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ut you know what there’s not an ADA code for? Wisdom. We don’t charge patients for our wisdom. On the flight from Charlotte to Orange County, I was reading the recent AACD journal accreditation cases. What magnificent dentistry is being done within that organization. I just love looking at those cases. But what I’d be really curious to find out is, how much profit are they generating? I wonder how much profit there is considering the amount of time they’re spending on incisal edge matrixes and reduction guides and customized incisal guide tables and custom shading. MD: And that’s one of my pet peeves in journals, as well. They will show a direct composite, where they’re rebuilding a mesial incisal angle and a lot of the facial on an anterior tooth, and they’ll do a model, a Diagnostic Wax-Up and then a putty matrix of it to help build up the lingual of the composite. And I’m looking at all this stuff going, “This is insane! You’ve got to charge $1,000 for this composite to be able to do it like this,” which is fine if you can get it. But you’re right. I think the average dentist who looks at it and tries it would lose a lot of money, because we’re just charging this straightforward fee without any wisdom built into it. PH: At the heart of advanced restorative dentistry is wisdom. What have we learned from the previous cases? For example, take the profession of law. You walk into a law firm and there are 50 attorneys. You’ve got the old ones and the young ones. Now, whose hourly fee is going to be the highest and why? MD: You would think that those who have been there the longest would be the highest paid because they have seen the most cases. Especially if your case is a little bit more difficult, they might go, “You know, I tried something like this 14 years ago and read about it. Here’s what we need to do.” A young attorney might not have that experience or wisdom. PH: Yes, so you’re paying lawyers a premium fee for their wisdom. Patient comes to you with a severe overbite, jaws clicking, periodontal problems, muscular problems and phonetic problems. That’s a difficult case. There’s a lot of risk there. A case like that requires a lot of wisdom. And really, I think the point of this article is or where I’d like to go is, how does a dentist take what they’re doing now and begin to assess: What’s the risk? How much wisdom do I need to apply? But do it in a practical way so you’re not guessing what your fees need to be. There’s a more objective way of looking at what the fee needs to be when you really understand your fee based on time, skill, risk, remake or change in patient medical history. Patient medical history is a real big one, Mike. Most rehabs are going to occur in a patient’s fifth or sixth decade of life. They’re going to be in their 50s or 60s. How many of these folks are still employed? So let’s say you’re going to do a big case, a $12,000 to $15,000 case. Even by today’s fees, sometimes it costs as much as $10,000 per quadrant depending on if you’re doing sinus elevations, bone grafts, implants, progressive loading, multiple units. If you take a high-fee case, a $20,000 case, on a person who’s in their late 50s or early 60s, that person is typically still in their income-producing years. And they’re kind of at the peak of their earning power. Now, you have a case that’s supported by posterior implants and fixed bridgework. The anterior teeth are all porcelain in the anterior guidance. What’s the probability that you’re going to have a problem somewhere in that case 10 to 15 years down the line, Mike? What’s the probability? MD: Off the top of my head ... maybe 85 percent? PH: I’d say 100 percent (laughter). MD: Well, I was putting a few weak-muscled patients in there, patients who won’t be able to chew anymore. PH: The patient’s medical history changes. So, one thing we don’t recognize as we read the journal articles is what the case will look like 20 years from now. Show me that case when the patient’s sugar level is 250 and spinning out of control. Show me that case when the patient loses partial control of their hand or their eyesight starts to go and they aren’t able to clean their mouth. MD: Or Sjogren syndrome patients, who run out of saliva and the teeth just deteriorate from underneath it. PH: Or from all the medication they take. The difference now is that the patient is retired and they’re living off their retirement income. Now the case has a problem. Now you’re going to have to assign a fee. The fee to the patient now feels much greater than it did during their income-producing years. The point I’m making here is, when you initially do the case you cannot take shortcuts. If there’s a question between doing 2 units or 28 www.chairsidemagazine.com
