The end of cavities? Part II

The end of cavities? Part II

October 26, 2007 -- After attending a meeting on plaque in the late 1990s, Albany, California dentist Nathan Kaufman, DDS, began to see just how much dentists could do to prevent caries. The realization gradually led him to transform the way he treats his patients -- and the way he makes his living. "We're changing the paradigm," he says

Dr. Kaufman has joined a new movement in dentistry called caries management by risk assessment (CAMBRA). Adherents use diagnostic tools to estimate each patient's risk of developing cavities, then bring to bear preventative therapies -- frequent cleanings and exams, fluoride varnishes and gels, calcium phosphate, xylitol gum and antibacterial rinses -- to according to the patients' needs.

The movement is gaining steam; the Journal of the California Dental Association is devoting its October and November issues to the topic, along with an endorsement of CAMBRA signed by representatives of most U.S dental schools. "Not only is it scientifically interesting, it's the right way to treat patients," says Dr. Kaufman, who argues that CAMBRA will soon become the legal standard of care.

When the approach works, patients get far fewer cavities. For the dentist, that means less money from restorations. But it also means attracting more patients, Dr. Kaufman says. "If you have twice as many patients but do half as much work on each one, you make the same money."

Not everyone is ready to hop on the CAMBRA wagon. Some dentists operate as if nothing has changed. They encourage brushing and flossing, but don't bother with more aggressive prevention techniques. They may cater to patients who didn't benefit as much from the fluoride revolution and have plenty of restorations that need maintenance.

Other dentists are emphasizing cosmetics, catering to patients with healthy teeth who want to brighten or balance their smiles.

But a cutting edge group of dentists like Dr. Kaufman who embrace CAMBRA claim they make as good or better money than their hide-bound peers. "I have a small number of colleagues around the country who are making a good living doing this," said John Featherstone, M.Sc., Ph.D., dean of the University of California at San Francisco dentistry school and one of the movement's leaders. How is this possible?

Ready or not

The answer isn't obvious. First there's the problem of reimbursement. Few, if any, insurers will cover more than two examinations in a year, much less chewing gum. Patients are often reluctant to pay for anything their insurance won't cover, so it's hard for dentists to reap a profit on these services and prescriptions.

And it's hard to attract patients before they feel any pain. "Prevention just doesn't sell," says Ed O'Keefe, a Chicago dental marketing consultant.

But insurers are beginning to embrace preventive techniques, since they drive down the companies' own costs says Tom Limoli, an Atlanta insurance consultant. Employers are driving the change because they shoulder most of the cost of dental insurance in the United States. As insurance portability laws take effect, argues Limoli, there will be more competition among insurers, forcing them to look for more efficient approaches to dental care -- such as CAMBRA. Already some Delta Dental plans are paying for fluoride varnishes.

Being on top of such trends can make a dentist stand out from competitors, says Dr. Kaufman.

Limoli suggests offering promotional discounts -- such as those through a dental discount plan -- to get patients in the door. Once in the chair, the dentist must deliver a good experience.

Dr. Featherstone insists patients will buy into preventative treatments once they understand the benefits. "People like to know that they won't be coming back with pain, for implants, for bridges. And they are telling their friends. Every [dentist] I know who is doing CAMBRA in private practice is building their practice."

By the time Dr. Kaufman went into semiretirement in 2005, he had built his practice up to 3,600 patients, creating a constant stream through the door. "We had to start early and work through lunch," he says. His only marketing has been word of mouth.

One key to CAMBRA as a business model is relying more on hygienists who can do fluoride treatments and much of the other work. Kaufman booked 13 days of hygienist time per week.

"This is the future," says Dr. Kaufman. "Whether you join now or later."


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The,end,of,cavities?,Part,II

Caries prevention: New legal standards?

Caries prevention: New legal standards?

October 26, 2007 -- Where professors tread, lawyers are sure to follow. A new consensus statement that will be published in the November issue of the Journal of the California Dental Association looks likely to increase dentists' liability for preventing cavities.

"Consensus Statement Caries Management by Risk Assessment: Implementation Guidelines to Support Oral Health" briefly describes how dentists should assess their patients' risk of caries and work aggressively -- using counseling, antibacterials, and remineralizing agents -- to prevent the disease from damaging teeth. It includes endorsements by caries experts from most U.S. dental schools, including 18 deans.

