P. Croatto

Instead of a third-tier celebrity or a well-groomed politician spouting aphorisms you’ll forget by brunch, we want to give you graduates something substantive this year. Yes, this is a milestone. You have devoted four years to an advanced level of study to help others.

There’s much to learn, as these folks behind me can attest. Allow me to introduce:

 general practice resident in dentistry at North Shore LIJ.

, general practice resident in dentistry at North Shore LIJ.

, director of the international student program, department of comprehensive care, at Tufts University School of Dental Medicine.

 founder of igniteDDS, a free continuing education community for dental students and young dental professionals.

, practice transition consultant for Doctor’s Choice.

, soon to graduate the SUNY Buffalo school of dental medicine.

The field is changing so fast, and there are so many new innovations and new things available, that if you’re going from what you learned through your education, you’re almost immediately not up-to-date. And a lot of that is on you. I don’t think it’s particularly stressed well that if you want to be good, if you want to be one of the preferred dentists in the area, you do have to do a lot on your own.

You learn more in residency on how to compromise. There are certain things we have to fix. But if your biting is off, but you only want to fix one small aspect of your smile, then fine we can figure it out. You also have to explain that if, down the road, you want to change something about your smile we might have to redo the work, because it’s not going to be right for you anymore.

There are a lot of roadblocks that come along. It’s not you and the patient anymore. You have to play the game of keeping within the realm of insurance for people who can’t afford outside of insurance, because it’s a very large population and it’s an understandable concern. For the last couple of decades, the maximum coverage (for dental) has stayed very similar among companies. A patient may get a root canal, there’s no money left in their insurance reserves at that point, and you have to wait for the year to end for them to move forward with treatment. That’s not really what you want, because you want them to get to the most stable point as soon as possible so you can have a better outcome long term. You don’t realize those things in dental school. You get taught the ideal and you just try do the best toward that ideal, but in real life most things aren’t ideal.  

You have to think out of the box a lot of the time. Keep up with your education: the articles, the different methods to do things. Then if you need to make it your own — change some stuff — make it your own. 

The biggest thing in your minds is, “I’ve got to get my requirements done. I’ve got to pass the CDCA exam or the WREB exam or the credits exam so I can practice and I’ve got to get a job. I’ve got to get a job!”

But you’re not asking the right questions.

Where do you want to get a job? Not only where do you want to get a job, where does your significant other want to get a job? Where do you want to settle? What kind of practice do you want to be in? Do you want to be in a family-oriented practice? Or do you want to be kind of like a meat-market? What’s the contract?

If you’re going to get a job, what does this mean? Does that mean I just give all the little fillings or do I have an opportunity to give crowns? Do I have to do all the exams? Do I get paid on exams? Do they pay for my liability insurance? Do they pay for CEs? Do they pay for uniforms? Do they pay part of my cellphone (bill)?

You’re not asking the questions to know whether this is a good opportunity or a bad opportunity.

A lot go into situations with a handshake. If you’re going into an associateship, you want to know that there’s a future for you. And we recommend you get a signed contract.

One of your greatest pain points is debt load. That is a universal truism. The average number that’s reported lands around $275,000 in debt. I would argue that is a 

underestimate. I hear $300-$350 (thousand) every single week of the year. With that, there’s pressure. And with that pressure oftentimes, the tendency is to choose a job that’s going to pay well.

Your focus is to be the best dentist you can be and to be the best dentist to your patient that you can be. But you have to learn the other parts in order to alleviate your debt. How does billing work? Do I need to do certain procedures faster? Learning to manage your time better, learning how much your time is worth: I think that’s how you figure out paying back either your debt or making money for your practice.

Mentorship is the No. 1 thing. Your first three to five years out of dental school are your most critical years, so build a team of mentors. Have folks who are excellent clinical dentists. Get with the right financial advisers. You need a great accountant. You need a great attorney. Pretend you’re the CEO of your own personal company — build your board of directors with these mentors.

People who go straight to work, you don’t have that as much unless you’re working for someone who’s really good about being a mentor and open to teaching you. I don’t think that’s something that everyone gets, unfortunately.

It’s a tribe of sorts. I think most good people in all walks of life want to help, but because you really go through the trenches with all these people, you see yourself in every young student and dentist who is up and coming up. You want to give back.

The whole organized dental (tier) is a great place. As a student, ASDA. As a new dentist, the ADA. They’re tremendous networks, and a lot of it is because they have this national component that breaks down to a state component that breaks down to a local component, so you can really get into a good groove in your own hometown. Going to the dental trade shows — also huge. It’s a major trend that young dentists are 

going, but those are huge opportunities for networking. All the right people not only go there, they designate time.

