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There are many changes in our profession lately; from the types and numbers of procedures we accomplish to the types of continuing education we need, even the way we get products is changing. It is an exciting and unprecedented time in dentistry.
I had the pleasure of discussing these issues with Gordon J. Christensen, DDS, MSD, Ph.D, who is a well known practicing prosthodontist in Provo, Utah. I have known him as a professional and a friend for over 25 years and truly respect his impact on dentistry. The following comments are what he had to say about many of the issues present in our field today and in the years to come.
The Next Generation of Dentists
Dr. Doherty: There are 64 accredited dental schools in the United States. I am amazed that some dental schools closed for various reasons, but then new ones keep opening. What is the reason to keep opening these new schools?
Dr. Christensen: That is an important question and one on which I appreciate the chance to share my opinion. Many of these are schools are privately owned and are not in a typical university environment. Although many of them are nonprofit, the tuition is extremely high. The reasons for the new schools are very dependent on the entrepreneurial individuals who start them.
Also, it’s important to look at geographic areas that have the potential need for a dental school. Perhaps they have been waiting for years to start one, and that has never culminated because of the politics in their state. Therefore, the new private school have the opportunity to move in without the political impediments of state politics. Although many of the new schools appear to be financially oriented, many new schools are also altruistically based.
Dr. Doherty: Is there a need for these new schools?
Dr. Christensen: The need for these new schools is a moot point. Some states need new schools, but most of them do not. In the state of Utah, were I live, there are now two new schools; one is in a university environment, and one is a private school. They will be turning out a very significant amount of dentists soon, but it is well known that this state does not need additional dentists. Other positive aspects of a dental school will have to be emphasized. That is true in many of the states. It is clear that the new schools will dilute the market relative to the numbers of patients for each dentist.
As you know, a typical general practice in the USA has somewhere around 1,800 to 2,000 patients, according to the American Dental Association (ADA). When new dentists move into an environment that is already saturated, it will have some negative affects for the established dentists in the area. The fees decrease because there is much more competition and some patients shop for the lowest priced dentist. There is not a need for many new schools at this time, and the new schools will rapidly over-saturate the market significantly in many of the states.
Dr. Doherty: The ADA wrote an article in the June 2014 issue of JADA about graduating dentists and the debt they have incurred, many of them in the range of $200 to 300 thousand dollars or more. Would you still recommend to young men and women that dentistry is a career that they should pursue?
Dr. Christensen: I am asked that question very often. I often counsel young dentists, helping them get into dental school. New dentists are coming out of school with debt estimates higher than you just stated, around $330,000 or more in debt. I have seen some new young dentists coming out at a million dollars in debt, plus the debt that they carried with them before they got into dental school.
When observing the typical current dental school tuition for a private school, and some state schools, most of them have tuition somewhere around $80,000 a year. In addition, they have to have at least $20,000 a year to live, so that means about $100,000 per year for tuition and living expenses. If they go into dental school with some debt already, you can see debt at graduation is a major challenge.
Is that going to be paid back by being a dentist? I will be candid again and say, not for several years. I predict it will take a typical young dentist at least five years to get out of debt to the point that they are making enough revenue to feel justified for their years of schooling.
However, I am very strong on my opinion that dentistry is still a fine profession for those who are seeking altruistic service to the public and a good income. New dentists can eventually make a comfortable income after graduation if they are skilled, but they must go into it with their eyes wide open. If they are married, their spouses should it will take several years of building a practice to become financially stable.
Dr. Doherty: If a young dentist came up to you after one of your seminars and said, “Gee, Dr. Christensen, I am really in tough shape here. I don't know what to do. How do you feel about me going into corporate dentistry?”
Dr. Christensen: Corporate dentistry provides for many dentists the exact kind of a vocational relationship that they desire. Many do not want the worry and hardships of administration of coordinating many employees. They would prefer to start each day at a given time, go home at a given time, and receive a consistent salary.
Many young dentists get out of school incapable of making adequate income without going into corporate dentistry. Corporate dentistry provides a means for further education past dental school, helping young dentists with building speed and learning techniques that were not taught adequately because of time constraints in dental school.
Overall corporate dentistry has had a bad reputation because of some shady groups that dominated the industry over past years. But there are numerous groups currently trying to overcome that sterotype. I was just speaking for University of the Pacific Arthur A. Dugoni School of Dentistry recently and I was highly impressed with how they are addressing quality of care and attempting to build the expertise of their young dentists to the level where they are productive as well.
Dr. Doherty: Are you endorsing Pacific?
