The Road Ahead
5 factors that shaped the past and drive dentistry's future
Brad Guyton, DDS, MBA, MPH; Linda Niessen, DMD, MPH
We have all heard the problems and complaints. And more than likely we have all said most of it at one time or another: “Student debt is at an all-time high. Insurance coverage is prohibitive. Technology is too expensive. It is impossible to find good people. Continuing education and practice management services are too expensive.” The list goes on.
Folks, the sky isn’t falling. However, its color is changing slightly. We have all read plenty of articles around “effective change management” and predictions about the future of dentistry. In the words of John F. Kennedy, “Change is the law of life. And those who look only to the past or present are certain to miss the future.”
In Table 1, we have summarized how dentistry has changed for better and for worse. The chart is roughly broken down into three 25-year segments: yesterday (~1970-1995), today (~1995-2020), and tomorrow (~2020-2045). While the dates blur during the transition years for each of the attributes, we can still get a sense for the general trends that are occuring. It demonstrates how the role of the dentist has changed over time in terms of being a clinician, a business leader, and a team leader. We have also included an example of a few trends during each time period.
Dentistry is currently in flux more so now than possibly ever before; our intent is to point out some of these trends so that the reader might be better prepared and more actively involved in shaping his/her own future.
Doctors of yesterday viewed themselves as artists. This began back with dentists mixing their own amalgam and waxing and casting their own gold restorations, and then extended into the 1980s with the start of the cosmetic dentistry explosion. On the business side, life was simpler, with most dentists successfully able to run a cottage industry small practice. All they needed was a pegboard system or a simple computer at the front to track patient ledgers and schedules. Traditional dental insurance and fee for service dentistry was the norm. Dentists often received their full posted fee. Lastly, most offices remained small in terms of people—the key to success was assembling three to five employees and trying to keep them for 30 years.
Practice Structure
Dentists entered the profession primarily because they wanted to help other people, enjoy the artistry of dentistry, and be their own boss. Doctors who assembled a small team of 3 to 5 members with 3 to 5 operatories often found this sufficient to meet goals for success. Patients stayed with their dentists often for their entire lives. Differentiation among practices was often minimal. Patients needed a reason to leave.
Practice locations were somewhat invisible, less convenient, and often hidden on the second floor of an office or medical building. (We referred to it as the “medical assessment test”—if the patient could walk up the steps, his/her medical status was probably okay for treatment today.) Practices had limited to no marketing, with internal referrals and telephone book advertising being the primary ways to attract patients.
Technology and the Laboratory
Technology for decades was basic, with the norms being unesthetic amalgam, gold, 2-week lab turnarounds, and simple cements. Bridges and partials were the standard for missing teeth. Dentists outsourced esthetic crowns and removable work to local dental laboratories where the lab technicians often visited the dental office regularly. Large national laboratories were just starting to gain traction, which would bring economies of scale to lab products.
Collaboration with Colleagues
General practitioners often worked with a limited number of specialists, usually as one-off referrals. There was negligible communication between dentists and physicians—typically only for premedication and clearance for very sick patients.
Debt and Reimbursement
During this time, there was a misperception that students who couldn’t get into medical school became dentists. Debt levels were typically relatively minor expenses that were easily taken care of in the first decade of practice.
Dental care was reimbursed by cash and fee for service plans and little to no managed care. Indemnity-driven dental practices began during this time and peaked before the end of the period.
Access to Care
Care for the underserved was limited mostly to dentists privately caring for a select group of their patients in their own offices at reduced or no fee.
The current state of dentistry is more complex. Materials and technology have improved, but in many cases, have become increasingly more technique sensitive. Difficult interdisciplinary cases have multiplied with the population aging, retaining teeth, and having multiple comorbidities and more chronic illnesses. Patient demands on the dentist for “unrealistic” outcomes clipped from a magazine photo have intensified. General practitioners today are clinical acrobats—often finding themselves delicately balancing multiple specialists, the demands of more informed patients, and a constant evolution of new products, techniques, and equipment.
