Thanks For Asking

Kathy Edwards, RDH, Margaret Boyce-Cooley and Dana Morano of the Practice Support Team

Kathy Edwards, RDH, Margaret Boyce-Cooley and Dana Morano of the Practice Support Team

Burkhart’s Practice Support Team provides support to doctors by answering hundreds of questions that come in through our toll free number and email. It is our pleasure to provide answers and resources—at no fee—to all of our Burkhart clients. Consider it a value-added service from Burkhart. We’ve compiled the most frequently asked questions and shared some insight on those here:

Q. I’m leaving a practice as an associate to start up my own practice. Do you have any resources I can use to make sure I have my bases covered?
A. We are able to work with doctors on a number of support areas. The first thing we need to know is if this is a new build with Burkhart or an existing practice purchase. If it is a new build, we like to find out:
• Will the practice be a general or specialty practice?
• Have you owned a practice prior to this?
• Will you be doing your own hygiene to start?
• Is the practice fee for service, or will you be contracting with insurance companies?
• How many days a week will the practice be open?
• Are you actively working with a marketing firm on logos, web page and social media presence?

Support Available
Below is a list of specific areas where we can lend support. We want to find out YOUR main areas of focus and develop a “course of action” from there.
• Business Planning: Manage your cash flow, your patient experience, and develop a productive and happy team.
• Marketing: Differentiate your practice by presenting a memorable image backed-up with an exceptional patient experience.
• Operations & Leadership: Create a positive work environment with a clear vision and goals. Get best practices in place to ensure compliance.
• Communication Protocols: Provide the best possible dental care with your patients’ best interests at heart.
• New Patient Checklist: Burkhart Dental can also provide a New Practice Checklist to get you started. Ask your Equipment Specialist for this and other valuable resources.

Q. I just hired a front office person with little to no dental experience. Do you have any tools to help get her started?
A. We offer a recorded three-part webinar series, Front Office Essentials; however, our webinars assume knowledge and experience for the most part. We do recommend the purchase of Dr. Charles Blair’s Coding with Confidence book (which can be ordered through your Burkhart Equipment Coordinator). We also recommend two sets of “Dental 101” level webinars:

Dental Trade Alliance

AADOM Resources
(There are some great resources here)
We feel strongly that most practices benefit from hiring someone with dental front office experience, especially if yours is a start-up practice. If the candidate doesn’t have dental experience (or at least medical experience), you’ll need to be prepared to invest in the new employee’s education and understand the costs involved to the practice through:
• Time and productivity lost by training the new employee on your own
• Time and productivity lost by having another team member train the new hire
• Revenue lost through trial and error at the front
• Online and additional training resources for the new employee

The Importance of I.T. in Your Multi-location Equation

By Dawn Christodoulou, President, XLDent

As a dental software development and services company, XLDent has seen more private dental practice owners expand to two or more locations in the past nine months than we have in the past nine years. This emerging trend is exciting to say the least! It means our small business community is overcoming the challenges of over-regulation and rising costs. They are seeing opportunity in consolidation of business systems and expansion of service offerings. They are taking control back! Our private practice owners are doing what all small business owners do. They provide needed services, employ people in their communities, and work to grow their businesses.

The Vehicle in Your Expansion Plans
As with all expansions, there is a lot to think about. This article is intended to highlight the importance of information technology (IT) in a multi-location growth strategy. It’s often over-simplified by the belief that what is working for the current location will work for a small enterprise. It very well may work, but will it give you the records consolidation, performance and continuity that you need to be efficient and productive? Will the software and infrastructure you are using be the headache or energizer in your trek to grow your business? Your IT solution needs to be the vehicle in your expansion equation that gives you and your team flight, not the boat anchor that brings you down.

Consider How to Manage Your Database
If you are considering the purchase of a second (or third, or more) location, also consider how you want to manage your EDR and business systems – your databases. Consider whether or not patients will travel between locations. If this is a likelihood, a single patient database will be necessary if you want to maintain a single dental chart for each patient. It is also an important consideration if you intend to consolidate patient billing and insurance functions. If not, stand-alone databases at each location may be a better option, especially if you build up the location and patient goodwill to sell it off someday.

