Orthodontic Practice US January/February 2019 Vol 10 No 1 by MedMark, LLC

3Shape TRIOS Orthodontics 3Shape 3Shape TRIOS TRIOS Orthodontics Orthodontics

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January/February 2019 – Vol 10 No 1 • orthopracticeus.com Let’s change dentistry together Let’s change dentistry together

Dr. Laurance Jerrold

Principles of informed consent

Dr. Bruce H. Seidberg Contact reseller regarding availability of 3Shape products in your region Contact youryour reseller regarding availability of 3Shape products in your region

Engaging wires, engaging employees: part 2

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EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Bradford N. Edgren, DDS, MS, FACD Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-inchief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

© FMC 2019. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Orthodontic Practice US or the publisher.

new year often brings upon reflection of the previous year’s experiences, successes, and challenges while also stimulating our minds to generate fresh ideas. As professionals, business owners, and highly motivated individuals, we naturally seek to better ourselves and those around us by leveraging past experiences and knowledge. The challenge in taking on new ideas is in fully understanding the nature and consequence of the change, sound implementation of the process, and securing acceptance by others involved. Simon Sinek describes leaders possessing two important qualities in his book, Start with Why: How Great Leaders Inspire Everyone to Take Action. He writes that leaders “must have a vision of a world that does not exist, and they must have the ability to communicate it.” In a budding or thriving practice, there is a continuous flow of needs and opportunities, and those are best captured by us, the orthodontists, who possess both the 30,000-foot and day-today view of operations and function. The development of change intended to improve our results — practice, patient, community, or otherwise – requires comprehension of how the said change can effectively be integrated as well as how it can truly be maximized in impact. Mentally immersing ourselves into that process begins to provide a simulated picture of the journey of implementation. We also would be remiss to not ask our peers (includes orthodontists, team members, family, friends, patients, and community) calculated, thoughtout questions and scenarios about their views on the idea and implementation. Data and correct data interpretation lead to less assumptions and more accurate next steps. The common language that binds us all is empathy. What normal languages of the world cannot bridge can be resolved with a soft smile, a welcoming gesture, or a kind act, for example. This language drives relationships with our patients and community as well as our teams and willing participants joining our lives and professional journeys. What does empathy and language have to do leadership, particularly in our discussion of implementation and acceptance? It has everything to do with pushing an idea forward. Dale Carnegie spoke extensively about relationships and how they drive the business world. Our discussions in the office are better served when they are true dialogues with our team, patients, and community. Involving our peers in our solutions provides several benefits, most notably expanding our own myopia through incorporation of other’s experiences as well as having the change be created by a group of people rather than by one individual. This approach has the ability to galvanize more enthusiasm in addition to readily gaining acceptance. Inspire others by allowing them to inspire you! We will be sure to face unanticipated hurdles along our journey, and when the vision is unique and untested, even small failures can result in loss of trust among the team. Resilience and re-centering becomes a key focus in reestablishing that faith and belief in questionable moments. You alone, the visionary, know that by unequivocally rising again and pushing forward, success will emerge at some point with the greater good as the beneficiary. That success may be in quantifiable or intangible ways — perhaps more money or even just through incremental growth experiences. Through calculated, coordinated, and diligent efforts, however, you can assure yourself that your ideas, implementation, and larger acceptance will be heard, realized, and earned. In our family, we always say “believing is seeing.” Believe in your ideas and the orthodontic profession’s future. With a heart full of love, hands of compassionate care, and an unparalleled vision, forge ahead relentlessly with grit and hustle — and of course, empathy. Bring to life your dreams and the dreams of others while also realizing that rarely do we journey alone, so embrace the amazing and wonderful people around you. When you reach your ultimate goal, you will then have many people around you with which to celebrate. One love to all and to all a peaceful and incredible 2019 — make it the best year you’ve ever had! “Be the change that you wish to see in the world.” — Mahatma Gandhi Dr. Shalin Raj Shah

Shalin Raj Shah, DMD, MS, received his Certificate of Orthodontics and Masters of Science in Oral Biology from the University of Pennsylvania and is a Diplomate of the American Board of Orthodontics. He is also a graduate of the University of Pennsylvania College of Arts and Sciences and School of Dental Medicine. Currently, Dr. Shah is in private practice (Center for Orthodontic Excellence) in Princeton Junction, New Jersey, and Philadelphia, Pennsylvania. You can contact Dr. Shah by email at drshah@coesmiles.com, or visit his website: www.coesmiles.com.

ISSN number 2372-8396

Volume 10 Number 1

Orthodontic practice 1

INTRODUCTION

Jan/Feb 2019 - Volume 10 Number 1

Leadership – paving new paths and inspiring others in 2019 and beyond

TABLE OF CONTENTS

Clinical

CEREC Ortho software — where do you send your scans? The powerful software used in CEREC for orthodontic applications is used widely for Invisalign®, but there are several other uses that can easily be accessed. Dr. Patrik Zachrisson looks at some of the other recipients that you can incorporate in your digital workflow

Research Magnitude of monthly pubertal mandibular growth in untreated Class II teens, and the relationship between upper and lower incisor movements and horizontal versus vertical expression of chin growth Drs. James E. Eckhart and Thikriat Al-Jewair quantify how much the mandibles of untreated pubertal boys and girls grow per month and show how certain growth of the chin is related to how the incisors change positions during that growth.............16

Continuing education Principles of informed consent

Technique 12 Expedited space closure Dr. Donald J. Rinchuse discusses various solutions for maintaining a timely debonding

2 Orthodontic practice

Dr. Bruce H. Seidberg discusses the consensual relationship between patient and doctor and how to document the patient’s understanding of the proposed treatment............... 28

Volume 10 Number 1

Clinically Proven. Clinician Controlled. New SureSmile® Aligner • Ceph registered to 3D model and smile photo supports more biologically achievable outcomes that enable shorter, efficient treatment times. • Treatment plans are digitally designed with ABO® graded finish*. • Open platform accepts all STL files. Cloud based with 24/7 access.

Discover our redesigned website today at www.suresmile.com *SureSmile automated quality scoring methods were designed and implemented in accordance with ABO Calibration Kit. ABO is not a registered trademark of Dentsply Sirona; no endorsement is implied. © 2018 Dentsply Sirona Orthodontics. All Rights Reserved. Dentsply International Raintree Essix | 7290 26th Court East, Sarasota, FL 34243

TABLE OF CONTENTS

Product profiles The SLX™ Clear Aligner System — Clearly Different Let the Carriere Motion 3D Class II Appliance do the heavy lifting for you! ....................................................... 38

EverSmile. The Orthodontic Accessory Company. ....................................................... 39

Continuing education

When the patient breaches the doctor-patient contract

Dr. Laurance Jerrold discusses how to terminate a contract with a patient

Employee engagement Engaging wires, engaging employees: how employee engagement in the orthodontic office is tied to productivity and profit — part 2 Manon D. Newell, JD, explores ways to implement employee engagement in the orthodontic environment............ 40

Marketing Connecting is the key: Digital technology can help orthodontic practices grow Scott Hansen discusses how to effectively engage with patients....... 44

PUBLISHER | Lisa Moler Email: lmoler@medmarkmedia.com

Marketing momentum Important factors to millennials that you should consider promoting on social media — part 2 Marketing consultant Julie Yeomans discusses how to reach out to a growing market or prospective patients......... 46

EDITOR IN CHIEF | Mali Schantz-Feld, MA Email: mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkmedia.com VP, SALES & BUSINESS DEVEL. | Mark Finkelstein Email: mark@medmarkmedia.com NATIONAL ACCOUNT MANAGER | Celeste Scarfi-Tellez Email: celeste@medmarkmedia.com CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkmedia.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkmedia.com

Stay Connected Between Issues Sign up for our E-newsletter at orthopracticeus.com Like us on Facebook at facebook.com/OrthodonticPracticeUS Watch our DocTalk Dental videos at doctalkdental.com Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

4 Orthodontic practice

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Volume 10 Number 1

Your expertise. Our technology. A powerful combination. It takes insight and skilled hands to turn technology into a powerful tool. When you use the Invisalign® system and an iTero® scanner to create amazing smiles, that’s exactly what you do. With more than 6 million* cases and counting, the mission is clear: Let’s do amazing things together. Learn more at Invisalign.com/partner.

Scott Runnels, DMD, PA Destin, FL

CLINICAL

he use of an intraoral scanner allows a fast and easy way for you and your staff to accurately obtain patient data; it improves turnaround times for the planning setup plan and allows the patient to avoid uncomfortable impressions. Further benefits are showing the high-tech equipment in your surgery, being very precise, and reducing the need for costly impression materials. More and more dentists are waking up to the digital revolution, and patients are starting to expect it too. The implementation of CEREC in your workflow is usually straightforward and, using the CEREC Omnicam, the digital models are directly available and therefore ready for use for planning as well as for discussion with the patient. For orthodontic scans on CEREC, the add-on software CEREC Ortho by Dentsply Sirona is needed if you want to send to Invisalign®, but there are several other uses too. It is worth noting that some labs accept scans sent directly with CEREC Connect. The CEREC Ortho software differs greatly from the conventional scan you get when using CEREC Premium software 4.5, CEREC Connect, or CEREC software 4.6, in that you have to follow a strict pattern in order to get a detailed model. It is easy to learn, with tones and arrows and symbols guiding you through the correct pattern, and can be delegated to a suitable assistant. Invisalign claims that the guided-scan pattern has resulted in far fewer rejections of scans and greater accuracy Patrik Zachrisson, LEG TDL, KI, CertDentImp, FICOI, is a partner of Wensleydale Dental Practice. He graduated as a dental surgeon from the Karolinska Institute in Stockholm, Sweden, in 1996 and has worked in Britain ever since. He is founding partner of the Digital Dental Academy, vice president of the International Digital Dental Academy, and module leader of the Digital Dentistry MSc course at CoLDS. He has been accredited a Platinum provider for Invisalign® orthodontics. Dr. Zachrisson has also earned a fellowship status in the International Congress of Oral Implantologists (ICOI). He has become a key opinion leader with CEREC by Dentsply Sirona, a leader in digital dental technologies. In addition, Dr. Zachrisson won Highly Commended for Dentist of the Year at Dental Awards 2018.

6 Orthodontic practice

Figure 1: CEREC Ortho choices of pre-installed recipients

while still being faster than two-phase silicone impressions. When scanning, you have two windows displayed: one showing a live video picture and the other a guide showing where to scan as a live progress. Once the scan is done, the digital color 3D model is trimmed by defining the borders, and then any inconsistent areas can be rescanned to create a good “watertight” model. Both jaws are scanned, and then the bite is registered bilaterally to ensure that the full-arch alignment is correct. When the models are completed, you can also easily add a model base, which is useful if you are using the scan for other applications. When starting a CEREC Ortho scan, you have a number of pre-installed recipients available. The imminent introduction of the new CEREC 1.3 will provide a significant upgrade from previous versions and is expected to include an automatic treatment simulation of the situation to further enhance the consent process and improved case acceptance.

But where does the scan go … ? • Sirona Connect Portal: Contact your chosen dental laboratories • Invisalign: Clear aligners • MTM® Clear Aligner: Clear aligners • Ideal Smile® Aligner: Clear aligners and Eclipse lingual appliances • ClearCorrect: Clear aligners • DW Lingual Systems: Lingual appliances • 3M Incognito™: Lingual appliances • Dolphin 3D: Case administration and practice management • OnyxCeph™: Software for digital case planning and imaging • Stratasys: 3D printed models • SICAT: SICAT Function, SICAT Air, surgical guides and implant planning • CA® Digital: Clear aligners, digital setups, bonding trays, retainers. After acquisition and creation of the model, you have to select a laboratory to send your scan to. Specially tailored Volume 10 Number 1

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to delivering the highest quality, most advanced care possible. Here at Boyd, expert craftsmen like Conner, Hanh, and Brandon not only respect that kind of dedication, but they practice it themselves. Every day, in our US-based factory, our team creates the highest quality dental equipment and furnishings, using only the ﬁnest materials while adhering to the most demanding manufacturing standards: our own.

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CLINICAL

Figure 2: Guided scanning acquisition

Figure 4: Eclipse lingual fixed brace

interfaces are pre-installed recipients that allow easy transfer of data from the clinic. The recipients vary a little depending on which version of software you are using. Most clinicians use mainly Invisalign and Sirona Connect Portal, but there are a number of other applications too. The now familiar clear aligner Invisalign treatment is based on a scan or impression that is sent to Invisalign, and a treatment plan done on their web portal. These will then be combined in the lab, and a treatment plan for the clear aligners is set up and delivered in the ClinCheck® software by Invisalign. Invisalign currently accepts only digital intraoral scans from CEREC, 3Shape, and iTero® in Europe. The CEREC Ortho is needed if you are submitting Invisalign cases from a scan in CEREC to Invisalign to ensure highest accuracy and reduce the number of rejected scans. Sirona Connect Portal is used for uploading your digital impressions (scans) to 8 Orthodontic practice

Figure 3: Verification of bilateral bite registration

Figure 5: Memotain® fixed lingual wire from CA Digital

one of the over 2,000 laboratories of choice, and you can easily add your own favorite labs, and see what services they accept. I often use the CEREC Ortho scan if I need greater accuracy in a full-arch situation. A benefit is the improved bite registration that is achieved with a bilateral bite. For milled TMJ appliances such as a Tanner appliance, the bite registration is particularly useful and can be sent directly through SironaConnect Portal. MTM Clear Aligners are custom-made clear aligners by Dentsply Sirona. MTM is using an “open pathway” architecture and integrated “force points” rather than attachments to allow teeth to move easily and naturally into the desired position. Dentsply Sirona also makes the similar Ideal Smile clear aligner. For a fixed alternative, Dentsply Sirona makes the Eclipse lingual for planning and positioning of small, smooth, fixed lingual brackets. Further lingual options are DW Lingual with its flat design and an arch wire

Figure 6: Milled Tanner appliance on a 3D-printed model made using CEREC Ortho

bent by “computer-assisted bending robots” — a spot of trivia that will surely impress patients. The lingual 3M Incognito is designed to allow comfortable, invisible lingual fixed brackets fully customized for each patient for a wide range of cases. The system uses Volume 10 Number 1

Give your patients a better Class II treatment experience. Invisalign ® treatment with mandibular advancement—a clinically proven, more efficient, more patient-friendly choice.* Visit www.invisalign.com/MA to learn more.

*Data on fi le at Align Technology, as of February 2017. Based on the multicenter NA clinical study, which included 9 doctors and total enrollment of 40 patients. 8 of the 9 doctors in the study responded to the survey, answering the question: “How does Invisalign treatment with mandibular advancement feature compare your (doctor) chairside time required for Class II to Class I correction to other similar Class II functional appliances you’ve used in the past (Twin Block, Herbst etc.)?” in a scale of 1-3 with 1 being ‘greater than other treatments’ and 3 being ‘less than other treatments’. Based on the multicenter NA clinical study, which included 9 doctors and total enrollment of 40 patients. 8 of the 9 doctors in the study responded to the survey, answering the question: “In your experience, Invisalign treatment with mandibular advancement feature is more patient-friendly than traditional Class II functional appliances (Twin Block, Herbst etc.).” in an agreement scale of 1-5 with 1 being ‘strongly disagree’ and 5 being ‘strongly agree.’ AD10062 Rev A

CLINICAL

Figure 7: Incognito lingual brace

gold low profile bases that are designed to maximize the efficiency and, at the same time, be almost invisible. ClearCorrect is an easy-to-use, clear aligner system that is more affordable than Invisalign. The system works well; you plan your treatment and get a digital setup, maybe not as slick and with as many options as the Invisalign ClinCheck, but an alternative worth trying. Dolphin 3D is a tool for simply processing digital 3D data such as medical CT scans, cone beam CT scans, MRI, and facial 3D scans. It allows case administration, practice management, analysis, and visualization for easy treatment planning, documentation, and presentation. You can find software for planning surgical guides for implants and order them from the SICAT lab Portal. You can use the SICAT Function for tracking motion of the temporomandibular joint for diagnostics and therapy. Furthermore, it is possible to assess the upper airway space for the appliance-based treatment of sleep apnea using SICAT Air. Stratasys makes some amazing highend 3D printers such as the Objet30 for making quality models and surgical guides and the J700 for production of clear aligners. As purchasing, running, and maintaining printers like these isn’t practical for most of us, it can be useful to send a scan and let labs produce orthodontic and crown/bridge models as well as guides. In orthodontics, we easily end up with a lot of physical models, so digitizing is a great way of keeping precious office space, and then the models can be quickly produced when needed. 10 Orthodontic practice

Figure 8: Invisalign clear ortho appliance

OnyxCeph provides an all-in-one dental imaging software for case-related 3D/2D data, allowing virtual treatment planning for occlusion and jaw alignment, virtual setups, aligner planning, placing virtual brackets and wires, generating transfer and treatment trays, evaluation of treatment progress, and of course, presentation of cases, patient education, and documentation. The final pre-installed recipient is CA Digital, where you can order CA® ClearAligners. It has a clever system where three different material thicknesses are used over a 4-week period to gradually move teeth in a safe and comfortable way. CA also allows the clinician to either order finished aligners or just models if you want to produce the aligners in your practice lab using a thermoforming machine and retain full control over the process and

reduce the cost. CA also makes the beautifully cut Memotain® retainer wires in Nitinol, a shape-memory alloy, to allow very close fit and detailing, accurate positioning, and high durability of a lingual retainer wire.

