From the ivory tower: Dentistry at a crossroads - chainstore vs. private dental practice

By Edward F. Rossomando, DDS, PhD, MS, and Mathew Moura

In a recent Time Magazine article, Bernard Stamler stated, “Americans buy everything from burgers to coffee to karate lessons at franchises. They’re convenient, predictable, and often cheap. So why not try franchising a service most of us avoid like a trip to the dentist? Actually, it is a trip to the dentist. Meet Vital Dent, purveyors of franchise dentistry.”

It may be that today most, especially those in the dental industry, do not see the possibility of such chainstore-franchise dental “practices” making much headway in the market. Though popular in Europe, especially Spain, many dismiss such a threat by quoting the old saying, “It can’t happen here.”

Given the changes in the delivery of health care in pharmacy and medicine, the probability of Vital Dent and other such companies encroaching on delivery of dental services seems unavoidable. In the delivery of pharmaceutical services, the past 15 years has seen a decline in privately owned drug stores of more than 20 percent while chain stores and mail order have acquired half the market of pharmaceutical drug retailers, leaving the “mom and pop” stores a mere 14 percent. Similarly, Wal-Mart has become involved in the delivery of medical services by opening clinics staffed by nurse-practitioners who prescribe medicine. In some states, these nurse practitioners even treat patients. Clearly the delivery of health care through chain stores is on the rise and the question is whether this increase poses a threat to the dental profession.

While Stamler glamorizes Americans as convenience-driven, what Americans seem to be looking for in health care is that it is affordable and, perhaps more important, accessible.

Is it possible that the delivery of dental care will undergo the same, or perhaps a similar, paradigm shift away from independent, privately owned practices to chain stores?

The access to health care crisis

The establishment of the Vita Dent delivery model suggests that there is a need for greater access to oral health care - a need that is not currently being met by the dental profession. In fact, this need was addressed in 2000 in the Report of the U.S. Surgeon General on Oral Health in America.

The 2000 Surgeon General’s Report described the oral health care crisis:

• 108 million Americans do not have dental insurance
• For every child without medical insurance, there are 2.6 without dental insurance
• For every adult without medical insurance, there are three without dental insurance
• In 1998, a total of 53.8 billion was spent on dental care with 52 percent covered by insurance and government, and 48 percent paid out of pocket.

With accessibility decreasing, especially among low-income families, and insurance premiums increasing sometimes quadruple the rate of inflation, the report predicted that many Americans had no choice but to opt out when faced with fee-for-service dental procedures offered at private practices.

While financial constraints are often cited as one reason for patients’ lack of access, there are other factors such as location of the dental office. Location of a practice is sometimes more vital to access than the acumen and skill of the dentist. Consider the example of the pharmacy - a major reason that chain stores such as CVS can afford a highly trained pharmacist, who works perhaps three days a week and “technicians” with less training filling out the rest of the hours, is because CVS does not exclusively rely on revenue generated from its pharmacy. In other words, just as Wal-Mart uses CDs as a loss-leader, CVS can afford to keep a pharmacy operating with high overhead because its convenience attracts consumers to whom the pharmacist can suggest generic, CVS brand supplementary medication (81 percent of people in a 2004 survey answered that they bought generic brands due to rising health care costs). A dentist, if affiliated with a chain store, would have the same opportunity for suggestions for additional oral health care.

As more and more dentists retire, and with only 4,200 graduating from dental schools nationwide, the problem of access for many Americans will increase and the chainstore option will become even more appealing. Given the decrease in dentists, it is reasonable to expect that many beginning dentists will seek to open high-end, metropolitan private practices. These markets, however, run the risk of becoming saturated. Those patients in rural or low-income areas, where many private practices cannot survive because of the lessened likelihood of those families having insurance or being able to afford out-of-pocket expenses, will seek out chainstore dental care.

Biodontics as part of the need for educational reform

Although chainstore dentistry may represent a very real threat, it is also a sign that our profession needs reform. The most logical place for this reform is in the dental curriculum, the “playbook” schools use to teach new dentists the basics of our profession.

One such attempt at reform of the dental school curriculum is underway at the University of Connecticut School of Dental Medicine. This pilot program, the Biodontics Educational Program, was designed to enhance access in two ways:

• Increasing the use of new products and technologies in the dental schools
• Including the latest management techniques to increase teamwork in dental practice.

If successful, the Biodontics program will provide dentists with the skills to critique, assess, and use new technologies and products, encouraging their introduction into dental practices and allowing the office to function more efficiently and productively.

The Biodontics Educational Program is but one attempt to educate a new kind of dentist, one with a skill set that incorporates the latest technologies and more efficient management techniques. With the 2000 Surgeon General’s Report in mind, a Biodontic dental practice will be able to increase the efficiency and productivity, thereby allowing the dentist to provide access and better care to more patients.

The delivery of dental care is at a crossroads. Whether Americans choose chain stores or private practices may depend not only on issues related to cost and location, but also on the specialized skills and training of the dental professional. Such a highly skilled professional will provide care that cannot be found at Wal-Mart or chain stores.