Orthodontic Practice US May/June 2020 Vol 11 No 3 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews May/June 2020 – Vol 11 No 3 • orthopracticeus.com

Dr. Ryan P. Robinson

Vertical control and efficiency in treating a Class III malocclusion Dr. Michael T. DePascale

NOVEMBER

Dr. Alfred C. Griffin Jr.

13 TH-15 TH,2020

3D mathematics, software, and 3D printing = advanced IDB

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Improving patient health through sleep dentistry

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A NEW PARADIGM IN TREATMENT EFFICIENCY “SmartArch treatment appeared to minimize the lag phase…leading to an estimated 50% savings in leveling and alignment time.” 1 – Dr. Marc Olsen, JCO February 2020

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

Olsen, Marc. SmartArch Multi-Force Superelastic Archwires: A New Paradigm in Orthodontic Treatment Efficiency. Journal of Clinical Orthodontics. February 2020.

The opinions expressed are those of the author(s). Ormco is a medical device manufacturer and does not dispense medical advice. Clinicians should use their own professional judgement when treating their patients.

What do you want for the future?

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

e’re living in unprecedented times. The COVID-19 pandemic has changed the way we live, work, and even think about healthcare. What’s more, it has shifted my job description from fulltime orthodontist into fourth-grade teacher, sous chef, sanitation engineer, virtual-visit specialist, retainer solver, on-call Netflix navigator, and all-around problem solver. In an effort to find some distraction from these burgeoning responsibilities, my husband and I sat down to watch Season 3 of the crime drama “Ozark.” (It might have been at noon. Don’t judge!) Dr. Amy B. Jackson This week the lead character, Marty Byrde, was kidnapped by the head of the Navarro drug cartel and forced into solitary confinement. Each time the drug lord visited his cell, he asked Marty one simple question: “What do you want?” And each time Marty would answer with a half-baked truth. It wasn’t until Marty came forward with a pure, honest answer about what he wanted that he was set free and sent back to his family. So, what is it that you want? You want COVID-19 to disappear as quickly as it arrived. You want your practice to not only survive but thrive. You want to put people first and be a leader in your community. And 10 years from now, you want to look back and recognize how tough this time really was, but also see the good that came from it. I know because I am walking this journey with you. But as we continue down the COVID-19 path and its aftermath, we also should be keenly aware of what our patients want and pivot our practice to meet those needs. But what do they actually want? Patients want efficient treatment, esthetic solutions, and clear communication. They want treatment to finish on time and retainers not to be a burden. They want to be treated in a sterile environment and have necessary appointments easily coordinated with their schedule. Not least of all, they want to know that we care. In short, patients want us to make every aspect of orthodontics easy for them. Together, we will speak to the needs of our patients. Like the Phoenix that rises from the ashes, we too will emerge from COVID-19 even better than we were before. We will encourage and depend upon each other, and the success of our profession will soar like never before. We are more than orthodontists. We are thinkers, problem solvers, community leaders, philanthropists, and artists. We are greater than the sum of our parts. Just like that Phoenix, our profession will emerge stronger, smarter, and more agile. The world has changed. Our patients’ expectations have changed. We will rise together to face these new challenges and find new solutions. And that’s the pure, honest truth.

CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT

Dr. Amy B. Jackson

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.

Dr. Amy B. Jackson is a Board-certified orthodontist who graduated Magna Cum Laude from Baylor University and began her dental career in Houston where she attended The University of Texas Health Science Center. While at Houston she was awarded a Summer Research Fellowship from the AADR and the Barnard G. Sarnat Award in Craniofacial Biology from the IADR. Dr. Jackson continued her specialty training for Orthodontics at The University of Texas Health Science Center in San Antonio. Her resident training included a master’s degree through the periodontal department and a research grant through the AAED for her published work with midpalatal implants. Dr. Jackson currently practices at South Texas Orthodontics. Disclosure: Forestadent has partnered with Dr. Amy B. Jackson and her program Retainers For Life®/After Ortho Revenue™. For more information visit, afterorthorevenue.com or speak with your local Forestadent representative.

ISSN number 2372-8396

Volume 11 Number 3

Orthodontic practice 1

INTRODUCTION

May/June 2020 - Volume 11 Number 3

TABLE OF CONTENTS

Case study Vertical control and efficiency in treating a Class III malocclusion

Publisher’s perspective Rolling with the changes

Dr. Michael T. DePascale discusses his experience in the development and use of a new clear aligner system

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

Orthodontic concepts The reality of virtual orthodontics Dr. Christopher Cosse discusses a novelty that is becoming a necessity .......................................................16

Orthodontic perspective “Primum non nocere” Drs. Donald J. Rinchuse, Dara L. Rinchuse, and Mr. Donald N. Rinchuse discuss the safety and health of patients, orthodontists, and staff during the COVID-19 crisis .......................................................18

Corporate spotlight Smile Stream Solutions

2 Orthodontic practice

Industry news.................21

Volume 11 Number 3

Data analytics software that drives winning practice performance.

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TABLE OF CONTENTS

Continuing education Improving patient health through sleep dentistry Dr. Ryan P. Robinson discusses how recognizing possible sleep issues in oral anatomy can lead to more comprehensive patient care.............26

Step-by-step

Tie-On Rotation Wedge (TORW) for perfect orthodontic finishing: part 2

Continuing education

Dr. Lloyd Taylor presents additional techniques using Tie-On Rotation Wedges........................................... 29

Dr. Alfred C. Griffin Jr. discusses how technology led him back to indirect bonding

3D mathematics, software, and 3D printing = advanced IDB

Technology The McLaughlin Bennett 5.0 orthodontic appliance and archwire system Dr. Richard McLaughlin discusses the updated system that promotes increased clinical efficiency..............30

Product profiles AcceleDent Optima™ — Increasing predictability of clinical outcomes.......................33 ®

Gaidge Three keys to practice health amid the COVID-19 crisis............................... 34

Marketing momentum Ready, set, present! In this article, Jackie Raulerson discusses how to share your practice and treatment successes with an effective presentation.......................35

Telemedicine marketing checklist: 10 things orthodontists should do Marketer Rachael Sauceman discusses safe and effective marketing evolving after the COVID-19 crisis .......................................................38

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

CONNECT with us on social media Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

4 Orthodontic practice

Volume 11 Number 3

See patients less. Treat them better. The VProâ&#x201E;˘ Series is the only FDA-cleared high frequency vibration product line proven to accelerate orthodontic tooth movement and increase predictability in just 5 minutes a day. Equip your patients with this simple and easy-to-use tool for a referral worthy orthodontic experience in fewer visits.

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PUBLISHER’S PERSPECTIVE

Rolling with the changes

“I

’ll be here when you are ready, to roll with the changes.” — REO Speedwagon As I write this perspective, the world has been going through a period of changes and modifications like never before. COVID-19 regulations have shuttered many restaurants and retail stores. Stay-at-home parents have transformed into surrogate teachers, and Zoom has become the go-to method of connecting families and employees, surpassing 300 million Zoom meeting participants each day. The image of heroes who wear capes and masks has been replaced with heroes who wear scrubs and masks, stand behind grocery store and pharmacy cash registers, or deliver food to those in quarantine. Even Lisa Moler dental offices have been relegated to treating only emergency Founder/Publisher, MedMark Media patients and are seeking innovative answers to sterilization and sanitization for the benefit of team members and patients alike. At MedMark Media, our leadership and team have been Zooming, brainstorming, and striving to serve our readers and advertisers with creative ways to keep in touch and open for business and information. Our CEs and webinars are online so that you can continue to accumulate knowledge and gain CE credits. Our web news is consistently updated, and we are always having interesting discussions with insightful key opinion leaders in our podcasts and videos. Check out our website to keep informed of our latest offerings. In this issue of Orthodontic Practice US, we cover clinical topics that can help your practices grow and articles on how to survive COVID-19 adjustments to your business. In our CEs, Dr. Ryan Robinson discusses the importance of recognizing possible sleep issues in the oral anatomy that can adversely affect patients’ overall health, and Dr. Alfred Griffin Jr. discusses advanced indirect bonding and enhanced capabilities related to 3D printing of ceramic brackets. Dr. Donald J. Rinchuse, et al., address some considerations that orthodontists need to make to enhance safety to patients and staff as the country “reopens” from the COVID-19 crisis. Dr. Christopher Cosse looks at virtual consults and appointments to regain efficiency, and marketer Rachael Sauceman offers a telemedicine marketing checklist to facilitate patient awareness of implementation of telehealth solutions. The ways that we approach our work have changed, but our commitment to keeping the publications relevant and flowing on schedule remains the same. Our advertising and editorial departments continue our everyday endeavors, even though we are more physically “socially distant” than we would like. We also are spending our time wisely by searching for ways to help you all regain your strength, spirit, and resources after this challenging time passes, and you are ready to return to the new normal in the dental office. The song quoted at the top of this message remains my mantra. We are here for you. When you are ready, we will be here to roll with the changes. Stay safe, stay strong, and stay ready for reopening and reinvigoration. To your best success, Lisa Moler Founder/Publisher MedMark Media

Published by

PUBLISHER Lisa Moler lmoler@medmarkmedia.com DIRECTOR OF OPERATIONS Don Gardner don@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com MANAGER CLIENT SERVICES/SALES SUPPORT Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING & DIGITAL STRATEGY Amzi Koury amzi@medmarkmedia.com EMEDIA COORDINATOR Michelle Britzius 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 3

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Dr. Dania Tamimi (Oral & maxillofacial radiology)

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CASE STUDY

Vertical control and efficiency in treating a Class III malocclusion Dr. Michael T. DePascale discusses his experience in the development and use of a new clear aligner system Introduction In 1998, the field of orthodontics changed completely when the clear aligner system was approved as an alternative to fixed appliances. When first introduced, clear aligners were less efficient than braces and challenged practicing orthodontists with a steep learning curve. Today significant advances in clear aligner technology (largely through improved 3D software and materials) across multiple vendors provide the orthodontist with many options using the power of digital dentistry in the treatment of various malocclusions. Additionally, given the flexibility of clear aligners and patient desires for esthetic treatment options, arguing against the growing use of clear aligners would be futile. I had the opportunity to work with Ormco™ on Spark™ Clear Aligners, a new clear aligner system that was developed and piloted with orthodontists from around the world. Using TruGEN™ material, Spark was designed to exhibit improved sustained force retention for more efficient tooth movement. I practice daily applying efficient mechanics with passive self-ligation, so two important questions should be answered: Can I deliver the same results with aligners, and can I do it in fewer appointments?

orthodontic space, efficiency can be defined as “achieving a beautiful smile and occlusion with the simplest mechanics possible, using the fewest number of appointments, in the least amount of time.” Accomplishing this begins with proper diagnosis and case setup, and must also be supported by a product that can perform to the orthodontist’s needs. The Spark™ advanced Approver™ software streamlines the planning process with precise anatomical reproduction of teeth and simulated library roots, as well as extensive customization of tooth movement and auxiliary controls. If digital tooth movement is designed properly by the orthodontist, amazing results can be achieved.

Diagnosis A 31-year-old female presented with a chief complaint of crowding, bite issues, and dissatisfaction with the appearance of her smile. Additionally, she had previously seen a periodontist regarding the recession on her lower 1’s. The periodontist recommended that she see an orthodontist to idealize the

occlusion and to reduce the risk of further recession. Clinical and radiographic exams revealed that she presented with a Class III skeletal and dental malocclusion with moderate maxillary crowding, mild mandibular crowding, and a full anterior crossbite.

Treatment objectives The treatment objectives were to eliminate the maxillary and mandibular crowding, to fully correct the anterior crossbite, to improve lip support while maintaining torque of the incisors, to eliminate the Class III mal-occlusion, to align maxillary and mandibular midlines, and to improve the smile arc and esthetics. The smile was designed to be improved by extruding the maxillary incisors while maintaining the vertical position of the posterior teeth and transverse dimensions.

Treatment design This case was set up using the digital Approver software for Spark Clear Aligners. The initial setup included horizontal rectangular attachments to control posterior teeth

What are the key factors in efficient treatment? Efficient can be defined as “capable of producing desired results with little or no waste (of time or materials).” In the

Michael T. DePascale, DMD, MS, is a New Jersey native. In 2014, he graduated at the top of his class from the Rutgers School of Dental Medicine in Newark, where he earned his Doctor of Dental Medicine degree. In 2017, after completing a 3-year orthodontic residency at the University of Maryland, he received a Masters in Oral Biology. Soon afterward, Dr. DePascale, joined the team at Kozlowski Orthodontics — a practice that matched his dedication to high-quality treatment, innovation, efficiency, and education. Disclosure: Dr. DePascale is a member of the Spark™ Founders Group and a Key Expert for Ormco™.

Figure 1: Initial photos 8 Orthodontic practice

Volume 11 Number 3

AcceleDent is the only FDA-cleared vibratory device that has clinically proven its effectiveness with 3 RCTs. It increases the predictability of clinical outcomes and enables orthodontists to treat even complex cases with aligners. Furthermore, AcceleDent speeds up tooth movement by up to 50 %* and reduces pain and discomfort.

Make complex cases less complex

INITIAL

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Case presentation by Dr. Tommaso Castroflorio from Torino, Italy (Case ID: 042)

30 MONTHS ACTUAL TREATMENT TIME WITH ACCELEDENT

18 MONTHS

40% less time Diagnosis: Dental & Skeletal Class II, Normodivergent, Overjet > 10mm, Transversal deficiency Aligner change routine: 14 days until maxillary second molars were fully distalised, then 10 days until first molars were in final position, then 7 days until end of treatment Mechanics: - Class II elastics Âźâ&#x20AC;? 4 oz - Severe maxillary overjet resolved with Class II aligner mechanics

Focus: significantly flared incisors and overjet

For more case presentations and information: acceledent.com

* Lobre et al.: Pain Control in Orthodontics Using a Micropulse Vibration Device: A Randomized Clinical Trial. The Angle Orthodontist, 2015.

