The short answer
Google does not place ads by budget alone. Every search runs an auction, and each ad gets an Ad Rank based on six things: your bid, the quality of your ad and landing page, minimum thresholds for each position, how close the competition is, the context of the search (location, device, time, the words used), and the expected impact of your assets such as call buttons and sitelinks. A competitor sits above you when their combination wins for that search. To move up, check auction insights to see who beats you and how often, then make your ads and landing pages a closer match to the search, add the assets that fit, tighten your location and keyword targeting, and raise bids only where the searches bring you patients.
How Google Decides Who Shows First
When a patient searches "emergency dentist" or "dental implants near me", Google runs separate auctions for the ad spots above the results and the spots lower on the page. In each one it calculates an Ad Rank for every eligible ad, first to decide whether the ad can show at all and then to set the order. Google lists six inputs:
- •Your bid. The most you are willing to pay for a click. You often pay less.
- •Ad and landing page quality. How useful and relevant the ad and the page behind it are for that search, measured at the time of the search.
- •Ad Rank thresholds. Minimum scores an ad must reach to show, set higher for the spots above the results.
- •How competitive the auction is. When two ads are close, each has a similar chance at the spot.
- •The context of the search. The words used, where the person is, their device, the time, and what else is on the page.
- •The expected impact of assets. How much extras like a call button, location, or sitelinks are expected to help the ad.
Because context is part of the score, there is no single "position" for your practice. You may be first for one search in one neighborhood and absent for another. That is also why a simple formula like "bid times Quality Score" does not describe how Google ranks ads today. Google also says that on each click you pay only what is needed to clear the threshold and beat the ad ranked just below you, so a well-matched ad can sit higher without paying the most.
What Quality Score Does and Does Not Do
The 1 to 10 Quality Score in your account is a summary, not the thing Google uses in the auction. Google calls it a diagnostic tool, says it is not an input in the ad auction, and says it should not be treated as a performance goal. It is still worth reading, because it breaks down into three ratings compared with other advertisers who showed for the same search over the last 90 days:
- •Expected click-through rate. How likely the ad is to be clicked when shown.
- •Ad relevance. How closely the ad matches the intent of the search.
- •Landing page experience. How relevant and useful the page is to people who click.
Add these columns to your keywords view and start with any rating marked "Below average". That tells you whether the ad, the page, or the keyword choice is the weak link.
Find Out Who Outranks You
Before changing anything, measure. The auction insights report, available for Search campaigns, ad groups, and keywords with enough activity, compares you with the other advertisers in the same auctions:
- •Impression share. How often an ad showed out of the times it was eligible.
- •Overlap rate. How often a competitor's ad showed when yours did.
- •Position above rate. How often their ad sat above yours when both showed.
- •Outranking share. How often you ranked above them, or showed when they did not.
- •Top and absolute top of page rate. How often each ad appeared above the organic results, and how often it was the very first ad.
Next, check whether budget or rank is holding you back. If the campaign status says "Limited by budget", Google is showing your ads less often than it could because the daily budget cannot cover all the eligible traffic. If the campaign is not limited by budget and your impression share is still low, the gap is in ad quality, landing pages, or bids. The fixes are different, so find out which one you have. Note that the auction insights report shows nothing when your impression share is under 10 percent.
Make the Ad and Page Fit the Search
This is where most practices can gain ground without raising bids. Google's quality measures reward ads and pages that match what the person searched for.
- •Group keywords by treatment. Implant searches, aligner searches, and emergency searches each deserve their own ad group, ads, and landing page, so the ad can speak to one need.
- •Say what the patient searched. If the search is about a same-day emergency visit, the headline and the page should both say how to get one.
- •Send clicks to the matching page. An implant ad that lands on a general home page makes the patient hunt. Our landing page guide covers what that page needs.
- •Clean up the search terms report. Add negative keywords for searches you do not want, such as jobs, schools, or treatments you do not offer, so your spend goes to searches you can win.
For headline ideas, see our guide to Google Ads headlines that get clicks.
