Tools of the Trade

In the current market of increasing competition to not only attract new patients but also retain them, never before have GPs' abilities to offer specialized procedures been more valuable.⁵ Decreasing insurance reimbursement amounts, increasing material costs, increasing labor costs, and other factors continue to squeeze dentists financially. In this environment, keeping procedures in house that were previously referred out can open new revenue streams for GPs. However, this must be done with careful consideration of what is in each patient's best interests. GPs should only perform specialty services that they are trained to provide as well as a specialist.

Beyond advances in technology that have made treatments more predictable and streamlined protocols to make them more accessible, education and experience are the critical components enabling the expansion of GP services to include more specialized procedures. Increasing confidence through learning has the potential to change GPs' perceptions of clinical practice. Education has been shown to lead to an increase in confidence in communication skills as well as an increased ability to undertake complex restorative procedures, which can lead to greater treatment acceptance by patients and, subsequently, result in better job satisfaction.⁶

One of the specialties for which many GPs are beginning to provide more services in house is orthodontics. According to a recent study, 42% of GPs offer orthodontics, but of those, 68% reported receiving insufficient orthodontic training in dental school.⁷ Despite this, 61% reported that they increased the orthodontic care that they offer in recent years. When these GPs referred patients to orthodontists, the most important factors affecting their decisions were the complexity of the case (41%) and the patient's age (21%); however, the most important factors for choosing a specific orthodontist for a referral were the orthodontist's skill (66%) and his or her proximity to the patient (34%).⁷

Clear aligners have transformed orthodontics. What began as a treatment option for mild crowding and spacing is now being used to treat even the most complex of malocclusions.^8,9 Furthermore, the development of various clear aligner systems has enabled GPs to offer orthodontic treatment with different levels of involvement, ranging from the SmileDirectClub/CandidPro model of just scanning a case and outsourcing the rest to more comprehensive models in which 3D printers make in-house aligner fabrication possible. For those who desire even more involvement in the process, aligner manufacturers and several professional associations offer continuing education courses in orthodontics.

According to the results of a 2021 survey of GPs by Inside Dentistry, 62% of respondents indicated that clear aligner treatment should only be handled in person, whereas 21% indicated that certain services that involve clinician partners are beneficial options, and 17% indicated that at-home aligner services expand access to care and are a good option for certain patients. Clear aligner therapy may be indicated for the treatment of diastemas, mild malocclusions, deep overbite problems, nonskeletal constriction of arches, and mild relapses after fixed appliance therapy.¹⁰ Treatment success relies on clinicians' knowledge and experience with aligners, proper case selection, and patients' adherence to the treatment instructions. When indicated, in-house aligner options can make patients more likely to accept minor orthodontic treatment.

One reason that implementing orthodontics is desirable to GPs is the fact that increased access to orthodontic treatment can cut down on the need for more invasive restorative treatments.¹¹ "As a restorative dentist, I believe that occlusal harmony is a major predictor of long-term success for any restoration that we deliver. This is where having a strong background in orthodontics has been helpful," explains Stephen Dadaian, DDS, a private practitioner in Cresskill, New Jersey. "It has allowed me to reestablish occlusion and move teeth to ideal positions to set the stage for the restorations that I place. Because occlusal overload can also be a risk factor in implant dentistry, I have found there to be crossover utility in that field as well."

At this stage in the dental implant revolution, there are clinicians in nearly every specialty who provide implant surgical services to their patients. Of the responding GPs surveyed by Inside Dentistryin 2021, 56% reported placing implants. Increasing demand, due in part to the aging population, as well as technological advancements that have increased the predictability of implant placement are helping to drive this trend. Timothy Kosinski, DDS, a diplomate of the International Congress of Oral Implantologists and private practitioner in Bingham Farms, Michigan, is a big advocate of GPs becoming involved in both the prosthetic and surgical aspects of implant dentistry. "There is much more to understand about the process than just learning how to create an opening in the hard tissue and thread in a ‘screw,'" he says. "Modern tools, such as cone-beam computed tomography (CBCT) and design software, allow the GP to precisely place an implant in an edentulous space and visualize the final emergence profile and smile design prior to any placement. This is an art in dentistry that took me years to master."

Intraoral scanners, CBCT machines, 3D implant planning software, and CAD/CAM systems that fabricate surgical guides and provisional restorations have become standard tools to facilitate precise implant placement that is restoratively driven.¹² Continuing education, training, and product-specific instruction from manufacturers and dental laboratories are available to help GPs learn how and when to utilize these tools. "I'm really into the tangible," explains Dimple Desai, DDS, a private practitioner in Newport Beach, California. "Seeing is believing. With my digital scanner and 3D printer, I can display the existing condition of the teeth, create and print models, and design the proposed restorations needed to restore and improve occlusion." Although many clinicians are still placing implants freehand using 2D imaging, digital implant planning and 3D printed static guides have become quite common, particularly among GPs who have more recently begun to place implants.¹³

In this changing landscape of dentistry and challenging economy, the opinions and referral practices of GPs matter significantly because patients identify the generalist as the one leading overall treatment initiation.¹⁴ Appropriate referrals are an integral part of quality healthcare management. The decision to refer a case should be based on the education, training, experience, and interest of the referring dentist as well as the unique needs of the patient.⁵ In order to best serve their patients, GPs need to decide when it is appropriate to incorporate a new, more specialized skill into their practices. "I highly value being able to manage cases from start to finish (always beginning with the end in mind) so that I can get more predictable outcomes," says Desai, who recommends that GPs pursue continuing education focused on very specific skills to master.

