Ask Dr. Straight Orthodontic Blog

The Orthodontist's Nightmare Patient

2010-08-30T11:22:00.002-04:00

This was sent to me over the weekend and I have to share it with all of you. My thanks to the individual who created it. It is one of those times when fact is funnier than fiction. Enjoy!

http://www.youtube.com/watch?v=XuPQu7vnwxY&feature=email

Would you trust your orthodontist to do your heart surgery?

2009-10-20T21:35:00.004-04:00

I recently was paging through the Southern Association of Orthodontists newsletter and saw a great handout. There are two similar handouts with the picture of a woman on one and a little girl on the other. It reads: "You wouldn't want an orthodontist to perform your face lift. So why consider anyone but an orthodontist for your family's orthodontic therapy?" On the back is a checklist of pertinent points on the qualities and qualifications of an AAO member orthodontist. What a great idea! I am going to order a ton of these and give them out in all of my new patient handouts and keep them at the front desk. What I really ought to do is mail them to all those quasi-educated dental professionals (and I know who they are in my area) that are doing their patients an injustice by trying to treat them after taking their morning certification for clear aligners or their weekend motel ortho course.

Speaking of weekend ortho courses, I just received an email about a 2 day orthodontic course for general dentists using passive self-ligation brackets. A two day course to do ortho! I must be an idiot. I had to go through a residency and have spent over 15 years in practice and I am still learning. And you know what is worse? The course is sponsored by a major orthodontic company. That's right. The same company that has spent megabucks promoting its self-ligating brackets to anyone who will listen. I guess a lot of orthodontists are not listening anymore and they have decided that a two day ortho-educated general dentist will. Oh, I could have a field day with this. Is it any reason that this company has lost so much credibility?

Come Fly with Air Ortho

2009-10-05T11:52:00.003-04:00

I recently attended a meeting and had the unfortunate experience of having to get there and back via the airlines. How things have changed over the years with them and other services.

What if we ran our orthodontic offices like some of the companies that are “pledged” to customer satisfaction?

“Hello, Mrs. Jones…oh, you want to change Jimmy’s appointment? Sure, I’ll be glad to help you with that. We can change that from tomorrow to next Tuesday at 3:30. Fine, I have made that change. Would you like to pay for that with a credit card now or just put it on your account? The fee for that is $100.”

“Tricia, we are going to have you wear elastics to correct your bite. Here are two packs of elastics to last you till your next appointment. Don’t lose them because they are $5 per package. We’ll just add these to your balance.”

“Magazines? Yes, we are still happy to provide our patients with them while they are waiting in the reception area. They are $4 per hour or any part thereof. Exact change or credit card would really be appreciated.”

“Yes, Mrs. Smith, the $16 charge for telephone support is correct. We know that you needed help in how your son was supposed to wear his elastics and we are more than happy to provide that information to you over the phone. I would suggest he pay closer attention during his appointment when instructions are given. If you think this will occur again in the future we can sign you up for our yearly support program. It’s only $27.50 per month.”

“The fresh baked cookies? Yes, we still have them. We just don’t put them out for general consumption anymore. They are $1.50 a piece. Would you like two or three? Do you need bottled water with that?”

“The doctor is usually not in on Fridays but we could schedule you an appointment to see him. We can plan that from 8-12 and hopefully he will stop in sometime during that time frame. If he does not show, we can reschedule it for another time. The usual rates apply.”

“Toothbrushes? They are located in the patient bathroom in the vending machine. Do you need change?”

"The wires and instruments are over there. Help yourself. If you'd like an assistant to help you with that she can for a nominal fee."

“Our new motto? Well, with many of the changes we have made, we decided that “gentle”, “caring” or “warm” really are not indicative of who we are. We now say “we get your teeth straight”. Much more direct, to the point and we don’t have to worry about living up to the niceties.”

Orthodontic Vendors Beware-Patients Pay Attention!

2009-09-16T09:25:00.004-04:00

I view myself as your typical, "in the trenches" wet fingered orthodontist. I am certainly not an academician, a lecturer or brilliant by any stretch of the imagination. I am a practitioner that is trying to provide the best treatment for my patients that I possibly can using the techniques that I have been trained in or have learned through continuing education and employing my years of clinical experience as guidance. I have worked hand in hand, with a great deal of trust I might add, with my orthodontic companies and their reps to provide the best materials and proven techniques for my patients.

Lately, I have notice a real paradigm shift in the role that some orthodontic companies are taking. They are marketing directly to my patients and trying to influence their decision making process rather than continuing the time honored and successful method of the orthodontist deciding with the patient what the best course of treatment is and what technique or appliance to use to attain the desired results.

Maybe I shouldn't say trying. They are! I have patients come in demanding a certain bracket because they have seen an ad espousing the benefits of said bracket. I have had patients come in saying that they want a certain clear aligner and that is what is going to work for them. (Check out some of the comments in previous columns on this site. You will see what I mean.)

Well, you know what? This average, "in the trenches" orthodontist is starting to resent some of these orthodontic vendors. Attention orthodontic patients! Make no mistake about it, they are vendors. They are selling a product and if they can't sell it to the orthodontist they are going to sell it to you. I have real issues with these policies and the way they do business. I am not in agreement with trying to cut the orthodontist out of the treatment planning and treatment of patients by directly marketing to patients. I look at them as threats to the well being of my patients. I think it should be remembered that these vendors exist because of the needs of the patient and the orthodontist and not the opposite. We are the decision makers and treatment planners/coordinators for our patients, not them. I will not deal with a company that tells the general public that their product is better, faster, more comfortable, etc when there is no scientific evidence to back it and that if your orthodontist is not using it then he is not technologically savvy or up to date. We are the ones to decide what the Standard of Care is and not the vendors. By supporting them with my business I feel that I am, in the very least, condoning their practices. I won't do it.
Orthodontic vendors beware. If this one average orthodontist is thinking this way, what does that say about the rest of the orthodontic community? You may find your business policies backfiring. We are still the ones that ultimately buy the brackets and appliances. We are still the ones that know what is best for our patients!

