Orthodontic Practice US November/December 2019 Vol 10 No 6 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews November/December 2019 – Vol 10 No 6 • orthopracticeus.com

PROMOTING EXCELLENCE IN ORTHODONTICS The do’s and don’ts of hiring office staff Ali Oromchian, JD, LL.M.

“Peg-shaped” maxillary lateral incisors and orthodontics Drs. Donald J. Rinchuse and Dara L. Rinchuse

Lessons learned: a two-phase orthodontic treatment plan Dr. Klifford T. Kapus

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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.

find it incredibly interesting to hear orthodontists discuss the role that products play in their practice. The “discussion” is often more charged than it is collegial. The topic of twin versus self-ligating bracket systems is the most contentious, but it doesn’t stop there. Extraction versus non-extraction, braces versus aligners, pan/ ceph versus CBCT, impressions versus intraoral scanning — the list goes on and on. In an issue devoted to “practice and patient management systems,” I’d like to share the one system that I believe would help any practice improve. Reduce your treatment time! Jeff Kozlowski, DDS That’s right! Reduce your treatment time. Rather than arguing with one another about which system is best, or which treatment is best, or which software is best, let’s focus on taking better care of our patients. And I believe this focus starts with reducing the time that our patients are in treatment. We can all agree on one thing — patients prefer less time in treatment. The problem is that, generally speaking, our profession is not focused on the same things our patients are focused on. In numbers reported by Gaidge from 2017 across more than 1,000 practices in the United States, the average estimated treatment time was 24 months. 2 years! But the real problem is that the average ACTUAL treatment time was 27 months. This means that, on average, we as a profession are not living up to the promises that we make to our patients. And we as a profession are left scratching our heads wondering why patients are searching out short-term ortho solutions and DIY orthodontics. We can and we must do better! But how? Follow the advice of Peter Drucker — “If you can’t measure it, you can’t improve it.” However, we can measure treatment time in our practices with a simple spreadsheet. I encourage every orthodontist to do this exercise. Look at your last 50-100 cases of each treatment type (braces, aligners, Phase I). Track your estimated treatment time versus actual treatment time. Look to see if you are living up to the promises that you make to your patients. While you are at it, you’ll find it helpful to track the number of appointments it took you to complete the treatment — how many total visits, how many regular visits, and how many emergency appointments. Whenever I lecture on treatment efficiency, I ask the audience to raise their hand if they track any of these data points. In every lecture, it’s less than 5% of the people who do. My guess is that the most proactive orthodontists attend CE on a regular basis, so it’s likely a smaller percentage of the total orthodontic profession that actually knows its average treatment time. So I’ll change Peter Drucker’s quote to “If you DON’T measure it, you won’t improve it!” Given the technologies we have available to us today — imaging and diagnostic tools, superelastic wires, efficient bracket systems, early light elastics, bite correctors and bonding resin, which allow for bonding of all the teeth and elimination of metal bands, we should no longer be aiming for a treatment average of 24 months. Let’s band together as a profession and make 18 months the new 24 months when setting goals for treatment. Who knows — maybe the next generation of orthodontists will then be able to aim for 12 months — further helping us keep orthodontic patients in the hands of trained orthodontists. And while we are at it, let’s start living up to the promises we make to our patients. To do this, some of us will need to change — change our mechanics, attend CE, and learn what experts are doing in all types of bracket systems or treatment philosophies. Change our office systems — engage our teams in helping us reduce appointments and treatment time. And finally, change our mindset — because “If you don’t measure it, you WON’T improve it!” Dr. Jeff Kozlowski Jeff Kozlowski, DDS, an internationally sought-after lecturer on quality orthodontic treatment results and clinical efficiency, has presented all over the world on topics, including clinical efficiency, digital orthodontics, efficient early treatment, orthodontic treatment mechanics, and treatment planning for facial esthetics. Dr. Kozlowski graduated with a BS in Economics from Syracuse University prior to receiving his DDS and Orthodontic Specialty Certificate from the State University of New York at Buffalo. He has been published in numerous journals, including the Journal of Clinical Orthodontics, Seminars in Orthodontics, Clinical Impressions, and The Progressive Orthodontist. Dr. Kozlowski is cofounder of OrthoFi — a company dedicated to making high-quality specialty orthodontics affordable for orthodontic consumers. He has been practicing orthodontics for more than 20 years and owns thriving practices in New London, East Lyme, and Mystic, Connnecticut. Dr. Kozlowski currently resides in Waterford, Connecticut, with his wife, Amy, a pediatric dentist, and their two teenage children, Amelia and Jake. Dr. Kozlowski is an avid cyclist and spends most of his free time outdoors skiing, hunting, fishing, spearfishing, and wake surfing.

ISSN number 2372-8396

Volume 10 Number 6

Orthodontic practice 1

INTRODUCTION

Nov/Dec 2019 - Volume 10 Number 6

“If you don’t measure it, you won’t improve it!”

TABLE OF CONTENTS

Orthodontic perspective

Lessons learned: a two-phase orthodontic treatment plan Dr. Klifford T. Kapus discusses a case presentation

Publisher’s perspective Celebrating 15 years of growth and learning Lisa Moler, Founder/CEO, MedMark Media................................6

Technology profile Cloud computing — a secure way to reduce downtime and save money Dr. Andrew Nalin discusses his experience with CS OrthoTrac Cloud .......................................................16

Technology Superelastic archwire can achieve efficient movement and reduced trauma

Orthodontic perspective

Drs. David M. Sarver and W. Eugene Roberts discuss a new generation of multi-force archwires.......................18

“Peg-shaped” maxillary lateral incisors and orthodontics Drs. Donald J. Rinchuse and Dara L. Rinchuse discuss treatment for this tooth type for orthodontists in conjunction with the family’s treatment team

ON THE COVER Inset X-ray on cover courtesy of Dr. Klifford T. Kapus. Article begins on page 8.

2 Orthodontic practice

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TABLE OF CONTENTS

Continuing education 3-Way maxillae expander appliance innovations Dr. Duane Grummons discusses nasomaxillary orthopedic 3-dimensional expander techniques to overcome structural form discrepancies of the maxillae, having dentoalveolar compensations................................26

Product profile EverSmile® Oral care breakthroughs for cleaning clear aligners and clear retainers......31

Myofunction junction Working together in identification and treatment of sleep-disordered breathing (SDB) Nicole Cavalea, MS, discusses the need for comprehensive management of SDB...........................................32

Product profile In-network insurance Marla Merritt discusses preparing yourself for smart growth.................34

Continuing education The do’s and don’ts of hiring office staff

Ali Oromchian, JD, LL.M., discusses the process of hiring and welcoming a new team member

Product profile

Practice management

EZ-Align .....................................36

Uniquely orthodontic medical billing

Going viral

Christine Taxin discusses coding for the new age of orthodontics .......................................................38

4 data breach best practice tips for your orthodontic practice Mark Pribish discusses how an orthodontic practice can prepare a response to cyber threats................37

Product profile Gaidge......................................... 40

www.orthopracticeus.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter

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4 Orthodontic practice

Volume 10 Number 6

PUBLISHER’S PERSPECTIVE

Celebrating 15 years of growth and learning

s the publisher of Orthodontic Practice US, I have had so many opportunities to read, meet, and learn from “master teachers” — their wisdom comes from many fields, from dental KOLs to management gurus to technology and self-improvement. One of the ways that I keep their tenets in mind is through collecting meaningful quotes — one of my greatest passions. Quotes from Wayne Dyer, Jim Rohn, Zig Ziglar, Marianne Williamson, and Tony Robbins reflect where I’ve been and what I’ve achieved in my half century on this earth. Each insight, opinion, and perspective has served as an integral part of my own personal growth, as well as the growth of each of MedMark Media’s publications. In the coming year, MedMark Media celebrates its 15th birthday! It’s Lisa Moler Founder/Publisher, MedMark Media been a growth experience, not only for me, but also a time of growth, learning, and building relationships among our readers, authors, and advertisers. This issue of Orthodontic Practice US offers both clinical and management articles as part of the editorial focus on practice and patient management. Dr. Duane Grummons discusses 3-Way maxillae expander appliance innovations, and Ali Oromchian, JD, LL.M., points out the do’s and don’ts of hiring. Drs. David M. Sarver and W. Eugene Roberts discuss a new generation of multi-force archwire for efficient movement and reduced trauma, and ID theft and data breach risk management expert Mark Pribish shares four data breach best practice tips to enhance your practices’ safety. Both the clinical and business sides of your practices must be nurtured to reduce your stress and increase your success. Fifteen years ago, MedMark Media’s home office was based here in my hometown of Scottsdale — my corporate headquarters was comprised of a makeshift office in my tiny second bedroom. My sole employee was a 17-year-old intern who found the job from a posting that one of my fellow publishing friends put up at one of the local colleges. I had a hopeful hunch that she would work out. Diving into contracts and paperwork, we shared a computer and a dream of producing a publication that mattered in the dental industry. Within that first year, my Arizona market held the top ranking out of about 12 markets at the time. And amazingly, 15 years later my first employee, Adrienne Good, is still a valued member of the much larger MedMark Media team that now has grown to include departments for editorial, production, advertising, and digital media. I am fortunate to be a part of this beautiful “dental world” and can honestly say that this industry, and the amazing people I’ve met within it, have literally saved my life. I found my niche, and for 15 years have been striving, along with my team, to help you find and cultivate your niches. We all continue to innovate and seek new ways to help our readers reach new personal and professional heights. Of course, as in any profession, there will be challenges, but we want to provide you with the tools to step back, take a deep breath, and think, “I got this.” Feel free to contact us to share your ideas and articles. Along the way, I have had so many conversations and learned that everyone has a unique way of looking at the world and overcoming obstacles. We start this 15th year with hope, appreciation, and the knowledge that every day is an opportunity for learning. Thank you for being a part of our journey. To your best success! Lisa Moler Founder/Publisher MedMark Media

6 Orthodontic practice

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PUBLISHER Lisa Moler lmoler@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA mali@medmarkmedia.com Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez celeste@medmarkmedia.com CLIENT SERVICES/SALES SUPPORT Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING STRATEGIST Matt Simpson emedia@medmarkmedia.com SOCIAL MEDIA & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com CONTENT MARKETING Lauren Nash emedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

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ORTHODONTIC PERSPECTIVE

Lessons learned: a two-phase orthodontic treatment plan Dr. Klifford T. Kapus discusses a case presentation

erhaps the most dramatic change in my practice philosophy since I achieved my orthodontic certification in 1999 has been my stance on early interceptive Phase I treatment of patients in the mixed dentition. As residents, my classmates and I devoted an entire Wednesday morning to a Phase I clinic each week. There we learned about the advantages of early treatment and the benefits for the patient. For the most part, I still agree with those teachings, and I don’t hesitate to recommend early treatment for a patient with a developing problem who would benefit from a proactive approach. However, I now believe that there is a very broad continuum between the reactive and proactive stance, and where each individual practitioner places himself/ herself along that continuum is a personal

choice and part of the art of orthodontics. I still strongly recommend that all patients get screened for possible Phase I treatment by ages 7 to 8; however, I have personally become much more conservative about the patients for whom I recommend it.

guidance are going to massively simplify a child’s treatment and finish him/her at a younger age with a better final result. These are the patients for whom you recognize that NOT doing a Phase I is going to negatively impact their overall final results or oral health.

Early consultations: ranking patients into one of three categories

2. Patients with questionable hygiene, extreme timidity, or special needs For these patients, I would lean toward treatment, but something about their behavior causes me to doubt making a strong recommendation. Sometimes the treatment is right for the patient, but the patient isn’t right for the treatment. In situations like these, I will discuss my reservations with the patient’s parents, and if I feel as though we can proceed, we will.

1. The absolutely need-to-do Phase I patients This is the arm-waving, up-on-a soapbox, “I’d surely do this if it were my child” patient. These are the children who have partial anterior crossbites with the strong potential for recession and attachment loss or uneven attrition of the enamel. They are the ones who are an absolute train wreck of crowding where serial extraction procedures and eruption

Figure 2: Final Phase I

Figure 1: Initial Phase I (patient at age 7 years 6 months)

Klifford T. Kapus, DDS, MSD, obtained a Bachelors of Science degree in Genetics from the University of California at Davis in 1994. He graduated from the University of the Pacific School of Dentistry with a DDS degree in 1997 and continued there in residency to obtain an MSD and Orthodontic specialty certification in 1999. Dr. Kapus currently operates a private orthodontic practice in Livermore, California. Before entering dental school, he had worked as an exotic animal handler and also a molecular biologist. He now enjoys hiking, road trips, and spending time with his wife and three sons.

Figure 3: Final Phase I (patient at age 9 years 1 month) 8 Orthodontic practice

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ORTHODONTIC PERSPECTIVE

Figure 4: Phase I post-retention progress panoramic

Figure 6: Phase II initial photos (patient age 14 years 5 months)

Figure 5: Phase II initial panoramic

3. “Parents’ choice” Phase I patients The patient perhaps has mild-tomoderate crowding or a small diastema, and the parents explain that they are awfully and terribly concerned about these features and simply cannot stand to leave it and look at it for several years without intervention. Sometimes the patients themselves are concerned; perhaps they have been teased at school about their appearance. In situations like these, I am happy to provide treatment; despite feeling as though I will get a better result clinically, there is some valid psychosocial benefit to the patients or parents and no negative impact from the treatment.

