The Essential Piece

Why Patients Decline Treatment

Many would say that money, fear, and time are the biggest reasons that patients decline treatment. Although these are certainly applicable, they are oftentimes excuses, and clinicians who make assumptions about their patients' situations may be missing the bigger picture.

"Most dentists blame declined treatment on a patient's low dental IQ, financial obstacles, or ‘insurance-based mindset,'" says Amy Morgan, vice president of consulting strategy at Spear Education. However, she adds, "about 50% of financial objections are just ways of saying ‘no.'"

Some dentists have no solid data regarding how many of their treatments are declined by patients and for what apparent reasons. Whatever their stated responses, it is obvious that many patients hesitate to admit that they do not want the proposed treatment for other reasons. Perhaps those reasons are less tangible and more personal-too personal, perhaps, to discuss with a dentist with whom they have little connection. This is the crux of the problem and the reason behind why the majority of patients actually reject proposed treatment: a lack of trust and connection with their dentist.

"People make decisions based on how they feel," says Amanda Seay, DDS, a clinical instructor at the Kois Center and owner of a private practice in Mount Pleasant, South Carolina. "And if they don't trust you, then the details don't matter."

As an important component of a patient's well-being, dental health decisions are both very personal and at the same increasingly commodified. Patients are, after all, consumers, and they want the greatest benefit.

"Most people don't accept treatment largely because they don't trust the person who recommended the treatment," says Edward McLaren, DDS, MDC, chief executive officer of Art Oral America. "Value wasn't provided for the service."

The Importance of Personal Connection

If trust is going to be a part of the practice's value proposition to the patient, then it needs to be at the forefront of each patient's experience with the practice from his or her very first contact. Many dentists believe that this begins with their first interaction with the patient, but they may be surprised to learn that it begins long before then.

"The patient experience starts with marketing," Morgan says. "What is the messaging on the practice's website? Does it indicate a collaborative environment between the clinician and the patient?"

From there, a new patient begins to move through the journey of care by making the first phone contact with the office. Upon entering the office for the appointment, they are greeted by and have their first interactions with the office staff, dental assistants, hygienists, and then, finally, the dentist. Even at that early stage, using sophisticated scripting that has a warmer, more congenial feel than simple standardized responses can contribute to fostering trust in the patient. "The practice can differentiate itself by providing a collaborative experience with the patient, rather than just hosting a run-of-the-mill health appointment," Morgan says.

"Patients are at ease when they see the staff and dentist at ease, especially during the time of COVID-19," concurs Andrew De La Rosa, DMD, owner of an Aspen Dental practice in Jensen Beach and several other Florida locations. "Their comfort will translate into patient comfort."

Building a rapport with patients is also critical to fostering trust. "Dentists can help overcome patient fear by establishing good relationships with their patients," says Shalin Patel, DMD, partner and chief clinical officer at DECA Dental Group. "Having that face-to-face interaction is so important, which is why needing the extra personal protective equipment (PPE) these days can feel restrictive." In the past, Patel had advised the dentists in his group to never wear a mask when first going in to meet a patient. "Seeing a face can be so important," he says. Now, of course, preventing the spread of COVID-19 is at the forefront, making masks a requirement at all times. "Today, I advise our dentists to focus on making eye contact, and, as always, to greet the patients when they are sitting up, rather than reclined, in the operatory."

Spending some quality time with a new patient before starting the clinical exam is important, and not just for the preexamination interview and to discuss any specific concerns. "When new patients come in, I want to have a 15- to 20-minute conversation with them, especially talking about their past dental experiences-any fear or bad experiences," says Robert Sorin, DMD, owner of a private practice in New York, New York.

Of course, during COVID-19, spending as much face time with patients may not be advisable, but it is important not to let infection control measures interfere with establishing good relationships. "With PPE, social distancing, and infection control, building a connection through masks can be tough," Morgan says, "but it's even more important to build that relationship in this restrictive environment. Here's where we can apply the innovation of teledentistry to relationship building-the preclinical interview. Setting up a 10-minute teledentistry meeting between the patient and dentist before they meet in person for the first clinical visit is such an advantage. What better way to see the human face behind the mask?"

This is when the importance of the dentist's language and tone with the patient comes to the forefront. "Many of us get too excited about the science of dentistry and start talking in clinical terms," Patel says. "Using everyday language can help put patients at ease. Imagine yourself at your first day of dental school and talk to patients like that."

One of the purposes of talking  with patients is to learn from them; however, that aspect can be easily lost. "Sometimes, dentists need to stop presenting and start listening," says Roger P. Levin, DDS, chief executive officer of the dental consulting firm Levin Group. "Start conversing. Engage the patient. Ask open-ended questions. I make a point to learn something new about the patient every time I see them." The idea is to build the relationship from transactional to trusting.

