Orthodontic Practice US January/February 2020 Vol 11 No 1

clinical articles • management advice • practice profiles • technology reviews January/February 2020 – Vol 11 No 1 • orthopracticeus.com

Intersecting areas of law and dentistry: part 1 Dr. Bruce H. Seidberg

Severe crowding with a transverse skeletal discrepancy impacting self-esteem Dr. Antonino Secchi

Effective protocols for treatment of Class II malocclusion with moderate dental crowding Dr. Michael Bicknell

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l Orlando, Grande Lakes, FL The Ritz-Carlton

John Fisher, JD, CHC, CCEP

2020 HSO Symposium l March 26 - 28

Creating an effective process to identify and address regulatory risk in dental and orthodontic practices

THE EXCELLENCE REVOLUTION

PROMOTING EXCELLENCE IN ORTHODONTICS

A NEW PARADIGM IN ORTHODONTICS Recent publications by Dr. Eugene Roberts and Dr. David Sarver call SmartArch “a new paradigm in orthodontics” 1 and describe how SmartArch “averaged approximately 50% greater tooth movement than the control group”. 2

READ THE LATEST

1 2

Visit ormco.com/smartarch to learn how doctors are leveraging SmartArch.

Roberts, W.E. et al. SmartArch Multi-Force Super-Elastic Archwires: A New Paradigm in Orthodontics. JDO 55. July 1, 2019 Sarver, D.M. and Roberts, W.E. Superelastic archwire can achieve efficient movement and reduce trauma. Orthodontic Practice. Vol. 10 Number 6. November 2019

© 2019 Ormco Corporation

MKT-19-1026

ormco.com/smartarch

Jan/Feb 2020 - Volume 11 Number 1

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 2020. 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.

ISSN number 2372-8396

Volume 11 Number 1

E

ntering 2020 brings a new year and decade ahead. For some people, this is a moment to establish both short-term yearly resolutions and long-term decade goals. Regardless of what steps we laid out for ourselves, family, practices, and other important life interactions, we all shared January 1st as an opportunity to pause, reflect, calibrate, and plan for the days ahead.

What I find so beautiful in this day is our collective ability to break away from our daily routines to focus inwards and remind ourselves of our dreams. We empower ourselves to recenter our minds and thoughts again, and it allows us to focus once again on our passions.

In orthodontics that encompasses our practices, patients, teams, colleagues, and ourselves.

A decade in orthodontics can be a significant landscape change in so many of the spheres in which we interact. For example, the last decade included advancements in TAD-borne expanders, 3D printing, aligner therapy (in-house, direct-to-consumer, and multiple aligner companies), social media connections (patients and peer-to-peer), and braces technology among many other notable changes. Ten years can be a significant time period for positive and impacting changes, and as we carefully stack each year of progress on top of each other, we are creating profound changes in the orthodontic treatment process, experience, and outcomes in even 10-year blocks.

My father retired from dentistry at the beginning of 2020, and when we all reflected on his career, we reminisced not only about the last decade but almost 4 decades worth of memories. While most memories were fond moments of patients and their care, some of the reflections were milestones achieved in those many blessed years of practice ownership.

It was a moment to certainly celebrate, but we realized that it was not a celebration of just one individual.

I shared the following with him on the day that he was to sign the papers and officially have someone else write the next chapter in that practice’s story: “It is not a legacy that is only your story, but one that encompasses the narrative of so many that chose to journey with you. You are celebrating your accomplishments as much as that of your patients, your family, your current and past team members, and all those who have come in and out of the practice’s evolution — your electrician, IT support, practice cleaning staff, mail carrier, etc. None should be forgotten, and all should be loved and remembered at this moment. We rarely reach a personal milestone alone; it is the support of many along the way that help us to individually become successful.

“It is also important to remember that as much as you have helped so many with their dental and health needs, your contribution was not only to them. You helped bring people within the community into your team, helped them build their lives, and helped them support their families. Furthermore, your personal gains from your practice helped you build your family. As important as both of these achievements are, your equally greatest benefit of your personal gains comes in the way of your strong capacity to have given back to the people who need it most in the world. The philanthropy and charitable contributions are what really fill our hearts and minds, and those acts of kindness profited from what the practice could do for you.

“Value in this world should have less of a focus on consumption and more on giving.

You can now be grateful for the memories, achievements, challenges, and growths that the years have brought you, and when you finally make that last signature, you can be proud that the baton will be passed to help others write their own incredible story for themselves, their patients, their team, their community, and hopefully in helping those who need it most.”

As we establish our goals for the coming year and decade, may we remember that our orthodontic goals and hard work ethics can benefit so many around us, and when we reach those milestones, it was because of the many helping hands carrying us to those moments.

May you all move forward with clarity and 20/20 vision. The future for orthodontics is bright, and if the advances of the last decade are any indication, we are in store for some beautiful changes in the coming decade.

Finally, for those of you who may be leaving orthodontics in the coming decade or left in the last decade, thank you for being our inspiration, role models, and mentors — and for showing us that love and passion can successfully thrive in our orthodontic profession!

Dr. Shalin Shah Shalin Raj Shah, DMD, MS, received his Certificate of Orthodontics and Masters of Science in Oral Biology from the University of Pennsylvania and is a Diplomate of the American Board of Orthodontics.

He is also a graduate of the University of Pennsylvania College of Arts and Sciences and School of Dental Medicine. Currently, Dr. Shah is in private practice (Center for Orthodontic Excellence) in Princeton Junction, New Jersey. You can contact Dr. Shah by email at drshah@coesmiles.com, or visit his website: www.coesmiles.com.

Orthodontic practice 1

INTRODUCTION

20/20 visions

TABLE OF CONTENTS

Case report Severe crowding with a transverse skeletal discrepancy impacting self-esteem

8 Publisher’s perspective

Dr. Antonino Secchi illustrates his two-phase treatment plan

Resolution or resolve? Time to take positive action in 2020!

Lisa Moler, Founder/CEO, MedMark Media................................6

Orthodontic perspective Alveolar bone augmentation through orthodontic tooth movement: a case report Dr. Donald J. Rinchuse shows how evidence-based literature helped guide his treatment plan............................ 20

Continuing education

Case study Effective protocols for treatment of Class II malocclusion with moderate dental crowding Dr. Michael Bicknell discusses how two patients who declined the primary treatment plan still achieved an excellent outcome

2 Orthodontic practice

14

Creating an effective process to identify and address regulatory risk in dental and orthodontic practices John Fisher, JD, CHC, CCEP, discusses the elements needed to implement an effective compliance program..........................................24

Volume 11 Number 1

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TABLE OF CONTENTS Book review

Marketing momentum

Elemental: How the Periodic Table Can Now Explain (Nearly) Everything...................................35

Your dental message — delivered

Going viral Does your cybersecurity commitment in 2020 support your orthodontic practice compliance requirements?

Mark Pribish defines terms to help your office recognize and avoid cyberattacks....................................36

Continuing education Legal matters Intersecting areas of law and dentistry: part 1 Dr. Bruce H. Seidberg begins his comprehensive discussion of risk management...................................28

Orthodontic insight Changing with the times Dr. Bill Dischinger discusses delivering a better product to an ever-changing patient population............................34

Using a Truth-in-Lending Statement in clinical orthodontic practice Dr. Laurance Jerrold discusses legal requirements that relate to extending credit to patients..............................38

Product profile Make complex cases less complex with AcceleDent® Optima™......................................41

Dental marketer, Jackie Raulerson, offers insights into crafting engaging articles for dental publications.......... 42

Practice management How to find a paymentprocessing partner that will help you make money Samantha Ettus discusses how controlling payment-processing is crucial to your business................... 45

Compromise is the difference between a good leader and a dictator Dr. Christopher Hoffpauir discusses insights into providing feedback to employees....................................... 46

Small talk The abundant leader Drs. Joel C. Small and Edwin McDonald love the idea of abundance and promote this concept with their clients.............................................. 48

Stay Connected Between Issues Like us on Facebook at facebook.com/OrthodonticPracticeUS Share with us on Instagram at instagram.com/orthodonticpracticeus Follow us on Twitter at twitter.com/orthopracticeus Watch our DocTalk Dental videos at doctalkdental.com Opt-in to our eNewsletter at orthopracticeus.com Connect. Be Seen. Grow. Succeed. www.medmarkmedia.com

4 Orthodontic practice

Volume 11 Number 1

PUBLISHER’S PERSPECTIVE

Resolution or resolve? Time to take positive action in 2020!

T

he New Year is a time for resolutions — which has led me to think of the true meaning of that word. Resolution is defined as “a firm decision not to do something.” That doesn’t sound so positive to me. I am more invested in the word resolve, defined as to “decide firmly on a course of action.” That’s more like it!

As leader of the MedMark team, our vision and our goals for 2020 are positive — we don’t want to “not do something”; we are going to take action on many exciting innovative, creative projects for our readers and advertisers. This year, on our media side, we continue to inform and educate through DocTalk videos and podcasts. For clinicians involved with dental sleep medicine, our new ZZZ Pack Podcast will bring news and views from some of the most knowledgeable sleep-focused dentists in Lisa Moler Founder/Publisher, MedMark Media the niche. Also, Dr. Rich Mounce will feature many of our most popular authors on his Dental Clinical Companion Podcast. In the past few years, I have been fortunate to help motivate our audience by interviewing some phenomenally inspiring people — Shaquille O’Neal, Tony Robbins, Simon Sinek, and Dr. Oz, and I will continue to connect you with those who can encourage you to expand your horizons.

Our print and digital articles continue to keep you on the cutting edge of clinical and practice management ideas and information. In this compliance-focused issue, our two CEs deal with how this important topic impacts the dental practice. John Fisher, a practicing health care regulatory lawyer, identifies the importance of creating and operating effective internal compliance programs in dental and orthodontic practices, and identifies the basic elements for an effective compliance program. Dr. Bruce Seidberg, a Board-certified endodontist and consultant for dental malpractice cases, authored part 1 of a comprehensive discussion of risk management. Dr. Laurance Jerrold explains legal requirements that relate to extending credit to your patients. On the clinical side, Dr. Michael Bicknell shows his effective protocols for treatment of Class II malocclusion with moderate dental crowding, and Dr. Antonino Secchi illustrates his treatment for a patient who suffered from self-esteem issues due to severe crowding with a transverse skeletal discrepancy. Also, Dr. Donald J. Rinchuse shows how evidence-based literature helped guide his treatment plan for a patient who needed alveolar bone augmentation during orthodontic treatment.

2020 has just started, and the opportunities to expand your practice potential are endless!

Along with our constant resolve to inform you through the written word of the most current technologies, products, services, and techniques, keep watching for us online and in person at major dental meetings and events across the United States. Please continue to contact us with your article ideas or if you want to take part in one of our online chats or podcasts. This year, “resolve” along with us to “embrace the exceptional.” Start the decade as we have — deciding firmly on a course of positive action based on solid science, facts, and innovation.

To your best success in 2020!

Lisa Moler Founder/Publisher MedMark Media

Published by

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 FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

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6 Orthodontic practice

Volume 11 Number 1

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CASE REPORT

Severe crowding with a transverse skeletal discrepancy impacting self-esteem Dr. Antonino Secchi illustrates his two-phase treatment plan

A

few years ago I had the opportunity to treat a little girl with a rather big selfconfidence problem mainly due to her smile.

We always praise our specialty for changing people’s lives as we improve their smile and self-confidence, but it takes a case like Caitlin’s to really appreciate the power of what we do with orthodontics, and how much we can positively affect someone’s personality and self-esteem.

Caitlin, an 11-year-old female, consulted in our office with the chief complaint of “my front tooth is sticking out of my mouth.” Her medical history was not relevant, and she had no dental and/or TMJ pain or discomfort. She was in late mixed dentition, showing Class II end-on with severe crowding on her upper arch and moderate crowding in her lower arch. Her upper right central incisor was ectopically positioned (Figure 1). She had a skeletal transverse discrepancy diagnosed using the CAC analysis.1-3 Her maxilla was narrow when compared to her mandible.

My treatment plan was to treat Caitlin in two phases: • Phase 1 with a rapid palatal expander (RPE) to correct the transverse discrepancy in conjunction with partial bonding of the upper arch to improve the alignment, specifically of the upper right central incisor.

• Phase 2 with comprehensive orthodontic treatment bonding the upper and lower arch

Antonino G. Secchi, DMD, MS, is an alumnus of the University of Pennsylvania School of Dental Medicine, where he received his Doctorate of Dental Medicine, Certificate in orthodontics, and a Master of Science in oral biology. Dr. Secchi is a Diplomate of the American Board of Orthodontics and a member of the prestigious Edward H. Angle Society of Orthodontists. He also holds membership in various local, national, and international dental and orthodontic societies and was the 2016 President of the Greater Philadelphia Society of Orthodontists. He is currently in practice in Pennsylvania.

Phase 1 treatment (Figures 2-4) A Haas-type RPE was cemented and activated at a rate of two turns per day for 20 days to open the expander 10 mm. Once the RPE activation was finished, we partially bonded the upper arch, including first premolars, lateral incisors, and central incisors.

The appliance used was an In-Ovation® R CCO® (Complete Clinical Orthodontics) Rx

(Dentsply Sirona Orthodontics). The initial wire was a 0.014" Sentalloy® followed by a 0.020" x 0.020" BioForce® (Sentalloy and BioForce are thermal activated superelastic wires from Dentsply Sirona Orthodontics).

The RPE was removed after 4.5 months. The 0.014" Sentalloy and the 0.020" x 0.020" BioForce were in place for 4 months each.

This phase of treatment lasted a little over

Figure 1

Disclosure: Dr. Secchi is the founder of the Complete Clinical Orthodontics System™ (CCO System), which he teaches to orthodontists in the United States and worldwide.

Figure 2 8 Orthodontic practice

Volume 11 Number 1

INITIAL

FINAL

Case presentation by Dr. Gina Theodoridis from Athens, Greece (Case ID: 048) ESTIMATED TREATMENT TIME

30 MONTHS ACTUAL TREATMENT TIME WITH ACCELEDENT

17 MONTHS

44% less time Diagnosis: Class I molar, Class III canine, right posterior crossbite, Anterior open bite Aligner change routine: 5 days Mechanics: - Simultaneous sequential distalization in all four quadrants - Anterior crossbites of lower canines and reverse smile line resolved with aligners - Right side occlusion: the lower incisors were pushed forward

Focus: palatally-displaced and crowded lateral incisor

CASE REPORT

Figure 3

8 months. The main two objectives, to correct the transverse discrepancy and to align the maxillary incisors, were achieved.

Phase 2 treatment (Figures 5-11) Needless to say, after Phase 1, Caitlin and her mother were very happy with the result. They were excited and anxious to start “full braces� and, therefore, we decided to start Phase 2 a little earlier than what I would have wanted since the upper canines were not in yet. They understood that starting now would probably make the overall treatment time longer, but they were fine with that.

