Financing a career in orthodontics can be daunting. For April J. Cole, DDS, MBA, joining the DSO Absolute Dental was the answer to financial certainty in her career.

By Greg Thompson | Photography by Paul’s Vegas Photography

Owning your own private practice has long been seen as a signpost on the road to professional success in orthodontics. But times are changing. And that option doesn’t always make the financial sense it once did.

When April J. Cole, DDS, MBA, completed her orthodontic residency at Roseman University of Health Sciences in Henderson, Nev, in 2016, she opted to start her career at a DSO, or dental support organization, because she needed to start earning a paycheck. Like many of her cohort, she was saddled with the massive student loan debt that comes with dental school and then specialty training. And while she thought she’d eventually make the jump to owning her own practice and following that traditional career path, she’s changed her mind. She’s discovered that life as an associate in a DSO has its benefits.

Unexpected detours

The road to becoming a successful orthodontist can be long, winding, and dotted with unexpected detours. Cole is a case in point. She may well be the only orthodontist who has also performed the high stress job of 911 dispatcher.

Cole earned a degree in molecular and cell biology at the University of California, Berkeley, but her intellectual curiosity extended beyond the sciences. While the biology-focused degree is typically a sign of pre-med ambitions, Cole admits, “I never intended to go into medicine. I always wanted to be a lawyer and did go to law school for about 1 year. It took me that year to realize it was not quite right for me. I wanted to be rooted in the sciences.”

After opting out of law school, she decided to work for a couple of years, eventually finding employment as a 911 dispatcher. The job required clear communication and calm under considerable pressure—talents that came naturally.

“The most emergent calls I fielded as a dispatcher were ‘hot calls’ when officers needed to pull their weapons,” says Cole, a southern California native. “In cases like this, the emotions of the officer are understandably heightened and one of your jobs as a dispatcher is to maintain calmness while efficiently dispersing the information needed. I learned the importance of honing a high emotional intelligence, and it serves me well to this day.”

During this time away from academics, Cole missed the sciences, particularly its clarity and “right and wrong” ethos. Law is rife with gray areas, but science often has objectively correct answers.

Absolute Dental
Orthodontic treatment is often a cosmetic intervention, and as such insurance doesn’t always cover the cost. “So being able to establish rapport and convey the benefits of orthodontics is important,” says Cole.

Embracing orthodontics

After acceptance to the University of California, San Francisco Dental School, the long road to get her degree eventually got a little longer. “I thought I would graduate as a general dentist because I felt I needed to be done and start earning a paycheck,” Cole remembers. “[But] it was through the specialty rotations that I considered orthodontics and really felt a connection to that discipline. I applied to orthodontic residency. It’s a competitive specialty and I was fortunate that I had been involved at UCSF even before I planned to specialize.”

The orthodontic residency brought Cole to Roseman where the analytical aspects of treatment planning immediately drew her in. “It was something I was good at and could see myself doing long-term,” she says, before adding, “Orthodontics is also a bit easier on the body than general dentistry.”

Once finished with her residency, Cole immediately went to work as an associate at Absolute Dental, a Nevada-based DSO with some 40 affiliated dental practices. There, the combination of explanatory skills and scientific acumen has served her well.

“There is a strong selling side to orthodontics that extends beyond dental normative needs,” Cole says. “A lot of patients who present for orthodontic consults don’t come for pain, looking for immediate treatment. It’s often a cosmetic intervention. Insurance doesn’t always cover it, so being able to establish rapport and convey the benefits of orthodontics is important.”

Leveraging the CareCredit credit card to help increase treatment acceptance

Absolute Dental
“Our front office team members are experts in helping patients fit orthodontic treatment comfortably into their family budget,” says Cole. Absolute Dental offers patients CareCredit to help finance treatment.

Patients and families want straight and functional smiles, but often the main concern is cost. When it comes to discussing money and payment solutions, Absolute Dental has a team that is trained for these particular conversations. “This way I can focus on what I do best, which is delivering treatment,” Cole says. “Our front office team members are experts in helping patients fit orthodontic treatment comfortably into their family budget…For the most part we are not willing to risk the patient relationship, or risk non-payment, so we decided to give patients the option of the CareCredit credit card. With CareCredit approved patients can pay over time, often with promotional financing.”

Amilya Quassani, office manager for the past 6 years at Absolute Dental initially discovered CareCredit while working at a different company. “We did offer in-house financing but required a down payment. That’s why I leaned toward CareCredit,” she says. “Where I was before, we only used CareCredit as a financing option.”

