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Inside Dentistry
January 2012
Volume 8, Issue 1

Getting Them in the Chair

Finding patients and increasing production remain top concerns for practicing dentists. Find out what else your colleagues say are the main challenges facing them today.

By Jackie Syrop

Inside Dentistry recently surveyed more than 200 practicing dentists, asking them to rank-order a list of the top challenges they face in today’s practice climate. Given the economic conditions still facing the country, it should come as no surprise that the top five challenges which emerged—summed up in the graph on page 100—relate to practice building and the ability to plan and save for retirement.

Like most Americans, dentists have been living through difficult economic conditions for the past several years and, like most Americans, they face continued uncertainty about the future and how to plan for what’s ahead. While the top five challenges cited in the survey certainly aren’t new ones, the current state of the economy has focused renewed attention on practice building.

Most dentists tend to not concern themselves with the business side of their practice, “but when things begin to slow down, they start asking questions,” explains Brad Durham, DDS, a Savannah, Georgia, cosmetic dentist, author, and clinical instructor at the Las Vegas Institute for Advanced Dental Studies.

“I think these concerns are what they’re always struggling with,” agrees Fred Joyal, CEO and co-founder of 1-800-DENTIST. “The biggest challenges remain the same: attracting new patients, effectively presenting to patients, collecting money, and getting people to respect the appointment book. The economy has just exacerbated these problems.”

More attention is being drawn to practice management because everyone’s taking a financial hit, explains Gary Radz, DDS, owner of Cosmetic Dentistry of Colorado in Denver and a consultant for cosmetic/elective dentistry. “All you can do is try to make more money, and more money means you need more patients.” If you are concerned about getting more patients and higher production, you will be more focused on getting your practice in better shape.

The “Recession Proof” Myth

As recently as February 2008, TIME magazine listed dentistry as a profession that appeared to be recession proof.1 In an article titled, “Dentists: Smiling in the Face of Recession,” TIME cited 17% profit margins in dentistry, higher than any other industry. At the time, dental profit margins were outpacing accounting, tax preparation, bookkeeping, payroll services, and even legal services.

But as it turned out, dentistry was not recession proof; it just took more time than most professions and industries to feel the hit—and feel it, it did. Since 2008, estimates of the dental downturn range from 18% in general dentistry to about 28% in elective/cosmetic dentistry, according to William Howard (Howie) Horrocks, founder and CEO of New Patients, Inc., a dental marketing firm headquartered in Las Vegas, Nevada. Mr. Horrocks explains that the downturn in elective dentistry occurred largely because people no longer have the equity in their homes that they did earlier in the decade, and are no longer able to fund cosmetic and elective dental work. Most dentists, including those in general dentistry practices, are seeing the numbers of new patients drop and an erosion in their existing patient base, agrees Mark Dilatush, New Patients, Inc.’s vice president of professional relations.

Five or six years ago, many dentists were looking for the “right” patients who were able to spend on elective procedures, but now many dentists just want to be sure they have enough patients, says Mr. Dilatush. New Patients, Inc. has been advising clients to rebrand toward the family-oriented and family-friendly practice, to go back to the “core staples” of dentistry: family dentistry, children’s dentistry, orthodontics, and emergency, with an eye to making their practices as close to “one-stop shopping” as possible. This means offering convenient early-morning and evening hours and convenient financing and a wide range of dental services. “Moms do not need five more relationships in their lives, so if they can get everything taken care of in one place they will be more than grateful,” Mr. Horrocks notes. “Her kids’ braces, her husband’s snoring, and her own periodontal care. Convenience is more important now than ever.”

It’s the same story around the country. “Patients are not taking big elective treatment plans,” agrees Tom Limoli, Jr., an expert on dental insurance coding and benefit claims based in Arlington, Tennessee. “Cosmetic dentistry is a much smaller niche market now,” he says. “Most dentists who have been catering to that market are finding there are a lot fewer patients willing and able to afford and proceed with that treatment.” Although 70% of people in the workforce continue to have dental insurance of some type, it’s restrictive, paying only for repairing and replacing, not for cosmetics.

If this survey had been carried out 4 years ago, very different top challenges would have emerged, according to Dr. Roger Levin, CEO of Levin Group, Inc., a dental practice-management consulting firm in Owings Mills, Maryland, and himself a third-generation dentist. “Dentists weren’t worrying about attracting new patients. Most had the right numbers of patients coming into the practice and they were not particularly concerned about referrals or even increasing production through areas such as recall,” he says. This is why case acceptance is now showing up as a top concern: Practices need new patients and more production.

