The Real Cost of In-Office Milling



Computer aided manufacturing (CAD/CAM) is all the rage these days and with it people can create everything from the simple to the complex: jewelry, tools, machine parts and toys. Considering the widespread utilization of this type of technology, it’s no surprise that CAD/CAM machines are in widespread use throughout the dental industry. In-office milling machines—which are used to create dental crowns—are the most common examples of this type of technology.

The principle of these computer aided manufacturing machines is pretty simple: First, a dentist takes a digital impression of a patient’s mouth. Then, that image is sent to the machine’s computer. The dentist then uses the machine’s software to design the dental restoration. Once the design is complete, a small porcelain block is placed in the machine and the milling process begins. After the base crown has been milled, the dentist must hand-polish the crown. To give the tooth’s surface a more natural appearance, a natural coloring is then applied. Next, the crown is placed inside a porcelain oven for firing or curing. Finally, the dentist polishes the tooth again and seats the crown in the patient’s mouth.

Ideally, when these types of machines are used, patients can have a crown completed in a day because the dental office has become the lab. This idea of same-day dentistry has caught the attention of many dentists throughout the country as a way to stay marketable in an ever-changing industry.

But are such machines really helpful or necessary? Are they the most productive way for dentists to run a practice? Will in-office milling machines truly allow dentists to do the type of dentistry that will differentiate his/her practice and stay competitive?

‘Ideal’ versus ‘Real’
As noted earlier, some people claim that in-office milling machines will make dentistry more efficient, productive and profitable. The companies that produce these machines often claim that by eliminating the middleman (i.e., a dental lab), dentists who invest in this technology should be able to significantly cut their expenses, attract more customers, and reap greater financial benefits for their overall practice.

But does this technology truly perform as the companies claim? Are such machines really the ‘genie in the bottle’ that will make all your dreams of profitability come true? While such claims may be true for some dentists, they definitely are not true for a majority of dentists. Before a dentist decides to invest in any kind of advanced technology, it’s best to conduct a thorough examination of their business model and make sure that the decision to buy the product is based on what’s best for the business and not on hyped-up claims.

So how do dentists effectively evaluate whether or not these particular devices will benefit their practice? I advise using the following strategies, which I teach in my “Know Your Numbers” course.

Don’t Get Wowed By the Latest and Greatest
First, don’t let new technology wow you too much with it’s flashiness, impressiveness and promises of profitability. Just because a particular machine is the most advanced gadget on the market doesn’t mean that you need to have it. It might be great, it might do great things, but the real question is, will it really benefit your practice or will it just end up becoming a very expensive dust collector in the corner of your office?

When I am evaluating a piece of equipment or device for my office, I ask myself a series of key questions. These questions help me determine whether or not the technology that I am considering will be a good fit for my office. I would recommend that other dentists consider asking themselves these questions—or something similar—as they contemplate making major purchases for their businesses:

• How long will it take for the equipment to pay for itself?
• Is the equipment easy to learn?
• Can it be implemented into my practice immediately or are 
additional investments in training     and resources required?
• Will my staff be willing and able to operate the equipment or will I need to use my time to           operate it?
• If my staff can operate it, will I need to hire another full-
 time person to manage its operation?
• If I have to operate it, how much of my time will be spent
 each day actually using the                 equipment and how much is 
 that ultimately going to cost in chair-side production?
• Will I get a chance to use the equipment before I buy it?
 (Will my staff get a chance to use it       as well?)
• Is my staff enthusiastic for the new equipment to be added 
to the office?
• Will the equipment enhance the type of dentistry I want 
to do or does it dictate the type of           dentistry I have to do?
• Hypothetically, if I bought this tool and then had to give
 it up, would my dental practice’s             productivity be negatively 
 impacted, positively impacted, or would there be no measurable         impact?

Essentially, the questions are meant to provide a quick evaluation as to what an overall return on investment (ROI) might be. Such questions help me to understand the real cost of equipment ownership and not the ideal cost of ownership that is presented to me via flowery sales pitches.

Evaluating the Real Cost
My second piece of advice is that you understand the finances of your specific business before making any major purchases. Do you really know how much money it costs to open your office every day? If not, then you should find out and you should know this figure before you write a check for an expensive gadget. In-office milling machines, for example, are extremely expensive, ranging between one-hundred-thousand to one-hundred-thirty thousand dollars. Of course, the sales teams will convince you that you will make this money back in no time because you will no longer be sending cases to an outside lab.

However, you must evaluate whether this machine is something you can afford and estimate how long it will take for the machine to pay for itself. You certainly don’t want to get in over your head financially because that affects the type of dentistry you can perform. You should be in charge of the type of dentistry you offer in your practice. You don’t want a machine—which you just shelled out six figures for—to determine what you can offer to your patients. For example, if you have a case that really would benefit from an outside lab making the crown, you don’t want to make the crown in-house just because you want to utilize a costly machine.

A basic idea in economics is opportunity cost. Everything has a cost. If you choose to do one thing, the opportunity cost is losing out on being able to do something else. From a financial standpoint, it is best to choose things that have the lowest opportunity cost. For example, if you decide to buy an in-office milling machine, what is its real opportunity cost? You can determine this by using several different variables. First, consider that if you pay six figures for the machine, you will not be able to use that money to buy something else. Maybe there is another piece of equipment that would have reaped greater rewards for your office and now that you’ve tied up your money, you won’t be able to purchase it. Also, if all your capital is tied up in expensive equipment, you may no longer have the ability to retain key talent, which could result in a high turnover rate among your staff.

