Orthodontic Practice US Summer 2022 Vol 13 No 2 by MedMark, LLC

AAO Special Section

4 CE Credits Available in This Issue* The New Standard of Care

Summer 2022 Vol 13 No 2

Chris Bonebreak Cover Banner Specifications Jackson, DMD, MS Publication trim size 8.375” x 10.875”

orthopracticeus.com

Introducing 3 exciting new products and features from LightForce:

CUSTOM B UCCA L TUB ES

Finding LightForce Managing controlled substances in dental practice: prescribing and record keeping

MIX ED D EN TITION A N D STAGED TR EATMEN T SUPP ORT

Tyler Dougherty, PharmD Michael O’Neil, PharmD Nikki Sowards, PharmD

Company spotlight Specialty Appliances

Smile bleaching and orthodontic treatment is a perfect match Drs. Jaimeé Morgan and Stan Presley

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INTRODUCTION

Treatment results — what’s ahead?

Summer 2022

n 1959, Dr. Cecil C. Steiner in his classic article, “Cephalometric in Clinical Practice” asked, “Do you really want to know what you are doing to your patients, or are you afraid to find out?” This question reflects the resistance to cephalometric analysis 63 years ago. The same argument could be made today about the use of CBCT in clinical practice. As orthodontic specialists, we should differentiate ourselves from the other orthodontic providers with our superior treatment outcomes. Using 1959 technology (cephalometrics) is inconsistent with this goal. For example, decrowding of dental arch via lateral expansion is not measurable using cephalometrics. It is almost as if we are playing the system by expanding the lower intercuspid width to decrowd while measuring changes with a pre- and posttreatment cephalometric radiograph, which mostly looks at the changes in the incisor position. Modern-day technology allows us to visualize individual teeth and the supporting alveolar housings. This changes not only how we treatment plan our cases, but also how we evaluate our finished orthodontic results. Poor treatment results cannot be hidden by the wide focal trough of the cephalometric radiograph. Think about the following scenario: A patient comes to your office with 12 mm of lower crowding. You want to extract, but the parent is against it. You tell the parent that you would be willing to level and align the arches and take a progress ceph to see if the treatment approach is acceptable. Eight months into treatment, you take your progress ceph. The progress ceph shows slight flaring of the lower incisors, perhaps 2-3 degrees. At this point, you tell the parent that you believe you can continue the nonextraction approach with some interproximal reduction. Unfortunately, the cephalometric radiograph cannot measure the “primary” mechanism for decrowding via lateral arch expansion. It is almost as if these broad-form or lateral development archwires “trick” the cephalometric analysis system. Let’s take the same scenario, but instead of only an 8-month progress ceph, we take a progress CBCT. No doubt the CBCT will show significant root dehiscence, which was completely missed via ceph/pan analysis. Despite no shortage of rationalizations in the orthodontic community, attempting to explain away what we see on the CBCT is not what we see. Most orthodontists would not knowingly promote a treatment approach resulting in significant dehiscence. While minor root dehiscence may not be accurately diagnosed via CBCT, larger orthodontically induced dehiscence can be easily and accurately visualized. Now let us jump to 2032. This same patient is at his/her general dentist for an annual checkup. I would predict that most all general dentists will be replacing panoramic X-rays with CBCT over the next 10 years. I believe it will be fairly easy to connect the dots once the general dentist looks over the CBCT scan and sees a generalized root dehiscence pattern, which could only be associated with orthodontic treatment. Imagine the phone call from the general dentist asking how he/she should deal with the significant root dehiscence now visible via CBCT. As orthodontists, we get blamed for many things not associated with our treatments. Orthodontically induced root dehiscence is not only directly connected to orthodontic treatment, but also easily diagnosed with CBCT even in the absence of gingival tissue recession. To once again quote Dr. Steiner, “Do we really want to know what we are doing to our patients, or are we afraid to find out?”

Jeffrey Miller, DDS, PA, graduated summa cum laude from Towson University in 1978 and earned his dental degree from the University of Maryland in 1982. He received his orthodontic certificate from SUNY at Buffalo in 1984. In 1991, Dr. Miller become a Board-certified orthodontist. He has specialized in orthodontics for over 35 years and is a regent for the AAO Foundation.

Orthodontic Practice US

Volume 13 Number 2

Editorial Advisors Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD 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 Board Bradford N. Edgren, DDS, MS, FACD Fred Stewart Feld, DMD Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA Justin D. Moody, DDS, DABOI, DICOI Lisa Moler (Publisher) Mali Schantz-Feld, MA, CDE (Managing Editor) Lou Shuman, DMD, CAGS

© MedMark, LLC 2022. 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 Endodontic Practice US or the publisher.

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TABLE OF CONTENTS

PUBLISHER’S PERSPECTIVE

A little bit of summer Lisa Moler, Founder/CEO, MedMark Media............................... 8

ORTHODONTIC CONCEPTS

A proposed grading system for severity of a skeletal maxillary transverse deficiency

COVER STORY

Chris Bonebreak Jackson, DMD, MS Finding LightForce Cover image courtesy of LightForce.

Dr. John L. Hayes says that a grading system can help increase communication with patients ...............................................................16

PRACTICE MANAGEMENT

“Are you ready to start your treatment?” Drs. Donald J. Rinchuse and Dara L. Rinchuse discuss the importance of establishing a policy for the retention phase ........................................................ 24

AAO SPECIAL SECTION

COMPANY SPOTLIGHT

Specialty Appliances

Innovator and leader of digital technology

Orthodontic Practice US

Volume 13 Number 2

3M™.............................................. 30 Brava by Brius™............... 31 The Norris 20/26® System.........................................32 Gaidge..........................................33 Ormco™.....................................34 Step-1 PumEtch................35 Spark Aligners....................36 Specialty Appliances.... 37 uLab Systems, Inc......... 38

TABLE OF CONTENTS

PRACTICE MANAGEMENT

How to handle negative reviews Dr. Len Tau discusses how to soothe the sting of a negative review............................................. 39

CONTINUING EDUCATION

PRODUCT PROFILE

Built to Last. Built for You. Built by Boyd!............50

CONTINUING EDUCATION

Smile bleaching and orthodontic treatment is a perfect match

Drs. Jaimeé Morgan and Stan Presley discuss how appealing to patients’ desires for esthetic enhancement during orthodontic treatment can have other positive effects

PRODUCT PROFILE

VISION by SoftSmile

............................................................... 52

Ormco™

The Damon Ultima™ System..... 54

ORTHO PERSPECTIVE

A new orthodontic mindset Dr. Amy Jackson discusses athome, direct-to-door delivery of orthodontic care..........................56

*Paid subscribers can earn 4 continuing education credits per issue by passing the 2 CE article quizzes online at https://orthopracticeus.com/category/continuing-education/

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

Orthodontic Practice US

Volume 13 Number 2

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PUBLISHER’S PERSPECTIVE

A little bit of summer

hile writing my message for this summer issue, John Mayer’s song “Wildfire” started playing on the radio. It started me thinking about what summer means. The song says, “… a little bit of summer is what the whole year’s all about.” After the past 2 years of rethinking, regrouping, and reopening, we’ve all worked so hard to get back to business. Working hard is what dentists do best — outfitting the office with the best equipment, taking continuing education courses, and learning new management techniques to keep the offices running smoothly. Lisa Moler All the while keeping patients happy and offering the best Founder/Publisher, dental care. Throwing your practice into high gear takes lots MedMark Media of energy and diligence. But we also must remember to take a step back and at least for a little while, enjoy some of the joys of summer. An article in Forbes titled, “The Evolving Definition of Work-Life Balance,” says that “maintaining work-life balance helps reduce stress and helps prevent burnout in the workplace.” The article continues, saying that stress is one of the most common health issues in the workplace, leading to high blood pressure, stomach issues, aches, pains, and heart problems. Emotionally, stress can lead to depression, anxiety, insomnia, irritability, and low work performance.1 Balance means different things to different people. To alleviate stress, some people just like to spend some quality time with family or friends; some want to hop back on that cruise ship; and others like to hit the hiking trails and commune with nature. Whatever brings a smile to your face will keep summer in your heart and mind for the rest of the year. Take us with you! On vacation or on your backyard deck, you can still consider new concepts to bring back to your office. Whether you read our publications in print, on your laptop, iPad, or phone, our articles are meant to inform, intrigue, and inspire you to new techniques, products, and services that promote success. The cover story in our summer issue focuses on Dr. Chris Bonebreak Jackson, the new Director of Clinical Affairs for LightForce Orthodontics. Read about the extraordinary analytical, engineering, and orthodontic skills that she brings to the LightForce team. Don’t miss our AAO Special Section, featuring companies that are transforming orthodontics with their products — aligners, tooth-moving systems, digital technologies, patient management platforms, and tooth prep products. Jot down their booth numbers to see these innovations for yourself! A CE by Drs. Jaimeé Morgan and Stan Presley discusses the benefits of smile bleaching during orthodontic treatment. Don’t forget to take the quiz to obtain your CE credits. How do you know when to take a step back so that you can continue moving forward? Here are a few tips: • Be aware of your feelings. If you start to feel more sad or grouchy than energized and content, it’s time to figure out why. • Consider your priorities. What is most important to you in life? Do you need more time for yourself, friends, family, or just your pet? • Don’t be afraid to change. Once you decide on a plan — do it! Change or rearrange your office duties to help create a calmer or more effective workplace. We love our work. But we also have to remember to include a bit of play. At work, you are changing lives, and at play, you are making memories. We need to rest and rejuvenate to create. John Mayer’s lyrics sum it up so well — “a little bit of summer makes a lot of history.” To your best success! 1.

Kohll A. The Evolving Definition of Work-Life Balance. Forbes. March 27, 2018. Accessed April 21, 2022. https:// www.forbes.com/sites/alankohll/2018/03/27/the-evolving-definition-of-work-life-balance/?sh=78c3e10d9ed3.

Orthodontic Practice US

Volume 13 Number 2

Published by

Publisher Lisa Moler lmoler@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 Sales Assistant & Client Services Melissa Minnick melissa@medmarkmedia.com Creative Director/Production Manager Amanda Culver amanda@medmarkmedia.com Marketing & Digital Strategy Amzi Koury amzi@medmarkmedia.com Digital Marketing Assistant Hana Kahn support@medmarkmedia.com Webmaster Mike Campbell webmaster@medmarkmedia.com eMedia Coordinator Michelle Britzius emedia@medmarkmedia.com Social Media Manager April Gutierrez socialmedia@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 Rate 1 year (4 issues) $149 https://orthopracticeus.com/subscribe/

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COVER STORY

Chris Bonebreak Jackson, DMD, MS Finding LightForce

t 39-years old, Dr. Chris Bonebreak Jackson has been a mechanical engineer, a bond trader, a dental faculty member, a patent holder, and an orthodontist. Patients call her Dr. Jackson. Three daughters call her mom. At LightForce, she’s Bones. Like her monikers and her careers, she defies a singular definition. Now she brings her extraordinary analytical, engineering, and orthodontic skills and insights to LightForce as Director of Clinical Affairs. In our cover story, Dr. Bonebreak Jackson delves into her orthodontic roots, her search for a fulfilling and productive vocation, and the epiphanies that led her to LightForce.

LightForce’s translucent bracket, the Light Bracket

What detours did you take on your road to orthodontics?

Tell us about your family’s orthodontic legacy.

My dad, Byron Bonebreak, DMD, MS, was the town orthodontist in Columbia, Maryland. After school and during the summer, I worked at his office. He loved his job and his patients. We went to his patients’ football games. If patients he met there were wearing their retainers, he gave them a dollar. When I was growing up, all of our vacations were at the AAO. While my dad attended meetings, my twin brother and I would run around the exhibit floors with big bags and collect all the swag. At home, my nightstand drawer was filled with floss and proxy brushes that I collected. My brother, David Bonebreak, DDS, MS, decided to be an orthodontist, so I was not under pressure to take over the family business. Orthodontic Practice US

I really liked math and science as well as working with my hands and designing, so I studied mechanical engineering at MIT. During that time, I was an intern engineer at a few labs, and after work, I played poker with my coworkers. I found the game fascinating — the odds, the thrill of winning, and the analytical math involved. Those after-work Texas Hold ‘em sessions developed into an online poker hobby. During my senior year, my roommates were applying to the big banks for jobs. I decided to send my resume too. Goldman Sachs called me for an interview. In my final round, one of my questions entailed a hypothetical

Volume 13 Number 2

COVER STORY

poker hand. I had to figure the odds, analyze risk assessment, know what risks to take, and know the markets. I got the job as a bond trader and stayed for 5 years through the tough financial crisis. I loved the professional team, the fast-paced work, and the math. The algorithms behind the trades indicated to me immediately how changes in the market would affect the outcome.

ters. Many orthodontists, including me, who already had tickets to Boston for the AAO went to the LightForce FUTURE conference instead. I heard users talk about their experience with LightForce approaching orthodontics so uniquely and felt the excitement that echoed throughout the community. I felt the need to get on board with the LightForce system or to get left behind. On returning to Chapel Hill, my partner and I implemented LightForce, and I also brought the technology to my UNC residents. Alfred reached out again later that fall, and I was ready to listen.

What brought you back to orthodontics?

I missed working with my hands and helping individuals. I was open to something new and started checking engineering job boards. In 2009, my whole family went to the AAO in Boston. It was the weekend before my birthday. I wanted to eat lobster rolls with mom and collect some swag on the exhibit floor. During that meeting, I saw all the new technology that had been developed since I last worked in my dad’s office — 3D printing, clear aligners, in-office milling options. It was a very exciting time for dentistry and orthodontics. I had my career-changing epiphany. Orthodontics was my chosen form of engineering. Orthodontists use forces to move teeth, and I can visualize the center of resistance and what moment I am going to get by applying those forces. It all comes naturally to me. I started studying for the DAT and taking night classes to finish my dental school prerequisites. I would sneak off the trading floor at 5:30, which is early for finance. One of my friends would pick up an extra sandwich at lunch and slip it into my bag so that I would have something to eat on the way to school. That thoughtful and caring friend was to become my future husband, Robert. I started Harvard School of Dental Medicine in 2010. Then during my residency at University of Chapel Hill Adams School of Dentistry in North Carolina, I wanted to study customized orthodontic systems. While doing research, I found some local labs that were doing 3D metal printing, and I designed a bracket and had to validate the use of 3D printing in orthodontics for my research. In 2017, I presented that research at the AAO and won the Charley Schultz Resident Scholar Award. This was very validating for me because the orthodontic community was recognizing that 3D printing was going to change orthodontics.

What is your role in LightForce?

