First Impressions Magazine

Something to Smile About
Cosmetic dental procedures help consumers look and feel their best. They’re also a booming market for distributor reps.
Laura Thill

Call it a revolution. Advances in materials and technology have led to a booming cosmetic dental industry. For distributor reps, that means positioning themselves to educate their dental customers on the best products for their practices.

Evolution in materials and techniques make it necessary for dentists, lab technicians and distributor reps to work together, according to Michael Sesemann, DDS, FAACD, vice president of the American Academy of Cosmetic Dentistry. "On one hand, this is an exciting time to be in the dental field," he says. "On the other hand, [dentists] have to effectively separate the substance from the hype of a new or improved dental commodity. That is a big responsibility."

Defining cosmetic dentistry
Cosmetic dentistry refers to a broad range of procedures "which make an individual’s smile and appearance more attractive and functional," says Susan Marcus, East Coast sales manager at SDI Inc. (Bensenville, Ill.). "This can include whitening or an entire makeover, or procedures such as composite restorations, crowns, veneers, bridges, implants, orthodontics and crown lengthening." As long as the supporting structures of the oral cavity are healthy (or appropriately treated following an evaluation), most patients are candidates for whitening or restorations, she adds.

Today more than ever before, cosmetic dental techniques are incorporated in general dentistry, says Sesemann. Of course, different practices emphasize aesthetic dentistry to various degrees. "However, all of the patients who receive dentistry from us expect it to be aesthetic in that it represents a natural appearance," he points out.

Irwin Smigel, DDS, founder and president of the American Society for Dental Aesthetics and developer of the "bonding" technique in the early 1970s, believes aesthetics motivate up to 80 percent of his patients’ visits. "Today, it is a different world," he says. "Patients want their teeth to look more alive and whiter.

"And, the competition for dentists has gotten very stiff," he continues. "Patients don’t want to visit a dentist today unless he can show he is aesthetically aware."

Indeed, patients of all ages and backgrounds are interested in cosmetic dentistry today. As people live longer, healthier lives, "older individuals previously house- or wheelchair-bound are now vital to our economy and the growth of our country," says Marcus. "Their desire is to be physically, aesthetically and mentally vital." And, both genders are interested in health and cosmetics, she adds. "More men ask for tooth whitening and restorative procedures than in the past.

"Our younger generation of children, teens and 20-somethings, [who compete in] school and the workplace, want to look like celebrities and athletes," she continues. This makes them especially focused on cosmetic procedures. Add to this "instant communications, peer pressure at all ages and increased consumer awareness of health risks and medical advances to increase longevity," she says, pointing to a slew of television makeover, reality and fitness programs and infomercials, all of which draw consumer attention to aesthetics and appearance.

The power of television changes everything, adds Smigel. "When I first developed bonding in the 1970s, no one was aware of it," he says. All that changed years later, however, when he appeared on a television show called "That’s Incredible" and performed cosmetic bonding on a dancer whose teeth were badly darkened. "I made her teeth white, and suddenly I was receiving four or five bags of mail daily from people who wanted this procedure."

But, whether patients become informed about aesthetics and restorative treatments through television, newspapers, Internet or word of mouth, the most competitive dentists keep in mind how important it is to offer a wide range of cosmetic services.

"In my practice, we place no limitations on helping people feel better about their visual appearance," says Sesemann. "After careful communication to accurately determine what patients’ desires are, we … suggest ways they can obtain their objectives.

"I recently completed a case of porcelain restorations on a 72-year-old woman in good health," he continues. "She was a practical individual who had seen world wars and had lived through the Great Depression. But, as an active person in the 21st century, her oral presentation did not project how she felt about herself. It was one of the most fun cases I’ve ever done. We [knew] she had been wanting to make this change for years. It was an emotional experience for her, my staff and myself."

Advances in technology
As stronger materials and more efficient technologies make it easier for dentists to offer cosmetic procedures, some practitioners find it increasingly necessary to handle such cases with an interdisciplinary approach. Sesemann, for example, has been borrowing from various dental fields to create more aesthetically pleasing end results for his patients, "Including various periodontal procedures, such as gingivoplasty or crown lengthening, [ensures] a greater opportunity to satisfy bilateral dental harmony of contralateral tooth shapes," he explains.

Whether dentists complete a restoration in their office or rely on a lab technician to handle part of the process, the industry is "drastically different" today, he continues. In fact, he expects optical impressions [which use CAD/CAM technology] to replace traditional impressions in the average practice very soon. To skeptics, he says, "I only need to point out how quickly CAD/CAM dentistry is changing the methods we use and materials involved." CAD/CAM (computer-aided design/computer-aided manufacturing) in the dental industry refers to mini-cameras capable of taking more accurate pictures of the teeth than traditional cameras.

