- Published on
Dr Chris Baker (right) practices dentistry in Abu Dhabi, UAE, and teaches orthodontics and practice management worldwide.
For us dentists, we have been guided by a need, a dream, to help others. Going to dental school, and to residency and further training, takes a whole lot of “get-up-and-go” and a whole lot of “stick-to-it-iveness.”
Our schooling and hard work was (and is) driven by our need and dream to help others AND to make a good living for our families and ourselves.
Sound familiar? Then, in practice, you start working, working, working, calling on your “get-up-and-go” and your “stick-to-it-iveness.” You take more continuing education. You believe in education.
You work long hours, after your staff has gone, and sometimes before your staff arrives in the morning. You take time away from your family. For some of us, probably especially us girls, we have the children at the office frequently because that’s where we are. Still, your family time and routines are centered around your job, your practice. After all, it’s how you take care of the family, right?
You do whatever you can for the patients, because you want them to be happy, to like you - to love you - to become part of your “family.” You do whatever you can for your staff because you want them to be happy, to love you, to be part of your “family.” And they are. Often the staff see you as the benevolent “parent” in this purported family. Your immediate family may not see you enough.
And somewhere along the way, it feels all mixed up. Do you feel significant? You feel tired.
Do you feel capable? You feel confused.
Do you make enough money to support your family the way you want? The practice overhead is huge, eating you up.
Do you have enough time with your family? For yourself? Do you feel appreciated, loved?
What is missing in your picture?
Why doesn’t your life work better? Why doesn’t your practice grow?
Because YOU don’t.
How will you solve your dilemma?
The only way is by reinventing your system to solve it.
Start by identifying what is missing. Certainty? Security? Love? Significance? Growth?
Each element or core human need has a corollary that holds you back. Certainty - stability, security, consistency - is hidden by your fear. Fear of what patients, staff, family, even strangers think of you. (Read recent blog, “Way too.”) Fear about your capability.
Love may be hidden by your being too “busy” to notice, to participate. While doing for others is the way you give love, your need for love may be so depleted that there’s not much to give.
Significance may be so hidden by your exhaustion, your need, that you cannot see it. Your life is just way too hard.
And growth? Who has time or energy for growth when you are THIS busy?
What is missing in YOUR picture?
What does the most important person here need? YOU!! What do YOU need?
To solve your dilemma, begin creating a system that will free your time, your energy, your emotion. Believe it or not, growth is what’s needed.
“Wha-a-a?” you say. “How can I have time or energy for more education?”
This education will help you find the tools, the methods, the processes to begin the system that will free you from the whirlwind of your life.
Start with:
You are too valuable and too wonderful to keep being vulnerable to your fear, your whirlwind and your exhaustion.
Why not now?
Why not?
Why not you?
Books to read ASAP:
Dalio, Ray, Principles
Gerber, Michael E., The E-Myth Revisited
Baker, Chris, Real
Our schooling and hard work was (and is) driven by our need and dream to help others AND to make a good living for our families and ourselves.
Sound familiar? Then, in practice, you start working, working, working, calling on your “get-up-and-go” and your “stick-to-it-iveness.” You take more continuing education. You believe in education.
You work long hours, after your staff has gone, and sometimes before your staff arrives in the morning. You take time away from your family. For some of us, probably especially us girls, we have the children at the office frequently because that’s where we are. Still, your family time and routines are centered around your job, your practice. After all, it’s how you take care of the family, right?
You do whatever you can for the patients, because you want them to be happy, to like you - to love you - to become part of your “family.” You do whatever you can for your staff because you want them to be happy, to love you, to be part of your “family.” And they are. Often the staff see you as the benevolent “parent” in this purported family. Your immediate family may not see you enough.
And somewhere along the way, it feels all mixed up. Do you feel significant? You feel tired.
Do you feel capable? You feel confused.
Do you make enough money to support your family the way you want? The practice overhead is huge, eating you up.
Do you have enough time with your family? For yourself? Do you feel appreciated, loved?
What is missing in your picture?
Why doesn’t your life work better? Why doesn’t your practice grow?
Because YOU don’t.
How will you solve your dilemma?
The only way is by reinventing your system to solve it.
Start by identifying what is missing. Certainty? Security? Love? Significance? Growth?
Each element or core human need has a corollary that holds you back. Certainty - stability, security, consistency - is hidden by your fear. Fear of what patients, staff, family, even strangers think of you. (Read recent blog, “Way too.”) Fear about your capability.
Love may be hidden by your being too “busy” to notice, to participate. While doing for others is the way you give love, your need for love may be so depleted that there’s not much to give.
Significance may be so hidden by your exhaustion, your need, that you cannot see it. Your life is just way too hard.
And growth? Who has time or energy for growth when you are THIS busy?
What is missing in YOUR picture?
What does the most important person here need? YOU!! What do YOU need?
To solve your dilemma, begin creating a system that will free your time, your energy, your emotion. Believe it or not, growth is what’s needed.
“Wha-a-a?” you say. “How can I have time or energy for more education?”
This education will help you find the tools, the methods, the processes to begin the system that will free you from the whirlwind of your life.
Start with:
- Making time each evening for your family. Give them - and yourself - 30 minutes of your undivided attention. Maybe the children get 30 minutes and your beloved gets 30 minutes.
- Awaken each morning and spend five minutes before you get up, thinking of the things you are grateful for.
- Add some prayer and meditation time then or later in the day. 10 minutes is powerful.
- Begin reading a few pages in a good growth book every day. Some ideas are below.
- Understand the answers are all the same - give abundant love to yourself so you can truly give abundant love to all. It’ll make you feel and BE very significant, make more money as your practice grows without your depletion.
You are too valuable and too wonderful to keep being vulnerable to your fear, your whirlwind and your exhaustion.
Why not now?
Why not?
Why not you?
Books to read ASAP:
Dalio, Ray, Principles
Gerber, Michael E., The E-Myth Revisited
Baker, Chris, Real
- Published on
Dentists who treat children often deal with certain fears about their profession. There are some great choices that can "rescue" these dentists from their fears. Dr Chris explains...
- Published on
The languages dentists have to learn!
Do you-speak 'insurance company-speak'? Do you speak 'parent-speak'? Do you-speak 'child-speak'?
Today I am looking at insurance company-speak.
And btw (by the way - that's 'text-speak') - “corporations” here refer to insurance companies, big box and other corporate dental practice owners, and government entities including Medicaid and Medicare, all of whom skim your money off the top, so you do not get paid what you have earned.
What on earth are you paying them for?
The privilege of keeping some of your money after you spend more money paying staff to file claims for the patient, to wait on hold on the phone for hours, literally, waiting to talk to the “corporations” to evaluate how much of your money they will send to you, file appeals, and then find out the appeal reached the corporation after the “deadline”. Why is there a deadline on getting your money?
I am a dentist, not a provider.
Provider sounds like a waiter.
Provider, they say, as if somebody has to help you do your job.
Provider means anybody can do it – it does not imply many years of school, experience, professionalism, licensing, board examination and wisdom.
“Provider” is insurance-company-speak, just like;
“Usual and customary” - whose usual? whose customary? Not yours, for sure!
“Acceptable” - to whom?
“Estimate of benefits” (EOB) - that is the patient’s benefits - it should have NOTHING to do with you. they are not be YOUR benefits. Because they are not benefits at all, but rather the “spoils” left after the corporations took a lot of your money.
“The network” - a list of doctors whom the corporations have convinced should share their income with the corporations.
“Participants” - see “the network” above
“Network providers” - see “the network” and “participants” above. Amazing how many names you are being called.
“participation” - the act of becoming a “network provider” or “participant” and reaping the losses as you pay the corporations.
“Healthcare” - insurance-speak for disease care; the acts and services of restoring diseased organs in the body, of addressing adverse growth and development, and at disease care’s best, of working to help the patient PREVENT disease and adversities of growth and development.
“Healthcare” is also the name the corporations use for themselves, and not for the practice of medicine that you provide.
As Dr. Paul Henny reminds us, we don’t make health; that is something that cannot be bought by the rich nor given to the poor. It is something the patient maintains and works on and with.
Interestingly, the corporations have successfully made the education of patients and parents as to how they can take responsibility for their health, a “non-reimbursed” “service.” In insurance-speak, this means it looks completely worthless to the corporation and relatively worthless to the patient. This leaves the impression that the doctor who is dedicated to helping the patient learn prevention can just do it for free.
And now, the corporations are taking on the diagnosis of your patient. They are defining what periodontal disease is, for example. (Insurance-speak parameters for periodontal diseases may not even include the presence of calculus, or pockets of a certain depth.)
It’s amazing that an administrator/clerk/bureaucrat working for an insurance company/corporation in another state purports to know your patients’ conditions more than you, even though you’ve been treating the patient for many years.
Think about it - do you really want to continue contributing to the corporation executives’ seven-figure incomes out of your pocket? Do you want to continue working for that?
The story of the frog comes to mind, who finds himself in cool water and doesn’t understand there is a burner under his pot of cool water. As the water gets warmer and warmer, the poor frog doesn’t realize he is being cooked and will soon be dead.
Are you serving yourself and your patients? Or are you serving the corporations? ...and their executives and stockholders? (And some of their CEOs with seven-figure incomes?)
“Choose this day whom you will serve.“ ~ Joshua 24:15
Do you-speak 'insurance company-speak'? Do you speak 'parent-speak'? Do you-speak 'child-speak'?
Today I am looking at insurance company-speak.
And btw (by the way - that's 'text-speak') - “corporations” here refer to insurance companies, big box and other corporate dental practice owners, and government entities including Medicaid and Medicare, all of whom skim your money off the top, so you do not get paid what you have earned.
What on earth are you paying them for?
The privilege of keeping some of your money after you spend more money paying staff to file claims for the patient, to wait on hold on the phone for hours, literally, waiting to talk to the “corporations” to evaluate how much of your money they will send to you, file appeals, and then find out the appeal reached the corporation after the “deadline”. Why is there a deadline on getting your money?
I am a dentist, not a provider.
Provider sounds like a waiter.
Provider, they say, as if somebody has to help you do your job.
Provider means anybody can do it – it does not imply many years of school, experience, professionalism, licensing, board examination and wisdom.
“Provider” is insurance-company-speak, just like;
“Usual and customary” - whose usual? whose customary? Not yours, for sure!
“Acceptable” - to whom?
“Estimate of benefits” (EOB) - that is the patient’s benefits - it should have NOTHING to do with you. they are not be YOUR benefits. Because they are not benefits at all, but rather the “spoils” left after the corporations took a lot of your money.
“The network” - a list of doctors whom the corporations have convinced should share their income with the corporations.
“Participants” - see “the network” above
“Network providers” - see “the network” and “participants” above. Amazing how many names you are being called.
“participation” - the act of becoming a “network provider” or “participant” and reaping the losses as you pay the corporations.
“Healthcare” - insurance-speak for disease care; the acts and services of restoring diseased organs in the body, of addressing adverse growth and development, and at disease care’s best, of working to help the patient PREVENT disease and adversities of growth and development.
“Healthcare” is also the name the corporations use for themselves, and not for the practice of medicine that you provide.
As Dr. Paul Henny reminds us, we don’t make health; that is something that cannot be bought by the rich nor given to the poor. It is something the patient maintains and works on and with.
Interestingly, the corporations have successfully made the education of patients and parents as to how they can take responsibility for their health, a “non-reimbursed” “service.” In insurance-speak, this means it looks completely worthless to the corporation and relatively worthless to the patient. This leaves the impression that the doctor who is dedicated to helping the patient learn prevention can just do it for free.
And now, the corporations are taking on the diagnosis of your patient. They are defining what periodontal disease is, for example. (Insurance-speak parameters for periodontal diseases may not even include the presence of calculus, or pockets of a certain depth.)
It’s amazing that an administrator/clerk/bureaucrat working for an insurance company/corporation in another state purports to know your patients’ conditions more than you, even though you’ve been treating the patient for many years.
Think about it - do you really want to continue contributing to the corporation executives’ seven-figure incomes out of your pocket? Do you want to continue working for that?
The story of the frog comes to mind, who finds himself in cool water and doesn’t understand there is a burner under his pot of cool water. As the water gets warmer and warmer, the poor frog doesn’t realize he is being cooked and will soon be dead.
Are you serving yourself and your patients? Or are you serving the corporations? ...and their executives and stockholders? (And some of their CEOs with seven-figure incomes?)
“Choose this day whom you will serve.“ ~ Joshua 24:15
- Published on
Dr Chris explains one possible challenge with orthodontic finishing.
- Published on
Who's watching out for their orthodontic development?
- Published on
Let Me Ask You -- Should You Treat Their Kids?
How and When?
As a young dentist, I remember feeling the exhilaration of the possibilities of helping children. Therein lies worth to a young mother and to a young dentist, imprinted with the passion for helping children.
After all, what more is there, than helping to make the best life for my child and for other children?
One day, in the clinic at the University of Louisville School of Dentistry, covering pediatric dental residents, I watched one of the residents impassionately counsel a young mother with baby in stroller and two toddlers beside. The resident explained the etiology of dental decay in this mom’s young children.
Because it was a residency program, we could spend the extra time with the parents - even when they had Medicaid coverage that didn’t pay much for that time. But today, this sweet mom and the pediatric resident had reviewed the four etiologic areas:
1. The "bugs" (bacterial plaque);
2. Food for the bugs (contribution of sugar and carbohydrates),
3. The teeth (tooth enamel and how well it resists the former two), and
4. Diluting the acids (saliva, content, volume, and hydration).
They had gone through the solutions to each:
1. Plaque control/oral hygiene practices,
2. Dietary changes to reduce sugar and carbs,
3. Regular recalls so the dentist can help evaluate how the enamel and teeth are doing, and
4. Lots of water intake.
Whew! This mom was “armed”.
She would work on brushing and flossing her children’s teeth, she said.
She was already careful with sugar, juices, soft drinks, etc., and rarely gave those, she said.
She would stay regular with the recalls, she said.
I helped her, as she wheeled the stroller out of the operatory and corralled the two toddlers.
“Hold up!” I exclaimed as I noted red liquid pouring out of the diaper bag in the stroller basket. Something was leaking.
“Uh oh,” said Mom. “It’s the Kool-Aid,” she stammered. “Sorry - I didn’t want you to see that.” (And it was in a baby bottle.)
Reboot. Now what?
Let’s regroup here. Take me - that passionate, loving, caring young mother who wanted to help children. Take you - the same. Life lessons in pediatric dentistry:
As the saying goes, “What is it that the rich cannot buy, and cannot be given to the poor? It is health.” Dental health is only reachable by the interested, willing and capable persons.
Put your passion, your energy, your love to all, and focus on the children whose parents partner with you in prevention. Then you will have given what you can - to those who will willingly take and use it!
We talk about this in ELEMENTS weekend seminars! Ask us about "chickens to concierge practice."
It’s amazing stuff!!
How and When?
As a young dentist, I remember feeling the exhilaration of the possibilities of helping children. Therein lies worth to a young mother and to a young dentist, imprinted with the passion for helping children.
After all, what more is there, than helping to make the best life for my child and for other children?
One day, in the clinic at the University of Louisville School of Dentistry, covering pediatric dental residents, I watched one of the residents impassionately counsel a young mother with baby in stroller and two toddlers beside. The resident explained the etiology of dental decay in this mom’s young children.
Because it was a residency program, we could spend the extra time with the parents - even when they had Medicaid coverage that didn’t pay much for that time. But today, this sweet mom and the pediatric resident had reviewed the four etiologic areas:
1. The "bugs" (bacterial plaque);
2. Food for the bugs (contribution of sugar and carbohydrates),
3. The teeth (tooth enamel and how well it resists the former two), and
4. Diluting the acids (saliva, content, volume, and hydration).
They had gone through the solutions to each:
1. Plaque control/oral hygiene practices,
2. Dietary changes to reduce sugar and carbs,
3. Regular recalls so the dentist can help evaluate how the enamel and teeth are doing, and
4. Lots of water intake.
Whew! This mom was “armed”.
She would work on brushing and flossing her children’s teeth, she said.
She was already careful with sugar, juices, soft drinks, etc., and rarely gave those, she said.
She would stay regular with the recalls, she said.
I helped her, as she wheeled the stroller out of the operatory and corralled the two toddlers.
“Hold up!” I exclaimed as I noted red liquid pouring out of the diaper bag in the stroller basket. Something was leaking.
“Uh oh,” said Mom. “It’s the Kool-Aid,” she stammered. “Sorry - I didn’t want you to see that.” (And it was in a baby bottle.)
Reboot. Now what?
Let’s regroup here. Take me - that passionate, loving, caring young mother who wanted to help children. Take you - the same. Life lessons in pediatric dentistry:
- As a young dentist, this is dizzying for you,. You work hard to encourage and educate, so your time and energy have the best chance of helping. (You hope and pray.)
- As a seasoned dentist, this is dizzying for you. You become disenfranchised with the whole thing, tired of working so hard for little and rare “success” in changing children’s hopes for dental health in their future. It becomes way too hard, way too frustrating, without obvious success or benefits, and your own worth as a professional is in question, in your own mind.
- A child can barely be helped if the mom isn’t truly interested, willing and capable. This sweet mom was not. Oh yes, she had brought the children to the clinic. Oh yes, she wanted to please us - by misleading us and telling us what she felt we wanted to hear. She wanted to be well-thought-of, loved. But she just wasn’t capable of facing the truth herself. She could not use what we offered.
- There are many parents who are not interested, or willing or capable - one or more of those limits.
- There ARE parents who are truly interested, willing and capable. These folks truly want your help. They want to work at helping their children, and utilize what you can offer.
- You can work to spend your time with the parents who will team with you to help their children. You can throw your passion in the ring where there are children who need your help, and in turn help your family in your best way. You can use your complex knowledge and understanding of preventive dentistry for the parents who show a reliable commitment to working with you for their children’s sakes.
- You will feel less stress, less hopelessness about dental health and about your practice.
- Then, surely, in your spare time, you can do "missionary work" - volunteering in clinics and programs where there are children who need primarily redundant restorative treatments, though many to most of those parents will not be able to partner with you for true dental health.
As the saying goes, “What is it that the rich cannot buy, and cannot be given to the poor? It is health.” Dental health is only reachable by the interested, willing and capable persons.
Put your passion, your energy, your love to all, and focus on the children whose parents partner with you in prevention. Then you will have given what you can - to those who will willingly take and use it!
We talk about this in ELEMENTS weekend seminars! Ask us about "chickens to concierge practice."
It’s amazing stuff!!
- Published on
ELEMENTS™ Seminars remind us that orthodontics -- and dentistry in general -- is all about love. Your success as a dentist relies on your abilities to put love into action in your practice, made effective with certain systems. Dr Chris talks about this and more, with our upcoming ELEMENTS Seminars, beginning July 13, 2018.
- Published on
Recorded near Dr Chris Baker's Abu Dhabi clinic, in the United Arab Emirates.
- Published on
Ectopic teeth in a smile and in orthodontics
For a patient whose teeth are ectopic - out of place - it is distressing.
A child will often say, “I don’t like my fangs.” And, if the teeth do not show up, are ectopic and unerupted, it is distressing to have spaces in your smile.
It is also distressing for you, wanting to be efficient and effective in helping create an even more beautiful smile. It is distressing in planning and carrying out your orthodontic mechanics in an often difficult situation with potential for negative sequelae.
A child will often say, “I don’t like my fangs.” And, if the teeth do not show up, are ectopic and unerupted, it is distressing to have spaces in your smile.
It is also distressing for you, wanting to be efficient and effective in helping create an even more beautiful smile. It is distressing in planning and carrying out your orthodontic mechanics in an often difficult situation with potential for negative sequelae.
IF, and that is, IF, you see the child early enough, there is a MOST HELPFUL answer to reducing the treatment time, the risk of sequelae, and improving the smile earlier on. It is simply, clearing the path of eruption.
While the scholarly articles about this topic are many, and great academics like Ericson and Kurol have written excellently, the bottom line is that the first and most important treatment/prevention is to clear the path.
As Fox and Fletcher wrote in the British Dental Journal, “ Late detection of palatal canines may have treatment implications for the patient and medico-legal implications for the dental practitioner.”
While it is rewarding to be thought of as the hero who helps a child have the most beautiful smile, it is no fun to be implicated in the parents’ and patient’s thoughts as someone who at worst, “harmed or worsened the smile,” and at best, “didn’t make it better, after all that ‘time and money.’"
While the scholarly articles about this topic are many, and great academics like Ericson and Kurol have written excellently, the bottom line is that the first and most important treatment/prevention is to clear the path.
As Fox and Fletcher wrote in the British Dental Journal, “ Late detection of palatal canines may have treatment implications for the patient and medico-legal implications for the dental practitioner.”
While it is rewarding to be thought of as the hero who helps a child have the most beautiful smile, it is no fun to be implicated in the parents’ and patient’s thoughts as someone who at worst, “harmed or worsened the smile,” and at best, “didn’t make it better, after all that ‘time and money.’"
Neither is it fun for the parent and patient to be unhappy with their smile, first and foremost, after orthodontic treatment, and neither is it fun for the parent and patient to be unhappy with the provider of orthodontic care.
Neither is it fun for the orthodontist to have a treatment plan extended by sometimes - yes - 2-3 years, working to aide eruption of the tooth/teeth, soothe the patient and parent as well as him/herself because everyone wants it to go quicker and easier.
Like all of your skills, surely you can learn to utilize, competently choose, plan and intermingle techniques necessary, including exposure, surgical attachment, orthodontic mechanics of wires, chain, forces, biomechanics including anchorage with TAD’s, appliances.
And, there will be patients who no one saw early enough to clear the path before the trajectory of the ectopic tooth/teeth was set and difficult.
And, there will be patients who BEFORE you even considered how to guide eruption and orthodontically reposition for that patient, there was damage to adjacent tooth roots, occurring as nature’s adverse trajectory triggered the resorption of other permanent tooth roots. And patients whose adverse position is such that the tooth cannot/should not be erupted due to risks.
As Jon Kurol states, “The correct development of a stable, functional, and aesthetically acceptable occlusion is an integral component of comprehensive oral health care for all paediatric dental patients.
It is the responsibility of the dentist to recognize, diagnose, and manage or refer abnormalities in the developing dentition.”
So what to do?
Prevent as often and as much as possible. Engage nature and natural eruption. Clear the path as early as is feasible and appropriate. Consider expansion if maxillary teeth are involved.
How to identify and diagnose aberrant eruption tracectories, ectopic teeth? Take a panoramic x-ray. Routine pano should be taken when any permanent tooth is erupting into the mouth. That is the time to initially identify possible aberrancies.
Neither is it fun for the orthodontist to have a treatment plan extended by sometimes - yes - 2-3 years, working to aide eruption of the tooth/teeth, soothe the patient and parent as well as him/herself because everyone wants it to go quicker and easier.
Like all of your skills, surely you can learn to utilize, competently choose, plan and intermingle techniques necessary, including exposure, surgical attachment, orthodontic mechanics of wires, chain, forces, biomechanics including anchorage with TAD’s, appliances.
And, there will be patients who no one saw early enough to clear the path before the trajectory of the ectopic tooth/teeth was set and difficult.
And, there will be patients who BEFORE you even considered how to guide eruption and orthodontically reposition for that patient, there was damage to adjacent tooth roots, occurring as nature’s adverse trajectory triggered the resorption of other permanent tooth roots. And patients whose adverse position is such that the tooth cannot/should not be erupted due to risks.
As Jon Kurol states, “The correct development of a stable, functional, and aesthetically acceptable occlusion is an integral component of comprehensive oral health care for all paediatric dental patients.
It is the responsibility of the dentist to recognize, diagnose, and manage or refer abnormalities in the developing dentition.”
So what to do?
Prevent as often and as much as possible. Engage nature and natural eruption. Clear the path as early as is feasible and appropriate. Consider expansion if maxillary teeth are involved.
How to identify and diagnose aberrant eruption tracectories, ectopic teeth? Take a panoramic x-ray. Routine pano should be taken when any permanent tooth is erupting into the mouth. That is the time to initially identify possible aberrancies.
Dental panoramic tomograms/ radiographs are widely taken in practice, but not often enough when permanent teeth are just beginning to erupt.
Look at the radiograph. Identify each and every permanent tooth’s presence and trajectory. Diagnose aberrancies. Inform the parent. Plan to manage or refer. Every single time.
Management at early transitional dentition may include: clearing the path, expansion, monitoring with progress films. Just don’t ignore the aberrancy! Instead, change a life!
Look at the radiograph. Identify each and every permanent tooth’s presence and trajectory. Diagnose aberrancies. Inform the parent. Plan to manage or refer. Every single time.
Management at early transitional dentition may include: clearing the path, expansion, monitoring with progress films. Just don’t ignore the aberrancy! Instead, change a life!
- Published on
© 2018 Dr Chris Baker
LEFT: Patient "Miss A" (see below for case explanation), displaying a right lateral openbite and forward tongue. © 2018 Dr Chris Baker
Funny how we call detailing the tooth alignment and the bite, “finishing”. Funny because it all starts from diagnosis. Actually it starts at the initial examination. What we do at the beginning makes our finishing time longer or shorter.
Here are three examples of finishing challenges that can become overwhelming, and how you can know of the facts, and handle the challenges better, from the start:
Facts and challenges like:
Patient Miss A may need lengthy and difficult anterior bite closure - how do you know?.
- ENT referral and treatments
- Tongue exercises that you prescribe
- Sublingual frenectomy
- Habit treatment
- Bite turbos, posterior biteplate, or other posterior intrusion therapies
- UAW or other molar positioning and incisor extrusion where appropriate
- TAD anchorage with posterior intrusion
- Lower full coverage splint following ortho treatment
And look at the concern typed onto the treatment plan for this patient, just above the signature line for the parent/patient:
Concern – Airway issues, habits and adverse tongue positions all contribute to adverse growth and continued adverse forces on teeth, with or without orthodontic treatment. Adam’s growth is vertical, which is made worse by mouth-breathing and low tongue position.
This may predispose him to an openbite. All treatment will be directed to improving these adversities, but longterm stability is lessened and risk of relapse is greater, depending on the success of the airway treatment, tongue position improvement and habit cessation.
OR
Vertical growth patterns are difficult to correct, and when corrected, often relapse, with a return of the open bite (space between upper and lower incisors, when the patient is biting on the posterior teeth.)
Even in the best-case scenario, openbites may relapse. Beginning treatment as soon as is feasible may help in longer-term stability. Compliance with elastic wear, if indicated, is important. All treatment is directed to improving the openbite pattern with as much stability as possible.
Annie’s tongue position is low and forward, and probably is contributing to the spacing of her teeth. Tongue training may be helpful, including CM circle and ball on retainers, and wear of her retainers as directed, will be critical, because the teeth often exhibit connective tissue memory/relapse without excellent retainer wear, due to the tendency of the tongue to remain forward and low throughout life.
Patient Mr. B may have later excessive mandibular growth, “outgrowing” your orthodontic treatment that attained a beautiful Class I, and the patient ends up Class III with open bite tendency. How do you know?
A patient and his mother presented for a recall orthodontic evaluation, and the mom said her dentist had asked her why we took the braces off, when he had 0 overbite and 0 overjet. A review of his final photographs at orthodontic completion showed a Class I occlusion with 3 mm overbite and 3 mm overjet. Indeed that was not the case any longer.
His treatment plan had listed the concern of possible excessive mandibular growth. He had a chin sling for nighttime wear prescribed for wear with his retainers, which had not been worn. Don’t we dislike these concerns expressing themselves in reality?
But - we don’t make the growth, and we are pleased to stress the concern at the diagnostic and retainer delivery stage. The patient compliance may not work to advantage. We hate that, of course.
Treatment during or throughout the original active phase, not just during what we call finishing may include:
- Class III Correctors - Motion or D2 appliances
- Chin Sling or Facemask wear
- Posterior intrusion therapies
Communication of growth progress to the parent is critical, throughout treatment. Keep them in the reality loop!
Patient Miss C may have difficulty attaining and maintaining adequate canine and/or posterior overbite. How do you know?
- Tongue exercises
- Blue Grass or other beads in palate
- Castillo-Morales circle in palate
- Crib on appliances
- Expansion therapy
We could similarly lay out the signs of future TMJD, of lack of eruption of an ectopic tooth, adding 2-3 years to a treatment time, of the complete dependence on the patient’s compliance if the occlusion is to be corrected, and on and on…
So, before you even consider putting appliances into a patient’s mouth, consider the findings - all of them. Do excellent diagnostics. Get all the information - about medical, airway and breathing, dental, skeletal, growth and finally dental findings. THEN put it together in a comprehensive treatment plan that you can share with the parent /patient, giving them the information they need to make good informed decisions about the treatment.
Then, pay the closest attention to your bracket placement. Bracket placement, though impossible to do perfectly, can make huge differences in finishing needs.
Keep everyone — parents, patient, your chart — in the loop. Be honest and open with the progress, OR LACK THEREOF. This will help you throughout the treatment. Your finishing will be more predictable, and could be a lot less surprising, a lot less difficult, and a lot less stressful for all.
- Identifying the existing risks, discrepancies, malpositions, and adverse trajectories of erupting or unerupted teeth begins your finishing.
- Making them part of your written treatment plan information for the parent/patient puts you all on the same page, reducing surprises and disappointments later.
- When you work these out, discover, document, and add the concerns to the treatment plan, and review with the parents/patient BEFORE you start, you will feel better, they will feel better, and even though the challenges are there for all of you, there is a better chance of working together with the realities.
Here are three examples of finishing challenges that can become overwhelming, and how you can know of the facts, and handle the challenges better, from the start:
Facts and challenges like:
Patient Miss A may need lengthy and difficult anterior bite closure - how do you know?.
- Signs and symptoms of airway and breathing limitations (bedwetting, ADD/ADHD, mouthbreathing, snoring, bruxism/grinding, enlarged tonsils, enlarged adenoids, dense turbinates and more).
- Vertical or dolichofacial growth and muscle patterns
- Forward and low tongue position, tongue habits, forward tongue swallow, difficulty with sibilant sounds and even generalized spacing between teeth
- Short sub-lingual frenum, which makes the tongue stay low and forward
- History of or current finger, thumb or pacifier habit
- Deficient overbite
- Protrusive incisors
- ENT referral and treatments
- Tongue exercises that you prescribe
- Sublingual frenectomy
- Habit treatment
- Bite turbos, posterior biteplate, or other posterior intrusion therapies
- UAW or other molar positioning and incisor extrusion where appropriate
- TAD anchorage with posterior intrusion
- Lower full coverage splint following ortho treatment
And look at the concern typed onto the treatment plan for this patient, just above the signature line for the parent/patient:
Concern – Airway issues, habits and adverse tongue positions all contribute to adverse growth and continued adverse forces on teeth, with or without orthodontic treatment. Adam’s growth is vertical, which is made worse by mouth-breathing and low tongue position.
This may predispose him to an openbite. All treatment will be directed to improving these adversities, but longterm stability is lessened and risk of relapse is greater, depending on the success of the airway treatment, tongue position improvement and habit cessation.
OR
Vertical growth patterns are difficult to correct, and when corrected, often relapse, with a return of the open bite (space between upper and lower incisors, when the patient is biting on the posterior teeth.)
Even in the best-case scenario, openbites may relapse. Beginning treatment as soon as is feasible may help in longer-term stability. Compliance with elastic wear, if indicated, is important. All treatment is directed to improving the openbite pattern with as much stability as possible.
Annie’s tongue position is low and forward, and probably is contributing to the spacing of her teeth. Tongue training may be helpful, including CM circle and ball on retainers, and wear of her retainers as directed, will be critical, because the teeth often exhibit connective tissue memory/relapse without excellent retainer wear, due to the tendency of the tongue to remain forward and low throughout life.
Patient Mr. B may have later excessive mandibular growth, “outgrowing” your orthodontic treatment that attained a beautiful Class I, and the patient ends up Class III with open bite tendency. How do you know?
- The patient has more than 4 total clinical deviations from the norm toward Class III, between Porion Location, Ramus-Xi position, Cranial Deflection and Molar Position.
- The patient presents with Angle Class I occlusion or Super Class I occlusion
- The patient has a brachyfacial growth and muscle pattern.
- The patient is skeletal Class III.
A patient and his mother presented for a recall orthodontic evaluation, and the mom said her dentist had asked her why we took the braces off, when he had 0 overbite and 0 overjet. A review of his final photographs at orthodontic completion showed a Class I occlusion with 3 mm overbite and 3 mm overjet. Indeed that was not the case any longer.
His treatment plan had listed the concern of possible excessive mandibular growth. He had a chin sling for nighttime wear prescribed for wear with his retainers, which had not been worn. Don’t we dislike these concerns expressing themselves in reality?
But - we don’t make the growth, and we are pleased to stress the concern at the diagnostic and retainer delivery stage. The patient compliance may not work to advantage. We hate that, of course.
Treatment during or throughout the original active phase, not just during what we call finishing may include:
- Class III Correctors - Motion or D2 appliances
- Chin Sling or Facemask wear
- Posterior intrusion therapies
Communication of growth progress to the parent is critical, throughout treatment. Keep them in the reality loop!
Patient Miss C may have difficulty attaining and maintaining adequate canine and/or posterior overbite. How do you know?
- Low and adverse tongue position
- Narrow palate, result of low tongue and cheek muscles strong without tongue balance
- possibly Class III tendency
- Tongue exercises
- Blue Grass or other beads in palate
- Castillo-Morales circle in palate
- Crib on appliances
- Expansion therapy
We could similarly lay out the signs of future TMJD, of lack of eruption of an ectopic tooth, adding 2-3 years to a treatment time, of the complete dependence on the patient’s compliance if the occlusion is to be corrected, and on and on…
So, before you even consider putting appliances into a patient’s mouth, consider the findings - all of them. Do excellent diagnostics. Get all the information - about medical, airway and breathing, dental, skeletal, growth and finally dental findings. THEN put it together in a comprehensive treatment plan that you can share with the parent /patient, giving them the information they need to make good informed decisions about the treatment.
Then, pay the closest attention to your bracket placement. Bracket placement, though impossible to do perfectly, can make huge differences in finishing needs.
Keep everyone — parents, patient, your chart — in the loop. Be honest and open with the progress, OR LACK THEREOF. This will help you throughout the treatment. Your finishing will be more predictable, and could be a lot less surprising, a lot less difficult, and a lot less stressful for all.
Patient "Mr B" (case discussion above), displaying zero overbite, zero overjet and excessive mandibular growth. © 2018 Dr Chris Baker
Patient "Miss C" (see above for case discussion) displaying an adverse tongue position. © 2018 Dr Chris Baker