Software to Service Multiple Dental Specialties
If you also intend to expand by offering multi-disciplinary services, keep in mind that you will need software that serves multiple dental specialties to maintain continuity in not only patient delivery and communication systems, but business systems. And again, consider whether or not it will be necessary to maintain a single patient database.

Help from I.T. and Software Partners
As you set up your business structure or “shell” with your accountant and lawyer, it will be important for you to know the ins and outs of your database configuration, software capabilities, and how production, collection and profitability numbers will be reported. This will require the aid of your IT and software partners. Don’t count on your accountant or lawyer to know any of these details. They can help you build your accounting, incorporation and tax equations based on your variables, but only if you do your homework so you can explain all of them, including your database configuration and software capabilities.

Single or Multiple Databases?
Ultimately, evaluation of your database and software needs begins with identifying whether you will run your operation with a single or with multiple databases, with a single or with multiple software solutions, and understanding how these locations need to be connected. An experienced IT partner will complete a thorough needs assessment, help you answer these very important questions, and also provide you with options when selecting a solution.

IT Team That Specializes in Dentistry
Because the technology landscape today includes so many options like VPN, RDP, clouds and hybrid clouds, it’s important to choose an IT team that specializes in dentistry. Your technology needs truly are specialized and unique, so don’t settle for anything less than experts in the field. XLDent, for example, has been serving the dental community since 1971. We offer a software solution that is scalable for single practitioners, group practices, multi-location, and multi-specialty practices. We provide computer hardware and network services, as well as partner with NSPs that specialize in dental practice installations across the country.

Growth and prosperity await you! Work with all of your trusted partners—accountant, lawyer and IT professionals—to build a successful equation that is productive and efficient to maintain.

The 5 Most Commonly Asked Questions About CBCT

Dr. Louis Kaufman answers five of the most popular questions he gets asked about imaging equipment.

By the Dental Products Report PR Editorial Team

Dr. Louis Kaufman is a Chicago dentist who lectures nationally on CBCT and implantology for imaging equipment from Planmeca USA, Inc. Like all lecturers, he gets dozens of questions from other dentists who attend his lectures. Dental Products Report decided to explore some of the most common questions he receives about CBCT.

What is the return on investment or how do I justify this amount of capital?
When you purchase a cone beam, I suggest that you look at the ability of the machine to generate images in different formats. You need to ask yourself, besides taking a three dimensional image, can this machine create panoramic images? If it can take panoramic images, ask yourself, “How many panoramic images do I take in a year?” Then ask yourself, “What do I charge for those images?” For example, if I charge $100 and I take 400 panoramic images a year, then I just billed out $40,000. If this machine cost you $120,000, dollar for dollar, you recoup the expenditure in three years. Realistically, you pay for it over four years.

Remember, it’s just not about the X-rays. It’s about the amount of undiagnosed dentistry and implant planning we can do with this technology. It generates better comprehensive treatment planning and ultimately better dentistry for the patient.

How has communication improved with your patients using CBCT?
Patients are blown away when they see a three-dimensional image of their jaw. When I can show patients where I can place an implant in their jaw using their own anatomy and a chairside model, patients can visualize and comprehend the procedure more clearly.

I would encourage the use of videos that all the major dental implant companies produce. Check with their marketing departments and incorporate a video into your website. While the patient is in the chair, you or your team can pull it up on your website for the patient to view. This serves two purposes. First, patients can visualize it more clearly. Second, when they go home to their significant others, they can pull up your website and explain the procedure to them.

Do you need a dental radiologist to review all your scans?
It’s extremely important to have a working relationship with a dental radiologist. Of course, then the question becomes, “Do I need to send every scan to the radiologist?” In my opinion, when a large field of view is taken, I recommend sending the scan to the radiologist. The beauty of this technology is that it allows us to take small fields of view or limited fields view. Therefore, it is not necessary to send every scan to a dental radiologist. I can’t stress enough the importance of reviewing all your scans even after the patient has left the office.