Conclusion CEREC Ortho is a very versatile software that has many uses apart from the popular Invisalign. It benefits greatly from the bilateral bite registration and the detailed guided scan. It can sometimes be difficult to get a quick scan, but it gets better with some practice. The guided-scan pattern you have to use slows you down but provides a predictable result that is easy to implement in your digital workflow. The pre-installed recipients in the CEREC Ortho software make it easy to connect to some of the big companies as well as your favorite labs using Sirona Connect Portal. OP

REFERENCES 1. Drake CT, McGorray SP, Dolce C, Nair M, Wheeler TT. Orthodontic tooth movement with clear aligners. ISRN Dent. 2012;2012:657973. doi: 10.5402/2012/657973. 2. Gu J, Tang JS, Skulski B, et al. Evaluation of Invisalign treatment effectiveness and efficiency compared with conventional fixed appliances using the Peer Assessment Rating index. Am J Orthod Dentofacial Orthop. 2017;151(2):259-266. 3. Knösel M, Klang E, Helms HJ, Wiechmann D. Lingual orthodontic treatment duration: performance of two different completely customized multi-bracket appliances (Incognito and WIN) in groups with different treatment complexities. Head Face Med. 2014;10:46. 4. Melsen B. Adult Orthodontics. Oxford, UK: Wiley-Blackwell; 2012. 5. Miller KB1, McGorray SP, Womack R, et al. A comparison of treatment impacts between Invisalign aligner and fixed appliance therapy during the first week of treatment. Am J Orthod Dentofacial Orthop. 2007;131(3):302. 6. Naziri E, Schramm A, Wilde F. Accuracy of computer-assisted implant placement with insertion templates. GMS Interdiscip Plast Reconstr Surg DGPW. 2016;13;5:Doc15. doi: 10.3205/iprs000094. 7. Rossini G, Parrini S, Castroflorio T, Deregibus A, Debernardi CL. Efficacy of clear aligners in controlling orthodontic tooth movement: a systematic review. Angle Orthod. 2015;85(5):881-889. 8. Rosvall MD, Fields HW, Ziuchkovski J, Rosenstiel SF, Johnston WM. Attractiveness, acceptability, and value of orthodontic appliances. J Orthod Dentofacial Orthop. 2009;135(3):276.e1-12. 9. Sarment DP, Sukovic P, Clinthorne N. Accuracy of implant placement with a stereolithographic surgical guide. Int J Oral Maxillofac Implants. 2003;18(4):571-577. 10. Wooten C. ClearCorrect: Competing at the cutting edge. The Business Journals. https://www.bizjournals.com/houston/ stories/2009/08/24/smallb1.html. Published August 23, 2009. Accessed December 26, 2018. 11. Zheng M, Liu Z R. Ni Z. Yu. Efficiency, effectiveness and treatment stability of clear aligners: a systematic review and metaanalysis. Orthod Craniofac Res. 2017;20(3):127-133.

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TECHNIQUE

Expedited space closure Dr. Donald J. Rinchuse discusses various solutions for maintaining a timely debonding

lice is here for her 9:00 a.m. “debonding” appointment in operatory number 3. Alice and her mom are so excited that she is finally getting her braces off. The orthodontic assistant comes to Dr. K to inform him that Alice is here, and he needs to check to make sure it is okay to remove her braces. When Dr. K looks into Alice’s mouth, he notices that there is about 1/12 mm of space between her maxillary central incisors (Figure 1A). At Alice’s prior appointment, the orthodontic assistant failed to place a chain elastic and instead placed single tooth O-ring ligature ties.

So now here are two considerations for Dr. K: 1) Should he tell Alice and her mother that the braces will not come off this morning because of the space and re-appoint Alice to come back in 1 week and then place a chain elastic in the upper arch? 2) Is there any way to close the space within 15-20 minutes and still remove Alice’s braces today?

Space closure at debonding As the old saying goes, “when there is a will, there is a way.” And there may be a solution for the conundrum that faces Dr. K. So Dr. K searches into his bag of tricks and finds a technique that has worked well

for him for several cases in the past. The technique is the placement of a double (closed) chain — that is, one chain under (Figure 1B) and then the second chain over the archwire (Figure 1C). In about 15 to 20 minutes, the space is closed (Figure 1D). Some judgment must be made in deciding when the space is too large to close in an expedited manner. I think the threshold is 2 mm. Beyond this limit, the patient should have a single, closed chain placed over the archwire, and then schedule the patient back in 1 to 2 weeks for a final check. If the space is closed, a debond can be performed.

Figure 1A: Space present between the maxillary central incisors at the debonding appointment

Figure 1B: Application of double chain (closed) elastics; this photo shows the chain elastic that is placed under the archwire

Figure 1C: Chain elastic placed over the archwire

Figure 1D: Correction of the maxillary diastema

Donald J. Rinchuse, DMD, MS, MDS, PhD, received his dental degree (DMD) and Master of Science degree (MS) in Pharmacology and Physiology in 1974, a certificate and Master of Dental Science degree (MDS) in orthodontics in 1978, and a PhD in Higher Education in 1985 — all from the University of Pittsburgh. He has been involved in orthodontics for more than 42 years. He is a Diplomate of the American Board of Orthodontics and a manuscript review consultant for several journals including the American Journal of Orthodontics and Dentofacial Orthopedics. He has 130 publications to his credit, which include two books. He has given many lectures and presentations. Dr. Rinchuse is presently in corporate orthodontic practice in Greensburg, Pennsylvania.

12 Orthodontic practice

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TECHNIQUE

Figure 2A: Buttons placed

Figure 2B: Elastic placed

Figure 2C: Ligature wire placed

Space close in retention There are a host of incidents when space opens between the maxillary central incisors when a patient is in retention with no brackets on the teeth. Some of the reasons for “spacing relapse” are poor cooperation in wearing removable retainers, misplaced retainers, broken retainers, and so forth. There is also the situation when a fixed lingual retainer breaks with similar consequences. And at times, the space opening is more or less due to the bite and not totally due to a lack of retainer wear. That is, there is space opening caused by a “Class III edge-to-edge-type” bite or where there is a tooth size discrepancy (Bolton analysis) with relatively smaller maxillary incisors. In both cases, there are undue traumatic bite forces on the maxillary incisors when coming into occlusion (and contact) with the mandibular incisors. In these instances, it is not a simple matter of expedited space closure but a treatment-planning decision that may involve placing brackets on again with “interproximal reduction” of the mandibular incisors, removing a lower incisor, and/or having the family dentist build up (crowns, veneers) the maxillary incisors (centrals, laterals, or all). If the maxillary incisor teeth need to be enlarged via cosmetic dentistry, then the maxillary incisor spacing may need to be “positioned” and orthodontically moved in a way that the cosmetic dentist can most easily enlarge the four maxillary incisor teeth. When the space opening is due to a typical relapse issue, there are several ways to close the space(s). Some are recommended ways; others are possible ways, but not generally recommended. Buttons can be bonded to the mesial of the central incisors (to avoid rotations) and positioned vertically based on the angulation position of the central incisors crowns. If the central incisor crowns are tipped outward, then the buttons should be placed incisally, and vice versa (Figure 2A). Not so highly recommended ways to close maxillary central incisor space 14 Orthodontic practice

Figure 3A: Dental cast with maxillary diastema (cast turned upside-down to make the modification)

Figure 3C: Dental cast showing distal-incisal edges of the maxillary incisors shaved

Figure 3B: Dental cast with blue “block-out” resin between the maxillary central incisors

Figure 3D: Vacuum-formed retainer fabricated after modification of the dental cast

would be to place (lasso) “circle” elastic (Figure 2B) or ligature wire (Figure 2C) around the incisal edges of the central incisors. As known, there is the danger of the elastic or ligature wire migrating gingivally, with dire consequences, if it is not monitored. Patients should never leave the operatory with an elastic or ligature wire in place.

Space closure at debonding or in retention In addition, an impression (or scan) can be made and the dental cast (3D-printed model) modified prior to fabricating a “vacuum-formed retainer” (VFR) (Figures 3A through 3D). The space between the central incisors needs to be blocked out (Figure 3A and 3B) in order to provide space for the maxillary central incisors to be moved mesially, and then the distal incisal edges of the

maxillary central incisors need to be “shaved” in order to induce a mesial-incisal force within the VFR. The same can be done to include the maxillary lateral incisors as the need arises. The VFR is then fabricated over the altered dental cast (Figure 3D) and subsequently delivered to the patient. The patient is re-appointed in a few weeks to evaluate the outcome of treatment.

Summary and conclusions This article provides a number of ways to close maxillary incisor spacing in an expedited manner, but obviously, there are many more ways for expedited space closure. The possibilities are more or less based on the imagination, creativity, and experience of the orthodontist. Readers of this article are encouraged to brainstorm the potentialities for expedited space closure. OP Volume 10 Number 1

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RESEARCH

Magnitude of monthly pubertal mandibular growth in untreated Class II teens, and the relationship between upper and lower incisor movements and horizontal versus vertical expression of chin growth Drs. James E. Eckhart and Thikriat Al-Jewair quantify how much the mandibles of untreated pubertal boys and girls grow per month and show how certain growth of the chin is related to how the incisors change positions during that growth Abstract Objective To quantify how much the mandibles of untreated pubertal boys and girls grow per month and to show that the horizontal and vertical expression of that growth of the chin is related to how the incisors change positions during that growth. Materials and methods Lateral cephalograms from untreated deep-bite Class II boys and girls chosen to be of pubertal age were selected. Films were approximately 2 years apart. The films were fiducialized, and landmarks were drawn on the T1 film and transferred to the T2 film by one experienced investigator. Changes in upper and lower incisor positions and gnathion were measured for both vertical and horizontal components. The average monthly radial movement of gnathion was calculated, and the relation between incisor movements and gnathion horizontal and vertical movement was graphed. James E. Eckhart, DDS, attended dental school at the University of Southern California where he was class president and valedictorian and graduated in 1970. After practicing general dentistry for 2 years, he attended the orthodontic program at University of California at San Francisco and obtained his certificate in orthodontics in 1974. He has practiced orthodontics in Manhattan Beach, California, since 1975. After using the Herbst appliance for some years, Dr. Eckhart, along with Dr. Douglas Toll, started developing the Mandibular Anterior Repositioning Appliance (MARA), and obtained a patent for it in l996. Thikriat Al-Jewair, BDS, MBA, MSc, MS, FRCDC, ABO Dip, is an Associate Professor and the Director of the Advanced Education Program in Orthodontics and Dentofacial Orthopedics at the University of Missouri â&#x20AC;&#x201C; Kansas City. She obtained her MS and a Certificate in Orthodontics from the University at Buffalo. She has also completed a Masters in Dental Public Health from the University of Toronto and a 1-year Certificate program in Clinical Research from Harvard Medical School. Further, she is a Diplomate of the American Board of Orthodontics and a Fellow of the Royal College of Dentists of Canada in both Orthodontics and Dental Public Health.

16 Orthodontic practice

Figure 1: 1) Condyle position before growth. 2) Condyle position after growth, depending on direction of growth (Bjork).7 3) Original pogonion position before growth. 4) New position of pogonion after growth of condyle to position 2. 5) Original mandible position before growth. 6) New mandible position after growth

Results For boys, the average radial monthly movement of gnathion was 0.27 mm/mo. For girls, it was 0.18 mm/mo. The horizontal and vertical movements of the lower incisor were then subtracted from the horizontal and vertical movements of the upper incisor, and that sum was graphed against the ratio of the gnathion horizontal movement vector (or the gnathion vertical movement vector) to the gnathion radial movement vector, and a near-linear relationship was found for both boys and girls. Conclusions The percentage horizontal growth (and vertical growth) changes in gnathion is

related approximately linearly to the sum of horizontal and vertical growth movements of the upper and lower incisors. Pubertal untreated boys grow the chin 50% more than pubertal girls.

Introduction It is common to see articles showing chosen cases of Class II correction in as few as 6 months, documented by photos showing before-and-after buccal occlusion. Occasionally, an article also shows singlecase superimposed head film tracings demonstrating the profile change resulting from the Class II correction. It is much less common to consider the question of how the chin profile of a group of treated persons Volume 10 Number 1

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RESEARCH compared to that of a similar untreated group of persons. We are presenting here information about the normal pubertal chin growth of untreated Class II boys and girls, so that other papers can compare the pubertal chin growth of a group of treated Class II boys and girls to these control groups. Therefore, the teen subjects in this paper are referred to as “controls,” even though they are not compared to a treated group in this paper. It is reported to be possible to increase mandibular growth compared to what would have occurred in untreated controls, using mandibular advancers, provided that the treatment occurs during puberty, and provided that the treatment period be long enough duration,1,2,3,4 but it has not been specifically reported how much the mandible grows per month during puberty in control boys and control girls. We have studied herein one group each of untreated boys and girls to establish gnathion growth information for untreated “controls.” It has been reported that the horizontal/vertical growth repositioning of the chin depends on the amount and direction of condylar growth, the amount and direction of glenoid fossa growth, and other factors that control the rotation of the mandible.5 Few if any papers have discussed the relationship between incisor position changes and horizontal/vertical chin profile changes, in controls or in treated groups. It has been published that the pubertal period averages 30 months, during which the unassisted mandibular growth rate averages 59% higher for boys and 34% higher for girls than the pre-puberty average of 2.4-2.1 mm per year.6 If the optimum time to try to improve horizontal chin projection is during pubertal growth, correctly estimating the timing of the pubertal growth is important. Mellion, et al.’s6 study of untreated pubertal teens (most of whom were not Class II’s), showed that peak mandibular growth in boys averages 4 months later than their peak statural growth, and for girls the peak mandibular growth rate averages 7 months later than their peak statural growth.6 The study showed that

Figure 2: Summary of possible pogonion (Po) growth changes, depending on upper incisor behavior. ★= condylar growth direction, according to Bjork,7 ○ = new pogonion position with no incisal guidance (Po moves to ○), □ = new pogonion position with deep bite incisor guidance (Po moves to □), ∆ = new pogonion position with upper incisors moving down and backward (Po moves to ∆).

boys begin the mandibular growth spurt at an average age 11.9, and girls begin it at an average age 9.5, leading us to conclude that because of the pubertal age differences and the mandibular growth magnitude differences, mixing sexes in selection of control groups and clinical trials should be avoided. Historically, the reason studies have mixed girls with boys may have been the difficulty in finding large enough samples of untreated Class II control girls in the proper age range. This retrospective study aims to quantify how much the mandibles of untreated pubertal boys and girls grow per month, and to show that the horizontal/vertical expression of that growth is related to how the incisors change positions during that growth. As shown in Figures 1 and 2, drawings of the mechanics of mandibular growth7 suggest that the horizontal/vertical

components of gnathion growth depend on how the upper and lower incisors move (in deep bites), because the drawings show that extrusion and retraction of the upper incisor, whether by orthodontic movement within the maxilla or by orthopedic movement of the maxilla, or both, is accompanied by downward vertical rotation and some backward rotation of the chin, and extrusion and protraction orthodontic movement of the lower incisor increases vertical rotation of the growing chin.

