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Inside Dentistry
December 2019
Volume 15, Issue 12

The Next Generation Speaks

Sefira Fialkoff

In dentistry, shifting generational and gender-balance dynamics are reshaping every aspect of the industry from school to retirement. Although the dental industry is still dominated by baby boomers (38.6% of current dentists are age 55 or older),1 it is the millennial generation that is shaping the future and setting new trends. One dramatic way that this is affecting the future of dentistry can be seen in the increase in dental service organizations (DSOs). Millennials are also incorporating social media and digital technologies into their practices at an unprecedented rate. At the same time, the proportion of female dentists is steadily increasing. Forty years ago, only 7% of all dental school graduates in the United States were women; now that number is nearly 50%.2 This new gender balance is even affecting the way that some offices do business.

Inside Dentistry interviewed a diverse group of young dentists to learn more about the future of dentistry and the amazing changes that this generation is creating regarding technology, research, education, advocacy, and leadership. The field of dentistry is quickly evolving with new technologies and practice models.

In our conversations, we began by asking what motivated these millennial practitioners to become dentists and what inspires them day-to-day in their careers.

Brooke Blicher, DMD, co-founder of Pulp Nonfiction, a company that focuses on "evidence-based endodontics for the real world," chose dentistry because of some reinterpreted family advice. "My great aunt famously advised all the young ladies in our family to ‘marry a dentist,' and my modern translation of that was that dentistry would be a pretty good deal for me." says Blicher. "My mentors encouraged me to focus on endodontics and instilled in me a drive to achieve excellence in clinical practice and a desire to pursue evidence-based work and research."

Jamie Toop, DDS, graduated from Loma Linda University's School of Dentistry, where the motto is "to make man whole." The students are taught to provide treatment to make patients whole again-mind, body, and soul. Toop embodies this motto by publishing and speaking about the oral-systemic link. Her work reveals how 7 of the 8 leading causes of death in America are linked to inflammation and pathogens in the mouth, and her inspiration as a dentist is clear: "Practitioners can save lives through bread-and-butter dentistry in their everyday practice."

Sometimes the route to a career in dentistry is more circuitous.

Andrew Ferris, DDS, who is now an orthodontist, describes his career path as a funny story. "In college, I played National Collegiate Athletic Association Division I golf and majored in finance and real estate so that I could better manage the money that I thought I'd make playing professionally. However, I quickly realized that I wasn't going to be the next Tiger Woods," says Ferris. "My uncle was a dentist with a good life helping people. He had the autonomy of being a business owner, supported his family, and was able to play a lot of golf." While at school, Ferris fell in love with the fast-paced environment of orthodontics and its ability to transform lives. In retrospect, the finance and real estate degrees came in handy. "A big part of orthodontics is running a business, and I'm currently building my own office building," he says.

Davina Detrik, DDS, has a career path stemming from a summer that she spent waitressing, albeit poorly. "When I was younger, I waitressed and loved taking the time to get to know customers and forming connections. That approach resulted in one great tip, several customers who left no tips, an angry boss, and a bad summer," Davina explains. "Dentistry was different and a God-send because forming connections is encouraged, and that came naturally to me."

Dentistry is often referred to as an art. It is largely based on maintaining proper oral health and function, but it seeks to provide beautiful esthetics. This balance of science and art is what attracts some to the profession.

In this way, Galen Detrik, DDS, attributes his predilection for dentistry to his parents. "My dad is a custom home builder, and my mom is a classically trained painter, so delicately walking the tightrope between artistic and functional was something that I learned to appreciate. Dentistry is the perfect expression of those two characteristics, and it enchanted me."

Similarly, Rebekah Lucier Pryles, DMD, an endodontist and the other co-founder of Pulp Nonfiction, was drawn to dentistry through an interest in both the arts and the medical sciences. "I can explore my research interests, scratch the itch to make something beautiful, and thoughtfully care for the public. I chose endodontics because I was drawn to the intensive diagnostics, the emergency medicine component, and the ability to make a large difference in the lives of patients undergoing significant dental pain." In addition to joining a full-time endodontics practice, she began to teach in local endodontics residency programs. Her participation in academic dentistry continues to satisfy her desire for scientific inquiry and was the inspiration for a textbook that she wrote with Blicher.

