Basic Philosophy

For our purposes, calibration will be defined as:

Office wide uniformity in WHY we recommend certain dental procedures to our patients, WHAT we are saying to our patients to communicate the need for that dental treatment and HOW we go about acquiring records to help us educate patients and formulate treatment plans and case presentations.

We will identify common conditions that we see in our dental offices and the treatments recommended for those specific conditions.

Before we discuss certain clinical situations, we would like to describe best practices that we have found leads to deeper trust and better communication with our patients.

Philosophies

Certain “best practices” create a higher level of perceived service in patients eyes. Companies like Starbucks, Southwest Airlines, many restaurants and hotel chains utilize these techniques without us (the consumer) even realizing it, we just know when we leave that place of business we “like them” and feel “well taken care of.”

Philosophy #1: Create Worst Case Scenario

Unfortunately, dental treatment is often hard to predict accurately. Frequently, we hear patients from other offices share stories of:

“I never knew what the dental work was going to cost?”

“Often times I was told one fee and then when I got to the check out they would give me a higher fee saying they had to do more work”

No one likes to be quoted a price for a service and then have that price of treatment increase during the middle of the treatment/appointment. The trust and rapport one is trying to build with a patient is eroded when prices are increased.

What if there was a way to not only avoid this situation, but instead leverage the lack of predictability in dentistry to build MORE trust and rapport?

The trust between a dental office and patient is strengthened when a patient is given the expectation of certain cost, and then the actual treatment performed is less expensive.

“Great news John! That deep cavity did not extend into the nerve of your tooth, so we won’t need to do a root canal today. That’ll save you some money.”

The gray area which we will define later-on is in which situations to plan worse case scenario. For example, when a patient has radiographic decay to the nerve, yet is only presenting with reversible pulpitis, treatment planning a root canal just in case makes sense. In contrast, it makes no sense to treatment plan a root canal for a small occlusal cavity.

After treatment is reviewed by the clinical team the patient is handed off to the treatment coordinator at the front desk to review finances. The handoff of the patient to the treatment coordinator should follow the NDTR protocol (see below). The out of pocket cost for each patient is determined by the insurance breakdown obtained from the insurance company. When fees are reviewed with the patient we always make sure to let them know that the insurance payment shown on their treatment plan is an estimate. Our estimates are based on previous payments from each insurance company for each service. Letting the patient know that dental insurance is more of a benefit than an insurance goes a long way in helping the patient understand what kind of payment they can expect from their insurance company. Dental insurance can be compared to:

A fixed benefit (Typically around a $1000 max per year)
A coupon where the insurance covers 50% up to $1000 per year

Letting patients know that dental insurance does not work like their medical insurance goes a long way in helping them understand how dental insurance works.

What are some typical examples in creating the worst case scenario for a patient when treatment planning a case?

For direct resin restorations, always assume the cavity will be bigger than you are planning. Plan OB’s or OL’s when you think it may just be an occlusal resin. Plan for MOB, MOL or MOLB when you think it’s a simple MO. We want to be reasonable, if it’s just a small occlusal pit there is no need to add another surface, but if there is any thought that it might extend when the doctor is doing the work, it should be PLANNED as such. Our doctor team is ethical and will remove surfaces as appropriate when they complete the appointment. This is another reason it’s imperative the appointment is completed in the back, BEFORE, the patient makes it to the front.

As a general rule interproximal decay on a virgin tooth usually ends up being a simple MO or DO. If there is interproximal decay already under an existing restoration it often ends up being a MOL, MOB or MOLB.

If a tooth is treatment planned for a crown, always treatment plan the build-up as well. We will often remove this in the doctor’s chair if it is not appropriate, but it’s better to assume they will have it and end up owing less.

For teeth treatment planned for build ups and crowns, always ask yourself if a root canal is a possibility. Traditionally we would treatment plan for a root canal if the tooth:

Patient presents with a very large existing filling or broken cusp
Has caries very close to the nerve, even though the patient has no symptoms
Patient presents with biting pain or signs of a fracture

By explaining to the patient that root canal is either unlikely/possible/probable/likely they now have ownership of the problem and they will be informed of the financial implications if in fact a root canal is needed. If this conversation is had AFTER the tooth has been prepped now the perception is the dentist caused the need for the root canal.

Likewise at the New Patient Exam the Doctors will review the patient’s x-rays and evaluate their Periodontal condition by spot probing. Some patients will very clearly need scaling and root planning (SRP) and the conversation about surgical treatment at a specialist versus non-surgical treatment at our office will be had.

This should all be notated in the procedure note. If a RCT is unlikely/possible/probable/likely.

