by William C. Sutton

Understanding why patients accept treatment will help you meet an unmet demand

Whether to treat more adults in an orthodontic practice has long been a debatable issue and a subject that draws very strong opinions to the pro and con poles. Let’s explore some thoughts, opinions, experiences of mine, and orthodontic demographics. We’ll scrutinize three considerations: Typical reactions to adult orthodontics; the thoughts and opinions of three health care professional friends of mine; and why, in the majority of ortho practices, increasing the number of adult patients makes good clinical and business sense.

Reactions to Adult Orthodontics
Over the years I’ve listened to many and various orthodontists’ opinions about whether to treat adult patients. I’ll recall (no pun intended) some of these thoughts.
“Adults are too difficult to manage.”
“Adults are easier to manage.”
“Adults are clinically tougher to treat.”
“Adults are clinically easier to treat.”
“The little ones really need ortho.”
“I’d rather treat children.”
“I find the relationships I form with adults during treatment more rewarding.”
“Adults talk too much during treatment.”
“Adults present too many periodontal issues.”
“After I’ve had a perio evaluation performed on the prospective adult patient, I can make a proper, informed decision on whether to treat that  adult.”
“I can’t make adult ortho profitable enough to do routinely.”    
“Adults ask too many questions and cause increased chairtime during treatment.”
“My staff and I find that adults provide us a nice change of pace from the traditional, adolescent patients.”
“Adults are simply a departure or diversion from standard operating procedures which we can’t afford in our practice.”
“We’ve found that finished adults provide the finest referral base possible. A referral base we can gatekeep ourselves.”

Enough?! Yes, I think you have the idea. There are many opinions out there. Some are true. Some are not. We’ll return to these opinions and draw some conclusions later in this article. Let’s next learn from some health care friends of mine.

Perspectives From Other Health Care Professionals
Irregularly, I play golf with three buddies: an orthodontist, a plastic surgeon-dermatologist, and an oral surgeon. All are between the ages of 40 and 60, male, would be termed “successful,” are upfront with their opinions on all subjects, and are respected by their colleagues. These guys are solid health care professionals. They are not solid golfers. About 1 year ago, I told them I was going to write an article that addressed why adults accept orthodontic treatment. I asked each of them to give me their ideas on why their adult patients “finally accept” their respective specialty’s treatment (and not major facial restoration or treatment that is essential to life, but treatment that is geared to patients’ self-esteem enhancement). Let’s see what they had to say.

The oral surgeon summarized that he thought that in each person’s life, a time comes when his or her facial presentation in the “daily mirror” simply needs a change, if the patient’s perception is that it does. People simply tire of the crooked, overlapping central, for example. This was also a comment offered by the physician and the orthodontist. The patient-to-be comes to a point when “it is their turn for some care” instead of their childrens’ or their spouse’s. The fee for treatment was not a consideration in the majority of cases presenting for treatment.

As we all know, the oral surgeon and the plastic surgeon do not carry their patients for 2 years. Acceptance is, in almost all cases, an emotional issue relating to the patient, not the specialty concerned. To wit, comparing an oral surgeon’s patients to an orthodontist’s is mostly worthless. The surgeon’s pace of life is usually speedier than an orthodontist’s. His cases take only 1 month to treat. The surgeon makes decisions more easily than the orthodontist does. My experience tells  me that the long, average, treatment time of the average orthodontic case causes “decideophobia” in the majority of orthodontists and is pervasive in his life—too many alternatives and no definite decisions unless the case involves surgery.

In my opinion, the plastic surgeon/dermatologist offered a more cosmetic (of course) rationale. He said that an adult man or woman has lived with his or her face for many years, is basically reconciled that “this face is mine,” and that unless a major event or breakthrough occurs, the facial and dental status quo will be preserved. The dermatologist said that previous-patient and third-party referrals are 90% of his renewing patient base. He reports that a few—perhaps fewer than 5%—patients who have experienced significant facial change actually are uncomfortable with being prettier or more handsome and want their “old appearance” to return. I believe it’s well-documented in psychology and psychiatry that “beautiful people” live tougher, edgier, and more traumatic lives than you or I. This physician makes certain, in his series of pre-op conferences, that the patient is sold on, really wants, and will be happier with the “new model.” And he papers the patient-treatment agreements and contracts liberally with disclosures and offers no guarantees of any sort. And, of course, changes outside of the mouth are more visible than are those within or usually covered by clothing.

