Laura Dorr is the former executive editor of DPR's Modern Dental Network and a regular contributing author.

Laura Dorr

Integrating Oral Health Care into Systemic Disease Management. Image credit: © freshidea – stock.adobe.com

The term oral-systemic health is just a long way to say what it really is: Health. The mouth and the rest of the body are intrinsically linked—a fact that often goes overlooked. Dentistry and medicine continue to march forward on parallel paths that have historically not overlapped, leaving health care siloed into care for the body and the mouth, much to the detriment of overall health.

“Oral-systemic health is probably the most critical missing link in healthcare today,” says Sam Shamardi, DMD, diplomate of the American Board of Periodontology and Implant Surgery. “So many major medical health issues are directly linked to the mouth (and more specifically, to periodontal disease). Having a greater awareness of this within the medical community and greater population would create a seismic shift in overall patient care.”

Many dentists, doctors, and organizations like the American Association for Oral-Systemic Health (AAOSH) want to shift this paradigm. Oral health care is critical to overall healthcare due to the many associations between oral inflammation and systemic disease. However, the traditional mindset (for both patients and clinicians) has been that medical and dental specialties stay in their lanes. Dentists do teeth, and doctors do everything else.

“There isn’t cohesiveness between medicine and dentistry,” says Parul Dua Makkar, DDS, FACD. “Medical insurance and dental insurance are separate, so patients—and some practitioners—subconsciously feel like healthcare and oral health care are different. Groups like the AAOSH are bringing together masterminds of different professions in medicine and dentistry and combining them to make these associations.”

Oral health conditions such as periodontal disease have been linked with numerous health conditions, including heart disease, stroke, cancer, Alzheimer’s, respiratory disease, and more. Oral inflammation, bacterial contamination, and soft-tissue issues are all factors that can affect systemic health. This association with systemic conditions makes oral healthcare critical to health in general.

“The mouth is the gateway to overall health,” says Ellie Campbell, DO, MS, FAAOSH, secretary of AAOSH. “If you don't have proper nutrition and diet, your body cannot fight back. If you have bad oral health, infections, or periodontal disease, that’s all passing through the same bloodstream that goes to your heart and lungs and affects those organs. It’s all interconnected.”

In addition to associations between periodontal disease and oral infection with overall health, the physical structure of our mouths and jaws greatly affects the health of the rest of the body.

“Pathogenic oral bacteria affects so many areas of total health,” says Mike Milligan, DMD, a founding member and board member of AAOSH. “In addition, the structure, posture, and function of our mouths affect the quality of our airways, the way we breathe, how well we breathe and sleep, the oxygen and carbon dioxide levels in our blood, and our overall health.”

Where Oral Health is Being Integrated into Care

For Dr Campbell, learning about oral-systemic health was necessary to improve patient care in her integrative family medicine practice. She had an elderly patient whose blood pressure and cholesterol were managed with medication but was otherwise healthy. Despite this apparent good health, the woman suffered a stroke. Unfortunately, hemorrhagic transformation complications developed, and the woman ended up passing away.

Dr Campbell was troubled by the case. Where had conventional medicine failed and what had caused the stroke when the woman was presumably healthy? She began researching to determine what triggered the event, ultimately learning about the link between periodontal disease, inflammation, and stroke.

“I learned the woman had been complaining of a toothache in the weeks before her stroke,” Dr Campbell says. “Now I understand that I have leading indicators and bloodwork that I can do that can tell me months and years in advance that this patient has an inflammation problem, that their arteries are inflamed, and likely, depending on which markers, it's either a periodontal or endodontic problem.”

Since Dr Campbell began identifying sources of inflammation and the associated underlying root causes in her patients 7 years ago, she hasn’t had any patients suffer heart attacks or strokes.

“Every day we’re hearing about more and more comorbidities,” she says. “This is where I wanted to take steps to eliminate this potential link for my patients.”

Unfortunately, Dr Campbell says, she hasn’t seen an emphasis on this link in many fields outside of integrative medical doctors or biological/holistic dentists. While dentists and doctors are beginning to cross the aisle, the integration is nowhere near where it needs to be.

“The American Dental Association and the American Heart Association both have initiatives on oral-systemic health,” she explains “But I feel like it's mostly just talk at this point; I don’t think it’s been translated into action. There's always an implementation gap whenever there's a new initiative. And I hope that in 2024 and 2025, we'll see more and more doctors become enlightened as they hear these stories.”

Despite the slow adoption, tests, and diagnostics that can identify problem markers are entering the field. These indicators can alert clinicians to issues in both oral and systemic health.

“When people start taking a comprehensive approach, it will shift the mindset away from medicine and dentistry being separate,” Dr Dua Makkar says. “By having open conversations and getting more patients involved in their care, you can help them understand how the two are linked. The holistic approach, where we are doing salivary testing and associating that with a dental exam is where people will start to integrate, and more and more will happen over time.”

This saliva testing is one method that is beginning to close the gap between dental and medical healthcare. Through salivary diagnostics, the antibodies, cytokines, enzymes, and antimicrobials in saliva and blood can help identify underlying pathogens that can cause periodontal disease. These biomarkers can isolate potentially problematic bacteria that could be early indicators of disease, giving time to stave off larger problems before they start. As the availability of in-office salivary diagnostic testing increases, dentists and doctors can easily integrate saliva testing into their routine practice.

Unfortunately, while salivary testing is becoming more accessible in dental practices, that isn’t always the case for patients: insurance often stands in the way. While it may not be overly expensive, the lack of insurance coverage still presents a financial hurdle for many patients.

