How ortho is changing dentistry

March 29, 2017

Orthodontics is an arena more accessible to general dentists than ever. So how are general dentists embracing this trend-and what challenges have they found?

When the general public thinks about orthodontics, they likely still have an image of an awkward teenager sporting a mouthful of metal, hoping for the day when she can chew caramel again. But for many general dentists, that image is not only archaic, but it bears very little similarity to what they can do for their patients-and, for many general dentists, what they can do in their offices. 

More adults than ever before are requesting orthodontic appliances, and while there are a multitude of benefits for improving tooth alignment and occlusion-such as better oral health, improved digestion and reduced headaches, just to name a few-it is largely thanks to the improved esthetics of invisible orthodontics that adults are requesting it. In fact, the invisible orthodontics market is expected to grow by 13 percent in the next five years-twice the rate at which dental imaging equipment is anticipated to grow in the next few years (6.8 percent), according to one study.1 And it is thanks to companies like Invisalign or Progressive Orthodontics Seminars that more general dentists are offering it. 

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Age of the patient and whether the dentist is a specialist are no longer considerations for orthodontics. What was once reserved for gangly, acne-ridden teenagers as just another impediment on their quest for status is now the hard-earned reward for dissatisfied adults who have a couple thousand dollars to spare. 

It is widely accepted that adding procedures, performing more high-profit dentistry and adding new patients are solid steps on the path to increasing practice revenue. With orthodontics, a general dentist can do all three at once. By adding orthodontics as a treatment option, dentists offer a low-cost, high-profit procedure. Case acceptance goes up, along with referrals, and no marketing is necessary. It seems like a win-win scenario. 

After all, orthodontists have years of education on the specialty; what makes general dentists think they can grab a piece of the pie just because they want to?

For one: they kind of have to in order to stay competitive. And for two: Despite the common one-day training programs, comprehensive training programs do exist. Those programs, offered by organizations like Progressive Orthodontic Seminars (POS), the United States Dental Institute (USDI) and the Academy of Gp Orthodontics (AGpO), aim to equip general dentists with the tools necessary to perform more complex orthodontic cases. 

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Whether those programs compare to years of studying orthodontics in school is inarguable. But the onus is on the dentist to accept cases that require the skills in which they are confident and to refer those that are out of reach. 

One thing that helps to bring more procedures within reach is new technology. General dentists can now perform simple surgery, thanks to surgical guides. They can print their own chairside restorations, thanks to milling machines and advances in 3D printing. So why not do ortho? 

“The fact of the matter is that esthetically, orthodontics is a fairly minimally invasive way to get fantastic results,” says Amisha Singh, DDS, a practicing dentist in Denver. 

Dentists know that offering invisible orthodontics is a great way to grow their business. It’s becoming more popular for new dentists to use ortho as a primary method of increasing revenue. “It used to be four or five years into their practice before they took the course,” says David Dana, DDS, education director at Progressive Orthodontic Seminars. “Today, I’m seeing newer graduates coming into the course.” 

 

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Options in invisible orthodontics

Invisible orthodontics encompasses clear aligners, such as the highly popular Invisalign and ClearCorrect brands, as well as ceramic, clear and lingual brackets. The more attractive option from the patients’ perspective is a clear aligner: the appeal is that nothing is attached, they can be removed at any time, they are easy to clean and they are virtually invisible when worn. The downside is that many experts feel that clear aligners are best for simple restorations such as minor crowding or orthodontic relapses. 

According to a study in theAmerican Journal of Orthodontics and Dentofacial Orthopedics2 that compared Invisalign to braces, Invisalign did not treat malocclusions or large anteroposterior discrepancies and occlusal contacts as well as braces in the sample study. Its strengths were “its ability to close spaces and correct anterior rotations and marginal ridge heights.” 

Many young people are finding their way back into the realm of orthodontia, paying for their mistake of inconsistent (or non-existent) retainer use. But it’s unclear just how many patients in the U.S. wear some kind of clear aligner. Invisalign claims 3 million patients, while ClearCorrect claims 15,000 providers. Then, of course, there are the doctors who make their own aligners with a chairside CAD machine

The benefit of clear aligners is that training is simple: general dentists can start treating patients after a one-day training program, in the case of Invisalign. With ClearCorrect, the training is online. And both offer online content as a constant resource. 

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“Invisalign has hundreds of hours of recorded, free CE for dentists to watch, from seminars all over the world,” says dentist Jason Watts, DMD, of West Cape Family Dental in Cape Coral, Florida. 

Meena Barsoum, DDS, owner of Impressive Smiles in Chicago, appreciates that he is in charge of the training schedule. “ClearCorrect’s program is based on your time,” he says. “They have a web portal that includes videos, articles and tutorials to get you started. You follow along at your own pace.” 