R-E-S-P-E-C-T

2009-08-27T16:08:00.003-04:00

If you're walking around thinking that the world owes you something cause you're here
You're going out the world backward like you did when you first came here...
"Respect yourself", Staple Singers

It seems that lately I have had an abundance of teenage patients with the attitudes that they are superior to their parents in every way. Now I know that this is nothing new but when you sit there in front of a complete stranger (me) and backtalk disrespectfully to your parents then something is wrong. Excccuuuuusssse Me! These are the same parents that are putting a roof over your head, feeding you, and busting their butts in this rotten economy to make sure that you have the latest fashions, downloads for your Ipod and payments made on your cell phone. They are the ones that are footing the bill for your orthodontics so that you can have a great smile for the rest of your life.

The next time you start to give the big exaggerated theatrics or throw some snide comment back at your parents in my presence, we are going to have a quiet little talk while you are chair side. If it continues I'm going to correct you in front of them or the whole reception room. If you want respect, you have to earn it and respect others. That starts with your parents!

I'm an Orthodontist-not a Car Salesman

2009-06-23T11:42:00.003-04:00

When I went through dental school and residency the focus was on the treatment of your patients to the best of your abilities. We received very little in the way of business courses or the running of an orthodontic office. Our professors told us that if you were warm and caring to your patients and treated them well, the money side of things would take care of itself.

Obviously they had no idea that the economy would look like it does now and that the idea of payment for services rendered would fall to the wayside for many people. While I don’t want to get into the debate that everyone in the world is entitled to health care, I will affirm that providers do need to be reimbursed for their services. While we are health care professionals, we are also business owners. Our hard work and talents provide income for employees, dental suppliers and their reps, utilities, insurance companies, office suppliers and a myriad of other people that are support services. If I don’t get paid, they don’t get paid.

It amazes me how the mindset has changed in the years that I have been in practice. I have seen a progression in the number of patients that feel that they must bargain with you over your fees. They will go to three or four orthodontists to compare fees and then try to convince you to charge whatever is the lowest fee. They are not comparing treatment modalities, your reputation and knowledge, professionalism of the staff, or office appearance; they are comparing fees.

Just yesterday I had a woman come in with her daughter for a consult. I had treated both the woman and her older son with great results, had an excellent relationship and we even went to the same church. They are financially very comfortable and send their children to a private school where the tuition is higher than a lot of colleges. After we had done the exam and I had left the room, my treatment coordinator went over financials, took 10 percent off as a family courtesy and was told that they had seen another orthodontist who quoted them $225 less. That is the price that she felt she should have to pay. She was told that we felt our fee was a fair one and that was the price. They left without scheduling an appointment. They are going to travel an extra twenty miles to a practitioner that they have no experience with for the sake of $225.

Maybe you can argue her side, but I think that is insane. I also felt quite betrayed......

Invisalign-Care for Patients or Profits??

2009-06-09T11:12:00.004-04:00

I recently received an email from Align Technology letting me know that they now have proficiency requirements for the use of their appliance. Align Technology are the makers of Invisalign. I am sure you have seen their commercials on television and how they are the clear alternative to braces. Wear their clear retainers; change them once every two weeks and soon you will have a wonderful looking smile without having to wear unsightly braces. As an orthodontist, I wish it was that simple and worked that well. I would imagine that Align wishes it worked that well too. If it did, they would be inundated with cases from orthodontists rather than having to peddle their product to general dentists with little or no training in orthodontics (oops, I forgot that they get certified in a special one day course! Heavy training, huh?) or run TV ads targeted to the uneducated public.

Sorry, I digress. Back to the initial “proficiency requirements” email. It seems that Align has created a monster in “certifying” more than “40,000 Invisalign-trained doctors in North America” and now they want to make sure that visitors to their web site are referred to doctors with enough product knowledge and experience to treat them correctly. I guess the one day certification course did not do that. Now they are requiring a doctor to complete at least 10 cases by the end of the year or their special Invisalign provider designation will be lost and they will not be able to use the product. (Darn, I’m not going to be able to use a product that I viewed as inferior when compared to traditional braces. AJO-DO Volume 127, Issue 2, Pages 268-269 (February 2005).

I have a problem with a company deciding if I am qualified enough to use their orthodontic product. That is a responsibility of a state or federal licensing bureau, dental board or state certification board or the ABO. This is not the responsibility of a company that has given “certifications” to under-qualified individuals in order to boost its bottom line.

On the surface, I would applaud the effort of a company to make sure that its users are competent and educated in the use of their appliance. But that cynical part of me keeps looking toward the bottom line part of the equation. It seems that by making it mandatory that doctors do at least ten cases by the end of the year, they are boosting their profits quite a bit in the wake of a very slow economy. It will be interesting to see how this plays out.

A Giant Has Been Lost.

2009-06-03T11:41:00.007-04:00

Word has been received that Dr. Anthony A. Gianelly passed away on May 28, 2009 (http://www.neso.org/). If you are an orthodontist you know how much this man meant to the orthodontic community. If you are a patient, please read his obituary. This man was a giant in his field and a wonderful, caring human being.