Figure 5

Figure 6

Figure 4

For full bonding of the upper and lower arch, we used In-Ovation R CCO Rx. This phase of treatment was divided in three stages following the CCO treatment

mechanic sequence.4-6 For Stage 1 (Figure 5), we used a 0.014" Sentalloy followed by a 0.020" x 0.020" BioForce wire with the objective of leveling, aligning, correcting all rotations, and beginning to level the occlusal plane. For Stage 2 (Figures 6 and 7), we used a 0.019" x 0.025" SS wire. At this stage, upper and lower wires were coordinated to achieve the proper overjet from molar to molar. Spaces were consolidated using a power chain. The occlusal plane was completely leveled thanks to the stiffness of the steel wires, and sagittal correction was achieved using short Class II elastics (3/16" 4 oz) from upper canine to lower second premolar.

For Stage 3 (Figure 8), we used a braided 0.019" x 0.025" SS wire. Although this wire is a steel wire since it is braided, it provides enough flexibility to be able to improve the intercuspation when using elastics in a vertical triangular fashion (3/16" 4 oz). Also, if there is the need to do any bracket reposition, this wire can easily engage the bracket from it new position.

After 24 months, braces were removed, teeth were polished, and upper and lower

Figure 7

Figure 8 10 Orthodontic practice

Volume 11 Number 1

Orthodontists are using Invisalign First treatment to stand out from the competition. ®

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CASE REPORT Essix retainers were given to Caitlin with the instruction of wearing them every day at nighttime.

Orthodontically speaking, most goals were achieved, and Caitlin’s smile was greatly improved (Figures 9-11). However, the changes between the before-and-after treatment pictures cannot properly show how much Caitlin’s confidence, self-esteem, and overall happiness were transformed. In our daily busy schedule, when sometimes treatments fall into a routine, it is good to be reminded that often we do a lot more than straighten teeth. OP

REFERENCES: 1. Hayes JL. In search of improved skeletal transverse diagnosis. Part 1. Orthodontic Practice US. 2010;1(3):34-39.

2. Hayes JL. In search of improved skeletal transverse diagnosis. Part 2: A new measurement technique used on 114 consecutive untreated patients. Orthodontic Practice US. 2010;1(4):34-39.

3. Hayes JL. Proposed clinical skeletal transverse measurement technique—palpation adjacent to the molars. Orthodontic Practice US. 2011;2(2):28-29.

4. Secchi AG. Complete Clinical Orthodontics: Treatment Mechanics Part 1. Orthodontic Practice US. 2013;4(1): 28-35.

5. Secchi AG. Complete Clinical Orthodontics: Treatment Mechanics Part 2. Orthodontic Practice US. 2013;4(2): 28-32.

Figure 9

6. Secchi AG. Complete Clinical Orthodontics: Treatment Mechanics Part 3. Orthodontic Practice US. 2013;4(3): 38-41.

Figure 10

Figure 11 12 Orthodontic practice

Volume 11 Number 1

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CASE STUDY

Effective protocols for treatment of Class II malocclusion with moderate dental crowding Dr. Michael Bicknell discusses how two patients who declined the primary treatment plan still achieved an excellent outcome Introduction In today’s market, patients are exposed to numerous options when it comes to orthodontic care. In order to remain the clear and best option, the orthodontic specialist must be able to provide better outcomes and an improved patient experience to remain the provider of choice. Luckily, there has been amazing product innovation that we can use as tools in this endeavor. By coupling these innovative technologies with a desire for continual learning and refining of our skills, we can simplify our processes, reduce treatment times, and improve the patient’s experience — all while achieving excellence in our results. Exceptional patient results along with amazing patient experiences are what will continue to differentiate the orthodontic specialists from other market choices available, now and in the future.

When I began my clinical career, I was fortunate to have been taught by a wonderful group of instructors all with varying techniques. With today’s access to information, we are not only able, but also obligated to pursue improved techniques to deliver the highest quality of patient care. When I began using passive self-ligation (PSL), I was drawn to the beautiful smiles and artistry that I wasn’t seeing in my own cases. These amazing results were the primary reason for my move to PSL. It wasn’t until later that I realized, in addition to the beautiful smiles, PSL would also allow for increased efficiency,

decreased sensitivity, and an improved patient experience.

There are times as orthodontists that we have an ideal treatment plan worked out, but it is not accepted by the patients or parents of our patients for a variety of reasons. This results in stress because of altering our recommendation to satisfy the patients’ requests and the fear of not being successful in our desired outcomes. The following two cases illustrate a deviation from the original treatment plan proposed due to strong patient objections over the recommended treatment. They also demonstrate the power of light forces, anterior torque control, and transverse dental development in regard to the treatment of crowding and Class II correction. The final results satisfied the original treatment objectives, provided excellent outcomes, and created very happy patients.

Case 1 Diagnosis An 11½-year-old male presented with a Class II Division 1 malocclusion with severe maxillary crowding and moderate mandibular crowding. The facial profile was convex with a retrusive mandible. Thin lip strictures were noted along with tapered buccal segments and a poor smile arc due to insufficient incisor display when smiling.

Objectives/plan The objectives were to create space for the U3’s while maintaining maxillary incisor position, attain Class 1 molars and canines, improve the smile arc by erupting incisors, and develop the posterior segments for increased arch length as well as improved smile width. The initial treatment plan presented included using a Herbst appliance to address the Class II malocclusion; however, the parent declined using the function appliance due to a strong bias against it. Therefore, passive self-ligation with Class II elastics was the treatment plan that was presented and accepted.

Case setup The brackets chosen were Damon™ Q passive self-ligation standard torque upper and lower. The severe crowding in the maxillary arch would normally lead to a low torque bracket selection; however, the Class II elastics would negate the forward movement, thus the reason for the choice of standard torque. All permanent teeth were bonded except for the U3’s. The U/L 5’s along with the U/L 7’s would be bonded once they erupted. As an observation, initiating treatment while the deciduous second molars are present helps with the Class II correction by utilizing the e-space, assuming the patient is wearing Class II elastics when they

Michael Bicknell, DDS, MS, earned his DDS and completed a residency in orthodontics at the University of Illinois at Chicago College of Dentistry where he also received a MS in oral biology. He is a former clinical instructor at the university and continues his involvement there by lecturing to dental students and orthodontic residents throughout the year. In private practice in Elmhurst, Illinois, he is a Diplomate of the American Board of Orthodontics and an internationally recognized educator, presenting to thousands of orthodontists on subjects such as efficient treatment, esthetics, leadership, and creating a culture of excellence.

Disclosure: Dr. Bicknell is a Damon™ System Mentor.

Figure 1: Case 1 14 Orthodontic practice

Figure 2: Case 1 — initial Volume 11 Number 1

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CASE STUDY

Figure 3: Case 1 — initial pan

are exfoliated. The bite was disarticulated, and 2 oz. 3/16 elastics were started from the U4’s to the L6’s.

Case progression Visit 1: Bracket placement with 0.014 CuNiTi U/L and NiTi open coil springs from the U2-U4 R/L were placed to create space for the U3’s. An early elastic protocol was started using 2 oz. 3/16 Class II elastics from the U4’s to the L6’s full-time. The occlusion was disarticulated by placing bite stops on the U6’s to reduce the effects of incline planes.

The next appointment interval was 10 weeks.

Visit 2: Change wires to 0.018 CuNiTi U/L with activation of open coil springs and continue Class II elastics. The next appointment interval was 10 weeks.

Visit 3: Change wires to 0.14 x 0.025 CuNiTi U/L with activation of open coil springs and continue Class II elastics. The next appointment interval was 10 weeks.

Visit 4: Maintain archwires with activation of open coil springs and allow U3’s to erupt.

The next appointment interval was 10 weeks.

Visit 5: Bond U3’s, replace wires, and continue Class II elastics. The next appointment interval was 8 weeks.

Visit 6: Change wires to 0.018 x 0.025 CuNiTi U/L and continue Class II elastics.

The next appointment interval was 8 weeks.

Visit 7: Progress records were taken, and repositioning of brackets was completed

Figure 7: Case 1 — final pan 16 Orthodontic practice

Figure 4: Case 1 — initial digitized ceph

along with bonding of the U/L 5’s. Archwires were changed to 0.014 x 0.025 CuNiTi U/L due to the position of 5’s. The next appointment interval was 8 weeks.

Visit 8: Change wires to 0.18 x 0.025 CuNiTi U/L, and continue Class II elastics.

The next appointment interval was 8 weeks.

Visit 9: Change wires to 0.019 x 0.025 stainless steel (SS) upper and 0.016 x 0.025 SS lower, Lace U3-3 and place tiebacks from posts to U6’s on the upper arch. The next appointment interval was 6 weeks.

Visits 10-12: Finishing details were completed along with direct placement of the upper 2112 braided SS fixed retainer and a digital scan for interim U/L Essix retainers and a custom-made 0.026 SS fixed L3-3.

Figure 5: Case 1

Posttreatment follow-up: Final records and scan for final Essix retainers — two sets U/L worn at night.

Overview An overview of the case resulted in the Damon Q passive self-ligation standard torque upper and lower correcting the Class II maloccluision to functional Class I occlusion along with substantial arch development. Maxillary incisor position and angulation were maintained with some advancement and proclination of the lower incisors observed. Overall, the patient grew in a favorable direction and was very compliant, only requiring 2oz. 3/16 elastics for the duration of the treatment worn from the U4’s to

Figure 6: Case 1 — final

Figure 8: Case 1 — final digitized ceph Volume 11 Number 1

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CASE STUDY the L6’s. From a clinical efficiency standpoint, the patient had 12 treatment visits and was completed in 18 months.

Case 2 Diagnosis A 28-year-old female presented with a Class II Division 1 malocclusion with moderate maxillary crowding and mild mandibular crowding. The mandibular first molars were missing due to previous extractions as a child, resulting in mesial tipping of the second molars. Over-eruption of the maxillary left first molar was evident from the effects of the extractions as well. The facial profile was convex with a well-positioned mandible. Radiographic analysis shows protruded and proclined maxillary incisors and protruded lower incisors. Lips were full and protruded along with tapered buccal segments and a poor smile arc due to insufficient incisor display when smiling.

Objectives/plan The objectives were to improve maxillary incisor position through retraction, attain Class I canines, improve the smile arc by erupting incisors, and develop the posterior segments for improved smile width. The initial treatment plan presented included extraction of U4’s to reduce overjet and retract incisors; however, the patient had such a negative experience as a child with the removal of the mandibular first molars that she would not allow additional extractions. Therefore, a non-extraction plan using passive self-ligation with Class II elastics, along with the use of temporary anchor devices (TADs) to protract the mandibular posterior segments and to intrude the maxillary left first molar, was the treatment plan that was accepted.

Case setup The brackets chosen were Damon Q passive self-ligation standard torque upper and lower with high-torque brackets on the maxillary canines. All permanent teeth were bonded, and four 8mm VectorTAS™ were placed — one on the buccal and one on the palatal of the UL6 to intrude, and one between the mandibular canine and first premolar on both the right and left sides.

A stainless steel ligature tie was twisted and ligated from the TAD to the first molar bracket to prevent distal movement of the crown and to encourage mesial root tip of the first molars during leveling. The bite was disarticulated, and 2 oz. 3/16 elastics were started from the U4’s to the L6’s.

18 Orthodontic practice

Figure 9: Case 2

Figure 10: Case 2 — initial

Figure 11: Case 2 — initial pan

Case progression Visit 1: Bracket placement with initial 0.014 CuNiTi U/L and placement of TADs as noted above. An early elastic protocol was started using 2 oz. 3/16 Class II elastics from the U4’s to the L6’s full-time. The occlusion with disarticulation by placing bite stops on the U6’s to reduce the effect of incline planes. The next appointment interval was 10 weeks.

Visit 2: Change wires to 0.018 CuNiTi U/L. Activate intrusion on the UL6. The next appointment interval was 10 weeks.

Visit 3: Change wires to 0.14 x 0.025 CuNiTi U/L. Activate intrusion on the UL6.

The next appointment interval was 10 weeks.

Visits 4-6: Change wires to 0.018 x 0.025 CuNiTi U/L, and continue Class II elastics. At this point, the UL6 was level, and the intrusion was complete; therefore, the maxillary TADs were removed. The mandibular first molars were still uprighting, so the current wires were maintained for three visits, and the patient was seen every 10 weeks.

Uprighting was complete, and the mandibular TADs were removed at the sixth visit, which was 60 weeks into treatment.

Visit 7: Progress records were taken, repositioning of brackets was completed, and the archwires were maintained for an additional 4 weeks.

Visit 8: Change wires to 0.019 x 0.025 SS upper and 0.016 x 0.025 SS lower, lace

Figure 12: Case 2 — initial digitized ceph

U3-3, and place tiebacks from posts to U6’s on the upper arch. The next appointment interval was 6 weeks.

Visits 9-13: Finishing details along with esthetic gingival recontouring was completed on the U2-2. Retention plan included direct placement of the upper 2112 braided SS fixed retainer and a digital scan for interim U/L Essix retainers with a custom-made 0.026 SS fixed L3-3.

Posttreatment follow-up: Final records and scan for final Essix retainers — two sets U/L worn at night and a referral was given for removal of the maxillary left third molar.

Overview An overview of the case resulted in the Damon Q PSL standard torque upper and lower correcting the Class II malocclusion to a functional Class I occlusion along with substantial arch development. Maxillary incisor position was improved, and angulation was maintained. The significant arch development created along with the Class II elastics allowed for the incisor retraction. The patient was very compliant, only requiring 2 oz. 3/16 elastics for the duration of the treatment worn from the U4’s to the L6’s. From a clinical efficiency standpoint, the patient had 13 treatment visits and was completed in 23 months.

Summary and conclusion The two case examples presented Volume 11 Number 1

Figure 15: Case 2 — final pan

Figure 14: Case 2 — final

Figure 16: Case 2 — final digitized ceph

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Volume 11 Number 1

Orthodontic practice 19

CASE STUDY

Figure 13: Case 2

illustrate many of the outcomes that become very predictable with the Damon System.

Significant transverse arch development, Class II correction using light elastics, and torque control of the incisors are only a few of the benefits that help improve our clinical results. Shorter treatment times, reduced number of appointments, and decreased discomfort provide an improved patient experience. With the newest addition to the Damon System, the Damon Q2 bracket — featuring 2x rotational control for improved precision, predictability, and reliability — treatment efficiency can be increased.

Because of this, I have incorporated Damon Q2 into all of my treatment cases. In an everchanging market filled with multiple choices by our patients, providing excellent results along with enhanced patient experience will differentiate the orthodontic specialist as the best choice for orthodontic treatment to our patients. OP

ORTHODONTIC PERSPECTIVE

Alveolar bone augmentation through orthodontic tooth movement: a case report Dr. Donald J. Rinchuse shows how evidence-based literature helped guide his treatment plan

A

n 11-year 7-month old female presented for an orthodontic consultation with a Class II malocclusion and all four second bicuspids extracted as well as the mandibular right first molar (Figures 1A-1E). The extraction spaces for these teeth were open and particularly large for the mandibular right second bicuspid/first molar area. The patient’s mother said that a pediatric dentist removed these teeth some time ago, and she did not know the reason (possibly to mitigate crowding and/ or tooth decay).

