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 Mary Osborne, RDH 

Dr. Rachel Naomi Remin says, “Doctor, you may know what’s best for the disease the patient has but that’s not the same as knowing what’s best for the patient.”  

It’s difficult to let go of our own assumptions about what we’re supposed to do, how healthy this person should be based on our criteria, and what is the best path forward in every situation. Our clinical training leads us to believe that we’re supposed to know what’s best for our patient. 

There is another quote, from Dr. Albert Schweitzer, which has challenged my thinking about patient care for a long time:  

“Patients carry their own doctor inside.”  

I believe that every one of us has opinions, ideas, and knowledge about our own health. That is the doctor inside. Dr. Schweitzer said patients come to us knowing we have expertise, but “we are at our best when we give the physician who resides within each patient a chance to go to work.” When we do that, we help people become healthier. 

There is a place for our solutions. There is a place for our expertise to show up. But if we slow ourselves down a half step, we are often amazed at the answers patients come up with. They can be downright creative and elegant. The reason they are elegant is because they are their solutions, and patients are more likely to follow through with solutions they conceive. I’m not saying we shouldn’t guide them to understanding the advantages and disadvantages of their solutions and other possibilities that you we know are out there, but we should be open to allowing them to think about solutions and not prejudge their choices. 

For example, if a patient says she or he doesn’t have time to floss, I was trained to say, “Well, don’t you watch the evening news? You can do it while you’re watching the news. Right?” That’s about me having the solution. But now I sit back and say to the patient, “Well, it sounds like you’re very busy. Is there any time at all during the day when you’re sitting, and you feel that you could floss easily?” When I ask the question, they usually have a better answer than the nightly news. It’s a better solution because it’s their solution. They have bought into it at some level.  

In many cases, we see the “treatment” for a problem as we’re seeing the problem. That’s something that we take a great deal of pride in. But when we come together with our patient, sitting eye to eye, we can often come to a much more elegant treatment plan, one that moves us more comprehensively toward our goal of improved health. In between what is and what is possible, we encourage the patient to discover the level of health to which they aspire. We come to mutual agreement about going forward in a certain way to accomplish some things that are bigger and better than just solving “a problem.” 

By Paul A. Henny, DDS 

Today, I am revisiting the value of personal authenticity and its transformational power within truly helping relationships. We know can’t evolve into becoming more authentic with our patients until we first “know ourselves,” which is another way of saying “until we’ve developed a lot of personal insight.” 

Personal insight is the beginning point of understanding what tends to drive our behavior and thinking, therefore, it’s the beginning point of change. But there’s another key variable in the facilitation-of-change process that’s often overlooked: What is the level of personal insight within the person we are attempting to help?  

What happens when we and our patients share similar values? 

We’ve all had experiences with patients with whom we easily and almost automatically connect. The conversations flow smoothly, and there’s a lot of agreement regarding what needs to be addressed, how and when. It happens because these folks share similar values and priorities, and likely, they’ve had some personal experiences that strongly support those beliefs. 

But let’s be honest. Those moments are rare for most dentists who have undifferentiated practices. 

What happens in undifferentiated dental practices? 

When I use the adjective “undifferentiated,” I mean the practice has a lot of patients who come for reasons other than shared values, agendas, and purpose. A patient’s dental insurance is a prime reason patients go to a particular dentist. Nearly free new patient exams and limited x-rays offered by many dentists is another reason. Being accessible for emergency dentistry in the patient’s local neighborhood is yet another. 

PPOs are likely the most common reason a patient sticks with an undifferentiated dentist. Patients with “insurance” don’t really have insurance. They have a minimal and limiting benefit plan disguised AS IF it were insurance. Consequently, misconceptions occur due to the intentionally confusing language. 

Additionally, insurance causes people to naturally focus more on their benefits (a reductionistic concept) than on their health (a holistic concept). So, in a very twisted and often dysfunctional way, dental insurance can cause people to make bad decisions that negatively influence their health as they psychologically prioritize money over their health.  

The Scarcity Bias 

The human brain has a bias toward scarcity thinking unless it’s actively circumvented through more right-side prefrontal cortex involvement. This scarcity bias occurs as most dental patients make treatment choices, and when this happens, we have a choice. 

1. We can play along and rationalize it. “It is what it is.” We can take the checks and focus on economy-of-scale strategies and production. 

1. We can actively work to remove insurance carrier influence from the patient decision-making process while facilitating greater patient involvement and problem ownership. 

Put another way: We either accept the codependency relationships (and all the anger, confusion, disappointment, and frustration that it brings along with the insurance benefits), or we actively work at creating interdependent relationships with patients, wherein they become the co-creators of their health future and share responsibilities associated with that goal. 

