“The secret sauce” — more than the golden rule: part 1

Dr. Donald J. Rinchuse starts a discussion on marketing orthodontic practices

Introduction

If you have recently attended an American Association of Orthodontists National Meeting, you may have noticed an enormous attendance at the “practice management” sessions versus the scientific sessions. This is antithetical to what was the situation some years ago when the attendance was highest for the scientific program and rather meager for the practice management program. Attendee orthodontists, particularly the younger ones, are most interested in finding “the secret sauce” to increases profits in orthodontic practice — that is, success in orthodontics measured in the amount of money the practice generates. As we know, all the leading businesses and industries boast of a secret recipe, ingredient, or sauce for the success of a product or business.

Part of the impetus for the interest in profitability in orthodontics is the indebtedness of orthodontic graduates in recent years. The costs of college, dental school, and then orthodontic practice have skyrocketed. This puts added pressure on graduates to make money not only to live, but also to pay back educational loans. Also there has been an increase in “entrepreneurial-ism” in orthodontics, with larger and increased numbers of practices per orthodontist.

Before we discuss “the secret sauce” to profitability in orthodontics, let us consider several elements that affect orthodontics. The reader should be reminded that the American Association of Orthodontists (AAO) has useful marketing information on its website.

History of advertising

The history of dental advertising in the United States in the past 100 years would certainly start with “Painless” Parker (1872-1952). Edgar RR Parker was a flamboyant American street dentist at the turn of the 20th century, who officially changed his name to “Painless” Parker. He practiced in Brooklyn from 1897 until he moved to San Francisco in 1912. He was the “neon light” king of dental advertisement and the “snake oil salesman” of the day. He was thought of as much a showman as a dentist. He was accused of false advertising for claiming his dentistry was painless. The American Dental Association considered him a “menace to the dignity of the profession.” He hired one of PT Barnum’s ex-managers to help him in advertising. He created the Parker Dental Circus, a traveling medicine show with a dental chair on a horse-drawn wagon while a band played. He was reported to have extracted 357 teeth in one day. At one point, he had about 30 West Coast dental offices, employing over 70 dentists and grossing $3 million per year.¹

As a reaction to the outlandish advertising of “Painless” Parker and others, and in order to establish a more professional image of dentistry, the American Dental Association established guidelines for advertising, as did other professional organizations that were having similar problems (e.g., lawyers). This author can remember when he started orthodontic practice in 1976 that the ADA guidelines on advertising were very strict. Signage for a practice could not have lettering more than 2 inches in height, and a new dental graduate, on announcing the opening of his/her practice (at that time most dentists/orthodontists started their own practices), could not include a picture, nor list his/her telephone number.

The legal challenge to uphold advertising

The legal challenge to professional standards on advertising was first initiated by lawyers who believed that the professional organizational standards were illegal, violating the Sherman Antitrust Act and the First Amendment of the U.S. Constitution. Several of the important Supreme Court cases were Goldfarb v. Virginia State Bar (1975) and Bates and O’Steen v. State Bar of Arizona (1977).

The Goldfarb case was not directly related to advertising but to price fixing (i.e., minimum fee schedule) by the Virginia State Bar Association. The Supreme Court in the Goldfarb case held that lawyers engage in “trade or commerce” and were therefore not exempt from the statues of the Sherman Antitrust Act. Therefore, the State Bar could not establish a minimum fee for legal services — i.e., price fixing. This case is important in the sense that it limited the power and authority of professional organizations to establish codes, including a minimum fee for legal services.

The Bates Supreme Court Case of 1977 upheld the right of lawyers to advertise. In the holding, the court ruled that advertising by lawyers was “commercial speech” entitled to protection under the First Amendment. The court held that speech does not escape protection under the First Amendment merely because it “proposes a mundane commercial transaction.” The court went on to say that commercial speech serves significant societal interests in that it informs the public of the availability, nature, and prices of products and services, allowing them to act rationally in a free enterprise system.² So advertising by professionals of any trade is legal as long as it is not false or misleading to members of the general public.

