Cover feature: Tarek Aly | Great changes, great opportunity

With the right mindset, and skillsets, dental group practices can create a high quality of service for their clients amid a challenging environment.

The initial career path for Tarek Aly wasn’t negotiable. His parents wanted him to become a doctor just like them and his brother, so that’s what he did. And while he enjoyed practicing dentistry, Aly had a stronger leaning.

“I’ve always had business in the back of my mind,” he said.

Through dentistry, Aly has been able to fuse the two into a successful career both as a periodontist, and now as the chief operating officer at OrthoDent, a dental support organization built for dentists, by dentists.

In the following interview, Efficiency in Group Practice discussed a wide array of topics with Aly, including the challenge of balancing clinical expertise with developing business skills, how COVID-19 has affected dental group practices, and what adjustments he believes group practices need to make in order to maintain success in the future.

Efficiency in Group Practice: You practiced dentistry and periodontal surgery, and then got into management and marketing. Can you talk about what interested you with the business side of dentistry?

Tarek Aly: I’ve wanted to be a businessman since I was young. But being from a family of doctors, and also being Egyptian – if you know anything about Egyptian parents, you don’t negotiate with them – they wanted me to become a doctor just like them and my brother. I was intrigued by medicine in general, but my passion has always been business. So, I did join dentistry for my parents, and I ended up falling in love with it. However, I didn’t see it as my dream career.

I’ve always had business in the back of my mind. After my periodontal residency, I went on to receive an MBA, a marketing diploma, CVA, and many other business certificates. I loved that marriage between the clinical and the business aspect of dentistry.

As a dentist, by the time we graduate from dental school, we have a decent amount of clinical skills, but very little amount, if zero, of business skills. This includes accounting, finance, marketing, procurement, business analytics, compliance, strategic development, etc. So, we either learn these skills on the job as we go – which takes years – or we go get formal business education, which I chose to do. If you’re going to start a business, which is basically your clinical practice, you must master these skills, on top of soft skills that we have to master, like communication skills, persuasion skills, conflict management skills, etc.

EGP: As you were practicing clinically, you were also building expertise with the business side of a clinic. What were the challenges that came up that you saw that you and your colleagues would face?

Tarek Aly: When you are practicing dentistry, you are completely focused on the tactical aspects of dentistry. You are providing the ultimate quality of clinical care for your patients. However, you don’t dedicate enough time and attention to the business aspect, which is also serving patients, by making sure that you provide top quality of care, you have less waiting time, you’re efficient and effective, you have happy, satisfied team members, and returning patients with a positive impact. That in itself is difficult because you are functioning with two minds. You have the dentist’s mind, and you have the business mind. And that is definitely hard. In the beginning you are handling everything. You’re doing all these things. But as you grow, you have the ability to break down some of these functions and give them to a specialist, who has the formal education, knowledge and the experience to tackle one piece at a time. It is definitely challenging, but, as you scale, it becomes easier.

EGP: What about marketing? That seems like a different gear than other business functions such as management or accounting. What intrigued you about marketing?

Tarek Aly: Marketing is in all aspects of our lives. It’s communication skills. It’s how we present ourselves. How we present our practices. How we train our teams. Our message. Our quality control. Marketing is everything.

Before you start a practice, whether to build one, or buy one, you must do market analysis. This includes geographic, demographic, and psychographic analysis. Including your competition analysis, consumer behavior analysis, and product analysis. What services are you providing? What’s your USP, your Unique Selling Proposition analysis? What is special about my service, or product, or what I’m delivering? What is my competitive advantage, so to speak?

Then we have the advertising part of marketing. What is the message that I’m trying to convey to the public? What is the vehicle that I’m going to use for this message? Am I going to use billboards, radio, TV, social media, or Search Engine Optimization? Who is the sender? Who am I and what am I trying to achieve here? What is my unique selling proposition? And who is the receiver, the target audience? How do I learn more about the receiver, the consumer behavior, what drives them to do the things they do? And how do I provide the best quality of care that they deserve, and I care about?

EGP: Can you talk about the origins of OrthoDent; how it started, your involvement, why you saw there was a need in the marketplace for it?

Tarek Aly: We were started in 2012 by Dr. Kyle Raymond, our partner, who was the founder and he saw a need in underserved communities in Texas, which is a big state. So, he assembled a team, and I was one of the team members. We partnered and decided to focus our attention on providing quality care in an affordable fashion of pediatric dentistry and orthodontics to the underserved communities. The partners are Dr. Kyle Raymond, Dr. Nieku Manshadi, Dr. Dustin Roden-Johnson, and me. We provide mainly pediatric dentistry and orthodontics.

EGP: What are some of the keys to the business model?

Tarek Aly: Number one is providing the best pediatric dentistry and orthodontics care under one roof, which keeps high efficiency and effectiveness. We also support dentists and specialists by providing them with the resources they need in order to provide the excellent quality of care the patients deserve. It’s the pediatric dentistry and orthodontic model, coupled by the services support including marketing, IT, business intelligence, analytics, procurement, compliance, strategic development, revenue cycle management, accounting/finance, and so forth. This enables the dentist to completely focus on the quality of care while the business part is taken care of, in an environment where it is friendly, encompassing, and high quality.

EGP: A worry that some independent clinicians have in joining a DSO is losing a sense of identity. How is OrthoDent able to help those practices maintain their sense of identity within their community?

Tarek Aly: OrthoDent mainly supports the back-end services, the services that patients can’t see, so the clinicians can maintain their own individuality, identity, and maintain their own brands. Every location has its local feel and a local name. The team members are local. The dentist mainly is, in most cases, local or lives in the area. And it does not lose that local feel. At the same time, they are supported by the back-end services, so they maintain this microculture within the culture.

EGP: This year has obviously been a disruptor in a lot of ways. How have you observed COVID-19 affecting dental practices?

Tarek Aly: COVID has greatly impacted the industry in general. There have been pros and cons with COVID. I feel that there are more pros than cons, in some aspects of our business, or the dental industry in general. We’ve definitely incurred some suffering from the mandatory closure and the extra precautions we now have to implement. However, this motivated us to build better systems and operations to fit the new model, and work as effectively and efficiently so that we can deliver that quality of care, but also meet that operational capacity.

As you know, COVID has taught us, on the personal and the professional level, that you can sustain a high quality of service, or high quality of life, with much less than what we had before. This has translated into our business as well. We’re now lean, we have better systems and processes, we’re faster now, and the team members are more aligned. When there’s a pandemic or a major impact to communities, people tend to come together and have the common goal of “Let’s defeat this. We’re in this together.”

EGP: What was demand like for reopening?

Tarek Aly: It was great. It was more than what we expected, which proves, time and time again, that dentistry is an essential service. You can’t really just shut down dentistry with few implications. There are a ton of cases that otherwise would go to the hospital and have a negative impact on the hospital capacity. As a result we have received, after the lockdown, a massive influx of patients wanting to come in.

EGP: What are Key Performance Indicators (KPIs) for dental group practices like now? Have they changed amid the pandemic?

Tarek Aly: The KPIs we track are different now. The ranges we consider normal are different. Some leading and lagging indicators are different. It has been an adjustment.

The reason we track KPIs is to monitor the health of the business, or specific processes. And since the processes have changed, and some outcomes have changed, we had to maneuver and be more sensitive to some KPIs we didn’t track. And some of the KPIs we did track, didn’t get as much attention as before.

EGP: What’s an example or two of an essential KPI in our new environment?

Tarek Aly: KPIs, like patient waiting time, used to not be on the top list because we just never had an issue with patients waiting. Our systems were so efficient. But now since you have a limited number of patients, you must be very sensitive to patient waiting time.

Staff efficiency metrics have been developed to monitor efficiency.

Compliance and safety metrics have a much higher place in the top 10 now. Apart from making sure that the team is safe, and the patients are safe, which have always been a top priority, we need to be in compliance with all regulatory bodies in the industry.

EGP: Long-term, what are some other ways that you see dental group practices changing?