The more we review and educate ourselves on the normal anatomy, the better we become at identifying the obscure. I also encourage taking classes that are continually being offered throughout the country on how to review a cone beam.

Do I need an intraoral scanner and CBCT?
Having an intraoral scanner and a cone beam is the perfect marriage. Both are completely independent of each other. The scanner focuses on teeth and tissue and the cone beam addresses the bony architecture. When the STL files are joined in the lab, there is complete harmony. Like a great marriage, they make each other better.

From my understanding and speaking with different vendors, one can take a DICOM file obtained from the CBCT, convert it, make a virtual model, 3D printed model and fabricate a crown. So, in theory, you could prep a tooth and have an edentulous area. Plan the implant and make the crown or partial all at the same time. And then there are times we just need to take an intraoral scan and make a crown inlay or onlay.

What’s your opinion on the obsolescence of a machine you purchase today?
The most important question to ask the equipment sale rep is, “Is the hardware upgradeable?” Also, is there a fee for upgrading to a newer version of the software? Many companies have software version updates, so you should ask what is included with your purchase.

Like any other technology, there are advances in how it’s delivered. Going with a company that’s one and done is not the way to go. I want to do business with a company (and there are many out there) that wants a long-term relationship with the buyer.

Financing Acquisitions, Expansions & Upgrades

By: Doug Fettig, CPA, MBA

Throughout the course of one’s career in dentistry, opportunities arise that call for outside financing. Recent dental school graduates dream of starting their own practices. Existing practitioners want to upgrade or expand their practices or perhaps purchase a satellite location. All such initiatives tend to be capital intensive, and therefore generally require taking on debt. Fortunately, lenders deem dentists a good credit risk given their low default rate on loans.

This article provides guidance on how to prepare for making a loan application and what options are available to secure financing.

Get Your House in Order
Like other entrepreneurs, dentists need to present themselves and their businesses as worthy of investment. Personal credit history is a good place to start as it plays a key role in lender determinations.

The three major credit bureaus—Equifax, Experian, and TransUnion—provide free credit reports and credit scores based on payment history, outstanding debt, length of credit history, credit inquiries for loan applications, and types of credit in use. The higher the credit score, the greater the opportunity to secure a loan and obtain attractive rates and terms. To increase one’s score, credit reporting errors should be challenged and cleared. Past due bills should be brought current and unneeded debt retired. A good track record combined with a manageable debt load suggests an individual with the requisite discipline and restraint to meet future obligations.

Create a Plan
A dentist must create a business plan that demonstrates knowledge of the relevant market, a credible plan for generating revenue in that market, a viable operational model for service delivery, and an administrative approach that yields a sustainable business. He or she must have an awareness of the demographics, indicators also provide critical insights—e.g., production and case acceptance, continuing care, mix of services and relative profitability, scheduling optimization, collections, etc.

Armed with this information, the dentist can identify the rationale for external funding, define the use of loan proceeds, and work through the mechanics of how the loan would be repaid. This analysis also determines whether he or she is eligible for credit and, if so, which loan types and terms are best suited to the present need. While many of the skill sets required to conduct this preparatory work fall outside one’s professional training, CPAs, tax advisors, consultants and others who specialize in this market are available to provide expert guidance and support.

Finally, some lenders require life and disability insurance (or business overhead insurance) as a condition of financing. This requirement arises due to the fact that loan repayment depends upon the life and health of the dentist. As underwriting for this insurance can take 4-6 weeks, it’s worthwhile to start this exploration well in advance of tendering a loan application.

Small Business Administration
The Small Business Administration (SBA) offers a number of programs to help dentists launch or expand their practices and help them flourish.

