Orthodontists spend most of their working hours in their practices, so they usually don’t get many opportunities to see what it’s like inside another doctor’s office. Orthotown magazine’s recurring Office Visit profile offers a chance for Townies to meet their peers, hear their stories and get a sense of their practice protocols.
In this issue, we visited Orthotown’s own editorial director, Dr. Daniel J. Grob, a seasoned orthodontist who recently teamed up with a pediatric dentist in Peoria, Arizona, to expand his offerings, provide joint consultations and ultimately shake up the orthodontic industry. Learn how this unique partnership works for Grob and what working with a pediatric dentist has helped him learn about the industry.
What inspired you to become
an orthodontist? How long have you been practicing?
I took the long, circuitous way into the profession. After graduating from dental school, I entered a two-year prosthodontic residency in Milwaukee and then became an assistant professor at Marquette University in prosthodontics. I was charged with staffing the county hospital dental clinic where conventional and maxillofacial prosthodontics were performed.
Because I was single and had a lot of energy, I was encouraged by Dr. Charles Bohl, a dual-trained prosthodontist and orthodontist, to pursue orthodontics. After my training, I joined him in practice for two years before I got married. My wife, Nancy, and I decided that we wanted to live in an area where we could have a swimming pool. I joined one of my best friends, Dr. Mark Donovan, in Tucson, Arizona, where we had a successful three-office, 35-employee practice for 28 years. After the sale of that practice, Nancy and I moved to Scottsdale, Arizona, where the summers are hotter, the traffic is more congested and the air a little hazier. We love it! One thing led to another and, lo and behold, I was practicing in a facility that has been an orthodontic office for more than 30 years, serving three different practices and doctors! I populated it with patients from a family corporate practice that made the decision to not continue with orthodontics.
You just recently started sharing space and working with a pediatric dentist, Dr. Robert Matthews. What’s that like?
I’ve always enjoyed practicing with many people surrounding me. Whether it be doctors, staff or patients, activity keeps me going and it fuels my energy. As a seasoned practitioner who has done the independent practice thing for years (with a business partner), I can say that the environment is different in this sharing situation. Much like an orthodontic practice, there are many staff, lots of delegation and lots of activity. The beauty of practicing in this situation is that the parents are very concerned about their kids’ dental condition. As Robert likes to say, he “tees ’em up” for me to treat.
Although we still do get a few patients seeking other opinions, the fact that I am in the office and my name is on the door makes it easier to gain their confidence. Our combined teams work very hard to speak the same language regarding care from the pediatric dentistry point of view as well as the orthodontic point of view. This arrangement requires lots of effort on both sides to present a unified message to the parents and patients. We have monthly training meetings where we discuss simple things like sealants or more complicated issues such as growth and development. In the end, having everyone in the office be knowledgeable about both the pediatric and orthodontic specialties is the key to success. It requires more effort, but the practice grows as a result.
What led you to make the decision to partner with a pediatric dentist, and how did you go about choosing one to work with?
After my purchase of the patients who populated my current practice, I was personally delivering consultation letters to Robert—something I do regularly when new dentists appear attached to new patients. I had a number of them from Robert and the patients loved him and were very loyal. We got to talking about his new spacious office that was about 20 miles away from my current office, and I wished to continue to see patients of his. I mentioned to him that I had experience working in other practices and that the situation helps to reduce overhead for both parties in addition to benefiting overall patient care. I also showed him the system that I use for referral of patients.
Behind the scenes and during the next couple of months, he contacted many people in my past practice area of Tucson, because he earned his pediatric specialty certificate in a residency there. Fortunately for me, he got great reports about me and my treatment results and reputation. We decided to forge a business relationship.
As you know, most business partnerships in dentistry don’t go well or last very long. My previous experience with Mark Donovan was an exception to the rule. I think that just like marriage, a business relationship needs to focus on the same goal of keeping clients happy—but each partner has to have a different personality. Just like Mark, Robert—or Robbie, as I call him—likes to hunt and fish, while I like to sit on the beach and golf. We have different personalities, but we’re both concerned about doing the right thing for patients and getting it done.
We also have a somewhat low-key approach to care. In other words, we present the findings and give patients the options. If framed well, most will opt to choose the care that we suggest. We realize that families need to make tough financial decisions every day and we try to make their dental care an affordable and stress-free option. It’s rare that we can’t make it workable to treat a patient who needs care and wants to take ownership.
How do you two work together?
We have a very flexible schedule, with the goal of each doctor having some time by himself and some time together. We both try to be in the office four days per week, which works well to maximize production based on school and patient schedules. The facility has three individual rooms that we use for consultation, sedation, and banding and bonding. There are also five open bay chairs that we share for shorter, more routine visits. Our software uses a grid system for scheduling, which we arrange based on who’s in the office when. Both of our practices use multiple checklists and procedures, so working side by side is quite seamless.
