Treatment Planning in a Challenged Economy

Steve L. Rasner, DMD

In an interview facilitated by Dr. Damon Adams, Dentistry Today’s editor-in-chief,
Dr. Steve L. Rasner, candidly expresses his thoughts on current topics affecting the profession.

How has the economic downturn altered your approach to the new patient exam?
Dr. Rasner: It is my opinion that it would be a mistake to alter your approach to the initial examination. There is no doubt that patients are concerned that going to their dentist may be costly. In an article as recent as July 26, 2013, The Street cited 50% of the population in the United States is without dental insurance and more than half of them are not seeking it! It would be intuitive for some clinicians to become more myopic in their treatment. Treating “only” the symptomatic tooth certainly will have higher case acceptance, but it is a dangerous precedent for turning your practice into an “emergent care center.” That not only leads to poor healthcare; it is a recipe for the fast track to burnout. Conversely, what has sustained many practices in the past few years is a more thorough initial exam with a broader range of services.
It has been my experience that new patients do not object to a comprehensive exam when the benefits are proactively explained. This is not to be confused with “selling” the new patient on an array of services unrelated to their concerns. Communication is everything.

Could you elaborate when you say, “communication is everything”?
Dr. Rasner: Well I think the very first step to improving case acceptance is to ask yourself, do you have a systematic approach to your new exam? Is it a 20-minute, random, inconsistent, “let’s see where this goes” exam? I have embraced the same approach since the last recession (2001), because it works! It might be useful to review: Our new exam actually begins over the phone. My new patient coordinator is far from random. She is that person on your team who believes in your commitment to comprehensive care and truly understands the value. During the initial phone call, we do what I call a “mini dental history.”

The patient is asked:

1. When was the last time you were at the dentist?
2. Do you wear anything removable in your mouth?
3. Are you aware of any problems with your gums?
4. Is there anything else you would like us to know before your appointment?

This initial approach covertly tells patients what type of office they have contacted. We actually go further and explain to the patient in user-friendly terms that the doctor will be looking over all of the teeth before he makes a recommendation. Some patients might state right then and there that they just want one tooth treated. When it is proactively explained that they will save both time and money in the long run if we make a treatment decision based on their overall oral health condition, an overwhelming majority of patients will embrace this approach. That being said, you will end up referring some patients elsewhere. It is noteworthy, that your tone of voice, and your belief in a comprehensive exam goes a long way toward patient acceptance. In short, no one will accept a comprehensive treatment plan if it is not offered.

What do you consider the cornerstones of “case acceptance” in the present economic environment?
Dr. Rasner: There are several fundamentals that separate case acceptance from “I’ll think about it.” One critical protocol that precedes the patient’s first visit I refer to as the Significant Other Protocol: When a new patient indicates “significant” need over the phone, the patient is asked to bring a significant other with them, if possible. Now, before I receive a bevy of e-mails telling me to “get real,” let me explain. It is my opinion that many clinicians would agree that dentistry is at a very different place than it was 30 years ago when I started my practice. In the early 1980s, advancements in restorative options, hard- and soft-tissue augmentation procedures, and implant dentistry were not in play in the way that they impact treatment planning in 2013. Ten-thousand-dollar-plus treatment plans were not a weekly occurrence. Today, a comprehensive treatment plan (possibly involving the periodontist, the orthodontist, the endodontist, and restorative care) could end up representing a huge investment, rivaling or exceeding a plastic surgery fee. It is my experience that most couples don’t make major financial decisions independent of one another. Naturally, you won’t get 100% of the patients with significant others to comply. However, based on my experience, it is reasonable to expect 60% to 70% of new patients to agree to come in with their “other half.”
I want to point out what has been intuitive to me for years. Why go through all of this? Why do I think it is worth it to have a system in place to raise the level of case acceptance? Like many of my colleagues, years ago I fell in love with the continuing education (CE) this profession has to offer. As I incorporated the teachings of great thought leaders like Drs. Frank Spear, Carl Misch, Peter Dawson, William Strupp, and a host of others, it opened my eyes to significantly better restorative outcomes. Sandwiching a single unit in a maloccluded dentition does cost less but doesn’t represent optimal care! It would be a grave mistake to assume all patients will “see the light” of a thorough approach to their perceived dental issues. I believe it was Dr. L. D. Pankey who cited knowing and educating our patients as part of being a “complete dentist.” I believe that approach is one’s best chance to practice at the highest level possible.