Tarek Aly: I see that dental groups will be running leaner and will be focusing on learning and development. I see dental groups having tighter systems and processes and see them working together collaboratively. I have seen an increase in camaraderie happen because of COVID. A lot of us got together. Big or small, east, west, central, south, we all got together. There was this sense of “Hey, we’re in this battle together.” I see more handholding with dental groups in the future.

EGP: What about the DSO model within the dental industry? Do you think COVID has been an accelerator of that trend?

Tarek Aly: Dentists now realize that you really do have to work together and hold hands. Specialization is everything. If you have a need for a dermatologist, you’ll go to a dermatologist, because this particular person is very specialized. And that’s what they have done for years of their life, only dermatology.

It’s the same concept with almost all business aspects. There are marketing specialists that do only marketing. The same with accounting professionals, and other departments. Dentists that are business owners and clinical operators at the same time, may now have more inclination to collaborate with other business specialists and professionals. In a post-COVID world, they will be thinking “I can hold hands with professionals that can take me to the next level.” I see a lot of that happening in the near future.

EGP: You have a real passion for providing education and insights for the industry to improve business functions within a dental group practice. What are some things that you’re doing now, in our changing environment, to maintain that platform?

Tarek Aly: Right now, we are working on a few great projects, and we’re creating some courses to help with these projects.

KPIs and business analytics are definitely passions of mine. They’re like the X-rays you need to see before you treat the tooth. You must look inside your businesses like you look at the X-rays pre-treatment. How can you drive a car without looking at your gauges? How can you fly a plane without looking at your gauges? Yet, most dentists run their dental practices without looking at the gauges, which absolutely needs to change in the industry. I’m also trying to spread awareness of checklists and creating proper systems and processes within the industry. I’m a big fan of letting the process lead you to the outcome you deserve, minimizing the chances of human error.

So with COVID, we’re now focusing on more online training, learning and development, performance tracking, online checklists, automation, etc. I feel that the dental industry is further behind, in some of these aspects, than other industries including medical, pharmacy, IT, construction, aviation, and others.

There’s a reason for being behind. Remember that revenue covers all sins. Because dental practices have been very profitable in the past there has not been a big need to enhance one’s systems and processes. And the average dentist didn’t see a big need to go that extra mile. But now I think the trend is going to be different. Now there are more constraints, including operational capacity constraints, financial constraints, lending constraints, and more. This will stimulate the industry to run leaner, have better quality of care and focus on the patients, and elevate the industry. So, yes, I see great changes on the horizon.

About Tarek Aly, BDS, MBA – Co-founder, Chief Operating Officer, OrthoDent

Tarek Aly practiced Dentistry and Periodontal surgery for years while simultaneously working in Management and Marketing. He graduated from the Faculty of Dentistry, Alexandria University in Egypt. He has a graduate certificate in Periodontics & Oral Medicine from the same University and a Diploma in Sales & Marketing from the American University in Cairo. He has an MBA from Stephen F. Austin State University in Texas. Tarek has a CVA certification from the National Association of Certified Valuation Analysts and is also a Business Broker working on his CBI Certification.

His expertise includes M&As, Business Valuation, Business Operations, Dental Organizations Management, and Dental Support Organizations platform development and management. He has written three publications and is currently working on a book addressing Management of the Dental Practice and DSOs. He is currently the Chief Operations Officer/Co-founder of OrthoDent Management LLC. Tarek is also a public speaker and competes in Toastmasters International.

DEO Case Study: Timber Dental

How discarding more traditional models for growth and rethinking their approach to the business side of dentistry has led to success for one dental group practice in the Pacific Northwest.

Timber Dental was founded in Northeast Portland in 2014 by the husband and wife team of Dr. Matt Kathan and Dr. Molly Kathan.

Now, the practice has 8 dentists and around 50 employees across its four Portland-area locations. Despite the hardships created earlier in the year, Dr. Matt Kathan says that each location is thriving again, with patient volumes close to what they were pre-COVID-19.

In order to grow from the original, single location into the prominent group practice that it is now, Dr. Kathan says he and his team had to discard more traditional models for growth and rethink their approach to the business side of dentistry. 

Location, location, location

Dr. Kathan and the leadership of Timber Dental say that they try to think of their business as being “retail.” This has meant going after a narrowly defined target population and investing a lot of resources into getting and maintaining visibility with that population.

The practice offers general dentistry to all patients, but the practice has rejected the mindset of trying to be all things to all people. The leadership team worked to create a “patient avatar” and focus its efforts on trying to cater to and draw in that population. For Timber Dental, that target population is millennials, with most of the practice’s patients being in the 30-45 age range.

Timber Dental’s focus on approaching dentistry as a retail business can be seen simply by looking at the practice’s four locations around Portland. All of the locations are within 2 miles of another Timber Dental office. All locations are on street corners and highly visible. The downtown location even has a 30-ft marquee sign to draw even attention to the practice.

In addition to making sure their practices are highly visible, Timber Dental has made it a priority to consider several types of demographics when opening new locations in order to best capture its chosen market. Part of that strategy has included opening each new location in a “dental desert” – areas where there are a lack of dental health professionals relative to the area’s total population.

Timber Dental’s strategy of prioritizing both the practice’s physical visibility and its online marketing efforts have paid off. Dr. Kathan says that – prior to the COVID-19 pandemic – each location was seeing 100-200 new patients each month. He also says that a large percentage of those patients tend to be people who are new to the Portland area.

Standardizing for success

Many group practices, Dr. Kathan says, are structured such that a given dentist has a stake in the location at which they practice. This style of buy-in naturally causes people to prioritize the success of their
particular location instead of working to benefit the organization as a whole.

Dr. Kathan says he believes that a part of his organization’s success comes from moving away from
that model.

The practice has adopted a “One Timber” philosophy, which ties the dentist’s buy-in to the success of the organization as a whole, and not to a physical location. 

This means that all Timber locations operate in the same way and support each other. This standardization has made it easier to shift around personnel when the need arises. And perhaps more importantly, it has allowed the practice to streamline and standardize processes and resources across all of its locations, saving time and money while improving patient care quality.

Editor’s note: Watch the full DEO Case Study featuring Jacob Puhl and Dr. Matt Kathan:

Aligned Integration

Along with Timber Dental, Dr. Kathan has another business, Aligned Integration (, that “came about by accident” in May when Timber went back to work after the COVID-19 shutdown.

Dr. Kathan’s dental group needed to provide aerosol reduction devices to increase the team’s, and patient’s, safety.  “We went to buy adapters for the Dry Shield system and Isolite, and they were backordered for months from China,” he said.

Aligned Integrations is the collaboration of two Portland-based professionals: Dentist, Dr. Matt Kathan (owner of Timber Dental) and Professional Engineer, Jason Kennedy (KIC Engineering). Having used the Dry Shield system in his practices for the past 7 years, Dr. Kathan realized the crisis of COVID 19 created an immediate need for affordable access to tools to protect dentists and hygienists from harmful aerosols.

“We went to work to find out how we could make a cost effective and improved version for our group here in Portland, Oregon. We then discovered that other groups needed these and kept making them.” Dr. Kathan said they are in the process of adding more dental aerosol reducing products to their line.

Best Practice: Developing a PPO Participation Strategy

By Nick Partridge, founder and president of Five Lakes Dental Practice Solutions

Why being contracted directly in-network for every plan no longer works.

As the dental industry returns to form, many dental group practices and dental service organizations (DSOs) are rebuilding their teams. If our clients are any indication, it seems that most groups are using this opportunity to build leaner, more focused organizations.

In doing so, strategic consideration should be paid to the role and cost associated with your PPO participation strategy. Let me explain…

While groups pursue different market niches and strategies, many embrace the strategy of participating in-network with nearly every PPO available in their respective market(s). To achieve broad participation, many groups contract directly with each payer or network. Payers often prefer direct contracts, and at first glance these contracts facilitate the groups’ mission to be easily accessible and cost effective for patients. Being in-network across the board makes it easier to get patients to convert, to accept treatment, to stay in recall and even refer friends and family. The recently released Dental Benefits 2020 survey from Guardian supports this line of thinking. The survey results showed 85% of patients visited an in-network dentist and nearly 50% chose their dentist as a result of a referral from friends and family.

