THE READERS' CORNER

This month's topics are positioner appliances and employee embezzlement.

1. In what percentage of your cases do you use a positioner appliance?

Although 77% of the respondents said they used positioners, more than two-thirds of these did so infrequently (fewer than 5% of their cases). The remaining one-third of the positioner users were equally divided between those who prescribed them in about 20% of their cases and those who used them more than 75% of the time.

What are your indications for use of a positioner appliance ?

The primary indication was a high degree of patient cooperation throughout treatment. The major clinical indications listed were open bites, the need for detailing and settling of the posterior occlusion, and cases where treatment had to be discontinued early.

What are your instructions to the patient?

Patient instructions varied widely among the respondents, but the most popular protocol was full-time wear for 48 hours (often over a weekend following a Friday debonding), then nighttime wear plus four hours per day. Other commonly mentioned regimes were nighttime and four hours per day, with no full-time break-in period, and a gradual reduction in daytime wear while continuing at night.

For how long do you generally have a patient wear a positioner?

About half of the clinicians usually asked for two to three months of positioner wear. Fewer respondents prescribed positioners for two to three weeks or three to six months, and even fewer for six to 18 months.

How much correction do you expect from a positioner?

The most common reply was "minimal" (more than 60% of the positioner users). The remaining users also had limited expectations, often expecting 1-2mm of correction.

Do you find patient cooperation a problem ?

More than 70% of the readers felt that cooperation with positioner wear was a significant problem. This was particularly true for those who prescribed positioners for extended periods. All the respondents who did not experience cooperation problems stated that they carefully screened patients before selecting them for positioner wear.

Have you observed any adverse effects from use of a positioner?

Half of the clinicians reported observing some adverse effects. The principal problem cited was muscle tightness and discomfort, particularly in patients with TMJ dysfunction. Another major concern was that if the positioner did not prevent the eruption of the terminal molar, this tooth could overerupt and produce an anterior open bite upon removal of the positioner.

Do you use different colors of positioner material? Do you find color to be a motivating factor in terms of patient cooperation?

The vast majority of the readers did not use colored positioners and did not believe they provided motivation. A few felt that clear positioners provided the greatest incentive for patient wear.

Do you routinely prescribe airholes?

More than 90% of the respondents said they used airholes. Many added, however, that these holes were too small to have any effect on breathing, and that they placed them primarily for the patients' peace of mind.

Have you used Elastodontics? With what success?

Only about one-fourth of the orthodontists had used Elastodontics. They reported a variety of success rates, ranging from "poor" to "some success" to "good results".

Specific comments included:

"I use positioners especially for those cases that don't lend themselves to finishing elastics, such as multiple missing teeth."

"I use positioners on patients who have been cooperative during treatment. With positioners being as expensive as they are, I am reluctant to throw good money after bad."

"I use them to detail or seat the occlusion if cooperation has been a problem, the patient has been in treatment for a long time, and I'm concerned about decay, etc."

"Cooperation is better than with functional appliances and worse than with headgear."

2. Have you ever had a staff member embezzle money from you ?

Six of the 46 respondents (13%) reported incidents of embezzlement. Most of the others added the caveat, "not to my knowledge".

If so, what position did the staff member hold?

In five of the six cases, the employee involved was in a front-desk or business position. The sixth was a chairside assistant who had been taking money to the bank.

What amount was embezzled?

The amounts ranged from $200 to more than $10,000, with most between $1,000 and $5,000.

How was it done and how did you find out?

Most of the techniques involved cashing isolated patient checks or depositing them into the employee's own account. These were eventually picked up either by one of the check writers, who noticed the wrong account number or the forged signature on a canceled check, or by another staff member balancing the deposits when the embezzler was on sick leave.

In one case, the embezzler was altering the day sheets. In another, the employee was pocketing cash payments without crediting them to the patient, while depositing only checks; this was discovered when patients began to question their balances.

Was your bookkeeping done manually or by computer?

All six of the victimized practices were using manual bookkeeping, and most of them recommended changing to a computerized system.

What advice do you have for others?

Suggestions included hiring trustworthy people (such as the orthodontist's spouse) to do the bookkeeping, double- and triple-checking the books each day, making daily deposits, notating checks and cash separately, and having two staff members reconcile the day sheets. Other advice was to have more than one person familiar with the payment system and never to take anything for granted.

Respondents also recommended that the orthodontist always look at the day sheets and fully understand the office accounting system. Finally, they advised keeping temptations to a minimum--a good reason to have computerized bookkeeping.

