Journal of International Oral Health

REVIEW ARTICLE
Year
: 2017  |  Volume : 9  |  Issue : 5  |  Page : 191--196

Current challenges in private practice


Treville Pereira 
 Department of Oral Pathology and Microbiology, DY Patil University, School of Dentistry, Navi Mumbai, Maharashtra, India

Correspondence Address:
Treville Pereira
Department of Oral Pathology and Microbiology, DY Patil University, School of Dentistry, Sector 7, Nerul, Navi Mumbai - 400 706, Maharashtra
India

Abstract

India is the second most populated country in the world with the largest democracy. Inspite of this, nearly 70% of the Indian population reside in villages. Hence, the demand and supply ratio of the availability of dentists is far inadequate and insufficient. We consider that the profession of dentistry is a noble one. Only after years of devotion toward the subject of dentistry does one obtain the graduate degree of Bachelor of Dental Surgery. Unfortunately, even after such painstaking efforts, the dental practice for graduates in India is grave. There are a lot of issues that are the main cause for this problem. Such a situation will lead to a negative effect on the integrity of the budding dentists as well as the trained dental workforce of the country. It is a known fact that the appropriate dental skills can prove to be beneficial in preventive dental care services to the public and aid in achieving the goal of universal oral health coverage. Now, we are nearing the second decade in a new century, and a new millennium. As part of these new beginnings, it is worthwhile to reassess the ability of dental workforce in India who are efficiently providing dental care to a population that is growing in size and diversity. We need a strategy that can be used on an ongoing basis and ensure that our nation maintains a workforce with the skills and cultural competence to provide the care that the nation demands. This article provides a review of the major issues facing dental practices today and how these challenges can be effectively tackled.



How to cite this article:
Pereira T. Current challenges in private practice.J Int Oral Health 2017;9:191-196


How to cite this URL:
Pereira T. Current challenges in private practice. J Int Oral Health [serial online] 2017 [cited 2018 Sep 25 ];9:191-196
Available from: http://www.jioh.org/text.asp?2017/9/5/191/216949


Full Text

 Introduction



The first dental college was opened in Calcutta nearly 100 years ago.[1],[2],[3] The first private dental college was established in 1966.[4] Out of the 310 dental colleges in the country, 292 are private colleges and only 40 are run by the government.[4],[5],[6] There is a steep rise in the number of dental colleges all over the country. This rise in dental colleges has led to a higher number of dental graduates.[6] Though this increase in the number of dental graduates is probably good for the overall oral health of the country, there is a growing number of dissatisfied dental graduates mainly because there are very low prospects of a job.[4] In 1970, there were only 8000 dental students who graduated from dental institutions in India; however, the figure was 180,000 in the year 2015.[6]

Dental disease is a noncommunicable disease. It is not life-threatening but does affect the quality of life. It is important to remember that “dental diseases are expensive to treat; however, simple to prevent.”[7]

 Demographics of India



India with a large democracy of over 1.251 billion people (estimate for May 2015), only next to China, is the 7th largest country in the world. More than a sixth of the world's population lives in India.[7]

This country has diverse ethnic groups, geographical characteristics, culture, religion, and languages. The sex ratio at birth is 1.12 male(s)/female(s). The average life expectancy of an individual is approximately 66 years. India has a literacy rate of 71%.

However, India has an astonishing demographic dividend, where more than 50% of its population is below the age of 25 and more than 65% is below the age of 35. It is expected that, by 2020, the average age of an Indian will be 29 years, compared to 37 for China and 48 for Japan. Approximately 70% of the population live in villages, and the remainder in towns and cities. Out of the 1.251 billion population, 646.38 million are male and 604.62 million are female.[8]

 Geographical Factors



Oral health has improved significantly over the years. However, this improvement has not been equal across all the population sections. Urban oral health population has shown a better improvement as compared to its rural counterparts. By and large, dentists are working in urban areas and those taking care of rural population are very few in number.[2],[3],[5],[9],[11],[12] According to the WHO guidelines, oral health-care services in rural parts of India are very limited. Moreover, there is a great variation on social parameters such as income and education seen in both these areas.[13] Studies conducted on the rural population of India have concluded that the treatment need of the population is very high and the services present are inadequate in most parts of the country.[13],[14],[15],[16]

