Robert Waugh, DMD, MS, doesn’t believe in turf battles—whether it be with the local orthodontic competition or the referring dentists in town.

In the early 2000s, after 12 years spent establishing a successful two-office practice in Athens, Ga, Waugh knew he wanted to expand. Once he found his ideal property, he realized that Billy Allen, DDS, an orthodontist with the largest practice in town, had an office nearby. Waugh knew it made no sense to build a new office in the same area; but instead of looking elsewhere, he decided to approach Allen and ask about his plans. Allen was interested in joining forces and, in 2002, to the shock of his peers, the two merged to form Waugh+Allen Orthodontics. Instead of maintaining their collective five locations, they streamlined the practice down to three because it made economic sense. A few years later, Allen announced his retirement and Waugh found himself undertaking a massive project to create a clinical and teaching facility that has allowed him to undertake a forward-thinking approach to orthodontics and, more importantly, patient hygiene.

At the heart of Waugh’s office is the wheel—a group of six chairs arranged in a circular formation that are focused on diagnostics and, more specifically, hygiene.

At the heart of Waugh’s office is the wheel—a group of six chairs arranged in a circular formation that are focused on diagnostics and, more specifically, hygiene.

The Wheel

under one roof. Instead of trying to build his dream facility within one of the existing offices, he elected to find a location in the middle of the three offices—the idea being that an entirely new location would limit patients asking why the office nearest them closed. Waugh in turn built a new 8,800-square-foot, 24-chair facility, opened in 2008, that allowed him to incorporate the latest technology. “When you have multiple offices, you can’t do that in every office. It’s just too much,” he points out.

With Allen’s retirement in 2007, Waugh decided to take their three Athens-area offices and again consolidate, this time

Countdown timers on the wall keep Waugh and his staff on track with each 15-minute wheel session.

Countdown timers on the wall keep Waugh and his staff on track with each 15-minute wheel session.

At the center of the facility is “The Wheel”—a group of six chairs arranged in a circular formation. While the arrangement is based on the Cutler Wheel used for adjustments, Waugh’s wheel is used for diagnostics, with an emphasis on hygiene. Like the Cutler Wheel, the doctor is able to bounce from chair to chair quickly and efficiently. Once patients are admitted as a group into the wheel, they are whisked through a three-step diagnostic process that takes all of 15 minutes. First, a hygienist uses a Prophy Jet air polisher on the facial surfaces of patients with braces who need it. In addition, the hygienist does an evaluation and recommends relevant hygiene products. The patient then receives a grade for their hygiene.

Next up for the wheel patient is a photography session with the staff’s dedicated photographer. Waugh is a firm believer in photography at every patient visit. “This is the orthodontist’s best teacher,” he says. “With it, you become more efficient because you see what happened from visit to visit. You’re more informed and you’re not trying to remember each patient and what happened last time. You can see it.”

Typically, the photographer takes five intraoral photos and a smile shot. Within 2 minutes, those photos are downloaded, cropped, and passed on to Waugh who then comes chairside to do his assessment. With the photos, he can quickly assess how the teeth are moving and what’s needed next. Using his digital recorder, Waugh makes a note of what the plan is for that day’s patient visit and what should be on the agenda for the next visit. When the countdown timer on the wall chimes that 15 minutes is up, the six patients in the wheel are dismissed and taken into the clinic for their individual adjustment appointments, which typically last 30 minutes or less. The practice typically runs 20 sessions a day in the wheel.

As Waugh describes it, the wheel runs much like an airport, where large groups of passengers arrive at the gate where they are then assembled into smaller groups that are then allowed on the plane. In the wheel, patients arrive at the office and are placed in groups of six. That group of six is then taken into the wheel. Once their 15-minute session in the wheel is completed, the group is dismissed and those patients filter into their individual adjustment appointments. Meanwhile, the next group of six patients is ushered into the wheel.


