The Orthodontic Opportunity
Aligning teeth requires aligning your education with your patients’ needs
By Amanda Harvey
With the global orthodontic services market expected to grow at a compound annual growth rate of 12.51% from 2017 to 2021, many general practitioners (GPs) are seeing an opportunity to expand their practices and increase revenue by offering orthodontic treatment. When considering adding orthodontic services, GPs should remember that orthodontics is not simply about straightening teeth, but rather, providing the correct services for each patient in terms of cosmetics, occlusion, and function. Obtaining the proper continuing education, including hands-on clinical experience, is imperative in this pursuit, as is staying abreast of the latest techniques and available products. Adding an orthodontic component to restorative and periodontal treatment can allow GPs to offer more comprehensive care to their patients; however, proper case selection based on the skill of the GP and the complexity of the case should always guide the decision to accept or refer out to a more experienced orthodontist.
Payam Ataii, DMD, MBA, a private practice owner in Laguna Hills, California, sees many patients with malocclusions that are affecting their overall health. As healthcare providers, general practitioners have a duty to offer the best possible treatment for the total systemic health of the patient. “The opportunity for GPs to provide orthodontic intervention is growing because of the correlation between orthodontic deficiencies and patients’ overall systemic wellness,” he says.
From the patient’s perspective, the convenience and comfort of going to a dentist you already know for orthodontic treatment can be less stressful than being referred to someone else for extensive work. It can also make the patient more likely to accept the treatment plan and improve their oral and overall health significantly.
For Ben Miraglia, DDS, a private practice owner in Mount Kisco, New York, the driving force behind getting involved in orthodontics in his practice was offering truly comprehensive care for his patients. Miraglia and two of his partners decided that adding an orthodontic component could help their patients in a way that they were unable to at the time. “We decided the best opportunity to offer adult orthodontics would be with clear aligner therapy. When you’re providing comprehensive dental care to adults, there’s almost always an orthodontic component because they have some sort of malocclusion to correct. A comprehensive treatment plan, including an orthodontic, restorative, and periodontal component, gives us the opportunity to guide unhealthy patients back to health,” he says.
While patients in many parts of the United States have easy access to dental professionals, including both general dentists and oral specialists, patients in more rural areas may be more underserved. “Many of our members come from smaller cities where access to specialists may be limited. The GP in smaller towns and rural areas must learn as many skills as possible because the family dentist has to meet a greater array of dental needs, including orthodontics,” says Tom Chapman, Executive Director at the American Orthodontic Society.
Aside from the obvious benefits of convenience for patients and offering care where specialists are not as common, there is also an economic opportunity for GPs who seek to expand their practices into the orthodontic field. While the main goal of any healthcare provider is to provide necessary services to patients, if you plan to make the investment in expanding your services, it is important to know that the return on that investment is worth it.
“Because general dentists already have access to many patients, no outside marketing is needed to develop a large orthodontic practice. From an economic perspective, orthodontics is extremely profitable, especially because the cost of materials is very low in comparison to the fees. Orthodontic patients are primarily paying for the knowledge and expertise of the practitioner, with the materials being a very small percentage of the fee,” says Miles McGann, President of Progressive Orthodontic Seminars.
Understanding Patients’ Needs
Orthodontic treatment is suitable to address a variety of concerns for all patient age groups, but it is important to understand the different needs of patients as individuals and how to treat the early dentition of children versus the late dentition of adults. This will require different types of continuing education, as the treatment plans for these varying patient groups will address different aspects of the dentition.
“In order to learn how to treat children, we would recommend that GPs take an interceptive orthodontic course with a hands-on component taught by a pediatric specialist. This can set up faster and easier comprehensive cases as the kids develop their adult dentition,” notes Adam Griswold, Executive Director of the Academy of Gp Orthodontics.
Lou Shuman, DMD, CAGS, Founder and CEO of Cellerant Consulting Group, recognizes that when treating adults, the patient is ultimately the decision maker. Adult patients commonly seek treatment for improved appearance of the “social six” (ie, teeth Nos. 6 through 11) with little understanding that achieving proper occlusion is critical not only to their esthetic goals but also to a stable outcome and their long-term oral and systemic health. One of the key roles of the practitioner is to provide patients with a comprehensive evaluation and educate them to look beyond the “social six” when full-arch orthodontic treatment is in their best interest.
GPs expanding into orthodontics will inevitably face adult patients focused on the quick cosmetic fix. “Don’t assume that adult patients are aware of their clinical needs, treatment options, and the consequences of not treating malocclusions,” advises Shuman. “When bite issues are causing misalignment, explain to the patient that correcting these issues will create a stable smile that lasts and outline what’s necessary to achieve an ideal occlusion and finish at the end of treatment. Many patients will relate to orthodontic treatment as a major investment that they can make once and enjoy for a lifetime. When you educate patients about the relatively small additional costs of treating anterior issues only versus the lifelong benefits of full-arch treatment, they are better equipped to make an informed decision and have appropriate treatment goals and expectations.”