My only regret in knowing Dr. Gianelly is that I did not train under him. He was absolutely brilliant with an incredible command of the orthodontic literature. His common sense, realistic approach to orthodontic treatment and his honest assessments of what worked and didn't made going to his lectures an absolute enjoyment and enlightening educational experience. I patterned so much of my orthodontic treatment after his teachings.
My personal experience with Dr. Gianelly was limited seeing him briefly at meetings and saying hello or asking a question after one of his lectures. I did have the opportunity to bring him to our state meeting to lecture our group and found him to be so unpretentious and friendly (unlike some of the prima donna lecturers that I have dealt with) that there was an immediate desire to do whatever it took to make his stay with us a great one. From the email I received from him later I like to think he was being more than just gracious in his thanks. He was that type of man.

Dr. Gianelly is gone but I assure you that this orthodontist will never forget him and will keep his memory alive through the smiles that he has helped me create.

Self-ligating vs Ligating Revisited

2009-05-20T09:09:00.003-04:00

To be brief and concise, coming from the AAO meeting in which I listened to a number of lectures and networked with my fellow orthodontists, the evidence and literature are pointing to the fact that there is no significant difference in treatment time, comfort, quality of treatment or any other parameter between self-ligated and ligated brackets. In the words of one lecturer, "...the answer is in the wire, not the bracket".
I will editorialize at this point. Some orthodontic manufacturers are now targeting the patient, rather than the clinician, in order to sell their products. This is similar to the drug companies and their heavy TV commercials targeting the consumer with a vast array of pharmaceuticals. My comment on this is "let the buyer beware and be aware".

AAO Annual Session

2009-04-28T10:36:00.002-04:00

Boston is about to be inundated with orthodontists, staff members, orthodontic companies and their salespeople and all of the supporting members of the industry. These people are not only from the USA but from all over the world. It is time for the 109th Annual Session of the American Association of Orthodontists.

You might be surprised as to all that goes on. Aside from the fact that every orthodontic company under the sun is there displaying the latest and greatest in appliances, braces, office supplies, equipment, etc., there are also a multitude of lectures on all aspects of orthodontic treatment given by the top gurus in the field. This is one of the major opportunities for your orthodontist to get his education hours in that are necessary for state regulations. Many of our patients don't realize that we are constantly going "back to school" on an ongoing basis, partly because we want to keep up with the very best treatments for our patients and partly because we are required to by laws in our individual states.

There is also some fun time involved. It gives us a chance to network with other orthodontists, touch base with old friends and orthodontic reps and to experience a major city that we might not have visited. (I would have liked to see the Red Sox play at Fenway but they are out of town this weekend. Maybe I can catch a Celtics playoff game).

One other very important activity that occurs is the meeting of the AAO House of Delegates. This is a body of representative orthodontists from across the country that perform much like Congress in the passing of resolutions that are meant to benefit our patients and the practice of orthodontics on a whole. It might be something as simple as cleaning up the wording on a previous resolution to something as complex as assessments for a national education campaign.
It is definitely not as contentious as Congress and from what I have observed, the participating orthodontists don't have the individual agendas that some of our elected officials have. (They also are not bombarded by lobbyists).

So I'm shipping off to Boston and will return next week.....

Smiles Change Lives

2009-04-23T08:49:00.005-04:00

You may have noticed a new multi-colored link on this page. It is to the Smiles Change Lives website. "Smiles Change Lives is a national nonprofit organization that provides life-changing, essential orthodontic treatment for children from low-income families. Based in Kansas City, the program has treated more than 1,200 children since 1997. With its origin as the Virginia Brown Community Orthodontic Partnership, Smiles Change Lives has emerged as the nation’s leader in providing access to orthodontic care for underserved youth."

Go to their website (www.smileschangelives.com), look around and get involved with this very special group of people. I know that you have a choice of many charities to support but as members of the "orthodontic family", this one has a special place. Wouldn't it be heart warming to know that every time you looked in the mirror and saw your smile, you knew that you helped someone else to smile for the rest of their life too?

The Future of Orthodontics

2009-04-09T18:07:00.003-04:00

I am not a futurist by any stretch of the imagination. (If I were, I would be extremely wealthy having seen the past two years of economic decline.) But as an exercise, I think it would be curious to write down where I think the state of the specialty is headed in the near and the distant future and maybe someday look back on this and see how accurate I was.

I think it is rather obvious that orthodontic practices have been in a state of decline for the past two years. A recent survey by the AAO bears this out with nearly two-thirds of orthodontic practices reporting a decline in new patient starts since January 2008 (The Bulletin, April 2009 Vol. 27, No. 2). How long this will last is open to conjecture but recent news and financial reports lead one to believe that the economic downturn will continue for another year before it starts to move in a positive direction.

This will mean that all aspects of dentistry will suffer and we will probably see an increase in what I call “poaching” by practices that are trying to increase their bottom line by adding new services or types of treatment to their practices. This would include a blurring of the traditional lines between the specialties (i.e. oral surgery-periodontics, oral surgery-prosth) and traditional lines between specialties and general dental (i.e. endo and ortho). We are even seeing a blurring of lines between dentistry and plastic surgery (Botox injections, spa practices). On the specialty-general dental subject, orthodontists have been seeing a significant increase in the number of general dentists attempting to do orthodontics whether it is taking a weekend course on fixed appliance therapy (braces) or a half day certification process for clear aligners. With that increase, orthodontic referrals from these practitioners is decreased. And with the downturn in the economy, publicly traded companies dealing in these modalities will be pushing even harder to increase their market share and improve their bottom line in order to make their stockholders happy, regardless of the training or quality of treatment being performed by these practitioners.

Taking all of this into consideration, I look at the immediate future (wouldn’t that be the present?) as one in which there is an increase of dental practitioners doing orthodontics that are not as well qualified or experienced as the traditional orthodontic practitioner. Take it a step further and I see a lot of mediocre to poor treatment being performed on patients because some practitioners feel a need to increase the scope of their practice for strictly financial necessity. Unfortunately the patient may not realize this as many people don’t care about quality but rather the price point-until it is too late. These “lightly trained” practitioners will leave a trail of broken dreams and false promises with the unsuspecting public.