I’ve always been a subscriber of attitude before aptitude, so when I find people who are passionate — they’re hungry, they want to learn, they want to better themselves — I’ll answer that email or text or phone call every single time. When I feel like someone is going through the motions, when I get the impression that 

I’m just doing this because I know I’m supposed to do it

, I’d rather invest my time in people who I know are very passionate and committed.

When it’s a mass email: “Dear Doctor” or “To Whom It May Concern” then I know I am part of a giant group of people you’re reaching out to. Life is about relationships. And if you emailed or texted or called and said, “Hey, David Rice, my name is so-and-so and I’m from such-and-such, can you help me?” Absolutely. But if you lump me in with 500 people, I’m not interested.

Does anyone have advice for current students? 

It was the end of my first year, beginning of my second year, when I reached out to the current fourth-year dental students and said, “Hey, the workload seems to be getting heavier and I’m looking for a good way to manage it.” They were very willing to sit down with me and tell me what their plan was to get a grip on things. It was incredibly helpful. The first year there’s definitely a huge learning curve to understanding this setting and I think it would have been helpful to reach out to one of the senior year dental students a little bit sooner.

The good thing about dentistry — you make a decision that doesn’t mean it’s the end-all, be-all. If you decide during your residency and general practice that you want to specialize, you still have that opportunity. It’s not gone forever. There’s no “that’s it” with dentistry. Some people decide they don’t want to do dentistry anymore, so they end up working for a consulting company or a law firm or teaching. There are so many different options out there, so don’t despair.

Most of the time you’re used to being at the top (in school), and you have that feeling when you’re done — I’m guilty of this — that you know so much and you’re ready to go. Each day has been such a learning experience and each year I’ve been in clinical practice is just an exponential growth — you learn so much more. It’s been months and you’ve seen how much you’ve done and how naïve you were. It was just that much to learn. It’s something that continues throughout the entirety of your career. We call it “practicing” for a reason.

Articles

Dental school graduation season is upon us. Though the years of hard study have just ended for recent grads, many new, business-related challenges lie ahead, many of which predecessors didn't have to contend with. Dentist's Money Digest® reached out to several dental professionals to get their take on what new dentists need to keep in mind as they begin the next leg of their clinical journey.

You Just Graduated Dental School. Now What?

It's time to shed some light on the danger that could be lurking in your dental supply closet: black- and gray-market dental products.

Bernie Teitelbaum, former executive director of the Dental Industry Association of Canada (DIAC), had just finished a talk in Vancouver about the risks dentists run using dental products purchased on the black and gray markets.

A dentist stood up: “Name me one dentist who’s ever been brought up before the disciplinary committee for using non-compliant product?”

Before Teitelbaum could offer his retort — “You want to be the first?” – another audience member rose to his feet. “I’m counsel for the British Columbia College of Dental Surgeons,” Teitelbaum remembers the man saying. “And I can tell you categorially, that you will never be brought up on disciplinary charges for using non-compliant products. You will be brought up on disciplinary charges for professional negligence. And we won’t let you hide behind the product.”

That dentist probably stopped frequenting the gray and black markets.

 “We’re well aware that (the gray market) hasn’t been cleaned up,” says Tim Rogan, vice president of marketing for merchandise at dental product and technology distributor Patterson Dental.

Simon Hearne, 3M Oral Care’s international vice president, admits awareness over the risks of using black- and gray-market products is “very low.”   

What are the differences between the two categories?

“When we talk about gray market, we are talking about genuine products sold through an unsecured supply chain,” Hearne says. “These products include inferior goods that have been diverted from the manufacturers’ secured supply chain. Counterfeit goods or black-market goods are fake products that are often sold alongside gray market goods.”

The sale of gray-market products is also legal in the United States, says Gordon J. Christensen, D.D.S., M.S.D., PhD and CEO of Practical Clinical Courses, who has written on gray and black market dental products. “I have repeatedly asked the major dental companies about the amount of their products that are gray or black, and I always get the same answer,” he says. “The percentage of gray and black market products is estimated to be about 15 percent of total product sales.”

Rogan of Patterson Dental says a distributor must have “the ability to say no” to tempting offers from gray market dealers. Doing so means leaving “a fair amount of margin dollars on the table. But when you say yes to gray marketers, you put yourself at risk that you’re buying product that could be harmful to our customer’s customer, the patient.”  

These products, Christensen adds, are “commonly consumable dental products” such as cements, composites, and bonding agents.

“The only motive to buy these products is price,” he says.