There are also no materials or tools to invest in: just the cost of the trays themselves. Dentists can take impressions with whatever material they already have and then send the digital scans directly to the manufacturer. Intraoral scanners make the process even easier. 

“It’s cost effective,” Dr. Watts says. “All you really need is an impression tray and PVS material. You don’t even need a scanner. You can take photos with a handheld, iPhone or professional camera. You send the pics into Invisalign, coordinate the technology and pay the fees. 

“Once you send the case to Invisalign, their lab techs help you design the ClinCheck. It shows you the alignment of how your patient’s teeth are going to be structured and how many trays you’re going to have. We can edit that as we please because we as the dentists are the drivers of the treatment. We approve the treatment, they cut the aligners and you just need some flowable composite. So your returns are anywhere from 250 to 400 percent, depending on how much you charge.” 

Dentists can expect to spend about $4,000 on training and the aligners for their first three cases with Invisalign. The return on investment is immediate: the average cost of one patient’s case is $5,200. 

Competition is strong between Align Technology (makers of Invisalign) and ClearCorrect, but the differences in their training styles and indications are notable. 

 “I do mild to moderate cases that are done in six months or a year, so ClearCorrect was more cost effective for our practice,” Dr. Barsoum says. “We don’t get into open bites or extrusions or any complex occlusion changes.” 

Dr. Watts is doing more complex cases-the kinds of cases that orthodontists would feel comfortable doing. But he is confident that he has the training and skills required to complete the cases successfully. 

“It’s like riding a bike,” he says. “You want to start off with safe, Class I cosmetic cases and then you take the training wheels off and go. Once you’re on your own, you can experiment with smaller movements and minor turns before you start poppin’ wheelies.”

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“Wheelies,” in Dr. Watts’ case, include Class II bites, distillation and occlusion. “I’ve taken on more advanced cases than simple alignments,” he says. “As you educate yourself further and take the necessary CE and ask questions, you start to understand the process, mechanics and fundamentals more and more. The cases become more selective and the success is 100 percent if you pick the right case.” 

When it comes to revenue, Class I cases are sufficient and common. And there are plenty of people who missed the boat for orthodontics as teenagers but could benefit from simple alignments. 

“I’m trying to stick mostly to crowding and mostly young adults who are comfortable with their bite and might just need some crowding fixed,” says Leah Capozzi, DDS, owner of Metropolitan Dental in Buffalo, New York. “I had a 68-year-old woman who wanted straight teeth for her 50th high-school reunion, so clear aligners were perfect for her. I also had a patient in his mid-60s who was unhappy with the alignment of his teeth. These patients would probably not even consider going into metal braces, but clear aligners give them that more cosmetic option.” 

But there is more to invisible orthodontics than just clear aligners. Some of the big players in ortho-such as 3M, Dentsply Sirona and Ormco-all offer ceramic and lingual braces. Ormco also offers clear brackets for another esthetic option. For dentists that want to take on more complex cases and are ready to invest in training and materials, these more traditional options might be a good idea.

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The return on investment

Progressive Orthodontic Seminars, the United States Dental Institute and the Academy of Gp Orthodontics all offer “comprehensive” weekend training programs for dentists that span a period of two years. Topics covered range from how to diagnose and treat “bread and butter” cases to what to know about vertical dimension. To compete with training programs for clear aligners, POS offers a one-day introductory seminar, while USDI’s includes an Invisalign certification at a reduced cost. 

These comprehensive courses train on both brackets and aligners, which means that dentists have the option to expand into one or the other upon completion of the course. The cost of training is significantly higher than that required to use clear aligners, but the cases are also more complex (and more profitable). Then again, it’s nothing compared to the $100,000-plus tuition that orthodontists are responsible for. 

The cost ranges from $10,000 to $20,000 over the two years, but the organizations all assert that the return on investment is solid. POS even claims that general dentists can break even after 10 cases. Because of that return, it’s a great way for dentists to drastically increase their revenue. 

“In my own career, it took me about six to eight years to add orthodontics into my practice,” Dr. Dana says. “If I could do it again, I would start doing ortho as soon as I started my practice.”  

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Adding ortho as a revenue stream is catching on and recent graduates are on top of the trend. 

The initial investment when working with traditional orthodontics materials is between $7,000 and $18,000, according to POS. General dentists will have to invest in building an inventory of orthodontic tools and materials. “The orthodontic tools are a little different than what most general dentists have, like sets of pliers, wires and brackets,” says Dr. Dana. “The initial investment is about $10,000, but that is enough to get any general dentist going.” 

Altogether, the investment in materials and education for a traditional, comprehensive ortho training program is between $20,000 and $40,000 total. While that number may certainly seem steep, there are two cushions: the time it takes to spend that much (about two years) and the chance to start making returns almost immediately. By offering orthodontic treatment just a few months into the course, dentists can start making their money back before they have spent most of it. How much money? That depends on how aggressive the approach is. 

