"Only the best-quality dentistry ..."Oh, really?

Joe Steven, Jr., DDS

"Only present the same quality of dentistry that you would want in your own mouth." Oh, really?

Throughout my 25 years in practice, I have often heard that advice from all the top leaders in dentistry. I first remember hearing those words from Dr. Omer Reed, Dr. Dick Barnes, and others, when I was fresh out of dental school.

We still hear those hallowed, golden words from most of our current speakers and authors in dentistry. They strongly encourage each of us to present quality dentistry to each and every one of our patients and never attempt to diagnose their wallets. They often say that you should only present the quality of dentistry that you would want in your own mouth or that of a loved one.

I used to consider this to be valuable advice in the beginning stages of my practice. Then, the real world of dentistry hit home and I have avoided heeding that sage advice. On the surface, the statement is very convincing. Yes, if a gold or porcelain inlay is good enough for me or my wife, then, by gosh, I should definitely offer it to every one of my patients as my recommended treatment. Some believe that this is a responsibility we have as professionals and that we should strive to provide the best. Many also believe we should not even offer alternative treatment plans — only the best!

As I said, this statement sounds very convincing, but let's qualify it another way. Let's try rephrasing this advice: "Only recommend the same quality dentistry that you would want in your own mouth or those of your loved ones, and be willing to pay full retail fees, and not be able to deduct the cost as a business expense, and not have the added benefit of using that new dentistry to help you sell more quality dentistry to your patients."

Do you see what I'm getting at? Most dentists who have excellent dentistry in their mouths did not pay full retail cost for it. My mouth is full of gold inlays, onlays, and crowns, one porcelain onlay, and a couple of small amalgams (most dentists weren't doing posterior composites when those amalgams were placed so I'm leaving well enough alone). The most I ever paid for all that dentistry was just the lab bill. And then, I was able to deduct it! Furthermore, I've opened my mouth hundreds of times to show my patients how much I value gold.

At my Efficient-dontics seminars, I often will take an informal survey of all the attendees about just one situation so they can reevaluate their philosophies about presenting dentistry. Here's the scenario: You are a retired or disabled dentist and you relocate to another city where you don't know any of the dentists. You go to a local dentist in your new town, he finds out you're a dentist, and you have a nice conversation about our profession.

Now, upon examination, he detects interproximal caries on the mesial surface of tooth No. 31. The tooth only has an occlusal amalgam. (Yes, more dentists have amalgam restorations than some would like to think.) The doctor says, "OK Jim, let's talk shop. You know all the materials involved; what would you like to have done? I've been doing a lot of these beautiful porcelain inlays and onlays, the patients love them, and we're getting great results. My own mouth has been restored with many of these." (He proudly shows you.)

"Or," he continues, "I could place a DO direct composite or an amalgam. I charge $750 for the inlay, $125 for a direct composite, and $95 for the amalgam. What would you like me to do for you?"

I then say to my audience, "Doctors, you know dentistry, and if you knew you would have to reach into your wallet and pull out $750 to pay for this quality dentistry, would you do it, especially knowing that you don't have the luxury of writing it off as a business expense?" Ninety-nine percent of all attendees choose the composite or amalgam restoration!

I've treated other dentists who often have told me to "put a little more amalgam in there" to get them by for another 20 years. Now please, let's not be too hasty and accuse all these dentists of being poor-quality clinicians. There are many dentists who are excellent clinicians, yet have amalgams in their mouths. I do realize that there is that group of dentists who cannot accept that fact. I'm sorry, but I will not be able to appease that group with anything I write here.

Why do I even bother "rocking the boat" with this new perspective of presenting dentistry? I do this because I see way too many dentists struggling financially — even to the point of bankruptcy — because they are misdirected. I've often said that the business side of dentistry is not that difficult if we have our priorities straight and we're headed in the right direction. Too many dentists are headed in the wrong direction simply because we can't all have "Rolls Royce" dental offices.

If 99 percent of dentists would choose the composite or amalgam given the above scenario, then why should we assume that the average patient should select the porcelain inlay over a less-expensive restoration? The reality of it is that most patients don't, and that's why so many doctors are struggling financially when they try to narrow their treatment recommendations to only the "best-quality dentistry."

There is another very important tangent to this "only the best" philosophy. It not only makes it more difficult to sell dentistry, but I believe it does little to help generate new-patient referrals. How many times have you walked in to do a clinical exam and the patient has both hands up in the air with his fingers crossed just hoping you don't find any cavities? He certainly is not wishing for a $30,000 treatment plan!

