sustaining growth of business. No matter how much technology has entered the marketing world, the most powerful form of advertising will forever be word-of-mouth.”

Putting your Why into Practice

Identifying a purpose that consumers are looking for is the first step to answering the question, “Why?” Extending it through your employees is next. For that to happen, we need employees who not only share our purpose, but execute on it daily: “We provide ‘X’ to more easily help our patients improve and maintain their dental health.”

  • Make sure you have the right employees
  • Have meetings to craft a Purpose Statement about Why your practice is important to patients
  • Collaborate on the best ways to deliver the experience your target market wants
  • Jointly set performance standards for executing your Purpose
  • Meet regularly to objectively assess performance measurements for the practice (you and your employees)

Once your office is clear on what your Purpose is and how to fulfill it, it is time to tell the world who you are and why they need to know. This is the kind of practice differential branding that resonates with those looking for what you offer. Make it stick.

Visit Simon Sinek’s exceptional You Tube video on the topic of “Why” we do what we do, which applies not only to outbound marketing, but also internally.

Molar 3-10-16 W-O B

Facts about Zirconia Degradation and Strength

Full contour zirconia, like the above, is increasingly replacing lithium disilicate as the restoration of choice, even in anteriors. However, according to many dental lab owners, zirconia preparation guidelines provided by manufacturers lost during clinical procedures can place even zirconia at risk of failure. How important is meeting reduction criteria and margin design? In some ways a lot, while in other ways, not as much. Even researchers don’t always agree.

Most often, margins with a chamfer or a rounded shoulder are suggested, with occlusal reduction of 1.5 mm and axial reduction of at least 1.0 mm. But what are the tolerances when we don’t meet these guidelines?

A study by Beuer et al on zirconia axial thickness of 0.4 mm, showed preparation design differences led to significant variations in fracture strength. Vult von Steyern reported that load to fracture for zirconia three unit bridges was much higher with shoulder margins than when a deep chamfer was used. According to some, the data is less clear for single unit monolithic zirconia crowns.

According to Kobayashi et al, “A limiting factor could be the aging of Y-TZP, due to its potential sensitivity to Low Temperature Degradation (LTD).”  When Y-TZP is subject to low temperature degradation (LTD) in the presence of water it undergoes a phase change from tetragonal to a weaker monoclinic structure. This can decrease strength and alter the surface.

A study was conducted to determine the combined effects of margin design and LTD. Three designs were tested with .8 mm occlusal clearance: a shoulderless margin for control was stored dry, a .4 mm chamfer underwent 5,000 TC and mechanically loaded (1,200,000 at 50N), and a .8 chamfer that experienced LTD from 3 hours of autoclave to simulate 10 years at body temperature.  Full zirconia crowns with identical contours and uniform 50 µm cement layer thickness were designed for each preparation.

All crowns were subjected to airborne-particle abrasion with 50 µm aluminum oxide using 0.4 MPa pressure, cleaned with steam and 70% alcohol, then cemented to metal dies with RMGI (KetacCem, 3M ESPE) under a static load of 50 N for 10 minutes.

Preparation form Control group Thermocycling 5-55, 5000 cycles, 60 s per cycle Chewing simulation Autoclave 137, 2 bar for 3 h Chewing simulation
Shoulderless 5712 (758) 5487 (310) 4799 (500)
Slight chamfer 4703 (787) 4613 (626) 4527 (596)
Chamfer 5090 (741) 5138 (328) 3414 (457)

For the above: Chart Link 

The results showed margin design and LTD affect flexural strength. However, although some research has indicated that .5 mm occlusal thickness is adequate, the amount of tooth reduction was substantially less than manufacturer recommendations of 1 mm axially and 1.5 mm occlusally. Minimal reduction can have a negative effect.

In the above study, the shoulderless margin showed highest fracture loads. However, this margin design has been reported to be detrimental to gingival health, since feather style margins always terminate at a point of zero reduction, making them over-contoured. It is advisable, based on the study, to use a small chamfer instead of a feather edge margin.