The Credit Goes To

The wheel concept is the result of Waugh’s long-time commitment to patient hygiene, which he largely credits to his on-staff hygienist Tracy Vitug, RDH. Twenty years ago, Vitug, then Waugh’s orthodontic assistant, suggested he hire a hygienist. Initially, Waugh balked, worrying about a possible turf battle with referring general dentists. But Vitug, who went on to be trained as a hygienist, convinced Waugh of the need, and the two set up Partners in Prevention. That program focused on having a hygienist on staff who would do alternate cleanings, much like a general dentist would do with a periodontist. Waugh and Vitug made it clear that the practice wasn’t trying to step on anyone’s toes. Instead they emphasized that their goal was to take care of the referring dentist’s patients and return healthy patients back to the dentist.

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TracyVitugHygiene Crusader
How often, when cautioning a new patient about the importance of good hygiene habits during treatment, do parents point to their own teeth and tell you how they were left with white spot lesions after their own orthodontic treatment? How do you ensure that their child won’t leave with a beautiful—but imperfect—smile?

For more than 20 years, Waugh+Allen Orthodontics’ hygienist Tracy Vitug, RDH, has been leading the charge in ensuring that patients finish treatment free of decalcifications that can mar that beautiful smile.

Vitug was instrumental in helping Waugh establish his practice’s own hygiene protocol and “wheel” treatment concept. Today, Vitug, who facilitates an annual dental hygiene continuing education program for the area’s 100 plus dental hygienists, can be found lecturing at industry meetings and visiting practices to help them implement an appropriate variation on this protocol.

To get started, Vitug recommends that practices look at initially targeting patients struggling with hygiene and employing a hygienist part time to get those patients on track. From there, she provides guidance on services to offer, focusing on air polishing, in-office fluoride treatment, and varnish application. Vitug then provides information on medications and aids, communication, and patient motivators.

At Waugh+Allen Orthodontics, the hygiene program has become a key draw for new patients. “It’s really exciting to hear them come in and say they want to come here because of that,” Vitug says. “I tell other offices, if you want to set your practice apart in this really competitive market, do everything you can to do what’s best for your patients and provide everything you can to ensure a healthy orthodontic result.”

For those orthodontists worried about turf battles with referring dentists, Vitug contends that communication can go a long way to dispelling such concerns.

“The majority of dentists want what’s best for their patient. The key to [eliminating any turf issue] is to really make sure to communicate what you are trying to do from the start,” she says.

In addition, she points to the fact that, at Waugh+Allen Orthodontics, they don’t bill insurance for hygiene treatment. Instead the cost is absorbed in the overall treatment fee. What’s more, by educating patients about the importance of hygiene during orthodontic treatment, and the importance of still seeing their dentist during their orthodontic treatment, patients are more likely to follow up with their dentist for recare appointments—thus providing dentists with more business.

Given the fact that over 50% of orthodontic patients nationally are finishing treatment with some type of decalcification, Vitug contends there is no time like the present to implement a hygiene protocol in your practice and start protecting your patients’ future smiles. OP

Partners in Prevention ran for a decade, but it never reached the number of patients Waugh and Vitug wanted, nor did it reduce the incidences of decay as they hoped. “It was only getting to the people who could afford it. Only a third of the patients used it,” he recalls. So, with the new office, Waugh and Vitug amped up the concept and introduced Bright Brace® which incorporates the wheel format. When Bright Brace launched, Waugh evaluated 100 consecutive cases treated with and without the Bright Brace protocol. The results showed that Waugh’s practice was able to cut decalcification in half with the new protocol.

Cutting decalcification is a major concern for Waugh. Not only does he want his patients to finish treatment with beautiful smiles, but he wants to protect himself. “It’s my understanding that the number two reason that orthodontists get sued now is because they are negligent in supervision of hygiene. Patients get their braces off and they have 10 cavities, and no one said a word about cavities during treatment. Well, this way, I don’t worry because my hygienist already spotted it, already warned them, already documented it, and I never look back,” he says.

