Orthodontic Practice US Winter 2021 Vol 12 No 4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews Winter 2021 – Vol 12 No 4 • orthopracticeus.com

PROMOTING EXCELLENCE IN ORTHODONTICS Connecting the dots and drawing the lines to success Suzanne Wilson

Amy Jackson, DDS, MS

The five best dental job interview questions to ask to build an outstanding team Ali Oromchian, JD, LLM

Software special section

TMD-occlusionorthodontic connection revisited

Helping Orthodontists Run Their Businesses Better

Practice spotlight

Drs. Barry Glassman, Don Malizia, and Daniele Manfredini

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EDITORIAL ADVISORS

Welcome to 2022 and goodbye to 2021!

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 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 Laurence Jerrold, DDS, JD, ABO Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD 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 Bradford N. Edgren, DDS, MS, FACD Fred Stewart Feld, DMD Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA

021. A year in which we thought we had gotten a grip on the COVID-19 pandemic. Businesses were coming back, vaccines were rolling out of the manufacturing facilities and going into 200 million-plus arms. Life was looking good, and the light at the end of the tunnel was not an oncoming freight train. That glimmer of hope though turned a bit darker as the new delta variant and now the omicron variant worked their way through the population as this is being written. However, 2022 is looking bright. Never has more of the population received vaccines and boosters as now. Wages are up, Ricky E. Harrell, DMD, MA and some sense of normalcy, however fleeting, is on the horizon. Orthodontics is booming along with the exponential injection of technology into our treatment-delivery systems. Much of the interjection of technology into orthodontics in the last couple of years has been pandemic-driven. Remote dental monitoring, fixed appliances that basically are designed with the tooth movements built into the system, 3D-printed __________ (you fill in the blank), telehealth, virtual appointments, increased applications of CBCT imaging, 3D surgical treatment planning and fixation fabrication, improvements in aligner technology, and increased possibilities of orthodontic/orthopedic movements are all technologies that make our practice lives easier, more productive, and eventually, more profitable while delivering superior clinical results. While some may lament that “orthodontics is not what it used to be,” others have grabbed onto the new technologies and are very thankful that “orthodontics is not what it used to be.” As a specialty, we are fortunate to have come out of 2021 with a $12 billion national expenditure on orthodontics. Currently, there are almost 12,000 orthodontic practitioners in the United States. If one looks at output per provider, the number comes to an average of more than $1 million per practitioner. That is not a bad day’s work. I would ask that each member of the reading audience take a few moments and not only reflect back on the past year, but also gaze into the future and ask the question, “What if?” If we think the past couple of years have been difficult, let’s think back on what some of the orthodontic greats such as Drs. Angle, Case, Hawley, Strang, etc., faced. They endured World War I, the Spanish flu epidemic, the Great Depression, World War II, and the Korean War. Their suffering makes enduring COVID-19 seem like a walk in the park. And yet they endured and prospered, paving the way for an easier path for future generations of orthodontists who followed in their footsteps. Our future is bright. Never have more sought orthodontic treatment, never has treatment been easier and more convenient to deliver, and never has there been a job market better for young practitioners. Let’s not dwell on the past but instead, look forward to what is possible in our future. We should all be thankful to be members of one of the best professions in the world. Here’s to all of you sharing this journey. Cheers to all and a bright 2022 for everyone!

Justin D. Moody, DDS, DABOI, DICOI Lisa Moler (Publisher)

Dr. Ricky E. Harrell

Mali Schantz-Feld, MA, CDE (Managing Editor) Lou Shuman, DMD, CAGS

© MedMark, LLC 2021. 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.

Ricky E. 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. He 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 12 Number 4

Orthodontic practice 1

INTRODUCTION

Winter 2021 - Volume 12 Number 4

TABLE OF CONTENTS

Practice spotlight Amy Jackson, DDS, MS

Publisher’s perspective With a gladiator’s determination Lisa Moler, Founder/Publisher, MedMark Media................................6

Fulfilling orthodontic and entrepreneurial dreams

Clinical Examining the dental canon Drs. Francesca Scilla Smith and Larry W. White discuss centric occlusion, centric relation, and the role of canines ....................................................... 15

Case study

Cover story

Pushing the limits Dr. Jeffrey M. Heinz illustrates a clinical case study treated with Spark™ Clear Aligners........................................... 20

Connecting the dots and drawing the lines to success

Suzanne Wilson, Chief Operating Officer of Gaidge, discusses the importance of monitoring performance, analyzing practice metrics, and making decisions

ON THE COVER Cover image of Drs. Hilda Oweisy, Ray Rafetto, and Mark Fiss courtesy of Alpine and Rafetto Orthodontics and Gaidge. Article begins on page 12.

2 Orthodontic practice

Volume 12 Number 4

Take the next steps in running a better business Visit Gaidge.com or Call 800.287.3396

TABLE OF CONTENTS Research study Practitioner perceptions of the link between orthodontics and temporomandibular disorders (TMD): a survey of dentists, orthodontists, and oral and maxillofacial surgeons Drs. Chadwick Augusty, Shadbeh Taghizadeh, Vincent Graves, John Stockstill, and Courtney McCracken (biostatistics) study the perceived association between orthodontics and TMD...............................................22

Continuing education TMD-occlusion-orthodontic connection revisited

Drs. Barry Glassman, Don Malizia, and Daniele Manfredini discuss various viewpoints on occlusion, pain, and dysfunction

Continuing education The five best dental job interview questions to ask — and two to avoid — to build an outstanding team Ali Oromchian, JD, LLM, offers suggestions to find out about your potential new hires without legal concerns.........................................33

Special section DIBS AI by OrthoSelect A New Standard in Digital IDB.........38

tops Platform One.....................39

Product view Orthodontists asked, and LightForce listened New invention eases emergency appointments.................................. 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

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

4 Orthodontic practice

Volume 12 Number 4

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PUBLISHER’S PERSPECTIVE

With a gladiator’s determination

“I

am a gladiator! Winter is my season. This is my time. I will not be denied. … I will add more value than anyone else. … Give me your fears, give me your limitations, and I’ll give you results. I am a gladiator!” — Tony Robbins Welcome to our winter issue! The above inspirational message by Tony Robbins sums up how our MedMark team approaches your practices, your patients, and your future. Our goal is to add more value than anyone else. Through our publications, we inform you about trends in dentistry and provide articles that can help you grow clinically and professionally. Our CE articles educate you, and our webinars and podcasts bring amazing opportunities for growth. Our marketing expertise Lisa Moler spreads the word to audiences that are searching for insights Founder/Publisher, MedMark Media from leaders like you. This is your time, and we want to give you results! Throughout 2021, you have pushed past fears and muscled through limitations. We were courageous, creative, tenacious, and bold. Our focus was on not only getting back to normal, but also setting and surpassing new goals. We have heard of many triumphs since the beginning of 2021 — not just reopenings, but how you grew this year — with new technologies and techniques that improved patient care and expanded your capabilities. We are honored and thrilled to be a part of your continuing process. Our cover story by Suzanne Wilson, Chief Operating Officer of Gaidge, shows how “connecting the dots” of your business by monitoring performance and analyzing practice metrics can lead to better decision making for the whole practice. Our CE by Drs. Barry Glassman, Don Malizia, and Daniele Manfredini offers various viewpoints on TMD, occlusion, and the orthodontic connection. As the article points out, “This seemingly simple concept of occlusion has evoked significant controversy.” Another CE by Ali Oromchian, JD, LLM, shows how to avoid legal concerns during job interviews in “The five best dental job interview questions to ask — and two to avoid — to build an outstanding team.” Our Practice Spotlight features Dr. Amy Jackson who is fulfilling her orthodontic and entrepreneurial dreams. Read about her solution for retainer- and retention-related emergencies. This coming year is going to be exciting. We are renewed, rejuvenated, revitalized, and ready to take the dental arena by storm. Winter is OUR season, and we are picking up the momentum for 2022 — ready to face the new year with a gladiator’s determination to empower our dental community! To your best success, Lisa Moler Founder/Publisher MedMark Media

Published by

PUBLISHER Lisa Moler lmoler@medmarkmedia.com DIRECTOR OF OPERATIONS Don Gardner don@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA, CDE mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com NATIONAL ACCOUNT MANAGER Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING & DIGITAL STRATEGY Amzi Koury amzi@medmarkmedia.com WEBMASTER Mike Campbell webmaster@medmarkmedia.com EMEDIA COORDINATOR Michelle Britzius emedia@medmarkmedia.com SOCIAL MEDIA & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com SALES ASSISTANT/CLIENT SERVICES Melissa Minnick melissa@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.medmarkmedia.com www.orthopracticeus.com SUBSCRIPTION RATES 1 year (4 issues) $149 Subscribe at https://orthopracticeus.com/subscribe/

6 Orthodontic practice

Volume 12 Number 4

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PRACTICE SPOTLIGHT

Amy Jackson, DDS, MS Fulfilling orthodontic and entrepreneurial dreams What can you tell us about your background? I was born and raised in Texas, and like any true Texan, my dreams were big. As the oldest of two, I saw my parents work tirelessly, and they instilled in me the core values of family and hard work. It was these very values that drove me to become only the second person in my father’s family to pursue a higher education. I attended Baylor University for my undergraduate degree where I studied science and was a cheerleader. For my postgraduate studies, I attended the University of Texas Health Science Centers in Houston for my dental training and San Antonio for my orthodontic residency.

Is your practice limited solely to orthodontics, or do you practice other types of dentistry? I believe no practice is ever limited to just orthodontics. As orthodontists, we must perform as entrepreneurs, CEOs, managers, negotiators, and strong, active members of our communities. These experiences gave me the skills to fulfill one of my dreams: to create a new company that betters our industry and improves the lives of doctors and patients. With these values in mind, I founded Retainers For Life®.

Why did you decide to focus on orthodontics? During my junior year in dental school, I worked in a lab that studied the transcription factor PAX9, which is critical for patterning and morphogenesis of teeth and taste buds. In the lab, we worked with families, taking buccal swabs that allowed for sequencing and studying of this missing signaling factor leading to tooth agenesis. When a patient is missing teeth, it affects both function and esthetics, and I was working with multiple families affected by this generationally. During my journey with these families, I witnessed how orthodontists quarterback treatment plans and guide esthetic outcomes. This was the first time in my journey that I really understood the importance of orthodontics in the dental profession and felt drawn to a specialty with the ability to help these individuals and families. 8 Orthodontic practice

Dr. Amy Jackson treating a patient

Do your patients come through referrals? Yes, most of our patients come through direct in-office referrals from patients and family members in combination with referrals from colleagues in the dental profession. I take pride in the relationships I have with our families; they are our livelihood. This is precisely why I believe we need to continue care in the retention phase of treatment once active treatment is completed. Volume 12 Number 4

I have been practicing orthodontics for 16 years. For diagnosis and treatment planning, I use the Kodak 9500 Cone Beam 3D System, and Robbins and Rouse Global Diagnosis. I use a variety of different aligner systems, Forestadent BioQuick® brackets, Pitts21® philosophy and system, iTero® scanning, and of course, Retainers For Life to continue orthodontic care through the retention phase of treatment.

Who has inspired you? Some of the people who inspired me professionally are Drs. Vincent Kokich, William Robbins, Jeffrey Rouse, Olin Vaughan, Ronald Roncone, and Tom Pitts, who is finding time to teach the next generation. I also find inspiration in my resident classmates making positive differences in their local communities; those individuals are superheroes to me. My biggest personal inspirations are my family, who support me and my dreams, and working moms because I know how challenging that can be.

What is the most satisfying aspect of your practice? The most satisfying aspects of my practice are the interactions with patients and their families and seeing positive treatment outcomes improve someone’s self-worth and confidence. I also hold the pro bono work I do for fallen firefighter and military families close to my heart. I feel as orthodontists, we are incredibly

lucky to have such a rewarding and satisfying job.

Professionally, what are you most proud of? I’m a problem solver. When I see a problem starting to become a pattern, I get excited at the prospect of investigating the problem and providing a solution to fix it. One such solution was Retainers For Life when I started it inside my practice. I was experiencing firsthand the daily headaches retainerand retention-related emergencies were causing. I’m proud to say with Retainers For Life, I solved that problem inside my practice, fueling my inner geek.

What do you think is unique about your practice? Because we want to be the best part of the patient’s day, we listen and communicate. We also offer the most advanced technologies, but what really makes us shine is how we continue providing orthodontic

Dr. Amy Jackson with the South Texas Orthodontics staff Volume 12 Number 4

Orthodontic practice 9

PRACTICE SPOTLIGHT

How long have you been practicing orthodontics, and what systems do you use?

PRACTICE SPOTLIGHT

Top 10 favorites 1. 2. 3. 4. 5.

Retainers For Life® Gaidge impact360 EasyRx® Reliance Lingual Wire: Retainium® 3M™ Unitek™ and Forsus™ Appliance 6. Monobond™ Universal Primer 7. Intraoral scanner 8. Weave: Text-to Pay 9. SureSmile® 10. Aligner therapy Dr. Amy Jackson believes in a good work-life balance. Her priority is to spend time with family and friends

care once active treatment is complete. Ultimately, what we’ve seen by using Retainers For Life, is that our patients never lose touch with us. They enjoy the Amazon-like replacement retainer ordering experience and value (especially the busy moms) the direct-todoor delivery experience.

What would you have been if you didn’t become a dentist? If I hadn’t gone into orthodontics, I would have become an algebra teacher. My love of problem solving, teaching, and inspiring our next generation of humans would have been my Plan B, but I can’t tell you how happy I am that my Plan A worked out!

What has been your biggest challenge?

What are your top tips for maintaining a successful specialty practice?

I believe our industry is facing a huge challenge. Patients are demanding less appointments, more virtual treatment, and they value and want more free time. These convenience factors are why companies like SmileDirectClub™ and Byte experienced success. However, the quality of care suffers when patients are not being seen by doctors. DIY dentistry and orthodontics is dangerous. This is not a passing fad, and orthodontists need to think outside the box to continue to remain relevant.

Never give up the love of learning, and work to improve your skill and knowledge every year. Hire thoughtfully; fire quickly. Work to foster the relationships and morale of your team. Provide excellent customer service and be proactive to solve problems. Celebrate the small wins, and design a unique bonus system every year that targets the key metrics that you want to see improve. Monitor your key performance indicators. Complete your patients’ treatment plans when you say you will, and find a solution to

10 Orthodontic practice

continue providing care into their retention phases of treatment.