3 units of implant to support a bridge, use three. Will it be more difficult to sell the case with three implants? Yes, it will. But if you do not engineer the case for the lifetime of the patient, when they do have failures and remakes in their retirement years, you are going to have a huge management headache. Second point about fees is that, if you’re not doing many complex-care cases – let’s say you’re doing one or two or three a year, Mike – that’s what I call a hobby. It’s like the old guy that sits with the beret at the state fair building with the ship in a bottle. He loves it because he loves doing it, not finishing it. 400 MD: But dentists want to chase the big cases, right? They go, they take courses: “If I get just one big case per month, it will pay the bills.” Really, in terms of profit, what you’re saying is, for a 12-unit case, where you’re almost doing that full maxillary arch, the dentist would actually be better off doing four 3-unit bridges on four different patients in terms of profit than one 12-unit case on a single patient? PH: Absolutely. Because you can do four 3-unit bridges without having to spend the time and planning that you do with Profit per Hour MD: Isn’t that like somebody who goes golfing just three times a year? They go out there but they’re terrible at it. Can you be good at something you do three times a year? PH: You can’t be good, you can’t be fast, but you can still enjoy it. So, it doesn’t make any difference what you charge for a case like that. Enjoy it, have fun with it. But I think for the majority of us doing complex-care dentistry and trying to make a living at it, if we’re doing one or two cases a month or one or two cases a week, the importance of setting the right fee becomes especially important. Without the right fee, what will happen with complex-care cases? Your gross will go incredibly high but your net will begin to dip. You’ll feel like hell, you’ll feel more stressed, and the overall quality of your practice and other cases will begin to suffer, too. The big cases will pull the rest of the practice down. MD: How confusing must that be for a dentist to see the gross go up, be high-fiving people: “We had a great production day! Woo hoo!” And then the net goes down so far it becomes depressing. PH: That was me. My first 10 years in practice, I pursued quality. I was like a sled dog chasing a rabbit. I was on a quest for quality. Yet our gross was incredibly high. I think my practice at one time was in the top half-percent of solo practitioners’ productions. But my net, hell, I was embarrassed to talk about it. I was doing these big implant cases, but to tell you the truth I was secretly praying for a couple of simple 3-unit bridges to walk in so I could pay my bills. And you know what? That’s another dirty little secret – these big cases often don’t yield the profit that they really need to. 300 200 100 Tooth Dentistry Figure 1 Centric Relation Dentistry Rehabilitative Dentistry one 12-unit case. You don’t need to think about it that much. You know, ultimately where this conversation is going to lead is that when you’ve got six or more units and you do the cases right, Mike – I’m talking about preoperative photos, preoperative study models, incisal edge matrixes, customized provisional temporaries, using temporaries as diagnostic tools, putting in nightguards, corrected equilibrations and follow-ups. When you do the case well, my studies have shown that typically you’re going to need to add 40 percent more to the fee over your fee schedule. So, if you’re $1,000 per unit and you’re doing 6 units, in order for those numbers to work out well for you, you’re going to need to add 40 percent to that fee. And if you’re 12 units or more, Mike, in order for those units to work out well, you’re going to need to add 70 percent to your fees in order for that case to be profitable. MD: Wow. And you’re talking about fees that are already in place for 1-, 2- and 3-unit crown Interview with Dr. Paul Homoly29
Page 1: Chairside® A Publication of Glidew
Page 4 and 5: Contents 45 Practice Management: So
Page 6 and 7: Letters to the Editor “Dear Dr. D
Page 8 and 9: Contributors Michael C. DiTolla, DD
Page 11 and 12: PRODUCT........ TrollFoil Dr. DiTol
Page 13 and 14: Dr. DiTolla’s CLINICAL TIPS PRODU
Page 15 and 16: Book Review “Aesthetic & Restorat
Page 17 and 18: Figure 5: The fractured ceramic sur
Page 20 and 21: Too Much Tooth, Not Enough Tooth Ma
Page 22 and 23: Creating suitable incisal edge posi
Page 24: tion using “s” sounds as well;
Page 27 and 28: Interview with Dr. Paul Homoly 25 I
Page 29: grand scheme of things, that single
Page 33 and 34: MD: And I bet most dentists know th
Page 35 and 36: have to do that you didn’t forese
Page 37 and 38: Several years ago, Reader’s Diges
Page 39: one; you’re a fantastic employee,
Page 42 and 43: 3. Acrylic provisionals should be p
Page 44: ■ Reasons for Biologic Shaping 1.
Page 48 and 49: Glenn Lombardi: Well, let me start
Page 50 and 51: Second, if you’re not comfortable
Page 52 and 53: GL: Exactly. And the names of those
Page 54: anti-snoring devices.” That is go
Page 57 and 58: other while seeking wealth, attenti
Page 59 and 60: ubber and drive the bur into the fl
Page 61 and 62: inflammation in lesions on the wear
Page 63 and 64: In 1976 it also went out on a limb,
Page 65 and 66: Dr. DiTolla’s Patient Product Rev
Page 67: The Chairside ® Caption Contest IN

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