How to Sell a New Denture Patient an Implant Case

Every new patient that comes into a dental office comes with a dental past that is filled with good and bad experiences. With every new patient exam and with every patient's new dental experience, there is a history that the doctor must understand. I am not referring to the patient's exact dental history such as times, dates, and procedures but the mindset of the patient that relates to you as his/her new dentist. To adequately understand the patient's expectations and concerns, the dentist should ask some general questions. "How may I help you?" "Why have come to our office?" "How did you loose your teeth?" "What changes would you like to make?" These are very important open-ended questions that will help the dentist gain insight into the patient's concerns and perceptions about their past dental experiences and will help the dentist predict the success or failure of the patient's case.

Interpretation

It is extremely important to remember the following: (1) What the dentist has in mind for treatment, may be the furthest thing from the patient's mind. ["My brother had implants and they did not work, or no one is going to drill nails into my bone."] (2) The information that you want to impart to the patient must be presented in a way that is acceptable to the patient and fits their personal experiences so there is no "shift" in their buying patterns. ["If money was no problem, can we start today?"] (3) Acceptance of a treatment recommendation is contingent on the patient's past dental experiences. ["Every time I go to the dentist, it hurts me."] (4) The doctor's expectation as to the outcome of treatment may exceed or may not meet the patient's desires or expectations. ["You told me that I would be able to eat corn on the cob."] (5) Both the doctor and patient must be on "the same page" when it comes to the dental care given. ["I did not know that I would need implants to have my dentures work."] Disappointment in the outcome of treatment makes both the dentist and patient unhappy. Dr Roberta Golden^{1 [1]} tells us that: "from a psychological point of view the initial appointment is the most important step in the process of achieving an outcome that is mutually satisfying to the patient and the dentist." Every denture patient we see in our offices started out with a full set of natural teeth and has now presented with the ultimate dental failure, upper and lower dentures. That patient has had a tremendous number of dental experiences. Those experiences, whether positive or negative, have an effect on the patients psyche and will determine how the patient reacts to the "new" dentist's recommendations for treatment.

Informed Consent

"Informed consent" must be discussed to be complete. This is a subject that has been given a great deal of press in the dental literature. In my training for implantology with Dr Paul Schitman,^{2 [2]} informed consent was discussed at great length. My contribution to this discussion was a pneumonic method to help me remember the steps in the discussion. This simplified approach, I have presented in lectures over the years to make sure that informed consent is always covered. I call it the B.R.A.N. theory ["If you eat BRAN, then everything will come out ok."]. For informed consent to be covered the following must be discussed: The Benefits of receiving the dentist recommended treatment. The Risks involved in having procedures done that will give the desired outcome. What are the different Alternatives of treatment available to the patient? There is a No Treatment option as long as the patient understands the consequences of no treatment with pathology present. Not everyone wants or can have the recommended treatment.

Patient Centered

While presenting the treatment options to the patient, it is very important that the dentist understands the difference between features and benefits. Features are things like porcelain teeth, titanium implants and the best materials. Benefits are when the dentist uses "you" in the statement when talking to the patient. YOU will be able to chew better. YOU will be able to have a prettier smile. Consumers do not buy features but are interested in buying benefits. Dentists must understand that patients are consumers of dental services. No patient is bound by the dentist to have treatment. Dr Paul Homoly^{3 [3]} in his lectures teaches,"You can not turn a carp into a trout;" and no matter how hard you try, you cannot change an unwilling patient with an extremely low dental IQ or someone who simply can not afford extensive treatment into someone who wants treatment or can afford it. This is why the patient centered interaction is so very important for the case presentation.

Example

The following is a scenario of how a patient was treated in our office that allowed her a comfortable experience and to follow our recommendation for treatment that would satisfy desires of both the patient and the dentist [fig. 1].

Figure 1. This is our patient that presented for a simple tooth emergency replacement for her denture. Note the previous graft that was placed in the position of the lower centrals. This is an indication of a relatively high dental IQ patient that accepted sophisticated dental treatment.

