By Paul A. Henny, DDS 

Effective leadership in dentistry requires open-mindedness and empathy, while at the same time, assertiveness, consistency, adaptableness, and resilience.  

That’s a tall order! 

Many of us struggle to be assertive and empathetic at the same time, particularly when we are under pressure. All too often, we lean into our positional power and superior knowledge and don’t stop to ask ourselves: 

• How does the patient feel about my message? 

• Does the patient understand the long-term implications of the information I have presented? 

It’s important to remind ourselves that decision-making is a two-step process: 

Step 1: The recognition of accurate, relevant, timely, and important new information 

Step 2: Reasoning to make choices that align with values and goals 

Few people fully understand the nature of their problems, needs, and the complex processes necessary to realize their goals when they first come into our dental offices. Patients often behave dogmatically or too emotionally, which leads them to choices that result in more failure and frustration. 

Our ability to facilitate learning in others and lead them to decisions with predictably better outcomes can be developed. This is good news! With understanding, practice, and reinforcement through successful experiences, we can all learn how to become more effective leaders and develop a more successful practice. 

The 6 Key Steps to Effectively Guiding Our Patients 

1. Slow down and manage your time more strategically to spend more time with each patient.
2. Demonstrate empathy. Stay in conversation and ask questions to understand what they know and how they feel about the information you are giving them. 
3. Create a safe and effective environment for learning. This entails slowing down your delivery of information into the bite sizes that are appropriate for the patient and pausing often for their minds to catch up and for them to experience self-discoveries.  
4. Show deference for the fact that each person is the best expert regarding themselves, their feelings, values, and goals. Let them know you will support them in their process and invite them to learn more and weigh their new knowledge against their values, priorities, and long-term goals.
5. Give each person enough time to make complex decisions as well as work through the logistics necessary to make their decisions fit into their life.
6. 6. Remain clear and assertive about what is in the patient’s best health interests and consistent with your values. Only proceed with treatment decisions that are mutually agreed upon as appropriate.

By Edwin A. McDonald, DDS 

It is amazing to me to realize that I have practiced for more than 40 years in a relationship based, fee for service dental practice. Dentistry has become much more complex during that time. What has not changed is the need for human beings to be loved, accepted, significant, understood, and heard. Also, people who have a high value for their health seek high clinical competence and thoughtful patient management.  

Two years ago, I started looking for a partner to continue providing my patients with comprehensive, relationship-based care. (My hands, back, and body had been telling me that it was time to slow down.) My primary goal in this transition was to create a future where the culture of my practice would continue, and the practice would thrive and grow. 

I received a call 18 months ago from my good friend, Dr. Lynne Gerlach. She said: “Mac, I want you to meet Dr. Shawn Luck.” Lynne went on to say, “I interview young dentists every day and I rarely meet people like him.” 

Shawn and I met, and I immediately understood what she meant. After a few more meetings, several phone calls with colleagues that knew Shawn well, and a thorough financial analysis, it was time for “Team Mac” to meet Dr. Shawn.  

Team relationships are critical to a successful transition. Shawn was met with enthusiasm from my team. That meant we could move forward with a detailed agreement that included terms of employment and terms of practice purchase.  

Shawn’s well-grounded character, confidence, enthusiasm, and intelligence were the factors that guided my decision. We both needed what each other had. I needed Shawn’s character, youth, energy, ambition, and strong desire to own a practice. He needed my clinical training, experience, and commitment to be a focused, consistent, and relentless teacher. 

I began communicating the transition with my team and patients a few months before meeting with Shawn. I mailed a formal letter to my patients that said that I saw three to five years of clinical practice remaining for myself. The letter began and ended with a big thank you for their loyalty, trust, and support. It let them know that I was actively looking for a young dentist to partner with who would continue to take care of them. This letter was a huge success with a thank you from almost every patient. A few patients began to schedule pending treatment that had been on their mind. 

We sent a second letter four months later to announce Dr. Luck. We began communicating about his arrival in person with enthusiasm and emailed a digital copy. The main takeaway here is that the transition immediately benefitted from consistent, focused, and abundant communication with all practice stakeholders about what we were planning and hoping for.  