Case presentation The case I am presenting is a typical twophase treatment plan, but it demonstrates a few interesting lessons that I have learned over the years. • Early removal of C’s to provide immediate space for the eruption of the 2’s and alignment of the anterior teeth does not eliminate the possibility of cuspid impaction. • Strategic timing of the removal of an obstructive tooth can and often does lead to spontaneous correction of cuspid impactions • Extraction of bicuspid teeth to address crowding does not absolve the risk of molar impaction 10 Orthodontic practice

I now believe that there is a very broad continuum between the reactive and proactive stance, and where each individual practitioner places himself/herself along that continuum is a personal choice and part of the art of orthodontics. • Uprighting impacted second molars while the patient is still in orthodontic treatment is one of the most positive functional benefits we can offer our patients. The patient originally presented for consultation at age 7 years 6 months with chief complaint of anxiety about the appearance of his upper central incisors. The pediatric dentist had referred him because of ectopic eruption of the upper first permanent molars. I noted severe upper/lower crowding and proclination of the anterior teeth, early loss of the lower right primary cuspid (R), mild lip incompetence, and hyper-mentalis strain. I strongly suspected the patient would eventually require extraction of all first bicuspids not only to address the severe arch length discrepancy, but also to minimize the risk of impaction of unerupted teeth. Note that the upper left permanent cuspid (No.11) shows no evidence of impaction on the initial panoramic provided by the pediatric dentist. Phase I treatment (Figures 1-3) My recommendation was Phase I interceptive orthodontic treatment with extraction of remaining primary cuspids C, H, and M and partial fixed appliances on the upper

and lower teeth. Goals of Phase I therapy included alignment of the upper/lower incisors. Treatment ran longer than normal for a Phase I (I typically prefer to stick to a 14-16 month maximum duration) due to the slow eruption of the upper lateral incisors. The patient completed treatment at 19 months with end on molars. Despite the early loss of the upper E’s during treatment, I was able to utilize fixed appliances to prevent mesial drift of the upper 6’s. The upper and lower incisors were too proclined for my tastes, but I was hopeful that the eventual extraction of the 4’s would provide another opportunity to retract them. Retention was provided by the use of upper and lower Hawley retainers. I continued to monitor the eruption of the permanent teeth every 12 weeks. At 2 years into retention (age 11 years 1 month), when I could see that the first permanent bicuspids were present and accessible, I took a progress panoramic and noted that the lower right 7 (No. 31) was impacted as was the upper left cuspid (No. 11). At this point I was faced with a choice. I did not feel that placing the patient back in fixed appliances at this point was appropriate. Therefore, the only proactive move I had available was to recommend the extraction of all four permanent Volume 10 Number 6

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ORTHODONTIC PERSPECTIVE first bicuspids to facilitate the eruption of the remaining permanent teeth. Seven months later after the extractions had been completed, I recalled the patient for a routine retainer-check appointment and took another panoramic X-ray to see how the upper left cuspid was responding. I was pleased with the amount of spontaneous selfcorrection but still felt that delaying the start of Phase II was prudent in order to minimize the amount of time spent in active therapy. We continued to monitor eruption, and the patient requested that we delay starting treatment until after his 8th-grade band sessions ended at school. He played trumpet and was rightly concerned that fixed appliances would interfere with his embouchure. Finally, by age 14 years 5 months, he was ready to start, and we were all thrilled to see that what I had previously thought to be a definitive impaction of the upper left permanent cuspid resolved itself without any interference, save the otherwise needed bicuspid extractions. Phase 2 treatment (Figures 4-6) We proceeded with Phase II treatment, which included fixed appliances on the upper/lower teeth (In-Ovation® C self-ligating brackets, Dentsply Sirona). Our goals were to align the upper/lower teeth, close any residual crowding and then re-assess the impaction of the lower right second molar (No. 31). Unfortunately, despite our success with the cuspid, the lower second molar did not self-resolve, and 7 months into Phase II treatment we referred to a local oral surgeon to extract all third molars and expose the crown of the lower right second molar. Once the crown of this tooth became accessible, we bonded a molar tube and uprighted it. This required repositioning of the tube bracket more than once, but eventually the molar was placed in proper position. Treatment was completed 24 months after starting the Phase II treatment. Final results (Figures 7-8) The final results are good, although I feel that the anterior teeth are still somewhat proclined. There is evidence of root tip blunting on the final panoramic, so I was hesitant to apply too much additional torque, and the patient and parents felt that the profile and inclination of the teeth were acceptable. De-impacting second molars is an enormously beneficial service we are able to offer our patients and represents possibly one of the biggest functional improvements we can provide as orthodontic specialists. And yet 12 Orthodontic practice

Figure 7: Final panoramic

Figure 8: Final results (patient at age 16 years 6 months)

this often receives the least amount of attention and fanfare. Patients don’t often notice that their second molars are in poor position, and while they may not perceive the extent of the improvements you can provide, this is a huge opportunity for open discourse with the patient and their parents. It’s important to explain that leaving a second molar impacted beneath the neighboring first molar can lead to decay and/or loss of one or both molars in that quadrant.

Key takeaways • Two-phase treatment is appropriate at least some of the time, but how

you prioritize patient “need” for Phase I is an individual choice. • Removal of the obstacle preventing eruption of upper cuspids often leads to self-correction of an ectopic eruption. • Extraction of bicuspids does not frequently provide sufficient room to de-impact second molars. • De-impaction and uprighting of second molars represent an enormous functional benefit to our patients, and this benefit should be thoroughly conveyed to patients and their parents. OP Volume 10 Number 6

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ORTHODONTIC PERSPECTIVE

ased on the meta-analysis by Hua, et al., in 2013,1 the prevalence of pegshaped maxillary permanent lateral incisors (Figures 1A, 1B, 1C, and 2) varies by race, population type, and gender. Overall, the prevalence of peg-shaped maxillary permanent lateral incisors is 1.8%. It is highest in the Mongoloid (3.4%) race. The prevalence in an orthodontic population is 2.7%. Women are 1.35 times more likely than men to have peg-shaped maxillary lateral incisors. Although the prevalence is the same for unilateral and bilateral pegshaped lateral incisors, the left side is twice as common as the right side.1 The dilemma for the orthodontist (and family dentist) is what to do in cases with peg-shaped maxillary permanent lateral incisors (i.e., extract, enlarge, keep the same size and shape, etc.), which is a decision the orthodontist makes in consultation with the cosmetic dentist as well as the patient/family. These writers are not certain that the primary responsibility for making the decision on what to do for these teeth (i.e., restorative-wise) is that of the orthodontist alone; certainly, it is a team decision. Nonetheless, the orthodontist will have to make accommodations for what is decided in his/her orthodontic treatment. There are several possibilities for these teeth, and there are several algorithms that can be used, but in most instances, the decision is made based on the unique circumstances with which each patient presents. One of the first considerations is whether or

Figure 1A-1C: Intraoral photographs of an 11-year 9-monthold female patient with a peg-shaped maxillary right lateral incisor and missing maxillary left lateral incisor

Donald J. Rinchuse, DMD, MS, MDS, PhD, is presently in corporate orthodontic practice in Greensburg, Pennsylvania. He has co-authored two books and written over 130 articles.

Dara L. Rinchuse, DMD, is in private orthodontic practice, Orthodontique, with three office locations: Belle Vernon, Leechburg, and Natrona Heights, Pennsylvania. She has published articles in several professional journals, including the American Journal of Orthodontics and Dentofacial Orthopedics.

14 Orthodontic practice

Figure 2: Panoramic radiograph of the same patient demonstrating a peg-shaped maxillary right lateral incisor

not to keep these teeth; certainly, at times it may be better for the patient if these teeth are extracted. The patient’s type of dental occlusion and facial pattern would be several of the considerations for deciding on

extraction(s). For instance, if the patient has a Class III occlusion with an anterior crossbite, there would be more of a tendency to keep peg-shaped lateral incisors. On the other hand, if the patient has an Angle‘s Class II1 Volume 10 Number 6

ORTHODONTIC PERSPECTIVE

malocclusion with a severe overjet in need of upper arch extraction, it would make sense to consider extracting bilateral peg-shaped lateral incisors. When the occlusion is Class I, it is a more difficult decision on whether to extract peg-shaped lateral incisors. Another consideration would be whether there is unilateral or bilateral peg-shaped lateral incisors. If both laterals are peg-shaped, does this lead more so for the tendency to extract? If the peg-shaped lateral incisor(s) is/are neither extracted nor enlarged (i.e., kept as they are), then they should be moved and positioned incisal/gingivally, so they are as long as the central incisors. They can also be extruded and made longer than the central incisors and then have the pointed incisal edge(s) “ground off.” The shorter these teeth are next to the central incisors, the more diminutive they will appear. So keep them “long.” This same concept is also true for small-sized lateral incisors (not truly pegshaped) that will not be enlarged. Parenthetically, after a patient wears a maxillary vacuum-formed clear retainer for even a very short period of time, these lateral incisor teeth (that have been so diligently positioned at the height level of the central incisors) can

In most instances, the decision is made based on the unique circumstances with which each patient presents. move gingivally and get shorter. The reason for this occurrence is unclear. It should also be mentioned that when using fixed orthodontic appliances, peg-shaped maxillary lateral incisors can be bracketed with lower incisor brackets rather than regular-sized maxillary lateral incisor brackets. If the decision is to “build” these teeth up (enlarge with bonding material or crown), then the question is, Should they be enlarged to a relatively normal size versus just enlarging them a minimal amount? Obviously, the esthetics will be better if these teeth are enlarged to a relatively normal size. However, peg-shaped laterals obviously have very small, slender roots, which are proportional in size to the small size of the crowns of these teeth. This presents some concerns. If these teeth crowns are enlarged to a normal size, the crowns of these teeth will be proportionally large compared with

the roots. So you would now have a very large tooth crown supported by a small tooth root. This would present a liability for a child orthodontic patient possessing peg-shaped lateral incisor(s), who will have to deal with the consequences (i.e., stress and forces) of a large size crown on a small, slender root for many, many years to come. The other aspect of having a large crown on a very small, slender root would be creating a ledge at the juncture of where the crown meets the root. This would present a periodontal/oral hygiene concern from food trapping in this junction area. Similar considerations are for enlarging retained deciduous maxillary incisor teeth when the permanent teeth are congenitally missing. OP REFERENCE 1. Hua F, He H, Ngan P, Bouzid W. Prevalence of peg-shaped maxillary permanent lateral incisors: A meta-analysis. Am J Orthod Dentofacial Orthop. 2013;144(1):97-109.

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TECHNOLOGY PROFILE

Cloud computing — a secure way to reduce downtime and save money Dr. Andrew Nalin discusses his experience with CS OrthoTrac Cloud

odern practices are taking on more business responsibilities, with a bigger focus on tasks and roles that have not typically been a part of the traditional orthodontic workflow. Marketer, HR manager, and IT support are just few of the hats a doctor and team are expected to wear to stay competitive. A competent office manager, an efficient team manning the front desk, and the right practice management software all help to alleviate some of the realities that come with owning and operating a small business, but there are still issues that are simply outside the wheelhouse of even the most experienced team such as updating computers, installing software or maintaining a server. Do you pay maintenance fees to a third-party IT company or keep a full-time tech on staff? Like any smart business owner, you delegate the hassle of IT to the cloud. “Cloud computing” is a hot term across multiple industries. If you save your vacation pictures to Box.com or open a Google Doc on your cellphone to check a grocery list you started on your laptop, you’re taking advantage of the cloud. As orthodontics has gone digital and more practices have become paperless, practice management has also ascended to the cloud to give practices added security, less downtime, more updates, and often lower fees.

Andrew Nalin, DDS, earned a bachelor’s degree in microbiology (1990) and a Doctorate of Dental Surgery (1998) from the University of Washington. After dental school, he completed an Advanced Education in General Dentistry residency at the Wright Patterson Air Force Base Medical Center (1999) and served our country in the United States Air Force for 9 years. In 2005, he completed his Orthodontic Residency in the Tri-Service Orthodontic Residency Program in San Antonio, Texas. Dr. Nalin is a published author and is currently involved with research at the University of Washington. He is a member of the American Association of Orthodontists, American Dental Association, Washington State Dental Association, Pacific Coast Society of Orthodontists, Washington State Society of Orthodontists, and the Mount Baker District Dental Society. Disclosure: Dr. Nalin is a key opinion leader for Carestream Dental.

16 Orthodontic practice

Reduce downtime; save money In a busy practice, every second counts. Doctors and their teams juggle many tasks throughout the day to keep the practice productive. Updating technology can be disruptive, leading to downtime and lost revenue. However, switching from onpremise software to a cloud environment is typically straightforward and handled remotely on the back end by the software manufacturer. If you’re working with an established technology company like Carestream Dental and transitioning from on-premise software to a hosted environment, the process is simple. For example, when my practice made the transition from on-premise (server-based) CS OrthoTrac to CS OrthoTrac Cloud, there was no reason to close my office for a lengthy installation. Plus, since the interface of both on-premise software and cloud solution are identical, there was no learning curve and no reason to retrain staff. Once on the cloud, all future updates and backups are handled by the company’s data center automatically, helping the practice stay current with the latest versions and avoiding the need for future manual update installs. In addition to keeping a practice up and running efficiently with fewer hiccups, switching to CS OrthoTrac Cloud has the potential to save a practice money in other ways such as reducing costly IT fees. In the case of my practice, we had been happily working with the on-premise version CS OrthoTrac. However, when it came time to expand our capabilities and add modules, it made more sense to switch to CS OrthoTrac Cloud. Rather than continuing to pay expensive monthly maintenance fees to a thirdparty IT company, in addition to the add-ons we wanted, it made more sense to move to CS OrthoTrac Cloud since fees for the cloud include modules and future upgrades.