Robert Kaspers, DDS, who maintains a private practice in Northbrook, Illinois, would emphasize that, in any patient, it comes down to proper diagnosis. “With children, you have a growing individual, but with adults, you have a non-growing individual, so it limits your treatment modalities. Of course, in children, you would like to not only develop a structurally sound occlusion, but in many cases, significantly improve their airway so they won’t run the risk of having obstructive sleep apnea later on. Diagnosis is everything. If you diagnose the case correctly, you can really help these patients out, and that’s where cone-beam computed tomography (CBCT) technology is going to be a huge help for the profession,” he says.
Other Important Considerations
Learning the basics of orthodontics is the first step to offering this service in the general practice. In a study, Purmal and colleagues found that 59% of general dental practitioners felt that the undergraduate orthodontic syllabus was not adequate; therefore, continuing education is key not only for general practitioners who are learning orthodontics but also for orthodontists who are already practicing.1
“There are many companies providing orthodontic instruction on a continuum from weekend classes to multi-year mini residencies. Weekend courses are very popular, but they tend to focus on a narrow spectrum of cases and highlight case selection criteria to identify patients who are compatible with the system’s treatment planning. Alternatively, GPs who are interested in learning orthodontics in depth to treat a wide variety of cases are encouraged to seek out a mini residency. Some of the educational institutions offering orthodontic instruction are the Academy of Gp Orthodontics, the American Orthodontic Society, and Nagy Orthodontic Academy,” notes Tyler Sisson, Clear Aligner Product Manager at Great Lakes Orthodontics.
As far as Kaspers is concerned, “The best reason in the world to enter into the orthodontic profession is to become more knowledgeable in acquiring a good structural bite for patients, and if practitioners can get the learning aspect down, then I don’t have a problem with anyone doing orthodontics.”
But this continuing education in orthodontics isn’t just for the GP. Your office staff is just as important in integrating this new service, and they will need to understand the process as well. “In addition to educating the GP, there are also educational courses that provide instruction for dental assistants and hygienists. Ensuring office staff is trained in orthodontics is critical to successful treatment, office workflow, and time management,” adds Mr. Sisson.
For fully comprehensive orthodontic training, the United States Dental Institute recommends at least 8 to 10 weekends during a 20- to 24-month period to achieve competency.2 Miraglia, a graduate of the United States Dental Institute, notes, “The institute offers comprehensive orthodontic training, including diagnostics, cephalometrics, treatment planning, traditional bracket and wire techniques, as well as expander techniques.” Although he invested the time and money to primarily practice orthodontics, most GPs will likely split their time between orthodontics and general dentistry. But what financial considerations should the GP explore before he or she decides to adopt this approach?
Aside from the cost of the necessary education, there is also the cost of some tools and equipment to consider, but it’s really more of a question of the value in this investment and its potential returns.
“As a GP, you may be referring as much as $150,000 in business per year to an orthodontist, 75% of which you probably could do yourself with quality continuing education, so the economic impact is fairly significant. We all go to dentists, and hopefully, we only go to dentists that we trust. Over a period of years, dentists perform many procedures for patients’ families, so from the patient perspective, integrating orthodontics gives you a chance to better serve their needs, while retaining much of that orthodontic revenue you were referring out,” says Chapman.
Before plunging into this investment, perhaps the wisest move would be to calculate the potential cost of adding the service and the anticipated revenue gained. “In order to estimate revenue, the doctor would need to look at the number of patients they are referring to orthodontic specialists, multiply that by the average orthodontic treatment fee in their market, and then expect about 75% of that amount, because they will still want to refer out the tougher cases to a specialist until they are more experienced. The largest startup expense should be continuing education, preferably with a hands-on clinical component, so they can confidently and competently get started doing orthodontics in their practice,” adds Mr. Griswold.
Another key consideration is the amount of time spent performing this new service. “A general dentist should also be aware of the amount of time they expect to spend chairside with their average patient and how that impacts their hourly rate. Case selection is a primary concern here, and it takes experience to make these decisions wisely,” adds Sisson.
As productive as orthodontics will make a general practice, there are some challenges that will come up too, such as patient compliance. All healthcare providers are familiar with patient compliance issues, which can range from patients incorrectly taking medication prescribed by their primary care physician to poor flossing and failure to address other hygiene concerns identified by the hygienist and general dentist. Orthodontics is no exception.
“Patient compliance has a huge impact on both the length of treatment time and the end result. Therefore, there is increasing interest in new technologies that reduce the need for patient compliance while improving treatment success. Some of that new technology is in fixed appliances, whereas in the past, most practitioners were using a larger number of removable appliances. Another critical area is in retention. You can do all of the quality orthodontics that you want, but if the patient is not committed to whatever form of retention they are provided with, the treatment will revert as they age. Retention is a critical component of successful orthodontics, and it must be seen that way by the patient,” notes Chapman.
When to Refer
If you do decide to pursue orthodontics to the fullest extent, there may still be cases that are too complicated for you to handle. That’s where a relationship with an experienced orthodontist is essential.
