In-House Milling & 3D Printing: Making the Right Call for Your Practice

You know, it's interesting when they were starting to push scanners many years ago before printers came out, they were saying, oh my God, get a scanner. You don't have to store your models. Now printers came out. I got models to store. I always think it's really funny. That's interesting. Listen, I think, and I could be wrong in this podcast, you know, in history will come to either put egg on my face or maybe I was right. I think 3D printers are going to be the way. once ceramics are predictably printed. And that is coming. Welcome to the Phil Klein Dental Podcast. In-office milling and 3D printing are cutting-edge technologies. Having them in the office can offer advantages like same-day dentistry, immediate delivery of night guards and appliances, and of course, the luxury of printing your own models and never using alginate again. But like any major investment, these tools come with their own set of questions. Is this the right time to spend the money? What kind of volume do I need to make this investment profitable? Are there any ongoing costs? And do I have the staff to manage these machines? Today, we'll be talking to our guest, Dr. Chris Pescatore. who will present his candid viewpoint on the pros and cons of these in-office technologies. Whether you're a tech-savvy early adopter or a cautious decision maker, my hope is that this episode gives you valuable insight into how in-office milling and 3D printing could impact your workflow, finances, and patient care. As I mentioned, our guest is Dr. Chris Pescatore, a general dentist who has been a pioneer in digital dentistry since the early 1990s. He maintains a full-time practice dedicated exclusively to aesthetic restorative dentistry in Danville, California. We'll be getting to our guest in a second, but first, silver diamine fluoride, SDF, is a game changer in carries management. offering clinicians more time to plan appropriate care while effectively desensitizing teeth and arresting caries. Centrix, a trusted leader in dental materials, offers SilverSense SDF, a cost-effective, fast, and easy-to-use solution. Its bactericidal silver particles stop caries' progression in its tracks and instantly eliminate hypersensitivity, providing a more comfortable experience for your patients. Unlike other SDF products, SilverSense SDF won't stain healthy tooth structure. Only the treated lesion darkens, which can later be restored to full form, function, and aesthetics. So it's time to elevate your caries treatment with Silversense SDF from Centrix. To learn more, visit centrixdental.com. Dr. Pascator, it's great to have you back on the show. Thank you for having me. It's always great to be on these podcasts with you. The feeling is mutual, and we're very happy to have you on the show. And I do recommend everybody who's listening, if you have time, log into VivaLearning.com and listen to or watch Dr. Pescatore’s webinar titled Utilizing Digital Dentistry in Today's Dental Practice. It is really a phenomenal presentation. I mean, it covers all aspects of digital dentistry. He talks about, through his 30 years of experience, what he's done with digital dentistry over the years, what works, what doesn't. how to incorporate it into the workflow, what the expectations are. And so if you're still analog or partly analog, and maybe you just have a scanner, there's certainly something to be learned from this webinar. And you can also find the other things that Dr. Pescatore has done with us on VivaLearning.com, like podcasts, episodes like this one. So for this episode, we're going to be talking about the dentist who's ready to make the leap into more digital workflow. They might have a scanner, but most of what they're doing is taking impressions with that scanner and then off to the lab. Now they're looking to expand into more in-office stuff like chair-side milling with CAD CAM and also possibly a 3D printer. What do you think should be kept top of mind when a dental practice is looking to make these purchases? The first thing I would say is... Is it financially feasible? And by saying that, I don't want it to sound condescending in any way because you can have a very successful practice to not have any of this stuff. I always say, make sure you can afford it. Make sure you have the volume. And you say, well, the volume for what? In-office CAD CAM or printer? Yeah, make sure you have the volume because some months I have had in-office CAD CAM for 20 years. There are some months I almost don't touch it because most of my cases are going to the lab. If you're that kind of person, I think it's getting to the point in the profession that this hybrid, like I have it and I use it every now and then, but I send cases to that. I think that's going to be weeded out because the cost and the upkeep of these systems, people think I buy this, I'm done. It's not a pop. It's not a pay one price. There are upgrade charges. There's warranties. There's service agreements. There's material costs. And then no one talks about this price. This price you pay. No