On the business side, doctors are finding themselves administrating many practice partners—from attorneys to practice management consultants to financial planners. Attempts to manage the managed care in dental offices have become more complex, with dental insurance becoming increasingly PPO (and in some markets, HMO) driven. In response to flat or decreasing reimbursement rates, doctors feel pressure to compensate with volume, which has expanded the size of many dental teams. In many cases, it is no longer sufficient to assemble and manage a small team; doctors now must have tangible leadership skills to avoid feeling like air traffic controllers with teams running in different directions.
Practice Structure
While almost every dentist at the end of their career will ultimately be most proud of helping other people, many dentists enter the profession with the primary intent to make a good living. We know new dentists today still want to make a difference, but the financial pressures that they feel are unprecented. New dentists enter the profession with the desire to find a practice opportunity that enables them to balance their lives while making a good living so that they can repay their student loans.
Patients today are on the move more than ever before; and dentists must find unique ways to meet these increasingly nomadic needs. Practices must now differentiate themselves from their competitors not only to attract new patients but also to keep their current patients. To keep patients for life, practices often provide patients with text appointment reminders, birthday wishes, referral incentives, and same-day dentistry. As opposed to patients of yesterday needing a reason to leave, patients of today need a reason to stay.
More competition is occurring among dental practices, especially in urban areas. Dentists are seeking patient-centered locations in high traffic retail centers. Dentists are often spending as much as 4% to 6% of expenses on marketing. Internal referrals, websites, and accepting insurance are the primary ways to attract new patients.
Technology and the Laboratory
Technology has dramatically improved with esthetic options for patients that are often faster, better, and sometimes less expensive. Digital radiography and robust practice management software have changed the look and capabilities of the modern-day dental office. Same-day milled crowns, bridges, and implant abutments are now a reality and we are now eight generations into adhesive dentistry with the universals. Dental implants have become the standard for missing teeth. Costs of operations have gone up in smaller practices in response to these new technologies, labor costs, and the complex web of insurance management.
Dentists feel the pressure on margins and are responding with same-day, in-office CAD/CAM dentistry or intraoral scanning with centralized non-human milling. Some dentists are opting for traditional impressions outsourced to off-shore laboratories. During this period, we saw overseas laboratory outsourcing estimates as high as 35%. This number is expected to decline as centralized and in-office milling will keep more business inside the United States. The dental laboratory industry is consolidating into large, national-based businesses. The small, one or two room dental laboratory servicing a dozen dental offices is diminishing. The esthetic and multi-disciplinary case lab technician prevails, but is increasingly becoming more niche.
Collaboration with Colleagues
General practices are referring to many external specialists. When it comes to the process of seeing a specialist, patients—and general practitioners—have difficulty navigating when to go, whom to see, and what was done. Most software systems in dentistry and medicine do not communicate effectively with one another. While there has been pressure to “go digital,” there has been less attention to building digital platforms that can speak to one another both inside and across offices.
More patients present to dental offices with multiple comorbidities and polypharmacy. Dentists recognize there are oral-systemic links, physicians still pay little attention to it, and more patients are asking more questions about oral health and heart disease, pregnancy, and diabetes. To continue the facilitation of dentist/physician collaboration, patient management software and billing must be streamlined across professions so that providers can better communicate with one another and share necessary patient information. Oral health and overall wellness linkages need to be further developed and promoted. Dental practices that learn now how to make this happen will lead later.
Debt and Reimbursement
Dental school is on par with medical schools in terms of competition for admission. Incomes are also comparable. Students are more demanding of faculty time outside the classroom. Students demand more in part because the cost of education is at unprecedented levels. Schools are challenged to incorporate new technologies that reflect the changing environment into the curriculum and yet still prepare students for clinical board exams. Dental schools prepare graduates to become beginning practitioners; their clinical confidence will improve as they gain clinical experience in practice. Mentorship is more important now than ever before because new doctors cannot possibly master the expanded world of dental procedures, products, and techniques during their 4 years in dental school. Debt levels are reaching unprecedented levels. The tipping point at which dental school candidates will start to say no to the profession is unclear. When school debt levels exceed 2.5 times the expected average annual career income, will doctors begin to challenge the return on investment of their education? Will it be when school debt levels are high enough that doctors cannot qualify for home ownership? (In January 2014, federal rules took effect granting mortgage lenders legal protections only for mortgage buyers whose total monthly debt does not exceed 43% of their monthly gross income.)
