Orthodontic Practice US November/December 2020 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews November/December 2020 – Vol 11 No 6 • orthopracticeus.com

PROMOTING EXCELLENCE IN ORTHODONTICS

Anterior open bite correction in skeletal Class I patient

Practice management efficiencies to ease your team’s workload JoAn Majors, RDA, CSP

Dr. Diego Peydro

Five reasons orthodontics will return to the specialty arena Dr. Jeffrey Miller

Two-way text messaging can solve many patient engagement challenges Lea Chatham

Adjusting to the digital age — digital workflows are a necessity in postCOVID-19 times Dr. Alfred Griffin III

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Nov/Dec 2020 - Volume 11 Number 6

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

© FMC 2020. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Orthodontic Practice US or the publisher.

t would be an understatement to describe 2020 as one of the most disrupted years in recent history. Political chaos, a disputed presidential election, and to top it all off, the proverbial cherry on the sundae — a COVID-19 pandemic that rode in on the winds of March with no definitive end in sight. As both a private practitioner and an orthodontic educator over the past 4 decades, I can honestly state that there has been no public health crisis which has so impacted the practice of dentistry, both in the United States and across the globe in my lifetime. The introduction of AIDS and the HIV presence in the United Ricky Harrell, DMD, MA States had a great impact on our profession with regards to the importance of universal precautions. Wet-fingered dentistry, for those of you old enough to remember it, went the way of the Edsel. But its impact on dentistry was mainly in how practitioners protected themselves. COVID-19, in my opinion, has a far greater impact that permeates almost every aspect of our practices. Despite the challenges these current times present, most of us have figured out how to modify our routines to accommodate public health measures to protect society as a whole from the ravages of this disease. Out of the adversity and challenges presented by COVID-19 have sprung innovation and forward thinking about how to resolve these issues. At Georgia School of Orthodontics at a point in the past, I thought that digital patient records with scanned impressions were merely riding the wave of technology into the 21st Century. With COVID-19, some of the disinfection challenges presented by traditional impressions, model pouring, and trimming were resolved by this digital technology. Like many private practices, we altered our normal routines to check in patients virtually without having greater exposure to the disease in the reception areas. We spaced out our normal visit intervals for appointments and added a virtual visit between actual in-house treatment visits so that the quality of care could be maintained and yet protect the patient population. Alternating chairs in the clinic that allowed for social distancing during visits provided a physical safety measure. Rooms were repurposed to provide safe spaces for the production of aerosols during procedures. Intraoral cameras and holders for cell phones came to the marketplace, which greatly facilitates moving dental visits into the 21st century mode of practice. Teledentistry is quickly catching up with the popularity of telemedicine visits, which the medical profession has been using in remote areas for years. The ability of a practitioner to remotely supervise orthodontic treatment by a resident or skilled mid-level provider is currently being investigated at our institution with research projects addressing the issue. The popularity of the use of clear aligner technology to treat both routine and notso-routine cases is on the rise. Current dental students and residents are now being taught safe and effective ways of dealing with COVID-19 in the office and clinic space. These future practitioners are reaping the benefit of being enrolled in educational programs that are preparing them for their future practice situations. The ability of schools to deliver online curricular content has been a godsend for most programs. In a real about-face, educational programs are actually sharing lecturers and content between institutions. I do not feel that this online content delivery would have become as mainstream as it now seems just 10 months into the pandemic. The toll that COVID-19 has taken on both this country and the world defies description. It is the disruptor of a lifetime. However, if one steps back and looks at the larger picture, COVID-19 has also served as a catalyst to drive innovation in both private practice as well as institutional clinical settings. If there is an uplifting message in all of this, perhaps this embracing of technology can be considered as the silver lining in the COVID-19 cloud. Everyone please stay safe, and practice intelligently as if your life depends on it. Because it really does! Ricky Harrell, DMD, MA, is a 1979 graduate of The University of Alabama School of Dentistry. After serving 3 years as a general dentist in the Navajo Area Indian Health Service, he returned to The University of Alabama at Birmingham (UAB) and completed his orthodontic residency in 1984. After 22 years in the private practice of orthodontics in Westminster, Colorado, he entered into full-time orthodontic education at the University of Colorado in 2006. Dr. Harrell became Program Director for the PG Orthodontic Residency at the Medical University of South Carolina from 2015-2017 and then came to Atlanta to assume the role of Program Director at Georgia School of Orthodontics in 2017 where he still holds that position. Dr. Harrell is a life member of the American Dental Association and the American Association of Orthodontics. He is an ABO Diplomate and a Fellow of the American College of Dentists.

ISSN number 2372-8396

Volume 11 Number 6

Orthodontic practice 1

INTRODUCTION

2020 – The year that keeps giving

TABLE OF CONTENTS

Publisherâ&#x20AC;&#x2122;s perspective Looking forward to 2021! Lisa Moler, Founder/CEO, MedMark Media................................6

Orthodontic perspective

Five reasons orthodontics will return to the specialty arena Dr. Jeffrey Miller shares his insights on how orthodontists can bring more value to the specialty

Orthodontic pearls Maxillary molar anchorage preservation Drs. Larry W. White and Francesca Scilla Smith discuss a technique for maxillary molar anchorage preservation .......................................................16

Continuing education Two-way text messaging can solve many patient engagement challenges

Case study

Lea Chatham describes ways that text messages can update and connect patients........................................... 18

Anterior open bite correction in skeletal Class I patient Dr. Diego Peydro demonstrates treatment for an open bite in seven appointments

ON THE COVER Cover image courtesy of Dr. Diego Peydro. Article begins on page 13.

2 Orthodontic practice

Volume 11 Number 6

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TABLE OF CONTENTS Practice development MOGA® — make orthodontics great again! Dr. Ronald Roncone discusses how to create a new paradigm for the orthodontic office............................. 26

Technology Options mean opportunity Dr. Melissa Shotell talks about the opportunity an open intraoral scanner brings to her practice........................28

Adjusting to the digital age — digital workflows are a necessity in post-COVID-19 times Dr. Alfred Griffin III discusses how digital technologies blend to benefit patients and practitioners................ 30

From analog to digital — keeping treatment on track during the COVID-19 crisis Dr. Regina Blevins discusses technologies that cater to the needs of the contemporary patient ................32

Continuing education

Practice management efficiencies to ease your team’s workload JoAn Majors, RDA, CSP, discusses how technology and outsourcing can improve efficiencies during COVID-19 times and beyond

Service profile

Orthodontic practice consolidation trends accelerate — rewards and risks abound

Next-level strategies to protect your orthodontic practice

Chip Fichtner highlights future risk or value created in “silent partner” practices.........................................36

Bre Cohen discusses preparing your practice for unforeseen risks............ 38

Industry news................. 40

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

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4 Orthodontic practice

Volume 11 Number 6

PUBLISHER’S PERSPECTIVE

Looking forward to 2021!

Published by

hrough all of the challenges and changes of 2020, I look forward to 2021 as a year of renewal and rejuvenation. 2020 changed our perspectives on patient care and the way we run our businesses. Sanitizing and masking have become part of daily routines, and new methods of communicating with patients and sharing information with colleagues have brought new efficiencies to dental practices. Our November/December issue’s editorial focus is on practice management systems. 2020 also has taught us that managing our offices efficiently can navigate us through hard times and make the good times even better. This year dentists discovered that teledentistry can keep them clinically connected with Lisa Moler patients as well as keeping information flowing. The American Founder/Publisher, MedMark Media TeleDentistry Association notes that teledentistry can: • Improve dental hygiene of patients • Reduce the cost of care and increase efficiency through reduced travel times, shared professional staffing, and fewer in-person appointments • Be an innovative solution for the mainstream healthcare industry • Improve access to care for patients • Reduce the amount of time patients need to spend away from their offices • Make in-office appointment times more accessible • Make in-office appointment times more accessible to patients who really need them In addition, PPE and aerosol containment policies and other safety precautions will allow you to make future plans to expand your skills and techniques. Orthodontic Practice US continues to be a trusted source for introspection, invention, implementation, and innovation for your dental practice. Your strength and dedication to your craft and your teams is truly inspirational. In this issue, we feature two CEs on practice management efficiencies to ease your team’s workload: JoAn Majors focuses on technology and outsourcing, and Lea Chatham centers on how two-way text messaging can solve many patient engagement challenges. Dr. Alfred Griffin III takes a look at how digital technologies can create a smooth and effective clinical and business workflow, and Dr. Jeffrey Miller offers his insights into how orthodontists can emphasize the “special” aspects of their specialty. Dr. Regina Blevins notes how moving from analog to digital can keep treatment on track during the COVID-19 crisis. The November/December issue is our last issue for 2020, and I think I am joined by all of you in saying that 2021 can’t get here fast enough! We look forward to starting the next year with healing, hope, and vision for a profitable future. As I have said before, stay positive, stay focused, and stay with us as you have over the years. We appreciate and value you, and invite you to contact us regarding submitting articles in 2021. All the best, Lisa Moler Founder/Publisher MedMark Media

PUBLISHER Lisa Moler lmoler@medmarkmedia.com DIRECTOR OF OPERATIONS Don Gardner don@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA, CDE mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com MANAGER CLIENT SERVICES/SALES 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 6

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ORTHODONTIC PERSPECTIVE

Five reasons orthodontics will return to the specialty arena Dr. Jeffrey Miller shares his insights on how orthodontists can bring more value to the specialty

oday more than ever, orthodontists are concerned about the future of their specialty. Although do-it-yourself orthodontics is not new, more technology-savvy companies are reintroducing “DIY” with a precepted sophistication alternative to orthodontic treatment. With the oversimplified promotion of orthodontics to the general practitioner, and the complacency of our specialty in fighting this trend, it should not be surprising to anyone that for some providers, orthodontics has been dumbed down to the mechanical alignment of the clinical crowns. Considering that the average younger general dentist graduates with hundreds of thousands of dollars in student debt, it appears to be the correct financial decision to take a bite at the oversimplified aligner orthodontic market to increase revenue — especially when one considers the onslaught of aligner marketing directed to them. Even considering all the present market forces, it is this humble orthodontist’s opinion that our specialty is actually headed back in the direction of the specialist. It seems counter-intuitive at first, based on current events; however, I believe this change back to the specialty arena is happening before our eyes. It may take 5 or more years to fully be recognized, but for sure it is coming. I believe it will happen for the following reasons. 1. CBCT technology will allow dentists and orthodontists to better visualize and diagnose dehiscence and fenestrations for post-orthodontically treated patients. 2. Online and social media reviews spread fast, especially negative Jeffrey Miller, DDS, is an orthodontist in private practice in Maryland. He speaks both nationally and internationally on CBCT topics related to orthodontics. Please feel free to email Dr. Miller at drmiller@orthodonticassoc. com with questions.

8 Orthodontic practice

Figures 1A and 1B: Orthodontically Induced Dehiscence of significant magnitude discounting the relevance of 0.6 mm nonvisible bone argument. 1A. Sagittal view: Orthodontically Induced Dehiscence, tooth No. 23. 1B. Axial view: Orthodontically Induced Dehiscence showing apical portion of root completely outside alveolar, tooth No. 23

Figures 2A-2C: 2A. Lower left cuspid showing possible naturally occurring root dehiscence. 2B. Lower right central incisor, left central incisor, and left lateral incisor all showing Orthodontically Induced Dehiscence. 2C. Clinical photo of B: 20 years’ post active orthodontics showing tissue dehiscence

feedback, so consider the current negative feedback for the DIY aligner companies. 3. We will better understand the correlation between dehiscence and longterm periodontal health. 4. Poor treatment planning has consequences other than relapse and retreatment. 5. Lawyers can use CBCT to show potential damage in the absence of gingival recession. Before starting to explain the preceding list, we first need to review how the information derived from CBCT changes the way we evaluate finished orthodontic results. We have all heard about the 0.6 mm of non-visible bone hidden on our CBCT slices; however, few actually understand what this means for orthodontics. Does this 0.6 mm margin of error discount CBCT as a proper

diagnostic tool for dehiscence? Simply stated, the answer is no. Most all studies that review the accuracy of bone measurements taken on CBCT slices use naturally occurring dehiscence and fenestrations in their sample (few exceptions), which are generally minimal and mostly do not have devastating gingival consequences. Orthodontically Induced Dehiscence (OID) is a different category of dehiscence by its higher magnitude and generalization (affecting cuspid to cuspid). In other words, while natural or minimal dehiscence and fenestration do not seem to be a major problem for our post-orthodontic patients, OID does (Figure 1). In a study published in the American Journal of Orthodontics and Dentofacial Orthopedics, Sun, et al., state, “If there was a severe dehiscence on the CBCT image, there was probably a true dehiscence.”1 While Volume 11 Number 6

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ORTHODONTIC PERSPECTIVE smaller dehiscence was harder to accurately diagnose via CBCT, larger dehiscence and fenestration were easily and accurately diagnosed using CBCT (Figure 2). For the purpose of this article, I am going to assume that CBCT can accurately diagnose OID of significant magnitudes and that the higher the magnitude of the OID, the more compromised the health of the tooth — i.e., the further the root is orthodontically pushed outside of the alveolar housing, the more compromised the long-term health.

