Introduction: Consumer decision-making in healthcare services, particularly dentistry, is inherently complex due to the intangible nature of services, information asymmetry between patients and providers, and the high levels of dental anxiety and fear of pain. Unlike physical goods, dental services cannot be evaluated before consumption, forcing patients to rely on mental heuristics and emotional responses. Despite existing clinical needs, many patients exhibit negative demand, avoiding necessary treatments due to financial concerns, fear, or prior unpleasant experiences. Behavioral economics and cognitive psychology have demonstrated that individuals are not perfectly rational Homo Economicus; rather, they are susceptible to various cognitive biases, including loss aversion, anchoring, confirmation bias, and availability heuristic. One of the most robust phenomena in this field is the framing effect, where the way a choice is presented (without changing its objective content) significantly alters preferences and decisions. In marketing, option framing has been studied in two primary forms: additive framing (starting with a basic package and adding desired options) and subtractive framing (starting with a full package and removing unwanted options). To explain this internal conflict, dual mental accounting theory proposes that individuals simultaneously activate two mental accounts: consumption pleasure and pain of payment. Within this framework, two key psychological mechanisms emerge: pleasure attenuation – the reduction of expected pleasure due to the salience of costs or negative aspects – and pain buffering – the mitigation of payment distress by focusing on long term benefits or reframing payment as an investment. The present study aimed to (1) examine the direct effect of additive vs. subtractive framing on dental service choice, (2) investigate the mediating roles of pleasure attenuation and pain buffering, and (3) provide managerial insights for dental clinics.

Methods: A scenario based, between subjects quasi experimental design was employed. A convenience sample of 143 actual and potential dental service consumers was randomly assigned to either an additive framing group (starting with a basic package and adding options) or a subtractive framing group (starting with a full package and removing options). Participants were randomly assigned to one of two online questionnaire versions containing identical service content and total price (11,000,000 Tomans) but different framing: additive (start with a 2,000,000 Toman basic package, add optional services) or subtractive (start with the full 11,000,000 Toman package, remove unwanted services). Measurement instruments included validated scales: pleasure attenuation (3 items), pain buffering (3 items), service choice / purchase intention (3 items) from Rick et al. (2008) and Martin & Herrero (2012), all on 7 point Likert scales, and price sensitivity (4 items) from Goldsmith et al. (2003). Manipulation checks and randomization checks (Chi square and independent t tests) confirmed successful experimental manipulation and group equivalence.

Finding: Subtractive framing, compared to additive framing, significantly increased both service choice intention (H1) and pleasure attenuation (H2). Pleasure attenuation negatively predicted service choice (H4) and acted as a significant mediator (H6), revealing an inconsistent suppression effect. Pain buffering was the strongest positive predictor of service choice (H5), but it was not significantly affected by framing (H3) and did not mediate the framing–choice relationship (H7). The final model explained 65% of the variance in service choice.

Conclusions: This study makes several theoretical and practical contributions. First, it extends prospect theory and dual mental accounting to dental services, showing that subtractive framing effectively increases service uptake by leveraging loss aversion. Second, it reveals that pleasure attenuation plays a significant mediating role, but in the opposite direction to the direct effect – an inconsistent suppression effect that deepens our understanding of framing’s underlying mechanisms. Third, although pain buffering was not influenced by framing, it emerged as the strongest positive predictor of service choice, highlighting the importance of focusing on long term benefits and reframing payment as an investment. For practitioners, the findings suggest that dental clinics should strategically use subtractive framing for comprehensive, multi service packages (starting with the full package). To manage the side effect of increased pleasure attenuation, clinics should immediately offer flexible payment options (installments, insurance) and emphasize total value and savings. Crucially, communication strategies should actively activate pain buffering by highlighting long term benefits (e.g., “investment in a lasting smile”, “prevention of future costly procedures”) and training staff to reframe costs as investments in health and quality of life.