Trends in Dentistry 2022

Digital adoption reaches a major milestone

Jason Mazda

Uncertain times have not slowed the adoption of technology in dentistry. If the most significant entry point for digital dentistry is intraoral impression scanning, a major milestone was surpassed in this year's Inside Dentistry readership survey because 52% of respondents reported that they use digital impression systems in their practices. It should be noted that these surveys, which have been conducted in each of the past 4 years, are collected digitally, so the data may be skewed toward more technologically savvy dentists. However, the progression of digital impression system usage from 36% of respondents in 2019 to 52% in 2022, including a massive jump from 43% in 2021, is certainly indicative of a major trend. With CAD/CAM software and fabrication technology continuing to open new possibilities, and newer dentists graduating from dental schools with experience in scanning, the only question seems to be just how rapidly this trend will continue to develop. "I believe that we will see more dentists using completely digital workflows to treatment plan cases from start to finish," says Melissa Seibert, DMD, host of the Dental Digest podcast.

Technology on the Rise

Digital impression systems are not the only digital technology on the rise in 2022. The percentages of dentists who reported using lasers (45% this year, 36% in 2021), cone-beam computed tomography (CBCT) scanners (36% this year, 28% in 2021), electric handpieces (60% this year, 49% in 2021), and 3D printers (9% this year, 2% in 2021) all jumped dramatically in the 2022 survey as well. Earlier this year, Inside Dentistry's technology issue reported on the arrival of 3D printed permanent crown materials (insidedentistry.net/2022/07/the-race-for-the-crown), and the ongoing material innovations in that realm could further accelerate the adoption of 3D printing in future years. "We have almost exhausted the limits of what we can do with subtractive manufacturing techniques," Seibert says. "Additive manufacturing is the future. We just are not completely there yet."

Looking forward to some of the next frontiers, dentists remain relatively skeptical of teledentistry and artificial intelligence (AI). Only 29% of the 2022 survey respondents reported that they have implemented or are open to teledentistry options, compared with 31% who indicated that they are not at all open to teledentistry. The remaining 41% indicated that they have not yet considered it but might be open to it. Similarly, only 33% of the 2022 survey respondents reported either integrating AI modules into their workflows or considering it, compared with 37% last year, and 16% remain steadfast that AI is not a fit for their practices. Seibert emphasizes that AI modules are merely tools that can help increase efficiency, especially in practices where staffing shortages have been an issue since the COVID-19 shutdown. "There is a lot of virtue in tools that can streamline operations and eliminate the need for staff to perform certain mindless tasks," she says. "Taking advantage of AI capabilities is the direction that we are going in the profession. Nobody wants to lose the human touch, but there are also so many menial tasks in dental practices that humans do not need to be doing."

Regarding technology as a whole, dentists seem to have picked up the pace of their willingness to invest with respect to pre-COVID levels. The percentage of responding dentists who reported devoting 15% or more of their yearly practice budget to purchasing new technology dipped from 56% in 2019 to 53% in 2020 and 47% in 2021; however, it is back up to 55% in this year's survey. "Investing in technology is a part of doing business," Seibert says, "and many patients expect to see the latest technology in the office." Although a number of group purchasing organizations, or buying groups, are available to help smaller practices get better prices when purchasing supplies, only 23% of the 2022 survey respondents reported that they utilize these resources, which is nearly identical to the percentage for each of the past 2 years. "Quite a few private practitioners just may not know about group purchasing opportunities," Seibert suggests.

The Business Side

As lucrative as operating a dental practice can be—63% of the 2022 survey respondents reported a yearly practice net income of more than $350,000, which is up from 39% last year—the business of dentistry can be as complex as a full-arch rehabilitation. Declining insurance reimbursement rates, competition from dental service organizations (DSOs), and other factors are making it as important as ever to run an efficient practice. The percentage of dentists who report that they accept private insurance continues to linger in the mid-80s, coming in at 84% this year. Approximately 51% of the 2022 respondents reported that they utilize membership plans or other alternatives, which is up from 44% last year, and 74% reported that they offer healthcare financing plans, which is up from 62% last year. "The typical dental insurance is disgusting," says Cary Goldstein, DMD, a private practitioner in Georgia. "My practice dropped every insurance plan nearly a year ago, and within the first 6 months, we were doing better than ever before. We saw fewer patients, made more money, and had more fun doing it. Fee-for-service dentistry is not an option for every practice, however, so others need to figure out how to play the insurance game and do the very best dentistry that they can in an efficient manner."

One important way of doing that is by converting a high percentage of complex treatment plans. In this year's survey, 60% of the respondents reported that more than half of their complex treatment plan proposals are accepted, which is up from 57% last year, but this is still not as high a number as some would like to see because it indicates that more than one-third of dentists are having the majority of their complex treatment plans rejected. "We are never trained in sales techniques, how to really talk to patients, and how to present cases properly," says Goldstein, who estimates that his own acceptance rate for complex cases is approximately 80%. "I teach dentists to take their time, avoid interruptions, and explain everything to patients in terms that they can understand. Television commercials are typically designed to be understood by seventh graders because advertisers want to make sure that everybody understands them. We should be presenting treatment plans in the same way."

Of course, bringing patients into the practice in the first place is critical. In this year's survey, 42% of the respondents reported using email marketing, 20% reported using direct mail, 62% reported using social media, and 78% reported using practice websites as marketing channels. Among those using websites, 14% indicated that they utilize chat bots, which is up from 7% last year. "Marketing is essential," Goldstein says. "We spend significant amounts of money each month bringing in new patients. I recently hired one company to work on my website's search engine optimization and another to improve our Google presence."

