Products in Practice

A snapshot of today’s marketplace and how to make smart buying decisions

Dozens, if not hundreds, of products are required for the efficient operation of the average dental practice. Once chosen, every item is subject to evaluation and potential replacement by a competitor. Beyond that, the rapid evolution of dental technology means that new forms of treatment and tools for accomplishing treatments appear almost daily. How do dentists cope with the daunting task of product selection? How should they be approaching this important arena?

“I think most dentists buy a lot of things on a whim,” states Dr. John Burgess, the dean for clinical research at the University of Alabama at Birmingham. Burgess, who also directs the university’s Graduate Biomaterials Program, observes, “Maybe they’ll be at a conference, and there’ll be a reduction in price, or some lecturer will say, ‘Hey, this is the best new product since sliced bread.’ They’ll go buy it but not really understand the nuances of the material. And then, not surprisingly, their performance is not very good, so they use it once or twice and then it goes in the drawer full of the other materials they never use. That happens all too frequently, unfortunately.”

Dentists also can be conservative in their purchasing behavior, asserts Dr. Robert Margeas, whose private practice is based in Des Moines, Iowa. “When they find a product they like, they’re very reluctant to switch. For example, when they find a brand of composite they think handles better, polishes better, looks better, they’re going to pretty much order the same thing over and over.” They value consistency and will resist facing the learning curve that accompanies any product change “unless another product is much better than what they have.”

Game-changing products do sometimes appear. One example offered by Margeas is bisacryl composite for temporization of crown and bridge. Early versions required hand mixing before being put into a syringe and injected. “When Luxatemp^® (DMG America, www.dmg-america.com) came out in an auto-mix, that took market share. Then Clearfil™ (Kuraray Dental, https://kuraraydental.com), a self-adhesive, came out and literally took over 40% of the market almost immediately because that product had very little sensitivity. You didn’t have to etch the enamel. You could save time.”

Must-Have Products: Booming Successes vs. Catastrophic Failures

Still, irresistibly superior options come along rarely, Margeas notes. “There are so many me-too products out there.” Another reason for caution is that some products that initially appeared revolutionary later have failed catastrophically. Dr. Gerard Kugel, Associate Dean for Research at Tufts University School of Dental Medicine, says such events “have cost us a lot of time and money in dentistry.” He mentions the case of composite materials that were bonded to metal. “Thousands and thousands were done, and the composite debonded from the metal. Dicor crowns were another example of a material used by many dentists that failed. Fiber-reinforced bridges were popular until they started fracturing at unacceptably high rates. I could go on.” In an attempt to avoid such disasters, dentists often simply stick with the materials and equipment they used when they were learning to be dentists. Margeas says, “The dental schools play an important role in buying habits because if someone used a digital scanner in school, the likelihood is pretty high they’ll buy the same type. They’re accustomed to it. If you use a particular brand of adhesive or composite or an air-driven handpiece in school, when you get out, you’re probably going to go with the same products, at least initially.”

Influences for Product Selection

Later, personal relationships can significantly influence the product-selection process, a number of key opinion leaders attest. “The manufacturer’s reputation, the brand name of the product—all those things are important,” says Dr. Lee Ann Brady, whose private restorative practice is located in Glendale, Arizona. She adds that relationships also carry a lot of weight. “If a dentist has a good relationship with a particular sales representative, they’re going to tend to trust that person, and that trust gets transferred into products.” Brady suggests that this phenomenon should not be discounted. “Given the plethora of materials and information, we have to figure out how we’re going to sort through all of it, and one of the ways we sort through it is we go to trusted relationships,” she says. “Whether it’s a relationship with a trusted manufacturer or a representative, that can be more reliable than getting your information from an unknown source on the Internet.”

Brady notes that besides being ignited by direct sales messages, the impulse to switch to a new dental product is sparked by the perception that an existing material isn’t working as well as it should. She frequently teaches courses about dental materials and says she’s often asked for product recommendations to solve a problem plaguing her questioner. She believes that more often than not, the problems can’t be eliminated simply by switching products. “The reality is we’ve got really great checks and balances today for materials that come onto the market, and most of the time when dentists are struggling with something in their offices that they think is materials-based, more often than not, it’s technique-based. If you put 50 dentists in a room with every impression material currently on the market, I promise you could find dentists who say about every product, ‘I love it. It’s my favorite thing. You’d have to kill me to take it away from me.’ And sitting right next to them would be someone else who says, ‘Oh my god. I hated it! I could never get an impression with it!’” Dr. Todd Snyder, a cosmetic dentist based in Laguna Niguel, California, concurs. “It’s crazy to see how much misinformation or misuse of materials there is out there.” When Snyder taught at UCLA in the Center for Esthetic Dentistry, “I’d see some part-time instructors who’d been teaching for many years using products incorrectly. I would basically tell them politely that they shouldn’t be using them in that fashion, and their response would be, ‘Well, this is how I use it in private practice.’” Snyder has come to believe “there are a lot of products out there that aren’t necessarily bad but may just be being used incorrectly.”

Systematic Approach for Product Purchases

Brady says over time, she has developed a systematic approach to buying products and equipment for her own office. Whenever a purchasing decision arises, she begins by asking herself some specific questions. “The first one is: Is this new thing I’m looking at going to provide superior clinical results for my patients? Yes or no? Do I think this is a superior product?” If the answer is yes, and the product is also more cost-effective because it requires fewer steps, takes less chair time, and/or is less expensive, “then I’m absolutely interested.”