I am Director of Clinical Affairs and in charge of clinical education and research — ensuring that doctors are empowered with all of the information and tools for success with our technology, and conducting internal and external studies that help us to continually innovate. LightForce reduces doctor time, appointments, and treatment times through its efficiencies by putting the right bracket in the right place the first time. I also help bridge the gap between the orthodontic community and our engineers so that we can develop products that orthodontists are asking for. I can speak orthodontics, and I can speak engineering. I love to be the first person to get my hands on a product, test it, and offer feedback. There is no such thing as a bad

How did you become involved with LightForce?

I had known Alfred (Dr. Alfred Griffin, DMD, PhD, MMSc, cofounder and CEO of LightForce) when we often crossed paths on the interview trail for our residencies. We both shared an interest in the value of 3D printing. After my residency, I received a National Science Foundation Small Business Innovation Grant and started a company that continued research into 3D metal printing. Alfred chose a path of 3D ceramic printing. I was happily living my dream in Chapel Hill in private practice 2 days a week, doing research 2 days a week, and teaching at UNC as adjunct professor of orthodontics 1 day a week, while raising my daughters. In 2020, Alfred reached out and asked me to join LightForce. I was not ready to move. In 2021, when the AAO was canceled, LightForce hosted an event at its headquarorthopracticeus.com

LightForce’s new fully customized, 3D-printed buccal tubes (above left). Dr. Chris Bonebreak Jackson at the LightForce office (above)

Volume 13 Number 2

COVER STORY

list supporters.” Once you try it, you don’t want to try anything else. I want people to come to LF FUTURE 2022 with an open mind and see what LightForce users have already discovered. I am so excited for this year’s conference in June and to hear my peers like Dr. Maz Moshiri, Dr. Lisa Alvetro, and Chris Bentson speak.

How is LightForce different from other systems on the market? Some orthodontists think they have already experienced custom orthodontics because there are systems that will help you to place a bracket in a custom position. In those cases, a bracket will offer a custom slot or base, but there is no system that does everything that LightForce does. LightForce 3D-prints a custom slot and custom base, and can attain custom placement because we are the only company that can 3D-print a 100% custom bracket. With those “almost custom” systems, inaccuracies and inefficiencies still require the doctor to compensate by either bending wire or by repositioning a bracket. With LightForce’s 100% customization, there are no compensations because everything is already in its place.

LightForce’s new, fully customized, 3D-printed buccal tubes in the LightPlan software (above). Dr. Chris Bonebreak Jackson and LightForce CEO Dr. Alfred Griffin at LF FUTURE 2021 (right)

idea. There may be limitations, but we have engineers who really think outside the box. We are reimagining braces. Thanks to 3D printing, we can change a product through design. Other companies have to retool a mold at a huge expense to change an item. That is why there has been minimal progress in orthodontics over the last 100 years.

What innovations will we hear about at LF FUTURE 2022?

How do you spend your time outside of work?

My husband and I keep very busy raising our three daughters, ages 4, 6, and 8. I love that they see me working hard for something I am passionate about. I want to inspire them to innovate and take risks. My daughter is already learning about perseverance. She said to me, “Nothing is impossible, it’s just challenging. You have to figure it out.” That is so true. When I decided to return to school for 7 more years after I had already been a professional for 5 years, my coworkers on Wall Street thought I was crazy; but after those 7 years, I am doing something I love.

How did your past careers position you for success?

In a private practice and throughout my schooling and residency, I had to learn to collaborate with different people. It is helpful to be able to have a calm professional conversation with someone who has a different viewpoint. Also, on Wall Street, I learned to synthesize a lot of information very rapidly. I had six monitors, and I had to take all the incoming data, internalize it, and then be able to make a market. Now in my orthodontic practice, we also have to be able to synthesize information rapidly — the patient’s starting occlusion; how the teeth got that way; where the teeth have to move; and how we are going to achieve our tooth movement goals. LightForce has amazing tools to make that easier.

What are you expecting at LF FUTURE 2022?

I want people who are on the fence to come and see what LightForce is all about. LightForce has a community of “evangeOrthodontic Practice US

LightForce in its current form is already amazing and has been a game changer for my practice. But we continue listening to orthodontists and giving them what they ask for. We recently announced a big product release that we called LightForce 2.0. In this update, we added 6’s and 7’s to our product line, which were very challenging to perfect; but for us, challenges turn into realities. Our doctors are now able to submit additional scans to incorporate newly erupted or previously impacted teeth during treatment, which allows them to treat these patients with all the benefits of a 100% custom system. Also, we added more diagnostic tools in the software to help our in-house technicians as well as our doctors when they plan their cases. Through collaborations with orthodontists, we have improved tie-wing and hook directionality, placement, and shape. LF 2.0 is the product of the feedback from the doctors over the past couple of years, and at LF FUTURE 2022, that conversation will continue. At breakout sessions, we will hear from our users about their wants and needs, and we will bring this discussion to our engineers. With LightForce, if we can think it, we can make it. We don’t just make braces; we 3D-print tooth-moving tools. There is enough excitement and new things evolving at LightForce that I will never run out of things to do and imagine up. It really is the perfect amalgamation of my experience in business, engineering, teaching, and orthodontics. I don’t know that I could find another job that would be better suited for all of those things. The AAO has been my epiphany place. It was there I decided to pursue orthodontics, and there that I discovered the phenomenon that is LightForce. These lightbulb moments at AAO have allowed me to come full circle. OP Volume 13 Number 2

Meet The New Standard Of Care

THE WORL D’S FI RST FULLY CUSTOM , 3 D P RI NTED, BRAC KE T SYSTE M WW W.LF.CO/V 2

COMPANY SPOTLIGHT

Specialty Appliances Innovator and leader of digital technology

pecialty Appliances, founded in 1981 by Scott Huge, has since become an industry leader in orthodontics. The company’s rich history is built on fabrication of all types of functional appliances, retainers, fixed- and removable-arch development appliances, and the Herbst® appliance. The company is on the forefront of indirect bonding both labial and lingual services and working with TAD appliances. Taking pride in innovation, Specialty Appliances started making Clear Image® Aligners in 2006 and invented the MiniScope® mechanism, M4™ mechanism, AppleCore® Screws, ROC™ Crowns, Shim Crimping Pliers, Shim Guides, and Herbst® extension tubes. Today Specialty Appliances is 3D-printing splints, laser-sintered bands and crowns, and can also print entire appliances out of metal. Additionally, the company worked to develop a 3D wire-bending machine for orthodontic laboratories. Specialty Appliances always uses the best materials and systems available. The company is committed to using state-of-theart technology and the most advanced techniques, along with using laser welding for over 20 years, digital scanners for over 13 years, and digital printers for over 11 years. Specialty Appliances’ commitment to making the best appliances in a timely manner shows on a daily basis. In 2013, the company received its ISO 13485 certification. Specialty Appliances also follows all FDA GMP practices and is registered with the FDA. Specialty Appliances will always stay committed to developing and maintaining the same high-quality standards that have helped the company advance the orthodontic world for 40 years. OP

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This information was provided by Specialty Appliances.

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Volume 13 Number 2

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ORTHODONTIC CONCEPTS

A proposed grading system for severity of a skeletal maxillary transverse deficiency Dr. John L. Hayes says that a grading system can help increase communication with patients Abstract

Introduction This article proposes a grading system for the severity of a patient’s skeletal maxillary transverse deficiency. Although there are medical staging systems available to grade the severity of medical maladies for improved communication, there is presently no grading system to describe the severity of an orthodontic patient’s skeletal maxillary transverse deficiency.

Materials and methods A device was constructed from a modified vernier caliper mounted to a base with molar form No. 14 attached to the sliding caliper scale. Mandibular tooth form No. 19 was fixed to the base beneath No. Figure 1: As the CAC differential of the maxilla versus the mandible varies from plus 5 mm to 14 and prevented from translating (rotation about its negative 10 mm, molar inclination increases from zero to 25 degrees. The X axis shows the center of rotation was possible). By sliding the calwidth differential between the maxilla and mandible. For example, plus 5 means that the maxiper’s scale, tooth No. 14 could be made to move illa is 5 mm wider at the 6-year molars than the mandible at the 6-year molars. A negative in the transverse direction and also rotate about its 5 mm means that the maxilla is 5 mm narrower than the maxilla (10 mm deficient from the center of rotation. Inclination measurements were ideal). A photograph of the THID is also shown taken as the caliper’s scale was moved to simulate a transverse narrowing of the maxillary arch form (mandibular molars was 17 degrees from vertical (with lingual inclination molars inclined lingually as the maxillary molars inclined bucof the mandibular molar and buccal inclination of the maxilcally). Skeletal width measurements were taken using the Center lary molars). Six grades of increasing severity are proposed for of Alveolar Crest technique, (CAC), previously reported. improved communication.

Results

Conclusions

With the maxillary arch 5 mm wider than the mandibular arch, the molars were found to be fully upright with no buccal or lingual inclination. Along the X axis, when the maxilla was 5 mm narrower than the mandible, the inclination of the

As the maxilla narrows in relation to the mandible, the severity of malocclusion increases along with added stress on supporting periodontal tissue and increased severity of nasal airway-related medical maladies and not limited to the above. Improved communication is a good thing.

Introduction

John L. Hayes, DMD, MBA, received his dental degree from the Boston University, Henry M. Goldman School of Graduate Dentistry, and his orthodontic certificate from the University of Pennsylvania, School of Dental Medicine, Orthodontic Department, where he is a Clinical Associate. He continues to research and lecture on the advantages of early interceptive treatment and on the etiology of malocclusions. Dr. Hayes is in private practice in Williamsport, Pennsylvania, with his wife, Sharon, who is also an orthodontist. He can be reached at jhayesortho@comcast.net.

Orthodontic Practice US

The medical use of staging systems to grade the severity of maladies is well-known to improve communication. There is presently no grading system for describing the severity of an orthodontic patient’s maxillary transverse deficiency. Grading would help bring measurements into the picture to help provide information regarding prognosis and treatment — it would be important for improved communication.

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ORTHODONTIC CONCEPTS

It has previously been reported that an ideal skeletal relationship between a maxilla and mandible in the transverse dimension can be re-created. It is important to accurately measure boney landmarks from dental casts or scans. An accurate measuring technique was invented, previously reported.1 The criteria for skeletal Harmony (the differential measurement between the maxilla and mandible) were determined by measurement of old and prehistoric skulls — the “templates” with unquestioned lifelong stability — previously reported.1-4

Results The inclination of the molars was recorded when the maxilla was 5 mm wider than the mandible (using the CAC measurement technique), which revealed zero inclination (ideal, fully upright molars). The fully upright posterior tooth attitude and the 5 mm maxilla/mandible differential is representative of the hundreds of old and prehistoric dentitions found in natural history museums and other sources that could be measured.1,2 Molar inclinations were plotted as follows: • when the maxilla was 5 mm wider than the mandible • when the maxilla was equal in width to the mandible • when the maxilla was 5 mm less width than the mandible • when the maxilla was 10 mm less than the mandible in width It was found that molar inclination increased from zero inclination to 8.5 degrees to 17.0 degrees to 25.0 degrees, respectively. For comparison, Figure 2 illustrates the inclination of tooth No. 19 using a negative 10 degree bracket prescription; the same tooth is shown using a negative 30 degree bracket prescription (a negative 20 degree tooth inclination). Six increasing levels of deficiency were measured with the THID; results were cross-referenced with actual patients. See more on this in the “Discussion” section.

Materials and methods A Transverse Harmony Indication Device, (THID), (Figure 1) was constructed to measure the inclination of the 6-year molars. The THID consisted of a modified Vernier caliper with a mm indicator dial. The caliper was permanently attached to a mounting base. The upper and lower jaws of the caliper were removed; the distal lower jaw was replaced with an extension to allow attachment of a tooth No. 14 form (available from an aftermarket dental supplier). A tooth No. 19 form was positioned on the mounting base below tooth No. 14. Both No. 19 and No. 14 were pinned to their respective attachments at their centers of rotation. Tooth No. 19 could only rotate about its pin, while No. 14 could rotate about its pin and also be caused to translate by moving the caliper’s sliding main scale. The inclinations of both No. 14 and No. 19 were measured with a protractor, and the distance that the maxilla moved in the transverse was recorded. The transverse movement in mm and corresponding inclination in degrees were easily repeatable and were recorded (Figure 1).

Six proposed grades of severity (Table 1) Grade 1. The transverse deficiency would be 0 mm to 2 mm (CAC), and the molar inclination would be in the range of 0 degrees to 3.5 degrees (i.e., an ideal skeletal situation). This would mimic the skeletal harmony seen naturally prior to the

Table 1: Grading the severity of a skeletal maxillary transverse deficiency by CAC measurement (ideally the maxilla is 5 mm wider [CAC] then the mandible)

Grade

CAC Deficiency

Avg. Inclination of 6-year molars maxilla and mandible

Symptoms

# RPEs needed for Skeletal Harmony

RPE Prognosis: child/teen

RPE Prognosis: adult - surgical

0 to 2 mm (maxilla is 3 to 5 mm wider than the mandible)

Ideal arch differential for maximum stability and nasal airway morphology

0 to 3.5 degrees

No RPE needed

N/A

2 to 4 mm (maxilla is 1 to 3 mm wider than the mandible)

Crowding; some canine impactions

3.5 to 7.0 degrees

One RPE may be needed: consider patient’s symptoms: asthma, dental crowding, ADD/ ADHD, disturbed sleep, etc.

Good result

No treatment (risk/benefit evaluation)

4 to 6 mm (maxilla is 1 mm wider to 1 mm narrower than the mandible)

All of the above plus: CL II; high angle; AOB; deficient nasal airway (mouth breathing; disturbed sleep; snoring); common canine impactions; incipient TMJ symptoms; posterior crossbites start here

7.0 to 10.0 degrees

One REP is typical; occasionally two RPEs are needed depending on age/maturity

Good result

No treatment (risk/benefit evaluation)

6 to 8 mm (maxilla is 1 mm to 3 mm narrower than the mandible)

All of the above plus: CL III; sleep apnea possibility; other airway related maladies

10.0 to 13.5 degrees

Two RPEs may be necessary

Good result

Possible RPE surgery; weight risk/benefit

8 to 10 mm (maxilla is 3 to 5 mm narrower than the mandible)

All of the above plus increased severity and risk of othognathic surgery

13.5 to 17.0 degrees

Three RPEs may be necessary

Good result for child; teen may have a dual bite

Likely RPE surgery

Over 10 mm deficiency (maxilla is 10 mm or more narrower than the mandible)

All of the above plus increased need for othognathic surgeries (adults) to improve ability to chew food and breathe normally; address transverse deficiency during preteen years for less involved treatments

17.0 degrees and over

Three or more RPEs may be necessary

Good result for child; teen may need future surgery

Likely RPE surgery

Six Grades of increasing maxillary deficiency are shown along with their requirements. The number of RPEs also estimated for each Grade eventually end up with a Grade 1 (ideal). The prognosis of children/teens is also compared to the adult prognosis. Symptoms expected at each Grade level are listed.

