Sure they have the wow-factor, but what are the pathways for digital impressions to return on a dental sleep medicine practitioner’s investment? Here’s how several clinicians make digital dentistry pay off.
A few well-coordinated waves of a high-tech wand are all that’s needed for a 3-D image of a patient’s mouth anatomy to appear on the dentist’s computer screen. And for the patient in the chair who needs a custom oral appliance for sleep apnea, the wand’s capabilities are every bit as magical as those of the wands wielded by the classic fairytale characters of childhood.
The wand is one piece of an intraoral scanner; it projects light onto the teeth, gums, and other anatomy inside the mouth while its camera captures minute details. The other piece is the software, which takes the images or video (depending on the model) and triangulates their points of interest into a 3-D optical impression that is viewable on a computer.1 Abracadabra!: the traditional impression material vanishes from the dental practice—replaced with high-tech, gag-free impressions that fit into the workflows of everything from mandibular advancement devices to crowns and bridges.
But the price of an intraoral scanner—typically $20,000 and up—quickly brings reality back to the fore. For a dental sleep medicine practitioner, what is the return on investing in an intraoral scanner? Here, four dentists who create oral appliances for sleep apnea share how they recoup their costs with strategies such as creating devices faster (and getting paid faster), spending less chair time per patient (with the same or better outcomes), and being more mobile.
Ryan O’Neill, DMD, Tennessee
In the view of Ryan O’Neill, DMD, the ability to digitally acquire impressions for crown, bridge, and implant cases justified the intraoral scanner investment from day one. In the past year, he began taking digital impressions for all of his oral appliance and orthodontic cases too. “The financial rewards of owning an intraoral scanner have drastically increased since we started scanning full mouth cases, which can be quite expensive using a PVS [polyvinyl siloxane] technique,” says O’Neill, who splits time between his sleep apnea clinic Sleep Nashville and the four locations of Tennessee Family Dental, where he focuses on surgical procedures like dental implants and wisdom teeth extractions. “These types of cases fit in well into our ‘scan & send’ philosophy since we outsource our ortho and sleep to a third-party for design and processing.”
The amount of time that goes into an oral appliance case start to finish can be overwhelming. “Every small improvement in speed and decrease in cost can result in dramatic increases in overall practice efficiency and growth,” O’Neill says. “The ability to receive a case back from the lab more quickly (less than 2 weeks) allows us to submit a medical insurance claim faster, which gets us paid faster. This speed helps with office cash flow and communication with our referring providers.”
Since buying a digital scanner, O’Neill has observed a decrease in how often the practice brings patients back to take their impressions again and in the number of device remakes. “In the past, our lab would call us asking to take a new impression if there was a problem. Our intraoral scanner has all but eliminated that phone call from ever happening since we can approve the virtual model before sending it through the portal,” he says.
What’s more, the active time has decreased on average for two important stakeholders: patients and assistants. “I was surprised how much my chair time for the delivery appointment decreased due to a well-fitting appliance,” O’Neill says. “Additionally, my assistants are not having to stay at the office late to pour up models and ship the cases off on very busy days that we start several sleep cases.”
O’Neill’s recommendation for dentists considering an intraoral scanner is to think about two types of benefits in particular: cost and convenience. “If you have a high-volume office, the cost benefit alone may justify the expense,” O’Neill says. “Or the many convenient benefits of intraoral scanning could justify the expense: receiving a case quicker, less chair time, improved patient care, time saving pouring up models/shipping to a lab, and getting paid faster by medical insurance. It would be hard for me to imagine my sleep practice without an intraoral scanner due to these benefits.”
David E. Federici, DMD, New Jersey
At Federici Dental in Manahawkin, NJ, the two dentists—who are brothers—are exemplary in their willingness to share. The intraoral scanner they purchased in 2017 for single crowns, bridges, removable partial dentures (if no muscular issues), and oral appliance therapy scans gets a lot of use between the two of them. “We sequence the patient appointments so we don’t have simultaneous need for the scanner,” says David E. Federici, DMD. “We both knew from the get-go it was a technology we had to have once we realized our sleep medicine full mouth scans would be occurring very frequently.”
The 2-dentist, 3-hygienist practice offers general dentistry services—cleanings, white fillings, root canals, crowns, bridges, implant restorations, etc—as well as all-on-four dental implants (working with a local oral surgeon) and oral appliances for obstructive sleep apnea (working with a local pulmonologist). When it comes to obstructive sleep apnea (OSA), “we plan on ramping up our treatment of this disorder,” Federici says. “We have created an OSA patient education center in our waiting room with a video loop as well as a CPAP machine and oral appliances along with brochures. We currently send about 5 to 8 patients per week for sleep studies.”
