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 Over-the-Wires ARCHIVES FOR ALL ISSUES OF

Over The Wires:
A POTPOURRI OF ORTHODONTIC REFLECTIONS,
PERSPECTIVES, POINTERS AND OPINIONS

Ted Rothstein, DDS PhD
Brooklyn Heights
"Nobody does it better."
 Over the Wires is sanctioned by the American Association of Orthodontists
 

 Winter '11, #31 Dental implants treatment sequence Parts 4, 5 and 6 conclusion of treatment sequence done on Dr. Rothstein Part 4  Part 5  Part 6

Spring '10, #30  On May 3, 2010 I will present my work on Orthodontic Jaw Wiring to my colleagues at the meeting of the American Association of
                                      Orthodontists in Washington, DC: [SEE POWERPOINT PRESENTATION. See also: E-Synopsis containing the documents
                                      referred to in the PowerPoint presentation: E-Synopsis

Spring '10, #29    Learn about TMJ check out the simulated real-life films on the normal TMJ and the dysfunctional TMJ and the simple do's and don'ts
                                        that a person with TMJ should adhere to.

Winter '10, #28       Accelerated orthodontic treatment using "Piezocision".

 Winter '10, #27    Airing on YouTube: Placing an archwire on SmartClip braces: Just go "click-click"

 Winter '09, #26   Obstructive Sleep Apnea Surgical Update of the American Association of Oral and Maxillofacial Surgeons (AAOMS)
                            Volume 22,issue 1 December 28, 2009  (7 pages PDF)

 Winter '09, #24

                      Read the article on Small Claims Court that I wrote for the American Journal of Orthodontics in March of '99.

 Winter '08, #23

                     I invited seventy-five Jaw Wiring for Weight Control patients to take a seventy-seven question survey including 1-3Demographics  4-20Background    21-30Safety  31-40Effectiveness
                    41-55Problems  56-73Conclusions    74-77Miscellaneous,   Twenty four patients completed the survey.  SEE THE RESPONSES TO THIS SURVEY
                         The responses can be also be viewed in HTML, and Excel spreadsheet formats:  Responses to survey with links to comments and subtext;  Responses to survey: Excel
                    spreadsheet version with comment and subtexts   The two versions above present the results along with the comments and subtext that were requested in some
                    of the questions, for example, questions: 11, 18, 28, 30, 35, 37, 40, 55, 57,  58, 70, 71, 74 40, 57, 58, and 74 are particularly revealing. 
                    the two version above are more pleasant to look at.

 Summer '08, #22

                          See two 10-minute videos at http://www.youtube.com/user/drteddrted on the Development and Application of Orthodontic Jaw wiring (OJW) for
                          compulsive overeating: Part I: Ray McDowell, showing the use of SmartClip braces to limit jaw opening to preselected maximum distance apart,
                          and Part II: Erica Smith, using the standard brackets for OJW, but wiring using the "through-the-bracket" method to achieve a
                          limited jaw opening in the patient's unique comfort zone.

Summer '08, #21

Topic:  What you can expect when you go to Small Claims Court.

                         Small Claims Court is the people's court. It is fondly known to the judges and volunteer lawyers who staff it as "Liars Court". Here is a court
                         where the little  guy can make his last stand to address that grievance that is vexing him/her. You can make a claim or have a claim brought
                         against you for up to $5000. In well more than half the case the plaintiff  wins and the judge awards the plaintiff a judgment who is now burdened with
                         having to collect his bounty. But hold on.  "There's many a slip twixt cup and lip" is a Greek proverb that warns you that life is filled
                         with surprises. Over the years Chapter 5 of my book on Small Claims Court remains one of the most valuable. It is called :12+1 Scenarios.
                         This chapter takes away the surprises that you may encounter when navigating your way through this court from filing your Initial Claim
                         to obtaining the judgment and collecting the money you believe is your just due. [Read 12+1 Scenarios.]

Summer '08, #20

Topic:  Taking the fear out of four first premolar extractions.

                        Orthodontists are often confronted with patients whose teeth are so crowded or protrude so far in front of their lips they cannot
                         comfortably close them together. About 5% of an orthodontist's patients present this problem. The diagnosis in orthodontic parlance is 
                         termed "bi-maxillary protrusion."  The treatment plan calls for fixed braces accompanied by the removal of four teeth, most often the
                         removal of the upper and lower, right and left first premolars.  KD came to my office with this problem. I prescribed the  removal of
                         his first premolars teeth. This experience can be very frightening. Herein  KD presents his experience. We orthodontists are way too cavalier
                         about our patient's apprehensions and forebodings apropos of this procedure. Just imagine substituting of the word "amputation" for "removal"
                         or "extraction". So direct your patient's feet to the sunny-side of the street as KD describes it.

Spring '08, #19

Topic:  The OJW Questionnaire survey developed to measure the efficiency and effectiveness of OJW provided to carefully selected patients.

