Trends in Dentistry

It is a trend that skyrocketed from production of 2.5 million units in 2010 to 9.5 million in 2015 and shows no sign of slowing down. By 2020 it is estimated that monolithic zirconia will comprise 14.6 million of the total 26.8 million zirconia units manufactured in the U.S. The millable all-ceramic revolution has reshaped the practice of dentistry faster and more emphatically than any other material type that came before it. Its impact transformed the laboratory industry from strictly analog to automated production overnight and resulted in dentists moving away from the rising cost of conventional gold alloy-based restorations in favor of stronger, more biocompatible, and less expensive all-ceramic replacements. Today more than half of the 50 million-plus crowns and bridges manufactured in the U.S. are all-ceramic restorations. Nearly 50% of those all-ceramic restorations are milled from zirconia blocks and discs. By 2020 that percentage could reach 70%, with monolithic zirconia taking the bulk of market share. The trend has every materials developer looking for new formulations to grab a piece of the millable all-ceramic pie.

Until now, however, the lucrative millable zirconia market has been the exclusive purview of the dental laboratory industry. That will change in early 2016 with the introduction of the first chairside millable zirconia materials. Two new zirconia material technologies are destined for chairside milling units: Sirona inCoris TZI zirconia coupled with the inFire HTC speed furnace from Sirona Dental, Inc., and BruxZir NOW from Glidewell Laboratories. Additional formulations of new milling materials are also currently in the development stage, with most primarily targeting the clinical chairside milling market.

But why all this energy devoted to the development of materials destined for use by the small percentage of dentists who own chairside milling units, and how will the introduction of these new materials impact the laboratory market? The first part of the question is easier to answer than the last. New trends in patient expectations and attitudes toward dental care as well as rising global population growth projections, the shrinking numbers of dental laboratories, a projected decrease in the dentists-to-patients ratio, and the growth of group and corporate dentistry all may be contributing factors incentivizing this investment. Some believe that opening the door to economically mill zirconia in the dental practice will dramatically increase the adoption rate of chairside milling and the demand for same-day dentistry.

"Dentists want to save chairtime and patients are eager for affordable dental care that doesn’t require taking off work multiple times to get that single crown," says Rella Christensen, PhD, head of TRAC Research, the clinical studies part of CR (Clinician’s Report) nonprofit foundation dedicated to in-depth and long-term clinical studies on restorative materials. "My hope is that these new material developments are able to move chairside milling from strictly high-end dentistry to affordable dentistry for the masses." She believes that in the future chairside milling will be an essential component to providing access to dental care for the growing world population for whom healthcare is rapidly becoming a right rather than a privilege for those who can afford it.

But rapid adoption will only come if these machines, techniques, and materials fit within the comfort zone of the average dentist, says David Casper, President of IOS Technologies, Inc., a device and materials manufacturing arm of Glidewell Laboratories. "The key components necessary to increasing adoption of in-office CAD/CAM are simplicity and familiarity," Casper says. "First, the system and software must be simple to use and offer solutions for dentists that are known to their office and suit their chairside techniques and normal prescribing habits."

If chairside systems are able to meet these criteria, Christensen says, these new millable zirconia materials and the others destined for the practice that follow will definitely impact the laboratory by taking a bite out of the single unit market.

So what are these new materials? Both are formulations of Tosoh zirconia powders. According to Christensen, Sirona inCoris TZI zirconia is a partially sintered zirconia that comes in single blocks (20, 40, and 55 mm in length) and mills in approximately 10 to 22 minutes in the Sirona CEREC chairside mills. Single units will require a 15- to 30-minute sintering cycle in the Sirona inFire HTC speed sintering furnace, specially developed for the material, and reportedly exhibit a final flexural strength of 1200 MPa. Milled crowns can be polished or stained and glazed. The competitively priced single blocks will be marketed as the Sirona inCoris TZI milling block and will be available to dentists through Patterson Dental.

BruxZir NOW is a pre-shaded, fully sintered zirconia indicated for producing single units milled in Glidewell’s IOS TS150 chairside mill. A single monolithic crown can be milled in an average of 45 minutes and requires only polishing with no sintering, staining, or glazing necessary. "It comes in 14 shades that correspond to the most popular VITA shades and is indicated for single crowns anywhere in the mouth, though its primary use will likely be for molar and bicuspid crowns due to its 1100 MPa average flexural strength," Casper says. The material is delivered in packages of three blocks and three milling burs and costs $165 per box.

