Editor's Note: This article is the second in a series of interviews featuring insights from the Spear community and our Spear Talk forum moderators. Subscribe to Digest to be the first to hear about new interviews exploring social media, collaborative dentistry, clinical innovation, and more as they are published.

Dentist holding mirror in front of patient

Our theme this month centers around collaboration and the working relationship with our dental specialist partners. Today, dentistry is a changing environment and treatment demand is on the rise. Post-Covid, patients are concerned about health and safety now more than ever before. Additionally, there are significant “market challenges” in our profession that are impacting how, who, and why dental services are implemented and performed on a daily basis.

To provide context to this interview, it is necessary to set the perspective and outline the parameters that are driving an alternative view towards dental specialty care and treatment. A recent review of the dental marketplace draws attention to some underlying themes and challenges that directly affect dentists' actions and thoughts toward referring patients for specialty care.

  • The average dental student debt is $241,097 (American Student Dental Association, 2014)
  • Specialty residency debt is $600,000+
  • Corporate practice growth has had an 85% increase in last four years
  • Rapid growth of corporate dentistry has increased competition for new patients
  • Virtually all corporate practices participate in Managed Care Plans
  • Managed Care Plans “freeze”, then reduce reimbursements creating a “work harder for less pay” environment
  • Corporate practices are “black holes” for dental specialists
    • Specialty care is provided by employee associates or outside specialists as independent contractors
  • Only 25% of young dentists are owners/partners in private practices (survey from Graduates of Last Decade meeting – 2014 Hinman Meeting)

Given these challenges confronting dental care providers, it is important to address the relationship and role of the dental specialist in today's changing world of dentistry.

With that background in mind, our Moderator Highlight interview for this month revolves around collaboration and interacting with our specialty partners — to gain some insight on the subject, we spoke with Dr. Ashley Hoders.

Ashley is a dual-boarded periodontist and prosthodontist that practices in Tacoma, Washington. She received her specialist training from San Antonio, Texas. Ashley hails from Florida and attended dental school at University of Florida — prior to entering her specialty training, Ashley practiced as a restorative dentist in Maryland for two years. During that time, she attended continuing educational programs at the Pankey Institute in Key Biscayne, Florida. While in practice, she was introduced to the value of dental study clubs as a source of education, support, and professional growth. Her primary focus in her specialty practice now is interdisciplinary collaboration and esthetic periodontal and implant surgery. As a “dual-degreed” specialist, Ashley is a unique team member and offers exclusive insight to treatment planning and performing surgery with a restorative mindset. She is very cognizant of how biology influences the restorative outcome and enjoys sharing her knowledge and working as a team to help patients.

This interview is aimed at discussing what we refer to as the younger dentists' "present view value" of dental specialty care in our world of increasing corporate dentistry and enlarging debt service.

This is a quote that I've talked about before: "You can't treat what you don't see, and you won't see what you can't do." Can you give your perspective on the way collaboration is today from your experience relative to that statement?

Dr. Hoders: “ This quote really highlights how our treatment plan and treatment is influenced by our own blind spots, biases, and limitations! We need each other – we need to collaborate – in order to see more, treat more, and work past ourselves.

If we don't know what we are looking at and do not collaborate, then we ultimately end up with an incorrect treatment plan. A snowball effect happens because we don't know what's happening or why it's happening. Without understanding etiology, we will not make a correct diagnosis. Without the right diagnosis, we can't pair a treatment solution with that diagnosis. That means we won't have the right plan and will not treat the problem appropriately. This is super frustrating for the clinician, but also for the patient as we chase our tail and potentially get into trouble. So there is also a literal lesson to learn from the quote “You can't treat what you don't see” — which is “Don't treat it if you can't see it!” And if you are not sure what you are looking at, then ask someone to help you.

Invest in yourself and increase your exposure to more knowledge, and also surround yourself with people that are better than you, that inspire you, that can help you understand more — and seek out their time.”

How do you get other dentists to see beyond single tooth dentistry and to the bigger picture?

Dr. Hoders: “I think defaulting to single-tooth dentistry type of treatment planning is so comfortable, especially when we encounter a situation that is a little bit different than what we've seen before. And when this happens, we're naturally going to look to try to break that down into pieces that are less overwhelming and more familiar — the basic findings and diagnosis model that we learn in school. So moving beyond single-tooth dentistry starts with exposing yourself to comprehensive treatment planning and collaborating with your specialist team to learn what the big picture looks like for them. Every specialty has their own set of knowledge, so you want to understand that and how it applies to your particular patient so you can work together for the best outcome.