one talks about who is doing it. If you have someone in your office doing it, that's like a lab technician. That's why I always laugh when someone says, well, my in-office CAD CAM crown cost me $35 because that's the block cost. Well, that's like saying, and the lab cost is $300. I saved, you know, a lot of money. Well, if the lab charged you only for porcelain, I guarantee it wouldn't be more than $35, probably less because they buy it in bulk. So you're not comparing apples and oranges. If you have someone in your office trained, if you have someone doing it, you've now taken them away from doing something else in your office. So you essentially have a lab technician in your office and you're paying them a wage. Are you paying them retirement? Are you paying their medical? All those things factor in. No one wants to talk about. It's kind of like you're not comparing the same things. Let me ask you this, though. When it comes to, I know a 3D printer is a lot less expensive than an in-office CAD CAM system. So we'll talk about each one of those separately. But so tell me the scenario where a practice finds these tools. Let's talk about CAD CAM. Let's start with that. Where the efficiency and basically the workflow, the whole system brings this efficiency to a level where they're... bringing much more money to their bottom line. And the patients are happier because they're getting their restorations sooner. They don't have to wait for the lab. Tell us a scenario where it does work, where this is something you absolutely should consider and start learning how to employ in your practice. Well, I think it's if you want to make it work, you will. kind of thing. You know, you have to have the volume. That's why I always tell people, if you're considering this stuff, okay, keep tabs on it for maybe three months. How many crowns are you really doing? How many night guards are you really doing? How many surgical guides are you doing? How many of this are you doing? And keep track because at three months, if you're seeing you're not doing the volume, well then, you know, it can't support itself. And why should you buy it? There are offices. I know the single visit, all this stuff. I see people going, oh my God, you know, my patient broke a tooth. I was able to get them in and they left with a crown in an hour and a half. That's way quicker than I can do it because I take my time a little bit more for sure. So, I mean, that's great, but you're not going to lose that patient if they broke their tooth and you temporized it. I mean, I get the selling points. Like I said, I've had it, but for, I'd say at least three quarters of the time I've had my in-office CAD CAM, well, half to three quarters, most of my patients still chose two visits. And why would they do that? They work better with their schedules. I can't give you that much time. I got to come back. Okay. You know, and people couldn't believe it. And I said, well, because we give my patients, I give my patients a choice. Now, in the last... Five, six years, I haven't given them that much of a choice. I have, but not. My office manager kind of, well, we can just do it in one. And so I've done more one visits when you don't give them a choice kind of thing. And that's fine. We can do it. But I think with all this stuff, you're just bringing, understand you're just bringing the laboratory in your office. What about the marketing of the one visit appointment? And I know you addressed that to some extent already. That seems that that would attract patients to the office and help with word of mouth. And you see that. I mean, we used to see it more. I don't see it as much, but for a period of time, it was like one visit crowns in this practice. Is that a good marketing tool? Maybe. I don't use it. I've never used it. I think I mentioned it on my website. Maybe that's a bad thing. Maybe I should be marketing it like crazy. But then again, I don't do any marketing. So marketing is all internal with patients. And just to clarify to our audience, we talked about Dr. Pescator's practice over the years and his real practice building foundation comes from word of mouth, not outward marketing. He doesn't do a lot of marketing outside of his patients doing the marketing for him, which has been very effective for him because he has a very successful practice. So, but anyway, getting back to the system. So we are talking about 3D printers and CAD CAM, but we're not talking about scanner. Now, the intraoral scanner, you don't have to justify that, right? On a volume practice. That's another ballgame. And we've covered that in a different podcast. This one is the... downstream technology from an intraoral scanner and a lot of dentists are saying what you're saying they're saying i'm not trying to discourage anybody from getting a 3d printer or a cad cam system but a lot of dentists are saying i don't want to be the lab but you know i i don't even want to design it some people take the scan design it and then send it out right right i mean and i don't want to either i have them So it's not like I, but I have them for my use and they