Both materials can be traditionally cemented rather than bonded and both have been submitted to Christensen’s TRAC Research center for a multi-year, longitudinal clinical study to validate their clinical performance.

How deeply and how quickly these new chairside millable zirconia materials will impact the dental industry here and abroad remains to be seen. It may take another five years, maybe 10, but it only takes a short memory to recall how BruxZir changed the face of dentistry.

Expanding dentistry’s role in healthcare delivery

It is estimated that as many as 6.5 million¹ Americans have one or more serious undiagnosed health conditions because they do not seek regular medical checkups. From hypertension and diabetes to cardiovascular disease and hypercholesterolemia, this "at risk" population, if left untreated, will inevitably reach an acute stage in the disease progression, which then leads to increased medical costs as the disease progresses to the chronic stage. So what do these undiagnosed medical conditions have to do with dentistry? Everything, says Jeff Bauer, PhD, an internationally recognized thought leader, consultant, and healthcare futurist. "Dentistry has great contributions to make to the overall health of the patient," Bauer says. "Many health problems have oral manifestations that could be identified by a dental practitioner before they threaten the patient’s overall health." Indeed, according to a survey study conducted by the Harvard School of Dental Medicine in conjunction with the Department of Developmental Biology and Harvard Business School, and published in the Harvard Medical Student Review, many of these "at risk" patients don’t visit a primary physician on an annual basis and fall through health system cracks, but they do regularly visit the dental office.¹ "Dentistry is missing out on the opportunity to engage in the healthcare system and fill a strategic gap to manage patients’ oral health as a key component of their overall health," Bauer says.

Bauer also notes that 50% of the dollars spent annually by taxpayers on healthcare in the US are spent on the 5% of Americans with chronic health problems. According to the Harvard study, "A Business Case for Oral Physicians," dentists offering limited primary care services for patients could save the healthcare market as much as $15.2 billion per year.¹ "Dentistry needs to be participating in healthcare plans that are looking for ways to better manage patient health expenditures," Bauer says. "Dentists are health providers every bit as much as physicians, nurse practitioners, and clinical pharmacists. Each is responsible for a different but complementary dimension of human health. We must not forget the ultimate focus of dentistry is the overall health of the patient." It is a mantra that Bauer continues to preach and act on since his days lecturing to dental students at the University of Colorado School of Dentistry more than 30 years ago.

Although Bauer believes education, practice standards, and reimbursement methods would need to be refined in order for dentists to actualize their full potential as members of the health care team, the integration of oral and systemic health within the dental practice setting would help relieve what is of growing concern in the field of medicine. Projections are that by 2025 patient visits to a primary care physician will increase by 29% due to population growth and the rise in those newly insured under the Affordable Care Act.¹ According to the Harvard study, during those same years the number of primary care physicians is expected to increase by only 2%-7% with many medical students continuing their education to pursue higher paying specialty degrees.

Integrating systemic health screening into oral health care would also solidify dentists’ position as a valuable member of the healthcare team and network. "My futuristic dream is to have dental care recognized by other health professions, health plans, and patients as a basic health service," Bauer says. Progressive dental practices would carry out primary prevention screenings, take a patient’s blood pressure each visit, explain health problems to patients, record prescription drug usage, and ask pertinent questions that relate to dental problems and systemic disease. The data would be entered into an electronic record that is tied into the overall medical community’s database. "The dental practice of the future should be part of the digital transformation of health care delivery. This will better help identify patients with chronic conditions or underlying health problems," Bauer says.

On the other end of the spectrum, Bauer hopes that the integration of medicine and dentistry will result in physicians and nurse practitioners adding basic oral evaluations to the traditional physical exam and then referring patients with health problems tied to oral disease to a dental practice for consultation and treatment. It would be a multidisciplinary approach to health care assessment, care coordination, and case management for diagnosing and treating a patient’s physical as well as oral health conditions. "We need to eliminate the disconnect that exists between oral and physical health management," Bauer says. "We must recognize that a patient’s oral health is an incredibly underdeveloped link to overall health and to redefine the dentist’s role as a primary key to disease prevention and treatment as well as that of a provider of traditional dental care." Bauer concludes that "dentists must take a leadership role in getting the recognition they deserve because other caregivers are preoccupied with their own challenges and do not generally understand how dentistry can help them improve overall health care for their patients."