Contextual environment

As we are aware, there are many diverse types of orthodontic practices. There are solo and group private practices, group specialty practices, corporate practices, university, hospital, and military graduate resident practices, and so on. You also have associate orthodontists who are salaried or independent contractors. And there are entrepreneurial orthodontists who have established a host of orthodontic offices. Each type practice has a different mission and goals (Table 1).

There are also the political, social, economic, and professional environments that impact and interface with the various types of orthodontic practices. Further, there is now do-it-yourself (DIY) dentistry and orthodontics, which includes tele-orthodontics (e.g., Smile Direct Club). Patients need not actually go to an orthodontic office to receive treatment. There is also the argument that the historical and traditional orthodontic fixed bracket system is outdated compared with the digitally mastered software technology involved in making clear aligners. Not only is the argument that fixed orthodontics is outdated but also less effective and efficient. This claim is not supported by the evidence. Parenthetically, it was originally thought that through the use of tele-medicine and tele-dentistry, healthcare providers would be able to expand their reach, helping rural patients stay in their communities and avoid traveling long distances for specialized care. In respect to medicine, the tele-medicine with doctor-and-patient telephone calls, video conferencing, and internet diagnosis and treatment recommendations is a far cry from when doctors actually did house calls.

There is also the legal battle in Texas as to determine who is a dental specialist. This decision has always been the prerogative of the American Dental Association, but this is constitutionally a state-to-state determination. It has recently been argued in Texas that dentists who have taken numerous continuing education courses can call themselves specialists without graduating from an ADA-accredited residency program. The argument in Texas also applies to advertising as a specialist in non-ADA-recognized dental specialties such as orofacial pain. The American Association of Orthodontists, as a reaction to the Texas case and other influences, has modified and lessened the restrictions on the scope of orthodontic practice; i.e., orthodontists can now perform some minor dental procedures outside the boundaries of orthodontics proper.

And, there is the issue of more general dentists doing orthodontics — i.e., Invisalign®, Six Month Smiles®, etc. It is argued that non-orthodontists are doing more orthodontics than “real” orthodontists. How will this impact orthodontics now and in the future?

Furthermore, there is now the thinking (mostly unsupported by scientific evidence) that extractions of bicuspids in the maxillary arch, with retraction of the anterior teeth to reduce maxillary protrusion, can cause, or intensify, sleep apnea. There are some dentists who are then bashing orthodontists based on this ideology and disparaging their treatment in the presence of patients. How will this and other developments affect present-day orthodontics?

Considering the current contextual environment of orthodontics, there are pessimists who argue that orthodontics (orthodontists) has seen its better days; and perhaps in the next 10, 20, or so years, there will be little or no need for orthodontic specialists. Conversely, the optimists contend that the demise of orthodontics is predicted every decade or so. This author can remember in the early 1970s, with the arrival of the “straight-wire” appliance, coupled with bonding of brackets (versus banding), it was envisioned that orthodontics would be simplified to the point that non-orthodontic specialists would be able to do orthodontics to the point that there would be no need for a “real orthodontist.” As we know, this did not happen.

Belief in success: positive thinking

Belief is an important ingredient for success in any endeavor. “Whether you think you can or can’t, you’re right.”³ That is, whether it is true or not, it doesn’t really matter because it is likely that the outcome will be as you believe it to be. The philosophy is, If you believe you will be successful, you will be successful. There is an often told story about a businessman who had just won millions of dollars in the lottery and that this would be his last day at work. He did more work and production in this 1 day than he did in a month; he did not have any worries, and believed that with his new found wealth, he could “conquer the world!”

The secret sauce?

There is no real “secret” to the secret sauce for orthodontic success and profitability. The secret sauce is a nebulous concept and is clearly not one factor for all practices. Each practice has its peculiar niche in which a marketing plan can be developed. Some of the factors that practices can highlight are a special technique or appliance (e.g., self-ligating brackets, clear aligners, non-extraction treatments, and early treatments), Sleep Apnea,⁴ TMD, communications, WOW service, website, internal marketing, tele-dentistry, Adult Smile Center,⁵ and so on.