From the payer side, these insights clearly highlight the importance of network size to manage claims costs effectively. Outside of getting providers to contract directly, network leasing has evolved as one of the most prevalent examples of the tactics networks use to increase network size. Today, more than 73% of the largest dental networks have four or more network partners. The obvious outcome of network leasing is a bigger network brought about by adding providers who have contracts with other payers. However, one of the other less obvious and much less discussed consequences for providers is that networks can and have adjusted reimbursement rates down to the contracted rates for these partner networks. Thus, credentialing with direct contracts across the board can not only cost more to execute and manage, but may contribute to reduced reimbursements.

For example, a provider contracted with both Insurance Company A and Insurance Company B can be paid according to the Insurance Company A fee schedule despite having a direct contract and fee schedule with Insurance Company B. Insurance Company B will process claims based on the lowest fee schedule as the two have a network sharing agreement. This can be done at the code level or claim level, which makes it even more confusing.

The lowest common denominator

Thus, when you participate in everything, you leave yourself open to being paid on the lowest common denominator amongst overlapping partnerships. To illustrate this point, a search on the provider directory for a general dentist in Schaumburg, Illinois, for Insurance Company A returns hundreds of results. The webpage indicates that results are prioritized to show offices with greater potential cost savings. As a result, all the providers affected are revealed first. Eighteen of the first 20 contracted providers were paying from the lower fee schedule due to the network sharing relationship.

The same search in Irving, Texas, yields similar but slightly better results. Ten of the first 20 providers returned in the search are being paid according to Insurance Company A’s fee schedule. How many providers nationally are being paid from a lower fee schedule instead of their actual contracted rates?

Combining the searches, 70% of the contracted providers were paying off the lower fee schedule. The results show most dentists and dental groups aren’t doing anything about it. 

This is the problem festering in revenue cycle teams across the group practice/DSO landscape. Claims are reviewed to ensure proper payment to the way the claim was adjudicated, not to the proper fee schedule.

Complicating the matter further, there were several occasions where providers at the same facility were contracted differently. This means either the group is cross-credentialing and there was no real impact to the practice, or claims are being paid differently in the same office depending on which provider a patient sees. Surely, that is not creating the desired patient experience.

The answer is not to necessarily drop either insurance company. Instead, develop and execute a PPO participation strategy to better manage how claims are paid and do so with greater efficiency.

Case study

When engaged by a group practice with nine locations, we were able to reduce PPO participation by 31%. There are many ancillary benefits to these efforts. First, we were able to protect against payers adopting the lowest common denominator approach. Secondly, we were able to keep the practice in-network and on the provider directories to extend the strategy of broad PPO participation. In fact, we were able to consolidate payers and move these four plans to higher reimbursing fee schedules which resulted in over $577,000 of annual incremental revenue. Third, we were able to meaningfully reduce credentialing workload. For each new provider, our efforts resulted in having to complete four fewer applications with four fewer fee schedules to manage at the practice level and nearly 120 fewer re-credentialing requests in a three-year cycle. With only modest doctor turnover, shrinking participation for this group reduces credentialing costs by over $8,000 per year.

Credentialing in every PPO network is no longer a viable credentialing plan. In today’s dental marketplace, the amount of overlap created as a result of network sharing requires a well-developed PPO participation strategy.

About the Author

Nick Partridge is the founder and president of Five Lakes Dental Practices Solutions, a consulting and technology firm helping dental practices develop, implement and manage a PPO participation strategy to attract and retain patients. Five Lakes has helped over 2,200 practices nationwide. The company is a four-time Inc. 5000 honoree as one of the fastest growing private companies in the United States.

For more than 10 years, Partridge has been an industry leader in understanding and analyzing the impact of dental insurance networks on the financial health of a dental practice. He has been featured as a guest speaker and guest columnist for many events and publications on the topic of dental insurance and dental benefits.

Dental Growth Model: How to take your dental group organization from fragile to unshakeable.

By Jake Puhl, partner and CEO of The Dentist Entrepreneur Organization

We’ve worked with hundreds, if not thousands, of dentists and dentist entrepreneurs who are looking to scale and grow. Whether it was adding a second, fifth and even tenth location, or solidifying the first location to build on, what we saw across these organizations as they started to grow and leaders put pressure on their organizations to push forward were some inevitable issues. For dentist entrepreneurs they can feel like a dark tunnel.

First, you’re going to run into your own leadership ceiling, or as John Maxwell says, a lack of executive capabilities. You will run into issues with hiring and training your team. There will be issues with associates as an inevitable byproduct of scaling. You’re going to find issues with creating leaders inside your organization. Other issues include systems, infrastructure, centralization, finances, and keeping track of where the money is going. What kind of accounting do you want to set up? Do you want to use accrual accounting, standard accounting, or cash basis?

These are all inevitable issues that you will run into. At the DEO, we’ve taken these issues and developed a framework to help you figure out where to spend your time. We help identify where your biggest issues are, where you need to level up inside your organization, or how to make it to that next level. This is what we do inside the DEO – provide you with the training, education, and peer-to-peer networking that you need to get through that dark tunnel.

The following is what we call the dental organization growth model. It’s a trademarked framework that we’ve developed after talking to many scaling dentist entrepreneurs and looking at what’s working and what’s not working in the industry.

We discovered that the best groups start with one thing – vision. Now, this is not just your vision of your business, although that is usually what most people talk about. This is the potential future vision for yourself, as well as your business. Where do you want to go personally? What is this business doing for you? Where do you see the business going? What is the vision of the actual business? That’s what you’ve got to figure out first. Start with your vision.


Once your vision is set, there are three kinds of levers you can pull when you’re looking to fulfill that future vision and scale your dental organization.

No. 1: Yourself

You can up-level and grow yourself in some kind of way. Typically, dentist entrepreneurs embarking on this journey are experiencing a lot of anxiety. With the proper training, the proper environment, and the proper education, you can go from anxiety to confidence.

No. 2: Team

The next lever you can pull when it comes to achieving your future vision for yourself is your team. This is a huge one. It may involve getting out of the chair and becoming more of a CEO. You’re trying to take your team from chaos to momentum. This is going to happen over and over again. You’re going to oscillate between these states – chaos to momentum. The more you can keep yourself in momentum, the more your organization is going to thrive. Sometimes you’re going to wake up in the morning and it’s going to feel chaotic, but your job is to get it down and build that momentum.

No. 3: Business

Finally, there’s the business side of the lever that you can pull. That’s the nuts and bolts of your business. You’re trying to create a business that goes from feeling fragile to unshakeable.

A lot of people have discovered in this turbulent time that their business was fragile. Dentistry as a whole is usually a solid industry. But we’ve discovered vulnerabilities in some people’s businesses. With the DEOs, we’ve led a lot of people to analyze their business model and figure out ways to make things more unshakeable.

The following are the things that you will need in order to successfully pull those levers:


  • Consistent Clarity. Regardless of the circumstances, do you have the clarity to go from anxious to confident?
  • Executive Capabilities. There are certain capabilities that no one is born with, but must be developed. You must learn to become an executive. As you grow and scale, you will start to have higher level people around you, but you’ve got to have a certain level for yourself.
  • Peer Connection. It can be a lonely road as an entrepreneur who is growing and has big aspirations and dreams. And that peer connection is absolutely crucial.


  • Talent Management. This is the hiring, training, letting go of and constantly managing the talent in the organization.
  • Alignment Systems. How are you building alignment inside your organization so everyone knows where you’re going, why you’re going there, what their expectations are, what the outcomes are, and what you’re looking for?
  • Leader Growth. This is a big one. You need to develop leaders. As your organization grows, eventually it stops becoming about you and it starts becoming more about the people around you.


  • Top Line Growth. There’s a saying that top line revenue covers all sins.
  • Operational Systems. Systems will set you free. Systems are huge inside a growing and
    scaling business.
  • Cash Management. Where is your money going? When is it going out? When is it coming in? Keeping track of those everyday dollars in this turbulent time has become even more important.