“The problem right now is that salivary diagnostics that look for oral bacteria are often not covered by insurance,” Dr Campbell says. “So, it takes a motivated, interested patient with enough discretionary income to prioritize their dental and medical health and make the necessary sacrifices to cover those tests.”

Another comprehensive approach to oral-systemic health is the BaleDoneen Method. This method integrates tests (such as bloodwork), oral assessments for periodontal disease, and lifestyle/diet evaluations to assess a patient’s overall risk for cardiovascular disease.

More health care practitioners are becoming aware of the effect of periodontal and apical pathogenic oral bacteria on overall health,” Dr Milligan says. “I have worked with several physicians trained in the BaleDoneen Method of prevention of heart attack, stroke, and dementia, who have an incredible record of preventing these debilitating events. They say they cannot get the results they do without help from a dentist who is aware of and trained in detecting and minimizing the pathogenic periodontal and apical oral bacteria.”

This approach provides a more well-rounded approach to both oral and cardiovascular health. By emphasizing preventative care, periodontal issues can be avoided long before they progress to arterial disease. The BaleDoneen Method is also a critical education tool for patients to help them understand the links between oral and overall health—and that dentists aren’t only examining your teeth but are looking at interconnected systems.

“The mindset needs to shift away from thinking of dentists as cavity hunters,” Dr Dua Makkar says. “When we talk to patients, we need to explain we aren’t just checking for cavities, we’re looking at overall health. I’m taking X-rays because I’m checking for abnormalities. I’m checking your airway, looking for nodes, and screening for oral cancer. Patients don’t know this because it hasn’t been talked about.”

Getting patients to understand these links also opens doors for dentists to educate patients on the importance of nutrition, sleep, and other healthy habits that may typically be associated with body health.

“Some dentists help their patients with lifestyle choices like nutrition, exercise, posture, breathing, and healthy sleep,” Dr Milligan says. “The vast majority of physicians and dentists today are not educated and trained in these areas, but progress is being made, and hopefully many more will become educated and trained. The overall health of our patients will greatly benefit.”

Historically, dentists and physicians have, for the most part, stayed in their respective silos. They treat what they know best, excluding other aspects of the patient’s overall health.

“No one can know everything, so health care providers focus on different areas of interest to them,” Dr Milligan says. “But for maximum overall health for the patient, understanding how oral and overall health interact is extremely important.”

While this is critical in overall oral-systemic health care, it also comes into play in day-to-day treatment. Some patients have conditions that make dental cleanings a risk. For example, it has been recommended that patients with mitral valve prolapses take antibiotics every time they go to the dentist to avoid releasing bacteria into the bloodstream. Many dentists were unsure of what prophylactics and aftercare these patients required. If doctors and dentists communicated better about medical conditions, it would mitigate these concerns.

“When a patient gets an echocardiogram, they don't put whether or not the patient needs antibiotics before dental care at the bottom of the report,” Dr Campbell says. “If you get a knee replacement, there’s no report that says they need to be on prophylactic antibiotics at dental cleaning. If this information was included on discharge paperwork, the patient and the dentist would be educated and could make decisions accordingly. And that’s the sort of interprofessional collaboration we need.”

From a medical standpoint, this communication is just as critical. Many patients don’t get cleared before they go for surgery, leaving surgeons in the dark. Dr Dua Makkar says this could be as simple as noting whether the patient has missing teeth before intubation, or if they have metal fillings before undergoing radiation for oral cancer treatment. Sharing this information between doctors and dentists would form partnerships that not only benefit patient care but also make clinicians’ lives a lot easier.

This transition is beginning, as surgeons and dentists learn more about oral-systemic connections. Dentists are requiring signoffs from surgeons before cleanings, and surgeons are requesting a clean dental bill of health before surgeries.

“I do see more orthopedic surgeons who require a letter of oral health from the patient’s dentist before doing joint replacement surgery,” Dr Milligan says. “I see sleep physicians and dentists collaborating to help patients with UARS and obstructive sleep apnea (OSA). Continuing and growing this is critical. Over time more physicians and dentists are learning about the oral-systemic connections and implementing it in their overall patient care. This process has been slow, but I think it is improving.”

In addition to communication between doctors and dentists, Dr Dua Makkar believes clinicians across the board should be better versed in oral cancer and its potential connections with other systemic cancers. Since different types of cancers can metastasize to the oral cavity, dentists need to know a patient’s medical and cancer history so that the dentist can be vigilant about it. The correlations between systemic and oral cancer are not a one-dimensional story, so multi-dimensional approaches must be taken. To address this, educational opportunities such as the 

“We want to bring together the different facets of medicine and dentistry and how they correlate to oral cancer,” Dr Dua Makkar says. “We look at oral-systemic links, treatment protocols, screening, psychological and nutritional impacts—a comprehensive approach to cancer that clinicians across both fields should know.

While oral health has slowly been introduced into systemic disease management, there is still a long way to go. In addition to dental and medical clinicians collaborating more openly, education and communication need to improve.

“It’s time we begin taking periodontal health far more seriously as a population and medical/dental community,” Dr Shamardi says. “No other area of health care right now can make a bigger impact! Clear communication and teamwork between the medical and dental fields on a high level along with our academic institutions are key to improving integration.”

Before communication is facilitated, clinicians need to be educated about its importance. Integrating oral-systemic health education into medical, dental, and hygiene schools would provide clinicians across the fields with valuable information before they enter the workforce.

“I think a foundation of oral-systemic education should be at every level,” Dr Campbell says. “This starts with the next generation, but I think we all need to participate. Oral-systemic education should be part of the requirements to maintain our licensures.”

Education is critically important because it trickles down to patients. If practitioners don’t understand the importance of oral-systemic health, patients won’t either. And if patients don’t appreciate the connections between oral and overall health, systemic approaches won’t evolve.

