September 13, 2021

Are we slowly losing control of our profession?

This is a guest post by Dr Chris Riolo who is a full-time specialist orthodontist in Seattle, USA. He discusses one way we can begin to take control of both our workflow and data using in house aligners facilitated by our professional organizations.  It is a very interesting and ambitious viewpoint.

 

The problem

Digital orthodontics and Computer-Aided Design (CAD) technology, in combination with subtractive and additive manufacturing technology, have the potential to be a transformational force for good in the care of our patients.

Unfortunately, up until now, these disruptive technologies have benefited only corporations that focus on market share and profits, not patient care.  One of the consequences of these technologies is the rise of corporate “providers”, i.e. Invisalign, Smile Direct Club, Byte (Now Dentsply Sirona) and Candid Co.

Today, dental corporations are commanding a higher and higher percentage of “practice revenue” as they enter the doctor-patient relationship.  They use a myriad of tactics to increase their influence on our practices and the relationship we have with our patients:

1. Direct to Consumer Marketing:

In some cases, the patient is treated without the supervision of a dentist, let alone an educationally qualified orthodontist.  Frequently, essential safeguards, including initial radiographs or documented pre-treatment periodontal and caries clearance, are absent. Instead, the responsibility for treatment readiness is placed on the patient.

2. Direct Corporate Referrals:

Corporations now frequently refer patients directly to select providers through online portals or storefronts. As the percentage of patients received and started by a particular provider increases, the relationship between the orthodontic provider and the corporation begins to blur. When the referrers objective is to sell a specific product or appliance, who dictates the treatment plan? Provider or Corporation?  This move, in effect, makes all of us their unpaid sales force.

3. Tiered Pricing:

Corporations commonly employ tiered pricing to influence orthodontists to treat patients with a particular appliance system. These pricing tiers are now the rule rather than the exception.  The Orthodontist is “encouraged” to start a certain number of patients every quarter.

If the Orthodontist makes the next tier, they can save hundreds of dollars for every patient started the next quarter.  Importantly, when the Orthodontist is “just a few starts” away from the next level, the implicit pressure is to push a few more patients into aligner treatment that the clinician would instead start with fixed appliances.  The cost to the orthodontic practice of ignoring this tiered pricing scheme can be thousands of dollars each month.

One company has taken tiered pricing to a new level with select practices offering “unpublished pricing discounts” to high volume practices that “open their books” to guarantee that a PERCENTAGE of the patients will be started with the company’s product!  In addition, these corporations are merging/consolidating and are beginning to bundle “products”. So, for example, the cost of your practice next scanner may well depend on the number of patients you commit to starting with the company’s product.

4. Corporate Education:

Corporations are holding their own “educational” meetings; they have “faculty”. And why not? The corporations are gathering the data and doing most of the research on these new appliance systems. But, of course, they do not share this data with the public; the evidence is presented back through their “Key Opinion Leaders” (KOL’s- Orthodontist paid to endorse/ influence) and their own “educational” events as well as large corporate dental meetings.  These corporations initially use orthodontists to “train” their Artificial Intelligence (AI) programs by collecting massive amounts of treatment data.  The AI programs are then used to power the company’s software.

5. Proprietary Data:

Private Insurance companies have been collecting data for years. However, the amount of data available for collection has exploded due to the advent of digital orthodontics, and the data is far more granular in detail. It is not a coincidence that almost every major company collects data; to a greater and greater extent, in this new economy, data is power, data is money.  If our professional organizations ignore this fact, they are destined to become insignificant like their counterparts in Medicine.

The encroachment of corporate dentistry into our profession and our relationship with our patients is most evident in North America and the United States in particular.  Nevertheless, these corporations are multinational, and so are these trends.  This issue sounds very grim for the orthodontic profession, but disruptive technologies cut both ways.  Digital design paired with 3D printing of resin and metal has the potential to disrupt centralized manufacturing.  We can now make custom orthodontic appliances like Incognito and Invisalign locally in our own offices rather than in multi-building manufacturing facilities located globally. The future of our profession lies in taking control of our Data and our Workflow, as opposed to relying on multinational corporations for our custom appliances and at the same time ceding all our data.

First steps towards a reimagined future?

It is clear that we have a problem; what is the solution?  I believe the answer is for educationally qualified orthodontists to stand together to benefit our patients and our speciality.  Our power lies in our participation in organized dentistry through organizations like the AAO, EOS, and WFO.

