This is not to say you should spend the same amount of time with every patient. It becomes obvious that not everyone will be receptive to learning the differences between quality and average treatment. In the final analysis, it will be up to you to determine if the patient who is not interested in understanding the differences will be the patient you wish to treat. Generally, these patients are shoppers who will base their decision on price only.

The different classifications of patients will have different motivations and expectations for esthetic dentistry (see page 17). Some are influenced more by the life expectancy of the restoration while others care more about the esthetic result.

Almost every patient wants to know, “How much is it going to cost?,” even before visiting the dental office. In fact, some patients, the price shoppers, will call to request prices before deciding to make an appointment. These people are usually driven primarily by price, and yet still may have a high esthetic dental need. Probably the most difficult task most dentists face is answering the fee question. Your fee should reflect the quality of care your office provides and should not be presented with apology. If the patient views the treatment as a need and is aware of the benefits of that treatment, he or she will usually consent to the proposed treatment plan, provided finances are not a problem.

The patient will usually feel more at ease with a third party, the treatment coordinator, and thus more comfortable voicing questions about fees at this time. If necessary, a compromise or a different treatment alternative can be introduced when there is genuine dissatisfaction or a problem with a patient’s ability to pay. If this situation occurs, it is often helpful for the treatment coordinator to suggest, “Let me speak with the doctor and see if some compromise treatment can be arranged.” You may then choose to alter the terms, the total fee, or suggest alternative treatment plans. Although there may be no question about the best method for solving a particular esthetic problem, we must always be aware that alternative treatment plans can be given in most instances.

The amount of a fee is not as important as how your patient perceives it. A company president may reject even moderately priced dentistry, whereas the president’s secretary may accept the same treatment plan and fee if he or she realizes the need and finds a way to prioritize the expense. One of the most important components of any case presentation is showing your patients the difference between ordinary and exceptional esthetic dentistry. For instance, show the difference between a regular porcelain crown and one of inlaid porcelain. Show the difference in an extracted tooth that has routine bonding versus one with characterized bonding. Always have two types of laminates: one with opaque monochromatic porcelain and one with color and artifacts built in. And, remember, not every patient wants or appreciates the difference. Patient feedback helps you know who your patient is and how to approach your esthetic dentistry treatment plan to gain acceptance.

Many dentists have little awareness of the factors upon which they should base their fees for esthetic dentistry. Therefore, they feel inadequate or unable to properly define and, unfortunately, even defend their fees. One thing should be made clear from the outset. Most patient insurance policies do NOT appropriately cover fees for esthetic dentistry. So how should fees be determined? The following are key factors that should be considered when you establish your fees for esthetic dentistry:

1. Training

This consists not only of your educational background but also the amount of time and money you invest in brief and/or extensive courses and educational videos, reading books, magazines, and newsletters (including the volumes of information you receive from dental suppliers and manufacturers). Do not forget all those dental meetings you have attended—not only the cost of the meeting but the cost of lost income and the time away from your family and personal life.

2. Procedure

Is a crown just a crown? Is it just as difficult to do a crown on a right central incisor as it is to do one on a bicuspid? Or how about a “hidden” second molar? Laminating or crowning a single tooth to match an adjacent tooth is many times more difficult a procedure to accomplish than if you crown or laminate two or four teeth. More advanced clinical and laboratory skills are needed for the former. Is it not considerably easier to match a maxillary first or second molar to another one than to perfectly match one central incisor to another? In fact, if you are treating a single tooth, your cost per tooth is considerably more than that for doing six or eight teeth. Consequently, there is a significant difference in your cost, depending upon which procedure you are doing.

3. Technical Skill

Those of you who have been practicing 5, 10, 15, or 20 years and have reached a high level of skill and are teaching other people should be charging more because your technical skill level is higher than someone just coming out of school. And it is also higher than someone who does not take the time for additional training to improve skills.

4. Time

The amount of time necessary for a procedure is just part of the formula. Consider the extra time it will take to answer your patients’ questions. How much extra time will you allow for patients who ask a lot of questions? Time should cover diagnosing, planning, accomplishing the procedure, redoing, repairs, and postoperative visits.

5. Artistic Skill/Patient Requirements

Patients vary. Some truly do not care what your result looks like, just as long as it fits. Others may not seem to care—until he or she goes home and looks closely in the mirror. Always give a patient a mirror and have him or her hold it at arm’s length because that is the perspective from which other people will observe. The patient who holds the mirror very close requires something different of us; he or she is usually the perfectionist and you may need to adjust your fee accordingly. Another important consideration is your artistic ability. It is accepted, often expected, in every profession and culture to pay more for the best. We pay more for the best sculptures, artwork, photographs, ceramics, jewelry, and all types of other things that require artistic skill. We refer to our profession as “the art and science of dentistry.” The science is well-understood, but the art has been ignored for too long. You deserve to be compensated based in part on your artistic skill.