Maintain trust with added security The relationship between orthodontists and their patients is one built on trust and communication. While that’s true for any

doctor, orthodontists have a special responsibility in caring for young patients. Digital practice management streamlines appointments, makes scheduling easier, and simplifies keeping in touch with patients, reducing stress for busy parents and making patients feel valued. However, what happens when there’s a breach of trust, even when it’s out of the practice’s hands? Say, a flood or accidental fire damages your server, or a laptop with sensitive patient data is stolen. With a hosted management solution, the all-important question of security is handled offsite at a Tier 4 data center, exceeding all HIPAA and security measures. If the unthinkable happens, files and data are not just “recovered” (which indicates that they were lost in the first place) but simply accessed from a different computer. A practice can be back up and running sooner, with patients experiencing the same smooth front desk experience and communication they’re used to.

Go and grow anywhere Smart business owners are always looking for ways to grow, and for practice owners that could mean a new location. Fortunately, cloud computing centralizes a practice’s data, so your existing hosted practice management can expand with your practice. Teams can access patient information, contacts, and appointments from anywhere, whether it’s the second office or from home. For example, if I get an emergency call, I can look up a patient chart from home on my cellphone or tablet without having to set up a complicated virtual private network. Running an efficient digital practice means more than having the latest diagnostic tools. Practice management software to smoothly manage the patient experience from the front to back office plays a crucial role in the providing effective care. When it comes time to consider the next step in your digital practice management workflow, switching to the cloud may be the efficient choice for your practice, especially if you’re looking to grow in the future. OP Volume 10 Number 6

SOME PURSUE WORKFLOW EXCELLENCE CS ORTHOTRAC CREATED IT

2018: CS OrthoTrac Carestream Dental

1992: ORTHOTRAC OMSystems, Inc.

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CS OrthoTrac v14: new and improved and ready to wow. Carestream Dental may be a new standalone company, but we have a long history of defining practice management and imaging technology. Our strong legacy brands—which include Eastman Kodak and OrthoTrac—have paved the way for the new realm of digitalization. In the newest release of OrthoTrac, version 14 optimizes your digital workflow with a newly designed treatment card that gives you one-click access to all of your important patient data. With new clear aligner tracking, patient compliance monitoring, and other information at your fingertips, you are better equipped to assess treatment, make decisions and engage your patients. With OrthoTrac v14, the legacy of innovation continues.

For more information, call 800.944.6365 or visit carestreamdental.com

TECHNOLOGY

Superelastic archwire can achieve efficient movement and reduced trauma Drs. David M. Sarver and W. Eugene Roberts discuss a new generation of multi-force archwires Introduction Superelastic archwires have been commonly used in orthodontic practices for over 2 decades, and these archwires have been based primarily on nickel-titanium materials. These archwires are relatively uniform in their force delivery across the arch form, meaning that force levels are ideal for some teeth, but not for others. What do I mean by that? Just think about the periodontal ligament (PDL) surface area of a maxillary lateral incisor versus that of the maxillary first molar. The force needed to move a first molar is much greater than what is needed to produce similar movement of a lateral incisor. Current archwire technology results in appropriate force levels in some areas of the mouth, but not in others. This may be expressed in many ways, such as irregular progress in correcting malocclusion and a tendency for increased root resorption on susceptible teeth like maxillary lateral incisors. What is new in superelastic archwire technology? The current generation of superelastic wires are all resistant to permanent deformation, deliver relatively uniform force, and have a lower modulus of elasticity compared to stainless steel and TMA wires. A new generation of multi-force archwire has been developed that has differential

superelastic properties based on advanced concepts in materials science and PDL physiology. What makes the new arch wire different from copper-nickel-titanium (CuNiTi) superelastic wires? What if you could have an archwire that is “programmed” to deliver loads that are specific for each tooth in the arch? For example, a lighter force delivered to lateral incisors, and a heavier one for molars? Basically, that is the idea behind the development of a multi-force archwire. Using pulsed fiber laser conditioning of shape memory alloy (SMA) wires such as copper-nickel-titanium (CuNiTi), a patented multiple memory material concept can precisely program narrow transition zones with numerous superelastic unloading profiles programmed into a single CuNiTi wire. The idea is to simply deliver the right amount of force for a specific tooth to achieve efficient movement and reduced trauma to the PDL.

Clinical study How does this new archwire technology compare to CuNiTi ? Study A: A single 0.016" Ormco SmartArch™ laser-engineered CuNiTi technology produced 25% faster (143 vs. 180d for controls), and >56% more efficient initial alignment because of fewer residual

David M. Sarver, DMD, MS, received his DMD from The University of Alabama School of Dentistry and MS in Orthodontics from the University of North Carolina in 1979. He is a Diplomate of the American Board of Orthodontics, a member of the Edward H. Angle Society of Orthodontists, a Fellow in both the International and American Colleges of Dentists, and a Fellow of the American Academy of Esthetic Dentistry. In addition to his private practice, Dr. Sarver’s book, Esthetics in Orthodontics and Orthognathic Surgery, was published in September 1998. He is also co-author (with Drs. Proffit and White) of the surgical text, Contemporary Treatment of Dentofacial Deformity, and is co-author the 4th, 5th, and 6th editions of Dr. Proffit’s classic textbook, Contemporary Orthodontics. He has given more than 400 professional presentations in the United States, Europe, Australia, and the Middle and the Far East. Dr. W. Eugene Roberts, DDS, PhD, received his DDS from Creighton University, his PhD in Anatomy from University of Utah, and Clinical Certification in Orthodontics from University of Connecticut. He is a Professor Emeritus of Orthodontics at Indiana University, Adjunct Professor of Mechanical Engineering at Purdue University School of Engineering and Technology, and Visiting Professor of Orthodontics at Loma Linda University and St. Louis University. Dr. Roberts was awarded a Docteur Honoris Causa (honorary degree in medicine) from University of Lille, France; a U.S. Navy Commendation Medal with Combat V, an Isaiah Lew Memorial Research Award; a Jarabak Award for Orthodontic Education and Research; a Salzmann Lecture; a Dr. Dale Wade Award for Excellence in Orthodontics; and an ABO Ketchum Award. Disclosure: Dr. Sarver and Dr. Roberts have no financial or other conflicts of interest related to the products in this article.

18 Orthodontic practice

discrepancies, improved deepbite correction, and a reduction of the curve of Spee.1 Study B: In approximately 6 months, two SmartArch wires (0.016" for 111days followed by 0.017" x 0.025" for 87 days) corrected axial inclinations in 3D to a near ideal alignment (cast discrepancies <29 points).1 In comparison, it usually requires about 6 months to only align a crowded lower arch with routine CuNiTi and stainless steel (SS) archwires. The bottom line is two SmartArch wires are more effective than 4-6 routine archwires for correcting malocclusions with a deepbite >3mm (>75% of all malocclusions in the total sample of 50).1 Why are multi-force SmartArch archwires more rapid and efficient for tooth movement? 1. Optimizing the load (moment-to-force ratio) for individual teeth is important for PDL health. Like all archwire activations, SmartArch results in some areas of PDL necrosis when it is first engaged, but there is only one archwire change during treatment, and that is when the rectangular SmartArch is installed. In effect, gentle continuous force accomplishes the treatment with minimal PDL necrosis because only two archwires are required. 2. Since molars have the largest PDL/ bone interface, SmartArch archwires are stiffer in the posterior compared to anterior segments. Thus, anterior crowding is corrected with gentle force at the same time the arch is leveled with the same archwire.1

Case examples Case 1 This 12-year-old patient was referred for correction of her moderate Class II deep bite malocclusion. She represents a patient in the initial study of the 90 days in the 0.016" SMA group. Her initial images were gathered (Figures 1 and 2), and she was submitted for setup using the Insignia™ (Ormco) appliance. When we received the Volume 10 Number 6

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TECHNOLOGY setup, the brackets were bonded and the 0.016" archwire placed, and the alignment after 90 days showed good alignment of the lower arch and overcorrection of bite opening (Figures 3 and 4). Conclusion/critiques I would have reset the lower left canine rotation prior to the photograph, but that would have contaminated the data of our study. The significant observation in her case is how efficiently the bite was opened in 90 days with one continuous archwire. SmartArch delivered gentle and continuous forces that were preferred for optimal tooth movement and patient comfort. Case 2 This 12-year-old girl was referred by her dentist for consultation regarding her severe crowding (Figure 6). She had totally blocked out her mandibular left canine, and her leeway space had been held during her transitional dentition with a lingual arch. However, she still had quite a bit of crowding, but a reasonable posterior occlusion (Figure 7). The patient was clearly mandibulardeficient (Figure 8) and had a good vertical incisor display, smile arc, and maxillary projection, while the maxillary incisors were slightly retroclined in compensation for the mandibular deficiency (Figure 9). I performed a setup (Figure 10) for a lower incisor extraction, but the outcome showed an unacceptable amount of overjet. In consultation with the periodontist, we agreed on an approach utilizing biomimetic grafting material to reinforce periodontal root structure in preparation for orthodontic treatment. This was achieved using EmdogainÂŽ (StraumannÂŽ) (enamel matrix derivative) with synthetic bone grafting (EDTA) preparation. Approximately 4 months after the graft was placed, treatment was initiated with full-fixed appliances (Titanium Orthosâ&#x201E;˘, Ormco), and 0.016" SMA archwires (SmartArch) were placed in both arches. Three months later 0.017" x 0.025" SMA archwires were placed (Figures 11 and 12). Conclusion/critiques Treatment time can be more efficient by engaging the posterior teeth at the beginning of treatment and minimizing repetitive archwire adjustments. Significant changes had occurred 180 days after initial archwire placement and two archwires (Figures 11 and 12). 20 Orthodontic practice

Figures 1 and 2: Case 1 initial images

Figures 3 and 4: Case 1 90 days in treatment

Figure 5: Case 1 final smile

A new generation of multi-force archwire has been developed that has differential superelastic properties based on advanced concepts in materials science and PDL physiology.

Figure 6: Case 2 initial image

Figure 7: Case 2 reasonable posterior occlusion

Figures 8 and 9: Case 2. 8. Our young patient was moderately mandibular deficient. 9. She had adequate incisal display and smile projection but retroclined upper incisor in compensation for her mandibular deficiency

Figure 10: Case 2. A setup was performed showing too much overjet with lower incisor extraction; since we did not want to retract anterior teeth in her face, a second setup showed good occlusion without extraction Volume 10 Number 6

TECHNOLOGY

Figure 11: Case 2 initial alignment

Conclusion Conventional wire progressions step through multiple rounds of progressively greater size and force. That approach challenges the variable root biology throughout the arch, introducing multiple episodes of lag phase prior to tooth movement. Inevitably, this prolongs treatment times. In both cases, SmartArch wire technology — a patented, highly controlled application of

Figure 12: Case 2 180 days after 0.016” and 0.017" x 0.025" archwire (90 days in each)

pulsating, precision laser energy to predetermined portions of the memory shape CuNiTi archwire — avoided these lag phases. Our clinical study demonstrated that SmartArch averaged approximately 50% greater tooth movement than the control group comprised of standard CuNiTi archwires. Clinicians are able to engage anterior and posterior teeth for more efficient leveling and aligning. Clinicians may also schedule longer intervals

between appointments. Retrospectively, it appears the best time to begin treatment with SmartArch is upon full eruption of the second molars. This takes full advantage of posterior molar uprighting from Day One. OP REFERENCE 1. Roberts WE, Roberts JA, Tracey S, Sarver, DM. SmartArch® Multi-Force, Super-Elastic Archwires: A New Paradigm in Orthodontics. Journal of Digital Orthodontics. 2019;55. http:// iaoi.pro/archive/post/id/328. Accessed October 8, 2019.

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Volume 10 Number 6

Orthodontic practice 21

CONTINUING EDUCATION

The do’s and don’ts of hiring office staff Ali Oromchian, JD, LL.M., discusses the process of hiring and welcoming a new team member Abstract This article presents a few essential requirements in the hiring process for a dental practice. It discusses the pros and cons of a working interview versus a nonworking interview based on legal considerations as well as practical. In addition, the article discusses the rigorous rules required by the various government agencies regarding prohibited interview questions and the consistency of the interview process. The collection and storage of employee documents is also discussed with references to various state and federal retention requirements. In addition, the reader is made aware of the difference between exempt and nonexempt employees and the necessity of not misclassifying an employee due to steep fines. Finally, the article details the required legal documents upon hiring and suggests some additional documents to protect the practice in case of dispute.

Educational aims and objectives

This article aims to present a few essential requirements in the hiring process for a dental practice.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 25 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify legal and illegal interview questions.

•

Understand the importance of proper storage and disposal of employee documents.

•

Recognize the elements of an offer of employment.

•

Recognize the difference between exempt and nonexempt employees.

•

Realize the importance of proper employee documentation.

Introduction Building a successful working team is essential to the success of any practice. The process of hiring and welcoming a new team member is fraught with pitfalls, but with careful preparation those pitfalls can be minimized. The interview is an essential part of the process. This is the first faceto-face chance for the practice to evaluate the candidate and the first chance for the candidate to evaluate the practice. However,

Ali Oromchian, JD, LL.M., is the founding attorney of the Dental & Medical Counsel, PC law firm and is renowned for his expertise in legal matters pertaining to dentists. Mr. Oromchian has served as a key opinion leader and legal authority in the dental industry with dental CPAs, consultants, banks, insurance brokers, and dental supplies, and equipment companies. He serves as a legal consultant for numerous dental practice management firms that rely on his expertise for their clients’ businesses. He is also recognized as an exceptional speaker and educator who simplifies complex legal topics and has lectured extensively throughout the United States. To contact the author, please email ao@dmcounsel or visit www.hrforhealth.com. Disclosure: Mr. Oromchian is co-founder and Chief Executive Officer of HR for Health in the San Francisco Bay Area.

