HOW TO PROFIT FROM...adhesive dentistry

May 1, 2000
Esthetic dentistry increases profitability and creates enthusiasm in the dental team (including the doctor) and happy patients that are willing to pay - with gratitude.

Esthetics ushers in the platinum era of dentistry

Estel L. Landreth, DDS

Esthetic dentistry increases profitability and creates enthusiasm in the dental team (including the doctor) and happy patients that are willing to pay - with gratitude.

I am entering my 33rd year of general practice in Wichita, Kan. Rather than slowing down, I`m busier than ever. Since last June, my practice`s production has increased by 40 percent. Our dramatic increase in production (and profitability) is due to presenting - and gaining acceptance of - anterior and posterior bonded esthetic dentistry.

The new materials are wonderful. They are very user-friendly, both for the dentist and the laboratory. If everything is done correctly, the results are predictable and patient acceptance is nothing less than enthusiastic. Scheduling is more relaxed because of the longer and more productive appointments with quadrant and multiquadrant dentistry. Esthetics is one of the fastest-growing services in dentistry, and is usually value-based - also known as wants-based. Insurance pays very little, if anything, of esthetic fees, but when people want something, insurance becomes less important to them. More and more dentists are choosing not to participate with insurance plans. Esthetic dentistry is a wonderful tool to become insurance-independent.

We have never participated in insurance plans, and the practice has always been what I define as a "semi-cash" practice. We file claims on behalf of our patients, accept insurance benefits as partial payment, and help our patients manage the difference by spreading treatment - not payments - over time as needed to fit within the patients` budgets. We expect payment at the time of service, and offer a courtesy fee adjustment of 5 percent for prepayment in full of any case costing more than $3,000. If finances are a major concern, we prioritize the patient`s needs in terms of short- and long-term goals. We do "phase dentistry" when indicated by economics, and always stay focused on long-term quality.

Patients are becoming more knowledgeable about insurance limitations. They know insurance doesn`t always pay well, especially for new technology. If anterior and posterior esthetic dentistry is explained properly, it creates an attitude of value-based dentistry. We are not anti-insurance; we simply choose not to accept their fees. Our patients still benefit from having insurance. We try to give such good care and service that of those who leave our practice because of insurance issues, many end up coming back. It is very challenging to give patients the very best dentistry if they are insurance- and needs-based. We handle insurance issues up-front, informing the patient of costs before we do the work. We believe in "inform before you perform."

Over a 10-year period, our once-40-percent profitable practice had slowly decreased to slightly below 30 percent. This decrease in profit created stress for the staff. Too much time was focused on budget and money issues. It was also stressful for me when employees deserved raises, but the only way to increase their salaries was to decrease mine. Economic stress created emotional stress and this had to change. Our economic turnaround occurred last year. Profits have increased, stress has gone down, and team members` attitudes have become more positive.

An enormous part of getting patient acceptance is related to the team`s attitude regarding quality of care. Outside educational sources are essential for the entire team to stay current. Team members should participate in the same CE courses as the doctor. Third-party reinforcement is a powerful tool. Most progressive dental practices could not excel without coaching. Recall our sudden growth in 1999, just three years after we started doing bonded esthetic dentistry. Was it a seemingly "overnight" change? You can probably guess why the change occurred. I took several key staff people to an Experdent course entitled "Leadership," which brought together the business principles and communication skills that we needed to create a complete patient experience. This course gave us a format to present and receive acceptance for the quality dentistry we knew how to produce. It doesn`t do any good to have technical expertise "on the shelf" if you don`t obtain case acceptance. The increased profitability was so dramatic that we have now committed to taking the entire team to "Leadership."

You have heard that "timing is everything." Adhesive dentistry and changes in our society`s values have come together perfectly. People are living longer, want to look better, and consumers have more discretionary money available than ever before. Our society`s quest to look better is a value-based decision. Esthetic dentistry is the icing on the cake! People who choose esthetic dentistry are enthusiastic and grateful. These patients spend thousands of dollars for elective procedures that most of us would say they do not need in order to keep their teeth for a lifetime. The teenager with badly discolored teeth, the adult who does not like his or her appearance, and the post-ortho case with anterior interproximal spaces want it, pay with gratitude, and become enthusiastic promoters for our practice.

Dentistry is now beginning to treat the patients` emotional needs in addition to "tooth-related" needs. We have spent the last 30 years educating our patients that they can keep their teeth for a lifetime, which has opened the door for elective dentistry. Dentistry is a lifetime need. To stay in relationship with our patients, we have to continually recreate value through education. Part of that educational process is to make people aware of what modern dentistry has to offer and what it can do for them. The public is constantly bombarded with information about dental health and whiter teeth. Bleaching was a big step in getting our patients to think about value-based dentistry. Now bonded esthetic dentistry is the next step in our patients` natural progression toward looking and feeling better. I want to stress "feeling better," because we have seen many patients` attitudes change after having their mouths restored with modern materials. Happy patients make happy dental teams. Team members` attitudes also change; they now consider their jobs as professions.

Anterior esthetics can be dramatic, but posterior bonded inlays and onlays have become the foundation of our practice. These are routinely done the same way we used to do direct restorations. They are easy to present and easily accepted because they look good. These restorations seem to disappear into the tooth and look even better on follow-up maintenance visits. Tooth contours and margins are outstanding.

