THE READERS' CORNER

Topics are patient cooperation and upper first molar rotations.

1. Do you have a method for identifying uncooperative patients before treatment?

About 80% of the respondents said they had no particular method. Suggestions from those who felt they were able to judge cooperation included:

"We actually before treatment ask the patient directly whether he or she is sincere about wanting treatment, and spend time talking about the need for cooperation."

"We judge their attitude toward orthodontic treatment, their hygiene (oral and otherwise), and their dress."

"If the parents mention that they prefer all after-school appointments because the patient is having difficulty with school work, I find this often indicates that the patient will be lax in cooperating with headgear, elastics, etc."

How early in treatment do you measure cooperation?

Well over half the clinicians started to measure cooperation as early as possible, often within the first three months. This evaluation could start with the patient's response to separators and the initial oral hygiene instructions. Other responses ranged from every month to every six months. Specific comments included:

"We measure overjet and overbite at each visit and ask for a report on the hours of elastic and headgear wear. We check the mobility of the teeth at the first visit after the headgear or elastics were started."

"As early as the records visit, if we have commented on oral hygiene and instructed the patient at the initial exam appointment."

What do you do about noncooperation?

A large majority said they began by having personal talks with the patient and parents. This was often followed by letters to the parents, and finally, if necessary, a change in the treatment plan.

The biggest problems mentioned were compliance with headgear wear (72% of the respondents) and oral hygiene (66%). Poor elastic wear was mentioned by 47%, followed by functional appliance wear (28%) and maintaining appliances in good condition (22%). Only 15% said that keeping appointments was a problem.

Suggestions for dealing with noncooperation included:

"We attempt to modify or improve behavior by gentle persuasion and educating the patient to understand the consequences of noncompliance, by stressing that his or her cooperation is essential."

"If we are having a problem with oral hygiene, we have a conference and tell the patient and parents that they have the following options: 1) remove appliances now; 2) the patient brushes faithfully and we see an improvement; 3) the mother brushes the teeth for the patient twice a day (teens dread this option but it does work); 4) weekly professional prophy by the general dentist or hygienist (this costs $35 per week, and most dentists are set up to do this and are very cooperative; two or three visits usually cures the problem)."

"If there is lack of functional appliance wear, we either switch to headgear for the same fee or stop treatment, refund 50% of the fee, and wait for maturity."

"We always have a conference with the parents after three failed appointments and tell them that we can't adjust the braces if the patient does not show. After 13 failed appointments total, or five in a row, we transfer them to another orthodontist. I 'resign' as their orthodontist, often giving a 100% refund. It is worth it to have them treated elsewhere so I can enjoy cooperative and happy patients."

Do you do anything special for cooperative patients?

More than 80% of the clinicians reported that they did not do anything special either during or after treatment. During treatment, the most common response was verbal praise, followed by giving small rewards (stickers, inexpensive toys, etc.) and acknowledgment of cooperation with a "patient of the month". After treatment, some practitioners sent special letters to patients and parents; a few others gave certificates. Suggestions included:

"We stroke patients with praise throughout treatment if they are doing well. We show them progress photos and model comparisons."

"We sometimes reduce the total fee paid if there is good cooperation leading to an early finish."

2. How do you correct upper first molars that are rotated mesial-in?

About two-thirds of the practitioners used fixed appliances; most of the rest used transpalatal arches. Occasional mention was made of headgear, cross-elastics, and lip bumpers.

Do you overcorrect? If so, by how much?

Fifty-six percent of the clinicians overcorrected molar rotations. The amount was most frequently expressed as either 5-10° or 1-2mm.

How do you retain the corrected positions?

A large majority felt there was usually little relapse associated with this procedure, and therefore they used their regular retention procedures. In more than 80% of the responses, this involved a maxillary Hawley-type retainer, perhaps with Adams clasps to retain the molars as well as the appliance.

JCO wishes to thank the following contributors to this month's column:

Dr. Scott P. Arbit, Milwaukee, WI

Dr. Raymond Barbre, Arlington, TX

Dr. Maurice J. Belden, Presque Isle, ME

Dr. Eugene C. Brown, Jackson, MS

Dr. Charles Buchanan, Albany, NY

Drs. W. Jerry Capps and J. Richard Moulton, Atlanta, GA

Dr. William H. Claypoole, Durham, NC

Dr. Olwyn Diamond, Baltimore, MD

Dr. Rodney C. Dubois, Bellevue, WA

Dr. David Engst, Bellingham, WA

Dr. Gerald Ginsberg, Phoenixville, PA

Dr. Barney M. Hom, Manhattan Beach, CA

Dr. Leif B. Johannessen, Wakefield, NH

Dr. Donald C. Jordan, Tacoma, WA

Dr. Michael F. Kelly, Suffern, NY

Dr. Marcel Korn, Fitchburg, MA

Dr. William J. Kottemann, Maple Grove, MN

Dr. Thomas A. Kroczek, Griffith, IN

Dr. Lester L. Luttrell, Griffin, GA

Dr. William A. Laughlin, San Jose, CA

Dr. Barry I. Matza, Boca Raton, FL

Dr. E.M. McFarland III, Pittsburgh, PA

Drs. David J. McKenna, John C. McKenna, andPaul J. McKenna, West Hartford, CT

Dr. Barry D. McNew, Greenville, TX

Dr. Charles E. Meyers, Fort Meade, MD

Dr. Terry L. Moore, Hurst, TX

Dr. William S. Rothschild, Succasunna, NJ

Dr. Mark Rothstein, San Diego, CA

Dr. H.G. Stringert, Pueblo, CO

Williamsville Dental Group, Williamsville, NY