Orthodontic Practice US January/February 2018 Vol 9 No 1 by MedMark, LLC

Ali Oromchian, JD, LLM

8 HR resolutions to protect your practice in 2018

FEBRUARY 22-24, 2018 | SCOTTSDALE, ARIZONA

Dr. Laurance Jerrold

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Consenting adults: agreeing on what’s going to happen

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January/February 2018 – Vol 9 No 1

ORTHODONTIC EXCELLENCE & TECHNOLOGY

clinical articles • management advice • practice profiles • technology reviews

Effect of surgical corticotomy versus low level laser therapy on the rate of canine retraction in orthodontic patients Dr. Noha Ali El-Ashmawi, et al.

A survey of orthodontists’ perceptions of smile esthetics Dr. Alys M. Murdoch, et al.

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

© FMC 2018. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Orthodontic Practice US or the publisher.

ISSN number 2372-8396

Volume 9 Number 1

Making innovation happen

esides reading and editing clinical articles and working with the best authors and practitioners in the orthodontic world, my favorite pastime is playing with my 4-year old granddaughter, Emma. After careful deliberation, about a year ago, she announced that she had decided to become a dentist. I would expect nothing less from a child who owns six toothbrushes and a bag of pre-loaded flossers. The Play-Doh “Doctor Drill ‘n Fill” set that she got for her birthday clinched her decision even more. Not only do budding toddler dentists get to mold teeth out of Play-Doh and drill holes to fill cavities, but they can also roll out colorful orthodontic brackets and attach them to the teeth, to get some much needed practice between preschool and graduate school. Contemplating Emma’s possible journey into the orthodontic world made me think of the specialty’s evolution over the years and its amazing potential for the future. In the 1880s, orthodontic pioneer Norman W. Kingsley experimented with many different materials to move teeth, including linen twine, rubber tubing, leather, and vulcanite. It wasn’t a great time for patients. Some had to endure treatment such as an apparatus placed over the top of their heads and secured to their chins or held with bands secured to maxillary incisors.1 Thank goodness, now patients need fewer extractions before orthodontic treatment, and brackets and wires are made from materials developed for increased patient comfort and more precise movement. With the advent of clear aligner technology, some patients may not even need traditional braces. Because of different techniques, many patients can wait longer between appointments and even speed up the rate of tooth movement. CBCT imaging and digital impressions bring even more precision to the treatment process. Years from now, the potential for new innovations will take orthodontics to even greater heights for treatment options and patient care. In each issue, Orthodontic Practice US features case studies, CEs, and other articles that showcase both new and tried-and-true technologies, techniques, equipment, and materials. Many other opportunities are available for hands-on learning as well. For example, Drs. Dave Paquette, Jep Paschal, John Graham, and Luis Carriere are inviting orthodontists to attend what they tout as the biggest and best clinical education and marketing event of the year — Henry Schein® Orthodontics’ (HSO) Orthodontic Excellence and Technology™ Symposium. With a theme of “Innovation Happens Here,” this informative meeting will be held at the Westin Kierland Resort and Spa in Scottsdale, Arizona, from February 22-24. The event will feature new product innovations such as the Carriere® Motion 3D™, the all-new Carriere SLX 3D Clear Bracket System, as well as breakthrough treatment concepts such as Sagittal First, with clinically proven protocols for faster braces and aligner treatment. Hands-on training and breakout sessions will be available for both doctors and staff members. In this issue, an editorial focus of our two CEs is the legal aspects of running an orthodontic practice, specifically in the areas of informed consent and measures to avoid costly human resources issues. Besides staying current on the clinical side of the practice, being aware of possible legal pitfalls can keep everyone aware to avoid stressful situations. As we welcome 2018, the team at Orthodontic Practice US welcomes you to become involved and invested in our publication. Please email me with your ideas for articles on any topic that is of interest to the specialty, from clinical to technology to practice management. Or, if you want to call, I’m always ready to discuss subjects that will help our readers become more successful. For those who want product profiles or web-based marketing, our MedMark Media team is ready to help you spread the word. The orthodontic community can make a difference by sharing ideas and insights. And in a couple of decades, if Emma actually decides to trade Play-Doh teeth for real brackets and archwires, hopefully she will be able to use your inventions and techniques to change her patients’ lives. Until then, let’s enjoy the journey, and help make innovation happen! Until next time, Mali Schantz-Feld, MA Editor in chief

1. Posnick JC. “Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery.” Orthognathic Surgery. London: W.B. Sanders Co. Ltd., An Imprint of Elsevier Health Services; 2014:18-60.

Orthodontic practice 1

INTRODUCTION

Jan/Feb 2018 - Volume 9 Number 1

TABLE OF CONTENTS

Clinical research Effect of surgical corticotomy versus low level laser therapy (LLLT) on the rate of canine retraction in orthodontic patients Drs. Noha Ali El-Ashmawi, Mohamed Abd El-Ghafour, Shaimaa Saeed Nasr, Mona M. Salah Fayed, Amr Ragab El-Beialy, and Essam Mohamed Nasef Selim compare techniques to accelerate certain tooth movements

Continuing education

Research 20

8 HR resolutions to protect your practice in 2018

A survey of orthodontistsâ&#x20AC;&#x2122; perceptions of smile esthetics

Ali Oromchian, JD, LLM, discusses taking preventative measures to avoid costly HR issues.............................. 29

Drs. Alys M. Murdoch, Daniel Rinchuse, Thomas Zullo, and Daniel DiBagno explore a survey and literature to define the ideal orthodontic outcome

ON THE COVER Inset photo on cover courtesy of Drs. Noha Ali El-Ashmawi, et al. Article begins on page 6.

2 Orthodontic practice

Volume 9 Number 1

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TABLE OF CONTENTS

Continuing education Consenting adults: agreeing on what’s going to happen Dr. Laurance Jerrold explains informed consent and why it is important to the orthodontic practice

Practice management Industry news...............50 “The secret sauce” — more than the golden rule: part 1 Dr. Donald J. Rinchuse starts a discussion on marketing orthodontic practices......................................... 40

Book review The Golden Age of Orthodontics - Decline and Aftermath A History of the Business of Orthodontics • Norman Wahl, DDS, MS, MA • First Edition Design Publishing Inc., Sarasota, Florida ....................................................... 48

Materials & equipment.........................52

PUBLISHER | Lisa Moler Email: lmoler@medmarkmedia.com EDITOR IN CHIEF | Mali Schantz-Feld, MA Email: mali@medmarkmedia.com | Tel: (727) 515-5118 MANAGING EDITOR | Lou Shuman, DMD, CAGS Email: lou@medmarkmedia.com

Small talk

ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkmedia.com

Five powerful leadership and culture-building statements

NATIONAL SALES DIRECTOR | Kristin Sammarco Email: kristin@medmarkmedia.com

Dr. Joel C. Small discusses how to cultivate shared values and a common purpose...........................................56

Stay Connected Between Issues Like us on Facebook at facebook.com/OrthodonticPracticeUS Watch our DocTalk Dental videos at doctalkdental.com Check out our Webinars at orthopracticeus.com/webinars

NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez Email: celeste@medmarkmedia.com CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkmedia.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkmedia.com OFFICE MANAGER/EXECUTIVE ASST. | Mystey Helm Email: mystey@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.orthopracticeus.com | www.medmarkmedia.com SUBSCRIPTION RATES 1 year (6 issues) 3 years (18 issues)

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Volume 9 Number 1

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CLINICAL RESEARCH

Effect of surgical corticotomy versus low level laser therapy (LLLT) on the rate of canine retraction in orthodontic patients Drs. Noha Ali El-Ashmawi, Mohamed Abd El-Ghafour, Shaimaa Saeed Nasr, Mona M. Salah Fayed, Amr Ragab El-Beialy, and Essam Mohamed Nasef Selim compare techniques to accelerate certain tooth movements Abstract The present split mouth trial compares the effect of surgical corticotomy and low level laser therapy (LLLT) on the rate of maxillary canine retraction. Orthodontic patients (16 years to 25 years, both sexes) whose treatments necessitated maxillary first premolar extractions followed by canine retraction participated. At the day of premolar extractions, both interventions (corticotomy and LLLT) were randomly allocated to both sides of the maxillary arch followed by canine retraction. LLLT used was: In-Ga-As Semiconductor diode (power output: 1.43 W/ cm2, total energy density: 29.3 J/cm2) with the following time table: L0: At the day of first premolar extractions, L1: after 1 week, L2: after 2 weeks, L3: after 3 weeks. Then every 2 weeks until the end of the study â&#x20AC;&#x201D; i.e., 4 months after the start of canine retraction. At each laser session, an impression for the maxillary arch was done to make dental models used for assessment. The principal outcome measured the rate of canine retraction; the second outcome measured was the maxillary first molar anchorage loss. Randomization and allocation concealment were accomplished for 20 patients. Blinding of the operator and the patient was not possible; however, outcome assessment was performed by a single blinded assessor. Data were collected as mean

Noha Ali El-Ashmawi and Mohamed Abd El-Ghafour are Demonstrators at the Department of Orthodontics and Dentofacial Orthopedics, Faculty of Dentistry, Cairo University, Egypt. Shaimaa Saeed Nasr is an Associate Lecturer, Department of Periodontics, Modern Sciences and Arts University, Cairo, Egypt. Mona M. Salah Fayed and Essam Mohamed Nasef Selim are Professors at the Department of Orthodontics and Dentofacial Orthopedics, Faculty of Dentistry, Cairo University, Cairo, Egypt. Amr Ragab El-Beialy is a Lecturer, Department of Orthodontics and Dentofacial Orthopedics, Faculty of Dentistry, Cairo University, Egypt.

6 Orthodontic practice

values, standard deviation and analyzed by paired sample t-test. In 4 months, the maxillary canine on the corticotomy side traveled 4.318 mm, SD=1.29 mm with 4.547 mm and SD=1.72 mm for the laser side. No statistically significant difference occurred between either intervention at any time (Mean 0.23 mm, CI 95%, -0.7 - 1.2, P: 0.64). Similarly, we found no statistically significant difference between the sides in the mean distance traveled by the maxillary first molar at any time (Mean diff 0.33mm, 95% CI, -1.22 - 0.55, P = 0.45). Our results discovered that LLLT with previously tested dosage and frequency might have the same stimulatory effect of a corticotomy on accelerating orthodontic tooth movement (OTM).

Introduction Acceleration of orthodontic tooth movement has held interest for many investigators since the beginning of the last century. Even so, finding a method that is simple, efficient, and comfortable for patients has presented a formidable challenge. Surgical corticotomy, one of the popular and widely used surgical techniques to accelerate OTM, has had several systematic reviews, which have proven efficiency, efficacy, and safety of the surgical flap corticotomy in accelerating OTM.1-4 Although investigators have used different surgical corticotomy techniques to effect the regional acceleratory phenomenon (RAP),5-13 in spite of this, corticotomy still involves an invasive surgical treatment, which may cause some side effects such as postoperative bleeding, pain, swelling and negative effect on patientsâ&#x20AC;&#x2122; quality of life.14 Since the development of the first laser by Theodore M. Maiman in 1960, dental interest in lasers has been high, and research has continued into ways to improve dental treatment through laser application.15 The convenient and versatile nature of the laser device has encouraged orthodontists to use

it in several applications as in diagnostic procedures, prevention of white spot lesions, bracket debonding, and minor surgical procedures such as gingivectomy and frenectomy.16 Soft laser therapy is a special category of laser application in orthodontic treatment. It is known as low level laser therapy (LLLT) or cold laser therapy. The discovery of biostimulatory effect of LLLT in 1967 paved its way for use in several ways; e.g., acceleration of OTM, pain reduction during treatment, retention protocols, and assisting in maxillary expansion.17-21 Although LLLT is a simple and noninvasive technique in orthodontic therapy, some debate has occurred about its efficacy in accelerating OTM1 Consequently, several systematic reviews have questioned the effectiveness of LLLT as a way to accelerate OTM.2,22-24 Therefore, comparing the effectiveness of a noninvasive modality such as LLLT to accelerate OTM with an efficient but relatively invasive technique such as surgical corticotomy could offer benefits to clinicians and their patients.

Specific objective The present study compares the effect of surgical corticotomy and LLLT on the rate of maxillary canine retraction. A secondary consideration evaluates the effects these two techniques have on molar anchorage.

Materials and methods The trial design is a randomized, splitmouth parallel group comparative trial with 1:1 allocation ratio.

Participants, eligibility criteria, and study settings Patients were recruited according to the following criteria: age ranging from 16 years old to 25 years old from both sexes; a malocclusion that required extraction of the maxillary first premolars followed by canine Volume 9 Number 1

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CLINICAL RESEARCH retraction; treatment mechanics that allowed initial stage of leveling and alignment before extraction of the first premolars; normal shape and structure of maxillary canines; no history of restorations or root canal treatments in the maxillary canines; and a healthy periodontal condition. Patients with craniofacial anomalies — e.g., cleft lip and palate patients and patients with a history of chronic diseases or drug therapy that might affect OTM — were excluded from the study. Patients’ recruitment started from July 2013 until October 2013. On average, 30 patients were screened daily at the orthodontic outpatient clinic for inclusion in the study. The start of orthodontic treatment and follow-up visits were performed by the principal operator at the orthodontic outpatient clinic, faculty of Oral and Dental Medicine, Cairo University. Surgical interventions and the periodontal follow-up visits were done by the same qualified periodontist, and both procedures were performed at the periodontal outpatient clinic. This latter clinic was equipped to perform periodontal surgeries and minor dental surgical procedures. Upon completion, the protocol was sent to the ethics committee at Faculty of Oral and Dental Medicine, Cairo University, for revision and evaluation. After patients’ recruitment and consent (19 females, 1 male), orthodontic treatment was started with the placement of fixed orthodontic appliances. (MINI 2000, Ormco; Grēngloo adhesive from Ormco for metal brackets; Medicem glass ionomer Promedica for bands.) The leveling and alignment stage continued until a 0.016×0.022 SS archwire could be placed passively in the maxillary arch (Figure1). To ensure maximum anchorage status, miniscrews (HUBIT, Korea; 8mm in length

and 1.6 mm in diameter) were placed between the maxillary second premolars and first molars on both sides and secured to the first molars via L-shaped wire (0.019×0.025 SS). At that stage, patients were referred to the oral surgery department for extraction of both maxillary 1st premolars. All dental extractions were done by the same dental surgeon for all the patients under local anesthesia using premolar forceps. The study design was a parallel group split mouth design in which the low level laser therapy (LLLT) was performed on one side of the maxillary arch and a corticotomy on the other side. Low level laser therapy was applied to the assigned side using a laser machine (Biolase Epic™ 10 console) with the following criteria: • active medium: In-Ga-As semiconductor diode • wavelength: 940 ± 10 nm Parameters of soft laser application for acceleration of tooth movement were adjusted according to manufacturer instructions as following: Power output: 1.43 W/ cm2, continuous wave, 300 seconds, total energy density: 29.3 J/cm2. Eye protection was secured for the patient and the operator using protective eyeglasses. The active laser tip was held against the buccal mucosa at the mid-root area of the canine (Figure 2). The principal operator performed the laser operation throughout the study. Laser regimen was performed as a single-point application according the following time table: L0: At the day of first premolars extraction, L1: after one week, L2: after 2 weeks, L3: after 3 weeks. Then every 2 weeks until the end of the study, i.e., 4 months after the start of canine retraction. The corticotomy used the following protocol: profound anesthesia was guaranteed

Figure 2: Active laser tip applied intraorally against the buccal mucosa at the mid-root area of the canine 8 Orthodontic practice

through labial infiltration of local anesthesia (Mepivacain 2%, Levonordefrin 1:20000) in the area of surgery. Then, a submarginal Luebke-Ochsenbein flap design was done (Figure 3). The length of the maxillary canine root was first measured by the previously acquired periapical X-ray film to avoid injury of the root during the decortication. Scalpel blade (number 15c) was used to make the bucco-labial incision. Using the previously measured maxillary canine root length, the apical limit of the decortication was marked on the bone using a No. 2 surgical fissure bur. Then by using a No. 2 round bur mounted on a low-speed hand piece (22,000 to 27,000 rpm) and under copious saline irrigation, corticotomy perforations were made around the root of the maxillary canine. Ten to 15 cortications were made according to the canine root length (Figure 5). Full-depth cortical perforation was checked using the periodontal probe to ensure medullary bone involvement. Finally, the flap was carefully repositioned and sutured with resorbable 5-0 Vicryl® (Ethicon) by using the single interrupted technique. Postoperative instructions were given to the patients as follows: soft diet and strict oral hygiene instructions, including regular brushing and the use of 0.02 chlorhexidine mouthwash for 1 week. Ice packs were prescribed during the

Figure 1: Leveling and alignment stage completed

Figure 3: Diagramatic representation of submarginal Luebke-Ochsenbein flap Volume 9 Number 1

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CLINICAL RESEARCH

Figure 4: Start of canine retraction on both sides (corticotomy and laser sides), using NiTi closing coil spring, and with SS ligature tie on maxillary canine bracket

first 12 hours, followed by hot packs for the next 48 hours. For pain control, Paracetamol (500 mg) was prescribed as 1 gm every 12 hours for 4 days. Patients were advised to contact the operator if they experienced excessive swelling, bleeding, or severe pain. Canine retraction was started on both sides the same day of the first premolar extractions and immediately after the completion of the laser and corticotomy procedures. A NiTi closed coil spring (Ormco) was placed between the hook of the canine and the molar band, which delivered a force of 150 g as measured by a force gauge (Figure 4). At each laser application, reactivation of the spring was done when necessary to maintain 150 g of force delivery. Additionally, molar anchorage and canine retraction were measured from models made with alginate impressions. No alginate impression was done at 2nd LLLT session — i.e., 1 week after the surgery in order to stabilize the surgical flap.

