Download Establishing realistic treatment objectives for adult patients

1/20/2014
“Establishing realistic treatment objectives for adult patients”
A few “warm-up” questions & a “do-it-yourself” survey:
Goals of presentation
I.
Describe uniqueness of adult ortho patients
II. Clarify the meaning of “realistic treatment objectives”
for 21st century orthodontics
III. Describe a standardized method of communication that
helps patients and providers achieve their objectives
IV. Reduce risks of adverse legal action and at the same
time enhance internal marketing
2. In your experience with adult IDT patients which
of the following interdisciplinary treatments result
in the least predictable outcomes?
a)
b)
c)
d)
e)
Orthodontics and restorative
Orthodontics and Orthognathic surgery
Orthodontics and periodontics
Orthodontics, periodontics, & estorative
Orthodontics, periodontics, restorative and
orthognathic surgery
f) Any combination of the above and TMJ symptoms
at treatment start
4. Which of the following technologic advances have
allowed reduction in treatment limitations of your
adult IDT patients?
a) Additional diagnostic information from 3-D cone beam
radiographic assessment
b) The use of removable aligners (Invisalign, Clear Choice,
etc.)
c) Utilization of TADS to provide more predictable anchorage
and control
d) Utilization of methods of accelerated tooth movement
(Wilkodontics, Surg Facilitated Ortho Tx, etc.)
e) IDT study club meetings in which each specialty is
represented
f) Other, Please
list_____________________________________________
1. In your experience please rate, in order of importance (1—
being most important), which of the following most
frequently limits the achievement of the treatment goals in
adults patients?
( ) IDT teamwork failure of communication
( ) Pre-existing periodontal disease
( ) Cost of the Interdisciplinary treatment plan-- unable to be
completed
( ) Lack of patient compliance with treatment (missed appointments,
Oral Hygiene, lack of elastic wear, etc.)
( ) Underlying surgical skeletal imbalance and Orthognathic surgery is
denied by insur. or refused by pt.
( ) Patient treatment expectation beyond what is feasible
( ) Other_________________________________________
3. For your answer to question #2, what do you
think is the most likely cause of outcome
deficiency?
a) Lack of IDT teamwork among doctors
b) Lack of IDT teamwork among office staff and treatment
coordinators
c) Frequency of unexpected complications
d) Lack of insurance coverage resulting in treatment
compromises
e) Patient “burn-out” as they go through the treatment process
f) Other___________________________________
5. In your treatment of complex, IDT patients, what specific
measures have you taken to minimize limitations of
treatment
outcomes?_______________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Survey answers from experienced orthodontist at end of presentation .
1
1/20/2014
“Perio and
too old for
treatment”
Cases and concepts
“Only way to
treat is w jaw
surgery”
Significant variation in adults
challenges “adult label”
Previous tx,
but unhappy!
Adult orthodontic patients— 19-80 yrs.
Age/social factors
1.
2.
3.
4.
19-29 still in transition to independence
30-39 pressure, pregnancy, stress, $$$, TMJ
40-49 time for self; before it’s too late
50-65 use insurance, prepare for retirement,
other health issues— “stay younger longer”
5. 65-80 preserve and restore; role of implants!
“Two stage
surgery? Cost
and
coverage?”
“25 and
considering
dentures”
Biologic System/Patient
Intrinsic factors
Doctors/Staff/
IDT Team
Biologic
System/Patient
•
•
•
•
•
•
•
Insurance/
Legal
System
Periodontal
Skeletal
Dental
Neuromuscular
Psychological
Financial—2007—2014 and beyond
Capacity to commit to tx duration & plan
10
Case #1--70 y old Female:
What is her chief concern? What are her kids chief concern?
“Establishing realistic treatment objectives for adult patients”
Goals of presentation ”
I.
Describe uniqueness of adult ortho patients
II. Clarify the meaning of “realistic treatment
objectives” for 21st century orthodontics
2
1/20/2014
What is your/your patient’s concept of
acceptable treatment goals?
F unction (Optimal)
R2 eliable/Realistic
E2 sthetic/Economic
S2 tability/Satisfaction
H ealth--dental/physical/mental
Who determines which goal is prioritized?
