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This article focuses on outcomes as a means to aid practitioners in treatment planning for endodontics procedures; specifically, the ways in which clinical prognostic factors can affect outcomes for our “big 3”—nonsurgical root canal therapy, nonsurgical retreatment, and apical microsurgery endodontic procedures.

An understanding of outcomes is fundamental to diagnosis and treatment planning in endodontics. Although some patients are often initially concerned about whether proposed treatment options are going to hurt, many are far more focused on the predictability and reliability of endodontic treatment. Treating clinicians must not only evaluate risk based on clinical and radiographic findings but also communicate both the risks and benefits of all treatment options as part of informed consent. Much of the conversation about risk centers around outcomes data and the factors that affect those outcomes.

Though extraction, informed refusal, and vital pulp therapy may be alternative options, treatment plans for endodontic pathology frequently include the “big 3” procedures within the specialty’s scope: nonsurgical root canal therapy, nonsurgical retreatment, and apical microsurgery.

Outcomes studies may report success or survival. Survival is the broader representation and refers to the absolute presence or absence of the tooth in the mouth, whether or not there are signs or symptoms of disease. In the prognosis literature, survival is synonymous with “clinically functional.” Success takes that cohort of survived teeth and excludes any with symptoms or radiographic pathology.

 Failure in both includes teeth that have undergone extraction following endodontic treatment.

As far as the numbers are concerned, endodontic procedures are immensely predictable. For nonsurgical root canal therapy, success rates approach 90%; for retreatment, 82%; and for apical microsurgery, 90%.

 That said, these reported success rates do not represent absolute numbers. Clinicians should recognize that certain preoperative and treatment-related factors can significantly influence success in endodontics, both positively and negatively.

They must consider these factors, and discuss them with patients, to ensure thoroughness in informed consent. In this article, we focus on outcomes as a means to aid practitioners in treatment planning for endodontics procedures, specifically on how clinical prognostic factors can affect outcomes for the big 3 endodontic procedures. Applying these principles will allow for discussions on expected success and survival tailored to the individual patient.


Patients may present with certain preoperative factors that can directly affect outcomes. Though outside of clinician control, these factors must be considered with respect to treatment planning. The 3 associated with outcome alterations include apical periodontitis, periodontal status, and treatment history. Treatment-related factors go beyond the delivery of competent care. Successful nonsurgical treatment requires the locating, cleaning, shaping, and obturation of the root canal space, whereas surgical treatment requires the resection of the root apex, retropreparation into the root canal space, and adequate restoration of the apex. The treatment-related factors we discuss here represent those items within clinician control beyond the delivery of adequate care and include restorative care and the utilization of modern technologies. The factors are listed in

 Several factors can impact the prognosis following endodontic treatment, including preoperative factors and treatment-related factors. Preoperative factors represent those factors completely outside clinician control, whereas treatment-related factors go beyond the delivery of adequate care.


A comprehensive endodontic assessment requires a clinical and radiographic examination to formulate both a pulpal and periapical diagnosis. Apical periodontitis, particularly asymptomatic apical periodontitis, represents one of the many periapical diagnoses, and results from the egress of bacteria from a necrotic pulp or previously treated root canal space into the apical periodontium, leading to bony destruction.

 Essentially, the interplay between bacteria and host immune responses causes bony destruction. The bacterial component can present a significant treatment challenge.

The presence of apical periodontitis, and its relative size, are associated with a reduction in success rates following both nonsurgical root canal therapy and nonsurgical retreatment.

 This does not mean that patients with a diagnosis of apical periodontitis should be excluded from endodontic treatment. Rather, they should be informed of the factors beyond clinician control that may negatively influence treatment outcomes. The presence of apical periodontitis warrants mention so that patients can understand its interplay with respect to outcomes, particularly if other comorbidities exist. Larger apical radiolucencies are associated with a greater bioburden and more robust immune response, and consequently more effort is needed on the part of the immune system in order to heal. For this reason, patients should be encouraged to pursue endodontic care when lesions are small, rather than delaying until they enlarge. 

 depicts a case where apical periodontitis was successfully treated.