Orthodontic Practice US

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ORTHODONTIC CONCEPTS

1800s and for millennia prior to that. The optimal maxillary morphology would create an optimal nasal airway width at Ln-Ln, and the arch relationship would be optimal from an orthodontic point of view. No RPE would be necessary if this were to be an initial patient presentation.. Grade 2. The transverse deficiency would be in the range of 2 mm to 4 mm deficient, and the molar inclination would be in the range of 3.5 to 7.0 degrees. One RPE might be advised. The patient would have some incisor crowding, and there would be some chance of canine impactions. Molars would be inclined at 3.5 degrees to 7.0 degrees. One RPE could resolve the transverse deficiency if the patient was young enough. A female patient older than 13 years old might have a fused palatal suture. Given airway related symptoms (asthma, ADD, ADHA, Figure 2: Prescription and inclination — The photograph shows a No. 19 molar with disturbed sleep, dental crowding, etc.), RPE taken to ideal negative 10 degree prescription; reveals an upright molar with zero inclination (Grade should be considered. 1). Another No. 19 molar is shown with a negative 30 degree prescription; reveals a lingual inclination of 20 degrees. Brackets are .018 slot; archwires are .017 x .025 Grade 3. The transverse deficiency would be in the range of 4 mm to 6 mm, and the molar inclination would be in the range of 7.0 degrees to 10.0 degrees. All of the symptom possibilities above plus: CL II, high mandibular plane there are more symptoms along with increasing severity. Some angle, anterior open bite (AOB), and canine impactions tend to symptoms can impede a person’s ability to chew food or to sleep become more common, and disturbed sleep may be noted. One easily and worse (Figure 2). RPE is typical; occasionally, more than one RPE is needed to Grading systems are not perfect. Stepwise grade levels were gain harmony depending on the maturity of the maxillary suture. attempted to be based on meaningful increased severity. CAC Adults may choose to avoid treatment due to surgical risk/ measurements techniques were used for accuracy, and the 5 mm benefit analysis. differential harmony was used for reasons previously discussed. Grade 4. The transverse deficiency would be in the range of For example, from Grade 1 (no treatment) to Grade 2 (possible 6 mm to 8 mm deficient, and the molars would be inclined in use of one RPE), there can be an increase in canine impactions the range of 10.0 degrees to 13.5 degrees. All of the previously and along with incipient symptoms suggesting asthma, disturbed mentioned symptoms indicate possibilities along with greater sleep, ADHD, etc. Each succeeding grade from 1 through 6 has tendency toward CL III and for sleep apnea. Children and teens important implications for a patient’s severity of symptoms, recmay require two RPEs in sequence with a rest period in-between. ommended treatment, and prognosis. Severity is in the range where adult orthognathic surgery is conThe THID device measurement causes the maxillary and sidered — weigh the risk/benefit. mandibular inclinations to be equal. That is reflected in Table Grade 5. The transverse deficiency would be in the range of 8 1 and Figure 1. Orthodontists are aware that individual patients mm to 10 mm deficient, and the molars would be inclined in the can reveal mandibular molars that are inclined more to the linrange of 13.5 degrees to 17.0 degrees. All of the previously mengual than the THID chart would suggest — while at the same tioned symptoms represent possibilities along with increased time, the maxillary molars would be inclined less (to the buccal) risk of the need for orthognathic surgery for adults. Children and than the chart would suggest. Regardless, the inclinations would match the chart values. (For an actual patient, add maxillary teens might require more than two RPEs. value to the mandibular value, then divide by 2 for the average Grade 6. The transverse deficiency would be in the range of THID value). It is also possible that molar inclination could vary 10 mm or more, and the molars would be inclined in the range of from the left to right sides for reasons of asymmetry. 17.0 degrees and greater. Three or more RPEs may be necessary Here is a hypothetical pretreatment consultation excerpt for children and teens. Teens might require future orthognathic with Mrs. Wilson and her daughter: surgery. An adult would be candidate for orthognathic surgery. “Mrs. Wilson, Emily has a Grade 4 narrow maxilla. It may be part of the reason she has an open bite and an overjet. Discussion It is not the most serious Grade of upper jaw problem (that From historical and prehistoric data available in museums would be a Grade 6), but it would be an advantage for Emily and other sources, it was evident that the skeletal transverse to get some help before she gets too old.” maxillary arch versus the mandibular has for millennia been 5 mm wider at the 6-year molars (CAC measurement technique). Apparently, starting about 200 years ago, maxillary transverse Other important understandings deficiency started to develop in populations. Today the maxillary The RPE used in all the exercises was a modified Haas. The arch is rarely 5 mm wider than the mandible. The various grades buccal wire struts are routinely deleted, by design, to ensure of a transverse deficiency extend from Grade 1 (ideal) to a severe a more flexible and “kinder” RPE. The column on the Table 1, Grade 6. Along the X axis of increasing transverse deficiency, which discusses the number of RPEs needed, would not likely be Orthodontic Practice US

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ORTHODONTIC CONCEPTS

accurate for TAD-supported RPEs because dental inclinations are avoided with TAD supported RPEs. When a RPE is recommended and provided, the regimen is to wait 5 weeks after the RPE has been removed to remeasure the expansion progress or lack of progress. No retention is used while the unwanted dental expansion dissipates. Our studies have shown — with thousands of RPEs evaluated — that although the suture may not be fully mature radiographically, nevertheless, the new sutural bone is apparently mature enough to hold any boney expansion after a 5-week wait. We also use a slow turnbuckle regimen: one turn every 2 days (and one turn every 3 days for females older than 12 years old).

Conclusions 1. The maxilla is ideally 5 mm wider than the mandible (CAC measurement). 2. On the X axis (Figure 1), a maxilla that is 5 mm narrower than the mandible (10 mm transverse deficient) will have severely inclined posterior teeth — 17 degrees or more. 3. As the maxilla narrows in relation to the mandible, the severity of malocclusion increases along with added stress on supporting periodontal tissue and increased severity of nasal airway related medical maladies and not limited to the above. 4. A grading system is proposed for several advantages — primarily to improve communication.

Appendix 1

Appendix 3

Improved communication is a good thing.

Appendix Notes 1-5 are a review the Center of Alveolar Crest (CAC) measurement technique.2 OP

REFERENCES 1.

Hayes JL. “A Clinical Approach to Identify Transverse Discrepancies”(abridged). Pennsylvania Association of Orthodontists, Annual Meeting; Philadelphia, Pennsylvania, Hayes JL. March 8, 2003. E-only: ResearchGate. Accessed January 27, 2022.

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

Hayes JL. “Orthodontics.” In: Owsley DW, Jantz RL. eds. Kennewick Man: The Scientific Investigation of an Ancient American Skeleton. Texas A&M University Press; 2014.

Hayes JL. Proposed clinical skeletal transverse measurement technique — palpation adjacent to the molars. Orthodontic Practice US. 2011; 2(2);28-30.

Hayes JL. A new regimen of phase I care applied to anterior open bite — 10 case studies: an etiology proposed by the strategy of triangulation. Orthodontic Practice US. 2012;3(3);18-26.

Hayes JL. A new regimen of Phase I care applied to potential canine impactions. Orthodontic Practice US. 2013;4(3);44-51.

Hayes JL. In search of the etiology of malocclusions — a common discovery technique is proposed. Orthodontic Practice US. 2018;9(5):60-64.

Hayes JL. In search of … [the etiology of malocclusions]. Orthodontic Practice US. 2019;10(3):1.

Hayes JL. The etiology of malocclusion and the “scientific method”. Orthodontic Practice US. 2020;11(2):62-65.

Appendix 2

Appendix 5: CAC with OrthoCad: 48.1 + 53.2/less 51.5 = 1.6 mm maxillary deficient = excellent Phase I result (original deficiency with 11 mm)

Appendix 4

Orthodontic Practice US

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PRACTICE MANAGEMENT

“Are you ready to start your treatment?” Drs. Donald J. Rinchuse and Dara L. Rinchuse discuss the importance of establishing a policy for the retention phase

rthodontists around the world echo a similar cordial greeting to patients at the start of their treatment. That is, “Are you ready, Suzie, to start your treatment?” However, have you ever heard of the orthodontist asking the same question when the patient is about to get his/her “braces”/ appliances off? The patient and parent(s) would look at the orthodontist bewildered. They would think to themselves, I just went through 2 years of orthodontic treatment, and the orthodontist is asking if I am ready to start my orthodontic treatment? What does he/she mean? Orthodontists then have the opportunity to explain these seemingly contradictory and paradoxical remarks by affirming that the braces/appliances part of orthodontic treatment has ended. But this phase of treatment was just the preliminaries, and the real part of orthodontics starts when patients get their braces off, not when they get them on. Orthodontists edify their comments. If orthodontic patients do not wear retainers after orthodontic appliances are removed, the teeth will move and shift back toward where they were before treatment started. The only unknown is how much they will go crooked and relapse. Orthodontists advise, “If orthodontic patients do not wear retainers as directed, and the teeth relapse, the patient and family have wasted time and money.” Assuredly, the issue of retention and relapse has been explained to the patients and family prior to the start of treatment as part of the informed consent. To be clear, we are writing about removable retainers and not fixed retainers — i.e., fixed retainers have their very own advantages and disadvantages. Of note, a recent study found that mandibular lingual fixed retainers failed 52.3% of the time after just 2 years.1 The reason for this may be that few patients keep their fixed orthodontic retainers over a lifetime. Somewhere during the patients’ life, a fixed retainer will break. Then often the teeth will relapse before the patients realize it or schedule an appointment to repair it. Often the fixed retainers are removed, and patients are left without a retainer or are switched to a removable retainer.

Donald J. Rinchuse, DMD, MS, MDS, PhD, has practiced orthodontics for 46 years and has coauthored two books and written more than 130 articles.

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

Orthodontic Practice US

No retention plan will be successful without the wholehearted participation of both the orthodontist/staff and the patient/family.

General considerations With the competitive contextual environment of present-day orthodontics coupled with the large indebtedness of recent orthodontic graduates, retention has taken a backseat to other practice considerations — i.e., active treatment, marketing, advertising, staff management, scheduling, risk management, etc. This is particularly true when most orthodontists have a fee schedule that focuses on remittances only during active treatment. It is therefore not surprising that motivating patients to wear retainers may not be a priority for modern orthodontic practices. As previously mentioned, many orthodontists have a fee schedule that includes both the active and retention phases of treatment bundled into one sum. The financial arrangements for payment of the fee, irrespective of the payments terms, is that full payment is due before braces/aligners are removed. This desensitizes the orthodontist and patient to take the retention phase of treatment seriously because the orthodontist has received the total payment during the active phase of treatment. The orthodontist often feels that he/she is seeing retention patients without any monetary remuneration. The consideration of many orthodontists is that retention patients clutter their workday and take away from a financially productive schedule. Many financial gurus tell orthodontists to see retention patients as less often as possible, with many only seeing them for a year posttreatment. Retention patients are then advised to only call and schedule an appointment if they have any problems, such as lost retainers or the teeth moving.

Motivating the orthodontists Astute business-oriented orthodontists realize that it makes perfect sense to pay attention to the retention phase of orthodontics. An old adage is still true today: “Take care of your patients, and the money will take care of itself!” Without the enthusiastic attention to retention by the orthodontist and staff, even the best retention strategies will fail. The orthodontist and staff must take to heart the sobering conviction that all the hard work and effort put into play to achieve an excellent orthodontic outcome will be lost if patients do not wear retainers as directed. One would think that this would be enough to motivate the conscientious clinical orthodontist. Importantly, an orthodontist’s professional image in a community is based upon patients’ teeth staying straight. If orthodontic patients’ teeth relapse, this is poor public relations for the orthodontic practice. Soon the word will get around in the community Volume 13 Number 2

