Thursday, September 23, 2010

Orthodontists, beware

Hey all,

I am at a meeting today, so I got a ghost writer to post today. He is a little ticked, to say the least.

I have been biting my tongue long enough. I want to preface this blog by saying that, if you are an orthodontist, I would love your feedback. I would love to hear about the reasons you cannot accomplish what you know is a successful case. In fact, I would love to hear anything from you because another issue I have with you is that you are fairly poor communicators.

Ouch! I am not starting out very friendly, am I?


I don't know a thing about how to move teeth. I don't know the stresses that are on orthodontists. I don't know the limitations to moving teeth. I don't know anything. I know what a Bolton's discrepancy is, but that'ss about it.

But I do know is what a good bite is supposed to look like. It kind of looks like Class I. ONE. It is the first bite classification that we learn in dental school.
It is what we learned at the first day of the first continuum at the Pankey Institute. Mid-lines lining up. About 30-40% overbite. Anteriors actually touching. Canines lining up so that when the jaw moves to the left or right, the canines guide the occlusion. I think this is called CANINE GUIDANCE. What I also know that when someone's teeth are in a good class I occlusion, their teeth last longer.

This is something I know because I have seen it. I know from looking at 5,000 65-year-olds with all their teeth. I know that having a good bite will make teeth last longer with less dentistry. Simple.

So why is it that only about 40% of my patients come back from the orthodontist with a bite I can be proud of? And I feel like I refer to really good orthodontists!

Here is my deal. Regardless of what the orthodontists think, WE, the general dentists, are responsible for this patient. They see this patient for 2 years but we have to see them for the rest of their lives.

While I can't speak for the rest of the general dentists, I feel responsible when I refer someone out. It stands to reason that, when I give a patient a recommendation to an orthodontist, I am somewhat responsible for the result.

So when then come back to me and their front teeth don't touch, I feel responsible.
When they come back with a 10% overbite and they don't have canine guidance, I feel responsible. All because I know the long-term implications to a bite that doesn't have canine rise.

Before I forget, I am not sending you a patient of mine to straighten their teeth. Straight teeth might be what my patients and their parents are looking for, but not me. I have seen tons of people with perfect bites that have crowded front teeth. And these people are far better off dentally/occlusally than the straight-toothed person that has no bite to lock into.

I live and die by my results. I want my patient to be happy with my dental work. But really I do dentistry to make me happy. Let me explain.

My patient doesn't know anything about dentistry except what they can see and feel. They can feel a shot, whether it hurts or doesn't. They can see if a filling looks good or not, and if it is a "white filling." They know if it hurts afterwards, and if it looks okay, they are thrilled. That is what the patient knows.

Me? I know about the decay. I know about the bonding materials that will make this thing last longer and not have any sensitivity. I know the composite materials I put in this restoration. I know the matrix bands I use. I know anatomy and making this thing look like a tooth. And I try to do this at a fair price.

When the filling looks good, and I know all everything that went into it, and I call them the next day and it doesn't hurt them, I know they are going to be thrilled. But most importantly, I'm thrilled.

I can't imagine that you, as an orthodontist, can't see what I see. Are you seeing this kid in this end-to-end occlusion and resting well at night? Are you thrilled with this result?

If not, then what the hell are you doing sending them back to me? And you send them back to me with a form letter with your signature on it. "Looks great, great kid. Thanks for your referral."

NO, it doesn't. I am supposed to tell you that it doesn't look great?!?! You should know.

If it doesn't look good, you know, and I know it. Why do you send that letter? It should be a hand-written letter telling me why this case looks the way it does. It could tell me the issues you were having. It could tell me about this kid's non-compliance. It could mention that the teeth, regardless of the force, would not move. It could tell me that the narrow palate was too much to compensate for. It could tell me about how the angulation of the mandible was a crutch that you couldn't overcome. But don't insult me by telling me the result was great.

The worst part of it is the money. Not that I think that it is not worth it. I am not talking about how much money it costs. I am talking about what some parents have to go through to afford orthodontics for their children. They go into debt to have their kids in braces. There are parents who can't afford it but still do what is ever in their power to pay for their kid to go into braces. They take money out of their 401k. They keep buying their clunker cars. They don't go on vacations. And all so they can do for their kids what they think is best for them.

This is very hard for me to swallow. I take this very personally. I know my patients and, sometimes, I know their struggles. Sometimes I will do things for a reduced price in order to make it more feasible for them to afford it.