“Education of the physicians, dentists, and all healthcare personnel needs to be much better on how the mouth affects the body and vice-versa, as well as the diagnostics and most effective treatment methods,” Dr Milligan says. “The healthcare personnel must understand and believe it and be competent in the diagnosis and treatment before the patient will accept the diagnosis and treatment. Communication with the patient also needs to improve.”

This communication must continue outside of the practice. Dr Shamardi believes that the message won’t make a sufficient impact if patients only hear it from their providers. “We need less bureaucracy and more action,” he says. “There needs to be a major national push to make this topic more of a priority. Cancer and Alzheimer’s receive far more attention than oral health. The irony is that they too are directly linked to periodontal disease!”

“We just need to get the word out,” Dr Campbell says. “We need to start this at the grassroots level and get the information in the hands of consumers. Heart attacks are optional, strokes are stoppable, and dialysis is not your destiny. And all those conditions share something in common: The oral health component. We now have leading indicators, and those things can be preventable. But no cardiovascular prevention program is complete without a medical provider, a dentist, and a hygienist on the team.”

Articles

Whole body health is interconnected, and teaming up across concentrations can be key to keeping a patient healthy and happy. 

Integrating Oral Health Care into Systemic Disease Management 

Diets and Dental Hygiene | Image Credit: © New Africa – stock.adobe.com

Many patients enter the dental practice thinking they’ve done all they can to protect their oral health. They brush, they floss, and they regularly make their 6-month appointments. They think if they tick these boxes, they have taken all the steps toward ensuring their oral health.

However, these patients are missing a critical piece of the puzzle: diet. While patients understand that getting their fruits and vegetables is important for overall health, there’s little comprehension of how a poor diet can affect oral health.

“People don’t understand that their oral health is related to their diet,” says Ellie Campbell, DO, MS, FAAOSH, secretary of the American Academy for Oral & Systemic Health (AAOSH). “They think, ‘Oh, it may affect my body, my weight, my energy level, or my sleep,’ but they don’t think about oral health. I think people have made systemic connections to their diet, but I don’t think most people have a clue that it affects your mouth as well.”

Another part of the problem stems from the lack of understanding about oral-systemic health in general. While poor oral health has been linked to a wide range of systemic conditions (including stroke, diabetes, and cardiovascular disease), many people don’t understand how issues in the mouth can contribute to systemic problems.

“Diet is an essential piece of the overall puzzle,” says Sam Shamardi, DMD, diplomate of the American Board of Periodontology and Implant Surgery. “So much of our population suffers from diabetes and overall insulin resistance, all of which are linked to overall wound healing and periodontal inflammation and breakdown. We are what we eat, is the saying; hence what we eat will impact our health.”

According to the American Dental Association, 2 oral health factors can contribute to these systemic conditions.

 The first is inflammation in the oral cavity. Chronic inflammation (such as that caused by periodontal disease) can increase inflammatory markers in the bloodstream. This can affect the body’s immune response and stress the body’s disease burden. Secondly, pathogenic bacteria in the oral cavity can enter the bloodstream and travel throughout the body, affecting other areas.

“The mouth and rest of the body are completely connected,” says Mike Milligan, DMD, a founding member and board member of AAOSH. “One affects the other. It has been said that the mouth is the gateway to the body and that good health begins in the mouth. Oral pathogenic bacteria and their toxic byproducts and effects enter the bloodstream and travel throughout our cardiovascular system and tissues with varied deleterious effects.”

Inflammation is triggered by several factors, many of which stem from dietary decisions. It is well known that consuming sucrose-rich food such as sugars and carbohydrates plays a large role. Sugars attract bacteria that result in biofilms and bacterial plaque.

“The biggest culprits of inflammation are sugar and flour—and all the products made from them—as well as the consumption of too many omega-6 vegetable oils like soybean, corn, and sunflower found in many processed foods,” Dr Milligan says.

The bacterial components bolstered by sugar can trigger inflammatory responses that result in periodontal disease. As bacteria within the plaque metabolize the sugar, they release acid—a primary contributor to caries and decay.

Because acid can demineralize and dissolve enamel, bacterial acid production is a big concern. Demineralization occurs when pH levels drop below 5.5 for a significant period. When more fermentable carbohydrates are available to plaque bacteria, the pH rises. When carbohydrates are not available, the pH decreases. These fluctuations affect the demineralization and remineralization processes. As such, the frequency of sugar intake, duration of exposure, and pH level of consumables can greatly affect demineralization.

“There’s no such thing as junk food; it’s either junk or it’s food,” Dr Campbell says. “We need to talk to our patients about nutrition and inform them. If you see dental plaque, let them know it may mean they have too much acid in their diet. What are they drinking? Inform them about the effects of high pH beverages and how [they] can weaken enamel.”

For example, water has a neutral pH of 7.0 with zero sugar content. Beverages with pH levels below 7.0 and with higher sugar content begin to cause demineralization. In comparison, Pepsi has a 2.49 pH, with 9.8 tsp of sugar per 12-oz can. Mountain Dew has a pH of 3.22 and contains 11 tsp of sugar. Even sugar-free drinks can cause issues due to their high pH: While Diet Pepsi doesn’t contain sugar, it has a pH of 3.05.For reference, battery acid has a pH of 1.0—just 1.49 lower than a can of Pepsi.

Sports drinks are also problematic because of their high pH and sugar content, and prevalence of use across demographics. A bottle of Gatorade has a pH of 2.95 and 3.3 tsp of sugar.

