The days of hanging up your shingle and drilling and filling your way to a career are long over. The profession is changing, and today’s successful dentists need to be experts in demographics, systemic health, big data, and business management as well as clinical care if they want to succeed both now and in the future.
In its recent white paper, “The Future of Dentistry: Improving America’s Oral Health and Wellness,” the Guardian Life Insurance Company tackles these emerging trends—the aging population, the growth of corporate dentistry, dental-medical integration, risk-based models, and a focus on quality and value—and how they will impact the dental healthcare system.
The Aging Population
For example, the paper notes, more than 250,000 Americans turn 65 each month. By 2030, 67 million Americans or close to 20% of the population will be 65 or older. Thanks to decades of better preventive care, these people are keeping more of their teeth than their predecessors, even into their eighties and nineties.
“The need to understand the geriatric patient has never been greater than it is today,” said Randi S. Tillman, DMD, MBA, chief dental officer and second vice president at Guardian as well as author of the white paper. “Treating an older patient is much more complex because they will have a combination possibly of decay and periodontal disease.”
Additionally, many older patients have chronic medical conditions that impact oral health, particularly if they are on medication that causes dry mouth. Or, these patients may have difficulties with brushing and flossing because of declining vision, coordination, and cognition, further negatively impacting their oral health.
“You’ve got a patient that has complex clinical needs and complex medical needs, and you’ve got to balance the two,” said Tillman. “Maybe you can’t do everything you want for this patient because of their medical history. Maybe you have to come up with a more creative treatment plan. I find that there needs to be more time and attention paid to the over 65 population.”
Senior citizens also have limited access to dental insurance, preventing many of them from getting the care the need. Often retired, seniors aren’t covered by any employer. Also, Medicare does not cover routine dental care in its basic benefits. Only 12% of Medicare beneficiaries have some kind of dental insurance coverage.
“One of the issues is education about the importance of oral healthcare. I think that’s particularly a challenge with somebody who’s on a fixed income—how and when they’re going to spend their money. I think that once you get patients into the office, you can talk to them about home care. So much of dentistry, or oral disease, is preventable.”
Corporate Dentistry
As the general population gets older, dentists themselves seem to be getting younger as millennials replace retiring baby boomer clinicians. Yet these new dentists are graduating with huge debt, including an average of $287,000 in 2016. This burden leaves them unable to open their own practices, so they are joining corporate practices as associates.
Business models such as dental service organizations (DSOs) offer several advantages for new dentists, Tillman notes. They offer a more predictable income stream without additional financial obligations. Associates also can focus on clinical care instead of trying to run a business. However, the long-term impacts of these models on dentistry are yet to be seen.
“Every young dentist joining the dental profession has to decide on the best career path for himself or herself. If you choose to join a corporate dental practice, there is less autonomy in regards to decision making and treatment planning. However, you are likely to have more control over your schedule and salary,” said Tillman.
“A private practice is for the young dentist that wants full autonomy, is entrepreneurial, is willing to make the financial investment, and willing to take the associated risk,” Tillman said.
Meanwhile, Tillman notes other key trends that will impact care. First, the average dental school class is now at least 50% female. Second, new dental schools have opened with a focus on providing care in rural and other underserved communities. Finally, the role that dental therapists will play in providing access to care continues to be debated.
“The advent of corporate dentistry models has altered the dental landscape. One of the positive outcomes of corporate dental practices is that they have the potential to provide additional points of access for those who live in underserved communities,” said Tillman.
The Dental-Medical Connection
Historically, dentists and doctors have treated their patients separately. But research continues to find connections between oral and systemic health. In fact, the FDI World Dental Federation reports that up to 57 diseases have been studied for their relationship to gum disease. Dentists and doctors, then, will need to coordinate and collaborate to provide better care.
For instance, patients with diabetes who control their periodontitis will see improvements in their diabetes, and vice versa. Periodontal disease can impact cardiac health and has been linked to stroke, chronic obstructive pulmonary disease, and other chronic conditions. Recent studies have found links between oral health and dementia as well.