1. CBCT technology will allow dentists and orthodontists to better visualize dehiscence and fenestrations for post-orthodontically treated patients. Consider a younger dentist purchasing X-ray equipment for a new office or a more established dentist who needs to replace his/ her current panoramic X-ray machine. The cost difference between a digital panoramic X-ray unit and a CBCT machine is becoming smaller. However, there are significant differences between the patient fee for a panoramic at around $100 versus CBCT, which will generate a fee of between $350 to $650. Since revenue is a consideration when purchasing or upgrading new equipment, I believe many dentists will begin to see the value of an in-office CBCT and therefore make a decision to incorporate CBCT. Once these dentists acquire CBCT imaging, it is safe to assume that the CBCT will replace the panoramic X-ray. (It is already happening.) When the dentist takes a CBCT on a patient, someone is going to need to read the CBCT, whether it is the dentist himself/ herself or an oral maxillary radiologist; OID may be present. The very first question once the dehiscence is visualized is likely to be, “Did you have orthodontic treatment?” At that point it does not take much to connect the dots. Furthermore, traditional panoramic/ cephalometric imaging cannot diagnose dehiscence or fenestration. It is simply not a tool for that — CBCT is. To sum up by way of example: A 16-yearold female with upper-lower crowding of 6 mm per arch receives treatment from one of the DIY aligner companies. The aligner prescription uses expansion to de-crowd the teeth since interproximal reduction or extraction is not an option. Proper alignment 10 Orthodontic practice

(a bit of a stretch for DIY) is achieved by intercuspid expansion (80%) and proclination (20%) of the anterior teeth. A posttreatment panoramic X-ray will show only the vertical heights of the interseptal bone and therefore cannot comment regarding dehiscence or fenestration. The posttreatment cephalometric radiograph will likely look reasonable since it cannot evaluate changes in the cuspid position, which is where most of the de-crowding space was created (Figure 4). CBCT would not only show OID of the cuspids, but also could show unreasonable proclination of the incisors, which would be hidden by the ceph’s wide focal trough. I also believe that the dentist is obligated to mention the OID to the patient and either follow or refer to the periodontist in the absence of gingival recession.

Simply put, the orthodontic case that is finished today will likely have a CBCT taken within the next 5 years and therefore be evaluated for OID that was completely missed in a panoramic/cephalometric post-orthodontic evaluation. A short word about “standard of care,” which is relevant at the time the patient was in active treatment. I believe, regardless of the diagnostic tool used, OID has always been considered a breach of the standard of care; we were just were less mindful of it.

2. Online word and social media spreads fast, especially negative feedback, considering the current feedback for the DIY aligner companies. This is an easy one to explain. All you have to do is look at the online reviews for the

Figure 3: Orthodontically Induced Dehiscence — note generalized pattern from first bicuspid to first bicuspid

Figures 4A and 4B: CBCT showing changes to the lower cuspid position within the alveolar housing. These changes cannot be visualized with traditional 2D imaging. 4A. Patient de-crowded by tipping/clinical crown expansion of lower cuspids. 4B. Untreated patient lower cuspid position for comparison Volume 11 Number 6

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ORTHODONTIC PERSPECTIVE

Figure 5: Overexpanded incisor position resulting from aligner therapy and poor treatment planning. Notice the adaptive resorption of the alveolar housing in an effort to comport to the overexpanded root position therefore complicating retreatment or root repositioning

DIY aligner companies. Despite the encouragement to have their patients write positive online reviews, the negative reviews continue to grow and will likely overwhelm any positive postings.

3. We will better understand the correlation between dehiscence and gingival recession. There is no denying the correlation between gingival recession and orthodontic treatment. What we do not completely understand, at what point does the dehiscence result in gingival defect? And how does gingival phonotype and oral hygiene contribute to the predictability of gingival defects? Can orthodontic expansion/constriction, which results in a “washboard gingival” appearance, change the gingival phenotype from thick to thin? Even with higher magnitude OID, the tissue recession seems to lag, taking 5 to 10 years to fully manifest. Once we have a better understanding of the dehiscence/gingival recession relationship, orthodontists will need to carefully consider how much dental expansion/ constriction is reasonable. This adds another layer of complexity to even the simplest orthodontic case (Figure 5).

4. Poor treatment planning has consequences other than relapse and retreatment. As orthodontists, what if we want to treat a case using a certain strategy, and if the case relapses, do we simply retreat? The problem with the preceding question is there are consequences to poor 12 Orthodontic practice

Figure 6: Photo of presentation slide taken at the 2016 American Association of Periodontics Annual Session. Note “Key Question: Does Alveolar Bone Bend?” Clearly from photos, the answer is no. (Speaker’s name unknown)

CBCT technology will allow dentists and orthodontists to better visualize dehiscence and fenestrations for post-orthodontically treated patients. treatment plans. Once the tooth is orthodontically expanded (or constricted) outside the alveolar housing, adaptive resorption of the alveolar process occurs leaving a smaller alveolar housing for future tooth repositioning (orthodontics). Consider this aligner case where expansion (Figure 5) was used to de-crowd the lower incisors. The alveolar process resorbs to comport to the new position of the expanded root. If retreatment is considered, this case is significantly more complex, limiting this patient’s orthodontic options.

5. Lawyers will use CBCT to show potential damage in the absence of gingival recession. I am sure I do not need to remind anyone how lawyers operate and the “herd” mentality of “follow-the-money lawsuits.” All you have to do is think back to the 1980s when there was a plethora of TMD/orthodontic-related lawsuits. Does anyone think that the legal profession would hesitate to file plaintiff claims related to CBCT-visualized OID in the absence of tissue recession? If our periodontal colleagues are already making these exact claims, how long before the attorneys make use of this information (Figure 6)? In summary, I believe CBCT provides additional information that will ultimately

benefit our orthodontic patients. However, this additional information not only challenges traditional orthodontic theory, but also adds additional complexities to our treatments — complexities that could remove the perception that orthodontic treatment is simply a mechanical skill to align clinical crowns. As orthodontists, we do not practice dentistry in a vacuum. There are other dental specialties and general dentists with whom we share patients. At some point in the near future, the orthodontic patients of today will have a CBCT scan taken. This CBCT scan can be an additional evaluator for long-term successful outcomes. It is my humble opinion, once the dental community begins to realize the potential damage of focusing only on the mechanical alignment of the clinical crowns without any consideration for the root position and alveolar housing, orthodontics will return to the specialty arena where it belongs. Acknowledgment: Dr. Miller extends his appreciation to Drs. Tina Mahmoudi and Adam Miller for their participation in this article. OP

REFERENCE 1. Sun L, Zhang L, Shen G, et al. Accuracy of cone-beam computed tomography in detecting alveolar bone dehiscences and fenestrations. Am J Orthod Dentofacial Orthop. 2015;147(3):313-323.

Volume 11 Number 6

Dr. Diego Peydro demonstrates treatment for an open bite in seven appointments Introduction Over the years, there have been many approaches to treat open bite cases with fixed appliances, but in this case report, I will demonstrate how a complex case with a severe open bite can be treated efficiently. I was able to complete treatment in a short time frame while improving the patientâ&#x20AC;&#x2122;s experience, avoiding fixed appliances, and keeping facial esthetics in seven appointments with Sparkâ&#x201E;˘ Clear Aligner System.

Figures 1-4: Initial facial photos

Diagnosis A 27-year-old female, who was unhappy with her smile, presented with an open bite, periodontal problems, and a narrow and gummy smile. Furthermore, the patient was complaining of having issues with TMJ causing intermittent pain. The study of her panoramic and lateral cephalometric X-ray revealed that she presented with Class I skeletal pattern. Intraoral evaluation disclosed periodontal problems, healthy gums, molars in normal occlusion, and severe open bite extended to the canine region.

Figures 5-7: Intraoral photos of upper jaw, bite, and lower jaw

Treatment Goals The goal was to expand both arches in order to allow the retrusion of upper and lower incisors that were proclined. After that, the next step was the intrusion of the upper molars in order to allow mandibular to underrotate and close the open bite.

Figures 8 and 9: Intraoral photos right side and left side

Treatment plan and progress The patient began Spark treatment in

Dr. Diego Peydro earned his dental degree from the University of Valencia, Spain, and his specialty in orthodontics from the University of Southern Mississippi Institution of Spain. He is codirector of the Clear Ortho International Program where he teaches how to apply the most advanced aligner techniques for optimum results. Published in international orthodontic journals, he is in private practice with his sister, Dr. Marta Peydro, where they receive patients from all over the world to solve complex cases. Disclosure: Dr. Peydro is a paid consultant for Ormco.

Volume 11 Number 6

Figures 10 and 11: Initial panoramic radiograph and lateral cephalogram radiograph

March 2019, completing it in May 2020. The treatment was split into two phases. The first phase consisted of 22 aligners, changing them every 10 days and sometimes every week. The second phase consisted of 19 aligners. During the two phases, there was

a refinement. The patient wore the aligners for 22 hours per day, and the treatment was completed in seven appointments. This case was designed with digital 3D Approver software from Spark. Photos show attachments used and amount of IPR. Orthodontic practice 13

CASE STUDY

Anterior open bite correction in skeletal Class I patient

CASE STUDY

Figure 12: Screenshot of Spark Approver

Figure 14: Screenshot of Spark Approver

Figure 13: Screenshot of Spark Approver

Figure 15: Screenshot of Spark Approver

Figures 16-20: Facial photographs after treatment

At the beginning of the first phase, the patient was wearing passive aligners with no attachments, allowing the mouth to get accustomed to this new process. Figures 12-15 show photos of the case using the Spark Approver software. At aligner 12-13 of the first phase, I placed screws in the upper arch (Figure 21). The combination of the screws and aligners aimed to intrude the molars. The goal was to correct the bite without making any extrusion to the incisors and correct the esthetic of the smile (Figures 23-25).

Figures 21 and 22: Final intraoral photographs of upper and lower jaw

Treatment results Orthodontic treatment was completed successfully with the Spark Clear Aligners 14 Orthodontic practice

Figures 23-25: Final intraoral photographs Volume 11 Number 6

CASE STUDY

Figures 26 and 27: Final panoramic radiography and lateral cephalometric radiography

within 15 months. The open bite was solved with no extrusions, and the occlusion of the patient was satisfactory with molars and canines in normal occlusion, excellent overjet and overbite ensuring that the patient has a very good dental arch and smile line. The support of the lips is obvious, which was reassuring for the patient, since a better smile was one of her main goals. The posttreatment cephalometric radiography shows the skeletal structures and the mandibular plane angle are similar through the whole treatment considering the substantial closure

of the patient’s severe open bite. The retention of the treatment was completed with a retainer to ensure the final result of the treatment.

Conclusion This case report demonstrates how a complex case with a severe open bite can be treated efficiently with Spark Clear Aligner System. The results that I have found with Spark are likely due to its TruGEN material, which has proven to have higher sustained force retention compared to the leading

aligner brand, and Spark’s use of the latest in aligner manufacturing technology, which results in better contact surface area between the tooth and the aligner than the leading aligner brand.* With a short time frame improving patient’s experience and avoiding fixed appliances, I was able to keep facial esthetic in seven appointments. I am excited by the success of this Spark treatment and how much easier and quicker they are than what I was previously doing with fixed appliances. OP * Data on file with Ormco.

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Volume 11 Number 6

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Maxillary molar anchorage preservation Drs. Larry W. White and Francesca Scilla Smith discuss a technique for maxillary molar anchorage preservation

axillary molar anchorage has perplexed orthodontists since the beginning of premolar extraction therapies. Every clinician knows from sad experience that maxillary molars easily displace and rotate mesially when challenged with mesial space and force. Obvious and early remedies — e.g., transpalatal arches,1 Nance arches,2 intermaxillary Class II elastics,3 and headgears4 (Figure 1) — proved incapable of providing reliable molar anchorage. More recently, the use of miniscrews has enjoyed some popularity although they require local anesthesia while also bringing more expense and often equivocal stability. Melsen and Fiorelli5 have advocated the use of occlusal anchorage enhancements using Triad® light-cure gel (Dentsply Sirona, Charlotte, North Carolina) (Figure 2). Recently, a variation of the Melsen and Fiorelli occlusal pads has proven effective and doesn’t require the occlusal coverage of mandibular molars and premolars, while providing a more defined stop for the maxillary second premolar when maxillary first premolars have been extracted (Figures 3 and 4). This places an occlusal stop solidly against the maxillary second premolar and, as seen, prevents the maxillary posterior teeth from moving forward. For want of a proper name, these are called Anchorage Posterior Occlusal Guides, aka, APOGs. The APOGs are made using the Bite Ramp Mini Mold™ (Ortho Arch Company,

Figure 1: The Nance (left) and a transpalatal arch (right) have been used as maxillary molar anchorage in first premolar extraction patients

Figure 2: Occlusal pads made of Triad® Gel (Dentsply Sirona, Charlotte, North Carolina) to reinforce maxillary molar and premolar anchorage in first premolar extraction patients

Clinicians can apply APOGs easily and quickly with minimum armamentarium, small cost, and no laboratory involvement.

Francesca Scilla Smith, DDS, MS, was born and raised in Arezzo, Italy. She graduated summa cum laude at the University of Florence Dental School and obtained her orthodontic degree from Nova Southeastern University College of Dental Medicine in Fort Lauderdale, Florida, with a master thesis on conventional and digitally driven indirect bonding. Dr. Scilla Smith practices orthodontics in Dallas, Texas. Larry White, DDS, MSD, FACD, is a graduate of Baylor Dental College and Baylor Orthodontic Program and now has an orthodontic practice in Dallas, Texas.

