A woman in her thirties has wanted to fix her smile since high school. One evening she searches for Invisalign, sees an ad that promises $1,000 off and taps it. The page that opens is the practice's home page: a smiling teenager, a paragraph about the doctor's philosophy, a menu with eleven items, and no mention of Invisalign above the fold, let alone $1,000 off. She scrolls for a few seconds, wonders whether the offer exists, and goes back to the search results.
The practice paid for that click. It will pay for the next one too, and Google noticed the mismatch.
This chapter covers how Google decides whose ad shows and in what position, and why the cheapest improvement most orthodontic accounts can make has nothing to do with the bid. Our examples come from 12 orthodontic practices we found running Search ads in one example market, Detroit, described as patterns rather than by name. Your market's practices will differ. The fix won't.
Google Grades the Ad and the Page Every Time It Runs an Auction. Quality Score Is Only the Report Card.
A parent types "braces near me" and, in the fraction of a second before the results appear, every orthodontist bidding on that phrase is entered into a sealed auction. The winner of the top spot isn't simply the highest bidder. Position goes by a score Google calls Ad Rank. Google names six ingredients. The money you're willing to pay is one. How good your ad and its page look for this exact search, right now, is another. There's a floor every ad must clear to appear at all, and the strength of the other orthodontists bidding matters. So does who is searching and from where, on what device, at what hour. Last comes a guess at the lift from add-ons: a tap-to-call button, sitelinks to the braces and aligner pages.
You'll also see a number from 1 to 10 next to each keyword, called Quality Score. Practices love to obsess over that number. Google is unusually blunt that it isn't: the score itself plays no part in deciding who wins. It's a diagnostic, a report card that summarizes three grades.
The click forecast. In Google's terms, expected clickthrough rate. Think of it as the odds that a parent scanning the results picks your braces ad over the three around it. Google strips your page position and your add-ons out of that measurement, which means you can't buy a better grade by bidding your way to the top.
The topic match. Google labels it ad relevance: an aligner search should meet an ad about aligners, not one about the practice in general.
The page grade. Google labels it landing page experience: once the parent or adult arrives, does the page give them what the ad promised, quickly, on a phone?
Google doesn't publish an equation that turns those grades into a price, and some agencies quote one anyway. Ignore it. One idea on Google's Ad Rank help page is worth taping to the monitor: the better the ad, the less each click tends to cost. That's enough to act on.
The grades are easy to find once you know where to look. In the keyword table, add the Quality Score columns, and each keyword shows its 1-to-10 score plus a status for each of the three parts: above average, average or below average. Each status measures you against the orthodontists and dentists who showed up for that same search across roughly the last three months, which is why a brand-new account shows little until clicks accumulate. Read them as a map, not a scoreboard. A keyword with below-average ad relevance is telling you the ad group holds searches its ad doesn't speak to. Below-average landing page experience points at the page. Below-average expected clickthrough rate usually means the ad isn't the most compelling answer to that search, and the next section and Chapter 8 deal with that.
Ad Relevance Is the Lever a Practice Controls Most: One Treatment per Ad Group, One Page per Ad Group.
Ad relevance is the grade most within reach. It takes an afternoon with the account's structure, not a website rebuild. It comes down to how the account is organized.
A Google Ads campaign is divided into ad groups, and each ad group holds a set of keywords and the ads that show for them. Put "braces," "invisalign," "palate expander" and "retainer replacement" in one ad group and its ad has to speak to all four at once, which means it speaks clearly to none of them. Split them into tight groups of five or six closely related keywords and each ad can say exactly what was searched.
For a typical orthodontic practice that means a handful of treatment ad groups:
- Braces: traditional and ceramic braces searches, with the ad naming braces and the page about braces.
- Invisalign and clear aligners: the aligner searches, landing on the aligner page.
- Children and early treatment: pediatric and Phase 1 searches, landing on the page written for parents.
- Adults: searches like "braces for adults," landing on a page that talks to grown-ups about discretion, time and cost.
- Palate expanders: a narrow group for a narrow search.
