The Journal of Clinical Pediatric Dentistry STANDARD

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Volume 5, Number 3 May-June 1997

IN THIS ISSUE:

Laser Assisted High Tech Dentistry shows how to use a laser in gingival retraction, vital bleaching,
apthous ulcer treatment, periodontal pocket debridement and curing bondable restorations.

Air-Abrasive Micro-Dentistry sm can diagnose and prescribe a treatment plan for each area of an
individual tooth, in a fast, easy to use way, that is economically enhancing to the practitioner.

Ribbond® Bondable Reinforcement Ribbon is a technique that shows how to make better ortho-
dontic retainers (your orthodontist may want to refer cases to you to do this) how to make laminated
bonded bridges and how to make endodontic post and cores.

Improving Practice Profitability gives the dentist key cost ratios to monitor the practice and deter-
mine where to improve production and where to lower costs to get more profitability.

Laser Assisted High Tech Dentistry

This presentation was made by Dr. V. Kim Kutsch to the meeting Air-Abrasive Micro-Dentistry sm,
February 15, 1997 in The Houstonian Hotel, Houston, TX.
The best laser for Air-Abrasive Micro-Dentistry sm is the argon laser, which has two primary wave-
lengths, namely, blue at 488 nm which cures composites and green at 514.5 nm which will cut soft tissue.
By changing the switch, the dentist can control which wavelength to use in the HGM machine. Other
machines may have only one wavelength.
Lasers are monochromatic, coherent, collimated light sources that create photothermal effects. The
absorption of the light by tissue creates various effects, for example heating tissue to 50-60˚C results in
coagulating, 70-80˚C results in welding, 90-100˚C results in vaporization, 100-150˚C results in carbonization,
more than 150˚C results in cutting without carbonization.
As a transilluminator, the argon laser is as effective as the caries dye in detecting caries. It will find
interproximal caries very easily. This is done using 0.08 watts, continuous wave function and using a 300
micron fiber.
By using 2 watts of energy, the practitioner can do a pulpotomy with the laser.
When the laser is used to cure composite, the result is 2 times the strength with less shrinkage and
increased polymerization rate. There is no directional curing with a laser as contrasted with the usual
chairside light source. With a laser the whole tooth is lighted, like a lantern. Use 0.25 watts, 10 seconds
pulse and a 300 micron fiber. Re-etch and place the final layer of unfilled resin to secure the margins and
minor cracks that occurred during the finishing phase.
The laser is very useful in gingival retraction. Use 1.00 watts and a water spray. The healing is better
than gingival retraction. (This will be very useful in teenagers when trying to do stage 4 dentistry.)
Mastering Clinical Pediatric Dentistry Published Bimonthly by The Journal of Pedodontics, Inc. 801 5th Avenue South,
Birmingham, AL 35233. Editor is George White. Subscription $39.00 individuals, a year in the United States, United
States posessions, and Canada, $49 for foreign and institutions. Copyright by Journal of Pedodontics, Inc. all rights
reserved. No part of this newsletter may be reproduced in any form by microfilm, xerography, or otherwise, or incor-
porated into any retrieval system, without the written permission of the copyright owner. Mastering Clinical Pediatric
Dentistry educates clinicians in advanced clinical pediatric dentistry. Articles and ideas are welcomed and should be sent
with 3 copies by the 1st of the month. Our Web page is located at http://www.pediatricdentistry.com
Mastering Clinical Pediatric Dentistry Volume 5, Number 3/1997

The laser is very useful in vital bleaching. It is recommended to use Sho-fu Hi Lit for 3 minutes per
tooth.
For apthous ulcers, set the machine to 0.75-1.00 watts, pulse mode for 0.1 second. Use a topical prior to
using the laser. The treatment should take about one to two minutes.
The laser is also very useful in periodontal pocket debridement, because, it results in delayed epitheli-
um down growth, which is why most periodontists use some form of Goretex. The patient is treated once
per week until bone is healed.