Randomization A computer generated random numbers for 20 patients (19 females, 1 male) using Microsoft® Office Excel 2007. The right sides of patients were firstly randomly assigned to one of the two interventions (laser or corticotomy). Then the left sides were assigned to the alternative interventions. The patient randomization numbers were written on opaque white papers folded 3 times to form sealed envelopes and kept inside a box in the secretary’s office. At the time of intervention, the department secretary selected an envelope for the allocation of each side of the maxillary arch and presented it to the principal operator who selected each side for the corresponding intervention according to the randomization codes.

Outcomes measured The primary outcome would assess the 10 Orthodontic practice

Figure 5A: Dental cast measurement. Landmarks identified on the dental cast: (1) cusp tips of maxillary right and left canines, (2) mesio-buccal cusp tips of maxillary right and left first molars, (3) right third rugae, (4) left third rugae, (5) midpalatal raphe

Figure 5B: Scanned image of the dental cast. (CR,CL) perpendicular lines from cusp tips of right and left maxillary canines to midpalatal raphe, (MR,ML) perpendicular lines from right and left mesio-buccal cusp tips of maxillary first molars to midpalatal raphe, (RR,RL) perpendicular line through right and left third rugae and midpalatal raphe

Table 1: Dental model landmarks and line Landmark/Line 1: The midpalatal raphe

MPR

2: The most medial point on the third right rugae

3: The most medial point on the third left rugae

4: The right canine cusp tip

5: The left canine cusp tip

6: The right first molar mesio-buccal cusp tip

7: The left first molar mesio-buccal cusp tip

rate of maxillary canine retraction on both sides of the maxilla. A secondary outcome would assess maxillary molar anchorage. Both outcome evaluations occurred through a series of dental models acquired at the start of canine retraction and at each laser application session until completion of the 4-month study. Measurements were carried out on 2D-scanned dental models using the third rugae as reference point (Table 1 and Figure 5). Outcomes measured by the distance traveled by maxillary canines and first molars relative to the third rugae were described in terms of mean and standard

Figure 6: Maxillary CBCT used for measurement of the distance traveled by maxillary canine in reference to frontal plane

deviation. Outcomes were calculated by directly measuring the distance between 2 points (cusp tip of maxillary canine and the mesiobuccal cusp tip of maxillary first molar) for 20 dental casts, using digital calipers and comparing with the corresponding measurements on the scanned images of the same dental models. To assess the three-dimensional movements of the canines, a CBCT was captured before canine retraction and after 4 months Volume 9 Number 1

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CLINICAL RESEARCH Table 2: Results of interclass correlation coefficient for random and systematic errors

Figure 7: Mean distance traveled by the maxillary first molar (referred to baseline) on the corticotomy and laser sides

of canine retraction. The CBCT field of view was restricted to the maxillary arch with minimum CBCT machine parameter settings. The distance traveled by the canine cusp tip was measured from the frontal reference plane at the pre- and post-retraction time points (Figure 6).

Blinding was not possible for the operators during the application of the therapies or subsequent visits. One assessor, blinded for the assignment of each intervention, performed the dental model measurements.

Statistical analysis

ICC

Intra-observer

0.39

3.6%

.989

.985

.991

Measuring methods

0.18

1.8%

.885

.733

.953

Mean distance traveled at 2 weeks follow-up (mm/2 weeks)

95% confidence limits

Min

Max

Mean

Avg. daily rate of canine retraction in mm/day

Corticotomy

1.84

-2.69

-0.95

1.02

-0.07

Laser

0.53

-4.04

-0.97

1.08

-0.07

Corticotomy

0.67

-2.32

-0.98

0.87

-0.07

Laser

0.24

-3

-1.31

0.84

-0.09

Corticotomy

1.68

-2.07

-0.21

1.17

-0.02

Laser

1.71

-2.44

-0.05

1.04

-0.004

Corticotomy

0.6

-3.02

-0.85

1.09

-0.06

Laser

0.72

-2.59

-0.82

0.86

-0.06

Corticotomy

0.22

-2.49

-0.34

1.02

-0.02

Laser

2.85

-1.54

-0.09

0.99

-0.01

Corticotomy

1.62

-2.84

-0.66

0.97

-0.05

Laser

0.7

-6.08

-0.81

1.56

-0.06

Corticotomy

1.54

-1.19

-0.17

0.96

-0.01

Laser

1.12

-1.71

-0.19

0.92

-0.013

Corticotomy

1.12

-2.11

-0.46

1.05

-0.03

Laser

1.01

-2.11

-0.81

0.97

-0.06

Weeks

2nd

7th

9th

11th

Two hundred dental models for 20 patients who received 220 LLLT sessions were measured for canine retraction and molar anchorage. SPSS in general (version 17), and Microsoft Office Excel performed the statistical analysis, data, and graphical presentation. Quantitative variables were described by the mean, standard deviation (SD) and the

Relative Dahlberg Error RDE

Table 3: Descriptive statistics of the mean distance traveled by the maxillary canine on the corticotomy and laser sides at 2 weeks interval for 4 months follow-up

5th**

Blinding

Dahlberg Error DE

13th

15th

17th

-ve sign denotes distal movement of the maxillary canine ** Distance traveled by the maxillary canine from the 3rd week to the 5th week follow-up

Table 4: Paired t-test results comparing the mean distance traveled by the maxillary first molar referred to baseline on the corticotomy and laser at each observation time Weeks

2nd

3rd

5th

7th

9th

11th

15th

17th

19th

Side

Mean

Std. Error Mean

Corticotomy

0.446

1.01

0.23

Laser

0.189

0.90

0.20

Corticotomy

-0.166

0.81

0.18

Laser

0.204

0.93

0.21

Corticotomy

-0.027

1.11

0.25

Laser

0.354

0.97

0.22

Corticotomy

-0.023

1.31

0.30

Laser

0.046

0.98

0.23

Corticotomy

-0.005

0.94

0.21

Laser

-0.116

0.99

0.22

Corticotomy

-0.272

1.50

0.34

Laser

-0.172

0.94

0.22

Corticotomy

0.039

1.26

0.29

Laser

-0.144

1.15

0.26

Corticotomy

-0.440

1.06

0.28

Laser

-0.361

1.33

0.74

Corticotomy

-0.814

1.41

0.31

Laser

-0.480

1.36

0.31

12 Orthodontic practice

Paired Differences

95% Confidence Interval of the Difference

Mean

Std. Error Mean

Lower

Upper

Size Effect Est. Cohenâ&#x20AC;&#x2122;s d

Pvalue

0.26

1.14

0.26

-.732

.772

.253

1.004

.327

-0.37

1.25

0.28

-.362

.686

-.458

-1.325

.200

-0.38

1.68

0.38

-.378

.885

-.343

-.989

.335

-0.07

1.92

0.44

-.687

.865

-.052

-.156

.877

0.11

1.47

0.33

-.580

.676

.116

.335

.741

-0.10

1.81

0.41

-.771

.464

-.066

-.241

.812

0.18

1.96

0.45

-.654

.561

.145

.408

.687

-0.13

2.99

0.80

-.974

.913

-.074

-.161

.874

-0.33

2.09

0.47

-.593

1.051

-.237

-.715

.483

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CLINICAL RESEARCH range (Maximum â&#x20AC;&#x201C; Minimum). Coefficients (ICC), including 95% confidence limits. Kolmogorov-Smirnova and Shapiro-Wilk tests of normality were used to test normality hypothesis of all quantitative variables for further choice of appropriate parametric and non-parametric tests. Dahlberg error and Relative Dahlberg Error (RDE) together with Interclass Correlation Coefficients (ICC) including 95% confidence limits measured intra-observer error as well as the error of methodology. A paired t-test and Mann-Whitney U Test compared the mean changes between the two groups. A repeated measure test (ANOVA) compared both groups at different time points. Two-tailed tests were assumed throughout the analysis for all statistical tests.

Results Patientsâ&#x20AC;&#x2122; recruitment started from July 2013 until October 2013. All recruited patients successfully completed the 4-month study. A total of 10 interim dental models (20% of a total of 200 interim dental models) were dropped out during the duration of the study. Eight of them were dropped out for seven patients who missed eight laser application appointments (4% of a total of 220 laser application sessions), and two further models were excluded being unsuitable for measurements. Outcomes of the rate of canine retraction and molar anchorage loss showed

normal distribution in each intervention side (corticotomy and laser). Consequently, parametric tests were chosen to evaluate the statistical significant differences between these variables on both the corticotomy, and the laser sides. The result of interclass correlation coefficient (error of methodology) was (3.6%, 95%CI: 0.98 - .991) for intra-observer measurements and was (0.885, 95% CI: 0.733 - 0.953) for the measuring method, which indicated good reliability for both readings (Table 2). The total distance traveled by the maxillary canine in 4 months Figure 8: Surgical corticotomy: flap reflection and surgical decortication on the corticotomy side was 4.318, SD:1.29 mm (Table 3). The highest 5th and the 2nd weeks, which was recorded rate of canine retraction was recorded in the 2nd and 5th weeks, which showed an to be 0.09 and 0.07 mm/day, respectively, average daily rate of 0.07 mm, while the while the lowest average daily rate was lowest average daily rate of 0.01 mm/day recorded at the 7th week (0.004 mm/day) The total amount of molar anchorage loss was found in the 15th week (Table 6). The total molar anchorage loss on the cortiwas 0.480, SD: 1.36 mm at the end of the cotomy side was 0.813 SD: 1.41 mm at 4th month, and the highest anchorage loss the end of the 4th month, and the highest occurred at the 15th and 17th weeks (Table 4). anchorage loss occurred at the 15th and Comparison of the mean distance trav17th weeks (Figure 7 and Table 4). eled by the maxillary canine on both sides The total distance traveled by the canine (corticotomy and laser sides) at each obserin 4 months was 4.547 on the laser side, SD: vation time showed no statistical significant 1.72 mm (Table 5). The average daily rate of difference between both sides throughout maxillary canine retraction was highest at the the study (Mean diff 0.23 mm, 95% CI, -0.59

Table 5: Paired t-test results of the mean distance (mm) traveled (referred to baseline) by the canine on the corticotomy and laser sides at each observation time Weeks

2nd

3rd

5th

7th

9th

11th

13th

15th

17th

Side

Mean

Std. Error Mean

Corticotomy

-0.95

1.03

0.23

Laser

-0.97

1.08

0.24

Corticotomy

-0.78

0.62

0.14

Laser

-0.94

0.91

0.20

Corticotomy

-1.76

0.77

0.18

Laser

-2.02

0.93

0.21

Corticotomy

-1.98

1.14

0.26

Laser

-2.07

1.07

0.25

Corticotomy

-2.80

0.84

0.19

Laser

-2.85

1.09

0.24

Corticotomy

-3.18

1.21

0.28

Laser

-3.02

1.18

0.27

Corticotomy

-3.81

0.99

0.23

Laser

-3.77

1.19

0.27

Corticotomy

-3.97

1.40

0.37

Laser

-3.94

1.27

0.34

Corticotomy

-4.32

1.29

0.29

Laser

-4.55

1.72

0.38

14 Orthodontic practice

Paired Differences

95% Confidence Interval of the Difference

Mean

Std. Error Mean

Lower

Upper

Size Effect Est. Cohenâ&#x20AC;&#x2122;s d

Pvalue

.0200

1.608

.35956

-.732

.772

.019

.05562

.956

.1620

1.119

.25037

-.362

.686

.262

.64703

.525

.2536

1.311

.30088

-.378

.885

.330

.84313

.410

.0889

1.611

.36980

-.687

.865

.077

.24053

.812

.0480

1.342

.30018

-.580

.676

.057

.15990

.874

-.1536

1.282

.29423

-.771

.464

-.126

-.52232

.607

-.0463

1.261

.28947

-.654

.561

-.046

-.16000

.874

-.0307

1.635

.43707

-.974

.913

-.022

-.07027

.945

.2290

1.756

.39286

-.593

1.051

.176

.58291

.566

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CLINICAL RESEARCH –1.05, P=0.57) (Table 5). Similarly, the output of repeated measurements (ANOVA) showed no statistical significant difference between the two sides for any time point (P= 0.46) (Table 6). Comparing the distance traveled by the canine via the two measuring modalities — i.e., 2D-scanned dental models and the CBCT — a minimum clinical difference of 0.4 mm and 0.5 mm for the corticotomy and laser group, respectively (Table 7) was found (Figure 8). The mean distance traveled by the maxillary first molar, showed no statistically significant difference was found between both sides at any observation time (Mean diff 0.33mm, 95% CI, -0.59 – 1.05, P= 0.48) (Table 3). Fourteen patients (70% of a total of 20 patients) reported post-surgical swelling on the corticotomy side which lasted from 4 to 6 days, while two patients (10%) reported swelling on both sides. Four patients (20%) presented on the 1st week follow-up visit with a marked swelling, which was observed by the principal investigator and lasted for 14 days. Seventeen patients (85%) reported post-surgery pain, which was more severe on the corticotomy side and necessitated 1 week of pain medication (Paracetamol (500 mg). One patient (5%) experienced sensitivity in the maxillary lateral incisor on the corticotomy side that started 2 weeks after surgery and lasted for 3 months. Sloughing painless ulcers at the site of first laser application occurred in two patients (10%), which necessitated topical medication.

Discussion The present RCT compared surgical corticotomy with LLLT in acceleration of the OTM assessed by the rate of maxillary canine retraction. The matched measurements extracted from both measuring mechanisms regarding the total amount of canine retraction, denoted a consensus of outcome. This validates the “poor’s man’s technique” (model scanning) for assessment of canine retraction. In the present study, the rate achieved by the maxillary canine on the corticotomy side measured from the dental models was highest during the first 5 weeks and lowest at the 15th week. Previous clinical trials5-8 showed the acceleratory effect of corticotomies maximized during the first month. Moreover, a consensus regarding the limited effect of acceleration following surgical corticotomy has been noted by several systematic reviews.3,4,13 16 Orthodontic practice

Table 6: Repeated measure tests (ANOVA) Source

Time

Time Group

Error (Time)

Sphericity Assumed Greenhouse-Geisser Huynh-Feldt Lower-bound

Type III Sum of Squares

Mean Square

Sig.

Partial Eta Squared

537.761

59.751

84.770

.000

.779

537.761

4.329

124.224

84.770

.000

.779

537.761

5.620

95.686

84.770

.000

.779

537.761

1.000

537.761

84.770

.000

.779

3.622

.402

.571

.820

.023

3.622

4.329

.837

.571

.698

.023

3.622

5.620

.644

.571

.742

.023

3.622

1.000

3.622

.571

.457

.023

152.251

216

.705

152.251

103.895

1.465

152.251

134.882

1.129

152.251

24.000

6.344

Table 7: Mean distance traveled by maxillary canine assessed by dental models and maxillary CBCT Dental models

CBCT

Group

Mean

Corticotomy

4.32

1.29

3.92

1.63

Laser

4.55

1.72

4.06

1.46

P> 0.05 Nonsignificant

The design of the surgical corticotomy performed mimicked that used by Aboul-Ela, et al.,6 and Abed and Al-Bustani,5 in which a conservative labial submarginal LuebkeOchsenbein flap was performed around the area of intended tooth acceleration, i.e., the maxillary canine. Reviewing the literature, we found no data regarding the advantage of combining labial and lingual corticotomy compared to labial corticotomy. Additionally, the effectiveness of a particular decortication design — i.e., holes, lines or combined design — was not investigated. Consequently, the most conservative, yet effective, design was chosen in the present study. On the other hand, other investigators performed less invasive flapless corticotomy techniques using piezosurgical cortical cuts.7,9,10 These latter techniques might be more suitable for comparison with the non-invasive LLLT on the rate of OTM. But this literature shows weak evidence about the effectiveness of these techniques in accelerating tooth movement. On the laser side, a similar pattern of early acceleration of OTM was found. A sharp decrease in the rate of canine retraction on the 7th week (0.05mm/2 week) was observed, which was not found on the corticotomy side. Two theories might explain this deceleration of OTM on the laser side. The

P> 0.05 Nonsignificant

first could be due to the normal lag phase in OTM, which represents the time needed to remove the hyalinized tissues in order to resume the canine retraction. Such a lag phase did not occur on the corticotomy side, which indicates a benefit that corticotomy might add by reducing the hyalinized tissue, a finding that was previously shown by Lino, et al.25 A second cause could be the decrease in the frequency of the laser application after the 1st month, and such dose dependent acceleration nature of LLLT was also observed by Doshi-Mehta.18 Reviewing the literature displays a vast heterogeneity of protocols for LLLT applications to accelerate OTM both in frequency of application and energy density (Youssef, et al.,29 and Cruz, et al.,28 Genc, et al.,27 Limpanichkul29 and Heravi30). We followed the manufacturer’s recommendation of LLLT for acceleration of OTM as follows. The energy dosage (29.3 J/cm2) was delivered through a single application (300 seconds) via an active tip held against the buccal mucosa at the mid-root area of the canine. Four laser applications were performed in the 1st month followed by 2 applications per month for the next 3 months. Comparing the rate of canine retraction on both intervention sides, the corticotomy Volume 9 Number 1

CLINICAL RESEARCH and laser sides showed no statistically significant difference in the total distance travelled by the maxillary canine in 4 months. Moreover, the rate of maxillary canine measured at each recall visit, at 2 weeks interval, didnâ&#x20AC;&#x2122;t show any statistically significant difference between corticotomy and laser side. No study comparing the LLLT with surgical corticotomy has entered the orthodontic literature, and these results show that LLLT may have the same stimulatory effect as corticotomies. The 2-week assessment showed rapid canine tipping movement followed by a slower movement associated with canine root uprighting. This tipping uprighting cycle repeated each month. The highest rate of molar anchorage loss coincided with the period that exhibited the lowest rate of canine retraction on both sides, i.e., at the 15th and 17th weeks. Molar anchorage loss was not studied in other studies18,27,28,29 investigating the effect of LLLT on tooth movement. In our work, if one miniscrew failed, the contralateral miniscrew was removed, and anchorage was re-established for both sides a week later. This protocol minimized the effect of miniscrew failure on the measured molar anchorage loss. No major post-surgical side effects were encountered in the present study. Most of

Our results discovered that LLLT with previously tested dosage and frequency might have the same stimulatory effect of a corticotomy on accelerating orthodontic tooth movement (OTM). the post-surgical swelling and pain were experienced more frequently on the corticotomy side and lasted only for 1 week. Our results matched conclusions of two systematic reviews1,3 reporting the safety of the surgical corticotomy as an adjunctive procedure to orthodontic treatment. Although LLLT showed less side effects and less patient discomfort, the need for frequent laser application visits resulted in some missed appointments, which totaled 8 of 220 total laser appointments (4%). Clinicians should always weigh cost/benefit risk for every patient before applying interventions for accelerating tooth movement. According to our results, LLLT could achieve the same rate of canine retraction as surgical corticotomy procedure. The lack of a control group limits this study, but could not be done with this split mouth design. Additionally, the 4-month duration did not compare the effectiveness

of these techniques on the overall treatment duration.

