THE EDITOR'S CORNER
Most orthodontic emergencies are not emergencies at all. They are extra service visits required for adjustment and repair. Probably the word emergency gives them a sense of urgency that they do not deserve, but, on the other hand, most of them are better taken care of as soon as possible for the comfort of the patient and the continuity of treatment. While most emergencies are minor and require only a snip, a tuck, a tie, or a bend, it is the neglected emergency that becomes the chain-reaction emergency and that is the one that hurts. A lower bicuspid band loosens. Its movement causes breakage in the archwire. Its loss of cement lining causes decalcification of the tooth. Mistaken continued use of Class II elastics causes loss of anchorage and irregularity in that quadrant. If this occurs in a quadrant in which a first molar or a second bicuspid has been extracted, you may spend considerable time recovering the position of the teeth distal to the space.
Many emergencies are not classified as such because the patient waits for his next regular appointment and does not call for an emergency visit. Many of these become the chain-reaction emergency. Frequently the reason that the patient waits for his regular visit is because the orthodontist is so disagreeable about emergency visits. He resents the damage or destruction of his handiwork and he resents the additional demand on his time which he feels should be unnecessary. This attitude is exactly wrong.
The fact is that emergencies are a normal part of orthodontic treatment because our appliances dwell in a forceful environment. Emergencies must be looked upon as a part of our service and a satisfying part at that. They are practice builders. You can make good friends of your patients by always being available to help them cheerfully when they need help. To reap the favorable psychological benefits that derive from the relief of pain or discomfort, don't delegate emergency care. Do it yourself.
How to Reduce Emergencies
However, in view of the inconvenience, loss of time, and retardation of treatment, we would all agree that emergencies are undesirable and we would like to reduce their number and severity. One of the best ways to do this is to classify what your emergencies are. Take a look at your last fifty or one hundred emergencies. They will have a pattern. Some will be reduceable or preventable. You may find a lot of your emergencies involve recementing the same bands, distal ends of wire sticking into tissue, loose ligature ties, clasp arms traumatizing tissue--repetitive things that can be reduced when you are aware of what they are.
A help in reducing the number and severity of emergency visits is to schedule patients who have frequent emergencies at closer intervals than you usually would. This may seem unfair to you, but you have to consider that at least you are scheduling them at your own convenience, and planning on the time for them. And, you will cut down on the chain-reaction emergencies. The best way to reduce the severity of emergencies is to encourage your patients to call you for the most minor emergency and see them to take care of them as quickly as possible.
Some orthodontists make the scheduling of emergencies a kind of punitive thing. Patients with emergencies are only seen at certain times. This may seem like the most convenient thing to do and an efficient way to run a practice, but it is not necessarily the smartest way to handle emergencies. With the number of chairs that most orthodontists have, you can slip a lot of short emergencies into your schedule. The longer ones can be made comfortable and rescheduled. Most emergencies can be taken care of as soon as possible. Often, the next regular visit can be skipped, so that the emergency visit was not a total loss of time.
Many orthodontists express the feeling that most of their emergencies are confined to a very few patients in their practice, that the same people are having emergencies all the time. This may be one of those generally accepted fallacies. For, while it is certainly true that a relatively few patients have a very large number of emergencies, they do not have a majority or anywhere near it. For example, my last 100 emergencies over a period of four months were divided among 81 patients. These 81 patients had a total of 388 emergency visits up to that point in their treatment. Among that group were 24 patients who had more emergencies than the average and there were 4 who had a very large number of emergencies--a total of 83 out of the 388. So, while these 4 did have emergencies all the time, there were 20 others who had more than their share of emergency visits.
