Which ads started cases?

Orthodontics runs on free consultations, which means marketing is optimized for something the practice gives away. Conversion from consultation to started case varies enormously between channels, and nothing in a cost-per-lead report reveals it.

Ranking by started case value shows which channel produces families who proceed. It routinely turns out that the cheapest consultation source converts worst, and that a more expensive channel is the profitable one.

Direct-to-consumer aligner brands trained patients to shop and compare before booking, which lengthened the decision and increased the number of consultations that go nowhere.

That makes attributing on started cases more important, not less. The consultation count went up; the thing worth measuring did not change.

A case starts with a signed contract worth $5,600 and is paid over twenty-four months. The practice therefore holds two entirely honest numbers for that patient: the contract value on the start date, and a stream of installments stretching into the year after next. Both are in the practice-management system, both are used internally for different purposes, and choosing between them changes which channel appears to be winning by a margin large enough to move a budget. Neither number is more honest than the other; they are answers to different questions, and the practice has usually never been asked which question it is trying to settle.

For marketing, the contract value on the start date is the better instrument. It lands close to the decision the advert influenced, it is complete rather than partial, and it lets a campaign be judged within a quarter instead of two years later. Installment-based reporting has the opposite property: every month's ranking is dominated by cases started long ago, so a campaign switched on in March barely registers until the following year, which is far too late for the decision it was supposed to inform.

There is a caveat worth stating plainly, because it is where this goes wrong. Contract value is what was agreed, not what was collected, and practices with meaningful write-offs or defaults will overstate every channel by roughly the same proportion. If that proportion differs by source — and with heavily financed cases it sometimes does — the honest approach is a second import built from collections, compared against the first. Running both once a year costs an afternoon and settles the question for that practice rather than in general.

Interceptive treatment and recall create a lag no advertising system was designed for. A seven-year-old is seen, nothing is started, and the family is placed on observation. Three years later the same family returns and a full case begins. The inquiry that produced them happened before the child had adult teeth, and any measurement built on sessions, cookies or platform-reported conversions lost that thread within ninety days. The advert gets credited with a free consultation and nothing else, forever. Meanwhile the family has been in the practice's system the whole time, under the same phone number, which is the detail that makes the case recoverable.

Matching on the patient rather than the session means the eventual case credits the original inquiry whenever it lands, provided both rows are in the files you upload. That is what makes a historical review worth running here: a practice can upload three years of starts against three years of inquiries and finally see what the observation pipeline was actually worth, without having had anything installed at the time. The records exist because they were kept for billing and scheduling, not for marketing.

Phase I and Phase II cases are the clearest example, and they are best handled by the date range rather than by a column. A source producing a great many early-phase patients is building a pipeline that will convert slowly and predictably, and a source producing adult comprehensive cases is producing revenue this quarter; run over a range long enough to include the second phase, the early-phase source is credited with both. A treatment-phase column would make the split explicit, but what somebody was treated for is health information and stays out of the export. Funding the two from a short-range ranking treats a deposit on the future as though it were cash today, which is how practices end up disappointed by the channel that was quietly doing the long work.

In most practices the general dentists down the road send more cases than any advertising account does, and the relationship is managed on instinct: lunches, a newsletter, a rough sense of who has gone quiet. The referrals are recorded — the front desk asks and writes it down — but that record has never been joined to what those referrals were worth, so a practice knows who sends volume and has no idea who sends cases that start. The two facts sit in the same building and in different files, and joining them has never been anybody's job.

The join is the same one. List each referring practice as a source in the inquiry file and it is ranked alongside Google and Meta on started case value, with the count beside it so a total carried by one large case is obvious. The ranking by value may look nothing like the ranking by volume a practice had in its head, and that at least one relationship everybody assumed was strong is sending observation patients and second opinions.

It changes what the marketing budget is for. If three referrers produce a third of the started value, the argument for another few thousand on search is weaker than the argument for someone spending a day a week on those relationships and the twenty practices near them. Nothing about that conclusion is available from an advertising dashboard, because the advertising dashboard can only rank the things it sells, and the referral network is the part of the practice it cannot see.