work with me. I'll get into printing in a little bit. I don't have a dental printer. I have a different printer for a very specific reason. But, you know, here's the thing. Dentists, we all love gadgets. We love working with our hands. That's one of the reasons we became dentists. If you like doing this stuff or have it, you know, then get it. There's no. Get it. There's no one to tell you not to. But most people delegate. Right. Is it worth getting a 3D printer, though, in order to obviate the need for alginate? And you just print these models and they're very strong models. They last way longer than stone. Isn't that an advantage in itself? Just if you just did it for models? You know, it's interesting when they were starting to push scanners many years ago before printers came out. They were saying, oh, my God, get a scanner. You don't have to store your models. Now printers came out. I got models to store. I always think it's really funny. That's interesting. Listen, I love marketing, marketing, marketing. Yeah, I think, and I could be wrong in this podcast, you know, in history will come to either put egg on my face or maybe I was right. I think 3D printers are going to be the way. once ceramics are predictably printed. And that is coming. Ivoclar, as I know, working with Sprint, right? So I think the first product we'll see is a lithium disilicate print. They're probably working and fine tuning that. When you can print ceramic. That's when I'll invest probably in a 3D printer. I saw Sprint Ray, one dentist in particular, he has one printer just for models because it's like the best model printer and he uses his Sprint Ray for something else or whatever. You know, I would say, you know, printers are a lot. less costly, but there's also a difference in the material you're handling. The material is not a friendly material. It's a lot more, you know, I show in my video how long it takes to just process a night guard. It's not like it's people think if you think it's a push of a button and it's done, you're going to be really, really disappointed. It's the same with milling CAD cam. But if you're I would never get a printer for night guards. Like how many night guards are you really doing? And I could scan it and send it to a lab and get my hundred dollar night guard back and not even worry about all that stuff. I'd rather the lab. pay the upgrade for their equipment and all that stuff instead of me owning it. I think a lot of dentists might get into it, love it, but I think that shininess wears off. I know a lot of local dentists who've had the systems and I talk to them and they say, yeah, it's a potholder right now. It holds my plants because I got tired of using it. My staff didn't want to do it anymore. Yeah, you mentioned you have a 3D printer, but it's not a dental printer. So obviously what you're printing is not going in the mouth. What kind of printer do you have and what are you doing with that printer? I just print models. That's the only thing I needed to do. I print models and my digital wax ups. for me because I'll make a putty index for temporaries. But I have a very expensive printer. I bought it years ago. You can get it on Amazon, I think, for almost under $200 now. Now, I know people, there are people I've heard who, you know, were lecturing on 3D dental printers and they're like, you know, don't invest in a toy printer. I hate to tell them. I've been in labs where they're using these toy printers. So it's... It depends. If I was putting stuff in the mouth, I would go with a dental printer. I'd go with a Sprint Ray or something. We'll be getting back to our guest in a second. But first, are you looking for an air-driven handpiece that rivals the power and torque of electric? Well, I have good news. It's finally here. It's called the TMAC-Z and it's from NSK, a company we all know and trust as a world leader in dental handpieces. In addition to being lightweight and ergonomic, this revolutionary air-driven handpiece delivers unprecedented 44 watts of power, allowing it to cut through tough zirconia smoothly and quickly. In fact, the TMac-Z reduces overall cutting time by 30%. That means less chair time, reducing the burden on you and your patient. Take a test drive of the TMAX Z air-driven handpiece from NSK. For a free 10-day trial, go to nskdental.com and find your local rep to inquire. Experience the power and excitement of the TMAX Z series. I don't see the point in getting it for a night guard or bleach, whatever. Now, if you're doing clear aligners. and you're really going to do them, okay, now we're talking about you should invest in a serious dental printer. It all depends what you want to do. Yeah, I just did a podcast with someone who's a general dentist, but also highly trained in orthodontics, who does a lot of clear aligner work, and it all goes to Invisalign. Everything gets fabricated through Invisalign. And I asked her, she's big into 3D printing, but not at all interested in doing aligners in-house. And someone who does tons of them. She's not interested in doing aligners. She does aligners on patients before she does