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Technology and Health Care 4 (1996) 283-289 IOS Press
From R&D to the mouth - a viable roadmap
for the technology era

Dr. Murray Simon, DDS, President, D/R/S HealthCare Consultants, 3127 Eastway Drive, Charlotte, NC  USA

Abstract.  This article serves as an overview of the status of dental technology as the profession approaches a new century.  Its purpose is to define various ways in which dental manufacturers and marketers can better understand the thinking of the dental professional, those factors that influence their thought processes and how to use this information to develop more effective and predictive marketing strategies.  
     With the advent of more complex and expensive dental technologies, e.g., video imaging, digitized radiology, electronic data transmission, etc., the dentist is faced with a variety of decisions relating to purchasing, implementation and costs/benefits analysis that go beyond the normal daily concerns of delivering competent dental care.  It is no longer enough for a manufacturer to make a good product; successful marketing strategies must also include a means for guiding the dentist in the successful integration of these technologies into their offices. 
     In order for dental marketers to meet the competitive demands of this advanced technology era, there must be a commitment to the development of strategic information through the use of third party, customized marketing research.   Too much of the input currently used to develop marketing strategies is anecdotal, inherently biased and often not representative of the target market as a whole. 
     It is hoped that this article will effectively challenge the reader to look at the development of dental products and services from a somewhat different, less traditional perspective and that it will provide the impetus and direction for creating better targeted and more rewarding marketing strategies. 

     Among dentists, the 1960s are often categorized as the "golden era" . . . young dentists were graduating relatively debt-free, banks were eagerly lending start-up capital at single digit interest rates and the biggest decision was whether to equip one or two operatories in the new office.  The 1970s represented the "quiet era" . . . nothing earth shattering happened in dentistry except for occasional tremors from the stock market and late of failed appointments due to a gasoline shortage.  The 1980s will certainly be viewed as an "era of major change" . . . new and more complex therapeutic materials, the public's desire for cosmetic procedures, advances in periodontal disease therapy, computerization, shifting patterns of insurance reimbursement, cost containment, dentists advertising, concerns over infectious diseases, OSHA, etc. 
     And how will the 1990s eventually be categorized?  This will probably be remembered as the "technology era" . . . digitized radiology, tomography, oral imaging, electronic data transmission, CAD/CAM, full office/computer integration, etc.  It is an exciting era for dentistry, but it is also a time fraught with problems and concerns. 
     Dentists are now faced with developing an understanding of concept/technology management they were not trained to deal with in dental school:

     -Cost/benefits analysis of new technology acquisition and implementation. 
     -Disruption in established office functions to integrate new technology. 
     -Lease vs. buy decisions in the purchase of expensive equipment.
     -Extensive staff orientation/education/hand-holding.
     -The need for computer equipment/software upgrades as tasks become more complex.
     -Fears that new/expensive technology will rapidly become outdated. 
     -What should it cost to be perceived as a "leading edge dentist"? 
     -Where do you put it after you buy it?

     Dentistry has always been a tension-inducing profession...high suicide, divorce and heart attack rates . . . and now dental practice bankruptcies, while not a prevailing problem, have begun to show up in various parts of the country.  Can we expect to see more as the technology era accelerates and matures? 
     Dental manufacturer have their own technology related problems to deal with:

     -High end R&D costs. 
     -Expensive inventories.
     -Fluctuations in foreign and domestic currency values. 
     -Finding people qualified to market, sell and service high tech systems. 
     -Establishing and maintaining market share in highly competitive markets. 
     -Breaking through the dentist's information clutter. 
     -Guiding professionals through the rough waters of purchasing/integrating high tech systems.

