When Anthony Puntillo, DDS, MSD, opened the doors to his Crown Point, Ind, practice in 1994, the small space had three chairs, one employee, and virtually no patients. With a limited budget, he weighed whether or not to purchase a computer to handle scheduling at the front desk. Now, 24 years later, the practice has two doctors (Puntillo and Christopher Crane, DDS, MSD)—and is looking to add an associate; four locations; almost 40 employees; and computers and digital equipment in
every corner.

The practice’s growth over the last two decades is the result of quality patient care and practice acquisitions. Only a few years after starting his practice, he was approached by a local orthodontist who was looking to retire and sell his practice. The same scenario played out three more times. While one of the four practices was rolled into Puntillo’s existing offices, the other three purchases created additional locations.

Anthony-Puntillo-6To manage this practice growth, Puntillo, an Indiana native, second generation dentist, and former walk-on defensive end for the University of Notre Dame football team, embraced digital technology. Honestly, he had to. Multiple offices call for digital data, whether images, schedules, or financials. “To have a digital record of that is much easier to manage in a larger practice with multiple locations than it is in a paper-based system,” he says. “There were times where we really didn’t have a choice. We had to move toward digital if we were going to be able to continue to grow and control that growth.

“Initially, we began with one computer. I think the first progression was to a digital camera to move away from developing film. Then as digital charting really became available, we moved pretty quickly to that. Again, with multiple locations, we didn’t want to  have to transfer patient records. Our offices are close enough that our patients jump from office to office.” Today, Puntillo’s practice has a single database that is self-hosted on the cloud, and backed up on additional servers.

From there it was on to digital radiographs, integration of suresmile® from Orametrix and their early intraoral scanner, and a CBCT system. Currently, the practice has three CBCT machines across its four offices. As Puntillo says, the ability to capture three dimensional images of the teeth and use that with suresmile was not only a time-saver but also a crucial component of the practice’s treatment planning process—to the point where it felt unnatural to look at cases without having 3D radiographic images.

During this time, Puntillo says the practice took a giant technology leap forward with the move to digital models. “Initially we were taking impressions and sending them to Cadent for their scanning and digital model creation so that we didn’t have to store as much plaster. Then when Align Technology bought Cadent and released their first intraoral scanner, it made sense for us to move in that direction. So, we purchased one of the first intraoral scanners from Align.”

Currently the practice has seven intraoral scanners—four iTero® Element scanners from Align Technology, and three TRIOS® scanners from 3Shape. The portable TRIOS scanners are moved from office to office, allowing the practice to have at least two scanners when a location is seeing patients.

Anthony-Puntillo-3Rethinking Design

The practice’s digital evolution means it is now paperless and impressionless and this has meant a rethink of how Puntillo designs his future offices.

“We’re looking at designing a new office right now and I will tell you that one of the big things that is going to look drastically different for us is our lab,” Puntillo says. The old lab was designed to handle a lot of plaster and model trimming. That lab is now completely digital—the big box of plaster, model trimmer, vibrator, and aerator done away with. In their place sits an EnvisionTEC Perfactory® Vida 3D printer purchased in 2016, and a second one that is on the way. Another office’s darkroom that once was used to process x-rays has been converted into a dedicated intraoral scanning room—the hardware and plumbing needed to process those x-rays stripped out, and a patient chair put in their place.

But it’s not just the practice’s technology transition that is causing Puntillo to rethink future office design. Retail ventures like SmileDirectClub’s Smile Shops and Align Technology’s Invisalign® stores have caused him to shift his design priorities. Instead of only focusing on straightening teeth, he’s giving thought to how the office’s design appeals to today’s consumer and how these retail spaces are influencing their expectations.

“SmileDirectClub obviously has locations around the country where you can go in, get scanned, and have aligners sent to you at home. There’s a much different feel in those types of situations, as opposed to a traditional doctor’s office where you go into the waiting room and you’re taken back. I’m certainly thinking about how the new office should look and feel…and what [consumer] expectations are and how they are changing,” Puntillo says. While still in the concept stage, Puntillo is considering carving out a portion of his waiting area to add a dedicated scanning center—like those found in retail environments. This would allow parents who may be waiting for their child to quickly see what their teeth might look like with orthodontic treatment—all without needing to schedule a separate appointment or being taken into the back.

And it’s the influence these retail-style orthodontic ventures are having on consumer expectations, and not necessarily any poached patients, that weighs on Puntillo’s mind. “They are changing patients’ expectations of what orthodontics should be. Yes, they are broadening the base and probably bringing people into the orthodontic market who never would have seen an orthodontist or had orthodontic treatment before; but those aren’t patients they’re necessarily taking away from me. But as they cast a net for those patients, they are also having an influence on the patients who would traditionally be coming into my office. Those patients are never going to do [their orthodontic treatment] at home, but it does change their expectations when they come into our office to see us—not only for cost, but for what the experience should be like.

“It makes it very difficult [for us] when patients see a slick commercial with all of the technology to have them then walk into an orthodontist office and the office hasn’t been updated since the 1970s and the doctor is in a white lab coat and still taking impressions. I think that patient is probably going to say, ‘Well, I don’t know that this feels like what I’m looking for.’”

