Is it Time to Bring an In-House Specialist to YOUR Office?

Is it Time to Bring an In-House Specialist to YOUR Office? A New Paradigm in Dental Practice

By Eric Z. Shapira, DDS, MAGD, MA, MHA
Author Contact Info: (650-619-1251)

Kenneth Chenault, an American business executive known for being the CEO of American Express since 2001, recently stated, “Companies will need to pursue a more diversified business model, but I think those companies that have what I call a focused diversified business model will be more successful.” The Traveling Specialty market is shifting rapidly towards the In-House model and away from the basic Brick and Mortar concept of the one-person dental practice business model.

Acquired Debt

In our present society, a majority of graduating dental students, now practitioners, chalk-up dental school debt service in an amount averaging from $247,227 to $500,000! 1 When speaking of the average specialist coming out of school, a debt service in excess of $500,000 precludes almost any chance at all for any young practitioner to open up their own practice from the “get-go.” With an average debt service of $375,000, it is almost impossible to open up a private specialty, fee-for-service practice by ones’ self. Loans for practicing dentists are somewhat easily obtainable, as well as financing on equipment and supplies from the large dental supply conglomerates. However, making regular monthly payments on dental equipment, supplies, salaries, insurance and all the other things that go into starting a dental practice is almost impossible based upon a “normal” 40 hour work week under the “old” business model of doing dentistry.

Change is Constant

The “new” or older part-time specialists, who may want to work only a limited amount of time, may find himself or herself competing with more and more generalists doing specialty treatment on their patients. Decreased production for specialists, based upon declining referrals from general practitioners doing more of their own treatment, makes it very precarious to own your own facility. The majority of a specialist’s practice is made up of referrals. Walk-in new patients are few and far between, making paying the ongoing debt service next to impossible.

Way Back When…

Starting a practice 20 or 30 years ago was stress-provoking from this author’s perspective. However, the debt service of five school loans and the impending issue of borrowing more money to open an office produced probably the same amount of anxiety and stress as today’s new dentist thinking about opening a practice. After 35 or 40 years of active practice and leaving my practice due to an injury, this author was faced with re-evaluating having a dental practice at all. Questions arose like: “Should I go back to doing dentistry? Could I go back to doing active full-time practice? Can I borrow money again and start all over? How can one afford to do dentistry again when the economy has changed? Will my age keep me from making an adequate income? And, what can I do to continue paying the rent and meeting the debt service in this present-day high economic society?” Knowing what physical condition one is in and the potential to practice dentistry at a pace that one worked when one was younger is a great motivator in making the correct decision for each of us facing the issues of maintaining some kind of a practice in our twilight years or younger, hence earning an adequate income in this society.

Running a Practice…

Thirty years ago running a practice was fraught with much change and many unknowns. A lack of business experience was also a stopgap to some extent because one had to learn to “shoot from the hip,” so to speak. “There are no mistakes, only experience,” I always told my students. That is how it went and probably still goes for most “newer” practitioners. There is a great deal of competition as always. However, this author always advocated that if one were good at what they did, the money would always be there.

Collaborative Care

Collaborative practice encompasses any ongoing, systemic professional relationship between two or more health care providers, each having some degree of authority to independently provide health care services within his or her legal scope of practice. These relationships are distinguished primarily by their variation on two key dimensions. Firstly, there is a level of formality of the relationships among the practitioners involved. This level includes whether the relationship involves specific practitioners, is structured by a collaborative practice agreement or involves a formal referral network, as well as the specificity for services performed by the parties. Secondly, there is the degree of autonomy of the practitioners involved that allows for the relationships between dentists to form mutual respect, cooperation, a mutual interest in the patient with regard to his or her welfare and the ability of same to provide overall care by allowing each person the right to his own discipline when treating patients’ needs. 3 Collaborative Care increases access to care and improves practice productivity and efficiency, which effectively increases a practice’s capacity to handle a larger patient base and visits. Lowering or managing costs occurs. Improvement in patient clinical outcomes and improved patient satisfaction increases. 4,5

Within the scope of a collaborative practice whereby specialists are recruited by general practitioners, scenarios play out that allow for each practitioner to treat a common patient. For example, take an oral surgeon who in the course of extracting an impacted third molar inadvertently fractures an adjacent tooth. He or she may call upon the general dentist in the practice to repair this tooth in the same office on the same day. The patient is not inconvenienced by having to travel to another office to see their general dentist at another time.