You must also consider the opportunity cost in your overall level of productivity. If you purchase one of these machines, what role will you be playing in its operation? If you have to actually make the crown yourself, you have now taken yourself out of the role of dentist and instead have become a dental lab technician. How many patients are you unable to treat because you are fulfilling a role that was once filled by someone else? If you decide to hire a full-time employee to run the machine and make the crowns, that too has a cost. How much will their salary cost you? How much will it cost you to train that person to run the machine? Training—whether internal or external—costs both money and time.

In addition, think about the physical logistics of where the patients (for whom you are milling the crowns) will wait for their crowns to be completed. Will you ask them to just ‘hang out’ in the chair for an hour or so waiting for the machine to finish? Probably not. Therefore, you will likely need to determine where patients can sit while they wait for a finished crown. You might end up having an additional cost of extra waiting rooms or furniture.

Along with such costs, dentists who consider purchasing in-office milling equipment must also evaluate the operation costs for the equipment itself. The six figures you initially paid isn’t all the money you’ll need to invest and run the machine. All machines require regular maintenance and repairs, software updates, etc., which definitely lengthens the ROI on the device. Oftentimes, the most expensive machines require the most expensive repairs and maintenance-related issues. Moreover, just like a photocopy machine needs paper and toner to run, a milling machine also needs similar supplies. One of the main ancillary supplies is the porcelain milling blocks, which (while not extremely costly) are an expense that will accrue over time.

Dentists should also consider the question of redundancy. What happens if the milling machine breaks down for a period of time? Either you will need a backup machine for the office, or you will need to send all of the cases out to a lab. The first solution of having an additional backup machine doubles an already large investment. The second solution also has its own set of problems. If you’ve been making all of your crowns in-house on a milling machine, you may no longer have a relationship with a lab and therefore no lifeline to call when you need someone who knows you and is readily familiar with the way you like your cases handled.

Here’s a specific example of ideal cost versus real cost. A recent advertisement for an in-office milling machine claims that it only takes “9 crowns a month” to recoup an investment on the equipment. However, by completing a simple mathematics calculation with the numbers presented in the advertisement, I quickly deduced that according to their price point, it would cost 180 dollars per crown for the machine. That figure doesn’t include the other costs associated with milling machine ownership, such as time, materials, staff compensation, updates, repairs, training and retraining. After taking the time to crunch the numbers, this particular sales pitch did not add up. That is why I evaluate equipment purchases carefully and from all angles before making an investment.

Unforeseen Problems
Dentists considering expensive purchases (such as milling machines) must also understand that sometimes unforeseen problems arise with the technology. For example, there is a learning curve in creating the perfect crown on a milling machine. During the learning period, mistakes are possible—even likely. Such mistakes cost money, time and can impact your reputation. Here’s a possible scenario: you spend the time to make a crown on the machine, yet for some reason the machine wasn’t exactly set just right or your prep wasn’t exactly perfect and the resulting crown doesn’t fit the patient. The incorrectly created crown has cost you both time and money.

Patient Expectations
The big argument for in-office milling machines is a competitive advantage: “You must buy one because if you don’t, patients will go to another office where they can get the same-day dentistry they want and expect.” I totally disagree with this idea. Most patients don’t care about same-day dentistry. Most have never even heard about this option or the technology of in-office milling.

Patients generally care about the following considerations when choosing a dentist:

• Is the dentist close to where I live or work? Is it convenient 
 to get to his/her office?
• Does the dentist accept my insurance?
• Is the office clean?
• Is the staff nice and efficient?
• Is the dentist proficient enough not to hurt me while he or 
 she completes a procedure?

Rarely do patients care about whether or not an office has the latest and greatest technology. Patients look to build a long-term relationship with a dentist—they want to find someone whom they can trust and who has their best interests in mind. They aren’t looking to build a relationship with a roomful of expensive machines. Sometimes those machines can actually be a detriment to attracting patients. Patients may look around a room with expensive gadgets and think, “Wow, this is why the dentist charges me so much—this equipment must cost a fortune!”

Make a Wise Plan
I’m certainly not suggesting that dentists should never consider purchasing equipment to make their practices better. That is not a practical mind-set in the world we live and work in today. However, dentists must be smart with their purchases. I write from personal experience on this matter. There are some pieces of equipment that have made a tremendous impact on my practice and there’s no way that I can imagine doing business without them. On the other hand, there are other items that literally have become proverbial “white elephants.” They never reaped financial benefits and they have now become very expensive dust collectors.

When you decide to make your purchases, keep the aforementioned tips in mind. Analyze the financial state of your practice and evaluate how this equipment may benefit you as a dentist and business owner. Don’t let pressurized sales pitches influence your decision. You are the leader of your own practice. Find out the facts, know and understand your practice and finances, and make an educated decision that is based on real knowledge rather than emotions. If you do, you won’t cringe every time you see that six-figure, dust-collecting-white elephant sitting in a much-avoided corner of your office. Instead, you’ll make wise equipment purchases that will benefit your practice in profitable and effective ways.

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Dr. Jim Downs received his DMD degree from Tufts University School of Dental Medicine in Boston, MA. His post-dental education includes numerous prestigious institutes in advanced restorative fields, such as dental implants, temporomandibular dysfunction and occlusion, full mouth rehabilitation, cosmetic dentistry, lasers, office management, and leadership training/mentorship. Dr. Downs has placed more than a thousand implants since 1989 and has restored numerous full mouth cases. Dr. Downs’ extensive knowledge includes many modalities of dentistry, and he intertwines such principles with a down-to-earth, caring sensibility. Dr. Downs has lectured extensively in the U.S.A. and abroad and has published many articles on dentistry. He is currently the clinical head instructor for the Dr. Dick Barnes Group in Salt Lake City, UT, and practices dentistry at Denver Dream Dentistry in Denver, CO.


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