6. Overhead

Your overhead is based on many factors, including where you are geographically. It is also based on OSHA requirements. It can cost as much as $25 or more per patient in some offices just for sterilization procedures. Laboratory fees, if any, must be considered, as well as the quality of the laboratory, the materials, and the equipment that you use. Does your office employ the latest in high-tech equipment? All of these things benefit the patient but cost money. If your office is a state-of-the-art facility, then it should be differentiated from the offices that appear outdated and are, in fact, furnished with antiquated equipment.

7. Warranty
What do you guarantee? Are you giving a minimal or extended warranty? Is it 3 months, 6 months, or 1 year? For how many months will you render free aftercare and for how many years will you provide service at a reduced fee and at what percent discount? Are your patients told to wear a protective appliance? Do they? They may have accidents, caries, periodontal conditions, tooth loss, or root fracture; are you guaranteeing your treatment against all those things? You prescribe home care; are they going to do all that you expect? Your warranty must point out the circumstances under which you will guarantee your dental treatment. Are you guaranteeing that if your patient bites into a candied apple your laminate will not break? If eating habits are expected to change after you insert your ceramic crowns or laminates, then this, too, must be stressed and put into your warranty. The best car manufacturer may not honor its warranty if the owner does not fulfill the agreement—changing oil and allowing the dealer to perform necessary maintenance. Are you prepared to honor your warranty for patients who do not come in for routine prophylaxis and clinical examination? Certainly, damage caused by neglect can be costly. A well-constructed warranty and fee structure can help to protect you against patient-neglect situations.

How esthetic procedures differ from ordinary dental procedures should be explained. The patient must understand that esthetic dentistry may be time-consuming and, unlike routine procedures, does not always produce immediate results. Differences such as time involved for extra try-ins, treatment plans that require chairside carving and shaping of temporaries, staining of porcelain at chairside, and the dentist’s time and expertise should all be discussed. The patient must be convinced and satisfied that any additional time necessary for better esthetic results is worth the investment.

Dentists should be aware that patients are often completely unfamiliar with esthetic dentistry and are reluctant or unable to ask the important and relevant questions about the procedures. The limitations of esthetic dentistry should also be explained to the patient. While esthetic treatment can produce dramatic improvements, it cannot do everything. If compromise is necessary, say so. It becomes the dentist’s responsibility, therefore, to see that all doubts and questions are cleared away during the final case presentation. You must be careful not to impose your own esthetic notions on the patient. Superior knowledge and training make dentists the arbiter of what is practical and workable; they do not give him or her any precedence in matters of esthetic preference.
Esthetic treatment demands personal communication between patient and dentist that must continue throughout treatment. Be an acute observer, a precise listener, and an understanding interpreter. Always remember that good communication can make it possible to change an insecure frown into an assured smile.

The second consideration is that you should never proceed with your treatment plan until both you and your patient have a thorough understanding of what your treatment will be. Make sure your treatment coordinator has your patient sign a form, following an oral presentation of recommended treatment, that all options were presented and that the patient understands the options and agrees with the treatment. Next, follow up with a detailed treatment letter listing any exceptions or potential problems that could be encountered.

The third precaution to take when treating problem patients is to consider treatment phases. The advantage of treating problem patients in phases is that you never proceed to the next phase until the patient is pleased with the current phase of treatment. The following is an example of how this may occur:

First Phase. Diagnosis and treatment planning. This may consist of soft tissue management, all diagnostic tests and records, specialist referrals, and appropriate endodontic and periodontic therapy.

Second Phase. Treatment splinting and/or bleaching. This is the time to redo and alter, as necessary, treatment crowns or bridges until your patient is esthetically pleased and signs your release to proceed to Phase Three. If a problem patient says, “I like them just the way they are except I want this tooth built out a little more,” you should not proceed to the next phase of treatment. Make the necessary changes and let the patient live with the changed restoration for at least another week to make sure no other exceptions arise. The patient must be pleased with the appearance of the treatment splints, otherwise he or she may well be dissatisfied with the final restoration, stating, “I thought it would be different!” It also means using a capable laboratory to make well-shaded and proportioned acrylic temporaries.

Third Phase. Placement of final restorations. Your treatment should virtually duplicate the temporaries. Take either a very good alginate or even better, a vinyl polysiloxane impression to accurately record just how your patient wishes to look. When all is done, the patient should be satisfied with the esthetic treatment you have painstakingly performed.

