Getting Case Acceptance to 90% 

Paul A. Henny, DDS 

Studies show that the average comprehensive care treatment plan acceptance rate is in the 30% range. Why do you suppose that is? 

Humankind’s Innate Prediction Machine 

Our brain is a prediction machine that’s always turned on. To a large degree, it operates like the autocomplete function on our phone – it’s constantly trying to guess the next word when we listen to a book, read, or conduct a conversation. Contrary to speech recognition AI bots, our brains are constantly making predictions at different levels, from meaning and grammar to specific speech sounds. Our brain continuously compares sensory information with memories. The more negative the memories, the more negative the predictions. 

Additionally, there’s a central purpose behind our prediction machine: Survival, successful reproduction (propagation of our genome), and rewards that might take the form of rising up in the social hierarchy or gaining scarce resources. 

Regarding survival, our brain likes to stack the odds 4:1 in its favor, meaning, it tends to predict negative outcomes 4X more often than it will positive outcomes. This is nature’s way of staying safe so we’ll have the opportunity to live another day. 

Stacking odds in Its favor is very primal, yet the stacking influences many of our impressions and decisions. Complex situations requiring complex decisions must go through this 4:1 negative bias loop. 

A Steep Slope to Climb 

Now, apply this information to how you work with your patients. Unless you enter a relationship with a stellar reputation that has transferred a high level of trust, you are starting off with 4:1 odds against the advancement of your agenda. That’s a steep slope, yet we ignore that truth every day. 

The only way to overcome the 4:1 odds against us is to allow trust to organically develop in the relationship. And that must be achieved in small steps: Simple proposals, agreements, and experiences that meet unspoken expectations.  

Would you agree to hire a contractor to build your dream home after talking with them for only 15 minutes? Wouldn’t you want to see examples of their work and call one or more of their clients to learn how good they are at following through and sticking to their word? 

I thought so but for some reason, we all want to believe that when a person needs extensive oral restoration or rehabilitation, that they will be ready to make a multi-thousand dollar decision within minutes of seeing our amazing digital presentation. In fact, we’re so confident that it will work, that we’ll do our exams for free to create a “sales funnel.” 

The Common Approach Fails 

Most people don’t react well to this approach because it’s too much information-too fast, and it’s all coming from a virtual stranger. They’re not ready to have us build their dream home for obvious reasons. Why, then, do we ignore all of that and call them “tire kickers?” 

The Alternative Approach 

Dentists who deploy the co-discovery, co-diagnosis, and co-success treatment planning process outlined by Dr. Robert F. Barkley often get above 90% case acceptance. I bet you wouldn’t be surprised to know that Pankey Institute faculty are among them. Understanding how the mind works and structuring your new patient processes to beat the 4:1 odd is more than possible. I invite you to read my recently published book: Co-Discovery: Exploring the Legacy of Robert F. Barkley, DDS. The book is available at the Pankey Institute now with all proceeds benefiting the Institute. 

Complex dental cases often need support from multiple specialties for a final successful outcome. The approach to work out these cases can be a “multidisciplinary approach” or an “interdisciplinary approach.”

In the case of “multidisciplinary treatment planning,” each of the dental professionals makes their own plan for the treatment they will provide and they seek the help of other disciplines as the need arises. A fairly common example is when a patient finishes orthodontic alignment and then sees a dentist for esthetic restorations.

“Interdisciplinary treatment planning” takes another approach. Treatment is preplanned among the restorative dentist, specialists, and the laboratory team prior to commencement. What is notable in this approach is that you communicate, you collaborate, and you create the plan together as a team. As a restorative dentist, my role is to sit at the center of the specialist, the lab technician, and the patient. In my experience, involving the lab technician from the beginning produces best results and a more efficient process of treatment.

Avishai Sadan — my colleague and the dean at USC, says interdisciplinary treatment planning results in “being able to formulate a custom-tailored treatment plan that addresses patient present and future needs and to execute it to the highest clinical level possible, using state-of-the-art techniques and technologies.” This statement defines for me the best way to do dentistry.

The Benefits of Interdisciplinary Treatment Planning

The foremost benefit is to our restorative patient, whose well-planned dentistry optimally solves current and future needs. Not only are restorative results at the highest clinical level, but we can practice what we enjoy doing most at our highest skill level, while enjoying collaboration with others who are working at their highest skill level. Liability is lower, and we learn from each other.