For the distant future, I am going to be optimistic for the patient’s sake and say that orthodontic treatment will improve. Either the technology will increase to the point that inexperienced practitioners will be able to treat cases to a passable level or it won’t. Assuming the later, those lightly trained practitioners will realize that there is much more to treating an orthodontic case and will no longer attempt it, assuming the economy is favorable. (Many GPs who have already dabbled in orthodontics have realized that they are in the treatment for an extended time without generating additional revenue at each visit. That's not appealing to them as much in this economy, when they can focus on things like whitening (the percentage of patients who have had this professionally done is amazingly low and a wide open market.) Plus it opens the door to additional cosmetic procedures that are quicker both in treatment time and in financial compensation).

If the technology improves to such an extent that general dentists can perform passable treatment, I still see a necessity for orthodontic specialists but not at the patient loads of the past. If technology does not improve to that extent then I see an initial increase in patient loads from those that have put off treatment in the past years, those that are dissatisfied from previous treatment performed by inexperienced practitioners and the general new patient population.

There are two other factors that have not been mentioned here. They are the possibility of a national health care (socialized medicine) and the impact of orthodontic manufacturers marketing directly to the public and general dentists which I feel will not be in the best interest of the general public. (Stay tuned to this channel…..)

Be a patient Patient

2009-02-19T09:58:00.007-05:00

"When are my braces coming off?" "When can I get these things off?" "My mother wants to know how much longer?" If you are an orthodontist, you hear these questions every day. My response is varied depending upon my mood and the patient involved. "Not too much longer" "They'll come off when they're ready." "Sometime before I retire." "Hopefully someday before I die." Yes, sometimes I get tired of hearing those questions.

When you came in for your consult, your orthodontist gave you an estimate of your treatment time. In my practice, this is more of a "guess-timate" rather than an estimate. Based on your malocclusion, cooperation during treatment (this concerns hygiene, broken brackets, elastic wear) and my clinical expertise, I tell my patients how long I think treatment should take. This is not carved in stone! Too many times I have had patients or their parents treat that estimate as an exact time. Sorry, it just doesn't work that way. There are too many variables and we are dealing with the human body. Some patient's teeth move quicker and some slower. This is especially true with adults. Time in treatment with adults can be very variable.

My advice to you as a patient? Be a patient Patient. Don't ask me 6 months into treatment when the braces are coming off or telling me you have a wedding, graduation, cruise, birthday, etc that they have to come off in time.

Believe me, I don't want you in treatment any longer than you do! But I do want you treated correctly and finished correctly. That's why you came to me. Give me the time to get you there and you will thank yourself in the long run.

"I Dunno...."

2009-02-06T09:49:00.005-05:00

Years ago, one of my favorite comedians, Bill Cosby, did a routine on his children. In it he lamented the fact that he thought his children were "brain dead" because they would do totally ridiculous or stupid things and would answer his question of "Why?" with the comment "I dunno". Well people, we orthodontists face that same thing every day with some of our patients.
Let me share a few examples with you.
A 13 year old young man comes in the other morning without his lower archwire in place. It is not displaced nor has it slid over. All the little colored elastomeric ties are still in place. But the archwire is not there! The conversation goes something like this:
Me: Where is your archwire?
Him: I dunno.
Me: Let me rephrase that. What happened to your arch wire?
Him: I dunno.
Me: You left here last appointment with a wire down there. Can you try to remember how it came out?
Him: Oh, I was eating a cookie and it came out.
Me: A cookie?
Him: Yes, a cookie. And it came out when I was eating it.
Me: How did it come out when you were eating the cookie? (Now mind you, all the ties are still in place.)
Him: I dunno.
Mr. Cosby, move over!!

Here's another one:
A 15 year old girl comes in with 5 broken brackets. Not one, not two but five!
Me: You have a lot of loose brackets today. What happened?
Her: I dunno.
Me: What do you mean, you don't know. You have to know how they got loose. Did you eat something hard? Were you chewing on a pen? (Or a crowbar?)
Her: No, I don't know how they got loose.
Me: Did they get loose all at once or was it a gradual thing?
Her: I dunno.
Me: Did you just wake up and they were all loose?
Her: Yea, that's what happened.
Me: Did you give us a call to tell us so that we could give you more appointment time to fix them?
Her: I dunno.
Bill, do you see what I'm up against?

Just one more:
A 16 year old male comes in for a retainer check. We use a clear aligner type retainer made of plastic that fits snugly around the entire tooth.
Him: My retainers don't fit anymore.
Me: Well, let me take a look. (I open his retainer case and I am staring at two retainers that look like they had been chewed up by a mad pit bull and then flattened by a steamroller.)
Me: Looking at these retainers, I can understand why they don't fit. What happened to them?
Him: I Dunno. (You guessed it.)
Me: (Big sigh) What do you mean you don't know. You have to know. Look at them!
Him: I must have dropped them.
Me: Huh?
Him: Yea, I dropped them and now they don't fit anymore.
Me: Where did you drop them? (In your garbage disposal?)
Him: I dunno.
Me: C'mon, you have to know were you dropped them for them to look like this.
Him: I dropped them in the sink when I was cleaning them.
Me: You dropped them in the sink and they turned out like this? How? (Get ready...)
Him: I DUNNO!

Cos, by all that is good on earth and in heaven above, help!!