Respecting the patient's emotions goes a long way in establishing trust, too. "In our interview questions, we ask them to rate their dental anxiety on a scale of 1 to 10," Sorin says. "When dentists are prepared for high levels of patient anxiety, we're better able to overcome that barrier to treatment acceptance."

Being able to communicate well is perhaps the second most important characteristic of a dentist and, sadly, one that isn't taught in dental school. "Dental schools are outputting graduates who don't know how to develop a full treatment plan and communicate it effectively to their patients," McLaren says. "There are postgraduate programs out there-Kois and Spear, among others-that can help to bridge these gaps. They're doing what graduate programs should have, ideally, in teaching dentists how to run a practice and apply the science of dentistry to real-world situations." Learning these "soft skills" helps dentists increase their ability to communicate effectively with their teams and patients, which in turn helps patients feel more confident about the clinician's ability to provide the best care.

Tools for Gaining Treatment Acceptance

Every treatment proposal should address the major concerns that patients usually have in these cases: the details of the treatment, including the length of time from start to finish; the benefits of the treatment; the cost of the treatment; and payment options. Addressing all of these key concerns up front will go a long way in reinforcing the trust of the patient-dentist relationship.

"For every patient, the dentist needs to answer the five big questions," Levin says. "What is the procedure and why do I need it, how much will it cost, how much will it hurt, how long will it take, and what are the benefits? Most dentists think that the financial question is the biggest one for patients, but really, it's that last one-‘what's in it for me?'-that is the most important. Addressing that should be 60% of the team's efforts when presenting treatment."

Discussing Payment Options

Despite feeling that the financial discussion is the most important decision-making factor for their patients, many dentists leave it for the end of the treatment plan presentation, which has its own benefits because it can be easily handed off to a staff member who focuses on the financials.

"Like in medicine, dentists should completely remove themselves from the financial aspects," Patel says. "Leave it to the front desk."

McLaren knows this from personal experience. "I used to get less case acceptance that way, doing everything myself. Chairside is not a good place to discuss money. The patient may already be anxious about needing treatment, and sitting in an operatory chair, rather than at eye level, can make them feel less secure about making such decisions on the spot. Taking the discussion outside the operatory changes the dynamic. Since I delegated the nondentistry to the nondentists, my case acceptance has gone up, and I keep my focus on the teeth."

Of course, the specific order in which these concerns are addressed is up to each practice and the person presenting the case. "Normally we suggest saving the payment conversation for the end, but now we're telling our dentist clients to discuss this much earlier," Levin says. "Many patients are concerned about the stability of their jobs and the possibility of a recession. In challenging times, we need to relate to people differently." He emphasizes the need to give patients confidence about accepting treatment by discussing their financial options. "If patients don't feel confident about being able to pay for the treatment in one way or another, it's more likely they will reject the treatment. It's up to the practice to find a way to boost that confidence," he adds.

The usual patient concerns about payment have taken on new urgency during the time of COVID-19 and its effects on the American economy and the practice of dentistry. In an Inside Dentistry survey, respondents reported decreases in elective and routine visits across the board. An overwhelming majority, 71%, said that the economy and rising unemployment was impacting their business approach in terms of clinical treatment plans. And 45% noted that more patients are citing financial constraints when hesitating about treatment now than they did prior to COVID-19 mitigation efforts.

"There need to be supportive financial guidelines," Morgan says. "Practices need to be more flexible with financial options so that they can get dentistry done and get paid, especially with longtime patients and in tough economic times." Offering interest-free financing through the practice is one way to accomplish this. "The percentage of patients who lapse on full payment is pretty low. If your flexible financial arrangements can garner a net gain, take it," she advises.

Other options include offering patients a discount for advance payment in full, particularly for larger cases; allowing half the balance to be paid up front and the remainder before the completion of treatment; accepting major credit cards; and presenting third-party offers of credit for care. When patients have the option to "make convenient monthly payments that help minimize the burden on their budget, it's a very compelling and motivating factor for them to say ‘yes' to treatment," Levin says.

Treatment options accepted may also differ based on economic concerns. Levin cites the decline of implant procedures during the last recession. "In 2007, implant treatment was growing at 16.3% per year. By the end of 2008, it dropped to under 3% growth." He admits that it may not experience as severe a drop during this current economic downturn because implant dentistry is now more widely understood and accepted, but it is certainly a consideration for dentists working with edentulous or partially edentulous patients.

"I've been through six recessions over my 40-plus years in this profession, and during every one, people opted to extract rather than restore teeth," says Robert Kreyer, CDT, director of advanced dentures and implants at MicroDental Laboratories. "In these times, the demand for removable prosthodontics skyrockets."

