With Lawrence s. Harte, dds
OP: How important is the case-selection process to the success of an orthodontic practice?
Harte: It may well be the most important aspect in the building or destroying of a practice. It has been my experience that the most successful practices spend a great deal of time and energy in this area.
On the other hand, a lack of detail in the case-selection process can destroy a practice financially. It is disheartening to see excellent orthodontists and their highest principles falling prey to this situation. It does not have to happen.
OP: Is a case-selection process taught in resident training?
Harte: The student is encouraged to diagnose and treat most types of cases. This training is part of the didactic and academic process.
From a practice standpoint, the instruction can include a case-selection process. Meaning, what are the ramifications of potential problems? How much time is needed? What kind of result can be expected? A critical part of education is understanding the nuances of different types of cases and the patient personalities that go along with those nuances.
Today’s orthodontists are the cream of the crop and are well-trained. In schools, we are all taught how to diagnose and start cases; however, students are not usually around to finish the cases they have started. In fact, in starting a case, we should look at the ramifications of finishing the treatment before we begin the process.
OP: What order would you use for this case-selection process?
Harte: I would place the order of the selection process as follows:
1) diagnose the case;
2) determine the potential treatment problems;
3) consider how to prevent the potential treatment problems;
4) plan what to do if the problems do occur;
5) figure out what extra time may be needed;
6) determine the additional fees;
7) decide if additional x-rays are needed;
8) gauge the patient expectations of length of treatment and result;
9) assess the personality, attitude, and responses of patient;
10) take a medical history; and
11) discuss cooperation.
OP: Can you tell us more about cooperation?
Harte: Cooperation is essential to patient and practice satisfaction, and would consist of:
1) maintaining oral hygiene;
2) listening to instructions; and
3) having minimal breakage.
If patients have a poor-cooperation appointment, we add 1 month to the debracing date, and the patient initials it. We also explain in a positive way the ramifications of this on the treatment and results.
If a final result is not going to be to our standards, we offer the Olympic medal philosophy. There are gold, silver, and bronze medals in the Olympics; just getting there is a magnificent feat. Your child may end up with a bronze or silver, which is pretty good, but not perfect.
OP: Are there any specific staff techniques that point to a successful conclusion of the case-selection process?
Harte: Yes, the staff and the doctors should have a 30-minute training session per week on this type of treatment process.
OP: What should be part of this training session?
Harte: At each visit, the orthodontist and/or the office coordinator will encourage the staff to check that the patient is cooperating, that the patient is following instructions, and that the patient has minimal breakage. If these things are not happening, we train the staff to help modify the patient’s behavior.
OP: On a practical level, how does the case-selection process work?
Harte: We begin with the initial contact to the office and then follow these specific steps:
3) intake sheet; and
4) medical history.
The patient is interviewed by the staff; two questions that we always ask are the following:
1) What is your main concern?
2) If there is only one thing the orthodontist could do for you, what would it be?
One would be surprised that even though the two questions sound the same, the answers are quite different.
After this, the patient’s pan and photo are taken. The orthodontist then reviews the records, reads the medical history, and asks the treatment coordinator (TC) for input.
The orthodontist then greets the patient and asks the same two questions. The answer can be different from the one given to the TC.
OP: Do you have a prototype for determining types of cases?
Harte: Yes, we divide them into the following six categories:
1) Easy case, compliant patient; estimated at less than 24 months for completion.
2) Difficult case, cooperative patient; estimated at 24–30 months for completion.
3) Easy case, noncooperative patient; estimated at 30 months for completion.
4) Difficult case, noncooperative patient; estimated treatment time remains open.
5) Difficult case with specific diagnosis (such as impactions, open bite, Class III malocclusions), compliant patient; estimated at 24–36 months for completion.
6) Difficult case with specific diagnosis (such as impactions, open bite, Class III malocclusions), noncompliant patient; open treatment time and open fee.
OP: From a practical point of view, how do you take care of a noncompliant patient?
Harte: There are a couple of ways to take care of these patients. The first is the Olympic medal analogy: The patient has come a long way. The result is not as perfect as we would like, but bronze is pretty darned good. The second is, “three red strikes and you’re out”: If the patient has three red marks for noncompliance within a 6-month period, the parent is brought in. The orthodontist then offers the following alternatives:
1) Take the braces off and have the parent sign a release letter.
2) Continue treatment with the understanding that the result will not be as excellent as either we or the patient would want it to be.
3) If the noncompliance continues, we must take the braces off for the protection of the patient.
OP: What about practices in small markets where there are fewer choices of what cases to take on?
Harte: Tough question. Let’s break it down into two areas. First, if you are starting a practice, you do not want to lose patients; so the orthodontist is going to have to take more chances—but not heroic ones. If there is a heroic case, advise the referring dentist and, if possible, refer this case to a dental school.
If your practice is in a small market, I would suggest the following:
1) Advise the referring dentist.
2) Refer the case to a dental school.
3) Have another orthodontist in the area have this wonderful opportunity.
4) If you are gung-ho, carefully advise the patient of the pluses and minuses of treatment, with the patient acknowledging in writing all that you have told him or her.
OP: What factors affect case selection?
