There is one question that every orthodontist wants the answer to: What practice model will ?ensure career long success?

Unfortunately, there is as yet no crystal ball with the answer. Instead, orthodontists like Illinois-based Derek Bock, DMD, MS, must experiment and find their own answer to this question—and, along the
way, accept the advice of those who might know better.

When Bock met his wife Anokhi Bock, DMD, MSD, at Tufts University School of Dental Medicine, they had both intended to go into orthodontics; but Anokhi soon changed paths and pursued a specialty in pediatric dentistry. Little did Bock realize, her decision would profoundly shape his future orthodontic practice.

When it came time to do their residencies, Anokhi persuaded Bock to return to the Midwest where she grew up—she to take up a residency at Riley Children’s Hospital through the Indiana University School of Dentistry and he at the University of Illinois at Chicago. While there may have been promises to eventually return to Bock’s native Massachusetts, the couple opted to stay in the Midwest following their residencies.

Today, they have a joint pediatric dentistry/orthodontic practice in Lake Forest, Ill. There had been no plan to go into practice together—well, at least Bock didn’t think there was. “It was her plan,” Bock says with a laugh, “but I didn’t really understand that straight out.” Anokhi’s residency program included a strong orthodontics component. And it was she who saw the benefits of a combination pedo/ortho practice.

“She saw it as this is what you should be doing for the patient,” Bock says. “She saw a need for early treatment and a synergistic approach to orthodontics and pediatric dentistry early on. She had worked at a very busy pediatric practice and saw a lot of orthodontic cases that were missed early on. She wanted to do that business model because she saw it was the best for the patient.”

Bock, however, was hesitant to be in a practice that focused so much on early treatment. “At Illinois, I got very limited early treatment training. Most residency programs don’t teach a lot of early treatment. And I came out and said, ‘I’m not going to do that. We’re going to wait for the teeth to come in like we are trained.’” But Anokhi persisted on the merits of a pedo/ortho combination. When Bock’s buy-in to an existing orthodontic practice fell through, Anokhi finally convinced him to open their current pedo/ortho practice from scratch.

“We’ve been living this [pedo/ortho] model for quite a while now. That was not the original plan, but it should have been,” Bock says.

Bock and his wife, Anokhi Bock, DMD, MSD, have been in practice together for 8 years.

Bock and his wife, Anokhi Bock, DMD, MSD, have been in practice together for 8 years.

Growing Pains

Bock is honest about the growing pains associated with a pedo/ortho model. When opening such a practice from scratch, the reality is the pediatric dentistry side will grow faster than the orthodontic side, he says. First off, a pediatric dental practice early on traditionally is filled with 3 to 7 year olds. Thus, the orthodontic partner is going to need to be patient. “Your ortho population isn’t going to be there for quite some time,” Bock points out.

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Practice Profile

Practice name: Forest Orthodontics and Pediatric Dentistry

Location(s) and square footage: Lake Forest, Ill—3,900 sq ft; Round Lake Beach, Ill—2,400 sq ft

Number of chairs: Lake Forest—9 treatment chairs, 2 consult rooms; Round Lake Beach—8 treatment chairs, 2 consult rooms

Years in practice: 9

Education: DMD—Tufts University School of Dental Medicine; MS, Cert ortho—University of Illinois at Chicago

Average number of patients per day: 75 to 90

Days worked per month: 16 to 18

Top five products used: Damon Q (Ormco Corp), Invisalign (Align Technology Inc), Propel VPro5 (Propel Orthodontics), I-Cat (Imaging Sciences International), Dolphin Suite (Dolphin Imaging & Management Solutions)
[/sidebar]And then there is the referral problem. “Ortho kind of suffers early on because your general dentist referrals don’t want to send you anything,” he says. “They’re scared your pediatric side of the practice is going to take the 12-year-old hygiene patient, which is the easiest production in a general dentist practice. You have to accept the fact that you’re not going to get a lot of outside referrals from other professionals.”

While the fear among the general dental community has lessened over the years, Bock still doesn’t rely on referrals for new orthodontic patients. Instead, the practice focuses on going direct to the consumer to bring new patients in.

