Building a cosmetic practice from recall

by Debra Engelhardt-Nash

Make new friends * but keep the old * one is Silver * and the other Gold.

The advice in the children’s song, above, should be heeded in the marketing strategy for your practice. It is important to remember the value of established relationships with patients currently enrolled in the practice. Many practices underplay the importance of committing patients of record to elective care. While they are busy concentrating on attracting new patients, they neglect marketing to loyal patients already committed to their practice. They look for new patients to introduce cosmetic possibilities, and overlook the potential elective treatment presented by existing patients.

For practices that strive to build a more cosmetic or elective, fee-for-service practice, their first efforts should be directed toward active patients of record.

Familiarity breeds apathy

A history with certain patients may create bias in presenting treatment options, and prevent the dental team from discussing elective treatment options with the same zeal and conviction applied to new patients. Patient familiarity can sometimes lead to inaccurate assumptions about patients’ interest in elective treatment. Some offices review the hygiene patients’ charts for the day with a “been there, done that” attitude. In reviewing the chart, the team will look at the patient’s record and say, “They don’t need anything”. They forget to take the next step and explore the patient’s “wants”. The doctor and hygienist may feel they know these patients would not be interested in cosmetic treatment, or provided an updated comprehensive treatment plan.

The staff may assume that the patient doesn’t want anything more than what they wanted 3, 5 or 10 years ago — when they first entered the practice as a new patient. They may even be afraid of offending long-term patients if they emphasized outstanding treatment needs or introduced updated techniques and materials.

So, existing patients are not informed of the cosmetic and esthetic treatment options the practice now offers. They will never choose these procedures because they are unaware or only peripherally aware of their existence.

A prime example of this comes from a practice in upstate New York. The doctor relates the story of an existing patient scheduled in his hygiene department. During the morning huddle, they reviewed the patient’s chart and noted that she had been told of the necessity to repair two broken teeth with crowns. The team recalled that the patient had been told several times about the need for treatment, but the patient had declined. The team also mentioned that the patient had several stained anterior composite restorations, but assumed since she was not interested in repairing the broken teeth, she would certainly not be interested in exploring the alternatives in replacing the worn, stained composite restorations. They considered her appointment to be a “standard” recall visit.

When it was time for the hygienist to inform the doctor she was ready for the exam, she forewarned him of the patient’s current condition. The hygienist told the doctor that since the last visit, the patient had sixteen porcelain veneers placed by another dentist. After recovering from the shock of this information, the doctor went in to examine the patient and said, “Your veneers are beautiful. May I ask you why you didn’t have us do them?” The patient replied, “I didn’t know you did this kind of work. You never told me about it. My friend had the work done, so I went to her dentist. Now, I’m ready to do those crowns that I need”.

Some people might argue that this was an exceptional situation, but it occurs in dental offices everywhere, every day. When the doctor and the dental team commit to reeducating and renewing a comprehensive treatment plan with their patients of record, many patients respond affirmatively.

A doctor in a small, rural town was concerned about presenting cosmetic treatment options to his patients. He thought he was too close to his patients to discuss this level of care with his patients. “I go to church with these people and my kids go to school with their kids”, he lamented. He assumed that his patients in his small town would not be interested, or would not be able to afford this type of work.

Tentatively, this doctor began approaching his patients about what modern dentistry could do for one’s dental health and appearance. He reports the response from patients was overwhelming. His patients were interested and eager to accept esthetic and cosmetic treatment alternatives.

Patients must be informed of new treatment alternatives and cosmetic recommendations before they can accept them. Working off the assumptions that patients 1. Don’t want, 2. Aren’t interested, 3. Can’t afford, or 4. “Insurance driven” establishes a foundation of failure. Negative attitudes about patient acceptance can often be detected in voice inflection, body language and commonly used phrases. For example, the doctor might say, “I would really like to restore these with a natural colored material…. But your insurance will only pay for amalgam.” Could it be that unknowingly, the office dissuades the patient from accepting fee-for-service care?

Strength taken to excess becomes weakness

Soft tissue management programs have taken hold in many dental offices today, and have increased hygiene production by large percentages. Dental health for a multitude of patients has also improved with periodontal health programs. However, if the program is not well monitored, patients may continue to be recycled in the 3-month, 4-month, 6-month intervals, but additional elective treatment is seldom reviewed. Now, the hygiene department is busy, maybe too busy, with current patients in the system. But those patients are not moving into a comprehensive treatment plan that includes elective care. And, the success of enrolling these patients into the soft tissue management program has jammed the department, which impedes other patients of record to return. Those patients are not even notified, because the practice has nowhere to put them. So the office continues to recycle the same patients in hygiene, but does not move them into definitive restorative treatment. These are the patients that may not “NEED ANYTHING”, in terms of necessary dentistry, and they are never asked what they want in elective care.

