by Lee Ann Brady 

Have you ever noticed a confused look on the face of an older dental patient when you tell them they have a cavity? Many people falsely assume that only small children develop cavities. When I let older adults know that they have one or more cavities, they say something like, “Wait, I thought only kids get cavities” or “I haven’t had a cavity in decades.”  

They honestly think we outgrow that, so I typically say to these patients, “I know you’re thinking that cavities are something that only kids get, and you’ve outgrown this. But that isn’t accurate. Yes, kids are often prone to getting cavities, but adults can get them for the same reasons.” 

Most of my older adults with cavities are doing a good job with their oral hygiene, so I will explain four things to them.  

1. As we age our saliva is no longer as protective. There are also lots of medications older adults take that diminish saliva production. But, even if our mouth does not feel dry, the saliva does not protect us against bacteria and plaque as well as when we were younger. 
2. As we age our taste buds change, and the foods that satisfy us the most are carbohydrates, so like children, older adults tend to eat more sugary foods. 
3. As we age, if we have gum recession, we have larger space between our teeth, and this tends to trap more food particles that feed bacteria.
    
4. After teeth are restored, normal function over time can introduce openings in the restoration, and bacteria can creep into those openings. 

After we talk about the various reasons that they and other older adults may get cavities, we talk about the fact that there are several preventive strategies and I suggest ones they might like to try.  

My patients enjoy our conversations because they know I really care about them, and I will happily spend time explaining why changes are occurring in their mouth. They appreciate hearing that their problem is not unusual and there are strategies to avoid cavities going forward. 

By Paul A. Henny, DDS 

The word “prescriptive” recently got stuck in my head. It made me think about the important distinction between a relationship that’s primarily focused around “giving directions or injunctions” versus mutually goal-oriented and collaborative. It’s all too easy in the middle of a busy day to reduce our patients’ complex problems down to prescriptive responses so we can move on to the next problem or obligation on our schedule.  

The reality of dentistry was brilliantly stated long ago by Bob Barkley, “Our goal is to design dentistry that will fail at the slowest possible rate.” This humble statement should always sit at the center of our practice philosophy: We aren’t gods; hence we aren’t perfect, and we can’t control the future. The best we can do is learn, practice, and do our best with the best of intentions. The rest will be up to the patient and fate.  

If our patients choose to not assertively take charge of their oral microbiome through appropriate oral hygiene and diet management, then all of our skills and good intentions will be undercut, and the failures sometimes blame-shifted onto us. That thought brings me around to the central reason behind why I’m writing today: We can’t be successful unless we are also good teachers and leaders. We have to want our patients to be successful on a very deep level. 

Last year my daughter Allison graduated at the top of her high school class, and it was easy to think “Wow! Look at what she did!” Yet it wasn’t just her efforts that made it happen, so the thought should be “Wow! Look at what WE did!” as the effort was communal and very philosophically-driven. It’s clear that Allison’s Principal and teachers LOVED her enough to invest a significant part of themselves in her development. You could feel it, see it, and hear it in their words. 

Are we similarly invested in our patients success? Are we doing a whole lot more than just being prescriptive? Are we investing a significant part of ourselves in our patients’ lives because we want to see them succeed? Can they feel it, see it, and hear it?  

By Paul A. Henny, DDS 

Effective leadership in dentistry requires open-mindedness and empathy, while at the same time, assertiveness, consistency, adaptableness, and resilience.  

That’s a tall order! 

Many of us struggle to be assertive and empathetic at the same time, particularly when we are under pressure. All too often, we lean into our positional power and superior knowledge and don’t stop to ask ourselves: 

• How does the patient feel about my message? 

• Does the patient understand the long-term implications of the information I have presented? 

It’s important to remind ourselves that decision-making is a two-step process: 

Step 1: The recognition of accurate, relevant, timely, and important new information 

Step 2: Reasoning to make choices that align with values and goals 

Few people fully understand the nature of their problems, needs, and the complex processes necessary to realize their goals when they first come into our dental offices. Patients often behave dogmatically or too emotionally, which leads them to choices that result in more failure and frustration. 

