Date: July 31, 2015

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Prosthodontics – Podcast

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Show Notes:

Session 28. The specialty of Prosthodontics

By Scott McDonald

Hello, this is Scott McDonald and welcome to the Perfect Place to Put a Practice Podcast.   Normally, our discussions focus primarily upon the consideration of issues relating to office spaces, locations, and marketing.  I had a very productive conversation with a young prosthodontist this week who inspired me to put down my observations and experiences because I think there are some things that need to be said that will, in fact, help guide locations where prosthodontic practices are practical and where they are not. To do this, I need to talk about the other dental specialties to provide a reference point to the practice of prosthodontics.  Please be patient with me.

As a very young man (in my mid-twenties), I was working as a staff person at the California Dental Association.  The topic had been presented to a certain council I was working with regarding the various dental specialties and how they were trying to protect themselves from losing control of particular procedures that they had traditionally offered.  To be honest, I assume that everyone has heard these stories and knows of these debates.  Unfortunately, I cannot be sure so I am going to share what I know and present recommendations from my experiences.  It is likely going to step on some toes and maybe hurt some feelings.  That is certainly not my intention.  In fact, my hope is to discuss how prosthodontists can thrive in the current healthcare environment.  But I should also confess that my point-of-view as a marketing professional and researcher with more than 30 year’s practical experience may contrast sharply with organized dentistry, legislative and regulatory agencies, the dental education establishment, and the governing bodies of the prosthodontic organizations.   Please accept the fact that I am a supporter of prosthodontics as a specialty, separate and distinct from general dentistry.

It became clear in the early discussions of dental specialties that some have a natural advantage in defining their niche of services.  Pedodontists (who eventually branded themselves as pediatric dentists), obviously treated children.  The range of services for these practices was never really as clear as the patient character that they tended to treat.  Where they treating infants? Was they value in treating deciduous teeth?  Was the real value of a pediatric dentist in their handing special anesthesia needs?  You get the message.  At least, it was easy for the public to have even a vague notion of WHO should go to them and that has served them. But it should be noted that regulators did little to defend this or other specialties.  The trend has been to let the market decide.

By contrast, orthodontists were the good folks who put on braces.  Until appliance like Invisalign came along, general dentists did not have the clinical expertise to provide this service.  The waters have been muddied as weekend courses intended for GPs were intended to add some kind of orthodontics to their armamentarium of services.  Rather than get into a discussion regarding the validity and effectiveness of this technology and the wisdom of having GPs offer this service, the numbers indicate that orthodontists continue to maintain significant market share as providers of these appliances.  It is undeniable that the referral patterns to orthodontists have waned.  In the old days (when I was young), no patient would seek care from an orthodontist without a referral.  Granted, this pattern continues in some cases but not to the extent it once did. Now, most patients and parents of patients find an orthodontist on their own via their own research.  The AAO has worked hard to facilitate finding member orthodontists and providing the air of uniqueness to their care.

Oral and Maxillofacial surgeons were always involved in extraction and, frankly, so were general dentists.  Over time, a consensus seems to have formed in which “difficult” cases were assigned to the specialist OMS while simple extractions are still done regularly by general dentists.  But as we have followed the surgeons and their practices, many push the envelope of what oral surgery is.  Should it be limited to hard tissue rather than soft tissue?  Are cosmetic procedures not just in the mouth but on the face be included? In some communities, Botox injections are quite common in the OMS office.  Some have delved into procedures that rival the plastic and cosmetic surgeons. This includes surgeries on noses, ears, and breasts.  It is not hard to imagine why as many surgeons have added an MD to their professional credentials.  Still, the surgeons still maintain the majority of difficult procedures like the removal of molars and endodontically treated teeth.

This brings us to endodontists. They are known for doing root canals (obviously).  But a surprisingly large number of general dentists have decided that they are capable of doing most if not all treatments.  It is one reason that our anecdotal research indicates an ever increasing number of failures of these treatments with some pretty awful results.  What many GPs don’t seem to grasp is the technological advances available to endodontists that have changed the standard of care.  The increased uses of operating microscopes, for example, along with tools and techniques to deal with difficult cases have improved their success rates.  My purpose here is not to advocate for a specialty or a specialist.  Rather, it is to place into perspective the specialties in the dental market place. 

Endodontists depend upon the referrals of general dentists and seem frustrated (based upon our experience) with the decline in these referrals as are oral surgeons.  We are well aware that many dental consultants (and we mean no offence here) seem to advocate for more and more treatments to be done by general dentists to make up for declines in new patient care and reductions in compensation.  Root canals and extractions pay well.  The problem is that unless a general dentist is doing many of these procedures usually reserved for Endodontists and OMS, the point of profitability is more illusory that not. 

