Australasian Dentist Magazine March April 2021

Category Australasian Dentist 109 and teach the general dentists which cases should be tackled in the general dental environment and which cases would best be referred out. This is no different to any other field of dentistry including endodontics, periodontics or oral surgery. Orthodontics is not so difficult, once you learn and understand the basic principles and it is very important you are taught correctly. I believe you must understand risk management as this will save you a lot of heartache in the future, and this applies not just to fixed appliance therapy, but also aligner treatment. My advice is to find a course taught by specialist orthodontists which provides you with the entire gamut of orthodontic education including proper risk analysis. I would imagine very few dentists would be referring out an upper right central root canal therapy to their local endodontist – so I ask the question, “Why do they refer out the most simple of orthodontic cases to their orthodontic specialist?” The reason being, orthodontics has been a ‘closed shop’ for too many years and it’s time to open up the lines of education so that patients obtain the best possible outcomes in the most practical manner. Orthodontic specialists should be there to look after the more difficult and challenging cases – and it is our job as specialist orthodontists to teach the general dentists to manage the simple cases and to identify correctly the more difficult cases that really should be referred out. v v v Dr F says, “I just had a patient come for a second opinion from another general dentist – in brief, the patient had a Class II malocclusion and the dentist was suggesting the removal of the upper second molars in order to distallise the upper arch and when I asked the patient why the upper second molar extractions were suggested – they said that it would reduce the impact on the facial profile. Is that true”? This is a great question. Back in the early 80’s Dr Witzig believed extraction of the upper second molars would reduce the retraction of the upper anterior teeth and hence maintain the profile. Dr Witzig also believed extraction of upper second molars was far more preferable than extraction of upper first premolars as he believed that extraction of upper first premolars caused TMD issues. and I believe this is totally incorrect. The principal of the practice should have a higher fee schedule reflecting their level of experience and knowledge. If you use the analogy of an accounting or legal firm there are always different fee schedules based on the seniority of the professional. In other words, the senior partner will charge a higher fee than a junior partner and this is a normal, acceptable business principle. The principle should remain the same in a dental practice – there should be a different fee schedule for the less experienced dentist compared to the experienced principal – thus providing a way to promote the assistant/associate dentist within the practice. I hear from many dentists about the difficulty in diverging patients from the experienced practitioner to the assistant/associate and with different fee schedules in a practice, there is a true incentive for a patient to move to the assistant/associate dentist. Thinking about this logically, the scenario remains the same when a hygienist is employed by the practice, as there is a different fee schedule for a hygienists’ scale and clean compared to the principal of the practice – and rightly so as this is the correct way to ensure the patients are brought over to the hygienist for those types of procedures. Hence, I would urge you to consider when employing an assistant/associate dentist to have varied fee schedules – and in fact it would be worthwhile at that point to increase the practice principal fees and make your time far more profitable. It’s important for dentists to take on ‘typical’ business principles that are seen in all other professions. v v v Dr B of Sydney asks, “I have been thinking about doing orthodontics – but I’m so worried that I’ve been told by my orthodontic specialists that general dentists shouldn’t be doing orthodontics. Can I please have your advice on this matter?” Dr B, I am often asked this by my general dental clients, and I have to apologise for my orthodontic colleagues who believe general dentists should not be tackling orthodontics. There are numerous cases in fact probably 80% of patients can be treated adequately and successfully by general dentists, providing they have the correct knowledge and training in orthodontics. I believe the orthodontic specialists should be providing general dentists with adequate training to treat these patients columnists Both of these suggestions are a total myth – as the amount of retraction of the upper arch is determined by the position of the lower incisors. In other words, whether you extract upper second molars, or you extract upper first premolars, you can only retract the upper incisors to the position of the lower anterior teeth (providing an ideal 1mm overjet). Hence, it would make no difference as to how far we retract the incisors whether we remove the upper second molars or we remove the upper first premolars. The caveat on the impact on the facial profile would be that one needs to maintain adequate torque on the upper incisor segment. In other words, it’s very important there is adequate torque in the upper incisor area and this needs very good orthodontic control. With regards to removal of the upper second molars, this would need excellent co-operation from a patient with either wearing a head gear or elastics. It used to be argued the wisdom teeth would come in to the position of the second molars and take their place – but this does not happen routinely. I would beg the question, “In your mouth, would you prefer to have a second molar in place, or a wisdom tooth (with less ideal root structure) in the position of a second molar”? Once again, the argument of extraction of first premolars causing TMD issues has never been proven through any scientific studies – provided you have adequate torque on the upper incisors and prevent any lingual interference on closure that causes distal positioning of the mandible and the condyle, it is my belief it is very unlikely the extraction of first premolars and retraction of upper anterior teeth will cause any TMD issues. This question really demonstrates some of the myths that have been taught by practitioners over the years – none of which have been proven in any scientific capacity at all and we need to relate our treatment to evidence based orthodontics. u Dr Geoffrey Hall, Specialist Orthodontist and director of the OrthoED Institute, geoff@orthoed.com.au, 1300 073 427