“What we need to focus on when we think about oral health and its relationship to systemic health is the role of inflammation. It’s really about inflammation being the mediator between oral health and illness elsewhere in the body,” said Tillman.
Also, dental treatment for pregnant women has been found to be safer than previously thought. Routine preventive, diagnostic, and restorative care is safe for most patients who are expecting. Meanwhile, failure to maintain good oral health during pregnancy can have significant negative long-term consequences on both the mother and child.
Overall, Guardian found, compliance with oral healthcare recommendations can produce significant savings on related medical costs, with an average of $1,037 among patients who received cleanings and routine periodontal care over a 12-month period. The greatest savings were associated with patients who otherwise were non-compliant with their medical care.
Improved health and reduced costs will be key drivers as doctors learn to examine the mouth and teeth as well as the rest of the body. This extra step would especially benefit those patients who don’t regularly see a dentist. Doctors and nurse practitioners also are beginning to apply fluoride varnishes in their offices.
“There’s a huge opportunity there for physicians, even if they don’t know what they are looking at. They may notice a patient has bad breath. They may notice if the patient’s gums are puffy and inflamed. There may be bleeding,” Tillman said. “If physicians could be trained to at least screen for dental disease, that would make a big difference.”
On the dental side, clinicians are taking more detailed medical histories and acting on what they find. Medication often has a significant impact on the oral cavity, with many prescriptions leading to dry mouth and tooth decay. Also, patients with cardiac issues can’t take local anesthetics that have epinephrine in them.
“I think the value of that medical history is becoming increasingly important. Years ago, we were told to take a medical history, and I think we weren’t quite sure what to do with it. What do we do now that we know all this? I think practitioners have a much better idea of the relevance of the patient’s medical history to their treatment plan,” Tillman said.
Risk-Based Models
Traditional dentistry has relied on the fee-for-service model. As practitioners provide more care, they make more money. But this can lead to over-treatment and over-charging, which does not serve the patient. New models are emerging, however, emphasizing preventive care.
Pay-for-performance (P4P) or value-based payment models attach financial incentives and disincentives to provider performance based on clinical outcomes. Patients at high risk for periodontal disease or decay would be identified, and dental offices would be rewarded financially for providing them with outreach, education, and preventive care.
“We’re realizing that when it comes to dentistry, it’s not one size fits all. So I may have very poor oral hygiene, and my dentist says I need to come back four times a year. You on the other hand may have excellent home care, and it may well be that you only need to visit once a year,” said Tillman. “It’s really personalized medicine.”
More than 18 states and the District of Columbia are participating in a pilot program that provides support to state Medicaid agencies for value-based incentive payment models. Also, many carriers are now discussing how they may design various plans based on these oral health risks, as defined by the medical condition or oral health status of their patients.
A Focus on Quality and Value
Finally, other disciplines such as pharmacology have successfully evaluated the clinical values of the financial expenditures of treatment. But while research has shown which dental strategies have the best payoffs for the patient, their utilization remains consistently low while other treatments still see broad application. That will change in the years ahead, Tillman said.
“There are very good preventive procedures for children, like sealants and fluoride. Yet most of the statistics that I’ve seen, and I would love to be proven wrong, show these services are underutilized. And I don’t understand that. They’re inexpensive, they’re highly effective, and yet some studies show they’re just not being done as frequently as they could be,” Tillman said.
Tillman points to the ADA’s Dental Quality Alliance, which was developed in recognition of the increasing demand for accountability from the public and payers to help them know when dental procedures are “worth” the cost. While it aims to help measure and define quality and outcomes, most of its measures are process measures only, though that is expected to change.
“How do you define value? Value is really the relationship between cost and quality. So how do we know that a more expensive procedure is really the right procedure?” asked Tillman. “We’re beginning to ask some of those questions in dentistry now, and data will make a big difference in our ability to assess how to define value.”
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