We are in the middle of year one and I am focusing on mentoring Dr. Luck. We are hoping to play the infinite game as we create and pass on opportunities to the next generation. 

My hope for my Pankey Institute colleagues is you will surround yourself with great people that make you better. Build partnerships with them. Build trust at a deep level. Build community. Serve one another. Seek opportunities to pass on the values of relationship-based practice to the next generation. If you invite young dentists into a relationship and repeat the mentoring you received, we can all play this forward. Dr. Shawn Luck has already captured the spirit of wanting to do just that. 

By Mary Osborne, RDH 

Developing a partnership begins with an attitude of curiosity. It stems from a belief in the possibility that by working together we can achieve more than either of us can accomplish alone. With an attitude of curiosity we can develop the skill of listening and asking questions before going too quickly to teaching and telling. 

How do we help our patients see the part they can play in improving their health?  

We can begin by inviting the patient to share with us what they know about their health. They come to us with attitudes, beliefs, biases, and concerns about their health, as well as specific knowledge of their history. The more we know about where they have been the better able we will be to help them plan their future. We will have information to share about what we find and recommendations for how to proceed, but if we listen first we honor their perspective. We can also begin to hear their aspirations for their health in general and their dental health in particular. 

When dentists discover plaque or bleeding in an initial exam, they can tell the patient that the hygienist will help them with home care. But if we ask the patient if they would like help with home care and they say yes, we now have an invitation to give them information. The difference is subtle, but important.  

You can also ask the patient if a solution they have thought of or a recommendation you have made is something they would like to try. A yes is a commitment on some level to share in the oral hygiene process with you. Inviting and asking means moving the locus of control from you to the patient. I recognize that that is not our default mechanism, so doing this takes intention.  

How can we help patients to see us as a trusted advisor and seek our guidance? 

One of the things that I have learned over the years is that, when I remember who is really in control of the patients’ health, I am better able to partner with them. This process may take a little longer initially, but I would like to suggest we have all the time we need. We have the lifetime of our relationships with our patients.  

Once you agree that you have the mutual goal of moving toward improved health, you can invite them to deeper levels of conversation and understanding around health. You can avoid assuming what is best for them and help the physician inside each patient go to work. As they share their thoughts, they often become clearer about what they hope for.  

When you are genuinely interested in your patient, you earn a level of trust that opens the patient to hear more about their existing conditions and your concerns for them. By making connections with them over what is possible to achieve and what they want to achieve, you create a bond that opens the patient to your expert perspectives. When you ask for and respect their input on solutions, they are more likely to commit to a solution. 

When a new patient needs urgent treatment, how can we meet those treatment needs and still commence a lifetime journey toward health with the patient? 

Of course, we want to help our patients with immediate treatment when disease conditions are acute, but we want to do so in a way that inspires the patient to see the bigger, more comprehensive health picture. We want to help them see health as a journey and see us as empathetic fellow travelers who understand their suffering. As we facilitate dialogue about the health outcomes of treatment, we uncover their broader health aspirations. 

We intentionally deliver the message that we are here for them. We are interested in them and care about them as a person, and we let them know they can count on us to help them become healthier and maintain achieved levels of health. We do not allow the fact that the patient needed immediate relief to get in the way of a long-term commitment to their overall health.  

How do we engage our patients in being curious about their total health? 

At every visit, we can invite them into conversation about their health. The questions you ask will shape the conversation. Instead of “Any changes in your health history?” you might begin with, “How has your health been since the last time we were together?” Pause and listen to learn about your patient’s experiences, opinions, and feelings.  

In my experience, this process respects the physician that lives within each patient and leads to continuous co-discovery and collaboration toward health. Every conversation can empower the patient a little bit more to become clearer about their knowledge, attitudes, beliefs, biases, and barriers. The insights developed over the lifetime of your relationship enable you to become a trusted advisor to your patients.  

By exposing your interest about a range of health issues (diabetes, heart disease, obstructive sleep apnea, weight loss, smoking cessation, stress reduction, etc.), they will see you as a professional with broad knowledge and a worthwhile perspective. They will see you as a valuable resource. They will see you as someone who knows about health and ¾ more important ¾ someone who knows them.  