1. Long H, Pyakurel U, Wang Y, Liao L, Zhou Y, Lai W. Interventions for accelerating orthodontic tooth movement: a systematic review. Angle Orthod. 2013;83(1):164-171.

11. Mostafa YA, Mohamed Salah Fayed M, Mehanni S, ElBokle NN, Heider AM. Comparison of corticotomy-facilitated vs standard tooth-movement techniques in dogs with miniscrews as anchor units. Am J Orthod Dentofacial Orthop. 2009;136(4):570-577.

laser on bone regeneration after rapid maxillary expansion. Am J Orthod Dentofacial Orthop. 2012;141(4):444-450.

2. Gkantidis N, Mistakidis I, Kouskoura T, Pandis N. Effectiveness of non-conventional methods for accelerated orthodontic tooth movement: a systematic review and metaanalysis. J Dent. 2014;42(10):1300-1319.

12. Wang L, Lee W, Lei DL, Liu YP, Yamashita DD, Yen SL. Tisssue responses in corticotomy- and osteotomy-assisted tooth movements in rats: histology and immunostaining. Am J Orthod Dentofacial Orthop. 2009;136(6):770-771.

3. Hoogeveen EJ, Jansma J, Ren Y. Surgically facilitated orthodontic treatment: a systematic review. Am J Orthod Dentofacial Orthop. 2015;53(6):491-506.

13. Liem AM, Hoogeveen EJ, Jansma J, Ren Y. Surgically facilitated experimental movement of teeth: systematic review. Br J Oral Maxillofac Surg. 2015;53(6):491-506.

4. Kalemaj Z, DebernardI CL, Buti J. Efficacy of surgical and non-surgical interventions on accelerating orthodontic tooth movement. Eur J Oral Implant. 2015;8(1):9-24.

14. Cassetta M, Di Carlo S, Giansanti M, Pompa V, Pompa G, Barbato E. The impact of osteotomy technique for corticotomy-assisted orthodontic treatment (CAOT) on oral health-related quality of life. Eur Rev Med Pharmacol Sci. 2012;16(12):1735-1740.

REFERENCES

5. Abed SS, Al-Bustani AI. Corticotomy assisted orthodontic canine retraction. J Bagh Coll Dent. 2013;25:160-166. 6. Aboul-Ela SM1, El-Beialy AR, El-Sayed KM, Selim EM, El-Mangoury NH, Mostafa YA. Miniscrew implant-supported maxillary canine retraction with and without corticotomyfacilitated orthodontics. Am J Orthod Dentofacial Orthop. 2011;139(2):252-259. 7. Alikhani M, Raptis M, Zoldan B, et al. Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013;144(5):639-648. 8. Al-Naoum F, Hajeer MY, Al-Jundi A. Does alveolar corticotomy accelerate orthodontic tooth movement when retracting upper canines? A split-mouth design randomized controlled trial. J Oral Maxillofac Surg. 2014;72(10):1880-1889. 9. Sebaoun J-DM, Surmenian J, Dibart S. Accelerated orthodontic treatment with piezocision: a mini-invasive alternative to conventional corticotomies. Orthod Fr. 2011;82(4):311-319. 10. Uribe F, Davoody L, Mehr R, et al. Efficiency of piezotomecorticision assisted orthodontics in alleviating mandibular anterior crowding - a randomized controlled clinical trial. Eur J Orthod. 2017;39(6):595-600.

18 Orthodontic practice

15. Maiman TH. Stimulated optical radiation in ruby masers. Nature. 1960;187:493-294. 16. Reza F, Katayoun KAM. Laser in Orthodontics. In: Naretto S (ed) Principles in contemporary Orthodontics. InTech: 1994. 17. Mester E, Szende B, GĂ¤rtner P. The effect of laser beams on the growth of hair in mice. Radiobiol Radiother (Berl). 1968;9(5):621-626. 18. Doshi-Mehta G, Bhad-Patil WA. Efficacy of low-intensity laser therapy in reducing treatment time and orthodontic pain: a clinical investigation. Am J Orthod Dentofacial Orthop. 2012;141(3):289-297. 19. Tortamano A, Lenzi DC, Haddad ACSS, Bottino MC, Dominguez GC, Vigorito JW. Low-level laser therapy for pain caused by placement of the first orthodontic archwire: a randomized clinical trial. Am J Orthod Dentofacial Orthop. 2009;136(5):662-667. 20. Kim YD, Kim SS, Kim SJ, Kwon DW, Jeon ES, Son WS. Low-level laser irradiation facilitates fibronectin and collagen type I turnover during tooth movement in rats. Lasers Med Sci. 2010;25(1):25-31. 21. Cepera F, Torres FC, Scanavini M, et al. Effect of a low-level

Summary The low level laser therapy used in the current study achieved the same rate of maxillary canine retraction as the surgical corticotomy and offers a noninvasive alternative method to accelerate OTM. The corticotomy caused an initial acceleration with later deceleration. Low level laser therapy may have a cumulative dose dependent on the biostimulatory effect on OTM. Both interventions showed similar amounts of molar anchorage loss during the study.

Acknowledgment The authors would like to express their deepest gratitude to Dr. Larry White for his support and efforts in preparing this article for publication. OP

22. Long H, Zhou Y, Xue J, et al. The effectiveness of low- level laser therapy in accelerating orthodontic tooth movement: a meta-analysis. Lasers Med Sci. 2015;30(3): 1161-1170. 23. Carvalho-Lobato P, Garcia VJ, Kasem K, et al.. Tooth movement in orthodontic treatment with low-level laser therapy: a systematic review of human and animal studies. Photomed Laser Surg. 2014;32(5):302-309. 24. Ge MK, He WL, Chen J, et al. Efficacy of low-level laser therapy for accelerating tooth movement during orthodontic treatment: a systematic review and meta-analysis. Lasers Med Sci. 2015;30(5):1609-1618. 25. Hoogeveen EJ, Jansma J, Ren Y. Surgically facilitated orthodontic treatment: a systematic review. Am J Orthod Dentofacial Orthop. 2014;145(suppl 4):S51-64. 26. Iino S, Sakoda S, Ito G, Nishimori T, Ikeda T, Miyawaki S. Acceleration of orthodontic tooth movement by alveolar corticotomy in the dog. Am J Orthod Dentofacial Orthop. 2007;131(4):448.e1-8. 27. Genc G, Kocadereli I, Tasar F, Kilinc K, El S, Sarkarati B. Effect of low- level laser therapy (LLLT) on orthodontic tooth movement. Lasers Med Sci. 2013;28(1):41-47. 28. Cruz DR, Kohara EK, Ribeiro MS, Wetter NU. Effects of low-intensity laser therapy on the orthodontic movement velocity of human teeth: a preliminary study. Lasers Surg Med. 2004;35(2):117-120. 29. Youssef M, Ashkar S, Hamade E, Gutknecht N, Lampert F, Mir M. The effect of low-level laser therapy during orthodontic movement: a preliminary study. Lasers Med Sci. 2008;23(1):27-33. 30. Limpanichkul W, Godfrey K, Srisuk N, Rattanayatikul C. Effects of low- level laser therapy on the rate of orthodontic tooth movement. Orthod Craniofac Res. 2006;9(1):38-43. 31. Heravi F, Moradi A, Ahrari F. The effect of low level laser therapy on the rate of tooth movement and pain perception during canine retraction. Oral Heal Dent Manag. 2014:13(2):183-188.

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A survey of orthodontists’ perceptions of smile esthetics Drs. Alys M. Murdoch, Daniel Rinchuse, Thomas Zullo, and Daniel DiBagno explore a survey and literature to define the ideal orthodontic outcome Abstract Introduction The aim of this study was to investigate what orthodontists’ perceive as the important aspects of smile esthetics. It investigated whether orthodontists agree with the current literature involving the smile and smile esthetics. This study attempted to determine what orthodontists find important when treatment planning a case, finishing a case, and generally improving a patient’s smile esthetics. Methods An email invitation from the American Association of Orthodontists (AAO) Partners in Education was sent to a random sample of AAO members in the United States and Canada (n = 2,300), requesting participation in a 10-question online survey (SurveyMonkey®) regarding different aspects of smile esthetics. The email blasts provided by the AAO were sent to these participants twice, spaced out approximately 6 weeks, to maximize the return rate. A total of 112 orthodontists participated in the survey. Results It was found that there was consistency among orthodontists with considerations for how the face will change over time and that achieving a consonant smile is an important

Alys M. Murdoch, DMD, is a Resident, Seton Hill University, Advanced Educational Program in Orthodontics and Dentofacial Orthopedics in Greensburg, Pennsylvania. Daniel Rinchuse, DMD, MS, MDS, PhD, is a Professor and Program Director, Seton Hill University, Advanced Educational Program in Orthodontics and Dentofacial Orthopedics in Greensburg, Pennsylvania. Thomas Zullo, PhD, is an Adjunct Professor of Biostatistics, Seton Hill University, Advanced Educational Program in Orthodontics and Dentofacial Orthopedics in Greensburg, Pennsylvania. Daniel DiBagno, DMD, is Assistant Professor and Director of Clinical Training, Seton Hill University, Advanced Educational Program in Orthodontics and Dentofacial Orthopedics in Greensburg, Pennsylvania.

20 Orthodontic practice

consideration in orthodontic smile esthetics. In addition, according to the survey, most orthodontists (over 70%) agree or strongly agree with the following: Centering the maxillary midline with the facial midline is more important than centering the maxillary and mandibular midlines with each other; midline deviations of less than 2 mm are visually acceptable; canine-protected occlusion is a goal of treatment; and buccal corridors are important in smile esthetic treatment planning. However, when determining if smile esthetics are more important than achieving an Angle’s Class I occlusion, 43.75% agree or strongly agree, and 43.75% remain neutral. Finally, when determining if four premolar extractions cause negative effects on smile esthetics, 76.57% of respondents disagree or strongly disagree. There were no statistically significant differences between male and female respondents. There was a statistically significant difference on two questions. First, orthodontists in practice for 20 years or less thought that smile esthetics were slightly more important than did those in practice for more than 20 years. Second, orthodontists in practice for more than 20 years thought that canine-protected occlusion was slightly more important than those in practice for 20 years or less. Conclusions Most (98.20%) orthodontists surveyed account for facial changes and aging when treatment planning children. According to this survey, over 70% of orthodontists believe achieving a consonant smile, midline deviations of less than 2 mm, canine-protected occlusion, buccal corridors, and centering the maxillary midline with the facial midline are all important aspects of smile esthetics. In addition, most (76.57%) orthodontists feel that four premolar extractions will not cause harm to smile esthetics. There were inconsistencies when determining if smile esthetics are more important than achieving an Angle’s Class I occlusion. However, generally speaking, the surveyed orthodontists seem

to be adhering to the evidence-based topics of smile esthetics.

Introduction Orthodontists can have different definitions and understandings of the various aspects of smile esthetics, which they believe are important for orthodontic diagnosis and treatment planning. Kaya, et al., wrote that ideas of facial esthetics are thought of as being subjectively based rather than evidence based.1 Therefore, this makes it difficult to determine the essential features of the smile that should be considered when treatment planning. Isiksal, et al., state that even though the occlusal relationship is the primary basis of orthodontic treatment, more emphasis is being placed on the paramount dentofacial features necessary for facial esthetics.2 Stedman’s Medical Dictionary defines esthetics as a branch of philosophy that is focused on art and beauty.3 The new paradigm for orthodontic treatment is based on the soft tissue relationships and not necessarily on Angle’s ideal occlusal relationships.4 In addition, it has been found that when patients are pursuing orthodontic treatment, they are looking for an improvement of their appearance, hoping to increase their quality of life.5 Therefore, are orthodontists including smile esthetics as part of diagnosis and treatment planning? Janson, et al., published a systematic review, including articles of average and high quality. They described a set of certain features related to smile attractiveness, which should be considered when preparing an orthodontic treatment plan.6 The list ranges from maxillary gingival display, buccal corridors, smile arc, and maxillary to mandibular midlines, overbite, occlusal plane, maxillary midline in relation to the face, and maxillary gingival height discrepancies. There is controversy in the literature concerning which features are most important for the ideal smile. Orthodontists continue to debate which aspects of smile Volume 9 Number 1

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RESEARCH esthetics should be focused on to help improve a patient’s smile. Parekh, et al., state that individuals who have excessive buccal corridors and flat smile arcs are shown to be less attractive.7 Whereas, in another study, McNamara, et al., showed that buccal corridors, smile arc, and posterior corridors have no correlation with smile esthetics.8 In addition, there have been studies that have defined a particular tooth as the key to smile esthetics. According to Parrini, et al., the maxillary incisors followed by the maxillary canine are most critical when determining smile esthetics.9 Another controversy that greatly affects the practicing orthodontist is extraction versus non-extraction, and the impact this has on the overall smile appearance. Some studies showed in patients with ideal occlusions or Class I malocclusions, the treatment modality, whether it be extraction or non-extraction, did not cause a difference in smile esthetics.1,10 With a constant influx of differing information throughout the literature, it is easy to see why there is not an accepted standard of key features that define smile esthetics, and maybe there cannot be for every patient. Sarver has divided facial esthetics into three categories. First, he defines macroesthetics “to include the profile and vertical dimension, in other words the face.”5 Next, are miniesthetics which are “smile attributes such as buccal corridors, smile arc, incisor display, etc.”5 Finally, Sarver describes microesthetics as “the tooth and their many attributes such as contacts and connectors, embrasures, gingival shape and contour.”5 These may be considered when analyzing facial and smile esthetics. Overall, the systematic review performed by Janson, et al., for the purpose of our findings, is considered the gold standard of smile esthetics. It is considered the gold standard here due to hierarchy of evidence (systematic review) and due to low risk of bias according to Janson, et al.6 They included 20 articles, 13 of which were high quality and 7 which were average quality. In addition, no low-quality studies were included in the systematic review.6 Furthermore, using a grading system defined by Pandis, et al., the introduction of Evidence-Based Clinical Orthodontics, the systematic review is given a grade of 2++.11 A grade of a 2++ means that it is a high-quality systematic review of case controls and cohort studies.11 Current research still continues to show that there is no consensus to the key esthetic features, which should be included in the diagnosis and treatment planning of orthodontic patients. 22 Orthodontic practice

Table 1: Results of a 10-question survey of orthodontists on the topic of smile esthetics Topic

1. Number of years in practice

2. Gender

Results of 112 Respondents 1-5 years

20.91%

6-10 years

10.91%

11-15 years

4.55%

16-20 years

10.00%

20 + years

53.64%

Male

73.64%

Female

26.36%

Weighted Average (Mean)

N/A

Choose not to respond

3. Achieving a consonant smile is a consideration in orthodontic smile esthetics.

4. Buccal corridors are important in smile esthetics and important in orthodontic diagnosis and treatment planning.

5. Smile esthetics are more important than achieving an Angle’s Class I occlusion.

6. When treating children, you consider how the face will change and age over time.

7. Canine-protected occlusion is a goal of orthodontic treatment.

8. Maxillary and/or mandibular midline deviations of less than 2 millimeters from each other are visually acceptable.

9. Centering the maxillary midline with the facial midline is more important than centering the maxillary and mandibular midlines with each other.

10. Four premolar extractions cause negative effects on smile esthetics.

Strongly Disagree

2.68%

Disagree

0.00%

Neutral

7.14%

Agree

45.54%

Strongly Agree

44.64%

Strongly Disagree

0.00%

Disagree

4.50%

Neutral

13.51%

Agree

49.55%

Strongly Agree

32.43%

Strongly Disagree

0.89%

Disagree

11.61%

Neutral

43.75%

Agree

33.93%

Strongly Agree

9.82%

Strongly Disagree

0.00%

Disagree

0.00%

Neutral

1.80%

Agree

41.44%

Strongly Agree

56.76%

Strongly Disagree

2.73%

Disagree

10.00%

Neutral

17.27%

Agree

49.09%

Strongly Agree

20.91%

Strongly Disagree

0.90%

Disagree

12.61%

Neutral

13.51%

Agree

60.36%

Strongly Agree

12.61%

Strongly Disagree

0.00%

Disagree

3.57%

Neutral

12.50%

Agree

51.79%

Strongly Agree

32.14%

Strongly Disagree

33.33%

Disagree

43.24%

Neutral

17.12%

Agree

4.50%

Strongly Agree

1.80%

4.29

4.10

3.40

4.55

3.75

3.71

4.13

1.98

Volume 9 Number 1

RESEARCH Materials and methods A 10-question survey, shown in Table 1, was sent to a randomized sample of orthodontists across the U.S. and Canada via two email blasts through the AAO. The survey was composed of eight questions relating to potential important aspects of smile esthetics and two questions that established the survey demographics. A finalized copy of the 10-question survey was generated using Survey Monkey. The survey was then forwarded to the AAO for approval. The AAO then sent out an email, including a link to the survey, to a random sample of 2,300 of its members. A letter was distributed with the survey asking for participation as well as an agreement to participate. The survey link was first distributed on June 8, 2017. Then to increase participation, a second email was sent 6 weeks later on July 20, 2017, to the surveyed population. After data collection, the survey instrument was utilized to compile responses into useful figures and charts. In addition, a t-test was used to provide analyses of responses according to the number of years in practice and gender. (All analyses employed IBM SPSS Statistics v. 24 [IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp.]).

