The future of dental practices

May 24, 2017

Article

Experts say the field of dentistry is shifting and new advancements will accompany the change. What will your dental practice look like five years from today?

Times are changing, and the dental industry is, too. With shifts toward the dental service organization model, as well as exciting technology advancements, many dental practices will look very different in the coming years. But how will the changes affect your practice-and what will they mean for the long term?

As I spoke with expert dentists-those who have been in the game for a while or are in touch with the goings-on in the industry-about the future of dentistry, most echoed what their colleagues were saying: Practices themselves will undergo a huge shift, leading to advancements in technology and the presence of multiple specialists in a single location. That shift will facilitate an increase in diagnostics and patient education.

The pendulum is still swinging, and practices are still trending toward the dental service organization model (DSOs). As the model keeps growing, its wake will leave space only for certain kinds of private practice: the Neiman Marcus/Wal-Mart model, as one doctor says, and the solo-group practice model, as another doctor says.

The good news is that the space dentists will find themselves in will facilitate investment in technology. If dentists can adapt to the new frontier, they can be rewarded greatly. The same holds true for patients-at least for those who can afford the treatment.

A lot will change in the next five years, if not in market availability, at least in ideas. In forecasting the future, there’s a lot we could talk about. The rise of minimally invasive dentistry, 3D printing or the increasing acceptance of sleep specialists are all going to change dentistry-but this article is not long enough to venture down every rabbit hole! Instead, let’s focus on two particular aspects of technology: imaging and artificial intelligence.

The practice

The trend toward DSOs is slowing down, but it’s already made its mark. And because it can help lighten the burden of student loan debt, which averaged $260,000 for 2016 graduates, that’s an appealing promise. While more than seven percent of licensed dentists are involved with corporate dentistry, the number is twice as high for dentists under 30.

“When these students graduate, their debt load is so substantial that a lot of them go into corporate dentistry to pay the bills,” says John Flucke, DDS and technology editor for Dental Products Report. “What happens is they’re there for a while and they get used to a certain lifestyle and realize if they want to be in private practice they have to take a pay cut, but with increased personal responsibilities like families, it’s not going to happen. So, I think it will continue to grow and threaten private practice.”

And corporate dentistry has its benefits. “We’ve all known that that’s been coming,” says Brian Gray, DDS, of Giannini Gray Dental Partners in Washington, D.C. “The corporate model has come in and created greater efficiencies in dentistry, not just on the supply chain side, but more importantly efficiencies in the management side, which has been pretty much a cottage-type industry.”

DSOs won’t take up 100 percent of the market-but the space they leave will be available only to a certain kind of practice.

“I do think you’re going to see more individual dentists owning more practices, but not necessarily more large group practices coming out,” says Parag Kachalia, DDS, of Innovative Dental Concepts in San Ramon, California. “I think it comes down to a financial standpoint: All these groups are getting together to get the sum valuation that they can sell the private equity. That’s kind of what we’ve seen along the way, that dentistry has a cash flow standpoint that seems good from a Wall Street component to invest in a private equity standpoint. But there are fewer and fewer groups to gobble up. There will be some degree of saturation of group practices, and then it’ll start to swing back.”

At that point, he says, the trend will head toward a private practice model. But what kind of private practice?

“Some offices won’t be able to compete,” Dr. Flucke says. “Corporate fees are often lower than private practices, so I can see an independent practice having trouble.

“I think relationship building will always have a market, although it will shrink while corporate grows,” Dr. Flucke continues. “I think you’re going to see people who want a personal relationship with their doctor, office and staff. I see it often. People come in and say they were going to a corporate office but they didn’t like it. They feel it’s impersonal because there’s a lot of turnover. They didn’t feel like anyone knew them.”

While there will still be a demand for private practices, they won’t be based off a traditional model. Dr. Kachalia believes that there will be an increase in solo-group practices-offices where multiple, single practices operate in a given physical space.

“I think how we define the private practice model is going to change,” Dr. Kachalia notes. “Dentistry is an incredibly inefficient model and there’s a vast majority of offices that are unused for a significant portion of the week. Dentists may work four to five days a week, but it’s a six- to eight-hour schedule on a given day. There are 12 hours-plus that an office is not being used.”

