The New Standard?

Maryam Beyramian, DDS


The New Standard?

This decade will most likely bring another great shift in how dentistry is practiced, but will it be a move back in time and back to the basics? In the past year or so, I have personally extracted more teeth and placed more pa­tients in full dentures than in all 13 years of my practice. More and more patients these days have severe untreated health and dental problems.

Just today, I met Don, a severely overweight male patient in his 50s, requesting full-mouth extractions. A medical history review was done, and according to his paperwork, he was in perfect health. No medications, no allergies, and no significant health concerns. When a patient is even borderline obese, a “clear” medical history causes immediate red flags, so we took his blood pressure; it was 226/113. This suggested that either he had not seen a physician in many years, or perhaps he was noncompliant with a previous medical diagnosis and simply not taking prescribed medications. As it turns out, this gentleman had not seen a physician (or dentist) in 8 years because he had lost his insurance. He was actually unaware of his high blood pressure until this visit. He stated that recently he had been feeling lethargic and sometimes dizzy, but thought it was due to fatigue. So, this borderline obese patient with seriously high blood pressure, severe dental decay, multiple abscesses, and unbearable pain, was a high-risk patient who was currently too unhealthy to treat without first seeking medical care. After listening to his symptoms and his reasons for not seeking medical care, I felt an overwhelming of sadness and empathy take me over. Only a decade ago, I had set up my first office with the vision that my practice would focus on prevention and enhancement. Today, as I listened to this patient, I realized how far away I was from the more idealistic practice vision and goals.

Many of us entered dental school with the goal of one day establishing a private practice in which we could be the driving force in creating a balanced environment of care and professionalism. We wanted to own our business, have autonomy, and to eventually enjoy financial freedom. I graduated from dental school in 2001 in a transitional time. It was at a time when certain new technologies (such as CAD/CAM, digital impressions, and radiographs) were in the process of becoming more mainstream, cosmetic dentistry was gaining momentum, and patients were increasingly more interested in wants rather than needs.

In 2002, I opened my first dental office. This was my baby. It was an office designed for the new millennium, completely paperless with an emphasis on patient education and comprehensive treatment planning. The office had all the latest and greatest—coffee and snacks in the reception area, digital x-rays and computers in every operatory, intraoral cameras, headphones for music and movies, and even Internet access for patients. Our goal was to transform the way dentistry was perceived and practiced. This was the future of our profession as I saw it in the early 2000s. Every 20 to 30 years, dentistry evolves, and in my opinion back in 2002, this was the evolution for the next 2 decades of practice.

For more than a decade, between the late 1990s and mid-2000s, the everlasting quest for youth gained momentum in the popular culture. The modern dental office evolved, with the help of the media, to create the perception of dentistry as the new must-have “cosmetic enhancement.” Patients came to see us wanting a perfectly balanced face to complement their most recent plastic surgery enhancements. Straying from the sterile, cold, medical environment that dominated many dental practices in the 1980s, the modern offices had digital capabilities, allowing patients to “see” what we see, becoming more intimately aware of their own dental conditions and feeding their desire for im­proved aesthetics. The birth of the “spa dental practice” was the pinnacle of this wave, creating a relaxed and patient-centered environment for those who came seeking cosmetic procedures that could cost many thousands of dollars.

Dentists shifted their practices to accommodate the growing demand of cosmetic procedures. More and more continuing education classes became focused on teaching the latest cosmetic procedures, and a new wave of practice management courses sprung up to help with the growing physical demand of a larger patient pool. Like most great advancements, few were quick to adopt, while others viewed from the sidelines disapproving of it all. Like it or not, a paradigm shift had occurred, and dentistry would never be the same again.

Many dentists enjoyed great prosperity during this time period, both emotionally and financially. They set up their dream practice in the location of their choice. They employed all latest and greatest technologies, seeing patients at convenient hours of operations and enjoying the growth of their patient pool and income year after year, not knowing what the future would bring.

The 2008 economic meltdown that was the start of the Great Recession marked the beginning of a new era for us. Most patients were scared, cautious of spending, worried about their jobs, and understandably concerned about their futures; fewer and fewer patients called to make appointments. In many practices, the number of new patients soon began to diminish and treatment plan acceptance started to decline. Dentistry was shifting, once again.

For my practice, 2009 was the breaking point. It began with more bad news—housing markets, financial institutions, and the domestic automotive industry, we were told, were on the brink of collapse. The middle class became more and more concerned about their families’ ability to provide the basic needs of food and shelter and much less concerned about their general and dental health. The steady fall of the middle class and the rise in income disparity impacted our practices in a significant way. Start-up practices were now unable to sustain their huge overheads. Practices went into foreclosure, and the dental economy also headed into serious recession. Suddenly, patients began to view dental services, especially cosmetic services, as a luxury. As a profession, we had shifted the public’s opinion of our services, but now fate seemed to be working against that previous shift.

