DIGITAL IMPERATI. Thomas J. Balshi, DDS, PhD, FACP, is a board-certified prosthodontist widely known for his DIGITAL DENTURES

Transcription

1 B Y DIGITAL DENTURES P A M Each December, IDT identifies major trends in dentistry poised to impact your clients and your businesses. For the coming year, there are three business environment changes on the horizon: digital dentures, sleep dentistry, and dental insurance. J O H N S O N DIGITAL IMPERATI Thomas J. Balshi, DDS, PhD, FACP, is a board-certified prosthodontist widely known for his contributions to implant dentistry. His four-decade career includes degrees from Temple University School of Dentistry, the University of Toronto, and the Institute for Applied Biotechnology in Gothenburg, Sweden. IDT s Editor-in-Chief, Pam Johnson, put this pioneerturned-expert to the question about the new and exciting development of digital dentures. IDT: The emergence of digitally designed and manufactured dentures is still in its infancy. What factors do you believe will positively impact the momentum of adoption by clinicians? Tom Balshi, DDS, PhD, FACP: There is no doubt that the profession is moving in this direction. In fact there are projections that the digital denture market will experience exponential growth over the next few years with the numbers of dentures produced via digitally empowered production processes doubling in that timeframe. For clinicians the attraction of this process is the reduction in the number of patient visits from five appointments to as few as two, as well as the precision of the final prosthesis. The result is a savings in chairtime and greater patient satisfaction, since the precision of the final prosthesis results in fewer follow-up appointments to make adjustments for sore spots. IDT: Isn t the precision of the final denture reliant on accurate record taking, a problem that the dental profession has historically struggled to achieve? Balshi: Yes. There is no doubt that the record-taking step is most critical for the digital denture process to work correctly and accurately. If the clinician does not take good impressions or if the bite registrations are flimsy, then the end result will reflect those weaknesses. However, the threshold of errors that can occur should be caught by the laboratory, which becomes the filter for the system. The laboratory will identify any deficits in the record-taking process and bounce those back to the clinician. This safeguards the process and offers the laboratory the opportunity to get further involved with the client in helping him or her with the impression- and record-taking steps to achieve a successful outcome. In the end, it s forcing clinicians to do a better job. IDT: What are the advantages of the system for clinicians who adopt the digital denture concept? Balshi: Of all the digital modalities on the market for the clinical side of dentistry, digital dentures will be the easiest to integrate into the practice. There is nothing to buy in terms of capital equipment 16 Inside Dental Technology // December 2017