The influence of the aligner companies on the marketplace can’t be denied. And given that Puntillo’s practice, like most practices, is only seeing an upswing in the number of aligner cases it does, that influence is unlikely to dissipate. “I do feel like there’s going to be almost a two-tiered system, like with eyeglasses. There are the eyeglasses you can get at your local strip mall versus what you might get in your ophthalmologist’s office. Some people may only need to run in with their prescription, which may be pretty straightforward and simple, and pay $99 for a pair of eyeglasses; and some people may need more extensive care. The same thing with orthodontics,” he says.

Anthony-Puntillo-4Assessing Efficiencies

While the patient experience at Puntillo & Crane Orthodontics is all digital from text appointment reminders to records and diagnosis, Puntillo and Crane, a fellow University of Notre Dame and Indiana University School of Dentistry graduate, have decided to keep one aspect of treatment analog. For bracket placement, the practice relies on OrthoSelect’s DIBS (digital indirect bonding system) software to digitally position and print bracket trays from the practice’s in-house 3D printer. But for wires, the practice has actually moved away from suresmile and its robotically bent wires.

“We used [suresmile] for a number of years, but eventually [Chris and I] felt like the cost associated with the system wasn’t working,” Puntillo says. “[The system] worked great. We got nice results for the patients, but there was an added amount of doctor time and there was added expense. Eventually we came to the conclusion that the additional time and expense for the patient and for us really didn’t balance out with the additional benefits that were potentially there. Chris and I still bend wires and still position brackets directly in the mouth if we’re doing a single bracket or a few brackets. The decision to move back to manually bent wires was made from an efficiency and cost standpoint.”

Anthony-Puntillo-5Puntillo’s commitment to assessing the impact of the practice’s digital transition along the way and willingness to step away from technology when it doesn’t best serve the practice means that the practice is focused in on efficiency. The fact is any new technology is going to impact the schedule and flow of the office. As such, staff meet monthly to discuss how the systems in place or new ones being added are affecting the practice.

While it may seem counterintuitive, Puntillo actually sees fewer patients on a daily basis than he did before the practice’s full digital transition. On an annual basis, however, he starts more patients. “We’re able to stretch appointments out longer,” he says, adding that treatment moves from point A to point B in a more predictable manner. Patients finish on time; which means a more efficient and productive practice and more time to start more cases.

That’s not to say that a digital practice doesn’t have its pitfalls. All technology can eventually fail, resulting in unplanned downtime. And this is where duplicate technology is a must. Those seven intraoral scanners are not just about quickly and efficiently scanning patients at every office location; and that second 3D printer is not just to increase the practice’s print volume. That duplication is there to keep the practice running should a piece of equipment be down for any reason. And, as Puntillo sees it, Align’s decision to end TRIOS’ integration with Invisalign at the end of 2017 should give a practice pause before putting all its eggs in one basket (or tying itself to one company’s products) when investing in expensive technology. The reality is that a larger practice, like Puntillo & Crane, has an advantage here. They can afford duplicate technologies. And as Puntillo sees it, the cost of having a consistent and efficient digital practice is just as much a factor in the trend toward large, multiple office, multiple doctor practices, as student debt.

Anthony-Puntillo-2A Bird’s-Eye View

For 8 years, Puntillo served on the American Association of Orthodontists’ (AAO) Technology Committee, terming out last year. His position afforded him a bird’s-eye view of just how much technology has changed the orthodontic practice—everything from the rise of social media as a marketing and patient communication tool to the increasing use of CBCTs in treatment planning. “Technology moves so quickly over 8 years. It’s amazing to see how much additional technology now gets incorporated into all of our practices.”

One aspect of the technology boom that excites Puntillo is the data analysis potential. The various practice management software systems are in a position to consolidate practice data—everything from patient financial information to treatment records—and allow use of that data for research purposes that could go a long way—not only telling orthodontists how to better run their practices, but how to better treat patients.

“Everything is going to ones and zeroes. Digital information, or big data, can be collected, consolidated, and analyzed in a meaningful way that has the potential to improve patient care,” he says. “One company that’s doing this now—that’s providing some of that [analysis] to orthodontists—is Gaidge. While it’s more from a practice management standpoint, it allows you to look at consolidated data from orthodontic practices around the country and compare the metrics of your office to other offices; and then it allows you to ask, ‘Okay, well, if other offices are finishing cases in 20 or 22 months, and it’s taking me 26 months, what is it that I need to look at?’ Then you can dive deeper into your treatment mechanics to decide how you could improve or make it more efficient for the patients within your office.”

Puntillo likes to think that as a group the orthodontic profession is more forward thinking than not; however, he admits there are still those slow adapters and those who continue to push paper around the office. “I would hope that not too many [of my peers] are still taking film-based radiographs at least, that they are moving toward digital radiography,” he says.

The advancements in technology are fast-moving and Puntillo contends that staying plugged in is key to staying informed. He is a member of the Midwest Angle Society and he and Crane are both members of the Schulman Study Group. Puntillo follows a number of online forums to keep abreast of the latest developments. In addition, he stays connected to his students at Indiana University School of Dentistry who tell him what they see happening and what they think is going to be important as they move into their practices.

Technology is and will continue to have a disrupting influence on the profession, just as it has in so many other sectors. But this doesn’t mean the sky is falling. “Our profession will be different [in the future]. I think we have to step up [as a profession] and make sure we have a strong voice in what it ends up looking like. We have to make sure that we are directing, as much as we can, the impact technology has on our profession.” OP