Stephanie Zeller, DDS, attributes her success as a prosthodontist, researcher, writer, and speaker to working absurdly hard, always being open to criticism, and finding amazing mentors. In her career, she often speaks about how the world is shifting into an age of creativity and how dentists can benefit by leaning in.

The academic and educational fields associated with dentistry allow dentists to specialize in areas that they are passionate about.

Nate Lawson, DMD, PhD, an assistant professor and the director of the Division of Biomaterials at the University of Alabama at Birmingham School of Dentistry, wanted to be a dentist ever since kindergarten, inspired by the three dentists in his family. "My path toward research and academia was circuitous," says Lawson. "After school, I spent a year in corporate dentistry before entering academia." Lawson likes academia because it exposes him to constantly changing projects, bright-minded students, and faculty peers and friends, which makes his job both mentally stimulating and exciting. He evaluates cutting-edge materials and technologies and shares this information at meetings and in publications. As he explains, "The sacrifice made with a career in academics is that the financial compensation will never equal what can be obtained in private practice."

Irina Dragan, DDS, is the director of faculty education and instructional development at the Tufts University School of Medicine, where she is involved in various clinical and educational research projects, teaches periodontology in the postgraduate clinic, and sees patients one day a week. Dragan is a first-generation dentist who moved to the United States from Romania nearly 10 years ago to pursue advanced education at New York University and Tufts University. Dragan stresses that the role of education is vital and emphasizes that "academic institutions are molding the next generations of dentists, so they need to prepare graduates for an unpredictable future."

Education is playing another pivotal role in shaping the future of dentistry. When asked, "What are the biggest challenges that young dentists face?" many pointed to student debt.

The enormous debt load that dental students take on is affecting the way that many dentists start their careers and the types of practices they establish. The average educational debt for all indebted dental school graduates in the class of 2018 for both public and private dental schools was $251,869 and $326,133, respectively.3 This enormous amount of debt may play a role in the rise of DSOs. Young dentists are able to join a DSO without having to buy in, as is the case with a group practice, or buy outright from an individual retiring dentist.

"The six-figure student debt burden faced by young dentists is the single largest challenge facing this new generation," says Pryles. "Many dentists join the profession with hopes of mentorship, future practice ownership, control of their work-life balance, and an income that can support their families. The debt burden can limit their opportunities to pursue practice ownership by traditional means and may impact the types of jobs that they select following school. When coupled with continually decreasing third-party reimbursements for valuable dental services, this situation has the potential to financially cripple this generation of dentists."

Zeller agrees that the crippling financial debt is a challenge, adding a lack of mentorship to the list, and Dragan notes that this debt burden impacts both the professional and personal aspects of a young dentist's life. According to Ferris, "The cost of education is one of the biggest challenges to starting a practice. Competing in the market often means investing in expensive technology, which can be difficult to do while paying off student debt."

"The rise in student debt coupled with a hyper-competitive business market makes it more stressful and difficult for new dentists to establish themselves," elaborates Toop. "Young dentists are passionate about technology, which is expensive. The landscape has become increasingly complex, and although the solo practitioner is not going extinct, the migration toward group practices will continue."

Blicher suggests that "with reduced reimbursement rates and the outsized costs of dental education, practices need to adapt to new models. Young dentists must find alternative ways to maintain their autonomy in private practice settings that provide exceptional individualized care for patients."

The Detriks agree. "Without a doubt, the biggest challenge is massive student loan debt," says Davina. "The issue is less about the debt itself and more about how it prevents young dentists from experiencing life, which is the entire point of it all. Because of debt, it's extremely difficult for young dentists to lay the groundwork for the lifestyle and practice style that they want. A growing subset of millennials wants to provide more complex, top-shelf treatment, which is the stuff that transforms dentistry from a daily grind into a fine-tuned hustle. They want to take continuing education courses from the world's best, they want a thriving lifestyle, and they want autonomy-the freedom to make their own choices, paint their very own office walls, and engineer their own patient experience. The challenge is in the ‘and.' It can be difficult to enjoy a lifestyle AND maintain autonomy. DSOs and group dentistry are making it easier than ever for a fresh style of private practitioners, fee for service dentists, to elevate the experience they deliver and create a brand with staying power."