 In a 2016 survey of adolescents, 87% of respondents indicated that they drank sports drinks, with over 50% reporting drinking them at least 2 or more times per week.

 Other studies have shown an increased risk of dental caries in elite athletes who regularly consume sports drinks.

 Because athletes train regularly and often take repeated small sips of the beverages, they increase their exposure time to pH and sugar.

Because increased exposure time results in increased periods of demineralization, sticky foods with high pH and sugar content pose a significant risk. This can be compounded by high levels of citric acid in fruit-flavored gummies, chews, or candies. For example, Skittles and gummy bears both have a pH of 2.5. Other high-exposure foods include hard candies that must be sucked on for extended periods of time.

With so much talk of foods that are bad for oral health, it’s also important to emphasize to patients the foods that can bolster oral health and well-being (and ones that can mitigate the effects of inevitable dietary bad habits). When it comes to mitigating the effects of diet on oral health, there are several things that patients can do.

“Putting a higher priority on minimizing processed foods, decreasing sugar intake, and trying to create more balance in what and how much we eat all make a major impact,” says Dr Shamardi. “It doesn’t take radical changes to create radical results.”

This balance comes from making good nutritional choices that benefit both oral and systemic health.

Thanks to high concentrations of phosphates and calcium, dairy products can help strengthen tooth enamel. In addition, milk and other dairy products are noncariogenic and can counter high pH levels by temporarily reducing them. Research in Denmark discovered that adults with high milk intake had a reduced risk of periodontitis.

 Additionally, another study found that consuming milk lowered saliva pH after 5 min before it rose again at the 15-min mark.

Increased whole-grain and fiber intake has also been associated with a reduced risk of periodontal disease.

 Replacing refined grains (which are often high in sugar) with whole grains can have a positive effect on oral health. A study of over 34,000 male health professionals in the United States found that participants in the highest quintile of whole-grain consumption were 23 percent less likely to develop periodontitis.

 Diets high in whole grains have also been associated with a reduced risk of type 2 diabetes.

In addition to whole grains, high-fiber foods like crunchy fruits and vegetables have an inverse association with periodontal disease. In addition to being high in fiber, foods that require more chewing (such as apples, carrots, broccoli, and celery) stimulate saliva production. Saliva is one of the most important factors in reducing dental erosion, as it neutralizes dietary acids and promotes remineralization.

Leafy greens such as lettuce, cabbage, spinach, and collard greens contain vitamins and nitrates that can bolster oral health. Nitrates stimulate healthy oral genera and help protect against acids by increasing lactate consumption and ammonia production.

Studies have also found that a high intake of green and leafy vegetables rich in vitamin C, folate, and carotenoids offers anticarcinogenic properties and can decrease oral cancer risks.

Saliva production is reduced when dehydration occurs, so staying hydrated is critical to oral health. Adults should drink at least 64 oz of water daily to stay properly hydrated. Water also helps flush out the mouth, removing debris, reducing bacteria, and supporting a healthy oral microbiome. Thanks to its neutral pH, it does not introduce acids into the oral cavity but instead helps neutralize the pH of saliva.

By making smart nutritional choices, patients can prevent periodontal issues, enamel erosion, and caries. However, since nutrition and oral health are intrinsically linked, one is impossible without the other.

“Tooth loss, decay, periodontal disease, and thermal sensitivity can all affect chewing, food choices, and getting the proper nutrition that is essential for total body wellness,” Dr Milligan says. “Conversely, proper nutrition can significantly affect dental health, including pocket depth and bleeding sites. So, the mouth affects nutrition, and nutrition affects the mouth.”

Dental professionals have a unique opportunity to educate patients on the contribution of nutrition to oral health and oral-systemic well-being. Through education, patients can learn to make beneficial nutritional decisions that increase their oral health.

“Many dental patients don’t have a primary care provider, or a person who is their trusted health provider—except for the hygienist,” Dr Campbell says. “I think this is a role the hygienist can pick up when they have the patient as a captive audience. Clinicians should ask patients what their water intake is, or how many fruits and vegetables they are getting, and explain how these things keep teeth strong and promote oral health. It’s a minute of offhand conversation that can start their wheels turning.”

Introducing this to patients early and consistently can pay off, Dr Campbell says. If patients hear this message at every dental cleaning, twice a year, it starts making an impact.

“As health professionals—whether you’re a dentist, an eye doctor, a dermatologist, or a primary care doctor—we all need to be spending more time on those fundamentals of wellness,” Dr Campbell says. “Then hopefully we can keep that prescription pad in our back pocket for the times when these therapeutic lifestyle changes don't work.”

1. Oral-systemic health. American Dental Association. Updated September 11, 2023. Accessed April 3, 2024. https://www.ada.org/resources/ada-library/oral-health-topics/oral-systemic-health/

2. Sugars and tooth decay. Action on Sugar. Accessed April 2, 2024. https://www.actiononsugar.org/sugar-and-health/sugars-and-tooth-decay/

3. Joshipura K, Dietrich T. Nutrition and oral health: a two-way relationship. In: Bales CW, Ritchie CS, eds. 

4. Minnesota Dental Association: acidity (pH) and sugar content of beverages. Oralsystemiclink.net. May 17, 2017. Accessed April 1, 2024. https://oralsystemiclink.net/health-care-providers/profile/minnesota-dental-association-acidity-ph-and-sugar-content-of-beverages-1

5. Broughton D, Fairchild RM, Morgan, MZ. A survey of sports drinks consumption among adolescents. 

6. Frese C, Frese F, Kuhlmann S, et al. Effect of endurance training on dental erosion, caries, and saliva. 

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9. Shimazaki Y, Shirota T, Uchida K, et al. Intake of dairy products and periodontal disease: the Hisayama study. 