The dentist population is more concentrated in the urban area which has led to a high competition among them. Furthermore, this competition has led to a number of social and behavioral issues in dentists, such as involvement in unscrupulous and corrupt practices. Besides, this level of competition can also take a toll on the mental and physical health of the dentists. It is very clear that there is an obvious imbalance between the demand and the supply of dental professionals. According to the WHO, ideal dentist–population ratio is 1:7500 [Figure 1]. In 2004, dentist–population ratio in India was 1:30,000. According to the World Health Statistics-2014, the ratio is 1:10,000.[4] In the year 2004, India had one dentist per 10,000 people in urban areas and one dentist per 1.5 lakh people in the rural areas.[17]{Figure 1}

Dental caries has a high prevalence while the provision for restorative treatment is quite inadequate in most parts of the country. A national survey conducted by the Dental Council of India to determine the prevalence of dental diseases in different states of India showed some alarming results. The prevalence of dental caries was 40%–80% with it being very high in northern states (85%–90%). Periodontal conditions usually increase with age and are found more in rural areas. The incidence of oral cancer and precancerous conditions is in the range of 3%–10% (highest being in Odisha, 7% [world's highest]).[18]

In the recent times, there have been a variety of factors which have enabled and encouraged dentists to move away from traditional forms of dental care delivery. Some of these include new clinical techniques, growing consumerism, and a much greater awareness of health-related issues in the public. A marked deregulation within the dental profession with the development of vocational training and the recently mandatory lifelong learning has only added to the woes of the dentists at large. The number of females in the dental profession has also increased with many young dentists voicing their reluctance to finance dental practices.[19]

Not long ago, India with its ever-increasing population had a handful of professionals such as engineers, doctors, lawyers, and those who were good had their hands full with projects, patients, and clients, respectively. Lately, the Indian educational sector has been growing rapidly with newer colleges, more degrees, and more options and is graduating lakhs of engineers, thousands of doctors and lawyers. This huge influx of graduates in the market is bound to bring about some major changes in the market.

The engineering degrees are luckily recognized outside the country and students can go out for higher education and those degrees obtained from outside are recognized in India. This has allowed those students to provide their services on a worldwide basis, hence we can have them working on foreign projects and for foreign companies.

The dental fraternity has not been as lucky. Their Indian degrees are not recognized in developed countries such as the USA and Singapore. This means that their education and services can be rendered only in India, thus limiting their market.

Hence, for a sustainable business, the dentists must be educated and make more patients aware about the dental treatments and its benefits. Without this, they will only be targeting the same base of patients, which will not be sufficient for rapid growth of the dental community.

 Dental Practices in India



In India, we have single-unit dental setups to the most modern lavish multi-chaired exotic dental clinics which may include dental spas which have the most modern equipment and gadgetries spread all over in cities and metros. On the other hand, we have roadside quack dentistry being practiced in the country too [Figure 2].{Figure 2}

 Major Issues Facing Dental Practices Today



As long as the economic conditions are still up in the air and the Gulf region oil spill is still undetermined, dental practices are most certainly in control. Below is a series of issues we commonly see in dental practices, and how to ensure that our practice will not be victimized by these issues.

Do not blame the economy

We are all affected by the economic downturn sometime or the other, but we should not let such trends be an excuse for not performing. Dentists should be in charge of their practices and help to educate patients on the importance of immediately addressing small dental issues, which, if left untreated, can turn into expensive health-threatening issues.

Look into consistency and continuity of staff members

Do we keep all our staff on the same pay role? Is the office atmosphere lowering the morale of the staff? We know that the dental office is generally a place that causes anxiety for some patients, so we must take positive steps to ensure that the office has a calm and peaceful environment. Patients are more likely to be at ease during their visit and willing to pay balances when they have a positive experience from the waiting room to the dental chair. The office productivity will definitely increase as the staff morale increases. If a dental team is fragmented, patients sense this.