The patient came to our office for a tooth to be replaced on her upper denture . She was extremely upset that her own dentist did not have time to see her explaining, "You are not in pain and, therefore, it is not an emergency." Her response was "It is an emergency to me because I can not go to work looking like this." After complaining to a friend of hers, she was told: "I am sure that my dentist will see you." When she called the office, she was told to come down and we would work her into the schedule and repair her denture. I understand that offices need to run on time but there is always time to see an emergency even if it extends your day. My friend Dr. Joe Steven, Kisco Dental says that: "the extra treatment room will make you money." The extra room gives you a great deal of flexibility to handle emergencies. Maybe a hygienist is free to screen an emergency but whatever the case, extend yourself to your new and existing patients.

Questions

The denture repair took a "very long time" but while the repair was being done, the open-ended questions were asked. "How did you find our office?" [I really know the answer to this question because I have an emergency slip on the front of the chart that tells me who referred this new patient to our office]. "How long have you been wearing your teeth?" "How did you loose your teeth?" We are just trying to get into a conversation with this new patient. The patient's response to our open-ended questions was, "I did everything I could to save my teeth and spent thousands of dollars and I still had to have my teeth out. The dentist told me in the past that I could save my teeth if I did what they said. I did it all, and it did not work. I had to have dentures and, even with that, my teeth do not fit right, and I can not chew my food correctly." The mistake that the dentist might make at this point is to say: "I can do a better job." Dr Paul Homoly has demonstrated and explained in his lectures that the patients have experienced the promises of dentists before and it immediately sets off a red flag for the patient. "I have heard this before and everyone in the past has let me down, so why should I trust this person?"^{4 [4]} It is important that the negatives of the past be recognized and acknowledged. You are just another dentist making another promise. Let us discuss a different approach that will make it easier for this patient to accept treatment.

"Money Issue"

The denture repair was done in less than 10 minutes and when carefully placing the dentures in her mouth the question is asked, "When is your birthday?" Regardless of the answer, the next question is asked, "Did you get a present from me?" Of course the answer is no and so your response is that the denture repair is for her birthday and there is no charge. One of Joe Steven's articles asks the question: "Are you giving away enough dentistry to make money?"^{5 [5]} At this point we have broken down the "money issue" and we are on the way to having a relationship with this patient that is different from their past dentist experiences.

Fatherly Advice

Giving away service is a difficult concept for some dentists to understand. A rule in our office is that we do not charge for consultations. Twenty-three years ago, my father, who owned a small grocery store was listening, in the background, to one of my first case presentations. When the patient came to the front desk, she paid a twenty-five dollar [1978] consultation fee. After she left the office he asked me: "Why would you charge twenty five dollars to have them hear that they are going to spend two thousand dollars in your office?" [Eight crowns at two hundred and fifty dollars apiece, 1978]. I tried to explain that I had given an opinion and that I had spent my time, taken x-rays and models to come up with my treatment plan. His answer was "So what?" My dad went on to explain: "When a person shops for a car, the dealer does not require the prospective customer to pay a fee to discuss whether or they can buy the car. The truth is that there are many car dealers that will sell this person a car and you should not set up barriers for getting the 'sale'." Do not try to change a patient's buying pattern for all the "elective treatment" they need. I have used this advice over the years and it has served me very well. My case acceptance rate is very high with a wide range of fees. Many dentists feel that because they rendered a service they should get paid for it, and I cannot academically disagree, but what I am trying to do is to have the patient understand that our office is a different place. I do want to "shift their paradigm" for their dental experience and for their dental expectations. Patients are usually very pleasantly surprised because everything in the dentist's office costs money. The next thing that the dentist should say is, "If I can ever help you make your lower denture more stable and fit better, please let me know." STOP TALKING! There are people who are reading this article that will say this "cute" style is not something I will or can do. Also how do you know what is involved in treatment? If this is the case for you, then leave out the "birthday present part" and just ask the open question: "If I can ever help you make your dentures more stable and fit better, please let me know."