“I really only have five general dentists that refer to me; but it’s ok. It’s harder to get those referrals in this day and age, and it’s a lot more work than just doing word of mouth and whatever is in house from pedo,” he says.

As a result, the practice allots about 70% of its marketing budget to the pediatric side, focusing on bringing in pediatric patients who will eventually funnel into the orthodontic side. Among the practice’s marketing targets are preschools and community events that cater to children up to third/fourth grade.

“Your influx of new potential ortho patients through the pedo channel is more exponential. Pedo drives in twice as many new patients on a monthly basis than ortho does,” Bock says.

Lessons Learned

Now with 8 years of experience with the pedo/ortho model under his belt, Bock firmly agrees with his wife’s view that the model is better for the patient. “I think it’s more comprehensive in treatment timing for a child,” he says. “When they can come in at age 7, whether they need treatment or not (and most of them don’t), they can be followed very closely on one system, in house, for years.”

In addition, getting parents to accept their child’s need for orthodontic treatment is a lot easier in this model, says Bock.

“[The parents and their children] have been here for years and they already trust the practice. There’s no real hard selling in this business model. It’s more about when they’ll be ready for treatment.”

So what are the downsides? “Noise. 100% noise,” Bock jokes. Initially, he and his wife shared time, both working 3 days a week; but the noise of the pediatric practice called for a plan B. Today, the two only share 1 day a week in the office—a day that is dedicated to patients who overlap between the two sides of the practice. This allows the practice to do cleanings and adjustments at the same time, saving patients a visit.

And the other downside: Overcoming the idea that you’re a pediatric orthodontist. “That is probably my biggest hurdle,” Bock says. “Because our practice is called Forest Orthodontics and Pediatric Dentistry, in the consumer’s mind, I’m a pediatric orthodontist no matter how many full mouth reconstruction cases I do or how many friends of parents I treat.”

Bock also cautions that the prevalence of phase I and early treatment cases in the pedo/ortho model, if not done right, can be a financial drain on the practice. “You’re seeing these kids for more appointments in two phases, for maybe only 25% to 30% more than your regular comprehensive treatment fee. So if you’re not efficient and pragmatic, and you don’t have the systems in place, it can be a cash drain until you figure it out,” Bock says.

“My biggest word of wisdom for people out there that want to get into the pedo/ortho model: You have to be ok doing phase I and you have to do it efficiently.”

Workplace Realities

Bock argues that starting a pedo/ortho combo practice from scratch together rather than joining an existing pediatric dentistry practice has its advantages. When Bock and his wife first opened their practice, Bock also joined an existing pediatric dentistry practice. He expected the large pediatric dentistry practice would have the patient base for an orthodontist to be instantly successful. He was wrong.

Bock contends that pediatric dentists can often have a mindset that makes it difficult to get those orthodontic patient referrals. “Pediatric dentists don’t traditionally look at [their patients] for orthodontics. They look at them for oral hygiene and cavity prevention.”

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The Pragmatic Orthodontist

Derek Bock, DMD, MS, doesn’t just rely on his own experience to make decisions about the future of his practice and treatment of patients. He also relies on the input of almost 1,700 other orthodontists throughout the country to inform his views about the path his practice should take and the future of the profession as a whole.

Bock is the sole admin of his Facebook study group, The Pragmatic Orthodontist. The forum strives to help orthodontic residents and orthodontists at the beginning of their careers; however, its membership includes orthodontists at all career stages and ages. According to Bock, a self-described “tooth nerd at heart,” the study group aims to be a welcoming environment for newer orthodontists to share and talk through clinical cases. As the group’s description says, the goal is to provide advice that is based on learned experience rather than theory and to be another tool in an orthodontist’s toolbox.

“I spend a good portion of my week, along with other contributors I’ve brought in, teaching younger practitioners what works and what doesn’t work. We’re sharing our trials and tribulations and putting it all out there,” he says.

Now that the study group is 2 years old, Bock is in the process of taking it to the next level. This month, a Pragmatic Orthodontist website will launch. The website is designed to catalog the 2,400 threads on the Facebook page and give members search functionality. According to Bock, there are anywhere from 8 to 15 new subject threads per day on the study group’s Facebook page. In addition, the website will offer on-demand learning.

To join the free study group, and have access to the new website portal, an orthodontist must submit an application and have their credentials verified.

