Embrace Progress: Don't Be Just Another Bracket in the Wall by Dr. Daniel Grob

Dentaltown Magazine

by Dan Grob, DDS, MS, editorial director, Orthotown magazine

We don’t need no education! (Actually, we do.)
I often find myself writing my monthly column while flying home after a CE meeting, relaxing and reflecting during the plane ride—listening to Pink Floyd this time and enjoying some wine. It seems like this is always the time to compose my thoughts about being thankful for having ended up in one of the best professions in the world. Who else gets to keep working, learning and sharing at this age while balancing time with family, friends and colleagues?

During the past few years, I’ve turned into somewhat of a continuing education junkie, trying to shake the old habits while making room for new ideas and techniques. It’s obvious that at my age, people have the tendency to be set in their ways, and if they’re not open to new ideas, they quickly turn into dinosaurs—not just ancient but also mostly irrelevant.

While the basics of orthodontics— namely growth, cooperation and habits—have remained stable for more than a century, new views of many past ideas and techniques for evaluating success and failure have led to new processes. Some of the most obvious pertain to treatment timing and length of care, creation of an aesthetic smile, and the views of tooth removals.

I belong to several online groups in addition to Orthotown, and many of these topics are continuously raised. I’ve spent some time recently addressing my view and the changing view of Phase I treatment. Suffice it to say, I am performing more Phase I treatment for several reasons, not the least of them being available cooperation, airway health, and the ability to consolidate Phase II treatment into a smaller time frame (leaving the possibility open for aligner, fixed or other removable treatment at a later date).

Running over the same ground
The topic of length of care is receiving much attention, whether in online comments, discussions at CE meetings or articles in all the major ortho journals.

We’d all agree that it is possible to treat many malocclusions in a shorter period of time than was thought possible. The incorporation of new technologies, techniques and materials has led to this new reality, and this has had enormous effects on facility size and design, staff and finances.

The most obvious, of course, is the immediate perception that shorter time leads to lower fees. In many situations that could be the case; however, the fixed costs of performing orthodontic care have not been reduced. In many situations, fees have increased as a result of newer, more expensive technologies. Facility, materials and staffing percentages, as a portion of revenue, are all up, and patients are demanding better service and results, which all require a big spend on infrastructure and appliances.

One factor that is not discussed much but was highlighted during an American Association of Orthodontists lecture by Ken Alexander is the valuation metrics for practice. When the practice I was a part of was sold many years ago, the accounts on the books were valued by a formula designed by Thomas Ziegler, which factored payments being made by patients for a couple of years into the future. This figure, in turn, was to be financed quite easily as “seasoned” paper for potential buyers.

New techniques, laboratory costs and a paradigm shift in the orthodontic professions has skewed this formula in a different direction. Gone are the large account balances of the past corresponding to months remaining in care. Gone are the current patients from the office who were expected to linger for a few years in the facility.

The modern orthodontic practice is geared toward treatment of Phase I and Phase II (or around a year or so), leaving a lot of the account balances collected or financed for longer periods with no contact with the patient. The new practices are sold and leveraged perhaps not on the money on the books, but on the marketing expertise of the practice to keep the patients coming?... or some other means of retention.

Also, many practices participate in PPO insurance contracts that change from year to year, making stability not what it was in the past. How long will it take insurance companies to see that treatments are being completed in less than two years to start varying their benefits accordingly?

Not the end of the world, but these are important factors going forward.

You run to catch up with the sun, but it’s sinking
On a separate note, while vacationing this summer, my wife and I had the opportunity to attend a relatively elaborate wedding in France. While that is not the story, let me just say that in addition to my wife, there were some incredibly attractive women and men in the group. What struck me was the smiles of those in attendance.

As you can imagine, most had straight teeth. However, what was noticeably obvious was the difference in the smiles. You probably can guess where I am going with this.

Some were large and brilliant, some of course have been created out of porcelain?... but some were hardly to be seen. In the group of attendees, varying in age from mid-20s to late 60s, sharp distinctions could be seen between those who had been orthodontically treated by different philosophies and practitioners. Need I say which one I prefer?

It is apparent that just “straight teeth” is not the answer to creating a beautiful smile for life. Plaster on the table won’t cut it any longer. Dr. David Sarver has created, years ago, a wonderful video showing the changing face as we age and mature. It is worthwhile to watch this if you have any doubts when deciding how to treat young children and teens.

It’s tough staying in practice so long and seeing what is changing in front of our eyes. But now that the orthodontic profession has entered its second century, it behooves us all to react and alter our philosophies and benchmarks for what is stable, beautiful and functional—and relevant.

Kicking around on a piece of ground in your hometown
One last point: I learned that in October an Invisalign store will appear in my neighborhood. The basic business plan, from what I can ascertain, is to market directly to patients, scan them in the store and then refer them to “partner” orthodontists in the area. Patients are going to be given, in most situations, a choice of (possibly three) options for treatment and a fee structure to match. One, which includes no attachments or IPR, will be the most basic offering for a relatively low fee. A fixed fee will be available to those orthodontists (or dentists) accepting the patient.

A second option would include more aligners—a reboot, if you will—and IPR and attachments. The third option—what most of us would call “the unlimited plan”— involves what many patients really need these days. Fees are, from what I can understand, unlimited. The traditional doctor–patient relationship appears to be more evident in this final option.

There can be many benefits and pitfalls to these options, and we would all agree that the direct-to-consumer market is still evolving. From just reading my brief summary, I’m sure that you can create a list of questions, problems and advantages that will unfold during the next several years. And without a doubt, all interested parties involved will be watching closely.


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