By Mary Osborne, RDH 

One way to involve patients in making choices about their health is to ask for an invitation to give information. Everyone on the team can look for ways to get permission before taking action. For example, if the dentist observes bleeding or plaque while doing an initial exam, the dentists often say, “The hygienist will help you with that.” That’s okay but getting an invitation for the hygienist is even more helpful. Instead of telling the patient what the hygienist will do, the dentist could ask for an invitation. “Would you like the hygienist to help you with that when you see her?” Patients typically say yes, and that sets the hygienist up for a different conversation when she sees that patient.  

When the hygienist sees a note that the patient wants some help removing deposits in a certain area, she has been invited to give information. The hygienist can say, “So, I understand from the doctor that you’d like to have some help with being more effective at removing the deposits that are around this tooth on the lower right.” 

In this circumstance, I might ask the patient, “What have you tried in cleaning that area?” I pause and allow the patient to think and speak. Perhaps they would demonstrate how they brush or floss in that area. If I do make a recommendation to a patient, I like to follow it with, “Is that something you’d like to try?” 

The dentist and hygienist are a team, and the patient is the third team member in partnering for health. In ideal practice, all clinical and front office team members are part of the collaboration and share their understanding of the patient with each other. Many times, especially with elderly patients, I find there is a family member who is a health partner, and we can invite them to participate in consultations. In dentistry, when we become trusted health advisors to our patients, we can also influence their choices in other areas of their health.  

When we listen well, we can filter our information through the lens of improving overall health. We can make connections between their perspective and our own. When we understand the patient as an individual with special circumstances, opinions, and emotions, we can help them get in touch with their own aspirations for health and help them move toward those goals.  

By Paul A. Henny, DDS, and Deborah E. Bush, MA 

The traditional rational economic model used in classical decision-making theory routinely fails to predict patient behavior because it fails to consider the psychology of decision-making and the inductive neuro process necessary to change one’s mind about what is best for oneself. 

Classic Decision Theory 

Classic Decision Theory (CDT) models a decision-making process that involves a fixed set of alternatives about which a person knows little. In response, they relate their limited knowledge to the situation at hand, use their beliefs and expectations associated with the options to project an outcome, and then use logic to make the final decision based on their goals. 

According to this theory, people primarily make decisions based on their desire to maximize gains and minimize losses, an objective. This deductive process is largely driven by a heuristic known as “scarcity bias.” However, anyone who has practiced dentistry for more than a day outside of a teaching institution knows that CDT fails to explain many of the decisions patients make when they’re confronted with a complex problem they don’t fully understand.  

Simple decisions such as “Should I get this filling replaced because it’s broken?” or “Should I allow Dr. Smith to help me make this tooth stop hurting?” are predictable. What’s much less predictable is whether a person will allow us to equilibrate their occlusion or leverage restorative dentistry to reestablish proper form, function, esthetics, and neuromuscular modulation. Why? Because these are complex issues that require an understanding of how the stomatognathic system works before the proposed solution makes sense and appears to be the logical best option to the patient. 

Neuroeconomics is an interdisciplinary field that aims to explain human decision-making. By integrating psychology and neuroscience, this discipline can help us better understand how humans process alternatives to make choices and follow through on a plan of action. Neuroscience affirms that re-evaluating perspectives is a right-brain activity and an inductive process. 

The Dentist’s Challenge  

In practice, we often see patients making decisions we think are unwise for their long-term oral health. A person’s values and belief system influence their decisions. Not only may the person’s understanding and belief system be underdeveloped in relation to the value of properly planned, designed, and executed health-centered restorative dentistry, but their memories may be distorted. In this case, the person makes what we perceive to be unwise decisions because their memories do not align well with our understanding of the situation. They don’t know what we know.  

Helping Patients Think and Feel Differently Through Inductive Reasoning 

Reassessment, modification, or outright replacement of beliefs is a right-brain process known as inductive reasoning. The purpose of Co-Discovery is to take the patient through an inductive reasoning process. Oral health providers who understand how and why Co-Discovery works have experienced how it can change the trajectory of a person’s decision-making process. 