On evaluation of the initial panoramic radiograph (Figure 2), it was observed that the area of the large extraction space of the missing mandibular right second bicuspid/ right first molar was very radiolucent, indicating a bony defect. Further, from a clinical examination of this region (as well as a consideration of the panoramic radiographic findings), it was noted that there was little alveolar ridge in this region. The most logical explanation for the bony defect in this area was that on extraction of the mandibular right second bicuspid and right first molar, the buccal and lingual cortical plates were fractured. Parenthetically, the most distal molar in the mandibular right quadrant was by all accounts a third molar.

The issue for space closure into the bony defect left from the extractions of the mandibular right second bicuspid and right first molar was whether or not this was possible without jeopardizing the teeth being moved into the defect. That is, would the teeth being moved into the bony defect now be surrounded by defective bone and then be fraught by periodontal and endodontic

Reading and knowing the dental and orthodontic literature, particularly the evidence-based literature, are clearly an important part of modern-day orthodontic clinical practice and can improve patient care.

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.

Figures 1A-1E: Initial intraoral photographs of an 11-year 7-month-old female orthodontic patient 20 Orthodontic practice

Volume 11 Number 1

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ORTHODONTIC PERSPECTIVE

Figure 2: Initial panoramic radiograph showing the bony defect of the mandibular right quadrant where the second bicuspid and first molar had been extracted

Figure 3: Progress panoramic radiograph 9 months later showing the bony defect improving as space was closing

problems leading to tooth loss? Or, on an optimistic note and based on the literature,1-6 would bringing the so-called good bone of the adjacent teeth into the bony defect augment the bone in this area?

Orthodontic treatment included the use of a .022 inch slot, pre-adjusted, fixed edgewise appliance; light Class II inter-arch elastics; intra-arch power chain elastics; and .016 x .025 inch and .018 x .025 inch stainless steel maxillary and mandibular “working” archwires.

At the end of orthodontic treatment, all the extraction spaces were closed in all four quadrants, including the large one in the mandibular right quadrant. Orthodontic treatment took 23 months and 17 appointments. From an examination of the progress and final panoramic radiographs (Figures 3 and 4), it was evident that orthodontic space closure caused bone augmentation of the mandibular right second bicuspid/ first molar region, consistent with reports in the dental literature.1-6 Incidentally, the third molar in the mandibular right quadrant was nicely aligned.

Reading and knowing the dental and orthodontic literature, particularly the evidence-based literature, are clearly an important part of modern-day orthodontic clinical practice and can improve patient care. And as gleaned from this case report, it served to guide the treatment of this patient. OP

REFERENCES 1. Goldberg D, Turley PK. Orthodontic space closure of the edentulous maxillary first molar area in adults. Int J Adult Orthodon Orthognath Surg. 1989;4(4):255-266.

2. Hom BM, Turley PK. The effect of space closure of the mandibular first molar area in adults. Am J Orthod.

1984;85(6):457-469.

3. Lindskog-Stokland B, Wennström JL, Nyman S, Thilander B. Orthodontic tooth movement into edentulous areas with reduced bone height. An experimental study in the dog.

Eur J Orthod. 1993;15(2):89-96.

4. Wennström JL, Stokland BL, Nyman S, Thilander B. Periodontal tissue response to orthodontic movement of teeth with infrabony pockets. Am J Orthod Dentofacial Orthop.

1993;103(4):313-319.

5. Vardimon A, Nemcovsky CE, Dre E. Orthodontic tooth movement enhances bone healing of surgical bony defects in rats. J Periodontol. 2001;72(7):858-864.

Figure 4: Final panoramic radiograph showing closure of the extraction space of mandibular right quadrant and bony defect corrected through orthodontic tooth movement

22 Orthodontic practice

6. Nemcovsky CE, Beny L, Shanberger S, Feldman-Herman S, Vardimon A. Bone apposition in surgical bony defects following orthodontic movement: a comparative histomorphometric study between root- and periodontal ligamentdamaged and peridontally intact rat molars. J Periodontol.

2004;75(7):1013-1019.

Volume 11 Number 1

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CONTINUING EDUCATION

Creating an effective process to identify and address regulatory risk in dental and orthodontic practices John Fisher, JD, CHC, CCEP, discusses the elements needed to implement an effective compliance program

S

ystematic compliance programs have become a necessary mechanism to reduce the risk of potential regulatory penalties. Providers are putting more and more resources into formal programs and processes aimed at proactively identifying areas of regulatory risk and using self-audits to self-police for overpayments, potential abuse, and even health care fraud. This article identifies the importance of creating and operating effective internal compliance programs in dental and orthodontic practices and identifies the basic elements that should be present to assure that a compliance program is effective.

Reimbursement risks and compliance focus The primary force necessitating proactive compliance efforts are the potentially serious penalties for health care reimbursement fraud and abuse.1 Providers are subject to potential program exclusion, civil monetary penalties, False Claims Act penalties, and even criminal exposure for failure to follow complicated reimbursement rules.2 Dental and orthodontic practices receive significant governmental reimbursement, especially through the Medicaid program. In fact, the Affordable Care Act resulted in an expansion in orthodontic coverage for children whose medical necessity criteria are met in situations involving medical issues such as malocclusions that are caused by trauma. As reimbursement opportunities have expanded, we have seen an upswing in fraud enforcement actions in the dental

John Fisher, JD, CHC, CCEP, is a practicing health care regulatory lawyer and is certified in health care compliance with the Health Care Compliance Association and in corporate compliance and ethics by the Society for Corporate Compliance and Ethics.

Disclaimer: This article is intended to provide general information and is not intended as legal advice. The law and interpretations of the law may change, while each situation is distinct. For legal guidance on specific situations, dentists should consult their attorneys.

24 Orthodontic practice

Educational aims and objectives

This article aims to discuss the importance of creating and operating effective internal compliance programs in dental and orthodontic practices.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 27 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Define systematic compliance programs.

•

Realize the potential for serious penalties for health care reimbursement fraud and abuse.

•

Recognize the structure of a compliance program necessary to minimize potential regulatory risk.

•

Recognize the importance of compliance training.

•

Realize the need for consistency in compliance policies.

area. Claims audits, overpayment demands, governmental investigations, and even fraud prosecutions are becoming more common in the dental industry.

Recent dental fraud cases You can open virtually any dental industry trade publication and find current examples of fraud prosecutions involving providers in the dental industry. A few recent fraud cases illustrate that dentistry is not immune from fraud and abuse scrutiny.

• In 2014, a large national pediatric dental chain was excluded from participation in the Medicare and Medicaid programs following allegations of overbilling resulting from the provision of medically unnecessary services.3 • In 2019, North Carolina prosecutors reached a $728,450 settlement with a dentist following allegations that the provider performed and billed for medically unnecessary services.4 • A New York dentist, office manager, and dental assistant were accused of paying Medicaid recipients $25.00 to undergo minimal dental procedures and billing Medicaid for additional dental services that were not provided. According to the DOJ press release, the dentist was

sentenced to a prison term of up to 10 years.5 • A West Virginian dentist was sentenced to 5 years in jail and agreed to repay $2.2 million for falsely billing Medicaid more than $700,000 for services that were improperly upcoded from simple extractions to extractions of impacted teeth.6

More typical compliance issues While the reported cases are illustrative, the typical dentist does not normally engage in systematic health care fraud. Yet even the most honest provider can fail to adequately document a service in a manner that supports the code under which the service is billed. The more common situation occurs, for example, when a provider knows that he/she actually provided a medically necessary service, but the documentation does not sufficiently support the medical necessity of the service or a more complex service. For example, a dentist might extract a wisdom tooth, but not properly document that a more complex extraction was necessary because the tooth was impacted. Documentation deficiencies tend to be repeated if they are not monitored or audited. The end result can be a significant overpayment obligation over time. Although these cases might not amount to intentional fraud, they can still Volume 11 Number 1

Compliance program structure Consistently operated compliance programs are the single best way to minimize potential regulatory risk. A compliance program creates a living and breathing process to continually assess the risks that are present in a specific organization. Large organizations will have broad compliance program coverage to reflect the risk profile of a large and diversified organization. A smaller and more operationally focused organization will have a smaller risk profile, and the scope and depth of compliance coverage will necessarily be more modest. What is important is that each organization focuses on the specific risk that applies to the nature and scope of its operations. Each organization should have a process to identify and rank the most significant areas of risk. Based on a Volume 11 Number 1

The compliance system is cyclical in nature, always assessing itself, always improving, always detecting new risks, and always measuring ongoing performance. prioritized list of compliance risks, the organization can make decisions about allocation of resources in furtherance of proactive auditing, monitoring, or other processes to determine compliance and to take corrective action where necessary. That is a compliance program in a nutshell.

The seven elements of a compliance program There are numerous details that should be present to assure compliance effectiveness, many of which should be reflected in policy and in practice. The compliance industry has developed standard compliance program elements and the detailed requirements within each of these requirements.8 For the most part, these compliance program elements emanated from the Federal Sentencing Guidelines, which give cooperation credit based on the existence of an effectively operated compliance program.9 Seven core elements of compliance can be distilled from the sentencing guidelines. These basic elements have been brought forward into more recent regulations that mandate compliance program operation in certain areas of health care, as well as compliance program guidance documents that have been issued by the Office of Inspector General and the United States Department of Justice over the years.10 Every compliance program, large or small, should contain each of the following core seven elements of compliance.

1. Compliance officer A high-ranking member of management must be appointed to act as compliance officer. In a smaller practice, a complianceresponsible individual can be used rather

than a full-blown compliance officer. Compliance program structure can be scalable to the size and resources of the provider and the nature and complexity of the business.

Larger organizations will require a dedicated compliance officer and even a developed compliance department with a range of compliance support staff. Smaller organizations can get by with a compliance individual who holds other roles within the organization. Be careful about relying too much on concepts of scalability. The central requirement is that the individual who is responsible for compliance has sufficient time and resources to properly conduct the necessary compliance activities at a level that is appropriate for the size and nature of the provider organization.

2. Compliance policies Compliance policies should be put in place that describe the process to be used to conduct ongoing compliance activities.

Compliance policies will define compliance operations and will also outline requirements in risk areas that are specific to the nature of the practice. Every program should have certain core areas of policy coverage such as establishment of a continually functioning process, definition of the seven key elements, and other areas that are central to the core requirements of compliance.

Each organization should also develop specific policies covering areas of identified risk within the organization. For example, an organization that takes government reimbursement will want to have reimbursement policies. There can be general reimbursement policies, but there should also be policies covering the requirements for common areas of billing that take place within the organization. For example, an orthodontic practice that provides medically necessary services to children and receives Medicaid reimbursement should have a specific policy addressing the requirements for receiving reimbursement, including appropriate documentation of medical necessity.

3. Compliance training Employees, contractors, and others must be trained on basic compliance program elements and risk areas that are applicable to their job functions. Compliance training requirements should be described in training policies. All staff should be required by policy to take core compliance training and periodic refresher training. Staff should also be Orthodontic practice 25

CONTINUING EDUCATION

result in significant penalties if not handled appropriately.

In the worst circumstance, the resulting overpayment is not discovered by the provider but is investigated by the government when it is identified by a government audit, by whistleblower complaint, or through statistical analysis of the provider’s claims data. The more favorable set of circumstances occurs when the provider discovers the pattern of mistaken documentation and resulting incorrect billing through self-auditing performed as part of an effective compliance program. Discovering the problem internally permits the provider to correct the situation going forward and repay the overpayment that occurred through past incorrect billing. Self-disclosure never permits the provider to avoid the obligation to repay the overpaid amount. In fact, failing to promptly repay a discovered overpayment can result in very serious penalties or even criminal charges for deliberate fraud.7 However, providers will normally not incur serious penalties if they bring the error to the attention of regulators and promptly repay any resulting overpayment. This is where a systematic compliance program comes into play. The compliance program operates to identify the most critical areas of risk to the provider and focuses resources on identifying and preventing regulatory violations in the identified risk areas. Where past infractions are discovered, the compliance program requires prompt identification, repayment, and possible use of the selfdisclosure protocols when necessary to mitigate further regulatory exposure.

CONTINUING EDUCATION required to take more detailed or specialized training in areas required by the nature of their position. For example, billing staff will need to undergo more detailed and specific training on the billing process and rules that they are likely to encounter. Health information staff may require more detailed training on HIPAA and patient privacy issues. The bottom line is that each employee should receive the training that they need to assure that they perform their job tasks without running afoul of regulatory requirements.

All training must be adequately documented with employee rosters, coverage material, employee training acknowledgment, and other details. Assume that you will be in the position in the future to have to prove that your employees received the training that they need. You should also be certain to follow up to assure that employees comply with training requirements. Discipline should be issued if necessary to assure compliance.

4. Compliance reporting and nonretaliation A compliance reporting system and protection of individuals reporting potential compliance issues is a critical element of any compliance program. It is much better to learn about potential problems internally before they ripen into situations that are difficult or expensive to solve. Your compliance program must continually emphasize the importance of reporting potential issues.

Systems should be set up to encourage reporting, protect confidentiality, and assure that those reporting potential issues are protected from retribution. Every employee must know that they are encouraged to report concerns without fear of retaliation. Protection against retaliation must be enforced even if the report turns out to be incorrect, as long as the report is made in good faith.

5. Disciplinary standards Policies mean very little if employees think that nothing will happen to them if they do not follow them. There needs to be policy coverage that ties compliance requirements to the employee discipline process. The discipline process should be used where appropriate to enforce standards. There cannot be selective enforcement. It should be clear that everyone in the organization — from the newest, lowest level support worker through the most productive licensed provider, owner, and most senior executive — is subject to discipline if they fail to abide by the compliance program.

26 Orthodontic practice

6. Compliance risk identification A compliance program must include a system to continually identify areas of potential compliance risk. The areas of most significant risk should be ranked by priority.

Prioritized risk should be integrated into regular compliance work plans. Even if a risk area is not scheduled for auditing, a record should be created to indicate that it was considered, and a reasonable judgment was made that other issues were higher priorities. Although resources must be allocated to compliance in order to make an effective program, the level of available resources will not be infinite. Reasonable choices about relative importance of compliance risk areas are appropriate. Even if a compliance infraction occurs in an area of less critical risk, the documentation of a reasonable risk identification and prioritization process will help reduce the risk of penalties.

7. Systematic investigation and response to detected violations A compliance program must include a system of appropriately responding to identified compliance problems through creation of appropriate corrective action. Policies should include requirements for investigating and addressing reported compliance issues. Where appropriate, repayment, selfdisclosure, and other appropriate corrective action should be mandated by compliance policies. These policies define the standards and requirements to audit against to assure that standard processes are followed when issues are reported. Based on your assessment of adherence to investigation and corrective action standards, enhancements can be identified and implemented through additional policies or revision of current policy.

The “living and breathing” ongoing process of compliance Perhaps most importantly, a compliance program should create a “living and breathing” process of continual operation of improvement. It is not adequate to adopt a set of compliance policies, put them on the shelf, and watch them collect dust over the years. In order to mean anything, a compliance program must be effectively operated to detect and address compliance issues.