ESTIMATED TREATMENT TIME

CASE STUDY

Figure 2: Initial frontal smile

Figure 3: Initial ceph

and cutouts for elastics to aid in bite correction. Specifically, there were button cutouts on the facial of the lower 3â&#x20AC;&#x2122;s in preparation for Class III elastics as needed, as well as button cutouts on the palatal of the UL3 and LL34 in preparation for crossbite triangle elastics. The lower aligners were designed to have lingual bite turbos on the L1â&#x20AC;&#x2122;s to guide the maxillary anterior teeth forward to correct the crossbite. Once the crossbite was corrected, the refinement setup was designed to focus on improving the smile arc and anterior occlusion while finishing the Class III correction on the right and improving the midlines with elastics. Gingival-beveled attachments were applied wherever extrusion of teeth was necessary. Finally, Caplin Hooks were placed on the facial of upper and lower 56â&#x20AC;&#x2122;s in the settling stages to use box elastics to detail the posterior occlusion.

Treatment progression

Figure 4: Initial pan

Figure 5: Initial lower aligners with lingual turbos

Figure 6: Initial center 10 Orthodontic practice

Figure 7: 5-month progress center

Appointment 1: Attachments were placed on teeth, and the patient was instructed to wear aligners for 22 hours a day with a Class III elastics (5/16", 3.5 oz) from the LR3 to UR6 full time. Appointment 2: First aligner progress appointment. Seating of aligner was evaluated to make sure all teeth were properly tracking. Tracking was ideal. IPR was completed on L4-4. Patient was instructed to continue the Class III elastics on the right side only and begin adding crossbite elastics (3/16", 3.5 oz). A Caplin Hook was added to palatal of UL3 at this visit. Appointment 3: Second aligner progress appointment and refinement scan. Patient completed aligner 20/20 in her initial set. Tracking remained ideal. Crossbite elastics on left was stopped. Patient was instructed to continue Class III elastics on the right fulltime. A digital intraoral scan was completed for a refinement. Appointment 4: Refinement No. 1 delivery. Anterior and posterior attachments were placed to help with vertical control of posterior segments while extruding U2-2 for smile arc. Class III elastics on right discontinued. Appointment 5: Refinement No. 1 progress. Tracking was ideal. Posterior occlusion had opened slightly, so Class III elastics were restarted bilaterally full time to help remove premature anterior contact (see Figure 8). Appointment 6: Refinement No. 1 progress appointment No. 2. Patient was finished with aligner 14/14 in refinement Volume 11 Number 3

a simple

THANKS to all the front-line heroes making a difference around the world. G&H Orthodontics would like to express our sincere gratitude for your extraordinary service and support.

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CASE STUDY

Figure 8: Appointment No. 5

No. 1. Tracking was ideal. Alignment was ideal. Posterior occlusion slightly open. All attachments were removed, button cutouts were made in upper and lower 56â&#x20AC;&#x2122;s, and Caplin Hooks were placed on upper and lower 56â&#x20AC;&#x2122;s. Box elastics U56/L56 (1/4", 4.5 oz) bilaterally were applied full time. Appointment 7: Posterior occlusion fully seated, and treatment objectives were achieved. Total treatment time was 9 months with 34 aligners. Patient was instructed that if her bite became uncomfortable again, additional aligners could be used to add torque U2-2. Due to her Bolton discrepancy and full anterior crossbite initially, this possibility was explained. *Please note that the final i-CAT images could not be obtained due to the time in

Figure 9: Final occlusion

which this article was written. At the time, all dental offices were mandated to be closed for anything but emergent care due to COVID-19, and her appointment for final imaging was within this time frame. However, I would be happy to provide the final images to anyone inquiring once they are obtained.

Summary and conclusion Following a carefully designed treatment plan with very little auxiliary mechanics, a patient presenting with a Class III malocclusion achieved a Class I functional occlusion and esthetic smile in less than 12 months and only 7 appointments using Spark Clear Aligners. Furthermore, the treatment incorporated lingual bite turbos, a novel method with clear aligners.

Orthodontists have used bite turbos to aid in Class III correction for years with braces but have not done the same with aligners. This case clearly demonstrates that these mechanics can also be applied successfully with aligners, and potentially in less time. As orthodontists attempt to reduce treatment times, treat in less appointments, attend to patient desires, and improve patient experiences, this serves an example of how that goal can be attained. Gone are the days of claiming that plastic cannot move teeth the way fixed appliances do. Clear aligners can, they do, and they will only continue to be developed into systems that deliver more predictable, more reliable, and more precise results than ever before. Transverse, anterior-posterior, and vertical control were maintained, torque was controlled throughout this entire treatment, and the patient had to be seen only 7 times. When planning is proper, patient education is thorough, and a versatile, customizable product is available, there are no limits to what can be accomplished. I do still practice with a great deal of Damonâ&#x201E;˘ brackets, and I do not intend to change that. As orthodontists, we should be able to treat effectively with both fixed and removable appliances. I firmly believe we are only at the beginning of what can be achieved with aligners. I hope that this case undoubtedly illustrates the changes we can make in the lives of our patients, doing it in a way that provides both the patient and orthodontist excellent results and a fantastic experience. OP

Figure 10: Before-and-after smiles 12 Orthodontic practice

Volume 11 Number 3

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CORPORATE SPOTLIGHT

Smile Stream Solutions

mile Stream Solutions is a family-owned company that started as a strategic sourcing supplier, exclusive to some of the largest single private and group practices in the country. These practices and groups recognized the changing dynamics in the marketplace as the manufacturing establishment continued to increase prices yearover-year on products that were already difficult to justify. This pricing strategy — combined with an almost cyclical restructuring of corporate leadership from outside the industry, a growing transiency of sales representation, and quarter ending stockup promotions that conflict with best inventory management practices — made an alternative to traditional supply absolutely necessary in our customer’s minds. As a result, Smile Stream Solutions was established, and by effectively delivering highquality products and services at reasonable prices in a manner that improved efficiencies and returns, word began to spread. This groundswell of word-of-mouth referrals has not only fueled our unprecedented growth, but also further validated an ever-expanding need within the marketplace for clear, fair pricing; 24/7 remote access; human-based customer support; timely delivery; and valueadded services that are all meant to improve the vitality of the single private and group practice community. In fact, our mission is to enhance the vitality of the orthodontic community through savings and efficiencies in clinical supply.

Positioned for growth Smile Stream Solutions is now well positioned and prepared to extend our model and its benefits to the greater orthodontic

Our mission is to enhance the vitality of the orthodontic community through savings and efficiencies in clinical supply.

marketplace. We currently provide a full line of high-quality, globally sourced products ranging from brackets, bands, and wires, to aligner systems, hand instruments, and a wide range of supplies. Many of these are available in either branded, or privatelabeled form, and we are further open to sourcing products on a custom basis in support of the unique needs of your business. All of these are very well stocked, and most orders get turned around and delivered within the same day. However, we’re not stopping there. Moving forward, we will be leveraging our network of clinical, manufacturing, and strategic partners to develop new innovative products, continuing education programs, and consulting services that will best support your vitality and growth into the future.

24/7 remote access

Smile Stream Solutions user-friendly online ordering websites enable you to find information, order your products, track status, and pay your bills at any time and from any device 14 Orthodontic practice

At Smile Stream Solutions, we recognize that you can no longer wait to be visited by a sales representative or have access to information regarding your supplies be limited to a 9-to-5 workday schedule. That is why we’ve developed one of the most userfriendly, end-to-end online ordering websites where you can find information, order your products, track status, and pay your bills at any time and from any device. At the same time, we also recognize the place and need

for human-based interaction, relationships, and support. That is why we also have a full complement of sales and service representatives who can speak, chat, or meet with you about whatever it is you need to find, know, or resolve.

Streamline your practice Between the acumen of our leadership team across procurement, general business management, and engineering — along with the experience we have from working with some of the most successful single private and group practices in the country — we have the expertise to help you streamline your practice from a supply and inventory management basis. Remember, your practice is just as much a business as it is a source of clinical treatment, and the most valuable asset of any business beyond their people is its supply. These are challenging times in our industry, and we want to do our part in providing solutions to both your needs and the greater orthodontic community. Thank you for the opportunity to partner with you towards achieving our mission. To learn more, please visit us at www.smilestreamsolutions.com, or call 1-888-261-9933. OP This information was provided by Smile Stream Solutions.

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ORTHODONTIC CONCEPTS

The reality of virtual orthodontics Dr. Christopher Cosse discusses a novelty that is becoming a necessity

n the day that this is being written, April 11, 2020, the whole country is on lockdown. Stay-at-home orders have been issued in almost every state. The country is experiencing the COVID-19 virus. At this time, orthodontists really don’t know when it is safe to return to work, and what the office schedule will look like when that finally happens. If you’ve ever experienced virtual reality, you know that it does an incredible job of tricking your brain into thinking that you are hanging from a cliff, fighting a monster, or driving a race car. It takes a little getting used to at first — some people don’t know how to work the controls; some people don’t know what to do; some are overwhelmed by the whole thing. But once you get settled in and embrace the new virtual reality, it can become quite enjoyable and take you to places you never dreamed possible. The same is true with virtual consultations and virtual appointments. The combination of improved technology, a generation raised with smart phones, and a need brought on by COVID-19 accelerated virtual orthodontics to the forefront. Like a newborn colt trying to stand for the first time, it was a little unsure

Christopher Cosse, DDS, is a graduate of Louisiana State University School of Dentistry and he completed his orthodontic training at Oregon Health Science in Portland. He is regularly invited to speak about orthodontics nationally and internationally. He is married and has four children. Dr. Cosse is a Damon Premier Provider and Educator and is in private practice in Shreveport, Louisiana. For more information about virtual consults/appointments, visit Dr. Cosse’s FaceBook group VirtuOrtho. Disclosure: Dr. Cosse is the founder of Braces Academy – The prescriptive patient education™ system and OrthoScreening.

16 Orthodontic practice

Virtual consult and virtual appointments will very likely be among the most important additions to regain our efficiency and survive this reentry back to our practices. and awkward, but now after a few weeks of massive usage, that colt is starting to look like a future thoroughbred. Necessity is truly the mother of invention. A helpful addition to the mix is government-relaxed privacy laws, massive patient/doctor demand, and a worldwide adoption by everyone from businesses to families to grandparents. As we start reopening our practices, it is very likely that government entities will limit the number of patients in the office or at least mandate 6 feet of space between patients. Efficiencies that orthodontic offices have been honing for years will be flipped on their heads. Increased hours, increased days, and split staff hours will be a reality for many practices. Virtual consult and virtual appointments will very likely be among the most important additions to regain our efficiency and survive this reentry back to our practices. But how can virtual consult and virtual appointments impact the orthodontic practice? Some dentists are skeptical of the virtual consult, thinking that if they will need to see the patient in person anyway, the virtual consult seems to be a waste of time. This can be true if the clinician doesn’t open his/ her mind to the possibilities of virtual treatment. I’m not advocating treating a patient without seeing them physically and doing a full set of records and X-rays. However, you can get good insights into treatment

planning for a new patient based on the diagnosis from pictures and understanding the patient’s chief complaint. You can devise a tentative treatment plan and verify once the patient comes in person to your office. For existing patients, many times the orthodontist can progress the treatment and monitor progress with elastics, brushing, retainer/ aligner wear, and more. This type of technology will save time when in-office appointments reopen, and patient appointment backlogs are likely to occur. Additionally, as businesses and schools reopen, patients are going to be busier than usual, and many may want to continue social distancing to some degree. Virtual consults and virtual appointments will save patients time in their busy schedules, decrease work time missed (which will be even more important since they have been off work), and lessen the hassle of physically coming into the office by doing virtual appointments when appropriate. Also, virtual consults will help us to treat and reach out to our current patients during this time. All of our current patients will be contacted via text, email, or phone, and checked on.

Synchronous and asynchronous choices As virtual consultations evolve, two categories of online consults have emerged — synchronous and asynchronous. Both are Volume 11 Number 3

Divide and conquer During this time, we should be reaching out to current patients and dividing the patients into different categories — those who need to be seen on an emergency basis, those who need to be seen relatively soon, and those who can be pushed back for at least a few weeks. Patients under observation with ectopic eruptions, with exposures, reverse-curve archwires, torquing springs, Forsus springs, Herbst appliances, Carriere® appliances (Henry Schein® Orthodontics™, Carlsbad, California), for example, need to be seen ASAP and in person. These are not appropriate for virtual consultation because there is not much treatment that you can do on these patients. Patients who are over treatment time, who have poor oral hygiene, elastomeric chains, in danger of overcorrecting, and with active aligners and some adjustments Volume 11 Number 3

ORTHODONTIC CONCEPTS

appropriate depending upon the situation and patient needs. Synchronous means that the doctor and the patient must be present online at the same time, and the consult happens in “real time.” This provides for immediate interaction with the doctor. Asynchronous consults are not live. Patients can provide the information at their convenience, and the doctors can respond and plan treatment and the consult also in a “self-paced” way. This type provides for more flexibility for the doctors and patients, as well as for patients with varying work schedule hours. Because of the “live-consult” nature inherent with the synchronous type of virtual consult, such as doxy.me and Zoom calls, a limited number of exams can be accomplished in a day. Doxy.me, Zoom, Skype, and FaceTime necessitate coordinating a specific time with the patient, and there can be potential awkwardness on a Zoom call if the parent is not present. To some, picking up the phone and calling the patient might seem more personal. An asynchronous option, OrthoScreening™, has reported its dentists using this application seeing an average of 5,000 virtual exams per week. Many dentists are able to evaluate several hundred patients per day because of the efficiency and workflow of this type of virtual consult. This asynchronous option can achieve maximum reach with minimum effort. It also is sustainable and easily adopted. Whichever application is chosen, be open to whatever the patients feel comfortable with, and try to accommodate their needs.