Bock—whose wife, pediatric dentist Anokhi Bock, DMD, MSD, runs her own Facebook-based study group, The Progressive Pediatric Dentist—contends that Facebook is a great platform that plenty of younger orthodontists embrace as a resource for learning and information sharing. “They were brought up on Facebook,” Bock points out. However, many older orthodontists can be resistant to Facebook as a learning resource, which is unfortunate in his opinion. “There is an entirely different world out there that they are missing. There is so much data.”

As Bock sees it, online study groups, like his Facebook group, are a more efficient way to learn from peers and a key to future learning. “It’s like a phone conversation versus me flying out to meet you,” he says. “It’s just a lot more efficient.” OP [/sidebar]So, what’s an orthodontist to do in this situation? Bock says, pediatric dentists need to be coached to anticipate a patient’s orthodontic needs.

Bock ended up leaving that pediatric dental practice, finding it easier and more profitable to work with his wife, with whom he was on the same page from the beginning.

As for actually working with pediatric dentists, well, Bock jokes that there are a lot more Care Bears and rainbows. “Pediatric dentists have to be able to relate to a 5-year-old kid and get [those children] to understand what they want them to do,” he points out. “If you kind of peel back that personality, most pedos are just big kids. So that’s the environment of your practice—and most orthodontists aren’t big kids. They’re more Type A, OCD. Sometimes that can be a friction in the pedo/ortho model. If you can’t sit back, relax, and chill a little bit with a pediatric dentist, then it’s hard to pull off. You have to figure out your personality when you want to start a group practice.”

And that’s if you can find a pediatric dentist with whom to partner. While the specialty is growing, there are only 7,163 pediatric dentists practicing in the United States as of 2015, according to the ADA Health Policy Institute’s study, “Supply of Dentists in the US: 2001-2015.” In addition, Bock contends that their salary requirements are higher than general dentists.

The Insurance Game

In April, the practice opened a satellite location with a specific agenda: to diversify the practice’s revenue and patient streams. While the gross household income within 3 miles of the practice’s main location in Lake Forest is $300,000, according to Bock, the new Round Lake Beach satellite office is in an area with a gross household income of $80,000. While still relatively high, the patient population is more dependent on insurance for orthodontic treatment.

As Bock sees it, insurance is going to be a major player in the years to come. Couple this with the fact that general and pediatric dentists are both doing more orthodontics, and fees are more likely to decrease, not increase over time. To get ahead of the curve, and to make sure his practice is in the game, the satellite office was opened to allow Bock and his wife to start capturing more of the insurance-based patient population.

In addition, Bock wanted to bring the same service associated with the Lake Forest brand to this community and make orthodontic treatment an easier prospect for this population. According to Bock, the satellite office possesses a higher-end, boutique style, with an emphasis on high-quality customer service that isn’t often seen in orthodontic practices in the area. In addition, by accepting insurance, the satellite office helps prospective patients overcome the sticker shock of orthodontic treatment. “People have benefits they want to use,” Bock says. “[Our goal] is to make insurance more customer friendly and easier. We want to remove barriers to get them to commit to treatment. By being in network with their insurance, in their minds, it’s easier.”

As Bock sees it, the future lies in combo specialties like pedo/ortho and insurance-based practice models. “The pedo/ortho model is all about controlling the patient base—controlling your referrals. And the insurance model is about decreasing barriers and getting more people started in orthodontic treatment.”

But the future of Bock’s practice doesn’t end with these models; he expects his practice to eventually transition to a multi-specialty model, adding general dental services. The goal is to create a family dental practice that captures the dental needs over the patient’s lifetime. “We have an aging pedo population that needs to go somewhere,” he says. Moreover, Bock can envision a time in which insurance will refuse to cover pediatric dentistry specialty fees, thus pushing families to seek treatment at family dental practices.

For Bock, the future of orthodontics is all about creativity and constant reinvention. “Just change your mindset from you can’t do that to people are doing it. Go out there and fight a different way instead of being sucked into the negativity that’s out there. We’re still growing [as a profession] and we still have successful practices. As long as you figure out a way to get patients through your door, no matter what your fee is or what type of patient it is, everybody is successful.” OP