Cliff's Notes

The Business of Dentistry

“Cerec vs E4D, The Real Story!” & “A Product Review – GrandioSO Flow by VOCO”

Cliff’s Notes for August 19, 2012

Cliff Marsh, Henry Schein ……Cell: 201-321-7494……Fax: 201-262-2210…..E-mail:

The reason we do what we do, is so that we can to do what we want to do, when we want to do it!

It’s a tongue twister, but working as a team and making informed decisions, will get us there.



“Learning is not attained by chance; it must be sought for with ardor and diligence.”

Abigail Adams




This Week’s Feature on the Cliff’s Notes Channel

“GrandioSO Flow & Heavy Flow”

Over 100 Dental Videos



In This Week’s Issue

  • The Office Manager – Meet Dayna Johnson?
  • This Week in Dentistry from the ADA – Is the Third Party Bundling Procedure Codes?
  • Dental Marketing Up-Date – The New Phonebook Has Arrived!
  • Product Review – Ceramir by Doxa Dental!
  • The Henry Schein Outlet Store – Special of the Week “Carbide Bur Overstock”!
  • “The Root of It Commentary – Cerec vs E4D, The Real Story!



The Office Manager Blog.……………………………………………………………………………………..

Meet Dayna Johnson

2:03 Click Here  

Meet Dayna Johnson, author of The Dentrix Office Manager blog, helping practices develop Dentrix “Super Users” to improve productivity

To read Dayna’s Blog, log onto

This Week in Dentistry from the ADA………………………………………………………………..

Is the third-party payer bundling procedure codes, or is it something else? ADA News – August 09, 2012

The Council on Dental Benefit Programs receives phone calls and emails from many members concerning procedure code bundling and possible misuse of the CDT Code.  A Letter to the Editor ran in the March 19 ADA News on this same topic. The council wants to clarify bundling and CDT Code misuse and has issued the following guidance.

An explanation of benefits that shows reimbursement for fewer services or for different procedure codes than reported on the claim raises eyebrows and prompts dentists to call ADA and ask, “How can this happen? Isn’t the third-party payer doing something wrong or illegal? It looks like the CDT Code is being misused.”

The first step in answering these questions and concerns is to look at what guidance is in place concerning CDT Code use.

• A CDT Code license, which a third-party payer must sign in order to legally use this ADA intellectual property, clearly states that a procedure code entry cannot be changed—meaning a code’s nomenclature and descriptor are fixed and cannot be redefined. An example of redefinition and possible violation of the license is when a claim that reports delivery of D0120 (periodic oral evaluation), D1120 (prophylaxis – child) and D1203 (topical fluoride-child) is returned with the payer stating that all three services are part of D0120. Here the third-party payer is redefining D0120.

To read the rest of this article log onto:


Dental Marketing Up-Date!…………………………………………………………………………………..

Well, today I found my new Verizon Phonebook (Hackensack Area) lying on my driveway in a nice waterproof plastic bag. At first I thought about putting it on top of last years, in the cabinet next to my family room sofa but instead, I through it in with the recyclables. But then I had a revelation! I thought about checking the “Dentist Adds” to see which of my personal clients hadn’t yet seen the light, drank the Cool Aid and spent advertizing dollars on something that 95% of the population never looks at.

I found 10 large ½ page & ¼ page ads and only 1 was my client. That was not bad considering the ethnic background and culture of the office and it was only a 1/6 page add. A language barrier will sometimes lend itself to more old style traditional marketing. However, I was pleased to see that my client base is hearing what I am saying about the changing demographics and looking at their ROI!

For more information on current marketing techniques, please feel free to contact me at any time @ 201-321-7494 or



Product Review – Ceramir Crown & Bridge Cement!……………………………………………

This unique product has been distributed by Henry Schein for 2 years. Although the reports from the field have been outstanding, it escaped my focus. After an “off the record discusion“ with Dr. Howard Glazer, I thought I should highlight the product. Sorry Howard, sometime I can’t hold back on what we talk about.