Patient photos from virtual orthodontic appointment.

need to be seen relatively soon, and most can benefit from a virtual consult/appointment as well. Some patients can be pushed out a little while longer. Retainer checks, patients in elastics who need much more time in treatment, observation appointments, and some aligner patients can be monitored with virtual consults/appointments. New patients are vitally important at this stage because most people who don’t have virtual consult capabilities have not been seeing new patients for quite some time. That means some orthodontists are well behind yearly and quarterly financial goals. To recoup that revenue, while trying to catch up on treating existing patients, clinicians will either need to work significantly more hours, bring in help in the form of an associate, or implement virtual new patient exams. Again, I am not advocating for virtual exams to replace in-office comprehensive exams and X-rays. The CBCT and/or cephalometric and panoramic radiographs are imperative to proper diagnosis. A virtual consultation can offer a good indication, in

most cases, as to whether the patient can be treated and possible treatment options to some degree. Virtual consults also offer the ability to pre-qualify patients before they come to the office and take up a valuable new patient appointment slot — when they may not have scheduled had they been aware of the price or time involved or didn’t qualify for a specific treatment such as aligners. This COVID-19 period will eventually end, but the lessons that we have learned will last. Think back to reaction of the taxi companies when Uber started driving, bookstores when Amazon opened, or Blockbuster when Netflix launched. Our world has changed, and we must change along with it to survive and thrive. Whether you choose synchronous or asynchronous methods, virtual consults and virtual appointments are here to stay. We have a saying at Braces Academy™, “the customers will get what they want.” Patients will find virtual consults more convenient, more transparent, and more efficient. If you aren’t doing virtual consults, I would suggest that you look into them because “the customers will get what they want!” OP Orthodontic practice 17

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“Primum non nocere” Drs. Donald J. Rinchuse, Dara L. Rinchuse, and Mr. Donald N. Rinchuse discuss the safety and health of patients, orthodontists, and staff during the COVID-19 crisis Abstract This article explores the impact of the COVID-19 pandemic on orthodontic practice. It reports on the current public health and evidence-based medical and scientific news related to the novel coronavirus. Addressed in this paper are the considerations that orthodontists will need to make once the country “reopens.” This paper alerts practitioners to orthodontic treatments and behaviors that are good and beneficial versus those that are harmful and jeopardize personal safety.

Introduction The COVID-19 pandemic has certainly affected the lives of the world. “Stay at home,” “shelter in place,” “safe at home,” ”stop the spread,” “flatten the curve,” “safe distancing,” “wash your hands” — all are cautionary statements we have recently heard. Of course, there is the sobering reality of the many lives that have been lost due to COVID-19. Scientists around the world are working on diagnostic tests, treatments, and a vaccine. The mantra is, Test, trace, isolate, treat, and pray for a vaccine. Unfortunately, it has been estimated that a vaccine will not be produced for 12 to 18 months. Renowned physician-scientists on the national news such as Drs. Anthony Fauci, Deborah Birx, and Sanjay Gupta have cautioned on using drugs and treatments before the science is proven effective. The

Donald J. Rinchuse, DMD, MS, MDS, PhD, is presently in corporate orthodontic practice in Greensburg, Pennsylvania. He has coauthored two books and written over 130 articles. Dara L. Rinchuse, DMD, is in private orthodontic practice, Orthodontique, with three office locations: Belle Vernon, Leechburg, and Natrona Heights, Pennsylvania. She has published many articles in orthodontic professional journals, including the American Journal of Orthodontics and Dentofacial Orthopedics. Donald N. Rinchuse, MS, PA-C, is a Physician Assistant at Trinity Health System, Steubenville, Ohio. He has coauthored several articles in orthodontic journals, including the American Journal of Orthodontics and Dentofacial Orthopedics.

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efficacy and safety of the drugs and/or treatments have to be evaluated. Even though there was an abundance of the COVID-19 diagnostic tests approved by the FDA, many have been found to be inaccurate with poor sensitivity and specificity. There are anecdotal reports of the effectiveness of several of the COVID-19 treatments such as the anti-malaria drug hydroxychloroquine (Plaquenil), which is presently used to treat autoimmune diseases such as lupus and rheumatoid arthritis, and azithromycin (Z-Pak). However, studies are demonstrating no benefit and serious side effects. Recall that Tom Hanks and his wife, Rita Wilson, were in Australia working on a movie when both contracted COVID-19. (It may also be that they brought the virus to Australia from California.) Both recovered, but Rita Wilson later lamented that the chloroquine drug regimen she was given had many profound adverse side effects. A recent French study (i.e., Dr. Didier Raoult, Marseille, France) found that the chloroquine regimen did not work and caused severe side effects. In addition, there was an RCT study in Brazil also testing the efficacy of the chloroquine protocol, which had to be halted because those in the high-dose treatment “arm” of the study (same doses of chloroquine as given in China) had fatal heart complications with 11 deaths.1 In another recent hydroxychloroquine study involving patients in U.S. Veterans Health Administration Medical Centers, the drug was shown to not be an effective treatment against COVID-19 and caused twice as many deaths as those who were not given the drug. Medical treatments must be effective, efficient, and most importantly, safe. There is also the recent proposal for a transition drug like the tuberculosis vaccine, Bacillus Calmette-Guérin (BCG), first used in the United States in 1921. In addition, there has been a clinical trial to test the efficacy of the antiviral Ebola drug, remdesivir. Furthermore, proposals for the testing of convalescent plasma from recovered COVID-19 patients are underway. Parenthetically, Michigan has launched the largest antibody study. As of this writing in April, as many as

40 clinical trials and more coming each day are focused on combatting COVID-19.

“Do no harm” Primum non nocere is the Latin for “First, do no harm.” This maxim has sometimes been recorded as “Primum nil nocere.” The origin of this adage is not certain, but most scholars trace it back to the “father of western medicine” — the 400 B.C. Greek physician, Hippocrates. The Hippocratic Oath includes the promise “to abstain from doing harm.” Nonmaleficence (“doing no harm”) is perhaps the most important precept of bioethics. This moral injunction is included in every medical/dental professional code. A more expanded and encompassing aphorism of “do no harm” is when confronted with a medical/health problem, it may be better not to do something, or even do nothing, rather than to risk causing more harm than good. Medical/dental treatments should be safe. In this light, healthcare providers are cautioned against the use of an intervention that carries obvious risk(s) of harm when there is uncertain possibilities of benefit. Importantly, the first phase of all medical clinical trials is to evaluate the safety of a drug, product, and/or treatment. Nonmaleficence is often contrasted with the adjunctive corollary beneficence, which means to do “good.” Healthcare providers are called to do “good” and not harm. “Good” in the healthcare context could have many meanings. Obviously, treatments should have a benefit and be based on the best available science and evidence. Treatments should not be based on therapies that are fostered by personal opinions, conjectures, and anecdotes. This brings us to the question, Is it irresponsible to use an experimental drug or treatment that so far has no real proven benefit and shows little promise, i.e., tested in clinical trials? And is this more of a concern in nonemergency situations? However, in lifethreatening situations, could the argument be made that, when all known and standard treatments have not worked, does it make sense to try an untested and experimental Volume 11 Number 3

Nonmaleficence and beneficence in orthodontics Does the debate on the treatments for the COVID-19 pandemic prompt orthodontists to consider the safety and efficacy of their diagnostics and treatments? Because orthodontics is elective, and in light of what we have learned so far from the COVID-19 pandemic, orthodontists must take an ardent look at what treatments and procedures are, and can be, harmful. Much, if not all, of the potentially harmful side effects of orthodontic treatment are enumerated in the American Association of Orthodontists (AAO) Informed Consent Documents. Orthodontics can cause or contribute to root resorption, decalcification, decay, and periodontal disease. Although not causative, orthodontics can be associated with, and contribute to, temporomandibular disorders.2,3 Certainly, bonded lingual retainers can cause harm when they become detached and/or remain in Volume 11 Number 3

We have the opportunity to make our profession and ourselves better from our struggles in dealing with COVID-19.

place for extended periods and become a hygiene/periodontal concern, mostly due to neglected follow-up appointments. Further, when a patient is at an increased risk for harm, due to a procedure or patient comorbidity, certain mitigation procedures can be performed. For instance, for patients at risk for root resorption, lengthening out appointments, using lighter forces, more frequent imaging, erroring toward nonextraction therapies, and so forth, can be implemented. Nonetheless, some patients should not be treated; the risks outweigh the benefits. Orthodontists must continually weigh the benefits versus the risks of treatments for all patients, and for all situations. The preceding examples are some of the physical harms that are possible consequences of orthodontics. There are also ergonomic and economic (time and money) harmful effects from improper diagnoses, treatments, and treatment mechanics. For instance, cases that are strictly “orthognathic surgery-orthodontic” that are treated solely orthodontically can often have devastating consequences; treatment results can be very poor, and orthognathic surgery may not be an option later on. It is important for orthodontists to pay attention to the evidence-based literature that is based on RCT, meta-analyses, and systematic reviews. Not doing so can cause harm to patients from the viewpoint of efficacy, efficiency (increased burden for orthodontists and patients), and costs. Certain Phase I treatments (e.g., Class II’s with 7 mm-plus overjets) that were performed years ago are not currently supported by the evidence. That is, the same or similar results can be attained with one comprehensive phase of treatment versus two separate phases of treatment. The point of stressing evidencebased treatments was well articulated by the health scientists in regard to proposed treatments for COVID-19. The foregoing addresses some of the potential harms of orthodontic treatment. But what about the harm that we, our staff, and family could face? The safety and health of all we come in contact with should be our highest priority. How do orthodontists lessen their exposure and those of others? Much

of what orthodontists will need to do upon reopening will be decided by the federal and state governments, CDC, ADA, and AAO. These dictates will come as requirements and/or guidelines. We have all become familiar with the details of these obligations. Interestingly, the American Dental Association (ADA) has just called for the U.S. Health and Human Services (HHS) to furnish coronavirus testing kits to dentists so they can swab patients prior to treatment once the economy reopens. As we are well aware, there are aerosol clouds (potentially containing the virus) produced from dental high-speed (possibly low-speed) drills. Addressing the COVID-19 pandemic will be more of a marathon than a sprint. Importantly, orthodontists must seriously contemplate the real possibility of facing a “rebound” and a second wave of COVID-19. Parenthetically, there were three waves during the 1918 Spanish Flu. Without a sustainable reopening, there could be a “rebound.” This would lead to an increased numbers of cases due to states reopening prematurely and citizens ignoring the strict guidelines imposed during the initial COVID-19 wave. In addition, the CDC has issued a warning that there could be a second wave of the COVID-19 virus occurring this coming fall and winter. This wave could be larger than the first. And there could be the simultaneous presences of both the COVID-19 virus and the regular flu virus(es). Either of these two episodes could lead to another shutdown of the country. The lessons learned from other infected countries should be our guide. This all leads to the question, Are orthodontists thinking and planning for the possibility of a “rebound,” second wave, and another shutdown? On the reopening of dental and orthodontic services by the individual states, will the states only allow a “soft opening?” — that is, patient appointments limited in number and social distancing observed as much as possible. Or will it be up to each practice owner to make his/her own decision. In the infection control world, “herd Immunity” protects a population from contagious diseases. However, as the world works its way back from the COVID-19 pandemic and Orthodontic practice 19

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drug and/or treatment? Does this have any comparison to enrolling terminally ill cancer patients in experimental clinical trials when all else has failed? This of course is dependent on the therapy being safe, i.e., with limited side effects. The argument is then “nothing tried, nothing gained, and nothing lost.” The families of those who have lost loved ones trying an experimental drug or treatment would probably have been grateful for the opportunity to have at least tried something — no lingering regrets in that they saw to it that all options were exhausted. But if experimental drugs being used to treat COVID-19 are also ones that are presently used to treat other illness — chloroquine to treat lupus and rheumatoid arthritis — then you could deplete the supply of that drug needed so badly by others. Further, by using one experimental drug and treatment over another one (because of bias toward that drug), you have then eliminated the use of other experimental drugs and treatments that may possibly have more benefit and actually work. Furthermore, there is the issue of giving false hope. In addition, if states “reopen” too soon, this could lead to a “rebound” increase in the virus. There could potentially be more virus in our communities at the “reopening” than there were at, and during most of, the closing. The decision on when to reopen the country in some cases has pit public health advocates against those who are concerned about economic health, and certainly there is no good answer. This is a further issue of benefit versus risk and beneficence versus nonmaleficence.

ORTHODONTIC PERSPECTIVE reopens, there will still be infected people out there. As more businesses start to open their doors, it may not be the time in orthodontics to do “herd scheduling” — that is, return to a full schedule of patients or even schedule more patients than before the pandemic. Even with the best infection control procedures, just having a lot of patients scheduled in our offices at one time would increase the risk of spreading the virus. But the argument will be, “I have lost so much money during the shutdown that I have to make up for it.” As an aside, teledentistry/teleorthodontics has been important during the shutdown, and it will be equally or more important during the reopening. This is especially true for clear aligner therapies. This COVID-19 pandemic has challenged the orthodontic community to further investigate all the possible uses of teleorthodontics. What about consults and starts? This is where the new money is made. Will orthodontists go back at the outset of the reopening doing consults and starts? This is not a moral, right or wrong decision, just a point to consider. In addition, will orthodontists be able to keep up with the escalated demand for more elevated types and quantity of personal protective equipment (PPE), and keep up with the enhanced infection control engineering protocols aimed at reducing the spread of the virus and protecting the safety

of everyone? In this period of the COVID-19, the business side of orthodontics will most likely overshadow the professional side. Orthodontists may be placed in positions that require them to make difficult decisions that will be based more so on economics and finances than service to patients. Will the survival of the practice take priority over just about everything else, albeit safety? This will be a difficult situation for orthodontists who have placed an emphasis on the professional and service side of orthodontic practice. The justifiable argument for taking the side of business over profession (and it is certainly justifiable) will be, “If I lose my business, how can I possibly do the good deeds that I have always done to support the profession, the public, my church, and the needy?” Every so often, we orthodontists need to be reminded of our duty to “do good” and “do no harm.” As the saying goes, “The darkest part of the night comes before the dawn!” In the darkness of the pandemic, let us try to open up the light of love! “Good” orthodontics is delivered in a kind, caring, and empathetic manner. Do unto others as you would have them do unto you. And better yet, do unto others as you would want them to do unto your kids and grandkids; we love our kids and grandkids more than ourselves. Give patients more than what they paid for. When possible, orthodontists should strive to

make “the orthodontic experience” the best part of a patient’s day.4,5 Crisis situations bring out the best and the worse in people. Let this COVID-19 pandemic bring out the best in us. As we shelter in place, we will have time to contemplate the new normal in orthodontics. We have the opportunity to make our profession and ourselves better from our struggles in dealing with COVID-19. We need to once again earn the respect of the public, our staff, and patients/families. As we lie down at night, and if we dream hard enough, we may also in some small way envision the displays of gratitude relegated to the frontline COVID-19 health providers with our cities lit up in “blue lights” with signs saying, “Heroes work here!” OP REFERENCES 1. Thomas K, Sheikh K. Small chloroquine study halted over risk of fatal heart complications. The New York Times. April 12, 2020. https://www.nytimes.com/2020/04/12/health/ chloroquine-coronavirus-trump.html. Accessed April 23, 2020. 2. Rinchuse DJ, McMinn J. Summary of evidence-based systematic reviews temporomandibular disorders. Am J Orthod Dentofacial Orthop. 2006;130(6):715-720. 3. Rinchuse DJ, Greene CS. Scoping review of systematic review abstracts about temporomandibular disorders: Comparison of search years 2004 and 2017. Am J Orthod Dentofacial Orthop. 2018;154(1):35-46. 4. Rinchuse DJ, Rinchuse DL, Sweitzer EM. What is the patient’s name? Am J Orthod Dentofacial Orthop. 2004; 126(2):234-236. 5. Rinchuse DJ. “The secret sauce” — more than the golden rule: part II. Orthodontic Practice US. 2018;9(2):40-47.

