Pedonomics: The new economics of pediatric dentistry

Through the years, one indicator that experts used to judge the financial success of a dentist was whether the dentist had stopped treating kids. Making the decision to stop treating kids was considered to be an indicator for various reasons, including child behavior (terrible), parental behavior (demanding), the issues associated with a mixture of adult and child patients (kids' furniture), and kids' interest in dentistry (none!). Truthfully, dentists were mainly choosing not to see kids because they saw no economic benefit.

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Through the years, one indicator that experts used to judge the financial success of a dentist was whether the dentist had stopped treating kids. Making the decision to stop treating kids was considered to be an indicator for various reasons, including child behavior (terrible), parental behavior (demanding), the issues associated with a mixture of adult and child patients (kids' furniture), and kids' interest in dentistry (none!). Truthfully, dentists were mainly choosing not to see kids because they saw no economic benefit.

This practice "segregation" worked as the onslaught of baby boomers flooded practices wanting cosmetics, orthodontics, nonsurgical perio, sedation, etc. Why would you have treated kids who needed cheaper services when you could have treated the baby boomers who wanted expensive rehabilitation services? Eventually, we reached the point when more dentists wanted to be adult reconstructive dentists, while few wanted to treat children. The result was an increased supply of general dentists who limited their practices to adults and fought over a finite supply of baby boomers.

Another reason to avoid treating kids was that many of us believed that someday a vaccine would be available to eliminate caries. A cautionary warning was given that treating kids in a practice would lead to a "prophy practice" with low profitability. Of course, this "caries-free" scenario never happened.

READ MORE |Behavior management considerations in the pediatric dental patient

The U.S. birth rate, which peaked in the late 1950s with approximately 4.3 million annual births, was expected to decline steeply, making the baby boom a once-in-a-century, postwar phenomenon. Well, that didn't happen either.

Today, birth statistics, caries occurrence, dental workforce issues, and dental benefits present new challenges for general dentists. Our birth rate is at approximately four million annually. By 2020, more than 25% of our population (approximately 80 million) will be younger than age 18. This segment of the population will have grown to exceed the baby boomers, who now represent the largest population segment, at just less than 25%. The birth rate is higher in minority populations and in low- to middle-income populations.

Dental caries is now the leading childhood disease, and it's reaching epidemic proportions. Caries appears earlier in our preschoolers and later in our teenagers, which is attributed to the rise in sugar-laden fluids and foods. Our emerging ethnic populations are at greater risk for caries. Dental disease in children has become the single largest unmet health-care need in the United States.

Currently the United States has about 180,000 practicing dentists, 80% of whom are general dentists. Pediatric dentists compose less than 3% with most located in large metropolitan areas. With fewer than 80 postdoctoral programs producing a total of approximately 350 new pediatric dentists each year, the demand exceeds the supply.

Dental benefits in private carrier plans and governmental programs are offering increased coverage for children. True, this coverage may have limitations of procedural coverage, fees, networks, etc., but more and more parents today have some third-party coverage for their kids' dental care.


Together, the following two case examples will illustrate what "Pedonomics" is all about:

MINIMALLY INVASIVE CARIES

Child A is a school-age child from a middle-class family. Upon examination, you diagnose occlusal caries on primary molars A, J, K, and T. Deep occlusal grooves on all first permanent molars necessitate sealants. The patient is behaviorally manageable and will be scheduled for two half-hour visits (one visit for 3, A, and 30, T, and another visit for 14, J, and 19, K) for restorative care and sealants with nitrous oxide and local anesthesia. The child is on the father's comprehensive dental plan with a copayment requirement to 100% of your fee schedule.

RAMPANT CARIES

Child B is a school-age child from a middle-class family. Upon examination, you diagnose large multisurface caries on all eight primary molars with pulpal involvement and small occlusal caries on all four permanent molars. All primary molars will need pulpotomies with crown coverage. All permanent molars will need occlusal restorative care. The patient is behaviorally manageable and will be scheduled for four half-hour visits (one quadrant for each visit) with nitrous oxide and local anesthesia. The child is on the mother's preferred provider organization (PPO) dental plan that covers approximately 70% of your fee schedule with no copayment.


The concepts of "Pedonomics" and the "Time Economics Model" are based upon your profitability per unit of chair time, which is the most important factor in determining the financial future of your practice. Many experts, particularly those dealing with adult dentistry, consider only the revenue generated by those patients on the highest percentage of fees billed ("100-percenters"). They advise dentists not to accept any patient who is on a PPO or reduced-fee program unless the dentists are new to practicing. This might be good advice in an adult practice with lab-related services or dental hygiene-dispensed services with high fixed and variable overhead, but it is poor advice in a practice that treats children and that offers no lab-related services and minimal dental hygiene-dispensed services. As many smart dentists know, "It's the profit, not the income, that matters."

Can 'Pedonomics' and a 'Time Economics Model' be applied to your practice?

Do you see children with a high incidence of caries? The answer is "no" if the children either have no caries or minimal caries or if you have a prophy practice with high volume, low revenue, and high overhead. If the answer is "yes," you will have a comprehensive rehabilitation practice with high revenue from pulpal therapy and crown placement.

What are the demographics of the children in your area who have minimal or high caries incidence? Consider birth rate, ethnicity, number of children per household, socioeconomic segment, and dental benefits coverage (private fee-for-service, private PPO, governmental program, etc.).

READ MORE |Pediatric dental radiographs: What I do when things aren't easy

If you want to treat children in your practice with a high incidence of caries, do you want to get involved with benefit plans that reimburse less than 100%? If you do, what is the lowest percentage of reimbursement you will accept? Decide where the cutoff line is beyond which you will not participate.

If you are not experienced in treating children and/or have not kept current with the advances in clinical pediatric dentistry, are you and your staff willing to devote training time and travel, practice money, doctor and staff improvement efforts, etc. to perform clinical pediatric dentistry at a higher degree of proficiency and efficiency? Do you need practice management assistance on such things as proper scheduling of children?

Not every general dentist can or wants to apply "Pedonomics" and treat children according to a "Time Economics Model" in his or her practice. However, with higher birth rates, higher incidence of caries, shortages in the dental workforce, and expanding dental benefits for children, the financial impact of pediatric dentistry in dental practices can be significant. It will be your decision. Pedonomics: It's the new economics of pediatric dentistry!


Roger G. Sanger, DDS, MS, is a pediatric dentist who cofounded one of the largest private pediatric dental groups in California, featuring multiple pediatric dentists and general dentists in multiple offices with two surgicenters and a hospital practice. He is also a principal in the Institute for the Clinical Practice of Pediatric Dentistry and the director of pediatric sedation dentistry for DOCS Education. Aside from authoring numerous clinical textbooks, chapters, and scientific articles in pediatric dentistry, he also authored The Entrepreneur's Children's Dental Practice.

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