SBA 7a General Purpose Loan
Using a SBA 7a general purpose loan, dentists have the ability to:
• Finance or refinance their practice
• Build, purchase, renovate, or refinance
a building or facility
• Finance equipment
• Consolidate debt
• Obtain more working capital
To be eligible, a dental practice must operate for profit, conduct business in the U.S., have revenues less than or equal to $7.5 million, and have reasonable invested equity. Equity may be gifted or contributed by a seller for practice acquisition. One-hundred percent financing may be available for established practices with a strong balance sheet. The borrower must demonstrate a need for funds to address sound business purposes that exceed the capacity of alternative resources (e.g., personal assets, cash flow from business operations). And the borrower must not be delinquent on any debt obligations to the U.S. government. Loan maturities vary—e.g., up to seven years for working capital, up to ten years for equipment, and up to 25 years for real estate. The SBA expects all loans to be secured.

SBA 504 Loan
An SBA 504 loan can be used to build a new office, renovate or expand an existing facility, or refinance a current facility as part of an expansion. While it is more difficult to structure 100% financing, this program offers fully amortized, long-term commercial financing at low rates with no balloons, calls, re-qualifying, or refinancing at a later date. Acquisition of energy efficient technology enhances borrowing capacity.

Commercial Lender
As noted earlier, low default rates among dentists make them attractive credit risks for commercial lenders. Many lenders offer 100% financing for practice acquisition, expansion, and upgrade. Limits to a borrower’s credit capacity include unattractive personal credit histories, high debt in relation to practice assets or equity, and concerns regarding core business skills to make a practice thrive. The latter includes one’s ability to develop and retain patients, make compelling arguments to accept treatment plans, and institute effective business and fiscal management practices. As with SBA loans, commercial lenders expect to secure loans with some form of collateral.

Build Relationships
Building relationships with prospective lenders yields a number of benefits. Dentists can get educated on the approval criteria for the lender’s underwriting department and use that information to build a strong loan application. Dentists can also learn about the types of financing available and choose the one that best aligns with current needs. Assuming dentists demonstrate competency in their practice management and ask reasonably intelligent questions, they can influence their lending officers’ subjective appraisal and secure an ally in the loan application and approval process.

Talk to Several Lenders
A lender’s market presence may change based on its desire to establish a position (or increase share) in the dental market, its overall credit availability, and its recent experience with defaults. As such, it’s worth talking to a few different lenders (or a commercial broker) to find the most attractive terms. It may also be prudent to make application to more than one lender to improve one’s negotiating position.

Seller Financing
When dentists do not have sufficient borrowing capacity or wish to manage the time frames over which they assume debt, sellers may need to participate in financing.

Associate Partnership
With an associate partnership buy-in to buy-out, a solo practitioner adds a dentist who agrees to purchase 50% of the practice within a prescribed time frame. This arrangement works best among individuals who enjoy collaborating with other professionals and for whom a mentoring relationship confers mutual benefit. After working as partners for a pre-set or variable time frame, the associate agrees to purchase the remaining 50% share. If the practice has grown to occupy two full-time dentists, a strategy must be put in place to support the original dentist’s retirement.

Associate Buy-Out
An associate buy-out generally involves a shorter period of employment during which the associate establishes rapport with staff and patients while securing the financial resources for business transfer. The seller may opt to reduce his or her patient load gradually to make room for the buyer while adjusting to a new phase of life. The seller may remain as a part-time employee after the transfer for some period of time.

Formal Contracts
In either case, formal contracts dictating the terms of the agreement reduce the incidence of costly misunderstandings and conflicts downstream. These contracts specify both parties’ duties and obligations, the financial terms of engagement, and time frames for key milestones and/or decision points. This recommendation proves useful even when transactions involve family members as it ensures that everyone is on the same page.

When dentists cannot secure loans independently or enter into associate buy-out arrangements, they have the option to enlist the support of family members or friends. Recent graduates may draw upon this form of financing due to their high debt load from dental school combined with their lack of experience in practice management and loan repayment. Such cases call for a brutal honesty with respect to the borrower’s reasonable ability to service the debt and the lender’s reasonable ability to assume the risk of loss. All parties to loan default experience unpleasant side effects financially and emotionally. When such transactions involve intimates, the impact to relationships can be long-lasting.