If the product is not clinically more effective but is only equivalent, it may still be more cost-effective, and Brady says she would still feel confident about buying it. If the answer to both questions is no, however, she says she recognizes that the only reason to buy the product is that “I might just want to play with it.”

To answer the first question and determine whether any item is clinically superior to its competitors can be challenging. Clinical studies may be biased. Margeas says, “One company has a study showing their product is the best, while their competitor has one showing theirs is the best.” While he thinks clinical studies are important, he says he scrutinizes them carefully in an effort to find those that are unbiased. Brady concurs that for any study, “It’s not always readily obvious what to do with that information. You have to understand a little about research and literature, and you have to be able to understand whether the study was done well or not. There are places where you can work around that, like the Cochrane Review.” Another alternative is to look to an authoritative colleague who can assess the quality of the research. Brady says, “I think that’s partly what dentists are trusting, that key opinion leaders have gone in and looked at the science and the research, and that they’re talking about something based on a preponderance of information. Or they’re trusting that the manufacturers’ reps and their distributors have culled through that information so that their opinion is based on reviewing that knowledge base.”

All too often, however, clinical studies simply have not been done. “They’re expensive, and companies don’t want to do them,” says Kugel. “The NIDCR doesn’t pay for them.” He mentions that in the past, some materials gained widespread use with few clinical studies backing them. “Sometimes there are case reports, but not a lot of good clinical data. What I say is that in dentistry, a lot of the clinical research is done in your patient’s mouth.”

Even when studies do exist, clinicians often lack the time or energy to track them down and read them. “At the end of the day, they get home, and they just want to shut off.” Kugel says he tries to counter that impulse with his lecture audiences. “It isn’t that hard to do a little homework on the Internet. The ADA has an evidence-based dentistry website, ebd.ada.org, that reviews clinical studies” if they are available.

Instead of weighing whatever evidence exists, “I think a lot of dentists sometimes switch to new material only because they’re new,” Kugel says. He gives one lecture on the topic of adhesive bonding in which he shows that “some of the newer bonding systems have been inferior to many of the old systems. But people sometimes switch because it’s sexy, and maybe because they have a good relationship with a certain company’s sales rep.”

Even when there is good evidence that a product works well, that doesn’t always guarantee that it would be a good investment for every dental practice. Dr. Martin Jablow, who practices cosmetic dentistry in Woodbridge, New Jersey, says, “A classic example are CAD/CAM machines. You have to ask, ‘How am I going to get my money back? What if I buy it, and I don’t like it, and I just spent $50,000 to $100,000?’” Jablow adds that the competition for those dollars isn’t necessarily other products that would make someone’s practice more productive. “It’s retirement funds, vacations, college funds, a new car. That’s where your competition is.”

He says over time in his own practice, he has come to focus much more on how any new product can make his workspace more efficient. “How is it going to return its investment to the practice? It’s a bottom-line calculation. Can I do this more efficiently with less stress? Can my office staff perform certain functions with less strain so that it allows them to do more things?” Jablow argues that all dentists should be looking at their practices as a business. “Buying decisions should be based on good business principles, not on emotion. That’s not to say you can’t buy something for $500 just because it would be cool, and you want to do it. That’s discretionary. But when you start having to make real business decisions, they need to be made with numbers and some process, some system. I think the system needs to be generated like any other business in this world. If you’re not looking at all that, then the practice is running you. You’re not running the practice.”

Final Considerations

At the same time, key opinion leaders who have studied the product-selection process stress that no single formula applies to every dentist and every practice. Differences in personality must be taken into consideration. “When something new comes out, you always have the early adaptors—those who, no matter what the technology is, are going to buy it,” says Margeas. “They don’t care what the price is. Then you’ve got the ones who will wait to see what happens.” Finally, there are the late adaptors who don’t embrace new products until several years after they’ve entered the mainstream. Practices, too, have different characteristics that shape the buying process. Kugel explains, “For some doctors, CAD/CAM may not be the best fit. Not yet. Are you willing to re-evaluate how you schedule patients to fit your new technology? Some doctors don’t like to be stressed. They don’t want to have one person in a chair having a crown milled while the dentist is seeing another patient.” Adding CAD/CAM would not be advisable in that situation. At the other extreme, Kugel says one partner in his practice enjoys using CAD/CAM so much that “he does it all. He does the scanning. He does the design. Many dentists delegate, but for him, it is less about the money and more about what he enjoys. It’s fun for him. But it has to fit your personality and your office profile.”

Along these lines, Burgess urges clinicians who are evaluating new products to carefully consider how much the acquisition will require incorporating new clinical techniques. “If you have to radically change what you’re doing in order to get better results, you may or may not want to do that.” As an example, he cites composite materials. “Different resins have different viscosities. Some people like sticky resins, while others prefer ones that do not stick or adhere to the instrument at all. And the two will never come together. Manufacturers have asked, ‘Well, what kind of composite resin viscosity do you think will be universal?’ and I have to say, ‘That’s not going to happen.’ People have these basic preferences, and they won’t like the new alternative version. They won’t get good performance from it because they’re used to the handling of their current materials. Handling is the first thing evaluated by a clinician. If you place a lot of composites, amalgams, or crowns, materials that will facilitate the placement, cementation, and polishing and finishing of these different restorative materials can be very effective for you—if it fits into your normal routine. If it doesn’t, if it alters your technique significantly, then you probably won’t pick it up too rapidly.”