Many dentists, Teitelbaum says, “don’t have a clue” what they’re buying.

Ira Newman, DDS, who practices on Long Island, New York, and previously worked for a dental supply company, says a dentist “involved in doing his purchasing has way too many empty spots in his appointment book.” A hygienist or an assistant is usually assigned that task. That employee wants to look good. The dentist, Newman says, only has time for the headlines. “We’re busy, you saved me money, we’re profitable. It’s a good day.”

Gray-market goods are often purchased outside of certified supply chains. As a result, they could be prone to failure due to environmental exposure.

Some dentists, Teitelbaum says, “are absolutely convinced they’re getting ripped off” and will pursue bargains outside accepted channels — such as Amazon, eBay, or, as Newman recalled, an endodontist selling supplies from his garage.

It’s a gamble, says Christensen. A dentist has no guarantee if the project is legitimate or if it will do what it is intended to do. “If some treatment fails and the failure can be related to a deficient product,” he says, “the legal implications are obvious.”

What’s even more troubling? “The dentist doesn’t see the product until he uses it,” Teitelbaum says. 

The sense of doom extends beyond the black market. “Many gray-market goods bought by dental practices have often changed hands numerous times since they were diverted from the manufacturer-secured supply chain,” Hearne explains. “Often they have not been handled and stored under required climate-control conditions, and then may no longer meet the manufacturer’s original specifications. Typically, these products do not comply with U.S. regulatory requirements either. Sometimes, gray-market goods are even repackaged or relabeled with phony expiration dates. In some cases, products may be sold years past their expiration date, which can lead to problems like improper curing or bonding.”

Buying from a manufacturer’s authorized dealers — which Teitelbaum says he believes “a big percentage of the market” does – comes with security. “If I have a problem, I have full recourse,” he says. “If my patient sues me because there’s a problem, I can go after the manufacturer and the dealer. I’m protected. The entire chain of custody was as recommended by the manufacturer.”

There’s also the small matter that dentists may not be saving as much as they think by going the black- or gray-market route.

“For most dental offices, expenses for supplies is about five to seven percent of gross revenue,” Hearne says. “Saving on the supply expense is minor when considering risks to patient safety and productivity and financial loss to redo treatment and manage complaints or even lawsuits brought by dissatisfied patients. The damage to a dental practice’s reputation is much more of a significant loss compared to a few dollars of saving on supply expense.”

Dentists’ net income, adjusted for inflation, is at 1997’s level, according to Christensen. Overhead is 70 percent of their gross revenue. Throw in “significant third-party payment company and government limitations and reductions,” he says, and dental professionals remain eager to whittle operating expenses.

Dentists can still be thrifty and buy supplies from authorized dealers. “If they’re really clever, they demand a high level of service from that dealer that they’re working with, because they know they’re paying a premium price,” Teitelbaum says.

Christensen offered other options for practitioners: joining “dental cooperatives” that “have programs discounting products up to 25 percent”; negotiating with local retailers; buying distributor private label brands, which typically carry “significantly lower prices.”

 “Just because a retail price is written in a catalog,” Newman says, “doesn’t necessarily mean you have to pay that price.” Here’s the logic: “Supply houses don’t want to lose business,” he continues. “So if they have to discount a little to keep the business, they’re (still) profitable. It’s when that person doesn’t buy at all — and does buy in gray market – that they’re losing money. So there is a pressure on them to give on price point to a degree.”

A dentist's best line of defense is to purchase products from reputable distributors.

Teitelbaum says he believes “90 percent of the profits that are missing in a dental practice are in the patient charts.” In other words, patients need additional work, but turn it down. Or it gets forgotten about.

 “The office manager doesn’t know anything about dentistry, but she’s out there saving money for you,” Teitelbaum says. “The problem is why isn’t she taking a course on how to reduce the number of cancellations? Or why isn’t she taking a course on patient acceptance” so she can help a patient with payment options for additional work? Teitelbaum says that the extra money for buying products from a reputable channel can recouped (and more) with “one crown a month.”

“I think if the manufacturers made a better effort at somehow educating staff as to the purchasing process and why they should buy from authorized sources, that might help,” Newman says. “I don’t think you’re going to find a practitioner sitting there checking shipping lists to see who you’re buying from.”

With 3M.com/BuyDental and dentalsupplyintegrity.com, 3M and Patterson Dental, respectively, are among the major dental players doing just that. Education also extends to the dentists compelled to roll the dice, who should “at least have the common sense to check the product when it comes into the office,” Teitelbaum says.

