‘No’ Doesn’t Mean ‘Never’: How To Present Treatment for Advanced Cases

The goal of a Spear-trained dentist is to be confident when planning treatment for patients who require advanced restorative treatment. However, advanced treatment can be surprisingly expensive for many people seeking care. Often, there’s a disconnect between the actual cost of the treatment and what the patient thinks it will cost.

In dental school, we were taught to present care in the order we would treat — starting with periodontal conditions, then necessary and elective restorative care. However, a better course of action would be to discuss what the patient is most interested in before talking about the order in which treatment would be performed. Addressing the patient’s priorities right away illustrates Habit #5 of Stephen R. Covey’s The 7 Habits of Highly Effective People: “Seek first to understand, then to be understood.” (In fact, the author refers to this idea as “the single most important principle I have learned in the field of interpersonal relations.”)

Many patients who express interest in extensive restorative treatment are less concerned about the process and more interested in the outcome. For example, a patient might schedule a smile evaluation because she wants her crooked, discolored teeth restored so her smile can look nice in photos taken at her daughter’s upcoming wedding. But what happens when the complete examination discovers 5–6 mm periodontal pockets in her posterior quadrants?

In case presentation, start with what they think is important

A traditional case presentation would follow the order of treatment: You’d start with the patient’s periodontal conditions and discuss scaling and root planing and the benefits of eliminating the anaerobic bacteria contributing to bone loss around her molars. Her discolored, mispositioned teeth usually wouldn’t be mentioned until after the periodontal and biomechanical conditions — but this might cause her to lose interest.

While treating the appearance of the teeth before addressing the periodontal and biomechanical conditions would be malpractice, we can present the care in an order that first addresses what the patient is most interested in, then links additional conditions they might not be aware of back to that chief concern.

In our example, the conversation would begin something like this:

“Mrs. Jones, I understand you want to improve the appearance of your smile for your daughter’s wedding. We can increase your confidence in wedding photos by getting your teeth in the correct position using Invisalign. Then, by replacing the enamel layer with veneers, we can give you the smile you want.

However, when we last met, we discussed the infections under the gums in your back teeth. Before we give you the smile you want for the wedding pictures, we need to get rid of those infections.

Tala, our hygienist, will do a special cleaning that will remove the build-up causing the infection. This is important because the back teeth are there to protect the front teeth, and I know you want to ensure our work on the front teeth will last.”

It’s important to recognize that this is not informed consent; it’s case presentation. Informed consent is needed before treatment is accepted, but at this point in the process, we’re discussing case acceptance. Patients like the one described above are looking more for hope than information about how the result will be accomplished. We create more engagement between patient and dentist when we address their concerns before discussing which conditions must be addressed to get the desired outcome.

Use an “outside-in” approach

This approach, sometimes called an “outside-in” approach, discovers what’s going on in the patient’s life outside of the dental office, as well as the solutions they seek in our practice. Often, something has compelled a patient to schedule their appointment; ask open-ended questions and allow them to tell you their story before you conduct any examination.

Recognizing the outside events the patient is juggling or why they want their teeth fixed provides the dental team an opportunity to become patient advocates and discuss the challenges while presenting the case. It’s rare for a patient not to have other expenses they’ll need to fit into the cost of dental care.

Using the example earlier, the conversation sounds like this:

“Mrs. Jones, I know you want to improve the appearance of your teeth for your daughter’s wedding, and planning a wedding can be time-consuming and expensive. Before we discuss the treatment steps for addressing the appearance of your teeth, I want to make sure we can get your teeth fixed while you’re planning for your daughter’s big day. As we’ve discussed, dentistry can be time-consuming and surprisingly expensive. While we’re good at working with our patients’ schedules to get the work done, I want to ensure you know the time and cost it will take for you to get the smile you want for the wedding.”

At this point, it’s imperative to remain quiet and allow the patient to think about their schedule and budget. The typical response is, “What will the treatment cost?” and the response is, “I can’t tell you exactly what your treatment will cost, but similar cases have cost around $10,000–$15,000.”

Discuss possible fees and provide options

Discussing the outside-the-office events and giving the patient a ballpark for treatment cost opens the conversation about fees early. This can save the dental team time because records won’t be collected on patients who can’t afford treatment — and, more importantly, we avoid disappointing patients who can’t afford the care. Disappointment can lead to embarrassment, which in turn can result in the patient leaving the practice.

Discussing the cost of treatment early in the process avoids disappointment. After ballparking the cost of the proposed treatment, the patient will say, “That’s about what I thought,” or, “Wow, I had no idea it would cost so much!” In a perfect world, every patient’s response would be the former, but unfortunately, many patients don’t know how expensive treatment can be. For those patients, the goal is to keep them in the practice until they become ready.

A good way to respond to the patient is, “I know — that’s why I wanted to bring up the cost before we get started. We’re good at working within people’s budgets. Some people want to get all the work done at once, others need to spread treatment out over time, and others need to take care of any infections in their mouth now and postpone treatment until the time is better. Today, we’ll evaluate your conditions and discuss the options for your care. Will that work for you?”

The goal has shifted from getting the patient to say yes to creating awareness of the benefits, risks, and possible outcomes of treating the conditions in their mouth and waiting to complete it.

Understanding the patient’s thought process will have a positive impact on the relationship between the patient and the team. When there’s understanding, patients realize the dentist and the team are on their side, and once they know we’ve become their advocate, there’s an increased likelihood they’ll remain in the practice.

An informed patient will decide when they’re ready

When your practice has a pool of patients who need care but aren’t quite ready to start treatment, you have stacks of patients who’ll become ready on their own. For example, if you add 10 patients per year who are aware they need treatment but aren’t ready, after five years, there will be 50 patients in the practice who need complex dentistry. Over time, those patients will tell you when they’re ready.

A common example is the patient who has just finished putting their children through college. They’ll be at the office for a hygiene appointment and say, “You know the conversation we had four years ago about the appearance of my teeth? My kids have finished college, and I want to take care of myself and get my teeth fixed. Four years ago, you said the cost would be around $10,000–$15,000. I’m sure the cost has gone up, but I’d be interested in finding out if we can still fix my teeth. Can I schedule an appointment to discuss?”

The difference between the situation now and the appointment four years ago is that the patient understands the process and cost. When the dentist, the team, and the patient are all aligned at the start of treatment, it removes the stress from the patient because they already understand the cost and process of fixing their teeth, and it removes stress from the dentist and the team because they no longer worry if the patient can afford the care.

Understanding the patient’s inside- and outside-the-office concerns before recommending treatment reduces stress for both the patient and the dental office. When the patient knows their dental team understands how they need to manage outside-the-office events along with their dental concerns, it builds a relationship in which they see the dental team as their advocate.