The relative pricing differences between restoration and extraction as well as the costs involved in replacement will certainly come into play. All of these issues impact not only which treatments dentists present to patients, but also how the patients will ultimately consider financial investment in their dental health.

"We don't want to overwhelm them," Sorin says. "But don't shy away from presenting treatment, of course. We just have to be more sensitive to their needs and concerns in the time of COVID-19."

Patient Education and Value Propositions

The patient education portion of the treatment proposal, in which the dentist lays out the case for the problem at hand, the plan(s) for treating and resolving the problem, what the patient can expect of treatment, and the anticipated outcome, is where all of the aforementioned efforts to foster a trusting relationship with the patient will pay dividends. It is also where the patient's trust in the knowledge and expertise of the whole practice becomes incredibly important. If patients trust that the dentist and everyone involved in their dental care sincerely has their health and well-being at heart, they are more likely to listen to the proposals with an open mind and to figure out how to accommodate the selected treatment plan in their lives and budgets.

Of course, the presentation still needs to be as compelling as possible, and that requires patient engagement. Keeping the language used as clear and as simple as possible is, as always, very important. "We can get excited when discussing specific issues, treatments, or technology, and easily get carried away," Patel says. "That's because we are dentists and interested in dentistry, but most patients aren't as interested in the science behind it. They want to know how the problem or treatment is going to affect them, so we have to make sure that we stay on point."

One of the most important aspects of patient education is addressing how the treatment will benefit the patient. "Education sinks in when it impacts you, the person who needs to learn, especially if it has immediate consequences like pain," Morgan says. "So, dentists need to energize the patient enough to solve the issue. That's where education belongs-prompting action." And it isn't a one-way street, Morgan warns. "Dentists often mistakenly believe that they alone are the active ones in the dentist-patient relationship, but really, it needs to be both. Leadership is something you do with people, not to people," she says. Engaging patients, like any students, is the most effective way to get them invested and interested in their care and, hopefully, to agree to the proposed treatment.

As in most educational settings, using audiovisual and even tactile aids goes a long way toward capturing and keeping the attention of patients. When outlining problems for patients, many dentists are tempted to show them the issues using radiographs, but that is falling out of favor. "Patients have no basis for comparison when looking at radiographs," Patel says. "We do because we're dentists, but they're really not helpful to patients." Instead, he and others recommend using high-resolution photographs and even images from intraoral scans to show patients the problems in their mouths. "You absolutely must show pictures," Patel continues. "It has immeasurable benefit in case acceptance for any procedure-from simple fillings to root canals and esthetic cases."

"The value of the imagery is important," McLaren agrees. "Whether it's using an intraoral scanner, a digital SLR camera, or a smartphone with an attachment for high-quality photography, images help the patient really ‘see' the problem, which goes beyond the dentist communicating the need for treatment to the patient."

Photographs of the patient's mouth are not the only ones that can make a difference. "It's good to show patients the before and after pictures from cases similar to theirs, so they can really get a sense of what to expect to gain from the treatment," McLaren says.

Photographs are just one type of media that can be used to help engage patients. Allowing them to hold something tangible is another. "We will have them hold crowns, clear aligners, study models, etc," Patel says. "We don't need to get into all of the technical details of specific materials. We tell them what they need to know and use whatever makes it easier for them to understand."

Smile design software and try-in technology are especially helpful in cosmetic and restorative cases. The only difference is whether it is done in two dimensions or three. McLaren is a fan of software options that allow for smile customizations of patient images. "There are options that facilitate putting patients' images into the program and making tweaks and customizations on the spot, while we are in the same room together, based on their suggestions and feedback," he says. "Not only do they know that I'm listening to them and paying attention to what they want, they can also see on screen what could be possible. They can take a printout home with them and show it to others. That kind of minor smile design takes very little time in the office and, if done proactively, can even result in more cosmetic cases from regular patients."

For larger restorative or cosmetic cases, some clinicians prefer to use 3D methods of mocking up new smiles for maximum effect. "Patients can't conceptualize things like function or equilibration without having a visual end goal in mind. And they have no idea of how it would feel by just looking at it," Sorin says. "I prefer 3D mock-ups to computer screens. That way, patients can see the actual size and shape of the teeth and have the opportunity to ‘test-drive' their new smiles. Lots of patients have a ‘wow' reaction, and they're much more likely to accept treatment."

This is especially helpful when proposing treatments that need to be done in steps, such as those for temporomandibular joint issues and bite problems, which can sometimes take months before getting to the final restoration. "Without transferring to a 3D medium, neither the dentist nor the patient sees how it actually works in the face," Sorin says. "Seeing it in their mouth, they know they want it."

