Economic Pressure and the Age of the Super Dentist
Trends in Dentistry
Every December, Inside Dental Technology explores trends on the clinical side of dentistry—from sleep apnea treatment to chairside milling to insurance developments and more. This year, the two major trends identified were the slow recovery from the Great Recession of 2008-09 and the rise of interdisciplinary dentistry. As we delved deeper into each of these subjects, it became apparent that they shared a common thread regarding their impact on laboratories: the importance of serving as a knowledge resource for dentists.
According to the American Dental Association (ADA) Health Policy Institute, general practitioners (GPs) in private practice saw their average net income drop from a peak of $215,876 in 2005 to $180,950 in 2013, and by the beginning of last year, it was at $197,190,1,2 which is more than 30% lower than 2005 when inflation is considered.3 Meanwhile, Levin Group Data Center research indicates that the average age of retirement for a dentist has risen to 71 years,2 according to Levin Group Founder and CEO Roger P. Levin, DDS; that research also indicates that the average age of retirement is trending toward 75 in the next 5 years. Clearly, laboratories are serving a clientele that continues to feel the pressure of tighter profit margins; subsequently, any help a laboratory can provide to increase these margins carries great value.
The type of work that GPs and specialists are doing is evolving as well. Levin Group Data Center research in 2014 indicated that significant percentages of GPs were performing endodontic (75.7%), orthodontic (60.2%), and implant (37.3%) treatments. As recently as 2016, American Academy of Implant Dentistry research indicated that 57% of implant dentists got less than 25% of their practices' gross receipts from implants.4 Even specialists have expanded their scopes, as implantology and other complex treatments lead to overlapping.
Whether a dentist is examining every opportunity to salvage profit margins or working on cases that they once might have referred out, laboratories have an opportunity to provide more value than simply fulfilling prescriptions.
Following a precipitous drop around the time of the Great Recession, dentists' average income has been rising again in recent years—slowly.
"The profession today is economically better than it was 10 years ago," says Levin, whose organization conducts an annual survey of 4,000 dental offices. "There is no question that practices are performing better each year, but incomes still have not returned to their pre-Recession levels."
Levin cites three factors as contributing to the steady growth. First, the strong US economy makes patients more likely to accept treatment. Second, while insurance coverage often limits reimbursements, there is more insurance coverage overall, and patients are taking advantage of their plans. Third, elective services such as cosmetic dentistry and implants have become more popular. Still, the slow pace of that growth is one reason why more dentists are now practicing into their 70s.
"When income is low," Levin says, "the difference typically comes out of what would have been put away for long-term savings."
Obviously, increasing their income is one way dentists can grow those long-term savings to a point where they can retire, and that is where a laboratory can help.
"This is my opinion, but it is a strong one: I have always viewed the dental laboratory as a partner in or an extension of the dental practice," Levin says. "To the degree that laboratories can help educate their customers, they will attract more customers, have fewer remakes, and provide more value for the fees that they are charging."
Perhaps the strongest validation of the importance of this concept can be found in some of the initiatives undertaken by Glidewell Dental, the world's largest laboratory. Glidewell publishes a magazine for dentists and holds educational courses, including an annual symposium.
"These efforts are all devoted to giving our dentists additional information that will make them more successful in their practice," says Neil Park, DMD, Vice President of Clinical Affairs for Glidewell. "When we publish an article about atraumatic extraction and socket grafting—which has become the standard of care but was not taught to most dentists in dental school-we might be helping create a new revenue stream in a dentist's practice. That is not even something we sell as a laboratory, but we want our dentists to see us as a resource and a partner in their success."
Similarly, laboratories have an opportunity to educate their clients on business topics such as leadership and management.
"A clinical course may serve as a marketing tool as well, but more importantly, we just want to be a great partner," Park says.
Clinical help, of course, is also something a laboratory can offer. The volume of cases that any laboratory handles is typically enough to provide valuable insight to a dentist who only sees his or her own work on a daily basis. More directly, a laboratory's ability to provide case-specific help in real time can save dentists valuable time and money.
Economic forces can shape the needs of each dentist in that regard in different ways. Dentists with an eye on their retirement funds might need different types of assistance than new dental school graduates who are seeking to pay off piles of student debt.
"Supplementing a new graduate's education is probably one of the best ways that a dental laboratory can help a dentist become more successful," Park says. "There is less direct exposure to laboratory procedures in the dental schools now than there was 15 to 20 years ago, partly because squeezing all of the information available today into a curriculum is so challenging. These dentists often have a bit more trouble talking to the laboratory, so it helps to have technical advisors who can talk to dentists, find out what they need, and translate that. It can be something as simple as taking a shade—a dentist has every reason to believe that shade guides should be consistent from one to another, but they are not, so recommending a photograph of the shade guide next to the tooth can help them complete the case as efficiently and successfully as possible."
Another way dentists can boost their profits is by expanding their scope of services. General practitioners and even some specialists are increasingly performing procedures themselves that they once would have referred to another dentist, and some are even incorporating services that go beyond traditional dentistry, such as Botox treatments. For example, surveys conducted by the American Academy of Facial Esthetics (AAFE) indicate that members can add $29,500 in monthly production by adding injectable services, according to AAFE President Louis Malcmacher, DDS, MAGD. The Levin Group has said that a general practice can expect a 12% to 15% increase in production on average by adding one or more specialty services.1
Nonfinancial reasons exist as well for the merging of specialties. Most significantly, the capabilities that modern technologies, materials, and techniques provide make interdisciplinary dentistry beneficial for the patient in many cases.