“If a dentist, GP or otherwise, cannot see and understand how the teeth are going to move from beginning to end, they should refer the patient to a specialist,” says Ken Fischer, DDS, an orthodontist and the Clinical Advisor for ClearCorrect.
Kaspers emphasizes that gaining knowledge is the most important thing that any dentist can do to correctly evaluate a patient’s occlusion. He encourages any GP who is thinking about this path to pursue the knowledge and then decide if it is truly something they want, but cautions that part of that knowledge is knowing what you can and cannot handle. “Even if you decide not to pursue orthodontics for your practice, just gaining that knowledge should give you a greater appreciation for orthodontists who are concerned about the function of a bite. It would aid you in finding an orthodontist who would treat your patients the way you would want them to be treated,” he says.
According to Shuman, case selection is critical to success, which comes down to an honest and realistic assessment of your comfort level. “GPs providing specialized services, such as implants, understand that they must decide which cases they can treat themselves and which ones they refer out based on their clinical experience and professional judgment. It’s no different for GPs offering orthodontic treatment. It’s critical to establish your comfort zone. As with other specialties, the appropriate selection of orthodontic cases helps avoid protracted problem situations that are unprofitable and frustrating for doctors and disappointing to patients,” he says.
Tools of the Trade
General dentistry requires its own impressive amount of tools and equipment for various treatments, and expanding into orthodontics will necessitate that even more products be added to your armamentarium, from clear aligners and brackets and wires to smaller, basic tools and a CBCT scanner, if you do not already own one. It also requires a good relationship with a laboratory that can produce clear aligners and expanders. Keeping up with the current tools and techniques will help to advance your productivity and success, but this is an ongoing exercise because new technologies and products are continually introduced to the orthodontic market.
“The general dentistry market is moving toward expediting treatment—whether it be how efficiently candidates are identified, how quickly manufacturers are delivering treatment plans to dentists, how fast aligners are being delivered to patients, or perhaps most importantly, how rapidly the treatment itself is being delivered. Obviously, the faster that treatment can be completed without sacrificing its effectiveness, the better for the doctor and the patient. Manufacturers are looking for ways to meet that demand and speed up the process from when the patient is in the chair to the actual completion of treatment. As manufacturers deliver innovations in this regard, it forces the market to respond. I think we will see more of that in the next year or so as companies come out with ways to meet that demand. As a company, Dentsply Sirona is focused on doing just that by empowering dental professionals to provide better, safer, faster dental care,” notes Caroline Weaver, Technology/Clear Aligner Platform Lead at Dentsply Sirona Orthodontics.
With the rapid growth in this market, getting up to speed on the current trends may seem like a daunting task, but knowing the basic products will help keep you abreast as new ones surface.
According to Fischer, one way to stay on top of the market is to work closely with the product and equipment representatives for education and assistance. “There are a number of companies providing clear aligners, intraoral scanners, impression materials, and auxiliary products that are essential to an orthodontic practice. GPs should take numerous courses and attend tradeshows and professional meetings to get a good understanding of the appliances and the techniques,” he adds.
Putting It All Together
Some orthodontists believe that GPs should not be performing orthodontics, and some GPs feel that they simply cannot rely on the orthodontists in their area to give their patients a structurally sound bite, but there are two things that everyone seems to agree on: orthodontic treatment can significantly improve the oral and overall health of patients and getting the proper education is essential before even considering offering treatment with orthodontics.
Shuman notes that no matter who ultimately treats the patients, what should always be most important is that they are getting the necessary care to improve their oral health. “Personally, I’ve been very comfortable with the growth of orthodontics in the general practice office because ultimately, when they assess a patient, they are looking at a long-term relationship. It’s not just about winning case acceptance; they want that patient to be with the practice for the rest of their lives,” he says.
While thinking about these patients in terms of lifetime relationships, also consider your team, the people who support you every day, and your partnerships. Ataii encourages GPs to talk to their teams first. “Getting the team to buy in is the key. Setting a meeting with a company representative is not always about sales, but rather partnerships. Just like proper case selection is essential to ensuring the best patient outcomes, selecting the right partners also plays a vital role in achieving successful outcomes. In my practice, my team and I have carefully selected our partners based on the focus of the practice,” he says.
“The biggest advice that I give to all dentists who are considering offering orthodontics is to look for a comprehensive course that has a curriculum that makes sense to them logically. If you take a good course, you can offer orthodontic treatment at the level of the specialty, which is the only way that you should be doing any specialty in my opinion. The key to being successful in orthodontics is to have a thorough understanding of the science, a support system to help you as you learn, and realistic expectations,” concludes McGann.
1. Purmal K, Alam MK, Mohd Nor NS, Zakaria N. Orthodontic Treatment by the General Dental Practitioners and Their Opinion about Orthodontics. International Medical Journal. 2013;20(2):243-246.
2. United States Dental Institute Website. http://www.usdinstitute.com/about-orthodontics/. Accessed September 11, 2017.