In 2016, DIAC developed “A Suggested Protocol for Checking Product,” a checklist that could be posted in the office. “One knowledgeable person” should review all product purchases that arrive. Among the questions to ask: does the product have the same name as advertised — and is it in English? Is the product in its original package or crammed in a plastic baggie? Does the package, or its contents, have markings indicating it might have been rerouted?

Initially, it might take 15 minutes to vet a shipment, but Teitelbaum says repetition will turn the examination into a “non-issue” within six months. “Because at the point,” he says, “if they are buying from unauthorized sources, they’re going, ‘This isn’t worth it. Too much of what we’re getting is garbage.’”

Teitelbaum and Newman would like the business education to start even earlier — in dental school. Maybe, Teitelbaum says, a dentist takes a practice-management course or eventually hires a consultant. Then they open their doors for business and “they haven’t got a clue how to run a dental practice.”

Aside from continuing education, collaboration is key.   

“The black and gray market products put patient safety at risk, and it is up to the entire industry, manufacturers, distributors and dental professionals to do their part to keep patients safe,” Hearne says. “By working together, we can all help protect the integrity of the industry that we’ve worked so hard to build.”

What's in your dental practice's supply closet? Where did those supplies come from? If you're like most dentists, you don't handle the supply-ordering process in your practice. You just sign the checks. Some well-intentioned staff member may be searching high and low to find you the best deal on your supplies. But are they ordering from reputable distributors? If not, those products might be coming from the black or gray market. Discounted dental goods come with a hidden cost: putting your patients and practice at risk. Here's how to protect yourself.

Special Report: Danger Lurks in your Dental Supply Closet

As dental service organizations become more popular, experts see the business of dentistry as they know it changing right before their eyes. Image source: Fotolia

Dentistry is, for better or for worse, a business. The business of dentistry is something an increasing number of practitioners have little time or patience for running, prompting the rise of dental service organizations, or DSOs.

According to the American Dental Association, 7.8 percent of dentists are part of a DSO, where a dentist handles the clinical side but another party owns the business and handles the accompanying responsibilities, such as payroll, ordering supplies, and staffing.

Dental professionals say they already see the change arriving in full force.

Maria G. Melone, CPA, CVA, is a partner at MORR Dental Solutions in Westborough, Mass., which handles the buying and selling of dental practices. She says several factors over the last 10 to 15 years have contributed to the increased allure of DSOs, especially among younger dentists.

Today’s dental school graduate graduates with an average of $300,000 in debt.

 buying or investing in a dental practice, which carries a $500,000 to $1 million price tag. Oh, and don’t forget opening the practice, which includes technology and securing dental insurance.

“Not having strong business acumen, you can get upside down very quickly if you’re not paying attention to things,” Melone says.

DSOs fit the new generation of dentists, a group, Melone says, that craves a better work-life balance. Older doctors worked six days a week or early mornings to jump start their careers. Today’s younger doctors are perfectly happy working 32 clinical hours, Melone says.

By working for a DSO, a young dentist immediately makes good money, none of it headed to various business expenses.

“You come out of school and you own 300,000 bucks in student loans or more,” says attorney Patrick Wood, founder of Wood & Delgado, a Mission Viejo, CA law firm specializing in the business needs of dentists. “You can go into the corporate world and right off the bat do fairly well.”

Wood teaches practice management courses at a couple of dental schools. He estimates that up to 85 percent of his students want to enter corporate dentistry.

“What I think is great about DSOs is that they really train the dentist on case presentation, case acceptance,” Wood says. “They keep them very busy. I heard one of the DSO’s leaders saying they felt that 90 percent or more of their time was spent on patient treatment. If you’re just coming out of dental school and you’re doing all that, your skill-set is going to get better. Plus, they’re highly motivated to be sure that you’re successful as a young dentist.”

The rise of DSOs is not just a young person’s trend. Melone says older dentists she talks to love taking care of their patients. But after decades “the headaches” of running a business — managing payroll and staff, for example — beat them down. Selling to a DSO relieves that burden. Plus, they can step away slowly, working an abbreviated schedule, as opposed to the usual hastiness involved in a doctor-to-doctor transition.

Dentistry has seen outside investment because it’s a stable industry.

“If you talk to the dental lenders, they’ll tell you that they have a default rate on their dental loans of less than one percent, which is pretty remarkable for start-up businesses.” Wood says. “I think it’s attractive Wall Street money.”

Every week, Wood’s office fields a couple of phone calls from parties interested in setting up a DSO. It is not for everyone. Beyond knowing the dental industry, the DSOs that do well are “capitalized properly. The guys that try to come in on a shoestring budget — I just see a lot of failures.”