The Problem Patient
Since some patients can go through treatment with no emergency visits while others have eight or ten or, in an extreme case, twenty-eight emergency visits, you know that there are individual differences in patients. We are all aware of the careless child with oral habits he cannot or will not control--the gum chewers, the pencil biters, the careless eaters who tear away at their food including apples, carrots, bones, corn on the cob and the like. We are sometimes hard put to figure out why some seemingly cooperative patients have frequent emergencies. They may be victims of inherent possibilities of emergency built into our appliances. Headgear leverage can loosen molar bands. Free-end wires can be pulled out or bent. I think that non-functional grinding is responsible for a lot of repeated damage to appliances. This includes the tooth gnashers and night grinders, especially in the presence of a close or closed bite. So, the very occlusion that we are treating is frequently traumatic to our appliances. Getting the bite open early should help reduce emergencies in this group, although some of the occlusal and muscular habits can continue to be damaging.
Extra Fee?
Should there be an extra fee charged for the extra time and materials of emergencies? As general office policy, I believe not. I think it would create, antagonism and possibly the counter-charge that the appliances were at fault. It would take out of the treatment of emergencies most of the favorable aspects of the relationship in which you are helping the patient in trouble, relieving him of pain or discomfort, keeping his treatment on a proper course. Better to build a contingency fee into the overall fee for treatment, particularly if you expect to have a difficult patient. However, there are two exceptions.
A charge for a lost or destroyed plastic appliance repays you for the significant cost of the appliance, encourages proper care and assures a diligent search if it should be mislaid. This charge is detailed to the parent in advance and becomes a normal, expected extra charge. There is nothing punitive about it. The only other extra charge that I would consider is in cases of repeated and flagrant damage to fixed appliances requiring extraordinary replacement of parts and expenditure of time. These few patients have gotten beyond the point where you would consider that caring for their emergencies was contributing to patient-orthodontist rapport or was practice-building. You will never build a practice on them. If someone flagrantly takes more of your time and materials than his fee estimate provides plus a usual extension of treatment time, then an additional fee is reasonable. It is made more reasonable if you include a line in your confirmation letter indicating that the fee you are quoting is established on the expectation that you will receive cooperation on the part of the patient in keeping his appliances in good condition and in completing his treatment in a reasonable amount of time. You can set for yourself a limit to the amount of repair that you will make without charging an additional fee and, as you approach that limit, send a note home indicating that if the problem continues an additional charge will have to be made in accordance with an accompanying schedule of additional charges. When I have resorted to these extra fees, I have sometimes observed that the need for them was eliminated or reduced. If it happens, this is the greatest benefit from instituting such fees.
Full Office Coverage
In order to handle emergencies properly, constant office coverage is necessary. This means a 24-hour telephone answering service of some kind so that the patient can get his message through at any time. As a practical matter, I can recall one emergency in the middle of the night in the past twenty years and very few evening calls. From one point of view I guess I wasted a lot of money on the extended answering service. However, I consider it money well spent. Full coverage is the only worthwhile coverage.
Automatic Coverage
A full-coverage system for emergencies requires some arrangement for professional coverage of your patients when you are not available. The best of these is an automatic or semi-automatic arrangement between two or more orthodontists for mutual coverage under all circumstances when one of the group is unavailable for an emergency. Depending on the number of orthodontists involved, the service can be set up in automatic rotation. All it may need is some system of checking and notification when members of the group know they will be unavailable as in cases of conventions, courses, illness, or vacation. It can also automatically cover relatively normal absences such as golf, dinner or theatre. This will assure that someone will be minding the store. All that is needed to make the system operable is agreement among the orthodontists with a willingness to participate fully, an equitable use of the system by the members of the group, and notification of the telephone answering service about the system of alternates and how it works.
In the event that all members of the group are unavailable, the suggestion can be left that the patient in dire need should see his own general dentist for relief until the orthodontist or a member of the group is available.
Just as in the individual practice, no charge should be made for other men's emergencies. The benefits are mutual and more or less cancel out. The reasons for not charging, therefore, remain the same as for the individual practice.
The attitude of the orthodontist toward emergencies can be most significant to the well being of his patient, his treatment, and himself. A helpful and cheerful attitude toward emergencies will make your own days more pleasant. If you are going to become angry and resentful at every emergency, you are going to have a lot of unenjoyable times. The emergency is here to stay. 