Not all zirconia is the same. Some have impurities, internal voids, or inconsistent compaction. The affects of LTD will depend on which full contour zirconia is used, prep design, and material management in the lab and chair side. LTD can cause functional wear, and/or lead to micro fractures that may or may not close. This can be especially problematic for weakened zirconia crowns placed in high occlusal stress areas that are made too thin or drilled/adjusted after sintering.

The best thing we can do for patients when using zirconia, is to make sure we follow manufacturer guidelines, refrain from using lower strength “anterior” products in posterior regions, and use smooth diamonds with copious water when adjusting zirconia surfaces.

cemented-vs-screw-retained-crowns

Limitations to Hybridized Implant Restorations

Dentists restoring implants always want successful outcomes. One area of constant concern is the potential for peri implantitis that occasionally leads to implant failure. To help avoid this, many dentists have migrated to screw retained crowns and bridges, eliminating possible complications from cement. However, screw retained crowns also present risks for future complications. The answer might be a blending of the two.

Implant related cement sepsis is a known cause for peri implantitis. However, Korsch found, in 2014, this to be more cement type related that previously thought.  Another complication for cemented abutment crowns is abutment screw loosening. Screw retained implant crowns eliminate complications from cement related risks. However, a problematic lightly cemented implant crown can be removed and repaired or temporarily replaced with an easily fashioned temporary crown holding its position. A problematic screw retained crown is far more difficult and expensive to repair or replace, and its space more complex and time consuming to temporize. This has led some to rely on hybridized screw retained crowns that are cemented and cleaned extra orally with a prefabricated, lab-placed screw access hole.

It is important to understand materials’ strengths and weaknesses before deciding upon a new application, such as a hybrid screw retained implant restoration. In the past, implant crowns have been primarily made from porcelain fused to metal (PFMs). In recent years, there has been a move away from PFMs to cleaner and more esthetic all-ceramic crowns made from lithium disilcate or zirconia. Some dentists have shown a preference for lithium disilicate in esthetically critical cases. However, little is known about the long-term performance of this material as an implant crown with a screw access hole.

Research by Biskri in 2013, noted the brittleness, low elasticity, and unidirectional crystals of lithium disilicate. But the material has also been widely reported to be more fatigue resistant than feldspathic porcelain. Despite its benefits over traditional porcelain, research by Dhima in 2014 showed far more predictable strength when lithium disilicate is at least 1.5 mm thick, occlusally.

Lassle, in his 2015 master’s thesis, described testing the viability of hybridized lithium disilicate screw retained crowns affixed to Nobel conical, 5.5 stock abutments with a 1.5 mm collar. The crowns were digitally designed, mandibular first pre molars, with 2 mm of occlusal thickness and axial walls ranging from .5 mm gingivally, to 1.5 mm near the occlusal table. Occlusal access holes were created in #1 prior to glazing in the “blue” state, #2 after glazing, both using copious amounts of water for cooling. The control had no access hole. The crowns were silanated and cemented with RelyX™ Unicem (3M Espe), and allowed to set 24 hours prior to testing. A control group followed the same protocol, but without an access hole.

 

Results

implant loosen stats

 

It is clear from the results that placement of a screw access hole in lithium disilicate leads to a significant decrease in load bearing strength. According to Lassle’s findings, lithium disilicate would be contraindicated for this purpose.

Despite our potential for bias in selecting screw retained, cemented, or hybridized screw retained, some researchers believe there is inconclusive evidence of clinical significance between them, as reported by Sherif in 2014. Cement retained implant crowns are less expensive, seat passively, and are easier to work with. Screw retained implant crowns eliminate possible cement related complications, and offer retrievability after screw loosening. A deciding factor for the third option should be the material to be used.

The research conducted by Lassle was revealing. However, we should keep in mind that people don’t chew with a constantly increasing pressure of .1 mm per minute against a 3 mm steal ball. Yes, lithium disilicate is definitely weekend by a central fossa hole, as evidenced by the early fractures along the central groove. But that doesn’t mean they will always fail, clinically. However, if we are looking for greatest certainty when using hybridized screw retained implant crowns, zirconia would be a surer bet, according to testing by Hussien et al, in 2016, showing zirconia to be over 3 times stronger than lithium disilicate.

purpose image

Marketing, “Why My Lab”

One of the biggest challenges facing laboratory owners is how to set themselves apart from the competition. Every laboratory has or has access to the same materials and digital technology. To make matters worse, digital technology has made most restorations “good enough” to the point they are often difficult to discern. This has dentists, under consistent fee pressures, asking, “Why pay more when ‘good enough’ costs less, and that is all insurance companies and patients are paying for?” Today, labs can either raise the bar on service & knowledge, or compete on lowest price and turnaround times. In either case, there is so much competition, that no matter the decision, the lab astute lab owner will go one step further and “identify” a business Purpose and its message.