Summary Protocol for Air-Abrasive Micro-Dentistry sm

1. Take preoperative radiograph to determine if interproximal caries are present.
2. Isolate, preferably with a rubber dam.
3. Use caries detecting dye to find carious lesions.
4. Rinse for 3-5 seconds and using magnification, determine areas of decay.
5. Use the air abrasive unit with high volume evacuation, placed in the proximity of the tooth and
nozzle of air abrasive unit. (To keep suction from being clogged, previously place a cut to size cof-
fee filter over the amalgam trap.)
6. After a few seconds of initial preparation, examine the preparation for decay.
7. Reapply caries detecting die.
8. Complete the preparation, using the caries detecting dye, until all caries are removed.
9. Apply the etchant for 20 seconds on permanent teeth. Rinse with water spray.
10. Disinfect the cavity preparation with chorhexidine or other materials. It also acts as a wetting agent
for a moist dentin surface to bond.
11. Within 10 seconds, apply the dentinal bonding agent. This will create a glossy appearing hybrid
layer.
12. Immediately place the correct shade of composite. Use flowable for very small and narrow lesions.
Photo-polymerize the material for 40 seconds.
13. Use a bullet nosed twelve fluted carbide finishing bur for initial shaping.
14. A flame shaped twelve fluted carbide finishing bur is helpful for shaping the restoration in the
grooves and detailing fine anatomy.
15. A flexible polishing cup, point or disc will provide the final polish for the restoration.
16. Reapply etchant over the entire surface.
17. Apply unfilled resin in a thin layer.
18. Photo-polymerize the entire restoration again for 40 seconds.
19. Remove the rubber dam and check the occlusion. Adjust if necessary.

Air-Abrasive Micro-Dentistry sm
Air-Abrasive Micro-Dentistry sm was a day long presentation by Dr. J. Tim Rainey from the Texas Insti-
tute for Advanced Dental Studies, P.O. Box 1044, Refugio, Texas 78377-0956, phone 512-526-4695. The
meeting took place February 14, 1997 at the Houstonian Hotel, Houston, TX.
The revolution for Air-Abrasive Micro-Dentistry sm began over 50 years ago by the second cousin of
G.V. Black, namely Robert Black of Corpus Christi, Texas. It was delayed because the design and use of
adhesive dental products had to wait many years to be developed and accepted. Today, the innovation of
the past and the products of the moment have met to produce a new operative dentistry, specifically Air-
Abrasive Micro-Dentistry sm
The unique characteristic of Air-Abrasive Micro-Dentistry sm is that it can diagnose and prescribe a
treatment plan for each area of an individual tooth, in a fast, easy to use way, that is economically enhanc-
ing to the practitioner.
Dentistry continues using G.V. Black’s method of destruction of large portions of the tooth, without
reasonable scientific evidence to do so. When G.V. Black wrote his hallmark article, “Management of
Enamel Margins” which was first published in 1891 in Dental Cosmos, he had no way to detect carious
lesions except with the explorer. There were no means to detect with radiographs, transillumination with

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Mastering Clinical Pediatric Dentistry Volume 5, Number 3/1997

