THE READERS' CORNER

Topics are non-acceptance of treatment and ceramic brackets.

1. What do you do to avoid failed appointments at the first appointment? the records appointment following initial consultation? the case presentation appointment following records appointment? the first treatment appointment following case presentation?

About two-thirds of the respondents took specific actions to avoid failed first appointments. This generally involved a welcoming letter that confirmed the appointment time and date. Another 25 % said they would call the patient, usually 24 hours prior to the appointment, as a reminder.

More than three-fourths of the readers reported calling patients 24 to 48 hours in advance of a records or case presentation appointment. Offices that used records laboratories expected the labs to carry out this task. Several practices said they took records at the same visit as the initial examination and therefore didn't have this problem.

Several strategies were suggested for the first treatment appointment, with a telephone call the most common, followed by a letter after the case presentation that might include an appointment card for the next visit. The placement of separators at the case presentation appointment was mentioned as an effective reminder.

What do you do in the event of a failed appointment at any of these pretreatment stages?

A follow-up telephone call, usually the same or the next day, was universally recommended. If telephone contact could not be made, a letter was then sent by many respondents. Some offices said they would rebook a patient only once or twice after missed appointments before discontinuing contact.

Do you determine your case acceptance rate by tracking all patients from referral to acceptance or non-acceptance? Do you try to contact all patients who do not accept treatment to determine their reasons?

Fifty-four percent of the readers answered "yes" to each question.

What reasons do patients give for not accepting treatment?

"Finances" was by far the most commonly cited reason for not accepting treatment. The respondents said this might involve the cost of treatment, the family financial situation, or both. Problems with insurance coverage were also frequently mentioned, as was shopping for a lower fee.

Do you generally agree with patients' reasons for not accepting treatment?

Two-thirds of the orthodontists said they could understand the patients' reasons, although some felt strongly that patients were making decisions based on price, rather than on the need for or quality of treatment.

Do you do anything to overcome patients' objections to treatment? If so, how successful are you?

Making special financial arrangements--including reducing the fee, stretching out the payments, or decreasing the initial payment--was the most commonly used method. Many respondents did not want to pressure their patients if they sensed a reluctance to enter into treatment, and would try to contact them later to see whether their financial situation had improved.

Specific comments included:

"We do nothing to avoid a failed first, (exam) appointment. We feel that this is somewhat of an indicator as to the level of motivation or desire for braces. "

"We make the initial exam visit real soon after the first phone call (i.e., same week or within one week). "

"We set up the records, case presentation, and first treatment appointments in advance and give reminder cards to be put in the patient's home calendar. "

"We charge for all unkept visits except the first time--at which stage a letter is sent reminding the patient that it is our policy to charge."

"We try to make the records appointment as soon as possible, so that not too much time passes. In many cases, we take records the same day as the initial exam."

"We always charge $25 for failing the first treatment appointment and any other failed work appointments. "

"If there are missed or canceled appointments prior to the case presentation, the fee is raised based on the assumption that the patient is likely to be careless with appointments in the future."

"We work with patients who have financial reasons for not accepting treatment, but we don't haggle, cut deals, or use any pressure tactics."

"In order to overcome patient objections to treatment, we will often have patients with unusual problems (such as orthognathic surgery) talk to previously treated patients."

2. In what percentage of your cases are you using ceramic brackets ?

Respondents to this question fell into three clearly defined groups. A minority (about 20%) used ceramic brackets on 50-70% of their patients, primarily adults . About 40 % used ceramic brackets occasionally (5-10 % of their cases), and about 40% rarely used them. Readers in both of the latter groups said they used ceramic brackets because of patient demand, and that aside from esthetics, they could see few advantages and many disadvantages to the appliances.

What do you regard as indications and contraindications for ceramic brackets?

Esthetic demand from patients was the principal indication for many respondents, who tried to limit their use of ceramic brackets to short treatment on sound teeth, in patients who required little torque and did not have deep bites.

Deep bite was by far the most frequently mentioned contraindication, particularly for the lower arch. Readers were concerned about enamel wear if maxillary teeth came into contact with ceramic brackets on the mandibular teeth. Patients with bruxing habits, short clinical crowns, or anterior teeth with cracks, crazing, or large restorations were also felt to be poor candidates for ceramic brackets. The need for significant incisor torque was a commonly listed contraindication, and several respondents also mentioned poor oral hygiene and the prospect of orthognathic surgery. Many felt that ceramic brackets were contraindicated in children because of the brittleness of the appliances.

Are you doing anything different in your etching and preparation from your bonding procedures with metal brackets?

More than 90% of the clinicians had made no changes in their etching and bonding procedures. Reducing the etching time to 30 seconds was the change made by most of the remaining respondents.

Do you normally use ceramic brackets on the upper arch, lower arch, or both?

About 60% of the readers reported using ceramic brackets on the upper arch only, usually from canine to canine. Those who also bonded the lower arch were more likely to bond from bicuspid to bicuspid in both arches.