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PRACTICE MANAGEMENT

that the teeth of this orthodontist’s patients do not No retention plan will be successful without look so good. Patients and families often blame the orthodontist rather than take responsibility for retenthe wholehearted participation of both the tion failures. With this in mind, parents (and patients) orthodontist/staff and the patient/family. will tell other parents that Suzie’s teeth moved back because the orthodontist took her braces off too soon. Some orthodontists have a “retention fee” built into the financial structure. Their fee structure is parent signs as a witness to this document. The patient executes based on separate remittances for active treatment and retenretention agreements prior to the start of treatment as well as at tion treatment. In this set up, the orthodontist will not be seeing the end of treatment. Having signed a “Patient Retention Agreepatients without receiving compensation. All considered, this ment” before and after treatment, patients and families would seems to be a better financial arrangement compared to the onehave difficulty denying that they were not informed of the imporfee schedule for both active treatment and retention. tance of orthodontic retention. There are a number of in-house and commercial programs Further, the orthodontist and staff can talk to attentive adothat offer patients replacement retainers at a cost outside the lescents about the positives of having a beautiful smile now and contracted fee. This could be for a limited number of replacelater in life. It can be explained to patients that a pleasing facial ment retainers or for a lifetime. Certainly, the advent of in-house appearance and, importantly, a nice smile has been demon3D printing has helped offices with replacement retainers. Based strated to provide those with these physical characteristics with on recent technology (scans, 3D printing, etc.), permanently more attention from teachers, better jobs, more love interests, held scans can be used to produce retainers at any time. These and so on.3 For some patients, it can be mentioned how importprograms would benefit both practitioners and patients in regard ant it is going to be to have straight teeth on their wedding day. to fostering appropriate retention protocols. Nonetheless, how There are many psychosocial applauding consequences of havthese programs translate into patients taking orthodontic retening a healthy smile.3 tion seriously has yet to be researched. There are many other ways orthodontists and staff can elicit a positive retention result. Orthodontists can add more retention Motivating the patients appointments before releasing patients to their own accountabilMotivating patients to wear removable retainers can be an ity. From a fiscal viewpoint, this is perhaps not the best option arduous task. Nonetheless, the first step is to convince patients for orthodontists who have one fee that includes both active and families that retainer wear is important. From an intellectual treatment and retention. A consideration can be made about text and practical perspective, and even though they know this, the messaging patients to remind them of retention appointments and orthodontist and staff can explain to them that all the time and to remind them to wear their retainers. There are numerous orthomoney spent on orthodontics will be wasted if patients do not dontic software programs that make this a relatively easy process. wear retainers, and their teeth move back. This statement can be made even clearer by telling them that orthodontists have a new Conclusions influx of patients coming into their offices. They are middle-aged Today’s orthodontists are in a better position than past generpost-orthodontic patients who did not wear retainers as preations to set up effective retention compliance programs. What scribed, and their teeth relapsed. Now they are coming in to see better advertising and marketing is there than having posttreatthe orthodontist for retreatment, mostly looking for clear aligners. ment orthodontic patients walking around your community and They are paying for orthodontics a second time. Lesson learned? showing their friends and neighbors how nice their teeth look, Certainly, patients and families are motivated to follow even after being out of braces for several decades? Orthodontists orthodontic retention protocol in different ways. One way is as must recognize that there is a reward for paying attention to the discussed previously, “Are you ready to start your treatment?” retention part of orthodontics, even if this is in the long term. For Using such hyperbolic and paradoxical expresses can work for sure, adequate monetary remunerations need to be established some patients and families. Another way is a repeated interrogfor orthodontic retention appointments. Orthodontists underatory; recite back and forth several times the consequences of stand this, but they need to take it to heart and execute a well not wearing retainers. That is, the orthodontic assistant will ask thought-out retention plan that perhaps utilizes one or more of this question and give the answer. “Johnny, what will happen if the suggestions in this article. OP you don’t wear your retainers? Your teeth will move back.” The orthodontic assistant repeats again, “Johnny, what will happen if you don’t wear your retainers?” Then this time Johnny answers REFERENCES the integratory by stating, “My teeth will move back.” This can be 1. Wegrodzka E, Kornatowski K, Pandis N, Fudalej PS. A comparative assessment of failrepeated several times. ures and periodontal health between 2 mandibular lingual retainers in orthodontic patients- a 2-year follow-up, single practice-based randomized trial. Am J Orthod Patients can be asked to sign a “Patient Retention AgreeDentofacial Orthop. 2021;160(4):494-502E1. ment.” The language for the agreement is something like this: “I 2. Rinchuse DJ, Rinchuse DL. Risk management: supplemental informed consent docuunderstand that if I do not wear my retainer and follow the retenments. Orthodontic Practice US. 2018;9(2):98. tion protocol I received, my teeth will move back (relapse) and 3. Rinchuse DJ, Rinchuse DJ. Orthodontics justified as a profession. Am J Orthod Dentofacial Orthop. 2002;121(1):93-96. get crooked. I also understand that retainer wear is lifelong.”2 A Orthodontic Practice US

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What can AAO attendees expect from 3M™ this year?

Our team is excited to highlight the innovations that make 3M™ an industry leader in digital workflows. Don’t miss our speaker sessions where we’ll dive into detailed overviews of our priority digital solutions, including the 3M™ Oral Care Portal, 3M™ Clarity™ Aligners Flex + Force, and 3M™ Digital Bonding.

Tell us more about Clarity Aligners Flex + Force and how the materials fit into the 3M digital workflow space. A two-material system like Clarity Aligners Flex + Force gives orthodontists the flexibility to seamlessly leverage complementary materials throughout a single treatment plan. Updates to the Oral Care Portal allow clinicians to customize each patient’s treatment using Clarity Aligners Flex + Force in a single treatment design for truly customized treatment.

How is 3M addressing the biggest challenges facing orthodontists today? From the Oral Care Portal to the new Clarity Aligners Flex + Force materials, we’ve designed tools and products that can give you the choice and control you need to deliver results. Through our robust education offerings, you can stay on the cusp of the orthodontic industry through extensive training. And when you run into challenges, you can lean on your dedicated customer care team of sales and service executives who provide on-demand custom support.

Visit 3M at AAO Booth No. 3400

Clarity

™

Esthetic Orthodontic Solutions

It’s all in the details. Actually, five layers of detail that can add up to

100%

doctor satisfaction.

Orthodontic Practice US

Volume 13 Number 2

SPECIAL SECTION

rius Technologies is a forward-thinking innovation company dedicated to improving the orthodontic experience of both patient and orthodontist. Brava™, its flagship product, is the first orthodontic system to provide simultaneous, independent tooth movement — a radical departure from traditional mechanics. The Brava Independent Mover™ System consists of an anchorage base and flexible NiTi arms that connect independently to each tooth via a bracket. Unlike traditional bracket systems that can cause unwanted tooth movement and round-tripping, Brava’s reactive forces translate to its anchorage base, which then dissipate along the entire arch. With clinically insignificant reactive forces, the AI preprogrammed into Brava puts each tooth on an independent path to its planned position. The movement of any tooth has little to no effect on any other tooth. Leveraging digital workflow (scan, setup, and approval),

the sophisticated algorithms of Brava’s proprietary Planner Software consider ethnicity, age, gender, and root morphology to calculate the precise moment and force for each tooth for each patient. Brava’s optimized, AI-driven biomechanics result in an esthetically superior, personalized, and highly effective and efficient treatment. With machine learning to further customize treatment for tomorrow’s patients, Brava is built for now and the future. Not braces. Not aligners. Independent Movers.

Visit Brius at AAO Booth No. 1003

Who says a smile can't change the world?

Not Braces. Not Aligners. Independent Movers™

orthopracticeus.com

AAO SPECIAL SECTION

Brava by Brius™: Bringing transformative technology to orthodontics

Volume 13 Number 2

SPECIAL SECTION

The Norris 20/26® System

AAO SPECIAL SECTION

ontrol over torque and tip has eluded clinicians for years and has been compensated in various ways — from specifying additional degrees in programming, to repositioning, to wire sequencing. Finally, a solution is available with the Norris 20/26® System. Developed by Dr. Robert “Tito” Norris, this system provides unbelievable control with precise tooth movement and superior case finishing.

A bracket slot that better fits the wires you want to use

For doctors who love the PSL workflow but want an easier time finishing in a 19 x 25 wire, the .020 x .026 slot allows clinicians to pick up torque control earlier in treatment and maintain optimal three-dimensional control of the teeth throughout the finishing phase.

Why settle for an unreliable door? If a bracket door breaks, collects plaque, or self-opens, the benefits of self-ligating go out the window. A self-ligating door needs to be user-friendly for staff and dependable throughout treatment. The Norris 20/26® door employs the most advanced door technology and ensures doctors and clinical teams will love its reliability from start to finish. Come see for yourself at the DynaFlex® No. 2413 Booth in Miami. Each day we’ll have in-booth lectures, product demos, and exciting giveaways.

Visit DynaFex at AAO Booth No. 2413

Make The Switch To

Start To Finish In Three To Four Common Archwires

Exceptional Three Dimensional Control With A Precise .020 x .026 Slot

Advanced, Reliable Door Technology With Assisted Opening and Closing Mechanism

Orthodontic Practice US

Volume 13 Number 2

SCAN TO GET

$200 OFF INTRO KIT

SPECIAL SECTION

e. Which patients need follow-ups f. Breakdown of treatment recommended, outcome, contracts, and fees 2. Reporting: View your critical Treatment and Observation Coordinator performance metrics in chart and graphical formats. Everything from conversion ratio to financials helps you monitor starts achievement and individual performance against your goals or bonus programs. a. Evaluate case acceptance, starts, and exams by TC. b. View statistics for all pending patients and monitor follow-ups. c. Track contract amounts, initial fees, and production. 3. Treatment + Fee Presentation: Seamlessly display your treatment recommendations and fee options. a. Payment Slider Tool with down payment, discounts, and insurance b. Ability for patients to accept treatment via email

top by Booth No. 2018 at the AAO to see Gaidge’s latest development — the New Patient Tracker! This addition to the Gaidge suite of business solutions will allow practices to track new patients from the moment they call in through the time they convert into an active start! The New Patient Tracker will feature: 1. Patient Dashboard: The dashboard will offer organization and workflow management for all patients in the start queue. The dashboard features a comprehensive list of new patients and observation-ready patients with custom-sorting capability to make it easy to organize and track all pre- and post-appointment tasks, including: a. Insurance verification completion b. New patient forms submission c. Appointment confirmations d. Next appointment scheduled verification

Visit Gaidge at AAO Booth No. 2018

New Patient Tracker

View at the AAO at Booth 2018!

Track Your Observation + New Patient Tasks in a Comprehensive Dashboard Gain Detailed Insights Into Conversion + Financial Performance Metrics Make Conversion Seamless with a Customizable Payment Presentation Tool

orthopracticeus.com

AAO SPECIAL SECTION

Gaidge: Introducing a better way to manage your patients

Volume 13 Number 2

SPECIAL SECTION

Ormco™

AAO SPECIAL SECTION

The Damon Ultima™ System

he new Damon Ultima™ System is the first true full expression* orthodontic system with a proprietary integrated wire and slot design that virtually eliminates play for faster and more precise finishing. It provides orthodontists with earlier and precise control of rotation, angulation, and torque. This unique and patented technology is designed to deliver the signature Damon™ Smile, resulting in full expression with lighter forces to treat in less time and to fully express your prescription with fewer wire bends. The Damon Ultima System is designed to reduce wire bends throughout treatment. With this system, rotations are completed with the first round-sided rectangular wire, and full expression is achieved with the second. After all rotations are corrected, the wire/bracket interface returns to a passive state while maintaining the desired rotational

alignments throughout the remainder of treatment with the .0275” dimension wires.

Options for enhanced torque control The Damon Ultima brackets are available in neutral, retrocline, and procline options for enhanced torque control. Larger size and different material Damon Ultima archwires are available for more torque control when needed. To learn more about the Damon Ultima System, please visit: https://ormco.com/products/damon-ultima-system/. *Data on file. Ormco is a medical device manufacturer and does not dispense medical advice. Clinicians should use their own professional judgment in treating their patients. Individual patient results may vary.

Visit Ormco at AAO Booth No. 3617

THE FIRST TRUE FULL EXPRESSION SYSTEM Designed for Faster & More Precise Finishing*

Completely Re-engineered to Virtually Eliminate Play for Precise Control of Rotation, Angulation and Torque

Orthodontic Practice US

Volume 13 Number 2

SPECIAL SECTION

Step-1 PumEtch

flow of liquid was specially designed to ensure the proper mix of both pumice and etchant, every time. Step-1 PumEtch is then easily dispensed into a dappen dish and applied with a microbrush for either isolated or full-tooth coverage. With Step-1 PumEtch, the first step in your tooth prep is the only step you’ll need.

Visit Smile Stream Solutions at AAO Booth No. 2226

SMILE STREAM SOLUTIONS

STEP-1 PumEtch The First Step in your Tooth Prep is the Only 1 you need Reduces Chair Time, Procedural Steps, and Material Cost Greater Application Control More Effective Tooth Coverage Eliminates Slow Speed Handpieces No Need for Prophy Cups or Paste Saves Time and Money

Combines Pumice and Etch into one Solution Invented by board certified Orthodontist Dr. Frank Besson, DMD Patent Number: 8,033,829

orthopracticeus.com

AAO SPECIAL SECTION

mile Stream Solutions is excited to launch our most recent breakthrough, innovative product — Step-1 PumEtch. Step-1 PumEtch is a patent-protected, tooth preparation formula that combines pumice and etchant into one singular solution. Step-1 PumEtch has received FDA 510(k) clearance and is indicated for use in preparation of a tooth’s surface for the direct bonding of orthodontic appliances, as well as in preparation for dental sealant procedures. In this way, Step-1 PumEtch not only eliminates a procedural step, but also virtually eliminates the need for redundant materials and equipment like slow speed handpieces. Invented by a Board-certified orthodontist, Dr. Frank Besson, and exclusively developed by Smile Stream Solutions, Step-1 PumEtch brings clinical perspective together with manufacturing excellence. Even the dropper bottle that controls the

Volume 13 Number 2

smilestreamsolutions.com 720.689.1536

SPECIAL SECTION

AAO SPECIAL SECTION

The science and innovative features behind Spark Aligners

oin Dr. Trevor Nichols; Dr. Marc Olsen; and Mr. Rick Matty, VP/GM, Global Innovation, as they share their insights and techniques regarding Spark Aligners. Spark’s advanced technology enables more sustained force retention* and better surface contact with the tooth compared with the leading aligner brand.* The superior force retention and surface contact of the Spark Aligner is due to its manufacturing technology. Spark Aligners are made with 80%* better printing resolution and a more uniform surface texture than the leading aligner brand.* In addition, doctors can obtain results without resorting to optimized attachments. Spark’s beveled attachments conform to a patient’s oral anatomy, matching the surface of each tooth for a more uniform attachment surface.* Plus, Spark’s Approver Software™ is designed to give orthodontists start-to-finish control for more efficient and effective

treatment planning. CBCT integration lets orthodontists import and visualize CBCT patient data,* while posterior Bite Turbos can be added to address complex cases.* Join us to learn more about the Science Behind Spark and how orthodontists like you are using Spark to achieve great finishes and beautiful smiles. Be sure to ask about our On-Site Promotions. *Data on file.

Visit Spark at AAO Booth No. 3617

THE SCIENCE BEHIND SPARK ALIGNERS 80% Better Printing Resolution*

More Uniform Surface*

Better contact between the aligner and the tooth.*

Over 98% of doctors agree

that better aligner contact predicts better outcomes*.

Watch the video and learn more at ormco.com/spark/science-behind-spark/

Orthodontic Practice US

Volume 13 Number 2

*Data on file

SPECIAL SECTION

Specialty Appliances

Visit Specialty Appliances at AAO Booth No. 1200

Includes: Bracket Removal & Model Printing Fees

Made with durable Zendura™ material

invisible retainers

TWO retainers starting at

orthopracticeus.com

Volume 13 Number 2

AAO SPECIAL SECTION

pecialty Appliances started integration of advanced technology in 2006. Today Specialty Appliances is 3D-printing splints, and both laser-sintered bands and crowns, and can print entire appliances out of metal. The advantage of digitally designed 3D-printed appliances can be appreciated by both doctors and patients. The doctor benefits by saving time and money with the elimination of unnecessary separator appointments. Practices will enhance patient satisfaction by cutting repeat appointments due to band fit issues. Digitally designed printed appliances further improve patient experience by eliminating uncomfortable tissue blanching. With over 40 years of experience and leadership, Specialty Appliances remains on the forefront of progress in digital technology.

SPECIAL SECTION

uLab Systems, Inc.