fiber optic, transillumination with laser light, caries detecting dye or Air-Abrasive Micro-Dentistry sm. Since
he lacked the means to detect caries and the teeth did not have the benefits fluoridated water, so the
caries were rapid. Further, endodontics did not exist. So he did what any good surgeon would do with a
disease process that could not be detected, he removed a lot of good tooth structure to be sure the carious
process would not come back to that surface again.
However, today, we do have these benefits and we have magnification as well. So now we can see bet-
ter and have the means to detect early carious lesions, before the dental explorer can find them. This can
be done clinically easily using a carious detecting dye. Now there is very little reason to use the high speed
drill to remove good tooth structure, produce high vibrations in the tooth and cause micro fractures of the
tooth.
Dr. Rainey currently uses the Kreative air abrasion unit. He is the direct link between Robert Black
and today’s manufacturers. Dr. Black gave Dr. Rainey his old units and showed him how to perform the
procedures.
To do a class I preparation with a Kreative unit, use 80 psi, 27.5 micron aluminum oxide particles and 3
grams/minute powder flow rate with a 0.014 inch diameter tip.
For comparison, a class V is done using 40 psi, 2 grams/minute powder pulse rate, 0.011 inch diameter
tip for about 5 seconds.
The molar life cycle starts with children. It starts with the simple class I amalgam. The amalgam is
placed using extension for prevention principles. In about 14 years, the amalgam is replaced and more
tooth structure is lost. Eventually, a bigger amalgam is replaced with a crown, which is replaced with
endodontics/post and core, crown. Eventually, the tooth may even be lost.
The question concerns a very small lesion, do you “gut” the occlusal surface because G.V. Black gave
the principles of “Extension for Prevention” over a 100 years ago without the benefits that we have today,
or do you use magnification, caries detecting dye, and Air-Abrasive Micro-Dentistry sm? This is the revolu-
tion that has come to dentistry.
The revolution is about massive, indiscriminate destruction of tooth structure, which has been the
“standard of care” over the last century vs. using magnification and a caries detecting dye, finding the ini-
tial decayed areas, removing only the diseased tooth structure and replacing the lost tooth structure with a
tooth colored material.
The philosophy of Micro-Dentistry is based on three principles:
1. Accurate diagnosis of unsound tooth structure and decay.
2. Accurate removal of unsound tooth structure and decay on the microscopic level with minimal
destruction of sound tooth structure.
3. Restorative treatment planning based on the probability of longevity of the restorative unit.
This service provides the benefit to the patient of minimal removal of sound tooth structure combined
with modern adhesive restorative procedures in the initial restorative phases to minimize the initial
restorative trauma and provide maximum caries resistance.
The materials used in Micro-restorative procedures should have adhesive properties compatible with
enamel, dentin, or when bonding to both, the bonding materials should exhibit a maximum compromise
between the characteristics of enamel and dentin. Adhesiveness of the materials will help create a stronger
tooth/restorative unit. The adhesive restorative materials of choice include:
1. Autocure glass ionomers
2. Light cure glass ionomers
3. Composites bonded to enamel. Sealants (unfilled, minimum filled); flowable microfills; microfills;
hybrids; posterior composites; anterior composites
4. Composites used with a direct dentin bonding agent
5. Composite/Glass Ionomers. Adhesive materials used in double bonds or hybrid laminates (sand-
wich preps).

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Mastering Clinical Pediatric Dentistry Volume 5, Number 3/1997

Autocure glass ionomers

The use of autocure glass ionomer liners has little or no use in the restorative armamentarium, because
they are mixed too thin and contain too much polyacrylic acid. Lack of incorporation of polyacrylic acid
into the matrix will reduce all favorable characteristics of the material and lead to sensitivity.
Autocure glass ionomer bases are true dentin replacement materials and are the material of choice
when the clinician is selecting a material with similar characteristics to dentin. Select an autocure glass
ionomer that is low in anhydrous polyacrylic acid component, e.g., Shofu base. The anhydrous component
provides smoothness and ease of handling, but a significant amount of anhydrous component will remain
unincorporated in the final mix, leaching free H+ (ion) over an indeterminate amount of time, which may
adversely affect the pulp and result in hypersensitivity.

Indications for autocure glass ionomers:

Interim restoration
This material may be used when moisture control can be maintained for a brief period of time. Auto-
cure Glass Ionomer may be easily overlaid several months or years later.

Permanent restoration
It can be used as a terminal restoration when the tooth is unopposed. It may also be used for root
restorations when esthetics are not a concern and maximum fluoride release is important. Exposure to
abrasion should be minimum.

Base restoration
It can be used as a base restoration for crown buildups and as a base for double bonds or “sandwich
technique.”