Our challenge is to create an optimal learning environment in which people can safely reevaluate their beliefs, values, and priorities. Being patient with patients and taking our time to guide them through the inductive process of Co-Discovery will comfortably provoke new thinking, new beliefs, and new emotions. Through the process, a great many patients come to realize that their historical perspective is not serving them well, and they decide to have that equilibration or restorative dentistry that will serve them best in the long-term.  

They may not choose treatment the first time it is recommended but will subsequently realize it is in their best interest. We just have to stay in conversation with them in Co-Discovery mode and guide them through the inductive process to arrive at their new goals.  

Long-term, this is healthier for dentists and their care teams as well. The conversations we have with patients change the trajectory of our dental practices. Better conversations result in better decisions, which in turn result in better outcomes. Better outcomes result in lower stress and a thriving practice that is much more fulfilling for dentists and care team members.   

By Paul A. Henny, DDS 

Today, I am revisiting the value of personal authenticity and its transformational power within truly helping relationships. We know can’t evolve into becoming more authentic with our patients until we first “know ourselves,” which is another way of saying “until we’ve developed a lot of personal insight.” 

Personal insight is the beginning point of understanding what tends to drive our behavior and thinking, therefore, it’s the beginning point of change. But there’s another key variable in the facilitation-of-change process that’s often overlooked: What is the level of personal insight within the person we are attempting to help?  

What happens when we and our patients share similar values? 

We’ve all had experiences with patients with whom we easily and almost automatically connect. The conversations flow smoothly, and there’s a lot of agreement regarding what needs to be addressed, how and when. It happens because these folks share similar values and priorities, and likely, they’ve had some personal experiences that strongly support those beliefs. 

But let’s be honest. Those moments are rare for most dentists who have undifferentiated practices. 

What happens in undifferentiated dental practices? 

When I use the adjective “undifferentiated,” I mean the practice has a lot of patients who come for reasons other than shared values, agendas, and purpose. A patient’s dental insurance is a prime reason patients go to a particular dentist. Nearly free new patient exams and limited x-rays offered by many dentists is another reason. Being accessible for emergency dentistry in the patient’s local neighborhood is yet another. 

PPOs are likely the most common reason a patient sticks with an undifferentiated dentist. Patients with “insurance” don’t really have insurance. They have a minimal and limiting benefit plan disguised AS IF it were insurance. Consequently, misconceptions occur due to the intentionally confusing language. 

Additionally, insurance causes people to naturally focus more on their benefits (a reductionistic concept) than on their health (a holistic concept). So, in a very twisted and often dysfunctional way, dental insurance can cause people to make bad decisions that negatively influence their health as they psychologically prioritize money over their health.  

The Scarcity Bias 

The human brain has a bias toward scarcity thinking unless it’s actively circumvented through more right-side prefrontal cortex involvement. This scarcity bias occurs as most dental patients make treatment choices, and when this happens, we have a choice. 

1. We can play along and rationalize it. “It is what it is.” We can take the checks and focus on economy-of-scale strategies and production. 

1. We can actively work to remove insurance carrier influence from the patient decision-making process while facilitating greater patient involvement and problem ownership. 

Put another way: We either accept the codependency relationships (and all the anger, confusion, disappointment, and frustration that it brings along with the insurance benefits), or we actively work at creating interdependent relationships with patients, wherein they become the co-creators of their health future and share responsibilities associated with that goal. 

The Violation of Personal Boundaries 

When we actively participate in dependency-centric relationships, we violate interpersonal boundaries.  

On this, Avrom King brilliantly commented, “Dependency is the word we use to identify an individual who, for whatever reason, cannot claim and develop their latent personal power; instead, they negotiate psychological contracts with other people whose ego needs are served by accepting responsibility for the dependent person’s outcomes.” 

The minute we start to take responsibility for other people’s responsibilities, we begin a journey down a road that commonly leads to dysfunction, conflict, and frustration. 

Heath-centered dentistry is only possible through interdependent relationships, which means that ALL codependent relationships aren’t health-centered. They are centered on other things that are often associated with insecurity.  

To be continued in Part 2… 

By Mary Osborne, RDH 

How much time do you schedule for a new patient, non-emergency visit? Is your priority efficiency or effectiveness? Is your goal to gather as much clinical data as possible, or is it to begin to build a relationship of mutual trust? Both are possible if you see the new patient visit as more of a process than an event.   