Use the Assets That Fit Your Practice
Assets, formerly called extensions, add your phone number, address, extra links, and short callouts to the ad. Google counts their expected impact in Ad Rank, they cost nothing to add, and Google suggests using four or more asset types. They only appear when Google predicts they will help and when your Ad Rank is high enough, so adding them is not a guarantee.
- •Location assets connect the ad to your Google Business Profile, showing your address and directions.
- •Call assets add a call button. Schedule them for the hours your front desk answers the phone.
- •Sitelinks point to useful pages such as new patient information, financing, or emergency care.
- •Callouts and structured snippets list true, specific details, for example services offered or languages spoken in the office.
Compete Where Your Patients Are
A competitor may look like they are "always" above you because you are both bidding across a wider area than either of you serves. Target the area your patients actually travel from, by city, ZIP code, or a radius around the office. Google notes that very small targets may make ads show only now and then. Also check the location option: "Presence or Interest" can also reach people outside your area who have shown interest in it, while "Presence" keeps ads to people in your targeted locations, which often fits a practice that patients visit in person.
Ad scheduling lets you choose the days and hours ads run, or adjust bids for specific times, so your budget goes to the hours your office can answer calls and book patients. Most automated bid strategies ignore time and location bid adjustments, so with those, use the schedule itself.
Bids and Budget, Last
Raising bids does push Ad Rank up, and Google says higher positions above the results usually cost more per click because the thresholds there are higher. So spend that money only where it pays back. Use conversion tracking to see which searches lead to calls and booking requests, and put more budget behind those. If the top spot on a broad term brings clicks but no patients, ranking second or third on a specific term is the better deal. Our guide to ads that get clicks but no conversions helps you find out which.
If you would rather have us review the account, our Google Ads management service works with dental and medical practices, or you can contact our team.
Sources
Google updates these pages often, so check them for current wording.
- •Google Ads Help: About Ad Rank
- •Google Ads Help: About Quality Score for Search campaigns
- •Google Ads Help: Actual cost-per-click (CPC)
- •Google Ads Help: Use auction insights to compare performance
- •Google Ads Help: About impression share
- •Google Ads Help: About assets
- •Google Ads Help: Target ads to geographic locations
- •Google Ads Help: About the search terms report
- •Google Ads Help: About ad scheduling
- •Google Ads Help: Fix "Limited by budget"
Frequently Asked Questions
Is my competitor just outbidding me?
Maybe, but not necessarily. Google ranks ads by Ad Rank, which combines the bid with the quality of the ad and landing page, minimum thresholds, how close the auction is, the context of the search, and the expected impact of assets. A competitor with a lower bid can still sit above you if their ad and page are a better fit for the search.
Does a higher Quality Score push my ad up?
Not directly. Google says Quality Score is a diagnostic tool and is not an input in the ad auction. What counts is the ad quality Google measures at the moment of each search. The Quality Score columns are still useful, because a 'Below average' rating on expected CTR, ad relevance, or landing page experience shows where your ad or page is weak.
How do I see which competitors outrank me?
Open the auction insights report for a Search campaign, ad group, or keyword. It shows each competitor's impression share, how often their ad showed alongside yours (overlap rate), how often they ranked above you (position above rate), and how often each ad appeared at the top of the page. Google does not show insights when your impression share is below 10 percent.
Will adding sitelinks and call assets move my ad higher?
Assets can help, because Google estimates their expected impact when it calculates Ad Rank. They are free to add, but they only show when Google predicts they will improve the ad and when your Ad Rank is high enough. Add the ones that fit your practice, such as location, call, sitelink, and callout assets, and keep them accurate.
Should I just raise my budget to match theirs?
Look at why you are missing impressions first. If the campaign shows 'Limited by budget', more budget can help it show more often. Budget does not raise Ad Rank, though, so if you are losing position rather than running out of money, improve the ad, the landing page, or the bid on the searches that bring you patients.
Why do I never see my own ad when I search?
Ads do not win every auction, and if your targeting does not include the place you are searching from, you will not see the ad at all. Google points advertisers to the Ad Preview and Diagnosis tool for checking an ad, and to the top and absolute top metrics for seeing where ads appear across real searches.