There are disadvantages to autocure glass ionomers. They can be adversely affected during the critical
first minutes of set by moisture contamination and are sensitive. These materials have low wear resistance
when directly exposed to occlusal wear forces. Their physical characteristics are similar to dentin and as
such do not significantly increase the strength of enamel because they are weaker than enamel.

Clinical tips for better results with autocure glass ionomers:

Use dedicated (glass ionomer only) instruments and glass slab. Autocure glass ionomers must not be
mixed for more than 30 seconds and they must be applied within 45 seconds from the start of mixing.
Additionally, they should not be manipulated more than 1 minute and 20 seconds after placement. The
autocure glass ionomer must lose its sheen, i.e., go to the gel state, within one minute and 30 seconds.
Lastly, the autocure glass ionomer must not be wetted for 5 minutes after it loses its sheen.

Resin Modified Autocure Glass Ionomers (RMAGI)

The RMAGI are significantly stronger than dentin and glass ionomer bases. They have significantly
better wear resistance than autocure glass ionomers and approach the characteristics of traditional com-
posites, while retaining a fluoride re-uptake and releasing mechanism. However, the resin modification
does result in shrinkage characteristics noted for composites in this class of materials.

Indications for use of RMAGI

This esthetic material will impart caries resistance if the margin is unsuccessfully sealed or fluoride
release is needed for caries resistance. These are good materials for primary teeth, where the release of
fluoride, increased strength and wear resistance are needed, e.g., occlusal surface, but not load bearing sur-
faces and class II restorations in primary teeth and tunnel preparations in bicuspid teeth.
However, RMAGI may not bond well to a subsequent overlay of conventional composite or may stain
during etching with phosphoric gels, thus they are not recommended for layered double bonds.

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Mastering Clinical Pediatric Dentistry Volume 5, Number 3/1997

Clinical tips for the use of RMAGI

If enamel is involved, the enamel must be etched first with a 37% phosphoric acid, washed, rinsed, and
left damp. Apply the dentin conditioner (10% + polyacrylic acid) for 15 seconds. “Damp dry,” then apply
the RMAGI. Otherwise there will be little bond between the enamel and RMAGI. Failure to do this may
result in a circumferential “leakage line” around the prep.

How to successfully use compomers (RMAGI)

1. Eliminate all the smear layer with air-abrasion.
2. If bonding only to dentin, apply Prime and Bond and go to step 4.
3. If enamel is present, acid etch for 15 seconds, rinse all acid etched enamel vigorously with an
air/water stream for 5 seconds.
4. Do not air dry if at all possible!! Suction the preparation dry, making sure you do not pull blood or
saliva into the field. Do not completely dry the preparation.
5. Now apply the Prime and Bond to the applicator. Don’t even think about uncapping or putting any
dentin primer out until immediately before use. These materials are incredibly volatile and will
degrade in 30 seconds or less.
6. Pool the Prime & Bond liquid (3 months of shelf life!) into the wet prep. Keep the prep “pooled”
for at least 30 seconds while keeping suction away.
7. Suction and gently blow “pooled” primer off. (Be sure there are no contaminants in your air line.
Most dental offices have oil and water contamination, unless extraordinary efforts have been made
to get clean air. Poor air quality will affect the bonding results.) The priming agent has now pene-
trated the decalcified collagenous matrix of the dentin. Acetone will be left on the surface as a
result and must be removed, or it can continue to act as a solvent on any composite. Ideally, the
priming agent should be four molecules thick above the hybridization zone.
8. Light cure the thin layer of Prime & Bond. It is thought that this is necessary to allow the passage
of fluoride through the primer layer.
9. Apply the Dyract compomer. Do not coat the hybridization zone with an adhesive or Fluoride can-
not penetrate through the primer layer.
10. Apply the final restorative material of choice. Use an instrument to create a light hole in the
restoration. Just put a perio probed in and wiggle it about. Light cure.
11. Before the procedure, check the occlusion by grasping the angle of the mandible with the thumb
and forefinger and feeling the vibrations of the closing mandible. Now that the procedure is fin-
ished, do it again. If it does not feel the same, adjust the occlusion until it does.