Having an annual budget

Most dentists have heard of the term “budget,” but few have attempted to really prepare one. One can simply start by looking at the previous years' finances and use some key benchmarks to set some current goals. These goals should not just be prepared and kept in the cupboard. Nowadays, automated software programs are easily available which can be used to understand a practice's financial data.

Update the fee schedule

How often has a dentist updated the fee structure? If the dentist or his/her staff cannot seem to remember, then it is time to update the fee structure. Even a small change in the routine procedure can mean a significant progress. A strong financial policy with clearly accepted treatment plans can only benefit the practice.

Regular control of the cash flow and appointment schedule

Even in a highly successful practice with a good cash flow, things can go haywire. One has to watch out for patients paying 2–3 months late. One has to work with an accountant regarding the cash collection policy both during the boom time and during the lull phase of practice. Patients should be asked to make payments upfront. This ensures that they do not miss their scheduled appointment.[20]

 Reasons for the Current Crisis



A number of factors have led to the present crisis among the dental graduates. Some of these factors could be associated with a lack of interest in dental practice and of the lack of government jobs along with random distribution of dental colleges all over the country. Some other factors include a high competition in private practice, costly equipment along with lack of awareness about oral health in Indian public [Table 1].{Table 1}

For dentists still adapting to a health-care environment influx, the decision to become a salaried dentist with a larger group or hospital can be seen as one way to escape increasing administrative burdens or achieve a more satisfactory lifestyle.

 How Should One Tackle the Challenges in Private Practice



The dental profession has now begun to undergo some fundamental changes. The ever-increasing presence of dental management companies, i.e., “corporate dentistry” and the even more increase in the number of private practices are some of the issues facing young dentists who intend to enter private practice. So, what should a young dentist do? A successful dentist in private practice of the future will likely

Have a secure financial planningShould be savvy at marketingHave business and management sophistication.

Financial planning

A dentist who is a private practitioner will be financing the purchase of a practice and the purchase of a home along with facing increasing competition in the marketplace. In addition, there are other issues such as raising a family, saving for their children's education, saving and investing for retirement, and striving to maintain a comfortable lifestyle. Managing all that well and protecting it from loss requires a well-thought-out, realistic, and effective game plan.

Marketing savvy

First, we have to understand about corporate dentistry. Corporate dentistry generally comprises large organizations that are often managed by nonprofessional corporations and funded and controlled by private equity groups. They have sophisticated business models and large marketing budgets.

So, why should we be affected by corporate practice? Corporate dentistry has done a much better job than most solo practices in the way that they market and manage their offices. However, the solution requires attention to the local market conditions along with stepping up their game of messaging, promotion, and administration. In the future, private practitioners will have to employ more sophisticated marketing strategies to set themselves apart from corporate dentistry and attract patients.

We must know that dentistry is a highly personalized service, requiring the nurturing of relationships. The corporate profit-driven organization often does not support that. Therefore, as long as private practitioners focus on developing patient relationships, there will be a place in the market for them.

Business and management sophistication

Nowadays, private dental practice is evolving into more group practices. Medicine is always followed by dentistry. Although the economics work out to be somewhat different, the basic practice protocols are somewhat the same. With an increase in the governments' oversight through rules and regulations, with third parties squeezing harder, and with the cost of doing business going up, solo dental practice is going to have trouble managing these forces.

Group practice by its very nature requires a more complex and sophisticated business model than solo practice. Managing people, setting and monitoring performance goals, strategic planning, and marketing for a group practice require greater sophistication and the reliance on advice from business advisors.

India is a developing country, both economically and socially, and this will bring certain challenges to this profession. We have a mix of both urban and rural patients to cater to, and awareness is limited to a small section of the population. The influx of students per year in this career ensures that the majority of Indian metros and markets are getting increasingly saturated by every passing month. Another factor to be considered is the experience you have in this profession – there is a general notion in India that age brings wisdom and this creates a lot of hindrance to a young dentist.[21]

What can one do to overcome these challenges?