22 Orthodontic practice

the employer must abide by certain rules regarding what questions can be asked, and what cannot be asked. After a successful interview, the offer letter is next with explicit details of the position and what the employee can expect in the way of benefits — pending successful completion of background checks and references. Before any new team members join the practice, it is essential that they be classified correctly as exempt or nonexempt. Finally, collecting and securely storing all documents pertaining to the new team member is an important part of any hiring process.

Working interview A trend in the dental industry is to assess a candidate’s skills through a working interview. Although a working interview might seem like an ideal way to get a feel for how a potential team member fits into the actual environment of the practice, it is risky. If a candidate uses your equipment on your patients and under your supervision, the Department of Labor (DOL) considers them as working in your office, and thus, your employee. Furthermore, you cannot classify them as a Temp nor as a Contract worker. Misclassification of an employee can cost you dearly in fines. Volume 10 Number 6

Interview questions Many interview questions are prohibited under the Americans with Disabilities Act (ADA)2 and the Fair Employment and Housing Act (FEHA).3 Many states have passed laws that prevent you from asking about previous salary history. In addition, some states also restrict questions about previous convictions until later in the interview process. With these restrictions, you might wonder how you can ask questions that won’t get you into trouble. The secret is in the framing. Focus on questions that directly concern the requirements of the job rather than questions that address the candidates’ personal circumstances. For instance, you cannot ask if the applicant is a citizen, but you can ask if they are authorized to work in the U.S. You may not ask about their observation of religious holidays, or about childcare issues, but you may ask if they will be available to work the required schedule. Rather than asking about the candidate’s particular disability, instead Volume 10 Number 6

You must ask all candidates the same set of questions, in the same order, and evaluate them with the same criteria and the same scale. To avoid claims of discrimination, it is essential to stay consistent throughout the interview process.

focus on the job, and ask if they can perform the required duties. Finally, you must ask all candidates the same set of questions, in the same order, and evaluate them with the same criteria and the same scale. To avoid claims of discrimination, it is essential to stay consistent throughout the interview process.

Resumes A potential team member’s resume contains personal information about the candidate and as such should be kept secure. You will need to store resumes and applications so that they are accessible only to those who require the information, such as human resources or hiring managers. In addition, they must be disposed of in a secure manner. In most cases, resumes and applications must be kept on file for at least 1 year from the date of the position being filled, whether the position is temporary or permanent. In cases of ongoing litigation, you are required to keep those documents until the litigation is settled. However, if you suspect that the team member is over 40 years old, you might need to keep their file for 2 years according to some Age Discrimination in Employment Act (ADEA) requirements. There are also situations where the Americans with Disabilities Act (ADA) requires a 2-year retention of those documents. Because of these and other requirements, it is better to err on the side of safety and keep this paperwork for 2 years.4

Offers of employment Once you have found the ideal person to join your team, you need to make a written offer. This document acts as both a clarification of the conditions of employment and protection for your practice in case of misunderstandings. Ideally, the offer letter extends a warm welcome to the new team member

and generates excitement about the position. It should clearly state basic employment information such as the job title, salary, overtime eligibility, start date, and supervisor. It should also provide general information about any practice benefits and eligibility dates for those benefits. To protect the practice, the letter should also notify the new team member that the employment is an “at-will” position if you are located in an at-will state. This means that the employee or employer may terminate employment at any time, for any reason, except an illegal reason. This is spelled out in Title VII Civil Rights Act of 19645 and other state or local laws governing employment. Under Title VII, an employer is prohibited from discriminating in matters of recruitment, hiring, discipline, and termination based on race, national origin, gender, religion, age, and disability. In addition, the offer letter should notify the candidate that the offer is conditional, pending the successful completion of background and reference checks, and/or drug tests, if applicable.

Exempt or nonexempt? Once your new team member has been selected, the question becomes whether they are classified as exempt or nonexempt. An employee who is nonexempt is covered under the Fair Labor Standards Act (FLSA)6 overtime requirements, which means that he/she is entitled to overtime pay for time worked over 40 hours per week, or over the daily limit in some states. Some states also have strict rules regarding meal and rest breaks for nonexempt employees. Usually this means team members who are paid hourly are nonexempt, but there are exceptions. Starting January 1, 2020, federal regulations specify any salaried employee who earns less than $35,568 per year is Orthodontic practice 23

CONTINUING EDUCATION

In order to avoid violating the DOL1 rules, you need to legally “hire” any candidates for the time spent working at your practice, even if it is only for an hour. You must pay them at least minimum wage, deduct any taxes due, perform background checks and credential checks to protect your patients, and verify their eligibility to work in the United States among other requirements. It is recommended that you provide an offer letter of temporary employment that clearly states the start/end date of the working interview. As a protection for your practice, it would also be advisable to make sure they are covered by Workers' Compensation in case of injury while working at your location. The working interview is indeed fraught with risk. A better option than the working interview is the Behavioral Interview where you ask the candidates how they would handle a relevant work or life situation. For example: “How have you dealt with an angry or upset patient?” Or, “Have you ever had to defend a patient’s point of view? What did you do? Why?” Another one could be: “Tell me about a problem you solved in a creative way.” Another option would be to use a Skills Test where the candidates describe how they would perform a critical task. By using these methods you can gain an understanding of how your candidates would act in a pressure situation that might not occur during the few hours of a working interview.

CONTINUING EDUCATION considered nonexempt and is entitled to overtime pay. However, these salary amounts might vary in your state. As always, check your state regulations. The U.S. Department of Labor classifies the following employees as exempt: • Executive • Administrative • Professional • Outside sales employees • Certain computer employees. Exact definitions for each area can be found on the DOL’s website.7 If employees are exempt, it means they are exempt from the FLSA requirements and are not compensated for working over 40 hours per week (or over the daily limit, depending on your state). Every exempt employee must be paid on a salary basis of more than $35,568 per year starting in 2020. In addition, each employee’s primary duties must fit his/her category. For example, an executive must run the whole or a part of the practice and have the authority to hire and fire. A manager must manage at least two people, including interviewing, hiring, firing, setting pay, and may perform various other duties. Administrative positions must be non-manual and related to the management of the business. In other words, the actual duties of the employees must match the category in which they are classified as exempt. The FLSA rules are clear regarding which employees are exempt and which are not. Violations of those rules can be costly to your practice.

New documents and onboarding In addition to the offer letter, the candidate is legally required to receive the following documents at minimum: • W-4 • I-9 (confirming eligibility to work in U.S.) • State withholding tax • Employee benefit notifications • Any additional state required notifications (check your state’s regulations) The following additional documents will help protect your practice: • Employment application • Non-compete agreement (if enforceable in your state) • Non-disclosure agreement • Employee invention form (if applicable) • Employee handbook and acknowledgment form for same 24 Orthodontic practice

New hire documents The candidate is legally required to receive: • Offer letter • W-4 • I-9 (confirming eligibility to work in U.S.) • State withholding tax • Employee benefit notifications • Any additional state required notifications (check your state’s regulations)

Having these documents on file will clarify the status of the new candidate as a member of the team. Proper documentation is also essential should any future discrepancies arise. Your careful record-keeping not only protects you and your team member, but ensures that you are both aware of the benefits and limitations of the employment status. From the initial interview to welcoming a new team member, hiring can be a stressful process. However, by following these few guidelines you can save many unforeseen headaches and ensure that you build the best team possible for the success and growth of your practice. Note: This article is not to be taken as legal advice. Please consult a lawyer regarding compliance with federal and state laws in your area. Author’s note: This article is not to be taken as legal advice. Please consult a lawyer

These additional documents will help protect your practice: • Employment application • Non-compete agreement (if enforceable in your state) • Non-disclosure agreement • Employee invention form (if applicable) • Employee handbook and acknowledgment form for same

regarding compliance with federal and state laws in your area. OP REFERENCES 1. U.S. Department of Labor: Wage and Hour Division. Misclassification of Employees as Independent Contractors. https://www.dol.gov/whd/workers/Misclassification/ index.htm?apartner=undefined. Accessed October 11, 2019. 2. U.S. Equal Employment Opportunity Commission. Job Applicants and the Americans with Disabilities Act. https:// www.eeoc.gov/facts/jobapplicant.html. Accessed October 11, 2019. 3. California Department of Fair Housing and Employment. Employees and job applicants are protected from bias. https://www.dfeh.ca.gov/employment/. Accessed October 11, 2019. 4. strategic HR inc. Keeping Resumes and Applications. https://strategichrinc.com/keeping-resumes-and-applications/. Accessed October 11, 2019. 5. U.S. Equal Employment Opportunity Commission. Title VII of the Civil Rights Act of 1964. https://www.eeoc.gov/laws/ statutes/titlevii.cfm. Accessed October 11, 2019. 6. U.S. Department of Labor. Handy Reference Guide to the Fair Labor Standards Act. https://www.dol.gov/whd/regs/ compliance/hrg.htm. Accessed October 11, 2019. 7. U.S. Department of Labor: Wage and Hour Division. Fact Sheet 17A: Exemption for Executive, Administrative, Professional, Computer & Outside Sales Employees Under the Fair Labor Standards Act (FLSA). https://www.dol.gov/ whd/overtime/fs17a_overview.pdf. Accessed October 11, 2019.

Volume 10 Number 6

REF: OP V10.6 OROMCHIAN

FULL NAME

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $149; call 866-579-9496 or visit www.orthopracticeus.com to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

AGD REGISTRATION NUMBER

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To provide feedback on this article and CE, please email us at education@medmarkmedia.com

Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

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Your CE certificate(s) will be emailed to the address you provided above. Please add medmarkmedia.com to your Approved Senders List in your email account. You may need to check your junk/spam folder for your certificate email.

The do’s and don’ts of hiring office staff OROMCHIAN

1. If a candidate uses your equipment on your patients and under your supervision, the Department of Labor (DOL) considers him/her as _______. a. working in your office and, thus, your employee b. strictly an interviewee, and not your employee c. a temporary employee d. a contract worker 2. (For the time the candidate spends working in your practice) You must pay him/her at least minimum wage, ________, and verify his/her eligibility to work in the United States among other requirements. a. deduct any taxes due b. perform background checks c. perform any credential checks d. all of the above 3. (During the working interviews) As a protection for your practice, it would also be advisable to make sure ________ in case of injury while working at your location. a. they are covered by their own health insurance b. they are covered by Workers’ Compensation c. they understand that their medical bills will not be covered by your practice d. that there will be no chance of them being hired permanently 4. Many interview questions are prohibited under the ________.

Volume 10 Number 6

a. b. c. d.

Newly Hired Labor Standards Act Americans with Disabilities Act (ADA) Fair Employment and Housing Act (FEHA) both b and c

5. Finally, you must ask all candidates ________, and evaluate them with the same criteria and the same scale. a. different questions depending on their age b. questions related to their specific religious holidays c. the same set of questions, in the same order d. questions related to an obvious disability

c. U.S. Department of Labor Exempt Employees Act d. Fair Dental Employees Act 8. An employee who is nonexempt is covered under the Fair Labor Standards Act (FLSA) overtime requirements, which means that he/she is entitled to overtime pay for time worked over _______, or over the daily limit in some states. a. 20 hours per week b. 25 hours per week c. 30 hours per week d. 40 hours per week

6. (Regarding keeping resumes and applications for potential hires on file) Because of these and other requirements, it is better to err on the side of safety and keep this paperwork for _______. a. 2 years b. 3 years c. 4 years d. 5 years

9. The U.S. Department of Labor classifies executive, administrative, professional, outside sales employees, and certain computer employees as _______. a. nonexempt b. exempt c. non-salaried earning less than $35,568 per year d. non-benefit eligible employees

7. (The contents of the welcome letter, such as informing the new team member that the employment is an “at-will” position if you are in an “at-will” state or reasons for termination of employment) This is spelled out in ________ and other state or local laws governing employment. a. Americans with Disabilities Act b. Title VII Civil Rights Act of 1964

10. In addition to the offer letter, the candidate is legally required to receive the following documents at minimum: W-4, _______, any additional state required notifications (check your state’s regulations). a. I-9 (confirming eligibility to work in U.S. b. state withholding tax c. employee benefit notifications d. all of the above

Orthodontic practice 25

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

3-Way maxillae expander appliance innovations Dr. Duane Grummons discusses naso-maxillary orthopedic 3-dimensional expander techniques to overcome structural form discrepancies of the maxillae, having dentoalveolar compensations

he objectives of this article are to share several clinical design innovations with key clinical information for the effective and successful implementation of the selected 3-Way expander appliance design in various maxillary arch conditions. This article shows the application of several appliance variations and their three-dimensional benefits in the initial stage of maxillary arch development with arch-length gains. These 3-Way maxillary orthopedic appliances overcome structural form discrepancies1 having dentoalveolar compensations. The 3-Way appliance began in the 1980s with the G-Rax expander (Bevins Lab, Leone Orthodontics, AOA Lab, Space Maintainers Lab), which matured into today’s 3-Way 3-dimensional Smart Click appliance (Great Lakes Orthodontic Dental Technologies). Any discussion regarding noncompliance fixed jaw (orthopedic) or arch development (dentoalveolar expansion) therapeutic approaches must credit and hugely acknowledge the long-standing appliance contributions by Dr. James Hilgers (i.e., Pendulum, T-Rex, Pendex)2,3 and others.4,5,6 Earlier versions of the 3-Way appliances appeared in my nonextraction noncompliance publications.4 The 3-Way can also be a key maxillary orthopedic appliance therapy

Duane Grummons, DDS, MSD, is board-certified in facial orthopedics and orthodontics and has authored and lectured for over 35 years. His Facial Frontal Analysis and facemask orthopedic appliance innovations are extensively utilized. He is a leader in adolescent airway analyses and “earlier” (ages 2-8 years) facial orthopedic interventions for breathing/airway with life-changing benefits. His individualized pre-aligner therapy approaches and nonextraction methods are widely applied. Dr. Grummons is Associate Professor of Orthodontics at The Loma Linda University Medical Center Orthodontic Department, San Bernardino, California. He developed two efficient and productive practices — first in Marina del Rey, California, and again in Spokane, Washington. He has appeared before orthodontic, dental, and medical conferences, and made radio and TV appearances. Dr. Grummons can be reached at grummons@me.com, or visit drgrummons.com. Disclosure: Dr. Grummons has neither financial interests nor conflicts regarding the appliances mentioned in this article. He lectures at conferences sponsored by Great Lakes Dental Technologies and for Rocky Mountain Seminars, and he receives an honorarium for these.