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10. Sharma A, Sharma D, Singh S, Sharma A, Sharma R, Sharma M. Milk and its products: effect on salivary pH. 

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11. Nielsen SJ, Trak-Fellermeier MA, Joshipura K, Dye BA. Dietary fiber intake is inversely associated with periodontal disease among US adults. 

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12. Merchant AT, Pitiphat W, Franz M, Joshipura KJ. Whole-grain and fiber intakes and periodontitis risk in men. 

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13. Fung TT, Hu FB, Pereira MA, et al. Whole-grain intake and the risk of type 2 diabetes: a prospective study in men. 

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14. Buzalaf MA, Hannas AR, Kato MT. Saliva and dental erosion. 

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15. Rosier BT, Buetas E, Moya-Gonzalvez EM, Artacho A, Mira A. Nitrate as a potential prebiotic for the oral microbiome. 

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16. Hirayama T. A large scale cohort study on cancer risks by diet: with special reference to the risk reducing effects of green-yellow vegetable consumption. 

What you need to know about how your patients’ diets impact their oral health.

Diets and Dental Hygiene

Focusing on the Details: Blind Spots to Avoid When Buying a Dental Practice | 

Buying a dental practice can be a complicated, daunting process. With so many things to consider, it can be easy to overlook critical numbers or find yourself floundering as you slog through metrics. Plus, what about all the things you haven’t even considered?

Factors like financials, patient attrition rates, and accounts receivables are all critical to examine during the practice acquisition process, but the considerations when buying a practice go beyond the numbers. There are other blind spots that buyers often overlook that can cause big problems in the long run.

“It’s probably the biggest investment of your life,” says Bruce Bryen, CPA, CVA, a dental practice valuation analyst at Baratz & Associates, P.A.“You want to be sure you do it right, and are thorough in your process. The decisions that you make in the acquisition period could affect your practice for years to come.”

What blind spots should buyers avoid to prevent making the wrong decisions? There are a few things to keep in mind.

Before the sale even gets off the ground, there are pitfalls for buyers to fall in to. A big one is not assembling the correct support cast to assist with the process. This includes a broker or practice-transition consultant, dental CPA, experienced dental evaluator, and a good attorney. A dental-experienced lender can also streamline the process, as they will have a better understanding of goodwill than a general lending.

While you may think you know what you’re doing, having a team of experts like this behind you can ensure you get the most for your money.

“Get the best dental evaluator you can get,” Bryen recommends. “Get the best dental CPA you can get. And get the best attorney who knows something about dental. It's rare to find an attorney who has experience with dental, but it can make a big difference. You don’t want to use someone who is not informed on dental. Maybe you use an attorney who might be a good divorce attorney, or a personal injury attorney, but they don’t have experience with dental practices. This is a mistake. Why wouldn’t you use the person who has the expertise?”

There are of course upfront costs that come with recruiting legal or valuation assistance, but it’s worth the money. While the numbers may seem daunting at first, it is important to remember that over the course of your practice tenure, these costs will be insignificant—and could end up paying dividends in the future.

“I think a mistake people make is that they don't want to spend the money,” Bryen says. “They want to get an evaluator that charges the lowest amount, which is less than what a good dental practice evaluator would charge. While the upfront cost can be intimidating, it you amortize it over the time you have the practice, it’s nothing. And it could save you a lot of money in the future if you have it done correctly at the beginning.”

Collaborating with a dental CPA also has benefits. They will know which red flags to look for before a buyer signs an agreement, and may even know more about what to look for in said agreement than the attorney.

“One example is work in progress,” Bryen says. “That is such a big deal and it is often overlooked, especially by an attorney that doesn’t have dental orientation. It is one of the biggest problems. Work in progress, the accounts receivable, how slow they are coming in, existing staff, infrastructure, etc. Is anyone going to leave due to the change? These are all important things that need to be examined.”

Hiring a consultant to evaluate the practice processes, staff, and systems, and perform audits can also be beneficial. Consultants like these can also be helpful after the due diligence period and through the post-sale transition. They can give advice on where changes can be made to make the practice run more efficiently, suggest staffing adjustments, and help adjust protocols to meet your preferences.

Even if you take steps to assemble a team, not choosing the right evaluator—or not doing your own valuation at all—can be a blind spot that can really backfire. The buyer should always get their own valuation of the practice. After all, if you purchase a house, you don’t solely rely on the seller’s valuation.

“Everyone is going to think their house or their business is worth more than an appraiser will say it is,” Bryen says. “If you are buying a house, you’re not going to listen to the seller; you are going to get your own appraisal. The same thing goes for buying a dental practice. The person that is paying gets the advantage, so you want to bring in an independent party.”

Once you bring in an evaluator, you need to ensure you’re getting the information you need. A quick look at the books is not a sufficient evaluation of a practice.

“A good valuation should be 25, maybe 30 pages,” Bryen says. “It shouldn’t be a 1-page valuation. You want it to be thorough. You should have an evaluator that is detail-oriented and has a realistic amount that the dental practice is worth—not just what the seller or a general business evaluator says. Then you’re off to a good start.”

Finding an evaluator that can give you these things means taking the time to do some research, so that you know you are getting one that will be effective. After all, this is the person that will put a number on the business.

“Picking the right evaluator is really important,” Bryen says.“If you choose a general business evaluator, you’re making a terrible mistake. That person is not going to understand that a dental practice is primarily goodwill.”

Bryen recommends interviewing 2 or 3 evaluators to learn about their experience, such as how many dental practice valuations they have prepared, how many years they’ve been doing it, and how many critiques of other valuations they’ve completed. It’s also important to determine if an evaluator is willing to go to court if it comes to it, and how many times they’ve had to do that.