Some of the specific strategies that I use and find helpful include making time to help by sharing my unique perspective as a dual-trained specialist. I like using Facially Generated Treatment Planning to break down something that seems overwhelming into less overwhelming pieces in order see the big picture. Then, I want to make sure the person I am trying to help leaves the conversation with a sequenced plan and knows what to do next. But I also stress something else that Spear highlights in pretty much every video that we watch or article we read: the importance of getting the right diagnostics, including photos — there's no way you're going to see beyond single teeth if you're treatment planning using only X-rays or study casts.

When I was in San Antonio, Jeff Rouse and Bill Robbins explained big picture planning by asking us residents to just imagine that every patient needs a denture. If you're at that wax try-in stage, and you're trying to figure out where those teeth need to exist in space, where they need to exist in the face, and how to get them to function well — what would you need to do? And that's such an easy concept for every dentist to go back to, and is a concept that is the foundation of treatment planning at Spear known as FGTP (Facially Generated Treatment Planning) that uses the AEFSB (Airway, Esthetics, Function, Structure, Biology) approach. If we know where the teeth should exist in space, and we know what a healthy system looks like and how it should function, then that's how we go beyond single tooth dentistry and build on concepts of understanding why what we're looking at might be deficient and how we can fix it.”

Can you talk about holding to the standards of the specialist? What does that term mean to you? And what does that mean relative to other dentists doing things that, let's say, might be beyond their scope?

Dr. Hoders: “I think being held to the standards of the specialist means that any service you provide for a patient needs to be on par with the quality that a specialist would provide for the same procedure.

If you are pushing your limits as a general dentist and something doesn't go quite right, then that's the standard to which you're going to be held accountable. It's understandable that dentists want to provide more services for their patients and they want to challenge and invest in themselves. These are all good things. I think it's really important, though, to find a balance between investing in ourselves and challenging ourselves in a way that we can prevent getting in over our heads.

It's important to understand where our limitations are, and to appreciate that no matter what course you take, you're not going to leave with as much knowledge – or certainly as much experience – as that of your specialists. So let them help you. Make time to review cases together and ask them to walk through cases that will push your limits. It's a super valuable opportunity to work together and to determine which cases might be good to try and which ones might be a major challenge that you don't see coming!”

Group meeting, taking notes, collaboration

Let's talk a little bit about Study Clubs. Can you talk about your experiences with study clubs and how you see them impacting dentists and their teams?

Dr. Hoders: “Yes! I am a study club junky of sorts! I love study clubs.

I think the reason for that is because I was so fortunate to be exposed to a very high-level group in my first year in private practice (2008), and that's how I met Dr. Gregg Kinzer and “grew up” with his influence. This group – these people – are my extended family and will always be my mentors. Being a part of that group in particular just really showed me what's possible when you surround yourself with people that are better than you and people that are invested in being better themselves. It solidifies the message that you will never develop yourself on your own island as much as you will with a study club. They've been the most influential part of my journey and I am so grateful for each of them.

I think that's what makes a study club really successful is having the right mix of people and creating an environment where people feel comfortable and safe sharing with each other. They can largely impact dentists and their teams because they allow the community to feel more connected with each other.

Study clubs are not just about the dentistry. They are about connectedness, relationships, and the opportunity to grow yourself as a person and as a professional, as a business owner, a family member, etc. I can't say enough good things.”

Is there something more or different that we should be doing to try to engage the younger generation of dentists in order to get them to appreciate and value that connectedness that the “older generation” might have? Or does it just come with experience?

“I think the biggest question is: How can we embrace the changes that are happening in dentistry to maximize our potential and to also make sure our patients get the best care?”

Dr. Hoders: “From what I have observed in my own experience — but also in talking with some colleagues around the country — it seems that in general, the dentists that are a generation or more older than me seem to value study clubs as a way to reinforce interdisciplinary collaboration and heavy reliance on specialist referrals to help their patients as they focus on big picture diagnosis, collaboration, and refinement of their restorative skills and techniques.

In general, I think that there has been a slight shift in focus for dentists that are my generation and younger. I am finding that the study club platform for the younger clinician is primarily a way to share what they are doing in practice and also as a way to be connected as life transitions through becoming a practice owner, to balancing kids, family, and practice. I have also noticed a shift in the role of the specialist to some extent and how specialists are utilized. There seems to be a shift towards asking for specialist advice on procedures that would traditionally be referred, as more dentists are expanding their services and offering procedures such as implants or tooth alignment technologies to their patients. Maybe this trend is something that will shift again with experience and with determining what is most enjoyable and where to put focus — but perhaps this is the reality of how things are changing in dentistry.