What happens if you do these things? If you’re able to up-level yourself and your team, you’re going to find that you have more time on your hands. If you’re able to up-level yourself and your business, you’re going to find the business is probably more profitable. Now, your team might be going crazy, and everyone might be running around like their hair is on fire, but the business will likely see more profit.

Then, if you’re able to build an amazing team and momentum, and you have a business that’s unshakeable, you’re going to be able to impact a lot of people. You might feel anxious all the time and not very competent, but you will be impacting people.

The middle is where we are leading entrepreneurs. The middle is the sweet spot.

If you’re interested in figuring out ways to go from anxious to confident and feel more momentum in your business, schedule a call with our team. We’ll help you figure out where your biggest weak points are to improve upon, and where the biggest opportunities are as well. We want to get you on the path to grow like you want to.

For more information on how the DEO can help you, go to:

Sponsored : Align Technology | Utilizing the iTero Element intraoral scanner across the entire practice

James Wayne Leonard, DMD, has been using an intraoral scanner for more than 20 years and today, considers it the go-to tool in his technology-driven practice. “We are known for our technology—our practice is a lean, mean technology machine!” he says. As for intraoral scanners, “They are not just about making crowns or providing Invisalign® treatment. My iTero® Element scanner is a very versatile, full-practice tool. In fact, it is the most advanced technology we have in the office.”

Dr. Leonard has been practicing dentistry for 23 years, first in private practice, and for the last 6 years at two Heartland Dental locations, Smiles on Beach Boulevard and Sawgrass Complete Dentistry, in Jacksonville, Florida. He also serves as a Heartland Regional Doctor Mentor of Operations.

Dr. Leonard has had an iTero Element intraoral scanner for four years and relies on it for patient education, tracking and updating patient records over time, and for creating digital impressions for restorative and implant cases. He considers the iTero scanner to be critical for gathering data for treatments, including smile makeovers, orthodontics, implant-supported and traditional crowns and bridges, removable dentures, and implant-retained partial and full dentures. He notes the dental assistant and hygienist lead the charge in utilizing the full mouth scan to promote patient education. The hygienist always take a scan before they start a cleaning.

Dr. Leonard considers the role that iTero visualization technology plays in patient education to be extremely beneficial to helping patients understand their oral health, from periodontal tissue status to bone loss and the condition of their dentition. “We take a look at the scan together,” he says. “It is a more effective and faster way to educate patients than trying to explain things with just words.” Dr. Leonard notes that it is no longer necessary to take intraoral photographs for patient education when he can use an iTero scan to then show patients the size of an amalgam, a broken tooth, or cracks around a filling magnified on a screen.

He also uses iTero scans in conjunction with Digital Smile Design to plan smile makeovers together with patients, and uses the TimeLapse feature to demonstrate how their teeth have moved over time. “If they say, ‘This one tooth hasn’t moved,’ I can use TimeLapse to show them a snapshot of small changes that have occurred to date which they might not have noticed otherwise, such as tooth wear or gingival recession. They trust it and love it and it gives them greater confidence in their treatment plan,” he explains. Dr. Leonard uses this feature to help patients understand the value and success of any type of dental or orthodontic treatment. “This is not a reactive tool, it’s a proactive tool—we’re not just showing patients what we can do, we’re showing them what’s there. It keeps the doctor/patient relationship healthy.”

According to Dr. Leonard, restorative case acceptance has gone up considerably because patients are fascinated with the iTero technology and its visual educational aspect during their appointments. And the Invisalign Outcome Simulator on the iTero Element scanner helped Dr. Leonard’s Invisalign cases double within the first 6 months, with revenue increasing from $1.4 million per year to $2.5 million1. He attributes these areas of growth to his ability to show patients simulations of proposed treatment outcomes, which empowers them to better understand the treatment they are receiving. “It doesn’t mean they will always accept treatment immediately,” Dr. Leonard notes. “But when we provide the [Occlusogram] image showing bite problems, wear, or broken-down teeth, the patient has a chance to own his or her problems. This technology helps them trust the treatment plan.”

Patients are not only impressed, but also appreciate the time-saving accuracy of digital scanning, as do the dentists and dental labs using the technology. Digital scanning takes less time than making a PVS impression and results in 10x fewer rejections when submitted for Invisalign aligner production2. Also, through the direct connection between doctors and labs, communication with dental labs and consultations with specialists has never been easier.

In addition, crowns are usually returned from the lab within 4 or 5 days, so patients are in temporaries for a shorter amount of time. And with his practice’s 99.5% successful seat rate, crowns and other restorations fit much better without alteration.

“This all makes for a great work life,” Dr. Leonard says. “I have more confidence. I walk into the operatory knowing that things are going to work out well. I have more time to talk with patients about what they really want for their potential future smile. I can talk to them more as a person while the technology helps them understand what’s going on as a patient.”  

Dr. Leonard also notes that in his experience, patient appointments can be substantially shorter with digital scanning and describes some of the other advantages: “Any discrepancies can be addressed while the patient is still in the chair and there will never be any distortion of the scan, either at the dental lab or in the patient record. Scans are uploaded to the dental lab in the time it takes me to walk out of the operatory. Plus, cases can be tracked at by both dentists and laboratories, so everyone always knows where in the process the case is.” He estimates that he saves $7 on impression material, $20 on materials for each crown, plus his lab gives him a $20 discount for using digital scanning. “So, I’m saving $50 a crown [over traditional workflows], with case acceptance up 10%,” he explains.

For Dr. Leonard and his team, the iTero scanner has become an integral and indispensable part of patient assessment and treatment. If clinicians are considering adding the intuitive, open-system iTero scanner to their practice, Dr. Leonard advises that “You have to go for it in full force. It takes courage! Don’t try to grow into it or you will always be bogged down. Just dive in and start doing it. Help is only a phone call away—it comes with a tremendous support system. Every single day I think I could have shown patients more or done even more with the scanner!”

1 An independent evaluation among all iTero Element orthodontic users indicates sustained average/additional Invisalign case increase of 22.67% through 12 months and 27.88% through 24 months. *Study sponsored by Align Technology. Retrospective data evaluation and quantitative analysis completed by Dr. MacKay, University of Memphis. 495 Orthodontic practices worldwide. Accepted for publication in the Journal of Clinical Dentistry.

2 Rejection calculated based on cumulative submissions of PVS and iTero scans from January 2017 to June 2018. Data on file at Align Technology, as of July 2018.

July/August 2020

Publisher’s Note: The Gift of Freedom

Cover Story: Smile Magic

Dental News: North American Dental Group names new CFO

Managing Through the Pandemic: How to successfully overcome new PPE costs

PPE Past, Present and Future: A PPE leader examines how the spike in demand due to COVID-19 compares to other historical markers, and how it could reshape the industry moving forward.

First Class Infection Control: Prepping teeth with no water spray and no aerosols

An Interview with Dr. Andrew Matta, DMD, MBA, Founding Partner & Chief Medical Officer, North American Dental Group

Sponsor Story: Test, Shock, Maintain

Smile Magic

By focusing on the customer, dental service organizations have an opportunity to make great gains in the marketplace – even amid a pandemic.

In today’s climate, it’s easy to get overwhelmed. Emmet Scott, CEO and co-founder of National Dental Partners™ and Smile Magic Dentistry, and the newly elected president of the American Dental Service Organizations (ADSO) said he’s tried simplifying things during challenging times with a guiding principle. He calls it his North Star, and it’s kept him on course, even amid the changing marketplace and a global pandemic.

Scott asks himself one question – What does the customer want?

“If I want to know what the future is going to hold, I look to my customers, namely their lives, needs, and wants,” Scott said.

Efficiency in Group Practice discussed a wide array of topics with Scott, including what it takes to build a successful group practice, where dental offices were with re-opening as of mid-summer, and his insights on how 2020 will shape the industry for years to come.

Efficiency in Group Practice: Can you give us an overview of National Dental Partners? How did it get started?

Scott: In many ways, everything begins and ends with friendship. My partner, Dr. Chad Evans, and I have been friends since we were 2 years old. As we grew up, we both pursued our passions, his being dentistry and mine, business.