Figure: 3: A typical Class II malocclusion that will require the removal of maxillary first premolars 16 Orthodontic practice

Volume 11 Number 6

ORTHODONTIC PEARLS

Schaumburg, Illinois). The mold is filled with the Triad gel and applied to the distal occlusal surface of the mandibular first premolar and light-cured. If upon removing the mold, the APOG doesn’t touch the maxillary second premolar, a small amount can be applied to the scaffolding of the bite ramp until it makes contact with the upper tooth. If the mold touches prematurely, it is easily smoothed to fit with an air turbine bur. Clinicians can apply APOGs easily and quickly with minimum armamentarium, small cost, and no laboratory involvement, while using the ever-present occlusion as reinforcement for posterior maxillary anchorage in maxillary premolar extraction patients. OP

REFERENCES 1. Melsen B, Bonetti G, Giunta D. Statically determinate transpalatal arches. J Clin Orthod. 1994;(10):602-606. 2. Nance HN. The limitations of orthodontic treatment; mixed dentition diagnosis and treatment. Am J Orthod. 1947;33(4):177-223. 3. Kesling PC. The Tip-Edge PLUS® Guide and the Differential Straight-Arch® Technique. 6th ed. TP Orthodontics: La Porte, IN; 2006. 4. Melsen B. Effects of cervical anchorage during and after treatment: an implant study. Am J Orthod. 1978;73:(526-540). 5. Melsen BG, Fiorelli G. Biomechanics in Orthodontics. 3rd ed. Aarhus: Denmark; 2013.

Volume 11 Number 6

Figure 4: Note the anchorage pads made of Triad gel (blue arrows) extended vertically to engage the maxillary second premolars having allowed the alignment of the anterior teeth, while preventing the mesial movement of the maxillary posterior teeth

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CONTINUING EDUCATION

Two-way text messaging can solve many patient engagement challenges Lea Chatham describes ways that text messages can update and connect patients

ince the COVID-19 pandemic began, dentists have faced office closings and challenges to reopening. Dentists have had to work diligently to communicate with patients effectively and within HIPAA guidelines. As patients increasingly depend on technologies such as the internet and social media for their information and connections with others, many also seek technology options for communications with their medical personnel. Every change and update needs to be communicated to patients so they are prepared and know what to expect when they return to the office or appear for a TeleVisit. Since medical and dental providers may be the only source of accurate information for patients, they are in the unique position of being able to reach out to patients with accurate, up-to-date information. When done effectively, texting can offer updates, connection, and appointment information that builds trust and loyalty. SR Health by Solutionreach commissioned a recent study, which showed that during the COVID-19 crisis, patient satisfaction in communication was reduced.1 The study noted, “Patients’ responses indicated less timely communication with their providers, a tougher time getting questions answered, and not being 'heard' as well during the pandemic.” Before the pandemic, phone conversations with a live person were the most desirable form of communications across baby boomers, Gen Xers, millennials, and Gen Z-aged patients. However, during COVID-19, patients’ interest in live phone calls dropped 14%. Even before the pandemic, interest in phone calls had already started to wane. A study quoted by CBS News MoneyWatch noted that only 18% of people listen to

Lea Chatham is the Director of Content Marketing at Solutionreach, the leader in patient engagement solutions and innovation. She is responsible for developing educational resources to help dentists stay connected to patients throughout the care journey. Lea spent over 5 years leading engagement at a small integrated health system and has 15 years of experience developing educational content for leading patient engagement, practice management, and EHR companies.

18 Orthodontic practice

Educational aims and objectives

This article aims to discuss the benefits of implementing a texting protocol with patients.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 20 or take the quiz online at orthopracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify the texting habits of various age groups in a health setting.

•

Realize how texting habits have changed during the COVID-19 crisis.

•

Realize that certain aspects of text messaging are particularly attractive to certain patients.

•

Realize how text messaging can be used for various aspects of the patient’s experience.

•

Identify some ways to stay HIPPA compliant.

a voicemail from a number they don’t know.2 Even if they do recognize the number, often busy lives don’t allow for time-consuming communications. Ron Kinkade, senior marketing manager at eVoice® j2 Global, which conducted the survey, said that voicemail often, “requires some sort of action,” and people are reluctant to add to an already busy schedule. Also, while the person can skim to relevant parts of an email, listening to someone leave a slow voice message can be incredibly frustrating.2 However, interest in digital communication is up with patients believing that text and email are more effective for communication across their journey. Text is particularly appealing. A patientprovider relationship study by Solutionreach found that 73% of patients desire the ability to text their dentist and 79% want to get texts from their provider, especially about appointments.3 The study also found that 70% of Gen Xers favor appointment reminders by text, and 67% appreciate texts to remind them of the need for follow-up care or treatment. Both automated and real-time, two-way text messaging is of interest to patients. At Solutionreach, where approximately half of the clients are dentists, 50 million messages were facilitated in March with updates about COVID-19 and closures. The company has continued to see high volume whenever there have been substantial changes to protocols, openings, or closures. Right now the combination of the two types of text messaging can be very effective. They can be used across the entire patient experience.

• Appointment reminders and instructions: Automated texts can be used for appointment reminders and can include instructions for things such as park and text waiting or what to do if the patient has COVID-19 symptoms. • Real-time pre-screening: Two-way text can be used to reach out to patients who haven’t confirmed to not only confirm the appointment, but also to pre-screen patients with a few questions about COVID-19 symptoms such as whether they have a fever, sore throat, or cough, or if they had contact with anyone who has tested positive for COVID-19. • Answer questions: Patients have many questions now about safety protocols in addition to the usual questions about insurance coverage or directions. Encouraging patients to text questions is more convenient, and responses can be preset for many common questions to save time. It can be helpful to designate a staff person to regularly check incoming text messages and respond. • Digital intake: No one wants to be picking up a clipboard right now. Send digital intake forms through text to make it easy for patients to complete them at home. You can add COVID-19 pre-screening and other forms to your usual packet. Depending on the system you use, Volume 11 Number 6

Volume 11 Number 6

can’t manage being compliant with text messaging. It’s surprisingly easy to stay compliant with a few simple rules. • Know the difference between a healthcare message, which you can send to patients without written consent, and a marketing messaging, which requires written consent. Healthcare messages are those that relate to patient care like reminders, recall, follow-up messages, education, test results, etc. • Know the basic requirements for compliant text messages. Patients do not need to consent to receiving healthcare messages. If they are a patient of record and have given their cellphone number, you can text them healthcare messages. However, there must be a clear opt-out. You need to regularly update and verify patient contact information. Texts can’t be more than 160 characters long. • Adhere to the minimum necessary standard if sending texts through a third-party service. Provide only the information required to get the message delivered with the correct information. And always have a business associate agreement (BAA) in place. HIPAA requires all covered entities to sign a BAA with any third party that will have access to patient data. That includes private message (PM) and electronic health records (eHR) vendors, patient communications vendors, and billing companies, among others. Basically, a third party that might come in contact

with patient information needs to sign a BAA. • Finally, if any patients want to discuss protected health information over unsecure text or email, be sure to ask them for consent first. It’s as simple as letting them know that text is not secure, and that you need their permission to continue. Once patients give consent, you can discuss protected health information (PHI) and be compliant. Research from OpenMarket that polled 500 millennials cites that 75% of millennials would forego the call function on their device as long as they were still able to text. Most patients would like to have text as an option because they believe it is more convenient.4 Currently, it can also provide a better experience by letting patients stay in touch, be prepared, and get questions answered. Disclaimer: Consult your attorney to ensure you are compliant before instituting a texting program. This article is intended to provide general information and is not intended as legal advice. Laws may vary by state. OP

REFERENCES 1. The COVID-19 impact. SR Health website. https://www. srhealth.com/resources/the-covid-19-impact. Accessed October 1, 2020. 2. Vanderkam L. Are you still checking voice mail? CBS News MoneyWatch web site. https://www.cbsnews.com/news/ are-you-still-checking-voice-mail/. Published April 11, 2013. Accessed October 1, 2020. 3. The Patient-Provider Relationship Study: The Ripple Effect Starts with Boomers. Solutionreach website. https://www. solutionreach.com/rethinking-the-patient-provider-relationship. Published 2017. Accessed October 1, 2020. 4. Cawley C. Study: Millennials would rather text than talk [press release]. https://www.openmarket.com/press/ study-millennials-would-rather-text-than-talk-infographic/. Published June 23, 2016. Accessed October 1, 2020.

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the forms can be embedded in the text, or you can send patients a link to wherever your digital forms are available (i.e., website, portal, etc.). • Patient follow-up: Use real-time text to check on patients after a procedure. It just takes a few seconds to send a note asking if they feel OK or have any questions. It’s a good way to remind patients what to do if they have any complications. The real-time text can be facilitated by the doctor or assistant, whoever can most effectively help the patient. • Communicate changes quickly: Anything can happen right now. If there is an unexpected closure or a change to the process for checkin, sending a group text to all the patients being seen that day (or week) is much faster than trying to call. Some patient communications software allows the practice to text a large group so it appears to be an individual text, and the patient can respond as an individual just to the practice. Because it is done through the software, others in the group cannot see individual responses. • Surveys and reviews: Automated or real-time text can be used to request reviews or ask patients to complete a post-visit survey. It’s fast and easy, and patients are often logged into Google or Facebook on their phone already. • Recall: Automated recall is an incredibly effective tool for filling the schedule, and recall reminders can be sent via text or email. As practices work to recover revenue, real-time text can also be effective. Reach out directly to patients who are overdue or haven’t followed through for highprofit margin services like crowns or Invisalign® to try to boost revenue quickly. • Address barriers: If patients are canceling appointments or not responding to outreach, consider texting directly to ask why. Is there something you can do to help? It may be fear about COVID-19 or problems with insurance coverage or transportation. A simple, friendly chat over text may be enough to help address the issue or problem-solve to get them in. Clearly, there are a lot of ways to use text messaging to connect with patients and keep the lines of communication open. Providers often worry, however, that they

REF: OP V11.6 CHATHAM

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Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $149; call 866-579-9496 or visit www.orthopracticeus.com to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Go online to orthopracticeus.com/ce-articles, click on the article, then click on the take quiz button, and enter your test answers n Mail this completed quiz to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9, Scottsdale, AZ 85260 To provide feedback on this article and CE, please email us at education@medmarkmedia.com Legal disclaimer: Course expires 3 years from date of publication. The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

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Two-way text messaging can solve many patient engagement challenges CHATHAM

1. Before the pandemic, ________ were the most desirable form of communications across baby boomers, Gen Xers, millennials, and Gen Z-aged patients. a. phone conversations with a live person b. text messages c. personal emails d. email portal messages 2. During COVID-19, patientsâ&#x20AC;&#x2122; interest in live phone calls ________. a. dropped 28% b. dropped 14% c. increased 14% d. remained the same 3. A study quoted by CBS News MoneyWatch noted that only _______ of people listen to voicemail from a number they donâ&#x20AC;&#x2122;t know. a. 5% b. 18% c. 35% d. 43% 4. A patient-provider relationship study by Solutionreach found that ______ of patients desire the ability to text their dentist and 79%

20 Orthodontic practice

want to get texts from their provider, especially about appointments. a. 26% b. 57% c. 67% d. 73% 5. The study also found that ______ of Gen Xers favor appointment reminders by text, and 67% appreciate texts to remind them of the need for follow-up care or treatment. a. 25% b. 35% c. 70% d. 85% 6. Automated texts can be used for ______. a. appointment reminders b. instructions for things such as park and text waiting c. what to do if the patient has COVID-19 symptoms d. all of the above 7. (Regarding compliance with text messaging) Healthcare messages are those that relate to patient care like reminders, ______, and test results.

a. recall b. follow-up messages c. education d. all of the above 8. HIPAA requires all covered entities to sign a/ an _______ with any third party that will have access to patient data. a. business associate agreement (BAA) b. independent contractor agreement (ICA) c. non-compete agreement (NCA) d. unilateral agreement (UA) 9. If any patients want to discuss protected health information over unsecure text or email, be sure to ask them for consent first. a. True b. False 10. Research from OpenMarket that polled 500 millennials cites that ______ of millennials would forego the call function on their device as long as they were still able to text. a. 54% b. 68% c. 75% d. 86%

Volume 11 Number 6

CE CREDITS

ORTHODONTIC PRACTICE CE

JoAn Majors, RDA, CSP, discusses how technology and outsourcing can improve efficiencies during COVID-19 times and beyond

ecently on a call, a team member explained, “I don’t have the time to chat with my patients. With reviewing a screening form, recording temperature, timing CaviCide™ spray for 3 minutes (wipe), plus 3 more minutes, plus a 60-second (or two 30-second) rinse(s) with hydrogen peroxide before treatment, I can easily lose several minutes per patient.” With all of the new sanitizing and PPE tasks to remember to keep patients safe in the dental office with efficient practice and patient management systems in place, efficiencies can still be achieved to save time and to use the time that is allotted more efficiently. During this period when dentists and teams need to rethink time-management protocols, it is the perfect time to embrace what technology and outsourcing can do to help gain that time to connect with our patients. With all of the stressors that are a part of daily office life during the COVID-19 reopening, instituting even more office management protocols probably would be an unpopular announcement too. Inspirational speaker Tony Robbins says, “People will do more to avoid pain than they do to gain pleasure.” It is important for the team

JoAn Majors, RDA, is a content creation specialist and co-founder of The Soft Skills Institute, LLC, a National AGD PACE provider. She earned a CSP® — Certified Speaking Professional — the highest designation for a professional speaker from the National Speakers Association. Majors is also a member of GSN, SCN, AADOM ASCA, DSI, and ADIA. She serves on the advisory board for DeW Life magazine and is Vice President of Education for DrDDS. An ambassador to select dental companies, Majors works weekly as the Comprehensive Care Coordinator in her husband’s practice. She has been published in over 25 magazines and newsletters, and is the author of four books. To learn more, visit www.joanmajors.com. For a list of sample patient text messages to use with your Reminder System, send a request to joan@joanmajors.com, Subject Line: MedMark COVID Messaging. Disclosure: No compensation was received for this article. JoAn Majors has received honorariums for speaking in person and virtually for two services mentioned in this article: CareCredit® and WEAVE.