"Once this is out there and published, it's going to become the standard of care," said co-author John Featherstone, M.Sc., Ph.D., acting dean of the University of California San Francisco School of Dentistry. The standard of care is the scale juries use to weigh a dentist's guilt or innocence in malpractice lawsuits.

Although the full legal implications of the consensus statement might take some time to work out, Dr. Featherstone argued that the principles in the statement -- known as caries management by risk assessment (CAMBRA) -- have been known for years and that dentists should already be putting them into practice.

But most aren't. "If somebody comes in with frank cavities in their teeth, we know there is bacteria in their mouth," he said. "But what does the dentist typically do? They fill the teeth and say, 'Go home.' The prevention they offer is, 'Brush your teeth and you'll be all right.' "

Attempts to change that attitude are already under way at most dental schools, according to Martin Davis, D.D.S., a professor of pediatric dentistry at Columbia University. "We have to educate the whole profession on this."

He questions whether CAMBRA (which some advocates refer to as "anticipatory guidance") has the force of law. "Nobody is going to come down on anybody yet," he said.

But somebody already has. Dental malpractice attorney Edwin J. Zinman, D.D.S., J.D., argues that most of the consensus statement's ideas are taught in dental schools and were articulated in a similar 2003 statement in the Journal of the California Dental Association and statements by the American Dental Association. "The legal ramification is that it's the standard of care," he said. "It's what all reasonable dentists should be doing."

In fact, Dr. Zinman said, he has already won cases against dentists who aren't taking aggressive enough measures to prevent decay in their patients' teeth. He cited one recent $75,000 settlement won from a dentist who replaced a patient's broken restoration without taking steps to control the patient's caries. "Dentists who are not doing this are putting their patients at medical risk and putting themselves at legal risk."

The guidelines

So what must dentists do to protect themselves and their patients? The consensus statement says they should use factors such as past history of caries to sort their patients into three categories: low, medium, high, and extreme risk.

Moderate-risk patients should get "improved remineralization therapy and reduction of other risk factors, which may include antibacterial therapy." High-risk patients should get all of the above including antibacterial therapy. Extreme risk patients should get all the same treatments as high-risk patients plus, if they have severe salivary dysfunction, "buffering agents and calcium and phosphate supplementation." (The statement gives no advice for low-risk patients.)

The document does detail some specifications of the antibacterial and remineralization products that dentists should use.

Other articles printed in the October and November issues of the Journal of the California Dental Association offer even greater detail on these products, and more specific risk assessment guidelines.

Though the consensus statement captured a wide representation of dentists, not everyone is on board. Domenick Zero, D.D.S., M.S., a caries researcher at Indiana University said he declined to sign. "The article contained endorsements of commercial products," he said. "The [authors] give them all this credence, and I don't think it's right."

For example, he objects to the document's endorsement of xylitol as an antibacterial agent and amorphous calcium phosphate for remineralization. He argues that large, randomized, placebo controlled trials are still needed to prove these agents are effective.

But he agrees with CAMBRA's underlying concept of assessing patients' risk and employing well established preventative strategies, such as fluoride varnish and dietary counseling. The bottom line, as he tells his students: "You either pay attention to me or you pay attention to lawyers."


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Caries,prevention:,New,legal,standards?

Science journals take on poverty

Science journals take on poverty

October 25, 2007 -- The Council of Science Editors (CSE) organized a Global Theme Issue on poverty and human development on Oct. 22, with 235 science journals from 37 countries simultaneously publishing more than 750 articles on the topic.

"The goal of the CSE Global Theme Issue is to stimulate interest and research in poverty and human development and disseminate the results of this research as widely as possible," according to a press release by the Council of Science Editors.

Several dental journals participated in the effort. A guest editorial in the Journal of Dental Research highlighted the dental problems plaguing the poor.

"Caries in adults and children, acute oral viral infections and noma, oral lesions of HIV/AIDS, periodontal diseases, craniofacial and dental developmental defects, and oropharyngeal/salivary gland neoplasms occur largely unchecked in resource-poor nations," the editorial noted. "It is clear that much of the global burden of oral disease affects the poor and neglected segments of humanity in both rich and poor countries."