Materials and methods This is a retrospective study of a sample of untreated boys and girls obtained from the Michigan and Bolton-Brush growth studies.8 We selected Class II boys and girls but excluded open bites because of our intention to test the relationship of incisor change

Table 1: Beginning ages and film intervals for boys and girls Boys Michigan

10 boys

Beginning age range years

Average beginning age years

Average film interval months

Film interval months range

Girls

13.0-14.2

13.5

25.2

21-39

Michigan

5 girls

Beginning Average age range beginning years age years

Average Film interval film interval months months range

10.9-11.8

19.4

11.2

12-25

Bolton-Brush

14 boys

12.9-13.2

13.0

24.1

22-27

Bolton-Brush

10 girls

9.9-11.3

10.2

32.9

21-36

Both boy groups combined

24 boys

12.9-14.2

13.2

24.6

21-39

Both girl groups combined

15 girls

9.9-11.8

10.6

28.4

12-36

Table 1: There were 24 boys aged 13.2 ± (-.0.3, +1.0) years, measured over 24.6 ± (-3, +15) months. There were 15 girls aged 10.6 ± (-0.7, +1.2) years, measured over 28.4 ± (-16, +8) months. 18 Orthodontic practice

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RESEARCH to horizontal chin change. As shown in Table 1, for 24 boys, the average T1 age was 13.2 years, and the average T2 age was 15.2 years. The average film interval was 24.6 ± 3.6 months, range 21-39 months. For 15 girls, the average T1 age was 10.6 years, and the average T2 age was 12.9 years. The average film interval was 28.4 ± 8.8 months, range 12-38 months. In selecting a method to assess pubertal status, we chose Mellion’s chronological age method. Gabriel, et al.,9 reported poor reliability between observers using the CVM10 method, and Mellion6 reported that the CVM method was the least reliable at predicting pubertal growth spurts. This paper shows distinct results of boys and girls control selections. In both (boys and girls) control groups, the T1 and T2 digital films were fiducialized and corrected for known magnification, per published reports.11 Lines were drawn on the T1 film for SN, S-A, S-U1, S-Gn, palatal plane, and functional occlusal plane (Figure 3A). Also, the incisal tip of L1 was marked, and three dots circumscribed sella. These points were chosen because they are easy midline structures to identify accurately. Although many published studies measured Co-Gn or Ar-Gn to assess mandibular length, we found to be easier to see S-Gn when comparing two films. This method had a small error of overlooking glenoid fossa growth, which we chose to ignore due to its small magnitude and due to the short T1-T2 intervals. Mandibular radius was approximated to be from sella to gnathion for both T1 and T2, wherein only the change in gnathion was examined. Then the T1 lines and dots were grouped, copied and pasted (Figure 3B), and transferred to the T2 film and superimposed on SN at S (Figure 3C). Sometimes the T2 film had to be rotated in PowerPoint so the grouped lines would superimpose correctly on SN, depending on the variation in tip angle of the head between T1 and T2. The T2 A pt, U1, L1, and Gn were then marked and grouped onto the T2 film (Figure 3C). Next, the incisor changes and gnathion change (ΔU1, ΔL1, and ΔGn) were measured in their X and Y distances from the T1 U1, L1, and Gn, using the T1 occlusal plane as the reference X axis (Figures 4A-4C) . The Δ measurements were made by viewing the films at 200% to increase accuracy, and then correcting the tables to 100% in Excel. As shown on the legend for Table 2, we measured the X and Y changes of the upper incisor, the lower incisor, and gnathion, for 20 Orthodontic practice

Figure 3: 3A. T1 film with reference lines and dots, U1 = upper incisor, L1 = lower incisor, Gn = Gnathion, A = A point, S = Sella, N = Nasion. 3B. T1 grouped lines and dots ready to transfer. 3C. T2 film with T1 lines and dots superimposed, and new dots for U1 (upper incisor), L1 (lower incisor), and Gn (gnathion)

Figure 4 (from T1-T2, registered on SN at sella, relative to T1 occlusal plane as the X axis): 4A. Upper incisor changes, how far the upper incisor tip moved forward and downward, T2U1 = Time 2 Upper incisor, T1U1 = Time 1 Upper incisor, ∆U1X = movement of Upper incisor parallel to T1 occlusal plane, ∆U1Y = movement of upper incisor perpendicular to T1 occlusal plane. 4B. Lower incisor changes, how far the lower incisor tip moved forward and downward relative to gnathion, T2L1 = Time 2 Lower incisor, T1L1 = Time 1 Lower incisor, T2L1X = distance of T2 Lower incisor from T2 gnathion parallel to T1 occlusal plane, T1L1X = distance of T1 Lower incisor from T1 gnathion parallel to T1 occlusal plane, T2L1Y = distance ofT2 Lower incisor from T2 gnathion perpendicular to T1 occlusal plane, T1L1Y = distance of T1 Lower incisor from T1 gnathion perpendicular to T1 occlusal plane, Δ (change in) L1X = T2L1X - T1L1X, Δ (change in) L1Y = T2L1Y - T1L1Y. 4C. Gnathion changes, how far gnathion moved forward and downward, T2Gn = Time 2 gnathion, T1Gn = Time 1 gnathion, ∆GnX = change in gnathion from T1-T2, parallel to T1 occlusal plane, ∆GnY = change in gnathion from T1-T2, perpendicular to T1 occlusal plane

24 boys and 15 girls, over a period of a little more than two years.

Results • Note that as shown in Table 3, the lower dentition of the control boys moved backward 0.4 mm in 24.5 months, or -0.02 mm/month. • Average ∆Gn of all control boys = 0.27 mm/month during peak mandibular growth.

• Average ∆GnX of all control boys = 0.17 mm/month. • Average ∆GnY of all control boys = 0.22 mm/month. • The lower dentition of the control girls moved backward 0.8 mm in 28.4 months, or -0.03 mm/month • Average ∆Gn of all control girls = 0.18 mm/ month during peak mandibular growth. • Average of all control girls GnX = 0.12 mm/month. Volume 10 Number 1

RESEARCH Table 2: Changes in upper incisor, lower incisor, and gnathion for boys and girls Control Boys Michigan and Bolton Deep Bites Only #

T1 AGE

∆ U1X

∆ U1Y

∆ U1

∆ L1X

∆ L1Y

∆ L1

∆ GnX

∆ GnY

∆ Gn

∆GnX /∆Gn

∆GnY /∆Gn

∑∆ U1X + ∆ U1Y -∆ L1X -∆ L1Y

826

156

1.8

-7.0

7.3

5.3

6.6

8.5

-2.2

9.7

9.9

-0.2

1.0

-17.2

3219

156

2.5

-2.3

3.3

2.3

3.2

3.9

1.8

6.3

6.6

0.3

1.0

-5.2

2009

158

4.0

-3.7

5.4

0.0

6.2

3.5

8.4

9.1

0.4

0.9

-5.9

3059

157

2.7

-2.3

3.5

1.4

3.8

4.1

2.7

6.3

6.9

0.4

0.9

-4.7

3501

156

4.1

-2.7

4.9

1.8

2.7

3.2

1.4

3.2

3.4

0.4

0.9

-3.2

259

155

1.6

-3.6

3.9

-0.7

1.4

1.5

2.7

5.4

6.0

0.4

0.9

-2.7

2426

156

1.8

-3.2

3.6

-0.7

0.0

0.7

3.6

5.9

6.9

0.5

0.9

-0.7

1204

156

2.3

-2.9

3.7

-2.0

2.0

2.9

5.9

8.6

10.4

0.6

0.8

-0.7

2207

158

0.0

-4.4

4.4

-0.9

-1.8

2.0

2.2

3.1

3.8

0.6

0.8

-1.8

1157

156

4.0

-2.2

4.5

-1.8

3.3

3.7

6.6

9.3

0.7

0.2

3003

156

4.1

-0.9

4.1

0.9

3.6

3.7

5.9

4.5

7.4

0.8

0.6

-1.4

2378

156

4.6

0.0

4.6

-1.8

3.1

3.5

6.2

4.4

7.6

0.8

0.6

3.3

2326

156

4.5

-1.8

4.8

-2.9

0.9

3.1

7.7

4.1

8.7

0.9

0.5

4.7

1167

156

3.1

-2.9

4.2

-1.5

2.2

2.7

12.8

5.7

14.0

0.9

0.4

-0.4

2392

167

0.0

1.5

1.8

2.3

-0.6

4.2

-0.1

1.0

-3.3

7573

168

1.6

-4.7

4.9

-1.2

1.2

1.8

0.0

5.6

0.0

1.0

-3.1

2410

156

1.3

-4.1

4.3

2.5

3.5

4.3

0.6

5.7

0.1

1.0

-8.8

2407

158

2.5

-2.5

3.6

-0.9

3.2

3.3

1.9

6.3

6.6

0.3

1.0

-2.2

2181

161

6.2

-5.6

8.3

-1.9

2.2

2.9

6.2

6.8

9.2

0.7

0.3

1562

170

4.8

0.0

4.8

-1.0

3.2

3.3

5.1

7.2

0.7

2.6

2377

159

5.1

0.0

5.1

-0.6

3.6

6.0

4.8

7.7

0.8

0.6

2.1

2099

161

5.0

-1.2

5.2

-4.1

5.3

6.7

8.3

5.3

9.8

0.8

0.5

2.7

2257

158

3.4

-0.6

3.5

-3.1

1.2

3.3

7.4

1.9

7.7

1.0

0.2

4.7

2595

157

1.9

2.7

0.9

1.3

1.6

3.8

0.0

3.8

1.0

0.0

1.6

Control Girls Michigan and Bolton Deep Bites Only M2437

138

7.6

-4.1

8.6

-1.6

-1.3

2.0

1.6

0.9

1.8

0.9

0.5

6.3

M2817

131

5.7

-1.9

6.0

-1.3

4.7

4.9

3.2

4.5

0.7

0.3

M2406

131

3.8

0.0

3.8

0.0

3.2

0.9

3.3

1.0

0.3

3.8

M2762

131

2.5

-3.8

4.5

-2.2

1.3

2.5

5.7

8.0

0.7

-0.3

M2409

142

0.6

-2.5

2.6

-0.6

0.0

0.6

1.3

1.6

2.0

0.6

0.8

-1.3

B1269

120

3.6

-0.9

3.7

-2.7

0.9

2.8

3.2

2.7

4.1

0.8

0.7

4.5

B2146

120

3.4

-3.2

4.6

-2.7

2.3

3.5

3.8

5.4

0.7

B2259

120

4.1

-5.0

6.4

1.4

-0.5

1.4

2.3

9.0

9.3

0.2

1.0

-1.8

B2440

120

4.1

-2.3

4.6

-0.5

2.3

5.9

4.5

7.4

0.8

0.6

0.0

B2491

120

3.6

-3.6

5.1

-0.9

5.0

3.4

5.9

6.8

0.5

0.9

-4.1

B3232

120

2.3

-3.2

3.9

-0.2

2.7

2.3

5.0

5.4

0.4

0.9

-3.4

B3275

121

1.8

-5.9

6.1

0.5

1.4

2.3

9.5

9.7

0.2

1.0

-5.9

B3381

132

5.0

-0.9

5.0

1.6

3.2

3.5

3.6

1.8

4.0

0.9

0.4

-0.7

B3754

119

1.8

-3.6

4.0

-1.4

0.7

1.5

2.9

4.5

5.4

0.5

0.8

-1.1

B4665

136

4.1

0.0

4.1

-1.4

1.1

1.8

4.5

2.3

5.0

0.9

0.4

4.3

Table 2: Excel sheet of incisor and gnathion changes for control boys and girls Footnotes: # = control patient ID number from Bolton or Michigan T1 AGE = age of patient in months at time point 1 ET = number of months between film 1 and film 2 ∆U1X = change of upper incisor position between films, parallel to T1 occlusal plane, films superimposed on SellaNasion at Sella (SN at S) ∆U1Y = change of upper incisor position between films, perpendicular toT1 occlusal plane, films superimposed on SN at S ∆U1 = vector distance of change of upper incisor tip position between films, films superimposed on SN at S ∆L1X = change of lower incisor distance from its own Gnathion between films, parallel to T1 occlusal plane, superimposed on SN at S

22 Orthodontic practice

∆L1Y = change of lower incisor distance from its own Gnathion between films, perpendicular to T1 occlusal plane, superimposed on SN at S ∆L1 = vector distance of change of lower incisor tip position from its own Gnathion between films, films superimposed on SN at S ∆GnX = change of Gnathion position between films, parallel to T1 occlusal plane, films superimposed on Sella-Nasion at Sella (SN at S) ∆GnY = change of gnathion position between films, perpendicular to T1 occlusal plane, films superimposed on sellanasion at sella (SN at S) ∆Gn = vector distance of change of Gnathion position between films, films superimposed on SN at S ∆GnX/∆Gn = percent of gnathion change between films which is parallel to T1 occlusal plane ∆GnY/∆Gn = percent of gnathion change between films which is perpendicular to T1 occlusal plane ∑ = “the sum of”

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RESEARCH • Average of all control girls GnY = 0.14 mm/month. Note that in controls, the pubertal chin growth has a higher vertical component than horizontal component. For clarity, the Table 3 entries called “AVG ∆U1-∆L1” should more accurately be called “AVG (∆U1X + ∆U1Y ∆L1X - ∆L1Y). For control boys and girls, the sum of the upper incisor X and Y movements, minus the sum of the lower incisor X and Y movements was related linearly to the proportion of chin growth that was horizontal and to the proportion of chin growth that was vertical. For control boys, the Pearson correlation coefficient was r = 0.8262, and the probability factor was p = < 0.00001. The result is significant at p < 0.05. For control girls, the Pearson correlation coefficient was r = 0.8081, and the probability factor was p = 0.000267. The result is significant at p < 0.05. Movements of the upper incisor forward and upward tend to accompany the horizontal expression of growth at gnathion, and movements of the lower incisor downward and backward also appear to accompany the horizontal expression of growth at gnathion. As shown in the Figure 5 graphs, the sum of the upper incisor movements in x and y direction, minus the sum of the

lower incisor movements in x and y direction, is approximately related linearly to the percent of mandibular radial growth which is expressed in the horizontal (x) direction (x being the T1 occlusal plane). Conversely, the same sum of incisor movements is also related linearly to the percent of mandibular radial growth which is expressed in the vertical (y) direction.

Discussion Future authors in studying the effect of mandibular advancers on increasing mandibular radial growth in pubertal teens can assume that pubertal control boys would grow 0.27 mm/mo., and that pubertal control girls would grow 0.18 mm/mo., relative to superimposition on sella. Clinicians hoping to maximize horizontal chin profile

Figure 5: Graphs showing boy and girl controls relation between pubertal growth incisor changes and horizontal chin change and vertical chin change. ∆GnX = growth of gnathion from T1-T2 parallel to T1 occlusal plane. ∆GnY = growth of gnathion from T1-T2 perpendicular to T1 occlusal plane. ∆Gn = overall growth of gnathion. ∆U1X = movement of upper incisor from T1-T2 parallel to T1 occlusal plane. ∆U1Y = movement of upper incisor from T1-T2 perpendicular to T1 occlusal plane, ∆L1X = movement of lower incisor relative to gnathion from T1-T2 parallel to T1 occlusal plane, ∆L1Y = movement of lower incisor relative to gnathion from T1-T2 perpendicular to T1 occlusal plane.