“You want an evaluator that is going to support you if something happens,” Bryen says. “You want someone that will go all the way. If the answer is no, they won’t go to court, then you want to pick someone else. You may not think you will end up in court, but these situations happen, and you want the evaluator to support you.”

In these situations, having an evaluator becomes even more important. Even experienced buyers should not go at it alone. For example, say a second-time buyer that used an evaluator for their first purchase decides not to use a practice evaluator for the second practice acquisition. They go through the first valuation and try to follow it step by step. But then an issue arises and it goes to court. The judge may not accept the valuation or opinion of value, because the buyer is not independent.

“You know more as a dentist about the practice, but you have a problem,” Bryen says. “Your word is not going to be accepted by a court because you’re not independent or impartial. They want someone who is independent, and will probably be more conservative than you. So, you need to have someone that will go all the way with you, just in case.”

While combing through the financials and understanding the numbers is important, it’s also critical to evaluate the value and state of the physical building, equipment and inventory. If something goes wrong in these areas after a sale, it can end up costing the dentist a lot of time and money, which hurts the investment.

One example Bryen gives is that of a buyer who purchased a practice, and discovered after taking over that the air conditioning didn’t work. They then learned that it hadn’t worked for a long time, and nobody was made aware. They ended up going to court over the nondisclosure, which was time consuming and costly for everyone involved.

“It’s like buying a house in that you want to get a physical inspection,” Bryen says. “You don’t want to get stuck with problems that should have come up before the purchase, because it’s going to cause a lot of issues on the other side.”

Inspections should also go beyond the physical structure. Inventory should be evaluated (including small tools and instruments), and equipment and software carefully examined. Inheriting outdated or malfunctioning tools means hefty investments right out of the gate.

“Evaluate the condition of the equipment,” Bryen says. “What sort of shape is it in? How old is it? It can be older if it’s in good shape and there is a contract or warranty covering it and someone comes out to keep it updated. But if you don’t know the state of the equipment, the buyer might have to sink $100,000 to $200,000 into new equipment after closing. That’s going to add many more years before you start seeing any payback on purchasing the practice.”

Buyers will also want to consider if the technology in the practice is compatible with their preferred practice-management software. If you will be transitioning the practice’s current software to another platform, ensure that existing hardware such as digital imaging tools will integrate with the new software. Digital sensors alone can cost up to $10,000 (before hidden fees), and CBCT price tags reach into six digits, so replacing this equipment would be expensive. Some platforms and hardware don’t play nice together, and investing in software that isn’t compatible will result in additional necessary purchases.

If significant technology purchases are necessary immediately, the financial projections established during the purchase will no longer apply, leading to cash flow issues for the dentist.

“The income generated is going to be enough to amortize what was borrowed to buy the practice, but now you have to borrow a second time for the equipment,” Bryen says. “Your projection of the amount needed to amortize the debt changes when you take out a second loan. That money to pay that loan is going to come out of what the dentist planned to live on. Having someone that can give you a clean bill of health on equipment is an important thing that cannot be overlooked.”

You may have found what seems like the perfect practice to purchase, but the seller needs to be the right fit as well. While ideally every seller would be honest, upfront, and agreeable, that isn’t always the case.

Be wary of sellers that rush you to close quickly, or go without your own valuation. This scenario is often indicative that they are trying to hide something, or wrap up the contract before a dealbreaker comes to light. Don’t allow yourself to be rushed by a seller, no matter how eager and persuasive they may be. If the seller seems pushy, you may want to look even closer at their records and finances.

The seller should also be open to providing you whatever documents you request, such as financial records. While they may be hesitant to reveal confidential information, it is your right to know what you’re getting into. They may ask that you sign a non-disclosure agreement, but they should be forthcoming with the information. If you are provided with projections, remember that they are not guarantees. Likewise, a patient count might include all patients, including inactive ones, so be sure you are getting counts of only active patients, rather than ones that are just padding the statistics.

In addition to being forthcoming, the seller should also be supportive of the process. A responsible seller should introduce you to the staff, and give you access to employment histories and payroll. If there has been high staff turnover in recent years, explore why that has happened. Is it a culture clash with the departing dentist? Is the team being paid competitively enough? Determining the problems that are causing people to leave can help establish if there are adjustments that can be made to retain staff, or if the practice is a sinking ship.

The seller should also be willing to inform patients of upcoming changes, to help smooth the transition to the new owner. Patients build relationships with their dentist, and will trust the seller’s recommendations, if they are given enthusiastically. If there is a sudden switch to a new dentist with no endorsement or explanation from the prior clinician, the chances of patient attrition are high.

“You want to work with a seller that is collaborative and supportive,” Bryen says. “An introduction from the seller is a critical thing. A letter should go out about the sale, introducing the buyer. If it's not enthusiastic, it can cost you a lot of patients. You want the acknowledgement and blessing of the seller to go out to the patients, to build trust with them. The seller should be hyping the buyer.”

Ultimately, there are lots of factors to consider when deciding to purchase a practice, and it’s important to be sure you cover your bases. Assembling a strong advisory team, being thorough in your evaluations, performing the proper inspections, and entering into a positive relationship with a seller can make the process a success.

There are several factors to consider when deciding to purchase a practice, and it’s important to be sure you cover your bases with the help of a strong advisory team.


Focusing on the Details: Blind Spots to Avoid When Buying a Dental Practice

Care From Afar | Image Credit: DC Studio - stock.adobe.com

Access to care has long been a challenge for dentists and patients alike. While preventive care could prevent numerous oral health issues, it’s not accessible for a large percentage of patients—a percentage that has increased year over year.