     For the dental marketer or distributor, there was a time when technology concerns related to the new doctor in town who would need equipment for an operatory or the really high tech practitioner who decided a Panorex would benefit the office and patients.  Today there are concerns about rapidly changing technology and its influence on the dentist's potential to be successful.  Manufacturers are looking to dealers/distributors to provide the after-sale technical support; dealers are either reluctant to do it or expect to be adequately compensated for it.  And when you talk to the average dentist about leased technology, he/she is still not knowledgeable about the advantages and disadvantages.  All of these considerations are creating a new world within dental marketing . . . a world of high tech/high ticket/high pressure concerns, and they are dictating the evolution of a new business approach by dental manufacturers.   But there are some who are still trying to do it the good old fashioned way.  
     I practiced dentistry for twenty four years, first as a solo practitioner and then in group practice.  I started during the "golden era" of the 1960s and finished just as the "technology era" was dawning.  In the late 1970s I had begun to do market research on an ad hoc basis for some of my patients who were marketing consultants in the health care field.  While I was learning more about marketing research techniques, the health care field became more turbulent and market research became more challenging and stimulating.  For the past ten plus years I have been doing market research in dentistry, medicine and allied fields on a full time basis.  My purpose in writing this article is to share some of the learning that has evolved from my research experiences with an eye towards stimulating some new thought processes among those who are currently hard at work on the manufacturing/marketing side of this dental technology era. 
     When all is said and done, knowledge is power and a little bit of well focused, strategic knowledge can go a long way and save a lot of headaches.  We did a project a few years ago for a company that markets medical biopsy equipment.  They were considering licensing a new biopsy technology from a Scandinavian company.  There are two basic types of biopsies - core biopsies that take a plug of tissue and aspiration biopsies that aspirate a tissue slurry.   The technology under consideration by my client involved one of these biopsy methods and there were two particular questions of concern: 

     1.  What is the future of biopsy technology - core, aspiration, both? 
     2.  What factors will influence future directions in biopsy technology? 

     The company had intended to do a national quantitative mail survey among physicians who perform biopsies, but in developing the study they realized they had basic information gaps that would impede their efforts to create a comprehensive questionnaire.  My company's services were retained to develop and execute six focus groups with physicians in three major cities with the intended objective of broadening and updating the clients' current base of knowledge. 
     During the second focus group, one of the physician respondents made a comment that resulted in a significant saving of time and money for my client.   He was discussing the various medical/diagnostic factors that influence doctors in their choice of biopsy techniques and concluded by saying, "Of course, if you've got a good pathology tech at your hospital and he or she prefers core or they prefer aspiration . . . well, good pathology techs are hard to find and you've got to keep them happy".  This issue was probed in the succeeding discussions and we determined that the pathology lab tech plays a muted but very significant role in the choice of biopsy techniques.  This information might have evolved from the subsequent quantitative study, but by knowing about it up front my client was able to direct questions at this specific issue and target pathology lab techs as part of the initial study sample. 
     Anyone who has been involved in dentistry for a while, whether as a practitioner or a marketer, knows that there have been profound changes impacting on the profession - some are obvious but others prove to be elusive.  In the mid-1980s there was a lot of interest among various dental/oral care manufacturers in what was perceived to be a developing market for periodontal diagnostic systems.  Companies were spending money on R&D and looking for systems that were available for development and/or licensing.  There were a number of periodontal diagnostics under development at various universities and certainly a good bit of time and effort was spent in evaluating them.  But eventually most of this activity stopped for a very basic and important reason . . . practicing dentists were not interested in periodontal diagnostic technology, i.e., there was little or no potentially viable market for it. 
     Early, properly targeted investigation could have saved a lot of time, effort and money.  It would have pointed up the following:

     -Dentists tend to look at periodontal disease from a decidedly subjective viewpoint, i.e., I know          periodontal disease when I see it. 
     -One dentist's periodontal disease is another's gingival irritation. 
     -In the mid-1980s, dentists were reluctant to charge for diagnostic procedures . . . insurance        
       companies are still giving them a hard time on this issue.
     -Dentists are accustomed to selling tangible items, e.g., fillings, crowns, cleanings, etc.:  many are
       not as comfortable with trying to sell conceptual services such as periodontal diagnosis. 

     If you also take into consideration dentists' concerns such as how to deal with situations in which periodontal diagnostic systems indicate a continuing periodontal disease in patients who have had treatment and claim to be following home care instructions, it suggests that the successful marketing of periodontal diagnostic systems will require a great deal of professional education and handholding over a long period of time. 
     The message here is do the due diligence - many dental manufacturers do not do sufficient, ongoing due diligence.  Market research is not a line item in many dental manufacturers' budgets.  There is still a strong tendency to rely on intuition, feedback from detail reps (who often have their own agendas) and conversations with dentists on the convention floor.  
     Here are some examples of subtle but significant issues that have come from qualitative market research studies with dentists, dental specialists and hygienists that might otherwise have gone unnoticed: 