Dot Your I’s and Cross Your T’s
When preparing a loan application, make excellence the hallmark of your efforts. Provide a complete application with all required schedules and attachments. Be your own advocate and make a compelling business case for your credit request. Offer written explanations for anomalies or potential lender concerns. Identify assets that can be pledged as collateral. Respond quickly to lender inquiries.

Access to credit correlates strongly with practice success. Make time to attend to this key aspect of your practice. Leverage outside expertise to help polish and present your personal and professional stories in the best possible light.

Lydian Dental, Aspiring to Reinvent The Dental Experience

By Anne Baer
Photos by Ivan Martinez

It may be unusual to find someone who truly enjoys a trip to the dentist, let alone someone who wants to hang out there because the environment is fun. But that’s precisely the vibe the team at Lydian Dental aims to create. Co-founders, Dr. Scott Connell, Dr. Josh Turnbull, and Clayton Nylander, have created the first Lydian location in Tempe, AZ that captures their vision for a place where both patients and dental team members want to go.


Tell us about your background and how the three of you came to be Lydian Dental:

Scott: I’ve been practicing since 2004. Basically, I got out of the Dental College of Georgia and was looking to purchase a practice and become my own business owner immediately. I bought two different offices, but was never very happy about how dentistry operated.

I wanted to change the doctor/patient interaction and began looking at the new model of concierge health services. In that model, members pay an annual fee to join with a doctor and then have access to that provider’s dedicated care. I wanted to shift the focus away from procedure-driven and more to keeping the patient happy and healthy. That’s been my philosophy from the start.

Josh: I started in dental school at Harvard, but after the first two years, I took a year-long sabbatical to get some perspective on what I wanted from dentistry. During that time, I did a study at the Mayo Clinic that evolved into a study on the business of dentistry. That study was eventually published with Gordon Christensen in Dentistry Today. I learned a lot about the shifting landscape for dentistry. After returning to dental school, I continued my studies at Harvard Business School which is where I first worked with Clayton, collaborating on a project.

We started asking ourselves, “Why is there no brand of dentistry that, when I graduate, I’m high-fiving my colleague that I get to go to work there?” Our vision is to create the most aspirational brand of dental clinics in the country. We want to create a brand that dentists can be proud of. We are focused on the experience, not just for the patient, but for our entire team.

When I got out of dental school, I wanted to partner with someone who shared that philosophy. That’s when I met Scott and his approach to patient care. His philosophy on how he treats people was very consistent with what I wanted and what I envisioned creating. I got to know Clayton during my studies when we did a project in school, rolling out a brand of clinics in China.

Clayton: My dad was a dentist in the military, so we hopped around a lot. I met Josh when we were students at the Harvard Business School. We graduated in 2013 from business school. Josh and Scott partnered that summer—then I came in 2014.


Why did you decide to move to this new location? Why did you select this particular site?

Scott: When Josh and I decided to team up, we wanted to work on his idea to create an “aspirational brand.” I had an existing office nearby, but we wanted to rebrand and move to a site that incorporated our new brand from front to back.

Josh: We want someone to walk in our office and say, “Wow, this is different! I just want to come here and hang out.” This site was also near some new corporate offices with people who are potentially more brand-conscious and attracted to a better dental experience.

When you decided to make the change, how long did the process take?

Scott: I’ve built a few offices, but this one was much more detailed. We started researching in 2013 working with Rapt Studios to flesh out who we were and what we wanted for the brand. In 2014, we moved ahead with rebranding my current office as Lydian and starting the process. Concept work for the office started late in 2014, and we moved in October 2015.

What impact has the rebranding had on your practice? What unique things can you share about the design? What has been the patient perception to the change?

Josh: The response has been amazing. To give some perspective, we chose “Lydian” as it was the name of a stone used to determine veracity of gold and silver. We see our brand as a standard by which other dental experiences are measured. Rapt Studios created an innovative feel unlike any dental visit. The experience is more residential than a typical clinic. To that end, things are hidden away, like all the delivery systems, hoses and sharps—all the things that scare people at the dentist.

We used bright color in spots throughout the office and warm touches like a chair sock (that covers the end of the chair). The entrance area feels more like a family room and reflects an open and inviting space. Our patients and staff love the bright feel and warm atmosphere.


