Patient Information Archives - The Ortho Cosmos

Rejecting Facemask Fundamentalism

August 9, 2017 by Scott Frey 2 Comments

Facemask Fundamentalism

It has been well established that the early correction of anterior crossbites is beneficial for jaw development¹ so certainly interceptive treatment to resolve crossbites is advisable. However, there seems to be significant confusion in the orthodontic community about what exactly people are achieving with certain treatment modalities.

I continue to be astonished by the persistent dogma that reverse-pull facemasks “protract the maxilla” because a comprehensive and unbiased examination of scientific evidence reveals this to be little more than wishful thinking.

There is zero evidence of any anterior displacement relative to controls of actual skeletal structures, such as the zygoma, pyriform aperture, etc. with facemask therapy.^2,3,4 The sutural strains produced (with or without any expansion protocol) with a facemask are several hundred fold lower than the frost thresholds required for any orthopedic effect based on finite element analysis.⁵ Why a dentoalveolar landmark like A-point, which is known to remodel significantly in response to both retraction and protraction of the dentition, has served as the basis for assess the “skeletal response” in so many papers makes very little sense.
The counterclockwise rotation of the maxillary occlusal plane is a hallmark of dental movement and not an orthopedic effect. The data on Bone Anchored Maxillary Protraction (with infrazygomatic plates) resoundingly confirmed Ricketts proposal that the center of resistance for the maxillary bone (not the maxillary dentition) is at the pterygoid plates. Thus, true orthopedic traction of the maxilla will exhibit a clockwise rotation and not the counterclockwise rotation that we try to mitigate during facemask therapy.⁶
Although palatal TADs due to their easy and predictability of placement have been proposed as an alternative means of bone-anchorage, their addition does not improve the effects on the maxilla. In fact, the palatal TADs actually seem to reduce the effects of maxillary traction on A point, backward rotation of the mandible, and any positive dental “side effects” in the maxillary arch.⁷ Anchoring the dentition to TADs is a strategy that is better suited for hyperdivergent class 3 patients where vertical side effects may be less desirable, but it does not translate into an improved effect on maxillary hypoplasia.

The bottom line is that the clinical effectiveness of a facemask is entirely due to dentoalveolar changes and an improvement in sagittal position of mandible. There is no effect on mid-face, and if that were required then a surgical procedure or bone anchored maxillary protraction should be explored as an option for that patient (though better long term data on BAMP is still needed).

Facemasks are certainly more cost effective to use than many alternatives; however, the same basic outcome that you are prescribing with a facemask can be achieved just as effectively using appliances that facilitate better compliance and are less traumatic to patients.

References:

Tollaro I, Baccetti T, Franchi L. Craniofacial changes induced by early functional treatment of Class III malocclusion. AJODO 1996;109(3):310–8.
Pangrazio-Kulbersh V, Berger J, Kersten G. Effects of protraction mechanics on the midface. AJODO 1998;114(5):484–91.
Arman A. Evaluation of maxillary protraction and fixed appliance therapy in Class III patients. Eur J Orthod 2006;28(4):383–92.
Masucci C, Franchi L, Defraia E, Mucedero M, Cozza P, Baccetti T. Stability of rapid maxillary expansion and facemask therapy: A long-term controlled study. AJODO 2011;140(4):493–500.
Holberg C, Mahaini L, Rudzki I. Analysis of Sutural Strain in Maxillary Protraction Therapy. Angle Orthod 2007;77(4):586–94.
Nguyen, Tung, et al. “Three-dimensional assessment of maxillary changes associated with bone anchored maxillary protraction.” American Journal of Orthodontics and Dentofacial Orthopedics 140.6 (2011): 790-798.
Ngan, Peter, et al. “Comparison of two maxillary protraction protocols: tooth-borne versus bone-anchored protraction facemask treatment.” Progress in orthodontics 16.1 (2015): 26.