What advice would you give to budding orthodontists? Be the best part of the patient’s day. Stop and take stock to appreciate how far you have come, and find time to give back to your community and profession. Never stop learning. Protect your work-life balance, and recognize your professional career is a marathon, not a sprint!

What are your hobbies, and what do you do in your spare time? I make time to volunteer and love going on mission trips with our church. The Special Olympics and National Charity League are very close to my heart. My priority is to spend time with friends and family. I believe strongly in a good work-life balance; that’s not saying I’m good at it, but I’m doing my very best! OP Volume 12 Number 4

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COVER STORY

Connecting the dots and drawing the lines to success Suzanne Wilson, Chief Operating Officer of Gaidge, discusses the importance of monitoring performance, analyzing practice metrics, and making decisions

hile the pandemic continues to be a part of our lives, we now have the rear-view understanding of how this disruption has affected people and industry. We’ve experienced the unexpected high of the pandemic-driven economic spike and more recent leveling. The U.S. economy proved resilient, and we saw growth across the orthodontic industry through the first half of 2021, but during the second half of the year, most practices experienced a leveling or even declines compared to the anomaly of the previous year. The ups and downs facing business owners are fatiguing at best, but in order to thrive, a steadfast and thoughtful approach to managing your practice with business acumen is the key to successfully navigating fluctuations. Enduring in any market, especially long periods of unrest, requires focus and clarity of vision so as not to get worn out or drained from pouring precious resources into activities that don’t provide returns. So how can practice owners connect the dots to better understand the whole picture? As all industries, including orthodontics, continue to progress toward data management and data-driven decision-making, we will discuss what is separating the pioneers from the followers who are working to catch up. Delaware-based Alpine and Rafetto Orthodontics, featured on the cover, has been leveraging business intelligence for the better half of the last decade and continues to stay on the cutting edge of team and practice performance. With 3 locations, 3 doctors, and a team of 40, Alpine and Raffetto Orthodontics have found success using a leadership style of empowerment, education, and regularly setting and managing to goals. How? Well, their secret isn’t really a secret. You’ve likely heard orthodontic experts and

Suzanne Wilson is Chief Operating Officer at Gaidge, the leader in orthodontics business intelligence and practice analytics. A driven operations and marketing leader with over 20 years of experience in technology and medical devices, Wilson is an expert in strategic planning, customer insights, data-driven decision-making, process creation, and brand building. Learn more at www.gaidge.com or email info@gaidge.com.

12 Orthodontic practice

Delaware-based Alpine and Rafetto Orthodontics has been leveraging business intelligence for the better half of the last decade and continues to stay on the cutting edge of team and practice performance. Pictured here are Drs. Ray Rafetto, Hilda Oweisy, and Mark Fiss (left to right)

industry pundits call for better practice data, and how to make better business decisions using all available information. But what sets Alpine and Rafetto apart is its sustainable and consistent systems for monitoring performance, analyzing practice metrics, as well as identifying and developing the key people who can make decisions for the betterment of the practice based on the insights they gain. Does your practice lag behind when it comes to understanding your data? It’s time to reassess how practice data can empower you to make informed decisions and give you the ability to connect the dots, so you can clearly see the full picture of your practice’s potential as well as potential pitfalls. Robust data analysis and data-led decisions are not simply trends. Common sense tells us — and studies show — that practices that adopt data-driven decision-making enjoy a higher level of output and productivity. Specifically, there are some clear examples of why your orthodontic practice should collect better data, and how insights from that data can affect real, positive change in your business.

Better practice data can improve collections While tracking net collections is a mustdo, most practices don’t dive deeply enough to gain a true picture of their financial health. Collections are just one part of the equation, and simply tracking data doesn’t help you understand if there are problems. Putting your data to work by leveraging insights from a grouping of data and putting it in a visual format helps you understand the next steps to take and how to increase your collections. For example, consider the number of no-show patients. This simple metric alone can tell you a lot about opportunities to improve your operations and increase collections. Let’s say you’re already tracking no-shows: Your number of no-show patients makes up approximately 7% of your total appointments, and your average collection per visit is $250. Your business has always tolerated these missed collections and performs just fine otherwise. But look deeper. Volume 12 Number 4

Better practice data can reduce prospective patient attrition Another common metric is new patient flow. If you’re keeping an eye on the number of patients coming through your door, that should be good enough, right? Not quite. Let’s say, in addition to new patients, you begin tracking initial phone calls as “patient adds” to your system. In doing so, you might discover that the number of patients calling to learn more about your practice is only

Gaidge net production versus net collection dashboard

Gaidge between phases observation patients breakdown Volume 12 Number 4

converting to 50% of those who schedule an initial appointment. New patient opportunities are dropping off before they even come into your office, and that’s a major problem relating to your patient acquisition and conversion. This information suggests there may be work to be done on your initial greeting, your intake protocol, marketing, and importantly your availability for new consults. Visibility to this issue is not exactly earth shattering, but note what it can mean for your marketing return on investment, and with a few simple internal fixes, watch that conversion ratio go up. Another metric critical to your success is case acceptance. Many experts consider this to be one of the most important key performance indicators (KPIs) your practice measures. Let’s say out of the 50% of patients who called and came in for a consult, only 60% started treatment with you. By tracking this metric and measuring it against industry benchmarks and other offices like yours, you might see that your case acceptance isn’t exactly up to par. From here, you can now consider possible solutions such as a TC and doctor script or protocol, doubling down on

patient education, offering a greater variety of treatment options, payment options, or perhaps changing your messaging tactics when delivering treatment plans, thereby increasing treatment starts.

Better practice data can enhance operational efficiency There’s a chance you’re already measuring many of these practice metrics, but that doesn’t guarantee the way you collect data is efficient. If you or your staff are manually gathering and inputting performance data into spreadsheets, pulling and sifting through reports and spending significant time compiling, let alone interpreting the data, these are strong indicators that your practice is not being operationally efficient. Even with robust practice management software in place, orthodontic practices are still missing the comprehensive level of data analysis necessary for practice health. It’s a mistake to view your business from only a clinical perspective — though patient care is top priority — your competition is waiting for the opportunity to eat your lunch. The solution is a better practice performance data analysis tool. With the proper data analysis tool, you can automate the process of measuring practice performance information. This saves time and resources that could be devoted to improving your practice, creating a better patient experience, team environment, and the operational efficiencies that will truly drive long-term revenue and profitability. Data automation produces reliable, accurate practice analysis by eliminating the risk of human error from manual data entry. Furthermore, the right tools will help visualize data in eye-opening ways, allowing you to quickly catch nuances and insights that would be much more obscured in a report or clunky spreadsheet.

Visualizing data in graphs and charts accelerates your reaction time to opportunities and setbacks It’s not necessarily the size of a dataset that matters most (although it certainly helps when identifying large-scale trends) but rather how fast you can react to it. By drastically reducing the amount of time you spend looking at data and figuring out what to do, you can use your expertise to act more quickly and take advantage of opportunities or reverse setbacks as soon as they appear. And the best way to accelerate data analysis is through visual dashboards. The best data analysis tools provide intuitive visual representations of a practice’s performance. By seeing your practice performance data through graphs and charts, you Orthodontic practice 13

COVER STORY

What if you had the dataset to show that the industry standard was actually 5% no-shows, and regional comparisons for similar offices in your area only had 4% no-shows? Suddenly, it’s clear there’s an issue where you didn’t see one before. A loss you previously tolerated becomes the difference between your practice and your competitors — giving them an advantage. This data could incite you to change your appointment messaging, look into new scheduling options, scheduling reminders, staff training, and other methods to prioritize appointments, all of which could help increase profitability and efficiency per visit.

COVER STORY

Gaidge overhead expense percentages dashboard

waste less time trying to digest and understand data and more time responding to important data findings. Furthermore, visuals can steer you away from bad assumptions or incorrect “gut feelings” about your data.

Data analysis helps realize capacity and HR needs A common problem practices have faced more in the past 24 months is team turnover. Looking into your schedule and understanding how virtual appointments and treatment efficiency metrics can be used to get ahead of HR needs and/or restructure responsibilities are far superior approaches to following emotional impulses. Practices are focused on their most important goal first — treating patients with excellent care. But the business side of this equation comes down to available chair time and staff to fulfill essential functions. When things change, how do we know where we should focus resources during busy times? For example, having your eyes on your observation pool is an area that often becomes overlooked in practices because there are no red lights beeping or external triggers that something needs to be solved. In your practice perhaps this task falls to your already swamped treatment coordinator (TC)? When is the right time to consider hiring another TC or dedicated observation coordinator? Industry consultants advise practices should pull ~20% of their starts from their observation pool, but only those who put forth a concerted effort are able to achieve and sustain this. If you are not using data and internal resources to understand your starts conversion from observation patients, you are leaving money on the table.

Tracking expenses helps realize the value (or cost) of change Implementing new technologies often comes with a lot of promises and hopes. 14 Orthodontic practice

But as many business school graduates have been taught, hope is not a strategy. Exploring and adopting new technologies is progressive and often worthwhile, but in some cases it’s not as easy as it seems. The first step should be to create a plan to ensure that the health and profitability of your business is top-of-mind. Creating a baseline of understanding from the current state of staff expenses and treatment expenses is the next step in measuring the impact of change. It’s not uncommon that practices may experience a spike in treatment-related expenses and even staff expenses depending on the technology. The only way to know if the change you’ve implemented is bringing positive impact or not is to be able to follow the data trends and observe how the expense, production, starts, and efficiency metrics perform over time as the newness turns into routine.

Get the metrics, benchmarks, and reporting you need to compete — and win Imagine a vast warehouse of data that contains the secrets to running a better business — but you can’t get inside. Every practice that’s capturing data through practice management software is sitting on “warehouses” of operational data. The trick is to ensure all that data is synthesizing, analyzing, and displaying trends and insights that result in something that can be translated into meaningful action. For all the good that large quantities of data can bring to a practice, none of it is usable without a way to connect the dots, so practice owners can clearly see how it impacts the big picture. No matter the size of your practice, you must first harness the power of data to first sustain your success in a competitive market, but second, how else can you effectively manage without understanding

Gaidge mobile net production versus net collection charts

what’s driving and, equally important, what’s dragging your practice? Leveraging data takes out the guesswork and provides facts to build upon. Whether you’re focused on operational insights or industry benchmarks, the right data will augment your approach and help you understand why your practice performs as it does, support you in your efforts to implement the highest priority changes, measure your results, and follow a path of continuous improvement. The task of tracking the essential practice KPIs doesn’t have to be daunting. Take it in bite-size pieces, tackling your practice like the CEO of a business. With business intelligence tools, software automation, comparison data, plus the expertise of industry benchmarks, your practice can establish where you truly are and then unleash the clarity required for your go-forward plan on achieving your goals. OP Volume 12 Number 4

Drs. Francesca Scilla Smith and Larry W. White discuss centric occlusion, centric relation, and the role of canines Canines Prior to 1958, when Dr. Angelo D’Amico1-6 published his six articles on the role of canines in functional occlusion, most dental restorative practitioners ascribed to the group function theory that arranged the teeth in a balanced occlusion with group function on the working side. D’Amico challenged this prevailing application by showing how the canines could be instrumental in guiding the occlusion in lateral excursions7,8 by having the osseous support of dense compact bone9 and the longest roots10 of the dentition to tolerate lateral forces better than other posterior teeth. One additional advantage discovered for canine-protected occlusion was that fewer muscles activated during eccentric movements than when posterior teeth contact.11 D’Amico’s theory has had an enormous influence among gnathologists and subsequently dental faculties and caused some to allege that without canine protected occlusion (CPO), orthodontic patients would have a predisposition to TMD as well as treatment relapse.12,13 Still balanced occlusion seems to appear often in people with Class I and optimal occlusions.14 Another study has revealed that CPO and group function rarely exist in a pure form, and that balanced occlusion appears as a general rule.15 McNamara16 has perhaps summarized the controversy of occlusion by pointing out that several acceptable functional occlusal systems can exist harmlessly; and that although orthodontic therapy tries to achieve a stable occlusion, the failure to achieve a specific, gnathological goal doesn’t predispose patients to TMD, discomfort, or dysfunction. Certainly, occlusal interferences need to have reduction when they cause tooth mobility, a vibratory sensation, or deflection in mandibular movements; but so many occlusal variations exist. A prescription for one universal schematic seems pointless and even counterproductive.17

Centric relation The classical definition of centric relation (CR) was the most retruded, posterior, and superior position of the condyle in the Volume 12 Number 4

Figure 1: This patient presented with a Class III subdivision malocclusion complicated by arch length discrepancies, a missing maxillary right canine, anterior crossbite, and a midline deviation. Two mandibular canines and a maxillary left second premolar were removed, resulting in a successful treatment outcome achieved in 19 months. (Treatment from the files of the late Dr. Tom Creekmore)

glenoid fossa, and this formed the raison d’être for gnathologists, prosthodontists, and dentists generally for decades. In 1995,18 the Academy of Prosthodontists changed this definition and, for the most part, defined the normal condylar position as being in the most superior and anterior part of the glenoid fossa. Some have implied that the centric occlusion (CO) and centric relation (CR) should be coincident, but that notion has not found corroborating evidence.19 Neither the classic definition nor the newly minted definition of CR had any scientific grounding but was entirely arbitrary.17 Even as far back as 1969 with telemetry studies,20-22 researchers discovered entire occlusions restored to a retruded CR still functioned around 2 mm forward of that condylar position. Many people have an anterior slide and can prove it by positioning the tongue on the soft palate, which puts the condyle in its most retruded position and then brings the teeth together. An anterior slide of 1 mm-3 mm is quite common and apparently has a muscular component as well as dental. To presume that there is one particular CR position for an entire population rather than a range of possible positions begs credulity. One can never know if D’Amico intended to confer sainthood on the canine and make it sacrosanct, but that has certainly been the effect — to the extent that dentists will

seldom honor an orthodontist’s request for the removal of canines, even those severely impacted with little or no likelihood of ever occupying an ideal occlusal position without serious periodontal compromise. The tergiversational decision by dental faculties, dentists generally and specialists specifically have limited the interest in even discussing the merits of this feature of the dental canon, much to our professional peril and to our patients. There are reports of successful occlusal, esthetic, and orthodontic outcomes with the extraction of canines, and even a recent perception study found no difference in 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 W. White, DDS, MSD, FACD, is a graduate of Baylor Dental College and Baylor Orthodontic Program and now has an orthodontic practice in Dallas, Texas.