As a team, we have developed a smooth process of communicating, contributing knowledge, and deciding what will be an optimal course of treatment. We document with photos the procedures each of us performs so we each have complete documentation of the cases we do together.

The others who are on my interdisciplinary team refer patients to me because they are comfortable with the process we have developed and value the quality of the restorative dentistry I do. My practice is distinguishable from dental practices that do not do interdisciplinary treatment planning. Patients who are referred are commonly told about this interdisciplinary planning approach before they arrive. They anticipate a high level of personal attention and a course of treatment that all doctors agree upon. Case acceptance is high when all doctors and the lab team agree on what is best for the patient. Communication and agreement among the providers is so complete, the patient can be optimally informed about what to expect at each stage of treatment.

Before I come up with a treatment plan, I always do certain things in a certain order. That structure has allowed me to feel confident that I can treatment plan any case that walks into my office. That structure, or process, affects how I approach my exam, make my diagnosis, and ultimately make my treatment plan.

The process begins by looking at the following five areas during the patient exam. I gather information in each of these areas in the following order:

1. The patient parameters of the case
2. The aesthetic parameters of the case
3. The functional parameters of the case
4. The restorative parameters of the case
5. The biologic parameters of the case

The first area I look at is the patient. What is the patient interested in? What are the patient’s circumstances, temperament, and dental health objectives? What is the patient’s current understanding of their dental health? How does that compare to my perception of their dental health? After answering these questions, I then move on to the four technical areas.

The first technical area I look at is the aesthetics of the teeth, gingiva, skeletal structure, and face. I then look at function, including the jaw joints, muscles, occlusion, and airway. The third area I look at is the restorative parameters of tooth structure, missing teeth, and the restorative materials and restorative techniques previously used in the mouth. And finally, I look at the biologic parameters, including caries, periodontal, and endo.

When I do my examination, I want information gathered in all five of these areas. When I sit down to do my exam diagnosis and treatment planning, I have all of that information in front of me and I’m going to always consider the five areas in the same order as I proceed with diagnosis and begin treatment planning.

When I plan the stages of treatment that will occur, the treatment sequence is in the order that is most appropriate for the case. For example, if the patient has a biologic health condition, perhaps, the need for a root canal or significant perio inflammation, I’m going to treat that condition at the front end of the treatment sequence, and not in the order in which I gathered information and reviewed it. The most appropriate treatment sequence will be the order in which I need to do restorative procedures to most predictably achieve the total best outcome.

Although my “structured approach” may not be the same as yours, I thought sharing mine with you could be of benefit to you. By establishing a process in which you gather and consider information in all five areas (Patient, Aesthetics, Function, Restorative, and Biologic), you will have all the information you need to consistently do diagnosis and treatment planning with efficiency and confidence.

For more information on this topic, I encourage you to take Treatment Planning and Case Presentation with me on June 11th – June 12th. This is a phenomenal way to solidify your knowledge and spend two days in sunny Key Biscayne, FL.

Every successful dental case begins with a conversation. 

A Case of Great Dental Expectations

“So what should we do next?” my patient asked. I rolled my chair beside him, excited about the challenge of achieving his preferred future.

I looked him in the eye. “Do you really want to know?”

“Yes!” he said.

I responded, “I don’t know right at this moment. However, may I take some models, photographs, and study your mouth? Taking time to study your mouth with this information will allow me to develop viable options for you to decide what you would like to do next.”

This conversation came after my patient lost #12 and had an implant placed. He had never asked this question before and his past dental history was single tooth dentistry.

Once the records were gathered, I spent some time in my office lab opening up his vertical according to the principles that Mike Fling teaches in his worn dentition course as well as the Pankey restorative footprint and clinical sequence taught in our Essentials 3 curriculum.

From my patient’s diagnosis, I discovered that he had two options: ortho plus restorative treatment or restorative treatment without ortho. Space was needed and form and function would definitely improve with improved space. We met for a conversation.

We looked at photos and models, then discussed the options. He explained to me that he would prefer to do the restorative plan without the orthodontics. My team and I invited him to experience a mock-up of the potential outcome from a wax-up by our own John Lavicka of Dental Ceramics. The patient immediately replied, “Let’s do it!”