Invitation

If the patient asks you how that can be done, you have been invited to offer information. I believe it is wrong and very forward to offer information without being asked. When the patient's interest has been piqued, that is when it is appropriate to offer more information. If the patient has not responded to the open-ended question, that means they are not emotionally ready for solutions for their "denture" problem. If the dentist pushes the patient into a decision when a patient is not receptive, the negatives of the past dental treatments and failures will come to the surface. These feelings may not be verbalized by the patient, but they are just below the surface getting ready to "bite." I truly believe that it is a mistake to say to the patient things like: "If the money issue can be worked out, is there any reason why we can not start today?" This is pushing the patient and again shifting their usual buying habits. There are people reading this article saying that I have manipulated this patient. I think it is just the opposite. I have allowed the patient to feel comfortable in asking for more information on his or her own terms. The buyer of the service has decided for himself or herself without being pressured.

Initiation

Now is the time for the dentist to explain to the patient that in order to know if they can help the patient, we need more information. "If I could take some necessary (that is one word as taught to me by Ms. Jenny de St George) X-Rays, examine your mouth more completely and perhaps take some models of your mouth, I would have the information I need to see if you and I can make some teeth that will allow you to smile, chew and feel better." The phasing is very important because you have explained to the patient that you are interested in the details and that you are going to partner with them to try to solve their problems. At this time, the dentist should ask the patient what they think the problems are with the teeth they are wearing. We can expect standard responses: "I can not chew." "I hate my smile or it looks like I am wearing dentures." "My lower moves around when I chew." "My upper 'plate' drops when I chew, yawn, smile." We have gone through a lot of steps in our discussion without one word addressing the name and purpose of our article: "How to Sell a Denture Patient an Implant Case." Remember we are dealing with a new concept for the patient, no matter how common implants are in the dental world today. Each of the patient concerns need to be addressed and if you think about each of these concerns, implants will help the patient greatly. Now remember the patient may have been thinking about their dental problems for a long time but because they are in your office now, the problem is immediate.

Immediate Need

The immediate need for the denture patient is not really any different that when a patient calls the office to have their teeth cleaned. It has been a patient management question whether patients should be allowed to have their teeth cleaned on the first visit. When a patient calls an office and they are given the answer to the question: "I am calling to set up an appointment to have my teeth cleaned." "That is not what we do in our office, you must have an exam with the doctor, with x-rays to determine what treatment is required." The patient is thinking: "I just want my teeth cleaned." Again the patient's buying practices are being questioned and changed. Why throw a roadblock up in front of the patient? When a patient calls our office: "I would like a cleaning." the answer is YES. We want this patient to come into our office to find out how wonderful our office is in providing the dental services the patient needs. In the past, when conventional implants were placed there was a healing period. We now have a way to avoid this healing time to give the patient some immediate relief for their denture movement. I have had great success with the Imtec implant for immediate loading and denture stabilization. I use this system as an addition to my two-stage standard implant treatment. When talking with the patient about their concerns I bring up the concept of implants, but I make an important distinction that is critical in building the relationship with the denture patient. I explain very carefully that I cannot place their "long" term implants until I have made the best denture that I can make for them. That until the denture is fabricated, I will not know exactly where to place their implants. "The error that is often made Mrs. 'Patient', is that the implants are placed before the dentures are made and the result is not a good as we would like. I have had a situation in the past that the new dentures have been such an improvement that we did not have to place the implants right away." This scenario has been true many times that the denture treatment has worked out very well and that we did not have to place implants to satisfy the patient. Someone reading the article can now say: "I thought we were talking about converting a denture patient into an implant patient." I absolutely agree, but many times I have had patients come in and discuss the fact that all their dentist talked about was the implants, and all they were interested in was new dentures. Once again I am breaking down that barrier between the dentist and patient. By agreeing with the patient that perhaps new dentures are all that is needed you have endeared the patient to you and your office. When the denture patient has told us that they would like to consider new dentures or, have we have been given the "go ahead" with the new dentures, the patient has been given the fee for the dentures, the cost of subsequent Imtec and conventional two-stage implants. The patient is presented the total fees up-front, so there is not this response, "You did not tell me how expensive it was to have implants."