Our ability to facilitate learning in others and lead them to decisions with predictably better outcomes can be developed. This is good news! With understanding, practice, and reinforcement through successful experiences, we can all learn how to become more effective leaders and develop a more successful practice. 

The 6 Key Steps to Effectively Guiding Our Patients 

1. Slow down and manage your time more strategically to spend more time with each patient.
2. Demonstrate empathy. Stay in conversation and ask questions to understand what they know and how they feel about the information you are giving them. 
3. Create a safe and effective environment for learning. This entails slowing down your delivery of information into the bite sizes that are appropriate for the patient and pausing often for their minds to catch up and for them to experience self-discoveries.  
4. Show deference for the fact that each person is the best expert regarding themselves, their feelings, values, and goals. Let them know you will support them in their process and invite them to learn more and weigh their new knowledge against their values, priorities, and long-term goals.
5. Give each person enough time to make complex decisions as well as work through the logistics necessary to make their decisions fit into their life.
6. 6. Remain clear and assertive about what is in the patient’s best health interests and consistent with your values. Only proceed with treatment decisions that are mutually agreed upon as appropriate.

By Edwin A. McDonald, DDS 

It is amazing to me to realize that I have practiced for more than 40 years in a relationship based, fee for service dental practice. Dentistry has become much more complex during that time. What has not changed is the need for human beings to be loved, accepted, significant, understood, and heard. Also, people who have a high value for their health seek high clinical competence and thoughtful patient management.  

Two years ago, I started looking for a partner to continue providing my patients with comprehensive, relationship-based care. (My hands, back, and body had been telling me that it was time to slow down.) My primary goal in this transition was to create a future where the culture of my practice would continue, and the practice would thrive and grow. 

I received a call 18 months ago from my good friend, Dr. Lynne Gerlach. She said: “Mac, I want you to meet Dr. Shawn Luck.” Lynne went on to say, “I interview young dentists every day and I rarely meet people like him.” 

Shawn and I met, and I immediately understood what she meant. After a few more meetings, several phone calls with colleagues that knew Shawn well, and a thorough financial analysis, it was time for “Team Mac” to meet Dr. Shawn.  

Team relationships are critical to a successful transition. Shawn was met with enthusiasm from my team. That meant we could move forward with a detailed agreement that included terms of employment and terms of practice purchase.  

Shawn’s well-grounded character, confidence, enthusiasm, and intelligence were the factors that guided my decision. We both needed what each other had. I needed Shawn’s character, youth, energy, ambition, and strong desire to own a practice. He needed my clinical training, experience, and commitment to be a focused, consistent, and relentless teacher. 

I began communicating the transition with my team and patients a few months before meeting with Shawn. I mailed a formal letter to my patients that said that I saw three to five years of clinical practice remaining for myself. The letter began and ended with a big thank you for their loyalty, trust, and support. It let them know that I was actively looking for a young dentist to partner with who would continue to take care of them. This letter was a huge success with a thank you from almost every patient. A few patients began to schedule pending treatment that had been on their mind. 

We sent a second letter four months later to announce Dr. Luck. We began communicating about his arrival in person with enthusiasm and emailed a digital copy. The main takeaway here is that the transition immediately benefitted from consistent, focused, and abundant communication with all practice stakeholders about what we were planning and hoping for.  

We are in the middle of year one and I am focusing on mentoring Dr. Luck. We are hoping to play the infinite game as we create and pass on opportunities to the next generation. 

My hope for my Pankey Institute colleagues is you will surround yourself with great people that make you better. Build partnerships with them. Build trust at a deep level. Build community. Serve one another. Seek opportunities to pass on the values of relationship-based practice to the next generation. If you invite young dentists into a relationship and repeat the mentoring you received, we can all play this forward. Dr. Shawn Luck has already captured the spirit of wanting to do just that. 

By Mary Osborne, RDH 

Developing a partnership begins with an attitude of curiosity. It stems from a belief in the possibility that by working together we can achieve more than either of us can accomplish alone. With an attitude of curiosity we can develop the skill of listening and asking questions before going too quickly to teaching and telling. 

