The Dental Landscape
Where are we now—and where are we heading?
With the dental industry facing change on all fronts, Inside Dentistry asked key opinion leaders for their perspectives on the critical factors to watch for emerging trends in patient care and business models.
Allison M. DiMatteo, BA, MPS
Ongoing Innovation Pays Off
Dental product manufacturers continue to innovate the profession, with dozens of new products introduced into the marketplace each year. From direct composites to high-strength indirect ceramics, and from operative equipment to computer-based, digital technologies, the trends in dental product and equipment research, development, and manufacturing are coming to bear on dentistry in increasingly positive ways. All of this bodes well for dentists—and dental product manufacturers—alike.
According to Gary Price, Chief Executive Officer of the Dental Trade Alliance, the ongoing innovation the profession has experienced—along with the introduction of new products—represents the culmination of internal research efforts by dental manufacturers. Science and technology transfer from private and government research has also influenced groundbreaking developments that manufacturers are applying to solve the everyday problems faced by dentists today, Price explains.
“New strength in the dental market is a good sign that innovation and research will increase,” Price observes. “Additionally, the temporary suspension of the ill-conceived medical device tax will hopefully help with resources for innovation.”
It’s impractical and imprudent to call out or project the future trends that have—or will have—an effect on specific dental product manufacturers, their products, and/or their product categories, Price notes. However, he has witnessed manufacturers in the United States finding a very strong market for their products overseas.
“The increase in US company presence in exhibitions around the world has significantly affected demand,” Price says.
New Materials Gaining Traction
When talking about current trends in dental materials, two different concepts emerge. One focuses on restoring general oral health and the other refers to structured dentistry for restoring and/or replacing tooth structure.
Restoring general oral health requires materials that demonstrate what some call biomimetic properties—although that term still elicits controversy—and an ability to remineralize tooth structure, prevent decay, and stop decay around restorations. In the beginning, these materials were glass ionomers that release fluoride, but they have since expanded to include materials that release calcium, phosphate, and fluoride to augment remineralization.
“The latter are newer materials that are beginning to gain traction and be used by more and more dentists,” observes John Burgess, DDS, MS, Professor and Assistant Dean for Clinical Research at the University of Alabama at Birmingham. “Currently I think that’s the wave of the future, although we don’t have all of the scientific, clinical evidence showing they really are efficient and effective. We’re taking it on faith that because they release ions that promote remineralization they build new tooth structure.”
When restoration of tooth structure is required, bulk filling posterior composite materials have gained momentum, Burgess says, with more and more practitioners using these materials based on speed, ease-of-use, fewer layers, and shortened curing times. The idea that materials are easier and faster to place closes any window for contamination, which is especially important considering that most practicing dentists do not use rubber dam isolation; contamination is more difficult to control without an isolated field, Burgess explains.
Additionally, CAD/CAM fabricated restorations are also replacing many other traditional posterior options, almost—but not totally—eliminating porcelain-fused-to-metal (PFM) restorations. Now that issues surrounding failures related to chipping and lackluster esthetics have been overcome, materials like zirconia—which can be adhesively bonded or cemented—are used for indications previously restored with PFMs. Although newer, more translucent zirconia materials have recently become available, Burgess cautions that these are a different type of zirconia; they are significantly more translucent and esthetic than traditional opaque stabilized zirconia, but they are not as strong.
“The introduction of newer materials is a two-edged sword,” Burgess says. “On the one side, manufacturers are really trying to introduce materials faster, but on the other side, the timespan to validate current generations of materials is much shorter than it used to be, so there is very little clinical testing.”
Unfortunately, dentist demands, patient demands, and the need to remain competitive all contribute to the pervasive trend of increasing numbers of new products and materials being introduced to the profession at breakneck speeds. Manufacturers want to solve the problems that dentists encounter and make things simpler, Burgess points out. And when procedures can be simplified and applications can be shorter and faster, patients benefit and the treatment outcomes may be improved.
“Simplified directions, for example, mean that these materials can be placed more efficiently, without introducing errors to the procedures themselves. The more simplified the techniques, the more predictable and successful they can be,” Burgess explains. “The biggest challenge really is to learn what material goes where, as well as their application and step-by-step procedures.”
Because newer materials may differ from previous generations, it’s important to follow the application steps as directed because they may have changed. As an example, Burgess cites the differences between how stabilized zirconia and newer translucent zirconias are handled. The former can be sandblasted, whereas new translucent zirconia is weakened when sandblasted with alumina.