What is your debonding technique?

Most of the clinicians followed the manufacturer's instructions and used the debonding instruments for their particular appliances. Other instruments mentioned included ligature cutters and various kinds of band splitters. Many respondents reported using high-speed burs to remove adhesive flash from around the brackets before debonding, and this sometimes included producing slight undercuts below the bracket bases.

What problems, if any, are you experiencing with ceramic brackets? How have you handled these problems?

The two most commonly reported problems were incisal wear of opposing teeth and frequent fracturing of tie wings. Also of concern to many of the orthodontists were difficulty of torquing and tipping, increased archwire friction, longer treatment time, underfinishing, discomfort of bracket removal, and discoloration of elastomeric ligatures.

Many clinicians said they avoided placing ceramic brackets in the lower arch, or when this was necessary, used a bite plate. Other responses included placing lower brackets more gingivally, changing elastomeric ties more often to avoid discoloration, and using fewer steel ligatures to prevent tie-wing fracture. The use of more nickel titanium or lighter stainless steel wires was also frequently mentioned.

Comments included:

"Adult patient acceptance is very high for ceramics. Younger patients generally prefer metal brackets with the variety of colored elastics we have to offer."

"Many kids have no interest in ceramic brackets, since they are not visible. The popularity of multicolored elastomerics is evidence that kids want people to know they are wearing appliances."

"Some adults feel that from a distance others perceive that their teeth are 'dirty', whereas metal brackets are immediately recognized for what they are."

"Lower incisor rotations are difficult to control, and bending vertical closing loops out away from the gingiva will always break the brackets, as does heavy torque."

"I don't trust adult patients to wear their bite planes with ceramic appliances, so deep bites are still a problem."

"I very much resent the industry for not warning us of the abrasiveness of ceramics when they first came out. We have had severe incisal wear on deep-bite cases within three weeks and now don't use them on the lower except in open-bite cases."

"Tie-wing fracture and subsequent bracket replacement contribute to increased overhead and increased stress in my life, and may indicate to the patient that inferior appliances are being used in their mouth."

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

Dr. Randall D. Adams, Mesa, AZ

Dr. John P. Anderson, Atascadero, CA

Dr. James E. Bradley, Silver Spring, MD

Dr. Arthur S. Burns, Jacksonville, FL

Dr. H. Paul Carbonneau, Jr., Vernon, CT

Dr. Richard E. Cowan, Indianapolis, IN

Dr. B.C. Dorminy, Waycross, GA

Dr. Walker C. Dorsett, Jr., Arcadia, CA

Dr. Jack Dunlevy, Midlothian, VA

Drs. Lawrence R. Gurin and Howard A. Fine, Mount Kisco, NY

Dr. Bruce P. Hawley, Lynnwood, WA

Dr. Calvin K. Heinrich, Scranton, PA

Dr. P.R. Higginbotham, Spartanburg, SC

Dr. Arch Talbot Hodge, Scituate, MA

Dr. William Hubbell, Jr., Port Huron, MI

Dr. Arthur L. Hudson, Glendale, CA

Drs. Gerald W. and Ronald J. Huerter, Kansas City, KS

Dr. Robert B. Julius, Maumee, OH

Dr. Nelson D. Kahler, New Braunfels, TX

Dr. George Kaprelian, Sunnyvale, CA

Dr. John Kapust, Olympia, WA

Drs. Ralph E. and Mary Ann Karau, Alexandria, VA

Dr. M.C. Koen, Goodlettsville, TN

Dr. Robert J. Kuhn, Santa Barbara, CA

Dr. David G. Lloyd, San Antonio, TX

Dr. Elizabeth A. Long, Austin, TX

Drs. John A. Maddrell and Charles S. Borden, Jr., Galesburg, IL

Dr. Robert Mason, Durham, NC

Dr. B.C. McConnell, Jr., Anderson, SC

Dr. Roger H. McConnell, Media, PA

Dr. Barry McNew, Greenville, TX

Dr. Brian H. Miller, Newton Centre, MA

Drs. Nelson, Meyer, and Ung, Berkeley, CA

Dr. John B. Pike, St. Cloud, MN

Drs. Jerry and Barry Raphael, Clifton, NJ

Dr. Curtis A. Rohrer, Winona, MN

Dr. James P. Sadlon, Rockford, IL

Dr. Gregory P. Scott, Lakeland, FL

Dr. Roy L. Scott, Warren, OH

Dr. Jay R. Singer, Boca Raton, FL

Dr. Van R. Speas, Fort Myers, FL

Dr. Carl A. Touchstone, Gulfport, MS

Dr. Richard P. West, Lakeport, CA

Dr. J. Clifford Wood, Dallas, TX

Dr. Warren D. Woods, Sandwich, MA

Dr. Don Woodworth, Arlington, TX