Volume 11 Number 6

Educational aims and objectives

This article aims to discuss the benefits of technology and outsourcing to help gain more time to connect with patients.

Expected outcomes

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

Understand technologies that can alleviate stress for the team.

•

Realize the need for financing options.

•

Realize the significance of connecting with the modern patient.

•

Realize how to safely connect in a COVID-19 and post-COVID-19 climate.

•

Recognize the importance of having a dedicated insurance professional to facilitate patients’ understanding of procedures and coverage.

to understand that even the most remarkable technologies will have a learning curve, and everyone needs to be patient because learning new skills will increase the whole team’s long-term success. The learning curve or time lost because of COVID-19 changes can be transformed into a benefit when life is made easier in the long run because of the new methods. After the frustrations of lockdowns and social distancing, people are craving connection more than ever. Reopening the office was therapeutic for many dental professionals and teams. We would have liked to greet our patients back with a hug or have more time to connect with in-depth conversations during this stressful period, but post-COVID-19 office procedures with less touch and less teeth (smiles covered by masks more often), resulted in more intentional interaction and increased focus. Technology efficiencies can help the team move from transactional to transformational. The communication that goes with these technologies is as significant as the technology or service itself.

Efficiency No. 1 The COVID economy — financing options are no longer optional in today’s climate When possible, consider the money issues that face patients in the COVID-19

economy before it becomes an issue that affects treatment acceptance. It is advantageous to offer some third-party financing with one of the many companies available. The inability to provide some payment options today can be a real barrier to treatment. According to an August 8th report from CNBC, 32% of Americans were behind on mortgage payments.1 Patients are deciding whether they should pay their mortgage that is already several months late or take their child or even themselves to the dentist. The “want to” types of treatment have also been affected by this change in our economy. The ADA News reported an ADA Health Policy Institute poll in April, which stated, “The volume of total collections is down significantly with 82% of respondents saying collections were less than a quarter of what is typical in their practice.”2 Patients have options for financing dental treatment.3 • Traditional third-party financing: When patients use their own credit cards, the practice can receive payment within 48 hours. The practice pays average credit card fees of up to 3%. • Dependent third-party financing: The dental practice partners with a third-party provider. The dental office has zero liability if the patient Orthodontic practice 21

CONTINUING EDUCATION

Practice management efficiencies to ease your team’s workload

CONTINUING EDUCATION defaults. The dentist can offer terms and conditions and payment plans that increase case acceptance. Advantages to choosing this type of plan are the practice gets paid up front and doesn’t take any risk for nonpayment, and the practice can increase case acceptance by introducing more favorable terms. • In-house financing: Patients set up a payment plan with the practice. In this scenario, the practice holds the risk for nonpayment. • Hybrid financing: Patients sign a legal financing agreement and are charged interest and an intermediary administrates the program. The doctor is not fully paid up front, but the deposit usually is equal or greater than the bottom line costs of the treatment plan. Making it easier for someone to pay can be easier with many incentive plans offered by outside financing companies during this time. Rates are temporarily lower, and these companies can provide alternative payment methods. Lending Tree®, Compassionate Care, Partial.ly, and CareCredit® are just a few of the companies that can fulfill this need. Since each office’s needs differ, research companies such as these should discuss which one would provide the most beneficial plans and can best support your team. Many team members are not aware that an outside financing company has data accessible for new and existing patients before they get in the chair. In my office during the COVID-19 crisis, we were only allowed to see emergency patients on 2 days; some new patients were so grateful to find a dentist at all. With limited availability, same-day dentistry for emergencies was and still can be efficient. Prequalification functionality is often built into these platforms, so both the doctor and patient will know the amount of funding available. Having this ability to access the available credit with the name and phone number of a new patient can be extremely helpful. On the CareCredit dashboard, we could easily see the funds obtainable before the patient arrived in our office, which increased productivity and improved customer service. Saving time that way allowed us to be more efficient. We knew how to respond regarding financing when the patient said, “It’s tough for us right now because my spouse didn’t work during the pandemic shutdown.” 22 Orthodontic practice

73% of healthcare practices say outgoing communication that is personalized performs better than communication that is not personalized.

In one of the last articles written by Sally McKenzie, an incredible dental colleague, mentor, and management professional, she shared, "payment plans enable your practice to schedule the number of appointments required to complete treatment, not the number patients can afford. This means patients will be less likely to cancel at the last minute or not show up at all, reducing broken appointments and all the trouble they bring.”4

Efficiency No. 2 COVID-19 concerns about spreading germs — reducing surface “touch” and increasing “staying in touch” Adopting a healthier “touch it once” mindset is more serious than ever in today’s practice. With all the fear of spreading these germs with a sneeze or droplets, why in the world would we still have multiple people touch paper? The CDC website FAQ about transmitting COVID-19 through the mail, packages, or surfaces with the virus on them, notes: “It may be possible that people can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads.”5 Touch may not be the “main” way the virus is spread. Still, it presents a possibility that can be avoided while creating a time-saving efficiency for our teams and all patients. A better, safer way to obtain all of the necessary information is through electronic submissions. Consider paper referrals and the possibility of how referrals or film X-rays or printouts can be lost in the mail, misfiled, or lost in a patient’s or parent’s car on the trip to the office. However the information goes missing, it still causes unnecessary wasted time for the referring dentist, the treating specialist, and the patient, who may have to spend extra time in the office or be reappointed because of the missing information. Having digital records management saves time for your front office and the referring dentist. The outgoing phone call to the

Image courtesy of WEAVE

referring office takes time and touch. The other office needs to answer the phone and research the missing file — more time and more touch. The investigation continues — did the form get scanned into the practice management system before the patient left? If not, where is it now? The front office person not only has to interrupt her tasks to check, but also may have to ask the assistant or even interrupt the doctor. In these already challenging COVID-19 times, offices should help team members touch fewer surfaces while maintaining more connection with the patients’ records as efficiently as possible. Office software such as LOOP and OneClick can help with this issue. I’ve used the latter as a clinical assistant in the front office. The patients have appreciated that I was able to sit with them chairside and tell them that I will click on the “easy” button and give them a “jump-start” to whom the doctor would recommend as the best “specialist” in the community. At that time, I am able to electronically send the patient’s X-rays, details for the evaluation, and medical history. From that management system, the referring dentist can keep up with the patient’s treatment and progress as well. As soon as I send the information, our patient can receive a text message from the specialists’ team momentarily and begin the process to move the patient through the office’s care cycle and let the administrative team know a referral has taken place. The only surface touch that Volume 11 Number 6

Efficiency No. 3 COVID-19 protocols and patient communication requiring consistent communication Selecting a reminder system that serves the patient’s needs and the practice’s desires for communication and efficiency is more important than ever. There are many companies that can fulfill that need such as Solutionreach, Lighthouse 360, and WEAVE. It is important to have a flexible system, and in the case of our office, WEAVE works best for us. Today in our practices, we are overloaded with multiple dashboards for identifying various clinical and business aspects. Finding a system that can create multiple efficiencies while meeting your desires and budget is essential. As a soft skills specialist, our most important need was the ability to customize the many messages we need to disseminate as well as to share new COVID-19 protocols. Efficiency is paramount; we needed to know all of the information about who is calling and connect with a patient as quickly as possible while matching his/her patient picture with the name. Even when the employee or dentist is not working from the office, this function allows the owner and team to be and look very efficient. With all of this information, I have the opportunity to take customer service a step further when I can say, “Ms. Jones, would you like to go ahead and schedule Susan’s appointment too? She is due next month, and I can take care of the balance from your husband’s appointment now too.” All this can be achieved by viewing the same app or pop-up window. The communication system in our office is set up to begin with a 2-week phone call before any appointment if the patient has not been in since the pandemic. This allows the staff to make patients aware of our new protocols and keep them safe. It Volume 11 Number 6

Image courtesy of WEAVE

also gives us the necessary time to replace a patient appointment if they had concerns and opted to wait. (This is very helpful with senior patients.) Then we send customized text messages at 7 days, 4 days, 2 days, and 2 hours before their appointment, allowing us to be more efficient in many ways. According to a survey of 750 healthcare professionals and their clients commissioned by WEAVE, 73% of healthcare practices say that personalized communication increases response rates and performs better. The survey also states that over half of these practices indicated that it is easier to reach clients with a text than a phone call.”6 The app also gives us the opportunity for attaching the ADA screening form, communicating about our Open Chair FeeSM for a missed appointment, and send a reminder about our curbside check-in. The curbside check-in, sent the same day, generates a message that appears at the top of the patient’s text messages and allows the patient to type a quick message letting us know they have arrived. Then based on our appointment flow, we text when the patient can enter for his/her appointment. We also have a follow-up message thanking patients for their trust and helping our small business survive. This aspect of personalization is appreciated and receives some of the best replies. With concerns about touching money, credit, or debit cards during the COVID-19 crisis and even after, sending a link for patient payment offers more safety. We ran multiple communication types during the pandemic through our system, communicating in both email and text.

We learned over time that the old 5-digit messages are often ignored. Now during an election year, when everyone is inundated with unsolicited texts, it is even worse; I reply STOP on those immediately! So that the messages are taken more seriously and not just deleted, our messages derive from our actual phone number. We love that our patients even respond to our birthday message (now revolving around COVID-19 and a distant hug), and those messages can be changed yearly. Many patients perceive that the message is straight from the doctor and respond. The ability to listen to those messages at home during COVID-19 also was a game-changer. The missed-call text and our ability to quickly see the patient’s response message are how we gained so many new loyal patients. Many said they could not get anyone in other offices to return their call. Allowing someone on the team to rotate to watch the app each day also gave a few hours of work to team members who had requested more hours. Now at the end of the year, we will launch a campaign through the system for “Use it or Lose it” benefits, and then “Are you dreaming of a white Christmas?” whitening special. A reminder system needs to do more than remind to be considered efficient and effective for today’s discriminating buyer. Implementing any new technologies has a learning curve. Before implementing a new system, do some research by asking colleagues on message boards or calling other dentists to see which system has worked for them. Keep in mind that you’ll need to be discreet and adhere to HIPAA regulations Orthodontic practice 23

CONTINUING EDUCATION

is needed is for my keyboard. No duplication of effort is needed. If the administrative team members want or need to know more, they can access the dashboard and check it out. With products like this for referral and lab prescriptions, the office has the opportunity for less confusion and, more importantly, today, less contact via the phone and paper. The fewer times we can touch a piece of paper or the phone for that matter, the better and more efficient we are. Also, with this additional time, dentists and teams can serve patients better and connect by listening to their concerns.

CONTINUING EDUCATION with messages to your patients. For years we were warned about leaving personal patient information on a recorder that someone other than the patient might hear. Even though you are texting their personal device, it’s a good idea to keep messages generic in nature that shouldn’t violate HIPAA laws. If you are texting with a patient, and money or other personal matters that could be of concern come up, consider saying, “Ms. Jones, I can call you about this, or you can give me your permission to communicate this type of information here by text.” Clarity is never a mistake when communicating with patients.