Emerging trends to watch include those involving new materials and application techniques, such as self-adhesive esthetic flowable composites that can be used as direct restorative materials. CAD/CAM milled restorations may ultimately be replaced by printable restorations, which Burgess says can then have color built into the material itself. Bulk filled materials with very short curing times will become the established technique and, long-term, biomimetic materials will become more and more popular, he predicts.
Technology Transforms the Patient Experience
Digital technology and computerized processes have infiltrated dental practices and laboratories and now touch every aspect of the profession, from patient marketing to disease diagnosis and clinical/esthetic evaluations; from treatment planning to fabrication; and from claims processing to ongoing disease prevention. The ongoing development and introduction of digitally based dental technologies has changed—and will continue to transform—how dental professionals are able to work, collaborate, plan, and ultimately deliver patient-focused care.
“When digital dental technologies and processes are integrated according to an understanding of the patient experience, practices and laboratories can improve efficiencies and productivity, as well as remove complexities, in their clinical and administrative operations,” explains Robert Gottlander, DDS, Vice President of Henry Schein. “The exciting results include lower costs for practices and patients, and predictable and consistent treatments because variables associated with material and human error are reduced, if not eliminated.”
According to Gottlander, the disruptive, transformational technologies that have been introduced over the past 20 to 30 years range from intraoral cameras for greater diagnostic acuity and improved patient education and communication, to digital radiography and CBCT systems that enable more accurate and timely diagnoses of disease with fewer materials, less handling, and enhanced planning and collaboration with specialists. Digital intraoral scanners allow dentists to exchange digitized records with their laboratories and specialist colleagues, while caries detection devices facilitate non-invasive monitoring of patient conditions, Gottlander adds.
Additionally—and perhaps generating the most attention—there are CAD/CAM units for dental practices that can be fully integrated and open for single-visit dentistry, without the need for temporaries, as well as systems for laboratories that feature the latest advancements in subtractive milling, additive 3D print production, design software, and 3D scanners. Simultaneously, the restorative materials introduced for use with these technologies further expand the clinical opportunities for more convenient and efficient patient care, Gottlander says.
Overall, the increasing adoption of digital dental technologies is helping to streamline the way cases are handed off within a practice, and enabling an increased number of patients to be seen and treated in a day, Gottlander observes. This partly results because patient appointment chairtime can be reduced, since same-day indirect crowns and restorations are now possible when practices have an in-office CAD/CAM unit. Additionally, many of these technologies (eg, 3D scans, radiographs, treatment planning software, restoration CAD restoration design software), when combined, enable dentists to engage patients in an interactive dialogue about their condition and proposed treatment. When patients can see what the problems are using intraoral 3D scans and/or 2D or 3D radiographs—and dentists present them with solutions in the form of a treatment plan—they’re more likely to accept treatment and avoid unrealistic expectations.
“When thinking about and attempting to implement digital technologies into the practice or laboratory, dentists and technicians might face fear of the unknown, and change can be difficult,” Gottlander admits. “To overcome these challenges, it’s helpful to focus on what digital dental technology enables you to do more efficiently and comfortably for patients, as well as more productively and profitably for yourself, rather than on the technology itself.”
However, realizing all that digital dental technology can allow dentists and laboratories to do is predicated on the interoperability and scalability of the technologies themselves. Therefore, an increasing number of options in multiple dental technology categories have been introduced with an open architecture. This allows dentists and laboratories to select equipment from different manufacturers of their choice, without worrying about compatibility.
“Digital dental technologies provide tremendous solutions compared to traditional administrative, business, clinical, and laboratory procedures,” Gottlander says. “However, compatibility and interoperability with a range of software, hardware, and advanced technology is essential for an uninterrupted, efficient workflow and the highest level of patient satisfaction outcomes. If individual technologies do not integrate well, then maximizing a return on investment may be difficult, if not impossible.”
Educational Platforms Evolve
A number of trends are occurring in dental continuing education (CE), the most prevalent being the tremendous increase in online instruction, which goes beyond dentistry. Integration of online content, either as a standalone or part of a blended learning offering, is enabling another trend—less time away from the practice for classes.