Table 3: Average incisor and gnathion changes for control boys and girls Boys

STD

Girls

STD

AVG AGE MOS

158.5

4.1

RANGE 155>170 mos = 12.9>14.2 yrs MEAN YEARS = 10.6

AVG AGE MOS

126.7

8.0

RANGE 119>142 mos = 9.9>11.8 yrs MEAN YEARS = 13.2

AVG ET MOS

24.5

3.6

RANGE 21>39 mos

AVG ET MOS

28.4

8.8

RANGE 12>38 mos

AVG ∆U1X

3.0

1.6

RANGE +0.0>+6.2 mm

AVG ∆U1X

3.6

1.7

RANGE +0.6>+7.6 mm

AVG ∆U1Y

-2.4

2.1

RANGE -7.0>+1.9 mm

AVG ∆U1Y

-2.7

1.7

RANGE -5.9>+0.0 mm

AVG ∆U1

4.4

1.5

RANGE +0.0>+8.3 mm

AVG ∆U1

4.9

1.4

RANGE +2.6>+8.6 mm

AVG ∆L1X

-0.4

2.1

RANGE -4.1>+5.3 mm

AVG ∆L1X

-0.8

1.3

RANGE -2.7>+1.6 mm

AVG ∆L1Y

2.6

1.9

RANGE -1.8>+6.6 mm

AVG ∆L1Y

1.6

1.8

RANGE -1.3>+5.0 mm

AVG ∆L1

3.4

1.7

RANGE +0.7>+8.5 mm

AVG ∆L1

2.4

1.4

RANGE +0.0>+5.0 mm

AVG ∆GnX

4.1

3.4

RANGE -2.2>+12.8 mm

AVG ∆GnX

3.3

1.3

RANGE +1.3>+5.9 mm

AVG ∆GnY

5.3

2.1

RANGE +0.0>+9.7 mm

AVG ∆GnY

4.1

2.6

RANGE +0.9>+9.5 mm

AVG ∆Gn

6.7

2.4

RANGE +3.4>+14.0 mm

AVG ∆Gn

5.2

2.4

RANGE +1.8>+9.7 mm

AVG ∆GnX/∆Gn

0.6

0.3

RANGE -0.2>+1.0

AVG ∆GnX/∆Gn

0.6

0.2

RANGE +0.2>+1.0

AVG ∆GnY/∆Gn

0.8

0.3

RANGE + 0.0>+1.0

AVG ∆GnY/∆Gn

0.8

0.2

RANGE +0.3>+1.0

AVG ∆U1-∆LI

-1.6

4.7

RANGE -17.2>+4.7 mm

AVG ∆U1-∆LI

0.1

3.4

RANGE -5.9>+6.3 mm

AVG ∆GnX/∆GnY

0.78

AVG ∆GnX/∆GnY

0.80

AVG ∆GnX/mo = 0.17 mm/mo

AVG ∆GnX/mo = 0.12 mm/mo

AVG ∆GnY/mo = 0.22 mm/mo

AVG ∆GnY/mo = 0.14 mm/mo

AVG ∆Gn/mo = 0.27 mm/mo

AVG ∆Gn/mo = 0.18 mm/mo

Footnotes; (see Table 2) 24 Orthodontic practice

Volume 10 Number 1

2017-2019

RESEARCH expression may do well to avoid retracting or extruding upper incisors in deep bite cases. Clinicians hoping to maximize vertical chin profile expression may do well to retract and extrude upper incisors and avoid intruding or retracting lower incisors.

Conclusion • For control boys, the mandibular growth was 0.27 mm/month, and it was 44% horizontal. (∆GnX/(∆GnX + ∆GnY)) • For control girls, the mandibular growth was 0.18 mm/month, and it was 46% horizontal. (∆GnY/(∆GnX + ∆GnY)) • Pubertal untreated boys grow the chin 50% more than pubertal girls. • Because of the large mandibular growth rate difference between pubertal boys and girls, they should not be mixed in studies involving mandibular growth. • The vertical component of untreated

pubertal mandibular growth is larger than the horizontal component. • For both boy and girl pubertal controls with deep-bite Class II’s, the upper incisor forward and upward movements, minus the lower incisor forward and upward movements (sum) was related linearly to the ratio between the horizontal vector of mandibular growth and the radial vector of mandibular growth, and also to the ratio between the vertical vector of mandibular growth and the radial vector. • Incisal guidance seems at least to be related to direction of chin profile expression. The drawings of the mechanics involved suggest the relationship is causative. OP

REFERENCES 1. Freeman DC, McNamara JA Jr, Baccetti T, Franchi L, Fränkel C Long-term treatment effects of the FR-2 appliance of Fränkel. Am J Orthod Dentofacial Orthop. 2009;135(5):570.

2. Rabie AR, She TT, Hägg U. Functional appliance therapy accelerates and enhances condylar growth. Am J Orthod Dentofacial Orthop. 2003;123(1):40-48. 3. Malta LA, Baccetti T, Franchi L, Faltin K Jr, McNamara JA. Long-term dentoskeletal effects induced by bionator therapy. Angle Orthod. 2010;80(1):10-17. 4. Franchi L, Pavoni C, Faltin K Jr, McNamara JA, Cozza P. Long-term skeletal and dental effects and treatment timing for functional appliances in class II malocclusion. Angle Orthod. 2013;83(2):334-340. 5. Buschang PH, Jacob HB. Mandibular rotation revisited: What makes it so important? Semin Orthod. 2014;20(4):299-315. 6. Mellion ZJ, Behrents RE, Johnston LE Jr. The pattern of facial skeletal growth and its relationship to various common indexes of maturation. Am J Orthod Dentofacial Orthop. 2013;143(6):845-854. 7. Björk A. Prediction of mandibular growth rotation. Am J Orthod. 1969;55(6):585-599. 8. AAOF Legacy Collection. http://www.aaoflegacycollection. org/aaof_home.html <incomplete citation> 9. Gabriel DB, Southard KA, Qian F, et al. Cervical vertebrae maturation method: poor reproducibility. Am J Orthod Dentofacial Orthop. 2009;136(4):148. 10. Baccetti T, Franchi L, McNamara JA Jr. The Cervical Vertebrae Maturation (CVM) Method for the Assessment of Optimal Treatment Timing in Dentofacial Orthopedics. Semin Orthod. 2005;11(3):119-129. 11. Scaled Measurements from the AAOF Legacy Collection Images. http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved= 0ahUKEwjTy6TSwJPWAhVp.mMKHdipB3kQFggmM AA&url=http%3A%2F%2Fwww.aaoflegacycollection. org%2FAAOF_Images%2FAAOFScaledMeasurement. pdf&usg=AFQjCNFtiRt9Miz_mtcWDhEJx5mX3DWXfA Accessed December 19, 2018.

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26 Orthodontic practice

Volume 10 Number 1

Largest Orthodontic Business Event in the U.S. October 25-26, 2019 Hilton Anatole Dallas Register now at www.MKS2019.com Use code OPUS to bring your spouse or one team member FREE. Expires 4/30/19

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Progressive and traditional orthodontists meet in a casual, interactive environment to learn from the best doctors in the industry. Meet like-minded peers and listen to speakers who have proven experience in addressing rapid changes in the business of orthodontics. Thousands of doctors and team members have attended MKS over the last five years. Many attend every year because the speakers are new and exciting each year. Learn how successful doctors navigate the rapidly changing orthodontic environment. Learn why some doctors love the “new market”—expanding Smile Direct Club and Invisalign retail efforts— but why the booming adult market could be a trap for practice values. MKS speakers run supersuccessful practices. Learn how and why what they do makes them winners. We guarantee you will take home new, exciting and actionable knowledge.

Don’t Miss the 5th Annual Opening Night Reception on October 24th! “I always learn something new that adds to my bottom line.” - Dr. A, Honolulu (Four-Year Alum) “I wish I hadn’t missed MKS 2017—with 700+ doctors—I think I missed a lot.” - Dr. E, Ohio, (2016 & 2018 Alum) “I like the different speaker line-up every year. The more points of view the better!” - Dr. B. (Four-Year Alum)

CONTINUING EDUCATION

Principles of informed consent Dr. Bruce H. Seidberg discusses the consensual relationship between patient and doctor and how to document the patient’s understanding of the proposed treatment

he principle of informed consent is recognized worldwide. Many states have laws specific to informed consent and how they relate to professional negligence. The bottom line is that there must be a consensual relationship between patient and doctor and an understanding of the proposed treatment by the patient prior to commencing any dental/medical treatment.

Understanding the doctor-patient relationship Before the rationale for informed consent can be realized, it is important to understand what the doctor-patient relationship is and how it evolves. In orthodontics, as in all of the specialties of dentistry, patients are usually referred by another practitioner, after which a doctor-patient relationship must still then be established. It is usually not just with a patient, who is more than likely a minor, but with the parents or guardian as well, collectively referred to as the patient. The referral has purpose, but the orthodontist must be the one who diagnoses and confirms the need for any specific treatment. The orthodontist must first build a bridge of confidence with the patient and the responsible adult, parent, or guardian. Before proceeding to that step, the dentist should have a good understanding of the patients' concerns and understanding of why they were referred and what their desires and expectations are. Let patients talk first and express their concerns before talking about treatments. Bruce H. Seidberg, DDS, MScD, JD, DABE, FCLM, DABLM, FACD, is an Endodontist, practicing in Liverpool, New York. He is a Past President of the NYS Onondaga County Dental Society, Past President of the American College of Legal Medicine, Past Chairman of the NYS Board for Dentistry, and currently Secretary of the American Association of Dental Boards. He lectures about risk management in dentistry and can be reached at bseidbergddsjd@me.com. Disclaimer: The opinions stated in this paper are those of Dr. Seidberg and not of the organizations he has represented. The opinions are not to be construed as legal advice; any informed consent issues that the readers may have should be directed to their own attorney.

28 Orthodontic practice

Educational aims and objectives

This clinical article aims to discuss the consensual relationship between patient and doctor and how to document the patient’s understanding of the proposed treatment.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 33 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • • • • • •

Realize some of the history behind informed consent. Identify the concept of informed consent. Realize the conditions for which informed consent is needed. Identify the elements of informed consent. Recognize the standards for disclosure of information. Realize who can and cannot provide informed consent.

It is generally accepted that when a dentist offers a professional opinion from which it is anticipated that the patient will rely upon and act upon, a doctor-patient relationship is established. The relationship can develop with or without monetary consideration. A doctor and patient enter into a simple contract — the patients hoping that their issues will be treated and cured and the doctor optimistically assuming that he will compensated.1 Doctors are not obligated to treat everyone who seeks treatment. It is only with the doctors’ consent after full disclosure and discussion with the patients and understanding of the patients’ concerns and desires, whether express or implied, that a doctor-patient relationship develops. A doctor can refuse to enter into the relationship if the patient requests a course of treatment, even from among reasonable alternatives that the doctor regards in his/ her professional judgement as inappropriate. By entering into the professional relationship, it is implied that the patient is obligated to follow all instructions, will keep all appointments, and will truthfully answer all administrative and clinical inquiries (Table 1). In turn, the doctor is obligated to exercise his/her knowledge and skill when treating the patient, be truthful as to the diagnosis and treatment proposals, provide a safe and infection-controlled environment, recognize his/her limitations for the scope of proposed treatment, be courteous and treat the patient

Table 1: Implied duties owed by the patient 1. All instructions will be followed. 2. Will not request inappropriate treatment. 3. Appointments will be kept. 4. Fees for services rendered will be paid. 5. Patients will be truthful regarding all valid clinical and administrative inquiries; i.e., medical issues and drugs. 6. Patients will conform to accepted modes of behavior.

Table 2: Implied duties owed to the patient by the doctor 1. Exercise his/her particular talents, knowledge, and skill on behalf of every patient he/she encounters during the course of the day. 2. Recognize his/her limitations and refer to colleagues more capable of treating various situations. 3. Be truthful as to the diagnosis and treatment proposals. 4. Provide a safe and infection-controlled environment. 5. Be courteous and treat the patient with respect. 6. Inform the patients of their needs in a way they can understand.

with respect, and inform the patients in terms that they understand. (Table 2). The issue of informed consent has been misunderstood by many healthcare professionals over the past decades. Yet the issue is increasingly more prevalent in modern-day practices because of inclusion in the litigation Volume 10 Number 1

CONTINUING EDUCATION

arena. The primary cause of malpractice litigation is patient injury or a perceived injury; the secondary cause is lack of consent. To minimize the liability of risk, the doctor must avoid causing the patient to seek legal counsel by implementing proper communication, assuring patient understanding and acceptance of proposed treatments. The Doctrine of Informed Consent is based on a special fiduciary relationship between the doctor and patient — a relationship of trust, confidence, and responsibility.

The importance of informed consent Dentists are required by law to obtain informed consent for any non-emergency treatment or diagnostic procedure. It is the conversation a dentist has with a patient prior to treatment in which options and possible risks of the proposed treatment are explained and discussed. As required by law, the dentist must explain the indicated procedure in understandable terms and the reasons for the procedure. The intensity and importance of the consent has been brought to the forefront of the health provider’s presentations to patients, specifically in the dental and medical professions. Consent has progressed from a trust of the dentist to that of the more sharing of information and understanding by each party. In the past, patients possessed full confidence in treatments provided by doctors who could do no wrong, no questions were asked.2 One of the causations of concerns about the need for consent after developing the doctor-patient relationship is from the patient’s listening to social comments from friends and/or co-workers, unsolicited opinions, and Internet research. Now patients want to know in-depth details because of what their perceived knowledge received from the Internet. These opinions can affect the listening ability and understanding by the patient and cause a more inquisitive and suspicious attitude toward the dental provider and office. Smith3 reviewed current literature from various sources to develop a general sense and understanding of informed consent. He noted that the doctrine of informed consent has significantly influenced relationships among healthcare practitioners and their patients in the past quarter-century. He, too, found an erosion of the paternalistic approach leading to more patient sovereignty and decision-making. Today, the sharing of information approach is a legal necessity because the Volume 10 Number 1

The bottom line is that there must be a consensual relationship between patient and doctor and an understanding of the proposed treatment by the patient prior to commencing any dental/medical treatment.

patient has rights — i.e., the right of freedom from bodily harm, the right to choose treatment, the right to consent to treatment, or the right to refuse treatment. The patient has the right to have the opportunity to ask questions and the right to have them answered. In fact, one might observe that the patient has more rights than the provider. Lawsuits are usually triggered because the patient was surprised and angry about an unexpected result or inconvenience; therefore, it is important for dentists to discuss, prior to care, what is to be expected, and this can then prevent surprises if complications occur.4,5 Providers must interact with the patient, explaining the procedures contemplated with accuracy in terms that the layperson will understand. Patients must be informed of the benefits of the procedure, alternatives, and consequences for alternatives, including no treatment at all and any known risks associated with the procedure. Avoid discussing a list of risks so specific that it can be deemed to exclude risks not mentioned. When in doubt of how specific to be, use the phrase “risks include, but are not limited to, risk A, risk B, or risk C.” In addition, providers must explain the

probable treatment prognosis, alternative treatments, and probable prognosis if the patient refuses to have the procedure done, discuss any foreseeable complications, and allow questions to be asked and completely answered.

The approach to informed consent The approach to informed consent should be formalized to ensure that you consistently cover all the required elements, including but not limited to allocating plenty of time to the informed consent discussion for concerns and questions, not rushing the patient, and using a relaxed approach. The patient should feel no pressure and should have the opportunity to really listen and understand your explanations. Draw pictures to describe the problem and treatment, and maintain them as part of the record. The foundation of modern-day informed consent was established in 1914 by Judge Benjamin Cardozo. In Schloendorff v Society of New York Hospital,6 he stated “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patients' Orthodontic practice 29

CONTINUING EDUCATION consent commits an assault for which he is liable in damages.” In the case of Nathanson v Kline,7 it was stated that “the fundamental distinction between assault and battery on one hand, and negligence such as would constitute malpractice, on the other, is that the former is intentional and the latter is unintentional.” This was one of the first cases to label the lack of informed consent as “professional negligence” instead of “battery.” The seminal case on the matter was that of Canterbury v Spence,8 which expanded the idea that true consent requires an informed exercise of choice and the opportunity to knowledgeably evaluate the available options and attendant risks: “Failure on the part of a health care provider to obtain a patient’s informed consent before treatment constitutes professional negligence, a deviation from the standard of care, and not the intentional tort of assault or battery.” In this case, the concept of informed consent was redefined and established a new standard for information disclosure. Informed consent is now understood to be the ongoing dialogue between patient and healthcare provider in which both parties exchange information, ask questions and come to an agreement on the course of specific dental/ medical treatment.