In order to meet effectiveness requirements, a compliance program must continually operate to identify new risk areas, address these areas in policy, continually assess

compliance and operational requirements, identify enhancements, and integrate those enhancements by adopting new or revised standards. The compliance system is cyclical in nature, always assessing itself, always improving, always detecting new risks, and always measuring ongoing performance. If you are able to create this type of “living and breathing” compliance organism, you can be rest assured that you have an effective compliance program. OP REFERENCES 1. Billing-related fraud is not the only driver of compliance activities. The dental industry is subject to a variety of regulations, including Health Insurance Portability and Accountability Act (HIPAA), OSHA regulations, and various regulations promulgated under the Affordable Care Act such as translation requirements and prohibitions against a variety of discriminatory activities. Reimbursement issues carry potentially catastrophic fines and penalties and have been a primary force driving proactive compliance program development.

2. For example, the Federal False Claims Act imposes penalties of three times the amount of an overpayment plus between $11,000 and $22,000 per claim. Under federal law, a simple overpayment becomes a False Claim if not repaid within 60 days after the overpayment is identified.

Final regulations were published in the Federal Register on February 12, 2016 in 81 Federal Register 7653. https://www. federalregister.gov/documents/2016/02/12/2016-02789/ medicare-program-reporting-and-returning-of-overpayments 3. OIG Excludes Pediatric Dental Management Chain from Participation in Federal Health Care Programs, Office of Inspector General Newsroom, April 3, 2014; https://oig. hhs.gov/newsroom/news-releases/2014/cshm.asp 4. Attorney General Reaches $728k Settlement in Medicaid Fraud Case, Dentistry Today, June 3, 2019; https:// www.dentistrytoday.com/news/industrynews/item/4908attorney-general-reaches-728k-settlement-in-medicaidfraud-case 5. Unlicensed Dentist Convicted of Healthcare Fraud, Conspiracy to Commit Healthcare Fraud, And Conspiracy to Violate the Anti-Kickback Statute, Press Release from the Department of Justice, U.S. Attorney’s Office, Southern District of New York, December 10, 2018; https://www. justice.gov/usao-sdny/pr/unlicensed-dentist-convictedhealthcare-fraud-conspiracy-commit-healthcare-fraud-and 6. The dentist was sentenced to 5 years and agreed to repay approximately $2.2 million; https://www.wvgazettemail. com/news/legal_affairs/ex-charleston-dentist-sentencedto-federal-prison-for-medicaid-fraud/article_af48c94783fc-5478-b0d3-9eab4b7178ff.html 7. Repayment and Self Disclosure of Known Overpayments, John H. Fisher, Blue Ink Blog, May 3, 2017; http:// www.ruderware.com/blue-ink-blogs/health-care/ repayment-and-self-disclosure-known-overpayments/ 8. The Office of Inspector General of the Department of Health and Human Services has issued a series of compliance program guidance documents covering a variety of segments of the health care industry. The most helpful guidance documents to dental and orthodontic practices follow: The Compliance Program Guidance for Individual and Small Group Physician Practices (65 Fed. Reg. 59434; October 5, 2000) and the Compliance Program Guidance for Third-Party Medical Billing Companies (63 Fed. Reg. 70138; December 18, 1998). These documents can be accessed on the OIG’s Compliance Guidance web page located at https://oig.hhs.gov/compliance/complianceguidance/index.asp 9. The United States Federal Sentencing Guidelines offer incentives to organizations to reduce and ultimately eliminate criminal conduct by providing a structural foundation from which an organization may self-police its own conduct through an effective compliance and ethics program. §8B2.1 of the Federal Sentencing Guidelines identifies various factors that are indicative of an effective compliance and ethics program. https://www.ussc.gov/ guidelines/2015-guidelines-manual/2015-chapter-8 10. On April 30, 2019, the United States Department of Justice released its Evaluation of Corporate Compliance Programs.

The document provides detailed guidance on compliance program structure. See Criminal Division Announces Publication of Guidance on Evaluating Corporate Compliance Programs, April 30,2019; https://www.justice.gov/ criminal-fraud/page/file/937501/download

Volume 11 Number 1

REF: OP V11.1 FISHER

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Creating an effective process to identify and address regulatory risk in dental and orthodontic practices FISHER

1.

The primary force necessitating proactive compliance efforts are the potentially serious penalties for health care reimbursement fraud and abuse. Providers are subject to potential program exclusion, ______ for failure to follow complicated reimbursement rules. a. civil monetary penalties b. False Claims Act penalties c. criminal exposure d. all of the above

2. Dental and orthodontic practices receive significant governmental reimbursement, especially through the _______. a. Medicaid program b. Give Kids a Smile program c. Mission of Mercy program d. Progressive Dental Reimbursement Act of 2015 3. In fact, the _________ resulted in an expansion in orthodontic coverage for children whose medical necessity criteria are met in situations involving medical issues such as malocclusions that are caused by trauma. a. Progressive Dental Reimbursement Act of 2015 b. Affordable Care Act c. United Dental Health Act d. Minors Orthodontic Coverage Act 4. The more common (compliance/healthcare fraud) situation occurs, for example, when a provider knows

Volume 11 Number 1

that he/she actually provided a medically necessary service, but the documentation does not sufficiently support the _________. a. types of insurance that the practice accepts b. dentist’s capability for performing that procedure c. medical necessity of the service or a more complex service d. second opinion necessary to commence treatment for that procedure 5.

In the worst circumstance, the resulting overpayment (in the occurrence of an overpayment by Medicaid) is not discovered by the provider but is investigated by the government when it is identified by a _______. a. government audit b. whistleblower complaint c. statistical analysis of the provider’s claims data d. all of the above

6. (After discovering a billing problem internally) Selfdisclosure ______ the provider to avoid the obligation to repay the overpaid amount. a. always permits b. never permits c. sometimes permits d. is the best way for 7. _________ is/are the single best way to minimize potential regulatory risk. a. Consistently operated compliance programs

b. Having team members take turns double checking the accounts each night c. Having a compliance disclaimer on your website d. Checking for compliance risk every 6 months 8. For the most part, these (standard) compliance program elements emanated from the _______, which give cooperation credit based on the existence of an effectively operated compliance program. a. Food and Drug Administration b. Federal Sentencing Guidelines c. American Dental Association d. State Dental Associations 9. (For compliance training) All training must be adequately documented with ____, and other details. a. employee rosters b. coverage material c. employee training acknowledgment d. all of the above 10. Systems should be set up to encourage reporting, _______, and assure that those reporting potential issues are protected from retribution. a. provide for public identification of the employee whistleblower b. protect confidentiality c. provide for punishment if the information that was reported in good faith, turns out to be incorrect d. decide which employees need compliance training

Orthodontic practice 27

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

Intersecting areas of law and dentistry: part 1 Dr. Bruce H. Seidberg begins his comprehensive discussion of risk management Introduction Risk management involves several areas of a dental practice, including, but not limited to, the doctor-patient relationship, communication, informed consent, and documentation.1,2 The principles of documentation and informed consent are recognized worldwide, and this primer is intended to provide a better understanding of both concepts and how they interact with the law. Understanding the issues, communicating appropriately, and then following the proper concepts of informed consent and documentation and properly applying them are the ways to assist the healthcare provider prevent one aspect of medical malpractice litigation.3 Another aspect of risk management is to understand the concepts of harassment and substance abuse,4 and these two topics will be covered in part 2.

Juries weigh credibility in a malpractice suit. They rely on experts to explain the treatment and care rendered because they do not understand dentistry. They have their own sets of values, but must distinguish between someone who is telling the truth or embellishing the facts for his/her own needs.5,6

Standard of care The standard of care7,8,9,10 is in a constant state of change, vacillating between expert Bruce H. Seidberg, DDS, MScD, JD, is a board-certified endodontist with a private practice in Liverpool (Syracuse), New York, and a consultant for dental malpractice cases. He is a Past President of the American College of Legal Medicine, the NYS Onondaga County Dental Society, Past Chairman of the NYS Board for Dentistry, and currently Treasurer of the AADB. He received his MScD in Endodontics from Boston University School of Graduate Dentistry. He was awarded the AAE Presidential Award for his dedication to Endodontics and the ACLM Gold Medal for his work on behalf of law and dentistry. He lectures about risk management issues in the dental office and can be reached at bseidbergddsjd@me.com.

Disclaimer: The materials presented in this manuscript are for general information to be used as suggestions to reduce and manage various risks in the practice of dentistry, and not to be interpreted as legal advice. You should communicate with your personal attorney for actual legal advice pertaining to any legal dispute you may be involved in. Repetitive information is for emphasis purposes only.

28 Orthodontic practice

Educational aims and objectives

This article aims to discuss the principles of documentation and informed consent.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 32 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Define standard of care.

•

Identify a doctor-patient relationship.

•

Realize some history and facets of informed consent.

•

Recognize the importance of proper and consistent documentation.

Volume 11 Number 1

Doctor-patient relationship A doctor and patient enter into a simple contract; the patient hoping he/she will be cured and the doctor optimistically assuming that he/she will be compensated.14 The general rule is when you offer a professional opinion — upon which you expect the patient to rely and upon which the patient acts to establish a doctor-patient relationship — the information obtained in the consultation and establishment of a relationship must be kept confidential.15 Communication is the cornerstone for delivering a positive patient experience and long-term patient relationship. It is defined by the imparting or exchanging of information between the individuals involved.

Be careful of what you say and how you say it; words have consequences and must be used wisely. “The real art of conversation is not only to say the right thing at the right time, but also to leave unsaid the wrong thing at the tempting moment.”16 A doctor must build a bridge of confidence with the

patients by listening to their understanding of the situation, assessing the issues, and then informing them of what can or cannot be done. Neither the doctor nor the patient is a mind reader; therefore, communication must be explicitly clear and thoroughly understood by both.

Informed consent Many states have informed consent laws that dictate when, and if, dentists must fulfill their duty to obtain informed consent from a patient before performing dental procedures.17 When presiding over an informed consent lawsuit, courts will usually refer to relevant case law from which standards are used to decide if the provider properly disclosed the risks to the patient. Failure to obtain consent is a form of negligence and can be instrumental initiating a lawsuit.

Very little has changed since the inception of the informed consent concept introduced by Judge Benjamin Cardozo in the case of Schloendorff v. Society of New York Hospital,18 where he stated “every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages.” The concept was reinforced in the case of Nathanson v. Kline,19 which was summarized by stating “the fundamental distinction between assault and battery on one hand, and negligence such as would constitute malpractice, on the other. The former is intentional, and the latter unintentional.” This was one of first cases to label lack of informed consent as “professional negligence” instead of “battery.”

There are relatively few differences between those two introductory case concepts and current-day practice. The concept of informed consent was later refined in Canterbury v. Spence20 and established a new standard for information

disclosure as stated that “failure on the part of a healthcare provider to obtain a patient’s informed consent before treatment constitutes professional negligence (substandard care) and not the intentional tort of assault or battery.”

Patients have the right to self-determination to accept or reject the proposed treatment(s).21 They deserve to be informed about their treatments and what the consequences are. Informed consent is a fundamental tenet of the U.S. healthcare system, rooted in the ethical principles of respect for the patient autonomy and enhanced wellbeing. Patients now must be informed and must have the ability to consent to treatment whether for pharmacologic or non-drug therapies. The rules of the professions are now “they who cut must inform” and “they who prescribe must also inform.”

The legal aspect involving the risk management of informed consent is that it provides documentation of the consent in the event of legal allegations. It reduces misunderstandings or miscommunication between the provider and patient which may in turn reduce the likelihood of adverse outcomes and frivolous complaints. A patient who is properly informed is less likely to launch subsequent litigation over undisclosed risks that manifest22 (Table 1).

Informed consent is the conversation a doctor has with a patient prior to treatment in which options and possible risks of the proposed treatment are explained and discussed, as required by law22 (Table 2).

It is the ongoing dialogue between patient and healthcare provider in which both parties exchange information, ask questions, and come to an agreement on the course of specific dental/medical treatment. It is based on a special fiduciary relationship between the doctor and the patient; a relationship of trust, confidence, and responsibility is formulated.

Informed consent is a core component that should be provided at the initial

Table 1: Elements of an informed consent lawsuit

Table 2: Elements of informed consent

• • • •

As required by law, the dentist/physician MUST explain: • The indicated procedure in understandable terms • Reasons for the procedure • Benefits of the procedure • Alternatives for a proposed treatment • Consequences for choice including no treatment at all • Known risks associated with the procedure

Existence of a doctor-patient relationship.

Provider has a DUTY to disclose information.

There was a failure to provide information.

Had the information been furnished, the patient would not have consented to treatment.

• Failure to disclose was the proximate cause of plaintiff’s injury and damages claimed.

• Patient’s perception of wrongdoing on the part of the practitioner.

Volume 11 Number 1

Orthodontic practice 29

CONTINUING EDUCATION

witnesses’ testimony, new technology, and improved procedures. Generally, all allegations reference the standard of care; therefore, it is necessary to understand what it means and what it is. The standard of care is defined as “that reasonable care and diligence ordinarily exercised by similar members of the profession in similar cases in like conditions given due regard for the state of the art or, in other words, the duty to which one will be held.”11 The ease of availability for continuing education from institutions of higher learning, educational journals, local dental society-sponsored courses, and the mobility of dentists to travel to educational centers have caused the local community standards to be replaced by national standards. Generalists are held to the standard of care of the specialist using the same degree of care and skill when acting in the same or similar circumstances.12,13 Today all dentists must meet the national standard of care.

CONTINUING EDUCATION appointment and when developing a treatment plan that may include the use of controlled substances. Patients must be able to participate in decisions about their medical care, weighing the pros and cons of a recommended intervention or treatment and understanding the risks, benefits, and alternatives to ensure the care they receive reflects their goals and preferences.21 The purpose of disclosure is to prevent surprises prior to care if complications were to occur and for the protection of the doctor and patient.

Lawsuits are usually triggered because the patient was surprised and angry about an unexpected result or inconvenience. Disclosures act to diffuse unreasonable patient expectations.

In addition to the verbal discussion, a written treatment plan (Table 3) helps explain the responsibilities of the patient and provider during treatment, outline possible consequences of noncompliance with instructions regarding treatment, and provide thorough information about the treatment plan. Essentially, it is an agreement that lays out the responsibilities of both the provider and the patient summarizing, “What I will do for you and what you will do for me based on mutual trust and honesty.”

Without a basic understanding of risks, benefits, and alternatives, patients cannot meaningfully participate in the decision making — although providing such information does not guarantee they will understand and use the information wisely.23 A causal connection does exist when disclosure of significant risks incidental to treatment would have resulted in a decision against treatment. The connection also exists when the risk materializes. If an undisclosed risk materializes, resulting in injury to the patient, allegations for legal action could be instituted.

Before a patient can prevail in a lawsuit against a dentist for lack of informed consent, a patient must prove that a reasonably prudent person (such as the patient) would not have undergone the treatment if fully informed of the risks, benefits, and alternatives, and that the lack of informed consent served as the proximate cause for the injury. This implies that the failure of the dentist to warn the patient is what proximately caused the injury. After understanding the risks involved, a patient can agree to the procedure. What they are not agreeing to is the procedure being done negligently.17 The dentist must still provide 30 Orthodontic practice

Table 3: Model written treatment plan • • • • •

Be reasonable, readable, and flexible.

Given ideal plan and a secondary plan that will work.

Provider’s responsibility to work with patient to relieve pain, if present.

Provider’s responsibility to correct any known dental defects.

Promote open communication; clarify frequent issues that arise and prevent misunderstanding.