“Didactic content can be delivered online, allowing time in the classroom to be dedicated only to those components that require live participation, such as hands-on skill development,” explains Joan Forrest, President and CEO of The Dawson Academy. “In dentistry there will always be a need for a certain amount of time in skill development activities that require supervised performance of tasks in an appropriate learning environment.”
Growth is also occurring in small group learning environments, such as study clubs, to supplement formal learning. Some of this growth is the more formal structuring of groups that had already been meeting, but without any outside content support. According to Forrest, a handful of continuing education institutions, including The Dawson Academy, are packaging content and providing organizational assistance to these groups, which have more longevity than non-connected clubs due to such support.
Interestingly, the availability of technologies is shaping all CE; dentistry is not unique in this regard. Methodologies such as online platforms and e-learning/distance learning are utilized because they solve common problems for adults seeking to continue to learn and expand their professional competencies, Forrest says.
For dentists and all professionals, societal trends are driving trends in CE. They all need to continually learn and develop new skills. In dentistry, the rapid development of digital technology, the increased role of dental implants as a treatment option, and continuous advancements in materials, to name a few, have increased the subject matter on which dentists need to remain current, Forrest observes.
Simultaneously, working professionals—men and women—want to spend less time away from home. Forty years ago, going away to a nice location and taking a few days of CE, perhaps with the family along, was part vacation and part learning. Now, the increased number of couples both holding professional positions, along with a greater amount of content to learn, has reduced the desire and ability to be away from home, Forrest says.
“For dentists, another factor driving the desire to minimize time out of the office is the stagnant income levels in the 2000s, which influences the belief that time cannot be allocated for CE,” Forrest adds. “As a result, I see more lecture content delivered online as well as a shortening of time in classroom courses.”
There is no doubt that CE is necessary for practicing dentists. The vast areas in which information changes and continuous learning is needed continues to grow. One challenge for the practitioner, then, is deciding where to focus his/her resources, Forrest says.
For private dental CE institutions that do not accept outside funding, a challenge is maintaining tuitions that are competitive with those that have external sources of funding. The Commission for Continuing Education Provider Recognition (CCEPR) 2015 Annual Report lists 442 recognized CE providers, and an additional 107 local dental associations were approved by eligible state dental societies and national dental specialty associations through the ADA CERP Extended Approval Process. Many of these providers have multiple lines of revenue from non-CE products and services, so they can subsidize the costs of CE with means other than tuition.
“Before deciding where to invest time and money, investigate the credentials of the instructor and the reputation of the institution,” Forrest advises those exploring CE options. “Ask mentors and peers for recommendations on course work, instructors, and institutions and commit to being a continuous student.”
Maximizing Post-Recession Opportunities
Today, eight years after the great recession of 2008 and 2009, dental practices are feeling the downward pressure. Many are experiencing lower production; more doctors have lower incomes because production is down; and overhead is up.
“In the past, dentistry was essentially recession proof,” observes Roger Levin, DDS, founder and CEO of Levin Group. “Dentistry had never seen a recession hurt a dental practice; and this recession certainly did for 75% of practices, according to the Levin Group Data Center.”
Although things aren’t back to where they were pre-recession, Levin notes that on the plus side, patient behaviors are changing to the point where they’re accepting more treatment. On the down side, the demand for dental services overall has declined, but an emerging trend is an increase in emergency dental visits—even by patients who’d previously been regular, every-six-months preventive/oral hygiene patients who’ve since dropped off.
If you feel you’re on a roller coaster, you’re not alone. Today, many insurance company reimbursements are lower, and many offices have watched their current insurance reimbursement reduced by another 15%. Levin is also seeing a trending toward the PPO model, which will likely continue and become the predominant model.
Competition is higher, too, Levin adds. Between 2004 and 2016, more than 15 new dental schools have opened, increasing the supply of available dentists and, therefore, competition. Fueling further competition for private practitioners is the rise of corporate dentistry (ie, dental service organizations). Small group practices—which are comprised of anywhere between 5 and 15 doctors, and between 4 and 15 practices—are also trending, says Levin.
What do these trends mean for dental practices, practice management, and dentists today? If practices aren’t running as efficiently as they could be—or are running the same way they did 10, 5, or even 3 years ago—then they might not be maximizing the opportunities they do have. For example, with the right scripting so that team members know how to communicate, practices can increase case acceptance by 50% to 70%.
“In the long run, dental practices need an excellent business model to follow, clear objectives, and much better measurement protocols of those objectives for the practice and staff,” Levin advises. “They also need excellent, reproducible business systems that any staff member can follow.”