26 Orthodontic practice

Educational aims and objectives

This clinical article aims to discuss the application of several three-dimensional maxillary expander appliance variations and benefits in the initial stage of maxillary arch development with arch-length gains using each of these designs.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 30 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Recognize how this modernized 3-Way maxillary arch expander can accomplish differential molar distalization, intrusion/extrusion and rotational movements.

•

Recognize how this device can facilitate molar root uprighting distally.

•

Realize the device’s molar extrusion/intrusion capabilities.

•

Identify the asymmetric movement capabilities within each quadrant.

•

Realize this expanders’ capabilities to individualize movements, so each quadrant can differentially move in three dimensions to correct transverse, Class II, midline, and occlusal plane variations.

Figure 1A: 3-Way appliance with sheaths at Smart Click screw and molar bands (Photo courtesy of Great Lakes Dental Technologies; www.greatlakesdentaltech.com)

for pediatric breathing disorders/functional airway issues. Initially, the 3-Way appliance is placed in the mouth passively to confirm ease and accuracy of fit and then sealed into position. The appliance molar springs are mildly activated 15 degrees distally as expansion turns begin. These turns are slow, so sutural regions are stimulated over a longer time for best orthopedic benefits and with less buccal and distal tipping of posterior teeth. This longer time achieves the molar distalization with uprighting movements. Typically, the expansion turns are one turn every 2 days (slow expansion protocol) for approximately the first 20 turns. Thereafter,

Figure 1B: Either a Weingart or Howe plier is preferred for spring activations

the turn rate slows to one or two turns per week until expansion target is reached. Five or more turns can be added for width overcorrection at a pace of one turn per week while the molar roots continue derotating with distal molar root uprighting to the treatment objective. 3-Way capabilities include: • transverse gains in maxillary basal structure and intemolar widths • molar derotation with distal translation • occlusal plane improvement by molar extrusion or intrusion • asymmetric movements possible with differential activations of the molar loops/springs These springs can be soldered or laserwelded to the screw and molar bands. Volume 10 Number 6

Figure 3: Frontal analysis (Grummons) is traced upon RMDS: Rocky Mountain Data Systems (Ricketts)12, 13

At the screw, the soldered design can be used, though high heat could affect the screw mechanism, so laser-weld-to-screw is preferred. The .032-inch spring can either be soldered to the lingual region of the molar bands or be inserted into an .036inch welded sheath. This sheath method is preferred at the screw and molars, so the spring can be disengaged and activated for first molarsâ&#x20AC;&#x2122; distal (de)rotation, distal movement, differential expansion or constriction, molar eruption or intrusion (occlusal plane leveling), and/or for distal tip/uprighting of molar roots. The frontal analysis specifies these treatment objectives.12,13 To reactivate at the molars, the spring is disengaged, and the helix is gripped with either a Howe/Weingart plier or a heavylocking hemostat plier. The spring arm is bent and (re)activated distally by 20-30 degrees beyond the molar sheath and re-engaged into the molar sheath â&#x20AC;&#x201D; less activation when the appliance is first inserted. Subsequent activations can be applied unilaterally to one first molar, and the next visit for the opposite first molar. This approach is more anchorageefficient (a less reciprocal effect) and accomplishes more molar distal rotational movement with true molar translation distally. The spring activations are intentionally light (approximately 120 gm per molar), which is consistent with the root ratings forces to accomplish molar derotation and distal root relocation/ translation with root uprighting. Overactivation of springs will result in some undesired mesial movement of premolars. The solution is to apply lighter molar spring activations. Asymmetric movements of molars are possible with specific derotation, differential extrusion or intrusion (occlusal plane leveling), distal root translation with molar uprighting achieved based upon bends placed in loops, and sheath arms of molar spring wires. Think in three planes of space like aeronautics: tip, yaw, and roll.

or spring activations to accomplish stabilized maxillary orthopedic changes in three dimensions with effective molar root uprighting and stability as confirmed by research.4, 7, 8, 9, 14 The horizontal loop by molars is directed anteriorly and can be widened to cause that

Volume 10 Number 6

Figures 4A-4D: 3-Way molar spring activations are demonstrated. A. Plier disengages spring arm. B. Loop activated from molar sheath. C. Spring arm engaged. D. Spring secured with elastic ring

Figure 5: The molar spring effectively relocates the molar distally with increased inter-root distance between first molar and second premolar after 3-Way appliance movements

Maxillary first molars become distalized with root apices of first molars/second premolars distinctly moved apart from each other, indicating true molar distal rotation/ relocation/uprighting. The 3-Way appliance is left in place for 2-3 months after final turns

Orthodontic practice 27

CONTINUING EDUCATION

Figure 2: 3-Way appliance soldered at screw with sheaths at molars. Springs are passive after fabrication. Molar springs are mildly activated before placement and as expansion begins

CONTINUING EDUCATION molar to extrude or be shaped smaller/ narrower to cause that molar to become intruded. This is done to level the occlusal plane. It is preferred to activate only one molar vertically (alternate right and left side) for efficiency of extrusion or intrusion movement. Extrusion of a molar (1 mm-3 mm) is more predictable than intrusion. Light forces over time are indicated to achieve the desired occlusal plane changes. When more intrusion (3 mm-4 mm) of maxillary first molars are planned, it becomes indicated to place a buccal TAD in maxillary first molar region and tied to the first molar being intruded. For a maxillary first molar to be extruded (3 mm-4 mm) significantly, a TAD can be placed in the lower molar region to connect this TAD to the maxillary molar needing extrusion to achieve the treatment objective for occlusal plane change. This 3-Way appliance provides benefits before fixed brackets or clear aligners to first unlock the malocclusion10,11 by transverse/

width and arch-length gains with transverse structural and arch space-gaining procedures. Arch-length analysis should be recomputed after the maxillary orthopedic and arch development are completed, so less deficiency will be evident, and visualized treatment plan (VTP) will reflect improved conditions and case requirements to convert a crowded arch into nonextraction status.

3-Way pre-aligner: Unlocking before clear aligners After 3-Way appliance influences, the arch shows transverse/perimeter expansion, molars distalized and derotated, arch length gained to accommodate crowded/ rotated teeth, with a nonextraction orthodontic approach with efficient and predictably successful clear aligner treatment. This stage of progess represents an excellent transition stage when the 3-Way is removed, and the case is intraorally scanned to initiate

Figure 6: The 3-Way appliance is used in initial stage of full-fixed orthodontics, with a utility arch next to locate upper incisors in smile

Asymmetric 3-Way Maxillary appliance Each half of the maxillary arch requires diagnosis12,13 for specific and differential movements to create and establish bilateral symmetry with arch uniformity. As a clinician views/inspects the maxillae and upper arch morphology, it becomes obvious that the buccal segment on one side of this arch may require more expansion or more distal molar rotation. Thus, asymmetric first molar activations achieve arch perimeter and intraarch changes until both halves of this arch become symmetrically aligned.4,12,13

3-Way sideways screw maxillary space-gainer The palatal screw (Smart Click) is placed sideways, with an acrylic Nance Button added directly in the mouth utilizing

Figure 7: Utilizing 3-Way appliances for 4-6 months will accomplish important sutural, dentoalveolar, and/or arch changes so that subsequent clear aligners for finishing are made routine with an exceptional clinical outcome

Figure 8: Optimal expansion and first molars distal movements accomplished. This is good stage to convert to clear aligners 28 Orthodontic practice

the aligners process to complete the orthodontic correction.

Figure 9: 3-Way appliance with unilateral arch development features Volume 10 Number 6

Figure 10: Efficient and significant molar derotation with distalization are accomplished initially with partial brackets or before clear aligners

Quad-Helix follows 3-Way Expander phase A pre-formed quad-helix (Ricketts, Rocky Mountain Orthodontics) is placed upon removal of the 3-Way appliance. This quad is removed from packaging, shaped directly in the mouth using lingual arch forming pliers (2 beaks grip the quad-helix on molar insertion arms to maintain form and torque) and while viewing the upper occlusal photo to match the existing molar rotation, width, and palatal morphology.15 This quad-helix requires .072 molar sheaths and can hold the molar A-P, vertical and lateral molar positions and arch form. Also, this quadhelix can be activated to accompish further desired changes in maxillary arch form, molar positions in 3 dimensions, and serve as orthodontic anchorage for the ongoing treatment process.

Concluding remarks

Figure 11: 3-Way sideways screw utilized in beginning stages of full fixed nonextraction orthodontic therapy

The patient should triumph after treatment with optimized function, elevated self-confidence, optimal facial structural harmonies, optimized breathing/sleep conditions, with a wide radiant smile. This 3-Way appliance achieves significant maxillary structural and dentoalveolar improvements on the pathway to efficient fixed orthodontic appliances, or full treatment with synchronized clear aligners to completion. Wisdom is knowing these 3-Way gamechangers and what to do with them.

Figure 12: Pre-formed quad-helix with arms in place

Author’s note: This article is not intended to be a case study. Case studies require many photos, X-rays with superimpositions, and appliance pictures through each stage of treatment from start through finish. These would greatly expand the article without adding benefits about the advantages of utilizing these 3-Way pre-aligners appliances initially. This article shows various appliance designs and their effectiveness. OP

8. Corbridge JK, Campbell PM, Taylor R, Ceen RF, Buschang PH. Transverse dentoalveolar changes after slow maxillary expansion. Am J Orthod Dentofacial Orthop. 2011;140(3):317-325.

Volume 10 Number 6

Figure 13: Pre-formed quad-helix without palatal arms

REFERENCES 1. Haas AJ. The treatment of maxillary deficiency by opening the midpalatal suture. Angle Orthod. 1965;35:200-217. 2. Hilgers J. The pendulum appliance for class II non-compliance therapy. J Clin Orthod. 1992;26(11):706-714. 3. Hilgers J, Tracey S. The mini-distalizing appliance: the third dimension in maxillary expansion. J Clin Orthod. 2003;37(9):467-479. 4. Grummons D. Nonextraction emphasis: space gaining efficiencies, parts 1 and 2. World J Orthod. 2003:3:21-32, 177-189. 5. McNamara JA Jr, Lione R, Franchi L, et al. The role of rapid maxillary expansion in the promotion of oral and general health. Prog Orthod. 2015;16:33. 6. Lione R, Ballanti F, Franchi T, Baccetti T, Cozza P. Treatment and posttreatment skeletal effects of rapid maxillary expansion studied with low-dose computed tomography in growing subjects. Am J Orthod Dentofacial Orthop. 2008;134(3):389-392. 7. Chung CH, Font B. Skeletal and dental changes in the sagittal, vertical, and transverse dimensions after rapid palatal expansion. Am J Orthod Dentofacial Orthop. 2004;126(5):569-575.

9. Marshall SD, Southard KA, Southard TE. Early transverse treatment. Semin Orthod. 2005;11:130-139. 10. Hilgers J. Bioprogressive simplified. J Clin Orthod. 1988;12:48-69. 11. Rocky Mountain Orthodontics RMDS. 2017. “RMO Data Services Syllabus.” https://www.rmortho.com/wp-content/themes/ rmo/rmods/rmods_syllabus.pdf. Accessed September 13, 2019. 12. Ricketts RM, Grummosns D. Frontal cephalometrics: practical applications, part I. World J Orthod. 2003;4:297-316. 13. Grummons D, Ricketts RM. Frontal cephalometrics: practical applications part 2. World J Orthod 2004; 5:99-119. 14. Akkaya S, Lorenzon S, Uçem TT. Comparison of dental arch and arch perimeter changes between bonded rapid and slow maxillary expansion procedures. Eur J Orthod. 1998;20(3):255-261. 15. Grummons D. Quad helix innovations: pocket aces. Rocky Mountain Orthodontic Clinical Review. 2014;1-7.

Orthodontic practice 29

CONTINUING EDUCATION

light-cure Triad® (Dentsply Sirona) or similar adhesive material. Incisors can be bracketed with a utility arch to position the upper incisors in place during 3-Way appliance therapy to locate upper anteriors optimally for best smile display and lip/smile relationship prior to clear aligners. The esthetic and functional outcome is superior when upper molar(s) position(s) and optimal incisors placement are established reasonably well prior to the clear aligners for optimally finishing the case.

REF: OP V10.6 GRUMMONS

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

To provide feedback on this article and CE, please email us at education@medmarkmedia.com Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

TELEPHONE/FAX

Please allow 28 days for the issue of the certificates to be posted.