Autumn '07, #18

Topic:  Submitted to the American Journal of Orthodontics and Dentofacial Orthopedics on October 28, 2007: Orthodontic Jaw Wiring (OJW): The Dental Professional’s Role in Weight Control for Compulsive Overeating Leading to Obesity. October 28, 2007.  Abstract <200 wordsIntroduction: Obesity is legion and epidemic in our country, and recognized as a precursor to a host of serious illnesses. Indeed, Medicaid and Medicare have classified obesity per se as a disease. These agencies are seeking new and less expensive approaches to the costly surgeries extant. Method: Orthodontic Jaw Wiring for weight loss is my approach to a serious social, psychological and physiological problem that can help some people who are obese or on a path to obesity and its potentially grave consequences. OJW can help alleviate this epidemic in those cases where it may be applicable to carefully selected individuals whose Body Mass Index (BMI)* indicates they are overweight or obese as diagnosed by their physician. Results: Providing OJW to 85 persons since 1989 has demonstrated that it is safe and effective using the protocols developed over time, available to my colleagues gratis at drted.com. Conclusions: Given that we are the caretakers of the mouth and uniquely empowered with skills and mechano-therapy to provide services to the overweight, it is our obligation and responsibility as part of a health-care team to provide our expertise to the overweight heading towards obesity, and those who have already reached that state.
* To calculate your body mass index BMI, follow these four steps:
Measure your height in inches (without shoes) and your weight in pounds (without clothing). Multiply your weight by 703.    2 Divide that number by your height.    Divide again by your height.
These categories were established after several studies examined the BMIs of millions of people and correlated them with rates of illness and death. The studies showed that the BMI range associated with the lowest rate of illness and death is approximately 19–25 in men and 18–25 in women, so people with BMIs in this healthiest range are considered to be of normal weight. Higher BMIs are associated with progressively higher rates of illness and death. People with BMIs of 25–30 are considered overweight, and those with BMIs of 30 or higher are considered obese. Obesity has recently been further subdivided into mild (BMI of 30–35), moderate (35–40) and severe (BMI of 40 and above). Severe obesity is roughly equivalent to being 80 pounds overweight if you are a woman or 100 pounds if you are a man.  Or go to http://www.nhlbisupport.com/bmi    

Summer '07, #17 

Topic:  Orthodontic Jaw Wiring  (OJW) :The Protocol for Providing OJW to Your Patients: A New Service in Dentistry

Summer '07, #16

Topic:    How to make indirect bonding trays: detailed instructions

Summer '07, #15

Topic:    Communicating with your colleagues,  your referring dentists and the patients in your practice by email en masse.

You have just installed that new digital pan-ceph, or mirabile dictu, a wonderful 3-D cone beam technology or completed a course on microimplants and now you want to crow. So how do you do that?  It would be ideal to send each person an individual handwritten letter (using pen and ink), but you really don't even have the time to inhale. Here is the solution that works for me.  Since January of 2002 I have assiduously asked for the email address of every doctor or patient I have made a contact with. I strongly advise you to begin keeping such a database if you haven't had the sense to do it as yet.  Now you need your website (which is an powerful instrument of communication) to act as the postman.  I use ixwebhosting.com  ($10 /Mo) on  the recommendation of Chris Boyd  the I-T guy who services the soft and hardware needs of many of the friends and professionals that I know. (Chris Boyd, 917 204 7993, cboyd@speakeasy.net ) Using the "Webmail" feature of the of the host site I was enabled to send of an important email to many parties as individuals i.e., one email for each recipient you want to communicate with. You must of course first have created your mailing database. My groupings include: Staff, Referring doctors, Orthodontist, Family and friends, Psychiatrist/other docs, Miscellaneous. In the mailing I just did, I wanted the doctors who refer patients to me to know about the introduction in to my practice of 3M-Unitek's SmartClip Straight wire system. So I selected the "Referring doctors" list and imported my SmartClip Straight Wire letter , hit the "Send"  button and fait accompli !  Of course you can test the mailing by sending it to yourself to see if you have edited out the errors and it is satisfactory in all ways.  Alas, as part of the learning curve I forgot one important aspect of the "test mail" feature and accidentally sent four test mailings to my colleagues... all 128 of them. Arrghh. Ps. Your email automatically will include an "Unsubscribe" button. And let it come as no surprise that some recipients will not wait one nanosecond  before "UNSUBSCRIBING" or even worse, blocking any further emails from your address forever. GET OVER IT ! I suggest you limit your infobyte emails to about one every three months. For me, I have many a mile to go and in my next mailing I will send the patient version (work in progress) of  "Over the Wires" before the summer has flown away. Best regards to all, Ted Rothstein drted.com 718 852 1551.