Trouble with Transparency Under the Sunshine Act

June 7, 2017 by Scott Frey Leave a Comment

Time for Transparency

In order for fellow orthodontists, as well as the general public, to adequately assess for conflicts of interest and general bias, all monetary contributions from companies and organizations made either directly or indirectly to doctors must be publicly disclosed in some fashion. The Physician Payments Sunshine Act, passed in 2010, was an attempt to provide greater transparency; however, the law doesn’t adequately cover all streams of income that can flow from manufacturers and distributors. This means that many doctors are on the honor system to provide this information and it allows for some to keep the origins of their income concealed.

Each year, the previous year’s data for Open Payments is submitted from manufacturers by March 31st, and they allow a 45 day process for dispute and review before the information is published to the Open Payments Database on June 30th. If you are interested, these payments made directly to doctors can be looked up for anyone you are curious about using the Open Payments Data Search Engine. Our concern however are the payments that are going unreported and do not appear on the site.

While the Sunshine Act requires medical product manufacturers to disclose to the Centers for Medicare and Medicaid Services (CMS) any payments or other transfers of value made to physicians or teaching hospitals, transfers of value that are made to a third party that isn’t a doctor or teaching hospital do not need to be disclosed creating the potential for abuse.

Clever individuals and groups are able to essentially ‘launder’ money provided by companies through educational organizations, industry magazines, educational grants for meetings or forums, vendor fees at the same meetings, internet groups, etc. because these entities do not have reporting requirements under Sunshine regardless of whether or not the entities are owned by a doctor or a group of doctors. In the instances where these entities are doctor-controlled, once the money goes in they are able to reroute the funds to themselves, pay it out to affiliated doctors or speakers, or pass the funds between other organizations and groups that are aligned with their interests and working towards the same end. Furthermore, preferred pricing on products extended to key accounts are not adequately disclosed.

Naturally, we are beginning to see more and more organizations like this popping up with affiliated doctors organizing themselves into what can only be described as “mutual admiration societies” to help establish credibility and coordinate promotional efforts. Since the industry money is being ‘cleaned’ by passing it through or amongst these entities first, these doctors can also technically deny that they receive compensation from these companies, and without them opening their books completely it essentially impossible to distinguish funds that are provided by manufacturers from those that are earned by other means (ticket sales, membership fees, etc.). They are basically on the honor system to disclose any potential conflicts of interest.

There are plenty of other forms of bias out there that can cloud research and recommendations, but financial conflicts are an extremely important disclosure to make. The dilemma we now face as a specialty is that we simply may not be able to get straight answers from the types of entities we have outlined here on the sources and extent industry financing the receive. Therefore, we must consider the information flowing from these organizations, and their affiliated doctors, with increased skepticism and challenge.

In the interests of greater transparency, we list all disclosures of any financial relationships our doctors have either directly or indirectly with companies or any of the entities in question on our Speakers page under the About tab.

12 Months the New Target for Treatment Time

May 3, 2017 by Scott Frey 2 Comments

The New Normal

In the age of instant gratification, parents and patients (and doctors) expect orthodontic treatment to be far more efficient than the traditional 24mo estimates of generations past. A recent survey conducted regarding their perceptions of orthodontic treatment found that the majority of patients (74% of adolescents and 59.2% of adults) felt that treatment should be completed 12 months or less.

Patient Treatment Time Expectations — *Uribe F, 2014.*

Understanding patients’ perceptions toward treatment is important because when treatment length is significantly out of step with their expectations this will have an impact on both case acceptance and patient compliance. Adolescents in particular had strong negative opinions in the survey about treatment going longer.

Our failure as a specialty to recognize this shift in expectations has left a vacuum now filled with gimmicks like 6month smiles and “Fast Braces” where patients are considering paying for inferior results simply to avoid a what they think will be a 24 month “sentence.” Shorter treatment times don’t have mean cutting corners, and it is about time that we start communicating what we have to offer more effectively to the public.

Given the advances in technology, patients’ perceptions about how long treatment should take with decent compliance are actually pretty spot on. My target treatment time for all patients, in Invisalign or braces, is now 12 months. This is 100% achievable with Invisalign or with precision passive self-ligating braces in combination with digital technology.

