Trends in Dentistry 2020

Undoubtedly, COVID-19 was the predominant trend of 2020. Just a few weeks after thousands in the industry gathered in Chicago, Illinois, for the Chicago Dental Society's annual Midwinter Meeting and surrounding events, dentistry ground to a halt when the American Dental Association advised practices to limit their work to only emergency cases during the height of the pandemic. Unsurprisingly, the impact of COVID-19 is ubiquitous, from the projected proliferation of private insurance to an increased demand for cosmetic services that at least one leading dentist attributes to the increased frequency of videoconferencing this year.

"COVID-19 advanced the dental industry by 5 years in 5 months," says Roger P. Levin, DDS, CEO of the Levin Group.

Many trends, however, can be attributed primarily to developments in technology and materials science, changing attitudes and philosophies within the profession, and other factors. For example, COVID-19 does not seem to have slowed the adoption rates of digital intraoral scanning, cone-beam computed tomography (CBCT) imaging, chairside milling, and in-office 3D printing.

"We are not far from a time when anything besides digital technology will be unimaginable," says M. Reed Cone, DMD, MS, CDT, FACP, a prosthodontist in Portland, Maine.

The most powerful economic driver in dentistry is probably private insurance, which 86% of the dentists surveyed said they accept. In recent years, membership plans have emerged as challengers, and 48% of the dentists surveyed now offer them; however, Levin believes that these options will merely supplement private insurance, not replace it. The Levin Group Data Center projects that the number of dentists accepting private insurance will reach 94% to 95% by the third quarter of 2021.

"Insurance companies are big, well-
capitalized, and powerful; they are not going anywhere," Levin says. "This was a trend we anticipated, but it is accelerating as we hit a rougher economy during the COVID-19 era."

Despite the pandemic's economic implications, 86% of the dentists surveyed reported that the yearly net income of their practice is more than $100,000. Among individuals, the safest bet seems to be working for dental service organizations (DSOs); independent practice presents higher risk but higher rewards. Only 8% of the DSO dentists surveyed noted that they make less than $100,000 in yearly personal income, whereas 67% make $100,000 to $200,000. Among independent practitioners, 27% reported that they make less than $100,000 yearly, but 31% make more than $200,000.

Levin anticipates that DSOs will become a viable long-term career path for more dentists in the future but emphasizes that they will still continue to serve as a stepping-stone for others. "More dentists will find the financial stability of working for a DSO appealing at a young age as they pay off student loan debts, but as they get their lives going, they might not want to take the risk of opening their own practices," he says. "However, I do still talk to many young DSO dentists who regard it as an opportunity to gain experience while paying off debt and intend to start or join a private practice in 3 to 5 years."

Business models for practices vary. For example, 13% of the dentists surveyed work with a practice management consultant, and 29% say that they spend more than 2 hours per month on staff training.

"For every dollar that businesses spend on training, they can recoup $3 to $5," Levin says. "Dental practices are highly focused on production, which I endorse, but if you do not spend time on training, then you are dependent on the economics. In a good era, such as 2019, you can do fine. In the post-COVID-19 world, you need to access the full potential of the practice."

Another way to access that potential is through marketing. One-quarter of the dentists surveyed reported that they use outside professionals to create their marketing materials. In addition, 64% use social media for marketing, and 74% use a practice website. The data indicated that social media is a more popular strategy among dentists who have been in practice for 5 years or less (76%) than among those who have been practicing for more than 10 years (58%).

"Social media can depend on the platform, so understanding the different platforms is important," says Adamo Notarantonio, DDS, FICOI, AAACD, a private practitioner in Huntington, New York, who has nearly 15,000 Instagram followers. "I get some patient referrals from Instagram, but Facebook accounts for more because the demographic is different; it is a bit more family-oriented."

Levin notes that although 65% of patients visit a practice's website prior to or after making an appointment, 50% of patients who say that they found a practice online actually did not. "Somebody referred them, but before they called, they looked at your website," he says.

Brooke Blicher, DMD, an endodontist in White River Junction, Vermont, suggests that patients look up practices online regardless. "You really cannot avoid having a web presence, so being in control of it with your own website is a crucial marketing tool," she says.

Of course, controlling everything is impossible. Online reviews can have a tangible impact on a practice-even if 73% of dentists say referral by established patients is a more significant source of new patient appointments. Levin worked with one practice that had received only 10 reviews, but simply by learning how to ask patients for reviews, they got more than 200, and their new patient numbers increased by 20%.

Blicher affirms that her own research shows that patients use online reviews to supplement personal recommendations. "People take the word of someone they know, but then they often look up reviews to make sure that there is nothing negative out there about which their acquaintance was unaware," she says. "As a specialist, I even hear from patients that they look up our reviews after being referred by another professional."

Cone notes that most, if not all, of his practice's new patients say that they looked online and saw positive reviews. "Dentists underestimate how savvy their patients are," he says.

