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AI-Driven Growth of DSOs

DENTAL
ARTIFICIAL
INTELLIGENCE

T
he dental practice landscape has changed substan- Practice Analysis and Affiliation
tially over the past two decades, as a consolidation DSOs have built a powerful value proposition to support dental
of solo practices has resulted in increased numbers practices, and a key way in which DSOs expand is through practice
of multi-location group practices, with significant affiliation.2 In December 2019, Heartland Dental became the first
growth coming from the administrative support of DSO in the United States to pass the 1,000 supported office mark.3
Dental Support Organizations (DSOs). The concept of the DSO Smile Brands has more than 650 affiliated dental offices, and North
originated in the early 1990s, with a new business model that sought American Dental Group (NADG) is currently at 245 practices and
to handle the nonclinical operations of a dental practice to allow continuing to grow. The way in which a DSO assesses the risk, value,
clinicians to focus on what they do best-dentistry. DSOs would and potential of each practice affiliation is dependent on many pro-
contract with a dental practice to provide the necessary business prietary factors; however, prior treatment norms can be critical.4
management support that was previously borne by the practice Traditionally, in the context of prospective affiliations, DSOs
owner. Additionally, by supporting multiple practices, DSOs could take a small sample of patient charts to understand the existing
better negotiate equipment costs, manage insurance reimburse- standard of care and other attributes of the patient population.
ments, and roll out technology. This model caught on in a short Dental AI unlocks the ability to complete this review in detail for
period of time, with many dentists flocking to these partnerships.1 every patient of the practice and provide detailed data to support
DSOs have been at the forefront of adopting technology that clinical and business decisions on an affiliation. Understanding the
demonstrates value-add to their businesses. Hence, DSOs have scope of dentistry by the legacy dental team can greatly help shape
been quick to identify artificial intelligence (AI) as a transformative future conversations, assess risks, and identify opportunities before
means to support their business and clinical processes to benefit an affiliation is finalized. Moreover, after an affiliation, practice-
patient care. Specifically, AI can unlock clinical insights to inform and patient-level insights can inform a clinical and operational
practice affiliation and post-affiliation onboarding. Next, it can help onboarding plan, which can be monitored centrally through prac-
support a standard of care across practices for compliance. And fi- tice reports automatically generated by AI algorithms and analytics.
nally, AI technology can improve practice performance through the To solidify this point, consider that every radiograph, both his-
use of visualization tools to support dentists with patient treatment toric and recent, can be analyzed during due diligence to identify
discussions and professional development of associates. important clinical, business, and patient factors that influence

Christopher Seth A. Anas Athar, DDS, Frank Nia, Mitchell Olan, BS Matthew Zubiller
M. Balaban, Gibree, DMD MS, MSD DMD, MSEd Executive Chairman, Chief Growth Officer,
DMD, MSc Senior Director of Private Practice, Chief Clinical Officer, Dental Care Alliance, Smile Brands Inc.,
Clinical Advocacy, Dallas, Texas North American Dental Sarasota, Florida San Diego, California
Clinical Director,
Overjet, Inc.; Clinical Heartland Dental, LLC, Group, Professional
Faculty, Boston Atlanta, Georgia; Fellow, Dental Alliance,
University Goldman Academy of General Atlanta, Georgia
School of Dental Dentistry
Medicine; Private
Practice, Boston,
Massachusetts

2 compendium March 2021 Volume 42, Number 3

 the affiliation decision. For example, these factors could include
the following:
• the percentage of edentulous spaces that exist in the current pa-
tient pool, indicating a potential for implants and hard- and soft-
tissue grafting (See Figure 1 for an example.)
• the proportion of Class 2 and Class 3 carious lesions that have
yet to be treated (Figure 2 and Figure 3 show examples of this AI-
powered analysis.)
• the periodontal health of the practice (See Figure 4 for an example
of an AI-powered analysis.)
• the proportion of existing crowns and restorations that have re-
current decay, and how old they are (Figure 2 and Figure 5 show AI Fig 1.
analyses examples.)
• the proportion of posterior teeth that contain amalgam restora- Fig 1. AI automated detection of edentulous areas is shown.
tions encompassing 50% or more of the coronal area, and the age Here, the absence of tooth No. 30 is recognized and document-
ed, allowing for insight into the percentage of edentulous spaces
of these restorations 
that exist in the current patient pool. (Source: Overjet, Inc.)
As dental AI proliferates and increases quantification of the clinic,
practice brokerage firms may themselves release detailed, standard-
ized data extracts powered by their artificial intelligence vendors to Undoubtedly, the deeper quantification of practice data will im-
potential partners or acquirers. An example of this concept can be pact the strategy, valuation, and operational integration of DSO
found in the automotive sales market. The Carfax® report and simi- practice supported affiliations.
lar data reports have emerged as a standard document exchanged
between buyers and sellers to establish a shared fact base on the Comprehensive Chart Review
accidents, service history, and potential valuation of a vehicle. In the Assessing compliance, risk, and utilization becomes increasingly
future, the dental industry may have its own AI-powered standard- important as an organization grows. As the number of supported
ized reports on the clinical, business, and patient data for a practice. offices increases, the ability to provide supported dentists with data
to review and understand their standard of care becomes crucial
as the liabilities of not doing so can grow.
Improvements in AI analytics allow an organization to better un-
derstand the pulse of a dental practice. DSOs can provide supported
doctors with tools to track metrics and answer questions such as
whether all patients are in compliance with updated medical histo-
ries, what proportion of patients in the practice/organization have
Wardah Inam, Ryan Kennedy, Robert A. perio charting or outdated charting, and what part of the patient
PhD, SM MBA, MPP Faiella, DMD, pool is without radiographs or hasn’t had updated radiographs
Chief Executive Officer, Chief of Staff,
MMSc, MBA within 18 months. AI practice support can not only allow these
Overjet, Inc., Overjet, Inc., Chief Dental Officer,
Boston, Massachusetts
questions to be answered and tracked, but also create alerts to help
Boston, Massachusetts Overjet, Inc., Boston,
Massachusetts; the supported dentist understand missing outstanding information,
Diplomate, American which helps reinforce best practices within the supported office.
Board of Periodontology; In addition to tracking clinical protocol metrics, having the abil-
Private Practice,
Osterville, ity to automatically quantify and track treatment outcomes can
Massachusetts help support higher levels of care.5 For DSOs striving to provide