3-Way maxillae expander appliance innovations GRUMMONS

1. Initially, the 3-Way appliance is placed in the mouth passively to confirm ease and accuracy of fit and then sealed into position. The appliance molar springs are mildly activated _______ distally as expansion turns begin. a. 5 degrees b. 10 degrees c. 15 degrees d. 20 degrees 2. Typically, the expansion turns are one turn every ______ (slow expansion protocol) for approximately the first 20 turns. a. day b. 2 days c. 3 days d. 4 days 3. Five or more turns can be added for width overcorrection at a pace of ________ while the molar roots continue derotating with distal molar root uprighting to the treatment objective. a. one turn per week b. two turns per week c. three turns per week d. four turns per week 4. These springs can be _______ to the screw and molar bands. a. attached with a dental adhesive b. soldered

30 Orthodontic practice

c. laser-welded d. both b and c

c. light d. overactivated

5. This sheath method is preferred at the screw and molars, so the spring can be disengaged and activated for first molarsâ&#x20AC;&#x2122; distal (de)rotation, ________, and/or for distal tip/uprighting of molar roots. a. distal movement b. differential expansion or constriction c. molar eruption or intrusion (occlusal plane leveling) d. all of the above

8. The 3-Way appliance is left in place for _______ after final turns or spring activations to accomplish stabilized maxillary orthopedic changes in three dimensions with effective molar root uprighting and stability as confirmed by research. a. 1 month b. 2-3 months c. 4-5 months d. 6 months

6. To reactivate at the molars, the spring is disengaged, and the helix is gripped with either a Howe/ Weingart plier or a heavy-locking hemostat plier. The spring arm is bent and (re)activated distally by _______ beyond the molar sheath and re-engaged into the molar sheath â&#x20AC;&#x201D; less activation when the appliance is first inserted. a. 10-15 degrees b. 20-30 degrees c. 35 degrees d. 40 degrees

9. When more intrusion (3 mm-4 mm) of maxillary first molars are planned, it becomes indicated to place a ________ in maxillary first molar region and tied to the first molar being intruded. a. buccal TAD b. lingual TAD c. palatal TAD d. none of the above

7. The spring activations are intentionally _______ (approximately 120 gm per molar), which is consistent with the root ratings forces to accomplish molar derotation and distal root relocation/translation with root uprighting. a. forceful b. heavy

10. This quad is removed from packaging, shaped directly in the mouth using lingual arch forming pliers (2 beaks grip the quad-helix on molar insertion arms to maintain form and torque) and while viewing the upper occlusal photo to match the existing _______. a. molar rotation b. width c palatal morphology d. all of the above

Volume 10 Number 6

CE CREDITS

ORTHODONTIC PRACTICE CE

PRODUCT PROFILE

EverSmile® Oral care breakthroughs for cleaning clear aligners and clear retainers

s the orthodontic profession embraces clear aligners, more patients are using this nearly invisible method of straightening teeth. Aligners need to be worn up to 22 hours each day to achieve best results, which means that patients are constantly removing and replacing them for meals, beverages, and snacks. Orthodontist and inventor Michael Florman repeatedly heard the same question: “How do I keep my aligners clean on the go?” Other cleaning solutions require a lengthy soak, extending the time the aligners remain outside the mouth. Dr. Florman invented EverSmile® WhiteFoam™, the first aligner cleaner worn in the aligner trays themselves, enabling maximum wear time for better patient compliance. In addition to cleaning aligners and teeth, WhiteFoam freshens breath and gently whitens teeth, addressing patients’ insecurities about “aligner funk” and discoloration, and enabling the most pleasant and effective aligner experience possible. With EverSmile WhiteFoam, your aligner patients finish treatment with the straightest, brightest, healthiest smile possible! EverSmile WhiteFoam is a lightly minty blend of hydrogen peroxide and anionic surfactants that eliminate 99.999% of bacteria that lead to decay and bad breath. The peroxide also breaks up staining molecules that would otherwise be trapped between the aligner and teeth. Using WhiteFoam regularly will gently whiten teeth without painful sensitivity. No stains and no biofilm — “Say Goodbye to Aligner Funk!” WhiteFoam leaves aligner patients feeling confident and fresh. Since its introduction in 2014, EverSmile WhiteFoam has become the No.1 aligner cleaner, with over 1 million bottles sold. WhiteFoam works with ALL clear aligners: Invisalign®, Orthly™, Smile Direct Club™, Candid®, ClearCorrect®, and all others. No matter which choice your patients make, we are here to help them on their journey to bright healthy smiles. WhiteFoam can also be used with permanent retainers after treatment is finished! In addition to WhiteFoam, EverSmile has released AlignerFresh™, a pocket-sized Volume 10 Number 6

No stains and no biofilm — “Say Goodbye to Aligner Funk!” WhiteFoam leaves aligner patients feeling confident and fresh. spray with the same formulation as WhiteFoam, to ensure that your patients can care for their teeth and their aligners even in situations where it’s not possible to brush — in the car after their morning coffee, before an important meeting, while at a festival, or even after drinks at the bar. We will soon be releasing WhiteFoam F, which will add .02% sodium fluoride to WhiteFoam’s formulation, to help protect enamel and prevent cavities. We have also released OrthoChews™, designed to relieve the discomfort associated with braces adjustments or new aligner trays. Gently chewing on these ensures that aligner trays are properly seated, so treatment progresses as planned. The quatrefoil shape enables grip and comfort, and they are made from medical-grade, biocompatible, hypoallergenic silicone. Two hardness levels

in each package allow patients to choose the one that brings the most relief. You’re doing your best to make sure your patients achieve their best smiles. Your patients have invested time and money, and yet compliance can still be a challenge. Let EverSmile help you and your patients toward the best outcomes by making aligner treatment as easy and comfortable as possible! Our products are available on Amazon. com as well as in stores at select CVS locations, Bed Bath and Beyond, and Harmon. In 2020, EverSmile products will also be available in select Walgreens and Walmart locations. You can access more information and our full line of products at www.ever smilewhite.com. OP This information was provided by EverSmile®.

Orthodontic practice 31

MYOFUNCTION JUNCTION

Working together in identification and treatment of sleep-disordered breathing (SDB) Nicole Cavalea, MS, discusses the need for comprehensive management of SDB

he role of pediatric dentists and orthodontists in identification and treatment of sleep-disordered breathing (SDB) has become increasingly important as research provides us with more information. Openmouth breathing patterns, postural abnormalities of the mouth and tongue, and structural development of the oral cavity

Nicole Cavalea, MS, is the founder of Strategies for Success, a speech-language pathology practice and myofunctional therapy clinic. She has worked in the field of communication disorders for 19 years. She received her MS degree in Speech and Language Pathology from San Jose State University. Cavalea has extensive expertise working with children of all ages in the assessment, treatment, and management of speech and language disorders, auditory processing delays, and myofunctional disorders. After incorporating myofunctional techniques into her practice, she began noticing her clients improving with quicker and more precise results, leading her to further her training in myofunctional disorders and treatment, and attending multiple intensive training courses from the Academy of Orofacial Myofunctional Therapy. Recent studies include an advanced course on breathing re-education, focusing on restoring adequate breathing in sleep apnea patients. Recently, Cavalea has expanded her practice nationwide through telepractice, and values and enjoys collaboration and cotreatment with multidisciplinary teams across the country. Nicole Cavalea can be reached at ncavalea@gmail.com.

32 Orthodontic practice

and airway are often first recognized by pediatric dentists and orthodontists. The increase in mouth breathing is associated with less time spent with tongue to the palate and, therefore, with narrowing of the maxilla and an increased facial height. This downward and backward rotation of the maxilla and mandible is a powerful predictor of SDB as well as TMJD and malocclusion. Early identification of mouth breathing is therefore recommended as early as the first year of life.1 A narrow maxilla leads to increased nasal resistance, which promotes mouth breathing and subsequently SDB. Premature infants are much more likely to present at 1 to 2 years of age with a high and narrow hard palate, abnormal nasal resistance, and mouth breathing, all of which promote the development of an abnormally long, inferior third of the face. Orthodontists and pediatric dentists are the specialists that can recognize these risk factors and bring them to parental attention.2 Improper oral resting posture of the tongue will have a negative influence of the oral cavity and airway. The anatomy of the upper airway in turn guides the growth and

development of the nasomaxillary complex, mandible, temporomandibular joint, and ultimately, the occlusion of the teeth; thus, malocclusion and facial dysmorphism may be the result of compensation for a narrowed airway.1 Short lingual frenulum is a known factor in altering orofacial growth particularly impacting development of the maxilla due to the low placement of the tongue. It leads to the abnormal development of a high and narrow hard palate, and secondarily, mouthbreathing during sleep.3 Obstructive sleep apnea (OSA) has become increasingly recognized as a notable health concern in children given its consequences on behavior, function, and quality of life. Statistically, 40% of children who suffer from SDB develop ADD, ADHD, and/or a learning disability. Additionally, if a child is diagnosed with SDB in the first 5 years of life and is left untreated, he/she is 60% more likely to require special needs education by age 8. Most children with OSA have difficulty breathing through the nose. Allergic rhinitis is the most commonly cited disease, followed by hypertrophy of the tonsils and adenoids. Volume 10 Number 6

Volume 10 Number 6

Comprehensive management of SDB requires an integrated effort of the sleep physician, otolaryngologist, allergist, orthodontist, pediatric dentist, and myofunctional therapist. functions and lesser muscular coordination.4 The therapist activates and strengthens the oral facial muscles of mastication to support the mandible and the genioglossus at night. Approximately 30% of OSA patients have poor genioglossus muscle responsiveness to airway narrowing during sleep.6 The tongue muscles are trained to achieve palatal tongue rest position (aiding in correct tongue posture during rest, speech, and swallow). Proper placement and precision are taught in regard to the function of swallowing. When swallowing correctly, the client is instructed to voluntarily place his/her tongue against the roof of the mouth while bringing lips together and creating a suction to swallow. Finally, correct nasal breathing, along with a proper resting oral posture is established. Achieving proper nasal breathing will result in improving lung volume, increasing nitric oxide through the body, improvement in sleep, and the reduction of allergies and illnesses. To restore efficiency in breathing, first, the myofunctional therapist will educate the client on proper nasal/diaphragmatic breathing. Once coherence is established, the client will learn a series of exercises that focus on the biomechanical and biochemical aspects of breathing. Biochemically, the client is instructed to breathe in a way that creates a desire for air (such as narrow, light breaths). This technique will decrease the clients sensitivity for CO2, therefore creating a larger threshold to eliminate sleep disturbances. Biomechanically, the client is instructed on ways to practice techniques that maximize breathing skills. For example, the client learns deep, slow breathing through the nose, where the air effectively expands the diaphragm. Treatment will last anywhere from 4-6 months, with exercises and practice daily. In a retrospective study,7 24 teenagers who had previously been diagnosed with SDB between the ages of 3Â˝ and 7 and had been treated appropriately with

adenotonsillectomy and orthodontia and also had been instructed to commence myofunctional reeducation. Recurrence of OSA occurred in 13 subjects. Each of these presented with oral-facial hypotonia and mouth breathing during sleep. In contrast, the subjects with normal breathing at long-term follow-up had normal oral-facial tone, nasal breathing during sleep, and had completed myofunctional therapy. This study illustrates the importance of myofunctional treatment as an adjunct treatment of SDB children.7 More recently, a series of studies on the application of myofunctional therapy of SDB in children from Stanford University showed that the addition of myofunctional therapy to adenotonsillectomy or palatal expansion reduced the risk of recurrence of SDB.4 In conclusion, research indicates that successful treatment of SDB depends on the collaboration of multi-disciplinary teams aimed at identification and treatment of SDB. Comprehensive management of SDB requires and integrated effort of the sleep physician, otolaryngologist, allergist, orthodontist, pediatric dentist, and myofunctional therapist. OP

REFERENCES 1. Moeller JL, Paskay LC, Gelb ML. Myofunctional therapy: a novel treatment of pediatric sleep-disordered breathing. Sleep Med Clin. 2014;9:235-243. 2. Ruoff CM, Guilleminault C. Orthodontics and sleep-disordered breathing. Sleep Breath. 2012;16(2):271-273. 3. Huang YS, Quo S, Berkowski A, Guilleminault C. Short lingual frenulum and obstructive sleep apnea in children. Int J of Pediatr Res. 2015;1:1. 4. De Felicio CM, da Silva Dias FV, Folha GA, et al. Orofacial motor functions in pediatric obstructive sleep apnea and implications for myofunctional therapy. Int J Pediatr Otorhinolaryngol. 2016;90:5-11. 5. Guilleminault C, Sullivan SS. Towards restoration of continuous nasal breathing as the ultimate treatment goal in pediatric obstructive sleep apnea. Enliven Archive. 2014;1(1):001 6. Huang YS, Guilleminault C. Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences. Front Neurol. 2012;3:184. 7. Osman AM, Carter SG, Carberry JC, Eckert DJ. Obstructive sleep apnea: current perspectives. Nat Sci Sleep. 2018;10:21-34.