How do we help our patients see the part they can play in improving their health?  

We can begin by inviting the patient to share with us what they know about their health. They come to us with attitudes, beliefs, biases, and concerns about their health, as well as specific knowledge of their history. The more we know about where they have been the better able we will be to help them plan their future. We will have information to share about what we find and recommendations for how to proceed, but if we listen first we honor their perspective. We can also begin to hear their aspirations for their health in general and their dental health in particular. 

When dentists discover plaque or bleeding in an initial exam, they can tell the patient that the hygienist will help them with home care. But if we ask the patient if they would like help with home care and they say yes, we now have an invitation to give them information. The difference is subtle, but important.  

You can also ask the patient if a solution they have thought of or a recommendation you have made is something they would like to try. A yes is a commitment on some level to share in the oral hygiene process with you. Inviting and asking means moving the locus of control from you to the patient. I recognize that that is not our default mechanism, so doing this takes intention.  

How can we help patients to see us as a trusted advisor and seek our guidance? 

One of the things that I have learned over the years is that, when I remember who is really in control of the patients’ health, I am better able to partner with them. This process may take a little longer initially, but I would like to suggest we have all the time we need. We have the lifetime of our relationships with our patients.  

Once you agree that you have the mutual goal of moving toward improved health, you can invite them to deeper levels of conversation and understanding around health. You can avoid assuming what is best for them and help the physician inside each patient go to work. As they share their thoughts, they often become clearer about what they hope for.  

When you are genuinely interested in your patient, you earn a level of trust that opens the patient to hear more about their existing conditions and your concerns for them. By making connections with them over what is possible to achieve and what they want to achieve, you create a bond that opens the patient to your expert perspectives. When you ask for and respect their input on solutions, they are more likely to commit to a solution. 

When a new patient needs urgent treatment, how can we meet those treatment needs and still commence a lifetime journey toward health with the patient? 

Of course, we want to help our patients with immediate treatment when disease conditions are acute, but we want to do so in a way that inspires the patient to see the bigger, more comprehensive health picture. We want to help them see health as a journey and see us as empathetic fellow travelers who understand their suffering. As we facilitate dialogue about the health outcomes of treatment, we uncover their broader health aspirations. 

We intentionally deliver the message that we are here for them. We are interested in them and care about them as a person, and we let them know they can count on us to help them become healthier and maintain achieved levels of health. We do not allow the fact that the patient needed immediate relief to get in the way of a long-term commitment to their overall health.  

How do we engage our patients in being curious about their total health? 

At every visit, we can invite them into conversation about their health. The questions you ask will shape the conversation. Instead of “Any changes in your health history?” you might begin with, “How has your health been since the last time we were together?” Pause and listen to learn about your patient’s experiences, opinions, and feelings.  

In my experience, this process respects the physician that lives within each patient and leads to continuous co-discovery and collaboration toward health. Every conversation can empower the patient a little bit more to become clearer about their knowledge, attitudes, beliefs, biases, and barriers. The insights developed over the lifetime of your relationship enable you to become a trusted advisor to your patients.  

By exposing your interest about a range of health issues (diabetes, heart disease, obstructive sleep apnea, weight loss, smoking cessation, stress reduction, etc.), they will see you as a professional with broad knowledge and a worthwhile perspective. They will see you as a valuable resource. They will see you as someone who knows about health and ¾ more important ¾ someone who knows them.  

By Mary Osborne, RDH 

One way to involve patients in making choices about their health is to ask for an invitation to give information. Everyone on the team can look for ways to get permission before taking action. For example, if the dentist observes bleeding or plaque while doing an initial exam, the dentists often say, “The hygienist will help you with that.” That’s okay but getting an invitation for the hygienist is even more helpful. Instead of telling the patient what the hygienist will do, the dentist could ask for an invitation. “Would you like the hygienist to help you with that when you see her?” Patients typically say yes, and that sets the hygienist up for a different conversation when she sees that patient.  

