recovery Archivi - Magazine Key-Stone

The recovery phases in the dental sector

We are all asking ourselves “when” we will return to normal life after this pandemic, but although this is the most pressing issue, the most disturbing question is probably “how” this hypothetical normality will be.

The pandemic impact

Perhaps also for this reason, all over the world we speak more and more often of “new normal”, namely that phase, which will probably last for years, characterized by at least three influencing variables coming into play:

the management of the endemic phase of the virus
the new logics of socialization
the great economic crisis ahead of us.

These three points certainly don’t need much comment. As regards the management of the endemic phase, it is rather obvious that the timing for achieving herd immunity, the real effectiveness of vaccines also against any other variants, the modalities and programming for periodic boosters are all factors affecting both behavior and social organization. In the workplace, remote work will in any case be more frequently exploited and business travel limited (a return to the level of air traffic recorded in 2019 is expected not before 2025). Certain economic sectors will suffer the impact of the pandemic for a long time, for example those most affected by remote work, which will become regular practice even for just a few days a week (with an impact on services related to commuting, food services, etc.), or the retail trade, if we consider the enormous impact of the development of e-commerce and its inexorable acquisition of market shares. At the same time, some areas will also considerably grow, such as IT, pharmaceuticals, delivery services, etc. There will also be sectors strongly supported by the European Recovery Fund, but these too will only allow the development of specific sectors, according to each national Government’s plan, whose fundamentals are based on ecological transition, digital transformation, employment and smart, sustainable and inclusive growth, measures looking to the next generation, including education and skills development, etc.

As anticipated, not all sectors will have the same support. The dramatic collapse of gross product, production, and export, as well as the significant rise in public debt, will take years to return to 2019 levels. Unfortunately, the only aspect we are sure about is the uncertainty regarding these factors.

Despite everything, as we will see here following, the dental sector can be considered as central and essential to the health of the population.

Let’s see then throughout this article some thoughts on the impact of the pandemic in Italy and on the probable recovery dynamics occurring in the dental sector.

My job, as head of the Key-Stone research institute, is to collect, process and analyze data, but I am often also asked to produce forecasts and strategic guidelines. Well, over this year my writings, interventions and seminars have been numerous, however, I have always explained the serious lack we have faced, that is the uncertainty due to the total absence of past data. This aspect makes it impossible to work on mathematical models, moreover, there are just few similarities with past pandemics, since in the last serious ones the social and healthcare context was totally different.

Nonetheless, in this catastrophic year, Governments, international organizations, the biggest world strategic consultants, all research institutes (including Key-Stone), companies and associations, have begun to collect and catalog qualitative information and quantitative data, developing economic forecasts and theories on the post-Covid-19 recovery.

Also in relation to the Italian dental sector, we can count on numerous researches and studies carried out this year, and thanks to this contribution I would like to share some food for thought, by explaining what we believe the steps to recovery will be, in terms of demand for dental services.

As I have already had the opportunity to write, the current crisis arises from an interruption in interconnections. During the three-month lockdown, we were prevented from moving, from consuming, although there would have been financial possibilities, in theory. But even later, until today, if we give up buying and consuming certain products or services, it is often not because of a shortage of money, but rather because of an objective unfeasibility connected to social distancing policies. In addition to that, we must take job uncertainty into account, another dominant word in recent months; an uncertainty that now affects many millions of Italian families, especially considering those who work in sectors heavily affected by the pandemic (travel, tourism, food service, non-food retail trade, etc.).

But what happens in consumption, when we are faced with a phase of uncertainty or, worse, of real or imminent worsening of the family economic situation? First, all those spending decisions that are deemed unnecessary or simply not indispensable are postponed. Unfortunately, among these, we also find the expenses for dental services.

