Coaching Dental Practices and DSOs to Improve Diagnosis and Case Acceptance

When Dr. Steven Katz brings his Smile Potential team into dental practices and DSOs the result is growth.

DSOPro: Tell us about your career.

I had a very comprehensive care practice which I lost 25 years ago due to a series of life tragedies. I was in an accident, needed multiple surgeries, and was out of work for two years. I returned to work on the Tuesday after Labor Day in 2001. I had gathered a great team and trained them well. The first week was great, but the following Tuesday was 9/11. It was a horrible event for the country and for the city of New York. We lost 16 patients, and immediate family members of my team. It was not a time to think about re-growing the practice.

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Things picked up in the spring of 2002 until one of my dental assistants was in a terrible accident in which she lost one leg when she was struck by an out-of-control drunk driver while crossing a street in Manhattan. As a team, we decided to dedicate our practice to her benefit. Over the next 6 months, we were able to purchase for her a computerized prosthetic limb, a hand-operated vehicle, and we gave her half a million dollars in cash. That became our epiphany. We realized that we don’t go to work each day to fix teeth and heal gums. We do it because we have the potential to really change lives. When that is your purpose, it really changes how you work. The whole team embraced it. Once we refocused our efforts on the practice, it grew very quickly, and within 3 years it went from nothing to becoming a multi-million-dollar practice.

After serving as a mentor/coach to many struggling doctors I decided to dedicate my career to helping other doctors grow their practices. I sold my practice in December 2015. This would enable me to affect the care of many more patients than I could ever treat myself.

In my experiences with coaching there was often a disconnect between coaches and members of the team whose jobs they simply didn’t relate to. The system I developed was to have a member of each department go into practices as a coach. I work with the doctors on diagnosis, treatment planning, leadership, and verbal skills. Our administrative coaches work with and empower administrators. Our hygiene coaches work with hygienists on their diagnosis and verbal skills, and their ability to transfer treatment from their chair to the doctors’ chairs. This elevates the hygienists’ value to the practice, which adds to the overall practice value.

We have now worked with 145 practices and have helped them cumulatively achieve over $185 million in growth.

DSOPro: What do you consider is generally the area of biggest need within a practice?

There is a discrepancy in diagnostic criteria within practices. From using analytics, we know that the average practice will diagnose treatment to be done on 34% of the patients coming through hygiene. In a million-dollar practice with a diagnosis percentage of only 18%, if we bring that up to 30%, which is still below average, they will see a 60% growth in productivity based on the opportunities to do more diagnosis-based dentistry.

You must diagnose in order to have the opportunity to gain treatment acceptance. Discrepancies in diagnostic criteria is one of the things that contributes to low productivity. Magazines have published articles claiming that if you go to 10 different dentists, you’ll get 10 different diagnoses. What happens if that’s happening within the same practice? That really erodes patient confidence in the practice.

Some doctors may have a conservative philosophy, but often it is because of “approval addiction.” Doctors are hesitant to tell patients what they need because they fear that patients won’t like them and might go elsewhere. They don’t have confidence in their verbal skills to overcome patient objections.

Many dentists think out loud. They tell patients things like, “Well, I think this is going to need a crown, but maybe I can fix it with a filling or an onlay.” This is confusing for patients. It would be better if doctors paused, thought through their strategy, and then were more definitive. It’s the difference between a “Hmm” doctor and an “Aha” doctor. “Aha” doctors develop greater confidence in their patients.

Many doctors are conservative because they don’t want to be considered aggressive. Think of the scenario when a doctor tells a patient they need a filling, and during treatment a cusp breaks off. Now they tell the patient they need a crown instead of the filling. That lowers patient confidence. Patients think it’s a “bait and switch” situation. Another example is when the doctor tells the patient, “We were going to do a crown, but the decay is very deep, the nerve is exposed, and now we have to do a root canal in addition.”

What if while doing the crown, the doctor found decay on the adjacent teeth, and now the patient will need another filling or maybe another crown. Patients hate that. This highlights that doctors often do not make the proper diagnosis in the first place.

I teach to diagnose protectively. If I know there is a chance root canals are going to be necessary, I talk about it and include it in the initial treatment plan. If it becomes unnecessary, I can tell the patient after the procedure, “I have great news! Because I was so careful, I was able to avoid the root canal and you are getting a refund.” That builds trust and confidence for the patient. When you tell a patient what you’re going to do before you do it, it’s a diagnosis, but when you tell them what you’re going to do after you do it, or while you’re doing it, that really becomes an excuse.


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DSOPro: Tell us about your blueprint for growing practices.