Standards for disclosure of information There are two standards for disclosure of information. The first is the professional standard of disclosure when a healthcare provider discloses information that another provider of the same profession, acting under the same or similar circumstances, would have disclosed. The second standard is that of a layperson’s standard when a provider discloses information that an ordinary, reasonable patient under the same circumstances would deem necessary in making an informed decision. The consent disclosure process must actively involve both parties. The discussion must occur between the person performing the procedure, who is licensed, and the patient. It cannot be delegated to an assistant or any other office personnel. It primarily concludes when the patient agrees on a specific course of treatment recommended by the provider. Secondarily, it continues throughout treatment changes, continued care, and as unexpected results or findings happen. Similarly, there are two types of informed consent suits. One is the subjective standard suit where an individual patient must establish that he/she would not have undergone 30 Orthodontic practice

Table 3: Elements of consent 1. Date and time of the consent process 2. Diagnosis in layperson's language explaining the problem 3. Nature and purpose of proposed treatment in language understandable by the patient 4. Explanation of risks and consequences 5. Probability of success 6. Feasible alternative treatments 7. Expected prognosis if treatments are not accepted 8. Statement that patient was given the opportunity to ask questions or that the patient’s questions have been answered 9. Signature of patient or legal guardian and a witness 10. Signature of the healthcare provider

Table 4: Documenting informed consent Informed consent should be documented in the chart. The notation in the chart should be initialed by the dentist. When a written consent form is used, the signing should be witnessed by someone other than the dentist. The dentist should observe the signing of the written consent form. The document becomes a permanent part of the patient’s record.

the dental treatment had the non-disclosed information actually been provided; in some jurisdictions, the patient’s viewpoint must be reasonable. The other type is the objective standard when a reasonable or prudent person, in the patient’s position, would have submitted to the dental procedure or course of treatment if suitably informed of the risks. In order to make an intelligent decision, the rule of the “prudent person” prevails. Appropriate communication with the patient will diffuse the unreasonable patient expectations that one may have about the care to be given. A reasonably prudent person is an individual who uses good judgment or common sense in handling practical matters. The actions of a person exercising common sense in a similar situation are the guide in determining whether an individual’s actions were reasonable. The prudent patient standard for assessing whether informed consent was given prior to a procedure is based upon whether the patient received the information about the risks that a reasonably prudent patient would need to consider in making a treatment decision.

Elements of informed consent The elements of informed consent are quite specific (Table 3) having evolved from various court decisions that every healthcare provider must be knowledgeable of, and of their application. First is knowledge. The doctor imparts knowledge to the patient by disclosure of risks and benefits of the

proposed procedure, alternatives to the proposed procedure, or the prognosis if the procedure is not done. Second is autonomy. The patient must have the option to withdraw or refuse treatment. Third is competence. The patient making the decision must be competent to understand the disclosure that was made and be able to intelligently make a decision to go forward or not. The dialogue must take place in layperson's language so that the patient can easily understand it. It should include the nature and purpose of the proposed treatment and the probability of its success. An informed consent form may be given to the patients to read when they are given other office documents to complete. The purpose of giving it to them in advance is to allow them to formulate their concerns to ask during the discussion phase. They should not sign the form until a conversation is complete with the doctor. There should be an area on the consent form that the patient can sign stating that he/ she was given an opportunity to ask questions and have them answered. The provider should also sign and date the document, and a standby witness should sign it too (Table 4). The witness can be either a related or non-related person known to the patient or an assistant to the provider. That statement becomes the only evidence in the record that the critical process of communication between the dentist and the patient took place and that the patient truly understood Volume 10 Number 1

Consent means “willing” and can be understood as either express or implied (Table 5). Express consent is that to which the patient requests the proposed treatment, whereas implied consent is that to which the patient has implied a desire to have the treatment performed. Informed consent is that to which the patient has enough information from which a decision can be made and is then “willing” to proceed or refuse. Only the patient or parent/legal guardian for patients under the age of majority or those patients without capacity can grant valid consent — not a husband for a wife, or vice versa, or an adolescent for aging parents. Exceptions for obtaining consent exist in a limited number of circumstances. There is implied consent when a patient is not lucid, and emergency intervention is required, or if a patient is a danger to themselves or others, or is gravely disabled and emergency care is required. In a conservatorship situation,

Table 5: Types of consent A. Express agreements (those for which the patient requests the proposed treatment): 1. Cannot be violated or will be vulnerable to a lawsuit 2. Patient agrees to acceptance of proposed treatment 3. Includes agreements as per fee for service B. Implied agreements by the provider: 1. Patient has reason to believe that provider is: a. licensed b. employs trained personnel c. keeps up with the changes in the profession C. Implied agreements by the patient: 1. To keep appointments 2. To pay for services promptly 3. To advise provider about changes in medical history Volume 10 Number 1

when a patient is declared legally incompetent by a court, an appointed conservator must be granted specific authority by the court for the patient’s elective healthcare. A patient may designate someone to consent for elective care in the event that the patient loses mental capacity to consent. A formal written document is required. In certain lifethreatening emergencies, a court can override the patient’s right to refuse consent and order the patient to be treated. The parent or legal guardian has the authority to consent for the medical/dental treatment on behalf of a minor. Implied consent may be used if the parent or legal guardian cannot be contacted in an emergency. Certain minors may be emancipated by statute for the purpose of consenting to dental/medical care. Consent, therefore, is an ongoing dialogue between the health provider and the patient in which both parties exchange information, ask questions, and come to an agreement on the course of specific dental/ medical treatments. When the patient agrees on a specific course of treatment, the dialogue has reached its goal; however, the dialogue does not end there. Consent and communication about the process of obtaining consent are not limited to obtaining permission for treatment. It continues throughout the course of treatment and alterations of the course of treatment, during follow-up evaluations, and as unexpected results or procedural mishaps occur. It must occur only between the person who will perform the procedures and the recipient patient, especially for any invasive procedure. Neither partners nor staffs harbor the authority to obtain consent on behalf of the actual operator. The provider has a responsibility to assess each patient and clinical situation and then needs to determine the scope of disclosure. A causal connection exists when disclosure of significant risks incidental to treatment would have resulted in a decision against treatment, when a risk actually materializes. When an undisclosed risk materializes, resulting in injury to the patient, and the patient proves that he/she would not have consented to treatment had the risks been disclosed, it may be deemed that there has been no consent, and legal action can proceed. Patients must be warned about inconveniences that are anticipated or could be anticipated during their treatment. Accurate descriptions allow patients to understand what is actually involved. Unexpected Orthodontic practice 31

CONTINUING EDUCATION

the parameters of the proposed treatment and agreed to it. The dentist who can testify that it is his/her customary and usual practice to orally inform patients of the benefits, alternatives, and risks of a given procedure is in a strong position to refute claims by patients that they did not know what they were signing. Documents do not replace the verbal process of informed consent; they only act to memorialize the process. Whether or not a document is concurrently developed to support the oral discussion depends on the level of risk under which the provider wishes to practice. It is appropriate for the provider to present the facts, follow the elements of the process, and conclude with the patient signing a form acknowledging the process. The purpose of the informed consent form is to provide evidence and memorialize that the informed consent discussion took place.2

CONTINUING EDUCATION Table 6: Emergency treatment without consent In a genuine emergency, a dentist can act without a patient’s consent, but these situations are rare. A genuine emergency exists when the patient is in need of immediate attention, and the attempt to obtain consent would result in a delay of treatment that would substantially increase the risk to the person’s life or health. In an emergency, it is essential to only deal with the emergency and not go beyond that treatment until consent is obtained for any non-emergency treatment.

inconveniences are a common source of dissatisfaction and anger if not disclosed. Inconveniences can include, but are not limited to, effect of drugs, special diets, pain, limited activities, uncomfortable devices, uncomfortable examinations, length of time from start to finish, and the number of potential appointments. Discussing discomfort, annoyances, and inconveniences is a worthwhile activity to abort patient surprises.

Clear communication is imperative Orthodontics and Dentofacial Orthopedics is the dental specialty that includes the diagnosis, prevention, interception and correction of malocclusion, as well as neuromuscular and skeletal abnormalities of the developing or mature orofacial structures. In orthodontics, like any specialty or any phase of dental therapy, a thorough descriptive discussion must be held with the patient. In orthodontics, that includes the goals of the treatment results which cannot and should not be guaranteed, that all complications and consequences cannot be anticipated, and how long it will take to accomplish the results. Explanations should be made relative to potential discomfort during treatment or potential causation for relapse after treatment. The methods of treatment including, but not limited to, extractions, types of “braces,” headgear if necessary, and injury from orthodontic appliances should be discussed as well as potential root resorption, need for endodontic treatment, periodontic treatment, or temporomandibular dysfunction.9 Withholding information has been looked upon by the courts as willful desire on the part of the dentist to deprive patients of their ability for redress. Therefore, there must be a consensual professional relationship prior to the commencement of any treatment. An action alleging a lack of informed consent sounds in negligence10 although some courts have viewed it as technically a battery.11 In a genuine emergency, a dentist can act without a patient’s consent, but these situations are rare. A genuine emergency exists when the patient is in need of immediate attention, and the attempt to obtain 32 Orthodontic practice

consent would result in a delay of treatment that would substantially increase the risk to the person’s life or health. In an emergency, it is essential to deal only with the emergency and not go beyond that treatment until consent is obtained for any non-emergency treatment (Table 6). A patient must prove that a reasonably prudent person, such as the patient, would not have undergone the treatment if fully informed of the benefits, alternatives, and risks and that the lack of informed consent served as the proximate cause for the injury. This means that the failure of the dentist to warn the patient is what proximately causes the injury and could be subject to litigation.

Informed refusal Another concept of informed consent often overlooked is that of informed refusal for recommended treatment (Table 7). A patient can reject care or treatment deemed necessary by signing an informed refusal form. Such a form documents the action of refusal and is placed into the patient’s record for the protection of the dentist. A refusal usually follows the consultation appointment, consent discussions, or prior to the scheduled appointment to begin treatment. It is not advised to undertake treatment with a non-English-speaking patient until there is certainty that the patient has had an understandable and intelligent discussion with about the treatment, its benefits, alternatives, and risks. This may require a foreign language interpreter, and this is required by

Table 7: Informed refusal for recommended treatment A patient can reject care or treatment deemed necessary by signing an informed refusal form. Such a form documents the action of refusal. The form is placed into the patient’s record.

law. A consent form in a patient’s native language is a good idea but cannot substitute for the actual oral informed consent discussion. A deaf patient must give informed consent like any other patient. Law requires you to make appropriate and reasonable accommodations for all disabled patients. This may require you to provide a sign language interpreter. Such services are available at little or no cost from local social services or charitable agencies. The dentist must exercise his/her best judgment as to whether or not the patient has the capacity to fully understand the proposed treatment. An adult patient cannot give informed consent if he/she lacks the mental capacity to do so. It is the legal guardian of the person who is mentally challenged must give informed consent on behalf of the patient. Every individual therefore has the right to expressly consent or refuse consent for healthcare unless one of the legal principles creates an exception to this right. A patient who is properly informed is less likely to launch subsequent litigation over undisclosed risks that manifest. A healthcare provider who has proper documentation memorializing the informed consent discussion is less likely to be involved in a lawsuit proclaiming lack of consent. It is important to remember that informed consent is the conversation with the patient, not the signed form; the signed form is the evidence memorializing the conversation. OP

REFERENCES 1. Hammonds v Aetna Casualty & Surety Company, 243 F Supp 793 (ND Ohio 1965). 2. Seidberg BH. Understanding the legal concept of informed consent. Bulletin Fifth District Dental Society. 2011;56(2):1,4,7. 3. Smith, TJ. Informed consent doctrine in dental practice: a current case review. J Law Ethics Dent. 1988;1(3):159-169. 4. Seidberg BH (DDS, JD). Case Summaries. Mediation Committee. East Syracuse, New York: Onondaga County Dental Society. Personal Files from Dental-Legal Consultant Records. 5. Liability Arising from Consultation, Medical Legal Lessons. ACLM. 2000;1(3). 6. Schloendorff v Society of New York Hospital, 105 NE 92 (NY 1914). 7. Nathanson v Kline, 186 Kan 393, 350 P 2nd 1093 (1960). 8. Canterbury v Spence, 464 F 2d 722 (DC Cir 1972), cert. denied, 409 US 1064 (1974). 9. Drs. Callahan, Flanagan & Smith Orthodontics. Syracuse, New York: personal communications. 10. Oberbreckling PJ. The components of quality dental records. Dent Econ. 1993;83(5):29-30,32,34. 11. Stimson PG, George LA. How to practice defensive dentistry. J Gt Houst Dent Soc. 1990;61(8):11-13.

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Principles of informed consent SEIDBERG

1. The referral has purpose, but the ________ must be the one who diagnoses and confirms the need for any specific treatment. a. orthodontist b. general dentist c. parent d. guardian 2. By entering into the professional relationship, it is implied that the patient ________. a. is obligated to follow all instructions b. will keep all appointments c. will truthfully answer all administrative and clinical inquiries d. all of the above 3. Dentists are required by law to obtain informed consent for any ________. a. non-emergency treatment b. diagnostic procedure c. phone conversation d. both a and b 4. Providers must interact with the patient, explaining the procedures contemplated with accuracy _________. a. using dental terms and jargon

Volume 10 Number 1

b. in terms that the layperson will understand c. but without mentioning any risks d. but without discussing alternatives 5. The foundation of modern-day informed consent was established in 1914 by _____. a. Judge Oliver Wendell Holmes b. Judge William R. Day c. Judge Benjamin Cardozo d. Judge Edward Douglass White 6. The doctor imparts knowledge to the patient by _______. a. disclosure of risks and benefits of the proposed procedure b. alternatives to the proposed procedure c. the prognosis if the procedure is not done d. all of the above 7. The patient must ________ to withdraw or refuse treatment. a. have the option b. not have the option c. not be involved in the ultimate decision of whether d. get an opinion by another person before deciding whether

8. __________ is that to which the patient requests the proposed treatment, whereas implied consent is that to which the patient has implied a desire to have the treatment performed. a. Express consent b. Memorialized consent c. Requested consent d. Process consent 9. In an emergency, it is essential to ________. a. deal only with the emergency b. not go beyond that emergency treatment until consent is obtained for any non-emergency treatment c. to deal with the emergency plus any other non-emergency treatment needed. d. both a and b 10. A patient can reject care or treatment deemed necessary by signing a/an ______ form. a. express consent b. informed refusal c. undisclosed consent d. potential causation

Orthodontic practice 33

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When the patient breaches the doctor-patient contract Dr. Laurance Jerrold discusses how to terminate a contract with a patient

he court’s decision stated: “Any time a doctor undertakes the treatment of a patient, [a] …consensual relationship of physician and patient is established… . [The] doctor and patient enter into a simple contract, the patient hoping that he will be cured, and the doctor optimistically assuming that he will be compensated.”1 Whether we like to admit it or not, the doctor-patient relationship has traditionally been viewed in many respects as a pseudo contract; and like any contract, there are rights and obligations that each party assumes. While doctors owe their patients many obligations, the number of them that our patients owe us is few. This will be discussed in detail later in this article.

Termination of the contractual relationship The contractual relationship of the doctor and the patient can be terminated in five different ways. The first is when the patient is cured. The court in Weiss noted that: “Once a physician has taken charge of a case, that relationship continues until …the medical situation becomes one in which the physician’s services are no longer needed.”2 The second is the death, disability, or incapacity of either party. While death needs no further support or explanation, neither party can reasonably expect the other to continue fulfilling the rights or obligations owed the other if they are suffering from a type of disability that would render that person unable to do so. In Warwick, the court noted that: “Where defendant, …was obliged to leave the vicinity because of his own ill health, but left plaintiff in the charge of Laurance Jerrold, DDS, JD, ABO, is the Chair and Program of Orthodontics and the Director of the Orthodontic residency program at NYU Langone Hospital – Brooklyn. Dr. Jerrold can be reached at 904-710-5125 or laurance.jerrold@nyumc.org Disclaimer: This article is intended to provide general information and is not intended as legal advice. The law and interpretations of the law may change, while each situation is distinct. For legal guidance on specific situations, dentists should consult their attorneys. Nothing in this article is to be construed as defining the standard of care for practitioners.