Traditionally, dentists have taken an impression prior to constructing a crown. "If the impression is no good, [he or she] must take it over again," says Smigel. "Today, CAD/CAM provides much more accurate pictures of the patient’s teeth. It is still too expensive for [many] dentists to carry, but it’s the future."

"As a dentist it is my responsibility to keep up with change and modify my methods of providing services in order to satisfy the big picture," Sesemann adds. Better materials also have contributed to more proficient and easier bonding procedures, he says. "We have very good materials that are being tweaked by manufacturers to become even better. The search for an easy bonding system that provides clinical predictability similar to fourth-generation, three-step total etch systems will happen one day, permitting clinical superiority over time."

The availability of glass isomers also add a new dimension to cosmetic dentistry through "their ability to provide rechargeable fluoride and [facilitate] the re-mineralization of hydroxapetite," adds Marcus. "All composites have been shown to leak, but glass isomers have shown the least amount of microleakage."

Glass isomers also can be used as a pit and fissure sealant, or for core build-ups, she continues. "This material’s properties help rebuild tooth structure, making the tooth less susceptible to recurrent decay," she says, adding that glass isomers have also improved the delivery of fluoride. Capsules and paste packs enable dentists to easily formulate them, with little variability from one patient to the next, and with better long-term outcomes, she notes.

For Smigel, newer, better dental materials have helped him refine old procedures. "Today, we build out dentures into the face muscles so that patients look better," he says, likening the procedure to a non-surgical facelift. And, rather than constructing crowns with porcelain over gold, dentists have switched to zirconia-oxide, which is stronger and more aesthetically pleasing, he adds. Adult patients are not the only beneficiaries of improved products. "Pediatric dentists now use tooth-colored fillings for children, just as dentists do for adults," he says.

What’s the payoff?
While dental customers may drool over new, high-tech devices and systems on the market, they also might balk at the higher price tag these items carry. No doubt, they will look to distributor reps to spell out the payoff of adding new procedures to their practices.

Sesemann says that such procedures as whitening, which can be delegated to the dental staff, generate revenue more easily than higher-tech procedures. "Once the cost of materials, the expense of new equipment and the training of staff is factored into the equation, the profit [of some new procedures] isn’t necessarily what it appears to be up front," he says.

"With all technology, there must be an acquisition strategy for the dental office," he continues. "I wince when I hear that new dental graduates have placed their practices in debt because they had to have a certain technology to appear competitive to their patients. At times, there are alternatives that can provide the same service at a reduced cost."

"I love my soft-tissue diode laser," he says, adding that it enables him to "work within an interdisciplinary manner." Still, he believes he could do the same procedures 15 years ago using a much less expensive electrosurgery unit, and achieve equally accurate results. "I’m not saying don’t buy soft-tissue diodes," he explains. "However, I’m glad there was a suitable alternative when I came out of dental school, and that I had the option to add laser when [I could afford it]."

For this reason, Sesemann urges dentists and their distributor reps to work closely and strategically when it comes to adding big-ticket items to their practice. Young dentists should start out with technology they need and then plan for the higher-tech, higher-cost systems down the road, he says. And while he acknowledges that dentists must bundle some products and technologies, distributor reps who help their dental customers pace themselves will find these customers are more loyal down the road. "A more profitable dentist will ultimately be a better long-term client," he points out.

Marcus agrees that some technologies are more affordable than others, but adds that if procedures are done well and marketed to patients properly, they can generate effective revenue for dental practices. "When the patient is in the operatory for a whitening procedure, that is the ideal time for the dentist and hygienist to identify the need for restorative procedures," she says. But, while some procedures are more costly than others, dentists should bill higher for these. Charges for dental procedures must take into account the education and time required to perform them, as well as their level of difficulty, she says. "Therefore, implant procedures, which are quite technical, command a high dollar price."

How much dentists can bill for certain procedures will vary depending on what part of the country they are located in, adds Smigel. "Prices vary across the country, and people who live in larger cities generally expect to pay more," he says. Regardless, new and expensive procedures are the future of dentistry. "As technology improves, it becomes very expensive, especially since only a handful of people take advantage of it," he says. "But, as the technology catches on, and more people have it done, the price generally drops." And, dentists must begin adding new technology to their practice sooner than later, since patients are coming to expect this level of service, he points out.

"Really, the only reason a dentist would not offer a newer procedure would be that [he or she] feels uncomfortable performing it," adds Marcus. "But, once dentists receive the additional training needed to complete these procedures, they [are sure] to offer them to their patients."

Future trends
For Smigel, the future of dentistry is now. "When I appeared on ‘That’s Incredible,’ I thought bonding was the future," he says. "Then veneers and whitening came along, and I thought that was the future. Really, the future is always evolving." So, newer methods, such as Invisiline, which is an alternative to braces for straightening teeth, are today’s future of dentistry. In many situations, patients who have all of their adult teeth can avoid wearing braces and still successfully move their teeth, he says. "Tooth-colored trays gradually straighten the patient’s teeth," he explains. "And, if I take very good impressions (e.g. optical impressions), I can predict how long the patient will need treatment. Using computers, I can even see how the patient will look after treatment."

