I went the the Florida National Dental Conference last weekend. I didn't see much that excited me as far as lectures go, but as you know, I am thinking about lecturing on posterior composites, so I went and saw what I thought was going to be competition.
Dr. Burgess, out of UAB, was presenting a lecture on posterior composites made easy. I have heard great things about Burgess and I was kind of amped about seeing him. I must not have read the program right: it was a hands-on course.
Anyway, Dr. Burgess is a big wig in the biomaterial department. He has graduate students doing research on all materials that he oversees, and he does some private practice stuff also. To be able to see the materials in the lab and then see them in the mouth would be an ideal job for me. That would be cool. But that is besides the point.
What is the point? Okay, I am getting to that. I sat in a room with 24 other people and he started by telling us a new flowable product that is having 100% success. Have you heard of Surefil SDR?
Then he talked to us about how to do a class II composite filling. For the next hour, we did a class II composite filling on a model. I was blown away. I have been doing it the way he teaches for over 13 years. Do you know what that means? Nothing has changed really in a long time when it comes to composite fillings AND there are people out there that have never seen it done this way. I was bored out of my mind and others in there were riveted by everything he was saying. Are you kidding me? Some people have not heard of the Triodent V3 ring, or the Garrison ring. WOW!!!
My buddy and I were at the bar after our lectures and we got to talking. I was refreshed to hear that he practices just like me. Lots of fillings to save teeth from the crown cycle. Very conscientious. He was taken aback like I was about the people in my class NOT knowing how to do a simple class II composite. He wondered how our prices can be the same as these other dentists.
Before we go into that, let me tell you about the first part of our conversation. He told me you can't make a lot of money doing fillings, but I thought you could. He broke it down for me. He said, "How much do you charge for two class II composites and how long does that take you?"
"$480 and about 50 minutes."
He broke his overhead down. Paying all the bills, paying all his staff and how many working hours he spends in the chair, his break-even point is $400 an hour. He said with my speed and my prices, I make about $80 for that hour.
He schedules 90 minutes for a crown. That is $1200. Take away the lab bill and it is still $500 or so an hour. He says that is why so many people are skipping the filling and going right to a crown. He and I both believe it is wrong to over treat for the money, but he was just telling me the way it is.
He wrote me an email saying he was convinced that he needs to raise his prices on his fillings. What convinced him was that he knows he does it better than most. And if you are doing it better shouldn't you have higher prices?
(This is a photo he sent me of some fillings he did. Very good. 30-MODF and 29-DO.)Now, we are not comparing apples to apples when it comes to product. You can't compare the price of a guy who does this all the time and does it very well to a guy that is throwing in a tofflemiere and plopping in some resin, pressing his thumb on it and calling it a filling.
So back to the original question. How do you price yourself? This was the next part of our conversation. I call all the local dentists in town and ask them how much they charge for a two surface class II composite. I don't want to be the guy that is super expensive. If you use this method, you are going to be making $80 an hour for the rest of your life.
But his argument is that he is better at it than they are and he will save your teeth longer because of his methods, so he should charge more for being conservative and being good at it. I totally agree, but...
1) Patients don't know he is better.
2) Patients don't know he is conservative.
3) There really isn't a way to educate a patient on the ins and outs of fillings and why you are charging $100 more for a filling than the guy down the street.
4) I don't see how we can do this.
Is this the mountain we are going to die on? Because I think we WOULD die on this mountain. You know what I am talking about: the "I am good at this so I feel like my service is worth more" attitude. I get it. But knowing more, and doing a better job, I think, is for me. Knowing I am doing the best I can for my patients, using the best products available is for me.
I know I can make a good living doing dentistry the best way I know how. And if I want to charge a couple bucks more to make myself feel better, that is going to be fine. But if we charged $100 more for a filling than the guy down the street, we would eventually lose the patients that are concerned about money right now. And that is a lot of people. That is just my opinion right now. (Maybe you can convince me otherwise.)
I love this topic. I want to marinate on it awhile. I am going to go home today and have a beer and sit in the pool and think about it. And I want you to do the same. Think about the ideal situation, and we will talk about it on Wednesday.
Have a great weekend.
john
P.S. Last thought: my prosthodontist charges more than twice what I charge for a crown.
The enamel-saving fee is quite the topic lately. Ask Bob Margeas or Newton Fahl; two of my composite heroes. I also had a patient ask me this week, "So, your job is to tell me how to avoid seeing you?". I believe many dentists are too cavalier with people's teeth and willing to dispose of their enamel. I think this is where CAD/CAM dentistry has it's greatest strengths: subtitled Return of the Onlay.
ReplyDeleteSo my Dad breaks off the MB cusp of #3 and the moderate sized MO amalgam is still there. Why would I ever want to wipe out his huge, intact ML cusp?
Oh yea, and what about the patient (or patient's parent) who gripes about how expensive Clinpro or Prevident is? Clearly, I didn't do a good enough job of explaining the benefits or maybe they just aren't interested.
You've touched on a very broad reaching topic. Essentially quality or quantity. However, patients are demanding composite fillings over amalgam despite their insurance companies often not covering the difference in fees. Perhaps you are right, we aren't charging enough for composites and maybe patients will understand the value.
Did I read that correctly? Dr. Burgess likes the Surefil SDR technique? I'm sure he carefully chose his words short of fully endorsing the product...
ReplyDeleteWhat are your opinions on using rubber dan for posterior composites?