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Volume 11 Number 3

INDUSTRY NEWS

Infection prevention products from Great Lakes These heavy-duty HEPA filtration equipment and protective supplies are ideal for the waiting room and operatory. The Vanguard Gold Mobile Chairside HEPA Filtration Unit is a new extraoral dental suction unit designed to safely capture chairside aerosols. The Pure Breeze HEPA Air Purifier cleans and filters the air for a safer environment. The air purification system can exchange air in a 10' x 11' x 8' room 96 times per hour or 1.6 times per minute. Great Lakes Face Shields are constructed with medical-grade, optically clear PETG thermoplastic and designed to protect against aerosols, sprays, droplets, and mists. Accommodates most dental loupes, safety glasses, and masks. For more information, visit GLDTprotection.com, or call 800-828-7626.

RMO® focuses on helping practices during COVID-19 pandemic Rocky Mountain Orthodontics® (RMO®), an innovator of products and services for the orthodontic industry since 1933, has focused on helping orthodontic offices during the COVID-19 pandemic. The company has provided practices with information about financial resources such as Small Business Assistance Loan relief options to support the business success of its customers. RMO has discounted several of its most popular products. At this time of need, RMO has stepped up efforts to help local non-profits. RMO implemented health precautions including temperature checks of all employees, face-mask requirements, proper hygiene manners, and adhering to social distancing throughout its facilities. For more information, visit https://www.rmortho.com/.

RH-Pro9 RapidHeat sterilizer

Weave announces free continuing education series Weave, the complete business toolbox, announced free CE credit for all dental professionals. The announcement comes at an important juncture as dental practices prepare to reopen their doors in the wake of canceled events and working restrictions due to COVID-19. The free online continuing education segments include speakers JoAn Majors, Lois Banta, Jennifer Hirsch Doobrow, Laci Phillips, and more. Content is available to watch on-demand at the viewer’s convenience and will be available throughout The online content covers keeping remote teams engaged, leveraging the right software during the pandemic, ensuring HIPAA/ PIPEDA compliance while working remotely, following next steps for when practices can open again, and more. As state mandates continue to lift, Weave is coupling the free CE credit with recovery kits for its customers, including curbside pickup tools, Practice Analytics, and 3 months of free access to Weave Lite. To learn more about Weave’s online continuing education, please visit https://www.getweave.com/free-ce/.

Volume 11 Number 3

CPAC introduces the RapidHeat RH-Pro9 compact tabletop sterilizer. The RH-Pro9 has three large trays and can complete a 12-Log Kill cycle from start to finish in less than 20 minutes for pouched instruments and 40 minutes for wrapped cassettes. Unlike autoclaves, the RH-Pro9 requires NO drying cycle that can be bypassed or shortened to speed up instrument turnaround — a practice that is in violation of FDA and CDC requirements. With the absence of water, steam, and pressure, RapidHeat sterilizers do not require extensive maintenance. For more information, visit www.cpac.com, call 800-828-6011 ext. 1372, or email dbaker@cpac.com.

Orthodontic practice 21

CONTINUING EDUCATION

3D mathematics, software, and 3D printing = advanced IDB Dr. Alfred C. Griffin Jr. discusses how technology led him back to indirect bonding

s an orthodontist in practice for over 35 years, I have seen many changes in the way we practice. I entered the profession well after the integration of “prescription brackets” into the orthodontic armamentarium, and bonded brackets had been around for a long while. I’ve been through many iterations of how best to place the bracket on the dentition. During my residency at the Eastman Dental Center, I remember asking Dr. Lawrence F. Andrews himself where the bracket was supposed to be placed, and he responded simply, “in the middle of the tooth.” We used height gauges, but I quickly discovered that the same gauge and millimeter measurement did not fit the same tooth on every patient, and eventually abandoned the gauge for “eyeballing it.” Indirect bonding was introduced in the 1980s as a method of placing brackets on the teeth in a more accurate and efficient way.1-3 Many different variants of indirect bonding have been introduced over the years, from the initial efforts of placing brackets after drawing scribe lines on study model teeth and adhering the brackets on the models with “Sugar Daddy” candy up to modern-day 3D printing of the transfer trays and subsequent loading of the brackets into the independently created trays.3-5 (Editor’s note: “Sugar Daddy” technique was proposed by Swartz in 1974, using caramel candy as an adherent to place brackets to models. After the final trays have been completed, the caramel-candy water-soluble material was removed from the back of bracket base, and mesh pads were exposed for bonding in the clinic. The clean base method with a single silicone

Educational aims and objectives

This article aims to discuss a digital platform that fully customizes tooth movement with the 3D-printed bracket system.

Expected outcomes

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

Recognize various types of indirect bonding.

•

Realize some disadvantages of the traditional indirect bonding technique.

•

Realize some advantages of the 3D-printed bracket technology.

•

Recognize how to reduce human error in IDB tray fabrication by 3D-printing technology.

•

Recognize the need for minimization of the amount of bonding cement.

delivery tray is the original technique used in indirect bonding.”6) On at least four different occasions, I have changed my office bonding systems to indirect bonding only to revert back to direct bonding. Each time I went to indirect bonding, I found it more cumbersome and/ or less accurate due to the many variables involved in the process. The original goal of indirect bonding was to be both more efficient and more accurate. Several research efforts did not support the enhanced accuracy benefit.1-3 In an American Association of Orthodontists article published in September 1999 on the accuracy of direct versus indirect bonding, Koo, Chung and Vanarsdall stated, “Our results indicated that both direct and indirect bonding techniques failed to execute ideal bracket placement.”2 The past few years have brought what I believe to be the greatest advances in fixed appliances since the prescription brackets of the 1970s. Today with the wedding of enhanced software capabilities and 3D printing of ceramic brackets such

Dr. Alfred C. Griffin Jr., DDS, is a practicing orthodontist in Virginia since 1982. He received his bachelor’s degree in Biology and Psychology at the University of Virginia before attending the Medical College of Virginia for his DDS and completing his Residency at Eastman Dental Center. A member of Georgetown University School of Dentistry for 8 years, he has also been an active faculty member of Harvard School of Dental Medicine since 2015. Disclosure: Dr. Griffin Jr. is a speaker for LightForce™ Orthodontics, a digital platform that allows orthodontists to fully customize tooth movement with 3D-printed bracket system. His son, Dr. Alfred Griffin III, is CEO and founder of LightForce™ Orthodontics.

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as LightForce™ Orthodontics brackets (Cambridge, Massachusetts), we no longer have to accept the “one-size-fits-all” concept of traditionally manufactured brackets. The new biomechanical treatment advantages of full-customization (base + slot) have been illustrated in recent articles and forums. While 3D-printed brackets have taken the spotlight, it is the application of novel 3D-software algorithms that has drastically improved the efficacy of indirect bonding in terms of increased efficiency and accuracy in our office. (Editor’s note: The author reports that, currently, to his knowledge, there are no other fully customized 3D-printed brackets manufactured anywhere. He adds that some manufacturers provide different torque values, depending on the treatment plan (KLOwen™, Fort Collins, Colorado), and some have manufactured customized slots welded to stock bases, but no other bracket has a customized slot and base that is manufactured to exactly fit the individual tooth morphology.) When I first started using 3D-printed ceramic brackets, I did so despite my trepidation about the indirect bonding delivery system (IDB). I was fortunate to be an early adopter of this 3D-printed bracket technology and was able to voice my many concerns about IDB in general. Four years later, it is my preferred way of delivering fixed appliances. All of my former problems with IDB were a function of the human Volume 11 Number 3

Volume 11 Number 3

Figure 1: Removal of IDB tray

Figure 2: Preloaded IDB with second set of customized Rx brackets

Figure 3

Figure 4: Automated assistance in defining individualized ideal positioning of brackets

trays being fabricated over the bracketed study models, the IDB trays are independently fabricated by 3D-printing methodology. This eliminates the human error in IDB tray fabrication and the occasional bracket displacement during the tray fabrication. This process also creates a uniform transfer tray in terms of thickness, shape, and material consistency. Combined with the ability to design the 3D-printed ceramic bracket to be compatible with IDB transfer, this lends itself to a much more reliable and consistent chairside procedure. Initially we tried many iterations of the 3D-printed IDB tray, from whole arch to half arch to segmented arches. We found the segmented arches (right and left posterior

and an anterior section for upper and lower arches) to be most consistent (Figure 2). Material consistency and dimensional exactness lent itself to reproducible results with one exception. We found that the incisogingival positioning varied more than we would prefer. This was due to a lack of vertical stop of the incisors in the anterior segments. Because of the accuracy of 3D printing, we were able to design the anterior segments with occlusal rests on the cuspids on the palatal without any interference from the cuspid brackets already bonded on the labial surface. This gave enhanced vertical support to the anterior segments and led to much more consistency of placement of the anterior trays in all dimensions. Orthodontic practice 23

CONTINUING EDUCATION

error inherent in the fabrication of the IDB trays and subsequent delivery — from the need to still “eyeball” the placement of the bracket on models to the manual fabrication of the IDB tray on the bracketed models and the subsequent removal of the IDB tray from the models, hopefully with the brackets still in place. The delivery appointment was also fraught with peril. Was the tray seated correctly? Did I manually place enough finger pressure both occlusally and labially/buccally to get the brackets where they belong? In which direction do I remove the tray, and when I remove the tray, will it come off in one piece? My journey from skepticism to enthusiasm for IDB is the result of the application of sophisticated software development paired with 3D-printing capabilities. I will go through the entire process so that I can illuminate the differences between “then” and “now.” In my opinion, the placement of an orthodontic bracket on a tooth in its ideal position is of the highest importance to successful treatment outcomes. Up to now, it has always involved human placement, either directly on the tooth or on a model for transfer to the natural dentition via a transfer tray. Today with virtual treatment planning software for 3D-printed ceramic brackets, we have the capability to define the longitudinal and latitudinal axes of a tooth in an automated fashion and maintain that the bracket face remains parallel to this facial axis (FA) point, regardless of where it is placed. Therefore, unlike standard, “off-the-shelf” bracket systems, 3D-printed brackets do not need to be placed directly on FA point. Rather, an offset in the base is created to allow the appliance to be bonded anywhere on the labial surface. The slot orientation automatically changes to deliver the same direction of force as if it were centered on the tooth. Such “offset” positions are used to avoid occlusal interferences or to bond to severely rotated or blocked-out teeth. Automated assistance in bracket placement like this eliminates one of the most common hindrances to accurate tooth positioning and is only possible via 3D printing. Unlike stock orthodontic brackets, 3D-printed brackets are actually designed and fabricated to be delivered via IDB tray, so that both adherence in the tray and subsequent tray removal with brackets remaining on the dentition can be optimized. A custom release angle is designed into every IDB segment (Figure 1). Also, instead of the IDB

CONTINUING EDUCATION

Figure 5: Superimposition of virtual LightForce pretreatment setup and immediately post bonding scan

I bonded my first cases of 3D-printed ceramic brackets and was very pleasantly surprised at the ease and perceived accuracy of the bracket placement. Next, I wanted to test the position of the brackets on the patient’s teeth compared to the virtual position I had approved through the LightPlan software setup (Figure 4). I therefore bonded the next five IDB cases myself and had my assistants immediately scan the patients before archwires were placed. I subsequently sent these post placement scans back to LightForce™ and asked them to superimpose the post placement scans over the prefabrication virtual setup images (Figure 5). Every one of the pre- and post-scans superimposed perfectly, thus proving to me the exact transfer of bracket positioning from the virtual setup to the patient’s dentition. Up to this point in my practice, I had placed every bracket on every patient myself, either directly or indirectly. With this newfound confidence in the transferability of the 3D-printed brackets with the 3D-printed IDB trays, I decided to have my assistants perform this task without my participation. State laws vary on this, so orthodontists need to check on the regulations that adhere to specific state guidelines. Again, after bracket placement, this time completely accomplished by an assistant, we took post bonding scans and asked for superimpositions. Again, there was exact superimposition between the pretreatment virtual setup and the post bonding patient scan. Today all of my IDB with this system is accomplished by my assistants, and I am confident that their capabilities to deliver exact bracket placement are equal to mine. This has allowed me to spend more time within the practice focused on diagnosis, treatment planning, and patient and parent management, while still feeling secure that the most important clinical procedure on 24 Orthodontic practice

Figure 6: Fully customized base — minimal adhesive thickness required

Figures 7A and 7B: 7A.Too much adhesive. 7B. Ideal amount

our schedule is being accomplished in a superior fashion. 3D-printed ceramic brackets with customized prescriptions to the individual patient’s anatomy and treatment plan have been introduced into several orthodontic residency programs. I am a part-time faculty member in the orthodontic department at the Harvard School of Dental Medicine, and when we introduced the LightForce System, we had a first-year resident with almost no real clinical experience bond the first case. I was there to oversee the procedure, but she performed the entire bonding process herself. Again, exact placement was achieved. Probably the most difficult part of bonding the customized 3D-printed brackets is the minimization of the amount of bonding cement needed. Remember, these bases are also customized and an exact mirror to the specified labial surface of that particular tooth (Figure 6). My advice to residents is to place the thinnest volume of bonding material possible while still covering the whole pad. One can use any type of light-cured orthodontic bonding material. The important point is to use the least amount possible (Figure 7). Despite the minimal amount of bonding material used, I would expect to see more consistency of bond strengths due to the more uniform thickness of adhesive throughout the tooth-bracket pad interface.