     -A large percentage of dentists are resistant to change.
     -There is a psychological comfort factor for the dentist in manual overrides for equipment that is
       computer assisted or computer controlled because they worry about computer breakdowns and
       staff/programming mistakes. 
     -Many dental schools are not keeping up with the computer revolution that is knocking at the
       door of dental offices. 
     -Once they have made a computer hardware/software purchase and integrated it into the office,
       most dentists are strongly reluctant to spend for upgrades and/or add-ons. 
     -If a marketer sells a high tech system for the dental office, the package must include staff training
       by the manufacturer.  If the dentist is given the training responsibility, problems are likely to
       ensue. 
     -At the present time, there is little movement towards integrated computer systems (terminals in
       the treatment rooms) in the offices of "leading edge/early adopter" dentists.  Counter space, cost
       and asepsis are major concerns. 
     -When it comes to their attitudes towards oral home care products, dentists are consumers.  Hy-
       gienists are more thoughtful about this product category, and they are believers. 
     -Despite editorial comments to the contrary, the professional relationship between periodontists
       and GPs is often not very cordial.  There is still a lot of talk out there by GPs who complain
       that they lose too many patients when they send them to the periodontist.  Many periodontists
       criticize GPs and claim they let their desire to keep fees in-house cloud their periodontal treat-
       ment decisions. 
     -Samples are still the most effective way to promote oral care products within the dental office:
       dental patients expect to receive a sample when they come to the office for a prophylaxis visit.
       To the dentist/hygienist, dispensing samples is good public relations.  To the patient, a sample is
       a product recommendation. 
     -Clinical studies are important to the dentist . . . but they find them boring to read, they do not         know   how to evaluate them and they believe most are biased by the companies that pay for          them.
     -The majority of dentists and hygienists are not aware of the process by which a product receives
       ADA certification, but the ADA seal had become a must, i.e., they look for the seal and gen-
       erally will not recommend an oral care product that does not have one. 

     Market research can be a potent marketing tool, but too often it is research by the numbers rather than research that is based on objectives and needs.  It is frequently a measurement of what has happened rather than what is likely to happen.  Too often research is used the way the inebriated use a lamppost . . . for support rather than illumination.  The computer has made it possible to accumulate large quantities of information over very short periods of time, but a mass of data can turn out to be a mess of data.  With the rapid changes taking place in dentistry, there is an obvious need for customized market research . . . but dental manufacturers are still reluctant to explore the possibilities.  It is not difficult to understand why:

     -Market research with health care providers is costly. 
     -The dynamic dentist/patient/manufacturer relationship is subtle and complex and many market
       researchers do not have the proper experience that equips them to explore it.  
     -Results and expectations are sometimes at odds with one another.  

     But in this dental technology era, to develop marketing strategies without market research is to try to fly while the airplane is still being built.  A common problem is a lack of familiarity with the process of developing customized market research projects.  The following are some planning precepts that should be considered in developing marketing research strategies. 
     Choose research partners carefully.  If you are going to do a research study in Russia, it is important that the researchers understand the Russian language and culture.  Russian society speaks its own language, tends to be inwardly directed and is often suspicious of outsiders.  Health care providers are not unlike Russian society - they speak their own language, erect walls for self-protection and are suspicious of outsiders who ask them questions.  In choosing a company to do market research, it is very important that you examine their credentials.   Make sure they are not claiming health care research experiences that are actually based on studies dealing with medicated shampoos, moisturizers, cold remedies, etc.   Some companies claim health care literacy based on the use of backroom nurse part-timers who function as human medical dictionaries.  Not all studies require a high degree of dental/medical expertise, but that determination should be made before hiring a researcher. 
     Educate your research partners.   Somewhere it seems to be written that marketing research projects must be done in a crisis mode, i.e., yesterday!  This can lead to inadequate researcher preparation.  Many health care projects involve complex products or issues and adequate preparation is essential.   The best way to ensure adequate preparation is to have a lot of information in the researchers' hands as early in the process as possible.  This can take the form of abstracts of clinical studies, detailing materials, advertisements, sample inserts, instruction sheets, product samples, reports and questionnaires from previous studies, etc.  Face-to-face client/researcher meetings are far more productive if they occur after the background materials have been reviewed.  Meetings can be productively used to outline and clarify objectives and issues to bring the research team "up to speed" on the complexities of the product or service to be researched. 
     Good project specs are essential.  All too often a research project begins with "We need some feedback on this" and does not develop much further than that in terms of project design and protocols.  Many factors have to be explored in developing a good project design:

     -Who are the appropriate respondents and how are they best identified and reached? 
     -Is it necessary to have statistical validity or is it more important to understand the underlying
       attitudes and motivating processes - a qualitative vs. quantitative issue.  Is a combined qualita-
       tive/quantitative study the best way to go? 
     -Which research protocol or combination of protocols would best provide the information needs
       -a mailed survey, telephone interviews, face-to-face focus groups, telephone focus groups, one-
       on-one in-office interviews, convention interviews, etc.?
     -How many respondents are necessary to bring validity to the study?  Having more than eight in a
       focus group tends to limit individual speaking time and might have a negative impact on the depth
       of the responses.  A focus group of six or less respondents, on the other hand, prompts con-
       cerns about how representative the group(s) might be.   It is sometimes necessary to "back into"
       a determination of the proper sample size for a quantitative study, i.e., what is the budget, what
       is the cost per interview, are the information needs primarily predictive or cognitive and will
       these parameters generate an appropriate sample size?  
     -Is geographic diversity a factor?  Issues relating to usage patterns and price point sensitivities
       often show regional variations among health care providers but this has to be weighed against
       the fact that a local study costs a lot less than a national study. 
     -Exactly what are the questions to be answered?  Marketing researchers sometimes feel like a
       locomotive pulling a long freight train with cars being constantly added.  It is considerably more
       difficult to get dentists to respond to a telephone interview in excess of twenty minutes than one
       that takes ten minutes.  In general, the shorter and more concise the questionnaire, the less ex-
       pensive the study. 
     -How are the results to be reported to the client?  Is a full report necessary or will a summary
       report serve the purpose?  Is the raw data to be tabulated in-house or should the research firm
       do it?  Will a presentation be needed?   Will videos of the focus groups be of help to those who
       could not attend?  Are standard tabs sufficient or will more complex analysis be necessary? 
       These are just some of the reporting-related factors that can have a significant impact on the cost
       of a study. 

     A popular marketing book in the 1980s, Positioning, The Battle for Your Mind by Ries and Trout makes the statement that the marketer's task is to get his/her product to be ranked first along some significant dimension of purchase.  If the market contains a strong number one brand, a challenger can play one of two strategic roles:

     1.  The "underdog" role.  "We're number two.  We try harder."
     2.  The "uncola" role, i.e., the marketer finds a space in the customer's mind not occupied by another product.  Seven-Up advertises as the Uncola so that consumers will think of it first when they want a non-cola drink.

     The most important factor in developing positioning strategy is to first develop a clear under-
standing of the underlying wants, needs and attitudes of the target market.  In the case of dental pro-
fessionals, this is often easier said than done.  While dental manufacturers and distributors are eager to communicate the benefits of their products and services, dentists often complain that the lines of communication are inadequate . . . they believe that too many of the factors that have a direct influence on how dentistry is practiced come from outside of the profession with little or no input from the dentist.  I have been interviewing dentists for fifteen years and I am still hearing many of the same criticisms in 1996 that I heard in 1980. 

     -Dentists generally classify manufacturers as too "market driven" and too quick to bring out new
       products that are not adequately developed.   They feel that the dental office often becomes the
       test lab. 
     -Professional advertising too often takes a "me too" approach... a cloning of the advertising that
       has preceded it.  Could this have something to do with the widespread low level of dental pro-
       duct brand awareness among dentists in this country?  
     -Manufacturers too often take liberties in their competitive benefits claims. 
     -Dentists in the focus group setting ask the same question repeatedly, "How unbiased are clinical
       trials when the manufacturer has paid for them?"  
     -When it comes to professional detailing and product support, many dentists look over their
       shoulders at the marketing activities directed at their medical colleagues and come away feeling
       like neglected orphans. 
     -Many dentists resent having to buy oral care samples for distribution to their patients.  They feel
       they are providing an important marketing/advertising/public relations function for the manufac-
       turer and, at the very least, should be getting free samples for that effort. 

     Some of the above perceptions may be untrue or inaccurate, but that old marketing axiom still prevails - the perception is the reality.  The mandate for any company that is actively developing products and services for this dental technology era should be to define and understand the perceptions and recognize that what is visible on the surface is sometimes not a true reflection of what lies underneath.   Manufacturers who successfully position themselves as sensitive to dentists' needs - as companies who are committed to helping dentists improve the quality and profitability of their practices - they are the companies that will profit in the technology era. ¤

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