Since we live in such a hugely populated country, one should look into practicing in the rural side. Younger dentists assume that, by practicing in rural areas, one cannot get big clients, but they will definitely develop a steady and busy practice. One's personality, attitude, tongue, and skills matter more. It is said that “Give a man his perfect dentures, and he will idolize and cite you forever-take away a tooth pain, and you will win instant admiration of a lifetime”Again, it is unfair to assume that success will come imminently. No one in the armed forces becomes an overnight general, no one in politics becomes the overnight prime minister, and no one in trading becomes overnight opulent, it takes time and dedication to earn a name, and this stands true for any occupation, profession, and career. We are no exceptions. Practice makes one perfect, and in that perfection, you will find your epithetThis is regarding the expectation that our professional seniors and peers will be recommending and supporting our juvenile practice. Unfortunately, the market does not work like that. We are as much a competitor to their share of wealth and prosperity, as much as they are to ours. For sure, there are occasional aristocratic and virtuous kinds who will bother to take pity over us and will majestically stimulate or boost our career, but they are like miracles that seldom happen and not necessarily with everyoneThe fantasist and the dreamers should upgrade their career constantly – follow an master, he/she teach you things and tricks that are far beyond the innate capabilities of a bachelor. Getting there is difficult, and not always financially compatible, but we should choose our dreams wisely. There are general stores as well as shopping malls if you get my point here. Dentistry is not abnormal and nothing is wrong in this profession, there are simply no rules. You do not enter dentistry expecting the world to be supportive and nice, or expecting people to make a beeline for you and shower you with countless prosperity which you always dreamt. It is as tough as every single profession is, and to excel here, you need a combination of luck, dedication, and finance. Make wise choices according to your capabilities. Dental practice in India has its own challenges, right from government rules to dishonorable practices to quack dentists and con-artistsOne should not be bothered by the disrespectful attitude shown to us by other members of the medical fraternity. Indians live in a hierarchical order; every profession is ranked here, so nothing should be taken personally. Accept it as a bitter truth. And, this segmentation is everywhere, in every fraternity – a neurosurgeon will not look into a general physician with much grace and nobility, a general physician will not look into a dental surgeon with the same grace, a dental surgeon will not look into their less fortunate and ranked medical professionals with benevolent eyes, and so on – this phenomenon happens in every profession. Hell, even our ruling party looks into the opposition as a pitiful disgrace. The point is, we are too miniscule as individuals to control minds and individual thoughts because we will not live forever, so we should take those things that suit us bestFinally, India is seeing an economic boom, the situation is far better than before, awareness is on the rise, so be pragmatic. People have money and do not mind spending it on their dental upliftment. It is just that they chose someone else to do that job. The reality it brings is harsh, but aspire to be that someone else someday.[20] India is called the “oral cancer capital” of the world attributed to its high intake of both smoked and smokeless tobacco products, strongly associated with oral neoplasms. Most of these highly prevalent oral diseases are largely preventable as they share common risk factors (tobacco, alcohol, and unhealthy diet) with other life-threatening chronic diseases which can be reduced through various health promotion and preventive measures. The expected rise in burden of oral diseases will pose a massive challenge to the health system. The demand for equitable distribution of oral health hence indicates the need to reflect on effective preventive strategies adopted in other countries. A comprehensive dental workforce with appropriate skill mix is one such strategy adopted to address these issues.[21],[22],[23],[24] The new challenges of saturation and inadequate employment are coming up, but they are not confined to dentistry alone, every single professional out there, irrespective of his/her field, is facing the same bitterness, with a fast dwindling pay check, or worse, none at all. It does not matter how and where you work, just focus and be dedicated, do not lose hope so easily, make a way for yourself. If you want it, you will get it. Countless dentists and specialists are making their way, some have made it, some are fast making it, and some have started making it. Adapt.!![20]