34 Orthodontic practice

Educational aims and objectives

This clinical article aims to discuss the rights and obligations of the clinician to the patient and how to terminate the contact, if needed.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 37 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • • • • •

Identify the five ways a contract can be terminated. Identify the six legally accepted reasons that practitioners can invoke in order to dismiss patients from their practice. Recognize the certain steps that must be followed if it is determined that the circumstances are appropriate to terminate the doctor-patient relationship. See certain legal cases where patient termination was appropriately and effectively instituted. Realize some obligations of patients to their clinician.

another physician who continued the treatment, it was held that there was no ground for complaint of abandonment … because of the change in doctors.”3 The third means of terminating the doctorpatient relationship is by mutual assent. Usually this takes the form of a patient relocating, usually for job or retirement opportunities. No one seriously expects the professional relationship to continue on a long-distance basis, although on occasion this does occur. An Iowa case noted that: “When a physician takes charge of a case his employment continues until ended by mutual consent … .”4 The fourth reason occurs when the patient desires to unilaterally terminate the relationship by act or statement. This is often seen when the patient becomes disenchanted with the provider, his/her staff, or some aspect of his/her facility. The most common reasons are either the result of a breakdown in communications or a perception on the part of the patient of having been treated improperly in some fashion. It has been noted that “Once a physician has taken charge of a case, that relationship continues until …the physician’s dismissal by the patient… .”5 Finally, we come to the situation where the doctor desires to unilaterally terminate the doctor-patient relationship. This can only occur when the patient has breached one or more of the six obligations patients owe their doctors under the doctor-patient

contract. These “breaches” are the legally accepted reasons that practitioners can use to “void” their contract with the patient and terminate the doctor-patient relationship. While the doctor has the right to do this, he can only proceed provided certain legally established protocols are followed. This was clearly stated in a Michigan case that held: “The physician has a definite right to withdraw from the case provided he gives the patient reasonable notice so as to enable him to secure other medical attendance. Such a withdrawal does not constitute an abandonment.”6

Six legally accepted reasons to dismiss a patient The six legally accepted reasons that practitioners can invoke in order to dismiss patients from their practice are as follows: 1. Patients are not following our instructions to the best of their ability. Our instructions are given to them with the intention of maximizing the results of any ministrations we may render. These instructions are for the benefit of the patient and often, when instructions are not followed, a less than desirable treatment outcome often occurs. This duty crosses all healthcare delivery lines and can be observed by the cardiologist whose patient does not stop smoking; the psychiatrist whose patient does not take their meds; the physical therapist Volume 10 Number 1

2. Scheduled appointments will be kept. Our practices, aside from being businesses, which can suffer in many ways if patient’s schedules are not maintained, serve as sites from which to dispense healthcare related services. Often these services are based on a sequence of timely spaced ministrations. When these appointment intervals are not maintained, treatment can become interfered with, which can lead to any number of minor negative sequelae. On the other hand, if appointments are missed for extended periods of time, very serious problems may result that can jeopardize the health and safety of the patient. If patients breach this obligation owed under the doctor-patient contract and continually miss or cancel and reschedule appointments to the point where it may compromise treatment, the doctor has every right to terminate the doctor-patient relationship in order to once again, both save the patients from themselves and save the doctor from potential exposure to liability. As was noted in the Dashiell decision: “If a patient fails to come to the office of the physician or surgeon whom he employs … and then fails to return to the office for further treatment, and in consequence thereof suffers injury, he is not entitled to maintain an action against the physician, because it is his own default and misfeasance.”8 3. When patients attempt to inappropriately dictate the terms of treatment. Today we have many patients who either believe themselves to be enlightened as a result of internet searches or emboldened through its “power or the pulpit.” Patients today have no problem attempting to dictate the parameters of orthodontic treatment Volume 10 Number 1

The doctor-patient relationship has traditionally been viewed in many respects as a pseudo contract; and like any contract, there are rights and obligations that each party assumes. for themselves or their children. The third reason that doctors can employ as a basis for terminating the doctor-patient contract is when patients attempt to inappropriately dictate the terms of treatment. We all recognize that patients have autonomy in terms of accepting or rejecting recommended treatment. What we also need to recognize is that doctors have the same degree of autonomy regarding their right to provide or refuse to provide inappropriately directed treatment by patients. If the doctor encounters patients who are attempting to inappropriately dictate treatment, the doctor once again has the legal right to terminate the doctor-patient relationship. The court in George noted that: “…the doctor’s conscience and professional oath must also be respected. In the present case the patient voluntarily submitted himself to and insisted upon medical care. Simultaneously he sought to dictate to treating physicians a course of treatment amounting to medical malpractice. To require these doctors to ignore the mandates of their own conscience, even in the name of free religious exercise, cannot be justified under these circumstances. The patient may knowingly decline treatment, but he may not demand mistreatment.”9 4. As previously noted, our healthcare delivery facility operates as a business, and like any other business, it has overhead expenses to meet and is also designed to provide the practitioner with a source of income. While there are any number of healthcare delivery sites that provide free or low-cost care, private practitioners are not obligated to treat patients who cannot pay their fees. “A physician is entitled to protect his ability to generate an income and need not accept a prospective patient who cannot pay the established fee charged all patients.”10 Going further into this area, we can see that: “Abandonment was not established by patient who… sought treatment from physician whose bookkeeper told her she was no longer a patient because she had not paid her bill; [as] …patient was not at critical stage of treatment when physician

terminated his care for her.11 You can never leave a patient “in extremis." This is generally defined as in severe pain, bleeding, swelling, or in any condition where the patient’s health may be jeopardized. Finally, it is clear that it is perfectly permissible to dismiss a patient in mid-treatment who is not paying his/her bill. As was stated in Watkins: “The standard of care “very clearly” requires a dentist to continue to see an orthodontic patient even though there is an outstanding balance on his or her account… until the dentist (1) sends the patient a letter terminating the dentistpatient relationship and (2) provides the patient with an opportunity to find another orthodontist.”12 5. Patients have a duty to be forthcoming, forthright, and truthful regarding valid administrative and clinical inquiries. If patients are lying about aspects of their health history or history of prior treatment it could significantly impact the treatment to be rendered. If they are not honest about their employment, financial, or other aspects of their lives, it could negatively impact on their ability to receive third-party reimbursement and the doctor’s ability to be paid. The healthcare practitioner does not have to accept this behavior, and if this disingenuousness is discovered, it is within the practitioner’s right to choose to terminate the doctor-patient relationship if he so chooses. This was made clear in a Texas case that noted: wherein the court stated, “… a patient has a duty to respond accurately and truthfully to all questions posed to him … .”14 6. The last legally accepted basis for a health care practitioner to unilaterally terminate the doctor-patient relationship is when the patient or legal guardian is unable to conform to accepted modes of behavior when present in the healthcare facility, particularly when the actions of the individual in question are creating an inhospitable or hostile work environment. One court stated that it was clear that the doctor “…had no legal obligation to continue providing dialysis treatment to an unruly and uncooperative patient, where patient was Orthodontic practice 35

CONTINUING EDUCATION

whose patient does not do his/her exercises; the periodontist whose patient doesn’t maintain good oral hygiene practices; and the orthodontist whose patient does not wear his/her elastics, or whatever other instructions we need patients to follow in order to optimize their care and achieve any desired or expected result. If patients breach the obligation to participate in their own care by following reasonable instructions, the doctor has every right to terminate the doctor-patient relationship in order to both save the patients from themselves, and save the doctors from potential exposure to liability. As was noted in Urrutia, “… if a physician is ever justified in withdrawing … it can only be where the patient obstinately refuses to follow the treatment prescribed.”7

CONTINUING EDUCATION given sufficient notice that treatment would be terminated and was provided with a list of other dialysis providers in the area.”14

Providing notice and informing the patient In those cases when you determine it is appropriate under the circumstances to terminate the doctor-patient relationship, certain steps must be followed. The patient

must be provided with notice of your intention. This can occur in many forms such as by telephone, mail, email, etc. What is important regarding this first step is that the practitioner have proof that such notice was given to the patient. Let’s assume this notice took the form of a letter. Proof might be as easy as Return Receipt Requested or by obtaining a Certificate of Mailing. The letter must spell out the reason you are dismissing the patient

Notice of Termination of Care To: ___________________________________________________________________ Patient’s name: _________________________________________________________ Date: _________________________________________________________________ Due to the fact that: q There has been a lack of cooperation in following instructions that has been very detrimental to q your q your child’s dental health, thus compromising our ability to achieve an adequate orthodontic result, q We have not been able to agree on the goals for and/or method of treatment for correction of q your q your child’s particular problem, q We are unable to coordinate appointments and treatment with q you q your child, and after repeated attempts have been unable to do so for some time now, q You have not kept up with your financial obligations to pay for services rendered, q You have not been honest and forthright regarding certain clinical or administrative inquiries, the result of which may be compromising your treatment or our ability to render professional services to q you q your child, q There are significant interpersonal differences and/or problems between you and some members of our clinic staff that has resulted in disharmony and/or disruption of our clinic routine and activities, We must inform you that we are withdrawing from rendering further professional attendance to q you q your child’s orthodontic needs. Since q her q his q your dental condition requires further treatment, we urge that you seek continued care and treatment with another orthodontist without delay. If you wish, we will be available to attend to any orthodontic needs you may have for the next _____ (30, 45, 60) days: (1) on an emergency basis only, (2) to help you with any necessary referrals, or (3) if you need help seeking another doctor. This should give you ample time to select another orthodontist. In the alternative, should you decide to discontinue with your treatment entirely, we will remove your appliances during this time frame. Should you authorize the release of q you q your orthodontic records, we will be happy to forward them to you or the orthodontist of your choice along with any other clinical information concerning the diagnosis and treatment rendered by us. We regret having to take this action but the situation as noted above has left us no other option. If you have any questions please feel free to call us at XXX-XXX-XXXX. Thank you.

by indicating which one(s) of the six duties owed under the terms of the doctor-patient relationship were breached. You also need to inform patients that treatment is not completed, and that you recommend they seek continued care at their earliest convenience; and if they choose not to do so, that they should have their appliances removed. You must let patients know that if they need help in securing substituted care, you will help them obtain it, and that you will be available for consultations and emergency care only during a reasonable period of time within which they are expected to obtain substituted care. Inform patients that you will make their records available to them or any subsequent treating practitioner of their choice, and if patients choose not to pursue further treatment and wish you to remove their appliances, that you will do so. Remember, it is you who wants to terminate the relationship. Do not put any hurdles in the patients’ path to secure substituted care by badmouthing them to potential subsequent treating practitioners or by placing financial burdens such as records duplication fees or an appliance removal fee. While a doctor is also free to relocate his practice for any number of acceptable reasons, he has to do so with the mindset that he is not abandoning the patient. When a doctor plans on relocating, all active mechanics should be removed, the patient placed in passive appliances, and the patient should be informed of the need to seek substituted/continued care at their earliest convenience. The patient needs to be informed that this must occur by the time of projected re-location. Sample dismissal letters are available from many sources. The following is a sample of one that you are free to adapt and adopt as you see fit. OP REFERENCES 1. Hammonds v Aetna Casualty & Surety Company, 243 F Supp 793 (ND Ohio 1965). 2. Weiss v Rojanasathit, 975 SW2d 113 (Mo 1998). 3. Warwick v Bliss, 195 NW 501, App 216 NW 85 (SD 1923). 4. McGulpin v Bessmer, 43 NW2d 121 (Iowa 1950). 5. Glenn v Carlstrom, 556 NW2d 800 (Iowa 1996). 6. Tierney v University of Michigan Regents, Docket #239690 (Aug 5, 2003). 7. Urrutia v Patino, 297 SW 512, App 10 SW2d 582 (Texas 1927). 8. Dashiell v Griffith, 35 A 1094; (Md 1896). 9. United States v George, 239 F Supp 752 (D Conn 1965). 10. Goldman v Ambro, 512 NYS2d 636 (1987). 11. Surgical Consultants, PC v Ball, 447 NW2d 676 (Iowa Ct App 1989). 12. Watkins v NC State Board of Dental Examiners, 358 NC 190 (1982). 13. Axelrad v Jackson, 142 SW3d 418 (Texas App 2004). 14. Payton v Weaver, 182 Cal Rptr 225 1st Dist (1982).

36 Orthodontic practice

Volume 10 Number 1

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When the patient breaches the doctor-patient contract JERROLD 1. While death needs no further support or explanation, ________ can reasonably expect the other to continue fulfilling the rights or obligations owed the other if they are suffering from a type of disability that would render that person unable to do so. a. neither party b. the patient and child c. the doctor and patient’s spouse d. none of the above 2.

If patients breach the obligation to participate in their own care by following reasonable instructions, the doctor has every right to terminate the doctor-patient relationship in order to _______. a. continue payments b. save the patients from themselves c. save the doctors from potential exposure to liability d. both b and c

3. We all recognize that patients have autonomy in terms of accepting or rejecting recommended treatment. What we also need to recognize is that doctors _______ regarding their right to provide or refuse to provide inappropriately directed treatment by patients. a. have the same degree of autonomy b. do not have the same degree of autonomy c. may not make decisions d. must always defer to the patients’ opinions 4. While there are any number of healthcare delivery sites that provide free or low-cost care, private practitioners _______ . a. must help patients find the proper site to pay their fees

Volume 10 Number 1

b. are always obligated to treat patients whether or not they can pay their fees c. are not obligated to treat patients who cannot pay their fees d. must find funding to continue treatment 5. If they are not honest about their _______, it could negatively impact on their ability to receive third-party reimbursement and the doctor’s ability to be paid. a. employment b. financial c. other aspects of their lives d. all of the above 6.

The last legally accepted basis for a healthcare practitioner to unilaterally terminate the doctor-patient relationship is when the patient or legal guardian _______. a. is unable to conform to accepted modes of behavior when present in the healthcare facility b. when the actions of the individual in question are creating an inhospitable environment c. when the actions of the individual in question are creating a hostile work environment d. all of the above

7. (When providing a notice of intention) The letter _______. a. must spell out the reason you are dismissing the patient by indicating which one(s) of the six duties owed under the terms of the doctor-patient relationship were breached b. can point out that you will no longer see the patient, but no reasons are necessary c. can be sent by regular mail with no return receipt or certificate of mailing requested

d. does not need to mention their continued care or appliance removal 8. You must let patients know that if they need help in securing substituted care, _______, and that you will be available for consultations and emergency care only during a reasonable period of time within which they are expected to obtain substituted care. a. you will help them obtain it b. you can have no part in recommending other care c. they should ask their friends d. you cannot recommend your colleagues due to their issues 9. Inform patients that you ________, and if patients choose not to pursue further treatment and wish you to remove their appliances, that you will do so. a. cannot make their records available to them or to any subsequent treating practitioner of their choice b. will only make certain records available to the treating practitioner of your choice c. will make their records available to them or any subsequent treating practitioner of their choice d. will make records available only after a hefty records’ duplication fee is paid 10. When a doctor plans on relocating, ________. a. all active mechanics should be removed b. the patient should be placed in passive appliances c. the patient should be informed of the need to seek substituted/continued care at their earliest convenience d. all of the above

Orthodontic practice 37

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The SLX™ Clear Aligner System — Clearly Different Let the Carriere Motion 3D Class II Appliance do the heavy lifting for you!

comprehensive treatment solution for adults and teens, SLX™ Clear Aligners are uniquely clear, provide a precision fit, and offer numerous workflow and treatment efficiencies. This new aligner system by Henry Schein® Orthodontics™ incorporates the SAGITTAL FIRST™ Philosophy with Carriere® MOTION 3D CLEAR™ Appliances for ultimate esthetics and efficiency. HSO’s lead clinical advisor, Dr. Dave Paquette, notes that SAGITTAL FIRST™ treatment with MOTION 3D CLEAR™ Appliances — to establish a Class I occlusion prior to aligners — can significantly reduce the number of aligners needed for use in a typical case, providing meaningful time savings and clinical benefits to both doctors and patients. This combined treatment approach is designed to simplify and standardize your aligner cases, reducing total treatment time and both the number of attachments and aligners required. The SLX™ Clear Aligner System utilizes a proprietary ClearWear™ material and meticulous manufacturing process to achieve aligner clarity and a precise fit for greater comfort, improved tooth control, and a reduced need

“By correcting the sagittal first with Motion 3D, I’ve reduced my number of aligners by an average of 62%! I’ve improved facial aesthetics, airway, and TMJ when needed — in a way that I am not able to do with aligners alone.” — Dr. Luis Carrière

for attachments. The intuitive web portal accepts STL digital impressions from all leading intraoral scanners and is easy to use — without the need for extensive training. The SLX Clear Aligner System provides an enhanced esthetic orthodontic treatment option for consumers, as well as an easy-to-use case submission and treatment planning process for clinicians that offers efficient high-quality outcomes.

Building a future together Our future is you! We work hard to earn our customers’ business. While we are growing, we are not resting on our laurels. The orthodontic community is a small community where relationships matter, and every customer is important. Our employees pride themselves in working hard to develop successful relationships. Our teams, in the field and in the office, are dedicated to the success of the clinician’s business by helping you provide your patients with a great smile, plus total-health solutions. From clinician to staff member, know that you can “Rely on Us.” OP Treated case and case simulation by Dr. Luis Carriére 38 Orthodontic practice

This information was provided by Henry Schein® Orthodontics.