"Now is the best time," echoes Galen. "There's a demand for the highest level of care, and global marketing is a powerful tool. As a result, 40% to 50% of our clientele fly in for reinventive dentistry. We aren't competing with DSOs on their terms; we're building a highly profitable niche brand. The key is to get in the game early and become highly visible, making it easy for decision-making patients to choose your office as their concierge dental home."

The traditional dental practice landscape is changing, and dental schools are evolving to support new dentists.

"New graduates have more career choices than ever before, and dental schools need to educate students about the different models of practice, patient communication skills, the complex arena of dental insurance, and the metrics that will help them build a successful and enduring practice," says Toop. "Dental schools will evolve to better prepare students for real-world dentistry by continuing to broaden their curriculum in areas of oral-systemic health and interprofessional collaboration."

Dragan notes that academic institutions are aware of the shift and adapting curriculums to future trends to prepare graduates for long-term success. "The challenge is finding a balance between traditional models of practicing dentistry and the latest technologies," she says. "Skills like critical thinking and lifelong learning are being emphasized in all settings now—from didactic to clinical."

Concepts of "the next big thing in dentistry" involved a greater focus on the patient and the doctor.

"Collaborative practices and patient-centered care are certainly the future of our profession," posits Dragan. "As educators, we have a responsibility to prepare graduates to adapt to new trends. I advise my residents to focus on procedures that, despite advances in science and technology, will endure in periodontology. Centering a practice around a specific expertise allows us to remain key players in the collaborative care of our patients."

Galen believes it will be authenticity. "The shiny object right now is technology disruption, but that's not the next big thing," he says. "That's just an agent of change. It's the void that it creates and how people react to it that presents the greatest point of leverage. Being fully yourself and expressing that unapologetically in your business is an act of rebellion that will pay major dividends if you commit to the process early. Doctors who refuse to separate their personalities from their practice brand and, instead, integrate them fully are having all of the fun and making all of the money."

When asked what the industry would look like in 5 to 10 years, many saw a future of collaboration.

"This is a challenging question because the profession is advancing so quickly," says Dragan. "With the many stakeholders involved, I hope that clinicians will be able to implement strategies to improve care efficiently and at a reduced cost."

Davina believes that there will be both "mechanics" and "magicians" in practice. "In 5 years, 75% of the field will be mechanics, working for corporate DSOs. The magicians will work with autonomy, prioritizing time with clients, and operate their businesses their way," she says.

"The mouth-body connection should encourage collaboration with medical providers," notes Toop. "For example, cardiologists and family physicians should work with dentists to screen for and treat periodontal disease as a form of therapy for heart disease. Through proactive steps and clear communication between providers, we can potentially prevent or even reverse some systemic conditions. I also believe that we'll continue to see a greater focus on patient centricity at an affordable cost, more integrated technology solutions, and innovative practice models."

 Pryles remains optimistic that dentistry in the United States will continue to provide exceptional patient-centered care despite the disturbing trends in third-party reimbursements. "Dentistry and endodontics have experienced an increase in partnerships and group practices. I see this as an evolving trend given the desire of millennials to problem-solve collaboratively," she says.

"Perhaps young practitioners simply do not have the time, experience, motivation, or encouragement to enter into leadership roles," suggests Blicher. "But, I hope that as the younger generation enters the dental workforce, we'll see more of us in leadership roles."

"The spread of digital photography and social media impacts the way that I teach and conduct research," Lawson explains. "We document clinical cases with digital photography and demonstrate procedures in shareable videos. Social media platforms allow passionate dental educators to share knowledge, opinions, and collaborative opportunities with students and colleagues across the world."

Zeller believes that the industry as a whole will continue to be transformed by digital integration and other advancements, including improvements to technologies from artificial intelligence and machine learning, developments in 3-dimensional printing, and the integration of augmented reality and virtual reality. "The mindset of modern patients' evolved values includes authenticity, creativity, and efficiency," she says. "The businesses that excel will be those that explore and integrate creativity into their offices and marketing as well as those that hold space for patients, allowing in an element of vulnerability."