As important as marketing is, patient demand is another critical part of the equation, especially for cosmetic dentistry. Anecdotally, Notarantonio suggests that demand seems to be increasing due to the proliferation of videoconferencing during the pandemic. "We have had patients say, ‘I see myself on a screen more than ever, and it bothers me,'" he says. "I was a bit shocked by that, but my associate has heard it also. When you look at something over and over in a way that you never looked at it previously, you can become more self-conscious."

An increased demand for cosmetic dentistry would at least partially explain why the percentages of dentists who offer various bleaching services increased from last year's survey, with the use of custom trays going from 61% to 76%, chairside whitening from 20% to 47%, "go trays" from 5% to 21%, stock whitening trays from 3% to 8%, and whitening strips from 2% to 9%.

GPs are widely performing specialty services as well, with 69% of those surveyed saying they place implants and 76% saying they perform endodontic procedures. Blicher believes that GPs can be capable of performing excellent endodontic treatment when appropriately trained and equipped. The survey results indicate that the vast majority of GPs do not handle more than 25 endodontic cases per month and that most only perform standard root canals.

"The American Association of Endodontists has created a great resource called the Endodontic Case Difficulty Assessment Form and Guidelines to help dentists decide whether a case should be referred out to a specialist," Blicher says. "Endodontics is complicated, and if we mismanage cases, we will get treatment failures and complications, so we need to make sure that GPs are working only on cases that they are comfortable with and capable of doing."

Opinions are even stronger on the subject of implant placement. "Most of the implant work that I do as a specialist involves fixing other dentists' work," Cone says. "Implants can be very challenging, even for specialists. There are real people attached to the end of these titanium screws, so decisions should not be made for primarily financial reasons."

Timothy F. Kosinski, DDS, MAGD, who has been placing implants since 1984, says the keys are proper training and knowing your limits. "Anybody can put a screw in a jawbone, but few can place it in the perfect position," Kosinski says. "It requires more than just a weekend course. You need to fully understand what you are doing-and what you cannot do. I place approximately 1,200 implants per year, but I still refer a lot to my oral surgeon and periodontist, particularly in the anterior region where you cannot make little mistakes without potentially ruining somebody's life."

Maria L. Geisinger, DDS, an assistant professor in the Department of Periodontics at the University of Alabama at Birmingham, emphasizes that anyone placing implants must be aware of the various considerations involved. "There is a strong economic driver to place implants," she says, "but the caveat is that if we are setting ourselves up for success as a profession and thinking about what we can do for the betterment of the patient, reducing the risk of peri-implant diseases-in particular, biologic complications, which have been reported in as many as 47% of all dental implants that are placed-really requires a comprehensive view of the patient. Our department chair, Nicolaas Geurs, DDS, MS, always says that dental implants should be restoratively driven and biologically executed. If we understand both the restorative components and the underlying biology, that really informs the type of treatment we should be providing. Therefore, implants should not necessarily be the purview of any one specialty, but there should be required learnings and trainings necessary to place them. In many cases, implant site preparation procedures, including both soft-tissue grafting and restorative components, are critical to ensure the long-term success of implants."

One of the primary decisions to be made when planning implant treatment is whether to utilize screw or cement retention. In last year's survey, 66% of dentists reported that they placed cement-retained implant restorations and 61% reported that they placed screw-retained implant restorations. This year, 64% of respondents reported that they use screws and only 53% reported that they use cement. Kosinski explains that the push toward screws has been driven primarily by a desire to avoid periodontal problems caused by the presence of cement in the sulcus but notes that screw-retained implant crowns also are significantly less expensive. "However, you can only utilize screws when the angulation is appropriate," Kosinski says. "The other disadvantage is needing to cover the access holes with composite, which does not look quite as good."

In addition to avoiding peri-implant complications and affordability, screw retention offers other benefits. "I really like the retrievability of screw-retained implant restorations," Cone says. "If the occlusion is managed properly-and this is where working with a good laboratory technician is important-it is a much better option."

Beyond placing implants, GPs perform other periodontal treatments. According to a weighted survey question, full-mouth debridement is the most common, followed by gingivectomy/gingivoplasty and crown lengthening. "As long as full-mouth debridement is being used appropriately," Geisinger says, "it is absolutely appropriate for it to be performed by any skilled practitioner. Similarly, gingivectomies, gingivoplasties, and crown lengthening can certainly be performed successfully by a range of individuals. However, it is important to know when gingivectomy is the ideal treatment and when crown lengthening or recontouring might be more beneficial."

No discussion of dentists' capabilities for certain procedures would be complete without addressing the technologies at their disposal. For example, CBCT has dramatically increased diagnostic and planning capabilities for implants, endodontics, and more. Among the dentists surveyed, 28% overall reported they use CBCT in their practice, which is up from 22% last year; 60% of respondents working for DSOs use it.

"CBCT imaging is not yet the standard of care in endodontics," Blicher says, "but it is on the cusp. For situations involving previously treated teeth, dental resorption, or traumatic dental injuries, the guidelines and position statements that are available indicate that CBCT should be used, if possible."