When the hygienist sees a note that the patient wants some help removing deposits in a certain area, she has been invited to give information. The hygienist can say, “So, I understand from the doctor that you’d like to have some help with being more effective at removing the deposits that are around this tooth on the lower right.” 

In this circumstance, I might ask the patient, “What have you tried in cleaning that area?” I pause and allow the patient to think and speak. Perhaps they would demonstrate how they brush or floss in that area. If I do make a recommendation to a patient, I like to follow it with, “Is that something you’d like to try?” 

The dentist and hygienist are a team, and the patient is the third team member in partnering for health. In ideal practice, all clinical and front office team members are part of the collaboration and share their understanding of the patient with each other. Many times, especially with elderly patients, I find there is a family member who is a health partner, and we can invite them to participate in consultations. In dentistry, when we become trusted health advisors to our patients, we can also influence their choices in other areas of their health.  

When we listen well, we can filter our information through the lens of improving overall health. We can make connections between their perspective and our own. When we understand the patient as an individual with special circumstances, opinions, and emotions, we can help them get in touch with their own aspirations for health and help them move toward those goals.  

By Paul A. Henny, DDS, and Deborah E. Bush, MA 

The traditional rational economic model used in classical decision-making theory routinely fails to predict patient behavior because it fails to consider the psychology of decision-making and the inductive neuro process necessary to change one’s mind about what is best for oneself. 

Classic Decision Theory 

Classic Decision Theory (CDT) models a decision-making process that involves a fixed set of alternatives about which a person knows little. In response, they relate their limited knowledge to the situation at hand, use their beliefs and expectations associated with the options to project an outcome, and then use logic to make the final decision based on their goals. 

According to this theory, people primarily make decisions based on their desire to maximize gains and minimize losses, an objective. This deductive process is largely driven by a heuristic known as “scarcity bias.” However, anyone who has practiced dentistry for more than a day outside of a teaching institution knows that CDT fails to explain many of the decisions patients make when they’re confronted with a complex problem they don’t fully understand.  

Simple decisions such as “Should I get this filling replaced because it’s broken?” or “Should I allow Dr. Smith to help me make this tooth stop hurting?” are predictable. What’s much less predictable is whether a person will allow us to equilibrate their occlusion or leverage restorative dentistry to reestablish proper form, function, esthetics, and neuromuscular modulation. Why? Because these are complex issues that require an understanding of how the stomatognathic system works before the proposed solution makes sense and appears to be the logical best option to the patient. 

Neuroeconomics is an interdisciplinary field that aims to explain human decision-making. By integrating psychology and neuroscience, this discipline can help us better understand how humans process alternatives to make choices and follow through on a plan of action. Neuroscience affirms that re-evaluating perspectives is a right-brain activity and an inductive process. 

The Dentist’s Challenge  

In practice, we often see patients making decisions we think are unwise for their long-term oral health. A person’s values and belief system influence their decisions. Not only may the person’s understanding and belief system be underdeveloped in relation to the value of properly planned, designed, and executed health-centered restorative dentistry, but their memories may be distorted. In this case, the person makes what we perceive to be unwise decisions because their memories do not align well with our understanding of the situation. They don’t know what we know.  

Helping Patients Think and Feel Differently Through Inductive Reasoning 

Reassessment, modification, or outright replacement of beliefs is a right-brain process known as inductive reasoning. The purpose of Co-Discovery is to take the patient through an inductive reasoning process. Oral health providers who understand how and why Co-Discovery works have experienced how it can change the trajectory of a person’s decision-making process. 

Our challenge is to create an optimal learning environment in which people can safely reevaluate their beliefs, values, and priorities. Being patient with patients and taking our time to guide them through the inductive process of Co-Discovery will comfortably provoke new thinking, new beliefs, and new emotions. Through the process, a great many patients come to realize that their historical perspective is not serving them well, and they decide to have that equilibration or restorative dentistry that will serve them best in the long-term.  