Orthodontic practice 15

CLINICAL

Examining the dental canon

CLINICAL

Figure 2: This adolescent female presented with a Class I malocclusion complicated by a retained mandibular right primary canine and a retained maxillary left primary second molar. Additionally, she displayed an impacted mandibular right permanent canine and a midline discrepancy. The treatment plan would remove the retained primary teeth and the impacted canine. The mandibular left quadrant would then protract, and the mandibular right first premolar would replace the extracted permanent canine

Figure 3: Treatment outcome of patient in Figure 2 with the mandibular right first premolar occupying the canine position with excellent occlusion with optimal overbite and overjet

Figure 4: This adolescent female presented with a Class II subdivision malocclusion complicated by maxillary and mandibular arch length discrepancies, a midline discrepancy, and an impacted maxillary left permanent canine. The treatment plan called for the extraction of the impacted canine and for the maxillary left first premolar to act as the canine substitute. The mandibular arch length discrepancy would be solved with interproximal enamel reduction and alignment

smile attractiveness between maxillary canine extraction and premolar extraction patients.23-26 An assessment tool — used by Ericson and Kurol27 and used by Sigler, et al.,28 to evaluate the severity and/or morbidity of erupting and aligning of impacted maxillary canines — has proven useful in the decisionmaking regarding impacted maxillary canines. Rinchuse, et al.,29 developed an orthodontic 16 Orthodontic practice

informed consent that identified the potential morbidity associated with the alignment of impacted teeth, which the American Association of Orthodontists accepted as a supplement to their consent form. I include below some of the patients with successful canine extraction therapies to illustrate that D’Amico’s idea of the canine protected occlusion has less universal appeal

and usefulness than he originally envisioned and intended (Figures 1-5).

Conclusion Jacobs30 averred long ago that a wellpositioned tooth should never be removed to make space for a poorly positioned one (Figure 6), while Stewart, et al.,31 discovered that aligning impacted maxillary canines took Volume 12 Number 4

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CLINICAL

Figure 5: The treatment outcome of patient in Figure 4 displays the maxillary left first premolar occupying the canine position esthetically and functionally with optimal occlusion and the arch length discrepancies in both arches resolved

The sanctity of the canine needs serious reconsideration by the profession for the good of our patients. longer, which has consequences beyond properly aligning the canine such as loss of molar anchorage, compromised periodontium, and root resorption of adjacent teeth. Bowman32 has suggested that in many instances to do something for the simple reason that we can doesn’t mean that we should. My personal experience has been such that I wish someone had offered the idea during my training that some impacted canines can and should be removed to avoid morbidity, the burden of extra and unnecessary care, longer treatment, more expense, more trauma, and more uncertainty about the outcome. Of all that comprises the dental canon, the sanctity of the canine needs serious reconsideration by the profession for the good of our patients. OP REFERENCES 1. D’Amico A. The canine teeth: normal functional relation of the natural teeth of man: No. 4. J South Calif State Dent Assoc. 1958;26(5):175-182. 2. D’Amico A. The canine teeth: normal functional relation of the natural teeth of man: No. 2. J South Calif State Dent Assoc. 1958;26(2):49-60. 3. D’Amico A. The canine teeth: normal functional relation of the natural teeth of man: No. 3. J South Calif State Dent Assoc. 1958;26(4):127-142. 4. D’Amico A. The canine teeth: normal functional relation of the natural teeth of man: No. 5. J South Calif State Dent Assoc. 1958;26(6):194-208. 5. D’Amico A. The canine teeth: normal functional relation of the natural teeth of man: No. 6. J South Calif State Dent Assoc. 1958;26(7):239-241. 6. D’Amico A. The canine teeth: normal functional relation of the natural teeth of man; No. 1. J South Calif State Dent Assoc. 1958;6(1):6-22. 7. Grosfeld O, Czarnecka B. Musculo-articular disorders of the stomatognathic system in school children examined according to clinical criteria. J Oral Rehabil. 1977;4(2):193-200. 8. Magnusson T, Carlsson GE, Egermark-Eriksson I. An evaluation of the need and demand for treatment of

18 Orthodontic practice

craniomandibular disorders in a young Swedish population. J Craniomandib Disord. 1991;5(1):57-63. 9. Swanljung O, Rantanen T. Functional disorders of the masticatory system in Southwest Finland. Comm Dent Oral Epidemiol. 1979;7(3):177-182. 10. Dibbets JMH. Juvenile temporomandibular joint dysfunction and craniofacial growth. A statistical analysis. 1977; Rijkesuniversiteit. Groningen, the Netherlands. 11. Hansson T, Nilner M. A study of the occurrence of symptoms of diseases of the TMJ, masticatory musculature, and related structures. J Oral Rehabil. 1975;2(4):313-324. 12. Roth RH. The maintenance system and occlusal dynamics. Dent Clin North Am. 1976;20(4):761-788. 13. Roth RH, Rolfs DA. Functional occlusion for the orthodontist. Part II. J Clin Orthod. 1981;15(2): 100-123. 14. Turk DC, Rudy TE, Kubinski JA, Zaki HS, Greco CM. Dysfunctional patients with temporomandibular disorders: evaluating the efficacy of a tailored treatment protocol. J Consult Clin Psychol. 1996;64(1):139-146. 15. Woda A, Vigneron P, Kay D. Nonfunctional and functional occlusal contacts: a review of the literature. J Prosthet Dent. 1979;42(3):335-341.

Figure 6: This patient displays a Class I malocclusion complicated with maxillary and mandibular arch length discrepancies and a poorly positioned maxillary left canine. The patient also had a midline discrepancy, an open-bite tendency, a protrusive profile, and the left lateral incisor in a crossbite. The treatment plan calls for the extraction of the maxillary right first premolar, the maxillary left canine, the mandibular left and right first premolars. This treatment plan illustrates Jacobs’ principle of not removing a well-positioned tooth for a poorly positioned one30

16. McNamara JAJ, Seligman D, Okeson J. Occlusion, orthodontic treatment, and temporomandibular disorders: a review. J Orofac Pain. 1995;9(1):73-89. 17. Rinchuse DJ, Kandasamy S, Sciote J. A contemporary and evidence-based view of canine protected occlusion. Am J Orthod Dentofacial Orthop. 2007;132(2):90-102. 18. Glossary of prosthodontic terms. J Prosthet Dent. 1995; 94(1):10-92. 19. Rinchuse DJ. A three-dimensional comparison of condylar position changes between centric relation and centric occulusion using the mandibular position indicator. Am J Orthod Dentofacial Orthop. 1995;107:319-328. 20. Pameijer J, Glickman I, Roeber F. Intraoral occlusal telemetry: 3. Tooth contacts in chewing, swallowing and bruxism. J Periodontol. 1969;40(5):253-258. 21. Glickman I, Martigoni M, Haddad A, Roeber FW. Further observation on human occlusion monitored by intraoral telemetry (abstract 612). International Association of Dental Research. 1970; 201. 22. Pameijer JH, Brion M, Glickman I, Roeber FW. Intraoral occlusal telemetry. V. Effect of occlusal adjustment upon tooth contacts during chewing and swallowing. J Prosthet Dent. 1970;24(5):492-497.

Orthop. 2013;143(1):125-133. 25. Thiruvenkatachari B, Javidi H, Griffiths SE, Shah AA, Sandler J. Extractin of maxillary canines: Esthetic perceptions of patient smiles among dental professionals and laypeople. Am J Orthod Dentofacial Orthop. 2017;152(4):509-515. 26. Al Shhab MK, Mansour EE, El-Beialy AR, Mostafa YA. Unusual extraction combinations in patients with impacted maxillary canines. J Clin Orthod. 2019;53(10):603-610. 27. Ericson S, Kurol J. Radiographic examination of ectopicall erupting maxillary canines. Am J Orthod Dentofacial Orthop. 1987;91(6):483-492. 28. Sigler LM, Baccetti T, McNamara JA Jr. Effect of rapid maxillary expansion and transpalatal arch treatment associated with deciduous canine extraction on the eruption of palatally displaced canines: A 2-center prospective study. Am J Orthod Dentofacial Orthop. 2011;139(3):e235-e244. 29. Rinchuse DJ, Jerrold L, Rinchuse DJ. Orthodontic informed consent for impacted teeth. Am J Orthod Dentofacial Orthop. 2007;132(1):103-104. 30. Jacobs SG. Localization of the unerupted maxillary canine: how to and when to. Am J Orthod Dentofacial Orthop. 1999;115(3):314-322.

23. Creekmore, T., Where teeth should be positioned in the jaws and how to get them there. J Clin Orthod. 1997;31(9): 586-608.

31. Stewart JA, Heo G, Glover KE, et al. Factors that relate to treatment duration for patients with palatally impacted maxillary canines. Am J Orthod Dentofacial Orthop. 2001;119(3):216-225.

24. Mirabella D, Giunta G, Lombardo L. Substitution of impacted canines by maxillary first premolars: a valid alternative to traditional orthodontic treatment. Am J Orthod Dentofacial

32. Bowman SJ. One-stage versus two-stage treatment: Are two really necessary? Am J Orthod Dentofacial Orthop. 1998;113(1):111-116.

Volume 12 Number 4

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CASE STUDY

Pushing the limits Dr. Jeffrey M. Heinz illustrates a clinical case study treated with Spark™ Clear Aligners

n my practice, I have traditionally reserved my most challenging cases for braces rather than clear aligner therapy, including some tricky adult cases. However, in my experience, when faced with the fact that a majority of adults are more interested in clear aligners than braces, it can make treatment plan presentations delicate, which can decrease case acceptance. It just so happens that my mother represents one of these cases. Orthodontic care was not a financial option for her family as a child, and so her dentist decided to extract a unilateral maxillary first bicuspid to “get rid of her crowding,” leaving me with a tricky orthodontic case. This report will take you through the nuances of her case, all of which had to be completed on a short timeline prior to my wedding! In my continuing quest to become the best orthodontist I can be, I have dived into the world of clear aligners and have been continually pushing the limits of what I see as “an aligner case” — taking the complicated and making it predictable, comfortable, and patient centric. In late 2018, I discovered Spark™ Clear Aligners. Spark Aligners can treat a wide variety of patient malocclusions, including open bite, deep bite, overbite (Class II), underbite (Class III), crossbite, crowding, and spacing.1 In my opinion, a combination of esthetic and preferred features of Spark Aligners versus the leading aligner brand

made the decision to use Spark Aligners for my mother a simple one. I’ve found several important patientcentric differences with this product: • Spark Aligners are more transparent and minimize staining compared to the leading competitor, allowing patients a discreet treatment.1 • TruGEN™ material has been proven to provide advanced “sustained force retention” and also have 19% better contact surface area with the tooth, which may result in more efficient tooth movement and productive

treatment compared to the leading aligner material.1 • Unlike the leading aligner brand, Spark Aligners are designed with scalloped and smooth edges to enhance patient comfort and improve the overall treatment experience.1

Diagnosis At the time of treatment, my mother was 64 years old. Her childhood dentist extracted her UR4 due to crowding since her family was not able to afford braces (Figure 1). This left her with a half-step Class II molar

Figure 1: Pretreatment records

Jeffrey M. Heinz, DDS, MSD, graduated from Michigan State University, attended the University of Detroit Mercy School of Dentistry, and spent 2 years at Indiana University where he received his Certificate in Orthodontics and Master of Science in Dentistry. Dr. Heinz lectures nationally on how to straighten teeth efficiently and effectively with clear aligner systems, participates in clinical trials shaping leading-edge orthodontic products, is a multi-year recipient of HOUR Detroit Magazine’s “Top Orthodontists 2021” award, and is a Diplomate of the American Board of Orthodontics. Dr. Heinz has two private practice locations in Kentwood and Rockford, Michigan. Disclosure: Dr. Heinz is a paid consultant for Ormco™. The opinions expressed are those of Dr. Heinz. Ormco is a medical device manufacturer and does not dispense medical advice. Clinicians should use their own professional judgment in treating their patients. (Patient results may vary.)

Figure 2: Refinement photos after initial 30 aligners 20 Orthodontic practice

Volume 12 Number 4

CASE STUDY

Figure 3: Before and after cosmetic bonding U2-2 performed at refinement

and a Class III canine on the right side. She was also a half- step Class II on the left side, which combined to make her upper midline off to the right and her lower midline off to the left, approximately 3.5 mm (Figure 1). She had constricted arches and a significant deep bite causing attrition to her upper and lower incisors. In my experience with aligners, significant asymmetric bite correction has been tough to achieve, but Mama Bear wasn’t too keen on the idea of braces, so we decided to give it a shot.

Treatment plan 1. Clear aligner treatment utilizing Spark Aligners for dental expansion and deep bite protocols 2. Class III elastics on the right side and Class II elastics on the left side 3. IPR L3-3 4. Cosmetic bonding U2-2 after deep bite is eliminated 5. 14 months of treatment (30 initial trays plus 15 trays refinement)

Treatment progression After 30 trays (Figure 2), the vast majority of dental expansion and alignment was completed. Class II correction on the left side and Class III correction on the right side were both progressing nicely, and she started wearing her elastics. Her deep bite was opened, so I performed some cosmetic bonding prior to her refinement scan to eliminate the attrition that was caused by her malocclusion (Figure 3). I then prescribed 15 active trays with continued bite correction and settling of her right side posterior occlusion. Final records were taken after the 15-tray refinement, and we were thrilled with the results (Figure 4). My mom turned out to be a great patient and loves her new smile. We Volume 12 Number 4

Figure 4: Final photos taken the day of debond

I have been continually pushing the limits of what I see as “an aligner case” — taking the complicated and making it predictable, comfortable, and patient centric. achieved a healthy Class I canine relationship on both sides and a socked-in posterior occlusion. No settling was necessary posttreatment; these photos were taken the day of debond. Her upper midline is now coincident with her facial midline, and her lower midline has made significant improvement from pretreatment records.

