Achieving Increased Efficient Profitability Through Collaborative Treatment Charles W. Fischer, DDS

Revisiting and Improving the General Dentist/Periodontist Relationship

No one needs to tell the dental professional about the economy. The reality is in the appointment chart; in the pushed-off or cancelled recalls; in the patients opting for less expensive – and frequently less effective – restorative options; choosing a patchwork of temporary restorations where they might previously have chosen crown and bridge or implant restorations; and forgoing cosmetic procedures entirely.

With 75 percent of dentists polled by the Chicago Dental Society reporting patients are putting off needed work (fall 2009),1 it is clear that comprehensive marketing of advanced treatment to reluctant patients – and efficient completion of those procedures – is crucial to practice solvency. How can the general dentist increase case acceptance and the accompanying revenue?

While the first instinct might be to keep as much work in-house as possible, assisted by the training and materials offered by manufacturers, there is a growing concern that the endeavor to “do it all” could actually impede the profitability of the general dental practice.

Instead, the general practitioner should look to decrease overhead, eliminate unprofitable chairtime, reduce the need for remakes and increase successful, timely outcomes that generate greater case acceptance.

In the case of implants, crowns, bridges and even veneers, there is a proven, readily available road to these optimal results that might not be the first tactic a general dentist considers, but is increasingly difficult to ignore: collaboration with periodontists.

The Case for Collaboration

In a market that four years ago was estimated to generate $1 billion annually, with some 500,000 Americans expected to receive dental implants each year,2 implantology seemed a smart choice for expanding the reach and revenue of the general practice.

CE courses were presented regularly, manufacturers offered increasingly accessible materials and technology, and most importantly, patients for implants and other periodontal procedures were plentiful.

Being well educated, well informed, clinically capable and encouraged from all sides to keep procedures safely in-house, the confident general dentist invested in expansion. In more robust times, the investment made sense. Manufacturers, key opinion leaders and dental trade media all promised increased revenue, improved patient acceptance and loyalty, along with greater professional autonomy to the general dentist who could “do it all.”

Flash forward to 2011, where the ongoing economic downturn has reduced the acceptance of discretionary services across the board. Job and insurance losses have left patients unable or unwilling to invest in procedures not considered a health priority. Faced with a decreasing pool of likely patients and increased costs in maintaining education and inventory, more general dentists are now finding that the outlay needed to perform advanced procedures often outweighs the advantages.

“I have advanced training in placement of implants,” says Stuart Chavis, a general dentist in New Jersey, “but right now I feel it is best to have the periodontist place them. Their surgical background and the fact that they’re placing implants all year for their referring doctors allows them to keep current with the investment in advanced technology. So I’m referring my implant cases to them.”

A Step Backward, or Savvy Economics?

The desire for improved cash flow is hard to argue with when dentists are reporting a 90 percent decrease in patient acceptance of cosmetic cases (Chicago Dental Society).1 It therefore seems counter-intuitive to send revenue- generating procedures out of house, especially when a practitioner feels confident in his or her ability to successfully complete the procedure.

David Schwab, PhD, of David Schwab and Associates Health Care Marketing, understands the recessionary pressure and the reasoning behind keeping patients in-house, but questions the traditional business model. “As the economy slows down, the general dentist will say, ‘I really have to keep everything in-house because my patients are scarce and I would, frankly, rather have the revenue myself,’” says Schwab.

Then why does Dr. Schwab recommend to his clients that they refer periodontal care to a periodontist? In his view, the two offices working together can encourage more patients to accept treatment, can complete procedures faster and can produce highly successful outcomes, creating economic rewards for both partners in a dry market.

“The ultimate goal is to get the dental patient to accept care,” says Schwab. “This is no time for a silo mentality. The new patient flow is down and acceptance is down; it’s now more important than ever to educate the patients we have. And the way to do that is have a specialist, such as a periodontist, and the general dentist work together. Get the patient in, have them referred to the specialist in a timely way; they’ll get the educational message from two doctors, plus the benefit of combined expertise. The general dentist will get the patient back, finish all their restorations and have the opportunity to keep them for life.”

