Long-Term Retention: What’s Your Plan? by Dr. Blair Feldman

Prohibitive fees could prohibit new business too

by Dr. Blair Feldman

There’s an old joke about two orthodontists who are considering a partnership and they are wrestling with the problems of division of labor and profits. Finally, one says, “Let’s do it this way: I’ll do all the hard work—i.e., straightening the teeth and all that goes with it. You do the easy work and we’ll split the income 50/50.” The other says, “You mean I take care of the problems in retention?!”¹

Orthodontic retention is generally one of the least-considered aspects of treatment; practices typically have a protocol for retention that involves a set of retainers and a set number of visits. Orthodontists expect that patients will do their part to wear the retainers as directed to allow the teeth to stabilize and the periodontal fibers to reorganize. Patients expect that their teeth will stay in the final positions forever. Both the orthodontists’ expectations and those of the patients have areas of misunderstanding, but a well-designed retention program can bring the expectations closer to reality.

Initially, retention is an exciting time for both patients and offices, because it represents the culmination of hard work and the reveal of the final results. In many cases, patients have waited for years to see the results of their efforts.

If we consider retention to be a phase of treatment, and we recommend long-term retention to maintain orthodontic results, then retention is the longest phase of treatment.

The retention phase represents not only the longest portion of treatment but also the largest portion of our overall patient list, because more retention patients are added to this group each day. This large group deserves attention from the practice in terms of fees, replacement options, processes and referral potential of this phase.

Retention plans

In general, there are five categories of retention plans, as shown in the chart below. They range from the traditional plan of replacing retainers as needed up to programs that replace retainers for free forever. Each of the five plans has pros and cons in terms of the benefits to the patients, benefits to the practice, the costs incurred by the patient, staff and doctor time involved, and the ability to leverage this service to stay top of mind with the patient so that they remember their orthodontist and remember to refer family and friends.

It’s important for offices to consider each of these plans in terms of what makes the most sense for each office. These plans should be well detailed and described to the orthodontic team as well as patients in terms of benefits and associated fees.

If we consider, for this article, that retention is long term and it involves clear thermoformed retainers with or without bonded retainers, here are basic descriptions of each of the plans.

Replace as needed: If a retainer is lost or broken, retainers are replaced as needed by the office. This is the traditional plan and the most basic. The average fees are between $200 and $800, although some offices will provide a single replacement at no charge. Patients may ask, “How often should I replace my retainers?” The typical answer for these patients is, “If you lose them or they break, call us to replace them.”

These offices count on patients to wear their retainers as instructed and return to the office at a regular interval for evaluation of the fit of the retainers and the orthodontic results.

Replacing retainers usually involves two appointments: an impression or scan appointment and a delivery appointment.

Retainer insurance: This program is uniquely designed by each office with the goal of lessening the cost of lost or broken retainers. A nominal annual or monthly premium is paid to the office to keep enrollment current. If a replacement retainer is needed, the patient must come into the office for an impression or scan and pay the reduced insurance rate for replacement of the retainers.

The patient benefits from the reduced fee they pay for replacement retainers. The process generally involves two office appointments: an impression or scan appointment and a delivery appointment.

Lifetime retainers: Programs like this acknowledge that retainers are a lifetime commitment and that they should be replaced periodically over time. In general, this program is presented as an additional service at the initial treatment consultation. Fees range between $500 and $800 added to the treatment fee, but they are often spread out over the financing term for the treatment fee as a whole. This fee gives access to free or significantly discounted retainers as long as patients bring in their models, which are given to them at the end of treatment. If the models are lost or broken, an additional fee may be charged.

After the regular required retention appointments, patients in this program may replace their retainers by returning to the office and presenting their orthodontic models. They can then return to the office after the retainers have been fabricated for a fit-and-deliver appointment.

Subscription retainer programs: Can be uniquely created by each office, or an office can partner with programs like Retainer Club. These programs acknowledge that retainers are a lifetime commitment and that regularly replacing them is important to maintain the fit and performance of the retainers. Retainers are replaced at regular intervals and either delivered in office or sent directly to the patient, often at a significantly reduced fee.