Dr. Kachalia believes that, by sharing space while running independent businesses, dentists will benefit from being able to invest in technology together and streamlining rent. This could be another solution to the problem of dental school debt. “A big reason group practices are thriving the way they are is because they’re offering an opportunity for dentists coming right out of school to get a job where they’re doing dentistry and there’s potentially some loan repayment,” he says.

But ultimately, working for oneself will be the feature that wins. “There’s definitely a movement toward working for someone else and not having to worry about anyone else but yourself, but I think dentists historically have been co-owners,” Dr. Kachalia says. “We like to do our own thing. We don’t necessarily like to work for someone else forever. I do think the pendulum will start swinging back.”

Dr. Gray sees three possibilities in the future of private practice. While the corporate model will comprise over half of all dentists in the future and be there to “treat the masses,” other practices will be smaller shops. “I think that those are going to be the ones that struggle the most because they’re going to fall between the Wal-Mart model and what people often call the Neiman Marcus model, which is high-end,” he says. “There’s not enough room right now to have that middle section survive.”

What’s left is what he calls the “dying mom-and-pop model,” which will be further divided into three categories: “The boutique dental practice, which is going to be a small, fee-for-service type practice; the cutting-edge specialty practice, which could be a practice that is focused in on one of the new things, from doing clear aligner treatment to sleep medicine to even just bleaching; and then the super practice, which will be a high-end, fee-for-service practice that will be team-based,” he says.

The team-based practice will have general dentists and specialists working together.

“To me, that’s going to be the ultimate model,” Dr. Gray says. “There is no way you can have any single dentist able to do all the different specialties, and I don’t think that personally at this point in my career I would want to be that kind of Jack-of-all-trades, master of none. Having those specialists who do these things on a regular basis work together under the same roof is going to provide an incredible patient experience. They’ll be able to offer cutting-edge technologies and stay abreast of what’s going on with the other specialties. When each specialist brings these things to the table through that workflow model, we can really change the way that we’re doing stuff.”

An investment in technology

The benefit of the practice models of the future is that they will facilitate an investment in technology, primarily in the imaging world, according to Dr. Kachalia.

“Imaging will be expanded,” he says. “Not just radiation-based imaging, but non-radiation-based imaging, both for diagnostics and digital impressioning and the likes.”

Advancements in imaging will get a boost from the medical field as well.

“Years ago, we saw the proliferation of cone beam CTs,” he says. “That came from the predicate technology of digital CAT scans. In the next stage, we’ll see things like ultrasound and MRI come to dentistry.”

The hold-up with these technologies is that the area of the scans is so much greater in medicine than in dentistry, where the area of focus is measured in millimeters. The clarity needed in dentistry is not available in these technologies yet. But when it is, those will be the next big things in imaging, according to Dr. Kachalia.

“The beauty of all those is that there’s no radiation involved in any one of them,” he observes. “Everyone knows that in a single office visit to the dentist, the radiation levels are really, really low. But I understand that people are more concerned with overall lifetime exposure to radiation. If we can find technologies to get rid of it completely, there’s no reason anyone would advocate that we must have radiation.”

He also anticipates dentistry borrowing from ophthalmology. “I think that optical coherence tomography (OCT) will come into dentistry in a form that can actually be used in dental offices,” he says.

As for the technology dentistry already uses, cone beam CT scans seem to be the most exciting due to their superior diagnostic capabilities.

“I think cone beam CT is becoming the standard of care, especially in endodontics,” says Emily D. Hobart, DMD, of Bayside Dental in Anacortes, Washington. “I think they’re going to help us diagnose so that patients get the right treatment in the right amount of time and they have the best information to make the right decisions for their health.”

Erinne Kennedy, DMD, a dental public health resident at Harvard School of Dental Medicine, shared those sentiments.

“I’m excited about cone beam,” Dr. Kennedy says. “My practice has a lot of patients who come in and say, ‘This tooth feels funny,’ but diagnostically nothing comes of it. Radiographs show nothing because it’s 2D. I went to [the] Sirona 3D Summit and they were showing cases of patients who had complaints, but the X-ray didn’t show anything. Then they showed the cone beam, and it shows exactly what you wanted to see: something you couldn’t see or diagnose with any other method.”

