key: cord-282234-yzozbf7p
authors: Edelstein, Burton L.
title: Disruptive innovations in dentistry
date: 2020-07-24
journal: J Am Dent Assoc
DOI: 10.1016/j.adaj.2020.05.003
sha: 
doc_id: 282234
cord_uid: yzozbf7p

nan

T his commentary is about disruptions underway in dentistry today. It is not about the kind of disruptions that occur unexpectedly like natural disasters or the COVID-19 pandemic but rather about the kind of disruption that can be anticipated by simply scanning the environment looking for incipient changes. This expected kind of disruptiondwhat Christensen called "disruptive innovation"dis always present at the periphery of every business, industry, or profession. 1 Because it can be anticipated, it can be managed.

As dental practitioners and educators, we owe it to today's dental students and young dentists to prepare them to recognize and deal with changes in US health care delivery and financing now underway that will almost surely affect their careers. 2 We need to adopt the approach taken by physicians and medical educators who prepare their students by teaching health systems science in addition to biomedical and clinical science. The American Medical Association's Education Consortium puts it plainly in a book introducing health systems science: "Over the last decade it has become clearer that trainees require knowledge, attitudes, and skills beyond the scope of, and in addition to, the basic and clinical sciences if they are to be prepared for practice in our current and future health care system." 3 Roiling the profession are disruptions in technology, communications, workforce, payment, and management, all driven by creative innovators sponsored by venture capital, nonprofits, and governments alike. Churning dentistry's environmentdjust as parallel forces are reshaping medical caredare direct-to-consumer and doit-yourself dentistry like orthodontic aligners, tooth whiteners, and intraoral appliances 4 ; Dr. Google offering free dental advice on the internet 5 ; dental therapists restoring teeth 6 ; alternative payment mechanisms tied to health outcomes 7 ; and expanding delivery systems like dental service organizations, accountable care organizations, and patient-centered medical homes.

There are many change drivers that are persistent and impactful on dental practice: n the internet, which continues to propel an information revolution; n shifting generational values, expectations, and norms of boomers through millennials (with Generation Z around the corner); n artificial intelligenceeequipped technologies; n consumer demand for low cost and convenience; n large sums of venture capital looking for the next big thing.

There are also societal forces churning the larger health care environment: n unaffordability of health care as reflected in mounting medical debt and bankruptcy along with care deferral and self-treatment; n gross class inequities in health care that leave too many helpless in the face of illness or injury; n recognition from the disciplines of public health that more of our health comes from social, environmental, and behavioral determinants than from our health care system and its doctors. For dentistry, the single most important change driver is unaffordability of care. We simply have outpriced ourselves for far too many people, particularly adults with and without dental insurance. The American Dental Association's (ADA) chief economist and vice president of the Health Policy Institute (HPI), Marko Vujicic, and his colleagues captured this message in the title of a 2016 article in the influential journal Health Affairs titled "Dental Care Presents the Highest Level of Financial Barriers, Compared to Other Types of Health Care Services." 8 Multiple HPI publications document the problem of unaffordability and the downward trend in adult oral health care use. HPI's 2020 Annual Dental Industry Report notes, "Declining dental care utilization rates among adults with and without dental insurance are the main drivers of the shrinking adult population base among dentists." 9 Capturing this problem, ADA President Dr. Chad P. Gehani, when asked by ADA News about the biggest issues facing dentistry today, responded, "For the profession, consumerism. Our patients look upon us as providers of service. They look for convenience and cost effectiveness." 10 What happens when an established industry, like traditional dentistry, does not respond sufficiently to its consumers (patients) as they look for convenience and cost-effectiveness? According to Christensen and colleagues, 11 "In any industry . while the dominant players are focused on improving their products and services . they miss simpler, more convenient, and less costly offerings initially designed to appeal to the low end of the market."

Dentistry has long been actively engaged in improving its products and services for its core highend patient market through expensive new technologies, materials, techniques, and payment arrangements. These begin in upscale markets before sifting downward to the overall dental market if they do so at all. Technologies like computer-aided design and computer-aided manufacturing, lasers, and older transitions (for example, from foot pedal and motor-driven belt handpieces to airdriven high-speed units) entered dentistry wherein substantial fees could support their high-cost acquisition. Similarly, new dental materials that sparked the adhesive revolution and enhanced cosmetic dentistry, new techniques like dental implants and high-tech endodontics that left highincome people with more teeth than lower-income people, and payment arrangements through dental insurance that benefited those with higher-paying jobs all followed the same high-to-low path into dental practice.

Today, looking at the low end of the dental market, we see a host of disruptive innovations important to dentistry's future that mostly work in the opposite direction: from the low-to-high social aspects of the dental industry. These can be categorized as a 4-tiered hierarchy, with the first tiers already clearly evident and the higher tiers just now evolving.