The Violation of Personal Boundaries 

When we actively participate in dependency-centric relationships, we violate interpersonal boundaries.  

On this, Avrom King brilliantly commented, “Dependency is the word we use to identify an individual who, for whatever reason, cannot claim and develop their latent personal power; instead, they negotiate psychological contracts with other people whose ego needs are served by accepting responsibility for the dependent person’s outcomes.” 

The minute we start to take responsibility for other people’s responsibilities, we begin a journey down a road that commonly leads to dysfunction, conflict, and frustration. 

Heath-centered dentistry is only possible through interdependent relationships, which means that ALL codependent relationships aren’t health-centered. They are centered on other things that are often associated with insecurity.  

To be continued in Part 2… 

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  

The questions we ask on a health history form have more to do with disease history than health history, right? The focus is on disease right away. I like to shift that focus to health by saying, “I see that you’ve filled out this history and I’d like to talk to you about specifics, but I wonder if we can begin by you telling me a bit about your health in general? How healthy do you think you are?”  

I have found that if I start with health, I’m more likely to have a patient talk about health. If a patient says, “I think I’m pretty healthy,” I can ask, “What do you do to take care of yourself?” I can relate by acknowledging that I am trying to take better care of myself and how it isn’t always easy. Or I can pick up on something that is important to the patient, such as a concerted effort to get enough sleep or stick to healthier foods or to bicycle many miles a week. I can say, “Tell me more about that. It sounds like you feel better when you do that.”   

The questions you ask shape the conversation. And by the way, that does not just apply to reviewing a health history with new patients. It applies to every single interaction, with every single patient, with everyone on the team.   

When someone comes for their routine hygiene check, I might ask about their recent vacation or how their kids are doing, but I also always ask questions that open a conversation about health. Instead of starting with, “Have there been any changes in your health history since I last saw you?” I like to ask, “How has your health been since I last saw you?” Instead of asking, “Have there been any dental problems that you want us to pay attention to,” I ask, “What have you been noticing about your teeth recently? What are you noticing when you brush or when you floss?”  

We have to deal with disease. That’s a part of our job but moving toward health is more enriching. It’s positive.   

If you want to be seen as a partner in health, then moving the conversation in the direction of health is much more powerful than focusing on disease. The truth is everyone has a personal health story. There are things they are happy about and things they are sad about. When we take a little time to explore that story with questions, we and our patient gain insight into their experiences, attitudes, and feelings about their health. We and our patient get a better understanding of their motivations and the strategies they employ to become healthier. If we invite them to share their perspective with us, they will be more willing to hear our perspective, and we can extend an invitation: “Would you like to hear my perspective about that?”  

I recognize that inviting and engaging the patient in expanded conversations about their health may take a little more time, but it is effective time. Over the years, I noticed that when I thought I was being most efficient, I was generally being less effective. And in the long run, I ended up spending more time understanding what the problem was and trying to give more information without getting enough feedback to know if I was being heard or influencing the patient.   

One of my favorite things to hear from a patient is “You know, I never thought about that before.” I remember a woman who told me that she had been a smoker, but she had quit smoking. And I asked her how she did that. What prompted her? She said it was when her daughter was born that she realized that she didn’t want the smoke around her daughter. In her health review and preclinical conversation, she mentioned one of the things she did for exercise was tap dancing lessons, so I asked her how she got into that, and she said, “I figured I could spend time with my daughter, get exercise myself, and set a good example for my daughter. Wow, I guess my daughter is really a good influence on my health, isn’t she?” 

Those are the light bulb moments that light up my day.  

By Kelley Brummett, DMD 

A situation occurred in my office when I was working with a patient who needed a 30-year-old PFM crown replaced on #8. I was struggling with the shade because the adjacent teeth were an in between color. What I did was take a shade photo of the brightest one, which was B1, and then I took a shade photo with A1–because those were the two shades that matched the best. They weren’t what we were looking for. So, I made a provisional out of the A1 shade and a a provisional out of the B1 shade. I took the extra time to place both of them onto the tooth and let the patient look with me and help me decide. The patient chose the A1 shade. 

After I placed the A1 provisional, we sent  photos to my lab. These photos included the first shade photos of B1 and A1 alongside the tooth, photos of the B1 and A1 provisionals, and photos of the provisional I placed on the tooth from various aesthetic views. I then talked to the lab over the phone while we viewed the photos together so they could create the right in-between shade.  

At the end of the process, my patient expressed gratitude for taking the extra steps and meeting her expectations for a beautifully blended smile. 

Laura S. Harkin, DMD 

I’m the owner of a third-generation dental practice. My father was a special person who cared for his patients as much as he did his dentistry. One important piece of advice that he gave was to make sure that my patient records were always complete and pristine. He said, “Anything that you are sending to the laboratory or to a specialist, even down to how you write your lab script or note, must be precise. And the reason is not only to minimize adjustment at the end but to also set an expectation for the same level of care returned by the lab or specialist.” 