Identify Your Purpose

Purpose statements aren’t Mission Statements explaining an area of focus.  Mission explains what we do and for whom, our Vision is about us, and our Principles speak to how we will conduct ourselves. In contrast, our Purpose Statement explains Why we exist, our personal motivation, not our goals. Without an articulated Purpose, marketing lacks a distinct message.

An example of a purpose statement comes from Greg Ellis, former CEO and managing director of REA Group, a leading online ad agency for real estate: “…to make the property process simple, efficient, and stress free for people buying and selling a property.” His outward focus connects with the heart and the head and emphasizes serving customers and their needs by putting employees in customers’ shoes. Other examples come from giant companies such as the financial company ING: “Empowering people to stay a step ahead in life and in business”, the insurance company, IAG: “To help people manage risk and recover from the hardship of unexpected loss”, and General Electric: GE people worldwide are dedicated to turning imaginative ideas into leading products and services that help solve some of the world’s toughest problems.”

An Extraordinary Business

Starts with Extraordinary People

Extraordinary People Start with Purpose

Jesper Lowgren, business author

The philosophy is simple: continuously share your Why (motivation) with interested, like-minded dentists. Doing so, “Solidifies your brand with whom you share your values. When you share the core beliefs of your business with like-minded people, a natural connection is made. People whose beliefs are in line with your own automatically retain your business as part of their community.  More importantly, because your business feels right, these clients will become walking advocates, sharing your business with other like-minded people in their network. The result is a natural, self-sustaining growth of business. No matter how much technology has entered the marketing world, the most powerful form of advertising will forever be word-of-mouth,” writes Sinek.

Putting your Why into Practice

Identifying a purpose that dentists are looking for is the first step. Having it felt by and extending through your employees is next. For that to happen, we need employees who not only share our purpose, but execute on it daily: “We offer X to help our customers take better care of their patients more profitably,” In considering that the job of a technician is to help their customers restore and maintain health, the Purpose Statement offered above is on target, but can be modified for your lab.

  • Make sure you have the right employees
  • Have meetings to craft a statement about why your lab is important to dentists and patients
  • Collaborate on the best ways to create what your target market wants
  • Jointly set performance standards on how well your Purpose is being executed and experienced
  • Meet regularly to objectively assess performance measurements and that of your employees

Once your lab is clear on what your Purpose is and how to fulfill it, it is time to tell the world who you are and why they need to know. This is the kind of branding that resonates with those looking for what you offer, and your differential. Make it stick.

A Great Video on “Why” 

Visit Simon Sinek’s exceptional You Tube video on the topic of “Why” we do what we do, which applies not only to business marketing, but also internally to employees.

https://www.ted.com/talks/simon_sinek_how_great_leaders_inspire_action?language=en#

boxing gloves

What’s happening to Dentistry, Why, and What to do about It

There was a time when people would say, “All you need to do is hang your shingle and you’ll have it made.” Nobody predicted today’s exorbitant cost of a dentist’s “shingle,” the smaller ROI it now brings and how industry changes would affect dental laboratories. The story of old has crumbled. We need to tell a new story to bridge the gap between that which is, and that which should be.

Facts: What is Happening

Finally, we have good news about the economy. All measurements are up, with durable goods and manufacturing beginning a small uptick. However, private practice dentists and dental labs are continuing to lose revenues to outside interests. Insurance companies and DSOs are forcing changes to benefit themselves at the expense of 90% of the dental industry and sometimes, the patients they serve.