I will outline one obvious solution; companies like Invisalign, Smile Direct Club, Byte and Candid spend hundreds of billions of dollars branding themselves. They do this to develop the market share that a large professional organization like the AAO, EOS and WFO could command on day one.  If a large professional organization acquired or developed aligner staging software, it could change the whole trajectory of our profession.  All orthodontists will soon own and operate 3D printers daily; all orthodontists can create a thermoform aligner in house using a Biostar, Drufomat or the equivalent.  All we lack is cloud-based staging software to provide our patients with affordable aligner treatment. Whether this would be limited, comprehensive, or hybrid therapy in conjunction with fixed appliances.

I am suggesting that our professional organizations rethink their role in our profession and facilitate in house workflow through an affordable staging platform, benefiting orthodontists who are members of organized dentistry and their patients worldwide.

Importantly, I am not proposing that orthodontists exclusively provide in-house appliances to our patients. Instead, I suggest that we provide affordable and flexible treatment when it benefits our patients.  When we deem it is better to employ a commercial system, we will have that option.  But these corporations will have to compete honestly for the privilege of participating in our patients’ care.

Let us consider the consequences of implementing this scenario:

1. A new player:

Orthodontists themselves would overnight become a major player in the multi-billion-dollar aligner market. These commercial companies spend fortunes on branding and advertising for patients.  Orthodontists, as a community, are the market that they are trying to tap.  We already have what these corporations are spending hundreds of millions of dollars to develop; we are the market share.   The professional association that develops staging software 100% owned and controlled by its membership will become a significant player in the aligner marketplace overnight.

2. Reverse Declining Membership In Organized Dentistry:

The strength of any professional organization is membership; to maintain and grow membership, an organization must provide value. Our power is in the numbers; it is imperative that no matter which professional organization develops cloud-based staging software, it should be made available to any “educationally qualified” orthodontist in the world.  By allowing the use of the software to an orthodontist who is a member of their local or international professional organization, we add value to all professional organizations, not just the organization that developed the software.

Consider the consequence of providing unlimited use of aligner staging software for only $100 per month to any educationally qualified orthodontist who is a member of organized dentistry in their country.  Just 10,000 member users would generate $12,000,000.00 per year for continued development and improvement of the software.  We could easily see more than double that number of member users worldwide.  In Nepal, the average orthodontic fee ranges from $350 to $1150, depending on the appliance system employed.  Access to this staging software through an orthodontist’s local organization would add tremendous value to the membership not just for the North American or European Orthodontist but for member orthodontists worldwide.  Importantly, access to affordable staging software will likely reverse the recent declining participation in organized orthodontic associations in North America.  The more membership increases, the greater our power in the orthodontic marketplace.

3. Funding The Future:

“Non Dues Revenue” gets the attention of any orthodontic organization. The professional organization that foresight to provide this service will also have access to the excess revenue generated. We can use this type of staging software to offset member dues and essential projects like an Orthodontic Registry.  We generate vast amounts of digital data in our offices through the process of treating our patients.  These data have to be systematically collected and collated into an orthodontic registry that could be invaluable, making our profession leaders in evidence-based care.  Developing the means to collect, store, and interact with these data is the first step in controlling our data for the good of our patients and the profession and implementing cloud-based staging software does precisely that.

Two important guiding principles

For organization based staging software to be successful and have the intended effect on our profession, we must adhere to two important guiding principles:

First, the software must be cloud-based and 100% owned and controlled by the professional organization’s membership. Second, any educationally qualified member of a legitimate orthodontic professional organization should be able to participate.

The first principle addresses the need to control our DATA and our WORKFLOW; the second principle acknowledges that we need to stand together as a profession. Many of these corporations are international, and we cannot afford to be fragmented.  We are all orthodontists facing similar challenges. If we stand together, we all benefit.

Nobody is better positioned than professional orthodontic organizations like the AAO, EOS or the WFO to disrupt the orthodontic marketplace.  We do not have to be victims of the changes we are now seeing.  We can be the disruptors!  We have to act; the first step will be the hardest, convincing our leaders to think outside the box and work to preserve our profession. Orthodontists value a marketplace that allows the flexibility to treat patients affordably with the tools to address patient needs and desires.   It is not factories and distribution systems alone that command power in this new marketplace; it is SOFTWARE and DATA.  Software and data are power, and organized orthodontics is uniquely positioned to leverage this power to benefit our patients and our speciality.