Promoting treatment technology may also be an aspect of the proposal, both in terms of how it can benefit patients and how it can differentiate one provider over another. "If the practice emphasizes that it uses certain types of technology, it can make patients more confident because of predictable outcomes," Levin says. "It might not be the one thing to make or break a patient's acceptance of a treatment plan, but a practice promoting its own capabilities never hurts."

Of course, like 3D mock-ups, certain advances can create a "wow" factor for patients. "When you offer printed surgical guides for implants, guided surgeries, and fixed hybrid prosthetics with implants, patients are blown away by this kind of technology," De La Rosa says. Even the difference between tooth-sparing and tooth-replacement technologies can make a difference to patients. "It used to be that dentists would do everything we could to save teeth, but there's been a shift for some patients who want something that's more predictable long-term," he suggests. "That's where the technology of implants makes a big difference. For some, saving a tooth with a root canal and a crown isn't as attractive as getting an implant with long-term success. These patients are more willing to do work that will last a long time over any heroic, tooth-sparing dentistry. The value of this technology is its longevity."

It is one thing to get patients engaged in their treatment to resolve their dental problems; it is another to get that work done at your specific practice using your proposed method. Offering patients several different treatment options can help prevent them from looking to other practices for alternatives. If they are given only one option, they may feel that they're in a "take it or leave it" situation. "I like to offer multiple treatment options and give patients the best information about their conditions," Sorin says. "They're going to choose what they feel is most appropriate. I'm just there to give them my full attention and consideration to help them make the most informed decision. It all fosters trust, which goes a long way."

In the current climate where patients are regarded as consumers, it is not unheard of for them to do their own research on other treatments and possibly shop around among other dentists as well. However, this too can be minimized or even prevented by having proactively fostered a trusting relationship between patient and provider. "It's critical to go through all the available options with patients," De La Rosa says. "If we didn't do that, and they found out about other options, it would hurt the rapport. If we're doing our jobs right, we will cover everything. They will ask us all of their questions, and we will tell them everything that they need to know. I can't remember the last time a patient decided to opt out of treatment because of their own research. That's a good sign."

Some dentists see patients' impulses to learn more on their own as a sign of true patient engagement or at least ownership of their dental health. "Clinicians want to make sure that their patients are educated, inspired, and comfortable," Morgan says. However, if patients are looking for second opinions, it could mean that "the first dentist missed cues where they ‘lost' the patient's interest or trust."

Others expect and even encourage patients to do their due diligence. "The bigger the treatment plan, the more the patient is going to want to talk to their friends or get a second opinion," McLaren says. "It's possible to get ahead of that by preparing a referral list for patients in case they want a second or third opinion. Having that confidence in your treatment plan can make a big impression on the patient. You're letting them know that what you've proposed will hold up to outside scrutiny."

Levin agrees. "In the case presentation, you need to build value for your specific practice over others by emphasizing your experience, relationship, capabilities, and more," he says. "Be proactive about this so that anywhere else pales in comparison if the patient goes looking, and they're not motivated to follow through with any other options."

The Power of Following Up

Regardless of whether a patient accepts or rejects a treatment proposal, it is always best practice to follow up. If he or she has accepted the treatment, it is optimal to get it on the schedule as soon as possible, preferably before the patient leaves the office. But whether it is put on the calendar or not, the dentist should realize that this does not mean that the treatment is a "done deal."

"Patients need to feel that the dentist or treatment coordinator is accessible in case they have any questions," Levin says. "This is still a pretty new concept, so if the practice uses case planners or treatment coordinators, this expectation must be made clear. This follow-up by the practice and having an open door to continued communication with the patient are just as important as answering the immediate questions they ask. In the practices I consult, I have seen production increase year after year due to follow-up."

Follow-up can also be valuable when a patient rejects treatment but stays with the practice. First, it offers the office the opportunity to track such rejections and their reasons. "In my network, we have what we call ‘90-day case acceptance metrics,' where we follow up with patients regardless of whether they scheduled treatment or not," Patel says. Such data, especially if it clarifies patients' reasons for not pursuing treatment and what they did about it after that point, if anything, can help inform the practice's approach to presenting treatment or engaging with patients. There is always power in data. Second, it offers a valuable learning opportunity for the dentist and the practice.

"The doctor will always have future opportunities to present treatment again and do a better job of educating and motivating new patients to proceed with the recommended care," Levin says.

Healthy Relationships, Healthy Practice

Ultimately, patient health and satisfaction are the primary concerns of any dental practice. Dentists are responsible for dental diagnosis and treatment, not relationship building; however, they cannot ignore the many benefits to the health of both their clientele and practice that are gained by creating and maintaining healthy relationships. Investing in patient trust at any stage will pay dividends in treatment acceptance as well as in the success and reputation of any practice.