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 

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 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? 

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.  

By Mary Osborne, RDH 

There was a time when I thought “partnering in health” was just about getting people to take better care of their teeth. 

Many years ago, I had a patient who was excellent with her home care, but she showed up periodically with an acute periodontal infection. We asked about stress and her overall health, but she was not aware of any issues. We would treat the infection and she would be fine for a sometime. We knew she worked for National Public Radio, and one day we made the connection that her infections showed up concurrent with NPR’s fund-raising drives. That shared realization allowed us to help her see that her stress was affecting her dental health and her overall health. She was open to conversations about lifestyle changes that would help her be healthier. My relationship with her influenced my thinking and my ability to connect with my patients from a perspective of Whole-health Dentistry. I came to understand that I had been missing opportunities to influence the way people think and feel about health. I knew that I wanted my patients to see me as “a partner in health.” 

Unfortunately, most of our patients come to us with the perspective that we are fixers of teeth, not partners in health. 

In the culture today people are bombarded with information about what is healthy. From friends and families, social and news media, and a wide variety of health care practitioners, everybody expresses opinions on how they are supposed to take care of themselves. Why, then, are we surprised when our patients don’t know whom to trust? Why are we surprised when they shrug their shoulders or appear confused? It’s not always a case of conflicting facts but a case of various perspectives that people don’t know how to navigate. 

Think about where you place your trust. How do you decide whom to trust about decisions—whether it’s about your health, or about your finances, or about how you raise your children? When I ask myself that question, two criteria surface. They need to know their subject and to know me. I want that person to know what it is they’re talking about. I want them to be well informed. I also want someone who knows me, who understands my values. I want that person to have a sense of who I am and what is important to me. 

As we get to know our patients over the years, most of them come to see us as trusted advisors when it comes to their dental health—but fewer see us as trusted advisors when it comes to their general health. If we jump too quickly to making recommendations about their overall health, we are more likely to meet resistance. If we want to cross the bridge into influencing our patients’ overall health and wellbeing, I believe we need an invitation to cross that bridge.   

The Missing Piece in our quest to influence the overall health of our patients is the failure to invite patients to share their perspectives on health. Beginning a conversation with a new patient with the question, “What can you tell me about your health in general?” is an invitation for them to talk about their experience of their health, not just details. Instead of “reviewing” health histories, what if we “explore” health histories? As we connect and get to know each other we can learn to listen beyond information to hear attitudes, beliefs, fears, biases, concerns, barriers, etc. As you understand their perspectives on health issues that come up in conversation, it’s easy to ask if they would like your perspective on that issue. These conversations often lead to more questions and answers that invite more and more invitations from our patients to be their partner in health. 

Kelley Brummett, DMD 

After you do a crown preparation, do you tell your patients that you’re going to make them a temporary or a provisional?  

Provisionals are more than temporary restorations. They are part of a process. They’re the dress rehearsal to the final outcome. They are the prototypes for the final restorations.  

The “provisional” process is an opportunity to gain trust with the patient while modifying the length of teeth, the shape, or the color. It is also a way to communicate with the patient how their functional and parafunctional findings may have contributed to the destruction of their teeth. 

As the patient comes back to have their bite checked and to talk about what they like and don’t like, we are building trust. We’re involving them in understanding what they feel and think. We’re listening to improve their conditions. 

I’ve had patients who were fearful about moving forward with extensive treatment because they couldn’t envision the transition from the prep appointment to the final. What would those temporaries look like? What would they feel like? How would they function?  

So, when I am discussing a case with a patient, provisionals are all part of one treatment fee. We talk about the prep process, the provisional process, the lab process, and the final seating process—all as one process for which there is a fee. We discuss how the provisionals will guide us in optimizing the lab plan to achieve the desired comfort, function, and aesthetics.  

Whether it’s a single tooth or whether it’s multiple, I encourage you to help the patient understand that what you are providing in the interim between a preparation and a seat of a restoration is called a “provisional.” 

A provisional protects the underlying tooth structure. It keeps tissue in place. It helps the patient feel confident. It allows us to understand what might be going on functionally. It helps us communicate better with the lab. It’s more than a temporary restoration. It’s a guide on our journey toward predictable and appreciated relationship-based dentistry. 