Composites bonded to enamel

This category includes sealants (unfilled, minimum filled); flowables, microfills, hybrids, posteriors,
anteriors. Bonded composites are the materials of choice when used as enamel replacement materials.
Their characteristics include: good wear, strengths that approach that of enamel, and excellent esthetics.
The disadvantages of composites bonded to enamel are: most do not release fluoride and have no fluo-
ride re-uptake mechanism. Also an excellent seal must be achieved to impart caries resistance. There is
poor dentin bonding when not used with a direct dentin bonding agents.

Composites used with a direct dentin bonding agent

When used with direct dentin bonding agents these materials have excellent sealing characteristics of
dentin with the exception of the axial proximal box floor of complex restorations. This method will desen-
sitize dentin and shows increased strength of the tooth/restorative unit.
There are several disadvantages of this material, which include the following: no fluoride release and
re-uptake, leakage in the proximal box, and shrinkage towards the light source (which can be minimized
with an argon laser light source).

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Mastering Clinical Pediatric Dentistry Volume 5, Number 3/1997

Composite/glass ionomers
If the proximal box marginal seal is questionable, use an autocure glass ionomer base. Glass ionomers
may be laminated with a composite overlay at a later date.
A composite compomer laminate can be used where maximum aesthetics are desired. This restoration
is used to impart maximum strength to the tooth/restorative unit.

Clinical principles to better dentinal bonding

1. The more time you spend from start to finish, the greater likelihood of introducing a bonding error,
affecting the longevity of the tooth/restorative unit.
2. The periphery of any hydrophilic bonding procedure must be secured to prevent moisture contami-
nation.
3. After acid etching the collagen matrix is very fragile. Over-drying, over-manipulation, over-wetting
with water will and does affect bond strength. The term “wet dentin bonding” is unfortunately very
misleading and has probably led to more unsuccessful bondings than any other single element. “Wet
dentin bondings” is a myth. “Damp dentin bonding” accurately describes bonding to dentin with a
hydrophilic material. Place dentinal bonding agent in a pool and gently scrub.
4. Over manipulation of any procedure will result in the introduction of fatal bonding errors.

Technique for large composites; displacing the need for indirect inlays
1. Prepare the tooth with the removal of the minimal amount of tooth structure.
2. Achieve complete control of any sulcular moisture contamination. This may be done with the rubber
dam or flap procedure.
3. Initial buildup of fluoride containing material with fluoride re-uptake mechanism, e.g., Dyract, glass
ionomer. If glass ionomer was used, then air-abrade, followed by etching. If direct dentin primer was
used, then proceed with layering.
4. Place fabric reinforcement material with coating of flowable composite on the floor of the prepara-
tion. The recommended flowable/stackable material is Ultradent PermaLute, a dual cure. The rec-
ommended light is an argon laser.
5. Continue layering buildup of posterior composite. May add more fabric or composite ball to improve
interproximal contact.
6. Adjust the occlusion and apply a final sealer.

If the cusp needs to be cover or shoed, do an indirect or laboratory technique. Currently ArtGlass is
being used.

Ribbond® Bondable Reinforcement Ribbon

This video entitled, Ribbond ® Bondable Reinforcement Ribbon, is produced by the Ribbon, Inc.
1-800-624-4554, fax 206-382-90354. In the video are several excellent techniques that should be brought to
the attention of advanced practitioners.

Ribbond® Composite Bonded Orthodontic Retainer

The first technique is to make a lower lingual post orthodontic retainer, which would replace the stain-
less steel wire retainer with two stainless steel bands. The technique is simple, but requires care in doing
the procedure. The first step is to determine the amount of Ribbond that is going to be used. This is
accomplished by placing tin foil against the teeth in question and removing it. The foil is flatten and mea-
sured. This measurement guides the operator in knowing where to cut the Ribbond®.
Cotton pliers are used to remove the Ribbond® from the sealed package. Ribbond® comes in several
widths, 2, 3, 4, and 9mm widths plus and orthodontic width. The cotton pliers are used to handle the Rib-
bond® because oils from the skin or powder from the gloves, will contaminate Ribbond®. Therefore, never
touch Ribbond® unless it is covered with resin.