www.compendiumlive.com March 2021 compendium 3

DENTAL ARTIFICIAL INTELLIGENCE | Transforming Dentistry

the best data and information to supported dentists, AI analytics the specific business and clinical objectives of each practice. Tactics
help the dentists identify areas to improve consistency and quality.6 for operationalizing these metrics include dashboards displayed
For example, AI algorithms can review radiographs and assess the around the office, weekly email reports, provider-specific scorecards/
quality of obturation for root canal therapy teeth or marginal seal on dashboards, morning huddle dashboards, and end-of-day reports.
cemented crowns.7 By being able to quantify the quality of treatment
performed, AI can assist in identifying areas for targeted continu- Clinical Performance Enhancement
ing education courses to help improve patient care and outcomes. As dentists graduate from dental school, they typically look for a
Many businesses and healthcare organizations have embraced practice that incorporates the latest in dental technology, high stan-
the concept of dashboards to display key performance indicators. dards of patient care, and a consistent patient flow. By having the
Frequently, large television screens are mounted around the work business acumen and financial means to invest in advanced tech-
area to display metrics in real-time and reinforce organizational pri- nologies across the entirety of its organizations, the DSO-supported
orities. With the advent of dental AI, these dashboards in the dental model is increasingly attracting dentists. Whether a young graduate
clinic can move beyond traditional business metrics and now encom- or transitioning owner, a provider can feel supported to offer the
pass oral health objectives and outcomes. For example, among the highest quality of care to their patients. Most students who have
current week’s regular hygiene appointments, how many patients ap- recently graduated have had some exposure to digital technologies,
pear to have untreated periodontitis and how many of these patients whether through 3D-printed models, CAD/CAM, or guided implant
has the practice scheduled for an appropriate follow-up treatment? surgery.8 Soon, dental AI is likely to be added to the technology cur-
Change management is difficult for any organization. For DSOs riculum that dental students study. Graduates rightfully expect that
looking for ways to provide data to supported dentists so they can their exposure to and utilization of technologies does not get left
add value to their affiliated practices, AI software can provide new behind after dental school and that these technologies will be part
tools, rich with clinical and business insights and configurable for of the office workflow where they will be employed.

Fig 2. Fig 3.

Fig 4. Fig 5.

Fig 2. Class 3 carious lesion detection by machine learning algorithms trained to specifically detect both primary and secondary
decay on anterior teeth is shown. In the image on the right, recurrent decay can be seen in red on the mesial of teeth Nos. 7 and
9, with primary decay detected on the distal of No. 7. (Source: Overjet, Inc.) Fig 3. The following image illustrates periodontal in-
sights from AI radiographic assessment. Bone levels marked in red indicate potential areas of radiographic bone loss as measured
from the CEJ to crest of bone. Calculus is detected automatically and highlighted with the orange box. In addition to perio chart-
ing, the “periodontal health” of a practice can now be assessed and quantified. (Source: Overjet, Inc.) Fig 4. Detection of defec-
tive margins around prosthetic restorative materials is shown. In the image on the right, defective margins are identified in red on
teeth Nos. 7 (ceramo-metallic crown) and 9 (ceramo-metallic crown). (Source: Overjet, Inc.) Fig 5. Class 2 caries detection on a
posterior radiograph is shown. In the image on the right, the carious lesion is masked in yellow on tooth No. 19. Additional tooth
numbering AI models and bone level models are also being run and results displayed in this image. (Source: Overjet, Inc.)

4 compendium March 2021 Volume 42, Number 3

 Through a more thorough and complete understanding of a pa-
tient’s oral health, artificial intelligence allows for better treatment
planning, patient understanding, and clinical output. Machine learn-
ing algorithms can, for example, detect and visually identify caries,
periodontal disease, and compromised restorative margins (Figure
6). In the operatory, this visualization feature can serve two purposes.
First, it helps reinforce previous training for newer dentists leaving
the academic setting and acclimating to the busy rhythm of active
practice. Second, visualizations support effective communication by
dentists who must explain their diagnoses and receive patient con-
sent for the recommended treatment plan. DSOs can know they are
equipping their affiliated dentists with the latest software to support
Fig 6.
diagnoses founded in evidence-based science and optimal communi-
cation in the operatory. Patients receive the right recommendation
at the right time, and dentists can feel confident and comfortable in
both their understanding and communication of treatment.
Now more than ever, DSOs are striving to make investments to sup-
port their clinicians and their respective offices not only because they
understand the expectations of a new generation of clinicians, but they
realize the value technology can bring to the patient. At the end of the
day, it is the patient experience that is at stake, and bringing technology
to the forefront of their clinical armamentarium can help practitio-
ners acquire new patients and provide better care to existing patients.

Specialty Referral Support

The power of AI can also be applied by DSOs to support affiliated Fig 7.
dentists when they consider making specialty referrals. Oral sur-
gery, orthodontics, and periodontal treatments are likely to be Fig 6. A bitewing radiograph with AI annotations to support dentist
early areas where AI analysis on radiographs may help DSOs and communication with the patient is shown. Findings include but are
not limited to caries, compromised margins, bone level, and furcation
affiliated dentists track the potential for referrals.9 For instance, involvement. (Source: Overjet, Inc.) Fig 7. This image shows AI being
the ability for AI to detect tooth number, clinical crown, and man- used to assess edentulous areas and restorative potential for pos-
dibular and maxillary bone allows for the assessment of the percent sible implant placement. In addition to flagging patients as potential
periodontal/oral surgery referral, tooth angulation and occlusal plane
impaction of wisdom teeth and their associated angulations. With irregularities can be assessed and signal an orthodontic referral in
respect to orthodontic recommendations, spacing, crowding, tip- multidisciplinary treatment scenarios. (Source: Overjet, Inc.)
ping, impacted canines, and potential space discrepancies with
erupting dentition can be measured and scored. Combining these
organizations-are-here-to-stay/. Accessed February 9, 2021.
findings can help to drive comprehensive multispecialty treatment 2. Garcia RI, Santa Fe Group. The restructuring of dental practice: den-
planning if needed and patients can benefit from understanding the tists as employees or owners. J Am Dent Assoc. 2014;145(10):1008-1010.
complexities of their oral health during their initial visit with their 3. Barron J. Heartland Dental Passes 1,000 Supported Office Mark -
dentist. Figure 7 shows examples of AI-powered analysis in this area. First in the Nation. DSO News website. December 11, 2019. https://
dsonews.com/heartland-dental-passes-1000-supported-office-mark-
first-in-the-nation/. Accessed February 9, 2021.
Conclusion 4. Dental Quality Alliance. Quality Measurement in Dentistry: A
Dental Support Organizations have been at the forefront of adopt- Guidebook. American Dental Association on behalf of DQA. June 2019.
ing new technological innovations with affiliated practices. Dental https://www.ada.org/~/media/ADA/DQA/2019_Guidebook.pdf?la=en.
artificial intelligence holds early promise to support the underly- Accessed February 9, 2021.
ing mission of DSOs to help affiliates reach new levels of business 5. Choudhury A, Asan O. Role of artificial intelligence in patient
safety outcomes: systematic literature review. JMIR Med Inform.
and clinical excellence. From the decision to affiliate with a prac-
2020;8(7):e18559.
tice, to the morning huddle at the clinic, to the ultimate patient 6. Schwendicke F, Samek W, Krois J. Artificial intelligence in dentistry:
experience in the operatory, AI will be an important tool for DSOs chances and challenges. J Dent Res. 2020;99(7):769-774.
and the dentists they support. 7. Balaban C, Inam W, Kennedy R, Faiella R. How AI is transforming
dental practice. Compend Contin Educ Dent. 2021;42(1):14-17.
References 8. Davidowitz G, Kotick PG. The use of CAD/CAM in dentistry. Dent
Clin North Am. 2011;55(3):559-570.
1. Dental Care Alliance. Infographic: Why Dental Service Organizations 9. Khanager SB, Al-Ehaideb A, Maganur PC, et al. Developments,
Are Here To Stay. Dental Care Alliance website. Januay 2012. https:// application, and performance of artificial intelligence in dentistry - a
www.dentalcarealliance.net/news/infographic-why-dental-service- systematic review. J Dent Sci. 2021;16(1):508-522.

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