Dr. Flucke is confident that digital caries detection will continue to be a growth industry.

“The visual aspect-taking pictures of teeth and then showing where decay is on the screen-that’s going to continue to advance,” he says. “There is a very strong possibility that ability may move into other devices as well.”

Dr. Gray values his role with research groups-the role of a clinician who gets to learn firsthand if products meet clinical acceptance in his field. And while more than half go back to the producer to be reconfigured, the ones that survive are “fantastic.” “Digital scanners come to mind,” Dr. Gray says. “We got our first about a decade ago and made our first purchase about eight years ago. We couldn’t practice without it.” He says the three he uses in his practice help with the workflow because information is automatically stored or sent to the right place.

Where will the dental practice be in five years? Much more reliant on digital scanners, he says. There are more uses for digital scanners than are currently put to use. The first is data capture itself. By doing scans on new patients as part of the comprehensive exam, dentists have their data stored, should they need it. Say the patient undergoes a trauma to his or her mouth: Clinicians can print off a perfect 3D model of the teeth before the accident. They’ll no longer have to guess.

“Digital scanning will play an integral role and be a standard of care in the initial comprehensive exam in the near future,” Dr. Gray says.

It’s already trending that way with a rapid increase in usage of digital scanners.

“I would say that more practices by far are going to be involved in digital impressions,” Dr. Flucke says. “I’ve seen statistics from dental labs that show that the number of cases coming in that are digital versus analog are rapidly increasing.”

Digital photography can do the same thing. “There’s really no reason why we shouldn’t have every single dentist on every single patient be taking a landscape set of photos before we start treatment,” Dr. Gray. says “We should be taking eight photos: five intraoral and three extraoral, of every patient, at the initial clinical exam and every time we see a condition that is abnormal.” Dentists can also use the intraoral camera to look at fractures in the teeth, lesions and anything else that looks suspicious, he advises. And getting in the habit of capturing data at every turn will be beneficial in the long run.

Digital scanners have many benefits: They are faster than the traditional method, provide a much better patient experience and improve the workflow. But they have their limitations as well. So much so that Dr. Gray uses traditional impression material a quarter of the time.

“The biggest limiting factor with digital scanning that a lot of docs aren’t aware of is that a scanner can’t be used for every single situation,” Dr. Gray says. “If you’ve got anything at all that is obscuring the margin of your preparation - if there’s any fluid, be it blood, saliva or intra crevicular fluid, or if your margin is way subgingival and gingival tissue hangs over it - you can’t use a scanner.”

Because digital scanners capture only what’s in the line of sight, traditional impression materials are a better option for the situations he describes.

That’s all going to change in the next few years, thanks to multi-wavelength scanners. “Imagine having, in essence, a cone beam scan able to be used as a digital scanner that is able to take photos and create a 3D model of our patients,” Dr. Gray says. “We will be able to peel off the layers in images, starting with the skin and going down to the densest object, say teeth, from a single pass around the body.”

With the multi-wavelength scanner, clinicians will be able to visualize where the margin is underneath obstructions.

The technology will be revolutionary, says Dr. Gray. “We’re not just going to use these to look at stuff like gross changes, say tooth eruption pattern or jaw development,” Dr. Gray explains. “We’re going to be able to use these also to look at decay interproximally and, yes, we’re at the point where we can look at lateral canals. Imagine being able to have this single scan to be accurate enough to properly perform endodontic treatment or use it for implant placement or [to] determine how large a fracture is, all on top of a real human face that’s in three dimensions.”

Having the accurate imaging systems sets the practice up well for what’s coming next: insane amounts of data and the new technologies that will not only be able to read said data but make diagnoses as well.

“I think the coolest thing that’s going to be available in the next year is a number of different software [options] that are out there that are able to look at minor changes in the oral cavity that occur over a long period of time,” Dr. Gray says.

If a patient breaks a tooth playing football, they can take a picture of their tooth with their phone and send the image straight to their dentist, who can then line the image up with the image on file to determine how much tooth structure was broken. “That was really cool when we first got it and started using it,” Dr. Gray remembers.