Too often new patients are rushed through an assembly line: brief conversation, clinical exam, diagnostic records, and treatment presentation! Is that really the best way to help people make choices about their health?  

There is no one right way to schedule a new patient. Different practices are successful with different models based on the values of the practice, practice growth, and the personality and skills of doctors and team members. The most important determinant of success is our ability to meet each patient where they are and join them on a journey to health. I am not suggesting we should be without practice standards of care.  We have a responsibility to decide what we need before beginning treatment. Our challenge is to guide patients to understanding why we need what we need, and why that is relevant to their unique situation.   

We may anticipate that patients will resist this type of experience, but if we make it truly about the patient and are flexible, I have found that patients are more than willing to participate in an individualized process that best meets their temperament and circumstances. 

I remember seeing a new patient that I was told was a “very busy attorney” because his secretary said so when she made the appointment and his wife said so when she confirmed the appointment. I anticipated that he would be a driver and prepared to efficiently move him through his appointment.  

As I explored his health history with him he expanded on the specific answers to questions. Soon, he was leading the conversation. When I remarked that I wanted to make sure we were making good use of his time. He said, “Mary, what’s this about time?” I replied that I knew he was very busy. He said, “Mary, this is about me. I have time for me.” 

His statement has stayed with me because I realized that if the conversation had been about me going through my check list and not listening to him, it would not have been a worthwhile experience for him. It also wouldn’t have been a worthwhile experience for me. 

I have learned that when the patient feels in control of the process they are willing to give that time to themselves. A lot of aha moments occur as they learn about themselves while speaking. When patients feel like they are on an assembly line being moved through our system, they have every right to be resistant.  

Empowering patients to lead the process is both an attitude and a learnable skill. When we can lose ourselves in the moment, really listen, really encourage, and really care about the patient’s thoughts and feelings, it is easy to make connections to the next step we recommend.  It is my experience that I can more quickly become a trusted health advisor when I intentionally share control with my patient. 

Most patients are willing to invest more time in the process when they see the connection between their needs and what we recommend.  These are typically patients who have or have had complex health issues and are seeking to improve and retain health. They perceive the value of the extended process and how much value you place on spending in-depth time with them.  

The entire team’s communication can deliver the message that everyone in the practice is keenly interested in them, and their appointment is uniquely planned to meet their needs.  

What has been your experience? Are you open to scheduling more time for conversations that typically garner trust and appreciation earlier in the relationship? 

By Lee Ann Brady, DMD 

A patient chipped a tooth on her lower hybrid denture and loosened an implant screw. The denture had been placed 18 years ago, so she had an old titanium bar with denture teeth and pink acrylic. That day, I put the screw back in and smoothed out where the tooth was chipped. During this visit we had a great conversation about the future of her hybrid denture. 

I have had a similar conversation with several patients in recent months. They have the original, traditional bar retained hybrid denture that is nearing the end of its lifespan. And so, what are the options? 

1. If the bar is in great shape, new denture teeth and a new denture base can be milled and placed over the existing titanium bar. 

1. Alternatively, we can get rid of the bar and go to something that is all zirconia. 

If there is a preference for the first option, the first requirement is to make sure the titanium bar is in good condition. After 18 years, we would take it off and have the laboratory examine it under microscopy.  

If converting to all-zirconia and the patient has had upper and lower dentures, we must consider if one arch can be converted without converting the second arch. A zirconia arch is going to wear an opposing original denture fast if there is parafunction, and the zirconia arch is likely to fracture the opposing original prosthetic teeth. 

We have options today we can think about with our patients, but many have in their minds that when they got their hybrid dentures years ago, the dentures would last. All the time, energy, and dollars to freshen up or replace their denture is a big deal to them. Shifting their mindset from “I thought I was done investing in dentistry” to “My denture is at the end of its lifespan” is a big hurdle. So, the earlier we can start those conversations before they need to invest, the easier they can transition their minds to accept care with grace when the time comes. 

When your bar retained hybrid denture patients visit for perio maintenance and your exams, inform them of the lifespan of their denture is at most 20 years and set expectations for discussing the best available options at some point in the future.  