So, in the words of Reisinger, “Know who you are and what you're good at. That will help you target the right clientele and start a successful relationship with that base. Represent yourself professionally and work hard. It's definitely not easy to develop and maintain your own practice, but the hard work does pay off.”[25]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Database of Dental Council of India. Available from: http://www.dciIndia.org/search.aspx. [Last accessed on 2016 Sep 10].
2Vundavalli S. Dental manpower planning in India: Current scenario and future projections for the year 2020. Int Dent J 2014;64:62-7.
3Jaiswal AK, Srinivas P, Suresh S. Dental manpower in India: Changing trends since 1920. Int Dent J 2014;64:213-8.
4Dagli N, Dagli R. Increasing unemployment among Indian dental graduates-High time to control dental manpower. J Int Oral Health 2015;7:i-ii.
5Mathur MR, Singh A, Watt R. Addressing inequalities in oral health in India: Need for skill mix in the dental workforce. J Family Med Prim Care 2015;4:200-2.
6Jain H, Agarwal A. Current scenario and crisis facing dental college graduates in India. J Clin Diagn Res 2012;3824:1892.
7Demographics of India. From Wikipedia, the Free Encyclopedia. Available from: htttp://www.google.com. [Last accessed on 2016 Jul 30].
8CIA World Factbook Demographic Statistics. Demographics. Available from: https://www.cia.gov/library/publications/the-world fact book/geos/in.html. [Last accessed on 2016 Aug 18].
9Elangovan S, Allareddy V, Singh F, Taneja P, Karimbux N. Indian dental education in the new millennium: Challenges and opportunities. J Dent Educ 2010;74:1011-6.
10Halappa M, Naveen BH, Kumar S, Sreenivasa H. SWOT analysis of dental health workforce in India: A dental alarm. J Clin Diagn Res 2014;8:Ze03-5.
11Rao KD, Ryan M, Shroff Z, Vujicic M, Ramani S, Berman P, et al. Rural clinician scarcity and job preferences of doctors and nurses in India: A discrete choice experiment. PLoS One 2013;8:e82984.
12Singh A, Purohit BM. Addressing oral health disparities, inequity in access and workforce issues in a developing country. Int Dent J 2013;63:225-9.
13Vashisth S, Gupta N, Bansal M, Rao NC. Utilization of services rendered in dental outreach programs in rural areas of Haryana. Contemp Clin Dent 2012;3 Suppl 2:S164-6.
14Agarwal V, Khatri M, Singh G, Gupta G, Marya CM, Kumar V. Prevalence of periodontal diseases in India. J Oral Health Comm Dent 2010;4:7-16.
15Bali RK, Mathur VB, Talwar PP, Chanana HB. National Oral Health Survey and Fluoride Mapping; 2002-2003. India, Dental Council of India, New Delhi; 2004. p. 16-7.
16Bhat M. Oral health status and treatment needs of a rural Indian fishing community. West Indian Med J 2008;57:414-7.
17Tandon S. Challenges to the oral health workforce in India. J Dent Educ 2004;68:28-33.
18Shan N, Pandey R, Duggal R, Mathur U.P, Kumar R. Oral Health Survey in India: A report of multicentric study, WHO – Oral Health Survey; 2004.
19Newsome PR. Current issues in dental practice management. Part 1. The importance of shared values. Prim Dent Care 2003;10:37-9.
20Metsky KI, Cooperman C. Issues Facing Dental Practices Today. Available from: http://www.dentistryiq.com. [Last accessed on 2016 Sep 16].
21Monse B, Benzian H, Naliponguit E, Belizario V, Schratz A, van Palenstein Helderman W, et al. The fit for school health outcome study-A longitudinal survey to assess health impacts of an integrated school health programme in the Philippines. BMC Public Health 2013;13:256.
22Nakre PD, HarikIran AG. Effectiveness of oral health education programs: A systematic review. J Int Soc Prev Community Dent 2013;3:103-15.
23Gallagher JE, Lim Z, Harper PR. Workforce skill mix: Modelling the potential for dental therapists in state-funded primary dental care. Int Dent J 2013;63:57-64.
24Wanyonyi KL, Radford DR, Gallagher JE. Dental skill mix: A cross-sectional analysis of delegation practices between dental and dental hygiene-therapy students involved in team training in the South of England. Hum Resour Health 2014;12:65.
25Challenges in Dental Practice. Available from: http://www.dentalentrepreneur.com. [Last accessed 2016 Aug 20].