It’s amazing to me that we, as a profession, still don’t consider keeping braces on people beyond estimated treatment time a bad idea. It IS a terrible idea for many, many reasons – mainly because having braces on more than 24 months is BAD FOR PATIENTS’ oral health but also because it means we suck at our job and destroys the trust patients showed us by starting treatment. AN OVERTIME PATIENT IS AN UNHAPPY PATIENT. Unhappy patients degrade your business and will ultimately be the death of it. It is so simple to avoid this issue becoming definitive for our practices but we refuse to acknowledge the problem and deny the root cause.

So the AAO and Gaidge put out these stats based on what AAO members are willing to admit. After several years in a study group that collects practice numbers on members annually I’ve grown a healthy skepticism for self reported stats and I KNOW that there is almost always a wide gulf between what is reported and reality when orthodontists talk about our practices… I don’t believe a word of this report – I especially don’t believe the patients past estimated completion date stats.* An overtime rate of 23.6 percent is ridiculously high and extremely detrimental to any practice but most of the practices I’ve seen are actually in the 30-40 percent range when it comes to overtime patients. Most doctors/offices extend treatment time in their software for patients past estimated date so this hides the real number (and makes us feel better because the red line disappears). But patients know better. They remember what you told them.** The important part to understand and acknowledge here is that we do a terrible job of delivering on our promises even if you believe what I consider to be a gross underestimate of the percentage of overtime patients (the 23.6 percent reported by Gaidge). What if FedEx or UPS had this kind of failure rate? What if any of the vendors you deal with – your lab for example – failed to deliver on time at this rate? You’d be furious and you’d stop using them immediately. Yet we do this to patients every single day, don’t think twice about it and cannot understand why patients are attracted to different, disruptive models. As I’ve said many, many times – orthodontists are like taxi drivers!

Can you not see the issue here? Don’t you understand that this is a MAJOR threat to your practice and your business and your relationship with patients? Overtime patients are death for a practice’s reputation and overhead. You can’t afford either of these millstones tied around your neck! I don’t care much about broken bracket rates as there is no cost to additional appointments unless you are at capacity (and almost no one is) and patients who have a couple broken brackets tend to finish faster because of the extra visits. I also don’t care much about no-show rates other than to point out how few new patients the average practice schedules a month. BUT overtime patients are a huge, huge, huge deal that we, as a profession, must address if we hope to remain viable long term.

After insuring you get enough new patients in the door and that you start enough cases, controlling how many overtime patients you have is the most important thing you can do. If you consciously make a decision to refuse to have overtime patients you’ll work less, make more and, most importantly, have much happier patients. An overtime patient is an unhappy patient. Period. If they haven’t done what needs to be done in 18 or 24 months they won’t do it in 30 or 36 or 42 or 48 months and holding them in braces is just stupid. Ideal is stupid. What we do is Enhancement and the result that patients want is Straighter. PLUS, orthodontists are not perfect! We cannot work miracles and there is no such thing as a perfect case. Get over yourself and deliver the best you can in the time you promised. Your patients will thank you…


*To be clear I don’t blame the AAO or Gaidge for the lack of accuracy I suspect is present – they can only go on the numbers they are given by members.

**Oh, BTW, for those of you who think you’re clever and give a “range of time for case completion” know that patients only focus on the low end while you only focus on the high end so this is a recipe for disaster and increasing the number of patients who perceive they are overtime when you do not. For example, if you say, “We will complete the case in 18-24 months” at the new patient visit, the patient will only hear 18 months and you will only see 24 months so you are setting yourself up for failure. FWIW

*** You should monitor your overtime patients daily in the morning meeting, by running a “patients with a zero balance report” weekly and by doing everything you can to finish patients on time every single day. If you allow patients to run you over on scheduling so it’s crazy at your office after school you’ll never finish cases on time.

Related Reading:

Don’t Piss Momma Off!

How To Tell If A Patient Is Wearing Elastics

Ideal is Dumb

But It’s Not Perfect!