Harte: First, personalities. Certain personalities can affect treatment in a positive or a negative fashion. Quite often, on the negative side, cases can go longer and not have as good a result as they might, with strong implications to the future of the practice. Patient and parent attitudes strongly affect case selection. Some difficult personality types are the following:
1) Narcissists: people who love themselves 100%, to the exclusion of everybody else.
2) Tyrants: people who are angry and mean, to the exclusion of everyone else.
3) Attention-getters: people who insist on doing anything to get your attention.
4) Patients with unusual symptoms: those who have bizarre reactions, such as itchy hands when braces are put on.
5) People who make negative facial grimaces, or people whose body language is rigid.
6) Perfectionists, who will not settle for anything that is not 100% correct in their mind.
7) People who are “against” various treatments, such as extractions, jaw surgery, interproximal reduction, and headgear.
There are also many different types of patient and parent responses:
1) The hatchet person didn’t like the last five orthodontists, and—guess what?—you’re going to be the sixth.
2) The answer-demander wants an answer for every question, even if there is no answer. As Gertrude Stein was reported to have said, “There is no answer, there ain’t no answer, and that will be the answer.”
3) Deniers deny that they did anything wrong.
4) Paranoid people feel that the office is out to get them.
5) When a wife says that her husband is out of work, she’s often telling you that you’re not getting paid.
6) Controllers want to control patient scheduling and sometimes treatment protocol.
7) Go-getters are very enthusiastic, but they have to be kept on this high plain to maintain their attitude.
8) Adulators rave about you to the heavens and then the next moment will blame you to Hades.
We don’t try to change these people; we just try to modify their habits.
Another factor affecting case selection is if a patient has a skeletal Class II malocclusion. In these case where the lower jaw is recessive, there are many possible solutions, including a Herbst-type appliance, headgear, or a combination of orthodontics and orthognathic surgery. Quite often, the patient will say, “Do the best you can without surgery.” If the orthodontist does not feel the case will look good and have adequate function after treatment, the orthodontist may not want to accept this case.
Skeletal class III malocclusions, where the upper jaw is deficient, also have a number of treatment options. Quite often, this type of case can be resolved early with the use of an expansion appliance and a face mask. Class III malocclusion can also occur where the lower jaw is forward. Again, if the orthodontist does not feel that he can get an adequate result without surgery, he should not consider starting the case. The orthodontist should not start this case even if the patient is willing to accept the result, because the patient can change his or her mind later on.
Skeletal anterior and posterior open-bite cases are difficult to close and even more difficult to maintain with only orthodontic care. The patient can also have a relapse, even with surgery.
And as we all know, impacted cuspids, molars, or other teeth can be difficult to bring into the arch. Early x-ray diagnosis of impacted teeth can help prevent future problems. If the crowns of the maxillary cuspids are affecting the upper anterior teeth by angulations, this could cause a change in diagnosis. This treatment quite often will go longer then expected with the possibility of not as good a result as we want.
OP: How can case selection improve or detract from an orthodontic practice’s bottom line?
Harte: As an example, if a case is quoted with a 2-year fee and goes 3 years, you have actually given away the case for nothing. To make a bad joke: If you gave the patient $100 and didn’t start treatment, you’d be ahead of the game financially and when it comes to peace of mind.
We have three methods of fee arrangements. We offer a 5% discount for payment in full. Otherwise, we allow patients to use credit or debit cards for monthly payments.
OP: How can case selection improve or hurt a practice’s reputation?
Harte: The only standard a community recognizes is that an orthodontist’s capabilities are built through trust and reputation. If an orthodontist promises to finish the case in 2 years and goes over this prediction, they have lost the patient’s trust, even if the patient was completely in the wrong.
Increased time in braces can lead to the following:
1) decalcification and/or decay of the teeth;
2) periodontal involvement;
3) lack of optimum occlusion;
4) TMJ symptoms;
5) bruxism habits;
6) relapse of bite because of lack of retainer wearing; and
7) criticizing the orthodontist to the referring dentist and the community.
Even if patients acknowledge that they were not correct in their assessment of the orthodontist, they usually do not go back and tell their friends that they made a mistake.
OP: How can case selection reduce malpractice claims?
Harte: Most malpractice claims occur because of the lack of consistent positive communication between the orthodontist and the patient throughout the treatment process. By losing the trust of the patient and having additional problems due to treatment, the orthodontist holds himself up to additional claims.
OP: Anything else?
Harte: I would like to leave your readers with a philosophy that my Uncle Lou, who was 106 when he passed away, gave to me. I call it “The Art of Living”:
1) Assume nothing.
2) Never go against your gut.
3) Do not harass the opponent.
4) Don’t look back; you are never really alone.
5) Keep your options open.
6) Never burn your bridges.
7) Look and see.
8) Hear and listen.
9) Think and have the courage to act on your convictions.
10) The greatest failure is the failure of imagination.
11) Make each day a challenge rather than a blessing or a curse.
12) Like and be who you are!
Lawrence S. Harte, DDS, is in private practice in Livingston, NJ, and is the vice chair of the Public Health Council of New Jersey. He is the founder and director of The Cosmetic Enhancement Facial Center. He has lectured throughout the United States and the world on topics of management and feeling good about yourself. He can be reached at [email protected].