Unlocking New Efficiencies with Same Day Dentistry

You're listening to the Phil Klein Dental Podcast. For those of us who are doing chairside milling, we have a lot more choices in materials than we did several years ago. In fact, there is now a CAD-CAM block that actually does not require sintering. So why is this significant? Because it shaves off as much as 25 minutes from the in -office manufacturing process. Today, we'll be talking to Dr. Jennifer Bell, who is all about high -quality dentistry with an emphasis on efficiency. She's big into digital dentistry and has had great success with her now favorite milling block. Today, she will be offering all sorts of recommendations that focus on efficient same-day dentistry, including 3D printing. Dr. Bell, it's a pleasure to have you on the show. Well, thanks for having me back. I have missed you quite a bit. Yeah, it's been a while. It's kind of scary how fast the years are turning by, but they are. And by the way, before I forget, you're doing some stuff online with some other fine dentists. Tell us about that real quick. Yeah, absolutely. It's a hump day happy hour that we do on Wednesdays. It's live called Dentist in the Know, where we commiserate together and talk about the latest things that are going on in dentistry. And it's so exciting to hear that KOL's key opinion leaders like yourself and really knowledgeable, experienced clinicians share their wealth of information with the dental community through these digital programs that are so accessible anywhere you are. It's just really good stuff. So we're going to be talking about some indirect dentistry today. And to begin, I just want to ask you, where are you seeing some of the biggest return on investments when leveraging same-day dentistry workflows? It's really the number of delegated procedures that you have embedded in those digital workflows for the indirect dentistry. You know, the actual chair time for most clinicians shouldn't exceed more than about 20 to 30 minutes. And then I can delegate a good number of those procedures out to my team members. If we couple that with really good technology and really good dental materials, we can make those appointments incredibly efficient. Patients love being able to come in and receive same day dentistry. And I particularly love not managing temporaries through a two or three week period of time where we have to keep the patient happy and healthy during that transition. It's been a big win. And you know, the other cool thing that's coming with that is how we're empowering our employees to take on bigger responsibilities. I mean, they really own that appointment, right? They're directing the doctor to do their productive procedures. But in general, the team member is owning it in a time where we're really struggling to find good quality team members, giving them opportunities for professional growth and development within the practice has been an additional win that we really didn't. anticipate at first. So just out of curiosity, Dr. Bell, and I've been hearing this many times on this podcast show from other KOLs, that they're having challenges with retention of good staff members, getting them into the office, getting them trained and up to speed, and then holding on to them. And it's getting more and more difficult. What do you attribute this to? Oh, that's a deep well to dive into. I think one on the hygiene side, we're just seeing not enough graduates coming out to replace the retirees and to enhance the increase in the number of dentists that we have hitting the marketplace. And we're up three to 5% year over year of new grads coming out into the marketplace. But we are losing hygienists. We lost a good chunk during COVID. But, you know, the statistic that I found alarming was the attrition rate in hygiene school now is around 25 to 30 percent. So they may accept 25 students, but only graduate 15 to 17. If on average every school has that type of attrition rate, we're not even replacing the marketplace for what we have currently doing hygiene. So that's the hygiene side. I think there's and their salaries, you know, in general, they can leave you tomorrow for a bigger pay. And so that's forcing doctors to. determine how to be competitive. On the assistant side, I think it's just making sure that you're providing them continued growth and opportunity within your practice and certainly pay benefits. All the other things that come along with being an employee are really important. A cohesive team where we're all working really well together. Culture definitely plays a big role in that, but also giving them more opportunities for growth. They get really excited when they get to learn new technology, new dental materials. see you do a new procedure, encourage you. Like, for instance, if I'm pursuing my AACD accreditation, they want to participate. They feel value in that journey with you. And then that comes along with pay raises as they learn these new skills and are showing growth and development. I am able to reward them on that journey as well. So, you know, if doctors aren't leveraging those opportunities, they're going to have a hard time keeping employees in the practice. But it's just an interesting world we're in right now. with staff. And it's so challenging to be a dentist because especially a dentist that's a practice owner who has to employ people, you have to understand the psychology behind hiring people and keeping them there and allowing them to grow professionally, cost of training. is very expensive. And once you get someone dialed in to what you want to do and then they leave, it's like, oh my God, you're heartbroken. And the efficiency of the practice really deteriorates when someone leaves that's very valued in the office. So we're talking about delegating duties. And this actually applies to any business, any company that expects to grow any business. The person who started the company can't expect to keep doing everything because they'll burn out and they'll be unhappy and the whole thing falls apart. So tell us about the delegated duties within. the indirect workflow. Same day dentistry we're talking about. How does an office become more productive by delegating some of these tasks to the staff? Yeah, well, as I mentioned before, with that particular procedure, your assisting team is taking care of seating the patient, you know, getting them prepped and ready for the treatment. You may come in and provide the anesthesia. And then they're going to do pre-scans, pre-impressions in case you have to do a temporary, talking to patient through the procedure, all the preoperative things we have to do for insurance filing. And then the doctor is going to come in and leverage their skill set, their defined skill set, the thing legally they have to do, which is to prepare the tooth for the final restoration. And so they'll do tooth reduction and then potentially tissue management as well, although a good portion of that can be delegated to your team. And then I can get up and leave the operatory at that point. And it is pretty common that I will either move to a new operatory to perform additional restorative procedures because I've now given the rest of the crown appointment over to my assisting team who will get the tissue prepared, take the final scan. They will give it to me for the margination and design, but then they're in the manufacturing phase from that point forward, keeping the patient comfortable until it's time for cementation. So, you know, I can be very productive. I either will come back to that existing patient and do additional restorative procedures on them while we're in manufacturing phase. Or I'm moving on to other patients and we're doing other procedures during that time. So we can be very efficient, which is already a pretty productive and profitable appointment for us because we've reduced the lab fee and a lot of the other additional costs that come along within direct dentistry. We've already leveraged those hard costs, but now we're leveraging both our staff productivity as well and making sure that everybody is optimizing what they legally are allowed to do. team does the scanning they're trained to use that intraoral scanner okay and what I hear from a lot of KOLs that I interview as far as the design uh part of it the software design a lot of them don't want to get involved with that so they they you know the dentist will just send it off to the lab and they have it designed there you you are designing yourself in-house? I am. There are some softwares now that really, they're using a lot of AI generation to give you pretty reasonable outlets very quickly and designs very quickly. So if I leverage the technology well, it doesn't take me more than about five to eight minutes to define my margin and allow the software to design a crown, particularly in the posterior. You know, in the anterior, it's still more of a digital. off to the laboratory to get those customizations, the high-level aesthetics that you're looking for. But in a posterior crown where you want something that's attractive, that fits well in the tooth, but we're not having to do a lot of customization and characterization, I can do most of those designs pretty quickly. But it's very dependent on the software that you use. whether or not that's going to be an arduous task or not. There are a few labs out there that are setting themselves up to be designers as well, and you could just do the scan, export it out quickly, and wait for that to come back. I think the interesting thing will be what 3D printing will mean for same-day dentistry, which is definitely moving in that direction as well. So as far as efficiency regarding chair time, when that patient gets scanned, Now they're done for the time being, right? They're waiting for what you call the manufacturing stage, which is the milling, the chair side milling. You did mention that you might go back to that patient. What happens if that patient doesn't need anything else? Do they just occupy that chair? They can. You could put them in the waiting room if you want, but we've kind of designed our business model around that where there's an overflow chair sort of always in the wings that we are manipulating patients around. So if we schedule them appropriately with like a two hour block. And now with some of the newer blocks, we don't even need that much time. But if we book in a two-hour block and then I can piggyback other restorative procedures adjacent to that, it's really not lost time because it's really my time. It's not the chair specifically. It's where can I be doing dentistry at any given moment? Right. So there's a lot of materials out there when it comes to chair-side dentistry. The blocks, I remember when... first started, there wasn't a lot to choose from. There was a couple of blocks out there. Now there are more. And I know we talked offline, Dr. Bell, about efficiency. You're all about efficiency. And that's part of what this podcast is focused on is how to get the best return on investment out of same-day dentistry. It's great for the patient, but it has to be great for the practice too. So what... you to the point where you felt confident about material selection using chairside milling. What was your journey there? How did you decide what to use and how did it bring the highest level of efficiency to your workflow? Well, I think you'd really have to go back to what happened around 2015 with the lithium desilicate blocks that came out that were able to be milled chairside. That was a real tipping point for a lot of doctors. They finally felt really confident. in the porcelain materials that were available to us, Chairside, not just to laboratories, that we could deliver a strong aesthetic and predictable restoration pretty routinely. Fast forward what we're seeing in the zirconia world as well. Those are all moving in the direction where doctors can be doing milling zirconia and lithium desolate pretty routinely as great work products for their practice. I will say... Most recently, I discovered this block from GC. It's called the Lissy block. And now we're seeing lithium disiligates that don't require additional firing time. So when you look at the manufacturing time of me stepping away from the operatory, you have to count the milling piece of that. But then you also have to count the centering time in the furnace. which can range anywhere from 20 to 25 minutes. If you're doing zirconia, it can be even longer than that. So if you can reduce that piece out of it, look how much more you've reduced your chair time. And you've not tied up an assistant in a manufacturing phase for 45 minutes. And are you getting the aesthetic results without the centering? Absolutely. They are very true to the Vita Shades. Again, if you're looking for highly customized, then you're probably sending to the lab. But if you've got true to Vita Shade and you can perform in that range, the Lissy blocks have been hitting it out of the park. Certainly better than most of the zirconia out there. So we've been really pleased with that. And I will tell you the margins for me was one of the real reasons why I went to try the Lissy, some of the data that I was seeing on it. look like it might be a good switch for us. And I've been really pleased thus far with how they're adapting to the margin, coming from the mill straight to, you know, a pre-op radiograph before a cement to make sure we've got a closed margin. And I'm incredibly happy. In fact, I have one case, you might like it or not, but you almost can't even see the crown on the tooth. Like it blended in that well. So we were happy with the outcome. So tell us, Dr. Bell, how did you come across this new material for same-day dentistry in your practice? what were you currently using at the time yeah i was using emacs before and i just had some issues with with marginal adaptation they looked great at delivery uh and then we were looking at them three four years out uh chair said and just were not happy and to the point that we started taking some of them off um because we were concerned that the margins were open so i was investigating some additional materials just to make sure we're staying current with what was on the market today and You know, if the centering or firing in our practice was what was contributing to any marginal adaptation issues over time, then I thought maybe if we could get away from the centering piece, we might get better margins. And I talked to some additional colleagues that had shared some some challenges. You know, they take the pre-op bite wing and the margin would look pretty dialed in. And then, you know. After cement, it didn't quite match up. So just trying to make sure that we're staying current. I don't like to redo my work, as you stress. I like efficiencies. I like to be maximizing my investments. So I want to see my work hold up and I have a high standard for how long I think it should be there. And so, you know, anytime you're your own worst critic, then you're going to go back to the drawing board to make sure using the thing that's best in your hands. And dentists can never underestimate. There can be a thousand really good products, but at the end of the day, what's working really well in your hands is the one that you should be using. I think it's really important on this topic is to mention to our audience that they should be open-minded about trying new products because a lot of companies, they come out with claims and they always want you to switch and buy their stuff. And if you're successful with what you're currently using, that's great. But you are a healthcare provider. And if you can get better results, even though you're very happy with what you're getting now, if the research shows that some of these products are designed to address challenges that come up time and time again, you should be open-minded. And I know I talked to a lot of KOLs. And they always say, you know, I've been using this cement for years. I didn't really want to switch, but I was an evaluator. They sent me the product and I went, wow, this actually does work. Or I know you, Dr. Bell, are probably one of the evaluators, right? For different companies where you give them feedback and say, This is great, except you need to, before you release this to the general population of dentists, fix this. And then you actually dial it in even closer. Yeah, we do that all the time. In fact, I am on the advisory board for Align. And so that's a big part of what that group does. We sit down and we discuss at length products that are coming to the market, whether it's aligners, scanners, you name it. and the different digital workflows within that. So to have the opportunity to sit down with top levels of that company to say, in our hands, these are going to be an issue and have you thought about it this way. And it's impactful to know that big companies that we think are disingenuous and don't have the pulse of the clinicians actually are building a pretty... robust architecture internally to make sure they have the pulse of the consumer. And I sit through midwinters like the KOL Mecca. You sit through one KOL session after another, evaluating