- Retainers: replacements and follow-up care, if the practice wants those patients.
The good news from our example market: every one of the 12 practices we checked already has an Invisalign or aligner page on its site. The pages exist. The problem is where the ads send people.
Five Orthodontists Advertised $750 or $1,000 Off. Their Own Sites Never Mentioned It.
Among the 12 practices, five ran Search ads with a dollar-off offer: $750 off braces or Invisalign, $1,000 off comprehensive treatment, $1,000 off Invisalign with an end date. We went to each practice's website and looked for the offer. None of the five showed it anywhere we could find. A sixth practice had the opposite problem: a $1,000-off offer on its own site that none of its current ads mentioned.
From the patient's side, this is the moment from the start of the chapter. She clicked because of the offer. The page doesn't confirm it. Maybe the offer lives on a landing page we couldn't see; maybe it's expired; maybe the front desk honors it if asked. She doesn't know, and she isn't going to call to find out. Some will, of course, but each one who hits Back instead is a click the practice paid for and a signal to Google that the page didn't answer the search.
Offers carry rules of their own, from Google's pricing policy to federal and state rules on "free" and on monthly payments. Chapter 14 covers those. The fix here is simpler: an offer in an ad gets repeated, in the same words, near the top of the page the ad opens. If it can't be on the page, it shouldn't be in the ad.
A Landing Page That Returns 404 Is the Most Expensive Page an Orthodontist Can Buy.
The offer problem has a worse cousin. Two practices in our sample sent their ads to landing pages on a separate subdomain, and every one of those pages returned "page not found" each way we tried to load it, including as a phone would. Two of those ads were still showing on the day we checked. We couldn't click a live ad ourselves, so it's possible a real click behaves differently, but from every angle we could test, paid clicks were landing on an error page.
Three more practices had display paths in their ads, the readable part of the address shown under the headline, that led to "page not found" when typed directly. Display paths don't have to be real pages, so that's a smaller issue, but it's usually a sign of ad copy written for a site that has since changed. And one group sent all 15 of its current ads to its home page, whatever the ad said.
Nothing in the ad itself looks wrong, which is why this kind of break can run for weeks. The fix takes ten minutes a month: open every ad's final URL on a phone and look at what loads. An error page or a page that contradicts its ad gets repaired, or the ad gets paused, before lunch.
A Treatment Page Earns the Click With Three Things: the Treatment's Name, the Offer, and a Way to Book.
A landing page doesn't need to be clever. It needs to continue the conversation the ad started.
The treatment's name, the way the ad said it. If the ad says Invisalign, the page's main headline says Invisalign. If the ad says braces for adults, the page talks to adults. The person should know within a second that they landed in the right place.
The same offer, in the same words. If the ad promised a free consultation or a dollar amount off, the page repeats it near the top, with whatever conditions apply.
A way to book, without hunting. A phone number that dials when tapped and a booking button, both visible without scrolling on a phone. If the booking happens on a scheduler hosted elsewhere, the tracking from Chapter 1 has to follow the visitor there.
Then check the speed. Google's free PageSpeed Insights tool grades how fast a page loads on a phone and what's slowing it down. A page that takes too long to appear loses some visitors before they ever see the headline, and those visitors cost exactly as much as the ones who stay.
None of this is decoration. The top of the page is where most of the tapping happens, and the order up there is set by Ad Rank. A practice with tight ad groups and pages that match them can win those positions without being the highest bidder in the room.
An orthodontist who would rather have the ad groups and pages lined up for them can see what our Google Ads management covers.
Next: Keyword Planner Read a Dental Group's Site as a Dentist's. Chapter 5 Seeds It With Orthodontists Instead.
The ad groups need keywords, and where you get them matters. Chapter 3 worked out what a booked exam is worth. Chapter 5 shows how to build the keyword list from other orthodontists' sites, which ideas to keep, and which ones quietly belong to a general dentist.
This chapter is part of Google Ads for Orthodontists, our sixteen-chapter guide for orthodontic practices anywhere in the US.