During a combined workday, we have the opportunity to chat, do joint consultations and discuss specific patients. I must compliment the team of assistants because they share X-ray equipment, sterilization areas and laboratory areas so well. There’s no doubt about it: The assistants need to be prepared to work together, which is one of the criteria for hiring. Although we currently have different teams, we strive to bring them together as much as possible. We huddle in the morning and afternoon together, talk about patients and how the day went, and what we can improve upon tomorrow.
The Peoria practice is about
20 miles away from your main
practice in Scottsdale. Have you noticed any differences between
the two locations?
Our Scottsdale practice has a very different demographic from the Peoria office. Both are wonderful, enjoyable groups of patients. Because of my age, my new focus on face-centered orthodontics, and a desire to eliminate the need to extend my financial commitment for many more years, I opted to enter into an office-sharing arrangement. The Peoria practice is on the fringe of a growth area in the valley and, like the Scottsdale office, has easy access to a freeway.
One of the largest requirements of orthodontic offices and pedodontic offices is parking. Because we’re located in a mall area, there’s plenty of parking for staff, patients and visitors. We have a large fish tank in the window that attracts a lot of viewers during the day and after hours. We’re sandwiched between a yogurt shop, a Mexican restaurant and a fitness club. There’s plenty of traffic!
What do you do to set your practice apart from others and market to new patients?
Most combination practices offer a specialist only once in a while. The patients can sense this and feel they’re not getting the full experience. Robert and I decided from the first day that the orthodontic and pedodontic departments would be available every day of the week for treatment and emergencies. We have staff from morning till closing, and when I’m not in the facility, a representative of the orthodontic practice is present to handle questions, emergencies and other issues. The patients are not told that “the orthodontist will be here on such-and-such day only.”
Also, we believe strongly in the face-first philosophy of orthodontics and growth. We pay lots of attention to oral habits, breathing and sleeping. Of course, this results in quite a lot of Phase I treatment, which I strongly believe in. If I have one regret in practice over the past 25 or so years, it’s that I have not addressed the need for lateral expansion coupled with myofunctional therapy enough. We now have a strong referral network as well as protocol for handling these patients. We have a great ENT practice that we regularly work with to handle airway issues.
Is there anything different about your marketing because of your new setup?
We benefit greatly from the contacts made in the elementary and middle schools through the pedodontic practice. Robert and his wife, Catherine, know everyone in the area. They have four young children who are all active in dance, sports and school. Just like when my wife and I were involved in the school and sport scene, these connections make it very easy to meet new families. We continue with the Smiles For Charity events, which basically provide free orthodontic care to groups that support our practice. In just under five years in Scottsdale, I personally was responsible for just under $100,000 of cash raised for these groups and almost $200,000 of services donated.
When we jointly attend the schools or other external events, Robert and his team focus on brushing, flossing and regular checkups. When we’re set up side by side, we focus on oral habits, airway and sleeping. Also, we encourage the ADA and AAO recommendation of the first dental visit at age 2 and the first orthodontic visit at age 7.
Practice ownership isn’t new to you. Prior to settling down in Scottsdale, you owned a practice in Tucson, which you sold over five years ago. What, if anything, would you say has changed in practice ownership between now and then? What about orthodontics as a profession?
I’m sure that most of the readers will agree that it’s every man and woman for him- or herself. I’m not criticizing, just stating the obvious! Almost every new practice that opens does all phases of dentistry. I’ve rented from a periodontist both in Tucson and Scottsdale whose biggest referral recently sold his practice to a young practitioner. This new doctor does everything, essentially drying up a good portion of the periodontist’s practice. All of us need to find a particular niche to fill and address it with external marketing as well as patient retention and internal marketing. Staff is so important to this. For the better part of the past five years, I was building a cohesive team. Finally, I have a staff that works together and understands the vision.
Do you plan on maintaining your practice in Scottsdale in addition to working out of the Peoria practice?
I’m actually going to sell it to orthodontists whose growth strategy involves multiple individual-office arrangements. My new growth strategy, meanwhile, is based on dropping an orthodontic practice into an existing practice capable of referring. Both business models should do well moving into the future.
What’s an average day like at your practice? Walk us through it.
I arrive early and do the computer-related treatment, such as review X-rays and clear aligner treatment plans. I’m very fortunate that I have a team who believes arriving “on time” is being late. We have a morning huddle where we review the new patients, debandings and deliveries. Cases that involve income or production are called in advance, in addition to using the automated messaging system that’s integrated into our Edge software. We review pertinent marketing activities for the upcoming week and month and make sure that they’re staffed properly and that the social media for them is up to date.
