Trends in Dentistry 2023

"The best advice I was ever given about practice ownership was that you can never have a chip on your shoulder because you need to be open to anything and everything," says Varisha Parikh, DMD, who graduated from dental school in 2017, completed her advanced prosthodontics residency in 2020, and opened Parikh Prosthodontics in Los Angeles, California, earlier this year. "It is crucial to understand that the dentistry is the easy part; all of the other elements of practice ownership require significant effort. We need to be open-minded and willing to learn how to be successful at management, marketing, and other aspects of running a practice that might not immediately come to mind when imagining the job description of a dentist."

Fortunately, more tools to help practice owners, both in the chair and beyond, are available now than in the past. From increasingly accessible CAD/CAM hardware and software to evolving artificial intelligence modules, teledentistry platforms, and laboratory communication tools, today's dentists have the resources at their disposal to help them build a thriving practice for the future. The key is for each practice to select the most appropriate options for its development and maximize their impact.

With that goal in mind, Inside Dentistry is pleased to present the results of its annual Trends in Dentistry surveys, which help to shed light on what your colleagues are doing in their practices. All of the data referenced in this article was collected via three email surveys—business, clinical, and products-that were sent to Inside Dentistry's readership during the third and fourth quarters of 2023.

In 2022, 52% of the survey respondents indicated that they used digital impression systems, surpassing half for the first time. This year, that number dropped slightly to 49%, but it remains well above the 37% that was reported in 2020, and all indications are that it will resume its increase in the coming years. According to Matt Nejad, DDS, a private practitioner in West Hollywood, California, and owner of the Nejad Institute, in addition to more dentists adopting the technology, intraoral scanners are being used for more applications. "We started scanning several years ago," he says, "but primarily for diagnostics. Now, we are scanning for final restorations, whether they are milled or printed. Today's scanners all have advanced tools that can help in a number of ways."

The reported utilization of in-office 3D printing continues to rise, from 2% in 2021, to 9% in 2022, and to 12% this year. Parikh emphasizes that her 3D printer has been critical in reducing overhead to combat the rising costs of staffing and other expenses. "3D printing has helped us minimize the cost of goods for certain procedures, and we continue to incorporate new applications for it," she says. "That has been transformative."

Nejad notes that he has been 3D printing Maryland bridges, inlays, onlays, final crowns, night guards, and more. "For a patient who needs an implant, imagine having the ability to 3D print three or four Maryland bridges to use throughout the process as well as six-unit implant bridges and temporaries," he says. "That level of control has resulted in a completely different thought process for us: instead of asking ourselves what the laboratory can do, we are asking ourselves what are we willing to do?"

Among other digital products, milling machines (16%), digital radiography sensors (75%), cone-beam computed tomography (CBCT) units (32%), lasers (41%), and electric handpieces (49%) were reported to be utilized at relatively similar levels to those of recent years. Nejad explains that the benefits of electric handpieces should not be underestimated, even though the technology is no longer new, and he touts the benefits of CBCT and lasers as well. "We bought a laser to remove veneers, and it has worked incredibly, even for removing crowns," he says. "I have also used it to desensitize patients, and it almost seems like magic. I do not own a CBCT unit yet, but we send patients down the hall for CBCT scanning, and the ability to combine those images with intraoral scans, 3D facial scans, and jaw motion analysis data to create a virtual patient allows us to understand cases better and make more informed decisions."

Despite advances in artificial intelligence (AI), its adoption within dentistry seems to be slow thus far. This year, only 9% of the respondents reported having integrated some AI modules into their workflows, 26% indicated that they were monitoring the developments and considering adding AI, and 51% indicated that they may be open to it. Two years ago, when Inside Dentistry first asked our survey participants about AI, those numbers were 18%, 19%, and 47%, respectively. In addition, the percentage of respondents who reported that they did not believe that AI was a fit for them has only dropped from 16% to 14% since 2021. Nonetheless, Nejad notes that AI has a number of useful applications. "We know AI is helpful, but sometimes, we do not realize how cool it is for our patients," he says. "They often refer friends after seeing us use AI for help in caries detection. I also use it for help in writing and updating website content, and our phone software has an AI feature to help us be more efficient with voicemails."