Is Cosmetic Dentistry Down for the Count?

Even though cosmetic and elective dentistry has been hardest hit, not everyone agrees that dentists should move away from elective dentistry. “I’ve spent 12 years making a practice and marketing a practice centered on cosmetics, and while I still have a general dentistry practice that I try to grow, what I enjoy doing is cosmetics,” Dr. Radz asserts. There are still patients who want cosmetic dental work—for example, those who are unhappy with work they’ve previously had, or patients who had cosmetic work done 10 to 15 years ago that needs to be repaired or replaced. “Even though times are tight, people still want to look good, or they’re looking for jobs and want to look better for their interviews,” Dr. Radz says. “Yes, we took a hit in 2009 and 2010, and we saw a drop, but quite honestly, in 2011 we’re on track to have a great year. We’ve probably grown 10% to 15%.”

Learning Leadership

It’s a fact that dentists, no matter how skilled they might be as clinicians, are not necessarily great businesspeople. This theme emerged repeatedly from the practice building and insurance experts. Dentists as a group tend to focus on their clinical skills and not the business side of their practice—to their detriment.

Today’s dentist simply has to be more business-savvy than was necessary in years past. Dentists can no longer afford to overlook any area of the practice as potential areas to improve upon. “The days of hanging a shingle and having success automatically occur are over,” Dr. Levin explains. Today’s economic environment and lower demand have meant that dentists must to learn to run their practices as an excellent business at the same time they perform excellent dentistry.

“Learn how to get patients in, and how to treat them better,” Dr. Durham advises. “Learn how to run a practice like a business. That’s not going to happen as a random event.” Take business and marketing courses to learn from the experts.

Practice building does not happen by itself. Like any organization, a dental practice needs good leadership. “The number-one thing I see in dentistry where most dentists fall short is leadership,” Dr. Durham says. “Most dentists don’t understand that they are the leader of their practice; they tend to show up like an employee and expect things to happen. That’s certainly not the case.”

His approach to practice building is methodical. “Most dentists want positive results in their practice but they don’t really want to spend the time organizing their practice or making it work more like a business,” he says. But they have to spend the time to get the results: every dentist should systematically go through his or her practice and set it up to do what they want it to do. “Spend one day each week working on the practice instead of in the practice,” he says. “Work on leadership, systems, staff training, continuing education—things that can make the practice better.”

Unfortunately, many dentists don’t really envision themselves actively developing their practices. To successfully develop your practice, you have to know what type of practice you want. “Dentists need to decide what procedures they want to deliver, the type of patients they want to attract, what size practice they want to have, what kind of staff and what level of training the staff needs to have,” Dr. Durham advises. “All of this needs to be reflected in the fee structure.”

The most important task for any practice is to develop congruency throughout the practice--consistency of the message the patients are getting about who and what the practice is. “In marketing this is called developing a strong brand,” Dr. Durham points out. Once the dentist becomes a leader in developing this vision of his or her practice, then systems can be developed to support that vision.

What’s Next?

Taking a more challenging approach to the discussion of practice building, Mr. Limoli predicts that there are big changes afoot in dentistry. “The dentist is going to have to evolve to become much more of the decision maker and diagnostician in the practice,” doing more leading, planning, and practice building, and adjusting to changes in the profession that he believes are bound to happen, mainly “expanded function” and the advance of the dental therapist: the chairside assistant who can do more than simply hand the dentist instruments. Like the emergence of physician assistants and nurse practitioners in the medical field, non-dentists are evolving to have a much bigger role in dentistry because technology has replaced the need for the dentist in some areas.

Through his work consulting with dental practices around the country and his contact with young practitioners newly out of dental school, Mr. Limoli believes that the days of controlling the marketplace to the extent that has been possible in the past are numbered. “Dentistry will have to change to better reflect society,” he warns. The profession as a whole needs to learn to understand and embrace the idea that dentists are deliverers of health and sellers of health. “Mr. and Mrs. America won’t pay continually rising prices for dentistry,” he cautions, and the new generation of young dentists coming out of dental school are facing mountains of educational debt and a different healthcare environment than previous generations did. These young dentists believe that the status quo doesn’t serve them, and they are willing to do procedures for lower prices and run their practices differently, adjusting to what the market wants, and offering patients increasingly accommodating schedules. “Does Barnes & Noble shut down at lunchtime with an answering machine that says, ‘we take lunch at 12:30’?” Mr. Limoli asks. “Of course not!”