Results Of the 2,300 emails sent to a random sample of orthodontists who are members of the AAO, 112 participated in the survey, amounting to a response rate of

When discussing the topic of smile esthetics and trying to determine a gold standard, it is important to note that each patient should still be treated on an individual basis. approximately 4.48%. The survey was completed anonymously. The important findings from the survey are shown in Table 1. There was consistency among respondents for including facial changes as a part of their esthetic treatment plan. Most respondents (98.20%) said they agree or strongly agree that when treating children, they consider how the face will change and age over time. The majority of the respondents (90.18%) agree or strongly agree that they believe achieving a consonant smile should be a consideration in orthodontic smile esthetics. However, there is slightly less consistency in determining whether buccal corridors are important to smile esthetics and treatment planning. Of the respondents, 81.98% agree or strongly agree. Furthermore, 83.93% agree or strongly agree that centering the maxillary midline with the facial midline is more important than centering the maxillary and mandibular midlines with each other. Most of the respondents (72.97%) agree or strongly agree that maxillary and/ or mandibular midline deviations of less than 2 millimeters from each other are

visually acceptable. However, 13.51% of respondents were neutral, and 13.51% of respondents disagreed or strongly disagreed with this statement. In addition, 70.00% of respondents agreed or strongly agreed that a canine-protected occlusion is a goal of orthodontic treatment. Meanwhile, 17.27% remained neutral on the subject, and 10.00% disagree. When asked if smile esthetics were more important than achieving an Angleâ&#x20AC;&#x2122;s Class I occlusion, there were some differing philosophies, with 43.75% who agreed or strongly agreed and 43.75% who remained neutral. Finally, when determining if four premolar extractions cause negative effects on smile esthetics, most respondents (76.57%) disagreed or strongly disagreed. Of the 112 respondents, 73.64% were male. In addition, the largest group (53.64%) had been in practice for 20-plus years. When the t-test was performed, it was found that there was no statistically significant difference between male and female orthodontists on any of the subjects shown on Table 2. Of the eight questions, only two had a statistically significant difference (p-value <.05) when

Table 2: Male versus Female Orthodontistsâ&#x20AC;&#x2122; Group Statistics

Achieving a consonant smile is a consideration in orthodontic smile esthetics. Buccal corridors are important in smile esthetics and important in orthodontic diagnosis and treatment planning. Smile esthetics are more important than achieving an Angleâ&#x20AC;&#x2122;s Class I occlusion. When treating children, you consider how the face will change and age over time. Canine-protected occlusion is a goal of orthodontic treatment. Maxillary and/or mandibular midline deviations of less than 2 millimeters from each other are visually acceptable. Centering the maxillary midline with the facial midline is more important than centering the maxillary and mandibular midlines with each other. Four premolar extractions cause negative effects on smile esthetics.

24 Orthodontic practice

Gender

Mean

Std. Deviation

Std. Error Mean

Sig. (2-tailed)

Male

4.41

.633

.072

.464

Female

4.31

.604

.112

.456

Male

4.13

.817

.091

.740

Female

4.07

.651

.121

.713

Male

3.44

.880

.098

.367

Female

3.28

.797

.148

.346

Male

4.55

.549

.061

.780

Female

4.52

.509

.094

.772

Male

3.77

1.062

.119

.950

Female

3.76

.739

.137

.941

Male

3.74

.882

.099

.669

Female

3.66

.897

.167

.673

Male

4.19

.776

.086

.262

Female

4.00

.707

.131

.244

Male

1.95

.953

.107

.350

Female

2.14

.833

.155

.322

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RESEARCH Table 3: Years in Practice Group Statistics

Achieving a consonant smile is a consideration in orthodontic smile esthetics. Buccal corridors are important in smile esthetics and important in orthodontic diagnosis and treatment planning. Smile esthetics are more important than achieving an Angle’s Class I occlusion. When treating children, you consider how the face will change and age over time. Canine-protected occlusion is a goal of orthodontic treatment. Maxillary and/or mandibular midline deviations of less than 2 millimeters from each other are visually acceptable. Centering the maxillary midline with the facial midline is more important than centering the maxillary and mandibular midlines with each other. Four premolar extractions cause negative effects on smile esthetics.

comparing number of years in practice. It was determined that respondent orthodontists who had practiced for more than 20 years found canine-protected occlusion slightly more important (p-value .003) and smile esthetics slightly less important (p-value .040) than those who were practicing for less than 20 years, shown on Table 3. Significance levels in Tables 2 and 3 reflect tests of equal variances assumed and equal variances not assumed, respectively.

Discussion The results of this survey demonstrate that the majority of respondents consider smile esthetics important during treatment planning and when providing orthodontic care. Sarver stated that over the past 2 decades, the shift from hard tissue-based treatment is due to the acknowledgment of smile appearance.12 Of the surveyed orthodontists, 98.20% believe that when treating children, it is important to consider how the face will change and age over time. Dickens, et al., found that incisor display, gingival display, and lip separation will decrease as we age.13 In addition, incisor display is perceived as more youthful.13 Therefore, it is important during treatment planning to pay close attention to these esthetic features. According to this study, most orthodontists, 90.18%, believe that achieving a consonant smile is important for smile esthetics. However, a systematic review performed by Janson, et al., determined that 26 Orthodontic practice

Years in Practice

20 years or less

Mean

Std. Deviation

4.37

.528

.074

.754

More than 20 years

4.41

.708

.095

.751

20 years or less

4.02

.787

.110

.380

More than 20 years

4.16

.812

.107

.379

20 years or less

3.57

.781

.109

.040

More than 20 years

3.24

.878

.114

.039

20 years or less

4.49

.543

.076

.205

More than 20 years

4.62

.524

.069

.206

20 years or less

3.48

.995

.141

.002

More than 20 years

4.03

.858

.113

.003

20 years or less

3.71

.923

.129

.924

More than 20 years

3.69

.842

.111

.924

20 years or less

4.08

.868

.122

.531

More than 20 years

4.17

.647

.084

.540

20 years or less

2.04

.894

.125

.548

More than 20 years

1.93

.971

.127

.546

buccal corridors and smile arc alone do not seem to affect smile attractiveness.6 Similarly, 81.98% felt that buccal corridors are important to smile esthetics and important for orthodontic diagnosis and treatment planning. However, this can depend on how an orthodontist is viewing the smile arc and/or buccal corridors. Kokich, et al., stated that when determining buccal corridors based from digital manipulations, if enough teeth are removed from the lateral sides of the smile, there is a decrease in overall smile esthetics, and the smile may appear unnatural.14 Accordingly, Janson, et al., determined that in articles where digital manipulation was used, there was a high correlation between smile arc, buccal corridors, and decreased smile esthetics.6 However, in articles where the raters were viewing smiling photographs, no correlation was found between smile arc, buccal corridors, and smile esthetics.6 When determining if the position and discrepancy of midlines affects the smile esthetics, 83.93% of respondents found that centering the maxillary midline with the facial midline is more important than centering the maxillary and mandibular midlines with each other. In addition, 72.97% of respondents thought that an intraoral midline discrepancy of less than 2 millimeters is visually acceptable. Johnston, et al., found that as the maxillary midline deviated farther from the facial midline, attractiveness was affected negatively.15 It has also been stated that a maxillary to facial midline discrepancy of 2 mm can, in fact, be considered normal.16, 17

Std. Error Mean

Sig. (2-tailed)

Yet, per Pinho, et al., a midline discrepancy of more than 1 mm is visually unacceptable.18 Conversely, three additional studies found that deviations of up to 2 mm are acceptable.19,15,17 When asked if four premolar extractions had negative effects on smile esthetics, 76.57% of the surveyed orthodontists disagreed or strongly disagreed. This follows closely to numerous studies, which have concluded that four premolar extractions do not affect smile esthetics. Meyer, et al., stated that there were no perceived attractiveness differences for extraction and non-extraction groups.20 In addition, Rushing, et al., stated that orthodontists and general dentists were unable to determine which facial profiles belonged to those with or without extractions.21 As well, 70% of the respondents believe that canine-protected occlusion is a goal of orthodontic treatment. Rinchuse and Sassouni, found that canine protected occlusion should not be the gold standard or a goal of orthodontic treatment. They found that 97% of the treated and 95% of the untreated subjects in their study, who were judged to have “ideal” static occlusion, had nonworking (balancing) side occlusal contacts.22 There were inconsistencies in agreement when determining if smile esthetics are more important than achieving an Angle’s Class I occlusion. Less than half (43.75%) of respondents said that they remained neutral on the topic. In addition, 43.75% agreed or strongly agreed that smile esthetics are more important than a Class I occlusion. Therefore, these Volume 9 Number 1

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RESEARCH responses may show that this is an area of smile esthetics that requires further research. A study performed by Schlosser, et al., looked at the anterior-posterior position of the maxillary incisors and determined which was the most esthetically pleasing.23 The least desirable photograph was when the maxillary teeth were retracted 4 mm, which suggested that most orthodontists and laypersons preferred normally protrusive to advanced maxillary teeth but not retracted maxillary anterior teeth.23 There were a few studies that evaluated the importance of smile esthetics when compared with an Angle’s Class I occlusion. More research is needed to determine if orthodontists prefer to finish cases Angle’s Class I while compromising smile esthetics or if smile esthetics should be the focal point of diagnosis and treatment planning. There were two questions that demonstrated a statistically significant difference when analyzing years in practice. These questions were canine-protected occlusion is a goal of orthodontic treatment, and smile esthetics are more important than achieving a Class I occlusion. The orthodontists who have been practicing for more than 20 years found slightly more importance in canine-protected occlusion and gave slightly less importance to smile esthetics than those who have been practicing for less than 20 years. This may demonstrate how orthodontics is changing towards the soft tissue paradigm. With regard to the soft tissue paradigm, Proffit, et al., stated, “Both the goals and limitations of modern orthodontics and orthognathic treatment are determined by the soft tissues of the

face, not by the teeth and bones.”4 In addition, the authors go on to state that we are moving away from the Angle paradigm that was commonly believed in the 20th century when treatment goals were based on occlusion classifications.4 There were no statistically significant differences in male or female respondents. When comparing the outcomes of this study to the results of the systematic review published by Janson, et al., it was found that the surveyed orthodontists (>70%) responses are consistent with the literature demonstrated in the systematic review. Janson, et al., were in agreement that there is no effect on smile esthetics from four premolar extractions, that buccal corridors do not effect smile esthetics, and that a dental midline deviation of 2.2 mm is determined to be clinically acceptable.6 This matches the results of the surveyed orthodontists. The goal of this survey was to determine orthodontists’ perceptions of smile esthetics and whether orthodontists agree with the current literature involving the smile and smile esthetics. Finally, when discussing the topic of smile esthetics and trying to determine a gold standard, it is important to note that each patient should still be treated on an individual basis.

Conclusions There have been numerous definitions of what defines the ideal orthodontic outcome. The inconsistency among different schools of thought seems to make the topic of smile esthetics a continuous debate. The purpose of this study was to survey orthodontists

REFERENCES

throughout the U.S. and Canada to assess their thoughts and beliefs of smile esthetics, their importance in our profession, and their relevance to the current evidence-based literature. The respondents in this survey demonstrated: • The majority of orthodontists (98.20%) are taking facial changes and aging into account when treatment planning children. • Most orthodontists (90.18%) believe that achieving a consonant smile is a consideration of smile esthetics. • The majority of orthodontists (76.57%) feel that four premolar extractions do not cause negative effects to smile esthetics. • The most debatable topic is whether smile esthetics are more important than an Angle’s Class I occlusion. • Most orthodontists (72.97%) feel that a midline deviation of less than 2 mm is visually acceptable and does not harm smile esthetics. • There was no significant difference in responses from male or female orthodontists. • Orthodontists in practice for more than 20 years found canine-protected occlusion slightly more important and smile esthetics slightly less important than those in practice for less than 20 years.

Acknowledgments The authors of this article extend a special thank you to the surveyed members of the AAO who participated in this research topic. OP

1. Kaya B, Uyar R. Influence on smile attractiveness on the smile arch in conjunction with gingival display. Am J Orthod Dentofacial Orthop. 2013;144(4): 541-547.

12. Sarver DM. Interactions of hard tissues, soft tissues, and growth over time, and their impact on orthodontic diagnosis and treatment planning. Am J Orthod Dentofacial Orthop. 2015;148(3):380-386.

2. Işiksal E, Hazar S, Akyalçin S. Smile esthetics: perception and comparison of treated and untreated smiles. Am J Orthod Dentofacial Orthop. 2006; 129: 8-16.

13. Dickens ST, Sarver DM, Proffit WR. Changes in frontal soft tissue dimensions of the lower face by age and gender. World J Orthod. 2002;3(4):313-20.

3. Stedman TL. Stedman’s Medical Dictionary for the Health Professions and Nursing. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.

14. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception of dentists and laypeople to altered dental esthethics. J Esthet Dent. 1999;11(6):311-324.

4. Proffit WR, Fields Jr HW, Sarver DM. Contemporary Orthodontics. 5th ed. St. Louis, MO: Mosby; 2013,

15. Johnston CD, Burden DJ, Stevenson MR. The influence of dental to facial midline discrepancies on dental attractiveness ratings. Eur J Orthod. 1999; 21(5):517-522.

5. Sarver DM. Enameloplasty and esthetic finishing in orthodontics-identification and treatment of microesthetic features in orthodontics part 1. J Esthet Restor Dent. 2011;23(5):296-302.

16. Gul-e-Erum, Fida M. Changes in smile parameters as perceived by orthodontists, dentists, artists, and laypeople. World J Orthod. 2008;9(2):132-140.

6. Janson G, Branco NC, Fernandes TM, Sathler R, Garib D, Lauris JR. Influence of orthodontic treatment, midline position, buccal corridor and smile arc on smile attractiveness. Angle Orthod. 2011;81(1):153-161.

17. Shyagali TR, Chandralekha B, Bhayya DP, Kumar S, Balasubramanyam G. Are ratings of dentofacial attractiveness influences by dentofacial midline discrepancies? Aust Orthod J. 2008;24(2):91-95.

7. Parekh SM, Fields HW, Beck M, Roosenstiel S. Attractiveness of variations in the smile arc and buccal corridor space as judged by orthodontists and laymen. Angle Orthod. 2006;76(4):557-563.

18. Pinho S, Ciriaco C, Faber J, Lenza M. Impact of dental asymmetries on the perception of smile esthetics. Am J Orthod Dentofacial Orthop. 2007;132(6):748-753.

8. McNamara L, McNamara JA Jr, Ackerman MB, Baccetti T. Hard- and soft-tissue contributions to the esthetics of the posed smile in growing patients seeking orthodontic treatment. Am J Orthod Dentofacial Orthop. 2008;133(4):491-99.

19. Beyer JW, Lindauer SJ. Evaluation of dental midline position. Semin Orthod. 1998;4(3):146-152. 20. Meyer AH, Woods MG, Manton DJ. Maxillary arch width and buccal corridor changes with orthodontic treatment. Part 2: attractiveness of the frontal facial smile in extraction and nonextraction outcomes. Am J Orthod Dentofacial Orthop. 2014;145(3):296-304.

9. Parrini S, Rossini G, Castroflorio T, Fortini A, Deregibus A, Derbernardi C. Laypeople’s perceptions of frontal smile esthetics: a systematic review. Am J Orthod Dentofacial Orthop. 2016;150(5):740-750.

21. Rushing SE, Silberman SL, Meydrech EF, Tuncay OC. How dentists perceive the effects of orthodontic extractions on facial appearance. J Am Dent Assoc. 1995;126(6):769-772.

10. Johnson DK, Smith RJ. Smile esthetics after orthodontic treatment with and without extraction of four first premolars. Am J Orthod Dentofacial Orthop. 1995;108(2):162-167.

22. Rinchuse DJ, Sassouni V. An evaluation of eccentric occlusal contacts in orthodontically treated subjects. Am J Orthod 1982; 82(3); 251-256.

11. Pandis N, Rinchuse DJ, Rinchuse DJ, Noble J. Introduction: Evidence-based clinical practice. In: Miles, Rinchuse DJ, Rinchuse DJ, eds. Evidence-based clinical orthodontics. Chicago, IL; Quintessence Publishing; 2012.

23. Schlosser JB, Preston B, Lampasso J. The effects of computer-aided anteroposterior maxillary incisor movement on ratings of facial attractiveness. Am J Orthod Dentofacial Orthop. 2005;127(1):17-24.

28 Orthodontic practice

Volume 9 Number 1

Ali Oromchian, JD, LLM, discusses taking preventative measures to avoid costly HR issues

any professionals like to believe that a dramatic difference exists between those who succeed in business and in life and those who fail. The truth, however, is that it is often the small things that can change a person’s success over time. Philosopher Jim Rohn explained this concept well: “Success is nothing more than a few simple disciplines, practiced every day; while failure is simply a few errors in judgment, repeated every day. It is the accumulative weight of our disciplines and our judgments that leads us to either fortune or failure.”1 As practice owners, you understand the day-to-day decisions and difficulties that can affect your practice. But how can you tell when a decision is one that can snowball into a larger problem, affecting your overall success? One solid rule of thumb is to treat all HR-related issues as serious matters, as they have the potential to impact your reputation and the financial stability of your practice. Many matters, which at first appear to be small, can quickly lead to larger problems if they are not addressed right away. This is why being proactive is so helpful for the longterm viability of your business. Many orthodontists and other medical professionals tend to overlook HR problems, believing them to affect only larger businesses. In truth, however, the majority of the HR rules that apply to a Fortune 100 company also apply to the neighborhood dental practice. The good news is that by taking preventative measures now, you can avoid costly issues in the future. And, the new year provides a wonderful opportunity to take a “clean slate” approach towards protecting yourself and your practice. Here are 8 HR resolutions to protect your practice in 2018.