Of the dentists surveyed, 37% use digital impression systems, including 52% of those in practice 5 years or less and 43% of those in DSOs and small group practices. The overall number of users was 36% last year. "Especially with COVID-19, companies are marketing digital impressions as a safer, more sterile method," Cone says. "It is important to remember, however, that this should not be a shortcut or a proxy for good preparations."

Lee Culp, CDT, CEO of Sculpture Studios in Cary, North Carolina, notes that the cost of entry still is prohibitive for many dentists. "Some leading scanners have all-in prices approaching $65,000," he says. "The prediction is always that ‘next year' will be when scanning adoption takes off, but we have yet to see that happen, and I anticipate the growth to continue very slowly."

Interestingly, the overall use of chairside milling is up from 15% last year to 22% in this year's survey, including 27% of those who work for DSOs and those in practice for 5 years or less. "For DSOs and dentists who want to mill, it makes sense," Culp says. "For the average dentist, a 1-hour crown might seem attractive, but they quickly learn that everything needs to be executed perfectly in order for that to be a reality. As a result, we still see a lot of mills being purchased and then not used on a regular basis."

Notarantonio points out the financial ramifications of milling, as well. Typically, insurance reimbursements are higher for chair time than for laboratory work. "My office is 100% fee-for-service, so I can charge whatever I want; taking the time to mill a restoration and put it in does not impact my overall production," he says. "In offices that need high patient turnover rates, it might not work."

Regarding materials, the percentage of dentists using low-viscosity impression material decreased from last year's survey to this year's (90% to 85%), as did the percentage of those using bulk-fill direct resin composite (82% to 72%) and amalgam (44% to 39%). Amalgam is used by significantly fewer dentists who have been in practice for 20 years or less (29%) and DSOs (27%), in particular.

Kosinski notes that amalgam does still serve a purpose. "Elderly patients on medication often have dry mouths, so composites do not retain well," he says. "The mercury issue is important, but amalgam does last really long."

When purchasing new products, the recommendations of "key opinion leaders" are the most popular sources for research and evaluation, according to the survey results. Clinical research was listed as being paramount or very important by 78% of respondents in practice for more than 10 years versus 59% of those in practice for 5 years or less.

"Many experienced dentists have been burnt by the early adoption of products that ended up being less than ideal," Geisinger says. "Now, individuals can obtain information from a wider variety of sources, such as YouTube and Instagram, but ideally, clinical research that demonstrates clear benefit is preferable. Still, it takes time to achieve that level of clinical research, and we often need to make decisions based on the best evidence available."

Another resource that dentists can turn to when considering new materials is a dental laboratory. Among the dentists surveyed who do indirect restorative work, 73% reported that they exclusively use outside laboratories, 6% employ a dental technician, and 29% do at least some of their own laboratory work. Only 12% reported sending any of their work overseas, but most states do not require laboratories to disclose whether that is being done.

In that regard, dentists' expectations for outside laboratory work might be at odds with reality. Despite the efforts of the National Association of Dental Laboratories (NADL), only 8 states require dental laboratories to register with the government, and only 11 require point-of-origin disclosures. However, 87% of the dentists surveyed indicated that they believe laboratories should be required to register and/or disclose point of origin. In addition, 76% indicated it is either paramount or very important to use a laboratory whose technicians are CDTs, and 73% indicated it is paramount or very important to use a laboratory whose technicians graduated from an accredited dental technology program.

"In reality, very few dentists ask about CDT certification, formal education, regulation, or disclosure," Culp says. "Formal education is voluntary. The US dental laboratory market is somewhat like the Wild West because, in most states, anybody and their brother or sister can open a laboratory tomorrow with no regulation, certification, or licensure." Culp adds that the US Food and Drug Administration's increased attention on the CAD/CAM production of laboratory products in recent years could eventually accomplish the objective of elevating the profession through regulation.

Dentist-laboratory collaboration seems to be on the rise. Overall, only 26% of the surveyed dentists reported that they communicate face-to-face or by phone with the laboratory prior to the delivery of restorations for most of their cases; however, that number increases to 60% among responding dentists in practice for 5 years or less. Similarly, 13% of the overall respondents indicated that they send full-face photography on most cases, but that number jumps to 40% among those in practice 5 years or less.

"The most common restoration is still the single molar, which typically does not require a high level of collaboration," Culp says. "Dentists who are doing more complex cases are communicating more frequently with laboratories, especially as digital communication tools make it increasingly easier."

As dentistry progresses into 2021, Inside Dentistry will continue to monitor the trends in the profession for next year's installment of Trends in Dentistry. Undoubtedly, the impact of COVID-19 will continue to be felt. Levin predicts that one of the most significant developments in the next 3 to 5 years will be a staffing shortage, followed by a phase in which a large volume of new people are brought into the profession. Whether this comes to pass or not, throughout whatever changes this ever-evolving profession undergoes, running an efficient business with clinical philosophies, products, and partners that best align with each individual practice will be critical to future success.