THE READERS' CORNER
This month's topics are nickel titanium wires and referrals from general dentists.
1. What do you regard as the principal indications for using a nickel titanium archwire in particular stages of treatment?
The vast majority of respondents felt that nickel titanium archwires were particularly well suited to three functions: initial alignment, correction of rotations, and initiation of leveling. Other commonly mentioned uses were to engage impacted or severely displaced teeth (such as canines) and to provide gentle, continuous forces during extended periods between appointments (such as summer camp). About one-third of the clinicians said they regularly used nickel titanium archwires to begin torquing, especially with ceramic brackets. A similar number used them as final archwires to aid in settling.
Which types of nickel titanium archwires do you use routinely?
Two-thirds of the practitioners used predominantly round wires (mostly .014", .016", and .018"), while one-third also used rectangular wires (mostly .016" x .022" and .017" x .025"). The rectangular wires mentioned were often of the preformed reverse-curve type. About half of the clinicians said they used standard nickel titanium archwires, with the other half using superelastic wires in most of their cases. Only about 10% of the readers rarely used nickel titanium archwires in their practices.
Do you use the same wire for all purposes?
The respondents were evenly split between those who had a principal nickel titanium archwire that they used for most purposes and those who used a variety of wires, depending on their treatment goals.
What problems have you encountered with nickel titanium archwires?
Three specific problems were most commonly mentioned: the difficulty of placing bends, steps, and stops in the majority of these wires; the brittleness and breakage of the wires, especially when subjected to biting forces over long spans; and the tendency of the archwires to slide from side to side, sometimes causing them to stick out beyond a terminal molar. Annealing the ends to allow bending appeared to be an unsatisfactory solution to the last problem, because the ends often frayed or broke. Several readers also expressed concern about the continued high cost of these archwires.
What properties would you most like to see in any new nickel titanium wires that might be developed?
Bendability was the most commonly requested property, closely followed by resistance to breakage. Other characteristics mentioned included reduced friction and more strength for leveling.
Specific comments included:
2. What do you do to establish new relationships with general dentist referrers?
Virtually all the respondents mentioned taking a new dentist to lunch to get acquainted as their usual procedure. Several said they tried to refer new patients to the GP, while others suggested attending seminars, study clubs, and local dental society meetings. Having a new dentist and staff visit the orthodontist's office for a lunch-and-learn session was a common technique.
What do you do to maintain ongoing relationships with general dentist referrers?
Many of the readers reported continuing the same procedures that they employed with the new dentists. In addition, emphasis was placed on continuing communication by telephone and mail. Most of the practitioners sent frequent progress reports on mutual patients and scheduled occasional meetings to discuss cases. Keeping the orthodontist's name in the mind of the referring dentist appeared to be the principal goal. Many clinicians also recommended inviting the GP to social events as long as there were shared interests and the socializing was not forced.
What do you do if a patient's general dentist recommends against your treatment plan?
The universal response was to telephone the dentist and discuss his or her concerns about the treatment. A lunch meeting might be scheduled to allow for longer discussion if the phone call did not resolve the problem. Most of the readers felt this was a rare occurrence, but that when it happened, an open-minded approach on their part was the most productive. Some indicated they might change the treatment plan under certain circumstances, while others believed that as specialists they knew more about a patient's orthodontic problem and what the best treatment plan would be.
In your opinion, what are the main reasons for a general dentist to stop referring?
Many respondents said they had rarely encountered this situation. The most commonly cited reason, however, was that a new orthodontist had moved into the area and was either closer to the GP in location or had developed a better relationship. Some thought the general dentist might also want to help a new specialist get started. The second most common reason was personality conflict, including the feeling by the GP that he or she had supported a specialist who was now more successful. Other reasons mentioned frequently were lack of communication and dissatisfaction with treatment results, whether noticed by the dentist or by one or more patients. Several readers felt that a GP starting to perform orthodontic treatment or hiring an in-house orthodontist might be responsible for a drop in referrals.
What do you do if a dentist stops referring?
About half the practitioners reported that they usually did nothing, but felt they should have taken some action. The other half said they made an attempt to visit the dentist to reestablish communication and find out if they had done something specific that was causing a problem.
What do you do if a general dentist asks for your advice on an orthodontic case he or she is treating?
Virtually all the respondents said they would give advice in good faith, trying not to show up the dentist. If they felt the case was complex, they would do their best to point out potential problems, in hopes that the GP would recognize the difficulty of treatment and not continue.
Readers' comments included:
JCO wishes to thank the following contributors to this month's column:
Dr. A. Dean Alpine, Wilmington, DE
Dr. Mark R. Bare, Rock Island, IL
Dr. Stephen M. Begezda, Youngstown, OH
Dr. Joel E. Broussard, Jr., Austin, TX
Dr. Charles H. Buchanan, Albany, NY
Dr. Jerry F. Cash, Springfield, MO
Dr. Richard L. Chodosh, Pittsford, NY
Dr. Charles T. Corwin, El Campo, TX
Dr. Mel DeSoto, Shreveport, LA
Dr. James R. Dyer, Grapevine, TX
Dr. H. Brown Elmes, Princeton, NJ
Dr. Randy M. Feldman, Tampa, FL
Dr. Ronald G. Heiber, Lancaster, OH
Dr. Paul C. Hermanson, Marshalltown, IA
Dr. Michael W. Hinderstein, San Diego, CA
Dr. Robert V.V. Hurst, Mandeville, LA
Dr. Marvin Kaplan, Newport News, VA
Dr. Albert O.J. Landucci, Foster City, CA
Dr. David T. Lawless, Scottsdale, AZ
Dr. DeWayne B. McCamish, Chattanooga, TN
Dr. William T. Mahon, Rogers, AR
Dr. Norman K. Nakaji, Salisbury, NC
Dr. Jack H. Okun, Lake Park, FL
Dr. Charles W. Patton, New Castle, PA
Dr. Jose Luis Soto Perozo, Miami, FL
Dr. Carmine N. Petrarca, Bethesda, MD
Dr. C. Edwin Polk, Stillwater, OK
Dr. Leon Rossman, Sherman Oaks, CA
Dr. Norman Sanders, White Plains, NY
Dr. Larry C. Smedley, Downingtown, PA
Dr. Irene D. Strychalski, Dunkirk, NY
Dr. Kent S. Thompson, Granite Bay, CA
Dr. Robert P. Windauer, Kalispell, MT
Dr. H. Warren Youngquist, Colorado Springs, CO