PPO-driven practices are becoming the norm in most markets along with HMOs in more competitive markets. Macroeconomics is having an impact on employers. In most industries, margins are tighter now than they have been. Expenses are up—with greater costs associated with the Affordable Care Act, employee insurance rates, and employee benefits. This pressure leads employers to select dental plans with low insurance reimbursement levels, stagnant annual maximums, and increasingly cumbersome reimbursement paperwork (which impacts utilization rates). Dental insurers are struggling selling the premium plans to employers. Most patients do not seem to know the difference. And dentists are caught in the middle, trying to help their patients while their office managers are engaging in benefits counseling, as opposed to the employer’s human resources (HR) department. Make no mistake—dentists are feeling the pinch.
Access to Care
Care for the underserved is more ubiquitous among practitioners and is often being discussed as part of the culture of dental practice. Caring for the underserved has expanded outside the dental office with many dentists volunteering in their communities at events sponsored by local and national dental organizations and outreach programs. Some of these programs, such as the American Dental Association–initiated Give Kids a Smile or specific Mission of Mercy events sponsored by state dental societies, are making great strides in helping communities across the country.
The future state of dental practice is guaranteed to be different, exciting, and even more challenging. Dentists will become architects of the oral cavity, navigating between the various oral-systemic links and conditions. We will begin to screen patients for systemic conditions and work closely with physicians to improve whole body wellness. When it comes to the dental team, general dentists will be called to lead large groups of clinical and administrative team members (dental assistants, office managers, mid-level providers, hygienists, lab technicians, and even specialists) whose roles and scope of services will change as the oral health needs of the public change. These changes will be essential for the dentist to compete, provide access to care, and maintain income. There will always be small niche solo practices that meet the needs of rural communities or high-income clientele, but the solo practitioner will fall out of the majority within the next decade.
The Millennials are digital natives and have been collaborative learners throughout their lives. This will play a role in their desires to work in small and large groups and in terms of the technology they demand. Most practices of the future will be small and large group practices that benefit from economies of scale in HR, insurance, education, marketing, and management systems. Large group practices that offer these benefits coupled with ownership opportunity will lead the space. These benefits of large group practice, combined with greater income potential and occasional loan repayment options, will provide new dentists different choices for their careers. Small practice management firms will become increasingly more niche in their service offerings (communication, scheduling, leadership), as they will lack the data to drive change across large groups of independent private practices. Independent solo practitioners will make attempts to band together to achieve economies of scale in purchasing and services. While some will succeed, most will not for two reasons—culture and consensus. The groups that band together with a strong common culture and consensus around products, services, and vision for the future will win. Dentists, regardless of their chosen model of practice, who learn to coach and mentor their junior partners—and attend to their success—will be the most successful dental leaders of tomorrow. They will learn the value of working through others, in contrast to the value of over-working.
Practice Structure
Dentists will enter the profession to become architects of oral health and overall wellness. Incomes may be limited for many solo practitioners for reasons discussed above, but those who enter group models will see greater potential.
Patients will need multiple reasons to stay with their dentist group, as choice of practitioners will be abundant. Service and integrated care under one roof will be paramount to compete. Medical care will be the last bastion of poor customer service. Dentists who choose to become experts in customer service will thrive. The practice that refines and masters the details of the patient experience will gain and retain the patients.
Dentists will compete with Starbucks and other retailers for prime locations. Rent in desirable high-traffic areas will be prohibitive for most small solo practitioners. Dentists will spend more on rent and less on marketing than they do now. Internal referrals, location, social media, and third-party review sites will be the primary ways to attract new patients.
Technology and the Laboratory
Dentists will become more accessible to their patients for real-time virtual consults. They will hire team members to address patient concerns in real time, with some limited examinations and screenings being handled virtually. No technology will ever substitute for the face-to-face interaction between the doctor and the patient, but we will evolve to greater platforms of integrated technology. Technology will continue to enhance patient experience and costs will come down as the interface between doctors and patients becomes more interactive. Same-day dentistry will become the norm. Dentists will become technology experts. Regeneration coupled with implant options will be the standard for missing teeth.