I take great pride and satisfaction in telling a patient, "I didn't find anything that needs to be treated at this time." I even break the Great Gurus' Golden Rule and will actually watch suspicious areas. Patients love you for this conservative approach, and that's one of the things that help generate new-patient referrals. They're proud to recommend you to their friends and family because they trust you and know their friends will be treated properly. Of course, there are exceptions to every rule; but I just don't believe the average patient is inclined to tell all his friends about you after receiving a treatment plan with a price tag equivalent to a new car! Actually, many patients would be embarrassed to do that. So, I believe that this increasingly popular concept of presenting the "big case" is often very counterproductive. The vast majority of these patients don't return for treatment and they certainly don't recommend that dentist to others. That's why most of our leaders now are strongly recommending that dentists advertise to attract many new patients — hoping that a few will accept these big cases every month.

Yes, I understand that some doctors have success with this type of practice and I compliment them and wish them well. But, for every one of them, there are 100 practices that are struggling with that philosophy. There's nothing wrong with part of our profession catering to the very affluent sector of society who demands the best dentistry money can buy. And yes, all dentists should be informed about this philosophy of practice. Every business, after all, has varying tiers of clients. But, when 95 percent of all our seminars and literature promote this as the only way to practice, many dentists believe it. Unfortunately, most of them are faced with financial distress and disappointed patients who couldn't possibly accept these expensive treatment plans.

Another reason I feel compelled to write is because I truly believe that this "big case" trend sweeping our profession is a significant factor in dentistry's decline in popularity. Dr. Gordon Christensen, Dr. Woody Oakes, and Dr. Howard Faran have written similar sentiments on this subject. The Gallup poll shows us slipping from No. 2 to No. 8 in the eyes of the public when evaluating all professions in terms of honesty, integrity, and trustworthiness.

Last year, Mark and I were returning from our annual seminar in Las Vegas. I was sitting in an aisle seat, an elderly lady was sitting to my right, and her husband was by the window. She saw me reading Dental Economics and started up a conversation. She said she was getting ready to spend $20,000 to restore all of her lower teeth. She had just spent $20,000 to restore her upper teeth. I asked if she wouldn't mind my taking a peek inside her mouth if it wasn't too embarrassing. She gladly opened, and I had a look. The upper restorations were indeed beautiful. On her lower, I saw a few crowns and a couple of amalgams, but I really didn't see anything bad. I asked her why the doctor wanted to restore them. She said the doctor told her that they were getting worn down and starting to crack.

I invited "Iris" to stop by my office Monday or Tuesday for a free second opinion since she said she would be in town for a few days. She came in Tuesday and I did a very thorough exam with a pano and bitewings, perio, tmj, and cancer screening. She had four good crowns on her lower molars and three small Class II amalgams and no restorations or cavities on her anterior six teeth. I told her that everything was in good shape and she had no decay or cracks. At 70 years of age, her lower anterior teeth were healthier than many of my 30-year-old patients. I would venture to say that most dentists would have made the same diagnosis.

Iris and her husband were elated that their little plane trip saved them $20,000. While on the plane, she told me that they live on a fixed income and sometimes cash-in her husband's old gold crowns for a little discount. I'm sorry folks, but that just isn't right! Why in the world did that little old lady need $40,000 worth of dentistry?

You may wonder just how I told the patient about the discrepancy of these two opinions. (Déjà vu: "How Honest Are Dentists?" Readers Digest, February, 1997.) I have been a strong advocate of supporting my colleagues in most situations because I would like to think they would do the same for me. I am aware that some of my dentistry out there is not the greatest. Most dentists would admit the same about their practices. So, I think we should always avoid belittling one another to a patient. Remember the movie, "Pay it Forward"? It's something like that.

As difficult as it was, I attempted to defend her dentist by explaining that some dentists are perfectionists and want everything restored perfectly according to the extensive training they've received and their own philosophies. I did compliment the dental work on her maxillary teeth because it truly was exceptional (although I'm not sure it was necessary). I believe she left my office with no hard feelings about her dentist but decided not to go through with the rest of his treatment plan.

I often wonder how many dentists would spend $40,000 if they were in a situation like Iris and weren't able to write it off and use it to help sell more quality dentistry to their patients. Dentistry is a business; and to succeed, we need to get in step with our patients and apply some basic human-relations principles. This is especially true when presenting treatment estimates. Why would the average American worker — whose income is considerably less than a dentist's — choose a $750 restoration when the large majority of dentists would not?

Certainly, we all should be prepared and able to offer the best dentistry available, but also have a quick back-up plan of basic, less-expensive dentistry. There is so much dentistry out there that needs to be done that there really is no reason to struggle or to advertise unless you're targeting that very narrow niche of affluent patients — the most challenging thing to do in dentistry.

So, the next time you hear that ever-popular mantra, "Only present the same quality dentistry that you would want ..." maybe now you will be like me and think, "Oh, really?"