This whole arena of the rationale behind getting cosmetic surgery, dentistry, orthodontics, and facial orthopedics is a quickly evolving niche of health care. I would recommend that any orthodontist who is thinking about doing a bunch of adult orthodontics have a “health care buddy” who is already heavily involved in cosmetics. But, orthodontists are prone to overevaluation, so beware of this trap.

The orthodontist, of course, had the most to offer you and me. He said that his experience was essentially that, once he’d removed his blocks to adult treatment, he found it rewarding in all respects. His adult patients are about 30% male and 70%. female. Of all his starts, adult starts (patients older than 18 and not a part of a phased treatment that started at age 18) are now 31% of his practice. He began at 11% in 1999. His goal is 40%. He is currently promoting male, adult orthodontics in order to reach a needy market segment that is under-represented,  usually higher compensated, and thus, better able to pay for orthodontics. The orthodontist believes than the men don’t care as much about health as women do. However, men are observant about other men and will seek advice from another man before he seeks it from a woman or even his wife (right?!) about things like how much braces hurt and how long it will take.  

The orthodontist found that his finished adults were the best missionaries for his practice that he ever had. He suggested that each prospective patient should have a periodontic evaluation if any minor issues presented at the new-patient exam. The more adults he treated, the more he believed that the fee quoted to the adult was not an issue in treatment acceptance.

He found that the new-patient exam was time to determine “if the adult in the new-patient exam” would drive him and his staff crazy during treatment. If the orthodontist or his treatment coordinator was at all leery, he would not start the adult. During the new-patient exam, the orthodontist determined what additional chairtime, beyond his usual adolescent and adult chairtimes, that the prospective adult would require, if any. If, for instance, the patient was an engineer, a schoolteacher (although a schoolteacher would be a great referral source), or someone who needed control in his job, an extra fee may be necessary. These were his sage comments.

His average adult fee is $1,050 more than a comprehensive, nonsurgery, adolescent case. The practice sees adults right along with the adolescents and encourages parents to experience orthodontics simultaneously with their children, which is a great bonding (again no pun intended) experience to share for a lifetime. During the Thanksgiving/Christmas season, the practice offers an “adult start” promotion tied to the concept of a Christmas gift.

The orthodontist maintains that after the practice accounted for the difference in TLC and clinical care necessary for an adult, that adolescent and adult cases can be treated in a way that served the needs of each patient. He also has grown to love the “adult” relationship he shares with his adults and finds their public visibility to be special in a way that adolescent orthodontic patients are not. He rewards referring past patients with a nice dinner for two, a dozen roses, or another elegant “thank you for the referral” remembrance.

Final Thoughts
In my years of experience in orthodontic activities of several types, through education in selling skills courses and in education in negotiation seminars, I’m convinced that people purchase products emotionally and back up the purchase logically in most transactions. There is no doubt in my mind. If an adult who needs orthodontics presents in your practice, is “perio-correct,” has the wherewithal to pay your fee, will be a good patient, and, after treatment, will be a good missionary for your practice, then by all means start the case.

Promote your practice as “Orthodontics for Adults and Adolescents.” Joan or John Doe is not as informed as you’d think about all orthodontists being qualified to treat patients of all ages. If you’re taking a partner or transitioning your practice to a buyer over a few years, use those early years to increase the adult base. It’s a natural! As you walk around in your local mall, you certainly notice the number of adults who need orthodontics. It’s a sad but true fact: Walk around the halls of the next orthodontic meeting you attend and be amazed by the number of orthodontists who need orthodontics.

If you’re not fulfilled in your practice, you need more challenges. Orthodontics is not rocket science and is nowhere near as unpredictable. Burnout is apparent to me in a small segment of veteran, technique-driven (rather than patient-driven), micro-oriented orthodontists who always see the trees and not the forest.  If you want to experience a practice that represents and resembles the real world and will almost promote and perpetuate itself, then increase your adult starts!

William C. Sutton is the principal of Sutton Consulting, Greensboro, NC. He can be reached via e-mail at [email protected].