AAO SPECIAL SECTION

Helping you build the digital orthodontic practice of the future Providing you the highest-quality aligners in packaging that features your practice

Our uDesign 7.0 release, now with uAssist treatment planning, is a comprehensive aligner workflow solution that can be used across moderate to complex cases and gives you the convenience, efficiency, control, and flexibility you need when it comes to treatment planning, pricing, and delivery. Plan cases yourself, or use the new uAssist button within uDesign to send it to our digital assistants. Options are at your fingertips, so you can focus on what’s best for your patients and your practice. uDesign 7.0 from uLab — It’s the upgrade you’ve been waiting for • uAssist — concierge treatment planning services

• Improved Guided Setup — both faster and smarter than before • Auto Staging — one-click intelligent collision avoidance and sequencing • uView — chairside consulting and treatment plan details on the web See all of our AAO activities and register at ulabsystems.com/ulab-AAO. • AAO Booth No. 2400 • The uLab Forum, May 20, Loews Hotel • Daily booth presentations • Individual uDesign 7.0 demonstrations — by appointment • Fred Talk, May 22, Dr. Bryn Cooper • Tech Select LIVE!, May 21, Dr. Rooz Khosravi

Visit uLab Systems at AAO Booth No. 2400

Creating perfect smiles is your specialty

AAO Booth #2400

Giving you a more efficient and effective way to do it is ours

INTRODUCING

uDesign® 7.0 from uLab™ Now with uAssist treatment planning– it’s the upgrade you’ve been waiting for Our uDesign 7.0 release, now with uAssist treatment planning, is a comprehensive aligner workflow solution that can be used across moderate to complex cases and gives you the convenience, efficiency, control and flexibility you need when it comes to treatment planning, pricing, and delivery. No printer? No problem. uSmile aligners delivered in 3-5 business days.

Auto Staging

Improved Guided Setup

One-click intelligent collision avoidance and sequencing

Both faster and smarter than before

uAssist

uView

Chairside consulting and treatment plan details on the web

Concierge treatment planning services

Orthodontic Practice US

Volume 13 Number 2

PRACTICE MANAGEMENT

How to handle negative reviews Dr. Len Tau discusses how to soothe the sting of a negative review

o matter how much we try, negative reviews are inevitable. And with how hard we work as dentists to serve patients well, negative reviews can sting. Naturally, many dentists fear that each negative review will cause them to lose patients or turn away potential new patients. We all know how important reviews are to attracting new patients to your practice. Almost 80% of consumers trust reviews as much as a personal referral. But that doesn’t mean one or two negative reviews will destroy your practice. What you do in response to negative reviews is much more likely to impact your patient base than the negative review itself. How do you respond to the inevitable negative review?

Don’t get emotional Pause, take a deep breath, and relax. It’s hard, I know. It’s especially hard when the review is scathing, unwarranted, unfair, or even an outright lie. No matter how wrong the review is, you need to pause. If you get too emotional, it can impact how you show up in your practice, how you treat your team, and how you and your team treat patients. And that can cause other patients to have poor experiences and lead to more negative reviews. It’s natural for a negative review to ruin your breakfast, but don’t let it ruin your lunch. And don’t let it impact how you show up to your practice that day.

Don’t respond right away I have been very vocal about not publicly responding to the review. The worst thing you can do is respond and get into a public back-and-forth with someone who was just upset enough to leave a negative review. If their review was unreasonable or wrong, there’s no predicting what else they’ll say in response to you if you reply publicly disagreeing with them. Even worse, dentists have inadvertently violated HIPAA in their responses to negative reviews. If you do respond, remember, you are not only responding to the reviewer, you are responding to everyone who will visit that review site in the future. Would your response make it more or less likely for patients to want you to be their dentist? A much safer approach is to try to take the conversation offline. Contact the patient. Taking the time to personally con-

Len Tau, DMD, purchased his practice, the Pennsylvania Center for Dental Excellence in Philadelphia in 2007. He practiced full-time while consulting to other dental practices, training thousands of dentists about reputation marketing, leading the dental division of BirdEye, a reputation marketing platform, and hosting the popular, Raving Patients podcast. He recently authored the book Raving Patients and 100+ Tips to 100 Five Star Reviews in 100 Days. He can be reached at len@drlentau.com

orthopracticeus.com

nect with the patient who left the negative review will show you care and are looking to help resolve their concerns. Frequently, when you reach out personally, the patient will even take the bad review down or update it to make it positive.

Don’t try to remove legitimate bad reviews If a review violates the rules of a platform, it’s possible to get a review taken down. However, many professionals have tried to take this concept way too far by requiring clients or patients to sign away their rights to reviews to the practice or by suing the reviewer for defamation or some other cause of action. While those professionals might technically have the right to sue and get them taken down, it inevitably backfires and causes what’s called the Streisand Effect, a social phenomenon caused when someone tries to hide, remove, or censor negative information and it backfires, causing more attention to be paid to the negative information. It started when Barbra Streisand sued a website owner to get a photo of her residence removed from their website. Before the lawsuit, the image of her house had only been downloaded six times (two of which were by Streisand’s attorney). But the attention from the lawsuit caused the image to be seen more than 400,000 times. The same thing happens when a dentist sues a patient about a review. Your lawsuit will attract press attention. Who wants to go to a dentist who sues a patient? Focus on getting positive reviews to push down the negative ones (but don’t buy the positive reviews). The best defense to negative reviews is a good offense. If you get a negative review, renew your focus on earning and asking patients to leave you positive reviews. A steady stream of recent positive reviews will have a much greater impact on your practice than one or two negative ones, especially as time passes. However, make sure your positive reviews are legitimate and avoid buying them. Not only is it against the terms and conditions of most review sites, but it’s obvious to most people who will see your reviews that the reviews are from people who never visited your practice. After patients tell you or your team members how wonderful their experience was, ask if they’ll be willing to leave you a review when they get back home or to the office if you send them a direct link to do so easily. Then follow up and send them a link to your page by text (preferable) a short time later for them to follow through on their promise to do so. Continue those efforts until your practice generates a steady flow of positive reviews. Then any negative reviews you receive will be quickly pushed down by all the positive things your patients have to say about you. When you do, having a few negative reviews among the positive ones can actually be a good thing, as it makes it clear to people reviewing it that your reviews are, in fact, real. OP

Volume 13 Number 2

CONTINUING EDUCATION

Smile bleaching and orthodontic treatment is a perfect match Drs. Jaimeé Morgan and Stan Presley discuss how appealing to patients’ desires for esthetic enhancement during orthodontic treatment can have other positive effects

rthodontic patients are often overlooked when it comes to addressing their needs for whiter teeth. These patients are usually forced to wait until the end of treatment when the brackets are removed before tooth bleaching is even mentioned. Their arches may be beautifully rounded and teeth completely straightened, but oftentimes the discoloration or stains on the teeth distract from what should be a perfect smile. One group of orthodontic patients falls into this category; the other falls into a category of needing extra help in improving their oral hygiene. Both of these groups of patients can be addressed with the use of hydrogen peroxide (HP) and carbamide peroxide (CP) bleaching agents during their orthodontic treatment. Patients going through orthodontic treatment seem to face real challenges when it comes to maintaining healthy gingival tissue and dentition. Plaque buildup, inflamed soft tissue, and bleeding can make even a simple retie appointment difficult (Figure 1). Then there are the long-term adverse effects, which include decalcification and decay around brackets (Figure 2). Preadolescent- and adolescent-aged patients make up about

Educational aims and objectives

This self-instructional course for dentists aims to discuss the benefits of smile bleaching during orthodontic treatment.

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: • Realize how motivation and compliance can interfere with the tooth- whitening process in non-adults. • Recognize possible benefits of carbamide peroxide (CP) and hydrogen peroxide (HP) in the tooth-whitening process. • Realize the benefits of prefilled, disposable trays and strips for tooth whitening. • Identify some dentist-prescribed and -supervised products that allow the clinician to remain in control of the tooth-whitening process. • Recognize some drawbacks to using some OTC products. • Observe a case of tooth whitening during orthodontic treatment on a nonadult patient. CREDITS

2 CE

Jaimeé Morgan, DDS, received her dental degree from the University of Texas Health Science Center at San Antonio. She was recently named one of the top 25 women in Dentistry. She divides her professional career between clinical practice and teaching. Her lectures have spanned the globe from the United States to Europe, South America, Australia, and Asia. She regularly contributes articles on cosmetic dental techniques for the general practice. She served as a founding member of the South Texas Chapter of the American Academy of Cosmetic Dentistry. Salt Lake City, Utah, is the site of her dental practice where she provides cosmetic and restorative dentistry with her husband Dr. Stan Presley. Dr. Morgan has earned the reputation of teaching cosmetic techniques using a practical approach that is both enjoyable and useful. Stan Presley, DDS, received his dental degree from Baylor College of Dentistry in 1977. His training at the L.D. Pankey Institute has provided him with a sound cosmetic treatment philosophy. Dr. Presley was one of the founding members of the South Texas Chapter of the AACD where he served as secretary and vice-president. In recognition of the need to provide an alternative to porcelain restorations in his practice, Dr. Presley focused his attention on conservative esthetic restoration combined with orthodontic treatment. He is co-developer of the Simplified Layering Technique for composites along with his wife, Dr. Jaimeé Morgan. Dr. Presley lectures internationally using both didactic and hands-on courses and has contributed numerous articles demonstrating realistic and learnable procedures for general practitioners. He currently practices cosmetic and restorative dentistry with his wife Dr. Jaimeé Morgan at Morgan & Presely Dental in Salt Lake City, Utah.

Orthodontic Practice US

Figure 1: Tissue inflammation and presence of plaque can make a simple retie difficult

80% of orthodontic treatment although adults seeking treatment is on the rise. Research has shown the emotional developmental stage of the non-adult group brings additional challenges — i.e., they can be influenced by peer pressure, reject authority, and

Volume 13 Number 2

CONTINUING EDUCATION

Figures 3 and 4: 3. Opalescence Go prefilled and dipsosable whitening trays. 4. Opalescence Go prefilled and disposable whitening trays easily adapt around orthodontic brackets without impeding movement of the teeth

Figure 2: Long term adverse effects of poor oral hygiene during orthodontic treatment include decalcification and decay around brackets

believe that they are exempt from compromised health because of their uniqueness. Sending patients home with a detailed home care instruction list and the armamentarium to accomplish these daily tasks include disclosing tablets, mechanical and manual toothbrushes, oral irrigating devices, mouth rinses, fluoride rinses, and floss. Even with all these excellent tools and instructions, it still comes down to motivation of and compliance by the patient. Considering patients generally have conventional in-office care only twice per year, the long-term benefits are not truly significant. The prevalence of white spot lesions (WSLs) remains at 61% when removing orthodontic appliances even with in-office efforts of prophylaxis and prevention., Therefore, home care with parental involvement must be emphasized. With the introduction of fluoride varnishes, fluoride-releasing band and bracket adhesives, fluoride-releasing bonding agents, and antimicrobial orthodontic hardware, there have been decreases of WSLs as long as the varnishes are reapplied on a regular basis, and the fluoride in the fluoride-releasing materials is recharged. Recently introduced selenium-releasing bonding agents show promise although there has not been an abundance of studies comparing it with fluoride.3 Even with these clinically integrated products, the most effective course of action still remains the age-old approach of attacking the problem at its source — hence a combination of repeated home care instruction, frequent prophylaxis, and in-office and home-delivered topical fluoride. At this time, the patient is not released from participation in this effort. Although CP and HP are excellent in decreasing plaque, inflammation, decalcification, and the incidence of decay, they are often overlooked.5,6,7,8,9,10 This omission is probably due to the common misconception that these materials must use custom trays. And where fixed orthodontic appliances are being used, a custom tray would impede the planned movement of the teeth, or as the teeth moved, the trays would no longer fit. The other even bigger misconception is that using these materials, while brackets are in place, will result in a yellow spot in the center of each tooth where the bracket had been. CP and HP can now be used to treat orthodontic patients thanks to the introduction of prefilled, disposable trays (Opalescence Go®, Ultradent Products, Inc.) and strips (SheerWhite!®, CAO Group, South Jordan, Utah). The preloaded appliances easily adapt to fit both arches even if the teeth are orthopracticeus.com

Figures 5 and 6: Opalescence Go prefilled and disposable whitening trays easily adapt around orthodontic brackets without impeding movement of the teeth

malaligned. They do not exert pressure on the teeth, and they do not interfere with orthodontic movement. The misconception that CP and HP must contact every surface of the tooth to provide even whitening results was laid to rest in the early 1990s. It is well-known that CP and HP will readily penetrate the natural tooth within 5-15 minutes and will bleach under an existing restoration or bracket, although the restorative material nor bracket will be whitened. This means that even in the presence of an orthodontic bracket, the entire tooth will whiten.10 There are dentist-prescribed and -supervised products that allow the clinician to remain in control (e.g., Opalescence Go 10% and 15% hydrogen peroxide, Ultradent Products). Also available are over-the-counter products (OTCs) (e.g., Crest® White Strips, GLEEM, Proctor & Gamble, Smile™ Direct Club, Access Dental Lab), which leave the clinician out of the treatment protocol and supervision. In reviewing some of the OTC products, packaging will state the active ingredient (i.e., hydrogen peroxide), but most fail to state the concentration of the active ingredient. Going to their websites does not reveal the concentration of the bleaching agent either. With new packaging comes different concentrations of the active ingredient, which makes it more confusing. Seems these whitening products fall between 5%-15% HP. As a professional, recommending an OTC proves difficult because the concentration of the active ingredient is not readily known. Crest White Strips states on the packaging: “Do not use on loose teeth, restorations, or braces.” GLEEM states on the FAQ section on its website: “GLEEM whitening treatments should not be used with braces because they will only whiten the parts of the teeth which the whitening gel comes into contact with. As braces cover some parts of the tooth, these parts will not whiten, leaving unevenly colored teeth when the braces are removed. Also, GLEEM whitening treatments may change the color of the metal.”17 These OTC products are effec-

Volume 13 Number 2

CONTINUING EDUCATION

tive in whitening and will, in fact, work on orthodontic patients, but because they are not using well-founded and well-known research on which to base their instructions and not stating the concentration of the active ingredient, it puts the professional at risk for recommending one. Dentist-prescribed and -supervised prefilled trays incorporating both hydrogen peroxide as well as potassium nitrate (P) and neutral sodium fluoride (F) can be found in Opalescence Go (OG). These are prefilled, adaptable, disposable trays with either 10% or 15% hydrogen peroxide gel with PF (Figure 3). These trays easily adapt to and around the orthodontic appliance (Figures 4 to 6). The patient wears the OG 10% HP trays for only 30-60 minutes per day, whereas the OG 15% HP tray is worn for 15-20 minutes per day. Although the bleach will whiten the teeth even under the brackets, there is no effect to the existing bond. The patient will benefit from the whitening effects of these products as well as other benefits of decreasing plaque formation, inflammation, decalcification, and decay. The addition of PF to hydrogen peroxide and carbamide peroxide bleaching agents has created an even greater ability of these bleaching agents to improve the health of the teeth while preventing or diminishing sensitivity. Besides decreasing the incidence of sensitivity from bleaching, research has shown an improvement in the microhardness of the enamel with this combination. The benefits of fluoride are well-known — it is lethal to bacteria, aids in the remineralization of enamel, and forms fluorapatite, which is more acid-resistant than hydroxyapatite. Warburg and Christian reported in 1941 that the benefits of fluoride are due to the inhibition of enolase., The fluoride inhibition of enolase is important in the treatment of dental plaque in which deep layers are highly anaerobic and dependent on glycolysis for energy requirements. Fluoride also has long-term desensitizing effects. Fluoride’s desensitizing effects come from its ability to block the tubules and slow the flow of fluid that causes sensitivity. Potassium nitrate is also a desensitizing agent and has been used in toothpastes (e.g., Sensodyne®, GlaxoSmithKline U.S.) for many years. Potassium nitrate easily penetrates the tooth similarly to hydrogen peroxide and has a direct effect on the nerve. It interrupts the pain cycle by preventing the nerve from repolarizing after it has depolarized.13 It is used primarily for acute sensitivity. It’s easy to see why the addition of PF to bleaching agents has been groundbreaking.