Volume 10 Number 1

ne of the most frequent questions patients undergoing Clear Aligner Treatment ask is, “How do I keep my aligners clean and fresh?” In 2012, Dr. Michael Florman, an orthodontist, and top Invisalign® provider, continued hearing the same question from his patients. He contacted his Invisalign representative and asked her what Align Technology recommended for cleaning aligners. His representative told him that the only products available were appliance soaks. He began telling his patients this, and they told him “no, you don’t understand; how do I clean and freshen my aligners while on the go, at work, after a snack, or after a meal!”

EverSmile® WhiteFoam™ To solve this problem, Dr. Florman invented WhiteFoam™, the first and only on-the-go, wearable aligner cleaner. Gone are the days of soaking, replaced with an easyto-use foam solution that patients simply apply to aligners, wear, and go. EverSmile® WhiteFoam™ combines hydrogen peroxide and oral care surfactants and cleaners into a foam that cleans clear aligners, retainers, attachments, and teeth. To use WhiteFoam™, patients remove aligners from their mouth and apply the foam to the inside of the aligners, spreading the foam to cover all areas before reinserting. Any excess foam is spit out, and the procedure is complete. No waiting, no rinsing, no soaking. Just clean and go. The foam dissipates on its own naturally and quickly without leaving residue. The minty flavor tastes great, unlike other aligner cleaning products. WhiteFoam™ is easily applied to aligners twice daily and can be used in the mouth

(while the patient is wearing the aligners), or outside the mouth (while aligners are in their case). The formula is gentle on the teeth and gums, causing no sensitivity, and offers patients a value-added effect of whitening their teeth while they align them. The gentle whitening effect of the hydrogen peroxide penetrates through tooth enamel under any aligner attachments, so there will be no visible discoloration when the attachments are removed. EverSmile® WhiteFoam™ is compatible with all clear aligners such as Invisalign® and ClearCorrect®, and all vacuum-formed plastics used to make Essix®, Invisalign® and Vivera® retainers. Since EverSmile’s official launch in 2014, over 1 million bottles of WhiteFoam™ have been distributed to patients by thousands of dentists and orthodontists worldwide. Doctors can either purchase WhiteFoam™ to resell it to patients, or refer patients with coupons to CVS®, Amazon, or the EverSmile® website. With the success of WhiteFoam™ on its shoulders, EverSmile® set out to tackle an even larger group of patients: those wearing braces.

EverSmile® OrthoFoam™ OrthoFoam™ is a patent-pending hydrogen peroxide, anionic cleaning formula for braces and teeth that removes plaque by breaking it down. OrthoFoam™ can be used three different ways: 1. As a foaming rinse in conjunction with brushing. 2. As an add-on “brushing booster” used alone or with your regular toothpaste. 3. Applied to teeth in custom or stock dental trays, which is the most effective method. Give kids a boost with OrthoFoam™, the fun way to clean braces. Orthodontists can either purchase and resell the product to patients, or give patients coupons redeemable at CVS® and Amazon. Cleaning aligners and braces, however, is just the beginning of EverSmile’s story.

FastTrack™ with VibraSeat™ Technology FastTrack™ is a revolutionary new device that enhances and accelerates the seating of aligners and alleviates the pain associated Volume 10 Number 1

with orthodontic treatment at a price you and your patients can afford. The FastTrack™ vibrating elastomeric PowerChew™ vibrates at 300Hz, aiding patients undergoing orthodontic treatment in seating their orthodontic aligners in only 2 Minutes Daily™. Patients use the device in the morning and evening for 1 minute each. FastTrack™ is available for just $99 each to professionals with a suggested retail price of $199 to patients.

OrthoChews™ Last but not least, EverSmile® has redesigned the age old “Chewie.” During the research and development of the FastTrack’s PowerChew™, EverSmile® discovered that patients desired Chews with different hardness based on personal preferences. In Q1 of 2019, EverSmile® will be officially launching the first patent-pending OrthoChews™ set, which will include two color-coded chews with soft and medium hardness. OrthoChews™ will also premier EverSmile’s new “flower shape”, which helps the chew stay in place when biting on it. OrthoChews™ also are made using medical grade platinumcured silicone, which enhances patient comfort as compared to less expensive elastomerics currently used.

Get in touch To learn more about EverSmile® products or to place an order, visit doctors.eversmilewhite.com with the passcode “whitefoam” to enter our Doctor’s Portal. Or you can send us an email at info@eversmilewhite.com or give us a call Monday to Friday 8 a.m. to 6 p.m. Pacific Time at 855-595-2999. OP This information was provided by EverSmile®.

Orthodontic practice 39

PRODUCT PROFILE

EverSmile. The Orthodontic Accessory Company.

EMPLOYEE ENGAGEMENT

Engaging wires, engaging employees: how employee engagement in the orthodontic office is tied to productivity and profit — part 2 Manon D. Newell, JD, explores ways to implement employee engagement in the orthodontic environment

n part 1 of this article, we explored the importance of employee engagement in the orthodontic practice and its relationship to productivity and profit. We learned what employee engagement looks like, why it’s important, the key performance indicators that it drives, and how to utilize the Gallup Q12® in order to measure engagement over time. But just knowing that employee engagement is key to positive business outcomes isn’t enough. If employee engagement is the first step in the orthodontist’s journey toward excellent business practices, how is it achieved? How do we develop employees who are doing more than simply showing up? At first glance, engagement might seem like an abstract concept. However, research shows us some concrete steps that we can take to create and nurture employee engagement in our practices. To start, three key areas of focus that every orthodontist needs to pay attention to are employee strengths, communication, and clear expectations and goal setting. In our approach to working with clients, we always start with strengths! This is the first step toward helping employees along the road to engagement. Gallup researchers have studied employee strengths for decades. This research shows unequivocally that when we focus on employees’ strengths, rather than their weaknesses, we produce more competent, happier, and more engaged employees.1 Strength-based work cultures

Manon D. Newell, JD, has a unique background that weaves together experience in law, business, and orthodontics. After focusing in appellate and employment law, Manon transitioned into a business role in Medical Orthodontic Devices. In 2016, Manon became a partner and COO at Systemized Orthodontics Consulting Group and married her passion for orthodontics and business. At Systemized, she manages the day-to-day business of the company. She works closely with clients on their financial benchmarking and goal setting. Manon also coaches clients and especially enjoys working with practice administrators to develop their strengths. She most enjoys seeing the progress that practices make in the time that she partners with them.

40 Orthodontic practice

produce employees who reach competency quicker, have higher productivity and better work product, are less likely to leave, and increase your bottom line.1 In Gallup’s most current study on engagement, employees who strongly agreed that their managers focus on their strengths and positive attributes rather than their weaknesses were more than two times as engaged as their counterparts.2 Likewise, the study found that employees who used their strengths every day at work are six times more likely to be engaged.2 Strengths and employee engagement go hand-in-hand. In order to increase engagement, there must be a simultaneous focus on both strengths and engagement. Simply put, when managers focus on the strengths of their employees, engagement increases! In working with orthodontic practices across the country, we begin by having both

doctors and staff members take Gallup’s StrengthsFinder® Assessment. By learning the top five strengths of the individuals that make up the teams we work with, we are able to evaluate the makeup of the team, assess positions within the team, and understand how the team operates as a whole and individually. We work individually with doctors and their staff to help them discover their innate talents and learn to use them most productively. We implement leadership teams in every practice that then become accountable for helping to develop strengthsbased and engagement-based cultures. Ongoing strengths coaching and leadership development are imperative to successful development of engagement in the orthodontic practice. Our clients who are the most dedicated to developing and nurturing a strengths-based culture are typically the most productive practices and report the Volume 10 Number 1

Web Solutions Designed For Orthodontists

EMPLOYEE ENGAGEMENT highest levels of workplace satisfaction among both doctors and staff. At the same time, these clients see improvements in key business outcomes such as increased case starts, profitability, and work-life balance, as well as a reduction in overhead, staff turnover, and workplace conflict. It is often said that good communication is the first step to a good relationship. Good communication is also one of the first steps to achieving employee engagement. Gallup research has shown that consistent communication is directly correlated to increased engagement.3 In fact, employees who report daily communication with their managers have the highest rates of engagement.3 Communication between employees and their managers fosters better relationships and helps keep everyone on the same page. Research shows that employees are further engaged when they feel that their managers are invested in them as people, both in terms of their performance in the workplace as well as their lives outside of work. The very best leaders and managers make an effort to really get to know their employees and create a safe environment for collaboration and communication. When employees feel valued and understood, they are more motivated and productive. They are less likely to be the employee who is merely showing up to get a paycheck. When employees feel invested in emotionally, they are much more likely to be personally invested in the work that they do. Great leaders care about the success of their teams. They understand the individual strengths of the people on their team and provide opportunities for their strengths to be used at work every day. An excellent leader will empower employees, provide recognition, and encourage them to contribute their ideas and opinions. Because the role of manager or leader is crucial to developing employee engagement, orthodontists should treat leadership positions as unique, with distinct functional demands that require a specific talent set.4 When we work with orthodontists, we encourage them to focus on the daily transactions that they currently have with their staff. From morning huddle to chairside collaboration to staff meetings — these touchpoints should become a focus for developing the type of communication that fuels engagement. Doctors and leadership teams must strive to focus on quality and positive communication. The goal is to realize that each employee is unique, to approach them as such, and to manage toward the highest performance possible. An integral 42 Orthodontic practice

Three key areas of focus that every orthodontist needs to pay attention to are employee strengths, communication, and clear expectations and goal setting. part of this type of communication is identifying the strengths of the employee. All doctors and members of practice leadership should be familiar with the strengths of each person on their team. Strengths identification offers a jumping off point to a more personal and highly effective form of management. Orthodontists know that they can’t apply the same treatment plan to all patients and expect excellent results. Likewise, they must understand that all people cannot be managed the same. Development of a leadership team is a key part of implementing an engagement strategy. Because Gallup’s research has found that managers are primarily responsible for their employees’ engagement levels, we conduct in-depth training and coaching with leadership teams and hold them accountable for their team’s engagement. We want doctors and leadership teams to take an active role in building engagement plans with their team, create accountability, track their progress, and ensure that the culture of engagement is ingrained in their strategic planning. Gallup’s Q12® Assessment is not only a measurement tool, it provides a framework for building engagement, and we encourage doctors and leadership teams to see the questions as elements for successful managing.

Building on the concept of excellent communication with employees is the development of clear expectations, goals, and consistent opportunities for review. When employees aren’t sure what is expected of them at work, they feel disconnected and frustrated. Annual reviews and written job descriptions are not enough. Gallup’s Q12 research shows that clarity of expectations is one of the most basic employee needs and is vital to performance.4 Helping employees understand their responsibilities is critical to employees’ developing a full understanding of their role. Great leaders engage in frequent conversations about responsibilities, goals, and progress with their employees. Similarly, leaders must communicate the goals of engagement in ways that their team understands. Engagement goals should be discussed frequently and woven into daily transactions with a team; it must become part of the workplace DNA. Leaders in the best companies strategically align their employee engagement efforts, meaning they find ways to communicate engagement’s effect throughout the year. They use every opportunity, touchpoint, and communication channel to reinforce and recognize the organization’s commitment to employee engagement. Volume 10 Number 1

developmental and aspirational in nature rather than punitive. Leaders must work with employees to identify barriers to engagement and opportunities for positive change. The research is clear that engagement is a crisis globally and that it has serious impacts on multiple key business outcomes. We can extrapolate from Gallup’s data that fully two-thirds of any orthodontic team are disengaged employees. But the engaged employee doesn’t have to be an elusive concept. The research shows us concrete ways to improve engagement. Employees are truly every orthodontic practice’s best asset. Thus, doctors and leaders should make caring for them a priority. Recognizing the engagement crisis provides a valuable opportunity to transform the work environment and allow workers to bring their best to work every day! Real change happens when leaders set the tone from the top. Our clients who realize the most benefit from engagement initiatives are those who weave strengths and employee engagement into performance expectations and enable their

team to execute on those expectations. We don’t have to guess if this approach is successful. We implement the Q12® Assessment at the beginning of our work with a client and periodically thereafter. The clients who embrace the work most fully and integrate it into the culture of their practice, see drastic improvement in Q12® results over time. The one thing that our most successful clients have in common is that they start with strengths! OP REFERENCES 1. Kappel, Mike. How to Establish a Culture of Employee Engagement. https://www.forbes.com/sites/mikekappel/ 2018/01/04/how-to-establish-a-culture-of-employeeengagement/#88883c98dc47. Published January 4, 2018. Accessed November 28, 2018. 2. Sorenson, Susan. How Employees’ Strengths Make Your Company Stronger. https://www.gallup.com/workplace/231605/employees-strengths-company-stronger. aspx. Accessed November 28, 2018. 3. Harter, James and Atkins, Amy. What Great Managers do to Engage Employees. Harvard Business Review. https:// hbr.org/2015/04/what-great-managers-do-to-engageemployees. Published April 2, 2015. Accessed November 28, 2018. 4. Reilly, Robyn. Five Ways to Improve Engagement Now. Gallup Inc. https://www.gallup.com/workplace/231581/ five-ways-improve-employee-engagement.aspx. Accessed November 28, 2018.

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Orthodontic practice 43

EMPLOYEE ENGAGEMENT

In the name of setting clear expectations and goals, we encourage our clients to develop written job descriptions in collaboration with their team. These job descriptions take into consideration the strengths of the employee filling the role as well as the strengths of the rest of the team. Collaboration in this process tends to breed accountability. Orthodontic practices should develop meaningful and clear mission statements and core values. When employees are emotionally connected to a company culture, they are automatically more engaged. Leaders should be able to clearly describe what success looks like in their practice. They should utilize clear descriptions and emotive language to give meaning to the goals that they set and foster a sense of commitment with their team. Finally, employee review should happen more than once per year. The process of review should also be a collaborative effort which spurs meaningful conversation around the themes of strengths development, improved engagement, and employee contribution. Review should be

MARKETING

Connecting is the key: Digital technology can help orthodontic practices grow Scott Hansen discusses how to effectively engage with patients

eople choose orthodontic care for many reasons. Parents might want their children to have a winning smile. Adults might be looking for relief from speech difficulties or jaw pain. Because orthodontic treatment can be a significant financial investment, patients expect a higher level of customer service. Patients not only want to make sure they are making the right treatment choice, but they are also concerned about making a wise financial choice. The stakes of gaining and keeping patients are very high for orthodontic practices because of this financial investment. Strong, effective digital technology is the key to reaching new patients and keeping your current ones satisfied. Using digital technology, orthodontic practices have a great opportunity to connect with people before they even become patients. Social media marketing and live website chat can offer convenient, yet personal, ways to engage potential patients. They can be some of the easiest and most cost-effective ways your practice can gain new patients and keep current ones satisfied. By using the latest digital technology, orthodontic practices can connect with people at the crucial discovery stage of their customer journey. Here are some practical ways to use digital technology to help your orthodontic practice grow.

Harness the power of human connection Human connection can help one orthodontic practice stand out from the others. Previous generations have benefited from the human connection of mom-and-pop shops and gas station attendants. Our current

Scott Hansen is the founder and CEO of OrthoChats, a leading professionally managed website chat service exclusively for orthodontists. The company has grown from one to more than 100 employees since 2016 and is recognized as one of the 100 fastest growing businesses in the country.

44 Orthodontic practice

generation expects the same level of human connection but in more convenient ways such as digital technology. Practices seeking to gain new patients have the opportunity to connect with potential patients while they are browsing the Internet. Digital technology allows an orthodontic practice to show potential patients the level of service they’ll receive before they even enter the practice’s doors. Digital ads put the orthodontic practice at the forefront of the customer’s mind while he/ she is researching options. Website landing pages can direct patients to the most useful information. Live website chat can take that connection one step further, offering a human touch once the patient has arrived on the orthodontist’s website. Acting as an extension of the practice, a live chat specialist can connect with potential patients 24 hours a day. People spend a lot of time researching online after business hours for their needs. Digital technology such as live website chat offers a personal way to connect with patients no matter the time of day.

Create brand advocates One of the most overlooked and yet most effective outcomes of effective digital technology is the development of brand

advocates — happy patients who tell their friends about your practice. Positive brand advocates can help steer potential patients in your direction. More than 80 percent of people seek out recommendations before making decisions on purchases.1 Brand advocates can help influence people to trust your brand. A positive customer experience is the only way to ensure that brand advocates are made and that they will continue to share with others their favorable experience with your practice.