Hygienist screening patients for caries utilizing DIAGNOdent (KaVo) is a part of a thorough exam and education of our patients.	Hygienist screening patient for suspicious lesions with VELscope (DenMat). All adult patients are offered this service.
Dr. Rasner confirming the DIAGNOdent and VELsope findings provided during the initial exam by the hygiene team.	Critical to case acceptance is clarity to patient issues and concerns. The “one to one” meeting at the initial visit (with the significant other when possible) is an opportunity to attain private or personal concerns.

Another cornerstone to case acceptance is The One to One Interview: This only takes an additional 5 to 10 minutes. It is done in a private office, conducted by your new patient coordinator, where the patient is totally comfortable to speak. Your new patient coordinator should briefly review the intake from the original phone call and a state a recapitulation of the patient’s needs/concerns as their significant other sits by listening. Why do this, you might ask? I have no science to support this, but I do have abundant anecdotal evidence; if you seek higher case acceptance, then do not skip this step. Patients will often provide a very different overview of their oral health than what was said over the phone. It is almost universally enlightening when we conduct this private, “tell us once again” opportunity. Multiple missing teeth, apparent periodontal disease, or deep phobias somehow have developed since the initial call about a “chipped tooth.” The more you know, even if it is right before you meet the new patient, the better this is going to go.
The hygienist then takes the appropriate radiographs (full-mouth periapicals and bite-wings, and/or a panoramic radiograph), thorough charting, and plentiful upbeat dialogue about the patient’s interest and concerns. The hygienist is an obvious integral part of the new patient exam. Like your new patient coordinator, the hygienist must be educated, on board, and passionate about the best care available. It is important to realize that one very genuine reason you may not be reaching your full potential might be related to the team you have assembled. We are not all passionate about advancements in dental care, and thiscan include everyone on your team. One of the very first steps to being able to turn your practice in the right direction, and to be more successful in comprehensive treatment planning in a downturned economy, is to assess the quality of the team that you have in place. Educate them, give them the opportunity to grow, or replace them. It’s that simple!

What is your opinion on the impact of recent technical innovations and how they fit into today’s practice in this economy?
Dr. Rasner: What I know to be true is that if you practice “scared,” you put yourself at greater risk for failure. Many clinicians with reduced revenues are hesitant to engage the needed CE and technological commitment for long-term success. Dr. Gordon Christensen duly noted in this journal a year ago that younger dentists are not attending CE courses and meetings in as high of numbers as their predecessors; many now access their CE from the Internet. I can say without equivocation that the greatest value I received from years of attending CE events was the many clinical and management pearls I garnered from fellow dentists while attending these meetings in person.
Dentistry is changing so fast that sitting on the sidelines for a few years could be a costly mistake. Whether you are ready to dive into Enteral Sedation, Six Month Smiles, CAD/CAM technology, or digital impression systems will be a personal choice, but it is clearly a mistake to not learn, investigate, and try out the technologies that are impacting the daily practice. Many companies have purposefully designed brief “trial periods,” allowing you to feel and use the technology without having to commit.
The final portion of our exam is a recording of the patient’s blood pressure, pulse, head and neck exam along with an oral cancer screening (with their consent). I would highly encourage my colleagues to incorporate these final components of the new patient visit. The investment in a pulse oximeter will be one of the better ones you ever make. It provides a quick and significant upgrade in your present health history records.
Remember this: Patients have many options for dental services. What will separate you from the rest will be your team and value added services that have little to do with “new production” yet everything to do with distinguishing your practice.

What change would you implement with the greatest impact for the average practice?
Dr. Rasner: Two words: oral sedation! There is no way I could overstate the positive outcomes from incorporating enteral sedation in your practice. Quite simply, it is the easiest, yet most powerful skill set you could add to your array of services and this is why: There remains a tremendous market for patients with dental fear. These patients are emotionally driven, not unlike plastic surgery patients. They are the patients that will go out-of-network to seek your care. They typically put off treatment for years. Pain or the loss of a tooth in the aesthetic zone is what typically drives them to seek your care. If they sense confidence in your ability to help them, they will become a tremendous source of satisfaction to you and also will be the powerful source of referrals in your patient base. Most states require 24 hours of CE to attain the needed permit. It undoubtedly will be the best return on your investment in CE that you could make.