Educational aims and objectives

The purpose of this article is to explore some HR issues that have the potential to impact the reputation and the financial stability of your practice.

Expected outcomes

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

Recognize the importance of completing and maintaining proper documentation on employees.

•

Identify when firing is inadvisable.

•

Realize some details regarding sick leave, vacation, and final paychecks.

•

Know some of the law regarding differences between employees and independent contractors.

1. Updating and using your employment handbook An up-to-date and valid employment handbook is your first line of defense in any potential employment-related litigation. Not having an employment handbook makes it easier for lawyers to bring claims of wage and hour, discrimination, retaliation, and unlawful termination. This can easily be avoided. It is very important that you not only have a handbook, but that it has been customized for you and your practice. Your handbook can act as a valuable communication piece for both employers and employees because

Ali Oromchian, JD, LLM, received his BA from University of California at Davis, LLM in taxation from George Washington University Law School, and JD law degree from the University of California, Davis School of Law. He is the founding attorney of the Dental & Medical Counsel, PC law firm and is renowned for his expertise in legal matters pertaining to dentists. Mr. Oromchian has served as a key opinion leader and legal authority in the dental industry with dental CPAs, consultants, banks, insurance brokers, and dental supplies and equipment companies. He serves as a legal consultant for numerous dental practice management firms that rely on his expertise for their clients’ businesses. He is also recognized as an exceptional speaker and educator who simplifies complex legal topics and has lectured extensively throughout the United States. Disclosure: Mr. Oromchian is co-founder and Chief Executive Officer of HR for Health in the San Francisco Bay area.

Volume 9 Number 1

it defines the practice’s mission and vision, and it relays valuable information pertaining to its policies and procedures. It also communicates essential information about an employee’s benefits such as vacation, sick leave, and other state and federal laws surrounding employment. The handbook also provides guidance as to how issues should be resolved when they arise, which is especially important when defending yourself against claims of harassment and discrimination. This is why companies, such as HR for Health, provide comprehensive employment handbooks and essential annual updates to strengthen this crucial first line of defense.

2. Completing and maintaining proper documentation As an employer, there are certain documents that you must complete and maintain for your employees. On average, there are 12 documents that each employee needs to complete, which then must be stored in a safe place. Some of the documents you Orthodontic practice 29

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8 HR resolutions to protect your practice in 2018

CONTINUING EDUCATION need to have include: employee withholding form (W-4), Employment Eligibility Form (I-9), acknowledgment of the at-will relationship, and acknowledgement of the receipt of the employment handbook. Your state may also have its own requirements, such as a state withholding form, notice to employee regarding payment of wages, workers’ compensation brochure, and a report of new employee form. The I-9 is worthy of focus, given that it has been recently updated by the federal government. Therefore, as you hire new employees, it is important that you provide them with that document instead of the old I-9.2 The I-9 is the document used to ensure that you are hiring someone who is authorized to work in the United States. The document must be completed by both the employer and the employee, with the employee attesting to his eligibility for employment, and the employer verifying such eligibility by reviewing documentation. The I-9 instructions provide a list of acceptable documentation that can be used to verify identity. Note that you are not permitted to discriminate as to which documents an employee provides, as long as they are valid. The I-9 instruction form3 is very helpful and provides easy-to-follow instructions as to accepting and reviewing documentation, and completing the I-9 form itself. Follow these and all instructions completely and accurately when it comes to employment documentation to avoid future issues.

3. Understanding at-will employment and when firing is inadvisable At-will employment is the most common employment categorization in the U.S., covering the vast majority of employees and terminations. This means you as an employer can terminate any of your employees without reason and without notice, and that they can quit for no reason and without notice. However, while at-will may be the rule in theory, in practice there are times when it is simply not a smart practice to fire someone. Most often, this is because your termination decision can be mistaken as one which was unlawful when the decision pertains to persons who qualify for additional protections under the law such as pregnancy, age, or disability. Therefore, you should be aware of the risks if you fire an employee under any of these three circumstances. The first is when the employee is pregnant. The likelihood of a pregnancy discrimination lawsuit is very high when you terminate a pregnant employee. In fact, it is 30 Orthodontic practice

recommended that you keep the employee on staff during the pregnancy and during the pregnancy leave. And you should not, of course, fire the employee the day she returns from work. Instead, if termination is truly necessary, I recommend waiting at least 1 year in order for there to be no confusion as to the fact that the termination was not based upon her pregnancy, as that would be a violation of the Pregnancy Discrimination Act.4 There are exceptions, of course, such as in cases of theft or other egregious behaviors. However, if you are simply looking to take advantage of your “at-will” rights, it is advisable that you not take the risk if you can avoid it. You should also be wary of terminating an employee who is older. We recommend that you are more careful as the employee approaches 60 years old, and that you properly document everything as you plan a termination to avoid allegations of age discrimination. Even if your reasoning for terminating the employee is justified, it is advisable that you support your decision to terminate (if you truly cannot avoid a termination), due to potential allegations of violating the Age Discrimination in Employment Act.5 Finally, you should be hesitant to fire an employee if he/she is disabled or has suffered from a workers’ compensation injury. There are many protections in place when someone has a disability or injury, and you need to be very careful before you terminate that employee as the definition of disability can vary and is typically very broad. Americans with disabilities are protected by the Americans with Disabilities Act Amendments Act of 2008 (ADAAA),6 and FMLA Regulations 825.702(c)(4) and (d)(2) address

the interplay of the FMLA with workers’ compensation and the ADAAA. The bottom line of these provisions is that firing someone who is disabled and/or currently on workers’ compensation can be unlawful and, therefore, is usually not worth the risk to employers except in egregious circumstances.

4. Understanding “use it or lose it” vacation/sick leave If you, like most medical-based employers, offer your employees vacation or sick leave, then you need to make sure that you are adhering to the law when it comes to implementing “use it or lose it” policies. In most states, the employee cannot forfeit his or her unused vacation time, as this time is akin to wages.7 You can, however, limit how vacation time can be earned and used. Also, note that in many states and cities, employees are now entitled to sick time. In addition to knowing these laws, it is important that you review the state/local paid sick leave laws and compare them to one another because in cases of conflict, the portion of each which is most beneficial to the employee will be the rule that applies.

5. Following rules regarding final paychecks You must ensure that you know and are following the rules in terms of providing a final paycheck. Many states have rules that require you to provide the final paycheck immediately upon termination. In some states, the final paycheck must be provided by the next payroll. Regardless of which rules are followed in your state, the best practice is to prepare for terminations in advance so that you can ensure that you are adhering to all applicable rules.

Federal protections include the following: • Sex (including pregnancy, childbirth, breastfeeding and/or related medical conditions) • Race • Religious creed (including religious dress and grooming practices) • Color • Gender (including gender identity, gender expression, and being transgender) • National origin or ancestry (including language use restrictions and protected use of driver’s licenses) • Disability (mental and physical, including HIV and AIDS) • Medical condition (cancer/genetic characteristics and information) • Marital status, registered domestic partner status, age (40 and over) • Military and veteran status • Sexual orientation • Any other basis protected by federal, state, or local law or ordinance or regulation Volume 9 Number 1

The employee/independent contractor distinction is one that can get orthodontists and other dental professionals into trouble. First, understand that there are important legal differences between these two categories of workers. For employees, the practice withholds income tax, Social Security, and Medicare from wages paid. For independent contractors, the practice does not withhold taxes. Therefore, you must understand which classification your workforce falls under. The Equal Employment Opportunity Commission (EEOC) has provided a guide to be used when determining whether someone is an employee or an independent contractor.8 Generally speaking, the more control a company exercises over how, when, where, and by whom work is performed, the more likely the worker will be considered an employee, not an independent contractor. No single factor is completely determinative of whether he/she is an employee or an IC. However, there are some factors that are used by the IRS9 in making this distinction. They fall into the following three categories: • Behavioral: Does the practice control or have the right to control what the associate does and how the associate does his/her job? • Financial: Are the business aspects of the associate’s position controlled by the practice? (For example: how the associate is paid, whether expenses are reimbursed, who provides tools/supplies, etc.) • Type of relationship: Are there written contracts or employee-type benefits such as vacation time?

An ounce of prevention now can save you major troubles in the long run. nonexempt status, always remember to check your state laws for guidelines that are potentially more stringent. Job titles do not determine exempt status. Here are the exemptions under the Fair Labor Standards Act.11 Executive exemption • The employee’s primary duty must be managing the enterprise or department. • The employee must regularly direct the work of at least 2 or more full-time employees. • The employee must have the authority to hire/fire other employees or the employee’s suggestions and recommendations must be given particular weight. Administrative exemption • The employee’s primary duty must be the performance of office or nonmanual work directly related to the management or general business operations of the practice or patients. • There must be exercise of discretion and independent judgment with respect to matters of significance.

Professional exemption • The employee’s primary duty must be the performance of work requiring advanced knowledge. • The advanced knowledge must be in the field of science or learning and must be acquired by a prolonged course of specialized intellectual instruction.

8. Documentation, documentation, documentation Our final suggestion is a rule that you should apply to HR matters in your practice across the board, regardless of how they arise. This rule is to ensure that you have reduced your risk by always creating, maintaining, and updating full documentation of HR matters pertaining to your employees. We have discussed the employment handbook and the required documents, but you must make sure that you are keeping accurate and up-to-date records. For example, you should maintain records not only related to employment terms and conditions, but also those related to disciplinary matters, days missed, and late arrivals. If this sounds like a hassle, consider that documenting such matters can save you time and stress in the event of a future discrimination allegation. In addition, you can use an electronic system similar to HR for Health to house all of your HR documents safely and to make document maintenance a much simpler process. Regardless of how you maintain your materials now, remember that an ounce of prevention now can save you major troubles in the long run. By implementing these and the other strategies above, you can ensure that 2018 will be your most successful year yet. OP

7. Proper designation of employees as exempt or nonexempt An employee’s exemption status will determine whether he/she is entitled to overtime pay for working more than 40 hours per week or 8 hours in a day (in certain states). Determining a person’s qualifications to be designated as exempt or nonexempt can be completed using rules promulgated by the Department of Labor.10 To qualify for exemption (meaning that they are not entitled to minimum wage laws or to overtime), employees generally must meet certain tests regarding their job duties, and they must be paid on a salary basis, at an annual rate of $23,660.00 or higher under federal law (with some state laws using a higher salary). While you must adhere to the Fair Labor Standards Act (FLSA), requirements regarding exempt/ Volume 9 Number 1

REFERENCES 1. Rohn J. Rohn: The Formula for Success (and Failure). Success Magazine. https://www.success.com/article/rohn-the-formulafor-success-and-failure. Accessed December 26, 2017. 2. United States Citizenship and Immigration Services, I-9, Employment Eligibility Verification. https://www.uscis.gov/i-9. Accessed December 26, 2017. 3. Instructions for I-9, Employment Eligibility Verification, file:///C:/Users/sarar/Downloads/i-9instr.pdf. Accessed December 26, 2017. 4. U.S. Equal Employment Opportunity Commission, The Pregnancy Discrimination Act of 1978. https://www.eeoc.gov/laws/ statutes/pregnancy.cfm. Accessed December 26, 2017. 5. U.S. Department of Labor, Age Discrimination. https://www.dol.gov/general/topic/discrimination/agedisc. Accessed December 26, 2017. 6. U.S. Equal Employment Opportunity Commission, The Americans with Disabilities Act Amendments Act of 2008. https://www. eeoc.gov/laws/statutes/adaaa_info.cfm. Accessed December 26, 2017. 7. Ballman, Donna. States With Pro-Employee Laws: No Use-It-Or-Lose-It Vacation. Lexis-Nexis® Legal Newsroom. https://www. lexisnexis.com/legalnewsroom/labor-employment/b/labor-employment-top-blogs/archive/2014/12/10/states-with-pro-employeelaws-no-use-it-or-lose-it-vacation.aspx?Redirected=true. Accessed December 26, 2017. 8. U.S. Equal Employment Opportunity Commission, Compliance Manual, https://www.eeoc.gov/policy/docs/threshold.html#2-III-A. Accessed Nov. 8, 2017. 9. See Internal Revenue Service, Independent Contractor (Self-Employed) or Employee? https://www.irs.gov/businesses/smallbusinesses-self-employed/independent-contractor-self-employed-or-employee. Accessed December 26, 2017. 10. U.S. Department of Labor Fact Sheet, https://www.dol.gov/whd/overtime/fs17a_overview.pdf. Accessed December 26, 2017. 11. Section 13(a)(1) of the Fair Labor Standards Act as defined by Regulations, 29 CFR Part 541. https://www.dol.gov/whd/overtime/ regulations.pdf. Accessed December 26, 2017.

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CONTINUING EDUCATION

6. Knowing the law as to employees and independent contractors

REF: OP V9.1 OROMCHIAN

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Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $149; call 866-579-9496 to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

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8 HR resolutions to protect your practice in 2018 OROMCHIAN

1. Not having an _______ makes it easier for lawyers to bring claims of wage and hour, discrimination, retaliation, and unlawful termination. a. employment handbook b. electronic records system c. office-to-patient portal d. office brochure 2. Your handbook can act as a valuable communication piece for both employers and employees because it _______. a. defines the practiceâ&#x20AC;&#x2122;s mission b. defines the practiceâ&#x20AC;&#x2122;s vision c. relays valuable information pertaining to its policies and procedures d. all of the above 3. On average, there are _______ documents that each employee needs to complete, which then must be stored in a safe place. a. 2 b. 5 c. 7 d. 12 4. The ______ is the document used to ensure that you are hiring someone who is authorized to work in the United States. a. W-9

32 Orthodontic practice

b. I-9 c. 825.702(c) regulation d. Fair Labor Standards Act 5. _________ means you as an employer can terminate any of your employees without reason and without notice, and that they can quit for no reason and without notice. a. At-will employment b. Employer Compensation Act c. At-leave employment d. Discrimination in Employment 6. For __________, the practice withholds income tax, Social Security, and Medicare from wages paid. a. independent contractors b. employees c. at-will employees d. clinical staff only 7. For independent contractors, the practice _____ withhold(s) taxes. a. partially b. does c. does not d. directly 8. The ________ has provided a guide to be used when determining whether someone is

an employee or an independent contractor. a. Fair Labor Standards Commission (FLSC) b. Family and Medical Leave Commission (FMLC) c. The Equal Employment Opportunity Commission (EEOC) d. Employee Discrimination in Employment Commission (EDEC) 9. To qualify for exemption (meaning that they are not entitled to minimum wage laws or to overtime), employees generally must meet certain tests regarding their job duties, and they must be paid on a salary basis, at an annual rate of ________ or higher under federal law (with some state laws using a higher salary). a. $11,356.00 b. $23,660.00 c. $35,465.00 d. $42,598.00 10. This rule (that should apply to all HR matters in the office) is to ensure that you have reduced your risk by always ________ full documentation of HR matters pertaining to your employees. a. creating b. maintaining c. updating d. all of the above

Volume 9 Number 1

CE CREDITS

ORTHODONTIC PRACTICE CE

Dr. Laurance Jerrold explains informed consent and why it is important to the orthodontic practice Part 1: Becoming informed about informed consent “Every human being of adult years and sound mind has a right to determine what shall be done with his own body.” Justice Benjamin Cardozo Schloendorff v. Society of N.Y. Hosp. 211 N.Y. 125, 105 N.E. 92 (1914) Informed consent has been around for a long time, and yet the concept of what it is and how best to use it still confuses many practitioners. Breaking down this legal doctrine into its individual elements is critical to understanding the risk management application of this basic fundamental legal and ethical principle. The easiest way to do this is to consider its legal application through a metaphor about dating. “Whatcha doin’ later tonight? How about you and me getting together and see where the evening goes?” First, one has to start by realizing that there is a difference between consent and informed consent. To put it into simple terms, if I ask you out on a date and you accept, you have just given me your consent to get together and do something. We don’t know what yet, but you have consented to accompanying me to do something. Whether we merely go out to dinner coupled with casual conversation, or we go back to my place for a dalliance of some sort is informed consent. In other words, before you can obtain patients' informed consent to render specific treatment, you first must obtain their general consent for you to be their doctor. Three elements are required for a patient’s consent to treatment to be deemed valid. First, it must first be given voluntarily. Second, the person granting the consent must be of legal age. Finally, this person must possess sufficient mental capacity. Let’s look at these a little closer and start Laurance Jerrold, DDS, JD, ABO, is the Chair and Program of Orthodontics and the Director of the Orthodontic residency program at NYU Langone Hospital – Brooklyn. Dr. Jerrold can be reached at (904) 710-5125 or laurance.jerrold@nyumc.org.

Volume 9 Number 1

Educational aims and objectives

The purpose of this article is to explore the reasons behind informed consent and several ways to achieve the understanding and consent of patients.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 38 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Define the concept of informed consent. •

Identify the elements required for a patient’s consent to treatment to be deemed valid.

•

Identify some ways to document the necessary informed consent.

•

Realize what to do if treatment is not going according to the predetermined treatment plan.