Most, if not all, orthodontists know all the latest and best marketing principles, strategies, and so-called gimmicks. It is more or less a matter of:

1. Researching and determining which of the many marketing strategies aligns best with an orthodontist’s practice.
2. Spending the time, energy, and money to execute the marketing plan.

Why doesn’t every orthodontist execute a marketing plan? Some practices do not have the resources and time to go forward with their chosen plan. It has been said that it takes money to make money; and some practices just can’t afford the money necessary to efficiently market their practices. Many times the reply back to practices/doctors who need to market and say they cannot afford to do it is that they can’t afford not to. And some orthodontists don’t see the benefit in spending the time and money to hire staff and/or a company to do their marketing.

From a consideration of what makes each practice unique leads to development of a mission statement, goals, and objectives (Table 1). Goals and objectives can be long and short term. As mentioned, orthodontists must determine what is unique about their practices that sets them apart from the others. A practice can then develop a brand with a logo and motto. A marketing plan and strategy are necessary to “sell” the strengths of the product that the practice promotes (Table 1).

With the above in mind, there is the belief of some that the keys to success in orthodontics are GENERALLY service and price, with the consideration of the results/outcome of treatment. Let us discuss each one of these, starting with price, and then results, and finally service. (The first two of these (price and results) will be discussed here in Part 1.)

Price

For sure, price (fee) is a consideration for many potential patients/families. Some families believe that all orthodontists and treatments are alike and would not necessarily pay more for treatment from one office versus another. They are the shoppers who search out the lowest price. They rationalize that all orthodontics are similar because even the worst orthodontist by reputation still possesses a dental degree and has had orthodontic training at some level. In addition, many families have considerable debt and have so much money going out, particularly for essential items, that they cannot afford to pay any more money for orthodontics than at all possible.

In many instances, price is not an isolated factor but considered alongside of service and results. The families listen to neighbors or social media reports about a certain practice that provides exceptional service and/or offers a special type of treatment and result. Of course, price is still factored into the equation as to where they will seek orthodontic care (Table 1).

Results

We would like to think that results in orthodontics would in some way encompass precision orthodontics delivered in the most efficient and effective manner. And the degree that orthodontic outcome and results are valued is at times a debatable subject. That is, the issue of results and outcome in orthodontics becomes the eyes through which the results are evaluated; i.e., orthodontist, patient, referring dentist, and so on. Patients may have their focus on what we call the alignment of “the social six.” Their only concern is generally how the upper six front teeth look with little to no concern about occlusion and facial esthetics. How many times have orthodontists been asked by patients, when they are going to get their braces removed, when they have only had their braces on for several months? And, it could be argued that families and patients who pay less for orthodontics may be satisfied, and myopic, to the results; only that “I got a good deal” (Table 1).

The orthodontist, on the other hand, is more concerned about occlusion, smile esthetics, facial esthetics, and so on; the orthodontist is looking for that ABO finish — precision orthodontic treatment delivered in the most efficient means. And there is the referring dentist who is perhaps judging the orthodontic finish based on what he/she learned at his/her latest “Esthetic and Occlusal Institute Course” such as centric relations, functional occlusion, and so on, which in some cases have no evidence-based support.

Related to results and outcomes in orthodontics, a key question is, Does the orthodontist and practice have a measurable quality assurance/performance improvement plan in effect (Table 1)? Certainly, some aspects of the ABO certification process raises awareness of quality in a practice, but this is not, and cannot be, the actual “QA” plan. It could be grading finished cases based upon the ABO Grading System or PAR Index or the like. Or it could entail establishing quantitative and/or qualitative grading metrics in which a standard for excellent, good, and poor finishes are ascertained, and a summary final report is made as to how to maintain or improve the outcome of cases.

Look for the Part 2 of this article in the next issue.