• Specify behaviors that are red flags for abuse by the patient.

• Describe possible outcomes if patient engages in certain red flag behaviors.

• Stress patient’s responsibility to follow instructions.

Understanding the issues, communicating appropriately, and then following the proper concepts of informed consent and documentation and properly applying them are the ways to assist the healthcare provider prevent one aspect of medical malpractice litigation.

treatment within the standard of care of the profession.

The dentist must exercise his/her best judgment as to whether or not the patient has the capacity to fully understand the proposed treatment. It is the legal guardian of the patient who is deemed unable to provide consent on his/her own behalf who must receive and give informed consent on behalf of the patient. The law requires that a provider not undertake treatment with a non-Englishspeaking patient until there is certainty that the patient has had an understandable and intelligent discussion about the treatment, its benefits, alternatives, and risks, and that may require a foreign language interpreter. The law also requires appropriate accommodations be made for disabled patients. A sign language interpreter may be necessary when discussing informed consent and treatment options with a hearing-impaired patient.

Informed consent is the discussion NOT the form. The purpose of the informed consent form is to provide evidence that the informed consent discussion took place.

The best-informed consent form should be tailored to the particular procedures and circumstances of each individual case.

Informed Consent and Written Treatment Plans establish boundaries and consequences, but both have to be readable, reasonable, flexible, and understandable.

The informed consent form should be limited

to the treatments proposed and should not include financial information.6 It is the duty of the doctor performing the procedure to inform the patient. Obtaining informed consent cannot be delegated.

Informed consent is the conversation with the patient, not the signed form. A document does not replace the verbal process of informed consent, but it is essential to have and to be signed by the patient. The document only acts to memorialize the process. The written treatment plan is the prescription with instructions for a patient’s treatment and used primarily when restorable efforts are to take place and/or pharmaceuticals are used.

A healthcare provider who has proper documentation memorializing the informed consent discussion and what was done is less likely to be involved in a lawsuit.

Documentation Treatment records are the best method to provide a strong defense for any matter brought against your professional care. They are subject to review by several third parties such as insurance companies, attorneys, a judge, and a jury. Failure to maintain a record for each patient that accurately reflects the evaluation and treatment of the patient can be construed as unprofessional conduct. A good record-keeping system ensures that required information is recorded consistently Volume 11 Number 1

Table 4: Basic patient record Medical history

Copies of prescriptions (pharmacy/lab)

Dental history

All correspondence

Radiographs

Consultation and referral reports

Study models

Referral information

Progress notes

Patient demographics

I-STOP findings

Treatment plan

Signed consent forms

Discharge/termination notes

Table 5: Dental history content Chief complaint

Patient’s view of oral hygiene status

Past dental records

Oral hygiene status

Past dental treatments

Oral hygiene habits

Radiographs

History of bruxism

outcome, patient anger, a perceived wrongdoing, lack of clear communication by a colleague trying to explain a previous treatment from another, or lack of morality or breach of ethics. Always communicate clearly with your patients. Make sure that

they are informed about your proposed treatments and that they understand them. Document the informed consent conversation, take a good medical history, and document all aspects of treatment and correspondence relating to the patient. OP

REFERENCES 1. Seidberg BH. Risk management concepts for dentists. Endodontic Practice US. 2015;8(1).

2. Seidberg BH. Risk management concepts for dentists. Endodontic Practice US. 2015;8(2).

3. Seidberg BH. Legal aspects of dentistry. In: American College of Legal Medicine. 7th ed. Chicago, IL: Harcourt Publishers; 2007.

4. Seidberg BH. Harassment – Crossing the Professional Line. Endodontic Practice US. 2013;6(5):42-45.

5. Seidberg BH, Sullivan TH. Dentists’ use, misuse, abuse or dependence on mood-altering substances. N Y State Dent J. 2004;70(4):30-33.

6. Regan B. Risk Management Comments. On The Cusp. An EDIC Publication. 2013;16.

7. Regan B. Credibility vs. The Informed Consent Form. On The Cusp. An EDIC Publication. 2013;16.

8. James AE, Perry S, Zaner RM, Chapman JE, Calvani T. The Changing Concept of Standard of Care and the Development of Medical Imaging Technology. Humane Medicine. 1991;7(4).

9. Curley A. Standard of Care Definition Varies. J Amer Coll Dent. 1986;53.

10. Shandell R, Smith P. Standard of Care: The Preparation and Trial of Medical Malpractice Cases. Law J Press. 1.01 (2a), 2000; 1996: Advincula v. United Blood Services, 176 Ill. 2d 1, 678 N.E.2d 1009, 1018.

11. Jerrold L. Defining the Standard of Care. J Amer Coll Dent. 2019;86(3).

12. Weinstein B. Ethics and Its Role in Dentistry. Gen Dentistry. 1992.

13. Taylor v Robbins, Tex., Harris County 281st Judicial District, No. 85-28095, May 4, 1988.

14. Jerrold L. When the patient breaches the doctor-patient contract. Orthodontic Practice US. 2019;10(1).

15. Hammonds v Aetna Casualty, 243 F Supp 793 (1965) (N.D. Ohio 1965), July 1965.

16. Neville-Rolfe D (English poet). https://www.goodreads.com/quotes/69022-the-real-art-of-conversation-is-not- only-to-say.

Accessed December 16, 2019.

17. Gillman S. A Conversation on Consent. https://www.dentaltown.com/magazine/article/7665/a-conversation-on-consent.

Accessed December 16, 2019.

18. Schloendorff v. Society of New York Hospital, 105 N.E. 92 (N.Y. 1914).

19. Nathanson v. Kline, 186 Kan. 393, 350 P.2d 1093 (1960).

20. Canterbury v. Spence, 464 F.2d 772 (D.C. Cir., 1972), cert. denied, 409 U.S. 1064 (1974).

21. Graskemper JP. Informed consent: a stepping stone in risk management. Compend Contin Educ Dent. 2005;26(4):288-290.

22. Seidberg BH. Principles of Informed Consent. Orthodontic Practice US. 2019;10(1).

23. Schenker Y, Meisel A. Informed consent in clinical care: practical considerations in the effort to achieve ethical goals. JAMA. 2011;305(11):1130-1131.

24. Seidberg BH. Record Keeping in Dentistry. Nevada Dental Journal. 2010.

Summary (part I) Causation for doctors to be sued include, but are not limited to, a poor or unexpected Volume 11 Number 1

25. Engar RC. Risk of Prescribing Antibiotics with No Documentation. https://www.webdentistry.com/Article5956-eng.html2018.

Accessed December 16, 2019.

26. Seidberg BH. Risk Management Concepts for Dentists. Endodontic Practice US. 2015;8(1).

27. Seidberg BH. Risk Management Concepts for Dentists. Jnl NYS AGD. 2015.

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CONTINUING EDUCATION

for every patient visit, every time, and that the same format is followed for every patient of record. The information written in the patient’s record must be accurate and complete. All information must be included, and the records have to be authentic and not be altered25 (Table 4). Patient treatment records should never include derogatory comments, or fee information, but they should include missed appointments, the facts of treatment provided, and any referrals made. All entries must be initialed by the individual who makes the entry.

There is a risk of not having documentation for pharmaceutical prescriptions26; therefore, all telephone Rx’s have to be documented because pharmacies do not track prescriptions, especially narcotics. Be aware of cumulative effects of multiple antibiotics, and avoid detrimental effects on patients taking multiple drugs. Obtaining a thorough and reliable medical and dental history is a component of a good record and of the standard of care.27 A protocol for logging in all Rx’s from outside the office must be kept in the patient’s record. The I-STOP program, utilized in most states or one similarly named, is used to track Schedule II, III, IV controlled substances prescribed to a patient that can be reviewed prior to prescribing additional medications.

The universally accepted documentation format follows the SOAP formula: Subjective findings (chief complaints in the patient’s words), Objective findings (results of testing, radiographic findings, medical, and dental history), Assessment (diagnosis from accumulation of collected data), and Planning for treatment (recommendations and informed consent)28 (Table 5). Never alter records, and never part with the original documents.

If records are requested by the patient or by a third party, provide only copies. Requests should be in writing, and the patient must consent in writing if it is from a third party.

Electronic record keeping is allowed but must be able to demonstrate authenticity.

Use a program that “locks” the records to prevent alteration within a reasonable time (24-48 hours) and that has a tracking ability to identify improper access. All HIPPA regulations must be fully compliant. It is recommended to have multiple back-ups and transmit data to a secure offsite location.

REF: OP V11.1 SEIDBERG

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Intersecting areas of law and dentistry: part 1 SEIDBERG 1. The general rule is when you offer a professional opinion — upon which you expect the patient to rely and upon which the patient acts to establish a doctor-patient relationship — the information obtained in the consultation and establishment of a relationship _______. a. must be kept confidential b. can be altered or changed if treatment is challenged in court c. can be used on marketing materials and social media without consent once the patient is informed d. can be disclosed to all family members without consent of the patient 2. A doctor must build a bridge of confidence with the patients by _________. a. listening to their understanding of the situation b. assessing the issues c. informing them of what can or cannot be done d. all of the above 3. ________ have informed consent laws that dictate when, and if, dentists must fulfill their duty to obtain informed consent from a patient before performing dental procedures. a. All states b. Many states c. Individual dental practices d. Only three states 4. When presiding over an informed consent lawsuit, courts will usually ________ to decide if the provider properly disclosed the risks to the patient.

32 Orthodontic practice

a. discuss with the patient b. ask another dentist from a close general geographic area c. refer to relevant case law from which standards are used d. survey the patient’s friends and family 5. Very little has changed since the inception of the informed consent concept introduced by Judge Benjamin Cardozo in the case of _______, where he stated “every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages.” a. Schloendorff v. Society of New York Hospital b. Canterbury v. Spence c. Taylor v. Robbins d. Hammonds v. Aetna Casualty 6.

Patients ________ to self-determination to accept or reject the proposed treatment(s). a. do not have the right b. have the right c. have only partial rights d. should not consent

7. ________ is the conversation a doctor has with a patient prior to treatment in which options and possible risks of the proposed treatment are explained and discussed, as required by law. a. Prescribe and inform risk discussion b. Standards of care consultation c. Informed consent

d. Litigation avoidance consultation 8. In addition to the verbal discussion, a written treatment plan helps _________ . a. explain the responsibilities of the patient and provider during treatment b. outline possible consequences of noncompliance with instructions regarding treatment c. provide thorough information about the treatment plan d. all of the above 9. Before a patient can prevail in a lawsuit against a dentist for lack of informed consent, a patient must prove that ________ would not have undergone the treatment if fully informed of the risks, benefits, and alternatives, and that the lack of informed consent served as the proximate cause for the injury. a. only an expert in the field b. an expert in a non-dental field c. a reasonably prudent person (such as the patient) d. a lawyer who specializes in dental law 10. A good record-keeping system ensures that required information is recorded consistently for every patient visit, every time, and that the _______. a. same format is followed for every patient of record b. format is changed depending on the mental capacity of the patient c. chart can be altered to include more information in the event of litigation d. chart can be altered to remove interoffice derogatory comments

Volume 11 Number 1

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ORTHODONTIC PRACTICE CE

AUTHOR GUIDELINES Orthodontic Practice US is a peer-reviewed, bimonthly publication containing articles by leading authors from around the world.

Orthodontic Practice US is designed to be read by specialists in Orthodontics, Periodontics, Oral Surgery, and Prosthodontics.

Submitting articles Orthodontic Practice US requires original, unpublished article submissions on orthodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education.

Typically, clinical articles and case studies range between 1,500 and 3,000 words.

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Manuscripts should be double-spaced, and all pages should be numbered. Orthodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available.

Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses.

Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 11 Number 1

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Number tables consecutively, and provide a brief title and caption (if appropriate) for each.

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Aesthetic & Implant Dentistry. 2000;1(1):92-96.

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Orthodontic practice 33

ORTHODONTIC INSIGHT

Changing with the times Dr. Bill Dischinger discusses delivering a better product to an ever-changing patient population

I

recently had an article published in an orthodontic magazine. In one of the final drafts, the magazine editor was requesting more content on the “treatment.” As a practicing orthodontist, I have to be honest; we all can diagnose cases, and we all can treat cases, but our profession right now is at a crossroads. The debt level coming out of residency for these “kids” (sorry, I know they aren’t kids, but they are to me) is so outrageous; they will struggle to ever pay it off.

They are entering into corporate practices, making lower salaries, and some are trying to start a private practice in their “free time.”

They have to be as efficient as possible and see these patients as few times as possible to make these “side gigs” work. In addition, corporate orthodontic companies are able to run with lower overheads and thus provide treatments at lower fees than some private practitioners. Direct-to-consumer ortho is not going away: Any orthodontist who thinks eventually it won’t be a good, viable product that threatens our specialty is the same, backward-thinking doctor who tried to say Invisalign® would never fly, and that braces would always be the only and best way to treat patients.

We orthodontists need content that is not so focused on the minutiae of diagnosis but on the overall big picture of delivering a better product to an ever-changing patient population with different “demands” than in the past. We need to be giving patients treatment options that are faster — with fewer visits and more comfortable — and for us, more profitable, as there is definitely a ceiling to where we are going to be able

We orthodontists need content that is focused on the overall big picture of delivering a better product to an ever-changing patient population with different “demands” than in the past.

to take our fees as more and more corporations get involved in orthodontics. We have to deliver the best customer service experience possible as well. I know I’m totally on a soapbox right now, but I am sure we are all quite familiar with Dr. David Sarver. He is one of the most respected orthodontists in our profession and has been for a long time. One of his agendas over the past 5 years is exactly what I’m talking about — how to help our specialty be the best it can be moving forward with all the things I have

Bill Dischinger, DMD, earned his degree from the Oregon Health & Science University School of Dentistry and his certificate in orthodontics at Tufts University in Boston. Dr. Dischinger, an adjunct professor in the orthodontics department at the University of The Pacific in San Francisco, has lectured nationally and internationally on subjects including functional jaw orthopedics, passive self-ligation, clear-aligner treatment, and practice management.

Dr. Dischinger has been published in the Journal of the Asian Pacific Orthodontic Society, Orthodontic Products, Orthotown, and Ormco’s Clinical Impressions. He is involved in national study clubs that address the latest treatment techniques. Dr. Dischinger is also a member of the American Association of Orthodontists, the Pacific Coast Society of Orthodontists, the American Dental Association, and orthodontic professional associations that enable him to participate in continual education and to remain current on advances in orthodontic treatment.

34 Orthodontic practice

described earlier. Recognizing that there are, and always will be, changes within our profession, Dr. Sarver is having me and many others speak at the AAO in Atlanta on the range of topics we must discuss. I will be specifically addressing exactly this and how we can evolve our practices to achieve this, whether it be with more efficient treatments, better customer service, and so on.

These messages need to be in the forefront right now, not just “case studies.” I hope I’m not offending anyone in how I’m writing this viewpoint, but I love my specialty. That is why I teach at University of the Pacific, why I lecture and teach around the world. We have to be better than what we currently are, or we will lose this great profession. When I was in dental school, the number one respected profession was pharmacy. That profession is vastly different now. Orthodontics is right behind it if we don’t change. OP Volume 11 Number 1

By Tim James 216 pages; 2019 Abrams Press, New York, NY

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im James is an educator, blogger, inventor, and popular science lecturer with degrees in chemistry specializing in computational quantum mechanics. He now teaches high school chemistry and physics. In Elemental, he provides an informative, entertaining, historical, and quirkily illustrated guide to the periodic table that shows how this abstract graphic relates to our day-to-day lives.