2 Digital dentistry s newest frontier tackles removable prosthetics VE and they can use the same analog record-taking processes they learned in dental school. One of the big advantages to the digital process is the bio-functional try-in. It is milled from a monolithic block of white material in different tooth shades and is a clinical preview of the final denture. Patients can actually wear the try-in denture to test-drive its fit and function ie, their ability to chew and speak as well as get feedback from family and friends on the esthetics of the proposed final denture. Another major advantage of the digital process is the value of the digital record. That digital file of the patient s impression, bite, and vertical dimension of occlusion, and the approved design of the final denture can be used to create an exact copy of the patient s denture with the push of a button. If the patient loses the denture or breaks it somehow, the clinician doesn t have to bring the patient in and create new records and start the process from scratch. Another plus with the digital process is that the dentist can offer the patient a backup denture at the time of delivery for much less than the original for a win-win insurance policy against loss or breakage. IDT: What are some of the advances in the digital denture concept that we may see in the near future? Balshi: As was shown at the International Digital Denture Symposium in October by prosthodontist Dr. Charles Goodacre and his son Dr. Brian Goodacre, there is research ongoing to test the potential of using digital impression-taking devices to capture the fully or partially edentulous arch. The ability to capture the underlying soft tissue with intraoral scanning technology will improve as the scanners and software get better and better. The same type of technological revolution that occurred with the cell phone will happen with scanning technology. In the end it may be a digital technology that we are not aware of right now. Being able to morph the CAD design and the virtual representation of the final denture with an image of the patient will be the next step. We are working on how to do that now and we should see that development in the next couple of years. You can overlay the denture smile design with the 3D image of the patient and do soft tissue mapping to see what type of lip support the denture will provide and be able to demonstrate the effects of moving the teeth forward or back and what will happen to the position of the lips in profile. Another exciting aspect of this technology as it evolves is the ability to actually recreate the natural tooth form of the patient. If a patient presents with old crown and bridgework or even natural teeth and loves his or her smile, but is faced with tooth extraction due to severe periodontal disease, we can replicate the exact form, shape, and length of the natural or crowned teeth in the denture. You can take an intraoral scan of the existing teeth, or take an impression, and exactly replicate those teeth in the denture once digitized. That is a powerful tool for patient case acceptance. IDT: Many project that the future of digital denture production lies with 3D printing technology. What are your thoughts on 3D printing overtaking milling of the final denture? Balshi: 3D printing will probably overtake milling for the manufacture of the final denture somewhere in the future. The technology already has its foot in the door with the printing of custom impression trays and denture bases. And already we ve seen two companies with FDA approval of Being able to morph the virtual representation of the final denture with an image of the patient will be the next step overlaying the smile design with the patient s 3D image and doing soft tissue mapping. long-term denture materials for this market. It will take 5 to 10 years for 3D printing to get to a level of sophistication for the manufacture of dentures. IDT: What about advances in material development? Where will that lead us? Balshi: What we have now is a material that is eight times stronger than the traditional acrylic used to manufacture removable prosthetics. And by milling a monolithic denture puck with white tooth material incorporated within that puck, we have completely eliminated denture tooth pop-off. I believe the monolithic concept will definitely take over the digital denture market and individual denture teeth will become an interesting story in prosthodontic history. Although we are at a very satisfactory point with the materials that are on the market for digital denture manufacture, are we at the end point? Probably not. There is always the opportunity to develop new materials or take existing materials from the industry and reformulate them to fit the digital denture process. Look at what has happened to the ceramic market. That tells you material development is always ongoing. IDT: What signals do you see that the digital denture concept is more than a trend? Balshi: The fact that dental schools such as University of Connecticut, Rutgers, Nova Southeastern, Maryland, Loma Linda, and many others are now incorporating the digital denture concept at both the undergraduate level and in their residency programs sends a clear signal that the digital denture concept has moved past the trend stage. In addition, government agencies such as the Veterans Administration have incorporated digital dentures into their patient treatment systems, as has the US military. These are all good indicators that digital dentures, especially the monolithic fully milled products, are becoming the backbone of removable prosthodontics. insidedentaltech.com // Inside Dental Technology 17