Keep in mind that oral surgery and endodontics have still been able to identify a core range of services even though they are often reserved to difficult cases.

Periodontics has had an easier time.  Soft tissue surgeries are typically difficult and require a knowledge of techniques and pharmacology that most general dentists just don’t want to tackle.  Even the public is aware (at least vaguely) about periodontal disease.  They “get it” on a certain level and so do general dentists.  But it is the fact that a person who is already medically compromised would seek care from a periodontist makes the success rate far lower that is could be.  It is no one’s fault but it is fairly well understood that making sick tissue healthy again is often an uphill batter especially when one considers how the patient got to this state to begin with.

From our own proprietary studies, we know that the general public can understand that there is a difference between these specialties and can be fairly easily convinced of their necessity.  True, some procedures like dental implants tend to cross all over the profession and still are not “owned” by any of them including general dentists.  A good case can be made for any of them.  But when we consider prosthodontics, the general public is in the dark.  The word itself is cumbersome and tends to defy description.  It does not help that the prosthodontists themselves, including those in academia, have done next to nothing to help brand the benefits and features of the specialty in the dental marketplace. 

Not so long ago, a prosthodontist was responsible for providing bridges and dentures.  Most specialists either owned or were affiliated with a dental lab.  In some states, it appeared that for a lab to be “certified” it had to have a prosthodontist associated with it.  Now, dental labs are independent, sometime international, and often highly technically competent.  Crown fabrication in a general dental office is no longer a rarity.  Once again, it is not my intention to debate the value of this technology.  I just want to point out that they are ubiquitous.

 

Where does this leave prosthodontists?  The fact is, their niche has largely disappeared.  Many prosthodontists come to us at DoctorDemographics.com and ask where they can practice successfully.  Our first line of inquiry is to ask them the range of services they contemplate.  Will they be true specialists who “limit their practices” like other non-GPs or do they intend to compete with GPs by attempting provide a full range of service but offering some “perks” based upon their advanced training?  The tip off for us is to ask if they will hire a hygiene staff.  If the answer is, “yes,” we know that they are not going to attempt to influence general dentists to refer.  In essence, they become “super-GPs” who are competing with their potential referral base. 

It might be useful to consider ophthalmologists.  This branch of vision care may be the model for prosthodontists to renew and restore their niche.

I have maintained a relationship with vision practices (which are optometrists, ophthalmologists, and opticians). The division is that optometrists are generalists and have a professional designation.  Ophthalmologists are physicians, most often with an M.D.  Like surgeons, they can cut into the eye and perform far more invasive procedures than an optometrist.  They can prescribe medications and treat a wide range of diseases.  But it was a single, new procedure that resurrected what was a fairly obscure branch of medicine: Lasik surgery.  The technique does not need to be described here.  But essentially, it represents a significant departure from optometry that had previously had been the only serious manifestation in vision care.  It is almost as though this procedure was invented o give ophthalmology a reason for being. 

From my perspective, the ideal would be to go back to the clinical side of prosthodontics and examine the materials and procedures that set this specialty apart.  At one time, it could have been dental implants but, to be honest, the other specialties jumped on this very quickly and effectively when representing their positions to national and state regulators.  But I thoroughly believe that there are advances in dental materials that prosthodontists should grasp with both hands (and a foot).

The second step would be to brand the specialty and the procedure(s).  The word prosthodontics is well understood to someone who speaks Greek or Latin.  It is not so well understood by anyone else.  That is why I recommend a name change to the specialty that would be better understood intuitively for what it is.  I don’t pretend to have had the time or the inclination to do this but I know that it can be done. As an example, we NEVER refer to ophthalmology any more.  But everyone knows who the Lasik surgeon is and what he does.  I believe that these two steps are vital and should precede any membership drives or appeals to regulators.  If the first two steps are successful, all subsequent steps will follow. 

 

Personally, I believe that prosthodontics can thrive as a dental specialty but only if the professionals understand what it is that they do that is different from their general dental colleagues.  They cannot afford to wait around for someone else to decide for them.  I also believe that the associations of prosthodontists should get a wake-up call regarding what they can do rather than being passive.  These efforts would be greatly enhanced with the additional support of those who teach in dental schools.  In my opinion, I fear that they consider the clinical aspects of this specialty but don’t seem to be active in considering the promotion of a consolidated brand.  It can be done and it should be done as soon as possible.

In conclusion, all of the associations over all of the specialties have an obligation to continue to identify their niches in the marketplace and not to resort to regulatory bodies to decide these issues for them.  I don’t believe that a national constituency exists to do that.

This is Scott McDonald and thank you for listening to the Perfect Place to Put a Practice Podcast.  Take a look at our web site at DoctorDemographics.com for the services that will be of help as you develop your practice.


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