veneers Like you mentioned in a previous podcast, she wants to straighten those teeth out before she starts with her indirect restorations, which I think is a good idea, but not interested in doing it in-house, but she does rely on 3D printing. Yeah, I mean, just because she's using Invisalign, I would be with her. I wouldn't bring all that stuff in-house. I think that gets very tiresome. You got to remember, most practices are delegating this stuff like crazy. They're not touching it. Even the dentists aren't even doing the scans. And, you know, in my mind, okay, you have an in-office technician then. Right. You do. So do you think we're moving to a time in dentistry where there'll be some dental practices that have it all? They'll have the full CAD CAM system. They'll have the 3D printers. Everything will be done in-house as much as possible. And you'll always have that group, that busy volume practice, multiple, you know, eight dentists, 16 chairs, and that kind of thing. But for many of us who are practiced more like you do, who fits in a podcast in between patients like you're doing now, for those kinds of people, do you think that the scanner will become the de facto digital tool? And then once that scanner does its job, it's off to a lab that's fully equipped on the latest and the greatest stuff. Do you think that that's going to remain a big piece of it is what I'm asking? I do. I do. I, you know, like I'm not, I love the equipment. I love printers. I love CAD cam. I love, I love the equipment. I love the tools because I'm a, I'm a closet lab rat too. I mean, I think if I wasn't a dentist, I'd be a technician, but I love this stuff. But does it fit into a practice is the key. And making it fit into a practice carries other obstacles that you might not want long term. Because, again, buying this is a long term commitment. You know, in-office CAD CAM systems are going to cost you well over 100 grand. complete systems. You know, your 3D printer is going to cost you 20 to 25 grand, but then there's costs of the resin, there's maintenance costs. You have to add it to your overhead on a regular basis. Now people, I don't have a lab bill. Okay. But you are still paying. I don't know. If the savings is as significant as people lead it, because I don't think they're comparing apples and oranges. So how does a dentist figure out his return on investment? Should he get an accountant and say, here's my volume? What's your thought on that? Maybe an accountant should do it. I think that's why I say keep track of everything and talk to your account. If you're not talking to your accountant, then you don't know. But again, Dennis, we love gadgets. See, that's what I was just going to say. And I'm not trying to, you know, we're really trying to sell it here. And I'm saying that sarcastically. Listen to us having this conversation trying to sell dental technology. Yeah, we don't want to have these dental companies that are trying to sell this stuff. Put this podcast on their website. But what I'm saying is dentists typically get excited when a sales rep will walk into their office. and show them how they could create in two minutes a night guard, an occlusal guard, or a model where they can do a suck-down technique, can create a retainer, an orthodontic retainer, you know, whatever they want to do. But let me ask you this. If someone is dedicated to using a 3D printer for dentistry, not a toy printer, but one that they're actually using it for appliances that go in the mouth, how steep is the learning curve to get somebody that already works there? to be involved with that process of using it from the scanner to the printer? Well, I don't think it's that steep of a learning curve. They have made these tools and the software very, very friendly. And that's probably one of their ongoing future goals is to make it as simple as possible. They'd love to just be a push button thing. It'd be a great, but they are making it. more and more streamlined. And you got to tip your hat to them for that. They understand their audience and that they don't want to be computer programmers. So I think if you have someone inclined to want to learn and do this, I think it's a really good win-win for your office. As long as, again, you have the volume. But if you don't have the volume and you just want to bring it in to have that control, a friend of mine, he's a big CAD CAM guy, very well known. And a guy, he talks about reliance. You know, he's self-reliant in his practice. He does everything. He makes everything. And he wants that control. And, you know, amazing clinician, great guy and lecturer as well. And that's what he wants for his practice. Some people want that. Some people want a version of that. Some people don't want any. So that's the biggest thing of figuring out. That's why I say starting with a scanner and then figure out what you want to add if you need to, because you might find that that's all you want. Yeah, let me ask this. When you talk about volume, could you give us an idea of what volume you're talking about for, let's start with an in-office CAD CAM system. How