Orthodontics is a changing specialty within a changing profession. Over the last 10 years the world of orthodontics has undergone several key factors that will permanently alter how orthodontic practices function, provide care, acquire referrals, and start patients. Practices that ignore these factors and continue to operate the way they have in the past will eventually find it more challenging than ever before to maintain orthodontic practice production and success.

The New World of Orthodontics – TRENDS

The following emerging trends are creating change in orthodontics.

  • Expansion of DSOs. DSOs, also referred to as corporate dentistry, have been expanding since 2008. According to the Levin Group Data Center, DSO growth will continue for many years into the future, adding orthodontic services and orthodontists to their corporate groups.

  • Dental insurance carriers lowering all reimbursements to the PPO level. This means that in the next few years orthodontic insurance will not grow significantly or keep up with basic inflation. In fact, it may decline and lose pace with new treatment methodologies due to higher laboratory costs and increasing orthodontic practice overhead.

  • More dentists. The increase in dentists can be attributed to the emergence of almost 20 new dental schools opening since 2004, dental schools expanding their class sizes, and dentists practicing 10 years longer and extending the length of their careers by almost 25%. This oversupply of dentists has created intense competition among general practices, forcing general dentists to seek ways to increase practice production and revenue. One area where dentists have discovered new opportunity is in aligner orthodontics. In the last 12 months, general practices have increased the number of aligner cases, although still a minority of the total cases, by 24%.

  • Direct-to-consumer orthodontics. Direct-to-consumer orthodontics, often referred to as DIY ortho, has rapidly increased its national profile. At the time of the writing of this whitepaper one major direct-to-consumer company has signed an agreement with a national drugstore chain to open 1,000 aligner dentistry mini-stores across the United States. There are also several other national companies emerging and receiving significant capital infusion. While there is great debate as to what the future will be for direct-to-consumer orthodontic companies, they are now doubling the number of cases performed annually. According to the Levin Group Data Center, approximately 50% of the direct-to-consumer patients are additive (meaning that they would not have gone to an orthodontic practice for treatment) but that 50% are cannibalized (meaning that they would have visited an orthodontic practice in the past for their treatment.) It is also notable that direct-to-consumer companies have significantly lower fees than the average orthodontic practice case. This may begin to impact the general public perception of acceptable fees in the future.

The New World of Orthodontists – RESULTS

The trends listed above are resulting in significant change in the orthodontic profession including:

  • Increased competition. There’s no question that orthodontic practices, which traditionally had a strong flow of new patients on an annual basis will be under much higher competitive pressure than ever before for the acquisition and closing of new patients.

  • Slower orthodontic practice growth. In the past, over 94% of orthodontic practices grew every year in production. Today, 50% of orthodontic practices will either not grow, remain relatively flat, or be in a state of gradual decline. The other 50% will experience a range from slow to highly accelerated growth.

  • Fewer referrals per referral source. The availability of orthodontic patients is decreasing due to the previously mentioned aspects of general dentists providing more aligner orthodontics and direct-to-consumer orthodontics. According to the Levin Group Data Center and the 2019 Dental Economics/Levin Group annual practice survey, 90% of all orthodontic cases in general practices use aligner treatment. It will become imperative that orthodontic practices focus on scheduling every new potential patient caller and closing a higher percentage of potential orthodontic new patients. More than ever before, practices will depend on the skill, technique, and scripting of the orthodontic treatment coordinator (TC).

  • Increased shopping. Parents have always shopped around for orthodontic practices, mainly to compare costs. However, according to the Levin Group Data Center, the average parent now shops 2.1 practices and this trend has been slowly increasing over the last 10 years. We believe that it will increase further as parents see more national advertising of lower direct-to consumer fees and payment plans.

  • New training for all staff positions. Unfortunately, 96% of orthodontic office managers have no management background, 98% of orthodontic treatment coordinators have no sales background, and 92% of orthodontic front desk staff have no administrative background. In the past this was not relevant because the number of new patients and current patients accepting treatment was consistently high. However, in this more competitive era of orthodontics, the ability of each team member to function optimally in each position will be an essential element of practice production and practice success. Orthodontic practices looking to be in the top tier of orthodontic practice must provide ongoing training for all orthodontic staff in the newest, most up-to-date methodologies.

Two Keys to Sustaining a Successful Orthodontic Practice

Increased competition will require orthodontic practices to become more strategic. There are two key areas that will contribute to the success of an orthodontic practice: marketing strategies to increase referrals and management systems to increase production. A thorough understanding and effective implementation of these key areas will lead to referrals, production, and a great orthodontic team.