Self-ligating Brackets Revisited

2008-12-19T07:43:00.004-05:00

It seems there isn't a day that goes by that I am not asked about self-ligating brackets. Invariably it is in reference to the Damon brackets (which is a testimony to the amazing public marketing job that Ormco/"A" Company has done in in promoting its bracket). Are they more efficient, do teeth move faster, does treatment go quicker, are they more hygienic and are they less painful?

In the November 2008 issue of the Journal of Clinical Orthodontics (http://www.jco-online.com/), Fleming, Dibiase and Lee reviewed the published evidence for the reported advantages of self-ligating appliances in their article "Self-Ligating Appliance: Evolution or Revolution?".

Their conclusions were "To date, published prospective trials on these systems have considered alignment efficiency during the initial stages of treatment, torque expression in the upper labial segment, pain experience, and the efficiency of appliance manipulation. By and large, the clinical promise of the self-ligating systems has not been reflected in the outcomes of these controlled clinical trials. A lack of supporting evidence does not invalidate the appliances....Nevertheless, in this era of evidence-based dentistry, further affirmative evidence would be reassuring...".

I will let the readers draw their own conclusions......

This Rotten Economy Hurts Everyone!

2008-12-13T21:24:00.005-05:00

I can't tell you how many new patients we have seen in the last three months that are putting off treatment until "the new year" or "when things get better". I hate to say this but what if things don't get better soon? Even our President-elect has stated that he expects the economy to get worse before it gets better.

Obviously, the slow down in work is bothering me. Everyone has slowed down and most dental practices across the board are slower. Many have laid off employees in an effort to survive the poor economic environment. But what bothers me is that the longer my patients have to wait for treatment, the more complex and tougher their treatment is going to be. Patients that I could do interceptive treatment on or start at a certain time are delaying treatment which may in fact cause them to have extractions or longer treatment times in the future. That really bugs me.

We are trying to work with our patients financially to make it possible for them to get the treatment that they require. More of them need to realize that "you can pay me now or pay me later". The later is going to take more time, expense, and complication.

I am not a judge, lawyer or marriage counselor....

2008-11-17T20:18:00.004-05:00

My office manager almost lost her mind today. "Ms. I'll get him" came into the office complaining loudly that her ex-husband is a no good so and so and that we need to call to tell him to pay his part of the kid's orthodontic expenses. Forget the fact that we have told her twenty times or so that she signed the kid's contracts and that she is the responsible party. Forget the fact that we have no right to contact him about the overdue bill and that it is her responsibility to deal with him. And forget the fact that we are not a mediator, judge or lawyer beholden to her to harass or threaten her ex. Didn't do any good. She said she is not paying "his half" even though legally there is no "his half".

In our office we have one parent sign the contract and become the responsible party. We have been burned too many times by divorces that end with one parent moving out of the area, state, or country and forgetting their responsibility to our office. Our legal recourse was little and we ate a lot of write-offs. Now it is one parent that is responsible and we let the court and parents decide how they will divide the bill. We will not and cannot contact someone who is not the responsible party.

I know that divorces are highly emotional and miserable things to go through. And although finalized at some point, they last a long time. But don't put us in the position of trying to wreck havoc or get some type of emotional or financial vengeance upon your ex-spouse. We won't go there. Be adults, settle your differences for your kid's sake (and ours) and come to terms on financial responsibilities either on your own or through the court. And for all that is holy, don't vent in front of your children or my full reception room. Neither your kids nor my other patients want to hear about your problems.

Going back to "Ms. I'll get him", I told my office manager not to worry about her today. You can't argue with a crazy person.

When is it time to see the orthodontist?

2008-11-12T22:48:00.004-05:00

The American Association of Orthodontists (http://www.aaortho.org/) suggests that a child be examined by an orthodontist at the age of 7. You might ask yourself "Self- why so young?" At this age, a lot is going on in the mouth of your average first grader. She actually has more teeth in her mouth than you do. There is hopefully a complete set of permanent teeth and most of her deciduous or baby teeth. She is probably missing some of her upper and lower incisors.

At this age, your orthodontist can tell you what you can expect in the coming years concerning your child's teeth and jaw growth. For those of you that like to plan for future expenditures, it is nice to know if little Jimmy is going to need braces, at about what age and for how long. That way you have a few years to plan.

This is also a good age to determine if any treatment is necessary now or in the near future. There are times when an underlying problem can be resolved and make further orthodontic treatment easier and take less time.

So if you are bringing in one of the older kids for treatment or an exam, make an appointment for little brother. He won't feel left out and you will be doing him and yourself a big favor.

Extraction vs Non-Extraction Treatment

2008-10-23T21:45:00.007-04:00

I was recently reading the posts to a great website that caters to adult orthodontics ( www.archwired.com) and was surprised to learn that one of the major concerns of adults is that orthodontic treatment will change their facial appearance. Specifically, most of those concerns centered around the fact that they had to have extractions and they were worried about how their finished treatment would look.

The debate of extraction vs non-extraction has been going on since the early beginnings of orthodontics over 100 years ago. The pendulum has swung back and forth over the years between an overabundance of extraction cases and then the same with non-extraction cases. In the last twenty years, I have seen it go both ways with the pendulum having swung back into the non-extraction mode with the claims of certain orthodontic bracket companies concerning their new self-ligating brackets. (I touched on this subject July 14, 2008-check the archives.)

Now I don't like having to have teeth removed as the next orthodontist, but sometimes it just can't be helped. Somtimes you have to take out teeth. As one of my old professors once told me, "You can only put so many marbles into the bag before they start spilling out." There has been a myth perpetuated that extracting teeth will ruin faces, cause TMD problems and bring about the destruction of the world. OK, I exaggerate on the last point but the first two are actual.