Not every generation is going to be the same, and dentistry is certainly evolving. I think the biggest question is: how can we embrace the changes that are happening in dentistry to maximize our potential and to also make sure our patients get the best care?”

As a Spear Talk moderator, do you see it as a great resource for learning and growth for new dentists?

Dr. Hoders: “Yes, I do see it as a great resource, and I am so happy that people utilize this platform to ask for advice. I think that you can see its positive impact in the amount of replies, in the content of the replies, and in how the moderators and faculty help guide and influence the discussion in an impactful way. When I'm commenting as a moderator, my goal is to share knowledge in order to help someone understand from a restorative perspective and from a surgical perspective what they are looking at, why it is happening, and what can be done to fix it!

I also try to incorporate and attach literature references, and include any material that Spear offers, in an effort to direct them to more resources. There have also been times that what results from these discussions is a personal message communication about their case, which really helps me to know that I am making a difference — whatever I can do to help someone else have a solid plan and get a favorable outcome.”

Let's talk about corporate dentistry. Obviously, corporate dentistry is really creating a lot of change in our world of dentistry — by the nature of what we have to do, how the dentists have to work in those environments and just the scheduling, the busyness, the rat race of it all. What are your thoughts on corporate dentistry and how it's impacting the world of dentistry today?

“I believe that there will always be a place for relationship-based care, and that there will always be a need for great specialists and patients that will seek out that model.”

Dr. Hoders: “I definitely think that there's an increase in corporate dentistry, and I also think that dental students are graduating with so much more debt load.

I think with the increases in corporate dentistry and increased debt load, we're going to see a shift in the private practice model of dentistry and who will seek out that model of care. As specialists, I think there will continue to be a shift in what gets referred and when it gets referred. With corporate dentistry, the goal will likely be, “How can we keep as much as we can in-house? How can we keep overhead low?” Specialists will likely be a part of the corporate network, and that option will likely be who the dentist can refer to. So that means that your network will be as good as your specialists and there may be lost control over what gets referred, when it gets referred, and who it gets referred to.

I think these changes will impact dentistry as a whole including the world of the specialists and referral-based care. For the new grads, whether they're going to transition into taking on more debt and buying a practice or they're going to become an associate, I think they're going to have similar goals as the corporation because of the increased debt load. A natural consequence will include the desire to increase profit and decrease the overhead. That means an increased pressure to provide more services for patients, or perhaps hiring a specialist to retain some of those profits while also being able to offer the convenience for the patient to stay in one location.

These strategies can seem like a great idea and great opportunity — until it's not — and you can end up feeling scattered, overwhelmed, and stressed in being able to keep up. Unfortunately, these stresses can contribute to losing sight of patient-centered care and end up shifting our goals away from outcomes and toward what might be best for our bottom line. When this happens, it will be important to recognize the solution is narrowing the focus and honing skills that patients will seek you out for.

Because the good news is that I believe that there will always be a place for relationship-based care, and that there will always be a need for great specialists and patients that will seek out that model.

It's important to recognize these changes, and change, too — in terms of modifying some of our strategies for attracting patients and even being ready to modify how we practice. As specialists, we may see an increase in complex cases, and increase in re-treatments with a history of failure, etc. We have to be prepared to help these patients but to also be able to talk about them, too, in a delicate way.”

That puts specialists in a challenging position when you get these failing cases that walk in.

Dr. Hoders: “Absolutely. It's challenging for everyone involved in the failure, including the patient. You cannot avoid failure — it's going to happen to everyone — but it's really important to learn from our mistakes. Many times, it's something that was not recognized during the planning process that contributes to the failure. So we have to be smart about what we choose to do ... and that circles us back to the advantage of collaboration and being a part of a study club.”

Dr. Jeff Bonk is a Spear faculty member and, along with Dr. Ashley Hoders, is a moderator for Spear Talk, our doctors-only forum for Spear members.

Dr. Ashley Hoders' Current Reading List

  • “Lifespan: Why We Age – and Why We Don't Have To” by David Sinclair
  • “Breaking The Habit of Being Yourself: How to Lose Your Mind and Create a New One” by Dr. Joe Dispenza
  • “Think Again: The Power of Knowing What You Don't Know” by Adam Grant
  • “The Plant Paradox” by Dr. Steven Gundry
  • “Plastic-Esthetic Periodontal and Implant Surgery: A Microsurgical Approach” by Drs. Otto Zuhr and Markus Hürzeler
  • “Evolution: Contemporary Protocols for Anterior Single-Tooth Implants” by Drs. Iñaki Gamborena and Markus Blatz
  • “Resin-Bonded Fixed Dental Prostheses: Minimally invasive - esthetic – reliable” by Dr. Matthias Kern