Kosinski agrees. "My advice to any GP who wants to incorporate newer, more sophisticated dental therapy is to get involved with high-quality dental education," he says. "This will eventually lead to becoming a true ‘Super GP,' which will allow you to personally treat your patients with the procedures that they request and do so at a high level."

In Inside Dentistry's 2021 survey, 70% of the responding GPs reported that they perform endodontic procedures. Of these GPs, 68% performed standard root canals, 15% handled re-treatments, 11% performed apexification procedures, and 1% treated root canal obstructions. This is not surprising because a foundation of endodontic and periodontal health is important to enable the success of subsequent restorative treatment and ensure overall patient health.¹⁵

Regarding periodontics, the 2021 Inside Dentistry survey found that 76% of responding GPs performed full-mouth debridements, 58% did gingivectomies or gingivoplasties, and 47% performed crown-lengthening procedures. "Dentists have to ask themselves if they are really the right person to perform any given procedure," emphasizes Sandra Hulac, DDS, a fellow of the American Academy of Cosmetic Dentistry and private practitioner in Hong Kong, China. "And that will depend on how much training and experience that they have in the procedure. For example, if one is a novice at esthetics, he or she may want to refer full-arch crown-lengthening procedures for patients with very thick bone. Single-tooth procedures in patients with thinner bone are more appropriate for less-experienced clinicians, then they can gradually proceed to more difficult cases." Many more GPs perform nonsurgical periodontal therapy than those who perform surgical periodontal therapy.^16,17 GPs who are looking to expand into periodontics should consider less technique-sensitive procedures to start. "I believe that esthetic crown lengthening is a good option," suggests Hulac. "Personally, I am planning to attend a soft-tissue grafting course very soon and hope to be able to do some of that myself."

For some GPs, expanding their procedural knowledge into more specialized fields is dependent on their office's patient demographics. The global population of individuals aged 65 and older is growing at a significantly faster rate when compared with any other age group, bringing with it an increased demand for dentures and other prosthodontic services. Although the complexities of the traditional, analog process of denture fabrication kept it out of reach for many dentists, the introduction of digital protocols, particularly intraoral scanning, have made prosthodontics more accessible. Since its introduction in the early 1970s, intraoral scanning has become part of mainstream clinical dentistry and is now used in virtually every protocol from the delivery of fixed single-tooth and implant-supported restorations to occlusal devices, removable partial dentures,  complete dentures, and maxillofacial prostheses.^18-21 Despite the advantages of intraoral scanning, the implementation of a direct digital workflow in fixed implant prosthodontics is not without difficulties.²² Technology has increased the predictability and success rates of prosthodontic procedures; however, GPs must carefully consider if the investment, both financially and intellectually, is right for them.

The provision of specialized services can be a means for GPs to adjust to the availability of dental specialists in their areas and to the overall demand for services in their practices, but it has other benefits as well. "Expanding my role as a clinician allowed me to have greater control over the final outcomes of cases," says Dadaian.

Desai agrees with this assessment and adds that patient satisfaction also plays a role. "Once patients trust you, they often want you to control their case from start to finish," she says. "They don't want to go to someone new."

Because the complexity of procedures is highly variable, both across and within the specializations, for some GPs, expanding to offer these services may require a prohibitive amount of continuing education and/or investment in technology. It is also important for GPs to allow sufficient time for the education and not rush to begin offering services before they are ready. "Oftentimes, continuing education courses can provide a great experience in a controlled environment, but taking on too much too soon will be problematic, especially if problems arise unsupervised," says Dadaian. "I also believe that finding a mentor in the field of their choosing is invaluable to GPs who wish to grow."

Ultimately, it is up to each GP to assess whether his or her education, training, and experience is sufficient to provide the specific treatments needed by the patient in each particular case. Cases that require referral to a specialist with a specific skill set necessitate clear, open, and ongoing communication between the providers and with the patient.²³ Effective interdisciplinary treatment involves a triad comprising the GP, the patient, and the specialist, and the success of this triad depends on teamwork, mutual understanding, and respect. As GPs expand into specialty services to address the evolving needs of the profession, in order to meet the standard of care, it is essential that they "know what they know and know what they don't know" and that all continue to engage in the interdisciplinary triad with the same mutual understanding and respect.