The fourth precaution is to make sure your fee is adjusted appropriately. You should apportion your fee to the various phases after determining your expenses and desired profit in each phase of treatment. The fact that your increased fee may be considerably higher than that of your colleague across the hall or down the street also should play no role in setting your fee. Your attitude should be, if the patient does not understand your special abilities and the extra effort you will expend in helping to solve his or her problem, you are better off letting another dentist suffer the consequences, including the financial loss, in dealing with this type of problem patient.

In the final analysis, you should thoroughly consider all of the problems associated with each patient, whether a difficult clinical or emotional issue, or both. In some cases an astute staff member may sense that you cannot satisfy a particular patient. In all cases, be upfront and honest about your decision that a particular patient may be better treated by another dentist. Issues of patient abandonment do not apply if you decide to not treat during the diagnostic phase and before any treatment has begun.
The fifth and last precaution in treating problem patients is to pay particular attention to your treatment warranty. Make sure your patient knows exactly what you are guaranteeing so there is no misunderstanding about what is explicitly stated and what is implied.

The purpose of classifying potential problem patients here is not to dissuade you from treating them. Rather, it is to make you and your staff more aware of the potential consequences of treating certain types of patients. You and your staff should now be able to recognize better a potential problem before it happens. The chain of people who can give you information as to the patient’s personality is the receptionist, the assistant/hygienist, and then the treatment coordinator. Be sure to use the input from these key staff members before you elect to take up a patient’s esthetic treatment. Should you decide to treat a problem patient, be sure to adjust your fees accordingly.
Remember, it is not enough to just cover the cost of treatment of such patients. If you elect to dedicate the extra time, effort, and above all, stress (not only yours but also that of your staff and perhaps even your family), you are entitled to a reasonable profit for doing so. Your staff and family expect and deserve it as well. The greater is the difficulty, time, and effort required, the greater is the multiple of one’s routine fee. In the past 40 years many of the perceived “difficult” patients who elected not to proceed with my proposed treatment due to the increased fee have gone elsewhere for treatment—only to come back years later, still not happy. Now they will have to spend even more money to have their treatment redone. Incidentally, if you misjudged the patient the first time by referring when, perhaps, they might have been a perfectly acceptable patient, do not make the mistake of underestimating the amount of time, stress, and costs involved in redoing that patient’s case.

These patients are afraid of looking old. They expect esthetic dentistry to make them look young again, expecting you to get rid of their wrinkles by “plumping out” the restorations. Unfortunately, your dentistry may not be able to accomplish this esthetically, which can make for patient dissatisfaction.
The other type of patient in this category is the reverse—the one who claims that after your esthetic treatment, wrinkles appeared. This is one of the situations where the before full-face photograph is essential. It is advised that these photographs be taken with and without makeup. Ask the patient to remove all makeup, thus allowing you to more accurately see facial characteristics, which will help you in your diagnosis and treatment. Then point out every wrinkle and/or other facial deformities that are not likely to change. However, be quick to point out to this type patient that you work with an excellent team which includes a plastic surgeon, and that, following your dental treatment, the plastic surgeon may be able to improve that condition. Follow this suggestion with a recommendation for a consultation with a plastic or oral surgeon during your diagnostic stage—never after your treatment is complete. Make sure to document the recommendation so that you will not be taking responsibility for something you cannot control.

These are three basic methods for helping patients visualize your suggested solutions for their individual esthetic problems:

1. Soft, Tooth-Colored Wax or Composite Resin Applied Directly in the Mouth

The advantages to this technique are:

• it is the least costly for the patient;

• it is the quickest method;

• it is especially useful in space or diastema problems.

2. A Waxed Study Model

When the potential solution to an esthetic problem requires extensive tooth preparation, this method can be effective for those patients who are used to visualizing plans, such as an architectural blueprint (Figure 2-17). The waxed model is also important from a diagnostic standpoint when your patient has a space problem. By preparing the teeth, then waxing them, you can determine if there is too much or too little space for normal-sized tooth replacement. This allows you to adjust the treatment plan as necessary to make certain you can create an adequate esthetic restoration.

3. Computer Imaging

By far, esthetic imaging is the best method to help your patient visualize your intended corrections. The printouts and the image on the monitor can be effective communication tools. This method also allows you to easily alter your treatment plan to reflect various compromises. Rarely will it be necessary for your patient to return for further imaging if you have thought of possible options in advance. It is also extremely effective to show your patient the various choices, since most people will opt for the best look, provided they can find a way to afford the correction.

For patients with complex problems, the combination of computer imaging and waxed diagnostic models will be the best choice for complete visualization.

WHEN NOT TO TREAT… BUT TO REFER
It is impossible for any one dentist, regardless of how capable he or she is, to satisfy every patient’s esthetic needs. Most new patients are on their best behavior during the initial interview session. That is why it takes a skilful dentist and staff, as well as extra time, to ascertain what kind of patient is presenting to your office. Your goal is to determine who should be the patient you refer. To help with the decision, the following patient-type categories can be incorporated into your treatment philosophy.