I can assure you that a well diagnosed and treated extraction case will only improve a patient's facial esthetics and will not cause TMD problems. You want proof? Look closely at a smiling picture of some top models and actors. Count the upper teeth. I'll give you a hint on one: she has a very successful show on Bravo (http://www.bravotv.com/) concerning runway fashions. She is missing bicuspids. I am sure that you will agree with me that her smile is fantastic.

"You're Fired!"

2008-10-20T21:20:00.004-04:00

I had to fire someone last week. In this poor economic environment with the holidays closing in on us rapidly, I had to let one of my staff go. I hated to do it but I really didn't have a choice. Oh, I guess I did but then I would have lost most of my other staff members either by their quitting (probably not) or losing my credibility (more probable).

You patients may forget that I wear many hats. One of them is a small businessman who employs 7 or 8 people. And some of my staff forgets that I am their boss and that there is not a whole lot that goes on in the office that I am not aware. It may take me a while to respond to it but if backed into a corner I will react. My reaction has a sense of finality to it. Someone loses a job.

When you work with a group of women, they know way before you do who is slacking or taking advantage of the boss and his good nature. I initially take it as "petty woman stuff" until it gets to the point where I have struggled with it for six months or so. I seem to always expect that they will pull out of the nosedive they are in, act like adults and get back to being ideal employees. And as it goes, they seldom do. By the time the staff is getting ready to mutiny, I pull the trigger (metaphorically speaking please).

In the small office environment, it is not just about doing your job. It is about working closely with a select group of people whom you grow to love and trust (or at least like somewhat and trust). You can treat those patients like gold as a receptionist or chairside, but if you are treating your fellow workers like pox infested peasants and you're the queen of the office, you are "heading" for the job guillotine. Liken it to Manny Ramirez who is probably one of the best hitters the modern era has seen. He felt he was too good to hustle and play hard for the Red Sox. Wrong! They traded him.

Staff members-realize that no one is indispensable. All of you can be "traded". (Let's face it, even I can be replaced if I cop the wrong attitude. Patients will fire me and go elsewhere). Don't forget to respect, maintain the trust and work with your fellow employees. It is about the patients AND about those around you. Seriously, I hate to fire people!

SureSmile

2008-10-10T17:51:00.007-04:00

On Thursday morning, "Good Morning America" (http://abcnews.go.com/GMA/OnCall/story?id=5990013) presented a piece on SureSmile, a system that integrates digital imaging, computer modeling, robotic technology and high-tech materials into an orthodontic treatment process. It is currently being used by approximately 260 orthodontists in the US and Canada and most have been using it less than 3 years.

SureSmile (http://www.suresmile.com/) from my point of view is very high tech and has a big learning curve. But what it allows the orthodontist to do is get a very clear idea of his treatment plan before the braces go on. He can plan tooth movements and reach a finished product on the computer and then decide it he can actually attain those results. From what I have seen, what you see is what you get assuming the judgement is correct on the tooth movements made.
To an orthodontist, that is a big advantage. No more cutting plaster models apart and doing set ups. No more "guess-timates" on whether a treatment result is attainable (or at least it cuts them down significantly. There will always be practice experience and the clinical judgement that goes with it).

There is also a time advantage for the orthodontist and the patient. The wires that are bent by the robot are more precise and detailed than any wire your orthodontist routinely bends. (I don't think I have ever bent a wire as detailed as these). Therefore, the patients teeth are going to move more efficiently and thus faster to their final position. Important to note-SureSmile does not move the teeth faster, it moves them more efficiently. (Like taking a straight path to grandma's house rather than the "scenic route"). So the patient's teeth are not being hurt or being moved "too fast".

Hey, it's Friday and the weekend is here. We will continue this in a few days. If you have any questions or comments, feel free.... Until then, keep smiling.

Where does the time go?

2008-10-09T19:43:00.003-04:00

I can't believe that it has been August since I reflected on my orthodontic world. Where does the time go? Now we are mired in election year rhetoric and one of the worst economic crisis' in a long time. Today the market hit a 5 year low. Thank God that I do not plan on retiring soon. My portfolio (or what I have of one) has taken a bad beating in a very short time. People are cutting back on everything and very wary of spending on all but the essentials. In many regards, they do not feel that orthodontics for their children or themselves is one of these essentials.
I had a teenage patient in the chair yesterday that wished that he was a rich orthodontist like me. If he only knew the truth. When you have an established orthodontic practice it takes quite a bit of money to keep it running. And if you have a large practice, it takes even more. If suddenly you are not starting a certain amount of cases, things can go downhill real fast. It is like shooting craps: you can make big money and you can lose big money.
People do not realize that the dental profession on a whole and orthodontics in particular have been down the past two years. Dental supplies houses are showing loss in revenues and orthodontic companies have been trying to combat lower unit orders with higher priced brackets. (I heard at a meeting this past weekend that even a very well known "clear aligner" company showed a 6% loss the past year, even after a very aggressive marketing campaign.)
I am finding in my own practice that we are not only down in starting patients the last two years but we are having many more delinquent accounts that my office manager is having to spend time. Again, the teenage boy mentality that I'm a rich orthodontist so my payment won't be missed. Get enough people to think that way and my peers and I will be shutting our doors and sweeping the floor of the Soggy Dollar Bar in the islands. (Hmmm...work for drinks, sleep in a hammock, chill on the beach....something to be said for that.)
Anyway, I digress in the fact that I have been remiss in my writings. I shall make a better effort to share my thoughts with the 6 or 7 people that read it. I promise an article tomorrow on SureSmile and what it is all about.
Until then....keep smiling! We need it in these times.

"Mom, Please stay in the reception room."

2008-08-28T22:56:00.003-04:00

And that goes for Dad too.....