Of course, joining a DSO is always an option for private practitioners, and there are various models allowing different degrees of autonomy. However, 59% of non-DSO respondents to the 2022 survey reported that they are not at all open to joining one—the same percentage as last year. The data suggests that attitudes about joining a DSO vary significantly based on experience levels: of the non-DSO respondents, 67% of those in practice for more than 20 years indicated that they are not open to joining one, but 67% of those in practice for fewer than 20 years indicated that they were at least somewhat open to the idea.

Clinical Evolution

For the third year in a row, the majority of general practitioners who responded to the survey reported averaging more than 50 direct restorations and more than 10 crown and bridge restorations per month. "Direct composites are coming back," says Brian LeSage, DDS, a fellow of the American Academy of Cosmetic Dentistry who maintains a private practice in Beverly Hills, California. "More dentists are doing them, but more dentists should be trained to do them well. A significant percentage of my esthetic cases get some type of composite bonding; I may do veneers on the maxillary teeth but composite bonding on the mandibular teeth because the edges are just a bit worn. It is a wonderful service to only do small composite restorations on these edges as opposed to veneers. Almost every new patient who comes into my practice asks about minimal preparations. More and more dentists are learning the skill and applying it. And by charging a fair fee, we can make almost as much money on composite restorations as we do on veneers."

Expanded whitening services continue to be a growing trend. Although the overall percentage of responding general practitioners who offer whitening services has consistently remained around 90% for the past 4 years, the percentages continue to increase for certain whitening modalities, such as custom trays (80%), go trays (23%), and strips (22%). "They all work," LeSage says. "The effectiveness can vary from patient to patient, but the cost and risk are both minimal, so trying different modalities is worthwhile. Whitening is a fabulous revenue source because dental assistants can do almost all of the work, if not all of it."

The majority of responding general practitioners surveyed reported that they place implants (61%), and of those, 19% reported that they do more than five implant cases per month. "Case selection, as well as the clinician's training and ability to handle complications during surgery, will always be important for implants," LeSage says. "If general practitioners are well-trained, this is a great service that they can provide—especially with today's guided surgery options." Screw-retained implant restorations seem to be more popular than ever. For the 2022 survey, 71% of the respondents reported that they place them compared with 50% who reported that they place cement-retained restorations. Those numbers were 61% and 66%, respectively, in 2019. Furthermore, the percentages of responding dentists who reported that they deliver overdentures (40%) and perform all-on-X procedures (23%) both increased for the third year in a row. "All-on-X has provided an affordable option for dentition in the mutilation state among patients of lower socioeconomic status," LeSage says. "Dentures can become loose and mobile, causing more bone loss. All-on-X is a very secure, efficient, and cost-effective treatment modality to restore dental health and improve overall health long term."

For the second survey year in a row, the percentage of responding general practitioners who reported that they perform endodontic procedures dropped slightly, but it remains at 66%. Standard root canals (66%) are the most common, followed by re-treatments (12%), apexification procedures (9%), root canal obstructions (7%), and incomplete endodontic therapy (6%). "In dental school, we are fairly well trained to perform root canals," LeSage says. "Very few graduates have placed an implant in dental school, but they are taught the root canal system, how to clean canals, and how to obturate canals. Where implant therapy is similar to endodontics is in case selection: general dentists need to know which they are qualified to treat and which they should refer out."

Although the options for orthodontic treatment continue to expand with the various clear aligner services on the market, attitudes toward teledentistry models among the responding general practitioners remained largely negative, and 64% indicated that clear aligner therapy should only be monitored in-person. "The intention of the at-home modality is great, but a compromised occlusal result could lead to other sequalae, such as dental pain, temporomandibular joint problems, and periodontal issues," LeSage says. "Whereas any sensitivity from at-home bleaching goes away, a compromise in an inadequately monitored orthodontic outcome can have a long-term impact." That being said, LeSage emphasizes that the aligner therapy trend as a whole is very positive. "Probably as many as 50% of my esthetic cases start with some type of aligner therapy," he says. "Moving teeth to a more predictable, stable position can allow for more bonding and generally less invasive dentistry. It is a fantastic pre-prosthetic modality."

For indirect restorative work, 77% of the respondents reported that they exclusively use outside laboratories, whereas 6% reported that they employ in-office dental technicians. Among the respondents who use laboratories, 59% reported that they work with three or more, and only 6% reported sending any laboratory work overseas. "Last year was so huge for dentistry that comparing year-over-year monthly revenue is difficult now," says Stephenie Goddard, CEO of Glidewell. "Many laboratories are either flat or down from last year. We are waiting to see if that is more a result of people resuming travel and other activities that might keep them from seeing the dentist as much, or if the economic situation is leading people to start putting off dental care like many did back in 2008."

Laboratory collaboration seems to be less of a trend this year. Only 32% of the responding dentists reported that they communicate face-to-face or by phone with the laboratory prior to the delivery of restorations for at least half of their complex cases, which is down from 46% last year. However, 68% reported that they always or often solicit the laboratory's input when treatment planning those cases. Just 32% of respondents indicated that they send full-face photographs of the patients to the laboratory for more than half of their complex or esthetic cases, which is down from 37% last year.

Each Practice Is Unique

The thing about trends in dentistry is that they are just that: trends. Paying attention to what others in the profession are doing is certainly worthwhile, but what is right for one practice—or even for the majority of them—is not necessarily right for all of them. Whether practices use analog or digital workflows, are private or DSO-affiliated, do extensive specialty work, or exclusively refer to specialists, each recipe for success can be different because every patient population is different. Some of the most talented restorative dentists that Seibert knows use purely analog workflows. When dental practices are well run, various models can prove both lucrative and rewarding. "This is still a great time to own a dental practice!" Goldstein says.