Programs like Retainer Club often capitalize on the accuracy of 3D intraoral scanning and 3D printing to create near-perfect replicas of the initial retainers without having to bring the patient back to the office for an impression or a scan. These programs can reduce the number of in-office visits because the orthodontic models are either stored physically or digitally and available for replacement in case a retainer is lost or broken.

Free retainers for life: These programs acknowledge that replacement of retainers can be expensive, which can be objectionable to patients before they start treatment. Offices that use this program will often market this program to prospective patients as a value add to treatment.

In general, offices that use this program will replace retainers whenever the patient requests (frequently there is an annual limit) at no charge. The patient may be required to store their final models and bring them to office when a replacement set is needed.

Consumer perception

How does the patient’s perception of the orthodontic office’s services evolve after treatment is complete and the retention process begins?

At some point in the past decade, orthodontic patients have changed into orthodontic consumers. These consumers are influenced by what they read and see on the internet in terms of information as well as marketing.

Modern orthodontic consumers look at their experiences and results, both during treatment and after treatment, in terms of other consumer experiences they have. Consumers often use Amazon as their benchmark; services should be easy, convenient, affordable and available online, just like that company. They often discuss these opinions online in terms of Amazon reviews as well as Google reviews and Yelp.

Today’s media portrays orthodontic treatment in a very different manner than just a few years ago. If you are to believe the marketing claims of companies that are often referred to as “DIY orthodontics,” patients can manage the bulk of their treatment themselves. They can use the online platform of their choice to order more aligners, order retainers, and report issues and concerns with their treatment.

Therefore, the competition for orthodontic services, including retainers, does not come from DIY companies or other orthodontists. The competition is human nature and convenience. If a process is easy and convenient, a patient will do it. If it’s complicated or cumbersome, let alone painful and expensive, a consumer is unlikely to do it.

This consumer perception ultimately influences how patients value our services both during and after treatment. Orthodontic retention programs are evaluated by consumers in terms of time spent in the office, costs of the retainer services, and ease of use of the program. Each of the programs presented has value to the patient and each program has an associated perception of costs vs. value.

The dangers of not meeting your patient’s needs when they need you:

A pediatric dentist colleague shared this story: During a routine exam, he mentioned to an 11-year-old patient’s mom (we’ll call her “Pam”) that it was time to see the orthodontist. Noting that Pam had already taken her two older children to Dr. Smith, a well-regarded orthodontist in the community, the dentist said, “I’m sure Dr. Smith will take great care of you.”

Pam replied, “We aren’t going back to that office.”

“I’m surprised to hear that!” the dentist said. “Your other two children had amazing results. What happened?”

“We had a really positive experience in that office until our son lost his retainer,” Pam said. “We called to get it replaced and they told me that I would have to bring him in for two appointments and pay $500 to get the retainer replaced. I just gave the doctor $12,000 for my two kids. I’m not paying $500 and pulling him out of school. I’m looking to go somewhere else.”

This orthodontist unknowingly lost two patients and $6,000 of office production due to poor communication and a poorly designed retention plan. His goal of charging a “fair fee” for his retainers actually cost him thousands of dollars in lost production. If we multiply that loss by the tremendous size of our retention patient base, the losses can become extreme.

Conclusion

A clear, convenient and easily understood long-term retention plan is an important part of a professional orthodontic practice. The longer a practice has been in business, the larger the retention phase database of patients will be. Meeting the needs of this group of patients and consumers represents an enormous opportunity—both financially and for new patient referrals. Good programs should provide easy access to retainers at a fee that makes sense in the consumer’s mind. Staying top of mind as the preferred orthodontic practice long after orthodontic treatment has completed is a valuable asset for a thriving and profitable practice.

References
1. Parker, American Journal of Orthodontic and Dentofacial Orthopedics, 1989:95, 505–13