Conclusion My mom initially had 30 active trays followed by 15 trays in refinement. She was in treatment for a total of 14 months and had seven in-office visits. We could have shaved

off a progress appointment or two since she was doing so well wearing her trays, but we had fun working together, so I didn’t mind a few extra appointments! As we push the limits of aligner therapy, I am continually impressed by what we can accomplish with plastic, specifically Spark Clear Aligners. Treating cases confidently with plastic has changed my practice and will continue to play a bigger and bigger role in our office. OP REFERENCE 1. Ormco Corporation. Data on file.

Orthodontic practice 21

RESEARCH STUDY

Practitioner perceptions of the link between orthodontics and temporomandibular disorders (TMD): a survey of dentists, orthodontists, and oral and maxillofacial surgeons Drs. Chadwick Augusty, Shadbeh Taghizadeh, Vincent Graves, John Stockstill, and Courtney McCracken (biostatistics) study the perceived association between orthodontics and TMD Abstract Background Orthodontics as a possible causative, contributory, or curative factor in temporomandibular disorders (TMD) has been the subject of numerous studies in the past. Little evidence has been found to link the two; however, practitioner perception may not be consistent with those findings. We studied the perception of practicing dentists with respect to TMD to determine if more education and standardization is needed regarding any causative or associative relationship with orthodontics. Materials and methods In April 2021, a survey was emailed to the members of the Georgia Dental Association to evaluate the perceptions of dentists, orthodontists, and oral and maxillofacial surgeons on the diagnostic and treatment associations between orthodontics and TMD. Results Significant differences in attitudes of general dentists with and without orthodontics toward an association between clear aligner therapy (CAT) and TMD (in patients without a TMD history) were observed, with those with orthodontics in their practice more likely to disagree with an association (68%) and those without orthodontics less likely to disagree with an association (34.3%). For traditional bracket therapy on patients without a TMD history, doctors with predoctoral TMD training and those with

Chadwick Augusty, DMD; Shadbeh Taghizadeh, DMD; Vincent Graves, DDS; and John Stockstill, DDS, MS, are associated with the Georgia School of Orthodontics, Atlanta, Georgia. Courtney McCracken, PhD, is associated with the Medalytics Group, a biostatistics consulting group for clinical research.

22 Orthodontic practice

TMD-related CE training were statistically more likely to disagree with any orthodontics-TMD association (72.6% and 91.7%, respectively). When the patient had a history of TMD, fewer respondents disagreed to an association, and no significant findings were noted for or against an association between orthodontics and TMD. Conclusion More research is needed to eliminate any perceived association between orthodontics and TMD in patients with and without a history of TMD. Additionally, it is suggested that a standardized, evidence-based curriculum is needed at the predoctoral, postdoctoral, and continuing dental education levels to more clearly and concisely inform doctors regarding current evidence for appropriate TMD diagnostic and management standards as well as the lack of sufficient evidence for any causative, associative, or curative relationship of orthodontics to TMDs.

Introduction The link between orthodontic treatment and temporomandibular disorders (TMD) has been extensively studied since the 1980s in response to a lawsuit, which claimed that orthodontic treatment caused a patient’s TMD-related pain complaint.9 By definition and in keeping with current, evidencebased concepts, TMDs are characterized as a family of physiologically related disorders, including craniofacial pain involving the temporomandibular joints, muscles of mastication, and/or neuromuscular and neurovascular components of the head and neck. In an attempt to more clearly and concisely categorize these disorders and to define any correlation between orthodontic treatment and TMDs, numerous studies have been conducted in an attempt to determine what correlation, if any, exists between orthodontic

treatment and these temporomandibular joint disorders.1,2,3,4,6,8,10 Orthodontic treatment routinely incorporates fixed appliances (braces), growth modification devices such as jaw repositioning appliances, including, for example, Herbst® (Dynaflex® Inc., Wentzville, Missouri), Forsus™ (3M – Hutchinson, Minnesota), Twin Block (Dynaflex® Inc., Wentzville, Missouri), and MARA (Dynaflex® Inc., Wentzville, Missouri) appliances. Treatment may also include extraoral appliances such as headgear and reverse pull headgear. Past studies have covered a wide range of treatment factors within the orthodontic field, including, but not limited to, elastic wear, extractions versus non-extractions, auxiliary and adjunct appliances or devices used, and history of TMDs.1,2,3,4,6,8,10 A longitudinal prospective study showed there was little to no effect on the TMJ when using Class II elastics in a treatment involved with extractions.6 On the contrary, a finite element analysis that studied the effects of Class II and Class III elastics illustrated that elastic wear showed stresses on the TMJ especially for Class II patients.2 A meta-analysis of the literature concerning any relationship between orthodontics and TMD was determined inconclusive.4 The results of these studies1,2,3,4,6,8,10 and others seem to reflect contradictory and/or inconclusive claims that show causal relationship between orthodontic treatment and the TMJs in the development of TMDs. As a result, there are differences within the dental community regarding any cause-and-effect relationship for orthodontics and the onset or exacerbation of TMDs. Therefore, the aim of this study was to determine current perceptions of any perceived or suspected link between orthodontics and TMD among practitioners who most commonly see patients with TMD in the dental community, including general Volume 12 Number 4

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.

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Orthodontic practice 23

RESEARCH STUDY dentists, orthodontists, and other related dental specialists who diagnose and/or treat TMD patients (orthodontists and oral and maxillofacial surgeons for this specific study).

Materials and methods Following the establishment of the study design for this research, a waiver of IRB exemption was determined appropriate by the Sterling Institutional Review Board under the premise that this was a Non-Human Subjects Research and no personal or identifiable data would be collected from any of the survey participants. For this study, a survey was created at the Georgia School of Orthodontics (GSO) and distributed by the Georgia Dental Association (GDA) to its members via email in April 2021. This survey consisted of a maximum of 20 questions for the participant determined by branching logic within the survey. Given that the GDA was integral in distribution of this survey, participation was limited to those practitioners who were active members of the GDA at the time of distribution. As such, inclusion criteria for this research included: 1) active member of the Georgia Dental Association, 2) current practicing dental professional, 3) general dentists with or without orthodontics or clear aligner therapy in their office, 4) orthodontic or oral and maxillofacial surgery specialists, and 5) willing respondent of the digital survey. Exclusion criteria for this research included: 1) non-member of the Georgia Dental Association, 2) non-practicing dental professional, and 3) fields of practice not included in 3) or 4) of the inclusion criteria. Within the survey, the first 10 to 12 questions were about the respondents’ background and demographic information. The remaining four to eight questions were regarding orthodontic treatment and its association with TMD. Of those, the first half referred to patients without a history of TMD, whereas the second half referred to patients with a history of TMD but no signs or symptoms at the initiation of treatment. There were also questions within those eight maximum questions regarding intraoral rubber bands (elastics) and extraoral appliances such as headgear that were limited to the general dentists with orthodontics, the orthodontists, and the oral and maxillofacial surgeons. Following distribution, the survey was available for completion by the GDA membership for 3 weeks to allow ample time for participation. Once the 3 weeks was over, the survey was closed, and the results collected and statistically analyzed. 24 Orthodontic practice

Descriptive statistics were calculated using counts and percentages. Likert-scale responses were treated as ordinal data when possible; however, in some cases collapsing across responses was necessary due to the small cell counts. Associations between provider and practice patterns were examined in relationship to attitudes around orthodontic treatment and TMD using chi-square tests. Statistical analyses were conducted using SAS v. 9.4 (Cary, North Carolina), and statistical significance was assessed at the 0.05 level.

Results Of the responses received from the survey, 147 met the inclusion criteria. Table 1 displays a summary of the participant backgrounds and demographics. Most respondents practiced general dentistry (81.6%), of which there were more whose practice did not include orthodontics. The respondents tended to be more experienced practitioners, with 63 (42.9%) doctors having worked more than 31 years in practice. A majority received TMD training in their predoctoral education (64.6%), while a larger majority had attended TMD-related CE courses since practicing (84.4%). Slightly over two-thirds of respondents report diagnosing and treating patients with TMD (68.7%), while just under one-third report not diagnosing and treating patients with TMD (31.3%). Due to the lack of separation of the “diagnosing” and “treating” criteria within the question, it is presumed that all practitioners would diagnose but not necessarily treat; thus, this question was interpreted as “Do you treat patients with TMD?” Following respondent backgrounds and demographics, questions about their attitudes toward orthodontic therapy and their associations with TMD were explored. Additionally, response patterns and changes were further analyzed based on patient history of TMD with respect to both clear aligner therapy and traditional metal or ceramic bracket therapy. Observations included whether there was any answer change at all, if there was a change but stayed in the same category, or if there was a change that moved to a different category (e.g., disagree to neutral or agree, agree to neutral or disagree, neutral to agree, or neutral to disagree). For traditional metal and ceramic bracket therapy, 52.9% did not change answers once the patient was categorized as having a history of TMD; however, 36% changed to a different category, with most changing

Table 1: Respondent demographics and backgrounds N (%) N = 147

Characteristic Type of Practice General Dentistry (no Ortho)

70 (47.6%)

General Dentistry (with Ortho)

50 (34.0%)

Orthodontics

12 (8.2%)

Oral and Maxillofacial Surgery

15 (10.2%)

Years in Practice 0-10 years

18 (12.2%)

11-20 years

28 (19.1%)

21-30 years

38 (25.9%)

31+ years

63 (42.9%)

Received formalized training on TMD during pre-doctoral education

95 (54.6%)

Attend TMD-related CE Courses

124 (84.4%)

Primary Source of Information for TMD Dx and Management Self-taught or anecdotal

14 (9.5%)

Journal Articles

16 (10.9%)

Presentation at CE Programs

76 (51.7%)

Predoctoral Education

21 (14.3%)

Other

20 (13.6%)

Actively Dx and Treat Patients with TMD

101 (68.7%)

Treats with: (N = 101) Splint Therapy

74 (73.3%)

Reassurance

10 (9.9%)

Other

12 (11.9%)

Orthodontics

3 (3.0%)

Surgical Intervention

1 (1.0%)

Physical Therapy

1 (1.0%)

Does not Dx and Treat Patients with TMD

46 (31.3%)

Refers to: (N = 48) TMD Specialist

29 (63.0%)

Oral/Maxillofacial Surgeon

11 (23.9%)

Orthodontist

5 (10.9%)

Other

1 (2.2%)

from “disagree” to either “neutral” or “agree.” Also, 11% changed answers but stayed in the same category. For clear aligner therapy, 48.5% did not change answers. However, 44.9% changed answers to a different category, with most changing from “disagree” to “neutral” or Volume 12 Number 4

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RESEARCH STUDY “agree.” Only 6.6% changed answers but stayed within the same category. The responses to TMD association with clear aligner therapy and traditional metal and ceramic bracket therapy in patients with no history of TMD were analyzed with respect to the respondents’ demographic information and training. Due to the response distributions, these responses were grouped into two categories and treated as ordinal data for analysis. As such, each question and its responses were treated in a manner similar to a null hypothesis, with respondents either “disagreeing” (disagree and strongly disagree responses) with the statement or “failing to disagree” (neutral, agree, or strongly agree responses) with the statement. Table 2 displays the results of the analyses with respect to clear aligner therapy (CAT). There is a significant difference (p < 0.001) between the attitudes of general dentists without orthodontics and those with orthodontics when it comes to CAT causing TMD.

Discussion The results of our study suggest several possible trends along with several significant outcomes; however, this study was not without its limitations both in the study design as well as the survey itself. One measure worth noting is the distribution of respondents’ practice type. General dentists made up 81.6% of respondents while orthodontists and oral surgeons made up 18.4% of respondents. According to the American Dental Association (ADA),13 as of 2020, approximately one-fifth (21.2%) of dentists reported their practice as an ADArecognized specialty. Thus, while the overall number of responses to our survey was lower than desired (N=147), the distribution was relatively close to the national numbers with respect to practice type. Our study revealed a similar trend seen in past research with respect to TMD treatment modalities. One previous study noted that of 53 U.S. and Canadian schools that responded in 2007, 34% utilized didactic TMD training, while 66% utilized a combination of clinical and didactic training.5 Of those schools, the majority (72%) utilized interocclusal appliance therapy (splint therapy), with 64% emphasizing patient education and pharmacotherapy, while fewer than 50% taught physical therapy, behavioral management, or diagnostic/therapeutic anesthetic injections for treatment modalities.5 While occlusion has been shown to play a minor, if any, role in the etiology of TMD,13 occlusal 26 Orthodontic practice

Table 2: Results of analyses among various practitioners

Characteristics

In patients with no history of TMD prior to initiating orthodontic treatment, clear aligner therapy causes TMD

P-value

Fail to Disagree N = 76

Disagree N = 71

General Dentistry (no Ortho)

46 (60.5%)

24 (33.8%)

General Dentistry (with Ortho)

16 (21.1%)

34 (47.9%)

Specialty*

14 (18.4%)

13 (18.3%)

20 or Less

21 (27.6%)

25 (35.2%)

21-30 years

19 (25.0%)

19 ()26.8%

31+ years

36 (47.4%)

27 (38.0%)

Received formalized training on TMD during predoctoral education

45 (59.2%)

50 (70.4%)

0.156

Attend TMD-related CE Courses

61 (80.3%)

63 (88.7%)

0.158

0.800

Practice Type

0.001

Years in Practice 0.481

Primary Source of Information for TMD DX and Management Self-taught or anecdotal

7 (9.2%)

7 (9.9%)

Journal Articles

10 (13.2%)

6 (8.5%)

Presentations at CE Programs

36 (47.4%)

40 (56.3%)

Pre-Doctoral Education

12 (15.8%)

9 (12.7%)

Other

11 (14.5%)

9 (12.7%)

Actively Dx and Treat Patients with TMD

52 (68.4%)

49 (60.0%)

adjustment (equilibration) of either partially or fully dentate patients was still being taught in several of the schools.5 Despite the lack of evidence that either occlusion or orthodontics is a primary etiological factor, the past study emphasized that neither should be ignored as a potential secondary or contributory role in the overall diagnosis and management of TMD.11 Our results showed splint therapy as the primary treatment (73.3%) modality with orthodontics being listed as another choice of treatment (3% of responses). Our survey did not specifically ask about occlusal adjustment as a treatment; however, it may have been considered in the “Other” (11.9%) category by respondents. We noted that the general dentists with orthodontics category (general dentists also practicing orthodontics) had the highest percentage of respondents who had attended TMD-related CE courses (94%). This could be anticipated considering that these clinicians may have intended to add a treatment commonly considered a specialty into their practice, requiring additional education prior to treating patients.