Then about ten years ago he reached out to me. At the time, I had a consulting firm called Entrepreneur Advisors and a radio show called The Entrepreneur Life. The radio show centered around answering the question, “How do you move from entrepreneur to executive?” I found that that’s really the key issue challenging potentially successful entrepreneurs and clinicians – they don’t know how to scale to that next level.

At the time, Chad was in the Dallas area, and was going to start his first practice. He had been really successful as an associate but now things were different, so he called me for advice about setting up a good practice, and as a friend, I was eager to help.

After a visit, I looked at the marketplace and saw a really big opportunity – especially when it came to scaling his dental business. Again, like most business owners Chad’s response was, “Well, I know how to take care of patients and deliver excellent dental care, but I don’t know how to scale a business.” So, I agreed to help.

In many ways that moment was the planting of a seed that would later blossom into National Dental Partners (NDP). It was the combining of two friends, two partners, who each wanted to do the best that he could in the way that he serves, for the good of the practice and ultimately, to deliver the best service and experience to the patients.

Efficiency: Can you give us some concrete examples of some changes you made in Chad’s business that allowed him to grow his practice effectively and efficiently, truly making it a leader in the field? It’s a wonderful case-study of the success when dental expertise combines with business expertise.

Scott: Of course, here are some real-life examples of changes we made…

The first thing we had to get right was really designing his practice. Chad wanted to see and serve kids. He was a general dentist, he himself has seven kids, and he had been treating kids already – all of this meant he could handle what came along with the pediatric dental market (including behavioral management). At the same time, he had a passion for the Medicaid market and taking care of the underserved.

In Texas, a lot of the kids who need care are on Medicaid, and a lot of doctors don’t want to treat Medicaid. So, there was already this theme developing from day one, of, “We’re going to treat the underserved. We’re going to treat those who don’t get care.” We were finding his niche, his specific customers, and developing his brand. Eventually this focus allowed us to make choices that helped our patients choose Smile Magic over other practices.

For instance, as we looked at pediatric dental, there was nothing particularly exciting happening in the market. Nothing felt different, unique, or truly innovative. Dentistry’s hard to market in general, but pediatric dentistry in particular. So, we said, “Who has a really good model out there?” Well it comes to serving children and families, creating a positive experience they’ll want to come back to, we were inspired by companies like Disney & Chuck E. Cheese (in its glory years). There was a time when 10 years ago Chuck E Cheese was really the only space that you could take your family for quick easy fun. Disney remains the happiest and most desirable place on earth for families to visit. As crazy as it may sound, we wanted to create that type of experience in a dental practice. This led us to ask ourselves, “What if we combined outside industries into dentistry?” 

It’s that’s kind of thinking that has led Smile Magic Dentistry’s growth – it’s been our theme from the beginning.

Efficiency: How does that kind of thinking play out in your dental practices? What does that look like?

Scott: We built a movie theater and a play gym right in our lobby, and we built the practice as if it was a storybook. That’s a lot of what Disney does, it makes the rides a story. So, when you go into the X-ray room, it says, “Once upon a time, there was a chipmunk named Charlie…” And so, the experience begins. And remember, we aren’t just creating an experience when we do this, we are creating a lifelong relationship between our pediatric patients and their dental health that feels far better and far different than their friends and counterparts are getting at other practices.

Anybody who’s been on a Disney ride kind of knows how the excitement of visiting different parts of the theme park is, and our patients feel the same things when they visit us. Along the way, each operatory is a different page in our storybook, and the kids get gold coins as they complete each piece. At the end, after their treatment, patients sit on a throne and we crown them to celebrate them while saluting them with, “For your bravery in dentistry, we now crown you king or queen of Smile Magic.” Everybody claps, and they leave with a balloon and sticker that says, “Amazing Child of Smile Magic.”

That is how you create families that want to come to the dentist – that choose to come to the dentist. At a time when so many are opting out of visiting dental practices (the statistics are staggering) it is our job to find ways to make patient acquisition and retention part of the work we do, and again the friendship that evolved into a business relationship, the joining forces of two talented professionals in their fields, is how we managed to do it.

Efficiency: Can you tell us about how you celebrated the moms of your patients who also quickly came on board the practice and brand you created?

Scott: Of course! Moms are a big part of the treatment and experience, so we created new stickers that read, “Amazing Mom of Smile Magic” which they receive in the process as well. Now everyone wins when they come through our doors, and these kids are walking out our door and immediately saying to their parents, “When do I get to go back to the dentist?” We achieved it. Oral health is now fun. Smile Magic is accomplishing its mission, and my friend is doing what he loves (and leaving the rest to me and my team).

Efficiency: How did you grow the business from there?

Scott: At a good dental practice, if you can get 100 new patients in, that’s great. If you can have 400 patient visits, that’s even better. We had 1,000 first visits in the first three weeks. So, we scaled and built multiple Smile Magic locations, and we were off to the races trying to just manage all of this.

As we grew I was able to use my business acumen on the back end to make the rest of the practice flow more smoothly and successfully, which meant the dentists could do what they do best while I made
sure they were supported by the best possible practice.

Some examples of systems that we saw needed an overhaul, that allowed us to grow (and continue to grow today):

Our billing systems needed a serious upgrade to handle growth and multiple locations. This was upgraded and changed – today we have a fully centralized billing team.

As you grow you are managing more humans and more patients and lots of regulations, which led to me immediately hiring a compliance officer on the first practice – something that many now consider commonplace which at the time was a very new idea.

Other additions as we grew included a software development team and call center. We really just tried to build things right so the practices could do their best and their teams could feel their best and most supported. And they do.

Efficiency: Using these systems and changes, what else led to your scaling from a pediatric dental partnership to National Dental Partners?

Scott: I think what really made us National Dental Partners, beyond just pediatric dental partners, was our awareness that there was a group of practices that were struggling in rural towns and dentists that needed help. These were practices that served communities that needed them, and they needed us, or they wouldn’t survive. The ripple effect of that is huge, and the fact that these practices could stay afloat simply by getting our support, while they carried on serving as they know how to serve really called to us.

Dr. Evans ended up buying those locations and we started supporting them. With that we expanded our work for the underserved beyond pediatric Medicaid underserved, to rural towns with all types of underserved populations.

The kids need care there, but the adults need care there too, and we decided to provide that to them sealed our vision for National Dental Partners. We’re going to support dentists who are serving the underserved, whatever their age or location.

By doing this, we allow dentists to retain autonomy in terms of how they practice, because they know their patients and communities, and we’re able to bring in what we know works on the back end to support their business while they support their community’s dental health, without stressing about practice survival.

Efficiency: Can you talk about your new offering with National Dental Partners and how that works? I’ve heard it called “Open Source” and I’d love to hear more about what that means.

Scott: That’s correct, we are the first truly Open Source DSO™. We always want the practices and dentists we support to feel like they have the time to do what they do best and enjoy the most, while we handle the rest, so the first thing about Open Source is that they, the dental practice members, choose what and how much support they need. Is it accounting? Call center support? Scaling advice? What are the blocks and issues holding you back? You tell us so we can take care of them with you. We don’t charge any markup for our services either. Everything we do is at cost. If you imagine a practice was stuck in the dark while trying to get to the light at the end of the tunnel, think of us as the bridge that gets going to get you to that light faster than you can imagine.

Participating practices can customize their support needs and we will serve them in the ways they need, as determined by them. Dental practice work isn’t one-size-fits-all and neither is the way we support our partner businesses.

Anytime we’re partnering on a DSO entity with another doc, we always like to be 50/50 at the DSO level and the doctor owns 100% of the practice. Maybe that 50/50 comes from that community feel of two friends, which again, is how this all began, through friendship. We feel like that equal partnership is an authentic and strategic way to say “Hey, let’s bring our value together and be partners. We’re in this together.”

It’s also important to note that only dental clinicians can own practices, so there aren’t “businessmen with money” in the background running the show secretly. We are very strict on corporate practice of medicine laws and have been from the beginning. I, not being a clinician, can never own a practice. Dr. Evans can. Our other member doctors and associate doctors can. What we own is an entity that supports them, and we provide them services. So, I’m a shareholder in a business that works to support the success of a dental practice that is run by a dentist, a member of the dental community.