"We'll continue to see a shift from analog to digital," says Ferris. "With cone-beam computed tomography, intraoral scanners, 3D printers, and all of the advances in software, we are going to be able to treat in a more effective, efficient, and patient-friendly way. Technology is an investment, so it's important to know how to leverage it to get that return on investment."

Younger practitioners are experiencing major changes in general dentistry and the specialties.

Ferris notes that, during the last decade, clear aligners were one of the biggest advancements in orthodontics. "Aligner therapy allows us to correct the underlying foundation while gaining case acceptance in all age ranges, thereby improving all other aspects of dentistry," he says. "Moving forward, the digital aspect of aligners, as well as improvements in digital bracket placement and wire design, will continue to revolutionize how patients are treated, improving quality and efficiency."

"I worry about how quickly we've transitioned from predominantly amalgam restoration to the ubiquity of composites and ceramic materials; it is striking," says Lawson. "These modern materials provide such favorable properties that they can hide mistakes without resulting in short-term failures. I fear that in 5 to 10 years, failure rates will increase because we've pushed these materials to their limits. We need to teach students how to prepare teeth for minimally invasive restorations, manage deep caries, achieve great isolation, bond, and contour and polish restorations."

Blicher explains that endodontics has been at the forefront of research and technology and that there are several areas for its advancement in dentistry as a whole that she is excited to be a part of, such as regenerative endodontics. "We utilize the body's own tissues to heal from disease," she says. "I see this becoming a much more reliable and routine part of endodontics, periodontology, and operative dentistry. The use of 3D imaging has also revolutionized our field. A dedication to research and technological advances makes endodontics increasingly relevant in giving patients biological choices for treatment. Keeping up with products, techniques, and continuing education can be overwhelming, and deciding where to get that information can result in decision fatigue."

Technology has certainly transformed the industry, but this generation's quick adoption of new technology is just one of the many ways that millennials are making their mark on dentistry.

Zeller has been speaking a lot lately about the fusion of millennials and technology and the huge impact the two are having across every industry, disrupting the old power structures. "The millennial mindset embodies both ‘thinking outside the box' and an ‘I can do this myself' attitude," she says. "In addition, social media provides an opportunity for everyone to have his or her voice heard on a potentially large scale. The millennial mindset, access to others, and technology creates a shift from the old, top-down power structures to new, more lateral power structures. In turn, this impacts every single industry, particularly marketing."

"The millennial generation grew up technically savvy with computers," adds Ferris. "They will continue to advance away from analog methods and to push the envelope in terms of technological capabilities."

According to Toop, millennials are at the frontiers in technology-enhanced dentistry. "They are performing treatment more efficiently, getting better results, and creating an easier experience for patients," she says. "They utilize social media and other online marketing techniques, which gives dentistry a new image. Inspired by student loan debt and a desire to offer convenience to their patients, they often have flexible schedules, offering same-day procedures and working evenings and weekends. Furthermore, the line between the patient and the consumer has blurred. In addition to online reviews, patients have unlimited access to information and demand choices, convenience, and value."

"Millennials are digital natives, using technology in ways that digital immigrants did not even think was possible, says Dragan. "They will leverage their technological savvy to improve patient care."

Blicher notes the barrage of information-social media posts, podcasts, email blasts, and new and interesting conferences are popping up every day. "Direct-to-consumer products are providing alternatives to traditional large dental manufacturers and personal sales representatives. These options can be both a great thing and a challenge. Millennials have the reputation of shaking things up, and it's exciting to see the impact our generation is having on the evolution of dentistry," she says.

"Millennials are often maligned as entitled, selfish, and averse to hard work," laments Pryles. "What's often overlooked is their incredible ability to work collaboratively to solve problems. This, coupled with a conscientious desire to have a positive impact on their world, makes millennials an incredible force for positive change within the profession, within academics, and within organized dentistry."