Analysis of the short-term impact on dental treatments

In November 2020, Key-Stone interviewed 1,200 Italian families and it emerged that one in four Italians, aged between 20 and 74, would have renounced the dentist, except for urgent needs, until the end of 2021. These are 13 million Italians, whose uncertainties due to the pandemic are now added to their traditional economic and cultural problems. The percentage rises to about 40% for those who have had or think they have precarious employment and economic situation because of the pandemic.
However, considering that a part of the population would have renounced the dentist anyway (most of them because of structural economic reasons not attributable to Covid-19), 61% of these undoubtedly attribute this choice directly to the pandemic, because of the consequent worsening of their economic situation or for fear of being infected.
On the other hand, a positive note comes from the segment of children and adolescents: according to Key-Stone’s research, the intention to give up on treatments is reduced in the case of children aged between 6 and 19, whether it deals with more expensive treatments -such as orthodontic ones- or checkups and routine treatments.
In conclusion, the real effect of the pandemic would cause a reduction in the demand for dental services estimated around -13%, at least one billion less in dental expenditure and therefore in lost revenues for the sector.

Possible future needs

In this context, Key-Stone explored the topic in depth, trying to understand which areas of need are most felt by the population and which is the expected procrastination time for treatments.

First of all, it is worth remembering that the citizens interviewed do not always have the clinical skills to be able to judge their own needs in terms of dental services, moreover the climate of trust can change suddenly depending on the overall pandemic situation and on personal experience.

The research conducted confirmed how a certain fear for infection, but above all economic and employment uncertainty has pushed part of the population to postpone non-urgent dental care. This situation is also quite usual in times of famine, crises when confidence in the future decreases. In fact, it is normal for people to prefer to solve basic needs (in our case pain or urgent functional problems), neglecting other expenses that may be postponed.

By re-processing the data coming from the research, we have extrapolated the percentage of adult population claiming to be likely in need of certain dental therapies and treatments, even if not in the immediate future.

In Figure 1 we can see a ranking of the main treatments, first of all, fillings then oral hygiene, concerning almost half of the interviewees, immediately followed by extractions, implants (with consequent prostheses), and traditional orthodontics. There are fewer esthetic needs, such as veneers, or treatments with aligners.

Intention to postpone dental treatments

To the same people who stated possible future needs, we asked if they thought to be treated soon or if they would have preferred to postpone dental care as later as possible, or even to give it up. In Figure 2, we can see how the intention to postpone dental treatments is higher for those rated as more expensive. It is slightly surprising that some treatments more related to esthetic needs have a rather high procrastination rate even though patients who manifest these needs have medium-high levels of education and income.

Map of the potential needs and the intervention priority

By matching the results of the potential needs with the intervention priority (i.e. the reverse of the intention to postpone), it is possible to have a clearer representation (Figure 3) of the therapeutic areas that could be most affected in the short term, a period that we could probably frame up to the end of 2021.

The areas of implants and prostheses will probably have greater difficulties in recovering in the short term, while others -more related to restoration– could move faster towards a normal condition. The situation of orthodontics is peculiar, since for adults it may present a certain slow recovery, while as regards therapies for children (not shown in this chart), a much smaller crisis is expected, as explained here following.

However, the scenario just outlined depends on the type of the dental practice patients, considering their average socio-economic level, the working sector of their families and the geographical areas where they live, in the event that the local economy is particularly affected by the effects of the confinement measures.

The dental treatments are essential

At the same time, this research reveals some very important information, already widely emphasized in the media, namely that 30% of those who during the phase of total confinement (March-May 2020) had problems with their teeth or mouth without having been able or willing to go to the dentist, reported a worsening in their oral situation. The numbers coming from the research carried out by Key-Stone for SIdP at the end of the lockdown period speak for themselves: over 10 million Italians had problems with their teeth and gums during the ten-week confinement and about 3 million state that the situation has worsened because of the impossibility to go to the dentist. It is therefore unquestionable that dental treatments must be considered essential.

We are therefore dealing with a sector, and indeed also a market, where the fundamentals are solid, where long-term structural crises cannot be foreseen, but which can contract or expand based on economic and social external phenomena, which lead to the postponement of certain treatments in particular periods.