"Specialties are evolving," says Richard A. Sousa, DDS, a general practitioner who says he works in almost every area except orthodontics. "Postgraduate prosthodontic programs teach implant placement, which was once the domain of oral surgeons and periodontists. Additionally, some of today's complex procedures have a better chance of success if specialists participate in case planning from the beginning, which is something that previously was done mostly by restorative dentists and prosthodontists. All of the different aspects of treatment are merging together."
The AAFE promotes the use of facial esthetic treatments to complement more conventional dental procedures. Controlling masticatory muscles, for example, can be critical to the success of cases across various disciplines.
"A 28-veneer case may provide the patient with beautiful teeth, but if all the soft tissue around the mouth is in poor condition, then all you have accomplished is providing a bunch of individual teeth; you have not given the patient a great smile," Malcmacher says.
The rise of implantology has been a major driver of the rise of interdisciplinary dentistry as well. Many dentists were practicing before Per-Ingvar Brånemark introduced osseointegrated dental implants to North America in 1982.5 The American Academy of Periodontology, American College of Prosthodontists, and others now list implants as part of those respective specialties.
"Periodontics are totally different today," says Robert A. Levine, DDS, Founder and Co-Director of the Pennsylvania Center for Dental Implants and Periodontics. "When I was in dental school, we were only trying to save teeth. Now, we still try to save teeth, but 80% of what I do is implant-related, which includes surgical implant placement and implant site development. Other than scaling and root planning, nearly everything we do today was not around 40 years ago."
Even endodontists are venturing into implantology, as many postgraduate endodontic programs are incorporating implant training.6 While placing the implant is the opposite of salvaging a tooth, endodontists are in a unique position to provide this service because of their role in determining the restorability of teeth.6
"That was a crossover that I had not seen coming," Sousa says. "A former dental school classmate told me that, as an endodontist, he often finds himself in situations where GPs send patients for root canals and he recognizes that the tooth is fractured and should be replaced. With implant training, he can now provide that alternate treatment."
Various associations also are actively promoting interdisciplinary dentistry. Levine and Sousa are officers for the International Team for Implantology (ITI) and the NGS Academy of Multidisciplinary Dentistry (NGS AMD), respectively, and both say their organizations place a strong emphasis on featuring the entire dental team among their membership, including laboratory technicians. The NGS AMD went so far as to change its name from the Northeastern Gnathological Society last year to reflect the changes in the direction of the profession.
"The main goal of dentistry is to meet the needs of patients," Sousa says. "We are here as a team to perform the necessary dentistry to help compromised or dentally embarrassed patients get good results, and that often requires the skills of multiple disciplines. The NGS AMD formalized this concept and now incorporates multiple disciplines into the educational programs presented at their semiannual meetings."
Of course, interdisciplinary dentistry requires each team member to know their limits.
"There is no greater referral specialist than a general dentist who has been trained in that specialty, because they know what they do not know," Malcmacher says.
Naturally, these teams' success requires a high level of competence from every member, including the laboratory. Simply fulfilling a prescription is often not enough. The laboratory must provide useful and necessary knowledge and expertise.
"We need everybody's input throughout the case to make this a seamless experience for the patient," Levine says. "The laboratory must be able to advise us on the best materials to use for long-term success, among other things. We cannot have a weak link on the team, so we work with laboratories that provide significant value with their knowledge and expertise."
Conversely, laboratories should be prepared to sometimes work with dentists who are pushing the limits of their expertise and may need more assistance and education than others.
"Many GPs do not realize when a case is too complex for them to handle," Levine says. "A good example is the esthetic zone, where at least 90% of complications are caused by the surgeon due to a lack of ‘checklists.'"7
Sousa says he has taken hundreds of hours of continuing education over the years to expand his expertise, but he still places a high value on his laboratory to supplement that knowledge.
"On complex cases," Sousa says, "we are partners."
These clinical trends bring many laboratories to a figurative fork in the road. With so much at stake, dentists whose needs are not being met may look elsewhere. However, tremendous opportunity exists to go above and beyond in meeting those needs.
Laboratories may be well served to always keep in mind the financial constraints that are impacting their clients, whether those clients are paying off student loans or saving for retirement.
"The dentist's monthly laboratory bill is probably their biggest variable expense," Park says. "When times get tough and margins get tighter, that expense is likely to come under scrutiny. However, laboratories that position themselves as a trusted resource can make themselves integral to the dentist's success and justify that expense."
Likewise, laboratories also should be prepared to work with anyone from a prosthodontist to a general dentist to an endodontist on different types of cases and to provide knowledge and expertise as needed in each relationship.
"The more you become a ‘super dentist,' the more you need a laboratory partner you can really trust to contribute significant value," Malcmacher says. "There is absolutely no question that collaboration now is more important than ever."
1. Weintraub J. Becoming a super GP. Inside Dentistry. 2015;11(9):36-42.
2. Dental Practice. American Dental Association website. https://www.ada.org/en/science-research/health-policy-institute/data-center/dental-practice. Accessed October 30, 2019.
3. 2005 dollars in 2019 | Inflation Calculator. U.S. Official Inflation Data, Alioth Finance. https://www.officialdata.org/us/inflation/2005. Accessed October 30, 2019.
4. AAID. AAID Publishes Comprehensive Implant Dentistry Benchmarking Study. AAID website. https://www.aaid.com/news_and_publications/105. Published May 24, 2016. Accessed November 15, 2019.
5. Norkin D. An era of evidence-based implant dentistry: 30 years since Toronto. Compend Contin Educ Dent. 2012;33(8):618-9.
6. Aminoshariae A, Montagnese TA, Solanki PD, Mickel AK. Introduction of implants into postdoctoral endodontic residency programs. J Dent Educ. 2011;75(9):1244-8.
7. Levine R, et al. 10 keys for successful esthetic-zone single immediate implants. Compend Contin Educ Dent. 2017;38(4).