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Inside Dentistry
January 2019
Volume 15, Issue 1

Trends in Dentistry

Statistics and opinions as the profession embarks on a new year

The day-to-day requirements of treating patients and (for some) managing a practice can occupy so much of a dentist's time that it may be easy to neglect one of the most important parts of succeeding in any profession: keeping abreast of trends among your peers. In order to help you keep your finger on the pulse of the profession, Inside Dentistry has compiled data from various sources, including surveys of our own readers, to provide a snapshot of the current state of dentistry. From clinical data, such as the frequency at which your peers are performing certain procedures, to purchasing patterns, such as the percentage of dentists using certain digital technology, to business issues, such as the continued ascent of dental support organizations (DSOs), the profession continues to evolve rapidly. The spending growth of US dental services peaked at 5.5% in the fourth quarter of 2016 and remained at 3.5% by the first quarter of 2018,1 so ample opportunity exists for dentists-if they are able to capitalize on the current trends.

In the Operatory

Among clinical trends, perhaps the most significant is the movement toward general practitioners performing work that traditionally was referred to specialists. Approximately 21% of dentists surveyed said they place more than five implant restorations per month, 57% said they do at least some endodontic procedures, and 49% perform gingivectomies or gingivoplasties.2 "Especially with the abundance of new digital technology available, dentists have a lot more tools at their disposal to keep more procedures in-house," says general practitioner G. Franklin Shull, DMD. "Some of that is good, and some of that is bad. A need always exists for specialists to handle the more difficult cases. However, minor orthodontics or straightforward implant cases, for example, offer an opportunity for the general dentist who is well trained with new digital technology to provide exceptional care for his or her patients."

However, specialists and general dentists alike caution that working outside of one's comfort zone or scope of experience is not in the patient's best interest. Endodontist Allen Ali Nasseh, DDS, MMSc, says general dentists can learn to handle easy, straightforward endodontic cases, but he emphasizes that no technology or one-day course can replace 2 years of education. "The challenges of difficult endodontics are not easily solved technologically," Nasseh says. "For example, a certain amount of experience and knowledge is required to handle some of the more difficult curvatures and calcifications in a tooth." Similarly, periodontist Barry P. Levin, DMD, notes that he often sees patients whose restorations were placed too far subgingivally when they should have been referred for crown lengthening with hard- and soft-tissue reduction. "If another dentist spent years after dental school learning a specialty and does it all the time, they can make it more comfortable, pleasant, and quicker for the patient," Levin says.

Of course, patient demand plays its part in driving what procedures are being performed overall. Approximately 66% of dentists surveyed said they place 10 or more crowns per month.2 "The health and beauty industries are driving more people to seek elective dentistry," says cosmetic dentist Amanda Seay, DDS. Part of that demand seems to be directed toward cosmetic specialists in particular; only about 8% of dentists surveyed said they perform more than six veneer cases per month.2 "Unlike 10 to 15 years ago, patients now research online before they make a decision," says cosmetic dentist Betsy Bakeman, DDS. "Patients are definitely seeking a dentist that they feel has the skill and experience to deliver the results they want."

For many dentists, tooth bleaching continues to be in demand as well. Approximately 87% of dentists surveyed offer some sort of tooth bleaching services, including custom trays (59%), chairside whitening (20%), go trays (4%), strips (2%), and stock whitening trays (2%).2 "They all work," Bakeman says. "The patient's lifestyle determines which option will work best.  Many patients who travel a lot like the go trays. For patients who prefer to sleep in their trays, we use a different type of gel. Whitening strips provide a very affordable, easy entry point. In-office treatment is costlier to the patient because it requires chair time."

Many dentists are devoting more of their chair time to implant restorations as new options such as all-on-X and angled screw channels for abutments have become available. Among the dentists surveyed, approximately 67% place cement-retained restorations, 61% place screw-retained restorations, 42% provide overdentures, and 18% perform all-on-4 cases.2"The cement-retained option appears to be decreasing rapidly in usage, which is good because peri-implantitis is a major problem and cementing restorations makes it virtually impossible to ensure you will avoid that," Levin says. "New implant components such as angle-correction abutments and angle-
corrected implants are geared toward increasing the number of screw-retained restorations, which is much more favorable biologically." However, these new solutions present their own set of challenges. "An occlusal surface that is occupied by a screw access channel can impact the occlusion and the stability of the sealing agent," says periodontist Sonia S. Leziy, DDS, who also notes that cementation is not the only cause of peri-implantitis. "You need to very carefully design the occlusion for whatever type of sealant is used there."