 Though cases presenting with preoperative apical periodontitis may have a reduced prognosis, complete apical healing is possible following endodontics. This patient presented with preoperative asymptomatic apical periodontitis on tooth #30 (A). Endodontic treatment was completed on the tooth (B), and at a 5-year follow-up (C) complete lesion healing was noted.


As part of the comprehensive endodontic assessment, a periodontal exam should be performed on endodontic patients, specifically measuring for probing depths and mobility. Marginal periodontitis, like its apical cousin, represents a bony response to bacterial challenges.

 For all the big 3 endodontic procedures, comorbid periodontal disease has the potential to negatively affect treatment outcomes.

 The presence of preoperative periodontal disease increases the odds of tooth loss following nonsurgical root canal therapy more than 5-fold.

 Periodontally involved teeth are similarly lost at higher rates following apical surgery.

 As with apical periodontitis, the presence of periodontal disease does not preclude endodontic therapy as a treatment option for patients; rather, patients must be informed of its potential negative impact on expected outcomes. More severe periodontal disease is associated with a greater likelihood of tooth loss.

 This represents a rationale for early treatment of periodontal disease to prevent progression.


Teeth with a history of endodontic care warrant careful radiographic examination when clinicians are considering nonsurgical and surgical endodontic retreatment. Clinicians must take into account the impact the quality of prior treatment may have on outcomes. Outcomes are more predictable for teeth in which the quality of the initial treatment was poor.

 Poor quality may refer to untreated anatomy, ledged canals, and short fills, among other deficiencies. Clinicians should inform patients that when defined problems are found that can be fixed, outcomes are significantly improved. Quality should also include an assessment of complications from the prior procedure. Outcomes are less predictable for teeth with preexisting complications, including perforations, as seen in 

 Teeth with preexisting perforations have a poor expected prognosis for nonsurgical or surgical retreatment. This patient presented with severe palpation tenderness and an associated 7-mm periodontal probing depth on the facial aspect of tooth #8. Although the periapical radiograph (A) appeared largely normal, the sagittal view on cone beam computed tomography (CBCT; B) revealed restorative material extruded through a perforation. Extraction was recommended.

Treatment history becomes particularly important with respect to surgical care. When performing surgery on previously endodontically treated teeth, clinicians can expect the outcomes to be far more predictable when the initial treatment quality was poor, particularly with respect to the length of the initial endodontic fill.

 Another historic factor of importance is the technology associated with prior apical surgery. Historically, resurgery involving older surgical techniques using bur retropreparations and amalgam, intermediate restorative material (IRM), or SuperEBA (ethoxy benzoic acid) retrofills was associated with a poor prognosis.

 With more modern surgical techniques, a surgical history may be less relevant in terms of prognosis. Now resurgery is as predictable as initial treatment.


The clinician will assess the restorative history and existing coronal structure of any tooth being considered for endodontic treatment. Endodontic care does not exist in a vacuum. Outcomes are intimately tied to restorative care, and consideration with respect to restorability should be given both pre- and postoperatively. Restorability—namely the presence of adequate coronal structure—is perhaps the greatest preoperative consideration in deciding to pursue root canal therapy. Other factors excluded, the ability to maintain a ferrule and cavity wall length has a direct impact on outcomes.

 The same is true for nonsurgical retreatment. Teeth retaining less than 30% of their initial coronal structural volume have a higher proportion of unfavorable outcomes.

Before delivering endodontic care, clinicians should make patients aware of the importance of definitive restorative care. Teeth that are not definitively restored following endodontic treatment are more than 5 times likelier to undergo extraction.

 The type, quality, and timing of restoration selected all matter with respect to the prognosis for endodontically treated teeth. Outcomes in the posterior dentition are more predictable, with indirect restorations providing cuspal coverage as opposed to direct composites or amalgams, whereas anterior teeth may be successful when restored directly.