My blueprint outlines how to increase practice revenue without marketing, additional rooms, or hiring additional teams. It’s about becoming more efficient in your diagnosis. We know that there is the opportunity to do at least one more filling a day in each doctor’s chair in every practice. I’ve frequently seen patients come through hygiene with missed diagnoses. Hygiene visits are the ideal time to identify decay, chipped teeth, occlusal wear, etc. The hygienist should be able to identify where potential treatments could benefit a patient. 

If a dentist is working 8 hours a day and performs one more resin a day, at $200 that raises production by $25 an hour. Over the course of a year, that’s $40,000. Doing one more crown a day, at $1,000, raises the hourly production by $125 an hour. In a year, that’s $200,000. Up to 80% percent of the population has periodontal disease, and most practices are doing 90% prophies, which is a preventive procedure. If they appropriately convert one prophy a day to a scaling, that increases the hygiene production over the course of a year by $30,000.

How many patients are seen each day who have a chipped tooth, a broken filling, occlusal wear, mobility, fremitus, abfraction, or spacing—all criteria for a night guard? Doing one night guard per day at $400 increases the practice production by $50 an hour. Over the course of a year, it’s $96,000. 

If you simply just do these things, cumulatively, it’s an instant $366,000 increase for a typical practice.

Multiply that by the providers in the multiple locations of a DSO and you’re talking about increasing revenue by $600,000 or $700,000 in a 2-doctor practice, a million dollars in a 3-doctor practice, and more in 10, 40, or 100 practices by delivering better care. Production is a measure of the amount of dentistry that patients have made better decisions about for themselves.

Team members sometimes resent references to money and production, but if everyone knows that all of this is dependent upon delivering a higher level of care, it’s a lot easier to get a team committed to that sense of purpose, and that outcome. This is also how you develop a much more motivated team.

DSOPro: Aside from being conservative, why is there such general misdiagnosis? 

Thoroughness. Unfortunately, many doctors think that the only thing they do that is productive is cutting teeth. They don’t spend enough time on diagnosis, or they don’t train their team, particularly hygienists, to help them. When it comes to diagnostic criteria, it’s important to bring hygienists into that conversation so they are laser focused on seeing these things and understanding what treatments the doctors would recommend for those conditions.

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DSOPro: What’s the best way to handle that?

We teach a method of communication of dental treatment that is called “Triple Hear.”

Marketing experts have determined that people can process three pieces of information well. They also understand that if you give a message multiple times, it registers better. They’ve established that three seems to be the magic number. That’s why infomercials are not 30 minutes, but 10-minute segments repeated 3 times, consecutively.

Translating this to a hygiene room involves having a photograph up on the screen. Patients have no idea what they’re looking at on x-rays, even if they are nodding their heads. A photograph is a much more effective way of communicating because most people are photograph obsessed. In the “Triple-Hear,” the three communications are between the hygienist and the patient, the hygienist and the doctor (in front of the patient), and then between the doctor and the patient.

The hygienist shows the patient a photograph and says, “This tooth decay or this crack is a serious problem. If you don’t do something about your problem, you could have pain, develop an infection, or even lose that tooth.” That’s giving them ownership of their problem. Continue with, “When the doctor comes in, he or she is going to recommend something that will make this tooth stronger, healthier, last longer, avoid pain and infection, and make the tooth look absolutely beautiful.”

All those things are the benefits of treatment. Notice we’re not talking about what or how we’re doing it. People don’t buy fillings or crowns. They buy the benefits of what those restorations do for them.

When the doctor walks in, the photograph should cue them up for the conversation about restorative opportunities. The doctor says to the hygienist, “Tell me what you were discussing with Mrs. Jones about that photograph on the screen.” It immediately targets the conversation on restorative needs.

The hygienist repeats what she told the patient. Then the doctor looks at the x-ray, does an exam, and goes back to the Triple Hear, repeating what the hygienist said, and adds, “In this particular case, I do recommend a crown.” So, the patient has heard the problem, the consequences, and the benefits—told exactly the same way—three times.

The best question to ask when concluding the hygiene check is, “Is there any reason why we shouldn’t go ahead and schedule the next visit to begin this treatment?” The reason for asking that question is to try to bring out all the patient’s objections to treatment—Can I afford it? Do I have the time to do it? Is it the right time for me with what’s going on in my family?

Getting a patient to say yes involves the entire team helping them overcome those objections. The typical objections are cost, fear, time, sense of urgency, and trust. A cost question should only be answered by the administrators or the treatment coordinator. The doctor should reply, “Our treatment coordinator is an expert at making treatment affordable for you. Since she can make the treatment you want affordable, do you see any other reason why we shouldn’t schedule the next visit to begin the treatment?”