From a patient's point of view, I think you're right that most of us couldn't tell a well executed filling from a bad one so unfortunately price does become an issue. I know from experience that my own dentist is extremely expensive but my view is that he takes the time to explain the treatment, he doesn't push unnecessary work, he's a stickler for detail and if that means a filling takes 2 hours, then that's what it takes. It's about his whole approach to me and my teeth. THIS is what I pay for. He also goes to the bother to explain that a filling may take time to settle and there may be some flare up with a deep filling as the nerve settles - previously I would have been in a bit of pain, blamed the dentist for being crap, gone somewhere else and ended up with a crown. The extra time he takes to reassure me about this is why I pay him the extra. And I don't begrudge it but I do however make damn sure that I play my part in ensuring he has as little work as possible to do. Nice to see he's not alone in realising there is a patient attached to the teeth !
ReplyDeleteWas the CE presenter "sponsored" by Dentsply / Caulk? Just looked up Surefil SDR and they market it as a posterior bulk fill flowable base. They say it allows for a 4 mm bulk fill. Tricky marketing - just by looking at the ads you would think that it could be used to fill an entire prep in one quick application. Place, cure, done. Not so fast. did your presenter mention that? 100% success?!? The only thing that predictable is death and taxes. Not buying what that guy is selling....
ReplyDeleteThere certainly has to be a fair market price for the dentist (vice the dental factory - sorry, I can't think of a better name for it). I think the comment above that begins with, "From a patient's point of view" is very, very telling. These are exactly the types of patients that our practice looks for.
ReplyDeleteI read a book lately that you might not think would have anything to do with the business of dentistry - but, it has me thinking. "What Would Google Do", by Jeff Jarvis, is a collection of thoughts and ideas about how the Internet has changed the way people think and therefore how businesses should think. (And how Google has leveraged that change.)
Here are a couple of rules from the book. See if you think they apply:
- Give the people trust and we will use it. Don't and you will lose it. The powerful (companies, institutions and governments) used to be in charge because of the control they had, but the world has changed. They can only win it back by being more transparent and listen to their customers
- Your customer is your advertising agency: Google spends next to nothing in advertising, people spread the word for them. Let your customers do that for you.
Great topic. Appreciate your blog.
Okay about Dr. Burgess. I think when writing this blog I was in the middle of thought and got called away. I told you he like SureFil SDR. One thing I didn't tell you is that he liked it as the bottom part of a sandwich technique. Almost like a flowable. Then he recommended a hybrid on top. But he said the bond to the tooth with SureFil is 100%.
ReplyDeleteIt seemed that the course may have been sponsored by Dentsply/Caulk (because all the products we were using were from Dentsply, there was a Dentstply rep in the room, there was a Dentsply place mat on every station) but he says he doesn't get paid to endorse any product.
I don't really mind that though. I don't know why, I just don't.
He sounded very honest to me (I know, I am very naive).
Hope that clears it up
john
Anonymous,
ReplyDeleteI know you like the "I don't care how much you know until I know how much you care."
I try to live by that principle. And I totally appreciate patients like you. I want someone to know how much I care. I want to not "drill fill and bill", I want my patient to think I am knowledgeable, good at what I do and that I care.
And they appreciate how much having those things cost me. And be willing to pay a little more for that.
Thanks
john
Thomas,
ReplyDeleteRubber damn. Here is my thing...I don't use them.
I know a lot of the guru's use them. But I just don't get it.
I will look at a picture they show in a lecture and there is a giant hole in this rubber damn they are using. Inevitably they have to cut the rubber damn to make it fit.
If the rubber damn is not sealing up around the tooth, what good is it?
It means you just can't see when the flood gates are coming.
Maybe I am justifying why I don't use it.
I have had so much success without it that I don't think I can improve my product with it.
So the short answer is NO, I don't use it. And I never will.
Thanks Gator! I respect your opinion and that is why I asked. I am a year out of dental school and I haven't seen a rubber dam used on anything except for endo or on dentaltown ce videos demonstrating composite techniques. I have only used it a few times for operative dentistry since graduating and I have a fear that one day all my patients will show up with the composites I placed missing... I gues the dental school faculty did a good job at convincing me the importance of isolation.
ReplyDeleteAnyway, thanks for sharing your thoughts. I admire your openness and passion for dentistry and I aspire to those qualities too.
Personally I rubber dam ALL endo, the mantra being "no rubber dam, no endo" with single tooth isolation, and double tooth isolation with one hole punched if otherwise impossible. If you evert the edges the floodgates don't come. The only time a rubber dam comes off during endo is after the orifice barrier is set, and I'm restoring, and only if I can't get the matrix band on over the rubber dam with the clamp off.
ReplyDeletePosterior composites involving any margin I tend to rubber dam and use a V-ring. So by that anything more than a single surface gets a rubber dam unless it's really impossible and I compromise with great suction, parotid shield, tongue retraction (on occasion even a svedopter!! but I no longer have those lying around to use). I also tell every patient that I work on a composite without a rubber dam ie anteriors, that they have to breathe through their nose and stay open the whole time and keep suction in there the whole time alongside the cotton roll isolation. If the patient so much as breathes through their mouth the moisture contaminates the prepped surface and I'm not taking any risks when composites are in question, to the point that I don't do posterior composites in one of the practices I work in as they don't have a sectional matrix system.
Perhaps I'm a bit obsessive about this but really once you get used to rubber damming it gets really fast and the peace of mind can't be beat. It also has the additional bonus of keeping some patients from talking constantly (and ruining your moisture control) but there's always some that manage to talk through the rubber dam (and then I breathe easy knowing my prep is dry!)