 “Ceramir is a dental bioceramic technology based on biological principles developed methodically in Sweden over the last 25 years,” says Emil Abrahamsson,CEO, who claims that the chemistry of Ceramir’s materials results in long-term superior sealing properties and biocompatibility. Ceramir mimics natural teeth in that it is designed, to the greatest extent possible, to have natural thermal characteristics. Ceramir has low thermal conductivity, like teeth, and “moves” in almost the same way as enamel and dentine. This minimizes the risk of thermal shock when the material is subject to sudden temperature change. 

Product Manager Kelley Reinfelds says the most unique aspect of the chemistry of Ceramir is that its material is alkaline, and she explains that the product “bonds to the tooth in the same way as when the tooth rematerializes, so that, rather than degrade, the cement improves in the mouth.”

Ceramir was designed to be stored and used within the mouth’s naturally wet environment, and Reinfelds remarks that due to its “distinctive” consistency, “Ceramir enables placement of a crown without resistance, even if the fit is tight and the prepared tooth/abutment is parallel.” She references a letter from a clinician, who used the product for a high noble metal ceramic crown on a custom milled implant abutment that was “very retentive” because it had “very parallel walls and grooves.”

For more information, log onto:

Ceramir Trial Package #477-0000 … $49.99

Cliff’s Notes client’s discount programs will be applied.

The Henry Schein Outlet Store: Special of the Week!…………………………………………..

Outlet Store offers are limited in quantity and only available on a first come-first serve basis. The inventory is very fluid so it pays to check back frequently for new listings.


Condition: Overstock
Part Number: 808-0037-N  Manufacturer Part Number: 231004
Catalog Price: $22.49 … Outlet Price: $9.99

Warranty: N/A

100 Unit package – $89.00 #231004CN

For a complete listing of shapes and sizes, log onto:

Product Categories

OVERSTOCKED: New Products that are in the manufacturer’s original sealed package
DEMO MODEL: Open-box products that have had no clinical use
RECONDITIONED: Products in excellent condition, restored to the manufacturer’s specification

All products include comprehensive warranties backed by Henry Schein

The Root of It Commentary…………………………………………………………………………………

Cerec vs E4D – The Real Story!

 Cad Cam dentistry and digital impressions are the future. If you will be practicing dentistry for more than another 5 years, you will need to engage in this technology and the good part is that it is getting better and simpler. However, don’t be Ralph Crandon (Jackie Gleason’s Honeymooners) and wait for 3D TV. 

Today there are only 2 dental office based systems available in the industry and it will remain that way for a long time. Cerec by Sirona and E4D by D4D Technologies are the choices and like politics, the sales pitch often masks the truths. So let’s try to get past the smoke and mirrors and get a grip on the real story.

Both Cerec & E4D are office based digital impression systems that have the capacity of connecting to in-house milling machines that will produce single unit all ceramic crowns, inlays, onlays and veneers. Both systems will be able to mill multi-unit ceramic bridges in the very near future, as soon as the ceramic blocks are available. The end result is that both systems do a great job and produce final quality restoration. 

However, there are 4 very important differences that are often omitted from demonstrations and presentations.

The first difference is the milling unit:

  • The Cerec Mill is small and compact requiring less floor space. The larger units are designed for labs and heavy use. There is an on screen alert when the diamond cutting instrument is worn and needs to be replaced. Office staff would then have to change the diamond so the unit can continue production. The Cerec program provides in-house maintenance by a factory trained technician once every year and the staff is responsible for weekly maintenance.
  • The E4D Mill is large and weights about 200lb. It is industrial grade and designed for heavy use by dental offices or labs (same unit for both). The unit has a 5 diamond carriage and automatically changes cutting instruments when needed eliminating staff interruption. The E4D program provides in-house maintenance by a factory trained technician 4 times per year (quarterly) and the staff is responsible for weekly maintenance.

The second difference is the camera:

  • The Cerec Camera has recently changed. The new camera that was introduced last week claims that it does not require powder. For years Sirona has claimed that powder was necessary and now it is not. The reason for this change in philosophy is to compete with E4D’s powder less laser environment. The camera now offers automatic imaging that in the past was looked at as not practical due to the number of pictures required. The new camera is smaller in design and ergonomically acceptable. The new camera also provides color adaptations, but it is the first off the assembly line and up-graded models are sure to follow. Shade matching is not recommended at this time.
  • The E4D Camera is a little larger and has always incorporated laser technology and steadying alert features. It has never required powder and was originally designed with automatic imaging and on-screen guidance. The ergonomic design is very acceptable. Software up-grade are expected and are provided at no cost to the user.

