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How Patient Anxiety Reduces

Practice Income: A Model.

· Blog

Our last blog post discussed the importance of appreciating the potential impact dental anxiety can have on a practice's productivity. But to date no economic models have been developed looking at the flow from dental anxiety, through patient behaviour, to practice income. This post outlines a model developed by FEMDA that does just this. It shows that for a 6,000 patient, 3 dentist practice poorly managed anxiety can cost a practice 34% of its potential income.

Research is clear that highly dentally anxious patients are more likely to engage in behaviours that can significantly affecting a dental practice’s productivity. The model described here looks at three patient behaviours that are correlated with a patients’ dental anxiety and will impact a practice’s productivity.

Patient Behaviours That Reduce Practice Productivity

Booking Frequency

There is considerable evidence showing that dentally anxious patients avoid going to the dentist [6,7,9,10,11,12]. In the model described here, it is assumed that patients without dental anxiety visit the dentist between once or twice a year. This level of recall is recommended by NICE [5]. However, for patients with dental anxiety this frequency of booking will be considerably less [3,6,7]. The model assumes that patients with low anxiety go, on average 1.5 times a year. This reflects the fact that some patients will have annual check-ups and others will have 6 monthly check-ups patients with medium dental anxiety go once every 2 years and high dentally anxious patients go to the dentist just once every 3 years. This variable is the annual booking frequency.

Failure to Attend Rate

For patients with dental anxiety, even if an appointment has been made for them there is a likelihood that they will fail to attend or DNA (Did Not Attend). Even in patients without dental anxiety will be a low failure to attend rate. But for patients with dental anxiety the failure to attend rate will be much higher [1].

Treatment Efficiency

Finally, there is evidence to suggest a relationship between productivity and dental anxiety. Most dentists will attest to the reality that dentally anxious patients have high emotional demands and treatment takes much longer once in the chair [15,16,17,18]. For patients without dental anxiety we have assumed that a dentist, on average over a year, delivers 2.5 units of dental anxiety (UDAs) per patient visit. This treatment efficiency is greatly reduced in patients with dental anxiety. We have made reasonable estimates based on some of the qualitative reports by dentists in the literature. On average, it is assumed that for highly dentally anxious patients, a dentist delivers on average, 1.25 UDAs per appointment rather than 2.5.

The Model

The model is based on a single practice covering 6,000 patients and serviced by 3 dentists. For simplicity we have ignored other care givers such as hygienists or therapists. The model looks at productivity over a 12-month period with a total of 260 working days. It is assumed the dentists have 7 weeks annual leave which reduces the available number of working days per dentist to 225.

Productivity is measured by the total number of units of dental activity (UDAs) worked in the year. It is further assumed that a dentist on average delivers 2.5 UDAs during a patient appointment.

The model works by calculating the number of patient appointments booked in the year using a patient’s annual booking frequency. The actual number of appointments attended is then calculated by taking into account the failure to attend rate. Finally, the number of UDA’s generated during an appointment is calculated using the patient’s treatment efficiency rate.

In our model patients fall into one of four categories of anxiety: no anxiety, low anxiety, medium anxiety and high anxiety. The model considers three different scenarios of patient anxiety mix. The first scenario in which no patient has any dental anxiety is termed “Anxiety free”. This unrealistic scenario acts as a control to show what is the maximum possible productivity for our model practice. We have called the second scenario, the “UK average” as it assumes levels of dental anxiety that were revealed in our latest national survey of dental anxiety. In the third scenario we investigate the productivity of a practice where it has taken a proactive approach to managing their patient’s dental anxiety and reduced levels of anxiety compared to the UK average baseline.


Scenario: Anxiety "Free"

In the anxiety free scenario all 6,000 patients book 1.5 appointments a year. As a result, in the anxiety free scenario, a dentist will see 12 patients every working day. However, with a failure to attend rate of 3%, this means the actual number of appointments attended is only 8,730 (compared to the 9,000 booked). The treatment efficiency is assumed to be 100% which means, at an average of 2.5 UDAs per appointment, 21,825 units of dental activity are delivered over the 12 months. Assuming a payment of £25 per UDA then the “Anxiety free” practice generates a yearly income of £545,625.

