Discretionary Dentistry and the Patient Perspective

Patients arrive at the dental practice with individual objectives, motivations, and perceptions. In addition, their standard for an optimal treatment result is on a continuum between esthetics and function-an outcome that they may find difficult to describe or quantify. For esthetic consultations, patients have their own concept of an attractive smile, but often no comprehension of what that would require in treatment, time, and expense. Other patients arrive seeking dental care because physiologically they are not at optimal oral health. They are in search of help to address their oral health concerns, but they have no clear understanding of the extent of care they require.

When patients need complex or high-end dentistry, an important aspect of the treatment is adjusting and customizing patient education and presentation to elicit case comprehension and acceptance. Many dental therapies are discretionary. In contrast with non-discretionary services (such as emergency care for cardiovascular distress), patients have a choice of whether to proceed with treatment or not.

Levels of case acceptance are different for a general dental practice compared with a specialty practice. Achievement levels can be as high as 80% to 90% in a general practice.¹ Some specialty dentists have reported case acceptance levels as high as 100% because patients are referred to them by other dental practitioners.² Nevertheless, acceptance percentages can likely be increased in both types of practices when the dental team focuses on engaging patients using a permission-based philosophy. When the team asks questions and elicits permission from a patient to provide a solution, the ensuing discussion can lead to greater acceptance achievement.

Initial Engagement

Consumers who feel emotionally involved and in control are more likely to make discretionary purchases, including dental treatment.³ Dental professionals can begin to engage the decision process by asking patients for permission to educate them regarding their dental problems and offering suggestions for possible solutions.

When patients are considering complex or high-end dentistry, it is especially important for them to feel in control of the decisions. Patients are less likely to proceed when they feel pressured and their concerns are discounted.³ Often doctors will rely too much on a superficial approach that does not relate to or respect the individual patient's perspective.

If patients are not forthcoming on their concerns, the dental team may not recognize a case acceptance opportunity. For example, previously diagnosed treatment that the patient may have forgotten to complete may still be possible. These opportunities can be identified through a series of simple, standard questions. After the dentist and patient work together to identify these issues, the dentist can move forward with discussing completion. Finally, any new findings or concerns for dental treatment should be discussed with the patient in a timely manner.

Another problem with case acceptance is when it is not truly finalized in the consultation room or treatment room and patients continue to have questions as they reach the front desk. When they have not been in control of the decision and have not fully committed to treatment, the next step of making an appointment or arranging for financing prompts them to reconsider and delay treatment.⁴Because treatment is often discretionary and not immediately initiated, patients have ample opportunity to retreat.

Authentic patient engagement naturally begins with the hygiene appointment, especially if the patient trusts and communicates with the hygienist. Specific oral health questions can then be relayed to the doctor, who can take the next step in identifying case presentation opportunities. Opportunities may arise many times during a hygiene appointment; therefore, choreographing the hygiene appointment and case presentation is critical.² The hygienist should attempt to elicit and deliver efficiently and consistently; being consistent as a team is more beneficial to the dental practice business model.

  The Treatment Coordinator Influence

How does a practitioner gain commitment from a patient? In the book Contact: The First Four Minutes, authors Leonard Zunin, MD, and Natalie Zunin state that the first 4 minutes of an encounter leave an indelible impression.⁵ For example, patients coming into a dental practice will make judgments as they meet various team members, especially when it may be a stressful situation for the patient. In these 4 minutes, the first dental team member the patient meets should become an advocate for the remainder of the appointment. This advocate can be a doctor, manager, or hygienist, as long as she or he fulfills the treatment coordinator (TC) role.

To increase the possibility for open communication and case acceptance, the patient should be met by the TC within the first 4 minutes.⁵ This introduction helps solidify a favorable impression on the new patient. Next, the TC should walk the new patient into the consultation room (nonclinical setting) and ask a series of standard questions that contribute to the process of the TC becoming an advocate for the patient, such as:

• How did you find this dental practice?
• Whom may the practice thank for the referral?
• Why were you referred?