3 SLEEP DENTISTRY SNOOZE ALARM Dentists and laboratories need to wake up to sleep dentistry s market potential Payam Ataii, DMD, is an award-winning graduate of Tufts Dental School who has treated more than 1,000 patients with clear aligners and sleep oral appliances as mono- and combo-therapies at his private practice in Laguna Hills, California. Below, IDT asks him about the emerging market of sleep dentistry. IDT: Undiagnosed and untreated sleep disorders in the US have been characterized as a rising albeit hidden epidemic. What are the statistics that support that characterization and what economic impact does this have on the American economy? Payam Ataii, DMD: Approximately 70 million Americans suffer from some form of sleep disorder problem with an estimated 60% of these 70 million having a chronic disorder, according to published studies by the National Center on Sleep Disorders Research (NCSDR), an organization within the National Institute of Health (NIH). The American Sleep Apnea Association estimates that nearly 80% of patients who have moderate to severe sleep apnea are undiagnosed. Left untreated, sleep disorders can lead to serious health risks such as hypertension, risk of stroke, asthma, and heart disease, as well as mental health issues such as depression, anxiety, and insomnia. These associated health problems are a major driver of healthcare costs in the US. Sleep disorders, sleep deprivation, and sleepiness add an estimated $15.9 billion to the national healthcare bill, says the NCSDR. The CDC adds that up to 6,000 fatal crashes each year may be caused by drowsy drivers. 3 IDT: What role has dentistry traditionally served in identifying, diagnosing, and treating patients with sleep disorders? Has that role been changing in the past few years and if so how and why? Ataii: Dentists have traditionally been on the fringe of sleep disorders by screening and referring patients to sleep physicians or, occasionally, receiving a referral from a sleep physician of a failed CPAP patient. However, dentistry s role has been changing as the medical profession now recognizes the unique position that dentists play in healthcare. Most patients see their dentist more often than they see their physician, and at the same time more dentists are realizing that they have a responsibility for the airway since it is within their scope of practice. This was supported recently by the ADA s position statement that urges every dentist to screen patients for sleep disorders, increase their education on this topic, and treat patients with oral appliance therapy as appropriate. IDT: What is the revenue stream potential that could be realized by incorporating sleep disorder therapy in the dental practice? Ataii: Treating sleep patients can be a good source of new revenue for a dental practice if done correctly. Even if we, as an industry, treated just a fraction of the 70 million Americans who have chronic sleep Although the dental sleep industry is still very nascent, more and more programs and lectures are now being offered at dental conferences. disorders with oral appliances, this could result in a multi-billion dollar industry. Doing the math: 1% of 70 million is 700,000 patients multiplied by $5,000 to $10,000 per treatment. That s a $3.5 billion to $7 billion market! IDT: There has been an explosion of sleep appliances launched onto the market as well as personal health tracking devices that offer consumers a method to track sleep habits. Are these indicators of a potential upward trend toward public awareness and dentistry adapting to a growing demand? Ataii: Although the dental sleep industry is still very nascent, more and more programs and lectures are now being offered at dental conferences. In addition, public awareness of the dangers of sleep disorders has been increasing with news stories about train and bus accidents where the engineer s or driver s sleep apnea was the major contributing factor to the accident. As a result, manufacturers have now responded with personal devices such as Fitbits that measure not just steps but also sleep activity. These type of devices have helped raise the awareness of the general public about the importance of sleep and its impact on overall health. IDT: As manufacturers of Class-II sleep disorder appliances, what do laboratories need to know to effectively service this market segment? 18 Inside Dental Technology // December 2017

4 the many appliances currently on the market. Offering a limited number of appliances is an issue because dentists are quickly realizing that they need many different appliance choices since patients are all different and no one appliance fits all patients. As a general practitioner who treats sleep patients, and given the high profile nature of sleep medicine these days, I only want to work with laboratories that are FDA-approved and that offer a wide selection of FDA-cleared sleep appliances. FDA compliance is important for dental insurance reimbursement for these appliances and also because of increased FDA compliance enforcement due to this industry s increased visibility. IDT: Are there controversies among sleep dentistry experts on the best appliances, techniques, and protocols to use for patients suffering from sleep disorders? 21.3% Percentage of dental laboratories offering sleep apnea and medical devices. Ataii: Since the dental sleep industry is still in its infancy, our protocols remain very rudimentary. For example, often the standard of care to set the bite registration on sleep patients is recommended at 70% of maximum protrusion. That percentage is arbitrary and can lead to possible complications, such as temporomandibular disorder (TMD), malocclusion, and other problems if these dental appliances are positioned without careful consideration. The reality is that to avoid these issues, multiple disciplines should be involved in the development of an appropriate treatment plan that aims to properly fit a patient with an oral appliance. Beyond sleep dentistry which is what is mainly being taught today you will need to incorporate orthodontics, TMD, myofunctional, and airway management expertise. That is why companies that have brought all of these disciplines together under one roof such as SleepArchiTx are gaining traction NADL BUSINESS SURVEY Ataii: Most laboratories only offer one or two of Explore axsysdental.com to learn about the technology, our special pricing on consumables and more! (Circle 17 on Reader Service Card)