James starts with the Greeks, who counted the number of elements on one hand, and progresses to June 2016, when the final four elements of nihonium, moscovium, tennessine, and oganesson completed the periodic chart.

Along the way, James displays his erudition coupled with a rare sense of humor regarding the personalities who have made the discoveries so vital to what we now know about the elements of our universe.

For example, in describing John Dalton, a polymath who taught himself science, mathematics, English, Latin, Greek, and French and achieved the rank of headmaster in his teens, James adds, “Don’t be fooled though. While a fierce academic, Dalton still knew how to have a good time and, like any youngster, spent his free moments collecting samples of swamp gas from local bogs.

Surprisingly, he never married.”

Even more poignant is his brief consideration of the Swedish chemist Carl Scheele, whom James calls the unluckiest man in the history of chemistry. Scheele discovered barium, chlorine, manganese, tungsten, oxygen, and the chemistry for photography, but for one reason or another never received credit for any of them.

Dmitri Mendeleev, the Russian scientist, gave us the periodic chart by inventing a game of solitaire based on chemical properties that would establish a pattern about their organization. Mendeleev stayed awake for 3 days and nights before collapsing from exhaustion. While sleeping, he had the most vivid dream of his life with cards dancing and Volume 11 Number 1

dropping into place perfectly, revealing their pattern. He realized that the elements were arranged in a sequence of increasing mass, and the spaces missing elements were those that had not yet been discovered.

During the 1500s, Germany had a scientific renaissance, and one of the most prominent figures was the Swiss physician Paracelsus. His real name was Theophrastus Bombastus von Hohenheim, and he was the first person to investigate medicine as a science rather than a superstition. HIs most famous dictum is named the Paracelsus principle: “The dose makes the poison.” In other words, whether

something is beneficial or harmful is all about the quantity. James avers that even cyanide contained in apple seeds has the potential to kill provided you eat the seeds of 18 apples (assuming radioactive bananas don’t kill you first).

This reviewer has never found as enjoyable a book on science as what James has developed in this tome. His light, elegant, allegro prose combines with brevity and measured tone: humorous but not frivolous, exciting but not sensational, erudite but not academic. This one is a keeper. OP Review by Dr. Larry White.

Orthodontic practice 35

BOOK REVIEW

Elemental: How the Periodic Table Can Now Explain (Nearly) Everything

GOING VIRAL

Does your cybersecurity commitment in 2020 support your orthodontic practice compliance requirements?

Mark Pribish defines terms to help your office recognize and avoid cyberattacks

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ost people think identity theft is a problem for the individual consumer only.

However, based on “The latest healthcare data breaches in 2019 (https://port swigger.net/daily-swig/the-latest-healthcare-data-breaches-in-2019),” identity theft and data breach events have become a significant compliance and risk management issue for all business sectors, including dental offices and dental patients.

As an orthodontics practice, you need to pay attention to the unprecedented rash of data breaches and focus on identifying gaps and vulnerabilities to improve your cybersecurity posture to defend against cyberattacks.

That said, let’s begin with four basic information security and governance fundamentals in the orthodontist industry: • Orthodontists handle Personally Identifiable Information (PII), including social security numbers, credit card information, bank account information, driver’s license numbers, birth dates, and private health insurance information.

• Orthodontists use e-mail, computerized accounting, and electronic procurement to store and transfer employee, customer, and member data within and outside their computer networks.

• Orthodontists fall into the Healthcare business sector where Healthcare data breaches will cost the sector $4 billion this year, with hackers outpacing the security technology and processes of provider organizations.

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.

36 Orthodontic practice

In just the past 4 months, news headlines regarding data breaches have included “dental offices, dental patients, and dental records” including: • Ransomware at Colorado IT Provider Affects 100+ Dental Offices (https://krebson security.com/2019/12/ransomware-at-colorado-it-provider-affects-100-dental-offices/) • Nearly 400K dental patients affected in Alabama ransom attack (https://www.healthdata management.com/news/nearly-400k-dental-patients-affected-in-alabama-ransom-attack) • Two dental practices alert 2,600 patients of data breaches (https://www.beckersdental.com/ dentists/35026-2-dental-practices-alert-2-600-patients-of-data-breaches.html) • Ransomware attack on digital dental records impacts many providers (https://health itsecurity.com/news/ransomware-attack-on-digital-dental-records-impacts-many-providers)

• Healthcare organizations, including orthodontists, face financial penalties when a data breach occurs and are accountable to the Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Act (HITECH).

If these four points do not heighten and amplify your concern for your orthodontic practice for better information security and governance, then maybe Experian’s 2020 Data Breach Industry Forecast (https:// www.experian.com/content/dam/marketing/ na/assets/data-breach/white-papers/ Experian-Data-Breach-Industry-Forecast2020.pdf) will.

According to Experian, “Cybercriminals will get more creative in 2020, harnessing technology and advanced tactics to cause disruption for businesses, governments, and consumers.”

Experian stated the top data breach trends of 2020 include the following: • “Cybercriminals will leverage textbased ‘smishing’ identity theft techniques to target consumers participating in online communities, such as those supporting presidential candidates, with fraudulent messages disguised as fundraising initiatives.”

• “As cities install more free public Wi-Fi systems, hackers will take to the skies via the use of readily available drones to steal consumer data

from devices connected to unsecure networks on the streets below.”

• “Cybercriminals will use so-called ‘deepfake’ video and audio technology to disrupt the operations of large commercial enterprises and potentially create geo-political confusion among nation states, in addition to disruption in financial markets.”

• “As a form of protest, we will see many burgeoning industries, such as cannabis retailers, cryptocurrency entities, and even some environmental organizations, targeted for cyberattacks as a result of online activism or ‘hactivism.’”

• “With mobile payment options popping up everywhere from a local café to the beer vendor at a stadium, Experian predicts that there will be a significant spike in identity theft as cybercriminals seek to exploit the convenience of point-of-sale transactions, especially at large venues like concert festivals and sporting events.”

So how can your orthodontic practice stop a data breach event from ever happening? The simple answer is you can’t and you won’t. Just ask Equifax, Capital One, or Delta Dental of Arizona.

All three companies represent the credit bureau, banking, and health insurance business sectors.

These three business sectors have more financial and information technology (IT) resources than any other industry groups, Volume 11 Number 1

Account takeover: An account takeover is when a fraudster uses personal information to obtain products and services. Credit card fraud is the most rampant, but skimming and phishing are also common types of account takeovers.

Malware: A portmanteau of “malicious” and “software,” malware describes any software created with the specific intent to cause disruption or damage. Trojans, bots, spyware, worms and viruses are all types of malware.

Credential cracking: Credential cracking describes the various methods — word lists, guessing, and brute force — cybercriminals use to obtain passwords. Credential cracking threats are why it’s important to create varied and complicated passwords for all accounts.

Pharming: Sometimes called “phishing without a lure,” pharming is a type of scam where malicious code is installed onto a device or server to misdirect users onto illegitimate websites.

Data breach: A data breach is when private or confidential information is released to an untrusted environment. Cybercriminals can infiltrate a data source physically or remotely bypass network security to expose passwords, banking and credit data, passport and Social Security numbers, medical records, and more.

Dark web: The dark web is the part of the Internet that can only be accessed through browser software, which keeps visitors anonymous and untraceable. It’s not illegal to be on the dark web, but many illegal transactions occur on the dark web (such as buying credit card or Social Security Numbers).

Deep web: The deep web is the part of the Internet that’s not accessible through standard search engines such as Google or Bing. Passwordprotected and dynamic pages, encrypted networks, and the dark web are all part of the deep web.

Encryption: Encryption is a way to scrambled data using computer algorithms to prevent unauthorized access to data or sensitive information.

Firewall: In computing, a firewall is a software program that blocks unauthorized users from getting in without restricting outward communication.

Formjacking: Formjacking is when a hacker infiltrates an e-commerce checkout page to steal credit card information. Similar to an ATM skimmer for the Internet age.

Ghosting: In the context of identity theft, ghosting refers to when someone steals the identity of a dead person.

Honeypot: A honeypot is a decoy target used to mitigate cybersecurity risks or get more information about how cybercriminals work.

Internet of Things: The Internet of Things, or IoT, describes the interconnectedness of all devices that access WiFieasy, including cell phones, cameras, headphones, and an increasing number of other objects, including washing machines and thermostats.

Keylogger: A keylogger is a computer program that records a person’s keystrokes to obtain confidential data.

and they could not prevent a data breach event from happening.

Why? Because information security and governance is more than an IT event.

Equifax was initially hacked via a consumer-complaint web portal, with the attackers using a widely known vulnerability that should have been patched along with failing to renew an encryption certificate on one of their internal security tools.

Capital One’s data breach was impacted by the insider threat where a former Amazon cloud employee lacking character and integrity is now being charged with computer fraud.

Delta Dental of Arizona became aware of suspicious activity and learned that a Delta Dental employee fell victim to an “email Volume 11 Number 1

Phishing: Phishing is a popular type of internet scam in which fraudsters send emails claiming to be from a reputable company to trick individuals into revealing personal information. Phishing attacks decreased from 1 in 2,995 emails in 2017 to 1 in 3,207 emails in 2018.

Ransomware: Ransomware is a type of malware that threatens to expose or block an individual’s or business’ data unless a ransom is paid.

SIM swap scam: Sometimes called a port-out scam or SIM splitting, a SIM swap scam is a complex type cell phone fraud that exploits twofactor authentication to access data stored on someone’s cell phone.

Put simply, if a fraudster has your phone number, they can call your phone company and ask to have the number transferred to “your” new phone. The fraudster then has access to all of your accounts that use two-factor authentication.

Skimming: Skimming is a type of credit card fraud in which the victim’s account numbers are copied and transferred to a counterfeit card.

Smishing: Similar to phishing, smishing (or SMS phishing) is when someone attempts to mine sensitive information under a fake identity through text messages.

Spoofing: A spoofing attack is when an illegitimate website falsifies data to appear as a trustworthy easy to read website to visitors.

Spyware: Spyware is any software designed to gather data from an individual or enterprise. The four primary types of spyware are adware, Trojan horses, tracking cookies, and system monitors.

Synthetic identity theft: Synthetic identity theft is when a criminal combines stolen and fake information to create a new, fraudulent identity.

Trojan horse: Like its classical namesake, a Trojan horse is a type of malware disguised to appear like safe software. Cybercriminals use Trojans to access sensitive data and gain access to private systems.

Whaling: Whaling is a phishing attack that targets high-level employees within a company to steal confidential information or sensitive data.

Vishing: Like phishing or smishing, vishing is when an identity thief attempts to gain sensitive information over the phone.

phishing scheme” that allowed an unauthorized individual to gain access to said employee’s email account.

In each case, each of the three data breach events was preventable except for current and former employee negligence and malice.

The fact is that hackers and the insider threat (current and former employees, vendors, and contractors) will target orthodontic and dental practices along with other healthcare providers because patient records include sensitive data that can be used to commit crimes like identity theft, credit card, and health insurance fraud.

While it is critical for every orthodontic practice to implement and update information security and governance policies and

processes, including penetration testing and vulnerability scanning – I believe employee training is the number one defense against the risk of identity theft and data breach events.

Based on the above, I recommend that every orthodontic practice share this Consumer Affairs link (https://www.consumeraffairs.com/ finance/identity-theft-statistics.html#) on 2019 Identity theft trends and statistics.

Read the easy-to-read glossary above, and understand identity theft terms to help employees keep up on the current threat environment.

To conclude, the more your employees understand identity theft and cybersecurity terms, the more equipped they will be to help safeguard employee and customer information. OP Orthodontic practice 37

GOING VIRAL

Glossary

LEGAL MATTERS

Using a Truth-in-Lending Statement in clinical orthodontic practice Dr. Laurance Jerrold discusses legal requirements that relate to extending credit to patients

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ecause of the nature of orthodontic practice, the fact that it is expensive and extends on average for upwards of 2 years, we have, as part of our practice management strategy, designed payment plans to enable patients to meet their financial obligations. Legally, this is viewed as extending credit. Therefore, we are required to follow certain legal requirements that relate to the extension of credit to our orthodontic consumers. These consumers must be apprised of any finance charges or interest charged on the “loan” we are extending (our payment plan). In addition, we often charge the patient additional fees for such things as expenses incurred relating to the collection of past due accounts, including legal fees, fees for returned checks, late payment fees, fees for lost or excessive breakage of appliances, missed appointment fees, etc. Traditionally, this responsibility was handled through the use of a contract letter. Recently, this intra-office communications tool has been supplanted by using a Truth-in-Lending Statement. This article deals with how to design and use Truth-inLending Statements.

What is a Truth-in-Lending form, and why should orthodontists want to use one?

This is a common question and the answer lies in Regulation Z of the Consumer Credit Reporting Act. This Act requires all sellers of goods or services to provide the consumer of that product or service with a type of financial informed consent that in essence discloses the terms and the costs associated with the extension of any credit offered. The Act’s applicability to orthodontics lies in the fact that it must be utilized when businesses or individuals who are

Laurance Jerrold, DDS, JD, ABO, is Professor and Chair Emeritus of the Advanced Education Program in Orthodontics and Dentofacial Orthopedics at NYU Langone Hospitals. He can be reached at drlarryjerrold@gmail.com or 904-710-5125.

38 Orthodontic practice

Figure 1: This model should be used in those situations or practices where a down payment is “forgiven” or is “lessened,” and this amount is incorporated into the monthly payments. It merely reflects an agreement between you and the financially responsible party that if there is a transition during treatment, the full down payment amount is owed even though it was not collected upfront Volume 11 Number 1

LEGAL MATTERS

extending credit meet all of the following elements.

1. Credit is offered. In our practices this is an everyday occurrence.

2. The offering of credit is a regular part of doing business. Unless we have received payment in full up front, virtually all of our patients make their payments to us over time. This payment plan is in reality an extension of credit.

3. The credit is subject to finance charges OR is payable by four or more installments excluding the down payment. This is almost universal to orthodontic practices.

4. The credit is issued primarily for personal, family, or household purposes. This fits orthodontic practices like a glove.

There are several really good reasons to employ a Truth-in-Lending (T-in–L) Statement. First, the form itself is your contract with the patient. If you ever need to pursue legal action to collect your fee, this becomes the proof of the agreed-upon contract between you and the patient. Second, the T-in–L provides documented evidence of your contracts outstanding for the purposes of practice valuation. Third, the T-in–L is very Figure 2

Figure 3 Volume 11 Number 1

Orthodontic practice 39

LEGAL MATTERS useful in divorce or separation situations in that each parent should sign relative to his/ her respective financial obligations.

The fourth, and arguably the best reason, is that if you don’t comply with the law, you are subject to a fine of $5,000 and/or a year in jail.

The figures in this article show different forms of Truth-in-Lending Statements.