As Waugh sees it, orthodontists often assume their assistants can properly assess hygiene, but that’s not their job. Their job is to do the adjustment. “[Assistants] are working under the stress of getting the adjustment done. Eventually they get numb to the fact that patients need [advice] on how to keep their teeth clean. But by hiring a hygienist, you have someone whose mission in life is to save teeth from decalcification,” he says. As to the expense of bringing a hygienist on staff, Waugh points out that many hygienists are often looking to pick up a day here and there, and that a practice need not hire a full-time hygienist. But the fact is, Waugh bit the bullet because he knew it was the right thing to do for his patients.

At Waugh’s practice, the cost of hygiene care is included in treatment costs, which gives every patient access to the same care. Moreover, it eliminates any potential conflict with referring dentists. As Waugh describes it, if the practice were to offer the service only to patients who wanted to pay, dentists could accuse him of poaching hygiene patients. For Waugh, the possibility of antagonizing referring dentists isn’t worth the extra dollars of providing hygiene care only to patients who are willing to pay.

“That’s not even worth it to me,” he says. “To me, the real value in doing this is that it distinguishes our practice. Our practice is well known for returning patients without decalcification.”

Waugh is a huge advocate of photography and considers it an orthodontist’s best teacher.

Waugh is a huge advocate of photography and considers it an orthodontist’s best teacher.

Positive Effect

As for the wheel concept as a whole, Waugh praises it for the efficiency it brings to the practice. For example, the photography component allows Waugh to really zero in more quickly on what is working and what is not in the course of treatment. “Some people just keep doing the same thing over and over until they realize, ‘Oh gosh! It’s not working!’—but 3 or 4 months later they realize that. [With the photography], I see it the first time because I compare the pictures at every visit.”

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Learn More

Robert Waugh, DMD, MS, firmly believes that a hygienist needs to be a part of the orthodontic practice, especially if the specialty is going to cut down on the cases of white spot lesions. On October 12, 2017, Waugh will lead a free webinar, hosted by Orthodontic Products and sponsored by 3M, that will explore the protocol he has implemented in his practice and how it has made a difference in his patients’ lives. What’s more, the webinar will look at the physical facility requirements, as well as the management requirements to keep such a venture affordable for the practice. Finally, the webinar will address how this protocol can be used as a marketing tool to help distinguish the practice.

“White spot lesions are a constant problem. It’s really the bane of orthodontics when you’ve done all this nice work. Basically, we have to raise the bar,” says Waugh.

Visit to register for the webinar and/or view it on-demand. OP[/sidebar]

Furthermore, the wheel’s positive effect extends to scheduling. “In our older office, people would arrive late and they would expect that we would still see them,” he says. With the introduction of the wheel, the practice would call all the patient names in the six-person group at once. Patients would then be brought into the wheel precisely to the minute of their scheduled appointment. No one was allowed to be late.

“We said, ‘Come early. There’s plenty to do. We encourage you to brush your teeth and enjoy the game room—but please be here on time because that’s when you’re admitted to the wheel.’ We literally would call all the names for that group and then literally pull a rope across, like at the movie theater, and close the wheel,” he says.

Yes, Waugh admits patients would still walk in late and expect to be seen. But the staff’s response was a hard-and-fast “no”—those patients wouldn’t be allowed to join the wheel and receive hygiene care. However, they would be able to get their adjustment when their wheel group dismissed. They would then be reminded that if they came on time to their next appointment they would have access to the value-added offerings like the Prophy Jet air polishing, the hygienist review, and the photography. Within about 6 months of introducing the wheel and its strict scheduling, the practice saw a reduction in patients arriving late. This in turn translated into a practice known for running on time.

Twenty groups of patients pass through the wheel per day.

Twenty groups of patients pass through the wheel per day.

“That’s been a huge thing,” Waugh says. “Everybody knows when they come to Waugh+Allen that they’re going to be seen on time.”