Figure 7: Isolation begins with KleerView cheek retractors in preparation for in-office power bleaching

Orthodontic Practice US

With more orthodontic offices providing professional cleanings by hygienists, another motivational opportunity is created. In-office or “power bleaching,” as some call it, can be done by hygienists in most states. At-home prefilled trays provide more benefits of decreasing plaque formation, inflammation, etc., because they can be used several days in a row and for multiple treatments. In-office bleaching may be used as a reward for those patients who are exhibiting excellent oral hygiene. The hydrogen peroxide will bleach under the brackets without affecting the existing bond strengths in the same way that the above-mentioned trays do. A side benefit of both in-office and home-bleaching methods is that stain from around and on porcelain brackets is removed. This falls perfectly into the esthetic needs of the patient who has opted for an esthetic bracket because their appearance is ultimately important to them even during orthodontic treatment.

Case presentation An 11-year-old male patient had been in orthodontic treatment for several months when he inquired about the possibility of whitening his teeth during treatment. There were no contraindications to bleaching his teeth even, though he was in mixed dentition. Bleaching can always be done again after the remaining permanent teeth erupt. Based on information reported by Scherer, et al., patients appeared to be motivated in their oral hygiene home care during and after bleaching their teeth. Considering this patient’s oral hygiene was fair, we expected to see improvement post bleaching. The orthodontic wire was removed, and the patient’s lips were moistened with lip balm. The teeth were isolated using cheek retractors (KleerView™ cheek retractor, Ultradent Products, S. Jordan, Utah) (Figure 7). A combination bite block-tongue retractor (IsoBlock™, Ultradent Products, S. Jordan, Utah) was then placed. The gingival tissue was then air dried, and a resin gingival barrier (OpalDam™, Ultradent Products, S. Jordan, Utah) was syringed onto the gingival margins of the teeth to be bleached overlapping approximately 1 mm onto the teeth. The barrier was also extended one tooth beyond where the bleach was to be placed. After placement, the resin barrier was light cured. The gingival barrier replaced the need for a rubber dam, thereby saving time and making the procedure more comfortable for the patient. After isolation was completed, the chemically activated 40% hydrogen peroxide bleaching agent (Opalescence™ Boost™,

Figure 8: Isolation of teeth completed with cheek retractors, bite-block tongue retractor, OpalDam gingival barrier, and Opalescence Boost whitening agent placed on the incisal ½ of the teeth

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CONTINUING EDUCATION

Figure 9: Immediately after removing Opalescence Boost from the teeth

(Ultradent Products, S. Jordan, Utah) was mixed using a syringe to syringe method; no mixing pads necessary. To show how the bleaching agent travels once it penetrates the tooth as well as how effective it is, it was only syringed onto the incisal one-half of the teeth (Figure 8). The gel was kept off the gingival barrier to prevent accidental contact with the soft tissue. The gel was left on the teeth for 15 minutes, removed, and reapplied for a total of two cycles. Normally, a four-cycle regimen of 15 minutes each would have been used, but due to the patient’s young age, it was decided that two cycles would be enough for one treatment. The gel was removed between applications without rinsing in between. Once the second application was removed, the teeth were thoroughly rinsed, and high-volume suction was used. The gingival barrier was removed followed by another thorough rinse (Figure 9). Although HP and CP bleaching agents do not affect existing bond strengths, research has shown it is necessary to wait at least 7 days after bleaching to initiate any new bonding including repositioning brackets. Three weeks after the bleaching treatment, this patient returned to the office for evaluation of the bleaching effects. A bracket was removed to show there was no dark area where the bracket had been, and where the bleach did not have direct contact with the surface of the tooth. By comparing the maxillary bleached teeth with the mandibular unbleached teeth, a significant whitening effect was obvious (Figure 10). It’s important to remember not only the health issues associated with patients undergoing orthodontic treatment, but also their esthetic needs during and after treatment. Appealing to their desires for esthetic enhancement may be one of the most effective means to also improving the health of the soft tissues and protecting the teeth by increasing the micro-hardness of the enamel making them less impervious to decay. At-home tray delivery utilizing prefilled adaptable disposable trays or by providing in-office treatments are excellent and easy methods of getting your patients to be more diligent with their oral hygiene efforts. OP

Figure 10: Bracket removed from upper right central incisor 3 weeks after Opalescece Boost whitening session to show there is no resulting yellow stain where the bracket had been and that the gingival ½ is also whitened even without direct contact with the bleaching agent Dentofacial Orthop. 2001;120(1):28-35. 3.

Krasniqi S, Sejdini M, Stubljar D, et al. Antimicrobial Effect of Orthodontic Materials on Cariogenic Bacteria Streptococcus mutans and Lactobacillus acidophilus. Med Sci Monit Basic Res. 2020;21:26.

Bentley CD, Leonard R, Crawford JJ. Effect of whitening agents containing carbamide peroxide on cariogenic bacteria. J Esthet Dent. 2000;12(1):33-37.

Shapiro WB, Kaslick RS, Chasens Al, Eisenberg R. The influence of urea peroxide gel on plaque, calculus and chronic gingival inflammation. J Periodontol. 1973;44:636-639.

Reddy J, Salkin LM. The effect of a urea peroxide rinse on dental plaque and gingivitis. J Periodontol. 1976;47:607-610.

Zinner DD, Duany LF, Chilton NW. Controlled study of the clinical effectiveness of a new oxygen gel on plaque, oral debris and gingival inflammation. Pharmacol Ther Dent. 1970;1:7-15.

Shipman B, Cohen E, Kaslick RS. The effect of a urea peroxide gel on plaque deposits and gingival status. J Periodontol. 1971;42:283-285.

Napimoga MH, de Oliveira R, Reis AF, et al. In vitro antimicrobial activity of peroxide-based bleaching agents. Quintessence Int. 2007;38:329-333.

10. Gurgan S, Bolay S, Alacam R. Antibacterial activity of 10% carbamide peroxide bleaching agents. J Endod. 1996;22:356-357. 11. Haywood VB, Parker MH. Nightguard vital bleaching beneath existing porcelain veneers: a case report. Quintessence Int. 1999;30(11):743-747. 12. Haywood VB, Leech T, Heymann HO, Crumpler D, Bruggers K. Nightguard vital bleaching: effects on enamel surface texture and diffusion. Quintessence Int. 1990;21(10):801-804. 13. Haywood VB, Heymann HO. Nightguard vital bleaching: how safe is it? Quintessence Int. 1991;22(7):515-523. 14. Morgan JA, Presley S. In-office “power” bleaching of vital teeth as an adjunct to at-home bleaching. Advanced Tooth Whitening: A comprehensive Guide to Whitening. Prac Perio & Aesthet Dent. 2002;14(suppl 2):16-23. 15. Morgan JA. Striking the right balance; Trends in tooth bleaching. Dent Equip Materials. 2003;May/June:74-76. 16. Morgan JA. Orthodontics with a twist: bleaching, bonding, and gingival recontouring. J Amer Orthodontic Society. 2005;5(2):20-23. 17. GLEEM. Frequently Asked Questions (FAQs). https://gleem.com/faq/#whitening-kit34. Accessed April 24, 2022. 18. Summitt JB, Robbins JW, Schwartz RS. Fundamentals of Operative Dentistry: A Contemporary Approach. 2nd ed. Quintessence; 2001. 19. Al-Qunaian TA. The effect of whitening agents on caries susceptibility of human enamel. Oper Dent. 2005;30(2)265-270. 20. Warburg O, Christian W. Isolierung und Krstallisation des Garungsferments Enolase. Die Naturwissenschaften. 1941;29(39):589-590. 21. Qin J, Chai G, Brewer JM, Lovelace L, Lebioda L. Fluoride inhibition of enolase: Crystal structure and thermodynamics. Biochemistry. 2006;45(3):793-800. 22. Hata S, Iwami Y, Kamiyama K, Yamada T. Biochemical mechanisms of enhanced inhibition of fluoride on the anaerobic sugar metabolism by Streptococcus sanguis. J Dent Res. 1990;69(6):1244-1247.

REFERENCES 1.

Proffit WR, Fields HW Jr, Sarver DM. Contemporary Orthodontics, 4th ed. Mosby Elsevier; 2007.

23. Scherer W, Palat M, Hittelman E, Putter H, Cooper H. At-home bleaching system: Effect on gingival tissue. J Esthet Dent. 1992;4(3):86-89.

Øgaard B, Larsson E, Henriksson T, Birkhed D, Bishara SE. Effects of combined application of antimicrobial and fluoride varnishes in orthodontic patients. Am J Orthod

24. Morgan-Godwin JA, Barghi N, Berry TG, Knight GT, Hummert TW. Time duration for dissipation of bleaching effects before enamel bonding. J Dent Res. 1992;71:A590.

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Continuing Education Quiz Smile bleaching and orthodontic treatment is a perfect match MORGAN/PRESLEY

1. Preadolescent- and adolescent-aged patients make up about _______ of orthodontic treatment although adults seeking treatment is on the rise. a. 20% b. 30% c. 80% d. 92%

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. n To receive credit: Go online to https://orthopracticeus.com/continuingeducation/, click on the article, then click on the take quiz button, and enter your test answers.

2. Even with all these excellent tools and instructions (such as sending patients home with a detailed home care instruction list as well as disclosing tablets, mechanical and manual toothbrushes, oral irrigating devices, mouth rinses, fluoride rinses, and floss), it still comes down to __________. a. cost b. motivation of and compliance by the patient c. fear of failure of the process d. fear of excessive chemicals

AGD Code: 780 Date Published: May 5, 2022 Expiration Date: May 5, 2025

2 CE CREDITS

b. will not list allergies to the ingredient c. will not list detrimental effects of the active ingredient d. none of the above

3. The prevalence of white spot lesions (WSLs) remains at ______ when removing orthodontic appliances even with in-office efforts of prophylaxis and prevention. a. 32% b. 61% c. 72% d. 81%

7. The benefit(s) of fluoride is/are well-known — ________ . a. it is lethal to bacteria b. it aids in the remineralization of enamel c. it forms fluorapatite, which is more acid-resistant than hydroxyapatite d. all of the above

4. Although carbamide peroxide (CP) and hydrogen peroxide (HP) are excellent in decreasing ________ and the incidence of decay, they are often overlooked. a. plaque b. inflammation c. decalcification d. all of the above

8. Warburg and Christian reported in 1941 that the benefits of fluoride are due to the inhibition of ________. a. enolase b. amylase c. maltase d. intertase

5. It is well-known that CP and HP will readily penetrate the natural tooth within _________ and will bleach under an existing restoration or bracket, although neither the restorative material nor bracket will be whitened. a. 5-15 minutes b. 20-30 minutes c. 45-55 minutes d. 60-75 minutes

9. _________ easily penetrates the tooth similarly to hydrogen peroxide and has a direct effect on the nerve. a. Propylene glycol b. Potassium nitrate c. Dioctyl sodium sulfosuccinate d. Sodium saccharin 10. Based on information reported by Scherer, et al., patients appeared to be motivated in their oral hygiene home care during and after bleaching their teeth. a. True b. False

6. In reviewing some of the OTC products, packaging will state the active ingredient (i.e., hydrogen peroxide), but most __________. a. fail to state the concentration of the active ingredient

To provide feedback on 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.

Orthodontic Practice US

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CONTINUING EDUCATION

Managing controlled substances in dental practice: prescribing and record keeping Tyler Dougherty, PharmD; Michael O’Neil, PharmD; and Nikki Sowards, PharmD; review key considerations when prescribing and storing controlled substances Introduction Prescription medication misuse, substance use disorder (SUD), and diversion continue to remain problematic across the United States. Dental practitioners are often targeted by patients since they are a potential source of potent prescription opioids. Additionally, dental practitioners are subject to investigations by the Drug Enforcement Agency (DEA) as part of routine inspections or for potential violations of the Federal Controlled Substance Act (CSA).1 Dental practitioner prescribing and office management of controlled substances require vigilance, careful scrutiny of all records, and well-organized record keeping of both patient medical records and controlled substance records. This article will review key considerations when prescribing and storing controlled substances.

Educational aims and objectives

This self-instructional course for dentists aims to provide an overview of necessary practices to consider when prescribing and storing controlled substances.

Tyler Dougherty, BA, PharmD, BCACP, received his Bachelor of Arts degree in Biochemistry from Maryville College in 2011 and his Doctor of Pharmacy degree from the University of Tennessee College of Pharmacy in 2015. He completed a postgraduate residency at South College School of Pharmacy in 2016. Dr. Dougherty is a Clinical Community Pharmacist and Assistant Professor of Pharmacy Practice where he specializes in community pharmacy practice and teaches ethics and pharmacy law. Dr. Dougherty is an invited speaker for healthcare professionals teaching ethics and law with emphasis on medication management.

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: • Define key terms used when prescribing and storing controlled substances. • List methods to minimize diversion and fraud of controlled substances. • Outline federal requirements for storing controlled substances. • Identify specific records that must be readily retrievable should a dental practice be audited or investigated. • List common violations of the Controlled Substance Act by dental practitioners.