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Science,journals,take,on,poverty

Study: Cancer treatment causes caries

Study: Cancer treatment causes caries

October 25, 2007 -- Radiation therapy for thyroid cancer can cause long-term dental disease, researchers at the University Hospital in Basel Switzerland report in this month's Journal of Nuclear Medicine.

Previous research showed that zapping thyroids with high doses of radioiodine damages salivary glands, often leading to sialadenitis and xerostomia. So the investigators contacted 176 patients who had undergone this treatment over the previous three decades and asked them and their dentists about the health of their teeth.


This graph shows the dramatic increase in tooth extractions after radiation therapy for thyroid cancer. Copyright ? by the Society of Nuclear Medicine Inc. From "The Dental Safety Profile of High-Dose Radioiodine Therapy for Thyroid Cancer: Long-Term Results of a Longitudinal Cohort Study," by Martin A. Walter, et al., Journal of Nuclear Medicine 48: 1620-1625.
They found that these patients were 98.8 percent more likely to have caries after the radiation than before it. And they were 8.14 percent more likely to have a tooth extracted for every gigabecquerel of radioiodine they had received.

So what can be done? First, the investigators suggest, only those patients who could benefit most from radioiodine therapy should undergo it. Second, patients who have had this therapy should take precautions above and beyond normal hygiene: they should be careful to avoid dehydration; they should try glandular massage to preserve their saliva flow; and they should be cautious with anticholinergic drugs, which can also cause xerostomia.


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Study:,Cancer,treatment,causes,caries

Cosmetic confidential

Cosmetic confidential

October 23, 2007 -- The dark truth behind those bright smiles

Ah, for the glamorous life of a cosmetic dentist. No more bratty kids or cranky codgers filling up the waiting room. No more extractions, fillings, or root canals. You'll spend your afternoons bleaching Lindsay Lohan's teeth or straightening Ashton Kutcher's smile. Who knows? You could end up with your own "Extreme Makeover"-style reality TV show.

Before you decide enter into the realm of pure aesthetics, though, take heed. We've drilled deep inside the world of cosmetic dentistry, peeled off its thin veneer and revealed the decay beneath.

OK, maybe that's overstating it a bit. But we have talked to some of the top dental professionals in the country and got the inside skinny on the booming world of cosmetics. Bottom line? It's not as easy as it looks or as profitable as it seems (more on that later).

Part I: So you wanna be a cosmetic dentist

You may be a whiz with an explorer and a root canal ace, but the differences between general dentistry and aesthetic dentistry are more than cosmetic. Success demands skills that often reside outside the comfort zone for many general dentists. Here are some keys to success.

Choose your lab carefully. Your work will only be as good as the lab you partner with, so pick a good one -- or more than one. Surveys by the American Academy of Cosmetic Dentists (AACD) show that 8 out of 10 dentists use multiple labs, often a cheaper one for basic treatments and higher-end techs for cosmetic work.

"Dentists really need to shop around for the right lab," said Laura Kelly, who holds the distinction of being both the first woman and the first nondentist to be named president of the AACD. A ceramist by trade, she knows quality cosmetic dentistry requires close collaboration between GDs and techs. "You need to make sure their skill level mirrors where you want to go with your practice, you share the same philosophy, and speak the same language."

And once you've got a lab you like, work hard to maintain a good relationship. When they've done a good job, show them the "after" pictures and send a little sugar their way, Kelly said. "Too often the ceramist only hears when adjustments need to be made," she said. "Smart dentists will call them up and say, 'Hey thanks, you really made me look good.' You can make a technician's month with just one phone call."

Polish your shutter skills. Being good with a handpiece is essential to being a successful cosmetic dentist. But how good are you with a Nikon or an Olympus? No patient will engage you without first checking your portfolio. If your shots are out of focus, over- or underexposed, or simply unattractive, you won't gain their trust -- no matter how good you are. You'll also want to bring your photos when you visit a new lab, so they can understand the standards of work you expect. One step in the right direction: Take a dental photography class (the AACD offers some).

"I see photographs in dental journals and I'm embarrassed for my profession," said Dr. David Landau, an accredited member of the AACD who operates a private practice in San Diego. "The teeth look fake, the gums look red or washed out instead of pink and healthy, and the exposure is so off you can't tell the chroma and value of the porcelain. As a member of the AACD, one of the first things you learn is how to be an excellent clinical photographer."