“Don’t Stop Marketing, Ever!”

An external marketing system that works for the practice and supports the direction the dentist wants to go in is key to practice building. There are different ways to market, none of which have to be prohibitively expensive.

Dr. Radz’s website is his strongest marketing tool. It brings a lot of traffic. “Although it’s not cheap to set up initially, the return on investment is exceptional,” he says. He also uses social media, which is extremely affordable and a good way to increase his practice’s reach. “Creating an office-specific Facebook page is a very affordable way to get in touch with people and increase your reach and stay in touch with patients you already have.” Having current patients become Facebook friends of the office gives your practice access to all your patients’ Facebook friends. “The key is to get existing patients to become fans of your page, which can be a bit challenging, but once you do it… Think of how many friends you have on Facebook: you say something nice about my office and it goes on their Wall and your 557 friends see it. That’s a great testimonial/advertisement for your practice,” he notes.

Ads in newspapers and magazines that also list your website can also be an economical way to provide additional marketing. However counterintuitive it might seem, in a recession it pays to keep marketing the practice. “In a recession, most dentists do precisely what they should not: they pull back on marketing spending,” says Mr. Dilatush. “There’s a fear that stops dentists from promoting the practice through a recession, but ultimately, pulling back on your promotion budget is probably the number-one thing you should not do.”

Many dentists spend very little on marketing when things are going well. They tend to let things slow down to the point where it’s a struggle to spend money on marketing, thus creating spikes and valleys in their practice. “What you want to do during a recession is simply to maintain,” Mr. Dilatush advises. In the current recession, consumers don’t have access to cash and credit as they did between 2001 and 2008. But when that cash comes back into the system, the dentists that promoted through this recession—even if they didn’t grow their practice and just maintained it—will be the ones seeing the majority of the elective cases and majority of the restorative cases. “We know what happens when you don’t go to the dentist for 3 or 4 years,” Mr. Horrocks points out: You’ll be back to repair the damage. “If you stop promoting dentistry, you will be behind the eight-ball when things improve.”

The don’t-stop-marketing-ever rule worked well for Dr. Radz’s cosmetic practice. Despite taking a financial hit in 2009 and 2010, he kept marketing his practice strongly with the same ads, and he worked on his website and got into social media. “I needed to keep the brand I worked 10 years to create out there in front of people,” he says. “Quite honestly, I think the reason we’ve seen the increase this year is that people were holding off in the past couple of years, and once they started getting a little bit of confidence in their jobs and the economy, they came in. I had four people tell me this year that there’s no use putting their money in the stock market, so they might as well spend it on their dental work.”

Everything’s Connected

The top concerns ranked in Inside Dentistry’s reader survey—getting new patients, increasing case acceptance, and increasing production—are inextricably linked, because once a new patient enters the practice, there is a web of interconnecting relationships that affect whether that patient is retained, accepts treatment, and brings everything full circle by recommending another new patient, thus increasing production and building the practice. Perhaps Mr. Joyal sums it up best with this bit of wisdom: “Everything you do in the practice either increases or decreases case acceptance.”

There’s a great deal of advice about how to improve this web of relationships and decision-making within your practice. There are a number of different approaches, all worth understanding and considering.

New Patients

“Probably the most important thing a dentist can do after establishing leadership is to determine the best way to bring new patients into the practice,” advises Dr. Durham. Who in the practice is going to deal with the new patients? Who does the examinations? How is treatment presented? All of this needs to be very well orchestrated.

Building Loyalty

Building patient loyalty is key to building your practice. “Clinical skills are, of course, very important, but what’s actually most important for the patient in terms of binding them to the practice is the experience of visiting that practice and communicating with that practice,” notes Mr. Joyal. The practice must give patients an exceptional experience through careful attention to details that make a huge difference, he says. Does the dentist call patients back at the end of the day to see how patients are doing? How does the practice handle the first phone call when a patient case is coming in?

Effective Case Presentation

One of the biggest challenges in dentistry is effective case presentation. “It’s not just what the dentist is saying at that moment—as much as that matters. The question to ask is, does the whole environment help to convince patients that what the practice offers is a great investment?” Mr. Joyal asks. “There is no other way patients can spend their money that has a greater impact on their lives, affecting every meal, every conversation, every smile. The message that needs to get to the patient is, ‘Your health, which is inextricably linked to your oral health, is my responsibility, and I am trying to make sure you have healthy teeth and gums for the rest of your life.’” The priority is to help the patient understand how important investing in dental work is.