Outsider influence has raised the cost of a dental education to as much as $400,000, while its value has in many cases, plummeted. Sky high debt and inadequate education has made entering private practice upon graduation, the life blood of domestic dental labs, largely impractical. Meanwhile, insurance companies are lowering the number of procedures performed and their reimbursements. This has caused average annual income for dentists to drop 22%, from 2009 to 2014, and currently sits at the 1995 income level. Many labs have been equally affected, or are not growing as much as they should.

The result from the above for most dental labs is, more units need to be produced to keep a level income. Thanks to digital technology, productivity has been easily increased. However, digital technology has also increased product consistency, making new client acquisition more difficult (less reasons to look for a new lab), and lab differentiation more often about cost than quality.

Facts: Why this is Happening

Dentists and their organizations have allowed these changes to occur, and in some cases, supported them. Outsiders see patients as the headwaters of the revenue stream, and the earnings they bring, low hanging fruit in a wide open, fragmented industry. Influencing the mass market in ways that individual dentists and lab owners can’t, consumers naturally form attitudes and beliefs shaped by outsider messages and brands.

Unfortunately, everything that happens to dentists is quickly felt by dental labs. A future challenge for dental labs is, as technology advances and becomes more productive, smaller labs may be priced out, and larger labs will find it more difficult to remain profitable as price wars become more aggressive.

Below is a link to typical DSO information being distributed. Individual dentists need to confront this  with an equally powerful, but more complete, rendition:

Wisconsin Dental Board Legislation

We are not opposed to DSO practice management services. Neither is state dental board oversight. Like us, state dental boards are interested in protecting patient welfare in all practice models, as they do now only in private practice settings, or, supposed to.

DSOs have the right to exist, but not the right to practice dentistry without a license. If they are not practicing dentistry without a license, why should they care about falling under state dental board regulation? 

Why is the DSO lobby opposed to that?

Why is no one in the public spotlight asking that question?

How is being regulated by state dental boards anti competitive?

 The Response: Take Action or Do Nothing

Trends from doing nothing are clear: the number of private practices is shrinking, and we don’t see fee increases as often as decreases. The question is, “What can we do?”

The obvious first step is to organize and take advantage of newly competitive opportunities. Individualistic thinking is increasingly placing lab owners of all sizes at risk. Lab owners who want to survive and thrive need to discard the artificial barriers that have long existed and begin working for the common good.

If you are a dentist, laboratory owner, distributor, or manufacturer, now is the time.  The same mass marketing tools being used against us could be working for us. Together, we can take advantage of everything the internet offers (including social media marketing), and add public relations, pressure legislators and regulatory agencies, and develop new business models in direct competition for market influence, including insurance.

To change the trend line, we need to pull together to educate and attract consumers as informed patients who clearly understand the value of traditional dental care. The good news is, consumers only want the truth, something traditional dentistry is in the best position to provide. More good news: Accomplishing this is easier than in the past. Research shows that consumers want genuine information they can trust. No patient deliberately chooses to be misled or mistreated, yet it happens daily to hundreds, perhaps thousands while the industry remains silent. Traditional care is a key marketing advantage, but only if we make it one.

“We believe big visions need big stories to match…We believe in the power of collaborative community, and the choices you can always make to change your story. We believe in messages that make people feel inspired and connected to something greater. We are truth-seekers teaching a new paradigm of story. Michael Margolis, CEO and founder, Get Storied

Great stories untold die in obscurity.

We have a great story to tell,

But only if we are willing to tell it.

 This is Our Story to Tell

Through professional marketing and a consumer website, OPT-In Dental Advantage is the only dental organization telling the story about the value of traditional dentistry. We employ professionals for website SEO, SEO support for our members’ web pages, bi monthly consumer blogs with SEO, and more recently, a national public relations campaign, managed by Braithwaite Communications, to brand the image of traditional dentistry and present our story to consumers, nationally.

We invite dental laboratory owners, dentists, and companies to join us in making the advantages of traditional dentistry known, and preferred. Please help our voices to be heard through stories consumers want and need to hear. Contact us today.

Please visit our website, OPT-In Companies, or call us at 855-321-OPTN (6786). It’s time to be a part of the solution.

IOS image

Intra Oral Scanners, How Good are They

Traditional impression materials have served dentists and their patients quite well for decades. Does it make sense to replace the goop with microchips? Is the new technology better? Will the added expense be more cost effective in managing the continued pressure on dental fees?