I am going to make this short and to the point today. Parents, your child undergoes an orthodontic procedure better if you are not there trying to hold his/her hand. Period.

When you come back and I have a challenging procedure to perform, the child has two too many chiefs to listen to- me and you. I need your child to listen to me and me only. When you throw your two cents in, no matter how well meaning, it gives the child two avenues and I need him driving on mine. Add to that is the fact that instead of me having to deal with only one personality, I have to deal with two and sometimes counteract well-intentioned but misguided comments from you.

If you trust me so much that you are bringing me your child to treat, then you need to trust that we know what we are doing back there and doing what we feel is the very best for your child. You have to give up some of your control and trust me with that control. I know its hard but I won't let you down and your child will do much better for it. Thanks.

"Braces are too expensive...."

2008-08-25T12:32:00.003-04:00

How many times do I hear that in the course of a day? Way too much if you are on my side of the fence. Let me share some things with you.

Running an orthodontic practice is expensive. I should say "orthodontic business" because that is what it is. People are not aware or forget that not only am I a health practitioner but also a small businessman. Strictly from a business model, I sell braces. Through my expertise I provide a service of using those braces to give you a healthy and esthetically pleasing smile.
Now what do those braces cost me as the retailer? Well, its not only the braces. It is the building that I am in, the utilities for the building, the phone system, the computer systems, specialized software, the dental supplies and equipment, lab fees, the digital radiograph machine, the furnishings, employees, insurance, payroll, etc., etc., etc. Do you catch my drift?

Now that is just the day to day costs. Let's talk about training and starting a practice. Your orthodontist goes through four years of college, four years of dental school and two to three years of residency. That means he/she is coming out of school with a ton of school loan debt. In many cases this debt is in the $2-400,000 range. Let's add on to that the start up costs for a practice. That is going to run about $500,000. Add it all up and that is one big nut to crack!

The average orthodontic case is around $5000. If you complete your treatment at age 14 and you live to be 80 (hopefully longer) the cost of your beautiful smile is roughly 20 cents a day. Two dimes and you have better oral health, an increased positive self image and a smile that will last you a lifetime. Now that is a bargain!

"Sometimes I wear them..."

2008-08-13T22:16:00.006-04:00

Call them what you will: rubber bands, elastics, pain in the mouth, etc. But, in many cases, you are never going to finish your treatment correctly without wearing them like you are instructed. Nothing slows up treatment or brings it to a standstill like not wearing your elastics.

Elastics are worn to correct your bite. In most cases you are wearing them from the upper front to the lower back. That is to correct an excessive overjet. (Your teeth are sticking out too far in relationship to your lower teeth.) In some cases, it is the opposite. You are wearing them from the lower front to the upper back to correct a negative overjet (or underbite). Add to that any number of ways to combine their wear to bring the teeth together in a proper relationship.

It boils down to wearing them. A friend of mine likens it to your mouth and braces being a high performance sports car. (He likes Porsche.) The elastics are the gas for the car. If you don't put the gas (elastics) in the car (mouth), the car doesn't go anywhere. Your super sports car goes nowhere and so does your treatment.

Here's another orthodontic metaphor. You push a car that has no brakes up a hill. Spend all that time and energy getting it almost up the hill and then let go of it. What happens? The car rolls all the way back down the hill. That is pretty much what you are doing by wearing your elastics only part of the time. Your teeth never get to the top of the hill!

Ask any of your friends who have been in braces for over 2 years if they are wearing their elastics like they were told. I'll bet you that the majority will tell you that they "wear them sometimes". No wonder their treatment time is so long! They are wasting time by not following treatment instructions.

I know it is hard to believe but as an orthodontist, I get lied to every day. Gasp! Kids look me straight in the eye and tell me they are wearing their elastics "all the time". Never mind that they can't remember how to put them on or where they go when we ask them. Teeth don't lie. If I don't see any change in the bite and they have supposedly been wearing them for the last 16 months, I know someone is stretching the truth.

Take control of your treatment and the time you spend in braces. If you are to the point of wearing elastics, it is all in your hands. Use them to put your elastics on and keep them on. Your parents, your orthodontist and most importantly, you will be thankful that you did.

Who can versus who should?

2008-08-03T21:00:00.006-04:00

If I saw my internal medicine physician concerning heart surgery and he told me that he would be happy to do it, I think that would concern me. After the initial shock wore off, my first question would be as to his qualifications. What kind of training, how long was it and how many cases have you previously performed would be at the top of my list.

If I went to my friendly optometrist and she told me that she could remove the cataract that had formed in one eye, I would be hard pressed not to ask her if I should not trust my sight to a trained and experienced ophthalmic surgeon.

If my dermatologist told me that he would be happy to take out my enlarged thyroid gland because he had attended a weekend course and had passed the 10 question "certifying exam", I would certainly wonder how something as complicated as that could be learned that quickly.

If my family dentist told me that he would be happy to put braces on my child or treat my orthodontic problem with "clear retainers" I think that I would reread the previous three paragraphs.....

"Something's loose..."

2008-07-27T21:06:00.004-04:00

As an orthodontist, I hate that phrase (especially on a Monday morning). It usually means that you have a broken bracket and you didn't have the courtesy to call us so that we could adjust the daily schedule to allow enough time to fix it. Now the staff and I are hard pressed to repair whatever is wrong and still stay on schedule so that the rest of our patients don't have to wait. Come in first thing in the morning with an unannounced "emergency" and you set a stressed tone for the rest of the day. Put two of you together and patients with appointments after you are definitely going to wait.

We, like most orthodontist that I know, ask you to call us when you have something broken or loose. Some of you do (thank you) and some of you don't (grrrr). When you do, we can provide the proper time to take care of you. It's good for you, for us and it's fair to the patients that would have to wait behind you.