•

Identify common records and information needed on the first appointment.

with one’s mental capacity. While we all have patients whom we believe are “a few sandwiches short of a picnic,” the issue of one’s mental capacity in clinical orthodontics usually involves those with easily recognizable mental deficiencies or those who are impaired. Fortunately, we rarely encounter these issues in daily practice. Take, for example, patients (or parents) who show up at the consultation visit acting in a manner that would lead you to believe they were impaired secondary to drug or alcohol abuse. If they respond irrationally to the treatment plan you suggest, the issue of their capacity to grant consent, for themselves or for others

in their charge, may come into play. You may also find this issue when dealing with the patient who voices totally unreasonable demands, is attempting to dictate inappropriate treatment, or who exhibits evidence of body dysmorphic syndrome. The more common problems relating to consent fall into the other two categories. The legal age issue is far more common and arises in two contexts. First, when the patient is a minor, someone under the legal age of majority (usually 18), you must have the legal guardian’s consent to treat that child. Understand that at this point we are not talking about how we will treat the child; Orthodontic practice 33

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Consenting adults: agreeing on what’s going to happen

CONTINUING EDUCATION we are merely seeking permission to actually do something such as perform an examination or render emergency treatment for someone who is not a patient of record. If grandma, an aunt, the housekeeper, or even the non-custodial parent accompanies the minor to your office, you don’t technically have consent to render treatment. You can obtain general consent by phone, letter, or healthcare proxy, but make sure the legally recognized party is the one granting you consent to treat. A second example arises when you are treating a minor, and right in the middle of his orthodontic therapy, the patient turns 18, the legal age of majority. The patient says, “Take my braces off,” while mom retorts, “Over my dead body.” What do you do? Legally, the patient has the final say. To leave the braces on after a patient of legal age requests their removal is a battery — legally defined as the unauthorized, harmful, or offensive contact with another. Finally, whether the consent was obtained voluntarily or not may turn on patients’ claiming that they were mentally coerced into accepting treatment. This can arise when patients are told something such as “If you don’t undergo orthodontic therapy, you will either lose these teeth from periodontal disease, suffer TMD problems, won’t be able to get a good job, never get a date for the prom,” etc. These remarks cannot be made if there is no clinical evidence to substantiate them or if they cannot be supported by scientific evidence. Nor can you imply that a patient’s self-image or facial esthetics are such that they will be socially ostracized or scorned because of “crooked teeth.” You cannot make untrue or unfounded statements that “bully, guilt, or guile” people into accepting orthodontic treatment. “Great, so how about we go back to my place, open a bottle of wine, and see where the evening goes?” So, now that you’ve consented to go out with me; let’s see, what shall we do? Aha, informed consent. Patients must be told in a language that they can both understand and comprehend such things as what the problem is, what you are going to do, how long treatment will take, what they can expect, what can go wrong, and how much it will cost. Sounds simple, right? Maybe, maybe not. Let’s take each item separately. But before we do that, there is just one more thing we must know: Which standard of care is applicable for disclosing this information? There are basically two standards for disclosure, and which one you are required to use 34 Orthodontic practice

Obtaining informed consent fosters a close doctor-patient relationship as all parties are now on the same track regarding the diagnosis, treatment plan, and prognosis.

depends upon which state you practice in. The more traditional standard is the professionally based one. Under this approach, the only information you need to disclose to your patients is the information that would be usually be disclosed by other doctors under the same or similar circumstances. In other words, the doctor decides what and how much to tell the patient. The more modern approach, followed by a majority of states, requires us to give patients all of the information that a reasonable person in the patient’s position would deem material in order to make a decision to accept or reject the proposed treatment. Ethically, the patientbased standard is the preferred alternative. Looking further at the individual elements, one can see that patients who have a problem with the English language should be spoken to in their native tongue in order for them to understand what is being said. Next, be sure to speak in the nonclinical language and not in “Dentalese,” as this will help patients comprehend what you are telling them. To tell patients that they have a retrognathic mandible and aplasia of tooth No. 7, and that you recommend a vertical oblique ramus osteotomy with an implant prosthesis in the maxilla may be technically correct. However, it is infinitely more comprehensible to say that their bottom jaw is too small, they are missing an upper front tooth, and that the best way to solve their problem is by surgically bringing the bottom jaw forward and replacing the missing tooth with an implanted fake one. English, or whatever the patient’s native language is, ideally at the fourth to sixth grade level, is preferable to “Dentalese” at all times. You never want patients to say when they are claiming that there was a lack of informed consent, that yes, the doctor did say that, but I didn’t understand what he/she was saying. Whatever treatment you are proposing may be clear-cut in your own mind, but you must learn to put yourself in the patient’s position. If any doctor were to recommend a certain procedure to be performed on you,

I’m certain that being the intelligent person you are, you would want to know what your other treatment options or alternatives are. You would want to know what the risks are for each one, the consequences of doing x, y, or z, and what limitations may exist, etc. Why should our patients be different from us? They aren’t; and just because we are talking about teeth, doesn’t make it any different. Patients should also be apprised of all viable treatment alternatives, even if you don’t perform these procedures. Remember, it’s their bodies we are invading; only they can give us the right to trespass and in what way. Patients also have the right to know what will happen if they choose not to undergo treatment; for in most cases, as orthodontics is almost always elective in nature, this is another viable alternative. How long treatment will take and how much it will cost are also factors involved in obtaining patients’ informed consent. It is a common presumptive mistake for the doctor to make unsubstantiated judgments as to what patients can or should be able to afford. The amount of time that treatment will take may be of major significance to some, while far less crucial for others. Your estimate of how long treatment will take should not “guild the lily” in the hope that the patient will not be turned off. We should not be engaging in paternalism by believing that we “know” that the treatment we are recommending is “the best thing for the patient.” The reason for this is that often our best intentions are not “the best thing for that particular patient” due individual idiosyncrasies, financial, or temporal hardships whether real or perceived. Finally, patient must have the opportunity to ask and have answered all of their questions. Remember, we don’t give informed consent; we get it; the patients grant us their informed consent for the treatment being rendered. In other words it’s a two-way street; you provide patients with sufficient information, which in turn allows them to accept or reject the course of therapy you are recommending. Volume 9 Number 1

“The evening takes a turn.” Suppose my date and I agreed only to go out to dinner, but somewhere between salad and dessert, things changed, and the two of us decide to go back to her place for Volume 9 Number 1

after-dinner drinks in her hot tub. Well, the same thing happens with informed consent; it is an ongoing process. Many doctors make the mistake of believing that if informed consent was obtained at the onset of treatment, their patients no longer have to be informed if negative sequelae start to occur. If, in the midst of treatment, you discover that root resorption, periodontal disease, and decalcifications are just beginning, you know that at some point a decision may have to be made to possibly discontinue active treatment prematurely even if the treatment goals have not been realized. Who makes that decision? If you say the doctor, you’re acting paternalistically again. If you say patients, how are they to know how far to go before you have to call it quits, and what are the ramifications of doing so? It should be obvious that the process of informed consent is an ongoing give-and-take between the doctor and patients based on what is occurring at any given point along the treatment time line. It is an ongoing exchange of information. Informed consent is continually given to allow you to continue on with treatment or to discontinue active therapy if the situation warrants it or if a patient demands treatment to be stopped for whatever reason. If that occurred, the reason should be documented to show that informed consent has been withdrawn. Either one can only occur based on the sufficiency of the information you provided. “Who told you that?” One more thing that needs to be discussed is who is allowed to give the required information and obtain patients’ informed consent? The bottom line is, it doesn’t matter. The information can be given by anyone in the office and in almost any medium. Each of us should develop our own style of information transmission. Some will go high tech via computer imaging, prepackaged interactive programs, or proprietarily produced videos. Others will discover that educational brochures or forms work best. For some, a good old-fashioned conversation with the patient is the way to go. How it is done and by whom (the doctor, treatment coordinator, assistant, front desk personnel, etc.) is totally irrelevant. The only thing that’s important is the sufficiency of the information provided. However you choose to undertake this duty should be reflective of your personality and conform to the socio-demographics of your patient population. Metropolis methodologies don’t always play well in “Smallville” and vice versa.

What did you think of our little date? Want to see me again? We can experience things you’ve never thought about ... at least as far as risk management and chairside ethics in orthodontics is concerned.

Part 2: Application In days of yore, when a new patient called for an initial appointment, many orthodontists sent a “welcome to our office” packet that usually included a letter thanking the patient for selecting their office as well as confirming the time of the patient’s appointment. Orthodontists might also have included a brochure about the office and the doctor, a map showing the office location, and possibly a health questionnaire to be filled out in advance. Today most of that is accomplished via a website. Either way, this is a good opportunity to start obtaining informed consent before you even meet the patient. Along with whatever other data is disseminated, consider using the following letter entitled “Your Right to Know,” or versions of it, as it sets the stage for an interactive relationship between the doctor and the patient. Letter to the patient: your right to know It’s been said “an informed consumer is our best customer.” This has never been truer than in the provision of healthcare services. What should you expect when you first visit an orthodontist? You should be told what the problem appears to be; what examinations are necessary to properly diagnose the problem and formulate a treatment plan; and in the case of a child, whether now is the appropriate time to begin therapy or whether it is best to wait until a future date to initiate treatment. Let’s look at these individually. When patients either desire to have their teeth straightened or are informed that orthodontic therapy is recommended, they should be told why it is in their best interest to undergo such treatment. Some of the more common reasons for seeking treatment are: • To improve cosmetics (crooked teeth, overbite, etc.) • To facilitate other necessary dental work (to properly position teeth for capping, bridges, or implants) • To correct a jaw discrepancy or skeletal disharmony (“one’s bite is off”) • To help patients maintain their periodontal status (the health of the supporting gums and bone) The next step is the gathering of necessary information by obtaining diagnostic records. Some doctors will obtain Orthodontic practice 35

CONTINUING EDUCATION

“Wow, you really got a date? What did you guys do?” A frequently asked question is, What is the best way to document that you obtained the patients’ informed consent? Let’s go back to our analogy. If you had to, how would you prove what actually occurred or didn’t occur regarding your little assignation? This could be important. From an informed consent perspective, think of it as standing on a risk management ladder. The higher the rung you are on the ladder, the safer you are from the rising tide of accountability. Did you surreptitiously videotape the evening? That might be the best depicter, the highest rung on the risk management ladder. Some doctors do actually videotape their consultations to validate the verbal interaction. The next rung down on our risk management ladder is audiotaping what was discussed. Both of the scenarios offer wonderful proof of what was said, and they also prove what was not said. The third rung down is having the patients write in their own hand their understanding of the recommended treatment and what the risks and alternatives were. By doing this, they can never claim they didn’t understand what you told them; after all, they wrote it. Next would be a printed form of some type that is acknowledged via a signature. Following that would be a notation in the patient’s chart that some type of form or booklet of information was given, but without the patient’s signature. The next rung down is documenting in the chart what information you verbally told the patient or parent that is then “corroborated” by his/her signature or initial. This would again be followed by the same entry without such acknowledgment. No, you don’t need a patient’s signature; however, obtaining it places you one rung higher or the ladder. There is a legally accepted presumption that if something was written in the chart, it was said or done. The corollary also applies, if it was not written, that it was not said or done. Nearing the bottom of our risk management ladder, the patient’s record might say that the risks and alternatives were discussed without actually elaborating on the discourse. The next rung might merely note that informed consent was discussed. Finally, the last rung would evidence no indication of a consultation discussion — it’s your word against the patient’s.

CONTINUING EDUCATION Checklist for informed consent regarding risks, compromises, and limitations q Hygiene-related problems q Caries and decalcification q Root resorption â&#x20AC;&#x201D; Generally q Specific morphology prone to resorption q Scout films necessary q Periodontal complications q Rebound or relapse vs. normal tooth movement q TMJ / TMD / MPD (possibility of developing symptomatology during treatment) q Endodontic involvement q History of trauma q Deep decay/restorations q Canine or first premolar roots perforating buccal plate q Allergies q Acrylic appliances q Latex q Nickel q Ceramic Brackets q Attrition q Opposing cusp fracture or wear q Debonding fracture

q Retention q Long term, lifetime q Fixed q Removable q Notice as to when treatment is over q Prognosis long term q Limited treatment q Correct specific objective only, not treating entire ortho dontic problem q Tooth size/arch length discrepancies q Need to leave spaces posttreatment q Need for restorative posttreatment q Temporal factors relating to treatment

q Removable appliances q Loss and responsibility regarding replacement q Headgear (possible ocular or facial injury) q Oral surgery q Inability to close extraction spaces q Inability to close osteotomy sites q Potential consequences of going after impacted teeth q Growth q Excessive q Unanticipated q Insufficient q Ingestion / aspiration of appliances

q Fees associated with treatment q What is included and what isnâ&#x20AC;&#x2122;t q Additional fees q Amount and what for q Anatomic limitations q Underlying skeletal component q Associated dental compensations q Timing of treatment (delays in start of treatment compromising results) q Systemic medical problems q Respiratory blockage or allergies q Metabolic disorders, etc. q Pharmaceuticals impacting care

q Patient cooperation q Lack of progress or attaining treatment goals q Early discontinuation of treatment q Extended treatment time

q Continued deleterious habits and effect on stability q Tongue / digit / pacifier q Musical instruments / objects q Parafunctional

q Secondary restorative treatment needed q Permanent fixed retention q Prosthetics / restorative

q Interproximal Reduction

36 Orthodontic practice

q Laser therapy Volume 9 Number 1

Volume 9 Number 1

appliances. Once the type of orthodontic appliances has been decided upon and you receive them, make sure you have been given careful instructions on how to care for them. Check to be sure that your doctor will either be available or will provide for coverage if an emergency (breakage) arises. You also need to be told that you have certain responsibilities to meet in order to achieve the best results possible. Some of these are maintaining good oral hygiene, wearing rubber bands as instructed, keeping your regularly scheduled appointments, etc. You must continue to see your general dentist at least twice a year unless your orthodontist recommends otherwise. At the completion of active treatment, you will undergo a period of retention care. This phase of treatment is necessary to monitor and help maintain the results achieved. An appropriate retainer will be fabricated to maximize the stability of the finished result. Remember, nothing lasts forever, and some movement of your teeth over the years is normal and should be expected. Orthodontic therapy carries many benefits. Evaluating these can be done only if you have been given sufficient information on which to base your decision to undergo care. You have a right to know. To be educated is to be able to choose wisely.

Using the checklist Once you have acquired whatever diagnostic records you need, your consultation is, in actuality, your informed consent discussion. A checklist of risk factors should be identified and individualized for each patient. In other words, while not all of these risks will happen to everyone, everyone should be aware that some of these commonly

encountered risks may happen to them. Potential risks should not be transmitted in so overbroad a fashion that they become meaningless to any one individual; nor should they be presented in such graphic detail that patients will become confused or so put off or afraid of potential negative sequelae that they refuse the benefits of orthodontic therapy. Orthodontic-related risk factors should be case-specific. Since this is not always possible, it reinforces the notion of ongoing informed consent. Regardless of the medium used to dispense the required amount of information or the person appointed to disseminate it to the patient, it is universally accepted that at a minimum, the following information needs to be discussed. The checklist on page 36 shows commonly encountered risk factors. The doctor should check off those that apply to the specifics of a patient’s case so that whoever is tasked with obtaining a patient’s informed consent can present the required information.

Summary Obtaining informed consent, when done properly, can be a very rewarding practice, patient, and risk management procedure. It fosters a close doctor-patient relationship as all parties are now on the same track regarding the diagnosis, treatment plan, and prognosis. Your patients will understand and appreciate more of the complexities that are involved with their orthodontic treatment, thereby having a greater respect for the fees charged. It gives the doctor an aura of openness, honesty, and caring. All in all, if used as a sword and not a shield, obtaining informed consent will serve to benefit the patient, the doctor, and the profession through open communication. OP

REFERENCES - The following sources were used in the development of this article 1. Abdelkarim A, Jerrold L. Orthodontic chart documentation. Am J Orthod Dentofacial Orthop. 2017;152(1):126-130. 2. Abdelkarim A, Jerrold L. Litigation and legislation: risk management strategies in orthodontics. Part 1: Clinical considerations. Am J Orthod Dentofacial Orthop. 2015;148(2):345-349. 3. Helling v. Carey, 519 P2D 981 (Wash 1974). 4. Jerrold L. Litigation and legislation: what do patients actually consent to? Am J Orthod Dentofacial Orthop. 2011;139(1):133-135. 5. Jerrold L. Litigation, legislation, and ethics: defending claims for lack of informed consent. Am J Orthod Dentofacial Orthop. 2004;125(3):391-393. 6. Jerrold L. Litigation, legislation, and ethics: the limits of informed consent. Am J Orthod Dentofacial Orthop. 2002;121(5):542-544. 7. Jerrold L. Informed consent and contributory negligence. Am J Orthod Dentofacial Orthop. 2001;119(1):85-87. 8. Jerrold L. Litigation, legislation, and ethics: informed consent and the fourth dimension. Am J Orthod Dentofacial Orthop. 2000;118(4):476-477. 9. Jerrold L. Informed consent and orthodontics. Am J Orthod Dentofacial Orthop. 1988;93(3):251-258. 10. Ketchup v Howard, 543 SE2d 371 (Ga 2000). 11. Madsen v Park Nicollet Medical Ctr, 431 NW2d 855 (Minn 1998). 12. Matthies v Mastromonaco, 733 A2d 456, (NJ 1999). 13. Salgo v Leland Stanford Jr University Board of Trustees, 317 P2d 170 (Cal 1957). 14. Wilson-Toby v Bushkin, 72 AD3d 810 (NY 2010).