Regarding teledentistry, 14% of the respondents to this year's surveys reported having implemented teledentistry options—the same number as in 2021-whereas 32% indicated that they were not open to it, which isn't much of a change when compared with the 33% who indicated that they weren't open to it in 2021. Parikh believes that teledentistry will be "nonnegotiable" for dental practices in the future, but she emphasizes that it should be used with caution. "Incorporating teledentistry and keeping your mind open to its potential is important, but setting boundaries is also important," she says. "The reality of dentistry is that we probably will never be able to do it completely remotely-at least, not in our lifetimes. I have very clear-cut boundaries for the use of teledentistry with my patients because, although it is great for obtaining a baseline of information without requiring them to visit the office, so much of our work is in the details of what we see intraorally, so we cannot be fully reliant on teledentistry consultations. The key is to make it work for you."

In addition to having an efficient workflow, two of the most important keys to operating a profitable practice largely hinge on the patients themselves: case acceptance and new patient referrals.

The percentage of respondents who indicated that the majority of their complex treatment plan proposals are accepted by patients was 57% this year—the third consecutive year that this number was between 57% and 60%. Only 13% of the respondents reported that more than 80% of their proposals are accepted, and 20% of respondents reported that less than 25% of their proposals are accepted.

There are tools available that can help more dentists get their case acceptance rates closer to 90%, which has been cited as a realistic goal.¹ Case presentation is critical, so the use of advanced hardware and software applications that can produce clear, concise, and compelling images to help patients visualize their needs can be transformative. "Utilizing my software platform's case presentation feature has been huge for case acceptance on my complex cases," Parikh says. "Seeing is believing in dentistry, especially for a new practice owner because patients are often suspicious of upselling."

Getting those patients in the chair can be challenging, of course; however, acquiring new patients presents its own challenges. Although the degree to which practices depend on new patient volume varies, this year, 58% of the survey respondents reported that they treat more than 10 new patients per month, including 26% who indicated that they treat more than 20 new patients per month. Only 8% indicated that they treat three or fewer new patients per month.

In the pursuit of new patients, 86% of the respondents reported having a website, and 65% indicated that they utilize their websites as marketing channels. A total of 9% of the respondents with websites indicated that they use chat bots on them. Regarding other approaches to marketing, 48% of the respondents reported that they use social media, including 64% of those who have been in practice 10 years or fewer; 42% reported using email marketing; 15% reported using direct mail marketing; 16% reported that they place online advertisements; and 19% reported using print advertisements.

Despite the use of so many marketing approaches, 68% of the respondents indicated that referral by established patients was their most significant source of new patient appointments, and 12% cited referral by fellow practitioners. Only 8% of the respondents reported that online marketing was their most significant source of new patients, and 4% reported that it was online reviews. Parikh touts the importance of using modern practice management tools to impress patients and entice them to refer their friends, family members, and colleagues. "We employ a suite of products to create a nice practice management cocktail that patients have raved about," she says. "We have also brought everything online for them: new patient forms, consent forms, payments, text message reminders, appointment scheduling, and more. Even older people, who make up much of my practice's patient base, love having everything available online. It makes them feel like they have access to me much more readily than if they needed to call the office for everything."

The rate of respondents who accept private insurance has remained similar for 3 consecutive years: 84% this year, 83% last year, and 86% in 2021. Meanwhile, the percentage of all respondents who offer alternative membership plans dropped from 51% last year to 36% this year, but for those in practice for 10 years or fewer, this number is still hovering around 50%. In addition, 60% of this year's respondents indicated that they offer healthcare financing options.