Examples
1. Is function more important than facial esthetics?
i. e. canine rise vs. flattened upper lip and
accelerated facial “aging?”
2. Is total cost of treatment a consideration—eg.
missing laterals—space opening or closure?
3. Surgical risks, costs, coverage and borderline
surgical cases?
4. Is it acceptable to push boundaries of stability to
achieve a more esthetic outcome?
For adult orthodontic patients, realistic
treatment objectives…..
1. …are determined through a thorough diagnostic
process and thoughtful conversation;
2. …most important objectives are the primary
treatment goals of the patient;
3. …are sensitive to the age of the patient and
realizes that ideal goals that are possible may
not be desirable;
4. …more that 75% of the time require
interdisciplinary teamwork to achieve reliable
outcomes.
Template guided diagnosis and treatment planning—
Chapter 24
16
1Creating referrals
Goals of presentation
8
Establishing realistic treatment objectives for adult patients
2
Initial Phone Contact
Feedback review
I.
Describe uniqueness of adult ortho patients
II.
Clarify the meaning of “realistic treatment objectives” for 21st
century orthodontics
III. Describe a method of communication that helps
patients and providers achieve their objectives
8 Step Discipline®
Completion Summary
7
System of operation
Framework for patient care
Mechanism for providing consistency
Internal marketing/External Marketing
Medicolegal protection
System in which all senior staff can be TC ‘s
3
First Dr.
meeting
4
6 Retention/Stabilization Rpt.
Tx. Conference Rpt.
5
Progress Rpt.
3
1/20/2014
The 8 Step Discipline
The 8 Step Discipline
Step 2: First Office Contact
Step 4: Tx Planning Conference/*Report
Concept: Good “first impression” is essential.
Trust can be gained or lost during the telephone
interview.
Check List: Will you…
4. Have mission statement reflected in the
receptionist’s skills? Is the practice mission part of
“shared vision” of doctors and staff?
5. Follow-up with welcome letter, brochure, etc.? Is
Concept: Presentation of plan with options and empathy is
critical. Try to provide a meaningful discretionary
experience.
Check List: Will you…(Keep good practice stats.)
9. Review records?
10. Illustrate possible outcomes?
11. Review consent form?
12. Tx. Plan report to DDS & patient?
your welcome genuine and shared by all of the staff?
Surgical Orthodontic Treatment
Adult Orthodontic Treatment (Ages 20 – 75)
Why is jaw surgery part of some orthodontic treatment plans?
The “facial form” is part of a complex genetic interaction of teeth and bones. In about 15-20% of the adult patients who seek orthodontic correction, the
jaw structure needs to be corrected. Therefore, the combined treatment of orthodontics and orthognathic surgery is required to achieve an ideal bite.
Yes, the jaw structure of adults is no longer growing which limits correction of certain types of bite problems. Additionally, adults are more at risk for
periodontal problems and adults have more missing and damaged teeth. However, adult orthodontic patients cooperate better than their adolescent
counter-parts and as a result their time in orthodontic treatment is frequently shorter.
Before
After
Is there anything special about adult orthodontic treatment?
