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Six steps to painless (and profitable) dentistry

April 1, 2007
The equation for dentists is really that simple. The monetary difference between painful and pain-free dentistry can mean tens of thousands of dollars of extra income in your pocket annually, and as much as half a million extra in your pocket at retirement.
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by Michael Silverman, DMD

The equation for dentists is really that simple. The monetary difference between painful and pain-free dentistry can mean tens of thousands of dollars of extra income in your pocket annually, and as much as half a million extra in your pocket at retirement.

Moreover, these numbers do not begin to tell the story of all the professional stress you can alleviate and the comfort you can provide patients by banishing pain from your practice.

During the past 20 years, I have made an informal study of the cost of dental pain, both in dollars and in human suffering, and it is staggering. When you factor in the higher price patients pay for delayed dental treatments - out of fear of pain, not to mention the burnout rate among dentists and their staffs who must cope with uncomfortable patients - the price tag easily tallies to many billions of dollars annually.

Amazingly, pain is not a necessary byproduct of good oral health and oral health treatments. Today’s well-equipped and properly trained dentists can - and should - run practices that are free of pain, both for the patients and for the professionals. I’ve helped train thousands of dentists on how to make their offices “pain-free zones,” and stand as a witness that doing so is easier than you may think. Dentists were meant to alleviate pain, not promulgate it. Unfortunately, many of our predecessors failed to read the memo and poked, drilled, yanked, and filled their way to ignominy.

Perhaps, 30 or 40 years ago, dentists might have been excused if they failed to adequately manage their patients’ pain. Perhaps. But there is no excuse today, given the array of available methods and medications to ensure patient comfort during and after procedures. Indeed, when patients talk about the pain of going to the dentist, many of them are really saying that they fear the discomfort, awkwardness, confinement, and lack of control associated with dental visits. The pain they experience when going to the dentist, more often than not, originates in the head, not the mouth.

Similarly, dentists who must cope with anxious, fidgety, and ungrateful patients describe them as “a pain in the ___.” The word that most commonly follows is not in the head, neck, or mouth. But the dentists’ pain is no less real.

Here are six steps that encapsulate what I’ve learned about pain through treating thousands of my own patients and studying the treatment of tens of thousands of other anxious and fearful patients in my position as cofounder and president of the Dental Organization for Conscious Sedation (DOCS). The steps alternate between those intended for patient comfort and those intended for the benefit of the dental practitioner.

Patient step #1: Where does it hurt? At home!

Dental pain begins long before a patient ever arrives at the dentist’s office. Indeed, a large majority of patients only seek out dental care when the pain they are experiencing surpasses the pain they associate with visiting the dentist. Until the pain balance tips to the intolerable side, these patients will frown and bear it.

For millions of Americans, the most difficult aspect of seeing a dentist is picking up the phone and requesting an appointment. Many patients don’t get that far or delay the call for years. Impatient receptionists, long hold times, and the sounds of whirring dental equipment in the background cause untold thousands of would-be patients to hang up and rethink their initial impulses.

We teach that dental care, especially for anxious or fearful patients, begins the moment the patient musters the courage to call in. If the receptionist sounds frazzled, or the caller is placed on the telephonic purgatory known as indefinite hold, who can blame the patient for wondering whether that dentist might be the path to heaven or elsewhere?

Nancy Hammel, who has dedicated years in the front office of her husband’s dental practice in Clay Center, Kansas, has been instrumental in developing effective protocols for dental team members to offer caring telephone and front office support from the patient’s first inquiry to the completion of the dental procedure, including follow-up phone calls after the patient is back at home or work.

“There truly is nothing like a first impression,” says Nancy, who trains team members at the same time that their practice’s dentists are learning the pharmacology and safety protocols of oral conscious sedation (OCS). “Our calm, our caring, and our patience set the tone for the patient’s entire course of treatment. As often as not, we get thank you cards from grateful patients who credit us with alleviating their anxiety.” Well-trained team members are the advance guard of a pain-free dental practice.

Professional step #1: God bless the finicky patient

There is a line in the long-running Broadway play “Fiddler on the Roof” where the rabbi of the small village of Anatevka in Russia is asked whether there is a prayer for the Czar, who oppresses and taxes the townsfolk mercilessly. The rabbi ponders a moment, tugs at his beard, and then replies with a kindly smile, “May the Lord bless and keep the Czar,” he intones, quickly adding, “far away from us.”

So it is with nightmare patients. They should receive proper oral health care. But given the wear and tear that these nettlesome patients can cause ­- taking time, resources, and energy away from equally needy cooperative patients - let the troublemakers, bless them, get their treatment elsewhere.

How do you screen out troublemakers? Effective target marketing has shown great acuity at reducing or eliminating patients who make dentistry more trouble than it’s worth. Ideally, we would serve all patients no matter their habits or attitudes. But boy, does it sting to hassle with an obstinate patient who cancels and reschedules multiple times, complains constantly while in the office, then stiffs the practice for dental services. It doesn’t take many of these “pains” to make most dentists wonder why they didn’t become botanists after all.

Sophisticated dental marketers use state-of-the-art demographic tools to laser-focus their marketing dollars on patients who are most inclined to keep their appointments, pay for their treatments up front, and share their positive experiences with friends and neighbors. In the case of OCS patients, many haven’t been to see a dentist in years. When they discover a dentist who will treat them without engendering fear and anxiety, they are typically so grateful that they swear by their dentists - not at them.

Patient step #2: Take this pill and see me in the morning!

In a brief overview such as this, it is not possible to convey all the training and safety procedures we inject into our three-day oral conscious sedation seminars.