The Detriks feel that millennials inherited a fascinating world. "The older generation worked for retirement, the younger generation wants instant gratification, and millennials are caught in the middle," suggests Galen. "We want lifestyle and autonomy, and we're getting it through innovation and creativity. These sentiments are why we built our company, The THRIVE Dentists. It's not hard work or no work-it's intentional work. It's not live for today or hope for retirement-it's presence. And, it's not the corporate compromise or the practice prison-it's the future. The cost is a growth mindset and disciplined actions. One believes, and the other builds; one inspires innovation, and the other achieves milestones. The result is a low-stress, high-profit practice."

"Working within an insurance-based practice is challenging," says Lawson. "Having the clinical confidence to recommend a procedure that isn't covered can be intimidating. There's also a balance to strike between performing a procedure at the highest level, which takes time, and the practicality of remaining profitable. In addition, considering how young I look, achieving credibility with my patients can be challenging. Of course, clinical confidence and competency help to overcome any skepticism, but I secretly celebrate each new strand of gray hair that appears on my head."

As millennials make their mark, the women of this younger generation are making their own unique mark on dentistry.

Blicher is proud to say that her graduating class was 60% female. "I truly respect my male colleagues, but for patients who connect better with women, more female providers will surely allow for better access to care," she says, "As the mother of a young daughter, I know that women can do anything that men can do, and dentistry is no exception."

"Personally, my perspective has shifted from chasing success to living in success," explains Davina. "I'm more deliberate in building things that I love in order to share. I wonder if this metamorphosis is happening to other female dentists? I am noticing that women in dentistry are undertaking really personal, connected, and inspiring projects-fostering an energy of service, sharing, collaboration, and innovation. From my standpoint, the much needed and welcomed evolution is one from competition to creativity."

"Women are well known for their collaborative and compassionate traits," says Dragan, "which are traits that strategically align very well with the profession's anticipated future trends."

Many of Pryles' female mentors recounted their struggles of fitting into a skeptical male-dominated profession. "Now, with more acceptance, women are able to make their mark," she says. "I continue to see exceptional examples of female-run businesses that provide exceptional care with a thoughtful (and maternal) touch. On the Vermont State Dental Society Executive Board, I've witnessed an increase in female inclusion that has correlated with increased value and respect from the vast majority of their fellow leaders."

Zeller agrees that more women will take the stage, become industry leaders, and add a degree of nuance to the industry and patient care.

Passing the Torch

It's a pivotal time in dentistry regarding providers, patients, and payments. Passionate and dedicated young dentists are transforming the industry. The forces of student debt, technology, and social media are challenging the traditional structure of dental practices, while creativity and innovation are propelling the industry to exciting new frontiers. Social media has changed the way that dentists interact with their peers, mentors, and patients. At the same time, a more holistic approach to health is also encouraging collaboration within and between dentistry's specialties. External factors such as insurance companies and consumer expectations contribute to industry change, impacting the way younger dentists run their practices and approach work-life balance. As the majority demographic shifts from baby boomers to millennials, dentistry can look forward to strong leadership and exciting innovation from this new generation of dentists. At the same time, the industry should expect a major shake-up in terms of business ownership and operation. As digital natives, millennials are integrating technology in an effort to maximize the timeliness, affordability, and quality of care. Perhaps most importantly, millennial dentists understand that the best investment they can make is in themselves; they're committed to continual learning and adaptation. Across specializations, dentists of all ages can benefit from understanding these shifting dynamics and the lasting effects that millennial dentists are having on the industry as a whole.

References

1. American Dental Association Health Policy Institute. Supply of dentists in the U.S.: 2001-2018. American Dental Association web site. https://www.ada.org/en/science-research/health-policy-institute/data-center/supply-and-profile-of-dentists. Accessed October 22, 2019.

2. American Dental Association. Wonder women of dentistry. American Dental Association News web site. https://www.ada.org/en/publications/ada-news/2019-archive/april/wonder-women-of-dentistry. Published April 15, 2019. Accessed October 22, 2019.

3. American Dental Education Association. Educational debt. American Dental Education Association web site. https://www.adea.org/GoDental/Money_Matters/Educational_Debt.aspx. Accessed October 22, 2019.

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