Orthodontic practice 33

MYOFUNCTION JUNCTION

Orofacial and pharyngeal muscles are involved in important functions, including breathing, with the vital role of maintaining airflow. Any upper airway (UA) obstruction may induce changes in neuromuscular function in order to ensure the passage of air. The most common consequence of UA obstruction is mouth breathing, a functional adaptation that may affect craniofacial growth and development during childhood. Another possible consequence is obstructive sleep apnea (OSA). Myofunctional treatment is aimed at correcting abnormal breathing patterns and muscular dysfunction that may impair upper airway patency.4 Adenotonsillectomy and palatal expansion have established their roles in the treatment of OSA after demonstrating considerable improvement related to adenoid or tonsillar hypertrophy, maxillary or mandibular deficiency, and orthodontic or craniofacial abnormalities. However, the implementation of other modalities such as myofacial reeducation also plays a crucial role in the optimization of sleep disordered breathing, as maladapted orofacial functions may be irreversible or present insufficient improvement even when their original cause is eliminated.4 If nasal breathing is not restored, despite short-term improvements after adenotonsillectomy (T&A), continued use of the oral breathing route may be associated with abnormal impacts on airway growth and possibly blunted neuromuscular responsiveness of airway tissues, both of which may predispose to the eventual return of upper airway collapse in later childhood or in the full blown syndrome of OSA in adulthood.5 There are several etiologic factors that have been linked in varying degrees to the development of SDB in children. A visual assessment of the following characteristics can indicate the need to co-treat with an orofacial, myofunctional therapist: forward tongue protrusion during resting, speech, and/or swallow, open mouth breathing posture, weak lip seal, postural changes to face, open bite, distorted speech, jaw instability, dark eye circles, short lingual frenulum, long face, and a high narrow palate.5 Co-treatment goals of the myofunctional therapist are to: First, determine the nature of the postural imbalances that are present and how they affect craniofacial development and functional ability. Next, correct muscular imbalances of the lips, tongue, and jaw through exercises meant to re-pattern, coordinate, and strengthen these areas involved. Children with OSA were found to have relative impairments in orofacial

PRODUCT PROFILE

In-network insurance Marla Merritt discusses preparing yourself for smart growth

ecently, I heard a phrase that may sum up the approach of many orthodontists in today’s competitive orthodontic market — growth at any cost. This catchphrase may refer to the very flexible financing of little-tono down payment and extended terms inoffice. Perhaps the expression alludes to the 5% or more of gross production that doctors are willing to hand over for a service with the hope of increased case acceptance. Or could it denote the discounts that practices agree to for in-network participation with an average of 20-plus benefit carriers? Given the fact that I elected to devote my more than 30-year career to sales and marketing, I am aware of the continuous need for growth. Nothing is more disappointing than seeing a business that once showed great promise fail miserably, and nothing is less exciting than people who remain stagnant in their personal development. Professional and personal growth is, without argument, one of the key factors in an orthodontic practice’s long-term success, but it is also very important that we do not lose site of the cost of that growth.

Is your practice “in-network” with multiple insurance plans? verywellhealth.com describes an innetwork provider as “a doctor or hospital that has signed a contract … agreeing to accept the insurer’s discounted rates.” Today’s savvy shopper knows that orthodontists participating in-network with their insurance company typically offer discounted treatment, so many potential patients will only visit in-network providers during the selection process. For this reason, the current trend is for orthodontic practices to participate in-network with multiple insurance plans as a strategy for growth. If this is a strategy for growth that you have selected for your practice, it is very important that you and your team seek

Marla Merritt is the CMO of OrthoBanc, LLC, where she has directed the sales and marketing initiatives since their inception in 2000. Under Merritt’s lead, OrthoBanc has added over 4,000 new customers and maintained one of the best reputations for exceptional customer service in the dental industry.

34 Orthodontic practice

education on the entire process and put systems in place for ongoing, in-office management. The success of plan participation, acceptance of benefit assignment, claim submission, and follow-up will come only as a result of team training and aligning your means, methods, and mindsets.

Choosing the right training and systems for managing insurance in your practice About 3 years ago, I began having conversations with Tina Byrne, consultant and industry insurance expert, regarding the training and systems needed to maintain in-network insurance plans in a way that would yield smart growth. Byrne has helped guide the success of leading specialty and dental practices, both large and small throughout the complex nuances of insurance management — so I knew she was the right person to address the growing need for insurance education within orthodontic practices. Around this same time, OrthoBanc surveyed our customers to ask if there was a desire to outsource insurance management for their practice. Our client base of more than 2,000 orthodontists overwhelmingly responded with “No. We prefer to have greater education and support to help our own team continue to manage insurance (in-house) rather than outsource those functions.” This is when OrthoBanc and Byrne decided to work together to offer insurance workshops for the orthodontic industry. As interest in these workshops grew, and as offices continued to seek Byrne’s

expertise, we determined there was a great need to automate the process of insurance management for orthodontic practices. The result is our iMaxX Insurance Optimizer, currently in beta, which will be released later this year.

How to maintain smart growth for your practice while participating innetwork with multiple plans While in-network plan participation can provide additional case starts for your practice, treatment fees are often cut significantly. This can result in the decline of profitability for your practice. In addition to the reduction of fees associated with in-network plans, the management necessary to keep up with the requirements and fee schedules for each plan can be quite overwhelming. This potentially leads to team dissatisfaction, unnecessary discounts, and unrealized production. The answer to these problems is neither to abandon multiple plan participation nor to outsource the management of your plans. Either of these choices could prove to be very costly for your practice. The key to smart growth through in-network participation is an efficient system for managing insurance that your team can easily learn and execute. If you establish a consistent approach of managing patient benefits to maximize in-network allowances, your practice revenue will grow along with your team’s confidence and satisfaction. The result of this professional and personal growth will be one more step toward the long-term success of your practice. Want to learn more about the iMaxX Insurance Optimizer? Email marketing@ orthobanc.com. OP This information was provided by OrthoBanc.

Volume 10 Number 6

EXCEPTIONAL CUSTOMER SERVICE IS THE DIFFERENCE Do your patients feel this way about your current payment solution? "What a refreshing difference â&#x20AC;&#x201D; Customer Service that actually serves the customer!" "The Customer Service Representative, Lucy, went above and beyond to help me. I am a staffing recruiter and talent like Lucy is hard to come by."

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Email us today to learn more and be sure to ask about the iMaxX Insurance Optimizer. marketing@orthobanc.com | 888-758-0585, option 2 | www.orthobanc.com

PRODUCT PROFILE

EZ-Align®

-Align® is a clear tray system that progressively aligns your patient’s teeth until the final results have been achieved. Choose any EZ-Align® system and feel confident in getting the results you expect at the value you deserve. Each aligner is expertly fabricated by highly trained technicians, using extremely effective, durable, and comfortable material. Each case you send to DynaFlex® is processed through our proprietary Treatment Review Software (TRS) and backed by our quality guarantee. Our TRS system is an extremely useful tool for your practice. You are able to review the treatment plan, see movement by aligner, and request changes if needed. It’s also great for case management and patient consultation. Each case is tracked step by step through our system; you’ll always know where your case is in our process. Our TRS system will continually evolve to keep up with the latest technology and innovations.

Once you’ve approved your case in TRS, fabrication begins. 3D models are printed, and the aligners are fabricated by highly trained and experienced technicians focused on quality and fit. Each aligner is marked by a state-of-the-art laser-marking system with the case number and aligner identification. Once your aligners are fabricated and checked for quality and fit, each aligner set is packaged in clearly marked pouches. For cases with 10 or more pouches, we provide an “Aligner Storage” box. You’ll also receive a “Patient Kit,” which includes a storage case with internal mirror, patientfriendly instructions, and an emery board for smoothing of edges as needed. There is a small compartment under instructions for you to add any other items you want to provide to your patient.

facilitate intermediate-to-complex tooth alignment of the upper-and-lower arches. Unlimited: Unlimited aligners per arch, with 6 full years of unlimited* aligners and retainers — For more complex cases, this comprehensive system is designed to facilitate alignment of the upper and lower arches. (*Unlimited refers to a reasonable number of aligners and retainers at the purchase price of the Unlimited System within the 6-year period.) Plus System: EZ-X® appliance plus any EZ-Align® System — The EZ-X® is a removable and clear lateral development

appliance utilizing a nickel-titanium, springloaded memory screw. EZ-X® reduces or eliminates the need for enamel reduction and attachments prior to aligner therapy. A second scan/impression is required after EZ-X treatment prior to EZ-Align® aligner therapy. Interested in getting started? EZ-Align® general manager, Francis Jerome B. Alcazaren, focuses on helping doctors with EZ-Align® systems, Treatment Review Software, and getting started. Contact him at francisa@dynaflex.com for assistance. You may also call 800-4894020, and a member of our customer care team will assist you. OP This information was provided by DynaFlex®.

EZ-Align® Systems Fast 5: 5 aligners per arch — An upper and lower system designed to facilitate minor tooth movement. Perfect 10: 10 aligners per arch — A versatile upper-and-lower system designed to facilitate minor-to-intermediate tooth movement. Terrific 20: 20 aligners per arch — A comprehensive system designed to 36 Orthodontic practice

Volume 10 Number 6

Mark Pribish discusses how an orthodontic practice can prepare a response to cyber threats

ccording to a September 12, 2019, TechRepublic article titled “How data breaches are hurting small businesses,” a Bank of America Merchant Services’ survey of consumers and small businesses presented these findings: 21% of small and midsize businesses (SMBs) reported a data breach within the last 24 months, and 30% of consumers said they would never again use a small business that suffered a data breach.1 In addition, according to a June 4, 2019, Security magazine article titled “Data Breaches Cost $654 Billion in 2018,” “cybercriminals exposed 2.8 billion consumer data records in 2018, costing more than $654 billion to U.S. organizations.”2 Personally identifiable information (PII) was the most targeted data with 54% of stolen PII being date of birth or Social Security Number along with name and physical address (49%) being the second-most common compromised type of PII — which is just the type of personal information that is collected by every orthodontic practice in the United States. Based on the preceding evidence, along with the 2019 Verizon Data Breach Investigations Report (DBIR)3 where Verizon found that 43% of data breaches happened to small businesses, I have listed my four data breach best practice tips to help small businesses prepare for and mitigate their exposure to a data breach event.

Best Practice No. 1 Every orthodontic practice needs to understand the cybersecurity threat landscape. Staying on top of all the security news and knowing the latest security trends is a time-consuming and challenging task. I Mark Pribish is the VP and ID Theft Practice Leader at Phoenix, Arizona-based Merchants Information Solutions, Inc., an identity theft and data breach risk management firm. He has authored hundreds of articles and is frequently interviewed by local and national media as an ID theft and data breach risk management expert. He is a member of the Identity Theft Resource Center Board of Directors and is a graduate of the University of Dayton.

Volume 10 Number 6

recommend regularly reading Brian Krebs,4 who is the author of a daily blog covering cybersecurity, data breach, and cybercrime trends.

Best Practice No. 2 Have a written information security and governance policy, and update this policy each year. Once complete, have all employees — even with a practice with two to three employees — sign this information security policy document acknowledging that they have read, understand, and agree to said policy.

Best Practice No. 3 Have a data breach risk management plan in place, as the lack of cybersecurity preparedness, the lack of data breach planning, and the lack of employee privacy training have made small businesses a target for cybercriminals. Your data breach risk management plan should include pre-breach planning with a focus on an information security risk assessment, as well as employee education and awareness. It should also include post-breach planning with a focus on state and federal breach notification laws and a list of incident response vendors such as your insurance broker, legal services, forensic services, and public relations.

Best Practice No. 4 Every orthodontic practice should consider having a cyber liability insurance policy, which can help protect your business from cybercrime and a data breach event. The CEOs and CIOs of Equifax and Target were not fired because they were hacked or breached; they were fired for their failed management response to their data breach events. Cyber liability insurance can help your practice be resilient and compromise-ready. With the threat environment changing so quickly, chances are your security policies and procedures (if your practice has security policies and procedures) are not keeping up, just as state and federal laws are not keeping up with the newest technologies. These four best practices will help your orthodontic practice respond to new threats along with the changing regulatory environment. OP REFFERENCES 1. Whitney L. How data breaches are hurting small businesses. TechRepublic. Published September 12, 2019. https:// www.techrepublic.com/article/how-data-breaches-arehurting-small-businesses/. Published September 12, 2019. Accessed on October 2, 2019. 2. How data breaches are hurting small businesses. Security magazine.. https://www.securitymagazine.com/articles/ 90320-data-breaches-cost-654-billion-in-2018. Published June 4, 2019. Accessed October 2, 2019. 3. Verizon. 2019 Verizon Data Breach Investigations Report (DBIR). 4. Krebs on Security. https://krebsonsecurity.com/.

Orthodontic practice 37

GOING VIRAL

4 data breach best practice tips for your orthodontic practice

PRACTICE MANAGEMENT

Uniquely orthodontic medical billing Christine Taxin discusses coding for the new age of orthodontics

n the category of billing in the dental field, gone are the days of simple cases and one type of coding. As each practice becomes more of a wellness and total oral healthcare provider, dentists are providing treatment plans for a wide array of patients. Orthodontic care is just one of these specific examples. In the modern dentist’s office, you will find that 4 out of 5 offices now own a CBCT scanner, which can diagnose and show so many needed details for requesting either traditional or alternative treatments in the orthodontic world. 3D imaging is quickly evolving as the standard of care in orthodontics as new ultra-low-dose CBCT technology offers safer and more affordable volumetric scanning than ever before. The advantages of CBCT over traditional 2D imaging are many, including: • 3D treatment planning and the transverse dimension • Airway-centered treatment from information not available using 2D imaging • Improved pre-existing TMJ knowledge and avoiding “surprises” during treatment • Mixed dentition and eruption guidance in 3D imaging • Visual Craniometric Analysis (VCA) — a new paradigm in 3D cephalometrics • Unparalleled imagery for patient marketing and case acceptance There are many dental codes for temporomandibular issues and cone beam necessity, but billing to medical will allow the clinician to use additional codes both during the case and at the end of case for documentation and medical necessity. Examples of these codes include:

Christine Taxin is founder and president of Links2Success & Dental Medical Billing, an online school for all billing issues. She serves as an adjunct professor at the New York University (NYU) Dental School and Resident Programs for New York City Programs. Taxin is on the board of the Stem Cell Collection and the Board of Certification for 3D Scans, and has a Fellowship with the AIDA. The AGD has approved her company Links2Success as a national provider of PACE® continuing education credits. Taxin’s workbooks “Introduction to Medical Billing,” “Introduction to CT Scan Billing,” and “Oral Surgery and Implant Surgery” have been received by many as the go-to workbook for training. Taxin’s new book Pedo Sleep Apnea can be found on Amazon or on her website www.links2success.biz. To purchase a book or book a web program, visit www.dentalmedicalbilling.com

