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Financially strapped?

Jan. 1, 2011
Today's economy has brought an ever-changing dimension to the modern dental office.
Learn to identify your patients' priorities

by Karen Donaldson, CDA, RDH, BS

Today's economy has brought an ever-changing dimension to the modern dental office. We not only have to juggle dental insurance rules to provide quality care, but now we are faced with an even stronger voice from our patients telling us, "I can't afford that," or "only if my insurance will pay for it."

Patients avoid care they need for optimum dental health that may also impact their overall health and well-being simply because they feel too financially strapped to receive this care. But are they?

Have our patients been using this excuse for years just to avoid dental care they do not understand the importance of, or do they avoid care because they want to spend the out-of-pocket funds on a different priority? How do we determine if they really are financially strapped?

Recently, I had a patient of record who had not been in the office for more than two years. She had a history of periodontal disease and had completed a periodontal therapy program three years ago. While updating her radiographs, I began a conversation about the importance of having a periodontal maintenance appointment every three months to slow the progression and recurrence of a disease that isn't cured, just in remission. Her response was one I have heard many times: "Well, my insurance doesn't cover those extra cleanings."

This is my cue to begin the almost-memorized lecture about the effects of periodontal disease on the mouth, the body, and overall health. I have said it so many times I can repeat it without thinking. During the lecture, I noticed my patient's nails. She had those fancy, well-groomed nails with custom designs applied. I couldn't help myself; I had to ask her how often she had those done. Her response was, "Every two weeks." The discussion continued with a focus on how she spends a costly sum to have that done as a splurge. After all, she deserved it!

That's all I needed to open a door I love to pass through. I began my emotionally driven discussion about the value of good health and how our dental health is proportionately related. As I cleaned her teeth, I focused on how deep her periodontal pockets were and compared them to her last charting. I did my best to create a visual of doom if she did not make her periodontal health a priority. Then I opened the proverbial can of worms. I suggested that her periodontal maintenance needed to become as important to her as her glamour nails. There was a long moment of silence as she delayed her response. But, surprisingly and to my relief, she agreed.

This event made me wonder: do we avoid the confrontational conversation when we see obvious situations where patients choose poor priorities? Do we just assume that everyone who says he or she is financially strapped really cannot afford the care? What is our responsibility to our patients in helping them choose the best direction for their limited funds?

The same week, I had a patient whom we share with a periodontist's office. She alternated between our offices for a three-month schedule of periodontal maintenance. She sat in my chair with her iPhone in hand. As a conversation opener, I commented that she had a fancy phone. Then I asked her about the expense of keeping one of those active. She agreed they were pricey, but said she had to keep up with her kids. I totally understood.

As we began her gingival evaluation, she started to fret about the bleeding I was calling out during probing. Pocket depths were mostly within normal limits, and some areas had recession. Bleeding did occur but was isolated and minimal. I stressed a different technique to clean these areas. Then the patient shared with me that the hygienist at her periodontist's office would not allow her to get away with that much bleeding. She was relieved she was not there today. I wondered, had I not been emphatic enough about her condition?

Have we created a mindset along with our patients of not stressing the importance and value of following through with treatment and being committed to good oral care, both at home and at our office? Since our economy is fluctuating in most everyone's life today, dental care needs to be a focus. Educating our patients – and perhaps educating ourselves as well – can only help develop that priority.

How can we effectively determine if our patient is really financially strapped? One of my favorite questions to ask a patient who refuses care because insurance doesn't cover it is, "If I were your heart doctor and told you that you needed a procedure, would you say no because your insurance didn't cover it?" This opens a whole new conversation about how our dental health affects our cardiovascular system. It's a great place to start to change our patients' priorities toward dental care.

Focusing on this new approach to dental care, we can also learn to evaluate the oral health of our patients using evidence-based dentistry. This approach combines the best evidence – our judgment and experience – and our patients' values and circumstances to improve oral health. It gives us a direction to begin moving our patients toward making dental health a higher priority based on their values and dental education. If it's too far from their level of dental education to understand the priority, we must first educate them to move toward the goal.

This may take more time than the usual appointment, and may take a change in our attitude toward the financial aspects of their care. As dental hygienists, we normally do not discuss payment options, but we can introduce the financial program our office uses and stimulate a conversation between our patient and the office personnel who can help get them qualified.

Part of our responsibility is to make sure our patients' treatment needs are done in a timely manner. This may require you to set up different appointment sequences than you usually recommend, allowing patients to creatively find the out-of-pocket funds by shifting their spending priorities. In our office, this may include treating periodontal disease one quadrant at a time instead of one side at a time. The new insurance code D4342 can even allow you to treat a sextant at a time if finances demand it. However, patients need to understand the quickest overall treatment is the best evidence-based approach to achieve generalized healing in a shorter time.

Using new technology to help educate your patients is a great approach to focus funds toward dental care instead of luxury items. Most patients walk into your office with a cell phone. If you introduce them to their oral cavity using a high-tech intraoral camera or laser caries detection as your doctor performs the hard tissue exam, they will be more likely to realize the importance of immediate care. The old saying "a picture is worth a thousand words" still applies to treatment planning. New technology can help nurture loyal patients who are committed to accepting the treatment you recommend.

If a new patient comes from an office that is still treating patients as in the Dark Ages and not evaluating periodontal health, it may take a bit of dental education to get the patient to understand the severity of his or her oral health. Have printouts of articles with information about the correlation between oral health and overall health. These are available at the ADHA and ADA Web sites. Walk the patient through the article before sending him or her out the door in case it ends up in the pile of papers that eventually hit the trash without review. This will at least give your patient an introduction and may spark further review at home.

If you plan to spend time discussing treatment compliance and finances with patients, you must plan ahead and have an understanding with your doctor on how these matters will be approached. This is a good staff meeting topic: delegation of duties and where or when patients will be approached with an in-depth focus to help them commit to treatment. An all-staff approach to motivating patients who present themselves as financially strapped can improve office production and help you reach bonus goals. After all, we are feeling these economic times today as well.

Many patients are looking at their spending today and choosing their priorities for the tighter budget. How we approach their oral health and guide them toward stronger dental health knowledge can direct them to accept treatment even if they believe they are financially strapped. Part of that guide is to continue to provide patients with the highest quality care we can, even if our office is also experiencing a budget crunch. We need to learn to employ the high-tech future of dental hygiene care to guide patients toward evidence-based dentistry and making good dental health a financial priority.

Karen Donaldson, CDA, RDH, BS, has worked as a dental hygienist since 1989 when she graduated from the University of Southern Indiana as a nontraditional student. She graduated magna cum laude in 1990 with a bachelor's degree in health sciences with a geriatrics and social services emphasis. She also holds certification from DANB as a certified dental assistant and has had expanded functions training.


Many patients are looking at their spending today and choosing their priorities for the tighter budget. How we approach their oral health and guide them toward stronger dental health knowledge can direct them to accept treatment even if they believe they are financially strapped.


The American Dental Association defines the term "evidence-based dentistry" as follows:

Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient's oral and medical condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences.

Translation please?

EBD in simple terms means:

An approach to clinical practice that combines the best evidence, your judgment and experience, and your patient's values and circumstances to improve oral health. EBD has systemic reviews that "use rigorous and explicit methods to research for and critically appraise the entire body of clinical research evidence related to a question."

Find evidence-based resources at There are two journals: The Journal of Evidence-Based Dental Practice and Journal of Evidence-Based Dentistry (find the first issue free online at

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