Dr. Christensen: It is the largest one; it is an example of one that has been making great efforts to overcome the previously bad reputation of corporate dentistry. If you want to add another large one, I could say Heartland is.
Dr. Doherty: Have you done surveys on any of your audiences regarding seeing a drop in income as the ADA has said we have?
Dr. Christensen: Estimates are that gross dentists’ production is up somewhere around 10-12% last year. However, it also estimated that collections are down around 10%. Overhead has slightly increased over the last few years to about 61%, and unfortunately net income is at about the 1998 level. That's frustrating.
Profit per owner is up only slightly. This can be attributed to the fact that many patients have put off needed treatment and, therefore, they have not come in for cleanings or even for rudimentary aspects of dentistry. We think that this will correct itself because waiting too long requires more expensive treatment. Yes, there has been stabilization, of dental income and a reduction of net income for the dentist.
Dr. Doherty: For a more permanent solution, the word being used is collaboration. This solution would bring three dentists together in a business entity titled managed group practice. What are your thoughts on this arrangement?
Dr. Christensen: Corporate dentistry allows chief executive officers, and chief financial officers to bargain with dental manufacturers and distributors and to reduce the cost of running a practice. As a result, when corporate groups come to a small community where a private dentist does not have the same opportunity to buy product at a lower cost, the corporate teams can charge lower fees. There is competition present. Can a group of dentists ban together and essentially be a small group? Of course. Then, they have some bargaining power with distributors and manufacturers, and they can produce dentistry at a lower cost.
Dr. Doherty: What advice might you give senior dentists who have not had anybody knocking at their door for associate-ships? Is there anything that you see that a senior dentist might be able to do other than sell out to corporate America?
Dr. Christensen: I have had nine associates over the many years of my practice when I have needed to have an associate. I have contacted the dental schools in my area and asked the operative dentistry chairperson or fixed prosthodontic chairperson, who were their most competent students. Then we interviewed those students, hired them and brought them into the practice at a moderate income. We allowed them to stay on a temporary basis of one year. Some have stayed longer than that; some have not. Some of them work out very well. I must admit, however, that out of the nine that I have had, only half of them turned out adequately.
Dr. Doherty: What would you like to say about dentistry ten years from now?
Dr. Christensen: Let us discuss some of the clinical areas and provide my ideas for you. In endodontics we are going to see continued improvement in debridement, better disinfection, and better sealants. All three of those areas are somewhat deficient right now. We need a simpler, easier, faster way to do endodontic procedures because this area will continue to grow.
In orthodontics, digital impressions will begin to dominate, and casts that are digital instead of being handheld stone casts that we have seen in the past will increase. There will be more planning done by computer orientation.
In fixed orthodontics we are going to see digital impressions begin to dominate soon. I do not think milling in clinical offices will grow rapidly. Milling in labs will be the future. Currently, there is no question that labs without milling machines are going bankrupt. We will see digital impressions sent in, and the milling done in the lab. The next advance in that area will be 3D printing. It is already present in most large labs. I predict this will happen in the next ten years. We see fixed prosthodontic procedures are dominating prosthodontics. Use of metal is rapidly dying, not only due to the cost, but also because of the allergic.
In oral surgery we are going to see a similar situation as is now present. Currently, general practitioners are doing the majority of routine oral surgery, with oral surgeons dominating in other more complex areas.
Pediatric dentistry will still need major preventive procedures and restorative dentistry, although some countries have reduced the amount of pediatric restorative procedures accomplished for children. That has not been common. Pediatric dentistry will be greatly in need in the United States. There will be more involvement with orthodontics and pediatric dentistry as more pediatric dentists are doing orthodontic procedures.
Dr. Christensen: In periodontics there will be more acceptance of a systemic disease connection with periodontal disease. Proven disease, stroke, and diabetic relationships to periodontal disease encourages patients’ physicians to become interested in dentistry because of the mouth being the mirror of the rest of the body.
Removable prosthodontics is still present and is larger than some have estimated. There are about 35-40 million edentulous people in America out of 200 million adults. It's time to recognize that this need is not going away. People are aging, and losing their teeth. The longer they live, the more teeth they lose and we will still have removal prosthodontics as a significant part of dentistry. We see right now a change to digital dentures. Digitally oriented dentures are those for which the dentist makes a conventional impression and then milling is done of the denture.