But he soon discovered a much bigger potential: the ability to track things he couldn’t see on a regular basis, such as recession. Trying to remember the condition of the patient’s gums at the last visit and taking a guess is not a scientific procedure. The question became: What if you could superimpose images of the patient’s mouth?

The answer, Dr. Gray says, is improved accuracy. “The accuracy of this is around a half of a tenth of a millimeter-.061 I think right now-so that when we’re looking at changes in the mouth, we can literally measure and say when their gums are receding and diagnose why that may be,” he notes. “I see that [this] type of technology is going to play a huge role in us being able to have data.”

“There are lots of different imaging things that are out there today, and lots of data that we’re getting, but no one in dentistry is really mining that data from a diagnostics standpoint,” Dr. Kachalia says. “People mine business metric numbers, but there’s nothing today that takes all the data you have, whether from cone beam CT or caries detection or intraoral imaging, and puts that together to extrapolate a differential diagnosis.”

Kachalia says there is a huge potential that a computer could read data and make conclusions.

“Kind of like IBM’s Watson for dentistry,” he says. “There’s no Watson of dentistry today, or anything even close to it. I do think there’s this A.I. component that is going to be able to read our diagnostic input and tell us to some degree, ‘Here’s what this A.I. component believes is happening.’ It’s not going to be an absolute from a medical standpoint, but it’s going to give you guidance. It’s almost a diagnostic GPS system that will say, ‘Here’s what’s maybe going on.’”

Though people are talking about it, it hasn’t been done yet. Dr. Kachalia attributes that to the number of proprietary software on the market. But now that more companies are providing open-source software, that will start to change.

“We’re starting to get to the point where people are more open with the data, and now they’re asking how they should gather that data,” he says. “There are lots of algorithms that need to be run in order to accomplish that. How that’s going to play out is the unknown.”

Data will also be the catalyst for another futuristic aspect of dentistry: augmented reality (think Snapchat).

“Those worlds are coming to health care,” Dr. Kachalia says. “That concept behind Snapchat’s filters will be involved in the medical world to show patients the potential of what they can have.”

He says showing patients a live composite image of their face will help show patients the picture before starting treatment.

“Two-thirds of people learn through visual communication versus auditory or tactile, but that visual role has not been in health care from an education standpoint in the past,” he says. “We used it from a diagnostics standpoint, but I think we’re bridging the gap so patients can understand what’s happening. A big part of understanding relies on them seeing value in their practitioner and not seeing it as a commodity. They start to see a rationale for picking a practitioner: someone who can truly educate them versus just handing them some words on a sheet. It’s taking informed consent beyond, ‘Here’s some text,’ to an actual visual standpoint of what’s happening.”

Of course, this is all down the road. But it’s a good idea to have a few basic technologies up and running to be able to get the data and all of its benefits. Step one, says Dr. Kachalia, is having an intraoral camera. Then it’s radiographs.

“Thankfully, we’ve seen a tipping point occur there,” he says. “Assuming you have those things, intraoral scanning is going to be the gateway to allow everything else to occur.”

These advances in technology pose an interesting question: How do you make it available to everyone? This is something that was on Dr. Kennedy’s mind at the Sirona 3D Summit.

“That has to be a focus in dentistry as well-making diagnostics and tech like that available to all health centers,” she says. “When you have advancements like this, they need to apply to everyone. Because the cost of having that technology and the training is so astronomical when you look at it across an entire population of dentists or people, I don’t know if there is one answer, but it’s definitely a question that should be asked. It could revolutionize dental care for everyone.”

Dr. Gray’s suggestion for his own practice is to offer treatment pro-bono.

“The bottom line is that, where I see our practice five years from now is that if we continue to have a consistent, excellent experience, we have patients that can pay a fee for service and they value, appreciate and can afford what we do, it gives me the ability to go ahead and offer reduced fee or even free dentistry for patients that value and appreciate it but can’t afford it,” he says. “It gives me a chance to give back in that model. It’s going to be a real hard line between those practices that can do that and the corporate model that’s out there.”