Brush your teeth!

2008-07-22T20:18:00.007-04:00

After years of treating patients, it gets a little tiresome when you come in looking like you have not brushed your teeth in weeks. Care is taken with your hair, clothes, make up etc., but it seems you have forgotten to use the fuzzy end of the toothbrush and dental floss is a non-entity. It is almost as if you are trying to bury your teeth under plaque in a heroic, albeit misplaced, effort in order to hide them so that proper care and treatment progress is made improbable. In other words, there is so much of last week's meals on your teeth and jammed under your braces and gums that you're creating your own toxic waste dump in your mouth.
Let's look at this on a professional level. You need to keep your teeth and gums healthy so that your treatment progresses in a normal time. This will also help to insure that you do not get those dreaded lifelong "white spots" on your teeth when your braces come off. And it will avoid cavities, periodontal disease and bone loss around your teeth. (I hate it when the braces come off and the teeth come with them.)
On a social note, it is definitely gross to be smiling at that "special someone" and flash a mouthful of swollen, bleeding gums with enough half digested food on your teeth and braces to feed the both of you for a long weekend. That is definitely not sexy or attractive and goes against all the effort that you put into your fashion statement for the day. Believe me, people notice if you have gross mouth!
Do yourself and everyone around you a favor. Listen to your orthodontist and assistants when they give you oral hygiene instructions. And then like the old Nike ad slogan said: Just Do It!

Which orthodontic bracket is the best?

2008-07-14T13:39:00.005-04:00

In the last few years there has been a huge push by the orthodontic manufacturers to convince orthodontist to use the "self-ligating" orthodontic brackets. They have made claims that these bracket systems are faster, less painful and produce better results. My humble opinion is that this is all commercial hype. (There is another name for it that starts with a B and ends with a T but this blog is rated G). I have used three of the major manufacturer's brackets over the last 5 years and am convinced, that in my office, the traditional non-ligating bracket is a better system. I see less breakage, no time difference, a better comfort level and better finished cases than I do with the "new and improved" bracket systems.
My thought on this matter is that the secret is in the orthodontic wire. The teeth go where the wire takes them, not the bracket. Without getting into the technical side of things, teeth don't know what they are wearing. They just react to forces. And the particular forces that you place through the wire are going to dictate the tooth movement no matter what bracket system you use. With the new advanced wires that we are using, the forces are lighter and continuous. This makes a big difference in tooth movement.
On a more cynical level, the new brackets are 10 times more expensive. If I am an orthodontic company trying to keep my bottom line above water in these tough economic times and I am seeing a 7-10% reduction in the total number of brackets sold, how am I going to make up the difference? Push a more expensive bracket. I hope that my paranoia is unfounded but the thought has occurred to me.....

I'll sign a waiver....take his braces off!

2008-07-10T21:21:00.005-04:00

I had a young man come in today whose treatment progress has been at a standstill because he won't wear his rubber bands. His father came back with him and told me that he would sign a waiver to take the braces off because the son "just would not listen to him." An appointment was then made to have his appliances removed. Treatment was not close to being finished but the appointment was made anyway.
When did it occur that the inmates were running the asylum? I hate to date myself but if had tried to waste my parent's good money and jeopardize my dental health, there would have been severe consequences. Namely, my father would have put me through a wall. (They didn't worry about HRS or Child Services back then.) It was called discipline and obeying your parents. Of course, being the wiser and more experienced in knowing what was good for me, they ran the show and made the ultimate decisions for my welfare. I'm so glad they did!

When are my braces coming off??

2008-07-08T19:05:00.003-04:00

If I could charge a dollar more for every time I hear that question, I could have retired long ago.

Contrary to popular patient belief, your treatment should not be terminated (braces should not come off) due to Senior pictures, proms, homecomings, birthdays, weddings, religious ceremonies, vacations, modeling pictures, hot dates, requests by significant others, etc., etc. Your braces should be removed when your orthodontist thinks that your teeth and jaws are aligned correctly and everything is as he/she wants it. This is a professional judgement made by a well-educated and clinically experienced doctor. (Not by your next door neighbor or best friend who probably does not know the difference between an end-on Class II and a high angle Class III but is giving you advice on something that will have a life long effect on your health and looks.)
Trust me. I know when it is time for your braces to come off. Don't get me wrong. I feel for you if you have to have them on one more time for pictures or special occasion. But think of all the special occasions you will have with a great smile and healthy teeth if you have a little more patience!

And by the way, if you ask me that question and you got your braces three months ago, or if you have been in treatment forever and you don't brush, wear your elastics and don't show up for appointments, I will charge you that dollar for asking me! Heck, I might charge you two!!

My dog ate my retainers....

2008-07-07T22:55:00.003-04:00

Let's start at the end of treatment. Your braces are finally off and you have a new retainer to wear. Instructions are given for their wear and care and off you go. You come back 6 weeks later and your teeth are going crooked. Mom swears that you have been wearing them (because you told her you did) and she is not a happy camper. Wha' happened?! Let's be honest. You have not been wearing them exactly as your orthodontist told you. Either that or you lost them at your local fast food shop, the dog ate them or you melted them in the dryer when you left them in your jeans pocket.
Face it-teeth do not move if you wear your retainers as ordered!! Period!! Have some self-discipline and wear them. Save you, your parents and your orthodontist some grief by taking good care of the appliances that are going to keep your smile intact.
Mom-Princess is not wearing her retainers if her teeth are getting crooked. If she says the retainers don't fit, it is because she didn't wear them adequately and the teeth moved. Believe me, the retainer fit on the day she got them or she would have complained then!
So wear your retainers as you were told and everyone will be happy! Don't blow it!