What was Burkhart’s role in your project? How did it impact the process?

Scott: I’ve done a few offices, but for this one, it was completely hands-off. Kip (Giro, Burkhart Equipment Specialist) would recommend what to order, and I would just tell him to do it. There was much more working through details with this one. I felt like they (Kip and Chris McCarthy, Burkhart Account Manager) were the ones calling me to make sure everything was going well and things were happening.

Clayton: Kip and Chris were solid guys and took very good care of us. They’ve helped us a lot in our new clinics. (Editor’s note: Lydian Dental is currently working on another office site in Arizona and two more in Austin, TX.)

Josh: The other day we had a call and we needed Kip on it, but he was in a meeting. I texted him and asked him to jump on the call which he did. Stuff like that really means a lot. They are there for us.

Any last thoughts as you build your next clinic?

Scott: There are lot of things that will evolve as we look at the next clinic. We’ll keep reinventing the brand with feedback from staff and patients. Whatever motivates the patients and makes them feel cared for will be incorporated into future clinics.

Josh: Our attributes of “fun and familial” will be dialed in to our future clinics. Our target patient group is more about what the experience is while they’re there and what their friends see. They are more focused on the perception.

Clayton: We are reinventing dentistry and doing so end-to-end. We want to be a true innovator in the industry.

Another Option: Collaborative Effort to Mimic Aesthetics

By Rhys Spoor, DDS, FAGD, Accredited Member of the American Academy of Cosmetic Dentistry

This case is an example of excellent collaboration between the restorative dentist, the oral surgeon, and the ceramist to give a patient a truly natural-appearing, functional prosthesis in a less-than-ideal environment. The patient was referred by his dentist due to a continual slow degradation of an anterior bridge that spanned from #5-#11. There had been several failed abutments over the years with two apicoectomies (Figures 1, 2, 3 and 4).

A CBCT revealed significant bone loss in the edentulous segments to the point that several areas did not show on the scan. The #7 abutment had an endodontic lesion and the bridge exhibited significant mobility. The existing bridge was positioned facial of the maxillary bony ridge to accommodate the occlusion and provide lip support.

After a diagnostic wax-up was completed, the bridge was removed and a directly made, stainless steel wire-reinforced provisional bridge was made from #5 to #12 (Figures 5, 6 and 7). Since it was a long span, it was decided to remove the pre-existing crown from #12 to double abut that end of the span. The preparations were impressed at that point and after placement of the provisional, an alginate impression was taken. That model was sent to the dental laboratory for digital scanning and combined with the preparation impression to create a milled polymethyl methacrylate (PMMA) provisional which was much more durable for the extended length of the treatment.

Tooth #7 was extracted, grafted and soft tissue augmentation was performed along the entire ridge with Alloderm and a temporary mini-implant placed in #8. The implant had to be placed slightly more facial than ideal because of the angle of the bone. The PMMA provisional was adjusted to fit (Figures 8 and 9).

Bone augmentation followed and implant placement in the areas of #6, #8 and #10 (Figure 10). The area was allowed to heal for one month and the PMMA provisional was modified by adding to the gingival volume (Figures 11 and 12).

The final impression was taken using polyvinyl siloxane (Kerr Take One) with an open tray and the impression copings stabilized with a composite core paste (Figure 13). The copings were placed in the impression and analogs were again stabilized with core paste (Figure 14). Shades were determined, including gingival shading (Figure 15).

The final prosthesis was a milled zirconia framework with titanium inserts coated with a gingival-colored composite (Bredent) (Figure 16). To get the best gingival color match, the final application of the composite was done intra-orally (Figure 17). Emax (Ivoclar) crowns where at first cemented temporarily, then finally with Panavia resin cement (Figure 18). The final result was a very close mimic of the natural dentition and gingival tissue (Figure 19).

The author thanks and appreciates the artistic skills of Dr. William Hooe, oral surgeon, Shoreline, WA and Mr. Daniel Sorenson, ceramist, Pleasant Valley, Utah.

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