Information gathering is extremely important at this point, and questions like these show that the practice cares about why the patient is there and is grateful for the referral. This creates a comfortable initial experience, relaxing the patient. Next the TC should move on to questions such as:

• How long has it been since your last visit to a dental office?
• Why did you leave your last practice?
• Do you believe you need a considerable amount of dental treatment?
• Is there any area you would like the doctor to focus on?
• Have you used your dental insurance before? (if applicable)

After the TC has completed the initial interview, the doctor now has knowledge to help transfer control to the patient and increase the likelihood of treatment acceptance. With the patient's permission, the team can then proceed with the imaging, measurements, and other diagnostic procedures, with the patient already engaged.

Educating the Patient

Educating a patient with integrity helps to ensure understanding of the concept of optimal oral health. This involves demonstrating the connection between oral health and minimizing the amount of time away from work, preventing pain and discomfort, saving the expense of more invasive treatment in the future, improving overall health, and potentially increasing life expectancy by 7 to 10 years.⁶ After conveying these points to the patient, the dental professional should ask: How does this sound to you? The dental professional should not attempt to persuade the patient to move forward with treatment until the patient thoroughly understands and aspires to oral health.

The road to achieving optimal oral health varies significantly from one patient to another. High-end or complex cases can range in cost from $25,000 to $60,000 per arch.⁷ Treatments may include considerable diagnostic time and technology. Guided dental implant surgeries incorporating cone-beam computed tomography (CBCT) and restorative diagnostic software allow greater accuracy in less time. Some treatment plans save costs in the operatory, but laboratory costs may be higher. In the author's experience, costs will be higher if a doctor chooses guided surgery techniques. The costs are generated by laboratory fabrication of 3D-printed acrylic and metal indexing guides, as opposed to free-handing the implant placement, eyeballing the restorative placement, and the conversion of the provisional procedure at time of surgery.  In the author's opinion, the results are worth the cost.  Restoring natural dentition in conjunction with temporomandibular joint (TMJ) therapy also provides the dentist and patient with factors to consider. In all cases, one should ask, what will be the outcome, and what (if any) are the guarantees?

The Patient Perspective: Value Versus Emotion

It is relatively easy for most doctors to explain logically the necessity for dental treatment, and thereby fill the "value glass" for a patient. However, emotions play a larger role in treatment-plan acceptance than logic; decisions are largely based on emotions.⁸ Again, this is where a stellar TC can increase case acceptance. The best TC is the employee who is passionate about the services the practice offers and excels at showing the patient the difference between value and money.⁹ For example, a patient may need a full-mouth rehabilitation, but will spend the money on a boat instead. A good TC understands this mindset and will listen carefully to patients to determine how to redirect them to treatment acceptance.

Using visuals is a means of presenting information to fill the value glass. Some patients absorb information more readily through images; others do better verbally or with written explanations.¹⁰ A practice will have fewer case acceptance achievements when a doctor or TC uses terms that the patient does not readily understand.¹Statements should be translated into everyday language, augmented with visuals, and positioned within the patient's values, not the doctor's.

For most doctors, the patient's "emotion glass" is not as easy to fill as the value glass. Emotional engagement is key to case acceptance and treatment completion.¹ The job of the doctor and team is to understand and help the patient manage his or her emotions. When patients are in a negative emotional state, they are resistant to treatment, and the team must calmly guide them through it. The goal is to end a presentation with the patient feeling happy, in control, and knowledgeable. Ask patients to express how they will feel when treatment is completed. Will they feel more confident, younger, healthier? Most importantly, do they feel they deserve this type of treatment? Wait for the answers and be prepared for the "yes."

Of course, sometimes the patient may have a treatment plan change or addition. Life can change, and the patient must understand that the dental practice will be there to help if an emergency occurs or the patient's dental health status changes.

The Affordability Barrier

In the ideal scenario, after the patient has been educated with integrity, the case presentation has been accepted, and informed consent has been delivered, the patient is ready to begin treatment. However, socioeconomics may be a barrier to treatment and can be difficult to discuss and solve. Expense is the No. 1 reason patients choose to delay dental treatment.¹ Considering the 80-20 rule, 80% of the patients in dental practices will be able to afford and complete treatment-planned dentistry within a 7-year period.¹ Sequenced care or annual-phase dentistry may be key for obtaining the commitment from the patient to complete treatment over a 4- to 5-year time frame.¹

Another barrier in fiduciary decision-making for dental treatment happens with the insurance-focused patient. For example, a patient who has been presented a treatment plan totaling $11,000, but who only has an annual limit of $1,500 in insurance, may decide it is unaffordable. The job of the dentist or TC is not only to demonstrate the value of the procedures, but also to explain how the patient can optimize oral health with annual-phase treatment. The concept to reach the goal of oral wellness is to complete the dental treatment, in this example, over the next 4 years, by budgeting $2,000 the first year, then $3,000 for each of the next 3 years.