Here is a treatment summary from my last 10 removals from braces and Invisalign showing total visits, clinical minutes, and months in treatment. The Invisalign group exhibited a slightly greater degree of difficulty and had a greater proportion of adult patients, but for both groups the average treatment time was right around a year.

I don’t really see many Class I mild crowding patients, so this wasn’t a slouch sample. Below is a representative case from the sample of a patient treated with fixed appliances. The patient was a 13yo Female. Treatment was completed in 11mo, 3mo with Carriere Motion Appliance for unilateral class II, followed by 8mo in SLX brackets.

Here is a representative case from the sample of a patient treated with Invisalign. The patient was a 39yo Female. Treatment completed in 15mo, with weekly aligner changes.

I think it is time we start embracing 12 months as the new normal for the targeted treatment time for our patients. Given the strains on motivation and the oral environment that occur with extended treatment times, delivering excellent results as efficiently as possible is the right thing to do for our patients. The concern that I hear doctors voice about people on flexible financial contracts skipping town after treatment is a red herring and really isn’t a reason not to do our best.

Are Passive Self-Ligating Braces Really Faster?

May 2, 2017 by Scott Frey Leave a Comment

Maximizing the Working Properties of Orthodontic Archwires

Long before there was the Damon System, which brought the idea of self-ligating braces and faster treatment into the mainstream, George & Fred Schudy sought to maximize light forces and favorable wire properties during initial alignment¹. They realized that while the greater range and lighter forces offered by nickel titanium archwires provide significant treatment advantages, the wires alone were only a partial step forward toward increased efficiency. Their conclusion was that we must consider basic changes to the bracket systems themselves.

The Schudy article established 3 criteria that appliances must leverage to maximize the working properties of orthodontic wires:

Increasing interbracket distance
Small, flexible initial archwires
As much intra-bracket play around initial wires as possible

A bracket system that meets these requirements would maximize the expression of desirable wire characteristics and increase alignment efficiency.

Passive Self-Ligation Increases Treatment Speed?

The findings in this study that intrabracket space has nearly as much impact on the clinical workings of an orthodontic appliance as does interbracket distance is a particularly important discovery. However, despite acknowledging that intrabracket space also reduces friction between the bracket and the wire, making leveling faster and easier, they found it difficult to resolve the puzzle between increased intrabracket play and regaining control using traditional edgewise appliances¹. Their solution to this paradox at the time was a bimetric appliance utilizing single-wing brackets and differential slot sizing; however, passive self-ligating brackets now provide a particularly elegant solution to this dilemma.

The use of a passive self-ligating brackets rather than traditional elastic or steel ligation, allows doctors to leverage the benefits of maximal intrabracket space during initial alignment, while still being able to gain control during the final stages of treatment. The significance of this intrabracket space is illustrated in a study conducted at the University of Connecticut², where you can see that with a 1mm in-out discrepancy passive self-ligating brackets remain inactive until an 020 wire is placed.

First Order Bracket Play — *Holbert MB, 2008.*

Naturally, the differences between the various bracket types become less apparent as these 1st order discrepancies are made more severe and as wire diameter increases, but the sweet spot for intrabracket space is simply wider for passive self-ligating braces.

On the flip side, you can have too much intrabracket space. Schudy’s paper outlined their concerns about a failure to adequately fill the bracket slot late in treatment resulting in the expenditure of needless effort and time in the form of repeatedly removing arch wires to place “artistic bends.” This has certainly been the case as of late with some passive self-ligating systems.

But Muh Meta Analysis

Well haven’t systematic reviews and meta-analyses shown no difference with traditional braces? I’m glad you bring that up. These flippant references to systematic reviews or meta-analyses that people love to toss around are not an argument on their own. No one should put their faith completely in the reviewers to properly audit and analyze papers for them. Always double check their assumptions and methods to rule out the possibility of confirmation bias.

The major irony about the Chen article³ being so frequently cited to support the idea passive self-ligating brackets perform no differently than traditional braces is that it is actually an indictment against their own argument.