Manufacturers and distributors all believe intraoral scanners should be in every practice. Of course, that’s their job. But dentists who have adopted the technology are universally pleased, reporting better accuracy, faster seat times, and in some cases, lower lab fees. But, let’s be clear. Those are subjective opinions. Below are some of the facts about intra oral scanners and their advantages.

Accuracy

One way to measure the advantages is accuracy. Intraoral scanning is consistently better when it comes to accuracy than are impression materials. That is not because PVS and poly ether aren’t good materials. They are. It is because intraoral scans are more consistently accurate in quadrants by eliminating the variables inherent to traditional impressions. Using strict research protocol, good impression materials provide errors of about 35 microns. In contrast, Pradies et al, reported scan results in 2015, showing “an average error of 18 – 30 μm for a single tooth and less than 40 to 60 μm error measured over the restoration and neighboring teeth and pontic areas, up to 7 units.” They also found that for a 4 unit bridge, the length error was less than 100 microns. However, accuracy declines when scanning a full arch. Testing showed that mean error for a full arch was 100 – 140 μm, indicating a good measure of unreliability.

There are many intraoral scanners to choose from. Deciding on which one might be as simple as feel, newly updated advances, ease of use, or ancillary costs. However, based on research, accuracy shouldn’t be a differential in most cases. Researchers at the University of Ohio tested three intra-oral scanners, 3M LAVA True Definition, 3Shape Trios and Cadent iTero, found similar accuracy, and showed that “digital intra-oral scanner impressions can be used for fabricating accurate short-span screw retained implant supported fixed dental prosthesis with a misfit range of 12.40 to 90.20 m.”

Implant Applications

Dental implant restorative is a growth area for dentistry minimally impacted by dental insurance. Intraoral scanners have become increasingly useful for implant diagnosis as planning becomes more digitized. In Lee et al’s report from 2015, 36 patients had a single missing molar replaced with an implant. “Of the 36 patients, 6 required contact adjustments, 7 required occlusal adjustments, and 3 required a gingivectomy around the implant to completely seat the restoration. Chair time for adjustments did not exceed 15 minutes.” Clearly, IOS and accompanying implant related technology [in the lab setting] provide better accuracy than building cases on stone models, plaster mountings, and resin-based adjuncts.

Tracking and Managing Occlusion

Another, but rather unexplored advantage of intraoral scanning technology is tracking and managing patient occlusion. In 2014, Meireles et al, looked into occlusal wear tracking: “Eight extracted teeth were etched with acid for different times to produce wear and scanned with an intra-oral optical scanner. Computer vision algorithms were used for alignment and comparison among models…Results demonstrated that it is possible to directly detect sub millimeter differences in teeth surfaces with an automated method with results similar to those obtained by direct visual inspection.”

The ROI

One thing to keep in mind is, chair time is expensive. If IOS can cut chair time and the cost of traditional impression materials, the investment might be worthwhile. However, there is a balance to consider because not all situations easily lend themselves to the current state of the art. Some clinicians have acquired lasers to help control the challenges gingival tissue presents.

As with all things, when considering an intra oral scanner, we need to avoid biases, do our homework, and keep an open mind.

ceramir kit

A new Cement Perfect for Zirconia and More

Ceramir Crown & Bridge (Doxa) is a new, unique category of permanent cement that might be the best suited cement available for zirconia. Additionally, it has been shown to chemically form hydroxy apatite on the surface of tooth structure, integrating the cement to the tooth, photo below, hence the description, “bioactive.”

ceramir dentin integration

What is Ceramir C&B?

Ceramir C&B is a hybrid composition of Calcium Aluminate and glass ionomer, that when combined with its liquid, undergoes an acid-base reaction similar to hydraulic cements.

The incorporation of the Calcium Aluminate gives it several unique properties that separate it from conventional GIC’s. After 3-4 hours of setting time, Ceramir C&B changes its pH from a very mild acid to a base of pH of ~ 8.5. Mild, lasting alkalinity allows continuous formation of apatite when adjacent to phosphate containing solutions of dentin. Additionally, the alkalinity of its dense matrix fixes the glass ionomer structure to help prevent the ionomer glass from continuously leaking over time. Below, we see hardened hydroxy apatite in the surface of the cement.

ceramir 50 micron cbs

Alkalinity also helps with pulpal compatibility. Histological data shows that even at a minimum distance from the pulp, there is virtually no irritation resulting in inflammation.