Tier 1 dental disruption comprises efforts to aggregate practices and enhance their business operation efficiencies. Early efforts at group practice are typified by Schoen's 12 collaboration with the International Longshore and Warehouse Union in the 1960s to establish oral health care for young children. Today, these are evident in the decline of solo and small partnership practices and the increase in dental support organizations (DSOs). As early as 1986, Lipscomb and Douglass 13 noted that group practices increase efficiency and reduce overhead. They also wondered "whether these apparent production efficiencies . are ultimately translated by the market into lower fees, shorter queues, or other nonprice benefits." 13 Clearly, the answer has been "no." Rather than benefiting patients, these efficiencies now profit the many entities that grew ever-larger dental groups and provided them with business services. Tier 2 dental disruption occurs when innovators fill market voids in which mainstream dentistry either fails to recognize or attend to unmet demand. A prime example was high demand for oral health care by families of publicly insured children (a low-end market). Lower-income parents faced significant challenges finding Medicaid-participating dentists who accept children. When they did, they sometimes confronted transportation, language, cultural, and other care barriers that left them unsatisfied. Into the marketplace came DSOs with a pediatric-dental Medicaid-only practice model that operated efficiently, provided high volumes of care, was profitable, and met low-end consumers with convenience. By 2009, an estimated 21% of the 13 million children enrolled in Medicaid who had a dental visit were treated at 1 of these pediatric Medicaid-focused DSOs. 14 Consistent with the theory of disruptive innovation, this innovation subsequently influenced mainstream dentistry with ever greater proportions of pediatric dentists participating actively in public insurance. 15 Tier 3 dental disruption aims to modify the very structures that characterize dentistry by changing key components of how dentistry operates. No longer tinkering around the edges (as in Tier 1 and Tier 2), Tier 3 innovators ask whether the way dentistry operates still works for patients and if not, what might work better. As with other disruptive innovations described by Christensen's 11 theory, this often begins in the low end of the market as evidenced by the advent of dental therapists, whom state legislators endorse as solutions to inequitable access, sometimes seeking to limit their deployment to safety-net sites. Other examples that offer convenience, cost-effectiveness for the payer, or presumed value for the consumer include teledentistry targeted to homebound and other underserved groups, employer-located dental services, cosmetic kiosks in malls, anddpotentially most impactful to dentistry's future modeldan expansion of pay-for-performance into alternative payment mechanisms (APMs) that replace fee-for-service payments. APMs that are already evident in medicine seek to ensure value by assessing health outcomes against cost. These range from FFS linked to quality and value to APMs with shared savings and shared [financial] risk to populationbased payments that blur the lines between insurers and health systems. 7 Tier 4 dental disruption borrows heavily from public health principles in seeking to change the very content of oral health care by calling on the profession to address the social, behavioral, and environmental determinants of oral health along with providing traditional dental procedures. These principles include allocating scarce resources to those with the greatest need, going upstream to prioritize prevention and disease management, addressing the full range of health determinants, and providing care within the contexts of family and community. They are reflected in the growth of accountable care organizations, patient-centered health homes, and other holistic, interdisciplinary, and outcome-oriented approaches to health care. One novel disruptive enterprise in medicine that reflects this approach is Cityblock. This primary care medical model "bring[s] together primary care, behavioral health, and social services to delivery better care for every member." 16 It was "founded on the premise that health starts at the neighborhood level." 17 It "aim[s] to build a new kind of care model that addresses the root causes of health" and seeks to "improve health in communities that have previously been underserved." A dental example is Columbia University's MySmileBuddy program (funded in part by the Center for Medicare & Medicaid Innovation and the National Institutes for Health), which fields technology-assisted community health care workers into the homes of children experiencing early childhood caries. These lay health care workers engage parents in sustained adoption of healthy dietary and hygiene practices to arrest caries and reduce the need for dental repair under general anesthesia. 18 Calls for expanding dentists' roles and responsibilities to include primary medical care screening and preventive guidance is an additional example of potential change in the content of care. [19] [20] [21] Each successive tier of innovation and disruption enhances dentistry's value proposition for our patients and would-be patients. Consistent with Christensen's 11 work, each offers "simpler, more convenient, and less costly offerings." Each holds potential to eventually change the character of dentistry as it has been practiced traditionally.

Disruptive innovations inform the discipline of health systems science, which seeks to enhance the value, quality, and safety of health care while promoting improved population-level health outcomes. With rapid change underway in US health care, now is the time to integrate this expanding sciencedalong with biomedical and clinical sciencedinto dental education from the first day of dental school to the last day of continuing dental education.

Many changes underway in dentistry today are potentially more disruptive to traditional care models than in the past because they reflect the larger US health care environment and because they enter dentistry through the low-end of the market. Potential changes will affect where and how care is delivered and how dentists will be paid. Dentists need to be aware of and prepared for these changes. n

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Pew Charitable Trusts. What are dental therapists: FAQs about practitioners who provide care in a growing number of states

Dental care presents the highest level of financial barriers, compared to other types of health care services

American Dental Association Health Policy Institute 2020

Gehani: transforming the face of dentistry

Will disruptive innovations cure health care?

Group practice in dentistry

Are larger dental practices more efficient? An analysis of dental services production

Children's Dental Health Project. Dental visits for Medicaid children: analysis & policy recommendations

Feasibility, acceptability, and short-term behavioral impact of the MySmileBuddy Intervention for early childhood caries

A model for dental practice in the 21st century

Primary care in dentistry: an untapped potential

Should dental schools train dentists to routinely provide limited preventive primary medical care? Two viewpoints