Fall '02,  # 1

Topic:    Practice Management

Have a standard "Payment Plan Worksheet" prepared by an appropriate staff member for each would-be patient/ parent.* This will provide patient and/or parents with an easy to use comparison sheet if they are going to have several consultations (second opinions). Consequently, should the patient/parent call with a question, other staff members will have a quick reference guide with which to provide answers. This will help minimize patients receiving conflicting information regarding their payment plan. Below is the template our office uses.

* Payment Plan Worksheet.pdf



Topic:   Growth and Development

Between 9.5 and 14.5 years the Maxillary First Molar in Class I FEMALES grows MESIALLY 3.0 mm and 5.3 mm in Class I  MALES.
Between 9.5 and 14.5 years the incisal point of the Maxillary Central Incisor in Class I FEMALES grows MESIALLY 3.8 mm and 3.5 mm in Class I MALES.

http://www.drted.com/part_II_ajodo_vertical_and_anter.htm  (Fig. 6)

Ted Rothstein DDS PhD   www.drted.com    NYU Ortho '73
drted35@aol.com  
Brooklyn Heights   718-852-1551   Fx 718-852-1894

Cc. Orthodontic Class '02, '03, '04, '05 and International Continuing Education students. PGO residents and senior faculty are cordially invited to contribute their insights, suggestions and comments at: drted35@aol.com
 

          Caleb, Joshua and Grampa Ted   

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Fall '02,  # 2

Topic:    Practice Management

Make three copies of your data and financial backups--(if you are networked, these are backups aside from the data that you are backing up to your server automatically).  These should be stored in three different places:   (a fireproof safe in the office, your home, staff member's home, etc). Many of you know this already, but who has the time...right? You can learn this lesson the way I did and once you pick yourself up off your knees and dry your eyes you will find the time to follow this advice!

Topic:   Prevention of accidental removal of the wrong teeth

In spite of the prescription I use* when making referrals to the General dentist/Oral Surgeon for the removal ("amputation") of teeth to facilitate orthodontic treatment, I have had three instances in the course of more than 28 years of practice where the wrong teeth were removed. In all three the prescription was written correctly, and in all three the blame for wrongful extractions was clearly attributed either to the dentist or the oral surgeon who removed them. In all cases the FUBAR principle prevailed.  In all three cases the patients were adults. In one of those cases the patient was the dental assistant of the referring dentist who removed them. In two of the three cases first premolars were removed instead of second premolars. In these cases the patients' treatment was continued to completion. The third patient decided to complete treatment with another orthodontist. When you discover that the wrong teeth have been removed. it is prudent that you reveal the error immediately. You can see that on the prescription form I use* the teeth to be removed are described in four different ways: 1. Xing out the teeth  2. Encircling the number (Universal system)   3.  Encircling the descriptive  words and 4. In Palmer notation with the Universal notation given once more.  In addition, I show the patient/mother/father the teeth to be removed.  You will note that there is an instruction to the oral surgeon not to remove the teeth unless all descriptions agree with each other.  Finally, note that after ninety days the prescription is void. At the moment you sit down to write that prescription make sure you have either the patient's models and, or the patient in front of you without any distractions that might cause your attention to wander. If it does happen, this prescription form will minimize the error of wrongful extractions attributable to you.
* Prescription form to General dentist/Oral Surgen.pdf

Archives for Over the Wires
 

Winter '03 #3

Topic:    The Staff  Meeting: Part 1 of 4

Staff meetings are essential to a good practice. The dates of all the staff meetings should be printed and distributed to the staff at the start of of every quarter. One of the office team should act as secretary and take notes as the meeting proceeds. The notes can be archived for future reference. We follow the agenda shown on the form below to take notes*. As you can see it follows the categories that are examined at each meeting. We hold our staff meetings once every two weeks and they last for about one hour. the next four Over The Wires will be dedicated to describing the agenda and purposes to which we put our staff meeting so that both staff and doctor feel gratified as a result of the meeting.

We use an agenda  whose categories are "fixed" yet comprehensive and  essential to the administration and health of the practice.  We begin our meetings with categories that we feel are unique and beneficial:
"Good and Welfare":
At every meeting every staff member, including the doctor, must present some new idea that would/could/might be implemented for the "good and welfare" of the office.  This is a great way to make every team member feel important. These suggestions should include for example: 1. Ways to make the office "look" and "work" better especially in the reception room and treatment room,  2. Ideas that will make the patients feel more comfortable and happy and welcome,  3. Ideas that promote mutual cooperation between the team members.
The doctor should be willing "try out ideas" that "push the envelope" for a three month period rather than casually dismissing a team member's idea.  The team members often see their part of the picture way more clearly then the doctor. Just always be open to new ideas from your team members.
Interpersonal:
Create an open forum between the team members. Try not to forget that although you are "boss" you are a member of your own team. Encourage the staff to use the "interpersonal" forum time  to voice any issues they may be having with you or each other. Think of this time as a spigot to allow the release of pent up negative vibrations that may have accumulated between team members.  Each member of the team should alot this time to airing personal grievances or ideed even saying something nice about a fellow teamie. Consequently, team members will feel they have cleared the air  as opposed to harboring petty grievances that create negative underlying feelings.   We sometimes use this opportunity to let a fellow team member know how much we appreciate them!  Ps. Doc encourage your team to tell you  in what ways your behavior caused them agita.
* http://www.drted.com/archives/Agenda for the team meeting.html
 

