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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: InterdisciplinaryTreatment 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