As a team, we have spent time evaluating our models and photos to discuss how they can be improved and to recognize our highest standard. Recently, I became a little concerned about some of the radiographs we’d taken in the office. I encountered a few bitewings in which I was able to see the bone levels or the image wasn’t anterior enough to check the distal of the canine. So, as a team, we set aside time to review current x-rays and discuss the diagnostic qualities that we seek to achieve in each type.  

A team huddle provides built-in time and a safe place to do something like this. While reviewing the images, it became very clear that the team knew how to take vertical and horizontal bitewings. They also had a clear visual for how the images should look. Sometimes, however, a team member was shy about retaking an x-ray for they worried that a patient would be uncomfortable with the process. Other times, I imagine, they felt pressed for time and hurried to move down their checklist. 

Our review of images reinforced the level of care we collectively aim to achieve in all facets of our clinical day. Just as we strive for beautiful, mounted study casts, we take our x-rays with intention for our ourselves, our referral sources, and, above all, our patients. Consider taking a team meeting to share each other’s tips and tricks for taking x-rays in patients with difficult anatomy, a gag reflex, or missing teeth. Our own team members have a wealth of knowledge that sometimes doesn’t move from one treatment room to the next! 

By David R. Rice, DDS 

I’m guessing your practice is a whole lot like mine. People can be challenging. Patients are people. Ergo, yes, patients often bring us challenges. With that and 29 years into dentistry, there are a few challenges I’m willing to admit and, like you, work to overcome.  

Our great patients get great dentistry.
Our challenging patients get our best effort.
Our job is to understand who each is, what each wants,
and how we do our best to deliver it. 

As you and I learn the best techniques and technology, we have to understand that many of our patients see the world differently. They see it differently than each other, and they see it differently than we do. At first glance, yes, this is an obstacle. But for those of us willing to spend time focusing on their views, this is a massive opportunity.  

About 20 years ago, the treatment planning and presentation mantra our team developed was: Pizza by the slice or the whole pie? 

 A talented and curious team with character, plus a well-defined process,
always equals complete care and profitable production. 

 Here are the four keys: 

1. Understanding who of our patients wants complete care—the whole pie right now. 

1. Knowing who of our patients isn’t ready for the whole pie today and needs us to serve that complete care one prioritized slice at a time. 

1. Recognizing that some patients love pepperoni, some love veggies, some are all NY and thin crust, some love that Chicago deep dish, and so on. 

1. Delivering each individual patient’s pizza the way they want it without yielding on our quality. 

All our patients come with a story. Some are ready for a whole pie. They want complete care and they want it now. Other patients are overwhelmed by the whole pie. Right or wrong, some past experience makes their yes to the complete care we know they need challenging. We can push them, or we can appreciate where they are and work with them one slice at a time. 

I’m not proposing we compromise our care. I’m offering us all an opportunity to elevate it. Whether you’re scanning and milling, 3D printing, injection molding, direct bonding, or prepping and temping long-term, the materials and technology we have at our fingertips today afford us an incredible ability to segment care. 

Complete-care case acceptance at 90%+ is a reality when we add great communication skills to the clinical skills we’ve worked so diligently to achieve. Today, I challenge you to assess, calibrate, and elevate your ability to deliver pizza by the slice…or the whole pie. 

By Laura S. Harkin, DMD  

My dad and I were enjoying our favorite lunch spot years ago when he turned to me and said, “Laura, isn’t it amazing? There’s an incredible sense of trust that our patients have in us. Sometimes, we give our best recommendation for treatment, and it is declined as if it weren’t important or a priority. I’ve recognized that, more often than not, our patients eventually choose to move forward, proving that it was more a matter of timing and circumstance than lack of value.” 

Trust is the cornerstone of our practice. It was transferred from patients to Grandpa to Dad and to me. I do believe that every morsel is earned through guidance, thoughtfulness, and skill. Trust is an entity that requires constant nurturing. In private practice, one should recognize that a doctor’s trust in their patient is equally as important as a patient’s trust in their provider. With synergy there’s the opportunity for optimal health. Even as a child, I had a very clear understanding of the care my dad had for his patients. This feeling is innate and deeply imbedded in me. I imagine that he felt the same.  

I don’t consider myself “a writer,” but I’ve always enjoyed the art of letter writing. I grew up writing frequently to my grandparents and friends and always loved picking out stationary that reflected my personality. Recently, I reread the letters that my grandfather typed on his old typewriter and my oldest brother scribbled on his Grateful Dead CD inserts – crafted just for me. It seems fitting then that I enjoy writing personalized letters to my patients. In fact, I’m pretty sure I salvaged my mental health during COVID by writing “updates” to my patients during months of closure. I digress. 