8 thoughts on “AAO/Gaidge Report – We Kinda Suck…

  1. Ben,
    The article’s main point is that patients who are in treatment a long time or overtime tend to not be happy patients….which in turn usually hurts a practice’s profitability. I agree. I disagree however with you discounting (and you’ve done this before) how emergencies and broken brackets aren’t bad for a practice and it’s profitabilty. You think patients like coming in 2-3-4 times extra to get their bracket put back on? They don’t. You might think it doesn’t cost you money and time to fix it (I’ll disagree with that too) but it costs these families money and time…and that most certainly hurts a practice. But I enjoy your articles. You always are provoking conversation about the survival of the specialty…and all of us need to be constantly thinking about that.

  2. Ryan you’re welcome to disagree any time but let’s be clear about your motives – you want to sell 3M APC brackets because that is what you do for a living and you also know that i’ve mentioned many times that if an orthodontist has excess broken brackets – to the point that it’s detrimental to the patient experience – they should switch to APC (I’m considering doing so yet again as we speak). Ryan, 1-3 broken bracket appointments over the course of treatment is not a big deal. How do I know? I’ve practiced for some time, treated tens of thousands of patients and know how to run an office that makes people happy. Also, extra visits cost you nothing in terms of time and money if you are not at capacity – despite what the consensus is among orthodontists and consultants. Think about it, if you have empty chairs and the staff is there then what is the cost? NOTHING. That being said if a practice has so much breakage that patients are getting upset then one must address this issue. I’ll also stand by the fact that in my practice, patients who have a couple broken brackets finish faster than those who do not because I see them a little more often and I am maniacal about advancing treatment every single time I see a patient so this means the “cost” to families is a wash at worst and positive at best because of the earlier finish. Thanks, as always, for your input. I’m sure you’re not the only one who thinks this way and I am always up for a spirited debate.

  3. Solid article. Great thoughts Ben and Ryan. I agree people get pissed if you are not finishing on time or ahead of time and we as a profession strive for perfection while most families are happy with excellence. If patient/family is not happy = less likely to refer other friends and family. My question is the overhead perspective and if a practice is not at capacity and the broken brackets don’t cost you, you are seeing them a little more, what is the difference if you see them for 16 appointments over the course of 20 months vs. 16 appointments over 27 months? It would be the same cost per appointment correct? The closer one comes to being at capacity the more of a negative broken brackets and time over estimated treatment become but if not close to being at capacity, it should not have as strong of an impact IMO.

  4. I’m not totally clear on the question but I’ll give it a shot. According to the industry surveys I’ve seen, 60 plus percent of practices admit to being well below capacity and the average practice admits to being at between 50 and 80 percent of capacity. This means there is a huge amount of unused capacity out there in the average ortho office and thus the “cost per appointment” theory is crap. You cannot think of an orthodontic practice like an accountant, you have to think about it like an economist if you are not at capacity.
    The question about the difference in seeing patients longer or shorter is a good one but from what I’ve seen, finishing in a shorter amount of time is always preferable. You’ll get a lot of traction from word of mouth marketing if you finish quickly and thus more patients and by finishing quickly this gives you more capacity. Part of the theory of my Smiley Face office is that I’ll have the new patient flow to basically get paid twice per chair if I can average 12 month treatment times with a 22-27 monthly payment schedule for most patients. That make sense?

  5. Ok so I think I get the longer treatment question about overhead. The point being that if you have a bunch of overtime patients that you have to treat those are patients who have paid in full yet you still are working on them meaning that a significant number of the patients in your office are not contributing to your revenue but you still have to have days open to see them. Patient days are expensive and the more you have the more your overhead creeps up – if you don’t have new patient starts on these patient days and especially if the active patients you’re treating are not paying you (because they already finished paying).

  6. Thanks for the thoughtful response, Ben. You definitely make some good points.

  7. The other issue with over treatment time patients is the increase in “administrative workload” and this is all based on treatment time. If you do 500 starts per year and the average tx time is 1 year then you have 500 active patients. If the average treatment time is 2 years then you have 1000 active patients. That’s double the amount of patients who call and change appointments and break brackets and don’t brush and have insurance questions,etc, etc. So the longer your treatment times for a given size practice the more administrative work you require. Just another way to think about it.
    Another note on the Gaidge numbers is that the average estimated treatment time is 24 months and the average actual treatment time is 27 months which means on AVERAGE we are always past treatment time in all of the Gaidge offices in North America. I agree with Ben that we, as a profession, can and MUST do better.
    Yes Ben, we kinda suck…

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