0.938

This group also had the largest percentage (94%) of respondents who report treating patients with TMD, which likely follows a similar rationale. Regarding the questions dealing with patients who do not have a history of TMD, we found that most doctors chose the neutral, disagree, or strongly disagree category concerning an association (between 87.1 and 94.5% of respondents answered within these categories). However, there were differences found between the attitudes of general dentists with and without orthodontics in their attitudes toward an association between clear aligner therapy (CAT) and TMD. While general dentists with orthodontics tended to disagree with any association between CAT and TMD, the general dentists without orthodontics failed to disagree with any association. Alternatively, this may be a clinical bias on our part as practitioners in that we may not want to believe our treatment has any downside. Similarly, we may be more likely to disagree with any negative association of treatment we provide. Volume 12 Number 4

education9,12 and increased dissemination of research and knowledge are integral to the diagnosis and treatment of TMD. Finally, it is intended that this evidence structured framework will eliminate the more anecdotal approaches to patient care and strengthen predoctoral, postdoctoral, and continuing dental education in the areas of orthodontics and TMDs.

Conclusion This study suggests that there is still uncertainty among general dentists and dental specialists (orthodontists and oral and maxillofacial surgeons) as to the association or lack thereof between orthodontics and temporomandibular disorders, despite past research failing to definitively suggest any association between them. By standardizing evidence-based TMD/Orofacial Pain education at the predoctoral, postdoctoral, and continuing education levels, it is hoped that practitioners may be more confident in their orthodontic diagnosis and management of TMD based upon rigorous scientifically valid studies rather than conjecture and “belief systems.” OP

REFERENCES 1.

Arici S, Akan H, Yakubov K, Arici N. Effects of fixed functional appliance treatment on the temporomandibular joint. Am J Orthod Dentofacial Orthop. 2008;133(6):809-814.

Gurbanov V, Bas B, Öz AA. Evaluation of Stresses on Temporomandibular Joint in the Use of Class II and III Orthodontic Elastics: A Three-Dimensional Finite Element Study. J Oral Maxillofac Surg. 2020;78(5):705-716.

Huang X, Cen X, Liu J. Effect of protraction facemask on the temporomandibular joint: a systematic review. BMC Oral Health. 2018;18(1):38.

Kim MR, Graber TM, Viana MA. Orthodontics and temporomandibular disorder: a meta-analysis. Am J Orthod Dentofacial Orthop. 2002;121(5):438-446.

Klasser GD, Greene CS. Predoctoral teaching of temporomandibular disorders: A survey of U.S. and Canadian dental schools. J Am Dent Assoc. 2007;138(2):231-237.

O’Reilly MT, Rinchuse DJ, Close J. Class II elastics and extractions and temporomandibular disorders: a longitudinal prospective study. Am J Orthod Dentofacial Orthop. 1993; 103(5):459-463.

Pollack B. Michigan jury awards +850,00 in ortho case: a tempest in a teapot. Am J Orthod Dentofacial Orthop. 1988;94:358-360.

Popowich K, Nebbe B, Major PW. Effect of Herbst treatment on temporomandibular joint morphology: A systematic literature review. Am J Orthod Dentofacial Orthop. 2003;123(4):388-394.

Porto F, Harrell R, Fulcher R, Gonzales T. Knowledge and beliefs regarding temporomandibular disorders among orthodontists. Am J Orthod Dentofacial Orthop. 2019;156(4):475-484.

10. Rey D, Oberti G, Baccetti T. Evaluation of temporomandibular disorders in Class III patients treated with mandibular cervical headgear and fixed appliances. Am J Orthod Dentofacial Orthop. 2008;133(3):379-381. 11. Rinchuse DJ, McMinn TJ. Summary of evidence-based systematic reviews of temporomandibular disorders. Am J Orthod Dentofacial Orthop. 2006;130(6):715-720. 12. Stockstill, J, et al. “Survey of orthodontic residency programs: teaching about occlusion, temporomandibular joints, and temporomandibular disorders in postgraduate curricula. Am J Orthod Dentofacial Orthop. 2011;139(1):17-23. 13. Health Policy Institute – American Dental Association. www. ada.org/en/science-research/health-policy-institute. Accessed September 20, 2021.

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Volume 12 Number 4

Orthodontic practice 27

RESEARCH STUDY

Another observation made regarding our survey responses was that once the patient history, including a past history of TMD, was posed to the respondents, perceptions as to causation and association seemed to become more uniform. Specifically, we observed an increase in the “agree” responses across the board regarding “history of TMD and management,” though no significant differences can be found among any of the groups. This “redirection of responses” may be due to the clinicians’ thought process that “if there is an issue, there must be a cause.” Additionally, when we as practitioners cannot find a specific cause, we may inadvertently fall back upon our clinical bias of “cause and effect”; in this case, orthodontic treatment as a curative and/or causative association of TMD. It is apparent that well-designed definitive research is needed to define any causative or associative relationship of orthodontics and TMD in both the diagnostic and management parameters. Along with the necessity for more appropriately designed research, it is equally imperative that standardized, evidence-based

CONTINUING EDUCATION

TMD-occlusion-orthodontic connection revisited Drs. Barry Glassman, Don Malizia, and Daniele Manfredini discuss various viewpoints on occlusion, pain, and dysfunction Introduction The study of dental occlusion and its potential contribution to pain and dysfunction has been a fascinating topic for generations of dentists who spent careers assuming a rather direct relationship. In 1957, Campbell wrote that while dentists should be proud of their advances in restorative therapy, “their concentration on the restorative aspects of their profession has, to some extent, blinded them to the wide implications of pain.”1 Within this historical framework, clinicians must bear in mind that the tendency in dentistry is to think of occlusion as a static relationship that describes how maxillary and mandibular teeth fit together when the elevators contract and maintain contraction — in other words, maximum intercuspation. This seemingly simple concept of occlusion has evoked significant controversy. Based on the belief or negation that less than ideal occlusion may be responsible for dysfunction of the stomagnathic system, clashes of cultures

Educational aims and objectives

This self-instructional course for dentists aims to demonstrate the lack of a direct relationship between occlusion and pain and dysfunction and suggest more relevant and important goals for orthodontic therapy.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions by taking 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: •

Recognize the history of empirical evidence linking occlusion with pain and dysfunction.

•

Explain the difference between proposed peripheral causes of bruxism and centrally mediated causes of bruxism.

•

Assess the role of dental education on the current state of knowledge base in terms of causes of TMD and bruxism.

•

Question the role of “interferences” in the causation of bruxism and TMD.

•

Predict what the future goals of orthodontic therapy may be in the near future.

characterized the second half of the 20th century. The discussion of the role of malocclusion as a cause of temporomandibular disorders (TMDs) has an extensive history in dentistry. An examination of the history of the “evidence” of occlusal concepts reveals

Barry Glassman, DMD, maintained a private practice in Allentown, Pennsylvania, which was limited to orofacial pain and dental sleep medicine. He is a Diplomate of the Board of the American Academy of Craniofacial Pain, a Fellow of the International College of Craniomandibular Orthopedics, and a Diplomate of the American Academy of Pain Management. He is a Diplomate of the Board of the American Academy of Dental Sleep Medicine. He teaches and lectures internationally on orofacial pain, joint dysfunction, and sleep disorders.

Don Malizia, DDS, limits his practice to orofacial pain and sleep-disturbed breathing at the Allentown Pain and Sleep Center inWilkes-Barre, Pennsylvania. Among his recent publications, coauthored with Dr. Glassman, are “The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Self-Reported Pain in Patients With Status Migrainosus” in Headache and “The Curious History of Occlusion in Dentistry” in Dentaltown.

Daniele Manfredini, DDS, PhD, MSc, received his DDS from the University of Pisa, Italy, in 1999, a MSc in Occlusion and Craniomandibular Disorders in 2001 from the same University, a PhD in Dentistry from the ACTA Amsterdam, The Netherlands, in 2011, and a Post-Graduation Specialty in Orthodontics from the University of Ferrara, Italy, in 2017. He achieved the Diplomate Status from the American Academy of Orofacial Pain in 2021. He was a clinical fellow at the Section of Prosthetic Dentistry, Department of Neuroscience, University of Pisa, Italy until 2005. From 2006 to 2016, Daniele Manfredini has been Assistant Professor at the School of Dentistry and coordinator of the research projects at the TMD Clinic, Department of Maxillofacial Surgery, University of Padova, Italy. Since 2017, Daniele Manfredini has held teachings in Oral Physiology and in Clinical Gnathology at the School of Dentistry, University of Siena, Italy. On January 2017, the Italian Ministry of University and Research (MIUR) appointed him as a Full Professor by scientific merit at the age of 41. Daniele Manfredini authored more than 210 papers in the field of bruxism and temporomandibular disorders in journals indexed in the Medline database (Scopus H-index=42). He also edited, among others, the book Current Concepts on Temporomandibular Disorders (Quintessence Publishing, 2010). Since 2018, Daniele Manfredini has been a Member and Coordinator of the Bruxism Consensus Panel within the International Association for Dental Research, which works on the updated definition and classification strategies for bruxism.

28 Orthodontic practice

how several unproven assumptions about occlusion came into existence and why those concepts continue to be taught as “science.” Exposing these potential myths helps us more accurately appreciate how the goal of an “ideal” occlusion in orthodontic care may in fact be out of perspective.

Empirical history As far back as 1967, Block wrote: “When a patient has myofascial pains in the area near the temporomandibular joint or pains within the joint, the dentist should suspect the presence of occlusal disharmonies.”2 Willie B. May, while researching over 120 chronically ill patients with his physician colleague, Lees, concluded the following about occlusal therapy: “When this treatment is fully researched and understood, it will be capable of revising every diagnosis, treatment procedure, and prognosis in the medical world.”3 In 1988, Fonder wrote of a “Dental Distress Syndrome” describing an etiology of malocclusion. According to Fonder, the resulting pathological structural response to that malocclusion is responsible not only for TMD, but also for neurologic pain, otalgia, visceral symptoms, gynecological symptoms, and various “general symptoms.”4 The orthodontic concept of ideal occlusion being a contributing factor to general Volume 12 Number 4

Volume 12 Number 4

has been refined as well as possible.”8 This unfortunate approach has led many dentists to assume that when there is a non-odontogenic facial pain pattern, the resolution will be in the “perfection” of the occlusion, and when an occlusal adjustment does not result in pain relief, the follow-up assumption will be that the occlusal adjustment was not done perfectly. This engineer-like approach to oral rehabilitation still permeates dentistry through the so-called study of gnathology and its derivates — a branch that is not even considered a medical subject heading for Medline search. Failure to consider the implications of nervous system physiopathology and the role of psychological features in the genesis of “pain and dysfunction” are just two of the reasons why gnathological approaches may backfire.

Dental school education of TMD, occlusion, and bruxism This long history of poorly done research leading to an acceptance of a direct causal relationship between occlusion and TMD without caveat has led to the entrenchment of the concept that “bad bites cause pain.” While it appears that there is limited teaching of occlusion in predoctoral programs, there is no question that students graduate with an awareness that occlusion is important, and that malocclusion can be a cause of TMD. The basic occlusal principles of balanced and bilaterally even contact, canine rise, and anterior guidance are taught at the predoctoral level, making every dentist aware of how important these principles are when performing restorative dentistry. Dentists are trained to avoid creating an occlusal contact that is not in harmony with the existing occlusion. Examples of occlusal prematurities leading to acute pain have further strengthened the concept of causation through confirmation bias. Despite the emphasis on the principles of occlusion, the basic dental education has not included validated mechanisms of the assumed “causal role” of occlusion in TMD. Predoctoral students report an even more limited curriculum of evidence-based principles on the diagnosis and treatment of TMD and orofacial pain that move past that formerly believed primary causal role of occlusion.9 Young graduates with a limited knowledge of both occlusion and TMD are soon faced with the need to learn more about TMD and facial pain in their new role as dentists. Unfortunately, their limited

Figure 1: Is it possible to suggest that this patient will have either pain or joint dysfunction? In fact, this patient was asymptomatic with no pain or dysfunction and was referred for oral appliance therapy for moderate obstructive sleep apnea

education in “occlusion and TMD” leaves them vulnerable to those still teaching a direct causal relationship between occlusion, joint dysfunction, and orofacial pain. Logic in the absence of science often prevails. Competing concepts of occlusion have been at the center of the conflicting TMD “camps” over the years. The difference in “camps” is often related to “joint position,” but they all seem to erroneously accept the role of occlusion as critical and a causal contributing factor in the development of TMD.