The third difference is work-flow functionality:

  • The Cerec System is relatively easy to learn. Once the restoration is captured & created it can be sent to the Mill or electronically to your lab for fabrication. It can be used as a digital impression system or the mill can fabricate the restoration. After the process is completed the system will store the patient’s data and you are ready for the next patient. Milling time takes 7-20 minutes depending on the brand of blocks you are using and the restoration being milled. The system will automatically adjust the process time when the material is selected. Training is provided at multiple training cites so user technique may vary. That inconsistency often causes some confusion among users when attending advanced training by different guest clinicians. 
  • The E4D System is also very user friendly, however, the E4D system incorporates 3 computers. One in the processing unit, one in the milling unit and a central server. The central server allows multiple patient restorations to be stacked and sent to the mill in a selected order. Once a restoration is sent from the process station, the next patient can be scanned immediately. The server also allows multiple offices to transmit through the internet to the milling unit without interfering with any other production. Like the Cerec system the E4D can transmit digital data to your lab or the in-house mill. E4D also provides education and training in one national facility in Dallas, Texas along with an SOS service that allows Dallas trainers to log into your system within seconds and assist in designing final restorations, that provides the user with continuous consistent support. The goal is to make the techniques standard so all advanced training will be consistent among clinicians.

The fourth and most important difference is the business model the 2 companies have incorporated.

  • Cerec is manufactured by Sirona and in the United States and Canada is distributed by Patterson Dental. Oddly enough Henry Schein distributes it in the rest of the world along with E4D. Patterson makes their money selling the blocks for milling. Blocks are made by 3M & Ivoclar Vivadent. Sirona makes their money by selling the hardware, software and up-grades. That is one reason why so many up-grades and changes are offered. Also, to receive software up-grades, the buyer needs to join the Cerec Club at a cost of about $220.00/month.
  • E4D is manufactured by D4D Technologies. D4D has partnered with 3M, Ivolcar Vivadent and Henry Schein. All of the partners share in the profit of the blocks and for that reason all up-grade are free of charge. There are no clubs to join, the E4D alliance is more concerned that the system is used and becomes part of standard office protocol. Blocks for both the Cerec & E4D units run about $25.00 each. It’s the old Gillett philosophy, give away the razor and sell the blades.

The bottom Line is that you need to do your due diligence. Both units cost about the same and if you are thinking about up-grading your Cerec, a trade-in for E4D is the same cost. Although E4D has a lower day by day operational cost due to less equipment and software maintenance, you need to use what feels best in your hands. The material costs for restorations, for both systems, are about the same (approx. $35.00/restoration). The blocks are the same, however, the chuck attached to the block is exclusive to the systems.

For more information, please feel free to contact me at any time @ 201-321-7494 or

Today is Sunday, August 19th. Enjoy the day and please be safe, there are a lot of people that need you. 


Join the ADA on Friday, February 8, 2013 to Give Kids A Smile

Call Cliff @ 201-321-7494 for details…It’s feels good to “give back”

Cliff Marsh

Henry Schein Dental

P.O. Box 663 / 45 Rt. 46East

Suite 605

Pine Brook, NJ 07058


August 19, 2012 - Posted by | Uncategorized


  1. Really appreciate the article pointing out the differences between the CAD/CAM systems. Thank you. Dr W. Baez

    Comment by william | January 24, 2013 | Reply

  2. There are some very severe inaccuracies in your “article” concerning CEREC. First, the Inlab and the Chairside mill are the EXACT same dimensions and are within 3 lbs of each other. The only difference is the four motor versus two motor design. In that same part of the article you failed to mention that the E4D mill requires air lines to operate. An added expense and complication to practices who don’t have sufficient volume compressors. A large, bulky mill that is so large, it can not even be demonstrated prior to the sale is not an advantage. The Cerec mill requires only an electrical outlet. Having a more efficiently designed, small form unit that operates much faster than the E4D mill is an advantage. Dental real estate is expensive, having the smallest X-ray sensors, curing lights, autoclaves and milling units and other equipment is the trend.