We practice in a middle-to-low income area in downtown Phoenix. Many of our patients have a very low dental IQ and have major untreated dental disease. Due to the demographics in the area, our practice is always filled with dental emergencies. So, when the economy started to falter, our practice was still going strong. In 2008 and 2009, while the world economy crashed, our practice seemed to be in a bubble. We were able to sustain our growth and our income. We often wondered how that could be possible—was it Arizona? Was it our unique patient pool? Was it due to how we managed our business? Or, could it be that we would be next?

The year 2010 started off a bit shaky, and we started to notice gaps in the hygiene schedule, but my own schedule was still steady. As the weeks progressed, cancellations increased. I called in the office manager, who had been with my practice for 10 years. “Melissa,” I said, “What are you guys doing to the schedule?” Of course, it must have been my team, because I was not doing anything differently. You know the story; our local economy seemed to be fine in the bubble! Her response was shocking: “They say they have no money.” No money? Impossible! We know patients always have money; it is simply a matter of where they choose to spend it, right?

At the next morning huddle, and for the next 6 months, we discussed treatment planning and explored and proposed various financial options.

Going back to my patient Don, I cannot help but think, was he like a window to our professional future? This patient told me that, when he last saw his dentist 8 years ago, he had been presented with a plan to restore his entire dentition and it was going to cost $15,000. At that time, he was still fully employed and had planned on completing the procedure in a few months when he had saved enough money. Due to the cutbacks at work, the patient had to use the money he had saved to pay for everyday expenses. His healthcare took a backseat to the daily need to survive. When he was talking to me about how his company had failed him, I couldn’t help but wonder about his own role and responsibility for his future. When the patient saw the ongoing layoffs, why was he not proactive in seeking other employment and concerned about his financial future? Why did this patient not seek additional training to make himself more marketable? Why did this patient maintain status quo, expecting a different outcome?

Some self-reflection was in order. As was the case for Don, I had been under as illusion that was supported by the thought of everlasting prosperity. My team and I believed in continuous professional and economic growth. We invested in newer technologies and upgraded our offices to present the look and feel of what we thought the future would be in dentistry. We increased our fees to reflect the more aesthetically pleasing options available in our treatment plans. We cut back our hours, had 3-day weekends, and took more vacation time. We believed that tomorrow would be better than today, but the time came when the predictability of our dental office was jeopardized. Our schedule was not as busy, there were more cancellations, fewer new patients were calling, and as the months went on, less and less revenue was coming in. As with my patient Don, I think it is crucial to ask the same questions in the context of our practice. When we saw that our office’s revenues were declining, why were we not proactive in seeking different methods of revenue growth? Why did we not seek additional training to be able to offer our patients more services to help make our practice more marketable? Why did we maintain the status quo, expecting a different outcome? Why were we not more proactive about our practice’s financial future? We expect our patients to adjust their daily routine emotionally and financially to achieve optimal oral health, so why do we not expect the same when dealing with our own business practices?

I had a vision for my future when I opened the doors to my first dental office. I was going to work hard, provide the highest quality of care, and my practice was going to grow, year after year. After a decade, I would have an established dental practice with a strong internal referral base of loyal patients that came for recall every 6 months.

The reality, however, is slightly different than the vision. After a decade of practice, I do have a strong loyal patient base, but I have altered my perception of who a “loyal” patient is. I have patients who I have not seen in a few years who continuously refer their friends and colleagues to me. I consider these patients loyal. Today, our office offers extended hours to offer convenience to our working families. We break down treatment plans based on need and offer many creative financing options to make dentistry affordable. We offer a more comprehensive setting where we offer many specialty procedures in-house. We have now begun to take our office through a journey, an evolution that takes into account the modern financial world.

We will again experience another shift in the near future. At a meeting a few weeks ago, I was talking to an orthodontist who had recently set up a private practice in a lower-middle to middle income area of the community. His business model was very interesting. He is starting upwards of 80 cases per month while offering his patients a financial option that works for their budget: $100 down and $100 per month for 36 months. He told me that this is the only way his patient population is able to afford placing braces on their multiple children. As you are shocked reading this; I was shocked hearing this. I stepped away from my conversation a bit confused. Is this orthodontist performing a service for the underserved population or is he possibly doing damage to our profession? This leads to a series of bigger questions: How could he hurt the profession if he is providing good quality care? Are we simply scared of the effect that this kind of discounting may have on our practices financially? Will practices like his shape the future of our profession?

Our profession is progressing. With the help of all the advances in technology, complex procedures are becoming further simplified, leading to broader utilization. Looking ahead, I can’t help but wonder how technological ad­vances, combined with a faltering economy, are going to shape the future of the dental profession. We need to take a look at our practices and answer this basic question: How can we prepare physically and mentally to face this imminent evolution? We have to be willing to step outside of the boxes, the ones we have created for ourselves, our comfort zones, and allow ourselves to create a new vision to ensure our practice’s survival in the new millennium. How prepared are we to accept this “new standard” as the future of dentistry?

Dr. Beyramian graduated from the University of Michigan School of Dentistry and currently owns 3 private practices in Phoenix, Ariz. Her vision to promote smart business practices for private practitioners has led her in creating and owning, an online dental supply company. She can be reached at (877) 850-2181 or via e-mail at

Disclosure: Dr. Beyramian reports no disclosures.