But here, in a nutshell, is the protocol: Patients are carefully screened to detect any health irregularities that would preclude them from receiving oral conscious sedation. Those who are eligible take a single, safe dose of a sedative in pill form the night prior to their appointment. In the office on the day of their visit, they are given another sedative about one hour prior to treatment. While in the office they are continuously and closely monitored, including the use of a pulse oximeter and blood pressure monitor. Depending on the length of the visit and the patients’ level of conscious sedation - patients must respond to verbal requests at all times - they may be given one or more subsequent doses of medication. Patients are escorted home by a companion after their procedures and dentists or staff members check in by phone to make sure the patient is doing well.

To the delight of patient and dentist alike, that’s it, more or less. Is this too easy and good to be true? Not for more than one million adult patients who have safely and effectively been treated using oral conscious sedation.

Because of the amnesia-like effects of the sedation medication, most patients remember little, if any, of their time spent in the dentist’s chair. Many of these patients have previously avoided dental treatment for years and years - even decades.

That oral conscious sedation is not offered by more dentists is only a matter of time and education. As more dentists come to realize the benefits to their patients and their wallets, OCS is certain to become the norm in treatment of fearful and anxious patients.

Professional step #2: Where less is much more

A funny thing happened on our way to serving anxious and fearful patients. While the patients take the pill, it is often the dentist who is relieved of anxiety. Instead of filling their appointment books with assembly-line dental patients, dentists find they are able to pass their days attending to fewer, more challenging cases, which keep the dentists and their teams fresh and motivated.

Let’s face it, after the 10,000th or so cleaning or filling, dentistry can become a bit routine for the clinician and rarely appreciated by the patient. By contrast, many of the fearful and anxious patients who seek out dentists who administer oral conscious sedation are in need of complex oral health remedies, and are eternally grateful.

Once sedated, these patients are a pleasure to work with. I know dentists who book only one or two high-value patients a day because these patients tend to present with mouths full of woe, requiring extensive dental expertise and creative solutions. And since these patients typically prepay, they are almost certain to keep their appointments.

Imagine having hours to work exclusively on a single, relaxed, and cooperative patient! When you leave the office at the end of a day, you are energized, not exhausted. Talk about pain relief!

Patient step #3: Safety, safety, safety

I use the word three times because it takes a troika of individuals to make certain that adult patients who are treated with oral conscious sedation are always cared for with the utmost dedication to their safety and health.

First, there are the dentists and their teams. Working closely, they screen patients for any health-related issues that might put them at risk, and gently but certainly refer those patients who might not do well under OCS. The dental team also closely monitors patients while they are in the office, when they are dismissed, and after they return home. There are no exceptions.

Second, there are the patients. Most are so relieved to finally have their dental problems attended to that they fully cooperate. This includes bringing a “chaperone” with them on their dental visit to be certain that the patient doesn’t attempt to drive him or herself while still under the mild influence of the sedation.

Third are the chaperones. Having a family member or friend along not only provides an early warning system of any unanticipated reactions to the sedation, it is also comforting for the patients to know they have a caring individual to look after them.

When patients complete their treatments and realize that everything went smoothly, they rapidly reprogram their image of dentists to that of soothers, not sadists.

Professional step #3: Public service and profit need not be oxymorons

OK, so we’re not supposed to think about making money in dentistry. Our first allegiance is to our patients and their health. Truth be told, I couldn’t respect any dentist who didn’t think that way. But it’s OK, too, to think about ourselves. In fact, I believe that happier dentists are better dentists, and that patients who are seen by contented dentists are direct beneficiaries of that satisfaction.

As a rule, dentists who offer their patients the choice of OCS do better financially than those who don’t. These patients accept fee for service, they pay up front, and require more extensive treatment than the average dental patient.

Moreover, after they’ve overcome their fears, many of them become evangelists for their dentists, referring them to everyone and anyone who will listen to their story of oral redemption.

Those referrals, of course, translate into even more business, and soon an OCS dental practice is earning more each year than the dentist ever dreamed possible. Best of all, the additional profit comes in the service of patients, not at their expense.

Many of us look forward not only to year-to-year income growth, but also to selling our practices for a favorable price at the time of our retirement. Again, sedation dentists enjoy a large advantage. It is quite common for those dentists with successful practices to discover that their valuations are significantly higher when it comes time to sell. How high? Of course, it depends upon both market and practice size, but it is common to see dental practices command $250,000 to $500,000 extra upon sale because of the value of their sedation businesses.

For anyone wondering how long the pain-free movement can continue to pick up momentum, I assure you that the “train” has hardly even left the station. More than 90 million Americans currently avoid regular dental visits out of fear or anxiety. As our population continues to age, those numbers will only increase as will the imperative to treat these patients before their overall health is compromised.

One day, perhaps 100 or 200 years from now, the collective public memory of painful dental visits may be replaced by one of the dentist’s office as a sanctuary of comfort and healing. I, for one, am working every day to make that vision a reality. Until then, however, the equation we began with will remain accurate. Pain will cost you and your patients dearly. Comfort will reward you in kind. The choice, fortunately, is yours to make.

Dr. Michael D. Silverman is globally recognized as a top dental innovator, educator, and advocate for patients’ rights. Having brought oral sedation dentistry to the forefront of general dentistry through his stewardship of the Dental Organization for Conscious Sedation (D.O.C.S.), almost 1,000,000 patients have been safely and effectively treated by D.O.C.S.-trained dentists. Dr. Silverman may be reached at (877) 325-DOCS or via e-mail at [email protected]. To learn more about D.O.C.S., go to

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