Efficiency No. 4 Insurance time crashers —understanding the scalability and profitability of outsourcing specific tasks Outsourcing these tasks does not replace team members; it replaces team members’ non-connecting tasks so that they can still be essential and efficient and help our practices to survive. For example, private or small group practices need a strong team for insurance benefits and billing issues — tasks that can take much time and effort because patients need to be educated on the difference between dental benefits and medical insurance. Mouth Healthy, a website of the American Dental Association notes that “An annual maximum is usually $1,000 or $1,500 and has not changed much in the last 50 years,” and that the time it takes to speak to a person about a specific procedure takes a lot of time.7 Years back, when a plan covered 50% of three crowns, the time that it took to explain and process the insurance form was more feasible. Today, the cost of technology and PPE makes this function quite different. Patients often do not realize how little their dental insurance will cover. And with the perio rules and coverage for other procedures changing regularly, patients need someone to make the connection with them and spend the time to plan their care within or in spite of their insurance plan. Consider orthodontic treatment and how some still perceive this as a “want to” rather than a “need to” service. A team member can create value by communicating one-on-one how significant a patient’s occlusion is to his/her long-term dental health. Speaking with a patient in the office rather than wasting time on hold with the insurance carrier will reap far better results. Patients must discuss and understand the possible risks and consequences of delaying 24 Orthodontic practice

Image courtesy of WEAVE

or not accepting a treatment recommendation, but that communication must be delicately delivered, taking time and focus. There has never been a better time to consider sharing seasoned insurance professionals’ cost as an outsource to your team. The assistant that loves to coddle and care for that frightened patient may not effectively also play the role of the detailed individual needed to file claims correctly. Some assistants want to be patient-facing, while other team members enjoy battling it out on the phone with an insurance company’s representative in a back room with no patient interaction. Outsourcing to a dedicated insurance professional offers an opportunity to ease the workload of those who need that time to connect with patients. With most practices experiencing shutdowns because of COVID-19 exposure or losing team members who are concerned about returning to work, having greater insurance returns can increase revenue and reveal the underlying plan details that can trip up the patient and cost money. A recent article in Becker’s Hospital Review, “Outsourcing is Exploding in Healthcare – Will the Trend Last?” shares this key point: “When the functions are outsourced, systems have access, through the vendors, to the most up-to-date technology for data collections and analysis without investing in capital.”8 Most of us can’t afford someone of this experience for less than about $15 to $16 an hour. The private practices recognize the scalability and affordability of the big groups and DSOs having a dedicated team with many of these services. There are so many, including Medusind, eAssist, Dental Hero, Dental Claims Support, and Peak Professional Partners, to name a few. It is an efficiency that can have an immediate

impact on the bottom line and the sanity of your team. Running a dental office has always been a complicated combination of catering to patients’ needs, providing excellent clinical care, and discovering the most efficient ways of helping patients navigate their financial choices while keeping the profitability of the office. COVID-19 times have made it even more necessary to find efficiencies through technology and expert third-party options. All of these choices will create a smoother workflow even after the crisis has abated. OP

REFERENCES 1. Adamczyk A. 32% of Americans had outstanding housing payments at the beginning of August. CNBC Make It. https://www.cnbc.com/2020/08/06/32-percent-of-americans-had-outstanding-housing-payments-at-beginningof-august.html. Posted August 6, 2020. Accessed October 19, 2020. 2. Carey M. HPI poll examines impact of COVID-19 on dental practices. ADA News. https://www.ada.org/en/publications/ ada-news/2020-archive/april/hpi-poll-examines-impactof-covid-19-on-dental-practices. Posted April 1, 2020. Accessed October 19, 2020. 3. Sadusky A. The Dental Drilldown: Patient financing programs 101. Dental Economics. https://www.dentaleconomics.com/ practice/patient-communication-and-patient-financing/ article/16385045/the-dental-drilldown-patient-financingprograms-101. Published January 1, 2019. Accessed October 19, 2020. 4. McKenzie S. 7 ways to increase cash flow in your office. Dentistry IQ. https://www.dentistryiq.com/practice-management/financial/article/14183768/7-ways-to-increasecash-flow-in-your-office. Published September 21, 2020. Accessed October 19, 2020. 5. Centers for Disease Control and Prevention. Frequently Asked Questions. https://www.cdc.gov/coronavirus/2019ncov/faq.html#Spread. Accessed October 19, 2020. 6. Weave. Doing Business in the New Normal: A Weave Guide for Healthcare Practices in the Age of Social Distancing. https://www.getweave.com/ebook-weave-got-this. Accessed October 19, 2020. 7. Mouth Healthy. Common Dental Benefit Terms: What They Mean and Why They Might Come with a Cost. https:// www.mouthhealthy.org/en/dental-care-concerns/commondental-benefit-terms. Accessed October 16, 2020. 8. Becker’s Hospital Review. Outsourcing Is Exploding in Healthcare — Will the Trend Last? https://www.beckershospitalreview.com/hr/outsourcing-is-exploding-in-healthcare-will-the-trend-last.html. October 4, 2013. Accessed October 19, 2020. This article is intended to provide general information and is not intended as legal or financial advice.

Volume 11 Number 6

REF: OP V11.6 MAJORS

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

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

Practice management efficiencies to ease your team’s workload MAJORS

1. The ADA News reported an ADA Health Policy Institute poll in April, which stated, “The volume of total collections is down significantly with ______ of respondents saying collections were less than a quarter of what is typical in their practice.” a. 14% b. 45% c. 64% d. 82% 2. When patients use their own credit cards, the practice can receive payment within ______. a. 48 hours b. 1 week c. 2 weeks d. 1 month 3.

Advantages to choosing this type of plan (dependent third-party financing) are the practice gets paid up front and ________. a. doesn’t take any risk for nonpayment b. can increase case acceptance by introducing more favorable terms c. can charge extremely high interest rates d. both a and b

4. (With paper referrals, film X-rays, or printouts) If the information goes missing, it causes unnecessary wasted time for the ________, who may have to spend extra time in the office or be reappointed

Volume 11 Number 6

because of the missing information. a. referring dentist b. treating specialist c. patient d. all of the above 5. According to a survey of 750 healthcare professionals and their clients commissioned by WEAVE, _______ of healthcare practices say that personalized communication increases response rates and performs better. a. 36% b. 52% c. 73% d. 92% 6. The survey (commissioned by WEAVE) also states that over half of these practices indicated that it is easier to reach clients with a ________.” a. phone call than a text b. text than a phone call c. USPS letter than a phone call d. USPS letter than a text 7. Keep in mind that you’ll need to be discreet and _______ in messages to your patients. a. only discuss marketing b. adhere to HIPAA regulations c. only schedule appointments d. only send COVID-19 updates

8. Private or small group practices need a strong team for insurance benefits and billing issues — tasks that can take much time and effort because _______. a. the paperwork is so complicated that even experts are not able to figure out benefits b. patients need to be educated on the difference between dental benefits and medical insurance c. patients never agree to treatment unless it is covered by their insurance d. none of the above 9. Mouth Healthy, a website of the American Dental Association notes that “An annual maximum is usually ________ and has not changed much in the last 50 years,” and that the time it takes to speak to a person about a specific procedure takes a lot of time. a. $1,000 or $1,500 b. $4,000 or $4,500 c. $6,000 or $6,500 d. over $10,000 10. Outsourcing to a _________ offers an opportunity to ease the workload of those who need that time to connect with patients. a. dedicated insurance professional b. clinical assistant who needs extra hours c. person from a part-time employment agency d. team member with extra free time that day

Orthodontic practice 25

CE CREDITS

ORTHODONTIC PRACTICE CE

PRACTICE DEVELOPMENT

MOGA® — make orthodontics great again! Dr. Ronald Roncone discusses how to create a new paradigm for the orthodontic office

any of us have heard about the “Golden Age of Orthodontics,” when orthodontists had all the patients they wanted and were able to see. In fact, those orthodontists actually sent potential new patients to clinicians just starting practice. When new patients arrived at your office, they always started after three more appointments. There were really no second opinions. That era (1950s and 1960s) is long gone in many ways. In those days, there was no need for marketing, and in fact, advertising was illegal in most places. GPs and pediatric dentists did not do any orthodontics. There was no insurance. Orthodontic residency programs were very small. Group practices were virtually unknown. There were no MSOs or DSOs. There was no internet. The post-WWII economy was booming. Then came “Progress”! Slowly at first and then very rapidly. Nothing was automatic anymore. You had to start working to get new patients in the door — marketing. Internal first, then external; then blatant in-your-face advertising became necessary. The public was being “educated” and wanted multiple opinions. Gosh, they even had opinions; chairside assistants turned into mini-orthodontists; “Treatment Coordinators” became de rigueur. Staff began to put the braces on (orthodontists no longer made and placed bands); staff members took diagnostic records and explained what they meant and how to pay for services; orthodontic supply companies made brackets that required no wire bending. This all became fashionable — how many colors are there in the rainbow? Colleagues became competitors. On what

Ronald Roncone, BA, DDS, MS, received his degrees in physiology from Marquette University and his postdoctoral Certificate in Orthodontics from Forsythe Dental Center and Harvard School of Dental Medicine. Dr. Roncone maintains a large practice in Vista, California, with 55% adult patients. Dr. Roncone has lectured extensively, presenting more than 1,000 seminars around the world, and is President and CEO of Roncone Orthodontics ® International , which offers practice management courses as well as in-office consulting and marketing services. Disclosure: Dr. Roncone is a key opinion leader for Forestadent® USA.

26 Orthodontic practice

Google page do we post our information? Some of us wondered, “What the heck is Google?” Simple and nice offices where we had only to think of what color chairs to buy (banana yellow was my favorite) and how white should the walls be, turned into multimillion-dollar temples of 3,000 to 10,000 square feet and more. Management companies and consultants were now a necessity in order to survive. Overhead changed from 25% to 60%, 70%, 80%, and more. The workday, which was a 9 a.m. to 5 p.m. tradition, became a 7 a.m. to 8 p.m. multiple shift at the other extreme. A one-office location became 2, 5, 15, 30 locations in multiple cities, states and countries — many with the intention of selling them to a DSO for some multiple of gross, net, or other accounting word. What once was a very nice, low-stress profession has become something very different. Admittedly, some orthodontists love where the profession is, but in talks with orthodontists who attend our courses and for those whom we consult, there is a desire for something different. Can we please … MAKE ORTHODONTICS GREAT AGAIN — MOGA®? The answer of course is “yes” for those who aspire for something different. This difference does not necessarily mean turning your practice into a mom-and-pop type arrangement. What is required? We must “simplify the complex”: 1. Use “strategic intent” and plan for absolutely outrageous outcomes. 2. Create meaningful systems (10 of them in an orthodontic practice). 3. Perfect those systems. 4. Do not allow anyone to limit you or tell you what is possible. 5. Develop flowcharts of possibilities (Figure 1). 6. Climb the inevitable learning curves all the way to the top. Do not stop in the middle. 7. Develop metrics for the most important systems (Not what you think for outrageous outcomes). 8. Change the word prefer to should: It is not what you prefer; it is about what you should do to achieve outrageous outcomes.

Figure 1: How do I reduce staff from 17 to 7 or 5 and be more profitable? • Decrease the number of appointments per patient. – What is required? a fewer arches/adjustments (What is required to get this?) a fewer bond changes (What is required to get this?) a fewer emergencies (What is required to get this?) a longer appointment intervals (What is required to get this?) a SLBs (Why is this better than twin brackets?) (Figure 2) a shorter appointment times (What is required to get this?) a schedule like things at like times (What is this?) • 27 to 32 patients per day/per assistant (Impossible? No!)

Figure 2: Elastomeric Modules versus Self-Ligating Braces (SLBs) 4 sec/tooth to remove elastomeric module x 20 teeth = 80 sec 16 sec/arch = 32 sec for both arches to open SLB 80 sec – 32 sec = 48 sec per person/saved @ 50 pts/day a 50 x 48 sec = 2,400 sec 2,400 sec ÷ 60 (sec per min) = 40 min/day 40 min x 46 weeks worked = 1,840 min 1,840 ÷ 60 (1 hour) = 31 hours [1 week saved by using SLB] Closing SLB or tying-in with elastics = 1 more week Save 48 seconds opening and 48 seconds closing versus elastomerics. If 2 weeks/year just in an equal amount of ties or opening and closing of SLBs If using elastomeric module … Need to see patients at most every 6 weeks (4 would be better). With SLB much less: 8-10 weeks If treatment takes the same amount of time with both types … i.e.: 16 months = 64 weeks @ 6 weeks = 10.5 appointments @ 9 weeks = 7 appointments 3.5 fewer weeks of appointments (at a 4-day week) 5.5 fewer weeks of work Example: 3.5 appointments saved per patient x 200 starts = 700 fewer appointments 700 appointments ÷ 50 pt/day = 14 less days if SLB 2 fewer weeks of work due to opening and closing SLBs + 3.5 fewer weeks of work because of fewer appointments = 5.5 weeks less work

Part of outrageous outcomes can be, What do I need to do to change my 4-day a week practice into 2 days without losing income? What is necessary to reduce emergencies to one per month? The goal is always zero. How do I reduce staff from 17 to 7 or 5 and be more profitable? 30% to 40% of what the average orthodontic practice does on a daily basis is: • an emergency • unnecessary • a redo Go counterculture! Change paradigms in the middle of a paradigm shift! Become a major disruptive force! MOGA! OP Volume 11 Number 6

AUTHOR GUIDELINES Orthodontic Practice US is a peer-reviewed, quarterly publication containing articles by leading authors from around the world. Orthodontic Practice US is designed to be read by specialists in Orthodontics, Periodontics, Oral Surgery, and Prosthodontics.

Submitting articles Orthodontic Practice US requires original, unpublished article submissions on orthodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Orthodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 11 Number 6

Pictures/images

Disclosure of financial interest

Illustrations should be clearly identified, numbered in sequential order, and accompanied by a caption. Digital images must be high resolution, 300 dpi minimum, and at least 90 mm wide. We can accept digital images in all image formats (preferring .tif or jpeg).

Authors must disclose any financial interest they (or family members) have in products mentioned in their articles. They must also disclose any developmental or research relationships with companies that manufacture products by signing a “Conflict of Interest Declaration” form after their article is accepted. Any commercial or financial interest will be acknowledged in the article.

Tables Ensure that each table is cited in the text. Number tables consecutively, and provide a brief title and caption (if appropriate) for each.

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques. Aesthetic & Implant Dentistry. 2000;1(1):92-96. (Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date].

Manuscript review All clinical and continuing education manuscripts are peer-reviewed and accepted, accepted with modification, or rejected at the discretion of the editorial review board. Authors are responsible for meeting review board requirements for final approval and publication of manuscripts.

Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity. Articles should be submitted to: Mali Schantz-Feld, managing editor mali@medmarkmedia.com

Reprints/Extra issues If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors. The publisher does not stock reprints; however, back issues can be purchased.

Or in the case of a book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide. London: Martin Dunitz; 2001. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

Permissions Written permission must be obtained by the author for material that has been published in copyrighted material; this includes tables, figures, pictures, and quoted text that exceeds 150 words. Signed release forms are required for photographs of identifiable persons.