Topic:   A KISS orthodontic appliance

"Keep It Simple Stupid" is a dictum we should keep in mind whenever we choose a particular appliance to facilitate our treatment objectives. Here is one I conjured up to correct mild-moderately spaced/flared upper or lower anterior teeth. It filled all the needs that the patient requested: "comfortable, invisible and removable." It worked like a charm. The cost is $2.00. It is fabricated of .40mm, 4"x4" sheet-plastic obtained from "Trutain" in packages of 50. I bought Trutain's thermoforming vacuum machine for $250 many years ago. The machine paid for itself within 10 days . The plastic is vacuum-formed over the mold and completely cut away from canine to canine. Clear-plastic button-hooks from TP orthodontics are bonded on to the buccal of the KISS at the first or second premolars. The patient is shown how to apply powerchain from button to button (elastics if you desire). The patient changes the powerchain every two weeks. As the anterior teeth retract, the plastic is cut back 1mm at a time. Buttons can be added on to the laterals and powerchain applied between them for additional traction to close anterior spaces and/or prevent the chain from moving incisally or gingivally on the surface of the anterior teeth. By adding button-hooks on to the  molars, posterior spaces can be closed unilaterally or bilaterally at the same time that the molars are being moves anteriorly. This is a versatile appliance.
 

KISS

Winter '03 #4

Topic:    The staff  meeting and practice management: Part 3 of 4

I have a list of office "PASSIONS"*.  They are by definition the guidelines/beliefs that we are certain are profoundly important in the delivery of a standard of  patient-care that is without equal. Our passions were created over a long period of time and culled from our own experiences, the teachings of many practice management articles and lectures on the subject. We add to them from time to time. All the team members know how essential they are, however, we think that they are important enough  to read aloud at the start of each staff meeting.  Our passions are posted where every team member can see them.  You can read them by clicking on the hyperlink below. 
We invite you to share YOUR PASSIONS with us once you've created them, or simply use ours as the starter kit for your own concept for delivering the very best orthodontic care.
* http://www.drted.com/Passions.html

Topic:    Lingual braces made simpler

The delivery of orthodontic treatment with lingual braces is in some ways more difficult than with labial braces. Chair time and treatment time are decidedly longer. This appliance is excellent for deep vertical overbites and mild-moderate crowding where no extractions are required. Premolar extraction cases can be very difficult. The good news is that the laboratory (Specialty Appliances) can now provide you with a direct bonding setup (about $450) as well as a series of performed archwires (about $65/arch). If you want to distinguish yourself from among other orthodontists you would be wise to become familiar with this technique. The American Lingual Orthodontic Association (ALOA) can provide you with the some good information regarding training courses.   The basic arch  wire is shaped like a mushroom and not terribly difficult to learn how to fabricate intra-orally. However, I personally do not have the skills to bend the retraction arch at the chairside needed in the premolar extraction case. Below I have documented how I go about doing it at my lab bench.
http://www.drted.com/index.html/Lingual braces arch form.HTML

Spring '03, #5

Topic:    The staff  meeting and practice management: Part 4 of 4

Let a junior team member lead the staff meeting once a month.  This forces and encourages  participation from team members who typically may not play a central role at team meetings.  This exercise will build confidence and give them a different perspective of their value to the team and the office. Make sure minutes are kept and a prearranged agenda** is followed.   Your team will be grateful for the responsibility and voice you are giving them.  Team members should recognize the practice as a "baby" whose health and well-being they are each responsible for...that is the true meaning of QUALITY CARE!

**see our agenda for the team meeting
* http://www.drted.com/archives/Agenda for the team meeting.html

ALOHA!  See you in Hawaii.

Topic:     Removing acid etch, a better method...not rocket science

One cotton roll and 10 seconds is all you need.  Orthodontists are sometimes fanatic in organizing their work table and their methods for delivering patient-care "efficiently."    Is your patience taxed as your patient dawdles endlessly while rinsing the acid etch off his/her teeth (average time 60 seconds)? I offer you the cure for this annoyance when you need to remove the etch from as many as 3 teeth (not recommended when many teeth are being etched such as for whole-arch bonding):
The photo below shows two containers of water (more than enough for a whole day) standing between the catalyst and the acid-etch.  Rather than allow the patient to rinse off the acid-etch at the fountain, or  use a three-way syringe to accomplish rinsing and drying after etching, I wet  a cotton roll on both ends and dab off the acid-etch  with one end of the roll then complete the removal with the other end ... then I squeeze all moisture from the cotton roll and dab off all remaining moisture from the surface of the tooth. Final drying is done with a warm air blower (Nola). The water on the cotton roll is sufficient to dilute the acid  and absorbs it all with no bad taste for the patient. No acid residue will remains to interfere with the adhesive properties of the bonding material if you are thorough.

Summer '03, #6

Topic:   Case acceptance:  You won't get them all but do you know why?

In the best of all possible worlds at the first visit you do your consultation exam, present your diagnosis, treatment plan and fee; take records, put on the braces and get paid in full: NOT!   I have learned not to take it personally when being told (at the time of our follow-up calls to those in our "pending" files)  "Oh, I chose to have my treatment at another office." You can still benefit from this disappointing turn of events. In keeping with our mission statement: "Our priority is caring for you and our mission is quality care," we have recently begun sending out follow up questionnaires to those patients who have decided to have their treatment elsewhere or even not have any treatment at all. We send this questionnaire with a SASE and a new $5 bill as a gift for taking the time to provide us with this priceless feedback. See/read our questionnaire by clicking on the following link:
follow up questionnaire. Please email us with any feedback you might have regarding the way your practice handles this situation. How do you follow up or do you?

Topic:      Patient's Financial Memo form and Notice of Informed Consent-- The two most important forms in your office.  

 Whether you open your own office, or you are employed by another orthodontist, these forms are essential elements of a vital professional practice.  We decided to meld them into a two-sided document for efficiency. This Fin-Mem/Inf-Con memo is reviewed and updated annually for accuracy, content and specific office needs. Along with the Summary of Consultation-Examination these three documents provide the information that empowers your patients to help finish the treatment that they have contracted for as well as to help form a mutually cooperative and happy patient-doctor relationship.  I just finished updating these forms:
See SumCon 2007-2008 and  Fin-Mem

Fall '03,  # 7

Topic:   Clinical: Moments, Forces and Couples of Orthodontics

Topic:    Practice Management:  Save time and money on the web.
I  recently discovered one more reason to be grateful for the Internet.  Click on the following link and you will find Verizon's online search feature http://www22.verizon.com/.  I use this site no less than 5 times daily.  I have not paid a directory assistance charge (411 information calls costs 80 cents each. ) since this website appeared.  Verizon allows you to search for either a business or a residence.  The search will return both an address and a contact number.  It has been the most helpful in locating other professionals, but I have also been able to track down patients who have moved and had forgotten to update their contact information with us...Other sites that I use on a daily basis are:

I would love to hear about the sites you use.  Please submit them by email to drted35@aol.com .  I will post them in the next issue of "Over the Wires."

Have a wonderful holiday season.

Winter '04,  # 8

Topic:  Diagnosis:  Interpreting the Panoramic X-ray

Winter '04,  # 9

Over the Wires is now sanctioned by the American Association of Orthodontists

 
Topic:  A potpourri of reflections for the starting orthodontist...a series in four parts: Part I: 
 
Some of us need to hold our hands in fire to learn that it burns.  Others need only be counseled about it's harmful effects. This article is addressed to those who wish to avoid being burned.  Seasoned orthodontists will immediately comprehend the benefits of the insights that are herein presented.
Key:
Se: Self... St: Staff...GO: General Office... Ex: Exam... Rec: Records... Dx: Diagnosis...Tx: Treatment... Re: Retention... PP: Practice Promotion... PM: Practice management.
                                       BLUE = ALWAYS...RED = NEVER
Se:  Never express anger toward a patient. If you do get angry you have lost control of yourself and the situation. When this happens I advise that you lose your ego and call the patient at home in the evening to apologize and try to make amends.
 
Se: Never use medical/dental terms to explain what you are doing or intend to do for the patient. Speak plainly, simply and clearly and avoid like the plague saying "Do you know what I mean"? Repeat yourself using other words if you suspect the patient does not understand you.
S:  Praise your staff in public.
St: Criticize your staff in private. If you lost it and criticized one of your staff in public be big enough to apologize to them without any delay. They never forget.
GO:  Have a major newspaper delivered to your office.
GO:  Have a television set, or even better, cable TV for your patients.
Ex:   Have handy a stethoscope to listen to any sounds the patient's TMJ might be emitting. Better you and they should know about them from the commencement of treatment rather than have your patient bring them to your attention in the middle, or at the end of treatment. Note on the patient's chart if they are loud or soft, bilateral or unilateral and whether they are occurring at the early middle or late point when the patient opens their mouth. Finally, advise them that the "sounds" they hear will likely be present at the end of treatment. Let them hear the sounds for themselves.
Rec:  Introduce the little ones, and the adults who seem nervous, to the procedures you will be doing when they return for their next records visit. Show them the equipment...be brief. Give the little ones a styrofoam tray to play-fit in their mouth.
Dx:  If you are certain the adult who accompanies the patient is the genetic parent make certain you "examine" them. You may obtain some insight regarding what you can expect from their growing child.
Ret:  Offer your patients an "insurance" plan for lost retainers. (Contact my office if you would like to know about the plan I offer at a fee of $195). This one measure has given me more reward/pleasure than I can express here. This measure is without a doubt a win-win proposition.
GO:  Never fail to document on the patient's treatment chart their canceled (CA) and/or broken (BA) appointments.
PM: Never be reluctant to use your local small claims court to collect fees owed to you for work well done.  See Dr. Ted's preparation list for a SCC encounter.  Looking forward to seeing you all again at the AAO NYU alumni meeting in Orlando.


Topic:   Practice Management: Email:  Enhancing communication with patients and staff.

My advice to you in this issue of OTW comes from my experience using email to communicate with our patients, and staff in the office and at home over the last five years. Communicating with patients by "electronic mail" evolved as a result of the launch of our web site http://www.drted.com in 1998.  We now encourage all patients to communicate by email, and over the last two years email has played a major role in how I provide "Quality Care" to our patients.
 Patients can now request appointments, inform us of broken wires, and detached brackets, or ask an insurance question and have it answered whether or not we are having patient-care hours.  Indeed, every new staff member must have a computer at home and when Dr. Ted needs to notify the entire staff he will do a group "staff" email. Likewise, I will notify other staff members of numerous kinds of information and events that enable them to help us SERVE OUR PATIENTS WITH THE BEST CARE POSSIBLE.
 I have spoken to other offices who frown upon the use of email because they feel it seems too impersonal. However, we feel that email has allowed us to address our patient's issues accurately and in a timely manner. Consequently, if a patient calls to ask about their insurance benefits at a very busy time of day, and I don't know the answer, or I might have to review some data in the patient's folder, being able to email my response allows me to do all of the above and compose my answer with more accuracy and efficiency. Given that our office is fully networked including patient charting, email was a simple avenue of communication to implement. Email will also save you from the long distance charges you would incur if you had to call Johnny and his parents at their summer home to assist them with unexpected problems like poking wires or detached brackets.  
 
One welcome side effect has been the enhanced communication I have with my staff on a daily basis, and it has certainly changed the way I communicate with Dr. Ted even though we use offices that adjoin.
 
For those of you who maybe slow to respond I must warn you that your patients, staff and doctor will expect a faster response.  We have often been complimented on the speed of our responses. Once you set the new standard you must keep it at that level.  You must remain attentive to your daily incoming email.  If you require 24-hours-notice-of-cancellation of appointments and one of your patient cancels on Sunday, by email, for his/her "Monday-morning by-special-arrangement" 7:30 am-appointment, you will not be justified in charging a late cancellation fee if you have not clearly laid down the ground rules for handling a situation like this.  This has happened. All patients are given Dr. Ted's home number once they get their braces on; we now encourage them to use it for late cancellations as well.  
 Overall, email has only made it easier for me to get more work done in one day and has decreased the number of times our front desk phone rings (for which my team is very appreciative).   This very issue of OTW traveled back and forth between Doc and myself for editing not less than nine times. In brief, snail mail is virtually defunct...long live email!
 A word of caution: be sure to keep copies of the more important email communications in your patient's folders i.e., promises to pay, late cancellations or issues concerning treatment plan decisions.
 Ps. Dr. Ted uses email to communicate his diagnosis and treatment plans to referring doctors and patients as well with Cc.'s to me for filing in the patient's folders. I look forward to meeting you all again at the AAO meeting in Orlando.

Spring '04,  # 10  Over the Wires is sanctioned by the American Association of Orthodontists

  Topic:  A potpourri of reflections for the starting orthodontist...a series in 4 parts: Part 2:   This article is addressed to those young orthodontists who can learn from the mistakes of others who have been at it for some time. For Part 1 see Winter '04, # 9
Key:
Se: Self... St: Staff...GO: General Office... Ex: Exam... Rec: Records... Dx: Diagnosis...Tx: Treatment... Re: Retention... PP: Practice Promotion... PM: Practice management.

Ex: Annotate on the patient's exam chart the shape and color of all the enamel hyper and hypocalcifications and any other abnormalities of form or coloration including bondings and laminates on the six upper and lower front teeth. If you are going to place brackets over any discolorations do show them to the patient. Photographs of the anterior teeth also are useful documentation but not entirely adequate.
Ex:  TMJ sounds/irregularities are best revealed/discovered at the initial exam and brought to the patient's attention and documented. If they are deemed innocent, one would be thorough to advise the patient of the sounds and tell the patient that the sound will probably still be present at the completion of his/her orthodontic treatment.
Ex: When you complete your Consultation-Examination how can your would-be new patients remember you and be encouraged to think that you and your office are special? I give my patients a Summary of their experience in my office. I tell them with a smile that my "SumCon" is not only interesting and informative but :-) suitable for  framing :-).  See Dr. Ted's SumCon: http://www.drted.com/SumCon 2007 to 2008.pdf
Tx: Patients are quite clever when it comes to handling their orthodontic emergencies. However, when they have exhausted their resources they need us and they call us for help. I urge all my patients to buy a wire cutter and encourage them as a last resort to cut off the offending wire if possible. This approach has spared me many a special emergency visit to the office.
Tx:  When you intend to do "extensive" interproximal sanding, advise your patient to take one or two Advil/Motrin (any mild pain reliever) and hour before the appointment. Apply a topical anesthetic to the interproximal gingiva (Hurricane). Have an assistant chairside to help with cheek retraction especially when doing IPS on the posterior teeth.
Tx:  When you are presenting your treatment plan to the patient you will at times have more than one plan in mind, for example, extraction vs non extraction? Each might be equally attractive to you. If you present too much information patients are often overwhelmed and become confused AND ANXIOUS and might draw the conclusion that you are unsure of what you are doing. If you have equally weighted choices or two treatment choices, present both as simply as possible and state the specific one you think offers the best solution to address the patients chief complaint, and then provide the reasons (never more than three) why you lean toward your preference.  Use expressions like "If you were my sister (brother, mother, father) I would prefer that you choose..."  (your preferred plan)...and state that plan again.)
PM: The typical payment plan is 30-40% initial payment and the balance in equal monthly payments over 15-24 months. In my office 18 months is the maximum. Be prepared at the get-go to offer your would-be new patients a variety and range of payment plans including a tempting discount for full-fee paid in advance by credit card, cash. At the other end of the spectrum, when appropriate, be prepared to offer a payment plan where the initial payment is relatively low such as or even Citihealth card (Learn more). The initial payment is most often the reason stated for not initiating treatment. Just be flexible.
PM: Shake hands with parent/parents in a manner suitable to the age and sex of the person. A limp-fish handshake to a strapping guy leaves a questionable uneasiness in the mind of some. As a corollary, beware of the unexpectedly steely grip offered by the person who has little respect for the value you place on your hands.
PM: Develop and check the x-rays you take for "diagnostic quality" before the patient leaves the office.
PM: After taking an impression for a lab appliance that you expect to provide at the next visit, remind the patient to call to verify that the appliance has arrived in the office before coming for their appointment. The preceeding  is your backup approach in the event your office fails to let them know their lab work has arrived.
PM: Come out and visit your patents in the reception/welcome room from time to time. You will often see a younger woman and an older woman sitting together. Never ask if one is the mother or grandmother of the other...better when in doubt, even in obvious humor, ask if they are sisters. It never fails to evoke smiles from both.
PM: Before you remove fixed appliances be certain your patient knows about any compromises you did not plan for at the start. Remind them that their own general dentist, or one that you can recommend, is there to finish putting the finishing touches to residual "problems".  You're not God and patients are forgiving. Just do your best.
PM:  Patients need to have a "standard way" of letting you know that they need you to stop whatever you are doing because they are in discomfort. I have my patients let me know by raising one finger.
PM: Make the removing of braces a very special/memorable event. I used to play the Triumphal March from Aida as I removed the braces. Nowadays, I gather the staff and make a "surprise" party that lasts about three-five minutes, with poppers, spray string and noise makers. Leave 'em "smiling" and they will never forget you.
Re: Tooth size-Jaw size discrepancies, in particular small teeth and large jaws, are the cause of spaces between the upper central incisor as large as 7-8mm. Sometimes that space is exacerbated by fleshy knots in the lower lip so palpate the lip to know if that is the case and then consider some kind of fixed or semi-fixed retention to keep the space permanently closed. Reopening the space between 8 and 9 is very common. Know thy enemy!
Special Note 1:  When one of our own appears in print we are very proud of them. Accordingly, I would like to bring your attention to Dr. Elliot Moskowitz NYU PG Ortho '75 who is now a contributing editor to the Journal of Clinical Orthodontics. In the February and March, 2004 editions of JCO you will l find the articles in which Elliot's thoughts on "Early Orthodontic Treatment" are included. Congratulations,  Elliot, we are proud of you :-). You can read the articles at the following hyperlinks: Hyperlinks to the JCO articles:
http://drted.com/index.html.bak2/JCOFeb04Roundtable.pdf
Nevertheless, I personally recommend if your not already a subscriber  that you become one.  To do this got to the Marketplace section of the JCO site and choose "subscribe".
Special Note 2:  The AAO meeting in Orlando is barely a few heartbeats away. The NYU alumni meeting is being held at the Hardrock Hotel Universal Orlando, 5800 Universal Blvd. on Saturday, 5:30-7:30pm. Get to know your alumni you may one day be an associate to one of them. See you there.
Special Note 3:  We wish Dr. Richard Kliefield, who heads the PG ortho clinic facility at St. Barnabas, our best wishes for a successful outcome on April 27-28 when the ADA site accreditation team comes to inspect the facility at Union Hospital in the Bronx. Alas, we will not know the outcome until June-July   This facility is beautiful and Dr. Kliefield has done an astounding job in preparing the awesome documentation for this visit. Special congratulations/greetings to the very first group of residents who will receive their certificates this June. Chapeau Dick.


Topic:   Practice Management:   Automatic deductions from checking and credit cards to cut accounts receivables

The first challenge I faced as an office manager was decreasing a huge accounts receivables left over from Dr. Ted's previous manager. It was a formidable and frightening challenge to my more youthful then self.  Six years later auto-deductions from the patient's checking and credit cards have been very effective in helping control accounts from ever becoming delinquent.
In our office, would-be new patients are made aware during their consultation call that personal checks are not accepted (unless by special arrangement). We do however accept ATM, debit/check, and all credit cards.   This eliminates the "surprise factor" regarding our offices payment policies and prepares them for how they will handle paying for their treatment.
Automatic credit card charges require you having on file:
A. an imprint of their credit card and
B. signature, authorizing that a charge be made.
For checking account deductions I use a very simple form, http://www.drted.com/Authorization to deduct.htm listing the monthly charge amount and total contract fee.  This form requires an original signature (fax/copy not acceptable).

Summer '04,  # 11
 
Topic:  Dr. Ted's approach to loss of retainers, relapse and retreatment: the Retainer Insurance Agreement

You must have a protocol in place for this commonly occurring and disappointing problem. The most important element of the approach I use is to transfer total responsibility to the patient for the maintenance of the straight teeth you put your heart and soul into creating. In essence, by providing your patient accurate information about why/how teeth commonly become crooked again you have given the patient the essential information needed to avoid relapse. When relapse does occur the patient is given two choices: to retain the present relapsed state, or to retreat at the fee you have decided in advance and have stated in your "Retainer Insurance Agreement".  The Retainer Insurance Agreement is given to the patient 1-3 months prior to removing the braces. You must be certain that this document is dated and signed and made part of the patient's file before or prior to the time you remove the braces. Evidence of payment is a "paid for" retainer insurance entry on the patient's payment ledger. The insurance is considered effective only when the fee for it has been paid in full.  See: http://www.drted.com/Retainer%20insurance.html

Ps. NYU alumni meeting in Orlando rocks
We had a wonderful time at the Hardrock Hotel Universal Orlando where the NYU PG Ortho alumni held it's meeting. It was great fun meeting the new residents and talking to the previous grads who are well on their way to becoming the practicing orthodontists they trained to be. Next year we'll be seeing each other again in San Francisco. I can hardly wait. We took some pics so go and take a peek at them and you'll recognize me, some of yourselves, and some other prominent personages as well. See the pics: http://www.drted.com/AAO%202004%20NYU%20alumni.html

Topic:   Technology:   Why Broadband is a necessity for your practice

Dr. Ted:  "Why should we install broadband in our office?  It's  $30 more each month isn't it?"
Chris: "It's a no-brainer doc...time is money and faster is better--Wait you'll only have to email one patient's digi photos to see the difference."

We all know that in the world of Internet faster is always better.  The Internet has become essential to run any business efficiently. To reap it's full benefits you must have a high speed connection. The following were my reasons for making the change:

1. Invisalign, Invisalign, Invisalign!  Clinchecks and emailing photos for case submission are a lengthy and tedious affair if you do not have a high speed connection.  You will find that 90% of your patients and/or referring dentists have broadband or DSL at their offices or in their homes. Moreover, being able to a send an .avi file (movie) of their Clincheck rapidly will allow and even encourage you to send your patient's Clinchecks as a substitute for an office visit. Remember to make an entry in the patient's chart that you sent them a CD of their Clincheck.

2. Most insurance carriers have really cut back on telephone support.  Navigating through MetLife's automated answering system has been known to take up to 48 hours LOL!  In their defense most companies have developed websites that will allow doctors submitting claims to check eligibility, benefit amounts and claim status.  Loading these webpages using a dial-up connection will take your staff as long as that phone call you will place to the automated answering system.  High speed has quadrupled the amount of information I can obtain in an hour via the Internet. In brief, high speed is very cost effective!

3.  Almost all of our suppliers now have websites that allow you to view complete catalogs including photos. Broadband/DSL makes ordering items over the net fast and easy, consequently, fewer catalogues to clutter your office.

4.  If you are using digital x-rays, a high speed connection will allow you to share your radiographs with your referring docs in the blink of an eye--literally!

5.  Broadband/DSL allows multiple users to be connected to the Internet within your office.  This means that you could be sending your photos while your staff is checking insurance.  With dial-up access you need to have a dedicated phone line for each workstation you want connected to the Internet.  If you do have dial-up on more than one computer chances are the cost will be the same as broadband/DSL.

If you are in New York City here are some links where you can find information on the cost and equipment necessary to have a high speed connection installed in your office:
TimeWarnerNYC:http://www.twcnyc.com/      VerizonDSL:http://www.verizononline.com/         Earthlink: http://www.earthlink.net/

Fall '04,  #12