“The vast population of this earth, and indeed nations themselves, may readily be divided into three groups. There are the few who make things happen, the many more who watch things happen, and the overwhelming majority who have no notion of what happens. Every human being is born into this third and largest group; it is for himself, his environment and his education to determine whether he shall rise to the second group or even to the first.”​
-Nicholas Murray Butler, President of Columbia University, 1931

My experience is broad and from that I have perspective. Rural, urban, private practice, group practice, hospital, university, academic, regulatory, local, regional, and national are all places or situations I have worked. I have observed what is happening in health care and dentistry from “on high” and “on the ground”. The high debt of graduating students and how that guides their decisions is very concerning. These high debt new doctors are reluctant to specialize for the reason of taking on more debt. I worry about the expansion of dental service organizations and the disappearance of small practices. I wonder about the disappearance of small dental laboratories and schools that teach technicians. The low reimbursements from dental insurance companies and how that affects the quality of care is disturbing. I strongly object to dentistry being paid almost entirely by surgical procedures and not by diagnosis and prevention that get at the cause. Our aging and gradually sicker population is more challenging to treat and has greater needs. I wonder about the push for midlevel providers gradually becoming providers for more and more patients. I strongly support evidence-based practice and despair how little dentistry is evidence-based. The advent of artificial intelligence systems is welcomed since that will focus on evidence but there is a lack of understanding of artificial intelligence systems and a tendency to always believe the black box. Robotic providers are arriving now. The doubling of biological scientific knowledge happens roughly annually and I know that the increasing knowledge of the disease process and treatments will outmode current practice. Primary care in medicine is woefully short and I wonder who will pick up the reins and how. I am disappointed in seeing the number of healthcare educators decrease when we need many more to work through all these changes. The changes are numerous, increasing, and accelerating.

What are stakeholders thinking?
From my perspective as a state commissioner that conducts public hearings regarding infection control, anesthesia, and other topics, I have a very good sense of what dentists are thinking. They want change to happen slowly if at all. They fear rapid change. As a professor, I have a pretty good idea of what students and faculty are thinking. Faculty and students are trying their best to satisfy requirements. As someone connected to national ADA efforts, the JCNDE, and other organizations, I have a pretty good idea of what they are thinking. The ADA, ADEA, CODA, and the JCNDE, groups I know, are planning for change but it is difficult to be too far ahead of your constituents and many decisions reflect what constituents want. It is difficult for constituents to be future-focused when the present has many challenges.

What can we expect?
The traditional solo dental practice is fading in favor of groups that can take advantage of corporate power and consistency. The continuing push for both efficiency and access to care will increase pressure to add midlevel providers and automation. People with the Dr title will be more and more removed from technical procedures. There will be polarization. Dentists will be forced to decide to focus on high-end dentistry (a small proportion), become a manager of DSO systems, become a dental specialist with high-level skills, or become an Oral Physician with primary care responsibility and capability. As the standards shift to overall health, the definition of competence will shift. A closer collaboration with medicine is being baked into education, expectations, and standards of care right now.

Speaking the language of medicine becomes imperative along with a broad understanding of health care.
Technology needs to be embraced but the limitations understood. The changes are coming faster than people expect, perhaps like climate change, the consequences are arriving today. The tipping point is long past. There is no going back. The essential problems are complacency, fear, the willingness to wait to respond, and even Pollyanna optimism.

There are choices.
What drives those choices? Our emotions drive our choices, fear, compassion, greed, anxiety, curiosity, gratitude, and generosity to name just a few. What drives you? Will you be meta-cognitive, understand your thinking and feelings, be able to look at the evidence objectively, and make the best decision for you, your family, and your practice? Many newly graduated dentists feel driven to join corporate practices for economic concerns as well as lifestyle. More than thirty percent were choosing that direction in 2020. What will be the outcome? Better access to care? Greater evidence basis? Will quality increase or decrease? Will there be an alternative to selling to a DSO?

Specialization will be increasingly attractive but without more programs and more educators, that is very limited.
Moving towards collaborative care with medicine, the Oral Physician specialist, is attractive and programs may well develop. They do not exist yet. There are currently many barriers, not just in insurance but in knowing medicine, knowing the language of medicine, and having the confidence to stand and collaborate with other healthcare providers as a full partner.