Checklist for article submissions: 3 A copy of the manuscript and figures, captions, including all pictures (low res) necessary for reviewers 3 Manuscript: double-spaced including separate references, figure legends, and tables 3 Abstract, educational objectives, expected outcomes paragraph 3 References: double-spaced, alphabetical, American Medical Association style 3 Tables: titled and cited in the text 3 Mandatory submission form, signed by all authors Please contact Mali Schantz-Feld, managing editor, with any questions via email: Mali@medmarkmedia.com

Orthodontic practice 27

TECHNOLOGY

Options mean opportunity Dr. Melissa Shotell talks about the opportunity an open intraoral scanner brings to her practice

y orthodontic practice shares our space with a restorative dentist. So, when it came time for us to look for an intraoral scanner, we were interested in finding a solution that we both could use. We knew the scanner had to be highly accurate for restorative, crown-and-bridge, and implant dentistry, and also had an open platform so that we could send scans to aligner and orthodontic laboratories as well as to restorative laboratories. From an orthodontic standpoint, I was looking for a solution that could scan quickly, accurately, and easily, especially because I work with many younger patients. For us, the 3Shape TRIOS® was perfect because of its fast scanning, the high level of accuracy, and the small wand size for younger patients. We were also very interested in the intraoral scanner having an open architecture so that we could export the STL files to any laboratory, including our own in-office laboratory. As an orthodontist, I also needed the ability to save the scans long-term instead of having to archive plaster models. Again, TRIOS ticked the right boxes.

Answering the clear aligner boom The clear aligner market is the fastestgrowing area in orthodontics for adult treatment and a very, very fast-growing area for children. TRIOS and its ecosystem of solutions and integrations enable orthodontists to take advantage of this market by giving us options on how we deliver clear aligner treatments. The scanner’s open architecture means that you can decide if you want to use the scan to make the clear aligners yourself with, for example, 3Shape Clear Aligner Studio, or send it to a commercial laboratory. This gives you, as a professional, ultimate control. And for me, this is incredibly important.

With clear aligners, many doctors tend to choose a laboratory for their larger clear aligner cases but produce the smaller cases in-house. The beauty of TRIOS as an intraoral scanner is that it offers both options. One of the things that frustrated me with commercial clear aligner makers was the time frame in receiving aligners and the time it took with the setup process. In a society where we are used to wanting everything quickly, the open architecture of the TRIOS scanner and the ability instead, to produce clear aligners myself, allows us to start cases much faster and create refinements much more easily. Again, TRIOS gives us ultimate control. When I began bringing the clear aligner process in-house, I found that there was not only a tremendous time savings, but also a cost savings because you are eliminating a lab bill when you create your own in-house aligners, which can be 50%-75% of the cost. Remember, with TRIOS, you already have the technology in your office as an intraoral

Melissa D. Shotell, DMD, MS, is a Board-certified orthodontist and practices in a multi-specialty practice in Sonora, California, focusing on the interplay of orthodontics and restorative treatment. Dr. Shotell received her DMD at Nova Southeastern University and advanced hospital training and General Practice Residency Certificate from The Ohio State University. After spending years in general practice treating a broad range of patients, Dr. Shotell returned to complete a certificate and master’s degree in orthodontics from Loma Linda University, where she focused her training on cutting-edge three-dimensional imaging technology for diagnosis and treatment planning for interdisciplinary dentistry. Dr. Shotell considers education to be her passion and regularly consults and lectures on dental technology, clear aligner therapy, orthodontics, in-office clear aligners, office efficiency and workflow, and teamwork. Dr. Shotell shares tips and tricks on orthodontics and clear aligners on social media as “alignerbee.”

scanner, but with it, you can take your practice a step further and begin making the clear aligners in-house because of its supporting software such as Clear Aligner Studio and the STL export options. The very fact that you are making your own clear aligners creates a more competitive price in the market. A commercial lab costs between $1,500 to $2,000 for a case, but by making the clear aligner yourself, you can reduce that price to $500 or less at times. That cost savings is passed along to the patient, which in turn means you end up with more cases and higher profitability.

The “wow” factor At our practice, we make sure to actively promote the technology we have in our office with the digital workflow. We let patients know that we are going to create their aligners for them by using our technology to achieve optimal results. Patients are very impressed by this. Their clear aligners are created in a customized process just for them. As a result, our patients leave with that “wow” factor. It’s fantastic for marketing our practice. After a TRIOS scan and using tools like Treatment Simulator, patients tell their friends that they had goop-free impressions and that we showed them models of their teeth onscreen. It is something that they talk about, and for us, a solution that drives more referrals and consults. OP This information was provided by 3Shape.

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Volume 11 Number 6

Creating value for you and your patients

“The beauty of having options.” Dr. Christian Groth, USA

Your open clear aligner workflow With 3Shape’s open clear aligner workflow, you decide whether to send your 3Shape TRIOS® scans to the industry’s widest selection of integrated clear aligner providers or to design and produce clear aligners in-house. From timeframe to costs, take control of your clear aligner cases with the award-winning TRIOS intraoral scanner, 3Shape Clear Aligner Studio® software, and your choice of printer.

Scan-and-send

1. Scan Take digital impressions with the award-winning TRIOS intraoral scanner for superior scanning

2. Simulate & send Increase case acceptance with the TRIOS Treatment Simulator and send to aligner providers

Explore more Scan QR Code Please contact your reseller regarding availability of 3Shape products in your region.

Produce in-house

3. Plan & design in-house Plan and design your treatment in-house with Clear Aligner Studio software

4. Produce in-house Designs created with Clear Aligner Studio can be manufactured on your choice of 3D printer

TECHNOLOGY

Adjusting to the digital age — digital workflows are a necessity in post-COVID-19 times Dr. Alfred Griffin III discusses how digital technologies blend to benefit patients and practitioners

“C

hange is the only constant.” – Greek philosopher Heraclitus During current post-COVID-19 days, the above quote represents both the frustration and the resilience in the orthodontic office. After 7.9 million reported cases of COVID-19 (by October 16),1 shutdowns, reopening, and new social distancing guidelines have changed patients’ requirements and led to more streamlined office procedures and protocols. One of the most efficient ways of implementing these new business and clinical procedures is to have a digital workflow. Being a part of the greater digital world fulfills many of the “new normal” needs in the dental office. Most recently, teledentistry has shown many benefits, offering patients access to their dental providers without having to step into the office. The CDC noted the importance of serving patients through teledentistry under certain circumstances. An article on the CDC website notes: “Teledentistry can be used for education, consultation, and triage, allowing providers to advise patients whether their dental concerns constitute a need for urgent or emergency care, whether a condition could be temporarily alleviated at home, or whether treatment could be postponed. When many dental offices are closed, and people are largely staying at home, communication and information via teledentistry can help lessen the burden of people seeking dental care at overwhelmed emergency departments and urgent dental care settings.”2

Alfred Griffin III, DMD, PhD, is a second-generation orthodontist from Virginia. He has a Masters of Medical Sciences from Harvard Medical School, his certificate from the Harvard School of Orthodontics and Dentofacial Orthopedics, and his DMD and PhD from the Medical University of South Carolina. His skeletal biology and bracket research have been published in multiple peer-reviewed journals, and he led the R&D creating the world’s first fully customizable bracket system. Disclosure: Dr. Griffin III is the founder and CEO of LightForce Orthodontics.

30 Orthodontic practice

The Agency for Healthcare Research and Quality agrees: “Although the COVID-19 pandemic has led to unprecedented mandated office closures, it’s still as important as ever to stay connected to our patients. As orthodontists, technology allows us to make several purposeful changes in how we connect with those under our care. This includes phone, email, and text communications. In addition, virtual visits can reach patients in a unique way that increases their confidence and compliance. These ‘visits’ also provide a sense of normalcy and connection for patients who are stuck at home.”3 Offices that have already implemented a digital workflow have a distinct advantage over those that are dependent on analog methods. Even before the COVID-19 crisis, patients have been requesting services that require less time in the office for both treatment planning and follow-up visits and longer periods of time between visits. For instance, patients’ focus on clear aligners is not only based on the esthetics of clear aligner technology, but also the fact that they can have fewer visits to the orthodontic office and reach their treatment goals more quickly. Align Technology CEO Joseph Hogan recently discussed company initiatives to support digital care in post-COVID-19 times. The company accelerated its pilot program of virtual care tools and virtual appointments, and increased its online learning platforms. He noted, “We honestly feel that, particularly

in the orthodontic community, there’ll be a much harder leaning toward a digital kind of environment because of the chance of reinfection rates with COVID-19 and concerns about future shutdowns or slowdowns. … So we’ll be going to our customers with programs that really help them figure out how to convert more and more of their volume to a digital environment.”4 In the same vein, Henry Schein® also unveiled its Medpod® program for staying personally connected and providing faster care for patients, as well as remote access and tools for triaging dental emergencies.5 The AAO discussed a possible virtual visit workflow implemented by Dr. Michelle Neal for her presentation, “Using Virtual Appointments to Maintain Continuity of Patient Care During a Crisis and Set Yourself Up for ‘Normalcy’ Upon Return” for the orthodontic practice. She noted that retainer checks were the easiest to complete virtually, while bonding and debonding days, of course, still necessitated the in-office visit.6

The digital workflow Early adopters of new technologies that complement the digital workflow are able to attract the changing consumers who place increased importance on convenience, time, fitting treatment into their lifestyle, and a full digital experience. This has become even more evident during COVID-19. With strict enforcement of PPE, social distancing, and sanitary measures, and with some patients now feeling more confident to re-enter dental Volume 11 Number 6

Intraoral scanning Intraoral scanning has changed digital workflow for ease of use by the team and for patient comfort. Dr. Lukasz Burkhart noted that 51% of patients in a study preferred intraoral scans compared to 29% of the subjects preferring the alginate impressions. “Reasons for preferring the intraoral scanner to conventional impressions included gag reflex, queasiness, difficulty breathing, uncomfortable breathing, and anxiety with the conventional technique.”7 Regarding accuracy, a systematic review of the literature suggests that digital models from intraoral scans are the new gold standard in orthodontics due to their accuracy and other perceived benefits — such as cost, time and storage considerations.8 Dr. Ricky Harrell recognizes the impact that digital scanning has on the modern dental practice. “In today’s practice, 3D intraoral scans are used for fabrication of fixed appliances and orthodontic study models, as well as indirect bonding trays. This technology is also useful in diagnostic setups, fabrication of aligners and removable orthodontic appliances, and diagnostic procedures.”9

Digital treatment planning An intraoral scanner is a mainstay of digital treatment planning for innovative companies such as, Invisalign®, SureSmile®, and LightForce. For these custom systems, the digital workflow looks something like this: 1. Enter patient information. 2. Take intraoral scan. 3. Indicate treatment details (or initially rely on technician’s expertise). 4. Approve or modify treatment plan. 5. Review and submit. 6. Receive patient kit with aligners (in the case of clear aligners) or IDB trays with fully custom brackets (for 3D-printed bracket system). During the COVID-19 crisis, many orthodontic practices noticed that their clear aligner patients weren’t impacted as negatively as their standard braces patients throughout the pandemic. While their clear aligner treatments progressed, their standard braces cases did not. This is more reason to use bracket technology that rises to the next level technologically and digitally. Volume 11 Number 6

While clear aligners are appropriate for some patients, ~80% of orthodontic patients still need treatment with fixed appliances. Like Invisalign, LightForce brings digital customization and workflow to the practice, starting with an almost identical workflow to aligner technologies to begin the treatmentplanning process. Bonding for both techniques can take place in 30 minutes, rather than an hour or more for traditional braces. And while Invisalign provides patients with the option of seeing the orthodontist every 2 to 4 months, rather than every 6 weeks with conventional braces, LightForce also caters to this patient preference by creating a direct path to the desired clinical outcome.