If you have not had any embezzlement in your practice, are there any steps that you think have prevented or discouraged embezzlement?

Responses to this question included:

"My wife works in the office; she makes all entries into accounts receivable and does the accounts payable."

"Paying attention to the office statistics related to starts, charges, and daily receipts, as well as a good cash management system."

"We utilize multiple personnel to handle payments. A computer-entered data system involves separate individuals running the day sheet and making adjustments. A daily record of any adjustments is placed on the doctor's desk."

"My accountant visits monthly to verify services rendered, receipts, deposits, and income."

"One person receives the funds and a second enters and totals daily receipts."

"I review, sign, and date the financial sheets every day. Any alterations are handwritten by the financial secretary and discussed with me daily. "

"All bank deposits are made by myself or my wife. All bank statements and canceled checks come to my home address. The accounts are checked and balanced by our bookkeeper, who does not post checks or cash. Unannounced spot-check audits are done by the accountant approximately every 18 months."

"The doctor signs all checks and makes all deposits. The doctor signs cash slips for cash payments and keeps any cash until the deposit is made. The doctor reviews the ledger card of every finished case as part of the final records review. The doctor does not 'steal' from the office by taking home supplies such as pens, paper products, soft drinks, etc., that belong to the office. The doctor expects the staff to uphold the same standard."

"We rotate our staff in money-handling positions and have an outside accountant do the books monthly."

"Every payment receives a receipt. If any entries are made on the ledger cards without a receipt, something is wrong."

"Even with our sophisticated computer security levels, I don't think we can fully prevent it. Hiring quality staff would seem most important."

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

Drs. Richard S. Arnstine and Bernard H. Friedman, Shaker Heights, OH

Dr. Daniel M. Auter, Johnson City, TN

Dr. Maurice J. Belden, Presque Isle, ME

Dr. Milton D. Berkman, Scarsdale, NY

Dr. Jackie Berkowitz, Columbus, OH

Dr. James D. Bettinger, Artesia, CA

Dr. Richard E. Boyd, Columbia, SC

Dr. H.I. Bussa, Alief, TX

Dr. George D'Louhy, Santa Rosa, CA

Dr. John R. Davis, Pocatello, ID

Drs. Ralph DeDomenico and Mark David Lively, Tampa, FL

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

Dr. Ken H. Farrar, Marietta, GA

Dr. Thomas C. Field, Gainesville, GA

Dr. Robert S. Fields, Stamford, CT

Dr. Alan K. Fulks, Iron Mountain, MI

Dr. Ronald L. Gallerano, Houston, TX

Drs. Michael F. Gannon and Todd A. Curtis, Crystal Lake, IL

Dr. C. William Groesch, Springfield, IL

Dr. Dennis E. Halford, Sugar Land, TX

Dr. Chester S. Handelman, Chicago, IL

Dr. Jene Jordan, High Point, NC

Dr. James I. Heslop, Lancaster, PA

Dr. Michael P. Kerr, Howell, MI

Drs. Christopher K. and Peter C. Kesling and R. Thomas Rocke, Westville, IN

Drs. Leonard M. Kessler, Thomas F. Morganstern, and Gary M. Wiser, Freehold, NJ

Dr. Earle A. King, Wexford, PA

Dr. Jay R. Morgner, Imperial Beach, CA

Drs. Richard W. Mullen and Jerold R. Shapiro, Pompton Lakes, NJ

Dr. Thomas D. Murphy, Duluth, MN

Dr. Herbert Nachtrab, South Weymouth, MA

Dr. John D. Nolan, Jr., New Orleans, LA

Dr. Patrick M. Ohlenforst, Irving, TX

Dr. Candland L. Olsen, Bountiful, UT

Dr. John Oubre, Lafayette, LA

Dr. Roy E. Parle, Simi Valley, CA

Dr. Richard M. Port, Vernon Hills, IL

Dr. William W. Robinson, Sherman, TX

Drs. John H. Rogers, Terry L. Duncan, and James K. Dillehay, Wichita, KS

Dr. Donald P. Rollofson, Elk Grove, CA

Dr. Barry Rosenberg, West Hartford, CT

Dr. Mark J. Schpero, New Haven, CT

Dr. David W. Warren, Miami, FL

Dr. Sheldon S. Watnick, Allen Park, MI

Drs. Joseph A. Wells, William A. Mitchell, and Richard F. Hewitt, Greenville, SC

Dr. David C. Wertz, Dubuque, IA