Laboratories will continue to consolidate. Digital laboratory technology will continue to innovate and costs will decrease. Intraoral scanners will miniaturize and come down in cost to below $8,000 and adoption will finally reach its tipping point. Analog plaster models and articulators will be considered a thing of the past. Dentures will be less “arts and crafts” and more “digital drafts” as the process becomes fully computerized. Centralized milling will lead the way in solo niche practices and onsite milling will be the norm for large and small groups. Will we one day see mostly full-mouth milled removable, implant splints, bruxism, sleep, and orthodontic applications? Yes.
Collaboration with Colleagues
General dentists will create networks of integrated specialists inside their practices to enhance income, access, and patient satisfaction. The “all under one roof” customer experience will win.
Physicians (both general practitioners and specialists), general dentists, dental specialists, pharmacists, nurse practitioners, mid-level providers, hygienists, and chiropractors will come together to create protocols for screening and improvement of overall wellness. Dental and other health practitioner providers will work together to improve patient outcomes. The role of the dental hygienist will expand. Dental schools, medical schools, nursing schools, pharmacy schools, manufacturers, and group practices will partner to lead the way. Collaborative models for research will provide evidence so that insurance companies may create more appropriate and updated reimbursement models. Collaboration between dental and medical professionals will far surpass the current state. Patients will win from this interaction.
Debt and Reimbursement
Debt levels will decline to 1 to 1.5 times the expected average annual career income. Students will demand curriculum that meets the demands of the current and future marketplace. Faculty will continue to innovate to incorporate new technology and new educational methods to educate dental students. Clinical board exams using live patients will be discontinued as a result of students’ and legislators’ ethical concerns. OSCEs, portfolios, GPR (general practice residency) requirements, and/or standardized patients may become the norm for initial licensure. Dentists will be required to take re-certifying examinations similar to several dental and medical specialties to demonstrate continued competency in the general practice of dentistry. Post-doctoral education will be driven by the needs of the public and large group practices, delivered by schools with new partnerships, evaluated by the Commission on Dental Accreditation, and supported by manufacturers.
As PPO providers become ubiquitous in markets, HMOs, POS, and other risk-sharing models will reemerge. Doctors will face unprecedented pressure to do more with less. Large and small groups will lead the way in cost-effective approaches to serve patients. Ethical standards will remain the norm, with the patient’s needs and wants always at the top of the priority pyramid. New quality and safety standard programs will be mandatory for doctors to be credentialed and licensed, with the best programs being inclusive of all providers, subject to routine and random reviews, and fully transparent to patients. Peer review will become a standard part of practice, driven by the dental profession, state licensing bodies, and third-party reimbursement.
Access to Care
Dentists will increasingly become global practitioners with some schools, manufacturers, dealers, and larger group practices leading the way in scalable programs to reach out to the underserved locally, nationally, and internationally. Practitioners will be less restricted by country borders and will be able to serve where the needs exist. Facility-bound geriatric populations will demand better care and business models will emerge to finally make an impact to improve their oral health. The oral health of all children will remain a top priority for both politicians and clinicians alike.
Dentistry has been, is, and will continue to be a rewarding and exciting profession. There will always be challenges, but the horizon for our profession remains bright with the ability to truly make a difference improving the oral health of the public. While we were intentional in limiting the scope of this article, we recognize there are many other aspects of dentistry that are also changing that we have not mentioned, including the aging and changing demographics of the population and its impact on practice, emerging technologies, and government influence on healthcare. Yes, the color of the sky is changing. And it is up to us as professionals to make certain that it is brighter and more appealing for future generations of dentists. To be successful, we must learn from yesterday, keep our eye on tomorrow, and rejoice in all that we have today.
Brad Guyton, DDS, MBA, MPH, serves as dean of dentist development for Pacific Dental Services and as associate professor at University of Colorado School of Dental Medicine. He practices dentistry in Denver, Colorado. He can be reached at guytonb@pacden.com.
Linda Niessen, DMD, MPH, serves the dean of the College of Dental Medicine at Nova Southeastern University in Fort Lauderdale, Florida. She currently serves on the DentaQuest Foundation Board of Directors and is immediate past president of the American Academy of Esthetic Dentistry. She can be reached at lniessen@nova.edu.