many cases do you need to do a week to make it even something to consider to have in your practice, assuming you have the room? i remember back in the late 2000s when we were talking about throwing these numbers around you know how many i remember i don't know what 18 or 20 crowns a month was the thing being thrown around but that was like to break even And it's so funny. We'll invest in equipment and talk about breaking even. Any business person will be like, I want 100% return on my investment, not a one-to-one. What are you talking about? So it's kind of funny that how we view things, you know, it's kind of like a 3D printer. If you're not doing 10 night guards a week, easy. 10 a week. a week i mean you got to use this equipment to really benefit from it if you're not doing i mean and then because they have these especially with 3d printers because people have now they're talking about making shells for temporaries doing all this stuff i'm like that's nothing new in dentistry You know, labs have been making shells for you for years. Most people don't use them because we use a diagnostic wax up, take an index off of that and fill it with like a bisacryl, like Luxitemper Integrity, because it's cheaper, it's quicker, and temporaries are great. So you're going to have a 3D printer. You're going to use it for all this stuff. Your overhead and all your procedures just went up. And I always laugh that people talk about, you know, these shells and how much better they are. And I say, well, you know, it's all technique. So if you got really good at using Luxitemper integrity in a matrix, you wouldn't worry about shells. And shells to me are only good for full coverage. What about partial coverage? We do a lot of partial coverage mostly. As I said, we're not doing a great job here trying to sell the 3D printer or the CAD CAM. But let's assume a dentist is ready to purchase that 3D printer when they're shopping for it. What's going through their mind? Talk about compatibility as far as materials. Do they want a closed system, open system, software, scanner? What are the key things they should be aware of when shopping besides the price for a 3D printer? Well, that's a really great question because, you know, the CAD CAM systems have gotten more open now where you can get a scanner from a different company. You can get a mill from a different company. You can get a different software. You can do that. Printers, I don't think are there yet. You can use different software. But the printer themselves are just the printers. You know, they're not they were never really sold as systems. There's a lot of great printers out there. What I would suggest is if you're looking for one, look at the leaders in the market. Sure, there are some other ones, but look for support. Most of them, like I said, are really getting very user friendly. Look for the support. Look for, you know, how much they charge for their bottles of resin. Yeah. And a lot of the new ones are open source on the materials. I know a SIGA is, they have like 500 different kinds of resin that goes in these things. And they work with all different companies, Voco and GC. So you don't want to lock yourself into a printer. And I think DMG has Dentimax. They have a printer that accepts any material, even though they make the material. So I think that's important. It's a pro and con. I'll tell you, it's a pro and con right now, right now in the Wild West. I think it's a pro and con because there are closed systems out there, but they're very efficient. If you take like Dentsupply Sirona's closed system, they're omniprint. You know, you're getting a QR code scan so that, you know, the computer knows what resin's being used because different resins require different curing cycles and times and they're slightly different. I know just with my system, if I use a different resin, sometimes I have to adjust it. So you have to maybe be a little more in tune to changing those things. And then again, that's another thing you got to worry about. Yeah. Again, it's going back to the point, Dr. Pescatore, that the office is now becoming the lab. It really is. No, it is. There's no ifs, ands, and buts about it. You're bringing lab into your office. The question is, is it truly feasible? I don't want people to think because they don't have this equipment, they're not a good practice or practitioner. That's absolutely absurd. I think for the right person and the right practice and their use case, I think these things are very valuable. Like I said, I have them. They're valuable to me with how I use them. But it has to be valuable to you. Right. That's very important. So as we get to the latter part of this podcast episode, I do want to ask you this. Will 3D printing, in your opinion, replace milling? as the materials become more advanced? On the lab side, probably not. On the dental office side, maybe. Because I'll tell you, as soon as I can print a ceramic material, I'm buying one, no doubt. I'm not buying it for resin. So you already have a printer, but you're going to buy a dental printer. Yeah, I'll buy a dental because these