Technology is making other treatments more viable for a wider range of practitioners as well. For example, 38% of dentists surveyed offer treatment services for sleep-disordered breathing, and approximately 5% treat more than five of these cases per month.2 "Sleep apnea treatment is an excellent option for dentists who want to pursue that," says practice management consultant Roger P. Levin, DDS. "Laser dentistry is a strong option as well. However, that does not mean that every dentist should attempt it. If you only dip your toe in a little bit, you likely will not be very productive with that service." Indeed, sleep apnea treatment, in particular, requires extensive education and collaboration with medical doctors. "Sleep appliances offer tremendous potential, but it should be a guarded potential," says general practitioner Chad C. Duplantis, DDS. "Too many dentists are fabricating sleep appliances without being properly educated on the airway, the orofacial musculature, and the temporomandibular joint. It is important to work closely with a diagnosing physician who has performed a sleep study to aid in establishing the need for an appliance for the patient."

Purchasing Patterns

When dentists decide to purchase new products, whether for a new offering such as sleep apnea treatment or just to upgrade their current equipment and/or materials, they consider information from a wide variety of sources-clinical research, peer-reviewed journals, the recommendations of key opinion leaders, and more. "The goal is to find the best value," says Jim Wiggett, interim CEO of The Dentists Supply Company. "Value is the balance between the quality/authenticity of the product and its price. For highly disposable products, dentists may be driven more by price, but anything that is going into a patient's mouth or has a clinical application requires more of a quality standard."

In a weighted survey question about what sources dentists utilize the most to research and evaluate new products, dental publications ranked the highest, followed by the influence of colleagues.2 "Consideration of a combination of factors is necessary when making purchasing decisions," Shull says. "We have access to large amounts of research and information; being able to sort through it to identify noncorporate, peer-reviewed studies is important. A trustworthy colleague's opinions carry weight as well."

Oftentimes, those trusted connections can be formed through professional associations and study clubs. Approximately 80% of dentists surveyed said they are members of at least one professional association, and of those respondents, 54% consider their professional associations to be an important resource when making product purchasing decisions.2In addition, 38% of the dentists surveyed said they were members of study clubs, and 74% of those consider the study clubs to be an important resource when making purchasing decisions.2"Dentistry can be very isolating, even at group practices, because most of your time is spent with patients," Bakeman says. "The opportunity to network is valuable for a variety of reasons."In addition to helping inform purchasing decisions, study clubs and professional associations offer continuing education that can help dentists optimize the results they get from their new products."Before using new digital tools, you need to know what the end point is," Seay says. "If you do not understand occlusion, smile design, and the entire process, then you will not get the most out of your tools."

Clinical research is important as well. Of the dentists surveyed, 75% said research is very important when deciding to switch to a new product.2 "Seeing that science supports a product's use is important," Barry Levin says. "For example, 2 years ago, we were looking to purchase a laser for our office. There are many lasers available on the market, so we needed to ask what we wanted a laser for and what nonpromotional articles were available in peer-reviewed journals. The literature needs to confirm that the science supports how you intend to use the product."

Once it is time to make the purchase, getting the best value is important. Several group purchasing organizations (GPOs) help smaller practices compete with DSOs and large group practices in that regard. Among the dentists surveyed, 29% said they participate in a GPO or buying group.2 "GPOs will become standard," Roger Levin says. "Eventually, the question will be, ‘which buying group do you belong to?' They are very popular in medicine and will become more popular in dentistry."

Purchasing the right products for the right price is paramount, in part, because of the amount of practice revenue that is being redirected toward new technology. Among dentists surveyed, 53% said they spend more than 10% of their yearly practice budget on purchasing new technology.2 "There are two keys to long-term success in dentistry," Dental Trade Alliance President Gary Price says. "The first is lifelong learning to keep up-to-date on the latest in oral healthcare, and the second is to have the most appropriate and up-to-date technology for your type of practice. Patients have a growing knowledge of the latest science and technology and expect their healthcare providers to be ahead of the curve."

Approximately 65% of dentists surveyed said that they have digital sensors. Other technologies employed by respondents include lasers (39%), intraoral scanning (28%), cone-beam computed tomography (CBCT)/3D imaging (17%), in-office milling (15%), and 3D printing (4%).2 Every person interviewed stated that they anticipate that those numbers will rise and that they expect digital sensors and intraoral scanners to have the highest ceilings because their benefits extend to more basic dentistry. "Digital dentistry is exploding-everything from digital scanning, which is not new but has more players in the market, to CBCT, the price of which has come down a lot," says Daniel Domingue, DDS. "Treatment planning software allows you to merge impression scans with CBCT scans and design and print a guide in your office for a fraction of what it sometimes costs to purchase a guide from a third party. Dental schools are adopting the technology, and students are learning how to scan in-office. Today's graduates are anxious to purchase CBCT scanners, intraoral scanners, and more." However, consideration of how the equipment will be utilized is important. "Technology is driven by the type of dentistry that you want to do," says Gregg A. Helvey, DDS, CDT. "A more traditional practice that does single crowns and perhaps an occasional bridge likely does not need to invest heavily in digital equipment, whereas a practice that wants to grow its implant business, for example, should consider a CBCT unit."