Orthodontic practice 37

CONTINUING EDUCATION

the required information at your initial visit while others will reappoint you for a records appointment. Either way, the most common records obtained are: • A review of your medical and dental history as there are many underlying physical problems that can impact on the success or failure of orthodontic therapy. • A comprehensive clinical exam to check for cavities, gum disease, and any other clinical manifestations that may have an impact on providing orthodontic treatment • A cephalometric X-ray of the skull to see the relationship of the teeth to the jaws and the jaws to one another. • X-rays of the teeth to determine how sound they are, whether the bony support for them is adequate, and what their positions and stage of development are relative to one another. • Photographs of the face and teeth to assess a patient’s profile, bite, and the effect that any proposed tooth or jaw movement may have on him/her. Following records acquisition, a chairside consultation between the doctor and the patient will either immediately occur, or you will be reappointed for a more formal consultation appointment. At this consultation, your doctor should explain to you what the actual problem is in a language you can understand. You should be told why correction is advised and how it is to be achieved. You should also be informed of all reasonable alternative methods of resolving your particular problem. As no form of medical treatment is without the potential for some risks, limitations, or compromises, you should be made aware of those that pertain to your specific situation. Next, you should be told what result you can expect from undergoing orthodontic therapy; and finally, what will occur if no treatment is undertaken. At this time, the fee for the services to be rendered should be discussed in full and suitable financial arrangements made to the satisfaction of both you and your doctor. Make sure that you have had the chance to ask and have answered all questions regarding the treatment plan proposed, how long it will take, as well as the financial responsibilities you are assuming. It is now time to begin treatment. The appliances or braces will be specifically tailored to your particular problem. You may require permanent and/or removable

REF: OP V9.1 JERROLD

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

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

Consenting adults: agreeing on what’s going to happen JERROLD

1. When the patient is a minor, someone under the legal age of majority (usually 18), you must have the ________ to treat that child. a. legal guardian’s consent b. child’s consent c. both the parent and the child’s consent d. consent of any person accompanying the child 2. You can obtain general consent by ______, but make sure the legally recognized party is the one granting you consent to treat. a. phone b. letter c. healthcare proxy d. all of the above 3. Looking further at the individual elements, one can see that patients who have a problem with the English language should be spoken to _______ in order for them to understand what is being said. a. in proper English b. very slowly c. in their native tongue d. using gestures 4. Patients should also be apprised of all viable treatment alternatives _________.

38 Orthodontic practice

a. only if you provide the procedures b. even if you don’t perform these procedures c. that the clinicians think they can afford d. that they can research on the Internet 5. It should be obvious that the process of ___________ is an ongoing give-and-take between the doctor and patients based on what is occurring at any given point along the treatment time line. a. determining mental capacity b. mitigating unreasonable demands c. informed consent d. pushing a specific orthodontic treatment 6. Who is allowed to give the required information and obtain patients’ informed consent? The information ________. a. can be given by anyone in the office and in almost any medium b. can be given only by the doctor in writing c. should be given by the office treatment coordinator and recorded d. should be given by the doctor and recorded 7. A part of the diagnostic records includes a comprehensive clinical exam to check for _________.

a. cavities b. gum disease c. other clinical manifestations that may have an impact on providing orthodontic treatment d. all of the above 8. (The patient should be advised to) continue to see their general dentist at least ____ unless your orthodontist recommends otherwise. a. once a year b. twice a year c. three times a year d. four times a year 9. A checklist of risk factors should ______ each patient. a. be the same for b. provide a common theme for c. be identified and individualized for d. not be provided to 10. The doctrine of informed consent fosters a close doctor-patient relationship as all parties are now on the same track regarding the ____. a. diagnosis b. treatment plan c. prognosis d. all of the above

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PRACTICE MANAGEMENT

“The secret sauce” — more than the golden rule: part 1 Dr. Donald J. Rinchuse starts a discussion on marketing orthodontic practices Introduction If you have recently attended an American Association of Orthodontists National Meeting, you may have noticed an enormous attendance at the “practice management” sessions versus the scientific sessions. This is antithetical to what was the situation some years ago when the attendance was highest for the scientific program and rather meager for the practice management program. Attendee orthodontists, particularly the younger ones, are most interested in finding “the secret sauce” to increases profits in orthodontic practice — that is, success in orthodontics measured in the amount of money the practice generates. As we know, all the leading businesses and industries boast of a secret recipe, ingredient, or sauce for the success of a product or business. Part of the impetus for the interest in profitability in orthodontics is the indebtedness of orthodontic graduates in recent years. The costs of college, dental school, and then orthodontic practice have skyrocketed. This puts added pressure on graduates to make money not only to live, but also to pay back educational loans. Also there has been an increase in “entrepreneurial-ism” in orthodontics, with larger and increased numbers of practices per orthodontist. Before we discuss “the secret sauce” to profitability in orthodontics, let us consider several elements that affect orthodontics. The reader should be reminded that the American Association of Orthodontists (AAO) has useful marketing information on its website.

History of advertising The history of dental advertising in the United States in the past 100 years would

certainly start with “Painless” Parker (18721952). Edgar RR Parker was a flamboyant American street dentist at the turn of the 20th century, who officially changed his name to “Painless” Parker. He practiced in Brooklyn from 1897 until he moved to San Francisco in 1912. He was the “neon light” king of dental advertisement and the “snake oil salesman” of the day. He was thought of as much a showman as a dentist. He was accused of false advertising for claiming his dentistry was painless. The American Dental Association considered him a “menace to the dignity of the profession.” He hired one of PT Barnum’s ex-managers to help him in advertising. He created the Parker Dental Circus, a traveling medicine show with a dental chair on a horsedrawn wagon while a band played. He was reported to have extracted 357 teeth in one day. At one point, he had about 30 West Coast dental offices, employing over 70 dentists and grossing $3 million per year.1 As a reaction to the outlandish advertising of “Painless” Parker and others, and in order to establish a more professional image of dentistry, the American Dental Association established guidelines for advertising, as did other professional organizations that were having similar problems (e.g., lawyers). This author can remember when he started orthodontic practice in 1976 that the ADA guidelines on advertising were very strict. Signage for a practice could not have lettering more than 2 inches in height, and a new dental graduate, on announcing the opening of his/her practice (at that time most dentists/orthodontists started their own practices), could not include a picture, nor list his/her telephone number.

Donald J Rinchuse, DMD, MS, MDS, PhD, received his dental degree (DMD) and Master of Science degree (MS) in Pharmacology and Physiology in 1974, a certificate and Master of Dental Science degree (MDS) in orthodontics in 1978, and a PhD in Higher Education in 1985 — all from the University of Pittsburgh. He has been involved in orthodontics for more than 41 years. He is a Diplomate of the American Board of Orthodontics and a manuscript review consultant for several journals including the American Journal of Orthodontics and Dentofacial Orthopedics. He has 130 publications to his credit, which includes two books. He has given many lectures and presentations. Dr. Rinchuse is presently in corporate orthodontic practice in Greensburg, Pennsylvania.

40 Orthodontic practice

The legal challenge to uphold advertising The legal challenge to professional standards on advertising was first initiated by lawyers who believed that the professional organizational standards were illegal, violating the Sherman Antitrust Act and the First Amendment of the U.S. Constitution. Several of the important Supreme Court cases were Goldfarb v. Virginia State Bar (1975) and Bates and O’Steen v. State Bar of Arizona (1977). The Goldfarb case was not directly related to advertising but to price fixing (i.e., minimum fee schedule) by the Virginia State Bar Association. The Supreme Court in the Goldfarb case held that lawyers engage in “trade or commerce” and were therefore not exempt from the statues of the Sherman Antitrust Act. Therefore, the State Bar could not establish a minimum fee for legal services — i.e., price fixing. This case is important in the sense that it limited the power and authority of professional organizations to establish codes, including a minimum fee for legal services. The Bates Supreme Court Case of 1977 upheld the right of lawyers to advertise. In the holding, the court ruled that advertising by lawyers was “commercial speech” entitled to protection under the First Amendment. The court held that speech does not escape protection under the First Amendment merely because it “proposes a mundane commercial transaction.” The court went on to say that commercial speech serves significant societal interests in that it informs the public of the availability, nature, and prices of products and services, allowing them to act rationally in a free enterprise system.2 So advertising by professionals of any trade is legal as long as it is not false or misleading to members of the general public.

Contextual environment As we are aware, there are many diverse types of orthodontic practices. There are solo and group private practices, group specialty practices, corporate practices, university, Volume 9 Number 1

Fol low

us!

PRACTICE MANAGEMENT hospital, and military graduate resident practices, and so on. You also have associate orthodontists who are salaried or independent contractors. And there are entrepreneurial orthodontists who have established a host of orthodontic offices. Each type practice has a different mission and goals (Table 1). There are also the political, social, economic, and professional environments that impact and interface with the various types of orthodontic practices. Further, there is now do-it-yourself (DIY) dentistry and orthodontics, which includes tele-orthodontics (e.g., Smile Direct Club). Patients need not actually go to an orthodontic office to receive treatment. There is also the argument that the historical and traditional orthodontic fixed bracket system is outdated compared with the digitally mastered software technology involved in making clear aligners. Not only is the argument that fixed orthodontics is outdated but also less effective and efficient. This claim is not supported by the evidence. Parenthetically, it was originally thought that through the use of tele-medicine and teledentistry, healthcare providers would be able to expand their reach, helping rural patients stay in their communities and avoid traveling long distances for specialized care. In respect to medicine, the tele-medicine with doctor-and-patient telephone calls, video conferencing, and internet diagnosis and treatment recommendations is a far cry from when doctors actually did house calls. There is also the legal battle in Texas as to determine who is a dental specialist. This decision has always been the prerogative of the American Dental Association, but this is constitutionally a state-to-state determination. It has recently been argued in Texas that dentists who have taken numerous continuing education courses can call themselves specialists without graduating from an ADA-accredited residency program. The argument in Texas also applies to advertising as a specialist in non-ADA-recognized dental specialties such as orofacial pain. The American Association of Orthodontists, as a reaction to the Texas case and other influences, has modified and lessened the restrictions on the scope of orthodontic practice; i.e., orthodontists can now perform some minor dental procedures outside the boundaries of orthodontics proper. And, there is the issue of more general dentists doing orthodontics — i.e., Invisalign®, Six Month Smiles®, etc. It is argued that non-orthodontists are doing more orthodontics than “real” orthodontists. How will this impact orthodontics now and in the future? 42 Orthodontic practice

Table 1: The Environment of the Orthodontic Practice TYPE OF PRACTICE: Which affects all the other elements of a practice Private: solo, partnership, group (with general dentist, pediatric dentist, specialists, etc.) Corporate: only orthodontics, with specialty services, DMOs Associate/contracted: leading to partnership/ownership, not leading to ownership University Military MISSION: What is unique about the office, treatment, service Goals: long and short term Objectives “Branding” PRACTICE MANAGEMENT Building: own/rent, space (how large), if own> space for tenants Physical Environment

Number of operatories: type (open/closed bay) Front desk, operatories, lab, sterilization, private office, consultation room(s), game room, waiting (adult, children), coffee, fire place, TV, fish, adults area, etc. Hardware: computers, iPads®, etc. Software program Website development and management/social media management Doctor(s)

Business Operations

Staff: reception, billing, insurance, lab tech, chairside assistants, treatment coordinator, marketing specialist (on staff or outside), etc. Scheduling/tracking Money management: billing, collections, aging accounts, etc. Audits HIPAA, OSHA, Material Safety Data Sheets, radiation safety and inspection (CBCT), HR department: sick days, vacations, health insurance, 401K, bonus, sexual harassment training, employment law, workers’ comp, etc.

Insurances Advisories

Malpractice Other: office, auto, life, umbrella, health, etc. Attorney, accountant, financial, etc. Quality control of patient management not of results of treatment

Patient Management

Patient-centered environment Educational/psychological principles for patient management Marketing plan

Marketing

External: social media, printed media, website, branding, billboards, etc. Internal: WOW service, T-shirts and other giveaways, spin wheel, therapy dog Referring dentists versus general public Targets, critical systems, etc.

Practice Evaluation

Patient satisfaction survey, social media posts Key performance indicators: consultations, starts, conversion rate, gross versus net income, referral base

PRICE High end, low end, average fees Discounts/specials Medical assistant programs Insurance programs: PPO, HMO, etc. Unique/different appliance/treatment types: phase I, comprehensive, clear aligners, clear brackets, special appliances Comparisons with other practices

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PRACTICE MANAGEMENT Furthermore, there is now the thinking (mostly unsupported by scientific evidence) that extractions of bicuspids in the maxillary arch, with retraction of the anterior teeth to reduce maxillary protrusion, can cause, or intensify, sleep apnea. There are some dentists who are then bashing orthodontists based on this ideology and disparaging their treatment in the presence of patients. How will this and other developments affect present-day orthodontics? Considering the current contextual environment of orthodontics, there are pessimists who argue that orthodontics (orthodontists) has seen its better days; and perhaps in the next 10, 20, or so years, there will be little or no need for orthodontic specialists. Conversely, the optimists contend that the demise of orthodontics is predicted every decade or so. This author can remember in the early 1970s, with the arrival of the “straight-wire” appliance, coupled with bonding of brackets (versus banding), it was envisioned that orthodontics would be simplified to the point that non-orthodontic specialists would be able to do orthodontics to the point that there would be no need for a “real orthodontist.” As we know, this did not happen.

Belief in success: positive thinking Belief is an important ingredient for success in any endeavor. “Whether you think you can or can’t, you’re right.”3 That is, whether it is true or not, it doesn’t really matter because it is likely that the outcome will be as you believe it to be. The philosophy is, If you believe you will be successful, you will be successful. There is an often told story about a businessman who had just won millions of dollars in the lottery and that this would be his last day at work. He did more work and production in this 1 day than he did in a month; he did not have any worries, and believed that with his new found wealth, he could “conquer the world!”

The secret sauce? There is no real “secret” to the secret sauce for orthodontic success and profitability. The secret sauce is a nebulous concept and is clearly not one factor for all practices. Each practice has its peculiar niche in which a marketing plan can be developed. Some of the factors that practices can highlight are a special technique or appliance (e.g., self-ligating brackets, clear aligners, non-extraction treatments, and early treatments), Sleep Apnea,4 TMD, communications, WOW service, website, 44 Orthodontic practice

Table 1: The Environment of the Orthodontic Practice (continued) RESULTS Special appliance(s) Quality control ABO finish versus what patients want versus what referring dentist may like Precision, effectiveness, efficiency Evidence-based treatment: study groups, journals, Facebook SERVICE Goals: long and short term Objectives “Branding” SERVICE “More than the Golden Rule” Patient-centered environment Autonomy versus paternalism Happy patient/happy referral base Disney and Ritz Carlton customer service principles Staff understands and appreciates quality service “The best part of the patient’s day!”

internal marketing, tele-dentistry, Adult Smile Center,5 and so on. Most, if not all, orthodontists know all the latest and best marketing principles, strategies, and so-called gimmicks. It is more or less a matter of: 1. Researching and determining which of the many marketing strategies aligns best with an orthodontist’s practice. 2. Spending the time, energy, and money to execute the marketing plan. Why doesn’t every orthodontist execute a marketing plan? Some practices do not have the resources and time to go forward with their chosen plan. It has been said that it takes money to make money; and some practices just can’t afford the money necessary to efficiently market their practices. Many times the reply back to practices/doctors who need to market and say they cannot afford to do it is that they can’t afford not to. And some orthodontists don’t see the benefit in spending the time and money to hire staff and/or a company to do their marketing. From a consideration of what makes each practice unique leads to development of a mission statement, goals, and objectives (Table 1). Goals and objectives can be long and short term. As mentioned, orthodontists must determine what is unique about their practices that sets them apart from the others. A practice can then develop a brand

with a logo and motto. A marketing plan and strategy are necessary to “sell” the strengths of the product that the practice promotes (Table 1). With the above in mind, there is the belief of some that the keys to success in orthodontics are GENERALLY service and price, with the consideration of the results/ outcome of treatment. Let us discuss each one of these, starting with price, and then results, and finally service. (The first two of these (price and results) will be discussed here in Part 1.)

Price For sure, price (fee) is a consideration for many potential patients/families. Some families believe that all orthodontists and treatments are alike and would not necessarily pay more for treatment from one office versus another. They are the shoppers who search out the lowest price. They rationalize that all orthodontics are similar because even the worst orthodontist by reputation still possesses a dental degree and has had orthodontic training at some level. In addition, many families have considerable debt and have so much money going out, particularly for essential items, that they cannot afford to pay any more money for orthodontics than at all possible. In many instances, price is not an isolated factor but considered alongside of service and results. The families listen to neighbors or social media reports about a certain Volume 9 Number 1

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PRACTICE MANAGEMENT practice that provides exceptional service and/or offers a special type of treatment and result. Of course, price is still factored into the equation as to where they will seek orthodontic care (Table 1).

Results We would like to think that results in orthodontics would in some way encompass precision orthodontics delivered in the most efficient and effective manner. And the degree that orthodontic outcome and results are valued is at times a debatable subject. That is, the issue of results and outcome in orthodontics becomes the eyes through which the results are evaluated; i.e., orthodontist, patient, referring dentist, and so on. Patients may have their focus on what we call the alignment of “the social six.” Their only concern is generally how the upper six front teeth look with little to no concern about occlusion and facial esthetics. How many times have orthodontists been asked by patients, when they are going to get their braces removed, when they have only had their braces on

46 Orthodontic practice

for several months? And, it could be argued that families and patients who pay less for orthodontics may be satisfied, and myopic, to the results; only that “I got a good deal” (Table 1). The orthodontist, on the other hand, is more concerned about occlusion, smile esthetics, facial esthetics, and so on; the orthodontist is looking for that ABO finish — precision orthodontic treatment delivered in the most efficient means. And there is the referring dentist who is perhaps judging the orthodontic finish based on what he/ she learned at his/her latest “Esthetic and Occlusal Institute Course” such as centric relations, functional occlusion, and so on, which in some cases have no evidencebased support. Related to results and outcomes in orthodontics, a key question is, Does the orthodontist and practice have a measurable quality assurance/performance improvement plan in effect (Table 1)? Certainly, some aspects of the ABO certification process raises awareness of quality in a practice, but this is not, and cannot be, the actual

“QA” plan. It could be grading finished cases based upon the ABO Grading System or PAR Index or the like. Or it could entail establishing quantitative and/or qualitative grading metrics in which a standard for excellent, good, and poor finishes are ascertained, and a summary final report is made as to how to maintain or improve the outcome of cases. OP Look for the Part 2 of this article in the next issue.