The recall renewal exam — objectives

To revitalize existing patients in the practice, and educate them on the new standards of care you offer, it may be time to renew the exam process during patients’ recall visit. The new patient exam you offered 3 years ago, 5 years ago, 10 years ago, is probably very different than the new patient exam you offer today. Your philosophy of care may have evolved, you may employ new learning technologies, and your patients’ lives and priorities may have shifted since you conducted the patient’s initial comprehensive exam. It may be time for a more in-depth review of existing patients’ records and allocate more time to renew the exam process with patients who have been in your practice for 5 years or longer. It may be time to look on this patient as though they were new to your practice and you are seeing them for the first time — more objectively, more comprehensively, more focused. An increase in treatment acceptance from patients of record is certain.


Review the scheduled recall patients’ records during the morning huddle. Determine which patients had their new patient exam more than 3 to 5 years ago. Whether they have an incomplete treatment plan is not a criteria.

If time permits in the schedule, the doctor will conduct a longer comprehensive exam at this appointment, rather than a brief recall evaluation. If the day’s schedule does not allow this, the patient is rescheduled for a comprehensive evaluation and consultation — at no additional charge.


The hygienist initiates the renewal process. She or he may say, “When we reviewed your records today, we noted that it has been 5 years since your first visit to our office. First, we want to thank you for your trust and confidence (and for the number of people you have referred to our office!). Today, we are going to conduct our exam as though you are new to the office — look at where you are now and where we are going in your dental future. Since your first visit 5 years ago, Dr. has taken many courses on new materials and techniques in dentistry. He continues to advance his education so he can always offer our patients the best alternatives for dental health and appearance. You have probably noticed many of the changes we have made in the office through the years — let me tell you how or philosophy of care has evolved over the last 5 years….”

The intra-oral camera tour is conducted, and multi-media education is utilized. Photographs, imaging technology is introduced. Radiographs, baseline health information is brought current. Scheduled hygiene services are conducted. During the prophylaxis, the hygienist is discussing the type of work Dr. has been doing, the increasing interest our patients have expressed in cosmetic treatment choices.

If the patient “doesn’t need anything”, the doctor or hygienist might say something like, “Working together, we have done an excellent job of improving and maintaining your dental health. Your restorative needs at this time are met. You are a perfect candidate to consider another level of care. Because of your excellent dental health, we can explore other options — treatment that can improve the appearance of your teeth and smile. It would not be fair for me to assume that isn’t something that interests you”.

Quality time

The hygienist and doctor may need more time for the recall renewal exam. This process requires more time with some patients and may be incongruent with a volume-focused practice. Adding 10 more minutes for these appointments will impact the practice in many ways. First, the office will have to determine how they will work this time into the schedule. Next, the office will need to monitor the effectiveness of the change. Are patients accepting more comprehensive treatment plans from hygiene when more time is being allocated?

Some daily hygiene schedules are so full there is no time for a comprehensive exam or “wants-based” treatment review. Taking time to discuss additional treatment is discouraged. A doctor, based in the southern U.S. complained that he wanted to do more cosmetic and esthetic treatment for his patients. His schedule was full months in advance of short, single unit restorative treatment appointments.

After reviewing his hygiene schedule, the cause was identified. His two hygienists were scheduled with 10 to 12 patients per day, with 45 minutes scheduled for the total visit. No additional time was given for more comprehensive visits. In fact, the hygienists silently hoped the patients didn’t need anything, because there was no time to talk about it. Doctor was coming into the hygiene operatory as briefly as possible, between patients. He was only given a few moments for each patient, so never had an opportunity to discuss ideal, long term care with existing patients. If the treatment is not presented, it cannot be accepted.

Work your dream

If building a more cosmetic practice is what you are hoping to achieve, begin by renewing your relationships with existing patients. Objectively review patients of record and avoid assumptions and misperceptions. Take the same time and attention devoted to establishing a new patient in the practice, and your existing patients will be renewed and revitalized. Provide the information they need to choose the treatment you both want.

Debra Engelhardt-Nash is a management consultant, trainer and presenter. She is a repeat Presenter for the American Dental Association. Debra is a founding member and served two terms as President of the National Academy of Dental Management Consultants. She is an active member of the American Dental Assistants Association and serves on the Board of the American Dental Assistants Association Foundation. Debra is also a certified member of the American Academy of Dental Practice Administration.

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