The “breakaway” design of these bases also delivers a consistent bracket removal at debonding time. This is an exciting time to be practicing orthodontics. The advances in software design and 3D printing have allowed a true customization of fixed appliance therapy that is predicated on our patients’ individuality. It has also led to much greater efficiencies in our office routine that allow the doctor to focus on diagnosis and treatment planning and the communication of that knowledge to our patients and families. That is what separates us from non-orthodontist care providers. OP

REFERENCES 1. Hodge TM, Dhopatkar AA, Rock WP, Spary DJ. A randomized clinical trial comparing the accuracy of direct versus indirect bracket placement. J Orthod. 2004;31(2):132-137. 2. Koo BC, Chung CH, Vanarsdall RL. Comparison of the accuracy of bracket placement between direct and indirect bonding techniques. Am J Orthod Dentofacial Orthop. 1999;116(3):346-1351. 3. Li Y, Mei L, Wei J, et al. Effectiveness, efficiency, and adverse effects of using direct or indirect bonding technique in orthodontic patients: a systematic review and meta-analysis. BMC Oral Health. 2019;8;19(1):137. 4. Schmid J, Brenner D, Recheis W, Hofer-Picout P, Brenner M, Crismani AG. Transfer accuracy of two indirect bonding techniques — an in vitro study with 3D scanned models. Eur J Orthod. 2018; 40(5)549-555. 5. Grünheid T, Lee MS, Larson BE. Transfer accuracy of vinyl polysiloxane trays for indirect bonding. Angle Orthod. 2016;86(3):468-474. Epub 2015 September 10. 6. Aggarwal P, Aggarwal R. Indirect Bonding Procedures in Orthodontics - A Review. J Dents Dent Med. 2018;1(4):120. https://www.boffinaccess.com/open-access-journals/ journal-of-dentistry-and-dental-medicine/jddm-1-120. pdf. Accessed April 28, 2020.

Volume 11 Number 3

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3D mathematics, software, and 3D printing = advanced IDB GRIFFIN

1. _______ was introduced in the 1980s as a method of placing brackets on the teeth in a more accurate and efficient way. a. Indirect bonding b. Direct bonding c. Light-cure bonding d. Wet-field bonding 2.

Many different variants of indirect bonding have been introduced over the years, from the initial efforts of placing brackets after drawing scribe lines on study model teeth and adhering the brackets on the models with _______ candy up to modern-day 3D printing of the transfer trays and subsequent loading of the brackets into the independently created trays. a. “Jolly Rancher” b. “Sugar Daddy” c. “Sour Patch Kids” d. “Gummy Bear”

3. In an American Association of Orthodontists article published in September 1999 on the accuracy of direct versus indirect bonding, Koo, Chung and Vanarsdall stated, “Our results indicated that both direct and indirect bonding techniques _______ ideal bracket placement.” a. failed to execute b. succeeded in executing c. were both very effective choices for d. none of the above

Volume 11 Number 3

4. While 3D-printed brackets have taken the spotlight, it is the application of _______ that has drastically improved the efficacy of indirect bonding in terms of increased efficiency and accuracy in our office. a. novel 3D-software algorithms b. new 2D-software applications c. more traditional techniques d. the prescription brackets of the 1970s 5. Today with virtual treatment planning software for 3D-printed ceramic brackets, we have the capability to define _______ in an automated fashion and maintain that the bracket face remains parallel to this facial axis (FA) point, regardless of where it is placed. a. the longitudinal axis of a tooth b. the latitudinal axis of a tooth c. the human placement nature of the bracket d. both a and b 6. Unlike standard, “off-the-shelf” bracket systems, 3D-printed brackets ____ placed directly on FA point. a. definitely need to be b. do not need to be c. are guaranteed to be d. are never 7.

(With 3D-printed ceramic brackets) The slot orientation automatically changes to deliver the same direction of force as if it were centered on the tooth. Such “offset” positions are used _______.

a. to avoid occlusal interferences b. to bond to severely rotated teeth c. to bond to blocked-out teeth d. all of the above 8. (Because IDB trays are independently fabricated by 3D-printing methodology) This process also creates a uniform transfer tray in terms of _______. a. thickness b. shape c. material consistency d. all of the above 9. Because of the accuracy of 3D printing, we were able to design the anterior segments with ________ without any interference from the cuspid brackets already bonded on the labial surface. a. no rests b. occlusal rests on the premolars c. occlusal rests on the cuspids on the palatal d. rests on the lingual surfaces of the two central incisors 10. My advice to residents (when using customized 3D-printed brackets) is to place _______ while still covering the whole pad. a. the thickest volume of bonding material possible b. the thinnest volume of bonding material possible c. a non-uniform amount of bonding material d. self-cured type of bonding material

Orthodontic practice 25

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

Improving patient health through sleep dentistry Dr. Ryan P. Robinson discusses how recognizing possible sleep issues in oral anatomy can lead to more comprehensive patient care

leep is considered one of the most important pillars of health and wellness, and it has been proven to help the brain and body heal. When people do not get a sufficient amount of hours of quality sleep, they are at risk for a multitude of potentially serious chronic illnesses — for example, heart attack, hypertension, heart disease, stroke, diabetes, cancer, anxiety, and depression.1 When people do not get enough sleep at night, the consequences are felt the next day. Besides sleepiness and grogginess, the side effects can be life-threatening. Insufficient sleep has been linked to increased motor vehicle and work-related accidents. According to the National Highway Traffic Safety Administration (NHTSA), in 2015 over 72,000 policereported crashes involved drowsy driving leading to 41,000 injuries and more than 800 deaths.2 Research by the CDC also found that skipping one night of sleep has the same effects as having a Blood Alcohol Concentration (BAC) of over .10%, which is higher than the legal limit to drive!3,4 Allowing enough time in our schedules to sleep is extremely beneficial, but what if there was something physically blocking the person from getting proper amounts of sleep? According to the American Sleep Apnea Association, an estimated 22 million Americans suffer from sleep apnea, with 80% of cases of moderate and severe obstructive sleep apnea undiagnosed.5 This disturbing reality has forced more healthcare providers to become part of a multidisciplinary effort

Ryan P. Robinson, DDS, graduated from dental school at the University of Maryland and completed his general practice residency at Christiana Health System. He is a Diplomate in the American Academy of Craniofacial Dental Sleep Medicine, American Board of Craniofacial Pain, American Board of Dental Sleep Medicine, and Orofacial Myology. Dr. Robinson is Delaware’s first and only doctor triple-board certified in Craniofacial Pain and Dental Sleep Medicine. He is owner and Chief Clinical Director of the The Pain and Sleep Therapy Center of Delaware Valley. Dr. Robinson has taken more than 1,000 hours of continuing education courses in Craniofacial Pain and Sleep Breathing Disorders and has been personally mentored by the world’s leading airway clinicians.

26 Orthodontic practice

Educational aims and objectives

This article aims to discuss how recognizing possible sleep issues in oral anatomy can lead to more comprehensive patient care.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 28 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Realize the serious nature and possible consequences of lack of sleep.

•

Recognize the role that dentists play in the identification and treatment of sleep-related breathing disorders.

•

Identify some necessary questionnaires for the process of the patient’s extensive medical history evaluation.

•

Recognize that CBCT can be a valuable tool in airway and supporting structure evaluation.

•

Realize some potential nighttime symptoms that can indicate a potential sleep-breathing disorder.

to help patients understand the root causes behind this epidemic and make the best choice for treatment. Airway issues, including sleep apnea, were historically very hard to identify and diagnose in the dental community due to lack of provider education and limited use and understanding of diagnostic equipment.6 Thanks to multidisciplinary approaches to sleep medicine and new technologies, rapid advancements in the dental industry through examination and imaging make the clinical signs and symptoms easy to identify. In 2017, the American Dental Association (ADA) released its first official statement regarding the role that dentists play in the identification and treatment of sleep-related breathing disorders.7 Dentists are now encouraged to screen patients for sleeprelated breathing disorders as part of a comprehensive medical and dental history to recognize symptoms such as sleepiness, choking, snoring or witnessed apneas, and an evaluation for risk factors such as obesity, retrognathia, or hypertension. As specialized doctors of the head and neck, dentists are arguably the most opportune providers in healthcare to be able to identify signs that are related to sleep problems. Recommended dental care for most patients consists of routine dental cleanings and examinations twice a year.8,9 This allows dentists and dental hygienists to spend a

considerable amount of time working within a patient’s airway. This unique opportunity allows dental health professionals to observe anatomical abnormalities that perhaps could be overlooked by their medical physician counterparts. One of the most crucial aspects of screening for sleep issues within the dental office is realizing what to ask and look for. This process includes an extensive medical history evaluation, sleep questionnaires known as an Epworth Sleepiness Scale and STOP-BANG, as well as a comprehensive oral examination to look for things within the mouth that are comorbid with airway issues.10,11,12 These screening forms ask questions related to snoring, likeliness to fall asleep in different situations, age, BMI, neck size, and perceived quality of sleep. A few of the oral signs that a dentist can identify indicating a potential sleep-breathing disorder include scalloped tongue, crowded teeth, large tonsils, narrowed dental arches, and wear on the teeth from nighttime grinding. More recently, technology including advancements in cone beam computed tomography (CBCT) and the expanded field of view is allowing dentists to look beyond the teeth and evaluate a patient’s airway and the supporting structures that comprise the airway. Utilizing this technology with a field of view up to 17 cm x 23 cm, dentists can perform a three-dimensional analysis viewing Volume 11 Number 3

REFERENCES

Figures 1A-1C: 1A. Minimum cross-sectional area of the oropharynx. 1B. Anterior protrusion. 1C. Increasing vertical using an oral appliance

the patient’s airway volume, the temporomandibular joints (TMJ), and the nasal complex, including the sinuses. By seeing these structures that otherwise could not previously have been identified through a routine examination, dentists can now see problematic areas using 3D technology, and this gives them much better ways to identify structural insufficiencies that can lead to a collapse of the airway during sleep.13 Figure 1 shows a 51-year-old male who presented for treatment of oral appliance due to failure of continuous positive airway pressure (CPAP), and whose airway has been measured through CBCT software. The minimum cross-sectional area of the oropharynx was 103 mm2 when the patient was closed down, and the teeth were touching. With different repositioning techniques of the lower jaw, the amount of space can change considerably within the airway. As indicated with various jaw repositioning techniques in Figure 1, anterior protrusion (Figure 1B) and increasing vertical (Figure 1C) using an oral appliance, the patient’s airway was increased to 147 mm2, which is about 50% better than previous positioning without the appliance. This shows the benefits that

technology can have on airway optimization through jaw repositioning. Another patient, a 42-year-old female, who was screened in the dental office was suffering from sleep apnea and could not tolerate CPAP. After CBCT imaging (Figures 2A and 2B), the dentist found that the patient had a severely deviated nasal septum and hypertrophic turbinates within the nasal complex (Figure 2A). Due to the obstructions seen within the nose, the dentist referred the patient to an ear, nose and throat (ENT) medical doctor who performed nasal septoplasty and turbinoplasty on the patient in order to optimize breathing space and function through the nose. The postsurgical CBCT scan shows the new anatomy of the nasal complex (Figure 2B). By coordinating treatment with the ENT and the dentist, the patient was able to see improvements in breathing both through the nose and in the oropharyngeal part of the airway, allowing for ideal airflow during sleep. The patient was appreciative that the dentist had use of such an important technology, which had helped triage her care and use a multidisciplinary approach. It is cases like these that show the extremely

1. Wheaton AG, Perry GS, Chapman DP, Croft JB. Sleep disordered breathing and depression among U.S. adults: National Health and Nutrition Examination Survey, 2005-2008. Sleep. 2012; 35(4):461-467. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3296787/. Accessed May 6, 2020. 2. U.S. Department of Transportation. National Highway Traffic Safety Administration (NHTSA). Asleep at the wheel: the national compendium of efforts to eliminate drowsy driving. https://www.nhtsa.gov/sites/nhtsa.dot.gov/files/ documents/12723-drowsy_driving_asleep_at_the_wheel_ 031917_v4b_tag.pdf. Accessed May 6, 2020. 3. Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature. 1997;388(6639):235. 4. Lamond N, Dawson D. Quantifying the performance impairment associated with fatigue. J Sleep Res. 1999;8(4):255-262. 5. American Sleep Apnea Association. Sleep Apnea Information for Clinicians. https://www.sleepapnea.org/learn/ sleep-apnea-information-clinicians/. Accessed May 6, 2020. 6. Levendowski DJ, Morgan T, Montague J, et al. Prevalence of probable obstructive sleep apnea risk and severity in a population of dental patients. Sleep Breath. 2008;12(4):303-309. 7. American Dental Association. The Role of Dentistry in the Treatment of Sleep Related Breathing Disorders. Adopted by ADA’s 2017 House of Delegates. https://www.ada. org/~/media/ADA/Member%20Center/FIles/The-Role-ofDentistry-in-Sleep-Related-Breathing-Disorders.pdf?la=en. Accessed May 6, 2020. 8. Flaherman VJ, Epstein J, Amendola L, et al. Preventative dental care at 6-month intervals is associated with reduced caries risk. Clinical Pediatrics. 2018; 57(2):222-226. 9. Marshman Z. High-quality studies needed to determine optimum dental check-up recall intervals. Evidence-based Dentistry. 2014;15:40. 10. Epworth Sleepiness Scale. American Sleep Apnea Association website. https://www.sleepapnea.org/assets/files/pdf/ ESS%20PDF%201990-97.pdf. Accessed May 6, 2020. 11. Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire: A Practical Approach to Screen for Obstructive Sleep Apnea. Chest. 2016;149(3):631-638. 12. STOP-BANG Sleep Apnea Questionnaire. Ohio Sleep Medicine Institute website. https://www.sleepmedicine.com/ files/files/StopBang_Questionnaire.pdf. Accessed May 6, 2020. 13. Olmos S. CBCT in the evaluation of airway — minimizing orthodontic relapse. Orthodontic Practice US. 2015;6(2):4649. https://orthopracticeus.com/industry-news/cbct-inthe-evaluation-of-airway-minimizing-orthodontic-relapse/ Accessed May 6, 2020.

