Overview of Some Significant Dental Benefit Industry Trends

1. Overview of Some Significant Dental Benefit Industry Trends Paul Manos, DDS Dental Director United Concordia Dental Plans of California, Inc.

2. Why Do We Care? • What happens in dentistry impacts: • Cost of care • Access to care • What materials and techniques will be benefited • What public relations/health issues we must address • What the public can afford to purchase • What disease interventions are available • What questions will be included in RFPs • What enhancements/additions groups will request

3. What Is Happening in Dentistry Today That Affects (or will affect) Dental Benefits?

4. Dental 101: The Foundation of Dental Diseases Two main primary dental diseases: • Caries (tooth decay) • Periodontal (gum) disease • Both diseases are infectious and communicable

5. Dental Technology • Implants • Adhesion/Cosmetic Dentistry • CAD/CAM • Lasers • Nanotechnology and Biologic Warfare • Stem Cells • Caries Management

6. Implants • Becoming the standard of care for single tooth replacement • Multiple applications other than single tooth replacement • Case selection and longevity • Maintenance • Cost

7. Implants • Three parts • Implant body • Implant abutment or post • Restoration • Types of Surgical Placement • Endosteal vs.Periosteal (Eposteal) vs. Transosteal vs. Mini-implants • Multiple Surgeries vs. single surgery

12. Adhesion and Cosmetic Dentistry • “Adhesion” used to describe a restoration or other device bonded to the tooth • Major focus in clinical dentistry today • Is used with: • Cosmetic dentistry • Restorative dentistry • Orthodontics • Frequently coupled with other technologies, such as air abrasion

18. Reversible vs. Irreversible • Reversible treatment • Bleaching • Veneers with no tooth preparation • Irreversible treatment • Veneers with tooth preparation • Fillings • Crowns, inlays and onlays

20. Preventive Crowns?

22. CAD/CAM • Computer Assisted Design / Computer Assisted Manufacturing • Used for one-visit crowns, inlays and onlays • Restoration milled from ceramic material after digital impression and computer design • Expensive, cosmetic and convenient

24. Lasers • Can be used for multiple purposes, including surgery, disinfection, bleaching, drilling(?) • One of several “tools” that a dentist can use under the right conditions • Frequently promoted as higher quality or used for practice marketing

25. Nanotechnology • Involves problem solving or treatment at the molecular level • Some chemicals have different properties on the nanoscale • Knocking on the door of science fiction • Research showing promise with certain dental treatments

27. Dental Applications of Nanotechnology • Fillings with cavity fighting properties • Implants with better integration into bone • Specific disease treatments

28. Biologic Warfare and Targeted Antimicrobials (STAMP™) • Caries (tooth decay) and periodontal (gum) disease are infectious, each caused by several different and specific bacteria • The mouth is teaming with both good and bad bacteria (Billions of bacteria, 600-1000 different species) • Antibiotics kill all susceptible bacteria, both good and bad • Through genetic engineering and nanotechnology, the bad bacteria can be specifically targeted, leaving the good bacteria unharmed • Possibility of developing vaccines

30. Dedrimers attaching to HIV Cells preventing infection, VivaGel, July 26, 2007

31. Stem Cells • What is a stem cell? • Controversial – embryonic stem cells • Can be used to grow teeth for tooth replacement with the patient’s “own” teeth • Theoretically, other tissues like gums and bone can be grown • Still in research phase

32. February 2007: Tokyo University of Science researchers report successful transplant of a bioengineered tooth into a mouse – Credit: Takashi Tsuji

33. Publications and Announcements • Scientists Find Genes That Grow Teeth – University of Rochester – 2-26-09 • Gene Could Allow Lab Growth of Teeth – Oregon State University – 2-27-09 • Genes That Allow Teeth to Grow in a Row – University of Southern California – 2-26-09 • Gene Therapy Promising for Growing Tooth-Supporting Bone – University of Michigan – 2-2-09

34. Caries Management • High quality dentistry, but not very exciting for most dentists – why? • Caries Risk Assessment • Prevention • Diet • Hygiene • Reversal • Restoration