kind of printers won't. I doubt we'll print the ceramic because I think they're going to have to change a lot of the particulars of the printer. So that's a game changer for you. If they could print ceramic. Absolutely. Why is that? Why? I think number one speed, the restorations, not that I'm built on speed, but it doesn't hurt. I think, and people talk about accuracy. I think that's kind of overused. I mean, I'm not getting anything inaccurate out of my mill. or from the lab but i just think it's because i love 3d printing when i can print a ceramic i'm going there and then you're done with milling you're done with milling uh yeah i probably will stop doing some milling because i don't i don't do zirconia in-house that might be a little different although i do know a dentist i met a while back maybe a year or so ago and he was actually printing some beta zirconia um from a different country yeah they do it in europe they're doing it yeah yeah they're doing zirconia right now i'd love to see it right it's not it's early stages of of i don't know what it looks like yeah i don't know what kind of what kind of zirconia it is Yeah. And that's the biggest drawback with whether you have milling or printing is you're not layering the ceramic. I know there's layered blocks, there's multi blocks and stuff like that. But really, it's nothing like something cut back and layered. But, you know, there's been improvements on that front. I start talking about that. One of the other things I think if you get a scanner, one of the things I would think about buying before maybe a printer or an office mill. would actually be an oven. Because if you get an oven and there's a kit called Mio 850 for Emacs, I can custom stain anything. So if it comes back from the lab and it's not quite right, this is an amazing kit. It's from Jensen Dental. I think they're actually back east. And anyone who knows about Mio 850 knows the power. It's a game changer. No cutback necessary. I can take a solid milled Emacs. and I can make it look like it was cut back because of the ceramic stains they have are just unbelievable. So I think to not send things back to the lab or maybe customize them in office, maybe an oven is something someone should think about because they're not very expensive at all. Again, you've got to evaluate your practice and what you're doing, where you want to go. I would just be – just check your numbers. It's real simple. Check your numbers. Before we wrap up this episode, Dr. Pescatore, share with us how you have a remote front desk person. Actually, my office manager is remote. We have a big monitor at the front desk and she's on it. I've been that way for almost two years now. How does your office manager? She can run the office remotely from where she is. Okay, but the interaction with the patient, she has no interaction. Oh, no. Walk in. She's on the big screen at the front desk. The way my office is set up, once you walk in the door, there's the front desk. There's some chairs and waiting room. There's the front desk. And she is on a big screen, life size. She's right there. And she can see them. They can see her. And she talks to them as much as when she's here. Okay. So is that special software that you have? Are you using Zoom or something like that? I'm using Zoom. And we have a D10 monitor. That's one of the Zoom. things they use it's a touch screen it's beautiful it's great it's um it has enabled my office manager to really she had a re she wanted to relocate for family reasons and she was such a great manager of the practice i didn't want to i'd have to hire two people to replace her unbelievable so she looked into this and we looked into it for a while and it's like i said it's pretty seamless she can do she can operate all the equipment uh, anything she needs to do. She can, she prints out treatment plans for patients when they come to the front desk. Um, and she talks to them. We have our credit card thing right there by the monitors. Everyone just swipes or if they get, have a check, they give it to me. Um, so it's, it's real straightforward. Yeah. There's a ways of doing things. Lots of ways of, uh, Skin in the cat, as they say. Yeah, incredible. All right, well, listen, it's all about efficiency. It's all about what you need. And it's not just the wow of saying, I just bought a new 3D printer or I now have CAD CAM in my office. Talk to your accountant, get a return on investment on it. And I'm talking to the audience, of course. Listen to people like Dr. Pescatore, who's been doing this for 35 years, and he's certainly gone through. iterations of uh different stages of his career where he's learned quite a bit and we're happy to have him share this with us Dr Pescatore. I'll let you get back to your veneer patient i think it's a veneer right you're doing yeah she's actually just walked through the door all right so yeah you got to go you got to go greet her now in the waiting room yeah okay we got to let you go all right Dr Pescatore it's been great and uh thank you very much for your time appreciate it oh thank you it's been a pleasure thank you again