According to the National Center for Health Statistics, the percentage of adults aged 18 to 64 years who saw a dentist fell from 65.5% to 62.7% between 2019 and 2020.

 Some of the decline may be attributed to the onset of the COVID-19 pandemic, but the numbers are still moving in the wrong direction.

“There are plenty of challenges in treating hard-to-reach patients: Funding, the number of caregivers willing to do the work, proper financial incentive to provide the care, and the amount of equipment required to perform dentistry are the main challenges I see,” says Stuart Kazen, director of domestic sales for Aseptico Inc. “On the positive side, there is more recognition about the lack of access to care and more effort to fund dental care. There is better equipment and technology.”

This technology may be key to bridging the gap. By utilizing technology-supported remote services and mobile technology, dentists can better connect with hard-to-reach patients and add the convenience to treatment that will keep patients coming back.

“Emerging technology holds tremendous promise in overcoming oral health challenges, reducing disparities, and enhancing access to care through various avenues,” says Maria Kunstadter, DDS, CEO of The TeleDentists.

These avenues encompass many areas, including precision dentistry using cutting-edge technologies that enable personalized treatment plans designed to improve outcomes for diverse patient populations; telehealth and remote monitoring that can bridge the gap between underserved communities and dental care providers; digital health records and analytics; mobile applications that encourage self-monitoring; and artificial intelligence (AI), computer vision, and machine learning.

“Technology has brought about transformative changes in how dental health professionals interact with and reach underserved populations, including improved care coordination,” says Tina Saw, DDS, founder and CEO of Oral Genome. “In the past, underserved communities faced challenges due to limited access to dental care and outdated communication methods like paper charts and phone calls. However, with the advancement of technology, dental practices have been able to bridge the gap and better serve these populations through enhanced care coordination.”

Bridging the gap to serve these populations isn’t easy. In 2022, there were 7192 dental care health professional shortage areas (HPSAs) in the United States—meaning the 69 million people living in those areas had limited or no access to dental care. To remove the HPSA designations across the United States, 11,896 practitioners would need to join the workforce.

This shortage of dental professionals and lack of access to care are particularly prevalent in rural communities, where 43% of people don’t have access to care.

 A 2019 study confirmed that people in rural areas were less likely to have seen a dentist in the prior year than patients in urban settings; 57.6% vs 66.7%, respectively.

“One significant hurdle is the lack of access to dental care in these communities, often due to limited facilities and a shortage of skilled dental professionals who are willing to work in such areas,” Dr Saw says. “Geographical barriers further compound the problem, making it difficult for patients in remote or medically underserved regions to access dental services.”

Even within urban populations, many people face challenges in accessing care. Language barriers, limited health literacy, and disabilities create unique obstacles to providing necessary oral healthcare. Disparities are also closely tied to other social determinants of health, which affect several racial groups disproportionately. Between 2019 and 2020, 66.6% of White adults aged 18 to 64 years reported going to the dentist compared with 56.8% of Black adults and 55.3% of Hispanic adults.

Financial differences also play into these disparities. Only 50.4% of adults in urban areas in homes with family income less than 139% of the poverty level received oral health care in the prior 12 months, while 79.3% of adults with income over 400% over the poverty level saw a dentist.

“Financial constraints and inadequate dental insurance coverage prevent many individuals from seeking regular preventive care or timely treatment, leading to the exacerbation of dental issues,” Dr Saw says. “Overcoming these obstacles requires targeted efforts to improve access, increase provider availability, implement outreach programs, and develop culturally sensitive approaches to ensure that all individuals, regardless of their circumstances, have access to quality dental care.”

In addition to income barriers, insurance deficits also negatively impact access to care. One study found that only half the children enrolled in Medicaid saw a dentist in 2019.

Medicaid is not required to provide dental benefits for adults.

“The biggest challenge is our profession,” Dr Kunstadter says. “Who is reaching out to those populations? When you look at the number of medical doctors who accept Medicaid, it’s in the high 80%. Dentists in my state who accept Medicaid is 29%. We need to engage our profession to provide services to those who need our help.”

Traveling to the dentist or even making room in a work schedule to go across town for an appointment can deter people from seeking treatment. To combat this, dentists are finding a way to bring treatment to people, instead of the other way around. Teledentistry is one way this is being accomplished.

“Why take half a day off from work or school to go into an office when the virtual consultation can be the solution?” Dr Kunstadter says. “For offices, why drag people in, use PPE [personal protective equipment], staff time, and chair time when a virtual consultation can solve the problem. It’s a learning curve for all new technology, but when implemented, will add innovation and improve workflow.”

With teledentistry, all it takes is an internet connection to have access to a dental specialist. Dentists can triage a problem, educate patients on home care, prescribe any necessary medications, and make assessments about whether the patient needs to come into the brick-and-mortar facility for hands-on care—all without the patient ever setting foot in the office.

“Virtual care helps patients be connected to that initial component of understanding the need for treatment and really eliminating the frustrations that are going to come up if you’re traveling an hour and a half to go see a doctor,” says Brant Herman, CEO and founder of MouthWatch and Dentistry.One. “If you have inflammation and need an antibiotic before your appointment, let’s get that done virtually. If you need to come in for treatment, let’s get the right stakeholders or family members on the call. If you have a follow-up appointment done virtually instead of in office, you’re more likely to attend it.”

In summary, Herman says, teledentistry gives clinicians the opportunity to educate the patient on why they should come in. They can address issues that might prevent a patient from going through with treatment before the appointment, allowing for a productive office visit when the patient does come in. The practitioner gets the opportunity to educate, reassure, and communicate all the things that might prevent treatment from happening, saving time and money for both the patient and the practice.