Fees

The fees are presented as follows: "Mrs. Smith, in our office upper and lower dentures are forty eight hundred dollars." If you and I decide that we want either the upper or lower denture not to move around immediately we can use the Imtec immediate implants. You would need a minimum of two on the bottom and they are at five hundred dollars apiece." "The conventional implants are $2500 apiece and you would need at least two of those on the bottom also." The math is pretty simple, forty eight hundred for the dentures, one thousand for the two Imtec implants, and five thousand for the two other conventional implant for a total of $10,800 for the complete job. Remember, I can not put in any of your implants until your dentures are completed, so you have time to think about the implant part of your treatment." What have we accomplished? The treatment plan has been discussed as well as the fees. The only thing left to explain to the patient is the timing of the case. Once the patient has made the decision to have treatment, timing is immediate for them. If the patient tells you they want to proceed with treatment [denture only or total case], financial arrangements are made and preliminary impressions are taken.

Decision

We have taken a step towards solving the patient's perception of their dental needs. Even if the patient commits to having implants at this time, they may still have "buyers remorse," so you having just the dentures is a fall-back position. Tom Orent, in his One Thousand Gem seminars, talks about presenting ten veneers with the fall back position of eight or six veneers to allow the patient to feel more comfortable.^{6 [6]} This is the point, that the patient must feel comfortable in their treatment decision as guided by the dentist. The dentist normally would do a wax try-in as a final step before final fabrication. I have added an important step. At the final try-in, a clear plastic stent, which is duplicated from the final denture, is put in the patient's mouth [fig. 2]. The cost of this stent should be relatively low as a laboratory fee.

Figure 2. The wax try-in with teeth has a matching surgical stent that has been fabricated by the lab.

Suggestion

The patient has a mirror in their hand getting ready to view their "new teeth" and the question is always asked by the patient: "What is that?" The answer given, "If you and I decide that you need to have the Imtec and conventional implants, this stent will tell me exactly where to place the implants." No more is said and the surgical stent is placed in the patient's chart or put in a place so that it will not be lost and can easily be brought out at subsequent appointments. At the insertion appointment, the surgical stent is brought out and placed first. With the mirror in hand, the patient once more is told what the surgical stent is to be used for in the future.

Feedback

At the important follow up visit the questions are asked, "How are you managing with your lower denture? Is it moving and are you able to chew?" This is again an open-ended question and allows your patient to direct treatment. Your job is done if the answer is, "Dr Hoos you are a genius and I love my teeth and can chew anything." Your answer is: "Thank you very much and because you are so happy please tell your friends." You must ask for referrals or patients will think you are not accepting new patients. Your response will be different if the answer to your question is, "My dentures are very nice and look great but the bottom, top or both still move around." Now is the opportunity to take out the surgical stent and place it in the patient mouth saying, "Do you remember this stent?" "This is the tool we need to go on to the next step to keep our teeth from moving around. Do you think you would like to do that?" STOP TALKING, and wait for the patient to answer. It may seem like the longest two minutes of your life. But, the first person to talk "looses the battle."

Acceptance

When your patient asks how to keep their denture from moving around, then review the steps, costs, and timing of the implant treatment making sure that BRAN is incorporated. Benefit, Risks, Alternatives, and No Treatment must be covered again remembering that patients buy benefits not features. The benefits are reviewed, "You will be able to eat and smile without having your dentures move around. The patient will understand the benefits of the Imtec immediate stabilization implants and the benefits of the long-term conventional implants. The patient understands that you are their partner in treatment and, from the very beginning of treatment, you did not insist upon the implant solution. You have lead the patient to their own conclusion using the above steps. The patient and the dentist have made the best denture that could be made, and that did not completely solve the problem of the "denture is moving around." By using the steps described, the patient is emotionally ready to take the next step of having implants placed to improve their situation. Proper case presentation and problem solving will simplify the case presentation and put the patient's expectations in the proper context. By setting up the right sequence of events, the patient can be informed in a non-confrontational manner the benefits of implant supported dentures. After a wonderful treatment outcome, they will refer many of their friends who also cannot wear their "free floating" dentures. Jeffrey C. Hoos, DMD, FAGD maintains a private group practice in Stratford, Connecticut with Dr Johna Zitnay and Dr Gemma Kwolek . He has been involved with implant dentistry since 1980 and was Branemark certified for surgical placement in 1988. Dr Hoos lectures extensively teaching a course, "Balancing: the Art, Science, and Business of Dentistry. [7]" He can be reached at jchdmd@bettersmile.com [8]. Notes: