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grand scheme of things, that single-unit crown is pretty basic.
That’s something we do every day.
PH: It’s pretty basic. And if you look at the most common
procedures a dentist performs, typically there are 10
to 12 procedures they’ll do 80 to 90 percent of the time.
Most of the time, those procedures are done one tooth
at a time. In these instances, working off a fee schedule
makes sense. Now, Mike, tell me this: If you were to do
two crowns, let’s say in the same quadrant, one right next
to the other – does doing two crowns take you twice as
long as doing that one crown?
MD: No, because I can anesthetize them both at the same
time, I can break contacts on both of them at the same time
with a bigger bur. Making the temporaries, they’re going to be
connected, so there’s just a little bit of bisacryl material.
PH: Take the impression at the same time. Take the bite
at the same time.
MD: That’s all going to be at the same time, as well, as opposed
to if they were in two separate quadrants. So, it’s not
twice as difficult – maybe 1.3 times more difficult.
PH: What if there were three crowns in the same quadrant?
Does the same apply?
MD: Yes, it would not take three times as much time to do
three crowns, but it would be slightly more difficult.
PH: It would be slightly more difficult. I think the fee
schedule, Mike, makes sense up to those 3 units per quadrant.
If my fee for a crown is $800 and I do two crowns,
it’s $800 times two. If I do three crowns, it’s $800 times
three. That makes perfect sense.
Now, let’s jump to complex-care dentistry, Mike. Let’s say
you’re doing 12 crowns. If you’re doing 12 crowns, chances
are real strong that you’re going to change the plane
of occlusion. If you’re doing 12 crowns, chances are really
good that you’re going to change the anterior guidance,
there may be vertical dimension involved, certainly changing
condylar position. Of the anterior guidance, vertical
dimension, plane of occlusion, condylar position, you’re
changing three or maybe even four of those variables.
MD: Whether you want to or not!
PH: Whether you intend to or not (laughter). Now,
let’s say you’re charging $800 per unit and you look at
your 12 units. How much sense does it make to take
your $800 per unit fee and multiply it by 12 for this kind
of complex-care case? How much more complexity is
there in the 12-unit case as opposed to 12 crowns done
one at a time?
MD: It’s huge! It’s a much bigger difference.
There is a much higher degree of difficulty in
pulling off that 12-unit case, not to have the
patient lisp afterward, be able to function
well with those teeth without breaking them
off in the anterior. There are a lot of factors
involved. But as a dentist, you would tend to
think: Well, if I did 12 single-unit crowns on
12 different people, that’s a lot of work! This
12-unit case is going to be great, I can do
it all on one person at one time. But it fails
to take into account all the systems that
you’re changing and the degree of difficulty
with successfully completing a big restorative
case like this.
PH: Sure, it’s not only the degree of difficulty
in terms of what you know to be true about
occlusion, but it’s also the degree of difficulty
relative to your planning. How much
planning, preoperative planning, are you to
do, Mike, for 2 units in the same quadrant?
How much planning do you do for a case
like this?
MD: None. You get them in the hygiene room
before they go home that day and prep it.
PH: You put them in the chair, you can see
the end result and you prep the case. Now,
let’s say you were going to prep me for 12
units and you were going to change those
four variables. How much planning would
you have to do? How much time would you
have to put into that case?
MD: Hopefully I’m going to put in a couple of
hours ahead of time and get some lab-fabricated
provisionals, which will add some expense, a
Diagnostic Wax-Up. The patient’s expectations
are going to be higher.
PH: You’ll be shooting photographs. You’re
going to be taking models. Your team’s going
to be pouring and mounting those models.
You’ll be talking to the lab. What if the
patient has gum issues or bone issues or
missing teeth and needs implants? Now you
have to get on the phone and call your specialist.
How much time does that take, you
playing phone tag back and forth? Sending
the models back and forth? So there’s a
huge additional component of time involved
in these cases that doesn’t appear on your
fee schedule. Know what’s not on our fee
schedule, Mike? We get all these ADA codes,
Interview with Dr. Paul Homoly27