The demand for “high-end” dentistry will likely increase.
There will be fewer laboratories to support the few dentists that can provide the highest quality. To travel that path will take increasing sacrifice, education, and determination. Costs will increase. The trend now includes far too few technicians that will remain in practice for the demand. With very few highly skilled technicians, high-end dentistry will be an aspiration attainable for very few.

What about solo or small group practices?
We can see that this group is getting squeezed. Being neither high-end nor corporate, their costs are higher than corporate and their fees are lower than high-end. Can this stabilize or will many be forced to make unattractive choices?
A heavy dose of truth and honest self-reflection is required for each dentist. Being fearful of change won’t help. Ignoring it is worse. We all have to ask ourselves what our mission is and how best to get there. What action will I take to shape my future and the future of oral health care?

The changes will be coming quickly over the next 10 years. Change is already in motion, a tsunami is approaching. Those of us close to retirement have little to worry about. Those of us in our early careers will have some flexibility. Those of us in the middle will have hard decisions to make. What will be the key characteristics of the successful healthcare provider of the future? I am certain that followers of the 2500-year-old Hippocratic oath will survive and perhaps thrive. Let me be pithy and summarize the spirit of that promise.

1. Be compassionate, ethical, and prosocially moral. Do what is in the best interest of the patient. Be truthful.
2. Practice critical thinking. Read and understand scientific literature and know how to determine truth from fiction.
3. Always be sharpening clinical judgment. Have and maintain a high level of expertise.
4. Have solid relationships with colleagues, auxiliaries, and patients.

Forty years ago when I saw my first patient, it was a very different world. There have been too many changes to list. There will be more change in the next ten years than in the last forty.

There is a saying in politics that the rules are made by those that show up. It applies to much more than politics. Showing up for continuing competence, initial competence, state licensure, interstate licensure, interprofessional collaboration, interprofessional knowledge, and infection control has been important and productive for me.  I have made friends on these projects that work on many other projects. There is much to do, the tasks of many. I have chosen to be part of the guidance to a better outcome, working with talented people. It requires doing your homework and following through to be an effective part of a state dental board, to volunteer through the ADA, to teach at a dental school, to lobby your legislature, and to seek opportunities to guide the future. Action cannot wait or dentists will be asking themselves, “What happened?”

David Carsten, DDS is a dentist anesthesiologist.

• BS in Biochemistry from Washington State University
• DDS is from the University of Washington
• Anesthesiology Residency NYU Langone
• 6 publications in the scientific literature.
• Award of Distinction in Continuing Education from the Academy of Dentistry International.
• Assistant Professor in Hospital Dentistry at Oregon Health Sciences University
• Course Director for Anesthesia and Sedation
• ADA Steering Committee for the DLOSCE
• Technical Advisory Group, CSG.org for the Interstate Dental and Hygiene Licensure Compact. Mentor of Tilikum Crossing Seminars OHSU
• Past Chair of the Washington State Dental Commission
• Chair of the Infection Control Committee
• Chair of the EFDA Committee

THE DENTAL STAFF -
I want to thank and recognize the entire dental team for all our clients.  The dental assistants we work with are so important to our communication process, the quality of work we receive, and the final result! The case schedule coordination and so much more could not exist without the skills of the dental office front desk. We know you do far more than work with our schedule of cases, but we truly appreciate and value your skills and communication effort. I have enjoyed overhearing my office staff refers to you as phone friends! Excellence requires the entire team and we are achieving it together. Thank you!
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​Please honor the feedback card rules, so that the feedback is accurate!

#1- Seat Time clock begins when temp is removed and prep is cleaned.
#2- Clock stops when restoration is adjusted and ready to cement.
#3- Please be fair and deduct unexpected interruptions that aren’t related to the seat appointment.

2020 was a year that none of us will ever forget and the fog of uncertainty still lingers. When our lab opened back up in late May, my staff felt a reawakening of how much we meant to each other in our career long search for excellence and some new lab goals were instinctively set.  Our 24 clients opened up state by state and we all shared the joy of getting started again, together and even better!  
 