A periodontist may find that during an effort to bone graft a tooth that it has a vertical fracture or that the tooth has subgingival caries necessitating either a subsequent extraction or some kind of a restoration. He or she may call upon a surgeon in the same practice or the general dentist, who can subsequently treat the patient in the same office, the same day, without the patient having to travel elsewhere or be reappointed. The advantages of a general dentist soliciting specialists for a solo private practice are self-explanatory. The same goes for the specialist who opts to seek out general dental practices to work extra days to supplement their own practice income or to work in different offices as his or her sole means to make a living. Referral services can be of great assistance in aiding all practitioners in their quest to seek out a new paradigm for practice.

Too many general dental and specialty practices are frequently seeing empty treatment chairs these days.


So it goes…running a full-time dental practice and choosing what aspects of dentistry in ones’ practice to hone in on is a very difficult process. Practicing multi-disciplines oneself makes the office overhead skyrocket and causes more stress and angst, especially with the prospect of making more money to pay the bills versus the time it takes to take out a third molar boney impaction without IV sedation. The same goes for advanced endodontic and periodontal specialty treatment. It’s a win-win proposition to follow the new paradigm of incorporating specialists within the scope of a collaborative general dental practice. Again, some of the benefits include:

  • – Better patient care: Patients want surgery done in the comfort of an office they have been traveling to on a regular basis.
  • – Better insurance benefits and processing.
  • – A more cohesive environment for patient treatment to be rendered when working with a specialist or specialists in a general practice office.
  • – Increased income and decreased overhead due to more treatment rendered.
  • – Office manager training on billing and the credentialing process by a company like Synergy Specialists, 6 who provide specialty dentists for private general practices, either through a general dentist soliciting the referral service or a specialist.
  • – Specialists being paid a percentage of production on a regular basis rather than waiting for collection income.
  • – Recapturing earned specialty income, essentially previously lost to the general practitioner, for their office.

The emergence of companies like Synergy Specialists is a long time coming. This type of referral business affords the specialty practitioner a place to call home with respect to his or her practice discipline. Synergy Specialists, like other similar businesses, assists with job placement, procuring proper equipment necessary to perform the specialty job in the general dental practice and assists with third-party challenges for the filing and subsequent collection of funds for the office and practitioner alike. The monetary results of the specialist’s work are divided equitably amongst the specialist and the office. Essentially, this would be an income lost to the general practitioner had he or she sent their patient out to a private specialty practice to be treated.

The new paradigm allows for a change in protocol from the single practitioner practice to a collaborative practice including multi-specialty disciplines. With change comes the responsibility of being able to manage a dental practice more efficiently and with more focus on making the practice grow in light of incorporating the added treatment modalities of ancillary specialty professionals who can bring their expertise to the general practice. The addition of these specialty treatments make the practice more productive and effective at giving patients all the necessary treatment options. With change comes experience and with experience comes wisdom and success. In the long run, changing a practice to the new paradigm will lessen stress, add freedom and time back into the general practitioner’s life as well as the specialist’s, and enhance everyone’s quality of life – especially the patient’s.

Bio: Eric Z. Shapira, DDS, MAGD, MA, MHA, practices part-time dentistry both in general practice and the limited practice of endodontics in multi-practitioner general practice offices within the State of California. He also practices clinical geriatrics and is a Professor of Geriatric Medicine and Dentistry, an educator and author. He can be reached at


  • 1. American Student Dental Association. The Issues: Dental Student Debt. Acquired July 26, 2015 from the Internet.
  • 2. Figure 1: Dental Student Debt. American Student Dental Association in conjunction with the American Dental Association. Acquired from the Internet, July 26, 2015.
  • 3. Mertz Elizabeth PhD, MA; Lindler Vanessa, MA; and Dower Catherine, JD. UCSF Center for Health Profession. Jan 2011. Acquired from the Internet July 28, 2015. 01_Collaborative_Practice_in_American_Dentistry_Practice_and_Potential.pdf.
  • 4. Wagonfeld JB, Murphy RF. The non-physician provider in the gastroenterology practice. Gastrointest Endosc, Clin. N. AM. Oct 2006; 16 (4): 719-725
  • 5. Reger C, Kennedy DW. Changing practice models in otolaryngology- Head and Neck Surgery: The role of collaborative practice. Otolaryngol Head Neck Surg. Dec 2009; 141 (6): 670-673.
  • 6. Synergy Specialists. Beverly Hills, California. National Dental Specialty Referral Service. (855) – 796-7374.