Think about comprehensive dentistry. Are you just focusing on one tooth? What does the rest of the mouth look like? What will be needed in the near future? Make sure the patient knows the full picture, so we aren’t just constantly patching one thing after another.

“Underpromise and overdeliver.”

It’s a great way to develop long term patient loyalty and trust.

Philosophy #2 : Patient Language: Very Important, Preventative, Cosmetic Patient Language: Very Important, Preventative, Cosmetic

Principles behind language

Our organization needs office wide uniformity in how we present the need and urgency of proposed treatment to our patients.
It is our job as dentists, clinical providers and advocates for the patient to inform them of their “very important” and “preventative” treatment needs. We can present cosmetic needs if the patient desires.
Even though we should be documenting full treatment plans, it’s up to the clinical providers to READ and UNDERSTAND the patients wants and desires and determine if they are emotionally ready to hear the full treatment plan or if it should be presented in phases. What are the patient’s goals? Are they proactive or reactive? HAVE YOU ASKED? This is not to say that we should withhold anything from our patients. We just need to be smart and empathetic in how we present things to our patients.
Patients want and need to know what their “preventative” proposed treatment needs are so they can plan accordingly. With this information they can make future dental insurance decisions, HSA contribution decisions and even decisions on if now is the right time for them or their spouses to retire from their jobs.
“Watching” something is no longer an option and it will not be included in the patient’s chart. If something needs to be watched then it should come with a treatment plan. For example, incipient decay should not be watched, the treatment plan should include in office fluoride. Another example is a tooth with a large silver filling. If it’s stable and the clinical provider does not foresee a future problem, it doesn’t need anything, then there is no treatment plan. If there are small cracks presenting and the provider is worried it will eventually get worse, a “preventative” tx plan should be developed for new a filling/crown so the patient has an idea of what fees they are looking at. If it is not to be done right now it should be moved to an inactive treatment plan which can be activated again later. It’s very important to move it to an inactive treatment plan so we are aware it is there, but so our team is not following up and calling them to schedule a treatment we have said is not absolutely necessary at this point. Document, document, document!
Be clear on the route slip if treatment is very important, preventative or cosmetic. This language will also be used by; the treatment coordinator. The patient will consistently hear this language from multiple sources in our office.
Also make sure that the proper perio recall is selected on the route slip for the front desk.

How to ensure a proper handoff? NDTR!

Next visit: The next visit needs to be very direct. What is the patient coming back for next? An example would be “Ok Jason let’s get you back next for the abutment and crown impression on your upper right” Can this procedure be done with any provider or does it need to be scheduled with a specific provider
Date: The date range do you want the patient back in. Saying “soon” or “in the near future” is very vague, again this needs to be very direct. An example would be “We would like to see you in three months for your implant abutment and crown”
Time: The amount of time it is going to take. This eliminates the misconception that the appointment is going to take all day leading to believing they need to take the day off of work or having to wait until a school break. Example “It will take us about an hour or less to get this done.” BE CRYSTAL CLEAR
Recare: Does the patient have their next hygiene appointment scheduled. This makes sure that we do not miss getting the patient scheduled while they are here in the office.

The hygienist or assistant would prompt the doctor to complete the NDTR hand off with every patient. Once the doctor tells the patient “Ok let’s get you back next for the abutment and crown impression on your upper right. We would like to see you in three months for this and it will take us about an hour to get this done for you.” The doctor can then exit or ask if the patient has any questions.

The hygienist or assistant would then hand off the patient to the Front Desk and relay exactly what the doctor said. “Ok let’s get Jason back next for the abutment and crown impression on the upper right. We would like to see him in three months for this and we would need an hour for this appointment, We need a 60 minute, first chair apt. It also appears Jason doesn’t have a wellness visit scheduled. Could you also help Jason get this scheduled?”

In a perfect world this appointment would be scheduled in the back by the hygienist or assistant but their should still be a handoff to the front so finances should be discussed.

Very Important Is it broken? Is it infected? Is it decayed?

“Very Important” treatment is treatment that must get done or serious consequences will soon occur. It is our responsibility to communicate to the patient that the conditions they present with need treatment and that treatment is urgent/very important. This very important treatment should be done as soon as possible to prevent more serious complications from developing. We are professionals and our patients come to us for our professional opinion, expertise and advice. We often will have to communicate information that the patient does not want to hear. We must look past that and give patients when they need.

Examples of very important tx:

Scaling and Root Planning for Periodontal Disease
Caries into the dentin or beyond
Root Canal therapy for an abscessed or infected tooth
Broken cusp on a tooth
Decayed roots
Abscessing primary or permanent tooth

All things being equal, very important treatment should be done before preventive or cosmetic treatment. In some circumstances, very important treatment can be done in conjunction with preventive and cosmetic treatment, for example, quadrants at a time.