The way forwards

We need to act now; what can you do? First, talk to your colleagues and contact your representative in your respective professional organizations. Emphasize the value that a staging aligner software would bring to you, your practice, and your patients.  Discuss the vast benefits of collecting and analyzing data on the orthodontic profession and its ability to deliver independent and evidence-based care. Tell them that without adding value to membership in our professional organizations, it will be tough to convince the next generation of orthodontists that membership in their professional organization has more value than an excellent orthodontic Facebook group.

A version of this post was  first published by the AJO-DDO.

Have your say!

  1. Many thanks Kevin for bringing this guest post by Dr Dr Chris Riolo to my attention. I applaud both of you. In my humble opinion this will extremely challenging and not easy. It’s a critical stage in orthodontics, and in both orthodontist and patient education. Orthodontists will need to stand together and I look forward to developments of this concept.

  2. Orthodontists lost control over their profession when we stopped the preceptor program and relagated all education to university programs. That was the beginning of the end.

    • AMEN! No real educators left

      • Dear Dr. Stoner and White,

        I do not want to take away from Dr. Riolo’s article and arguments. I think he has some nice ideas and thoughts that may help us as orthodontists.

        I do have to disagree with the statement there are “no real educators left”. I know several top flight orthodontic educators and they are as dedicated to our profession as any in the past. They are working with less than ever and they need and deserve our full support.

        We are changing and part of Dr. Riolo’s thesis is how some of our orthodontic education is being assumed by these corporations. We may be the problem…..not our educators.

    • As someone who has heard firsthand how valuable the preceptor program was, I can understand your point of view!

  3. Highly intelligent, reasonable, rational people will never be able to make a list of all the things that will never occur to them. Dr. Riolo nails this one. 20 years ago, we never could have imagined a future like the present we are living in. Let’s work together and change things.

  4. Thank you for this post it is indeed really interesting. I was just discussing with colleagues last week how we need to work to remove the barriers to certain types of treatment for our NHS patients. As technology advances and where certain patients will benefit we want the freedom to offer the best treatment modality and not for it to be constrained by cost.

  5. Congratulations to Dr Riolo, your visionary idea is probably the best and most important of the last decade for us orthodontists! It will certainly not be easy to implement it, but it is paramount to act if we want to avoid becoming serfs of these Corporations in a not too far future.
    I may add that, by entering the marketing arena with our professional organizations, we will also become more aware of other “dirty tricks” played on us by unscrupulous providers waging commercial wars agaist each others, like locking the use of expensive equipments such as IOS exclusively to one specific provider. Or by extorting exorbitant fees for yearly software upgrades that are neither requested nor required, and at the same time killing or acquiring all the smaller players, thus making impossible for us to find reasonable alternatives.
    Thank you, I will immediately contact my national organization.

  6. would be better to share all data – aligner and non- aligner… Thus enabling big data and hence the profession can see what systems / philosophies etc work and those that do not

  7. Indeed a well thought out proposal by Dr. Riolo. With respect to Dr. Riolo, while still being realistic, I’m afraid this dream will never come to pass. I have practiced for 30 years and have seen these changes throughout my career. In fact, I was an early adopter of Invisalign when it first arrived on the orthodontic scene. I did a hundred or so cases and became disillusioned with the results. I have subsequently only used other systems for occasional minor tooth movement.

    In my opinion, I believe the “horse has already left the barn” and has been running too long for any of us to make a significant difference. Most orthodontists will not want the hassle of dealing with a 3D printing lab. With a small practice and even some dedicated larger practices, it may be feasible; however, I know many young orthodontists, with thriving practices, for whom it just does not make financial sense. They are already getting discounted pricing. Outsourcing seems to be the status quo. Doing one thing well has certain advantages that are difficult to compete with. Unfortunately, I believe printing our own aligners will become a niche market. I speak from experience. I manufactured aligners in my practice for awhile but it just became unmanageable. Obviously, for others, it is not.

    When corporations get involved, and money is to be made, history has shown there is no stopping them. In a free market system, financial priorities prevail. We only have to look at our medical system to see how financial efficiencies have totally transformed the medical practice. Some of us pine for the old days, but change is happening at a rapid pace. Our proficiency is in providing orthodontics. A business’ proficiency is in making money. I’m afraid in this instance, we can not compete.

