I was at a dental exhibition over the weekend and bumped into an old colleague who was a guru in the field of dental practice management in his day. He always has interesting insights into various aspects of Dentistry. My short tete-a-tete with him again raised some interesting thoughts for me. Standing outside the exhibition entrance, he pointed at the entrance to the dental exhibition and the the entrance to the exhibition next door, which was a toys exhibition. He noted that there were a lot more people going into the toy exhibition than the dental exhibition. With a lower barrier to entry, there will always be more people buying toys that dental equipment. Then he asked me what I think is the going rate for a dental implant in an Orchard Road practice and on average how many implants get done a month. He said he knows of many practices in the suburban towns charging half that amount but doing four times as many cases. Do the math. Which one is the more successful model financially?
This got me thinking. How is it that some clinics can charge half the price and still be economically viable? I’ve been doing implants for more than twenty years and I do know the cost of providing that service. If I half my charges, I would not be able to break even. So, I try to breakdown the cost and see where we can reduce the fees.
- Fixed overheads- real estate prices in Orchard Road is probably a bit pricier than that of suburban estates. This part is probably unchangeable unless I relocate.
- Staff cost- well trained staff needs to be well remunerated or they leave. And well trained staff are needed to ensure that standards are met. Again, I wouldn’t dare dream of cutting salaries or getting untrained staff
- Sterile consumables- we use disposable drapes, gowns, etc, which are single use items. These are expensive (and environmentally unfriendly). So perhaps I can switch to using reusable drapes and gowns but there will be laundry costs involved and that will negate part of the savings.
- Instruments- I can use instruments that are made in Pakistan or India which will be cheaper than the ones made in Europe. But I have already invested in the European instruments and those are sunk costs to me now. So I can really save much on in this area.
- Implant systems- this is an area where we can save a fair bit. When dental implants first become commercially available, there were only a handful of manufacturers from Europe and then the USA. Over the years, as the science and technology of dental implant manufacturing becomes public knowledge there are more and more manufacturers emerging and selling their products at much more competitive pricing. These implant systems have also gotten approval from various regulatory jurisdictions such as the Food and Drug Administration of the USA and the CE mark of Europe. These products are proven to be as effective and as safe as the traditional European and American brands. Using these newly approved brands can shave 10-15% off the cost.
- Treatment plan- this is where the greatest variability lies. While a dental implant ie the titanium screw, is a commodity, implant dentistry is not and cannot be quantified in the same way. Each patient presents with his own unique needs and demands. Let me illustrate with a real case.
A colleague referred me his relative, a 60 year old female Asian patient from a neighbouring country, with a high aesthetic demand presenting with a very badly infected upper front tooth. The tooth has undergone root canal treatment which failed and has resulted in infection and bone loss. She needs to have the tooth removed and replaced with a dental implant.
However, she is also not prepared to be without a front tooth for any length of time and wants to have a fixed prosthesis. She has had 3 dental implants done at the back of her jaw some years ago and so she knows what dental implants are. However, her needs and demands now are completely different.
Due to the infection, the treatment needed to be done in stages.
Clearing the infection…
First the tooth must be removed and the infected area cleaned up. The wound must be left to heal and a temporary adhesive false tooth bonded to the neighbouring teeth.
Rebuilding bone and gum…
A few weeks later, a bone graft will be needed to rebuild the missing bone before an implant can be placed. The lost of bone has also resulted in shrinkage of the gum which also needed to be augmented with a gum graft taken from the palate. This has to be done after the bone graft has healed. So, before we even place the implant, the patient would have to undergo three procedures- removal of the tooth and cleanup of the infection, bone grafting, and gum grafting. For this particular patient, actually for most patients in fact, intravenous sedation is usually needed for a more pleasant experience. All these add to the cost. When the jaw bone and gum is ready, we place the implant.
For a front tooth, aesthetic demand is high and so I do the implant in two stages ie the implant is buried below the gum at the time of placement and a second stage surgery is done to expose the implant a few months later for the fabrication of the crown. This two stage approach enable fine tuning of the gum contour around the implant to more closely simulate that of a natural tooth emerging through the gum.
At this point, the restorative dentist takes over. There are multiple options for the crown. The crown can be made from various materials, eg precious metal alloy with varying concentration of gold., zirconium, non-precious metal, etc. The abutment, which connects the crown to the implant can be chosen from among the stock that the manufacturer makes, or be customized using CAD-CAM, is another cost variable. The option of whether to make a screw-retained or cemented prosthesis is yet another factor that impacts the cost. For front tooth, a provisional crown is usually done first to achieve good gingival contour and to get a sense of what the patient likes before doing the final crown.
Even after completion of the final crown, maintenance is essential to maintain the long-term function and aesthetics.
When I explained the above to the patient, she did not quite understand why this single implant costs as much as her three implants replacing her back teeth. There is another option, a purely functional one. She does have sufficient bone to place an implant without all the bone and gum grafting. I can just extract the tooth and let it heal for a few weeks and then place an implant on whatever bone remaining. We can then do a cement-retained porcelain-bonded-to-metal crown using non-precious alloy. This way, the cost can be reduced by more than half. However, the result will not be aesthetic. The new crown will be very long and the cuff of gum around the crown will not be the pinkish type but the reddish type of gum. Maintenance of the implant will also be more challenging and that in turn can lead to complications and failure. After several visits and phone discussions, she finally understood and proceeded with the original plan.
Some times, I present this case in my implant courses and some of the course participants will point out that some patients may not be concern about aesthetics and the second option may be good enough, especially given the difference in cost. My experience is that nobody is unconcern about aesthetics. A patient often cannot visualize how the final result will be. My car salesman told me that a customer who drives an old banged-up car will still scrutinize for the finest scratch when he buys a new car. Just because a patient’s existing tooth is all decayed and smelly does not mean that he does not expect perfection in his new implant.
At the end of the day, cost is a big factor in implant dentistry. We do try our best to keep the fees down without compromising on standards. However, within accepted standards, there exists a wide spectrum. No practice can be all things to all patients and dentists have to choose which segment of the spectrum they are best able to work. A patient should also choose carefully, base on their needs and expectations, which practice to entrust their needs to. Making a choice base purely on cost may actually be more expensive if remedial work needs to be done.