When we take the time to examine their analysis of the differences in total treatment time between self-ligating and traditional braces, we see that they identified three randomized control trials meeting their standards for inclusion in their review. Both the Eberting and the Harradine papers, show a clear reduction in total treatment time with self-ligating braces; however, the inclusion of the Hamilton paper nullifies this result.

Total Treatment Time Meta-Analysis — *Chen et al, 2010.*

I tracked down all three of these papers to look at their methodology, and what I found in the Hamilton paper was puzzling. Although they had a sufficient sample size, they were comparing active self-ligating brackets and single wing traditional braces instead of comparing passive self-ligating braces and traditional twins. Furthermore, the authors stated that “a number of” patients in both groups had Phase 1 treatment with a Herbst or Pendulum appliance, which certainly had an effect on total treatment time since both groups in the Hamilton paper had far shorter treatment times than either of the other papers. This is a big no no. If you are going to pool data together for a statistical analysis, you can’t combine apples and oranges. If the authors were doing their job, they would have excluded the Hamilton paper and their conclusions would show a clear advantage for passive self-ligating braces when it comes to treatment time.

Getting Down to Brass Tacks

Passive self-ligation certainly provides an elegant solution to the dilemma of intrabracket space, but it is not the only treatment approach that takes advantage of these principles. Simply put, we must apply the lessons of Schudy’s paper, and adapt our fixed appliances and our biomechanics to increase treatment efficiency by striking a balance between efficient alignment and controlled finishing. The one thing orthodontists should not be doing is burying their head in the sand because patients are not looking to spend more time in braces or even any time in braces at all.

References:

Schudy GF, Schudy FF. Intrabracket space and interbracket distance: critical factors in clinical orthodontics. AJODO 1989;96(4):281–94.
Holbert MB. First Order Archwire Deflections: Comparing Conventional, Active Self-Ligating and Passive Self-Ligating Mechanisms. SoDM Masters Theses 2008:171.
Chen SS-H, Greenlee GM, Kim J-E, Smith CL, Huang GJ. Systematic review of self-ligating brackets. AJODO 2010;137(6):726.e1–726.e18.

DIY Dental Monitoring Solution

April 29, 2017 by Scott Frey Leave a Comment

Teleorthodontics for Patients

The Dental Monitoring Software is based on the principle that because patients all carry their smartphones they can update you on their orthodontic progress at any time without having to take time off work or school to come to your office. This is certainly true; however, smartphones already provide this capability without the need for additional software.

There is certainly still value in the 3D monitoring service offered by Dental Monitoring, but you can implement a simple means of photographic patient monitoring today at almost no cost by scheduling FaceTime appointments or by simply having patients send you updates using the camera on their phone. Today we are going to go step by step with how to build a simple remote monitoring system using Google Forms.

Implementing Remote Monitoring

Items Required:

C-shaped cheek retractors (can be bought cheaply on Amazon)
A GSuite account with Google Forms
A designated treatment concierge to review submissions and contact patients
Patients who own smartphones

Step 1: Record Example Photo Monitoring Videos

Record with a team member some example videos that demonstrate exactly treatment progress information should be captured on a smartphone. You should record 3 example videos: one with teeth apart and aligners in, one biting down with aligners removed, and one teeth apart and aligners out. Videos work better than individual photos because data capture is continuous and the video can then be paused during viewing. To capture the videos, the patient can either hold the camera in front of a mirror of have a friend help, and they simply turn their head while keeping the camera still. It helps to keep traction on the cheek retractors with a free hand to visualize the side bite more effectively.

Step 2: Upload Example Videos to GSuite Youtube Account

Once you have your 3 example videos recorded, you will then upload them to your office GSuite account as ‘unlisted’ videos. Unlisted means that the videos do not show in search results and only people with the link are capable of viewing them. You will embed these uploaded videos into your Google Form.

Step 3: Create Google Form

Google forms within GSuite are HIPAA compliant and very easy to use so they are ideal for these purposes. They also allow users to upload files; however, this is limited just to people within the office network at the current time. When they change this feature, it will become even simpler to use for these purposes.