Beware trouble patients. Some people just can't be pleased -- and they're definitely not the ones you want coming to you for cosmetic work. One leading aesthetic practitioner who asked to remain anonymous tells the story of a woman who came into his office looking for extensive cosmetic work.

"The first thing she tells me is how her plastic surgeon 'butchered' her," he said. "Then she showed me a line over her eye that I couldn't see. The use of the word 'butchered' was a real warning sign that she had expectations no dentist in the world could possibly fulfill." He ultimately declined to take on the case.

"As an aesthetic dentist, you think 'I can do that,' but if you haven't read the patient well, it will cost you a lot of time and money," he added.

Avoid Dumbell U. Cosmetic dentistry isn't an ADA-accredited specialty, but continuing education in cosmetic techniques is a must for any general dentist stepping into this realm. "The technology develops so quickly that if you don't take courses every year you'll fall behind," warned Dr. Dan Nathanson, professor and chairman of the department of restorative sciences and biomaterials at Boston University. Just be careful about what that continuing education course really qualifies you for.

For example, taking a week-long course in occlusion doesn't mean you're able to perform complex prosthodontic procedures. "Some graduates get a false sense of security about their ability to do these things," he said. "If we could teach you to be a prosthodontist in a week, we wouldn't be offering a three-year degree."

General dentists who want to improve their skill set in cosmetic dentistry should look for courses associated with the local chapters of the AACD, American Academy of Esthetic Dentistry (AAED), or a university linked to those organizations. One example is Boston University (Nathanson is a director of the AAED); another is UCLA, where Dr. Brian LeSage, director of its Aesthetic Continuum, is also an AACD fellow.

Beware the malpractice monster. When it comes to patient lawsuits, you're three times as likely to get sued over crown and bridge work than dentures or surgical extractions, according to surveys by the ADA. But focusing on cosmetic dentistry doesn't guarantee you'll get sued less. It could make you a bigger target.

"Whenever you are dealing with the very subjective opinions of patients [getting cosmetic procedures], you risk displeasing them," noted attorney Frank Recker, an attorney and dentist in Marco Island, FL. "And an unhappy patient generally poses a greater risk of suit in my view, whether meritorious or not."

The best way to avoid legal jeopardy is to ensure that your patients understand everything that's involved in the procedure, and that you understand what the patient is expecting you to deliver, Landau said. (See "Beware trouble patients" above.)

Know when to call for backup. As a general dentist, you can perform virtually any procedure a specialist could -- but you probably shouldn't. If you get bitten by the malpractice monster, you'll be held to the standard of care typically provided by a board-certified specialist. Knowing which cases are too complex or exceed your skillset not only saves you money in the long run, it's also better for the patient.

"Different general dentists have different comfort zones," Landau said. "Sometimes to get to the ideal gum position you have to move the gum without moving the bone, which any dentist can do. Sometimes you have to move the gum and the bone, which some GDs wouldn't feel comfortable with. If you have to replace an anterior tooth with an implant, you're probably best referring it out to a specialist who understands the demands of making an implant look like a natural tooth erupting out of the gums."

But understanding the patient's cosmetic needs requires a trained eye, he said. "You need to understand what a natural healthy gum line should look like. A lot of general dentists don't know what they don't know."

"So much of what we do these days is in concert with cosmetic dentists, we're almost like a team," said Dr. Donald Joondeph, a professor emeritus of orthodontics at the University of Washington who operates a private practice in Bellevue. "The GD, orthodontist, periodontist, prosthodontist, oral surgeon -- each of us has his own role to play. We all look at the case and plug in to make the end product the best it can be."

One example, Joondeph said, would be a missing tooth that requires an implant. "Let's say a person had an upper lateral incisor congenitally absent and the adjacent teeth have drifted into the space making the space too small for an implant," he said. "A 'team' would then be required: an orthodontist to align the teeth and open the space where the tooth was missing, making the space the same size as the one on the opposite side; a periodontist or oral and maxillofacial surgeon to place the implant; and the general dentist to place the crown."