3D imaging Moving forward in a digital world, clinicians can add even additional helpful digital tools to their armamentariums. In-office CBCT units today can offer lowradiation options that can be useful in the orthodontic office for complex cases. The American Academy of Oral and Maxillofacial Radiology offered a position statement that noted a dramatic increase in the use of CBCT in dentistry over the past decade. The statement said, “CBCT imaging provides two unique features for orthodontic practice. The first is that numerous linear (e.g., lateral and posteroanterior cephalometric images) or curved planar projections (e.g., simulated panoramic images) currently used in orthodontic diagnosis, cephalometric analysis, and treatment planning can be derived from a single CBCT scan.” The value of this extra diagnostic information is typically casespecific. “The second, and most important, is that CBCT data can be reconstructed to provide unique images previously unavailable in orthodontic practice.” The directive suggested guidelines for the use of CBCT in orthodontics: 1. Image appropriately according to clinical condition. 2. Assess the radiation dose risk. 3. Minimize patient radiation exposure. 4. Maintain professional competency in performing and interpreting CBCT studies.10

3D printers In-office 3D printers are also entering the orthodontic practice mostly for production of aligners and retainers with a smaller investment than when using a third-party producer. Also, during COVID-19 shutdowns, some orthodontists found their 3D printers a good investment for replacing broken or lost retainers quickly. In an article

on the AAO website, Dr. Christian Groth notes, “The combination of 3D printing and intraoral scanning allows us to have a digital model that lives forever and can be produced in physical form at any time.”11 With that capability, fabricating a retainer and mailing it to the patient is very helpful in reducing unnecessary chair time and, during these COVID-19 times, can save PPE and possibly prevent COVID-19 spread. Together with teledentistry and new digital communications methods, a fully digital workflow allows patients to see the orthodontist less, finish treatment earlier, and provide more predictable outcomes — even during the COVID-19 crisis. Digital technologies are bringing changes to the orthodontic market not just during challenging times, but forever. Together the next generation of aligner companies and custom bracket and wire technology can offer patients the amenities and the esthetic results they want, and fewer and shorter office visits, while orthodontists can fine-tune their treatment plans with an eye for individualization and efficiency. OP

REFERENCES 1. ADA News. Current data on COVID-19. https://www.ada. org/en/publications/ada-news/2020-archive/march/currentdata-on-covid-19. Accessed October 26, 2020. 2. Brian Z, Weintraub JA. Oral Health and COVID-19: Increasing the Need for Prevention and Access. CDC. Volume 17, August 13, 2020. https://www.cdc.gov/pcd/ issues/2020/20_0266.htm). Accessed October 26, 2020. 3. Agency for Healthcare Research and Quality, Patient Safety Network. COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care. https://psnet.ahrq. gov/primer/covid-19-and-dentistry-challenges-and-opportunities-providing-safe-care. Published August 31, 2020. Accessed October 26, 2020. 4. Booth J. Will COVID-19 push orthodontics further into the digital space? https://coronavirus.dental-tribune.com/news/ will-covid-19-push-orthodontics-further-into-the-digitalspace/. Dental Tribune News. Published May 29, 2020. Accessed October 26, 2020. 5. Henry Schein Dental. Teledentistry. https://www.henryschein.eu/medpod. Accessed October 26, 2020. 6. American Association of Orthodontics. Office Operations during COVID-19. https://www1.aaoinfo.org/covid-19/ office-operations-during-covid-19/. Accessed October 26, 2020. 7. Burhardt L, Livas C, Kerdijk W, van der Meer WJ, Ren Y. Treatment comfort, time perception, and preference for conventional and digital impression techniques: a comparative study in young patients. Am J Orthod Dentofac Orthop. 2016;150(2):261–267. 8. Rossini G, Parrini S, Castroflorio T, Deregivus A, Debermardi CL. Diagnostic accuracy and measurement sensitivity of digital models for orthodontic purposes: a systematic review. Am J Orthod Dentofacial Orthop. 2016;149(2):161–170. 9. Harrell R. Intraoral Scanning in Orthodontic Practice. Decisions in Dentistry. September 11, 2018. https://decisionsindentistry.com/article/intraoral-scanning-orthodonticpractice/. Accessed October 26, 2020. 10. American Academy of Oral and Maxillofacial Radiology. Clinical recommendations regarding use of cone beam computed tomography in orthodontics. Position statement by the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116(2):238-257. 11. Groth C. 3D Printing and Efficiency: Eliminate Lost Retainer Visits from Your Practice. American Association of Orthodontists. [website]. https://www1.aaoinfo.org/3d-printingand-efficiency-eliminate-lost-retainer-visits-from-yourpractice/. Accessed October 26, 2020.

Orthodontic practice 31

TECHNOLOGY

offices, digital workflow works in tandem with healthy goals, saving time in the chair, and allowing more time between visits. The analog workflow is not ideal during this time because it amplifies current capacity burdens and reduces clinical certainty.

TECHNOLOGY

From analog to digital — keeping treatment on track during the COVID-19 crisis Dr. Regina Blevins discusses technologies that cater to the needs of the contemporary patient

y practice began its journey from analog to digital before the COVID-19 crisis, and since then, it has become even more apparent that digital tools and applications are imperative to keeping the orthodontic office running in both good and challenging times. From digital scanning tools to virtual aligner fit assessments, to virtual consultations, patients want efficient treatment more quickly and conveniently — and in COVID19 times (when I am writing this article), if patients can avoid in-office appointments, they are grateful for the technology-focused practice that can help them achieve many of their orthodontic appointment goals from the comfort of their homes. Tools that keep patients’ treatment moving in a positive direction are especially valuable. Keeping aligners on track and wellfitting became especially challenging during the 2½ months that my office was closed during the COVID-19 shut down, and now as the office reopens, tele-orthodontic appointments are here to stay. Whether in the office or at home, some bad habits never change — some patients are not as compliant in wearing their aligners as recommended, resulting in unseating and slowing of treatment. Aligner manufacturer ClearCorrect notes, “Compliance is the most common reason things go off track during treatment.” Reasons for this include lack of education on the importance of regular aligner-wear, embarrassment regarding wearing the aligners in public, and forgetfulness.1 Solutions to this problem are verification and accountability; if patients know that they will be monitored and accountable for their

Figure 1A: Deborah – Initial extraoral and intraoral photos

aligner wear, they will be more motivated to comply. While patients still want positive feedback for their aligner wear, they also are appreciative of fewer appointments during the course of treatment, and I have found an easy and technology-friendly solution to accountability — a high-frequency vibration (HFV)

Regina Blevins, DDS, started her career in dentistry in 1980 as a dental hygiene graduate of C.S. Mott Community College. She attended the University of Michigan, where she received her degree in dentistry. Her appreciation and love for the fine art of the cosmetic side of dentistry led her to pursue her orthodontic graduate training at the University of Minnesota, where she received her Master of Science and a certificate in orthodontics. Dr. Blevins enjoys staying up to date on the latest developments in orthodontics by maintaining a rigorous continuing education schedule and by following current orthodontic research. National speaking events on behalf of Invisalign® and Align Technology are a passion for Dr. Blevins. She is a member and past president of the Minnesota Association of Orthodontics, a Diamond Plus® Invisalign Provider, a Damon® System Premier Provider, and an Align Technology Master Faculty member. She also is an adjunct professor at the University of Minnesota. When she is out of the office, Dr. Blevins enjoys living an active lifestyle and spending time with her husband, Tom, and their four children, Noah, Rachel, Lucy, and Will. Disclosure: Dr. Blevins did not receive financial compensation for this article.

32 Orthodontic practice

device from Propel Orthodontics the patient uses for 5 minutes each night. Articles have reported that HFV facilitates aligner seating, pain reduction, and acceleration of tooth movement.2,3 And one of the most encouraging parts of this process is that patients can download an app that tracks their device usage and shares that information with the orthodontist so that we can virtually verify the patients’ progress and offer the appropriate positive feedback. The following patients achieved their orthodontic goals quickly and efficiently with virtual visits, clear aligners, and HFV.

Case report No. 1: Deborah (Figures 1-3) This 54-year-old female arrived at my office with the request of having a nice smile Volume 11 Number 6

Case report No. 2: Thomas (Figures 4-7) This 55-year-old male was diagnosed with the following issues: • Skeletal and dental Class I • Deep bite • Lower crowding • Abfraction • Attrition

He is a physician and became concerned when his general dentist pointed out that his bite was causing chipping and wear on his front teeth. At our consultation, he shared that he would need post-orthodontic anterior restorative treatment. Due to his busy clinic schedule, he requested the least amount and the most efficient appointments possible. In order to reach our clinical goals of arch

Figure 1B: Deborah – Initial panoramic and lateral ceph X-rays

Figure 1C: Deborah – Cephalometric data

Figure 2: Deborah – 12 months’ extraoral and intraoral photos Volume 11 Number 6

Figure 3: Deborah – Before and after (left) and final smile (right) Orthodontic practice 33

TECHNOLOGY

in time for her son’s wedding. She had undergone orthodontic treatment as a child and was missing teeth Nos. 5, 12, 21, 28, and her third molars. Another orthodontic office had told her that it would take 2 years and double jaw surgery to achieve her goal. The orthodontist had quoted a significantly higher fee, plus the cost of the surgery. Deborah’s diagnosis included the following issues: • Class III skeletal relationship • Class III dental relationship • Protrusive mandible • Narrow maxilla • Localized anterior crossbite • Flat lip profile • Anterior open bite • Moderate U/L crowding • Recession on tooth No. 9 and lower anterior teeth Treatment to achieve Deborah’s desired smile required arch development, broadening of the smile, improved overbite and overjet, and resolution of crowding. We determined that all of her goals could be met using Invisalign® clear aligners, Class III elastics and mandibular dental distalization, IPR, and Propel’s VPro™ with 5-day changes. She came into the office for five active treatment visits and sent in photos monthly to monitor her progress. Her goals were met in 12 months with no increase in recession. I was very proud to have her beautiful smile completed in time for her son’s special day. This would not have been possible without switching out her Invisalign trays every 5 days and using the VPro.

TECHNOLOGY development, broadening of his smile, reduction of his deep bite, and improvement of his overjet, we recommended using Invisalign clear aligners, IPR, and Propel’s VPro with 3-day tray changes. The patient completed treatment in 5 months with four active treatment visits. After treatment completion, he wears full-coverage retainers to protect his teeth from further wear due to nighttime grinding.

Case report No. 3: Markara (Figures 8-10)

Figure 4A: Thomas – Initial extraoral and intraoral photos

Figure 4B: Thomas – Initial panoramic and lateral ceph X-rays

Figure 6: Thomas – 3 months’ progress extraoral and intraoral photos 34 Orthodontic practice

This 33-year-old male wanted to correct his underbite. He presented with a Class III anterior crossbite with the following issues: • Negative overjet • Slight maxillary crowding • Moderate bone loss • Mandibular spacing • Evident maxillary anterior tooth wear We discussed the possible need for orthognathic surgery, but he wanted a nonsurgical treatment plan. The nonsurgical plan included Invisalign® clear aligners, interproximal enamel reduction, Class III elastics

Figure 5: Thomas – ClinCheck®

Figure 7: Thomas – 5 months’ progress extraoral and intraoral photos Volume 11 Number 6

TECHNOLOGY

for his bite correction, and lower lingual disclussion attachments along with Propel’s VPro usage and 5-day changes. This treatment hoped to address his arch development, improve his overbite and correct his crossbite, improve his alignment, resolve his upper crowding and lower spacing, and generally enhance his esthetics. The amazing part of this patient’s treatment was that after delivery of his aligners and with interruption of in-office visits due to the COVID-19 crisis, he nearly completed treatment using 60 stages in just over 12 months, with only four office visits to date. This result was not possible without vibration. Initial delivery of aligners was October 2019, an in-office progress assessment in February, then again in June (after COVID-19 visit delay), and September 2020, when he returned for his scan. Markara’s treatment was a “light-bulb moment” for me. He didn’t want to stop his treatment due to the COVID-19 closure, so with virtual visits, compliance, and the aligner seating technology that kept his aligners on track and seated, he achieved his goal. I could trust

Figure 8A: Markara – Initial extraoral and intraoral photos

Figure 8B: Markara – Initial panoramic and lateral ceph X-rays

Figure 9: Markara – ClinCheck

that everything would stay on track during quarantine because I knew he was using a VPro; it made the process stress-free. Transitioning from an analog to a digital practice and implementing virtual visits has been an eye-opening experience. All of our technology changes saved time for us, and allowed patients to stay home and safe when our office was closed without much interruption to their treatment. And knowing that the aligners we gave to patients would be seated properly and that teeth would continue to move in the correct direction, with the help of VPro, were extremely beneficial during this time. OP

REFERENCES 1. Somers JL. Non-Compliant Patients & Tips for Keeping Your Patient on Track. ClearCorrect Help Center. https:// support.clearcorrect.com/hc/en-us/articles/204801807Non-Compliant-Patients-Tips-for-Keeping-Your-Patienton-Track-. Accessed October 5, 2020. 2. Shipley T, Farouk K, El-Bialy T. Effect of high-frequency vibration on orthodontic tooth movement and bone density. J Orthod Sci. 2019;8:15.

Figure 10: Markara – 12 months’ progress extraoral and intraoral photos Volume 11 Number 6

3. Alansari S, Atique MI, Gomez JP, et al. The effects of brief daily vibration on clear aligner orthodontic treatment. Journal of the World Federation of Orthodontists. 2018;7(4):134-140.

Orthodontic practice 35

SERVICE PROFILE

Orthodontic practice consolidation trends accelerate — rewards and risks abound Chip Fichtner highlights future risk or value created in “silent partner” practices

f you have a larger orthodontic practice, you have already been contacted by several of the dozens of Invisible Dental Support Organizations (IDSOs) interested in acquiring your practice. If not, you will be shortly. The reality is that you will either join an IDSO or compete with many in due time. They are armed with size and resources that you will either benefit from or suffer against. Over the past 5 years, the consolidation of orthodontic practices has grown dramatically. Some of the groups interested in your practice will be ortho only, some will be ortho/ pedo, and there are many multi-specialty groups interested in adding orthodontic practices to their portfolios. These groups may be regional or operate coast to coast. Each potential partner is different in structure, levels of support, and most importantly, future risk or value created for their partner practices. You should at least understand the value of your practice in one of these transactions whether you are interested in pursuing a transaction or not. Your competitors are. Large Practice Sales (LPS) has completed hundreds of millions of dollars of orthodontic practice transactions with over $50 million in Q3 2020 alone. Values, even during the COVID era, are similar to 2019 with some exceptional practices still achieving values of over 3X collections. LPS’ primary focus has been pairing our doctor clients with IDSOs. These groups believe in the local brand power of the doctor and are thus “silent partners” in supporting the growth of their partner practices. In a typical IDSO transaction, the doctor sells between 60% and 90% of his/her practice for cash upfront and retains ownership of the balance in either the practice, the new partner, or both. The doctor remains leading the practice under his/her brand, team, and strategy for years or decades. The goal of the partnership is to increase the value of the retained ownership for both the doctor and IDSO partner and to capitalize Chip Fichtner is the founder of Large Practice Sales, which specializes in Invisible DSO transactions for large practices of all specialties. The company has completed more than $100 million of transactions in the past 6 months. Learn more at www.findmyorthodonticidso.com.

