One of the biggest stumbling blocks to offering quality esthetic dentistry is the mistaken belief that your patients will not pay for it. I once had a patient who was a bricklayer and who was dissatisfied with his smile. I spent a considerable amount of time trying to educate him as to why the best esthetic dentistry might cost more. I gave him three alternative choices for different qualities of esthetic treatment and thoroughly explained the differences among the three. Although he was dressed poorly and not well-groomed, the gentleman eventually chose the best quality dental service. My father had pointed out to me that he thought I might have spent too much time with someone who did not appear to be interested in such a high-quality procedure. However, this taught me (and my father) never to judge someone by first appearance.

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.

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