Get accredited. If you're serious about aesthetics, the AACD offers an accreditation program, but getting your sheepskin is no trivial task. Dentists must pass a written exam, then submit five patient cases over five years to a board of reviewers who evaluate each case on 50 separate criteria, and then pass an oral exam. Only a very small percentage of the dentists achieve accreditation within the five-year window the AACD allows. To become an accredited fellow (42 worldwide) requires a far more rigorous examination of clinical ability. The Academy of Comprehensive Esthetics (ACE), likewise has a tough certification program.

Just remember that the benefits are largely personal -- cosmetic dentistry is not an ADA board-certified specialty. Getting that sheepskin doesn't mean you'll automatically be able to charge more for your services, either. And many dentists who lack the AACD credential still do excellent work, saidDr. Larry Addleson, an accredited fellow and past president of the AACD who operates a private practice in San Diego. "But you can know for sure that those who become accredited are capable of performing at a high level."

Part II: Where's the money?

OK, here's the part of the story you've been waiting for. Is cosmetic dentistry your road to riches?

On one hand, pay for dentists has never been better. According to surveys conducted by the ADA, average annual salaries for dental practitioners rose from $166,000 in 2000 to nearly $186,000 in 2004. The number of cosmetic procedures rose 12.5% over roughly the same period, according to surveys conducted by the American Academy of Cosmetic Dentistry (AACD).

Ipso facto, cosmetics must good for your bottom line, right?

Not necessarily. While dental incomes are rising -- and cosmetic procedures certainly add to the kitty -- the main reason dentists make more money is that the ratio of dentists to the general population has been dropping since the 1980s, according to Boston University's Nathanson. There are more sick teeth and relatively fewer people to fix them.

Another limiting factor is insurance. Purely cosmetic treatments, such as veneers or teeth whitening, are generally not covered by insurance. That means patients must foot the bill themselves or finance the work through third parties like CareCredit or Dental Fee Plan (a Capital One credit card used to pay for dental work). Nearly 82% of dentists offer third-party financial help, according to the AACD.

The good news for dentists is that instead of getting paid a percentage of your fees by a PPO or insurance plan, you'll usually get paid in full, said Dr. Charles Blair, a practice management consultant in Charlotte, NC, and author of Coding with Confidence: The "Go-To" Guide for CDT-2007/2008.

The bad news: cosmetic dentistry is more sensitive to fluctuations in the market. When the national economy hits a tailspin, everyone has fewer reasons to smile -- or to pay $500 to whiten their teeth.

The inconvenient truth? "If you're doing cosmetic dentistry right, you're probably not making a lot of money," said Dr. Larry Addleson. For one thing, doing it right means using higher quality -- and more expensive -- labs.

"You can get a crown or veneer made in an offshore lab for $100, or you can pay a master ceramist $600," he said. "If the veneer costs you $100 and you charge the patient $800, you can make more money. But you can't charge six times as much for a $600 veneer and expect to remain competitive."

You must also be willing to send things back to the lab for a do-over -- or several do-overs -- until you and the patient are satisfied. Whether dentists can recoup the added costs depends on their relationship with both the lab and their patients, Kelly said, but the same market rules apply.

"You have to be willing to reject things that most dentists would say are beautiful," said Dr. David Landau. "When a cosmetic case comes back from the lab we call it a 'first fitting,' not delivery of the final product. Every time you do a fitting and reject the work, you lose money."

Doing it right means also taking more time to work with patients, especially when dealing with complex cases. It can mean spending more time and money for continuing education, and paying more for qualified staff.

Cosmetic dentists also incur greater advertising costs, according to Blair. "Pure cosmetic dentists typically spend 7% to 10% of their gross on advertising, versus around 1% for most general dentists," he said.

In his 25 years of consulting, Blair said he's seen a handful of GDs give up bread and butter dentistry and focus entirely on cosmetic work, but few end up sticking with it.

"Some people have walked the plank, gotten out of the PPOs and regular insurance plans, and tried to specialize only in cosmetics," he said. "But I've seen some stumbling there. Many have had to run back to general dentistry. I caution dentists to maintain their bread and butter practice and let cosmetics be the gravy."

For dentists like Addleson, money isn't the motivator. It's about raising the overall quality of dental work for his community as a whole -- one reason why he's a director of the San Diego Advanced Study Group and currently mentoring 10 dentists in his area.

"If you're really committed to cosmetic dentistry, you're not going to get rich," he said. "It's an inner passion. Yesterday doesn't matter. You're only as good as what you do today. It's like trying to understand why Van Gogh cut off his own ear. It's hard for people who don't share this passion to understand."


