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Dentists could raise fees, exit family practices as pandemic keeps patients away

Millions of Americans are delaying dental appointments over concerns about coronavirus infection, and that’s likely to trigger increased fees for patients, job cuts for workers and fewer family practices.

When the pandemic began this spring, essentially all dentists temporarily shut down for all but emergency appointments, putting hundreds of thousands of Americans out of work. While 99% of dentists have reopened, the number of patients visiting offices remains about 20% below usual levels, according to the American Dental Association.

And dentists don’t expect it to improve much more anytime soon despite significant safety measures they’ve rolled out to protect themselves and patients from COVID-19.

Spending on dental care could fall by up to 38% in 2020 and 20% in 2021, the ADA projects. Of dentists surveyed by the trade group, more than 46% said their patient volume was down at least 15% from usual levels during the week of Oct. 5.

About 15% to 20% of regular dental patients say “they’re not going to go back to the dentist until there’s a vaccine or a proven treatment,” said Marko Vujicic, chief economist of the ADA.

“They’re a segment of the population that’s very cautious, and they’re waiting for COVID to pass, so to speak,” Vujicic said. “They’re simply not returning to usual activities, period.”

Katia Lee is among them.

Lee, a self-employed professional photographer in Columbia, South Carolina, hasn’t gone to the dentist since before the pandemic began, in part because she doesn’t want to risk getting infected and passing it to her 76-year-old mother.

“The practice I go to, they are lovely, don’t get me wrong – I really like my dentist and my dental hygienist,” she said. “But I know at least half of them have families – that means you’re trusting not just them but their kids, their husbands, that’s why it’s so scary. I have to trust everybody else to keep myself safe.”

With COVID-19, can I visit the dentist?

In August, the World Health Organization angered dentists by advising that “routine nonessential oral health care – which usually includes oral health check-ups, dental cleanings and preventive care – be delayed until there has been sufficient reduction in COVID-19 transmission rates from community transmission to cluster cases or according to official recommendations at national, sub-national or local level.”

The ADA said it “respectfully yet strongly disagrees” with the WHO’s guidance, pointing to numerous safety measures dentists have set up to reduce the risk of transmission, steps advised by the Centers for Disease Control and Prevention.

Those measures include heightened use of personal protective equipment (PPE) such as N95 masks and surgical masks, disposable gowns, air purifiers, cleaning solutions, temperature checks, hand-washing and social distancing, including forcing patients to wait in their cars until their appointment is ready to begin.

Dental industry leaders have said they’re not aware of any documented cases of COVID-19 outbreaks stemming from dental offices, but they acknowledge that patients remain concerned about opening their mouths wide in the presence of others for extended periods of time.

“I know I would rather go into a dental office than a restaurant,” said Scott Asnis, a practicing dentist in his role as founder and CEO of Dental365, a network of dentists based in New York.

Consolidation coming

If patient volume remains at current levels for a few more months, dentists say they’ll give serious consideration to raising their fees, including for insured patients, as well as cutting jobs or selling their practices, according to the ADA.

“We’re at a very important next couple of months,” said Vujicic, the ADA economist. “I do think we will see additional layoffs and some exits in the market. It’s suggesting to me that it’s not a sustainable situation.”

Lee, the self-employed photographer, said that even if it’s safe to go back, it’ll be hard for her to justify going to the dentist since she doesn’t have dental insurance and the struggling economy makes her hesitant to spend hundreds of dollars on an appointment.

People’s hesitation to go back has led dentists to seek help. When they temporarily shut down, about 9 in 10 dentists applied for some form of financial assistance from the federal government, including forgivable loans, and the “vast majority” received some, according to the ADA.

“That’s actually helped them retain staff,” Vujicic said. “It would have been much, much, much, much worse” otherwise.

But they’re still hurting. The ADA estimated that the average dentist is spending an extra $15 to $20 per patient due to measures related to COVID-19 prevention. Some are passing those costs along to patients in the form of fee hikes.

Dentists are also unable to see as many patients as normal due to the extra time they need to devote to cleaning and spacing out patients to ensure they don’t come into contact with each other.

The upshot is that family dental practices are struggling the most since they are unable to spread out the costs of PPE. Industry leaders and analysts say dentists are increasingly likely to sell their family practices to private equity companies or other investors.

“To a lot of dentists that’s an attractive way to go,” said Brandon Couillard, a Jefferies stock analyst who tracks dental service providers. The pandemic “will make it more difficult for the single office practitioner to remain economical,” he said.

Asnis, whose practice has more than 50 locations, said he’s being flooded with inquiries from dentists seeking to potentially join his network.

“Everyone in this area is wanting to join group practices, and it’s happening throughout the country,” he said. “I’ve never had more dentists reach out to me than I have since June.”

To be sure, the move toward group practices and private equity ownership was already underway before the pandemic, in part because younger dentists with a lot of student debt aren’t as interested in taking on the financial burden of launching their own practice and handling office processes like payroll.

One increasingly popular option is for dentists to join dental support organizations, or DSOs, which provide back-office support for tasks like human resources and billing.

Emmet Scott, president of the Association of Dental Support Organizations, said DSOs are appealing to dentists who want to focus their time primarily on care.

Without support services, “they sit there doing crowns and fillings all days and then doing payroll on Friday evenings,” he said. “I think that drives more consolidation.”

Will pent-up demand save the day?

As anyone who’s ever had a cavity will know, the longer you put off an appointment, the worse it gets. Which is one reason why dentists have reported a quick uptick in patient volume in recent months after they began reopening.

But there is lingering concern about what will happen once they’ve satisfied pent-up demand for patients who were forced to defer treatment during the shutdown period.

“Volumes in dental offices hasn’t fully bounced back, and it’s beginning to flatline or taper,” Couillard said. “We maybe satisfied a lot of pent-up demand.”

Meanwhile, dentists are becoming more likely to embrace new avenues for doing business.

One option is that dentists may get involved in distributing COVID-19 vaccines. About 3 in 4 are willing to vaccinate patients or would consider it, according to ADA polling.

In addition, dentists are increasingly looking for new revenue opportunities in the form of clear removable plastic aligners, a braces alternative sold by companies like SmileDirectClub, Align Technology’s Invisalign and ClearCorrect. Unlike traditional braces, which are managed by orthodontists, dentists are qualified to manage treatment plans for aligners and say that aligners can generate new customers.

SmileDirectClub’s model is predicated largely on the distribution of mail-order aligners and remote monitoring of each patient’s progress through photos, eliminating the need to visit an office for treatment.

“The pandemic has clearly strengthened the argument for teledentistry,” Couillard said.

But are people really concerned about having straight teeth at a time when no one can see their smile in public due to face masks?

Christophe Carsault, vice president of North America at ClearCorrect, said aligners are still appealing to patients because they can help fix an overbite, underbite, or crossbite.

“The benefit of having straight teeth is way bigger than just the smile,” he said.

Among them: looking good on video while working from home.

“Some Invisalign doctors are hearing patients talk about the ‘Zoom effect’ from video calls and seeing patients focus more on their smiles and seeking treatment,” said Shirley Stacy, vice president of finance, corporate and investor communications for Align Technology, in an email.

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