Chapter 34 Practice Management
Establishing a cosmetic practice differs dramatically from building an “everyday” or traditional dental practice. Traditional dentistry typically focuses on need-based dental care and deals with broken teeth, decayed teeth, malocclusion, and so on. Cosmetic dentistry is an elective area wherein patients make a buying decision as to whether they want to spend discretionary dollars to improve their appearance.
In talking about building a cosmetic practice, it is necessary to first explore how practices grow. Cosmetic dentistry has provided a powerful engine for practices to experience a growth rate that is much more rapid than usual. Typical practices, when the economy is stable, will grow about 5% to 7% annually. Even in a depressed economy, practices can still grow. Cosmetic dentistry cases have a higher production level and higher profit margin but require less time and less overhead, not including possibly increased laboratory costs. Cosmetic dentistry typically has a higher comprehensive fee because most cases involve more than one tooth. Also, many cases involve smile design in both the maxillary and the mandibular arches. Thus we see higher average production rates per patient for esthetic dentistry cases, along with a higher profit margin. For these reasons cosmetic dentistry is very alluring to practices as an added service that most trained dentists can readily accomplish.
Dentists themselves often find cosmetic dentistry to be enjoyable and satisfying. Dentists may feel limited by managing one tooth at a time. Adding cosmetic dentistry is a gratifying choice because patient satisfaction is evident immediately after the case is completed. This positive feedback energizes both the dentist and the dental team.
In terms of patient demand, patients are becoming savvier about cosmetic procedures. The primary reason is Internet education, which has made the entire world much more aware of cosmetic opportunities. Second, there is increasing social pressure to look good. People want to look nice and to appear young at every age, even at 90 years old. When deciding who might be interested in cosmetic procedures, do not discount older people.
Another reason for the increased demand in cosmetic dentistry is the improved convenience of these procedures. Patient satisfaction surveys over the years reveal that the number one complaint concerning cosmetic dentistry was the lack of convenient access. This included obtaining appointments and scheduling completion of the procedures required. Today cosmetic dentistry is widely available worldwide. Not only are appointments easier to schedule, but also the procedures themselves require considerably less time than previously. We can literally change a mouth in a few days to a week if the patient is properly prepared and the case well designed.
Additionally, cosmetic practices have also benefitted from the extremely high success rate. In the 1980s and early 1990s, cosmetic materials were inferior to those available today. Cosmetic dentistry is now much easier and quicker to perform. When easier and faster are combined, the result is a service that breaks down several of the barriers identified by patients in years past. Most patients will invest 3 days to a week to complete a case, or 2 to 3 weeks or longer if implants are involved.
In the United States, patient financing is available for cosmetic procedures, which is yet another reason cosmetic dentistry has grown in popularity. This option enables patients to access a separate loan or line of credit. About 65% of patients are approved for these procedures, and 85% receive the entire amount requested.
Levin Group recommends that practices establish a system for superior customer service that provides patients with an exceptional experience so that they expresses appreciation for the doctor and staff and become an active referral source. By delivering exceptional customer service, dental practice team members begin to realize that the sole focus is no longer on treating teeth but also providing an experience for the patient throughout the entire process.
Although cosmetic dentistry decreased slightly during the recent recession, it is coming back again and offers a tremendous opportunity for practice growth. Cosmetic dentistry services should be a part of the service mix in every general practice. The minimum target proposed for elective dentistry is 22% of the practice production.
Abraham Maslow created a pyramid referred to as Maslow’s Hierarchy of Needs (Figure 34-1). As Figure 34-1 shows, for people at the physiologic level, lacking shelter or food, improving their life beyond meeting these physiologic basic needs is not an issue. Moving up the pyramid, people become interested in meeting other needs, such as safety or love and relationships. Once basic needs are satisfied, people become interested in addressing more complex needs, such as relationships. At the higher level, esteem, people may be seeking cosmetic dentistry.
FIGURE 34-1 Maslow’s hierarchy of needs.
(From Gerdin J: Health careers today, ed 5, St. Louis, Mosby, 2012.)
As this hierarchy demonstrates, the “want business” differs from the “need business.” Dentists are trained to meet needs, and many do not fully comprehend the difference between a need and a want. A need is something one has to have, often immediately. People find ways to obtain what is needed, such as food, clothing, or shelter. A want is something that is not necessary but is desirable. In dentistry, a want is considered elective. In the elective zone, patients are willing to start thinking about elective dentistry, cosmetic dentistry, and discretionary expenditures. Often, wants are related to an individual’s age or social situation.
Adding cosmetic dentistry to an existing traditional dental practice means having essentially two distinct practices under one roof. In many cases cosmetic dentistry is not being considered as a different kind of business with different systems, which creates problems. Five factors must be considered (Box 34-1):
1. Dentists trained in traditional dentistry have received education that usually merely touches on cosmetic procedures and implants. Dental schools have so much to cover that they really have no time to give the full array of information or to challenge students by doing many cases in this area. This approach stays with most dentists well into their career.
2. Clinical excellence does not create clinical success. Most dentists spend considerable time on continuing education but do not realize that clinical excellence is not a guarantee of either practice performance or practice success.
3. Traditional dentistry is self-evident. When something hurts or breaks or fails, we know it and we know it must be fixed. Our only consideration is which option we will choose. When something is not necessary but is desirable, we tend to think more about value. We may or may not choose to act, and we evaluate the choices very differently.