Extensive staff training, including scripting, is critical to effective case presentation, Dr. Levin advises. Levin Group’s recent data show that the number of hygiene visits is at an all-time low. With patients putting off hygiene visits, the dentist’s system of case presentation has to be better than ever.

“The best way to improve case presentation is by conveying the value of the service you are providing,” Dr. Levin explains. “Hygiene visits need to be clearly understood from a value point of view, not just, ‘I get my teeth cleaned every 6 months and get it over with.’” The staff needs to move from “functional” behavior to “value-based” behavior. Functional behavior is getting the patient scheduled and sending in the insurance; it’s about getting through the day. In contrast, value-based behavior is about creating value in the mind of the patient. Dr. Levin recommends these four principles to create value: create relationships with patients; raise the level of customer service and support; create convenience in appointment scheduling; and have multiple financial options available to help patients pay for treatment.

Finally, follow up with a patient after the first case presentation. This leads to higher levels of case acceptance, because the patient’s decision-making time frame is longer now than ever before.

Increasing Production

A tried-and-true way to address the decline in practice production is through the use of systems and specific targets for all key areas of the practice, says Dr. Levin. For example, he advocates setting these goals:

  • 98% of all patients who call the practice to make an appointment get scheduled
  • 98% of all patients are scheduled at all times
  • 90% of all cases presented are accepted

Practices should follow up on these patients, using excellent scripting and support, according to Dr. Levin. The goal is to increase elective dentistry and provide multiple ways for patients to pay for it. “Elective dentistry will grow again, as the economy improves,” he says.

Retaining Existing Patients

A really well-tuned patient re-care system is necessary to retain existing patients and get patients to keep appointments, Dr. Durham suggests. “The purpose of re-care is not only to manage the periodontal needs of the practice, but also to bring the patients back and make sure they’re maintaining a high level of dental health. It’s another chance to present ideal treatment to patients.”

Increasing Referrals

A good internal marketing system is needed to increase patient referrals. While just running on time and being painless is probably a big part of getting patient referrals, you need more than a toothbrush with the practice’s name on it. There are good, inexpensive ways to encourage patient referrals. “The target is to get 40% to 60% of patients to refer one other patient per year in general practices,” says Dr. Levin. “Most practices are well below 20%.”

Many dentists aren’t active enough about asking patients to refer other patients to them, says Mr. Joyal, perhaps putting too much faith in that sign at the front desk that says, “Accepting New Patients.” Be active about patient referrals, he advises. Remind patients how much your practice values them and likes treating them, and how much you’d like to treat any of their family and friends who need a dentist. You might consider making those initial exams for the referred friend or relative free of charge.

Planning for Retirement

“It’s been said before that most people spend more time planning their vacation than their retirement, and dentists are no different,” Dr. Durham remarks. Save 10% of net income every year so you can retire in 15 to 20 years, he advises. “If you have a system that automatically writes a check for 10% to a savings account, retirement is a non-issue.”

Levin Group data suggests that dentists’ concerns about retirement are well founded: the average dentist is now going to work 7 to 10 years longer than expected. Incomes are down, investment performance is down. That is why dentists should invest in their practices, says Dr. Levin. “Realize that it’s going to be the main wealth-accumulation vehicle today.” By investing in your practice, you’re investing in a business you understand. Set key targets and create excellent systems to achieve those targets. [See the Sidebar on page 96 for a case study of Dr. Harry Long’s successful retirement planning.]

Financing Plans

“We always recommend that if a doctor does not have some kind of a patient-friendly financing plan, that they get one—or two, or three,” notes Mr. Dilatush. “Americans can no longer max out their credit cards and pay them down with home equity lines.” Additionally, it’s very important to select the right staff members and train them fully in how to handle these financial agreements. Not every staff member is cut out for this particular job.

Continuing Education

A final, but often neglected, issue in practice growth—especially during a recession—is continuing education. Learning new procedures, how to diagnose better, makes a huge difference in the practice. “If you don’t recognize it, you can’t treatment plan it, and if you don’t know how to provide the dentistry, you can’t do the dentistry,” Dr. Durham notes. “Continuing education goes hand-in-hand with everything else we’ve said about developing systems and leadership.”


1. Gregory S. Dentists: smiling in the face of recession. TIME. February 19, 2008. Available at,9171,1881994,00.html. Accessed November 16, 2011.

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