“It all depends on the practice and how many cases they’re willing to take,” Dr. Dana says. “In my situation, I was willing to take as many cases as I could. Within one year, I recovered all my education investment, which was about $20,000 for tuition plus expenses (such as traveling) over two years.” 

He more than recovered the investment. Because Dr. Dana had 200 active cases at any given time, he claimed a revenue of $1.2 million that year. But a general dentist who wants to take a more relaxed approach to ortho could still garner a hefty sum. Taking one ortho case a week, at $3,000 per case (the low end of the spectrum), facilitates a return of $150,000 a year. 

That is not just POS’s math: USDI asserts that dentists can add $200,000 a year with ortho. The math is simple. The average material cost per case is under $500. With a typical markup of 600 to 1,200 percent, dentists can earn $2,000 per orthodontic hour. 

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Here’s a hypothetical: A general dentist is interested in taking the occasional, straightforward ortho case. She is looking for relapses and adult cosmetic procedures, focusing on those Class I cases that she can wrap up within eight months or so. 

To really understand the potential, let us say she spent $40,000 on her orthodontic education and startup materials: the high average. And we’ll say that she charges the low average of $3,000 per case. (And remember that she spends less than $500 a case on materials.) She has a lax approach to recruiting her patients to do ortho, so maybe she gets two cases a month. 

She still profits by $20,000 within her first year of offering orthodontics. 

Using the same formula, but for a dentist who trained on clear aligners, the number is about $72,000 in annual revenue from ortho. The estimated revenue from two cases per month at $5,200 (the average) is $124,800. 

 

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How tech facilitates GP orthodontics

Although it is possible and common to take impressions for ortho, new technology such as CBCT and intraoral scanners simplifies the workflow. 

The dentist can take a scan and immediately view the results in his ortho software. From there, he can plan the treatment and then 3D print the appliance or model, or the send the digital file to his preferred lab (thanks to the open STL files) and wait for them to send the appliance back. 

The benefit is not only a quicker, more efficient workflow, but also improved patient perception. 

“Obviously, there are many clinical benefits, such as faster impressions and the ability to send digital files,” Dr. Barsoum says. “But what some companies don’t understand is patient perception. Our patients don’t want impressions because they’re not used to it.” 

Dr. Barsoum attributes his practice’s growth to expanding his services and using more technology for the benefit of the patient. 

“We designed everything around technology and that’s what I attribute to our growth: using technology to provide better care and better understanding for our patients,” he says. 

Technology improves case acceptance in several ways: By presenting your office as cutting-edge, patients may perceive your skills and knowledge to be higher. They also appreciate the comfort that technology brings to standard dental procedures. It also improves patient education, since you can show instead of tell. 

That reaches beyond showing them the current state of their oral health: dentists can also show them the potential state of their smile with a photo mockup of their teeth after treatment. 

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It also keeps patients from changing their minds. “If a patient needs crowns or fillings, you usually want to do it before [orthodontic] treatment is started,” Dr. Watts says. “It’s hard to do fixed work like crowns while they are wearing aligners because they might not fit trays. That’s why having an in-office milling unit is great. Instead of prolonging the case to deliver the crown, you can do the crown that day, take the impression right after and then schedule the next appointment when their trays arrive.” 

Getting the ball rolling keeps patients from second-guessing their decision, says Dr. Watts. 

“Patients are more likely to reconsider treatment that is costly once they leave the office,” he says. “The longer someone has to think about something and analyze it, the less likely they’re going to want to do it. Milling can aid in orthodontic treatment because you can do restorative work faster.” 

Orthodontic software is comprehensive, making it easier to plan, analyze and track cases from beginning to end. Pretty much every major manufacturer offers software to help with the orthodontic workflow, so the process can be completely digital, at least for cases indicated for clear aligners. When used in combination with CBCT imaging or an intraoral scanner, orthodontic software replaces the need for extra inventory such as plaster and saves time. There is no need to produce, ship or store traditional stone models. 

“I can attain an STL file of the patient’s teeth and import them into the newer software to virtually move the teeth and virtually place the attachments,” says orthodontist Jack Fisher, DMD, owner of Artistic Smiles Orthodontics near Memphis. “The software then tells me how many aligners are needed. I import them into the 3D printer and print out the models. We then construct the aligners in our office.” 

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Certain companies partner their software with clear aligner manufacturers, such as the partnership between iTero’s OrthoCAD and Invisalign. The partnership allows dentists to send their scans either to their preferred laboratory or to Invisalign. Those files can be used for a variety of products, from orthodontic appliances to printed models. 

ClearCorrect is in partnership with CEREC, although they have their own web-based software. The benefit is that dentists can use whatever browser and computer they prefer. 