Two challenges that dentists face in terms of practice management and production, however, are insufficient knowledge and too little time. In the past, they may not have had the knowledge or the time, but they had the patient demand. Because demand has declined, they need to develop a franchise mentality that uses proven systems, good data, and reports, Levin says.
Although practice management software can provide tons of information, its usefulness is a factor of learning what to do with it, Levin says. Therefore, excellent leadership and staff empowerment are critical, and dentists need to put time into training their teams, he adds.
Adding to the importance of team training is the fact that technology will continue to advance and change dentistry, an already changing profession. But Levin cautions that technology must be purchased at the right time, with a technology plan and financial investment plan in place.
“We are in a time of rapid change in the profession. Dentists today are going to need new business skills to maintain and grow their practices. We are seeing many dentists thrive lately, especially those who have successfully implemented effective management and marketing systems to run their practices like a real-world business,” Levin says.
The DSO Environment
Current trends in dental service organizations (DSOs) are helping to realize benefits for dentists and patients alike in few key ways. First, dentists and patients have greater access to each other, and affordable dentistry through DSOs is helping more patients receive care. Second, DSOs afford dentists the opportunity to practice dentistry in a modern environment using proven technologies that solo practitioners may not have access to.
Contributing to these benefits are several factors, including the manner in which DSOs create repeatable, replicable systems and then train people to work well within those systems for greater individual clinician and team clarity, explains Joe Feldsien, Senior Vice President of Professional Partnerships for Pacific Dental Services. Additionally, at a time when there is more competition within the professional dental environment—with many more graduates entering the profession than there are dentists who are retiring—DSOs provide young dentists with an environment in which they can be trained by experienced colleagues to perform leading edge procedures. These include implants, CAD/CAM restorations, and other prosthetics, using proven technology that enables them to provide a better patient experience, Feldsien says.
“I think without DSOs, we would be in a very challenging position, with the average dental student graduating with between $250,000 and $300,000 in debt,” Feldsien cautions. “When they leave dental school, graduates have the very basic essential knowledge, but their skills are not well developed yet. So the challenge for them is perfecting their skills and earning an income. We support them here to become in their mind and in their heart the best dentist they can be to do the dentistry they diagnose.”
In Feldsien’s estimation, DSOs (eg, Pacific Dental Services) are seeing more clinically excellent outcomes, and he attributes that to the quality improvement success scores on which each dentist is evaluated. Under the direction of a national dental advisory board composed entirely of practicing dentists, 13 different metrics have been developed to help the dentist assess his or her effectiveness in two main areas: helping patients get healthier and measuring the level of patient satisfaction.
“It’s about healthier and happier patient outcomes, and how you do that is vitally important,” Feldsien explains. “You can sell patients dentistry and get dentistry done, but that’s short-term thinking. In order to create a patient for life, the challenge is to help the patient value their health and the decision to get healthier. If that happens then they truly are ‘healthier and happier.’”
Today, according to the American Dental Association (ADA), there are more than 1,000 DSOs, whereas only a few years ago, that total was about 600, and 20 years before that, there were only about 10 or 20. Looking ahead, Feldsien foresees expansion of the DSO model. As DSO models evolve, they are incorporating learnings from the past 20 years. This ensures the industry’s continued appeal to clinicians.
“I think DSOs suffer from a perception that they’re all about the money,” says Feldsien, noting that may have been the case in some select scenarios. “Most DSOs understand that they’ll be ultimately judged by their ability to support offices in attracting and retaining patients and their ability to attract and retain clinical customers through their support services.”
If either the patient or dentist feels compromised relative to what they’re paying for, what they’re getting, or how they’re feeling in the environment, they will ultimately walk, he explains. If they feel they’re getting great value and great care, they’re going to stay, Feldsien emphasizes.
Increasing Importance of Advocacy
At both the federal and state levels, a number of legislative issues are affecting how dentists practice dentistry, as well as how they handle different aspects of the care they provide. To help protect both their patients and the ability of the dental profession to provide care, advocacy is one of the most important activities in dentistry at both the federal and state levels, explains Robert A. Faiella, DMD, MMSc.