Start by filling in an appropriate title and description for the Photo Monitoring Google Form. In the settings require that an email address be entered and create a short answer section for the patient’s full name. This will allow you to link the survey results with the videos sent from the patient.

Next create a linear scale question allowing the patient to self-assess their level of compliance.

Add a multiple choice question to gather information about the patient’s progress (i.e. is this a routine progress update, did the bite correction with elastics get completed, is something broken or loose, etc.). You can also upload photos to accompany the choices to help guide the patient.

Next enter a text section with written instructions for the patient on how to capture the videos you require to perform remote monitoring of the patient. Below these instructions is where you will embed the videos that you previously uploaded, so your patients have an example of a good video capture.

Currently patients will still have to email you the videos (cannot upload directly to the form if they are not on your office network), so you will need to provide an email address and instructions on where to send the photos following form submission. Under settings you can have a confirmation message appear after submission with this information. I also like to add a message at the end of the form to remind them.

Link the form to a spreadsheet in GSuite and adjust your notifications settings so that your treatment concierge is notified about submissions and is able to contact the patients for follow up.

Once your form is complete you can use a short-link to share with patients on remote monitoring via email or text.

Step 4: Set Up Recurring Emails When Needed

Once your Google Forms are complete you are ready to implement your remote monitoring program to help patients who are traveling, patients in retention, or simply want the convenience of telemedicine. Setting up recurring emails within GSuite by installing any number of plugins from the Google Marketplace is simple and allows you to set it and forget it.

Remotely Monitoring Patients

This do-it-yourself teleorthodontics system is extremely useful for accommodating patients who might find it challenging to come to the office and certainly can make traditional orthodontic care more convenient for all patients. In addition to the simple photo monitoring, I highly recommend that everyone add an appointment code in their practice management software to accommodate FaceTime appointments. Facetime appointments work just like any other appliance check visit, but are simply done using a computer or smartphone in a private area to video conference with the patient.

Once you are up and running with these new appointment codes and systems, the following situations are ideal for offering more convenient options for your patients:

Better communication regarding loose/broken appliances, wire pokes, and other patient concerns so that your team can schedule repair appointments more effectively
Reduced appointments when using appliances that do not require doctor activation (Invisalign, elastic bite correction, jack screw expanders, habit appliances, etc.)
Improved monitoring during retention
Better coordination of care for patients who travel a distance or have challenging schedules

If you happen to be patient reading this article, know that orthodontists are generally a very forward thinking and flexible bunch so even if your doctor hasn’t presented this as an option, I am sure they would be more than happy to accommodate you. Hope you all found this post helpful!

Compliance in Orthodontic Treatment

April 13, 2017 by Sean Holliday Leave a Comment

Orthodontic treatment is not just technical steps and mechanotherapy. It is a human process, where the doctor and team have to leverage human behavior and motivation to gain an orthodontic result. When it comes to treating patients with clear aligner therapy, compliance is a key step for a successful outcome. Even with fixed appliance therapy and “non-compliance” appliances, a patient who follows instructions and proper care of the appliances still needs to be informed on potential ares of friction that may affect their lifestyle and lead to issues with treatment.

Compliance doesn’t just happen, it should be a fostered in our practices. Gaining proper compliance is a system in the office that should follow some basic premises:

People only do what they want to do

Fortunately, we work in an industry where patients elect to see us. Orthodontic treatment is a choice, and that in itself motivates patients to follow the treatment regimen and reach the outcome that is desired. Within the parameters of improving health and esthetics, it’s important to give patients what they are looking to achieve. Do you offer patients the path that they prefer to achieve that outcome?

Set expectations

In order to gain compliance, patients have to understand what they are complying to. Without proper communication and informed decisions, proper implementation can only be wished for. I have found the best way to set expectations is by reviewing a written success agreement. This standardizes what team members discuss with each patient, and is signed by the patient to clearly spell out those is expected to achieve the best outcome.