    Second, the new Omnicam, never requires powder, period.

    Most importantly, and this is a huge advantage over E4D, is that CEREC enables a doctor to offer one visit dentistry to their patients. This is not something I have seen any of the two or three E4D owners in the NYC area be able to do. All of them take traditional VPS impressions, pour up a model, then scan the model. This does not drastically improve the patient experience nor does it create a beneficial practice differentiator, since the work flow of impressions, and delivering a restoration changes little after the purchase of the E4D. One glaring fact left out of your article: there are 18,000 Cerec systems in the US, and 30,000 worldwide. There are less than 800 E4D systems in use. That fact is telling. After five years on the market E4D has a market share of less than 5% of chair side milling systems. At that same rate of growth it will be 30 years before e4D has HALF the market share Cerec currently has.

    Comment by John smith | May 12, 2013 | Reply

    • John, I do respect your views and I am sure that you are a cerec user defending your purchase or a Cerec sales person. At the time the blog was written the Omnicam was just introduced. The new Cerec mill has not yet been in the field. To start, Sirona, the makers of the Cerec, allow the system to be sold world wide by multiple distributors including Henry Schein. However, do to “politics” only Patterson Dental can offer it in the US and Canada so the world wide dental community is familar with both. As far as cost, it is a documented fact that Cerec ownership is more expensive in overall opertational cost. A cerec owner of the last 10 years that has incorperated all up-grades has spent around $200k additional. The Cerec Club is also an additional expense ($300/mo approx) that E4D does not have. Cerec has always promoted the powder environment until very recently when their technology caught up. As far as the air supply, the one time cost of running an air line is nothing more than a service call and usually included in installation. The size of the milling unit can be a concern, however that is part of the buyers due dilligence process. It is the size it is because it has its own sever that allows multiple restoration to be stacked and processed while new ones are being scaned. That is a feature that Cerec does not offer. New office designs allow for larger equipment to facilitate production and work flow and that I would be willing to debate anytime also curing lights and sensors are not in that equation. To address the impression technique, that is the users choice. My largest client has been a Cerec usre for over 12 years and is currently a trainer. He chooses to scan from impressions, so the option is there with both systems. At the end of the day, both systems result in fine restorations and the user needs to decide what works better for them. A local study club, here in the NJ/NY market, recently had their members do an apple to apple evaluation. One at a Patterson Center and one at a Henry Schein Center. The result was that the E4D was a more user friendly system. With all of that said, as a representitve of Henry Schein I am partial to E4D, however, I also believe that anyone incorperating this type of technology into their practice, needs to do their due dilligence. I would enjoy more discussions with you and to know how long you have been a Cerec user or representive. You can contact me directly at or by phone @ 201-321-7494. Thank you for your views, they will be posted in the comments on my blog. Today is Mothers Day so please enjoy it with your loved ones and thank you again for your comments.

      Comment by Cliff's Notes Blog | May 12, 2013 | Reply

    • Sorry, your assertion. That one visit dentistry isn’t done with E4D is dead wrong. I do so routinely, almost never take an impression, can recall the last time I did.

      And your numbers on CEREC ownership are misleading. First CEREC includes all iterations of its machine in the count. Obviously many of the older systems are no longer in use. And your E4D ownership numbers are also low.

      Based on the reaction to the high upgrade cost for Omnicam it won’t surprise me if we see significant inroads made in the numbers over the next year or so. Bottom line Sirona really soaks customers on upgrades. 40k for a new camera?? My E4D HD camera upgrade was 9k, new camera and PC. D4D simly takes better care of its customers. I’m hearing current users can’t even get omnicams as they units available are being reserved for new customers only. Way to reward loyal uses!!

      Comment by Mike Kelliher | May 18, 2013 | Reply

      • Mike, thank you for reading my blog and your reply to John Smith’s comment. User comments help those looking to engage this technology become informed.

        Comment by Cliff's Notes Blog | May 18, 2013

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