They may not choose treatment the first time it is recommended but will subsequently realize it is in their best interest. We just have to stay in conversation with them in Co-Discovery mode and guide them through the inductive process to arrive at their new goals.  

Long-term, this is healthier for dentists and their care teams as well. The conversations we have with patients change the trajectory of our dental practices. Better conversations result in better decisions, which in turn result in better outcomes. Better outcomes result in lower stress and a thriving practice that is much more fulfilling for dentists and care team members.   

By Paul A. Henny, DDS 

In Part 1, we looked at personal boundaries in dental practice. I mentioned scarcity bias and how it is prevalent in undifferentiated dental practices but not so much in dental practices where providers and patients mutually share the values and agenda of the practice. Because scarcity bias is so human, so ingrained in us, I want to discuss two things in Part 2: healthy relationships and also how to address scarcity bias as it occurs in our differentiated dental practices. 

Insight Into Our Boundaries Leads to Healthy Relationships 

Healthy interdependent relationships are only possible through first understanding our personal boundaries (Who am I? What am I responsible for? What am I not responsible for?). That’s critical because psychologically speaking, boundaries are like fence lines with consciously regulated gates.  

The aphorism “Good fences make for good neighbors” prevails.  The same logic applies to the practice of dentistry and the nature of the relationships that we create—consciously or not, within it.  

And Now, We Circle Back to Differentiation  

Healthy interpersonal boundaries lead us toward more interpersonal authenticity, which leads us toward higher-quality communication of our values and purpose. Higher quality communication leads to a more sophisticated level of collaboration and healthy results, including healthy interdependent relationships, self-reflection, self-responsibility, improved oral and total body health, improved mental health, and a constantly growing reputation for your values. That’s differentiation. That’s personal authenticity. That’s success. 

Addressing Scarcity Bias 

Once we understand ourselves well and we communicate consistently with personal authenticity, we still have the challenge of “knee-jerk” scarcity bias in our patients. This is where patience comes in and empathy—understanding and recognizing their feelings. 

People are biased toward the here and now. The mind is naturally focused on meeting immediate needs at the expense of future ones. We procrastinate important things such as dental treatment unless we have an urgent need for it. We fail to make investments, even when the future benefits are significant or the costs of not doing so are substantial. 

When the dentist and patient participate equally in a co-discovery examination process and co-discovery consultations to discuss health history and current findings, and the patient is empowered and becomes comfortable mentioning everything on their mind, we have already begun the powerful process of leading each other through understanding what is happening in the body and what is happening in the mind (feelings and thoughts). We can start to talk about what the patient would like to achieve long term—the patient’s beyond-the-moment oral health goals. We can start to talk about what is possible to achieve together and introduce the notion that we can take steps at the speed that is mutually comfortable for us. 

Inspiration to do “the work” is often planted with just a few words that create a future desirable image in the patient’s mind. If we have the patience to let the inspiration grow, without overwhelming the patient, scarcity bias can dissipate. Often patients come back to the conversation the next time they visit us and say, “I was thinking about what we talked about, and I think I am ready to…”  

Negotiating health goals between two adults starts as an invitation to agree upon common goals. We can start early in the doctor-patient and hygienist-patient relationships by instilling the thought that preventive health care is a partnership. They can’t do it alone and you can’t do it for them. Everyone must play their part responsibly. 

By Mary Osborne, RDH 

How can we make recommendations for care without fully understanding what the patient aspires to? The patient’s goals are the context or should be the context for recommendations that we are going to make as their partner in health. Too often, context is the missing piece in our conversations with patients.  

I’ve heard that Dr. Bob Barkley would say to his patients, “You know, Mrs. Jones, if I had taken X-rays of you every six months since you were born, we would have 80 sets of x-rays. And if I stacked them one on top of another and then thumbed through them, I would have a movie of the health of your mouth for the last 40 years. We would see how your teeth changed from health to the degree of breakdown we see today. We can’t do anything now to change that movie. That movie has already been made. But, if you like, you and I can work together to create the movie for the next 40 years. Is that something you’d like to do?” 