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Mastering Clinical Pediatric Dentistry Volume 5, Number 3/1997

Ribbond® is the same material used to make bulletproof vests and must be cut with a special shears
which comes with the kit. Most shears will not cut it. After cutting Ribbond® to the desired length, place it
back in the original package and seal it to extend the shelf life. The cut Ribbond® should be placed with
cotton pliers on a clean mixing pad until ready for use.
Prepare the lingual surfaces of the lower incisors for bonding in the standard manner. The use of a rub-
ber dam greatly increases the chances for success. The teeth can be cleaned with pumice or a microetcher
(air abrasion would be great). Acid etch the teeth.
Place unfilled bonding adhesive on the etched surfaces. Cure the layer. Using a Centrix syringe, apply a
thin layer of hybrid composite. Use the lightest shade of incisal or translucent available. This acts as the
“glue” to hold Ribbond ® in place.
Ribbond® must also be bonded. Therefore, use the same unfilled resin to wet the Ribbond®. All that is
needed is a few drops. Use a lint free gauze to remove the excess adhesive, by blotting the surface of Rib-
bond®. With the unfilled resin on the Ribbond®, it is permissible to touch it with clean fingers or washed
gloves.
Using washed gloves and an instrument, push Ribbond® through uncured hybrid resin and onto the
teeth. Pull on one end, while pushing with an instrument, just like placing a retraction cord for a crown
impression. Use your fingers to hold Ribbond® in place. Once adapted, remove excess composite. Make
sure the gingival embrasures are wide open. Cure the splint. All the strength that is needed is in the Rib-
bond® layer.
The splint needs an additional smooth layer to cover the Ribbond®. Therefore, paint a layer of moder-
ately filled composite over the splint. This can be the same material used to bond porcelain veneers, which
can withstand the wear. Cure the layer. Check the occlusion and remove all occlusal traumatic contacts.
Ribbond® does not polish well so be careful when finishing the composite. Finally, cure with a large and a
small tip.

Key points for success:

1. Absolutely clean teeth-Use a rubber dam as all the failures reported have been at the enamel-resin
interface.
2. Adapt the Ribbond ® closely to the teeth.
3. Remove excess composite prior to curing.
4. Add a smoothing layer of composite by painting it on.
5. Balance the occlusion.

Ribbond® Composite Laminated Bonded Bridge (direct or indirect)

This technique could be useful for cases of fractured roots that necessitate the removal of the roots, but
the crown can be used in the bridge, or an avulsed tooth which because of the length of time that it has
been out of the mouth or other factors such as fractured labial plate of bone, make replanting an unlikely
success. Use the patient’s tooth and bond it in place with this technique. It can also be used with pontic
teeth. It may be done directly in the mouth, but it proves easier to do it on a model then bond it in the
mouth. The advantages of this technique over traditional methods are: better bonding, better esthetics as
the abutment teeth are vivacious, translucent, and natural, less labor intensive.
To begin the technique, place the rubber dam on the teeth. Clean with pumice or air abrade, acid etch,
apply bonding adhesive in a thin layer and cure. Use unfilled composite as cement for the bridge and place
with continual pressure to avoid “suck back” of air and open margins. Contour the interface. Be sure that
there are adequate spillways. Use small curing tips for the interproximal areas, finish, check occlusion, pol-
ish and post cure. These bridges are exceptionally strong esthetic and non-invasive.