Avoiding the “Jack-of-All-Trades” Syndrome

What does a periodontist contribute that would lead a skilled general dentist to forgo completing periodontal work in their own practice? For some, it’s the freedom to excel at his or her craft, while providing patients with the best possible care. A team of specialists might serve as a necessary extension of a general practitioner’s quality comprehensive care plan.

Very few dental professionals can be a true jack-of-all-trades. A large majority of general dentists are currently highly skilled and consumed with performing a long list of new techniques concerning restorative technology. It is hard to imagine any dental professional performing periodontics, endodontics and orthodontics, all with the same expertise and precision. General dentists trying to deliver all aspects of dental care might struggle with simply finding the time to perform the specialty that they do best, and that’s usually restorative dentistry.

Periodontists are, by the nature of their specialty, usually exposed to more and newer treatments, technology, techniques and therapy for periodontal disease. On the other hand, the typical general dentist, with a much broader range of services to keep abreast of, cannot be expected to study and incorporate periodontal developments at the rate a specialist does.

As a result, for many general dentists, the innovations in periodontal care that can drastically improve their own cases remain buried beneath layers of more urgent reading material. Therefore, it is up to the periodontist to share this knowledge through consultation, case management and case referral, to the benefit of both parties.

“Many general dentists simply don’t know what the periodontist can now do for them, besides scale and root plane the teeth,” says Mark Setter, a practicing periodontist and educator who routinely speaks to general and restorative dentists, with eye-opening results.

One revelation that dramatically changes the dentist’s outlook on efficiency and profitability, according to Dr. Setter, is the description of pre-restorative periodontal treatment for crown cases.

In cases with significant thinning of tissue at a restoration site, such as a tooth with gingival recession, a dentist has little choice but to place the crown on the root, says Setter, where weak tissue is going to continue to recede. A periodontist, however, can provide pre-restorative grafting to build back the thickness of supporting tissue, allowing the crown to be properly positioned and quickly seated upon healthy tissue that won’t recede afterward.

Dr. Setter, who teams with a number of general dentists in his private Michigan practice, knows that he increases their efficiency when he provides such procedures, as well as when he places their implants, because they tell him as much. He wishes more generalists knew what periodontists can do for them. “When I describe to dentists how we can pre-restoratively establish adequate thickness and quality of tissue,” he says, “their jaws drop.”

Awareness of the periodontist’s abilities might influence case management from the moment he or she conducts a patient evaluation. For an adult who requires restorative care, their periodontal health is paramount. A solid foundation of good oral health should be in place before any restorative work is performed, as a healthy base will help establish and sustain optimum patient outcomes.

For example, early to moderate disease might just call for some basic periodontal therapy in-office. But without restoring the gum and tissue back to a stable condition, the restoration should be put on hold, pending a specialized periodontal evaluation and treatment.

Even in cases not involving periodontal disease, a periodontal referral can improve outcomes and efficiency. One such circumstance involves the patient who presents with a broken tooth, generally necessitating a lower crown placement. In this case, the periodontist can perform controlled crown lengthening to create a proper perio/restorative interface, along with a symmetrical, aesthetically pleasing smile line. Upon return to the general dentist, the crown can be easily seated without tissue packing, and without trauma to surrounding gingival tissue, a bonus for doctor and patient alike.

Teaming to Increase Implant Acceptance

Taking good advantage of clinical advances isn’t a difficult choice. But the case scenario most likely to ignite a dentist’s “do I or don’t I?” tug-of-war is the implant. While most dentists have at some time referred out high-risk or complicated implant placements, the argument for referring out all of them can be harder to embrace.

Management consultant David Schwab reminds his clients that when they collaborate with periodontists, they present to their patients a level of care that will boost implant case acceptance in the face of reduced demand.

As noted, the cost of maintaining equipment inventory might no longer be worth the expense for fewer implant procedures.