Digital files replace physical storage in the dental practice, but they also enable digital analytics, such as teeth width, space, overbite measurements, jaw alignment, arch length and other data points, helping any general dentist determine and analyze relevant details in each case. 

Orthodontic software’s open STL files improve communication among dentists as well as between dentists and laboratories. 

“Let’s say I need a fixed retainer,” Dr. Barsoum says. “We’ll use our CEREC Ortho scan and send it directly to one of our orthodontic labs and they’ll fabricate the final appliance based on our scan. The labs like it because they get a clean digital impression that they can print or modify and it can be turned around really quickly.” 

 

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The functional benefits of ortho

Providing orthodontics as a general dentist is about more than increasing revenue, of course. Many dentists find that having that extra service as a solution to their patient’s functional issues is a major benefit. 

“People look at aligners as an esthetic solution, but there are definitely biological and periodontal considerations that we have to make when we’re making that treatment,” Dr. Barsoum says. “It goes way beyond making your teeth look good. Crowding, especially of the bottom teeth, makes it harder to maintain healthy gums and teeth because it’s not a natural position. We’ll take photos of our patients’ teeth and educate them on why aligners would be a benefit for them and we continue to take photos throughout the process, showing how much healthier their gums are and how easy it is to maintain that health.” 

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“Because I’m a general dentist, I see a lot of patients with wear on their teeth, which might be related to the position of their teeth,” Dr. Capozzi says. “If I’m going to ask you if you’re clenching or grinding your teeth, I want to have available treatment options. If your teeth are out of position or you’re getting recession, we can discuss a mouth guard and clear aligners because they are services that I provide.” 

For many general dentists, the option to tackle the cause of the problem, rather than treat the result, is a major consideration. By keeping teeth healthier longer, dentists can avoid temporary options like restorations and veneers. Patients get the benefit of improved oral health and stronger teeth, which impacts digestion, stress, headaches and the health of supporting tissue. 

Is tech harming ortho? 

The benefits of improved function are not enough to earn the blessing from every member of the dental community, however. Technology, opines Dr. Fisher, does not make orthodontics easier: It makes it more difficult. 

“If I were a general dentist, I would not consider doing aligner treatment or brackets on patients for orthodontic purposes,” Dr. Fisher says. “Now that we can see the roots in 3D, we can see all of our mistakes with aligners and brackets. It is extremely risky for a general dentist to place braces and not even consider the placement of the roots in bone by evaluating with 3D imaging.”

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It is interesting to note that general dentists are not any less likely than orthodontists to use 3D imaging as a tool to evaluate root placement. Dr. Fisher himself claimed that only 2 percent of orthodontists in America use 3D imaging to diagnose their patients-a sign of what he calls an “education deficiency.” 

The solution is training, says Dr. Dana. “With proper training, general dentists can do whatever they want,” he says. “It’s like anything else: if you learn it and you do it, you master it. The main concern is confidence. But the truth is that anyone who can do dentistry can do orthodontics."

 

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The importance of mentors

Education, of course, is merely the first step. It is just as imperative to have mentors in the field and to be honest about your expertise and limits as a dentist. 

“The more we are able to collaborate with general dentists, specialists and labs, the better our final treatment for our patient becomes,” Dr. Singh says. “Gone are the days of waiting for a response. We can have conversations about the patient’s care and send digital visual markers for our discussion in real time. That helps the general dentist significantly because they can use the specialist’s knowledge to help build their own scope of practice while still being able to refer the more difficult cases. It also helps with diagnosis because now we can see right away which cases are difficult.” 

Knowing when to refer is crucial, but it’s also important to have guidance from expert peers in order to continue honing those specific skills. 

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“I have a great orthodontist that I work with and that I refer cases to that are beyond my comfort level,” Dr. Capozzi says. “If there are cases I’m not sure about, he’ll sit down with me and go over the case before I start.” 

“It is so important to be comfortable with your skills,” Dr. Singh says. “My advice is to take comprehensive orthodontics continuing education courses until you feel comfortable. Most of all, know when to refer. If a general dentist attempts a very complicated case, it is easy to go from having orthodontics as a practice grower to a practice tanker.” 

All dentists vow to continue studying for the rest of their careers. Dr. Capozzi favors learning from those around her. 

“Working closely with the people you’re referring to allows you to get better results for your patients,” she says. “And for me as a younger general dentist, it helps me learn. Who would you rather learn ortho from: your computer or a specialist who went to school for three years for it? I wouldn’t have the confidence to do what I do if it weren’t for those specialists that I can work with.”

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In the end, orthodontics is going to continue to grow. It has already been planted in the offices of general dentists, so there is no sense in trying to contain it within the walls of orthodontists’ offices. The most responsible and realistic option is to focus on education and have a solid sense of one’s own limitations. 

“In everything we do in dentistry, the better trained you are, the less risk you have,” Dr. Dana says.