REFERENCES 1. Kornberg School of Dentistry: Historical Dental Museum Collection. Person Record: Parker, Edgar R. R. “Painless”. http://temple.pastperfectonline.com/byperson?keyword= Parker%2C+Edgar+R.+R.+%22Painless%22. Accessed December 26, 2017. 2. Justia: US Supreme Court. Bates v. State Bar of Arizona. 433 U.S. 350 (1977). https://supreme.justia.com/cases/federal/ us/433/350/case.html. Accessed December 26, 2017. 3. Pausch R, Zaslow J. The Last Lecture. Hyperion: New York; 2008:165-8. 4. Kulkarni M. Changes lives, one airway at a time: rapid palatal expansion and reducing airway resistance. Orthotown. Oct 2017;10(8):40-45. 5. Hughes H. Thirty-one years into practice, Dr. Herb Hughes updates his business model. American Association of Orthodontists-The Practice Management Bulletin. Aug 2017;35(4):2-7.

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2018

BOOK REVIEW

The Golden Age of Orthodontics Decline and Aftermath A History of the Business of Orthodontics • Norman Wahl, DDS, MS, MA First Edition Design Publishing Inc., Sarasota, Florida

s orthodontics’ most eminent and thorough historian, Dr. Norman Wahl has assembled material from his other historical documents to offer readers the most complete body of orthodontic information ever presented. The amount of research and preparation contained in this small paperback tome will astonish readers. Dr. Wahl considers the time from the end of WW II to about 1970 as a golden age for orthodontists. The baby boomers coincided with the public’s increased optional incomes to provide orthodontists with a huge rush of patients heretofore unknown or experienced. Older friends have confided that a 6-month wait to even see a new patient was not unusual during this time. Nevertheless, the supply of orthodontists began to outrun the demand for their services, which occurred with the end of the baby boom. Additionally,

“the pill,” which diminished the number of births, and bonded appliances, which made it easier for others to apply orthodontic therapy, made that happy, almost delirious time for orthodontists come to a halt. Dr. Wahl uses Part One of the book to describe important events in the early history of orthodontics such as those from the late 19th century to 1930 and to also describe the development during the Depression of the 1930s to 1950. Dr. Wahl deftly discusses all of the factors that contributed to the decline such as prepaid dentistry, lawsuits, diminished birthrates, legislation, consumerism, group practices, technology, graduate glut, intradental relations, super clinics, and professional complacency. Part Two brings the reader into the 21st century where Dr. Wahl describes patient supply, GP orthodontics, corporate

orthodontics, MSOs, and government agencies such as OSHA, HIPAA, ACA, truth in lending, electronic health records, and continuing education requirements. A further chapter defines patient relations, economic cycles, consumerism, student debt, and interdental relations. In a successful endeavor to bring the book completely up-to-date, Dr. Wahl describes developments such as TADs, customized appliances, aligners, and 3D study models, along with do-it-yourself aligners. Chapter XIII devotes its contents to practice management issues such as marketing, orthodontics as a business, auxiliaries, pricing/fees, and practice transitions. Chapter XIV deals with risk management subjects such as payment disputes, adult treatments, and defensive practice techniques. The final two chapters of Part Two deal with orthodontic education and trends plus a summation of the second part.

Dr. Wahl has collected the most extensive bibliography on orthodontic matters this reviewer has ever seen or probably will ever see.

Dr. Wahl has collected the most extensive bibliography on orthodontic matters this reviewer has ever seen or probably will ever see. It boggles the mind to imagine all of the research, reading, and documenting that went into this book, but if you want to know the who, what, when, where, and how of orthodontic events, this is your book. Anyone with even the slightest interest in orthodontics needs to have this book, and orthodontic departments will do their residents a great favor by including this publication in their required libraries. OP Review by Dr. Larry White.

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Dental Business Consultants that Help Your Practice Grow! Doctor: Setting production and collection goals, reviewing practice operation costs and fees, doctor and staff motivation and reviewing practice management reports monthly Start-up offices: Systems, protocols and insurance Design of new office: Help design and set-up office flow Computers: Management of dental software and going paperless Marketing & Social Media: In-house and outside marketing and patient reviews Clinical Training: New Tech-

nology, SureSmile, iTero, Invisalign, i-CAT, digital x-rays, enhance record taking, perfecting photographs and lingual braces (Incognito) Front Desk Management: Proper way to answer phones and talk to patients, accounts receivables, proper new patient in-take, insurance verification and communication, appointment setting and practice management reports Account Receivables: Proper billing with patients and insuance, Ortho Banc and Care Credit, merchant services Patients’ Experience: Wowing the new patient and case acceptance, working the “will call back patients” to get them started

We plan, coach and train doctors, managers and staff. Building your team and understanding every department.

Meet the People Who Make it

“You don’t know what you don’t know, but we know what you don’t know.”

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INDUSTRY NEWS Dr. John Graham appointed to Henry Schein® Orthodontics’ Clinical Advisory Board Henry Schein® Orthodontics™ (HSO) announced that world-renowned orthodontist, inventor, and educator, Dr. John Graham, has been appointed to HSO’s Clinical Advisory Board. Dr. Graham will work in close collaboration with HSO’s research and development teams, the continuing education team, and the commercial teams, evaluating new products and solutions relating to orthodontic treatment. Holding both medical and dental degrees, Dr. Graham is an experienced consultant and well-respected key opinion leader in orthodontics. In addition, Dr. Graham has patented an orthodontic device and holds dual faculty appointments at the University of the Pacific and the University of Rochester. He also serves as an editor for several orthodontic journals. Dr. Graham has co-authored several orthodontic textbook chapters, written many professional journal articles, as well as authored the No. 1 bestselling book in orthodontics on Amazon.com: The Truth About Orthodontics: A Consumer’s Guide to a Beautiful Smile. Dr. Graham’s first lecture for HSO will take place at HSO’s Orthodontic Excellence & Technology Symposium, February 22-24, 2018, in Scottsdale, Arizona. For more information, call 877-448-8606.

Dr. John Graham

ClearCorrect™ offers 3Shape TRIOS® users half price on four clear aligner treatments ClearCorrect™, provider of clear aligners in the United States announced a special one-time cash-value offer for all 3Shape TRIOS® users in the U.S. The offer consists of four clear aligner treatments, based on TRIOS scans, at a 50% discount. Sign-up with ClearCorrect must take place before January 31, 2018, and the treatment setups for the four cases must be approved by March 31, 2018. The offer is valid to all 3Shape TRIOS users only in the U.S. ClearCorrect’s value-packed offer follows the recent termination of Invisalign® interoperability with 3Shape TRIOS scans. ClearCorrect and 3Shape have worked together to make this unique offer for the many doctors and patients seeking to change their clear aligner treatment provider following Align Technology’s sudden decision. 3Shape and ClearCorrect are committed to helping doctors and their patients continue clear aligner treatments despite the predicament Align Technology placed them in with very short notice. New ClearCorrect users must register at https://clearcorrect. com/doctors/ using the promo code TRIOS2018. Users can learn all about how to use 3Shape TRIOS scans with ClearCorrect through an exclusive free e-learning course available at https:// learn.clearcorrect.com/learn. This offer is also available to current ClearCorrect customers in the U.S. who own or purchase a TRIOS scanner. Coupons will automatically be applied to the accounts of ClearCorrect customers who have previously submitted scans to ClearCorrect via the TRIOS portal. ClearCorrect customers may request coupons by contacting 888-331-3323 and verifying TRIOS ownership by January 31, 2018.

Scans from CS 3600 intraoral scanner now accepted by Orchestrate Orthodontic Technologies Carestream Dental has announced that scans from the CS 3600 intraoral scanner are now accepted for use with Orchestrate Orthodontic Technologies. The process begins with a digital impression from the CS 3600. The scanner is ideal for orthodontic cases, as its high-speed continuous scanning facilitates the capture of dual arches. An Intelligent Matching System enables users to fill in any missing information in the data set, and the CS 3600’s three interchangeable tips — normal, side-oriented, and posterior — make scanning in hard-to-reach places easier. Clinicians can then choose to send the open STL files to Orchestrate for treatment planning and 3D printing; plan the treatment, and have Orchestrate 3D print models for aligners or other appliances; or plan and 3D print the case completely in-office. For information on Orchestrate Orthodontic Technologies, please visit www.orchestrate3d.com. For more information on Carestream Dental’s innovative solutions or to request a product demonstration, call 800-944-6365, or visit carestreamdental.com.

Share your good (ortho) news! Submit your press release for consideration to Editor in chief Mali Schantz-Feld via email at Mali@medmarkmedia.com.

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“

I love the ease of Kaleidoscope. I can do as much or as little as I want. And If I choose not to do anything, the display changes each month.

”

— Dr. Thomas Lee

Initial customization for no charge ($1200 value) includes over 300 layouts All of your practice is featured (i.e. team, social media, contests...) 50 professionally-designed layouts change every month 70 scheduled seasonal/holiday layouts change throughout the year Parents prefer Kaleidoscope – the soothing flow of information captures their attention

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M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT A Smarter RPE — Great Lakes Orthodontics introduces the SmartClick RPE™

Karl Schumacher Dental launches comprehensive suite of regenerative products Karl Schumacher Dental, LLC, marks its 70th year in business with the debut of a new family of regenerative products that includes allograft, xenograft, synthetic, collagen membranes, and dental wound dressings. The allograft particulate, putty, and paste are used in oral surgical applications, socket preservation, periodontal defect regeneration, dental implant bone regeneration, sinus lifts, and ridge augmentation procedures. It contains 100% human demineralized bone matrix and BMP-2, free from additive excipients required in other products for improved handling. All allograft tissue is recovered in the U.S. under the most stringent screening and testing protocols. Karl Schumacher offers both a xenograft-derived bone graft matrix and a synthetic calcium phosphate bone graft matrix. The xenograft particulate is an osteoconductive, porous, anorganic bone mineral with carbonate apatite structure derived from porcine cancellous bone. The synthetic putty is a synthetic mineral-collagen composite bone graft matrix for use in bone repair during oral surgeries. For more information about the complete offering of instruments and products, please visit www.karlschumacher.com.

3Shape and OrthoApnea join forces to help patients sleep better New integration between OrthoApnea and 3Shape orthodontics enables dental professionals to send intraoral scans from their 3Shape TRIOS® direct to OrthoApnea for the ordering and design of its new personalized sleep device for Obstructive Sleep Apnea Syndrome (NOA). According to OrthoApnea, 3Shape TRIOS digitalimpression accuracy helps the sleep device maker tailor each NOA device to the individual patient. OrthoApnea has reinvented the oral device concept using anatomical, craniofacial, and biomechanical characteristics of the patient when creating its personalized mandibular advancement devices. Because the 3Shape and OrthoApnea device manufacturing workflow is digital, it speeds up production turnaround time and gets patients into sleep apnea therapy faster. For more information, visit www.3shape.com.

52 Orthodontic practice

Exclusively from Great Lakes, the SmartClick RPE™ features a unique anti-unscrewing system, auditory feedback, hygienic housing, and telescopic components, making it user-friendly, safe, and stable, and offering peace of mind to clinicians and parents. SmartClick RPE’s anti-unscrewing system eliminates “backup.” As the screw is expanded, users hear an audible click at each turn, ensuring that no partial backup occurs when removing the key. A slightly beveled hole allows for easier key insertion, and the hole aligns easily for the next activation. SmartClick RPE’s unique housing is designed for maximum hygiene and prevents the expansion key from passing through the screw and impacting the palate. Additional features include overlapped telescopic components to maximize stability, even at full expansion, and the single-looped arms are laser-welded for strength and durability. A laser-marked graduated scale offers a visual expansion check throughout treatment, assuring clinicians and parents that they have fully completed each turn on the expander. The SmartClick RPE is available in 8 mm, 10 mm, and 12 mm sizes. For more information, call 800-828-7626, or visit GreatLakes Ortho.com.

Palmero™ introduces new pink safety eyewear to support National Breast Cancer Foundation Palmero™ Healthcare, a Hu-Friedy subsidiary, is adding a lightweight, disposable, cost-effective alternative eye protection that reduces eye splash contamination incidents to its line of Dynamic Disposables. A cost-effective alternative to traditional protective glasses, Dynamic Disposables can be worn comfortably with a clinician’s own prescription glasses. The lenses on our entire disposables line feature self-closing holes to prevent gaps and meet the OSHA and Centers for Disease Control’s Guidelines for protective eyewear. When the new pink safety eyewear is purchased, 5% of the proceeds will be donated to the National Breast Cancer Foundation, Inc.® To contact customer care, email customerservice@palmero health.com.

Volume 9 Number 1

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Consenting adults: agreeing on what’s going to happen Dr. Laurance Jerrold

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Ali Oromchian, JD, LLM

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Effect of surgical corticotomy versus low level laser therapy on the rate of canine retraction in orthodontic patients

Analysis of the latest groundbreaking developments in orthodontics

Dr. Noha Ali El-Ashmawi, et al.

A survey of orthodontists’ perceptions of smile esthetics

Practice management advice on how to make orthodontics more profitable Real-life profiles of successful ortho practices Technology reviews of the latest products

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PRODUCT PROFILE

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

Submitting articles Orthodontic Practice US requires original, unpublished article submissions on orthodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Orthodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot 54 Orthodontic practice

Pictures/images

Disclosure of financial interest

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

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

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

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

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

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

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

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

(Multiple) Doe JF, Roe JP

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

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

Volume 9 Number 1

Scheduling Simplified Get more appointments in less time

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Patients can schedule an appointment with you anytime

Call: 415.749.1444 Visit: RecordLinc.com

PATIENT PORTAL

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eFORMS

SMALL TALK

Five powerful leadership and culture-building statements Dr. Joel C. Small discusses how to cultivate shared values and a common purpose

dgar Schein, a noted authority on the subject of organizational culture, has stated that the primary job of a leader is to establish an organization’s culture. An organizational culture is considered to be the guiding principles that dictate how people work together to achieve a common goal. It has its foundation in shared values and a common purpose as well as other less tangible beliefs and assumptions shared by members of the organization. Schein is not alone in his opinion as other distinguished authorities refer to the undeniable link between leadership and an organization’s culture. The leader is both the architect and the guardian of an organizational culture. Unfortunately, many of us fail to realize that we serve in this capacity and that like it or not, we cannot delegate this vital role that is so essential to organizational health. We have only to observe well-functioning, highly productive clinical practices to substantiate this statement. If we could pull back the curtain, we would find that every successful, highly productive, and well-functioning clinical practice has two essential ingredients — an engaged leader and a strong culture. Having studied and witnessed both effective and ineffective leadership practices in healthcare organizations, I have come to the conclusion that there are certain types of statements that serve to define a strong leader and help build an optimal culture. It is not necessary to use these phrases in their exact form. Please change them to suit your specific comfort zone. My purpose is to present a different style of communication that has been shown to be highly effective in

promoting strong leadership and developing optimal cultures.

“Tell me what you think.” I know of no better way to empower staff and provide them with a sense of relevance than to ask their opinion on important practice-related issues. They not only will feel more a part of the team, but also will be more willing to offer helpful suggestions in the future. We will be more prone to ask for their feedback as well because we will likely find that they have valuable insights. Like my coach often says, “No one is as smart as all of us!”

“I’m sorry. I made a mistake.” I am a firm believer that unless we are willing to be vulnerable, we will never fully realize our leadership potential. We often worry too much about being “right” and fail to acknowledge the importance of being “real.” Our team appreciates that we are knowledgeable, but they also want us to be approachable. A healthy mixture of both is the proper prescription for sound leadership and a healthy culture.

“How can I best support you?” Checking in with team members is an important way to let them know that we care about them and what they are doing. This is also helpful in ensuring that team members feel as though they have received adequate resources and training to complete tasks. Ultimately, we will no longer need to ask. As our team realizes that we are interested in their success, they will willingly let us know what they need to be successful.

Joel C. Small, DDS, MBA, ACC, FICD, is a practicing endodontist and the author of Face to Face: A Leadership Guide for Healthcare Professionals and Entrepreneurs. He received his MBA, with an emphasis in healthcare management, from Texas Tech University. He is a graduate of the University of Texas at Dallas postgraduate program in executive coaching and limits his coaching practice to motivated healthcare professionals. He is a nationally recognized speaker on the subjects of leadership and professional development. Dr. Small is available for speaking engagements and for coaching healthcare professionals who wish to experience personal and professional growth while taking their practices to a higher level of productivity.

“How does this action align with our practice values?” When actions and decisions are aligned with our shared values, our culture is operating at peak performance. Post the practice’s values throughout the office for everyone to see and refer to. (You do have shared values for your practice, right?) Whenever we need to evaluate our actions or decisions, we should ask this question of ourselves and others. There is no greater form of accountability than living our values.

“No one is perfect, including you and me.” Mistakes will happen. What is important is to determine the intent. If someone has the right intention but makes a mistake, we have an incredible opportunity to show what leadership and culture is all about. This is a time to soothe the pain rather than demean the person. By accepting a well-intended misstep, we are then able to create a powerful teachable moment by asking a critical question: “What did you learn from this?” I can almost guarantee that you will notice significant positive change in your staff’s attitude and performance if you become comfortable using these phrases. How do I know that communicating in this manner is effective? I know this because this form of communication is the foundation of executive coaching and has a long and proven track record for achieving results. Currently, I am working on a program designed to bring a coaching culture to clinical healthcare practices. The concept is to train healthcare professionals in basic coaching concepts, so they can improve their leadership skills and create a strong vibrant culture in their practice. Expect to hear more about this in the near future. *If you have not already defined your practice values, please contact me and I will send you a step-by-step practice value exercise. OP

*To receive a free copy of my “Core Values Exercise,” please contact me at joel@joelsmall.com. I am also available for a complimentary coaching session to discuss your practice-related issues.

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