Care From Afar | Image Credit: Fotomomento01 - stock.adobe.com

“Virtual care is a game changer in providing care to more patients,” Dr Kunstadter says. “All offices should offer teledental services. It not only increases chair time by eliminating unnecessary trips to the dentist but also can reach new patients who want the convenience of teledental visits.”

Platforms such as TeleDent from MouthWatch are designed to improve patient outcomes with remote monitoring while improving chair time efficiency. Clinicians can message patients or have live video chats to discuss issues or treatments. TeleDent allows practitioners to store notes, visual treatment plans, tooth numbers, images, videos, and more in a patient record and share intraoral images with other specialists or providers.

For dentists who are hesitant to add teledentistry to their offerings, there are other solutions. Dentistry.One is a network of providers across the country. Working with an insurance company or rural health authorities, Dentistry.One connects patients with a dentist to do an evaluation, talk to the patient to get an understanding of their needs, and make initial treatment decisions such as calling in a prescription. If necessary, Dentistry.One can coordinate in-office care for the patient.

“Dentistry.One can then find a dentist who accepts their insurance that has an open time slot,” Herman explains. “We send an oral health report based on the virtual consult to the doctor, and they, without doing anything, have a new referral. They have a new patient coming in and they understand the need for treatment for that patient. We felt we needed to start bringing actual care delivery into the model.”

The TeleDentists is another digital teledentistry platform that provides teledentistry services to patients 24 hours a day. Patients can go online and get a virtual consult from a board-licensed dentist at any time, reducing the need for an emergency room visit. When follow-up visits are needed, appointments can be booked for the next day.

Teledentistry isn’t just a convenient tool to reach underserved populations; for many who go to the dentist regularly, it’s becoming an expectation. With the medical industry increasing digital offerings, patients are beginning to expect and want the same level of remote care from their dentists.

“The health care consumer is way more tech savvy and way more expectant of having visits virtually, when possible,” Herman says.

Technology can also help identify potential health issues before they start. Through early detection, potentially severe problems can be avoided before they become critical. Remote monitoring applications make early detection and preventive care more accessible to hard-to-reach populations.

One such remote monitoring service is Oral Genome, whose saliva testing uses machine learning and computer vision to identify often-undetected oral health conditions. The patient takes the saliva test and scans it with their phone to get a wellness report that details their results and any high-risk factors. Patients can then consult with their dentist about any concerning areas.

“Oral Genome’s point-of-care dental saliva test allows for remote screening and early detection of oral health issues,” Dr Saw says. “Patients in dental deserts can use this screening tool to assess their oral health status and receive personalized prevention plans without the need to physically visit a dental office.”

Saw says technologies like Oral Genome, in conjunction with Harmony Health Foundation, offer promising opportunities for increased access to care in areas known as dental deserts.

“Harmony Health Foundation’s collaborative approach can integrate telehealth solutions, enabling virtual consultations between patients in dental deserts and dental professionals from other locations,” she says. “This real-time communication empowers patients to discuss their oral health concerns, receive advice, and access specialized care without the barriers of distance.”

And advances in technology are the foundation that is making this possible.

“The integration of AI, computer vision, and machine learning greatly facilitates early diagnosis and risk assessment of oral health conditions,” Dr Saw says. “By analyzing patient data and identifying patterns, these intelligent tools support dental professionals in making more accurate and timely diagnoses, especially in areas where access to specialized care is limited.”

Technology is also supporting boots-on-the-ground efforts to bring care delivery to the patient. In March 2023, Congress passed the MOBILE Health Care Act, which expands the ability of community health centers to establish mobile clinics in underserved areas. Since 2019, there has been 40% growth in health center mobile units that bring care and treatment to patients outside the traditional office.

“Oral disease is the most prevalent disease in the world and is almost 100% preventable,” Dr Kunstadter says. “With teledentistry, a dentist and a hygienist can educate auxiliary staff at schools, medical offices, and community health centers to provide the hands-on care to apply fluoride varnish, silver diamine fluoride, and more. Teledentistry is the tool to improve oral health and health equity for millions.”

Through teledentistry the midlevel provider can bring a dentist into the appointment virtually, and they can work as a dental team for more complex dental treatments. This is happening, for example, in remote areas of Alaska, where there are few dentists. In these settings, travel logistics and distances can be arduous. With technology, the dentist can be in more locations virtually while hygienists and dental therapists (depending on state-by-state regulations) can travel to the patients to provide care.

“A virtual dentist can be anywhere there is internet,” Dr Kunstadter says. “Access to the right specialist from a community health center can be key to improving oral health for that community.”

Providing care to remote areas is important but the benefits of mobile health clinics are far-reaching and can help other populations as well. Schoolchildren, geriatric or homebound patients or those with special needs, patients who are incarcerated, and underserved urban communities are all target populations for mobile dentistry.

To reach some of these populations, The TeleDentists is working with the National Minority Health Association (NMHA) to increase access to care. The NMHA’s goal is to help close the disparity gap in minor health and health care. The organization’s Operation Healthy You program identifies areas of health care disparities and works with health care providers—such as The TeleDentists—to address those needs.

“We are working together to improve health equity by increasing access to teledentistry and offering a training course for application of silver diamine fluoride when recommended by a virtual dentist,” Dr Kunstadter says. “This is a game changer for children as it could prevent small cavities from being emergency room visits in a few years and reduce the burden of poor oral health.”

In addition to teledentistry capabilities, advances in mobile technology allow for greater onsite treatment that might not have been possible in the past.

Technologies help dentists connect with hard-to-reach patients and add convenience to treatment.  