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The topics include oral hygiene and OSHA compliance.

1. What do you do if a new patient presents with poor oral hygiene?

Virtually all the orthodontists responded that they would not start treatment. They would first show concern and explain to the patient Td parent the severity of the problem. They would then either start an in-office hygiene program or, in a more severe case, refer the patient back to the general dentist for oral hygiene instruction. Recording the problem in the patient's chart and sending a letter to the referring dentist were also frequently mentioned.

Specific comments included:

  • "We make note of the fact and always require a periodontal checkup and approval prior to actually banding a patient."
  • "We start an oral hygiene program, discussing it with the patient and parent. We reappoint in one to two months to re-evaluate and then take records."
  • How often do you check oral hygiene during orthodontic treatment?

    All of the respondents said they checked oral hygiene before starting treatment, and 95% did so at every appointment during treatment.

    What do you do if oral hygiene is poor during treatment?

    Most practices followed a series of steps, starting with noting the problem in the chart and informing the patient and parents. They would then start an oral hygiene program, often prescribing supplemental brushing and flossing aids. Special hygiene appointments might be set up for problem patients. Referral back to the general dentist was commonly recommended for more severe cases.

    When little improvement was seen, active treatment might be suspended, the archwires removed, and the patient placed on recall until the situation improved. Numerous letters to the parents and referring dentist stressing the possible complications of poor oral hygiene would be sent. In extreme circumstances, a special "notice" to be signed by the parent might be sent.

    Comments included:

  • "We explain brushing and flossing techniques. We explain the pathology that is occurring to the teeth and gingiva, as well as dispensing fluoride as part of our oral hygiene program."
  • Do you have a toothbrushing area in your office ? If so, how are brushes provided ?

    More than 95% of the respondents had toothbrushing areas. Of these, 76% used disposable brushes; the remainder provided the patients with individual brushes, which were often stored in the model boxes.

    Have OSHA regulations affected your toothbrushing setup?

    Three-quarters of the practitioners felt that OSHA regulations had not affected their toothbrushing procedures. Where any effect was noted, it was in the requirement for labeling and signs.

    Do you give toothbrushing instructions to patients? If so, how often? Do you provide printed oral hygiene instructions to patients?

    All the offices reported giving toothbrushing instructions; 55% did so mainly at the beginning of treatment, and 68% "as needed". Printed instructions were provided in 75% of the practices.

    2. What do you estimate to be your total initial cost in bringing your practice into compliance with OSHA regulations?

    The mean initial cost was $11,584, with a range from $1,850 to $80,000 (for a large group practice). The most commonly reported round number was $10,000. Of those who provided figures, 20% reported spending less than $2,000; 20% spent $2,000-3,000; 20% spent $5,000-6,000; 25% spent $10,000-15,000, and 15% spent more than $25,000. About 20% of the respondents did not know the initial cost of their compliance program.

    What do you estimate to be your cost per appointment in maintaining compliance?

    The mean cost per appointment was $4.30, with a range from 0 to $10. The most common round number was $5 per appointment. Thirty-eight percent of the orthodontists were not able to calculate their cost per appointment.

    Have you attended any courses or seminars on compliance with OSHA regulations? If so, how helpful were they?

    Eighty-eight percent of the respondents said they had attended courses or seminars on OSHA compliance. Of these, 35% found the courses very helpful, 41% moderately helpful, and 24% not helpful.

    Some specific comments:

  • "They were somewhat helpful, but each course seems to be based on different guidelines."
  • "They were most helpful for peace of mind. Most checks and balances were already part of our day-to-day operations."
  • Have you been contacted by any companies marketing items or services they claimed to be required by OSHA regulations? If so, did you find such claims believable? Did you purchase any such products?

    More than 70% of the practitioners reported they had been contacted by companies marketing OSHA-related items. A little more than half of these found the claims to be believable, and 66% had purchased products.

    Comments included:

  • "We purchased plastic to cover chairs and light handles, syringes and syringe tips, disposable lab coats, safety glasses, and shields. The company was helpful in deciding our needs."
  • "We purchased the items that seemed necessary, such as first aid kit, chemical spill kit, and emergency eye wash."
  • "I find it very annoying that some companies seem to play upon our fears (OSHA inspection, patient infection) to sell us products of large expense and dubious value. It further bothers me that they try to peddle their products directly to our staff, capitalizing on their less extensive education and scientific background."
  • What have you found to be the greatest problems in complying with OSHA regulations?