Most dental practices have patient populations of approximately 50% who are insurance-driven.¹¹ With annual-phase dentistry plans, these practices could have case acceptance achievement levels of approximately 90%.¹ The goal of phase dentistry is to have patients complete their dental therapy within a 4- to 5-year phase, with the intention of bringing them into an optimal state of oral health. Whether or not to use dental insurance should not be the focus of the presentation. The focus should be on dental wellness. On completion of the plan, the practice should place the patient in its dental wellness plan.

The patient's financial condition is a particularly private subject and must be handled carefully. If the TC has been with the patient from the beginning and developed a relationship, the patient will be relaxed and communicative about expressing concerns. The goal of the TC is now to help the patient comfortably afford the treatment. Often when treatment plans exceed $3,500, it may take up to 6 months for the patient to move forward with treatment.¹ In a survey, more than half the respondents said they have delayed elective healthcare or dental treatment because of cost.⁴ As the author has observed, complex or high-end treatment plans may well exceed $45,000 to $50,000 for a single arch. Obtaining third-party or other financing is critical for some patients to commit to treatment. Companies such as LendingUSA and CareCredit can be an alternative to obtaining funding for treatment instead of drawing on 401(k) plans or home equity lines of credit.

Conclusion

Treatment plans and case acceptance are the backbone of dental practices. Some practices are better than others at case presentation and consequently have greater case acceptance. However, it is possible to learn and improve on the team's interactions with patients, drawing on research in consumer and patient perspectives toward health expenditure. Training the dental practice team to be aware of patient concerns and perspectives helps create a well-choreographed appointment. For example, well-executed case presentations in a nonclinical setting are better received. Before committing to dental wellness,patients want clarity and control over the decision. The dental team's job is to provide education, communication, financial options-and then, ultimately, superior care.

References

1. Runkle K. The Paragon Program. https://www.theparagonprogram.com. Accessed May 29, 2019.

2. Homoly P. Making it easy for your patients to say yes. Paul Homoly.com. https://paulhomoly.com/making-it-easy-to-say-yes/. Accessed May 29, 2019.

3. Margalit L. The role of emotions in our purchase decisions. Psychology Today. https://www.psychologytoday.com/us/blog/behind-online-behavior/201509/the-role-emotions-in-our-purchase-decisions. Published September 11, 2015. Accessed May 29, 2019.

4. Cost barrier may cause individuals to delay health or dental care [press release]. Synchrony. https://carecredit.com/pressrelease/costs-cause-patients-to-delay-health-or-dental-care/. Published March 23, 2016. Accessed May 29, 2019.

5. Zunin L, Zunin N. Contact: The First Four Minutes. Ballantine Books; 1994.

6. Mayo Clinic history. Mayo Clinic. https://www.mayoclinic.org/patient-care-and-health-information. Accessed June 18, 2019.

7.Midwest Implant Institute (MII). Survey of MII fellows. January 2019. midwestimplantinstitute.com. Accessed June 18, 2019.

8.Camp J. Decisions are largely emotional, not logical: the neuroscience behind decision-making. Big Think. https://bigthink.com/experts-corner/decisions-are-emotional-not-logical-the-neuroscience-behind-decision-making. Published June 11, 2012. Accessed May 29, 2019.

9.Cross M. Deciding factor. Manag Care. 2006;15(3):28-35.

10.Switzer C. What are the benefits of visual communication over verbal? Leaf Group Lifestyle. https://oureverydaylife.com/157920-what-are-the-benefits-of-visual-communication-over-verbal.html. Updated January 10, 2019. Accessed May 29, 2019.

11. 2017 Dental Benefits Report: Enrollment. National Association of Dental Plans. https://knowledge.nadp.org/products/2017-dental-benefits-report-enrollment. Updated October 16, 2017. Accessed May 29, 2019.