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PH: That’s right. You’re better off doing 2 units at a time on six to eight different patients. Or even on that patient! MD: Even on that patient. Spend six years doing two crowns at a time. Your kids will be fatter, right? PH: Absolutely right. And that is something dentists miss all the time. I missed it early in my career, Mike; I’m sure you missed it, too. We were so in love with the process of fixing teeth that we didn’t really see or feel the bigger picture. When dentists hit their 40s, their backs begin to get sore, their eyes begin to go. You can’t make up for lost ground very easily. You are not the practitioner from 40 to 50 or 50 to 60 that you were from 20 to 30 and 30 to 40. You won’t have the same energy, you won’t have the same eyesight, and you won’t have the same stamina. The earlier dentists learn to set their fees relative to complex care, the easier it will be for them to accumulate wealth, to be able to build a profitable practice and to have what they really deserve. The practice of dentistry takes a lot: We capitalize our own businesses, we hire the people, we manage the facilities, we do the dentistry, we empty the plaster trap. We do a lot of things. And improperly set fees can drag you right down. MD: That makes a lot of sense. So, to do that 12-unit case correctly, the 12 times the singleunit crown fee is the baseline. NET FEE: Sum of (Patient Fee - Lab Fee - Office Overhead) Dentist’s Time PH: That’s right, that’s the baseline. You said it earlier, Mike: That’s your base pay. Now you look at, where should the fee be? When you look at the sweet spot, I’ve got it set at about $326 per hour. And that’s net fee per hour. MD: Define net fee per hour for us. PH: Net fee per hour is the patient fee minus the lab fee minus the lab overhead divided by time. That $326 represents my net fee per hour when I’m doing 3 units all in a posterior quadrant. That’s the safe sweet spot right there. Now, when we cross the line and start doing rehabilitative dentistry, where we’re doing those four variables, now our net fee has to be greater than that sweet spot. Here’s why: Because if it’s not greater, we’re not profiting at the level that the risk demands. If you were an investor and you were to invest in something that is safe, like U.S. Treasuries, you would accept a lower return on investment because you’re not making a tremendous risk in the marketplace. But what if you were invested in a very volatile, risky investment? What type of return would you expect there based on risk? MD: It’s got to be higher. PH: It’s got to be a lot higher. When you start doing rehabilitative dentistry, you’re making an investment in a risky business. Therefore, your net fee per hour must be greater than what you’re doing on a lower- or no-risk case. MD: In one sense, these complex cases are sort of volatile. There are just more things that can go wrong versus a singleunit crown. PH: Mike, they always go wrong! MD: It’s just a matter of getting it right in the end! PH: That’s right! Even in the end, it can’t be right all the time. I did rehabilitative dentistry for 20 years, and I can think of very few cases. You sit down and treatment-plan a patient. Let’s say you’ve got 12 units of root canals and implants and all sorts of moving parts in the mouth. You treatment plan that case out, you get your treatment planning form out and you color in all the teeth, color in all the arrows, you get it all done and you add it up. Now, what’s the probability that the treatment plan is exactly what you’re going to do at the end of the case? It’s about zero. There’s always stuff that will change. We’re going to pursue excellence. This is a great treatment plan and I practice in a very excellent way and this is the way it’s going to be. Dream on! There’s no amount of excellence that’s going to compensate for change of host resistance or act of God or anything else that goes on. MD: It reminds me of that old thing, how a plane flying from Los Angeles to Hawaii is off course 99 percent of the time, constantly correcting for the winds. But hopefully the pilots get that plane down where it needs to be in the end. It’s a constant matter of adapting to the environment. Build-ups you 32 www.chairsidemagazine.com
have to do that you didn’t foresee, that you didn’t plan on. Composites falling out and you’ve got to do some filler, and now that post is coming out. PH: Or you laid a flap and what looked like good bone now is mush and you have to graft the area and allow it to heal. Or you have a post-operative complication. You place three or four implants. I remember earlier in my career, we weren’t as sophisticated about our flap management. We’d place three to four implants. We’d come back in about 10 days or so, pull the lip back and you know what? Some of the cases, the flaps would open and we would see the tops of the implants, and that’s when I would feel the heat – the heat from my stomach come up, like swamp gas settling on my face. MD: That’s going to take a few minutes off of your life! And you weren’t being compensated for it, were you? PH: I wasn’t being compensated for it. So how do you fix a case like that? You don’t. You let it granulate in. You see the patient for 15-minute increments every two weeks and it’s like watching a death march. And the longer you look at the patient like a little thermometer, your profitability is going down. Now you’re just hoping to break even. And specialists wonder why more dentists don’t refer dental implants or complex-care patients. Because oftentimes the general dentist is much more profitable from the sweet spot on down, from 3 units on down, than they are with these big godalmighty cases that sometimes can take years to complete. The dentist that refers a lot, Mike, is the dentist that has abundance in his or her practice. The dentist who’s doing a lot of bread and butter dentistry, their bills are paid, they’re making their profit goals, their staff is happy, they have a good facility, they feel good about the dentistry they’re doing. Abundance drives referrals. That’s a different topic we can touch on another time – the specialist-generalist relationship. 400 300 200 100 consider adding 5 to 10 percent to my fee for consultations. Second thing I would look at is occlusal analysis. What does that mean? Well, it means that you’re at home or you’re at the office, you’ve got nobody else there, the study models in your hand, you’re on your articulator thinking. This is where you’re manifesting your wisdom. You get compensated for that. And occlusal analysis, with the accompanying Diagnostic Wax-Up and creation of templates, that’s got to be worth at least 20 to 25 percent of a premium fee. Another thing we miss is equilibration. Mike, I believe that equilibration is one of the finest arts in dentistry: knowing when to stop; knowing where to grind. Knowing when to grind, when not to grind. Knowing when enough is enough. How much do we need to adjust bites long-term on these rehabs? We’re always kind of touching things up. And equilibration is another 10 to 15 percent on these cases. So, if you look at the different areas that we typically don’t charge for, those can add up to 40, 60, 70 percent over those fees that one would Profit per Hour 275 2 crowns 177 1 crown 163 Composite 326 3 crowns 162 12 crowns 125 12 crowns with 5% remake MD: Right, but the point being that they need to be well versed and confident in their sweet spot dentistry to be able to think about referring out the comprehensive dentistry. Tooth Dentistry Figure 4 Centric Relation Dentistry Rehabilitative Dentistry PH: That’s right. And when you sit down and you treatment-plan your big case, you’re going to add fees to different areas of the case where we normally don’t add fees. Number one is going to be in consultation. Consultation with physician, consultation with specialists, consultation with laboratory, consultation with other dentists, consultations with pharmacists – whomever is going to be involved in the case, consultations take time. I would charge based on their fee schedule. You want to end up with your fee for the rehab case now. You want to end up where your profit – when you fee a case, plan on a 5 to 10 percent intraoperative remake. Mike, you work here with <strong>Glidewell</strong>. You see 20,000 units a month go out the door. Give Interview with Dr. Paul Homoly33
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 and 30: grand scheme of things, that single
Page 31 and 32: 3 units of implant to support a bri
Page 33: MD: And I bet most dentists know th
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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