Despite the potential offered by technology to keep more work in-house, the dental laboratory is still a valuable resource—often an untapped one—for complex cases. Although 74% of the respondents reported that they always or often solicit the laboratory's input when treatment planning complex cases, only 34% indicated that they communicate face-to-face or by phone prior to delivery on most of their complex cases, and only 34% indicated that they send full-face photography on most of their esthetic or complex cases. "I discuss 90% of my cases with my dentists, and we will not work without photographs, but that is not the norm," says Peter Pizzi, MDT, CDT, owner of Pizzi Dental Studio in Staten Island, New York, and editor-in-chief of Inside Dental Technology. "Dental laboratory technicians can offer so much to the team regarding knowledge of materials, tooth morphology, occlusion, and more, but in order to provide that expertise, we need information. If the dentist prescribes six lithium disilicate veneers and the technician fabricates them without considering the occlusal capabilities, the space that is provided, or how the shade is being communicated, then achieving the best possible outcome is unlikely. An educated technician can be a valuable asset when properly incorporated into the team."

Interestingly, 26% of this year's respondents reported that they do some sort of laboratory work in-house, including 8% who indicated that they employ in-office technicians. Pizzi notes that he has observed a trend of offices training dental assistants and other staff members to serve as technicians rather than hiring experienced laboratory professionals and that some have encountered challenges. "It is hard enough for a laboratory to train a technician who is already well-versed," he says. "In the clinical environment, that becomes even more difficult. These individuals are being trained in the process, but they are not learning the foundational knowledge." Some of Pizzi's dentists have sent their assistants to his laboratory for a few days to learn there. "They go back to their offices and look at their role completely differently," he says. "They start to look at teeth as individual forms and not just products to be designed on a screen." Pizzi anticipates more of this because laboratories can benefit from having a liaison in the office who can handle simpler cases and work directly with them on more complex ones. "As great as technology is," he says, "it is still about the user. To maintain a certain level of quality—true dentistry, true patient health, and true esthetics—a certain amount of knowledge must go into the process."

However, the amount of work that is performed in-office versus in the laboratory and the specific workflows used by practices is dependent on technology. For example, will 3D printing laboratory-designed restorations in the office for immediate placement become common? Pizzi believes that today's advancements in technology and materials will benefit the whole profession, but like all progress, each process will take time to evolve. "Although things are moving fast, and it seems as if tomorrow we will be able to hit one button to meet all of our needs, that is not realistic," he says.

Regardless of the materials being used, the knowledge and skill of an experienced dental technician is difficult to replicate; therefore, Pizzi believes that technology should be looked at as a tool to enhance communication with those skilled technicians instead of as a way to replace them. That kind of resource can be valuable for a practice owner. "The communication piece is the future," he says. "As great as technology is and keeps becoming, what really needs to increase is our brain capacity to communicate through the processes."

With all of the current challenges of independent practice ownership, one alternative is to work for a DSO. The three largest DSOs in the United States—Heartland Dental, The Aspen Group, and Pacific Dental Services—support nearly 4,000 practices between them.^2-4

Dentists' attitudes toward DSOs continue to evolve. This year, only 54% of non-DSO respondents reported that they were not at all open to joining a DSO, which is down from 59% each of the past 2 years. Although 37% indicated that they were somewhat open to it, 6% indicated that they were very open to it, and 2% indicated that they definitely plan to join a DSO. "Remaining solo against the various headwinds that practices face today is becoming increasingly difficult, and we work hard to provide an attractive alternative," says Rick Workman, DMD, founder and active executive chairman of Heartland Dental.

For those dentists who choose to remain independent, the industry continues to provide tools to help them compete. Parikh notes that one key is being judicious in technology adoption. "A common fallacy among new practice owners is that you need to have it all," she says. "You do not need to have it all. You do not need to front-load your overhead with a massive equipment budget. If you take the time to determine what will work for you, it becomes less intimidating."