  1. Marketing to increase referrals

    A marketing program in today’s orthodontic practice must include Five Focus Areas in order to maximize success. Levin Group has identified these areas as:

    • The Branded Patient Rewards and Referral Program
    • The Patient Ambassador Program
    • The Social Media Interface
    • The Referring Doctor Driver Program
    • The Full Awareness Community Program

    In the past, more successful practices focused on the combination of patient and referring doctor referrals to create outstanding and high production orthodontic practices. Today, marketing must span the five areas listed above in order for practices to compete effectively. Of course, patients and referring doctors will continue to be a great source for referrals. The better these referral relationships are, the higher the referral production tends to be. Practices should use social media to as a method of communication, outreach, and penetration to patients and referring offices. And finally, practices must never forget about the community right outside their door. Orthodontic practices should always be involved in their community’s schools, organizations, sports teams etc.

    Keep in mind that each of the five areas needs a minimum of 10–12 strategies that work simultaneously to create the right quantity of marketing to stimulate patients or referring practices to send referrals. When the number of strategies is correctly targeted and strategies are selected based on relevance and relationship building, orthodontic practices will enjoy a steady and growing stream of referrals.

    Practices must apply these five strategies together synergistically to get the right result. Practices that engage only in one or two areas may find themselves in the lower two tiers of orthodontic practices, struggling to create production and profitability.

  2. Management systems to increase referrals

    The key to orthodontic management success is implementing proven, documented systems that become the foundation for training the orthodontic team. As the team learns the systems and carries them out, it will help raise them to the highest level of skill and effectiveness available today. Practices that have these systems often move into the top 10% of orthodontic practices measured by production. Examples of systems would include concepts such as:

    • Production block scheduling. Each day should be mathematically calculated to achieve a production goal. You are probably used to the concept of scheduling starts and de-bonds in the morning and high-volume checks in the afternoon since parents want children to come after school. This is a workable concept but does not account for every 10-minute increment for every chair in the practice. When schedules are set up based on production block scheduling, we often see an immediate production increase of 11 – 12% assuming a reasonable flow of new patients.

    • Overdue de-bonds. Every overdue de-bond case now represents 100% overhead and 0% profit. Systems and concepts such as the Levin Group one-day rule, where any patient who is one day overdue is automatically contacted that day, is a critical system to reduce overdue debonds to the recommended 2% or less. Anything over 2% for overdue de-bonds represents in efficiency and effectiveness in practice systems and literally eats profit along the way. If the patient is not contacted and scheduled, then the one-day rule system is followed by a nineweek follow-up process where the average response time for the patient to schedule the next appointment is 2.2 weeks. The data is clear that the system works and will reduce overdo debonds to under 2% in approximately 90 days.

    • No-shows and cancellations. No-shows and last-minute cancellations directly increase overdue de-bonds, which in turn increases overhead and reduces patient satisfaction. Nobody likes to be in braces longer than originally anticipated. In working to reduce no-shows and last-minute cancellations use a system that requires calling the patient immediately after a missed appointment to explain that missed appointments can result in long delays in removing braces. The second time the orthodontic patient misses an appointment inform them that there is a significant fee for a missed appointment but that your office will not charge them this time. The third time and orthodontic patient misses an appointment put them in the category of a habitual offender and moves them into a long delay for de-bond. We recommend that you facilitate a “de-bond conference” explaining that treatment may have to be completely stopped until the child or, in rare cases the adult, are able to keep appointments.

    • The treatment coordinator sales process. The treatment coordinator (TC) is one of the most critical positions in an orthodontic practice because it is the sales position. As the brilliant management guru Peter Drucker once said, “Nothing happens until someone sells something.” This is certainly true for orthodontic practices. The reality is that 98% of TCs have no previous sales experience. While this may not have affected the practice in the past, today’s treatment coordinator must have continual training. Patient buying habits are constantly changing and TC’s must be able to explain to parents why they should make the investment for their child’s treatment in their practice. It’s no easy feat to explain why an orthodontic practice should command a fee of $5,000 or $6,000, while a direct-to-consumer product commands a fee of under $2,000. Especially when the goal is to close 90% of consults. Top practices invest heavily in training their TCs and measure results daily, weekly, and monthly as missed targets offer opportunities to identify methodologies for improvement. Orthodontic practices today simply cannot afford sale slumps.

    • The observation program. It is no longer a guarantee that your observation program participants will automatically accept treatment from your office. This is why we recommend that the observation program be completely overhauled. Observation participants should be treated as if they are already part of your orthodontic family. This means having six-month appointments, following up on missed appointments or last-minute cancellations, advising parents on how long their child’s treatment will be, and including them in the internal patient marketing. We’ve seen practices close 98% of their observation patients using this system.

Other key management systems include the new patient call, the new patient orientation, the patient confirmation process, Five Star customer service, overhead control, ordering and inventory, managing dental insurance, and follow-up systems for new patients.


The changing world of orthodontics has ushered in new competitive challenges and if orthodontic practices want to survive, and also thrive, they must change with it. Understanding the new trends and combating the results with comprehensive marketing programs and management systems, offer a clear and promising path forward.

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Levin Group

Levin Group is the leading ortho practice management and marketing consulting firm in dentistry. Their mission is to improve the lives of dentists.