Make connection convenient for the customer Face-to-face or phone conversation allows for connection. But potential patients must first reach out to your practice. Digital technology allows potential patients to interact with you whether your practice is open or not. An up-to-date website, active social media feed, and live website chat reaches patients at all hours of the day and night. By striving to have the latest in technology, you’re showing patients how much you care about their experience and making communication convenient for them. According to the Harvard Business Review, “Delighting customers doesn’t build Volume 10 Number 1

Go where the patients are Many of the decisions we make about products and services are done entirely in the digital space. When people are shopping around for a product or service, they often begin online. While they may have heard about a company from a friend or read about it on a printed piece, learning more about a company happens on the Internet. Digital technology is perhaps a practice’s most important investment in reaching out to new patients and maintaining happy ones. Orthodontic practices should examine ways they can connect with patients through a variety of digital means. Social media platforms and your website can provide potential patients with general information about your practice, reviews from other patients, and ways to connect further. A live website chat feature further answers patients’ questions in real time while still affording them some level of anonymity.

Use the latest digital technology We’ve determined patients still want human connection and that making that connection more convenient for them is essential. Now how do you go about doing that in the digital space? For starters, make the latest technology a priority with your practice. Your website and social media presence must be maintained. Information and social media posts must be current. People are constantly connected with technology. If your practice is not doing the same, you may miss the opportunity to connect with them. But when you show patients current and relevant information, you build credibility. Using the latest technology also means training your staff to do the same. Make sure a few people on your staff know how to update your website. If you choose to use social media, make sure someone is readily available to post regularly and respond to people who interact with your social media pages.

Create exceptional customer experiences 24/7 The only way to ensure you don’t miss potential patients or upset existing ones is to offer exceptional customer experiences 24 hours per day. Patients expect Volume 10 Number 1

round-the-clock support, especially when it comes to their health and well-being. Because they are currently or will be making a significant investment in your practice, they expect their customer experience to match their investment. The most effective way to provide 24-hour support isn’t by hiring more staff. By incorporating a live chat service as an extension of your practice, you can connect with patients all hours of the day while allowing your current staff to do what they’re best at: providing a great customer experience to patients.

Incorporate online chat While harnessing several aspects of digital technology is important, an online chat service can take your website and other digital marketing efforts to the next level. Your website can only disseminate information. Customer contact forms simply do not gather enough information. Email is best for mass communication. Social media offers a more personal touch, but it isn’t always in real time. An online chat service offers the real-time, human connection that other forms of digital technology can’t. Live chat also provides patients with immediate gratification while still allowing the sort of anonymity that has made digital technology attractive. Qualified and trained chat specialists can gather information about patients that other aspects of your digital marketing efforts cannot. Qualified, professional online chat specialists can connect people browsing your website directly with your office staff. Even when your practice is not open, a chat specialist will be available to address any questions a potential patient might have. With a live chat service on your website, you can offer patients the human connection and convenience they truly value. According to a recent survey, over 80% of customers expect a response within an hour, even after business hours.3 Live chat is the ideal solution to this customer demand. Qualified live chat specialists should have an average response time of 45 seconds.4

Beware of potential pitfalls While having the latest technology is one of the most important ways your practice can connect with potential and current patients, potential pitfalls still exist. A welldesigned website can still miss human connection. Using live website chat can help bridge the gap between a person simply window-shopping on a website and making

a connection with a real salesperson. Even then, a customer still has a certain level of anonymity. Transitioning from a live chat specialist to an actual employee at your orthodontic practice can be a challenge. The live chat specialist and your front desk staff must work together to develop the best possible solution for your practice as well as potential patients. Qualified chat specialists trained in the orthodontic industry can make the transition smooth. Your practice must be willing to provide exceptional service once a potential patient has decided to move beyond the live chat specialist and make that next step with you.

Connect all your digital marketing efforts Online chat can improve the return on investment of your other digital marketing efforts. If you maintain brand consistency across all channels, patients will trust your brand more. If you customize your chat software to meet your current brand standards, you’ll assure patients they are interacting with someone from your practice. Live chat software offers so many customization options. You can customize the chat software based on your current digital technology investment. For example, if you pay for Google AdWords, you can customize landing pages and chat boxes to coordinate specifically with the ad. Working with a qualified orthodontic chat specialist team, you can create scripts that best fit your practice.

Putting it all together Digital technology is essential in growing your orthodontic practice. It can be the first interaction a potential patient has with your brand, and it can be the first place a current customer leaves their opinion about your practice. Digital technology can be the most important step your practice takes in developing the best customer experiences, taking them from great to exceptional. OP REFERENCES 1. Kapadia A. Numbers Don’t Lie: What a 2016 Nielsen Study Revealed About Referrals. Business 2 Community. https:// www.business2community.com/marketing/numbers-dontlie-2016-nielsen-study-revealed-referrals-01477256. Published March 12, 2016. Accessed November 28, 2018. 2. Dixon M, Freeman K, Toman N. Stop Trying to Delight Your Customers. Harvard Business Review. https://hbr. org/2010/07/stop-trying-to-delight-your-customers. Published July-August 2010. Accessed November 29, 2018. 3. Toister J. Get ready to respond to customer email within one hour. Toister Performance Solutions, Inc. https://www.toistersolutions.com/blog/2015/4/13/get-ready-to-respond-tocustomer-email-within-one-hour. Published April 14, 2015. Updated April 2018. Accessed November 28, 2019. 4. Live Chat Benchmark Report 2017. Comm 100. https:// www.comm100.com/resources/report/2017-live-chatbenchmark-report/. Accessed November 28, 2018.

Orthodontic practice 45

MARKETING

loyalty; reducing their effort — the work they must do to get their problem solved — does.”2 What does that mean for orthodontic practices? It means doing whatever it takes to connect with patients in the ways that are most convenient for them by putting their needs first.

MARKETING MOMENTUM

Important factors to millennials that you should consider promoting on social media — part 2 Marketing consultant Julie Yeomans discusses how to reach out to a growing market or prospective patients

n the September/October 2018 issue of Orthodontic Practice US, I shared important insight from author Maria Bailey and her excellent book Millennial Moms: 202 Facts Marketers Need to Know to Build Brands and Drive Sales (available on Amazon). Millennials (born between 1980–2000) became the largest consumer group in 2015. As a patient, their decision-making process is completely different from what you have previously experienced, as is their ability to pay for treatment. Also, they perceive value, trust, and financial decisions differently than any other prior generation. Traditional marketing won’t reach this group, so you have to think creatively as well. In a changing landscape of consumer demands, what are some important social media themes to address in your marketing strategy? In this article, I will also address the “elephant in the room” — strategies to counteract the current treatment option available for patients at home. The recent growth in the last 2 years in at-home aligner treatment shows that over 250,000 patients have chosen one company to start treatment. But on a positive note, there are some takeaways we can learn as an orthodontic industry. Beyond price, why do patients feel this is a good choice? And how do you make a consumer take pause when choosing between DIY options and a licensed orthodontic professional? One main answer is that potential patients are not receiving education on the importance of choosing an orthodontist as they are searching for information on social media and Google. To give these potential patients the facts and information they need, you want not only to integrate education posts with treatment result posts, but also to share some core values of your practice that will make it an easier decision for patients to make the right choice to have their treatment done by an orthodontist. Further insights from Bailey’s book suggest promoting benefits that are already offered in your practice on your social media. Don’t Julie Yeomans is an orthodontic industry sales and marketing consultant. You can contact Julie at Julie@YeomansDesignGroup.com.

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Figure 1

forget to broadcast this news also on Facebook, Instagram, and YouTube. These sites are important to the “Millennial Moms” and probably to your entire social media community. Here are some important aspects of your practice to weave into your social media.

No. 1 — Affordability, benefits, and financing

With the rising financial college costs incurred by millennials upon graduation, student loan debt is a huge financial burden. Millennials are saddled with college debt that pushes them to seek low-cost options for their orthodontic needs. U.S. News and World Report recently published 20 years (1998-2018) of tuition cost increases by the 300 top ranked national universities in its 2019 Best National Universities rankings report.1 Here’s a quick breakdown: • The average tuition and fees at private national universities have jumped 168% since 1998. • Out-of-state tuition and fees at public national universities have risen 200%. • In-state tuition and fees at public national universities have grown the most, increasing 243%.

A recent article on CNBC.com noted, “The average monthly student loan payment for borrowers in their 20s is $351, and the median monthly payment is $203. That means that Americans in their 20s with student loan debt each have an average balance of about $22,135. Millennials in their 30s may have been dealt the worst hand of all. Twelve million people between the ages of 30 and 39 hold a whopping total of $408.4 billion dollars in debt. So while fewer 30-yearolds still hold debt, those who do have even more to handle.”2 This record-level financial college tuition debt will affect millennials’ decision for treatment. It’s easy to see why a less expensive and convenient option to orthodontic treatment is intriguing to this millennial patient base that wants to improve their appearance and fit the treatment in their monthly budget. Of course, you cannot compete on the DIY price, but with potential insurance benefits and financing, patients may realize your fee is more affordable than they perceived. Share frequently on your social media untapped orthodontic insurance benefits that can be applied in your practice and affordable financing options for the balance of Volume 10 Number 1

MARKETING MOMENTUM

treatment. Sharing local employer benefits on Facebook and Instagram may also be a good strategy as well as contacting HR departments on specials for their employees. For the typical consumer, understanding insurance coverage is frustrating and overwhelming. Your treatment coordinator and financial manager sharing those little pieces of knowledge will be enlightening and positive for your community. Share it on your YouTube Channel, occasional Facebook and Instagram posts, and tag the corporation if appropriate (their followers will see your post), and extend the offer to research their benefits for them.

No. 2 — Educate why it’s important to choose an orthodontist In a February 2018 blog post for Delta Dental of Washington, Dr. Kyle Dosch, DDS, Dental Director, wrote the following in an article titled “At-Home Invisible Aligners and Your Dental Coverage”: “The statistics around DIY invisible aligner treatments don’t lie. In 2017, the American Association of Orthodontists (AAO) found that 39% of orthodontists who reported seeing patients after an attempt at DIY therapy had to provide some form of corrective dental treatment to address problems caused by patients trying to straighten their own teeth. “It’s for these reasons that DIY treatments, orthodontic or otherwise, are not a covered benefit. As a dental benefit carrier, we have an obligation to help protect you. That’s why our dental benefit plans only cover treatment provided and completed by a licensed dental professional. Please keep this in mind when planning orthodontic treatment for yourself and your family.”3 Your office knowledge with your regional insurance providers on their coverage of at home orthodontics would be invaluable with your online followers and dental community. It’s important to share why your experience and education makes your office the best choice for orthodontic treatment in the online space outside of your website. Educate, educate, educate — it’s easier than ever and almost free on social media. The more “un-produced” a video is, the more authentic it is perceived. The AAO is taking a more active and aggressive role in educating the public on safety of treatment with an orthodontic professional, but it’s also important that you help the cause. For regional patients, it’s more likely your videos, posts, and blogs will come up in a local organic search. YouTube thumbnails with engaging titles such as “Orthodontics is not a safe DIY treatment,” and a 2-3 minute video will serve your practice well. Share your team’s expertise on insurance research and affordability of treatment with a specialist. Doing so will plant Volume 10 Number 1

Figure 2

Figure 3A: Stellar Go Live Kit

Figure 3B: LuMee Light-up Phone Cases

the seeds for when the patient is ready to get started. One way to educate and to introduce yourself to potential patients is by making a video, which is not such a difficult process. Recording video at a close distance with good sound (no echo) and good lighting is important and easy. Coach Glitter (Instagram @CoachGlitter Facebook pages CoachGlitter1 and website coachglitter.com) has easy tips to record effective live videos. Dr. Dovi Prero (Instagram @PreroOrthodontics — website PreroOrthodontics.com) has one of the most popular orthodontic Instagram accounts with very active engagement. His posts, “likes,” and “comments” are very impressive — you can check out his social media and get some pointers on how you may want to approach your own videos. Both Coach Glitter and Dr. Prero are great teachers to study from in social media strategy and entertaining video shots. It’s not hard to put your practice on the “live” social

media map, and you actually may enjoy your inner celebrity. Another key to good videos is good lighting and sound. Stellar Lighting Systems out of Los Angeles (stellarlightingsystems. com) has a high quality “go live” kit with an adjustable clip light for your phone and desktop tripod that will make a difference in your videos for $23.99. There are cheaper versions on Amazon, but this is the best light I’ve seen to “up” the quality of your video educating your community. Lumee.com also has a great phone case with lighting built in for selfies on the go both forward facing and on the back of the case for $69.99. Be authentic, educate effectively, and have fun being your true self. It is also critical to plan a monthly social media and YouTube schedule and rotate topics. Posts should include, but not be limited to, education, treatment success, affordability, philanthropy, experience, office personality, humor, love of patients, familiy, Orthodontic practice 47

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Figure 4

Figure 5

and community — rinse and repeat. You can also pre-schedule when these posts go live, so it is all done at once, and you are ready for the month. The online free site Canva allows you to create posts in a matter of minutes, and be sure to add your logo to the image (watermark app), so it stays with your page. Also, be sure to reply to comments daily in connecting with your community.

No. 3 — Report advances in your dental technology and how this will benefit your millennial patients

Author Bailey notes that millennials “want it now and want it fast” as well as wanting instant gratification. Orthodontic treatment can’t be as fast as an Amazon package at the doorstep, but technology advances put you in the running to promote convenience and efficiencies. • Ease of scheduling and communication: Millennials do not want to make phone calls but prefer online scheduling and text. Invisalign® has a local store in San Jose that offers an online service to schedule appointments much like the OpenTable.com experience on the website for an initial consultation. Hopefully online patient-facing systems will allow this trend to integrate into your current website and scheduling programs to streamline the new patient process. Ask your providers where they are going with these tools to meet the trends in convenience to the millennial population. In the meantime, consider a dedicated number a patient can text to schedule appointments or ask questions versus email. This saves a lot of time for the Millennial Moms, and they will most likely make an appointment right away. Promote this ease of scheduling and communication in your social media platforms. • Explain how easy and fast the initial consultation has become because of 48 Orthodontic practice

Figure 6

technology in your practice. Ensure the benefits of your new iTero® scanner and the quality of information it produces (versus sending selfies and impression material in patient records to at-home treatment companies), and the importance of full records for evaluation. Preview how long the process will take, and you will make it easy for millennials to understand their treatment plan and financial cost. • Share cutting-edge technologies that make treatment more convenient, comfortable, and faster. Some orthodontists are choosing to differentiate their practice through accelerated orthodontics (including MOPs, vibration, or low light level therapy) or lingual brace technologies like SureSmile® and InBrace. Figure 5 is one example of how Dr. Todd Dickerson in Phoenix, Arizona, promotes acceleration on his Facebook page to his patients and referring practices. Dr. Dovi Prero in Figure 6 highlights innovations of InBrace customized lingual brackets to his Instagram audience as another efficient esthetic treatment option.

Ease of scheduling, records and treatment modalities present a huge opportunity to promote on your website, to your referrals, and social media community — and to point out that these innovations are only available with a licensed provider. Technology has changed the landscape completely, and it’s exciting. Whatever you integrate that benefits the patient experience, convenience, and treatment outcome — promote it and promote it often. Educate your patients as to why specialist orthodontists are important, show your technologies and successful treatment results, and you will have millennials entrusting their smiles to you in the years ahead. OP REFERENCES 1. Boyington B. See 20 Years of Tuition Growth at National Universities. September 13, 2018. https://www.usnews. com/education/best-colleges/paying-for-college/articles/ 2017-09-20/see-20-years-of-tuition-growth-at-nationaluniversities. Accessed December 27, 2018. 2. Hess A. Here’s how much the average American in their 20s has in student debt. CNBC. June 14, 2017. https:// www.cnbc.com/2017/06/14/heres-how-much-the-averageamerican-in-their-20s-has-in-student-debt.html. Accessed December 28, 2018. 3. Dosch K. At-home invisible aligners and your dental coverage. Delta Dental website. February 12, 2018. https://www.deltadentalwa.com/blog/entry/2018/02/at-homeinvisible-aligners-and-your-dental-coverage. Accessed December 28, 2018.

Volume 10 Number 1

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