They all have as their core the information pertaining to finance charges, the interest rate, and the terms for payment. You can purchase preprinted forms from various companies or make your own. If you plan to levy any additional charges such as late fees, attorney’s fees, bank charges, etc., these must also be prominently specified in the T-in L Statement. As long as the annual percentage rate and finance charges are specified, you can mix and match the lower portion of the form. Feel free to copy these, or use them as a template to make your own.

Author’s note: This article is intended to provide general information and is not intended as legal advice. For legal guidance on specific situations, dentists should consult their attorneys. OP

What legal matters do you want to hear about from our advisory experts?

Contact us by email, or visit our Facebook or LinkedIn, and we will try to address concerns that can reduce stress and help your business to thrive.

Figure 4

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Volume 11 Number 1

PRODUCT PROFILE

Make complex cases less complex with AcceleDent® Optima™

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anufactured by OrthoAccel® Technologies, Inc., AcceleDent® Optima™ is the leading vibratory orthodontic device that delivers better orthodontic experiences for orthodontists and their patients.

As an FDA-cleared Class II medical device, AcceleDent Optima increases the predictability of clinical outcomes throughout the treatment process, even with challenging tooth movements.

AcceleDent Optima’s patented SoftPulse Technology® applies precisely calibrated low pulsatile forces that transmit through the roots of teeth, increasing cellular activity to stimulate the surrounding bone. SoftPulse Technology micropulses exert up to 8 times less force than a power toothbrush and 200 times less force than ordinary chewing. Ideal for traditional braces treatment and clearaligner therapy, AcceleDent Optima is a strategic, technology-driven tool for orthodontists that helps achieve high-quality clinical results.

For clear-aligner therapy cases, many orthodontists have found that AcceleDent

Optima’s gentle vibrations improve tracking and tooth movement accuracy so much so that the finished result mirrors the planned programmed movements precisely. Additionally, orthodontists report fewer refinement stages when integrating AcceleDent Optima into treatment.

AcceleDent Optima gives orthodontists greater control and the ability to give patients more precise treatment estimates and expectations. Published studies show that AcceleDent increases the rate of tooth movement by up to 50%1 without compromising case predictability while changing aligners every 5 to 7 days instead of a conventional 14-day protocol.2 In recent years, the number of adult patients with mainly esthetic dental requirements in the “social six” (top front six teeth) has significantly increased. Consequently, the overall required treatment duration is rapidly gaining importance among consumers. The SoftPulse Technology has shown a significant reduction in pain sensitivity in orthodontic treatment3 as well as an increase in

Published studies show that AcceleDent increases the rate of tooth movement by up to 50%1 without compromising case predictability while changing aligners every 5 to 7 days instead of a conventional 14-day protocol.2

bone modulation rate in the alveolar bone, which leads to faster, more accurate, and predictable tooth movements.

The science behind AcceleDent is supported by three randomized controlled trials and 14 peer-reviewed studies. The interactive online case gallery demonstrates the varying clinical benefits orthodontists and patients have realized with the device. The gallery includes an equal mix of braces and aligners cases and illustrates unique treatment approaches that show how doctors treat different levels of case complexities with AcceleDent Optima.

To view the interactive case gallery and peer-reviewed studies or learn more, visit AcceleDent.com, or http://orthoaccellearning.com/. OP

REFERENCES 1. Pavlin D, Anthony R, Raj V, Gakunga PT.Cyclic loading (vibration) accelerates tooth movement in orthodontic patients: A double-blind, randomized controlled trial. Semin Orthod. 2015;21(3):187-194.

2. Lombardo L, Arreghini A, Ghislanzoni LTH, Siciliani G. Accelerating aligner treatment using low-frequency vibration: a single-centre, randomized controlled clinical trial. Euro J Orthod. 2018;41(4):1-10.

3. Lobre WD, Callegari BJ, Gardner G, Marsh CM, Bush AC, Dunn WJ. Pain control in orthodontics using a micropulse vibration device: A randomized clinical trial. Angle Orthod.

2016;86(4):625-630.

This information was provided by OrthoAccel® Technologies, Inc.

Volume 11 Number 1

Orthodontic practice 41

MARKETING MOMENTUM

Your dental message — delivered Dental marketer, Jackie Raulerson, offers insights into crafting engaging articles for dental publications

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hen you have some great cases and experiences and want to share your success with colleagues via an article, providing comprehensive information in the best format can be a challenging but very achievable goal. The adage, “You only get one chance at a first impression,” applies to the written word just as much as a face-toface meeting. To properly show the many aspects of your successful treatment plan, you need to be familiar with the steps to present it well. You’ve worked too hard to perfect your clinical skills to let them be obscured by missing information. Ensure that your message is delivered in an organized and understandable form.

Developing a clear message is critical to your achievement as an author. To skillfully present findings and treatment plans to patients, your case presentation and information should be clear, concise, and tailored for your audience.

Publishers understand that you are foremost a clinician, not a writer by trade.

However, to construct an article, you need to harken back to the basic formulas that you learned in college for constructing an essay.

After my 20-year clinical career as a dental assistant, hygienist, and office manager, I worked for dental manufacturers in an editorial/marketing role. As part of my duties, I had the pleasure of assisting doctors and other dental professionals in delivering their messages. For a case report or practice management article, the process is basically the same. In my experience, the areas where I found I was able to lend the most assistance and guidance was in structure, written content management, and supportive images.

Here are some tips that I hope you will find helpful in your writing journey.

Jackie Raulerson, RDH, has been in the dental clinical field for 20 years and in dental development and marketing for 17 years. Working with both manufacturers and dental professionals, she helped to establish a strong editorial and social media presence for several global companies. Raulerson now operates her own business to help both dental sectors accomplish their marketing needs. She can be reached at jackie@yourmessagedelivered.net.

42 Orthodontic practice

Decide on a style This will be dictated depending on the type of article. Case studies need a more straightforward, clinical approach to the language and content. Continuing education (CE) articles need to explain or elaborate on a technique, innovative treatment, or technology. CE articles also are written in a formal tone and often must start with an abstract — a paragraph that summarizes the whole article and contains objectives/purpose, materials and methods, and results. The CE must contain citations/references to substantiate your information with another authoritative source. Depending upon the amount of credits offered for your CE, you may need to formulate a quiz. For a nonclinical style article, you can be more conversational. This gives you more of an opportunity to let your personality shine through. These kinds of articles can be enjoyable to write for you and interesting for readers.

the good news is, you already know how to do this. Approach your article as you did your patient’s treatment, moving from one step to the next, from one visit to the next.

Clinical articles should include introduction/objectives, diagnosis, treatments in order of occurrence, and conclusion. For nonclinical articles, an outline will also help you to stay on track. Here, the outline should include introduction/objectives or problem to solve and steps you took to solve the issue in order of occurrence, and conclusion.

Generate steppingstones/stages of information As your outline comes together, you will probably notice that your content is automatically dividing into sections. Before each section, a subhead, or short phrase, can allow for separation and an easier read. Each stage of advancement builds on the story, which can keep the reader involved.

Create an outline

Use concise language

To begin any type of article, you need to have a clear direction and path. An outline will help you stay on track to move through the process of generating a cohesive flow of information and ideas rather than jumping around.

You must be deliberate in this process. And

Wordiness can stall the reader’s attention and ultimately cause his/her mind to wander.

After all, you are putting lots of time and effort into your presentation and want to engage the reader all the way to the end. As you reread your content, look for places where Volume 11 Number 1

Move from the general to the specific For each section, the first sentence or few sentences should set up the topic for that section. For example, if you are discussing treatment, start with what was accomplished with this step of the treatment, and then break down the process. For example, “My treatment recommendation was surgical intervention. To start, I began with the exposure of tooth No. 5, which was impacted. Then I moved to …”

Deliver the proper details Offer basic yet concise details for each section. For example, “The patient came to my office and had a problem with anterior crowding that needed treatment” is not detailed enough. A better approach would be, “The 14-year-old female patient presented with anterior crowding. I set a course of treatment that included …”

Another example, “I was able to move the teeth into correct position,” would be better as “I was able to move teeth Nos. 6 through 11 into correct position.”

When describing what you did, usually a publication will allow you to mention product names, especially if the brand or type of product was integral to the successful outcome of treatment. When mentioning product names, it is best to first state the general product group and then the product name. For example, “As part of diagnosis phase, I recommended a 3D radiographic scan (enter product name, followed by a comma and manufacturer name, city, and state of the company headquarters) …” The exact information that must be included may be indicated by the publisher’s guidelines.

Develop a compelling bio Most articles require a short biographical paragraph of the author, some as little as 30 words. While you may have 300 words about yourself on your website, you will need to edit down the word count for an article. Most bios will give your educational background, affiliations, and milestones. Choose the most important items that you want your readers to know about yourself, as well as those that make sense for the information you are presenting. Group items in a shortened format as needed. For example, if you belong to your local, regional, state, and national organizations, and you also take many CE courses during the year, you can offer, Volume 11 Number 1

Figure 1: When space is limited, or images will appear in a smaller size, cropping is a good option to show the most important aspect of the image. On the left is a full screenshot. On the right is a cropped version showing just of the area of interest to your reader. (Images courtesy of Kaveh Ghaboussi, DMD)

To skillfully present findings and treatment plans to patients, your case presentation and information should be clear, concise, and tailored for your audience.

Figure 2: Using the appropriate tool in the imaging software can better show desired anatomy or features. On the left is a typical 3D X-ray sagittal view. On the right, the airway tool has been applied, clearly calling out the airway space. (Images courtesy of Robert Kaspers, DDS)

Figure 3: It is important to dry the teeth prior to camera images. On the left is an image where much saliva is present, obscuring the view. On the right, the tooth is dry, and the image is more readable. (Images courtesy of KaVo Kerr) Orthodontic practice 43

MARKETING MOMENTUM

you have repeated information. Then decide on the best place for that info, and do not repeat unless it is for emphasis or as part of your summary/conclusion.

MARKETING MOMENTUM “Dr. is a strong proponent of organized dentistry and continuing education.”

Make sure your pictures are worth 1,000 words Now that we have covered the written word, let’s move on to supporting images.

What I have learned clinically is that images we look at may not be the best in terms of composition and angulation and maybe even dose when it comes to radiation; however, they give us the information we need for our particular task. For example, your hygienist may take a bitewing X-ray where there is some overlap, which can happen due to many factors. However, clinically, if you are only interested in the contact point of two particular teeth for this appointment, that area is clearly shown. On the other hand, although the X-ray may meet clinical needs, it may not be the right resolution or position for a textbook or clinical article.

For case presentation in articles, it is imperative that the images meet or are very

close to what I like to call “marketing standards.” That is, they are crisp, clear, and presented at the right angle. When they meet all of these criteria, they visually tell the story of the case. This is especially important when showing newer technologies that others may not be familiar with; for example, 3D camera or radiographic images. Your readers need to know at a glance what they’re looking at, what you’re explaining, and how important it is to the case.

Most publishers have guidelines on what size and resolution is required for images.

Proper resolution ensures that images will not pixelate when enlarged for print. While high resolution and size is less important for web use, print is another story entirely.

Captions for images can be a summary of the text in the article, or they can have their own message. In the case of the latter, you can offer more information to your reader without creating redundancy. It’s also important to note that most readers will skim article images and captions before reading the

Figure 4: When taking camera images for case study articles, it is helpful to take several and then pick the best one. On the left is an image where the camera wand slightly moved, causing a blurry image. On the right is the same tooth captured with a still wand. (Images courtesy of KaVo Kerr)

entire article, so it is best to create compelling captions.

Ask for help Editors understand that you are under the time constraints of a busy practice, so they want to save you time and revisions by creating publisher’s guidelines. Typically, these guidelines specify the length, layout, and number of images you can submit for your article. They also share how to add and format references, if needed.

If you are new to the writing process, you may want to ask a colleague to review your article before submitting. Of course, he/she should be someone whose opinion you value, and who will be honest in his/her assessment.

While the publication’s editors will usually edit the text, references, and captions in your article, they may offer additional help if you are unsure about another aspect of your article. Since editors are often extremely busy during article due dates, don’t wait to the last minute. Most are happy to help during the writing process.

You can also seek the assistance of freelance writers that specialize in the dental field. You can find qualified writers through groups such as the American Medical Writers Association or marketing companies that employ writers who are experienced in the dental field.

When it comes to supportive images, often the manufacturer of the imaging product you use (cameras, scanners, X-ray) can offer clinical assistance. This is one activity I really enjoyed when working for imaging companies. Given my clinical background and software proficiency, I was able to help dentists find the best image, best viewing mode, and angulation to tell their stories. I was also able to help with resolution issues. You can begin by asking your product sales representative to make a recommendation within his/her company for someone who can offer a helpful hint or necessary graphic; typically, this is the Clinical Advisor or Product Developer.

If you would like to learn more about image screen capture, resolution, and size, YouTube offers an abundance of information.

One video that I found helpful without information overload is “The Confusing Concept of Image Resolution” at https://youtu.be/ XqWFfTrorRQ.

Go forth and share!

Figure 5: Saving an image in the correct resolution ensures better quality when displayed in the article. On the left is an X-ray saved in lower resolution (72dpi); the right is a higher resolution (300dpi), shows more details. (Image courtesy of KaVo Kerr) 44 Orthodontic practice

I hope that this information will give you more confidence in sharing your clinical and professional experiences. You can do this! As in dentistry, it all starts with a plan. OP Volume 11 Number 1

Samantha Ettus discusses how controlling payment-processing is crucial to your business

I

t’s a common misconception that you have to choose between saving money and investing in your business. There is an area where you can achieve both: payment processing.

Chances are, a majority of revenue you earn is through credit card transactions, with an increasing number of your patients even requesting to use Google or Apple Pay. Traditionally, the payment-processing industry has relied upon a double whammy.

First, some companies produce confusing invoices designed to mask that you are overpaying. Others offer poor customer service that doesn’t compare to what you were promised. From being PCI compliant to making sure you don’t get swindled on price, there are a myriad of things to look out for when choosing a payment provider.

Here are six ways to select the right one:

1. Time is money You know this, but are you living it? Here is what I mean: If your credit card machine breaks, your office manager needs to contact customer service. This could put her on hold for hours, pulling her off of other projects.

Whatever the circumstance, it is costing you money. You are unable to accept your customers’ credit cards until the problem is fixed, you are losing valuable employee time trying to fix it, and that employee has to spend additional time following up on unpaid invoices. A lose-lose situation. You need a payment partner whom you can reach and who will troubleshoot with you right away.

2. Technology has advanced significantly As an orthodontist, can you get away with using outdated tools? No! Staying up-to-date is essential for growth. The same goes for your Samantha Ettus is the founder & CEO of Park Place Payments, aimed at helping small- tomedium-sized businesses use payments to grow their businesses. Ettus holds a BA and an MBA from Harvard, is a best-selling author, and has dedicated her career to championing women in the workforce.

Volume 11 Number 1

payments. Making sure that your point-ofsale system incorporates the latest technology serves the following two purposes: 1. It demonstrates to your patients that you are modern, giving them confidence in your practice.

2. It shows that you are keeping up with industry changes that your competitors are likely already taking advantage of — for example, the ability to accept Apple Pay or access to speedier transaction processing.