Medium-long term recovery dynamics

According to the main theories on post-pandemic recovery, we must consider that after a first phase of giving up certain goods, especially services (which are generally postponed in the process of hierarchizing personal and family expenses) by part of the population, there will be a physiological long-term settlement (probably for at least a year) during which the population, gradually emerging from economic hardship or uncertainty, will resume even the most expensive treatments. In the meantime, it should not be forgotten that, unfortunately, some of those who have delayed oral care for too long will have a more compromised oral situation. Following this recovery, however, the demand for services should settle at slightly lower levels, following the trend that was already taking place in the three-year period 2017-2019. In this analysis, the observation of what happened during the great recession 2008-2013, with an exceptional recovery in dental care in the following two-year period 2014-2015 and the subsequent slowdown in growth up to the stagnant or slightly declining situation reported by ISTAT in 2018 and 2019, helps us a lot. As far as dental care is concerned, even the first phase of lockdown resulted in a strong recovery in summer 2020. It was very intense and short-lived, due not to the citizens’ waivers, but to the numerous tratments interrupted between March and May.

The recovery phases

In Figure 4, we can see the possible recovery phases characterizing the dental sector.

Let’s identify and analyze the six phases described in the model, and let’s make some reflections.

Pre Covid-19

The results obtained by the study about the last pre-Covid years should not be overlooked, as they are a key indicator of the sector business fundamentals. Obviously, if the clinic was under development and was in a financially prosperous position, it is very likely that it will recover more quickly, perhaps by increasing its market share, at the expense of those who already had problems in their own business, with declining results, difficulty in generating profit and financial weakness. For practices that were already having problems, the shock of this crisis could be lethal and some of them may decide to reduce their activity or close.

Lockdown

The almost total impossibility to access the clinic has had a devastating impact on their financial situation, as well as a long-term impact on the organizational system. Despite the possibility to benefit from payroll subsidies to reduce the impact of personnel expenses, during the three-month lockdown the dental practices’ owners had to incur the fixed costs, many of them by using their own resources and drawing upon personal assets, while some dentists have turned to banks for a loan. But these expenses will have to be recovered, or in any case, be returned to the family assets: it would therefore be appropriate to plan the profits for the next few years to calculate the payback times of the investment.

Technical rebound

The more-than-10-week total confinement halted an enormous amount of work, which poured into the clinics in the period May-September 2020, to carry out the suspended treatments and those for which patients had already decided. According to an accurate survey carried out by Key-Stone, the treatments remained blocked would have covered about 50 working days; the research was able to objectively affirm that at the resumption, in the second half of May, more than one billion euros treatments were resumed in the sector (more than 30,000 euros work to be completed on average per dental practice).

But it was a short-lived recovery. It must be remembered that, in the meantime, no new patients showed up for almost three months and new treatments took place only in the autumn, partially compromised by the lack of new visits in the previous period.

Prioritization needs

Since October 2020 there has been a new reduction in accesses and new patients compared to the same months of 2019, due to subsequent restrictions on mobility and increasing economic uncertainty. In this period, which will probably last until the end of spring 2021, the general performance has settled a few points below the results of 2019 and, as regards implantology, this reduction is quite important (on average -9% implants placed between October 2020 and February 2021 considering the same months of the previous year).
Recovering from the emergency phase (and much will depend on how long the vaccination campaign will take), the workload will gradually increase, but for a few million families directly affected by the crisis -because of the impact on their job and financial situation- that mechanism of expenses hierarchization will be frequent, leaving part of the treatments still in difficulty. This is a phase whose duration is unknown, but observing the macroeconomic predictions made by relevant institutions, the clearest positive signs will probably occur in 2022.
Those who manage a dental practice must take this aspect into account, since they could face a slowdown in recovery during this year, always compared to 2019, which is the reference year. In any case, this is a phase that will not last particularly long, but it is essential that the financial system of the clinic leaves room for a possibly extended resistance.

Physiological rebound

The procrastination of dental services for over a year generates a huge “lung” of treatments that are finally performed over a long period of time (even years), as families recover an acceptable economic situation, trust in the future and, in part, in the event that the oral condition does not worsen in terms of urgency (as anticipated, this phenomenon has already been documented in the two-year period 2014-2015). It is therefore very likely to witness an expansive cycle which, like after the “Great Recession”, could last for at least a couple of years, with undoubted advantages for those dental practices which will be able to plan their business in an entrepreneurial way, combining trust -that I often mention as a fundamental ingredient to overcome this crisis- and financial planning/control capacity, not to forget the strategic vision contributing to a successful value proposition.

New normal

There are no clear forecasts on what the health situation, social dynamics and economic weight of the different sectors will be in the endemic period.