Figures 2A and 2B: 2A. Severely deviated nasal septum and hypertrophic turbinates within the nasal complex 2B. Postsurgical CBCT after nasal septoplasty and turbinoplasty Volume 11 Number 3

Orthodontic practice 27

CONTINUING EDUCATION

beneficial relationship between the medical dental communities. The future of sleep medicine consists of a multidisciplinary approach between dentists and medical providers to work together to ensure patients are receiving the care that they deserve in order to improve and optimize their overall health and well-being. OP

REF: OP V11.3 ROBINSON

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Improving patient health through sleep dentistry ROBINSON

When people do not get a sufficient amount of hours of quality sleep, they are at risk for a multitude of potentially serious chronic illnesses â&#x20AC;&#x201D; for example, heart attack, ______, diabetes, cancer, anxiety, and depression. a. hypertension b. heart disease c. stroke d. all of the above

2. According to the National Highway Traffic Safety Administration (NHTSA), in 2015 over 72,000 police reported crashes involved ________ leading to 41,000 injuries and more than 800 deaths. a. drowsy driving b. drunk driving c. student drivers d. elderly drivers 3. Research by the CDC also found that skipping one night of sleep has the same effects as having a Blood Alcohol Concentration (BAC) of over _____, which is higher than the legal limit to drive! a. .04% b. .06% c. .08% d. .10% 4.

According to the American Sleep Apnea Association, an estimated 22 million Americans suffer from sleep apnea, with _____ of cases of moderate and severe obstructive sleep apnea undiagnosed.

28 Orthodontic practice

a. 15% b. 45% c. 80% d. 92% 5. Recommended dental care for most patients consists of routine dental cleanings and examinations ________. a. once a year b. twice a year c. every 18 months d. every 2 years 6. One of the most crucial aspects of screening for sleep issues within the dental office is realizing what to ask and look for. This process includes an extensive medical history evaluation, sleep questionnaires known as an Epworth Sleepiness Scale and ______, as well as a comprehensive oral examination to look for things within the mouth that are comorbid with airway issues. a. STOP-BANG b. National Wakefulness Assessment c. Nocturnal Sleep Subscale d. International Sleep Assessment Scale 7.

These (sleep) screening forms ask questions related to snoring, likeliness to fall asleep in different situations, ________, and perceived quality of sleep. a. age b. BMI

c. neck size d. all of the above 8. A few of the oral signs that a dentist can identify indicating a potential sleep-breathing disorder include scalloped tongue, crowded teeth, _______, narrowed dental arches, and wear on the teeth from nighttime grinding. a. small tonsils b. absence of tonsils c. large tonsils d. small uvula 9.

More recently, technology including advancements in _______ is allowing dentists to look beyond the teeth and evaluate a patientâ&#x20AC;&#x2122;s airway and the supporting structures that comprise the airway. a. cone beam computed tomography (CBCT) and the expanded field of view b. CBCT with a more limited field of view c. 2D digital radiography d. intraoral photography

10. (In the second case study) _______ , the patient was able to see improvements in breathing both through the nose and in the oropharyngeal part of the airway, allowing for ideal airflow during sleep. a. By coordinating treatment with the ENT and the general doctor b. By coordinating treatment with the ENT and the dentist c. With treatment by the dentist only d. With treatment by the ENT only

Volume 11 Number 3

CE CREDITS

ORTHODONTIC PRACTICE CE

STEP-BY-STEP

Tie-On Rotation Wedge (TORW) for perfect orthodontic finishing: part 2 Dr. Lloyd Taylor presents additional techniques using Tie-On Rotation Wedges

art 1 in the March/April 2020 issue of Orthodontic Practice US detailed the placement of Tie-On Rotation Wedges (TORW) with stainless steel finishing arches to achieve perfect proximal contacts. Part 2 below shows some of the additional uses for TORW as well as combinations with other orthodontic accessories. The following examples are just a few of the many combinations you may employ in your practice using TORW in your finishing technique.

Figure 1: Multiple wedges can be placed to achieve simultaneous rotations. Offset bends should be a maximum of 1 mm high since reciprocal adjacent tooth movement may occur with larger offsets

Figure 2A: Off-center bracket identified at the final end of finishing can be replaced to correct the tooth rotation of UR3. However, to be more efficient, TORW can be used to provide the required tooth rotation to align proximal contacts. A 1 mm offset will correct the off-center bracket

Figure 2B: Off-center bracket has been corrected in a single visit using TORW. This eliminated the placement of a new bracket and the sequential wire changes required to return to a final finishing full slot archwire

Figure 3: Round stainless steel finishing arches may be used when only rotations are required for final alignments. Offsets can be as large as 2 mm and tied into the bracket in a single visit. There is little risk of debonding as compared to rectangular finishing wires, which are best tied in 1 mm offset increments

Figure 4: Retentive elastic chain over TORW is rotating UL2 into ideal alignment. Elastic chain and TORW can be used at the same time. The elastic chain can be easily placed over the TORW to maintain the required space closure of the four anterior maxillary teeth

Figure 5: Bonded eyelet with elastic thread and TORW doubles the rotational forces. The archwire has only been tied one-half way into the ceramic slot to avoid debonding. With the addition of elastic thread, the tooth will completely rotate in just one visit

Figure 6: TORW used with NiTi closing springs to rotate both maxillary laterals. Although NiTi closing springs can rapidly close posterior spaces, by using TORW, rotations of both maxillary laterals are instantly corrected before posterior spaces even start to close

Figure 7A: TORW used with fractured ceramic tie wing may be just as effective as with a non-fractured wing if the finishing archwire can be totally seated in the bracket slot and tied down. Here only the three remaining wings can be tied

Lloyd R. Taylor, DDS, received his DDS degree from Fairleigh Dickinson Dental School. He first completed a 3-year residency in Oral and Maxillofacial Surgery and Anesthesiology and was Chief Resident at the Albert Einstein College of Medicine/Jacobi Hospital in New York City. Dr. Taylor then completed a 3-year Fellowship in Orthodontics at the Harvard School of Dental Medicine. He also completed an additional 3-year Fellowship in Orthodontic Teaching and Research at the Forsyth (Harvard) Dental Center. Dr. Taylor has practiced both Oral Surgery and Orthodontics in North Hollywood, California, for more than 50 years. Disclosure: Dr. Taylor is both the founder and president of OrthoSource since 1985.

Volume 11 Number 3

Figure 7B: TORW used with fractured ceramic tie wing has completely rotated UL2 into perfect proximal alignment. There was no need to rebond the tooth or to change archwires OP Orthodontic practice 29

TECHNOLOGY

The McLaughlin Bennett 5.0 orthodontic appliance and archwire system Dr. Richard McLaughlin discusses the updated system that promotes increased clinical efficiency Introduction Over the course of more than 40 years practicing orthodontics, I have worked with a number of orthodontic appliances, including the original Straight-Wire® Appliance (Ormco Corporation) developed by Dr. Larry Andrews. Most recently, working with Dr. John Bennett and the Forestadent Corporation in Germany, the McLaughlin Bennett 5.0 (MB 5.0) system has been developed. The system incorporates a number of significant changes based on our collective clinical and appliance design experience. MB 5.0 is a fifth-generation design that builds on previous designs, including the original Straight-Wire Appliance. Previous designs included changes in all dimensions — tip, torque, and in/out values. The MB 5.0 appliance system was developed in concert with Forestadent in Germany and involved adjustments to the values and design of their Mini-Sprint system that we had worked with for 18 months. The tip, torque, and in/out dimensions were a combination of ideas from our third- and fourth-generation appliances. The changes were built on our collective clinical experience as well as changes in archwire materials, dimensions, and shapes, as well as changes to our mechanics to increase clinical efficiency. In addition, other

Richard P. McLaughlin, DDS, completed his orthodontic training at the University of Southern California in 1976. Since then, he has been in fulltime orthodontic practice in San Diego, California. He has lectured extensively in the United States as well as internationally. He is a member of the Pacific Coast Society of Orthodontists, the American Association of Orthodontists, and a Diplomate of the American Board of Orthodontics. He is the Past Component Director of the Southern California Component of the Edward H. Angle Society of Orthodontists and Past President of the National Angle Society. He is the recipient of the 2009 American Board of Orthodontics Dale Wade Award as well as the 2010 Pacific Coast Society of Orthodontists Award of Merit. In addition, Dr. McLaughlin is a clinical professor at the University of Southern California, Department of Orthodontics in Los Angeles, California, and an associate professor at Saint Louis University, Department of Orthodontics. He has written more than 30 journal articles and co-authored five textbooks. Disclosure: Dr. McLaughlin is a key opinion leader for Forestadent.

30 Orthodontic practice

The changes were built on our collective clinical experience as well as changes in archwire materials, dimensions, and shapes, as well as changes to our mechanics to increase clinical efficiency. In addition, other significant features were added, including an integral base that enhanced reliability and esthetics.

significant features were added, including an integral base that enhanced reliability and esthetics. This article will detail how we arrived at the values incorporated in MB 5.0.

Background The Straight-Wire Appliance After graduating from the orthodontic program at USC, I began working for Dr. Lawrence Andrews in San Diego. He had finished collecting his 120 non-orthodontic normal study models, taken on untreated cases, and considered to have ideal occlusions. He evaluated these models and determined there were six key features that were present in all 120 of the models, which he detailed in his classic article, “The Six Keys to Normal Occlusion.”1 He followed this by measuring the tip, torque, and in/out values of each tooth on the models, which were used to design the original Straight-Wire Appliance, which significantly reduced the need for wire bending. During this period, I met Dr. John Bennett from London, England, and Dr. Hugo Trevisi from Sao Paulo, Brazil. We became good friends and colleagues, and they also began using the Straight-Wire Appliance with sliding mechanics. The Mclaughlin Bennett Trevisi 3.0 appliance In 1997, we began designing a third orthodontic appliance, the “McLaughlin, Bennett, Trevisi” appliance. The appliance had tip, torque, and in/out values that were based on two factors:

1. The Andrews’ non-orthodontic normal measurements, as baseline references for tip, torque, and in/out values in the appliance 2. The play between the .019 x .025 archwire, and the .022 bracket slot. This play was approximately 10°. This amount did not significantly change the in/out values and only minimally changed the tip values, but it significantly changed the torque values. For example, the non-orthodontic normal torque value for an upper central incisor was 7°. The torque value required in the new bracket for the upper central incisor was 17°. This was necessary to accommodate the 10° of play between the bracket slot and the archwire. In addition to the development of this appliance, we began using lighter force sliding mechanics (200 grams versus the previous standard 600 grams). With lighter forces, there was enough stiffness in the .019 x .025 rectangular steel archwires to avoid deflection and, hence, the need for the additional wire bending, such as reverse curve of Spee bends. The MB 4.0 bracket Our fourth experience with the preadjusted appliance began in 2009 with the Mclaughlin Bennett MB 4.0 bracket. Two important changes were introduced into the appliance. The first included reducing the in/ out values of the upper lateral incisors from Volume 11 Number 3

The Forestadent 5.0 bracket The experience with the previous four pre-adjusted appliances was invaluable as we began working with the Forestadent team. We started by using their Mini-Sprint II appliance, a very comfortable transition, since many features of this appliance were comparable to our previous appliances. We treated cases with Mini-Sprint II for a period of a year and a half, from the beginning of 2017 until August of 2018. Then the 5.0 bracket system was completed and released in the fall of 2018. The tip, torque, and in/out dimensions were a combination of ideas from our third and fourth appliances. In addition, there were other features added that were significant improvements. Each bracket was a single piece design with an integral base. This eliminated the need for the brazing process and prevented any separation or discoloration between a mesh pad and a bracket.

Discussion of each of the components of MB 5.0, including clinical considerations The upper central and lateral incisors (Figures 1-2) The upper central incisor brackets have +17° torque and +4° angulation; the upper lateral incisors +10° torque and +8° angulation. The upper lateral incisors also have reduced in/out values in comparison with the Andrews norms and previous versions. This provides a better relationship with the adjacent centrals and canines. In cases with palatally displaced upper lateral incisors, it is beneficial to invert the upper lateral incisor brackets to create -10° torque instead of +10° of torque (Figure 2). This creates the necessary labial root torque to aid in moving the lateral root forward.