The goals of any coronal restoration, direct or indirect, are to maintain functionality of the tooth, protect the remaining tooth structure, and seal against coronal leakage. Therefore marginal integrity is paramount to positive outcomes following treatment.

Ideally, definitive restorative treatment should be completed immediately following root canal therapy due to the risks of coronal leakage with temporary restorations and fracture prior to cuspal coverage in the posterior dentition. In one study, patients who delayed definitive restorative care more than 4 months following endodontic treatment experienced a 3-fold higher risk of extraction than those with teeth restored in a timelier manner.

 Ultimately, timely delivery of restorative care can prevent premature loss of endodontically treated teeth.

The PreXion3D Explorer PRO CBCT Scanner is designed to combine precise 3D imaging, large image detail, diagnostics, and digital planning.


Although many of the preoperative factors we have previously discussed are largely outside clinician control, treatment-related factors, particularly the application of modern dental technologies, give clinicians a direct opportunity to improve patient outcomes. One of the simplest technologies available to practitioners is the dental dam. The bacterial origins of apical periodontitis are directly inhibited by dental dam isolation, which serves to minimize contamination of the root canal system by indigenous oral bacteria. As a result, dental dam isolation is directly associated with improved survival in both initial root canal therapy and nonsurgical retreatment.

 The dental dam offers other benefits, such as aiding in visualization by providing a clean operating field and preventing the ingestion or aspiration of dental materials, irrigant solutions, and instruments; thus, its use is considered the standard of care in nonsurgical endodontics.

Surgical microscopes like the PromiseVision 3D from Seiler Instruments provide unprecedented depth of field and field of view.

Magnification—specifically the use of a surgical operating microscope with the added benefit of illumination—represents another means to improve outcomes in both nonsurgical and surgical endodontics. In a retrospective, case-control study, outcomes in teeth treated without magnification were poorer than in those treated with magnification, as apical periodontitis was found more frequently in the former group.

 Stated differently, teeth treated without the use of microscopes developed recurrent pathology (ie, failed) more frequently than teeth treated using high-power magnification and illumination. Intuitively, this makes sense. Successful endodontic therapy is predicated upon finding, cleaning, and filling the entirety of the root canal space. Magnification enhances our ability to find anatomy and therefore our ability to clean it completely. The use of this technology is also associated with improved outcomes for retreatment and surgical endodontics.

CBCT imaging represents a significant development in dental radiography. In 2 dimensions, structural overlap can significantly impede clinicians’ ability to discern the presence, and sometimes absence, of pathology. CBCT imaging facilitates the appreciation of the entirety of the root structure, supporting periodontium, and pulp anatomy, which can aid in the diagnosis of endodontic pathologies, even in the earliest stages.

 This patient presented for an evaluation of tooth #4, and the periapical radiograph (A) revealed a resorptive defect on the tooth. Further examination with CBCT noted the palatal resorptive defect on the axial (B) and sagittal (C) sections, as well as additional resorptive defects on tooth #3 that would have gone undetected without 3D imaging.

 This patient presented with biting pain associated with a previously treated tooth #14. The periapical radiograph (A) revealed thin root fillings in the tooth as well as the presence of posts. The axial (B) and coronal (C) CBCT sections revealed evidence of untreated anatomy within the mesiobuccal root of the tooth. Based on an understanding of prognostic factors, retreatment was recommended to address the untreated canal.

CBCT technology is particularly useful in identifying factors that complicate a simple endodontic diagnosis, including resorptive dental defects (

 With proper diagnosis, resorptive dental diseases can be predictably managed; however, their misdiagnosis can easily lead to failure of endodontic treatment.

 Though CBCT images do not often elicit fracture lines themselves, they can detect very localized areas of bone loss pathognomonic to this pathology. In particular, CBCT images are adept at detecting the narrow, angular bony defects adjacent to fractures, midroot lateral radiolucencies, and bony defects found on the buccal or lingual surfaces that are not visualizable on traditional 2-dimensional radiography.