We have a four-column schedule at this time: one column for new patients, one for long bondings, one for shorter appointments and one for short visits such as spacers, checking expanders and the like. Most of our appointment or clinic time is during the afternoon; the morning is reserved for the staff to do their tasks.
I usually work on patients four to five hours per day. New patients are scheduled for 45–60 minutes; we take records, introduce ourselves to the family and explain where we are coming from. We discuss “face-first orthodontics,” focused on eliminating habits, encouraging forward facial growth and creating an attractive, functional smile.
What would you say is the
cornerstone of your practice?
We are utilizing the CBCT or i-Cat as much as we can and as we learn. Our Phase I treatments are being preplanned digitally, which makes a great marketing tool. As I mentioned earlier, both Robert and I are quite involved in habit correction and facial muscle balance, so we perform a fair amount of lingual frenectomies. We remove primary teeth when the tooth-eruption pattern is way off symmetry; in other words, we don’t necessarily remove teeth for treatment, but when a tooth or two is ectopic or slow to exfoliate, we can have this handled swiftly and in the same office or even the same day.
What are some of your favorite technological advances in orthodontics? What do you like using?
I’ve seen many brackets systems over the years, and they’re continuing to become more accurate and easier to place and tie to. The introduction of thermal-activated wires with broad archform is my latest trend in the practice. I know that they’re not new, but when you’ve practiced for more than 25 years, it takes a bit to turn the ship. I believe that CBCT will become the standard in the future, allowing us to focus on not only sagittal diagnosis but also transverse and volume as well. As we become more adept at superimposition of volumes, orthodontists will trust what they’re seeing.
Intraoral scanning is used daily in the practice and we’re beginning to deliver retainers at debonding of previously scanned images. The ability to scan for expanders and the like is making it more enjoyable for the kids we see to have appliances made for and delivered to. Intraoral photography, while years old, has become so commonplace we forget what it was like decades ago with film and an SLR camera! Many hours were spent retaking photos or, worse yet, you had to accept less-than-ideal shots. Now, all staff can be trained to take great photos and they can check them instantaneously.
What is your patient
Well, the basis is my “Treatment by Twelves” philosophy, which has been published in Orthotown and Dentaltown magazines. It basically states that everything we deal with in a typical patient and our decision making is based on the eruption of the teeth, the jaw relationship, the function of the temporomandibular joint, and the influence of facial muscles and airway. I then break down patients into groups based on the teeth erupting. Young patients ages 6 to 9 are usually getting their first 12 permanent teeth. Adolescent patients between ages 10 and 14 are typically getting the next 12 permanent teeth. Lastly, after age 15 or so, most permanent teeth are in, and treatment can either be initiated and completed in one phase or it would represent the final phase of care.
I was never much of a Phase I treatment person, but the work of Drs. James McNamara and Sean Carlson has really opened up my eyes. Having adequate transverse dimension makes complete care so much easier and predictable. The CBCT evaluation is really allowing for planning treatment to achieve adequate width and make room for all of the teeth. In the past, we were concerned with stability of these early treatments. I still am. However, once you understand the influence of healthy breathing and facial musculature on the dentition, you can really change the dental relationship in so many patients.
What gives you the most
Getting it done! The reason that I keep going is because I love seeing the results, interacting with the patients and parents, and perfecting my mechanics. I am practicing 180 degrees differently than I was taught, and I love it! My business partner calls me a CE junkie. I am truly blessed to find a profession that allows me to continue to learn and perfect my technique.
You’ve been Orthotown’s editorial director for four years and interact with Townies on a regular basis. Based on what you’ve seen on the message boards and other interactions, what would you say are some of orthodontists’ biggest challenges? Is this a challenge you’ve experienced?
The busy-ness problem is real for so many, and yet for others it’s not. True, demographic areas are responsible in many of the situations, but so is attitude. I know personally that when I put the necessary time into training, marketing and customer service, the rewards are immense. When I get lazy and assume that everyone knows what I want, I’m not successful. Orthodontists need to think like businesspeople and understand that their product just happens to be straight teeth and a wonderful experience.
Tell us about your life outside of the practice. What are some of your hobbies?
I was a swimmer throughout high school and college, earning my tuition money as a lifeguard. I continue with swimming at least once a week, and hiking local mountains once a week with gym workouts practically every day. Because of the two previous hobbies, I am terrible at golf —I took it up at age 60—but I’m finally seeing a drop in my handicap, thanks to Scott O’Neil and Dave Ward, two longtime orthodontic product reps. Orthotown consumes a good portion of my free time. With children on both coasts and in my original hometown of Milwaukee, traveling to visit them consumes many weekends.