Ignored evidence The controversy continues despite the recent evidence showing limited if any contribution of the static occlusal relationships to pain and dysfunction. The historical acceptance of the causal role of occlusion has been so generally accepted that the mechanism is not fully addressed or questioned by students and dental professionals alike. At the heart of the problem is that many “facts” about occlusion have been developed empirically and passed down as truths.10-12 These “truths” are so cemented into the knowledge base of dentistry that there is great resistance, in spite of the current evidence, to reconsider their validity. Any theory that involves how occlusion affects the cranio-mandibular-cervical system includes the role of bruxism. There is the tendency to envision the teeth and arches as articulated upper and lower models always fitting together, i.e., occluding. In reality, the occlusal-dental interarch contact only occurs about 20 minutes in a 24-hour period.12 In addition to that, there is no evidence that such time is even spent with full contacts between the arches. Bruxing events with tooth contacts can then Orthodontic practice 29

CONTINUING EDUCATION

health dates back to the mid-1800s with a legendary dentist from Philadelphia, Dr. William Gibson Arlington Bonwell, who was influenced by Freemasonry and religion. Ackerman, et al., report through Bonwell, and later through his student, Angle, that the “science of occlusion emerged from a pseudoscientific tradition already characterized in the 19th century as composed merely of so-called facts connected together by misapprehension under the disguise of principles, and that from the beginning, there were strong overtones of religious belief in the concept of occlusion.”5 The work of Bonwell and Angle led to the belief that ideal orthodontic treatment was the basis of normal dental function and oral health. That myth, despite overwhelming evidence to the contrary over the past 20 years, continues to haunt the dental profession. The deflection to the assumption of purported influence on body posture is just the most recent example. Reid and Greene have outlined the role of conservative therapy in the diagnosis and treatment of orofacial pain and joint dysfunction.6 The likelihood of these well-advised conservative therapeutic principles being followed and understood by dentists other than orofacial pain experts will remain limited until these myths are appropriately dispelled. In 1973, Roth, an orthodontist, references a series of prosthetic journals and low-quality studies and concludes that it is “generally accepted that the occlusion should ideally be in harmony with the closure and movement patterns that are determined and dictated by the temporomandibular articulations.” His study of only seven post-orthodontic patients demonstrated the presence of TMD symptoms that were eliminated by occlusal treatment. The “control group” of two patients had no postoperative symptoms and no reported occlusal interferences or balancing contacts. This led to the conclusion that “occlusion may play a more important role in the production of the temporomandibular pain-dysfunction syndrome than heretofore ascribed to it.”7 Occlusion continues to be emphasized in a 1973 paper in which Dawson reports, without references, “In my clinical experience, tic douloureux is almost always a misdiagnosis. It is usually nothing more than a classical TMJ syndrome and can be resolved by occlusal therapy.” He further writes, “The pain of TMJ syndrome is almost always resolvable in a matter of minutes once the occlusion

CONTINUING EDUCATION become the time when occlusion could have the greatest effect on the cranio-mandibularcervical system. The theory that bruxism is caused by “occlusal interferences” dates back to Karolyi.13 It became an essential part of dental education with Ramfjord’s conclusions in 1961 that occlusal interferences were causal for pain because “Clinically all patients experienced relief of pain and discomfort after complete occlusal adjustment.”14,15 These were poorly designed studies by today’s standards without a control group and are examples of inductive reasoning that has been used to generalize findings far beyond their validity. Despite the preponderance of the evidence that bruxism is centrally mediated and not the result of any specific occlusal scheme, the causal myth continues.16 This long history suggests that bruxism is the result of malocclusion, and therefore, many patients have been referred for orthodontics or occlusal equilibration to correct their occlusion in order to control their bruxism. This continues to be taught despite the studies that have shown relief from mock equilibration without removing “interferences.”17 The concept of the role of an ideal occlusion and the “fact” that ideal occlusion is critically important to a pain-free and normally functioning trigeminal system remained an assumption in dentistry without any level of evidence beyond empirical observation. In the early 1970s, the National Institute of Dental Research and the National Council of the National Academy of Sciences assigned three independent panels of orthodontic experts to evaluate research related to malocclusion. They essentially concluded that without a good definition of ideal or accepted variations of ideal occlusion, no direct correlations can be made between occlusion and dysfunction.18 In 1976, Weinberg questioned both the concept of “centric relation” and occlusion in the development of joint dysfunction, suggesting that treatment response tended to vary from patient to patient, and that the occlusal scheme is dependent more on the preferences of the dentist, rather than what could be considered required for that unique patient.19 From 1982, the evidence separating occlusal schemes from causation of TMD begins to prevail. In 1982, Graham and Buxbaum conclude that “treatment modalities considered within the first 6 weeks should be conservative and reversible to eliminate or 30 Orthodontic practice

The future of orthodontic care as an essential specialty of dentistry is not dampened by the realization that the goal of orthodontic care is not occlusally related. decrease myofascial trigger zones and their area of referred pain. Alteration of the existing occlusion and maxillomandibular relations may be adjusted with caution if necessary.”19 Bush goes a step further in 1984, reporting that “occlusal adjustment appears unsatisfactory as a modality for management of pain.”20 By as early as 2001, Greene notes that the etiological theories on temporomandibular disorders have progressively shifted from peripheral to central factors.16 Despite the fact that some investigators continue to suggest that there is a higher prevalence of TMD in patients with malocclusion as opposed to the “normal population,” “the literature on the effects of orthodontic treatment supports the neutral effects on the temporomandibular joint.”21 The literature support for the lack of a direct relationship between TMD and malocclusion is, in fact, overwhelming. Okeson initially writes that both psychological stress and occlusal interferences were causes of bruxism, thus connecting occlusion as a direct cause of TMD.22 In 2015, Okeson discusses the evolution of the science and reports that “the data did not suggest that orthodontic therapy was a significant risk factor for the development of TMD.”23 Michelotti’s excellent study in 2005 demonstrated that occlusal interferences did not create any pain symptoms in healthy females.24 Manfredini reports that a systematic review (Dworkin) “concluded that there are insufficient research data on the relationship between active orthodontic intervention and TMD on which to base our clinical practice.”22 Another systematic review by McNamara reviews much of the quality evidence and confirms that malocclusion is not a cause of TMD.26 Manfredini, et al., in a retrospective study on a huge sample of over 600 patients concludes that “… our findings support the view that orthodontics is TMD-neutral.”22 While some investigations continue to suggest the importance

of various occlusal schemes and joint positions in the development of TMD symptoms,7,27,28 the vast majority of high-level evidence supports the disconnect between occlusion and the development of TMD signs and symptoms. As Greene states,” A clear implication from all those studies is that orthodontic therapy is not required to resolve most TMD cases, regardless of the various occlusal imperfections that may exist in each patient.”29

Summary The belief that malocclusion is the most likely direct “cause” of TMD has a long history in dentistry. Alvin Toffler has written, “The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn.”30 Unlearning is difficult. Restorative gurus continue to teach the direct relationship between malocclusion and pain and dysfunction. Confirmation bias continues to support the long history of empirical evidence. Occlusal adjustments and orthodontics continue to be recommended as first line therapy for patients with various forms of TMD. There is no better way to summarize the relationship of malocclusion and TMD than the recent findings of the National Academies of Sciences. “The early treatment of malocclusion through orthodontic treatments was previously considered a viable preventive treatment for TMD. However, the evidence was clear decades ago that orthodontic repositioning of teeth does not prevent the onset of TMD.31 Nevertheless, some dentists have the outdated belief that orthodontic treatment will prevent TMD … [and] … Although commonly suggested as a potential cause, no studies have implicated orthodontic treatment in the development of a TMD.”18 Despite the preponderance of the evidence that clearly separates the state of the occlusion from a direct cause of TMD, patients continue to be referred to Volume 12 Number 4

The role of orthodontics today and beyond Despite the preponderance of the evidence clearly separating “occlusion” from either pain or temporomandibular joint dysfunction, the role of orthodontic therapy

has become even more essential. Rather than having an emphasis on how the teeth occlude when the elevator muscles contract and maintain contraction in a nonfunctional posture, a posture that results in dental contact approximately 20 minutes in a full 24-hour period,34 orthodontics of today has the loftier goal of improving craniofacial esthetics with improved function. The orthodontist of tomorrow won’t have glass cases filled with models in ideal occlusion, but walls filled with photos of faces with improved profiles and smiles. Orthodontic therapy guiding early growth and development can play a major role in the treatment of sleep-disturbed breathing in the young child. “Craniofacial growth influence by genetic inheritance and functional factors can have an impact on general health.”34 Preliminary studies have suggested that orthodontic treatments, such as maxillary expansion or mandibular advancement with functional appliances, may be effective in handling pediatric snoring and OSA.35 Guillminault, et al., demonstrated the

REFERENCES

effectiveness of the combination of adenotonsillectomy and maxillary rapid expansion in the resolution of pediatric OSA, while treatment of either modality without the other was less likely to be effective.36 The future of orthodontic care as an essential specialty of dentistry is not dampened by the realization that the goal of orthodontic care is not occlusally related. The future is in fact brightened by the orthodontic potential to improve the quality of life by playing a role in the improvement of both esthetics and function. The massive improvement in esthetics can increase the sense of confidence and self-worth of their patients. The significantly increased health resulting from improved sleep with the correction of sleep disturbed breathing has the potential not only to improve the quality of life but also to add years to one’s life expectancy.37 It is the opinion of the authors that the orthodontic community should embrace these evidenced-based changes. This is a very exciting model change for the entire profession. OP

Prosthet Dent. 1976;35(5):553-566.

1. Campbell JN. Extension of the temporomandibular joint space by methods derived from general orthopedic procedures. J Pros Dent. 1957;7(3):386-399.

20. Graham MM, Buxbaum J, Staling LM. A study of occlusal relationships and the incidence of myofacial pain. J Prosthet Dent. 1982;47(5):549-555.

2. Block LS. Diagnosis of occlusal discrepancies that cause temporomandibular joint or myofacial pain. J Prosthet Dent. 1967;17(5):488-489.

21. Bush FM. Occlusal therapy in the management of chronic orofacial pain. Anesth Prog. 1984;31(1):10-16.

3. Fonder AC. The Dental Distress System Quantified. 1988.

22. Manfredini D, Stellini E, Gracco A, et al. Orthodontics is temporomandibular disorder-neutral. Angle Orthod. 2016;86(4):649-654.

4. Ackerman JL, Ackerman MB, Kean MR. A Philadelphia fable: how ideal occlusion became the philosopher’s stone of orthodontics. Angle Orthod. 2007;77(1):192-194. 5. Reid KI, Greene CS. Diagnosis and treatment of temporomandibular disorders: an ethical analysis of current practices. J Oral Rehabil. 2013; 40(7):546-561. 6. Roth RH.Temporomandibular pain-dysfunction and occlusal relationships. Angle Orthod. 1973;43(2):136-153. 7. Dawson PE. Temporomandibular joint pain-dysfunction problems can be solved. J Prosthet Dent. 1973;29(1):100-112. 8. Steenks MH. The gap between dental education and clinical treatment in temporomandibular disorders and orofacial pain. J Oral Rehabil. 2007. 34(7):475-477. 9. Guichet NF. Biologic laws governing functions of muscles that move the mandible. Part III. Speed of closure--manipulation of the mandible. J Prosthet Dent. 1977;38(2):174-179. 10. Guichet NF. Biologic laws governing functions of muscles that move the mandible. Part II. Condylar position. J Prosthet Dent. 1977;38(1):35-41. 11. Guichet NF. Biologic laws governing functions of muscles that move the mandible. Part I. Occlusal programming. J Prosthet Dent. 1977;37(6): 648-656. 12. Graf H. Tooth Contact Patterns in Mastication. J Prosthet Dent. 1963;13(6):1055-1066. 13. Karolyi M. Beobachtungen uber Pyorrhea alveolaris. Oesterr-Ungar Bierteljahrsschrift Zahnheilkunde. 1901. 14. Ramfjord, S.P., Dysfunctional temporomandibular joint and muscle pain. J Prosthet Dent. 1961;11(2):353-374. 15. Ramfjord SP. Bruxism, a clinical and electromyographic study. J Am Dent Assoc. 1961;62:21-44. 16. Greene CS. The etiology of temporomandibular disorders: implications for treatment. J Orofac Pain. 2001;15(2):93-105.

23. Okeson JP. Etiology and treatment of occlusal pathosis and associated facial pain. J Prosthet Dent. 1981;45(2):199-204. 24. Okeson JP. Evolution of occlusion and temporomandibular disorder in orthodontics: Past, present, and future. Am J Orthod Dentofacial Orthop. 2015;147(Suppl 5):S216-S223. 25. Michelotti A, Farella M, Gallo LM, et al. Effect of occlusal interference on habitual activity of human masseter. J Dent Res. 2005;84(7):644-648. 26. McNamara JA Jr, Seligman DA, Okeson JP. Occlusion, Orthodontic treatment, and temporomandibular disorders: a review. J Orofac Pain. 1995;9(1):73-90. 27. Alanen, P., Occlusion and temporomandibular disorders (TMD): still unsolved question? J Dent Res. 2002;81(8):518-519. 28. Monaco A, Petrucci A, Marzo G, et al. Class II malocclusion on the kinesiographic pattern of young adolescents: a case-control study. 2013;14(2):131-134. 29. Greene CS, Galang-Boquiren MTS, Bartilotta BY. Orthodontics and the temporomandibular joint: What orthodontic providers need to know. Quintessence Int. 2017;48:799-808. 30. Toffler A. Future Shock. New York:Random House; 1970. 31. McNamara JA Jr. Orthodontic treatment and temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;83(1): 107-117. 32. Zakrzewska JM. Education is better than splints in temperomandibular pain. BMJ. 2012;345:e7447. 33. Rinchuse DJ, Rinchuse DJ, Kandasamy S. Evidence-based versus experience-based views on occlusion and TMD. Am J Orthod Dentofacial Orthop. 2005;127(2):249-254. 34. Graf H. Bruxism. Dent Clin North Am. 1969;13:659-665.

17. Goodman P, Greene CS, Laskin DM. J Am Dent Assoc. 1976;92(4):755-758.

35. Huynh NT, Desplats E, Almeida FR. Orthodontics treatments for managing obstructive sleep apnea syndrome in children: A systematic review and meta-analysis. Sleep Med Rev. 2016;25:84-94.

18. NASEM. Temporomandibular Disorders: Priorities for Research and Care. National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2020.

36. Guilleminault C, Quo S, Huynh NT, Li K. Orthodontic expansion treatment and adenotonsillectomy in the treatment of obstructive sleep apnea in prepubertal children. Sleep. 2008;31(7):953-957.

19. Weinberg LA. Temporomandibular joint function and its effect on concepts of occlusion. J

37. Jordan AS, McSharry DG, Malhotra A. Adult obstructive sleep apnoea. Lancet. 2014;383:736-747.

Volume 12 Number 4

Orthodontic practice 31

CONTINUING EDUCATION

orthodontists for orthodontic care to either correct or prevent TMD. Patients are being advised to proceed with dental restorative and prosthetic care to treat or prevent pain or dysfunction. “It is disappointing that the notion that occlusion causes temporomandibular pain [TMD, persistent orofacial pain] persists.”32 In 2005, Rinchuse, et al., commented concerning the continued teaching of an occlusal causation of TMD and thus the support of orthodontic treatment for pain resolution. They wrote: “How can the scientific evidence-based occlusion/TMD knowledge point so clearly in one direction, but dentists and orthodontists ignore this information and practice in a totally different direction.”33

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 16 CE credits for only $149; call 866-579-9496 or visit https://orthopracticeus.com/subscribe/ to subscribe today.