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Cosmetic,confidential

OPINION: Dear New York Times: The answer isn't more dentists


October 23, 2007 -- In all the heated debate about the New York Times' recent controversial piece, "Boom Times for U.S. Dentists, But Not for Americans' Teeth," some basic history and economic realities have been ignored.

The boom in the number of dentists in the 1970s (my generation) didn't result in more people getting dental care. Back then, the federal government said we didn't have enough dentists. The result was a glut of dentists and less business for dentists all the way around. It took years to work off the oversupply.

Now the government is saying the same thing. But if we've learned anything, increased availability of a service doesn't necessarily increase utilization. If people can't pay for a service, they won't use it. And if people don't want to pay for a service, they won't value it, either.

The real problem is that federal and state medical assistance programs aimed at helping the underprivileged (and even the lower-middle class) don't come close to covering a dentist's overhead. Are dentists expected to provide medical care at a loss, to essentially subsidize dental care for those who can't afford it? I can't help but agree with Dr. Terry D. Dickinson, the executive director of the Virginia Dental Association, when he said, "Charity is not a healthcare system."

If dental care is truly important (and I wouldn't be a dentist if I didn't think it was), then we all need to step up to the plate -- Congress, state legislatures, and yes, taxpayers. Everyone should contribute to making dental healthcare available to the people most in need. Like attorneys, dentists do plenty of pro bono work. But ultimately, they have to make a living, too.

In Wisconsin, where I practice, the Marshfield Clinic is working with the Family Health Center to set up rural dental clinics to provide care to underserved patients.The only downside? The group doesn't cover Medford, where I practice. (More than 9% of the local population lives below the poverty line, including nearly 13% under the age of 18.) What makes this program possible? Federal grants, higher Medicare and Medicaid compensation, state grants, and more. If the government appropriately reimbursed dentists for their services, there'd be plenty of access to dental care for Americans of all economic stripes. There wouldn't be a need for dental "therapists."

Dentists are healers -- compassionate, civic-minded men and women who are dedicated to helping their fellow citizens. But we're not doormats. It's up to our elected representatives -- who, to date, have shown little backbone -- to tackle the inequities in American healthcare, and to come up with the bucks to make it happen.

Kim Gowey, D.D.S., practices in Medford, WI. He is a past president of the American Academy of Implant Dentistry. He was on the continuing education faculty of Howard University School of Dentistry's Implant Maxicourse, and Baylor College of Dentistry.

Related dental links: Bunsen Burner Dental Loupes Vacuum Forming Machine

OPINION:,Dear,New,York,Times:,The,answer,isn't,more,dentists

The battle of the power toothbrushes

The battle of the power toothbrushes October 22, 2007 -- Ultreo, Inc., makers of Ultreo, a power toothbrush based on ultrasound waveguide technology, filed a counter suit against Procter & Gamble in the United States District Court for the Southern District of New York last week. P&G, which makes the Oral-B power toothbrush, filed a suit against Ultreo in September for allegedly misleading consumers and dental professionals through false advertising. According to P&G, Ultreo's claim that their product's ultrasound waveguide technology creates bubbles that fight plaque--that bristle action alone leaves behind--is false. P&G further claimed that one of its studies proved the Ultreo toothbrush was more effective at removing plaque with its ultrasound waveguide technology switched off. "Ultreo has provided no clinical proof that the ultrasound makes any difference in plaque removal in the mouth. We're taking this action to prevent consumers from being misled and to protect our business," said Dr. Paul Warren, Vice President of Global Oral Care Scientific and Professional Relations for P&G in a press release. Ultreo has denied these claims in full, and in its countersuit says that P&G is misleading consumers and dental professionals by falsely disparaging Ultreo. Ultreo claims considerable scientific evidence proves its product's advantages, notably a 95 percent reduction of plaque within the first minute of brushing. "Our marketing focuses on the strong scientific evidence behind Ultreo and the proven consumer preference for the incredible feeling of clean Ultreo provides," said Ultreo CEO and President Jack Gallagher in a press release. "It’s obvious that this is the real source of concern for P&G. The fact that a $76 billion market leader is attacking and disparaging a $3 million startup offering a technological innovation simply validates Ultreo’s acceptance by the marketplace." Related dental links: Dental Loupes Vacuum Forming Machine root canal The,battle,of,the,power,toothbrushes

Work less, earn more? One dentist explains how

Work less, earn more? One dentist explains how

October 22, 2007 -- William Blatchford, D.D.S., had a successful practice but he wasn't truly happy. He worked five days a week, never had time for vacations, and always felt a cloud of stress hanging over him. One night while eating leftovers from yet another office dinner, his wife and fellow dentist, Carolyn, said, "We're eating the leftovers of the practice's revenues every month." One night, Blatchford had a realization: He needed to change the entire way he ran his business.