Implant dentistry, I am embarrassed to talk about implant dentistry. We are so behind in many areas and this is one of them. In some of the developed countries where I speak, most general dentists are placing implants. In America, implant placement by general dentists is much smaller. I’m concerned implants are portrayed as a significantly difficult procedure. I will candidly say that after 35 years of doing implant placement that placement of a single implant (and that’s 90% of implants), in a healthy person with good bone, is about the same difficulty as a class 2 composite resin procedure. Until we recognize the relative simplicity of implant placement, we are lagging grossly behind many other developed countries. We need to get into more involvement with implants because of the 200 million adults in America 178 million have one or more missing teeth. It is certainly time to wake up to this deficiency.
Radiology? I predict that in 5 years cone beam will be state of the art. It will gradually become the standard of care which is a legal terminology stating if we are not doing it and something goes wrong, we are remiss. I see cone beam as being a significant adjunct in any oral surgery procedure, implant placement and endodontic treatment, as well as in planning of complex cases.
Operative dentistry is not going away. We need improved restorations including the composites that we have today, improved ceramics, and better overall knowledge about how to place restorations. There is still a major need for meticulous operative dentists.
Dr. Doherty: You mentioned implants. What are your thoughts on mini implants?
Dr. Christensen: The FDA cleared mini implants (1.8 to 2.9mm in diameter) in 1997. They have proven similar clinical acceptability to standard diameter (3mm and greater diameter) implants when placed properly. Small diameter implants have an excellent ability to serve those people who do not have enough bone for standard diameter implants. I have been placing them for 14 years with success, and I have become fairly upset when I hear some people say there is something wrong with these implants. They are the same materials and have the same service potential as larger implants, they are just smaller.
Small implants 1.8 to 2.9 millimeters in diameter or conventional diameter implants of 3 millimeters to 6 and 7 millimeters in diameter are comparable in their ability to serve. The smaller the implant, the more implants are needed to support the given load. Every dentist should be well aware that proper home care is necessary to maintain these over a long time.
Dr. Doherty:Do you want to comment on detecting perio? What do you think of that?
Dr. Christensen: Proper use of periodontal probes is still the gold standard for evaluating periodontal disease. There are numerous electronic and mechanical periodontal devices that have been around for twenty years; some of them are good and some of them are bad.
Dr. Doherty:Okay, we are down to the last section “The Next Big Thing.” What is the next big thing coming to the profession?
Dr. Christensen: Most dentists are not aware that corporate dentistry is growing so rapidly that it will gradually dominate the profession, reducing solo practice. I don’t have many reservations in saying that; many of the younger dentists do not desire to have a private practice, and they want a more controlled and predictable life. Corporate dentistry is providing major services with lower fees; however, as I said before, it is challenging the private practice sector, which does have higher overhead expense. We are going to see corporate grow very rapidly. Solo dentists need to associate with other dentists to form small groups that can bargain with distributors and manufacturers and provide quality dentistry at a lower cost. We are a health service; we are not a hobby for the elite.
Dr. Doherty:Are you for or against sales of dental products on the Internet?
Dr. Christensen: At the present time, several of the large Internet retailers are making contracts with dental manufacturers to sell dental products. The typical dental distributors--there are half dozen fairly sizable ones--are concerned, and many practicing dentists are concerned about this, too. They are concerned because when purchase of products from a company that may or may not have adequate knowledge of what they are selling, can provide significant challenges for the dentist consumer, and therefore, the patient consumer. I don’t know how to predict this one. It will happen; it’s happening as we speak. We will wait to see how this can be controlled and if the companies, the Internet retailers who are now promoting this idea, can provide adequate information to satisfy the needs of the practitioner. We will see.
Local distributors, such as Henry Schein, Patterson, Benco, Goetze, Burkhart and others, which are well known to everyone reading this article, are able to provide educational information to dentists. They can provide information about which materials, devices, and concepts that are working, and which are not working. Can we provide this through the Internet? That is a very controversial point. At this point in my mind, it is doubtful.
About Dr. Gordon J. Christensen, DDS, MSD, PhD
Dr. Gordon J. Christensen is founder and director of Practical Clinical Courses (PCC) and chief executive officer of Clinicians Report Foundation in Provo, Utah. He has presented over 45,000 hours of continuing education throughout the world and published many articles and books.
Dr. Christensen and his wife Dr. Rella Christensen are co-founders of the nonprofit Clinicians Report Foundation (previously CRA), which Rella previously directed for many years. Since 1976, they have conducted research in all areas of dentistry and published the findings to the profession in the well-known CRA Newsletter, now called Clinicians Report (CR). Contact information: (801) 226-6569 or firstname.lastname@example.org