Difficult actions breed inaction

Better compliance is achieved by offering a path of least resistance. Taking difficult steps to achieve an outcome will lead many to path of discouragement and frustration. By simplifying a process, compliance increases. Keep this in mind when developing your clinical systems and patient instructions. Complicating habits such as aligner wear, oral hygiene and elastics will discourage patients from following the recommended actions. By giving simple instructions and easier steps, you can avoid analysis paralysis.

The power of trust

Gaining influence with patient behavior is best achieved in a relationship built on trust. Human relationships thrive in the presence of trust. This applies to our team members, our significant others, and our patients. When it comes to patients, trust is fostered saying what we do, and doing what we say. For example, if you claim your office runs on time, and you constantly run late, trust is broken and patients will not comply with office requests.

Things get done one step at a time (the Kaizen way)

If you want to achieve something, you have to gain momentum and even small steps help us achieve tremendous things by promoting a philosophy called Kaizen.

All changes, even positive ones, are scary. Attempts to reach goals through radical or revolutionary means often fail because they heighten fear. But the small steps of kaizen disarm the brain’s fear response, stimulating rational thought and creative play.” – One Small Step Can Change Your Life, Robert Mauer, PhD

Setting up systems for patients to take small steps to a successful outcome have been shown to improve productivity and success in achieving changes. Perhaps next time you plan on nurturing patient compliance, you will consider the Kaizen way.

Reward and encourage

Orthodontic treatment is a series of goals and achievements. It is important to acknowledge and congratulate patients of what they have achieved. Humans seek out outside recognition, and rewarding with praise and acknowledgement are very effective drivers to patient motivation.

Compliance cannot be achieved 100% of the time, but without implementing a process to nurture positive behavior, it relies solely on luck and threats. This can lead to anger and disappointment. It is not only important for us doctors to be involved, but encourage team members to be proactive with compliance.

What Patients are Saying About Smile Direct Club

March 25, 2017 by Scott Frey 1 Comment

Innovation that helps expand access to care is a great thing for healthcare, so when I saw Smile Direct Club entering the market I was very intrigued. In theory, mail order aligners and at-home orthodontic treatment has the potential to be helpful to a number of patients who otherwise would not be able to see an orthodontist. However, as is the case in many areas of healthcare, corporate greed can often taint a promising approach to treatment.

The inherent problem with Smile Direct Club is that it is not a doctor run organization; it is owned by Camelot Venture Group (Sharper Image, Lens Express, etc.). Their model is not about patient care, it is about profit, and they have been very successful at lobbying state legislatures to allow them to operate without the same oversight provided by state dental boards who’s mission is the protection of the public. Prospective buyers should treat this like any other medical decision and get multiple opinions. They may find that the local orthodontist they know and trust already offers comparable pricing for limited treatment as well as convenient at-home treatment.

There are certainly patients with minor tooth alignment problems who would be great candidates for this type of care model. However, it is hard to tell whether you are actually a candidate for their treatment because SDC provides a financial incentive for dental professionals to approve their treatments so they can ship cases. Additionally, it is extremely difficult for patients to track down reviews of Smile Direct Club, and when you find one it is hard to rule out whether or not it is a fake review or patient story sponsored by the company. Difficulty in gathering valid feedback from customers may stem from the company’s Terms of Service that requires customers enter into an Arbitration Agreement that covers “any dispute regarding the products and services.”

I thought it would be helpful if I could compile patient reviews of Smile Direct Club to make them easier to find. It took me a while, but I did my best to gather a representative sample of SDC reviews from people who actually appear to be verifiable patients of Smile Direct Club. I was hoping for better, but this is what I found.

Patient Reviews of Smile Direct Club

Read C S.‘s review of SmileDirectClub on Yelp Read Bradley B.‘s review of SmileDirectClub on Yelp

Read Samuel T.‘s review of SmileDirectClub on Yelp Read R O.‘s review of SmileDirectClub on Yelp

Read E C.‘s review of SmileDirectClub on Yelp Read Corie K.‘s review of SmileDirectClub on Yelp

Read Jen M.‘s review of SmileDirectClub on Yelp Read Karlyn B.‘s review of SmileDirectClub on Yelp