Certainly, we cannot fall into the error of believing that the “new normal” is a return to the conditions prior to Covid-19. We are facing a radical transformation, thanks to which some fundamentals of the social organization and economic system will undergo profound changes. We all hope this evolution moves towards an improvement in life quality for an increasingly large part of the population.

In the new situation of normality, the demand for dental treatments could slow down its development following the physiological rebound resulting from the treatments procrastination (as happened in the three-year period 2017-2019). In actual fact, this may lead to what we indicate in the chart as baseline, which represents the level of demand we would probably have had without the impact of the pandemic.

Anyway, those who have worked well in recent years, investing in clinical skills, facilities, technologies, training, and entrepreneurial management, will probably find themselves in a more prosperous situation than the one in which they were before this shocking health catastrophe.

An abnormal crisis

Previous international crises, and the 2008–2013 crisis in particular, have arisen from the collapse of the economic or financial system at the macroeconomic level, having an impact on businesses (for example, through the resulting credit crunch) and society, especially as a consequence of the resulting rise in unemployment. It is quite evident that all this has an impact on the real economy, or the purchasing power of families, creating a sharp drop in demand. All of this happened in the Western world in the 2008–2013 period. However, in the current case, it is different.

A crisis of interconnections

The economic and financial systems in Europe and the US were rather solid before the SARS-CoV-2 outbreak, being in full economic recovery and boasting positive fundamental indicators. What suddenly emerged with the pandemic was a crisis of interconnections or the impossibility of supplying and selling products and services owing to the need for physical distancing. In the lockdown phase, every country halted about 60% of its productive activity, causing an enormous economic shock, the magnitude of which is proportional to the lockdown duration. However, the origin is exogenous to the system, a sort of huge economic downturn that has struck the world.

It is precisely for this reason that, at the beginning, many economists thought that, when the external cause ceased, that is, at the end of the respective lockdowns, the economy would recover quickly. Experts call this a V-shaped recession, which is characterised by a rapid initial collapse, followed by a rapid subsequent recovery, and it was expected that the impact would have been limited as a direct consequence of the lockdown period. However, this was a rash and probably superficial evaluation because it did not take into account that the handling of the endemic phase would still have required a very long period of physical distancing, having evident consequences for the purchasing power of families and consumption.

Figure 1: *Critical factors of an economic crisis*

In addition to the economic and financial problems that have affected and will affect the production system, and small and medium-sized businesses, in particular, the methods of socialization have radically changed. On the one hand, we need to maintain a certain physical distance, and on the other, attitudes, behaviors, and prejudices are changing, and these will possibly result in an increase in social unrest. Given that this new way of life will partly reduce consumption owing to incapacity and production saturation, what interests us in this context is the possible transformation of the perception of dental practices and dental care by the population.

Dental practices situation

There has been clear and peremptory guidance for dental practices from competent institutes. We think that implementation of these principles, which provide for certain clinical protocols, patient management and the use of personal protective equipment, may be quite demanding in organisational and financial terms, but we believe that all practices will adopt them in order to guarantee the safety and health of their staff, collaborators and patients.

In all sincerity, we must always keep in mind that dentists have always worked in almost totally aseptic conditions. It is true that, in this case, we are dealing with pathogens that circulate by air, while dental practices have evolved to prohibit cross-contamination through blood, but the protective measures employed by dental professionals are already very high. The culture of protection and asepsis is already innate in the professionalism of workers in the dental field, and we firmly believe it will come naturally to employ more rigorous procedures.

As for patients, given that the relationship with a dentist is based on trust, we think it is very important to explain the procedures and devices adopted with available objective data while confirming the requisite behavior, focused on everyone’s safety.

Our qualitative research indicates that, when a dental expense exceeds about €1,000, it is no longer the individual choice of the patient, but enters into the basket of various family expenses. The expense is then evaluated and ranked according to other family needs, which are not always related to health. Clearly, non-urgent and higher value-added services, such as orthodontics and prosthetics, could more easily be postponed, but, according to dentists interviewed in April, treatments for aesthetic purposes will suffer above all, while those that solve functional problems may be less affected.