Scenario: "Average" Anxiety

The “UK average” scenario assumes levels of dental anxiety similar to those revealed in the last Adult Dental Health Survey (ADHS, 2009). The model assumes that 11% of patients have high levels of dental anxiety, another 29% have medium dental anxiety. 28% have low dental anxiety and a third of patients are not dentally anxious at all. The table below shows the levels of anxiety assumed in each of the three scenarios.

Using these averages the model calculates the number of patients in each anxiety group.

Dentally anxious patients are less likely to book appointments. Using the annual booking frequencies across all 6,000 patients, the total number of appointments booked is 5,648 (37% less than in the anxiety free scenario).


In addition to booking less appoints, patients with dental anxiety have a greater probability that they will fail to attend. Using the table of failure to attend rates the number of actual appointments attended is 5,081 (an overall failure to attend rate of 10%).

The productivity of the dental practice is further reduced as dentally anxious patients are more likely to be emotionally taxing and take longer to treat than non-anxious patients. Using the table of treatment efficiencies (See "Patient Behaviours That Reduce Practice Productivity") for each level of dental anxiety we have calculated the number of UDAs delivered in each appointment. The result is that from the 5,081 appointments only 11,436 UDAs were performed (at an average of 2.25 UDAs per appointment).

The total income generated under the UK average scenario was £285,905. This is £259K (48%) less than in the no anxiety scenario.

Scenario: Anxiety "Managed"

By implementing an effective anxiety management programme across the practice it is assumed that overall anxiety levels are reduced, and the patient anxiety mix is changed. See the table above for the change in patient munbers in each group.

This change in patient anxiety mix means that more appointments are booked in the year, 7,149 (an increase over the UK average number of 27%). The overall failure to attend rate is reduced to 8% with the result that the actual number of appointments attended was 6,599, an increase of 30%. Finally, the treatment efficiency was increased by reducing the overall level of anxiety and this meant that 15,325 UDAs were performed at an average of 2.32 UDAs per appointment. Ultimately this increased productivity translates into income of £383,133, an increase of 34% (£97K) on the UK average scenario.


The model described here is the first attempt to quantify the impact that dental anxiety has on a practice’s productivity (as measured in annual UDAs of treatment performed and income generated). The profiles assessed were no anxiety, UK average (or poorly managed anxiety) and well managed anxiety. The model focuses on three patient behaviours correlated to a patient’s dental anxiety: the probability of booking an appointment, the probability of failing to attend a booked appointment and the treatment efficiency.

There is a significant difference between the number of UDAs worked in the “no anxiety” scenario and the “UK average” scenario. As a whole, dental anxiety costs a practice 48% of its potential income. The “no anxiety” scenario though is unrealistic as anxiety about treatment amongst a patient population will never be entirely eradicated.

However dentists should not assume that suffering the economic cost of dental anxiety is a must. In the model’s “well managed” scenario, the improvement in dental anxiety assumed is relatively conservative and certainly achievable by employing a few key behavioural and psychological interventions. By better management of patients’ anxiety, the model estimates that a practice can achieve productivity gains of 30% and more. For most practices, an increase of 30% productivity, would add £100,000’s to their income streams. Although the model presented here is relevant for NHS dentists (with use of UDAs as a metric of activity), it is likely that the financial impact for private practices will be even greater.

Practically, it is entirely feasible today to offer all patients in a practice a non-pharmacological dental anxiety pathway. Dental practices can adapt their procedures, environments and communication to produce the most anxiety reducing environments. Furthermore, modern technology means that all patients can be offered help in managing their own dental anxiety. For a low-level investment, a practice can assess all their patients and offer a personalised treatment. As an example of the impact this type of approach can have, a recent study showed that simply by recognising a patient’s anxiety (by asking them to perform an assessment and handing it to the dentist) and providing space for emotional discussion reduced dental anxiety by on average 4 points [19].

The model described here shows that by managing all patients’ anxiety not only will a practice improve its patients’ quality of life but will also significantly improve its own productivity and profitability.

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