Once he did, Blatchford claims he eventually climbed to the top 1 percent of highest-grossing dentists nationwide. Then he founded Blatchford Solutions and became a coach and consultant to 2,500 dental practices. His selling point: Life is too short, so develop a practice that allows you the lifestyle you desire. When he is not flying planes; skiing near his Bend, Oregon home; or sailing in Puget Sound; Blatchford spreads the word about his theory.


Dr. William Blatchford
His "Show Me the Money" session at the recent ADA conference in San Francisco was a few years in coming. "Two years ago, the ADA told me not to talk about profit or use the 'S-word' at the conference." (We're assuming he meant "sell".) "This year, they actually requested I do this program. It shows how far the dental business has come."

One of his seemingly contrary discoveries: Customer service demands that you focus on income. "People want to go to a dentist who is profitable. They don't want a dentist working on their teeth who is preoccupied with paying the rent."

Cut back on overhead

What keeps dentists from boosting profits? They're bad at estimating what to expect to gross every month, says Blatchford. "A dentist has one month that's shockingly big and assumes it will always be like that and spends money on more staff and equipment. The next month, business goes back to normal and he's worrying about paying expenses. What did the dentist do to make that one month so big? Chances are, they don't know.

"Your 'range of predictability' shouldn't go up and down. It should become narrower."

In Blatchford's case, he scrutinized his staffing. He had 16 employees, five solely for hygiene. ("What does one dentist need 16 employees for?") He laid off three hygienists ("The worst day of my career"), then later cut his total staff to eight. A year later, he grossed slightly more than the prior year, even with half his staff.

Blatchford boasts that his clients gross between $2 to $3 million annually, even when working with staffs of five or fewer. More telling? His dentists work 3.5 days a week and take eight to 10 weeks vacation a year. All of them have cut their overhead and reduced their staff to a handful. "It's not about time spent or efforts made, or even how much you work. It's about results."

Getting there means cutting the small stuff, focusing on high-end treatments, and developing specialized niches. One of Blatchford's clients moved his dental practice to Florida and focused on cosmetic dentures and implants for the abundant population of well-heeled seniors. The dentist charges $6,000 to $10,000 a pop. The results: He went from grossing $800,000 a year to $2 million, with half his previous overhead (a team of five employees), and a four-day workweek.

Another client only works three mornings a week, but she focuses on dentures and implant-supported dentures in a Polish neighborhood in Chicago. "She doesn't do fillings or see kids," says Blatchford. "But she earns so much in her specialty that she throws in a spare set of dentures for free." She likewise trimmed staff, cutting overhead from 63 percent to 37 percent, and grosses $1 million annually.

Typically, 30 percent of a dentist's overhead is staff. Blatchford says it should be 12 to 20 percent. But pay those staffers you keep well--double their salaries. "I once hired someone incompetent and then had to hire a trainer to help her. That's stupid." Hire the most competent staff, give them incentives of higher pay and a reduced workweek, and they'll give you hard work and loyalty in return.

Focus on your top clientele

Blatchford is a firm believer that the top 20 percent of patients generate 80 percent of your income--and that the bottom 20 percent can actually be an income drain. "It's ludicrous to treat all patients the same when some are actually costing you money."

He suggests you create a spreadsheet of all your patients and how much they spend, then list them in descending order of expenditures. "When the descending total hits 80 percent of total income, study those people in that range. Look at their age, gender, and treatments needed -- that's your target market. Get rid of the bottom 20 percent."

Raise fees, lower receivables

Don't be afraid to raise fees, either. Blatchford actually recommends doubling them. "People go to my Chicago-based client because her dentures cost twice as much. They perceive it as quality."