CareCredit is a good solution for Absolute Dental’s business model, with the elimination of down payments making it a logical choice. “It aligned with our goal of providing convenient payment solutions for patients while enhancing operational efficiency,” Quassani says. “For example, we had a patient who required comprehensive orthodontic treatment involving braces and additional appliances. Upfront costs were an issue for the family. Utilizing CareCredit allowed them to initiate treatment promptly, leading to successful alignment, correction, and improved oral health without causing financial strain.”

Cole and Quassani have been breaking records with increased patient starts, patient satisfaction, enhanced collections, and time efficiency. Overall CareCredit has positively impacted the business and operational aspects by helping increase (and enhance) collections, while also improving patient satisfaction.

“One common misconception that I often hear about CareCredit is that it’s difficult to qualify for,” Quassani says. “A lot of people think they must have an 800 credit score to qualify, or if they have a bunch of loans already out, they think they will not qualify for CareCredit. The good news is they can see if they prequalify for the CareCredit credit card privately on their mobile device—with no impact to their credit score. So there’s no risk in seeing if CareCredit may be an option for them.”

Benefits of working for a DSO

Cole, who works in three of the Las Vegas area offices, is one of about 40-plus associates at Absolute Dental and one of a few practitioners designated as a clinical lead. In addition, some doctors, like her, have been able to invest in the company, but no practitioner is technically an “owner” at Absolute Dental.

Cole may not own Absolute Dental, but status as a DSO associate has its benefits, the largest being the ability to focus completely on patient care. With so many professionals to choose from, patients may be referred to orthodontists based on clinical or interpersonal strengths.

“I get the cases that involve difficult patient management,” Cole reveals. “The clinical side of orthodontics becomes pretty second nature. We will share x-rays and photographs among colleagues to get another set of eyes on certain cases. That is usually kept in-house with the original treating doctor. Patient compliance issues are another matter. Our particular demographic has a lot of patients who have not had dental care from early childhood. There is not a lot of dental knowledge, so battling that can be difficult.”

The ability to communicate tactfully and effectively has come naturally, but it’s also a talent that Cole has specifically cultivated. She has interacted with the informed (even over-informed) patient during rotations in San Francisco and Berkeley where the demographic tended toward “quite knowledgeable” about dental care.

“Those patients would come in and bombard you with really scientific questions,” she remembers. “You have to be on your game to have all of the correct answers, and assure them that you are doing the right type of treatment. I had to switch gears when I came to Nevada.” As Cole explains, the different patient demographic requires a different level of patient education and tactics to ensure they acquire the information needed to allow for informed consent.

Focusing on this communication and the clinical side of orthodontics itself is often a luxury for orthodontists who must also manage the intricacies of owning their own practice. A role that often involves precious time spent on purchasing decisions.

Sales reps covet DSOs like Absolute Dental, primarily because of the sheer patient volume. Cole sees about 80 patients per day—roughly 20% aligners and 80% braces; company-wide, those numbers are much higher. Fortunately, the DSO has a purchasing department that shields the doctors from persistent salespeople.

When sales reps do present a particularly promising new gadget, Cole considers it, but she is somewhere “in the middle” when it comes to the speed of technology adoption. However, there are exceptions.

“I wanted to jump into iTero intraoral scanners right away, because they were a slam dunk,” she says. “People don’t like impressions and the iTero was faster, more accurate—and you’re not storing models.”

Absolute Dental
Cole lands somewhere in the middle when it comes to speed of technology adoption; but there are exceptions. Case in point: the iTero intraoral scanner.

Associateship vs ownership

Like so many successful practitioners helping patients every day, Cole favors the “associate life” for practical and personal reasons.

“As associates, we are shielded from a lot of the non-clinical aspects of dentistry, particularly in a multidisciplinary practice like Absolute Dental,” says Cole. “With a robust administrative team, associates are not required to participate directly in promoting the business, recruiting patients, insurance submission/collections, billing, hiring/firing, managing equipment, ordering dental supplies, etc. For those who enjoy focusing on the clinical aspects of dentistry, this can be a huge plus.”

When Cole began practicing orthodontics, she admits that transitioning to ownership was a goal. However, that’s changed over the past few years, and Cole reveals, “I’ll likely continue working as an associate for the remainder of my career.” Part of that equation is the “headache of ownership” which most practice owners describe as the constant demand of managing people—with off time that is never truly off.

“One of the nicer aspects of associating is the ability to wash your hands at the door as you leave the office,” Cole enthuses. “Associates still take aspects of work home because they want to better their practices. However, the degree to which you use your off time to manage office problems is more of a choice than an obligation as an associate.

“For me, financial considerations come into play,” Cole continues. “Taking on more debt in the form of a business loan to own a practice is a deterrent when considering the massive student loan debt incurred during dental and specialty training. Associating often makes it easier to take time off and can allow for non-traditional work weeks. Yet, I still have autonomy in the office. There is not a boss who is directing my every move.”OP