Given that all of this will have to be demonstrated, there is no doubt that, in a Maslowian theory, on a hypothetical scale from pain to pleasure (for socialising, a sense of belonging and esteem to others and to oneself) in the case of reduced financial possibilities or psychological resistance, therapies aimed at aesthetics will be the ones that may initially be reduced, because they are less compelling (Fig. 1).

What practice should do is learn how to sell. This is not unethical; we must put aside all the false prejudices related to semantics which could generate negative reactions. Learning how to sell signifies the greater effectiveness of transferring value in the proposal of treatments so that the patient clearly understands the importance of the treatment being proposed and fairness concerning the treatment cost. There are too many instances in which families postpone dental treatments in order to prioritize other non-health-related expenses in the hierarchy of family expenses. Even consumer credit, carried out with the support of credit institutions, is a good opportunity for encouraging access to patient care.

The paradigm of reopening

It is fundamental to accept that we will no longer be able to return to the dental profession as it was back in March. The organizational system will be different, patients will be different and certain costs will inevitably increase. If we cannot endure the acceptance of this change, this veritable rebooting of the dental profession will prove difficult.

*Figure 2: The strategic path to reopening dental practices*

The dental practice has three important assets:

its clinical expertise
its organization (understood as structure, technologies, group of people, processes)
its base of patients; ideally, all the patients treated in the last three to five years represent a referral source for a conventional practice. However, it is different for corporate dentistry, which is more oriented towards the use of marketing to attract new patients.

Nowadays, just over 75% of the turnover of a dental practice that has been open for at least five years is generated by “known” patients, that is, those who have been treated in the past and their relatives. Therefore, it is necessary to maintain and retain the great value represented by patients treated in the past.

Following this logic, there are three phases to reopening (Fig. 2):

resist
relaunch
redesign

Resist

The real problem with this first phase of the crisis is the lack of liquidity, which arises from the lack of revenue in the previous months and the impact of fixed costs in this period. Let us try to rationalize this situation. In Europe, dental procedures valued at more than €7 billion are performed per month. During the lockdown phase, treatments worth at least €12 billion have been suspended, not canceled, because millions of patients under treatment have been asked not to visit their dentist (according to Key-Stone surveys, the average duration of dental treatment is about 112 days, orthodontics excluded). They were undergoing treatments that must be resumed as soon as possible and in total safety. Then, millions of patients suffer oral health problems and they will have to visit a dentist in the coming months. Net of a possible reduction in spending power and patients’ increased fear of the dentist, dental treatments are not consumable; they are not meals that were not consumed in a restaurant or nights not spent in a hotel. The population will return to the dentist, but timelines and ways will change.

For a dental practice that has not collected revenue during the lockdown period and does not have variable costs (such as laboratory, materials and medical collaborators), but has had to bear fixed costs (such as rent, utilities and staff), the latter is the true problem. In addition to supporting his or her family, the owner of a dental practice has had to cover the fixed costs.

Given that social safety nets, such as the use of lay-offs, can help reduce staff costs, we suggest classifying fixed costs into three categories:

costs that are indispensable and for which payment cannot be postponed
costs for which payment can be deferred
non-essential costs that can be eliminated during this phase.

Costs do not include investments, which are essential for improving a practice’s effectiveness and efficiency, which will eventually play a strategic role in the coming months of recovery.

With regard to revenue, another important operation during the resistance phase is to create a prevision of the treatments, considering those suspended, those that could be fulfilled from proposals that had been made to patients and are pending a response, and new visits planned, not to mention all the patients to be re-contacted for hygiene visits and check-ups, children under orthodontic monitoring, patients for whom implants have been fabricated and who require prostheses, and so on.

A prevision must be updated every month, but allows one to know in advance, net of all variable and fixed costs, the probable financial requirements. These are requirements to be met by resorting to bank loans and/or personal assets. Non-financing during this phase of the crisis means heading towards a possible closure, an eventuality declared in 14% of the sample of dentists interviewed in recent Key-Stone research (in Italy and Spain), a percentage that rises proportionally with the increasing age of the practice owner.