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Mastering Clinical Pediatric Dentistry Volume 5, Number 3/1997

Ribbond® Composite Endodontic Post and Core

The advantages of using Ribbond® for a post and core include: it is translucent, esthetic, minimal
removal of sound tooth structure (very important for young permanent teeth), adapts to natural contours
and undercuts of the pulp chamber, and it acts as a uniting structure for the tooth rather than a wedging
structure which tends to fracture the tooth.
Using a needle tipped syringe, place moderately filled composite into an acid etched prepared root
canal. Take previously cut piece of Ribbond® and covered with unfilled resin and using a gutta percha con-
densation instrument with a V shaped notch on the working end, push the Ribbond® down the canal. The
instrument engages the Ribbond ® and makes for an easier condensation within the canal. Push until it
touches the apical end of the prepared canal. Continue to condense until Ribbond® is filled to within 3 mm
of the coronal opening. If space permits, place a second piece of Ribbond® in the same way, but so that the
emerging ends of Ribbond ® are at right angles to the first piece. Since a dual cure composite is being used,
it is essential to place quickly. To form the core, place composite in the center of the emerging ends, and
wrap the Ribbond ® over the composite and cure. A rotary diamond instrument is used to shape the core.
The end result is an extremely strong retentive post with an esthetic core.

Reinforcing a Provisional Bridge

The advantages of this technique are that Ribbond® chemically bonds to acrylic, the bridge is strong and
esthetic.
This technique is useful for long span and/or long term provisional bridges.
Ribbond® is placed during the construction of the bridge. First measure the length of the bridge on the
cast, cut Ribbond ® to this length. Wet Ribbond® in acrylic and place acrylic dough in the clear crown and
bridge splint and seat on the teeth of the cast. When the acrylic is in the doughy stage, remove for the cast.
Take a scalpel and cut through the dough at the depth of the contact points to make a trough for
Ribbond®, which is placed by using 2 cotton pliers (on each end of Ribbond®). Reseat the bridge on the
cast.

Emergencies
Ribbond® can be used for splinting of a natural tooth that has been avulsed for more than 2 hours.
Remove the root and use the crown and Ribbond® to attach the tooth from the lingual.
It is also useful in repairing broken orthodontic appliance as well as prosthesis.

Improving Practice Profitability was presented by Dr. W. Charles Blair at the Excellence in Den-
tistry, Inc. seminar in Keystone, Colorado, August 7-10, 1996. 1-800-536-2996
One of the basic ways to increase profitability is lower the cost of the business of dentistry. There are
several barriers to this end as the dentist may work in the practice but not on the practice. Time should be
spent on analysis of the business of dentistry and then take steps to correct the areas that need it.
What acts as a barrier is often the problem of too much stress and/or burn out. However, the practice
should be profitable between 35 to 45 per cent of the gross income. To reduce stress there should be a sav-
ings program and a debt reduction program. Additionally, the dentist’s life should be made simpler rather
than adding to the stress. This can be done with a good retirement plan, spending time in the practice and
with the family.
The trends in dentistry are basically good. As an industry the growth factor is up. The per capita spend-
ing is up. Generally, busyness is up as manpower is decreasing due to less dentists being graduated each
year and those that are graduated are not practicing full time (about 50% are women who chose to take
time off to have children); however, our professional independence is being challenged by OSHA, other
government programs, insurance companies and other third party systems, etc. So the issue is how can we
be more profitable?

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Mastering Clinical Pediatric Dentistry Volume 5, Number 3/1997

What has been the impact of healthcare reform to dentistry? The fees and income of the dentist have
gone down, while working longer hours. The specialists have been hurt because the general practitioners
have expanded into their areas. The management information systems have improved as well as the finan-
cial management systems.
There are four basic overhead problems. The first is the fee schedule. Lack of high enough fees will
lead to low profitability. So, set the proper fee schedule. The second factor is the labor cost. This must be
controlled and measured. Later there will be a discussion on how to measure labor costs. The third factor
is the facility costs, lack of business increases the cost of the facility per patient. Finally, is the problem of
collections and discounts. The collections of the office should be at 98% or better. Why? In most offices
40% is from insurance companies, 40% is collected at the time of the procedure, which leaves 20% to be
billed. If 2% out of 20% is not collected, that means 10% is not being collected in the receivables! And
not 2% as some would have you think.