If we get agreement from the patient, “Yes, I’d like to work together with you to plan for the next 40 years,” that’s not a specific goal, but it begins to create a context for our recommendations. Instead of the provider setting the expectations of the patient, it becomes more of a mutual agreement to long-term planning, so that there’s a buy-in by both parties in the relationship. That’s moving toward a partnership.  

When we set a general mutual goal during the preclinical consults, it fits in well with our not knowing what we will uncover during the clinical piece of the appointment. Dentists and hygienists can be direct about it, and I think there is value in saying, “I’d like to come to a mutual agreement that we work together to understand what is going on in your mouth, and based on the circumstances we find, come up with the best solutions for you. Is that something you would like to do?” 

We can set expectations by saying, “As we go through this process, I will be asking for your input. We’ll take it slow and be thorough. We’ll discuss what you and I discover, and together we can think through the next steps you may want to take. How does that sound to you?” 

I think it is essential to this process to invite the patient to be in shared control by asking, “Would you like to proceed with the clinical examination? Do you have any questions for me before we begin?” 

When we come to the conversation as fellow travelers with the attitude that “the two of us can work together,” we open ourselves to working toward mutual agreement about what it’s going to take for this particular person to achieve the level of health to which they aspire. Starting as partners with the goal of improved health is a low-stress way of being in a relationship that is comfortable for both parties. 

By Mary Osborne, RDH 

How much time do you schedule for a new patient, non-emergency visit? Is your priority efficiency or effectiveness? Is your goal to gather as much clinical data as possible, or is it to begin to build a relationship of mutual trust? Both are possible if you see the new patient visit as more of a process than an event.   

Too often new patients are rushed through an assembly line: brief conversation, clinical exam, diagnostic records, and treatment presentation! Is that really the best way to help people make choices about their health?  

There is no one right way to schedule a new patient. Different practices are successful with different models based on the values of the practice, practice growth, and the personality and skills of doctors and team members. The most important determinant of success is our ability to meet each patient where they are and join them on a journey to health. I am not suggesting we should be without practice standards of care.  We have a responsibility to decide what we need before beginning treatment. Our challenge is to guide patients to understanding why we need what we need, and why that is relevant to their unique situation.   

We may anticipate that patients will resist this type of experience, but if we make it truly about the patient and are flexible, I have found that patients are more than willing to participate in an individualized process that best meets their temperament and circumstances. 

I remember seeing a new patient that I was told was a “very busy attorney” because his secretary said so when she made the appointment and his wife said so when she confirmed the appointment. I anticipated that he would be a driver and prepared to efficiently move him through his appointment.  

As I explored his health history with him he expanded on the specific answers to questions. Soon, he was leading the conversation. When I remarked that I wanted to make sure we were making good use of his time. He said, “Mary, what’s this about time?” I replied that I knew he was very busy. He said, “Mary, this is about me. I have time for me.” 

His statement has stayed with me because I realized that if the conversation had been about me going through my check list and not listening to him, it would not have been a worthwhile experience for him. It also wouldn’t have been a worthwhile experience for me. 

I have learned that when the patient feels in control of the process they are willing to give that time to themselves. A lot of aha moments occur as they learn about themselves while speaking. When patients feel like they are on an assembly line being moved through our system, they have every right to be resistant.  

Empowering patients to lead the process is both an attitude and a learnable skill. When we can lose ourselves in the moment, really listen, really encourage, and really care about the patient’s thoughts and feelings, it is easy to make connections to the next step we recommend.  It is my experience that I can more quickly become a trusted health advisor when I intentionally share control with my patient. 

Most patients are willing to invest more time in the process when they see the connection between their needs and what we recommend.  These are typically patients who have or have had complex health issues and are seeking to improve and retain health. They perceive the value of the extended process and how much value you place on spending in-depth time with them.  

The entire team’s communication can deliver the message that everyone in the practice is keenly interested in them, and their appointment is uniquely planned to meet their needs.  

What has been your experience? Are you open to scheduling more time for conversations that typically garner trust and appreciation earlier in the relationship?