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The new economics of pediatric dentistry

Feb. 1, 2011
Spurred by rising volume, patient demand, and a climate of ready innovation, dentistry has experienced a tsunami of new technology since 1990.

For more on this topic, go to and search using the following key words: pediatric dentistry, Dr. Roger Sanger, Dr. Peter C.J. Chiang, Dr. Kenji B. Saisho.

By Roger G. Sanger, DDS, MS; Peter C. J. Chiang, DDS; Kenji B. Saisho, MD, DDS

Spurred by rising volume, patient demand, and a climate of ready innovation, dentistry has experienced a tsunami of new technology since 1990. Computer-aided design and manufacturing, noninvasive cosmetic dentistry, nonsurgical periodontal therapy, oral conscious sedation, and myriad choices in restorative materials, implants, and adult orthodontics all helped power the surge.

Entrepreneurial dentists responded not only with technical savvy and clinical skill but collateral creativity in marketing, office environments, and financing. But what once defined the brave pioneer facing little competition now characterizes the vast majority of dentists. Aging boomers seeking youthful smiles can now retire with a full complement of teeth, which is great news for those targeting this market.

So what will the next paradigm shift look like? According to census figures, the next fastest growing segment of the U.S. population is the group under 18. By 2020 this segment is expected to top 80 million, thus surpassing the baby boomer bubble that originated in 1946.

But this rise brings increasing challenges as well, notably more caries. In the United States, 28% of preschoolers have untreated caries, compared to 14% of school-aged children. Approximately 4.5 million kids are estimated to suffer from early childhood caries. By the time they leave high school, it's estimated 80% of students have untreated caries.

The consequences of untreated caries - diseases and a variety of complex issues - are well known. No wonder their incidence among American children has been called a silent epidemic.

What is impeding efforts to care for these children is the sheer imbalance of the numbers. Despite escalating population gains, only 5,000 dentists specialize in pediatric care. Put another way, 178,000 dentists in the United States don't have special training to treat children.

Among the reasons for this disparity are historical maxims about profitability. In the fairly recent past, children and teens were either not accepted by many practices or quickly referred out. Pediatric dentistry was regarded as too difficult because it centered on children and was less profitable. (Little teeth need very little for a fee that's too little: the three dreaded littles.)

Treatment time was often stressful and time consuming. A dentist couldn't accomplish much in a single visit because the attention span of a child is measured in milliseconds, and therefore multiple visits were the norm, another disadvantage.

The educational system followed suit. While post-doctoral programs have increased in the past decade, there remain only around 300 positions available annually in the nation.

In the academic year 2008-2009, more than 8,000 dentists applied to these advanced programs, up from 5,000 in 2004. Obviously, general dentists must step up to help meet this pent-up demand for pediatric care.

As dentists who treat children exclusively, we view this as largely good news. Just as their parents and grandparents fueled the dental market of the past, today's pediatric patients offer potential and promise to the contemporary practice. Fierce competition clouds the fields of cosmetic dentistry and adult rehabilitation. Not so in the children's arena.

Of course, the conscientious dentist will require training to serve the unique needs of children and teenagers. This education doesn't have to consist of graduate preparation to be valuable.

Ample CE exists to stabilize the base of a general dentist who wants to make pediatric and teen care part of his or her services. In addition to learning new skills, the dentist will require special equipment and supply procurement. Of course, staff and other team members must acquire concomitant knowledge.

Fortunately, advances in education have paralleled those in technology. The learning curve is shorter and less costly. Many of these have paralleled improvements in adult dentistry, for example, oral conscious sedation. Dentistry led the way more than a century ago with nitrous oxide/oxygen analgesia. It is leading the way again in oral conscious sedation for children, teenagers, and adults.

Phobias prevent as many as one in three adults from seeking regular dental care. Similar fears afflict children and teenagers. Pediatric and teenage sedation has never been safer or more effective. With the development of new enteral benzodiazepine therapy and advanced monitoring technology, sedation dentistry can be an in-office treatment modality that general dentists can use after proper training.

In-office pediatric and teenage sedation has not only helped the phobic but has also reduced treatment stress for patients with gagging disorders. It has also made it possible to accomplish in one visit procedures that would normally have required several.

Continuing developments in restorative materials are another improvement. The use of amalgam alternatives with composites has been studied extensively. But stainless steel crowns proved a pleasant surprise. They were valued for their strength and caries resistance but were cosmetically disappointing, and are now dramatically transformed through composite overlaying. Research is also promising regarding nonmetal crowns; these will likely become as strong as their metal counterparts.

Advances in orthodontic therapy make this formerly daunting field much less intimidating and time-intensive.

To summarize, we consider the new economics of pediatric dentistry a simple formula. Treating this high caries population with advanced restorative and pulpal technology, while also applying modern pharmocodynamic therapy for patient management, can boost the productivity and profitability of a general practice.

We'll conclude with two typical examples

A healthy but exceedingly anxious 7-year-old presents. Clinical examination and full-mouth radiographs reveal large caries on all four posterior molars and large caries on all eight primary molars. The parents and child all wish to reduce not only treatment stress but appointment time, because school and work hours will otherwise be sacrificed.

They decide to have the care completed in a single 90-minute visit under oral conscious sedation. Twelve teeth are restored in one relaxed session.

In the other example, clinical examination and radiographs confirm the presence of numerous interproximal caries on 16 posterior and four anterior permanent teeth. The patient is a 15-year-old girl whose typical teen schedule demands one visit instead of four or five. Her parents agree. Again, full-mouth rehabilitation takes place in two hours and a congenial setting.

Let's review the economic benefits of each case. First, each patient is able to complete recommended comprehensive care without anxiety in a single session. And it isn't just the patient who gains more time. The dentist is now free to acquire three or four additional patients and schedule other income-generating appointments.

Roger G. Sanger, DDS, MS, is a practicing pediatric dentist with more than 40 years of clinical experience. He has completed more than 12,000 oral conscious sedation cases. Dr. Sanger is the founder of the Central Coast Pediatric Dental Group and a faculty member of DOCS Education's Pediatric Sedation Dentistry. He is also the author of "Fundamentals of Dentistry for Children" and "The Entrepreneur's Children's Dental Practice: A Ten Step Plan for Success."

Kenji B. Saisho, MD, DDS, served as a family medicine physician prior to becoming a dentist. He has completed hundreds of teenage oral sedation cases. Dr. Saisho is a faculty member of DOCS Education's Teenage Sedation Dentistry.

Peter C. J. Chiang, DDS, is a practicing pediatric dentist with more than 25 years of clinical experience. He has completed more than 12,000 oral conscious sedation cases. He is the managing partner of Central Coast Pediatric Dental Group and on the faculty of DOCS Education Pediatric Sedation Dentistry.

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