In most instances when there are difficult spaces to restore, even a minor orthodontic intervention can make a tremendous difference in the final result. It is important to let the patient know what options he or she has and the degree of excellence that could be obtained with or without orthodontic treatment.

The next most important specialty to consider is periodontics. The control and correction of bone loss that could complicate the diagnosis or compromise the treatment results are obvious reasons to refer to a periodontist. In addition, the patient’s soft tissue needs to be observed during maximum smiling. Could tissue repositioning help create a more favorable tooth size relative to the patient’s face or smile? Would ridge augmentation help make a more realistic result? These, plus other questions regarding where and what type of margins to create are typical problems that could be more successfully solved with the aid of a periodontist skilled in cosmetic surgical techniques.

When there are questionable areas regarding periapical pathology, such as in teeth with deep, old restorations or periapical thickening, an endodontic consultation is in order. Previously placed ill- fitting crowns or endodontically questionable teeth could also seriously compromise the esthetic results unless you treat these areas, if necessary, before you begin.

Finally, oral surgery must be considered when facial deformities could also complicate maximum esthetic results. This may mean scheduling a consultation with a plastic surgeon as well.
The best way to communicate the advantages of obtaining specialty consultations is to let your patient know that you work with an excellent team consisting of orthodontists, periodontists, plastic surgeons, endodontists, and oral surgeons, and that your interest is in obtaining the best possible result based on their desires or preconceived images. You also need to stress that you are treating him or her as a whole person, not just treating the teeth. Finally, make sure you help your patient visualize the various options available.

The diagnosis and treatment planning phase for the treatment of esthetic dental problems can occupy a considerable amount of time. However, the presentation of the findings can often be better handled by a treatment coordinator skilled in the art of patient communication than by the dentist.

THE ROLE OF THE TREATMENT COORDINATOR

The ideal dental treatment coordinator is skilled in all the phases of dental practice including insurance, patient accounts, and has a good rapport with people. The treatment coordinator’s job begins either when the patient telephones for information as a new patient or upon the patient’s initial meeting with the dentist. During examination and initial diagnosis, the treatment coordinator records the findings. The treatment coordinator needs a full and clear understanding of all phases of treatment to enable him or her to present the treatment plan to the patient in an easy-to-understand format. After the treatment coordinator has presented a plan that is mutually acceptable to the doctor and the patient, he or she then proceeds to schedule the treatment and make the financial arrangements.

With the increasing use of auxiliary personnel, a dental treatment coordinator can be the backbone of the treatment team’s communication process, providing support to the dentist, dental assistants, hygienist, receptionist, bookkeeper, and office manager alike. Your dental treatment coordinator should spend about half of the average workday dealing with treatment planning. Another third of the day will be devoted to necessary paperwork including insurance and accident cases. That leaves the balance of the day for patient problems—fees, miscommunications, and explanations of complicated dental procedures that the patient may not completely understand.

The dental treatment coordinator is responsible for office public relations as well as problem solving. All lines of professional communication help to provide a smooth and effective treatment process for the patient. The treatment coordinator should maintain the credibility of the dentist and staff and reinforce the entire staff’s dedication to ensuring the patient’s faith in treatment already begun. It involves organizing and streamlining all aspects associated with patient treatment. This also requires checking the insurance and personal information that the patient provides.

Although payment for esthetic dentistry is always arranged in advance, if the treatment plan extends over considerable time a payment plan may need to be developed and explained fully to the patient. Some dentists do not want to talk about money with patients while others are perfectly comfortable doing so. If you are uncomfortable discussing fees with patients, you may too often end up giving away a good portion of your time, or working for a lower fee than you would normally charge. Therefore, for the financial health of your practice, make sure the treatment coordinator discusses fees and methods of payment with the patient.

In many instances, one appointment is all that is needed to diagnose, image, plan treatment, and make financial arrangements with your patient. However, more complex patient problems will usually require a second appointment.

THE SECOND APPOINTMENT

A completed Smile Analysis form should be discussed after the patient has reviewed the radiographs with the dentist and understands the preferred course of treatment. With a thorough analysis, useful conclusions can be made about the patient’s attitude toward his or her esthetic problems.
The Smile Analysis provides information essential to the thorough knowledge and understanding of the patients’ attitudes, which should never be ignored. Patients may ask the impossible or make statements that point to more profound wishes and attitudes. Hear not only what a patient says but also what he or she means. If the planned esthetic treatment is simple, present the final treatment plan soon after the Smile Analysis has been discussed. For the patient with a difficult tooth problem (repositioning or periodontal involvement), consultation with a specialist should be arranged.