Efficiency: You mentioned that you as a non-dentist cannot own a practice, but really quickly I’d like to highlight that for a non-dentist you love the dental industry and are highly involved in it and respected by its community, tell me about that.

Scott: You could say I’m a bit of a dental industry super fan. I’ve recently taken on the role of president of the ADSO (American Dental Support Organizations), an honor for which I’m excited and humbled to take on and lead.

Outside of running National Dental Partners with my friend and partner Dr. Chad Evans, I’m also the host of the DSO Secrets podcast and community, and a senior faculty member and partner of DEO, the Dental Entrepreneur Organization.

Efficiency: From your observations, where are dental practices in the re-opening process as of mid-summer?

Scott: It’s been really interesting because as a member of ADSO I’m able to talk with some of the biggest DSOs. That coupled with my work with the DEO (Dental Entrepreneur Organization) and on our DSO Secrets FB group, gives me a flavor of the industry – in real-time.

What’s happening is, frankly, different than anything anyone predicted. People predicted customers and patients were going to be very concerned about coming into the dental office. That really hasn’t happened for many practice owners. I mean, not on a bulk scale.

What has happened, and I’m sure many people can relate to this, is that people are just wondering what your rules are. They’re asking, “So do I have to wear a mask here?” “Do I not?” “What’s going on?” There is an expectation that you’re a clinical office and you know how to handle this thing. Patients probably have had more respect for us than we’ve given to ourselves.

The reality is, dental offices are some of the safest places in the healthcare industry. Remember, we were the ones in the ‘80s who had to deal with the AIDS epidemic and since then a lot of the protocols have already been put in place.

We’re noticing patients want to come back and need to come back. So, the patient flow component is there and that’s happening across the industry.

The other interesting thing that’s happened is, we’re noticing a kind of the great exit. Instead of exiting over the next five years and however that would have segmented out, it just all happened in June. Dentists are just closing the doors. The way many are thinking is, if you were going to retire in the next three years and you’re 65-70-years-old, why ramp back up your workload in this chaos?

Another scenario? Maybe you’re a dentist with five locations. Two were doing well, but three weren’t. With those three an owner says, “I’m out.” It’s just too much to manage. Because the other side of this is yes, the patient flow and demand are there, but the staffing piece is super complex. The dentists who are willing and have patients coming in don’t always have the support around them that they need. I think that’s been a struggle.

Where these challenges may have been easier to manage before, life is more complex these days for everyone, from patients to practices and managing that can be more difficult than ever.

It’s been very clear through all of this that those with the biggest support teams are able to handle the most chaos. Members of DEO have leaned on each other and supported each other. Members of ADSO have done the same. This has been the great accelerator and humbler for all of us that we need teams of support to handle this level of workload and information.

What does this mean for dental practices? We encourage our practices to help make their patient’s lives easier and safer while taking the necessary steps to ensure their own business can survive and thrive.

Efficiency: Have you seen any forecasts on when we’ll be back to pre-COVID-19 levels?

Scott: We actually have the data from China and Europe that’s come out because they were ahead of us on a lot of it. They came out of the gates at like 50% the next month after re-opening, and then they were at 75%, and then they trickled back to 100%.

America has responded a lot faster than that. Across the board, at minimum, dental offices were at 50% as soon as their states reopened. Many are now anywhere from 75-100%, or even above 100%. It’s because the supply has shrunk. The demand stayed the same. So, all those reoccurring visits that didn’t happen in April, those needed to get in.

I would say the other interesting component is the limitation on distractions we’ve had as Americans. Typically dental gets moved down the stack of “most important things to do today.” We have to do a better job marketing the value of oral health and the oral systemic link. Right now we are getting an artificial boost but soon others industries will be marketing more aggressively and taking the hearts and minds of our patients to other products and services.

I fully believe supported practices with large teams are in the best position and I know so many in this industry who are feeling that as well, partly because the amount of information, data and complexity that this has put on the system is so high. For instance, now you’ve got PPP loans coming in, EIDL loans, etc. You’re navigating new compliance components and PPE. How do I procure all of this and ensure high level of compliance?

If you don’t have a division of labor capability, if you’re like the single doc trying to do it with staff who have their own life complexities, you just can’t ramp up fast enough into this game. But if you’re able to divide out and you have an infrastructure in place, you’re more ready to serve the customer, the patient.

Efficiency: Speaking on behalf of DSOs across the nation, has the pandemic made DSO offerings more valuable to the independent dental office?

Scott: Yes. I think this was already starting to happen. Even dentists who were kind of wary on DSOs are seeing that these DSOs are willing to provide more capital to them if they want to exit or if they’re looking for a partnership. That’s interesting to them.

They have teams that can help them navigate all this complexity. All great athletes, even if they look like they’re alone, have huge teams.

This complexity, having a team, network, and support system, I think everyone’s saying, “Yes, at this level you do need a team. You do need support.”

That leads me into how we evolved and became what we are today, National Dental Partners, which happened before we knew there was going to be a global pandemic. That said, the state of our country has shown us and participating (and interested) members that there has never been a better time for partnerships and collaboration like this in our industry.

National Dental Partners (NDP) is taking groups who have built some infrastructure or have a vision on how they could really support patients, but don’t have the finances for things like a call center and a full executive team. CFOs are expensive. You’re not just competing against dental offices for CFOs. You’re competing against a lot of industries. And they need CTOs to get the technology, to feed them the data. All of these needs quickly become expensive and a struggle if the infrastructure is not there.

We created National Dental Partners to provide our infrastructure to emerging DSOs, so that they can skip over that dark tunnel many are in and skip that place of having to build everything out. They simply must stay focused on just taking care of patients.

Efficiency: As you said earlier, doctors are retiring earlier, but many of the consequences due to the change in practice have been well-documented, such as the struggle for procuring and using PPE, staffing issues, and patient confidence returning. What are some of the unintended consequences of the change in practice you are seeing?

Scott: I call COVID-19 “The Great Accelerator”. People were using Zoom before COVID-19, so it wasn’t like Zoom got created during COVID-19. People were using telemedicine before COVID-19. There were regulations. There were roadblocks. There were mindsets. There were my own mindsets of where I needed to be to have a meeting with somebody.

There were things already in motion, and frankly, DSOs were in motion long before COVID-19, because of the complexity of dentistry and our desire to streamline our member’s work and organizations. We have been here watching and planning as regulation continues to increase and the patient’s demand for standardization, more availability and time open and all of that continues to increase as well.

Thank you, iPhone, Walmart and Amazon and every other customer centric company. They’ve made us entitled customers. What COVID-19 has done is move us five years into the future where we have needed to move.

I talked to someone the other day who set a goal at the beginning of the year to have a 20% of his meetings this year be virtual. He’s a forward thinker – this was before COVID-19. He said COVID-19 helped him crush his goal. He’s had 100% of his meetings virtual. That’s what I think has happened for anyone who was forward-thinking. Whether they saw it was a train coming or the future coming, it came fast and furious within 90 days instead.

If you were already running that way, then it just felt like you sped up. If you were resisting, it felt like you got shoved. Or if you were going in the wrong direction, you kind of got shoved into this direction.

I think that’s going to be the consequence of this. There will be some level of normalization. For example, that guy I mentioned above won’t be 100% next year with virtual meetings, he’ll drop down, but maybe he’ll drop down to 50%. So, he’ll be way ahead of where he thought he was going, but not so much being forced, like this is.

I think the DSO consolidation will go faster. I think anything that was technology driven will go faster. We’re all moving faster on that piece. Let’s call it unintended consequences of this or byproducts.

Efficiency: Looking into your crystal ball, what do you see for the next 12-18 months for the industry?

Scott: With so many things going on, it’s easy to get overwhelmed. It’s easy to see so many data points. My North Star in business and maybe for life has always been the same thing. What does the customer want? If I want to know what the future is going to hold, I’d look to the customer. What does the customer want? The good news is, all of us are customers. So, it’s easy to diagnose too, because we can say, “What do I want as a customer?”