What would you offer for general guidelines to treatment planning?
Dr. Rasner: I believe that top clinicians walk into the room with the intention of providing the most conservative yet responsible treatment plan possible. How many times have we seen a severely mesially inclined second molar with the first molar missing treated with endo and a crown; or a 5-unit bridge with 3 pontics; or a new mandibular full denture on a severely atrophic mandible? Somewhere in the clinician’s treatment planning options has to be palliative treatment and the advice to the patient to consider “putting off” a compromised treatment plan. Any amount of dollars spent by our patients on treatment that will be unpredictable is ill advised for long-term success of any practice.
Another way to approach the treatment planning process is to think of 4 possible outcomes:
First would be ideal care. There would be no financial restrictions. This patient might be treated with multiple disciplines. Combining, for example, ortho to idealize gingival margins prior to an anterior aesthetic case. In my world, I don’t treat many “ideal care” patients.
The next outcome would be compromised care, not to be confused with “poor care.” This patient has some financial limits. You might treat maxillary cuspid-to-cuspid with full coverage and “bond” the bicuspids for an aesthetic makeover; or 2 mandibular zest locators instead of a 5-implant bar-retained overdenture.
The third outcome, and a common one I might add, is what I call the, putting the fires out approach. These are patients who has been without care for some time. They are going to lose some teeth. They likely have early or moderate perio, but their condition does not condemn them to an edentulous state. Their budget prohibits fixed replacement or other advanced care. I will recommend to this patient that if possible, “just put the fires out.” It involves early periodontal therapy, possibly endodontics to maintain strategic teeth, but unlikely treatment with full-coverage crowns at this juncture. We would replace teeth with acrylic partial removable prosthesis with cast clasps. This treatment approach represents a plan to get rid of active pathology and transitional tooth replacement. Many patients I treat fall under this approach. They often are excellent patients who are very much motivated by being able to do something now to improve their present debilitated condition.
The fourth and final approach is to confine your treatment recommendations to the patient’s chief complaint. This usually results in palliative treatment or even removal of the offending tooth. This patient simply has no budget for dental care. They are treated with value, exactly like the other categories. The hope is that we maintain them as ambassadors of good will and perhaps when things get better we will be able to provide more complete care.

What are your thoughts moving into the future?
Dr. Rasner: I am totally aware that there are some clinicians reading this who will not “buy in.” The thinking presented here flies in the face of what many would think is logical. However, this is what you need to know: The recession may come to an end, but the changing face of dentistry is here to stay. Preferred provider organizations (PPOs), corporate run dental chains, even “middle providers” are going to adversely impact the clinician’s ability to provide complete dentistry. Remaining in the status quo is simply not an option. There exist many opinions on how to reach prior levels of success. Some will offer that turning to PPO plans is the way back. Others will reduce team size and hence expense. The approach I offer will unequivocally increase case acceptance, cash flow, and if your clinical care is excellent, it will lead to other patients who appreciate this level of care. It will come through increased education of your team, your patients, value-added services, and establishing a systematic approach to the new patients you meet. Yes, it demands more time, education, some investment in technology, and armamentarium. It mandates more energy and more risk. It is my belief this represents a better alternative that will, in fact, prove worthy.

Dr. Rasner is a general dentist who has nurtured a private practice in southern New Jersey for the past 33 years. He received his DMD from the University of Pennsylvania in 1980. He has accumulated close to 5,000 CE hours and was awarded his Mastership from the AGD in 1998. His memberships include the ADA, the Academy of Periodontology, American Board of Implant Dentistry, the International Congress of Oral Implantologists, and the International Academy for Facial Esthetics. In 1998, he founded Realizing the Dream, a company focused on practice management enhancing products including books, DVDs, and CDs. Dr. Rasner has received multiple speaking awards and has spoken in several countries abroad and most of the continental United States. His topics include practice management, simplified oral surgical principles for the GP, and implant dentistry. He can be reached at (800) 337-8435 or at drrasner@aol.com.

Disclosure: Dr. Rasner reports no disclosures.