To provide feedback on this 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.

n To receive credit: Go online to https://iorthopracticeus.com/continuing-education/, click on the article, then click on the take quiz button, and enter your test answers. AGD Code: 180 Date Published: January 4, 2022 Expiration Date: January 4, 2025

TMD-occlusion-orthodontic connection revisited GLASSMAN/MALIZIA/MANDFREDINI

1. The basic occlusal principle(s) of ______ is/are taught at the predoctoral level, making every dentist aware of how important these principles are when performing restorative dentistry. a. balanced and bilaterally even contact b. canine rise c. anterior guidance d. all of the above 2. Any theory that involves how occlusion affects the cranio-mandibular-cervical system includes the role of _______. a. bruxism b. mock equilibration c. tic douloureux d. peripheral factors 3. In reality, the occlusal-dental interarch contact only occurs about _____ minutes in a 24-hour period. a. 10 b. 20 c. 40 d. 55 4. The theory that bruxism is caused by “occlusal interferences” dates back to _______. a. Block b. May c. Karolyi

32 Orthodontic practice

d. Fonder 5. _______ initially writes that both psychological stress and occlusal interferences were causes of bruxism, thus connecting occlusion as a direct cause of TMD. a. Okeson b. Bonwell c. Roth d. Dawson 6. While some investigations continue to suggest the importance of various occlusal schemes and joint positions in the development of TMD symptoms, the vast majority of high-level evidence _______. a. supports the disconnect between occlusion and the development of TMD signs and symptoms b. refutes the disconnect between occlusion and the development of TMD signs and symptoms c. notes that orthodontic treatment can undermine normal dental function d. none of the above 7. Orthodontic therapy guiding early growth and development _______ the treatment of sleep-disturbed breathing in the young child. a. should have no effect on

b. can play a major role in c. should not be considered for d. should be avoided in 8. Preliminary studies have suggested that orthodontic treatments, such as maxillary expansion or mandibular advancement with functional appliances, may be effective in handling _______. a. pediatric snoring b. OSA c. myofascial pain near the joint d. both a and b 9. Guillminault, et al., demonstrated the effectiveness of the combination of _______ and maxillary rapid expansion in the resolution of pediatric OSA, while treatment of either modality without the other was less likely to be effective. a. adenotonsillectomy b. CPAP c. body posture d. myofunctional therapy 10. The significantly increased health resulting from improved sleep with the correction of sleep disturbed breathing has the potential to _______. a. improve the quality of life b. add years to one’s life expectancy c. eliminate trigger zones d. both a and b

Volume 12 Number 4

CE CREDITS

ORTHODONTIC PRACTICE CE

Ali Oromchian, JD, LLM, offers suggestions to find out about your potential new hires without legal concerns

hen you’re in the position of leading a company or charged with hiring a team to run a practice, you want to make sure you’re hiring the best possible candidates. However, when your business is a dental practice, it’s not only your financial success that’s a concern, but also people’s dental health and overall well-being. That’s why the job interview is essential to master — it‘s the key to bringing in candidates who can make your practice thrive. It can also be the roadblock that results in the construction of a lackluster team. To build a practice that consistently brings in loyal patients and provides quality care, start by focusing on the dental job interview. If you can master this first step in the teambuilding process, you’ll continue to build a solid foundation as your team grows. It’s essential to ensure the interview process is fair, nondiscriminatory, and most of all, legally compliant to avoid getting yourself and your practice in legal hot water. Keep reading to learn about the essential questions you should focus on during a job interview and which questions you should legally avoid.

Why the dental job interview matters The hiring process has always mattered for a dental practice. Choosing the right people to staff your team can make for a group of employees who work well together and help keep patients happy. Choosing the wrong people can make for an unpleasant and stressful environment both for colleagues and the patients they serve.1 However, the hiring process, including the job interview, is more important than ever because there is currently a shortage of dental job applicants post-COVID-19. In fact, according to ADA News from the American Dental Association, more than 80% of practices attempting to hire staff are currently finding the process either very challenging or extremely challenging.2 More than half of dental professionals even consider recruiting their most challenging HR issue.3 This means that dental practice owners or hiring managers Volume 12 Number 4

Educational aims and objectives

This self-instructional course for dentists aims to demonstrate the importance of the interview process in the dental industry to find quality hires.

Expected outcomes

Realize the importance of the hiring process and the regulations associated with it.

•

Recognize which questions dental professionals should avoid in the interview process.

•

Identify key questions to ask to find quality hires for dental practices.

are focusing on making their practice a desirable place to work. While a cohesive, kind, and qualified team may convince a candidate to join a practice, a disjointed, improperly trained, or unhappy team may turn someone away. Make clear in the interview process that you care about your team members and the overall culture at the practice. Allow team members to engage in open communication with candidates to ensure they receive an accurate picture of what to expect regarding the work environment and the role itself. Approaching interviews in this manner will yield more success and help you find the right, motivated, and qualified candidates you need to serve your patients.

The best dental job interview questions to ask candidates Now that you understand the importance of acing interviews in the dental industry, let’s see which interview questions are the right ones to ask. To begin, start by making a checklist of the technical skills and soft skills (i.e., personal attributes needed for success such as time management and teamwork) desired as well as the level of experience and competencies you need. This makes it quick and easy to hone in on which candidates are options to consider, and which are not. You’ll also want to leverage the expertise of an HR specialist to manage the process of hiring a new team member for your practice. HR specialists are experts in interviewing and

hiring, and they can ensure your process is legally compliant and effective. They can also identify both promising signs and red flags in a candidate that you may have overlooked due to a lack of interviewing or hiring experience. It’s also important to keep in mind that you can take time during the interview process to express interest in a job candidate and to make a potential new employee feel welcomed. The dental job interview is both a screening and recruiting process: You want to assess whether or not the candidates meet the requirements of the job description and if they are a good fit (i.e., they display those soft skills you desire). Once you have established that, you can determine if it is appropriate to engage them in further discussions that help attract the candidate to the role and your practice. The best job interview questions to ask a candidate for your dental practice follow. Ali Oromchian, JD, LLM, is the founding attorney of the Dental & Medical Counsel, PC law firm and is renowned for his expertise in legal matters pertaining to dentists. Oromchian has served as a key opinion leader and legal authority in the dental industry with dental CPAs, consultants, banks, insurance brokers, and dental supplies and equipment companies. He serves as a legal consultant for numerous dental practice management firms that rely on his expertise for their clients’ businesses. He is also recognized as an exceptional speaker and educator who simplifies complex legal topics and has lectured extensively throughout the United States. To contact the author, please email ao@dmcounsel or visit www.hrforhealth.com. Disclosure: Mr. Oromchian is cofounder and Chief Executive Officer of HR for Health in the San Francisco Bay area.

Orthodontic practice 33

CONTINUING EDUCATION

The five best dental job interview questions to ask — and two to avoid — to build an outstanding team

CONTINUING EDUCATION Why did you decide to work in the field of dentistry? Your field is a particular one: It has its perks and its drawbacks, and it offers very specific hours, benefits, and challenges. When you’re interviewing candidates, ask why they’re drawn to this particular field. This will give you insight into what they’re passionate about doing, how they want to spend their time, and how deep their knowledge of the field is. It is with these questions that you can get the candidates to talk about their education and previous dental work experience. All of the candidates’ experience should demonstrate purposeful steps toward making a decision to have a career in dentistry. When your candidates answer, listen for the qualities you are seeking. Do they align with the values expected of all employees at the practice? Do they like helping people? Do they have empathy for those in pain? Are they fascinated by the human body and innovative technologies being developed to help it? Alternatively, are they mostly focused on the paycheck? This is a question that reveals candidates’ true values and motivations and gives you insight into whether they’re in it for the same reason as the rest of your team. This can give you a clue into whether everyone’s values will align for a cohesive culture and shared interests. How do you envision dentistry as we move into the future? This is an open-ended question. However, it can show you whether candidates see potential growth in the field, and if they’ve considered ways their position might change down the road. In a dental job interview, you don’t just want to know if someone has the right skills to perform day-to-day tasks. You want to see if candidates are thinking about a long-term career with your practice — or at least in the field. The answer candidates give to this question also gives you insight into the candidates’ ability to think creatively, to genuinely understand issues in the dental field and, more importantly, understand new ways dental professionals might be able to help solve those problems. Static thinkers can keep a practice static. Dynamic thinkers can help ensure that a practice continuously evolves, staying on the cutting edge of what dentistry has to offer. Finally, in a job interview, you want to see if the candidates are planning to be in the field for a long time, or whether the job you’re offering is just a stepping-stone. You want to boost retention as much as possible and minimize turnover, so candidates who 34 Orthodontic practice

haven’t considered the future of dentistry might be giving a sign that you’re not in their long-term plans. How do you stay on top of the latest trends and news in the dental field? Similar to the previous question, this inquiry shows whether candidates are invested in the field and show the concrete ways they are doing so. To provide the best dental care possible, you need employees who are interested in how the industry is changing and improving. Again, dental job candidates who are thinking about the future of dentistry are likely to want to have a job in the field in the future. Those who are not may be thinking of this job as a temporary position on the way to doing something else. It’s important to keep an eye on this because it may be a sign that hiring them will lead to turnover, which is very disruptive and expensive for a dental team. According to a recent survey, 27% of employees in the dental industry will leave within 2 years of being hired.3 Have you previously worked in a stressful work environment? If so, can you describe a time when you performed well despite the stress you experienced? It’s no secret that working in a dental office can be stressful. This question can help identify if candidates are prepared for the stress that comes from working in a practice and how they might handle that stress. You want your candidates to demonstrate their competence and ability to remain calm when things get difficult. This is especially important because patients look to dental staff to calm them down when they’re scared or stressed. The professionals around them should be able to stay calm and avoid compounding stress in the office environment. Asking about stress management is also a window into your candidates’ emotional intelligence — a generally important quality to have when you’re working with patients and other team members. Have you experienced any failures in your career, and if so, how did they help you grow? This is another question that asks about the candidates’ weaknesses in a dental job interview — and it also allows you to see what mistakes they’ve made and, more importantly, how they have reacted when faced with a failure. You want new team members who can overcome any challenge, and who won’t get defeated if things become difficult.

This particular question gives some insight into creative thinking because candidates may reveal that they were able to come up with a clever solution to help improve their professional “failure.” Creative staff members are always exciting and motivating to have around, coming up with innovative solutions and forward-thinking ideas, which can help keep a practice growing and evolving as time passes.

Dental job interview questions to avoid asking any candidate The preceding questions are essential to ask in any dental job interview, as they allow you to examine candidates beyond their qualifications and achievements. The candidates can give you an idea of their quickthinking and problem-solving abilities as well as how they will interact with patients and colleagues. However, there are also some questions that you should never ask in an interview because they could get you or your practice in trouble. Many questions may seem harmless enough on the surface, but in reality they could be discriminatory or even illegal. Certain questions can also make your practice seem unappealing, which could drive away potentially great candidates in an already tough hiring market. So how do you avoid certain questions, while still finding out what you need to know about candidates? When interviewing dental practice candidates, make sure all questions are fair, nondiscriminatory, and solely based on experience or other job-related factors. Several questions that you should never ask in job interviews with dental candidates follow. What’s your current salary? While you can discuss salary in an interview if a candidate brings it up, it’s important to be aware of the state you’re located in, as many states have laws/restrictions around salary inquiries. Never, under any circumstances, should you ask the candidates what they make at their current job. Not only does it put the candidate in a weird position (allowing their potential employer to manipulate their offer based on what they currently make), but it’s a risky question legally, since many states prohibit it. If your candidates directly share their salary with you, that’s fine — but you’ll want to take note of the fact that they actively shared that info without being asked. Take this opportunity to redirect the conversation toward the topic of salary range for the particular role the candidates are interviewing for. You want to proceed Volume 12 Number 4

Table 1: Interview questions to avoid and legal alternatives

Tell me more about yourself [insert personal protected information here]. A lot of personal information is legally protected in the professional realm. Candidates and employees are not allowed to be asked about certain topics, since they might be discriminated against based on these answers. These topics include things such as disabilities (including pregnancy), age, previous medical history, marriage status, and more. Essentially, job interviews should be strictly professional and should be solely focused on the job duties/competencies required for the role and candidates’ professional experience — both in the past and their goals for the future. Avoid all personal topics if possible unless a candidate brings something up — then you can simply listen and attempt to redirect the conversation. Following these guidelines ensures you won’t risk discriminating against candidates based on personal or protected information they shared with you. How much longer do you plan to work before you retire? While on the surface it makes sense to ask this question — after all you don’t want to hire someone and get them trained just so they can leave you a few years later — this could get you into serious trouble. Instead try asking “What are your long-term career goals?” This will help you understand where candidates see themselves in the future and hopefully give you an idea of if they plan to retire soon.

How to hone your dental job interview questions for interviews that work again and again Now that you understand what questions you should and shouldn’t ask during a dental job interview, you can get to work creating a standard list of questions for each position at your practice. After all, the questions shouldn’t vary based on the person — the answers will be what makes a candidate stand out and seem hirable. Once you’ve created a set list of questions for each position, you should return to that list every time you have to interview new candidates for that job to ensure consistency with your hiring process and to avoid claims of discrimination. The questions should be a good tool for revealing who you will hire, and who is not the best fit for your practice.4 If you Volume 12 Number 4

What not to ask

What to ask instead

Are you a U.S. citizen? What is your birthplace or national origin?

Are you authorized to work in the U.S.?

How long have you lived here?

What is your current address and phone number?

What religion do you practice?

What days are you available to work?

Which religious holidays do you observe?

Are you able to work with our required schedule?

How much longer do you plan to work before you

What are your long-term career goals?

retire? Do you have or plan to have children, or are you pregnant?

Are you available to work overtime on occasion? Can you travel?

If you get pregnant, will you continue to work, and will you come back after maternity leave?

What are your long-term career goals?

Do you have kids?

What is your experience with “x” age group?

We’ve always had a man/woman do this job. How do you think you will stack up?

What do you have to offer our company?

How do you feel about supervising men/women?

Tell me about your previous experience managing

Do you have any disabilities, handicaps, or mental conditions? What is the nature or severity of your disability?

Are you able to perform the specific duties of this position?