36. Dental Treatment Trends • Whatever is new and exciting! • Whatever generates profits! • Does high price = quality?

37. Excerpts from Dental Trade Publications April 10, 2007 My Prediction: Future Dentists Will Be Rich, Important, and Well-Loved Editorial Dentist triples production with help from ADA Intelligent Dental Marketing Posted Jan. 23, 2008 PATIENTS, PROFITS & POWER: FINALLY-THE DENTAL PRACTICE YOU HOPED TO HAVE

38. $90K in Production from One Patient"My practice has noticed that more and more of our patients are coming through our WWW website. In fact, my office manager reported that our largest case this year reached over $90K in production. This patient requested an appointment online on our WWW website and came in as a sedation and implant case," writes Dr. XXX of Southlake, Texas.Dentist Rakes in an Extra $180K Annually"Three to four new patients a month, best month eight new patients, best patient $25,000 profit for cosmetics - the WWW [website] accounts for a 10% increase in business per month, or $180,000 per year." writes Dr. YYY of Chattanooga, Tennessee.Do You Like $22K Patients?"Three to four new patients a month, best patient $22,000 profit for sedation," writes Dr. ZZZ of Lexington, Kentucky.

39. Ever wonder why you lose treatment between the operatory and the front desk? (Email Ad to Dentists, March 1, 2009) • The patient seemed ready to go but when you checked with your admin team later that day, the patient walked out without an appointment. • The handoff may be the most important step in the enrollment process. In fact, some teams are now skipping this step all together by handling finances and scheduling in the op. • Whether your [sic] a doctor or hygienist, here are a few tips to make the handoff a success: • Physically walk the patient to the front desk • Share the patient's problem, the doctor's treatment plan and the level of urgency of treatment directly with your admin team • Be sure the patient hears this interaction

40. Treatment Trends – Amalgam vs. Composite Resin • Separating fact from fiction: The controversy • Amalgam is the most thoroughly researched and tested material in use • The mercury in amalgam is bound to other components • Composites contain formaldehyde and Bis-Phenol A, known carcinogens • Composites cost significantly more and last only a fraction of the time • There would be no controversy if amalgam was tooth-colored and composite was grey or black • Amalgam is accepted by the ADA, FDA, NIH, USPHS, CDC and WHO

41. What Industry Trends Are Happening That Affect Dental Benefits Today?

42. Evidence Based Dentistry (EBD) • The new “buzz” with organized dentistry and insurance industry • EBD consists of the conscientious, explicit and judicious use of current best evidence in making decisions about the care of patients. The practice of EBD means integrating individual expertise with the best external clinical evidence from systematic research. (Adapted from Sackett, et al., Evidence Based Medicine, 2000)

43. Evidence Based Dentistry (EBD) • The American Dental Association defines EBD as: “… an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient's oral and medical condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences. [emphasis added]

44. Current Applications of EBD • FDA guidelines on x-rays • ADA guidelines on fluorides and sealants • Development of a “saliva panel” • Caries and periodontal disease • Breast and pancreatic cancers? • Development of Rx-directed prevention • Medical-Dental Interface

45. Medical-Dental Interface: Oral Health Affects Systemic Health • Dental caries (cavities) and periodontal disease are infectious and communicable diseases • Evidence exists that poor oral health may impact general health • Moderate to severe periodontal disease is a factor in: • Cardiovascular disease • Stroke • Low birth weight babies • Respiratory infections • Diabetes • Osteoporosis • Tongue cancer 8

46. Medical-Dental Interface: What Are the Oral-Systemic Connections? • Inflammation • C-reactive proteins • Is the relationship causative or co-morbid? In other words, does one cause the other or are both caused by something else?

47. Population Growth and Demographic Trends

48. Total U.S. Population, 2000-2050 Millions Source: ADA

49. Absolute Population Growth by State: 2000-2025 Bureau of the Census: Projections

50. Projected Percentage Growth of U.S. Population Age 65 and Over • In 2000, 12.4 percent of the U.S. population was age 65+. • People ages 65 and over will increase to 16 percent of the population by 2020, and to 21 percent in 2050. 25.00% 21% 20.00% 16% 15.00% Percent 12.40% 10.00% 5.00% 0.00% 2000 2020 2050 Year Source: U.S. Census Bureau