The savings in traditional impression material does make a difference, Federici says, but that’s not the primary way he recoups costs. “The true savings is time and accuracy—as remakes and time inserting have dropped to barely any adjustments needing to be addressed. The time factor is both in scanning and no retakes of impressions as well as getting the cases back in half the time, which also means less temporary crown recementations and happier gum tissues with less time wearing a temporary,” he says. “And patients love the new technology and not having the goop in their mouths and retakes and gagging, etc.”
The fit of oral appliances now is generally “perfect,” Federici says, and he says the few remakes nowadays are typically restoration remakes related to shade—which, he notes, is not the scanner’s responsibility but the dentist’s.
One hiccup early on is the first intraoral scanner Federici Dental purchased actually hampered, rather than facilitated, the practice’s workflow. “We were lucky that the company who supplied the scanner we returned also supplies the new one we received. So in good business terms, they took the defective one back and credited what we paid on that toward the second one, which was more expensive,” Federici says.
Based on this experience, Federici advises dental sleep practitioners “go with tried and proven devices that fit your needs….If you will be doing larger full arch scans, the machine’s speed is the key to efficiency.”
Reza Radmand, DMD, FAAOM, Connecticut and Massachusetts
Reza Radmand, DMD, FAAOM, is frequently on the move. Though he has a stationary practice at Advanced Dentistry of Connecticut in Stratford, he spends almost half his time seeing patients in multiple healthcare facilities spread across not only Connecticut, but neighboring Massachusetts as well—a competitive advantage he attributes in large part to his intraoral scanner. “The portable and compact nature of the scanner, transported in a small carry on-sized suitcase is very convenient to move around from one location to another. Relative to the conventional impression technique, there are by far less pieces to be mindful of,” Radmand says.
In addition to the ability to run a mobile practice, he sees a return on investment via provider and patient referrals that he may not have received otherwise. “It exemplifies a progressive methodology for my specific practice,” he says. “The patients become more involved in the fabrication process of oral appliances. They have been more apt to talk about oral appliance therapy with other individuals with sleep-related breathing disorders.”
Radmand also views the scanner as a teaching and research tool. He documents routine scanning of the occlusion and follows the progress of patients’ bites as compared to the baseline so he will notice bite changes.
He adds, “Recommendations I can make on the process of selecting the proper scanning device primarily rely on the ease of hardware manipulation intraorally as well as reliability of the software.”
Andrew Swiatowicz, DDS, FAGD, Delaware
When intraoral scanners were first launched, the childhood dentist of Andrew Swiatowicz, DDS, was an early adopter—and a technologically-fascinated Swiatowicz was hooked.
Now as an adult with dental practices of his own, Swiatowicz’s first equipment purchase for general dentistry practice Swiatowicz Dental Associates in Wilmington, Del, was an iTero scanner (the same as his childhood dentist used); Swiatowicz upgraded to iTero’s Element model last summer, which he also uses in his dental sleep practice Delaware Dental Sleep Medicine. (Swiatowicz adds that his usage of this scanner does not mean he endorses it or any other specific intraoral scanner brands.)
Originally using the intraoral scanner for prosthetics and Invisalign, Swiatowicz has since incorporated the technology into many more services. “We are even incorporating it into our new patient exams. You can show patients any shifting or wear over time by comparing the models on the screen,” he says.
As dental sleep medicine was becoming a larger part of his practice, Swiatowicz took courses at The Pankey Institute, which helped him develop a system to fabricate patients’ sleep apnea appliances off digital scans. “Whether it’s a mandibular advancement device (MAD) or bite splint, the oral appliances I get back from digital scans are nearly perfect,” he says, adding that he hasn’t had to do a remake yet.
Because sleep apnea sufferers sometimes have comorbid sleep bruxism, the digital scans have become a valuable patient education and motivational tool. “It can give you a chance to discuss with the patient how their OSA has contributed to their dental condition. Sleep bruxism and OSA can go hand in hand,” Swiatowicz says. “Some patients really need to see some physical change to get them motivated.”
Swiatowicz’s advice to dentists who are considering purchasing intraoral scanners is to try the device out on a real person, not just on a typodont or dental model. “Scanners always work great on typodonts,” he says. “You need to make sure you are comfortable using it around a tongue, cheeks, lips, and saliva.” To try out a scanner prior to purchase, he recommends asking nearby dentists with the scanners if you can bring a patient over to take an impression on or asking the scanner sales representative if you can scan a team member at your practice.
Sree Roy is editor of Sleep Review.
Top Photo: Ryan O’Neill, DMD, uses an intraoral scanner, which captures the images shown on the computer monitor.
1. Mangano F, Gandolfi A, Luongo G, Logozzo S. Intraoral scanners in dentistry: a review of the current literature. BMC Oral Health. 2017;17:149.