In addition to securing the dental practice from a financial point of view, it is essential to guarantee safety and health security to patients and collaborators, but this will certainly become an obligation and, therefore, a prerequisite. What will make the difference is a practice’s ability to organise the workflows and processes to avoid mishaps, such as overcrowding, but also excessive downtime resulting from an excess of caution without proper planning.

Relaunch

Returning to the issue of the great patrimony of the practice, represented by patients treated in recent years, it is essential to look after it through an organised system of direct communication. It is very important to have a well-managed patient database, allowing segmentation of patients by age and treatments carried out, among others. It is just as essential that the management of this database complies with the requirements of the new European General Data Protection Regulation.

In this phase, it is important to maintain relationships through WhatsApp, email, videos, calls, and social networks. But what is important is the content of this communication aimed at informing patients, reassuring them about everything that is being carried out regarding their health and safety, and giving practical suggestions for oral and general health and for living a healthy lifestyle. While it is absolutely not recommended to generate communications aimed at selling services or treatments—it is not the opportune time for sales—it is the time, the opportunity, to strengthen your relationship of trust with patients. Similarly, it would be useless to produce information aimed at promoting services which, during this emergency phase, could appear anachronistic or not suited to the current priorities of the population.

Another important time is reopening. When a dental practice is ready to assist new patients, it would be opportune to communicate this and, in this case, even encourage visits. In this regard, in addition to revenue suspended during the lockdown phase, a very serious aspect to consider is that, during this period, new patients have not been acquired and new treatment plans and new treatment plan proposals have not been realized. This is a problem that will be felt in the coming months, even in this autumn season. For this reason, practices must absolutely maintain a space for the creation of new visits, although they may possibly find themselves in a crowded situation due to treatments that were left uncompleted or suspended.

Similarly, during the relaunch phase, once a practice has reopened, it becomes a priority to return to pending treatment plan proposals, for which is essential to obtain the highest possible acceptance rate. While considering possible demotivation by some patients, we suggest not soliciting responses to suspended proposed treatment plans with simple phone calls but inviting the patients to come back, to carry out a new motivational visit that serves the purpose of renewing awareness of the need and the reduction of any prejudices in order to favor the acceptance of the treatment plan.

Redesign

New organizational protocols will deeply change the organizational model of the practice, and this is precisely the time to collect data and information, consider your practice’s strengths and weaknesses, and evaluate opportunities and threats. It is also time to consider what emotional, organizational, and financial resources are available and which may be necessary with the goal of structuring a virtuous business model for dentistry to come.

Asking questions about changing the competitive system, re-evaluating the positioning and pricing policy, and deciding what your practice should look like in the future are fundamental steps and must be thought through calmly, reasonably, and creatively.

The dental practice owners need to consider for reopening the following factors:

Treatment demand
Regulatory compliance
Personal Protective Equipment (PPE) procurement
Workflow organization
Staff: commitment, motivation, conflicts
Impact on timeline
Saturation and productive potential
Functional investments
New composition of the revenue account
Pricing and cost policies

We believe that the truly great problem in the coming months, or perhaps years, will not be so much that of demand for treatment, nor the purchasing power of families, but that of the objective capacity of dental practices because there is no doubt that fewer patients will be able to be accommodated within the same number of work hours.

Planning the future

In order to survive this first stage unharmed, we must start to think about 2022. While the present year is economically lost, we can use it to plan for the future. Next year will also be difficult because we will most likely still be bound by physical distancing and rigid protocols in patient management. Even the economic and social crisis may continue to have a long and clearly visible tail. However, there is a great opportunity to return to performing excellent and successful dentistry in a new competitive context and with the payback of the trusting relationship. Everyone must have his or her own vision of the future and commit to fulfilling it with confidence and trust.

We would like to offer just one suggestion: do not make hasty decisions. Use the next few months, at least until the end of the summer, to collect information, taking note of problems, flaws, and areas of improvement. Use this period as if it was a beta phase for the practice. First, we need to fully understand, then design, and then build. If we change the order of these factors, the risk of failure increases.

During this time, we have come to realize that the key is not hope but trust. The first refers to something that should come to us from the outside, while trust derives from that intimate feeling that whatever happens it will be faced in the best possible manner, for we believe in ourselves and we have used a rigorous method of strategy development.

The article has been published on Dental Tribune in Italian and English.