 As the extension of fractures onto root structure is associated with a less predictable prognosis for treatment, early detection of these defects can facilitate more thoughtful treatment planning.

CBCT imaging additionally is critical in the assessment of teeth with a history of endodontic treatment. This imaging modality can inform clinicians of the presence of untreated anatomy, procedural errors, fractures, and other findings that can affect future treatment and the resultant prognosis, as previously discussed. With the aid of CBCT imaging, clinicians can develop thoughtful and informed treatment plans that take into consideration the 3-dimensional radiographic realities. 

 illustrates the use of CBCT in assessing a previously treated tooth.

Ultrasonics represent a significant addition to the endodontic armamentarium. Not only does this technology facilitate more conservative endodontic treatment, its use is associated with significantly improved outcomes. The use of ultrasonics, among other armamentaria, during nonsurgical root canal retreatments notably improves outcomes.

 Its utilization is similarly associated with improved outcomes in surgery. These instruments facilitate more conservative osteotomies and create retropreparations that are deep, parallel, and follow the existing anatomy.

 Taken together, these factors result in more conservative and efficacious treatment that in turn results in improved patient outcomes.

Apical microsurgery, using modern technologies including magnification, ultrasonic root preparation, and bioceramic-based root filling materials, has an excellent prognosis. This patient presented with a large lesion associated with tooth #9 on sagittal CBCT section (A), and both nonsurgical and surgical treatment were recommended and completed (B). At 1-year follow-up, complete reformation of the periodontal ligament was noted on sagittal CBCT section (C).

Bioceramic materials represent the final technological advancement associated with improvements in prognosis. These represent a significant development in endodontics, especially when applied to apical microsurgery (

). Their use as restorative materials in the resected and retroprepared root tip offers a dramatic improvement over previously standard materials, including amalgam, SuperEBA, and IRM, and represents the material of choice for modern surgical endodontics. Bioceramic materials seal exceptionally well, even in the presence of moisture, including blood, and are bioactive. They facilitate the deposition of bone and cementum over the apical seal, both of which facilitate better healing.

These materials have significantly improved outcomes in apical microsurgery compared with older materials.


Outcomes matter to clinicians but even more so to patients. Prognostic data are fundamental to case selection and can help both clinicians and patients make educated choices regarding the optimal strategies for individualized care. By treatment planning with the end in mind, clinicians can fully appreciate the variables that may impact outcomes and more appropriately care for their patients. Clinicians must recognize that some prognosis-related factors represent insurmountable hurdles, whereas others are entirely within clinician control. Thoughtful consideration of all these factors will facilitate the delivery of predictable endodontic care, allowing clinicians to maintain their patients’ teeth and their confidence.

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Prognostic data are fundamental to case selection and can help both clinicians and patients make educated choices regarding the optimal strategies for individualized endodontic care.

Successful Endo With Outcomes-Based Treatment Planning

Kellie Nock is the assistant editor for Dental Products Report. She graduated from Kent State University in 2018 with a Bachelor's in Journalism. Kellie enjoys multimedia content creation with a focus on audio and video storytelling. 

Dr Yamaoka (left) and Zach Yamaoka (right), went through 58 prototypes of the Ambience PPE Face Shield before landing on the final version.

When the COVID-19 pandemic began, there was an increased urgency in the manufacturing of personal protective equipment (PPE). Included in this PPE were face shields for dental practices. After reopening his Vancouver, Canada practice, periodontist Scott Yamaoka, DDS, MS, needed a high-quality face shield that could fit his loupes.

“When I looked to see what was available on the market, there were face shields…used for welding purposes or…for protection from using a chainsaw,” Dr Yamaoka says, “nothing, really, that met the needs from a dental perspective.”

Two issues he focused on were optical clarity and room for standardized loupes. Inspired by a YouTube video in which someone had created a face shield from acetate, a baseball cap, and duct tape, Dr Yamaoka decided he needed to make a face shield himself.