1. Hedayatnia S and Giddon DB. A Business Case for Oral Physicians: Market Analysis and Potential Practice Models for Dentists to Address the United States Primary Care Shortage. Harvard Medical Student Review. 2015. https://www.hmsreview.org/?article=a-business-case-for-oral-physicians-market-analysis-and-potential-practice-models-for-dentists-to-address-the-united-states-primary-care-shortage. Published September 27, 2015. Accessed October 12, 2015.

Moderate industry growth is a positive sign for dentistry’s future

A March 2015 online survey conducted by the Urban Institute Health Policy Center and published in the quarterly Health Reform Monitoring Survey newsletter revealed that dental care ranked No. 1 among the services that consumers, even those with dental insurance, are skimping on because of cost. Respondents said that they were more likely to open their pocketbooks to purchase prescription drugs, medical care, doctor or specialist care, and medical tests.

Dental care continues to be negatively impacted by the lingering economic effects of the Great Recession, increased out-of-pocket expenses for treatment care, and a general lack of recognition that oral health is linked to the overall health of the individual. These industry challenges have fostered new trends in the structure of dentistry and new work patterns in the general practice, and ignited efforts to expand or extend dental coverage within government programs as well as campaigns to encourage business leaders to include dental plans as part of their employee health insurance. Inside Dental Technology turned to Gary Price, CEO of the Dental Trade Alliance (DTA), an association of companies that provide dental equipment, supplies, materials, and services to dentists and other oral care professionals, for insights from his vantage point.

"From the 30,000-foot macro level, the state of the economy in general and consumers’ lack of confidence in their personal financial well-being has hindered the sense that they have the disposable income available to spend on dentistry," Price says. Coupled with the lack of dental reimbursement plans for more than 40% of Americans and increased out-of-pocket expenses for those with dental insurance, people have not yet decided they are ready to go back to the dentist, he says. On the positive side, the DTA is seeing indicators that the dental industry as a whole is experiencing moderate growth, and reports from the American Dental Association indicate that dentists are busier now than in the past but certainly not at the 1990-2000 levels. "Consumers can’t put off dental care forever," Price says, "and that postponement has created a pent-up demand. I think we are beginning to see evidence of that today. For dentists treating these patients, the oral problems have usually multiplied over the months and years of procrastination, which means expanded dental treatment plans and more dentistry."

Over those same years, dental care utilization patterns have been shifting. More children are seeing the dentist as a result of the Affordable Care Act and the Children’s Health Insurance Program (CHIP) as well as children being covered by expanded Medicaid coverage. However, the same cannot be said for adult populations, for which the numbers have declined. For those adults who do want dental care, their expectation for appointment times has shifted away from standard weekday hours to appointment times that do not interfere with the workday. This has pushed general practitioners to accommodate by offering evening and even weekend hours. "Dentists working the traditional 7 AM to 4 PM days, 4 days a week will have difficulty in the future," Price says. "Patients want weekends and evening appointments, and some practices are changing to meet that demand and experiencing growth as a result."

However, dentists broadening their practice hours to better accommodate patient demands and expanded dental insurance coverage for children does not solve the basic issue of dental insurance coverage for the average American. "Our projections are that the dental industry is providing only 40% of the dental care in the U.S. that could be provided if all Americans had some form of dental insurance and better recognized the link between good oral health and overall health," Price says. As disturbing as this percentage is, he says, it demonstrates tremendous growth potential for the industry. To that end, the DTA will be launching a campaign in the first quarter of next year that targets businesses, encouraging them to add oral health as a major component of their wellness programs and to offer dental coverage for employees. Called the Business Case for Oral Health, the campaign is designed to demonstrate the savings businesses would incur in terms of increased productivity. "It’s essential that companies recognize that to achieve better health for their employees, oral health is a critical component. Better health for employees translates into less loss of productivity," Price says.

Despite the challenges dentistry faces today and in the foreseeable future, Price is encouraged by the progress being made on discussions at the federal and state levels to provide and expand Medicare and Medicaid dental coverage, increased interest among physician groups to incorporate oral health screening as part of their physical patient exams, and the traction the oral health/systemic health link message has gained among patients and healthcare providers.

"I am excited and very bullish about the progress being made," Price says. "I think the dental industry is in for a good ride in the future." His biggest concern: If dental coverage is expanded to include the 30 million Medicare patients in the U.S. and if large percentages of the 60% of Americans not receiving care return to the dental office, will the dental industry have the personnel to meet those care needs?