Embrace Progress: The Pendulum and the Next Opportunity by Daniel Grob, DDS, MS, Editorial Director

Parents, practitioners and seasoned educators alike will probably acknowledge that attitudes and practices seem to change with time. This may take days, months, years or generations, but what's important to note is that things do change.

This is true in industry, as well—including dentistry and orthodontics.

I've been fortunate to have lived and practiced during many of swings of the pendulum from one stance to another. Each industry has its own timeframe defining how far or for how long a seemingly "new thought" is present and predominant in the mainstream; then, predictably, the thought seems to change or, as they say, history repeats itself.

Have you noticed any in your lifetime? The recent election certainly exposed a change in attitude of a good portion of the voting population. Look back many years, and generational changes have occurred spanning many decades.

The turbulent 1960s are, as far as I can remember, where social issues and government dissatisfaction was the most rampant. The '70s brought us back from a period of depression—or, as Jimmy Carter put it, "the era of malaise"—only to be reinvigorated with the '80s and renewed optimism. The turn of the millennium was filled with go-go times, as the real estate, practice and stock market valuations peaked. Many of the metrics to measure business and assets were discarded, only to be validated once again after the turn of the new century. Even the topic of globalism and nationalism has been visited before in our country's history.

Are you noticing a similarity?
Dentistry also has been swinging like a pendulum. Treatment planning, techniques, even materials have their own way of returning in and out of favor. These changes in philosophy are brought about with new energetic practitioners coupled with research and development.

One example I can think of is vertical dimension. The preponderance of thinking in my time was that vertical dimension could not be altered. Only a few rebels would dare tinker with this fundamental measurement of a patient's occlusal scheme. Then practitioners began opening the vertical dimension. Currently, there seem to be programs and practitioners lecturing on the benefits and steps involved in evaluating patients for opening the vertical dimension brought about by occlusal wear and cosmetic concerns. Many of us ask if it will last!

The value of insurance is a potentially emotional one with financial considerations.

At one point, having an agreement with an insurance or dental plan company was potentially disastrous. Insurance was the "patients' responsibility," the saying went.

Lately, except for some unique cosmetic practices, the existence of insurance and even the in-house offerings of closed panel dental plans in individual and group practices is commonplace.

The orthodontics pendulums
The first and most obvious example in orthodontics is the extraction debate. Angle, Case, Beeg, Tweed, Roth, Rickets, McLaughlin and now Damon have all had their say. I'm sure anyone who has attended an orthodontic residency program has been made aware of the science, philosophy and research behind the debate about removing permanent teeth, but this advantage is not shared by "weekend warriors."

Surgical intervention is another topic swinging in and out of favor. The decline in surgical intervention has in part been a result of decreased insurance reimbursement as the value of surgical orthodontics has been called into question as a medical necessity.

I have been in practice long enough to have witnessed several dozen "latest, greatest" orthodontic appliances. Torque-in-base, in-face, single-tie-wing and edgewise …yes, I've seen most of it. Self-ligating appliances were almost a cult years ago. The latest I get from the field and in talking with seasoned and thought-provoking practitioners is that while benefits are plenty, the feeling that self-ligating appliances would overtake the profession are premature.

My business partner used to say that the discussion about early versus one-phase treatment was a lifestyle decision—namely, that of the orthodontist! I would agree that busy-ness sadly influences the decision to initiate care on some patients; however, the pendulum is swinging in favor of early treatment because of recent revelations regarding airway, muscle therapy and the need to intercept childhood sleep apnea. All positive developments for the orthodontic profession and the patient!

One's place of practice or office is a topic for discussion. There was a time when the key to success was to move to where you wanted to live and purchase an office—build a practice with the intent of selling the practice, and eventually renting the office to the new practice buyer. Currently, this business model is not a guarantee to success in many of the "corporate competition" markets around the country.

In fact, if one looks at the business model of the corporate, private-equity-financed dental practices, they rarely own their own property. Instead, they rely on highly visible retail locations, which for years have been shunned by individual practitioners. However, the owner of these practices is a different animal. Most are owned by a distant Wall Street organization, focused on the "excess" profits being distributed to the owner dentists. They are concerned with rapid growth to justify business valuations and investment by third parties.

Now dentists are hopping on board the buyout craze. Like most things medical and dental professionals are guilty of in business, it may be too little too late: Do the numbers support many of the transactions that are occurring behind the scenes leading to the corporate buyout of the dental profession? After years of Wall Street-led buyouts of dental practices whose financials make it difficult to justify valuations, the current business environment is defined by who has the patients. (It used to be who has the facility.)

What's a practitioner to do?
During my practice tenure in another city, my partner and myself were involved in nine different office settings located in three distinct parts of the community. Each one of them was an opportunity we seized either professionally or investment-wise that ensured our success. Whether it be landlord givebacks or a practice opportunity because of a vacuum of providers, we were constantly looking for these situations. Almost the entire 28 years of practice was experienced without debt.

I'm sure that within several years after a relative drought of new facilities being built, the tide will change and again favor the practices whose infrastructure is geared to manage and treat patients, but for the time being it appears as if the patients are the driving force, many being manipulated by offers, plans and other than treatment outcomes to determine care.

As I mentioned, the pendulum swings either because of scientific evidence or disruptive technology are a part of progress. Will changing opinions and treatment philosophy be a part of practice forever? Yes!

What will be consistent throughout our practice lives is one simple fact: My mentor, Russell Kittleson, stated that people can see what they want in a straight smile and they will continue to seek out care. This is strengthened by the fact that population is increasing, which means there will be a constant demand for our services.

I'd like to paraphrase my tennis partner, a surgical ophthalmologist, who said something while we were discussing the changing landscape in practice of medicine and dentistry. "At the end of the day, it's how many eyes I fix. Some pay more, some pay less, but it's the number of eyes that determines my practice success."

So too is it the number of smiles—starts, if you will—that will determine your practice success. It's up to us to define the market, business plan and treatment to address potential patient needs.

Hopefully you'll ride the pendulum in the right direction!