I now consider posterior bonded restorations as a part of basic dentistry. More important than my opinion, however, is how the patient feels about it. I`ll use a 55-year-old male patient whose mouth was restored with gold at our practice in the 1970s as an example. He moved to another state and his new dentist raved about his beautiful gold onlays and inlays. Recently he moved back to Wichita, relayed the compliments to our staff, and told us how proud he was of his gold restorations. When he needed some minor repair, he chose esthetic dentistry, not gold. After seeing what was possible with modern materials, he asked me to replace his 30-year-old gold restorations - which were still good - with the new bonded type of restorations! This patient is not unusual. Just ask your patients if they want a tooth-colored restoration or gold. Esthetics will win almost every time. I still like to do second molars in gold, but I am finding more resistance to this. Many patients are willing to accept the increased maintenance in order to look good.

Society`s values are constantly changing. If change is a constant, then "persistence" should be the most important word in your vocabulary. Once you decide what kind of dentistry you want to do and what kind of service you want to provide, it takes persistence (staying focused on your vision) to achieve it. If you include the team in the same CE courses, they can help remind you of the vision everyone has for the practice.

Recently, a 47-year-old male patient with badly worn teeth and minor periodontal problems came in to be re-evaluated. He told me he had sold his house and was moving into an apartment because he was in financial difficulty. Hearing this, I quickly told him his immediate dental needs. He was starting to leave when the hygienist asked, "Doctor, would you like to diagnose what every tooth needs so I can help our patient outline his long-term goals?" Later that morning the hygienist escorted me to the conference room, closed the door, and asked, "Why did you not want to tell that patient what he really needed?" I had prejudged the patient`s ability to pay and his desire to fix his teeth. That patient not only wanted the procedure; he prepaid for the entire case in cash. I had violated one of my basic rules - The Relationship Rule. Remember that you are not in a relationship with a patient until you and the patient mutually agree on a plan of action. We can diagnose a patient`s dental needs but we cannot diagnose his or her pocketbook. Every patient deserves a treatment plan.

Taking the time and effort to educate can increase treatment plan acceptance. Our basic philosophy is to co-diagnose and arrive at a mutually agreed upon course of action.

Face-to-face communication is our primary means of education. Secondary means of education could be classified as practice promotion or marketing. We do only internal marketing.

As a dental professional it is your responsibility to evaluate the materials you use, whether they are restorative materials or bonding agents. Products are coming on the market at a very rapid rate. Don`t buy something until it has been tested in the marketplace. Rely on sources you know and trust for information, such as newsletters, educational groups, and fellow practitioners. If you are using something that works, don`t be overanxious to change. Only purchase new equipment when it makes good economic sense and there is a benefit to the patient and you.

As a dental professional, it is also your responsibility to have technical excellence ready before you present it to patients. If you make a commitment to performing large esthetic cases - especially anterior esthetics - you need to be prepared to exceed the expectations of the patient. There are many outstanding courses available to help you attain technical excellence. The most wonderful thing about many of the courses is that laboratory professionals and dentists take the course together. Good laboratory support makes esthetic dentistry exciting and predictable. Many cases may become multi-disciplined, as you work with periodontists, orthodontists, and oral surgeons. Patients can have demanding functional, esthetic, and emotional needs, and we must be prepared to meet those needs.

Dentistry is truly entering the most exciting and rewarding period it has ever experienced. It is up to you to decide what you want to do. If you want a value-based practice that is not insurance-dependent, esthetic dentistry can help you attain this goal. Patients that value this type of dentistry are less cost-sensitive.

The time is now. This is the platinum age of dentistry.

For more information about this article, contact the author at (316) 685-9276 or by e-mail at [email protected]. A biography of the author appears on page 8.


(1) Determine if the patient has a need. Ask questions and listen. It is very important to let patients decide if they really want this treatment, especially anterior esthetics, which is a highly emotional issue. If a patient is not very positive, we proceed slowly and remain very low-key. If a patient is committed to this type of dentistry, then we are excited and enthusiastic about what is available and what we can predictably produce. It`s easy to get excited about the new bonded esthetic materials because they are beautiful and much healthier for the patient from a periodontal standpoint. But we are very concerned about selling someone something that they are hesitant about. We want happy, enthusiastic patients when the procedure is completed.

(2) Staff members must have their mouths in good repair, especially the doctor. One of the most powerful tools I have in my practice is showing patients my own mouth, which was restored about three years ago. My case was documented with before-and-after pictures and models. The acrylic models show not only tooth position, but also color change. There is a very powerful message when you "practice what you preach," and when patients know that you, your family, and your team members have confidence in this type of dentistry.

(3) Dental photography is a dramatic tool to demonstrate what is possible. All cases displayed in our office are cases that we have done. Tastefully done albums are placed in the reception room and pictures of different types of cases are nicely framed and displayed throughout the office. When using photographs to show patients, we choose cases similar to their own. Many times when we ask patients what their expectations are, they will point to a picture and say, "I want to look like that."

(4) Once a patient has shown significant interest, we go to the diagnostic step. We secure needed records - including diagnostic models for waxing up - and "before" photos.

(5) When we determine what we can predictably achieve, the final step is case presentation. This includes fee presentation. All large esthetic cases are prepaid or paid in full at the time of service.

(6) During the restorative process, we give our undivided attention to the patient and create a pleasant environment for him or her.

(7) Upon completion, we invite the patient back for a follow-up appointment. At this time we complete the "after" photo series, recheck all work, answer the patient`s questions, and review the benefits of treatment. We also ask the patient to invite his or her friends and family members to join our practice.

(8) As a follow-up, we send before-and-after photos with a handwritten note to the patient, thanking him or her for allowing us to be his or her dental home.

(9) Let dental specialists know what you can do. Go to their staff meetings and make short presentations. Many dentists who refer patients to specialists are not doing this type of dentistry. Be willing to work with the specialists and general dentists, helping them in any way you can. It will pay big dividends.