Language that could be used for Very Important :

“You are developing periodontal disease, a serious condition that affects the stability of the gums and bone that hold the teeth in place. Periodontal disease also have detrimental effects on your overall health. Its Very Important for you to address this periodontal disease before it gets worse.”

“Mrs. Jones, getting this dental work done is very important. There is a good chance you are going to develop a toothache soon if you don’t take care of this cavity”

“I’m afraid you are going to lose this tooth if you don’t act soon” Getting this done is very important”

“Please consider getting this taken care of ASAP, It’s very important. It’s only going to get worse quickly”

“The cavity detecting x-rays taken today show new cavity forming under an old filling. Its very important you address this before the cavity gets larger and causes bigger problems to occur.

Preventative Will this eventually get worse in the future?

“Preventative” treatment is recommended when a condition will most likely get worse down the road. It’s not an immediate concern but the sooner the patient considers taking care of it, the better off they will be at preventing the condition from becoming urgent.

We would encourage patients to have preventative treatment done. There will be no more “watches.” It’s either classified as preventative or it’s not needed.

If the problem eventually will get worse or cause problems in the future, it’s considered a preventative treatment need. Preventative treatment is something that could be improved to prevent a problem in the future.

Examples of preventative treatment

Implants to replace missing teeth
Implants to stabilize a denture
Crowns for large fillings that show marginal ridge fracture
Orthodontics to improve hygiene and periodontal health
Sealants, Fluoride and desensitization
Night Guards for worn teeth or muscle tension issues
Replacement of discolored and leaking fillings
Incisal, facial and lingual anterior fillings when enamel has been eroded to pitted dentin
Open contacts leading to food impaction

Language that could be used for preventative treatment:

“Todd as you realize, your teeth are very prone to cavities. It could be part diet, part home care, part genetics….. Unfortunately you need to do much more than the average patient to prevent new cavities from forming. We would strongly encourage you to invest in fluoride. The newest research has shown this is the best way for patients that have a high cavity risk to minimize new caries in the future.”

“Mr. Jones, we are starting to see some minor cracking of these teeth that have these large silver fillings in them. These cracks will slowly get worse and will eventually need crowns. I suggest you plan accordingly to need to have these teeth fixed over the next few years. If you do not think that’s something that is feasible for you, at the very least you should invest in a custom night guard. It’s a very small investment to slow down the wear and cracking we are seeing”

“This treatment will be needed to be done over the next few years. You should plan accordingly. If you would like our front desk team to map out how we could maximize your insurance/HSA benefits over the next couple years to get this work done we would be more than happy to do this for you”

“Your teeth are shifting, spaces are starting to open between your teeth and it’s starting to affect your bite. This is due to you losing some teeth and not having those teeth replaced. I would encourage you to think about starting to replace your missing teeth with implants sooner rather than later. The shifting is only going to get worse. I am going to have the front desk plan it for you and go over fees, insurance and payment options. I’m not asking you to commit to anything, I just want you to be able to plan accordingly.”

Cosmetic Any procedure that would improve the appearance of teeth.

Examples of cosmetic treatment:

Veneers/Smile Makeovers
Whitening
Cosmetic orthodontics

Cosmetic treatment will NOT be automatically followed up on. It is the provider and Treatment Coordinator’s job to determine how interested the patient is and follow up appropriately. This is a balance, keeping it in their mind, but not being annoying and hounding them. When in doubt, do not follow up. You don’t want to be an annoyance to your patients.

Language that could be used for cosmetic treatment:

“Mrs Jones, this treatment would be completely elective. That being said if you have been thinking about doing it for a while I would encourage you to move forward. I will do my best to make you as happy as possible”

“Should you have this treatment done? It depends on how important it is to you. How often are you thinking about your crooked, dark teeth? If the only time you think about it is when you come in for a cleaning appointment then I wouldn’t move forward. If however you think about it 2-3 times a month or if you are hesitant about showing off a big smile then really consider having it done. Life is way too short to be constantly self conscious about your smile.”

“Do you not smile in pictures or do pictures of your smile appear dark? Do you cover you mouth when you find yourself about to laugh? Any self esteem concerns? If the answer is yes to any of these questions, we should find some time to have a deeper conversation.”

This language, very important, preventative and cosmetic will be marked in the treatment plan under “priority” so the treatment presenter understands how best to communicate need to the patient

Philosophy #3: How do we welcome new patients into the practice?