How do various areas of dentistry compare to their overheads?

Area of Practice Overhead Reasons
Prosthodontists 62-67% (About 18-20% of gross is a lab bill; however, due to the longer
appointments, they have lower labor costs.)
GP 60-65%
Pedodontists 57-62% (low lab costs, high labor costs)
Periodontists 55-60%
Orthodontists 50-55%
Oral Surgery 45-50%
Endodontists 35-45% (No lab fees, no hygienists, few supplies, smaller staff, longer
appointment with a higher fee.)

How do you use this information, when you are practicing in a specialty area? The goal should be to
achieve the same profitability that the specialist of that area achieves. Additionally, one should do more
procedures on less people to increase profitability.
Where should you be in production? The average practitioner produces $350,000 of dentistry per year.
That is about half of the dentists produce more. Therefore, taking into consideration the stress of produc-
tion vs. the dollar made, a reasonable goal is to produce $450,000 to $500,000 per year.
The net of that production should be around 40 to 45% total pay to the dentist. The net return to the
dentist includes direct compensation which is taxable, indirect compensation which is not taxable, e.g.,
medical insurance, disability insurance, seminars, family employment.
What reduces the net income to the dentist is the overhead expenses, which are of three types: variable
costs, which increase directly with more production, e.g., laboratory costs and supplies; fixed costs, which
are not related to production, e.g., rent, malpractice insurance; and step-fixed costs, which incrementally
increase with more production, e.g., part time labor.
There are six major types of overhead categories: labor (step-fixed), supplies (variable), laboratory
costs (variable), facility and equipment (fixed), administration (fixed) and marketing (step-fixed).
Labor costs are difficult to control because they are not well measured. Let us look at some means of
measuring labor costs. One method looks at the revenue per full time employee which is about $80,000 to
120,000 per employee. Another measure looks at the gross revenues and states that labor costs should be
about 24 to 29%.
Others find that labor costs should be 24 to 29% with a hygienist in the practice and 18 to 22% without
the hygienist. Still another ratio is the dentist (40% of revenue) to staff ratio (30% of revenue), which
should be around 120 to 160%.
When calculating the total compensation be sure to include all of the following: gross pay 20-23%; pay-
roll taxes 2-2.3%; fringe benefits 1-2%; retirement plan 1-3% for a total compensation of 24-29% of gross
income.

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Mastering Clinical Pediatric Dentistry Volume 5, Number 3/1997

One of the ways to lower labor costs, is to pay per hour rather than a salary. This routinely saves about
5% of the labor costs, and it is fair to all.
Another way to lower labor costs is to use part time personnel. They are more time and task sensitive,
they augment the full time, and usually do not have benefits.
Still another way to lower labor costs is to out source as much as possible. Tasks like payroll, accounts
payable, hard-nosed collections, errands should be out sourced.
How many front desk personnel should the office have? One measure is in the thousands of dollars per
month. The office should have one front desk personnel per 25-35 thousand per month. Another measure
is the business efficiency factor which is calculated by dividing the front desk labor costs by the total col-
lection. The result should be about 8-12%.
A clinical analysis of labor costs is to divide the clinical labor cost by the collections of the dentist and
this should be about 7-10%. This ratio is very dependent upon the speed of the dentist in doing
procedures.
To increase the speed of the dentist or the efficiency of the dentist the following should be done: all
operatories should be identical, use trays or tubs, there should be a procedure system so that the dentist
does not ask, double supplies for back up, question time and motion.
How does the front desk schedule for greater efficiency of the dentist? Use a long morning schedule of
5 hours where the high ticket items are done and using long appointments to keep the cost factors down,
like less labor. Schedule a shorter afternoon session with short appointments using part time help to assist
the full time help. Also this is a good time to see new patients. When new patients call for an appointment,
see them that day. This is when they are most interested in your office so seize the day!

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