Regarding restorative materials, the survey data indicate that dentists' habits are relatively consistent. For example, 71% of dentists surveyed use two to three different types of direct resin composite, including flowable (91%), bulk-fill (82%), and nano-fill (71%).2 "Bulk-fill direct resin composites have definitely become more popular because they are efficient and increasingly esthetic," Seay says. "The nano-fill options are great; it is moving toward not overcomplicating things, making restorations easier to place and as esthetic as possible." With respect to bonding agents, 83% of dentists surveyed use only one or two different types.2 "Having one standard operating procedure for adhesive technology is easier, and minimizing inventory is good for practice management," says prosthodontist Dean E. Kois, DMD, MSD. "Practicing proper adhesive procedure protocols is the most important factor; selecting multiple adhesive products depends more upon clinician preference." Meanwhile, 70% of dentists surveyed use two to three types of impression materials, whereas only 11% use just one.2 "I do not see a big shift coming in impression material science," Kois says. "The shift is toward digital dentistry, and that does not require impression material."

Balancing Business

The business of dentistry is shifting in several ways as well, and most of these ways somehow involve the DSO factor.

In 1990, private insurance and out-of-pocket payments each accounted for 49% of dental expenditures not funded by the US Centers for Medicare & Medicaid Services (CMS); by 2016, however, payments by private insurance increased to 52% and out-of-pocket payments decreased to 45%.3 "More and more dental insurers are moving to preferred provider organization (PPO) plans, or they are moving their reimbursements to PPO levels," Roger Levin says. "When reimbursements decrease, copays decrease as well. That lowers practice production, which subsequently increases the overhead percentage. The only way to compensate for those changes is to increase the number of patients seen, which requires simultaneously increasing efficiency because increasing the level of stress and chaos in the office is not advisable. All dental insurance will gradually drop to a PPO reimbursement level, bottoming out and staying there for quite some time. Practices need improved efficiency, controlled overhead, and increased production. The one thing you can directly influence is the level of the practice's production."

Although dental reimbursement rates are decreasing by 3.3% overall, that number spikes to 8.7% for solo practitioners, and the rates are actually increasing by 1.6% for group practices.1 Perhaps that explains why in a 2017 survey, 72% of solo practitioners said they were "not at all likely" to join a group practice, DSO, or GPO in the next 12 months, and none said they were "very likely" or "extremely likely," but in a 2018 version of the same survey, only 53% said they were not at all likely, and 9% said they were extremely likely.1 "Private practitioners almost need to just build a niche, because you can't compete with fees," Seay says.

Statistics indicate that DSOs are particularly appealing to two provider demographics: young people and women. As of 2016, more than 17% of dentists aged 21 to 34 were affiliated with DSOs, compared with 11% of those aged 35 to 49, 4.2% of those aged 50 to 64, and 3.2% of those aged 65 and older.1 This has been widely attributed to the benefits of a guaranteed salary for recent graduates with high amounts of student debt. Meanwhile, 11% of female dentists were affiliated with DSOs as of 2016, compared with 7% of male dentists.1 "Many dental schools have at least 50% female graduates if not more, which can lead to a higher number of female dentists at DSOs," Leziy says. "In addition, the reality is that young female dentists have the challenge of balancing work with lives that often include having children and being primary caregivers. DSOs may give them more freedom."

Within the private practice segment, business models vary greatly. For yearly gross billings, 30% of dentists surveyed are at $500,000 or less, 33% are at $1 million or more, and the rest are in between.2 For average yearly total expenses, 37% have more than $300,000, 26% have less than $100,000, and the rest are in between.2 Approximately 61% of dentists surveyed said they make between $100,000 and $300,000 per year in income, 25% make less than that, and 15% make more.2 "The Levin Group Data Center shows the average revenue for a general practice is $750,000, and the average take-home income of a general dentist is $180,000, which is down from $220,000 prior to 2008," Roger Levin says. "There will be a wide range of models going forward, and the distribution curve shows that the range of practices will be much wider than ever before. Unlike 20 years ago, there is an upper class, middle class, and lower class of dental practices."