For the patient who asks fear questions, like “Is it going to hurt?”, validate their fear rather than telling them not to worry. Respond that you will take every measure to ensure they are comfortable during and after the appointment and say, “As long as you know we are dedicated to your comfort, do you see any other reason why we shouldn’t schedule the next visit?”

The most frequent question after cost is about urgency. They may ask the hygienist, dental assistant, or the administrator about this. It usually surfaces in questions like, “Can I wait on doing this crown? Do I really need it? Can I do a filling, which is less expensive?” This is why scripting is extremely important. Everyone must be on the same page and relay the same message. If a patient asks multiple people the same question and gets different answers, that lowers their confidence and their likelihood of scheduling.

The technique for overcoming concerns of urgency is called, “Feel, Felt, Found.” Saying you understand how the patient feels is validating and shows you understand their concerns. When you say that many patients ask the same question and have the same concerns, that’s comforting too, because we all have herd mentality and we like to point out that concerns are shared.

The response to questions of whether something is needed, or if treatment can wait is, “The patients who follow the doctor’s recommendations have found they have an easier time, the treatment ends up being less expensive, there’s less discomfort, and the results are better. The patients who put it off for one reason or another end up having a more difficult time, it’s more expensive in the long run, there is usually more discomfort, and the results aren’t nearly as good. Which makes sense to you?” This gets back to the idea of helping patients make better decisions for themselves.

As you raise perceived value, you lower perceived cost. If you build up enough value by telling the patient what’s in it for them with a certain procedure, they will be less constricted by their wallet, because they’re going to want the treatment, not need the treatment.

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DSOPro: What are other examples of common mistakes?

One mistake that doctors make constantly is telling patients, “We can watch that.” It happens every day in almost every practice. The problem with watching it is that amounts to benign neglect. I can’t think of any problems with teeth that go away by themselves. It is necessary to diagnose things earlier, which is a result of being thorough. Tell patients that this is something that can be treated conservatively now and that if they choose to wait, it could develop into something much more involved and costly. 

They should come in at a sooner interval “to have it evaluated.” That develops trust.
If you say that you’re going to watch something, you now own their problem and if things go bad, they will be angry with you rather than take responsibility. Post-COVID, patients are more concerned with health and more likely to make proactive health decisions. We take that option away when we tell them we’re going to watch something.

Another huge mistake is using “minimizing terms.” Never say it’s just a little cavity, minor inflammation, or slight bleeding. When a patient calls to cancel and the administrator says, “Oh, why can’t you come in? It’s just a cleaning” that devalues the role of the hygienist.

To change your success, you need to change the way you practice. No one taught us this. That’s why I wrote a book called, They Didn’t Teach Us THAT in Dental School. It covers these types of soft skills that I think are so important. 

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About Dr. Steven Katz

Coaching Dental Practices and DSOs to Improve Diagnosis and Case Acceptance

Dr. Steven Katz is a Practice Growth Coach and the founder of Smile Potential Dental Practice Coaching. Dr. Katz began his career in oral & maxillofacial surgery, then transitioned back to general practice. He is a graduate of Columbia University and the Washington University School of Dental Medicine. For over 30 years he owned an award-winning complex-restorative and cosmetic practice in Malverne, Long Island. He has been an attending at North Shore University Hospital, the Team Dentist for the NY Jets, and an on-air dental consultant for Fox News. In 2014, he wrote and published the highly acclaimed book, They Didn’t Teach Us THAT in Dental School and in 2015 he was named the “Best New Speaker in Dentistry.”

Smile Potential Dental Practice Coaching

Smile Potential Dental Practice Coaching was founded in 2008 by Steven Katz, DMD, MAGD, FICD, and Kelly Fox-Galvagni, CDA. During the last 8 years, since Dr. Katz sold his multi-million-dollar complex/restorative practice, they have worked with over 145 practices and helped those practices achieve over $185 million in revenue growth. This was accomplished with a very unique multi-coach approach, with experts working with each department (doctors, hygienists, administrators, and clinical assistants) within the practices. Within the framework of their training, there is a strong emphasis on improving the quality of care and patients’ perception of the value of care and on calibrating the diagnostic criteria, increasing treatment acceptance, both restoratively and in hygiene, to promote dramatic practice growth. An abundance of time is spent on leadership development and team empowerment. The program is geared toward making patients want to make better decisions about their own care and choosing to have more comprehensive treatment. There is also a strong emphasis on quality assurance, which increases practice value to patients, motivation for team members, and prospective value to future investors.

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