If you're hesitant to double, add the bill cost to your current fee. "Then you can send work to the best lab around, because the patient is paying for it directly."

Accounts receivables are poison in his book. Say you have $100,000 in A/R on Jan.1. Over the course of a year, you'll lose $6,000 through inflation, $10,000 from money you could have invested (if you had it), $36,000 in the costs of trying to get patients to pay, and $24,000 in write-off of bad debts. By year's end, you will have lost $76,000.

"That's why my clients do not carry account receivables," says Blatchford. "It's check, cash or credit card upfront at the desk."

Make treatments affordable by offering financing options from outside sources. Why not?, says Blatchford. "That's how they pay for their car and big-screen TV."

Ply them with services

Consultants often tell dentists to focus on getting more hygiene patients, but Blackford says forget that. "You'll only break even. It will never be a profit center."

Instead, focus on doing more Class II and Class III procedures. "If you do two units of a crown or bridge, your net profit per hour triples." He also recommends offering additional services, such as denture implants, cosmetic dentures, and veneers.

How can you get patients to accept these offerings? "McDonald's made millions by asking, 'Do you want fries with your burger?'" says Blatchford. "Say to your patient during a procedure, 'I notice you'll need an additional crown here soon. We can get both done while you're still numb and save you two extra appointments.'"

Instead of trying to educate patients about treatments' benefits, appeal to their emotions. "People don't want dentures or veneers, they want their teeth to look good, feel good and last a long time. Instead of trying to sell the process, you should be selling the results."

Moneymaking aside, Blatchford emphasizes that all dentists should balance business and pleasure, and ensure that they can incorporate both into their practice. "Life is too short. Make a commitment to be happy. You should say, 'Thank God it's Monday!' Focus only on the things you want to do and enjoy them, both in work and life."


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New drug can 'revolutionize' oral and maxillofacial surgery

New drug can 'revolutionize' oral and maxillofacial surgery

October 22, 2007 -- Infuse Bone Graft -- a drug used in orthopedic procedures that stimulates stem cells to form bone -- has recently been approved by the FDA for dental use.

The drug consists of two parts: a solution containing rhBMP-2 (recombinant human bone morphogenetic protein 2) and the ACS (absorbable collagen sponge). It can be highly useful in oral and maxillofacial procedures. Surgeons at the School of Dentistry, Loma Linda University have successfully used Infuse to do reconstruction surgery on gunshot and trauma victims, as well as patients with cleft palates and oral cancer.

Until recently, surgeons harvested bone needed for reconstruction surgery from the patient's own hip or ribs. "This is painful, and requires a second surgery site [on the patient]," said Philip Boyne, D.M.D., M.S., D.Sc., professor emeritus of oral and maxillofacial surgery at Loma Linda, in a press release. Infuse can eliminate this entire process from oral and maxillofacial reconstruction surgery.

"The cleft palate cases are particularly rewarding," Dr. Boyne said. "This new drug makes a second surgery unnecessary and the bone generated from the patient's own stem cells forms bone that beautifully completes the natural arch. And the sponge doesn't have to be removed -- it is eventually absorbed by the body."

Infuse can be used in many areas of dentistry and will save patients considerable time and money. For example, cleft palate cases can be an outpatient procedure, saving insurers as much as $15,000, according to Dr. Boyne.


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Something to smile about

Something to smile about

October 22, 2007 -- October is National Domestic Violence Awareness Month and according to the American Academy of Cosmetic Dentistry (AACD) five million people are victims of domestic violence in the U.S. every year.

The American Academy of Cosmetic Dentistry Charitable Foundation's (AACDCF) Give Back A Smile (GBAS) program provides free dental care to victims of domestic abuse. They restore broken and damaged teeth at no cost to the victim. To date the foundation has treated 600 cases at a total cost of nearly $5 million.

"After suffering abuse, it is difficult for survivors to find something to smile about, and it's even harder when they don't have a smile to show. Time after time we have witnessed AACD members assist survivors of domestic violence by treating their dental injuries, restoring their smiles, their self-esteem and their lives," said AACD Foundation Director Erin Roberts in a press release.

If one of your patients is a victim in need of help, have them call GBAS at (800) 773-4227 and complete the application process. The AACD will connect eligible applicants with a local GBAS volunteer for treatment.


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