By Mary Osborne, RDH 

There was a time when I thought “partnering in health” was just about getting people to take better care of their teeth. 

Many years ago, I had a patient who was excellent with her home care, but she showed up periodically with an acute periodontal infection. We asked about stress and her overall health, but she was not aware of any issues. We would treat the infection and she would be fine for a sometime. We knew she worked for National Public Radio, and one day we made the connection that her infections showed up concurrent with NPR’s fund-raising drives. That shared realization allowed us to help her see that her stress was affecting her dental health and her overall health. She was open to conversations about lifestyle changes that would help her be healthier. My relationship with her influenced my thinking and my ability to connect with my patients from a perspective of Whole-health Dentistry. I came to understand that I had been missing opportunities to influence the way people think and feel about health. I knew that I wanted my patients to see me as “a partner in health.” 

Unfortunately, most of our patients come to us with the perspective that we are fixers of teeth, not partners in health. 

In the culture today people are bombarded with information about what is healthy. From friends and families, social and news media, and a wide variety of health care practitioners, everybody expresses opinions on how they are supposed to take care of themselves. Why, then, are we surprised when our patients don’t know whom to trust? Why are we surprised when they shrug their shoulders or appear confused? It’s not always a case of conflicting facts but a case of various perspectives that people don’t know how to navigate. 

Think about where you place your trust. How do you decide whom to trust about decisions—whether it’s about your health, or about your finances, or about how you raise your children? When I ask myself that question, two criteria surface. They need to know their subject and to know me. I want that person to know what it is they’re talking about. I want them to be well informed. I also want someone who knows me, who understands my values. I want that person to have a sense of who I am and what is important to me. 

As we get to know our patients over the years, most of them come to see us as trusted advisors when it comes to their dental health—but fewer see us as trusted advisors when it comes to their general health. If we jump too quickly to making recommendations about their overall health, we are more likely to meet resistance. If we want to cross the bridge into influencing our patients’ overall health and wellbeing, I believe we need an invitation to cross that bridge.   

The Missing Piece in our quest to influence the overall health of our patients is the failure to invite patients to share their perspectives on health. Beginning a conversation with a new patient with the question, “What can you tell me about your health in general?” is an invitation for them to talk about their experience of their health, not just details. Instead of “reviewing” health histories, what if we “explore” health histories? As we connect and get to know each other we can learn to listen beyond information to hear attitudes, beliefs, fears, biases, concerns, barriers, etc. As you understand their perspectives on health issues that come up in conversation, it’s easy to ask if they would like your perspective on that issue. These conversations often lead to more questions and answers that invite more and more invitations from our patients to be their partner in health. 

Kelley Brummett, DMD 

After you do a crown preparation, do you tell your patients that you’re going to make them a temporary or a provisional?  

Provisionals are more than temporary restorations. They are part of a process. They’re the dress rehearsal to the final outcome. They are the prototypes for the final restorations.  

The “provisional” process is an opportunity to gain trust with the patient while modifying the length of teeth, the shape, or the color. It is also a way to communicate with the patient how their functional and parafunctional findings may have contributed to the destruction of their teeth. 

As the patient comes back to have their bite checked and to talk about what they like and don’t like, we are building trust. We’re involving them in understanding what they feel and think. We’re listening to improve their conditions. 

I’ve had patients who were fearful about moving forward with extensive treatment because they couldn’t envision the transition from the prep appointment to the final. What would those temporaries look like? What would they feel like? How would they function?  

So, when I am discussing a case with a patient, provisionals are all part of one treatment fee. We talk about the prep process, the provisional process, the lab process, and the final seating process—all as one process for which there is a fee. We discuss how the provisionals will guide us in optimizing the lab plan to achieve the desired comfort, function, and aesthetics.  

Whether it’s a single tooth or whether it’s multiple, I encourage you to help the patient understand that what you are providing in the interim between a preparation and a seat of a restoration is called a “provisional.” 

A provisional protects the underlying tooth structure. It keeps tissue in place. It helps the patient feel confident. It allows us to understand what might be going on functionally. It helps us communicate better with the lab. It’s more than a temporary restoration. It’s a guide on our journey toward predictable and appreciated relationship-based dentistry.