Michael O’Neil, PharmD, received his Doctor of Pharmacy from the University of North Carolina at Chapel Hill, North Carolina. Dr. O’Neil has extensive experience in pain management, substance misuse, and medication diversion. Dr. O’Neil was editor and lead author for the American Dental Association’s book titled The ADA Practical Guide to Substance Use Disorders and Safe Prescribing, published in 2015. Dr. O’Neil has served as a consultant for prescription drug misuse and diversion for several entities including the Federal Drug Enforcement Agency. He is currently Professor and Chair of Pharmacy Practice at South College School of Pharmacy in Knoxville, Tennessee. Nikki Sowards, PharmD, earned her Doctor of Pharmacy degree in 2012 from the University of Tennessee College of Pharmacy in Memphis, Tennessee. She completed a PGY-1 Pharmacy Practice residency in Knoxville, Tennessee. Dr. Sowards joined South College School of Pharmacy as an Assistant Professor in 2013. In 2015, Dr. Sowards worked as a Director of Hospital Pharmacy in Knoxville, Tennessee. Dr. Sowards is currently an Assistant Professor of Pharmacy Practice at South College School of Pharmacy. She practices at Blount Memorial Hospital where she focuses on pharmacy operations and pharmacy management.

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Definitions Understanding of medical and legal terminology surrounding controlled substances is important when interpreting the medical/legal literature, and when trying to maintain compliance with state and federal statutes and regulations. The following terminologies provide guidance regarding safe and effective controlled substance management and prescribing practices.

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Prescription Medication Misuse Prescription medication misuse may be defined as taking a prescription medication outside of the boundaries of the initial prescription’s “intent for use” or directions. This may include a different diagnosis, taking the medication in larger doses or more often than prescribed, or to significantly alter/enhance one’s mental status.2

Substance Use Disorder (SUD)

Table 1: Common “Red Flags” Patients traveling extremely long distances between dental practicehome-pharmacy Early refills Utilizing multiple prescribers (emergency medicine, dental practices, hospitals, private practices) Out-of-state patients

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), no longer uses the terms substance abuse and substance dependence. Rather, it refers to substance use disorders, which are classified as mild, moderate, or severe. The level of severity is determined by the number of diagnostic criteria met by an individual.”3

Random, escalating/de-escalating doses of opioids or benzodiazepines Common “cocktails” consisting of opioids, benzodiazepines, muscle relaxants, and sedative hypnotics Morphine-Equivalent Daily Doses (MEDD) exceeding 90 mg/day Patients presenting “old” dental injuries as “new” injuries

Prescription Medication Diversion The movement of a prescription medication in any direction other than how legally allowed to be transferred by law.4

Prescription Drug Monitoring Program (PDMP) Prescription Drug Monitoring Programs are state-regulated electronic databases that store outpatient dispensing records for specific controlled substances.5

Red Flags Red flags are observations that potentially may deter prescribing or dispensing of a medication. Red flags require further questioning of the patient or clarification prior to writing or dispensing a prescription medication.6

Due Diligence “The practice of performing reasonable verification that the information presented is accurate and reliable in order to prevent deceptive or criminal practices. Reasonable implies that the practitioner is doing what any practitioner would and should do in the routine activities of the healthcare professional.”7

Readily Retrievable “Readily retrievable means the record is kept or maintained in such a manner that it can be separated out from all other records in a reasonable time or that it is identified by an asterisk, redline, or some other identifiable manner such that it is easily distinguishable from all other records.”7

Prescribing controlled substances Many dental practices prescribe controlled substance analgesics and anxiolytics prior to performing procedures and postoperatively. Recognition of attempts by patients to illegally obtain controlled substances is necessary to decrease risks to the dental practitioner and the dental practice. State and federal agencies require prescribers to practice “due diligence” when prescribing or dispensing prescription medications. The practice of performing “due diligence” for dental practitioners when prescribing controlled substances includes careful review of the patient’s medical history, review of previously prescribed conOrthodontic Practice US

Utilizing only cash payments for medications

trolled substances such as that found in the PDMP, evaluation of patient behaviors, patient interviewing, refusing to prescribe or dispense when diversion or fraud is suspected, and reporting these behaviors accordingly. Currently, many states now require prescribers to evaluate a patient’s PDMP report prior to prescribing controlled substances. (For a more in-depth review of utilizing a state PDMP, see the continuing education article in Orthodontic Practice US: “Practical Considerations for Utilizing Prescription Drug Monitoring Programs — A Primer.”) The PDMP provides controlled substances prescribed for patients that have been dispensed from a community pharmacy or outpatient clinic for a specific state. The PDMP is a helpful tool to optimize therapeutic decisions as well as to detect “red flags” that lead to further questioning prior to prescribing. Table 1 lists red flags commonly detected in a PDMP report.8 Dental practitioners should analyze this report for active controlled substances, recent controlled substance prescriptions from other prescribers, duplicate prescriptions, and early refills. It is important to recognize that any anomalies found should lead to further questioning of the patient since the information provided in the PDMP has not been validated by a secondary source and may have errors that occurred at the time of processing the prescription. Any verified abnormal findings should be thoroughly documented in the patient’s medical record. Other methods to divert controlled substances from dental practices include altering written prescriptions or falsifying phone-in prescriptions. Tampering of prescriptions is limited by use of tamper-proof prescription pads, and copying of prescriptions is minimized by utilizing embedded watermarks or photocopying resistant paper. The use of preprinted prescriptions with the medication name, medication strength, dosage, and directions is highly discouraged. The use of presigned prescriptions by the prescriber is illegal. Controlled substance prescriptions should be signed the day the written prescription is provided to the patient. Additionally, utilization of ePrescribing can minimize these types of diversion and fraud. Volume 13 Number 2

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ePrescribing

Dental practitioner prescribing and office manage-

Electronic prescribing of prescription ment of controlled substances require vigilance, caremedications, also known as ePrescribing, began after the passing of the Medicare ful scrutiny of all records, and well-organized record Modernization Act (MMA) of 2003. The keeping of both patient medical records and controlled MMA aimed to enhance the quality of patient care while also increasing the substance records. utilization of electronic medical records. It wasn’t until 2006, when the Institute of Medicine’s July report discussing the role ePrescribing can play on reducing medication errors, that ePrescribing began to the pain medication prescription to the pharmacy and not fill the be widely used.9 antibiotic. Finally, ePrescribing enhances and further improves In 2018, Congress passed the Substance Use-Disorder electronic health record information and exchanges of that inforPrevention that Promotes Opioid Recovery and Treatment for mation. The exchange of electronic health records is becoming Patients and Communities Act (SUPPORT Act), which aimed more vital as healthcare providers, patients, and insurance comto address the opioid epidemic. In addition, this legislation panies look to increase communication to better patient care. required Schedule II-V controlled substances for Medicare Part 10 D beneficiaries be ePrescribed beginning January 1, 2021. The Record keeping Centers for Medicare and Medicaid Services (CMS) has since Laws and regulations for prescribing, storing, administerdelayed the enforcement of the ePrescribing rule until January ing, and disposing of controlled substances are defined at the 1, 2022. Dental practices and other healthcare providers would federal level in Title 21, Code of Federal Regulations (CFR), clearly find it difficult to delineate Medicare and non-Medicare sections 1300-1316.13 The federal Drug Enforcement Agency beneficiary prescriptions, meaning the prescribing of controlled (DEA) is mandated to ensure compliance to these laws and substances must be electronic for all patients going forward. regulations. Compliance is usually under control of the state’s However, individual states are already implementing ePrescribBoards of Pharmacy and Dentistry. Controlled substances laws ing requirements for controlled substances. Currently, 25 states and regulations frequently mirror federal laws and regulations. require ePrescribing with some provider exemptions. More Required records for controlled substances — e.g., purchase states are expected to pass or implement legislation requiring receipts, invoices, DEA222 transfer forms, DEA106 theft loss ePrescribing starting in 2022 and beyond.11 The Centers for forms, and records of detailed disposed controlled substances Medicare and Medicaid Services (CMS) policy does allow for such as wastage or damaged product — must be maintained prescribers to be exempt from ePrescribing controlled subfor 2 years and must be “readily retrievable” should a dental stances in the following situations: The prescriber and dispensing practitioner be audited or investigated. It is also important that pharmacy are the same entity, the prescriber issues 100 or fewer providers remember to take a biennial inventory of all controlled controlled substance prescriptions per year for Medicare Part D substances. Individual states can have stricter requirements surpatients, or circumstances surrounding natural disasters.12 rounding how often inventories must be taken. Dental practices should begin to adopt ePrescribing for all prescriptions, controlled and non-controlled substances, for multiple reasons. Although the federal requirements center around Medicare beneficiaries, the combination of state specific regulations make it logistically difficult for practices to issue prescriptions in two different formats. Adopting ePrescribing can potentially improve medication safety while also preventing prescribing errors. For example, handwritten prescriptions can oftentimes be illegible or difficult to interpret, requiring pharmacists to make judgement calls or delay care for the patient in order to confirm the prescription information. Also, different state and federal requirements exist on the information that must be included on a prescription, including the address of the patient, phone number or address of the practice, and DEA number of the prescriber (for a controlled substance). This information would automatically be included with standardized ePrescribing systems. In addition, electronic prescribing can help with controlled substance diversion or patient selection of medications they want filled or not filled. For example, a patient who is prescribed two handwritten prescriptions for an antibiotic and a pain medication post-dental procedure could provide only orthopracticeus.com

Ordering and transferring controlled substances 21 CFR 1305.04 and 1305.05 require dental practitioners to be registered with the DEA if they intend to order Schedule II controlled substances (hydrocodone, oxycodone, etc.). They are referred to as a DEA registrant and are assigned a specific DEA registration number. The registrant may give authorization to other individuals to order Schedule II controlled substances through power of attorney. The ordering and transferring of Schedule II controlled substances requires the DEA222 form. The triplicate DEA222 form has been replaced with a single-sheet DEA222 form effective October 2021. The ordering of controlled substance medication Schedules III-V does not require transfer of the medications with the DEA222 form; however, the entities supplying and receiving the controlled substance must maintain records of the transactions.14,15

Storing and access of controlled substances Title 21, CFR Section 1301.71(a) specifies considerations for storing controlled substances at a business or practice site.

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Some of these include the type of building, type/quantity of controlled substances to be stored, type of safe, vault or locked steel cabinet, and alarm systems. Controlled substances purchased for dental office practices must be kept in a “locked, well-constructed metal cabinet or safe.” Access to controlled substances should be limited. Equally important is determining who may have access to controlled substances within the dental practice. The DEA lists very specific individuals who may not have access. This list includes the following: 1. Any person who has been convicted of a felony offense related to controlled substances 2. Any person who has been denied a DEA registration 3. Any person who has had a DEA registration revoked 4. Any person who has surrendered a DEA registration for cause Prior to hiring of personnel for the dental practice, it is prudent to complete thorough background investigations and screen for potential exclusions in this list.16

Summary

The controlled substances act. DEA. https://www.dea.gov/drug-information/csa. Accessed December 22, 2021.

Disposal of controlled substances

O’Neil M. Common Substances and Medications of Abuse. In: The ADA Practical Guide to Substance Use Disorders and Safe Prescribing. Wiley Blackwell; 2015.

Key terms and definitions. SAMHSA. https://www.samhsa.gov/section-223/certification-resource-guides/key-terms-definitions. Accessed December 21, 2021. Accessed March 21, 2022.

Melton S, Orr R. Detection and Deterrence of Substance Use Disorders and Drug Diversion in Dental Practice. In: The ADA Practical Guide to Substance Use Disorders and Safe Prescribing. Wiley Blackwell; 2015.

Prescription Drug Monitoring Programs (pdmps). Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/pdmp/index.html. Published May 19, 2021. Accessed March 21, 2022.

O’Neil M, Winbigler B, Sowards N. Prescription Medication Diversion: Detection and Deterrence. Journal California Dental Association. 2019;47(3):179-185.

Aquinos C. Office Management of Controlled Substances. In: The ADA Practical Guide to Substance Use Disorders and Safe Prescribing. Wiley Blackwell; 2015.

E-Prescribing. Centers for Medicare and Medicaid Services. https://www.cms.gov/ Medicare/E-Health/Eprescribing. Accessed March 21, 2022.

How to appropriately dispose of controlled substances and document the disposals are critical considerations when handling these medications. Whenever controlled substances need to be destroyed due to being leftover following patient administration, are found broken, have become contaminated, or have expired, the risk for potential diversion is high. Ideally, these medications should be transferred to a designated “take-back” facility commonly known as reverse distributors. An alternative method involves having the DEA Special Agent in the practitioners’ area destroy the medications on-site. Other alternative methods for destruction may be found in the controlled Substance Act 21 CFR Part 1317. These records must be “readily retrievable” and maintained for 2 years.17

In summary, management of controlled-substance prescribing practices and record keeping require a comprehensive knowledge regarding methods to detect and deter attempts to divert medications from dental practices. Two important methods to optimize prescribing include use of the state’s PDMP and implementation of ePrescribing. Maintaining detailed records for storage, transfer, and disposal of controlled substances is also necessary to ensure adherence to federal, state, and dental board statutes and regulations. Dental practitioners should only prescribe medications to patients registered with their dental practice. IP

REFERENCES

Reporting theft or loss of controlled substances When dental practitioners suspect theft or loss of controlled substances, they should complete an inventory of controlled substances and immediately file a DEA 106 Theft/Loss form, which is available online or through a downloadable PDF. If theft is suspected by burglary or employee pilfering, local law enforcement should also be notified.