Explaining Dentistry in a Way Patients Understand 

Clayton Davis, DMD 

Here are some of the ways I communicate with patients to help them understand dentistry. I hope some of these will be helpful to you in enabling your patients to make good decisions about their treatment.  

Occlusal Disease: In helping patients understand occlusal disease and the destruction it can cause, I have long said to them, “The human masticatory system is designed to chew things up. When it is out of alignment, it will chew itself up.” I tell them, “Your teeth are aging at an accelerated rate. We need to see if we can find a way to slow down the aging process of your teeth.” The idea of slowing down aging is very attractive to patients, and if you relate it to their teeth, they get it.  

Occlusal Equilibration: Typically, I come at this from the standpoint of helping them understand that teeth are sensors for the muscles, and when the brain becomes aware our back teeth are rubbing against each other, it sends the same response to the muscles as when there’s food between our teeth. In other words, the brain tells the muscles it’s time to chew, and this accelerates wear rates on the teeth. Equilibration is really a conservative treatment to reduce force and destruction of the teeth.  

Diseases of the Jaw Joints: Regarding jaw joints and adaptive changes and breakdown, patients understand that joints have cartilage associated with them. Saying there has been cartilage damage in your jaw joint gets the message across simply. 

Treatment Presentation: When patients say, “I know you want to do a crown on that tooth,” I jokingly say, “Oh, don’t do it for me. Do it for yourself.” I never say, “You need to get this work done.” Instead, I say, “I think you are going to want to have this work done.” 

Conservative Treatment: I have always enjoyed John Kois’s saying that no dentistry is better than no dentistry, so when talking about conservative dentistry, I’ll tell patients, “No dentistry is better than no dentistry. We certainly don’t intend to do any dentistry that doesn’t need to be done.” Another way I speak about conservative dentistry is to say, “Conservative dentistry is dentistry that minimizes treatment. In the case of a cracked tooth, a crown is actually more conservative than a filling because it minimizes risk.” 

Moving Forward with Treatment: I love Mary Osborne’s leading question for patients after they’ve been shown their issues and treatment possibilities have been discussed. The question is “Where would you like to go from here?” With amazing regularity, the patients choose a really good starting point for their next steps toward improved health, steps that feel right to them. Always remember, people tend to support that which they help create. 

Dental Insurance: I typically speak of dental insurance as a coupon that can be applied to their dental bills. I’ll say, “Every plan sets limits on how much it pays. The way dental insurance works, it’s as if your employer has provided a coupon to go toward your dental bills.” 

Presenting Optimal Care: If I want to present optimal care to a patient who is ready to hear it, I ask permission by saying, “Mrs. Jones, if I were the patient and a doctor did not tell me what optimal treatment would be for my problems because the doctor was concerned that I couldn’t afford it or that I would not want it, I would think, ‘How dare you make that judgment for me. You tell me what optimal care would be, and I’ll decide for myself if I want it.’ So, with that in mind, Mrs. Jones, would it be okay with you if I presented you with the optimal solutions for your problems?” 

It’s a hard truth to swallow: acquiring more and more new patients won’t always lead to success or contentment. What we think will solve all of our dental practice problems can sometimes be the exact opposite of what we really need.

I remember talking with a dentist who had empty patches in his schedule that he was desperate to fill. He had also noticed that his practice did a half day less of hygiene than the previous year. He then made it clear to me that he needed new patients, but wasn’t sure how to go about getting them.

Before I dove into a solution that might not work, I clarified the problem. It turned out we were dealing with a very different animal.

The New Patients Conundrum

I immediately asked him how many new adult patients he was averaging per month in the last year. His answer was around fifteen. This piqued my interest and set alarm bells ringing. I told him that doesn’t make sense and explained the math.

Fifteen new adult patients per month should imply two one-hour maintenance visits for every person. That ends up totaling 360 extra hours in the schedule or 45 full days of hygiene. Clearly, this dentist’s problem wasn’t attracting new patients, it was keeping them!

He was blown away by this realization, but it’s not uncommon for dentists to assume new patient acquisition is the problem. In reality, we need to think more like business owners and measure what is worth measuring. In this situation, my advice was to focus on figuring out why patients weren’t sticking around for the long haul.

How we see a problem can be a problem in and of itself. Once we recognize the true source of our frustration, we can take active steps toward a resolution. Hygiene is the core of a practice, after all, and deserves the right kind of attention.