Lower incisors (Figure 3) The Andrews norm for lower incisor tip is +2°. The brackets can be adjusted for minimal tip as needed at the time of placement. Torque is a challenge with lower incisors because of the thin labio-lingual bone. -1° of torque is best for Class 1 cases. And -6° of torque is best on Class II cases, especially when Class II elastics are needed. And +6° degrees of torque is best on Class III cases, especially when Class III elastics are needed. Upper canines (Figure 4) The upper canine brackets have +8° of tip, which is adequate for canine guidance. The routine upper canine torque used is -7°; however, inverting to +7° is occasionally needed if the upper canine root is very prominent, especially when showing labial recession. Because of the shape and prominence of the canines, the in/out dimension of the canine brackets is very minimal. Both upper canines are available with hooks. Because of their strategic position in the dentition, hooks are very useful for various types of elastics (Class II, Class III, and anterior cross elastics). Lower canines (Figure 5) Lower canines routinely have +3° of tip and 0° torque. But when there is labial root prominence of the lower canines, the canine bracket can be inverted to -6° torque. Lower canines have hooks, as these teeth are in very strategic positions for Class III elastics. Switching lower canines (Figure 6) In many Class III cases, lower canines are tipped distally, as are the lower incisors. It is most important to maintain the distal crown tip on the lower canines on these cases to prevent the incisors from being pushed

Figure 1

Figure 2 Volume 11 Number 3

Figure 3

Figure 4

Figure 5 Orthodontic practice 31

TECHNOLOGY

approximately .5 mm of in/out to approximately .25 mm of in/out thickness. This change brought the upper laterals slightly forward into better alignment with the upper centrals and canines. The second change was with the lower canines. When the bite deepened even minimally, the lower canines with -6° of torque tended to incline even more lingually. This was followed by some extrusion of the upper canines. Placing 0° of torque in the lower canines moved them to a more upright position and provided better support for the upper canines. These changes, although minimal, proved to be beneficial in this esthetic anterior area. The appliance was developed using a new manufacturing technique, which was more accurate than a metal injection molding process. The slot was milled at .0220 because it was unnecessary to deal with the heating, cooling, and shrinkage factors of a molding technique. However, the slot size change that had been introduced was not advantageous. Ironically, since the slot size was much more precise than previous brackets, it was too small for a .0195 x. 025 archwire. The result was too much torque in the appliance system, which was most evident in the upper incisors.

TECHNOLOGY

Figure 6

Figure 7

Figure 9

Figure 8

Figure 10

forward. Therefore, switching lower canines from right to left and left to right will create -3° of tip on each lower canine, as opposed to the normal +3° of tip. Upper bicuspids (Figure 7) The upper first and second bicuspids have -7° of torque and 0° of tip and are available with or without hooks. All four upper bicuspids are interchangeable, which is very helpful with inventory. The brackets can be placed slightly to the mesial of the center of the upper bicuspid crowns. This rotates them to the distal and brings the buccal cusps closer to a Class I position, especially when the second bicuspids are small. Bicuspids without hooks are preferred for patient comfort purposes, as the hooks are seldom used. At the end of the case, settling elastics are normally attached from the lower arch to the upper posterior bracket wings. There are usually no wires on the upper posterior teeth and no ties on the upper bicuspid and molar brackets during the settling process. Lower first and second bicuspids (Figure 8) Lower first and second bicuspids both have 2° of tip. The first bicuspid has 12° of torque, and the second bicuspid has 17° of torque and are available without hooks (Figure 8), or with hooks. 32 Orthodontic practice

Figure 11

Figure 12

Conventional upper first and second molar tubes (Figure 9) The Straight-Wire Appliance upper first and second molar tubes had 5° of tip. This was due to the brackets being oriented to the buccal groove of the clinical crowns, leaving them tipped up 5° on the mesial. Our decision on the conventional upper first and second molars was to place the brackets parallel to the occlusal plane with 0° of tip for easier visualization. Both positions achieve the same positive results. The tubes have -14° of torque and 10° of distal rotation. They have a funnel-shaped entrance for easier wire placement. Lower first and second molar tubes (Figure 10) The lower first molar has -20° of torque, and the lower second molar has -10° of torque. They have zero offset and zero

angulation. As with the uppers, they have a funnel-shaped entrance for easier wire placement. Upper and lower second molar mini-tubes (Figures 11-12) The design of the upper- and lowersecond molar mini-tubes allow for placement when the second molars are not fully erupted. Despite the small size, they provide good tooth control, patient comfort, and less interferences. They are placed on the middle of the mesio-buccal cusps of these teeth. The upper tubes have 0° tip, 4° of rotation, and -14° of torque. The lower minitubes have 0° tip, 0° of rotation, and -10° of torque. OP

REFERENCE 1. “The Six Keys to Normal Occlusion.” Andrew, LF. Am J Orthod Dentofac. 1972;62(3):296-309.

Volume 11 Number 3

PRODUCT PROFILE

AcceleDent® Optima™ — Increasing predictability of clinical outcomes

deal for traditional braces treatment and clear aligner therapy, AcceleDent® Optima™, a strategic, technology-driven tool for orthodontists, helps achieve highquality clinical results. Manufactured by OrthoAccel® Technologies, Inc., AcceleDent Optima is the leading vibratory orthodontic device that delivers better orthodontic experiences for orthodontists and their patients. Even for patients with challenging tooth movements, the patented technology of this FDA-cleared Class II medical device increases the predictability of clinical outcomes throughout the treatment process. SoftPulse Technology micropulses exert up to 8 times less force than a power toothbrush and 200 times less force than ordinary chewing, and the precisely calibrated low pulsatile forces that transmit through the roots of teeth increase cellular activity to stimulate the surrounding bone. 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 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.

“My patients and I are loving AcceleDent. With the shortened treatment time, I am convinced that our patients will be better focused throughout treatment, seeing results sooner.” — Dr. David Henderson, Henderson Orthodontics, Bloomington, IN

Volume 11 Number 3

Orthodontic practice 33

PRODUCT PROFILE

Gaidge Three keys to practice health amid the COVID-19 crisis

he best businesses do more than survive a downturn. They manage their cash, financials, and performance metrics closely. They seek opportunity and position themselves to thrive in the subsequent upturn.1 So, what should orthodontic business owners do to not only survive but also find ways to thrive after the COVID-19 pandemic?

1. Evaluate your business metrics to navigate your recovery First, understand the full picture of your business operations, and identify which are the critical metrics driving your business. Next, ensure you have a system in place for regular tracking, review, and action planning based on what your data tells you. Having a system to review your metrics is essential so that you establish a regular cadence and consistency in what you are measuring and reviewing each period — daily, weekly, monthly, quarterly, and yearly.

2. Extract value from every action The mantra of successful businesses since the Industrial Revolution has been about maximizing efficiency and minimizing waste by leveraging tools and technology to continuously improve. Successful, resilient practices embrace this concept for the betterment of their bottom line. In challenging times, the importance of this is amplified. You must ensure every action and resource spent brings value to the organization. When reviewing your metrics with your team on a regular basis, identify the areas where actions will have the greatest impact. Prioritize and commit to timelines for following through on actions. Use your metrics as a check-in to motivate, celebrate, and hold each other accountable to ensure the business stays on track to plan.

3. Explore as a solution seeker By understanding your end-to-end business performance, your mind is open to explore a multitude of solutions. We get stuck when we get caught in binary thinking or only focus on one idea to solve a problem. From managing your schedule, to harvesting your observation pool, to managing your collections, having visibility into the areas where you can make quick and immediate impact first is the best approach getting your business back to health.

Power your practice with tools that help manage your business better Gaidge answers the complicated question of what to measure and solves the system and time problems with automation and data visualization. This gives business leaders an easy way to comprehend large masses of information in a snapshot and thereby guiding them on where to focus efforts. Gaidge is a cloudbased business analytics software custombuilt for orthodontic practices. The program offers its users comprehensive analysis and seamless, automated access to their practices’ key performance indicators (KPIs). With over 80 available metrics and 35 visual reports, Gaidge is an essential management tool that provides business intelligence dashboards, functional performance detail, benchmarking, and practice performance comparisons.

Coming soon! Overhead expense tracking The Gaidge platform’s powerful features are automated with nightly uploads to give you unprecedented visibility into your practice’s performance, essential business metrics, and your most important goals. Launching in Summer 2020 – the new Overhead module will be integrated with QuickBooks® for automated expense tracking and added performance metrics. This new module allows you to view your expenses by category, making it easier than ever to review trends and control your overhead. For more information, visit www.gaidge. com or call 800-287-3396. OP

REFERENCES 1. Rhodes D, Stelter D. Seize Advantage in a downturn. Harvard Business Review. February 2009. https://hbr. org/2009/02/seize-advantage-in-a-downturn. Accessed April 16, 2020. 2. Levin R. The three stages of the COVID-19 crisis. Orthodontic Products. April 3, 2020. https://www.orthodonticproductsonline.com/practice-management/businessdevelopment/three-stages-covid-19-crisis/. Accessed April 16, 2020. 3. Furr N. Don’t let uncertainty paralyze you. Harvard Business Review. April 15, 2020. https://hbr.org/2020/04/dont-letuncertainty-paralyze-you?ab=hero-subleft-3. Accessed April 16, 2020.

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

34 Orthodontic practice

Volume 11 Number 3

In this article, Jackie Raulerson discusses how to share your practice and treatment successes with an effective presentation

powerful presentation creates curiosity, provokes thought, and puts the focus on you and your valuable information. Like telling any effective story, there are distinct steps to crafting the perfect deck of slides to support your lecture. During my career, I have enjoyed assisting many dentists and other dental professionals in creating or enhancing visual materials for their slide presentations. This article shares some tips and techniques that I’ve learned to produce a meaningful and memorable presentation. Depending upon the type of presentation — a clinical case showing the use of specific products or covering a practice-management technique — different approaches are necessary. The subject matter will determine the formality of the presentation and, in some cases, dictate its visual appearance. Presentations that offer continuing education (CE) credits come with their own set of guidelines and usually are peer-reviewed. Many CE providers specify that the presentation must be non-commercial; therefore, you are required to eliminate any identifying patient information and not show bias to a particular product. They may limit the use of brand names, instead preferring to use the generic type of technology or equipment these products represent. You also may need to include references for any clinical claim you make for any product or fact.

The key to building an effective presentation Your audience wants to focus on you and your information. Any distractions should be eliminated. Whether using PowerPoint®, Keynote™, or another program, the same

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. Jackie now operates her own business to help both dental sectors accomplish their marketing needs. She can be reached at jackie@yourmessagedelivered.net.

Volume 11 Number 3

Figures 1A-1B: On the left, a less wide resolution will present with black bars to each side. A correct size or resolution will cover the screen for full impact. (All clinical images herein courtesy of Juan-Carlos Quintero, DMD, MS)

Figure 2: Due to improper settings, the slides are stretched to fill the monitor’s screen

general “rules” apply. It all boils down to this: Keep it simple in both design and content.

Slide design Slide size or resolution Each venue will have a specific size of TV, monitor, or screen on which your presentation will be displayed. Before building your presentation, verify the specs with the event coordinator. You want your slide to grab the full screen (Figure 1B). If your presentation was built with a different resolution, you can make changes, but you will want to do this ahead of time. Before you present to your audience, run onsite tests to ensure that there is no slide stretching or squeezing and thus visual anatomical distortion (Figure 2).

Your master slide Some associations and companies (if you are speaking on their behalf) have a master slide that you are obligated to use. However, if there are no restrictions, you should create your own master slide that speaks to who you are but not too “loudly.” Your professional information If you want to use your logo, name, and contact information on each slide, the size and combination of these may be too distracting to appear slide after slide. In this case, consider showing the full information in a larger size at the beginning, for instance, on your “bio slide,” and then switch over to a diminutive version on the remaining slides. As seen in Figure 3B, the logo and practice Orthodontic practice 35

MARKETING MOMENTUM

Ready, set, present!

MARKETING MOMENTUM name show at the bottom the slide, smaller, and slightly watermarked or faded. Color and/or background When considering slide color and background, keep in mind that “clean” does not equal “boring.” White, black, or neutrals will keep the audience focused on the information on the slide. It is best to be consistent with one color throughout the presentation. For example, Figure 4B slide shown in various background colors within the same presentation can force changes in font color and interfere with image backgrounds. These changes also require the eye and mind to adjust before concentrating on the content. Slide transitions Busy slide transitions are one of the greatest offenders of distraction. Spinning, checkerboarding, or swooping of slides can be jarring — consider a simple fade from one slide to another for a more professional presentation.

Your audience wants to focus on you and your information. Any distractions should be eliminated ... It all boils down to this: Keep it simple in both design and content.

Figures 3A-3B: The left slide shows the initial and full use of your practice information, while the right slide shows name and logo only — much more appropriate for all remaining slides

Presentation Content Divide and conquer Sometimes too much information can be overwhelming. Breaking up a subject is the easiest way to conquer a huge amount of information. At some point, you will need to decide what to include and what to delete. This will be driven by your objectives and, of course, the time limit. Start with an outline Creating an outline will help you make editing decisions. An outline will also help you generate a cohesive, organized flow and avoid tangents. Limit the number of cases to those that meet the main statements of your outline. For example, if one of your objectives is to show how the use of aligners has worked in your practice, pick the best few examples. There is no need to show 10 cases when your point can be made with three.

Figures 4A-4B: The slide on the left is a basic (but not boring) background. The slide to the right changes to a blue background and drives a font color change. However, the logo and image are on a white background, which can be distracting unless you take the time to edit

Figures 5A-5B: Follow the 7 x 7 rule for slide text — try to use no more than seven lines of text and no more than seven words per line. Seen here, the right slide is obviously easier to understand than the left slide

Slide Content Text We’ve all seen presentations where there are way too many words on the slide (Figure 5A), which forced the presenter to become a “slide reader.” While it may be appropriate for more extensive information to appear on your handouts, the amount of text on a slide should be minimal. Edit text to be clear and concise. Typically, bulleted information is easiest to digest. Each bullet should be short and to the point. If you have more than a few bullets 36 Orthodontic practice

on a slide, consider splitting the information into several slides. Select a font, font size, font color, and bulleting style that are simple and easy on the eyes. These should match throughout your presentation. Use color, bold, italics, or underline select words for emphasis —just not all of these at once! 2D clinical photos and X-rays Your presentation will be displayed on a

large screen. This makes image resolution critical for all clinical images. A pixelated or blurry image is not useful. Capture and save clinical photos in high resolution. You can always reduce resolution after capture; you cannot increase it very successfully. Crop out distracting or unimportant information in the photo or image. Additionally, there is no need to heavily notate an image with text if you will discuss the same information in your lecture (Figures 6A-6B). Volume 11 Number 3

Video clips Use a video, especially in 3D technologies and imaging, to show anatomical structures. While you may be familiar with using your 3D program, others may not. I would urge you to plan ahead when recording specific procedures. It may be helpful to mix video with high-quality digital photographs that you take during the procedure. Charts Often there a clean, simple way to show

considerable amounts of information, especially numeric stats. For example, if you have a great deal of data in written form, make it easy for your attendees to see at a glance by using a chart. Programs such a Microsoft® Excel create attractive charts from line items (Figure 7B). Graphics Graphics and other photos can support your presentation and break up slide content to maintain interest. For example, if you want to speak about an increase in your

production, an image can often convey this, as well as or better than text (Figure 8). Give credit where it’s due The Internet offers all kinds of information in text and image form. While these exist in a public domain, someone created it. If you use this information, give credit either on the slide or at the end of your presentation. For copyrighted material, such as articles or a clip from a web series or TV show, request permission to use. Review, review, review Finally, review your presentation for specifics: spelling, consistency in alignment, font, transitions, and length. While it takes more time, it is productive to concentrate on one of these at a time. For length, consider your time limit, and run through your presentation to ensure you can stay within the time frame. Be sure to leave 5-10 minutes at the end for a Q&A with attendees.