I look to the future, that’s what I think is going to keep driving this industry. “Can you make it more convenient for me?” What’s more convenient? So, if convenience means more technology, then it’s going to drive more technology.

Here is another piece of advice as you plan for the future of dentistry, and your success in it: You can’t think of dental just from a clinician perspective of procedure types. You have to now start thinking about customer avatars within dental and think of bringing them exactly what they specifically need.

For example, I think how the 60-years-and-older demographic is going to have a very specific desire. Maybe there’s more desire around PPE and cleanliness and convenience, but maybe you’re not feeling as much pressure around time slots. Maybe they have more flexibility.

Those in the pediatric market, on the other hand, may be less concerned about PPE. Whether it’s subconsciously or consciously they are saying, “This hasn’t really affected kids as much, and I just need convenience. I need you to open at these times and I need you to not have too many demands on what I have to do to get an appointment.”

What else do I see when I look at providing convenience? I see two-way texting and communication becoming the demand. That’s something that we’ve now implemented. People want to communicate more than just yes or no on the confirm text. They want to be able to say, “I can’t do it right now, but can we move it to this time without having to call in?” We want to be able to get on when we get in bed at 10 o’clock at night and reschedule things. So, whether we like that or not from a business perspective, as a customer, we love that idea.

Efficiency: Any last tips for practices trying to take care of these patient avatars in the best possible way?

Scott: Really look at your practice and ask yourself: What do you hate? I’ll do what I call a feelings audit on a dental practice. I’ll drive up. “How do I feel right now?” I’ll look around at the space and notice things such as, “Okay, that tree bugs me,” or whatever it might be. The signage isn’t right, etc.

When I walk in, how do I feel as a customer? Because that’s the only thing customers are actually experts on, how they feel. They don’t know the margins. They don’t know any of that. They’re concerned with: “How do I feel? Does this feel safe? Is this good? Well, one of the things that I always hate is, I have to fill out that paperwork again.” So that goes on the list to solve.

Customers are going to keep demanding those kinds of things. And when I say demand, it means they’ll actually switch service providers over those type of things or simply stop coming and do something else with their day. I hear it all the time. “I left whatever relationship because they had an app and it was easier. I left this because they have this way that this worked, and it was just easier.” So, I would just say that if you’re preparing for the future, do that feelings audit and look for where convenience could be better driven in your business and in your practice. 

DSO misconceptions

What is the biggest misconception when it comes to DSOs?

The power that the clinician has, Scott said. The fear among dentists is a DSO will come in and tell the clinician what clinical care needs to be provided. Any investor or DSO wants the dentist to keep doing what he or she is doing and providing the care they know their community needs. “We will do all the admin and business things to keep their practice growing and thriving that they likely don’t love in the first place!”

Scott has his own term for that type of organization, a DCO – a Dental Control Organization. “And I don’t think those should be around,” he said. “I think the misconception is, they say DSO, but they don’t really think about what the name is. Dental Support Organization. As a clinician, you’re in control. You’re where revenue happens. So, when I hear stories of, ‘They came in, they told me what I needed to do,’ I want to say, ‘Well, tell them no or quit. You have power.’”

The Dental Support Organization’s goal is to relieve the clinician in such a way that they can provide better clinical care, Scott said.

“I want you to imagine two dentists. One is on his own. He feels independent. This means he or she is also responsible for payroll that week, for how many patients are coming in, and the tiff that’s happening between the front desk team members. The dentist is responsible for the computers going down and responsible for all of the admin and business chaos.”

How is that dentist providing better clinical judgment and care than a second kind of dentist who’s not responsible for any of that back-office stuff, who’s not responsible for patient flow and scheduling, HR human resources, and technology upgrades?

“I believe the second dentist actually has more autonomy to focus on the clinical care at hand and serve the patient. All he or she is responsible for is to show up and take the best possible care of that patient, and choosing what supplies they need for that,” Scott said. “I mean, just think about brain power and mental focus. You can see that a DSO done right, the clinical piece outperforms an individual dentist just because of human bandwidth realities.”

And finally, Scott adds, “This entire DSO world of National Dental Partners really began as the friendship between two people: a dentist and a businessman, Chad and Emmet. I like to think that in some way that is how a DSO done right can act for its member practices – as a true “friend” in the dental industry that is there for support, encouragement, helping you improve the places in your life that you need improvement, all from a place of trust and care, all with the benefit of all involved – both friends – in mind.”

Test, Shock, Maintain

When it comes to waterline treatment, ignorance is no excuse.  :  By Laura Thill

Despite the growing awareness around the importance of waterline treatment, some dental practices still don’t adhere to testing protocols to protect the dental team and their patients. Either they aren’t making the effort or they’re going about it all wrong, according to Air Techniques Inc. dental hygiene specialists Gaylene Baker and Carly Fish.

“It has been my experience that dental practices rarely get waterline treatment correct,” says Baker. “Either they don’t understand that something needs to be done, or they are utilizing a product completely incorrectly. Each product that is used to treat dental unit waterlines (DUWLs) has a specific protocol that should be followed to prevent biofilm growth and maintain units of heterotrophic bacteria per milliliter of water (CFU/mL) at or below 500 CFU/mL. Simply complying with a portion of a waterline treatment’s IFUs isn’t sufficient and can put patients and clinicians at risk of being exposed to disease causing microorganisms.

“In my experience, some dental offices are not doing as good a job as they can of maintaining and monitoring the dental waterlines,” says Fish, noting that some dental offices only test their dental water when an incident prompts them to do so. “Many clinical teams forget to maintain waterlines and are unaware of how to properly maintain the dental water quality, she points out. “If the practice doesn’t treat their waterlines, the microbial count can reach as high as 200,000 CFU/mL in a matter of days, even when the tubing lines are new. I’ve had dental assistants and hygienists discreetly tell me the water smells or tastes funny, which obviously is not a good sign.”

Fish recommends that dental practices take the following steps to ensure their waterlines meet acceptable standards:

  • Test. Test water on a regular basis (ideally every three months) and monitor the water quality to ensure bacterial counts remain at 500 CFU/mL or less.
  • Shock. If the dental practice suspects the waterlines are compromised and the microbial counts have exceeded 500 CFU/mL, it should initiate treatment immediately.
  • Maintain. The practice should follow manufacturer guidelines for disinfecting waterlines and eliminate dead ends in plumbing, where stagnant water can enable the formation of biofilm.
  • Daily drain and flush. Per recommendations by the Centers for Disease Control and Prevention (CDC), the American Dental Association (ADA) and the Organization for Safety, Asepsis and Prevention (OSAP), dental practices should flush their waterlines for several minutes each morning, before they begin patient visits. They should flush handpieces with air/water for 20-30 seconds between patient visits. And they should install sterilized handpieces and sterile or disposable syringe tips after flushing to reduce cross-contamination.

“Using an independent water reservoir system will eliminate the inflow of municipal water into the dental unit,” she adds. “This will permit better control over the quality of the water source, and eliminate interruptions in dental care when ‘boil water’ notices are issued by local health authorities.”


If some dental practices are lagging behind with regard to waterline treatment, it’s certainly not intentional in every case, note Fish and Baker. “Some dental practices may think that because they’re using distilled water, they are supplying safe water to their patients,” says Fish. “They may not realize that biofilm is growing within the water lines.”

Waterlines are moist, warm and dark, with periods of stagnation and slow flow rate, making them breeding grounds for biofilm, she points out. 

It’s not uncommon for dental practices to believe their treatment protocol is simpler than it really is, leading them to overlook important steps, says Baker. Furthermore, they may not realize they need to validate that they are complying with EPA and CDC treatment standards to ensure their water does not exceed 500 CFU/mL, she explains. Even if a product does not include validation recommendations in the IFUs, the practice must take necessary steps to validate their protocols and account for the possibility of errors occurring. “Dental offices often have a waterline design that facilitates growth of biofilm that can be released into treated water causing a CFU count over 500/mL,” she says. “If they don’t monitor their waterlines, how will they know this?

“There is also a great misunderstanding that utilizing distilled water is sufficient, and no treatment is required,” she continues. “Distilled water is a great source of water, but without waterline treatment, the DUWLs will absolutely grow biofilm.”