Dr Yamaoka created the first prototype of the Ambience PPE face shield by taking a construction helmet and cutting the top off for improved ventilation. He used magnets to attach an acetate sheet, typically used for school projectors, to the front of the helmet. Dr Yamaoka made more than 70 face shields in his garage, and then sent them to colleagues for feedback. Based on the initial positive response, Dr Yamaoka enlisted the help of his son Zach Yamaoka, who had previously worked at Dyson as a design engineer.

Scott Yamaoka, DDS, MS, made more than 70 first version prototypes of the face shield in his garage.

“The users of the first prototype really liked the construction helmet head suspension because it was different from their shields that had an elastic band or thin plastic head support,” Zach Yamaoka says.

“It was something Dad stumbled into, and turned out to be exactly what you want. The full head suspension doesn’t squeeze the head or shift around. This is very important in dentistry as you’re doing these hour-long procedures. Not having comfortable head suspensions was one of the many obvious shortcomings of shields at the time. They were simply not designed with the needs of dental practitioners in mind.”

“Zach took the first prototype, gave it some thought, and took it to the next level of things.” Dr Yamaoka says. “What I was doing was just MacGyvering and making it work as best I could, which did work out reasonably well, but Zach certainly [took] it to the next level.”

“The first prototype worked well. I really liked how my dad made it. It’s basically called ‘bottom-up’ innovation. When you do that, you just grab resources that are available directly,” Zach Yamaoka notes. “You solve problems that actually exist, very concrete problems, …[such as that the] loupes and lights can’t fit, and the lack of clarity, and that the head harness is not very comfortable.”

According to Zach Yamaoka there was always a desire to make things better, to improve on what already existed in order to suit the needs of clinicians. “There is no shield like the final version of the Loupe Shield, and hopefully it becomes the new standard,” Zach Yamaoka says. “It’s just how dental face shields should be.”

The father and son went through approximately 58 prototypes of the face shield, fine-tuning and improving on each model.

“Around the 40th prototype, we were ready to go to market. Then, I got a paper cut, and I noticed that the blood was seeping into the 3D printed plastic. This was a big concern for us,” Zach says. “We had planned to 3D print the face shield, but realized we would need to injection mold the parts so they could be sanitized.

“We had to go back to the drawing board and adjust the design. This turned out to be a blessing. It gave us time to identify an antireflective technology that has become a real game changer. We also incorporated more user feedback, adjusting the shape of the rim on the shield to make it stiffer and less bulky. Throughout the entire process we were sending prototypes to dentists and hygienists. By the time we got to the 58th prototype, we had a high level of confidence that clinicians were going to like the shield, because they helped design it!”

Each hurdle was an opportunity for improvement. The signature green color of the rim didn’t come until later in the process. There were also medical device regulatory processes that Zach Yamaoka had never experienced in his consumer-focused history at Dyson.

Ambience PPE’s Face Shield can suit any clinician’s specific loupes and measurements.

by Peter J. Ogrodnik,” Zach says. “It was the best thing. There are not a lot of resources online for medical design, so that book became kind of the bible, and really helped me with getting all the regulatory documents in place.”

Before COVID-19, shields were primarily used in industries other than dentistry. Designed for different applications, they do not meet a dentist’s needs—namely optical clarity, fitting loupes and lights, easy disinfection, and personal comfort. One standout feature of this shield, the antireflective coating, was a design decision that came later in the process.

“Manufacturers are…using a kind of polycarbonate plastic, which does have some benefits in terms of being more impact resistant. But in dentistry, what you’re trying to protect against isn’t flying nails, it’s splatter,” Zach Yamaoka says. “The functional requirements changed, which allowed [for] a lightweight plastic that has the antireflective coating. The shield is something that you’re going to have in front of your eyes for multiple hours a day, multiple days a week. Dentists are willing to pay more to have this antireflective coating, whereas a lot of other industries are just not willing to pay as much to have that optical clarity.”