At the federal level, current legislative issues include a broad range of topics affecting the practice of dentistry. Among them are the impact of student debt, the Medicare Part D opt-out, opioid prescriptions, and student loan availability, notes Faiella. Compliance with existing laws governing the collection, storage, and transfer of personal health information is also a concern for all dentists, requiring the use of Health Insurance Portability and Accountability Act (HIPAA)-compliant portals for patient privacy and security, he adds.
For many states, enabling legislation that would establish various midlevel provider models continues to be filed, Faiella notes. Such legislation is driven by a perception that more providers would help resolve the “dental divide” in America regarding access to dental care.
“Appropriate advocacy for student loan availability, providing needed information regarding reduction in opioid prescriptions, and the safeguards for protected personal health information all have a positive effect on the practice of dentistry and patients,” Faiella believes. “Helping legislators and regulators understand how dentists provide services for our patients can have a positive effect by avoiding the limitations and impact that certain laws and regulations could have on the patients we serve.”
Faiella emphasizes that this is particularly important regarding the midlevel provider issue and the perception of access to dental care. He adds that merely increasing the number of providers will not resolve the dental divide in America.
“Developing a broad approach to providing care for those who most urgently need it, fixing the public and private safety net, and employing education and prevention for vulnerable populations to stem the incidence of dental disease will enhance the chance for an impactful, sustainable solution to this important issue,” Faiella says. “The ADA Action for Dental Health program currently has many dentists making a significant impact in many states toward that goal.”
From economics to the social/political climate, in addition to lobbying efforts, emerging trends in the legislation affecting dentistry can be attributed to many reasons. For example, advocacy for expansion of dental coverage for both adults and children under the provisions of the Affordable Care Act for Medicaid and non-Medicaid state healthcare exchanges would have economic impact for access. The social/political climate is driving the need to limit opioid prescriptions for the safety and benefit of dental patients.
“Certainly, the efforts by various groups that advocate particular proposed limits or solutions will always continue to be a driver of legislative initiatives affecting the profession, requiring monitoring and analysis of the implications for the profession on patient care,” Faiella elaborates.
Of importance today: although the ADA has been successful in delaying enforcement of a rule for dentists and other providers to enroll in Medicare in order to provide prescriptions to covered patients under Part D (from June 1, 2016 to February 1, 2017), support for pending legislation (H.R. 4062) that would exempt dentists (and certain other providers) from that rule is underway, Faiella says.
Informed Decisions for Insurance Benefits
These days, the dental insurance benefits marketplace is probably best characterized as a “soft market.” There are very few client desires to seek out additional benefits or enhancements to their coverage. Instead, they are looking for ways to limit the administrative expenses for their plan and mitigate the cost of care increases.
According to James B. Bramson, DDS, Chief Dental Officer for United Concordia Dental, the majority of those costs are paid for directly by the purchaser through a contract with the benefits company. Such an arrangement is usually only for administrative services, such as claim processing, membership enrollment, etc.
“The marketplace is quickly moving away from an insured benefit product to one where the client absorbs the risk and we do the administrative support services,” Bramson elaborates. “In those situations, it is more up to the client to determine what type of network arrangement they need, what services they want to cover, and how they want to cover it. We (United Concordia Dental and/or insurance companies) regularly talk to our clients about coverage, new techniques, new science, new codes, etc, in order for them to make an informed decision about the benefit.”
Concurrently, many dental practices are looking for ways to run their operations more efficiently, much like what most small businesses have been doing. Where and when did this trend initiate? It harkens back to 2008. Since then, the overall pace of the US economic recovery has been tepid at best, Bramson observes.
The news isn’t all doom and gloom. According to recent industry data, more people are being covered by dental insurance now than ever before, whether it is under a commercial plan or a government plan, Bramson says. Theoretically, that should translate into better care for those who are insured. However, there remain many other people who aren’t insured, and advocacy by various groups for additional programs or coverage is ongoing, he says.
While it’s clear that having a dental benefits plan is the single largest predictor of whether or not someone goes to the dentist, the assumption cannot be made that everyone with dental insurance presents with enough “needed dentistry” to be performed annually to use up their entire maximum allowable benefit, notes Bramson. Although diagnostic services seem to be increasing, restorative services are down a little, he says.
“We see some of the same basic trends that have been reported in the dental press, from reports from the ADA and others,” Bramson says. “Most people who have been on a dental plan for a period of time have been diagnosed and had their needed dentistry performed in prior years, so now they are on a maintenance program. I would argue that those people are still using their dental plan to the maximum that they need it, even if it is below the annual maximum.”