Figure 7: The desired statistical information in this article can be placed into a nicely readable chart

Figure 8: Simple graphic that lets you and your information take center stage Volume 11 Number 3

Where to go for help In terms of selecting proper content and creating its flow, my article in the January/ February 2020 issue of Orthodontic Practice US should offer some assistance. I’m a big believer in YouTube™ learning. There are many how-to videos on good practices for building presentations, adding supportive visual materials, and even on delivering your information to audiences. By following a few simple slide-building rules, you can effectively share your clinical and professional experiences with your peers. But remember, you are the most important part of your presentation. 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 Orthodontic practice 37

MARKETING MOMENTUM

Figures 6A-6B: On the left is a slide with a pixelated image, too much text overlay, and unnecessary visual information; it is distracting. The slide on the right has a clear image with minimal text and is cropped to show the area of interest

MARKETING MOMENTUM

Telemedicine marketing checklist: 10 things orthodontists should do Marketer Rachael Sauceman discusses safe and effective marketing evolving after the COVID-19 crisis

ccording to the American Dental Association’s Center for Professional Success™,1 as of April 23, 2020, 32 states allow emergency-only dental care, 13 have deemed dentistry to be essential, and 6 have no specific regulations surrounding dentistry. Many states are operating with regulations that extend through late April or early May, while others are much longer such as Oregon, whose emergency-only dental mandate currently runs through June 15. As dental and orthodontic practices navigate state-by-state regulations — as well as recommendations set forth by the Centers for Disease Control and Prevention,2 the American Dental Association,3 and the American Association of Orthodontics4 — orthodontists and dentists are working to develop safe and effective ways to continue delivering care to patients and generating income during this challenging time. Across the entire healthcare vertical, we’re seeing an unprecedented adoption of telemedicine as a way to continue serving patients at this time. Telemedicine has long been a trend as younger generations prefer to access care on their own terms, but red tape from regulations and payers, as well as growing pains from the implementation process, have held back a lot of practices from adopting telemedicine. But in today’s environment, telemedicine is helping many practices and patients weather the storm. Whether you’ve implemented a telehealth solution already, or you’re considering one as your state approaches the return of nonemergency dental care, ensuring patients are aware of this new offering is just as crucial as implementing the technology. This 10-step checklist can help clinicians market virtual appointments from your orthodontic practice. Rachael Sauceman is the Head of Strategic Initiatives for Full Media, a Chattanooga, Tennessee-based digital marketing agency specializing in healthcare. Full Media offers a full spectrum of digital marketing capabilities within the healthcare space, including website design, online advertising, SEO, patient experience optimization, and analytics.

38 Orthodontic practice

Whether you’ve implemented a telehealth solution already, or you’re considering one as your state approaches the return of nonemergency dental care, ensuring patients are aware of this new offering is just as crucial as implementing the technology. 1. Update your website Especially during the COVID-19 pandemic, prospective patients are looking for detailed information about your practice’s current operations. And because different patients may consume information differently, it’s important to have your COVID-19 statement and telemedicine offerings accessible in multiple ways. If you already have a COVID-19 statement on your website, be sure to provide information regarding telemedicine options from that page — and while it may seem like a big project if you’re in a hurry to add virtual appointment details to your website, it’s important to have a specific page dedicated to telemedicine offerings. Although your existing patients would probably search for your specific practice, this may also be an opportunity to gain new patients who are uncomfortable returning to in-office appointments. Having a dedicated telemedicine page ensures you can capture both types of searches. We like this example from Hiser Orthodontics5 in Alpharetta, Georgia, an Atlanta suburb. Hiser has added links to a COVID-19 statement and Virtual Appointments information from the practice homepage. Additionally, the COVID-19 page addresses specific needs patients may experience, including virtual consultation information.6

2. Make sure patients understand what to expect The more questions you can answer for patients in advance, the more likely they are to be comfortable with a virtual appointment. Some common questions you might be able to address in an FAQ section on

your telemedicine page include: • Are you currently seeing existing patients only, or can new patients schedule a virtual appointment? • What types of orthodontic issues can be addressed with a virtual appointment? • Can patients access some treatments, such as teeth-whitening kits or clear aligners, by driving by the practice or having them mailed? • What types of orthodontic problems are considered to be emergent? • Will my insurance cover this appointment? • How do I schedule a virtual appointment? • What is the process to connect with a provider at the time of my appointment?

3. Contact existing patients Since existing patients are more familiar with your pre-COVID-19 processes and procedures, they may be unaware that telemedicine is an option. Send an email with details and a link to your new telemedicine page through an existing platform, if you have one, or consider reaching out to patients individually with short phone calls. “Virtual has been well received by existing patients,” says Doug Hiser, DMD, MS, owner of Hiser Orthodontics. “It actually increases our level of service and care because the communication lines are wide open.”

4. Promote on social media Although it can’t be your only form of outreach, be sure to notify your followers on social media. Volume 11 Number 3

MARKETING MOMENTUM

Figure 2: Google search

Figure 1: Post on social media

Since the average post on a Facebook business page reaches only 6.4% of all the people who like the page,7 it’s a good idea to consider boosting your Facebook posts. If you’d like to implement a more sophisticated marketing plan, you may decide to invest in ads on Facebook, Instagram, and Twitter — or whichever platforms currently draw the most engagement. Social media ads not only help your content display to more of your existing followers, but also draw in prospective patients who may not be familiar with your practice.

5. Consider Google Search ads Search ads offer highly effective marketing because they’re displayed to patients and prospective patients as they’re actually searching for you. As dental and orthodontic offices reopen before some people may feel comfortable with making a trip to a physical office, there’s a good chance that some of those individuals may search for telemedicine orthodontic consultations. By implementing Google Search Network Ads for your telehealth offerings, you’ll have a high likelihood of pulling this type of patient to your website. For example, orthodontists can’t target people who are having trouble with braces on Facebook. But they can target people who are looking up information about how to relieve pain from braces on Google Search. If you are rolling out a new virtual appointment offering, we suggest the following: • Start with branded advertising. Existing patients and those who may already be familiar with your brand will likely search for your practice specifically. Having an ad that references your virtual offerings will ensure those individuals are made aware of this new option. Volume 11 Number 3

Figure 3: Changes in traffic in the COVID-19 crisis (Source: WordStream8)

• Create ads to answer FAQs. As an orthodontist, the types of problems you may see are fairly specific. Do patients often ask you about gum pain or other effects of orthodontic treatment? Create ads that target the types of concerns patients may search for. • Implement more general ads. Since some patients may simply search for virtual orthodontic appointments, orthodontic telehealth visits, etc., ensure some of your ads focus on these general terms and topics. • Broaden geographic targeting. While advertising for in-office visits should be more targeted, patients from more distant or remote locations may be interested in your virtual consultations.

6. Be where your customers are going for information COVID-19 has changed essentially everything — the way we communicate, the way we work, our purchasing habits, and the list goes on. It’s also impacted the way users search for and consume content.

In this data from WordStream,8 we see that search volume is down, but content consumption on the Google Display Network and YouTube are booming. The Google Display Network enables advertisers to show ads on content throughout the web, such as local and national news websites, lifestyle blogs, YouTube videos, mobile apps, and games, which may be a good place for your practice to advertise. You may also choose to begin creating video content that you can upload to YouTube and embed into blogs or relevant pages on your website. Cellphone cameras can record video of decent enough quality without having to invest in high-dollar productions. (Online retailers offer cellphone tripods and/or light rings that can enhance the quality of your video.) Topics to consider include: • Educating patients about the telemedicine platform you’re using. Walk them through what to expect during a virtual consultation, and be sure to cover topics such as why you chose the particular platform you’re using, as well as patient privacy. Once you’ve uploaded this video to Orthodontic practice 39

MARKETING MOMENTUM YouTube, be sure to embed it on your telehealth webpage. • Introducing yourself to prospective new patients (if you’re taking them). Talk about the immediate needs for telemedicine as it relates to COVID-19, and explain your plans for the future. Are there situations in which you could consult with a patient who was previously seeing a different orthodontist? Explain that in your video. • Offering helpful tutorials that can prevent patients from needing emergent care. Do your patients have common symptoms and complaints? Could many of them be solved with better dental hygiene or compliance in their treatment plan? Make videos to address these topics. Even after COVID-19 is no longer a consideration, video content on YouTube can benefit your search rankings.

7. Update your local listings Did you know that more than 50% of searches result in no clicks9 whatsoever to a website? This means many prospective patients may take action by calling your practice or gaining other pertinent information directly from listings on Google, Bing, Yahoo! Maps, and Google My Business. Be sure to provide information about COVID-19 and virtual appointments in those listings (and keep track of what you’ve updated in a spreadsheet, so you can remove the COVID-19 details when appropriate). Google My Business is also currently allowing providers to add two unique links to

local listings: a link to COVID-19 information and another to telehealth information on your website. If your practice operates in more than one location, you’ll need to add the links to each profile, all of which can be found in your Google My Business dashboard.

8. Update meta information on your website Meta information is the blue link text and descriptive text underneath that appears directly in search results listings. While many websites have default meta information that is pulled from the site’s page title and content, it can be customized to offer more detail for searchers. Meta information is also crawled by search engines, meaning that it can increase the likelihood of your website appearing to prospective patients. Although you may not need to update every page on your site, be sure key pages — e.g., your homepage, provider pages, and location pages — make note of virtual appointment offerings. “We have seen an increase in virtual consultations [during COVID-19],” says Dr. Hiser. Dr. Hiser also explained that virtual appointments have reduced the level of stress and anxiety associated with being able to make a visit to a physical office — which means they’re also lowering the barrier of entry. Updating your meta information helps ensure patients can find your practice as they’re exploring these new options.

REFERENCES

9. Set up a direct-mail campaign Although it’s not as quick to implement as a digital marketing campaign, direct mail often generates good results. Whether you are notifying existing patients about your new offering or trying to reach prospective patients in your community, direct mail can be an effective approach.

10. Consider incorporating a HIPAAcompliant chat feature

Figure 4: Adding links to your profile

if virtual care is the appropriate solution for his/her issue. There may be uncertainty about costs and insurance. We’re experiencing unprecedented levels and sources of stress and anxiety; add to that having to navigate dental health needs in a new way, and patients may just avoid the problem entirely. By integrating a feature like chat, patients can engage directly with your scheduler or practice administrator to get answers to simple questions. You may also find out what is holding patients back and encourage them to feel comfortable with a less traditional path to care. (This can also be a great way to find out what’s not being answered on your telemedicine page on your website. Add content to address common questions you receive.) Many chat tools are very easy to integrate — they just require your developer to insert some code. Just be sure that you select a tool that is HIPAA-compliant! OP

Since telehealth visits are a fairly new offering — especially for orthodontic and dental practices adapting out of necessity to COVID-19 — we’re all still uncovering the challenges and barriers to care that patients may be experiencing. A patient may wonder

1. COVID-19 State Mandates and Recommendations. ADA Center for Professional Success. https://success.ada. org/en/practice-management/patients/covid-19-statemandates-and-recommendations. Accessed April 24, 2020. 2.

CDC Guidance for Providing Dental Care During COVID-19. Centers for Disease Control and Prevention. Updated April 8, 2020. https://www.cdc.gov/oralhealth/infectioncontrol/ statement-covid.html. Accessed April 24, 2020.

3. ADA recommending dentists postpone elective procedures. ADA News. Posted March 16, 2020. https://www.ada.org/ en/publications/ada-news/2020-archive/march/ada-recommending-dentists-postpone-elective-procedures. Accessed April 24, 2020. 4. COVID-19 Resources for Orthodontists. American Association of Orthodontists. Updated April 24, 2020. https://www1. aaoinfo.org/covid-19/. Accessed April 24, 2020. 5. Hiser Orthodontics webpage. https://www.hiserortho.com/. Accessed April 24, 2020. 6. Virtual Consultations. Hiser Orthodontics webpage. https:// www.hiserortho.com/virtual-consults. Accessed April 24, 2020. 7. Bain P. 10 Need to Know Facebook Marketing Stats for 2019. Social Media Today. Posted February 5, 2019. https:// www.socialmediatoday.com/news/10-need-to-know-facebook-marketing-stats-for-2019/547488/. Accessed April 24, 2020. 8. Irvine M. 4 Major Trends Caused by COVID-19 and How to Respond [Data]. WordStream. https://www.wordstream. com/blog/ws/2020/03/23/covid-19-business-trends. Updated April 16,2020. Accessed April 24, 2020.

Figure 5: Make sure that your pages reflect your telehealth options 40 Orthodontic practice

9. Nguyen G. Now, more than 50% of Google searches end without a click to other content, study finds. Search Engine Land. https://searchengineland.com/now-more-50of-google-searches-end-without-a-click-to-other-contentstudy-finds-320574. Posted August 14, 2019. Accessed April 24, 2020.

Volume 11 Number 3

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