Ceramir C&B relies on the mode of hydration by its key component, Calcium Aluminate, and the ionic bond of the GIC to bond to the tooth. That means, etching enamel or dentin and using a bonding agent isn’t needed. Moreover, its hydrophilic nature makes the material insensitive to oral fluids, while its alkalinity helps prevent bacterial growth and sensitivity.

According to Johanna Engstrand, et al, Ceramir C&B’s properties are unique. “Zinc phosphates are too acidic and do not contribute with Ca ions. Resin-based materials are not alkaline, and do not show extended ion leakage. Glass ionomers have an ion leakage but are acidic and cannot induce HA formation on its surface.”

Published by the American Ceramic Society, 2010

Author, Hermansonn, et al

“Ceramir C&B has a 2 minute working time, and a setting time of 4-5 minutes. Its film thickness is 15 microns. Its compressive strength at 24 hours is 160 MPa, similar to many resin-based cements, such as Rely x Unicem (157 MPa) but far greater than Rely x Luting’s (96 MPa). However, after one month, the bioactive nature of Ceramir C&B boosts its compressive strength to 200 MPa.”

Unlike RMGIs that expand as much as 4% and then contract, and resin cements that shrink as much as 4% then expand. Ceramir net change is essentially zero: “Expansion of Ceramir C&B is at most, 0.4%, and is due to the free growth of hydrated crystals associated with the formation of apatite. However, bulk expansion, measured as expansion pressure was recorded to be zero.”

Bacteria Resistant and virtually no Microleakage

Ceramir C&B is the only cement with the necessary components to form HA. Zinc phosphates are too acidic and have no free Ca ions. Resins aren’t alkaline and don’t provide ion leakage to the extent required to form HA. RMGI ion leakage is acidic and therefore, can’t initiate HA formation on dentin.

One advantage of Ceramir alkalinity is its antibacterial properties. Secondary caries caused by a wide variety of bacteria is a major concern for all. Jiang, in 2011, conducted a resazurin test on Rely x™ Unicem, Ketac™ Cem Aplicap™ (RMGI), Harvard zinc phosphate, and Ceramir® C&B cements for their antibacterial (S. mutans) properties. After different time periods, up to 10 days, Ceramir C&B with its calcium aluminate showed the strongest antibacterial properties, while the RMGI showed none. The other cements have only slight antibacterial properties. The strong showing of Ceramir is due to its initial pH 5.4 ending at pH 8.5.

Another important attribute of Ceramir C&B cement is a lack of microleakage. Because the process of forming HA creates a nearly insoluble barrier intimately integrated with dentin, Ceramir cement was reported in 2015 by Jefferies, et al, to have only minimal microleakage, and far less than the tested GI and RMGI: “There was no evidence of marginal gap occlusion for the three conventional control cements, whereas both bioactive, surface apatite-forming cements demonstrated occlusion of the artificial marginal gaps.”

Ceramir margins alone

The photos, left, described by Jefferies:

“Artificial margin gaps at 8 months of incubation in phosphate buffered saline: upper left photomicrograph is Fuji I (glass ionomer material), ∼110 μm gap; upper right is Rely X Luting Cement (resin-modified glass ionomer), ∼80–100 μm gap; lower left ProRoot MTA (calcium silicate/Portland cement-like hydraulic cement), ∼100 μm gap; and lower right Ceramir Crown & Bridge (calcium aluminate/glass ionomer cement), ∼300 μm gap. Cement material is positioned above the gap space, whereas dentin segment is below the artificial gap.”

What’s happening to Dentistry, Why, and What to do about It

There was a time when people would say, “All you need to do is hang your shingle, and you’ll have it made.” Nobody predicted today’s exorbitant cost of a dentist’s “shingle” and the smaller ROI it now brings. The story of old has crumbled, and as the Brazilian lyricist and author, Paulo Coelho suggests, we need to tell a new story to bridge the gap between that which is, and that which should be.