Before they completed their product design, there wasn’t a face shield available that contained these features. Aside from the optical clarity, loupe accommodation was a feature that Dr Yamaoka found notable.

“Everybody has a different set of loupes, and some of them are longer lenses and some of them shorter lenses,” he says. “Zach’s idea for how to accommodate that makes it a product that is quite widely acceptable and versatile from a practical perspective of working with it.”

The slot that accommodates loupes is able to slide back and forth for optimal customization. This feature is accompanied by a full head suspension to help create a more comfortable experience for dentists and hygienists.

Dr. Troy Martin, DDS, who used the very first Loupe shield prototype and now practices with the final version, is a proponent of the various features of the face shield.

 “Compared to the first prototype and other face shields I used, The final loupe shield is superior in clarity and lack of reflection. It’s easier to clean and maintains its clarity over time. The shield is so comfortable while wearing it and the clarity of the plastic is such that I forget that I am wearing it. I have actually thrown away all the shields we used previously and only have the Ambience Loupe Shield in my practice now. All of my team use them and no one would consider returning to any of the previous shields we had used.”

Without Dr Yamaoka’s perspective as a dentist and his son’s skill as a design engineer, the features and benefits of the face shield would not exist. Zach Yamaoka emphasizes that any idea can be put into motion with enough willingness and persistence.

“The best thing is what my dad did, when you don’t need to open a 3D CAD/CAM modeling software; you just need to very quickly test if [something’s] going to work,” Zach Yamaoka says. “If I was going to make a new type of scaler, I would use an existing scaler and then I would bend it to achieve a new shape. I would build from existing things, making small modifications to create a prototype. In my dad’s case, he used that existing helmet to make the first shield prototype.”

Turning an idea into something tangible is a key step in the development of a product.

“Being able to create a rough prototype is also a great test of technology readiness,” Zach Yamaoka points out. “If you are unable to make a quick simple prototype, it may be because the technology is just not there yet, [and] maybe there is a simpler solution to your problem.”

Dr Yamaoka remarks that having someone to consult on design was a great boon when moving forward in prototyping.

“As dentists we have a lot of great ideas, but we’re so busy with learning our own skill sets, we’re generally not that computer savvy,” Dr Yamaoka says. “Some of the younger dentists are, because of the CAD/CAM utilization for crown manufacturing…or CAD/CAM impressions, but to take it to an engineering perspective, you’d probably have to get in contact with a design engineer to make a prototype.”

Zach Yamaoka credits different manufacturing and e-commerce tools such as 3D printers, Alibaba, and Shopify for making it easier to mass manufacture products such as theirs. It’s all about being aware of the right resources in order to innovate.

“A year ago, I would have had no idea how to do any of what I’ve achieved over the past year. There have been a lot of great tools developed by others that made it all possible,” Zach Yamaoka says.

Faced with the COVID-19 pandemic, Scott Yamaoka, DDS, MS, and his son Zach Yamaoka set out to design a face shield that stands out from the rest. 

The First Antireflective Face Shield That Fits Loupes

Over the past 20 years, dental services organizations (DSOs) and large group practice models have been increasing in dental practice types. Meanwhile, over in medical, large medical groups and medical management services organizations (MSOs) have preceded DSOs in growth by at least a decade or more. We can explore the changing growth rates in dental practice types and what the dental industry can learn from the medical industry regarding the development of these practice models.

How dentists like to practice has changed over the past 2 decades. Just before the Millennium, the majority of dentists were solo practitioners. Per the Health Policy Institute of the American Dental Association, 65% of dentists in 1999 were solo practitioners. Twenty years later, that number has decreased to 50% in 2019, a proportion of 1 in 2. In other words, these days dentists are just as likely to be solo practitioners as they aren't.

Also, the age of the dentist affects their probability of skipping the solo practice type. Amongst dentists under 35, the proportion of solo practitioners drops to 1 in 4.