36 Orthodontic practice

on their combined size at a higher multiple in the future. IDSOs seek to partner with successful, larger practices, which can benefit from the IDSOs multiple resources to reduce cost and drive growth. Resources may include lower supplies costs (half the cost on clear aligners, for example) and sophisticated in-house marketing resources for increased new-patient generation. The IDSOs come in all shapes and sizes, and some were literally formed last month. Others have been partnering with ortho practices for decades. There are various strategies for achieving the highest values, but the best by far is to have multiple suitors for your practice. Doctors not only get several bidders driving up value, but also have a wider range of prospective partners from which to choose. An IDSO partnership is a marriage, not a onenight stand. The highest value upfront is not necessarily the best long-term choice. If you have a great practice, an experienced advisor will lead you to a heated bidding war and the right partner. There are a number of critical factors in choosing an IDSO partner, which include its history, its future, and importantly, its financial sponsors’ track record. While private equity (PE) groups have been active in dentistry for decades, there is an increased interest in specialty practices from family offices and small business investment companies

(SBICs). Over $250 million of the LPS transactions in 2020 will be with non-PE sponsored groups, a 500% increase over 2019. One element driving the explosion of doctors interested in the IDSO concept is the potential elimination of the long-term capital gains tax treatment. This could potentially double the doctor’s 2021 and 2022 tax bill and reduce net after-tax proceeds by millions of dollars in many practices. Doctors hoping for rapid growth in 2021/2022 could work harder and longer and yet net millions less due to taxes. The orthodontic industry is changing rapidly, not only at the practice level. Wise doctors will today go through the confidential and free process to understand the potential value of their practice to an IDSO partner. Without understanding the real market value of their practice, doctors cannot make an educated decision to consider an IDSO transaction or not. And in many cases, doctors may stop selling parts of their practices to associates at fractions of collections versus multiples of collections. Once doctors decide to pursue an IDSO transaction, they will then need to understand the risks and rewards of the multiple partner choices that they will hopefully be presented by an experienced advisor. Doctors can qualify for a confidential and free valuation of their practice with an IDSO by contacting LPS to learn more. OP Volume 11 Number 6

Silent Partners are Eager to Invest in Large Orthodontic Groups With Collections Over $1,500,000 In 2020, LPS will advise larger practices on over $400,000,000 of transactions with Invisible Dental Support Organizations (IDSO). Even with the impact of Covid-19, we are still achieving record values for clients across the country.

Recent Orthodontic Practice Transactions One-Doctor Practices:

4.3X Collections (During Covid) 4.4X Collections (During Covid) 4.5X Collections (During Covid) 2.1X Collections (During Covid)

Two-Doctor Practices: Three-Doctor Practices: 1.7X Collections 2.1X Collections 3.4X Collections

2.2X Collections 3.0X Collections

SILENT PARTNERS HELP YOU TO GROW BIGGER, BETTER, FASTER AND MORE PROFITABLY

To schedule a confidential call, and get a FREE practice value analysis, call 844-734-8533 or Email OPUS@LargePracticeSales.com

SERVICE PROFILE

Next-level strategies to protect your orthodontic practice Bre Cohen discusses preparing your practice for unforeseen risks

t’s safe to say COVID-19 has hit the dental industry hard. Having to close doors for months can be a big blow to any practice; and while traditional insurance is great, chances are it didn’t cover your business interruption during this pandemic. So, how will you handle the next adverse event? That thought makes many cringe and for good reason. However, entrepreneurial dental practices are finding ways to protect their business risks that fall outside of traditional insurance through Enterprise Risk Management programs like those from Strategic Risk Alternatives. These programs are nothing new; they’ve been utilized by Fortune 500 Companies for decades. Strategic Risk Alternatives saw a need in the market to make these programs available to small-tomidsize companies and did just that. Their Enterprise Risk Management program serves as a lifeline to successful companies going through a difficult time and allows them to be proactive instead of reactive in protecting their practices.

How does it work? Much like a 401(k) helps you use taxadvantaged dollars to prepare for retirement, the Enterprise Risk Management program by Strategic Risk Alternatives helps you use taxadvantaged dollars to prepare for unforeseen risk. It utilizes US Tax Code 831(b), which Bre Cohen is the Business Development and Marketing Manager for Strategic Risk Alternatives.

38 Orthodontic practice

The Enterprise Risk Management program serves as a lifeline to successful companies going through a difficult time and allows them to be proactive in protecting their practice instead of reactive. helps businesses set tax-deferred income aside for risks that fall outside of traditional insurance. This includes COVID-19-type disruptions as well as other cash flow disruptions. Examples follow: • Contingent business interruption • Political risk • Supply chain interruption • Key employee loss/critical illness • Payroll protection • and more … Strategic Risk Alternatives serves as 831(b) plan administrators to help you identify risks, create a customized plan, manage transactions, monitor compliance, prepare paperwork, and other ongoing client services to ensure you are prepared for the next unforeseen risk. “When COVID-19 hit, dental practices currently utilizing our program were able to recoup cash flow losses in a matter of days through their 831(b). If you own a successful practice, consider the advantages of setting pre-taxed dollars aside for unforeseen risks — big or small,” says Bill McKernan, President of Business Development at Strategic Risk Alternatives. “Unforeseen risk is real, and it happens every single day. It could be something as big as the next pandemic or as small as being out of work for a short period of time due to a medical issue. With our

program, you’re able to make your practice whole again and rest a little easier at night.”

Other programs for dental practices Strategic Risk Alternatives also offers a Dental Protection Plan program to help practices warranty their work. With a clearly defined warranty, you can increase patient retention and use pre-tax dollars to pay for rework. Strategic Risk Alternatives works with the practice to custom-design a defined warranty program based on their individual practice needs. Through this program, the practice would set aside money from transactions and put it in their 831(b) Dental Protection Plan to fund warranties for their work. Depending on the terms the dentist sets, the warranty may require a patient to come back once a year to check the work and honor the warranty. This creates customer peace of mind, retention, and loyalty. In addition, you are building a war chest to pay for any issues that do arise. Interested in learning more? Contact Strategic Risk Alternatives by visiting their website, strategicriskalternatives.com/DPP, or calling Bill or Ed at (208) 424-2249 for a free assessment and to learn more about protecting what you have worked so hard to build. OP Volume 11 Number 6

MITIGATE RISK THROUGH TAX ADVANTAGED DOLLARS

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PROTECT YOUR PRACTICE WITH NE X T LEVEL STRATEGIES info@dentistprotection.com (208)424-2249 www.dentistprotection.com

INDUSTRY NEWS Gaidge™ LLC announces Gaidge Executive Membership Program for orthodontists

Hinman Dental Meeting announces retirement of longtime Executive Director Sylvia Ratchford

Gaidge™ LLC announced a new program built to provide orthodontists with the most robust version of Gaidge, which includes the comprehensive analytics software platform, new financial tools, quarterly business reviews, and personalized coaching. The program was designed for orthodontists who desire quick and easy access to their practice and financial performance while saving time and increasing visibility to critical business drivers. The company recently built two new add-on financial modules that complement the analytics platform — the Overhead Expense Tracker™ and Practice Projections™ — both of which will be included for program subscribers. The Gaidge Executive membership provides an endto-end view of practice performance and includes the full suite of Gaidge software modules plus the expert guidance from impact360 practice management consultants during ongoing quarterly business reviews. For more information, email info@gaidge.com, or phone 800-287-3396.

The Thomas P. Hinman Dental Meeting announced that its longtime Executive Director, Sylvia Ratchford, will retire in May 2021, following her 25th Hinman Dental Meeting. She will continue to serve in the role in some capacity through May alongside her successor, Annette Sullivan, who has been named Incoming Executive Director. Sullivan brings more than 20 years of experience in the hospitality Sylvia Ratchford and meeting planning industry. Her most recent position was with the Georgia World Congress Center where she was a member of the national convention sales team. In addition, Hinman has promoted Lynn Leidel to Director of Meetings and Education. She will assume additional responsibilities that will aid in the transitioning of executive directors. Leidel has been with Hinman for more than 16 years, most recently as Senior Meetings and Education Manager. For additional information, visit Hinman.org, or contact Hinman at 404-231-1663.

Ortho2 announces inVisit Ortho2, LLC, announces inVisit, a branded app for orthodontists to conduct virtual appointments with current and prospective patients. inVisit is available regardless of practice management software. inVisit allows orthodontists to add a link to their website, so patients can begin their treatment journey from the comfort of their own home. The intuitive process guides existing and prospective patients through taking a series of photos and filling out a questionnaire customized by the practice. Orthodontists can then review submitted cases to determine the next course of treatment or contact a prospective patient to decide if treatment is necessary. The personalized management dashboard gives orthodontists complete, secured access to cases and allows them to stay connected with patients through email or text in the communication center. For more information, visit www.getinvisit.com.

40 Orthodontic practice

3M Oral Care shares two new digital applications with orthodontists 3M is launching one app, the 3M™ Tx Selector, and piloting another company’s app, the Grin Remote Monitoring Platform, to meet industry challenges. Orthodontists and treatment coordinators can build excitement for a treatment diagnosis with the 3M Tx Selector, which allows patients to superimpose various 3M orthodontic appliances on a live image of themselves. The app acts as a virtual typodont using face-tracking technology for a natural and realistic experience. This helps clinicians present treatment options and discuss lifestyle implications of specific treatment choices. Orthodontists will be able to download the 3M Tx Selector from the Apple Store beginning in early fourth quarter. The app operates on Apple iPad Pro version 2018 or newer. The Grin Remote Monitoring Platform, created by Grin, allows orthodontists to supplement in-office visits with virtual check-ins using the Grin App and the Grin Scope, an easy-to-use smartphone device that enables patients to upload self-scans. Through Grin Remote Monitoring, orthodontists can obtain a high-definition view of the patients’ mouth and monitor their progress using the Grin Doctor Portal. 3M will distribute the Grin Remote Monitoring Platform, offering it to doctors who join before February 2021. 3M is offering a limited number to qualified doctors free of charge for 6 months. To learn more, contact a 3M representative at 800-423-4588.

Volume 11 Number 6

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• Perfect for aligners and orthodontics. • Available CLEAR, WHITE, TOOTH. • Bondable with all adhesives. • In packs of 10 bondable buttons. 1 pack = 10 pcs $ 17.00 as low as 5 packs= 50 pcs $ 75.00 25 10 packs=100 pcs $125.00

compare $300.00

CHOMPERS ROUND or SQUARE ALIGNER SEATERS • For seating of all aligners. • SURFACE GRIPPERS for maximum pressure. • In bags of 20 pieces same or assorted colors. CHOMPERS ROUND CHOMPERS SQUARE 1 mm Point Contact 8 mm Power Contact

Color Red Green Blue Yellow Orange Purple Black White Pink Turquoise Assorted

Round 710-001-20 710-002-20 710-004-20 710-006-20 710-007-20 710-008-20 710-009-20 710-010-20 710-012-20 710-013-20 710-050-20

Square 710-201-20 710-202-20 710-204-20 710-206-20 710-207-20 710-208-20 710-209-20 710-210-20 710-212-20 710-213-20 710-250-20

Pack of 20 asst colors

Pack of 20 same color

BLUE GEL ETCH 12 gm SYRINGE

• Gel stays where placed. as low as • Easily washes off without any stain. 00 • Best selling etch since 1985! each

1 bag = 20 pcs $ 8.00 10 bags= 200 pcs $ 70.00 50 bags=1000 pcs $300.00 100 bags=2000 pcs $500.00

1 Syringe $ 5.00 10 Syringes $ 45.00 25 Syringes $100.00 compare $9.00

TIE-ON ROTATION WEDGES

compare $45.00

Available colors: Clear 650-327 White 640-327 Tooth Color 650-427

ADAPTAWIRE 60” SPOOLS

as low as 00 $

20 each

1 to 5 Spools $26.00 each 6 to 9 Spools $23.00 each 10 + Spools $20.00 each assort for quantity price

Cat No 010”x.028” 713-644

compare $55.00

• Choose from 10 beautiful colors. • Unbreakable with perfect latch. • In packs of 10 with patient label.

1 pack = 10 $ 5.00 50¢ each

as low as 10 packs=100 $ 47.00 47¢ each

¢ 40each

30 packs=300$120.00 40¢ each

assort colors for quantity price

• Perfect rotation and proximal alignment. • Easily done and needs only 1 or 2 visits. • Available in GRAY or CLEAR. • In packs of 10. as low as Technique in catalog page 42 GRAY 618-982 20 CLEAR 618-992 each 1 pack = 10 Wedges $14.00 5 packs= 50 Wedges $65.00 10 packs=100 Wedges $120.00

assort colors for quantity price

compare $24.00

Cat No 016”x.022” 713-642

AdaptaWire Floss Tied See our catalog pages 12-13 for other techniques

SUPERB RETAINER CASES

Cat No 557-617

assort for quantity price

40¢ each 35¢ each 30¢ each 25¢ each

assort for quantity price

compare $12.00

1each

• DEAD SOFT .016”x.022” or .010”x.028”. • Perfect lingual wire in 20 seconds!

as low as

¢ 25each

CLEAR COMPOSITE 5 mm BONDABLE BUTTONS

Special Cat No 831-099 100 Assorted Cases $45.00

compare 90¢

Purple Fire Orange Mega Pink Tangerine Red Green Blue Black Turquoise Cranberry

831-011 831-013 831-014 831-015 831-033 831-044 831-055 831-066 831-069 831-070