Misunderstanding or not, when dental professionals are negligent, they place both their patients and their practice at risk. Take an incident impacting a Georgia pediatric dental clinic in 2015, where 20 children who received pulpotomies required hospitalization due to chronic infections. “The investigation revealed a direct link between these infections and contaminated dental unit water at the clinic,” says Fish. “The average CFU count was 91,333/mL,” she explains. “M. abscessus was isolated from all water samples and genotyping validated that it was responsible for introducing infections into the chamber of the tooth during irrigation and drilling.” Signs and symptoms of this infection include pain, swelling, osteomyelitis (an infection of the bone), pulmonary nodules (a small, round- or oval-shaped growth in the lung caused by an infection) and fever. Treatment can be extensive and expensive.

“The bottom line is, if the dental office is negligent and doesn’t treat its waterlines, there are legal implications,” says Baker. “I didn’t know is not a defense. It is every dental practice owner’s duty to know what must be done in order to comply with laws or guidelines. They also have to train their employees on why waterlines must be treated, and how to treat them. And, they must implement an office policy specifying how the dental team should use their chosen product and validate compliance.”

The good news is that, while some dental practices have some catching up to do with regard to waterline treatment, market data reflects a growing interest in newer products available to ensure dental water meets EPA drinking water standards, according to Fish. “Given how much this product category has grown in recent years, it’s clear that more and more dental offices recognize the importance of treating their waterlines,” she says.

Today, in-office and chairside water test kits are available, which are convenient, economical and save doctors time, Fish points out. “Although less reliable than laboratory testing, in-office tests provide actionable results based on a pass/fail baseline, enabling the dental office to take fast action if biofilm starts to gain ground.

In-office tests require a sample be taken directly from each unit and left to incubate for 2-5 days, depending on the method used,” Fish continues. If used more frequently, these tests can help ensure staff compliance and provide an early warning if there’s a problem, she adds.

“Air Techniques offers Monarch Lines Cleaner, an intermittent, chlorhexidine-based liquid treatment,” Fish explains. “Monarch Lines Cleaner is both a shock and maintenance product. It removes biofilm containing odor-causing bacteria from dental unit waterlines with a fast, effective and efficient application. The solution is ready to use, with no mixing or diluting required. After coating the tubing walls nightly for 3 weeks to ensure buildup in waterlines is eliminated, Monarch Lines Cleaner should be used weekly.”

Clear and concise

As important it is for dental professionals to follow manufacturer instructions for use, it’s up to manufacturers to provide clear, concise instructions, notes Baker. IFUs for waterline treatment products can be confusing to say the least,” she says. “Is it necessary to shock? If so, when? Do I need to test? Again, when?” Whole office systems require maintenance with shocking and filter changes, she adds – something dental offices may not realize. “Many dental offices believe that once they install whole office systems, they are finished, but that’s not true,” she points out. Manufacturers bear the responsibility of providing easy-to-follow documents, which may also be used for recordkeeping to keep track of treatment, monitoring and protocols for addressing failed tests. “This would help dental practices follow proper protocols for their product of choice, and keep clinicians and patients safer in the long run,” she says. 

It’s especially important that dental professionals understand the risks involved if they do not follow the product IFUs and adhere to CDC guidelines, notes Fish. “Easy-to-follow instructions and instructional videos can be helpful,” she says. “In addition, manufacturers should follow up with the office once the sale has been made to ensure the customer is using the product according the to the IFUs.”

Running a dental practice can be overwhelming, says Baker. Add to that the need for regular waterline filter changes, shocking, monitoring and recordkeeping, she points out. The better educated dental professionals are with regard to the importance of adhering to waterline treatment protocols and maintaining EGP drinking water standards, the better equipped they will be to keep their staff and patients safe.

Publisher’s Note: The Gift of Freedom

Each summer I have always looked forward to celebrating the Fourth of July. I must admit this year it was a little tough to be excited. As the son and grandson of lifers in the Marine Corps – two men who were willing to lay down their lives for our country – I am saddened by the shape in which we find ourselves. But I think it’s important to take a hopeful look at what we are blessed to have as Americans.

We are all free to get on a plane and fly to see our parents and children. We are free to become whatever we want. We are free to choose our religion or have none. We are free to drive across this amazing country without restrictions. We are free to love who we want to love. We are free to use our voices. Freedom is a gift that many in this world never taste, yet as Americans we are free and we cannot forget that. Thank you to the men and women who provide us these freedoms.

As Americans we are free. There are times we all take it for granted, but as we pass the midway point of a chaotic year, let’s pause for a few minutes to be thankful for our imperfect country. Let’s turn off 24-hour news for a while and just be grateful for where we live and our ability to change and be free.

Dedicated to the industry,

R. Scott Adams

Dr. Andrew Matta, DMD, MBA, Founding Partner & Chief Medical Officer, North American Dental Group

Efficiency: What does it mean for your DSO to be a leader in today’s dental market?

Dr. Andrew Matta: For us, it really means leading the way in how we interface with the many constituents that we serve. Our approach has always focused on the team members that take care of our patients. When you approach your team with gratitude and empathy it creates a culture of compassion which is key when you are a healthcare provider. In doing so the patients win as they have highly motivated and engaged teams taking care of their needs. When patients are happy, communities are happy, which we believe is the true measure of success for long-term viability of our practice.

Efficiency: In your opinion, what are the three most important characteristics of a leading DSO?

Dr. Matta: We understand that we are in the business of taking care of people; whether our team members or the patients we serve. The three characteristics that we feel are most important is for us to have:

  • Clinical Leadership – It is essential to have a strong focus on clinical leadership. Also, having a healthy working relationship between the business and clinical leaders.
  • Servant Mentality – this allows all team members organizationally to know that we are all here to serve. When you lead by example from the top to the bottom and the bottom to the top it helps create cultural alignment.
  • Field First Approach – we know that patient interactions are critical in the quality of the care our supported doctors and supported teams provide and having the entire organization focused on that helps us make great patient decisions.

Efficiency: What is your organization’s mission? In order to be a leading DSO, must that mission change or evolve over time?

Dr. Matta: Our organization’s mission is to deliver “best in class care – every patient/every visit”. We have an internal dialogue and North Star of being the Cleveland Clinic of Dentistry. Cleveland Clinic and Mayo Clinic are among the world’s best health care institutions. Our doctor led organization has worked as a community to establish a group collaboration of high standards around quality and safety of care. Those standards and the mission should continuously improve and evolve.

Efficiency: How are dental patients’ expectations changing, and how do leading DSOs help their practices respond appropriately?

Dr. Matta: We have seen a continued focus on convenience, quality, and just-in-time care. Even though we serve many different demographics and socioeconomic statuses, we see that there is a general theme to make the overall experience more convenient to busy lifestyles. Whether that is scheduling tools, hours of operations, days of operation, and/or the customization of care, the convenience factor is in play. Quality matters – they are reading the reviews, watching the videos, and learning as much as possible of the people that are going to take care of them. We have seen an influx of decisions around online feedback versus historical community-based reputation. Lastly, patient do not want to wait. They are used to getting their way to what they want now, and the consumption of content and e-commerce has continued to train and evolve the consumer to this point. We feel that these three key points need to be an area of focus for us to remain viable. 

Efficiency: Are DSOs being called on to provide a new, creative leadership in dentistry? Dr. Matta: Leadership within the dental industry is continuously changing and we are being asked to step-in and fill the leadership void as we welcome new, young dentists starting their careers and, at the same time, senior dentists are retiring. We recognize the shifting landscape of our profession, but we also know that regardless of the paradigm, there is no substitute for excellent patient care. Whether we are partnering with a clinician in our organization close to retirement or with a new associate joining our group, we know we can unite around a collective purpose regarding patient care. Layering standards of care, measuring outcomes, and focusing on quality allows us to build bridges with these different mindsets. The flexibility in approach allows us to lead these people with some of the key common themes described. It is like a language where we are all using the same alphabet and our job is to make it all come to life with the same narrative so that it all makes sense.