    The readers mentioned numerous problems. Among the most common were:

  • 1. Knowing which regulations were applicable, trying to interpret the regulations, and deciding how much common sense could be used.
  • 2. The volume of paperwork required, particularly since the regulations were constantly changing.
  • 3. The amount of time it took to train staff members, and the increased chairtime required between patients to sterilize instruments and prepare the units. Both were seen to reduce the number of patients that could be appointed daily.
  • 4. The cost of sterilizing many different types of items, such as handpieces, lab coats, glasses, etc.
  • Some specific problems mentioned:

  • "The frustration of a government plan that has been imposed upon orthodontists with no input from our profession."
  • "Confusing, expensive, time-consuming, much of it not specifically related to orthodontics."
  • "Changing the old ways of doing things-- organizing procedures so that the same volume of patients can be seen in the same amount of time that it used to take."
  • Do you have any advice on complying with OSHA regulations that might help other orthodontists?

    Responses included:

  • "Use the ADA manual for in-office procedures."
  • "The AAO manual is too confusing."
  • "Call your local OSHA people for an inspection. Our state has two departments, one for information and one for enforcement. The information department does not penalize anybody. In this way, we found out what the local policy was."
  • "Some of my ideas are: rewiring chairs and lights for foot control; using a KaVo handpiece autoclave, which is less expensive than a full-size; using infrared-sensor faucets and soap dispensers to eliminate contamination of handles; separate trash containers for 'clinical' and office."
  • "Really evaluate instrument needs. Specialty pliers, if needed on patients back to back, will have to be resterilized and will cause delays."
  • JCO would like to thank the following contributors to this month's column:

    Dr. John P. Anderson, Atascadero, CA

    Dr. Glen A. Armstrong, Moscow, ID

    Dr. Marc Ausubel, West Hills, CA

    Dr. Michael Bunner, Elkins, WV

    Dr. E. Jan Davidian, Riverside, CA

    Dr. James R. Dee, Jr., Munhall, PA

    Dr. Kevin L. Denis, Maplewood, MN

    Dr. Floyd J. Dickson, Muskogee, OK

    Dr. Albert T. Foy, Jr., Montgomery, AL

    Dr. Anthony J. Furino, New Hartford, NY

    Dr. Bryce C. Gochnour, Boise, ID

    Dr. Joseph B. Gordon, San Diego, CA

    Dr. Myron S. Graff, New Port Richey, FL

    Dr. Earl T. Holdsworth, Yarmouth, ME

    Dr. Gary P. Hussion, Fredericksburg, VA

    Dr. Gerald Jacobson, Cherry Hill, NJ

    Dr. Sara C. Karabasz, Allentown, PA

    Dr. Jeff G. Keeling, Lubbock, TX

    Dr. Albert L. Kelling, Raleigh, NC

    Drs. Francis E. Khouw and Charles F. Post, Keene, NH

    Drs. Charles W. Kohout, Alan M. Patrignani, and Barry F. Wood, Williamsville, NY

    Dr. Albert O.J. Landucci, Foster City, CA

    Dr. Russell E. Little, Reno, NV

    Dr. Glenn M. Masunaga, Honolulu, HI

    Dr. Michael T. McKee, Burlington, NC

    Dr. Thomas B. Murphy, West Chester, PA

    Dr. Robert A. Palma, Astoria, NY

    Dr. John B. Pardini, Jr., Downingtown, PA

    Dr. Howard W. Peterson, Steubenville, OH

    Dr. Leonard H. Rothenberg, Miami, FL

    Dr. Thomas M. Stark, Ames, IA

    Dr. Daniel M. Taylor, Snohomish, WA

    Dr. Don Woodworth, Arlington, TX


    Dr. Sinclair is an Associate Editor of the Journal of Clinical Orthodontics and Professor and Chairman, Department of Orthodontics, University of Southern California School of Dentistry, Los Angeles, CA 90089.

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