38 Orthodontic practice

• D0382 - 70150 - Cone beam CT for maxilla (TC) Modifier • D0381 - 70110 - Cone beam CT for mandible (TC) Modifier • D0383 - 70486 - Cone beam CT for both arches (TC) Modifier • D0365 - 76376 - Cone beam CT of mandible arch (in office) • D0366 - 76377 - Cone beam CT of maxilla arch (in office) • Multiple - See list below - 70486 - Cone beam CT capture and interpretation with limited field of view - less than one whole jaw • D0380/D0393 - 76380 - Computed tomography, limited or localized follow-up study • None - 70490 - Computed tomography, soft tissue neck; without contrast material (sleep apnea) • D0340 - 70350 - 2D cephalometric radiographic image orthodontic • D0330 - 70355 - Orthopantogram (e.g., panoramic X-ray) For the code 70486, Cone beam CT capture and interpretation with limited field of view — less than one whole jaw, list the conversion with the following. Use the following for code 70486: • D0321 - Other temporomandibular joint radiographic images, by report • D0322 - Tomographic survey • D0360 - Cone beam CT - craniofacial data capture • D0362 - Cone beam - two-dimensional image reconstruction using existing data, includes multiple images • D0364 - Cone beam CT capture and interpretation with limited field of view — less than one whole jaw • D0365 - Cone beam CT capture and interpretation with field of view of one full dental arch - mandible • D0366 - Cone beam CT capture and interpretation with field of view of one full dental arch - maxilla, with or without cranium • D0367 - Cone beam CT capture and interpretation with field of view of both jaws, with and without cranium • D0368 - Cone beam CT capture and interpretation for TMJ series, including two or more exposures • D0380 - Cone beam CT image capture with limited field of view — less than one whole jaw

• D0381 - Cone beam CT image capture with field of view of one full dental arch - mandible In addition to orthodontic care, and while striving to provide complete patient care, another course of treatment many dentists are providing relates directly to sleep apnea. Since the inception of the American Academy of Sleep, an uptick in the number of oral physicians providing sleep apnea care has increased. Many dentists have taken courses and have become providers of durable medical equipment. This means that they are directly involved with medical billing. The good news is that billing for this specific area is quite straightforward, as there is only one diagnostic code for sleep apnea for both adults and children. The code G47.33 must be listed as the diagnosis on the sleep test or it will not receive payment. • G47.33 º Obstructive sleep apnea (adult) (pediatric) º Obstructive sleep apnea hypopnea Along with orthodontic care and the monitoring of sleep apnea, dentists need to be mindful of snoring and how appliance placement can possibly aggravate this condition in patients. The American Academy of Craniofacial Pain Task Force on Mandibular Advancement Oral Appliance Therapy for Snoring and Obstructive Sleep Apnea has a specific stance on just how appliances might increase the overall struggle with snoring. The OSA published a position paper in 2013 that states oral appliance therapy has the potential to cause TMD and that orthodontic specialists should be engaged in treatment of both OSA and TMD with expanders that can be watched as the child grows to prevent TMD.1 There are steps that you can implement to begin the journey of adding the ability to help screen a child for either treatment of sleep apnea or TMD. Of course, you must determine the treatment after the test results are available and collaborate with your patients’ medical provider. Some patients either do not want to go for a sleep test, or you may want to recommend the use of an expander for the opening of a small airway and still bill to medical as either a sleep appliance for a child or a TMD appliance. When treatment planning for TMD, bear in mind that reversible intraoral appliances (i.e., removable occlusal orthopedic appliance-orthotics, stabilization appliances, Volume 10 Number 6

Volume 10 Number 6

• M26.3 Anomalies of tooth position of fully erupted tooth or teeth • M26.4 Malocclusion, unspecified • M26.8 Other dentofacial anomalies • M26.89 Other dentofacial anomalies • Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) º Q65-Q79 Congenital malformations and deformations of the musculoskeletal system • Q67 Congenital musculoskeletal deformities of head, face, spine, and chest • Q67.0 Congenital facial asymmetry Cross Codes: • 21083 - Impression and custom preparation; palatal lift prosthesis • 41899 - UNLISTED PROCEDURE DENTOALVEOLAR STRUCTURES • 21110 - Application of interdental fixation device for conditions other than fracture or dislocation, includes removal All billing requires a Salzman Index to even get a pre-authorization or a sleep study. Next, all information must be completely documented in the form of a narrative template in a S.O.A.P format. S. Subjective information must be gathered: When the patient is calling to make an appointment, there are several key questions to ask. • Does the patient take any medications? • Is the child under the care of a doctor? (all, even a therapist) Document the doctors’names and numbers • Does the child tend to breathe through his/her mouth? • Have the child’s parent or teachers noticed: • Breathing pauses during sleep • Sleepwalking • Bedwetting • Daytime sleepiness • Difficulty concentrating or misbehavior • Poor school performance O. Objective: During your objective part of the visit, you must have a history and physical and /or consultation notes including: • Address the symptoms reported by guardian • Symptoms • Type of sleep study and the reason for ordering the test • Current treatment plan • Prior treatment for same issues • Failed CPAP if ever used • Copy of sleep test • Results (Salzman Test) or copy of

sleep study with a CPAP intolerance form. A. Assessment: Reading of all tests taken, Salzman Test, CT scan of the soft tissue of neck area, and the sleep test done with a monitor in an overnight sleep lab. • Results of apnea/hypopnea index for diagnosis in adults is quite different than for children E0486 - Oral device/ appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment. • For children: Enlarged tonsils and/ or adenoids are the most common cause of sleep apnea for children having surgery to remove the tissues and often correct the symptoms of sleep apnea. • List the type of appliance therapy you would use for the treatment showed with the outcome after use of the appliance. Always include the length of treatment. P: Plan of Action: • Establishment of medical necessity requires documentation to support the severe handicapping malocclusion and medical condition status. • To quality for insurance conversation, you must had a score of 42 points on Salzmann index, documentation with a written report from the attending physician, pediatrician and a qualified sleep test. • All the doctors need to agree or be part of the treatment plan. Many medical providers are asking to have children treated with orthodontic appliance therapy even before the child can have a sleep study. A final note: When billing some of the common appliances orthodontists make (soft and hard stabilization appliances, anterior positioning appliances, anterior bite appliances, and soft resilient appliances), you may need to use an unlisted code, and in your letter of medical necessity, you must write the entire description the dental code. You also may need to use the dental code on the medical claim since there are dental codes that are not cross coded but are covered with the correct diagnostic reason.2 All codes are owned by the ADA and the AMA and are copywritten by them. I have permission to teach and help providers understand the codes. OP REFERENCES 1. Spencer J, Patel M, Mehta N, et al. Special consideration regarding the assessment and management of patients being treated with mandibular advancement oral appliance therapy for snoring and obstructive sleep apnea. Cranio: 31(1):1.0 2. von Piekartz H, Lüdtke K. Effect of treatment of temporomandibular disorders (TMD) in patients with cervicogenic headache: a single-blind, randomized controlled study. Cranio. 2011;29(1):43-56.

Orthodontic practice 39

PRACTICE MANAGEMENT

occlusal splint, bite appliances/planes/splints, mandibular occlusal repositioning appliances) are or could be used for different reasons, but all are acceptable by insurance. Reversible intraoral appliances may be considered medically necessary in selected cases only when there is evidence of clinically significant masticatory impairment with documented pain and or loss of function. There needs to be a result of 6-8 months of monitoring prior to the application of appliance. The clinician cannot use words such as bruxism (because bruxism is a habit that can be broken so it doesn’t quality) or sports guard (because the sports guard is only worn to protect teeth while playing a sport). Each case must be pre-authorized. The diagnostic coding for most TMD treatment plans is listed with the insurance policy. You need to check each patient’s policy for the following information: • Diagnostic X-ray, tomograms, and arthrograms • Computed tomography (CT) scan or magnetic resonance imaging (MRI) (in general, CT scans and MRIs are reserved for presurgical evaluations) • Cephalograms (X-rays of jaws and skull) • Pantograms (X-rays of maxilla and mandible). º (Note: Cephalograms and pantograms should be reviewed on an individual basis.) The following nonsurgical treatments may be considered medical necessary in the treatment of a TMJ disorder: • Intraoral removable prosthetic devices/appliances, encompassing fabrication, insertion, and adjustment (such as soft and hard stabilization appliances, anterior positioning appliances, anterior bite appliances, and soft resilient appliances) • Pharmacologic treatment (such as anti-inflammatory, muscle relaxing, and analgesic medications) The following ICD-10-CM Codes are related to this specific billing: • Diseases of the digestive system (K00-K95) º K00-K14 Diseases of oral cavity and salivary glands • K00 Disorders of tooth development and eruption • K08 Other disorders of teeth and supporting structures • K08.8 Other specified disorders of teeth and supporting structures • Diseases of the musculoskeletal system and connective tissue (M00-M99) º M26 Dentofacial anomalies [including malocclusion] • M26.2 Anomalies of dental arch relationship

PRODUCT PROFILE

Gaidge Why measurement matters to an orthodontic business owner Business management icon Peter Drucker said it best: “What gets measured gets improved.” In other words, people can run on gut, hopes, and instincts, or they can run on facts and data points so that they actually know what is working well and what is not. Individuals must first understand what should be measured in their businesses, and then figure out systems to gather information (data points). From there, it is possible to begin to track and follow the trends that are impacting business performance and profitability.

• Added starts that detail and hover functionality with interactive selection on chart display • Color-coded arrows and numbers for quick reference comparisons • Improved practice administrator settings

Data tracking is now a must for managing business. It’s no longer “nice to have” It’s one thing to simply rely on financials or a few sources of information such as starts and conversion rate, but thriving practices know they are at risk if they aren’t capturing the whole picture. Fortunately, recent innovations in technology services offering cloud-based analysis have changed the game for the better. This has resulted in significant cost savings for small businesses, making it attainable to gain critical business insights and weave an end-to-end picture of their practice’s health.2 You don’t need a team or a dedicated individual to manage large volumes of data; you simply need to leverage the right tools.3

Powering your practice with tools that increase business performance Gaidge answers the complicated questions of what to measure and how to make it easy for business leaders to visualize and comprehend trends, thereby guiding them on where to focus efforts. Gaidge is a cloud-based business analytics software — custom-built for orthodontic practices. The program offers its users comprehensive analysis and seamless, automated access to their practice’s KPIs. With over 80 available metrics and 35 visual reports, Gaidge is

Suzanne Wilson joined Gaidge as the Chief Marketing Officer in September 2018. She has held leadership positions in operations, marketing, and business development in the oral care industry over the past 20 years. She earned her Bachelor of Arts in English and Executive MBA from the University of Utah. Learn more at https://www.linkedin.com/in/suzanne-wilson-8a158b1a/.

40 Orthodontic practice

an essential management tool that provides business intelligence dashboards, functional performance detail, benchmarking, and practice performance comparisons.

NEW! Just released — an improved platform, Gaidge 2.0 The Gaidge platform’s powerful features are automated with nightly uploads to give you unprecedented visibility into your practice’s performance, essential business metrics, and most important goals. The latest release of the software has been enhanced with a modern design, a simplified and more intuitive navigation, and several new features. Gaidge 2.0 was designed by a team of software developers and user experience (UX) designers to provide a fresh, easy-tonavigate, easy-to-comprehend software. The new platform features greater visibility to practice goal achievement, and users will find a new color-coding system intended to reduce cognitive processing and make information easier to understand in a snapshot. Gaidge 2.0 additional features: • Executive dashboard • Simplified and more intuitive topline navigation and location/period selection • Greater visibility to goals and goal achievement progress • Clear interactive legends, help, and analysis explanations

Celebrate progress and success to keep driving forward Gaidge provides significant time-savings and automation for up-to-date information about the health of your practice. Like a scoreboard, the Gaidge metrics provide owners what they need to celebrate wins and call the smart plays while also having an easier way to maintain team engagement and momentum.5 The principle behind the value of business metrics is not revolutionary, but it is proven: Keep your eye on your critical metrics, and improvement is inevitable. OP

REFERENCES 1. Quora contributor. How Is Big Data Changing the Business Landscape? Forbes. Published March 12, 2018. https:// www.forbes.com/sites/quora/2018/03/12/how-is-big-datachanging-the-business-landscape/#c9b95b63db25. Accessed September 23, 2019. 2. Lippa J, Pinnock C, Aisenbrey. What Health Care Leaders Need to Do to Improve Value for Patients. Harvard Business Review. Published December 3, 2015. https://hbr. org/2015/12/what-health-care-leaders-need-to-do-toimprove-value-for-patients. Accessed September 23, 2019. 3. Leong K. Your Team Doesn’t Need a Data Scientist for Simple Analytics. Harvard Business Review. Published October 30, 2015. https://hbr.org/2018/10/your-team-doesnt-need-adata-scientist-for-simple-analytics. Accessed September 23, 2019. 4. Kelleher K. What 3 Small Businesses Learned From Big Data. Inc. https://www.inc.com/magazine/201407/kevinkelleher/how-small-businesses-can-mine-big-data.html. Accessed September 23, 2019. 5. Davenport TH. How Analytics Has Changed in the Last 10 Years (and How It’s Stayed the Same). Harvard Business Review. Published June 22 , 2017. https://hbr.org/2017/06/ how-analytics-has-changed-in-the-last-10-years-and-howits-stayed-the-same. Accessed September 23, 2019. 6. Key performance indicators for dental practices: Management by statistics. Dental Economics. Published March 1, 2019. https://www.dentaleconomics.com/practice/article/ 16386298/key-performance-indicators-for-dental-practices -management-by-statistics. Accessed September 23, 2019.

Volume 10 Number 6

2.0 Data Analytics that Drive Winning Practice Performance

New Release! Redesigned with sleeker visuals, new time-saving features and better goal tracking.

Visit Gaidge.com or Call 800.287.3396. Connect With Us.