  8. Interesting and reasonable. I don’t think there is such a need to purchase aligner software that is in the cloud and can be printed at a very reasonable price. I believe the ArchForm is made for orthodontists who want to plan the movements of their patients’ treatments. The savings are very considerable.
    Gilberto Salas ArchForm spanish KOL

  9. Hello Doctors,
    I’m not a clinician. But close to orthodontic. If you think what dr Chris Riolo described as dream alternative is far away – you are wrong.
    I may support you immediately with system dr Riolo is describing as the idea for the future. As the post requirement I will leave my email for dr O’Brien knowledge. Let’s see what will happen.

  10. We can be the solution to this problem of companies and aligners, there are open source software available for any professional who wants to use them, there are the tools, it is only necessary to learn how to use them, understand all the details of digital flow: scanning, use of software , design, printing, etc.
    There are more courses in that sense, much of this learning work is done alone, only with a restless spirit and the desire to learn is what can make us move forward, there are the tutorials on You tube where one can understand little by little the design and printing tools and thus create one of your own invisible aligners, also so we can individually generate data to share and improve existing software, and advance knowledge about these treatments as well as their improvement.
    By doing so, we all take control of our profession and even the patient wins with cheaper treatments, since the participation of intermediaries is eliminated.

  11. Thought-provoking piece. I am always glad to see my inbox have another post from this blog. Agreed that we need to stick together.

  12. Totally agree, especially point number 3 in the problem list. Really good idea to centralise it but if that is hard then individual boards of each country should try and implement it and if that is hard then individual orthodontists should try and start the process in their respective practices. The Technology is there, affordability is not far, CAD/CAM in the aligner industry is a game changer and we need to step up.

  13. Dr Riolo, many thanks for sharing your forward-thinking proposals. I couldn’t agree more! I’ve used an in-house aligner process for over 18 months, for multiple reasons, and would never wish to go back to using a provider brand again. I find that this empowers me to follow my clinical instincts and offer every patient a range of genuinely-informed choices, rather than being a salesman for off-the-shelf branded products (with misleading advertising claims). It also facilitates the use of multiple techniques within the treatment journey, eg using fixed appliances for demanding tooth and arch changes, and then finishing with aligners.

    All of the practicalities related to 3D printing, appliance fabrication, sterilization and packaging can now be readily mastered by the orthodontic team. However, access to tooth manipulation software is more limited, as you’ve point out. I use one which requires an annual licence. There are other alternatives available in the USA, but they’re not currently licensed for use outside North America. Therefore, a non-branded speciality-driven software package would be most welcome for both orthodontists and specialty educators alike.

  14. This article completely misses the fact that this new “corporate” technology allows general dentists to perform many orthodontic services for their patients without any extra investment into orthodontic supplies or equipment. Last I checked general dentists outnumber orthodontists at least 20:1 — That’s where all the work has gone! (in addition to their being too many orthodontists in the first place). GPs aren’t referring as many patients any more — now it’s every man for himself aka dog eat dog. Waiting for organizations like the AAO to evolve is like watching a glacier. Orthodontists need to work on their relationships with referring GPs — otherwise we are just another competitor down the street.

  15. Is the threat to our profession over-stated? Our private practice grew by 25% and our overheads reduced by 10% in the past year. We stopped advertising and offering free consultations to online aligner company leads and shaped our clientele around those who value our service. As a result, we are doing fewer aligner cases. Is that really such a bad thing? Maybe a bit less plastic in our oceans would actually be a good thing. Sometimes I feel that our specialty is too obsessed with cornering 100% of the orthodontic market because that is the way that it has always been. I don’t subscribe to the notion that we need to start every patient who walks through our doors. In Australia, we seem to have plenty of crooked teeth to keep us busy despite GPs and corporate organizations sharing a piece of the pie. In my part of the world, our specialty seems to be as strong as it has ever been although you wouldn’t know it when you listen to my colleagues whinging all the time about having their grass cut.

  16. I 100% agree

  17. Making your own aligners depends mainly on 3d printer costs. There is another issue though in that we are reaching a point when the aligner companies are becoming the orthodontists and anyone can fit the aligners for them. It would appear obvious that there needs to be a clinical assessment for caries and perio but you dont need to be an ortho to do that. I forsee that aligners will be provided by all dentists if they want to (and they seem to) leaving the trained orthos to do what? We’ll probably just be left with impacted canines.

  18. Organized dentistry (AAO, CODA, ADA) have been at the helm throughout the decline of the profession. I respectfully disagree with the idea that these organizations will do anything other than make matters worse.

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