Even though the patient understood why I wanted to do the orthodontics, he wanted to attempt treatment without it. I was happy to move forward with a restorative-only treatment with one agreement: If it did not work, I could initiate orthodontics. He agreed.

To be continued …

Providing healthier mouths to patients and doing more fulfilling dentistry (and making more money as a result) are admirable goals most practices have. I have written a couple of times about techniques that help us improve case acceptance: creating curiosity and co-discovery, listening, the learning ladder, and more.

This brief overview is an attempt to see the process as a journey for the patient and to consider their perspective:

Patient’s Journey: Eighteen Inches at a Time

It Starts in the Head

Patients first listen to the facts about dental care, their need and wants, issues or diseases that they have, and potential treatment solutions. Sadly, facts are not enough.

Developing great listening skills, caring, and trust help patients come to see you as their health advisor. This requires an eighteen-inch ‘Journey to the Heart’! It is there that caring and trust live. The emotional connection is very important in case acceptance. To ignore it is to minimize your success. But that too is not enough.

The patient must schedule, keep appointments, and pay for recommended treatment. This ‘Journey to the Wallet’ is the next eighteen-inch trip the patient must take. It is the execution of the plan from their perspective.

Valuing dental care and oral health is demonstrated by their checkbook and what they spend time and money on. Still not done?

The next eighteen-inches take us to a knee. Appreciation helps fulfill us as caregivers. Most rewards are best when they are balanced, financial, and behavioral: money and warm fuzzies, you get the idea. Money alone does not buy happiness (but it does help you enjoy your misery in some mighty fine places!).

The final journey takes us eighteen inches to the patient’s feet. When patients tell others about your practice and refer their friends, you have come full circle. This trust display is the ultimate compliment to you and your team.

Keep the Patient’s Perspective in Mind

Ask yourself the following and seek answers with your team to enhance patient health, your fulfillment, and mutual rewards:

·       Have you helped nurture movement toward the heart?

·       Did the patient accept and schedule treatment? If not, why not?

·       Were they able to pay with gratitude and appreciation? (borrowed from Dr. Pankey)

·       Did you ask for and receive referrals of their friends and family?

Remember, it’s a journey, not a destination. Enjoy the trip and check the map along the way. You, your team, and your patients will all be the better for it.

A journey is best measured in friends, rather than miles. -Tim Cahill

Like with any big purchase or expensive commitment, it’s not surprising patients would want to try on a new smile before going all in. You wouldn’t expect someone to purchase a sports car without first riding it around the dealership, would you?

Think of your cosmetic treatment as a high-end experience and your patients will too. Even the most hesitant spenders will be much more interested in moving forward if they’ve gotten a taste of how beautiful their smile really can be. This is where the ‘trial smile’ comes in.

Cosmetic Case Acceptance: Let Patients Try Their Smile

There’s no need to feel daunted by the process of creating a trial smile. Patients want to find a dentist who will offer them the kind of care they feel they deserve and who are willing to give them exactly what they want. You’d be surprised how hard it can be to find someone who will listen to a patient’s expectations instead of delivering what they personally feel is best.

With esthetics, the patient should have the primary say. Invite your patients who have given indications of wanting cosmetic treatments to communicate their preferences in a very tangible manner. All you have to do is first conduct a co-discovery appointment complete with high-quality digital images and an occlusal exam as well. Then, temporarily put composite on their unprepared teeth.

With this strong foundation already in place, your patient can see the potential outcome of smile design. When you pitch a trial smile to them, you can even call it a ‘demo.’ If the patient loves what they see, it’s no problem to move on to a diagnostic wax-up using a model of their demo smile.

What case acceptance techniques do you find most effective? We’d love to know your thoughts in the comments section below!

Photo courtesy of Matt Roberts CDT, CMR Laboratory.

The Aesthetics Course taught by Matt Roberts, CDT, Dr. Frankie Shull, Dr. Susan Hollar, Dr. JA Reynolds and Mr. Michael Roberts is just the place to learn to use digital technology to help patients want an aesthetic makeover.

Consistent case acceptance is a skill it can take years to develop. Part of the reason it can seem so challenging is that a patient’s true motivations may not be clear from the outset. We have to hone that sixth sense that can tell us what information or guidance would truly speak to a patient.

Two aspects of case acceptance in particular often go ignored because they either seem too obvious or are just not as fun to dive into: offering individualized options and making sure patients understand insurance.