Lower Jaw Excess
Case #5: Skel Class III, spacing, impacted #11, perio, + attitude
Missing Posterior Teeth
Before
Missing posterior teeth:
Afterexcess with upper jaw
Lower jaw
deficiency:
 In this jaw imbalance, the lower jaw appears too
large to match the upper
 There is frequently an “underbite” and incisor
trauma
 There is frequently upper jaw width deficiency
and crowding
 Braces usually precede the jaw surgery by 12 to
18 months to prepare tooth position to match
the planned surgical correction of the jaw
relationship (see milestones)
 Loss of molars and congentially absent posterior
teeth contribute to jaw “over closure”
 Jaw over closure is also called “bite collapse” and
can accelerate progressive tooth loss through
incisor trauma which is secondary to over closure
and to an anterior deep bite
 The most predictable correction is accomplished
through:
o Reversal of the “bite collapse” with tooth
movement (orthodontic treatment)
o Periodontal re-evaluation of tissue response
o Reopen spaces in preparation for
restoration
o Stabilization with tooth replacement—
implant if possible to preserve bone and to
reduce crown preparation
Severe Jaw / Chin Deficiency
Before
After
Severe jaw and chin deficiency:
InterdisciplinaryTreatment
This jaw growth imbalance, gives the
Before
Interdisciplinary dentofacial therapy (IDT):
80% of adult patients require dental teamwork:
 Tooth loss and wear allow dental migration
 Dental arch collapse requires “reversal” (uprighting)
through orthodontic treatment
 If adequate bone exists—implants will replace roots
and crowns will replace the top portion of the tooth
 Restored function, health and esthetics are
achieved
 Dentofacial “aging” is reversed
Musich & Busch DDS, Ltd. 2006 ©
After
appearance of little or no chin
 The bite is characterized by a large overjet and
frequent upper and lower crowding
 “Late onset” lower jaw deficiency may be related
to degenerative joint disease
 Braces are needed to prepare the teeth for
appropriate surgical correction of the jaws
 Braces usually precede the jaw surgery by 12 to
18 months to prepare tooth position to match
the planned surgical correction of the jaw
relationship (see milestones)
22
Musich & Busch DDS, Ltd. 2006 ©
The 8 Step Discipline
Step 5: Progress Conference/ Report (JCO<10%)
Concept: Patients & parents are curious about
progress and have questions. This conference
gives you chance to inform, & build trust. Reduce
risk management issues.
Check List: Will you…
13. Take a panoramic x-ray + other needed records (?) about twothirds of the way through treatment?
14. Send a Progress Report to the DDS (including x-ray) with a copy
to the patient/parent?
15. Have educational materials to help patients understand options such as
implants, plasties, exposures, gingival grafts, Class III growth & jaw
surgery, verify restorative plan and future steps.
4
1/20/2014
The 8 Step Discipline
Step 6: Retention/Stabilization: Report-JCO<16%
Concept: Formal conference to review original
goals and the emphasize the importance of “after
care”(retention). Also, discuss case limitations.
Check List: Will you…
16. Have patients complete a questionnaire assessing
their orthodontic experience?
17. Provide the patient/parent with a post-treatment
report with a copy to their dentist?
18. Celebrate the patient’s accomplishment & provide
before and after photos?
Long-term fixed retainers are not
without problems!
“Establishing realistic treatment objectives for adult patients”
Goals of presentation



Describe uniqueness of adult ortho patients
Clarify the meaning of “realistic treatment objectives” for
21st century orthodontics
Describe a standardized method of communication that
helps patients and providers achieve their objectives
10 important tips from medical/defense attorneys:
1. Be selective in taking on new patients (Step #1; #2; #3)
2. Good communication—informed consent & tx plan;
billing & finances (Step #2; #3; #4; #5: #6)
3. Document good care provided & comm w other providers (#4;#5:#6)
4. ALWAYS document informed pt refusals in detail
5. Do not allow patients to dictate care
IV. Reduce risks of adverse legal action while
enhancing internal marketing
1.
5
1/20/2014
10 important tips from medical/defense attorneys:
(continued)
Case #5: Skel Class III, spacing, impacted #11, perio, + attitude
6. Do not criticize the care of another provider to the patient
7. Have a good system of standardized practices for tx plan,
progress repts, emergency, reminders, etc. (All of 8 Step)
8. Acknowledge limitations to your expertise; refer to others when
needed.
9. Treat staff and relatives in same manner as all other pts. T
10. Maintain a team approach and good working relationship w
other providers (#1, #2, #3—plus study club effort)
32
Achieving Objectives: Successes or Failures?
Note relative stability in 15 year follow-up
“…more logical to categorize patients as ‘responders (R)
or non-responders (NR).’”
In addition, post-treatment relapse patients should be
categorized as “adapters (A) and non-adapters (NA).”
Bell shaped curve—most favorable A and R at one end
and most unfavorable NR and NA at the other end of
a normal distribution curve.
Ackerman, JL
34
Variables that made this person a non-respondersmoker, perio disease susceptibility, poor mechanics, no progress rpt
Outcome:
• All upper incisors were extracted
• Implants needed to replace
• $350,000 insurance settlement
• License suspended
6