 Facts: What is Happening

Private practice dentists, and those supporting them, are losing revenues. Outside interests, mainly insurance companies and DSOs (dental service organizations), are forcing changes to benefit themselves at the expense of the other 90% of the dental industry and sometimes, the patients they serve.

Outsider influence has raised the cost of a dental education to as much as $400,000, while its value has in many cases, plummeted. Sky high debt and inadequate education has made entering private practice upon graduation, largely impractical, and supports the growth of DSO practice models. Meanwhile, insurance companies are lowering the number of procedures performed and their reimbursements. This has caused average annual income for dentists to drop 22%, from 2009 to 2014, currently sitting at the 1995 income level. This has caused each private practice to lose annual revenues in excess of $100,000. If that amount were invested each year for 15 years, a 45 year old dentist would earn about $30,000 per month at retirement (5% annual growth, before taxes).

Facts: Why this is Happening

Dentists and their organizations have allowed these changes to occur, and in some cases, supported them. Good clinicians see patients as people who need care. Outsiders see them as the headwaters of the revenue stream, and the earnings they bring as low hanging fruit in a fragmented industry with no barriers. Influencing the mass market in ways that individual dentists can’t, consumers naturally form attitudes and beliefs shaped by outsider messages and brands.

Below is a link to typical DSO information being distributed. Individual dentists need to confront this  with an equally powerful, but more complete, rendition:

Wisconsin Dental Board Legislation

We are not opposed to DSO practice management services. Neither is state dental board oversight. Like us, state dental boards are interested in protecting patient welfare in all practice models, as they do now only in private practice settings, or, supposed to. The linked article provides no proof to support assertions that DSOs routinely save patients money over private practices. Further, complaints filed  by several state attorneys general would assert otherwise. Unfortunately, nobody is calling this out, publicly. We intend to on the grounds that patients deserve protection in all practice settings.

DSOs have the right to exist, but not the right to practice dentistry without a license. If they are not practicing dentistry without a license, why should they care about falling under state dental board regulation? 

Why is the DSO lobby opposed to that?

Why is no one in the public spotlight asking that question?

How is being regulated by state dental boards anti competitive?

 The Response: Take Action or Do Nothing

Trends from doing nothing are clear, and personal losses (above) astronomical. The question is, “What can we do?” The obvious first step is to organize. Only when organized will newly competitive opportunities surface.

If you are a dentist, laboratory owner, distributor, or manufacturer, now is the time to get busy.  The same mass marketing tools being used against us could be working for us. Together, we can take advantage of everything the internet offers (including social media marketing), and add public relations, pressure legislators and regulatory agencies, and develop new business models in direct competition for market influence, including insurance.

To change the trend line, we need to pull in one direction, for one purpose: Educate and attract consumers as informed patients. The good news is, consumers only want the truth, something traditional care is in the best position to provide. More good news: Accomplishing this is easier than in the past. Research shows that consumers want genuine information they can trust. No patient deliberately chooses to be misled or mistreated, yet it happens daily to hundreds, perhaps thousands while the industry remains silent. Ethical care is a key marketing advantage, but only if we make it one.

Great stories untold die in obscurity.

We have a great story to tell,

But only if we are willing to tell it.

 

“We believe big visions need big stories to match…We believe in the power of collaborative community, and the choices you can always make to change your story. We believe in messages that make people feel inspired and connected to something greater. We are truth-seekers teaching a new paradigm of story.Michael Margolis, CEO and founder, Get Storied

 This is Our Story to Tell

Through professional marketing and a consumer website, OPT-In Dental Advantage is the only dental organization telling the story about the value of traditional dental care and the dentists who provide it. We employ professionals for website SEO, SEO support for our members’ web pages, bi monthly consumer blogs with SEO, and more recently, a national public relations campaign, managed by Braithwaite Communications, to brand the image of traditional dental care and present our story to consumers, nationally.

We invite dental professionals and companies to join us in making the advantages of traditional dental care known, and preferred. Please help our voices to be heard through stories consumers want and need to hear. Contact us today.

Please visit our website, OPT-In Companies, or call us at 855-321-OPTN (6786). It’s time to be a part of the solution.