3. Transparent pricing is available

It shouldn’t be easier for you to read in a foreign language than it is for you to read your merchant services statement. Your statement should be clear and simple. It should not be laden with hidden fees and shady charges. Expect transparency — the only pricing model you deserve.

4. Trust your rep

This industry has a history of using car salesman-like tactics to rope you into lengthy contracts and poorly priced deals. You want to work with a company and a rep who are reliable, who care about your practice and your time, and who are not charging you for the wrong products to benefit their own bottom line. You also want the kind of provider who gives you the best rate the first time, not as a reaction to someone else walking into your office with a better offer. You want one cost-effective rate from the beginning. If someone offers to match your best offer, they aren’t offering you their best offer

in the first place. The industry has evolved away from contracts, so don’t get caught in one. Your payments’ provider should have to earn your trust again and again every month.

5. There are compliance regulations you need to adhere to

Hidden among your fees might be one that is costly and very simple to avoid — payment card Industry (PCI) compliance.

It’s common for payment-processing reps to intentionally keep you in the dark about noncompliance fees because the reps profit from what you don’t know. Being PCI compliant may seem complicated, but there are payment-processing firms that help you file and fill out the paperwork annually so that you are not at risk. Choose one that provides this service.

6. Consumers are increasingly socially conscious Consumers today are increasingly aware of companies that are dedicated to a social mission, and they are more likely to support those businesses. With this in mind, choose vendors and partners that are committed to ethical business practices or are built to support a social mission. You can contribute to the larger business environment by selecting a payments’ partner that has a clear goal of diversity and inclusion.

You may not have realized that your payments setup can either grow your practice or cripple it. You can control this crucial piece of your practice by choosing the right partner for your payments. OP Orthodontic practice 45

PRACTICE MANAGEMENT

How to find a payment-processing partner that will help you make money

PRACTICE MANAGEMENT

Compromise is the difference between a good leader and a dictator Dr. Christopher Hoffpauir discusses insights into providing feedback to employees

“Y

ou’re unhappy. I’m unhappy too. Have you heard of Henry Clay? He was the Great Compromiser. A good compromise is when both parties are dissatisfied, and I think that’s what we have here.” — Larry David, Curb Your Enthusiasm Taking corrective action in the workplace is an uncomfortable but necessary skill to cultivate. Whether you are the boss who needs to address a concern or the employee who is faced with the realization that your performance has been under some scrutiny, the bottom line is that both the boss’s and employee’s openness to the change can create a positive or negative outcome.

To the employee Corrective action in the workplace is not a personal attack and not the employer’s attempt to tear down or upset you. Corrections are an opportunity — a sign that your employer believes in you and wants to mentor you into becoming the valuable employee that he/she believes you can be. Sadly, many employees respond to constructive criticism either by becoming covertly hostile and apathetic or by quitting.

But really listening and implementing suggestions shows that the boss’s insights and the business are important to you. Your flexibility and cooperation are qualities that the boss will recognize and appreciate.

To the employer Developing a corrective conversation with anyone about work performance isn’t pleasant. Because we are all human, taking

the time to correct and guide the employees to become better team members usually comes with the “cost of stomach lining” — it’s uncomfortable. We lose sleep over finding the right words and worry about the effect of those words on the employee. But taking the time to discuss potential problems with employees shows that you deeply believe in their potential and want to help them reach it. It’s what good leaders do.

First, you need to discover what is causing a particular problem. Look for the true basis for the issue. Do employees not understand their tasks? Is more training needed? Are the employees resistant to change or training?

Do they think doing it your way will not give the results required? Are they afraid that they can’t meet the standards set in the office?

Are they covertly hostile? (If an employee is just hostile, he/she needs to be fired because a person who refuses to be led ultimately will be toxic in the workplace.)

How to elicit change “Compliment-sandwich” technique One of my favorite tips for correcting employees is to use the “complimentsandwich” technique. Most employees will already be expecting a problem when they are called in for a conference. You can ensure that team members are in a receptive mood to receive instruction if you compliment them on something they are doing well before addressing the problem.

Then introduce the problematic situation very gently and positively. Refer to the following example as a model.

Christopher Hoffpauir, DDS, was born in Lafayette, Louisiana. Poor experiences at the dentist led him to a path of dental phobia. In 2002, a severe dental infection changed his life. Seeing firsthand what a difference proper dental care can make in someone’s life, Dr. Hoffpauir decided to go back to school in pursuit of a degree in dentistry.

Returning to school at 30 years old and years of work experience in various fields gave him a different perspective than that of most students. He graduated Magna Cum Laude from University of Houston Clear Lake with a BS in Biology with a focus on Molecular and Cellular studies, and his DDS from the University of Texas School of Dentistry in 2012. In 2013, Dr. Hoffpauir opened a new startup practice in Alvin, Texas, where he continues to practice today. He has a special interest in utilizing the latest technology to offer the best possible care to patients, with a focus on helping patients with dental phobia overcome their fears. Dr. Hoffpauir is creator/sole owner of “The Business of Dentistry,” a dentist-only Facebook group with more than 20,000 members.

Disclosure: Dr. Hoffpauir is an owner or partner in the following businesses: Modento, 4G Dental Lab, Dentira, PK Performance, Dentalogic, DocHoff Investments, Dream Makers Industries, Get Practice Growth, Infinity 3rd Coast BJJ, and nFoldAI Inc.

46 Orthodontic practice

“Henry, I wanted to tell you what a great job you did on that project for our new patient last week. I really appreciate all of your hard work. I also wanted to talk about an opportunity. I’ve been following your progress very closely, and I noticed that there is a task that you are doing that you can do an even better job at than you are doing currently. I have such high expectations for you, and I think you are an amazing team member. I just wanted to share this with you and see if we can work together on it.”

Remember to add corrective action or task that you would like to see improved.

Then return to complimenting.

“Henry, I’m glad that we got to chat. I’ll check back with you next week to see what progress you’ve made, but don’t hesitate to let me know if you need any help. By the way, before you get back to work, I wanted to say thank you. You make the hard parts of being the boss a lot easier because you are always so willing to improve.”

Compliment at the beginning, deal with the problem, and then compliment at the end.

Conflict resolution When a conflict involves two or more employees, the situation can easily turn into a “he said/she said.” In this case, usually neither person hears what is being said, but each is filtering it through his/her own experience or feelings. The boss needs to make an effort to hear both sides correctly and let both sides know that they are valued. Refer to the following example as a model.

“You both are too important to me, and you are both too important to this team to let some misunderstanding come between you or decrease your effectiveness.”

I invite them to calmly take turns telling each other their version of the situation. I emphasize that when this meeting is finished, and we all go back into the office, the problem will stay behind in the meeting room.

In a conflict like this, there is usually some bickering. To maintain decorum, each person must be given the opportunity to state his/ her side of the story without interruption. It Volume 11 Number 1

is very important that the team members explain what happened in facts only.

Emotion in relaying the event can derail the entire process. The team members will get a chance to address their emotions after both sides have finished telling their version of what happened.

The following dialogue shows how a boss can moderate: Employee No. 1 tells her side of the story.

Moderator asks employee No. 2: “How does what she said make you feel?”

Moderator asks employee No. 2: “OK, what do you remember happening?”

Employee No. 2 tells his side of the situation.

Moderator asks employee No. 1: “How does what he said make you feel?”

Moderator: “Now that we all know how both of you feel, what compromise do you both propose to make sure this problem doesn’t happen again?

I like to remind the two employees of Henry Clay’s definition of a compromise, which introduces this article.

All team members should feel as though their contributions are celebrated by those above and around them. This helps people to achieve greatness. However, if both parties are unable to reach an amicable compromise, the boss needs to intervene and say what needs to be done. This may include reprimands, corrective training, or even firing the one or both team members. The important thing here is to give the team members the chance to find a workable solution themselves before going from “moderator” to “boss.”

The job of moderator often falls to the office manager — and should. If that person is already embroiled in the situation or is a friend to one of the people in the conflict, one or both employees may become distrustful or expect a biased outcome.

In this case, the owner will need to step Volume 11 Number 1

in and act as moderator. It is important to note that even in the perfect mediation, no one will ever be 100% correct or happy.

(Remember Henry Clay?) The goal is not to make everyone happy; the goal is to fix the problem.

An important part of correcting employees, both for clarity and legal reasons, is keeping a record of the intervention. In my office, I record all talks on Zoom, and the recording becomes a part of the employee’s record. It is advantageous to record the interview because if the employee gets hostile or upset and claims it is because of something that you said, you can both can go back and listen to the recording and listen to the actual words used.

(Remember we talked about words being filtered through our emotions?) Employees should sign a form as part of the intake or hiring process that states that they submit to this policy. If they don’t sign, they have already shown that they are unwilling and should not be hired. A sample dialogue follows Boss: Why did you get upset?

Employee: You just said I suck at my job.

Boss: I actually didn’t say that. Let’s listen to the recording and see why I might have come across that way. (Taking ownership of the misunderstanding from the first sign of trouble will assure the employee and ensure that they are in a receptive frame of mind). I can see where you could have taken what I said that way. But now that you pointed that out, let me rephrase that because I did not mean to imply that you suck at your job; I said that there are some procedures that you are doing that need to be improved.

Note the lesson here. Apologizing for how employees interpreted what you said doesn’t cost you anything. It doesn’t make you wrong and them right. It may, however, keep a situation from escalating and lead to improved performance.

Sadly, in some cases, immediate dismissal is the only recourse. Here are a

few instances that should result in this worstcase scenario: • In a medical or dental office, taking shortcuts with the sterilization process, or anything that might endanger the patient, is a dramatic departure from employee training and procedures under the law.

• Screaming or cursing at the boss or even a coworker is disrespectful.

Epithets should not be used against anyone in the office, much less the person who signs the paychecks.

• Drama is not allowed in my office, so much so that my new hire paperwork states that if someone brings drama into my office he/she will be fired immediately. I determine what “drama” means.

• An employee who refuses to sign an action plan or written warning or is dismissive of the proposed corrective action and indicates that he/she isn’t willing to change should be fired immediately.

Sleep well Working together efficiently can affect every aspect of your business, from the front office to the operatory. Taking the time to correct and guide team members usually does so at the “cost of stomach lining.” As bosses, we lose sleep over formulating the right words to improve an uncomfortable situation. But if we deeply believe in our team members’ potential, this is the way to help them strive for a better outcome.

It’s what good leaders do. Many of us can approach confrontation calmly; others will sweat through it or perhaps even become somewhat abrasive when put on the defensive. However, in the final analysis, remember that true leaders take their employees’ failures as their own — and we share in all of the triumphs and victories too. OP Orthodontic practice 47

PRACTICE MANAGEMENT

Apologizing for how employees interpreted what you said doesn’t cost you anything. It doesn’t make you wrong and them right. It may, however, keep a situation from escalating and lead to improved performance.

SMALL TALK

The abundant leader Drs. Joel C. Small and Edwin McDonald love the idea of abundance and promote this concept with their clients

“People with a scarcity mentality tend to see everything in terms of win-lose. There is only so much;

W

e see the concept of abundance as both a philosophy and lifestyle.

People who lead an abundant lifestyle see their universe as infinite. They demand win-win scenarios in their personal and professional lives. In their world, it is not just acceptable for everyone to succeed; it is an imperative. In our dental communities, abundant leaders do not see other doctors as competition; they consider them colleagues, and a colleague is honored and respected as a friend.

Compare this to a lifestyle of scarcity, or what some call a zero-sum philosophy, in which the universe is viewed as finite. This philosophy requires that for every winner there must be a loser. Colleagues become competitors from which we must protect ourselves. We believe that somehow they will gain an advantage by taking what is rightfully ours, never considering the possibility that there is enough for all.

The same is true in our own practices.

A scarcity or zero-sum philosophy is not compatible with effective leadership because effective leaders are committed to assuring that everyone they lead is given the opportunity and resources to succeed. To an abundant and effective leader, realizing one’s dreams is a universal goal.

Scarcity-based leaders commonly believe that their role is to identify and judge others by their weaknesses rather than their strengths. This is a classic lose-lose scenario, which seldom creates a positive result for either party.

Drs. Joel Small and Edwin (Mac) McDonald have a total of over 75 years of dental practice experience. Both doctors are trained and certified Executive Leadership Coaches. They have joined forces to create Line of Sight Coaching, a business dedicated to helping their fellow dentists discover a better and more enjoyable way to create and lead a highly productive clinical dental practice. Through their work, clients experience a better work/ life balance, find more joy in their work, and develop a strong practice culture and brand that positively impact their bottom line. To receive their free ebook, 7 Surprising Steps to Grow Your Practice Through Leadership, go to www.lineofsightcoaching.com.

48 Orthodontic practice

Imagine what it would be like working in an office culture based on a scarcity philosophy, an office in which recognition is coveted by the doctor and seldom shared with the members of the team. This is an office in which the doctor has an emotional need for control or an environment lacking spontaneity, creativity, or the opportunity for personal development. Recent studies have shown that burnout is most likely to occur not only when people work long hours, but also when their long hours offer no opportunity for personal development. These are offices in decline, and they will continue their downhill spiral because the burdens created by the doctor’s zero-sum attitude cannot be supported by the weakened cultural infrastructure he/she have created.

Abundance-based leaders are the antithesis of scarcity-based leaders.

Abundance-based leaders understand that everyone has weaknesses, but they choose to judge others by their strengths.

Their dental practices are always more productive because they utilize individual strengths by positioning their people so they can further develop these strengths while benefiting the practice to the best of their ability. Research has proven that people who routinely utilize their most significant strengths in their daily work are among the most personally satisfied and productive team members.

We have also observed in organizational cultures that stress abundance and the development of individual strengths, there is a tendency for individual team weaknesses to spontaneously disappear. It is our belief that this unique phenomenon can occur only when failure is viewed as a learning experience and prerequisite for success, thus giving team members the ability and confidence to openly explore solutions for overcoming weakness without the fear of reprisal Now imagine working in an environment in which the doctor attributes achievements to his/her staff and is the first to accept the

and if someone else has it, that means there will be less for me. The more principle-centered we become, the more we develop an abundance mentality, the more we are genuinely happy for the successes, well-being, achievements, recognition, and good fortune of other people. We believe their success adds to ... rather than detracts from ... our lives.”

— Stephen R. Covey

blame for failures. What would it be like to work in an organization in which the leader was fully committed and engaged in assuring that all staff members reach their full potential and realize their individual dreams? This is an organization that will continually thrive.

Abundant cultures are participative as well as being creative and adaptive. They can tap into their vital stream of human potential which is a prerequisite for a highly productive and culturally mature organization. They promote self-development and self-direction. Such organizations are the icons of their industries.

Herb Kelleher, the untraditional CEO of Southwest Airlines, said this about his organization’s culture: “A financial analyst once asked me if I was afraid of losing control of our organization. I told him I’ve never had control, and I never wanted it. If you create an environment where the people truly participate, you don’t need control. They know what needs to be done, and they do it. And the more that people will devote themselves to your cause on a voluntary basis, a willing basis, the fewer hierarchs and control mechanisms you need.”

Is it any wonder that numerous studies have proven that organizations that create cultures based in abundance are significantly more profitable than those organizations whose culture is scarcity-based? OP Volume 11 Number 1

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