4. Cosmetic dentistry is always elective; it is never about need. People can live a long life without cosmetic dentistry. No one ever dies from having an unattractive smile. Cosmetic dentistry is based on discretionary income and the choice often comes down to money and whether or not the patient feels the procedure is worthwhile personally.
5. Elective choices are basically emotional. When you have a need, you make a logical decision after evaluating the options. With cosmetic dentistry, there is no need, so patients make decisions based more on motivation, excitement, or external investment. These are all more emotional than logical ways to make a decision.
Box 34.1 A Practice within a Practice
Box 34.2 Cosmetic Dentistry Growth Plan
Value creation. Dentists need to increase or replace the current systems serving the practice. These current systems are geared toward need-based dentistry, and adding cosmetic dentistry requires systems geared toward want-based dentistry along with the need-based side. Scripting is a critical component of the changes because in a cosmetic practice, the language must motivate and excite the patient plus create a sense of value and desirable return on investment. The basic script, which has proved functional with traditional approaches, must be augmented with text that conveys value. It can convey such value by helping people become knowledgeable and enthusiastic about cosmetic dentistry.
1. The initial phone call. In the first phone call about 20 steps and 18 scripts are available that can take just a few minutes to use. The approach is more than just getting the patients scheduled and their basic information. The patient also learns a little bit about the dentist and is exposed to some of the cosmetic procedure choices. The receptionist or front desk staff person who handles telephone communications actually spends time building a relationship with the patient. This is critical because the patient should always finish the phone call having the sense that this is the right office and placing a higher value on that office than before the call was made.
2. All new cosmetic and implant patients should be scheduled within 7 to 10 days. The reason is that the longer it takes to schedule the patient, the more the patient’s motivation wanes. The patient may cancel the appointment or something else may arise that raises a barrier to the cosmetic procedure. The scheduling system should be flexible enough to permit time for a certain number of patients to be seen and treated within a 7- to 10-day cycle. Focus on adding value by using benefit statements. Patients start wanting to know more about why the procedure will benefit them and how it actually will work.
3. The Golden 10, which means we learn 10 personal things about each patient before we ever touch him or her. By learning these 10 things, we move from a professional-only relationship to a professional and a personal relationship.
1. The office should “scream” cosmetics, from the office’s décor to patient education, it must be clear that the practice offers cosmetic dentistry. Many practices have focused on looking beautiful but have ignored marketing their cosmetic services. It is important to create a complete cosmetic feel that includes the physical beauty of the facility but goes further to specifically focus on cosmetic opportunities.
2. All patients in a practice should know about cosmetic dental options, whether they need them or not and whether they have rejected them in the past or not. Patients should be educated about what is available, from whitening to the newest crown and bridge, to posterior white restoration of the ceramic, porcelain, or composite. The goal is to create an understanding that cosmetic dentistry is available, real, in the mainstream, and worth considering.
3. In the new patient phone call, cosmetic opportunities should be mentioned even if the prospective patient did not call about cosmetics. This can simply be informing the patient that the office offers a complete array of cosmetic dental services and the dentist will be delighted to discuss procedures at the visit if the patient is interested. When you combine this introduction with the office “screaming” cosmetics, you are beginning to influence and open the patient’s mind.
4. Use before and after photography. Psychologists show that people learn by comparison. Often they do not know they have a less-than-attractive smile until they get a sense of what a beautiful smile could look like.
1. Identify the top three benefits of every service a practice offers and tell the patient these benefits for the desired service. You can offer at least 10 or 20 benefits, but when you give adults three, they respond best. Everyone in the office should know the top three benefits of each cosmetic procedure. Most patients, after a treatment consultation, will go to the front desk and ask a quick clinical or clarifying question. The answer they receive must give the same information as what was obtained from the dentist, hygienist, or treatment coordinator.
2. Request feedback. In about 10 to 12 seconds, the patient is asked what he or she is thinking. This is important information so that a customized presentation can be developed to help the patient understand the procedure and be comfortable that it is something that he or she wants. The patient will then become motivated to accept treatment. Use of several feedback loops is suggested, stopping to ask questions along the way.
3. In part three of phase 3, one tries to develop a key relationship with the patient. This relationship was begun in phase 1, but now it is advanced to cover more about why the patient would want cosmetic dentistry, what the individual thinks it will accomplish in his or her life, and what area he or she would specifically like to improve.
4. Focus on the key questions a patient is likely to ask during the presentation of cosmetic dentistry, specifically (1) What is it? (2) What will it do for me? (3) How long will it take? (4) How much does it hurt? (5) How much will it cost? Most of the time is spent on question 2 because the answer focuses on benefits.
1. All of the staff members are trained to discuss and promote cosmetic procedures. The hygienist, assistants, and front desk attendants should all be comfortable discussing cosmetic procedures and motivating patients in an educational manner.
2. Do not overstate technical information. Most patients do not care about the details of the clinical procedure. When they are interested, they will ask for more information. In most cases they want to understand benefits, not technical information.
3. Address the entire attitude of the office. Everyone on the team in a cosmetic office must be an upbeat, energized individual whose presence is enjoyable and who comes to work every day excited and enthusiastic about cosmetic dentistry.
4. The office must create a beautiful environment. No one will buy or believe he or she can buy excellent cosmetic dentistry in an office that does not represent a superior cosmetic facility appearance or design.
Features are about commodities and making comparisons, which are boring and typically do not create the excitement needed to sell the case. Benefits motivate, excite, and energize the patient. Benefits answer the question “What will it do for me?”—which is where the bulk of the time in treatment presentation is spent. Benefits create desire and sell the case (Box 34-3).