5 INSURANCE MODELS NO END IN SIGHT Dentists, patients, and laboratories squeezed by patient reliance on fee-for-service dentistry Since laboratories serve dentists, they too are subject to the market forces that impact dental practices including the fee-for-service model promoted by dental insurance companies. To learn more about the future of this model, IDT spoke with Tom Limoli Jr., president of Limoli and Associates/Atlanta Dental Consultants, Inc, which assists dental offices in streamlining the insurance reimbursement process. IDT: What are the biggest trends you are seeing in the third-party dental benefits arena? Tom Limoli: Unfortunately, the biggest trend today is the increasing influence of the Preferred Provider Organization (PPO) in the profession. Dentistry is still mired in its infatuation and reliance on the procedure-for-payment contract concept. What began in the 1950s and 1960s as a means to advance oral healthcare and increase access by reducing the cost of dental care has been wholly embraced by most of the patient base, but it has trapped private practice into providing discount dentistry. As a result, dentists equate the value of services rendered to the number of crowns that can be placed in a week or month. Today, 82% of dentists have signed on to one or more of the dental insurance PPO programs. Everyone is competing for the same patient in what today is a marketdriven economy. IDT: How is this negatively impacting the general private practice? Limoli: In today s economic environment, employers continue to pressure insurance companies to shave the cost of their employees dental care coverage, and insurance companies are obliging by cutting back individual treatment reimbursement rates. In the past, dentists were able to raise their rates each year to compensate for changing economic conditions and recoup lost revenue. However, with consumers now having to bear more of the cost for dental treatment, that fiscal response is untenable. So that leaves general dentistry chasing more dentistry in order to make more money. We are practicing the more you do, the more money you make dentistry. IDT: How have these factors impacted consumer response to dentistry? Limoli: When you look at what Americans are actually paying and then what they expect to pay for the value of services rendered, the competitive lure of multipractitioner offices, group dental practices, and DSOs is perceived as What began in the 1950s and 1960s to advance oral healthcare and increase access by reducing costs, the fee-for-service model promoted by PPOs has been wholly embraced by most of the patient base, but it has trapped private practice into providing discount dentistry. a more cost-effective choice in many cases, especially for the nearly one-third of Americans who have no dental insurance. These larger entities can negotiate competitive reimbursement rates for various procedures and are attractive to insurance companies because managing a large group or DSO organization is more cost effective than coordinating myriad small, individual private practices. This, in turn, has spurred dental insurance companies, capital investment firms, and even large suppliers to purchase practices and laboratories or partner with large groups to consolidate the industry for economy of scale advantages. Even some hospital groups are looking to integrate select dental services into their operations. IDT: Does this mean the fee-forservice reimbursement model may be changing in the future? Limoli: Dentistry is a fast-evolving market. However, the third-party insurance model will continue to dominate as long as there are economic striations in the patient base and as long as dentistry s primary focus remains less on prevention of dental disease and more on restoring the diseased mouth. 20 Inside Dental Technology // December 2017

6 That said, there is some movement toward dentistry following the medical model. On the medical side, hospitals in certain regions of the country are purchasing and integrating every type of specialty group in their state or neighboring state and then offering an attractive package to a large employer for their exclusive services, effectively cutting out insurance companies for basic medical services. The same type of model is occurring with large corporations; it s cheaper for them to partner with a large group practice or DSO to provide company employees with dental care than it is to contract with a dental insurance company. They understand that the more preventive services they offer employees, the less large-expenditure dental care that will be needed, and the more cost-effective that approach is. Private practices also are finding new ways to compete and ensure a loyal patient base as well 74M Number of Americans with no dental insurance. as capture patients with no dental insurance by offering a practice membership or buying club to their patient base. As an example, for a flat fee of $250 to $300, the patient receives an oral exam, two cleanings, and a set of X-rays per year, plus an across-the-board percentage discount for restorative services such as fillings and crowns. IDT: None of these solutions appear to be a panacea for the reimbursement insurance model. Limoli: I can t help but believe that if we could take the reimbursement model out of the equation, the dentists approach to what is best for the patient would be entirely different than the fixation today on type of insurance. SOURCE: ORG/DENTAL_BENEFITS_ BASICS/DENTAL_BB_1.ASPX High Aesthetics. Streamlined Inventory. 16 VITA Classical Shades with only 7 discs. The priti multidisc ZrO 2 multicolor can make this a reality for you. Natural Aesthetics Time Effective Easy-To-Use Available in High Translucent (>650MPa), Translucent and Opaque (>1150MPa) Multicolor blanks with aesthetic, harmonious shade gradient All priti multidisc ZrO2 materials, regardless of shade or translucency, can be sintered at 1450 C in the same furnace ZIRCONIA Reach out to one of our distributors in the US through Atlanta Dental, Pearson Dental or Open Dental Solutions to get started with priti multidisc ZrO2 today! AtlantaDental.com. PearsonLab.com. OpenDentalSolutions.com. Pritidenta.us (Circle 13 on Reader Service Card)