Individualized Options for Case Acceptance

You may think the concept of individualized options is a no brainer, but that isn’t necessarily the case from a patient’s perspective. If you’re willing to provide this extra level of specificity, you can put many ‘maybe’ patients right into the ‘yes’ category.

We accept that car and other big purchases are often paid in installments, so why not do the same with a large investment like dentistry? Offering financing or other piecemeal payment options to patients is a game changer. It also makes comprehensive dental care accessible to a broader demographic. That in and of itself is valuable.

When dealing with patients, break the payment options down into easily understandable terms. Tell them the total fee, but decrease the stress by making it clear that there are different ways they can arrange to pay, including pre-pay, pay as you go, and Care Credit. Using a term like Care Credit is helpful because everyone is familiar with the idea of credit. When they ask for more information, you can lay out the details of payment plans.

Understanding Insurance for Case Acceptance

The real role of insurance is a mystery to most patients. Some may deliberately avoid understanding it because of how convoluted and frustrating it can be. They may have an entitlement mindset complete with the belief that the only healthcare they can indulge in is the kind covered by insurance.

Before you ever even look in a patient’s mouth, my advice is to have the insurance talk in low-stress language. Explain the actual definition of insurance and describe how dental insurance functions more as a maintenance plan. Use analogies to clarify the fact that just like with car insurance, its more of a backup fund than a way to pay for necessary yearly interventions such as a new tire or oil changes.

Helping patients move past denial over their dental health is no easy feat. In your dental practice, you have likely encountered this situation many times.

The truth is, patients who won’t or can’t accept the treatment they need for improved oral health can be put on a more positive path. The hard part is that they often require a significant amount of patience.

In a previous blog, I discussed the mechanism of denial and how it functions to constrain our patients despite our best intentions. There is no ‘forcing it’ because the psychological weight is too heavy. Facing a loss of a measure of health is extremely difficult, despite whether we ourselves believe the issue isn’t significant.

Characteristics That Support Change For Patients in Denial

One way to help our patients in these situations is to avoid frustration. Acceptance of other people’s emotional struggles can come from checking in with our own personal response to stress.

How do you create lasting change? Exploration of this question can give you a clearer perspective about similar answers for others. It can also reinforce the sense that our reactions to stimuli or upset can be quite different.

Once you (or a patient) have accepted change, you will still need to rely on your own resilience to parry the unexpected difficulties or days where your resolve is less strong. Some of the qualities that help in this situation include courage, commitment, awareness, curiosity, confidence, support, and skill.

The foundation of change is the first of these qualities: courage. Making changes in spite of fear is reliant on our willingness to see the potential risks and move ahead anyways. A big piece of this is recognition. If you can recognize what is holding you back from change, you can externalize the fear, make it more manageable, and talk about it rationally with others.

How do you help patients accept and appreciate change? 

Ever since I started my AEGD residency following dental school, I have loved continuing education. I’ve always sought new courses, new educators, new techniques. But for me, the most impactful educational experience was taking The Essentials courses at The Pankey Institute.

Not only did I learn about the complex temporomandibular and masticatory system, perhaps more importantly, I gained the skill and confidence I needed to tackle complex esthetic cases and truly found my sweet spot in dentistry.

Finding My Way in Dentistry

I am a bread and butter general dentist. However, my favorite cases are the ones that have the capacity to change someone’s smile, to make them not only healthier and more beautiful, but most importantly, improve their confidence. Once I gained these skills I wanted to implement them into my practice as soon as possible, but unfortunately I tripped over a few stumbling blocks before I found the right way to do that.

I remember one particular patient I had who really could have benefitted from some esthetic dentistry. I spent hours mounting the case, cropping and organizing photos, even waxing up anterior teeth on a model to show him the dramatic esthetic improvement I could make to his smile. That patient was engaged and listened to everything I had to say.

He came back for his second consult, asked questions, but at the end of the day never pursued treatment. I learned a valuable lesson in that case and numerous others. When I stopped presenting the treatment I thought patients needed and instead let them tell me what they wanted, I started closing cases.

As a part of my comprehensive exam, after the radiographs, the periodontal probings, the hard and soft tissue exam, and often clinical photography, I simply ask the patient, “Is there anything about the way your teeth look that you would like to change?”

To be continued…