Relatedly, 30% of dentists surveyed said they treat 100 or more patients per week, 40% treat 51 to 100 patients, and 30% treat 50 or fewer patients.2 "Practices are structured differently," Bakeman says. "Some practices do smaller procedures and have higher turnover, whereas other practices are more service-oriented and specialize in those areas. Patients seek something that suits their needs, and there will always be a need for these different models."

Dental laboratories offer different models as well, which may explain why 69% of dentists surveyed said they work with 2 to 3 dental laboratories, whereas 12% use four or more, and 19% use one or none.2 "Every laboratory has its own niche, and price points vary," says Pinhas Adar, MDT, CDT. "The idea of partnering with one laboratory that does everything great with the best pricing is unrealistic." Despite this, the laboratory landscape is shifting toward consolidation and large corporate groups. Even some smaller laboratories are becoming full-service, and they are driven by the need to stay ahead technologically so they can always offer whatever services dentists need. "The ability of a laboratory to leverage digital capabilities and support the dentist digitally is extremely important," says Jim Glidewell, CDT, president of Glidewell Dental. "Being able to accept digital files is one thing, but what can you do with them?"

One thing that most dental practices seem to have in common is prioritizing short wait times. Approximately 83% of dentists surveyed estimate their average wait time per patient is 15 minutes or less.2 "Being respectful of the patient's time is critical," Leziy says. "The more difficult and complex the rendered treatments are, the greater the possibilities for things to go wrong and cause delays, so it is important to build flexibility into your schedule. The happy patient is the one who tells the next patient about how great your practice is."

Indeed, the experience of existing patients is important in generating referrals, which 72% of dentists surveyed consider to be their most significant source of new patient appointments.2 Despite that, most dentists actively market their practices as well, with 77% of those surveyed using their practice websites as marketing channels, 68% using social media, 48% using email, 34% using print advertisements, 21% using online advertisements, and 18% using direct mail.2 "Everything works, just not as well as it used to, and it costs a lot more money," Roger Levin says. "Digital marketing is fascinating because it is inexpensive and it can definitely work, but desired results are not guaranteed. Hiring a reputable social media firm is advisable, but again, this will not necessarily solve all your problems. Having social media and websites is not so much a competitive advantage as not having them is a competitive disadvantage. If patients look you up and cannot find you, they will just move to the next option. Our research shows that 85% of patients check out a new dental office online before they come in."

Levin also notes that the average attrition in a dental office is 12% to 15%, but that dentists who produce $1 million or more (excluding hygiene) have an average attrition of only 7% to 8%. One way to retain patients is by offering alternatives to insurance. Although 90% of dentists surveyed accept private insurance, 66% offer alternatives such as fee-for-service plans, dental discount plans, or patient membership plans.2 Kleer, a provider of patient membership plans, says that according to dentists who use its membership plans, patients with those plans visit the dentist two to three times more frequently than uninsured patients and accept twice the amount of treatment. "Membership plans help uninsured patients get the care they need while helping dentists grow their practices without adding new patients," Kleer CEO Dave Monahan says. These insurance alternatives also funnel more money directly to the dentists than to third parties; ProCare Dental Services says a review of 50 filings from insurance carriers has shown that $400 in dental coverage results in only about $186 to $240 going to dentists. "More people can afford care when less of their money goes to middlemen," ProCare CEO Qadeer Ahmed says.

Conclusion

As dentists continue to refine all aspects of their practice models, the overall climate of the industry seems to be positive. Dentists are increasingly able to retire, as outflow rates for those 55 and older bottomed out in 2012 but have risen steadily since then.4 The inflow of dentists from 2012 to 2017 was 16.5% higher than from 2007 to 2012 and 59% higher for foreign-trained dentists during that period.4 "Dentistry can offer a very comfortable lifestyle," Bakeman says. "It is like any other profession-if you invest more time and energy, you will reap the rewards of that. It can lead to a very good income."

References

1. Vujicic M and Beuchaw S. Trends + Key Forces Reshaping the U.S. Dental Market. 2018.

Morgan Stanley research (ADA Morgan Stanley Trends Webinar 2018).

2. Inside Dentistry surveys.

3. ADA Health Policy Institute. U.S. Dental Expenditures: 2017 Update. 2017. "U.S. Dental Expenditures: 2017 Update" (ADA Health Policy Institute).

4. Munson B, Vujicic M. Supply of full-time equivalent dentists in the U.S. expected to increase steadily. Health Policy Institute Research Brief. American Dental Association. July 2018. Available from: http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0718_1.pdf.

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