Managing the pre-orthodontic patients: Is your recall/observation program working properly?


Managing the pre-orthodontic patients: Is your recall/observation program working properly?


By Dr. Robert Haeger

We spend countless hours trying to get new patients to call our offices, and that is hugely important to the success of an orthodontic practice. But equally important is what happens after the patients come in for their initial appointments. The TC conversion rate monitors the patients that you recommend for treatment, but how you manage the patients put in your recall/observation program (these terms will be used interchangeably throughout this article) is vitally important to the profitability of your practice.

Patient starts come from only three sources: exams, the recall/observation pool and prior declines. Based on data collected from practices across the country, the top 20% of most profitable practices get 40% – 41% of their starts from their observation pools. The bottom 80% of profitable offices only get 24% – 30% of starts from their observation pool (see Figure 1). Figures 1 – 3 draw on data collected from orthodontic offices across the country and analyzed by Truenortho, a company offering benchmarking and practice management resources. (The top 20% of orthodontic offices make twice the profits of the bottom 80%, so it is worth paying attention to what they are doing.)

The percentage of starts that come from your recall pools varies dramatically based on the makeup of your practice. Practices where >18% of starts come from adults only see 27% – 28% of their starts from recall. However, high child practices see 45% – 47% of starts from observation patients (Figure 2). Based on this fact alone, you will see that a high adult practice needs to have a much higher number of exams to produce the same number of starts. With the change in patient populations over the past several years, you may notice that your number of adult exams has increased. Many offices have maintained the same level of exams and have wondered why their production has decreased. Adults have a lower conversion rate and result in your pre-treatment observation pool slowly decreasing in size. The compounding impact of putting fewer patients into observation and the lower adult start rates explains why some practices are seeing decreased production.

Similarly, practices that recommend a high number of Phase I treatments for their patients show lower starts coming from their observations pools. Figure 3’s 2014 data illustrate this trend. While 2013 data shows higher percentages of starts from recall coming from high Phase I practices, I have not been able to duplicate this finding in any other year. The better way to assess conversion of Phase I patients into Phase II is to calculate the percentage of active Phase I/Phase II patients in your practice. If 85% of your Phase I patients progress into Phase II, and your Phase I treatment is limited to less than a year, then the ratio of active Phase II patients/Phase I patients should be greater than 1. In looking at practices across the country, several have ratios of less than 1. These practices never realize the lost production from not adequately following up after Phase I.

Looking at every recall/observation appointment from my office between 2005 and 2016 shows interesting trends that will help improve your recall program. Figure 4 shows the percentage of observation patients who started treatment compared to initial exams during this same time period. As you can see, the start percentage for observation patients was approximately 10% higher than exams. The data was divided into two time periods in order to get independent samples from the same office. Because I start relatively few Phase I starts each year, the management of my observation patients is essential to my practice’s success.

Now that I have identified the importance of the observation patients, let’s look a little deeper at the data for actionable metrics. Knowing the start percentage is nice, but understanding the decline percentage is actually more significant, because many observation patient visits end up with another recall appointment months later. How does the decline ratio change from the first through fifth subsequent recall appointments? Figure 5 shows that the decline ratio is relatively low once you get the patients to follow up in your observation program. The number of patients who actually say “no thanks” to your recommended treatment is only 0% – 3% for recall appointments 1 – 4, but it is just above 6% on the 5th recall appointment. I am not sure why the number doubles at the 5th observation appointment.

We now know that observation patients are a great source of starts, and at really high percentages. The next logical question is, how to make sure these patients show up for their follow-up appointments? The best way to find out is to study no show percentages for patients (this includes no response to our follow-up attempts).

Let’s first look at no show percentages for recall appointments 1 – 5. Figure 6 depicts the no show percentages dropping with subsequent follow-up appointments. In other words, the first recall appointment is the most significant, because once the patients make it to their first observation visit, their no show rates continue to drop. In fact, the no show rate for the fourth observation is less than 4%. Couple that with the fact that only 0% – 3% decline treatment during this same time period, and you will see that observation patients are very important to a successful practice.

There are many ways to manage your observation pool, from running a “Kid’s Club” to scheduling appointments when patients leave the office. This article will not examine the success or failure of specific observation programs, but will rather speak to high-level tactics that should be incorporated into all recall programs. Ask yourself some questions about the logistics of your observation program. Are there any months that have lower no show rates? And is there an ideal interval for observation visits?

Because no show rates deminish after the first successful follow-up appointment, the most effective way to study the optimal months is to look only at no show rates for the first recall appointment (Figure 7). Again, in an effort to divide my practice data into two data sets, Figure 7 includes all patients from 2005 – 2009 and 2010 – 2016. Based on the data from Figure 7, I would try to schedule as many first observation appointments as possible in June, July, October or November. My second choice would be January or February. Once the patients show up for their first observation appointment, then I would not be concerned about what month to schedule the visits. (This makes sense when you think about how busy families with children are in August, September and December.)

The final area of investigation is the interval for the first recall appointment. Figure 8 shows the no show rate for first recall appointments increasing as the interval increases from 6 months up to 24 months. I would disregard the 18 month no show rate for years 2010 – 2016 due to a small sample size.


  1. The most profitable orthodontic practices get 40% – 41% of their starts from their observation pool.
  2. Practices with higher percentages of adults or Phase I starts are more dependent on initial exams for starts.
  3. The first recall appointment is by far the most significant.
  4. Start your follow-up interval with new observation patients at 6 – 9 months and progress to longer intervals for subsequent visits.
  5. If the patient is due for their first follow-up in August or September, try to make the visit in June, July, October or November.