New Patient Calls

When a new patient calls the office it is the responsibility of the person taking the call to gather as much information as possible, while forming the beginning of a relationship with the patient and providing them with an appointment that fits their needs and makes sense for the office schedule.

It is of the utmost importance to listen to the patient and try and extract from the conversation the reason for the call. Most of the time people are calling for one of these reasons:

They want to schedule a cleaning and exam
They are in pain
They are looking for a second opinion or a specific service.

Scheduling a NP who wants a cleaning/exam

Gather the required personal information. Typically all patients come through the hygiene department. We will schedule an hour and a half appointment (important they know this so they can plan accordingly). During this appointment they will have a series of xrays (bitewings) a complimentary panoramic xray, complete perio charting, doctor exam and if appropriate a cleaning. In the event a patient is diagnosed with periodontal disease it is likely they will not have all their teeth cleaned at that appointment. In that event our team will go over everything with them including their diagnosis and associated costs before we start any treatment.

Sometimes a new patient will call and start off by saying that they need a cleaning, but as you get into the conversation they disclose that they are having problems, and may be in pain. If this happens we try and give them 2 options. Something like:

“So Mr. Jones, I know you mentioned you are past due for a cleaning, but I also am gathering that the tooth on the LL is bothering you. I can do 1 of 2 things. We can schedule an exam right away to take a look at the tooth on the LL and get that tooth taken care of. Once we have put that fire out we can take a step back and do a comprehensive exam and x-rays to let you know anything else that is going on and hopefully get a cleaning done soon too. Or, we can schedule the comprehensive exam as soon as we have an opening, assuming it works for your schedule and come up with a full treatment plan for anything else along WITH the LL. Which works best for you?”

Schedule accordingly.

Patients between the ages of 12 and 17 Pretty straight forward gather necessary information. Find out if the patient is in orthodontics. Let the patient or parent know that we will schedule a new patient exam and necessary x-rays and the appointment will be approx 1 hour.

Patients between the ages of 3 and 11 again, pretty straight forward, but only 30 min. If it is the patient’s 1st visit ever and they are very young, let the parent know that we will only do what the child will allow, that we want him/her to have a positive first experience so if we can’t get through everything we will try at the next visit.

Emergency appointments

Patient calls with a toothache. They say they are in a lot of pain, have been up all night, taking lots of OTC meds, swelling, can’t eat or any combination of these symptoms. This will be scheduled as an emergency appointment. Gather the necessary info. Find out where in the mouth the pain is. How long have they been dealing with it, etc. Offer this patient SAME DAY. We normally have blocks preset for these apts, or, if there is not an opening check with the quarterback and ask when we can see this person. Another option is to schedule them in a hyg opening. If the patient says they cannot make this apt the same day then offer them the next available emergency appointment. Let the patient know that we will see them for an exam and necessary x-rays. The doctor will let them know what should be done and we will do our best to get them out of pain, Let them know we cannot guarantee we can treat the issue the same day but we will get them back for treatment ASAP. If the patient is very picky about their appointment time, this is likely not a true emergency and does not need to be scheduled immediately. Do not try to move the schedule to accommodate someone who is being picky, but cannot come when we are able. Remember the following:

“A lack of planning on your part does not constitute an emergency on mine”

Unfortunately, in dental we run into this a lot. Use your judgement and always feel free to ask the Quarterback for help.

If when a new patient calls and the front desk is trying to assess the need for an emergency visit but the patient is mentioning they have multiple areas of concerns in different areas of the mouth- we would encourage a full exam.

Consults/2nd opinions

Patient calls, mentions a specific service they are looking for. For instance, wants to know if we do implants, how much they are, how long it takes, etc. If they mention they need to have new dentures, or thinks they may need dentures, or if they have been told they need wisdom teeth extracted or a root canal and they are looking for a second opinion. This would be scheduled as a consult. Let the patient know we can see them for a consult at no charge. Be sure to let them know this consult will address the service they are inquiring about. Schedule with the appropriate doctor for 30 minutes preferably in the second column. By “appropriate doctor” we mean schedule the patient with a doctor that provides that service. Ortho, Implants, Wisdom Teeth, Immediate Dentures, Root Canals . . . We have different doctors that perform different procedures. Please schedule accordingly.

We do not quote prices over the phone. Many patients will call and feel like what they are getting is a commodity. We must communicate that they understand WHY they are asking that, but all crowns, for example, are different and if we quote over the phone we will likely over or under estimate. We then must explain why we have value, we offer great dentistry in an effective and efficient manner in a state of the art facility. Because of this we likely aren’t the cheapest, but we also aren’t the most expensive. If they want to go strictly on price we recommend they keep calling other offices, but if they want to see the great value we offer, we are happy to schedule them for a free consult.