Advocates say dental service organizations allow dentists to focus on what they do best: care for patients. Critics, however, are concerned about corporate interests. Image source: Fotolia

Still, Wood sees DSOs taking over the market in due time, while Ronald D. Perry, DMD, a practicing dentist and professor in the Department of Comprehensive Care at Tufts University School of Dental Medicine, believes most dentists will be part of a DSO in fewer than 20 years.

“That’s corporate America, understanding the consumer,” he says. “They’re treating it like a Walmart, like an Apple computer or McDonald’s. It’s the same business model. It’s the same thing that they did to corporate funeral homes.”

Perry believes the behavior of Millennial consumers has made this shift far more palatable. Not too long ago, a dentist served generations. Now, with Millennials using their smart phones to guide their decisions, “dentistry becomes the same commodity as picking a friggin’ restaurant,” Perry says: You head to Yelp and get a recommendation.

“People are not loyal,” Perry explains. “Think about when you’re buying gas. If you’ve got the guy across the street who’s a nickel cheaper, where are you going to go?”  Millennials, he adds, “demand digital. They demand service. They will complain and bitch and moan if you don’t give it to them, but they’re the first ones that won’t give it back.”

Dr. Dave Preble, vice president of ADA’s practice institute, says the association feels the public is best served by practices that are owned by dentists, though it counts dentists belonging to DSOs or dentists who own DSOs among its members.

“Currently, that’s the only way to have any legitimate oversight on making sure they’re doing the right thing,” he says. “The dental boards who are the entities that uphold how the dental practice statutes in each state are enforced — that make sure things are being done right, and that the public is being protected — their only sanction is over licensure. So, if you’re not a licensed dentist and you’re running a practice, then the state dental board doesn’t really have any way to regulate or make sure you’re doing what’s right for the public.”

The corporate flavor associated with DSOs concerns Preble.

“At no time do we want a world where the making of money, in any aspect of health care — not just dentistry — to be more important than what is truly valued and needed by the patient,” he says. What worries Preble is investors, including private equity firms, abandoning that principle. He believes firms can make money through dentist ownership.

If solo dental practices are to endure, Ronald Perry, D.M.D., says dentists must strive to set themselves apart from their corporate contemporaries. Image source: Fotolia

The Association of Dental Support Organizations (ADSO), based in Arlington, VA., has a code of ethics and a statement of principles its members must follow.

“These documents make clear that only a licensed dentist can make clinical decisions and treat patients; DSOs cannot interfere with the dentist’s clinical decision making or care,” an ADSO spokesperson said via email. “Members are also provided detailed tools to help them obtain the highly (

) level of compliance with all applicable laws and regulations.”

Out of all the misconceptions, “the biggest one is that DSOs are telling us how to practice,” says Dr. Lorne Yasbin of Dental One Associates in Frederick, Md. “You hear the word ‘quotas’ a lot. Like, ‘You have to do this many procedures.’ or ‘Why aren’t you doing this?’ I’ve been here for 15 years; I own the practice. All the clinical decisions are made by the clinicians.” There’s never been any input or discussion about clinical decisions from non-clinical personnel, he added. 

Landing in that prime situation requires a dentist to do their homework. Yasbin and Melone recommend interested parties be comfortable with the DSO’s culture.

“There are some DSOs that cater to more transient, maybe lower-income type of patient pool,” Yasbin says. “There are some that concentrate on dentures. There are some that concentrate on implants. There are some that concentrate on general family care. So I think finding the right fit, finding where you’re comfortable, is the most important thing.”

The solo practitioner model will endure, though the numbers will be diminished, Wood predicts. The DSO model is not for everyone, Melone says.

Dr. Yuval Azulay of Upper Dublin Family Dentistry, which has two offices in Pennsylvania is in that camp: He likes taking “the pulse of the practice.”

In this evolving environment, the independent dentist must step up their game, Perry says.

“You have to be smarter about your business,” he explains. “It’s very hard to compete against a DSO that has 30 practices or 50 practices or 100 practices and they’re buying product from Henry Schein at a discounted rate because they do it in bulk and then you’re trying to but it as a solo practitioner and you can’t compete with those prices.

“So you have to offer something more. Why does someone want to come see you? What is your vision? What is your mission statement in your practice that’s going to drive a patient to come see 

Dental service organizations sometimes referred to as dental support organizations are becoming increasingly common in dentistry today. The American Dental Association estimates that 7.8 percent of dentists now belong to one, contracting with a DSO to handle the business side of operating a practice so that they can focus on the clinical side. DSOs advocates say they allow dentists to focus more on caring for patients. Critics, however, are concerned about corporate interests.