The letters that I write to my patients are most often in reference to comprehensive treatment. They provide a bird’s eye glimpse of our most recent findings, diagnoses, and treatment recommendations. My older patients, especially, appreciate my thoroughness, organization, and systematic approach to recommended treatment. These letters certainly aren’t handwritten, but the hard copy renders a sense of care that’s transferred from my hands to theirs. We must remember that individuals comprehend and retain information differently. The one-on-one, verbal, treatment consultation can become lost in the shuffle of everyday. Add dental language and complicated procedures to the mix, and that’s simply a recipe for confusion.  

Whenever I present complex treatment to a patient, I write a letter in everyday language to support our conversation. It’s stored in their digital chart as part of their dental record. In my first paragraph, I state my patient’s chief complaint. A summary of clinical findings followed by bullet point. Next, I provide my best treatment recommendation, an appointment sequence, and the financial investment. Photographs are also a helpful insert to aid in explanation for family members who were unable to attend the consultation. I think there’s value in a tangible letter taken home to revisit.  

Treatment letters are also an irreplaceable resource for my team. When a patient calls to schedule treatment previously presented, my stored letter immediately becomes a reference for scheduling appointments, including time allotments and space in-between subsequent visits. In my office, we offer a courtesy for treatment paid in full. This amount is figured in the financial investment portion of my letter so that conversations regarding immediate payment or a payment plan can easily flow. Should a case not be accepted prior to a routine recare visit, this letter serves as an excellent reminder during team huddle. It’s inefficient to page through multiple chart notes and software-driven plans with no explanation of the diagnoses which caused a need for restoration in the first place.  

In my first few years of practice, it was hard for me to accept that I needed to view this document as fluid with a potential need for multiple modifications to suit my patient’s desires and limitations. For example, financial concerns often lead to the need for phased treatment or a compromise from the ideal. I’m committed to openly discussing what may occur if no treatment is rendered or if a compromised approach is chosen. Likewise, I believe in the importance of presenting the financial component of extensive treatment myself. As the dentist and business owner, I must “own” the fee that I’ve carefully determined to reflect indirect and direct time, the skill level and support to be provided by my team, the technical excellence of my laboratory technicians, and my own knowledge. The fee that I present is steadfast, barring an unanticipated need such as root canal therapy. Should there be a need for additional chair-time or visits, it’s included in the quoted fee.  

Finally, my letters include my expectations for post-treatment maintenance. For example, if we are to complete a hybrid case in conjunction with a surgeon, I’m careful to share the importance of periodontal health and frequent maintenance visits to prevent peri-implantitis. In patients who have pre-existing medical conditions that when uncontrolled can be contradictory, I stress the importance of regular monitoring. Ultimately, I strive to empower my patients to choose and achieve oral health, Undoubtedly, oral health positively impacts overall health. My personal letters are a distinguishing trait of my practice that convey the level of care to be carried from presentation through treatment and in maintenance. Consider the value in this extra step! 

By Lee Ann Brady, DMD 

A patient chipped a tooth on her lower hybrid denture and loosened an implant screw. The denture had been placed 18 years ago, so she had an old titanium bar with denture teeth and pink acrylic. That day, I put the screw back in and smoothed out where the tooth was chipped. During this visit we had a great conversation about the future of her hybrid denture. 

I have had a similar conversation with several patients in recent months. They have the original, traditional bar retained hybrid denture that is nearing the end of its lifespan. And so, what are the options? 

1. If the bar is in great shape, new denture teeth and a new denture base can be milled and placed over the existing titanium bar. 

1. Alternatively, we can get rid of the bar and go to something that is all zirconia. 

If there is a preference for the first option, the first requirement is to make sure the titanium bar is in good condition. After 18 years, we would take it off and have the laboratory examine it under microscopy.  

If converting to all-zirconia and the patient has had upper and lower dentures, we must consider if one arch can be converted without converting the second arch. A zirconia arch is going to wear an opposing original denture fast if there is parafunction, and the zirconia arch is likely to fracture the opposing original prosthetic teeth. 

We have options today we can think about with our patients, but many have in their minds that when they got their hybrid dentures years ago, the dentures would last. All the time, energy, and dollars to freshen up or replace their denture is a big deal to them. Shifting their mindset from “I thought I was done investing in dentistry” to “My denture is at the end of its lifespan” is a big hurdle. So, the earlier we can start those conversations before they need to invest, the easier they can transition their minds to accept care with grace when the time comes. 

When your bar retained hybrid denture patients visit for perio maintenance and your exams, inform them of the lifespan of their denture is at most 20 years and set expectations for discussing the best available options at some point in the future.