products, giving feedback from the year of the things that you've been using. And I'm always floored at how open and raw those conversations can be and how willing the manufacturers are to listen. They really want to put good things in people's hands. They're not interested in just making a dollar. at the behest of everything failing once it gets into clinical practice. So that's been shown time and time again with companies like GC and Shofu and Align. All these companies that we have partnerships with are very invested in their doctors and their KOLs providing deep feedback so that they can continue to get better. And it's not only the actual chemistry of the materials, but also how the kits are packaged, the ease of use of the material, the organization of using the material so that there's efficiencies in the workflow. I mean, it doesn't seem that long ago when companies sold composite kits that just had countless shades in it. I mean, these kits could fill up a whole table. The whole box was just so large. And you just had a... to these key opinion leader courses to know how to layer these composites on to get the aesthetic look and feel that you were trying to achieve. And for most dentists, it was overwhelming and it wasn't practical. And I think the dental manufacturers picked that up. And before long, they reduced the number of shades in these kits. And now we have companies that sell single shade composite solutions that really, some of them are very effective and they look great. Sorry to ramble on about that, but it was just something that I found interesting how they went from one end to the other. And it shows that the companies have their finger on the pulse. Seems like a scar, like a deep scar. Yeah, it was just overwhelming, overwhelming. So what do you think the future holds for indirect same-day dentistry? And do bring in 3D printing too, if you would. Yeah. Yeah, no, I think, one, I think the materials on the milling side will continue to get more and more efficient. And it may be that at some point we can eliminate centering. Certainly on the ceramics side, I don't know yet what zirconia looks like, but certainly on the ceramics side, I think there's more and more of these resin hybrid ceramics that are working very well and have been approved for long-term use as a porcelain. crown, but also just, you know, obviously in the lithium desilicates and the other porcelains that we're currently using. But I think 3D printing is going to come in. You know, it's that, it's going to be that horse that you didn't see pulling out at the very end. And I've, I've said pretty routinely in the last few years, I think a young doctor coming out of dental school. In five years, we'll look at a scanner and a 3D printer and we'll be able to do all the same day dentistry that I'm currently doing now with milling machines and 3D printers. So the milling machines, as an owner, and I've had one now for almost 10 years, it is a very temperamental piece of equipment. It's very sensitive to you alternating between different materials. You made a great point. It requires a very dialed in team. who knows how to maintain that equipment very, very well. You have one bad apple in the group and it will shut that whole milling machine down. It's the thing we call service on more frequently than anything else in the office. I've had a 3D printer for five years. I've had one service call on it and it was very minor on the software side. So these appear to be workhorses that are dialed in and ready to go without a lot of temperamental. high level equipment that requires this constant maintenance. And the ceramic, resin embedded ceramics now, you know, Sprint Ray and Formlabs both are pushing in that market pretty hard to have a same day crown that you can print as fast as you can mill with the same strength qualities. When we hit that. There's no reason why a doctor would spend $80,000, $90,000 for a millimachine. And so in 3D printing, you're probably using that quite a bit for occlusal guards, temperization. You're at the point now where you couldn't live without a 3D printer, right? For some of these. Yeah, for sure. I mean, if for no other reason just to get alginate out of your office. I mean, I only use alginate now to take a pickup impression for a partial repair. Otherwise, there's not been an alginate impression in our office in years. Say that as a doctor who still uses PBS. You know, I have application for PBS in our practice quite routinely for removable or for margins and fixed restorative that just do not scan well. But I don't see any value in ever bringing alginate back into the practice except for those very minor cases. And so for me, the 3D printer was very inexpensive and for no other reason to get rid of alginate was totally worth it if you're just doing your own models and thermoforming your own stuff. Totally worth it. But yeah, then you can start to print your own custom trays, fixed appliances. Clear aligners are coming. I think that's going to be, there's definitely been some push on the Essex style printable materials. That'll be very disruptive. That'll be very, yeah. I mean, can you imagine? Very. Yeah. The cost is going to drop dramatically. For sure. Because now the only workaround is they can send you all the models and you do all the suck downs. Right. But once you can print it, that'll be huge. And the same with crowns. Once we can get the tipping point of being able to print crowns within, it has to be competitive. 