We did bring our quality up another notch and the proof is in the 2020 Crown Seat Times results. This year was the lowest seat time average since we started publishing the results in 2009. We send sincere appreciation to our clients and staff for communicating with us to improve the quality of esthetics, fit, form and function of the lab work for their patients.  What a year!






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Please honor the feedback card rules, so that the feedback is accurate!

#1- Seat Time clock begins when temp is removed and prep is cleaned.
#2- Clock stops when restoration is adjusted and ready to cement.
#3- Please be fair and deduct unexpected interruptions that aren’t related to the seat appointment.

It is an honor to submit our Crown Seat Time results for the entire year of 2019. These results are acquired by the simple math of adding the total minutes, then dividing by the total crowns on all feedback cards by each quarter and year. We collect and publish this information for the sole reason of creating high expectations for your dental practice and our lab. When expectations are high, the doctor/lab team is compelled to communicate quickly and decisively to fix any seat time problems. The input from your dental assistant can play an important part of this magic! 

Please honor the below feedback card rules, so that the feedback is accurate!
 
    a) Clock starts when temp is removed and prep is cleaned.
    b) Clock stops when restoration is adjusted and ready to cement.
    c) Please be fair and deduct unexpected interruptions that aren’t related to the seat appointment.
 
Thanks to all of you for the support, excellence and healthy feedback in 2019, lets get even better in 2020!

Digital photography is great for Patient Case Presentation, Patient Records, and in large part, Patient Shade Information. A gray area does exist when the Case Presentation Photos are used for the needs of the Ceramist. When building a case, a ceramist would likely view Case Presentation photos from a different perspective than the clinician. After all, the Case Presentation photos were created for a different purpose than the desired ceramic result. Besides Value, Chroma and Contour, our ceramic result will also be judged on items like surface texture, interproximal papilla contours, dark dentin influence and much more. Would your case presentation photos necessarily support the ceramic decisions for these critical areas? So, what Patient Photo Communication would a skilled ceramist need from the clinician? Heart felt belief and high expectations have compelled us to thoroughly review this question and put forth the Shade Photos we need and the reasons our ceramists need them! Enclosed is a picture story told by our three expert ceramists and myself, made in the scope of desired distance, angles and exposure for Patient Shade Photography Communication; and created from twenty-five years of building complex cases together. We are asking our clients to view and then imitate our new photo series for anterior and posterior casework, exactly or as close as possible. It’s all about Distance-Angles-Exposure.

Our laboratory goal is to consistently create life-like functional restorations on each case we do! We are absolutely certain about the photographs we need, so they were taken and arranged in a chronological order for you. These photos are now on our website with reasoned text beneath each frame. We hope to compel you to reproduce our photos as closely as possible and feel free to alter some of the oblique photos, dependent on which teeth are being restored. ALWAYS include a few extra photos for an item of special concern and verify your concern points along with shade selections on the RX. Try to keep your extra photos to seven shots, so that we receive a maximum of fifteen photos per patient. Too many pictures from different time periods can be very confusing. This new Shade Photo Series represents a request only and will not make our ceramic result perfect, just a lot more consistent! We absolutely accept most Shade Guides and want you to use this same Photo Series now on our website. To aid you in Value Shade selection, you need to arrange your Value Shades in a chronologic order from (light to dark) in your cartridge. For instance, the classic Vita-Lumin Value order from light to dark is; B1-A1-B-2-D2-A2-C1-C2-D3-A3-D4-B3-A3.5-B4-C3-A4-C-4 and most companies will give you the Value sequence of their shade guide if you call them. If you elect to use a rare shade guide, include the shade tabs with your case. ALWAYS imitate our photo series with any Shade Guide system you use. We welcome your feedback and questions; so do not hesitate to call me. Lets get better together!
 
The Value (light or dark of the tooth) is the #1 reason that restorations are returned to the lab for shade change. Typically the RX will read, “fix shade” but the problem is typically the “wrong value”. Value is King for beautiful restorations! ALWAYS squint your eyes for better results when judging Value shades. Hue, (color of tooth) is more easily seen with eyes wide open. ALWAYS take Patient Shades Photos under color corrected or natural light! 
 
Please click here to view our new Shade Communication Photo’s.
Please click here to see Linearguide 3D Master instructional video.