Moreover, these numbers and trends do not include the curveball that COVID-19 threw many dental practices in 2020. Based on what dentists learned about what can happen when you are a solo practitioner without anyone in the chair for several weeks to months, these percentages could have changed even more.

So, how do dentists want to practice today? Many of them are working in groups; others are joining DSOs. In the DSO model, dental practices join the DSO, which then supports the dental practice for their non-clinical operations. Per the Association of Dental Support Organizations (ADSO), DSOs allow dentists to focus on delivering patient care with the support DSOs provide in professional office management.

Dentists like it too. In 2019, 10.4% of dentists in the U.S. were affiliated with DSOs, up from 7.4% in 2017. Also, the ages of these DSO dentists are skewing younger; 34% were under 49. Female dentists like them too; 13.3% of dentists in DSOs were women.

DSOs are offering an attractive option for dental professionals, although they are not where most dentists practice. The idea of "corporate dentistry" still has a long way to go in the dental community to become like the medical community where large groups and managed care organizations are nothing new to medical doctors. MSOs have been a part of medical practices for years, growing in popularity with the adoption of a managed care approach to medical care that prevailed in the 1980s and 90s.

 Unlike dental, medical has already navigated many problems and pitfalls of this change in practice type—and dental practices should take note.

Learning Vicariously from Medical Software Development

There are a few things that large medical groups can teach the burgeoning DSO organizations in dental. One of the most significant is implementing the software functionality medical uses in dental software programs.

Mike Uretz, Executive Director of Dental Group Partners and founder and editorial director of DentalSoftwareAdvisor.com, works with many group practices in the DSO space. He also worked in medical software for 12 years before moving into dental, where he saw the potential for improvement. He thinks DSOs can learn a few things from large medical groups regarding the technology they use:

 Medical groups have embraced cloud-based software systems. Uretz says that dental software and practice management systems have been moving toward cloud-based systems, but there is some resistance to them from practices still tied to their physical servers.

: Uretz says DSO and multi-location groups need to put everything they need in a single integrated database, from financial to patient care to operational information. While he says that many dental software vendors have integrated databases, it is not to the extent that Uretz would like to see.

: Although operations and claims management are key to a DSO’s success, it is also critical to focus on having good clinical and electronic health record (EHR) software. Software evolved in the medical industry and moved from concentrating on practice management functionality to including more powerful clinical care management and EHR tools in their software. Uretz would like to see dental do the same. He says that one of the criticisms of large DSOs and groups is that they can't deliver a good level of personal patient care, but by showing that you can with state-of-the art clinical and EHR software you can defend against that bias.

Take advantage of analytics and business intelligence tools

: Medical groups and MSOs have used analytics and business intelligence (BI) to manage their practices' key performance indicators (KPIs) for years, Uretz says. He would like to see DSOs use these tools more consistently.

: Medical has many different software systems that can talk to each other, which has been essential with the EHR following patients through their medical path. Uretz thinks dental practices must communicate with their medical counterparts and other dental systems, but dentistry has a long way to go in this area.

Embrace the Cloud and Prioritize Integration

Before becoming Director of Marketing for Planet DDS, David Means also worked in a healthcare technology company, specifically an ephemeral messaging app company tasked with helping medical professionals communicate more effectively. Like Uretz, Means also thinks a critical priority for DSOs is to use a cloud-based system rather than a server-based. Not only is it more remotely accessible and less vulnerable to theft or destruction, but cloud-based practice management systems are also less prone to in-house maintenance and obsolescence. Plus, your data is more secure in the cloud than it is physically in the practice.

"Unfortunately, dentists are becoming more of a target for ransomware attacks because a lot of practices do not have sophisticated security in place on their systems, but instead have rudimentary passwords or encryption on their servers," Means says. "But if they have a practice management solution in the cloud, then there's physical security, but also additional layers of security behind firewalls that are going to make it much more difficult for somebody to be able to access the patient data inappropriately."