As the most accomplished general dentist knows, even simple implant cases can present time-consuming clinical challenges that can cause allotted chairtime to run over, again negating fiscal gains and potentially necessitating a referral after all.

After referring out initially for a high-risk implant case, the dentist might discover it to be more profitable to refer out all implant cases, freeing that chairtime for patients returning for restorative work.

Many general dentists who position their practices as specializing in implants frequently refer implant placement cases to colleagues for superior results. Oftentimes, when they experience the aesthetically pleasing results of grafting or implant placement performed by the periodontal specialist, they are greatly relieved and satisfied that their work has been made simpler due to a solid foundation.

The Benefits of Knowledge Sharing

Physical accomplishments aside, the periodontist partnership can positively impact case management throughout the general practice. Shared knowledge of new diagnostic protocols can assist dentists in classifying and treating patients earlier in the periodontal disease process, leading to greater treatment success.

Inflammation, once a wait-and-watch symptom, is now understood by periodontists to be capable of causing immediate bone damage at the inflammation site and more importantly, to be a causative factor in systemic conditions, including cardiac complications.

Pocket depth can also be misleading as a factor in the severity of periodontal disease. However, teaming with the right periodontist can give general dentists their own sounding board for when to refer, and when to treat such cases in-house. Dialogue with a periodontal partner not only increases awareness of disease indicators, but provides general dentists with a trusted colleague to whom he can refer without hesitation such as a case of sudden pocket depth or bleeding, which might be a result of an underlying medical issue. Other cases might be more subtle, but patients can benefit from being referred to a specialist on a timely basis.

General dentists can also benefit patients by calling on the periodontist for procedures that might not be considered to be within their milieu, such as early trauma that might cause root resorption and bone tissue erosion later in life. When presented with such cases, many times a consult with the periodontal partner will better serve the patient.

Patient health is what is paramount, and the periodontist must remember that when working with a general dentist, says Dr. Mark Setter. “The periodontist has to earn their place on the team of a general dentist colleague. He or she must contribute and be willing to share knowledge with other team members.”

Finding a Clinical Partner

How does a general dentist select a periodontist to join their team? Dr. Setter suggests looking for a periodontist with the following qualities:

• Delivers the results you want: the better implant placement, and better understanding of prosthetics, that improves the profitability of your restorative phase by providing quick, outstanding implant treatment.
• Passionate about their specialty and nurtures it, both taking and teaching continuing education courses, and educating their patients and peers.
• Manages a practice where every staff member is dedicated to increasing case acceptance through education.
• Willing to assist you in diagnosis and treatment planning when you have questions.
• Understands the value of collaboration, and will impart their knowledge to both of your benefit; accomplishing a shared vision for the patient’s treatment.
• Prepared to be your go-to specialist – you are a general dentist and a talented clinician. Look for a periodontist who matches your standards, and you can improve patient outcomes together.

Summary

While the economic downturn might negatively affect some aspects of elective professional dental procedures, periodontal treatment need not, and indeed should not, be a casualty for the general dentist or periodontist.

Working together, general dentists and periodontists can achieve the goal of having patients accept needed treatment, while increasing the fiscal rewards for both practices.

Practitioners can work together to define which patients are candidates for being treated in-house, which pose challenges and potential complications that might best be handled in the periodontal office and how successful after-care and follow-up can create a patient for life for both practices.

Clear lines of communication, co-marketing and extensive training of office staff improve patient education, which in turn improves case acceptance. Having two doctors in agreement on the best course of treatment indicates to the patient that their outcome is important and that they are receiving the absolute best periodontal care in a collaborative effort from both offices.

References:

1. Tough economy takes its toll on teeth. PRNewswire Web site. http://www.prnewswire.com/news-releases/tougheconomy- takes-its-toll-on-teeth-85185387.html. Published February 24, 2010. Accessed March 17, 2010.
2. Dental implant facts and figures. American Academy of Implant Dentistry Web site. http://www.aaidimplant. org/about/Press_Room/ Dental_Implants_FAQ.html. Accessed March 17, 2010.