Have you had any recent or past illnesses or

Are you able to perform the essential functions of this job with or without reasonable accommodations?

operations?

teams.

already have a set list of questions, but realize you need to change up some of them, you can tweak the questions you already have. You don’t need to toss out the entire interview and start over! Here are some examples of questions that might seem discriminatory, but are actually useful — and fine to ask once tweaked. • “Do you have children?” might turn into “Are you able to meet the attendance requirements of this position?” After all, managers or bosses aren’t interested in whether a person has kids or not; they are wondering if there are life situations that will interfere with a candidate’s work regularly. • “How old are you?” can be shifted to “Are you over the age of 18?” You don’t need to know how old someone is for them to do the job; you only need to know that it’s legal for them to work for you. • “Are you religious?” can be shifted to “Are you available on weekends?” No boss needs to know potential team members’ religion. Bosses may only worry about religion because people who practice religion may be unavailable at certain times. So, ask about

the issue directly as it pertains to the requirements of the position — “Are you going to be available on weekends?” If they say yes or no, it doesn’t matter why. It just informs you about whether they have the availability to be at the practice on the days and at the times you need them to be there. Avoiding an expensive lawsuit and gaining peace of mind is easy when you follow the guidelines already discussed. OP This article is intended to provide general information and is not intended as legal advice. REFERENCES 1. Wojcik S. Destress in the office with these 4 Tips for dental practices. HR for Health. https://www.hrforhealth.com/ blog/destress-in-the-office-with-these-4-tips. Published April 20, 2021. Accessed October 21, 2021. 2. Versaci MB. Understaffed and ready to hire, dentists face applicant shortages as they emerge from COVID-19 pandemic. ADA News. https://www.ada.org/en/publications/ada-news/2021-archive/june/dentists-face-applicantshortages-as-they-emerge-from-covid-19-pandemic. Published June 9, 2021. Accessed October 21, 2021. 3. HR for Health. Unnecessary Risk: The State of Human Resources Compliance in Dentistry. A Special Report on Private Practices, Dental Groups, & DSOs [white paper]. HR for Health: 2021. https://f.hubspotusercontent40. net/hubfs/5014795/DSO%20Whitepaper%202021.pdf Accessed October 21, 2021 4. Wojcik S. Provide Your New Dental Hire with 4 Essential Documents to Prevent Getting Sued [blog]. https://www. hrforhealth.com/blog/four-essential-new-dental-hire-documents. Published September 2, 2021. Accessed October 21, 2021.

Orthodontic practice 35

CONTINUING EDUCATION

cautiously and ensure your knowledge is up-to-date regarding salary questions. You don’t want to violate a law before you’ve ever even decided whether you want to make a candidate an offer.

n To receive credit: Go online to https://orthopracticeus.com/continuing-education/, click on the article, then click on the take quiz button, and enter your test answers. AGD Code: 550 Date Published: January 4, 2022 Expiration Date: January 4, 2025

The five best dental job interview questions to ask — and two to avoid — to build an outstanding team OROMCHIAN

1. According to ADA News from the American Dental Association, more than _____ of practices attempting to hire staff are currently finding the process either very challenging or extremely challenging. a. 40% b. 66% c. 80% d. 92% 2. More than ______ of dental professionals even consider recruiting their most challenging HR issue. a. one-quarter b. half c one-third d. three-quarters 3. To begin, start by making a checklist of the _______ desired as well as the level of experience and competencies you need. a. technical skills and soft skills b. religion c. lowest salary d. attractiveness 4. With the question “How do you envision dentistry as we move into the future?” The answer candidates give to this question gives you insight into the candidate’s ability to _______. a. think creatively b. genuinely understand issues in the

36 Orthodontic practice

dental field c. understand new ways dental professionals might be able to help solve those problems d. all of the above 5. According to a recent survey, 27% of employees in the dental industry will leave within ______ of being hired. a. 6 months b. 1 year c. 2 years d. 5 years 6. Many questions may seem harmless enough on the surface, but in reality they could be _______. a. discriminatory b. illegal c. too difficult to answer d. both a and b 7. When interviewing dental practice candidates, make sure all questions are ______. a. fair b. nondiscriminatory c. solely based on experience or other job-related factors d. all of the above 8. Avoid all personal topics if possible unless a candidate brings something up

— then you can simply _______. a. tell the applicant a similarly personal bit of information about yourself b. listen and attempt to redirect the conversation c. realize that since the applicant started the topic, you can ask more personal questions d. stop the interview, and do not offer the candidate the job even if he/she is qualified 9. Now that you understand what questions you should and shouldn’t ask during a dental job interview, you can get to work creating a _______ for each position at your practice. a. list of questions depending on the applicant’s gender b. standard list of questions c. list of questions depending on the applicant’s age d. list of questions depending on where the applicant lives 10. Instead of “How old are you?” which may be construed as discriminatory, a more useful question would be __________. a. “Are you over the age of 18?” b. “How old are your children?” c. “What is your religion?” d. “Are you planning to have more children?”

Volume 12 Number 4

CE CREDITS

ENDODONTIC PRACTICE CE

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Each drug-free treatment plan is tailored to address the individual patient’s symptoms, and includes the use of several tested technologies, including ultrasound, photobiomodulation, microcurrent, and muscle manipulation.

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SOFTWARE

SPECIAL SECTION

DIBS AI by OrthoSelect A New Standard in Digital IDB What do you see as the biggest challenges facing orthodontists today? Staffing shortages, lack of doctor time, COVID restrictions, and patient satisfaction issues. These demands require doctors to find ways to provide superior treatment with limited time and resources. We created DIBS AI to help orthodontists tackle such issues.

What exactly is DIBS AI? DIBS AI is a software and hardware platform that is setting a new standard in digital Indirect Bonding (IDB) by helping doctors save time and become more effective in their orthodontic practices. DIBS AI uses more than 30 patented artificial intelligence algorithms to create case setups, perform predictive modeling for treatment outcomes, and 3D-print highly accurate IDB transfer trays.

How does DIBS AI save orthodontists time? DIBS AI creates efficiency and timesavings on three levels: First, the DIBS AI algorithms do most of the work for case setups, so doctors have to spend only a few minutes in the software per case. Second, our clients typically need less than 30 minutes for the actual bonding appointments. This time-savings frees up chair time, providing capacity to handle more cases. Third, because DIBS AI places brackets so accurately (+/- 0.1 mm), it can shorten overall

treatment time and reduce the need for repos and wire-bend appointments. We simply help doctors do more with less. That is why over 200 doctors in the past 12 months have adopted DIBS AI into their practice!

What differentiates DIBS AI from other options in the market? There are four elements combined that make DIBS AI unique: 1. While all software platforms require a certain amount of familiarization, our AI-powered system automates and simplifies the IDB process. This technology makes a complicated and time-consuming process much easier and faster for doctors and staff alike. 2. Our patented tray design fits, seats, and stays in place. Because we don’t encapsulate brackets, there are fewer gingival flash and debond issues as seen with some other options on the market.

3. We make the process easy. Our customers can do as much or as little of the case setups as they like. We’ll do the rest. We can even 3D-print IDB trays in our lab in under 24 hours. 4. We don’t use subscription pricing or contracts. We simply charge a low per-arch fee.

What types of software support is most important to orthodontists, and how do you provide for that? No two doctors or their needs are exactly alike, so we believe in providing flexible support options. That is why our customers can connect with us through a variety of means, including phone, email, chat or video — whatever works best for them. Our top priority is to make doctors successful, so we provide unlimited, free support with our U.S.-based team of support specialists. We are not satisfied until our customers are!

How does your company provide/prepare for the future of orthodontics?

To Learn More Visit DIBSAI.com for more information and a free demo.

38 Orthodontic practice

As new providers enter the market, orthodontics will become increasingly competitive. Therefore, we created DIBS AI to be a powerful tool orthodontists can use to differentiate themselves from their competition — and we continue to innovate and improve our software platform. In the coming months, we will introduce tooth-root integration and the flexibility to provide braces and/ or aligners all in one software platform.

Volume 12 Number 4

SPECIAL SECTION

SOFTWARE tops Platform One Why Platform One? “There’s never been any security issues with multiple locations in my 10 years of using tops. … The biggest positive that I can think of saying for tops, especially as a practice management software, is that I don’t really have to think about tops all day long because it’s just doing its job.” — Dr. Rob Aszkler of Aszkler Orthodontics

Why Platform One? “There’s a reason we’ve stayed with tops since 2008. They’re constantly updating and changing according to our needs and the needs of the orthodontic community in general.” — Dr. Sandra Maduke of Maduke-Bulat Orthodontics

Why Platform One? “For 15-plus years, I’ve had the same front desk. And she also helps with insurance and ﬁnancial contracts. In most offices, that is a multi-person arrangement. And because tops is so smooth and straightforward in that area, she’s always been able to carry all three of those hats as one person.” — Dr. Michael Fesler of Fesler Orthodontics

Why Platform One? “If I had to do it again and start over with a new team, [tops] would be my ﬁrst-round pick.” — Dr. Michael Geric of Geric Orthodontics

Why Platform One? “I’ve had tops for the last 6 years. It’s never not turned on or not worked. No security issues at all. As an orthodontist, I just need it to work. tops ﬂat-out works.” — Dr. Eric Leber of Leber Orthodontics

Why Platform One? Platform One combines all your subscriptions into a single orthodontic practicemanagement app — a comprehensive suite of tools secured by single sign-on, powered by the ultra-fast Lightning Cloud™. All backed by exceptional customer service. One vendor. One bill.

Platform One To learn more, visit topsOrtho.com, call +1 770.627.252, or email us at info@topsOrtho.com.

Why Platform One? Curbside check-in, digital forms, and more with plum. Call, text, or email us to learn more. Volume 12 Number 4

Orthodontic practice 39

PRODUCT VIEW

Orthodontists asked, and LightForce listened New invention eases emergency appointments

“R

ebonding using the IDB tray was very easy, very fast. We knew what bracket was off; we had the tooth prepared; we had the bracket prepared; the patient sat down; we cleaned the tooth and bonded it. It took maybe 5 minutes. With the LightForce new Rebond LightTrays, emergency rebondings have gotten a lot faster and less stressful.” — Just take it from Dr. Ella Osborn of Seaport Smiles. From the perspective of someone operating a fully digital practice, a broken appliance had previously been a headache. A rebond with a stock bracket can take up to 20 minutes for each missing piece. “When I see an emergency on the schedule, my stomach turns a bit because I know my day is not going to be as smooth as it could have been.” However, the new rebonding trays have decreased Dr. Osborn’s emergency appointment time by 75%. In the past, some orthodontists came up with a creative solution for rebonding broken brackets — cut the IDB trays into individual tooth segments. While innovative, this solution is imperfect as there is no designated place to cut the IDB trays. Without the context of the other segments of the IDB tray, there can still be inaccuracies in bracket placement. The Rebond LightTrays were invented based on the feedback and innovation of these orthodontists and the

The Light Bracket is a translucent, more esthetic option that blends in with the color of patients’ teeth 40 Orthodontic practice

Orthodontists can achieve new levels of precision with the LightForce custom-built Rebond LightTrays, which are manufactured to exactly match each patient’s teeth

desire to maintain precision when rebonding brackets if they do break. Kelsey Fafara, the director of hardware engineering at LightForce, said, “We knew from day one that we were going to need to make trays specifically for rebonding. The feedback from our orthodontic partners amplified that knowledge and helped us prioritize this project in the hardware department. The nice thing about having this project planned for so long is that we had the ability to integrate it smoothly into our 3D-printing process.” The new trays are printed specifically for rebonding, with segmented trays that make it easy to place brackets on each individual tooth that is missing its appliance. Just like the LightForce fully customized bracket, the rebond trays are manufactured to match each patient’s unique tooth morphology. The LightForce Rebond Tray has an occlusal shelf that makes it easy for orthodontists to apply pressure during bonding, and they can easily remove the tray from the patient’s mouth once the bonding is complete without any need for additional cleanup. In addition, the tray’s bridges are flexible but tough to break,

so you can maneuver them as needed, but you don’t have to worry about accidentally snapping them during the rebonding process. Replacement parts will be shipped in a smaller box with the initial case to be kept in the office after bonding so that orthodontists will not have to wait for replacement brackets to be made. Another important part of the rebonding process is the ease of delegation. Dr. Osborn spends only 30 seconds of the time that it takes to rebond with the new IDB trays. “With the extra time that I have, I am going to spend more time with my dog, who is often around the office with me.” The Rebond LightTray is just one of the LightForce newest products — the company also recently launched the Light Bracket. This translucent bracket offers all the same benefits of the Cloud Bracket, but is a nearinvisible option for patients who want a more discreet look. Learn more about LightForce, Rebond LightTrays, and the Light Bracket at wineandlearns.com. OP This information was provided by LightForce.

Volume 12 Number 4

OC OrthoCatapult Lorem ipsum

HELP MORE PATIENTS SAY YES!

“Since adding OrthoCatapult, our conversion rates have skyrocketed.” Dr. Lathe Miller, Orthodontist, Grand Rapids, MI

OrthoCatapult is the only orthodontic case acceptance platform focused solely on helping more patients say “Yes” to treatment. As an A to Z solution for your case presentations, OrthoCatapult is in a league of its own. Nothing else on the market comes close to the

quality, functionalities, or ease of use. That’s why we can confidently guarantee results!

The Ultimate Orthodontic Case Presentation System.

See it in action at orthocatapult.com.

The future of teen treatment is clear

95% of experienced Invisalign® orthodontists agree it’s the future of teen treatment.1 Experienced Invisalign orthodontists can treat nearly 70% of teens seeking treatment with Invisalign clear aligners.1 With technology like Mandibular Advancement and SmartForce® attachments, you get the control and predictability you expect while your teen patients get the smiles they want. Learn more about the technology behind more than 2 million teen smiles at Invisalign.com/provider/teen.

1. Data from a survey of 78 orthodontists (from NA, EMEA, APAC) experienced in treating teenagers (minimum of 40 cases, prior 8 months) with Invisalign clear aligners, regarding teenagers with permanent dentition; doctors were paid an honorarium for their time. © 2021 Align Technology, Inc. All Rights Reserved. Align, the Align logo, Invisalign, the Invisalign logo, SmartForce®, among others, are trademarks and/or service marks of Align Technology, Inc. or one of its subsidiaries or affiliated companies and may be registered in the U.S. and/or other countries. | MKT-0006346 Rev A