Means also agrees with Uretz that DSOs should prioritize integration. For example, when Planet DDS works with large DSOs, many of them centralize their back-office operations first thing. However, that team still needs access to the data from all the individual locations to assess the opportunities for improvement. Means says having an integrated product like Denticon is an excellent way for growing DSOs to have a common place for everything. Moreover, the technology optimizes the patient experience to ensure patients receive a consistent delivery of care each visit, a metric that investors—and dentists— like to see.

"They are putting in a process that enables the staff to ensure that they're giving great quality service and everything that patients need every time," Means says.

Bridge the Communication Gap Between the Different Practices for Patient’s Benefit

Dental and medical sciences have operated independently from each other for over a hundred years. However, research shows a connection exists between patients' overall health and oral health. In addition, more medical professionals see dental as a specialty for oral health, like a cardiologist is for heart health. As a result, Uretz thinks the future of financial and clinical success of all dental practices—solo, group, or DSO—will be enhanced by electronic communications with patients' medical counterparts.

Unfortunately, most dental software vendors haven't embraced this concept or prioritized it in development. Uretz would like to change that.

"Most people who read the studies can see where this relationship between medical and dental is going, but we don't have enough tools and software to make that relationship work," Uretz says.

Sam Ahani, DDS, CEO of Refera, an online referral platform for G.P.s and specialists, agrees that medical is doing better than dental for investing a lot in technology that supports the more effortless transfer of patient records. Investing in technology that can centralize recordkeeping and facilitate sending the patients' EHRs to other practices, medical or dental, is essential to large dental organizations.

However, dental practice management systems are not as compatible or ubiquitous as the large practice management systems for medical. Moreover, it is difficult for app developers to work with dental systems. For example, in the development of Refera, an app that connects general practitioners and specialists for patient referrals, Dr Ahani says one of the biggest obstacles was communicating with the practice management software. However, software developers are connecting multiple practices and getting the systems to talk to each other.

"But it feels like we're a long way from consolidating the platform," Dr Ahani says.

Finding Ways to Focus on Practicing Dentistry, Not Running a Business

Means says that the solo-practitioner is like a one-man band because they have to manage everything. From staff to payroll to human resources to administrative headaches, the solo-practitioner handles it all while also trying to deliver exceptional patient care.

Post-COVID, Means thinks the growth of DSOs will accelerate. Many dentists experienced first-hand the dangers of going it alone last year during the pandemic when most dental practices, especially smaller, older general practices, were shuttered.

"It was like, 'Well, why should I do this when I can have a partner help me manage this risk moving forward?" Means says.

Dr Ahani says that DSOs got off to a rough start. DSOs learned that focusing on delivering exemplary care was the recipe for success, a lesson he thinks medical had already learned. Large medical practices allow doctors to be "in the zone."

From the doctors' perspective, Dr Ahani thinks that DSOs and selling to a corporate dentistry organization appeal to dentists. Many dentists feel like artists and want to practice dentistry, not run a small business and all the details that entails. Dr Ahani thinks medical group practices are heading in the right direction.

"They're doing what they are supposed to do by building a lot of infrastructure and technology to improve the patient experience," Dr Ahani says of the medical group practices. "I also like the technology coming out, like the My Health online app, which is all about keeping patients in the loop and in control of their healthcare."

DSO's rough start was in part because of pushing productivity and profit improvements. From a business standpoint, boosting production is suitable for a dental practice. However, as a solo practitioner, Dr Ahani says it is difficult to put into place the marketing tools and staff you need to boost production while managing the patient schedule. So the DSO takes on those business marketing tasks, enabling dentists to focus on patient care, which will increase output inherently.

"You're producing more because you are doing what the patient needs," Dr Ahani says. "I don't see anything wrong with that."

"Becoming a part of a group practice or DSO helps free up some of those administrative, overhead management tasks, and allows practitioners to focus on patient care," Means agrees.

Use Technology to Give Patients the Experience They Want

The establishment of corporate and group practice models is increasing in dental. We explore what the dental industry can learn from the medical industry regarding the growth of these practice models.

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