Then, when it is all said and done, I have to go out in the reception area and lie to them? I go out and they say, "She got her braces off. Doesn't it look great?"
And I smile and say, "They sure are straight."

We both know that she has non-working interferences, she is end-to-end on her molars, and her anterior teeth don't touch. But they sure are straight.

Is he alone on this island? Is he the only one frustrated? I don't want this to be an orthodontist-bashing session; I want it to be constructive. I do have to agree with him on some of this. I agree that communication has to improve, but I think it must start with him.

You can comment now. But remember, no ortho-bashing. Just tell us what is on your mind.

Have a great weekend,

P.S. If you are an orthodontist, take a deep breath, marinate on this. Do not spit your venom yet. He is not saying that you don't care about all of the things he cares about. He knows you are passionate about your work. He knows you care about the money and how the parents have to sacrifice to have the work done. He knows you are good at what you do.

Think about this being the first step in treating your patients better.


Tom Gilbert said...

Nice job ghost writer! You have hit the nail on the head of a topic that has frustrated me more and more when I see my patients after they are supposedly done with ortho. I am comonly seeing this anterior open bite on patients that I don't see any reason that there should be open bite because they didn't have it when they started. The other thing that honks me off is that the parents are not aware of any limitations in the treatment. They have no idea just that the teeth are straight. It is uncomfortable to suggest to the parent that there is a problem with the occlusion and the ortho is already removed. I have addressed this with an orthodontist who I don't refer to and he had no reason for this error and how he didn't communicate it to the parent. That is why I don't refer to him. I don't think anyone should be surprised that so many general dentists are taking ortho ce to learn how to do this because maybe the technique is not the difficult but maybe caring to do the right thing is the difficult part.

Anonymous said...

Ghost Writer,
I am not a dentist, but as one who appreciates a job done right in any circumstance, I hear you.

If you were my dentist, and that passionate about the life cycle of your patients dental care, I would encourage (and I mean encourage with the connotation of a friend who believes strongly in another friend; desires nothing but the type of fulfillment that comes from one's feeling of your fulfillment, the truest and most proper dental care one would hope to receive) you to get the necessary training to do the orthodontic work yourself. Yes, there could be a financial benefit to keeping the work in-house, but it is obvious that you are not all about the money. We've all heard the phrase, "if you want a job done right, you have to do it yourself." Unfortunately, the entire population we live amongst does not hold those values as closely as we all need everyone there are times you just have to do it yourself.

Think about the possibilities. Maybe this causes an expansion to your practice. Maybe you then have the opportunity to bring a young dentist in with the same kind of passion for the work that you have. Maybe you make an impact on that person's life because your passion spills over onto those around you and you end up as cause in another person's growth and development. And what you've been desiring all along...the best care you and those on your team can provide to those of us who need, not just decent, but great dental care.

Anonymous said...

Amen. I also have a problem with teeth coming back with all the decalcifications, decay and holes.

Edward Logan said...

I think this is good for all general dentists to read, so that we all realize that we are not on an island alone when it comes to this dilemma. Maybe we can help by being the ones who open the line of communication and suggest to the orthodontists that certain cases simply are not ideal.

Anonymous said...

I am a new dentist, having graduated this May. This post has inspired me to try and communicate with the orthodontists in my town. I've seen one patient with a few 8 mm dehiscenses, whose teeth were clearly just transported out of the bone. It would be impossible for this to be missed when the brackets were removed, but the patient (2 months post-ortho) presents to me with an esthetic complaint. As a new dentist, I suggested that this was a result of straightening teeth and maybe we could send her to a periodontist to try and cover up those roots. You can guess what her Dad had to say about that...

Another patient presented with 0.5mm overbite and almost end to end, and now wants to have some fixed prosth up front for a missing #8 and undersized laterals. Oh yea and could I add some incisal length to those? Yikes! They didn't tell us about this stuff in dental school.

It's true that the general dentist is responsible for the patient before, during and long after ortho. Thanks for the post and underscoring the importance of holding specialists accountable for their work. If we don't let them know the problems we're seeing, no one will.

Brazilian Dentist said...

Very good article. The relation between patient and dentist must be very honest.


PLEASE NOTE: When commenting on this blog, you are affirming that any and all statements, and parts thereof, that you post on “The Daily Grind” (the blog) are your own.

The statements expressed on this blog to include the bloggers postings do not necessarily reflect the opinions of the Academy of General Dentistry (AGD), nor do they imply endorsement by the AGD.