20 to 25 minutes is probably the benchmark that it needs to hit. Then I think you'll see that uptick as well. And just think about the waste. It's additive. manufacturing as opposed to reductive right so when i take a block in there there i'm losing some amount of that material to manufacture that uh you're able to recapture a lot of your excess in the 3d printing space much more predictably and so you know you can even control your cost that much lower you know if an average model print is four dollars um then imagine how low you can get your print cost for a single unit ground yeah and the learning curve for 3d printing like you mentioned is not really that steep once the software is a whole lot simpler um it's not i wouldn't call it plug and play but it's not that far away from that on a recent podcast with dr susan mcmahon i remember her saying i'm no genius with software but i set my 3d printer up and it was like i don't know 30 minutes from the time i unpacked it it was thing was printing so she said if i could do it anybody can do it i bought it during 2020 as a covid project because i just like susan i thought I have no idea how this thing works. It's not intuitive to dentistry. So I'm a little concerned at this point that's going to take me a long time. And she's exactly right. Like fire it up. You do a little bit of tutorial on how it works. Now, if you want to get into fancy designs and stuff, you're going to have to either start looking at an Exocad or some of these design softwares or partner with a lab that can turn designs around really quickly, which. You know, there are 3D printing manufacturers now that have that service and can turn it around really fast. So if you can get a design back in five minutes, that's not much different than you using your own time to do the same thing. And I'm all about efficiency. So if I can give it to somebody, I can go do two hygiene checks. And in the time that I come back from the two hygiene checks, I have it ready to roll. Then, you know, I think that there's a place in dentistry for that for sure. So before we wrap up this podcast, Dr. Bell, and it's been very, very good. I wanted to ask you your opinion on or have you give your recommendations to our audience about staying up to speed on everything that's going on in dentistry because it's all moving so fast. And most of what you... an expert in, obviously you learned after you graduated dental school. And I saw your resume, your CV, you've gone to the finest continued education programs, Dr. Kois and Spear and so forth, really good stuff. So what do you recommend to them, our listeners, about purchasing the right equipment? buying things and integrating it into your practice that actually brings efficiency. We don't want dentists to buy things that they don't use. They sit on the shelf or they become doorstops and they're adding more debt to their practice. So just a few wise words based on your experience. Yeah, I think a couple of things. One, finding a continuum, whether it's Koi Spear or any of those. uh groups that kind of help you build a philosophy of practice a philosophy of clinical dentistry that sort of will help you start to build the pathway of what type of dentist you want to be and then then you start plugging playing those missing pieces for me it was leveraging investments in technology first that i knew that rois would be very quick to get so my first investment was a cbct because i could generate and come very fast on that If you're a young doc and every new patient needs a pan or a CBCT, depending on how you structure the practice, you're using that piece of equipment, whether you're capturing a pan or a CBCT. So that was easy, number one. Then the next would be a scanner because of the number of things that I can do with a scanner. Now being able to use it for a diagnostic tool to send out for, you know, removable, indirect, direct dentistry and leveraging that with Exocad Design. Getting the scanner unlocks up a whole portfolio of technology that you have access to. But I think you bring up a really valuable point. I definitely dove into the deep end and bought everything pretty close to one time, which was a pretty terrible idea. And if I could impart any piece of advice to get the maximum investment on any piece of equipment, buy it, learn it, educate yourself, take the courses, get trained, and then don't be afraid to apply it in clinical practice and have your patients walk that journey with you and say, We brought in this really cool new piece of technology. If you're okay, I'd really love to use it on you today and here's why. And let them be a part of that process so that they'll continue to encourage you on that journey. Once you master that or feel comfortable and you're at least making some money off of it and it's not a drain on the schedule, then start looking at your next investment. And the biggest myth out there is that Section 179 will keep you out of having to pay taxes forever. And all those mortgage payments come due all at the same time. that your Section 179 ends. And so now you're paying really giant mortgage payments on equipment that you thought would just be tax-free forever. So strategically implementing those things is really valuable for your mental health and for the success of your practice moving forward. Well said. Sharing some of the wonderful things you've learned through experience, huh? The hard way. Yeah, yeah. That's great, though. You're amazing, Dr. Bell. Thank you so much. I wish you the best of luck with your program online. You have incredible podcast equipment. I'm looking at it now. Our audience can't see it. But this woman is decked out with all the best stuff. The Shure SMB microphone and the Roadmaster. So she's got better equipment than me. And it's my show. So I'm so jealous. All right. Well, have a great evening. Thank you so much, Dr. Bell. We'll have you on again soon, I'm sure. Thank you so much. It was always a pleasure.