Common violations by dental practitioners Dental practitioners may be investigated and ultimately prosecuted for a variety of reasons. Frequently, this may involve being nonadherent to federal regulations — e.g., failing to maintain up-to-date inventory records, failure to store controlled substances safely, failure to dispose of controlled substances appropriately, and failing to renew registrant license. Out of convenience, dental practitioners may prescribe medications for nondental-related issues. For example, prescribing oral contraceptives for pregnancy prevention or potent analgesics for migraines would be considered prescribing outside the scope-ofpractice. Any prescription ordered by dental practitioners should be within their scope of practice and for a patient with records at the practice site.7 Orthodontic Practice US

10. H.R.6 – SUPPORT for Patients and Communities Act. Public Law 10/24/2018. https:// www.congress.gov/bill/115th-congress/house-bill/6/text. Accessed March 21, 2022. 11. Carter L. 2021 Survey of Pharmacy Law. National Association of Boards of Pharmacy. www.nabp.pharmacy. Accessed March 21, 2022. 12. E-prescribing. Centers for Medicare and Medicaid Services. https://www.cms.gov/ Medicare/E-Health/Eprescribing. Accessed March 21, 2022. 13. eCFR: 21 CFR Chapter II -- Drug Enforcement ... https://www.ecfr.gov/current/title-21/ chapter-II. Accessed March 21, 2022. 14. eCFR :: 21 CFR part 1305 -- orders for schedule I and II ... https://www.ecfr.gov/ current/title-21/chapter-II/part-1305. https://www.ecfr.gov/current/title-21/chapter-II/ part-1305/subpart-A/section-1305.04. Accessed March 21, 2022. 15. eCFR :: 21 CFR part 1305 -- orders for schedule I and II ... https://www.ecfr.gov/current/ title-21/chapter-II/part-1305. Accessed March 21, 2022. 16. eCFR :: 21 CFR 1301.71 -- security requirements generally. https://www.ecfr.gov/ current/title-21/chapter-II/part-1301/subject-group-ECFRa7ff8142033a7a2/section-1301.71. Accessed March 21, 2022. 17. eCFR :: 21 CFR Part 1317 -- disposal. https://www.ecfr.gov/current/title-21/chapter-II/ part-1317. Accessed March 21, 2022. 18. Theft/Loss Reporting. Significant Theft or Loss Reporting of Controlled Substances. Diversion Control Division: https://www.deadiversion.usdoj.gov/21cfr_reports/theft/. Accessed March 21, 2022.

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Continuing Education Quiz Managing controlled substances in dental practice: prescribing and record keeping DOUGHERTY/O’NEIL/SOWARDS

_______ may be defined as taking a prescription medication outside of the boundaries of the initial prescription’s “intent for use” or directions. a. Prescription medication misuse b. Medication diversion c. Substance abuse/misuse d. Red flag indicator

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), no longer uses the terms substance abuse and substance dependence. Rather, it refers to ________. a. substance misuse b. substance use disorders c. prescription misorder d. prescription diversion

________ is the movement of a prescription medication in any direction other than how legally allowed to be transferred by law. a. Due diligence b. Prescription Medication Diversion c. Substance mis-transfer d. Controlled substance misuse

_________ is the practice of performing reasonable verification that the information presented is accurate and reliable in order to prevent deceptive or criminal practices. a. Red flag deterrence b. Drug program monitoring c. Due diligence d. Dose Monitoring

________ means the record is kept or maintained in such a manner that it can be separated out from all other records in a reasonable time or that it is identified by an asterisk, redline, or some other identifiable manner such that it is easily distinguishable from all other records. a. Readily retrievable b. Due diligence c. Redline ready d. On file

Dental practitioners should analyze the Prescription Drug Monitoring Program (PDMP) report for _________ and early refills. a. active controlled substances b. recent controlled substance prescriptions from other prescribers c. duplicate prescriptions d. all of the above

2 CE CREDITS

The use of preprinted prescriptions with the medication name, medication strength, dosage, and directions is ________. a. highly discouraged b. always encouraged c. illegal d. mandated by the PDMP

According to Title 21, CFR Section 1301.71(a) specifies considerations for storing controlled substances at a business or practice site. … Controlled substances purchased for dental office practices must be kept in _______. a. a cabinet that may be unlocked, depending on its location b. a locked, well-constructed metal cabinet or safe c. a cabinet or box marked “controlled substances” d. a refrigerator that patients cannot see

Dental practitioners may be investigated and ultimately prosecuted for a variety of reasons. Frequently, this may involve being nonadherent to federal regulations — e.g., _________ and failing to renew registrant license. a. failing to maintain up-to-date inventory records b. failure to store controlled substances safely c. failure to dispose of controlled substances appropriately d. all of the above

10. Any prescription ordered by dental practitioners should be ________. a. within their scope of practice b. for a patient with records at the practice site c. handwritten for controlled substances only d. both a and b

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Volume 13 Number 2

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• Resists staining caused by common disinfecting agents. • Low-voltage DC actuators provide precise, smooth, and quiet movement for patient positioning. • Programmable foot control uses digital technology to operate the chair movements. • Steel frame and base construction are coated to provide years of corrosion and rust protection. • FDA-Listed/ETL Approved

Featured product: CDU-425 Side Unit The CDU-425 Side Unit provides a fully instrumented chairside unit with all the standard features of our traditional chairside unit, with a narrow profile to accommodate your spatial requirement. The CDU-425 keeps dental handpieces out of sight of dental patients while making them easily accessible for your use.

Key Features • Instrumented pull-out delivery with removable work surface • Pocket-style front door • Unit comes standard with Boyd’s Clean Water System These featured products can be combined with Boyd’s custom cabinetry — with numerous color and laminate options — to create a fully cohesive office. To learn more, visit us at www.boydindustries.com, and follow us on Facebook, Instagram, Pinterest, and Twitter @BoydIndustries. Boyd Industries is a ISO 13485:2016 certified company. OP This information was provided by Boyd Industries.

Orthodontic Practice US

Volume 13 Number 2

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PRODUCT PROFILE

VISION by SoftSmile

ISION is the innovative treatment planning solution by SoftSmile. The software is powered by artificial intelligence that generates key aspects of treatment planning while guaranteeing precision through every step of the process. Machine-learning algorithms automate the time-consuming processes of treatment planning and facilitate the final setup of aligned teeth based on orthodontic measurements. With VISION, doctors have ensured control over their patients’ treatment. This revolutionary technology can now be implemented in any practice without a doctor having to go through third-party designers and/ or manufacturers. Doctors won’t have to sacrifice high medical standards, alter their workflows, or invest a huge amount of time and money into learning new software or buying additional equipment. Any doctor who has ever worked with any of the main clear aligner solutions on the market will be able to quickly learn to use VISION. SoftSmile also provides flexible aligner printing options: Doctors can choose whether they want to use a lab partner, print with SoftSmile, or print their aligners in-house. The software’s interface is both intuitive and visually stunning. SoftSmile has combined advanced functionality and esthetics. VISION’s state-of-the-art visualization is based on biomechanical principles, which improve accuracy during treatment planning. The software provides a complete set of data, calculates actual forces and stress, analyzes the length of roots, the width of crowns, and even the density of the plastic material.

This one-of-a-kind software solution has capabilities, including but not limited to the following: • Intuitive and comprehensive staging º automatic IPR º group movement º full flexibility for treatment strategy • Automated treatment planner based on actual real-time stress calculation and biomechanical principles • Web viewer, editor, and a distributed managing system facilitating cooperation among doctors, technicians, manufacturers, and patients • Postprocessing that now includes automated cutting lines generation • Self-learning and automated segmentation • Advanced cloud infrastructure VISION’s absolute precision and unparalleled performance in treatment planning is powered by SoftSmile’s proprietary algorithms. SoftSmile has been granted over 40 U.S. patents in the past 2 years and has over 50 patents pending. VISION was recently cleared by the U.S. Food and Drug Administration (FDA) pursuant to a 510(k) pre-market notification. Additionally, over 100 of the most acclaimed orthodontists from around the world have tested the software. This FDA clearance sets in motion SoftSmile’s plans to transform the market by offering doctors treatment planning software directly, which makes it possible to offer more options to patients, thereby cutting costs and increasing efficiency. OP This information was provided by SoftSmile.

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TREATMENT PLANNING SOFTWARE YOU CAN SMILE ABOUT Our goal at SoftSmile is to provide doctors with the absolute best tools. VISION is an end-to-end treatment planner made by doctors, for doctors. We have built VISION to keep the control in your hands, guaranteeing precision, and improving patient outcomes.

PRODUCT PROFILE

Ormco™ The Damon Ultima™ System

rmco™ Corporation has launched a completely reengineered passive self-ligation brace system. The new Damon Ultima™ System is the first true full-expression orthodontic system with a proprietary integrated wire and slot that is designed for faster and more precise finishing. It provides orthodontists with earlier and precise control of rotation, angulation, and torque. This unique and patented technology is designed to deliver the signature Damon™ Smile, resulting in full expression with lighter forces to treat in less time and to fully express your prescription with fewer wire bends. In fact, the Damon Ultima System is designed to reduce wire bends throughout treatment. With this system, rotations are completed with the first round-sided rectangular wire, and full expression is achieved with the second. Results of the Ultima™ Clinical Evaluation* concluded that by engaging the buccal-lingual depth of the PSL bracket slot, the Damon Ultima .014 x .0275’’ round-sided, rectangular CuNiTi wires effectively achieved correction of first-order tooth rotations. After all rotations are corrected, the wire/bracket interface returns to a passive state while maintaining the desired rotational alignments throughout the remainder of treatment with the .0275’’ dimension wires. It predictably achieves first-order control earlier in treatment with minimal wire or bracket position adjustments, increases clinical efficiency, and has the potential to reduce treatment time in patients treated with this PSL appliance system.

The Damon Ultima System is completely reengineered with a unique round-sided rectangular wire and a parallelogram-shaped slot

lingual (horizontal) contact points in the slot earlier in treatment for rotational control. Vertical contacts in the slot are designed to achieve angulation control earlier while maintaining rotational control. As a result, the orthodontist gains precise control to move teeth more efficiently and reliably with gentler forces to help them finish faster with better patient comfort and a priority on patient health.* With the Damon Ultima System, the key is to let the wires do the work as it is designed to reduce wire bends. It’s simple to remember “no deflection, no correction.”

Options for enhanced torque control The Damon Ultima brackets are available in the neutral, retrocline, and procline options for enhanced torque control. Brackets are designed from the center point of the slot to line up with the FA point to express the desired torque and provide easier and more precise placement. Larger size and different material Damon Ultima archwires are available for more torque control when needed. The Damon Ultima™ System is the first true full-expression orthodontic system. • Designed for faster and more precise finishing. • Simplified bracket placement. • Reengineered to virtually eliminate play for precise control of rotation, angulation, and torque. • A system that reduces the amount of wire bends required throughout treatment. • Designed with the patient’s health in mind by treating with lighter forces. To learn more about the Damon Ultima System, please visit: https://ormco.com/ products/damon-ultima-system/. OP

Designed to eliminate play The Damon Ultima System is completely reengineered with a unique round-sided rectangular wire and a parallelogram-shaped slot that are designed to fit together precisely to virtually eliminate play. This proprietary wire engages the buccal

*Data on file.

The Damon Ultima brackets are available in the procline, neutral, and retrocline options for enhanced torque control Orthodontic Practice US

Ormco™ is a medical device manufacturer and does not dispense medical advice. Clinicians should use their own professional judgment in treating their patients. Individual patient results may vary. This information was provided by Ormco™.

Volume 13 Number 2

Transform Your Practice with TruDenta Our diagnostic technologies and FDA-cleared therapeutic procedures provide pain relief and rehabilitate force imbalances for new and existing patients with sleep apnea, chronic migraines and headaches, tinnitus, and other neck/jaw pain.

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.

Reap ROI With Your Investment Dental practices that provide TruDenta see nearly 389 percent in return on investment and $1,500 per hour for doctor chair time.

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ORTHO PERSPECTIVE

A new orthodontic mindset Dr. Amy Jackson discusses at-home, direct-to-door delivery of orthodontic care What is your opinion of direct-toconsumer aligner companies? Personally, I believe orthodontic therapy that is not doctor-centric can at best fall short of the goal and at worst lead to deleterious effects. However, this direct-to-consumer aligner surge has led to market awareness, increased consumer spending on orthodontic treatment, and educated us on how we can meet the demands of this new consumer behavior. Direct-to-consumer aligner therapy has no doubt resulted in unprecedented changes to orthodontic consumer behavior. It is important to recognize this for an industry like ours — one that is historically stubborn and hesitant to adapt to fast-paced changes. Systemic, industry-wide change usually comes from one of two places: accessibility to new, advanced technology and changes in consumer behavior. In our industry, we are experiencing both of these drivers simultaneously. In the case of accessibility to technology, almost every orthodontist I know has an intraoral scanner and has at least contemplated purchasing one, if not multiple, 3D printers. In the case of consumer behavioral changes, our patients are demanding easier access to care — thanks in large part to companies like Smile Direct Club. Throw in a dash of global pandemic to this recipe, and we’ve got ourselves a good old-fashioned industry revolution on our hands. So what are orthodontists meant to do amidst this onslaught of change? For starters, we must adopt a new mindset. My friends, the Future is Now. Whether we doctors like it or not, consumers have taken a bite of the proverbial apple that is at-home, direct-to-door delivery of orthodontic care. That is not to say I’m advocating for at-home orthodontic care. In fact, I would be remiss if I didn’t unequivocally state the best place for orthodontic therapy to be administered is in the chair of a Board-certified orthodontist. However, this doesn’t mean our patients cannot in some instances experience the benefits of our 21st-century economy.

Amy Jackson, MS, DDS, graduated Magna Cum Laude from Baylor University and then pursued her dental degree from University of Texas Health Science Center. Dr. Jackson continued her pursuit of excellence in specialty training for orthodontics at The University of Texas Health Science Center in San Antonio. While in resident training, she completed a master’s degree through the periodontal department and was awarded the AAED’s research grant for her work with midpalatal implants. Disclosure: Dr. Jackson is founder of Retainers for Life.

Orthodontic Practice US

Let’s examine a few instances where doctors should actively work to change their practice operations to satisfy the modern demands of a changing consumer base. 1. Offer options for virtual appointments. We all know there are some procedures and checks that must be done in person, but for instances where you can treat virtually, do so. 2. Offer easy methods of making and changing appointments. Of course, if patients want to call the office, they most assuredly can do so. However, in our app-based economy, a majority of consumers want to make and change appointments from their phones. All kinds of scheduling apps exist that can integrate with your practice management systems. Investigate which ones might work for you — your patients will thank you! 3. Touchless check-in. Add this to the list of things that the pandemic has changed, but in this case, file it squarely under the “pros” column. We check-in with our phones for flights, with Snapchat, and sometimes even in church. Offering an easy way to check-in for appointments from their phones is the new norm for patients. 4. Two-way messaging between office staff and patients. At first glance, this may seem like it’s biting off more than is worth chewing, but lots of scheduling apps have the ability to message with patients. In our ever-mobile centric world, providing patients a way to communicate with you via text is going to make their lives and, by extension, yours easier. 5. Retainer-replacement services. Retainer emergency appointments are a time killer, and they place undue stress on your patient and/or their parents. Partner with a company like Retainers For Life. They not only operate an A-to-Z retainer program for you and your practice, which allows us doctors to focus on more value-added activities like placing brackets on more patients’ teeth. They also ship directly to patients, pay you for using your intraoral scanner, and allow you to maintain a relationship with your retention patients. OP Volume 13 Number 2

Imagine a day when your retainer expenses disappear AND patients are provided with afforable, high quality retainers direct to their door.

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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