In fact, 3D computer technology reportedly can simulate the complete treatment plan, from the initial position of the patient’s teeth to the final one. A series of custom appliances, or trays, as Smigel calls them, are produced from the digital image. Each tray is worn for about two weeks, and the final tray serves as a retainer.

"At least 40 percent of people [who require teeth straightening] can use trays over braces," he adds. "But, this is not a good treatment plan for patients with extreme overbites." Some dentists have recently begun using trays on children, but Smigel would like to see more long-term results before he supports this.

Experts expect that dental materials will only get better in years to come. Systems such as CEREC, by Sirona Dental Systems, which restores teeth with ceramic should become more accessible to general dentists as the price drops. "It’s still too expensive for most dentists and patients to afford, but it’s the future," says Smigel.

The tooth-colored ceramic material is considered stronger than amalgam, gold and metals, which have been traditionally used to repair decayed or damaged teeth. Because ceramic materials are said to closely match the composition of the patient’s natural tooth structure, the restored tooth can expand and contract more easily when the patient eats hot food, followed by a cold drink, reducing the risk of cracking.

"The future of dentistry is quite exhilarating, as well as scary," says Sesemann. It is exciting to be involved in the continuously new developments, he explains. But, it can be overwhelming for dentists to ‘bring it all together and make it work in the context of everyday life," he says.

Patients today expect to look better after their visit to the dentist, says Smigel. That’s why dentists will continue to feel more pressure to deliver cutting-edge aesthetic services. And why not? "When I give presentations, I always ask my audience, ‘who owns your face?’"

"You do," he says. [FI]

Taking the lead With the right approach, distributor reps can help their dental customers assess their need for cosmetic services. Following are 10 leading sales questions distributor reps may ask their dental customers:

How would you like your dental practice described in the community? What are your clinical strengths?
What procedures do you currently provide at your practice?
What procedures do your dental hygienists or dental assistants provide? Would you like to expand these?
What procedures do your new patients ask about? Do you currently offer these procedures at your practice?
Do your patients seem to be concerned with their overall appearance and the appearance of their teeth?
Do your patients comment on their smile during their visit?
Does your dental/medical history questionnaire include a‘smile’ questionnaire?
Are there procedures you have wanted to add to your practice? If so, what are they?
What restorative procedures do you currently offer at your practice? Would you like to expand these?
Do you provide in-office and take-home whitening treatments?

And, distributor reps should never leave a customer without offering to further educate him or her on new products and services that can make his practice more competitive.

Source: SDI Inc. (Bensenville, Ill.)

Brighter Whites

Whiteners provide good revenue source.
By Laura Thill

Most dentists are interested in learning about cutting-edge systems and devices, which enable them to provide their patients with cosmetic dental services. Fewer, however, are interested in paying for high-priced equipment.

Tooth whitening is one cosmetic procedure that doesn’t necessarily cost significant dollars, but can generate revenue for the dental practice, says Susan Marcus, East Coast sales manager, SDI Inc. (Bensenville, Ill.). "Patients tend to keep appointments for tooth whitening procedures more consistently than for examination or oral prophylaxis," she points out.

Usually, dentists rely on a combination of in-office and take-home whitening treatments, such as SDI Inc.’s pola whitening system, according to Marcus. In-office whitening is performed by the dentist in the dental chair using a high concentration of hydrogen peroxide (usually around 35 percent). Depending on the product used, the process takes between 45 minutes and 2 hours of chair time. Factors for distributor reps to consider when helping their dental customers select the right product include product results, length of time patient will be in chair, cost of the whitening product, degree of tooth sensitivity associated with the product, peer reviews and the tools required for performing the procedure.

Sometimes, dentists prefer products that the patient can use in the reception area, such as those containing high concentrations (e.g. about 35 percent) of carbamide peroxide. The patient wears a custom whitening tray for 30 minutes and is monitored frequently while sitting in the waiting area, says Marcus.

To facilitate the whitening process, dentists often send their patients home with a tray and either the hydrogen peroxide solution or the carbamide peroxide solution. Depending on the final result they are trying to achieve, patients wear the trays for different periods of time, she continues. Drinking coffee, tea or red wine can stain the teeth and affect treatment.

Dental customers should be informed about whitening products with built-in desensitizing agents, such as potassium nitrate and fluoride. They also should be educated on appropriate lengths of time for patients to wear whitening trays, in order to avoid tooth sensitivity. "The patient may not achieve the desired benefit, or [he or she] may harm the hard and soft tissues in his mouth," says Marcus.

In-office laser bleaching is also available to dentists and their patients, but it is costly and requires special equipment.