by Al E. Atta, DDS, MSD, MBA

How getting patients to cooperate can boost your earnings

Excellence in the outcome of orthodontic care depends on patient compliance in the treatment process. Compli-ance is a team effort, a partnership between the patient and the orthodontist to ensure the expected result. For patients to comply, they must understand their orthodontic problems, as well as how and why the treatment will improve their health and comfortably provide continuous, long-term benefits. While we should monitor patients’ progress and reward them by making them see and feel the continuous improvement during the treatment process, an orthodontist is a maestro, not a master.

The medical profession recognizes that noncompliance in the treatment process is a real problem that costs more than $100 billion annually and results in at least 125,000 patient deaths per year.1

In orthodontics, assuming that the fee charged for 24 months of treatment is around $5,000, the direct and indirect cost of service consume at least 65% of the fee. That leaves a profit margin per case of a modest $1,750 per 24 months. If the active treatment continues for just an extra 6 months, this will add $1,236 to the total cost (6 x $208, the cost per month of $135 plus a profit of $73). There goes our profit margin.

Any practice that has 50 or more cases that are not finished on time will find that its costs exceed its profit.  Pareto’s Law, which states that 20% of the patients contribute 80% of the cost, applies to such a practice. Noncompliant patients create added stress and added cost, and deprive orthodontists of time to treat other new patients.

Carrying an inventory of unfinished patients creates a chaotic schedule, a stressed orthodontist, and a pragmatic shift from the maximum-profit Pull system of operation to the Push system, which forces the practice to start more cases, finish fewer cases, charge more, and end up providing inappropriate care and generating negative cash flow. Hiring more people to try to stop the chaos will add to the cost of this lose-lose strategy.

Relying on noncompliance mechanics in orthodontics is no more than an adhesive-bandage approach. Patients who do not comply with customized, more comfortable mechanics will reject such harsh systems. Most of the reduced-compliance appliances offer questionable and unstable long-term effects. Relying on a written manual or a high-tech video is shifting the blame. It may give added comfort to the orthodontist, but it gives no assurance to the patient.

There are three types of noncompliance:

1) Unwitting noncompliance comes from patients who misunderstand the required regimen. The fact that patients fail to process information was confirmed by a study at the Mayo Clinic, in which patients complied with less than 10% of orthodontists’ instructions. A system was then introduced at the Mayo Clinic in which nurses call patients at home to reinforce the information and increase compliance.

2) Unwilling noncompliance comes from patients who do not follow treatment orders because of physical discomfort, lack of confidence in the benefits of treatment, or emotional barriers. These are the core of our customers, the changing teenagers. They may have past dental trauma, they may resist authority, or they may be emotionally insecure or immature.

3) Intelligent noncompliance comes from patients who make the choice to alter treatment for their comfort and convenience. They show little improvement, but they are masters at shifting the blame and find comfort in complaining.

What influences compliance?

1) Communication with competence: Integrating patients, regardless of age, into the treatment process is centered on face-to-face interaction with the orthodontist. We need to educate patients on why, how, and when, using a time line and encouraging feedback to help them self-monitor their treatment. To establish and maintain the patient’s confidence, early integration should be followed by competent reinforcement from the orthodontist and the clinical coordinator or assistant.

2) Customization and comfort: We are in the culture of customization to encourage effective service. Not every central incisor will respond equally to 22° torque and 10° angulations built into a smart bracket. Biology is variability. Comfort with progress and feedback is critical for patient compliance.

3) Continuous improvement: Self-improvement through continuous change for the better is what patients appreciate. Lack of progress does not enforce compliance.

Integrating patients into their treatment process not only reduces treatment time, but allows time to detect and correct any undesirable secondary responses that may occur during the process. Reducing the gap between detection and correction of any deviation decreases costs.

Finishing active treatment in 18–20 months and keeping the appliance in active stabilization for another 4–6 months will ensure not only the long-term stability of the outcome, but also a high profit margin with less stress and a competitive advantage that attracts more new patients.

Al E. Atta, DDS, MSD, MBA, has a private practice in Deerfield, Ill. He is certified by the American Board of Orthodontics and can be reached at [email protected]


1. Silverman J. Physician-patient partnership key to compliance. Internal Medicine News. 2003;36(23):32.