For those practices that say they can’t devote six chairs to the wheel concept, Waugh points out that the six chairs are not a requirement. The six chairs were the result of the high volume of patients he was seeing when Allen initially retired. To staff the six chairs, Waugh needed two doctors, two hygienists, and one photographer. If the six chairs were filled, the first chair would always be for an observational retainer check—or something equally quick. Waugh would start at that chair. Meanwhile, the photographer and the hygienists would rotate in on the other chairs. As Waugh’s patient load evened out, he reduced the wheel to four chairs, sometimes five. In that case he only needs one hygienist, one photographer, and himself.

Waugh admits that doing a wheel—ie, creating a separate diagnostic space—would be difficult for a smaller practice; however, the hygiene component is still easily adoptable. A smaller practice can get started by dedicating one chair, even just once a week, to implement this concept on a smaller scale. Waugh advises that the practice schedule all patients with hygiene issues on that one day, put them in the dedicated chair, and build a schedule around it. With this format, the practice would only need to hire a hygienist one day a week.


Full-Service Facility

Waugh’s facility is run much like a medical clinic. In addition to the wheel section and the regular orthodontic clinic, the practice has a dedicated three-chair emergency clinic for short checks and other issues that don’t require doctor involvement. The clinic is open every day until 5 pm and is free of charge. The goal of creating the emergency clinic was to cut down on patients with broken appliances waiting until their regularly scheduled adjustment appointment to be seen, and then expecting to use that appointment to address the broken item and the adjustment. As Waugh puts it, the emergency clinic was a nice way to curb emergencies and their disruption to the schedule.

The facility also features a dental sleep medicine wing. Waugh ventured into dental sleep medicine with the retirement of local dentist Robert Ward, DMD, who had run his own dental sleep clinic for 12 years. Waugh recognized that sleep disordered breathing conditions were a real epidemic and wanted to learn how to treat them. Waugh acquired Ward’s practice in 2014 with Ward agreeing to teach Waugh his system. In addition, Waugh inherited Ward’s staff who did medical billing and knew the patients.

Waugh, who has passed his written boards and secured accreditation for the facility through the American Academy of Dental Sleep Medicine, admits the dental sleep medicine component will never truly mix with the orthodontic side of his facility. “These patients will never make an early morning appointment because they are sleepy. They’re generally older patients and you just can’t rush them. For me, it doesn’t really fit our style,” Waugh says, “but I do want to learn it so I made the commitment to do this.” Moreover, he contends that it helps him do “airway friendly orthodontics” with his regular orthodontic patients.

“When I walk out of one room and I’ve got a 60-something-year-old who’s got heart problems and they had a deficient mandible or they had extracted teeth because the orthodontist closed up the space and crouched the tongue and now they can’t breathe, and then I go in the next room and I see a 10-year-old and they’re borderline extraction, how am I going to treat that? I’m going to keep the teeth. I’m going to try to open the airway. I’m going to try to do everything I can with orthopedics to improve their bite and get the tongue off the back of the throat. For me, it really was an eye-opener in doing airway friendly orthodontics,” he says.

Whether it be providing patients with airway friendly orthodontics or hygiene care that guarantees them a beautiful smile, Waugh has created a practice that operates on the idea that orthodontics is more than just orthodontics. Turf doesn’t matter. What matters is good patient care. OP

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Practice Profile

Practice name: Waugh+Allen Orthodontics

Location: Athens, Ga

Number of chairs: 24

Years in practice: 28

Education: BS, Mercer University; DMD and MS in Oral Biology, Medical College of Georgia; Certificate in Orthodontics and MS in Oral Biology, Baylor College of Dentistry.

Average patients per day: 90

Days worked per week: 4

Staff size: 23

Top products used: Clinpro Glycine Prophy Powder (3M), Vanish 5% Sodium Fluoride White Varnish (3M), Clarity ADVANCED Ceramic Brackets with APC Flash-Free Adhesive (3M), Unitek Lateral Development Archwires (3M)

Practice website: [/sidebar]